WWUi^iWi !'t;m #P 1 i!W!v-* li!>:t!i h' i'; !!;,1i'''' r.+x-mw V.)\", , \'' '•;; '■ W ■. ■ ' ■ i ■' ! lllil mm^^ ■■■■ ■■■ "';IHi 111 83736002 Mi THE STUDY OF MEDICINE. B Y J OH N_ MA SON -^QO D, "m.d. f.r.s. f.r.s.l. MEM. AM. PHIL. 80C. AND F.L.S. OF PHILADELPHIA. IMPROVED FROM THE AUTHOR'S MANUSCRIPTS, * # AND BY REFERENCE TO THE LATEST ADVANCES IN ^hgaiologg, $athoios»> an* Practice. * BY SAMUEL COOPER, PROFESSOR OF SURGERY IN THE UNIVERSITY OF LONDON, ETC. SIXTH AMERICAN, FROM THE LAST ENGLISH EDITION. WITH NOTES, BY A. SIDNEY DOANE, A.M. M.D. TO WHICH IS PREFIXED, A SKETCH OF THE HISTORY OF MEDICINE, FROM ITS ORIGIN TO THE COMMENCEMENT OF THE NINETEENTH CENTURY. BY J. BOSTOCK, M.D. F.R.S. IN TWO VOLUMES. VOL. I. ■* NEW-YORK: PUBLISHED BY HARPER & BROTHERS, NO. 82 CLIFF-STREET. 1835. ' V Jjli-J «** JjJ * 9 : V [Entered, according to Act of Congress, in the year 1835, by Harper & Brother*... in the Clerk's Office of the Southern District of New-York.] ■•l %(■• TO JOHN W. FRANCIS, M.D., *■ , Late Professor of Materia Medica, Institutes' of Medicine, Medical Jurisprudence, Obstetricks, and the Diseases of Women and Children in the IJniversity of the State of New-York ; Member of the Medical and Chirurgical Society of London ; of the Wernerian Natural His- tory Society of Edinburgh; of the Academy of Natural Spiences of Philadelphia ; of the Lyceum of Natural History of New-York ; of the Historical Society of Massachusetts and of New-York; of the Literary and Philosophical Society of New-York, &c. the SIXTH AMERICAN EDITION • OF GOOD'S STUDY OF MEDICINE IS DEDICATED, BY HIS OBLIGED FRIEND, * New-York, August, 1835. A. SIDNEY DOANE. PREFACE OF THE AMERICAN EDITOR. The sixth American edition of the " Study of Medicine" is reprinted from the fourth English edition, which was issued in London early in the present year; beside the ample additions of Professor Cooper, it contains between four and five hundred notes of a practical character, derived principally from the writings of American physicians. It was with extreme diffidence, and with no little dread of appearing pre- sumptuous, that the American Editor assumed the responsibility of adding notes to a work characterized by such profound learning and deep research: but he was encouraged by the consideration, that although the " Study of Medicine" has been used as a text-book for several years in this country, and is thought to be indispensable to every medical library, it contains but few allusions to the important results of American practice; while some forms of disease peculiar to this country, and the contributions of American physicians to physiology, pathology, therapeutics, and the materia medica, are, generally speaking, unnoticed in it. In fulfilling his duty, the Editor has attempted to divest himself of local feelings; to consider the physicians of the United States as belonging to one family; to be just to all; and to present the results of their experi- ence with fairness. How far he has succeeded, may be seen by referring to the notes marked with the letter D., for which he alone is accountable. The desire, however, of printing the new edition in such a form as to place it within the reach of every one, and the constant inquiries for the book, which, to speak technically, has been out of print for many months, obliged the publishers to limit the Editor both as to space and time. This fact will account for the brevity with which many important topics have been treated, and also for some omissions. To those of his professional brethren who have so kindly tendered the results of their experience, the Editor returns his wannest acknowledg- vi PREFACE. ments and thanks ; and to no one are these due more than to a personal friend of Doctor Good, Professor J. W. Francis, of New-York, not only for many practical remarks of great importance, but also for the use of his extensive library of rare books, and for a free access to his ▼aluable cabinet of anatomical preparations, which, in many cases, has afforded the Editor an opportunity of verifying the statements of the text. Prefixed to the " Study of Medicine," the reader will find a new " History of Medicine," by the learned and eloquent Bostock; it forms a happy introduction to the main work, and its perusal will richly reward the careful reader. 232 Grand-street, % "* New-York, August 1, 1835. J THE HISTORY OF MEDICINE, FROM ITS ORIGIN TO THE COMMENCEMENT OF THE NINETEENTH CENTURY. • * BY J. BOSTOCK, M.D. F.R.S. HISTORY OF MEDICINE, FROM ITS ORIGIN TO THE COMMENCEMENT OF THE NINETEENTH CENTURY. By J. Bostock, M.D. F.R.S. CHAPTER L Introduction—Division of the History of Medicine into three great Chronological Periods—History of Medicine previously to its Introduction into Greece—Origin of Medicine—State of Medicine among the Egyptians—Among the Assyrians—Among the Jews—Introduction of Medicine into Greece—Chiron—^Esculapius—Machaon—Podalirius—The Asclepiadae—Records in the Temples of ^sculapius—Ancient Inscriptions—Pythagoras—Democritus—Heraclitus—Acron—Herodicus —Gymnastic Medicine. Although the primary object of this treatise is to present a view of the history and progress of practical medicine, yet it will be impossible to avoid entering occa- sionally into the consideration of the various theories and speculations which have so generally prevailed in the science. Medical theory and practice have been so intimately blended together, that it would be useless to attempt to separate thena. The terms which are employed in works of the most practical nature are, for the most part, derived from the theory which was current at the time of their publica- tion ; and even the narrative of facts, and the direct details of experience, are, with a few exceptions, deeply tinged with the prevailing doctrines of the day, or with the individual speculations of the writer. Those who are versed in medical science, and who are acquainted with the relation which it bears to the other physical sciences, with the mode in which it is acquired, and the nature of the evidence on which it rests, will easily perceive that, in this department, it is peculiarly difficult to separate facts from hypothesis. It may, however, be asserted, that until this be accomplished, medicine can never be placed upon the basis of induction, and that this alone can give it that stability which may entitle it to be regarded as a correct science. In its present condition, it will be impossible to do more than to approximate to so desirable a state; but it will be a speeial object of attention in the following pages to endeavour to point out the limits between practice and theory, between facts and the opinions that have been deduced from them. When we take an extended view of the progress of medicine, tracing it from its scanty sources, in the most remote periods of society, and observe its course, as gradually augmented by the stores of Grecian and Roman learning, obscured by the darkness of the middle ages, and again bursting forth in the copious and almost overwhelming streams of modern literature, we are naturally led to separate the narrative into three divisions, corresponding to the three great chronological periods. The first of these will comprehend the history of practical medicine, from the ear- liest records which we possess to the decline of Roman literature; the second will contain an account of the state of the science through what are termed the dark ages until the revival of letters ; the third will commence with the establish- ment of the inductive philosophy, and be continued to the commencement of the nineteenth century. X HISTORY OF MEDICINE. In tracing the history of this science from its earliest records, it will not be necessary to devote much time to a subject which was formerly discussed with great learning and acuteness, viz. the origin of medicine. It may be sufficient to remark, that in proportion to the progress of civilization or refinement, attempts would be made to remove or alleviate the diseases, and to repair the injuries to which the body is constantly incident. Subject as it is at all times to the influence of various noxious agents, and to a consequent derangement of its functions, to painful affections of various kinds, and to the loss or depravation of its powers or actions, we must conceive that mankind would be anxious to remove or relieve these evils. The means that would be employed must have been, in the first instance, extremely imperfect, and frequently ill-directed. They may have been suggested by the effects of certain kinds of food, or by the operation of certain external agent% on the body: some analogies may have been derived from the spontaneous actions of the system, by observing the natural efforts of the consti- tution to remove certain causes of disease, or to relieve the patient when suffering from their effects. Thus, in the earliest periods of*society, mankind must have been aware of the relief which was obtained in the derangements of the alimentary canal by an evacuation of its contents, and would probably have discovered, inci- dentally, that certain vegetable substances promoted this operation. In the external injuries to which the body is subject, more especially in a rude state of society, means would early be had recourse to for procuring present ease from pain, or for removing the obvious danger to life which would so frequently follow from various causes. It would soon be found that the pain was diminished by excluding the wounded part from the air, or from other extraneous substances; that by certain modes of pressure, the flow of blood might be restricted; and that in some cases an increased and in others a diminished temperature gave immediate ease to the patient, and tended to promote the ultimate cure. A rude species of medical and surgical practice of this description has been in all cases found to exist in newly- discovered countries, even when in the most barbarous state; while it has been observed, generally, that the improvement in the healing art has been nearly in proportion to the advancement of the other arts of life, and to the gradual pro- gress of knowledge on all subjects intimately connected with our existence or welfare. The historical records which we possess respecting the progress of practical medicine are scanty and uncertain; but so far as they extend, they coincide with the view of the subject taken above. The writers who have investigated this point with the greatest learning and assiduity, inform us that Egypt was the country in which the art of medicine, as well as the other arts of civilized life, was first cultivated with any degree of success, and that it had advanced so far as to have become a distinct profession. We are not, however, informed in what degree or to what extent that distinct appropriation was carried; whether medicine was made the exclusive business of certain individuals, who were regularly instructed for that purpose; whether it was attached to certain public functionaries, especially to the priests; or whether persons in different situations applied themselves to the practice of medicine from a real or supposed superiority in their skill and in their knowledge of the treatment of diseases. The probability, however, is, that the priests of the Egyptians were at the same time their physicians. This appears to have been the case among the Jews and the Greeks, who are supposed to have borrowed from the Egyptians many of their institutions; and indeed it seems to be the natural progress of society in its earlier periods, when the priests were generally the depositaries of knowledge of all kinds, and when they confined it as much as possible to their own use, for the purpose of maintaining their influence over the rest of the eommunity. From some remarks which are made incidentally in the writings of the ancients respecting the medicine of the Egyptian priests, it would appear that it consisted m a great measure of the employment of magical incantations, and, so far therefore as it effected the cure of disease, must have operated through the medium of th^ imagination. This has been in all cases the first step in the art of medicine if it may be so called, and its efficacy must have been in exact proportion to the S™ ranee and superstition of the people on whom it was exercised* A circumstance respecting the practice of medicine in Egypt is mentioned by * Le Clercj Hist, de la M^decine, par. i. liv. i. chap. 12. HISTORY OF MEDICINE. XI Herodotus as existing when he visited that country, and which it may be presumed was transmitted from a much earlier period, that certain individuals treated certain diseases only.* This division into separate branches might, at first view, seem to indicate a degree of manual dexterity and of minute observation in certain depart- ments. But, independent of any other consideration, we may rest assured that the science must have remained in a state of complete degradation, when we bear in mind that it was the custom in Egypt, as it is in the present day among many of the nations of the East, to transmit the same occupations from father to son, through a number of successive generations. This practice, although it may be favourable to the perfection of an art, or even of a science, in some of its minute details, must furnish an almost insurmountable obstacle to its general improvement, or to the development of the powers and faculties of the human mind. Although we are in the habit of considering Egypt as the parent of the arts and sciences, the empire of Assyria has been supposed, by many learned men, to pos- sess a greater claim to this distinction. Perhaps the priority of invention may be justly awarded to the Assyrians, but the memorials which they have left behind them are so scanty, that the degree of excellence to which they arrived is almost entirely conjectural. The priests of this nation, as in all other cases, appear to have been the depositaries of all the learning of the times, and of that of medicine among the rest. We have reason to suppose that their practice consisted of little more than the dexterous application of magical arts, and such other means as tended to impress the minds of the people with a sense of their power over the operations of nature, while any actual information which they possessed was carefully con- cealed under the guise of mystery and superstition.! ■ In the writings of Moses there are various allusions to the practice of medicine among the Jews, and more especially with regard to the treatment of leprosy. The priests appear in this, as in other cases, to have been the practitioners; the treatment consisted principally in certain regulations for the purpose of promoting cleanliness and preventing contagion, together with various ceremonies, which, so far as they could affect the patient, must have acted entirely on the imagination.^ So little is known respecting the state of the arts and sciences in the other coun- tries of the East, at these remote periods, that it is scarcely necessary to allude to them in this place. We shall only remark, that the imperfect and scanty notices which we possess on this subject would lead us to conclude, that the practice of medicine was even in a less advanced state than among the Egyptians, its progress being regulated by the greater or less degree of refinement or civilization of the respective countries, but in no case having advanced beyond the state of implicit credulity and gross superstition.^ After having given an account of the state of medicine among the ancient Egyp- tians and other contemporary nations, as far as can be gleaned from the scanty records that remain on this subject, we must follow it into Greece, and trace its progress from the period of its first introduction in the remote and semi-fabulous ages of their demigods and heroes, until it acquired the rank of a science under the genius of Hippocrates. It is generally admitted, that although Greece cultivated the arts and sciences with so much success, yet, in the first instance, she borrowed them from the ineighbouring nations; principally, as it would appear, from Egypt, and in some cases from Phoenicia. || To certain individuals who migrated from these countries, the Greeks themselves were in the habit of referring the introduc- tion of many of the most useful inventions; and during a considerable space of time all those who were desirous of acquiring a larger share of knowledge, either * Euterpe, $.84. t Herodotus, Clio, passim. Enfield's History of Phil. v. i. p. 25 et seq. t Leviticus, chap, xiii.-xv. Michaelis, on the Laws of Moses, chap. 4, art. 210-11. § For further information respecting the state of medicine among the Egyptians and the other nations of antiquity, previously to the Greeks and Romans, the reader is referred to the following works. Herodotus, Euterpe et Clio, passim. Diodorus Siculus, lib. i. sect. 25, 82. Plinius, lib. vii. cap. 56, lib. xxix. cap. 1. Plutarchus, De Iside et Osiride. Josephus, Antiq. Jud. lib. viii. cap. 2. (f. 5. Clemens Alexandrinus, a Potter, Stromat. lib. vi. p. 758. Conring, Introd. Art. Med. cap. 3. $. 2. et De Herniet. Med. passim. Barchusen, Diss. no. 1 et 7. Gruner, Analecta, Dis. 1. De JEgyptiorum Vete- rom Anatome. Schulz, Hist. Med. p. 1. $. 1. Le Clerc, par. 1, liv. i. chap. 1-8. Sprengel, Hist, de la Med. par Jourdan, $. 2. chap. 1-3. Enfield's Hist, of Phil. v. i. p. 86, 7 et alibi. Pauw, on the Egyp- tians and Chinese, part 1, §. 2. Bryant's Analysis, v. 2, p. 324 et seq. et in multis aliis locis. Cabanis, Revol. de la Med. chap. 2, $. 1. Ackermann, Instit. Hist. Med. p. 1. chap. 1, 2. Louth, Hist, de I'Anatomie, liv. i. Blumenbach, Introd. in Historiam Medicinas Litter, (j. 1-3. II Vide Bryant, ubi supra, et v. ii. p. 426 et seq. et alibi. XII HISTORY OF MEDICINE. theoretical or practical, than was possessed by their countrymen, visited Egypt, a* the great storehouse of science and learning. It is from this cause that we nnd so much analogy between the divinities that were worshipped in the two countries, as inventors or patrons of the various arts and sciences. For altnougntney acquired new names on their being transferred into Europe, yet their attributes, and even their forms, clearly demonstrate their origin. This is particularly tne case with respect to medicine, so that in the Orus and Thouth of the Egyptians we may recognise the prototypes of the Apollo and Hermes of the Greeks. It is not until comparatively at a late period, approaching to that of the Irojan war, that we find the names of actual personages who practised medicine in Greece : and of these, it is probable that some were natives of either Africa or Asia, wno brought with them the information which they had acquired in their respective countries. Of those whose history is better known, and who were acknowledged to be of Grecian origin, it was the general custom to travel into Egypt for the pur- pose of obtaining a knowledge of their art, and with this view they submitted to a system of rigid discipline, and to a variety of irksome and burdensome ceremonies; and after all this laborious process, so far as the science of medicine is concerned, the result seems to have been little more than the knowledge of magic and incantations, with some rude notions respecting the application of external reme- dies for the cure of wounds and of cutaneous diseases, with a very imperfect idea of the anatomy of the human body, and a very inadequate conception of its functions.f The first native of Greece who is more particularly singled out, as having intro- duced the art of medicine to his countrymen, is the centaur Chiron. There is much mystery attached to his character and to every thing connected with him, but what we may consider as the most probable conclusion is, that he was a prince of Thessaly, who lived about the thirteenth century before the Christian era; that he was distinguished above his contemporaries for his knowledge of the arts of life; and that, after the manner of his countrymen, he was frequently seen on horseback, so as to give rise to the fabulous account of his compound form. He is particularly celebrated for his skill in medicine and in music; a combination, it may be remarked, that was said to have existed in many other individuals. We are not informed by what means he obtained his superior knowledge in medicine ; but there are various circumstances which lead us to conclude that it was at that time regarded rather as a part of the education of all men of rank, than as attached to a particular profession. We accordingly find that he instructed the Argonauts in medicine, and the heroes who were engaged in the siege of Troy ; and that all the kings and warriors of that period were more or less acquainted with the treat. ment of wounds, and even with the practices which were adopted for the cure of internal diseases.J But although Chiron has the reputation of having introduced the art of medicine into Greece, it is to his pupil ^sculapius that, by the common consent of antiquity, is ascribed the merit of having first devoted himself to the cultivation of medicine as a science, and of having made it a distinct object of pursuit. The improvements which he made in the art were so considerable as to have induced his countrymen after his death to pay him divine honours, to designate him as the god of physic, to erect temples to him in various parts of Greece,^ and to derive his origin from Apollo himself. His history, when divested of all the fabulous appendages that were attached to it by his contemporaries, appears to be, that he was a native of Epidaurus, that he was exposed in his infancy, probably in consequence of his ille- gitimate birth, that he was accidentally discovered by a shepherd, and placed under the care of Chiron. His death was said to have been caused by the jealousy of Pluto, in consequence of the number of individuals whom he rescued from the grave; from which tale we may at least conclude that his reputation, as a suc- cessful practitioner, must have been much higher than that of any of his contemporaries.|| * Holler, Bibl. Med. pract. lib. 1. §. 7, 8. Hundertmark, in Ackermann, Opuscula, Exerc. no. 1. t Herodotus, Euterpe, passim. Diodorus Siculus, lib. i. passim. Josephus, Antiq. Jud lib viii caD 2 y. 5. Odyss. xix. 656 et seq. ^Eneis, vii. 753 et seq. ' ' t Was, xi. 636 et seq. Sprengel, t. i. p. 112, 3. Ackermann, par. 1, cap. 3, Y. 25-40. 4 Pausanias, lib. i. cap. 21; li. 10; ii. 13; iii. 22; iv. 31; vii. 21 ; vii. 23 ; vii. 27; viii 25 Strabo lib. vui. p. 592; ix. 668; xiii.899; xvi. 1097, k Casaubon. Amst. 1707. Le Clerc, par 1 Uv'i ch 20* II Diodorus Siculus, lib. iv. <$. 71. Hyginus, fcb. 49 et alibi. Le Clerc, par. i. Jjv. I ch' JJ-ie' HISTORY OF MEDICINE. xiii According to the custom of that age, he transmitted his profession to his sons Machaon and Podalirius, who accompanied the Greeks in the Trojan expedition, and are celebrated in various passages of the Iliad for their medical skill.* From the incidental mention that is made by Homer and the early Greek writers of the nature of the remedies that were employed by these individuals or their contem- poraries, it will appear that their practice was principally surgical, and nearly con- fined to the treatment of wounds, and that, with respect to internal diseases, these were for the most part conceived to be the immediate infliction of the Deity, and were therefore abandoned as incurable, or at least were to be obviated only by charms and incantations, and that the arts of magic formed no inconsiderable part even of their surgical practice.t The practice of medicine remained for a considerable time hereditary in the family of jEscuIapius, and in a great measure confined to it. His descendants obtained the name of Asclepiadae ; they were the priests of his temples, and pre- sided over and directed the rites and ceremonies. J These temples, indeed, became a species of hospitals, to which patients resorted from all quarters for the relief of the diseases with which they were affected. Under the direction of the priests of these temples they underwent a variety of ceremonies, the immediate effect of which must have been principally upon the imagination. Some, however, of the practices which were enjoined were of a dietetic nature, and were directly conducive to temperance and cleanliness; such as frequent ablution, and the abstaining from certain kinds of food. To these, if we add that the temples were generally erected in healthy situations, that the patients enjoyed rest and leisure, and that the mind was interested by a succession of new and pleasing impressions, we may suppose that they would be placed under circumstances not a little resembling those which are found so conducive to health by the invalids who frequent the medicinal springs and other analogous establishments of modern times.§ Although the accounts that have been transmitted to us respecting jEsculapius would lead us to conclude that he was a real personage, who actually possessed a greater degree of medical skill than any of his contemporaries, yet his whole history is so involved in fable and mystery, that it is impossible to obtain any correct idea of the details of his practice. It has been observed above that it was probably, in a great measure, surgical, and even confined almost exclusively to the cure of wounds or recent injuries. The treatment of these may be considered so far judicious as it was simple; it consisted in removing all extraneous bodies, in placing the parts as much as possible in their natural position, in fomentations and ablutions, and in the application of certain vegetables, which were supposed to be possessed of balsamic or styptic properties. Wine and other articles of a more stimulating nature were also used, while oleaginous substances were employed nearly with the same intention as in modern times, to defend the part from the air or other external agents, together with bandages and other means of mechanical support. We have no distinct evidence how far internal remedies were administered; for the most part they relied on magical arts and incantations, and although we have reason to believe that certain vegetable products were occasionally employed as internal remedies, we are scarcely able to discover what was the object of the practitioner, and we are frequently unable to ascertain what were the plants that were employed.|| But scanty and imperfect as is our knowledge of the state of medicine in the age of jEsculapius, after his death and that of his sons Machaon and Podalirius we have a long period, extending even to several centuries, during which we have still less information respecting the history and progress of the science. We have Ortelius, Capita Deor. lib. ii. in Gronovii Thes. Graec. t. vii. p. 278 et seq. Montfaucon, Antiq. v. i. book ii. ch. 1, 2. Sprengel,t. i. p. 119 et seq. Ackermann, par. 1, cap. 3, y. 41-59; and especially the second dissertation in his Opuscula, by Gimzius and Richter. * Le Clerc, par 1, liv. i. ch. 17. Sprengel, t. i. p. 127 et seq. Goulin, Encyc. M6th. Medecine, " Anciens Madecins." This article may be advantageously consulted on the subject of the Greek and Roman physicians. t llias xi. 636 et seq. Odyss. xix. 456 et seq. j Sprengel, t. i. p. 168 et seq. y Le Clerc, par 1. liv. ii. ch. 2-6. Schulz, par. i. y.2, cap. 4. Sprengel, t. i. p. 153 etseq. Cabanis, p. 59, 60. II Celsus, lib. i praef. Plmius, lib. xxix. cap. 1. Le Clerc, par. i. liv. i. ch. 15. Schulz, p. i. y 2, ch. 4. Sprengel, y 2,-ch. 4, 5. Cabanis, ch. 2, y.l. XIV HISTORY OF MEDICINE. not a'single improvement of any importance recorded as having taken place during this long interval, nor have we the names of any individuals transmitted to us who were of sufficient eminence to be distinguished above their contemporaries. We learn that the practice of medicine was entirely confined to the Asclepiadae, who were the guardians or superintendents of the temples that were erected in honour of ^Esculapius. It may be inferred from the very scanty materials which we possess on the subject, consisting entirely of allusions or indirect accounts, scattered through the works of the older poets and historians, that they sedulously kept up the system of rites and ceremonies, which had been handed down to them from still more ancient practitioners, that they carefully preserved to themselves the sole management of the art over which they presided, and we cannot doubt made use of the influence which they acquired over the minds of their contem- poraries for the purposes both of gain and of ambition.* But although we regard the general system of the priests of ^Esculapius to be nothing more than a tissue of mystery and delusion, it is very probable that the ample opportunities which they possessed of witnessing the phenomena of disease in all its forms, might enable them to obtain much valuable information respecting the nature and ten- dency of the morbid actions of the body, and of the effects of certain agents upon them. Men possessed of superior talents and sagacity would naturally profit by these advantages, and we accordingly find that some of these temples acquired a high degree of celebrity, in consequence of the supposed skill of the priests that were attached to them. These opportunities of acquiring experience were much facilitated by a practice which generally prevailed among the patients, whenever they were cured of their diseases, of depositing in the temple a votive tablet, on which was inscribed a narrative of the case, including a statement of the symptoms of the disease, and the means adopted for its removal. The temples were thus converted, to a certain extent, into schools of medicine, and as these records were religiously preserved, they became the repositories of much important information, which must have gradually led to an improvement in the art. Of the numerous temples that were dedicated to jEsculapius, there were three which acquired peculiar celebrity, those of Cos, of Gnidos, and of Rhodes; we are informed that Hippocrates made great use of these records, and it has even been supposed that one of the treatises which is generally ascribed to him, " Coacae Praenotiones," was composed from the records which he procured from the temple of Cos. Some ancient inscriptions have been discovered by the researches of the learned antiquaries of the last century, which would appear to consist of memorials of this kind; and from these specimens we may form some idea of the nature of the information that would be conveyed by them. For the most part they state little more than the name of the disease, together with a very brief account of the means adopted for its relief, which in many cases depended entirely upon certain ceremonies, and in others upon the application of remedies, which, we may ven- ture to assert, could have no physical operation.! Still, however, some experience of the nature and treatment of disease might have been conveyed by their means, and of this we may presume that an individual of a sagacious mind would have availed himself for the improvement of his art. Among the few circumstances that are transmitted to us respecting the principles and practice of the Asclepiadae, we are informed that the priests connected with the two rival establishments of Cos and Gnidos devoted their attention, in some measure, to different objects; those of the former assumed more of a philosophical cast, attempting to unite reasoning with experience, while the latter attached them- selves solely to the observation and collection of mere matters of fact Hence it would appear that a foundation was thus early laid for the two great sects of the Dogmatists and the Empirics, which long divided the medical world, and the influence of which is^ even at this day, not altogether destroyed. I may remark however, that the philosophy of the school of Cos, if it may be so called, was founded upon such totally incorrect principles, and upon so fallacious a basis that little immediate benefit was derived, from it, and that it was only useful so far as* might lead them to exercise their intellectual powers, and enable them to reason at;trP£5^ Tooke's Trans, v. i. p. 87 et seq P Y transmltted from the empirics of antiquity. See Jr*^Tca^.InSCrip- & GraVi°' Pl 17 et alibL **"*"». OP^ula, Diss. 3, y. 3> by 3^ HISTORY OF MEDICINE. XV more correctly bn medical subjects. By the mode in which Hippocrates speaks of certain practices, such as bleeding and the administration of emetics, purga- tives, and other analogous medicinal agents, we may infer that they were in common Use among his contemporaries, and probably had been so for a long time before him. We may in some instances obtain a knowledge of the vegetable substances that were employed in these early ages, as well as of the individuals wha intro- duced them into practice by the names which were afterward imposed upon them by the ancients. It must indeed be obvious that the indication derived from these names is far from being decisive, as applied to any particular case; but we derive a general inference from it as to the nature of the articles employed, while they serve to point out the persons who were supposed to have been the most eminent for their skill or their science. Some centuries had elapsed, during which the practice of medicine continued altogether in the hands of the priesthood,,and under their control had remained nearly stationary. It had been exercised, for the most part, for the purpose either of direct emolument, or for the still more selfish purpose of maintaining their influence over the minds of the people, when it began to be cultivated by a different description of persons, much more likely to produce a spirit of improvement, and from whom in reality it derived its first impulse. It was during the sixth ceHtllry before the Christian era that the genuine principles of philosophy first made their appearance in Greece; and among the other topics which then became the subject of investigation, the powers and functions of the human body were examined with considerable attention. This led to an inquiry into the nature and cause of diseases, and to the means of their removal; and although a long period elapsed before much actual advance was made in the knowledge of pathology or of the practice of medi- cine, yet we observe the effect of a more correct mode of reasoning, and may per- ceive that the strongholds of mystery and superstition, although not destroyed, were at least in some degree weakened.* The celebrated name of Pythagoras may be mentioned as the first of this class respecting whom we have any accurate information, and even his history is envel- oped in much obscurity. We may, however, conclude with certainty that he devoted the greatest portion of a long life to the pursuit of natural knowledge; that he made ' many considerable advances in various departments of sqience, and among others in the knowledge of the structure and actions of the human frame. It has been supposed that he dissected the bodies of animals, and hence acquired a certain acquaintance with anatomy; and that he publicly taught what he knew on this subject to a large assembly of students, who came from all the civilized parts of Greece and Italy to Crotona, where he established his school. We are informed that, for the purpose of acquiring knowledge, he travelled into those countries which, previously to his time, were regarded as the depositories of knowledge, particularly Egypt, where he is said to have passed no less than twenty-two years, and probably also Chaldea and some parts of Eastern Asia. From what has been stated above, we may form some conception of the nature of the knowledge that he would obtain from these sources, and we may conclude that he must have been possessed of a very superior mind to have been capable of extricating himself from the trammels of superstition and bigotry, in which every thing connected with those countries was involved.! We are scarcely able to determine in what degree he directly improved the practice of medicine; it is probable, however, that as he did not make it his pro- fession, but studied it only in connection with the other branches of natural philoso- phy, the actual additions which he made to it were not considerable.t This we may also conclude to have been the case with many of his pupils, who were among the most justly celebrated philosophers of that and the succeeding age. They may all of them be regarded as belonging to the school of Pythagoras, inasmuch as they cultivated natural knowledge by means of observation, and even occasion- ally of a rude kind of experiment; and although aone of them were exclusively devoted to the study of medicine, yet they gradually and indirectly contributed* to its advancement, so as to prepare the way for one of those great and commanding * Sprengel, 6. 3, ch. 1. t Diogenes Laertius, lib. viii. cap. 1-50. Cicero, de Fin. v. 29. Voter. Maximus, viii. 7. jElianus, Hist. Var. iv. 17. Clemens Alexandrinus, Stromat. lib. i. p. 3M77. Fabriciut, BiM. Graec. lib. ii. cap. 12. Enfield, vol. 1. p. 422 et seq. Ackermann, Instit. Per. 2, cap 4) 5; Opuscula, diss. 4, a Kuhn. I Sprengel, t. i. p. 337 et seq ,vi HISTORY OF MEDICINE geniuses who occasionally make.their appearance, and by their intS°^tual ascend- ancy produce such important revolutions in the world of science: it is unnecessary to state that I here allude to Hippocrates. „QTrip„ that During the interval from Pythagoras to Hippocrates there are few names tna* require any particular notice as improvers of medicine. DemocBtus and Hera clitust were among the most illustrious followers of Pythagoras, but they became famous rather from the ingenuity with which they supported their Pec»^r *3-in: eses than from the additions which they made to actual knowledge. 1 hey appiiea respectively their favourite doctrines of atoms and elements to explain tne phe- nomena of disease, and even the operation of remedies; but, it is unnecessary to say, with little real advantage. The former of these philosophers, however, deserves honourable mention from the attention which he paid to the study 01 comparative anatomy; and it has been conjectured that he so far rose superior to the prejudices of his age as to venture upon the dissection of the human subject. The name of Acron is mentioned by Pliny { as among the first who attempted, upon any general principles, to apply philosophical reasoning to the science oi medicine; but we have scarcely any knowledge of his history or character, nor have we any memorials left of the principles which he adopted.y We may also select the name of Herodicus as having been considered the inventor of what was styled gymnastic medicine,|| which was regarded by the Greeks as a very important branch of the art. Schools for the practice of the gymnastic exercises were established in various parts of Greece, and were placed under the direction and superintendence of persons especially trained for the purpose, who took charge of the health of their pupils, and who appear to have undertaken the treatment both of the accidents which occasionally occurred in their establishments, and also, when necessary, of internal diseases. These gymnasiarchs, as they were styled, must in this way have acquired a certain degree of information respecting the nature of disease, and seem to have been considered as among the most skilful practitioners of the age in which, they Hved.1T CHAPTER II. An Account of the Opinions and Practice of Hippocrates and his Contemporaries—Remarks on the History and Education of Hippocrates—High Estimation in which he was held—Remarks on his Character and Acquirements--On his Works—Account of his Principles and Doctrines, his Physi- ology, Pathology, Anatomy, and Practice. We now enter upon the history of an individual of very distinguished character and acquirements, who was destined to effect a complete revolution in his profession, and to introduce a system which may be considered as having laid a foundation for all its future improvements. The contemporaries and immediate successors of Hippocrates were so sensible of his merit, that he acquired from them the title, which he has since retained, of Father of Medicine; and it may be confidently affirmed that the science is more indebted to his genius and ability than to that of any single individual. It is a little remarkable that, notwithstanding the .great celebrity which he attained, we have no very correct knowledge of his history, of the mode of his education, or of the means by which he acquired his wonderful pre-eminence. All that we are able to learn on these points with any degree of * Le Clerc, p. 96-101. Enfield, vol. i. p. 422 et seq. Barchusen, diss. No. 1. Sprengel t i n 261-ft T| Le Clerc, p. 95> 96. Sprengel, t. i. p. 266-9. Enfield, vol. i. p. 436 et seq. ■»»••*" "*-«■ t Lib. xxiz. csp. 1. 6 Le Clerc, par. i. liv. ii. ch. 7. II Le Clerc, vox. i. liv. ii. ch. 8. Mercurialis, De Arte Gymnastica. Schulz, p. 192 et seq Barbier Diet. Scien. Med. art. " Gymnastique." Ackermann, per. 2, cap. 6. H JJarmer' n Plato, De Repub. passim, et De Leg. lib. vii. Schulz has judiciously summed up, in a series of general propositions, the history and progress of medicine up to the period at which we are now HISTORY OF MEDICINE. XVII certainty is, that he was brought up among the Asclepiadae, who were attached to the temple of Cos ; that he studied medicine under Herodicus, and that he embraced the philosophical hypothesis of Heraclitus : he is also reputed to have been a lineal descendant, in the eighteenth degree, from iEsculapius, and may therefore be sup- posed to have been devoted to the profession from an early period of life, and must have had access to all the records which were1 accumulated in the establishment to which he belonged. These circumstances may have had the effect of originally directing his mind to the pursuits in which he afterward became so eminent; but we must suppose that he possessed from nature a genius singularly adapted to the advancement of medical science, by which he was enabled so far to surpass all those who were placed in situations equally advantageous. We are informed that he spent a considerable portion of his life in travelling through foreign countries, partly for the purpose of obtaining information, and partly from the circumstance of his assistance being required to undertake the cure of persons of rank, to arrest the progress of epidemics, or to check the ravages of endemic diseases. The works that he left behind him are very numerous, and, considering their antiquity, they may be regarded as in a tolerably perfect state. Unfortunately, however, to those which appear to have a just claim to be con- sidered as his genuine productions there are appended a number of others, which it may be concluded are spurious, either written by his pupils or successors, or fraud- ulently attached to his name in consequence of his great celebrity. Many eminent critics have exercised their ingenuity in endeavouring to separate the genuine from the spurious writings of Hippocrates; and in such estimation was he held, that for many ages a main object with all writers on medical topics was to comment on the works of Hippocrates, to elucidate his principles by subsequent observation, or to support their respective doctrines by his authority. He is mentioned with great respect by Plato, Celsus, and Pliny, and by others among the ancients: Galen speaks of him with a degree of almost enthusiastic admiration; and at the revival of letters the most learned men of the times devoted themselves to the elucidation of his works by glossaries, commentaries, and criticisms of all descriptions. In Italy, Germany, and France, where learning first began to revive, and where the earliest universities were established, we have, among other illustrious names, those of Alpinus, Cornarius, Hollerius, Ballonius, Mercurialis, Fernel, Heurnius, Sennert, Foesius, Riolan, and Duret,* who, however they might differ in their opinions and practice, all coincided in regarding Hippocrates with equal respect, and considered him as having first placed the study of medicine on its correct basis.f We are hence naturally led to inquire what were the circumstances, in the intel- lectual or literary character of Hippocrates, which produced this powerful impres- sion, and perhaps we may assign the following as among the most influential. He appears to have had the sagacity to discover the great and fundamental truth, that in medicine, probably even more than in any other science, the basis of all our knowledge is the accurate observation of actual phenomena, and that the correct generalization of these phenomena should be the sole foundation of all our reason- ing. Every page of Hippocrates proves that he was not without his speculations and hypotheses, but at the same time we perceive that, for the most part, they were kept in subjection to the result of observation, and that, when they appeared to be in opposition to each other, he had the wisdom to prefer the latter. Hence his descriptions of particular diseases, after all the revolutions of customs and habits, both moral and physical, are still found to be correct representations of nature, while his indications of cure, and the treatment derived from them, are generally rational and practicable. When we reflect that at this period anatomy was scarcely practised,! that physiology was almost unknown, that the materia medica was nearly confined to vegetable substances, and of these to such as were indigenous to Greece and the neighbouring countries, our admiration of the skill and talents of Hippocrates will be still further increased, and we are induced to regard him as * In designating the names of authors who nourished after the revival of letters, it is somewhat difficult to determine whether we ought to employ their actual or their latinized names: I have adopted the former where it could be done without ambiguity or the appearance of affectation. t Conring, Intr. cap. 3. v. 8. et alibi. Holler, Bibl. Med. Prac. lib. vi.; it is entitled " Schola Hippo- cratica," and is carried down to the beginning of the seventeenth century. % Gruner, Analecta, diss. 2. " Hippocrates, corpora humana insecuerit necne ?" He discusses the question with much learning and candour, and decides in the negative. *> xvlii HISTORY OF MEDICINE. one of those rare geniuses, who so far outstrip their contemporaries as to form an %?thSJ^°^1SS^-r improvements which he introduceci into the.prac- tice of medicine, I may remark, that one of the first importance ™ *e "™J™ of individual cases of disease,—a plan which may perhaps have been suggested to himbyT votfve tablets deposited in the temple of ^sculapius but upon which he so farimproved as to be entitled to the merit of an inventor. The second pont on which I shall remark, was his method of endeavouring to remove particular svmptoms by carefully noticing what have been termed the juvanlia and the laden- tia watching the effect of his applications, and proceeding, by a cautious analogy, from individual facts to more general conclusions ; and hence deducing his indica- tions of cure from the operations of remedies, not from any preconceived or abstract principles, which were generally either fallacious or inapplicable. Hence his practice may be characterized as consisting in what has been termed a rational empiricism, where we first ascertain the fact, and afterward reason upon its consequences. In speaking of the writings of Hippocrates, it may be proper to remark, that the most complete edition of them, in all respects, is that of Fcesius, in which every circumstance is attended to that can illustrate them or render them more easily intelligible. He has given a list of all the commentaries and criticisms that had been written upon them, which, at the time of his publication, in the year 1595, would of themselves have formed an extensive library. It appears from this list that no less than one hundred and thirty-seven authors had published on the sub- ject of the aphorisms alone. It was remarked above that many of the writings which are commonly ascribed to Hippocrates, or at least are published in the col- lection of his works, are supposed not to have been his genuine productions; and hence it has been an object of interest with many eminent critics to distinguish the one from the other. It will not be necessary for me to enter into these discussions in this place; I shall only remark, that the number of treatises which are admitted to be certainly genuine is very small, compared to the whole number popularly ascribed to him. Of those which are printed in the ordinary editions of his works, which amount to more than sixty, Mercurialis, Haller, Gruner, and other critics, eonceive that there are a few only which were actually written by Hippocrates, and Ackermann has even reduced the number of the genuine works to ten.* In ascertaining what were the real opinions and practices of Hippocrates, besides the difficulty of discriminating the genuine from the spurious productions, we have a further difficulty arising from the peculiarity of his style. This is admitted to be brief and abrupt, and to be full of ideas, compared with the number of words employed to convey them; so that it appeared somewhat obscure even to his con- temporaries and immediate successors. Erotianus, who lived in the first century of the Christian era, thought it necessary to write a glossary for the express pur- pose of elucidating his phraseology; and the immense number of commentaries which have appeared, and which continued to be published until the commencement of the eighteenth century, must be regarded, not only as a tribute to his extraordi- nary merit, but, in some measure, as an indirect censure of his style. But after making all due allowance for these peculiarities, after rejecting all the doubtful works and obscure passages, and resting more upon the general scope and tendency of the treatises than on particular words and phrases, we have sufficient evidence left us of the nature of his principles, both as regards theory and practice. Although it is principally in the latter capacity that we are now to regard Hippocrates, yet it will be proper to make a few remarks upon his acquirements in the analogous departments of science. With respect to his philosophical tenets, it appears that the father of medicine must be classed generally among the Pythagoreans, and in the particular sect or school of Herachtus. The leading doctrine of this philosopher was, that fire is the prime origin of all matter, and that by the collision and peculiar combination of its particles, which are in perpetual motion, the four elements are produced-! From HiJpSfi" C& Anale^No! T iJ£fib^iffi P^^TOi^S^ °PTB A BMotheca Med. Prac. lib. i. v 17-2.. W Diet.' ^V^^^^^S^ Fwk^CaP' ' *' Blumenbach'Introd- v- 34. Goulin, Enc. Meth. Medecine," Hippocrate." + Enfield, b. 2, c. 14, v. 1, p. 436 et 6eq. HISTORY OF MEDICINE. XIX this doctrine Hippocrates derived his leading principles of pathology; it lies at the foundation of all his medical hypotheses, and is brought forward in various parts of his works. But although, like all his contemporaries, and indeed nearly all his successors up to the present day, he assumed certain theoretical principles; yet, as we remarked above, he had the extraordinary sagacity to perceive the necessity of detaching medicine from what was then styled philosophy. He professed to examine the phenomena of disease in the first instance, to ascertain what were the natural powers and properties of the animal frame, how far these were affected by external circumstances and by morbid causes, and hence to derive his curative indi- cations and his mode of treatment. It is in the writings of Hippocrates that we observe the first traces of what is properly styled physiology, i. e. an account of the functions and powers of the living body. Although some of his opinions were derived from the school of Pythagoras, and savour of its mysticism and obscurity, yet others appear to have been original, and founded upon a much more correct and philosophical view of the subject. We owe to him the invention of the hypothesis of a principle, to which he gives the appellation of nature { P" 79 « a^i. Sprengel, t. i. HISTORY OF MEDICINE. xxui great advances in the knowledge of nature; he was peculiarly well situated for the acquisition of new information on all subjects connected with natural history, and he diligently availed himself of his advantages. He was the first writer who pub- lished any regular treatises on comparative anatomy and physiology, and his works on these subjects may be still read with much interest after all the additions which have been made to them by the moderns.* But notwithstanding all these favour- able circumstances, it may be questioned whether the influence of Aristotle has not been ultimately somewhat unfavourable to the progress of knowledge. With his valuable facts and observations he mixed up a large portion of recondite and refined speculations, so that it is frequently not easy to separate the one from the other; and so great was the ascendancy which this genius acquired over the minds of men for many centuries after his death, that all his opinions, the most unfounded as well as the most philosophical, were indiscriminately received as established truths, which no one ventured to oppose or to controvert, f The next circumstance which we are called upon to notice in the history of medicine is the establishment of the school of Alexandria. This was effected by the munificence of the Ptolemies, who, about three hundred years before the Christian era, laid the foundation of the celebrated Alexandrian library and of the school of philosophy which is graced by so many illustrious names. The science of medicine was cultivated in this school with peculiar assiduity, and we owe some very essential improvements to its professors. Among the most famous of these are Erasistratus and Herophilus. We have not much accurate information respect- ing the personal history of these two individuals, nor have any of their works been transmitted to us; but we have a detailed account of their opinions and practice given us by Galen, Ccelius Aurelianus, and others, so as to enable us to form a tolerably correct estimate of their merits. They are particularly mentioned as being the first who dissected the human subject, for which purpose the bodies of criminals were allotted to them by the government; and it appears that they amply profited by the advantage which was thus given them, so as very considerably to advance our knowledge of the structure of the body, especially by pointing out those circumstances in which the human subject differed from that of the animals who most nearly resembled it, and in correcting the errors on this point into which their predecessors had fallen. Nearly every part of the great system of which the body is composed profited by their labours: they ascertained with much more correctness than had been previously done the structure of the heart and great vessels, and of the brain and nerves, and they even seem to have had some imper- fect knowledge of the absorbents. We are informed that Erasistratus was the pupil of Chrysippus, and that he imbibed from him his prejudice against bleeding and against the use of active remedies, trusting more to the operation of diet or the natural efforts of the system: hence we are to regard him as having improved the practice of medicine only indirectly by the addition which he made to our knowledge of anatomy.J The anatomical fame of Herophilus is so intimately blended with that of Erasistratus that we are unable to assign to each his respective share of merit; but it would appear that the former was more correct and more skilful in the practical department. Of this we have one proof in the fact which is stated by Galen, that Herophilus was one of the first who paid very minute attention to the varieties of the pulse; and his name is handed down to us by the ancients as entitled to the highest respect, both from his character and his acquirements.Y An important circumstance in the history of medicine, and more especially in that department to which our attention is particularly directed, occurred soon after the establishment of the Alexandrian school, viz. the division into distinct profes- sions, which were exercised by different individuals. Previously to this period the practice of what is more especially styled medicine and of surgery was exercised by the same person; the iarpos of the Greeks corresponding nearly to what we * Douglas, Bibliogr. Anat. p. 9-11. t Le Clerc, par. i. liv. ii. ch. 4. Schulz, p: ii. cap. 1, y. 2 et seq. Stanley, part vi. passim. Sprengel, $. 4, cap. 2. X Le Clerc, par. ii. liv. i. ch. 2-4. Schulz, p. ii. cap. 3, y. 35-66. Sprengel, t. i. p. 439 et seq. Lauth, p. 140, 1. y Le Clerc, par. ii. liv. i. ch. 6. Schulz, p. ii. cap. 3, y. 2-34. Sprengel, t. i. p. 433 et seq. Lauth, p. 139, 140.—For an account of the Alexandrian school generally, see Sprengel, sect. 4, ch. 3; and Lauth, liv. iv. XXIV HISTORY OF MEDICINE. should now term the general practitioner. But about this time the separation into the departments of dietetics, pharmacy, and surgery commenced, and was gradually admitted into all succeeding schools or sects. The terms did not, however, possess precisely the same signification as in modern times. Dietetics comprehended not the regulation of the diet alone, but every circumstance connected with the general health or management of the patient, and corresponded very nearly to the " medi- cus" or physician of modern times. The second included not merely the depart- ment of the apothecary or the compounder of drugs, but the performance of many of the operations of surgery; while to the third was allotted the treatment of sur- gical diseases, many of the operations, however, being committed to the professors of the second branch. That this separation eventually tended to the improvement of the respective branches of the profession will scarcely be doubted, although it must at the same time be acknowledged that many of the distinctions which were introduced were frivolous and invidious, and are now rapidly yielding to the supe- rior intelligence of modern times.* It was about this period, i. e. shortly after the establishment of the Alexandrian school, that the great schism, to which we have so often alluded, took place. It was occasioned by the formation of the rival sects of the Dogmatists and the Empirics. Neither of these terms, in the first instance, bore exactly the same meaning which they convey to a modern ear. The controversy really consisted in the question, how far we are to suffer theory to influence our practice. While the Dogmatists, or, as they were sometimes styled, the Rationalists, asserted that before attempting to treat any disease we ought to make ourselves fully acquainted with the nature and functions of the part which is affected, or rather of the body generally, with the operation of medical agents upon it, and with the changes which it undergoes when under the operation of any morbid cause; the Empirics, on the contrary, contended that this knowledge is impossible to be obtained, and, if possible, is not necessary ;—that the minute and internal changes of the system, and of its different parts, are beyond the reach of our most acute observation, that it is alone essential to watch the phenomena of disease, and to discover what remedies are best fitted to relieve the morbid symptoms;—that our sole guide must be experience; and that, if we step beyond this, either as derived from our own experience or observation, or that of others on whose testimony we can rely, we are always liable to fall into dangerous and often fatal errors. We may remark that this controversy, like so many others which have occupied the attention of mankind for a succession of ages, is partly verbal, and in so far as it is not verbal, that it is a question of degree. The boldest Dogmatist professes to build his theory upon facts, and the strictest Empiric cannot combine his facts without some aid from theory. The uniform experience of all the schools and sects from the days of Hippocrates to the present time, demonstrates that the undue extension of either of these systems is injurious, that they both originate from a partial view of the subject, and may generally be traced to some defect either in the acquired information or natural disposition of the practitioner. The controversy, however, forms so prominent a feature in the history of medicine, that it will be necessary to advert to it very frequently in the following pages; and we shall find that in estimating the value of the various opinions or modes of practice which will successively pass under our review, it will in most cases be necessary to inquire from which of these sects they emanated.! Respecting the individuals to whom the origin of these sects should be referred, there is some degree of obscurity: the Dogmatists generally claim Hippocrates for their founder, and it is certain that he investigated with great care the functions of the animal body, the action of morbid causes upon it, and the operation of remedies, or, as we should style them, the general principles of pathology and therapeutics. But while in this respect he acted upon the principles of the Dog- matists, he was no less remarkable for the accuracy with which he observed the phenomena of disease, and the actual operation of remedies upon individual cases or even upon particular symptoms; and it maybe affirmed, that in most instances' when his preconceived hypothesis seemed to be in contradiction to the results of his experience, he wisely followed the latter. We may, however, easily imagine Mld2inT'"Ub'*" F f" SchUlZ' P' "• C3P- 5- Le °lerC' Par' L Hv- "■ ch' 9" El°y< " PartaSe de la ptlZ'X^lTS-Z1 the argUmentS empl°yed m *» co^ersy, the reader is referred to HISTORY OF MEDICINE. XXV that his successors, not being possessed of his sagacity and industry, would prefer the easier method of indiscriminately adopting all his principles and speculations, to the more arduous task of correcting or extending them by their own observa- tion, and that they would in this way bring all theoretical reasoning into disrepute. It is more probable that this feeling would be gradually induced in the minds of practitioners, than that it would be at once announced by any single individual; and as a matter of historical fact, the ancients themselves were divided in their opinion as to the person to whom they should ascribe the origin of the empirical sect. Pliny attributes it to Acron, a physician of Sicily,* who was contemporary, if not prior to Hippocrates ; while Celsus states that Serapion of Alexandria, who was said to be a pupil of Herophilus, was the first who distinctly professed the opinion that theory is to be totally discarded in medicine, and that direct experience should be our sole guide.f We have little correct information respecting either the history or the practice of Serapion; none of his writings have been transmitted to us, but from the scattered notices which we meet with concerning him, dispersed through the works of the ancients, it may be conjectured that he was a man of considerable acuteness and sagacity, and that he generally adopted the practice of Hippocrates and his school, although he discarded their theory. J All the medical men of the period at which we are now arrived, and for some centuries subsequent to it, were attached to one or other of these rival sectSj and, it would appear, in nearly an equal proportion. Unfortunately, however, for the Empirics, it has happened that all their writings have perished, so that we are obliged to form our opinion of their merits principally from the representation of their antagonists. There is, indeed, one happy exception in the works of Celsus, who, in the commencement of his treatise, has given an account of the leading opinions of the two opposing sects, in so candid and judicious a manner as almost to supersede any more elaborate discussion. It has been thought by many that the view which Celsus gives of the controversy is too favourable to the Empirics; and we admit that we can scarcely read his account without being impressed with the opinion, that he advocates their side of the question. Yet the conclusion which he draws is perfectly candid, and is, indeed, not very remote from what the most enlightened practitioner would form at the present day;—that the perfect rule of practice is derived from a due combination of reason and expe- rience ; that without experience all preconceived theory would be vain and use- less; and that by simple experience, without any attempt at generalization, we should frequently fall into gross errors, and be unable to profit even by the very experience which is so much extolled. And, indeed, whatever may have been the professed plan of the supporters of the two sects, we shall always find that the practice of the most eminent of either party actually proceeded upon a judi- cious combination of the two systems ; and we are now persuaded that it is upon such a combination that all further improvements of the science and practice of medicine must essentially depend.^ * Lib. xxix. cap. 1. t In praef. sub initio. X Schulz, per. ii. cap. iv. $. 8 et seq. J § Galen, de Subfigurat. Empir. et alibi. Celsus, in praef. Barchusen, Diss. nos. 10 & 13. Le Clerc, par. ii. liv. ii. Schulz, per. ii. cap. iv. Sprengel, y. 4. ch. 1, 4. Ackermann, p. iii. cap. 10-13. D XXVI HISTORY OF MEDICINE. CHAPTER IV. On the State of Medicine among the Romans from its first Introduction into Rome until the Time of Galen—Roman Superstitions—Archagathus—Cato—Asclepiades—Themison—Origin of the Me- thodic Sect—Thessalus—Soranus—C. Aurelianus—Doctrines of the Methodics—Pneumatics and Eclectics—Aretaeus—Archigenes—Celsus, his Doctrines and Practice--Condition of Physicians in Rome—Pliny—Dioscorides.* For some centuries the school of Alexandria produced a succession of learned men, not only in medicine but in the other sciences, and contributed to the advancement of knowledge, or at least prevented the decay into which it was in danger of falling after the decline of the Grecian literature. It was during this period that the foundation was laid of the future grandeur of the Roman empire; but from the attention of this people being almost exclusively directed to warlike affairs, and perhaps also from other causes, science of all kinds, and medicine among the rest, was for a long time almost totally neglected. Rome had extended her empire far beyond the limits of Italy, and had subdued most of her rivals, before she condescended even to tolerate the pursuit of the arts and sciences. We are expressly told by Pliny, that for six hundred years she was without phy- sicians. We cannot conceive it possible that during this long period no attempts were made to remove diseases ; we can only understand by it that there were no individuals eminent for their knowledge or skill who were engaged in the profes- sion, or perhaps that it was scarcely regarded as the object of distinct pursuit, or that individuals were not especially trained to the exercise of it. We have, indeed, abundant evidence of two circumstances; that in this, as in every other subject connected with the arts of life, the Romans servilely copied from the Greeks,f and that, as far as their medicine was concerned, wherever they deviated from them it was for the purpose of adopting various superstitious rites and cere- monies, indicating the most profound ignorance and the grossest superstition. Nu- merous instances of this kind are incidentally mentioned by Livy; and although he wrote in the refined age and splendid court of Augustus, they are introduced in the thread of his narrative as actual transactions, without any observation indicative of his disbelief of their efficacy.J One of these is the account which he gives us of the introduction of the worship of ^Esculapius into Rome. Inconsequence of a fatal epidemic, the senate had recourse to the usual expedient of consulting the Sibylline books, where it was found to be enjoined upon them to transfer the wor- ship of the god from Greece to their city. A formal deputation was accordingly despatched for the purpose, by whom the deity, unwilling to leave his native place, was seized by a stratagem, and was conveyed under the form of a serpent into Italy. He was received by the people of Rome with unbounded transport; a temple was erected to him on an island in the Tiber; the usual appendages of priests, with all their ceremonies, were appointed; and the plague was of course suspended.^ Pliny further informs us that medicine was introduced into Rome at a later period than most of the other arts and sciences ; that the practice of it had even been expressly prohibited by the citizens, and its professors banished. The * For a concise, and at the same'time a comprehensive, view of this period of the history of medi- cine, the reader is referred to the fifth section of Blumenbach's Introduction. I may further remark that this work may be consulted with advantage, in connection with almost all the names that pass in succession under our review. v t Suetonius, de Grammal. sub initio ; the fact is admitted by Cicero and by Pliny and is fieauentlv alluded to in various parts of their writings. X The following references may be selected among many others of a similar kind -—Book i ch 31 Tullus consults the Sibylline books in order to stop the plague ;—iv. 25, for the same purpose a tern' pie is erected to,Apollo ;_v. 13, the books were again consulted;—vii. 2, a lectisternium was ordered tor the same purpose, and afterward the public games ;—vii. 3, the plague was stopped bv the dicta tor driving a nail. rr ' 6 Lhius, lib. 1. cap. 47, et epitome ad lib. xi Vol Maximus, lib. i. cap. 8. 6. 2. Schulz, p. ii. cap. 6. y. 1 et seq. Montfaucon, Anciq. Suppl. v. 1. b. v. ch. 1. Lucianus, Tooke's Trans, v. i. p. 635, note. HISTORY OF MEDICINE. xxvii account which he gives of so singular an occurrence is, that about two hundred years before Christ, Archagathus, a Peloponnesian, settled at Rome as a practi- tioner of medicine, and, as it may be inferred, was the first person who made it a distinct profession. He was received in the first instance with great respect, and was even maintained at the public expense ; but his practice was observed to be so severe and unsuccessful, that he soon excited the dislike of the people at large, and produced a complete disgust to the profession generally, which led to the transaction mentioned above.* His practice seems to have been almost exclu- sively surgical, and to have consisted, in a great measure, in the use of the knife and of powerful caustic applications. We hear little more of the state of medi- cine in Rome for the next century ; but from certain incidental observations we may infer that it remained principally in the hands of the priests, and consisted as before in superstitious rites and ceremonies. It appears, indeed, that the few in- dividuals who devoted themselves to the cultivation of natural science, among other subjects directed their attention to medicine ; and it is particularly stated that Cato introduced various articles into the materia medica, and wrote several treatises on medical topics. We are not able to form any just conception of their merit from the account which is given of them ; but it is worthy of remark that he was a professed opponent to Grecian literature in general, and we may there- fore conclude, would not avail himself of the improvements that had been made by the Greek physicians.f We may presume that the prejudice which was excited against Archagathus would be gradually allayed, and that the improvement of the Romans in intellec- tual cultivation, although not considerable, would be at least sufficient to make them sensible of the necessity of attempting something beyond the mere power of charms and incantations for the removal of disease. Accordingly, about a century before the Christian era, we find that another individual had acquired a very considerable degree of popularity at Rome, which he maintained through life, and in a certain degree transmitted to his successors,—Asclepiades of Bithynia. It is said that he first came to Rome as a teacher of rhetoric, and that it was in consequence of his not being successful in his profession that he turned his atten- tion to the study of medicine. From what we learn of his history and of his practice, it would appear that he may be fairly characterized as a man of natural talents, acquainted with human nature, or rather with human weakness, and pos- sessed of considerable shrewdness and address, but with little science or profes- sional skill. He began upon the plan which is so generally found successful by those who are conscious of their own ignorance, of vilifying the principles and prac- tice of his predecessors, and of asserting that he had discovered a more compendious and effective mode of treating diseases than had been before known to the world. As he was ignorant of anatomy and pathology, he decried the labours of those who sought to investigate the structure of the body, or to watch the phenomena of dis- ease, and he is said to have directed his attacks more particularly against the writings of Hippocrates. It appears, however, that he had the discretion to re- frain from the use of very active and powerful remedies, and to trust principally to the efficacy of diet, exercise, bathing, and other circumstances of this nature. A part of the great popularity which he enjoyed depended upon his prescribing the liberal use of wine to his patients, and upon his attending in all cases, with great assiduity, not only to every thing which contributed to their comfort, but that he flattered their prejudices and indulged their inclinations. By the due application of these means, and from the state of the people among whom he practised, we may, without much difficulty, account for the great eminence to which he arrived, and we cannot fail to recognise in Asclepiades the prototype of more than one popular physician of modern times. Justice, however, obliges us to admit that he seems to have been possessed of a considerable share of acuteness and discernment, which on some occasions he employed with advantage. It is said that to him we are indebted, in the first in- stance, for the arrangement of diseases into the two great classes of acute and chronic, a division which has a real foundation in nature, and which still forms an important feature in the most improved modern nosology. In his philosophical prin- ciples Asclepiades is said to have been a follower of Epicurus, and to have adopted * Lib. xxix. cap. 1. t Le Clerc, par. ii. liv. iii. ch. 1. Schulz, p. ii. cap. 6. Ackermann, p. iv. cap. 15. xxviii HISTORY OF MEDICINE. his doctrine of atoms and pores, on which he attempted to build a new theory of disease, by supposing that all morbid action might be reduced into obstruction of the pores and irregular distribution of the atoms. This theory he accommo- dated to his division of diseases,—the acute being supposed to depend essentially upon a constriction of the pores, or an obstruction of them by a superfluity of atoms; the chronic, upon a relaxation of the pores or a deficiency of the atoms.* Asclepiades was succeeded in his professional reputation by his pupil Themison of Laodicea, who had the honour of founding a new sect in medicine, which for some time almost eclipsed the former rivals; this was the Methodic sect. The great object of Themison seems to have been to adopt a middle course be- tween the Dogmatists and the Empirics, and to take advantage of the excellences of each of them. He was, however, strongly impressed with the great prin- ciples of Asclepiades, the importance of reducing the science to a few gene- ral laws, which by their simplicity might be universally intelligible and of easy application. He therefore rejected all the abstruse and recondite speculations of the Dogmatists, and substituted in their place a few positions derived from the tenets of his master, and founded upon the Epicurean doctrines. He remarks that it is an essential part of the business of the practitioner to make himself ac- quainted with the nature of the human frame, with its laws while in the state of health, and with the changes which they experience from disease. All these he referred to the respective states of constriction and relaxation, and to the undue preponderance of one of them over the other. To these two, however, he added a third, or mixed state, as he styled it, the nature of which is not very easy to under- stand ; while by classing all medical agents under the two great divisions of astrin- gents and relaxants, we learn how to apply the appropriate remedy for every disease. Themison's doctrine must be regarded as a refinement, and certainly an im- provement of that of Asclepiades ; for although we have the states of constriction and relaxation professedly copied from his master, it is disencumbered of the more objectionable speculation of the atoms and pores. The theory of the Methodics contemplates the solids as the seat and cause of disease, in which respect it is directly opposed to that of Hippocrates, who traced the primary cause of disease to an affection of the fluids, giving rise to what has been termed the Humoral Pa- thology. The humoral pathology was zealously defended by Galen, and was uni- versally adopted by his successors until the seventeenth century, when the oppo- site doctrine of Solidism was revived, and has been gaining ground until the present day. It has been justly objected to Themison's theory, that even if we admit the correctness of his views respecting the states of constriction and relax- ation- of the system, there is a palpable absurdity in supposing that they can be co-existent in what he terms his middle state, as they are directly opposed to each other. There is no work of Themison's extant, but we have an ample account of his practice in the writings of Caelius Aurelianus, who was a zealous defender of the tenets of the Methodic sect. They appear to have been diligent in the observa- tion of the phenomena of disease, and sagacious in their employment of remedies : they seem, indeed, to have sustained their character, of keeping a middle course between the Dogmatists and Empirics, avoiding the extremes of either, and com- bining the more useful parts of each system in a greater degree than had been done by their predecessors.! For some time after the death of Themison the opinions of the Methodics were generally adopted in Rome, and almost superseded those of the professed Dog- matists and Empirics, so that we shall have little to detain us in our progress, ex- cept to notice certain individuals who became remarkable from their personal his- tory or character, or from some peculiarity in their opinions or practice. The first of this description in point of time is Thessalus, who lived about half a centurv after Themison, and who ranks as one of his followers. He was, however an individual very different, both in character and in acquirements, from his master He is stated to have been of mean birth and of defective education, but, by cun- * Plinius, passim. Celsus, ubi supra et alibi. Le Clerc, par. ii. liv. iii. ch. 4-9 Svrenrel n.*. r. Another writer who lived about the same time with Pliny, and who, although less distinguished for general science, holds a conspicuous rank among the medi- cal authors of this period, is Dioscorides. The same obscurity hangs over every thing which regards the personal history of Dioscorides, as over that of so many individuals to whom we have had occasion to refer. It is generally supposed that he was a native of Asia Minor, and that he was a physician by profession. It appears pretty evident that he lived in the second century of the Christian era, and as he is not mentioned by Pliny, it has been supposed that he was a little posterior to him. The exact age of Dioscorides has, however, been a question of much critical discussion, and we have nothing but conjecture which can lead us to decide upon it. He has left behind him a treatise on the materia medica, a work of great labour and research, and which, for many ages, was received as a stan- dard production. The greater correctness of modern science, and the new dis- coveries which have been made, cause it now to be regarded rather as a work of curiosity than of absolute utility; but in drawing up a history of the state and progress of medicine, it affords a most valuable document for our information. His treatise consists of a description of all the articles then used in medicine, with an account of their supposed virtues. The descriptions are brief, and not unfre- quently so little characterized, as not to enable us to ascertain with any degree of accuracy to what they refer, while to the practical part of his work the same remark nearly applies, that was made above with respect to Pliny, that it is, in a great measure, empirical, although his general principles, as far as they can be detected, appear to be those of the Dogmatic sect. The great importance which was, for so long a period, attached to the works of Dioscorides has rendered them the subject of almost innumerable commentaries and criticisms, and even some of the most learned of our modern naturalists have not thought it an un- worthy task to attempt the illustration of his Materia Medica. Upon the whole, we must attribute to him the merit of great industry and patient research, and it seems but just to ascribe a large portion of the errors and inaccuracies into which he has fallen, more to the imperfect state of science when he wrote than to any defect in the character and talents of the writer.* CHAPTER V. Account of the opinions and practice of Galen—His history and education—Remarks on his charac ter and writings—His physiology, anatomy, pathology, and practice. The course of our narrative brings us to one of those extraordinary characters who are destined to form an era in the history of science, both from the actual improvements which they have introduced into it, and from the ascendency which their genius enabled them to acquire over the minds of their contemporaries Of these, one of the most remarkable that ever appeared, either in ancient or in modern times, is Galen. Galen enjoyed, both from birth and from education, every natund and acquired advantage ; his father was a man of rank, and his education appears to have been conducted upon the most liberal and judicious plan. He stEd philosophy m the various schools that were then in the highest estimation La with out exclusively attaching himself to any one of them, he is said to have tlken from each what he conceived to be the most important parts of their systems wkh the exception of the.Epicurean, the tenets of which he entirely refected H« professional studies were conducted upon an equally extensive plan;he attended * Le Clerc, par. iii. liv. ii.ch.2. Eloy,in loco, where we have an account of HiPvari™.^;,- ments, translations, &c Sprengel, t. li. p. 58-64. Ackermann p 4 can 1Q TtT £ ?dl'10ns>co™' 79-87. Goulin, Encyc. Metal M^decine,^ Dioscoride." DT&itrZarf, B£g' ft-S^E^ ' * HISTORY OF MEDICINE. XXXV the various schools and travelled through different countries for the express pur- pose of acquiring information; but it may be presumed that his knowledge of medicine was principally acquired in Alexandria, which still retained its character as the great depository of medical science. After passing a few years at his na- tive city of Pergamus, spending some time at Rome, and again at Pergamus, he finally returned to Rome, in consequence of the express request of the Emperor Aurelius, and made that city his residence for the remainder of his life. The works which Galen left behind him are very numerous, amounting in the whole to about two hundred distinct treatises; they are all on subjects directly or indirectly connected with medicine, and exhibit a great extent of knowledge on the subjects of which he treats, and a degree of information, as far as we can judge, greater than that of any of his contemporaries. He appears also to have been a man of a superior mind and of a very decided character; confident in his own powers, and paying but little attention to the opinions of others. Hence he may be accused of arrogance and want of candour, and he can only be defended upon the principle that he was so far in advance of his contemporaries, as to be fully convinced of the futility of their reasoning and the deficiency of their information. The result was, that he gained that superiority over his contemporaries which he assumed, and actually acquired a sway over public opinion, on all points connected with medicine, which has never been obtained by any individual either before or since his time. The rank which Galen held in the medical world has been compared not unaptly to that which Aristotle possessed in the world of general science. For centu- ries after his death his doctrines and tenets were regarded almost in the light of oracles, which few persons had the courage to oppose ; and all the improvements in medicine which were even contemplated, consisted of little more than illustra- tions of his doctrines or commentaries on his writings. In numberless instances it was deemed a sufficient argument, not merely against an hypothesis, but even against an alleged matter of fact, that it was contrary to the opinion of Galen; and it may be stated without exaggeration, that the authority of Galen alone was esti- mated at a much higher rate than that of all the medical writers combined, who flourished during a period of more than twelve centuries. Although such a brilliant reputation might, in some measure, depend upon acci- dental circumstances, and upon the mere personal character of the individual, we may fairly presume that there must have been a foundation of a more solid nature: and upon an actual survey of the writings of Galen, we shall find ample reason to conclude that he was a man of great talents and of very extensive acquire- ments. In his general principles he may be considered as belonging to the Dog- matic sect, for his method was to reduce all his knowledge, as acquired by the ob- servation of facts, to general theoretical principles. These principles he indeed professed to deduce from experience and observation, and we have abundant proofs of his diligence in collecting experience, and his accuracy in making observations. But still, in a certain sense at least, he regards individual facts and the detail of experience as of little value, unconnected with the principles which he laid down as the basis of all medical reasoning. In this fundamental point, therefore, the method pursued by Galen appears to have been directly the reverse of that which we now consider the correct method of scientific investigation ; and yet, such is the force of natural genius, that, in most instances, he attained the ultimate object in view, although by an indirect path. He was an admirer of Hippocrates, and al- ways speaks of him with the most profound respect, professing to act upon his principles, and to do little more than to expound his doctrines, and support them by new facts and observations. Yet in reality we have few writers whose works, both as to substance and manner, are more different from each other than those of Hippocrates and Galen, the simplicity of the former being strongly contrasted with the abstruseness and refinement of the latter. Those of his works which are the most truly valuable, and in which he actually rendered the greatest service to sci- ence are his treatises on physiology. The knowledge which he possessed on this subject was much more considerable than that of any of his contemporaries : in all that regards the operations of the animal economy he was much better acquainted with the facts, and much more ingenious in the application of them. He appears to have been well practised in anatomy, and especially in what may be termed patho- logical anatomy he far surpassed any of the ancients. His knowledge of particular structures was, in many respects, correct, and in his mode of classifying them he made no inconsiderable approach to the philosophical views which have been taken xxxvi HISTORY OF MEDICINE. of them by the anatomists of the present day. It appears upon the whole probable that he was not in the-habit of dissecting the human subject, and, indeed, this may be fairly inferred from his own remarks; but there is reason to suppose that he omitted no opportunity of examining the structure of those animals which the most nearly resemble it, and that from them he has drawn up his descriptions. Considering this radical defect, it must be admitted that they possess great merit, and we may justly express our surprise at the few points in which they betray the imperfection of their origin.* The pathology of Galen was much more imperfect than his physiology, for in this department he was left to follow the bent of his speculative genius almost without control. He adopts, as the foundation of his theory, the doctrine of the four elements, and like Hippocrates, he supposes that the fluids are the primary seat of disease. But in his application of this doctrine he introduced so many minute subdivisions and so much refined speculation, that he may be almost regarded as the inventor of the theory of the Humoralists, which was so generally adopted in the schools of medicine, and which, for so long a period, entirely en- grossed their attention. The four elements, the four humours, and the four quali- ties, connected in all the variety of combinations, presented a specious appearance of method and arrangement, which took such firm possession of the mind as to pre- clude all inquiry into the validity of the foundation, and to present us with one of the most remarkable examples of the complete prostration of the understanding in a physical science, where facts were daily obtruding themselves upon our observa- tion, but were either unnoticed or totally disregarded. The practice of Galen in its general character appears to have been similar to his pathology, and, indeed, to have been strictly deduced from it. His indications were in exact conformity to his theory, and the operation of medicines was reduced to their power of correcting the morbid states of the fluids, as depending upon their four primary qualities or the various modifications of them. Many parts of his writings prove that he was a diligent observer of the phenomena of disease, and he possessed an acuteness of mind which well adapted him for seizing the most prominent features of a case, and tracing out the origin of the morbid affec- tion. But his predilection for theory too frequently warped and biassed his judg- ment, so that he appears more anxious to reconcile his practice to his hypothesis than to his facts, and bestows much more labour on subtle and refined reasoning, than on the investigation of morbid actions, or the generalization of his actual experience. The number of treatises which Galen left behind him is very considerable, amounting to nearly two hundred separate works, embracing every department of medical science. His style is generally elegant, but diffuse, and, as may be im- agined from the multiplicity of his works, he frequently repeats and copies from himself. Considered under the two classes of anatomy and physiology, and of pathology and practice, the following may, perhaps, be selected as the most valu- able, both with respect to the absolute addition which they made to the previous stock of knowledge, and as to the reasoning employed in them. Under the first head we may select the treatise " On the Use of the Parts of the Body," in seven- teen books, in which he describes the structure of the different organs, and as- signs to each of them its use. This is a work of great anatomical research and physiological ingenuity, which contains many facts that were probably the result of his own investigation, and exhibits a very favourable specimen of his reasoning powers, when not too much under the influence of preconceived hypothesis. The same kind of merit, although less in degree, may be assigned to the treatise " On the Motion of the Muscles," and also to that " On the Formation of the Foetus " making due allowance for the greater difficulty and obscurity of the subject. Among the works of the second class the treatise '• On Temperaments" has been greatly and justly celebrated, as well as that " On the Seat of Disease " while that "On the Varieties-of the Pulse" affords a happy illustration of his peculiar turn of mind, of his acuteness and originality, and, at the same time, of his devoted attachment to hypothesis. The two works, " On the Differences and the Causes of Diseases," and " The Method of Cure," are more especially interesting, as contain mg the most detailed view of his peculiar doctrines of the humoral pathology of the indications of cure which he laid down, and the methods which he adopted for their accomplishment. These two latter works exhibit a very complete view of the * Douglas, Bibliog. p. 18-22. HISTORY OF MEDICINE. xxxvii practice of Galen and of that of his contemporaries, and enable us to form a cor- rect opinion of the state of the science when he entered upon the study of it, and of the additions which he made to it. To attempt an analysis of the works them- selves, or of the details of Galen's practice, would carry me far beyond the limits of this treatise, and, indeed, it would be principally as a question of literary cu- riosity that such an examination could be sustained. Their general character may be understood from what has been stated above, and I fully coincide in the remark of a learned and impartial critic, the late Dr. Aikin, who, after giving full credit to Galen for talent and acquirements, thus concludes:—" His own mass and modern improvements have now in great measure consigned his writings to neglect, but his fame can only perish with the science itself." The remark which was formerly made with respect to Hippocrates applies equally to Galen, that the great superi- ority which he acquired over his contemporaries appeared to repress all attempts at further improvement.* CHAPTER VI. An account of the successors of Galen—Decline of medical science—Sextus Empiricus—Oribasras —Aetius—Alexander Trallianus—Paulus Eginetus—Account of the state of Medicine among the Arabians—Conquests of the Arabians—Their patronage of science—Invention of Chymistry—Ah- run—Serapion—Alkhendi—Rhazes—Ali-Abbas—Avicenna—Mesue—Albucasis—Avenzoar—Aver- roes—Estimate of the merits of the Arabic school. In investigating the state of medicine during the middle ages, it is apparent that mankind seemed to be satisfied with the progress which had been made in the science, or were conscious of their inability to surpass the limits which had been assigned to it; and the result was, that for some time after the death of Galen we have few illustrious names to celebrate, and no discoveries to record. Literature in general was now, indeed, rapidly declining, and various causes, both moral and politi- cal, were coming into operation, which suspended the progress of science and learn- ing for many centuries, and produced what are justly and emphatically denominated the dark ages. Into these causes it is not our business to inquire ; it may be suffi- cient to remark that they were of so universal a nature as to operate on the human mind generally, and therefore to affect every intellectual pursuit. Medicine, among others, felt their paralyzing influence, although, from certain incidental circum- stances to be hereafter noticed, it was not allowed to remain so completely station- ary as most of the other branches of science. About the period when Galen flourished, the Roman empire began to exhibit very decided symptoms of that decline, which, proceeding with more or less rapidity, was never altogether suspended, until it terminated in complete destruc- tion. Even in the most splendid state of Rome, the cultivation of science was very limited, and we have had occasion to remark that almost all the physicians who acquired any considerable degree of celebrity were natives of Greece or Asia, and wrote in the Greek language. This was the case with Galen himself and with the few individuals who succeeded him, whose names are of sufficient importance to be introduced into this sketch. The medical writers of the third and fourth centuries have been characterized by Sprengel as " frigid compilers, or blind empirics, or feeble imitators of the physician of Pergamus."f The only exception to this remark is Sextus Empiricus, who appears to have been a contemporary of Galen, and probably derived his appellation from the sect * Conring, Introd. cap. 3. y. 16; cap. 4. y. 17, et alibi. Le Clerc, par. iii. liv.iii. ch. 1-8, contains a very ample account of all that regards the writings and opinions of Galen. At this period we lose the fur- ther aid of this candid and judicious historian of medicine. Barchusen, diss. no. 16. Nouv. Diet. Hist. " Galien." Holler, Bib. Med. lib. i. y. 80, 1. Lauth, liv. v. par. 1. Sprengel, sect. 5. ch. 6. Acker- mann, cap. 21,2. Blumenbach, Introd. sect. 75. Goulin, Encyc. Meth. Medecine, " Galien." RenauU din, Biog. Univ. " Galien." t T. ii. p. 170. xxxviii HISTORY OF MEDICINE. to which he attached himself, as there are some treatises of his still extant, m which he attacks the principles of the Dogmatists with considerable acuteness. We may conclude from his works that he was a man of learning and talents, well versed in the principles of the philosophers, and familiar with all the branches of literature and science which were cultivated in his time.* He is, however, the last medical writer to whom the character of Sprengel does not strictly apply. Oribasius, who lived in the fourth century, Aetius in the fifth, Alexander Trallianus in the sixth, and his contemporary Paulus of Mg'ma., were all zealous Galenists, who professed to do little more than to illustrate or comment on the works of their great master. Their writings are principally compilations from their predecessors ; they are, however, occasionally curious from the incidental facts which they con- tain, and by furnishing us with extracts or abstracts of treatises which are no longer extant; but this constitutes almost their sole value. The only additions to the practice of medicine which they afford are an account of certain surgical ope- rations, which is given us by Aetius, and a treatise by Paulus on midwifery, which is more complete than any that had previously appeared, and was long held in high estimation. But even these, which form but a small portion of the whole of their works, are connected with so much credulity and superstition, as to indicate at least the most degraded state of the science, if not the defective judgment of the writer. Aetius expressly recommended the use of magical arts and incantations, and that, not, as has sometimes been done in a more enlightened age, from a know- ledge of the effect they might produce on the imagination of the patient, but apparently from his own opinion of their physical operation on the system.f It must, however, be admitted that both in Alexander Trallianus and in Paulus we meet with various descriptions of disease, which indicate that they possessed the talent of accurate observation ; and we may conclude that, although in what re- spects opinions they were the devoted followers of Galen, yet in the simple detail of facts their authority may be relied upon with considerable confidence.^ With the death of Paulus, which took place about the middle of the seventh century, we may date the termination of the Greek school of medicine, for after his time we have no work written in this language which is possessed of any de- gree of merit. Those which occasionally appeared were mere servile transcripts of* Galen and his disciples, or compilations formed without judgment or discern- ment, devoid of original observation, or even of any attempt at generalization or arrangement. In this degraded state was the science of medicine reduced in the former seats of learning, when a new school arose in a different quarter of the world, which will require our attention, from the actual additions which it made to our knowledge, as well as from the mode of its origin and the nature of its connec- tion with the Grecian and Roman schools. The city of Alexandria still retained its reputation as the great school of medi- cine, partly resting its fame on the excellence of its former professors, and in some measure depending on the value of its extensive library and other institutions favourable to the cultivation of science, the forms of which at least were still preserved. But even these feeble remains were destroyed by the conquest of the Arabians in the seventh century, who, in the genuine spirit of blind bigotry ap peared to be actuated by the barbarous desire of totally eradicating science from the face of the earth. The catastrophe which befell the Alexandrian library is too well known to be repeated in this place,y a calamity, the fall extent of which can scarcely be appreciated by one who is in the habit of regarding literature onlv as it exists in modern times, when books of all descriptions are multiplied to an ex cessive degree and when the loss occasioned by the most splendid collection would be nearly confined to a single nation or community. It appears how- ever, that notwithstanding the brutal violence of the Saracen invaders, some'books escaped from the general wreck of literature and science, and that there were not wanting some individuals who were capable of estimating their value Amnria these relics were the writings of Galen, and we are informed that at an eSy * Enfield, v. ii. p. 136. t Coming, cap. 3. sect. 18-20. Sprengel, sect. 6. ch. 1-3 1.1 p^SlS181' Med' P' 398 Ct S6q- ^ P- 42° Ct SGq- Moy' " Paul *™*™-" Holier, Bib. Med. v ,l h.av„e adopted the generally received account of this transaction • but tt»» iP»moj ,„ A G2iT™^^rderahle'and perhaps not an ™-«^d^^iss5r5a£ ss! HISTORY OF MEDICINE. xxxix period of the Saracenic empire they began to be held in very high estimation; they were translated into the Arabic language, were commented upon and elucidated in various ways, and soon acquired a degree of celebrity scarcely short of what they had previously enjoyed among the Greeks themselves. The Arabians were also in possession of the works of Hippocrates, but the simplicity of this author was less adapted to their taste than were the metaphysical refinements and elaborate arrangements of Galen, so that, while the latter was regarded with a respect amounting almost to veneration, the former was little read or estimated. After the immediate successors of Mahomet had completed their conquest of a considerable part of the civilized world, they rested from their warlike triumphs, and seemed disposed to add to the splendour of their empire by the cultivation of the arts of peace. The patronage of literature was an express object of many of their rulers, and even the works of the Greek philosophers were translated and studied with much assiduity.* But the spirit of Mohammedanism was decidedly averse to intellectual improvement, and we accordingly find that no additions were made to general science, and that very little was accomplished even in the collec- tion of facts and observations. To this remark, however, medicine forms an ex- ception ; for although the Arabian physicians adopted implicitly all the theories and speculations of Galen, and seldom ventured in the smallest degree to deviate from his practice, we are indebted to them for the description of some diseases which either made their first appearance about this time, or had not been before specifically noticed.f I must mention in this place a remarkable occurrence in the history of science, and one which indirectly produced a very important effect upon the subject of this dissertation,—the invention of chymistry. The origin of chymistry, like that of all other sciences, is obscure and uncertain. Traces of what may be called chymical operations are to be found even among the Jews and Egyptians, but it is generally admitted that they are to be regarded as incidental occurrences, depend- ing upon accidental observations, pursued no further than the object immediately in view, and not considered, even by those who practised them, as more than mere insulated facts, leading to no general principles nor to any further investigations. The practice of chymistry as a distinct pursuit seems to have originated with the Arabians, and by them was made subservient to the purposes of medicine.{ It is not my business to inquire into the mode in which this art took its first rise, or to trace its subsequent progress, except so far as may be connected with my present subject; and this will be the most conveniently accomplished by giving in succession a brief account of the most distinguished writers who belonged to the Arabian school of medicine. The earliest Arabian writer on medicine, of whom we have any certain account, would appear to be Ahrun, who was a priest at Alexandria. He published a trea- tise entitled " Pandects ;" it has not come down to us, but it deserves to be noticed, as it is said to have contained the first description of the small-pox. He was contemporary with Paulus, and from the account of his works which has been transmitted to us by Rhazes, we may conclude that the scienee of medicine was cultivated at that time with at least as much success among the Arabians as among the Greeks. During the next three centuries, although we meet with the names of many individuals who acquired a certain degree of temporary celebrity, we have none who rendered themselves so far pre-eminent as to entitle them to particular notice in this brief sketch. The first author of whom it will be necessary to give any distinct account is Serapion : he lived in the ninth century, and is said to have been a native of Damascus. His treatise, entitled, according to the fancy of the translators, " Aggregator," " Breviarium," or " Therapeutica Methodus," was writ- ten originally in Syriac ; its professed object was to give a complete system of the Greek medicine, and to incorporate with it the principles and practice of the Ara- bians. Like those of the rest of his countrymen, the greatest part of Serapion's work is taken from those of his predecessors, and particularly from Galen; but it contains some few novelties with respect both to doctrine and to practice, and in one point, * The Arabians are said to have commenced the study of literature and science in the 108th year of the Hegirah, under the Caliph Almamoun ; Ockley's Hist, of the Saracens, pref. p. xi. t For an account of the Arabian school of medicine generally, the reader is referred to Freind, who treats upon every thing connected with it in the most ample manner. See also Barchusen, diss. 17. $. 12 et seq. Sprengel, sect. 6. ch. 5. Cabanis, §. 6. X Freind, Hist. Med. pars 2. sub init. Sprengel, t. ii. p. 246-266. x\ HISTORY OF MEDICINE. the preparation and composition of medicines, as well as in the articles employed, we may notice a decided improvement.* . At the same time with Serapion lived Alkhendi, a multifarious writer, who ob- tained a very high degree of celebrity among his contemporaries, perhaps more from the variety of his acquirements than from the excellence he attained m any particular department. He is said to have assiduously cultivated mathematics, and the various branches of natural philosophy, as well as medicine ; and among other subjects to which he particularly directed his attention, we find astrology expressly enumerated. In relation to his varied attainments, he was styled the subtle philosopher, the learned physician, and the Greek astrologer. As an ex- ample, both of the spirit of the age and of the genius of the individual, we may remark that Alkhendi applied the rules of geometrical proportion and of musical harmony to regulate the doses of medicines, and to explain the mode of their opera- tion—a mistaken application of science, which, however gross it may now appear, we must reflect was not entirely exploded until long after the revival of letters.f We now come to one of the most illustrious of the Arabian school, Rhazes. He was born at Irak in Persia in the ninth century; he is described as a person of various acquirements, as being well versed in general science, and, as his writings demonstrate, of unwearied industry. There is some reason to doubt whether the principal work which has been transmitted to us under his name, entitled " Conti- nens," is precisely in the form in which it was left by its author: but there appears to be sufficient proof of its general authenticity to enable us to deduce from it, as well as from his other acknowledged works, an ample and correct view of the opinions and practice both of Rhazes himself and of his contemporaries. For the most part, the writings of Rhazes are deficient in method and arrangement, and they consist principally of abstracts and comments on Galen and the Greek phy- sicians ; but they also contain observations that appear to be original, and we even meet with the description of some diseases which were either new, or, at least, were not noticed by the ancients. Rhazes gives us a correct and elaborate descrip- tion of the small-pox and measles, detailing the theory which was formed of their nature and origin by the Arabians, and the treatment which they employed. The most curious and original work of Rhazes is his " Aphorisms," in one part of which he professedly gives the result of his own observation and experience. But even this treatise, which was long regarded as of the highest authority in the schools of medicine, contains little that is really new and valuable ; and when we compare it with its celebrated prototype, we cannot but be impressed with the very small advance which had been made in the science and practice of medicine during a space of nearly thirteen centuries. The most important additions which Rhazes made were, perhaps, rather in surgery and in pharmacy than in medicine, strictly so called; and it is worthy of notice that, in the latter department, we have some of the earliest indications of the free employment of what were styled chymical remedies.J A short time after Rhazes lived Ali-Abbas, a writer of considerable celebrity who obtained the appellation of the magician. His principal work, entitled " Opus Regium," professes to contain a complete view of the state of medicine in all its branches ; it consists chiefly of abstracts of the doctrines and opinions of the Greek physicians, but along with these are contained some original observations. At the time of its publication it was very highly estimated, and perhaps may be considered as possessing more real value than most of the works that proceeded from the Arabian school. y The fame of Ali-Abbas was, however, almost entirely eclipsed by that of Avi cenna,|| who flourished about a century later, and who rose to the highest Ditch of celebrity, so as to be regarded by his countrymen as superior to Rhazes, or even *to* J&S'Sub m*. L P-183'9- For™ aCC°Unt °f the earlier Writers of the ^bian school, see t See particularly a paper by Balguy, on the mode of ascertaining the doses of vomitW a„H „„,-„ ^^t^Z^^^?' Published in 1737- «&» ^e supfnrnfie'S SS S^^Al^-SOl11'11^ Blb" Med' ^^ ^ * *■ 135- ^ *» loco. Lauth, p. 28CM, 6 Freind, p. 481. Holler, Bib. Med. lib. ii. 6. 137. t. i. p. 380. Svrene-rl t ii n wi ^ 11 Thetactualmine of this individual is said to have been Al-HufflSbcSi A1?'b™^?m u r, vu Sina. Sprengel, t. n p. 305. In most cases it appears that theTmes bv wh^hX a lah"Ebn" generally known in Europe were not their real names. y wmch the Al™ans are HISTORY OF MEDICINE. xli to Galen himself. Avicenna was born at Bochara, in the year 980, and was carefully educated in all the learning of the times, consisting principally of the Aristotelian logic and dialectics, with the imperfect mathematical and physical science, that was then taught in the schools of Bagdat. He appears to have been possessed of an ardent desire for acquiring knowledge, and of great industry, but united to a portion of fanaticism, indicative of a defective judgment, and fostered by the spirit of the age, which induced him to conceive himself under the influence of super- natural revelation. After a foundation of general science, he entered upon the study Of medicine, which he prosecuted with the same diligence, and with the same spirit of enthusiasm. His reputation became so high, that he was early introduced to the court, and for some years was without a rival in his profession. His death, which took place in the fifty-sixth year, was probably hastened by some political intrigues, in which he unfortunately became entangled. The works which Avicenna left behind him are numerous, and embrace both general science and medicine. The former long maintained a high character for extent of information and profundity of learning, and, according to the standard of the age, were probably entitled to this commendation. But his fame, both with his contemporaries and with posterity, principally rests upon his great medical work, entitled " Canon Medicinae," which may be regarded as a kind of encyclopedia of all that was then known of medicine, and of the sciences connected with it, anat- omy, surgery, therapeutics, and botany. Its celebrity was so great as to have acquired for its author the title of prince of physicians; for some centuries it was the received text-book in most of the medical schools, both of the Arabians and the Europeans; until the revival of letters it superseded, in a great measure, the works even of Galen; it produced scarcely less numerous commentaries and epitomes, and had not entirely lost its authority two centuries ago. Yet the matured judg- ment of one of the most learned and candid of the modern critics has not hesitated to bestow upon this so-much-vaunted production the character of an ill-digested and servile compilation, containing little that is new, either in the way of observa- tion or of practice. Indeed, the sole aim of Avicenna seems to have been to collect matter from all quarters, without paying any regard to its value, or to the mode in which it was arranged. He was a devoted admirer of A ristotle and Galen, and seemed to imagine that the ultimate object, either of the philosopher or the physician, consisted in being intimately acquainted with their writings, and in defending them against all objections. Upon the whole, after making every allow- ance for the period in which he lived, it seems difficult to account for the very great credit which he acquired, not only during his lifetime, but which was attached to his writings after his death; a credit so much greater than what they merit, either from the importance of the information which they contain, or the mode in which it is conveyed.* There are two Arabian writers of the name of Mesue, whose celebrity entitles them to a brief notice in this place, although considerable uncertainty attaches both to their individual history and to their works. The elder of them is said to have lived in'the eighth, and the younger in the tenth century; and they are both represented as being Christians of the Nestorian sect, but to have exercised their profession at Bagdat. The elder Mesue is principally remarkable as having been among the first who made correct translations of the Greek physicians, and espe- cially of Hippocrates and Galen, into Arabic; for although he appears to have composed many original works, we do not find that they rose into any high repute even among his contemporaries. To the younger Mesue is usually ascribed a treatise on materia medica and pharmacy, which for a long time was in great esti- mation, and was republished and commented upon even as late as the sixteenth century; it probably contained a full view of the state of the science when he wrote, and is interesting, as it indicates the introduction of several new remedies into medicine; but in other respects it is to be regarded merely as a literary curiosity, f The last of the Arabians who acquired any considerable distinction as a writer on medical subjects is Albucasis. So little is known of his personal history, that » Freind, lib. ii. p. 491-2. Holler, Bib. Med. lib. ii. y. 139. Eloy, in loco. Lauth, p 282-5. Enfield, v. ii. p. 222, 3. Sprengel, t. ii. p. 305-22. Hutton's Math. Diet., in loco. Goulin, Enc. Meth. M£de- cine, " Avicenne." " Avicenne," in Biog. Univ. t Freind, p. 481, 2. Holler, Bibl. Med. Prac. lib. ii. y. 126. Eloy, in loco. Enfield, v. ii. p. 23L Sprengel, t. il. p. 325. F xlii HISTORY OF MEDICINE. both his birth and the country in which he lived have been the subject of contro- versy, and appear to be entirely conjectural. His principal works are on surgery; and the reputation which he acquired in this department is almost as great as that of Avicenna in medicine. He seems to have been a man of learning and talents, to have made himself master of the writings and practices of his predecessors, and to have improved upon them. The description which he has left of his operations shows him to have possessed a degree of boldness and dexterity which could only exist in one who was well acquainted with his art, and had been habituated to the practice of it. His practice was what we should now consider as unnecessarily severe, making much more use of the knife and of the actual cautery than is done in modern times, and in all respects inflicting both more pain and more permanent injury on his patients. The works of Albucasis appear, however, to have afforded by far the most complete view of the practice of surgery which then existed; and from this circumstance, as well as from their real merit, they were for many ages considered as standard performances, and employed as the text-book in various schools and colleges.* It remains for us to give an account of two individuals, who, although natives of Spain, and residing principally in that country, were of Saracenic origin, and wrote in the Arabic language—Avenzoar and Averroes. Avenzoar was born at Seville, in the end of the eleventh century, and is said to have lived to the unusual length of one hundred and thirty-five years; but probably some error may have crept into this statement, in consequence of both his father and his son having been, like himself, engaged in the practice of medicine. His principal work, enti- tled " Thaissyr,"f which consists of a general compendium of medical practice, displays more originality and discrimination than the writings of any of the native Arabians; so that, although he was professedly a disciple of Galen, he does not hesitate, on certain occasions, to shake off his authority when his opinions or practice were not sanctioned by his own experience. We may collect, from cer- tain parts of his works, that he practised both surgery and pharmacy, as well as medicine, properly so called; and we have many valuable observations on each of these departments. Upon the whole, we may consider Avenzoar as respectable both from his general character and his professional skill, and entitled to our regard as one of the improvers of his art. J Besides the reputation which Avenzoar derived from his own merits, he was perhaps still more known among his countrymen as being the preceptor of the cel- ebrated Averroes. Averroes was a native of Corduba, and flourished in the twelfth century; he was of illustrious birth, and highly educated in all the branches both of literature and of science which were then taught in the Saracenic colleges of Spain. From certain political causes he was, in the early part of his life, the sub- ject of religious persecution; but he succeeded in repelling the attacks that were made upon his faith, and was finally reinstated in all his former honours and in the public estimation. These circumstances, coinciding probably with the peculiar temperament of his mind, gave to his character a degree of ascetic gloom and austerity; but he appears to have been a man of distinguished worth and of supe- rior abilities. Averroes's professional occupations were principally in a civil capacity; he is therefore to be regarded, not as a practitioner, but as a scholar, who pursued the study of medicine as a branch of physical science. But such was his ardour in the pursuit of general knowledge, and the fondness which he manifested for this particular department, that he made himself intimately acquainted with it in all its details ; and in his great work entitled " The Universal," he shows that he was not deficient in any part of the science which could be acquired by the mere study of books. As a philosopher, he was a zealous and obsequious follower of the opinions of Aristotle, and as a physician, of those of Galen; he published many comments on both of them, which acquired the highest degree of reputation, and for many ages were considered as standard performances. Yet there is reason to suppose that he was ignorant of the Greek language, and, like his contemporaries became acquainted with Aristotle and Galen only through the medium of Arabic translations. The great estimation in which the works of Averroes were held is * Freind, p. 506-524. Holier, lib. ii. y. 148. Eloy, in loco. Lauth, p. 285, 6. Sprengel, t. ii. t Freind designates the Thaissyr as " liber qui omnia victus et medicinae praecepta in plerisque morbis X Freind, p. 492-503. Hallcr, lib. ii. y. 141. Eloy, in loco. Sprengel, t. ii. p. 332-7 HISTORY OF MEDICINE. xliii proved by the number of editions of them which were published from time to time, one of which appeared at Venice so late as the commencement of the seventeenth century. With respect to his medical writings, as they do not profess to be the result of original observation, we cannot be surprised that their reputation is no longer supported. They are, indeed, entirely neglected ; and it may be affirmed that, notwithstanding the celebrity which they once enjoyed, and which they so long maintained, they have not left a single permanent addition to the science.* With Averroes terminated the Arabic or Saracenic school of medicine ; after his time we have no writer whose name is sufficiently distinguished to deserve partic- ular mention: even the study of the ancients began to be neglected, while no original observations were made, and no novel opinions or speculations were framed which might tend to exercise the mind or dissipate the darkness which now cov- ered all parts of the world. If we inquire into the causes of the great celebrity of the Arabian school of medi- cine, we shall be led to the conclusion that they were rather incidental and facti- tious, than derived from its absolute merits. It has been justly observed, that a considerable portion of this celebrity must be ascribed to the comparative condition of the neighbouring countries. From the eighth to the twelfth century was, per- haps, the period in which Europe was in the state of the most complete barbarism and superstition. The only remains of a taste for literature and science, or for the fine arts, were found among the Moors and Arabs; and it was from this source, by the intervention of the crusaders, and the intercourse which was thus effected be- tween the Asiatics and the Europeans, that the philosophical and medical writings of the Greeks were first made known to the inhabitants of Italy and of France. And even after their introduction into Europe, it appears that they were for some time read only in Arabic translations, or in Latin versions made from these translations ; so that it was not until a considerably later period that they were perused in their native language. Indeed, so completely was the study of the Greek tongue sus- pended during the dark ages, that it may be doubted whether the writings of the ancient physicians might not have been entirely lost to posterity, had they not been preserved in these translations. There are, however, two points in which the Arabians conferred a real obligation upon their successors,—the introduction of various new articles into the materia medica, and the original description of certain diseases. The additions which the Arabians made to pharmacy consisted partly in the vegetable products of the east- ern or southern countries of Asia, which were only imperfectly known to the Greeks, and with which they had no intercourse. Among other substances we may enumerate rhubarb, tamarinds, cassia, manna, senna, camphor^ various gums and resins, and a number of aromatics, which were brought from Persia, India, or the Oriental Isles. But a still more important addition which they made to the pharmacopoeia consisted in what were styled chymical remedies, such as were pro- duced by some chymical process, in opposition to those substances that were used nearly in their natural state. With respect to the origin of pharmaceutical chym- istry, it may be sufficient to observe, that a rude species of chymical manipulation appears to have been practised in Arabia in the fifth century, that distillation was performed, and that the metals were subjected to various processes, by which some of their oxides and salts were produced. The immediate object of these processes was the transmutation of the metals; an operation which, for many centuries, formed a main subject of attention to almost all the individuals who were consid- ered as cultivators of natural philosophy. With respect to the second subject alluded to above, the description of new dis- eases, it is well known that, from causes which are now altogether inexplicable, diseases of the most marked and distinct nature, which are the least liable to be mistaken or confounded with other affections, and which, had they existed, are too violent to have been overlooked, are not mentioned by the Greek and Roman physicians, and are described for the first time by the Arabians. Of these the two most remarkable are the small-pox and the measles. There is some reason to suppose that the small-pox had been known in China, and,:the more remote parts of India, at a much earlier period; but it is generally admitted that it was first recognised in the western part of Asia, at the siege of Mecca, about the middle of * Freind. p. 503-6. Boyle's Diet., in loco. Moreri's Diet., in loco. Holler, lib. li. y 112. Eloy, in loco. Nouveau Diet. Hist., in loco. Enfield, t. ii. p. 226-231. Sprengel, t. ii. p. 337-41. x\[y HISTORY OF MEDICINE. the sixth century, when it raged with great violence in the army of the besiegers. We have remarked above, that the disease was alluded to by Ahrun shortly after its appearance, but it was Rhazes to whom we are indebted for the first clear and distinct account of its symptoms and treatment. There is no subject in the whole range of medical science of more difficult solution than that which respects the origin of diseases, especially such as, when produced, are propagated solely by contagion. The full discussion of this subject would, however, carry me far beyond the limits of this treatise; it is only alluded to in this place as an historical fact, in connection with the writings of the Arabians.* We are indebted to them for the transmission of the works of the ancient Greek physicians, to which they made certain additions of insulated facts with respect to the description of diseases; but, with respect to the general principles of thera- peutics, the additions, if any, are few and imperfect. In anatomy they made no advances, and we have reason to suppose that the examination of bodies, either in a sound or a morbid state, was scarcely practised by them. Medical theory was much attended to, but their theories consisted more in subtle refinements, formed upon the Aristotelian model, than in the study of pathology, or an accurate dis- crimination of the phenomena of disease. Some little advance appears to have been made in surgery by Albucasis, but he is the only individual who seems to have aimed at improving this branch of the profession; and it may be doubted whether the practice of surgery was not, upon the whole, in a retrograde state during the period of which we are now treating. It is in the department of phar- macy alone that they made any additions of real value; and although in this case it may be attributed more to accidental circumstances than to any enlightened spirit of improvement, yet it is incumbent upon us to acknowledge the obligation, which was both extensive and permanent.! CHAPTER VII. State of Medicine in Europe after the Extinction of the Arabian School—Medical Schools of Monte- Cassino and Salerno—Medicina Salemitana—Constantinus Africanus—Actuarius—Rise of the Study of Anatomy—Mondini—Gilbert—Effect of the Crusades, of the Reformation, and of the Invention of Printing, on the Literature of Europe—On Medical Science—Alchymists—Establish- ment of Universities—Linacre—Chymical Physicians—Paracelsus—Appearance of New Diseases. During the flourishing period of the Saracenic school of medicine, which may be considered as extending from the eighth to the twelfth century, the science remained nearly stationary, or was even retrograde among the successors of the Greeks and Romans. We have scarcely a single name of sufficient importance to arrest our attention, and we have no improvements to record, either in theory or in practice. The only attempts that were made in Greece or in Italy during this period, which deserve to be noticed, are connected with the Neapolitan schools of Monte-Cassino and of Salerno, which acquired some degree of reputation in the eleventh century. It was at this period that the physicians attached to the school of Salerno wrote the verses on dietetic medicine, entitled " Medicina Salemitana," a work which, as afterward published with the commentary of Arnoldus de Villa- * On the origin of the small-pox, see Freind, p. 524-9 ; Mead's Discourse on Small-pox and Measles ch. 1.; lhompsons Inquiry into the Origin of Small-pox; Plouquet, Literatura Digesta "Variola Antiquitas, Histona," in loco: ample references may be found in this learned and laborious compila- tion on all analogous topics, but we may regret that the writer appears to have aimed rather at mul- tiplying his authorities than estimating their value. t J^LareTm2e^ted t0 Freind for a candid and judicious account of the Arabian medical school £ 529-33 Holler's second book of his B.bl. Med! Prac: is devoted to the samesubTect SeTalso Robertson's Charles V. vol. i. note 28. Berington's Middle Ages, App. No. 2. Gibbon'sf History vol x ch. hi. Ackermann, cap. xxvn-xxix. Oelsner, Des EfTets de la Religion de Mahommed p 196-9 this author is perhaps too much disposed to exalt the merits of the Arabmn school. Kuhnl fib Med n ^ what he sty es "Fontes Medicine," is entitled » Scnptores Medici inter ArWbes Prscipu^; L ^ PTi fftJm\c]t 1X> " DeS Anatomlstes * des Chirurgiens Arabes'' t i p 1« et seq. Blumenbach, Introd. sect. 6. "Arabes." v' HISTORY OF MEDICINE. xlv nova, acquired considerable celebrity, and may be regarded as a valuable docu- ment, by its affording, in a small compass, a correct idea of the state of Italian medicine at that early period.* In connection with this subject we may notice Constantinus Africanus, who is supposed to have flourished about the end of the eleventh century. He was, as his name imports, an African; he possessed an ardent desire to obtain knowledge, studied in the schools of Bagdat, and is said to have travelled even into India. At his return to his native country he was regarded as a sorcerer, and was compelled, in order to save his life, to take refuge in Italy, where he was finally attached to the university of Monte-Cassino. He principally employed himself in translating the works of the Greek and Latin physicians into Arabic, which was at that time the general language of science. His translations are, however, said to be incor- rect, and his style barbarous; while his works, which are not professed translations, appear to be composed of transcripts from other authors, without any* particular merit, either of selection or of arrangement.! We must mention in this place a writer whose real name has not been transmitted to us, commonly called Actuarius, from the office which he bore in the court of Constantinople.^ He is supposed to have lived in the twelfth century. The works which he left are numerous, and, although consisting principally of extracts from Galen and the Arabian physicians, with whose writings he appears to have been familiar, are not without some additions derived from his own observations and experience. He is considered as having been the first Greek physician by whom chymical medicines are mentioned, as well as various articles of the materia medica, which were originally introduced by the Arabians. We may regard Actuarius as a diligent collector of facts, acquainted with all the information of his age, and as more free from prejudice and bigotry than the generality of his contemporaries.^ After the extinction of the Saracenic school of Spain, we have an interval of about three hundred years, from the twelfth to the fifteenth century, during which what are termed the dark ages still remain enveloped in the deepest gloom; every department of science was neglected, and among others that of medicine fell into its lowest state of degradation. What remained, either of literature or of science, was in possession of the monks, who were themselves grossly ignorant, and whose interest it was to preserve mankind in the same state of ignorance. The exercise of the medical profession was principally in their hands, and they still adhered, for the most part, to the doctrines and practice of Galen, but with these they mixed up a large portion of superstition, and had not unfrequently recourse to magic and astrology. By these means they obtained an unbounded influence over the minds of the people, and operated so powerfully on the imagination of their patients as, in many cases, to give an apparent sanction to their confident assumption of super- natural agency.|[ The only branch of science which was cultivated with any ardour or success was chymistry. The chymistry of these times can indeed only be interesting to us, as having led indirectly to the discovery of various substances, which have been found of great importance in medicine, to which we have already referred. Its immediate objects were twofold, the transmutation of the baser metals into gold, and the discovery of what was termed a universal medicine, which should possess the property of removing all diseases, and preserve the constitution in a state of health and vigour; objects which, it is unnecessary to observe, were completely vain and illusory. Yet by promoting a spirit of research, and by making the experimentalist acquainted with the various forms and properties of the sub- stances on which he operated, they gave him some insight into the physical laws of matter, and by a gradual, although very slow process, laid the foundation of the splendid improvements of modern science. Many of the alchymists of the dark ages, we can have no doubt, were impostors of the lowest description, who were completely aware of the folly of their pretensions; but at the same time there were others who appear to have been the dupes of their own credulity, and who bestowed a large portion of their time and fortune upon these researches. Between * Haller ascribes the Latin verses of the Medicina Salemitana to John of Milan; he remarks, that of this work there had been published " editiones fere innumerabiles;" Bib. Med. lib. iii. sec. 140. See also Eloy, t. ii.p. 599. Ackermann, sec. 422. and Blumenbach, sec. 114. t Freind, p. 533, 4. Haller, Bibl. Med. lib. iii. sec. 159. Eloy, in loco. Sprengel, t. ii. p. 355, 6. X For the origin of the term, see Adelung, Gloss. Man., in loco. y Freind, p. 452-462. Eloy, in loco. Sprengel, t. ii. p. 241-4. || Sprengel, sec. vii. ch. i. xlvi HISTORY OF MEDICINE. these two extremes there were some rare cases of individuals, who may be entitled to hold an intermediate rank, who were sincere and honourable in their views, and, without giving full credit to the professions of the alchymists, conceived that the objects at which they aimed were at least not altogether impossible. To these we may add another class of individuals, consisting of that singular and unaccountable compound of knavery and folly, which is not confined to the subject now under consideration, where it is extremely difficult to draw the line between these two qualities, or to decide which of them forms the predominant characteristic. The school of Salerno, to which we have referred above, obtained a degree of celebrity from its local situation, this city being one of the great outlets from which the crusaders passed over from Europe to Asia in their expeditions to Palestine; and it was probably from this circumstance that Robert of Normandy stopped at Salerno, in order to be cured of a wound which he had received in the holy wars. It was on this occasion that the verses mentioned above, and which were addressed to him, were written. Upon the decline of the Saracenic univer- sities of Spain, the only medical knowledge which remained was in Italy, where a few individuals, who were not of the ecclesiastical profession, continued to comment on Galen and Avicenna, and occasionally to deliver lectures; but we have a long dreary interval, in which there is nothing to arrest our attention, or to relieve the dull monotony of ignorance and superstition. During this period the school of Salerno still retained its reputation, and was even favoured with especial privileges by the emperors; but its merits were prob- ably rather comparative than absolute, for we do not find any improvements that emanated from it, nor any authors whose writings maintained their celebrity after the age in which they were produced. It is, however, in one respect deserving of our notice, as it appears to have been the earliest establishment in which what may be styled regular medical diplomas were granted to candidates, after they had passed through a prescribed course of study, and been subjected to certain exam- inations. The regulations are upon the whole judicious, and display a more enlightened and liberal spirit than might have been expected in that age, when the human mind was in so degraded a state.* The school of Salerno maintained its celebrity until the thirteenth century, when it was eclipsed by the general diffusion of medical science through Europe, and more particularly by the rising reputation of the universities of Bologna and Paris. It was about this period that we may date the commencement of a practice which has eventually proved of the greatest importance to medical science in all its departments—the study of human anatomy. We have already had occasion to remark that the ancients, even in their most enlightened ages, seldom if ever ventured to examine the human subject, but were content to derive their know- ledge of it from the dissection of animals which were supposed the most nearly to resemble it, making up the deficiencies by the casual examinations which were afforded them by accidents or diseases, and perhaps more frequently by supposed analogies, or rather by the efforts of the imagination. The individual to whom the credit is ascribed of having so far overcome vulgar prejudice as to have intro- duced this most important improvement into his art, is Mondini, a professor in the university of Bologna, who is said to have publicly dissected two female subjects about the year 1315, and who published an anatomical description of the human body, which appears to have had the rare merit of being drawn immediately from nature. This work deservedly obtained a high reputation: for three hundred years it was considered as a standard performance, and was used as a text-book in the most celebrated of the Italian universities. Mondini is also entitled to the gratitude of posterity for having given a very early, if not the first example of anatomical plates; the figures were cut in wood, and although, as might be sup- posed, they were not executed with much elegance or delicacy, they are said to have been correct and expressive.f About the same time with Mondini lived Gilbert, surnamed Anglicanus, a writer who must be considered as peculiarly interesting to us, from his being the earliest English physician whose name is sufficiently celebrated to entitle him to a place in the history of medicine. There has been much controversy respecting the * Freind, p. 535-7. Eloy, art. " Salerne." Lauth, p. 291, 2. Ackermann, cap. xxxi t Freind, p. 546. Haller, Bibl. Anat. 6.120,1.1. p. 146, 7. Eloy, in loco. Portal, Hist Anat t i 209-16 Sprengel, t. ii. p. 432-4. Douglas, Bibliogr. Anat p. 36-9. Blumenbach, Y 118 HISTORY OF MEDICINE. xlvii date of his birth; but it appears the most probable that he flourished in the begin- ning of the fourteenth century. At this time medical science, as well as all other kinds of knowledge in this country, was in a state of the lowest degradation. There were no public means of instruction in any of the branches of natural philosophy. The light of science, which had dawned in the south of Europe, had not yet extended to the remote shores of Britain, and the learning of the age, which was confined to the monks, consisted entirely of scholastic disquisitions and the disputations of polemical theology. We are not, therefore, to expect in the writings of Gilbert much of genuine philosophy or of real science; his prin- cipal work, which is entitled " Medicina? Compendium," consists chiefly of subtile distinctions, disquisitions respecting trifling and insignificant topics, with minute divisions of his subject, which lead to no useful purpose or general conclusion. His medical theories are principally taken from Galen, while his mode of reasoning proceeds upon the technical principles of the Aristotelian dialectics; he adopts the former without discrimination, and employs the latter without judgment. He frequently refers to the Arabian physicians, and there is some reason to suppose that it was through their means, i. e. through the medium of the Latin translations of their writings, that he made himself acquainted with the opinions of Galen.* But although we are compelled to pass this general censure upon the works of Gilbert, justice demands it of us to admit, that his defects may be fairly ascribed to the age and country in which he lived, and that he deserves great commendation for the attempt which he made, however imperfect it may have been. Nor are his works entirely without merit or originality; he has described some diseases in such a manner as to show that, under more favourable circumstances, he might have excelled in the art of making observations; he occasionally gives us some particulars of his practice, which prove that he was capable of exercising a correct judgment in the treatment of the cases which were submitted to him, and we are indebted to him for some additions to the materia medica, and for some improve- ments in pharmacy-! About this period a grand political revolution was commencing in Europe, which eventually produced an entire change in the civil condition of its inhabitants, and indirectly affected, in an equal degree, its science and its literature. The feudal system, after being firmly established for some centuries, began to be shaken, per- haps in the first instance, by the crusades. These expeditions, although undertaken from a spirit of gross superstition and bigotry, yet, by giving a degree of excitement to the mind, and still more by making the crusaders in some degree acquainted with the literature of the Arabians, laid the foundation for subsequent improve- ments. There has been much controversy, not only respecting the absolute merit of the Arabian literature, but respecting the influence which it had on that of Eu- rope. On the first of these points, as far at least as regards the medical sciences, I have already offered a few remarks ; and on the latter I may observe, that at the period of the crusades, whatever may be our estimate of the absolute merit of the Saracenic schools of learning, they were undoubtedly superior to those of the Christians, if indeed these latter can be entitled to the appellation. The armies of the crusaders were certainly not the best adapted either for appreciating the learning of the countries which they invaded, or for transferring any portion of it to their own; but still an intercourse of two or three centuries could not fail of having produced some effect, and in fact we know, not only that Arabian books were read and studied in Italy and France, but that it was almost exclusively by the medium of these books that the knowledge of the Greek and Roman authors was kept alive.% The advantages which were derived to the Europeans from their intercourse with Asia were, however, of but little moment compared to the great events to which I alluded above. The first of these was the capture of Constantinople, in the middle of the fifteenth century, by Mahomet the Second. The Greek monasteries of this city had been for some time the refuge of the learned men who had been driven from Italy by the perpetual wars in which that country had been so long engaged. * Warton's Hist, of Eng. Poet. v. i. p. 443. t Freind, p. 547-50. Eloy, in loco. Aikin's Biog. Mem. of Med. in Gt. Brit. p. 8, 9. Sprengel, t. ii. p. 4026. X Gibbon, ch. lxi. Sprengel, sect. 7, ch. iii. I must remark that the opinion expressed- in the text, respecting the influence of the crusades on the literature and science of Europe, differs in some degree from that of Mr. Mills, as stated in his interesting work on the Crusades, v. ii. p. 354-68. xlviii HISTORY OF MEDICINE. They had taken with them what they considered as their most precious treasures, the manuscripts of the ancient classical writers, probably regarding them more as objects of curiosity than of real importance. These manuscripts had now been buried for a long time in their libraries, their existence being unknown to the rest of the world, when the monks were expelled from their retreats by the Turkish conquerors, and, flying into Italy, carried back with them their classical manu- scripts. A spirit of improvement had already begun to manifest itself in this country, which was considerably incited by their guests, who, in their turn, by their change of situation and by the new society into which they were introduced, be- came more aware of the value of their literary treasures; while their own acquire- ments, limited as they were, gave them a degree of respect with their new asso- ciates which tended to inspire them with a desire of further improvement.* The other event to which I referred, and which occurred about thirty years after the destruction of the Byzantine empire, was one of infinitely more importance, both in its immediate and its ultimate effects. Considered in all its bearings, both moral and political, it may probably be regarded as the most important which has ever occurred in the history of civilized society. My readers will not need to be informed that the great event to which I refer is the Reformation. Into the causes of this event, the motives of Luther and his associates, the difficulties with which they had to struggle, and the means by which they succeeded in overcoming these difficulties, it is not our business to inquire. It only remains for me to notice its effects on science, and more particularly on medical science. I have remarked above that a certain degree of mental exertion had begun to manifest itself in the fourteenth century, that this was in some measure brought into action by the ex- citement produced in consequence of the crusades, and that the minds of men were thus prepared to receive the great truths which were so powerfully impressed upon them by the reformers. The first effect, however, of the Reformation was rather unfavourable to the progress of science and literature. The attention was entirely absorbed by the violence of theological controversy, and the civil feuds which succeeded put a stop to the peaceful labours of the scholar and the philosopher. But if a temporary pause was thus produced, the subsequent advance was proportionally rapid. No sooner were the minds of men delivered from the thraldom of theological bigotry, than they felt a strong impulse to free themselves from the tyranny of opinions on all other subjects in philosophy; and although it still required the lapse of some centuries to shake off the undue authority of Aris- totle and Galen, and to form a fair estimate of their real merits, they were at least regarded as fair topics for discussion, while innovators were every day rising up, who ventured to question their infallibility, without the danger of being stigmatized as schismatics and heretics-! The happy invention of the art of printing, " an art which derides the havoc of time and barbarism," and which fortunately occurred about the same period, most powerfully tended to co-operate with the labours of the reformers, both in religion and in science, by affording them the means of more readily communi- cating the result of their inquiries, and of preserving the records of knowledge from the danger which they had lately experienced of being totally lost or destroyed.^ One of the first uses which was made of this important invention was, not only the multiplication of the works of the ancient classics, which had been brought by the Byzantine monks into Europe, but, by making mankind sen- sible of their value, other works of a similar kind were eagerly sought after and thus, in the course of a few years, manuscripts were discovered of almost all the classical writings of which we are now in possession.^ The munificence and even the voluptuous extravagance of Leo X. and the other Italian potentates, bv the direct encouragement which they gave to literature and the fine arts, povver- fully coincided with the current of public opinion. For, although by inciting the daring spirit of Luther to take those steps of open hostility against the papal authority, which he probably little contemplated in the first instance, they produced effects very different from those originally intended, yet they must be considered * Ackermann, ch. xxxii. Cabanis, y 7. t Enfield, v. ii. book 8 ch ii X For remarks on the scarcity and value of books, see Robertson's Charles V v i' ch v tw» in Warton's Hist, of English Poetry, passim ; Berington's Middle Ages, book vi. p' 507 8 ' ' 6 Gibbon, v. x. ch. Ixvi. Warton, passim. Berington, book vi. n 478 et -spn «;v,L,k„ j> i t e Poggio, passim. Hallam's Middle Ages, v. iii. p. 577 et seq. P' Seq" ShePherd's Life of HISTORY OF MEDICINE. xlix as among the indirect causes which conspired to produce the great mental revolu- tion of the fifteenth century. The science of medicine in its various departments was not slow in partaking of the beneficial effects of the change which we have been describing. The writings of the Greek physicians, which had for. some centuries been studied through the medium of Arabic translations, or even of Arabic commentaries, were now read in their original language, or in correct Latin versions.* It was found that Avicenna, Averroes, and the great luminaries of the Saracenic schools, had in many cases either misunderstood or perverted the doctrines and tenets of Galen. and his genuine writings now began to be substituted for the imperfect transcripts of them which had so long occupied their place. The works of Hippocrates were also printed in their original form; but it required a considerably longer period of mental education to enable the bulk of medical readers to appreciate his merits, so that, although various editions of his works were printed, and learned treatises written to explain them, Galen still retained the pre-eminence in public estimation. A practice began to prevail about the fifteenth century, which very materially contributed to advance the science of medicine, and especially the practical part of it—the publication of monographs of particular diseases and of individual cases, with the reports of hospitals or other public institutions. This plan was not, indeed, altogether new, for we meet with narratives of cases even in Hippocrates; but it had been either misunderstood, or had been so much perverted from its original design and legitimate object, as to have been rendered of little value. Many of these early collections, it must be acknowledged, were formed without judgment, and consisted rather of marvellous stories than of histories from which any practical inference could be deduced; but they served the purpose of inducing a habit of observation, and of directing the attention more to facts than to mere hypotheses. In each succeeding age we find this plan to have been more gene- rally adopted, and at the same time to have been much improved in its method; so that we may undoubtedly consider it as one of the means by which medical knowledge has advanced so rapidly in modern times. Before I close the second period of the history of medicine, it will be necessary to make a few observations on the progress of chymistry, and on the influence which it had on medical science. I have already made some remarks on the rise of this science, and on the progress which it made among the Arabians, and have stated that it originated in the futile and sordid desire of converting the baser metals into gold. In its primary object it of course totally failed; yet in the numerous and laboured efforts which the alchymists made to accomplish their object, it is admitted that they acquired considerable information about the nature and properties of the bodies on which they operated, and thus produced various compounds, principally of a metallic nature, which were eminently useful in the arts of life, and especially in pharmacy. We further owe to the Arabian chymists the discovery of the process of distillation, and the art of preparing extracts; they introduced the use of sugar into pharmacy instead of honey, in the compo- sition of syrups and conserves; they seem to have made some approach to the formation of the mineral acids, and to have procured several of the earthy and neutral salts. The art of alchymy was early transferred into the different countries of Europe, and was pursued with as much ardour as by the Arabians, and perhaps with even more superstition and credulity. Some of the alchymists acquired, during their lifetime, a high degree of popularity, and, notwithstanding the unphilosophical nature of their occupation, are not altogether unworthy of notice in the history of science. Albertus Magnus, bishop of Ratisbon, Raymond Lully, a Spanish ecclesiastic, and Arnoldus of Villanova, a professor in the university of Barcelona, all flourished in the thirteenth century, and left behind them writings which, although they are encumbered with a mass of folly and mysticism, exhibit in a certain degree the spirit of philosophical research, together with an ample share of industry and patient investigation.! In the same age lived Roger Bacon: he * There is reason to believe that Greek was little read in any part of Europe until after the capture of Constantinople in 1453; Ockley, pref. p. xii. + Freind, p. 543-5. Bayle's Diet., art. "Albert." Eloy, "Arnauld de Villeneuf." Moreri, art. '• Albert," t. i. p. 269; and " Amaud de Villeneuf," t. i. p. 346,7. Ackermann, y. 446, 7. Berington, book v. p. 370. Sprengel, t. ii. p. 437-413. Blumenbach, y. 120-3. Turner's Modern History of Eng- land, book ii, ch. i. p. 7,8. G F HISTORY OF MEDICINE. may be classed among the alchymists, inasmuch as he adopted some of their prin- ciples and practices; but in the turn of his mind, and in the spirit with which he entered upon his experimental researches, he exhibited a genius which far out- stripped the age in which he lived.* The philosopher's stone, which was the object of so much painful research, besides its property of producing gold, was supposed also to possess the power of curing all diseases, and hence obtained the title of the universal medicine. This vain and fantastical notion was indirectly the cause of some pharmaceutical discoveries; for to this we may consider ourselves indebted for the mercurial preparations, and for the experiments of Basil Valentine on antimony, which led to their introduction into medicine about the end of the fourteenth century. Among the distinguishing features of the period at which we are now arrived, I must not omit to mention the various universities which were established in many of the great cities in the southern parts of Europe, of which the medical chairs, in most cases, formed a very distinguished part. I have already had occa- sion to mention the university of Salerno, which was the first of these establish- ments after the destruction of the Roman empire. The next in order of time appears to have been that of Montpellier, which is said to have been established not long after that of Salerno, and which acquired a high degree of reputation, which it maintained for many centuries. We are informed .that Bologna had acquired considerable celebrity as a school of medicine in the thirteenth century; that about half a century later medical lectures were delivered in the universities of Vienna and Paris; and that about the same time medical schools were estab- lished in Padua, Pavia, Milan, Rome, and Naples, and most of the other cities of Italy, which each of them acquired a certain degree of reputation, necessarily varying with the abilities and characters of their professors, but all contributing to advance medical science, both by the actual acquisition of knowledge, and by the influence which they exercised in removing the undue veneration that was still paid to the writers of antiquity.f In the north of Europe the progress of litera- ture and science was much more tardy. The natural sciences were scarcely regarded as an object of attention, and medicine was still strictly confined to the study of the works of Galen, or even to those of his Arabic translators. The only exception of which our country can boast is Linacre, a native of Canterbury, who, after studying at Oxford, travelled into Italy, and spent some time at the court of Florence, where he acquired a portion of that love of literature which so eminently distinguished the family of the Medici. On his return to England he was appointed physician to the royal household, and employed his influence in establishing medical professorships in the universities of Oxford and Cambridge, and in forming the foundation of the London College of Physicians. J From the various causes which have been mentioned, and probably from some others of less moment, a spirit of general improvement now began to manifest it- self; the arts and sciences gradually revived ; philosophy, in all its branches, was studied on a more correct plan and with a more enlightened object, and medicine was not slow in partaking of the beneficial influence. One of the first symptoms of this improvement was an increasing relish for the writings of Hippocrates, and the revival of his method of studying and practising medicine. The taste for complicated theory and refined speculation gradually declined, and in the same proportion the value of correct observation and an accurate detail of facts began to be duly estimated. s A circumstance which tended in a considerable degree to shake the authority of * Freind, p. 537-543. Campbell, Biog. Brit., in loco. Bale, Scrip. Itmst. Brit. p. 342 4 Cave »^&Ba&;° is H*&r,r SSattft Jo?; i73 wSft'StflfSf taE ISVcS1 Cn^So. Enfald' HiSt' ™'' TOL "' "' ^ > ^ "> Aiki"'* G°"'Sq The: learned work of Tiraboschi,'< Storia delta Literatura Italian*," contains the most' am^iniS* ST /e2SpeCtlng the umversit^ of that country. See also Lauth, Hist. d'AnaTomJ liv v! part I'r • *i Frem£' I 587"59,1;. ^e oere lose the assistance of this learned and judicious historian FW in loco. Caban.s, p. 144, 5 Sprengel, t. ii. p. 8. Aikin's Biog. Mem. of Med p 28^7 In connec Zi with Linacre we may mention the name of Kev Kave or m ?r w»« l«tir,;,t!ji p r /"connection, of the times, Caius, whose liberality™ th■ ITniS'v of Cambrid£Z?a' aCC.0rdln& l° the custon» Aikin, Biog. Mem. p. 103-136; and Gen. B^viaffi. Eloy?m JJfCO h°™uxab]e mention. HISTORY OF MEDICINE. Ii Galen, and to diminish the veneration in which his opinions had been held for so many ages, was the rise of the sect of the Chymical Physicians. After chymistry had been used with advantage for the purpose of improving the processes of pharmacy, it was applied to the explanation of the phenomena of vitality, and of the operation of morbid causes upon the living system. The theories of these chymical physi- cians we now regard as altogether false and inapplicable; but they were advanced with so much confidence that they obtained many adherents, and for some time the opinions of the medical world were divided between the rival doctrines of the Galenists and the Chy mists. Among the most noted supporters of the chymical theory was Paracelsus, an individual whose claim to our notice depends more upon his consummate van- ity and presumption than upon his abilities and acquirements. His professed object was to undermine the authority of the Galenists; and for this purpose he did not hesitate to hold forth the most absurd claims, and to practise the basest arts of quackery. He boasted that he had discovered the elixir vita?, the universal remedy, of which mankind had been so long in search; and he publicly burned the writings of Galen and Avicenna, because, in consequence of his discovery, they were of no further use. It is somewhat difficult to determine in what degree Para- celsus was actually the dupe of his own folly; but whatever may have been his real opinion of the efficacy of his elixir, his own death, at the early age of forty-eight, served to humble the confidence of his followers, and to reduce his reputation to its real standard. But although the personal character of Paracelsus received an irreparable Shock by this event, his doctrines continued to attract a number of zealous advocates. With respect to the nature of these doctrines, it will be necessary to say but a few words in this place. The leading principle of the Chymists was, that the living body is subject to the same chymical laws with inanimate matter, and that all the phenomena of vitality may be explained by the operation of these laws. The proofs which they adduced in favour of this principle, and the illustrations which they gave of the nature of these laws, were completely futile and unsatisfactory ; and it may be asserted that the strength of their reasoning was much more appa- rent in the mode by which they attempted to controvert the hypothesis of the Galenists, than in the direct arguments which they brought forward in favour of their own doctrine. In truth, the chymical elements of Paracelsus were at least as hypothetical as the physiological elements of Galen, and were even less appli- cable to the explanation of the vital actions of organized beings. The only obliga- tion which we owe to the chymical physicians is the introduction into medicine of certain substances, chiefly metallic preparations, which, in the hands of the more enlightened practitioners of modern times, have proved very valuable additions to the materia medica.* After the death of Paracelsus, his peculiar theories fell into disrepute and were iittle attended to ; but the sect of the chymical physicians continued to flourish even as late as the seventeenth century, when we meet with many examples of men of learning and sagacity who attempted to explain the phenomena of the animal economy by the laws of chymistry. To the visionary speculations of the Chymists there was united a large portion of superstition and mysticism ; and so much did this feeling coincide with the spirit of the times, that even the men who were most illustrious for their learning and science were either actually infected with these notions, or did not venture so far to oppose the prevailing opinions of their contemporaries as to avow their disbelief of them. Astrology and magic were generally practised by the members of the medical profession, while various rites and ceremonies were observed, which implied the belief of supernatural agency, but which, by a singular inconsistency, was supposed to be a constant and necessary part of the process. Before we conclude this portion of our subject, we must notice the remarkable circumstance, that about this period, during the fourteenth and fifteenth centuries, some very formidable diseases made their appearance in Europe, the origin of which is still very obscure, after all the discussion and investigation that has * Le Clerc, p. 792 ef seq. Barchusen, Diss. 19. Conring, cap. xi. §. 16, 17. Haller, Bib. Med. t, li. p. 2 et seq Eloy, in loco. Sprengel, sect. is. ch. 2. Cabanis, sect. ix. Hutchinson's Biog. Med, vol. ii. p. 197-209. Enfield, vol. ii. p. 451-4. Aikin's Gen, Biog., in loco. Bluuienbach, Introd. $, \§9, Benauldin, Biog, Univ., " Paracelse." iii HISTORY OF MEDICINE. taken place respecting them. Among these, one of the most remarkable is what was termed the Sudor Anglicanus, which is first mentioned about the end ol tne fifteenth century, and which, for about fifty years, raged at intervals with extreme violence in England and in some other countries in the west of Europe. in the fifteenth century we have the first correct description of the hooping-cough; and from the manner in which it is spoken of by the contemporary writers, it would appear that it was considered by them as a new disease. The sea-scurvy, if not entirely unknown to the ancients, was at least not distinctly recognised until this period, so that, if it existed previously, we may conclude that it was less violent in its effects: a circumstance which has been ascribed, with great plausibility, to the spirit of naval enterprise which sprang up at this period, and which led to the un- dertaking of long voyages.f The great number of establishments which were formed during the dark ages for the cure of leprosy, was at one time supposed to be a proof that it was a new disease in Europe, imported, as was imagined, from Asia by the crusaders. There has been much nosological discussion concerning the exact nature of the disease to which this term ought to be applied ; whether there were actually two species of leprosy, one of which was indigenous in the East, and another species in Europe. Some writers have conceived that a combination of the two was produced at this period, while others, again, have supposed that the disease had previously existed in Eu- rope, but that, in consequence of the greater degree of communication between the different parts of it, which was brought about by the crusades, the disease was either more extensively propagated, or at least was brought more into notice, and that more active means were therefore employed for its relief.^ It was about the same period, when the western part of the old continent was in its lowest state of degradation, that we hear of the ravages of those varieties of fever emphatically styled the plague, which were described in the thirteenth, four- teenth, and fifteenth centuries as invading various parts of Europe and Asia, and sweeping away a large proportion of the inhabitants.^ The accounts which we have of these epidemics would indicate that they were not an absolutely new disease,, but that the symptoms were modified and aggravated by the peculiar condition of the great bulk of the people ; a conclusion which is confirmed by the fact, that, as the physicaL and moral condition of nations has been ameliorated, the occurrence of these diseases has become proportionally rare, so that we conceive them to be almost incompatible with the improvements in civilization and in medical police which exist in the greatest part of Europe. But whatever may be our opinion concerning the origin of the leprosy and the plague, there is another disease where, from the peculiarity of its symptoms, its decidedly contagious nature, the ordinary method of its propagation, and the uni- versality of its occurrence, we are enabled to fix the date of its appearance in Europe with more certainty. It is now generally agreed that it was near the close of the fifteenth centur}r that the symptoms of syphilis were first recognised in Italy, from which country the disease very rapidly extended over the whole of Europe. Con- cerning its primary origin much controversy has taken place ; many writers have attempted to prove that it was brought into Europe from America by Columbus; but this opinion, which was at one time pretty generally received, is now abandoned, nor are we able to offer any plausible conjecture respecting its introduction from any other quarter. The same difficulty, indeed, exists in this case as in that of all those diseases which are produced by no cause except by a specific contagion. Almost every individual is obnoxious to them upon the application of this cause, and this liability appears to be little affected by constitution, age, habits of life, climate, and other external circumstances. The question is, how were they first produced 1 It is im- possible to imagine that the first created individual was born with all these diseases upon him, yet we know of no distinct cause now in operation which could, in the first instance, have generated them. These remarks apply to the small-p'ox and the measles, which, as was stated above, were first known to the Europeans about *• Sennert, De Feb. lib. iv. cap. 15. Freind, p. 567,8. Plouquet, " Febris Sudatoria " t ii d 162 Cullen's Synopsis, t. ii. p. 77, 8. Sprengel, t. ii. p. 491-4. ' - t Freind, p. 583. Sprengel, t. ii. p. 494-6. X Sprengel, t. ii. p. 371-5. \ Plouquet, " Febris Mailgnar" and " Pestis," in loco. Cullen, t, ii. p. 74-7, 139-41. HISTORY OF MEDICINE. liii the middle of the sixth century, and it applies perhaps still more remarkably to the case of syphilis. This point must be regarded as one of those mysteries of which at present we are unable to offer any solution. It is true that the manners of the age in which this disease is recorded to have first made its appearance were grossly licentious, and in many respects unfavourable to health; but still we see no satisfactory reason why the specific poison of this disease should have been generated; yet it appears impossible to conceive that, if it had previously existed, it could have remained for any length of time unknown or undescribed.* I have now brought down the sketch of the history of medicine to the period when the light of improvement was bursting forth from various quarters, when men were engaged in the investigation of the different departments of science upon a plan which, although not free from error, was more correct than that of their prede- cessors, and which, by a slow but steady process, led to the establishment of those principles which eventually produced the complete triumph of truth and philosophy over error and superstition. CHAPTER VIII. General View of the State of Medicine during the Sixteenth Century—Revival of the Hippocratean School—Account of the Galenists—the Chymists—The Anatomists—Vesalius, Fallopius, Eu- stachius. I have already given an account of the manner in which the taste for the clas- sical writers of antiquity was gradually developed during the fifteenth century, and I stated that in medicine, as well as in the other departments of science, the Greek writers began to be studied in the original, instead of their being read through the medium of translations and commentaries. As this taste was further matured, the works of Hippocrates continued to rise into estimation in preference to those of Galen, and a new school of medicine was formed, which obtained the name of Hippocratean, the professed object of which was to proceed upon the inductive principle, of first ascertaining facts, and by their generalization to form the theory. That in every instance they adhered to this plan we cannot affirm: indeed we have too many instances where they forgot or misapplied their own principles, but still the importance of accurate observation was generally admitted, and although mankind could not at once abandon their former errors, they became aware of their existence, and of the method by which they might be corrected. The contest between the Galenists and the Chymists, which agitated the whole medical world during the fifteenth century, was indeed still maintained through the sixteenth ; but it was conducted upon more rational principles, and by men of more enlarged and more enlightened views. The Galenists were for the most part more scientific and learned than their adversaries; they consisted of the professors in the universities, and what may be styled the regular practitioners: and although they were still strongly attached to the tenets of their master, they did not omit to collect facts and to watch the phenomena of disease. Their practice may be characterized as being at the same time complicated and inert; their materia medica was principally taken from the vegetable kingdom, while their prescrip- tions were long and multifarious, consisting of a prodigious number of articles, combined together in such a manner as to render it almost impossible to conceive the probable operation of the compound, their indications, at the same time, being derived from an incorrect hypothesis, and being often either unintelligible or im- practicable. The Chymists were the bold empirics of the day, without learning or experience; but they endeavoured to supply the deficiency by confidence and temerity, and by * Freind, p. 568-583. Astruc, De Morbis Veneriis. Hunter, on the Ven. Dis. p. 9,10. Sprengel, t. ii. p. 499, et seq. Plouquet, " Syphilis, Historia," &c, in loco. Black's Hist, of Medicine, p. 147-155. liv HISTORY OF MEDICINE. these formidable weapons they frequently triumphed over their adversaries. They discarded the long prescriptions of the Galenists, rejected many ol the articles oi their pharmacopoeia, while they introduced the active metallic preparations, and made free Use of the most powerful remedies of all kinds. The rival sects mu- tually upbraided each other with the injurious effect of their respective plans of treatment, and probably there was but too much foundation for their accusations; for if on the one hand the Chymists, by their rashness committed many fatal blunders, the Galenists, by their feeble remedies, must have frequently failed in subduing disease or arresting its progress. It appears that, upon the whole, the Chymists, like the analogous characters in the present day, acquired a greater share of popularity than their opponents. Their arrogant pretensions, the more decisive and intelligible nature of their indications, coupled with the artifices which they practised for the mere purpose of acquiring popularity, gave them a decided advantage over their more learned and more dig- nified rivals, who were both unable and unwilling to contend with them in the race of empiricism. By degrees, however, the chymical physicians rendered themselves more worthy of the public estimation, by making themselves better acquainted with the principles and practice of their art; the search after the philosopher's stone was gradually abandoned; and although many of the doctrines which they still professed were altogether unfounded, they were less palpably absurd than those of their predecessors. Another circumstance occurred about the period of which we are now treating. which contributed to produce a most important reform in the science of medicine —I refer to the study of human anatomy. With a very few exceptions, which have been noticed above, during a space of more than a thousand years, since the death of Galen, very little advance had been made in our acquaintance with the structure of the body. The professors of the Arabian school, with their successors in Italy and France, for the most part contented themselves with copying the descriptions of the ancients, without ever calling in question their accuracy, or ^endeavouring to confirm or refute them by their own observations. Even after the examination of the human subject had been practised for some time, and its neces- sity generally acknowledged, it was long before mankind could so far free them- selves from the tyranny of authority as to admit that any imperfection could exist in the works of Galen, or that his descriptions were not to be preferred even to the evidence of the senses. In reviewing the state of medical science during the sixteenth century, it will assist us in our progress if we arrange the principal authors under the three classes of the Physicians strictly so called, the Chymists, and the Anatomists. Under the first head we purpose to include both the writers who still adhered implicitly to the tenets of Galen, and those who, paying less regard to mere authority, de- voted themselves more to observing the phenomena of disease, and the effects of remedies, and who may be considered as having laid the foundation of the modern Hippocratean school. Of these, some of the most distinguished by their character or writings were Cornarus and Mercurialis in Italy, Hollerius, Fernel, and Duret in France, Lommius and Forest in Holland, Sennert, Plater, and Foes in Germany, and Linacre in England.* The limits to which I am necessarily confined will not permit me to enter into any detail of the individual merits of these authors, or into any analysis of their writings or opinions. For the most part, they were possessed of a competent knowledge of ancient literature, and well acquainted with the works of the Greek physicians; many of them were professors in universities or teachers of medicine, and engaged in extensive practice. They were generally diligent collectors of facts, and many of them voluminous writers, either publishing their own observa- tions, or commenting on the ancients. Their practice was, in a great measure taken from Galen, with the additions that had been derived from the materia medica of the Arabians, and in a few instances from the Chymists; but these latter were regarded as dangerous and empirical, and it was not until they had been long sanctioned by popular use that they were received into the authorized pharmaco- poeias. The actual advance which the practice of medicine received from these authors was not very considerable; but by their learning and diligence and their general respectability, they contributed to raise the character of the profession * Sprengel, t. ii. passim. Cabanis, ch. ii. $. 10. HISTORY OF MEDICINE. Iv and to prepare the mind to receive the improvements in science which were gradually unfolded in the next century, and to apply them to the department of medicine. With respect to the Chymists of this period, although they composed a numerous and active body, yet there is none of them whose name is sufficiently distinguished above his fellows to require being particularized in this place. As science and knowledge gradually advanced, the absurdity of their speculations was more gene- rally perceived, and their pursuits were either abandoned, or were directed by a more philosophical spirit; and although the search after the universal medicine was not entirely discarded, they began to occupy themselves with inquiring into the chymical constitution of the body, and investigating the changes that were induced in it by disease. This investigation was, indeed, attended with little success: their experiments were crude and imperfect, and their modes of analysis altogether inefficient. But still some important observations were made, and new processes were invented, and the foundation began to be laid for the more enlight- ened views of their successors in the succeeding century. But the benefit conferred upon the science of medicine by the labours of the Chymists was trifling and uncertain compared to the great and direct advance which was produced by the researches of the Anatomists. Some attention had been paid to the structure of the body by the earlier Italians, and they had even ventured, in a few instances, to dissect the human subject; yet scarcely any discovery or any improvement deserving of notice had been made for many ages, when Vesalius, about the middle of the sixteenth century, entered upon his career of inquiry. He was the first anatomist who threw off the yoke of authority, which had been im- posed by a blind veneration for the opinion of the ancients, and who ventured to conceive the possibility of error in the writings of Galen. Vesalius prosecuted his researches with unwearied diligence; and, disregarding the obloquy which was heaped upon him, he succeeded in publishing an anatomical work, which at this day we behold with admiration, and which maintains its character as a faithful transcript of nature.* But the reputation of Galen was too firmly established to be affected in any con- siderable degree by the observations of any single individual, however highly he might be entitled to the respect of his contemporaries. Long and acrimonious discussions occurred between the defenders and the opposers of Galen, some main- taining that his descriptions of the parts of the body were absolutely perfect, while others undertook to prove, by direct and palpable facts, that Galen's knowledge of the human form was not complete. It was asserted, on the one hand, that he had seldom examined the human subject, and that his descriptions were frequently taken from apes and monkeys; an imputation which was firmly denied by his zealous advocates. Eustachius, Fallopius, and others of great and deserved repu- tation for their anatomical skill, undertook the defence of Galen; and it was not until after a long and severe struggle that the truth was established, and that it was agreed that the anatomy of the ancients was in many parts imperfect, and that the errors which had been pointed out by Vesalius actually existed.! It would be foreign to my purpose to enter into a minute examination of the labours of the individual anatomists, or to mention in detail the successive improvements which were effected in their department. With respect to the practice of medicine, which is my more immediate object, it does not appear that they effected any direct improvement; but they contributed indirectly to its advancement, in no small degree, by completely establishing the important point, that the opinions of the ancients were not to be considered as infallible, but were to be subjected to the ordeal of free inquiry. * Eloy, " Vesale." Haller, Bib. Anat. lib. 4. §. 163. t. i. p. 180 et seq. Sprengel, t. iv. p. 5-9; Douglas, Bibliogr. Anat. p. 64-73. Renauldin, Biog. Univ. " Vesale." t Haller, Bib. Chir. lib. 5. " Schola Italica ;" and Bib. Anat. lib. 5. " Schola Italica." Fallopius, $. 200. t. i. p. 218 et seq. Eustachius, §. 205. t. i. p. 233 et seq. Douglas, Bibliogr. Anat. in Fallopio, p. 94-6, et in Eustachio, p. 98-100. Ivi HISTORY OF MEDICINE. CHAPTER IX. State of Medicine during the Seventeenth Century—The Chymical and Mathematical Sects—Pro- gress of Anatomy—Fanatics—Chymical Physicians—Sylvius—Willis—Sydenham—Mathematical Physicians. All the changes of opinion which we have described as occurring in the sixteenth century, continued to advance with an accelerated progress during the seventeenth. The preference which was given to Hippocrates over Galen was daily gaining ground, and, as the consequence of this, the habit of correct observation was con- firmed, and the value of the observations was more justly appreciated. In the mean time anatomy was making rapid strides. Being a science which depended more immediately upon the accumulation of matters of fact, which required for their attainment little more than industry and mere observation, errors were more readily discarded than on those subjects in which much reasoning was necessary, and in which it was rather an inference from facts than the facts them- selves which constituted the object of the investigation. The investigations of the anatomists extended to every part and structure of the body; the forms and texture of the bones, the muscles, the nerves, the vessels, and the various viscera were each in their turn made the subject of particular and minute examination by some of the eminent men of the age. These labours were amply rewarded by the splendid discovery of the circulation by the immortal Harvey, and of the absorbent system by Asselli, Rudbeck, and Bartholine; while the structure and office of the lungs, ana the relation which it bears to the heart, were explained by Malpighi, Hooke, Mayow, and their associates.* With respect to the chymists of this period, their opinions were gradually dis- engaged from the tissue of mystery and credulity in which they had been so long involved, when about the middle of the century the science was finally placed upon its correct philosophical basis by the genius of Boyle. He correctly regarded it as an investigation into the change of properties which bodies experience by their action upon each other, and he pursued the investigation, not by presupposing the existence of certain occult causes and hypothetical agencies, but by an accu- rate examination of the effects which bodies actually produce upon each other when placed within the sphere of their mutual action, f It is, however, not a little remarkable that while the science of chymistry gen- erally, and more especially the sect of the chymical physicians, was purifying itself of its grosser errors, we meet with not unfrequent instances where it con- tinued to be combined with a singular degree of fanaticism. There was indeed no period, since the time of Paracelsus, when there were more remarkable exam- ples of the prevalence of this spirit, and in no country were they more notorious than in England. The writings of Fludd, who practised in London in the early part of the seventeenth century, afford a curious compound of learning and folly of profound erudition, united to an implicit faith in astrology and in all the cabalis- tic opinions of the Jewish doctors.^ Perhaps a still more remarkable example of this combination is that of the celebrated Kenelm Digby, a man of rank and of refined education, who, during his travels on the continent, became initiated into thi§ mysterious chymical philosophy, and on his return gave a specimen of his opinions by publishing an account of the virtues of the sympathetic powder.^ * The fourth volume of Sprengel is principally occupied with a luminous view of the anatomical discoveries of this period. Mmi,lu t Campbell, Biog. Brit, in loco, Haller, Bib. Med. lib. ix. 6. 702, t. iii d 109-13 Nirh«l«™ Aikin's Gen. Biog. in loco. Morell, Brewster's Encyc. in loco. Suard et Cuvier, Biog. Universelle, X Enfield, v. ii. p. 454, 5. Sprengel, t. v. p. 6-9. Eloy, in loco; Haller Bib MpH t ii n am Aikin's Biog. Mem. of Med. p. 271-5 Hutchinson's Biog. Med. v i p 303-5 P' $ Sprengel, t. v. p. 9; Eloy, in loco; Campbell, Biog. Brit, in loco. Aikin's Gen. Biog. in loco HISTORY OF MEDICINE. Ivii Another of these individuals who obtained great celebrity was Valentine Greatrix, who cured all diseases by the imposition of the hand, and who even ventured to oppose his power in this respect to the royal touch of Charles.* These circum- stances are interesting, not merely as forming a part of the history of medicine, but as displaying a singular feature in the history of the human mind; demon- strating the difficulty which exists in eradicating from it errors and follies, even the most gross and palpable, when they have once become deeply rooted.f While what may be more strictly termed chymistry was advancing into the state of a science, a combination was formed between its principles and those of physiology, which gave rise to the new sect of, the chymical physicians. Their leading doctrine was, that the operations of the living body are all guided by chymical actions, of which one of the most important and the most universal is fermentation. The states of health and of disease were supposed to be ultimately referrible to certain fermentations, which took place in the blood or other fluids, while these fluids themselves were the result of specific fermentations, by which they were elaborated from the elements of which the body is composed. Again, certain humours were supposed to be naturally acid, and others naturally alkaline, and according as one or the other of these predominated, so certain specific dis- eases were the result, which were to be removed by the exhibition of remedies of- an opposite nature to that of the disease in question. According to the theory of the chymical physicians, fever was supposed to originate in an acid condition of the humours, and was consequently to be cured by alkalies: and in conformity with what is so often found to take place in tracing the history of medicine, they discovered that alkalies were actually the most efficacious remedies for fever. The individual who may be considered as having first given a connected and consistent view of the theory of the medical chymists is Sylvius. He was born at Hanau in Flanders in 1614; he graduated in the university of Basil, practised for some time at Amsterdam, and finally was appointed to fill the chair of prac- tical medicine at Leyden, where by his genius and eloquence he acquired a high degree of popularity. From this circumstance his peculiar opinions obtained a very extensive circulation, and the hypothesis of fermentation, with the acid and alkaline states of the fluids, after some time became the fashionable doctrine of the French and the German physicians, and had many zealous defenders in our own country.J One of the most respectable of the advocates of the chymical doctrines of medicine was our learned countryman Willis. He was only a few years younger than Sylvius, and was early in life attached to the science of chymistry, which he afterward applied with much ingenuity to the explanation of the functions of the animal economy. In the year 1659 he published his celebrated treatise on fermen- tation and on fever, the object of which is to prove that every organ of the body has its peculiar and appropriate fermentation, and that a morbid state of these ferments is the cause of all diseases. The hypothesis is in itself totally false, but it is supported by considerable ingenuity, and his works are of real value, as containing an accurate account of the phenomena of disease. Willis was also the author of some treatises of very considerable merit on the nervous system, and on various physiological topics, by which his reputation is amply supported as one of the, most eminent medical philosophers of the age.$ The reputation of Willis has, however, been somewhat obscured by the still higher reputation of Sydenham, a man scarcely inferior to any that has passed under our review. He has been frequently styled the English Hippocrates, and there are various points of analogy between them, both as to general character, and as to their peculiar mode of viewing the operations of the animal frame. The writings of Sydenham, like those of his great predecessor, abound in theory, but they also resemble those of Hippocrates, in containing the most accurate detail Nouv. Diet. Hist, in loco. Aikin's (Miss) Mem. of Charles I. v. i. p. 410-16. See " A late Discourse," &c, by Sir K. Digby, translated by R. White : a work which affords one of those embarrassing cases, where it is so difficult to assign the exact limit between credulity and empiricism. * Phil. Trans, for 1699, p. 332-4. Lowthorp's Abrid. of Phil. Trans, v. iii. p. 11, 12. Sprengel, t v. p. 10. Hutchinson's Biog. Med. v. i. p. 373-80. t Sprengel, sect. 13, ch. 1. ». X Eloy, " Dubois." Haller, Bib. Med. lib. ix. t. ii. p. 627 et seq. Sprengel, §. 13, ch. v. Biog. Univ. in loco. 6 Barchusen, Diss. 23, uiic«» HISTORY OF MEDICINE. lxlx repaid by the unremitting attention with which" he devoted himself to the medical school of that metropolis. Of the high reputation which it has since enjoyed he may be said to have laid the foundation, while, by the publication of his Comment- aries on the Aphorisms of Boerhaave, he demonstrated, at the same time, the high respect which he retained for his preceptor, and the extent of his own infor- mation on all subjects connected with medical science. The Commentaries of Van Swieten contain a large and valuable collection of practical observations, partly the result of the author's own experience, and partly derived from his ex- tensive knowledge of books. He adopted the theory of Boerhaave with little al- teration, and in this respect the work must be regarded as fundamentally defective; but the great body of facts which it contains, detailed as they are in a clear and perspicuous style, will always ensure it a place in the library of the medical student.* The intimate acquaintance which subsists between the doctrines of pathology and an acquaintance with the laws of the animal economy in its healthy and perfect state, makes it necessary for me to give some account of an individual, who, although not a practitioner of medicine, contributed perhaps more to our knowledge of the nature of disease than any one who has hitherto passed under our review. I refer to the great name of Haller, who has been not unaptly termed the father of modern physiology. He was the pupil of Boerhaave, and imbibed from him his thirst for knowledge, his correct judgment, his undeviating candour, his un- blemished integrity, and, in short, all the intellectual and moral qualities which we have admired in the professor of Leyden. But to these qualities Haller added a more extensive and original genius, which led him never to rest upon the unex- amined opinions of others, and a clearness of conception, which taught him, both in his language and in his mode of reasoning, to avoid all ambiguous and undefined terms, and all irrelevant arguments. He possessed a mind at the same time com- prehensive and correct, equally adapted for discovering new paths to knowledge! and for investigating those which had been previously entered upon by others. The innate powers of the components of the body, which had been imperfectly seen by Glisson and by Hoffmann, were examined by Haller with his characteristic acuteness, and the result of his long and well-directed experimental research was rewarded by the establishment of his theory of irritability and sensibility, as spe- cific properties attached respectively to the two great systems of the animal frame, the muscular and the nervous, to which, either separately or conjointly, may be referred all the phenomena of the living body. But perhaps a still more impor- tant service which Haller rendered to science was the example which he held out of carefully abstaining from all opinions founded merely upon speculative grounds, and of deducing his general principles exclusively from experiment and observation. He gave an impulse to science no less by the actual discoveries which he made, than by the spirit with which he conducted his researches, so that we may regard the publication of his Elements of Physiology as having introduced a new era into medical science.f It would be incompatible both with the immediate subject of this essay, and with the limits to which it is necessarily restricted, to give a detailed account of the controversies and discussions to which the theory of Haller gave rise- Notwithstanding its merits, and the evidence by which it was supported, it was opposed, either in its full extent or in certain of its parts, by many individuals of high respectability; while, on the contrary, various experiments were instituted, by which his conclusions were confirmed and his principles extended. Among those who were the most successful in these researches I may select the names of Zimmerman,! Caldani,§ Fontana,|| Tissot,? Zinn,** and Verschuir. The last of these physiologists particularly distinguished himself by his experiments on the contractility of the arteries,ft a point which had been left undecided by Haller, but which formed a most important addition to the theory of the action of the vessels, and which had previously been rather assumed as what was probable, than de- duced from any ascertained facts. * Eloy, in loco. Nauche, Biog. Univ. in loco. t Elye, Mem. Acad. Scien. 1777. Henry's Life of Haller. Sprengel, sect. 15, ch hi. Aikin's Gen. Biog. in loco. Thomson's Cullen, v. i. p. 221-240. Cuvier, Biographie Universelle, in loco. Dewar, Brewster's Encyc. art. " Haller." Blumenbach, Introd. §. 468. Goulin, Enc. Meth. M&lecine, in loco. X De Irritabilitate. § Instit. Physiol. II In Haller, sur la Nature Sens, et Irrit L iii. . f In Haller, sur la Nature Sens, et Irrit. t hi. *■* Exper. circa Corp. Cal. etc. ft De Arter. ei Ven. Vi Irrit. Ixx HISTORY OF MEDICINE. Whytt and Pbrterfield may perhaps be considered as the most powerful of the opponents of Haller. They were natives of Scotland, and during the earlier part of the last century, were residents in the metropolis of that kingdom, and bore a conspicuous part in the scientific institutions for which it was so justly celebrated. The former of them was professor of medicine in the university of Edinburgh, at the time when it was rapidly advancing to that high reputation which it afterward more fully attained, under the genius of his illustrious successor Cullen. They opposed that part of the theory of Haller which ascribes all the actions of the living system to certain powers necessarily connected with the material parts of the frame, as well as to the separation of these actions into the two distinct powers of irritability and sensibility.* The controversy which Whytt carried on with Haller was conducted with acuteness and ability, but it manifests a degree of acri- mony which it is impossible not to regret, particularly as occurring in an individual who was otherwise so much entitled to our respect. And this is more especially the case when we consider the nature of the objections which he urged against the Hal- lerian hypothesis, which were rather of a metaphysical nature, than such as were either founded upon experiment or deduced from observation. His doctrine of the vital motions of the body, which formed the principal subject of the controversy, maybe regarded as intermediate between that of Haller and Stahl, or rather compounded of the two. He attributes these vital motions to the operation of the sentient principle, which is supposed to be something distinct from the corporal frame, at the same time that it is necessarily attached to it, and is under the influence of phy- sical causes, not like the anima of Stahl, acting by a species of independent con- sciousness and volition. The great error which pervades the speculations of Whytt and Porterfield consists in their reasoning more upon metaphysical than upon physi- cal principles, and in their assuming certain powers, the proof of which rests more upon their supposed necessity to account for the actions of the system, than upon any independent evidence that we have of their existence. They did not, indeed, like the Stahlians, consider the sentient principle as something independent of the body, and only, as it were, appended to it, but as a principle or power necessarily belonging to the living body, and imparting to it its vitality, although essentially distinct in its nature from anjfr of the properties of a mere material agent. Whytt may be regarded as the founder of the sect which obtained the name of the Semi- animists, which, under various modifications, included some of the most distin- guished physiologists both in this country and in France. Of the latter, one of the most eminent was Sauvages ; he was a native of Languedoc, and received his edu- cation at Montpellier, which, during the early part of the eighteenth century, held a very high character as a school of medicine. In 1734, he was appointed one of the professors in the university of that city, and during the remainder of his life contributed materially to maintain its credit by his talents both as a writer and a teacher. His reputation with posterity will principally rest upon his Methodical Nosology, a work which contains an arrangement of diseases into classes, orders, genera, and species, on the same plan which had been employed in the arrange- ment of the subjects of natural history. The Nosology of Sauvages is a work°of great and original merit, which, although now in some degree superseded by the improvements of later writers, mainly contributed to the advancement of medical knowledge by producing accuracy in the use of terms and in the discrimination of the characters of disease.f The same kind of service which Haller rendered to the science of physiology was performed for that of the practice of medicine by his contemporary Cullen Among those who have made the study of medicine their professed pursuit no one, since the revival of letters, has risen to greater eminence during his life- time, nor has left behind him a higher reputation than this celebrated individual During the greatest part of a long life he was engaged in the teaching of medicine or some of the collateral sciences, first in the university of Glasgow and afterward in that of Edinburgh, which latter he contributed, in no small degree to raise tn the rank which it long held, of the first medical school in Europe His peculiar excellence as a lecturer afforded him an ample opportunity of promulgating and enforcing his doctrines, while their real merit, no less than the mode in wnich they were announced, rendered them in the highest degree popular among his * See particularly Whytt on Vital and Involuntary Motions, and Physiological Fssavs PnrtP,. field on the Eye, passim and papers in Edinburgh Medical Essays. Thomson' 'Cullen v f p af 368 f Eloy, in loco. Haller, Bib. Anat. " Boissier," t. n. p. 300-4, $. 999. ^"'""i- v. 1. p. .m-xioti. HISTORY OF MEDICINE. Ixxi pupils and contemporaries. He possessed an acute and ardent mind; he was well skilled in the medical literature both of the ancients and the moderns, but he had no undue respect for the opinions of others on the mere ground of authority. He detected the defects of former hypotheses with shrewdness and sagacity, while he proposed his own views with a degree of candour and modesty, which tended to render them the more acceptable, and disposed his audience to receive them in the same spirit with which they were proposed. With respect to his physiological writings, they afford, in some respects, a re- markable contrast to those of Haller; for while the latter are extended to a great length, and are filled with the most minute and elaborate details, the former are no less remarkable for their compressed brevity, consisting principally in general views and abstracted deductions. Contrary, however, to what is so frequently the case with respect to works of this description, they are not to be regarded as mere speculative positions, but as the condensed result of patient research and exten- sive observation. Some of the leading doctrines of his pathology were pro- fessedly borrowed from Hoffmann; but to these he made many important addi- tions, by taking advantage of the various improvements that had been made in physiological knowledge, principally by means of Haller and his pupils. Still later discoveries in this science, and in that of chymistry, have indeed proved that cer- tain parts of his system are not tenable, and that others require to be considerably altered and modified ; but it may be asserted, that no one produced a more pow- erful and lasting effect upon the state of medicine, in all its branches, both theoreti- cal and practical, than Cullen. But his great and appropriate merit, and which entitles him to the admiration and gratitude of posterity, is the sagaeity and dili- gence which he manifested in the description and discrimination of the phenomena of disease. In this talent he may be considered as rivalling Sydenham, or any of his most distinguished predecessors, while the recent improvements in physiology and the other branches of medical science gave him an advantage which he did not fail duly to improve. In his treatment of disease he manifested no less judg- ment and sagacity than in the formation of his theories. He was prompt and de- cisive, without rashness; he estimated the powers of remedies by a cautious and accurate examination of their effects, with little bias from hypothesis, and with even somewhat of a skeptical disposition of mind, which prevented him from falling into those errors and inconsistencies to which the practice of medicine is so peculiarly obnoxious. In giving an account of the system of Boerhaave, we remarked that in its forma- tion he proceeded upon the eclectic plan, founding it upon the opinions of others, which he endeavoured to connect together, and to mould into a consistent and uniform theory. Cullen adopted the more philosophical mode of generalization and induction. He disclaims all hypotheses and theories not derived immediately from facts, and made it his great business to collect, by actual observation, the materials from which he mujht deduce his general principles. In this object he was eminently successful, and it is this which gives his writings their great value, a value which they must ever retain, amid all the revolutions of opinion, which attach to medicine more than to any other branch of science. But, although he was so sensible of the advantage of the inductive mode of investigation, he was not a mere empirical practitioner, who disregarded all theoretical reasoning, and never ventured to go beyond the simple result of experience. On the contrary, he inquires in all cases into the remote and primary causes of disease, and endeavours to deduce from them his indications of cure. Many of his individual speculations are indeed remarkable for their subtilty and refinement, and may be characterized as exhibiting more ingenuity than judgment. At the same time it is not a little remarkable, that these speculations, however carefully they were elaborated, had but little influence on his practice; and it is gratifying to observe with what caution he applies his hypothesis to explain or direct his method of treating disease. His great work, entitled, " First Lines of the Practice of Physic," is the one on which his reputation will principally rest; but the merits of his Institutions, of his Nosology, and of his Lectures on the Materia Medica, are each of them sufficient to have entitled him to a distinguished rank among the improvers of medical science. The last of these works, in which he takes a more philosophical view of the opera- tion of remedies than had been done by any of his predecessors, is one of peculiar value. It contains a great variety of important pathological observations, together Ixxii HISTORY OF MEDICINE. with a complete theory of therapeutics, and being the latest of his publications, we find in it his more matured and corrected views on many topics which had been treated in his former works. In none of them do we find more of that spirit of rational skepticism to which I have alluded above, and which led him to be more confident in opposing the opinions of others than in maintaining his own. Like Haller, with whom I have already taken occasion both to compare and to contrast him, he Contributed to introduce into medical reasoning a philosophical spirit, which has produced a permanent and highly salutary effect upon the healing art, and which associates the name of Cullen with those of the great benefactors of the human race. It is not easy to give, in a short compass, an account of the pathological doctrines of Cullen, because they consisted rather of a number of individual parts, as applied to the explanation of particular phenomena, than of one comprehensive system, which constituted a general theory of diseased action. The foundation of the system is, however, sufficiently simple ; that the living body consists of a number of organs, which are all of them possessed of powers of a specific and appropriate nature, distinct from those which are attached to inanimate matter. These powers are so ordered that they have a tendency to preserve the whole machine in a per- fect state, when its actions and functions proceed in their ordinary course. When any irregularity supervenes, either from internal or external causes, if it be not in an excessive degree, the self-regulating principle is sufficient to control the opera- tion of the morbid cause, and to restore the system to its healthy condition. This regulating principle, or, as it was termed, the vis medicatrix naturce, differs essen- tially from the archeus of Van Helmont or the anima of Stahl, inasmuch as it is supposed not to be any thing superadded to the body, but one of the powers or properties necessary to its constitution as a living system, and the existence of which is recognised by its effects. Although the laws of gravity and of chymical affinity affect the animal body, so far as it is composed of material organs, yet its appropriate actions are under the immediate influence of the specific laws of vitality. Hence all explanations, depending upon mere mechanical or chymical reasoning, were abandoned, and in their place was substituted the vital action of the parts, and more especially that of the extreme branches of the arterial system, or, as they are styled, the capillary arteries. Although it may appear that both Stahl and Hoffmann had, to a certain extent, preoccupied the ground which was taken by Cullen, as to the foundation of his system, and although the system, as detailed by him, is defective in some of its subordinate parts, yet we must admit, that the ample and explicit manner in which it was stated gave it the aspect and much of the merit of novelty, while the applications which he made of it were frequently just, and always ingenious. His physiology and his chymistry were not in all cases correct; he did not pay sufficient attention to the distinction between the powers of the muscles and the nerves, which had been so well discriminated by Haller, and he even confounds their physical structure. But, with all these abate- ments, we still regard the pathology of Cullen with much respect, and consider him as one of those who greatly contributed to improve the science no less than the practice of his art.* What may be termed the Cullenean school of medicine, including both his numerous pupils and the writers who either embraced his peculiar opinions or adopted his method of investigation, comprehends a large portion of the most distinguished of the British physicians during the remainder of the eighteenth century. The rational empiricism, as it has been styled, which he so firmly established, both by precept and example, has, in this country at least, so far superseded the taste for mere speculation and hypothesis, that we are, perhaps disposed to run into the opposite extreme, and to undervalue all attempts to inves- tigate the abstract principles of pathology, and to employ ourselves solely in the * For a minute detail of the opinions of Cullen, and those of his immediate predecessors and contem poranes, the reader is referred to the learned and ample work of Dr. Thomson^ which mav be charac" tenzed as containing a philosophical history of medicine and pathology during the beginning and" middle of the eighteenth century. The account which is given of Cullen's pupils must be perused with much interest—an interest which, in the case of the writer of this work, is exalted bv the sacred sentiment of filial piety: p. 461, 644-6. I conceive that Sprengel, t. v. p. 359-366, in criticisinnhe doctrines of Cullen, is somewhat deficient in that candour for which he is, in most cases so con ?WX» SCe ^ EnCyC' Brlt' ln l0C°; Alkin'S Gen- Bi°g-in l0C0; A Brer's Encyc. art HISTORY OF MEDICINE. Ixxiii accumulation of facts, without duly attending to the general conclusions that may be deduced from them.* We have, however, to notice one singular exception to this remark, where an hypothesis was advanced, of the most bold and lofty pretensions, disdaining the support of facts and experience, and professing to explain all the phenomena of life and of disease by a few simple aphorisms. In tracing the history of science, although it is proper, for the most part, to estimate books and opinions solely by their intrinsic merit, without any regard to the personal character of the author, yet we find them, on some occasions, so intimately connected, that it is impossible altogether to separate them. This is the case with the celebrated Brown, whose theory appears to have originated as much from spleen and disappointment, and a determination to oppose the doctrines of Cullen, as from a more legitimate motive. Neither the education of Brown nor his natural character were of the kind the best adapted for the prosecution of medical science. He was originally destined for the ecclesiastical profession; and when he afterward entered upon that of medicine, he never devoted himself to those elementary studies which are indis- pensably necessary to a correct knowledge either of theory or of practice. But what he wanted in knowledge he endeavoured to supply by the force of his own genius; and by meditating upon a few general or abstract principles, he ventured to form a new system of pathology, which he announced with a degree of confi- dence that, while it exhibited the strong powers of his understanding, proved no less the deficiency of his information. Medicine, which had hitherto been a con- jectural art, was now to be built upon a few certain and fixed principles, which, by superseding all that had been previously written upon the subject, and by being independent both of observation and of experience, required for its attainment little previous study or learning. The novelty of the attempt, the easy access which it promised to a science which before appeared of difficult approach, and the plausi- bility of some of its leading positions, acquired for the new theory a prodigious degree of popularity in the university of Edinburgh, where it was first promulgated. Brown had.been, in the first instance, patronised by Cullen; but, from some causes, both of a personal and a professional nature, which it is not difficult to comprehend, he forfeited the good opinion, and became the bitter antagonist of the doctrines of his former friend. The controversy to which this schism gave rise was carried on for some years with great vehemence, and was by no means confined to the place where it originated. In this country the Brunonian system obtained many adherents when it was first proposed, principally, indeed, among the students or younger members of the profession; while in some parts of the Continent, more especially in Italy, it was adopted by men of learning and science, and became the prevailing hypothesis in some of the most respectable medical schools. The general principles of the theory are few and simple. He assumed that the living body possesses a specific property or power, termed excitability; that every thing which in any way affects the living body acts upon this power as an excitant or stimulant; that the effect of this operation, or excitement, when in its ordinary state, is to produce the natural and healthy condition of the functions; when exces- sive, it causes exhaustion, termed direct debility; when defective, it produces an accumulation of excitement, or what is termed indirect debility. All morbid action is conceived to depend upon one or other of these states of direct or indirect debility, and diseases are accordingly arranged in two great corresponding classes of sthenic or asthenic; while the treatment is solely directed to the general means for increasing or diminishing the excitement, without any regard to specific symp- toms, or any consideration but that of degree, or any measure but that of quantity. Such general views and sweeping doctrines, however alluring to the uninformed * In this brief sketch I can do no more than merely mention the names of some of our countrymen who, either by the publication of single cases, or of monographs on certain diseases, have contributed to the advancement of pathological or practical knowledge. Among others we may select those of Gregory, the able successor of Cullen, Pringle, M'Bride, Huxham, Fothergill, Cleghorn, Brocklesby, Lind, and Russel. In our own times, we have had the no less illustrious names of the Hunters, of Percival, Withering, Johnstone, Falconer, Heberden, Baillie, Haygarth, Ferriar, Currie, Willan, Bateman, Marcet, and Parry. In mentioning the name of Gregory, I must be allowed to express the sentiments of respect and regard which I have always felt for my preceptor. The elegance of his literary taste, his clear and comprehensive judgment, and more especially the interesting mode in which he conveyed his instruction, all contributed to render him one of the most distinguished orna- ments of bis profession. K Ixxiv HISTORY OF MEDICINE. or the mere theorist, are altogether inapplicable to practice ; and it is a subject for our admiration how they could be for a moment entertained by any one who had studied the phenomena of disease, or who was acquainted with the intricate and complicated relations of the different functions and actions of the living, system. Accordingly, in this country, where, in consequence of the prevalence of the Cullenean school, the attention was more directed to practical than to theoretical details, the professed adherents of Brown were neither numerous nor influential] and even in Italy, where for some time it enjoyed considerable popularity, it has long ceased to be maintained. Yet it must always occupy a distinguished place in the history of medical science, as exhibiting a remarkable example of the force of original and unaided genius in erecting a system, plausible and captivating in its aspect, but devoid of the essential support of facts and observations, and therefore fated to share the lot of all systems built on so unstable a basis.* In connection with Brown I must notice a medical theorist, whose general prin- ciples bore a considerable resemblance to those of the " Elementa Medicinae," but whose character, talents, and acquirements were of a totally opposite kind. The " Zoonomia" of Darwin exhibits genius and originality; but in no other respect does it bear any resemblance to its prototype. Darwin possessed a knowledge of medical and all the collateral sciences in their full extent; he was familiar with practice, and had a taste for minute detail and experimental research, which, while it appeared to qualify him for a medical theorist, enabled him to give to his system an imposing aspect of induction and generalization. His speculations, although highly refined, profess to be founded upon facts; and his arrangement and classifi- cation, although complicated, seem consistent in all their parts. No theory which had ever been offered to the public was more highly elaborated, and appeared to be more firmly supported by experience and observation, while every adventitious aid was given to it from the cultivated taste and extensive information of the writer. Yet the Zoonomia made little impression on public opinion; its leading doctrines rested rather upon metaphysical than upon physical considerations; its fundamental positions were found to be gratuitous, and many of the illustrations, although ingenious, were conceived to be inapplicable and inconclusive. It is now seldom referred to, except as a splendid monument of fruitless labour and misapplied learning.f CHAPTER XII. Remarks on the State of Practical Medicine at the Conclusion of the Eighteenth Century—State of Medicine in France, Lieutaud—State of Medicine in Germany, De Haen—State of Medicine in Italy, Morgagni, Burserius, Rasori—Epidemics—Improvements in Pharmacy. While the British physicians were principally occupied in collecting facts and recording their observations, and, with the exception of the temporary suspension which was occasioned by the Brunonian controversy, were more intent in adding to the stock of knowledge than in forming systems, the continental physicians were more disposed to pursue the eclectic plan of Boerhaave. In France this was accomplished with the most success by Lieutaud. He was a native of Prov- ence, and was for some years a professor at Aix; in 1749 he was appointed physi- cian to the royal hospital at Versailles, and finally to the court of France. He was eminent both as a practitioner and an anatomist; his great work, the " Sy- nopsis universal Praxeos Medicae," published in 1765, contains much information * Beddoes's Observations, prefixed to his edition of Brown's Elements ; a writer possessed of ori- ginality and genius, but perhaps not unaptly characterized by Rothe as " a blind adherent of the new chymists and of Brown." M'Kenzie, in Brewster's Enc, art. "Brown." Parr's Diet, art " Bruno- nian System." Aikin's Gen. Biog. in loco. Sprengel, t. vi. p. 155-158, 315-334. Suard, Biographie Universelle, in loco. t Brewster's Enc, in loco. Sprengel, vol. vi. p. 269, 70, 278, 9. Young's Med. Lit., p. 54, 5. Brown's Remarks on the Zoonomia, an acute, but rather severe critique. Suard, Biographie Uni- verselle, in loco. HISTORY OF MEDICINE. Ixxv on all topics connected with medicine, and is valuable from its real merits in this respect, while it is interesting as affording a correct view of the state of medical science in France at that period. With respect to his general principles, he was an eclectic, uniting certain parts of the old doctrines of the mathematicians and the humoralists with those of Hoffmann and the vitalists.* Upon the whole, how- ever, 1 conceive that I shall not be accused of partiality or want of candour in stating the opinion, that the views of Lieutaud and his countrymen are less matured than those of his contemporaries in this island or in Holland. I may remark, in speaking of France, that for many years the great seat of medical science in that country was Montpellier. Its university was established in the thirteenth century, and was one of the earliest of those which rose to any considerable eminence; a distinction which it maintained until it was rivalled by that of Paris, which gradu- ally acquired its splendid reputation during the course of the seventeenth century. To the name of Sauvages, who was mentioned above as distinguished for his learned work on nosology, we may add those of Bordeu, Barthez, and Astruc as among the most eminent members of the school of Montpellier.f Of the medical schools of Germany, the most celebrated during the seventeenth and eighteenth centuries was Vienna. I have already mentioned the exertions that were so successfully made for its advancement by Van Swieten, who was appointed one of its professors in the year 1734. After he had occupied this situ- ation for about twenty years, he associated with himself his countryman De Haen, who materially contributed to support the reputation of the university, particularly by his talents as a practitioner. His great work, entitled, " Ratio Medendi," is a valuable repository of facts and observations, upon which I may make the same remark that I offered above respecting Lieutaud's " Synopsis." De Haen has been characterized as a man of great learning, united with much practical skill, and a talent for correct observation; but, on the other hand, he appears to have been unreasonably prejudiced against new opinions, and even improvements, in his art; for not only was he one of the most zealous opponents of Haller's theory, but he was no less decided in his opposition to the practice of inoculation, and to the use of various new remedies, which were at that period introduced into medi- cine, the value of which is now generally recognised. The state of medical theory then prevailing in Vienna was nearly the same with that which was taught in the universities of Leyden and Paris; the doctrines of the humoral pathology may be considered as forming the basis of their hypotheses ; but upon these was engrafted a certain portion of the new views respecting the action of the nervous system and the contractibiHty of the muscular fibre. In Italy, which so early acquired a high degree of celebrity for its medical schools, and which still retains a considerable portion of its former reputation, the sciences of anatomy and physiology were cultivated with success, while they were but little attended to in the other parts of Europe. What may be styled anatomical pathology took its rise in Italy in the seventeenth century. The indi- vidual to whom the merit of having opened this new road to the improvement of medical knowledge is principally due is Bonet,| who was born at Geneva in 1620, and at an advanced period of his life published his great work, entitled " Sepul- chretum," which was afterward enlarged by his learned and industrious country- man Manget.fy The Sepulchretum has been styled " The Library of true Pathology;" it consists of a great collection of cases, in which we have a history of the disease, with the appearances found upon dissection. The plan which had been commenced by Bonet and Manget was followed up by Valsalva, an eminent professor of Bo- logna, and still further perfected by the illustrious Morgagni. This eminent anatomist was a pupil of Valsalva's, and afterward became professor in the uni- versity of Padua, where for nearly sixty years, until his death, which took place in 1771, he devoted himself without intermission to the study of his favourite pursuit. The principal works of Morgagni are, his " Adversaria Anatomica," his " Epistolae Anatomicae," and more especially his great pathological collection enti- tled '' De Sedibus et Causis Morborum per Anatomiam indagatis." It proceeds * Hutchinson's Biog. Med., vol. ii. p. 63 et seq. t Moreau de la Sarthe, Encyc. Meth. M6decine, in loco. X Haller, Bibl. Med. lib. 10, §. 750, t. iii. p. 236 et seq. Eloy, in loco. Dezeimeris, Arch. Gen. de MeU xx. 158, 9, $ Haller, Bibl. Anat. lib. 7, $. 749, t. i. p. 103 et seq. Haller, Bib). Med. lib. 11, §, 889, t. iii. p. 603 fit seq. Eloy, in loco. lxxvi HISTORY OF MEDICINE. upon the plan of Bonet's Sepulchretum, and contains the observations which were made both by himself and by Valsalva, and has always been regarded as a reposi- tory of facts and observations on anatomy and pathology, unequalled in extent and accuracy.* The Institutions of Burserius afford a favourable view of the state of medical science in Italy at this period. He was born at Trent in 1724; studied first at Padua, and afterward at Bologna; he was for some years a professor in the university of Pavia, and finally removed to Milan, where he died in 1785.f Bur- serius was rather an eclectic than an original theorist, but his work is much valued for the information which it contains, and much admired for the elegant manner in which the information is conveyed. Like his contemporaries in Holland, France, and Germany, his doctrines are essentially founded upon those of the humoralists, but to these he unites various parts of those of the solidists and vitalists, and has proved himself deserving of the praise, not only of learning, but of candour and judgment. I have already had occasion to remark upon the effect which was produced in Italy by the theory of Brown; it was embraced by many of the learned men of that country, and for some time acquired a considerably greater ascendency over public opinion than it possessed even in its native city. It was not only defended in their publications, but its doctrines were applied to practice, and it was not until their insufficiency had been detected by fatal experience that the delusion was removed.^ At the conclusion of the eighteenth century it would seem that the medical theories of the Italians were considerably similar to those of the Cullen- ean school, and that the Italians, like the English physicians, were little disposed to form systems of medicine, but devoted themselves principally to the cultivation of anatomy and physiology, in addition to the more immediate studies of their profession. In tracing the additions and improvements which the science of medicine re- ceived during the eighteenth century, I must not omit to notice the descriptions of new diseases, either those which were conceived to have actually originated during this period, if there were any such, or those which had not been previously dis- criminated with sufficient accuracy from others that in many respects resembled them. The various epidemics which, from some unascertained and unexplained causes, have at different times passed over large portions of the surface of the earth; the endemic diseases attached to particular situations, originating in some circumstances connected with the atmosphere, soil, or climate of certain districts, or in the occupation or mode of life of its inhabitants ; and lastly, the contagious or infectious diseases, which have invaded entire cities or communities, from un- known, or at least obscure causes, and, after spreading destruction on all sides, have disappeared from causes equally unascertained. The first of these classes, the epidemic diseases, were made an especial object of attention, in the latter part of the seventeenth century, by Sydenham, whose remarks on them are among the most interesting of his works ;" also by Morton and by Ramazzini: at a somewhat later period we have the valuable observations of Huxham, of Lancisi and Torti in Italy, and of Stoll at Vienna. The science has been much enriched by various descriptions of the diseases incident to the army and navy, among which we may particularly notice those of Pringle, Brocklesby, D. Monro, Hunter, Lind, Hillary, Blane, Trotter, Larrey, and Desge- nettes.fy The formidable disease which has been emphatically termed the Plague, as it appeared in London, the Low Countries, Marseilles, Moscow, and other parts of Europe, in the latter part of the seventeenth and the beginning of the eighteenth century, and as it still exists in Turkey, Egypt, and the adjoining countries,|| as well * Eloy, in loco. Haller, Bibl. Anat. lib. 8, §. 797, t. ii. p. 34 et seq. Haller, Bibl. Med. lib. 12, §. 1029, t. iv. p. 424 et seq. Renauldin, Biog. Univ. in loco. t Vide Praef. ad Instit. Med. Prac. ed. Lips. 1787. X Rasori of Genoa appears to have been the first who made his countrymen acquainted with the doctrines of Brown, of which he was a zealous adherent; subsequently, however, he found reason from the result of experience, to change his opinions, and very candidly and honestly expressed his conviction of their erroneous tendency. An ample account of the pathological doctrines which are at present the most generally received in Italy, under the title of " Nuova Dottrina Italiana," may be found in the various publications of Tommasini, the learned professor of Bologna. () For a very complete list of works on these subjects, the reader is referred to the valuable work of Professor Ballingall on Military Surgery, p. 227 et seq. Ii Hecker's account of the " Black Death," which ravaged so large a portion of the globe in the HISTORY OF MEDICINE. „ lxxvii as the less formidable, although more extensive visitations of the influenza, have each had their historians ; and it is truly gratifying to observe that, in most cases, the writers have been more anxious to collect facts and to obtain correct informa- tion, than to support any particular theoretical views.* In reviewing the state of medical science during the eighteenth century, and tracing its gradual advancement, we are naturally led to remark upon the great additions which have been made to pharmacy, both in regard to the introduction of new articles into the materia medica, and the improvement that has taken place in the preparation of various substances, and the mode of their administration. It has been remarked, that in proportion as our knowledge of the virtues and qualities of medicines has been matured, our pharmacopoeia has been simplified, both as to the number of articles employed and the mode of compounding them. Accordingly, if we compare the successive editions of the British pharmacopoeias and dispensatories, we shall find that a number of superfluous and inert substances have been from time to time rejected, and that the complex formulae of the older physicians have been reduced in the same proportion. At the same time some substances of real efficiency have been added, while the improvement in chymical science has enabled us to obtain the active principles of these substances in much more condensed and commodious forms. This remark may be illustrated by Peruvian bark, a remedy which for a long period afforded a fertile field for contro- versy, both as to its power over disease, the nature of its operation, and the mode of its administration. Practitioners have long been aware of the futility of most of the points which were the subject of so much warm and even acrimonious discussion, and are satisfied with recognising its value as a powerful curative agent in certain diseases, without endeavouring to discover the nature of the occult qualities on which its operation depends; while the chymist has lent his aid in pointing out a mode by which its active proximate principle may be procured, detached from the inert matter with which it is naturally combined. The skill of the modern chymist has likewise been most beneficially exercised on the metallic preparations; giving them more fixed and definite combinations, pointing out the modes by which they may be produced with more ease and certainty, and ascer- taining the chymical relation which they bear to other substances, so as to indicate how they may be combined with them without decomposition, or even with an increase of their activity. CHAPTER XIII. Cursory Remarks on the State of Practical Medicine since the Commencement of the present Cen- tury—Difficulty of acquiring Medical Experience—State of Medicine in Great Britain—Pathologists of France—Physiologists of Germany—Medical Journals—Medical Societies—Schools of Medi- cine—Suggestions for the Improvement of Medical Science. As the historian of medicine approaches nearer to his own times, he finds his path encumbered with almost insurmountable difficulties. The subject on which he has to treat differs, perhaps, from every other branch of science in this circum- stance, that our actual information does not increase, in any degree, in proportion to our experience. Hence it follows that the accumulation of materials frequently rather retards than promotes its progress. In other sciences, although truth is not to be attained without a certain degree of laborious research, yet to those who are willing to bestow on it the requisite attention, it is, for the most part, attain- fourteenth century, may be mentioned as a work worthy of our notice, both as containing many interesting details of this tremendous pestilence, and as exhibiting a curious specimen of medical hypothesis. * For the names of the authors who have treated on these topics, I must refer to the respective articles in the Cyclopedia of Medicine. Copious lists of authors may also be found in Young's Med- ical Literature, a work no less remarkable for its learning than for the condensed form in which it is communicated. Much valuable information on this subject will be found in Sprengel, sect 16, ch. 3, art. 2. lxxviii HISTORY OF MEDICINE. able, or, if it still eludes our grasp, we are at least sensible of the deficiency, and can generally ascertain the precise nature of the obstacles which impede our pro- gress. In other sciences, when we enter upon an inquiry, or propose to ourselves any definite object for experiment or observation, we are able to say whether the result of our inquiry has been satisfactory, and whether the object in view has or has not been accomplished. But this is unfortunately not the case in medicine. There are certain peculiari- ties necessarily connected with the subject, which render it extremely difficult to appreciate the value of experiment and observation. In our experiments we are seldom able to ascertain with accuracy the previous state of the body on which we operate, and in our observations we are seldom able to ascertain what is the exact cause of the effect which we witness. The history of medicine in all its parts, and especially that of the materia medica, affords ample testimony to the truth of these remarks. In modern times, and more remarkably in Great Britain, no one thinks of proposing a new mode of practice without supporting it by the results of practical experience. The disease exists, the remedy is prescribed, and the disease is removed; we have no reason to doubt the veracity or the ability of the narrator; his favourable report induces his contemporaries to pursue the same means of cure, the same favourable result is obtained, and it appears impossible for any fact to be supported by more decisive testimony. Yet in the space of a few short years the boasted remedy has lost its virtue, the disease no longer yields to its power, while its place is supplied by some new remedy, which, like its pre- decessors, runs through the same career of expectation, success, and disappoint- ment. Let us apply these remarks to the case of fever, the disease which has been styled the touchstone of medical theory, and which may be pronounced to be its opprobrium. At the termination of the last century, while the doctrine of Cullen was generally embraced, typhus fever was called a disease of debility, and was of course to be cured by tonics and stimulants. No sooner was it ascertained to exist, than bark and wine were administered in as large doses as the patient could be induced, or was found able to take. No doubt was entertained of their power over the disease; the only question that caused any doubt in the mind of the practitioner was, whether the patient could bear the quantity that/vould be neces- sary for the cure. To this treatment succeeded that of cold affusion. The high character and literary reputation of the individual who proposed this remedy, its simplicityand easy application, the candid spirit which was manifested, and the strong testimo- nials which were adduced by his contemporaries, bore down all opposition, and we flattered ourselves that we had at length subdued the formidable monster. But we were doomed to experience the ordinary process of disappointment; the practice, as usual, was found inefficient or injurious, and it was, after a short time, supplanted by the use of the lancet. But this practice was even more short-lived than either of its predecessors; and thus, in a space of less than forty years, we have gone through three revolutions of opinion with respect to our treatment of a disease of very frequent occurrence, and of the most decisive and urgent symptoms. Are we, then, to conclude that all medical treatment is of no avail! that it is all imaginary or deceptive ? I should feel most unwilling to be compelled to form such a conclusion, nor do I conceive that it necessarily follows from the premises; but the facts certainly prove the importance of extreme caution in forming our conclusions, and still more that mere experience, without the due combination of well regulated theory, is a most fallacious guide. What objection can the man of mere experience, the rejector of all theoretical deductions, urge against the mul- tiplied testimony that is now presented to us in favour of the Ilomoiopathic doc- trine ?—what answer can be made to the report that has been recently brought forward, by the medical commissioners of Paris, on the subject of Animal Mag- netism ? The conclusion that forces itself irresistibly on the mind is, that no medical testimony is sufficient to establish a fact which is in itself incredible, and that this previous incredibility can only be ascertained by an extensive and accurate knowledge of the functions and properties of the living body, both mental and corporal, in all its modifications and under all circumstances, and by a correct and careful generalization of the knowledge thus obtained. These considerations, as HISTORY OF MEDICINE. lxxix well as others which will present themselves to the mind of the reader, may be deemed a sufficient reason for my attempting no more than to offer a few general observations on the state of medical science during the period at which I ani now arrived. I shall therefore devote this chapter to some cursory remarks on the practice of medicine as it now exists in the different countries of Europe, as well as on the state of some of the collateral or auxiliary departments, and shall con- clude by some suggestions for the best means for promoting its future progress. The prevailing and predominant feeling of the most enlightened and the most judicious of the British practitioners during the period referred to, has been to place little value upon theory, and to devote their minds almost exclusively to the observation and collection of facts. There can be no doubt that this is a less injurious extreme than the opposite; but if the statement which has been made above be correct, it will probably be admitted that this system may be carried too far. And the same exclusiveness has also induced them to pay too little attention to some of the collateral departments of science. In pathology and in pharma- ceutical chymistry they have been far outstripped by the French, and in physiology by the Germans. But at the same time that I feel it necessary to pass this judg- ment on my countrymen, I must fully admit that the spirit of rational empiricism, to which 1 have referred above as the characteristic feature of the Cullenean school, has produced a most beneficial influence on the general state of medical practice. If it has, on some occasions, produced fluctuation of opinion, and in others indecision or inertness, it has tended to sweep away much error, and to purify the science from many of the antiquated doctrines and practices that still maintain their ground among our continental brethren. This is more especially the case with our pharmacopoeias, where, if we compare those of London and Paris, we shall be struck with the number of what we conceive to be useless arti- cles that are still retained in the latter, sanctioned by the authority of the scientific and enlightened body of men who compose the medical faculty of the French metropolis. We are, however, indebted to France for the most important improve- ments which have taken place in pharmaceutical chymistry: by their method of obtaining the proximate principles of various vegetable substances, and the greater precision which they have introduced into the formation of the metallic prepara- tions, they have conferred a great and lasting benefit on the art, which, among all the revolutions of opinions and practices, can never be countervailed.* But the glory of French medical science is its pathology. We are justly proud of our Hunters, our Munros, and our Baillie; and there are certain individuals among our contemporaries who are emulously treading in their footsteps.'' But any feeling of national vanity which we might be disposed to indulge must be effectually repressed when we look at the illustrious band of French pathologists, when we review the labours of Pinel, Andral, Breschet, Broussais, Corvisart, Cruveilhier, Dupuytren, Laennec, Bayle, Louis, Gendrin, Foville, Chaussier, and others,! who have directed their attention more exclusively to pathology; and when we add to these the names of those who are-to be regarded more in the light of physiologists, Bichat, Vic-d'Azyr, Cuvier, Richerand, Majendie, Edwards, Dumas, Legallois, Adelon, Demoulins, Serres, Blainville, Flourens, St. Hilaire, Dutrochet, and others, we must admit that France exhibits an unrivalled assem- blage of medical philosophers. From the united labours of these eminent men it is impossible not to anticipate the most important results ; but I believe that I am justi- fied in asserting that, so far as the practice of medicine is concerned, the benefit is still rather in anticipation than in«existence. With certain exceptions, but these no doubt very important ones, I should characterize the French practice as decidedly less effective than that of our country ; dependence is placed on remedies which we * We have a very learned review of the state of medicine during the early part of the present century from the pen of the celebrated Sprengel. It is peculiarly valuable, from the numerous refer ences which it contains to the writers of Germany, and from the view that it presents of the opinions which prevail in that country. The German physiologists afford a singular admixture of profound investigation and fanciful mysticism.—Ed. Med. Journ. v. xii. p. 385 et seq. We have also an inter esting sketch of the progress of the science by Cuvier; Hist. Scien. Nat. t. i. p. 311-344, and t iv p. 2303-44. t I may refer my readers for an interesting account of the progress of pathology, since the com- mencement of the present century, to a series of papers in the Archives Generates de M^decine, by M. Dezeimeris, t. xxix. et seq. The " Dissertation" of Professor Alison, appended to the " Cyclo- paedia of Practical Medicine," contains an admirable view of the state of medical science generally during this period. lxxx HISTORY OF MEDICINE. conceive to be inert, and much of the dietetic regimen which enters so largely into the treatment can produce no effect in the removal of disease. In short, their " medecine expectante," although it may be a less dangerous weapon in the hands of ignorance or presumption, is, in the same proportion, less powerful and bene- ficial when under the direction of skill and judgment. If France is pre-eminent for its pathology, Germany is no less so for its physi- ology and its anatomy. The names of Camper, Blumenbach, Ludwig, Soemmering, Meckel, Wrisberg, Reil, Tiedemann, Wenzel, Sprengel, Jacobsen, Carus,Pfaff, Oken, Osiander, Ackermann, Rosenmiiller, Gmelin, Walter, and Treviranus may be selected from many others, as among the most celebrated throughout Europe, and as having made most important additions to our knowledge on the subjects to which they have particularly directed their attention. Yet, in Germany as in France, the effect of this scientific co-operation on the practice of medicine is not yet fully experi- enced. The treatment of disease is perhaps not more effective than in France, while it is still more encumbered with complicated formulae and with antiquated practices, which in this country have been discarded because they have been found useless or even injurious.* Italy, which so loHg took the lead in all scientific pursuits, now offers the aspect of a splendid ruin, where we occasionally meet with an illus- trious name, such for example as those of Scarpa, Caldani, Mascagni, Rolando, Bellingeri, and Tommasini, but where medical science, if it has not retrograded, has at least remained stationary. The practice of medicine has, however, had some zealous cultivators; I have already remarked on the activity with which the Brunonian controversy was pursued, and the excitement which was then produced seems to have had a beneficial effect in rousing the dormant energy of the mind, of which some traces are still visible. A circumstance which has materially contributed to the improvement of the knowledge of practical medicine is the publication of periodical works, whether in the form of journals or of the transactions of societies. They have brought before the public the daily occurrences and passing events in a commodious and interesting form, and thus by exciting attention to them, have tended both to diffuse and to increase our knowledge on these subjects. It is, however, very much to be re- gretted that so valuable a mode of communication should, in too many instances, be used as the medium of personal animosity, and that what ought to be employed for the promotion of the welfare of mankind should become a vehicle of the basest and the most malignant passions. On this point, as well as on the one referred to above, justice compels me to state that the French metropolis offers us an example by which we might profit, in the number, extent, and general character of its medi- cal periodicals; and the same sentiment leads me to remark, that the medical periodicals of London are decidedly excelled by those of Edinburgh and Dublin.— Among the published transactions of medical societies, the Medico-Chirurgical may fairly be selected for our approbation; these, in the short space of about twenty-four years, have amounted to eighteen volumes, and have acquired a character which is too well established to require recommendation or sanction. In connection with their transactions I may mention the effect of the societies themselves, which, when they are confined to subjects of medical science, must be highly beneficial. Perhaps no single institution has contributed more to the im- provement of our profession than the Edinburgh Medical Society, which, for so long a period, has maintained a reputation that reflects the greatest credit, not merely on its members, but even on the university to which it is attached. It is, indeed, a remarkable and an honourable circumstance, that an association, principally com- posed of students and entirely conducted by them, should have proceeded for above half a century in so uniform a course of respectability; that during this period they should have admitted of free discussion, without deviating into licentiousness, and that amid the fluctuations to which such an association must necessarily be subject, successors have at all times been found able to direct its progress and qualified to support its reputation. Another circumstance to which I must briefly advert, which is both the cause and the consequence of the progress of our art, is the improved state of medical schools of all descriptions, both those attached to universities or to public hospitals, * In speaking of the practical writers of Germany, it would be unjust to omit the name of Frank, and not to acknowledge, the obligation which he has conferred upon medical science. Among the pathologists, Hartmann of Vienna and Conradi of Gottingen are perhaps the best known in this country. HISTORY OF MEDICINE. Ixxxi and those conducted by private individuals. By a very singular anomaly it has happened that, in this cpuntry, the highest medical honours have been hitherto conferred by those bodies who did not profess to give the requisite means for their attainment. This circumstance may, indeed, in one point of view be regarded as paying the highest compliment to the English universities; but I believe that a very general sentiment now prevails among their most respectable members that this anomaly ought no longer to be suffered to exist, and that medical honours ought to be bestowed upon those, and those only, who have gone through what may be considered a sufficient course of preparatory studies, and who are able to give satisfactory proof that they have taken the due advantage of the means of improve- ment presented to them. But whatever may have been wanting in the English universities has been long supplied by that of Edinburgh, and, at a later period, by those of Glasgow and Dublin. The great London hospitals, and some of the private schools, especially those of anatomy, have, for a number of years, possessed teachers of the highest talents, and most admirably qualified for their office; but our me- tropolis could not be said to hold out the means of a complete medical education previous to the establishment of the London University and the King's College. These rival schools, rivals as I trust they will always be only in the talents of their professors and the excellence of their arrangements, have each of them laid down an academical course of medical instruction, which appears to be complete in all its parts, and which must have the.most salutary influence on the character and qualifications of the future members of the profession. The perusal of the foregoing pages may, I hope, enable my readers to form a tolerably accurate conception of the progress of practical medicine, of the obstacles which it has had to encounter, of the degree in which it has overcome these obsta- cles, and of its present state of improvement. This I am not disposed to under- rate ; but at the same time I must acknowledge, that when I reflect upon the im- mense mass which has been written on the subject, the result seems scarcely ade- , quate to the labour that has been bestowed. I may, therefore, be pardoned if I offer a very few remarks on the means by which, as it appears to me, the object in view might be more effectually attained. This, I conceive, should be attempted precisely upon the same plan as in other departments of science;—in the first place, by a more careful exposition of facts; and, secondly, by a more careful generalization of them. In medicine there are various circumstances which render it less easy to ascertain the facts than in most other cases. These depend partly on the nature of the subject, and partly on the situation and character of the observer. It was the shrewd remark of a learned professor that in medicine there are more false facts than false opinions. On all topics, either historical, scientific, or literary, mankind possess a strong avidity for the marvellous. From the constitution of the human mind, the love of novelty is one great principle by which the attention is excited and the intellectual powers are called into action. Hence, in a rude state of society, nearly the whole art of medicine consists in the dexterous employment of this agent, and hence it is still found the most effectual method of attracting the notice of the multitude, who are incapable of close reasoning or calm investigation. Perhaps one of the most easy and at the same time the most effective means of counteracting this mischievous influence, would be never to receive the evidence for any medical facts upon the authority of a single individual. They should, if possible, emanate from associated bodies, either from public hospitals, medical schools, or societies, the officers of which may afford their united testimony to the alleged facts. Another point which appears to me of vital importance, and which bears essentially upon every department of medicine, is that nothing should be re- ceived without the name of the author. The custom of anonymous writing, which has of late increased to so great an extent, has produced the most unhappy effects, both on the state of medical science and on the character of its professors; it has given rise to a degraded and depraved taste, no less at variance with honour and honesty, than with the spirit of scientific research. I will venture to assert that no man ought to publish any statement or any opinion to which he would scruple to attach his name. It may occasionally happen that an individual of a timid or a modest disposition may, by this restriction, be deterred from detecting an error or controverting a train of false reasoning, but the loss which might by these means be incurred would be amply repaid by the greater authenticity and the greater cor- rectness of our medical publications. A L Ixxxii HISTORY OF MEDICINE. With respect to the second suggestion, the more accurate generalization of facts, when the facts themselves are fully substantiated,—this must be accomplished by the due exercise of judgment and sagacity, and can scarcely be directed by any general rules. I may remark, however, that one obvious mode of attaining this end is to arrange our insulated facts, as much as possible, in the form of statistical tables, by which we may readily observe their connection with or relation to each other, and may thus be prevented from forming a hasty or unauthorized conclu- sion, derived merely from single cases or individual observations. Another important means of obtaining the object in view is to preserve great precision in the use of technical and scientific terms. How many controversies have occupied the mind for ages, and have filled almost innumerable volumes, which have essentially turned upon the definition of a word ? How frequently have remedies been prescribed, not for the symptoms, but for the name of a dis- ease 1 How frequently has an article of the materia medica been employed, not from an experience of its actual effects, but from some nominal property assigned to it by an imperfect analogy or imaginary quality 1 The means that have been proposed to check these aberrations, to rectify the above-mentioned errors, and to reduce medical science to its appropriate and correct limits, are indeed few and simple, and not of difficult application. But there is one essential requisite, with- out which they can be of no avail,—a mind disposed to the reception of truth, de- termined to follow it wherever it may lead the inquirer, united to a high sense of moral obligation, which may induce the medical practitioner to bear in mind that his profession is a deposite placed in his hands for the.benefit of mankind, and that he incurs an awful degree of moral responsibility who abuses this sacred trust, or diverts it to a base or selfish purpose. THE STUDY OF MEDICINE. TO SIR HENRY HALFORD, BART. M.D. F.R.S. F.A.S. PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON, PHYSICIAN TO THE KING, THIS WORK IS INSCRIBED AS A TRIBUTE OF GRATITUDE AND FRIENDSHIP. AUGUST VI, MDCCCXXII. EDITOR'S PREFACE TO THE FOURTH ENGLISH EDITION. When the learned and very distinguished author of the " Study of Medicine," much to the regret of every lover of talent and worth, went to that bourn from which no traveller returns, he had already advanced a considerable way in prep- arations for a new edition of this his favourite production; one to which he had devoted a great portion of the latter part of his life. At the period of his death, he had revised all the five volumes, which the work then consisted of, and he had introduced into each of them numerous additional observations, tending to aug- ment their utility and correctness. Various parts of the work, however, still de- manded further attention, and none more so than its surgical articles. It was under these circumstances that I was requested by his family to make some ar- rangement with the booksellers, by which the third edition might be completed and published; and finding that Messrs. Underwood were ready -to offer a fair consideration for the copy-right, if I would give my assistance as editor, terms were agreed upon, and the undertaking was finished towards the close of 1829. After the failure of Messrs. Underwood, the copy-right became the property of Messrs. Longman and Co.; and the third edition having been entirely disposed ofj a fourth has been called for, on which much time and labour have been expended, Subsequently to the date of the last edition, as it is scarcely necessary to explain, various important contributions have been made to medical science, bearing very materially upon some of the doctrines inculcated in the " Study of Medicine," sometimes corroborating, and, in other instances, as must be confessed, invalidating, or even refuting them. These stores of new and modern information, comprised in the writings of some of the most distinguished physiologists, pathologists, and medical practi- tioners of the present time, have been extensively resorted to for the correction and improvement of this system of physic. Whether I have exceeded the edi- torial functions, or whether too little or too much has been done, it is not for me, but the profession, to determine. One apprehension has constantly followed me in the task, namely, that of stepping over the bounds, within which every discreet editor ought to confine himself. On this account, I have not presumed to encroach upon the author's plan, which, whatever may be the defects in its execu- tion, rests upon a solid foundation, and has the pleasing recommendation of origi- nality. But although, with few exceptions, the arrangement of the subjects treated of has not been changed, I have sometimes ventured to express reasons for think- ing some of thern misplaced. With the same frankness, I have also stated the viii editor's preface. considerations which have now and then inclined me not to adopt precisely the views entertained by the author on certain points in physiology, pathology, and the treatment of diseases. So far as my own knowledge extends, no celebrated writers on medicine have yet been able completely to avoid hypothesis ; and, if ^the present author has occasionally soared into the regions of conjecture, he has only imitated all the greatest of his predecessors. For such flights every man, conscious of the difficulties of medical science, and aware of the zeal, perseve- rance, and active mind of the late Dr. Good, will readily find an excuse. If the general tenour of the book is good ; if many parts of it are executed in a truly superior style (their matter being daily referred to as high authority on the subjects to which they relate, and this by authors and lecturers of acknowledged judgment), surely the imperfections of so difficult an undertaking will be indulgently disre- garded by every liberal critic, and its genuine merit warmly admired. As a system of physic, adorned with learned research, it is, perhaps, unrivalled. In this fourth edition, a great deal of new and interesting matter has been in- serted, principally in the form of notes, in order to avoid taking too much liberty with the text, or mutilating the work in a degree that seemed to me unwarrantable. I may also observe, with respect to incorporations in the text, that they are marked in such a manner, that the reader will immediately perceive the passages for which my own character, and not that of Dr. Good, is responsible. In the fourth volume will be found the particulars of an extraordinary case, under Mr. Thomas Law, of Penrith, in which innumerable portions of taenia have been voided, and still continue to be so, from the meatus urinarius ; the only instance, I believe, of such an occurrence on record. Some of the specimens I mean to transmit to the Museum of the Royal College of Surgeons, and others to that of the University of London. S. COOPER. 7 Wobum Place, Russell Square, Nov. 1st, 1834. 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 suc- cess, 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 another that consti- tutes, or should constitute, in the art of medicine, the basis of nosological arrangement ; for by grouping diseases, not arbitrarily, but in the order of con- nexion 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. If it be convenient to concentrate the diseases of the nervous department into one division, as has been attempted by many nosologists, 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 arrange- ment 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 chymical 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 method than had X preface. 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 compre- hensive synopsis of diseases that the author was induced to undertake thif 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 jthe title of a " Phys- iological 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' continent; 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 learned 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 groundwork of the ensuing arrangement. It is not necessary in the present place to enter into a minute explanation of the subordinate parts of this system, nor of the occasional changes in medical nomenclature which are to be found in it; and which a close attention to correct- ness and simplicity seemed to render indispensable. All these are fully illustrated in the Preliminary 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 consideration 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 ar- rangement so readily allows, of prefixing 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 en- riched 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 de- velopment 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 doctrines are advanced will, at least, be found true to them- selves, and form a digested system, operating in accordance through the entire work, in what way soever they may be affected by future investigations. He trusts it will also be found, that nothing is newly 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 preface. xi 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 be- fore him, and to illustrate mem by analogies, instead of confining himself to a dry and wearisome history of morbid symptoms and operations. In therapeutics the author has allowed himself a liberal range, and has, occasionally, introduced into his Materia Medica, substances that are highly esteemed abroad, though little valued or even known at Rome, 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 £ all compass, and may be learned without burdening the memory. This remark may be allowed to those who are limited to a portable dispensary, as in travelling, or on shipboard; but when uttc ed under othe* 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 ue spared. We may easily, indeed, substitute one medicine for another, but it is very rarely that we can hereby obtain an integral representative ; a remedy pos- sessing not only the general but the particular qualities of that whose place is sup- plied, 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 pj atensis, or lady's smock, as Dr. Stoerck in proving, upon his own person, the violent powers of colchicum and stramonium. A common 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 overvalued ; were em- ployed upon all occasions ; produced frequent disappointment; and gradually fell into disuse."" The colchicum has been fortunate enough to ascend once more to its full zenith of popularity; many efforts have been made on behalf of the stramo- nium ; and the cardamine, though at present less successful than either of the others, still holds in abeyance its post in the established pharmacopoeias, waiting for some lucky trial to bring it once more into general esteem. A work erected upon scientific principles, should know nothing of these acci- dental 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 proper value, as far as he has been able to estimate it, whatever may have been the era of it^ credit; and as there can be no stronger ground for the study of botany, oryctoWy, or chymistry, than the advantage they afford to the art of healing, and as these are provinces cul- tivated 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 cathartics, or whatever other names may serve for a medicinal classification. It is this, indeed, that after all must chiefly constitute the Therapia, or Practice of Medicine, to which every thing else, though cf the utmost moment, is but in- troductory. " The First Lines" of Dr. Cullen, when read, as they were delivered, in connexion with his " Treatise on the Materia Mediea," constitute the most im- portant course of instruction that has ever, perhaps, been laid down and com- xu PREFACE. pleted by the same individual. But for this purpose 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 Prac- tice 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 alto- gether a practical work, replete with practical principles, and founded upon a prac- tical investigation. Whatever may be the theory or the practice advanced in the ensuing 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 copiousness, from ancient as well as modern times: so as to render the work in a certain sense a summary of the general history of medicine in most ages and countries. To the labours of our own countrymen, however, he professes to be chiefly in- debted for his supplies : to the illustrious dead and to the illustrious living : to all' of whom he has conscientiously endeavoured to do justice, even where he has been under the misfortune of differing from any of them in opinion. With the former he can have no controversy; and, with the latter, he has taken ihe 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 espe- cially to those with whom he has the honour of a personal acquaintance, the suc- cessive 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 misstatement, 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 authoritj^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 encroached 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 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 illustration of its definitions or opinions ; the whole of which will be found imbodied 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 Director-General. To his kind friend, Sir John Webb, he is also largely indebted for similar assistance from the Ordnance De- partment, 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 imperfectly. PREFACE. xiii To Dr. Latham he is under obligations on various accounts; 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 derived 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 important instances, he is under a similar obUgation 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 sta- tions as well as to domestic practice : 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 follow up the common diseases of a country into their respective varieties; for the general laws of the morbid action of the living prin- ciple 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 circurn- stances, and particularly the circumstances of habit and climate ; but the specific outlines are still preserved, and we are still capable of reducing them, under every disguise, to their proper relations, and of assigning them their proper posts. From a few nondescript skeletons 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 disap- peared ; as we have also, from the classifications of recent 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, while 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 modern 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 Aretaus and Galen, of Rhazes amd Avicenna, and the natural histories of Aristotle 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 affections 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 legis- lator, and have been intermediately assigned to it by Celsus. • - • / TABLE OF CLASSIFICATION. CLASS I. COZLIACA. DISEASES OF THE DIGESTIVE FUNCTION. ORD. L ENTERICA. AFFECTING THE ALIMENTARY CANAL. GEN. I. ODONTIA. MISDENTITION. SPE. 1. O. DENTITIONIS.— Teething. 2. DOLOROSA.— Toothache. 3. STUPORIS.— Tooth-edge. 4. DEFORMIS.—Deformity of the Teeth. 5. EDENTULA.— Toothlessness. 6. INCRUSTANS— Tartar of the Teeth. 7. EXCRESCENS.—Excrescent Gums. II. PTYALISMUS. PTYALISM. SPE. 1. P. ACUTUS.—Salivation. 2. INERS.—Drivelling. III. DYSPHAGIA. DYSPHAGIA. SPE. 1. D. CONSTRICTA.—Constrictive Dysphagia. 2. ATONIC A.—Atonic Dysphagia. 3. GLOBOSA.—Nervous Quinsy. 4. UVULOSA.—Uvular Dysphagia. 5. LINGUOSA.—Lingual Dys- phagia. , 6. PHARYNGEA.—Pharyngeal Dysphagia. IV. DIPSOSIS. MORBID THIRST. SPE. 1. D. AVENS.— Immoderate Thirst. 2. EXPERS.— Thirstlessness. V. LIMOSIS. MORBID APPETITE. SPE. 1. L. AVENS.—Voracity. 2. EXPERS.—Long Fasting. 3. PICA.—Depraved Appetite. 4. CARDIALGIA.—Heart-burn. W^ater-brash. Cardialgy. 5. FLATUS.—Flatulence. 6. EMESIS.—Sickness. Vomiting. 7. DYSPEPSIA.—Indigestion. VI. COLICA. COLIC. SPE. 1. C. ILEUS.—Iliac Passion. 2. RHACHIALGIA.—Colic of Poictou. Painter's Colic. 3. CIBARIA.—Surfeit. 4. FLATULENTA.—Wind Colic. 5. CONSTIPATA — Constipated Colic. 6. CONSTRICTA.—Constrictive Colic. VII. COPROSTASIS. COSTIVENESS. SPE. 1. C. CONSTIPATA.—Constipation. 2. OBSTIPATA.—Obstipation. CLASS I. CffiLIACA. ORD. I. ENTERICA. GEN. VIII. DIARRH03A. LOOSENESS. SPE. 1. D. FUSA.—Feculent Looseness. 2. BILIOSA.—Bilious Looseness. 3. MUCOSA.—Mucous Loosenesf. 4. ALBA.— White Looseness. 5. LIENTERIA.—Lientery. 6. SEROSA.— Serous Looseness. 7. TUBULARIS.— Tubular Loose- IX. CHOLERA CHOLERA. SPE. 1. C. BILI0SA.—Bilious Cholera. 2. FLATULENTA.— Wind Chol- era. 3. SPASMODICA.—Spasmodic Cholera. X. ENTEROLITHUS. INTESTINAL CONCRETIONS. SPE. 1. E. BEZOARDUS.—Bezoar. 2. CALCULUS.—Intestinal Cal- 3. SCYBALUM.—Scybalum. XI. HELMINTHIA. WORMS. SPE. 1. H. ALVL—Alvine Worms. 2. PODICIS.—Anal Worms. 3. ERRATICA.—Erratic Worms. XII. PROCTICA. DISEASES ABOUT THE ANUS. SPE. 1. P. SPASMODICA.—Spasmodic Stricture of the Rectum. 2. CALLOSA.—Callous Stricture of the Rectum. 3. TENESMUS.—Tenesmi. 4. MARISCA.—Piles. 5. EXANIA.—Prolapse of the Fun- dament. ORD. II. SPLANCHNICA. AFFECTING THE COLLATITIOUS VISCERA. GEN. I. ICTERUS. YELLOW JAUNDICE. SPE. 1. I. CHOLOSUS.— Biliary Jaundice. 2. CHOLOLITHICUS.—Gall- stone Jaundice. 3. SPASMODICUS.—Spasmodic Jaundice. 4. HEPATICUS.—Hepatic Jaun- dice. 5. INFANTUM.—Jaundice of In- fants. II. MEL^ENA. ME LENA. SPE. 1. M. CHOLG3A.—Black or Green Jaundice. 2. CRUENTA.—Blacjc Vomit. XVI CLASS I. ORD. II. GEN. Ill TABLE OF CLASSIFICATION. C03LIACA. CLASS II. PNEUMATICA. SPLANCHNICA. ORD. II. PNEUMONICA CHOLOLITHUS. GALL-STONE. SPE. 1. C QUIESCENS.—Quiescent Gall- St07t€- 2. MEANS.—Passing of Gall- stones. IV. PARABYSMA. VISCERAL TURGESCENCE. SPE. 1. P. HEPATICUM.— Tumescence of the Liver. 2. SPLENICUM — Tumescence of the Spleen. 3. PANCREATICUM.— Tumes- cence of the Pancreas. 4. MESENTERICUM. — Tumes- cence of the Mesentery. 5. INTE STIN ALE.— Tumescence of the Intestines. 6. OMENTALE.— Tumescence of the Omentum. ? . COMPLICATUM.— Turges- ' cence compounded of various CLASS II. PNEUMATICA. DISEASES OF THE RESPIRATORY FUNCTION. ORD. I. PHONICA. AFFECTING THE VOCAL AVENUES. GEN. I. CORYZA. RUNNING AT THE NOSE. SPE. 1. C. ENTONICA.—Entonic Coryza. ATONICA.—Atonic Coryza. 2. II. 'SPE.1. 2. POLYPUS. POLYPUS. P. ELASTICUS.—Compressible Polypus. CORIACEUS.—Cartilaginous Polypus. III. RHONCHUS. RATTLING IN THE THROAT. %SPE. 1. R. STERTOR.—Snoring. 2. CERCHNOS.— Wheezing. IV. APHONIA. DUMBNESS. SPE. 1. A. ELINGUIUM.—Elingual Dumbness. 2. ATONICA—Atonic Dumbness. 3. SVRDORUM.—Deaf Dumb- ness. V. DYSPHONTA. DISSONANT VOICE. SPE. 1. D. SUSURRANS.—Whispering 2. PUBERUM.—Voice of Puberty. 3, IMMODULATA.—Immelodious Voice. VI. PSELLISMUS. DISSONANT SPEECH. SPE. 1. P. BAMBALIA.—Stammering. 2. BL^ESIT\S.—Mismunciation. ORD. II. AFFECTING THE LUNGS, THEIR MEM- BRANES, OR MOTIVE POWER. GEN. I. BEX. COUGH. SPE. 1. B. HUMID A.—Common or humid Cough. 2. SICCA.—Dry Cough. 3. CONVULSIVA.—Hooping- cough. II. LARYNGYSMUS. LARYNGIC SUFFOCATION. SPE. 1. L. STRIDULUS.—Stridulous Con- striction of the Larynx. III. DYSPNffiA. . ANHELATION. SPE. 1. D. CHRONICA.—Short Breath. 2. EXACERBANS.—Exacer- bating Anhelation. IV. ASTHMA. ASTHMA. SPE. 1. A. SICCUM.—Dry or Nervous Asthma. 2. HUMIDUM.—Humid or common Asthma. V. EPHIALTES. INCUBUS. SPE. 1. E. VIGILANTIUM.—Day-Mare. 2. NOCTURNUS.—Night-Mare. VI. STERNALGIA. SUFFOCATIVE BREAST-PANG. SPE. 1. S. AMBULANTIUM.— Acute Breast-Pang. 2. CHRONICA.—Chronic Breast- Pang. VII. PLEURALGIA. PAIN IN THE SIDE. SPE. 1. P. ACUTA.—Stitch. 2. CHRONICA— Chronic Pain in the Side. CLASS III. H^EMATICA. DISEASES OF THE SANGUINEOUS FUNCTION. ORD. I. PYRECTICA. FEVERS. GEN. I. EPHEMERA. DIARY FEVER. SPE. 1. E. MITIS.—Mild Diary Fever. 2. ACUTA.—Acute Diary Fever. 3. SUDATORIA.—Sweating Fevfr. II. ANETUS. INTERMITTING FEVER. AGUE. SPE. 1. A. QUOTIDIAN VS.—Quotidian Ague. 2. TERTIANUS.— Tertian Ague. 3. QUARTAN US.—Quartan Ague. 4. ERRATICUS.—IrregulnrAgue. 5. COMPLICATUS.—Compli- cated Ague. III. EP ANETUS. REMITTENT FEVER. SPE. 1. E. MITIS.—MHJ Remittent. TABLE OF CLASSIFICATION. XVll CLASS III. HiEMATICA. ORD. I. PYRECTICA. GEN. III. EPANETUS. SPE. 2. E. MALIGNUS.— Malignant Re- mittent.* 3. HECTICUS.—Hectic Fever. IV. ENECIA. CONTINUED FEVER. SPE. 1. E. CAUMA— Inflammatory Fever. 2. TYPHUS.— Typhus Fever. 3. SYNOCmJS.—Synochal Fever. ORD. II. PHLOGOTICA. INFLAMMATIONS. GEN. I. APOSTEMA. APOSTEME. SPE. 1. A. COMMUNE.—Common Apos- teme. 2. PSOATICUM.—Psoas Abscess. 3. HEPATIC UM.—Abscess of the Liver. 4. EMPYEMA.—Lodgment of Matter in the Chest. 5. VOMICA.—Vomica. II. PHLEGMONE. PHLEGMON. SPE. 1. P. COMMUNIS.—Common Phlegmon. 2. PARULIS.—Gum-bile. 3. PAROTIDEA.—Parotid Phlegmon. 4. MAMMAE.—Abscess of the Breast. 5. BUBO.—Bubo. 6. PHIMOTICA.—Phimotic Phlegmon. III. PHYMA. TUBER. SPE. 1. P. HORDEOLUM.—Sly. 2. FURUNCULUS.—Bile. 3. SYCOSIS.— Ficous Phyma. 4. ANTHRAX.—Carbuncle. IV. IONTHUS. WHELK. SPE. 1. I. VARUS.—Stonej,ock. 2. CORYMBYFER.—Carbuncled Face. Rosy Drop. V. PHLYSIS. PHL YSIS SPE. 1. P. PARONYCHIA.— Whitlow. VI. ERYTHEMA. INFLAMMATORY BLUSH. SPE. 1. E. CEDEMATOSUM.—Edematous Erythema. 2. ERYSIPELATOSUM.—Ery- sipelatous Erythema. 3. GANGRENOSUM.—Gan- grenous Erythema. 4. VESICULA RE.—Vesicular Erythema. 5. ANATOMICUM.—Erythema from Dissection. 6. PERNIO.—Chilblain. 7. INTERTRIGO.—Fret. * a Autumnal Remittent. /? Yellow Fever. y Burning Remittent, i Asthenic Remittent. Vol. I.—B CLASS III. HiEMATICA. ORD II. PHLOGOTICA. GEN. VII. EMPRESMA. VISCERAL INFLAMMATION. SPE. 1. E. CEPHALITIS.—Inflammation of the Brain.* 2. OTITIS.—Earache. 3. PAROTITIS.—Mumps. 4. PARISTHMITIS.—Quinsy. 5. LARYNGITIS.—Inflammation of the Larynx. 6. BRONCHLEMMITIS.— Croup. 7. PN E UMONITIS.—Peripneu- mony. 8. PLEURITIS.—Pleurisy. 9. CARDITIS.—Inflammation of the Heart. 10. PERITONITIS— Inflamma- tion of the Peritonaium. 11. GASTRITIS.—Inflammation of the Stomach. 12. ENTERITIS.—Inflammation of the Bowels. 13. HEPATITIS— Inflammation of the Liver. 14. SPLENITIS.—Inflammation of the Spleen. 15. NEPHRITIS.—Inflammation of the Kidneys. 16. CYSTITIS.—Inflammation of the Bladder. 17. HYSTERITIS. -Inflammation of the Womb. 18. ORCHITIS.—Inflammation of the Testicle. VIII. OPHTHALMIA. OPHTHALMIA. SPE. 1. O. OPHTHALMITIS.—Inflamma- tion of the whole Eyeball. 2. EXTERN A.—Inflammation of the external Tunics. 3. INTERNA.—Inflammation of the internal Parts of the Eye. 4. STAPHYLOMA.—Protuberant Eye. 5. ECTROPIUM.—Everted Eye- lid. 6. ENTROPIUM.—Inverted Eye- lid. IX. CATARRHUS. CATARRH. SPE. 1. C. COMMUNIS.—ColdintheHead or Chest. 2. EPIDEMICUS.—Influenza. X. DYSENTERIA. DYSENTERY. SPE. 1. D. ACUTA.—Acute Dysentery. I 2. CHRONICA.—Chronic Dysen- tery. XI. BUCNEMIA. TUMID LEG. SPE. 1. B. SPARGANOSIS.—Puerferal Tumid Leg. 2. TROPICA.— Tumid Leg of hot Climates. XII. ARTHROSIA. ARTICULAR INFLAMMATION. SPE. 1. A. ACUTA.—Acute Rheumatism. * a Brain Fever. 0 Acute Dropsy of the Head. xviii TABLE OF CLASSIFICATION. CLASS III. ILEMATICA. ORD. II. PHLOGOTICA. GEN. XII. ARTHROSIA. SPE. 2. A. CHRONICA.—Chrome Rheu- matism. 3. PODAGRA.—Gout. 4. HYDARTHRUS.— White- swelling. RD. III. EXANTHEMATICA. ERUPTIVE FEVERS. EXANTHEMS. 5EN. I. ENANTHESIS. RASH EXANTHEM. SPE. 1. E. ROSALIA.—Scarlet Fever. 2. RUBEOLA.—Measles. 3. URTICARIA— Nettle Rash. II. EMPHLYSIS. ICHOROUS EXANTHEM. SPE. 1. E. MILIARIA.—Miliary Fever. 2. APHTHA.— Thrush. 3. VACCINIA.—Cow-pox. 4. VARICELLA.— Water-pox. 5. PEMPHIGUS.—Vesicular, or Bladdery Fever. 6. ERYSIPELAS.—St. Anthony's Fire. III. EMPYESIS. PUSTULOUS EXANTHEM. SPE. 1. E. VARIOLA.—Smallpox. IV. ANTHRACIA. CARBUNCULAR EXANTHEM. SPE. 1. A. PESTIS.—Plague. 2. RUBULA.— Yaws. ORD. IV DYSTHETICA. CACHEXIES. GEN. I. SPE. 1. 2. PLETHORA. PLETHORA. P. ENTONICA.—Sanguine Ple-thora. ATONICA.—Serous Plethora. II. SPE. 1. 2. HEMORRHAGED. . HEMORRHAGE. H. ENTONICA.—Entonic Hemor-rhage. ATONICA.—Atonic Hemor-rhage. ni. SPE. 1. 2. 3. 4. 5. MARASMUS. EMACIATION. M. ATROPHIA.—Atrophy. ANHAZMIA.—Exsanguinity. CLIMACTERICUS.—Decay of Nature. TABES.—Decline. PHTHISIS.—Consumption. IV. SPE. 1. MELANOSIS. MELANOSE. M. TUBERCULARIS.—Tubercu-lar Melanose. V. SPE. 1. STRUMA. SCROFULA. S. VULGARIS.—King's Evil. VI CARCINUS. CLASS III. ORD. IV. GEN. VII. SPE 1. L 2. ILEMATICA. DYSTHETICA. LUES. VENEREAL DISEASE. SYPHILIS.—Pox. SYPHILODES.—Bastard Pox. VIII. 2. 3. IX. ELEPHANTIASIS ELEPHANT SKIN. SPE. I. E. ARABIC A.—Arabian Elephanti- asis. Black Leprosy. ITALICA.—Italian Elephanti- asis. ASTURIENSIS.—Asturian Elephantiasis. CATACAUSIS. CATACAUS1S. SPE. 1. C. EBRIOSA—Inebriate Cata- causis. X. PORPHYRA. SCURVY. SPE. 1. P. SIMPLEX— Petechial Scurvy. 2. HEMORRHAGICA.—Land Scurvy. 3. NAUTICA.—Sea Scurvy. XI. EXANGIA. EXANGIA. SPE. 1. E. ANEURISMA.—Aneurism. 2. VARIX.—Varix. 3. CYANIA.—Blue-skin. XII. GANGRENA. GANGRENE. SPE. 1. G. SPHACELUS.—Mortification. 2. USTILAGINEA.—Mildew Mortification. 3. NECROSIS.—Dry Gangrene. 4. CARIES.—Canes. XIII. ULCUS. ULCER. SPE. 1. U. INCARNANS.—Simple healing Ulcer. 2. VITIOSUM.—Depraved Ulcer. 3. SINUOSUM.—Sinuous Ulcer. 4. TUBERCULOSUM.— Warty excrescent Ulcer. 5. CARIOSUM.—Carious Ulcer. CANCER. SPE. 1. C. VULGARIS.—Commni Cancer. CLASS IV. NEUROTICA. DISEASES OF THE NERVOUS FUNCTION. ORD. I. PHRENICA. AFFECTING THE INTELLECT. GEN. I. ECPHRONIA. INSANITY. CRAZINESS. SPE. 1. E. MELANCHOLIA.—Melancholy. 2. MANIA.—Madness. II. EMPATHEMA. UNGOVERNABLE PASSION. SPE. 1. E. ENTONICUM.—Impassioned 2. ATOmCUM.—Impassioned De- pression. 3. INANE.—Hairbrained Passion. III. ALUSIA. ILLUSION. HALLUCINATION. SPE. 1. A. ELATIO.—Sentimentalism. Mental Extravagance TABLE OF CLASSIFICATION. xiX CLASS IV. NEUROTICA. ORD. I. PHRENICA. GEN. III. ALUSIA. SPE. 2. A. HYPOCHONDRIAS.—Hypo- chondrism. Low Spirits. XV. APHELXIA. RE VERY. SPE. 1. A. SOCORS.—Absence of Mind. -Abstraction of 2. INTENTA. Mind. 3. OTIOSA.—Brown Study. V. PARONIRIA. SLEEP DISTURBANCE. SPE. 1. P. AMBULANS.—Sleep-walking. 2. LOQUENS.—Sleep-talking. 3. S A LAX.—Night Pollution. VI. MORIA. FATUITY. SPE. 1. M. IMBECILIS.—Imbecility. 2. DEMENS.—Irrationality. ORD. II. ESTHETICA. AFFECTING THE SENSATION. GEN. I. PAROPSIS. MORBID SIGHT. SPE. 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.—Opaque Cornea. 8. GLAUCOS1S.—Humoral Opa- city. 9. CATARACT A.—Cataract. 10. SYNIZESIS.—Closed Pupil. 11. AMAUROSIS.—Drop Serene. 12. STRABISMUS.-^ianring. II. PARACUSIS. MORBID HEARING. SPE. 1. P. ACRIS.—Acrid Hearing. 2. OBTUSA.—Hardness of Hearing. 3. PERVERSA.—PerverseHearing. 4. DUPLICATA.—Double Hearing. 5. ILLUSORIA.—Imaginary Sounds. 6. SURDITAS.—Deafness. III. PAROSMIS. MORBID SMELL. SPE. 1. P. ACRIS— Acrid Smell. 2. OBTUSA.—Obtuse Smell. 3. EXPERS.— Want of SmeU. IV. PARAGEUSIS. MORBID TASTE. SPE. 1. P. ACRIS.—Acrid Taste. 2. OBTUSA.—Obtuse Taste. 3. EXPERS.—Want of Taste. V. PARAPSIS. MORBID TOUCH. SPE. 1. P. ACRIS.—Acrid Sense of Touch or general Feeling. 2. EXPERS.—Insensibility of Touch or general Feeling. 3. ILLUSORIA.—Illusory Sense of Touch or general Feeling. VI. NEURALGIA. NERVE-ACHE. SPE. 1. N. FACIEI.—Nerve-ache of the Face. B 2 CLASS IV. NEUROTICA. ORD. II. jESTHETICA. GEN. VI. NEURALGIA. SPE. 2. N. PEDIS.—Nerve-ache of the Foot. 3. MAMME.—Nerve-ache of the Breast. ORD. III. CINETICA. AFFECTING THE MUSCLES. GEN. I. ENTASIA. CONSTRICTIVE SPASM. SPE. 1. E. PRIAPISMUS.—Priapism. 2. LOXIA.— Wry Neck. 3. RHACHYBIA.—Muscular Dis- tortion of the Spine. 4. ARTICULARIS.—Muscular Stiff-joint. 5. SYSTREMMA.—Cramp. 6. TRISMUS.—Locked-jaw. 7. TETANUS.— Tetanus. 8. LYSSA.—Rabies. Canine Mad- ACROTISMUS.—Suppressed Pulse. 9. II. CLONUS. CLONIC SPASM. SPE. 1. C. SINGULTUS.—Hiccough. 2. STKRNUTATIO— Sneezing. 3; PALPITATIO.—Palpitation. 4. NICTITATIO.—Twinkling of the Eyelids. 5. SUBSULTUS.— Twitches of the Tendons. 6. PANDICULATIO.—Stretch- ing- III. SYNCLONUS. SYNCLONIC SPASM. SPE. 1. S. TREMOR.— Trembling. 2. CHOREA.—*. Vitus's Dance. 3. BALLISMUS.—Shaking Palsy. 4. RAPHANIA.—Raphania. 5. BERIBERLA.—Barbiers. ORD. IV. SYSTATICA. AFFECTING SEVERAL, OR ALL THE SENSO- RIAL POWERS, SIMULTANEOUSLY. GEN. I. AGRYPNIA. SLEEPLESSNESS. SPE. 1. A. EXCITATA.—Irritative Wake- 2. PERTESA.—Chronic Wake- fulness. II. DYSPHORIA. RESTLESSNESS. SPE. 1. D. SIMPLEX—Filets. 2. ANXIETAS.—Anxiety. III. ANTIPATHIA. ANTIPATHY. SPE. 1. A. SENSILIS.—Sensile Antipathy. 2. INSENSILIS.—Insensile An- tipathy. IV. CEPHALEA. HEADACHE. SPE. 1. C. GRAVANS.—Stupid Headache. 2. INTENSA.—Chronic Headache. 3. HEMICRANIA.—Megrim. 4. PULSAT1LIS.— Throbbing Headache. 5. NAUSEOSA.—Sick Headache. XX CLASS IV. ORD. IV. GEN. V. TABLE OF CLASSIFICATION. NEUROTICA. CLASS V. GENETICA. SYSTATICA. ORD. I. DINUS. DIZZINESS. SPE. 1. D. VERTIGO—Vertigo. VI. SYNCOPE. SYNCOPE. SPE. 1. S. SIMPLEX.—Swooning. 2. RECURRENS.—Fainting Fit. SYSPASIA. COMATOSE SPASM. 1. S. CONVULSIO.—Convulsion. 2. HYSTERIA.—Hysterics. 3. EPILEPSIA— Epilepsy. VIII. CARUS. TORPOR. 1. C. ASPHYXIA.—Asphyxia. Sus- pended Animation. 2. ECSTASIS.—Ecstasy.' 3. CATALEPSIA.—Catalepsy. 4. LETHARGUS.—Lethargy. 5. APOPLEXIA— Apoplexy. 6. PARALYSIS.—Palsy. VII. SPE. SPE. CLASS V. GENETICA. DISEASES OF THE SEXUAL FUNCTION. ORD. I. CENOTICA. AFFECTING THE FLUIDS. GEN. I. PARAMENIA. MISMENSTR UA TION SPE. 1. P. OBSTRUCTIONS.—Obstruct- ed Menstruation. 2. DIFFICILIS— Laborious Men- struation. 3. SUPERFLUA.—Excessive Menstruation. 4. ERRORIS.— Vicarious Men- struation. 5. CESSATIONIS.—Irregular Cessation of the Menses. II. LEUCORRHCEA. WHITES. SPE. 1. L. COMMUNIS.—Common Whites. 2. NABOTITI.—Labour-show. 3. SENESCENTIUM.—Whites of advanced Life. III. BLENORRHCEA. GONORRHOEA. SPE. 1. B. SIMPLEX.—Simple urethral Running. 2. LUODES.—Clap. 3. CHRONICA.—Gleet. IV. SPERMORRHCEA. SEMINAL FLUX. SPE. 1. S. ENTONICA.—Entonic Seminal Flux. 2. ATONICA.—Atonic Seminal Flux. V. GALACTIA. ---- MISLACTATION. SPE. 1. G. PREMATURA— Premature Milk-flow. 2. DEFECTIVA.—Deficient Milk- few. GEN. V. GALACTIA. SPE. 3. G. 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. SPE. 1. C. ENTONICA.—Entonic Green Sickness. 2. ATONICA.—Atonic Green Sickness. II. PRC30TIA. GENITAL PRECOCITY. SPE. 1. P. MASCULINA.—Male Pre- 2. III. cocity. FEMININA.- -Female Precocity. LAGNESIS. LUST. SPE. 1. L. SALACITAS.—Salacity. 2. FUROR.—Lascivious Madness. IV. AGENESIA. MALE STERILITY. SPE. 1. A. IMPOTENS.— Male Impotency. 2. DYSPERMIA— Seminal Mise- 3. INCONGRUA.—Copulative In- congruity. V. APHORIA. FEMALE STERILITY. BAR- RENNESS. SPE. 1. A. IMPOTENS.—Barrenness of Impotency. 2. PARAMENIC A.—Barrenness of Mismenstruation. 3. INPERCITA.—Barrenness of Irrespondence. 4. INCONGRUA.—Barrenness of Incongruity. VI. EDOPTOSIS. GENITAL PROLAPSE. SPE. 1. A. UTERI.—Falling down of the Womb. 2. VAGINE.—Prolapse of the Va- gina. 3. VESICE.—Prolapse of the Bladder. 4. COMPLICATA.—Complicated Genital Prolapse. 5. POLYPOSA.—Genital Excres- cence. ORD. III. CARPOTICA. AFFECTING THE IMPREGNATION. GEN. I. PARACYESIS. MORBID PREGNANCY. SPE. 1. P. IRRIT ATI Y A.—Constitutional Derangement of Pregnancy. 2. UTERINA.—Local Derange- ment of Pregnancy. 3. ABORTUS.—Abortion. TABLE OF CLASSIFICATION. XXI CLASS V. GENETICA. ORD. III. CARPOTICA. GEN. II. PARODYNIA. MORBID LABOUR. SPE. 1. P. ATONICA.—Atonic Labour. 2. IMPLASTICA.— Unpliant La- bour. 3. SYMPATHETICA.—Compli- cated Labour. 4. PERVERSA.—Preternatural Presentation. 5. AMORPHICA.—Impracticable Labour. 6. PLURALIS.—Multiplicate La- bour. 7. SECUNDARIA.—Sequential Labour. III. ECCYESIS. EXTRA-UTERINE FETATION. SPE. 1. E. OVARIA.—Ovarian Exfelation. 2. TUBALIS.— Tubal Exfetation. 3. ABDOMINALIS.—Abdominal Exfetation.. IV. PSEUDOCYESIS. SPURIOUS PREGNANCY. SPE.-l. P. MOLARIS.—Mole. 2. INANIS.—False Conception. CLASS VI. ECCRITICA. DISEASES OF THE EXCERNENT FUNCTION. ORD. I. MESOTICA. AFFECTING THE PARENCHYMA. GEN. I. POLYSARCIA. CORPULENCY. SPE. 1. P. ADIPOSA.—Obesity. II. EMPHYMA. TUMOUR. SPE. 1. E. SARCOMA.—Sarcomatous Tu- mour. 2. ENCYSTIS.—Encysted Tu- mour. 3. EXOSTOSIS.—Bony Tumour. III. PAROSTIA. MIS- OSSIFICA TION SPE. 1. P. FRAGILIS.—Fragility of the Bones. 2. FhEXlLlS.—Flexilityofthe IV. CYRTOSIS. CONTORTION OF THE BONES. SPE. 1. C. RHACHIA.—Rickets. 2. CRETINISMUS.—Cretinism. V. OSTHEXIA. OSTHEXY. SPE. 1. O. INFARCIENS.—Parenchyma- tous Osthexy. 2. IMPLEXA.—Vascular Osthexy. ORD. II. CATOTICA. AFFECTING INTERNAL SURFACES. GEN. I. HYDROPS. DROPSY. SPE. 1. H. OELLULARIS.—Cellular Dropsy. CLASS VI. ECCRITICA. ORD. II. CATOTICA. GEN. I. HYDROPS. SPE. 2. H. CAPITIS.—Dropsy of the Head. 3. SPINE.—Dropsy of the Spine. 4. THORACIS.—Dropsy of the Chest. 5. ABDOMINIS.—Dropsy of the Belly. 6. OVARII.—Dropsy of the Ovaries. 7. TUBALIS.—Dropsy of the Fal- fopiaji Tubes. 8. UTERI.—Dropsy of the Womb. 9. SCROTI.—Dropsy of the Scrotum. II. EMPHYSEMA. INFLATTON. WIND DROPSY. SPE. 1. E. CELLULARE.—Cellular Infla- tion. 2. ABDOMINIS.— Tympany. III. PARURIA. MIS-MICTURITION. SPE. 1. P. ISOPS.—Destitution of Urine. 2. RETENTIONIS.—Stoppage of Urine. 3. STILLATITIA.—Strangury. 4. MELLITA.—Saccharine Urine. Diabetes. 5. INCONTINENS.—Inconti- nence of Urine. 6. INCOCTA.—Unassimilated Urine. 7. ERRATICA.—Erratic Urine. IV. LITHIA. URINARY CALCULUS. SPE. 1. L. RENALIS.—Renal Calculus. 2. VESICALIS.—Stone in the Bladder. ORD. III. ACROTICA. AFFECTING THE EXTERNAL SURFACE. GEN. I. EPHIDROSIS. MORBID SWEAT. SPE. 1. E. PROFUSA.—Profuse Sweat. 2. CRUENTA.—Bloody Sweat. 3. PARTIALIS.—Partial Sweat. 4. DISCOLOR.—Coloured Sweat. 5. OLENS.—Scented Sweat. 6. ARENOSA.—Sandy Sweat. II. EXANTHESIS. CUTANEOUS BLUSH. SPE. 1. E. ROSEOLA.—Rose Rash. III. EXORMIA. PAPULOUS SKIN. SPE. 1. E. STROPHULUS.— Gum Rash. 2. LICHEN.—Lichenous Rash. 3. PRURIGO.—Pruriginous Rash. 4. MILIUM.—Millet Rash. IV. LEPIDOSIS. SCALE SKIN. SPE. 1. L. PITYRIASIS.—Dandruff. 2. LEPRIASIS.—Leprosy. 3. PSORIASIS— Dry Scall. 4. ICHTHYIAS1S.—Fish Skin. V. ECPHLYSIS. BLAINS. SPE. 1. E. POMPHOLYX.—Water-biebt, XX11 TABLE OF CLASSIFICATION. CLASS VI. ECCRITICA. ORD. III. ACROTICA. GEN. V. ECPHLYSIS. SPE. 2. E. HERPES.*— Tetter. 3. RHYPIA.—Sordid Blain. 4. ECZEMA.—Heat Eruption. VI. ECPYESIS. HUMID SCALL. SPE. 1. E. IMPETIGO.—Running Scall. 2. PORRIGO.f— Scabby Scall. 3. ECTHYMA.—Papulous Scall. 4. SCABIES.—Itch. VII. MALIS. CUTANEOUS VERMINATION SPE. 1. M. PEDICULJ.—Lousiness. 2. PULICIS.—Fleabites. 3. ACARL— Tick-bite. 4. FILARIE.—Guinea Worm. 5. CESTRL—Gadfly Bite. 6. GORDIL—Hair Worm. VIII. ECPHYMA. CUTANEOUS EXCRESCENCE. SPE. 1. E. CARUNCULA.—Caruncle. * y Shingles. S Ringworm. 10 Scalled head. CLASS VI. ECCRITICA. ORD. III. ACROTICA. GEN. VIII. ECPHYMA. SPE. 2. E. VERRUCA.—Wart. 3. CLAVUS.—Corn. 4. CALLUS.—Callus. IX. TRICHOSIS. MORBID HAIR. SPE. 1. T. SETOSA— Bristly Hair. 2. PLICA.—Matted Hair. 3. HIRSUTIES.—Extraneous Hair. 4. DISTRIX.—Forky Hair. 5. POLIOSIS.—Gray Hairs. 6. ATHRIX.—Baldness. 7. AREA.—Areated Hair. 8. DECOLOR— Miscoloured Hair. 9. SENSITIVA— Sensitive Hair. X. EPICHROSIS. MACULAR SKIN. SPE. 1. E. LEUCASMUS.—Veal Skin. 2. SPILUS.—Mole. 3. LENTICULA.—Freckles. 4. EPHELIS— Sunburn. 5. AURIGO— Orange Skin. 6. P02CILIA.—Piebald Skin. 7. ALPHOSIS—Albino Skin. CLASS I. CCELIACA. DISEASES OF THE DIGESTIVE FUNCTION. ORDER I. ENTERICA. DISEASES AFFECTING THE ALIMENTARY CANAL. II. SPLANCHNICA. DISEASES AFFECTING THE COLLATITIOUS VISCERA. CLASS I. PHYSIOLOGICAL PROEM. According to the physiological arrangement proposed in this work, the first class of diseases consists of those which primarily affect, or com- mence in, the digestive organs, and impede the digestive function. I say primarily affect these organs, because they may be affected in a secondary manner, by sympathy or induction, in consequence of diseases which originate else- where, and, on this account, do not belong to the present class. Now, in order to obtain a clear idea of the nature of the diseases before us, it is necessary to have a distinct knowledge of the organs which are the seat of them, and of the function which they embrace. To follow up this inquiry into a very minute detail, is the joint province of anatomy, physiology, and animal chymistry ; and a finished practitioner must derive his informa- tion from these three sources collectively, pur- sued through an extent of many volumes. But, for our immediate purpose, it may be sufficient to give a general view of the subject. No animal function displays a greater diver- sity of 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, regarded as one of the leading features, by which the animal structure is dis- tinguished from the vegetable. [Some form of an alimentary cavity is, per- haps, the best criterion of an animal hitherto suggested. Cuvier distinctly states, that he knows of no animal unprovided with such an organ.—(Diet, des Sciences Med., torn. ii. p. 145.) On the other hand, plants do not contain any large, separate, internal cavity for the reception of their nourishment, which they absorb by pores on their surface, and especially by their roots and leaves. As the generality of animals pos- sess the power of locomotion, they could not have roots, by which they would be fixed in one situation. Most of them take their supply of food at once, according to need and oppor- tunity, carry it about with them, and digest it at their leisure. This object is fulfilled by an alimentary cavity, whose internal pores, for imbibing the nutriment, may be compared to vegetable roots, which take up food from the soil. Hence Boerhaave used to say, that ani- mals have roots within them; and the villi of the small intestines, as furnishing the general frame with the nutriment applied to their ab- sorbent mouths, are beautifully denominated by Beclard the radicles of animal life. A distinct alimentary cavity, generally having a reference to locomotion, is then, as Cuvier remarks, one of the most invariable characters of an animal. A single mouth, he says, which some naturalists have fixed upon as a criterion, and contrasted with the multiplicity of the pores of the roots of vegetables, is less constant; for some animals of the family of medusa have several mouths, yet only one common stomachic cavity. The superior relative importance of the di- gestive organs in the animal economy is further illustrated by the fact, that the existence of parts of them may be traced in the early stages of the foetus, long before any rudiment of the spinal marrow, brain, or heart, can be detected. In this instance we also find the principle con- firmed, that parts, first formed, are most rarely wanting. Thus, monsters have been met with, which consisted of nothing more than an ab- domen, more or less perfect; but the separate development of a head, or chest, has never been observed. Man may be so incompletely developed, as to approach the point constituting the full organization of certain lower animals, and to appear only as a mere digestive cavity. 24 PHYSIOLOGICAL PROEM. But, simple as his organization may be, the zoophite, which exhibits a like simplicity, can live and reproduce itself, such organization being natural to it; but man must perish ; for his exist- ence, as a mere unnnisaad. sketch of himself, would be a contravention of the laws of nature.*"] The alimentary cavity in man extends from the mouth through the whole range of the in- testinal canal; and hence, its different parts are of very different diameters. In the mouth, where it commences, and in the pharynx, it is comparatively wide ; it contracts in the oesoph- agus ; then again widens to form the stomach, and afterward contracts again into the tube of the intestines. The intestinal tube itself is also of various diameters, in different parts of its extent, and it is chiefly on this diversity of 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 ; [digestion in them being particularly active, from the greater supplies of nutriment required for growth and re- paration. Meckel found the length of the small intestines very irregular in different persons, and that it varied from thirteen to twenty-seven feet, without any proportionate difference in the stature of the body. In some animals, the in- testinal canal is imperforate, the dross of the food being rejected by the mouth. This was once supposed to be the ease in the medicinal leech : but Cuvier, Blumenbach, and Carus, all agree, in opposition to Dumeril, that the leech has a minute anus, from which, however, only a little fecal matter is discharged, most of it being voided by the mouth. No anus has yet been satisfactorily detected in the taps- worm.—(Carus's Comp. Anat., vol. ii. p. 15.) In the actiniae, one aperture combines the two offices of mouth and anus.]—(Carus, p. 3.) In the human subject, the anus is sometimes imperforate at (birth, with a preternatural outlet, formed in some neighbouring part or organ, to supply its place, in which case the feces have been discharged by the urethra, the vagina, the navel, or the groin. An extraordinary instance of such accommodation is that of a girl, who from birth was imperforate in the anus and meatus urinarius ; in fact, in the whole division of the vulva ; and who, to the age of fourteen, had regularly discharged her urine by the breasts, and her feces by a natural vomiting or rejection from the stomach.—(Samml. Med. Wahrnehm., b. viii. p. 29.) Generally speaking, the extent of the digestive cavity bears a relation to the nature of the ali- ments by which the individual is designed to be nourished. 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 assim- ilate them. Hence, the intestinal tube of her- bivorous animals is for the most part (for we still meet with exceptions) very long; or, in partic- * Andral, Anat. Pathol., t. ii. p. 131. The stom- ach is formed subsequently to the intestines, and is more frequently wanting. ular portions, exceedingly capacious ; in various kinds remarkably complicated, and often double or triple. Thus, in the horse, the large in- testines are of enormous size, and dilated into sacculi, while the ccecum is as capacious as the stomach. In the ruminant animals, besides the peculiar complexity of the stomach, the ali- mentary canal is twenty-seven times the length of the body. On the contrary, carnivorous animals have a short and straight canal ; their food, being already of their own nature, con- taining a larger quantity of nourishment in less bulk, and hence demanding a smaller proportion of time and space to become fit for use. [In them every circumstance concurs to accelerate the passage of the alimentary matter. It un- dergoes no mastication; it is retained but a short time in the stomach; the intestine has no folds, nor valves ; its diameter is small; and the whole canal, when compared to the body, is extremely short, being only as three or five to one. Whales, however, have a longer canal than other carnivorous mammalia, their stomach is complicated, and the intestine has longitudinal folds. Indeed, carnivorous mammalia, of aquatic habits, generally possess a considerable length of intestine ; a point in which they differ from most other animals of that class. The short- ness of the intestinal canal in the generality of fishes, is compensated by the length of time the food, which is usually animal, is detained in it. A perch has been observed to take food but once in ten days or a fortnight.—(Home's Comp. Anat., p. 340.) In omnivorous animals, the canal is not so long as it is in the herbivorous, nor so short as it is in the carnivorous. Thus, in the rat, its proportion to the body is as eight to one; in the pig, thirteen to one ; and in man, six or seven to one. In him the diminution in length is compensated by the numerous valvulae con- niventes and the preparation of the food by cookery.—(Blumenbach's Comp. Anat., p. 178.) The domestic cat, which eats bread as well as flesh, has an alimentary canal considerably longer than that of the wild cat.] The digestive canal of man is less capacious and complex than that of most mammalia, which take only vegetable food ; yet, larger and more complicated than that of other mammalia, which live entirely on flesh. Hence, man seems to be capable of subsisting either on animal or vegetable food ; 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, per- haps altogether, on fruits and roots ; as those of the yam, beet, and potato, the bread-fruit- tree, bread-nut (brosimum ahcaslrum), sweet- chestnut, banana, cabbage-tree, palm (areca ole- racea), and meal-bark Icycas circinalis). Others live on raw animal flesh, or flesh of the coarsest kind, as that of one species at least of the wal- rus (trichecus dudoyig), the sea-bear, and sea- calf. The Greenlander feeds voraciously on the skin and fins of the nord-capon, and on the flesh of whales. Many African tribes are baid PHYSIOLOGICAL PROEM. 25 to live on dead lions and hippopotami. Dogs are eaten in the South Sea islands, horses in Tartary, and cats in many parts as a substitute for rabbits. Among numerous tribes of savages, indeed, the flesh of man himself is still dressed for food : the custom may have been more ex- tensive formerly than in the present day ; but it still prevails in several of the Australasian isles, and is even exhibited in New-Zealand, where the inhabitants are nevertheless peculi- arly intelligent, and disposed to adopt the man- ners of Europeans. The Hindoos subsist chiefly on rice and maize, and will not touch flesh of any kind. Many tribes of wandering or nom- adic Moors on gums, principally gum seneca. The Kamtschadales, and the wretched inhabi- tants of the neighbouring shores, on fishes, or coarse fish-oil mixed into a paste with sawdust, or the rasped fibres of indigenous plants;"while the more polished and luxurious nations of Europe live on solid and liquid foods of every description.* Yet, it should not be forgotten that, in Ireland and some other places, trie only aliment subsisted upon in extensive and populous communities, whose poverty prevents them from obtaining any other, is the potato. Man, therefore, is omnivorous; but he is not the only omnivorous animal in the world : for the great Author of nature is perpetually show- ing us that, though he operates by general principles, he is in every instance the lord, and not the slave, of his own laws. And hence, among quadrupeds, the swine, and, among in- sects, the ant (and more examples might be adduced if necessary), possess as omnivorous a power as man himself, and feed equally on the fleshy parts of animals, and on grain, and the sweet juices of plants. [In this respect, there is a power of accommodation, where it would not a priori be expected. Thus, certain animals which, from the structure of their digestive organs, are plainly designed to live entirely either on vegetable or animal food, will subsist, as a matter of necessity, altogether on the par- ticular kind not intended for them by nature, especially when the change is made in a gradual manner. Thus, in the northern parts of Asia, where grain is scarce, horses and oxen are sometimes fed on fish. Spallanzani (Experiences sur la Digestion, c. 74 et 75) habituated an eagle to live on bread, and a pigeon on flesh. If fresh water mollusca are put at once into seawater, or seawater mollusca into fresh water, they perish ; but, if the change be gradually made, they live very well.f] * The diversified character of the aliment of man might be farther illustrated by the great variety of food used by certain tribes of the North American Indians, particularly those inhabiting the western regions on the borders of the Pacific Ocean.—D. t Ann. de Chimie, &c. vol. ii. p. 32, and Blu- menbach's Physiology, 4th edit. p. 309 Some- times a long deviation from the natural food is fol- lowed by a change in the structure of the digestive organs: thus, after a seagull has lived for some time upon grain, the strength of its gizzard is in- creased. See Home, Comp. Anat., vol. i. p. 354. It is sometimes suspected, that no animal can derive nutriment from any material not contain- ing a proportion of azote, one of the essential elements of the animal body, and existing in it far more largely than in plants. [This doctrine, however, must be incorrect, if spiders can live on sulphate of zinc (Thomson's Jinnals of Phi- losophy, vol. xii. p. 494), and. the Otomacs eat little else some months in the year, than large quantities of earth. A sudden change from a diet of fully azotized substances, like meat, bread, &c, to one composed of vegetables con- taining little or no azote, certainly cannot always be borne by the human constitution with impu- nity. This was proved in the eastern part of France, in the year 1817, where the failure of the crops produced such a famine, that the poor were compelled to contend, as it were, with the beasts of the field, for whatever vegetable pro- ductions could be found. The consequences were general anasarca, interruption of the men- ses, a diminution of the ordinary number of con- ceptions by one half, as carefully estimated by parochial documents, and permanent injury of the health. Even the sudden return to the use of barley bread, after the continuance of this miserable regimen for three months, was found not to be unattended with peril.]—(Gaspard, in Magendie's Jour., t. i. p. 237, &c.) It has often been a question, whether the abundance of azote in animals is derived from the atmosphere, by respiration or absorption, or by both these processes ; or whether it is pro- duced by the action of life itself; or obtained from articles of food. The experiments of M. Magendie favour the sftpposition, that the great source of azote in the animal body is the food; for, on feeding animals of various kinds on substances that contain no sensible portion of azote, as sugar, gum, olive- oil, and butter, together with distilled water, and confining them to this kind of -diet, they grad- ually fell into a state of atrophy, and died. The secretions assumed the character of those of herbivorous animals, the food was digested, but the muscles were reduced to one sixth of their proper volume. It is singular, that all the ani- mals before death exhibited an ulcer of the cor- nea, which sometimes spread through the mem- brane, and let out the humours of the eye. [Haller observes that "certain animals are de- stroyed by the use of sugar, although nutritious and salutary to others. In Stark's experiments, we have many examples of the indigestible na- ture of a diet composed of a single article, which was easily digested when mixed with other sub- stances. In order to render M. Magendie's ex- periments unexceptionable, Dr. Bostock (Physi- ology, vol. ii. p. 467) thinks, that a diet should have been tried, composed of a mixture of sub- stances destitute of nitrogen. In fact, M. Ma- gendie himself admits, that the question is not yet settled, whether life can be long supported by the sole use of any one species of aliment, however nutritive.—(Physiology, p. 222, 2d edit.) At the same time, it deserves particular notice that, in 1750, a caravan of above one thousand Abyssinians, in consequence of having 26 PHYSIOLOGICAL PROEM. consumed all their provisions, are alleged to have subsisted for two months entirely on gum- arabic, which happened to be among their mer- chandise.—(Hasselquish Voyages, <$•<;. in the Levant, p. 298.) If this be true, it proves that man can live on a single substance, which was found by Magendie to be insufficient nourish- ment even for dogs.] In general, the length of the alimentary canal is greater in mammalia than in the subordinate classes. It diminishes successively in birds, amphibia, and fishes ; being in some fishes even shorter than the body itself, which is never the case in the first three classes; and in insects and worms is so diversified, as almost to bid de- fiance to any kind of scientific arrangement; being, in many instances, short and narrow, as in the dragonfly (libellula); and in others, as proper hydatids and infusory worms, constitu- ting the globular membrane in which the entire structure of the animal consists. [On the whole, a long and complicated intestinal tube denotes that the insect feeds on vegetables ; while the contrary character indicates that its food is.ani- mal. So capricious has nature been in the lower beings that, in the animals of corals and sponges, the intestines of several individuals frequently communicate (e. g. in the animals of the pennalula, sea-feather), where the nutriment of all is derived from a common source.]—(Ca- rus's Comp. Anal., vol. i. p. 14.) Attached to the cheeks in some quadrupeds, as the monkey and marmot tribes, is a pouch or pocket, which conveniently holds i their spare food, or enables them to convey it to their win- ter hoards. The mouth communicates with the stomach* by the long, narrow, membranous, and muscular canal, denominated the oesophagus, or gullet. This in many animals is so dilatable, as to ena- ble them to swallow animals more bulky than themselves. [In those carnivorous animals which swallow voraciously, as the wolf, it is very large ; but in many herbivorous ones, of consid- erable size, and particularly such as ruminate, its muscular fibres are proportionably stronger, and capable of voluntary motion. The process of rumination implies a power of voluntary mo- tion in the oesophagus; and indeed the influ- ence of the will throughout the whole operation is incontestible. It is not confined to any par- ticular time ; since the animal can delay it, ac- cording to circumstances, when the paunch is quite full. In the occasional examples of the power of rumination in man, the operation is also found to be voluntary. The opening of the oesophagus into the stomach is marked by some differences, both with regard to its size and mode of termination : circumstances ex- plaining why some animals, as the dog, easily vomit; while others, as the horse, are scarcely susceptible of this operation,* which, in the lat- ter, is also partly hindered from taking place * Blumenbach's Comp. Anat., pp. 82—87, 2d edit. When a horse is compelled to vomit, he makes such efforts with the abdominal muscles, that the pressure on the distended stomach some- times bursts it, the rupture always taking place through the mouth) by the complete manner in which this cavity can be separated from the gul- let by the velum palati.] We have not time to follow up these playful diversities of nature ; and must confine our- selves to a brief glance at the general structure of the human stomach, to which the oesophagus conducts. This is situated on the left side of the diaphragm or midriff: in its figure it resem- bles the pouch of a bagpipe ; its left end is most capacious ; its upper side is concave, and its lower convex ; the two orifices for receiving and discharging the food are situated in the upper part. In its substance it consists of three prin- cipal coats or layers, the external and internal of which are membranous, and the middle mus- cular. The internal coat, moreover, is lined with a villous or downy apparatus, and is ex- tremely convoluted or wrinkled; the wrinkles increasing in size as the diameter of the stomach contracts. [Few parts are more largely sup- plied with bloodvessels than the stomach, and it not only partakes of the ganglionic nerves with the neighbouring viscera, but it likewise derives another supply of nerves from the spinal cord, and is distinguished from every other part, except the organs of sense, by having a pair of cerebral nerves almost entirely devoted to it, though it is situated at so great a distance from the brain.]—(Bostock's Physiology, vol. ii. p. 443.) In an adult it will commonly contain three pints, or rather more ; [and, according to Soemmer- ing, when it is moderately distended, it will hold from five to eleven pints. In opening some carnivorous animals directly after death, a middle muscular constriction is noticed, divi- ding the organ imperfectly into two compart- ments. Sir Everard Home deems a similar constriction natural to the human subject, and dwells much upon it in his theory of digestion. Soemmerring occasionally noticed it in females, in whom he supposed it to be caused by the pres- sure of the central bone of their stays. Accord- ing to Andral (Anat. Pathol, t. ii. p. 133), it is mostly the result of a change of texture, or of a contraction of the muscular coat, and sometimes a congenital imperfection. He conceives, that it indicates in man the first degree of tendency to the kind of division of the stomach distinctly manifested in some other animals. If, however, in him the stomach naturally consists but of a single cavity, without any constriction or parti- tion, a division of that organ is not the less evinced in him by other circumstances. Thus, the structure of the mucous membrane is cer- tainly not exactly alike in the splenic and pvloric portions of the stomach. Their functions are also quite as different, while they are still fur- ther distinguished by the relative frequency and even the nature of their alterations of texture. In some animals, the different organization of the two portions of the stomach is manifest to the eye : thus, in the horse, all the inside of the splenic portion is lined by a thick cuticle. The stomach of the negro is rounder and shorter towards its great curvature. Se Andra), Anat Pathol., t. ii. p. 107.—EmTOK, PHYSIOLOGICAL PROEM. 27 than that of the European ; and a still more re- markable roundness exists in the stomachs of apes, as is represented in Daubenton's excellent plates. With respect to the muscular fibres of the human stomach, the question is frequently agi- tated, whether they have any share or not in re- jecting the contents of that viscus in the act of vomiting 1 M. Chirac gave a dog some corrosive sublimate on a pUce of bread, which was almost immediately vomited up, though a violent retch- ing" afterward continued. In this state of things, the animal's abdomen was opened, and the peristaltic action of the stomach appeared to be so feeble, that Chirac was led to infer, that the expulsion oFits contents could not be owing to it. Even when the experimenter's finger was applied to the stomach, while the retching was going on, it is said, that no contraction of this organ could be felt.—(Hist, de VAcad. des Sci- ences, 1686.) Duvemey also regarded the stomach as «itirely passive in the act of vomit- ing. Mr. Hunter, if he did not go so far as the latter conclusion, certainly refers the chief part of the operation to the action of muscles.—(Ani- mal Economy, p. 200, 2d edit.) This doctrine received corroboration from the experiments of M. Magendie. Two grains of tartarized anti- mony, dissolved in an ounce and a half of water, were introduced into a dog's crural vein. Nau- sea was quickly excited. The stomach was then made to protoude through a wound in the abdomen ; when the spasm of retching was plainly seen to depend upon the action of the diaphragm and abdominal muscles ; the stomach itself remained free from contraction, and its contents were not discharged. After the stom- ach had, been returned info its natural situation again, so as to be capable of being acted Upon by the above muscles, vomiting took place, and at the. same time that viscus was felt with the finger to be relaxed. When the nervi vagi were divided, vomiting was not thereby prevented from being the consequence of the introduction of the tartarized antimony into the venous sys- tem ; a fact, confirming the result of some ex- periments made long ago by Dr. Haighton. Neither was vomiting hindered from being pro- duced by this use of tartarized antimony, when the abdominal muscles were removed, provided the linea alba remained entire, between which and the diaphragm the stomach was yet sub- jected to the necessary compression. When the phrenic nerves were qut, and the diaphragm was left with only a supply of nervous influence from a few filaments of the eleventh and twelfth dorsal nerves, it was so weakened, that it no longer duly antas>nized the abdominal muscles, and vomiting could only take place in a feeble way. Perhaps, however, the most curious ex- periment was that in which M. Magendie re- moved the stomach, substituted for it a bladder communicating with the oesophagus, and th%n threw the solution of tartarized antimony into a vein : even under these circumstances retching came on, and the contents of the bladder weie vomited up.—(Mim. sur le Vomissemcnt et Phy- siol., t. ii. p. 133.) On the contrary, Lieutaud and Haller looked upon the stomach as the chief agent, and Sir Charles Bell may be set dowm as on the same' side of the question ; and he adverts to a stomach in his possession, the coats of which are so thickened, that they couldrtiot be made to contract by the action of the muscular fibres, and consequently there was no vomiting.* Against Magendie's experi- ments, others are recorded by Maingault; as well as a most interesting case of malformation by Drs. Graves and Stokes,t which was attended with such a displacement of the stomach into Ae chest, that this viscus was entirely above the diaphragm, and beyond the reach of its con- tractions. Yet incessant "vomiting occurred during the patient's illness; " a fact worth a thousand experiments, and which completely decides the question, that vomiting may be pro- duced by the action of the stomach itself, unas- sisted by any external compressing force." On the whole, however, from the various facts which have been made out on the present topic, and to some of which we shall advert in the chapter on Limosis Emesis, it may be inferred, that, in ordinary vomiting, the contraction of the stomach itself is not essential, any more than the compression of the diaphragm and abdomi- nal muscles under extraordinary circumstances. Nothing can be more aptly contrived for the purpose of agitating, mixing, and presenting every portion of the alimentary mass to the surface, by which certain parts are to be ab- sorbed, than is the whole structure of the small intestines. While their muscular fibres are calculated to produce a constant undulatory vermicular motion, these are loosely lined by the absorbing membrane, whose numerous plicae and valves form a most extensive surface, with their villi erected, and even mixed, as it were, with the semifluid alimentary matter. Then the outside of these bowels consists of a smooth and constantly lubricated surface, greatly facili- tating the motion of the different convolutions upon each other.]—(Brighfs Lectures, in Medi- cal Gazette, for June, 1833, p. 282.) In the more perfect classes of animals, the division between the large and small intestines is distinctly indicated by a muscular valve, formed jointly of the coats of the colon and the ileum'by a short natural introsusception of the terminating portion of the latter into the com- mencing portion of the former ; the important * Anat. of the Human Body, vol. iv. p. 54. When we come to limosis emesis, however, an in- stance wfll be mentioned of incessant vomiting, though the coats of the stomach were prodigiously thickened.—Ed. t Dublin Hospital Reports, vol. v. 8vo., 1630. The mechanism of vomiting is yet a disputed point. Dr. Marshall Hall is led by his experiments to believe, that the contents of the thorax and ab- domen are subjected to a sudden and almost spas- modic contraction of all the muscles of expiration, the larynx being closed, so that no air can escape from the chest. Dr. A. T. Thomson inclines to the same vmw', and considers vomiting as an ex- piratory effort, rendered abortive by the shut state of the glottis. See his Elem. of Materia Med., &c. vol. ii. p. 193. 8vo. Lond., 1833. 28 PHYSIOLOGICAL PROEM. use of which is to moderate the flow of the contents of the smaller intestines into the latter, and to prohibit a regurgitation of feces into the former. And hence we never meet with fecal matter in the stomach, except in cases in which this valve or sphincter has lost the whole; or a considerable portion of its muscular power. In the hedo-ehog, and several other quadrupeds, the valve of the colon does not exist; and in a few others, as the sloth and armadillo, the coecum is wanting. In birds, the rectum, at the termination of its canal, forms an oval or elongated pouch, called bursa Fabricii, from the name of its discoverer; and then expands into a cavity, which has been named cloaca, from its receiving the extremities of the ure- ters and genital organs and their secretions ; so that the fluids from all these are discharged from one common emunctory. The same mech- anism is extended to a few quadrupeds, as the ornilhorhynchus paradoxus, and the hystrix: the penis of the male, and the horns of the uterus in the female, being equally lodged in its interior.—(Sir E. Home, in Phil. Trans., 1802, pt. 1 and 2.) Contributory to the function of digestion, per- formed in the stomach and the parts of the ali- mentary canal immediately adjoining to it, are several organs which lie near it, and are con- nected with it in a peculiar manner. Of these the chief are the pancreas, the liver, the spleen, and the omentum. The last two are less con- stantly found in the animal kingdom than the liver, to which they are by many physiologists supposed to be subservient. They 'generally become more obscure, or diminish in size, from quadrupeds to fishes : a remark that will equally apply to the pancreas, which upon the whole disappears sooner than the spleen. It is found in the shark and |he skate ; but, in other fishes, its place seems to be occupied and supplied by the coecal appendices and pyloric cosca. The largest and most important of all these organs is the liver, by which the bile is pre- pared, [and which, besides being supplied, like other parts of the body, with arteries, has a large quantity of venous blood constantly poured into it by the venaportae, formed by the junction of the veins from many of the abdominal vis- cera, and ramifying, like an artery, in its sub- stance. Thus, it has two sets of vessels going into it; and it has also two sets issuing from it; one, the vessels forming the hepatic vein ; the other, the biliary ducts, uniting together to form the hepatic duct. In addition to all this apparatus, ajjsorbents are distributed abundantly both to the surface and to the substance of the liver, and nerves from the hepatic^ plexus go to #very part of it. Besides all these vessels and nerves, the liver contains a granulated sub- stance, between the different portions of which a cellular tissue is interposed.]—(Bright, Op. cit.) It is the seat of a great variety of dis- eases, and* appears to produce a very powerful effect on the blood itself, by the removal of several of its principles, independently of its office as a digestive organ. It descends, under some modification or other, from man to the class of worms ; and, in the snail and several other" gasteropodous mollusca, is comparatively very large ; but, in various kinds, is destitute of a gall-bladder, as well among quadrupeds, as birds, fishes, and worms; though this appen- dage is common to all the amphibia, many of which, as the salamander, have livers of great magnitude. All these organs co-operate in digestion, though the peculiar effect produced by several of them is still a subject of inquiry. They present to our observation a variety of curious structures, which we shall notice more at large in treating respectively of their deviations from health ; and their surface is covered by a mem- branous plate, or sheet, supposed by Haller to be of condensed cellulaj membrane. Bichat has divided the proper membranes of the ani- mal frame into, three kinds ; serous, mucous, and fibrous. The first forms a common exter- nal coating for the viscera, whether substantial or hollow: it is possessed of few nerves, and is lubricated by a perpetually ascending halitus. The second, or mucous membranes, form an in- ternal coating to the larger tubes and hollow vis- cera, mostly connected with the skin at their ex- tremities, as the mouth, nostrils, oesophagus and intestines, the cavities of the urinary and the ute- rine systems. They are enriched with numerous nerves, and their structure is loaded with minute glands, which secrete a muculent fluid, with which the interior surface of the organs is con- stantly moistened. The thifd, or fibrous divis- •ion of membranes, belongs to another set of organs, and consists of the dura mater, which lines the scull, the periosteum, the membra- nous expansions of the muscles, the capsules of the joints, and the'sheaths of the tendons. The solid materials of the food are usually first masticated and moistened in the mouth and fauces, and in this state are introduced into the stomach, where 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 ad- ditional operation, transmuted into a fluid, often presenting a milky appearance, and denominated chyle; in which state they are absorbed or drunk up 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 abound upon the interior surface of the small intestines into which the stomach empties itself. These vessels constitute a distinct part of the lymphatic system. From the frequently milky appearance of their contents, they are known by the name of lacteals ; [but, as the chyle is not always white, perhaps a better name for them is chyliferous* vessels.] They anastomose, or unite together gradually, and at length terminate in one or two common trunks, the chief of which is termed the thoracic duct, whose office is to convey the different streams thus collected from the alimentary canal, as well as from other parts of the body, to the san- guiferous system, to be still farther operated upon by the action of the heart and lungs. [The saliva, or spittle, the fluid with which PHYSIOLOGICAL PROEM. T 29 the food is first blended in the mouth, is secre- ted by the salivary glands. According to Ber- zelius, its solid contents do not exceed seven in 1000 parts, the rest being water. The principal saline ingredient in it appears, from Tiedemann and Gmelin's abates, to be muriate of potash ; but the sulphate, pnosphate, acetate, carbonate, and sulphocyanate of potash are ^jikewise pres- ent in small quantity. The human saliva con- tains but little soda. All physiologists, in their account of the uses of the saliva, represent it as lubricating the aliment preparatory to deglu- tition ; as bringing sapid bodies under the in- fluence of the organ of taste ; and as softening the food for digestion? In the above sketch of digestion, the func- tion of the lacteals or chyliferous vessels has been cursorily noticed. It must now be men- tioned, that modern physiologists disagree about the extent of the office and power of these vessels. Thus, M. Magendie's experi- ments lead him to doubt, in oppositifh to the statements of Hunter, whether they ever ab- sorb any thing but chyle ; and it is one of his doctrines, that all other substances, and par- ticularly drinks, are conveyed from the alimen- tary canal into the circulation by the veins. It is the villi of the intestines, _ he observes, formed in part by the origins of the veins which absorb all the liquids in the small intestines, except the chyle. From the commencement of absorption until its conclusion, the proper- ties of those liquids are discoverable in the blood of the branches of the vena portae, but not in the lymph, or chyle, till long after ab- sorption has begun. Mageiidie's> experiments also tend to prove, that they then reach the thoracic duct, not through the chyliferous ves- sels, but by the communication of the arteries with the lymphatics. The vena portae, which is the trunk of all the veins of the digestive organs^ divSles and subdivides in the tissue of the liver. Now, certain other experiments, of which M. Magendie gtVes the particulars, in- duce him to conclude, that this arrangement in the human economy has the effect of mixing the matter, absorbed in the intestinal canal by the veins, intimately with the blood ; and that, if large quantities of drink and other sub- stances, not chyle, were to be at once trans- mitted to the source of the circulation by the thoracic duct, without having undergone a pre- liminary change in the liver, serious and fatal consequences would arise. The facts on which this reasoning is founded, are highly interesting. * Sir Everard Home formerly entertained a particular theory, that fluids passed from the * The views of Haller, Hunter, Musgrave, and others, in regard to the absorption of foreign sub? stances by the lacteals, are confirmed by the ex- periments of McNeven and Ducachet. " In the presence of Dr. Francis," says Dr. Ducachet, " I gave a cat about half a pint of milk deeply tinged with indigo. In half an hour I killed the animal, and upon dissection found the lacteals containing a fluid of a deep blue colour."—New-York Med. and Phys. Journal, vol. i., p. 132.—D. •tomach directly into the spleen? Though his observations disagree very" much with those of Magendie, they corroborate one point main- tained by the latter physiologist, namely, that fluids pass from the alimentary canal into the circulation by some other channel than that of the chyliferous vessels. Strong arguments against Sir Everard Home's particular theory are deducible from the fact, that, if it were true, animals certainly could not exist, or even enjoy good health, without a spleen. Some- times the spleen is wanting in man (Lieutaud, torn, i'., p. 234); and sometime! it has been re- moved from animals, which recovered and lived very well.—(Th. Bartholini, Anatomy, p. 155. Mayors Outlines of Physiology, p. 142.) The hypothesis also appears to be scarcely con- sistent with what happens in the horse, whose stomach, which is small in proportion to the size of the animal, could not contain the im- mense quantity of hay, grass, oats, and water, often consumed in a very short time ; and from which organ, Professor Coleman has ascer- tained by experiments, that the passage of drink along the intestines is sometimes equal to the rate of ten feet in a minute.] The means by which the food is broken down into 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. Sec- ondly, tlje high temperature in the stomach produces a concoctive resolution. And, thirdly, the stomach itself secretes and pours forth from the mouths of its minute arteries a very powerful solvent, which is by far the chief agent in the process, and thus effects a chymical res- olution. In this manner, the moistened and masticated food is converted into ehyme. It then passes into the duodenum, and becomes mixed with the secretions poured into this organ from the pancreas, the liver, and the duodenum itself, and subject to their action ; and hence its conversion into chyle. The whole process of digestion, therefore, as it occurs in the human body, to which the description now given chiefly applies, consists of three acts ; mastication, or chewing, chymi- fication, and chylification. M any substances are so hard and intractable as to sustain the action of the digestive organs without any other change, than that of beinc softened or otherwise partially affected, instead* of being entirely Subacted, and reduced to chyme or chyle. Such especial$are the seeds of plants : and it is well worth observing, that, while birds or other animals derive from this kind of food a valuable nutriment, notwith- standing 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 hereby ren- dered more easily capable of expanding in the soil into which they are afterward thrown as by accident, and have their productive power 30 PHYSIOLOGICAL PROEM. very greatly increased.* The olive-tree has till of late years only been raised in the south of France by cuttings, or wild plants obtained from the woods. It was remarked by an atten- tive inhabitant of Marseilles that, when pro- duced naturally, it is by means of kernels car- ried into the woods, and sown there by birds which had swallowed the olives. By the act of digestion, he further observed, these olives are deprived of their natural oil, and the ker- nels 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 experimenter to swallow ripe olives ; the dung was collected, containing the swallowed kernels ; the whole was placed in a stratum of earth, and frequently watered. The kernels thus treatedvegetated 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 afterward macerated in an alkaline lixivium ; they, were then sown, and proved highly productive. Most of the plants found on coral islands, and in various other places, are propagated by the same means of passing through the digest- ive 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, by the wisdom of Providence, animal digestion and vegetable fructification are equally dependant on each other, and are alternately causes and effects. Considering the comparatively slender tex- ture of the chief digesting organ, and the tough- ness and solidity of the substances it over- comes, it cannot appear surprising that man- kind should, at different times, have run into a variety of mistaken theories in accounting for its mode of action. Empedocles and Aippoc- rates supposed the food to become softened by a kind of putrefaction. Galen, whose doc- trine descended to recent times, and was zeal- ously supported by Grew and Santarelli, as- cribed the effect to concoction, produced, like the ripening and softening of fruits beneath a summer sun, by the high temperature of the stomach. Pfingle and Macbride advocated the doctrine of fermentation ; thus uniting the two * In many birds, the pylorus is close to the ori- fice of the stomach, and has no valve, so that the seeds of plants which have been swallowed readily pass into the intestinal canal. This ar- rangement must have an important effect in pro- moting their diffusion. Their disposition to vege- tate more quickly after having thus pervaded the alimentary tube, is a fact that was-particularly noticed by the late Sir Joseph Banks.—Ed. causes of heat and putrefaction assigned by the Greek writers : while Borelli, Keil. and Pitcairn, resolved the entire process into mechanical ac- tion, or trituration ; thus making the muscular coating of the stomach an enormous millstone, which Dr. Pitcairn was extravagant enough to conceive ground down the food with a pres- sure equal to, a weight of not less than a hun- dred and seventeen thousand pounds, assisted at the same time in its gigantic labour by an equal pressure derived from the surrounding muscles. Each of these hypotheses, however, being en- cumbered with insuperable objections, Boer- haave endeavoured to give them, force by inter- union, and hence united'the mechanical theory of pressure with the chymical- theory of con-. coction ; while Haller contended for the process of maceration. Still a something else was wanting, and continued to be so, till Cheselden, in a 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. Although Cheselden was mistaken in the pecu- liar fluid to which he ascribed the solvent en- ergy, namely, the saliva, still he led forward to the important fact; and the gastric juice was soon afterward clearly detected, and its power incontrovertibly established. [The doctrine of digestion by trituration, or mechanical principles, was founded in a great. measure upon an imperfect acquaintance with the digestive organs of birds. Although birds are not furnished with teeth, many of them feed upon hard substances, which, if they were un- broken, the gastric 'juice could not dissolve. Hence they are furnished with a crop, which is a large membranous cavity at the lower end of the gullet, for the reception of the food when it is first swallowed, and where it is softened by the secreted fluids of the part. They are also provided with a gizzard, into which the food, after being macerated in the crop, is transmitted. The gizzard is a cavity of a moderate size, and flattish, spherical form, composed of four strong muscles. Two of these, which constitute the greatest part of its bulk, are of a hemispherical shape, of a dense and firm texture, and lined with a thick callous membrane. The effect of their action is, to move them laterally and ob- liquely upon each other, so that whatever is placed between them is subjected to a very powerful combination of friction and pressure. The force is such, indeed, as not only to break down the hardest grains and reduce them to a complete pulp, but even to grind to powder pieces of glass, and to act upon silicious peb- bles and masses of metal; while the cuticular lining is so tough as not to be injured by the presence of lancets or other sharp instruments, which have been introduced into the cavity by accident, or for the sake of experiment. How- ever, the action, both of the crop and the gizzard, must be considered as essentially mechanical, the latter being equivalent to the teeth, and the PHYSIOLOGIGAL PROEM. 31 former serving merely for the purpose of mace- ration. A strict connexion is always remarked between the food of birds and the nature of their stomachs ; those alone possessing the gizzard which swallow substances that the gastric juice could not dissolve in the entire state. Many writers, in desGHbing the muscular stomachs of granivorous birds, speak of the gizzard as analogous to the. digesting stomach of man or of non-ruminant quadrupeds, whereas it is only a substitute for the organs of mastication. *- Spallanzani proved, however, that the triturated substance in the gizzard is acted upon by the gastric juice, which is furnished by a glandular apparatus,—the bulbus glandulosus, situated at the lower end of the gullet; the structure of the gizzard being evidently not adapted to its secretion. . In birds, therefore, digestion is pro- duced by a powerful solvent, just as it is in the human subject.] The gastric juice, this wonderful menstruum, the most active we are acquainted with in na- ture, is secreted, as I have already observed, by the capillary arteries that infinitesimally inter- sect the cellular texture of the stomach, and decussate each other in their ramifications. The quantity secreted during digestion is consider- able : Leuret and Lassaigne found that when the gullet of a horse was tied, so as to prevent the secretions of the mouth and gullet from en- tering the stomach, a full meal of oats became completely saturated with gastric juice in four or five hours. Mr. Cruickshank supposes the quantity of the fluid thus secreted to be about a pound in every twenty-four hours. Yet the quantity seems to vary considerably, ^according to the de^nand of the system, or the state of the stomach i^elf. In carnivorous birds, whose stomachs are called membranous from having little muscularity, and, consequently, whose food is turned into chyme principally by the ac- tion of the gastric juice", without any collateral assistance or previous mastication, this fluid is secreted in a much larger abundance ; as it is also in those who labour under that morbid state of the stomach which is called canine ap- petite, and will be distinguished in the present classification by the name of limosis avens; as likewise 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 vora- ciously and almost perpetually. [If the contents of the stomach be examined after a long fast, and without any stimulus being applied to its villous membrane, the fluid found in it is a clear, ropy, rather opaque liquid, nearly or quite destitute of acidity. But if any stim- ulus, even of the simplest kind, be applied to the inside of the stomach, then the fluid secreted is uniformly acid. Hence, during digestion, it is found to be distinctly acid; indeed, free mu- riatic acid was detected during this process by * In fact, in that kind of grasshopper termed acrida aptera, the heart-shaped gizzard has six lon- gitudinal rows of large teeth, and six intermediate double rows of smaller teeth, making in all 270 tQeth.—D. Dr. Prout in the stomach of the rabbit, hare, horse, calf, and dog (Phil. Trans., 1824); and also in the matter ejected from the stomach of persons labouring under indigestion. Tiede- mann and Gmelin obtained the purest gastric juice by making animals swallow quwtz pebbles after a long fast, and killing them an hour after- ward. It was generally grayish-white, ropy, and decidedly acid. When taken from the dog and the horse, it contained some mucous, osmazome, and salivary matter, alkaline sulphates and hydro- chlorates, the alkali being chiefly soda, besides phosphate and muriate of lime, with other salts in minut© proportion ; and the acidity was owing to the hydrochloric and acetic acids in the dog, and to these conjoined with the butyric acid in the horse. As the lactic acid of Leuret and Lassaigne is now acknowledged by Berzelius to be a vari- ety of the acetic, all parties may be regarded as agreeing about the presence of that acid in the gastric juice. The researches of Prout, Chil- dren, and Graves, confirmed as they have been so amply by Tiedemann and Gmelm, also fully establish the presence of free muriatic acid. When the secretion of the gastric juice is eli- cited by its natural stimulus, food of various kinds, the chymous mass is invariably acid ; and Tiedemann and Gmelin further maintain, as the result of their experiments, that its acidity is greatest when the food is most difficult of diges- tion. In dogs and cats, the greatest acidity was remarked when they were fed with coagu- lated albumen, fibrin, bones, or gristle ; it was less when they took starch, gelatin, potatoes, or rice ; and when they were fed with liquid albu- men, the alkaline quality of the food was nearly sufficient to neutralize the acidity of the gas- tric juice.] This singular secretion has the peculiar prop^ erty of coagulating milk, as well as all albumi- nous substances, which it also as completely dis- solves ; and hence the milk thrown up from the stomach of an infant, shortly after it has been swallowed, is always found in a curdled state. [By infusing six or seven grains of the inner coat of the stomach in water, a liquor is pro- duced, which, according to Dr. Fordyce, will coagulate 100 ounces of milk ; or, according to Dr. Young of Edinburgh, 6857 times its weight of milk.] But the two grand and characteristic properties of the gastric juice are, its astonish- ing power of counteracting and correcting pu- trefaction, and of dissolving the toughest and most rigid substances in nature. Of its antiseptic power, abundant proofs may be adduced from every class of animals. Among mankind, and especially in civilized life, the food is usually eaten in a state of sweetness and freshness; but fashion and the luxurious desire of having it subacted and mellowed to our hands, tempt us to keep several kinds, as game and venison for example, as long as we can endure the smell. The wandering hordes of gipsies, however, and the inhabitants of va- rious savage countries, and especially those about the mouth of the Orange river in Africa, carry this sort of luxury to a much higher pitch; for they seem to regard a fetor as a perfumo, 32 PHYSIOLOGICAL PROEM. and value their food in proportion as it ap- proaches 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 subject upon the dog, and found in every instance, that the most putrid meat it could be made, to swallow was in a very short period deprived of its pu- trescency. We cannot, therefore, be surprised that crows, vultures, and hyenas, which 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 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 ; while 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. Physicians and surgeons have, in like man- ner, availed themselves of this corrective qual- ity ; and occasionally employed the gastric juice of various animals internally, in cases of indi- gestion from a debilitated stomach ; and ex- ternally, as a check*to gangrene, and a stimu- lus to indolent ulcers. Yet, the * gastric juice is as remarkable for its solvent, as for its antiputrescent property. Of this any industrious observer may satisfy himself by attending to the economy of diges- tion in many of our most common animals. But it has been strikingly exemplified in the experiments of Reaumur, Spallanzani, and Ste-. vens.* 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 buz- zard. The meats were uniformly found dimin- ished 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 claspknives were found half-digested, and the blades blunted, in the stomach and intestines of a man, who had some time before swallowed these sub- stances out of hardihood, and at last died in one of the hospitals of this metropolis. [The experiments of Leuret, Lassaigne, Tiedemann, and Gmelin, all confirm the statements of Spal- * For Dr. Stevens's experiments, which were numerous and well conducted, see his Dissertatio Physiologica Inauguralis ; or an analysis of it in Edin. Med. Comment., vol. v. p. 146. lanzani, Stevens, Gosse, and others, and con- tradict those of Montegre, who supposed that the gastric juice did not act out of the body. Leuret and Lassaigne remarked*, that the fluid procured by long sponges from the stomach of a duck while fasting, when kept upon bread crumbs, at a temperature of 88 degrees Fah- renheit, soon divided them into minute particles, and formed with them a homogeneous mass, precisely like chyme ; and that, when flesh was mixed with the gastric juice or a dog, it was quickly softened and deprived of weight. The observations of Tiedemann and Gmelin are more particular.' The fluid found in the stom- ach of a dog, during the digestion of bones and coagulated albumen, was made the subject of experiment, and comparative observations were made with water and with milk. Various kinds of food were tried, such as bread, coagulated albumen, raw flesh, and boiled flesh; and in every instance it was observed, that the bread was broken down, in the course of eight or ten hours, into a pap, and the surface of the beef and albumen was converted into a pulp, which could be easily scraped off. Montegre is supposed to have failed in procuring similar results, because the fluid with which he oper- ated, was not gastric juice, secreted in conse- quence of the application of some stimulus to the stomach, but^a mixture of saliva, the mucus of the gullet, and the kind of fluid found by Tiedemann and Gmelin in the stomach while empty and not stimulated. Yet Leuret and Lassaigne, it is to be observed, succeeded with the gastric juice of a duck, though the animal was in the fastirfg state. A convincing proof of the power of the gastric juice to dissolve substances out of the body, as well as of its great antiseptic property, has lately been put upon record. A lad had a fistulous opening leading into the stomach, from which the gas- tric juice was readily p'rocured, by means of a hollow bougie and elastic bottle. A piece of beet, connected with a thread, was introduced into the stomach, and another piece was put into a vial of gastric juice, the temperature of which was 100°, the same as that within the stomach itself. The piece in the vial underwent a perfect dissolution, though more slowly than that in the stomach, probably in consequence of the latter being continually exposed to fresh gastric juice, and the peristal- tic action of the stomach. Solutions of beef and chicken thus procured, remained a whole • month m hot weather, free from fetor and sour- ness.*— (American Medical Recorder, January, 1826.) Tiedemann and Gmelin even attempted * The experiments here alluded to have recently been published in detail by Dr. Beaumont, who in his curious and instructive work entitled " Ex- periments and Observations on the Gastric Juice and the Physiology of Digestion," has added much valu- able information to this portion of physiology Alexts St. Martin, the subject of experiment, was accidentally wounded in the side by the discharge of a musket, which removed the integuments and muscles of the size of a man's hand. On recov- ering, a perforation about two and a half inches in PHYSIOLOGICAL PROEM. 33 to accomplish, by means of the simple sub- stances contained in the gastric juice, the same solution or digestion that is effected by this se- cretion itself; and they found that dilute acetic acid, dilute hydrochloric acH, a weak solution of acetate of ammonia, will severally dissolve most animal substances used as food. The ex- periments, however, were incomplete, because the effect of. the foregoing articles, united to- gether as they are in the gastric juice, was not tried.] It is in consequence of this wonderful power that the stomach is sometimes found in the ex- traordinary action of digesting its own self; and of exhibiting, when examined in dissection, va- 4 rious erosions in different parts of it, and espe- cially about its great extremity. It was the opinion of Mr. Hunter (Phil. Trans. 1772, vol. Ixii. p. 447), however, that such a fact can never take place except in cases of sudden dikth, when the stomach is in full health, and the gastric secretion, now just poured forth, is sur- rounded by a dead organ. For he argues plau- sibly, that the moment the stomach begins to be diseased, it ceases to secrete this fluid, at least in a state of perfect activity ; and that so long as it is itself alive, it is capable, by.its living principle, of counteracting the effect of this circumference still existed in the stomach. Dr. B. was thus enabled to observe its inner surface, * to remove its contents and secretions, to introduce and withdraw at pleasure any articles of food, and to study their changes. The following are some of his conclusions : The inner coat of the stom- ach is of a pale pink colour, varying in its hues, according as the stomach is full or empty. It has a velvet-like appearance, and in health is always covered with a thin transparent mucus, which differs physically and chymically from the gastric juice. The gastric juice is limpid, colourless, and slightly viscid. It is secreted by vessels distinct from the mucous follicles, and it is never found free in the stomach, unless excited to discharge itself by food or other stimulants. It acts as a solvent of the food, and its action is assisted by the warmth and by the transverse and longitudinal motions of the stomach. It contains, according to the analyses of Professors Silliman, Dunglison, and Emmet, free muriatic acid and some other active chymical principles. By introducing thermome- ters into the stomach, its natural temperature was found to be 100° Fahrenheit: the temperature was elevated by exercise and depressed by rest. In the New-York Medical Repository, vol. xii., Dr. Waterhouse has made known the particulars of % case of fistulous opening of the sdBmach, oc- curring in a German female who had borne several children; the phenomena marking the action of the gastric juice and the process of digestion, were in many respects similar to those noticed by Dr. Beaumont; and when Dr. Beaumont's commu- nication was read to the French Academy, M. Roux stated that a similar case had occurred in Paris, and that the patient's death was evidently hastened by the experiments tried on her. Pro- fessor Jackson, of Philadelphia, however, denies the existence of the gastric juice, and says (Princi- ples of Medicine, p. 348), " the presumed gastric juice is ^hen no other than the salivary, buccal, \ pharyngeal, oesophageal, and stomachical follicu- -V far secretions and exhalations, collected in the stomach."—D. Vol. I.—C solvent power. Yet it has been found thus eroded, in some cases, where death has fol- lowed long constitutional illness. Dr. Wilson Philip has occasionally found similar erosions in the stomachs of rabbits (Treatise on Indigestion, &c, p. 62. 8vo. Lond., 1824), and apparently from the cause suspected by Mr. Hunter.* * On this very curious subject, Andral has not yet made up his mind, and deems further observa- tions necessary.—(Anat. Pathol, t. ii. p. 28.) The late Dr. Armstrong also entertained some doubt respecting the correctness of Mr. Hunter's doc- trine. " If," says he, " the operation of the gastric juice after death, were the cause of the dissolution of parts of the stomach, this appearance would surely be one of the most frequent in morbid anat- omy; whereas it is notoriously very rare." He adds, that, in every instance that he had seen, the most unequivocal signs of disease existed for some time before death.—{Morbid. Anat. of the Bowels, p. 46. 4to. Lond., 1828.) On the contrary, Mr. Hunter asserts, that there are few dead bodies, in which the great end of the stomach is not in some degree digested.—(Phil. Trans., vol. Ixii.) The examples seen by Dr. Armstrong himself were perforations of the stomach during fife. Instead of most frequently occurring in the great, they happened principally in the pyloric extremity of that organ; they were also generally the result of disease, indicated before death by a train of vio- lent and rapidly fatal symptoms. The cases al- luded to by Mr. Hunter are totally different, being attended during life with no symptoms of disease of the stomach, and often occurring in persons who have been suddenly killed in the midst of perfect health. In order to explain why digestion of the stomach does not take place in all animals that are killed while in full health, Adams referred to the opinions of Hunter concerning real and ap- parent death; and was led to conclude, that the digestion only took place when life was so com- pletely and suddenly annihilated, that the blood remained fluid, and the limbs free from stiffness. The facts adverted to by Dr. Carswell, however, sufficiently refute this explanation. Certainly one of the most striking circumstances, in relation to the perforations of the stomach which happen after death, is their usual seat in the great ex- tremity of that organ. It is in this part that fluids accumulate after death by the influence of their own gravity. Mr. Hunter also pointed out an- other important consideration, which is, that alter- ations, resembling those of the stomach, are fre- quently met with in other viscera, to wlfeh the contents of that organ directly extend their ef- fects, after its own partial digestion ; as the fiver, diaphragm, spleen, left lung, and intestines. As my friend Dr. Carswell observes, another equally remarkable fact, is the extension of these altera? tions in a direction in which a fluid alone could act or be carried, together with the total absence of all redness or other sign of inflammation or ad- hesion, the formation of pus, &c.—(See Edinb. Med. and Surgical Journ., October, 1830.) This paper contains an account of various interesting experiments, and an examination of all the opin- ions hitherto delivered on the cause of dissolu- tions of the stomach met with in the dead subject. The observations of Adams, A. Burns, Spallanzani, Bretonneau (Archiv. de Med. t. xii. p. 345), Car- lisle, A. Cooper, and Carswell, fully establish the truth of Hunter's views. As Dr. Carswell has set down acidity of the gastric juice as essential to the production of the effects here treated of, it might be proper, in a repetition of his experiments, to substantiate this remark, by trying whether the • 34 PHYSIOLOGICAL PROEM. Is it upon the principle laid down by Mr. Hunter, that, when the stomach is in a state of disease, it ceases to secrete a gastric juice of full vigour and activity, that we can account for the existence of exotic worms and the larvae of insects and other animals for a considerable pe- riod of time without destruction 1 Thus Collini gives an example oi&lacerta aquatica,foxind alive in the stomach two days after it had ben swal- lowed.—(Journ. de Med., torn. Ii. p. 460.) Frogs and serpentshave, for a longer period of time, been equally able to resist the action of the stomach ; leeches, swallowed unintentionally in a draught of muddy water, have thriven and grown to an enor- mous size ; the eggs and larvae of various insects, and especially of the musca cibaria, and even of the spider, have been hatched or perfected in the stomach or intestines, and the kernels of plum and cherry-stones have germinated there. Muscular action, however, to a certain extent, seems still requisite as an auxiliary in man, and even considerably more so in many animals, es- pecially in graminivorous and granivorous birds.* I have already stated this as one cause of diges- tion : but M. Magendie has endeavoured to re- store it to a much higher importance than fair and unequivocal experiments justify ; for he as- serts that, what he, calls artificial digestion, or that of alimentary substances mixed with the gastric juice, and exposed to the temperature of the stomach, does not succeed in reducing the food to chyme. ' But this, admitting the fact, would only show us the use of a living princi- ple, and its influence upon every organ, and the operation or function of every organ; and which cannot be imitated out of the body. The assertion, however, is only advanced upon the single authority o%M. Montegre, [the failure of whose experiments, as we have already noticed, is# imputed by others to the fact, that the fluid with which he operated was not gastric juice, secreted in consequence of the application of some stimulus to the stomach, but a mixture of saliva with the mucus of the gullet, and the fluid found in the stomach while destitute of food, and not stimulated.t In the artificial imitations of the process of digestion, the churning action of the stomach, however, ought certainly to have been taken into consideration, and a substitute for it adopted. The influence of the par vagum on digestion is an interesting subject, that has excited con- siderable attention. Mr. Brodie divided these nerves on the cardia, yet the food still contin- neutralization of the gastric juice with alkalis, would prevent its action on the stomach. To the living subject they are often given very freely, for the express purpose of improving digestion.—Ed. * See Sir E. Home's articles, Phil. Trans., vol. xcvi. p. 357; xcvii. pp. 93,139; c. p. 184; cxiii.p. 77. t In relation to this point, I may again advert to the case of a healthy young man, who had a fis- tula in the epigastric region, communicating with the stomach, the consequence of a gunshot wound. Dr. Lovell, of the United States, having collected in a vial a certain quantity of the fluid that es- caped from the opening, put a bit of meat into it, which dissolved with great readiness.—See An- dral, Anat. Pathol., t. ii., p. 27.—Editor. uedto be transformed into chyme. M. MageW- die took out a portion of a rib, and divided the par vagum on the oesophagus immediately above the diaphragm : still the conversion of the food, both into chyme and chyle, was not interrupted. However, when the same nerves are divided in the neck, and particularly when a portion of them is removed, the formation of chyme is either very imperfect, or even quite prevented. The inves- tigations of Dr. W. Philip, Breschet, and Ed- wards, prove, that galvanism applied to the stomach, after the division of the par vagum in the neck, restores the digestive process; and hence the doctrine that digestion depends upon galvanic principles. The fact, however, may only prove, that galvanism is a sufficient stim- ulus to the vessels of the stomach, to enable them to continue for a time the secretion of the gastric juice. With respect to the power of the nervous system over digestion, a curious fact was de- monstrated by the experiments of M. Magendie ; namely, that when the brain and a large portion* of the cerebellum of a duck is removed, though the instinct of seeking food and even the power of deglutition may be lost, yet, if food be con- veyed into the stomach, it will be digested. If we are to believe some accounts, the car- diac portion of the stomach is the chief seat of digestion ; and when a part of the food has there been acted upon in a certain degree, it is con- veyed along the large curvature to- the pyloric portion, where the process is completed. It seems also now to be established, that the di- gestive process does not go on equally through the whole mass of the food, but principally where this is in contact with the stomach ; that it proceeds gradually from the surface to the centre of the mass, and that, as soon as a por- tion is reduced to a homogeneous consistence, it is transmitted into the duodenum, without the delay that would result from awaiting a similar change of the whole.* The food having undergone a sufficient de- gree of maceration and mastication, or other mechanical process, by which it is reduced to a state of sufficiently minute division, it is acted upon by the gastric juice and the peristaltic con- tractions of the stomach, and the result is a complete change in its.properties, its conver- sion into chyme ; an alteration in every respect analogous to a chymjeal change. During the process of fchymification, heat is occasionally extricated,' and not unfrequently gas, composed of carbonic acid, hydrogen, and azote in various proportions, is evolved. Dr. Bostock regards these, however, not as necessary steps in the process, but rather as the consequence of a mor- hid state of the function, t Previously to Dr. Prout's experiments, the generation of acid in .----__ * Prout, in Annals of Philos., 1819. t Physiol., vol. ii., p. 491. Dr. Abercrombie also believes, that, in healthy digestion, no gas is gen- erated in the stomach; but that a certain quantity is evolved in the further progress of the alimentary matters through the intestines, especially in the colon.—See Pathol, and Pract. Researches on Diseases of the Stomach, &c, p. 71., ed. ii., S. C- PHYSIOLOGICAL PROEM. 35 the stomach used also to be considered in the sa/ne point of view. Chyme is not always of the same quality, its properties depending much upon the nature of the food. According to recent experiments, made on dogs and horses, it appears that liquid albumen forms under the natural process of di- gestion a homogeneous fluid, in which the albu-. men remains quite unaltered; and this sort of chyme passes the pylorus more rapidly than any other. Coagulated albumen is much more slowly dissolved, and the fluid produced pos- sesses the properties of coagulated albumen dis- solved in acetic acid. Fibrin and vegetable gluten undergo a similar change. Gelatin is converted into a clear brownish fluid, in which neither gelatin nor albumen can be discovered. White cheese forms an opaque dirty white fluid, containing much animal matter, which, however, is neither the case with gelatin nor albumen. Starch is gradually dissolved, and loses its re- action with iodine, being converted into sugar and amidine. The results obtained with com- pound articles of food, such as milk, beef, bread, and oats, in various states of mixture, were such as the foregoing facts would lead one to antici- pate. Bones gave a liquid that contained not only animal matter, but a large quantity of lime. The general result is, that all the animal prin- ciples, except liquid albumen, undergo a mate- rial change during chymification, which change generally consists in their being made to ap- proach nearer in their nature to albumen.] So far, therefore, as the organ of the stomach is concerned in the digestive function, we have some insight into the process. But beyond this, that is to say, of the nature of chylifica- tion, we have little or no knowledge that can be depended upon. The aliment having been reduced to chyme in the stomach, is propelled into the duodenum, where it is converted partly into chyle, which is absorbed into the system from the small in- testines, and partly into a residual matter, that assumes the nature of feces in the large intes- tines, and is ultimately rejected from the sys- tem. As it is into the duodenum that the biliary and pancreatic ducts discharge their respective fluids, chylification is generally presumed to be essentially connected with the action of the bile and pancreatic liquor. [The constancy of the liver, not only in all red-blooded animals, but in the intervertebral wfth colourless blood, wherever a heart and bloodvessels are present, its magnitude, and the destructive and grievous consequences arising from its diseases, are convincing proofs of its high importance in the animal economy. With * In some rare instances, the vena portae, instead of going to the liver, has terminated directly in the lower vena cava; yet bile was secreted, and, of course, from arterial blood.—(Abernethy in Phil. Trans., vol. lxxxiii., and Lawrence in Med. Chir. Trans., vol. iv., p. 174.) M. Simon found, that tving the hepatic artery in pigeons did not prevent the secretion of bile; but that a ligature on the vena portae had this effect. On the other hand, Mr. B. Phillips tied this vein in two dogs, and ob- C 2 these facts, it may seem extraordinary that phys- iologists should not be in possession of some clear information respecting the functions of this organ, and the uses of the bile. In particu- lar, the action of the latter secretion in chylifi- cation is but imperfectly understood. Its ordi- nary production from venous blood is a peculi- arity that does not belong to any other secretion; * while the great difference of its chymical quali- ties from those of every other fluid in the body, is a point not less remarkable. One obvious mode of forming a judgment of the uses of the bile, is to remark what ill effects result from the stoppage of its flow into the in- testinal canal. On this point, however, the most discordant statements prevail. If we are to credit Dr. G. Fordyce, when the ductus com- munis choledochus is tied, or blocked up by a calculus, the formation of chyle is not prevent- ed, and consequently the biliary secretion is not essentially necessary for digestion. The same conclusion, with respect to its having no share in the formation of the chyle, is also adopted by some distinguished physiologists of the present time, as will be presently explained. On the otjier hand, Mr. Brodie, after tying the com- mon biliary duct in young cats, was led to es- pouse an opinion long ago prevalent, that the principal use of the bile was to separate the chyle from the chyme ; for he found, that when that duct was tied, and food given, chymifica- tion went on in the stomach as usual; but that no chyle could be detected in the intestines or the lacteals, which only contained a transparent fluid imagined to be lymph, and the watery part of the chyme.—(See Journal of Science and the Arts, vol. xiv., p. 343.) The same view is also supported by Mr. Mayo's experiments. Leuret and Lassaigne tied the common duct in a dog, and cleared out the intestines by giv- ing the animal a little castor-oil. Twelve hours after the operation, they thrice gave it bread and milk with sugar, at intervals of six hours; and eight hours after the last meal it was stran- gled, and immediately opened. The stomach contained an acid pulp, and a very soft, whitish,. sweet chyme adhered to the villous coat of the duodenum, and increased its consistence down- wards. In the great intestines it was firm, but had the same colour, and was nearly destitute of taste and smell. The thoracic duct was dis- tended wit!; a yellowish red, transparent fluid, which coagulated on exposure to the air, and yielded the usual proportion of fibrin, albumen, and saline matters. Tiedemann and Gmelin, whose investigations are more elaborate and precise, remarked, that animals were attacked with vomiting soon after served that in both instances bile continued to be secreted, though in small quantity. His experi- ments on the hepatic artery agree with those of M. Simon. The variety in the distribution of the vena porta? affects several hypotheses respecting the use of the liver, and especially that of M. Ma- gendie, which represents all drink as passing through the branches of this vein, and as undergo- ing some change in the liver, previously to its entrance into the circulation.—Editor. CAL PROEM. 35 PHYSIOLOG the operation ; then with thirst and aversion to food ; and that, on the second or third day, the conjunctiva of the eyes became yellow, the stools chalky and very fetid, and the urine yellow, and convertible to blue, and then red, by nitric acid. Some of the animals died ; others were killed. Of the latter, some had previously recovered from the jaundice, owing to the re-establishment of the duct by the effusion of lymph around the tied part, and the subsequent discharge of the ligature; a fact also noticed by Mr. Brodie in his experiments. In the cases-in which the biliary duct continued impervious, the colouring matter of the bile was found in the blood, the serous membranes, the cellular tissue, the coats of the arteries and veins, and in the fat. It was further observed, that chymifieation went on as perfectly as in a sound animal. In the small intestines, they found nearly the same principles as in the healthy state, with the exception of those derived from the bile ; and, in particular, they found in the duodenum, and in contact with its membrane, the soft mucous flakes which some physiologists consider, though, as Gmelin and Tiedemann think, erroneously, to be chyle. With the exception of the absence of certain biliary principles, the contents of the great in- testines were likewise similar to those met with in the bowels of healthy animals ; but they had an exceedingly fetid smell. In such animals as had been fed a little while before death, the thoracic duct and the lacteals always contained an abundant fluid, generally of a yellowish col- our. It coagulated, like ordinary chyle; the erassamentum acquired the usual red colour; its difference from the chyle of a sound animal was, that after tying the ductus choledochus, it was never white. The reason of the difference is ascribed to the circumstance of the white ; colour depending upon fatty matter taken up from the food by means of the bile, which pos- sesses- the power of dissolving fat, and probably, therefore, aids in effecting its solution in the chyle at the mouths of the lacteals. It is sup- posed that Mr. Brodie was deceived by the ab- sence of the white colour, which, it is true, the chyle usually possesses, but which, as it is well known, it does not exhibit unless the food con- tain fatty matter. Mr. B. Phillips also infers, that chyle may be formed independently of the influence of the biliary secretion, and he not only adverts to examples in which the ductus com- munis had been rendered impervious, by the pressure of tumours, but gives the particulars of experiments made on four dogs, in which he found chyle in the thoracic duct, after the duc- tus communis had been tied. The following are the uses ascribed to the bile by Tiedemann and Gmelin ; First, by its stimulant properties, it excites the flow of the intestinal fluids, as is proved by the unusual dryness of the feces in jaundiced persons, and in animals, whose common duct has been tied. Secondly, it probably stimulates the intestinal muscular fibres to action. Thirdly, as it con- tains an abundance of azotized principles, it may contribute to animalize those articles of food which have no azote in their composition. Fourthly, it tends to prevent the puSrefactitflJ of the food during its course through the intes- tines ; because, when it is prevented from flow- ing into them, their contents are much further advanced in decay than in the healthy state. Fifthly, it probably tends to liquefy and render soluble the fatty part of the food. Lastly, it is to be regarded as an important excretion. According to the researches of the same phys- iologists, many of the principles of the bile, such as its resin, colouring matter, fatty matter, mucus, and salts, are thrown out of the body, ; with the feces, in the natural state of the biliary system, or by the urine, or into the cellular tis- sue, when the excretory duct of the liver is ob- structed. These principles contain a large pro- portion of carbon, and would appear, therefore, to be intended to carry off the excess of that element which is introduced into the system ; with vegetable food, and not thrown off by the lungs. In the lungs, it is thrown off in the state of oxydation ; in the liver, chiefly in union 1 with hydrogen, and in the form of resin and fatty matter.' That the liver is thus intended to as- sist the lungs in decarbonizing the blood, seems to Gmelin and Tiedemann confirmed by the fol- lowing facts: The resin of the bile abounds- most in herbivorous animals, whose food con- tains a large proportion of carbon and hydrogen. In various tribes of animals, the pulmonary and biliary organs are in a state of antagonism to one another; a fact particularly insisted upon by Fourcroy. The size of the liver and the quan- tity of the bile are not proportionate to the quantity of the food and frequency of eating ; but inversely to the size and perfection of the lungs. Thus, in those warm-blooded animals- which have capacious lungs, and live always in i air, the liver, compared with the body, is pro- portionately less than in such as live partly in water. The liver is proportionately larger in reptiles, which have lungs with large cells, incapable of rapidly decarbonizing the blood; also in fishes, which decarbonize the blood but slowly by the gills; and, above all, in mol- luscous animals, which effect the same change very slowly, either by gills, or small, imper- fectly developed lungs. Another thing, pointed out as highly deserving notice, is the increased quantity of blood transmitted through the liver, when the pulmonary system becomes less per- fect. In mammalia and birds, the vena portae is formed by the veins of the stomach, intes- tines, spleen, and pancreas; in the tortoise, it leceives also the veins of the hind legs, pel- vis, tail, and vena azygos; in serpents, it re- ceives the right renal, and all the intercostal veins; in fishes, the renal veins, and those oi the tail and genital organs. Another observation, made by the same pro- fessors, is, that, during the hybernation of cer- tain animals of the class mammalia, when res- piration is suspended, and no food is taken, the secretion of bile goes on. An additional argu- ment, in favour of the preceding hypothesis, is deduced from the physiology of the foetus, in which the liver is proportionately a great deal larger than in the adult, and in which the bile PHYSIOLOGIC is secreted abundantly, as appears from the great increase of the meconium during the latter months of pregnancy. Finally, another argu- ment is derived from pathological facts. Ac- cording to Tiedemann and Gmelin, in pneumonia and phthisis, the secretion of the bile is in- creased ; in diseases of the heart, the liver is enlarged; and, in the morbus caeruleus, the liver retains its foetal.state of disproportion. In hot climates, where, in the opinion of these physiologists, respiration is less perfectly carried on than in cold ones, owing to the greater rare- faction of the air, a vicarious decaibonization of the blood is established by an increased flow of the bile. The foregoing hypothesis is, perhaps, better supported than that of Sir Everard Home, who considers one of the offices of the bile to be that of converting mucus, or the refuse matter of the chyle, as it passes along the colon, into fat, which is absorbed into the system. This indefatigable physiologist was partly induced to adopt this opinion by the example which he met with of a child, in which the peristaltic action of the bowels had been duly continued, and stools regularly produced, without any inter- mixture of bile, and even when no gall-bladder, nor any duct leading from the liver into the du- odenum, existed—(PhiL Trans., 1813, art. 21.) The mere circumstance of this child being in a state of marasmus at its death, without any mani- fest intestinal disease, however, scarcely war- rants the theory attempted to be built upon it, and which may be regarded as the reverse of what is inculcated by Fourcroy, Gmelin, and Tiedemann, who represent the bile as depriving the system of its redundant carbon and hydro- gen, and not as a means of supplying a larger quantity of these elements to it. Besides the secretion of the duodenum itself, which is supposed to be concerned in chylifica- tion, the pancreatic juice is another fluid appa- rently intended for the same purpose. The com- mon opinion has been, that, in its nature, it is very simdar to saliva : Tiedemann and Gmelin, however, represent it as differing materially from this fluid, and never containing any sulpho- cyanic acid, free soda, or mucus ; as being naturally acid; having a much larger quantity of solid matter ; and especially a greater pro- portion of albumen ; and, in the dog at least, a peculiar principle, soluble in water and in alco- hol, and, when pure, precipitated rose-red by chlorine. Sometimes, it contains also a good deal of phosphate and acetate of soda. The pancreatic fluid of the dog, horse, and sheep, when heated, yields a large quantity of coag- ulum, which the saliva does not. The particu- lar use of the pancreatic secretion in digestion is unknown. Tiedemann and Gmelin, reasoning from the large quantity of azotized principles which it contains, presume, that its use may be to animalize vegetable food. They remark, as a confirmation of this opinion, that the pancreas is much larger in herbivorous, than carnivorous animals.—(See Edin. Med. and Surg. Journ., Nos. 91 and 93.) Of the action of the omentum and spleen, we DAL PROEM. 3T know nothing certain.* The spleen secretes no peculiar fluid; its blood is of a dark livid colour, and coagulates with difficulty. It is even destitute of an excreting duct; and, in some instances, has been extirpated without in- jury to the general health. It is not found in any tribes below the class of fishes. [To some of the hypotheses concerning the use of the spleen, reference has already been made. The experiments of Leuret and Lassaigne led them to revive the hypothesis, that the spleen is a mere diverticulum for the blood during digestion. When the stomach and intestines are distended with food, and the process of digestion is going on, the blood flows in an increased quantity to the villous membrane of the whole alimentary canal, and consequently more venous blood re- quires to be returned by the hepatic vessels. These, however, being presumed to be inade- quate to the purpose, the splenic veins and cells become gorged. It was found, that the spleen of the dog, which generally weighs but a few ounces, acquired the weight of a pound and a half two hours and a half after a ligature had been ap- plied to the vena portae. In the dog, cat, rabbit, Guineapig, and other mammalia, the spleen pre- sented a rosy or vermilion tint while the animals were fasting ; after chymifieation had begun, it assumed a blue colour, and was somewhat tinged ; but it did not acquire its deep bluish-black colour, and greatest turgescence, till the chyme had passed the pylorus, when the intestinal membrane participated in the activity previously confined to the stomach. This hypothesis is liable to the objection, that, if true, the absence or removal of the spleen ought always to occa- sion more serious consequences than it is said to do. Tiedemann and Gmelin represent the struc- ture of the spleen as essentially resembling that of the lymphatic glands, and regard it as an or- gan which is merely an appendage to the ab- sorbent system. They believe that its specific function is to secrete from the blood a reddish fluid that has the property of coagulating, is carried to the thoracic duct, and, being there united with the chyle, changes it into blood. * Dr. James Rush considers the omentum to be "an organ for the secretion of fat, furnished with vesiculae for its reception, in order to supply the body with nourishment when the resources by the stomach fail." Among other reasons for this opin- ion, he mentions its structure, situation, its little sensibility, its presence in most animals, its ab- sence in others ; its state in the hybernating ani- mals, &c.—(See Med. and Phil. Reg., vol. vi., No. 1, p. 67.) In regard to the spleen, Dr. Rush savs (Med. Museum, vol. iii., p. 10), " AH the motions which go forward in the human body, are produced by external and internal stimuli. These stimuli ex- ert their influence directly and indirectly upon the bloodvessels. From innumerable causes they are liable to become excessive in their force. The pro- vision to defend the tender and vital- parts of the body from the effects of this force, I believe to be the spleen." This theory, which is supported by many ingenious arguments, has recently been re- vived as new, by Dr. Hodgkin.—See Ed. Med. and Surg. Journ., Jan., 1832.—D. 38 PHYSIOLOGICAL PROEM. The facts, elucidated by the experiments of these physiologists, are of great value: yet, their hypothesis, relative to the spleen being an organ of sanguification, is seriously shaken by the facts, that a vast difference really exists between the structure of the spleen and that of an absorbent gland ; that the chyle does not in- variably exhibit a reddish hue ; and that the ab- sence or removal of the spleen may happen, not only without fatal effects, but even without much subsequent disturbance of the animal economy. Notwithstanding the progress of animal chym- istry, and the multiplication of experiments on living animals, we are obliged to confess, that our knowledge of the rationale of chylification is still involved in considerable obscurity. But, though we know not the exact way in which this process is effected, our acquaintance with the properties of the chyle itself is more satis- factory. For the most accurate information concerning the chyle, we are indebted to Du- puytren, Vauquelin, Emmert, Marcet, Prout, Tiedemann, and Gmelin. If the animal, from which the chyle is extracted, has eaten animal or vegetable substances of a fatty nature, the liquid, drawn from the thoracic duct, is of a milky appearance, a little heavier than distilled water, of a strong, spermatic odour, of a salt taste, slightly viscid, and plainly alkaline. It soon separates into three parts: a solid one, that remains at the bottom ; a liquid one, at the top ; and a third, whjch forms a very thin layer on the surface. At the same time, the chyle assumes a bright rose colour. When, however, it is derived from food void of fat, it is opaline, and nearly transparent, instead of being of an opaque white colour, and the layer on the sur- face is less evident. Chyle never takes the hue of colouring substances in the food. M. Halle proved this by direct experiments. Magendie also made animals eat indigo, saffron, and mad- der, without the colour of these articles being communicated to the chyle. This fact, which is confirmed by the experiments of Tiedemann and Gmelin in Germany, Andrews at Edin- burgh, and Lawrence and Coates in America, is very important, because it is at variance with Mr. Hunter's statement, and upon its correct- ness the truth of the theory, which restricts the function of the lacteals entirely to the absorp- tion of chyle, and of no other matter, mainly depends. Chyle, derived from sugar, contains hardly any fibrin ; while that from flesh has a great deal. The appearances and quality of this fluid are, therefore, considerably modified by the kind of food; and it deserves particular recol- lection, that, as it is not always white, its pink or transparent look is not to be regarded as,a proof, either of the lacteals having imbibed madder, or of the imperfect formation of the chyle.] M. Magendie's experiments led him to conclude, that a dog, upon an average, forms about six ounces of chyle every hour. The subject is highly interesting : but to pursue it further, and especially into that diversity of structure which the digestive organs present in almost all the different classes and orders, adapted, as it is in each of them, with the most skilful attention, to the general economy of their nature, and the mode of life they are destined to lead, would occupy more space than we can spare, and carry us into the regions of general physiology. Enough has perhaps been said, and this is all that has been aimed at, to give a compendious view of the organs which form the seat of that class of idiopathic diseases, with which the nosological system about to be unfolded commences, and consequently to enable the reader to follow up those diseases with greater clearness and com- prehension in their distinctive characters and de- scriptions.* I have limited the above remark to idiopathic diseases; and it is necessary the limitation should be attended to. For, from the intimate connexion which the organs of digestion main- tain with other organs and sets of organs, there are few general complaints in which the first do not evince some sympathetic affection. This is particularly the case with the stomach, which, in the opinion of Mr. Hunter, is the seat and centre of universal sympathy ; a doctrine which appears to have been taught in France by M. de Bourdeu.t though with less caution, and from fewer premises, at the very time Mr. Hunter was teaching it in London. The sympathetic affections here spoken of, cannot fall within the range of the present class; but must necessarily appertain to those diseases and divisions of diseases, under which they rank as peculiar symptoms, and which can only be removed by removing the idiopathic malady. * Dr. Abercrombie sums up, in a few words, the principal circumstances necessary for the healthy condition of the process of digestion : 1. A healthy state of the muscular action of the stomach; 2. A healthy, consecutive, and harmonious action of the muscular coat of the intestinal canal; 3. A healthy state of the fluids of the stomach; 4. A healthy state as to the quantity and quality of other fluids, derived from the liver, pancreas, and mucous mem- brane of the intestines ; 5. A healthy state of the mucous membrane itself, both in the stomach and the intestines.—See Abercrombie's Pathol, and Pract. Researches on Diseases of the Stomach. &c d 71 ed.2. S. C. '' P' ' t See his Thesis, " An Omnes Corporis Partes Digestioni opitulantur ?" Paris, 1754, CLASS I. CCELIACA. '. ORDER I. ENTERICA. DISEASES AFFECTING THE ALI- MENTARY CANAL. DISQUIET OR DISEASED ACTION IN SOME PART OF THE PASSAGE FOR THE RECEPTION AND DETRI- TION OF FOOD. The diseases of the Digestive Function form the first class in the Nosological System about to be unfolded ; and to these, from the Greek term KOIAI'A, " alvus," " venter," or " the lower belly," I have applied the classic name of Cceliaca. By an easy and natural arrangement, this class is divisible into two orders ; the first em- bracing those disorders which affect the ali- mentary canal; and the second, those which affect the collatitious or auxiliary viscera. The former I have distinguished by the term Enteb- ica, and the latter by the term Splanchnica, both of which are Greek adjectives; the one being a derivation from tvrtptiv, " intestinum," " alvus;" and the other from o*\dyyvov, " vis- cus," " a bowel, or entrail." The present order embraces the following genera:— I. Odontia. Misdentition. II. Ptyalismus. Ptyalism. III. Dysphagia. Dysphagia. IV. Dipsosis. Morbid Thirst. V. Limosis. Morbid Appetite. VI. Colica. Colic. VII. Coprostasis. Costiveness. VIII. Diarrhoea. Looseness. IX. Cholera. Cholera. X. Enterolithus. Intestinal Concretions. XI. Helminthia. Worms. XII. Proctica. Proctica. tenance of the teeth, than of the bones from which they issue. , They are altogether limited to the duration of the teeth, sprouting forth at their commencement, and being carried away by absorption, on their decay or removal. They are also in every instance modelled by the shape of the teeth ; and, like the gums, parti- cipate in almost all their diseases. The character of the present genus is there- fore made sufficiently general to embrace the disorders of these adjuncts of the teeth, as well as of the teeth themselves : all which, as distinct species, may be conveniently arranged in the following order :— 1. Odontia Dentitionis. Teething. 2.-------Dolorosa. Toothache. 3. -------Stuporis. Tooth-edge. 4. ------Deformis. Deformity of the Teeth. 5.-------Edentula. Toothlessness. 6.------Incrustans. Tartar of the Teeth. 7.------Excrescens. Excrescent Gums. GENUS I. ODONTIA. MISDENTITION. PAIN, OE DERANGEMENT OF THE TEETH, OR THEIR INVOLUCRES. This genus has by some writers been called odontalgia and odaxismus. But as both these terms have been limited by other writers to a single species of the genus, that of odontia do- lorosa, or toothache, in order to prevent con- fusion, I have ventured to give it the name under which it now appears ; derived from 6&oi>s, " a tooth," which in fact is the common root of all the terms, and is here preserved in its simplest form. The involucres of the teeth are their gums, membranes, and sockets, or alveoli. The last, although an immediate apophysis of the jaw- bones, are rather to be regarded as an apper- SPECIES I ODONTIA DENTITIONIS. TEETHING. IRRITATION FROM CUTTING THE TEETH. Dr. Cullen did not allow dentition to enter into the list of diseases ; but this is to suppose the process of teething to take place at all times, instead of only occasionally, with perfect ease, and without irritation of any kind. When- ever it occurs in this manner, there is undoubt- edly no disease, and so far Dr. Cullen is cor- rect. But in a very large number of cases, perhaps, in refined and intenerated society, in the larger number, there is not only disease, but in many instances disease of an alarming and fatal character, strikingly severe in its prog- ress and complicated in its symptoms. The organism of the teeth, indeed, is peculiarly dis- tinguished by the following feature : that there is no other part of the human structure so brief in its duration, and none, with the exception of the uterus, so signalized by pain and inconve- nience during its progress. Yet their mechan- ism, notwithstanding these evils, is most ad- mirable. No effort of human wit has ever been able to improve upon it, even in imagination, and no organ is more strikingly impressed with marks of supernal goodness and intelligence. [The human teeth differ from those of animals, in being all of one length, and having no con- siderable interspaces between them. Another of their peculiarities is the perpendicular direc- tion of the lower incisors. In animals, these teeth slant backwards, and the jaw also slopes backwards directly from the alveoli, so that the full, prominent chin, is found only in man, while in animals it seems as if it were cut off. In 40, C02LIACA [Cl.L— Ord. J. man, the Obtuse tubercles of the grinders are very particular, not resembling the flat crowns with rising ridges of intermixed enamel, belong- ing to herbivorous animals, nor the cutting and tearing grinders of carnivorous ones.] There are three periods of life in which den- tition, or the breeding and cutting of teeth, uni- formly takes place—in infancy, in boyhood, and adult age. Besides which, we meet with in- stances occasionally of a reproduction of teeth in advanced life. Each of these formations is ac- companied with circumstances peculiar to itself; and when attended with pain or morbid action of any kind, affords a distinct modification of the present species of disease, and consequently lays a foundation for the four following varie- ties :— a Lactentium. Cutting the milk or shed- Milk teething. ding teeth. 0 Puerilis. Cutting the second set, Permanent teething, or permanent teeth. y Adultorum. Cutting the adult or wise Adult teething. teeth. S Senilium. Cutting teeth in ad- Climacteric teething, vanced life or old age. Before we enter upon the symptoms of these varieties, it is necessary to give some explana- tion of the causes which produce them; or, in other words, to take a brief glance at the or- der and economy of dentition. As the jawbones of youth are both wider and longer than thqpe of infancy, it is obvious that the teeth which are cut in the first year, must be incapable of filling up the bony arch of the fourteenth. They might, indeed, have been so contrived as to grow in proportion to the in- creased range of the jawbones ; but from their being extraneous bodies, this must have been a complex process, while the very circumstance of their growth, and the internal change which must have continually taken place, would have exposed them to many more diseases than they are subject to at present. A much simpler plan has been devised ; and the teeth of man, as indeed of most mammalia, are composed of two distinct sets, differing both in number and structure : the first, or smaller set, consisting of ten for each jaw, which are cut between the [sixth and twenty-fourth month after birth ; the most common period of their first appearance, however, being the commence- ment of the seventh,*] shed between the sev- enth and fourteenth year, and from the period of their protrusion called milk-teeth; and the second, or larger set, consisting of fourteen, fif- * Meckel's Anatomy, trans, by Doane, vol. iii., p. 237. A tooth, considered in the most general view, is essentially composed of two parts : one of these, which is constant and always the same, is the secreting part (the soft portion or pulp); the other, which is more or less developed according to the nature of the animal, and varies in shape, disposition, and number of its layers, is the se- creted part; the hard portion placed on the edges of the jaws, and sometimes on the vault of the palate, or at other points of the cavity of the mouth.—See Andral, Anat. Pathol., t. ii., p. 259. teen, or sixteen for each jaw, for they occasion- ally vary in number, which are cut progressively, upon the shedding of the first set, between the seventh or eighth, and the seventeenth or eigh- teenth year ; and which, from their continuing till old age, except in cases of accident or dis- ease, are denominated permanent teeth. The farthest grinder on each side, however, is sel- dom cut so early as the eighteenth year, gener- ally after the twentieth, and sometimes not till the thirtieth ; on which account, these teeth are denominated dentes sapientiaz, or teeth of wis- dom. Although, in the human subject, the teeth are of no use until a certain time after birth, preparations for their formation commence in the early stages of foetal life. Then the rudi- ments of all the first set, and of four belonging to each jaw of the second set, are produced, and may be distinctly seen when the foetus is about four months old: M. Serres declares that he has traced them, and even the teeth, at three.* [The jaw of a new-born child contains a num- ber of cells, separated from each other by im- perfect bony septa. By removing the external or internal plate of the jaw, the contents of these cells are exposed. They consist of mem- branous bags, named the capsules of the teeth, enclosing the rudiments of the bodies of these organs, and certain soft vascular substances, termed the pulps, on which the bodies of the teeth are forming. The bone of the body of the tooth is the part first formed; the enamel is added to this ; and the fang appears the last in order. The pulp, which, according to Meckel, grows up frorh the bottom of the capsule, about the fourth month of fcetal existence, accurately resembles in shape the body of the tooth which is to be formed on it. It is a soft, vascular sub- stance, and its vessels are most numerous in that part which is covered by the portion of tooth al- ready formed. The capsule is a whitish mem- brane, but very vascular on its inner surface. It includes the pulp, round the basis of which it adheres, and the rudiments of the imperfect tooth. On its outer surface it adheres firmly to the gum ; so that, if we attempt to tear the last mentioned part away from the jaw of a foetus, the capsules and their contents will come away at the same time. These membranes ad- here less closely to the bony cells in which they are contained. The office of the capsule is that of secreting the enamel; in its cavity is a small quantity of fluid. The ossification com- mences by the formation of the cutting edge of the incisors, and the grinding basis of the mo- lares. The bony substance being deposited on the pulp, as on a mould, the rudiments of the teeth are necessarily hollow; and the bony layers first formed, are those which will be in contact with the enamel when it is deposited. As the formation of the tooth advances, the pulp * Essai sur l'A.natomie et Physiologie des Dents, p. 3. 8vo. Paris, 1817. Andral states, that their rudiments may be detected in the 10th week, as their pulpy portion is then in the jaw; and that, at three months, it is covered with osseous points. —Anat. PathoL, t. ii, p. 259.—Editor. <3rn. I.—Spe. 1.] 0. DENTITI0NIS. 41 is gradually surrounded, till the whole is cov- ered by bone, except its base. The adhesion of the pulp to the newly-formed tooth or bone is very slight, and no vessels can be discerned going from one to the other : it is, however, most strongly attached round the thin elastic edge, which is the last part formed. When the bone has covered all the pulp, it be- gins to contract a little, and becomes somewhat rounded, making that part of the tooth which is called the neck, and from this place the fangs begin. The formation of the fangs makes the bodies of the teeth ascend through the sockets, and afterward through the gum, which is ab- sorbed in consequence of the pressure of the tooth. The pulp has originally no process answering to the fang ; but, as the cavity in the body of the tooth is filled up by the ossification, the pulp is lengthened, and the fang forms over it. The latter part grows in length till the whole body of the tooth is pushed through the gum, the socket at the same time contracts at its bot- tom, and grasps the neck or beginning fang, ad- heres to it, and rises with it. Thus the alveolus is raised with the fang, and the fang does not itself sink or descend into the jaw. If two or more fangs are to be formed, the process is rather more complicated. When the body of a molaris is completed, there is but one general cavity in the tooth, from the brim of which the ossification is to shoot, so as to form two or three fangs ; if two only, then the oppo- site parts of the margin of the cavity shoot across where the pulp adheres to the jaw, meet in the middle, and thereby divide the month of the cavity into two openings, from the edges of which the two fangs grow. It is a curious cir- cumstance, however, that at the very time when the pulp is restricted to the crown of the tooth, the number of future fangs is already denoted by that of distinct branches given off by the dental vessels.—(Meckel's Anatomy, vol. iii., p. 232.) When the surface of the tooth first appears through the gum, its body is yet more hollow than that of a perfect tooth, and the fang is only in an incipient state. In proportion as the tooth rises through the gum, however, the aollow is gradually filled up, and the fang is lengthened. When the bone of the body of the tooth is somewhat advanced in its formation, the enamel begins to be deposited on its surface from the vessels of the capsule. This deposition commences on the masticating surface of the tooth, and thence extends towards the root. The enamel is complete when the fang of the tooth begins to be produced, for at that time the body penetrates the gum, and thereby lays open the capsule, which at this period is found to have undergone great alteration in its texture and appearance. Instead of the soft vascular surface which it exhibited while the deposition of the enamel was going on, it is now dense, and almost tendinous, with very few bloodves- sels. When the fang begins to grow, the cap- sule also becomes connected to it, and forms its periosteum.] From what has been said, it appears that the | alveolus, or socket shoots up from the jawbone as the tooth advances. It accompanies its growth, and at first entirely surrounds it; by which admirable contrivance a firm support is given to the gums from the time of birth, and the infant is enabled to make a sufficient pres- sure for the purpose of sucking, without inter- fering with the form which the teeth, yet soft and amorphous, are destined gradually to as- sume. In due time, however, the alveolus yields in its upper surface, as the tooth, in con- sequence of the gradual elongation of its fang or fangs, is forced through, and cuts not only the socket but the gum; and when the first set, having answered its temporary purpose, loses its fangs by absorption, and the body of each tooth is shed or cast out by the gums, the attendant sockets are equally absorbed, and disappear at the same time. This wonderful change begins to take place, as I have already observed, about the seventh year, the artery of the milk teeth and its canal undergoing a more or less perfect obliteration (Serres, p. 19); at which time we possess far more teeth, including both the grown and the growing, than at any other period whatever : for we have in each jaw ten temporary teeth complete, ten incomplete to succeed them, and the two permanent grinders, whose stamina were formed during foetal life, making not less than forty-four in the whole. Other writers than Mr. Hunter place this change at an earlier period: Dr. Blake, indeed, as early as the fourth year; and M. Lemaire, who follows Blake in most other points, follows him in this also. The permanent teeth have separate sock- ets of their own ; and, in consequence of the prolongation of the jawbones, do not lie imme- diately under the corresponding shedding teeth, nor directly contribute to the process of shed- ding, which chiefly takes place in consequence of the absorption of the fangs and sockets of the temporary set, though their ascent contributes in some degree to the general process. I have observed that the alveoli, or sockets, (hough fixed upon the jawbones, and indeed is- suing from them, are rather to be regarded as appendages of the teeth than of the bones from which they spring ; that they participate in most of the diseases of the teeth, and are strictly coe- val with them ; sprouting forth on their origin, modelled by their shape, and disappearing on their decay or removal. It is this disappear- ance, which is the work of absorption, that prin- cipally produces that change in the character of the face which peculiarly distinguishes the pe- riod of old age. It follows closely upon the loss of all the teeth; and when these have uni- formly given way, and their respective sockets are no longer in existence, as not being wanted, the upper jaw becomes considerably diminished in its range, the under jaw reduced to a thin bone merely covered by the gums, and the roof of the mouth, instead of being arched, is ren- dered almost flat. And from this loss of sub- stance, which is nearly 'equal to an inch and a half in depth, the face becomes shortened, the cheeks wrinkled, and the chin projecting. 42 CCELIACA. [Cl. I.—Ord. I. It is curious to observe how differently the teeth are situated in different animals. In the more perfect, they are placed in sockets in the jawbones, some of which are in many kinds rendered moveable, as the two fore teeth of the lower jaw of the mus marilimus, or African rat, the largest species of the genus hitherto discov- ered. The same teeth are equally moveable in the kangaroo ; and the hollow tusks or poison- ing fangs of the rattlesnake, and other venomous serpents, are capable of depression or elevation at the option of the animal. In the lamprey and inyxine the teeth, which are almost innumera- ble, are placed on the surface of the tongue ; in the cancer genus, in the stomach ; where we likewise find them in the common earwig. In the cuttle-fish, they are also placed in the middle or lower part of the body, two in number, and horny, and in their figure resembling the bill of a parrot. In the echinus, or sea-hedgehog, they are five in number, arranged around the open- ing of the under part of the shell, and, being moveable by different muscles, they form a very complete organ of mastication. In the aphro- dita aculeata, or sea-mouse, they are fixed upon the proboscis, four in number, and are conse- quently extended or retracted with this organ at pleasure. The leech has three pointed cartila- ginous teeth, which it is able to employ in the same way, and by means of which it draws blood freely. * The form of the teeth is so different, even in the different genera of animals that possess them in a true or perfect state, that this diversity has been laid hold of by many naturalists, as a dis- tinguishing characteristic of their kinds or or- ders. Linnseus, confining himself to the fore teeth, has hereby formed seven distinct orders for the class of mammalia ; and M. de Blainville, carrying the basis of this distinction farther than to the form and structure of the fore teeth, has made it a foundation for the subdivisions of these orders into genera, f Whatever be the time in which teeth are generated and protruded, the process is often so gradual that little or no pain or other inconve- nience is experienced ; and, consequently, under such circumstances, there is no disease. But I have already observed, that there is often not only pain and irritation, and therefore disease, but, in various instances, disease of a severe, complicated, and alarming character. And it is to dentition under these circumstances, that I am now about to direct the reader's attention. It will readily be supposed, that the most violent symptoms of dentition are those produ- ced under the first stage referred to in the pre- ceding history, or during the growth and protru- sion of the milk or shedding teeth ; for the system is then in its tenderest state of infancy, and prone to disorder from very slight causes of irritation. The immediate cause of irritation in the * See, for other peculiarities, Phil. Trans., vol. lxxxix., p. 237.; xci.,p. 319. fNouveau Diet. d'Hist. Naturelle, vol. ix., art. Dents. Paris, 1817. present instance, is the pressure of the teeth in the gums ; and the degree of irritation depends upon the peculiar temperament of the child. [But, in addition to this circumstance, it may be stated as a general fact, that, the greater the number of teeth coming forward simultaneously, the greater the risk of indisposition ; and every man of experience knows that those children which cut their teeth late, usually suffer least.] As the teeth push forward, the superincumbent gum wastes in consequence of absorption, and is at last cut through, and the tooth makes its appearance. This pressure is not, however, uniformly exerted through the whole course of teething, but is divided into distinct periods or stages \ as though the vital or instinctive prin- ciple, which is what we mean by nature, be- comes exhausted by a certain extent of action, and then requires rest and a state of intermis- sion. The first active stage of teething is usu- ally about the third or fourth month of infancy ; and constitutes what is called breeding the teeth, or the production of their bone from the pulpy rudiment, buried in the gum, and formed during foetal life, which at the same time shoots downwards, and gives to every tooth a neck and fang. The first and most usual symptom of this change, is the looseness with which the infant grasps the nipple, and the frequency with which it lets go its hold, accompanied with fretfulness and crying, and succeeded by a copious dis- charge of saliva, the salivary glands partaking of the irritation of the gums. Next, the unea- siness of the gums is found to be relieved by the pressure of any hard substance upon them which benumbs their excited sensibility; and hence the child is pleased with having its gums rub- bed with the fingers, a coral, or a gold ring. This last is perhaps the oldest method, and it may be the best: for the experiments of Dr. Chrestien, of Montpellier, who has of late en- deavoured to revive the old preparations of gold as a part of the materia medica, show suffi- ciently that this metal, in very slight quantities of some of its simplest forms, is peculiarly ac- tive, and a powerful exciter of those secretions which have a tendency to diminish irritation and subdue inflammatory action. He has proved before a committee of the Royal Academy of Sciences at Paris, that friction of the tongue and gums with not more than four grains of powder of gold, produces sometimes a copious ptyalism, sometimes abundant alvine evacuations, and sometimes profuse perspiration.* Friction by the finger, or any other means, is sometimes con- demned, as likely to render the gum callous, and consequently more difficult to be cut through ; but, so far as I have observed, this idea is not supported by facts. In many respects, M. Lal- lemand has since confirmed Dr. Chrestien's ob- servations. + * Recherches et Obs. sur les Effets des Prepa- rations d'Or. 8vo. Paris. t Journ. Generate des Sciences Medicales, Aout, 1822. Rousseau, in his Emilius, objects to rubbing the gums with hard substances, and refers to the instinct of other animals, which leads them to ex- ercise their budding teeth, not on bones or stones, Gen. 1.—Spe. 1] O. DENTITIONIS. 43 If the irritation become very considerable, the gums swell, the child grows still more fretful, and starts in its sleep ; or, on awaking suddenly, there is heat, thirst, and other concomitants of pyrexy, with perhaps dulness or drowsiness ; the bowels are affected, which is a common symp- tom, and a rash appears on the skin, usually the red-gum; and if the irritation extend to the mus- cles of the chest, there is a dry and troublesome cough. It is the opinion of Dr. Withers, as given in his treatise on asthma, that a cough during dentition never takes place but from pri- mary affection of the respiratory organs: yet I have often seen this-effect produced as evi- dently from mere sympathy, as increased flow of saliva, or looseness of the bowels. In about ten days or a fortnight, these symptoms sub- side ; and though the infant may occasionally be teased with slight paroxysms of uneasiness, it generally passes on without much inconve- nience till the arrival of the second stage, or pe- riod of cutting the teeth, which we may expect to take place between the seventh and the close of the ninth month, though sometimes this does. not occur till a few months later. This is the usual progress ; but here, as in many other organs of the system, we sometimes meet with a singular precocity of action, and, at other times, with as extraordinary a hebe- tude : and hence, while it is no uncommon thing for an infant to be born with several of its milk-teeth already cut, a fact which has in va- rious instances occurred to my own observation, and is specially noticed by Helwig* and other writers ; sometimes these teeth are extremely tardy in their appearance, and, in one instance, are said not to have been protruded before the child was ten years old.f [M. Duges saw an example in which no teeth were cut till the age of eleven; and Smellie refers to instances of, much greater retardation, where persons were twenty-one or twenty-two years old when their teeth first appeared. The appearance of teeth at birth is sometime's alleged to be particularly but softer substances. In accordance with this view, a stick of marsh mallows, or of liquorice root, a piece of wax candle, or a crust of bread, has been recommended instead of coral; and in France, they often dip the substance in honey, or a sweet decoction of barley. In some parts of Germany, children are frequently seen sucking a small bag, containing a mixture of sugar and spices, which is given to them whenever they are fretful. By keep- ing them quiet, the nurse is saved trouble ; but the derangement of the stomach likely to arise from so free a use of these sweet stimulating ingredients, must be objectionable.—See Dentition, in the Cyclop, of Pract. Med., p. 518.—Ed. * Obs. 28. Richard III., Louis XIV., and Mira- beau, seem to have been bom with some of their teeth already cut; but the circumstance is com- mon enough in all ranks of society.—Ed. t Eph. Nat. Cur. Dec. 11. Ann. iv. Obs. 28. In all probability these were really the permanent teeth, and not the milk ones, as mentioned in the text. In such cases, Andral concludes, that the failure of the first dentition must be owing either to the non-existence of the germs, or else to the Eulp, though developed as usual, not secreting the ard portion.—Anat. Pathol, t. ii., p. 260.—Ed. frequent in infants born after the usual period (Meckel's Anat., vol. iii., p. 242); but such pre- mature dentition is neither a proof of protracted pregnancy, nor yet of, what is also stated, a strong constitution in the infant, which is often unusually small, and does not thrive. We have, indeed, high authority* for the observation, that perfectly ossified teeth are sometimes cut in the foetus of only six months.] It is the opinion of Mr. Fox (History of the Teeth, p. 6), that the premature teeth, which are usually the central incisors of the under jaw, are nothing more than the upper parts or crowns of teeth without the apparatus of fangs; that they have consequently a weak attachment to the gums, soon get loose, and produce a con- siderable inflammation in the mouth of the child, as well as great inconvenience to the mother ; and he recommends, accordingly, that they may be immediately extracted. Speaking generally, this account may be correct ; but, as there are instances in which teeth of this premature growth possess fangs, and are perfect, it is bet- ter to wait before we extract them till some in- convenience arises which may call for their removal. It is somewhat singular, that the natural growth of the first set of teeth does not seem to be varied, at least according to any general rule, by the degree of strength of the infant; for weakly children often cut their teeth even more rapidly than those in robust health, though the reverse is perhaps more generally the case ; and hence the stimulus of irritation, in the pro- cess of dentition, very nearly keeps pace with that of healthy vigour. At this time the gum is often extremely sen- sible, and, instead of being eased by the pres- sure of a hard substance, cannot endure the slightest touch. At the base it is florid and distended, but paler and whiter at the edge or upper part; and, when the tooth is on the point of protrusion, seems covered with a flat and whitish blister. ' • The other symptoms are a repetitionof-those just described, with a scabby eruption about the lips or head, erythematic inflammation behind the ears, and occasionally spasmodic move- ments of the mouth and jaws, convulsions, or epilepsy. The grand point is here to moderate the local irritation. A diarrhoea, or full discharge of sa- liva, does this naturally, and hence these are favourable symptoms. And if the former be too violent, or accompanied with griping, it should be merely corrected by magnesia or pre- pared chalk, [or rhubarb combined with ipecac- uanha, or hydrargyrum cum creta. If the evac- uations are fetid, blackish, or very pale, an occasional dose of calomel, to improve the in- testinal secretion, should be given. In particu- larly obstinate cases, the cautious use of the compound powder of ipecacuanha, with minute doses of calomel, is sometimes adopted. If the milk seem to disagree, the nurse must be changed, and beef-tea, rice-milk, and arrow-root * Andral, Anat. Pathol., t. ii., p. 160. 44 C02LIACA. [Cl. I.—Ord. I. given. In many cases, small doses of quinine are useful auxiliaries; but since a moderately lax state of the bowels lessens the risk of worse consequences from dentition, the practitioner should not be in too much haste to check the evacuations ; and probably, as Dr. Joy has ob- served, it should never be done so long as the appetite, sleep, and strength, continue unaffect- ed.] If the bowels be confined, we must em- ploy cooling laxatives; and the discharge of a small quantity of blood from the gums in the first stage, by lancing them, will often afford effectual relief. If the symptoms of oppression or spasmodic action be severe or incumbent, as drowsiness, difficulty of breathing, stertor, or irregular motion of the jaws, antimonial emetics and leeches should be had recourse to, and oc- casionally repeated; after which, blistering will be found useful, behind the ears or on the back. And when the bowels have been thoroughly emptied, the use of anodynes may be allowed, and will generally prove highly serviceable; though they should be employed with great judgment, and never intrusted to nurses. Hy- oscyamus, in most of its forms, has often suc- ceeded here, as well as in adult toothache, when judiciously administered.* In the second stage, or when the teeth are on the point of protrusion, the lancet will often afford immediate relief, not by a discharge of blood, for the upper part of the gum is now be- come so thin and wasted that little or none will follow; but by giving a direct opening to the tooth, which will frequently make its appear- ance in the course of a few hours. It is singu- lar, that the use of the lancet should be objected to so generally. The tooth is imprisoned by a membrane that surrounds it on a full stretch, and that is in a state of inflammation. Lancing the gum, or rather the inflamed membrane be- low the gum, takes off the tension, and sets the tooth free. The pain is slight and transient, and by no means to be compared with the per- manent 'uneasiness which the operation under- takes to relieve. It has been conceived, that a tough indurated cicatrix will be formed if the divided edges of the gum should unite after the lancet has been applied. Yet in the spongy texture of this organ, no such effect is found to follow ; but, on the contrary, the recently united edges of the gum, as in all other parts, far more easily give way to the process of absorption than they would otherwise have done; by which means the passage of the tooth is facili- tated, t As the erythematic inflammation which occa- sionally takes place behind the ears, proves often useful as a revellent* it has also been found sometimes serviceable to imitate it by a friction with savin ointment, or other rubefacients. But * Among other means, the warm bath, or pedi- luvium, and opiate frictions on the spine, deserve to be mentioned : the latter are sometimes prefer- red to narcotics by the mouth.—Ed. t For some excellent remarks on the morbid effects of dentition, see a paper by Prof. James Jackson, in the New-England Journal, vol. i., pp. 12, 113, 329.—D. I cannot advise that this or any other eruptions, when produced naturally, should be suffered to run their course without restraint: for I have often known them become a worse evil than the original disorder. In this case, they should un- questionably be exchanged for some other more convenient discharge. * In cutting the second or permanent set of teeth, it is not often that much uneasiness is encountered ; for, firstly, their progress is much slower than that of the shedding-teeth ; and next, the constitution, with the acquisition of a greater degree of strength, is at this time be- come much less irritable.. In a few cases, how- ever, they push forward too rapidly, and urge the shedding-teeth against the superincumbent gums so forcibly as to excite considerable pain ; and here a free application of the lancet affords the speediest and most efficacious relief. And not unfrequently the permanent teeth ascend with great irregularity, and press against the crown or fangs of those above them in errone- ous directions ; whence another source of con- siderable pain. In this case, the best, and indeed the only radical cure, is to extract the upper or cutting tooth, and thus allow freedom to the under tooth to right itself.—(De VArrangement des Secondes Dents, &c, par M. Duval Brock, 8vo. Paris, 1820.) [The milk-teeth occasionally continue in the jaw long after the common period of their be- ing shed ; and, as this circumstance does not necessarily prevent the permanent ones from being cut, the jaw seems at first really to con- tain a preternatural number of teeth; but, in most instances of this kind, the appearance of the permanent teeth is retarded, or they are even wanting ; a circumstance fully accounting for the anomaly of the extraordinary continu- ance of the others.—(Meckel's Anat., vol. iii., p. '242.) The permanent teeth occasion the fal- ling out of the milk ones principally by destroy- ing by their pressure the vessels and nerves of the latter, as well as their adhesion to the al- veoli. The destruction of the fangs is not an invariable effect, as the milk-teeth, when they * The principal disorders accompanying denti- tion are imputed by Dr. John Clarke, in his com- mentaries on the diseases of children, to plethora from over-feeding, and to the head being kept too warm. In fact, painful dentition itself brings on a great determination of blood to this part of the body. Hence Dr. Clarke, with the view of pre- venting bad effects, recommends us to wash the head daily during dentition with cold water, and, if a moderate salivation and lax state of bowels are not present, he directs the use of gentle ape- rients. The chylopoietic and respiratory organs, the brain and nervous system, the skin and the lym- phatics, are the chief seats of the sympathetic af- fections occasionally induced by dentition. The best description of a spasmodic affection of the glottis, excited by dentition, is that by Dr. Marsh in vol. v. of the Dublin Hospital Reports. For an account of a peculiar swelling of the backs of the hands and feet, occasionally brought on by the same cause, consult the writings of Underwood and Dr. Kelhe of Leith.—Ed. Gen. 1.—Spe. 1.] 0. DENTI' are shed, sometimes have those parts very per- fect.]—(Serres, op. cit., p. 102.) In the formation, and especially in the cut- ting, of the third set, or wise teeth, we ordi- narily meet with a far more considerable degree of pain and inconvenience, and this too for many weeks; and the pain spreads by sympathy to the ear, which is often more affected than the tooth itself. Such is especially the case where the formation takes place late, and after the jawbones have ceased to grow, and the gum has become thick and callous ; for we have here a want of sufficient room, and little power of en- larging it by absorption. In the upper jaw, moreover, the tooth on each side is frequently obliged to incline backward, by which means it presses on the anterior edge of the coronoid process in shutting the mouth, which causes an additional degree of uneasiness ; while, in the lower jaw, some part of the tooth continues to lie hid under the coronoid process, and the por- tion of the gum that covers it is perpetually lia- ble to be squeezed by the tooth below, and the corresponding tooth in the jaw above. In this case nothing but a very free crucial opening will suffice ; and often nothing but an excision of a very considerable piece of the callous gum: while there are other instances, in which the evil can only be cured by removing the tooth itself. We sometimes, though rarely, meet with playful attempts on the part of nature to repro- duce teeth AT A VERY LATE PERIOD OF LIFE, and after the permanent teeth have been lost by accident or natural decay. This most commonly takes place between the sixty-third and the eighty-first year, or the in- terval which fills up the two grand climacteric years of the Greek physiologists ; at which pe- riod the constitution appears occasionally to make an effort to repair other defects than lost teeth, on which we shall have occasion to treat more at large, when describing that variety of decay, which, in the present system, is denomi- nated climacteric. For the most part the teeth, in this case, shoot forth irregularly, few in number, and with- out proper fangs; and even where fangs are produced, without a renewal of sockets. Hence they are often loose, and frequently more inju- rious than useful, by interfering with the uni- form line of the indurated and callous gums, which, for many years perhaps, had been em- ployed as a substitute for the teeth. A case of this kind is related by Dr. Bisset of Knayton, in which the patient, a female in her ninety- eighth year, cut twelve molar teeth, mostly in the lower jaw, four of which were thrown out soon afterward, while the rest, at the time of examination, were found more or less loose.— (Edin. Mid. Comment., vol. viii., p. 373.) In one instance, though never more than in one, Mr. Hunter (Nat. Hist, of the Teeth) wit- nessed the reproduction of a complete set in both jaws, apparently with a renewal of their sockets. " From which circumstance," says he, " and another that sometimes happens to women at this age, it should appear that there TIONIS. 45 is some effort in nature to renew the body at that time." He alludes to a restoration of the catamenia, and to the climacteric change, which we shall have occasion to notice hereafter. The author of this work once attended a lady in the coun- try, who cut several straggling teeth at the age of seventy-four; and at the same time recov- ered such an acuteness of vision as to throw away her spectacles, which she had made use of for twenty years, and to be able to read with ease the smallest print of the newspapers. In another case that occurred to him, a lady of seventy-six, mother of the late Henry Hughes, Esq., printer of the Journals of the House of Commons, cut two molares, and at the same time completely recovered her hearing, after having for some years been so deaf as to be obliged to feel the clapper of a small hand-bell, which was always kept by her, in order to de- termine whether it rang or not. The German Ephemerides contain numerous examples of the same kind ; in some of which, teeth were produced at the advanced age of ninety, a hundred, and even a hundred and twenty. One of the most singular instances on record is that given by Dr. Slade (Phil. Trans., vol. xxvii., year 1713), which occurred to his father; wbo, at the age of seventy-five, repro- duced an incisor, lost tw«nty-five years before ; and at seventy-seven reproduced another to sup- ply a similar vacancy, so that at eighty he had hereby a perfect row of teeth in both jaws. At eighty-two they all dropped out successively ; two years afterward they were all successively renewed, so that at eighty-five, he had once more an entire set. His hair at the same time changed from a white to a dark hue ; and his constitution seemed in some degree more healthy and vigorous. He died suddenly, at the age of ninety-nine or a hundred. Sometimes these teeth are reproduced with wonderful rapidity ; but, in such cases, with very great pain, from the callosity of the gums, through which they have to force themselves. The Edinburgh Medical Commentaries (vol. iii., p. 105) supply us with an instance of this kind. The individual was in his sixty-first year, and altogether toothless. At this period, his gums and jawbones became painful, and the pain was at length excruciating. But, within the space of twenty-one days from its com- mencement, both jaws were furnished with a new set of teeth, complete in number. The jugglers on the continent, a century or two ago, were in the habit of taking advantage of this occasional playfulness of nature, and offering, as natural phenomena in the forma- tion of teeth, singularities which nature never dreamed of. Thus, a boy was at times started and hawked about the country with a golden tooth, much to the astonishment of both the learned and the unlearned; for though the tooth was in Teality a natural one, and only covered over with an inlay of gold, yet the gilding was in one or two instances so exquisitely effected as to deceive almost every spectator, when the trick was first brought forward, and to lay a 46 C02LIACA. [Ct. I.—Ord, I. foundation for no small number of learned scriptions and profound explanations upon subject. * SPECIES II. ODONTIA DOLOROSA TOOTHACHE. ACUTE PAIN IN THE TEETH, OR THEIR INVOLU- CRES. There is often a considerable degree of pain of a particular kind that accompanies the irrita- tion 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 suffi- ciently distinct. Pain of this kind may be produced by various causes, as a catarrh, or cold ; an exostosis or deposite of earthy matter on the sides of a tooth or its socket; a caries or decay ; a peculiar af- fection of the nerves of the sockets or jawbone, 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 ; by the 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, and in various instances has produced convulsions, and in others delirium ; or, in the language of the suf- ferers themselves, has actually driven them mad. In several of these cases, it occurs as a mere symptom of some other disease ; and can only be cured by a removal of the disease 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 ; a Catarrhalis. From cold. Catarrhal toothache. f} Cariosa. From decay or caries. Carious toothache. y Exostosa. From ossific deposite. Nodose toothache. S Nervorum. From irritability of the Nervous toothache. dental or adjoining nerves. Every tooth has an internal cavity, which commences at the point of its fang, and en- larges as it ascends into its body. This cavity is not cellular or rugged, but smooth on its sur- face : it contains no marrow, but appears to be filled with bloodvessels, accompanied with nerves, which must necessarily be derived from the second and third branches of the fifth pair, though they have never been distinctly traced. In the interior of this cavity the teeth appear to be peculiarly sensible ; and hence direct or in- direct EXPOSURE TO THE EXTERNAL AIR ; Or, in other words, a carious opening, or a current of * Horstius, De Aureo Dente, Lips. 1695, 8vo. Ingolstetter, De Aureo Dente Silesiaci Pueri, Lips. 1695, 8vo. Tylkobsky, Disquisitio duorum Pue- rorum, unus cum Dente Aureo, alter cum Capite Giganteo, in Lituania visus. Olivae, 12mo. sharp air without such opening (for the air seems in many instances to act through the substance of a sound tooth), will produce acute pain, and is, in fact, the common cause of toothache. The pain thus produced will sometimes cease very suddenly, and especially upon the application of an opiate, or some acrid essential oil. But the irritation is often communicated to the perios- teum of the tooth, and thence to the membrane that lines the socket, which is only a duplica- ture of it. And hence, the pain will often be- come 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 inter- mittent or periodical. In all these cases, wherever we can trace in the tooth a hole 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 af- fected nerve by caustics or cauteries, intro- duced through the hole itself. The pain may also be occasionally diminished by the applica- tion of opium or the more acrid aromatic oils, especially 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 the sensibility of the nerve : and hence relief is procured by ammonia and rubefacients ; or by a blister behind the ear of the affected side ; by burning the edge of the helix of the ear ; rubbing the cheeks with the cerambix moschatus, which possesses a vesica- tory power nearly equal to that of the lytta ; holding brandy or hot water in the mouth ; or 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 petiveria alliacea, or guinea-hen weed, a very acrid plant, is employed for the same purpose by the inhab- itants of Jamaica, who put a small plug of it into the diseased cavity.—(Trans. Stockh. Acad., 1644, p. 287.) 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 salivary glands to increased ac- tion, as the bulbs of the alliaceous plants, the root of several of the seselis, particularly the seseli vulgare, the common hartwort, or laser- pitium silcr, Linn. Such masticatories, however, are chiefly of use in the toothache produced by rheumatism, or where congestion has taken place in the neigh- bouring^ parts from inflammation of any other kind. The sensibility of the nerves may hereby, indeed, be in some degree exhausted, but it is the evacuation that principally affords relief. On * The oil of the anthemis pyrethrum also, is useful in assuaging the pain oftoothache.—D. Gen. I—Spe. 2.] O. DOL this principle relief is also not unfrequently ob- tained by smoking or chewing tobacco, and, as Dr. Cullen conceives, by the use of camphire (Mat. Med., vol. ii., p. 304); though the camphire and tobacco may partly operate by the sedative power they possess. As errhines promote the same secretion as sialagogues, these have also been frequently employed with considerable suc- cess, as well in toothaches as ophthalmias ; in both which cases, however, preparations of asarum have generally been found to produce more alleviation than those of tobaceo, which is the basis of our common snuffs. A local ap- plication of cantharides in powder or ointment is inconvenient, but the tinctura cantharidis may be often used effectually with little trouble ; yet the most elegant form of this stimulant for the present purpose is that of the French Pharma- copoeia, under the name of Oleum de Canthari- dibus. It is made by digesting for six hours, with a gentle heat, one part of powder of can- tharides in eight parts of olive oil (Codex Medi- camentarius, Paris, 1818); the oil thus impreg- nated is to be filtered, and is then fit for use. Electricity has also been tried, and occasion- ally with success. On the continent, magnet- ism has been a still more favourite remedy ; and has at least more writers in its recommendation,* whatever be the actual benefit it may have pro- duced, of which I cannot speak from personal knowledge. Animal magnetism seems at one time, indeed, to have been very extensively em- ployed 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 effect. The grand magnetiser of the day was the then celebrated Valentine Greatrake, who oper- ated by stroking his hands over the parts affected, much in the same manner as Mr. Perkins of America, not many years ago, employed his metallic tractors.—(Stubbes, An account of several marvellous cures performed by the stroking of the hands of Valentine Greatrake. Lond. 1666. 4to.) And as strong emotions of the mind are well known to produce a more immedi- ate influence on the toothache, than on any other disease whatever, we-may readily account for some of the cures hereby produced. Confi- dent 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 suf- fering pain just before the operation of extraction. The stopping of a carious opening in a tooth should only be attempted when there is no pain ; for otherwise the pain will be increased 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 tinfoil, are among the most useful, as they afford the best guard, and far less frequently require to be renewed. Yet none of them can be easily retained in cases * De la Condamine, Journ. de Med., tom.xxvii., p. 265. Glaubrecht, Diss. Analecta de Odontalgia, ejusque remediis variis, pracipue Magneta. Ar- gent 1766. Teske, Neuer Versucht in Curirung des Zahnschmerzens vermittelst eines Magnet- i6chen Stahls. Konigsb. 1765-6. )ROSA. 47 where the opening is wider at the top than the bottom ; and although attempts have been made to keep them in the proper situation by drilling a small hole through the sides of the teeth, and riveting a proper pin into the metallic sub- stance, they soon become loose, and admit air, food, and other acrimonious materials. Mr. Fox mentions a compound metallic sub- stance, as far better calculated to answer the purpose of a permanent plug, than any of the preceding. It is 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 supposed that this may in consequence be employed in a liquid state, and thus have an opportunity of striking, before it be- comes cool, into all the ramifications of the cari- ous part, so as to fill up the cavity completely, and form a fixture not easily to be detached. It has often occurred to me that some of the drying earths, employed as cements by our stone- 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 com- pounds of iron, alumine, silex, and carbonate 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 endeavouring to stupify the nerve of the tooth by a frequent use of hot essential oils intermixed with camphire and opium, or we may destroy it directly by a hot iron. And if these methods fail, and the ex- cision of the crown of the tooth, as practised by Mr. Fay with a pair of cutting forceps, should not be deemed advisable, the only alter- native is extraction, which, however, should never be had recourse 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 rendered torpid, may be of very essential service, as well as ornament, for many years, perhaps through the whole of life. Yet if the caries be accompanied by inflammation in the surrounding parts, the tooth should be removed without loss of time ; as the mischief may spread, and the adjoining teeth be hurt.—(Manuel du Dentiste, &.c. Par C. Maury, 8vo. Paris, 1820.) In extracting a tooth, a very troublesome hemorrhage will occasionally follow; sometimes profuse and of long continuance. Plater, Schenck, and others, have indeed given cases in which it has proved fatal.* [Mr. Blagden (Med. Chir. Trans., vol. iii., p. 224) recorded the par- ticulars of one remarkable instance, in which the use of styptics, the actual cautery, a plug in the' socket, and even a ligature on the carotid artery, * Plater, Obs. Lib. iii., p. 773. Schenck, Lib. L, Obs. 403, 405, p. 99. 48 CG3LIACA. [Ct. I.—Ord. 7* failed to suppress the bleeding, which proved fatal a week after the removal of the tooth. ] The best ordinary styptic is pressure with an elastic sub- stance, as a piece of sponge covered with wax, touchwood, spunk, or some other spongy bole- y tus, or a dossil of lint dipped in a strong solu- tion of alum or sulphuric acid.* I was not long ago requested to see a young man, who had been profusely bleeding from the gums and socket of an extracted tooth for five days, with- out cessation, and without sleep, till his wan cheeks and faint, emaciated frame, seemed to in- dicate 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 per- petually swallowing, had all the appearance of a melaena. On opening his mouth I found it crammed full of lint wadding, one piece having every hour been added to another, without a re- moval of the preceding, lest the hemorrhage should be increased, while the blood in which the wadding was soaked, and which had re- mained in the socket and over the gums for so long a period, was become grumous, 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 contract, I applied no pressure of any kind, but prescribed a gargle of equal parts of tincture of catechu and warm water ; and the hemorrhage soon ceased. It is not easy to explain by what means teeth become carious. Out of the body they are in- destructible, except by very powerful chymical agents ; and yet, in the opinion of many physi- ologists, 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 ab- sorbents. In caries of the bones, observes M. Auzebi (Traiti d'Odontalgic, &c. Lyons), the de- cayed part 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 adjoin- ing ; nor can any remedy we know of produce a separation between the part that is sound and that which is unsound. " And we have hence," says he, " a proof that there are no vessels in the substance of the teeth, and that they have a dis- tinct 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 * The sulphate of copper will often arrest hem- orrhage when other styptics have failed. We have reason to think also, that the nitrate of silver is ex- tremely valuable for the same purpose.—D- which they are produced at first, and their re- taining their natural colour after So long a use of madder as food that all the other bones of the body have become thoroughly tinged with it. " But they have most certainly," says he, " a living principle, by which means they make part of the body, and are capable of uniting with any part of a living body ; and it is to be observed, that affections of the whole body have less in- fluence upon the teeth than upon any other part of the body. Thus, in children affected with the rickets, the teeth grow equally well as in health, though all the other bones are much af- fected ; and hence, their teeth being of a larger size in proportion to the other parts, their mouths are protuberant." Cuvier, who has adopted all Mr. Hunter's views, has employed the same rea- soning (Diet, des Sciences Medicales, art. Dents); and M. de Blainville has apparently gone be- yond both; for he has denied not only a vascular structure, but even a living principle to the teeth. * Mr. Fox, however, is said to have succeeded in injecting both the external and internal layer of the dental germ, and even Mr. Hunter him- self appears to speak with some degree of hesi- tation in the treatise before us ; and in his sub- sequent work " On the Diseases of the 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, seemingly of the spina ventosa kind, like other bones ;" but he immediately adds, that " there may be a decep- tion 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 perpetually liable ; he regards the teeth as subject to the common inflammation 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.f Probably some internal action is continually taking place in the teeth, though we are not able to trace it very evidently. The chief causes of a caries are undoubtedly external, but it may be sometimes produced by an internal cause. We have already noticed exposure to currents of cold air, and the medical practition- ers of Germany and the north, appeal to the op- posite extreme of the habitual use of hot ali- ments, as a still more general and mischievous source of the same evil. In the Swedish Amoz- nitates Academical (vol. vii., art. 136), 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 oc- casion to condemn, in an especial manner, the custom of drinking hot tea and coffee ; and, in accordance with this remark and recommenda- tion, M. Tillasus, another celebrated writer in the same interesting journal, tells us, from Kalm, * Nouveau Diet. d'Hist. Naturelle, &c. vol. ix. in verbo. t At the end of this section, the editor has in- troduced the chief arguments against the vascu- larity of the teeth. Gen. I.—Spe. 2.] 0. DOLOROSA. 49 in his paper entitled Potus There, that the In- dians of North America knew nothing of the inconvenience of carious teeth or debilitated stomachs, till tea was introduced among them. There can be no question that the two extremes of heat and 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. To the abuse of hot beverages as a cause of caries, M. de la Salle 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.* 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 chymically, we shall find, that in their structure they consist very largely of phosphate of lime, with a small proportion of animal matter, and a much smaller of carbonate of lime ; and in their enamel, which is altogether of the nature of ivory, that they consist almost entirely of phos- phate of 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 when 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 ex- tend our research to the carbonic, since this can never be attacked till the enamel into which the phosphoric so largely enters be decomposed, and withdraws its protection. Now, by examining the tables of elective attractions we shall find that there are four, and only four acids, that precede the phosphoric in their affinity for lime ; the oxalic, sulphuric, tartaric, and succinic. We have daily proofs that the teeth, in the living subject, are greatly injured by the frequent or habitual use of several of these acids, t I have at this moment a lady under my care, who till of late possessed as sound and fine a set of teeth as can anywhere be boasted of. From a peculiar delicacy of constitution, however, it has been judged re- quisite that she should, among other medicines, use a very large quantity of eutohuric acid. This prescription has been continued for many months, and her general health is considerably * Journ. de Med., torn, xxxvii., appendix, p. 399. t As the fluate and carbonate of lime exist both in the bone and enamel of the tooth, and are even more abundant in the latter than the former part, several acids, besides those specified in the text, must have an injurious effect on the teeth.—Ed. Vol. I—D established : but, owing to her not having taken all the precaution that is requisite to guard the teeth while swallowing the acid, the pearly enamel is becoming yellow, and its coating very considerably diminished in thickness, -%a that at the apex of the incisors it is almost as thin as a razor, and is frequently chipping off. Sugar can have very little effect in destroy- ing the enamel of a tooth ; for, though it con- tains a principle of acidity, it cannot with pro- priety be regarded as an acid. It may 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-sorrel, is precisely of the same kind) ; and, in this combination, will evince a stronger attraction for lime than any other acid wha ever. 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 extremely weak* [General de Beaufort ate a pound of sugar every day for forty years, and lived to the age of seventy. After death his teeth were found to be quite sound,—(Anecdotes de Midicine, torn, ii., p. 35.) Plenck kept a healthy tooth in some diluted syrup two months, at the end of which time it had undergone no change.]— (Doctrina de Morb. Dentium, p. 52.) If sugar were a solvent of calcareous matter of any kind, it would first show itself in dissolving, and con- sequently preventing a lodgment of the carbon- ate or phosphate of lime, which the salivary glands are so continually secreting, and which is perpetually incrusting on the neck of the teeth in mankind, and separating 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 have1 no reason to suppose that it is a solvent of the enamel of the^ teeth in any material degree. It will be well to bear these remarks in memory in the composition of dentifrices con- taining acids of any kind. For the reasons al- ready assigned, the oxalic, sulphuric, and tar- taric 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 de- prived 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 produced, it appears to operate in three different ways; sometimes commencing in the internal cavity, and working its course outwards ; sometimes commencing outwardsf and working its course within ; and some- £^£,-2. 50 COELIACA. [Cl. I.—Orb. I times by a wasting of the enamel, and con- sequent denudation of the bony part.* The first, which is the least common affection (its reality being denied by several writers), is dis- coverable by an appearance of blackness within the whiter surface of the tooth ; the third is often to be met with ; but the second is the most frequent of the whole ; evincing at its commencement the appearance of an opaque white spot through the enamel, which gradually crumbles away about the spot, and thus dis- closes that part of the body of the tooth which forms the original seat of the 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 any particular age, or temperament, or state of health. It exists in infancy 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 pro- duced so much torture, that it has been neces- sary 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 disease of early, than of advanced life ; and that the teeth did not become carious after fifty years of age. Mr. Fox, however, met with several persons, who had not only passed fifty years without having had a caries in this organ, but who had been obliged, after having arrived at sixty, to have several teeth extracted, in con- sequence of toothache, produced by caries. In some general diseases of the constitution, the teeth seem to possess singular perfection, and even luxuriance. Thus, in phthisis, it is almost a proverbial remark, that the white and pearly gloss of the enamel, which is peculiarly char- acteristic of soundness, is more than ordinarily clear and bright; while irt rickets, in which the whole frame of the bones is shaken, and many of them become soft and spongy, the teeth as- cend as firmly and as regularly as if the system were in a state of the most vigorous health. If the teeth be vascular, there is no great difficulty in conceiving that, like other bones, they may be subject to exostosis, or a deposite of ossific matter on their surface, and particu- larly on the surface of their roots or fangs ; [a case, which the non-believers in the vascularity * On this subject, Mr. Parmly, an eminent dentist of New-York, remarks, " I consider the im- mediate and exciting cause of dental decay to be always external to the tooth itself, and to consist of certain corrosive menstrua, to which these organs are exposed from bodily disease, improper ali- ments, powerful "medicines, and the thousand other sources of acrid filth and destructive poi- sons, that become concentrated in the mouth and deposited on the teeth."-^Notes to Brown's Den- tologia. New-York, 1833.—D. of the teeth ascribe to original malformation. What is called an exostosis of the fang, exhibits no irregularities on its surface, as other exos- toses usually do ; nor is its substance at all dif- ferent from the rest of the fang. It is, in short, merely an accidental difference of form, where, as the offices of the part require no definite figure, variations in shape are quite common.] The author conceives, however, that, whether the crown or body oi the teeth be possessed of secernents in a mature state, they must have absorbents, since we behold their fangs, in very numerous instances, diminished, shortened, and truncated, and sometimes entirely carried away, which it is difficult to conceive can be done by the absorbents of any adjoining organ. And we may lay it down as a general rule, that there is no organ in possession of absorbent vessels, which does not at the same time possess secer- nents, so as to maintain a balance of action. We find, on extracting a tooth that has long been a cause of considerable pain, that the fangs at least are considerably incrusted with a de- posite of ossific matter, so as to give it an ap- pearance of that disease which was formerly but most incorrectly denominated a spina ven- tosa. And on examining the state of the alveoli after death, we 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, a considerable degree of pain, and generally an increasing degree, must 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 toothache, for the imprisoned 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 complaint is recent, we may often put a check to it by a free application of leeches, and the local use of mercurial oint- ment, or a mercurial 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. There is sometimes a peculiar irritability in the nerves of the teeth themselves, oi of those parts by which they are immediately surrounded, and with which they participate in action, that excites the sensation of severe and even agonizing toothache, without caries or any other concomitant. In this variety, 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 sym- pathy excited, and a sound tooth is extracted in its stead ; so that the torture remains unabated. And there are instances, in which the plan of extraction has been followed up from tooth to Gen. I.—Spe. 2] O. DOL tooth without any alleviation whatever, till the jaw has been entirely divested of its teeth on the disordered side. This is often an idiopathic affection, depend- ant upon a peculiar irritability, from a cause we cannot easily trace, of the nerves subservient to the aching tooth, or the tunics by which it is covered, or the periosteum, or the fine mem- brane that lines the interior of the alveoli. But it is more frequently a disease of sympathy, produced by pregnancy, or chronic rheumatism, or disorder of the stomach, in persons of an irritable habit. For this remote or indirect in- fluence it is not difficult to account, when we reflect that the great intercostal nerve, em- phatically called the sympathetic, ,and con- nected by ramifications with every viscus of the chest and lower belly, is connected 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. It is still less to be wondered at that the nerves of the teeth should often associate in the maddening pain of neuralgia faciei, or tic douloureux ; for here the connexion is both direct and immediate. In consequence of this, the patient, in most instances, regards the teeth themselves as the salient point of pain (and they may unquestionably be so in some cases), and rests his only hope of relief upon extraction, al- though, when he has applied to the operator, he is at a loss to fix upon any one tooth in par- ticular. 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 afterward, 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 Sir Astley Cooper, who, by dividing the affected nerve, produced a radical cure in a few days. Where the pain, therefore, proceeds from sympathy, it is of the utmost importance to trace it home to the organ idiopathically affected, for to this the attention should be chiefly di- rected. Where it exists as a primary disease, it is often of long duration, and difficult re- moval. 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 nar- cotics applied locally, hyoscyamus appears to be one of the best. Its seeds may be put to the cheek in the form of a cataplasm ; or their smoke conveyed by a funnel to the tooth itself. In this last form, it will often allay the pain of a carious tooth. Where the pain is remittent or periodical, a free use of bark, with change of air, has proved most salutary. [From the preceding observations it appears that the author of the present work joins those physiologists who regard the teeth as vascular, and he even carried this belief so far as to ex- press a suspicion, that these organs sometimes undergo an increase of size, whereby the inter- DROSA. 51 space produced between two of them, by the extraction of one, may be considerably lessened. In a former edition of this book, he mentioned the fact as having occurred in his own jaw, after the removal of one of the bicuspidati, when he was a boy. That the teeth frequently approach each other, so as to lessen, and even nearly fill up, the interspace occasioned by the extraction of one of them, is an undoubted truth ; but the correct explanation of its cause is not the enlargement of the teeth, but the change that follows in the situation of the socket. Hence when a tooth is removed from a young subject, whose jaw is yet growing, the inter- space may become in time nearly obliterated. If the gap were filled up by the expansion of the adjoining teeth, this could only happen from the enlargement of the crowns ; but though specimens of exostoses and swellings of the fangs of teeth are contained in museums, the editor has never yet met with a tooth, whose crown or body was enlarged. The question, whether the teeth are vascular, is extremely curious and interesting; and so unnatural is the idea of an harmonious con- nexion between dead and living substances, that the common opinion of the teeth being furnished with vessels and nerves, is not at all surprising. Nay, the excessive pain often seated in.these organs, and the remote, diversified, and very severe disorders, which they appear to excite sympathetically in the animal economy, are circumstances presenting something like a confirmation of the doctrine. Nor can it be denied, that much difficulty occurs in account- ing for certain changes in the teeth, unless this doctrine be admitted. But it is not because we cannot explain precisely the nature of every particular alteration or appearance of these organs, without supposing them to be vascular, that they must really be so ; for, if some of the phenomena in question take place also in arti- ficial teeth, and in teeth which have been boiled, or kept so long in a drawer as not to admit of the suspicion of their being alive,' the doctrine then immediately becomes a question- able hypothesis. The difficulty of accounting for caries of the teeth, and for the absorption of their fangs, un- less the belief in the vascularity of these organs be adopted, seems to have had great influence in determining the author of the " Study of Medicine" to consider the substance of the teeth as vascular. That he was also correct in his notice of the disagreement between Mr Hunter's Natural History of the Human Teeth and the Essay on their Diseases by the same distinguished man, is a truth, of which no per- son who has read these works can doubt. The subject was difficult,—so difficult as even to involve Hunter in hesitation, if not contradic- tion. Our author has not mentioned, however, some of the principal facts and arguments which such modern physiologists as disbelieve the vascularity of the teeth generally bring for- ward : a short account of them in this place may not, therefore, be uninteresting. In the second edition of this work, it was re- 52 CCELIACA. [Cl. I— Okv. I. marked by the author, that, " admitting the soundness of Mr. Hunter's experiments, and the accuracy of his reasoning, it seems impos- sible that the teeth, when once perfectly pro- duced in the gums, should ever decay ; for no action of the living principle can occasion a se- cretion of those chymical agents which would alone, in such case, be capable of destroying them." We have seen, also, that our author describes one form of caries as beginning within the tooth. Others, however, deny the reality of the latter case, and, if they are right, the answer is at once given to the foregoing argu- ment. They distinctly allege that caries never begins within the tooth ; but a speck is first seen upon the enamel, a portion of which being destroyed, the decay extends to the bone of the tooth, and proceeds from the surface into the cavity. As soon as the bone begins to be affected, the progress of the decay is much more rapid ; an excavation is produced ; and the enamel is left in the form of a, hollow shell. The following considerations are mentioned as ,proofs, that the decay is not the effect of vas- cular action. It first attacks the enamel, which is confessedly not vascular ; for though Bichat regarded this substance as sensible and organ- ized, because acids set the teeth on edge, the fact is, that the disagreeable sensation, here ad- verted to, is not situated in the enamel itself, nor is it ever excited by an acid merely applied to it. The acid must at the same time come into contact with the organ of taste, or extend its action directly to the sensible parts within the cavity of the tooth. Throughout the whole process of caries, there is no attempt at reparation. Artificial teeth are as much subject to decay as natural ones. The discoloration has, indeed, been sometimes thought to be more deep in the artificial teeth made of the tooth of the hippopotamus, than in the human teeth ; but, in ingrafted human teeth, the decay is acknowledged to be pre- cisely similar to that of the natural ones. , The alleviation of toothache by the applica- tion of muriatic acid, nitrate of silver, and other caustics to the carious surface, has been es- teemed a proof that the caries is an ulcer, and that its irritability may be destroyed by such treatment. Since, however, the remedies may act upon the exposed vascular contents of the cavity of the tooth, or may affect these contents by penetrating through the thin medium which remains, it is manifest that they can afford no proof of the point in question. At the same time, it is to be taken into the account, that toothache from caries may frequently be re- lieved by a plan nearly amounting to a demon- stration, that the pain does not arise from the ulcerated surface, but from the nerves in the cavity ; namely, let the decayed hole be stopped up (which is rather a rude method of treating an irritable ulcer), so as to prevent the access of the external air and of foreign bodies, and the pain will cease. The writer, from whom the editor has bor- rowed these judicious reflections, further ob- serves, that it is not perhaps so easy to deter- mine what the decay is, as what it is not. Those who consider the teeth as destitute of vessels, ascribe their decay to the chymical action of the secretions in the mouth, and of the articles of food. Here it is difficult to com- prehend now a cause which must necessarily be so general in its application, should be so circumscribed in its effects; never producing decay at once in an extensive surface, but in its commencement, limiting its action to a small spot. However, in artificial teeth, a large sur- face sometimes decays under circumstances favouring an accumulation of fluids in a particu- lar part; viz., the portion that corresponds to the gum, and is usually grooved, and also the lateral panrts of such teeth. Various considerations strengthen the infer- ence, that the decay of the natural teeth must depend upon a chymical and not a vascular operation. It commences in those situations where food or extraneous matters are most lia- ble to lodge, as between the teeth, and near the neck, just where the gum adheres. It is checked by stopping up the hole, and preventing the en- trance of the food and secretions of the mouth into it. It is most frequent in the higher classes of society, whose food is of the most unnatural and miscellaneous kind. It is very rare in the teeth of savages, and it is alleged never to occur in animals. In twelve or fourteen sculls, dis- covered in two barrows opened in Gloucester- shire, not a single decayed tooth was noticed. Now, as this mode of burial has not been em- ployed for the last six centuries, these sculls must have belonged to a time when the modern habits of luxury, in respect to food, were un- known ; and when the effects of such habits on the teeth were, of course, not discernible. One fact connected with the foregoing statements, and perhaps in some degree throwing a doubt on part of them, is the extraordinary prevalence of caries of the teeth in particular families, seemingly as if there were some original hered- itary imperfection in them, whereby the cau- ses of caries, whatever they may be, very read- ily produce their destructive effects. Another fact, universally acknowledged, is the frequent and almost regular occurrence of fine sets of teeth in- certain families through a long series of years ; a circumstance that seems, like the preceding one, to imply some hereditary differ- ences in the degree of perfection of these or- gans. That persons who smoke tobacco gen- erally have discoloured, carious teeth, is a fact universally recorded. Perhaps, therefore, the ingenious author of the present work was mis- taken in supposing, that the production of caries of the teeth could not be chymically accounted for, unless the secretion of chymical agents within them were admitted as a fact, which fact would, of course, imply vascularity. The caries, instead of beginning sometimes internally, as he supposed, always commences externally in the enamel, and proceeds from it into the bone of the tooth, so that the fluids, and other mat- ters in the mouth, have direct access to the af- fected surface. An inward decay of the teeth, with the whole shell of enamel perfect, is talked Gen. I—Spe. 2] O. DOLOROSA. 53 of by dentists; but, though the external aper- ture may be minute and concealed, its existence must not be denied, until a contrary case can be fully demonstrated. Our author supposed that madder and ana- tomical injections might not be sufficiently at- tenuate to enter the vessels of the teeth, and was not disposed to receive the fact of those substances not entering them as a proof of their non-existence. Certainly, in several instances, to conclude that parts are not vascular, because the vessels cannot be injected, would be deci- dedly erroneous. But in these particular cases, the phenomena of disease enlighten us and correct our judgment; which can hardly be said to occur with respect to the teeth, for their changes, whether vital or chymical, are en- veloped in the deepest mystery. As for the experiments with madder, however, they fur- nish the strongest argument of all against the vascularity of the fully formed substance of the teeth, without even affording the least room for the argument, that madder is not subtile enough to enter the vessels of those organs. This will be immediately evident, when it is recollected, that while the tooth of a young animal is only partly formed, if madder be given with the food, it is really transmitted by the vessels of the pulp, not indeed to the portion of the tooth already complete and void of vessels, but to that part of the organ which is developed sub- sequently to the beginning of the experiment, and is the work of the vessels of the pulp. Here, however, a most interesting fact was pointed out by Mr. Hunter ; namely, that when the tooth of a young animal has thus been tinged with madder, the stain is never after- ward removed, which is exactly the reverse of what occurs in bones died by feeding animals with the same substance. The bones, there- fore, must have vessels for the conveyance of the madder into them, and other vessels by which it is again removed from them. On the other hand, though the vessels of the pulp seem capable of communicating the red tinge of madder to the bone of the tooth upon its first deposition, they appear directly afterward to have no further communication with the new formation, which remains incapable of every change usually produced in other parts through the medium of arteries, veins, and absorbents. These conclusions, deduced from experiments with madder, may be set down as firmly estab- lished, without being at all weakened by an observation made by the late Mr. Gibson ; namely, that the fact of the power of madder to redden the bones is no demonstration, that a continual renovation of their particles takes place.—(Mem. of the Lit. Soc. of Manchester, 2d series, vol. i., p. 146.) Madder communi- cates to the bones a red tinge, which is after- ward gradually removed : these two facts prove, at all events, an interstitial action, as far as that substance is concerned, and thus are explicable only on the principles of vascu- larity and life. Just so the communication of a red tinge by madder to the phosphate of lime of a tooth that is undergoing development, is a tolerably convincing proof, that vessels then deposite both the earthy and the colouring mat- ter ; while the permanency of the tinge as clearly shows, that the coloured particles of lime in the tooth are not absorbed again, and that no vascular interstitial changes afterward occur. In confirmation of the preceding view, it de- serves particular notice, that the teeth never ex- hibit any appearances of reparation under cir- cumstances of accidental injury or supposed disease. The loss of substance occasioned by the friction of mastication is not repaired; a part broken off is not renewed, but the frac- tured surface remains unchanged; a hole caused by decay is never filled up again. The union of a fracture near the neck of a tooth, even if it be possible, as M. Duval* and others declare, does not at all invalidate the foregoing statement, because the union is as- cribed to the action of the pulp, and not to that of vessels within the substance of the tooth itself. The non-existence of vessels in the teeth may be inferred from another particular case ; a violent blow sometimes causes a general dis- coloration of a tooth, as if blood were effused through all its texture. This appearance is ex- plicable, either by supposing vessels to exist in the substance of the tooth, which pour out the blood in consequence of the injury, or by sup- posing that the vessel in the fang is ruptured, and that the extravasated blood mechanically discolours the substance of the tooth. If the former explanation be adopted, the colour ought not to be permanent; for wherever there are arteries, there must also be absorbents ; and these ought to remove the effused blood, as they do in bruises of the soft parts. By the other explanation we gain a satisfactory solu- tion of the difficulty ; we account for the dura- tion of the colour in the tooth in the same man- ner as of that which arises from feeding a young animal with madder. The teeth are exempted from all those dis- eases which ravage the bones :t lues venerea, scrofula, and rickets, which attack all other bones, never produce the slightest effect on the teeth, which remain unaffected even in cases of mollilies ossium, where all the other earthy matter of the system is absorbed. J In short, * Diet, des Sciences Med., torn, viii., p. 335. t This assertion is too unqualified. The influ- ence of constitutional causes, even of adventitious origin, and the effects of hereditary peculiarities, on the healthy or disordered condition of the teeth, may frequently be observed. The teeth of scrofu- lous persons, and the detrimental effects of the abuse of mercury on the teeth of some individuals, have been remarked by many writers. In mollities ossium, the teeth sometimes participate. A case of this is stated by Veirac, Abhandlung fiber die Rhachitis, pp. 54, 83.—Stendal, 1794. See, also, Isenflam, Versuch einger prakt. An merkungen fiber die Knochen, p. 427. A tooth resembling carti- lage was found by Krauss in Misc. Acad. N. Cur., 1697, p. 619. In the museum of Blumenbach is the back tooth of an animal, which, excepting the root, has completely expanded into a large bony tumour. Meckel has figured a similar case of a human tooth, tab. 7, figs. 8, 10.—D. X The museum at Leipsic, it is said, contains 54 CCELIACA. TCl. I.—Ord. I. the teeth never have the slightest participation in the general affections of the constitution. Their substance also never swells from inflam- mation ; it never throws out a fungus or exos- tosis ; for what has received this name is in all probability an original malformation, as Mr. Hunter first suggested.* Ossific depositions may be conceived to arise from the vessels of the pulp, or those of the membranous lining of the fang, so as to lessen, or even obliterate, the cavity or canal ; a change said to happen in old age, without supposing any part of the change to result from vessels in the substance of the bone. The same substance never ex- foliates. Whole teeth are sometimes included in an exfoliated portion of the jaw; but then they are not altered in structure or appearance, which is another proof of their want of vascular connexion with the rest of the body. If, says a well-informed writer, it be said that these teeth are dead, like the bone which contains them, we would ask, what are the distinctions in appearance between a dead and a living tooth ] Are they to be ascertained by inspec- tion in the living body, or can they even be de- monstrated by anatomical investigation 1 The absorption of the fangs of the temporary teeth cuts off the vessels long before these teeth are actually shed ; yet there is no sign nor charac- ter by which a tooth whose vascular supply is thus intercepted, can be distinguished from an- other in which it remains unimpaired.—(Rees's Cyclopedia, art. Cranium.) As is remarked by the same author, the dif- ference between the growth of the teeth and that of the bones is particularly striking. In the cartilaginous epiphysis of a young bone, vessels are seen entering from all sides ; in the centre there is a small bit of bone, of a loose and spongy texture, which can be made quite red by injection. We can trace this hard- ening through every intermediate stage, to that of perfect bone, the vessels of which, even in its most compact state, are still easily demon- strable. Let us compare with this the growth of a tooth. If we examine it at ever so early a period, when a speck of ossification only can be discerned, the part which is thus formed is complete, and has all the properties which be- long to the bone of the perfect tooth. It does examples of anchylosis of the teeth with the jaw, taken from rachitic subjects, and likewise other preparations illustrative of the fragility of the teeth in individuals of a similar constitution.—(Cyc. of Pract. Med., art Dentition.) But it appears to me that as fragility of the teeth is by no means com- mon in rachitic patients, and is sometimes ob- served in other persons, it can hardly be regarded as an unequivocal effect of rickets—Ed, * Soemmering and Fox each saw a case where several of the teeth were consolidated into one mass ; and Dr. Joy met with a similar instance in the museum at Leipsic, of two incisors grown to- gether by their crowns, while the roots were sep- arated. These abnormal appearances he refers to the deficient evolution of the alveolar septa.__(Cy- clop, of Pract. Med., art. Dentition.) In speaking of Odontia Deformis, we shall introduce some other explanations of this point.—Ed. not undergo that gradual development which is seen in the growth of bones ; but the smallest point, when once formed, never alters. In car- tilaginous epiphyses, the central portion of bone is imbedded in the cartilage : numerous vessels can be traced into it on every side ; while in a tooth, the ossification does not go on in the centre of the pulp, but the bone covers it like a shell. The connexion between them is merely that of contact of surface, and there is no dis- coverable vascular union. If any argument be drawn in favour of the vascularity of the teeth, from the fact of blood being sent into their cavity, it must be imme- diately weakened by the reflection that the in- tention of various other arrangements in the structure of the body is completely mysterious. Thus, we know as little why male animals have mamma? and nipples, as why the cavity of a tooth should contain vessels apparently for no purpose. With respect to the circumstance of a yellow colour being communicated to the bone of the teeth in jaundice, it is no proof of their vascu- larity. As is well remarked, the argument would prove too much. The vessels of the teeth, if any such exist, are so minute that they neither convey red blood nor coloured injection; yet they are capable of carrying so much bile as to tinge the tooth of a uniform yellow to a certain distance from the cavity. If this colour be then owing to a yellow fluid contained in vessels, these must be so numerous as to ren- der the tooth much more vascular than any other bone. The fact is, that the vessels of the pulp contain bile, and die this part of a uniform yel- low colour, which is mechanically imparted to the adjacent bone in the neighbourhood of the cavity ; the effect gradually ceasing at a little distance from it. The stain is produced, just as it is by immersing the teeth in bile after death. Another proof of the vascularity of the teeth, is attempted to be taken from their successful transplantation from the jaw of one person to that of another, or to parts of another animal's body, as the comb of a cock. These experi- ments, however, will succeed with dead teeth. The writer of the article Cranium, in Rees's Cyclopaedia, was shown a cock, in whose comb the late Mr. Moor, the dentist, had in- serted a tooth that had previously lain many months in a drawer ; and it was firmly adhe- rent. This adhesion then does not seem to re- quire even the living principle, of which it was regarded by Mr. Hunter as a proof. But no arguments have been more confidently employed by the believers in the vascularity of the teeth, than those deduced from compara- tive anatomy. Animals of the class glires, as the beaver, hare, rabbit, squirrel, rat, mouse, &c, have two very large incisor teeth in each jaw, which, being employed in cutting various hard bodies, wear down very rapidly. Hence, if these animals be kept entirely on soft food, their teeth grow out to a great length, and sometimes assume very ludicrous shapes : and i if these teeth be lost from one jaw, the opposite Gen, I.—Spe. 3.] O. STUPORIS. 55 ones grow out in the same way.* This con- stant growth is effected in the same manner as their original formation. They are hollow, and contain a pulp, which continues to deposite fresh substance below, in proportion as their upper part wears away. The tusks of the elephant and hippopotamus have a similar power of growth. It seems now, indeed, to be the com- mon belief of some of the first physiologists, that the teeth really present a strong analogy in their development to the hair, nails, and horns of the animal body, and also, as M. Geoffroy St. Hilaire has fully ascertained, to the beaks of birds. In the human subject, the process- by which the teeth are formed confirms this doc- trine ; but, as we have noticed, what happens in the incisor teeth of the gnawing animals is a still closer analogy, since the pulp retains for an indefinite period the power of secreting ad- ditional matter, by which the effects of the loss of the tooth at its cutting end are counteracted, and an incessant tendency to elongation, or growth, kept up in the organ. A list of distin- guished authorities, and a brief notice of some of the arguments in support of this physiologi- cal view of the nature of the teeth, are given by Meckel.! Bullets have been found imbedded in the tusks of elephants. Now, the advocates for the vascularity of the teeth have argued that the closure of the opening, by which the ball entered the tusk, and the swelling sometimes observed in these cases opposite the foreign body, could not have taken place without the agency of vessels. However, these occurrences are now satisfactorily explained, without having recourse to this hypothesis. The tusks are constantly growing, during the animal's life, by a deposition of successive laminae within the cavity, while the outer surface and the point are gradually worn away; and for this purpose the cavity is filled with a vascular pulp, similar to that in which the teeth are originally formed. If a ball penetrate the side of a tusk, cross its cavity, and lodge on the opposite side, it will * This remarkable growth is sometimes the consequence of a mere change in the direction of the teeth, without any of them being absent. In the head of an old rat, presented to the Royal Academy of Medicine, Andral noticed the follow- ing disposition of the incisors :—The upper right incisor had scarcely shown itself out of its socket, when it inclined obliquely downwards and backwards into the mouth; and, having reached the posterior opening of the nasal fossae, it turned upwards and entered the left cavity of the nose. After reaching the nostril, it next perforated the upper jawbone, insinuating itself into the socket of the adjoining incisor tooth, and now changing its course again, terminated in a point below the left orbit. The two incisors of the lower jaw were also curiously lengthened and twisted; and one of them, after passing close to the left eye, which it had destroyed, came in contact with the scull, and seemed ready to pierce it. Anat. Pathol., t. ii., p. 266.—Ed. t Anat., vol. iii., p. 234. See also Mem. sur l'Accroissement continue et la Reproduction des Dents chez les Lapins, &c, parM. Oudet, in Ma- gendie's Joum. de Physiol., torn. iii. et iv. become covered towards the cavity by the newly-deposited layers of ivory, while no open- ing will exist between it and the surface, to ac- count for its entrance.* All the various appear- ances attending the lodgment of bullets and pieces of other weapons in the tusks of ele- phants, can be accounted for by the power of the pulp connected with these organs. The absorption of the fangs of teeth is no proof of absorbents in them,—the fact only showing that those parts are capable of being acted upon by the organs of absorption, which may be situated in the alveoli, or in the cavities of the fangs, without being actually in the sub- stance of the bone of the tooth.] SPECIES III. ODONTIA STUPORIS. TOOTH-EDGE. tingling uneasiness of- the teeth from grating sounds, or frictions. There is sometimes a peculiar sensibility in the teeth or their sheaths, that induces a kind of vibratory pain, in which they are colloquially said to be set on edge ; and that in two ways as follows :— a A stridore. From jarring noises. $ Ab acritudine. • From vellicative or acrid substances. In many cases the teeth sympathize with the ear, on an exposure to harsh, dissonant, or stridulous sounds, as the grating of a file, the creaking of a door on its hinges, or of a swing- ing sign in the street. The same effect is produced whenever the teeth are vellicated by smooth substances, as a piece of silk or velvet, or exasperated by acid or other acrid materials. To explain these effects, it is necessary to observe in the first place, that a close recipro- city of feeling is at all times maintained between the teeth and the tympanum of the ear, by a union of their respective nerves ; as one of the branches of the seventh pair, destined to sup- ply the tympanum, anastomoses with the lingual branch of the fifth, which sends offsets to the teeth : by which means the latter become indi- rectly an organ of sounds, as well as of masti- cation. 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, when the wise or adult teeth are about to be cut, the tympanum not unfrequently endures more pain than the gum or membrane by which the tooth is covered; and hence, 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 pleas- ure to the teeth, from the vibrating tone proving agreeable to the ear, we can readily see why tones or sounds of any kind that are hateful to the ear, should be hateful also to the teeth. See Rees's Cyclopaedia, art. Cranium. 56 CCEL; This is the general principle : and it is suffi- cient to explain why all persons are in a certain degree subject to the tooth-edge, upon an ex- posure to the more common causes that produce it. But in constitutions of a peculiar kind, or where the ordinary association between the two organs has been specially and habitually culti- vated, or some early and very powerful impres- sion has been even accidentally communicated from the one to the other, the sensation of tooth- edge will be produced far more frequently and acutely than in other cases. And when, in such persons, the teeth are in a state of preternatu- ral sensibility from any kind of diseased action, or from irritating substances applied to them and the gums, as acerb or acid juices, the sensation may become so acute as to be intolerable. Bar- tholine (Epist. IV., p. 523) has recorded a case, in which the sharpening of a knife so highly ex- cited not the teeth only, but the surrounding gum, that, along with a very sensible jarring of ,the teeth, a profuse hemorrhage from the gum was occasioned. In many instances, the power of the imagina- tion alone, from a long habit of association, is sufficient to call up a very considerable degree pf this painful feeling ;* 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 excite- ment, who, by this action alone, have been suddenly thrown into convulsions. While this affection is permanent, or very fre- quent and troublesome, and proceeds from a morbid state of the teeth or their involucres, our attention must be particularly directed to the nature of the cause with a view to its removal: 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 rec- ommended 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 removal of the origi- nal disorder. Forestus (Lib. xiv., Obs. 9), Ba- ricelli (Hortus Genialis, p. 337), and others, as- sert, that relief may often be obtained by chewing purslane leaves. When it is the mere result ■of an association of ideas, or of great strength of sympathy, with an ear delicately alive to har- mony of sounds, it is best cured by an habitual exposure to the cause of the 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 saw- yer ; but., by being inured to it, he at length hears it with ^difference. SPECIES IV. ODONTIA DEFORMIS. DEFORMITY OF THE TEETH. TEETH IRREGULAR IN SHAPE, POSITION, OR NUMBER. Deformities of the teeth are for the most part produced naturally and in early life. Either * Darwin, ZoOnotn., sec. xvi. 10. & cl.-iv. 1, 2,3. tACA. [Cl. I.—Ord. 1. set may be too large or too small, or some of them much larger or smaller than the rest, or they may be irregular in their line of ascent. They may be misplaced by incurvation, or pro- jection, or obliquity. They may be crowded and confused, or, as has sometimes occurred, be multiplied in crops of double or triple rows.* In all these 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 er- ror of shape or number, but give a proper incli- nation, 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 deficiency of the calcareous matter which enters into the structure of the teeth. This has been sometimes so defective as to leave the teeth cartilaginous, or possessed of their animal part alone : and, in a few cases, as I have already observed, to retard the ap- pearance of even the first set till ten or twelve years of age. [Plenck extracted from a girl, seven years of age, a canine milk-tooth of the lower jaw, which was livid, as soft as cartilage, and Compressible by the fingers, especially at the fang.]t But the opposite extreme is by far the most frequent; and where this exists in a considerable degree, we not only find occasion- ally all the irregularities already noticed as re- sulting from plurality, but sometimes insepara- ble union between the teeth and their sockets, so that it is impossible to extract them without fracturing the sockets; 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 Schenckll and Borelli.1T Albinus records an instance, in * Bloch, Medicinische Bemerkungen, p. 19. For others, see Nosolog. in loc. t De Morb. Dentium, p. 39. X Bartholin. Hist. Anat. Sent, i. hist. 35. Henck- el, Sammlung Med. und Chir. Anmerkungen, vii. N. 16. § Schenck, lib. i., Obs. 412. Andral, Anat. Pa- thol., t. ii., p. 262. || Schenck, lib. i., Obs. 411. 1[ Cent, ii., Obs. 81. The supernumerary teeth, which are formed independently of the regular ones, may be in the same fine with them, though this is rare. Thus, Soemmerring saw five incisors in the upper jaw. Meckel mentions one instance, in which a rickety girl, fifteen years of age, had small bony points, resembling denticulatiOns of fish, interposed between the regular teeth; and Tesmer met with an individual, whose upper jaw contained four supernumerary molar teeth, ar- ranged in the same line with the others; three on the right side, and one on the left. In general, supernumerary teeth are not in the same line with the rest: they may be directly behind the incisors, or scattered over the roof of the mouth. Sandi- fort recites a ease, in which there were thirty-six teeth in each jaw. Supernumerary teeth are more frequently noticed in the upper jaw than the lower; Gen. I.—Spe. 5] 0. EDENTULA. n which a canine tooth grew in the substance of the nasal process of the jawbone below the or- bit.* Another cause of irregularity in the ascent of the permanent teeth is an inaccordance of time or manner, in the absorption of the fangs of the first set of teeth, and the protrusion of those of the second set. As the latter fangs are thrown forth, the former, in all cases of regu- larity, are carried away : and hence the perma- nent teeth, pressed forward by the gradual pro- longation of their fangs, bear before them the mere crowns of the shedding-teeth, and find little resistance to their ascent. In former edi- tions, the author referred to these circumstances in proof of the vascularity of the teeth ; observ- ing that, as the fangs pullulate from the bodies of the teeth, the latter parts must have vessels. The truth is1, however, that the fangs are formed from the vessels of the prolongations of the pulp.] 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 de- tached and set at liberty, as the under set, or any particular teeth in the under set, press for- ward, the latter must necessarily be thrown out of their proper line, and rise within, or without, or wherever they can force their way. The second set of teeth is also wider than the first; and hence, with the exception of the bi- cuspidati, which from this very circumstance 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 of irregularity. In consequence of all which, it is rather to be won- dered at, that we do not meet with more fre- quent instances of deranged or misshapen 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 per- manent, and have a tendency to throw them out of their proper line ; and any of the sec- ond set that may exceed their proper number, and, by their surplus, crowd and misplace the rest. and the cutting and canine teeth are more com- monly redundant than the molar.—See Andral, Anat. Pathol., t. ii., p. 263.—Ed. * Annot. Acad., torn, i., p. 54. The reference of these various cases simply to redundance of cal- careous matter, is not altogether satisfactory, in- asmuch as no redundant tooth can be formed with- out some peculiarity in the pulp. An extraordinary number of teeth may occur under three circum- stances : the milk teeth may not drop out in pro- portion as the permanent ones rise; 2dly, true supernumerary teeth may be formed; 3dly, a sec- ond development of the same tooth may take place. The first case requires no comment; in the second, there may be either an aggregation of several germs, and the supernumerary teeth united to the regular one ; or these may be completely separated from it; or a prolongation may be sent off from the regular tooth, giving it the appearance of being double.—See Andral, Anat. Pathol., t. ii., p. 263.—Ed. SPECIES V. ODONTIA EDENTULA. TOOTHLESSNESS. LOSS OR WANT OF TEETH. This is also a very common affection, and offers the following varieties :— a Peculiaris. From constitutional defect. 0 A vi extrinseca. From external violence. y A carie. From decay. 5 Senilium. From old age. As the teeth are often produced supernumer- ously, so are they often naturally deficient in number. [Sometimes the germs of the perma- nent teeth are either wanting, or are not devel- oped, and then the milk-teeth are in certain in- stances not shed during life, but merely dimin- ish in size from the effect of a larger attrition than what they were designed to bear. In other cases the milk-teeth are shed as usual, but not replaced. Lastly, examples occur, in which no teeth whatever are produced, and individuals have been known to reach a very advanced age, without ever having had a tooth in their mouths. If the edge of the jaws of persons thus circum- stanced be examined, it will be found to be of a fibro-cartilaginous consistence, like the hard substance noticed in infants which have not yet cut their teeth; or like what is reproduced in old persons, or that which always exists in rumi- nant animals in the places where their jaws are naturally destitute of teeth.—(Andral, Anat. Pathol., t. ii., p. 261.) But, the absence of teeth in man may be only partial; and, in this case, there is a difference in the frequency of the de- fect in relation to the kinds of teeth.] The dentes sapientiae, which are the last cut, are those which are most frequently not produced at all; however, there is hardly any particular tooth that has not sometimes failed in its devel- opment. This is sometimes the case with the bicuspidati, as it is not uncommon to meet with a person in whom one, two, or more of these, have never made their appearance. But it oc- curs more frequently in the incisors, particularly of the lower jaw : and Mr. Fox refers to an in- stance, in which this defect appertained to sev- eral individuals of the same family, none of whom had ever cut these incisors. [In one example on record, there were only four permanent teeth in each jaw, and in another, only a single inci- sor in the upper jaw.]—(Fox on the Teeth. Sa- ba tier, Anat., torn, i., p. 78.) But the other varieties of cause are more obvious and common : being Violence, by which they are suddenly mis- placed, or knocked out; Caries, or inflammation of the surrounding sheaths, by which they become loosened in their sockets; and The natural absorption of their sockets in advanced life. In many instances, therefore, the separated teeth are in a sound state; and, in a few in- stances, where the alveolus is also perfect, and the tooth has only been out of it for an hour or two, so that its living principle has not alto- '58 CCELIACA [Cl. I.—Ord. I, gether ceased, it may be replaced, and will take a fresh hold and become serviceable for many years ; though it rarely, perhaps never, forms so firm and permanent an attachment as before the accident which threw it out. Mr. Hunter extended this mode of supply to a transplantation of teeth from other persons : and, at one time, this method also was carried to a considerable extent of practice. Too much caution, however, cannot be employed in ascertaining the health of the individual by whom the scion tooth is to be furnished; for syphilis, and other diseases, may be transplanted at the same time. As an instructive case upon this subject, I may refer to the following, drawn up by Dr. Watson, and inserted in the Medical Transactions.—(Vol. iii. art. xx.) 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 the place very dexterously supplied by a like tooth from another young woman, who, upon examination for the purpose, appeared to be in good health. The scion tooth very rap- idly 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, discoloured, and ulcerated. The ul- ceration spread very fast, the gums of the upper jaw were corroded, and the alveoli left bare Before the end of another month, the ulcera- tion 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, sev- eral of the teeth gradually dropped out, and at length the transplanted tooth, which had hith- erto 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 excited ; a copious and fetid discharge flowed from the mouth and throat, which im- peded sleep; and the soreness of the fauces pre- vented a sufficiency of nourishment from being swallowed. The wisest plan would probably have been to have commenced from the first with a mercu- rial process, before the system had been 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 perse- vered 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 ; and, in the end, the patient fell a victim to the experiment. The person from whom the tooth had been taken, had, in the meantime, con- tinued in perfect health ; and, upon a minute inspection, as weir of the sexual organs as of the mouth, evinced not the slightest syphilitic affection. The case is. mysterious, and leaves much ground for the invagination 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 learned 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. Other cases might be advanced, but it is un- necessary. Mr. Hunter, partial to his own in- vention, endeavoured to account for most of these upon the principle of local irritation ex- citing ^remote evils, or universal sympathy. Yet thej-eases of mischief have been so severe and numerous, that the practice has long fallen into great disrepute. A transfer, however, of the mere crowns or bodies of sound teeth, with the fangs filed off, does not seem to have been productive of the same evil effects ; and hence these may be con- veniently made use of when the body of one or more teeth has been destroyed by caries, while the fangs have remained sound : for, by screw- ing 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 ad- joining teeth ; and, if due care be taken in the selection, it will make the best match, and pro- duce 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 hippopotamus; 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. SPECIES VI. ODONTIA INCRUSTANS. TARTAR OF THE TEETH. THE TEETH INCRUSTED WITH EXTRANEOUS MATTER. The teeth are always subject to be cov- ered over with layers of an earthy material, secreted as a constituent part of the saliva, and denominated tartar. Simple as this substance seems to be, no very clear explanation, either of its origin or character, has hitherto been given. According to Professor Berzelius (Animal Chymistry, p. 62), tartar, when it first settles on the teeth, is mere hardened mucus : " but during the de- struction of the mucus," says he, " we insensi- bly 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, be- sides the phosphate, about a fifth part of its weight of mucus, which has been exsiccated iu the earthy mass." Gen. I.—Spe. 7.] O. EXCRESCENS. 59 Tartar of the teeth, therefore, as far as it has been analyzed, consists of concrete or dried saliva, hardened by its own earthy materials. As it flows from the salivary ducts, it is always found most accumulated around those teeth which are situated nearest to their openings. In some persons the saliva is more loaded with earthy materials than in others ; for, while some have very little trouble in keeping their teeth from this deposite, 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 a black ; and often, in children, to a dark green. By degrees the teeth lose all their 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 decomposition of such a mass of animal matter. In some cases the accumulation has been so enormous, as to be half an inch in thickness, both on the outside and inside of the teeth (Berdmore, p. 56), or to cover the whole range of teeth, and unite them into a solid heap.—(Eustachius, Tract, de Denlibus, cap. xxix. Stoeler, Beobachtungen, &c, N. 3.) It is almost superfluous to point out the ne- cessity of attention to prevent so foul a dis- figurement. The daily use of a tooth-brush with any of the ordinary tooth-powders, will in most cases be sufficient for this purpose. The basis of these powders is of little importance, pro- vided they contain nothing that may injure the enamel. Pulverized fish-shells, cuttle-fish-bone, boles, bark, myrrh, mastic, soot, and charcoal, may be used with equal advantage, 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 impalpable in its reduction. If the tartar yield not to these means, the milder acids may be applied. 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, sulphuric, tartaric, and succinic. From these, therefore, we ought sedulously to abstain ; but most of the rest may be used very harmlessly, 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 then- substance.* But if the deposite still bid defiance to our * In recommending the use of the milder acids, the author has not duly considered their effect upon the carbonate and fluate of lime, which enter into the composition of the bone, and still more freely into that of the enamel, of the teeth. Were the teeth composed entirely of phosphate of lime, then certainly the weak acids could do no harm ; but as the fact is otherwise, their use is far from being commendable. Two of the acids most fre- exertions, it must be removed by the operation of scaling ; and the gums afterward be washed with some pleasant astringent lotion. In India, the accumulation of tartar is pre- vented 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 ingre- dients are not known. SPECIES VII. ODONTIA EXCRESCENS. EXCRESCENT GUMS. THE SUBSTANCE OF THE SURROUNDING GUMS EXCRESCENT. Not only by the concrete deposite called tartar, are the teeth occasionally incrusted and buried, but sometimes by a prurient growth of the substance of their own gums, which, from different circumstances, appears under the two following forms: a Spongiosa. Fungous, or spongy Scurvy of the gums. gums. 0 Extuberans. With distinct extuber- Extuberant gums. ances on the surface. The gums sometimes assume a soft, fungous, or spongy appearance: and this too, as Mr. Hunter has observed (Diseases of the Teeth, ch. iii.), in persons who are in all other respects per- fectly well: and this case, though vulgarly called a scurvy of the gums, is distinctly an idiopathic affection. It may, however, be symptomatic of dyspepsy, or some other disorder of the stomach, or some equally remote organ; or the result of a morbid state of the alveoli, or teeth themselves ; and, unquestionably, it may appear as a symp- tom of porphyra, or real scurvy, 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 examine it. But, in all cases in which the disease originates in the gums, and depends upon a lax state of their texture, scar- ification, freely and repeatedly made use of, will be the best, and, in many instances, the only remedy. It disgorges the overloaded vessels, and leads both to immediate ease and 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 ten- derness, that cannot endure the slightest touch. After scarification, the gums and mouth should be washed with some warm and resinous tinc- ture, as that of bark and myrrh ; and be gradu- ally accustomed to the friction of a tooth-brush, quently employed in medicine, are seriously de- structive of the teeth, though not enumerated in the author's fist of those which are calculated to decompose the teeth. When a tooth is steeped in diluted muriatic acid its earthy matter is dissolved, and the animal substance, with which it was united, left in a flexible state, and of the shape of the perfect tooth. What chymist is unaware that diluted nitric acid will dissolve the enamel ?— Ed. 60 CCEL] 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, and especially the cynomorion cocci- neum of Linneus, better known by the name of fungus Mellilensis. And, if this plan be not sufficiently 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 a dentifrice, equal parts of powdered catechu and bark, witb one fourth the quantity of powdered myrrh. The extuberant excrescence, which forms our second variety, is sometimes firm and un- yielding, rising into distinct and hardened knobs, instead of assuming the appearance of soft and spongy germinations. In these cases, the gen- eral texture and consistence is that of the gums themselves : and the only radical cure consists in extirpating them with the knife, a ligature, or caustic. Even after extirpation, they are very liable to grow again, and with great obsti- nacy and perseverance. Mr. Hunter mentions a case, in which they were reproduced six times, as he suspected, from a cancerous disposition. They are also, in general, largely supplied with bloodvessels, which often produce a trouble- some hemorrhage after the operation ; [for, as Mr. Hunter observes (Natural Hist, of the Teeth, p. 170, 3d edit.), arteries, going to in- creased parts, are themselves increased, and, becoming diseased, have not the contractile power of a sound artery. Excrescences from the gums sometimes have so cancerous an appearance, that surgeons are fearful of meddling with them. Here a remark made by Mr. Hunter, is extremely valuable to the practitioner; namely, that when the swel- lings arise at once from the gum, which appears to be the only diseased part, they have no ma- lignant disposition. When, however, there is strong evidence of a tumour having originated deeply in the alveoli, the teeth, perfect as they may be in appearance, must be sacrificed, as well as the alveolar process itself. The worst diseases of the gums, as Mr. C. Bell has re- marked, do not proceed from the irritation of bad teeth. We frequently see, indeed, a carious tooth attended with ulcer and gumbile, abscess of the jaw, fungous tumour of the gums, and even necrosis of the bone. We find the pain of the inflammation equal to that of tic dou- loureux : but the case is not to be compared, in point of danger, with the tumour, which has a deeper source, and is frequently seen growing up beneath sound teeth. The hemorrhage that follows its removal may generally be stopped with a dossil of lint, dipped in muriated tincture of iron, and pressed into the bottom of the wound. * There cannot be a doubt, that many cases on record, which are described as malignant * See C. Bell's Surgical Obs., vol. i.,p. 413, &c, and Gibson's Institutes of Surgery, vol. ii., p. 323. ACA. [Cl. I—Ord. I. diseases of the gums, and as having proved fatal, by extending themselves up to the base of the brain, were, in fact, fungous diseases of the antrum.*] GENUS II. PTYALISMUS. PTYALISM. INVOLUNTARY FLOW OF SALIVA FROM THE MOUTH. The saliva issues from three distinct sets of glands, distributed over different parts of the mouth, as the parotid, the submaxillary, and the sublingual; [and, according to Berzelius, a quantity of it equal to 1000, consists of water 992-9 ; a peculiar animal matter 2-9 ; mucus 1-4 ; alkaline muriates 1-7 ; lactate of soda and animal matter 0-9 ; pure soda 0-2.—(Med. Chir. Trans., vol. iii., p. 242.) What Berzelius sets down as mucus, is considered by Professor Thomson and Dr. Bostock to be albumen. This is insoluble in water, and, when inciner- ated, affords a large portion of phosphate of lime. The tartar of the teeth is derived from its gradual decomposition upon them The recent investigations of Tiedemann and Gmelin, however, to which reference has been made in the physiological proem, prove saliva to be a more compound fluid than was formerly sup- posed ; and one of their principal discoveries is, that the sulpho-cyanic acid, a most active poison, combined with potass, enters into its composition. Its solid contents are found to be, according to some chymists, 7 in 1000 parts, but, according to others, 1-25 per cent. The quantity of saliva secreted daily is considerable. Nuck and Lanzoni estimated it at a pound in twelve hours ; Mr. Cruickshank at a pound in twenty-four hours ; but it must vary according to circumstances. The secretion is more co- pious in children and old persons, than in adults ; in cold, than in warm climates ; in the day, than in the night. The smell or sight of any agree- able food makes the saliva flow into the mouth with surprising rapidity. The same effect re- sults from the irritation of smoking tobacco ; and from that of bitter, sour, or salt substances in the mouth. The habit of frequently ejecting spittle from the mouth renders an augmented secretion of it necessary. A person's talking much has a similar consequence ; and so large is the quantity of saliva secreted during meals, that Sabatier saw a soldier, who, at these periods, used to wet several towels with what was discharged from a fistula communicating with the parotid duct.t In disease, the secretion * For examples of the fatal ravages of some dis- eases of the gums, consult J. Bell's Principles of Surgery, vol. iii. ; C. Bell's Quarterly Report, vol. i.; Hill, in Edinb. Med. and Surg. Journ., No. 61; and Gibson, in Philadelphia Joum., vol. ii. t Traite d'Anat., torn, ii., p. 171. Dr. C. G. Mitscherlich, of Berlin, lately met with a similar case, in which the more solid and grateful the nature of the food was, the more copiously was the secretion of saliva carried on ; but when the masseters and tongue were at rest, and no stimulus Gen. II.—Spe. 1.] P. ACUTUS. 61 of saliva is sometimes increased; sometimes, almost suppressed.] Its office is twofold : that of moistening the mouth in combination with a small portion of mucus secreted by the labial and buccal glands, and that of contributing to the di- gestion of the food in the stomach and duodenum. Under the influence of the irritating passions, and especially of violent rage, it assumes a frothy appearance, and in many anirhals becomes poisonous. It is said, indeed, to become so sometimes in man himself.* When the saliva is secreted in a healthy pro- portion, and the various muscles of the mouth perform their proper office, it is never dis- charged from the mouth, unless voluntarily ; but passes readily from the fauces into the oesophagus. But it may be secreted immoder- ately, or the muscles of deglutition may not properly perform their functions : and, in either case, the saliva will flow from the mouth in- voluntarily, accompanied with a specific differ- ence of symptoms. And hence ptyalism, as a genus, offers the two following species of disease. 1. Ptyalismus Acutus. Salivation. 2.---------- Iners. Drivelling. SPECIES I. PTYALISMUS ACUTUS. SALIVATION. INCREASED SECRETION OF SALIVA FROM AN IN- CREASED ACTION OF THE SALIVARY GLANDS. An 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 salu- tary, 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, in jaundice, and dropsy; and other examples 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 dependant affection, we must defer our consideration of it in these re- lations, 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 master- wort. Simple mechanical pressure, produced by the manducation of any hard substance, as when we eat a dry biscuit, is also a stimulant was present, it ceased altogether. During meals, he found the saliva alkaline; at other periods, acid.—Ed. * Hoffman, Diss, de Saliva ejusque Morbis, p. 24. 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, at whatever time the teeth be produced. Even the mechanical irritation of another organ, with which the sali- vary glands are closely connected by continuity or sympathy, will often lead to a like effect. Mr. Powell has given an interesting instance of this in vol. ii. of the Medical Trans, 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 stimulated 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 ac- companiment of pregnancy ; as it is occasionally of some other irritation of the stomach or in- testinal canal; in which last case it frequently betrays its source by a saccharine taste. [In some cases, the cause is obscure. The editor knows a gentleman, who had several annual and tedious attacks of a very debilitating ptyal- ism, the reason of which was by no means ap- parent from any particularity in the previous state of his health, or in his regimen ; and M. Ribes mentions a porter at the hospital for in- valid soldiers at Paris, who was annoyed for six weeks with a salivation, that used to increase in such a degree at night, that the flow of saliva from the mouth might have been compared to a shower of very clear water.* No cause could be assigned for the complaint.] Generally speaking, however, though not al- ways, an increased flow of saiiva from any of the above causes is of such short duration, and so easily removed when troublesome, that it is rarely the subject of medical attention ; and the only varieties to which it gives rise, that are particularly worthy of notice, are the following: a Hydrargyratus. Mercurial salivation. 0 Sensitivus. Mouth-watering. y Mellitus. Sweet-spittle. Poduced by the use of mercury or its prep- arations. Produced by the sight, smell, or thought of agreeable food. Accompanied with a sweet or mucilagi- nous taste. * See Diet, des Sciences Med., torn, xlix., p. 459. M. Andral could detect no morbid appear- ances in the salivary glands of a man, who had had a ptyalism of long duration from no evident cause.—Anat. Pathol., torn, i., p. 345. M. Rayer relates the case of a woman, aged 24, who for many years, without any obvious cause, had an attack of profuse salivation every month or six weeks. The complaint generally continued 36 or 48 hours, the quantity of fluid excreted amounting to several pints in the course of 24 hours. Opium and quinine had no effect in relieving the disorder, but it was finally cured by the subcarbonate of iron.—(Journ. de Chimie M6d., Avrih 1833.) AACA. [Cl. I.—Ord, 1. 62 C(EI Quicksilver, in whatever mode introduced into the system, whether by the skin, the stomach, or the lungs, uniformly stimulates the salivary glands, and produces an increased flow of saliva : and is almost, if not altogether, the only substance we know of, which, introduced inter- nally, universally acts in this manner. Nitric and other acids have been suspected to produce a like operation. [The author of this work and Dr. Paris, how- ever, both consider the opinion groundless. Yet, according to the evidence of Dr. Scott, if the nitro-muriatic acid, lotion, or bath, be em- ployed to a certain extent, tenderness in the palate and mouth, and ptyalism, are sometimes produced ; but without any offensive smell of the breath or loosening of the teeth, as from mercury. These effects were excited in him- self and others, and he had seen as violent a salivation thus raised, as he had ever noticed from mercury.]-—(Med. Chir. Trans., vol. viii., p. 183, and Beddoe's Contributions, p. 430.) Antimony has also been thought by a few practitioners to have some such influence upon the salivary glands. " Dr. James lately in- formed me," says Sir George Baker (Medical Transactions of the College, vol. i., p. 378), " 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 in- stances of a salivation raised by his medicine. He added, that the patients who were thus sali- vated had neither their teeth loosened, nor their breath made offensive, as happens in a mercurial ptyalism." Fusch tells us (Dissert, de An- tochiria, Jen., 1681), that he has occasionally ob- served a like effect; as does Willich, when tar- tarized antimony has been employed.—(Baldin- ger, N. Magazin., band viii., p. 252.)—[Accord- ing to Dr. Paris (Pharmacologia, vol. i., p. 288, 6th edit.), the latter medicine in nauseating doses certainly promotes a salivation by mer- cury ; and so does the accidental supervention of any disease of debility. The editor has seen in the King's Bench and Fleet prisons, four or five cases in which an annoying degree of saliva- tion proceeded from the free use of the com- pound squill pill. A similar fact is recorded by Quarim.]—(Animadversiones Pract., Vienna?, 1786.)* From the general tendency of mercury to pro- duce this specific effect, those who are engaged in working quicksilver mines, as those of Idria or New Spain, are almost continually in a state of salivation : and when, which is often the case, condemned as criminals to such labour for life, drag on a miserable existence, in extreme debil- ity 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, t * The list of medicinal agents capable of indu- cing salivation might easily be increased by adding to those mentioned m the text, squills, iodine, and the oxymuriate of gold. We have seen excessive ptyalism produced also by an emetic of sulphate of zinc.—D. t" Emaciation is the constant attendant of a From the facility with which quicksilver evaporates, and combines, not only with other metals, but with almost all other substances, and especially with many of the elastic gases, a con- siderable degree of injury is often sustained by workmen in manufactories, in which quicksilver is occasionally employed, without their being for a long time aware of the cause. An instance of a similar kind occurred on board the Triumph man-of-war, which had received on board thirty tons of quicksilver, contained in leathern bags of fifty pounds each, that had been picked up on the shore at Cadiz from the wreck of two Span- ish 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 seawater, they soon de- cayed tand burst. The quicksilver, thus let loose, was-collected as well as it could be, and committed to proper casks : but much of it esca- ped into the recesses of the ship ; and not a little was secreted by the sailors, who amused themselves with it in various ways. The quick- silver that had escaped unnoticed sunk 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 offi- cers, to such an extent, that no less than two hundred 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 different degrees of effect upon different constitutions or states of the body. In a few rare instances, it has ex- erted no sensible influence whatever upon the excretories of the fauces : in others, a very small quantity of almost any of its preparations has stimulated them at once to a copious dis- charge. In persons of a highly nervous or irritable temperament, I have known salivation produced by a single dose of calomel; and that it is some- times caused by dressing ulcers with red pre- cipitate, is a fact mentioned by Hildanus, and well known to all experienced surgeons. In scorbutic, scrofulous, and other debilitated habits, very small quantities of mercury will sometimes act in the same manner ; and hence a considerable degree of caution is requisite in all cases of this kind. Even the wearing of a leathern girdle, or the occasional application of white precipitate or mercurial ointment to the head to destroy vermin, has often excited saliva- tion. mercurial course. In producing their effects, mer- curial preparations, whether oxides, chlorides, cyanides, iodides, or any other, are decomposed, and the mercury, in a metallic form, is either thrown out of the body by the skin and lungs, or deposited in the glands and bones." In Hufeland's Journal it is stated, that a pelvis, infiltrated with mercury, and taken from a young woman who died of syphilis, is preserved in the Lubben Mu- seum of Midwifery.—See Thomson's Elem. of Materia Med., t. i., p. 370—372. Gen. II.—Spe. 1.] P. AC When mercurial salivation is produced, it is accompanied with a high degree of' irritation, not only of the mouth and fauces, but of the sys- tem generally. The common course of symp- toms 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 appear, and terminate in mi- nute and offensive exulcerations ; the tongue tumefies ; the throat becomes sore ; pyrexy and sleeplessness supervene, and are, indeed, often present from an early period of the disease ; while in idiosyncrasies, or habits of great irrita- bility, we frequently 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 mercuriale by others. [Gangrene and necrosis may be the consequences of immoder- ate mercurial salivation. Large sloughs of the parts in the mouth are very common. Cullerier has seen a partial necrosis of the lower jaw pro- duced in this manner, and, in one young woman, a complete necrosis of the upper and lower al- veolary arches.—(Diet, des Sciences Med., torn. xlix., p. 455.) The editor of this work has wit- nessed several melancholy examples of the same kind.] It is difficult to determine by what means mercury produces its effect on the salivary glands. Dr. Cullen attempted one explanation of the subject; namely, that " mercury has a particular disposition to unite with ammoniacal salts, and that such salts are disposed to pass off by the salivary glands more copiously, than by any other excretion." But, as Dr. Murray has remarked, mercury has not any peculiar ten- dency of this kind. Indeed, if it had, no am- moniacal salts are mentioned, either by Berze- lius, or by Tiedemann and Gmelin, as entering into the composition of the saliva. Dr. Cullen regards mercury as nothing more than a general irritant, operating equally upon all the sensible and moving fibres of the body, and hence pow- erfully operating upon all the excretories of the system, without having a special affinity to one set more than to another. " It proves often," says he, " diuretic ; and I have particular proofs of its reaching and acting upon the organs of perspiration."* Another hypothesis is that of * Mat. Med., vol. ii., p. 443. Professor A. T. Thomson entertains a similar view :—" Mercury," says he, " in whatever form it is administered, and in whatever manner it is introduced into the living body, acts as an excitant; a febrile state of the body is induced, evidenced both by the condi- tion of the pulse, and that of the nervous system; and also by an augmented secretion and excretion of the saliva. It is this febrile excitement, over- coming or destroying the morbid action begun and maintained in the frame by the introduction of the syphilitic or venereal poison into it, which cures syphilis. The action on the salivary glands is only a symptom of this general excitement, induced by mercurials, and not in itself essential to their cura- tive power: it may not be produced by the admin- istration of mercurials, and yet syphilis may be cured by them. In this case the mercurials are UTUS. 63 Sir Gilbert Blane,* who considers the salivary glands as one of the outlets for the ramenta of the bones, because lime is detected in the saliva, and even concretes on the teeth. Now, as mer- cury is known to produce an active absorption of the solids, it is ingeniously conceived, that the fact in some measure explains its effect upon the salivary glands. However, as the kidneys and other excretory glands also furnish outlets for the old particles /of the body, and yet are not affected by mercury in the same degree as the salivary glands, this theory cannot be retained. The fact, however, remains the same, namely, that mercury, whether it possess a specific affin- ity or not for the excretories of the saliva, acts, from some cause or other, more readily and powerfully upon them than upon any other ex- cretories whatever. In attempting a cure of salivation from mercu- ry, our attention is 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 fruits, as the sloe, may be employed with great advantage, and should be used freely ; but if there be considerable irrita- tion, we must at first content ourselves with emollient gargles of barley-water or quince- seeds :f and in either case employ, at the same time, purgatives of Epsom or other neutral salts. When the system is much affected, sulphur and opium have been strongly recommended, and seem in many cases to have been successful. The former is trusted to, chiefly from its being well known to diminish the activity of mercury out of the body ;—a doubtful reason, however, for our employing it internally.X The latter is certainly of considerable use in allaying the gen- eral restlessness and irritation of the system. The free exposure of the patient to a cool pure air, was found by the late Mr. John Pearson to be one of the most decided means of checking profuse salivation. The diet should be of milk. It may also be added, that perhaps there is no disease in which the Lisbon dietdrink, or com- pound decoction of sarsaparilla, may be used with better effect. Taken in the quantity of a quart a day, it carries off the effects of the poi- son, and supports the system.§ nevertheless taken into the circulation, for they communicate a blue appearance to silver articles in the patients' pockets." Elem. of Materia Med., vol. i., p. 371. * Trans, for the Improvement of Med. Knowl- edge, vol. iii., p. 112. t As a gargle, Dr. Thomson recommends alco- hol or brandy and water, or the chloro-sodaic solu- tion of Labarraque in water, in the proportion of one part of the solution to four of water. Vol cit p. 375. X It is remarked by Professor A. T. Thomson, that the experience of those who have had the best opportunities of judging, has not satisfied them that it possesses any efficacy in diminishing mer- curial action. He adds, that if preparations of sul- phur have at any time proved beneficial in check- ing salivation, the effect is to be referred to their acting either as sudorifics or purgatives.—Elem. of Materia Med., vol. i., p. 375. § Dr. Falmestock states (Amer. Jour, of Med. Sciences, vol. v., p. 62), that in cases of salivation 64 CGELIACA. [Cl. I.—Ord. 1. [Some cases of inordinate salivation, recorded by Dr. Haskins, tend to prove that emetics have considerable power in relieving the disorder.*] Like most other poisons, mercury, when prop- erly directed, may be rendered a most valuable medicine ; and is at this moment, in its multifa- rious forms, one of the most common, as well as one of the most efficacious, in the Materia Med- ica. In this place, however, we can only con- template it as a source of disease. A certain degree of active ptyalism is also well known to be produced by any high degree of mental or sensorial 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 lach- rymal. 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 accom- panied with a similar biting of the lips and gnash- ing of the teeth. But the most striking proof of this effect is produced by an eager longing for agreeable food of any kind, whether seen, smelt, or only thought of; and which is vulgarly de- nominated MOUTH-WATERING. In man, this increase of secretion is seldom so considerable as to occasion an involuntary flow from the mouth ; but, in dogs, it flows freely and continuously; for here the-salivary glands are peculiarly irritable, so that the ani- mal is almost constantly slavering; the dis- charge appearing to answer the purpose of in- sensible perspiration in other quadrupeds. We meet also occasionally with an increased secretion of saliva from a cause less obvious, distinguished by a sweet or mawkish taste ;t to which some writers have given the name of sweet-spittle.X It is the dulcedo sputorum of Professor Frank, (j It may possibly 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 nau- sea ; the saccharine matter being formed, per- haps, by a like assimilating power as that pos- sessed by the kidneys in diabetes. It is relieved by magnesia, and other absorbents ; but is most from mercury, he has used, " with uniform and un- aralleled success," a gargle made from the inner ark of the root of the rhus glabrum. Professor Geddings, of Baltimore, has given the oleum tere- binth with the most satisfactory results. He gen- erally prescribes two drachms of the turpentine, mixed with eight ounces of gumarabic mucilage, to be used frequently as a gargle. He has also employed the undiluted turpentine, and with suc- cess.—(See Amer. Jour, of Med. Scien., vol. vii., p. 267.) Dr. Francis informs me that he has seen good effects resulting from pulverized charcoal, taken internally and at short intervals. In a late German periodical, Hufeland speaks highly in fa- vour ofiodine.—D. * Philadelphia Journal, No. 2. t Act. Nat. Cur., vol. iv., Obs. 59, 89 ; vol. v., Obs. 71. Degaye, Diss, de Natura et Usu Sahvae. Monspel. 1783. X Paullini, Cent, i., Obs. 81. $ De Cur. Horn. Morb, Epit., torn, v., pp. 59, 85. Mannh. 8vo. 1792. effectually cured by an emetic, followed by warm stomachics. A lady of delicate habit, under my care, has been subject to this variety for some years. It returns irregularly, for the most part once in about a month or six weeks, and generally yields to a course of rhubarb, taken sometimes in conjunction with two or three grains of calomel. Bloch (Bemerkun* gen, p. 203) mentions a case, in which it re- turned at periods still more regular. This variety of ptyalism is also occasionally the re- sult 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." A ptyalism frequently occurs during denti- tion ; -and is by no means an uncommon sequel or crisis of other diseases. In all these, as I have already hinted, it proves salutary, and terminates the disorder that excites it. Fevers afford, perhaps, the most numerous examples of this ; and the fol- lowing 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 meanwhile, she increased in strength, recovered her appetite, and got well. We have numerous instances, in which this discharge has proved equally serviceable, about the acme of smallpox ;* though in one or two cases death has succeeded, t The fluid of drop- sies is said to have been carried off at times by the same channel. In the Medical Obs. and Inquiries, vol. iii., p. 241, there is a singular case of an obstinate vomiting of five months' standing, being relieved upon a return of salivation, which for this pe- riod had ceased. But perhaps one of the most extraordinary instances to be met with is re- lated by Dr. Huxham, in the Phil. Trans., vol. xxxiii., for 1724. 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 calomel, and a grain of opium. Copious dejections followed ; and a few hours afterward the patient complained of pain and swelling in the fauces, spit up a little thick brown saliva, which was soon considerably increased in quan- tity, of a deep colour, resembling greenish bile, though somewhat thinner. This flux of green and bilious saliva continued for about forty hours; during which time the quantity dis- charged amounted to four pints. The colour * Act. Nat. Cur., vol. vii., Obs. 109. Fich, Diss. de Salivatione spontanea, praecipue Variolarum. Jen. 1713. t Riedlin, Lin. Med., 1695, p. 384. Weber, Ob* Med. Fascic. i. Gen. II.—Spe. 2.] P. INER3. 65 of the saliva then changed to yellow, like a solution of gamboge, with an increase rather than a diminution of the quantity. It continued of this colour for the space of forty hours more, after which it gradually became pellucid, and the salivation ceased as suddenly as it came on. During the flow of the saliva, the teeth and fauces were as green as if they had been stained with verdigris, and the teeth retained the same colour for a fortnight after the ptyal- ism had 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 colic ; 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 abun- dantly, and of a blackish hue. SPECIES II. PTYALISMUS INERS. DRTVELLING, OR SLAVERING. INVOLUNTARY FLOW OF SALIVA FROM A SLUG- GISHNESS OF DEGLUTITION, WITHOUT IN- CREASED SECRETION. There is a second species, which belongs to this genus, in the present system, distin- guished by the name of inert ptyalism, and which depends upon a want of command or power over the muscles of deglutition, rather than on any increased action of the salivary ex- cretories. In vulgar language it is denomi- nated DRIVELLING, Or SLAVERING. It OCCUTS under the three following modifications : a Infantilis. Of infancy. 0 Senilis. Of old age. y Moris. Of dotards, or idiots. It is found, therefore, in three states of life: among infants, before the will has acquired a power over the muscles of deglutition, and is altogether distinct from the salivary flux of den- tition ; in advanced life, in which the will has lost its power; and in idiots, who possess 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 avaU. GENUS III. DYSPHAGIA. DYSPHAGIA. PAIN OR OBSTRUCTION IN SWALLOWING, WITH- OUT INFLAMMATION, AND MOSTLY WITHOUT IMPEDED RESPIRATION. It is necessary to limit the character of this genus, as in the above definition, since inflam- matory affections, in whatever part of the sys- tem they occur, constitute one natural order ; and dyspnetic affections, or those essentially impeding the respiration, another order; and Vol. I.—E should, therefore, be arranged and considered in their respective associations ; the former, under the diseases of the sanguineous function, and the latter, under those of the respiratory. [Deglutition is a very complex operation, re- quiring the concurrence of many agents, from the mouth, where it begins, down to the cardiac orifice of the storfiach, where it terminates. It may be divided into three stages : in the first, the food passes from the mouth to the pharynx; in the second, it passes the opening of the glot- tis, and the nasal apertures in the fauces, and is carried into the oesophagus ; in the third, it passes through this tube, and enters the stom- ach. When a portion of food has been suffi- ciently chewed, it is placed by the actions of mastication upon the dorsum of the tongue. Mastication is then suspended, and the tongue applied to the roof of the mouth in succession, from its point to its base. The alimentary bo- lus is thus pressed towards the pharynx, and soon meets with the velum palati, which is raised up by it into the horizontal position, and made a continuation of the palate. As the tongue continues to press the food, it would push it towards the nasal openings in the fauces, if it were not for the tension of the velum pal- ati, produced by the circumflex muscles and the constriction of the pillars. With the ex- ception of the motions of the velum, these actions in the first stage of deglutition are slow, voluntary, few, and successive. In the second stage, the actions are simultaneous, multiplied, involuntary, and rapid; the food is conveyed by them only from the middle to the bottom of the pharynx; but quickness is essential, in order that the aliment may not insinuate it- self into the glottis, impede respiration, or glide into the nasal openings in the fauces, or the apertures of the Eustachian tubes. The aliment no sooner touches the pharynx, than it is embraced by this part and the velum palati. At the same instant, the base of the tongue, the os hyoides, and the larynx, are raised and carried forward to meet the morsel of food, and transmit it rapidly over the glottis, which is now shut, and also covered by the descent of the epiglottis. By the continued pressure of the pharynx and velum palati, the food is next pushed into the oesophagus, the larynx descends, the epiglottis rises, and the glottis itself is opened again for respiration. In the third stage of deglutition, the arrival of the food in the ■ upper part of the oesophagus causes the supe- rior circular fibres of this canal to contract, and propel the aliment towards the stomach. The subsequent fibres, now distended, contract in their turn ; and the same changes are continued in succession, until the food gets into the stom- ach. The experiments of Magendie convince him, that the aliment passes very slowly down the oesophagus, and, when its ready entrance into the stomach is prevented, it will sometimes rise and descend again several times before it is ejected* From the preceding account it * See Magendie's Physiology, by Milligan, Sd edit., p. 238. 66 C02LIACA. [Ct. I.—Ord.1. must be manifest, that many different causes may be concerned in bringing on a difficulty of swallowing; and that dysphagia, strictly speak- ing, is not a disease itself, but only one of the most dangerous effects of the diseases to which the organs of deglutition, or other parts in the neighbourhood of them, are subject. The his- tory of every form of dysphagia would make therefore a very long detail, comprising an account of most of the diseases of the mouth, throat, nasal cavities, pharynx, larynx,* and oesophagus, as well as of various accidental in- juries of parts about the throat, and of many sorts of tumours within or near the mouth, the pharynx, or oesophagus. + In the present part * Dr. Abercrombie has seen several cases of disease of the larynx in which the dysphagia was the prominent symptom, so as to lead to the sup- position of disease of the oesophagus. In one in- stance the epiglottis was thickened and much elongated ; the patient had no constant difficulty of swallowing, but was liable to sudden attacks of it during his meals, which threatened instant suffocation. In another case, the dysphagia was permanent, and combined with a hoarse, husky cough, and slight dyspnoea. The whole body of the larynx was very much enlarged and thick- ened ; and some ulceration existed in it internally towards the oesophagus. In both cases the oesoph- agus was entirely healthy.—See Abercrombie's Pathol, and Pract. Researches on Diseases of the Stomach, &c, p. 97, ed. 2. t Instances are recorded by Valsalva and others of dysphagia from dislocation of the os hyoides. In the Journ. des Progres, &c, t. xiv., p. 250, a ease of this kind is related, which was cured by reduction. Dr. Abercrombie gives the following particulars of another example: "An eminent medical man, now deceased, was liable to this accident, and I have seen him seized with it in an instant, while engaged in conversation. It pro- duced slight difficulty of articulation, and total inability to swallow. He easily relieved himself by a particular movement of the parts with his hand, which had become familiar to him from the frequent occurrence of the accident."—(Patholo- gical and Practical Researches on Diseases of the Stomach, Intestinal Canal, &e.,p. 102, ed. 2.1830.) See another case in Med. Gazette, vol. iv., origi- nally reported by Dr. Mugna in the Annali Univer- sali. Sir Charles Bell had a preparation, exhibit- ing a projection of one of the horns of the os hyoides into the pharynx in consequence of ul- ceration.—(Surgical Obs., p. 60.) Bleuland gives the particulars of a dysphagia produced by the pressure of an exostosis of the vertebrae upon the oesophagus. Sir Astley Cooper reports an exam- ple, in which the same consequence arose from a dislocation of the sternal end of the clavicle back- ward. Aneurism of the aorta frequently causes dysphagia, which may exist long before the ori- ginal disease is suspected. Dr. Abercrombie re- fers to a case in which a probang was passed, under the idea of stricture of the oesophagus; it occasioned rupture of the aneurism, and almost immediate death.—(Op. cit., p. 100.) Among nu- merous other circumstances which may occasion dysphagia by pressure on the oesophagus, I may mention enlargement of the thyroid gland, bron- chial glands, or glands in the posterior mediasti- num; great distention of the pericardium.—(Bleu- land de sana et morbosa QDsophagi Structura.) I dismiss from present consideration dysphagia from congenital malformations and imperfections of of this work, the author enters into the con- sideration of the six following species :—] 1. Dysphagia Constricta. Constrictive Dys- phagia. 2.---------Atonica. Atonic Dysphagia. 3. ----—— Globosa. Spasmodic dyspha- gia, or Nervou3 Quinsy. 4.----------Uvulosa. Uvular Dysphagia, 5. ---------- Linguosa. Lingual Dysphagia. 6. ---------- Pharyngea. Pharyngeal Dys- phagia. [The several cases of dysphagia arising from a diminution of the capacity of the oesophagus by disease of its texture, or from its being oc- cupied or compressed by tumours of different sorts, are at first so similar in their symptoms and progress, that a successful discrimination of them is not always easy. In all of them, one of the earliest symptoms is a difficulty of swallowing solids, followed, after a time, by that of swallowing fluids. This inconvenience makes more or less rapid advance, and if not relieved by medical treatment (which is too often im- practicable), terminates in a fatal interruption of the function of deglutition. With the excep- tion of spasmodic dysphagia, and cases of me- chanical injuries of the jaw and parts about the mouth and throat, almost all the species of dys- phagia come on very gradually, and with so little annoyance that at first they are apt to be disre- garded, more especially as the health is gener- ally good, and the inconvenience in swallowing sometimes abates for a time, or even quite ceases. Nor in general can any defect be seen or felt in the mouth or pharynx; the food passes the isthmus of the fauces very well, and proceeds duly towards the stomach ; but it soon rises into the mouth again, with a large quan- tity of saliva, unaccompanied by any effort of the stomach, diaphragm, and abdominal mus- cles. The patient again tries to swallow, and, perhaps, after repeated attempts, succeeds in getting the food into the stomach, in small quantities at a time. Thus the disease is al- lowed to go on unresisted for a long period,. The kind of rumination resulting from the in- verted peristaltic action of the oesophagus, dif- fers from common vomiting, inasmuch as the food is ejected without anxiety, indisposition, or cold sweats. Notwithstanding the difficulty of swallowing, the appetite often continues good4 almost until the very approach of death.] SPECIES I. DYSPHAGIA CONSTRICTA. CONSTRICTIVE DYSPHAGIA. DIFFICULTY OF SWALLOWING, FROM A PERMsA- NENT CONTRACTION OF THE CESOPHAGU6. Sometimes the diameter of the canal is di- minished in particular parts by a thickening of the mucous membrane, fleshy excrescences, or fungous,* or scirrhous tumours. The same the pharynx, oesophagus, palate, &c. Sir Astley Cooper reports the case of an infant which, though born without an oesophagus, lived eightdays.—Ed. * In Dr. Armstrong's Morbid Anatomy of the Gen. III.—Spe. 1.] D. CONSTRICTA. 67 effect may proceed from tumours formed be- tween the coats of the oesophagus.—(C. Bell's Surg. Obs., p. 60.) Sometimes a scirrhous thickening of its coats, or of the cellular mem- brane connecting them,* extends through its entire length ; and sometimes it becomes con- tracted by the conversion of a portion of it into cartilage or bone. Besides these cases, there are other casual and symptomatic obstructions, which do not fall under our present survey, pro- duced by hysteria and other spasmodic affec- tions ; enthesis, or the lodgment of foreign bodies in the canal; or external tumours, as in bronchocele, abscesses,! or aneurism of the aorta, pressing against its sides. [The oesophagus is much less frequently the seat of disease than the mouth and the pharynx, and especially than the stomach and other parts of the digestive tube, below the diaphragm.— (Andral, Anal. Pathol., t. ii., p. 244.) Its lining, like all other mucous membranes, is liable to be thickened by inflammation ; the diameter of the passage is thereby lessened ; the muscular fibres cannot act upon it with their usual power ; and the conveyance of the food into the stomach is more or less obstructed. True strictures of the oesophagus, like those of the urethra, generally occupy but a small extent of the canal, and are for a long time attended with very little thick- ening of the adjacent parts. The derangement is in the inner membrane of the tube ; there is no apparent disease of the tunica vaginalis gulae ; nor any degree of thickening of the glandular structure.—-(C. Bell, Surgical Obs., p. 80.) Stomach, &c. (Plate 8), maybe seen a representa- tion of a stricture occasioned by the cardia being surrounded by a tumour, that had the character of fungus hsematodes, or, as he terms it, fungus encephaloides. The same author had seen an- other similar case ; and both proved fatal before any degree of softening took place in the morbid substance. No similar formations were found in other parts.—Editor. * See Armstrong's Morbid Anat., fasciculus 2; pi. 7, fig. 2. t Mr. Carmichael has recorded two fatal ex- amples of dysphagia, from abscess between the oesophagus and cervical vertebra?, where, from the situation and circumstances of the disease, as found on dissection, he conceives that the patients' lives might have been saved, had the collection of mat- ter been discharged with a curved trocar.—See Trans, of Association of Physicians of Ireland, vol. iii., p. 170, &c. " A remarkable case occurred to Mr. George Bell, in which the dysphagia had existed so long that it was considered as an ex- ample of stricture of the oesophagus, and a probang was introduced. When this reached the part, which vr&s very low down, it ruptured the abscess, and an immense discharge of matter took place, with immediate and permanent relief."—(Aber- crombie 's Pathol, and Pract. Researches on the Stomach, &c, p.99.) The same author quotes from Bleuland a case of fatal dysphagia from abscess between the vertebrae and upper part of the oesoph- agus. Collections of matter in the lungs may also press upon this tube, and ultimately form a communication with it; examples of which are referred to in Dr. Abercrombie's work, on the au- thority of Bleuland and Kiinze (De Dysphagia).— Editor. E2 Strictures may occur in any portion of the tube; but their most frequent situation is immediately behind the cricoid cartilage at the termination of the pharynx. Sometimes the pharynx and beginning of the oesophagus are studded with scirrhous tumours of great firmness and white- ness, nearly closing the latter canal; while a general disposition to disease of its membrane is denoted by tumours of a similar nature lower down the passage. At the same time, the membrane, reflected over the glottis into the trachea, may be thickened, and even swellings of the above description present themselves within the latter organ. Another form of scir- rhus of the oesophagus is very analogous to the disease called the scirrho-contracted rectum ; it involves all the coats of the tube, and though it may affect the greater part of the passage, it generally commences either in the upper portion of it behind the cricoid cartilage, or far down near the cardia, where the structure is very glandular.—(Monro's Morbid Anat. of the Gul- let, &c, p. 325.) Scirrhus changes the texture of the oesophagus sometimes into a hard, uni- formly fleshy substance, and sometimes into a substance of a gristly nature, or intersected by membranes.—(Baillie's Works, by Wardrop, vol. ii., p. 93.) Under such circumstances, the canal is always rendered narrower, and often nearly closed. The disease is also frequently compli- cated with ulceration, which is mostly seen either above or below the most constricted point, not exactly in it. A fact meriting attention is, that obstructions situated high up in the oesoph- agus, frequently give rise to ulceration of the lower part of it, near the stomach, just as stric- tures in the urethra often produce ulceration of that canal towards the bladder. In the oesoph- agus, this kind of ulceration is most liable to occur when the obstruction has existed a long time ; and the frequent retching is conjectured to be the occasion of it. Though ulceration does not generally attack the most constricted portion of the tube, it does so in particular ex- amples, just as it does in the urethra, and this in such a manner that the obstruction is more or less removed. Relief only follows this event, however, in cases of common stricture of the mucous membrane ; for when the disease is of a scirrhous nature, ulceration always proves an aggravation of the complaint, instead of a pos- sible means of relief. Indeed, when the oesoph- agus has been rendered even more capacious than natural by the effects of scirrhous ulcera- tion, the continuity of the muscular action, by which the food is transmitted to the* stomach, is interrupted, and a disease, very different from stricture, resembles it in its most essentia! circumstance, the incapacity of swallowing.* By ulceration of the oesophagus, preternatural communications may be formed between that * Sir C. Bell, in Surg. Obs., p. 62. According to Dr. Armstrong, when a softening of the scir- rhous matter takes place, the muscular coat may suffer in the destructive process, and be attenuated. —(Morbid Anat., &c, p. 54.) He adds, that, in general, it seems thickened, owing to the cellular texture connecting its fibres being in this state. 68 CCELIACA. [Cl. I.—Orf. r. tube and the trachea,* Iungs.f or aorta. The latter state may also be the result of disease first commencing in the great arterial trunk itself.—(Meckel's Anat., vol. iii., p. 254.) Here also the remarkable case of Admiral Wassenaer deserves to be mentioned, who, according to Boerhaave, died suddenly in the act of attempting to vomit soon after dinner, and whose oesopha- gus was found to have given way in the seat of an ulcer, so that all the food and drink taken at dinner had become effused in the cavity of the chest. A similar case, i\aida, softness, or effeminacy. Whatever the cause, when this morbid pro- pensity has once obtained a triumph over the natural taste, the substances for which it ex- cites a desire are often not only of the most indigestible, but disgusting quality. We have had examples of an inclination for devouring dirt, cinders, ordure, fire, spiders, lice, toads, serpents, leeches, bits of wood, 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 ex- travagant kind:* and those who are desirous of gratifying themselves still further, may have full indulgence by consulting the Ephemerides of Natural Curiosities Mr. John Hunter de- scribes a longing for dirt, in the form of clay or loam, to have been an endemic disease among the blacks in Jamaica.t But he is surpassed by Dr. Darwin, who tells us that he once saw a young lady, about ten years of age, that had filled her stomach with earth out of a flower- pot, and then vomited it up, with small stones, bits of wood, and wings of insects among it. J There are other persons who have had a taste for harder substances, and have glutted themselves with stones,^ glass, II arid even leaden bullets. IT Others, again, have feasted on pieces of money, which have sometimes formed a very expensive repast; for Borelli gives us an in- stance of a pantophagist who swallowed a hundredlouis-d'ors at a meal.** Yet, perhaps, after all, the most maryellous, though certainly one of the most common exhibitions of de- praved 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 ; tt Prussian knife-eaters ;Xt Bohemian knife-eat- ers ;$$ and even, out of Europe, Brazilian knife- eaters.HII The wretched patients have some- times perished shortly after the extraordinary feat; and sometimes dragged on a miserable existence for a few years, before they fell vic- tims to their madness or malady. In a few in- stances, they have recovered. In an extraordinary instance of this kind, that not long since occurred in our own country, the knife-fancier, Cummings by name, and by (Craft a sailor, lived ten years after his first ex- * Cent, i., obs. 24, 52; ii., 37; iv., 25. t Obs. on the Diseases of the Army in Jamaica X Zoonom, cl. III., i, 2, 19. (j Act. Hafn., vol. v. II Camerarius, Memorab., cent. v. IT Bonet, Medic. Septentrion., lib. i., p. 510. Binninger, obs, cent, ii, ** Cent, iv., obs. 95. tt Act. Hafn., v. 107. XX Dolaeus, Encycl. Chir., p. 679. .W Crollius, Basilic. Chym., praef., p. 119. J|| Binninger, cent, v., obs. 7. periment, and occasionally persevered in the same trick during the whole of this time. The rash act is sometimes overcome, and the mate- rials discharged piecemeal; and it might have been so in this man, but for the foolhardiness that made him insensible to the earlier warn- ings given him, and urged him to a repetition of the offence.* Even the American States seem of late to have furnished us with a simi- lar example, in a young man who had long, we are told, been in the habit of swallowing various indigestible substances, as buttons, musket- bullets, and billiard-balls ; and being thus initi- ated in the art, on June 22, 1822, swallowed not less than fourteen knives within the course of the day. Repentance came too late. He sunk gradually beneath his exploit, and died on the ensuing 25th of August. Two of the knives had been discharged from the body, one was found in the oesophagus, 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, and to have evacuated them on the ninth day, darkened in colour, but not otherwise injured.t If this variety should happen to be united, as it sometimes is, with pica avens, or voracity,:): there may be no bounds to the deglutition, either in quantity or quality. § M. Fournier, in his Cases Rares, has given us an instance of this kind, so extraordinary, that if it had not been most unexceptionably attested, it would not have been credible. A galley-slave, he tells us, of this description, and who was dis- ordered in his intellects, fell at length a sacri- fice to a colic, accompanied with a cough ; and, * Marcet, Trans, of the Medical and Chir. So- ciety, vol. xii., p. 52. t New-Yotk Medical Repository, Oct., 1822. X In the Trans, of the Roy. Asiatic Soc. for 1833, General Hardwicke has given some details in re- gard to the East Indian cannibal, or sheep-eater, whose disgusting exhibitions have been attested to by numbers. The general, who was an eye- witness, there states, that the sheep-eater had with him two living sheep: after a brief harangue to the multitude around him, he seized the fleece of one sheep with his teeth, and, by swinging his head, flung it on the ground. In this position he tore the animal open, by stripping off the skin from the flank to the breast: he then took out the intestines, thrust his head into the peritoneal cavity, and drank the blood. The rest of the hide was then removed, the ribs separated, the limbs disjointed; each part was rubbed with dust, to dry up the blood, as he said, and to enable him to tear the meat from the bones with greater ease. He then swallowed one mouthful after anotherwith the dust adhering, and the performance was con- cluded by his collecting some leaves of the mad- der plant (asclepias gigantea) and chewing them; the milky juice of which, he said, would assist digestion. This monster, who was squalid and emaciated, generally ate two sheep at a meal.—D. $ In the Medical Gazette for 1832-33, p. 574, the case of a woman is quoted, who used to de- vour raw lights, and large quantities of grass. In July, 1828, she ate so copiously of grass and but. tercups for her supper, that she was seized in the night with severe pains in the abdomen; jaundice ensued, and she died in a few days.—Ep. Gen. V.—Spe. 4.] LIMOSIS CARDIALGIA. 87 on opening him, the stomach was found to oc- cupy the left 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 broomstick, 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 spoon, 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 weigh- ing about twenty-four ounces avoirdupois.— (Diet, des Sc. Med., art. Cas Rares.) 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. 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 combina- tion 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 is seldom more than temporary. In the mal d'es- tomac, or cachexia Africana, as it has been called, which is the disease of dirt-eating among the negroes referred to by Mr. J. Hunter, per- haps great acidity may exist, and instinctively call for the drier earths, as absorbents. SPECIES IV. LIMOSIS CARDIALGIA. CARDIALGY. IMPAIRED APPETITE, WITH A GNAWING OR BURN- ING PAIN IN THE STOMACH OR EPIGASTRIUM, AND A TENDENCY TO FAINT. The symptoms laid down in this definition, are sufficiently marked to separate cardialgy from dyspepsy, in which it is merged by Dr. Cullen and various other writers ; for, in the last, there is not necessarily a gnawing or burn- ing pain ; 'and the appetite is rather fastidious, than essentially, or at all times impaired. Car- dialgy is certainly sometimes found as a symp- tom in dyspepsy, as it is also in a multitude of other complaints ; as flatulency, scirrhus or in- flammation of the stomach, worms, retrocedent gout, suppressed menstruation, and various dis- eases 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 idio- pathic affection, and should therefore be de- scribed as such. Cardialgy admits of the three following varieties: a Mordens. Gnawing or burning un- Heart-burn. easiness, felt chiefly at the cardia, the ten- dency to faint being slight. /3 Syncoptica. The pain or uneasiness Sinking heart-burn, extending to the pit of the stomach ; with anx- iety, nausea, coldness of the extremities, fail- ure of strength, and great tendency to faint. y Sputatoria. Burning pain extending Black-water. over the epigastrium; Water-brash. and accompanied with an eructation of watery fluid, usually insipid, sometimes acrid. The first variety is perhaps the most common form of the disease. And as the gnawing or burning pain is in this case felt chiefly at the cardia, or upper orifice of the stomach, the specific name of cardialgy is derived from this symptom. The cardia is indeed generally supposed to be the immediate seat of affection: but this is an erroneous view. It is from the greater sensi- bility 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 pan- creas, spleen, and liver, will often produce the same local pain ; and, in some instances, it has been ascertained after death to have been occa- sioned by a schirrous, or some other, obstruction of the pylorus. In the second variety, we find the pain or un- easiness 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 sympatheti- cally affecting the general system, attended with coldness of the extremities, failure of strength, shortness of breath, and great tendency to faint, which continues till the system reacquires warmth and perspiration. From the wider circumference of the affection, Hippocrates denominated it periodynia stomaehi. It is distinguished in popular language by the name of sinking heart-iurn. The third variety is distinguished by a morbid increase in the quantity of the fluids secerned ; and hence me peculiar symptom of an eructa- tion, 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 de- scribed the disease ; though he has singularly separated 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 ap- pears most commonly," says he (First Lines, 88 CCELIACA. [Cl. I.—Ord. I. vol. iv., p. 13), "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 in- creased by raising the body into an erect pos- ture, and therefore the body is bended forward. This pain is often severe ; and, after continu- ing 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 lepeated ; and does not immediately give relief to the pain which pre- ceded 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 is 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 stom- ach at the time, possess an acidity in them- selyes ; a fact, which closely connects pyrosis with cardialgy 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-qualm. It is the pyrosis of Sauva- ges, and many other writers. Most of these varieties have sometimes re- turned, periodically,* especially in the spring ; and as their general causes and mode of treat- ment do not essentially differ, it is more con- venient to consider them jointly than under de- tached heads. Dr. Perceval, of Dublin, in the manuscript comment with which he has obliged me on the nosology, ingeniously inquires, "Does it ever arise from an affection of the pancreas 1" I think it likely that it does, from contempla- ting the structure and office of this organ ; and we have various cases in which, after death, the pancreas ha.s been found considerably enlarged, t * Bartholin. Hist. Anat., Cent, iii, Hist. 50. Zacchius, Consil. N. 54, 08. t Post mortem examinations demonstrate that this is occasionally the cause of pyrosis. An en- largement and schirrus of the pancreas have been found, says Dr. Francis, in eases whore the pa- tient has long suffered from this infirmity: he adds, that the disordered condition of this oxgan is also attended with great irritability of the stom- ach, the contents of which are ejected with great violence. These views are partially sustained by Dr. Sewall, of Boston, in his paper on the diseases of the pancreas.—(See New-Eng. Journ. of Med. and Surg., vol. ii.) The excessive drivelling of some inebriates who have indulged in the abuse of spir- ituous drinks, adds Dr. F., is in part at least to be explained by the altered condition of the pancreas, as demonstrated by autopsic .examination.—p. The remote causes then of the present spe- cies, under whatever variety it shows itself, which is chiefly regulated by the habit or idio- syncrasy 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 larvae; drastic purges ; obstructed perspiration ; re- pelled cutaneous eruptions ; and bile depraved, or excessive in its secretion. Of the indigesti- ble foods, the most common are animal fat, oil, butter, or cheese, eaten in excess; which last has produced a cardialgy that continued for three years.* The stones or kernels of fruits have often laid a foundation for the complaint, especially where they have remained, as they have occasionally been found to do, and par- ticularly cherry-stones, for two, or even for three years, with little or no change whatever, t It occurs also, as already observed, not unfre- quently as a sequel or symptom of some other affections. All these causes have a direct tendency to produce imbecility of the stomach, especially a loss of tone, or weaker action in its muscular fibres ; and a morbid condition of the fluids secreted by, or poured into it. Acidity seems to be common to all its varie- ties ; and this to such a degree that, as Dr. Darwin observes, the contents of the stomach, when regurgitated on a marble hearth, have often been seen to produce an effervescence on it. 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 chestnuts, an aliment that fer- ments 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 gas- tric fluid itself, which appears to be secreted in too dilute or weakly a condition for the purposes of digestion ; on which account, the food, in- stead 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 itself, when first secreted, may possibly contain too large a proportion of the muriatic acid, which, according to the late valu- able researches of Dr. Prout, is found in the stomach during digestion. It is not improbable that the third variety, cardialgia sputatoria, may, in some instances, be produced by inactivity of the proper absorb- ents 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 van- ishing. * Paulmi, de Nuce Moschata, sect, iii., p. 3. Eph. Nat. Cur., Dec. ii,, Ann. v., app. 71. t Bresl. Samml., 1725, i., p. 77. Gronen. Com- merc. Liter,, Nov,, 1733, p. 189. Gen. V—Spe. 4.] LIMOSIS C In applying to this disease the resources of the art of healing, it is obvious that our inten- tion should be twofold : 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 anti- spasmodics, as the ethers and ammonia; and where acidity is unquestionable, by calcareous and saponaceous earths.* Lime-water, or acid- ulous alkaline waters, or the carbonates of soda and potash, magnesia and lime, have been almost the only ones that have hitherto been em- ployed, or at least the others have not been sub- mitted 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 ; * Gastrodynia and gastralgia are terms frequently used almost synonymously with cardialgy. In one form of gastrodynia, described by Dr. Barlow, of Bath, the disease is represented as depending upon a redundant and unhealthy state of the mucous secretions of the stomach and bowels. Hence, instead of endeavouring, in the first in- stance, to palliate the pain with opium or stimu- lants, he begins with active purgatives of calomel and colocynth, with or without the addition of tar- tarized antimony. When the costiveness is ob- stinate and habitual, he exhibits every night, or every night and morning, if necessary, colocynth, aloetic pill, or colocynth conjoined with henbane, two parts of the former to one of the latter. While aperient medicines are continued, some of the mistura salina cardiaca of the Bath Hospital Phar- macopoeia is given, composed as follows :— ft, Sodae Subcarb. Siss. Aq. Purae Oviiss. Acid. Sulph. dil. 3 j. Confect. Aromat. 5 iij. Spir. Menth. Pip. 3 iij. " The foregoing quantities, thus combined, yield 324 grs. of sulphate of soda, 423 grs. of the sub- carbonate remaining unaffected by the acid. Thus each ounce of the mixture contains but a few grs. of either salt; yet, insignificant as the dose may appear, it is not inert. When gastrodynia still goes on, after the secretions of the alimentary canal have been rectified, Dr. Barlow has found the ox- yde of bismuth the best auxiliary medicine, in the dose of five grains, with one of aloes, given three times a day, in conjunction with the cordial mix- ture. For some cases, spirit of ammonia is a useful addition ; while for particular examples the camphire and cordial mixtures in equal parts; and for others, a blister to the scrobiculus cordis, are well spoken of."—(See Cyclopaedia of Practical Medicine, art. Gastrodynia.) With these observa- tions, delivered by Dr. Barlow, the practitioner may usefully compare those made by Jolly, in his account of Gastralgie, Diet, de Med., &c, Paris, 1833. In gastrodynia, not apparently occasioned by any thing in the stomach, " you find tinct. of opium an excellent remedy. In the continued form of the disease, prussic acid will answer better; but I never saw it succeed, when it was given for immediate effect."—(Elliotson's Lec- tures.) In full habits, he advises bleeding, which he has often seen relieve gastrodynia at once. Stramonium he has also known cure gastrodynia, and, as not producing costiveness, is preferable to opium.—Ed. ARDIALGIA. 89 but it seems to have a foundation, and should regulate our practice. Chalk, however, when used in large quantities, and long persevered in, has an indisputable evil, which does not equally belong to soda or magnesia; and that is, its aptitude to form balls or calculi in some part of the intestinal canal; and thus produce 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 calcu- lous 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 occa- sion to advert to more fully hereafter, of intro- ducing magnesia into the stomach, in habits possessing a tendency to form calculi in the kid- neys and bladder from a superabundant secretion of lithic acid, seems to show, that an acid prin- ciple, or base, still passes from the stomach into the circulation in certain cases, though too minutely divided to be detected by chymical tests; and that the introduction of magnesia into the stomach destroys or neutralizes it at the fountainhead.—(See Enterolithus and Lithia.) 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 magnesia, in doses of ten grains of the former to twelve of the latter. It is observed by Dr. Darwin that, as the saliva swallowed along with our food prevents its fermentation, considerable relief is some- times derived from frequently chewing parched wheat, mastic, or a lock of wool, and swallow- ing the saliva thus procured. Oleaginous preparations have also been em- ployed, and in some habits apparently with suc- cess. In such cases, it is most probable that they act, first, by converting a part of the acid into soap ; and next, by proving aperient, and thus accelerating the passage of the acid ma- terial into the intestinal canal. The complaint may also be palliated by mucilaginous sub- stances, such as Spanish liquorice, or gum- arabic. In many cases, speedy and effectual 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 are few medicines we can more fully depend upon than soap ; probably because in its decomposition it lets loose the oleaginous principle, which may in some degree obtund the pain, and at the same time unites its alkali with the acid of the stomach ; thus neu- tralizing its acrimony, and forming a valuable aperient. " It is often," says Dr. Cullen (Mat. ' Med., vol. ii., p. 400), " a more convenient 90 C02LIACA. [Cl. I—Opd. I. remedy than common absorbents or simple al- kalis." 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 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 afterward adds, relieves only the present fit, and con- tributes nothing to the prevention of future at- tacks.* It is hence necessary, in every case, to direct our view to the second intention I have pointed out: I mean that of preventing a recurrence of the paroxysm. Now, this can only be done effectually by re- storing 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 bitters, the metal- lic oxydes, and especially the oxydes of zinc and bismuth, first mentioned by Odier,t bid fairest for success. Of the bitters, one of the most elegant, as well as most effectual, is the extract of chamomile. The nux vomica, long since ex- tolled by Linneus, remains yet to be fairly ex- perimented with in this country. It has the peculiar property of diminishing the sensibility, while it increases the irritability of the animal frame—a property of which I shall speak more at large when discussing the subject of Paralysis. It is said to have been given in doses often grains three times a day. But this I very much ques- tion, where the drug has been sound and genu- ine. In palsy I have never been able to raise it above seven grains, without making the head stupid and vertiginous. J Among the aromatics, many of the terebin- thinate balsams will be found highly useful. The balsam of Gilead, and that of Mecca, amy- ris Gileadensis, and a. Opobalsamum, were once highly extolled, 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 * Among the means of affording prompt relief, ought to be mentioned hot fomentations to the epigastrium, and the use of the warm bath. Where tenderness on pressure is complained of, leeches are also frequently proper. If there be very fetid eructations, it is best to give an emetic; or, if this be not judged proper, the practitioner may try the effect of common acids, or two or three drachms of the solution of the chlorurets in ordinary use. Elliotson.—(See Med. Gazette, 1832-33, p. 659.)— Editor. t Odier's practice of administering the oxyde (subnitrate) of bismuth, when first introduced, was quite popular, and Dr. Moore published a thesis on the subject; but this remedy is now fallen almost into djsuse. The internal administration of char- coal, blended with a small proportion of pulverized myrrh, is recommended by many.—D. X According to Professor A. T. Thomson, the nux vomica, in the form of powder, has been car- ried to the extent of fifty grains a day.—Elements of Materia Medica, vol. i., p. 356. pharmacopoeias, cubebs, as much cheaper, have been ordered instead of the balsams. The diet should consist of articles least dis- posed to ferment; as animal food generally, shellfishes, biscuits; and the drink be, small brandy and water, toast and water, lime-water, or most of the mineral waters. SPECIES V. LIMOSIS FLATUS. FLATULENCY. IMPAIRED APPETITE, WITH AN ACCUMULATION OF WIND IN THE STOMACH OR INTESTINAL CA- NAL J AND FREQUENT REGURGITATION. It is supposed by Mr. Hunter, that air is oc- casionally secreted from the mouths of the se- cernents into certain cavities in which it is found : but, in the 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 fer- mentation. 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 fermentation. 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 stom- ach is overloaded, distended, and sometimes ready to burst with the air, for the most part carbonic acid gas, that is hereby let loose ; re- lief being only obtained by frequent eructation, or lejection upwards; crepitation, or rejection downwards, which the Greeks denominated fiifiSos, as the Latins did crepitus; or its com- bining loosely with such fluids as may exist in the large intestines, where it often rolls about in an ascending or descending direction, accord- ing to the action of the diaphragm and abdomi- nal muscles ; sometimes with a rumbling sound, where the intestinal fluid is but small in quan- tity, and sometimes, where it is considerable, with a gurgling noise, like air rushing into a bottle as the water contained in it is poured out; and hence by the Greeks denominated borborygmus. We have, in consequence, the three following varieties, under which this spe- cies presents itself to us :— a Borborygmus. With frequent rum- Rumbling of the bowels. bling of the bowels. 0 Eructatio. With frequent rejec- Eructation. tion upwards. y Crepitus. With frequent rejec- Dejection of wind. tion downwards. The quantity of air separated in the manner just described is sometimes prodigious, and may amount to an eructation of many hogsheads in an hour. Nor need we be surprised at this ; for, by 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 intro- duced into the stomach possess far more ven- tosity than apples. Flatulence, under one or other of the fo.ms Gen. V—Spe. 5] LIMOSIS FLATUS. 91 now enumerated, is often found as a symptom of other diseases ; especially in dyspepsy, chol- era, colic, hysteria, and hypochondrias. But there is no doubt that it occasionally exists by itself, and is strictly idiopathic, occurring after the deglutition, and even enjoyment, of a full ineal, without any other symptom of indigestion, and ceasing as soon as the process of digestion is completed. [Flatulence produces various feelings of dis- tress, according to the part of the alimentary canal in which the wind is generated, or pent up. When it is copiously generated in the stomach, and is not expelled by eructation, it gives rise to all the distressing consequences always resulting from great distention of that organ. In some , instances, severe pain is ex- cited by the simple extension of its fibres, or their spasmodic contractions. In others, espe- cially in hysterical habits, the adjoining organs are considerably affected by the pressure of the distended stomach ; whence great anxiety and oppression are felt in the chest from the imped- iment to the free motion of the lungs and heart; the respiration becomes laborious and difficult, with a sense of suffocation, and the action of the heart intermits, or violent palpita- tions occur. When the bowels are inflated, a sense of uneasiness is experienced, with a rumbling or gurgling noise. Sometimes colic is an attend- ant on the complaint, and sometimes the whole abdomen is enlarged by the general disten- tion of the intestines with air, accompanied with constipation. When this distention has been of some duration, a degree of paralysis of the muscular fibres of the bowels is pro- duced ; their power of expelling the wind is lost; the skin of the belly becomes as tight as the parchment of a drum ; and the patient falls into a state of great emaciation. This dis- ease is called tympanites.'] A very common cause of flatulence is drink- ing a large quantity of some cold fluid while the system is labouring under great heat. An- other is eating raw vegetables, cucumbers, rad- ishes, salads, &c, or cabbages and other vege- tables not duly boiled. Infants are peculiarly subject to this affec- tion, from the natural delicacy of the stomach, and particularly when brought up without their natural sustenance, and upon food which re- quires 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 watery diarrhoea; or an obsti- nate costiveness ; and sometimes with both in succession. Essential oils, absorbent powders, and aperients, may palliate the symptoms, but the best cure will always be found in a healthy breast of milk. Hypochondriacs, and others of weak digest- ive power, are very apt to acquire a habit of eructing; and are perpetually striving to throw up wind from the stomach in an expectation of relieving themselves from the elastic vapour with which they seem to be bursting. It was observed by Dr. Darwin, that when people vol- untarily eject carbonic acid gas from their stom- ach, the fermentation of the aliment is accele- rated ; just in the same manner as stopping the vessels which contain new wines retards their fermentation, and opening them again quickens it. [This idea, applied to the case of flatulence, may be ingenious ; but probably it will never persuade a single patient to repress his endeavours to relieve himself by eructations. The reality also of the ill effects of the prac- tice is doubtful.] If cardialgy attend, the air is sometimes eructed with a sense of burning so violent as to make the patient imagine he is actually, like a volcano, belching forth flames and fire from his entrails. There are some cases on record, in which persons appear to have a power of distending the stomach and abdomen to an enormous size at pleasure; and advantage has been taken of this by one or two female impostors, who, for particular purposes, have hereby pretended to be pregnant, and have succeeded by such an imposition. But a distention of this kind does not belong to the disease before us. The cure in this species, as in the last, de- pends upon giving tone to the muscular fibres of the stomach and intestinal canal; and hence the plan laid down already, and the course to be described under dyspepsy, will have the greatest chance of success. Emetics have occasionally been recommended with a view of giving a change to the action of the stomach ; but they are of doubtful effi- cacy. They have been of great service, how- ever, incidentally, by discharging some lurking body which has itself been a chief cause of the disease. In this manner, worms have at times been thrown up ; and at times also morsels of indigested fruit or other materials, as plum- stones, or fragments of a pear or apple.— (Ried- lin, Lin. Med., ann. iv. v.) The disease may be palliated by an innumer- able host of carminative plants, which vary in their several effects according to the variety of the idiosyncrasy, or the actual state of the stomach. The verticillate order affords an abundant stock, from which we may select at pleasure ; as marjoram, thyme, rosemary, lav- ender, spearmint, peppermint, and pennyroyal ; the aroma of all which resides chiefly in the leaves or calices. The coniferous order offers, perhaps, nearly as many, including the terebin- thinate and juniper tribes ; but of less activity than the preceding, except in the instance of the essential oil of juniper, the pleasantest of all the turpentine family. The medicinal virtue of both these orders is that of camphire, which they all contain very largely, especially the pep- permint, as shown by the experiments of Gau- bius.—(Adversar.) Trie pungency of this plant, however, is so acrid as to exhaust the sensibil- ity of the nerves of the tongue and palate for a moment, and hence to give a feeling of coldness in succession to that of heat. Its best form ia 92 C02I what is called its essence, which, as conjectured by Dr. Cullen, appears to be nothing more than its rectified essential oil dissolved in spirit of wine. On account of the acritude of this plant, it is less valuable, as well as less palatable, than spearmint; which last acts better, and is more pleasant to the taste, when fresh in infusion than when distilled. The umbellate order affords also a rich va- riety of carminatives, whose virtue, with a few exceptions, resides almost entirely in their seeds. The aroma of several of these is very pleasant, as the coriander, anise, and dill; while, in a few, as in the fennel, it approaches the nauseous smell and taste of the fetid gums. This, however, is an advantage in flatulencies occurring in hysteric or other nervous habits. To these may be added many of the aromata imported from hot climates in very different forms ; as barks, roots, berries, pods, and seeds, particularly ginger, cloves, cardamoms, cinna- mon, pimento, pepper, and capsicum. Like those already noticed, they all owe their virtue to an essential oil, in whatever part of the plant such virtue may reside: but several of them have likewise some other property, which may render them more or less eligible in different cases. Generally speaking, the stimulants we are now contemplating are more strictly entitled to the name of cordials than the umbellate or verticillate plants ; for, by exciting the nervous energy in a greater degree, they increase the action of the heart, and quicken the pulse. And hence, when the circulation is weak and languid, they have an advantage over the pre- ceding ; but when the pulse is already too fre- quent, they should be abstained from. To this general remark, however, there may be one or two exceptions. Newmann and Gau- bius, reasoning from the general use of pepper among the Hindoos and Javanese without any particular marks of excitement, have contended that it produces less effect on the sanguiferous system than many other carminatives ; but this may be resolved into habit. Dr. Lewis, from some less obvious train of argument, came to a like conclusion in respect to ginger ; which to many is as heating as any of the spices what- ever. But it seems generally conceded, that nutmeg is entitled to the character of a seda- tive and even of an hypnotic ; and hence, where flatulence is accompanied with great irritability, it becomes peculiarly valuable. Bontius speaks of this influence as a matter of frequent occur- rence in the East Indies, and one which had often fallen under his own observation ; and in the German Ephemerides (Dec. ii., Ann. ii., Obs. 120) we have an account of some extra- ordinary effects on the nervous system, occa- sioned by swallowing a large quantity of this spice. To which I may add the following con- firmatory evidence of Dr. Cullen, derived from his own practice. "A person by mistake," says he, " took two drachms or a little more, of powdered nutmeg. He felt it warm in his stomach, without any uneasiness; but in about an hour after he had taken it, he was seized with a drowsiness, which gradually increased to fACA. [Cl I—Or». I. a complete stupor and insensibility; and not long after he was found fallen from his chair, lying On the floor of his chamber, in the state mentioned. Being laid abed, he fell asleep; but waking a little from time to time, he was quite delirious; and he thus continued alter- nately sleeping and delirious for several hours. By degrees, however, both these symptoms di- minished ; so that, in about six hours from the time of taking the nutmeg, he was pretty well re- covered from both : although he still complained of headache and some drowsiness, he slept naturally and quietly through the following night, and next day was quite in his ordinary health." * Many of the foregoing remedies have often been combined with the oxyde or nitrate of bis- muth ; and as they have commonly been more successful with such adjuncts than when given alone, these preparations of bismuth itself may be regarded as a useful carminative. They are especially serviceable when the flatulence is chronic, and accompanied with distressing pain. Before quitting this subject, I will just notice two other remedies for flatulence, because they not only afford benefit at the time, but, by their tonic virtue, have some tendency to correct the disorder radically. The first of these is the tincture of aspala- tkus canariensis, the rosewood, or Rhodium lig- num of the old writers. This shrub readily yields its fragrant essential oil to rectified spirit; and the tincture is commonly made by mace- rating four ounces of the wood in a pint of the spirit. It proves a warm, balsamic, and pleas- ant cordial, in doses of from twenty or thirty drops to a drachm. The second remedy I have alluded to is the etherial oil, as it is now called, or the oleum vini, as it was called formerly, which is found in the residuum of sulphuric ether, and is easily made to float on the surface by the addition of water. It has a strong, penetrant, and aromatic odour, and readily dissolves in alcohol and ether. It is powerfully sedative as well as cor- dial, and is sufficiently known to be the basis of Hoffman's celebrated anodyne liquor. In the Pharmacopoeia of the London College, this anodyne is imitated in the compound spirit of ether, the only preparation in which the ethe- rial oil is an ingredient. For the purpose I am now speaking of, however, it should be dis- solved, and in double the quantity contained in the preceding preparation, in the aromatic spirit of ether. [Flatulence admits of being relieved by the generality of stimulant and antispasmodic medicines, such as assafoetida, the strong smel- ling gums, ammonia, opium, ether, &c. To- gether with internal remedies, Dr. Darwin ap- Elied fomentations to the epigastric region, and >r. Whytt, stimulating liniments.] * Hence, Dr. Cullen cautions us against giving this aromatic in apoplectic or paraly tic cases. The use of the nutmeg, as a medicinal agent, dates from the time of Avicenna. " The volatile oil ia sometimes ordered in the form of an oleo-saccha- rum in flatulent states of the stomach and intes- tines," &c—See Dr. A. T. Thomson's Element* of Materia Medica, &.C., vol. i.,p. 226. Gen. V.—Spe. 6.] LIMOSIS EMESIS. 93 SPECIES VI. LIMOSIS EMESIS. SICKNESS OF THE STOMACH. REJECTION OF THE CONTENTS OF THE STOMACH, OR TENDENCY TO REJECT. A disposition to regurgitate, or even the act of regurgitation itself, is not necessarily- a mor- bid affection ; and to render it such, it must be combined with the symptoms forming the ge- neric character, which, though not specifically repeated, are always supposed to constitute a primary part of the description ; and which, in the present genus, is an " impaired, excessive, or depraved appetite." Thus a regurgitation of food is natural to all grazing quadrupeds pos- sessing complicated or numerous stomachs, as the sheep and ox ; and it constitutes what is called rumination, or chewing the cud ; the in- verted action taking place at the will of the animal", and the food being thrown back from the first stomach, or paunch, into the mouth, for the purpose of further mastication. There are instances of rumination, or a simple volun- tary regurgitation of the food into the mouth, among mankind. The German writers upon this subject are numerous, and their collections of cases abundant. But one of the best ex- amples on record is that given by Dr. Slare. —(Phil. Trans., vol. xvii., 1690-3.) The subject was an adult man, in good general health ; the rumination regularly took place about a quarter of an hour after eating, at which time the food felt heavy in the lower end of the oesophagus. If he did not ruminate at the proper time, he soon became languid and sick. It is a question that has raised much contro- versy, which are the parts chiefly concerned in exciting the stomach to vomit? Haller, and the physiologists of his time, were wont to re- fer us to the stomach itself. It was the opinion of Mr. John Hunter, that this action is per- formed alone by the muscles surrounding the stomach, and that the stomach itself is at the time as passive as the lungs in expiration.* For the determination of this point, M. Ma- gendie lately instituted a series of highly curious * It has been already explained in the Physio- logical Proem, that, in vomiting, the pharynx is elevated and the glottis shut; and that, as soon as the contents of the stomach have been expelled, the pharynx again falls, the glottis opens, and a full inspiration takes place.—See Professor A. T. Thomson's Elem. of Materia Medica, vol. ii., p. 187. This work contains many judicious reflec- tions on the views given of this subject by Magen- die, Sir C. Bell, Dr. Marshal Hall, and others. The closure of the larynx, and the retention of air in the lungs, according to Dr. Marshal Hall and Dr. A. T. Thomson, prevent the ascent of the dia- phragm into the chest; and the pharynx being drawn up, as in the act of deglutition, opens the cardiac orifice of the stomach, and forms with this viscus one continuous cavity. This fact explains the remark of Magendie, that, " during the state of nausea, which preceded vomiting in some of his experiments, airwas drawn into the stomach." Dr. Thomson's explanation differs from Dr. Hall's, chiefly in representing the diaphragm as fixed, and not floating and loose.—Ed. experiments, of which a brief account has been given in the Physiological Proem. From these it would appear, that, in nausea, the action is confined to the organ of the stomach alone, or perhaps in conjunction with the oesophagus; that retching is produced by the contraction of the abdominal muscles, and rejection by the contraction of the diaphragm alone, or in con- junction with that of the abdominal muscles; and, consequently, that an emetic does not cause vomiting by irritating the fibres or nerves of the stomach, but, as suspected by Mr. J. Hunter, by means of absorption and irritation of the nerves of the muscles that surround the stomach ; or rather by the stimulus produced on the brain, instead of on the stomach, and especially transmitted to these muscles.* These experiments, however, have since been called in question by M. Portal, as not con- ducted with sufficient strictness, and leading to conclusions too generally and too hastily drawn. He maintains that vomiting commences by a particular action of the stomach, and is then aided and continued by the action of the ab- dominal muscles and of the diaphragm: but that, in many cases, this auxiliary assistance ia by no means necessary ; since, according to his experiments, vomiting may be produced in the stomach when the abdominal parietes have been removed.t And, consistently herewith, Dr. Parr informs us (Diet. Append., p. 101), that the diaphragm " has been wounded, torn, and its apertures enlarged, so as, either by laceration or dilatation, to admit of the passage of the stomach, or a part of the colon, into the thorax, without any uncommon symptoms." [In the example of incessant vomiting, recorded by Gondret (Magendie, Journ. de Physiol. Exper., torn, i., p. 280), where the coats of the stomach were found after death indistinguishably blended together, and converted into a homogeneous scirrhous mass, it may be doubted whether the organ itself had any share in the rejection of its contents. In the enormous dilatations of the stomach which sometimes fill the greater part of the abdomen, without any disease or obstruc- tion of the pylorus, some cases and dissections of which are well described by M. Andral, it is easily conceivable, how a slight pressure pro- duced on the stomach by the abdominal mus- cles, might occasion the frequent vomiting by the partial expulsion of its contents, notwith- * If emetics always acted by their local stimu- lating influence on the coats of the stomach, it might be expected that the time which elapses between the taking of an emetic substance into the stomach and its operation, would be much shorter than it is; and Professor A. T. Thomson is of opinion, " that, in every instance, unless from a mechanical irritant, the emetic substance must be taken into the circulation, before vomiting is induced. We know that when tartar emetic is introduced directly into the circulation,—into a vein, for example—it produces vomiting sooner than if it had been swallowed."—Op. et vol. cit., p. 188. t Mem. de 1'Institut Royal de France, Mai 19, 1817. Memoires sur Ia Nature et le Traitement de plusieurs Maladies, torn. iv. Paris, 1819. 8vo. 94 CffiLIACA, [Cl. I.—Ord. I. standing the paralytic state of its own muscular fibres ; the cause to which this author, with great plausibility, ascribed its prodigious dilata- tion.—(Op. Cit., torn, ii., p. 248.) This, how- ever, was a state of disease ; and by no means amounts to a refutation of the doctrine, that, under ordinary circumstances, the stomach it- self, as well as the muscles of respiration, as- sists in the expulsion of its contents. The same observation applies to the curious mal- formation recorded by Drs. Graves and Stokes (Dublin Hospital Reports, vol. v.), in which, though the stomach was lodged in the thorax completely above the diaphragm, continual vomiting attended the patient's illness. This case, with other facts bearing on the different views entertained of the question, seems to justify the conclusion which the editor arrived at in the Physiological Proem.] Doubtless, a close connexion and sympathy exist between the stomach and its surrounding muscles ; and hence, let the irritation com- mence in whichsoever organ it may, it will be instantly propagated to the other. We have the same proofs of sympathy in the stomach, the ileum, the oesophagus, and the fauces. And we can evidently trace the retrogressive action commencing in different diseases and under different circumstances, sometimes in one of these organs, and sometimes in the other. And we can sometimes, moreover, see this action limited to a particular part; sometimes running through a certain length of the chain, and sometimes through the whole. The idea of swallowing a nauseous dose of medicine, or an irritation of the fauces by a hair, will often excite a retrograde action in the oesophagus alone : a discharge of wind in cardialgy, or of a small portion of acid, or oil, or any other sub- stance floating on the surface of whatever may be contained in the stomach, seems to excite the fibres of the cardia alone, and they are ex- pelled by its simple and unassisted effort, pro- ducing a single act of eructation or belching. The sulphates of zinc and copper, and perhaps all the metallic emetics, act unquestionably upon the fibres of the stomach generally and prima- rily ; and probably all the ipecacuanhas, whether of the psychotria, the callicocca, or the viola genus, are first absorbed, as asserted by M. Ma- gendie, and then produce vomiting by irritating the .fibres of the surrounding muscles. Sea- sickness, and various affections of the head, apparently act in the same manner ; and the contractile and inverted action only takes place after a paroxysm of intolerable sinking and lan- * Experiments on the structure and functions of the nerves.—Phil. Trans., 1822, p. 406. Sir Charles Bell qualifies this theory by observing, " That when the stomach is excited tb vomiting, there is consent of the abdominal muscles, by which they are brought into violent spasmodic ac- tion ; not alternating in their action, as in the mo- tion of respiration, but acting synchronously, so as greatly to assist in compressing the stomach;" but " at the same time, the action of these muscles, however forcible their contraction, cannot alone cause vomiting; nor has this action any tendency to produce sucb an effect on other occasions, in guor. In ileus, the retrogressive movement, commencing in the bowel which gives rise to the name of this disease, runs with great vio- lence through the whole chain of the alimentary canal; insomuch that medicines introduced into the rectum are rejected by the mouth. In few words, then, " vomiting," to adopt the language of Sir C. Bell, " is an action of the respiratory muscles, excited by irritation of the stomach ;"* or, as we should add, of those muscles them- selves. Sickness of the stomach occurs under differ- ent forms : the three following are the chief varieties:— a Nausea. Tendency to reject, but with- Loathing. out regurgitation. P Vomituritio. Ineffectual effort to vomit. Retching. y Vomitus. Act of vomiting, or rejecting Vomiting. from the stomach. Sauvages and Linnaaus regard the first and third of these varieties as-distmct genera of dis- ease, and even arrange them as such. This appears highly incorrect; for, if minutely ex- amined, they will be found, in every case, to be little more than different degrees or modifica- tions of the same affection, produced by a greater or less inversion of the peristaltic motion of the stomach and oesophagus, whatever be the cause of such inversion, and allayed or overcome by the very same means. Where the stimulus, and consequently the degree of inversion, is slight, the effect is confined to nausea; if be- yond this, the nausea becomes retching; and then the retching, becomes vomiting. They may, indeed, exist separately ; for the cause may be of a kind or strength sufficient to throw the stomach at once into a state of violent in- version, and, consequently, to produce vomiting without the common, intermediate changes ; as in the case of various metalline emetics, sym- pathetic irritation from pregnancy, or the swal- lowing putrid vapour : while, on the contrary, minute doses of squills, or ipecacuanha, or any other cause that produces but a slight degree of action, will excite nothing more than nausea, or the first stage alone of the inverted action upon which the general affection depends. It is nevertheless curious, and of great im- portance, to observe the different and opposite effects produced on the animal frame by these two stages of one and the same disease. Nau- sea lowers the pulse, contracts the small ves- sels, occasions cold perspiration, severe rigours, and trembling, and diminishes, as long as it lasts, the action and even the general powers which the utmost contraction of the diaphragm and abdominal muscles is required for the com- pression of the viscera." Vomiting is not, there- fore, simply an action of the respiratory muscles. Dr. Marshal Hall's explanation of the mechanism of vomiting is this:—" The contents of the thorax and abdomen are subjected to the sudden and al- most spasmodic contractions of all the muscles of expiration, the larynx being closed, so that no air can escape from the chest, and the two cavities being made one by the floating or inert condition of the diaphragm."—En. Gen. V.—Spe. 6.] LIMOSIS EMESIS. 95 of life. The act of vomiting, on the contrary, rouses rather than depresses ; puts to flight all the preceding symptoms, and restores the sys- tem to itself.* There are few persons so debil- itated as not to bear vomiting, but many who would sink under nausea. It is obvious, there- fore, that these two different states of the stomach may be employed as powerful instru- ments in attacking a variety of general, and even of remote local diseases ; this organ being justly considered as the common centre of sympathy, and producing opposite results, ac- cording as it is excited to different modes or degrees of action. As nausea diminishes the action of the system generally, and particularly that of the small vessels, it has been often had recourse to with success in inflammation of vari- ous organs, particularly of the eyes and lungs ; as it has also on the approach of the first fit of intermitting fevers, or the accession of those of a continued type, which threaten a considerable degree of violence. Full vomiting, by augment- ing the general action, and consequently giving great additional energy to the absorbent system, has also been very advantageously employed to remove inflammation, though in a different manner ; and particularly inflammation of the suppurative kind. Orchitis and purulent oph- thalmia have often yielded to it as a charm ; and we have various instances, in which the fluid of extensive abscesses has been hereby carried off in a few hours. From the pressive violence of the action, it has also been highly beneficial in many cases of obstruction, or chronic torpi- tude : and hence its occasional utility in amau- rosis and caligo ; and still more so in conges- tions of the liver and other abdominal viscera, t * In vomiting, or the forcible ejectment of the contents of the stomach, the influence of the emetic is carried beyond this organ; for, the se- cretion of the liver being forced into the duodenum, and passing from that into the stomach, in the act of straining, is also ejected. Besides, by the same act, all the abdominal viscera are compressed; and by a repetition of this cause, the blood is propelled more forcibly through these viscera, and the secre- tion of the fluids thereby increased and altered. In particular, the blood is propelled through the vena portarum; and, consequently, the secretion of bile is both augmented in quantity, and altered in quality : the gall-bladder and biliary ducts are emptied ; the pancreas and spleen are also affect- ed ; and the action of the kidneys promoted. The pulmonary system likewise feels the influence on the whole constitution; and the circulation through the lungs is accelerated. But these organs are partly affected by their sympathy with the stomach, and not wholly by the mechanical action of vomit- ing. Vomiting excites the secreting and exhaling vessels of the lungs, and hence emetics hold a place among expectorants. They produce a change in the secreted fluids of the stomach itself, not only bringing about the evacuation of any superabun- dant acid, but so altering the action of the secre- ting vessels, that for a time all trace of acid disap- pears. See Dr. A. T. Thomson's Elem. of Mate- ria Med., vol. ii., p. 194; a work abounding in valuable matter.—Ed. t During the action of vomiting, as Professor A. T. Thomson observes, the blood is propelled, not only more quickly through the arteries, but As different emetics, however, produce not only a different action on the stomach, but also on the system at large or different parts of it, they are by no means to be used indiscrimi- nately, but in reference to the particular object we have in view. This difference of effect de- pends upon the peculiarity of their emetine, as the French writers denominate it, or emetic principle, of wliich we require further instruc- tion than has been obtained at present; though the experiments of MM. Magendie and Pelle- tier have given us some information concern- ing this principle, as it exists in the brown ipecac- uanha (psychotria emetica), the gray (callicocca ipecacuanha), and the white (viola emetica). [When given in doses of from a grain to three grains it produces full vomiting; and, as none of the other principles of ipecacuanha root pro- duce this effect, there is no doubt that its emetic power is owing to the emetine, a principle con- tained in the roots of some other plants, besides those of ipecacuanha.]—(See Thomson's Mat. Med., vol. ii., p. 209.) The ipecacuanhas, however, though posses- sing some diversities of power, concur in opera- ting very generally upon the skin, at the same time that they excite the stomach ; increasing, in a slight degree, the discharge of mucus from the lungs, and adding a little to the peristaltic motion of the bowels. The antimonial emetics, in a full dose, act more violently upon the stomach, bowels, and skin, but less upon the mucous secernents. While in small doses, the nausea they produce is accompanied with the most deadly languor, and with an atony, that, in numerous cases, has been succeeded with more mischief than any degree of benefit that couldhave been proposed by their use. " Many in this manner," says Dr. Perceval, of Dublin, in his manuscript remarks on the volume of Nosology, " have sunk under the nauseating doses of emetic tartar, employed, upon the hypothesis of Dr. Cullen, in low fevers. The heart of a frog is so torpified by this antimonial, as not to be excited by galvanism, which is not the case with opium. The fraction of a grain of tartar emetic, in a gouty habit, subject to melaena and palpitation, produced an alarming deliquium. In the same subject, a similar effect attended the use of other antimonials."* also through the veins. Thus, it is more generally and equally diffused ; and, of course, local deter- minations and congestions are removed. He doubts whether emetics really quicken the action of the absorbents, and is inclined to believe that the impulse communicated by them to the capil- laries, has the effect of lessening deposition, and, as the process of absorption goes on at its ordinary rate, collections of fluids, tumours, and thickenings of membranes disappear after the operation of emetics.—Op. cit., vol. ii., p. 195. This latter theory is different from what is commonly enter- tained.—Ed. * Dr. A. T. Thomson considers ipecacuanha preferable in every instance, in which the powers of the stomach are required to be maintained, and yet vomiting is indicated ; and, in cases of chronic diarrhoea, there can be but one opinion as to the superiority of ipecacuanha over tartar einetie. 06 C03LIACA. [Cl. I—Ord. 1. The squill and seneka* root act very gener- ally ; proving not only emetics, but cathartics and expectorants. The asarum, which was once extensively employed for vomiting both in its root and leaves, at the same time that it in- verts the stomach, acts powerfully on the olfac- tory 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 stimulant to the stomach ; and hence, unless there be other irritants in its cavity, rarely takes effect till the stomach becomes distended, and the nervous fibres of the pylorus are inordinately excited by the quantity swallowed. If, how- ever, we infuse in the hot water a certain por- tion of horseradish, mustard-seed, the root of mezereon, or a handful of chamomile flowers, we increase its stimulant power, and a much smaller quantity is sufficient. And it is proba- ble that all these substances act, in like manner, as simple stimulants alone ; 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 persons, as M. Goss, of Geneva, by swallowing and distending their stomach with air, are at any time able to dis- charge its contents. The sulphates of zinc and copper, and the more powerful preparations of antimony, are probably simple stimulants also, but of a high degree of activity. They act on the stomach almost as soon as they are intro- duced ; 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 intended to remove ; for they prove violently corrosive to the coats of the stomach, and excite haematemesis, or vomiting of blood.t There are some of the alkaline salts that act in the same manner when taken in excess, and throw not only the stomach, but other parts of the system, into violent spasmodic motions. Two ounces of nitre were taken by mistake for one ounce of Epsom salts. An almost 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 quantities of warm water were repeatedly drunk, and alternated with equal quantities of gruel and mucilage of gumarabic, When deleterious effects arise from over-doses of ipecacuanha, or emetina, the best remedy is infu- sion of galls, which, by forming an insoluble pre- cipitate with the emetina, renders it inert.—Op. cit. vol. ii., p. 214, 215.—Ed. * Seneka, or rather senega, root, is highly com- mended as one of the most certain emmenagogues, by Dr. Chapman, Professor of Materia Medica in the University of Pennsylvania.—Ed. t This remark must be taken in a limited sense: the vitriolic emetics, particularly those composed of the sulphate of zinc, may be used in doses of two, three, or even four drachms, without particu- lar injury to the stomach, or to the mucous mem- brane of the intestinal tube. They generally excite great thirst, which must be allayed by the free use of bland mucilaginous drinks.—D. to defend the surface of the stomach by an arti- ficial mucilage. The patient recovered, but was long afterward subject to chronic spasms, resembling chorea.—(Buller, in Edin. Med. and Surg. Journ., No. 53, p. 34.) The ipecacuanhas, and, indeed, most of the preceding emetics, excite vomiting as effectually by being introduced into the bloodvessels, and consequently exciting the abdominal muscles through the medium of the brain, as by being conveyed into the stomach. But there are some articles that will produce this effect on being applied to the surface of the epigastric region, or the hypochondria alone ; as the oil of croton, tobacco, and, what we should far less expect to possess such activity, the leaves of groundsel beat up into a cataplasm. Mr. Sted- man, of Kincross, who, I believe, first published an account of this power in both plants (Edin. Med. Essays, vol. ii., art. 5), availed himself of it as a remedy for agues, and parabysmic tumours of the liver. As the stomach is the common centre of sympathy, it is not to be wondered at that nau- sea, or sickness, should be a symptom common to a variety of diseases, seated in organs more or less remote from itself. And hence we find it occurring in colic, cholera, stone, the acces- sions of fevers, repelled gout, and various affec- tions of the head. The last is, indeed, a very frequent, perhaps the most frequent, of all the sympathetic causes whatever ; for nothing can disturb the regularity of the sensorial function without disturbing the stomach ; and hence sickness is sure to follow oppression of the brain, whether produced inter- nally by hanging, drowning, or apoplexy ; or externally, by a fracture of the cranium accom- panied with depression. A severe jar of the brain, as in the case of concussion, even without extravasation, is certain of exciting the same effect. Nay, any slighter motion to which the head has not been accustomed, as that of mov- ing it rapidly from shoulder to shoulder in a half rotary 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 act of swinging, of riding backward in a coach ; and all the languor and deep regurgitation of sea-sickness. The living frame, however, has a most wonderful in- stinctive power of accommodating itself to cir- cumstances ; and hence, by habit, we are ena- bled to undergo the new motion without any inconvenience to the sensorium, and conse- quently without any sickness of the stomach. And this power of accommodation is so con- siderable, that we have numerous instances of extensive depressions, and even of bullets and other foreign substances lodged in the brain, 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. Jn all these cases, however, the brain must still retain a certain degree of excitability : for, if this be entirely or very nearly lost, neithei the Gen. V—Spe. 6.] LIMOSI! muscles surrounding the stomach, nor even the stomach itself, possess energy enough to pro- duce an inversion of this organ. Hence, in an extreme state of apoplexy, or asphyxia, there is no vomiting whatever, nor is it possible to excite it in the profuse and sudden exhaustion of the nervous power which follows upon swallowing large doses of the atropa belladonna, and various other narcotics ; in combating the effects of which, fourteen grains of tartarized antimony have been administered to no purpose. " Now, if, in such a case," says Dr. Paris, " a copious draught of some vegetable acid be given, the emetic will be more likely to succeed." And, agreeably with the principles just laid down, " here, then," says he, " we perceive that the brain, being paralyzed 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."* In an affection resulting from such an infinite variety of causes, no one remedy or even plan of treatment can apply generally. Sympathetic sickness can only be radically removed by re- moving the idiopathic disease upon which it is dependant, though it may often be mitigated when very distressing, and the primary disorder is likely to be of long standing. The best pal- liatives, in most cases of this kind, will be found in carbonic acid gas; 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 grate- ful carminatives; and small doses of opium, t EMESIS. 97 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 smallest quantity, and of the lightest kind. A little toast and water alone, taken in small sip- pings, 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, cascarilla, or columbo ; or, where a more active stimulant is necessary, that of leopard's bane (arnica mon- tand) may be found useful. The cinchona [ex- cept in the form of the sulphate of quinine dis- solved in the compound infusion of roses] rarely agrees with the stomach. The oxydes of zinc and bismuth are frequently useful. Sea-sick- ness* is only to be cured by habit: yet it has often been rendered less distressing by small stomach. He declares that he has frequently seen vomiting, which has lasted for months, cease on the exhibition of the first dose of this medicine ; though, he admits, that some cases of spasmodic vomiting will not yield until it has been tried for a week. He also expresses his belief, that it will prove unavailing unless the distinction be made between the existence of inflammation, and the influence of distant causes on the one hand, and mere morbid irritability of the stomach itself upon the other. He reminds us, that hydrocyanic acid is an exceedingly powerful medicine, and cannot be given in so large a dose when the stomach is empty, as when it is full. If three drops ean be given three times a day after meals, it certainly will not be right to gi»e more than one or two drops when the stomach is empty. To avoid all confusion, he thinks it best always to give it after meals and to begin with one minim diluted with water,' or an aromatic water. In the course of a day, if no unpleasant effect be produced, the dose may be increased to two minims ; and on the third or fourth day, to three minims ; and so on until the desired effect, or some inconvenience, is felt. Although it will relieve the vomiting arising from mere morbid irritability, it will, if given too freely, produce extreme nausea, excessive vomiting, and perhaps violent pain in the stomach.—See Clinical Lect., Lancet for 1830-1, p. 423. In pregnancy, it is very common for the stomach to become so disordered, that life is rendered miserable, and even endangered, by the constant vomiting, and inability to retain any food whatever in the stom- ach. Hence, in addition to venesection and leeches on the epigastrium, the hydrocyanic acid, strychnine, and conium, are the medicines in which Dr. Elliotson confides.—See Med. Gazette for 1832-3, p. 659.—Ed. * We have derived much benefit in this dis- tressing affection, by due attention to the diet, to the free state of the alimentary canal, and by the use of effervescing mixtures. Lying on the back in the open air has -frequently given us immediate relief. For an excellent paper on this subject, see Dr. Miller's communication in the Med, Repos., vol. iv,, p. 34.—D. * Pharmacologia, p. 152, 5th edit. 1822. t When long-continued or frequent vomiting seems to depend upon morbid irritability of the stomach, the hydrocyanic acid, in doses of two or three minims three times a day, is an excellent medicine. The following case, related by Dr. El- liotson, exhibits the efficacy of this remedy. Eliza New had been ill five months, and had vomited every thing she had taken during fourteen days. She had been in a state of amenorrhea for two •months, and complained of pain across the epigas- trium, and over the whole abdomen. Her tongue showed no feverishness; there was no thirst; no heat in the stomach; no heat in the throat; nei- ther was there tenderness on pressurp on any part of the abdomen; nor was the pulse accelerated. Under these circumstances, Dr. Elliotson inferred that it was not a case of inflammation. The patient took the hydrocyanic acid as above directed, with- out any other medicine, or even being restricted to low diet; her vomiting ceased, and, in a fortnight, she was discharged from the hospital with her health re-established. When there is an affection of the stomach, Dr. Elliotson advises the practi- tioner to consider, in the first place, whether there be inflammation or not; for, if there be inflam- mation, the hydrocyanic acid will not cure it; the case must be treated like inflammation of any other part of the body. But, if no inflammation can be detected, nor any cause for the vomiting in any other parts (as irritation in the intestines, the kidney, the womb, and ten thousand distant causes), then the hydrocyanic acid will relieve the vomiting better than any other medicine. As an anodyne, Dr. Elliotson has not generally found it of the least use, except in cases of pain of the Vol. I.—G 98 CCELIACA. [Cl. I—Ord. i quantities of brandy, the aromatic spirit of am- monia, or laudanum. [Vomiting is frequently only a symptom of disease of the stomach itself. This is the case in chronic inflammation of the organ, in schir- rhus of the pylorus, and in ulceration of the mucous coat. When the latter membrane is either ulcerated or merely weakened by any previous morbid change, the effort of vomiting sometimes occasions a laceration of the other coats of the stomach, and a fatal effusion of its contents in the abdomen is the immediate re- sult.*] SPECIES VII. LIMOSIS DYSPEPSIA. INDIGESTION. THE APPETITE FASTIDIOUS ; THE FOOD DIGESTED WITH DIFFICULTY J HABITUAL COSTIVENESS.t This is by far the most complicated of all the disorders belonging to the present genus. The three preceding species may often be traced by themselves, or in a state of separate existence. Dyspepsy may be regarded as consisting in a combination of their respective symptoms irregu- larly intermixed ; sometimes one set of symp- toms 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 co- prostasis obstipata, dependant on a weakly tem- perament or a sedentary habit, and in which the discharged feces, instead of being conges- tive and voluminous, are hard, slender, and often scybalous. Dyspepsy, therefore, in the language of Dr. Cullen, may be described as " a want of appetite, a squeamishness, sometimes a vomiting, sudden * See J. N. Weekes on mpture of the stomach, in Med. Chir. Trans., vol. xW._Lallemand, art. Rupture, in Diet, des Sciences Medicales. Ex- amples are recorded, in which a fluid, containing urea, and having the sensible properties of urine was vomited. In one interesting case, under Dr! Bright, in the Westminster hospital, the patient, a young woman, had been for three months unable to void her urine without the aid of the catheter. The particulars are mentioned in the Lancet for 1832-3, p. 704.—Ed. t " Lenteur, 'difficulte, etat penible des diges- tions."—(Diet, de M6d. et Chir. Pratiques, vol. vi., p. 387.) . Such is M. Jolly's definition. Dyspepsy occurs in so many different affections, and under such a variety of circumstances, that many excel- lent physicians hesitate to set it down as a distinct and original disease itself. Besides, as digestion is a complex function, in which the action of parts variously organized is concerned, its disorders must be very different in different examples, ac- cording to the tissue affected, whether nerve, mus- cular fibres, or apart or "surface designed for secre- tion. Dr. Abercrombie, in considering dyspepsy, chiefly directs our attention to cases in which the derangement is of a functional nature, or not connected with any change of structure, either of the stomach itself, or of any of the neighbouring parts. The muscular action of the stomach may be deficient, so that the alimentary matters remain in it too long, are imperfectly changed, and un- and transient distentions of the stomach, eruc- tations of various kinds, heartburn, 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 cardialgy, flatus, and emesis, with a few others, enter in irregular modifications into, dyspepsy, as those of dyspepsy enter into hypochondrias. [Among the most constant symptoms of dyspepsy are, a furred tongue, flatulence of the stomach, and fretfulness, or depression of spirits. They may arise primarily from disorder or disease in the stomach itself; or they may depend upon an affection of the brain, liver, bowels, or some other remote or ad- jacent part.—(See Armstrong's Morb. Anat. of Stomach, &c, p. 68.) The necessity of a care- ful discrimination of the original affection by the practitioner is quite manifest.] There is also another complaint, which fre- quently enters into the multiform combination of maladies, of which dyspepsy is the general expression, and which has rarely been noticed by writers, although it is often a very trouble- some symptom, and that is, gravel. In treating of gravel, or lithia, as an idiopathic affection, we shall have to notice, that one of its ehief and most common causes is an excess of acidity in the prima? viae ; and, as such excess is almost constantly to be found in dyspepsy, gravel must frequently attend or follow, and is even a neces- sary effect where there exists what has been called a calculous diathesis. And, for a like reason, where there is a podagric diathesis, gout in some form or other is a frequent concomitant. The grand proximate cause of the three preceding species is debility of the stomach, whence, among other evils, an impaired secretion of gastric fluid. In the present instance, the debility is not often confined to the stomach, but extends to the intestinal canal, and the collati- dergo chymical decomposition. 2. There may be a deficiency of the corresponding and harmonious intestinal action, interfering with the second stage of digestion, and giving rise to imperfect chylifica- tion, and various morbid actions in the upper intes- tines. 3. The various fluids may be deficient in quantity, or morbid in quality. 4. If the mucous coat of the stomach be morbidly irritable, the mus- cular coat will probably be too easily excited to action, and substances will not remain in that or- gan a sufficient timo. for healthy digestion; but after producing much uneasiness, will either be rejected by vomiting, or propelled in a half-digested state into the intestine, where they prove a new source of irritation. If the irritability occur in the intestine, the articles may undergo the proper change in the stomach, but be propelled too rap- idly through the bowels for healthy chylification. —See Abercrombie's Pathol, and Practical Re- searches on Diseases of the Stomach, &c, p. 73, ed. 2. These views will serve to correct and mod' ify certain doctrines, delivered in the present sec- tion of the Study of Medicine. It may be observed, however, that the generality of writers insist on a weak, torpid state of the alimentary canal in dys- pepsy, and doubts are sometimes entertained about the soundness of the theory which refers partic- ular forms of this disorder to morbid irritability of the mucous coat of the stomach and bowels, inde- pendent of chrome inflammation.—Ed. Gen. V.—Spe. 7.] LIMOSIS DYSPEPSIA. 99 tious viscera, as the mesentery, the spleen, the pancreas, and especially the liver, in which it most frequently commences ; and hence another cause of the great complexity of this disease. The debility, and indeed torpitude of the in- testinal canal, is evident from the habitual cos- tiveness which so peculiarly characterizes this affection. Whether this be direct or indirect, intrinsic or sympathetic, 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 feeble- ness of its peristaltic motion, notwithstanding the acrimonious matters .that are so frequently diffused 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 teint; and possibly from the inactivity of the intestines themselves, whose peristaltic motion is con- ceived by Dr. Saunders and other pathologists to be, in a great measure, kept up by the stimu- lus of the biliary secretion. 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 dyspepsy. Of the. actual part taken by either, in the process of digestion, we have already had occasion to observe that we know 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 dyspepsy brought on by a habit of drinking spirituous liquors, the spleen is evidently affected as well as the liver. It is in this state of the disease that we fre- quently meet with that tenderness or other un- easiness in the epigastric region, and that pecu- liar hardness of the pulse, often accompanied by febrile symptoms, which Dr. Wilson Philip has pointed out as pathognomonic of what he calls a second stage of the disease.—(Treatise on Indigestion, &.c, p. 41, 8vo. London, 1824.) It has also been well observed by Dr. Philip (Op. cit., p. 323), that the lungs are, in many in- stances, apt to associate in the morbid action of the digestive organs,when it has become chronic, and to produce, as a result, a peculiar variety (with him species) of consumption, to which he has given the name of dyspeptic phthisis. The dyspeptic character of the disease, however, and especially the hepatic symptoms, together with those of lowness of spirits, flatulence, and other hypochondriacal 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 G2 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 secondary disease seems to afford relief to the primary, and that the organ first affected recovers its health in proportion as that subsequently affected yields to the attack ; in the same manner as, in erysipelas and the migratory forms of herpes, the eruption travels forward, the part relinquished heals, and fresh parts are affected in succession. In all such cases, the secondary complaint becomes a new malady, and must often be followed up under another principle and another mode of treatment. And, not unfrequently, we can very advanta^ geously take a lesson from this peculiar march of nature ; and, by exciting an artificial irrita- tion in some neighbouring and less vital part, can draw off the morbid action into such quarter. It is hy this means that blisters, setons, and other counter-irritants are so frequently found productive of the best advantage. And as a disease of the alimentary canal is thus some- times communicated or transferred 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. —(Trans, of the Medico Chir. Soc. of Edin- burgh, vol. i., 8vo. 1824.) In chronic inflammation of the stomach, and even in that form of it which terminates in ulcer- ation of the organ, and a fatal effusion of its contents in the abdomen,* we also meet with several, and sometimes all the symptoms of dys- pepsy ; 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. Under whatever form, and from whatever cause the disease occurs, there is a considera- ble degree of general languor and debility. Ex- ercise 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 always to be depended upon; for it is sometimes want- ing in the disease, 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 of the adjoining organs, is by no means difficult to conceive^ when w& reflect that they are all concerned, directly or indirectly, in completing the great object of the digestive process, which is that of furnishing a constant supply of nutrition for the system at large. Digestion is commonly supposed to take place in the stomach alone ; but this is an erro- * See Abercrombie on the Pathology of the Stomach, &c. in Edinb. Med. and Surg. Journ., No. 78; also in his Pathological and Practical Re- searches on Diseases of the Stomach, &c, p. 17, ed. 2. Edinb. 1830; Elliotson's case of ruptured stomach, in Med. Chir. Trans., vol. xiii., p.31; alsoj Louis in Archives Gen. de Med., torn. v. 100 GTELIACA. [Ct. I.—Ord. I. neous view, though, the stomach may be re- garded as 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 converted into the mixed principles of oil, gelatine, and sugar, and little else ; for, though we have some traces of .animalization, they are rudiments, and nothing more. Yet this, which is the first, is the most important stage of digestion ; and its perfection depends upon the vital power. Where this is small or enfeebled, the process of chymifieation is necessarily impaired or interrupted : the won- derful 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 tob inconditely. The next stage of the digestive process takes place in the duodenum, which easily admits of distention, and receives the food in the form of chyme from tSe 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 principles and its resin. The latter is discharged with, and gives a col- ouring matter to, the excrements; the former become decomposed, attenuate the chyme, com- municate their azote, and thus complete its ani- malization ; 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 intestines, is attacked, as it proceeds, by the mouths of a considerable number 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 ves- sels which concentrate their mouths on its inner surface. We thus see how largely the digestive pro- cess- 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 completely assimilated, has to be exposed to the action of the atmosphere, 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 connexion which sub- sists between the stomach and the lungs in the common function of providing for the suste- nance of the animal machine ; and to indicate the means by which a morbid action of the former may be communicated to, or lay a foun- dation for impaired action in, the latter; since, to say nothing of the sympathy of. approxima- tion, or of that sympathetic influence which is always found to take place between the ex- treme Units of a chain that runs through any part of the animal machine, it must be obvious that if the chyle, which originates in the stom- ach, and, when in a state of health, communi- cates a peculiar stimulus to the lungs, as it en- ters their substance in combination with the recurrent and exhausted blood, should be con- veyed to them in an unhealthy condition, this peculiar stimulus may be changed in its mode or degree of action, and the lungs, in consequence, become a sufferer ; more especially where they are predisposed to any kind of morbid action. And hence another origin of dyspeptic phthisis, which, like every other modification of the dis- ease, may depend, therefore, upon imbecility of one or more of the digestive organs. The common causes of this imbecility, wheth- er confined to the stomach, or co-extensive with the associate viscera, may be contempla- ted under two heads, local and general; under both which they are still further resolvable into the two opposite extremes of deficient and ex- cessive stimulation ; and, consequently, into a divergence 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 in- dulgence in sedative and diluting substances ; as tea, coffee, and warm-water, or similar liquids taken as a beverage ; or an«qual indulgence in stimulant and acrid materials, as ardent spirits, spices, acids, tobacco, whether smoked or chew- ed, snuffs, a daily habit of distending the stomach by ha«l eating or drinking ; or a rigid abstemi- ousness, and very protracted periods of fasting.* The general remote causes are, an indolent or sedentary life, in which no exercise is afford- ed to the muscular fibres or mental faculties. 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 de- pressing kind, as fear, grief, deep anxiety ; im- moderate libidinous indulgence ; and a life of too great muscular exertion. Perhaps the most common of this latter class of causes are, late hours and the use of spirituous liquors. Dyspepsy is hence presented to us under several varieties, of which the two< following are the chief:— * The following facts are noticed by Professor Elliotson, in proof of the great length of time cer- tain substances will remain in the alimentary ca- nal, and be the cause of various complaints. In the Philadelphia Journ. for 1822, there is an ac- count of a coagulum of milk, which was vomited two months after it had been taken. Dr. Elliot- son has seen a coagulum of milk, like birdlime, which had remained a week in the stomach, pro- ducing the greatest, uneasiness. Dr. Barlow has recorded an instance, in which sulphate of iron ills were discharged, per anum, a year after they ad been taken. Dr. Elliotson has seen a piece of salmon vomited by an infant, a month after it had been swallowed. A boy swallowed thirty grapes. without chewing them, and after three months' frequent vomiting and severe suffering, he was cured by an active purgative medicine ; ten of the grapes came away whole even then.— Lect. at London University, in Med. Gazette for 1832-3, p.. 660.—Ed. Gen. V.—Spe. 7 ] LIMOSIS DYSPEPSIA. 101 a Organica. Originating in the digest- Organic indigestion. ive organs, and princi- pally confined to them. 0 Enervis. Originating in a relaxed Enervative indiges- state of the constitu- tion, tion from causes act- ing generally. For both these, the general principles that should govern us in attempting a cure are the same, though the means of carrying such prin- ciples into effect will admit of diversity. Under what shape soever the disease may present itself, the first thing to be enjoined is a relinquishment of whatever cause has laid a foundation for it; we must next palliate the symptoms that aggravate and continue the dis- ease ; and, lastly, we must restore the debilita- ted 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 malady. The patient must, in the first place, be con- vinced of the necessity of putting himself under a new rule of conduct, and be deeply impressed with the idea that, though he may have contin- ued his late plan of life for a considerable period of time without having sensibly suffered for it, yet, now that he is suffering, nothing but his conforming to another plan will remove his present complaint. Severe and long continued study,* protracted, as I have often known it, through ten hours a day for many months, without any relaxation or interchange of pursuit, must give way to the exercise of walking or riding, and this not occa- sionally, but daily; and to the still better cor- dial of cheerful conversation. The last is of very great importance ; and without it even ex- ercise itself will be of little avail: for the mind, accustomed to a certain track of intellectual la- bour, 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 volun- tary forgetfulness of rare, the novelty of new scenes and new faces, and new family anec- dotes, and the perpetual routine of engage- ments, 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 re- fresh itself. Where the same effect has 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, * " Le cerveau est, sans contredit, l'organedont les affections reagissent avec le plus d'energie sur 1'etat des digestions.—II suffit mSme que le cer- veau, fortment preoccupe, n'apporte plus a l'acte de la digestion le concours de son influence, pour qu'il y ait dyspepsie."—Jolly in Diet, de Med. et Chir. Pratiques, t. vi., p. 387.—Ed. though it may be a change of residence, it is not a change of life ; and hence it is too often made without any benefit whatever. A total re- treat from the world, the unbroken seclusion of a remote hamlet, the sober society of a few in- timate friends, simple meals, and early hours, instead of close and heated rooms, crowded and motley routs, costly feasts, and midnight mad- rigals, 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 unfre- quented shores, where all is rude and simple, and spruce squares and long-drawn parades have not yet put to flight the scattered and ir- regular cottages of former times, these advan- tages may still be obtained. But it is rarely that patients, who are suffering from a life of dissipation, will consent to relinquish the higher attractions of our gayer and more public re- treats, for what they are apt to esteem the dul- ness of an unfrequented coast, till it is of little importance whether they go anywhere, or re- main at their own homes. In like manner, the habitual use of hard eat- ing and drinking must give way to a wholesome plainness of diet; though I am afraid that not a little mischief has often ensued from rigidly compelling the man, who is suffering from a long habit of the former, to abandon this habit at once, and run to an extreme of abstemious- ness. Nothing can be more injurious. Even in full health, the animal frame, though it may be brought to any extreme by degrees, very ill brooks abrupt changes; and I have often seen, where such changes have been attempted in an enfeebled constitution, that they have introduced worse complaints than they hare been intended to remove. The use of tobacco is not, in our own day, employed very often to such excess, whether in smoking or chewing, as to become a very alauming cause of dyspepsy: 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 to- bacco, under either or any form, has produced very severe dyspeptic affections; and, conse- quently, in such cases it ought to be relinquished by degrees. Nor is it 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 man- ner ; and in both, the salivary glands are ex- cited to a great waste of secretion ; which can- not take place without impairing the chymifac- tive process indirectly, as the introduction of the tobacco into the stomach impairs it more imme- diately. The areca, or Malabar nut, though a good bitter, when chewed for a long time, is well known to impair it in the same manner. Even in the form of snuff, tobacco has not un- 102 CCELIACA. [Cl. I—Ord. I. frequently been found to produce the same re- sult ; partly, perhaps, from the paresis of the olfactory nerves, in which the stomach partici- pates by sympathy, and partly from the portion of tobacco that is constantly passing into it from the nostrils. " I have found," says Dr. Cullen {Mat. Med., vol. ii., p. 275), " all the symptoms of dyspepsy produced by snuffing, and particu- larly pains of the stomach occurring every day. The dependanee of these upon the use of snuff became very evident from hence, that, upon an accidental interruption of snuffing for some days, those pains did not occur ; but upon a return to snuffing the pains also recurred ; and this alter- nation 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 afterward, nor, so far as I know, for the rest of life." Dr. Cullen tells us in another place (p. 274), 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 accustomed to take snuff, and t _ that at every time of day ; but who came at length to observe that snuffing a good deal be- fore dinner took away her appetite ; and that even a single pinch taken at any time in the morning, destroyed almost entirely her relish for that meal. When however she abstained entirely from snuff before dinner, her appetite continued as usual ; and after dinner, for the rest of the day, 6he took snuff pretty freely with- out any inconvenience. 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 at- tention to themselves, so as to discriminate be- tween the viands that sit ezusy on the stomach, and those that render it uncomfortable; for nothing in a morbid state is more capricious than this organ, and twenty different cases may perhaps demand 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 dele- terious effects it produces upon some stomachs. Yet while it acts as a narcotic upon many per- sons, 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.* , * Among the causes of indigestion deserve to be enumerated, imperfect mastication from loss of the teeth, or from the habit of swallowing the food too rapidly; sympathy of the stomach with the uterus, brain, kidney, or other organs, and violent emotions of the mind. Then, as Professor Elliot- son justly observes, with reference to dyspepsy de- pendant on the stomach and intestines, there may be either area! debility of them, an inflammatory state, or an organic disease of them : excesses at table'debilitate and destroy the tone of the stomach. Chronic inflammation of this organ is likely to be brought on by constant irritation of it. When or- ganic disease occurs, the cardia, or pylorus, is We must first then prohibit, in our endeavours to effect a cure, whatever we know to be a lo- cal or general cause of the disease. Our next intention should be, to palliate the symptoms that aggravate and continue it. As the stomach is often overloaded with cru- dities and acidity, Dr. Cullen recommends an emetic at the outset. I have rarely found this of use : it often adds to the debility of the stom- ach ; and at most is only of service for a few hours. For so long as the cause 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 quanti- ties ; 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 recommended, is rarely found of service, and very generally adds to the disease : for as the stomach and bowels have been accustomed to the stimulus of food, and a certain degree of impletion, if this be not maintained the atony will be increased, the natural function still fur- ther impaired, and all the symptoms of uneasi- ness 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 flatulence, most of the carminatives noticed under the fifth species of this genus may be conveniently employed ; and for that of acidity, limewater, the acidulous al- kaline waters, the carbonates of soda and pot- ash, and the absorbent earths. Magnesia is a remedy of peculiar value for this last intention. In some cases of great obstinacy, but evidently dependant upon a chronic tendency to an ace- tous fermentation, magnesia, given in the pro- portion of ^n ounce a day, has effected an entire cure ;t and i» all cases it resists the costive- ness as well as iW> acidity, and is far less dis- posed to coacervate m 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 kid- generally the seat of it; but there may be ulcera- tion, or a thickening, or a softening, of the texture of any portion of the stomach.—See Med. Gazette for 1832-3, p. 658.—Ed. * On this point, Dr. Elliotson's advice is judi- cious :—" Suppose that any thing injurious in its quality, or in its quantity, is the cause, the short- est way is to give an emetic, and empty the stom- ach, and it is much best to give one that does not pro- duce nausea, but an evacuation. The sulphate of zinc is as safe as any you can exhibit." In fat, short-necked subjects, he recommends bleeding to be practised before an emetic is given, which is to be followed by the exhibition of calomel, senna, and salts.—Ed. t See Dr. Watson's communication, Medic. Ob- serv., vol. iii. Gen. V.—Spe. 7.] LIMOSIS DYSPEPSIA. 103 neys and bladder that depend upon an acid principle. The eructations that occur in dyspepsy, how- ever, 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 process of putrefaction had commenced. In this case, instead of avoiding 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 powerful; and of these the sulphuric is by far the pleasant- est. It may advantageously be employed as a medicine ; but for acidulated dietdrinks it must yield to the vegetable acids. These are of three kinds, native, distilled, and such as are obtained by fermentation. The first are commonly the most grateful, and especially when they exist in the form of fruits ; but they are apt in weak stomachs to set free a large -quantity of air, and consequently to produce a very troublesome flatulence, and even promote the acescent dispo- sition 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 process. The last are called vinegars, whether obtained from malt, weak wines, or sugar ; and being of themselves, when properly refined, very pure and dilute, they are capable, with a little care, of being rendered highly grateful. Costiveness is a symptom of dyspepsy still more common than acidity, and one that re- quires a very vigilant attention. In our attempts to remove it, we. should always bear in mind that it is a chronic and not a temporary con- comitant ; and, consequently, that violent pur- gatives are of all things to be avoided ; and that such aperients should be preferred which act gently, and rather by soliciting the peristaltic motion of the bowels to the regularity of health, than by irritating them to a laborious excite- ment. Rhubarb is, for this purpose, one of the best articles in the Materia Medica ; for, while by its aperient power it relieves the present dis- tress, we cannot have a much better tonic than its bitter. Where the bowels are merely slug- gish, it will prove sufficient without any other cathartic ; though it is better to combine it with soap and such aromatics as agree with the pa- tient. It is often however incompetent of it- * One thing particularly advised by Dr. Aber- crombie is, to regulate the bowels by the daily use of very small doses of laxatives, combined with tonics, so as, without even purging, to imitate at all times that moderate but regular action, which attends the most healthy state of the bowels. For this purpose, various combinations answer ; such as columbo powder, with carbonate of potass, and a few grains of rhubarb, taken once or twice a day; sulphate of iron with aloes ; sulphate of quinine with aloes or rhubarb, and a few grains of ginger; self; and in such cases derives, in the form of an extract, a valuable assistance from half the quantity of the extract of aloes, or the compound extract of colocynth. * Since the publication of M. Daubenton's lit- tle tract in an English dress, very small doses of ipecacuanha, not exceeding a grain or a grain and a half, have been extensively tried, upon the recommendation 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 ad- vantage which is said to have been derived 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 in- testines. I 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 been produced by an external ap- plication of the tartar-emetic ointment, made in the proportion of four scruples of the tartarized antimony to an ounce of spermaceti cerate ; the quantity of a hazelnut being rubbed in every night till the eruption consequent upon this ap- plication appears. In numerous diseases of the digestive organs, 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 connect- ing branches or intersections, in consequence of exciting its extremity. 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 occasion- ally in use long before his time. The quicksilver, or blue pill, will also gener- ally answer a good purpose ; but it is chiefly to be employed where we have reason to appre- hend that the one or both the portals of the stomach, and especially the pylorus, is in a scirrhous state ; or that the dyspepsy is con- nected with a morbid condition of the liver, or some other allied viscus. In this case, much benefit has also been derived from the white oxyde of bismuth, now more generally known as a cosmetic, under the name of pearl-white. For scirrhous affections of the stomach it has been tried successfully by Carminati, of Pavia ; oxyde of bismuth with rhubarb or aloes.—See Ab- ercrombie, op. cit.,p. 79. Dr. Elliotson considers one of the best remedies for this state to be a very minute quantity of croton oil—about l-12th, l-6th, l-4th, or l-3d of a drop, given regularly with rhu- barb and colocynth; and, if it should gripe, a small quantity of aromatic oil should be added. The patient may take a pill of this kind every night, and one copious stool will be produced by it in the morning.—(See Elliotson's Lect. in Med. Gaz. for 1832-3, p. 660.)—Ed. J04 CCEL and apparently with equal advantage in France. (Beaumk, Journ, de Med., torn, lxxiv.; Hcufland, Neue Annalen, band i.) Independently of its discutient power, it has the virtue of allaying irritation in general; and on this last account, Dr. Odier, of Paris, has employed it satisfacto- rily in most of the acute diseases of the alimen- tary canal, especially in pains of the stomach, diarrhoea, and colic, as he has also in hysteria, and even in toothache.—(Journ de Med., torn. lxviii.) The best form of giving it is that of pills, in doses of from four to ten or twelve grains, four or five times a day. In the meanwhile, we must never forget that our primary object is to restore the stomach, or the system at large where the stomach is only secondarily affected, to its proper tone and strength. The general plan, as I have already hinted, must be the same ; for, as the virtues of medi- cines can only be communicated to the system at large through the medium of the stomach ; and as the state of the latter has at all times a powerful influence upon the former ; there can be little doubt that, by improving the digest- ive function, the vigour of the system will be improved generally at the same time, and con- sequently that the energy of the whole of the moving fibres will be increased : while the col- lateral means of cure that are applied exter- nally, as those of air, exercise, and sea-bathing, and which are chiefly designed to operate on the system at large, will convey an equal advantage to the stomach. The principal evils we have to encounter in dyspepsy are, deficient action, and a relaxed state of the fibres. For these, there are three classes of remedies to which we may have re- course ; stimulants, to increase the action; and bitters and astringents, to augment the tone. The first, however, are of a very doubtful ad- vantage : for a lax state of fibres will bear very little increase of action without incurring an equal increase of debility ; and hence stimulants can never be recommended alone, except in cases of emergency, as to remove a severe fit of pain or other inconvenience, and then only for a short period of time ; but they may be combined very advantageously with either as- tringents or bitters, and particularly with those medicines that possess these qualities jointly. Bitters, besides restoring tone where it is wanted, have another and more immediate ad- vantage in the disease before us : for they di- rectly attack that tendency to fermentation in the stomach which is one of the most prominent features of dyspepsy, and which is, indeed, the chief cause of the flatulence and acidity that so generally accompany it. Of this we have no doubt; for the experience of every day brings its testimony; and we employ bitters, as hops and quassia, for this very purpose., in our fer- mentable beverages. Stimulants, astringents, and bitters, are then the three classes ef medicine with which we are to make inroad against the intrenchment of dyspepsy. They may often be conveniently united, and have their forces hereby increased ACA. [Cl. I— Ord. I in a more than double proportion. The stimu- lants, 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. I have observed that dyspepsy is often graft- ed upon an hysterical or hypochondriacal dia- thesis ; and in these cases, we may indulge in stimulants of a much warmer character, as cam- phire itself, asafoetida, the alliacea, the spicy aromatics, and even capsicum. Of the last it may be remarked, that, though the hottest of all the peppers, it has a less tendency to pro- duce complaints of the head than any of the rest. It is one of the best carminatives possi- ble in the case of flatulence from vegetable food, and admirably calculated to remove that stony coldness, which distresses a weakened stomach when attacked by a transfer of gout. In selecting from among the simple bitters, we need not be particularly nice, for their prin- ciple is the same; the quassia perhaps posses- ses it in the highest degree, though some have doubted of this ; then the gentians ; and next to these columbo. Of the gentians the most powerful seems to be the g. purpurea, first im- ported into this country by Dr. Home, from Norway, and then known by the name of cur- suta, from its Norwegian name skarsote. As a simple bitter it is best to unite it with some aromatic. The tincture of gentian of the Lon- don College, which is an improvement upon Stoughton's or the stomachic elixir, by exchang- ing 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 em- ployed 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 disagreeable pungency, and has an aromatic smell. It is hence peculiarly cal- culated for dyspeptic affections, and in most cases will sit easy on the stomach in the form of powder, in doses of fifteen or twenty grains ; and will often give a check to sickness where bile is not present, more than any other medi- cine we can employ. It is singular, that, to the present hour, we are unacquainted with the plant that furnishes this excellent drug. Com- merson believed it to be a species of menisper- mum; and Willdenow a species of bryonia. [Formerly, the root was erroneously supposed to be named from the capital of Ceylon, which was regarded as the place from which it was exported. But according to Dr. A. T. Thom- son, it is now known to be a staple article of export with the Portuguese at Mozambique, whence an entire root was taken to Madras by M. Fortin, in 1805, and a plant raised from it there by Dr. Anderson. From a drawing in the possession of the Linnaean Society, the plant appears to be of the natural order of Menisper- meae ; but the genus cannot be determined, in consequence of the female flowers not having been as yet seen.—(London Dispensatory, 2d Gen. V.—Spe. 7] LIMOSIS DYSPEPSIA. 105 ed., p. 78.)] It seems to have been first noticed by Redi in 1685.—(Experimenta, &c, p. 142.) As a plant uniting the two principles of an essential oil, warm without being unduly stimu- lant, and a powerful bitter, the chamomile is, for the purpose before us, one of the best reme- dies. 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 possi- ble of its volatile aroma may fly off; and the infusion should not be continued for longer than an hour; and perhaps a shorter period may suffice. As we have medicines that unite the two qualities of bitterness, and a stimulant or aro- matic warmth, so we have those also that unite the two qualities of a bitter and an astringent; of which the cinchona furnishes us with a stri- king example : and hence this medicine has been long, and deservedly, one of the most pop- ular 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, not- withstanding the high encomiums that have been paid to it by the Stahlian school, which endeav- oured 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 infu- sion ; and in such cases, either the sulphate of quinine, or, in lieu of this, the cascarilla, may be prescribed. The acids, both mineral and vegetable, are valuable astringents in particular states of the stomach resulting from dyspepsy; but, it is obvious, that, from the tendency of this organ to co-operate in so many cases in the produc- tion of a superabundant acetous fermentation, acids cannot at all times be had recourse to. I have occasionally, indeed, employed the mineral acids, and particularly a mixture of the nitric and muriatic 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 generally ; 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 morbid action. The other mineral astringents which have been employed besides acids are not numerous, and may be limited to the preparations of iron and zinc. As general tonics, these, under dif- ferent forms, have proved very extensively suc- cessful ; but they are less adapted to dyspepsy proceeding from primary imbecility of the stom- ach or its adjuvant organs ; or, I should rather perhaps say, that they are apt to disagree with these organs till they have been restored to some increased degree of tone, beyond what they usually possess when medical aid is sought for. 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 dyspepsy 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 purpose 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 often with the happiest success. And that an acid adequate to this end does in most cases exist in the stomach is sufficiently proved where the rust of iron is em- ployed, by the black colour of the stools, which may be regarded as a test of the proper solution of the iron; as it may be also of the existence of bile in a state of healthy bitterness : for it is by a combination of the iron with the bit- ter principle of the bile that this blackness, which is a natural ink, and obtained by the same means as artificial ink, is produced. Some animals have a power of forming this sort of natural ink at option, as the sepia or cuttle- fish, but whether by a solution of iron, I cannot undertake to say. This, however, is veiy prob- able, if it be used, as it is generally understood to be by the Chinese, as an ingredient in the manufacture of Indian-ink. The cuttlefish, when exposed 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. It is on this principle that the flowers or ox- yde of zinc have, by 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 meas- ure 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 considerable portion of it may be lost, or remain inert. And, on this account, I think it better to have recourse at once to the sulphate of both these metals, whenever it is judged expedient to employ them, than to trust to the chymical changes that may take place with so much precariousness in the stomach. In employing the metallic salts, and, indeed, tonics of every kind, in disabilities of the stom- ach, it is a good rule to begin with small quan- tities, 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 grad- ually remitted, as soon as the object has been obtained. The chronic character of dyspepsy, on the contrary, allows us time ; and as no two stomachs will perhaps bear the same precise dose of a remedy with the same precise effect, on account of the caprice of this organ in a de- ranged state, it is better to feel our way before us, and to reach the proper point by degrees; for if we over-dose the patient at first, we add to the disease instead of opposing it, and re- quire many days, perhaps weeks, to bring him 106 COZL back to the actual state in which we found him. In conjunction with this internal treatment, it is probable, also, that an external application of the voltaic power to the stomach may in- crease its energy. In the hands of Dr. Wilson Philip, it appears to have been of decided ad- vantage. [According to the reports of Dr. A. T.T hom- son, Dr. Granville (On the Hydrocyanic Acid in Pulmonary Consumption, &c, 2d edit., 8vo. 1820 ; also, Farther Observations, &c, 1819), and Dr. Elliotson,* the prussic or hydrocyanic acid is a valuable medicine in dyspepsy, con- nected with morbid irritability of the stomach. Eighty years ago, it seems that nurses were in the habit of relieving the flatulence of infants by putting into the pap a laurel-leaf (Langrish, Phys. Exp. on Brutes), the virtue of which is supposed to have depended upon its containing a minute quantity of the acid under considera- tion. This remedy, however, was distinctly praised by Sprengel (Pharm.), in 1814, for its good effects in complaints of the stomach, dys- pepsy, and hypochondriasis; and even at ear- lier periods, for these and other cases by Hufe- land, Haller, Swediaur, and others. The dose for commencement may be one minim of the diluted acid, thrice a day, gradually increased to three. Strychnine, hyoscyamus, and conium, are other medicines calculated to lessen morbid irritability of the stomach : in the case which attends pregnancy, venesection, leeches to the epigastrium, and either some of these medicines or the prussic acid, may be tried.—(Med. Gazette for 1832-3, p. 659.) One of the most distres- sing symptoms, sometimes attending dyspepsy, is uneasiness in the chest, with occasional fits of palpitation; while, in primary organic dis- eases of the heart, many of the most troublesome symptoms of dyspepsy also occur, particularly flatulence. In such cases, Dr. Macleod (Med. Phys. Journ.) recommends the exhibition of hy- drocyanic or prussic acid, as a means by which the patient's sufferings may be considerably lessened. In one instance of diseased heart, accompanied by dyspeptic complaints, ten drops of diluted prussic acid were prescribed in a five-ounce mixture, of which two table-spoon- fuls were taken at first three times a day, and afterward the whole quantity in the course of twenty-four hours. From Dr. Macleod's ac- count, the medicine rendered the patient's jour- ney to the grave much more bearable than it would otherwise have been.] While, however, a proper course of medicine is pursued, a proper course of diet and regimen must accompany it, or, with the utmost profes- sional skill, we shall make no progress. And hence, to the remarks already made at the out- set, 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 regularity of meals, * Numerous Cases, illustrative of the Efficacy of the Hydrocyanic or Prussic Acid in Affections of the Stomach, &c, 8vo. 1820. ACA. [Cl. I—Ord. I 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 man in full health, engaged in a life of ordinary labour.. Yet there 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 di- gesting 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 period. 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 stom- ach may call for; for, in both these respects, there is a considerable difference. Thus shell- fish 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 cutaneous 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 effectu- ally than any other kind of animal food : an effect we should little predict, considering that they give out, on a chymical analysis, a smaller proportion of ammonia than the flesh of quadru- peds, birds, or even amphibials. The food of young animals is less nutritive than that of old, but it is, in general, digested with less irritation. Many writers have arranged the different ani- mals that furnish food in tables, founded upon their supposed degree of nutriment. But they have drawn them up with considerable varia- tions ; 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 turn to Dr. Darwin's, which is perhaps one of the best, and which they will find in his Zoo- nomia. 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-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 di- gested 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 animalized, than that of animals cooped up and fattened for th* table. Below the hare, we may place the. webfooted birds that are ordinarily brought to market; and below these, the oyster and lobster 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 Gen. V.—Spe. 7] LIMOSIS DYSPEPSIA. 107 of indolence, injure, instead of promoting, the health of a dyspeptic patient. We have already observed, that the saliva forms an important part in the chymistry 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 ac- count that concentrated 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 ferment in the stomach; and hence all kinds of new bread, sweet pre- serves, confectionary, and pastry, must be sedu- lously 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 allowed in mod- eration. Water too is the best beverage ; but where there is great flatulence, a small por- tion 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 treat- ment ; but they are disposed to provoke a false appetite, and hence to weaken the stomach by overloading it t 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 imper- fect and feverish sleep, when the languid idler immediately proceeds to a breakfast of tongue, ham, and eggs, in addition to the ordinary ma- terials of his meal, as though he had been al- ready labouring 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 mischievous oppression. Yet to this morning toil of the stomach succeeds, * Dr. Beaumont (Exp. and Obs. on the Gastric Juice, p. 269) has published a table showing the length of time required to digest certain articles of food. He found that boiled rice, pigs' feet, and tripe, soused and boiled, were chymified in an hour ; raw eggs, when whipped, boiled, and fried, salmon-trout, and barley soup, in one hour and thirty minutes; roasted turkey, goose, and pig, in two hours ; oysters, when raw, in two hours and fifty-five minutes ; when roasted, in three hours fifteen minutes ; beef-steak, roast beef, broiled and boiled mutton, in three hours; fresh bread, and boiled potatoes, in three hours thirty minutes ; po- tatoes when roasted or baked, in two hours thirty minutes ; chickens, ducks roasted or boiled, beef soup, in four hours ; and roasted pork in five hours fifteen minutes.—D. t On the subject of Dietetics, the reader may consult Arbuthnot on the Nature of Aliments, 8vo. Lond. 1731; Fordyce on Digestion, 8vo. Lond. 1791; J. Abernethy on Local Diseases, including Derangements of the Digestive Organs; A. P. W. Philip on Indigestion, 8vo. Lond. 1826 ; J. A. Paris on Diet, Lond. 1827; J. Johnson on Morbid Sensi- bility of the Stomach, Lond. 1827.—Ed. at about two o'clock, the ordinary luncheon in a still more solid shape ; followed in the even- ing 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 begun his quiet sleep; when, roused by a flow of factitious spirits, and primed for gayety and gallantry, the votary of pleasure, as it is called, sallies forth to join his comrades at the allotted place of ren- dezvous, and to pass the midnight in hot and crowded ball-rooms, or in orgies of a still more exhausting nature. Of the whole of this ca- reer, the only rational part of it is the luncheon a little after mid-day : 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 by six or seven o'clock in the morning in the summer, and by seven or eight in the winter; and, after having risen for an hour, he may 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 al- ready. The morning may be devoted to such exercises or recreations as may be most agreea- ble 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 con- clude 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, be- fore breakfast, will considerably add to the means of improvement wherever these advan- tages can be enjoyed, and particularly when the warmth of the season may give them the character of luxuries. [The systems of dietetics offered to the world are innumerable, and marvellously contradictory to each other. Some, looking with an evil eye on the refinements of society, would bring us back to the simplicity of savages, and have us live " according to nature." Though when we ask, with the Prince Rasselas, what it is to live according to nature, we are sure to meet with no more satisfactory answer than what was vouchsafed to that noble inquirer. The truth is, however, that our bodies would be as little bettered as our minds, by going back to the state of savages ; for it is now ascertained that sav- ages are universally short-lived, and subject to sudden and violent diseases. Population in- creases slowly among them, and the healthiest and strongest of them, if compared with the av- erage of well-fed civilized Europeans, will be found inferior both in strength and health. Some theorists, again, would have us live solely on animal food, and assert, that the human vis- cera bear vegetables " only in a grumbling way;" while others would reduce us to the diet of Nebuchadnezzar, and not leave a fleshpOt in our kitchens. The different notions on die- tetics by no means end here. Some sage doc- tors will never allow us to fill our stomachs, and some hold that they should never be altogether empty ; some reduce the whole mystery of nu- 108 CCELIACA. [Cl. I—Ord. I. trition to a skilful exhibition of successive stimu- lants, and others to the exclusion of all that can interfere with the balsamic simplicity of the in- sipid chyle ; some hold all fermented substan- ces pernicious, and others think fermentation the best preparative for digestion. But, as the ju- dicious critic, to whom we are indebted for the above reflections, has observed, how is it possi- ble to say what is absolutely the best diet for human beings, when we consider under what an infinite variety of different habits such beings are found to live in health and vigour, and by how many opposite causes their health and vigour are impaired 1 The same diet that is sanative to one, whose digestion has been weakened by scanty and penurious living, cannot possibly be suitable to another who has suffered from a long course of repletion and excess. The regimen that is most wholesome for youth is not likely to be well fitted for old age ; nor can that which answers for the active and laborious, be proper ■ for the studious and sedentary. Nay, your dry and adust subject plainly requires a different regimen from that of the plump and succulent. A lover should not be dieted as a miser; nor a champion of the fancy like a prime singer at the opera. Every man differs from every other in some of the important attributes of age, habit of body, occupation, temperament, and disposition, to which may be added climate ; so that all rules of diet must plainly require innumerable modi- fications to accommodate them to the condition of those classes of persons, even if it were pos- sible to reduce them to certain classes. Besides all this, there are special and apparently capri- cious varieties of digestive power, which the learned called idiosyncrasy, by which the appli- cation even of those vague and variable rules must be constantly frustrated.—(Edinb. Review, No. 93, p. 38.) All directions which are ra- tional, must be founded on the circumstances of the individual to whom they are offered ; and even then cannot be deemed valid, until they have been confirmed by his particular experi- ence. However, the general instructions given by the author of this work with reference to the diet of dyspeptic persons, may be considered as good and valuable.] Proper temperature and clothing are also sub- jects of some importance ; but, as we shall have occasion to enlarge upon these, more particu- larly when treating of phthisis, I shall only ob- serve 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 sensible perspiration, as this might terminate in a debili- tating chill. And where the languor is so ex- treme as to prevent exercise abroad, that of a swing or rocking-horse may be had recourse to at home; or where these cannot be endured, that of general friction, in any of the multiplied forms now in use, and especially friction of the stomach and belly, may be often employed as an advantageous substitute. Every tender mother is well acquainted with the benefit of such an external stimulant lo her infant; and when ju- diciously applied, it may often be rendered so to an adult in cases of great dyspeptic languor and weakness. [In the valuable paper by Dr. Abercrombie on chronic inflammation and ulceration of the stom- ach are many judicious observations on dys- pepsy. From the facts there related, it appears that the above dangerous affections of the stom- ach may exist with much diversity of symptoms. These may be severe, and indicative of serious disease, or they may be such as, without very great attention, are likely to be considered as merely dyspeptic. In one case of extensive malignant ulceration of the mucous coat of the stomach, which was under the care of Dr. Chambers, no nausea and sickness existed, and all the symptoms, such as tormina, tenesmus, and frequent discharge of small liquid bloody motions, seemed to indicate disease of the bow- els ; yet the latter parts were found after death very little affected.—(Med. Gazette, vol. i., p. 63.) There may be hardness in the region of the stomach, or nothing may be discoverable by the most attentive examination; and it is in fact extremely difficult to propose any rules by which chronic inflammation of this organ can be distinguished in its earlier stages. It may be suspected, when there is either permanent uneasiness in the region of the stomach, or pain recurring with regularity after meals, and incapable of prevention by attention to diet ; when there is tenderness on pressure, especially if the pain and tenderness be always referred to a particular spot of small extent, and distinctly defined; when, along with the symptoms, vom- iting occurs at short periods after meals, and after food of the mildest quality ; and when, without any urgent or defined symptoms, a pa- tient, with affections of the stomach, becomes progressively weakened and emaciated, in a manner which his symptoms, if considered as merely dyspeptic, could not account for. As Dr. Abercrombie confesses, however, none of these symptoms can be depended upon ; most or all of them may exist in connexion with a state of the stomach which is merely dyspeptic ; and, under a more serious form, they may end fatally, with every appearance of extensive dis- ease, and yet no morbid change be discovered in the stomach or neighbouring parts. Yet he rightly urges the remembrance of the important practical truth, that symptoms, which at first sight appear to be merely dyspeptic, often de- pend upon chronic inflammation of the stomach. When there are grounds for this suspicion, he thinks that, though general bleeding is seldom admissible, much benefit may result from topi- cal bleeding, blisters, issues, antimonial oint- ment, food of the mildest kind and in very small quantity, and the avoidance of stimuli and bodily exertion.—(See Edinb. Med. and Surg. Journal, No. 78, p. 12 ; also, Path, and Pract. Res. on Diseases of the Stomach, ed. 2, p. 17.) The foregoing observations derive much con- firmation from the statements of Mr. Annesley. —(Researches into the Causes, &c. of the Prev- alent Diseases of India, vol. i., 1828, 4to.) In Gen. VI.—Spe. 1.] COLICA ILEUS. 109 warm climates, he says inflammation of the mu- cous membrane of the stomach is a very com- mon form of disease ; and it takes place to a greater or less extent in the advanced stages of dyspepsy, the dyspeptic symptoms being truly the effect of gastric inflammation. Some highly interesting observations on this subject were published by Dr. Armstrong (Mor- bid Anatomy of the Bowels, Liver, and Stom- ach, p. 42, &c, Lond. 1828); and, if they be correct, a part of the difference in the symptoms, in different cases, may in some degree be ex- plained by the chronic inflammation being some- times situated in the serous, sometimes in the mucous membrane of the stomach ; a topic which will be further noticed in treating of gas- tritis. There is something forcibly striking in the expression of the countenance and colour of the skin in most organic diseases. Thus, in tubercular disease of the lungs and elsewhere, the cornea becomes more shining, and the con- junctiva more pearly and blanched than natural, with a softness and almost pensiveness of ex- pression ; while the face grows more and more sharp, and the skin acquires a much more deli- cate hue. In scirrhus, the expression is that of more or less solicitude, and the skin commonly has a sallow teint, like that of the pale yellowish willow ; whereas in fungus the skin has neither the delicacy attendant on tubercle, nor the sal- lowness accompanying scirrhus; but it is often of a dull muddled white, almost resembling that of tallow, or putty. Some change about the face and skin will frequently lead the experi- enced eye at once to suspect deep visceral de- rangement. Without being led away by first impressions, however, the pathologist will be careful not to confound the ventricular disturb- ance and sallowish aspect of the sedentary and studious dyspeptic with any organic disease of the stomach; for, though in him the face be " sicklied o'er with the pale cast of thought," yet it is most frequently an indication merely of dis- order which admits of cure, and even if contin- ued, may not at all shorten life.*—(Armstrong, op. cit., p. 68.)] GENUS VI. COLICA. COLIC. BELLYACHE. GRIPING PAIN IN THE BOWELS, CHIEFLY ABOUT THE NAVEL, WITH VOMITING AND COSTIVENESS. There are various diseases to which this definition will apply ; but which nevertheless * The learned author and his able editor, when treating of dyspepsy, might have enlarged with practical utility on the symptomatic form of the dis- ease, which arises mainly from causes distinct from the seat and functions of the digestive appa- ratus. One of the most frequent causes of dys- pepsy occurring in females is a deranged function, or a disordered condition of the uterine system. The close connexion between a disturbed state of the uterine economy and a diseased action of the stomach is indeed well known ; but this frequent source of dyspeptic evd is too often overlooked or disregarded.—D. 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 dis- tinct genus, under the names of gastrodynia, colica, rhachialgia, and ileus. Dr. Cullen, how- ever, judged differently and more correctly. He regarded their distinctions as of subordinate moment, and in their prominent symptoms traced so close a resemblance 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 rea- sons 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. Iliac Passion. 2.-----Rhachialgia. Colic of Poictou, o* Painter's Colic. 3. -----Cibaria. Surfeit. 4.-----Flatulenta. Wind-Colic. 5.-----Constipata. Constipated Colic. 6. -----Constricta. Constrictive Colic. SPECIES I. COLICA ILEUS. ILIAC PASSION. GRIPING PAIN, VOMITING, AND COSTIVENESS, ACCOMPANIED WITH RETRACTION OF THE NA- VEL, AND SPASMS OF THE MUSCLES OF THE BELLY. The name of Ileus (i\eog or n\eos, for it was written both ways) is entitled to veneration, as it has descended to us from the earliest Greek writers, who thus denominated it, either from that introsusception or convolution of the intes- tinal tube which so often accompanies the dis- ease, and which is the direct meaning of the term ; or from the ileum, or small intestine, in which the disease is principally or most usually seated. Sauvages, and nearly all the continental writers, continue the term. Dr. Cullen has exchanged it for spasmodica, as an adjunct to colica ; but from the comment to the Nosological Synopsis just referred to, it will be seen that he has gained nothing hereby, either in regard to precision or elegance. The griping pain or bellyache in this species is very acute, and the vomiting is accompanied with a discharge, not only of bile from the duo- denum, but of stercoraceous matter from the large intestines, or of injections introduced into the rectum; forcing their way through the strong muscular valve of the colon, which we have al- ready noticed as being formed by a natural pro- lapse of the ileum, for the purpose of preventing a regurgitation of the feces into this last intes- tine ; and evidently proving a powerful inver- sion of the peristaltic action through the whole HO C02LIACA. [Cl. I.—Ord. I. or nearly the whole length of the intestinal ca- nal. While the obstinate costiveness which attends at the same time, pretty clearly indicates a spasmodic constriction, though rarely produ- cing a total occlusion, of that part of the canal where the pain is most violent, often, indeed, extending to other parts, and even to the bile- ducts. And in this last case, even where the feces are discharged by the mouth, they are un- tinged with bile, while all the symptoms of jaun- dice supervene.—(Bartholin, Hist. Anat., Cent. v., 62 ; Ephem. Nat. Cur., Dec. i., Ann. iv. v.) The morbid action is, indeed, not unfrequently so violent as to excite inflammation over a con siderable part of the intestine chiefly affected; and consequently to aggravate all the other symptoms. And hence the disease is presented to us un- der the two following varieties :— a Faecosa. The vomiting accompa- Stercoraceous colic, nied with feces or sub- stances injected by the anus. (3 Inflammatoria. Accompanied with symp- Inflammatory colic, toms of inflammation.* The dissection of persons who have died of either of these varieties has shown us, in some cases at least, that one portion of the affected intestine, constringed and lessened in its diam- eter, has fallen into another portion below it, and thus produced what is called an introsus- ception, or involution of its coats. The fact is not difficult to be accounted for ; and it will readily explain the cause of the great torture which is often suffered under the influence of this grievous malady. In every case in which the intestinal tube is weakened, there is a very co- pious extrication of air, producing in many in- stances a palpable distention of the parietes of the abdomen. In ileus, however, there is also, as we have already observed, in conjunction * In a pathological point of view, the disease re- solves itself into three leading modifications, point- ed out by that able physician, Dr. Abercrombie :— 1. Simple ileUs, without any previous disease. 2. Ileus, with previous disease of such a nature, that it acts by deranging the muscular power, without mechanical obstruction. 3. Ileus with mechanical-obstruction.—(See Pathol, and Pract. Researches on Diseases of the Stomach, &c, p. 112, ed. 2.) Colic may be distinguished from en- teritis by the absence of fever, the pain being gen- erally relieved by pressure, the aspect of the coun- tenance, and the quiet soft pulse. However, in an advanced stage, inflammation may supervene. When the symptoms of colic arise from a hernia, the protrusion will generally lead to its detection. Many diseases, being accompanied by sympathetic vomiting, may be mistaken for colic. Renal or biliary calculi may excite such vomiting; but the former case is characterized by pain in the back, and along the groins to the testicle and thigh, and disorder of the urinary functions ; and the latter by a disturbance of the functions of the liver, and pain in the situation of the gall ducts. Besides, in neither of these diseases is there the same ob- stinate constipation as in colic.—See Whiting and Tweedie, in Cyclop, of Practical Medicine, art. Colic.—Ed. with this, a strong inversion of the peristaltic action operating from the rectum to the stom- ach, and forcing back whatever recrement or other materials are co-acervated in any part of the intestines. These, by intermixing with the elastic vapour of the intestinal tube, become very voluminous, and distend it to its utmost range wherever distention can be accomplished. In one or more parts, however, of its entire length, we have also seen that there is a violent spasmodic constriction, through which the dis- tentive force cannot prevail, excepting perhaps by snatches, or during a remission of the spasm. The two powers are hence brought into immedi- ate contact; and while the gut is in consequence rigidly contracted above, it is widened almost to bursting below; and, during the struggle which ensues, a part of the imprisoned contents of the expanded intestine is forced upwards, and the collapsed portion of the superior intes- tine at the same time slides downward at the point of the stricture.* * It is admitted by Dr. Abercrombie, that, in a fatal case of ileus, we generally find one part of the intestine in the state of distention, and another part empty and collapsed, presenting nearly the form of a cord. However, he considers the doc- trine of spasm in this subject entirely gratuitous. The collapsed state of a portion of the bowel, he regards as the natural state of healthy intestine, when empty. On the other hand, he adverts to several facts to prove, that a state of uniform dis- tention, with lividity, may occur as a primary dis- ease of the intestinal canal, without any appear- ance of obstruction, and without any part of it being in a contracted state. In ileus, the collapsed parts, he says, are commonly found in a healthy condi- tion ; the morbid appearances, whether inflamma- tion, lividity, exudation, or gangrene, being al- most entirely confined to the distended parts. Ac- cording to Dr. Abercrombie's views, the causes of ileus are referrible to a primary diminution, or de- struction of the muscular power of a portion of the canal, and impediments to its action; the conse- quence of which is, that a part, at first healthy, becomes impaired. Under the effects of this inter- ruption, primary destruction or diminution of the muscular power of a portion of the intestinal car- nal seems to take place from the poison of lead, and also in enteritis, where the bowel is distended, without any obstruction in the parts below. In- terruption to the action of a portion of the canal, giving rise to distention, and consequent impaired action of the part above, is exemplified in hernia, contraction and adhesion of the intestine, accumu- lations of fecal or undigested matter in thebowels. However, Dr. Abercrombie admits, that, in some cases, there may be an irregular or morbid contrac- tion of a portion of the canal, and that this may sometimes prove the first step in that chain of de- rangement of the harmonious action of the canal, which leads to an attack of ileus. At the same time, he regards the doctrine of spasm as in a great measure conjectural.—(Op. cit., p. 149—151.) However, several good practitioners do not follow Dr. Abercrombie on this subject. Thus, Dr. El- liotson conceives that opium may frequently do good by alleviating the spasm.—(Med. Gazette for 1832-3, p. 551.) The occasional vomiting of fecu- lent matter in colic appears to indicate a reversed order of the peristaltic action of the intestines. Drs. Whiting and Tweedie observe, that although Dr. Abercrombie calls in question the spasm of the Gkr. VI.—Spe. 1.] COLICA In the midst of this spasmodic commotion there is also another extraordinary change which has been sometimes found to take place in the rela- tive positions of different parts of the intestinal tube. For from the urgency of the moving power that works upwards, the natural effect of the gravitating power that works downwards, and the looseness of the convoluted canal itself in many parts, and its tightness from adhesions in others, it has sometimes become twisted into nooses and knots ; in which the portion forming an encircling cord or bridle has been drawn so tight as to produce strangulation, and render gangrene inevitable.* In one instance, indeed, the spasmodic action was so extreme, that the bridle not only produced strangulation and gan- grene, but cut through all the coats of the in- testine on the opposite side to the mesentery, and made an opening of about an inch in length. —(Med. Observ., vol. iv.) Generally speaking, however, there is more danger in the second variety than in the first; the symptoms, if not early opposed, are more rapid in their progress, and gangrene is produced in a shorter period of time. Yet when an ac- tive and well-discriminated course of treatment is pursued, the inflammation is very frequently subdued, and the patient escapes without fur- ther injury. It is a singular fact, that though ileus is no uncommon result both of introsusception and inflammation, it sometimes takes place without either of them, or at least without intestinal pain or other manifest symptoms of inflamma- tion or spasm ; for which we have the authority of Stoll (Ratio Mcdendi. viii., 129), Haller (Comment. Nova. Gotting., viii., 1), and Mor- gagni. t Even where inflammation exists, it is not difficult to distinguish the disease from en- teritis, by the spasmodic contraction of the ab- dominal muscles that accompanies it, the dimi- nution of pain which ensues upon pressing the abdomen,X and the small degree of fever which muscular fibres of the intestines, he cannot be said to have proved this point; he has, however, made it clear, that in many instances where colic has been supposed to arise from spasmodic con- traction of some part of the bowels, it ought to have been referred to another cause.—Cyclop, of Practical Medicine, art. Colic—Ed. * Mem. de l'Acad. Royale, xxiii. par M. de la Peyronie. Also-several cases in Abercrombie's Pathol, and Pract. Researches on Diseases of the Stomach, p. 119—125, 2d edit.—Ed. t De Sedibus, &c. xxxv., 19,21, 23. In one fa- tal case, noticed by Dr. Abercrombie, the only changes found on dissection were, a softened state of a part of the right lobe of the liver, and a great and uniform distention of the small intestine, with- out any appearance of inflammation.—Ed. X Some examples on record do not. correspond to this account; thus, in one case related by Dr. Abercrombie, the pain was increased by pressure at the very commencement of the attack, even be- fore any inflammation can be supposed to have existed; and, after death, merely a superficial blush of vivid redness was noticed, without any appearance of exudation.—See Pathol, and Prac- tical Researches on Diseases of the Stomach, &c, p. 114, ed. 2.—Ed. ILEUS. HI is present, compared with that by which enteri- tis is usually characterized. Both varieties of ileus are apt to run into each other, and the disease assumes the first or the second form from the patient's idiosyncrasy, the peculiar condition of the organs affected at the time of the onset, the temperament of the sea- son, or some other adventitious circumstance. The causes, therefore, for the most part, are alike, and very numerous. The more common are, acrid, cold, or indigestible esculents; cold beverages on a heated stomach ; catching cold in the feet or abdomen ; exposure to wet du- ring the flow of the catamenia ; unalimentary substances swallowed through bravado or by mistake, as knives, metallic money, or pieces of glass, plum, cherry, or other fruit stones ; an excessive flow of bile probably of bad quality ; worms ; drastic purgatives in an over-dose, as scammony, black hellebore, and colocynth ; cal- culous or other balls congested in the intestines and obstructing their passage, as scybala, be- zoards, biliary calculi, and indurated feces ; vio- lent passions, or other emotions of the mind, as extreme rage or terror; introsusception, a di- minished capacity of the intestinal canal from scirrhus or cancerous tumours, from internal hernia,* from an ossification, callosity, stricture, or coalescence of its internal tunic, [or from the difficulty with which the contents of the bowels sometimes pass that portion of the ca- nal which lies near the situation of a previous artificial anus.t] It is also at times a conse- quence of transferred gout or rheumatism. In the treatment of iliac passion, whenever there is inflammation, or a decided tendency towards it, evidenced by shivering or a full pulse, blood should be taken freely, and even repeatedly, from the arm, whether the patient be of a strong, robust, or of a delicate and weakly constitution. It is a practice, indeed, recommended generally by many writers in the commencement of the disease, even where no inflammatory action exists, with a view of relax- ing the spasmodic constriction; but, in these cases, it is not absolutely called for, and, where the habit is weakly, is likely to produce more harm than good.f * On the autopsy of a case of ileus terminating in enteritis, Dr. Francis observed a remarkable deviation from the normal structure ; a portion of intestine extended from the ileum to the umbilicus, forming a diverticulum of the ileum. For the de- tails of this curious case, with a plate, see Am. Med. and Phil. Reg. vol. i., p. 38.—D. t See Abercrombie, op. cit., p. 126.—En. X Ileus sometimes terminates in inflammation : this is one important reason for bleeding, when not forbidden by the patient's age, or the state of his constitution. Besides this obvious fact, Dr. Abercrombie believes there is a modification of the disease, depending upon inflammation limited to the muscular coat; here also blood-letting seems to him an important remedy ; and the fact is fa- miliar to every practical man, that the relief is often so immediate, that there is no time to raise the patient out of bed, or scarcely to tie up the arm, before complete evacuation takes place.— (Abercrombie, op. cit., p. 159.) The best modern 112 CCEI The two next points to be aimed at are, a removal of the griping or spasmodic pain, and a restoration of the intestines, from a state of inverted action, to their proper peristaltic mo- tion ; and hereby a resolution of the costiveness. For the first, humid heat in the form of a warm bath, warm fomentations, and warm and copious clysters, afford a rational chance of suc- cess. The last should be rendered emollient by a solution of oils, and moderately loaded with purgatives, so that both intentions of cure may be carried forward at the same time. In combination with these, opium may also be tried, and various other narcotics ; and espe- cially the extract of hyoscyamus, which in many instances evinces an aperient as well as nar- cotic power. [The introduction of tobacco- smoke, or the infusion of the plant into the Tec- tum, is frequently of service. Dr. Abercrombie regards the tobacco injection as the remedy of most general utility in all forms and stages of ileus : fifteen grains are to be infused for ten minutes in six ounces of boiling water ; and an hour after the injection of this quantity, if no effect has been produced, twenty grains may be infused, and their power tried ; and so on, until slight giddiness and muscular relaxation show that the peculiar action of this narcotic is taking place. If the case should not now yield speed- ily, Dr. Abercrombie recommends the clyster to be repeated every hour, or every two hours. With this means he associates full doses of mild purgatives, such as aloes and hyoscyamus, every hour or two. Also, if the patient be of a full habit, the pulse be rising, and a fixed pain or tenderness be complained of in any part of the abdomen, Dr. Abercrombie has recourse to one or two bleedings.—(Researches on Dis- eases of the Stomach, &c, p. 159, ed. 2.)] If the opium be employed in the form of a tincture, the dose should be from a hundred to a hundred and twenty drops in an injection of four ounces of warm olive-oil. If hyoscyamus be had re- course to, we may safely use either the seeds or the extract ; about four or five grains of the former, and ten of the latter, may be added to each injection. Clysters of a strong decoction of poppy-heads have also frequently been found highly beneficial.* And to these should suc- ceed the application of stimulants to the belly, as ammonia, or blisters. Sir John Pringle speaks highly of the latter, and not without rea- son ; for, if made sufficiently large to be active, they often succeed, not only in quieting the spasm, but in obtaining evacuations, after in- jections, purgatives by the mouth, fomentations, and opiates have been tried without effect. physicians certainly seem to be more in favour of venesection than Dr. Good.—Ed. * Colic may arise from hardened feces in the rectum, and hence another reason, very properly insisted upon by Dr. Elliotson, for the invariable use of a clyster, who prefers one composed of three ounces of oil of turpentine, blended with a pint of gruel or other fluid. Sometimes the re- moval of indurated feces from the bowel with the handle of a spoon becomes necessary.—See Lect. in Med. Gazette, for 1832-3, p. 551—Ed. dACA. [Cl. I— Ord. I. Purgatives for the second intention, and com- bined with antispasmodics, should, in like man- ner, be attempted by the mouth; though the vomiting is sometimes so incessant that we can get little or nothing to stay on the stomach. But the attempt must be made, and steadily persevered in. Calomel, in free doses of about four grains to a dose, will usually be found the best aperient medicine. It occupies the small- est space, and in the form of a pill, has the fair- est chance of being retained. If repeatedly rejected,* it must be combined with opium, which nevertheless has a tendency to retard its action; but as the opium may mitigate the spasm and diminish the pain, it will commonly be found a useful adjunct, and a grain or two of it may be given every six hours. Calomel, however, though sure, is slow in its operation; and should hence, where the stomach will bear it, be united with some other and brisker ape- rient. Of these the neutral salts seem to an- swer best; but if they cannot be retained, we must exchange them for tartrate of potassa, which is less likely to be thrown back. It is seldom that the drastic purgatives can be rec- ommended ; because, if they do not succeed, they are apt to excite inflammation where it does not exist, and to increase it where it does.t [One modification of ileus yields to a full dose of opium sooner than to any other treatment. Such case seems to Dr. Abercrombie (op. cit. p. 160) to be chiefly characterized by paroxysms of violent tormina, and, if these are accompa- nied by frequency of pulse, and fixed pain or tenderness, he deems a free bleeding, followed by an opiate, a successful practice. At the same time, he expresses a preference to the treatment with tobacco injections, as generally safer than the employment of opiates.] The relief derived from the symptom of vom- iting has led some practitioners to prescribe emetics ; but the benefit hence obtained is very transient. I do not mean to say that they have never been serviceable ; but they cannot be re- lied upon except in special cases, and have oftentimes aggravated the spasm. Dr. Cullen, on the advice of De Haen, rec- ommends a stream of warm water to be thrown forcibly and with a proper syringe into the rec- tum, so that it may play like water from an engine upon the constricted portion of the intes- tine ; and declares that he has-found this rem- edy to be one of the most effectual.^ When * In cases where purgatives have been rejected by vomiting, a small portion of the cuticle may be removed by a blister; after which, the application of one or two drops of croton-oil to the part, will commonly purge.—D. t Dr. Elliotson does not seem to be intimidated by this doctrine; for, after giving scruple doses of calomel, and finding that this medicine remains in the stomach, he prescribes a strong dose of castor or croton-oil, and Epsom salts. In one severe case, he gave with success a drop of croton-oil every hour or half hour, till the desired effect had been produced.—Op. et vol. cit., p. 550.—Ed. X In the Glasgow Medical Journal is a case, in which the inflation of the intestines with common [ air gave relief.—Ed. Gen. VI.—Spe. 2.] C. RHACHIALGIA. 113 the ordinary means, and particularly those of warm injections and the warm bath fail, some practitioners have been crrvrageous enough to try cold applications both external and internal. Sir George Baker tells us, that a physician of credit informed him he had once prescribed the cold bath with success. And Citois affirms, that, in several species of colic, this was his constant practice, even in the midst of winter, and calls upon all his fellow-citizens to attest, that most of his patients thus treated had been restored to health.* Saccassani relates (Epist v. Haller, Bibl. Med, Pr. iii., p. 601) the case of a person instantly cured by drinking a large draught of cold water. Zacutus Lusitanus narrates the history of a patient who speedily got well by being rolled in snow.—(Prax. Adm., lib. ii., obs. 23.) But these are extreme in- stances ; and, notwithstanding an occasional success, the practice is not to be depended on. It will prove most effectual where the colic is accompanied with, or produced by, hysteria. While, on the contrary, where it has been oc- casioned by too violent doses of drastic purga- tives, warm stimulants, as the oil of turpentine, and even brandy (Ctossius, obs. 27), have been taken with great advantage. Dr. Percival, Dr. Warren, and various other writers, upon their authority, advise that the antispasmodic plan, whether by the stomach or the rectum, or both, should take the lead, and the purgative plan follow. This will always be found the proper order in attacking the painter's colic : but we should lose much important time, and often allow the inflammatory symptoms to get fatally ahead, if we were to adopt this as a general rule in iliac passion; in which the symptoms, if not more dangerous, are more urgent, and demand a more rapid march of treatment. [After the explanation given of the numerous and very different circumstances ex- citing or accompanying ileus, it requires but a slight effort of the understanding to know that the treatment ought not to be conducted in any particular way in every example of the dis- order. Hence Dr. Abercrombie points out three varieties of ileus: one case, characterized by obstinate costiveness, distention of the abdomen, and considerable general uneasiness, but without tenderness, or much acute suffering. Another case, where the same symptoms are combined with fixed pain and tenderness, referred to a defined space on some part of the abdomen. A third case with violent attacks of tormina, oc- curring in paroxysms, like the strong impulse downwards from the action of a drastic purga- tive—the action proceeding to a certain point, * F. Citesii Opuscula Medica, p. 215. "When every thing has failed, I have known this affection of the bowels overcome by taking the patient out of bed, and dashing two or three pails of cold wa- ter upon the abdomen."—(Professor Elliotson's Lectures, Med. Gaz., 1832-3, p. 551.) Dr. Aber- crombie has repeatedlv tried the method of raising the patient into a standing posture, and dashing cold water about his legs; but no benefit resulted from it.—{Pathol, and Practical Researches on Diseases of the Stomach, &3., p. 160, ed. 2.)—Ed. Vol. I — H there stopping, and becoming inverted, followed by vomiting, the vomiting often feculent. Dr. Abercrombie thinks that these distinctions seem to denote the propriety of differences of treat- ment, according as the symptoms may indicate a deficient action in the canal, or one in which there is violent action limited to a certain part of it, though ineffectual for overcoming a de- rangement which exists in a lower portion of the tube. The practical application of the dis1- tinction refers chiefly to the use of purgatives in ileus. " There are some cases," says Dr. Abercrombie (op. cit. p. 158), " which yield at first to a powerful purgative; and others, in which an active purgative is. highly and deci- dedly injurious. A large dose of calomel will frequently settle the stomach and move the bowels ; but upon the whole, I think the best practice in general is the repetition, at short in- tervals, of moderate doses of mild medicine, such as aloes combined with hyoscyamus. The peculiar and intricate character of the disease appears very remarkable from the fact, familiar to every practical- man, that there are cases which yield to a full dose of opium, after the most active purgatives have been tried in vain."]* SPECIES II. COLICA RHACHIALGIA. COLIC OF POICTOU. PAINTER'S COLIC. DEVONSHIRE COLIC. the pain at first dull and remitting ; but progressively growing more violent and continued : extending to the back and arms, and at last producing paralysis. From the pains striking through to the back, Astruc first distinguished this species by the name of Rhachialgia (payiaXyia), literally, " back-bone-ache, or spine-ache ;" and as the term is highly expressive, and has been contin- ued by most of the continental writers, it is re- tained as a specific name in the arrangement before us, notwithstanding that it has been drop- ped, or varied, or exchanged for some other, by several writers of our own country, t The pain is most commonly seated, from the beginning to the end of the attack, at the pit of the stomach. It is at first dull, but gradu- ally grows more severe; and, as it increases, extends upwards to the arms, and downwards to the navel, back, loins, rectum, and bladder;. * Dr. Eberle mentions (Practice of Medicine, vol. ii., p. 338) a case of ileus, in which several inches of the intestine sloughed off, and passed away by stool. New adhesions formed, and the patient re- covered. In the same work we find a reference to a case, where, " other remedies failing, the Caesarean operation was performed, the invagin- ated intestine drawn out, and a perfect cure ob- tained."—D. t According to Dr. Monro, the pathognomonic symptoms of painter's colic are, the acute twist- ing pain about the navel, not increased by pres- sure ; the dragging inwards and hard feel of the abdominal parietes; tenesmus; and obstinate cos- tiveness.—Morb. Anat. ofHuman Gullet, die, p. 246.—Ed. H4 COSLIACA. [Cl. I.—Orp. I. and frequently to the thighs and legs. From the navel it sometimes shoots with so much vio- lence to each side, that the patient feels, and so expresses himself, as if some person were cutting him in two. Almost all the external muscles are rendered sore by the great violence of the pain, as though they had been affected with rheumatism, and can scarcely bear the weight of the bedclothes, or the slightest touch of a finger. Sometimes, however, the seat of pain alternates between the stomach, which nevertheless, as just observed, it never entirely quits, and the external muscles : it is violent in the stomach, while the lower bowels and the ex- ternal muscles are at ease ; or it nearly quits its hold on the stomach and lower bowels, and rages through the external muscles. Sickness is an early symptom, as well as costiveness ; and as the pain in the stomach increases, the sickness increases also ; even on the second day from the attack, the retchings are violent, and the discharge thrown up consists of acrid slime and porraceous bile. A momentary relief is hereby usually obtained, and the patient flatters himself that he is about to recover. Too soon, however, does he find himself disappointed : as long as the pain continues, the same morbid matter is secreted, and thrown into the stomach ; and the retchings return with perhaps accumu- lated violence : or, if they do not, their place is supplied with bitter eructations and hiccoughs. The pulse, notwithstanding the severity of the sufferings, is little affected at first, and for sev- eral days continues as quiet as in health. After the fourth or fifth day, however, it sometimes becomes quicker, but not always : and it may admit of a question, whether the acceleration be not even at this period rather the effect of the medicines taken to procure relief, than of the disease itself.—(Dr. Warren, Med. Trans., vol. ii., p. 72.) [The skin, though generally cold and damp, is occasionally rather hot; but there appears to be no tendency to inflamma- tion.] The urine varies so much in different individuals that no stress can be laid upon it. [In some cases, the sphincter muscles of the bladder and anus are so contracted, that the urine and feces cannot be voided, and a clyster- pipe is difficult of introduction.—(Monro, op. cit. p. 246.) Towards the close of the disease, there is generally a pain round the edges of the feet and at the extremities of the toes, which are often red and swollen, and to appearance gouty. Relieving sweats break forth, sometimes accompanied with an efflorescence. About the same time, a griping of a different kind from what has hitherto been endured, and which is more easily bearable, takes place, attended with a disposition to go to stool; and after large dis- charges of various kinds of excrement, fre- quently of scybala or hard lumps, in shape re- sembling sheep's dung, together with black and dirt-coloured slime, occasionally mixed with blood, the patient is perfectly relieved. After several attacks of this disease, a paralysis com- monly affects the fingers, or the whole hand and fore-arm, so that the former become contracted, and the hand, when the arm is extended hori- zontally, hangs at a right angle to the arm, the extensor muscles being in both cases more paralyzed than the flexors. The palsied limb shrinks very much; and the muscles lose not only their natural size, but also their natural structure, being converted into a suety sub- stance (Monro, op. cit, p. 247), or a soft pulp.* Some writers represent the bowels as exhibit- ing after death a remarkable diminution in their diameter; some have met with invaginations ; and others have found the bowels red and more or less injected. All these appearances seem, however, to be accidental, and not to constitute any essential part of the disease; for, in the first place, they may exist without being attend- ed with symptoms of colic; and, in the second, persons die of the latter disease, and yet when their bodies are examined, no morbid appear- ances of the above description can be traced. M. Andral has published the details of several cases, in which no vestiges of disease could be detected in the alimentary canal after death, and similar facts are recorded by M. Louis. Neither could M. Andral find any defect in the brain and spinal marrow; and yet serious de- greesof palsy had taken place.+] In a mild degree, and under the best thera- peutic plan, the disease can seldom be removed in less than five or six days; but if it be violent, neglected, or ill-treated, it will continue for weeks, or even months, with now and then a truce for a few days ; and will terminate in the above peculiar sort of palsy of the upper ex- tremities ; or in death, preceded by deafness, blindness, delirium, or epileptic fits. The remote cause appears in almost every instance to be lead introduced into the system, either by the stomach, the lungs, or the skin ; and hence the disease is found most frequently in those countries, and under those circum- stances, in which this metal is most freely used or most readily dissolved. In the neighbourhood of smelting furnaces, pigs, poultry, and other animals evince the same complaint. Thus, too, * Dehaen gives a remarkable instance of a soft- ening of the muscles in a person who was attack- ed by paralysis of the upper extremities, in conse- quence of colica rhachialgia. The muscles of the limbs, though capable of slight contraction, were converted into a substance as soft as pulp. After the removal of the paralysis, they recovered their usual consistence. Barthez mentions a case in which, under similar circumstances, the two del- toid muscles were softened in the same extraordi- nary degree; but returned to their natural condi- tion after the paralysis had been cured. It is well known to pathologists, that, when the muscles of animal fife have been long in a state of inactivity, they always grow pale, and lose their proper firm- ness.—See Andral, Anat. Pathol., t. i.,p. 220.—Ed. t See Andral, Anat. Pathol., t. ii., p. 210. " If " says this distinguished pathologist, "there be one tact established m medicine, it is, that the lead colic is not an inflammation." He considers it to be a neurosis, in which the spinal marrow and ab- ^3,^eXUM°f 916 great sympathetic nerve are affected. He refers the constipation either to an annihilation of the contractile motion of the in° testines or a suspension of their mucous secre- tion.— (Cluuque Med., t. iv., p. 506.)—Ed. Gen. VI.—Spe. 2.] C. RHACHIALGIA. 115 in Poictou and Devonshire, in which lead was formerly employed to destroy the acidity of the weak wines and ciders for which these provinces are celebrated, it was at one time so common as to obtain the name of Devonshire colic, and colic of Poictou. And hence house-painters, whose occupation leads them to a constant use of lead, and who are often tooJittle attentive to personal cleanliness, are to the present hour so frequently affected by it, as to give it the still more general name of painter's colic. Plumb- ers, potters, glaziers, workers in glass, gilders, chymists, miners, and printers, are, in like man- ner, exposed to its attack, from the large quan- tity of lead contained in the materials they are continually handling. I attended some years ago a printer, who had several times been af- flicted with this disease, but had fortunately re^ covered from every attack, though each return proved severer than the preceding. The cause had never been suspected till I pointed it out to him, by inquiring whether, after leaving the printing-office, he was careful to wash his hands before he sat down to his meals; to which he replied, that he had never been put upon his guard on this subject, and had, therefore, never attended to it. I rigidly enforced upon him the necessity of doing so, and he continued for six or seven years without the slightest return. At this period he again grew careless and confi- dent ; he again suffered, and lost his life.* [The power of lead to excite colic and para- lysis has been long known, these effects having been frequently traced to the accidental or de- signed use of the metal as medicine, or in the food and drink. During the sixteenth and sev- enteenth centuries, when preparations of lead used to be given in large doses medicinally, the colica pictonum and paralysis, in their severest forms, appear to have been very frequent. Nevertheless,, it was not until the investiga- tions of Sir George Baker were published, that the poison of lead was suspected even to be the common, much less the exclusive cause of col- ica pictonum. In countries where the disease was endemic, it was attributed to a free use of the sub-acid wines, or other acidulous liquors, peculiar to the respective districts with which, in fact, it was very obviously connected. In the West Indies, the endemic colic, called the dry bellyache, is observed to be the consequence of drinking freely of newly-distilled rum : and this liquor is therefore universally considered as the cause of the disease. Andral remarks, that an assemblage of symptoms, corresponding in every respect to colica pictonum, may arise from sudden and continual changes of temperature, as happens at Madrid ; and also from causes which primarily affect the nervous system. " The origin of some other cases," he says, * The distinguished Franklin, originally a prin- ter, first pointed out this affection (Phil. Works, vol. iii., p. 399) as occasionally occurring among these men of letters. It would be well for this valuable class of operatives to pay due regard to the cautions in the text. Cases of colica rhachi- algia and of partial paralysis can sometimes be traced to no other cause. — D. " baffles investigation. The positive reference of this form of colic in every instance to the action of lead, seems therefore not quite war- ranted."* Lead, under some modification or another, is now considered to be the real cause of this spe- cies of colic. The cider of Devonshire pro- duced the disorder much more frequently and extensively than that of other counties, as of Herefordshire ; and the wines of some districts on the continent excited the disease, when similar wines of other districts did not. Sir George Baker ascertained, that a small quan- tity of lead was employed in several of the mills, in which the apples were bruised for the manufacture of cider, to fasten the iron cranks which connected the stone-work. It is well known, too, that in several countries on the continent, the practice of sweetening the wines with litharge, and other-preparations of lead, was very common, and that, in these districts, the colic was particularly prevalent. Dr. Mose- ley was cautioned by Dr. Menghin, of Inspruck, to avoid all sweet wines whatsoever, but par- ticularly the common tavern wines, upon the road in the Tyrol and in Italy. He never de- viated from this advice but once, at Viterbo, and then he paid dearly for his indiscretion.—- (Treatise on Tropical Diseases, p. 527.) Col- ica pictonum is very prevalent in this metropo- lis and other large towns ; yet Dr. Bateman never saw an instance which was not decidedly traced to the operation of lead. A great pro- portion of house-painters ahd plumbers, he ob- serves, have the disease at some period of their lives ; and, in particular constitutions, a very minute quantity of lead will bring it on. Dr. Fothergill has recorded several cases, in which it took place in persons who painted in water- colours, and were in the habit of pointing the pencil in their mouths. In addition to these facts, it deserves notice that, in many specimens of cider, which were analyzed by Sir G. Baker, a small portion of lead was detected. And in the new rum of the West Indies, which excited the colic throughout several regiments, while others were totally free from it, Dr. Hunter dis- covered by analysis the presence of lead. After a time, the lead appears to be deposited, and then the rum loses its noxious quality.t] The question was next started, and it has been started again in our own times, whether pure water, as well as acid wine, be not capa- ble of dissolving lead in a metallic state ; and, consequently, whether the community be not daily running a great risk of being poisoned by employing this metal in pumps and reservoirs 1 The public mind was for a long time agitated by this discussion, 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 * See Andral, Anat. Pathol., t. ii., p. 210 ; and a Memoir by M. Pascal, in Journ. de Med. Mili- taire. t See Med. Trans., vol. iii.; and Med. Obs. and Inq., vol. v.; and art. Coiica, in Rees's Cyclo- paedia. 116 CC5LIACA. Cl. I.—Ord I. metallic lead.—(Obs. and Exp. on Lead, 1767.) Yet it was a course hardly necessary, since the daily use of lead in 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 insolubility of metallic lead in rain or river- water. Even saturnine lotions applied to the surface of the body have rarely, if ever, been found deleterious, although these also were at one time suspected of being highly mischievous. They may perhaps prove so in a few singular idiosyncrasies, but they do not affect mankind in general. Lead, however, so minutely divided as to im- pregnate the atmosphere with its effluvium, has frequently laid a foundation for the disease. But whether any preparation under the form of eosmetics has proveirihjurious, I cannot under- take to say. The disease has certainly been produced by sleeping in newly-painted rooms, of which a striking instance occurred a few years ago to myself. The patient was a sur- geon of highly distinguished character in this metropolis. When I saw him, at his particular request, he had been ill for a fortnight; and, the cause not having been suspected, his com- plaint was conceived to be obscure and anoma- lous. The symptoms, as they struck me, were evidently those of rhachialgia from lead; and upon pointing out to him my view of the case, I found that, about a month antecedently, he had sent the whole of his family into the coun- try, as his house was about to undergo a thor- ough repair in painting, while he himself re- mained at home, and slept there. The cause was admitted and acted upon, but the disease had gained too much ground, and was immove- able ; his spirits became deeply dejected, and he,fell a sacrifice in about two months from the attack. 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 vapour; and, at the same time, that, in different constitutions, it will show its effects upon different organs or in a different manner. Sir George Baker asserts, that he has known the disease originate from minute corpuscles rhrown off from the clothes which have been worn by plumbers while at work.—(Essay on the Endemial Colic in Devonshire, 1762.) And in corroboration of this remark, Dr. Reynolds observed, when he was physician to St. Thom- as's Hospital, that the colic of all the workers in lead frequently returned, under any manage- ment whatever, while they were allowed to wear the clothes in which they had been accustomed to labour: on which account such clothes were * Vol. ix., p. 233. See also Seguin, Annales de Chimie, lxxxviii., 263. never suffered to lie on the patient's bed. Sen- tin (Memorab., p. 114) was a witness of the same effect from hanging up labourers' wallets, filled with food for the day, in places impreg- nated with the vapours of lead. And the pres- ent author has occasionally met with other in- stances 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 affected by the surrounding atmosphere, as that of lead in a finely attenuated metallic state.—(Med. Trans., vol. iii., p. 420.) . 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 atmo- sphere, or even by the atmosphere itself, we may readily conceive that aerated waters are capa- ble of decomposing it in a slight degree, and of forming 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 recom- mended by M. Prout (Annales de Chimie, torn. lvii., p. 84), or with a slight surplus of the latter, as proposed by M. Vauquelin.—(Id., xxxii., p. 243.) 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 conceive 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 different from those in the preceding spe- cies, excepting that, in an attempt to remove the spasmodic pain, opiates may be allowed to precede the use of purgatives. [Colica rhachi- algia is attended with obstinate costiveness, and, therefore, one would be inclined to have recourse at once to the most aetive purgatives. The best physicians have differed, however, respecting the propriety of beginning with cathartics. Sir George Baker directs purgatives ; Dr. Darwin and Dr. Warren opiates.—(Zoonomia, vol. ii., and Med. Trans., vol. ii.) Dr. Bateman was also satisfied that, whenever colic could be de- cidedly traced to the operation of lead, the most effectual treatment is the administration of a large dose of opium, and repeated at short inter- vals until the pain and spasmodic stricture are relieved, after which the bowels may in general be easily opened, and the cure completed by tonics and cordials.—(Art. Colica, Rees's Cy- * Some late chymical analyses have shown the presence of a minute portion of lead in what is termed pure spring-water, when it has been re- tained for some time in leaden pipes or ves- sels—D. Gr.s. VI.—Spe, 2.] C. RHACHIALGIA. 117 clopadia..) One of the latest and best writers on the subject, Dr. Pemberton, has recommend- ed a union of castor-oil and laudanum. Dr. Cheyne has generally succeeded in relieving colica pictonum by following Sir George Baker's practice ; yet occasionally he has found it neces- sary to give opium, and that too in large doses, particularly when obstinate vomiting occurred. Dr. Pemberton (On Diseases of the Abdominal Viscera) states that in some examples, opium itself will act as a purgative, as he supposes, "by resolving the spasmodic affection of the colon, by which the feces are lecked up between its circular bands." And one critical writer recommends a large dose of opium with the same view, as after its exhibition the difficulty of pro- curing stools, he says, is not great.—(Edin. Med. and Surg- Journ., vol. iii., p. 72.) With Dr. Cheyne, however, a doubt may be entertained, whether the costiveness be owing to spasm.* " From the tormina we know that there is ex- citement in some part of the canal; from the vomiting we infer inverted peristaltic action; but from the obstruction we can infer no more than torpor of a particular part, and, judging from the i symptoms which afterward occur, this torpor would appear to be paralytic." This view of the state of the canal enables us, without the aid of spasm, as Dr. Cheyne conceives, to un- derstand how benefit results from opium. His p'ian is, to administer purgatives in the slighter cases, and opium with purgatives and stimula- ting clysters in the more severe ones.t Fomen- tations to the abdomen, the warm bath, and emol- lient injections containing laudanum, are useful means ; and venesection (See Gregory's Ele- ments of Physic, p. 513, 2d, edit.), if signs of in- flammation of any of the abdominal viscera be present.X In cases produced by the vapour of lead, Orfila says (Toxicologic, torn, i., p. 658), the antiphlogistic treatment should be abandon- ed.] The paralytic effect has been attempted to be subdued by the counteraction of other metals introduced into the system for this' pur- pose : and especially mercury and silver. Both have, indeed, been given from the commence- ment of the attack by many practitioners ; and, * Dr. Cheyne's opinion on this point is corrob- orated by the statement of Professor Andral:—■' *■ The bowels," says he, " have been alleged to be strongly contracted in the lead colic, and their cavity much smaller than in the natural state; but my own observations enable me to declare, that taothing is more incorrect than this assertion"— Anat. Pathol., t. ii., p. 119.—Ed. t Op. cit., vol. iv., p. 314. Dr. Elliotson doesnot particularly object to opium, provided it be briskly followed up by purgatives ; yet he thinks that the latter answer equally well by themselves, without bringing on subsequent costiveness, which opium is likely to do. He begins with a large dose of calomel (one scruple), and then gives half an ounce of castor-oil every two hours, until motions have been procured.—Ed. X In one of the earliest tracts which American medical literature can boast of, Dr. Cadwallader, of Philadelphia, about the year 1740, recommend- ed mild cathartics and opiates for the cure of this disorder, instead of the then popular practice by drastics of quicksilver,—D. as themselves relate, with great success. Dr. Warren and Dr. Biss were in the habit of per- severing in the mercurial process till they ob- tained a salivation ; and assert that they found the dull griping pain give way as soon as this was accomplished. The silver eltiployed in rhachialgia has usually been in the form of its nitrate, or lunar caustic, to the amount of four or five grains in the course of the day. Dr. Rob- erts 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 an antispasmodic: so much so, that a small quantity of opium was on this account added to the nitrate when given in its most frequent doses.—(Med. Trans., vol. v., art. v.) In treating of passive hemorrhage, we shall have occasion to observe, that whatever dele- terious property the acetate of lead 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 unfrequently 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 in- fluence 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 ; and to counteract its con- stringency by a union with calomel. This rational practice, which has been pursued in our own country 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 hem- orrhage, has now for many years been also tried with success in various parts of the continent. 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 Academia 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 Luzu- riaga, who prescribed a grain of opium every three hours ; and it will often be found neces- sary to augment this quantity.—(Las Mcmorias de la Real Academia, &c., Madrid, 1796.) As the sulphate of lead is a compound in- soluble in the stomach, and consequently al- together inert, M. Orfila ingeniously attempted to reduce the acetate and other preparations of this metal to the form of a sulphate, by giving large quantities of sulphate of magnesia ; and he thinks he hereby succeeded in effecting a decomposition in the stomach of two dogs, upon which he made experiments to ascertain this 118 C02LIACA. [Cl.I.-Ord. I. point, and in producing sulphate of lead in their stead. The experiments, however, proved fatal in both instances, though some portion of sul- phate of lead seems to have been formed, and the death of the second dog to have been re- tarded. As the want of complete success may be ascribed to the want of a sufficiency of sul- phuric acid in the re-agent employed, it would be better to try the experiment for the future, by giving the purgative salt in infusion of roses, or any other liquid adequately charged with the acid to answer the purpose ; or by a free ex- hibition of the acid in a diluted state alone. [Alum was at one time a popular remedy for painter's colic, but it has not. maintained its ground ; a fact rather against the efficacy of the sulphate of magnesia, as the merits of both de- pend upon the same chymical principle. Where, however, the colic arises from the presence of recently swallowed acetate of lead in the ali- mentary canal, and not from absorption by the skin, the method suggested by Orfila, with Dr. Good's improvement of it, seems the most prom- ising of any of the plans hitherto recommended for counteracting the poison of lead. In con- firmation of this observation, the editor begs leave to remind the reader of a statement made by Dr. Paris (Pharmacol., vol i., p. 338, 6th edit.), namely, that he has found, in the treat- ment of hcemoptysis, the effects of the acetate of lead quite invalidated by combination with alum, or by being prescribed with acidulated in- fusion of roses, or with small doses of sulphate of magnesia.] The best purgatives, where the costiveness is severe, are those impregnated with the prin- ciple of camphire, as the essential oil of turpen- tine ; and where these fail, the oil of croton in doses of one or two drops in the form of pills. [Dr. Elliotson sometimes has recourse to an injection of three ounces of oil of turpentine blended with fluid.* Two cases (Dublin Hospital Reports, vol. iv., p.- 45) of violent painter's colic soon yielded to the application of tobacco stupes to the abdomen, followed by the exhibition of cathartic pills, with croton-oil, and of a purgative clyster. The in- troduction of tobacco-smoke into the rectum is proper in obstinate cases, taking care not to continue it too long when the pulse and powers of the constitution begin to sink. Sydenham extols this practice in high terms. Injections of an infusion of tobacco are said to have been first recommended in this disease by Lentin.— (Mem. circa Aerem, vita genus, &c. Clausthali- ensium. Gotting. 1779.) When all usual plans prove unavailing, the bowels may sometimes be made to act by dash- ing cokl water on the legs and belly. Colica rhachialgia, besides being attended with perils arising from obstruction of the in- testinal tube, has also another source of danger by the inflammation of the bowels, with which it may become joined. From being a spasmodic * Dr. Flint (New-England Journal) has cured a case of colica rhachialgia of long standing, by the oil of turpentine.—D. complaint, says Dr. Elliotson, or a paralytic one of the intestines (as others declare), it may be- come an enteritis. The symptoms are at first colic ; the pain comes and goes ; and there is no pyrexia ; but, after a time, tenderness of the abdomen, fever, and all the marks of abdominal inflammation show themselves ; and ultimately mortification, ftence the occasional necessity for leeches, and venesection ; but unless the obstruction be removed, antiphlogistic treatment will not avail.] Those who have had this disease are liable for a long time to fresh paroxysms; and the slightest exposure to the same cause will be sure to reproduce it ; yet the appearances in different persons, as well afterward as during the attack, are extremely variable, from differ- ence of idiosyncrasy : a correct idea of which may be best, perhaps, obtained from Dr. War- ren's description of thirty-two domestics of the Duke of Newcastle's family, then residing at Hanover, 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 at- tacked in the common way, except one, whose first assault was an epileptic fit. This patient, as soon as the pain in the bowels which suc- ceeded 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 rest were without fever till the fourth or fifth day, their pulse be- coming quicker as the pain began to abate. In some the mouth was made sore by the acrimony of the matter vomited up. Four fell into a salivation for several hours every day, and said that their pain was abated during the spitting. Many had profuse 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.—(Med. Trans., vol. ii., p. 86.) The most useful means of guarding against a paralytic diathesis, or of removing the para- lytic sequel, where recourse can be had to them, are the Bath waters. And where the circum- stances of the patient will not allow him to have the benefit of these, the spine may be advan- tageously rubbed night and morning with the warm balsams or resins dissolved in spirits ;* * M. Ranque, principal physician of the Hotel Dieu at Orleans, in a memoir on the colic of Poictou (in Archiv. de Med., Paris, 1825), recom- mends counter-irritation on the abdomen, by means of a plaster containing camphire, theriaca, hem- lock, tartarized antimony, &c. He rubs every painful part with a liniment, composed of the aqua- lauro cerasi, ?ij. ; ether sulphuricum, |j.; and extract of belladonna, 3ij. He also administers twenty drops of an ethereal tincture of the leaves of belladonna, and ^ iv. of olive, or sweet almond- oil, as a clyster. The loins are covered with a plaster, two thirds of which are extract of hem- lock, and one third emplastrum plumbi.—Ed. Gen. VI.—Spe 3.] C. CI and the common restorative process of air, ex- ercise, friction, and tonic medicines should at the same time be had recourse to, and perse- vered in for many weeks, or even months, with- out remission. [The continued use of aperients has great effect in preventing a relapse.— (Gregory's Elements, &c, p. 514.) It is obvi- ous that the return of colica pictonum can never be effectually prevented, unless those avocations and beverages are relinquished which exposed the patient to the influence of the poisonous metal by which the disease was excited. A painter should also leave off the clothes in which he has been accustomed to work. With respect to the paralytic affection of the hand and fingers, Dr. Pemberton found it much benefited by keeping these parts extended on a kind of handboard, splint, or battledoor. Blisters have also done good. M. Magendie recommends, for the removal of paralysis, the use of strychnine, which has been successfully tried by Dr. Graves. —(Dub. Hosp. Rep., vol. iv., p. 46.) It may be given in the dose of one tenth of a grain, which may be increased to one eighth, three times a day. In one case, recorded by Dr. Elliotson, he tried this medicine and shocks of electricity ; though he had seen benefit result from strychnine in other instances, the cure which followed in this example, is referred by him entirely to the electricity ; first, because the dose of the medi- cine was only increased to one eighth of a grain, and no catching and tingling of the parts oc- curred, which are well known to be the first effects of this powerful remedy- After the sud- den discontinuance of it, the cure also proceeded as rapidly with the electricity alone as with both means united.* Electricity he regards as one of the best local applications. He advises it to be applied every day, not only to the hand, but the forearm, and thinks he has seen sparks an- swer better than shocks.] SPECIES III. COLICA CIBARIA. SURFEIT. THE PAIN ACCOMPANIED WITH NAUSEA, HEAD- ACHE, AND DIZZINESS BEFORE VOMITING, AND AFTERWARD TERMINATING IN A GRIPING LOOSENESS. I have already had occasion to remark, that the stomach is one of the most capricious organs of the entire system ; and hence we often find persons in an unsuspected state of health com- plaining, 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 is overloaded with plain * See Clinical Lect. in Lancet for 1830-1, p. 333. But, notwithstanding the inference drawn from this particular case in relation to strychnine, Dr. Elliotson makes a more favourable report of the effects of the medicine in other instances of this paralysis, where he tried it. " This is a species of paralysis," savs he, " where I have ex- hibited strychnine with decided advantage."—See Med. Gazette for 1832-3, p. 552. JAR1A. 119 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 husks, stones, or kernels of fruit with the fruit that is eaten, all which the stomach may at the time, or perhaps at all times, be incapable 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 on Nosology. When the stomach of the newborn infant is filled with any other food than its mother's first flow of milk, which is purgative, and removes the viscid meconium with which the alimentary canal is gorged, tormenting pains of a like kind follow : and if much air be extricated, the infant is overpowered with flatulence ; and the present species becomes connected with the ensuing, and exhibits the oppressive distinction of wind- colic. These are the common causes of the species before us, which is characterized 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 symptoms 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 intolerable itching or pricking in the skin, and an efflorescence on the surface, some- times in the form of minute red millet-seed papulae, sometimes in that of weals ; twitching of the tendons, and a peculiar 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 symptoms, in addition to those noticed in the definition, we meet with great anxiety and difficulty of breath- ing, 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 symptoms, however, vary considerably according to the general nature of the constitu- tion. For the most part, they are sufficiently distinct; but in many persons they are stf angely united ; and the lethargy, tenesmus, or coldness of the extremities, may be combined with the cutaneous eruption. And hence esculent colic may be justly contemplated as rami/ying into the three following varieties :— a Crapulosa. The symptoms indicating Common surfeit. an overloaded stomach, and usually ceasing on the evacuation of its contents. 120 CCELIACA. ** [Cl. I.-Ord. I. fi Effiorescens. The symptoms evincing Eruptive surfeit. the action of some nox- ious, deleterious princi- ple ; the skin covered with an efflorescence. y Comatosa. The symptoms evincing Comatose surfeit. great nervous irritation, with a rapid exhaustion of the sensibility. In the first on simple form of the disease, the violence of the symptoms generally works its cure. But if the nausea should exist with- out vomiting, a simple emetic of ipecacuanha should be given to excite the stomach to a more perfect inversion of its action, which should be followed thenext morning by a brisk purgative. In the colic of newborn infants, from viscid meconium, the purgative alone will be sufficient, and the best medicine for this pur- pose is castor-oil. If the congestion should pro- ceed from an enfeebled state of the stomach, and too long a retention of the food in its cav- ity, it will be afterward requisite to put the pa- tient 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 from a morbid irritability of the stomach operating upon a tolerably full meal of the most bland and innocuous viands ; but it more generally proceeds from animal foods of a particular description, or eaten under par- ticular circumstances, as comatose surfeit does from poisonous vegetables intermixed with com- mon food. The animal substances that chiefly operate in the manner above described, pro- ducing a dreadful feeling of suffocation, swelling of the face and eyes, intolerable thirst, a burn- ing 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, vertigo, and vomiting —are shellfishes, 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 ruricola), lobster (c. gammarus), conger-eel (murana major subolivacea of La Cepede), gray- snapper* (coracinus fuscus major), and yellow- billed sprat (clupea Thryssa, Lin.), thebaracuta, the kingfish, and several other species or varie- ties of scomber, as the bottlenose and ambar, the smooth bottlefish (ostracion glabellum), and the rockfish (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 hence are eaten very gener- * The American journals mention manv facts of this kind. Dr. Mease, of Philadelphia (New-York Med. Repos., vol. i., p. 161), has recorded several cases demonstrating the serious consequences arising from the poisonous quality of pheasants, (tetrao cupido, Lih.) Dr. Barton (Trans, of the Am. Phil. Society, vol v.) has stated cases of the poisonous effects of honey; and two cases of a similar character may be seen in Hosack's Medi- cal Essays, vol. ii.—D. ally as nutritious foods, it is a question of great importance, and which is yet open to discussion, what are the circumstances in which they occa- sionally disagree with the stomach, and produce the above symptoms 1 It has been supposed by many pathologists that the mischief is occasioned by some poison- ous 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 depends altogether upon the idiosyncrasy or peculiar state of the constitu- tion, or of the digestive organs of the persons that are thus affected. . [From an interesting paper by Dr. Combe of Leith, on the poisonous effects of muscles, we learn that muscles which had produced such con- sequences, and had been taken from a wooden bar in the wet-dock, had no very positive mark by which they could be distinguished from other muscles gathered elsewhere. His friend Dr. Coldstream was of opinion, however, that their livers were diseased, being darker and larger than natural. This disagrees with the investi- gations of Dr. Ferguson (Edin. Phil. Journ., vol. i.), who arrived at the conclusion that the deleterious effects are not connected with any organic change in the animal; but, as Dr. Combe has remarked, some change may happen in the structure or secretions of the animal, be- yond the sphere of our detection. The animals were quite fresh, and had no peculiar smell nor taste. The most delicate chymical tests gave no indications of cupreous impregnation; nor could a comparative chymical analysis of the poisonous and healthy fish,,undertaken by Dr. Christison, discover any peculiar principle in the former, or any difference in chymical nature be- tween them. The poisonous effects of the mus- cles gathered from the above wooden bar were not confined to the human race, a cat and dog having also been killed by eating them, though other muscles, gathered in the vicinity of the dock, were eaten by such animals with impunity. —(Edin. Med. and Surg. Journ., No. 94, p. 86.) The supposition of a cupreous impregnation of the poisonous fish in the West Indies, has been ably refuted by Dr. Burrows.—(London Med, Repos., vol. iii., p. 443.) The above particu- lars serve also to weaken the notion of putre- faction.] That many of the animals which prove thus noxious have derived their mischievous quality from some poisonous mineral, vegetable, or ani- malcule on which they have fed, seems proba- ble from the well-known fact that many of the most harmless and easily digestible species, if eaten without being disentrailed, grievously dis- order the stomach, and occasion many of the symptoms above noticed ; while even the bara- cuta, which is ordinarily one of the most dele- terious 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 Gen. VI.—Spe. 3.] C. CIBARIA. 121 produced, a strong metallic and especially a cop- pery taste in the offending substance when re- jected into the mouth, and which continues to affect the fauces for a long time afterward,— [though, as is above related, no copper can be detected in poisonous muscles.] M. Orfila has accurately noticed this last symptom in several of the cases he has enumerated ; and especially 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, " suf- fered more than the whites ; they all experi- enced a coppery taste in the mouth, and a sen- sation in the oesophagus, as if it were excori- ated."—(Traite sur les Poisons, &c.; torn, ii., sect. 1006.) It is in vain to urge that what is thus poison- ous to man, must have been at least as noxious to the animals that fed upon it; for poison is 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- crab is well known to feed on the manchineel tree (hippomane mancinella); the loxia or gross- beak of the Bahamas on the fruit of the amyris toxifera, or poison-ash ; partridges on the leaves, and bees on the flowers 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 fortu- nately not very common to our pastures, is fatal to cows, while sheep and horses eat it with impunity, and goals devour it with greediness ; a fact well known nearly two thousand years ago to the first naturalist of ancient Rome, and thus fully described in his poem, De Rerum Natura.—(Lib. v. 897.) —" Videre licet pinguescere saepe cicuta Barbigeras pecudes, homini quae est acre venenum." On the contrary, while horses feed with avidity and thrive to fatness on the agrestis arundpia- cea, or reed bent-grass, Linnaeus, 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. This interesting subject is pursued with great spirit and high advantage to the most important purposes of practical husbandry, in several ar- ticles published in the Swedish Amoenitates Academics ; which give us tables of the best and most agreeable foods for cattle and other domestic animals, deduced from an exercise of that wonderful instinctive power of selection which enables them to discern and to crop those that are a nutritious food for their own species, and to reject the rest. By one of these tables it appears that, of four hundred and ninety-four species of indigenous plants of Sweden, three fourths of them common to our own country, which were offered to horned cattle, two hun- dred 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.—(Vol. ii., art. 25. Pan Suevicus. Resp. N. L. Hcsselgren, 1749.) In another volume of the same inter- esting work, we have a like series of experi- ments on a great diversity of insects and worms, with a view of ascertaining how many of them are devoured or rejected by our common poul- try (vol. viii., art. 163. Esca avium domestica- rum. Resp. P. Holmberger, 1774); 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 inte- rior of animals, deleterious to the health of man, can be drawn from the position that such esculents must also prove noxious to the ani- mals that feed on them. It is at the same time well known that a con- siderable change takes place in the taste and nutritive qualities of many species of fishes, at various seasons and periods of life, by which they are divested of their nutritive power, and are rendered far less easily digestible; and which consequently lays a foundation for vari- ous affections of the stomach. This is partic- ularly the case with the more luscious or oily kinds ; as the herring, mackerel, eel, and sal- mon, all of which are unwholesome, if not per- nicious, when out of season. We may also reasonably conclude that climate has a consid- erable influence upon them, since the most per- nicious species are those that exist in the inter- tropical seas. It is, however, equally certain, that the dis- order before us is, in many instances, rather de- pendant upon idiosyncrasy, or a peculiar condi- tion of the stomach at the time, than upon any quality essentially noxious in the fish itself; for out of twelve or more persons dining together from the same diet, we often find only a single individual 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 sisters, 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 herrings ; and the third, from feeding on straw- berries. And hence many pathologists have been induced to ascribe every case of; colic, from the variety of surfeit before us, to idiosyn- crasy 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 ascrip- tion of the disease to this single cause. [The symptoms caused by poisonous muscles are care- fully detailed by Dr. Combe. In general an hour or two elapses before any ill consequences are felt ; and then the bad effects consist rather 122 CC5L in uneasy feelings and debility, than in any com- plaint about the stomach. In two or three hours, however, a slight tension of the epigas- trium is complained of, Cardialgy, nausea, and vomiting occasionally take place, but not gener- ally, nor for any considerable time. A prickly feeling in the hands ; heat and constriction of the mouth and fauces ; some difficulty of speak- ing and swallowing; numbness about the mouth, gradually extending to the arms ; and great de- bility of the lower limbs,—are the ordinary symptoms. Some patients have a bad or cop- pery taste in the mouth. In the abdomen a slight pain is experienced, which is increased by pressure, particularly in the region of the bladder, the functions of which are variously disturbed. In some patients the secretion of urine is suspended ; in others it is free, but passed with pain and effort. The action of the heart is feeble ; the breathing unaffected ; the countenance pale and anxious ; the skin cold ; the mental.faculties unimpaired.—(Dr. Combe, in Edin. Med. and Surg. Journ., No. 94, p. 89.)] The principles of cure are of easier compre- hension than the etiology. The peccant matter must first be discharged from the stomach 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 disagrees with the digestive organs may remain in them. The history of the symptoms shows us that the living power is rapidly, prodigiously, and sometimes alarmingly exhausted ; whence indeed, in many cases, the tremors, sense of suf- focation, 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. It is hence highly important to rouse the system with all speed, by means of the most diffusible stimulants, and warmest cordials and tonics, which may be commenced as soon as the stomach has been evacuated; the most useful of which are sulphuric ether, nitrous ether, ammonia, capsicum, and vinegar diluted with water, sweetened and drunk in abundance. The acids obtained by fermenta- tion answer better in this case than any others, because they possess more of an alcoholic prin- ciple. And it is truly striking to notice the al- most miraculous power which is sometimes ex- hibited by this cordial plan of attack. Upon the administration of a single strong dose of ether, the patient, apparently in the act of ex- piring, has in various cases felt all his symp- toms vanish in a very few minutes as by en- chantment (Orfila, torn, iv., sect. 1008 ; Dulong, Gazette de Sante, Oct. 1, 1812); the pains have ceased ; the absorbents, and indeed every other set of organs, recovered their wonted energy ; the general intumescence has subsided, and the nettle or other rash disappeared. If, however, the system have been shaken more deeply, and the symptoms do not yield with much readiness, the tonic plan must be persevered in for many days or even weeks. The third variety is usually produced by IACA. [Cl. I.-Ord. I. pernicious vegetables, instead of animals, that have been taken for food, or along with food ; or esculent vegetables that disagree with the stomach, as in the preceding variety, from a morbid state of this organ, or from a peculiarity of constitution. I have already observed that the symptoms in this modification of the disease evince great nervous irritation with a rapid ex- haustion of the sensibility. There is severe spasmodic pain in the intestinal canal, with cramp, spasms, or convulsions, extending over the system more or less generally, accompanied with or succeeded by a lethargic drowsiness, from which it is often difficult to rouse the pa- tient ; 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 deleterious fungi that have been mistaken for the genuine edible 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 mushroom, and the agaricus muscarius. It is possible, indeed, that even the genuine mush- room itself may prove deleterious to some idio- syncrasies, or to some stomachs in a morbid state of constitution ; 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 poisonous and salutary mush- rooms, we may lay it down as a general rule, that those should be suspected and avoided that grow in moist 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 calyp- tre or veU. There are, however, a considerable number of other vegetables that produce a like effect when taken by accident for food, or along with food; as the cicuta virosa, or water-hemlock, the leaves of which have been mistaken for smallage, and the tap-roots for parsnips; the alhusa cynapium, or fool's parsley, which has been culled for common parsley ; and the secale cornutum, or spurred rye. The last is produc- tive of very serious evils in different forms, and we shall hence have occasion to return to it when describing erythematic 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 numer- ous 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 pur- pose. And as the effects produced by the Gf.n. VI.—Spk. 5.] C. CONSTIPATA. 123 grain thus diseased are very different in differ- ent seasons or climates, we have reason to be- lieve, 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 grave- olens), when eaten to excess, is succeeded by the same symptoms of ventricular pains, spas- modic action, and coma, though in a less degree; but I have never seen such consequences, and have reason to think that they have been over- rated. Most of these symptoms are also produced by feeding on soups, or other dishes, that have been cooked in copper vessels containing ver- digris. We have the same violent gripings and muscular commotions, excited by the acid qual- ity of the plant just noticed, and in almost all instances headache and confusion of intellect, and sometimes coma. In all these cases, how- ever, we can easily detect the nature of the poison, by the intolerable coppery taste of 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 IMPEDING RESPIRATION ; ACCOMPANIED WITH GREAT FULNESS AND FLATULENCE ; AND RELIEVED BY PRESSURE, BENDING THE BODY FORWARD, OR EXPULSION OF WIND. This species is produced by crude and flatu- lent fruits, and whatever lowers the tone of the alimentary canal; as too long fasting, fear, or grief, and all the causes of dyspepsy, with which it is often complicated, and to which the reader may turn. Like dyspepsy, indeed, it seems to depend upon local debility, whose seat is in the small intestines, and consequently in the direct neighbourhood of the stomach. It is often ac- companied with great costiveness, from the spas- modic action, which mns in a larger or less de- gree through the whole of 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 in whom it is often combined with syncope or clonic spasms of various kinds. In attending to the means of cure, we may here proceed at once with some degree of bold- ness ; 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 warmest carmina- tives, and even alcohol, may be had recourse to; for whatever will carry off the flatulence, will carry off the pain and costiveness. Hence a spoonful of brandy, or, which is better, a dose of tincture of rhubarb, ammonia, infusions of herbs containing essential oils, as mint, pepper- mint, pennyroyal, are generally consoling 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 volatility than most others, and especially on account of its established reputation for pro- ducing quietism and even sleep, has a peculiar claim to attention. The only disadvantage of opium is, that it has a tendency to diminish the intestinal, and indeed all the secretions, excepting that of sweat: and, on this account, it has been ob- jected to by many physicians ; but, from its power of allaying spasmodic irritation, and con- sequently 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 indi- rectly 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 (Mat. Med., vol. ii., p. 249), may be administered. Opium may also be given in the form of an injection, which should not exceed five or six ounces, for otherwise it will probably be thrown back. It will be often of great use to unite with the narcotic a pretty free dose of turpen- tine, or some of the warmer balsams, especially that of copayva; and to apply rubefacients to the epigastric region. The convalescent treatment may be the same as already recommended under dyspepsy. SPECIES V. COLICA CONSTIPATA. CONSTIPAT1VE COLIC. THE GRIPING PAIN SEVERE ; THE COSTIVENESS OBSTINATE ; GREAT TENSION, WITH LITTLE FLATULENCE : THE VOMITING SOMETIMES AC- COMPANIED WITH FECES ; THE COSTIVENESS WITH BLOODY STRAININGS ; TERMINATING, WHERE NOT FATAL, IN A FREE DEJECTION OF THE INFARCTED MATTER. The pain is here produced by indurated me- conium, or feces, or other intestinal concretions, and especially those which are known by the name of bezoards, and will be hereafter de- scribed under the genus Enterolithus : and we hence obtain the following varieties :— a Meconialis. From viscid meconium. Colic of newborn infants. 124 C(EL 0 Faecosa. From indurated feces. Stercoraceous colic. y Enterolithica. From bezoards, and Stony colic. other intestinal con- cretions. The first two of these varieties are the result of a superabundant action of the intestinal absorb- ents, or of a deficiency in the peristaltic power of the intestinal tube ; in consequence of which, from the length of time the confined materials occupy in completing their descent, the meco- nium in infants becomes so viscid as not to be urged downwards, and remains in the intestines till it grows acrid ; and the feces of later life, ex- hausted of moisture, hardened 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 some- times they make a near approach to this sub- stance, and consist of masses of indurated feces, combined with a certain portion of mucus or oleaginous matter secreted into the intestines, and producing a cetaceous or soapy feel. Of the stony variety, the following is an ex- traordinary example related by Dr. Konig of Berne.— (Phil. Trans., year 1686.) A young woman of twenty-five years of age, by name Margaret Lawer, after an anomalous and gen- eral 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 peas, others of that of fil- berts. A clashing of stones against each other was felt by pressing the hand upon the abdomen: there was great constipation, severe gripings, and dysury ; and the urine, when voided, was often loaded with a gravelly matter. The ali- ment and injections being constantly returned by the mouth, Dr. Konig desisted for four months from offering her either meat, drink, or medicine of any kind, excepting occasionally a spoonful of oil of almonds. Blood was now and then vomited, from the violence of the spas- modic affection of the stomach ; and frequently urine to the amount of three or four ounces at a time, of a strong taste and smell. The dis- ease seems to have lasted, with remissions, from January, 1681, to February, 1683, at which period the history is abruptly dropped, though the pa- tient seems to have been in a state of recovery. It was preceded by the appearance of vesicular eruptions on the skin. The chymical examina- tion of the calculi is loose and unsatisfactory. The oleaginous purgatives, soap injections, and mucilaginous diluents, to diminish the ir- ritation of the intestinal absorbents, will here be found most successful. Small doses of neu- tral salts, sulphur, and acidulated drinks, may also be of service in promoting the latter inten- tion. If the griping be severe, and the case urgent, terebinthinate 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 ACA. [Cl. I.—Ord. I. the imprisoned matter and the coats of the in- testines : 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 cases of obstinate costiveness."* , SPECIES VI. COLICA CONSTRICTA. CONSTRICTIVE COLIC. A SENSE OF STRICTURE IN SOME PART OF THE INTESTINAL CANAL ; OFTEN OF FLATULENCE, GRADUALLY PASSING OFF BY THE STRICTURE ; THE BOWELS TARDY ; DISCHARGING WITH DIFFICULTY SMALL LIQUID STOOLS. This species bears a near approach to proc- tica callosa, or the callous contraction of the rectum ; which last, however, as accompanied with less griping and flatulence, and conse- quently having less of the character of colic, and more particularly from its being in most cases within the reach of manual examination and surgical aid, and capable of assistance by a different mode of treatment, is entitled to a distinct consideration. [Stricture of the intestines, in the early stage of the disease, gives rise to colic pains and cos- tiveness, alternating with bilious diarrhoea. After some time, solid feces are very rarely passed, and only after a great effort; and they are of an extremely slender calibre.] The proximate cause of the disease before us is a permanent stricture existing in some part of the intestinal canal beyond the reach of the fin- ger, from callosity, scirrhosity, a ring of tubercles or caruncles, or whatever else has a tendency to thicken its coats and diminish its diameter. [Strictures are more frequently met with in the colon and rectum, than in the small intestines : and Dr. Monro has seen the natural diameter of the colon so much reduced, that an ordinary quill would hardly pass the constriction. When the stricture is great, the bowel is generally en- larged above it (Baillie's Works, by Wardrop, vol. ii., p. 158), and even ulcerated. Sometimes, indeed, it gives way ; its contents are effused; and the patient, after labouring under colic for a few hours, is suddenly seized with very acute pain in the abdomen, rapidly followed by a sud- * Mat. Med., vol. ii., p. 181. Every man of ex- perience is aware, that when a person takes chalk mixture, or magnesia, in considerable quantities, intestinal concretions are liable to be formed, un- less the bowels be well cleared out occasionally with a brisk purgative. The carbonate of iron will sometimes accumulate in the bowels in large masses, creating obstruction. Dr. Elliotson has known collections of it take place in the rec- tum. He had a patient labouring under tetanus, to whom he gave this remedy with success; but, when purgatives were not given, there was pain in the rectum, and it was necessary to pick the iron out of it: a shovelful was found in his bed.— (See Med Gazette for 1832-3, p. 598.)—Ed. Gen. VII.] COPRO den sinking of the pulse, cold sweats, and death. —(Morbid Anatomy of the Human Gullet, &c, p. 301, 302.) When scirrhus affects the bow- els, the diseased portion of them is always ren- dered narrower, and sometimes nearly imper- vious. According to Meckel, the disease begins in the peritoneal coat and glandulae muciparae, whence it afterward extends to the muscular and villous coats. The effect of it is to con- found together all the tunics, to thicken and harden them, and, in the end, to produce can- cerous ulceration.—(Bourdon, Revue Med., Mai, 1824, and Meckel's Anat., vol. iii., p. 296.) The muscular coat is also subdivided by membranous septa, and the internal one sometimes projects in the form of hard irregular folds. In persons of advanced age, scirrhus of the large intestines is not uncommon, and it mostly attacks the sig- moid flexure of the colon or the rectum. The reason of this fact is referred by Dr. Baillie partly to the villous coat of the lower end of the great intestines containing many glands, and partly to the sigmoid flexure of the colon being naturally its narrowest part, and most liable to be irritated by the passage of hard substances. But though strictures are most frequent in the colon and rectum, they are sometimes met with in the small intestines. In the Museum of the University of Edinburgh is a specimen of a stricture, extending seven inches along the Ueum. —(Monro, op. cit., p. 301.) Besides the foregoing scirrhous disease, by which the intestinal tube may be obstructed, there are other morbid alterations by which the same consequence maybe produced. One is an elevation of the mucous membrane into thick- ened folds by an accumulation of the cellular membrane.—(Baillie's Works, vol. ii., p. 159.) Another is a thickening of the mucous or villous coat alone, coagulable lymph being effused upon it. In the collection of Mr. A. Burns is a spe- cimen taken from a child, where a gelatinous substance, mixed with coagulable lymph, ad- hered very intimately to the villous coat of the sigmoid flexure of the colon and the rectum ; and above the sigmoid flexure, the intestine had given way. In some instances the intestine is completely filled with coagulable lymph, which may either be voided by stool, or remain and prove the cause of death.—(Monro's Morbid Anatomy, &c, p. 119-122.) The intestinal canal, and particularly the colon and rectum, are some- times the seat of polypi, or of various other excrescences, some of which are hard and solid ; others spongy, loose, and soft. One is termed miltlike by Professor Monro, and has a very fetid smell: Meckel (Anat., vol. iii., p. 297) expresses a conviction that the disease here alluded to is in reality fungus haematodes : but such a case is rare, and has never been seen by Mr. Wardrop. —(Baillie's Works, vol. ii., p. 161.)] The colon and rectum, highly sensible in a state of health, are peculiarly irritable 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 the retention. In most cases the stricture lies fteyortd the reach of topical ap- )STASIS. 125 plications. Purgatives afford but temporary re- lief.—(Monro's Morb. Anat. of the Human Gul- let, &.c.t p. 302.) Of late the conium has been chiefly trusted to, in conjunction with the mer- curial pill. But I am not aware that these have proved decidedly advantageous. The spasmodic attacks must be encountered by the remedies already recommended in spasmodic and flatulent colic : and the habitual uneasiness felt in the intervals, will be best alleviated by a rigid at- tention to a light, liquid, and aperient diet. Un- frequent as this disease is in general practice, I happen to have at this time two patients labour- ing 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 infant; and the other a man, forty-nine years old, who has la- boured 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. [As the sigmoid flexure of the colon, near its termination in the rectum (Penkivil, in Edin. Med. and Surg. Journal, No. 72), is frequently the seat of the disease, this part should be care- fully examined in every case of total obstruction of the bowels, not arising from hernia. It is requisite for the purpose, says Dr. Willan, to employ a bougie thirteen inches long, and of a proportionate strength. He adds, " I lately saw a lady thus relieved, who had been twenty-six days without any evacuation from the bowels, and who seemed nearly exhausted by violence of pain and distention of the abdomen, hiccough, cold-sweat, &c. It is remarkable how long pa- tients subsist under these distressing circum- stances. In one instance, the time was twenty- nine days ; in another, thirty-three days. As the latter patient recovered, after enduring every torture such a disorder could inflict, practitioners- may be encouraged to persevere steadily in their attentions."—( Willan on Diseases in London, p. 185.) When this species of colic depends upon the presence of a polypus, or other excrescence in the intestinal canal, beyond the reach of sur- gical means, the palliation of symptoms is all that can be attempted. The true nature of such cases is scarcely ever ascertained till after death. GENUS VII. COPROSTASIS. COSTIVENESS. OBSTINATE RETENTION OF THE FECES IN THE INTESTINES. The generic character is expressed in the generic name, which is a compound term, im- porting emansion or retention of feces—ko- irooaraais, from Koirpos and i 1828.—Ed. Gen. VIII.—Spe. 4.] DIARRHCEA ALDA. 133 seed, quince-seeds, or comfrey-roots, for lubri- cating the intestinal canal, which has partici- pated in the irritation, will usually prove a suc- cessful practice. The last was at one time a popular medicine in diarrhoeas, and Dr. Cullen objects to its being omitted in the Materia Med- ica of the colleges. If the flux, and conse- quently the-excitement of the liver, should still continue, opiates may be employed with ad- vantage. SPECIES III. DIARRHCEA MUCOSA. MUCOUS LOOSENESS. THE DEJECTIONS CONSISTING OF, OR CONTAIN- ING, A COPIOUS DISCHARGE OF MUCUS. This species bears a striking resemblance to the defluxion from the nostrils in catarrh. Its common cause is cold, particularly in the feet; the motions are acrid, often with but little bil- ious tinge ; and like the nostrils in a catarrh, the lower part of the rectum is excoriated. It is hence denominated by many writers catarrhus intestinorum, and by Dr. Boerhaave diarrhaza catarrhalis. The disease is, perhaps, also sometimes pro- duced by acrid ingesta, as a coryza is occasion- ally excited by sternutatories in those not ac- customed to them. Here the process of pur- ging will rather add to the complaint than dimin- ish it ;.*and copious diluents and demulcents afford the most rational mode of treatment; with which plan the daily diet should be made to coincide.* This species of mucous or catarrhal diarrhoea, like the two preceding, is also frequently pro- duced by any sudden change in the temperature of the atmosphere from great heat to great chil- ness ; and hence its frequency and severity in passing rapidly from a warmer to a colder cli- mate, as into the North Seas in the summer * On this disease Dr. Stokes remarks, that the most efficacious remedies are the metallic astrin- gents and the turpentines and balsams, combined with some of the preparations of opium : in severe cases of this gleety discharge, he uses the acetate of lead in free and repeated doses, and he has con- tinued this remedy for six weeks without any ap- parent injury. He has used turpentine also with good effect. The same gentleman has recently drawn the attention of the profession to a form of chronic diarrhoea, occurring in persons of broken down constitution, or in those who have taken mer- cury freely. It is caused by small ulcers situated close to the verge of the anus ; these produce irri- tation in the colon, tenesmus, griping, and frequent evacuations. The successful treatment of this form of disease consists in touching the ulcers with the nitrate of silver. Dr. Stokes recommends the anus to be examined in every case where the diarrhoea has been of long standing—has resisted a great variety of treatment, is combined with te- nesmus, and a desire of sitting on the night-chair after atstool has been passed, showing irritability of the lower part of the large intestine; and, lastly, when the health of the patient does not appear to be so much affected, as it naturally should be where the intestine is much diseased.—(See Lond. Med and Surg. Journal, March, 1834.)—D. time. " In the outward-bound passage of the vessels in the whale-fishery on the coast of Spitzbergen," says Mr. Macartney Ross, " I have more than once had occasion to remark the very great effect of a transition into a cold latitude in "deranging the state of the alvine dis- charge. The vessels destined for this often perilous voyage, generally leave England about the end^ of March, when the weather is compar- atively temperate. A week or two serves to convey them within the Arctic Circle, in the course of which time few cases are beginning to appear. But after being fairly within the limits of the Frozen Sea, and encompassed with ice, so that the wind even carries with it a strong and pSnetrating frost, the cases daily in- crease, both in number and severity. The weather becoming progressively milder after the beginning of May, and the seamen by this time being more inured to Jhe climate, few or no cases are met with; and such as do occur, I have always found to arise from the patient hav- ing been called suddenly from bed in the course of duty, and exposed to an intensely freezing atmosphere." Where the looseness, of whatever species, is produced by a sudden chill on the surface, small doses of ipecacuanha, with or without opium, have generally been given with advantage.— (Toxe, Bibl. i., p. 118.) Fernelhuys (An omni alvifluxui radix Brasiliensis ? Paris, 1706) and Dr. Fothergill (Med. Obs., vol. vi., art. 18) rec- ommend it alone ; Dr. Stoerck (Klin, und 4.nat. Bemerk., p. 7), with more reason, in combina- tion. And if the disease should become chronic, the warmer astringents should be had recourse to, as columbo,—to which also Dr. Stoerck rec- ommends an addition of laudanum,—cusparia, and arnica (doronicum pardalianches, Linn.), which, though rejected in our own country, maintains its reputation all over the continent Of the arnica root, Dr. Stoll used to give a drachm every two hours.—(Mat. Med., part iL, p. 307; part iii., p. 163.) SPECIES IV. DIARRHCEA ALBA. WHITE LOOSENESS. THE DEJECTIONS MILKY, OR RESEMBLING IN THEIR APPEARANCE A MIXTURE OF WATER AND LIME, WITH A FROTHY SCUM. [In the preceding editions of this work, the learned author described two species under the names of diarrhoea chylosa and diarrhoea gypsata. The first is the case denominated in Cullen's Nosology, " diarrhoea cceliaca, qua tumor lac- teus, specie chyli dejicitur." The appellation of chylous looseness, had it been merely used as a simile, would have been but of little conse- quence ; but, promulgated as it has been by va- rious experienced physicians, and even by Dr. Good himself, as derived from the really chy- lous nature of the excrement, it.becomes a ve- hicle of error, and the judgmentof the practitioner in the sick-room is too apt to'be blinded by it.] The colour of the stools, according to Dr. 134 CCELIACA. [Cl. I—Ord. I. Good, affords evident proof, firstly, that the bile, which gives the usual tinge to the feces, is either not secreted, or impeded in its flow into the intestines ; and, secondly, that the food, after being converted into chyle, is not absorbed and carried into the system. The non-absorption of the chyle must proceed from some mischief in the lacteals or mesenteric glands ; which may either labour under such an inertness or torpitude as to render them incapa- ble of carrying on their proper function, or may be so obstructed in their course as to be pre- vented from exercising their function, notwith- standing their beingr in a state of health. [Dr. Rummel (Hufeland's Journal, Jtine, 1825) has taken an excellent survey of the va- rious descriptions of this supposed disease given by authors, and ably exposes the mistake they all committed in believing that there was such a disease as diarrhoea chylosa, the existence of which he completely disproves. It is to Dr. Graves of Dublin, however, that the profes- sion in this country is under particular obli- gations, for his judicious notice of the erroneous doctrines broached concerning the white forms of diarrhoea.—(See Dublin Hospital Reports, iv., 46, &c.) A gentleman applied to him, after having suffered a good deal from an epidemic dysentery. The febrile symptoms and discharge of blood had ceased for many weeks ; but the emaciation and weakness continued to increase. He had one or two natural stools daily, without tenesmus; but in the course of every twenty- four Tiours |je experienced eight or ten sudden calls to stool, attended with an impossibility of resisting the bearing down and weight felt in the rectum. Each evacuation consisted merely of two or three table-spoonfuls of muco-gelat- inous matter, which varied in colour and consist- ence, but generally resembled thick milk, or a pu- riform fluid, and occasionally a transparent jelly. Ibis fluid was evidently a secretion from the mu- cous membrane of the rectum in a state of irri- tation or chronic inflammation. It is observed by Dr. Graves, that such a condition of a mucous membrane constitutes the disease denominated chronic blennorrhoea ; and, when it occurs in the rectum, produces a disease which, on ac- count of the white colour of the discharge, would formerly have been called fluxus coeliacus, and the evacuation attributed to the loss of chyle by stool; for the chyle was supposed to be formed, but not absorbed, or carried into the system. As Dr. Graves very properly remarks, it is even less surprising that Dr. Good should have retained the old species, diarrhoea chylosa, than that he should have inserted a new one whose existence rests upon still more doubtful evidence. This new species he named diar- rhoea gypsata, in consequence of the evacuations resembling in their appearance a mixture of water and lime, which appearance he actually fancied to depend upon the presence of earthy particles in the fluid discharged. This view of the subject he also fortified by several inge- nious but premature reflections on the power of animals to secrete lime, and especially on the presence of lime in the intestinal calculi. Unfortunately, the main and essential proof of the existence of lime in the motions was wanting, all chymical analysis of them having been neglected. Dr. Graves has often seen stools of the colour here described, and so has the editor of this work, which colour was referable to the absence of bile, and a morbid secretion of white viscid mucus from the intestines. Vis- cid and whitish discharges from the mucous membranes -lining the eyelids, bronchial tubes, urethra, vagina, &c, are, as Dr. Graves ob- serves, extremely common, and depend on a state of irritation similar to that which produces the white and scanty alvine evacuations arising from the mucous membrane of the rectum. It is evident, says he, from the case I have re- lated, that chronic irritation of this part may produce much constitutional disease. When, however, the affection extends beyond the rec- tum, to the other portions of the large intestines, it occasions symptoms still more urgent. That a similar state of the mucous membrane lining the small intestines may occur, and give rise to a white secretion from its surface, is proved by examination of their contents in persons who die of the East Indian cholera, in many of whom white milk-like stools are observed during life. On dissection, these stools are found to depend on a secretion from the small intestines. The diarrhcea alba, described by Hillary as occasion- ally epidemic in Barbadoes, probably arises from a similar cause. This latter name, as convey- ing no erroneous hypothesis, the editor ventures to recommend for all the cases comprised under the heads of diarrhoea chylosa and diarrhoea gyp- sata in the former editions of this work. It is a name that simply expresses the fact of the white colour of the motion, without involving the reader in any hypothesis respecting chyle or lime being parts of what is voided. For a description of the disease to which the objectionable epithet gypsata was applied, Dr. Good says :] I am chiefly indebted to a valuable paper of Dr. Baillie, communicated to the London Col- lege, and published in its Transactions.—(Vol. v., art. xii.) " The evacuation," says he, " con- sists 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, anil the froth looks like yest. When it changes to a milder form, the evacuations are still more or less pale, but of the consistence of pudding, and do not occur oftener than two or three times in twenty-four hours. The appetite is often good, but sometimes defective. The countenance thin and sallow, but not much emaciated. The pulse varies but little from the standard of health, but is rather disposed to acceleration. The tongue is generally covered with a white fur of moderate thickness: the urine of somewhat deeper hue than natural, generally clear, occa- sionally turbid. * An examination of the abdo- men discovers nothing unnatural. The bowels are apt to be distended with wind ; but there is no tumour, nor sense of pain upon pressure." Gen. VIII.—Spe. 4.] DIARRHCEA ALBA. 185 The disease occurs most commonly in per- sons who have resided for a considerable time in a warm climate, or who have suffered from affections of the liver : but it is sometimes met with in persons who 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 frequently than women. Sometimes there will be a state of amend- ment, indicating a cure. The motions become figured, and of a darker hue, but rarely of the deep colour of health. This improvement, however, is mostly of 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 con- tinues with the changes just noticed, and they hardly ever fully recover. The mind, as in other diseases of irritable temperaments, seems to exercise some influence ; for the symptoms are aggravated, or the exacerbations appear more frequently, under the embarrassments of business, o? the agitations of anxiety. Repeat- ed returns of the complaint at length wear out the constitution, and the patient sinks from cor- poreal exhaustion. In the case formerly termed diarrhoea chy- losa, and supposed to depend sometimes upon obstruction of the lacteals and mesenteric glands, and sometimes upon a scanty supply of bile, Dr. Good recommended the following practice. In the first case, he says, the object is to remove the obstruction, which may be best accomplished by active stimulants, as calomel. In the second, if calomel be given at all, it should be in very small doses ; but the common preparations of zinc and iron offer a better chance of success : and the rheum rhaponticum., or English rhubarb, being very slightly aperient, and far more astringent than the rheum palma- tum,a. useful medicine in various kinds of loose- ness from relaxation, may here also be employed to advantage in doses of a scruple taken twice a day ; and where a more powerful vegetable astringent is required, we may find it in the leaves and young twigs of the rhus coriaria, or common sumach ; which, however, are chiefly cultivated in our own country for diers and tanners. The berries possess a like property, and are acid, austere, and cooling. To these medicines may be added blisters, or rubefacients to the abdomen. [The editor of this work is not inclined to place much reliance on any part of the above practice, except the calomel and blisters. As the disease seems to be connected with a scanty secretion of bile, and a morbid state of the se- creting vessels of the mucous coat of the in- testines, small doses of calomel or the blue-pill, joined with opium, counter-irritation of the skin of the abdomen, and anodyne or astringent injections, seem to him the most advisable rem- edies at first; and they may be followed by tonics, and other alteratives, according to cir- cumstances. In particular, the nitrous ether, and tinct. opii, which have been frequently ex- hibited in the camphire mixture, in many invet- erate cases of diarrhoea, with superior effect, should be recollected.] In the examples characterized by the resem- blance of the stools to a mixturO of lime and water, Dr. Baillie. estimates the influence of medicine as very inconsiderable. Half a grain of Calomel, three grains of pilulae hydrargyri, or a few of the hydrargyrum cum creta, taken every night, or every second night, have occa- sionally produced some advantage, by stimula- ting the liver to a better and more plentiful se- cretion of bile, without impairing the strength of the constitution; and bitters, as cascarilla or cusparia, combined with a few drops of lauda- num, have also occasionally had their use. But according to Dr. Baillie, the benefit is often only temporary. [Since the period, however, when this eminent physician wrote his observa- tions, experience has pronounced the sulphate of copper to be a valuable medicine for the re- lief of this and other forms of obstinate chronic diarrhoea. Dr. Elliotson prescribe^at first, half a grain of it twice a day, joined with one grain of opium. The dose is afterward gradually increased to one grain and a half or two grains; and the diet consists of milk, arrow-root, beef- tea, and a little wine.—(Med. Chir. Trans., xiii., 451, &c.) On the authority of Dr. Rummel, who had employed the extract of nux vomica, Dr. Graves (Dublin Hospital Reports, iv., 50) resolved to try the effect of strychnine in cases of djarrhcea alba. One twelfth of a grain was given, in the form of a pill, twice a day, and with a success- ful result. Dr. Rummel observes, that after endeavouring to remove the original cause of the disease, the best remedies are narcotics, combined with strengthening and astringent medicines. Nux vomica, he says, possesses a peculiar power in controlling blermorrhoea of the rectum. In the cases recorded by Dr. Rummel, he employed sulphate of iron and columbo, be- sides salphur, which has a particular action on mucous surfaces. The cure was generally pro- moted with hyoscyamus or opium, joined with nux vomica.]* * This form of diarrhoea, the alba, is occasion- ally seen among the inhabitants of some of our southern states, and sometimes succeeds repeated attacks of the bilious fever so prevalent at the south : it often follows also long-continued habits of indulgence in stimulating food, and the abuse of ardent spirits; and occurs likewise in those who are subjected to severe labour, and whose diet is indifferent and unwholesome : in short, those causes which primarily impair the tone and func- tions of tfre digestive organs, cause this disorder. Trfe mucous surface of the yhole alimentary ca nal is often affected by this complaint, and the stomach being capricious as to the quantity and quality of the food, its functions become after a while so impaired, that marasmus often ensues. The best treatment, unfortunately, is often unsuc- cessful; the blue-pill, and the hydrargyrum cum creta in limited quantities, are among the best mer- curials. Salivation will inevitably do harm. The slight mercurial doses may be followed by the as- tringent resinous gums, as the catechu or the kino, blended with chalk and a little camphire m AACA. [Cl. I.—Ord. I. 136 CCEL SPECIES V. DIARRHCEA LIENTERIA. LIENTERY. THE DEJECTIONS CONSISTING OF THE ALIMENT PASSED RAPIDLY, AND WITH LITTLE CHANGE. The signs entering into the definition of this species prove sufficiently in the first place, that the stomach is in a morbid state, and that the gastric juice is not secreted in a proper quantity or with proper qualities ; and next, that the bile is either not duly secreted, or else obstructed in its passage ; for were there a free flux of it, the feces, however crude, would display their com- mon yellow hue, which they rarely exhibit. [According to other writers, however, lienteric diarrhoea depends upon a morbid irritability of the stomach and bowels,* whence the food is prematurely expelled from the former organ into the intestinal canal, in an imperfectly digested state; and the bowels themselves being also morbidly sensible, very quickly void whatever they receive. The motions are at the same time loose and liquid, the exhalant vessels and excretories of the mucous glands pouring out an abundant quantity of their respective fluids. The disease is generally accompanied with great weakness of the digestive power, as well as morbid irritability of the stomach.] Lientery (\(ttvrepia), lubricitas intestinorum, was the name given to this disease by the Greeks, and it is here retained. The Latins, with a loose trans- lation of the term, called it levitas intestinorum; and the general idea expressed by both is, that the aliment passes lightly or fleetly along, and with little elaboration by the intestines ; whose peristaltic action is at the same time quickened. [The view taken by Dr. Good of the causes of the present disorder, led him to recommend the general plan prescribed for dyspepsy. Ac- cording to other physicians, however, the indi- cations are first, to lessen the irritability of the whole alimentary canal, by the exhibition of opium, joined with astringents and absorbents ; secondly, to increase the digestive power of the stomach, by the administration of tonic bitter medicines, as the infusion of cascarilla, gentian, or orange-peel, the decoction of cinchona, or small doses of the sulphate of quinine. Mod- erate exercise, especially on horseback, will tend to re-establish the functions of the stomach; and the form of a julap. The late Dr. Richard Bayley, of New-York, used freely a decoction of the sima- rouba. The practice of Dr. Elliotson has long been known among us : and the sulphas ferri in like doses, blended with half a grain or a grain of opium, is also administered as a judicfous tonic. We are not aware that any of our practitioners have used the strychnine in this affection.—D. * Bateman, in Rees's Cyclopaedia, art. Lien- tery. As if physicians were never to agree, it is the opinion of Drs. Crampton and Forbes, that "the variety (of diarrhoea) termed lientery, in which undigested aliment appears in the stools, has no claim to be considered as a distinct form of diarrhcea, as the circumstances supposed to characterize it may occur in every species of the complaint."—Cyclop, of Pract. Med., art. Dur- ehcea.—Ed, all cold articles of diet, or such as are difficult of digestion, should be avoided ; particularly salads, and other raw vegetables. Dr. Bateman once witnessed a severe attack of lientery, brought on by eating a little ice-cream, when the patient had been previously suffering from indigestion ; the enfeebled digestive powers seemed to sink at once, and the food was dis- charged almost unchanged. When the ali- mentary canal is in the abovementioned irrita- ble state, the invalid should refrain from exer- cise immediately after meals.] SPECIES VI. DIARRHCEA SEROSA. SEROUS LOOSENESS. THE DEJECTIONS ALMOST ENTIRELY LIQUID AND LIMPID. From the thin fluidity of the stools in this species, Hoffmann hasdescribed it by the name of diarrhoea aquosa. It is evidently dependant upon a very irritable state of the excretory ves- sels of the intestines ; and sometimes holds the same relation to the third species, diarrhcea mu- cosa, as the limpid defluxion of an incipient catarrh does to the mucous discharge in which it terminates. Yet the irritation is here much greater than in mucous diarrhoea, often pro- duced by different causes, and frequently re- quires a different mode of treatment. The mucous diarrhoea, or indeed any of {he pre- ceding, may run into it if long continued ; foi the common cause of the irritation is debility of the excretories. Here again it must be ob- vious that purging of any kind would be mis- chievous : and the most effectual plan of success that has occurred in my own ,practice, has been the use of warm astringents and gentle stimu- lants or tonics. The simarouba (quassia simarouba) is partic- ularly entitled to our attention, and will indeed be found useful in most of the species of the genus before us ; as will also, in many cases, the lopez-root (lopezia mexicana), which by Gaubius (Adversar) was preferred to the sima- rouba, and which seems to operate at least as much by tranquillizing the irregular or spas- modic action of the intestinal canal, as by any astringent power it may possess. The geum urbanum, Linn., better known by the officinal name of caryopbyllata, or herb bennet, was for- merly in high repute for all complaints of this kind; its taste is aromatic and austere. The punicagranatum, balaustine, or pomegran- ate-tree, is still continued in several pharmaco- poeias, and employed in practice in this and the preceding species, both in the flower and bark : the latter seems to have been a favourite med- icine with Dr. Mead, who prescribed a decoc- tion of it, with red *oses and cinnamon, in vari- ous diarrhoeas proceeding from debility. Cullen (Mat. Med., vol. ii., p. 44) thinks highly of it. It is indeed a powerful astringent, and as such is entitled to attention; but it has a roughness so unpalatable as to disqualify it for general use. Where these cannot be retained on the stomach, Gen. VIII.—Spe. 7.] ' DIARRHCEA TUBULARIS. 137 alum alone may often be given with advantage; and Dr. Cullen expresses his surprise that it is not employed more frequently or more freely. His dose is four grains at first, and afterward a scruple several times a day.* Where the disease is of very long standing, we often gain great benefit by uniting a tonic or astringent with a diaphoretic, thus strengthening the bowels, while we take off irritation by exci- ting a transfer of action on the skin. Upon this principle Dr. Fordyce proceeded when he pre- scribed a combination of tormentil and ipecac- uanha. A like transfer of action has sometimes been attempted by issues, blisters, and setons. Hippocrates (nepl Ua6Sv, lib. iii., p. 523), with more reason, employed for the same purpose emetics, and has been followed by Fontaine, and other practitioners; and Malvachini, with the same view, recommended diuretics.—( Utiles Collectiones.) Dr. Lind (On Diseases in Hot Climates) and Dr. Adair (Med. Commentaries, &c.) have recommended the native carbonate of zinc, or officinal calamine in fine powder. In a very obstinate case that fell to my lot a few years ago, in which the patient, a young woman of twenty-four, had, for ten years, 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 camphire mixture and pills of the resinous gums, after that, as I had reason to believe, all the usual routine of astringent earths and salts, astrin- gent purgatives and narcotics, had been tried, and spent their force in vain. It is probable that, in some cases of this kind, the superace- tate of lead, in doses of a grain, combined with three or four drops of laudanum, might prove equally useful. [Here, also, the sulphate of copper, in the dose of half a grain, gradually in- creased to a grain and a half, joined with opium, and given twiee a day, merits trial, the experi- ence of Dr. Elliotson being strongly in its favour.] This disease is also occasionally produced by drastic purges, as elaterium ; and is often criti- cally employed by nature to carry off dropsies, and some other remote accumulations 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 ar- ranged, and not often described ; but it occurs frequently in practice ; and appears to depend upon a peculiar irritability of the villous mem- brane of the larger intestines, which, in con- * In large doses it occasions nausea, vomiting, colic, and purging: in small ones, constipation. In old diarrhoeas, when ulceration of the mucous membrane exists, alum may cause mischief.—See A. T. Thomson's Elem. of Mat Med., voL ii., p. 59.—Ed. sequence, secrete an effusion of coagulating fibrin, fibrin mixed with albumen, instead of se- creting mucus, occasionally accompanied with some degree of chronic inflammation. It has a striking resemblance to the fibrous exudation thrown forth from the trachsa in croup, but is usually discharged in longer, firmer, and more compact tubes. There is commonly a consider- able 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 small calibre. From the laminated appearance of this effu- sion, it has generally been mistaken for a sepa- ration of the mucous membrane of the intes- tines ; with which it seems to be confounded by Dr. Simson (Edinb. Med. Essays, vol. v., p. 153); but the exudation has no vascular struc- ture, 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 inflammation, 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 per- fect as at first to excite 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 (De Morb. Intest., Dresd. 1747), gives similar ex- amples ; and a like case is described by Spin- dler, in which the secretion was worked up into a " materia alba, longa, compacta."—(Obs. 45.) It has sometimes assumed the exact shape of the intestine, as though this had cast off a tunic. —(Act. Nat. Cur., vol. v., obs. 126.) 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 of determining with tolerable accu- racy the part of the canal affected. From a valuable article, however, of Dr. Powell's (Med. Trans., vol. vi., art. vii.), it appears at times to take place in the narrower portion of the intes- tinal 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 obstruct- ed bile. From a small increase in the pulse, and a coating on the tongue, there seems to have been here also a slight degree of inflammatory action, though so inconsiderable that Dr. Powell ques- tions whether there was any whatever; but adds, which my own experience leads me most fully to confirm, that the disease is certainly not "disposed 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 evi- dent from his description of the material evacu- ated, which seemed " to have formed parts of 138 CCELIACA. [Cl. I.—Ord. I. 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." And he afterward compares the membranous material thus excreted to that " formed in the trachea, under croup ; but the symptoms," says he, "are there more violent and destructive from locality of situation." From the acute degree of pain which the disease thus situated produced, and must ne- cessarily produce, in the smaller intestines, as also from the spasmodic constriction of the bile- ducts, and the common symptoms of jaundice, the passage of gall-stones was at first suspected, till the character of the intestinal discharge spoke for itself. From a like effusion of fibrin in the uterus, Blumenbach has shown (Comment. Soc. Reg. Scienlice, Gottingen, vol. ix.) that a tunica de- cidua has been occasionally produced through the excitement of an aphrodisiac passion alone, without copulation or impregnation ; and Mor- gagni (De Scd. et Cans. Morb., Ep. xlviii. 12) has given examples of so perfect a formation of * Sauvages has mentioned a diarrhcea adiposa, in which liquid or solid fat is discharged from the in- testines. On this subject the most instructive document is a paper inserted by Professor Elliot- son in the last volume of the Transactions of the Medical and Chirurgical Society of London, en- titled, " Observations on the Discharge of Fatty Matters from the Alimentary Canal and Urinary Passages." This paper contains, indeed, all that is known on the curious topic to which it relates. Dr. Elliotson Jregins his remarks by adverting to the formation of ambergris, or gray amber, a fatty substance, consisting chiefly of what is termed ambreine, which is analogous to chloresterine, and supposed to be produced by disease in the alimen- tary canal of the spermaceti whale (physeter ma- crocephalus). Some declare that this fatty sub- stance is never seen higher than six or seven feet from the anus, and a mass weighing 182 pounds has been found in the animal.—(Phil. Trans., 1783.) Dr. Elliotson next remarks, that fatty matters, which have an external origin, are occasionally dis- charged from the human alimentary canal, and that castor-oil is frequently seen liquid in the evacuations.—(See Riverii Obs. Med., cent, ii., obs. 23, and the German Ephem.) But old au- thors detail instances of fatty discharges from the intestines, that do not appear to have originated externally; " and (says Dr. Elliotson) of every variety of those old cases I can adduce a modern and indisputable example. In some instances the fat was discharged solid." In a case related by Moellenbroccus, it was not unlike the fat of beef; and in another, recorded by Masbius, a daily dis- charge of a substance exactly like human fat oc- curred. Among other examples, Dr. Elliotson refers to a weaver, whose case is detailed in the Medical Essays for 1752. The .matter, voided with his excrement, was a whitish substance, the same membrane by the irritation that takes place in painful menstruation (paramenia difji- cilis), as to render it difficult to be distinguished from that, belonging to an ovum. So corpora lutea have been formed, and their cicatrices oc- casionally found, in the ovaries of virgins. The milder preparations of mercury, em- ployed as alteratives rather than aperients, have frequently proved serviceable ; and the balsam of copayva still more so. The last is indeed generally useful in a chrohic inflammation or irritable condition of the secernents of mucous membranes«rand in the disease before us, where I have not been able to induce the patient to take it by the mouth, Ihave recommended it in the form of injections. In one case in which I prescribed it in this form, three drachms, in- termixed with three ounces of mucilage of lin- seed, being thrown up three times a day, it proved eminently useful. Common emollient injections, moreover, em- ployed in much larger quantities, where the sphincter will allow the pipe to pass up, afford temporary'ease ; and a diluent and anodyne in- jection of warm water and laudanum alone, repeated twice a day, still more benefit. In the meanwhile, the mercurial preparations just adverted to, and especially the blue-pill, or Plummer's, which is still better (the pil. hy- drarg. submur. comp. of the London College), should be taken in a dose of four or five grains every night: and, if necessary, the bowels kept open by two drachms of sublimed sulphur daily.* about the bulk of a large walnut, and like tallow or Hardened marrow, composed of small globules. For various other instances on record of the evacuation of solid fat, the editor refers to Dr. Elliotson's paper. On other occasions the fat is discharged liquid, and then concretes into the ap- pearance of butter. The learned Professor of Physic in the London University quotes a case of this description from Tulpius.—(Obs. Med. Amst. 1685.) The yellow fatty substance, when thrown into the fire, burnt with a bright flame. He also reminds us of the specimen of such fat preserved in the Museum of the College of Surgeons, and voided by a child four years and a half old. The case was related by Sir Everard Home, as a proof that fat is sometimes formed in the intes- tines. Dr. Elliotson met with two cases of fatty evacuations, and he has described the appearances found on dissection in these and another example. One patient, a weaver, aged forty-five, was ad- mitted into St. Thomas's hospital, labouring under phthisis and diabetes mellitus. Soon after his admission, he complained of excruciating pain in the abdomen and in the back, and had diarrhoea. In his stools, which were often rather pale, a yellow substance was noticed, like concrete oil. On putting it into the fire, it burnt with a large flame. He continued to discharge more or less of this till Ids death. Long before, his urine be- came excessive; it seems that he had voided blood from his bowels, and that as soon as a matter like butter began to pass, the bleeding ceased and pain commenced. The fatty substance was examined by Dr. Prout and Mr. Faraday, who were satisfied of its oily nature. At length the patient grew thin and weak from the combined effects of ulcer- ation of the lungs, the discharge of sugar from the urinary organs, great suffering, and the dis- charge of fat from the bowels. On examination Gen. IX.] CHOLERA. 139 GENUS IX. CHOLERA. VOMITING AND PURGING. ANXIETY, GRIPINGS, SPASMS IN THE LEGS AND ARMS, WITH VOMITING AND PURGING, OR FLATULENT ERUCTATIONS AND OBJECTIONS.* Cholera has, by several late and present writers of distinction, been regarded as a mere species of some other genus, as diarrhcea, which is the view taken of it by Dr. Young ; or as a mere variety of some particular species, as romitus, which is the place it holds in Dr. Parr's jiosology. 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 character to the disease, and justifies its being arranged and treated of as a distinct genus. From vomitus, it is still more widely discrepant. after death, all the intestines looked yellow and greasy, as though they had been soaked in oil. Numerous black points were seen in some parts of their mucous membrane, like those frequently noticed after fever and chronic diarrhoea. But no other morbid appearances existed in the alimentary canal. The liver was healthy, and the gall-blad- der full of thick, dark bile. The pancreatic duct and the larger lateral branches were crammed with white calculi. The kidneys were sound; the lungs tuberculated and ulcerated. Dr. Elliotson was shown, by Mr. Pearson of Clapham, a woman who voided both solid and liquid fat. She died of this complaint and phthi- sis. Her liver was enlarged and painful; her urine scanty and pale; she was generally relaxed, and the evacuations preceded by pain. For many months she vomited several times a day. The feces were very pale, and almost destitute of smell. She passed daily about two ounces and a half of fat, and a third of an ounce of oil ; but the quantity of the latter varied considerably. After death no disease was discernible in the ali- mentary canal or urinary organs. The liver was healthy in structure, but very large and pale, des- titute of bile, no less than the gall-bladder, which contained a thick, greasy mucus, not inflammable. In one case, communicated to Dr. Elliotson by Dr. Prout, the coecum was found much thickened, and the mucous membrane of it and the colon ulcerated. Dr. Elliotson afterward quotes an example from Tulpius, in which fat was voided both from the bowels and bladder, a modern case of which he has also adduced in a lady of his acquaintance. It seems that Dr. Prout has several times noticed fatty matter that had been passed with the urine, and, in every instance, malignant disease of the kidney and bladder supervened. " I have thus (says Dr. Elliotson) not merely adduced recent examples of all the old wonder- ful cases of this kind, and even one example of the most wonderful, in which oil passed from both the intestines and Madden.; but have related one more extraordinary than any, in which while pus, a substance not found in the healthy body, was passing from the air passages, oil was passing from the intestines, and sugar from the urinary organs. " It also appears that organic disease of neither the alimentary canal nor any other part is neces- sary to the disease, though, in all the cases that The term cholkra is of ancient use, for we trace it in the writings of Hippocrates. Celsus derives it from ^0X17 and f*a>, literally bile flux; and Trallian from x°*«s an. 112 CCELIACA. [Cl. I.—Okd.I. twenty-four hours. The symptoms generally abate ou the second or third day, and the pa- tient recovers rapidly. If there be any consid- erable degree of weakness on the decline of the disease, it may be necessary to have recourse to the warm and bitter tonics, of which columbo will be found one of the best. [The following mixture is strongly recom- mended by Mr. Hope (Edinb. Med. and Sur- gical Journ., No. 88, p. 39), of Chatham, for its efficacy in cholera:—R^ Acid. Nitrosi 3i-, Mist. Cainph. 3viij. Misce et adde Tinct. Opii. xl. One fourth part to be taken every three or four hours.]* SPECIES II. CHOLERA FLATULENTA. WIND CHOLERA. THE VOMITING AND PURGING RARE, OR ABSENT ; GREAT AND OPPRESSIVE FLATULENCE ; RETCH- ING-, FLATULENT DEJECTIONS AND ERUCTA- TIONS. This species I have continued from Hippoc- rates, who denominates it, from the absence of liquid discharges, cholera, f^pi), as Sydenham, by translating the Greek term, has done, cholera sicca.—(Sect. iv.,cap. ii.) In this species the bile, instead of being ex- cessive in its flow, is obstructed or diminished in its quantity, and perhaps secreted with too low instead of too high a degree of pungency. The liver is evidently torpid and enfeebled ; and as flatulence 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, there- fore, cholera grafted upon a dyspeptic habit; and as, in dyspepsy, some quantity of air is let loose from most foods, whether solid or liquid, and an immense portion from many kinds, we are at no loss to account for the flatulence. The absence of evacuations is partly from spas- modic constriction, and partly from a want Of wholesome bile ; and the retching does not pass into vomiting, because the diaphragm, on whose * A form of this complaint, which is sometimes produced by the irritation of teething, is very prev- alent among children during the summer and fall months in the United States, and is also extremely fatal. We allude to the cholera infantum. By Dr. Hosack (Med. Essays, vol. ii.), this affection is con- sidered as a febrile disease, analogous to the bil- ious remittent of adults; and Dr. Butter seems very properly to have termed it the infantile re- mittent fever,—in which opinion the late Dr. Mann, of Massachusetts, also coincides. Accordingly, instead of prescribing anodyne and astringent mix- tures to lessen the discharges from the bowels, Dr. Hosack recommends medicines to allay the fe- brile irritation, ,and directs that the stomach and bowels be emptied by small doses of ipecacuanha and rhubarb: calomel and antimonials are fre- quently prescribed with good effect in this disease. The former medicine, in small doses, according to Dr. James Jackson (N. E. Journal, vol. i., p. 336), is one of the most useful—perhaps the most useful medicine employed in this disease, as it answers four intentions. 1st, It excites the stomach and bowels to evacuate their contents. 2d, It excites a change in the actions of the secretory vessels of expulsive co-operation the action of vomiting chiefly depends, forms a link in the entastic chain, as is obvious from the increased anxiety of die praecordia. When cholera, therefore, is an epidemic mal- ady, it will show itself under this form in per- sons of a highly dyspeptic idiosyncrasy, still more generally than when it appears as a spo- radic disease. But the 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 meinini ineunte hujus anni autumno." And on this ac- count Dr. Cullen has rejected the species alto- gether ; as others have transferred it to the genus Colica. But as the disease does exist, though it does not occur often, and as the dis- tinguished symptoms of anxiety and spasms of the extremities, which peculiarly draw the line between 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 sur- feit, cold drinks upon a heated body, cold vege- tables, as melons, inedible fungi mistaken for esculent mushrooms, poisonous animal and min- eral substances ; they all take place sporadi- cally, and all are at times epidemic. 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 recom- mended for dyspepsy. SPECIES III. CHOLERA SPASMODICA. SPASMODIC CHOLERA. BURNING PAIN IN THE EPIGASTRIC REGION; THE DEJECTIONS WATERY ; INEFFECTUAL RETCH- INGS, OR VOMITINGS OF A WHITISH FLUID ; those organs, and by sympathy produces similar effects in the liver and pancreas. 3d, In conse- quence probably of the last mentioned action, it appears to produce on the stomach the effect of a tonic. 4th, It occasions a more equal circulation over the whole body. The last effect is aided by frictions and warm bathing. Dr. Hosack remarks farther, " When the febrile symptoms are removed, weak brandy and water, or port wine and water, beef-tea, the liquor of oysters or clams, are useful in restoring the tone of the primae viae. But if the irritations of the intestinal canal continue after the febrile symptoms are removed, the chalk julap, with a little laudanum or paregoric, may judi- ciously be prescribed. In some instances, where the diarrhoea is attended with tenesmus, severe gripings, and the discharges are tinged with blood, small injections of starch and laudanum, or an in- fusion of rosemary (statice limonhim, Linn.), are among the most effectual aids to lessen these evils. But of all the modes of preventing or curing this disease, none is so effectual as removal to the sea- shore, where the atmosphere is not only cooler, but in a particular manner restores the appetite and strength of the patient."—D. Gen. IX—Spe. 3.] ' CHOLERA SPASMODICA. 143 SPASMS SUCCESSIVE AND VIOLENT, OFTEN EX- TENDING TO EVERY ORGAN ; BLOOD DRAWN FROM THE ARM BLACK AND VISCID ; GRIiAT DE- SPONDENCY AND PROSTRATION OF STRENGTH. There is no species of disease that has of late years attracted more, perhaps none so much, attention, both at home and in the east, as the fatal cholera we are now about to consider. We dare not say that it is an epideiny of modern origin, since it seems to be described by Bontius, and is supposed by some writers to be glanced at by several Greek physicians,* and even by Celsus. [Independently of the early notices left us by Bontius, and the more recent ones by Dellon,t in 1689, by Curtis and Paisley in 1774, and by Sonnerat from 1774 to 1781, Mr. ScottJ endeavours to prove that it was described by the medical writers of the Hindoos, and particularly in a work ascribed to Dhanwantari, a mytholo- gical personage, corresponding to the Greek Es- culapius. He also informs us that an epidemic prevailed at Arcot and other places about 1781, the occurrence of which was entered in the pro- ceedings of the Madras Medical Board on the 29th of November, 1787, in the following terms : —" A disease having in October last prevailed in Arcot, similar to an endemic that raged among the natives about Paliconda in the Am- bore Valley in 1769-1770, in an army of obser- vation in January, 1783, and in the Bengal de- tachment at Ganjam in 1781, &c, as well as to an epidemic over the whole const in 1783, under the appearance of dysentery, cholera mor- bus, or mordyxim, but attended with spasms at the proecordia, and sudden prostration of strength, as characteristic marks," &c. Mr. Scott adverts also to the occurrence of cholera in the Mauritius in 1778, and again in 1819 ; at Madras in 1782 ; at Vellore in 1787; at Ar- cot in the same year ; in the northern Circars in 1790 ; and in the vicinity of Trincomalee about 1804. Some fatal cases are also reported to have occurred at Jaulnah in 1814.] The subject, however, is yet unsettled ; and Mr. Annesley will not allow that the disease alluded to by Bontius, and still more lately by Sonnerat, is the exact disease before us.§ But we may at least affirm, that it has of late years assumed * Scoutetten thinks that it was described by Wang-Chou-ko, a Chinese, who lived before Hip- pocrates, under the term Ho louan. The Hindoo physicians assert that the cholera has always ex- isted in Hindostan.—(See Med. and Top. History of Cholera Morbus, translated by Doane. Boston, 1832.) t Voyage aux Indes Orientales. Amsterd., 1689. It was intimated to Dr. Good by the Army Medi- cal Board, that in a few official documents at the East India House, which were re-examined, the present disease is distinctly referred to, as having existed in the Bengal territory about a century ago, which will bring it only a little below the time when Dellon published his statement, and conse- quently give it confirmation. X Report on the Epidemic Cholera, &c, by W. Scott, fol., Madras, 1821. 6 Sketches of the most prominent Diseases in India, &.c, 8vo. Lond., 1825. an activity, fatality, and extent of range that it does not seem, from any history that has de- scended to us, to have possessed in earlier times ; and that cannot be contemplated with- out horror : on which account it has been com- pared by Mr. Orton to the sweating sickness, and various other pestilences, that, with great fury and mortality, have ravaged the world in former periods.* Some of the cases that occurred to Syden- ham in the first species of cholera, and which we have already noticed, were so rapidly fatal, that this distinguished pathologist has also been conceived to have been acquainted with the present species, and to have included it under thern. But his description does not seem to warrant any such conclusion ; [for, he says, it prevails at the end of summer and during the autumn, as regularly as vegetation comes in spring ; whereas this disease occurs at all sea- sons, and has no connexion whatever with heat. Sydenham describes it as a discharge of bile, and not of the peculiar fluid which we see in this affection.—-(See Elliotson in Med. Gaz. for 1832-3, p. 628.)] Dr. Cullen, in like man- ner, upon a cursory view, might appear to have had his eye directed to it; for he has loosely copied Sydenham's remark, that cholera is some- times so severe in its symptoms as to destroy life in twenty-four hours. But, on a more at- tentive survey, it will be perfectly clear that Dr. Cullen does not even, under this character, re- fer to the species before us ; for he 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 mark are samples of diarrhcea, or some other disorder, but do not appertain to cholera. Sauvages seems to have regarded cholera in all its species as a less momentous disease than even Cullen ; for though he professes to follow Sydenham altogether in the mode of treatment, he takes no notice whatever of Sydenham's re- mark, that its symptoms are sometimes so vio- lent as to destroy life in twenty-four hours. He has given, indeed, from Dellon, a species which he calls cholera Indica, but which differs very materially from the present, in being distin- guished by delirium, a strong though unequal pulse, and a. free flow of urine, both red and white, yet always limpid ; as though the com- plaint were accompanied with inflammatory fever. [It was from India and the adjoining countries, that the first clear and faithful descriptions of this species of cholera reached us ; and even before the disorder had extended to Europe, the Brit- ish practitioners in Asia had favoured us with so extensive a mass of communications that we were already in possession of a tolerably correct history of the general nature of the disease, how ignorant soever we might then be, and still are, of its remote cause ; and Professor Cru- * Essay on the Epidemic Cholera of India, pas- sim, 2 vols., 8vo. Madras, 1820. ,IACA. [Cl. I.—Ord. I. 144 CCEI veilhier (Anal. Pathol., I4me. Iivr., Paris, 1830) pays a very handsome and well-merited compli- ment to our countrymen in India, when he states that the observations subsequently collected at Moscow, Warsaw, Vienna, Berlin, London, and Paris, have only confirmed, or exhibited under new forms, the facts recorded in the modest ac- counts drawn up by our medical brethren at Cal- cutta. Not the slightest doubt, then, can be entertained of the absolute identity of the In- dian and European cholera: hence their de- pendance upon some common, grave, and pow- erful cause, which overcomes all the circum- stances of race, climate, temperature, season, and social customs ; hence also the suspicion that the disorder was imported into Europe by the Russian army in its invasion of Poland.] Among those who seem distinctly to have noticed it, though in a cursory way, are Son- nerat and Bartolomeo ; the first of whom tells us, that it is called by the natives mordczym, a term which, according to Bartolomeo, Sonnerat has transformed, rather than translated, into inort de chien; but which I am more disposed to think is a corruption of the Arabic mordekie, or mordechie, the very name by which Del- lon says the natives denominated it, and which significantly imports " the death-blow:" ac- cording to Golius, actio infer ens mortem; and hence synonymous with " mors repentina," or " mors violenta." By the name of mort de chien, however, in what way soever derived, it is, according to Mr. Curtis (An Account of the Diseases of India in 1782-3, &c. Edin., 1807), most generally known in the present day, and particularly at Madras ; and under this name, therefore, he has described it. To this gentleman we are in- debted for one of the earliest histories of the disease that within the last fourteen or fifteen years has reached our own country ; and which, added to Dr. Girdlestone's statement (Essay on Hepatitis and the Spasmodic Affections of India, Lond., 1787), began first of all to draw * At the present day, many practitioners object to the name for a reason which our author has not considered. Certainly if only one stage of the disease were regarded, in which vomiting, pur- ging, spasms, and prostration take place, the pa- thognomonic symptoms of cholera, the term spas- modic cholera would seem allowable ; but, as Dr. Brown argues, " when it is remembered that the choleric symptoms, if hot fatal, prove but the com- mencement of a series of changes, to which any one, who witnessed them alone, would give the appellation of fever, and which men of great expe- rience in the disease have declared they could not distinguish from typhus; if we observe, too, that long before this epidemic excited attention, symp- toms strikingly resembling those of cholera had been observed to form the initiatory stage of certain malignant fevers (see Dr. Negri's letter to Dr. Barry ; Morton, Pyretologia, pp. 16,13, 81; Torti, de Febribus, lib. iii., p. 124; and Med. Essays, by J. Brown, M. D., pp. 37-39), we are disposed to admit that it is really a fever, and that to designate it merely cholera is to take a part for the whole," &c—(Dr. Brown in Cycl. of Pract. Med.) The name which this gentleman prefers is that sug- the attention of British practitioners to its truly formidable character. Mr. Curtis, whose history was published in 1807, regarded it, at that time, as a new disease ; and finding no name for it in the nosological classifications, proposed, from its leading symp- toms, to call it spasmodic cholera ; and it is thus denominated in the present work. From the absence of yellow bile, and perhaps of bile of any kind, by which the disorder is peculiaily distinguished, some of the writers in India have objected to tbe term cholera, as conceiving that such a term necessarily imports a redundance of this fluid, and that too, of its natural colour, and other qualities ; yet, as I have already had occasion to show, there is no such necessity whatever imposed on the term, but merely an understanding that the bile is morbidly affected in its secretion, either in quantity or quality of any kind, and consequently 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 symp- tom. Mr. Curtis informs us, that soon after the attack, " the spasms began to affect the muscles of the thighs, abdomen, and thorax, and lastly passed to those of the arms, hands, and fingers ; but I never," says he, " then or afterward saw those of the neck, face, or back at all affected. The rapidity with which these spasms suc- ceeded the attack, and their severity, especially as affecting the muscles of the thorax and ab- domen, 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, gested by Dr. Johnson, namely, epidemic choleric fever. On the other hand, it might be argued, that a consecutive fever is not invariable ; and one re- mark made by Drs. Russell and Barry is, that such fever is of more frequent occurrence in Russia than India. In the cases which the editor has had opportunities of seeing, in the King's Bench and elsewhere, if the patients recovered from the stage of collapse, febrile symptoms always followed, though in very different degrees in different ex- amples. This observation accords with the fol- lowing statement:—" We can positively assert, that we have not met with a single case in Eng- land in which fever did not intervene between the choleric or cold stage and restoration to health ; and the result of inquiries we have addressed to individuals the most observing, and most familiar with the disease in this country, has proved that their experience has coincided with our own. It is true that in some cases this fever has been slight, but the choleric stage has been so like- wise ; for we have always observed a correspond- ence in intensity between these stages."-(Dr. Brown in Cyclop, of Pract. Med}—En. Gen. IX.—Spe. 3.] CHOLERA SPASMODICA. 145 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 Eastern cholera has of late assumed a severer and more fatal character, it is 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 the period to which his writings refer, 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 ex- hausted of sensorial power, as a Leyden vial 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 its attack in August, 1817, at Jessore, about a hundred miles to the northeast of Calcutta ; and spreading from vil- lage to village, reached Calcutta early in Sep- tember, having destroyed thousands of inhabi- tants in its course. From Calcutta it extended to Behar, depopulating many large cities, and compelling the residents to flee for safety to other spots. Benares, Allahabad, Goruckpore, Lucknow, Cawnpore, Delhi, Agra, Muttra, Meerat, and Barcilly, all suffered in succession ; the pestilence not diffusing itself at once, but travelling by a chain of posts, and attacking a second district after it had ravaged a first. At length it reached the grand army, and spread through its different divisions at Mun- dellah, Jubbulpore, and Saugor, marching in terrible array over the Deccan. At Hussinga- bad its havoc was dreadful for several days ; when, taking a course along the banks of the Nerbuddah, it alighted at Tannah. Having visited the famous cities of Arungabad and Ahmednugger, it spread to Poonah, and, in the direction of the coast, to Panwell, where it ramified north and south, crossed Salsette, and arrived at Bombay in the second week of Sep- tember, 1818, a twelvemonth after its appearance at Calcutta. While this was passing in the west of the Peninsula, the epidemy was making a like pro- gress to the east and south, progressively ex- tending over the whole Coromandel coast : whence it was reported to have spread, and a report that afterward proved to be but too true, to Ceylon; to the pure air and temperate cli- mate of Siam ; to Malacca ; and, across the Straits of Sunda, to China ; since which time, it has reached the Mauritius, and made its appearance on board vessels both in harbour and at sea. [In the summer of 1821, the disease first commenced its ravages on the borders of the Persian Gulf, after having raged in the earlier months of that year at Bombay. In * Dr. Rehman, in Hufeland's Joum. for June, 1824, or in Edinb. Med. and Surg Journ., Nos. 82 and 83. In 1828r it re-appeared at Orenburg, and in 1830, advanced through the southern provinces of Russia to Moscow. From Russia it extended Vol. I.—K 1823, it had extended itself, in one direction, to the shores of the Caspian Sea, and, in another, as far as the Mediterranean, making an apparent stand at Astrachan, and in the neighbourhood of ancient Antioch.* At this period, therefore, it very closely threatened Europe. It had passed over 90° of longitude and 66° of latitude ; hav- ing, in one direction, crossed the equator, and approached the boundary of the southern tropics; and, in another, traversed the northern tropic into the temperate zone.] The diagnostics-of this extraordinary pesti- lence are admirably furnished for the period before us, by Mr. Whyte, assistant surgeon to one of the divisions of the army, whose de- scription I shall copy ; premising that, while in the centre division the spasms preceded the vomiting and purging, in the others they gen- erally came on after the appearance of these symptoms. The disease, says Mr. Whyte, commonly be- gins with a watery purging, unattended with griping or any pain. At an interval of gen- erally from half an hour to five or six hours, and sometimes without any interval, the patient vomits a white fluid uncombined with bile. The spasms, in the division of the army from which this description is drawn, made their at- tack at no determinate period of the disease ; but, in general, not for many hours after the com- mencement of the vomiting and purging. - There was soon great debility and sinking of the pulse ; the extremities became cold; the eyes sunk in their sockets ; the vessels of the tunica adnata were injected with red blood, over which, if the disease advanced, a film was formed ; the fea- tures expressed the deepest anguish ; and the eyelids were either wholly or half closed. The patient invariably complained of great heat at the stomach, and called incessantly for cold drink. The tenesmus now became violent, while nothing was discharged but the fluid just noticed, and a substance like the coagulated white of an egg. The uneasiness and jactita- tion were so great, that it was with the utmost difficulty an opportunity could be got of feeling the pulse, which by this time was not always perceptible, although it was generally so till the spasms came on. These were always of the rigid kind, attacking first the toes and legs, and then extending to the thighs, chest, and arms. When they reached the chest, the breathing became so difficult, and the sense of suffocation so extreme, that the diaphragm most probably associated in the spasmodic action. [In one case, mentioned by Mr. Scott, where a man had been paralytic in his limbs, with a total numb- ness of them, they were severely affected with spasms, and became exquisitely sensible.] The most unfavourable and dangerous signs in the ordinary progress of the disease were, a coldness of the surface, extending over the region of the heart and stomach. The skin, itself into Poland, Germany, Great Britain and Ireland, Holland, France, Portugal, and the New World. Its general course has been, therefore, towards the northwest, with occasional deviations from it.—Ed. 146 C03LIACA. [Cl. I.—Ord. L under the nails, became incurvated ; the tongue was icy cold ; a universal colliquative sweat broke forth, with a shrivelling of the palms of the hands and soles of the feet: the spasms gradually declining as these symptoms increased. In general, all pain and spasm left the patient before death ; and even when the heart could not be felt to beat, he expressed himself easy, and said he was better. Sometimes, however, he was, at this period, in the greatest agony, rolling himself on the ground, groaning, and even bellowing most piteously; signs chiefly occurring in patients who lingered three or four days before death came to their relief. In this description the onset or invasion of the disease is hardly noticed with sufficient minuteness ; and I readily supply the deficiency, in this edition, from my friend Mr. Annesley's admirable delineation :—" The patient feels for several hours, or for a greater or shorter period, according to circumstances, a sense of general uneasiness and anxiety about the epigastrium, with a feeling of heat in the same situation. These symptoms increase more or less rapidly; and the countenance, which at first is merely expressive of uneasiness, soon becomes more and more anxious and distressed. The pulse at this time is generally quickened, and always oppressed. This state of the system forms the first stage of the disease ; a stage which, from its importance in the treatment, I have called the stage of invasion."* Mr. Annesley's two most prominent symptoms are the sense of heat, or burning pain, as he afterward caffs it, in the epigastric region, which is generally felt before the vomiting and purging take place ; and the black, thick, and ropy condition of the blood, particularly when the disease is fully formed. He expressly tells us, he never saw a case un- accompanied by the former of these symptoms, while the latter appears to have been as uni- versal ;f and I have hence been induced to add both these signs for the first time to its specific character. [The mind remains clear almost to the last. A favourable issue is denoted by a rising of the * Sketches of the most Prevalent Diseases of India, &c. By James Annesley, 8vo. Lond. 1825. The whole of this paragraph, in Dr. Good's hand- writing, was lately found among his papers, with a reference to the part of this work in which he intended to have inserted it.—Ed. t The appearances of the blood in the epidemic cholera of Europe correspond to Mr. Annesley's description of them in relation to the disease in Asia. The blood is observed to be black or dark- coloured, not unlike tar, and in its consistence thick, ropy, and semi-coagulated. It may be doubted, however, whether Dr. Good was correct in altering the definition, so as to embrace these changes in the blood; for, according to the Madras Report, in a few cases they did not occur, though the blood was always deficient in serum, and des- titute of the buffy coat. Chymical analysis of the evacuations from the stomach and bowels proves, indeed, that what the hlood has been deprived of is to be found in them, inasmuch as the fluid and more copious part of them consists of pure serum, and the coagulated part, or flaky matter, of fibrin. pulse, a return of heat to the surface, an incli- nation to natural sleep, and a diminution or ces- sation of vomiting, purging, and spasms ; - these indications being soon followed by the reappear- ance of foecal matter in the stools, of bile, of urine, and of saliva. Mr. Scott dwells on the rapid sinking of the pulse as one of the most invariable symptoms ; the exceptions being only a few, and chiefly where remedies are promptly administered. In an early stage the pulse gen- erally becomes small and accelerated, and, on the accession of spasm or vomiting, suddenly ceases to be distinguishable in the extremities. The length of time during which a patient will some- times live in a pulseless state, is extraordinary. Dr. Kellett relates a case where the pulse was gone within three hours from the attack; yet, the man lived in that state from the 3d of Octo- ber, at four P. M., to the 6th, at two P. M. On the cessation of the spasm or vomiting, and sometimes apparently from the exhibition of rem- edies, the pulse will return to the extremities for a short time, and again cease. The super- ficial veins and arteries are not always collapsed, even when the pulse has ceased; and, if open- ed, they will bleed. Their parietes then col- lapse, and no more blood can be extracted.. In every fatal case, the circulation stops, at least in the extremities, long before death.*] The following appearances were remarked on dissection : an enormous distention of the stom- ach and bowels, not from air, but a gelatinous substance; little sanguineous turgescence on the surface of the organs, but an absence of the moisture and glossy character of health: the liver much enlarged from the quantity of blood contained in its vessels, and, on one part of its convex surface, a considerable extravasation of blood : the gall-bladder filled with bile, and pro- jecting beyond the edge of the liver; the bile of a very dark colour, and the gall-ducts pervi- ous. The contents of the small intestines were dark-coloured, apparently from an admixture of bile : the contents of the large intestines resem- bled the white albuminous matter that was dis- charged before death, t The urinary bladder was * Scott's Report on the Epidemic Cholera, &c, p. 21-25. Madras, 1824. Professor Cruveilhier knows of some instances, in which the brachial artery was opened, but only a few drops of blood could be procured from it.—Anat. Pathol., livr. 14me. In several cases, the editor has felt the carotids beating forcibly, when no pulsation could be perceived in the arteries of the limbs. t In a certain number of cases at Paris which proved fatal at the blue period, Cruveilhier found the small intestines distended with an enormous quantity of choleric fluid. When, however, the patient had got through the blue stage, and died sometime after the reaction, none of this liquid was seen in the small intestines, but a yellowish or greenish pultaceous substance, which is compared to the meconium. The follicles were constantly enlarged: every shade of colour, from pink to a reddish black, was seen in different instances in the mucous coat. Frequently, points of ecchy- mosis were noticed; and when the intestine was of a brownish red colour, and a piece of it was held between the light and the eye, the most delicate arborescent vascularity was seen. Vascular con- Gen. IX.—Spe. 3.] CHOLERA SPASMODICA. 147 quite empty and wholly shrunk into the pelvis ; the kidneys apparently diminished ; the lungs so much collapsed as hardly to fill one half of the cavity of the chest: ho fluid in the pericardium. Such were the appearances in the body of a sepoy. In the European sabject they were the same, with the two following exceptions : the stomach and intestines were distended with wind, instead of with gelatinous fluid, and hence collapsed upon puncturing them: the veins on the outer surface of both, as well as of the meso- colon, were turgid with blood. [An excellent description of the appearances on dissection in the cases at Madras was pub- lished by Mr. Scott, and it shows that they vary considerably in different examples. No partic- ular alteration is found, he says, in the serous membranes; but the mucous ones generally exhibit signs of disease. The lungs are not unfrequently found in a natural state, but more commonly they are gorged with black blood, and assume the appearance of liv er or spleen. Some- times, however, they are collapsed, lying in the hollows at the sides of the spine, and leaving the thorax nearly empty. The heart and large vessels are distended, and sometimes even its left cavities are filled with dark blood. In the abdomen, the vessels of the viscera are turgid.* gestion was almost always most strongly marked near the valve of the coecum, and diminished in proportion to its greater distance from this point. Frequently, such congestion was restricted to the two or three last feet of the small intestines, though sometimes it was manifest through their entire length. In general, the intensity of the redness was in an inverse ratio to its extent. But, from all the facts which came under Cruveilhier's obser- vation, he concludes, that the morbid appear- ances are the most constant and important in the great intestines. These bowels are sometimes dis- tended with fluid; sometimes contracted at inter- vals, as if encircled with a cord at particular points. The choleric fluid was usually found in the great intestines, characterized by its limpid quality, and flakes of mucus, or its resemblance, to rice-water. The genuine fluid of cholera, according to Cruveil- hier, is only met with in the body of those who have been rapidly destroyed by the disease, and is not copious, unless the alvine discharges have been suppressed. When the patient has struggled two or three days against the disorder, the choleric fluid is not pure, being frequently of various colours, or, like the mucous secretion, tinged with blood. The follicles of the large intestines, near the valve of the coecum, are in general much developed, and perforated at their centre, which is indicated by a black point. Frequently they are surrounded by a red areola.—(Cruveilhier, Anat. Pathol., livr. 14me., p. 37.)—Ed. * The disease, as it presents itself in Europe, agrees with this account. In the post mortem ex- aminations at Paris, Cruveilhier noticed that the right cavities of the heart and the left ventricles were distended with a great quantity of blood. The left ventricle was sometimes moderately dilated, but, in other instances, so contracted as not to con- tain a drop of blood. The large arteries were full of liquid blood, but the small ones contained none at all. The whole of the venous system, and more particularly the veins of the abdominal viscera, were gorged with blood.—(Anat. Pathol., livr. 14me., p. 38.) j According to Mr. Scott, the stomach generally preserves its ordinary volume, sometimes con- taining greenish or yellow turbid matter. The intestinal tube is sometimes collapsed, but more frequently filled with air, distended into pouches containing whitish, turbid, dark, or green fluid. No fcecal or other solid matters are found in the intestines ; but, very commonly, large quantities of the conjee-looking fluid, or of turbid serous matter. The duodenum, and occasionally the jejunum, are loaded with an adherent whitish or greenish mucus ; at other times deprived of their natural mucus, and often quite healthy. Traces of bile in the intestines, or of any substance that has descended from the stomach, are exceedingly rare. Sanguineous congestion, and even active inflammation, Mr. Scott represents as more fre- quent in the bowels than in the stomach, yet as being often absent. He confirms the account given by other writers of the large quantity of bile in the gall-bladder; but he adds, that the gall-ducts are about as often constricted and impermeable as in the opposite state. The ap- pearances of the spleen, he says, are so diversi- fied, that they throw no light on the nature of the disease. The vessels of the mesentery are generally very full of blood. In the head, ap- pearances of congestion, and even of extravasa- tion, have been frequently observed, but not uni- formly. In one case, the sheath of the spinal marrow was inflamed.* The essential morbid appearances produced by spasmodic cholera, form yet a subject of in- quiry ; for those which sometimes occur and sometimes do not, cannot be regarded in this light, t Perhaps the accumulation of the greater * In the patients who were victims to the dis- ease at Paris, the spleen was generally small,dense, but more brittle than usual, and with an appearance as if the blood had been pressed out of it. The brain and cerebellum were healthy, but injected with blood as in asphyxia; sometimes with slight ecchymosis ; there was little serosity in the ven- tricles, or under the arachnoid membrane. The medulla spinalis was healthy, its different sections being tinged with red points. .The semilunar ganglions, the solar plexuses, the ganglions of the great sympathetic nerve, the intervertebral gangli- ons, the pneumo-gastric nerves, and the whole of the nervous system, appeared to Cruveilhier, in the numerous cases where he examined it, to be perfectly sound ; and he expresses his surprise that Delpech should have met with traces of inflamma- tion in the semilunar ganglions.—(Anat. Pathol., livr. 14me., p. 38, 39.) t On this interesting point, the statement of Cruveilhier confirms the truth of the remark in the text. After giving a description of the appear- ances revealed by dissection, Cruveilhier thus pro- ceeds :—" From what has been explained in rela- tion to the morbid anatomy of cholera, it is mani- fest that this disease is not one of those of whose nature a complete interpretation can be found in any anatomical lesions; since, besides the cases in which such lesions are clearly marked, others are met with in which they are slight, doubtful, and even totally absent. If,' then, we apply the fundamental axiom in morbid anatomy to cholera, namely, that every organic change that does not con- stantly attend a disease, cannot be considered as ma- king an essential part of it, the importance of post mor- T48 CCELIACA. [Cl. I.-Ord. I. part of the blood in the vessels of the viscera, the absence of all solid or foecal matter from the intestines, the suppression of the flow of bile into them, the full state of the gall-bladder, the empty and contracted state of the urinary blad- der, and the presence of a gelatinous or turbid serous fluid in the bowels, are the changes most inseparably connected with the worst and fatal forms of the disease.] The disease proved everywhere more fatal to natives than to Europeans : and, among many of the former, no blood could be drawn from the arm, however urgent the symptoms. The Bombay accounts differ in only a few particulars: the spasms were sometimes clonic or agitatory, instead of being entastic or rigid. " In a large proportion," says Mr. Orton, " there is no appearance of spasm in any part of the system. In many there is no purging ; in some, no vomiting; and, in others, neither of these symptoms.* I have already observed that these last were by far the most dangerous cases, and that the patients died under them, often in an hour or two; the nervous power appearing to be exhausted almost instantaneously, like the electric fluid from a Leyden jar. Mr. M'Cabe, depot-surgeon at Poonamallee," says the same author, " informs me that he has found the cases which to common observation might appear the most desperate (those which were attended with spasms and retchings of extreme violence), ac- tually among the most tractable : a truly valu- able remark, which my own experience fully confirms. Dr. Burrell saved eighty-eight out of ninety of his later cases" (Bombay Report, p. 68—80), meaning those of this kind. And in his general description of them he says, " that the retching was constant, and the spasms so violent as to require six men to hold the patient on his cot." On the other hand, nothing can tern examinations in the study of cholera will seem but limited, and the true characters of it must be looked for elsewhere."—Anat. Pathol., livr. 14me., p. 40.) Dr. Brown, after detailing what was re- marked in the dissections at Sunderland, expres- ses his conviction, that the symptoms during life throw much more light on the nature of the dis- ease, and its appropriate treatment, than appear. ances after death.—(Cyclop, of Pract. Med.) In Europe, the bodies of those destroyed by cholera putrefy slowly, as is always the case with subjects which have been deprived of considerable quanti- ties of blood. On the other hand, the alimentary canal putrefies rapidly, as happens in all cases of considerable sanguineous congestion of the diges- tive organs.—(Cruveilhier, op. cit., p. 35.) * In Europe the disease exhibits similar varie- ties : thus, with respect to the cases which occur- red at Paris, Cruveilhier informs us, that the most constant symptoms were thirst, pain in the epigas- trium, vast alteration of the features, with the eyes shut and retracted, small pulse, enfeebled voice, suppression of urine, and disposition to coldness. On the contrary, insome cases, evacuations from the bowtUy vomiting, and cramps, did not take place. The absence of evacuations from the bowels, how- ever, was a rare circumstance, and also an unfa- vourable one, as denoting not a stoppage of the flux, but merely an interruption of the excretion of the matters secreted.—(Anat Pathol., livr. I4me., p. 11.)—Ed. be more evident than the intractable and fatal nature of those cases, in which the pulse, in- stead of rising, sinks at once ; in which there are no spasms, and scarcely any vomiting or pur- ging ; and in which not only the excretion of bile, but of all the secretions, appears to be entirely suspended.—(Essay on the Epidemic Cholera, p. 29.) [It is also particularly remarked by Mr. Scott, that, in the low and most dangerous form of cholera, whether in European or native cases, spasm is generally wanting, or is present in a very slight degree.*] In a few instances, there was even an over- flow of yellow bile itself, making an approach to our first species : but these were uniformly of the slightest kind. " The bile," says Mr. Orton, " appears in excess only in the milder cases."—(Orion's Essay, p. 71.) And to the same effect Mr. Curtis : " The cases which ap- peared after this were all of a different nature, much less severe, and none turned out fatal. They were all of them combined with bilious accumulations."—(Diseases of India, p. 66.) The rapid or sudden fatality of the disease in its severest onsets is very singular. Even Sonnerat affirms, " that the patient was fre- quently carried off in twenty-four hours." But in the later epidemy of 1817 and 1818, this term was wonderfully abridged. " In the sec- ond, and very fatal visitation," says Mr. Orton, " of the epidemic experienced by Brigadier- general Pritzler's force, I am informed that vomiting, purging, and spasms were very fre- quently, in a great measuiey if not entirely, ab- sent ; all the powers of the system failing at once, and death commonly ensuing in three or four hours from the attack."—(Essay on the Epidemic Cholera, p. 41.) Several instances were heard of at Hoobly and other places, of natives being struck with the disease while walking in the open air : and who, having fallen down, retched a little, complained of vertigo, deafness, and blindness, and expired in a few minutes. Mr. Gordon gives a history of many cases of this kind. At Bellary, a tailor was * Report on the Epidemic Cholera, &c. Ma- dras, 1824. At Paris, the spasms were among the least constant symptoms of cholera, and Cruveil- hier assures us that the gravity of the disorder could not be estimated by them. They began in the muscles of the feet, and proceeded more or less rapidly to those of the legs, thighs, arms, abdomen, thorax, and masseters; they were exceedingly painful, occurred at more or less considerable inter- vals, and persisted, in some instances, to the last moment; while, in others, they ceased with the collapse.—(Anat. Pathol., livr. 14me., p. 12.) In the cholera at New-York, spasms occurred in about three fourths of the cases. They were sometimes late in their appearance. Their vio- lence seemed to be proportioned to the severity of the purging and vomiting; they were greatest in robust, especially intemperate persons, and more marked in males than females. In children they were rare, or slight.—See Paine's Letters on the Cholera Asphyxia, 8vo., New-York,. 1832: one of the most unprejudiced and candid works which the editor has read on this subject; and he feels much obliged to Dr. Paine for his kindness in sending him a copy of his valuable observations^ their former state as soon as the pressure is removed. Their shape is also very different from that of other hemorrhoidalptumours ; being broader at the base, rounder, and sometime* distributed in irregular clusters, like similar affections of the venae sapherwe. Tumours may also be presumed to be of this nature, when they can be traced from the anus far up the rec- tum.—(See Calvert on Hemorrhoids, &c, 8vo., Lond., 1824.)] Cutaneous excrescences about the anus, erroneously denominated, piles by the vulgar, may be taken off with a knife or a pair of scissors, in any number, or to any extent, without reserve. SPECIES V. PROCTICA EXANIA. FALLING DOWN OF THE FUNDA- MENT. INVERSION AND PROLAPSE OF THE VILLOUS TUNIC OF THE RECTUM, FROM ENTONY OB RELAXATION OF THE SPHINCTER. This is a very common and a very troublesome disease: but it is capable of a perfect cure in most cases, and of great relief perhaps in all. There are two varieties of it, proceeding from the two opposite causes of atony and entony, and which demand a very different mode of treatment. a Atonica. Relaxed Exania. 0 Spasmodica. Spasmodic Exania. Where the action of the sphincter is feeble, it collapses readily, and often imperfectly ; and the part of the rectum that always descends towards the verge of the anus upon a protru- sion of the feces, instead of being retracted with elasticity, remains exposed, or ascends imperfectly. Yet there is little pain or tumour, and reduction is easy. Under such circum- stances, exania, or a prolapse of the inner mem- brane of the rectum, will often oecur on the slightest dejective effort: but if, at the same time, the rectum be labouring under any morbid irritability from the stimulus of scybalous feces, ascarides, or purgatives, the protrusion will be greatly exacerbated, a much larger portion of the gut will be exposed, and its retrocession will be more difficult. Sometimes, indeed, the portion exposed has been very considerable ; for Morgagni relates a case, in which the val- vulae of the colon were hereby brought into view (De Sed., &c, xxxiii., lxv. 6); and Ha- gen (In Schroeder Verm. Schr., band i., p. 609, 1778) another, in which there was a prolapse of the entire colon itself. Common, however, as is the disease before us from local or general debility, it is perhaps still more frequent from that habitual or accidental excess of contractile action in the sphincter of the anus.* If the tumour remain down, it * The correctness of this explanation may be doubted: the case here described, probably, does not arise from excessive action of the sphincter, but rather from a bad habit of sitting long at stool, and from the protracted efforts of straining, in which many muscles tend to propel the rectum and its cpntents downwards, the sphincter and cellular connexions of the gut becoming thereby Gen. XIL—Spe. 5] PROCTIC A EXANIA. 197 becomes large, irritable, »nd painful; and, if assistance be Hot obtained soon, a violent and "serious inflammation will be sure to supervene. In the atonic prolapse, but little aid is neces- sary, in ordinary cases, to return the protruded part. A simple pressure-of the hand against the denuded part of the intestines, or sitting upoTi a plain and hard seat, will ordinarily be sufficient; and, if not, an introduction of the forefinger up the anus will always succeed. Hence patients, labouring under this variety, commonly return the gut themselves after evac- uation ; and in many instances it will ascend of its own accord. The chief difficulty is in effecting a cure ; which can only be accomplished in two ways : by invigorating and bracing the loose and re- laxed membrane, or giving it an adhesion to the subjacent cellular substance from which it is detached. The first may sometimes be accomplished by focal tonics and astringents; as cold water dashed against the buttocks, injections of cold water, solutions of alum, or sulphate of zinc, or an infusion of catechu, or gallnuts. The second can only be accomplished by ar- tificially exciting a slight continuous inflamma- tion in the cellular substance, by slipping off a small piece of the protruded membrane, as- rec- ommended by Mr. Hey, or passing a ligature through a small portion of it, and letting it re- main after the return of the membrane, till the inflammatory action has commenced ; by which means a radical cure is often obtained, in the ORDER II. SPLANCHNICA. DISEASES AFFECTING THE COLLA- TITIOUS VISCERA. DISQUIET OR DISEASED ACTION IN THE OR- GANS AUXILIARY TO THE DIGESTIVE PRO- CESS, WITHOUT PRIMARY INFLAMMATION. The order of diseases upon which we now enter, is in the present classification denomi- nated Splanchnica (XIIAArXNIKA), as pri- marily affecting, and being seated in, the viscera that are directly adjuvant to the function of di- gestion. The term Splanchnica is thus re- duced to its more limited and emphatic sense : for, in a loose and broader signification, it im- ports, like its Latin synonyme viscera, all the larger bowels or internal organs, to whatever cavity they appertain, and consequently includes the brain: but in its stricter and more exact in time so weakened, that a prolapsus ani ensues. In the production of the first variety described by the author, spasm of muscles has a share, partic- ularly when there is irritation about the rectum from piles, or other cause ; though, of course, the repeated protrusions will naturally, at last, weaken the sphincter.—Ed. same manner as a like cure is effected in scro- tal dropsy, by hooking forwards and cutting off a small piece of the tunica vaginalis after evac- uating the water. Mr. Copeland has employed this method in various instances, and with all desirable success. Where there is a prolapse of the upper part of the rectum, or of the colon, the dis- ease is of a different kindj for, in this case, the entire parietes descend, and the upper part is invaginated in the lower, as in an intro- susception of the smaller intestines ; but with less mischief in the present instance, as there ; is more space for play, and as the intestinal canal evinces less sensibility, and consequently admits of harsher treatment, in its progress towards its lower extremity. In this case, the whole we can aim at is to strengthen the fibres of the relaxed bowel, and restore them to a healthy elasticity by the use of tonic and astringent injections. In entonic or spasmodic exania, it will be often necessary to apply leeches, and to bleed pretty freely, before a reduction can be obtained. After which, as this is chiefly a result of spas- modic stricture, or depends upon like causes, the mode of treatment already recommended for the one will be the best plan to be pursued for the other. This complaint is also found occasionally as an effect in lithiasis, proctica marisca, helmin- thia podicis, scirrhus of the prostate gland, fistula ani, and other affections of the uterus, vagina, bladder, and neighbouring organs. meaning, it was formerly confined to those of the lower and upper belly, comprising what we colloquially call the Entrails ; and more espe- cially those which were consulted by the arus- pices, and constituted 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), are5 the liver, spleen, pancreas, mesentery, and omen- tum ; 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 acquainted with them, of the parts they respectively fulfil in accomplishing the economy of digestion ; we shall proceed, without farther delay, to a consideration of the diseases which belong to them under the proposed arrangement. The order embraces four genera : I. Icterus. Yellow Jaundice. II. Melaena. Black Jaundice. III. Chololithus. Gall Stone. IV. Parabysma. Visceral Turgescence. Of these, several comprise numerous species, which will be noticed in their respective places. 198 GENUS I. ICTERUS. YELLOW JAUNDICE. •YELLOWNESS OF THE EYES AND SKIN ; WHITE FECES ; URINE SAFFRON-COLOURED, AND COM- MUNICATING A SAFFRON D.IE ; THE COURSE OF THE BILE OBSTRUCTED.. This disorder was by the Greeks denomina- ted icterus (IKTEPOS) as above, and by the Romans, as Celsus particularly notices, Morbus arquatus, or Morbus regius : but on what ac- count either of these names has been given to it, we have no satisfactory information. Arquus means a rainbow, which requires more explana- tion than has 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, lascivia, per quae mens exhilaretur ; ob qu^e regius morbus dictus videtur" (Medicin., lib. iii., sect, xxiv.): —" 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 ori- gin or meaning of icterus, we are left altogether in the dark by the critics and lexicographers. It appears to the present author, however, prob- able, if he may venture upon a subject which has hitherto been tried in vain, that all these tprms are expressive of a common idea ; and, though not derived from a common root, are employed as equivalents to express its meaning. Icterus (iicrtpos), as it seems to him, is the He- brew term^ro witn a formative i producing "^p\y or " icter," and importing, as a verb, " to sur- round, circumfuse, encompass ;" and, as a noun, " a royal crown, or golden diadem." Icterus was a term also given to the golden thrush or golden pheasant, on account of its golden plu- mage : and hence the bird was fabled to be con- nected with the disease ; and it was believed, according to Pliny, that if a person labouring under the jaundice should look at the pheasant, the bird would die, and the patient recover. Regius, arquatus, aurigo, are not indeed univo- cals, but very clearly equivalents, and equally import gold, golden crown, golden bow, or cir- cumfusion; the colour of the disease, and its encompassing the body. There are other dis- eases however that produce or are accompanied with a yellow tinge of the surface, as well as jaundice ; as aurigo (Class vi., Ord. iii.. Gen. x., Spe. iv.), and sometimes porphyra or scurvy. Frank mentions a case of the latter, in which there was an intense yellowness of the whole skin, chiefly proceeding from broad maculae, even to the paims of the hands and soles of the feet. —(De Cur. Horn. Morb, Epit., torn, vi., lib. 6.) But in all these cases, the albuginea is little or not at all affected, and the urine does not com- municate the saffron die of jaundice. There is, however, a far more important in- quiry immediately connected with this subject, which I am afraid will be still less easily settled. We are sufficiently acquainted with the seat of sCOZLIACA. [Cl. I.—Ord. II. jaundice, which is the liver, and of its proxi- mate cause, which consists 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 secretes it ! Considering the large size of the liver in all animals that possess it, and, at the same time, how generally it is pos- sessed, being to all red-blooded animals as com- mon as the heart itself, there can be no doubt that it is of great importance in the animal economy, notwithstanding our uncertainty of the part it performs. Even below the rank of red-blooded animals, we often discover it, and of great extent; as in the snail, oyster, and muscle ; and frequently, too, where we cannot trace an organ answera- ble in structure and appearance to the liver, we are obliged to admit the existence of an organ that supplies its place ; for there are many in- sects, as the larvae 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 substance in which they find a habita- tion, and to give it a taste as bitter as ox-gall. The direct and obvious office of the liver is the secretion of bile, which, in most animals, is suffered to accumulate in a pear-shaped reser- voir, adhering to its concave surface, and de- nominated a gall-bladder. Yet, in many animals, even of different classes, we perceive no such reservoir, as the elephant, rhinoceros, stag, camel, goat, horse, trichecus, porpoise, rat, os- trich, and parrot: while we do not know of a reptile that is destitute of it. Upon the whole, however, it may be observed, that a gall-bladder is common to all carnivorous animals possessing a liver, and that it seems to be only wanting in those that feed on vegetables alone. Yet, while we see the distinction, we are ignorant of its cause, and incapable of applying it. In the hu- man subject, it has sometimes also been want- ing,* of which Dr. Cholmeley gives an example (Med. Trans., vol. vi., art. 4) : but such a de- ficiency has mostly occurred in infants who have perished soon after birth ; before which period, as there is no transit of feces through the intes- tinal canal, and perhaps no peristaltic action, it does not appear to be necessary. Perhaps, in- deed, antecedently to birth, there is no bile se- creted. In the case related by Dr. Cholmeley, although the whole of the bile, as fast 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. [The want of a gall-bladder does not always dangerously impair the health (Meckel's Anat., vol. iii., p. 312) ; and an example in which a person, with such malformation, reached the adult state, has been lately recorded.-^^m. de Mid. Mil., torn, xx., p. 406.) Cats bear the removal of the gall-bladder without fatal con- * Olivier, note sur l'atrophie de la vesicule bibl- aire, in Archiv. Gen. de M6d., torn, v., p. 196., Gen x-] ICTERUS. 199 sequences.—{Sir E. Home, Phil. Trans., 1813, part ii.)] It was stated in the physiological proem, that one supposed use of the bile is, to maintain the peristaltic action of the bowels. Yet Sir Eve- rard Home (Phil. Trans., 1813, pp. 156, 157) has given an example of a child that fed heartily, seemed to digest its food well, and had regular stools, and was nevertheless without a gall- bladder, or even a duct of any kind leading from the liver to the duodenum.* There are also a few other circumstances relating to the bile, that yet stand in need of explanation. The hepatic bile, or that secreted into the hepatic duct, is mild and sweet; the bile found in the gall-bladder is pungent and bitter; whence we might infer, that it is the gall-bladder that secretes the bitter principle. Yet, in children, the gall-bladder bile is as sweet as that of the hepatic duct; and in various in- sects, as we have already seen, a bile power- fully bitter is secreted without either gall-blad- der or liver. Who shall develop the cause of tfcese discrepances 1 Who shall unfold to us the use of the bitter principle of the bile, or explain why it is necessary to the animal econ- omy in an adult state, and not necessary in a state of infancy % fe Yet, whatever be the use of the bile, or the office of the liver, we know that the general symptoms of jaundice depend upon an obstruc- tion to the flow of the bile into the alvine canal, and its retrograde passage into the blood. [Thus in animals jaundice may be produced by apply- ing a ligature to the ductus choledochus ; and, in the human subject, dissection has frequently proved its origin from the direct or indirect pres- sure of various swellings and indurations, either of the pancreas, stomach, spleen, omentum, and other organs, against the biliary ducts. The * The daily escape of a considerable quantity of bile through a fistulous opening in the parietes of the abdomen, has occurred without serious im- pairment of the appetite, the digestion, or the health in general. This is a curious fact, and de- serves to be well considered in every physiological view of the hepatic system. Dr. Abercrombie visited, along with Mr. Lizars, a man, about fifty, who had had a biliary fistula for nearly four years. The complaint began with pain in the region of the liver, accompanied by vomiting and jaundice. After these symptoms had continued about three weeks, a tumour formed in the region of the gall- bladder, which was opened, and discharged much fluid of a mixed green and yellow colour, and some small biliary calculi. This opening closed, but another soon took place, which has continued to discharge ever since. The discharge varies in quan- tity, but is often so profuse as in a very short time to wet the patient's clothes as far as his knee, and in the night, to soak through his bed. Mr. Lizars at one time collected, in the course of fifteen or twenty minutes, about four ounces of a fluid, which on chymical examination exhibited all the proper- ties of pure bile The man has every appearance of good health, and except the fistulous opening, there is no appearance of disease in the region of the liver. His appetite and digestion are good, and the evacuations of a natural appearance.—See Aber- crombie on Diseases of the Stomach, &c, p. 395. —Ep. jaundice occasionally arising in pregnancy, is sometimes ascribed to the pressure of the grav- id uterus on the same canal, and sometimes to a plethoric state of the system, and of the liver in particular, in consequence of the suppression of the menses, which last opinion was espoused by Sauvages, Portal, and Powell. Dr. Elliotson has frequently seen jaundice in pregnancy ; not however as the result of pregnancy, but of in- flammation of the liver, and which subsided un- der the treatment for common inflammation, while the pregnancy went on.—{Med. Gazette for 1832-3, p. 488.) Whatever will produce hepatitis, or great congestion of the liver, will bring on jaundice.] It has been supposed, in- deed, that the bile might, after entering into the intestines, be absorbed and carried into the blood, and by this means produce a jaundice, and a jaundiced hue, without any obstruction to its flow into the intestinal channel. But, in this case, it seems impossible that the stools should not be tinged with a yellow, instead of present- ing a white hue, which is one of the common characters of the disease.* In order to consti- tute jaundice, there must generally therefore be some obstruction to the passage of the bile through its proper ducts into the intestinal ca- nal. And this obstruction may proceed from five sources, each of which may be accompanied with peculiar symptoms, and consequently fur- nish us with the five following species :—r 1. Icterus Cholaeus. Biliary Jaundice. ' 2.------Chololithicus. Gall-stone Jaundice, 3. ------Spasmodicus. Spasmodic Jaundice. 4. •------Hepaticus. Hepatic Jaundice. 5.------Infantum. Jaundice of Infants. The disease is also found symptomatically in pregnancy, colic, and fevers of various kinds; especially epanetus icterodes, or yellow fever, t [It is generally a sporadical complaint, but in- stances of its being epidemic, particularly at the termination of campaigns, in wet autumnal seasons, and also of its being endemic, are re- corded. J The disease appears to have been * Exceptions are occasionally met with, in which the feces are not white. Bile passes into the intestines; but so much is secreted, that all does not escape, and a portion goes into the cir- culation. It is conceivable then, that jaundice may arise from an excess of bile. This view, however, is sometimes regarded as hypothetical: thus, Dr. Abercrombie does not place confidence in morbid viscidity of the bile, spasm of the ducts, overflow of the bile, and what has been termed bilious congestion, as the causes of jaundice.—See Pathol, and Pract. Researches on Diseases of the Stomach, &c, p. 394, ed. 2. t The colour of the skin in yellow fever is not always regarded as the effect of jaundice. " The yellowness in this case is not universal; it occurs particularly about the neck ; and it appears rather to arise from a disordered state of the blood, or an altered condition of the blood as to some of its con- stituents, exactly as we see it in bruises."—See Elliotson in Med. Gaz. for 1832-3, p. 487. X See Monro on the Health of Soldiers, 2 vols. 8vo., 1780.—Pringle on Diseases of the Army, Edin., 1810.—Alibert, Nosologic Naturelle, &c, 4to., Paris, 1817, &c. 200 C02LIACA. [Cl. I.—Ord. II. epidemic at Cronstadt in 1784 and 1785, and at Geneva in 1814. In the latter city, it occurred after the hot weather of summer, being in some cases combined with a bilious fever ; in others, not associated with any other manifest disorder. —(Diet, des Sc. Mid., torn, xxiii., p. 414.) Persons who have been in warm climates are more predisposed to the disease than others.] SPECIES I. ICTERUS CHOLiEUS. BILIARY JAUNDICE. THE COURSE OF THE BILE OBSTRUCTED ; GEN- ERAL LANGUOR, NAUSEA, DYSPEPSY, AND OC- CASIONAL PAIN OR UNEASINESS AT THE STOMACH. The specific term cholaeus (\o\au>i) is here restored from the Greek writers, among whom it has been common from the time of Hippoc- rates. Dr. Cullen has not noticed this species : but it occurs in Bonet, Amatus Lusitanus, Fores- tus, Sauvages, and most of the later writers. It is easy, indeed, to conceive that bile may be- come inspissated from various causes, and par- ticularly from an absorption of its aqueous or thinner parts, by the lymphatics of the ducts themselves, or of the gall-bladder ; from an augmented secretion of the albumen, or, as Berzelius considers it, the mucus of the gall- bladder dissolved in the bile ; and from too vis- cid 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 tena- cious and high-coloured. [After the bile is secreted, if the hepatic or the common duct be obstructed, so that the passage of this fluid into the duodenum be pre- vented, it regurgitates into the liver, and is taken up by the absorbent vessels, and carried into the mass of the circulating blood,* in the serum of which it becomes dissolved, and thus gives it its own yellow colour. The blood, thus * The actual presence of bile in the blood of jaundiced persons is denied by M. Deyeux (Con- siderations Chimiques et Medicales sur le Sang des Icteriques, 4to., Paris, 1809); and doubted even by M. Thenard. On the contrary, the researches of M. Clarion (Journ. de Med. an 13), Orfila (Elem. de Chim. Med.), Saunders, Alibert (No- sol. Naturelle, 1817), and others, tend to prove the correctness of the belief, as ancient as Hippoc- rates, that the bile passes into the circulation. John Hunter supposed that the mixture of bile with the blood would make it coagulate ; but it is known that a quantity sufficient to give a yel- low tinge to the serum, does not have the effect in question. We know that the serous secretions assume a remarkable yellowness. If a person labouring under jaundice is blistered, the fluid from the blister is yellow, and the serous fluids within the body are of the same colour. Dr. Cheyne related to Dr. Marsh the case of a lady, affected with jaundice, whose linen was rendered quite yellow by the exhalation from her skin.—Ed. tinged, carries the die with it to every part of the body, and hence the general hue of jaundice is produced. It would seem, however, that the bile, in a liver, distended from obstruction of the ducts, is not only taken up by the absor- bents, but it is also forced into the mouths of the hepatic veins. In dissections, Dr. Saun- ders and Dr. Powell both notice bile in the tho- racic duct, and the first of these physicians found the serum of the hepatic veins in a dog, in which jaundice had been a short time before produced by a ligature on the common biliary duct, evidently more loaded with the colouring part of the bile, than the serum in other veins.* When the bile reaches the circulation, the in- tensity of tinge which different parts receive, will be in proportion to their vascularity, and the quantity of colouring matter thus carried to them ; or to the natural hue of the part being more or less calculated to show it, as in the eye, and white of the nails.] This species is found most generally in the autumn. In many instances, it commences slowly and insidiously ; there is felt a general restlessness, diminution of appetite, disturbed sleep at night, and disinclination for exertion of any kind : the urine is of a deep yellow, and deposites, perhaps, a pitchy sediment; the bow- els grow sluggish, the dejections are clay-col- oured or whitish, and have not the usual fecu- lent smell. In some examples, however, the bowels are loose. The eyes and surface of the body look yellower than usual, and there is a very troublesome itching of the skin. In this species, however, there is little or no pain in the right hypochondrium, and little or no sick- ness at the stomach, though a frequent sense of nausea. [In all cases of jaundice, except such as are very suddenly produced by the bites of venom- ous animals, and other particular causes, the yellowness commonly first shows itself about the inner angles of the eyes, the white of which is tarnished in a very early stage ; but the whole cornea soon becomes manifestly yellow. On the temples, light yellow patches are next seen, which daily assume a deeper and deeper tinge. Similar yellow discolorations then appear on the face, neck, and breast, and all at length spread and unite, so as to cause a universal tinge. Yellow semicircles at the roots of the nails make their appearance very early. It is a curious circumstance, however, in the history of jaundice, that the yellow die of the skin should generally first show itself on the upper parts of the body, which are likewise the first to resume their natural colour. * See Saunders on the Structure, Economy, and Diseases of the Liver ; Powell's Obs. on the Bile, p. 56; Bateman in Rees's Cyclopaedia, art. Jaundice. Where the presence of the yellow matter of the bile in most of the solids and fluids constitutes this disease, we are not to imagine that an impediment to the transmission of bile through the biliary ducts into the duodenum al« ways exists. In numerous persons, who died of or with jaundice, those ducts have been found perfectly free.—Andral, Anat. Pathol., torn, ii., p. 616, and Clinique Medicale. Gen. I.—Spe.2] ICTERUS CHO The tongue, palate, and teeth, have a yellow coating, which cannot be washed away. What- ever the patient puts into his mouth frequently has a bitter taste ; and, indeed, the bitterness in the mouth is very annoying, even not at mealtimes. A partiality to acids and sourish food is also generally experienced. In this affection, the pulse is ordinarily feeble. In the beginning, however, particularly if there be any pain in the hypocbondrium, it is hard, and even frequent and full. But after the pain subsides, the pulse has been known to sink to only thirty strokes in a minute, some examples of which are reported by M. Andree.—(See Diet, des Sci. Med., torn, xiii., p. 408.) In an early stage of the disease, free vomit- ing is of essential service. During this action, the diaphragm and abdominal muscles contract concurrently ; and the whole of the viscera of the abdomen is forcibly pressed upon. Such a pressure must necessarily, therefore, affect the gall-bladder and biliary ducts, and oblige them to pour out their contents very freely ; nor is there a more powerful means in our pos- session of unloading the liver of any viscous or stagnant fluid, or of restoring and invigora- ting its circulation. For this purpose, the anti- monial emetics are preferable to those of ipecac- uanha. They are less readily rejected, and ex- cite 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 purgative or two, with a copi- ous use of diluting, sub-acid drinks, which, in ordinary cases, will easily remove every symp- tom. But if the disorder, from the obscurity of its march, be not soon suspected, the impe- ded passages will become more obstinately ob- structed, 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 obstructing cause has been removed. Where the substance of the liver has been free, and the ducts alone obstructed, the quantity of bile that has accumulated in the gall-bladder has sometimes been enormous. In one instance, which terminated fatally, this reservoir was found, after death, to be so considerably dilated, as to be loaded with not less than two Scotch pints, or eight pounds, of this fluid.—(Edin. Medical Essays, vol. ii., art. xxx.) [Whether this case ought to be received as a confirmation of the statements of Galen, Darwin, and Powell, that jaundice is sometimes the result of paral- ysis of the gall-bladder, from immoderate dis- tention of it, is a question not easily solved.] 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 effect- ually relieved by the blue-pill, or small doses of calomel, or Piummer's pill, which is better than either, continued for two or three weeks at a time.* If the liver partake of this torpitude, * In the treatment of jaundice, Dr. Elliotson very judiciously recommends us first to consider LOLITHICUS. 201 and no acute symptoms occur, the disease is apt to run into the fourth species, and must be treated accordingly. 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 THE FECES ; FREQUENT RETCHING ; ACUTE PAIN IN THE HYPOGASTRIC REGION, INCREASED UPON EATING. This species is the icterus caiculosus of most of the nosologists. It is so closely connected with the genus chololithus, or gall-stone, forming the third in the present order, in its general origin, symptoms, and mode of treat- ment, that the reader may be referred for al- most all these to the latter. Yet it is neces- sary to give the two affections distinct places : for the yellow die of the skin and urine, which forms a pathognomonic symptom in icterus, oc- curs 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 (Heb- erden, Med. Trans., vol. ii., p. 124) ; 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 be- comes more disposed to crystallize. Dissection ha3 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 chololi- thus. whether any inflammation exist; whether the case is one of hepatitis ; and, if it be, then it is to be treated on principles applicable to the latter disease. He coincides with many other practi- tioners in considering mercurial purgatives more efficacious in jaundice than any others.—(See Med. Gaz. for 1832-3, p. 489.) When jaundice appears to be connected with any affection of the fiver of an inflammatory character, Dr. Abercrom- bie, after subduing the activity of the symptoms by local and general bleeding, blistering, low regi- men, and free and continued purging, recom- mends mercurial friction, and friction with iodine. —Pathol, and Pract. Researches on the Diseases of the Stomach, &c, p. 399.—Ed. * Jaundice takes place from the presence of a gall-stone in the biliary ducts, when the calculus is a considerable time in passing, so as to produce an obstruction of some continuance in the duct: when it passes in a shorter time, though the symp- toms may be equally severe, no jaundice follows. —(See Abercrombie on Diseases of the Stomach, the Intestinal Canal, the Liver, &c, p. 394, ed. 2.) " It has been disputed," says this able phy- sician, " whether biliary calculi are ever formed in the substance of the liver, or in the gall-bladder only. But Morgagni mentions several instances in which they were found in the fiver, and even of great size ; and, therefore, there is no doubt of another point, which has been disputed, namely, that they may produce jaundice by sticking in the hepatic duct."—Op. cit., p. 396.—Ed. 202 C02I 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, HYSTE- RIA, OR SOME VIOLENT PASSION OF THE MIND ; AND SPONTANEOUSLY SUBSIDING WITHIN A FEW DAYS AFTER THESE ARE REMOVED. The general symptoms of this affection are those of the preceding species, or of chololithus means, which so closely agree with the prece- ding ; but the causes and mode of treatment are different; and it is necessary to attend to their specific signs, in order that they may be distinguished. Spasmodic jaundice occurs for the most part in those of irritable habits, or whose liver, from a long residence in hot climates, from an undue indulgence in spirituous potations, or high-sea- soned dishes, 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, indic- ative of irritability and increased action of the liver, and of a larger regurgitation of bile into the bloodvessels than is necessary for the pur- pose 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. [Spasm of the common duct is particularly mentioned by Dr. Cullen among the causes of jaundice, and Dr. Powell deems the fact well established, although it has often been denied. Andral enumerates four principal causes of the complete or incomplete, temporary or perma- nent, obstruction of the biliary passages, viz., the lodgment of a foreign body in them ; their compression by membranous adhesions, or some kind of tumour ; their spasmodic contraction; and the thickening of their mucous membrane from inflammation.—(Arch. Gin. de Mid., torn. vi., p. 16.) Jourdan and Breschet, however, express their suspicions, that the latter state also prevails in every instance reported to be spasmodic.—(Meckel's Anatomy, vol. iii., p. 313, note.) Jaundice frequently accompanies spasmodic diseases. Thus it is said by Syden- ham to come on during hysterics, a circum- stance which the editor has never seen, and which is denied by Dr. Heberden. According to Dr. Saunders (p. 235), anger not only aug- ments the quantity of bile, but likewise vitiates IACA. [Cl. I—Ord. II. it. Hence, flowing into the duodenum in large quantities, and regurgitating into the stomach, it produces the same effects as an emetic ; and hence, probably, the term choleric, as applied to passionate people. If the ductus communis should not transmit it as fast as it is secreted, and the gall-bladder be already full, then it will return towards the liver, and, by entering the bloodvessels, produce jaundice. Dr. Bateman regarded this as the most probable explanation of the influence of the passions in producing a temporary jaundice, and of course he did not put much faith in the doctrine of spasm.* Among the less common causes of jaundice, a thickening of the biliary ducts is mentioned by Morgagni, who records a case of a total oblit- eration of the common duct.—(Op. cit., Epist. 37, art. 10.)] The primary cause of this disease we cannot always trace ; but it 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 sympathetic connexion which exists between the liver and various parts of the body. [The jaundice sometimes produced by corporeal suffering, irritation in the aliment- ary canal, and the bites of venomous animals, is referred by Hoffmann, Mead, and Bosquillon, to the spasmodic species.] An affection of the brain will also often produce jaundice (Marsh, in Dublin Reports, vol. iii.); and hence a fre- quent exciting cause is a sudden and violent burst of the depressing passions, as terror, jeal- ousy, 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 ful- ness at the stomach, accompanied 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, * Rees's Cyclopaedia, art. Jaundice. Dr. Aber- crombie doubts the truth of the doctrine of spasm of the biliary ducts as a cause of icterus (on Dis. of the Stomach, pp, 394 and 400); and Dr. Bur- der is of opinion that we have no evidence of its existence.—(Cyclop, of Pract. Med., art. Jaun- dice, note, p. 5.) The two following cases are quoted by Dr. Abercrombie, as proving clearly the origin of jaundice from passions of the mind: a woman, mentioned by Hoffman, was affected with jaundice every time that her mind was agi- tated ; and a medical gentleman, spoken of by Mr. Cooke (on Derangements of the Digestive Or- gans), became jaundiced almost invariably when he had a dangerous case under his care.—Ed, Gen. 1.—Spe. 3.] ICTERUS SPASMODICUS. 203 and girds them as with a cord. The epigastric region is greatly distended, and cannot endure the pressure of the hand; while the pulse ex- hibits little variation. The bowels are for the most part costive, and moved with difficulty. [The stools are scanty, of a grayish, or clay colour, and, as long as the urine is of a deep yellow or saffron colour, voided with difficulty. But, when this secretion becomes paler, they assume their natural yellowness again, are more copious, and the patient begins once more to be con- scious of the sensation preceding or accompa- nying their natural expulsion ; a sensation, that is lost while the bile continues to tinge the urine in a considerable degree. It should be understood, however, that costiveness does not always precede or attend the first symptoms of jaundice ; but as Monro, Pringle, and Powell attest, there is sometimes a considerable loose- ness, with grayish stools of a faint, or rather sour smell. At first the urine is yellow and quite limpid ; but it afterward becomes frothy, saffron-coloured, reddish, and very thick ; some- times almost black, depositing a sediment like brick-dust, or dark blood. In proportion as the yellowness of the skin fades, the urine loses its saffron colour, and becomes clear again.] This colour shows itself 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 sclerotic coat of the eye, assume the same livery. And if the disease 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 pericardeum, the heart, the peritoneum, the meninges, the substance of the brain, the car- tilages, and even the bones, are clothed with the common colour. Stoll (Rat. Med., part iii., p. 386, et passim), Lieutaud (Hist. Anat., p. 190), Bartholin (Epist. iii., p. 419), and Morgagni (Op. cit., epist. xxxvii., art. 7), give various ex- amples of this ; though the last observes, that a yellow tinge of the brain is a rare occurrence. One of the latest fluids that becomes tinc- tured is the milk in icteric wet-nurses ; probably in consequence of its rapid passage and elabora- tion from the fluids introduced into the stomach. Dr. Heberden has remarked, that, in wet-nurses, the milk is never tainted with the bile either in taste or colour ; but this assertion is too gen- eral, 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.* And hence, indeed, the only reason we can assign for the bilious and bitter taste that is often present in the stomach, insomuch that every thing the * Lin. Med., 1697, Febr., Obs. 7. In examining the body of a woman who died in the Lock Hos- pital of Dublin, from protracted disease, connected with jaundice, Dr. Morris found the mammae full; and, by moderate pressure, several ounces of a yellow tenacious fluid, having all the visible prop- erties of pure bile, were discharged from them. —Ed. 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-coloured. The fact is, that the whole mass of blood is so impregnated with bile, that the saliva, and all the other lubri- cating secretions of the mouth, fauces, and oesophagus, and probably the gastric and pan- creatic juices, are loaded with the same mate- rial, so that the sense of taste cannot be other- wise 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 yel- low object-glass ; from which we may judge, that the humours of the eye, like the other fluids of the body, are also tinged, as Celsus observes (Medicin., lib. iii., sect, xxiv.), with the resorbed bile, and communicate the tinge to the picture thrown upon the retina. Lucre- tius, 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 intro- duces (De Rer. Nat., iv., 333) as illustrative of another subject, and appeals to as a familiar fact:— " Lurida praeterea fiunt, quaequomque tuentur Arquatei; quia luroris de corpore eorum Semina multa fluunt, simulacris obvia rerum; Multaque sunt oculis in eorum denique mixta. Quae contage sua palloribus omnia pingunt. " The jaundiced, thus, see all things round them In yellow; every object a3 it flows [clad 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." Dr. Heberden, however, affirms, that all the jaundiced patients he has at any time attended have contradicted this opinion, with the excep- tion of two females, whose testimony he is disposed to hold lightly ; and Professor Frank is decidedly of opinion, that no such affection takes place. Yet from a single case in my own person, produced, when a student, by long- continued pressure of the epigastrium against the edge of a table in copying my shorthand minutes of medical lectures, I can confirm the general opinion : for, the first suspicion I enter- tained 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 already observed, that the crystalline lens, and, perhaps, all the humours of the eye, should be tinged, and acquire the yellow hue of 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 jaundice, perceive objects coloured with yellow, and others in their proper hues. [The statement here made by the author, and which agrees with what Morgagni has said 204 CGELIACA. [Cl. I.-Ord. II. relative to this curious point,* seems to be con- firmed. Dr. James noticed this disorder of vision in two old patients affected with jaun- dice. Hoffmann records two similar cases ; and Alibert met with an additional example in a girl who was in the Hopital St. Louis. Dr. Pemberton met with two instances, and in both the jaundice was not very intense. Dr. Elliot- son has also had patients similarly affected; and he remarked that, in these examples, there was either a fulness of the vessels round the cornea, or a degree of inflammation of the con- junction present.—(Med. Gaz. for 1832-3, p. 487.) The rarity of this affection of vision in jaundice corresponds to, and depends upon, the rarity of the extension of the yellowness to the humours of the eye.] I have said that this species of jaundice, and the remark may be applied to all the spe- cies except the last, sometimes assumes a chronic form. In this case the distressing symptoms of severe spasmodic pains, intumes- cence, and sickness subside ; but the bile does not flow freely into its proper channel, and con- tinues in a greater or less degree to be absorbed and carried into the circulation. 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, more- over, the bile that thus tardily finds its way into the duodenum must be grosser and more vis- cous than in a healthy state ; and hence another cause of retardation and irregular supply. There is also a change in the colour, as well as in the consistency, of the bile, frequently to be met with in the chronic state of the disease ; which may sometimes be the result of a morbid secretion, but is perhaps more generally that of a chymical decomposition, from the joint in- fluence of decay and animal heat. And under these circumstances, 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 (Eph. Nat. Cur., dec. iii., ann. iv., obs. 86); as tena- cious and limpid as the white of eggs (Stoerck, Ann. Med., i., 124); and as crowded and gran- ular as the spawn of frogs.—(Eph. Nat. Cur., dec. ii., ann. ix., obs. 9.) In this chronic form, jaundice has sometimes run on for a long period of time, occasionally for a twelvemonth. It has alternated 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 mil- iary and scarlet fever. The general functions, when it has assumed this form, and the con- stitution has become habituated to it, are some- times so little disturbed, that we see people of the middling and lower ranks of life who * Aliquando tamen, sed rarissime, fieri potest, ut flava in hoc morbo objecta appareant, nimirum si cornea tunica bile tota saturata sit, neque turn solum, quod et Mercuriafis concedit, verum etiam si quando oculorum humores summa flavedine infecti sunt. 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 cover- ing 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 cholceus, are of doubtful advantage. When, however, the bowels are particularly costive, or there is reason to suspect the lodgment of a small cal- culus, or of any inspissated bile in the biliary duct, purgatives are indicated in the first case ; and both purgatives and emetics in the last. But in all other examples they must add to the disease by increasing the irritation, and should give way to bloodletting, if the patient be in vigorous health, succeeded by opiates, the warm- bath, or warm and anodyne fomentations applied to the epigastrium.! The opiate should be given in pills, for the stomach will often 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 after- ward, and continued till the pain abates. Blis- tering 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 au- thor's practice, has at times effected a cure where other means had been found useless. A portion of the ointment, equal in size to a hazelnut, should be rubbed every night into the epigastric region till the ordinary eruption ap- pears. 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 * All men of experience will agree with Dr. Abercrombie on this part of the subject, namely, that long-continued jaundice generally depends either upon chronic disease of the liver, or upon other diseases of neighbouring organs, compres- sing the biliary duct. Yet, as this judicious and correct observer has remarked, chronic disease of the liver of most extraordinary extent is some- times unattended with jaundice.—See Abercrom- bie on Diseases of the Stomach, &c, p. 401.—Ed. t When jaundice is characterized more by spas- modic pain than inflammation, Dr. Elliotson deems the hot-bath and opium the best means of relief. But if the pulse be quick and strong, he recom- mends bleeding, as the most effectual antispas- modic that can be employed. He prefers also com- bining the opium with a full dose of calomel, which will prevent costiveness, and produce a free dis- charge from the alimentary canal. A poultice over the part, he says, is very useful.—(Lect. at London University, pub. in Med. Gaz. for 1832-3, p. 489.) Dr. Good has this eminent physician with him as a believer in the reality of spasmodic icterus.—En. Gen. I.—Spe. 3.] ICTERUS SF consequently there will be great languor, indis- position to labour, and a tawny skin. For all this, a generous diet, cheerful com- pany, and moderate exercise, and especially riding on horseback, go very far towards effect- ing 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. The dandelion (leontodon taraxacum, Linn.) has been highly extolled by many writers of es- tablished 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. Pem- berton have since contributed 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 alkalis, however, seem to have much better pretensions to favour; and have been still more widely employed in this disease, and pretty extensively regarded as general, and hence as hepatic solvents. Yet that they do not act as solvents in hepatic cases, is clear from a striking instance related by Dr. Heber- den, who tells us that he once attended a per- son 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 decom- posing power.—(Med. Trans., vol. ii., p. 65.) Soap, however, and ^her alkaline prepara- tions, may perhaps be useful in another respect: I mean, in becoming a substitute for the defi- cient bile, and cleansing the bowels by their possessing something of the same chymical 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- back against whatever may be the remedial powers either of soap or of the alkalis; and that is, their frequent and easy decomposition in the stomach, in consequence of its contain- ing at all times some quantity, and occasion- ally a very large proportion, of acidity. We may often, perhaps, introduce so much of these * The reputation of the leontodon is sustained by the experience of some modern American phy- sicians. The occasional use of the blue-pill, fol- lowed by mild aperients, with the alkalis and the infusion of dandelion, has been found effica- cious in some long-continued cases of the nature described in the text —D. ASMODICUS. 205 medicines as shall be more than sufficient to neutralize the acid ; but where a large quantity is wanted for this purpose, it is better to employ the alkali alone than combined with oil, as less troublesome to the stomach. And where this is done, the best, because the most manageable preparation of the alkalis, will be that which is the purest and most concentrated, as the liquor potassae ; nor does it appear that the other alkalis would answer better if we had forms for elaborating them in the same manner. The Cheltenham spring has unquestionably been serviceable in the relics or sequelae of the disease, 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 internally and externally at the same time, will be found more beneficial than those of Cheltenham. Another remedy to be spoken of, which of late years has excited great attention, is the diluted aqua regia bath, invented by the late Dr. Scott. For nearly thirty years he was in the habit of using this preparation, and had tried it in almost every variety of strength, and al- most every variety of proportion, which the two acids that enter into the composition may be made to bear to each other. He commenced his experiments in India, where, on account of the 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 found it proper to do in our own country ; and where, nearly thirty years ago, he plunged the Duke of Wel- lington into one up to his chin, for a severe he- patic affection he was then labouring under, and thus restored him to health in a short time. In England it was not often that he found it necessary to raise the bath much above the knees, and frequently contented himself with a mere foot-bath or common wash-hand basin alone. In both which cases, however, the at- tendants on the patient should sponge him at the same time with the diluted aqua regia, over the limbs, and occasionally over the body. The aqua regia should 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 observed, by those who are inclined to form this mixture extemporaneously at their own houses, that if either of the acids be poured immediately on the other, a large volume of very offensive gas will be disengaged ; on which account, it will be better to pour them separately and slowly on their proper measure of water. If the acids be of adequate strength, the mix- ture subdiluted for bathing will, to the taste, have the sourness of weak vinegar, and perhaps prick the skin slightly, and excite a peculiar rash, if very delicate, but rarelv otherwise, after 208 C(EL it has been applied to the surface for half an hour. But since these acids vary much in their degree of concentration, as distilled by different chymists, 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 what- ever other part is exposed to its action. A nar- row tub for a knee-bath, just wide enough to hold the feet and reach the knees, should con- tain 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 afterward every other day, or only twice a week. Dr. Scott affirms that he has employed this process with decided advantage in almost all cases dependant on a morbid secretion of bile ; whether the secretion be superabundant, defect- ive, or depraved. 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 em- ployed 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 operate like a charm, and produce almost immediate ease.—(See also Med. Chir. Trans., vol. viii.) From the rapidity, therefore, with which it acts in some cases, he is inclined to think that it operates, not by the absorbents, but by the nerves ; and has made various experiments to show that it is the chlorine of the muriatic acid alone, by the present process decomposed 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 of its intelligent inventor : but the process is worth following up, and va- rying in other proportions, as well as employing in other families of diseases. My own use of it is at present too limited to speak with de- cision ; yet, so far as I have tried it, it has cer- tainly appeared to me to allay irritation and produce a tonic effect. In two or three in- ACA. [Cl. I.-Ord. II. stances, the advantage has been decisive ; and patients who had hitherto been seldom two months without a severe return of the com- plaint, have entirely escaped, and apparently lost the morbid predisposition. In a few other cases, it has completely failed. Mr. Wallace has been employing chlorine in the form of gas, obtained by a mixture of mu- riatic acid with the black oxyde of manganese, as well as diluted with aqueous vapour ; and he regards the peculiar eruption brought out by it as a favourable sign.* SPECIES IV. ICTERUS HEPATICUS. HEPATIC JAUNDICE. THE COURSE OF THE BILE OBSTRUCTED BY A DERANGEMENT OF THE LIVER FROM SCIR- RHOUS OR OTHER INDURATIONS ; OCCASIONAL RETCHINGS AND DYSPEPSY : LITTLE OR NO PAIN IN THE RIGHT HYPOCHONDRIUM. In the preceding species, the appendages to the liver, as the gall-bladder or gall-ducts, are the chief seat of disease, at least in its com- mencement. In the species before us, the dis- ease is chiefly seated in the liver itself. It may be a result of the preceding species when they have assumed a chronic form ; but, as the liver itself is often affected from the first, it is enti- tled to be treated of as a distinct species. The course of the bile, indeed, is evidently ob- structed, but rather in its secretion, or separa- tion from the substance of the liver, than in its transmission by the biliary tubes. This species is noticed by Boerhaave, by Sauvages, and by Dr. Cullen in his Synopsis, though he has offered no remarks on It in his First Lines. In Boerhaave, however, it im- ports altogether a different disease, for it is jaundice produced by hepatitis,! or inflamma- tion of the liver ; and is hence a mere symp- tom, to be removed alone by a removal of the idiopathic complaint. It is more accurately described by Richter, who confirms and illustrates the opinion of Vo- gel and Selle ; both of whom suppose it to de- pend upon some peculiar irritation in the liver itself, or in the whole hepatic system ; but an irritation not dependant upon or directly leading to inflammation. This irritation is of various kinds, and produces different effects, all of which become causes of obstruction 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 con- cretions in its substance ; of which Richter gives a striking and complicated example in a person, who, after death, was found to be with- out a gall-bladder, and whose liver was filled with whitish calculi of different forms and * Researches respecting the Medical Powers of Chlorine, London, 1822. t Van. Swiet. Comment., Hepatitis et Icterus multiplex, torn, iii., t) 914. Gen. I.—Spe. 5.] ICTERUS INFANTUM. 207 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 obstruc- tion, without being collected into a reservoir. This is the worst state in which jaundice can possibly make its appearance ; for, though there is little or no pain, it shows disease in the structure of the liver, and is frequently a mark of a broken-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 often to witness the picture, drawn so feelingly of the Athenians during the plague :— "---- Defessa jacebant Corpora; mussabattacitoMedicina timore."* It is only in an early stage of this disease, if happily we should be so soon consulted, that mercury has any chance of being successful; and it should be given rather as an alterant in small doses pertinaciously followed up, than in large proportions so as to excite a ptyalism ; for we have here no strength to draw upon with- out injury. " I think," says Dr. Baillie, " that many practitioners of the present day have erred in administering mercury too long, and in too liberal doses. When mercury is carried beyond the point that is necessary, it often injures the constitution by weakening it, and rendering the nervous system very irritable." In some cases, small doses of calomel in combination with conium have been serviceable ; and I have cer- tainly found benefit from covering the hypo- chondriac region with a large plaster of the em- plastrum 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 by neutral salts, form the best mineral invigorant to which he can have recourse. Possibly, in this malady also, the diluted aqua regia bath may be of ser- vice, employed as recommended under the last species.t [In that state of the liver which produces * Lucr. De Rer. Nat., vi., 1176. t The Ballston and Saratoga mineral waters of the state of New-York have long been celebrated for their medical qualities, in several of the forms of jaundice or biliary obstruction, provided that general irritation and local inflammation be first judiciously remedied. Dr. Francis states that the sulphurous waters of the Avon spring, in Living- ston county, New-York, are extremely useful in like cases, particularly where the tone of the di- gestive organs is impaired.—See his Observations on the Mineral Waters of Avon, in the United States Med. and Surg. Journal, No. 1, New-York, 1834. The waters of the yellow and white sulphur jaundice towards the end of intermittent fevers, mercury is the best and only remedy ; and calomel, in small doses, is the form- under which it is the most efficient. When jaundice arises from congestion of the vessels of the liver, general bloodletting, or (if the patient's reduced state prohibit it) local bleeding, by the application of leeches, or cupping-glasses, to the right hypochondrium, will be proper; after- ward, mercurial and iodine frictions are indi- cated.] SPECIES V. ICTERUS INFANTUM. YELLOW GUM. JAUNDICE OF INFANTS. THE COURSE OF THE BILE OBSTRUCTED BY VIS- CID MECONIUM ; WITHOUT PAIN OR DYSPEPSY J EASILY REMOVED BY PURGATIVES. This is the mildest form under which jaun- dice makes its appearance, and that which is carried off with least trouble. In ordinary cases, the only symptoms are the pathognomonic colour, and a degree of languor and drowsiness beyond what is common to infants on birth or shortly after. A yellow hue, however, on the surface of infants, is not necessarily a symptom of jaundice, properly so called; for Lentin,* Cullen, and many others have well observed, that such a discoloration may also be the result of a pecu- liar yellowness of the serum of the blood, un- connected with bile (Muller Origine Ictcri, Jen., 1788) ; analogous to the golden teint which we so frequently 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.t A dose of castor-oil, or any other active springs of Virginia are highly beneficial to inva- lids suffering from disorders of the digestive or- gans, chronic affections of the liver, the sequelae of protracted intermittent fever, &c, and particu- larly in cases where mercury has been prescribed to excess for disorders of this character.—See Bell on Baths and Mineral Waters, pp. 436, 7.—D. * See Baume's Description de l'Ictere des nouveaux n^s, &c, Nimes, 1788. Cull. Synops. Nosol., Gen. xci., 5, note. t Cl. vi., Ord. iii., Gen. x. This view coincides with that taken by Andral: sometimes, he says, the icteric teint of the skin seems to be merely the result of an effusion of blood in its texture. Such appears especially to be the nature of the icterus of newborn infants, in whom the red hue of the skin may be seen gradually to change into a yel- low teint, which, in its turn, is effaced, and re- placed by the natural complexion. In the livers of such children, no constant lesion has been no- ticed that would account for the jaundice. This organ is said to have been sometimes seen gorged with blood; but it is quite as frequently found in this state, yet uncombined with icterus.—See Andral Anat. Pathol., torn, ii., p. 616. 208 CCEI purgative, will generally be sufficient to remove the obstruction, which in almost every instance proceeds from meconium more than ordinarily tenacious, and consequently will carry off the disease. But frequently the mouth of the duc- tus choledochus communis is so completely in- farcted with this viscid matter, that purgatives are insufficient; and, in this case, an emetic should be given, and in a few days repeated, if necessary. [Icterus being seldom a disease essentially mortal, and only having, in general, a fatal ter- mination when combined with some serious organic disease, a distinction should be made between persons dying with jaundice, and those dying from it ; a distinction first made by the celebrated M. Portal. The bodies of icterical subjects usually pre- sent the same morbid colour which they exhib- ited in life. However, according to M. Portal, the intensity of the colour is sometimes dimin- ished ; while some bodies, which never showed any marks of jaundice previously to death, afterward turn of a very deep yellow. A ten- dency to anasarca is generally noticed, and, when incisions are made in the cellular mem- brane, a good deal of serum, which is of a more or less yellow hue, flows out. Whatever fluid is found in the ventricles of the brain, or in the chest, or abdomen, is likewise either of that colour, or reddish. In short, every texture, and even the most compact parts, present a yellow tinge ; as the fat, the muscles (which with other organs are softened), the membranes, especially the serous ones ; the lining of the arterial system; the tendons; the cartilages ; the periosteum ; and the very bones. According to Morgagni, the lungs, heart, liver, spleen, and kidneys are softened, their texture containing a limpid yellow or reddish fluid. Most of the secretions partake of the same tinge. No part, however, is more frequently affected in jaundiced subjects than the liver. Some- times dissection demonstrates it to be either in a state of chronic inflammation,* or of preter- natural volume or smallness, or converted into a fatty matter resembling tallow. Abscesses, ulceration, biliary concretions within its sub- stance, and numerous close adhesions of it to the neighbouring parts, are likewise occasionally discovered after death, t The state in which the gall-bladder is found * In jaundice, an inflammatory condition of the liver, in an obscure form, and often of small ex- tent, may be suspected, when the disease is at- tended with pain, or tenderness in the region of the liver, though without fever, or any symptoms of active inflammation. The cases of more de- cided inflammation of the liver are alleged by Dr. Abercrombie to be attended with jaundice only when the inflammation is seated chiefly on or near its concave surface.—On Diseases of the Stomach, &c, p. 397. t Dr. Stokes (London Med. and Surg. Journal, March, 1834) has seen an instance of jaundice arising from an aneurism of the hepatic artery, and also mentions the accumulation of fecal mat- [ACA. [Cl. I.—Ord. II. is extremely diversified ; very often it contains calculi, of which there may be only one or many. The single one is occasionally very large ; the numerous ones, sometimes amounting to hun- dreds, are usually of diminutive size.* At the same time, the gall-bladder may contain no bile, or be prodigiously distended with it. Van Swieten speaks of a case, in which the gall- bladder reached from the liver to the crista of the ileum, and had more than a pint of bile in it. In some cases this fluid has been found viscid, almost black, and to contain gritty par- ticles like sand. Dr. Bostock (Bright's Reports, 4to., Lond., 1827) has given the analysis of the fluid of the gall-bladder in a case of protracted jaundice, accompanying tubercular liver and dropsy. It had an orange colour and thin con- sistence ; the animal matter in it was almost entirely albumen, with a little colouring matter different from that of the bile ; and, in fact, it contained none of the usual biliary principles. In particular examples, the gall-bladder exhibits traces of the effects of inflammation, its coats being thickened and indurated. In one instance Bonnet (De Ictero, obs. 13) found excrescences within its cavity. Sometimes the gall-bladder is adherent to the neighbouring organs. In one patient who died with jaundice, the gall-bladder and cystic duct were altogether wanting.— (Bourgeoise, De I'Ictere, 4to., Paris, 1814.) At various points of their course, the hepatic, cystic, and common biliary ducts frequently con- tain calculi of different sizes. When these con- cretions lodge either in the hepatic or common duct, they completely block it up; and hence it is often found tonsiderably dilated above the obstruction, and containing a large quantity of bile ; a circumstance that does not occur when the foreign body lodges in the cystic duct. Sometimes these several canals are so con- tracted, that a small probe cannot be introdu- ced into them. Stoll met with the common duct in what he calls a cartilaginous state. Cabrolius has recorded a case of jaundice, in which there was a malformation of the common duct, its end towards the liver being very wide, and its communication with the bowels as mi- nute as the extremity of a capillary vessel. The biliary ducts are often found compressed, and even more or less obliterated by various kinds of tumours formed in their vicinity. A most remarkable enlargement of the biliary ducts, in consequence of the pressure of a scirrhous pan- creas on the common duct, is recorded by Mr Todd. After death, more than a quart of bile was found in them. The patient's face is rep- resented to have been quite of an orange colour. ter in the intestines as another cause of this com- plaint.—D. * Calculi in the biliary ducts are not unfrequent causes of jaundice. " Their mere presence in the gall-bladder does not usually seem to produce either local or general inconvenience. Out of nineteen instances of biliary calculi, which oc- curred to Morgagni, besides four to Valsalva, in post-mortem examinations, not one had experi- enced jaundice."—Dr. Burder in Cyclop, of Pract. Med. Also Andral, Precis d'Anat. Pathol., torn. ii., p. 614. Gen. II-l MELAENA. 209 —(Dublin Hospital Reports, vol. i., p. 325.) Dr. Elliotson states, that jaundice has arisen from the lodgment of a lumbricus in the duct of the liver (Med. Gaz. for 1832-3, p. 488); and, if this be the case, the opinion entertained by Andral and Cruveilhier, that worms only pass into this situation after the patient's de- cease, would appear to be incorrect. When the common duct is rendered com- pletely impervious by the lodgment of a calculus, and yet no jaundice takes place (a fact that has sometimes been noticed), the possibility of the existence of a second biliary duct has been sug- gested as an explanation of the circumstance. This preternatural arrangement is even admit- ted as possible, both by Morgagni and Portal, whose statements rest upon several cases in which it had been traced. In some individuals who had been free drink- ers, and died with jaundice, Stoll found the pylorus contracted, and a considerable portion of the stomach hard and almost cartilaginous.— {Ratio Medendi, pars tert.) Sometimes the duodenum around the termi- nation of the common duct has been found scirrhous and ulcerated. Dr. Marsh has re- lated several instances, proving that jaundice may arise from an inflammatory state of the mucous membrane of the duodenum, whereby the mouth of the common duct was obstructed. —(Dublin Hospital Reports, vol. iii.) Dissections prove that the compression of the biliary passages may be the result of disease and enlargement of the pancreas or spleen. A case of black jaundice is recorded by Zacutus Lusitanus, as having taken place in a person in whom the spleen was entirely wanting. Sometimes the vena portae has been observed to be very considerably enlarged, not merely in its trunk, but its ramifications. Any cause pro- ducing an obstruction of the circulation in this vessel may give rise to a species of jaundice very difficult of cure. In one subject which was opened by M. Honore, the vena portae was almost impervious in consequence of a tumour formed in its parietes. The patient had been afflicted with jaundice, and the stomach was cancerous.—(Archiv. Gin. de Mid., Septembre, 1823.) Among other causes of jaundice, dissection, as well as clinical experience proves, that col- lections of fluid in the abdomen, and abscesses of the liver, deserve to be particularly mentioned. In a woman whom the editor opened some time ago at the request of Dr. Pinckard, and whose gall-bladder had been nearly annihilated, there were abscesses occupying at least two thirds of the interior of the liver. Jaundice is not an uncommon attendant also on organic diseases of the heart and lungs. When connected with those of the heart, it probably arises from the impeded return of the blood from the liver.—(Abercrombie's Path, and Pract. Researches on Diseases of the Stomach, &.C., p. 399, ed. 2.) Though the above account corresponds to what is commonly established by dissection, it is curious that sometimes ail the foregoing mor- Vol. I.—0 bid changes exist unaccompanied by the slight- est degree of jaundice. And sometimes jaundice prevails in subjects in whom no organic disease whatever can be traced after death. Here Hoff- mann and Morgagni have recourse to the sus- picion of spasm of the biliary ducts, which are supposed to become relaxed after death.] GENUS II. MELilNA. MELENA. the colour of the eyes and skin yel- low-green, fuliginous, leaden, or livid ; the dejections dark-coloured, grumous, pitchy, or consisting of blood ; bile and the intestinal secretions more or less altered; anxiety; depression of spirits.* This is the Melaena, or MiXalva voSaos of the Greeks: a name given to it by Hippocrates, who has been followed up by the Latin writers; among whom, with a mere translation of the term, it is called morbus niger, or the Black- disease, whence the name of black-jaundice. The colour of the skin under this disease is always dark, but differs considerably in its shades, and even in its hue, in different indi- viduals.—(Lib. xiii., obs. 23.) It sometimes ap- proaches to a green ; whence by Forestus, Ra- zouz (Tables Nosol., p. 129), and other writers, it has been called icteritia, or icterus viridis; on which account, it has of late been described under the name of Green-Jaundice by Dr. Baillie. This versatility of colour is not to be wondered at; for I have already had occasion to observe, that the bile, under different states of a diseased liver or its appendages, exhibits very different appearances. In respect to consistency, it has sometimes been found watery (Bianchi. Hist. Hep., p. 129 ; Sebez. Exercit. Mid., p. 93), vis- cid, or flaky; in respect to colour, green (Augen. Hor., torn, i., lib. xi., ap. 5), muddy, pale-white (Eph. Nat. Cur., dec. i., ann. iv., obs. 194 ; Cent, iii., ix., app. 9), pitchy-black, eruginous (Stoll, Rat. Med., part i., p. 292), and versi- coloured ; in respect to internal properties, in- sipid, salt, acid, or acrid and effervescent. In the disease before us it is always of a dark, and often of a black or pitchy hue. The stools are dark-coloured, and occasionally almost black ; but the urine is sometimes pale, and generally clear. Dr. Cullen seems to have been doubtful how to dispose of the genus melaena. In his Sy- nopsis, he has omitted it altogether : in his First Lines he has briefly noticed it, first under hae- matemesis, and again under diarrhoea, as though melaena were a variety of both these. But not satisfied with this distribution, he afterward in- troduced it into his " Catalogue of Diseases omitted, but which ought not to have been omitted" in his Nosology. * The pale colour of the evacuations, formerly mentioned by Dr. Good in his definition, is here omitted, as inconsistent with the etymology of the term, and the opinions generally entertained of the nature of the disease.—Ed. 210 cozi 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, accom- panied with or preceded by a considerable pain in both hypochondria. [Out author adopted Hoffmann's belief, that, in melaena, the liver and spleen were diseased, and their bloodvessels ruptured. Dissections do not prove the constancy of these circum- stances. Dr. Cheyne has known two instances in which inky blood was vomited up, in conse- quence of long-continued sea-sickness, where no reason existed for suspecting tumour, or obstruction in any of the solid viscera of the abdomen ; facts proving, in his opinion, that melaena may depend solely upon an excitement of the inner surface of the stomach. In the melaena cholaea, referred to a flow of ill-condi- tioned bile, though this fluid may really deviate very much from- its healthy quality, this may depend entirely on some modification of secre- tion quite unconnected with structural disease. Thus, as Andral particularly states, no relation can be established between those alterations of the liver which dissection reveals, and the changes of the bile as- detected by various tests. In the great number of diseased states of the liver, attended with change of structure, noticed by this author, the bile in the ducts and the gall-bladder was neither altered in its quantity or qualities. While, in other examples, where anatomy can discover no trace of any change in the parenchyma of the liver, the bile is either more abundant or more scanty than usual, or of a different quality from what it is in the healthy state. "I have," says he, "been sur- prised at the enormous quantities of bile dis- tending the digestive tube, where scarcely a slight hyperemia existed in this canal, and the liver seemed in no way changed."—(Andral, Pricis d'Anat. Pathol, torn, ii., p. 611.) How- ever, in cases of melaena cholaea, the liver may be diseased, and in the examples which have fallen under the editor's notice, it has generally been so; though it is proper to add, that the subjects of them had all been hard drinkers. In Dr. Markland's case, the liver was smaller than usual, and had a rough shrivelled appearance, with fissures one eighth of an inch in depth. It contained neither blood nor bile, and was of a natural consistence. The spleen contained little blood, but was of the natural size and appear- ance.—(See Edin. Med. Journ., No. 79, p, 301.) In the third case, recorded by Portal (Mem. sur la Nature, &c. de plusieurs Maladies, torn, ii., Paris, 1808), no visceral disease was discovered after death ; however, in two other examples described by him, the liver and spleen were diseased. They were also found diseased, as well as the stomach and small intestines, in a case published by Dr. Cheyne (Dublin Hospital Reports, vol. i., p. 263), who particularly men- tions, that the vessels of the liver and spleen appeared to be destitute of blood. In a curious example of sixteen pounds of melaena found in the colon by Mr. Geoghegan, there were tu- bercles of the liver, and a stricture of the rectum. [Cl.L—Ord. IL —{Trans, of the Assoc. Physicians of Ireland, vol. i., p. 197.) The above symptoms have been accurately distinguished by Hippocrates, who in conse- quence hereof has noticed the two following species 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. Melaena Cholaea. Black Jaundice. Green Jaundice. 2. ------Cruenta. Black Vomit.* SPECIES I. MELAENA CHOLAEA. BLACK J A UNDICE. GREEN J A UN- DICE. OCCASIONAL DEJECTIONS OF DARK OR PITCHY BILE, INTERMIXED WITH THE FECES ; OCCA- SIONAL VOMITINGS OF YELLOWISH-GREEN AND ACID COLLUVIES J GREAT LANGUOR , OFTEN VERTIGO ; HYPOCHONDRIA FREE FROM PAIN, BUT TENDER UPON PRESSURE. The liver is here generally diseased in its structure, and a morbid deep-coloured bile, ful- vous, greenish, or fuliginous, is secerned in- stead of the natural excretion ; the finer part of the fluid is first absorbed, and' afterward 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 Hanover, " black jaundice means nothing more than yellow jaundice of a more than usually deep die ; yet when the real dis- ease exists to which this name ought to be * Dr. Goldie has taken some pains to ascertain precisely what is said about MeXniva vovaos in the treatise ascribed to Hippocrates, and he no- tices, as a remarkable circumstance, that the an- cient description contains not a word respecting the black discharges by stool, which Sauvages and the moderns mention as characterizing me- laena. Dr. Goldie states, that our author was evi- dently mistaken in supposing the two species, me- laena cholaea and melaena cruenta, to have their derivation from Hippocrates ; and he does not ap- prove of Dr. Good's generic definition, inserted in the former editions, as seeming to rest wholly on the dark hue of the skin, and not that of the dis- charge from the alimentary canal. The editor certainly prefers Dr. Goldie's description, which runs thus :—" We mean, therefore, by melaena, the occurrence, as a symptom, in any disease, of very dark-coloured, grumous, pitchy, often highly fetid evacuations by stool, commonly joined with sanguineous vomiting ; or, we use the word as the name of a disease, in which such evacuations, with or without vomiting of blood, constitute the charac- teristic symptom. In these two senses authors speak of symptomatic and idiopathic melaena; but even where the latter phrase is with most pro- priety employed, the hemorrhage may generally be traced to some constitutional disorder, or local organic disease, as its primary cause."—See Cy- clop, of Pract. Med., art. Melaena.) One objec- tion perhaps may be made to Dr. Goldie's defini- tion, namely, that the recharge, when blackish, generally has no smell, and has not that highly fetid quality which he has specified.—Ed. IACA. Gen. IL—Spe. 2.] MELAENA CRUENTA. 211 limited, no practitioner, who closely examines the very dark colour of the skin and of the de- fluxions, and especially the danger that accom- panies it, can avoid concluding that it has some- thing peculiar in its nature, and cannot be merely an intense degree of yellow jaundice. It is highly probable," he continues, " that a part of the dark colour may depend upon the hue of the bile itself in a state of morbid se- cretion ; but, along with this, there is also a very great structural decay in the biliary organs as well; a decay which gives the chief charac- ter to the disease; prevents so frequently all beneficial effects from the best medical treat- ment ; and consequently renders the disease so often fatal.'"—{Med. Versuche, &c., Leipsic, 8vo., 1779.) The green jaundice is sometimes to be found in young persons, but far oftener in the middle and more advanced periods of life. In men it occurs more frequently than in women, proba- bly on account of the greater wear and tear of their constitution, as more exposed to all weath- ers and all climates; and appears to be less connected with intemperance than the yellow jaundice ; and Jess disposed to terminate in ab- dominal dropsy. In many instances, the hardness and enlarge- ment of the liver extend through its entire structure, but are perhaps more frequently con- fined to some particular part of it. Upon pres- sing the region of the liver, the patient is com- monly 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 noticed in yellow jaun- dice ; 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, con- tinues "natural, both with respect to strength and frequency, unless some circumstance may have occurred to irritate the constitution for the time." In the more striking cases, how- ever, 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 more than thirty. The stools are generally pale ; but, from some irregular excitement of the liver, appear sometimes tinged with bile of a pecu- liarly 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 sediment. The appetite varies, not only in different per- sons, but even in the 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 afterward, evincing a gen- eral taste for whatever is introduced upon the table. In the preceding species, jaundice is not a dangerous disease, except where the substance 0 2 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 pa- tient, 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 ser- . vice, and been severely tried by a change of climates. Contrary to what occurs in all the modes of yellow jaundice, the morbid hue is here so deeply rooted in the system that it never quits it. If the patient recover, it may become a few shades lighter, but it never leaves his person altogether, and is always visible in the counte- nance. When the pulse has been very slow, I have commonly found it connected with some affec- tion of the head, and particularly apoplectic or epileptic fits. As there is much obscurity in this disease, its medical treatment is indecisive. Mercurial preparations, which so often aid us in the first species, are rarely of service in the present. Dr. Baiffie thinks he has found neutral salts, taken daily as an aperient, of palliative use ; but of a radical cure he seems altogether, to de- spair. It has appeared to me, that, though mer- cury fails when employed alone, combined with antimonials, it is often highly beneficial; and of all preparations of this kind, I have by far preferred the form of Plummer's pill, or, in other words, the submuriate of mercury in union with the precipitated sulphuret of antimony, with a warm stimulant of gum-resin. I have also found unquestionable benefit from a union of alkalis and bitter tonics, particularly the liquor potassoe with infusion of columbo. The aqua regia bath is another tonic well worth try- ing. I think I have found it serviceable, but have not yet employed it on a scale that ena- bles me to speak peremptorily. Here also, as in spasmodic jaundice, the counter-irritation of the tartar-emetic ointment has occasionally proved highly beneficial. ■ [A medicine, now found to be highly worthy of trial in melaena, is the rectified oil of turpentine, recommended by Mr. Adair (Medical Facts and Obs., vol. iv.), as will be further noticed at the end of the next section.] SPECIES II. MEL^NA CRUENTA.' BLACK VOMIT. OCCASIONAL VOMITINGS AND DEJECTIONS OF GRU- MOUS BLOOD, INTERMIXED WITH DARK-COL- OURED BILE ; PUNGENT, TENSIVE PAIN IN BOTH HYPOCHONDRIA ; COMPRESSIVE PAIN AT THE PIT OF THE STOMACH, AND FAINTING. In this species, the organs subservient to the formation of bile are generally in a more de- cayed condition than in the preceding: and it may hence be contemplated as a disease com- 212 CCELIACA. [Cl. I.—Ord. II. pounded of melaena cholaea and hsematemesis atonica, or passive hemorrhage from the vessels of the liver, spleen, or both ; sometimes from those of the stomach. Little as we know of the exact part per- formed in the animal economy by these organs, we see enough to convince us, that the func- tions of the liver and of the spleen are inti- mately connected ; the blood in both is highly carbonated, as even5 the natural colour suffi- ciently indicates ; and the closest alliance sub- sists between them. On which account Hip- pocrates ealls the spleen the left, and Aristotle the bastard liver. It is a singular property of the blood of the spleen, that, like the catamenial discharge, it does not coagulate. Dr. Home took a like view of this disease : and affirmed it to be produced, not by a mere effusion of bile of a darker colour, as in black or yellow jaundice, but by an effusion of blood also, which, however, he imagined to proceed from the meseraic veins. He relates three cases, in which the disease appeared to be car- ried off by a critical discharge ; the first by a diarrhoea, and the other two by an efflux of sweat and thick urine. [The preceding observations require some comment. The doctrine, that the disease is in- variably connected with a morbid change of the liver and spleen, has been already refuted by a reference to dissections performed by M. Por- tal and Dr. Markland. The hypothesis also of ruptured vessels in these organs being the source of the blood in'the intestinal canal, is very re- pugnant both to the plain truths of anatomy, and to the facts disclosed in the dissection of per- sons carried off by the complaint. According to Portal, three kinds of matter are vomited up in melaena; blood not changed; blood so changed as not to be recognised; and bile, which may also be of a deep black colour.— (Mim. sur la Nature des plusieurs Maladies, 8vo., Paris, 1808.) When the stools are inodorous, and present a yellow colour on being diluted with water, Dr. Brooks sets down the case as a bilious melaena, in opposition to the sanguine- ous.—(Trans, of Assoc. Physicians of Ireland, vol. i., p. 148.) Anciently the liver was fancied to secrete a yellow, and the spleen a black, bile ; and the inky matter, which is sometimes vomited up, or discharged by stool, was sup- posed to pass from the spleen into the stomach through the vasa brevia. Dr. Home and M. Portal, however, have proved, that the black matter may transude from the minute arteries of the inner surface of the stomach and intes- tines ; and that it frequently is nothing more than blood altered from its natural appearance by some peculiar action of the vessels.] Dr. Baillie has, in a few cases, found this cocoa-like fluid thrown up in great abundance, where the stomach alone has seemed to him to have been solely affected, and the liver to have been apparently unconnected with it, though he admits the concurrent action of both viscera in other cases. But, in these special instances, there has been a peculiar obscurity or uncer- tainty, which is sufficient to justify us in not placing much reliance upon them. In certain cases, Dr. Baillie tells us, the patients were in some months restored to tolerable health ; and here it is difficult to speak with precision as to the extent of the disease. In one case, this distinguished practitioner tells us, the stomach was examined after death ; it appeared very capacious ; but no structural disease " so far as he recollects," was found either in the stomach, the liver, or the spleen.—(Lectures and Observations on Medicine, Posthumous,S\o., 1825 Intemperance, but especially habitual dram- drinking, is the common 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 ; the skin hot and dry ; the strength greatly impaired. . . As a symptom, this disease is met with in severe attacks of dysentery; but more frequently in those of yellow fever,* and especially that va- riety or stage of it which by some writers has been distinguished, though perhaps unnecessa- rily, by the name of Bulam fever. 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 had time to be ab- sorbed and enter into the circulation, so as to produce the true atrabilious tinge upon the skin, which distinguishes the idiopathic malady. In the case described by Dr. Markland, the whole line of the intestinal canal, in its villous coat, appears, on dissection, to have been more or less gangrenous ; and half a pint of black grumous blood was found in the stomach. The liver, as already noticed, was of a pale brown colour, smaller than usual, with a shrivelled fis- sured surface, without either blood or bile. In so worn out and exhausted a state of the affected organs, or perhaps of the constitution generally, as this disease indicates, little bene- fit 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, * Black vomit has been repeatedly observed by American practitioners, as occurring in yellow fe- ver as it has prevailed at different seasons, and in various parts of the United States. Dr. Cothveall supposed it to arise from causes connected with a derangement of the biliary secretions (see Am. Phil. Trans., vol. v.); but Dr. Physic concludes more justly, from morbid examinations, that it is a secretion from the inflamed vessels of the stom- ach and intestines (New-York Med. Rep., vol. v., p.. 130); in which opinion Dr. Barton, of New-Or- leans, coincides.—(Am. Journ. of Med. Sci., No. xxix., Nov., 1834.) Dr. Lyons, however, thinks (Lond. Med. and Phys. Journal, Feb., 1828) that the matter of black vomit is identical with altered blood, and he has produced a fluid perfectly similar to it, by adding muriatic acid diluted with water to blood. Drs. Hosack, Francis, Townsend, and others, have witnessed this species of coeliaca in individuals of depraved habits who have been vio- lently attacked with yellow fever. Sometimes a similar matter is vomited in the acute attacks of marsh fevers.—D. Gen. Ill] CHOLOLITHUS. 213 gentle means, whether in the shape of purgatives or emetics, or both, will answer hest; as we have a shattered fabric to work upon, and vio- lence will only add to its weakness. For the second purpose, the alkalis have very gener- ally 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 pre- ferred 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 ofthe vegetable acids, the fermented or acetous have answered better than the native. Mercurials seem to be of as little service as in the preceding species ; except where we have reason to expect afresh accumulation of the morbific material, in which case they may be employed as a purgative. But between the paroxysms, bitter tonics, as co- lumbo and simarouba, with such gentle exercise as may be engaged in without fatigue,—a light but generous diet, and the use ofthe Cheltenham waters, are what should chiefly be insisted upon, as best calculated to postpone the fatal issue. [Our author conceived melaena cruenta to be a hopeless case, and when the liver and other viscera are much diseased, the prognosis must certainly be very unfavourable. It is rather ex- traordinary, however, that he should not have noticed the occasional efficacy of the oil of tur- pentine. Besides the observations of Mr. Adair and other practitioners in its favour, two cases of melaena cruenta cured by it are recorded by Dr. Brooks,* and another by Dr. W. Nicholl.— (Op. cit., vol. iii., p. 274.) The latter prescribed it as follows :—R. 01. terebinth. 3SS ; syr. pa- pav. alb. 3J ; aq. menth. vir. jj. This draught was given five or six times in the first twenty- four hours, and the annexed clyster twice:—R. 01. terebinth, f j; mucil. acaciae |iss; decoct. avenae f xii. Afterward twenty drops of turpen- tine, with four black drops, were given every four hours, and five grains of the blue-pill at night. In addition to the preceding authorities in favour of turpentine, I may add those of Dr. Cheyne and Professor Elliotson. The editor has seen many cases of this disease in the great prisons, where he officiates as surgeon; and in some instances much benefit has resulted from calomel combined with opium, blistering the right hypochondrium, and giving small doses of the sulphate of magnesia in the compound infusion of roses.] GENUS III. CHOLOLITHUS. GALL-STONE. PAIN ABOUT THE REGION OF THE LIVER CATE- NATING WITH PAIN AT THE PIT OF THE STOM- * Trans, of Assoc. Physicians of Ireland, vol. i. The following is Dr. Brooks's formula :—R-. Olei terebinthins guttas xxv; aq. cinnamomi ^j; syr. aurantii 3J. M. Fiat haustus ter die sumendus. —Ed. ACH ; THE PULSE UNCHANGED ; SICKNESS ; DYSPEPSY ; INACTIVITY ; BILIOUS CONCRETION IN THE GALL-BLADDER OR BILE-DUCTS. In the preceding species we have had occa- sion to observe, that the bile is frequently found peculiarly viscid or tenacious, either from origi- nal secretion in this state, or from an absorp- tion of its finer and more attenuate parts in the gall-bladder or appended ducts. In the disease before us, we find certain portions of it indu- rated, and assuming a concrete form, often of a crystallized, sometimes of a laminated struc- ture, and perhaps most commonly of both,— evincing a tendency towards crystallized rays in the centre, with concentric laminae towards the surface.* , [They have generally been considered as closely resembling spermaceti; are soluble in boiling alcohol ; in ether ; and also very slowly in oil of turpentine. The substance, like sper- maceti, was regarded by Chevreul as a peculiar animal principle, and named by him cholester- ine. There is, however, another kind of biliary calculus, resembling inspissated bile, but not, like it, soluble in alcohol and water. The two compositions are frequently blended together, forming biliary calculi of intermediate charac- ters.!] These concretions were supposed by Four- croy to consist of a resinous matter cofnbined with a peculiar oil, and a certain quantity of al- bumen, forming three of the constituent prin- ciples 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, hitherto re- garded as albumen, is nothing more than a small portion of mucus, furnished from the gall- bladder. In all instances, perhaps, gall-stones are in- flammable ; 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 here al- luded to were only examples of spasmodic jaun- dice ; for nothing but the actual appearance of bilious concretions in the feces can fully prove their existence ; whffe the general symptoms may be produced by other causes. Gall-stones differ in specific gravity : some have been found heavier than water ; others a little lighter, bear- ing the proportion of nine to ten. In colour they are mostly dark brown ; a few are white externally, though still brown within.— {Heber- den, Med. Trans., vol. ii., p. 137.) It is possible that minute biliary concretions * Baillie, Morbid Anatomy, fol. 5, pi. vi., p. 109- 113. " C'est d'un changement dans la proportion des principes qui composent ordinairement la bile que resulte la formation des calculs biliaires."— Andral, Precis d'Anat. Pathol., torn, ii., p. 614. t See Brande's Manual of Chymistry, vol. iii., p. 187. Professor Orfila first proved that some biliary calculi are essentially composed of picro- rael. 214 CCELIACA. [Cl. I -Ord.IL oblong shape. The patient, who was a lady of sixty-six years of age, gradually recovered. [Sometimes a biliary calculus of very large size will produce an adhesion of the gall-bladder to the duodenum, followed by ulceration, by which means the foreign body passes into the bowels, and is voided with the stools. A case satisfac- torily exemplifying this fact, is recorded by Mr. Brayne.—(Med. Chir. Trans., vol. xii.) In other examples, however, biliary calculi of enormous size have made their way into the intestinal ca- nal, through the ductus choledochus, of which instances, have been published by Mr. Thomas, Dr. Craigie, and others.—(Edinb. Med. Journ., No. 81.) Instances are related by Andral and others, in which one of the biliary ducts, or the gall-bladder itself, gave way, in consequence of the lodgment of a calculus in one of these organs, and the result was a rapidly fatal peri- tonitis, from effusion of bile in the cavity of the peritoneum.] From the absence or presence of pain, the rest or transit of the gall-stone, which give rise to a considerable diversity of symptoms, as well as modes of treatment, the genus is divisible into the two following species :— 1. Chololithus Quiescens. Quiescent Gall- stones. 2 ---------- Means. Passing Gall-stones. maybe occasionally formed in-the penicilli, or the pores of the liver, perhaps in the ducts ; but the gall-bladder is the common seat of their origin; and they are here found of every diversified size, from that of a mustard-seed to that of a pullet's egg ; often, indeed, not only completely blocking up the cavity, but distend- ing the bladder far beyond its natural dimen- sions ; and the passing such large concretions shows what wonderful efforts nature is capable of making towards freeing herself from a mor- bid encumbrance ; for the natural size of the ductus communis choledochus scarcely exceeds that of a goosequill. The change thus occa- sioned is often very slow, and consequently ac- companied with less derangement of the gen- eral health than we should expect; but as the bitter of the bile is produced in the cavity of the gall-bladder, and this cavity is hereby generally obliterated, the bile loses a considerable pro- portion 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 sometimes remain quiet, and without being detached, for many years, with only occasional uneasiness in the hypogastric region. [The circumstances leading to the forma- tion of gall-stones are very imperfectly known ; but a life of indolence is remarked to bring on a disposition to them. They are much more frequent in women than men, and are chiefly met with in persons who have passed the middle and active period of life.—(See Gregory's Ele- ments, p. 488, ed. 2.)] " In some patients," says Dr. Heberden, " the jaundice will disappear in two or three days : in others I have seen it continue near a twelve- month before the gall-stone could pass into the intestine, or fall back into the bladder : nor will this long obstruction of the natural course of the bile have any lasting ill effects, or hinder the patient from being soon reinstated in perfect health after the removal of the obstruction." And as little real inroad upon the constitution takes place, in many instances, from a continu- ance 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 cer- tainly 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." —(Med. Trans., vol. ii., p. 134.) The irritation of a gall-stone has occasionally excited inflammation, and, where the gall-stone has existed in the liver, a large abscess; and the inflammation in the latter case assuming the adhesive form, the abscess has opened ex- ternally, and the calculus been discharged in this direction, of which a curious example is re- lated by Mr. Blagden.—(Op. cit., vol. iv., art. xvi.) The calculus, on examination, weighed nearly an ounce and a quarter, and was of an SPECIES I. CHOLOLITHUS QUIESCENS. QUIESCENT GALL-STONE. PAIN ABOUT THE LIVER, AND AT THE PIT OF THZ STOMACH, OBTUSE AND OCCASIONAL ; THE BILE LESS BITTER THAN USUAL ; THE DEJECTIONS IRREGULAR. In the quiescent species, the gall-stone re- mains usually at rest in the gall-bladder or the liver; and whatever be its size, the growth takes place, and the containing organs dilate so gradually as to produce little or no inconve- nience. In Dr. Baillie's plates, there is an ex- ample of a concretion of the size of a pullet's egg, which filled up the whole of the fundus. Yet so perfect was the adaptation of nature to the case, that the bladder not only became suf- ficiently enlarged at its base to hold the concre- tion, but was also sufficiently enlarged immedi- ately above it to form a new reservoir, and con- tain very nearly the usual quantity, which the gall-bladder is capable of hording in its healthy At times, however, even in this quiescent form of the disease, we meet with some degree of pain; occasionally, perhaps, produced by a sudden deposite of fresh concrescent matter ; occasionally, by abrupt starts of some propulsive power which it is difficult to explain ; and occa- sionally by some peculiar and temporary irrita- tion in the coats of the surrounding organ, by which the bowels are apt to be considerably affected. In this species, however, little medical treat- ment is necessary: for we have only to correct Gkn. III.—Spe. 2] CHOLOLITHUS MEANS. 215 the commotion of the alvine canal when thus excited, or to quicken its motive power when sluggish; and to have recourse to anodyne fomen- tations 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 comfort- able 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, had been gradually accumulating for thirty or forty years. [An interesting case of death from inflam- mation of the gall-bladder, caused by the pres- ence of a biliary calculus, was published by Dr. Scott of Cupar-Fife.—(Edinb. Med. Journ., No. 83, p. 297.) On dissection, the coats of the gall-bladder were found to be half an inch in thickness ; in its cavity was a stone, of about the size and shape of a green olive, with a few ounces of a thin blackish fluid, similar to very black-roasted coffee grounds, or rather to ink diffused through thin mucilage. A similar fluid was vomited up during the patient's indisposi- tion.] SPECIES II. CHOLOLITHUS MEANS. PASSING OF GALL-STONES. PAIN AT THE PIT OF THE STOMACH ACUTE, EX- TENDING TO THE BACK J FREQUENT VOMITINGS : DEJECTIONS WHITE, AND AT LENGTH LOADED WITH ONE OR MORE BILIOUS CONCRETIONS. It is not a little singular that, during the great anguish sustained in the transit of a gall-stone, the pulse is rarely or never quickened. " Inso- much," observes Dr. Heberden, " that this nat- ural state of the pulse, joined with the vehe- ment pain about the pit of the stomach, affords the most certain diagnostic of this illness. I have seen," says he, " a man of patience and courage rolling upon the 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 accustomed : and yet his pulse was all the time as perfectly quiet and natural, as it could have been in the sweet- est sleep of perfect health." Together with the pain at the pit of the stom- ach, which is acute in almost every instance, there is sometimes a pain also in the region of the liver; and not unfrequently it commences here. For this it is not difficult to account. Membranous canals, with a very few exceptions, are most sensible at their extremities ; and an irritation 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 insensibility of the rectum, which forms one of the exceptions to which I have just referred, faintness at the stomach is almost always accompanied with a relaxation of the sphincter ani, so that the stools issue involunta- rily- Now, as a gall-stone is passing, the pain. is greatest on its first entrance into any one of the ducts, or on its reaching the extremity of the ductus communis just before it is disgorged into the duodenum, in consequence ofthe 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 to- wards 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 fiver, we per- ceive readily why the pain is more pungent in the former, than in the latter region. When the concretion has fairly entered the ductus commu- nis, the pain remits, but generally returns with sudden violence on its reaching the duodenal point; and we hence see the reason of that ad- ditional attack of severe agony which a patient often sustains, after having flattered himself that the disease was completely subdued. The cal- culus, when voided, has sometimes been found to measure nearly two inches in its long diame- ter, and upwards of three inches and a quarter in its widest circumference.—(Brayne, Medico- Chir. Trans., vol. xii., art. 21.) In the treatment, all that we can accomplish is to ease, and, as far as possible, 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 sec- tion into the cyst. Bloch (Medic. Bemerkungen, No. v.) gives a singular case of this kind, in which not-fewer than sixty-two distinct calculi were taken away with success. But in general the operation has not answered, or has been fol- lowed by a formation of other crops of concre- tions ; so that Morgagni and many later writers* of eminence have strongly reprobated the use of the knife, and it is rarely or never had re- course to in our own day. In reality there seems to be no just cause for its use. At the time that the gall-stone is in the bladder, to whatever extent it enlarges, the progress of en- largement is slow, and the capacity of the gall- bladder will, in most cases, without much irri- tation, and sometimes with very little incon- venience, 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 kind, with a view of easing and quickening the passage of the gall-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 her- self. The duct becomes dilated by the circum- ambient pressure of the concretion as it gradu- ally passes forward, urged on by the same action * De Sed. et Caus. Morb., Ep. xxxvii., art. 52. Sharp's Critical Inquiry, ch. vi. Le Dran, Con- sultations sur la plupart de Maladies, &c. 216 C02LIACA. [Cl. I.—Ord. II. that propels the bile in a state of health. Vom- iting, therefore, by compressing the whole ab- dominal viscera, and, particularly, the full and distended gall-bladder and biliary vessels, may afford one means of pushing forward the concre- tion : but a gentle force, and consequently gen- tle 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, bleeding should precede the exhibition of emetics. Cathartics, by exciting the action of the intestines, and directly stimu- lating the mouth of the common bile-ducts, con- tribute, also, to excite action through its entire range, and thus farther favour the expulsion of the concretion. And as we often find its pas- sage evidently opposed by spasmodic constric- tion, opium given very freely, and repeated every hour or two, and relaxing the skin by fomenta- tions or the warm-bath, will in such cases be of essential service. Horse-exercise cannot always be made use of: but where it can be submitted to, it is one of the best auxiliaries we can rec- ommend.* We know of no solvent of biliary concretions worth attending to. The essential oil of tur- pentine was at one time regarded as a very powerful medicine of this kind; and, as such, was strongly recommended and very generally employed by Van Swieten {Constit. Epid., Lugd. Batav., p. 102), Bloch (Bemerkungen, No. v.), Duranae (Obs. sur I'Effi. du Melange d'Ether Sulph. el d'Huile Vol. de Tiribinth., &c, Strab., 1790), 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 possession of this virtue ; and if it were ever serviceable, it must have been as an antispasmodic rather than as a solvent. Du- rande, indeed, seems to have acted upon this view; for his formula consisted of three parts of sul- phuric ether to one of the oil. Yet, where there is danger of inflammation, such a medicine must be always too stimulant; and Dr. Percival has good grounds for remarking, that its internal use is productive of mischief.—(Essays, ii., p. 232.) 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. [Such predisposition is, perhaps, best * For the treatment of this affection, Dr. Stokes says (Lond. Med. and Surg. Journal, March, 1834), " bleed first, then leech, next employ purgatives, and when you have emptied the bowels, have re- course to opium." He remarks, that the employ- ment of emetics is not free from danger, as instan- ces have occurred where their exhibition was fol- lowed by rupture of the gall-bladder and fatal peri- tonitis. " Were I to hazard a conjecture," says he, " I would say, that emetics can be employed with safety only in the early stage of the disease, when there is no obstruction from organic disease; and again, you should never use them when there is evidence of a dis- tended gall-bladder"—D. counteracted by the exhibition of alkalis, soap, nitric acid, taraxacum, and the Cheltenham and other mineral waters.] GENUS IV. PAR ABYSM A. VISCERAL TURGESCENCE. KNOTTY OR UNEQUAL INTUMESCENCE OF THE AB- DOMEN FROM AN INDURATED ENLARGEMENT OF ONE OR MORE OF THE VISCERA CONTRIBUTORY TO THE DIGESTIVE FUNCTION ; DERANGEMENT OF THE GENERAL HEALTH. This genus is intended to comprise a natural and extensive division of diseases, consisting in an infarcted protuberance of one or more of the collatitious organs of digestion. The name under which the disease has been described by Hippocrates, is megalosplanchnus (utyaXdcirXayx^s) or " big-bowel:" which Cusson and others, on account of its length, have ex- changed for physconia, a word literally import- ing "inflation;" and so used by both Greeks and Latins. For dismissing the former, there is, perhaps, sufficient reason ; but physconia ill supplies its place, as conveying no correct or definitive meaning ; whence it has been employ- ed by different writers in so loose a manner, as to comprise a variety of organic tumours that have no relation whatever, in origin, position, properties, or mode of cure. The word, there- fore, is not worth preserving, either in respect to its primary or general sense : and it is on this account I have ventured to exchange it for PARABYSMA (nAFABYTMA), from -irapaSvu), 3 genuine Greek term, in use among the Greek classics, and distinctly signifying morbid conges- tion, coaeervation, or infarction, which is the prominent character of the genus. All the viscera of the abdomen are subject to an indurated enlargement of this kind from va- rious causes, of which some are common to the whole, and others peculiar to themselves ; among the former should be especially noticed that destitution of valves in their veins, and consequently that want of support to the re- turning column of blood which belongs to the veins that are distributed to more superficial parts. The local causes will be noticed when treating of those enlargements in their respect- ive order. The species are numerous, and may be arranged under the following heads : 1. Parabysma Hepaticum. Turgescence of the Liver. 2. ---------Splenicum. Turgescence of the Spleen. 3. ---------Pancreaticum. Turgescence of the Pancreas. 4. ---------Mesentericum Turgescence ofthe Mesentery. 5. ---------Intestinale. Turgescence of the Intestines. 6. ---------Omentale. Turgescence of the Omentum. 7. ---------Complicatum. Turgescence com-pounded of va-rious organs. Gen. IV.—Spe. 1.] PARABYSMA HEPATICUM. 217 SPECIES I. PARABYSMA HEPATICUM. TURGESCENCE OF THE LIVER. HARD TUMOUR IN THE RIGHT HYPOCHONDRIUM, VERGING TOWARDS, AND SOMETIMES APPEAR- ING AT, THE PIT OF THE STOMACH ; GENERAL LANGUOR ; PALE OR YELLOW COUNTENANCE; DYSPEPSY ; DEJECTIONS IRREGULAR, OFTEN WHITISH. It is necessary to observe, that the word tumour is used in different senses by different writers ; commonly importing a morbid, and mostly a circumscribed swelling or enlargement of any organ; but limited by Mr. Abernethy to " such swellings as arise from some new pro- duction, and which make no part of the original composition of the body."—(Surg. Obs., p. 68, 8vo., 1804.) This sense, however, he admits to " trespass against the usual import of the word;" and seems even too restricted for his own use ; since he is soon afterward obliged, as he confesses, to extend it to enlargements of glands while they still continue to make part of the original composition of the body, and even to perform their function. In the limited sense here aimed at, tuber would be a far better word than tumour, as less likely to produce con- fusion, and as already in some degree known to the language of medicine, in a restricted sense, by its diminutive tubercle. In the present work, the term tumour is employed in its ordi- nary signification. There is still much difficulty in accounting for the morbid growth of tumours of any kind, and especially of those which constitute the * To this opinion many pathologists would ob- ject. Mr. Abernethy's explanation of the origin of tumours seems to Mr. Lawrence to have been suggested by the statements of Mr. Hunter re- specting the production of vessels in coagulated blood, the supposed agency of this process in ef- fecting the union of wounds and fractures, and its occurrence in effusions of blood into serous cavities. " We now know that the adhesion of wounds, and the union of broken bones, are not accomplished in this way; moreover, that these processes take place most readily where no coag- ula are present. I have never seen any satisfactory proof of blood becoming organized when effused in wounds, bruises, or into serous cavities, or when deposited in aneurismal sacs."—(Lawrence, in Med. Chir. Trans., vol. xvii., p. 8.) Neither is Mr. Lawrence satisfied with the doctrine, that the growth of tumours depends upon the effusion of lymph, from inflammation. " Nothing," says he, " is more common, than the interstitial effusion of lymph, in consequence of inflammation; the sub- stance thus poured out is not formed into tumours; it is absorbed as the inflammation subsides, or its partial organization causes the enlargement and condensation of the affected structure. None of the phenomena usually considered as character- istic of inflammation, are observed to precede the formation of tumours. These growths occur in- sensibly, and often arrive at a considerable size before persons are aware of their existence."— (Vol. cit., p. 9.) In the Museum of the Royal College of Surgeons are some preparations put up by Mr. Hunter, in proof of coagulated blood becoming vascular, as the vessels appeared to him genus before us ; which sometimes are found, on dissection, to consist of an enlargement or extension of the general structure of the af- fected organ ; and sometimes of distinct lumps or tubers of a very different structure, imbed- ded in the body of the organ, seated on its sur- face, or merely attached to it by a narrow neck or footstalk. The simplest mode of conceiving their origin, is by the deposite of some living fluid into a cell of the cellular structure, or the follicular gland of a mucous membrane, possessing an increased excitement by the pressure of the surrounding parts, or from some other cause of irritation. Mr. Hunter believed, as we shall have further occasion to remark when treating of phthisical tubercles, that "the living fluid which has the greatest tendency to assume a vascular struc- ture when thus collected or effused, is the co- agulable part of the blood," for wbich opinion there seems to be great reason.* And hence, those who have chiefly supported his doctrines in our own day, and especially Sir Everard Home (Trans, of a Soc. for the Im. of Med. and Chirurg. Knowledge, vol. i., p. 231) and Mr. Abernethy, confine the origin of vascular tuber- ous growths to the sanguiferous system, and especially its coagulable part alone ; while Dr. Baron has still more lately restricted them quite as absolutely to the absorbent system : contend- ing that " our hopes of being able to avert or cure such maladies must rest upon some other means than those which are merely calculated to subdue vascular action."—(Inq. into the Na- ture of Tuberc. Secretions, &c, p. 122.). Either of these views appears to be too nar- row. Mr. Hunter has sufficiently shown, that a filled with fine injection; but, in a conversation which the editor once had with Sir Astley Cooper upon this subject, the latter explains the appear- ance by the coagula having had lymph effused under and around them, and that the vessels had really extended themselves into the lymph, and not the coagulated blood itself. This view agrees with some experiments related by Gendrin.—(Hist. Anat. des Inflammations.) Professor Carswell sees various objections to Mr. Abernethy's view. The latter, we know, " referred all adventitious formations to the coagulable part of the blood as their origin, and fixed their seat in the cellular tissue, in the parenchyma, and on the surface of organs. This plastic substance was supposed by him to be effused under one or other of these cir- cumstances, to become organized, and to derive the materials of its growth from the vascular sys- tem of the surrounding parts. It will readily be seen (says Dr. Carswell), that this view of the seat and origin of adventitious formations is both imperfect and inaccurate. Many of these forma- tions are not organized, not tissues, as he believed, and as they were described to be about the same time, by Laennec, but amorphous masses, all the changes which they undergo being dependant on the influence of external agents." It is further argued, that Mr. Abernethy's doctrine assigns fic- titious characters to these formations, and con- founds under the same head diseases of an entirely opposite nature. Various reasons are also given against other theories promulgated by Andral and Cruveilhier.—(See Carswell's Illustrations of the Elementary Forms of Disease, p. 2.)—Ed, 218 C02LIACA. [Cl. L—Ord. II. living principle appertains to almost all the fluids of the living body that are formed for its accre- tion, though the animal oil seems to possess less than any of the rest. He has shown it to exist in the chyle ; it is known to every one to exist in the semen, and is transferred to the egg when it first drops from the body of the mother, and before a single particle of blood is elaborated. It is this, in truth, which is the instinctive prin- ciple of healthy living matter, whether animal or vegetable : instinct itself being nothing more than the simple law of life, or of such living principle in a state of activity or operation, di- rected to the definite end of completing single organs or the general system, preserving them in health, or reproducing them for future use. It is hence probable that most, if not all the living fluids, and not merely those of the co- agulable part of the blood, or the semen, have a tendency to produce new forms and tissues, and will do so under a particular state of ex- citement, and if duly supplied for this purpose. So long as a state of health, or the natural law ef the instinctive principle, influences them, these productions will be uniform and definite : but if the healthy power decline, and the natural law dependant upon it cease, the action still continuing without a modifying guide, the pro- ductions must be indefinite and anomalous in every possible diversity, according to the con- tingencies by which they are surrounded. And hence, alone, as it appears to me, can we ac- count for the elaboration of all those infinite varieties of fluids or of fabrics which different tumours present to us ; and those monstrous at- tempts at organization which we occasionally meet with in organs of every description, some- times simulating or even elaborating hair, some- times flesh or muscular fibre, sometimes brain, sometimes suet, sometimes honeycomb or other cells, sometimes a tooth, or a nail, or various organs of a foetus in a nidus where we should least expect to find it, and marvel with all our might how it could possibly get there. " The tumour," says Mr. Abernethy, " derives its sup- ply of nourishment from the surrounding parts : it seems to live and grow by its own independent powers ; and the future structure which it may acquire, seems to depend on the operation of its own vessels." All this is quite correct; and it is the object of the preceding remarks to show from what source it is possessed of such inde- pendent powers, and by what means they are rendered subservient to such an infinite variety of sportive and anomalous effects. We have thus far supposed the morbid growths before us to have issued from the cel- lular texture, or the serous or mucous mem- branes of organs. But there is no difficulty in applying the whole of this argument to the sub- stance or parenchyma of organs, as well as to their surface ; for effusion may take place in any part of their structure, and the tubercle of the future tumour may consist of a minute drop of such effused fluid within the organized wall, or whatever it be that surrounds or imbeds it. And hence the morbid turgescence may consist either in an enlargement of the general sub- stance of the viscus, or in parasitic tubers more or less closely connected with its surface. " There seems every reason to believe," ob- serves Dr. Abercrombie, " that the peculiar de- position which constitutes it (tubercular disease) may take place from any tissue of the body : in some cases slowly and gradually ; in others, the result of a low inflammatory action of a peculiarly unhealthy character."* The organ hereby becomes weakened in its healthy action, and consequently is more dis- posed to fall a prey to whatever vermicles or their eggs are by any means able to obtain an entrance or a deposite in it: and hence it is nothing uncommon to meet with worms of va- rious kinds, as we shall presently have occasion to notice, that have converted one or more tu- bercles into a nest, or other habitation ; and to propagate their kind with great rapidity : and hence more especially the origin of flukes and hydatids in hepatic parabysma. Some consti- tutions are far more predisposed to such morbid changes than other constitutions ; and some animals than other animals. The swine genus more perhaps than any of the rest. It is not, however, easy, and at times is perhaps impos- sible, to distinguish between simple limpid tu- bercles in their first formation, and hydatid worms. Dr. Baron has withdrawn himself en- tirely from the question, and employs the terms almost, if not altogether, synonymously, without venturing -to determine upon the animalcular life of what are ordinarily called hydatids, under any form or magnitude. [According to Dr. Baron, the tubercle commences as a vesicle, and is nothing more or less than a hydatid. Dr. Armstrong finds, however, that the vesicular appearance of the tubercle is simply a acci- dental occurrence, dependant on the texture of the part in which it is placed. Tubercles, he says, may have the vesicular appearance in the lungs ; but, if minutely examined, they will be found to be the extremities of the bronchial tubes, or air-cells, into which the peculiar de- posite, constituting tubercle, often takes placet * On the Nature and Origin of Tubercular Dis- ease. Trans, of the Medico-Chir. Soc. Edin., vol. i., p. 687. The following, as Dr. Carswell con- ceives, is a correct definition of tubercles, or rather of the tuberculous matter which constitutes the essential anatomical character of those diseases, to which the term tubercular is now exclusively restricted. " Tuberculous matter is a pale yellow, or yellowish gray, opaque, unorganized substance, the form, consistence, and composition of which, vary with the nature of the part in which it is formed, and the period at which it is examined." Dr. Carswell sets down the mucous system as by far the most frequent seat of tuberculous matter; as for instance, the mucous system ofthe respira- tory, digestive, biliary, urinary, and generative organs. It is also formed on the secreting surface of serous membranes, and in the numerous minute cavities of the cellular tissue. One of Dr. Cars- well's plates represents tuberculous matter in the substance of the brain and cerebellum, in acci- dental cellular tissue, and in the blood.—See Pro- fessor Carswell's Illustrations of the Elementary Forms of Disease, p. 1.)—Ed. t This statement is confirmed by Professor Gen. IV.—Spe. L] PARABYSMA HEPATICUM. 219 On the serous membranes, Dr. Armstrong has never found them to be, strictly speaking, vesi- cles. He regards tubercles as secretions from the ultimate ramifications of the arteries.— (Morbid Anat. of the Bowels, &c, p. 16, 4to., Lond., 1828.)] Dr. Jenner seems at times to have carried the animalcular hypothesis too far, even admitting that it has a real foundation ; and the following passage which contains a val- uable piece of natural history, may at the same time form an illustration of this remark. It occurs in a letter to Dr. Baron :—" Nothing is more common than tubercles in the liver, and among other viscera, of the pig : but these for the most part arise from the common hydatids with thin coats, while those which give birth to the term measley, are of a different kind. They pervade almost every part of the animal, the heart, the diaphragm, the serous and the mu- cous membranes, the eyes, &c. The disease proceeds not unfrequently to such great lengths, that from a fourth to an eighth part of the ani- mal is infested with them. The inferior part of the neck and haunches now becomes oedema- tous, and effusions take place into the cavities. These hydatids differ from the hydatids of the liver, in being of a more diminutive size ; they are for the most part not larger than ordinary shot, and to the feel are almost as hard; they differ too in having thicker coats, and conse- quently have less fluid within them. I have rarely seen them so large as middle-sized peas. Similar to this species of hydatid is that which pervades the interior of the brain of sheep, and appears to be generated on the coats of the ventricles. I have found them adhering to it, and also swimming in the fluid which had been let loose into these cavities, occasioning hydro- cephalus internus, vertigo, and death."—(Baron on Tuberc. Accretions, p. 131.) Now the character of this last hydatid, the tenia cerebralis of Leske, has been sufficiently ascertained to admit its animalcular origin; it is rarely larger than a grain of sand, and is furnished with from thirty to thirty-six hooks, by which it fixes itself firmly to the substance of the brain or of its coats, and especially in yearling lambs, producing that staggering or vertiginous disease whieh is provincially known by the name of dunt. It is also highly proba- ble that the first kind of hydatids here referred to are equally entitled to an animalcular classi- fication ; but the measley tubercles that form the second seem rather to be an idiopathic dis- ease of the constitution itself, propagating new Carswell's researches. " Encysted tubercle has generally been described as existing in the lungs, but I feel perfectly satisfied that the term encysted, whether applied to pulmonary tubercle, or to tu- bercle in any other organ, is almost always incor- rect. In the lungs, encysted tubercle is a decep- tion, the distended walls of the air-cells having, in all probability, in almost every case, been taken for cysts. In the like manner, the dilated bulbous extremities of the biliary system have been described as cysts of the liver containing tuberculous matter."—See Carswell's Illustrations of the Elem. Forms of Disease, p. 1.—Ed, growths of the same kind from organ to organ through every part of the animal; and in the pig, as well as in other quadrupeds, well ascer- tained to be induced in many instances by in- nutritious food as an exciting cause. It is conceived by many pathologists, that the intumescences we are now considering neces- sarily require an inflammatory action of the organ for their production ; and that they are, in fact, for the most part, merely results of what is called chronic inflammation. M. Bichat has with great justness controverted this opin- ion in his remarks on membranous tubercles, that " foule de petits tubercules blanchatres qui est si frequent sur ces membranes" (Anat. Gen., torn, iv., p. 517); and has said that we must look to another quarter than that of phleg- masia? for their origin : although he seems mani- festly to err in regarding tubercles of this kind as solely capable of originating from serous membranes, and never existing in the subjacent substance of an organ, except towards the last stages of the complaint, in which they are pro- pagated by the cellular texture : being, in his estimation, " une affection propre aces mem- branes ; comme les eruptions miliares le sont a la surface cutan^e, 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 from the interior as well as from the surface of organs ; as their history will also, that they may originate with- out any sense of heat or pain, without any aug- mentation of the pulse, or any other sign of in- flammatory action. A certain but low degree of such action may indeed accelerate their growth and augment their number, as one kind of exciting cause ; but congestion from weak action is a cause far more frequent; and acci- dental irritation not much less so. The subject, however, is still a source of controversy ; the opinion of M. Bichat that inflammation is not a necessary source of tubercles in any case, being powerfully supported by MM. Bayle, Laennec, Rostan, Louis, Velpeau, and Armstrong ; while their origin from inflammation alone is as warmly contended for by M. Broussaisand his numerous adherents. [In particular, the latter is the doctrine adopted by Professors Andral (Clinique Med., torn, iii.) and Cruveilhier (Bibl. Mid., Sept., 1826); and, as Dr. Alison observes, the testi- mony of Andral is the more valuable, as his previous opinion in regard to the formation of tubercles appears to have been nearly the same as that of Laennec. The paper and facts by Dr. Alison himself, in support of thesame doc- trine, are highly interesting.—(See Edin. Med. Chir. Trans., vol. iii., ed. 1828.) Dr. Armstrong, who inclines to the opinion of Bichat, has observed, that against the idea of tubercle being simply the effect of inflamma- tion, many facts might be adduced. In numer- ous instances where tubercular points are scat- tered over the pleura or peritoneum, the serous membrane is transparent up to these points, and only becomes reddened or opaque when the «J20 COZLIACA. [Cl. I.—Ord. II. tubercle has become progressive or enlarged, so as to act as a local irritant. He considers it probable that tubercle is connected with fibrin- ous effusion, but that the latter is not neces- sarily connected with inflammation. He ad- mits that tubercle and inflammation are often co-existent, and so are the hydatid and tubercle occasionally ; but co-existence does not imply a direct dependance or relation.*] This disease .iiginates 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 :— a Coactum. From simple parenchy- Atonic turgescence. matous coaeervation. 0 Scirrhosum. Accompanied with a Scirrhous turges- hard and scirrhous cence. feeling.f * Armstrong, Morbid Anat. ofthe Bowels, &c, p. 17, Lond., 1828. t Excluding from present consideration chronic hepatitis, treated of in another part of this work, many of the different conditions of the liver seem to be intended to be comprised under these two first divisions; as, for instance, 1. Simple enlarge- ment of the liver, without change of texture; 2. Tubera of the liver, without disease of its struc- ture ; 3. The pale degeneration of the liver, con- sisting of change of colour, without remarkable alteration of texture ; 4. Pale colour of the liver, with induration ; 5. Dark induration of the liver ; 6. Tuberculated disease of the liver; 7. Tubercles and tubera of various characters, diffused through its substance, with disease of the intervening structure. These and other morbid states are excellently described by Dr. Abercrombie.—(See Path, and Pract. Res. on Diseases of the Stomach, Liver, &c, ed. 2, p. 364, et seq., 8vo., 1830.) The black ramollissement or disease, in which the liver is reduced to a dark-coloured mass, of very little consistence, could not, of course, be comprehended under Dr. Good's general definition; neither could the soft, flabby, fatty degeneration of it; but the white encephaloid disease of this organ, corre- sponding in its nature to fungus haematodes, would belong to this place. In considering chronic dis- eases of the liver, it is necessary to recollect, that this organ consists of a sanguineous or red part, and of a white or yellow, containing bile. Some- times it is only the red portion that is hypertro- phied, so that the organ is enlarged and red ; and sometimes the biliary portion, with the bile-tubes in a state of hypertrophy, and then the liver is enlarged and pale. Sometimes without fieing en- larged at all, it will be pale. The red part is atrophied, the vessels shrink, and the biliary part is either hypertrophied, indurated, or not changed at all. The whole of the liver is sometimes affect- ed in these ways; and, in other instances, only spots, or parts Of it. In some situations there may be hypertrophy of the red substance; in others, of the biliary ; so as to cause a mottled appear- ance of the organ when a section is made of it. In what is termed the gin-liver, white lines are seen traversing it, and sometimes granules, vary- ing in size from pins' heads to hazelnuts. Pro- fessor Elliotson, from whom the editor has bor- rowed these valuable remarks, adopts Andral's y Chololithicum. Accompanied with an Gall-stone turges- occasional dircharge cence. of bilious concretions. S Helminthicum. Accompanied with an Vermicular turges- occasional discharge cence. of worms or larvae. The first of these very generally paves a way to one or other of the three ensuing ; and is found most frequently in feeble children who secrete little bile. It is also found very fre- quently in intemperate eaters, and in foreigners who reside in hot climates ; a considerable de- gree of atony being produced in the liver from the exhausting stimulus of the rays of the sun, and an excessive use of spirituous potations. In a scrofulous habit, a liver thus enlarged and infarcted, is apt to become scirrhous in children, if not early attended to, as it is also in the gormandizers just alluded to, who have long habituated themselves to the luxuries of the table. Sometimes the scirrhous is con- fined to a part of its margin ; sometimes it ap- pears partially on its surface ; sometimes it runs through one or the other, or both its lobes .- and sometimes also, the portion that becomes scir- rhous evinces a tubercular structure, and con- sists of clusters of simple tubercles before the scirrhosity takes place. It is not always, however, that a scirrhous, or even a tubercular structure of the liver oc- casions its enlargement. In many instances, indeed, it does so; but Dr. Baillie has given examples, illustrated by plates, in which the liver has hereby shrunk into a size considerably below its natural proportion.* This disease may be generally detected by an accurate ex- amination of the hypochondrium with the hand.t belief, that the free use of ardent spirits induces a chronic change of the biliary portion of the liver, in which it becomes both hypertrophied and in- durated. Sometimes the liver is hardened in par- ticular parts of it; but, on the whole, diminished in size. A gin-liver is mostly of a bright yel- low colour, and attended with a degree of as- cites, and an opacity and hardness of its peri- toneal covering.—See Medical Gazette for 1832-3, p. 484.—Ed. * Morbid Anat., pi. ii., fig. ii., p. 102. In the disease of the liver, described by Laennec, under the name of Cyrrhose, from the part looking like a mass of yellow wax, and thought by Cruveilhier to correspond to a tuberculated form of liver dis- ease, spoken of by Dr. Baillie, there is a diminu- tion of the organ, and much deviation of it from its natural shape. It is beautifully illustrated by coloured engravings, in Cruveilhier's Anatomie Pathol., douzieme livraison. This pathologist finds that cancerous tumours in the liver are most dis- posed to form towards its surface, and refers to a case, in which sixteen out of twenty were so situ- ated. The name he assigns to this affection is, " Cancer du foie par masses disseminees." These masses vary in size from that of a miliary seed to that of the head of a full-grown foetus. He in- cludes, however, in his observations, not merely scirrhous tubercles and tumours of the liver, but those of the fungus haematodes kind ; and, what will seem extraordinary to English pathologists, asserts that he has met with both varieties in the same liver.—Ed. t This shrunken condition of the fiver is not Gen. IV.—Spe. 1.] PARABYSMA HEPATICUM. 221 Almost all the affections of the liver appertain- ing to the division before us appear to owe their origin to atony or hebetude in the organ : and hence the common rise of that variety of turges- cence which is accompanied with bilious cal- culi. These are sometimes diffused like granules over the substance of the liver, or among the bil- iary pores ; they are sometimes confined to, and load one or more morbid cysts existing in the liver ; and are sometimes naked, concrete, and crystallized; of which I have referred to various examples in the volume Of Nosology. These are occasionally to be found in the dejections. In the variety distinguished by the existence of grubs and worms, the fluke is, perhaps, sometimes to be found even in the human liver. Doever and Clarke, as already observed, assert this, and Darwin confirms their assertion. That they are found in almost all other animals is admitted by every naturalist; although Dr Har- rison, of Horncastle, has lately ventured to deny that they are to be traced in sheep in the well-known disease called the rot. But the vermicles chiefly observable in the variety of parabysma before .us, are hydatids. " These," says Dr. Baillie, " consist of spher- ical bags of a white or light amber colour, more or less transparent, and are lodged in cartilagi- nous cysts. The cysts are lined with a brownish pulpy membrane, resembling very much the coagulum of the blood; but this membrane is more or less distinctly marked in different cases. The cysts are sometimes surrounded on every side by the substance of the liver, and some- times are formed at the surface so as to be partially seen without dissection. The hydatids themselves contain a transparent fluid, which is capable of being coagulated by heat and by acids, and sometimes contain also smaller hyda- tids floating in this fluid. On many occasions very small hydatids are found adhering to the coats of the larger hydatids, and appear to the eye like small pearls. Hydatids of this species seem to be animalcules of a very simple struc- ture ; and although they are not often formed in the liver, yet they grow more frequently in this gland than in any other of the body."* uncommon in those who have long indulged in the use of ardent spirits. Dr. Hosack (Essays, vol. ii., p. 332) has related such to have been the fact on inspecting the viscera of the celebrated tragedian Cooke.—See also Francis's Cases of Morbid Anatomy, in the Trans, of the Lit. and Phil. Soc. of New-York, vol. i., p. 534. Dr. Francis informs me, that he has repeatedly obser- ved the liver greatly diminished, and of a firm and scirrhous state, in the bodies of gross inebriates, who have died suddenly, and have been dissected for municipal purposes.—D. * Morb. Anat., p. 107, pi. 6. The kidneys and the liver are the two organs of the body which are most subject to the formation of hydatids. In sheep, they have been observed to have a con- tractile power ; but this has not been noticed in the human subject. They sometimes lie within one another, like pill-boxes; sometimes they are attached to each other by peduncles from within, hanging one within the other; and sometimes they grow to the outside of each other. Sometimes they are attached to the fiver externally; but The hydatids die in process of time like other animal forms, and their place is supplied by their progeny. When they die, the bags and cysts are often broken up, and become frittered into minute tatters and filaments, fragments of which pass occasionally by the biliary ducts into the duodenum ; and, being rejected with the feces, are at times mistaken for portions of the villous coat of the intestines. As this species of parabysma depends almost entirely on an atony of the liver, the intumes- cence increases in many instances in propor- tion to that atony, and particularly where de- bility of the liver is combined with a general debility of the entire system. And hence the liver is frequently known to enlarge in propor- tion as every other organ becomes torpid and decays. On which account the liver is often found of an enormous size in dropsical patients. Mr. Gooch gives a case in which, during dropsy, it acquired the monstrous weight of twenty- eight pounds.—(Med. and Surg. Obs.) Bal- dinger reports another instance in which it reached twenty pounds (N. Magaz., band, vii., p. 275) ; and Bonet a third in which it weighed only two pounds less.—(Sepulcr., lib. i., sect. xviii.) In recent stages, and especially in children and young persons, this disease may often be successfully attacked by warm purgatives and tonics, and especially by those valuable alter- ants that change the action of both the excre- tory and absorbent system, diminishing the irri- tability of the first, and restoring the power of the second, and thus reinvigorating them alike.— (J. Kaemph., Abhandl., &c, 8vo., Leips., 1736.> Many of the metallic salts and oxydes have a> tendency to do this, and especially those of zinc, copper, iron, and silver. But those of mercury are, for the present purpose, far more valuable than any of the rest. This mineral should be given in mild forms and gentle doses only, so that it may be persevered in for a con- siderable period of time. The black or red sulphuret of mercury, or the blue mercurial' pill, has been employed indiscriminately ; but small divisions of calomel, as a grain or a grain and a half a day for an adult, or the compound generally speaking, are enclosed in a cyst.—(See Elliotson's Lectures, Med. Gazette for 1832-3,, p. 486 ; also Cruveilhier's Anat. Pathol., livr. 3.) The editor attended a man in the King's Bench, about two years ago, whose abdomen was occu- pied by a cyst containing several gallons of hyda- tids, the size of which varied from that of an orange to that of a pea. As the swelling was at- tended with fluctuation, a trocar was introduced into it, when nothing was discharged but a trivial quantity of glutinous matter. The cyst, which was found after death to be attached to the liver, is placed in the Museum of the London University. Dr. Elliotson attended a curious case of this kind, in which an ulcerated communication was estab- lished between the cyst and the air-passages, through the diaphragm ; and consequently the patient used to cough and spit hydatids until she died. For some interesting remarks on encysted tumours of the liver by Mr. Caesar Hawkins, see Med. Chir. Trans., vol. xviii.—En. ,IACA. [Cl. I.—Ord. IL 222 C(EI calomel pills, in the proportion of five or six grains a day, will often answer much better. In the meantime, an occasional purging must be persevered in; and if worms be suspected in the intestines, they must be removed by the treatment already laid down. I have also found benefit from an application of the emplas- trum hydrargyri cum ammoniaco, large enough to cover the entire hypochondrium : or the use of the tartar-emetic ointment, as already recom- mended in certain conditions of dyspepsy ; and, where particular circumstances have prevented me from using this, from sponging the abdomen daily with aqua regia, diluted with about forty times its measure of water, which, as already observed, reduces it to the sourness of weak vinegar. As far as my own experience goes, I have fiad so much reason to be satisfied with the good effects of mercury, that I have rarely em- ployed any other medicine ; and, though I can- not say, with Dr. Cullen, that its effects are to be-ascribed solely to the stimulus it gives " to the excretories, and not at all to any change produced in the state of the fluids," yet the following remark of the same distinguished writer is entitled to general attention : " Uni- versally mercury, in its active state, seems to be a stimulus to every sensible and moving fibre of the body, to which it is immediately applied; and, in consequence, it is particularly s stimulus to every excretory-of the system to which it is externally or internally applied. Besides its noted effects upon the excretories of the saliva, it seems to operate upon the whole of those of the alimentary canal. It proves often diuretic ; and I have particular proofs of its reaching and acting upon the organs of perspiration. Although it may sometimes operate more upon certain excretions than upon others, it may be presumed that, when any tolerable quantity is thrown into the body, it is in part distributed over the whole ; and there- fore its medicinal effect is, that it is the most universal aperient and dedbstruent known."— (Mat. Med., part ii., chap, xvii., p. 443.) I have not, however, found that it gains much advantage, at least in the disease before us, by being united with sulphur, or sub-doses of ni- tric acid, as in the pulvis mercurii cinereus of the late Edinburgh Pharmacopoeia; but the sul- phurets of antimony seem to increase, its effect. M. de Sauvages relates a singular case of this disease, in which this compound effected a cure, upon the authority of M. Broussonet, in whose practice it occurred.—(Class x., Ord. ii., Gen. ix., Physconia, y 3.) When the disease exists in feeble children, repeated emetics have been of service, by rous- ing the torpid absorbents of the liver into fresh action. As the use of the prussic acid has of late been revived for several kinds of visceral affections, I ought not to omit stating that, in the form of an infusion of laurel-water (prunus laurocerasus), it is said by various writers to have been serviceable in the disease before us, some of whom have tried it externally, others internally, and a few in both ways (Baylie's Pract. Essays; Percival's Pract. Essays, vol. i., p. 36); but, as I know nothing of it from my own experience, I limit myself to giving this hint. The preparations of iodine have a far better claim to our attention, not only in respect to the present, but to all the species of parabysma, from their peculiar tendency to promote ab- sorption in morbid growths in general. Dr. Ba- ron (Illustrations of the Inq. respect. Tubercu- lous Diseases, 8vo., 1822), who has extended and enlarged on M. Coindet's experiments, thinks there is no medicine that can rival their salutary, powers. But we shall have occasion to notice them still further when discussing bronchocele, in which they seem especially efficacious. In every trial, however, whether external or internal, they -require more caution than is ordinarily exercised, and should be com- menced in very small and circumspect doses. There is also another remedial plan, which has been greatly praised at various periods, and especially of late, for its certainty of success, and that is, a protracted nausea. In many cases this has been unquestionably, and even eminently, serviceable ; and tuberosities of ex- tensive range, and in some instances when seated on the surface of the body, or the ex- treme membranes, occasionally even those of bronchocele, have been wonderfully diminished, or even entirely removed, in a few weeks. It is only, however, when the general habit appears good, and the general strength pretty firm, that we can reasonably expect any advan- tage from protracted nausea ; and hence, com- paratively, but rarely in the present disease, which, as already observed, is for the most part an effect of laxity of structure, or hebetude of action. Weakly infants and children are far more subject to abdominal enlargements of the kind before us, than those in health ; and it is well known that we may at will produce any extent of tubercles in the liver of rabbits, by feeding them with poor or insalubrious food.* * Under the name of " parabysma hepaticum," Dr. Good seems to have brought together various structural diseases of the fiver, the morbid anato- my of which are more particularly described by Laennec, Andral, Abercrombie, Cruveilhier, and other pathologists. " These are diseases," as Prof. Elliotson has observed, " in which you can do nothing more than treat the patient upon the common principles of inflammation, and endeavour to excite absorption by means of iodine and mer- cury, and support the patient's strength. As to the greater number of them, you cannot, of course, distinguish them during life. You can tell that there is organic disease, by feeling that the liver is very large; and sometimes you find there are tubera, bumps in the region of the liver; but very often it is impossible to say what exact structural disease there is! If you have seen fungus haematodes, or scirrhus in other parts of the body, you may suppose the disease to be of the same nature."—(Med. Gaz., 1832-3, p. 486.) Dr. Abercrombie is not so much an advocate for mer- cury as the generality of practitioners are: for those chronic affections of the liver which are beyond the reach of any human means, he thinks that the treatment should be entirely palliative, consisting of a careful regulation of the diet and Gen. IV.—Spe. 2.] PARABYSMA SPLENICUM. 223 SPECIES II. PARABYSMA SPLENICUM. TURGESCENCE OF THE SPLEEN. INDURATED TUMOUR IN THE LEFT HYPQCHON- DRIUM, VERGING TOWARDS THE SPINE ; PALE COUNTENANCE ; GENERAL DEBILITY.* Enlargement of the spleen is, for the most part, less mischievous than enlargement of the liver ; and there is hardly any organ that either nature or art may take so many liberties with, without seriously affecting the general health. It has been found wanting (Pohl. Pr. Casus anatomicus, ccc, defecla Lienis., Lips., 1740); it has been found double (Schenck, observ., lib. iii., N. 84 ; Cabrolius, observ., N. 15), and even treble (Schenck, loc. citat.) ;t and, when in a state of disease, in a few rare instances, it the bowels, with mild tonics, &c. This he con- ceives to be a point of much practical importance, because these affections often exist for a long time, without materially injuring the health of the pa- tient ; and, by treatment entirely palliative, his life may be perhaps prolonged, and certainly ren- dered more comfortable. But, when such cases are treated actively by courses of mercury, the strength, he says, uniformly sinks in a very rapid manner, and the patient's life is often evidently shortened. In several cases of chronic affections of the liver, accompanied by jaundice, he has seen very good effects from the external use of iodine, 3 ss. to ^j. of hog's-lard.—(See Pathol, and Pract. Researches on,Diseases of the Stomach, Liver, &c, p. 386.) Where the liver is enlarged by the growth of acephalocysts in it, the frequency of more than one cyst is a consideration against un- dertaking any operation for their discharge, and we must agree with Cruveilhier, that the attempt would only be justifiable, when the cyst became adherent to the parietes of the abdomen, or was disposed to make its way outward, and burst of itself. The success which M. Recamier had by puncturing a tumour of this nature, and then em- ploying caustic»potassa and injections, is justly considered by Cruveilhier as an exception to what would generally be the result of such practice.— (See Anat. Pathol., livraison 3, p. 3.) The bilious discoloration of the fluid in these cysts, often no- ticed, is ascribed by this eminent pathologist to the biliary tubes not being obliterated in the part occupied by the disease, the consequence of which is, that they effuse bile into the cavity where the acephalocysts are contained. In the case which he has related, the patient did, not die of the dis- ease of the liver, or the ascites, but of a gangre- nous affection of the lower extremities, arising from an anasarcous distention ofthe cellular mem- brane, and the irritation of scarifications.—Ed. * The spleen sometimes produces an external swelling, without being enlarged ; as when fluid in the pleura presses the diaphragm towards the hypochondrium, and forces the spleen from its usual situation. Enlargement of the left lobe of the liver, or of the left kidney, or certain tu- mours of the peritonaeum itself, may have a similar consequence. See Andral, Anat. Pathol., torn. 2, p. 423.—Ed. t Heusinger, in his Mem. sur les Monstr. de la Rate, &c, p. 62, alludes to the existence of seven spleens in a subject; and Otto, in his Hand, der path Anat., p. 302, mentions a case where twenty- three accessory spleens existed.—D. has been utterly extirpated without injury,* or has continued of an enormous size for thirty years and upwards.—(Darw., i., ii., iii., 18 ; Sauv., loc. citat.) [But, though tbe spleen can- not be regarded as a vital organ, or one of much sensibility, it appears, as Dr. Abercrombie has correctly remarked (Edin. Med. Journal, No. 80, p. 1), to exert an important influence upon the functions of the stomach. It may, how- ever, only have this influence when diseased, for, according to numerous experiments per- formed under the inspection of Baron Dupuy- tren, the spleen may be removed from dogs, and yet such of these animals as recover from the operation, live afterward, without the slightest impairment of their digestion, absorp- tion, circulation, respiration, power of barking, secretions, nutrition, locomotion, sensibility, sensations, instinctive faculties, and generative functions.—(L. et P. P. Assolant, Recherches sur la Rate, 8vo., Paris, 1802.) In general, however, in the human subject, the more the spleen exceeds its natural size, and the longer it continues in this state, the greater is the emaciation of the individual, and the impair- ment of his health. Respiration, digestion^ and the functions of the intestinal canal, must, indeed, unavoidably be disturbed by any con- siderable enlargement of this organ. The spleen is liable to acute and chronic inflammation (splenitis); to suppuration ;t mor- * Valisneri, Opp. iii., p. 128. Bartholin., Hist. Anat., Cent, iv., Hist. 51. Ferguson, in Phil. Trans, for 1738. f According to Andral, pus is found sometimes in the form of separate little drops in the midst of the coagulated blood of the splenic cells, and sometimes in more ample collections, constituting true abscesses. Some of these are separated from the parenchyma of the organ by a pseudo-mem- brane ; while around others, nothing of this kind is remarked ; the pus and blood having no parti- tion between them. Andral has seen one case, in which about three fourths of the parenchyma of the spleen contained nothing but pus ; the fibrous tissue, in contact with it, being in some places unaltered, but in others softened, pulpy, and in progress to destruction. Where the pus had ap- proached the capsule, this was considerably weak- ened ; and it is conceived that if the patient had lived a little while longer, the pus might have escaped into the cavity of the peritoneum. In fact, abscesses of the spleen, having such a ter- mination, are recorded ; while others have burst into the stomach, colon, thoraxror urinary organs, or outwardly through the muscles of the abdomen, or back. One fact, well deserving of recollection, is, that the formation of pus in the spleen seems frequently to be simultaneous with suppuration in other viscera. In an example recorded by An- dral, the original disease was in the uterus, in the substance of which, and also in its veins, collec- tions of matter were found after death; but abscesses were likewise noticed in the veins of the pelvis, the spleen, lungs, liver, and brain: examples in which pus is observed only in the spleen, are considered by Andral as less frequent. One case of this description is" mentioned, which took place in a child three years of age, the spleen being converted into little more than a pouch of matter, with hardly any vestiges of its parenchy- matous texture remaining. During fife the symp. 224 CQSLI tification ; tubercular disease, and the slow suppuration usually following that affection. Inflammation may affect either its external peritoneal covering, or its substance, or, as Andral would say, its fibrous tissue.* The first case may be restricted to the investment of the spleen; but, in almost every instance, the peritoneum of the adjacent organs partici- pates in the affection. In peritonitis, also, the external coat of the spleen is inflamed as well as the rest of the peritoneum. Dr. Abercrombie had an opportunity of seeing a spleen that was studded throughout with innumerable tubercles, all in the solid state, in the body of an infant, aged eight months, who died of extensive dis- ease of the bronchial glands. In a more ad- vanced stage, this tubercular affection presents numerous small abscesses, resembling the vom- icae of tubercular lungs. The disease, how- ever, is usually complicated with tubercular disease in other organs, so that it is impossible to ascertain the symptoms which arise from the affection of the spleen.—(Abercrombie, op. cit.) Perhaps the tubercular enlargement may be more disposed to occur in scrofulous consti- tutions ; but it is less frequent than other chronic swellings of the spleen.] Parabysma splenicum, as a species, is traced under the following varieties :— a Coactum. From simple chronic enlarge- Ague-cake. ment. 0 Scirrhosum. Accompanied with a scirrhous Scirrhous tur- feeling. gescence. y Cartilaginosum. Accompanied with a cartila- Cartilaginous ginous induration of the turgescence. coats. The first variety occurs sometimes as a consequence of menostation, or of a peculiar kind of rheumatism ; but chiefly after obstinate remittents or intermittents, in strumous or other weakly constitutions, or which have been pre- viously debilitated by intemperance.t [It gen- toms had been, acute pain in the left hypochon- drium, continued fever, and some symptoms of irritation of the membranes of the brain. The latter organ, however, as well as the digestive canal, was quite healthy. In some soldiers who had suffered from Walcheren fever, Mr. Wardrop found the spleen reduced to a cyst, full of puri- form matter.—See Baillie's Works, ed. by War- drop.—Ed. * Exclusively of lymphatics and some nerves, only the following elementary parts are found in the spleen :—1. A fibrous tissue forming exter- nally the capsule, and divided internally into a multiplicity of filaments, among which the blood is effused. 2. A vein, which, in the whole of its course, communicates with the cells by large openings, or perforations in its parietes, and whose cavity is at length confounded with the cells themselves. 3. An artery that splits, directly after its entrance into the spleen, into an infinite number of small branches, which cannot be traced far, but appear to be distributed to the parietes of the cells. See Andral, Anat. Pathol., t. ii:, p. 416. t Andral entertains peculiar opinions respecting the origin of diseases of the spleen: some rare ones, he observes, are seated in the parietes of the internal cells, or in the capsule. The others, ACA. [Cl. I.—Ord. II. erally arises from intermittent fever, but it may take place from other causes, as from sup- pressions of the menses, or hemorrhoidal dis- charge. It is also met with, especially in warm climates, in feeble, unhealthy children, and seems to be produced by damp situations and bad nourishment.—(Abercrombie, op. cit., p. 411, ed. 2.)] When agriculture was in aruder state than in our day, and the land left in many parts swampy, and undrained of its stagnant waters ; and, consequently, when tertian and quartan intermittents were far more common than they are at present, this disease was also far more frequent and more obstinate. An injudicious and immoderate use of the bark is said also to have contributed to this affection, and very generally to have increased it. And although we meet with no such mischievous which are far more common, and of higher impor- tance, are situated in the matter itself contained in the splenic cells. Although this matter, this coagulated fibrine, has no distinct organization, it is perhaps more alive than the fibrous tissue around it. More frequently than it, then, it may be affected by irritation ; its nutrition may be so altered, that various morbid products are sepa- rated from its own substance; and pus, worms, &c, may be generated within it. The primary cause of several of these changes is quite un- known ; but there are some others, in which the cause is entirely physical, and more easy of esti- mation. Thus, certain modifications of colour and consistence, sufficiently remarkable to obtain the name of cancers of the spleen, appear to be simply connected with obstruction of one of the venous branches running more or less directly into the splenic vein. In this case, the detention of a little fibrine in the cells of the spleen would seem, according to Andral's views, to be adequate to lead to such modifications of this fibrine, as may give it a carcinomatous, tubercular, or other morbid appearance, &c. Softening of the spleen he refers to the blood in its cells being fluid ; indu- ration, to its dense consistence : change of size, he ascribes to the blood not being returned by the veins with due quickness, or to its deposition in the cells by the arteries, and its subsequent organ- ization and enlargement. Even the formation of pus, he conceives, may arise from changes in the blood, and in the cells of the spleen. In a part of these doctrines, we recognise the Hunterian opinion concerning the vitality of the blood, and its power of producing vessels within itself, when extravasated or stagnant in living textures. Yet, attentively as these opinions have been examined, and compared with the facts disclosed by morbid anatomy, they are far from being confirmed to the extent which Hunter, and especially Andral, would go. When the fibrine of the blood, or coagulated lymph, becomes vascular and organ- ized, it is now most generally believed, that the vessels shoot or grow into it from the adjacent ones. Indeed, Andral, after all, does not quite disregard the co-operation of the surrounding ves- sels in the work of disease; for, says' he, the blood in the cells of the spleen, in consequence of having lost its wonted qualities, may act as a foreign body, and irritate the surrounding parts. Then in the latter may commence a process of reaction, the result of which may be sometimes the adhesion of a morbid part, and its separation by a partition from the rest of the spleen; some- times its explosion.—See Anat. Pathol., torn, ii., p. 419-426.—Ed. Gkn. IV.—Spe. 2.] PARABYSMA effects in the present day, there can be little doubt that there was much ground for such a charge formerly. In intermittent fevers, Peru- vian bark, copiously administered, is not an idle medicine ; for if it do not assist, it will be sure to injure. And as it was formerly given in large and frequent doses, in districts where the patient was daily exposed to the operation of the same swampy miasm that produced the disease at first, it is difficult to conceive how it could produce any benefit.* " In enlargement of the spleen," observes Dr. Vetch, in an excellent essay upon the sub- ject (Medical and Physical Journal, 1824), and whose professional employment among the British army at Walcheren afforded him a large field for observation on the disease before us, " the patient seldom or never complains of much pain in the situation where it might be expected : his appetite is generally good, yet his powers of assimilation are obviously defi- cient : he loses flesh, and is incapable of any muscular exertion. His features have a pecu- liar, dark, bilious, or mahogany hue ; but the conjunctiva preserves its white and healthy appearance. Perspiration is in time wholly suspended, and the skin acquires the appear- ance and feel of satin ; the lips are pale, and there is generally much wasting of the gums ; the urine is limpid, and secreted very rapidly, but contains little or no urea. The patient's mind is generally morose and desponding." The extremities are commonly colder, and the pulse quicker, than in health, especially towards the evening. [Dr. Abercrombie states, that the bowels are generally irregular, and the motions dark-coloured. There is frequently a dry cough, and, in protracted cases, haematemesis, and, at last, general dropsy, t One of the most singula* facts in the pa- thology of the spleen, adverted to by the same physician, is the very rapid manner in which enlargement of it sometimes takes place, and the equally rapid manner in which it may sub- side,. Several years ago he saw, along with Dr. Combe of Leith, a seaman who had con- tracted ague a few weeks before : there was a firm defined tumour in the situation of the spleen, and projecting downwards several inches ; in about a week after this visit, the fever had subsided, and the tumour was entirely gone. * A remarkable case of enlarged spleen, occur- ring in the practice of Dr. W. M. Lee, of South Carolina, is recorded in the Am. Jour, of Med. Sc, No. xxiv. The spleen, when removed, weighed five pounds and a half, and the disease was not preceded by intermittent fever. The doctor states that his treatment is alterative doses of mercury at night, aided by frictions of tinct. of iodine, or cataplasms of stramonium, as recommended by Dr. Cunningham, of Arkansas.—(N A. Med. and Surg- Jour., vol. v.) He adds also, that he has cured several cases of splenitis by Fowler's min- eral solution.—D. t On Diseases of the Stomach, &c, p. 412. In other cases, the general health is not much disturbed, though the patients have a sallow ap- pearance ; and thus the disease may continue for many years.—Ed. Vol. I.—P SPLENICUM. 223 Probably this variety of parabysma splenicum never depends upon tubercle^ though enlarge- ments of the organ, from this cause, are not unfrequent.* Dr. Abercrombie has seen an immense bag of hydatids covered by the peri- toneal coat of the spleen, the substance of which was little altered (On Diseases of the Stomach, &c, p. 414); but this also is an affec- tion that has no connexion with ague.] When this variety of parabysma has occurred in feeble children, it has often been' dispersed by emetics given repeatedly, which stimulate the absorbent vessels into increased activity, and act with considerable success, where a per- severing nausea might prove highly mischie- vous. Cataplasms that excite vomiting have, for the same reason, in many instances, had the happiest effects. They have commonly been made of tobacco; and Mr. Stedman gives instances of its proving an effectual remedy in both the varieties now adverted to, and in an old man as well as in a boy.—(Ed. Med. Essays, vol. ii., art. v.) The former had in the first instance been attacked with a general numb- ness, in consequence of sleeping in the open air in the West Indies, while the serenadas, or night-dews, were gathering around him. This was succeeded by a jaundice, and the jaundice by a parabysma of the liver, in which the spleen also appears to have catenated ; the turgescence continuing to increase for five years, in spite of the medicines prescribed for him. A tobacco poaltice was at this time applied, and renewed daily for a month. It produced frequent vom- itings ; but, at the end of the month, the pa- tient was cured. The quantity employed at a time was six ounces : for a child, one ounce is sufficient. Cataplasms of common groundsel (senecio vulgaris, Linn.), the erigerum of the dispensatories, are said to prove equally useful by exciting a like effect. Dr. Vetch, from an extensive experience of * Andral describes tubercles of the spleen as very rare in adults, but more common in children. They hardly ever occur without presenting them- selves also in other parts. He has often noticed them in the spleen of horses; and in monkeys they are said to be even more common than the tubercles to which their lungs are so notoriously liable.—(Anat. Pathol., torn, ii., p. 431.) Besides hydatids, various other kinds of cysts may be formed in the spleen, and chiefly, according to Andral, within its cells. The most simple are small vesicles, full of serum, which are some- times dispersed very numerously within the spleen. In some instances they are detached from one an- other ;. in others, they are in clusters. MM. An- dral and Reynaud found them not only in the cells, but also in the veins of the spleen; some of them being loose, while others were connected to the parietes of the cells and vessels by a slender pedicle. Others, again, were contained in the very substance of those parietes. Certain cysts of the spleen are far more complex: Andral has seen a fibro-serous cyst, which was filled with fatty matter, in the midst of which some hairs were observed. In another instance, a serous cyst presented itself, the contents of which resem- bled honey.—Ed. 226 C03LIACA. [Cl. I.—Ord. LL its utility in the Island of Walcheren, strongly recommends a weak infusion of the leaves of the arbutus uva ursi, which operates bene- ficially both as a tonic and a diuretic.—(Med. and Phys. Journ., ut supra.) An attack of epistaxis, or an appearance of moisture upon the skin, is generally a sign of returning health. [For an enlargement of the spleen, accom- panied with the state of the constitution de- scribed by Dr. Vetch, or anhaemia, Professor Tomassini has found preparations of iron the best medicines. " It is now generally admitted," says Dr. Abercrombie, " that mercury is uni- formly and highly injurious, producing mortifi- cation of the mouth and rapid failure of the strength. In the earlier stages, when there is any considerable degree of tenderness, re- peated topical bleeding shouldbe employed, fol- lowed by blistering or a seton. In other re- spects, the chief reliance of those who have seen most of the disease, appears to be upon free and continued purging, and especially pur- gatives combined with tonics. The spleen pow- der and spleen mixture of Bengal are combina- tions of rhubarb, jalap, scammony, and cream of tartar, with columbo powder and sulphate of iron. About 20 days are stated by Mr. Twi- ning {Calcutta Trans., vol. iii.), as the period which is generally required for reducing by this treatment a very considerable tumefaction of the spleen, if the case has been recent. Others employ nitric acid with aloetic purges. " The natives of India employ the actual cautery, and a combination of aloes, garlic, and vinegar. They also employ aloes, combined with sul- phate of iron. It is probable the external use of iodine might be useful."—(Abercrombie on the Stomach, Liver, &c., p. 412, ed. 2.)] In turgescence of the spleen, whether originating from the preceding, or produced by a strumous diathesis, the organ sometimes as- sumes a scirrhous hardness ; and, in conse- quence of this symptom, is often felt more dis- tinctly than in the first variety. It acquires, in some instances, a very large size, though often not so large as the turgescent spleen without scirrhus. Sauvages quotes from Bonet a case, in which, after death, it was found to weigh thirty-three pounds, and to fill the whole of the abdomen. The complaint had lasted seventeen years before the patient died, during nearly the whole of which time she pursued her usual avo- cations.—(Class x., Ord. ii., Bonet. ex Hypol. Bosco.) Dr. Baillie has given other singular examples ; in one of which the spleen was three times its ordinary size, of a hard, but uniformly solid texture ; not tuberculated, nor disposed to suppurate.—(Morb. Anat., Fascic. vi. PI. iii.) When suppuration, however, takes place, the ab- scess is sometimes very bulky ; and the quantity of pus lodged in it has amounted to fifteen pints. —(Hist, de I'Acad. des Sciences, 1753, p. 196.) The coats of the spleen are occasionally con- verted into a soft cartilage, and exhibit a change which is rarely, if at all, found in other viscera. The enlargement in this case, beyond the natural size of the organ, is in general but trifling; and Dr. Baillie records an instance in which there was a diminution of size ; the coats, though sometimes evincing irregularities on the surface, are usually smooth and uniform ; and it is by these characters that we can alone judge of the nature of the disease during life. [Liy.re and Morgagni have seen the peritoneal investment of the spleen partially ossified, and Andral* met with one case, in which this organ was merely an osseous shell, with internal bony partitions, between which there was a small quantity of reddish fluid, resembling turbid wine.—(Anat. Pathol., torn, ii., p. 433.)] , With regard to the treatment of scirrhous spleen, it is not necessary to add to the re- marks already offered under the preceding species. [The whole substance of the spleen is some- times reduced to a soft mass of a dark colour, resembling a mass of coagulated venous blood, and breaking down under the slightest pressure after its peritoneal coat is laid open. In certain cases it is still softer, and of a pultaceous con- sistence, or even like a reddish mucus or pus. This change of the spleen is chiefly met with in old persons, or such as have passed the age of forty. Its exact cause is not known ; but it has been met with in persons who died with scurvy, or of continued or intermittent fevers ; or who had been afflicted with melancholy ; had experienced violent pain in the hypochondria and epigastric region ; or had had symptoms of melaena ; or laboured under ascites. Dr. Ab- ercrombiet suspects, that it arises from inflam- * In Hecker's Litterarische Annalen, Dr. Hack- mann has presented his views on spleno-malacia, or softening of the spleen, which has frequently attended epidemic fevers in the north of Germany. Dr. Hackmann thinks that softening of the spleen depends on over-congestion or venous inflamma- tion, which presents two stages, one of irritation or congestion, and one of true softening. The symptoms ot the former are fever, vomiting of a clear fluid often mixed with bile, praecordial dis- tress, great lassitude, pains in the limbs, vertigo, and extreme thirst, which, if satisfied, increases the praecordial distress : the abdomen is swelled, soft in the umbilical region, but not tender ; pain however is felt when the body is bent and the stom- ach or spleen is pressed. Pulsation is very sensi- ble in the epigastrium, and as the disease advances, this pulsation extends to the region of the spleen. The stage of softening is shown by the access of typhoid symptoms, and death ensues as in cases of fever, or follows a state of coma resembling apoplexy ; this apoplectic state frequently occurs in softening of the spleen. The disease is gen- erally rapid in its progress, and softening may take place in eleven or twelve days; but it is some- times chronic. In the more severe forms of soft- ening, the spleen bursts spontaneously, without any previous violence, the matter comes into the abdominal cavity, and death speedily ensues. In softening of the spleen, the bulk of this organ is not always much increased, unless the patient have suffered from endemic or remittent fever. Dr. Hackmann mentions eight cases of acute spleno-malacia.—D. t Edin. Med. Journ., No. 80, p. 2. Andral's ref- erence of this state of the spleen to the condition of the blood in it, has been already noticed ; and, in support of his belief, that it does not arise from inflammatory action, he asks whether it ought not Gen. IV.—Spe. 3."] PARABYSMA PANCREATICUM. 227 matory action. He has observed it, as the only morbid appearance in some obscure cases, which were fatal, with symptoms referable to the stomach; or frequent vomiting, loss of appetite, tendency to costiveness, &c, the pulse remain- ing Undisturbed.*] SPECIES III. PARABYSMA PANCREATICUM. TURGESCENCE OF THE PANCREAS. HARD ELONGATED TUMOUR, RUNNING TRANS- VERSELY IN THE EPIGASTRIC REGION ; DYS- PEPSY J GENERAL LANGUOR. The following are the chief varieties under which the species shows itself :— a Coactum. Chronic indura- Atonic turgescence. tion or enlarge- ment. p Calculosum. Accompanied Calculous turgescence. with calculous concretions. Diseases of the pancreas occur but rarely. [In many points it resembles the salivary glands, to which it is also analogous in the rarity of its morbid affections. This truth is confirmed by rather to be considered as an emblem of a gen- eral change in the whole mass of blood ? Hence its common occurrence in scurvy and typhoid fe- vers. M. Baillie noticed it in the pernicious inter- mittents of the Campagna of Rome. What, in- quires M. Andral, is the cause of these fevers ? Is it splenitis ? Or rather, is it not the poison of a miasm, which, by changing the mass of blood, must also modify that which is contained in the spleen ?—Ed. * All the diseases of the spleen which have fallen under the observation of Cruveilhier, have exhibited a character of remission, or intermis- sion ; a circumstance which he refers to the re- mission, or intermission, in the functions of this organ. " If," says he, " on the first accession of intermittent fever, it may be questionable whether the spleen has any concern with the disorder, no doubt can exist at a more advanced period. I have attended many of these cases, where each febrile attack was marked not only by the pa- tient's sense of oppression, swelling, and even pain in the spleen, but by an enlargement of it, very manifest to the physician." According to this distinguished pathologist, the induration of the spleen is always accompanied by an in- crease of its size and specific gravity, and vari- ous degrees of fragility, which eventually suhside, and are followed by a state of cohesion and com- pactness, that he has never noticed in any other tissue, excepting the fibrous transformation. In the ramollissement, or softening disease, the spleen never becomes so large as when it is indurated ; it is not unusual to meet with it above thrice its natural size, though occasionally, in the softened state, it has weighed seven or eight pounds. As for organic diseases of the spleen^ such as tuber- cles, the black degeneration of it, cartilaginous transformation, scirrhus, &c, they are completely irremediable. The same remark applies to collec- tions of hydatids, as far as medicine is concerned ; for the only chance of relief must here depend upon their being voided externally, or through some communication formed with the alimentary | canaL—Ed. f P2 extensive observation, and when the surround- ing viscera are found variously altered by dis- ease, the texture of the pancreas often con- tinues quite healthy. To say, however, that this organ is never diseased, would be incorrect. Inflammation of the pancreas seems to be a rare disease ; but several^ cases of it are re- corded by Barbette, Greizel, Tulpius, and Bar- tholine, where it was found suppurated and gangrenous. Pain, generally referred to the back, but sometimes resembling colic, attended the disorder. In a few cases, there was vomit- ing ; but it does not appear to have been a com- mon symptom. Guido Patin found an immense abscess occupying the whole of the pancreas. Portal met with a similar case in a man, who died suddenly after two or three attacks of vomiting, followed by syncope. The same pa- thologist found the pancreas gangrenous in a man who died with obscure pain in the abdo- men, accompanied by wasting and occasional nausea and diarrhoea. A gentleman mentioned by Dr. Perceval (Trans, of the Kingys and Queen's Colleges, vol ii.), had jaundice and bil- ious vomiting ; a tumour appeared in the epi- gastrium ; his strength failed ; blood and fetid pus were discharged by stool; and in three months he died, gradually exhausted. The pancreas was found much enlarged, and con- tained a considerable abscess. The ductus communis was obliterated by the pressure.* The pancreas sometimes contains calculi. De Graaf found seven or eight in the pancreas of a man, who had long been liable to vomiting and diarrhoea. In one enlarged pancreas, Por- tal found twelve calculi,, some of which were as large as nuts. In a case seen by Dr. Bail- lie (Works by Wardrop, vol. ii., p. 239), the calculi consisted of carbonate of lime ; in some other instances, their composition has been phosphate of lime. Dissections prove, that the pancreas is some- times changed in its texture, size, and figure, in consequence of chronic diseases ; but the symp- toms are so vague and uncertain, that those which might serve for discrimination, have not yet been pointed out by the most intelligent physicians. No doubt the chief causes of this difficulty depend upon the deep situation of the pancreas, its inconsiderable size, its little sen- sibility, and the very important organs by which it is surrounded. The valuable researches of Dr. Abercrombie show the remarkable diversity of symptoms in chronic diseases of the pan- creas. Of twenty-seven cases, which he found described by various writers, six were fatal, with gradual wasting and obscure dyspeptic complaints, without any urgent symptoms. In eight there was frequent vomiting, with more or less pain in the epigastric region ; and thir- teen were fatal, with long-continued pain with- * Abercrombie, Edin. Med. Journ., No. 79, and Pract. Researches on Dis. of the, Stomach, &c, p. 418, ed. 2. A case in which, on examination after death, the pancreas was found in a state of active inflammation, has been recorded by Mr. Lawrence.—See Med. Chir. Trans., vol. xvi, p. 367. 228 COZLIACA. [Cl. I.—Ord. II. out vomiting. In some of these, the pain ex- tended to the back ; and in others it was. very much increased by taking food. In several of the cases, there were dropsical symptoms; and, in three or four, there was jaundice, from the tumour compressing the biliary ducts. In the morbid appearances also there was great vari- ety, the pancreas being in many of the cases much enlarged ; in others in a state of scir- rhous hardness, with very little enlargement. No distinct relation could be traced between the urgency of the symptoms and the degree of enlargement, which was very considerable in some examples in which the symptoms were slight and obscure ; while hardness, with little or no enlargement, was noticed in some other cases, where the symptoms were defined and violent.] Of the diseases appertaining to the present species, Dr. Baillie never met with more, than the modifications specified at the commence- ment of this section. All the ordinary causes that produce atony in the liver and spleen may affect the pancreas ; but there is one that is peculiar to itself, and that is, an habitual excitement of the excretories of this organ by the daily use of tobacco, whether chewed or smoked, probably from a sympathetic action between the pancreatic and salivary glands, whose functions so closely co- operate, and whose secretions are so nearly alike. Dr. Darwin relates a case of this kind, which terminated in the death of the patient, who had been for many years a great consumer of tobacco, chewing it all the morning, and smoking it all the afternoon.—(Zoonom , Cl. i., Ord. ii., ii. 8.) The substance of the gland is generally hardened, though not determinately scirrhous ; and its lobular appearance is pre- served.* [With respect to the treatment of enlarge- ments of the pancreas, general and local bleed- ing, the exhibition of purgatives, the application * Dr. Sewall has published (New-Eng. Journ. of Med. and Surg., vol. ii., p. 22) many interesting re- marks on the diseases of the-pancreas. Scir- rhous and inflammation with its terminations in abscess and ulceration, are the most prominent ones. This organ is sometimes much enlarged, and approaches a state of induration, without any sensible derangement of its organization. This, however, seems to Dr. Sewall to be only the com- mencement of a process by which the natural structure is lost entirely, and the pancreas be- comes truly scirrhous. Dr. S. states further, that the most remarkable indications of an enlarged and scirrhous spleen are pain in the epigastrium, vomiting, and acidity of the stomach. Dr. Valen- tine Mott, in his reflections on the pulsation in epi- gastrio, considers this affection as arising, among other causes, from enlargement or disease of the pancreas.—(See Trans, of the New-York Physico- Medical Society, vol. i., p. 341.) The late Dr. War- ren, of Boston, considers a tumour in epigastrio with a strong pulsation as generally attending a scirrhous condition of this gland. This pulsation has not been much noticed; among those who have recorded it we may mention Baillie, Burns, Monroe, and Francis.—(Trans, ofthe N. Y. Phys. Med. Society, vol. l. p. 349.)— D. of a blister to the epigastrium,* and a course of alterative medicines, especially Plummer's pill, or iodine, afford the best chances of benefit.] In the calculous variety, the concretions are chiefly, and sometimes altogether, found in the excretory duct of the gland and its branches, which, in consequence, are often very much distended, and occasionally filled with them. They are usually of a white colour and very irregular shape, and by these characters, when discharged by the rectum, may be distinguished from gall-stones. As the duct is less sensible than those of the liver, the kidneys, or the bladder, It is not often that much pain or unea- siness is complained of, even when the passage, upon an examination after death, seems to have been long blocked up, and upon a stretch. Emetics, and such exercise as gives a gen- eral jar to the animal frame, as riding a hard- trotting horse, will contribute towards dislodg- ing the pent-up concretions ; and a free use of acids, acidulous drinks, and especially acidulous mineral waters, will have a tendency to dissolve them.t SPECIES IV. w PARABYSMA MESENTERICUM. MESENTERIC TURGESCENCE. INDURATED AND. IRREGULAR MASS OF TUMOURS BELOW THE STOMACH, YIELDING TO THE PRES- SURE OF THE HAND ; PALE, BLOATED COUN- TENANCE ; ATROPHY ; THE APPETITE SELDOM DIMINISHED, OFTEN VORACIOUS. This species shows itself under the following modifications or varieties :— a Helminthicum. Accompanied with Vermicular turgescence. hydatids or other worms. 0 Strumosum. Accompanied with Scrofulous turgescence. scrofula; mostly tubercular. y Scirrhosum. Accompanied with Scirrhous turgescence. scirrhus. S Sarcomatosum. Accompanied with Sarcomatous turgescence. fleshy excres- cences. t Steatomatosum. Accompanied with Steatomatous turgescence. adipose excres- cences. f Fungosum. Accompanied with Fungous turgescence. fungous excres- cences.J * See Crampton's case, in Trans, of King's and Queen's College, vol. ii., p. 138. t In some Observations on Diseases of the Pan- creas and Duodenum (Med. Chir. Trans., vol. xviii.), Dr. Bright mentions, that, in the only three instances of a discharge of matter like adipocire from the intestines, where he had had an opportu- nity of opening the bodies after death, there was a scirrhous state of the head of the pancreas, and fungoid ulceration of the duodenum. Yet, on other occasions, he had seen similar states of dis- ease of these organs, in which no such fatty evac- uation had been observed.—Ed. X In one case Mr. Wardrop found the mesenteric glands much enlarged, and converted into a soft Gen. IV.—Spe. 4] PARABYSMA MESENTERICUM. 229 These varieties are often complicated by a union of one of them with several others. Thus the strumous modification is sometimes found to have sprouted with fungous caruncles; the sarcomatous evinces a scirrhous or indurated texture ; and vermicles are occasionally found in most of them. It is chiefly a disease of in- fancy, and debility is the proximate cause ; but the predisposing causes are numerous. Innu- tritious food, a chronic and exhausting sickness, invermination, an impure atmosphere, a scrofu- lous diathesis, may all pave the way. And when the chylopoietic organs are hereby weak- ened, the weakness will soon extend to the mesenteric glands, which will become tumefied, and exhibit a tubercular or other irregular sur: face to the feel. The symptoms grow daily more manifest; because, as the lacteals which enter them are now obstructed and impervious to the chyle, the whole frame becomes emacia- ted, the superincumbent fat and muscles waste away, and the coacervated glands rise towards the surface, occupy their place, and are covered with a meager shrivelled skin alone. And hence, any of the varieties of the present spe- cies may become a cause of atrophy or tabes ; though both these species may also exist with- out such effect. A total obstruction, however, to the course of the chyle from a parabysma of the mesenteric glands, does not often occur, certainly by no means so often as is suspected. Mr. Cruik- shank admits it to be "possible that children and grown persons may sometimes have died of such obstruction; but," he adds, " in such enlargement of the glands, if they ever take place, we should meet with the stagnation of the chyle in the first set of lacteals; yet I never saw such stagnation on any occasion whatever : but as stagnation of the lymph from obstructed lymphatic glands of other parts is said to have been seen, it may be possible that the chyle, from the causes mentioned, may sometimes have been prevented from getting into the blood- vessels."—(Anat. of the Absorbing Vessels, part i., p. 115.) That a total obstruction to the course of the chyle does not necessarily follow very great en- largements of the mesenteric glands is certain, because many patients exist under this disease for a considerable number of years, in some in- stances not less than ten (Sauv., cl. x., ord. ii., ix., 6, § 3); and seem, even at last, to be car- ried off by hectic fever, or some other cause of irritation, rather than by actual innutrition. In perfect quiet, and freedom from exercise of all kinds, and where the form has acquired its full range of growth, it is astonishing to see how very small a portion of food entering into the system is capable of supporting life ; a subject we have already touched upon under limosis ex- pers ; and hence Morgagni and Dr. Hunter are inclined to believe, that in old people the glands medullary pulp. The patient had died of a large fungus haematodes of the thigh. In very rare ex- amples they have been found to contain earthy matter.—See Baillie's Works, vol. ii., p. 180. of the mesentery become obliterated; while Ruysch contended that, in the latter part of his life, he lived without his lacteals, and that old people in general do the same. In most of the varieties before us the tumours are often very bulky and conglobated ; and at times composed of, or accompanied with, cysts filled with a limpid fluid. In one instance, re- lated by M. de Sauvages, these amounted to twenty of various sizes ; one as large as a child's head, six as large as a man's fist, and the rest equalling hens' and pigeons' eggs. Hence the whole abdomen is in some cases so generally tumefied as to give a semblance of pregnancy, for which the tumefaction has sometimes been mistaken. This is particularly the case with the last variety; and as the appetite, state of the bowels, and bladder are often unaffected, or only affected casually and to appearance capri- ciously, there is not unfrequently some difficulty in determining between the two. Sometimes the parabysma is peculiarly complicated in its texture, which is glandular, tubercular, scir- rhous, and ossific ; the glands or tubercles ap- pearing like clusters of walnuts, interspersed with glands of less magnitude, of the size of peas, beans, or filberts ; for the origin of which the reader is referred to the remarks under the first species. Dr. Donald Monro gives a case of this kind in a young woman who died of hec- tic fever in St. George's Hospital in 1771. Upon laying bare the mesenteric glands after death, they were in some places found to re- semble spongy carious bones ; not consisting of one large firm piece of bone, but of a number of small pieces united by membranes. The general outline of the medical treatment will run parallel with the plan already laid down for the cure of parabysma hepaticum. If worms exist, the course recommended under the genus helminthia should be carried into effect, ac- cording to the kind of worm that discovers itself; a light, nutritious food, substimulant with salt and acid or aromatic condiments, should form the daily repast, with a free exposure to pure air, and such exercise as the patient is best able to take without fatigue. Our chief dependance, however, must be on small doses of mercury ; a mercurial plaster with gum ammoniac, large enough to cover the entire seat of disease ; or a small portion of mercurial ointment rubbed over the abdomen every night and morning with the friction of the hand, continued for at least half an hour or an hour at each time ; in which case the friction will be of almost as much ser- vice as the mercury. A salivation is not de- sirable, for it will only add to the general weakness; and hence whatever preparations are made choice of, they should fall short of pro- ducing this effect. The less stimulant and heat- ing of the gum-resins will often also .be found serviceable ; and especially myrrh, either alone or in combination with the fixed alkalis; and especially with some form of iodine, which, whether used externally as an ointment, or in- ternally in the mode of pills or tincture, has a tendency to afford more relief, and prove a bet- ter deobetruent in this species of parabysma than 230 C03LLACA. [Cl. I—Ord. II. in any other. The aperients employed should be gentle; and where calomel is not thought advisable from any particular circumstance that may occur, rhubarb alone, or in union with some of the neutral salts, will usually be found the best medicine we can have recourse to. Yet, it is only in recent, and uncompli- cated cases that we can fairly hope for success, let our medical plan be what it may. In the scirrhous, sarcomatous, steatomatous, and espe- cially the fungous modifications, and more es- pecially still, where several of these are playing their parts simultaneously, the art of medicine may possibly retard, but can never entirely ward off, the fate that is approaching, with perhaps a slow, unperceived, and insidious, but, at the same time, with a certain and irresistible stealth of footstep. SPECIES V. PARABYSMA INTESTINALE. INTESTINAL TURGESCENCE. TUMOUR HARD OR CIRCUMSCRIBED, ROUND OR ELONGATED ; MOVEABLE UPON THE PRESSURE OF BOTH HANDS ; IRREGULAR DEJECTIONS ; OBSTINATE VOMITING ; PYREXY ; AND FOR THE MOST PART EMACIATION. In this species the coaeervation exists in the coats of the intestines, and consequently is moveable with them. Almost always, however, a slight degree of adhesive inflammation takes place, and the tumefied part becomes united to the superincumbent parietes, or to some other part of the intestinal canal; on which account the disease belongs to the present, rather than to the preceding order. It has chiefly occurred under the two following modifications :— a Conglomeratum. Cohesive and con- Conglomerate turgescence. glomerated. ft Sarcomatosum. The tumour circum- Sarcomatous turgescence. scribed, and of a fleshy feel. Morgagni relates a striking instance of the first variety in a man subject to hypochon- driacal depressions of mind, as well as to a flux of the hemorrhoidal vessels. Upon an abrupt cessation of the hemorrhage, he soon complained of pains in the abdomen, sometimes sudden and transitory, at other times protracted, but never leaving him intervals of perfect ease. Some months afterward a hardness and swelling were noticeable in the belly, which gradually aug- mented, and from the pain and emaciation, and almost incessant vomiting with which it was accompanied, at length exhausted and destroyed him. The tumour lay manifest to the sight as well as to the touch, of a circular shape, equi- distant from the ensiform process and the navel, in its diameter about eight fingers' breadth. On dissection, the ileum and adjoining portion of the jejunum were found retracted upwards, coacervated, and firmly adhesive.—(Op. cit., torn, ii., ep. xxxix., No. 21, 25.) [Inflammation of the peritoneal coat of the intestinal canal is very often followed by a close and more or less general adhesion of the bowels to one another. These adhesions are some- times so numerous and intimate, that the intes- tines form only one mass, being inseparably blended with the substance connecting them together, and making, as it were, a kind of tube winding in the midst of the confused mass.— (See Meckel's Anat., translated by Doane, vol. iii., p. 296.)] The tumour in the second variety is often of an oblong shape, and lies below the hypo- chondria, inclining towards the epigastric region, prominent, with unequal hardness. Fantoni re- lates a case of this kind in a boy of a corpulent make, about ten years of age. It commenced with an excruciating pain in the belly, pyrexy, and vehement vomiting, and was soon followed by a tumour of the above description, but seated on the left side, in size resembling a prolapsed spleen. The patient, worn out by the violence of the symptoms, did not long survive. On dissection, every other part being found healthy, the colon under the stomach and towards the left side, for the length of the palm of the hand, was greatly indurated and distended, with a fleshy, fibrous, and peculiarly-thickened tumour, which contracted the diameter of the gut (Fan- toni, Obs. Med. Select., obs. ii.) ; and if the boy had lived much longer, would, in all probability, have adhered like the last to the surrounding parietes. From the violence of the symptoms, and the little prospect we have of allaying them, this disease is almost hopeless. It commences with a considerable irritability of the part of the in- testinal canal that is affected, and the effusion, growth of new matter, distention, 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 intro- duced.into the stomach. There are two indications to be followed up, and but two medicines that offer us any chance of success while holding the indications in view. Our first object should be to allay the irritabil- ity, and consequently the pain and sickness, which, after a free loss of blood by cupping, can only be attempted by opium given in large and repeated doses, if necessary, to the amount of ten, twelve, or even fifteen grains a day, if the patient be an adult. Ten and twelve grains a day, for three weeks, without intermission, I have myself prescribed, with great comfort to the paftient, and without stupor, or even sleep, the night being passed in a kind of refreshing re very, 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 consid- erably 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 subside. We should at the same time endeavour to counteract the morbid change of structure, and [ particularly to arrest its progress ; which con- Gen. IV.—Spe. 7.] PARABYSMA C0MPL1CATUM. 231 stitutes 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 oint- ment 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 per- manent good is to be expected from it. The bowels, however, may often be conveniently re- freshed 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. [In this section too many different diseases are comprehended under the two varieties, and the divisions of the subject,should have been more numerous. An advantageous basis for them might have been derived from morbid anatomy, by which the various swellings and indurations of each particular texture of the bowels might have been determined. Thus the origin of the scirrhous alteration of the intestines in their vascular coat and glandulae muciparae, and its subsequent extension to the mucous and muscular coats, might have been explained as the foundation of one variety. The thickened state, first of the mucous coat, and then of the peritoneal and muscular, from dysentery, with ulceration of the first-mentioned membrane, being only effects, and not the original disease, did not necessarily require description here. But the thickened folds of the mucous mem- brane, caused by an accumulation of the cel- lular substance (Baillie's Works, vol. ii., p. 159), might have been enumerated as a variety strictly appertaining to this species. The remark needs scarcely to be made here, that all organized fleshy indurations, thicken- ings, tubercles, adhesions, scirrhi, and fungoid swellings of any portion of the alimentary canal, must be deemed beyond the power of medicine.] SPECIES VI. PARABYSMA OMENTALE. TURGESCENCE OF THE OMENTUM. TUMOUR INDURATED AND DIFFUSED : FRE- QUENTLY SPREADING OVER THE WHOLE OF THE ABDOMINAL REGION : DYSPNOEA J EMA- CIATION. This species is especially characterized by its extent and the want of a definitive outline, by which it is particularly distinguished from the preceding. It is usually of a complicated texture ; infarcted, scirrhous, tuberculate, and cartilaginous. It has been found of various shapes and magnitudes, from a weight of five pounds to that 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 an ascites, so generally was the abdomen enlarged. She sunk, gradually worn out by atrophy and pains of various kinds ; and on examining the abdomen, the tumour, occu- pying 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 in- terior, filled with a sordid and fetid sanies. Laterally and below, it adhered to the surround- ing organs only slightly ; but was so firmly fixed to the fundus of the stomach and parts adjoin- ing, that it could not be separated without laceration.—(Greg. Hoist., prob. x., dec. vi.) In some instances the hardness has been al- most stony (Panarol., penfec. iii., obs. 10), in others osseous (Mongin, Hist, de t'Acad. des Sciences, 1732); sometimes loaded with many thousand glandules (Seger. Ephem. Germ.); and, in several of these, accompanied with ex- cruciating pains.—(Hux. Phil. Trans., vol. vii.) Whatever benefit maybe expected from med- icine, is to be collected from the remarks already offered on the preceding species. SPECIES VII. PARABYSMA COMPLICATUM. COMPLICATED TURGESCENCE. THE BELLY HARD, ELEVATED, AND DISTENDED AS THOUGH PREGNANT, AND OFTEN SUPPOSED TO BE SO ; YET MORE OR LESS KNOTTY AND UNEQUAL : RESPIRATION SELDOM IMPEDED : FOR THE MOST PART ACUTE PAIN, NAUSEA, OBSTINATE VOMITING, AND THIRST. Several of the preceding species are com- plicated as to the nature of the tumour with which the respective organ is affected ; the present is complicated as being compounded of various viscera, which are affected simultane- ously. And hence the symptoms must often differ in different individuals, according to the immediate seat of the disease and the nature of the tumour. The liver is, in perhaps all cases, more or less concerned: sometimes in connexion with the spleen, sometimes with the mesentery, sometimes with the stomach or intestines, and sometimes with all together. Hildanus found the liver so enlarged as to pass beyond the false ribs of the left side, with the spleen equally en- larged (Cent, ii., obs. 45), and fixed to the ad- joining 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 child's head. This case was also further complicated with jaundice.—(Miscell. Nat. Cur., Ann. vi., vii.) Bartholine mentions a woman of elegant form, in the flower of her age, attacked with another modification of this disease, which at length destroyed her : 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.— (Cent, ii., obs. 6.) Dr. Baron has given various examples of the same, both from earlier writers and from his own practice, of which the following is one of the most illustrative : the patient was a girl of about eighteen, and had laboured under the 232 CCELIACA. [Cl. I.—Ord. II. 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 peritonaeum were torn from their adhesions. It was impossible to do this from the intestines, for there the thickening and ad- hesions had proceeded so far, as to render any attempt at unfolding them impracticable. The mesentery and its glands were in a very dis- eased state : the latter were about the size of almonds, and had much of the same appearance when cut into. On separating the peritonaeum from its adhesions to the diaphragm, ^the liver was found of a much larger size than natural ; it was of a bright copper-colour, and, like the intestines, it had lost its proper texture. The fingers pierced it in every direction without re- sistance, and it appeared like a part in a state of incipient putrefaction. On cutting through the right lobe, a lumbricus was observed in one of the biliary tubes."—(On Tuberculated Ac- cretions, &.c, p. 25, 8vo., 1819:) Various morbid changes, as adhesions, thick- enings, tubercles, granulated masses, ulceration of the bronchial glands, and purulent discharge, were also observed in the thorax : for all the spe- cies of 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 the chest to the abdomen. Other cases of a striking character are re- ferred 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 mis- chievous effects of this monstrous race of dis- eases : diseases which we can rarely hope to conquer, unless we have an opportunity of strangling them in their infancy ; though we may sometimes give a check to their rapid strides, palliate their painful progress, and post- pone their fatal triumph. CLASS II. PNEUMATICA DISEASES OF THE RESPIRATORY FUNCTION. ORDER I. PHONICA. AFFECTING THE VOCAL AVENUES. II. PNEUMONICA. AFFECTING THE LUNGS, THEIR MEMBRANES OR MOTIVE POWER. CLASS II. PHYSIOLOGIC Before we enter on the dieases which dis- turb the function of respiration, and constitute our Second Class, it may be found advantageous to take a brief survey of the general nature of this function, and of the organs which form its instruments. The respiratory function is maintained by a current of air, alternately thrown into and thrown out of the chest, and is subservient to two important purposes : that of furnishing us with speech, or the means of vocally commu- nicating and interchanging our ideas ; and that of carrying off from the blood a gas recremen- tory and deleterious to life, and possibly of in- troducing in its stead one or more gases indis- pensable to animal existence. It is these two purposes that lay a foundation for the two Orders, into which the Class before us is divided ; the first entitled Phonica, comprising the diseases affecting the vocal avenues ; and the second, Pneumonica, comprising those affecting the lungs, their membranes or motive power. I. At the root of the tongue lies a minute semilunar bone, which, from its resemblance to the Greek letter u or u-psilon, is called the hyoid or u-like bone; and immediately from this bone arises a long, 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 windpipe ; and the upper part of it, or that immediately con- nected with the hyoid bone, the larynx ; and it is this larynx, or upper part, that alone consti- tutes the seat of the voice. [The larynx is situated on the median line, and consequently, according to the doctrine of Bichat, it is regular and symmetrical in its form, like all the organs of animal life. Considered as the upper termination of the trachea, it forms a striking contrast with the lower extremity of that tube, which, consisting of the bronchi, and concerned merely with the functions of CAL PROEM. organic life, is made up of two lateral portions not resembling each other. The lateral por- tions of the larynx, on the contrary, are exactly similar. This symmetry is necessary for the harmony of its functions ; and a discordant voice would inevitably result from different or- ganizations of the two halves of it, or from in- equality in the powers of the muscles of its right and left sides.] The tube of the larynx, short as it is, con- sists of five cartilages ; the largest, and appa- rently, though not really, lowermost of which 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 consequence of Adam's having eaten the for- bidden fruit. This is not a complete ring, but is open behind, the open space being filled up, in order to make a complete ring, with two other cartilages of a smaller size and power ; and which, together, form the glottis, as it is called, or immediate aperture out of 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 aper- ture, and closes it in the act of swallowing, so as to direct the food to the oesophagus. From its position it is called epiglottis. These four cartilages are supported by a fifth, which con- stitutes their basis, is narrow before, and broad behind, and has some resemblance to a seal-ring : on which account it is named cricoid, or annular. [It is situated between the two flat plates com- posing the thyroid or scutiform cartilage ; and, upon its elevated posterior margin, the two little arytenoid cartilages are loosely articulated, so as to admit of free motion. The chordae vo- cales are the two long edges of the rima glot- tidis, which meet together in front. They con- sist of a peculiar elastic substance, and reach iGICAL PROEM. [Cl. II. 234 PHYSIOLO from the forepart of the arytenoid cartilages to the thyroid cartilage. Hence, the size of the rima glottidis must necessarily be altered by every movement of the arytenoid cartilages. In the instrument of the human voice, the chordae vocales are analogous to the various contrivances for producing vibration in musical wind-instruments.] The larynx is contracted and dilated in a variety of ways by the antago- nist powers of different muscles, and the elas- ticity 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. The form of the glottis, composed of three 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 con- siderable time. [That the larynx is the primary organ, in which the original sound is produced, is proved by the voice being destroyed or modified by certain diseases and accidents. If an opening be made in the trachea below the larynx, so that no air shall pass through the latter, no voice is produced ; when, on the contrary, an opening is made immediately above the glottis, the voice is not affected. In Bichat's experiments, when the epiglottis was confined, or even cut away, the voice was not affected by it; though later ob- servations tend to prove, that it really answers a particular purpose in the vocal apparatus, as will be presently specified. When the same eminent physiologist cut through the arytenoid cartilages, or divided the thyroid longitudinally, he found that the voice was annihilated.] 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 or aperture into the mouth. The shrill- ness 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 modifica- tion 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 air is rendered sonorous in the glottis, and various explanations have been offered upon the subject. The oldest is that of Galen, who supposed the calibre of the glottis to be alternately expanded and con- tracted ; an idea revived in modern times by Dodart, who at the same time compares its ac- tion to that of a flute.—(Mim. de I'Acadimie, &c, 1700.) A second explanation is that of M. Ferrein, who supposes the variations of sound to depend upon variations of tension and relaxation in the ligaments of the glottis ; and, in this view, such ligaments become vibrating chords, and the entire apparatus approaches the nature of a violin.—(Id., 1741.) A third explanation is that of M. Richerand, who unites the two preceding conjectures, and supposes that the glottis is a wind and a chord instru- ment at the same time. To these explanations we may add that of Kratzenstein, who regards the glottis, in conjunction with the whole length of the larynx, as a kind of drum (Tentamen de Natura et Charactere Sonorum Literarum Vo- calium, 4to., 1781); and that of M. Blumen- bach, who views the former in the light of an - Philip, that the difficulty of breathing, caused by the annihilation of the nervous influence of the par vagum, may be temporarily removed by galvanism.] HI. But the most important part of the gen- eral economy of respiration consists in the change which takes place in the blood, in con- sequence of its being acted upon by the in- spired air. We see the blood conveyed to the lungs of a deep purple hue, and deprived of those qualities which fit it for nutrition, secretion, the preser- vation of the nervous influence, and the main- tenance of the vigorous action of every part and organ; or immature and unassimilated to the nature of the system it is about to support, in consequence of its being received fresh from the trunk of the lacteals. We find it return from the lungs spirited with newness of life, perfect in its elaboration, more readily disposed to coagulate, and the dead purple hue trans- formed into a bright scarlet. What has the blood hereby lostl How has this wonderful change been accomplished I These are questions which have occupied the attention of physiologists in almost all ages, and were as eagerly studied in the Greek schools as in our own day. To the present hour, however, they have descended in a mantle of Cimmerian darkness ; and though the re- searches of a more accurate chymistry have disclosed volumes of facts heretofore unknown, and the ingenuity of able theorists have laid hold of them, and applied them to an explana- tion of this curious subject in a great variety of hypotheses, I am afraid we are still almost as much at sea as ever; and that there is no in- quiry in the whole range of physiology in a more unsatisfactory state than that concerning the ventilation of the blood in the lungs. According to a course of well-conducted ex- periments, instituted many years ago by Sir Humphrey Davy, it appears that the general sum of a man's natural inspirations are about twenty- six or twenty-seven in a minute ; and that thir- teen cubic inches of air are, in every inhalation, taken in, and about twelve and three quarters alternately thrown out. The atmospheric or in- spired air was found to contain, in the thirteen cubic inches, nine and a half inches of nitrogen, three and four tenths of oxygen, and one tenth of an inch of carbonic acid; the twelve inches and three quarters of returned air gave nine and three tenths of nitrogen, two and two tenths of oxygen, and one and two tenths of carbonic acid. [Perhaps, in the foregoing statement, the quickness of ordinary respiration is exaggerated. Laennec says, that the breathing may be con- sidered natural when the number of inspirations in the state of repose is from twelve to fifteen in a minute.* In the latest works on physiol- ogy, its frequency is said to vary between four- teen and twenty-seven times in a minute, but the average rate to be from seventeen to twenty < —(See Mayo's Outlines, vol. i., p. 87.) In the healthy state ofthe system, Dr. Bostock (Physi- ology, vol. ii., p..56) observes, that we respire, upon the average, about twenty times in a min- ute, while the average velocity of the pulse may be reckoned at eighty ; and consequently the heart contracts four times during the com- pletion of each movement of respiration Laen- nec's estimate is probably the most correct.] From the experiments of Sir Humphrey Davy, therefore, there should seem to be a retention in the system of a large portion of the inspired oxygen, and a small portion of the inspired nitrogen ; and a discharge from the system of a very considerable portion of carbonic acid gas. And as the colour of the blood is well known to be changed in its passage through the lungs, from a deep modena to a bright scarlet hue, M. Lavoisier, following up with additional facts an earlier set of experiments of Dr. Crawford, en- deavoured to show, that while the modena hue is produced by the carbon with which the blood is loaded when it first reaches the lungs, its scarlet results from its losing this surplus of carbon, and acquiring oxygen in its stead; du- ring which process a very large quantity of caloric, or heat, in an elementary form, is sup- posed also to be disengaged from the air thrown into the air-cells of the lungs, and to pass into the adjoining minute bloodvessels in combina- tion with the oxygen. [The quantity of oxygen lost by air that has been respired varies considerably, not only in the different kinds of animals, but in different animals of the same species, and even in the same animal at different times, according to the operation of certain external agents, and par- ticular states of the constitution and functions. Under ordinary circumstances, a man consumes on the average about 45,000 cubic inches, or nearly 15,500 grs. of oxygen, in twenty-four hours, t] * Laennec on Diseases of the Chest, and on Mediate Auscultation, p. 13; transl by Dr. Forbes, ed. 2. t See Bostock's Physiology, vol. ii., p. 110. Dr. Marshal Hall has inserted in the Phil. Trans, some very interesting remarks on the inverse ratio which subsists between respiration and irritability in the Cl. II.] PHYSIOLOG The experiments of Sir Humphrey Davy were afterward repeated by Pepys and Allen ; but these acute analysts could not discover that any part of the inhaled nitrogen was retained ; since the same exact proportion appeared from their trials to be thrown back in every instance of ex- piration, as had been previously received in every instance of inspiration. And there have since been doubts on the part of Sir Humphiey Davy himself respecting the supposed caloric ; not merely in regard to its separation from the atmo- spheric air, but as to its substantive existence at all, either there or elsewhere , heat being, in his later view of the subject, nothing more than a rapid, vibratory, or repulsive action of the cor- puscles of a body that exhibits this phenome- non : thus reviving the doctrine of Aristotle and the Peripatetics, which was so ably controverted by the Epicureans, who, foretasting the spirit of the Lavoisierian system, strenuously con- tended that it was a substance sui generis.* While, to close the whole, Mr. Ellis has gone through another extensive range of inquiry, and instituted another numerous set of experiments, to prove that even the oxygen of the inspired air does not enter into the bloodvessels of the lungs, but becomes itself converted in the air- cells of these organs into the carbonic acid gas of the expired air, by uniting with the carbon ofthe blood, which he supposes, as a recrement, to be secreted in the form of a vapour into the air-cells, by the exhalants of the lungs, t He admits, however, the existence of caloric as an elementary principle ; conceives it to be disen- gaged in very large abundance from the inspired animal kingdom. He endeavours to prove that the quantity of respiration is inversely as the degree of the irritability of the muscular fibre ; or, in other terms, that in cases in which the quantity of res- piration is great, the degree of irritability is low. By the quantity of respiration is signified the quantity of oxygen gas consumed or exchanged for carbonic acid in a given time, by the animal placed in atmospheric air. Dr. Hall regards that muscle as the most irritable which, cmteris paribus, contracts most, and for the longest time, upon the application of the least degree of stimulus. Ac- cording to his researches,, respiration in the bird tribes and the mammalia is great, while the irrita- bility of the muscular fibre is low. On the con- trary, the reptiles, the batrachia, and the fish tribes are endued with a high degree of irritability, but possess only an inferior quantity of respiration. As Dr. Hall observes, the quantity of respiration is greater in proportion as the animal occupies a higher station in the zoological scale, being among the vertebrated animals greatest of all in birds, and lowest in fishes : the mammalia, the reptiles, and the amphibia, occupy intermediate stations. The quantity of respiration is also remarkably low in the very young of certain birds, which are hatched without feathers; and of certain animals which are born blind; and in hybernation it is almost extinct. Dr. Marshal Hall's paper is exceedingly valuable, and his contrivance for measuring the quantity of respiration with minuteness particularly ingenious : it is named the pneumatometer.—Ed. * See the Author's Translation of Lucretius. Note on book ii., v. 743. t Inquiry into the Changes induced on Atmo- spheric Air, 8vo., 1807. Vol. l.—Q ICAL PROEM. 241 air during its union with the secreted carbonic halitus ; and ascribes the recovered scarlet hue of the blood to its combination with this invisible fluid; as he does also whatever effects are pro- duced by the exercise of the respiratory function, not merely in animals, but in plants. Of the facts and arguments in favour of Mr. Ellis's hypothesis, which he extends to plants as well as to animals, the two following seem to be the chief. Firstly, the seeds of plants in germination, and plants themselves in growth, throw forth carbon in the form of aqueous vapour, or, in other words, dissolved in-water, even where no oxygen is present.—(Op. cit., 8vo., 1807, sect. 20.) And, secondly, such ejected fluid, wherever life exists, is the work of secre- tion. In consequence of which, he ventures to affirm that it is a secretion of this kind which is continually taking place on the surface ofthe 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 in- sects and worms, without 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 any aeriform fluid existing naturally in the blood (Op. cit., sect. 98, p. 122), and consequently have no reason to expect that any can be thrown out: while, if oxygen enter from the air-cells into the system, it must be' by absorption or chymical affinity. If by absorp- tion it would in animals take the regular course of the thoracic duct, and the blood in the right ventricle of the heart would first exhibit a scar- let 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 ex- isting in them.—(Op. cit., sect. 16, p. 18.) To the operation of chymical affinity, he conceives an actual contact between the air and the blood to be requisite ; but in the lungs we have an intervention of the coats of the cells, and of the bloodvessels. And if these be presumed so thin, that, when moist, they will allow the air or its oxygen gas to pervade them, the gas would rather pass into the interstices of the cellular substance than into the pulmonary ves- sels, and thus create an emphysema. But the whole of such permeation he holds to be gratu- itous, and contrary to experiment.—(Op. cit., sect. 101, p. 125.) The diminution in the bulk of respired air (calculated by Dr. Bostock to be on the average about one eightieth of its bulk), (Physiol., vol. ii., p. 112), he thinks, may be accounted for by a union of the carbon of the blood with the oxygen in the air-cells, and the formation of aqueous vapour by the disengage- ment of the caloric from the oxygen of the at- mospheric air.—(Op. cit., sect. 83, p. 99; sect, 107, p. 132 ; and compare with sect. 11, p. 13.) To these objections, however, it may be re- plied, that if caloric can penetrate animal mem- branes, and unite by chymical affinity with the blood in the bloodvessels, so, for any thing we know to the contrary, may oxygen. [Dr. Davy found, that in certain morbid conditions of the 242 PHYSIOLOG. chest, the pleurae had the power of absorbing, and probably of exhaling air ; and such absorp- tion extended likewise to air purposely intro- duced between these membranes in their healthy state. Hence he inferred that mucous mem- branes may generally possess the power of ab- sorbing and exhaling air ; and that these opera- tions naturally belong to the process of respira- tion.— (Phil. Trans., 1823, p. 496.)] 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.—(Thom- son's Annals of Philosophy, No. 43, p. 75, 76.) A like combination may take place between the voltaic or some similar fluid and the oxygen, and a part of the nitrogen gases in the air-cells of the lungs ; and a similar permeation may follow directly through the membranes of the bloodvessels ; and the carbon 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. Next, we have no proof that carbon will dis- solve in water, and produce such vapour ; and hence, at present, this idea is gratuitous. Again, air appears, in various cases, to have been actually disengaged, and is, perhaps, per- petually disengaging from the blood. Mr. J. Hunter declares he has discovered it in an ab- scess, in which it could neither have been derived from without nor from putrefaction (Animal Economy, p. 207) ; 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 extended to the vegetable world since his time ; for Mr. Bauer appears to have shown, that an elastic gas is constantly shooting forth in small bubbles from the roots of plants into the slimy papulae by which they are surrounded ; and that it is hence the slimy matter becomes elongated, and is ren- dered vascular, or converted into hair or down. And Mr. Brande instituted experiments tending to prove that carbonic acid does exist, and that, too, in a considerable quantity, in the blood of animals, while circulating through both arteries and veins ; and that it is so largely poured forth from blood placed, while warm, under the re- ceiver 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 exper- iments, seems to contain an equal proportion of this gas ; and he calculated that not less than two cubic inches were extricated from every ounce of blood thus experimented upon. And hence Sir Everard Home, following up the dis- coveries of Mr. Bauer, ingeniously conjectures that it is by the escape of bubbles of this gas from the serum of blood, in cases of effusion and coagulation, that new vessels are formed ; * See various facts in confirmation of this view in Dr. Davy's "Observations and Experiments on Air found in the Pleura," &c— Phil. Trans., 1823, p. 496. ICAL PROEM. [Cl. II. as also granulations in pus, as a like gas appears to be separable from this latter fluid.—(Phil. Trans, for 1818, p. 180.) [Dr. John Davy arrived, however, at a con- clusion entirely different from that of Mr. Brande, namely, that no free carbonic acid ex- ists in the blood. In the spontaneous coagula- tion of this fluid, and in that of the serum by heat, he never observed carbonic acid to be dis- engaged ; nor has he been able to procure car- bonic acid gas from blood just taken from the vessels, still warm, and placed under a receiver, and completely exhausted of air. He states that he has raised the temperature of the blood and serum to blood-heat, and coagulated both by a heat of 200° Fahrenheit, without a par- ticle of gas being extricated.—(See Edin. Med. and Surg. Journ., No. 95.) This discrepance between philosophers of such eminence seems to demand a careful repetition of their experi- ments by others.] After what has been stated, the observations of Mr. Ellis are by no means sufficient to sub- vert the Lavoisierian hypothesis of respiration. And some late experiments, both of Gay Lussac and of Magendie, tend to support those of Sir Humphrey Davy, since they concur in proving that, in the act of respiration, there is a little more carbonic acid gas than oxygen consumed. Since the first edition of this_ work was printed, the objections here offered to Mr. Ellis's conclusion, and the support thus at- tempted to be given to M. Lavoisier's hypoth- esis, have been amply and very plausibly sup- ported by a new set of experiments, conducted with the utmost accuracy, and upon a far more -extensive scale than ever, by Dr. Edwards of Paris, who is fairly entitled to be regarded as one of the clearest and ablest physiologists of the present day. [The doctrine, that the essential part of respiration is the union of the carbon of the blood with the oxygen of the atmospheric air, and the consequent formation of carbonic acid, implies that the carbonic acid produced in breathing is precisely equal to the volume of oxygen lost. Although this was maintained to be the fact by Allen, Pepys, Ellis, Magendie, and others, the experiments of Dr. Edwards may be considered as a decided refutation of the theory. According to this eminent physiologist, the excess of oxygen con- sumed in respiration, above the volume of car- bonic acid gas produced, varies from nearly one third of the oxygen that disappears to almost nothing. The variation depends upon the spe- cies of the animal employed ; upon its age, peculiarity of constitution, and condition at dif- ferent periods.* Hence a different theory of respiration. Part of the oxygen that disappears may be absorbed in the lungs, and the remainder may either combine with the carbon of the blood, and form carbonic acid, or the whole of the oxygen may be absorbed, and the expired carbonic acid be a new secretion. The latter hypothesis is espoused by Dr. Edwards. When, * De l'lnfluence des Agens Physiques sur la Vie, &c, p. 418. Paris, 1824, 8vo. Cl. IL] PHYSIOLOGICAL PROEM. 243 in the month of March, frogs are immersed in pure hydrogen for eight hours, after all the air in their lungs has been pressed out, they con- tinue to breathe, though less and less vigor- ously, and emit carbonic acid. The same fact was observed in kittens subjected to a sim- ilar experiment. A doubt has been suggested whether the carbonic acid came from the lungs, because it is exhaled when frogs are placed in hydrogen in the summer months, and breathe rarely, or not at all. It is also argued that, even supposing the carbonic acid were derived from the lungs in these experiments, it may not be exhaled by the lungs in the natural state of respiration. On the whole, however, Dr. Ed- wards's views must be allowed to rest on facts, not readily admitting of any other interpreta- tion than what he has given them.] The ex- periments of the same distinguished physiologist also prove, that nitrogen gas is exhaled, and likewise absorbed. The carbonic acid is some- times equivalent to the Oxygen which disap- pears, but sometimes also it is less ; and the nitrogen gas exhaled is sometimes inferior, sometimes equal, and sometimes superior, to the quantity absorbed. The quantity of air inhaled in a single act of inspiration, is found to vary in persons of different-sized chests; but the aggregate in- haled in a given period, does not essentially differ; since those who inhale most at a time make the fewest inspirations in a minute. I have said that Sir Humphrey Davy calculated the average number of respirations in a minute at twenty-six or twenty-seven, and that the measure of air inspired or expired was esti- mated at about thirteen 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. And it is by this explanation alone that we can in any way reconcile the different results which have been given by different experimenters upon this subject. Dr. Godwin calculated the inspired air at twelve cubic inches, and the expired at fourteen, being a difference produced by expan- sion from the heat of the lungs (Connexion of Life with Respiration, pp. 27, 37); which does not essentially vary from the above estimate of Sir Humphrey Davy ; and he calculated the re- siduary air in the lungs, immediately after expi- ration, 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 (De Motu Animal., p. 126); while Jurin, Haller, and Menzies give that which is expired at not less than forty.—(De Respirat., p. 32.) In good health, perfect quiet, witb an open chest, few persons, perhaps, are found to breathe more frequently than about twenty times in a minute ; and the quantity inhaled and exhaled, at a temperature of fifty-five of Fahrenheit, is estimated at from twenty-six to thirty-two cubic inches each time ; which, however, by the heat Q 2 of the lungs, and saturated with moisture,- be- come forty or forty-one cubic inches in the chest itself. Taking, then, twenty cubic inches as the ordinary quantity of external air inhaled and exhaled about twenty times in a minute, it will follow that a full-grown person respires twenty- four thousand cubic inches in an hour; or five hundred and seventy-six thousand cubic inches in the course of' a day ; a total equal to about thirty-nine hogsheads. The quantity of carbon thrown out of the system of the lungs, when estimated in the gross, may afford matter of no less astonish- ment. For, taking the gravity of the carbonic acid gas as calculated by Lavoisier, a person in health must emit from his lungs something more than is equal to twelve ounces of solid carbon, or charcoal, every twenty-four hours; or, ac- cording to another estimate, five thousand two hundred and eight grains.—(Bostock's Physiol.T vol. ii., p. 111.) The primary cause of the red colour of the blood is a chymical, rather than a physiologi- cal question : and belongs to the sanguiferous, rather than to the respiratory function ; yet, upon this point also, physiologists are by no means agreed, some ascribing it to the conver-- sion of the iron, which forms a constituent prin- ciple of the blood, into a red oxyde ; and others, and particularly Sir Humphrey Davy, to the af- finity which the calorific rays of light have for oxygen generally, and hence, for the oxygen of . the animal system ; against the surface of which it is perpetually impinging, and into which it is perpetually carried in combination with the inspired air ; separating it incessantly from its union with the carbon of the animal frame, and- transforming the carbon, thus decomposed and simplified, into a dark pigment. But there are difficulties that hang about both these, and, indeed, every other hypothesis that has yet been started, concerning even the primary cause of the red colour of the blood, as we shall have occasion to notice more at large hereafter. Yet, whatever may be the primary cause of the red colour of the blood, we find that, in respiration, there is some other cause super- added, and which, as observed above, heightens the colour the blood possesses at the time of its reaching the lungs, and converts it from a deep purple, or modena, into a rich scarlet. This M. Lavoisier, as we have already hinted, supposed to be produced by that supply of oxy- gen which he conceived it was the express ob-; ject of respiration to communicate to the blood ; and in support of this view, a variety of exper- iments were appealed to, which seemed to show that the colour of the blood becomes brighter whenever exposed to the action of oxygen. Yet, till all the objections of Mr. Ellis are satisfactorily removed, and those of Dr. Edwards are further confirmed, that oxygen in a free state is actually introduced from the aircells of the lungs into the adjoining minute bloodvessels, we can place little dependance upon this explanation, however plausible and inviting. But, may not the deepened colour of the 241 PHYSIOLOGICAL PROEM. [Cl. II. blood be produced by the carbon, with which it becomes gradually loaded in the course of its circulation, and which, by the consent of all parties, is separated from it in the process of respiration 1 and, consequently, may it -not re- cover its brightness by the mere loss of this dingy pigment, whether oxygen enter at the same time into the bloodvessels or not 1 If the primary colouring material of the blood be the iron which it contains, as first suggested by MM. Parmentier and Deyeux, and the carbon be a recrementory and adventitious material, this reply might be satisfactory ; but if, as sup- posed by Sir Humphrey Davy, the carbon of the blood be itself the pigment that colours it from the first, the explanation will content but very few. Yet this last hypothesis is as open to attack as any of the rest; for, to say nothing of the difficulty of conceiving how the carbon of the animal fluids can give a deep die to the blood, while it gives no die whatever to any of the fluids besides, it is sufficient to observe, that an abstraction of a part of this die may, indeed, form a lighter hue of the same kind, but not a different hue. The hypothesis has yet to account for that yellow or orange teint, which must be added to the red venous blood before it can become changed into the red of the arterial; for, as a simple dilution of venous blood will not furnish this teint, so neither will a simple abstraction of the only colouring mate- rial which is hereby supposed.* [In the consideration of the cause of the loss of the bright scarlet colour, one fact, pointed out by Mr. Hunter, merits particular notice, viz., that blood, when it is rendered stag- nant in an artery by the effect of a ligature or the tourniquet, or in the cellular membrane by extravasation, assumes the purple colour of venous blood.—(On the Blood, p. 65.) But, as Dr. Bostock properly remarks, even if Hunter's experiments, and certain others undertaken by Hassenfratz, were to be received as proofs that the change of blood from the arterial to the venous state may be effected independently of any addition from without, it does not necessa- rily follow that the reverse operation can happen in the same manner ; nor, indeed, have we any evidence that it ever has been accomplished, without the intervention of oxygen.—(Physiol., vol. ii., p. 133.)] It may perhaps be said, that though oxygen do not get admission, caloric does; and this, too, very freely, and becomes itself the cause * Some Observations on this subject, by Dr. Stevens and Mr. Hoffmann, will be referred to in the next Physiological Proem.—Ed. of this change of colour. And, in truth, this is the explanation offered by Mr. Ellis and various other physiologists ; who contend that the func- tion of respiration consists, firstly, in freeing the blood from its load of carbon, and, secondly, in introducing a very large portion of the matter of heat in its stead ; 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 quantity of vapour that is formed in the vesicles of the lungs simultaneously with a formation of the carbonic acid, and which they ascribe to this cause : regarding the lungs as the great labora- tory, in which the matter of heat or caloric is accumulated, and rendered fit for the use of the system. But this again is to take for granted what yet remains an unsettled question, namely, whether caloric be a substance or a mere quality of body. Independently of which, admitting the substan- tive existence of caloric, and that some organ or other is specially employed in its evolution and introduction in a free state into the system, it is by no means established that this organ is the lungs ; for Dr. Currie, in an ingenious paper published some years ago, attempted to show, by various experiments, that this is chiefly ef- fected by the action of the stomach, which was also the doctrine of Mr. Hunter. And Mr. Brodie has long since brought other experiments that seem to refer it to the action of the brain. —(Phil. Trans., 1812, p. 378.) Perhaps, how- ever, all these, and various other organs, may co-operate to the same effect. Much still remains to be ascertained upon this interesting subject. Even the recovery of the bright hue itself to the blood, by whatever means accomplished, and which by most physi- ologists is regarded as a fact of the utmost im- portance in the process of respiration, is con- templated by Mr. John Hunter as of scarcely any importance whatever, except as a proof that the blood has undergone the action of ven- tilation ; an action which he conceives, 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 par- ticles.—(On Blood, pp. 204-206, dec.) And hence, though we have an abundance of facts and experiments upon the subject before us, and an abundance of speculation in respect to them, " the commercium mentis et re- rum," 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 en gaged in it. CLASS II. PNEUMATICA. ORDER I. PHONIC A. AFFECTING THE VOCAL AVENUES. The term Phonica (*&'N1KA) is sufficiently explained in the definition. The order of dis- eases which it is intended to comprehend, are seldom dangerous or acutely painful; and are rather characterized by trenching upon the grace or utility of the voice, than undermining the general health. It embraces the following I. Coryza II. Polypus. III. Rhonehus. IV. Aphonia. V. Dysphonia. VI. Psellismus. GENERA. Running at the Nose. Polypus. Rattling at the Throat. Speechlessness. Dissonant Voice. 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, concerning which the Greek lexicographers are at a loss ; and have shown it to be a genuine and very ex- tensive as well as very ancient oriental term, common, under soma 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 ca- tastagmus to a defluxion from the fauces and thorax. Among modern writers, at least since the time of Cullen, coryza is used synonymously with catarrh, and is consequently regarded as a febrile affection. But this is rather to confound morbid 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 ophthalmia ; but it may also occur, and as a simple and idio- pathic affection does occur, without febrile ac- tion of any kind. In which cases, indeed, it is of little importance, and not often worthy 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 pro- ceed 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 dis- crepant symptoms :— 1. Coryza Entonica. Entonic Coryza. 2. Coryza Atonica. Atonic Coryza. SPECIES I. CORYZA ENTONICA. ENTONIC CORYZA. THE DEFLUXION PELLUCID, MUCOUS, OR ROPY; WITH A SENSE OF IRRITATION OR INFARC- TION. In this species there will always be found an increased action of the secernent emunctories of the nostrils, while the absorbents remain little disturbed in their function ; and as a mor- bid diminution of active power is ordinarily ex- pressed by the terms atony, and atonic, so en- tony and entonic are in the present work em- ployed to express the opposite, or a morbid ex- cess of activity. According to the difference 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 con- tinuous sympathy, as in crying or weeping; a damp chill, or some other change produced sud- denly in the temperature, or perhaps tempera- ment, of the atmosphere. And it is still more generally, and often with great abruptness, brought on by a transfer of action, or a sort of reverse sympathy with some remote organ. Thus, there are many persons, who, as Dr. Darwin observes (Zoonom., Cl. I., Ord. I., ii. 7), by sleeping at night with their arms or shoulders accidentally uncovered, become cold and torpid in the cutaneous vessels of these organs, and have their nostrils instantly affected with in- creased action, filled with mucus, and so thick- ened in the mucous membrane, as to render them almost incapable of breathing. An ozaena or nasal ulcer will also frequently produce a like effect; in which case the in- creased defluxion will be intermixed with a pur- ulent or ichorous matter, sometimes throwing forth an offensive smell: all which may be ar- ranged in a tabular form under the following va- rieties :— a Sternutatoria. /? Lachrymosa. Snivelling. y Catarrhalis. Snuffling. I Ozcenosa. From sternutatories : accorn- panied with sneezing. From weeping or crying : the lachrymal secretion being increased by mental emo- tion. From sudden chill or mois- ture in the temperature or temperament of the atmo- sphere. ' The defluxion more or less purulent; or ichorous and fetid. 246 PNEUMATICA. [Cl.IL—Ord. I. The last is a case of surgical rather than of medical treatment, and is often connected with a caries of the ossa spongiosa, or ossa nasi, and frequently with a lodgment of pus in the frontal sinus or antrum maxillare ; in both which cases the inflammation is at times accompanied with excruciating pain. The first is peculiarly com- mon to grazing animals, and especially to sheep, from the irritation of minute insects, and espe- cially those of the gadfly, 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 frequent under the name of naukera. The natives cure it in its onset by topical bleed- ing ; for which purpose they prick the inflamed membrane with a sharp-edged grass, which an- swers 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 yariety produced by a sud- den application of cold, Or a sudden change in the temperament of the atmosphere, and which imakes ^n approach towards a .catarrh, though without any sense of heaviness or oppression 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 S.chneiderian mem- brane. When it is the result of a reverse sym- pathy with the arms or other limbs, rendered chilly at night by being uncovered, it is easily and almost instantly removed by covering the chilly organs with additional bedclothes, and thus restoring the balance of heat and cutane- ous secretion. In a singular idiosyncrasy, reported in the Ephemera of Natural Curiosities, the odour of roses, without amounting to a sternutatory, proved a stimulus sufficient to excite a coryza whenever applied.—(Dec. ii., ann. v., obs. 22.) It is well remarked by Galen, that various foods produce a like effect (Fragment ex. Aphor. Rabi Moyses, p. 36); and Bonet, in one instance, found it occasioned by a globular tumour, sur- rounded by a fluid in the ventricles of the brain (Sepulchr., Jib. i.., sect, xvii., obs. W), probably from an excitement of the olfactory nerves, which take their rise in the corpora striata, situated in jthis quarter of the cerebrum. SPECIES II. CORYZA ATONICA. ATONIC CORYZA. THE DEFLUXION LIMPID, AND WITHOUT ACRIMONY OR SENSE OF IRRITATION. The chief causes are, exposure to a keen frosty air ; the natural paresis of old age ; and a long and immoderate use of strong aromatics, volatile alkali, or snuff; affording the three fol- lowing varieties :— * Miscellaneous Obs. on certain Indigenous Customs, &c, in India, by Daniel Johnson. a Algida. From exposure to a keen frosty air. 0 Senilis. From old age. y Superacta. From habitual indulgence in snuff, or nasal stimulants. In all these there is diminished action in both the secernent and absorbent vessels of the nos- trils, but chiefly in the latter, which almost uni- formly yield soonest, from causes we shall here- after have to explain. And hence, while the secernents are only capable of separating a thin limpid water, instead of a viscid mucus, the absorbents are too inert to carry off even this, which in consequence accumulates, and drips from the nostrils. A warm atmosphere, or the vapour of warm water snuffed up the nostrils, affords an easy remedy for the first variety of this species, which far more frequently occurs, and perhaps only occurs, in a dry, sharp, frosty air, than in an atmosphere rendered chilly from damp; damp being, as already noticed, rather a cause of the preceding species. In the former case, the severity of the cold overcomes all power of reaction ; and hence, notwithstanding there is a defluxion, because whatever is se- creted is not carried off by the correspondent absorbents, the discharge is checked in its quan- tity, at the same time that it is rendered more limpid. In the latter case the tone of the ex- cretories rises superior to the chill to which they are exposed, and the reaction ascends to something of a morbid excess. A warm room, and particularly the excitement of a gentle per- spiration, will cure both ; but the first is also often cured by brisk walking, or any other vigor- ous exercise proportioned to the sharpness of the frost; for as the system becomes roused generally, the nasal excretories become roused also, and triumph over the cold with a reactive power, which is at the same time communicated to the correspondent absorbents, when the de- fluxion immediately ceases. The last two varieties are beyond the reach of medical aid. The coryza, or snuffling of old age, is precisely analogous to its ptyalism or drivelling. In the one the atony is seated in the excretories of the salivary glands ; in the other, in those of the mucous membrane of the nostrils. Among the habitual irritants that lead to the same effect, snuffs are the worst; for the tobacco of which they consist operates with the mischief of a narcotic as well as of a stimu- lant ; and hence the copious and foul secretion with which the nostrils of aged snuff-takers are constantly deformed. GENUS II. POLYPUS. POLYPUS. FLESHY, ELONGATED EXCRESCENCE, GENERALLY SHOOTING FROM A COMPARATIVELY SLENDER ROOT ATTACHED TO SOME PART OF THE MU- COUS MEMBRANE OF THE NOSTRILS ; EXTEND- ING IN DIFFERENT DIRECTIONS, AND AFFECT- ING THE SPEECH. This is the polypus, properly so called, and Gun. II.—Spe.2.] POLYPUS CORIACEUS. 247 the disease to which the term is applied by Cel- sus, and continued to be applied till after the days of Heister, who uses it in the same re- stricted sense. More lately, however, the term polypus has been employed in a much looser signification, and made to import concretions and excrescences appearing in various channels or cavities of the body, of very different origins and textures, as those of the heart ; those of the uterus and bladder, which are caruncles or sar- cophytes, with a slender base or peduncle ; and those of the trachea in croup, which are con- crete gluten ; whence the croup is by such wri- ters denominated angina polypus or polyposa. It is better, with the old authors, to restrain polypus, as a distinct generic term, to peduncu- lar excrescences in the nostrils, and to distin- guish by the phrase polypous tumours, caruncles, or .shoots, such adscititious productions as may have a resemblance to them in other organs.* Polypus, in the above limited sense, com- prises two species, from the very different tex- ture 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 DIS- TENTION OR RELAXATION OF THE SCHNEIDE- RIAN MEMBRANE. This species is very apt to be affected by the state of the atmosphere ; being often retracted and shrivelled in dry weather, and enormously enlarged and elongated in thick, hazy weather. There is little pain during any stage of its prog- ress, however troublesome it may be to deglu- tition or the voice. [The most common va- riety of the compressible polypus is that which bears, in consistence, shape, colour, and size, a striking similitude to the common oyster.—(See Gibson's Surgery, vol. ii., p. 296. Philadelphia, 1825.)] If attended to when small, or in an incipient state, it may often be prevented from growing large by the use of astringent applica- tions ; as a strong solution of alum, a decoc- tion of oak-bark, or the application of vinegar or brandy. But where the excrescence becomes inconvenient from its bulk, it ought to be in- stantly extirpated. When timely attendance is not paid to it, and especially in unhealthy hab- its, it sometimes assumes a scirrhous character, and at length is apt to bleed with great free- dom, sloughs, and ultimately produces, from its increased size and malignity, a horrible disfig- urement of the face, and renders life most pit- iably distressing. And where it does not be- come strictly cancerous, it degenerates into a * Polypi are now regarded as growths peculiar to mucous membranes, or surfaces; and as these exist in various parts of the body, so must polypi also present themselves in different situations.— Ed. fungous ulceration, nearly as much to be dreaded.* [Experience proves that extraction with a suitable kind of forceps, is generally the best method of extirpating nasal polypi. In a very few instances other plans are allowable. Thus, in one case, under the care of Mr. Robertson, of Kelso, the size of the polypus rendered the introduction of a pair of forceps, or a ligature, impracticable. Hence, an incision was made through the nose on the affected side, and the mass of the polypus brought into view. Two ligatures were passed through it ; but its mag- nitude was such that its root could not be reached. By perseverance, however, so much of the tumour was cut away, with the aid of the ligature, that Mr. Robertson at length succeeded in detaching the root with the point of his finger, t] SPECIES II. POLYPUS CORIACEUS. CARTILAGINOUS POLYPUS. FIRM, CARTILAGINOUS, OFTEN PAINFUL, CHIEFLY DEEP-RED : APPARENTLY ORIGINATING FROM, OR CONNECTED WITH, CARIES OF THE ETHMOID BONE. This species is not only painful, but, from being firm and deep-seated, very troublesome in removal. It is not always, indeed, that it can be extirpated entire, or that it is advisable to ex- tirpate it when possible. When extracted im- perfectly, it is very apt to regenerate, and has sometimes become cancerous. It is too generally believed, however, that polypi in all instances may and ought to be ex- tracted ; and that, if the shoot can be laid hold of by the forceps, and we are not afraid of any hemorrhage, nothing is to be dreaded from the operation. Mr. Pott was of a different opinion : he had observed many cases, which, though neither scirrhous nor cancerous, were very unfit for any chirurgical process. Some circum- stances, he remarks, may forbid the attempt, from the impossibility of its being successful; others, from its being more likely to increase and exasperate the disease than to cure it. He dissuades from the operation in almost every instance of the second or coriaceous species ; in all those cases in which the polypus begins with considerable pain in the forehead and upper part of the nose, or is preceded by these symptoms ; and which, as soon as it can be seen, is either highly red, or of a dark colour ; which is never alternately smaller and larger, but rather progres- * Lectures of Sir Astley Cooper, Bart., with ad- ditional notes, &c, by F. Tyrrell, Esq., vol. i., p. 354, 355, 8vo., 1825. Whether the soft compres- sible polypus, originally of a benign character, ever becomes one partaking of a cancerous nature, or rather of the character of fungus haematodes, may be doubted.—Ed. t Edin. Med. Journ., No. 90, p. 44. Graefe has invented some most ingenious contrivances for trying polypi in the nostrils, as well as other situ- ations. These instruments are constructed and sold by Mr. Weiss, ofthe Strand.—Ed. 248 PNEUMATICA. ' [Cl. IL—Ord. I. sively increasing ; in which the common actions of coughing, sneezing, or blowing the nose, give pain, or produce a very disagreeable sensation in tbe 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 incompressibly 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 adhe- sion, occupy a very considerable space, and seem to consist of a thickening or an enlarge- ment of the membrane 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 character- ized, Mr. Pott was of opinion, that no trial should be made by the forceps ; and he advised further, ,t,hat 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 the polypus answers to the first species in elasticity and colour, he rec- ommends its removal, and by the forceps rather than by escharotics, ligature, or any other means ; and thinks it may be extracted with great safety, f GENUS III. RHONCHUS. RATTLING IN THE THROAT. jHARSH, SONOROUS BREATHING FROM STAGNATION OF MUCUS IN THE VOCAL CANAL. There are two species of morbid affection which may be arranged under this genus, each of which has been raised to the rank of a dis- tinct genus by Vogel and several other nosolo- gists ; while by Cullen, 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 sympto- matic 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 suf- ficient to afford instances in which both sorts * This form of polypus is termed bv Prof. Mott, the chondromatous ; it is often attached to the in- ferior turbinated bones. Dr. Mott recommends for its cure, the removal of the turbinated bone with which it is connected, which may be done without inconvenience.—D. t Chirurgical Obs.relative to the Cataract, Pol- ypus of the Nose, &c, 8vo., Lond., 1774. The most common malignant polypus of the nose, is now generally believed to be of the nature of fun- gus haematodes, or medullary sarcoma, to which the surgeon cannot usefully apply any operation in this situation. Palliative treatment is all that can be adopted.—Ed. 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 dis- ease. Many persons snore habitually during sleep ; and most persons have a tendency to do so as they grow old. Under such circum- stances, the affections before us are strictly idiopathic. They are not often indeed accom- panied with much inconvenience ; but, as de- viations from a perfect state of health, they have a full claim to their respective places in a general system of nosology. Confervas in botany, and infusory worms in natural history, are as confessedly objects of scientific arrange- ment 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 five ; 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 symp- toms, and not idiopathic affections. " For want," says he, " of a better, or more generic term, I use the word rale, rattle, or rhonchus, to express all the sounds, besides those of health, which the act of respiration occasions, by the passage ofthe air through fluids in thebronchiae, or lungs, or by its transmission through any of the air-passages partially contracted." He dis- tinguishes five principal kinds of rattle :—1. The moist crepitous. 2. The mucous, or gug- gling. 3. The dry sonorous. 4. The dry sib- ilous, or hissing. 5. The dry crepitous, with large bubbles, or crackling,* 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 observed, it is found idio- pathically in many instances, brought on by ad- vancing age, or peculiar to the habit. A syrup, made of the leaves of the erysimun officinale, or hedge-mustard, was for this kind of noisy breathing once popular ; and the pungency of the plant may often prove useful. The com- mon cause is here, a lodgment of the tougher and denser part of the mucous secretion of the larynx and fauces in these passages. In some cases, as in the atonic coryza of age, the excretories of these organs may be perma- nently relaxed, so as to admit of a larger de- fluxion than in health and vigour. And hence, local stimulants are particularly applicable ; among the best of which may be ranked cam- * De 1'AuscultationMediate, ouTraitedu Diag- nostique des Maladies des Poumons et du Coeur, &c, par R. T. H. Laennec, &c, 2 tomes, Paris, 1819; and translation, with Notes, by Dr. Forbes. , 2d edit,, p. 49, Gkn. IV.—Spe. 1] APHONIA ELINGUIUM. 249 phire, and other terebinthinate 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; but, as I have already observed, it is sometimes found as a primary evil, or independent of any other complaint. In the introductory dissertation to the present class we remarked, that a considerable quan- tity of aqueous vapour is formed in the air- cells of the lungs during the process of respi- ration ; supposed, by the physiologists who contend for the inhalation of caloric as a dis- tinct substance, to be produced by its separation from the inspired air of the atmosphere, and the union of a part of its oxygen with the hydro- gen furnished by the lungs. In 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 espe- cially when thrown upon a dark polished sur- face, as that of a mirror. But, if the bronchial vessels be obstructed by a more than ordinary increase or accumulation of mucus, it escapes with difficulty ; and, encountering the air that is thrown into the lungs, occasions that hissing or wheezing sound, which is always produced by a,current of air when it has to force its pas- sage through a body of dense vapour. Com- monly, therefore, this is a case of atony, local or general; and, like the last species, will be best relieved by those medicines that gently stimulate, and warm, and give power to the bronchial lymphatics, as the resinous gums, and the bulbs of the alliaceous plants. In fat peo- ple, and especially those who are low of stature, short-necked, and oppressed with fat about the chest, 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 extri- cated vapour is put into a smaller space, and has a narrow exit. And here the only cure must consist in taking off the obesity by re- peated venesections, active purgatives, vigorous exercise, and a low diet. GENUS IV. APHONIA DUMBNESS. SPEECHLESSNESS. INABILITY OF SPEECH. We now proceed to a group of diseases that affect not so much the trachea or general ave- nue of sound., as the organs of articulation fixed on its upper end, like a capital upon a pil- lar, as M. Blumenbach has elegantly observed, and consequently which impede or vitiate the power of speech. These have been very dif- ferently arranged 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:—Defects that depend on an utter inabffity 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 incor- rect or vitiated. It is the first of these divis- ions that constitutes the genus before us. Inability of speech may proceed from three different causes, each of which lays a founda- tion 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. SPECIES I. APHONIA ELINGUIUM. ELINGUAL DUMBNESS SPEECHLESSNESS FROM DESTITUTION OF TONGUE. This may be of two sorts; each of which lays a foundation for very different results :— a Congenita. The defect coeval with the birth. j3 Obl3esa. The defect produced by ac- cident, punishment, or dis- ease. The glottis is the chief organ employed in dividing the voice into distinct or simple tones or notes ; as the tongue chiefly divides it, either singly, or by a co-operation with other organs, into distinct articulations, so as to form proper language, which is hence commonly regarded as nothing more than a modification ofthe pow- ers of the lingua, as the tongue is called in Latin; and hence tongue and language are often used synonymously. It is obvious, there- fore, that, in all common cases, the man who is deprived of his tongue, whether by congeni- tal defect, by mechanical force, or by disease, 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 always accompanied with dumbness. It is not necessarily so in all cases of congenital destitution, and still less in all cases of privation that occur after speech has been acquired. In the Physiological Proem to the present Class we had occasion to remark, that the glottis alone, in some instances, either from a greater pliancy and volubility of the mus- cles proper to it, or from the possession of some superadded muscle or membrane, seems to have a power of forming distinct articulations with- out the assistance of the tongue: and I hence endeavoured to account for that singular tal- ent, which we denominate ventriloquism. But there is a more singular talent still, that some- times occurs in the history of the human voice, and which is probably resolvable into the same cause ; for we have examples, supported by in- I disputable authentication, of persons who, hav- 850 PNEUMATICA. [Cl. IL—Ord. I. ing lost the entire organ of the tongue, and a few of them of the uvula also, have still re- tained a power of speaking, and even of ex- pressing themselves 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 bar- barous 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. Some persons profess to disbelieve all the stories of this kind, for the mere reason that they have never witnessed any thing of the same kind in their own age or country. But such persons would have also joined the King of Siam in disbelieving the Dutch ambassador's assertion, that the rivers in his own country be- came 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 judg- ment 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 nosological system, which may be examined at the reader's leisure. Those now selected are taken from recent times, and from authorities that may in- deed be disbelieved, but cannot be disputed. In the third volume of the Ephemerides Ger- manicae, we have the history of a boy who, at eight years of age, lost the whole organ of the tongue, in consequence of a sphacelus proceed- ing from the smallpox, and who was able to talk after its separation. The boy was exhib- ited publicly, but a trick was generally sus- pected ; in consequence of which the boy and his friends were summoned to appear in court before the members of the celebrated univer- sity of Saumur. In the presence of this learned body, he underwent a strict examination as to the loss he had sustained, and the lingual pow- ers 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 records, that its reality might not be called in question in suc- ceeding 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 neverthe- less 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 physi- cian of character, who had accurately and re- peatedly examined 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 equally striking ex- ample of the same power, and which forms the subject of various papers in the Philosoph- ical 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 history of a young woman of the name of Margaret Cutting of Wickham- 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 re- tained the powers of speech, taste, and deglu- tition, without any imperfection whatever : ar- ticulating, indeed, as fluently and with as much correctness as other persons ; and articulating, too, those peculiar syllables which ordinarily require the express aid of the tip of the tongue for exact enunciation. She also sung to admi- ration, and still articulated her words while sing- ing ; 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 scarcely higher than the surface of the gums, in consequence of the injury to the sockets from the disease that had destroyed the tongue. The case, thus introduced before the Royal Society, was attested by the minister of the parish, a medical practitioner of repute, and another respectable person. From its sin- gularity, however, the Society evinced a com- mendable tardiness of belief. They requested another report upon the subject, and from an- other 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 afterward brought to Lon- don, and satisfied the Royal Society in her own person. To explain this unexpected power, we should not only turn our attention to what is actually and in our own day accomplished by ventrilo- quists, but should recollect, that the tongue is only a single organ employed 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, out of the twenty-four articulate sounds which fill up our common alphabet, the only two in which the tongue takes a distinct lead, are 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, and n ; the labial, as b, p, f, v, w; most of the dental, as c, d, z; together with all the vowels, 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 should receive the severest injuries, and submit to very violent operations, with less serious mischief than almost any other organ of the same size in the body. And it is on this account that the cruel and barbarous manner in which the tongue was extirpated by the ferocious tribes that overran Europe from the east formerly, was rarely productive of fatal consequences. Sir Everard Home published, Gen. IV.—Spe. 2] APHONIA many years ago, a paper upon this subject, con- taining 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 by the ligature. He does not state what effect was in any instance pro- duced on the speech, and we are hence led to conjecture, that nothing in this respect occurred of material importance ; but he draws the fol- lowing conclusions :—The internal structure of the tongue is less irritable than almost any other organized part of the body. Its nerves appear to be more easily compressed and de- prived of their power of communicating sensa- tion, than nerves in general; and any injury done to them is not productive of diseased ac- tion in the trunk of the injured nerve. The tongue also has the power of throwing off its sloughs in a shorter time than any other part. SPECIES II. APHONIA ATONICA. ATONIC DUMBNESS. SPEECHLESSNESS FROM ATONY OF THE VOCAL ORGANS. This atony is chiefly, if not altogether, con- fined 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 :— a Oblaesa. From lesion of the nerves of the tongue or glottis. 0 Soluta. From sudden or overwhelm- ing commotion, or shock of any kind. The instances of speechlessness produced by an injury of the lingual nerves are not com- mon. But a division of the recurrent nerves, which are offsets from the par vagum, and dis- tributed 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 duly to contract again, the glottis remains permanently open, and the diameter of the larynx suffers no vari- ety of contraction 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 bloodvessels of the trachea, the noisiest animal is immediately struck dumb, and made quiescent. It was supposed that the state of the bloodvessels themselves, and not of the nerves included with them in the ligature, was the cause of this effect; that the blood be- came intercepted in its passage from the heart, and that the animal became mute because ren- dered comatose : and hence the name of caro- tids, or soporific vessels (from icdpos, sopor), was given to the arteries whose ligature was sup- posed to produce this very singular result. Galen, however, demonstrated very satisfac- torily that the dumbness is, in this case, en-1 ATONICA. 251 .tirely owing to the pressure of the ligature on the accompanying nerves: and he afterward 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 unacquainted with anat- omy, in extricating 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 inarticulate. Where the speechlessness has followed upon an injury of some branches ofthe lingual nerves, we have numerous examples of recovery. In one instance the dumbness ceased suddenly, after the patient had been speechless for not less than ten yea.is.^-(Sammlung, 1721, ii., 406, 503, Bresl.) In other instances, dumbness is produced suddenly, from a total exhaustion of nervous power in the vocal organs, without any organic lesion whatever. A sudden and overwhelming emotion of the mind from terror, anger, or any other passion, has frequently had this effect in irritable habits. So has a violent fit of hys- terics, or any other vehement shock which* in- stantaneously deprives the nerves of their senso- rial power, and the muscular fibres of their irritability : as a stroke of lightning, or a severe and unexpected blow on the stomach, will some- times exhaust the vital energy of the entire system, 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 has sometimes arisen from deleterious ex- halations ; from eating mushrooms ; and in one instance, recorded in Hufeland's Annals, by repeatedly rubbing the wound made by a poi- sonous insect with saliva, and as often putting the finger to the mouth to obtain a supply of fresh fluid.—(Dupau, in Journ. de Medecine, Sept., 1789.) In like manner, Bonet informs us that the same effect has followed from'put- ting into the mouth a piece of money cankered with the rust of verdigris.—(Bonet, Sepulchr., lib. i., $ 22.) Where medical aid is required, our depend- ance must be on tonics, local or general, and topical stimulants. Blisters and masticatories have chiefly been made use of, and frequently with good effect; as has the vellication of a hair- brush contrived for the purpose. The dumb- ness has sometimes yielded to emetics, at others to electricity (Krazenstein, Pr. Hist. res. Lo- quelae par Elect. Hafn., 1753), and, in a few cases, to a cough (Iperen. Abh. qus holt. Schrif- ten, b. i., p. 356 ; Morgagni, De Sed.tt Caus. Morb., ep. lxiii., art. 15); and occasionally the same, or a like violence which occasioned the * Buchner, Miscell., 1729. Bartholin, Act. Hafii. i., Obs. 101, Schurig, Chilologia, p. 205. 252 PNEU: disease, has removed it, and the cause has be- come the cure ; as is reported of Athys, the son of Croesus. In like manner, we have examples of its having yielded abruptly to a fit of anger, or terror ; in one instance, to a fit of laughter (Ipcren., op. cit.); in another, to a blow on the head.—(Ephem. Nat. Cur., dec. iii., an. v., obs. 236.) SPECIES III. APHONIA SURDORUM. DEAF-D UMBNESS. SPEECHLESSNESS FROM DEAFNESS, CONGENITAL OR PRODUCED DURING INFANCY. The ears are as necessary to speech, or artic- ulate sounds, as the tongue, or even the glottis ; for, if such sounds be not heard, and distinctly discriminated, they can never be imitated. Per- sons who become deaf after a thorough acqui- sition of speech, do not become dumb, for the very reason that articulation has already formed a habit, and can easily be preserved by prac- tice. But, if deafness be congenital, or take place antecedently to such habit, articulation can never be acquired afterward, unless, by some rare good fortune, the ears should acquire hearing; and the unfortunate individual can only receive and interchange ideas by the eye, through which medium, however, he may be taught written, though not oral language, and thus still, happily for himself, have his mind almost as richly stored, though not his ideas as readily communicated, as through the outlet of speech. Persons thus organically defective are denominated sourds-muets, or sordi muti, on the continent, and sometimes deaf-dumb among ourselves. [In eastern courts, it has been usual from time immemorial to retain a number of mutes. These are not only employed to amuse the monarch, but also to instruct his pages in an art, to us little known, of communicating every thing by signs, lest the sound of their voices should disturb the sovereign. The mutes are also the secret instruments of his private ven- geance.—(See Edin. Med. Journ., vol. vii., p. 61.)] This is an interesting subject, and not uncon- nected with pathological 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 discus- sion. It is interesting also to us from the very considerable proportion o human beings which in all countries, and, apparently, in all ages, have been sufferers from this melancholy affec- tion ; a proportion that has been ingeniously calculated from a comparison of various tables, deduced from the extent of the disease in dif- ferent parts of the world, as amounting to 1 in 2441 individuals.—(Quarterly Journal of For- eign Med., vol i, p. 319.) [In Germany, it is estimated that, in every million of people, one hundred are deaf and dumb ; and, in the Danish dominions, the deaf and dumb amounted to 515 in the different bishoprics, whose population was only 820,621, according to Teturns, made LATICA. [Cl. IL—Ord. I. at the first anniversary of the Copenhagen In- stitution for this class of afflicted persons. In Bornholm, the proportion was still greater.*— (Altgemcine Litcratur Zcitung, June, 1807.)] And it is peculiarly lamentable to observe that, when the defect has once made an entrance into a family, whether from the influence it pro- duces on the nervous system of the mother, or from any other less obvious cause, it is partic- ularly apt to become common to those children which are born afterward: 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 distressing evil. " The late investigation in Ireland discovered families in which there were two, three, four, or more, thus circumstanced. In one family there were five children, all deaf and dumb ; in another, seven ; in another, ten ; and, in that of a poor militia officer on half-pay, there were nine born deaf and dumb in succession."—(Quarterly Journ. of Foreign Med., vol. i., p. 321.) Yet it is consoling to reflect that the defect is not always propagated to a succeeding generation, when the deaf-dumb have married, and even when both the husband and wife have been thus afflicted. [Still, it is said that such propaga- tion is not uncommon (Edinb. Med. Journ., vol. vii., p. 62), and, as deafness is, without doubt, often hereditary, the experiment of mar- riage should be carefully avoided.] To pursue the calamity, however, into the various plans which the benevolence and inge- nuity of the human mind have invented to sup- ply the defect of speech, from the times of [Juan Pabbo Bonnet,! of Madrid], 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 observe, that the grand principle laid down under almost all the * According to a late census, the Uuited States, with a population including slaves of 12,854,874, contain 7136 deaf mutes. The estimated propor- tion of deaf mutes to the population, as given in the Troisieme Circulaire de I'Institut Royal des Sourds Muets de Paris, 1832, varies materially from that stated by Dr. Good. A census of 47,339,952 souls gives 29,853 deaf mutes ; being about as 1 to 1585. Switzerland presents the greatest pro- portion of deaf mutes to her population, of any country in Europe. Reports from five cantons show, that of a population of 895,000, 1777 are deaf mutes; being nearly as 1 to 500. In the canton of Berne the proportion is as 1 to 350; while in the commune of Weyach, it is as 1 to 63. The number of institutions, in Europe and Amer- ica, for the instruction of these unfortunates, as stated in the French report, is 128, at which about 3732 deaf mutes are pupils. For many interesting facts on this subject, see An Address, &c, delivered by Dr. Samuel Ackerly, formerly Physician and Sec. to the New-York Deaf and Dumb Institu- ion, New-York, 1826.—D. t Redution de las lettras y arte para ensennar a ablas los Mutos. En Madrid, 1620, 4to. The earliest known work on the subject of instructing the deaf and dumb.—Ed. Gen. IV.—Spe. 3.] APHONIA S various plans and systems that have been de- vised, in order to obtain the proposed remedy, and supply the want of speech, is that of com- mencing 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 purpose 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 combi- nations of letters, when the learners are accus- tomed to them, will as effectually become the signs or representatives of the objects they are intended to express, as the pictures which pre- ceded their use. The power that appertains to each separate letter is a lesson to be learned long afterward; and still longer afterward an idea, for it can never be any thing more, of the vocal or articulate effects produced by different movements of the lips, cheeks, and throat, which that letter is designed to express.* An accurate and habitual attention, however, will teach the scholar this ; and he will, in a con- siderable degree, be able to make out what is spoken by the motion of the lips and other vo- cal organs alone ; and, if he possess a facility of copying these, he may be taught, still far- ther, 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 tinder the same defect, and having made an equal progress in the same kind of education, will understand his meaning, or the vocal terms he conveys, by the mere movement of the vocal organs alone. I have myself borne a part in such conversations at that excellent institution of this metropolis, the Asylum for Deaf and Dumb Children, and have seen schol- ars conversing 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 to- gether 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 ; supporting themselves by daily labour. They became deaf, * See the Abbe de l'Epee's Institution des Sourds et Muets par la voie des signes metho- diques, &c, Paris, 1776. As also the Abbe Sicard's "Theoriedes Signes, ou Introduction a l'etude des langues ; oii le sens des mots, au lieu d'etre defini est mis en action," torn, ii., 8vo., 1808. 3URD0RUM. 253 however, when children, after they had learned to speak ; and hence, in moving their lips, they continued to articulate, though not very dis- tinctly.— (Phil. Trans., vol. xxv., 1707, No. 312, p. 2468.) [A curious account is given by Bishop Bur- net of a girl at Geneva, who could hold a con- versation in the dark, by laying her hand upon her companion's lips. The possibility of such a circumstance, it is said, has not been con- firmed by subsequent experience. The mode adopted for conversing in the dark, is by wri- ting the word intended to be communicated upon the palm of the hand, or the back of the neck, thus addressing the sense of touch, which, as well as that of sight, is rendered by atten- tion and exercise wonderfully acute.—-{Edin. Med. Journ., vol. vii., p. 62.)] I have said that the mode of commencing in- struction in almost all the schools of the kind before us, is by pictures or other imitative signs, and that a knowledge of alphabetical characters does not take place till long afterward. The limitation is introduced, because in a few of the French schools in the present day, and particu- larly that at Bourdeaux, under the superintend- ence of the Abbe Gondelin and M. Gard, this easy and natural order is reversed, and the tutors have voluntarily loaded themselves with a very unnecessary difficulty, and their schol- ars with a useless and incomprehensible bur- den of many months' duration. For what rea- son 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 ex- pansion of genius, which the deaf-dumb have occasionally exhibited, are truly marvellous ; 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 childhood : 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 after- ward. 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 overcoloured; 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 his- tory, 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.—(Quart. Jour, of Foreign Med., vol. i., p. 322, 1819.) Yet it is well known, that there are several 254 PNEUMATICA. [Cl. IL—Ord. I. other scholars of the same school that have ex- celled even M. Gard; and who, having been born perfectly deaf, have been necessarily dumb, from the same period ; of whom it may be suffi- cient to mention M. Clerc and M. Massieu. The last was literally taken from the plough, in 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 assist- ant instructer to M. Sicard, in the Parisian school, where he teaches the departments of syntax, history, geography, and religion. On one occasion, happening to be robbed, he plead- ed his own cause in the court of justice ; and when, during the French revolution, his revered master was put into prison, he addressed a let- ter of so much force and feeling to the Presi- dent of the National Assembly, as to obtain his liberation. There are a few instances on record of a recovery from deafness many years after birth, and of a gradual acquisition of speech in conse- quence hereof; chiefly produced by some vio- lent but fortunate affection of the brain. Thus Lambzweerde relates the case of a fortunate fracture of the scull, through a fall from a con- siderable height, by which a young person, deaf-dumb from birth, was suddenly endowed with hearing, and, in process of time, with speech.—(Append, ad Amcenit.) In like man- ner, Mr. Martin gives an account of a native of Stratherig, near Inverness, of the name of Fra- ser, 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 afterward to un- derstand 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.—(Phil. Trans., vol. xxv., No. 312, p. 2469.) [Rosenmiiller has dissected most carefully the organs of hearing and of speech in persons born deaf, but could discover nothing peculiar in them. As a means of cure, he has tried galvanism without success, and it has been tried by others quite as ineffectually. One child suf- fered acute pain during the application of the pile, and seemed to be benefited for a month, but afterward relapsed.] Puncturing the tympanum has been recom- mended by M. Delear (Journ. Complimentaire, Juin, 1822); and in a few instances with our- selves, as well as abroad, it has succeeded. It is hence worth trying, though the success has been very rare. [In 1825, the particulars of a deaf-dumb boy, to whom the faculty of hearing was first com- municated when he was nine years old, were read to the Royal Academy of Sciences at Paris. The treatment from which this success was derived, consisted in injecting air and fluids into the tympanum through the Eustachian tube; a practice very commonly adopted by Dr. Itard. The boy, named Claude Honore Trezel, had a physiognomy of little expression ; the emblem of his understanding. He slodged and reeled about as he walked; could not even blow his nose ; and made his principal wants known by signs. The first few days immediately follow- ing the first establishment of his hearing, were a period of ravishment to him. All kinds of noises gave him excessive pleasure ; and, while listening to a musical snuff-box, he seemed in a sort of ecstasy. But it wassome time before he could comprehend, that speech was a means of social communication. Hence, at first he did not attend to the sounds by which it was formed, but only to the movements of the lips. For this reason, he fancied that a child, seven years old, spoke exactly like grown-up persons. At length, however, he was taught, that the sounds were of more importance than the motions specified. In this stage of improvement, he unluckily happened to hear a magpie utter some phrases, and, generalizing from this particular fact, he inferred that all animals were gifted with speech, and he actually beat a favourite dog to make it pronounce "papa," "du pain," the only words he could himself speak. These first advances in hearing produced a considerable alteration in the boy's physical state. His gait became firmer, his dull countenance assumed a smiling gay air, and he learned to blow his nose. A month passed away without much further improvement; and it was a quarter of a year before the lad could understand a few com- pound words, and the meaning of some plain short phrases. It was a good while also before he could ascertain the direction of sound. Hence, when a person concealed himself in his room, and called him, he had the utmost difficulty in finding out the place in which the speaker was hidden, and then traced it rather with his eyes and reason than his ears. The earliest sounds which he acquired the power of forming, were low and grave ; and the first words which he learned to speak were, "papa, tabac, dufeu," &c. But when he wished to pronounce more complex words, he exhibited various contortions of his lips, tongue, and all the agents of pronunciation, the uses of which he was completely ignorant of; resembling in this respect a beginner in dancing or swimming, who exhausts himself by useless ungraceful ef- forts. At last he succeeded in pronouncing a few compound words which had previously baf- fled him. His progress continued, however, to be very slow ; and he either skipped over many syllables, or pronounced them imperfectly. Per- haps, indeed, he would never have overcome this difficulty, had not the plan of instructing him through the sense of vision, instead of through that of hearing alone, been put in prac- tice. Various syllables were now written down, and pointed out to him ; and, from this period, his pronunciation improved fast, as he compre- hended with greater clearness the assemblage of vowels and consonants, and their reciprocal influence. Here, as M. Magendie observes, we see a very remarkable fact; namely, that the Gen. V.—Spe. 1.] DYSPHONIA SUSURRANS. 255 association of vision with the motion of the larynx was prompt and easy, while that of hearing with the organs of voice was always difficult, and but slowly acquired. Thus, when the boy looked at the written syllables, and they were pro- nounced near him, he could pronounce them himself; but if the writing were removed, the clearest pronunciation of certain syllables, close to him, did not enable him to articulate them himself. By dint of the foregoing method, the boy learned to read and write tolerably fast ; but, like persons who study a foreign language, and who generally learn to read and write it long before they can speak it, he still reads with his eyes, and writes infinitely better than he speaks. One curious circumstance is particularly record- ed : whenever a word is distinctly pronounced to him, he immediately repeats it. For instance, when he is called, he never fails to repeat his name. When his preceptor tries to make him understand things, it is by gestures and looks ; the means by which the boy himself most read- ily expresses his own ideas. The improvement of his condition is wonder- ful : a year previous to the date of this history he was so deaf that he was insensible of the loudest explosions ; he now hears all noises very well; knows whether they come from a dis- tance ; can distinguish their nature ; gets out of the way of carriages and horses, and runs to open the door when it is knocked. He relishes music, and understands and repeats by memory certain phrases within his compass, and gives answers to them. He is also able to do what his tutor directs him to do by words, though he cannot yet do this with other persons. Finally, as M. Magendie observes, when it is reflected how much the boy must have learned to attain his present improved state ; what new ideas and combinations must have taken place in his mind ; what instinctive associations must have been formed between his ear and under- standing, between this and his organ of voice, and his ear and his larynx, there is every reason to hope that his moral and physical state will yet continue to receive further melioration.— (Journ. de Physiol. Expir., torn, v., p. 223, &c.)] GENUS V. DYSPHONIA. DISSONANT VOICE. THE SOUND OF THE VOICE IMPERFECT, OR DEPRAVED. Voice, as we have already observed, is the sound of the air propelled through, and striking against the sides of the glottis : while speech is the modification of the voice into distinct artic- ulations, by 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. Hence, voice belongs to many animals in com- mon with man : speech, thus limited as to its object, belongs to man alone : for no other ani- mal can distinctly articulate, and make use of articulations, as signs of what is occurring in the mind : though a few animals may be taught to imitate articulate sounds without having ideas attached to them. The present genus embra- ces the morbid affections to which the voice is subject; the next, those which appertain to the speech. It includes three species :— I. Dysphonia Susurrans. Whispering Voice. 2. --------- Puberum. Voice of Puberty. 3. --------- Immodulata. Immelodious Voice. SPECIES I. DYSPHONIA SUSURRANS. WHISPERING VOICE. VOICE WEAK, WHISPERING, AND SCARCELY AUDIBLE. Many of the causes 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 Oblaesa. From lesion of the nerves of the^larynx. /? Pathematica. From sudden emotion of the mind. y Compressoria. From permanent compression of the trachea. S Catarrhalis. From neglected catarrh. t Enervis. From simple debility of the larynx, without any obvious cause. Independently of which the present species is occasionally met with as a symptom in me- lancholic, paralytic, and hysteric affections, as also in quinsy, dysphagia, and catarrh. The nerves which, when injured, chiefly pro- duce whispering, are the recurrent. When these are divided, dumbness, as we have already observed, is the result; but they are often weak- ened, and, perhaps, otherwise injured, without being divided : and in this case the voice is not actually lost, but dwindles to a whisper, and is recovered as soon as the nerves resume their tone. The voice has, in this manner, frequently been injured by straining the ligaments and the minute muscles which move the parts of the glottis on each other ; and in elevating the voice to a high pitch in public addresses, or striving at a note in singing which the natural compass of the voice will not reach. So Pliny tells us, that the voice of Gracchus, during a violent ex- ertion in speaking, suddenly sunk to a feminine treble. Astringent gargles, blistering the throat, cold local bathing, external and internal, with perfect quiet and silence, are the best means of recovering the voice under such circumstances. The last I have found most serviceable, and have made the patient gargle four or five times a day with ice-water, which, at the same time, should be applied to the throat with a wet napkin. A sudden and overwhelming emotion of the mind from various causes, will sometimes totally choke or stifle the voice, which is particularly the case with rage : but, where the effect is not so violent, the voice becomes an almost inaudible 256 PNEUMATICA. [Cl. IL—Ord. 1. whisper, and particularly when the passion is fright or terror. Rest, and return of confidence, will usually restore it in a short time ; but in some instances the effect has been permanent. There are various cases in Morgagni and Bonet, in which the voice was rendered almost inaudible from the pressure of an enlarged heart, a bronchocele, or an aneurism of the aorta against the vocal avenues. Sauvages has re- ferred to these ; and it is highly probable that such a pressure, by diminishing the capacity of the trachea, may lower the power of the voice. A catarrhal whisper is a frequent occurrence, and there can be few practitioners who have not met with examples of it. The voice is often injured from the commencement of the catarrh, as well in consequence of the inflammatory af- fection of the mucous membrane of the glottis, as of the increased secretion of mucus that is- sues from the interior of a great part of the trachea: and in some cases in which the in- flammation had become chronic, by pulling for- ward the tongue, I have seen the epiglottis covered with a cream-coloured coating, which was probably extended lower, and was the chief '■' source of the difficulty of utterance. But the variety before us is the result of that weakness which inflammatory action induces in the vocal organs, as a sequel, rather than a symptom, of the inflammatory action itself. Mr. Archdeacon Squire relates a singular case of this kind in an attorney at Devizes, of the name of Axford, who, at twenty-eight years of age having caught cold, was seized with a hoarseness that in six days rendered him totally speechless ; in which state he continued after the cold left him, being totally incapable of dis- tinct articulation, and scarcely able to make the least inarticulate sound. Four years afterward, he got so much intoxicated as to fall from his horse several times on his way home ; and was at last taken up by a neighbour, and put to bed in a house on the road. He fell asleep ; and dreaming that he had fallen into a furnace of' boiling wort, he was put into so great a fright, that struggling with all his might to call for help, he actually did articulate aloud, and re- covered the use of his speech from that moment as effectually and perfectly as he had ever had it in his life.—(Phil. Trans., vol.xlv., 1747-8, p. 148.) For habitual hoarsenesses, leading to the present affection, the siliquosae offer the best class of medicines; and, with respect to many of them, there is no great difference, except what results from their greater degree of acri- mony. It is common to all these, on being swallowed, to stimulate the fauces, and espe- cially their mucous glands, and thus to excite a more copious excretion of mucus. Of this fam- ily of medicines the erysimum officinale, or hedge-hyssop, was at one time in higher reputa- tion for habitual hoarseness than any of the rest: and Dr. Cullen seems disposed to support this preference, chiefly upon the ground of its being less violent in its stimulant power than the generality of them. He recommends the juice of this plant, mixed with an equal quantity of sugar or honey into a sirup. And where the erysimum is not at hand, he recommends its place to be supplied with a sirup of horseradish, but made weak, so that it may be frequently used, or long continued, without rendering the fauces sore or uneasy.—(Mat. Med., part ii., class v., p. 166.) For this purpose, a drachm of the root, fresh and scraped, may be infused in four ounces of boiling water for two hours in a close vessel, and made into a sirup with double its weight of sugar. Of this a tea-spoon- ful, swallowed leisurely for a dose, will often be found highly serviceable. We sometimes meet with a debility in the organs of the voice which reduces it to a whis- per, without being able to ascribe it to any par- ticular cause.* This is often temporary, and seems to occur from a sudden deliquium of ner- vous power in these organs; as when, in the middle of speaking or reading, and this too in an agreeable tone, the voice abruptly fails, and is as abruptly resumed. In the case of the orator Gracchus, to whom I have just adverted, Pliny informs us that the voice was restored by the sound of a pipe, that, being struck by his servant, gave the proper pitch. In some in- stances, however, this failure of the voice has been more or less permanent or intermissive. I had lately a lady under my care, of about forty-five years of age, who was usually attacked in sudden and irregular paroxysms, each con- tinuing for several weeks. Repeated blisters, stimulant astringent gargles, as of port-wine or alum-water with tincture of myrrh, and a steady perseverance in a tonic regimen and pure coun- try air succeeded. She recovered by degrees the full power of her voice, which, during the paroxysms, was nothing more than a weak and almost inaudible whisper ; and has had no re- turn of the affection for several years. In an- other case of the same kind, adverted to in the Nosology, the same plan proved less successful. The patient was a gentleman of about forty years of age, otherwise in good health, who had never spoken, except in a whisper, for more than eight years. [Electricity, galvanism, and tonic medicines might be tried ; and, in a few exam- ples, the editor has known the application of strong liniments, blisters, and antimonial oint- ment to the integuments covering the larynx, give the voice its proper strength, t] * A variety of aphonia sometimes arises from the long abuse of mercury in cases of this kind. For the cure of this, an alterative and tonic mode of treatment should be pursued. Dr. Francis has found stimulating gargles and the free use of the alliaciae to be useful in restoring the functions of the parts.—D. t Dr. Elliotson refers in his lectures to a species of aphonia, in which the voice is sometimes lost, or reduced to a mere whisper, without any inflam- mation, oedema, or obstruction of the parts. It oc- curs chiefly in females, and is regarded altogether as a nervous complaint. Frequently it comes on suddenly, and ceases in the same manner, and is sometimes accompanied by other nervous affec- tions. The shower-bath, and attention to the gen eral health, are the means of relief advised by Dx Elliotson.—Ed. Gen. V—Spe.3.] DYSPHONIA IMMODULATA. 257 SPECIES II. DYSPHONIA PUBERUM. CHANGE OF VOICE. VOICE OF PUBERTY. THE VOICE DISSONANT AND UNTRUE TO ITSELF, IRREGULARLY ALTERNATING FROM HARSH TO SHRILL : CONFINED TO THE AGE OF PUBERTY. ThS change that, during the period of pu- berty or adolescence, takes place in the sexual system for the purpose of giving perfection to lis organs, is well known to be Connected, by sympathy, with an equal change in various other parts of the body. In females, the breasts as- sume a soft and beautiful swell, and the nipples a pleasurable irritation. In males, the chin is covered with a beard, and the voice becomes fuller, deeper, and more sonorous. Before the voice, however, acquires this important change, it often exhibits great irregularity ; and the youth, incapable of modifying his own tones, passes abruptly from harsh to shrill, and from grave to acute. And it is this irregularity and uncontrollable dissonance of voice, which con- stitutes the present species. There is no great difficulty in accounting for this abnormal state of the voice, at the period before us. The glottis is nearly as complicated in its structure as the eye or the ear, and the modulation of its tones depends upon an equal degree of elasticity and pliability in all its move- able parts, and in their perfect submission to the authority of the will. To the attainment of a correct voice, it is necessary that there should be great accuracy of ear ; a perfect symmetry of the vocal organs ; equal tenseness in the ligaments of the larynx, which must be also nicely balanced by the powers of the muscles on each side ; the cartilages of the larynx must be delicately adjusted to each other ; the lateral cavities equally deep, and the cornua of the os hyoides of a like length. With such an organ- ization, the voice is perfected for exact modula- tion in speaking or singing; and it is from dif- ferent defects in this requisite mechanism, that some persons cannot speak, and others cannot sing in tune. Now in the change that takes place during puberty, every part does not always harmonize with the rest; some parts become more tense, others less, and yield more easily ; some are more relaxed, others more contracted ; and of the effect produced by such a state of the glot- tis, a tolerably distinct idea may be formed from a remark of Dodart, that a variation in the ca- pacity of the glottis, not exceeding the fifty- fourth part of a silkworm's thread, or one three hundred and fifty-fourth part of a hair, will oc- casion a difference of tone. Time, however, and repeated exercises of the will, usually tri- umph over these discrepances, wherever they exist, in a few months ; when the voice recovers its unity of tone, and becomes graver in propor- tion as its motive powers become firmer and denser ; and hence the reason why the voice of males is graver than that of females. In males, also, the glottis becomes more capacious, which forms another cause of gravity of tone. The Vol. I.—R deepest tones are struck by animals that have the largest glottis, as the phoca, the ox, the ardea stellaria ; while singing-birds which sound the acutest tones, have a glottis capable of the closest contraction. The deepest roarings are produced by animals that have the cartilages of the trachea entire, or imbricated, or tesselated with bones, as the lion, the elephant, and the peacock. SPECIES III. DYSPHONIA IMMODULATA. IMMELODIOUS VOICE. THE VOICE PERMANENTLY DEPRAVED, OR IN- HARMONIOUS. This species offers the six following varie- ties :-^- o Rauca. The voice naturally or Rough or harsh voice. habitually hoarse, harsh, or rough. 0 Nasalis. The voice sent with a Speaking through the cracked and grating nose. sound through the nostrils. y Clangens. The voice shrill and Squeaking voice. squalling. <5 Sibilans. The voice accompanied Whizzing voice. with a whizzing or hissing sound. r Stertens. The voice accompanied Guttural voice. with a snorting, sno- ring, guttural, or ster- torous sound. £ Palatina. The voice hoarse, ob- Palatine voice. scure, indistinct,with a fissure, or other de- fect, in the palate. Of most of these, the cause will be obvious from the observations already offered. Thus the squeaking voice proceeds ordinarily from too narrow a glottis ; the rough or harsh voice, from a glottis too wide, and not sufficiently moistened with mucous secretion. In the whiz- zing voice there is too much secretion, but of too limpid a consistence. The guttural, or stertorous variety is com- monly the result of a relaxed glottis, or velum palati, with an accumulation of thickened mu- cus ; and here local stimulants, astringents, and tonics, together with a steady and determined exertion to obtain a modulated voice, will fre- quently prove successful. If we put out of con- sideration a few cases, in which some fissures in the palate have been cured on the principles applied to the harelip, the obscure palatine voice, commonly congenital, but sometimes a sequel, of lues, can only be assisted by filling up the fissure in the palate with a silver plate, properly secured by a spring, or, when necessary, by an entire false palate of the same metal. Yet the most dexterous artist wiU sometimes find his ingenuity unavailing, and the defect beyond his skill. The nasal voice is produced ordinarily by an obstruction of the nasal fossae from con- densed mucus, as in a cold of the head, a poly- pus, or some Other organic defect; the remedy 258 PNEUMATICA. [Cl. II.—Ord. J. or removal of which, where this can be attained, will restore the voice to its proper clearness. In common language, we denominate this vari- ety speaking through the nose, but most incor- rectly ; for it is occasioned alone by our not having the nasal passages clear ; and conse- quently from not being able to speak through them with our usual facility. This last is often the result of affectation, or a foolish habit, not easy to be conquered when once acquired. GENUS VI. PS ELL ISM US. DISSONANT SPEECH. THE ARTICULATION IMPERFECT OR DEPRAVED. In the preceding genus the imperfection or depravity exists, not in the articulation, but in the sound of the voice ; whence the distinction between that and the present is clear. Psellis- mus embraces two species ; that of stammer- ing, and that of a vicious enunciation. 1. Psellismus Bambalia. 2.--------Blaesitas. Stammering. Misenunciation. SPECIES I. PSELLISMUS BAMBALIA. STAMMERING. THE FLOW OF THE ARTICULATION DISTURBED BY IRREGULAR INTERMISSIONS OR SNATCHES. This affection may be regarded as a sort of clonic spasm, or St^Vitus's dance, confined to the vocal organs, and offers us the two follow- ing varieties :— a Hesitans. Hesitation. 0 Titubans. Stuttering. In the hesitating variety, there is an in- Voluntary and tremulous retardation in articula- ting peculiar syllables. The organs are gen- erally 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 af- fection will be easily understood. As bad habits are more easily learned than good ones, because they are more striking, and more strongly ar- rest the attention, 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 in4he first; accom- panied with more impetuosity of effort. It con- sists in an involuntary and tremulous reduplica- tion of some syllables, alternating with a trem- ulous hurry of those that follow. " I would thou couldst stammer," says Shakspeare, with a striking illustration 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 actions 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 distinguished orators of both ancient and modern times are well known to have been subject to this affec- tion in their youth. In ordinary conversation, or where a man has time to pick out single words, instead of speaking whole sentences, the stammerer always hesitates most; and hence always least where his attention is completely engrossed. On which account, there are many stammerers that scarcely utter a word in speak- ing without betraying themselves, who never- theless sing, and enunciate the words of the song, without any hesitation whatever, their whole mind being led away with the tune, and a strong desire to keep in time and harmony ; while there are others who hesitate as little in reading, the words being immediately before them, and their attention being swallowed up in the subject. One of the worst stutterers I have ever known was one of the best readers of Milton's Paradise Lost. He was a scholar of considerable attainments, and had taken some pains with himself for his natural defect, but without success ; yet the moment an interest- ing poem was opened, his defect completely vanished, from hrs being led captive by the force of the subject, and the great interest he took in this branch of polite letters. This affords us one means, therefore, of reme- dying the evil before us ; the stammerer should learn by heart and repeat slowly whatever most arrests his attention. But, at the same time, the will must learn to obtain a control over the muscles of articulation ; and, for this purpose, single words should be uttered for hours at a time deliberately, and when alone ; and perhaps too, as was the custom of Demosthenes, a prac- tice of haranguing by the seashore, or on the brink of some awful waterfall, where the fear- ful noise and the magnificence of the scenery have a tendency to break in upon the habit, and render the conquest the easier, may be often found advantageous. It would at least stimu- late the speaker to strain his voice to the full extent of its power, and thus fit him for public speaking before large 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 firmness 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 en- tered 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. [Dr. M'Cormac (Treatise on the Cause and Care of Stammering, Lond., 1828, 8vo.) con.- Gen. VI.—Spe. 2.] PSELLISxMUS BL^SITAS. 259 ceives, that the cause of stammering arises from an attempt to speak while the lungs contain an insufficient quantity of air. This habit, he says, is acquired from undue haste and imitation ; and the successful method of treatment consists in making the patient always inhale a proper quantity of air into the lungs before he attempts to speak, and to direct, him always to pronounce very slowly, until the bad habit is b.oken. When the patient stutters very much, the practice of making long inspirations and expirations is stated to be a good preliminary exercise. The main thing to be attended to, and what in fact is the groundwork of the whole system of cure (Dr. M'Cormac says), is to expire the breath strongly each time when attempting to speak, the lungs being previously filled to the utmost. As it will be some time before the patient can husband the air of his expirations, so as to say all he would wish in one breath, he must not com- mence by repeating sentences during each ex- piration, but only simple monosyllabic sounds. During the intervals, all conversations should be avoided, until the cure is somewhat advanced. It appears to the editor, that although the prac- tice here inculcated is unquestionably right, the theory on which it is founded is not altogether so free from doubt. While the practice recom- mended by Dr. M'Cormac comprises slowness and deliberation, which are, indeed, indispensa- ble parts of it, the theory of the lungs not having air enough in them, and of this being the cause ofthe infirmity, may not be correct. The voice of some stammerers whom the editor has known, has been so strong as scarcely to justify such a conclusion; and he is still inclined to believe, that a want of proper control over the muscles concerned in articulation, must be regarded as the chief cause of the present affection. At the same time it must be granted, that the at- tempt to speak while the lungs have so little air in them, that an interruption will arise from the necessity of a fresh inspiration, cannot fail to embarrass a person addicted to stammering. The practice inculcated, therefore, is in every respect commendable, and the suggestion of it highly meritorious.] SPECIES II. PSELLISMUS BL^ESITAS. M1SENUNCIA TION. ARTICULATE SOUNDS FREELY, BUT INACCU- RATELY ENUNCIATED. The elementary articulate sounds which the organs of speech are capable of enunciating are but few; and hence they are the same in all languages, which are alone founded upon them : differently, indeed, modified in several of them, and with a difference of number in still more ; for diversities of language consist, not in different sets of articulations, to which the vocal Organs are not competent, but only in their different modes of combination, and the different ideas which such combinations indi- cate. So seven notes comprise the whole of music, and by their different arrangements, pro-1 duce that variety of harmony which we admire in the works of Handel or Mozart. If we would ascend higher than eight notes, we only com- mence another series of like proportions. In the same manner, to quote the words of the author of Hermes, "it is only to about twenty- four plain elementary sounds that we owe that variety of articulate voices, which have been suf- ficient to explain the sentiments of so innumer- able a multitude as all the present and past gen- erations of men."—(Book iii., chap, ii., p. 324.) The twenty-four plain elementary sounds- here referred to, are those which are denoted by the letters of the greater number of our Eu- ropean alphabets. Yet, of these, many are rather mere modifications of other sounds than distinct sounds in themselves; insomuch that the ingenious Wachter has endeavoured to re- duce the twenty-four to ten primary articulate enunciations, and to show that ,these a'one would be sufficient for the purposes of the most polished languages ; and, consequently, that an alphabet of not more than ten marks or signs might be sufficient to express its entire range.* 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 savage nations. In like manner, he regards all the gutturals as only modifications of another com- mon 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, r, s, m, and n, are distinct articulations, and will not readily blend with any others. These, no doubt, might be sufficient for all the purposes of speech ; for we find that ten simple numerals are adequate to all the pur- poses of arithmetical calculations, which ex- tend to infinity ; and that able mathematician Tacquet, who has worked the problem for the purpose, informs us, that the combinations ca- pable of being produced by the ordinary series of twenty-four letters, amount to not less than 620,448,401,733,239,439,360,000, without any repetition.—-(Arith. Theor., p. 517, edit. Amst., 1704; Astle, ut supra, p. 20.) So that the richest vocabulary has made but a small inroad into that inexhaustible mine of wealth which the wisdom of Providence has bestowed upon the few distinct and primary sounds, be they more or less, which the vocal organs of man are ca- pable of articulating; thus devising a plan, which is equally entitled to our admiration for the simplicity of its design, and the comprehen- siveness of its power. I have observed, that some languages have more elementary sounds than others; and as these are expressed by elementary characters or letters, it follows, that some languages must also have a more extensive alphabet than otheis. The proper Phoenician alphabet, which is, per- haps, the oldest of which we have any distinct * Nat. et Script. Concord., p. 64 ; Astle, Origin I and Progress of Writing, p. 20. 231) PNEUMATICA. [Cl. IL—Ord. I. ficcount, seems to have consisted of not more than thirteen letters at first ; it had afterward three added to it, making sixteen in the whole ; and, in this state, it seems to have been earliest employed by many of the adjoining countries, and is distinguished by the name of the Sa- maritan, or ancient Hebrew : for the terms and characters of this last are so nearly those of the Phoenician in its improved form, that it is difficult and altogether unnecessary to make a distinction. The Chaldeans introduced some change into the shape of the letters, rendered them more elegant, and added six other letters, as the Samaritan alphabet did not seem suffi- ciently full to express all the articulations of their speech; and thO Jews, during 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 Phoe- nician alphabet can be traced through every part of ancient and modern Europe, every re- gion of Africa where writing of any kind is eurrent, and the western countries of Asia. Over a very extensive portion Of this last continent, however, we meet with an alphabet that has no common origin, or conformity of principle, with any hitherto described. This is, the Nagari, or Devanagari, as it is called by way of pre-eminence. It consists of not less than fifty letters, of which sixteen are vowels, and thirty-four consonants, all arranged in the order of the alphabet, with a systematic pre- cision that is to be found nowhere else. The vowels take the lead, beginning with those most easily uttered, and terminating with those that approach towards a consonant sound. The consonants then follow, in five regular series of gutturals, compounds, palatines, dentals, and labials ; the whole closing with letters symbol- ical of sounds that do not exactly enter into any of the preceding series, and which may be regarded as a general appendix. 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 just claim to an exceedingly remote date. But its very perfec- tion is a sufficient confutation to its having been invented first of all. Something far more rude and incondite must have preceded, and paved the way for it: and, in the complex characters of which it consists, we seem to have the relics of those emblematic or picture-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 alphabetical char- acters in every quarter of the world. With a few trivial variations, this correct and elegant alphabet extends from the Persian 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 articula- tions that enter into the constitution of a lan- guage, or however modified in enunciation, they can only be learned with accuracy in early life, when the vocal organs are most pliable, and the untutored infant is most prone to imitation. And hence, unless care be taken to imprint upon the organs of speech a just and correct enunciation of the first elements of words at this time, it is with great difficulty that the art can be acquired afterward. This occurs to us under the best and most favourable circum- stances. Foreigners coming into our own country after the age of thirty, though urged by an ardent desire of speaking English, seldom pronounce the language tolerably. An Eng- lishman at the same age can hardly be taught to utter the guttural sound which the Welshman gives to the Greek x, or even the French sound of the vowel u: and of the stray and solitary savages that have been caught in the forests of Lithuania, and a few other regions, there is not, perhaps, a single instance of their having been able, after the age of manhood, to articulate any language, so as to be understood with facility. But we sometimes meet with less favourable circumstances to an acquisition of proper artic- ulate sounds, and this too in a state of child- hood, which is the immediate age of imitation. For, firstly, we sometimes see children, brought up under the care of those who have a vicious articulation themselves, from whom they will be sure to catch it ; and hence those pronun- ciations and rude dialects that are so frequently found in the remoter and less polished districts of almost every extensive people. Secondly, we occasionally meet with some natural disa- bility or want of harmonious power in the organs of speech themselves ; one or two of them evincing a greater mobility than the rest, and consequently taking the lead of 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 of the articulate sounds, moreover, in most, perhaps in all languages, though called simple, are produced by the joint exertion of two or more distinct organs : and unless these organs precisely accord in flexibility and power, and are equally under the command of the will, the sound will be imperfectly imitated. The Ar- abic t^J aHQ the Saxon" ft or >pt in English ex- pressed by th, is an articulation of this kind, be- ing compounded of a dental and an aspirate or guttural sound. From early habit, the natives of both countries are able to enunciate it per- fectly, 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 tryino- it i» early fife ; for the motive powers concerned in the sound will not move in sufficient unison. For the same reason, it is as difficult for a for- eigner to catch the German ch in the pronoun ich, the sch in sch'dtzen, or both in sch'ddlich, or schmdehtigkeit. But even these combined sounds have sometimes shades of distinction which constitute other sounds, and are ex- pressly intended to do so ; and, in such cases, the difficulty of an accurate enunciation is Gen. VI.—Spe. 2.] PSELLISMUS BL^ESITAS. 261 greatly enhanced. Thus the English th in thing, and in thou, is a different articulation ; and the Arabians, who have both, express them by dif- ferent marks or letters ; for the sign of the first mode is k^J and of the second (jo^ which, if expressed by our own letters, would, perhaps, be best written dth. And it is on this account, that where a common language -spreads over different countries, as the Arabian, or different parts of a country, which formerly made use of a diversity of tongues, as the English, varieties will necessarily take place in the utterance ; and the dialectic may be more in favour than even the original or normal enunciation. There are some persons who prefer the English of Edinburgh to that of London ; and the Arabic of Delhi, Ispahan, and Constantinople, has modifications of sounds as well as of inflections, which, though regarded as barbarisms by a na- tive of Cairo, are contemplated as excellences by those who make use of them. The organ chiefly employed in the articula- tion of sounds, is the glottis ; and subordinate to this are the fauces, the nostrils, the tongue, the lips, and the teeth. And hence the division of articulate 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 fauces 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 / and r ,• labial, as b, p,f, v, w ; and den- tal, 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 vicious enunciation, and consequently varieties of the species of morbid utterance be- fore us, from every one of these divisions ; but the following are the chief which occur in our own tongue, and those that are cognate with it: a Ringens. Vicious pronunciation of the letter R. 0 Lallans. Vicious pronunciation of the letter L. y Emolliens. Vicious substitution of soft for harsher letters. Z Balbutiens. Vicious multiplication of la- bials. * Mogilalia. Vicious omission of labials, or exchange for other let- ters. £ Dentiloquens. Vicious employment of den- tals. I Gutturalis. Vicious pronunciation of gut- turals. The vicious pronunciation of the letter r is produced by a harsh or aspirated vibration or redoubling of it. Examples of this inelegance are common to several of the northern provinces of our own country, as it is to the ruder prov- inces of France. Among the Greeks, from the letter p (ro), it was denominated rotacismus, and was common to the Eretrienses in the Isl- and of Eubcea. It is generally ascribed to the possession of too large and tardy a tongue.. But it is rather produced by pressing the point of the tongue downward towards the root-of theteeti},of the lower jaw, instead of upwards, with a slight vibration towards the palate. In the second variety of vicious enuncia- tion, the letter I is rendered unduly liquid, or substituted for an r. As when delusive is pro- nounced dehusive, as though the / possessed the power of the Spanish 11, or the Italian gl; or as when parable is pronounced payable. Al- cibiades is said to have laboured under this de- fect. The Greeks, from the letter A (lambda), denominated this lambdacismus; the Romans, with more severity, lallatio, or lullaby-speech. This is often the result of affectation ; some- times, perhaps, from not having the tongue suf- ficiently free, as where there is too great 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 articulation 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 -ib>n trNH '"ityK in tne opening of the first Psalm, read ^jyx WSH ,L?S5'X- In the next variety, the harsh letters are viciously dropped for softer; as in the substitu- tion of anzel for angel; capidol for capiiol; rfat for that. This may be the result of a debili- tated 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, whicb 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. i/le : and in the latter /lamar for clamare ; flaga for jslaga, and Aermosa for foi- mosa. It is curious to observe how, in this respect, the most barbarous and the most polished lan- guages agree. It is generally, but erroneously conceived, that the former are peculiarly harsh and dissonant; 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 observing, that " the words of barbarous languages are long, and full of vowels ; not short, and full of con- sonants, as has been imagined."* And the fol- lowing remark of my excellent and distinguish- ed friend, Dr. Perceval, of Dublin, in the manu- script commentary with which he favoured me * Origin and Progress of Language, second edit., vol. i., h. iii., p. 496. 262 PNEUM on the volume of Nosology, already spoken of in the Preface, is peculiarly in unison with this statement :—" In a paralytic affection of the organs of articulation, the patient pronounced the word cocoa, toto. The Otaheitans call Cook, Toote. Their language is beautifully soft and vocal. A sentence, reported in Cook's second voyage, is distinguished by the harmonious and expressive collocation of its words : ' Tootaha, taio Toote—mutte Tootaha.'-—Tootaha, the friend of Cook—dead is Tootaha." Man, in savage life, is fond of ease, and would not move a musele if he could help it: in the voluptuous- ness of polished life he loves it equally, and is, if possible, still less disposed to exertion : and hence this extraordinary accordance in the char- acter of their articulations. In the balbutient variety, we have the la- bial letters too frequently repeated, or enuncia- ted too harshly, or used instead of other letters. The Welch are proverbially addicted to this in- elegance, by confounding the v with the f, and the b with the p ; of which Sir Hugh Evans, in the Merry Wives of Windsor, affords a correct and amusing example :—" Ferry goof," says he, " I will make a prief of it in my note-book !" So infringe is often used for in/ringe, and iiory for ivory. And thus Veda is pronounced 2?eda, and Venares Benares, in Bengal, the Bengalee having no such letter or articulation as v. Infants, before they cut their teeth, are con- stantly using labials too freely, as the lips press together without resistance ; and hence they delight in iterating the same labial sound ; and it is from a copy of 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, from which these names have descended to Europe, and, indeed, to most other parts of the world, savage as well as civilized, are with- out any iteration whatever, being simply 3 ^ (a^) I—im (am); the first importing love, and the sec- ond sustenance; in Syriac rendered aba or ab- ha, and ama ; and the same in Chaldee : whence the Greek terms and their correlatives, ir&irxa or ■naitnat and p&pua (pappa or pappas and mamma), produced by a mere infantine balbutiation, or substitution of p for b, in the first term, and a reduplication of the consonant in each: and hence, too, am-o and am-or, in Latin. Persons in a state of intoxication, from the tremulous debility of their lips, often exhibit the same reduplication of the labial sounds; and thus make an approach towards one of the va- rieties of the last species. It is also often to be found in persons whose lips are unduly thick and broad, a deformity distinguished vernacularly by the name of blobber-lipped: to which cause Quintilian, who notices this variety of vicious expression, chiefly ascribes it, and hence dis- tinguishes it by the name of plateiasma, proba- bly from Theocritus (Idyl, xv., 88) : ATICA. [Cl. IL—Ord. I. Tpvyovtf CKKvaiaevvn ■nXarvacdoiaat airavra. " Cooing like pigeons with your blobber lips :" A verse designed to ridicule the Doric dialect, and consequently intimating that this kind of vicious enunciation was common to a consider- able part of Achaia. The erroneous articulation constituting the next variety, is of a character precisely op- posite to the preceding; and consists in omit- ting the harsher labials altogether, or exchang- ing them for others that are softer and more easily uttered. Thus mantle is broken down into antle, fish into flish, and pilfer into/ilfer. So in the Spanish the Latin /arina becomes Aarina, and/aia, hava, and in French the Latin siiilo, sij^er. 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 har- mony ; 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, are too frequently em- ployed, producing the effect of what is called lisping, or in common language, speaking through the teeth. This, 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 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 sometimes uttered imperfectly, by being introduced where they ought not, or with- held where they should be distinctly enunciated; and in this consists the last variety it may be 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 pronounced exAalt and exAasperate ; so collar is called kAol- lar, 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 unfurnished," we have " the Aupper part of the ouse Ais to be let Aunfurnished." And if the palate be fissured, or in any other way imperfect, "ghost" is pro- nounced "host," "jolly," "iolly," or " yolly," "coffee," "dhoffee," "Xerxes," "Zherzes." Where these defects depend on organic mis- formation, they will mostly be found without a remedy, though they may be palliated by a la- borious discipline. Where they are the result of debility or vicious habit, the remarks with which we closed the preceding species will be equally applicable here. Gen. I.—Spe. 1] BEX HUMID A. 263 ORDER II. PNEUMONICA. AFFECTING THE LUNGS, THEIR MEMBRANES OR MOTIVE POWER. THE RESPIRATION IRREGULAR, IMPEDED, OR PAINFUL. The idiopathic diseases that appertain to this order, differ very widely in their respective de- grees of severity and danger; and, upon the whole, are but few ; though the number is very considerable in which the lungs and their auxil- iary 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. Dyspnoea. Anhelation. III. Asthma. Asthma. IV. Ephialtes. Day-mare. Night-mare. V. Sternalgia. Suffocative Breast-pang. VI. Pleuralgia. Stitch. GENUS I. BEX. COUGH. SONOROUS AND VIOLENT EXPULSION OF AIR FROM THE LUNGS. This genus of diseases was by the Latins named tussis, a term that has been more gen- erally employed by nosologists than any other. I have ventured, however, to restore the Greek name bex (BHE) for the sake of uniformity ; so that the generic terms may all be derived from a single tongue. Cough, defined as above, is well known to accompany, as a symptom, a great multiplicity of other affections, some of which are very re- mote from the seat of coughing. Thus it occurs to us in pleurisy, in pneumonitis, hepa- titis, paristhmitis, empyema, asthma, catarrh, phthisis, haemoptysis, hysteria, helminthia, and dropsies of various species. Hence Dr. CuUen has omitted cough as an idiopathic affection, and has only introduced it as a symptom or synonyme of catarrh ; although it belongs at least as much to phthisis, and perhaps to every one of the diseases just enumerated : but Dr. Cullen's system 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. Cough, undoubtedly, occurs in its most fre- quent appearance as a symptom of some other complaint; but it is at times as truly idiopathic as any complaint whatever, and ought to be treated of as such. Under this form, its seat ia in the chest; and the parts principally affected are the trachea, bronchiae, the membranes, and substance of the lungs. In the act of cough- ing, the lungs, like the stomach in vomiting, continue inert ; and the active or convulsive part, by which the lungs are emptied, is per- formed by the muscles of respiration. " It is not necessary," observes Mr. John Hunter, " that the stomach should act violently to produce the evacuation of its contents; nor is it even necessary that it should act at all: for the lungs themselves do not/ act in the least when any extraneous matter is to be thrown up : and coughing is to the lungs what vomit- ing is to the stomach. The muscles of respi- ration are the active parts in emptying the lungs, and can act naturally and preternaturally. The action of vomiting is performed entirely by the diaphragm and abdominal muscles ; and we know by the same action that the contents of the rectum can be expelled."—(Anim. Econ- omy, p. 199.) In the Physiological Proem to the present class, I have endeavoured to estab- lish this remark in respect to the lungs ; and, under the species emesis, in the preceding 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 while running its regular course; but it has often proved highly dan- gerous in its results, by superinducing perip- neumony, haemoptysis, hectic fever, or phthisis. The whole of these remarks apply not more to common coughs than to pertussis, or hooping- cough : which unquestionably, therefore, ought to be arranged as a species under the present genus. In truth, the commencement of both is in most cases so much alike, 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 EXPECTORA- TION OF A MUCOUS OR SEROUS FLUID. To this species the Greeks gave the name of anaptysis, and anacatharsis ; which last has been copied by Sauvages, and appropriated to the present purpose. The species affords us four varieties ; one entonic, or accompanied with an excess of power, and three atonic, or dis- tinguished by enfeebled action. o Mucosa. Common mucous cough. 0 Anhelans. Chronic cough of old age. y Acrida. Frothy saline cough. S Periodica. Nervous cough. In the first variety, the discharge is chiefly mucous, and excreted freely. The exhalants - The opinions of various other physiologists on the mechanism of vomiting will be found at p. 27, and 93, of the present vol. 264 PNEUMATICA. [Cl. IL—Ord. I. of the bronchiae are stimulated by an irritation of some kind or other, frequently by a reverse sympathy, in consequence of cold and torpid feet, to act more powerfully than in 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 accompa- nies catarrh, or any other very troublesome dis- turbance of the respiratory organs. There is another variety, commonly called the chronic cough of old age, which occurs in long paroxysms, with a viscid and mucous discharge, excreted with difficulty and laborious breathing. Here the bronchial secretion of mucus is perhaps less copious than in ordinary health ; and, being peculiarly tenacious, is thrown up with great labour and repeated efforts. This kind of cough is particularly common to persons in advanced life ; or whose lungs, or bronchial vessels, are rendered weak and irri- table from a neglect of common mucous coughs ; which have at length run into the present va- riety, and become almost habitual ; showing themselves on every change of the atmosphere ; and particularly during the inclemency of winter. In the third, or acrid variety, 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 extremely perti- nacious. Dr. Darwin tells us that he met with it twice in the same person, at a distance of some years, during a fit of gout, so intractable as to resist venesection, 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 weeks, the patient never being able to sleep more than a few minutes at once during the whole time ; and never for a moment, unless propped up in bed with pillows.—(Zoonom., Class iv. ii., L, 9.) There is another variety of the present spe- cies to be met with, which developes a striking tendency to recur at stated periods. The cough, instead of being violent, is here partly restrainahle, and -the discharge, though thin, is not acrid. It is the nervous cough of Dr. Whytt, who, in his Treatise on Nervous Dis-. eases, has described it with great accuracy and judgment. It is a frequent attendant upon per- sons of a nervous or irritable temperament, and hence common to the hysteric, dyspeptic, and choleric. Like the last variety, it is also occa- sionally found in repelled gout. There seems here, also, to be some depravation in the nature of the secretion, dependant on the debility of the secreting organs. And hence we some- times find, that the morbid phlegm forms a ni- dus, as in various cases of phthisis, for the eggs of minute insects floating in the atmo- sphere, which are conveyed with the inspired air to the bronchial vessels, where they are hatched in the secreted fluid, and often thrown up in the shape of larvae or maggots. In like man- ner, 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 constitution, and nervous or hypo- chondriacal habit. For half a year, she expec- torated more or less of these in the midst of thick viscid phlegm, sometimes to the amount of twelve, fifteen, or twenty-four in a day, of vari- ous sizes, from that of a pea to that of a pul- let'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 ac- tion in the mucous membrane of the lungs, and mostly by sympathy with a remote organ, as in the case of cold and torpid feet, will be best relieved by diaphoretics and the warmer sedatives ; and especially the compound powder of ipecacuanha, which will restore to the sys- tem its harmonious balance of power. The warm batb, or bathing the feet in warm water ; warm and copious apozems, and oily or muci- laginous demulcents, are also peculiarly adapted to this species of cough. At the same time, the bowels 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 employ tartar-emetic in pref- erence to ipecacuanha, whether alone or com- bined with opium, as in the compound powder. It has been given in all complaints of the chest attended with defluxion, and in all possible pro- portions : in some instances, so diluted with water as to form a part of the common bever- age ; and, in others, so concentrated as to rival our boldest wholesale prescribers 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 * Dr. Elliotson, in his Lectures at the London University, mentions a case which he met with, where a communication was formed between a cyst full of hydatids and the air-passages, so that the patient was in the habit of coughing up hyda- tids for some time before she died.—Ed. Gen. I.—Spe. 1.] BEX HUMIDA. 265 gives in doses of fourteen grains in a day, without producing vomiting. And Dr. Duffin has lately informed us, that he swallowed from twenty to twenty-five grains of tartarized anti- mony 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 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.t 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 ac- counting for it is, by means of a specific deter- mination to the lungs. For, as we have pretty clear proofs of medicines operating specifically upon other organs, as that of mercury upon the salivary glands, and .cinchona upon the irritable fibre, there is no reason why we should not ex- pect a like operation upon the viscera of the chest. Dr. Cullen is quite at a loss upon this subject, from not admitting of specific medi- cines, or a specific action upon any organ.' As a general rule, he supposes expectorants to operate on the bronchiae merely by a diapho- retic power, or that of increasing the flow of the superficial exhalants at large, and conse- quently 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 that some med- icines act directly upon the exhalants of the skin, a specific power is hereby immediately conceded to one set of organs ; and if such 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 exhalation from the surface of the body. And further, the gen- eral explanation gives us no clew to the different operations of particular expectorants. It is possible that in all these there is a pecu- liar stimulus ; but whether this depends upon * There is reason to think that the excessive use of tartar-emetic, as now adopted* by some American practitioners, in not a few instances may prove detrimental. With Rasori and his disciples, fancy seems too frequently to have as- sumed the place of facts.—D. t Expectorants are usually defined to be med- icines which promote the excretion of mucus and fluids from the surface of the lungs and tra- chea. The reader will find an admirable chapter on the principles of their operation in Professor A. T. Thomson's Elem. of Materia Medica, vol. ii., p. 137.—Ed. 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 ex- pectorants are employed, they should be of a mild rather than of an acrimonious nature, as we have already an excess of action to en- counter. 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 doubtful, 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 represented 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 (Sat., lib. ii., viii., 51) as pos- sessing a bitter taste ; for he thus makes an epicure boast of having invented the sauce :— "—inulas ego primus amaras Monstravi incoquere." And in another (Sat., lib. ii., ii., 44), he describes it as acrid, or stimulating; for it is probably in this sense that the acida's should be under- stood :— " —acidas mavult inulas." While Lucretius (De Rer. Nat., ii., 430) makes it rather a mild general stimulant, or aromatic :— "----quae Titillare magis sensus, quam laedere possint, Faecula jam quo de genere est, inul^que sapores." 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 employed under this name in our own day. In the second variety, or chronic cough of old age, where the mucous discharge is pecu- liarly viscid, much smaller in quantity, and ex- creted with great difficulty and laborious breath- ing, and the general symptoms evince great torpor of the extreme vessels of the lungs, the warmer and more pungent expectorants can alone be of any service, as the alliacea, and stimulant gum-resins, especially ammoniac, ben- zoin, styrax, and perhaps all the turpentine modifications.* Tar-water was at one time a famous remedy; but has long fallen into great disesteem. From its warm terebinthinate impregnation, and the * In the chronic cough of old age, moderate bloodletting will often be useful: depletion in this way, and by mild aperients, followed by the use of stimulating expectorants, as the syrup of squills, &c, is not to be overlooked. Dr. Rush has well sustained the importance of occasional bloodletting in several varieties of this complaint; and the ex- perience of the best clinical observers accords in the utility of this practice.—See Dr. Scudder's Dissertation on the Diseases of Old Age, New- York, 8vo., 1813.—D. 266 PNEUMATICA. [Cl. II—Ord. II. approach it makes" to camphire and the gum- resins just enumerated, 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 em- ployed with advantage. The acidum atnetis, another old preparation of the same kind, seems, however, to be the most deserving of trial of all the terebinthinate forms, and has sunk into dis- repute without reason : it is the peculiar acid liquor, yielded along with the essential oil, in distillation of the fresh branches or fruit of the pinus sylvestris and p. alba of Linn^us. It is too acrid to-be drunk alone, and is usually dilu- ted with water: and combines in itself some portion of the terebinthinate-oil, with an acid very nearly resembling the acetous. The same tribe of medicines will generally be found useful in the third variety, or that in which the cough is followed by a thin, frothy, and saline excretion ; for here we meet with as much local atony and torpor of the excretories as in the preceding. We may here also with advantage employ several of the narcotic bitters, and especially the hop, in the form of pills or tincture ; and occasionally the narcotics them- selves, as opium, or hyoscyamus, or the extract of the common potato, solatium tuberosum, as recommended by Dr. Latham.—(Med. Trans., vol. vi., art. 6.) But where the cough is de- pendant upon morbid affection of some remote organ, and the lungs are only influenced by sym- pathy, as is often the case in chronic hepatitis, it is obvious that our chief attention should be directed to the primary disease. In the nervous or periodic cough, narcotics should be employed very cautiously, and only where the irritation is perpetual, or otherwise unconquerable ; demulcents will also be of no service. Though the warmer expectorants may be useful, our chief dependance must be on general tonics, as the columbo, cusparia, and cinchona, with which may be combined several of the metallic oxydes, especially those of bis- muth and zinc. When the flowers of zinc were in Jhe height of their popularity, they were sup- posed to be an unfailing remedy ; and Dr. Per- cival, of Manchester, has given numerous ex- amples of their complete success. By having been too highly advocated, this medicine has now fallen into an undue degree of disesteem. Camphire and ammonia will often prove pallia- tives for the cough, and maybe 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. 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, * Recherches Physiologiques et Cliniques sur l'emploi de l'Acide Prussique ou Hydro-cyanique, dans le Traitement des Maladies de Poitrine, &c. Par F. Magendie, &c, 8vo., Paris, 1819. Under the name of spasmodic cough, Dr. Elliotson refers to a cough that comes on in long and violent par- oxysms, and occurs in adult subjects: if united which has the peculiar power of diminishing the general sensibility, without affecting the func- tions of respiration or circulation. Of all the cases published by Magendie and Brera, in proof of its beneficial qualities, none are so de- cisive as those of chronic and nervous coughs.* Six drops of the acid, prepared according to Scheele's method, may be given in a wineglass of infusion of cusparia every four hours. SPECIES II. BEX SICCA. DRY COUGH. COUGH UNACCOMPANIED WITH EXPECTORATION. The symptom in the definition sufficiently shows that the seat of the disease is here, either in a remote organ or in the parenchyma, or general substance of the lungs, rather than in the mucous membrane of the bronchia?. The disease is commonly, indeed, produced by some irritable substance generated within the lungs, as in the case of a scirrhous or calcareous affec- tion of these organs ; or conveyed into them from without, as is common to glasscutters, hewers of freestone or sandstone, 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 afterward making their way through the delicate tunics of the air-cells. The dry cough is also at times to be traced to a remote irritation, as that of worms, or an inflammatory action in the intestines, liver, oi other abdominal organs : in most cases, the lungs themselves are probably quite passive, and only yield to the propulsive action of the dia- phragm, and its auxiliary muscles, to which the remote stimulus seems to confine its sympathetic power. The minute and invisible eggs of various in- sects floating in the atmosphere, are also some- times swallowed in like manner, and in a few instances hatched into larvae, which have been thrown up by the coughing.—(Bartholin. Act. Hafn., iv., obs. 46.) Minute pieces of bone, and the kernels of cherries and other fruits, have, moreover, occasionally slipped into the trachea accidentally; and, after exciting great irritation, and a hard dry cough for a considera- ble period of time, have ultimately been thrown up. A bean, in this manner, dropped into the trachea, was rejected on the fifth day in a vio- lent fit of coughing.—(Beaussier de la Bonchar- diere, Journ. de Med., xlv., p. 267.) It is more extraordinary that materials, introduced into or engendered in wounds in the thorax, should at times be found to work their way into the bron- chial vessels, and in like manner be thrown up by coughing. Yet in this way have been dis- charged surgical tents that have slipped beyond with inflammation, it is out of all proportion to it. In this disease, he has found the carbonate of iron the best remedy, sometimes preceded by bleeding if the patient be robust.—(Lect. at London Vnil versity.) The carbonate of iron might be tried in the chronic cough of elderly persons.—Ed. Gen. I.—Spe. 2.] ' BEX SICCA. 267 the lips of the wound ;* and the splinter of a fractured rib.f The varieties chiefly worthy of notice are the three following: a Ingenerata. From irritation produced From ingenerate ir- locally, as a scrofu- ritants. lous, scirrhous, or cal- culous affection of the lungs. 0 Extranea. From irritating materials From 'extraneous ir- inhaled from without, ritants. as in various opera- tions on glass, metals, sandstone, and mar- ble.* y Verminosa. ; From some remote ir- From remote worms ritation, chiefly that or vermicules. of worms burrowing in the intestines, liver, or other abdominal organ. Of these, the last is only to be removed by removing the primary disease. It is most com- mon to children, and has the associate signs of a tumid belly, and pale emaciated countenance. For the medical treatment we must therefore refer to the genus helminthia, in the prece- ding class. When the irritation proceeds from a scrof- ulous or calculous affection of the lungs themselves, our attention must be directed to the peculiar diathesis on which the disease is dependant. In the former case, small doses of the milder mercurial preparations, combined with the usual narcotics of the lurid and um- bellate orders, as conium CSnanthe (dropwort), hyoscyamus, and solanum, may afford local re- lief by their narcotic and alterative power : while the general state of the system should be sub- jected to the regulations which will be found laid down under the diseases struma and ma- rasmus Phthisis, in the ensuing class. The deposite of calcareous matter in the sub- stance or air-cells of the lungs, may be the re- sult 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 Ar- rangement. In the former case, acid inhala- tions, or fumigating the chamber with the vapour of tar, which always contains 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. Where the formation of calcareous matter appears to depend upon an osthetic diathesis, * Tulpius, lib. ii., c. 15. Fabric. Hildanus, cent. i., obs. 46 ; cent, vi., obs. 22. -f Hildan. ex Pigray., ep. 51. X Diemerbroeck, Anat., lib. iii., cap. 13. Ram- mazzini, &c. Morb. Artificum, cap. 26. or a constitution prone to generate lime, diluting apozems drunk freely will be serviceable; and particularly a very free beverage of aerated min- eral waters ; which, while they dilute, will tend to invigorate the system generally, and produce a beneficial change upon the habit. Where calculi are disposed to form in the kidneys or bladder, Dr. Russell has iccommended a very liberal use of seawater; De Haen of lime- water, of which he t*lls us, that in one case, not less than 1500 pints were drunk with very essential advantage. Many foreign physicians advise the continental mineral springs, as those of Pyrmont, Carolina, and Bareges : while other pathologists have found large quantities of pure water, hot or cold, prove as good a palliative or remedy: in all which, we trace out one com- mon principle, which is that of dilution, and we can trace out nothing else. A warm climate, which proves a perpetual diaphoretic, and urges perpetually to the surface, will also in all prob- ability be found serviceable ; and, above all things, pure air, and as brisk exercise as the patient 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, freestone, or any other material, minute particles of which are apt to fly about and im- pregnate the atmosphere, and pass by inhalation into the lungs, should be peculiarly careful to keep their mouths and nostrils covered with a handkerchief. And if the lungs be irritated with sharp spiculae, and a distressing and chronic cough be excited, all similar labour must be abstained from ; the diet be peculiarly light ; emetics be frequently administered ; and, in the interval, diluting apozems be used copiously, with bland demulcents. And if, by these means, we can check the irritation for some weeks or months, the lungs will often, by a growing habit of exposure to its cause, cease to be materially affected by it; and the patient may pass through life without much inconvenience. But if here- by we should not be able to succeed, inflamma- tion, hemorrhage, or phthisis, will probably be the result.* In this variety, we have also great reason to expect benefit from the use of mild expecto- rants and demulcents. Of the nature and operation of expectorants I have spoken already : and as there is no com- * Though various morbid affections of the lungs are imputed by Dr. Good, with many ancient and modern pathologists, to the inhalation of dust and other extraneous particles by several descriptions of workmen in their different employments, the correctness of the doctrine is denied by Professor Laennec (On Diseases ofthe Chest, &c. ed. 2, p. 137, transl. by Dr. Forbes), whose arguments, how- ever, turn chiefly on the escape of some individ- uals from the mischief, though exposed to the suspected cause, and on the fact of dust taken into the lungs being expectorated afterward with the mucous secretion of the bronchiae. Both these circumstances are true, and yet the temporary or partial lodgment of the extraneous matter may give rise in many instances to pulmonary disease. —Ed. 268 pxev* plaint in which demulcents can be employed to more advantage, and few in which they will prove so pleasant and tranquillizing, let us di- gress for one moment to examine into their na- ture and operation. Demulcents are medicines that obtund the action of acrid or spicular materials, not by changing their acrimony, but by covering them with a viscid and inirritant fluid. They are of two sorts, mucilaginous and oily ; and of the manner in which they act, when applied to the surface of the body, there is no doubt whatever. But, by what means they are able to retain their inviscating power, when passing through the stomach to a remote organ, is far less clear, and has been a source of considerable contro- versy. Where the irritation 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 substances 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 pro- duced in the upper extremity of the trachea, is propagated by sympathy through the whole of the bronchial ramifications and the air-cells of the lungs ; and that it is iff this manner demul- cents prove remedial in all pulmonic irritations. But this is no explanation of their obtunding power in remote quarters, as for instance in the kidneys and bladder, where these organs have been stimulated by a blistering plaster: and as Dr. Cullen is not willing to allow of a specific power in medicines of any kind, nothing has re- mained to him but to cut the Gordian knot ab- ruptly, and to contend that " the operation of demulcents in covering acrimony in the mass of blood, must be very inconsiderable."—(Mat. Med., part ii., cap. xii., p. 412.) But this is to uphold an hypothesis by an as- sertion, opposed to the experienced train of events, and to which he himself submits on other occasions ; for Dr. Cullen has no hesita- tion in recommending the use of demulcents, when we follow him into his practice, almost as freely as any other physician whatever. I pretend not to determine whether they act in every instance when employed internally by their sensible quality of viscosity, or by some insensible specific power ; but that, by some means or other, they are capable of allaying ir- ritation in 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 gumarabic, can be intermixed with many pounds of serosity, and still retain their sen- sible quality of inviscating sedatives, it is by no means more difficult to conceive this, than that moderate doses of sulphuric acid, intro- duced into the stomach, should pass copiously by the skin in its acid state, as Dr. Cullen al- lows it to do, and cure the itch ; or that the mu- riate of soda, employed as an ingredient in the manufacture of glass, should, in the melting of this material, impregnate the atmosphere of the glasshouse, be inhaled by the lungs of the ATICA. [Cl. IL—Ord. II. workmen, and passing with the matter of per- spiration through the pores of the skin, once more concrete in crystals on their foreheads. As several of the vegetable oils are obtained from narcotic plants, it is well worth inquiring, though a different question, whether, 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 most 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 asser- tion, 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 agricul- ture in 1773, with respect to the former. But as I 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 plants not yet examined for this purpose. The seeds of both plants give forth oil pretty freely ; those of the poppy often in the proportion of six or seven ounces of the oil to every two pounds of the seeds. In hot weather, sultry climates, or long voy- ages, where rancidity may be apprehended, the best, as well as the pleasantest of all the vege- table oils, is the expressed oil of the cocoanut, 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, quicklime, 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 obtained from the Iceland moss. If infused in water before it is boiled, it will lose much of its rough 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 putrescence. SPECIES III. BEX CONVULSIVA. HOOPING-COUGH KIN-COUGH. THE COUGH CONVULSIVE AND SUFFOCATIVE ; ACCOMPANIED WITH A SHRILL REITERATED HOOP; AND FREQUENTLY WITH VOMITING ; CONTAGIOUS. The Greeks denominated this disease Bex theriodes (Snpiwtins), which the Latins transla- ted literally Tussis ferina, " wild or untameable cough," from its violence. The name of Per- tussis, by which it has often been called in later times, is of doubtful origin and meaning; and I have hence followed M. de Sauvages. and exchanged it for Tussis convulsiva, the specific epithet being far more expressive than that of Gen. I.—Spe.3.] BEX CON VULSIVA. 269 the Greek writers. Our own name of Hoopirig- cough is evidently derived from the convulsive clangour which accompanies the fit. The name of Kin-cough, by which it is distinguished in the north, and which should rather be written Kind-cough, is derived^rom the Saxon or Ger- man term Kind, " a child," as being peculiarly common to this age. This cough is 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.* [Even La- ennec (Op. cit., p. 96) deems the contagious nature of hooping-cough not satisfactorily proved, and regards alternation of temperature quite as much a cause of this as of other catarrhs.] The remote cause of hooping-cough is often dif- ficult to trace. Frequently, indeed, like common or humid cough, it seems to proceed from cold, from some irritability of the stomach (Allgem. Deutsche Bibl., lvii., p. 434), or some peculiar affection ofthe lungs.—(Stoll, Prcelect.,p. 289.) I have already observed, that the dry cough (tussis sicca) has occasionally been produced by larvae 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 pro- duced in the same way by an insect of a pecu- liar kind.—(Aman. Acad., vol. v., p. 82.) This opinion has not been adopted beyond the pre- cincts of the Linnean school. But we are, nevertheless, very considerably in the dark upon the subject ; for there are numerous cases of the disease occurring daily in which it originates from a source that eludes our research alto- gether. It is most common 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 cir- cumstances, it may be inferred 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, essen- tially linked with fever. The excretion is at first small in quantity, but afterward more copious, though always viscid. The hoop, or sonorous spasm, is often accom- panied with a rejection of the contents of the stomach ;t and the whole system, during the * Rat. Med., part ii., p. 184. It is not an un- common belief, and it was adopted by Cullen, that hooping-cough is not contagious beyond a month or six weeks from its commencement, just as is the case with some other contagious diseases, as for instance gonorrhoea, though, as Dr. Elliotson well observes, nobody will venture to fix the pe- riod ofthe commencement of its innoxious char- acter.—Lect., Med. Gaz., 1832-33, p. 194. t When the child vomits, it is generally con- sidered a good sign : if there be no vomiting, the case is often found to be very severe. Dr. Greg- ory knew a lady who never hooped in the disease, but, instead of doing so, always fainted. The dis- ease prevailed in the family, and she had as vio- 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 forgot- ten ; and, after deeply panting for breath, he returns with as much eagerness as ever to his play, or otherpursuit: while the vomiting, which is commonly a good sign, is succeeded by a cra- ving for fresh food. [In the words of Laennec, a colourless, and scarcely frothy, but ropy phlegm, rather flows than is rejected from the mouth, after each paroxysm, while the patient leans forward to favour its escape. The par- oxysms at first recur several times every day, being almost always most severe towards the evening, but less violent in the night. After a certain time, they return only in the morn- ing and evening, and towards the end of the disease, in the evening only. Before it termi- nates the paroxysms are shorter, lose their pecu- liar characters, and are attended with an expec- toration more decidedly mucous. Sometimes the disease degenerates into a chronic mucous catarrh, with emaciation, and other symptoms resembling those of consumption. In the in- terval of the paroxysms, the patient coughs but little, and though Drs. Cullen and Watt repre- sent some slight febrile indisposition as being mostly observable at certain periods of the day, Laennec states, that the patient rarely has any fever, except in the case just now mentioned, or at the beginning of a very severe attack.*] lent a cough as the rest.—Elliotson's Lectures, Med. Gaz. for 1832-3, p. 194. * See Laennec on Diseases of the Chest, &c, transl. by Forbes, p. 96, ed. 2, 8vo., Lond., 1827. As bronchitis is not an infrequent complication of hooping-cough, especially of the most dangerous forms of it, febrile symptoms must occasionally attend the disorder. Dr. C. Johnson distinguishes four states of hooping-cough : 1. Simple hooping- cough. 2. Hooping-cough complicated with bron- chitis, or peripneumony. 3. Complicated with disordered bowels, or infantile remittent fever. 4. With convulsions, or hydrocephalus. The lat- ter ought, perhaps, to have made two varieties. We see then that the disease is liable to be com- bined with infantile remittent fever, as well as the common sympathetic fever of inflammation. A great number of the long-protracted cases are complicated with remittent fever, which some- times begins with a rigour, but more frequently comes on so gradually, that the date of its com-* mencement cannot be fixed. "The paroxysms of coughing become more frequent, and the breathing is quickened and oppressed ; but still it may be, with a little care, distinguished from the attack of bronchial inflammation. The steth- oscope affords us useful though negative evidence. The usual symptoms of bronchial inflammation are absent. The frequency and force of the res- piration are increased; but this increase is not accompanied by any rale, indicative of bronchial inflammation; while the daily remissions, the loaded tongue, the nature of the alvine discharges, the aspect of the child, constantly picking his nose and lips, all serve to determine the true character of the disease."—Cyclop, of Pract. Med., art. Hooping-cough, by Dr. C. Johnson.—Ed. 270 PNEUMATICA. [Cl. IL—Ord. II. The disease lasts irregularly from three weeks to as many months. [Each fit is composed of a quick succession of sonorous coughs, with scarcely any percepti- ble intervening inspirations, except that, from time to time, the expirations of coughing are suddenly interrupted by a very deep, seemingly convulsive, and noisy inspiration, accompanied by a lengthened hissing, that constitutes the pathognomonic sign of the disease. Laennec represents the peculiar sonorous inspiration as seated exclusively in the larynx and trachea. He also considers the spasmodic character of the hooping-cough as sufficiently proved by cer- tain phenomena, which occasionally show them- selves in the glottis, larynx, and even in the pendulous veil of the palate. The extraordinary noises made by certain patients in breathing, or coughing, he imputes to a spasmodic or volun- tary contraction of these parts. The same, he says, is true of the peculiar sounds which attend the hooping-cough. He has seen patients who crowed like a cock, or barked like a dog. Dr. Bally sent him a patient with hooping-cough, in whom the paroxysms were accompanied with a cooing, like that of a woodpigeon. Laennec was convinced by observation, and the aid of the stethoscope, that the sound arose from a spasmodic contraction of the veil of the palate and sides of the glottis. The opinion was fur- ther confirmed, by the suspension of the sound by an accidental inflammation of the throat, and its renewal, in a less degree, on the subsidence of the latter complaint.—(Op. cit., ed. 2, p. 96-98.)] The hooping-cough, when in the height of its career, is usually accompanied with very co- pious secretion of mucus, a free discharge of which mitigates the general symptoms. From this circumstance Dr. Butter concludes, that a morbid irritability of the mucous glands is the primary affection, to which the spasms are only secondary.—(Treatise on the Kin-cough, with an Appendix, &c, 8vo.) It is somewhat singular, that, with this view ofthe disease, he should place its seat, not in the larynx, or any part of the trachea, but in the alimentary canal. In infants, it is mostly alarming from its tendency to pro- duce convulsions, suffocation, apoplexy, inflam- mation of the brain, ruptures, and incurvation of the spine. [The younger the subject, the more dangerous the disorder generally ; and the large majority of those who die from its attacks, are observed to be under two years of age. Children born of phthisical, asthmatic parents, are most likely to suffer from the violence of the disease. Yet it is said that a healthy child under six months, who has a good nurse, will get through the disease better than one a few months older, who has been recently weaned, or in whom dentition has commenced. The following circumstances are also enumerated by Dr. C. Johnson, as justifying a favourable prog- nosis : dentition being completed, and the head, bowels, and lungs not being subject to deter- minations or irritations; the season of the year being mild and dry ; the patient not suffering, or not having recently suffered from any ofthe other diseases of childhood, and having a sound healthy constitution; finally, the accessions being at long intervals, the remissions complete, and the night, during which the symptoms are usually most severe, well spent. In adults, the prog- nosis is more favourable than in infants.] In adults, it excites pneumonitis more frequently than in children ; and, in pregnant women, has often led to abortion. A moist skin, warm ex- tremities, open bowels, plentiful expectoration, and free vomiting, are favourable symptoms. Frequent hemorrhage protracts the disease ; and if it proceed from the lungs, a foundation will often be laid for phthisis. The violence of the action occasionally excites inflammation in the trachea. Dr. Marcus, among other singular opinions that distinguished his career, brought himself at last to believe, that such inflamma- tion was always present: and having advanced thus far, he next undertook to show that hoop- ing-cough and croup are one and the same dis- ease. He died, indeed, while dictating the preface to his treatise on the former affection, which he hoped would establish this opinion. Dr. Dawson has since revived a part of this hypothesis, by conceiving that hooping-cough is a specific inflammation, seated in the glottis, or upper part of the trachea, and spreading more or less widely, according to the degree of its violence : but he does not identify it with croup. —(Nosological Practice of Physic, 8vo., 1824.) [Dr. Watt inculcated the opinion, that hoop- ing-cough is essentially an inflammation of the mucous membrane of the bronchiae, which state- ment agrees with Laennec's description ; and, if correct, the complaint should properly be re- garded, with Laennec, as a species of catarrh, and classed accordingly. The disease, when fatal, generally becomes so from severe bron- chitis. In several instances, in which the state of the lungs was ascertained by dissection after death, the most remarkable appearances were an inflamed condition of the trachea and bron- chiae, particularly of the latter, and an almost complete obstruction of the bronchial passa- ges with a serous or mucous fluid, interspersed with flakes of semipurulent matter.—(Treatise on Chin-cough, &c, p. 123, 8vo., 1813.) These effects may be supposed to be only the conse- quence of the violent cough; but as Dr. Forbes has remarked, the opinion, delivered on the seat of the complaint by Dr. Watt, is amply con- firmed by the early symptoms, and the indica- tions of the stethoscope.*] * Note in transl. of Laennec on Diseases of the Chest, &c, p. 98, ed. 2. In the greater numbeT of cases where children die, says Dr. Elliotson, there is a violent bronchitis, sometimes combined with an extensive inflammation of the substance ■of the lungs. But he adds, that, on opening chil- dren who have died of this disease, you some- times find very little the matter with the lungs, and death may have arisen from some other cause ; for the disease has a great tendency to produce hydrocephalus and convulsions. When the air- cells inflame, and the lungs become more or less hepatized, the silvery rattle may be heard with the stethoscope, and the breathing is excessively loud and rough throughout the chest—(Lect. at Lond. Univ.—See Med. Gaz. for 1832-3, p. 194.) The Gen. I.—Spe. 3] BEX CONVULSIVA. 271 In a few rare instances, hooping-cough as- sumes a periodic character, and is then sure to become peculiarly intractable. Dr. Perceval, in his Comments 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. [Notwithstanding the contrary statements sometimes made, Dr. C. Johnson believes that the hooping-cough rarely, if ever, affects the same individual twice ; and that it is seldom met with in adults, of which, however, instan- ces are upon record.] Dr. Cullen, in laying down his own mode of treatment, indulges in an ingenious, and I believe correct hypothesis, and divides the disease into two stages. The first consists of that part of it during which he supposes the contagion to be present and operative, which possibly may in- clude the first three weeks ; the second embra- ces the remainder of its duration. Throughout the former stage, our attention should be directed to whatever will moderate the influence of the contagious stimulus, retard the return of the con- vulsive paroxysms, and mitigate their violence. [If the patient can be made to drink by small and repeated portions during the paroxysm, its severity and duration, according to Laennec (Op. cit., p. 98), will be diminished ; perhaps from the effort of deglutition facilitating deeper inspirations, by counteracting the spasms of the bronchiae.] Bleeding, in severe cases, will usu- ally be found necessary for this purpose ; but it should be avoided under other circumstances ; and it will generally be found better to employ blisters as a substitute. The most effectual remedy is emetics ; whose action tends equally to interrupt the return of the paroxysms, and to keep the lungs unloaded, by producing a deter- mination towards the surface. [Laennec rec- ommends them to be repeated every day, or every second day, for a week or a fortnight; and prefers tartarized antimony to ipecacuanha, on account of the great inequality of power in the latter, and the solubility of the former allowing it to be more easily administered in doses pro- portioned to the exigency of the case.] The food must be light, and costiveness carefully prevented ; but no benefit seems to be derived from purging.* danger is in proportion to the affection of the head, the bronchitis, and the peripneumonia.—Ed. * A better founded division of hooping-cough is into the inflammatory and merely spasmodic forms. If there should be a constant oppression of the breathing, with spasmodic attacks, and a violent cough at times, an accelerated pulse, and a sono- rous, sibulous, and crepitous rattle, there is inflam- mation of the bronchiae, or the substance of the lungs. Here, as Dr. Elliotson properly remarks, you might give all the antispasmodics, all the nar- cotics, and all the medicines that are supposed to have a direct influence over spasm, and yet do no good. If the patient be old enough, he must be 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 suppose to be kept up by the stimulus of contagion. In its latter part, or second stage, in which a mor- bid 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 pro- cess ; and hence different tribes of medicines have been resorted tovwhich 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 pur- pose of local or general revulsion ; and tonics, for that of both local and general reinvigoration. The sedatives chiefly recommended, have been opium, hyoscyamus, belladonna, conium, musk, and the hydrocyanic acid. Though opium has the authority of many dis- tinguished practitioners (Hufeland, N. Annalen, i., p. 367; Demachy, Manuel dePharmacie, Paris, 1788 ; Ruling, Beobachtung der Stat. Northeim., p. 107), it has often been found of no avail, even where it has been given in large and frequent doses; and, still more generally, it has been productive of greater mischief than good. The compound powder of ipecacuanha is one of the best preparations of opium which can be em- ployed in this disorder. The conium has ac- quired a far higher degree of public favour, for which it is much indebted 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, more- over, in every form, whether of powder, extract, plaster, or cataplasm; but, for internal use, he gave the powder, allotting a grain a day to in- fants under six mouths, and ten grains to adults, with a gradual increase as they persevered. [After emetics, Laennec also prescribes narcot- ics in small doses, and considers the extract and powder of belladonna as the best medicine of this class. The dose is from i to £ of a grain. Its efficacy in lessening the severity of the cough, and shortening the duration of the disease, he conceives, may he accounted for by its lessen- ing the necessity of respiration, and consequently the dyspnoea; obviating the spasm of the bron- chiae ; diminishing the irritation produced by the vascular congestion of the mucous membrane ; and lessening the augmented secretion.] bled occasionally in the arm; leeches should be applied to the chest, and mercury and emetics exhibited. "In the greater number of cases, the inflammation is such as will yield to the application of a few leeches and the exhibition of emetics; but it is of great use likewise to clear out the bowels by calomel, provided the inflammation is severe, and to give it steadily in small and repeated doses." —(Med. Gaz., loc. cit.) Dr. Elliotson is also an advocate for the warm bath, and for not letting children with this disease overload the stomach, or move or run about a great deal; circumstances always aggravating the cough, and the bronchitis, if any degree of it be present.—Ed. 272 PNEUMATICA. [Cl. IL—Ord. II. Musk has been tried both abroad and at home, from six grains to half a drachm at a time ; but its effects are so various, and, in- deed, contradictory in different individuals, as to prevent confidence in its use. The prussic or hydrocyanic acid has unques- tionably subdued the spasmodic irritation, and consequently relieved the cough, in a variety of instances. It is here, indeed, and in ner- vous cough, that it seems to act with most ad- vantage.—(Recherches Physiol, et Clin, sur VEmploi de I'Ac. Prussique, &c, par N. Ma- gendie, D. M., Paris, 1819.) I have known it succeed when there was the utmost de- gree 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.* The stimulant plan, if it have not been more successful than the sedative, has at least been as powerfully supported. Its intention I have already stated to be that of taking off the pro- pensity to spasmodic 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, camphire, the herb Paris, and rhus Vernix. [Laennec has seldom found blisters of much use : instead of them, Autenrieth has proposed the application of tartar emetic ointment to the chest, a plan, from which more benefit has sometimes resulted than from blisters.] When blisters were formerly employed with great freedom in the hooping-cough, it was thought to be ascertained, that they always answered best when they irritated the bladder and occasioned strangury. And, on this ac- count, some practitioners have endeavoured to produce the latter effect without the pain ofthe former, and have for this purpose employed cantharides in tincture, in the proportion of twenty minims to a dose.—(Fmbes, loc. cit.) Dr. Barton of York first joined it with bark and the compound tincture of camphire, a practice afterward adopted by Dr. Lettsom, Hufeland, and others. But whether given alone or in combination, I have never found any decided benefit from its use. Where the intention is to divert the tendency to convulsive action by local revellents, it is far better to employ them externally, and particu- larly on the chest, and down the chain of the spine. The most common stimulants for this purpose are camphire, ammonia, ether, and the essential oils of amber and turpentine, which, in different combinations, have been long used, and still preserve their reputation. I have reason to believe that embrocations of this kind have often proved highly beneficial: and it is not difficult to account for such an ef- * If the child be young, Dr. Elliotson recom- mends one minim to be put in an ounce or two of almond emulsion, one teaspoonful of which, he says, will be the proper dose, three or four times a day.—Ed. feet : since the cervical and dors 1 nerves are so generally distributed over the muscles of the chest, the diaphragm, and the scapulae ; and some of them, as the accessory nerves of Wil- lis, 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 pro- ducing an excitement generally, and thus of acting as universal revellents ; as camphire, ammonia, and the sulphuric and nitric ethers. These have often been found useful, and, where narcotics are given, they rather assist than op- pose their good effect. [Dr. Andrews (Glasgow Med. Journ., vol. i., p. 178) prescribed the tincture of lobelia inflatat with striking success. He says that there is no other medicine that so effectually frees the bronchial vessels of their viscid secretion. It is emetic and antispasmodic. The dose gen- erally given by him was thirty or forty minims, every twenty minutes.] The rAus vernix comes also strongly recom- mended by many foreign writers of distinguished character, as a stimulant and antispasmodic 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 sirup, and gave a table-spoonful every three hours to a "child. [By Dr. Millar, a high opinion was enter- tained of asafcetida, as a remedy for hooping- cough, as well as asthma.] After all, if no bronchitis exists, perhaps the best antispasmodics are tonic medicines, and a tonic regimen. Dr. Cullen trusts almost ex- clusively to the cinchona : " I consider," says he, " the use of this medicine as the most cer- tain 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." The best and most convenient form of the bark for children is the sulphate of quinine. [It is observed by Laennec, that, when the parox- ysms of hooping-cough assume a periodical type, cinchona, and the sulphate of quinine, are as efficacious as in cases of ague.] When the sulphate of quinine disagrees, as it will some- times 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. [Dr. Elliotson considers the preparations of iron as the best tonics which can be employed * The inhalation of tar fumes, sometimes rec- ommended, is only allowable when no inflamma- tion is present.—See Elliotson, Med. Gaz., 1832-3, p. 196.—Ed. t This medicine is highly recommended by Dr. Thatcher also. See Am. Modern Practice of Physic, Boston, 8vo., p. 248. See also Barton's i Veg. Mat. Med. of the U. States, vol. i.; p. 127„—i> Gen. IL] LARYNGISMUS. 273 in cases of hooping-cough, where no occasion for antiphlogistic treatment exists. The sul- phate can be conveniently given to children in mixtures, or the carbonate blended with treacle.] ' As an important part of our tonic plan, may be mentioned change of air, and especially where the difference of temperament, or even temperature, can be rendered very considera- ble, as from a low to a high atmosphere, or from the interior of a country to the seacoast ; but cold-bathing, so far as my own experience ex- tends, has proved 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.* * The diversity of views presented in the text concerning the nature and treatment of hooping- cough, seems to demand a word from the Ameri- can editor. It is a truth painfully familiar to every observer, that, in our country, death by hooping-cough is not uncommon. The disease may fairly be considered as arising from a specific cause : of a contagious character, and as affecting adults of an advanced age as well as infants a few months old. " I have seen the disorder," says Dr. Francis, " sometimes occurringin children of some six or eight months of age, and but recently it proved fatal to an adult in his 82d year; nor does the system always enjoy an immunity from a second attack." From the circumstances which accompany it, it may be deemed occasionally of a spasmodic character, without inflammation ; but in most cases, it must be classed strictly among the phlogotica : it involves the glottis, and the mucous lining of the bronchiae is primarily affected with inflammation. Theeharacteristics of spasm which so generally marks it, is doubtless attendant upon the peculiar seat of the inflammation; and this principle is illustrated also by the phenomena which croup often exhibits. A practical writer of eminence, Dr. Eberle, in speaking of the pa- thology of hooping-cough, remarks, "It appears to me that hooping-cough is essentially a spas- modic or nervous affection, the proximate cause of which consists principally in a peculiar irrita- tion of the eighth pair, or the pneumogastric nerves."—(Practice of Medicine, vol. ii., p. 229.) This opinion has been advanced by several Ger- man writers; post-mortem examinations, how- ever, of bodies dead by hooping-cough, often pre- sent various and opposite conditions, and some doubtless which have no connexion with the dis- ease. A late writer, Desruelles, maintains that it is a bronchitis, which in its progress becomes com- plicated with cerebral irritation and congestion; that this encephalic irritation assumes an inter- mittent form, and is the primary organic cause of the convulsive cough which characterizes the dis- ease. He therefore proposes to designate the dis- order by the term, broncho-cephalitis.—(North Am. Med. and Surg. Journal, vol. ii., p. 156.) In- asmuch as there is a predominant tendency in this complaint to congestion of the brain and hydro- cephalus, this name is not without its practical advantages. If hooping-cough be neglected, or badly treated, without reference to its acute char- acter, it terminates so frequently in hydrocepha- lus, that the physician cannot be too mindful of this serious result. " Hooping-cough," says an- other distinguished American writer, " like ca- tarrh, divides itself into two stages : the first fe- brile or inflammatory, to be treated by bloodletting, emetics, small doses of antimony, abstinence, and I Vol. I.-S [The extract of common daffodil (narcissus pseudo-narcissus), and the infusion of its petals, were proposed, a few years ago, as a specific against this disease. Laennec, who tried the extract, found it, however, much less efficacious than belladonna. The dose is half a grain, a grain, or two grains, every two, four, or six hours, according to the patient's strength. Its mode of action is imperfectly known.*] GENUS II. LARYNGISMUS. LARYNGIC SUFFOCATION. sense of spasmodic suffocation in the larynx, commencing suddenly, and re- laxing, or intermitting ; cough trouble- some j scanty discharge of viscid mucus. There is a disease that often attacks the larynx, and especially of infants and children, which has so near a resemblance to croup, as to be very generally confounded with it, and which is hence commonly known by the name of spasmodic croup: but which, notwithstand- ing the resemblance of many of its symptoms, is essentially different 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 termina- tion that sufficiently distinguishes it from laryn- gitis, or inflammation of the larynx, yet a ter- mination that has the sanction of the best med- ical writers in every age.—(See Prelim. Diss. to the Author's System of Nosology.) The distinctive characters of bronchlemmitis, or the usual means constituting the antiphlogistic treatment. The second or passive stage, like the chronic state of catarrh, is frequently of long du- ration, and continued by the sensibility of, the lungs attendant upon weakness. Exercise, change of air, stimuli, in the form of food and medicine, the external application of various embrocations, with the occasional use of vitriolic emetics, Mosely's solution, or the fashionable antipertussis, are now indicated. I have also oftentimes given the com- bination of the tincture of bark and cantharides, as recommended by Dr. Lettsom, with the best ef- fects."—Hosack's Essays, vol. ii., p. 459. After suitable depletory means have been adopted, cor- responding to the activity of the disease, emetics are among our most valuable remedies. Ipecacu- anha is often efficient, and is generally a safe arti- cle : in this state of the disorder, however, Dr. Fran- cis advocates a free use of the vitriolic emetics, particularly ofthe sulphate of zinc ;.'.' they have the advantage," he says, " of not adding to the debility of the sufferer, and relieve promptly and efficiently by ejecting the overloaded excretion of the bronchial vessels, and by harmonizing the dis- turbed and oppressed respiration." Our remedies may control the violence of hooping-cough, and safely modify its course; but except in cases purely spasmodic, can have but little influence in cutting short its duration.—D. * When hooping-cough is complicated with in- fantile remittent fever, depending on constipation, or on derangement of the abdominal secretions, purgatives and alteratives are called for; espe- cially, in the former case, calomel, rhubarb, and scammony; and in the latter, rhubarb and car- bonate of 6oda, or the hydrarg. cum cretS, or Dover's powder, followed by castor-oil.—Ed. 274 PNEUMATICA. [Cl. II.-Ord. II. croup, are, inflammation of the mucous mem- brane of the trachea and bronchial vessels, and the secretion of a peculiar concrete and mem- brane-like material that lines the tracheal tubes, and threatens suffocation by obstructing them. In the disease before us, we have neither inflammation nor membrane-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. This species forms the spasmodic asthma of Millar, Parr, and various other writers. Yet it is not strictly an asthma, though it makes an approach to it; and the name under which it has been thus described, shows sufficiently that the present is the proper place for its reception. In asthma, the constriction begins in the chest, and chiefly exerts itself there, though the spasm may extend to the upper part of the trachea. In spasmodic laryngismus the con- striction commences in the larynx, and is chiefly confined to that organ, though it may extend to the chest. In the former, the respi- ration is wheezy, but the voice is not stridu- lous ; in the latter, the voice is stridulous, but the respiration is rarely wheezy, or seldom so in an equal degree ; evidently showing a differ- ence 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 nearer approach to croup. " The in- convenience," observes Dr. Parr, " is the greater, since, from the resemblance of the symptoms, remedies have been celebrated as successful in croup which were never used in the disease ; and the less experienced practi- tioner, trusting to them, has felt the severest disappointment." The suddenness with which this complaint commences its attack, forms another mark of distinction between itself and croup, almost as pathognomonic as the absence of inflammation, and the peculiar secretion in the latter. There are instances, indeed, in which genuine croup has also commenced abruptly, but these are very rare ; for it has usually the precursive symptoms of a slight cough and hoarseness for a day, and sometimes two days, as though the patient were labouring under a catarrh. In croup, also, the inflammation, when it has once taken effect, becomes a permanent cause of ex- citement, and the anxiety and struggle for breath continue, with little if any abatement, till the inflammation is subdued. In the dis- ease 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 the most common. It appears most frequently in relaxed and irritable habits, where, in truth, we should soonest ex- pect 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 rea- son for supposing some degree of local irrita- tion ; and it is on this account that I have pre- ferred entering the disease here, to an arrange- ment of it under the fourth class, consisting of diseases that are purely and idiopathically ner- vous. It is possible, however, that some of these symptoms may be the result of the spasmodic struggle itself. An active plan of treatment is imperiously demanded. Yet an antimonial emetic generally effects a cure as soon as it begins to operate, if employed early : but the diaphoresis which it excites should be maintained for some hours, by keeping the child in bed, and the use of diluents ; which will be the most effectual means of preventing a return ofthe spasm. The bowels should also be excited by a purgative of calomel. And if the emetic do not prove sufficient, or the 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 irrita- bility. Those who regard this affection as an asthma, have strongly recommended the fetid antispasmodics, as asafoetida, both by the mouth and injections ; but I have not found them suc- cessful. Generally speaking, after the action of the emetic, the child falls into a deep and quiet sleep, and awakes with few remains of the com- plaint. Yet, if the spasm be not attacked at once, suffocation may soon follow. Those who have once laboured under it, are more suscep- tible of it than before ; and the younger branches of some families seem much more predisposed to it than those of others. This disease has been noticed by M. Breton- neau of Tours, and described under the name of angina stridula. It was mistaken occasion- ally for a peculiar form of angina maligna, which was then prevailing as a contagious dis- ease, and in which the local inflammation, in- stead of producing ulcerations, threw off mem- branous or croupy exfoliations, and was accom- Gen. III.] DYSPNG3A. 275 panied with a croupy suffocation. But, in the case before us, there was no swelling of the lymphatic glands at the angle of the jaws; the tonsils and velum palati were free from redness or tumefaction, and no pain was complained of in the region of the larynx. While the attend- ants were about to apply leeches, and exhibit an emetic, the little patient fell into a refresh- ing sleep ; a gentle moisture appeared on the skin, the cough became looser and little trouble- some ; and next morning the complaint was nothing more than a common cold, which re- quired no further medical aid. M. Bretonneau regards this affection as only a simple cedema- tous tumefaction (une simple tumefaction cede- mateuse) of the mucous folds in the ventricles' of the larynx.—(Des Infl. spiciales du Tissu Muq., &c. Par P. Bretonneau, Paris, 1826.) GENUS III. DYSPNOEA.* ANHELATION. PERMANENT DIFFICULTY OF BREATHING J WITH A SENSE OF WEIGHT IN THE CHEST. There has been no small perplexity felt by nosologists in arranging the various diseases which are chiefly characterized by irksome or distressful breathing. The lungs, like the stom- ach, 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 asthma. Celsus, following the Greek physicians, regards them as only modifica- tions of the same malady, merely differing from each other in degree. "Each," says he (Medicinae, lib. iv., iv., 2), "consists in difficulty of breathing. When this * Dyspnoea is generally only a symptom of dis- ease. It is correctly observed by Dr. Williams, that as the elements or principal parts concerned in the function of respiration are three, namely, the blood, the respiratory machine, and the air, the causes of dyspnoea may arise from changes in any of these. Hence, in the consideration of this sub- ject, he divides it, 1st, into derangements which interfere with the respiratory movements ; 2dly, derangements which obstruct the passage of air to and from the pulmonary cells ; 3dly, derange- ments in the pulmonary tissue, obstructing the action of the air on the blood. Dr. Williams con- ceives that the muscular act of inspiration is ex- cited by a sensation arising from the presence of black blood in the lungs. The views adopted in the following passage should never be forgotten in the investigation of dyspnoea and asthma. " As the peculiar condition of the blood, which is called venous, is the immediate cause of the sensation of dyspnoea, so the blood being (if we may use the expression) more venous than usual, may give rise to the feeling of dyspnoea, without any derange- difficulty is moderate and unsuffocative, it is called dyspnoea; when it is more vehement, so that the breathing is sonorous and wheezing, it constitutes asthma ; and when it can only take place in an erect position, it is denomina- ted orthopnoea. The first is usually a chronic affection, thejatter two acute." Galen, on the 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 John Floyer and Dr. Bree have reduced the three divisions of Celsus to two, and have used the term asthma as a generic name under which to arrange them. These two divisions are continued asthma, and convulsive, or periodic asthma (Inquiry into Disordered Respiration, 5th edit., p. 231) ; the former being the dyspncea of the Greek wri- ters and of Celsus, and the latter uniting their 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 spe- cies to them when thus subdivided: though, if asthma be employed genetically, it would per- haps be more consistent with the rules of classi- fication to name the primary ramifications spe- cies ; and the secondary, sub-species or varieties. Almost all the continental writers make each affection a separate genus, as does Macbride among those of our own country. Cullen makes a genus of dyspnoea, as well as of asthma, but merges orthopncea in the former ; Dr. Parr and Dr. Young take as little notice of orthopnoea, 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 synonyme ; the former of which is applied by Sauvages to an entire order. Yet Dr. Cullen himself, in his First Lines, is untrue to his Nosology ; for having in his earlier work arranged and defined dyspnoea as a distinct genus, in his later he expresses doubts whether under almost every modification, it is to be re- garded otherwise than as a vicarious or symp- tomatic affection. On which account, probably, Dr. Crichton, though for the most part very ment of the respiratory apparatus. Of this nature is the dyspnoea arising from violent exercise, which ceases as soon as the flow of venous blood to the lungs becomes moderated by rest. Whether other processes, such as increased secretions, the digestion of blood, &c, be capable of producing the like effect, that is, of so changing the blood, that although the respiration be healthy, this fluid is arterialized with sufficient rapidity to prevent the feeling of dyspnoea, is uncertain: but the steth- oscope teaches us, that the function of respira- tion is more active in some individuals than in others, and .that there is also a difference in the same individual at different times." Dr. Williams then adverts to individuals whose lungs are defec- tive from disease, and who experience dyspnoea after taking food, though not usually sufferers from this complaint at other times. " It is," says he, " through the blood rather than in any other way, that diseases of the heart sometimes give rise to dyspnoea; any impediment to the pulmonary circu- lation causing imperfection in the oxygenating pro- cess."—Cycl. of Pract. Med., art. Dyspncea.—Ed. 276 PNEUMATICA. [Cl. II.-0rd.II. scrupulous in adopting Dr. Cullen's views, has banished dyspnoea as well as orthopnoea 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 asth- matic dyspnoea are synonymous for the same disease, and run parallel with the present genus. —(On Indigestion, &c, p. 377, 384, 4th edit., 8vo., Lond., 1824.) There is, nevertheless, a distinctive character, which, if steadily adhered to, may easily settle the question, and designate the proper place to which each respectively belongs. The difficulty of breathing is sometimes permanent; and some- times recurrent, with considerable intervals of perfect ease ; and, where it is permanent, it is occasionally distinguished by sudden and irregu- lar exacerbations. These characters are clear, and cannot well be mistaken ; and it is upon these pathognomonic marks that the arrange- ment we are now about to pursue has been founded. Dyspnoea distinguishes the cases of permanent difficulty of breathing ; asthma, those of the recurrent ; and orthopnoea, the cases of permanent difficulty^of breathing with irregular exacerbations. The first two, therefore, form distinct genera ; the last is necessarily a pecu- liar species of dyspnoea, linking it very closely with asthma. Thus bounded and distinguished, dyspnoea, as a genus, offers us the two following species : I. Dyspnoea Chronica. Short Breath. 2.-------Exacerbans. Exacerbating Anhela- tion. SPECIES I. DYSPNCEA CHRONICA SHORT BREATH. the breathing uniformly short and heavy ; mostly accompanied with a cough. The causes of this complaint exist in the chest locally, or in the habit or constitution generally : they are inbred, or the result of ac- cident ; and hence the disease exhibits the fol- lowing varieties : a Organica. From organic deformity, Organic dyspnoea. oppression, or acci- dental injury. 0 Extranea. From calcareous or other Extraneous dyspnoea. spicular materials, in- haled while working on stones or metals. y Vaporosa. From the mischievous Mephitic dyspnoea. action of metallic or other poisonous ex- halations. S Phlegmatica. From a phlegmatic or Phlegmatic dyspnoea. cachectic habit. i Pinguedinosa. Accompanied with op- Corpulent dyspncea. pressive fatness. Pursiness. When the chest labours under an organic deformity, or oppression, or the effects of an accidental injury, its cavity is contracted, and its motive powers are usually enfeebled, or cur- tailed in their action. This is by far the most frequent variety under which the disease makes its appearance. In some instances, the lungs have been found peculiarly small (Sandifort, Observat. Anat. Pathol.) and shrivelled (Bo- wer. Sepulchr., lib. x., sect, i., obs. 45) in per- sons who have died of this complaint. [Laen- nec says, that they diminish in size only from the effects of external pressure, or in conse- quence of the growth of accidental productions within their substance, which may be consid- ered as exerting a pressure from within out- wards. This opinion he illustrates by a refer- ence to what happens in cases of empyema and tubercles.—(On Diseases of the Chest, p. 147, 2d edit.)] The lungs are sometimes peculiarly hard, and cartilaginous in the duplicative of the pleura which surrounds them.—(Schreiber, Nov. Comment. Petropol., iii., p. 395.) There has been adhesion between the folds of their mem- brane ; or adhesion, sometimes ossification (Schachier, Diss, de Ossificatione Prater nat- urali, Lips. 1726), between the pleura and the ribs, sufficient to lay a foundation for difficulty of breathing. The lungs have been found loaded with hydatids, which have diminished their elasticity ;* and sometimes these animal- cules have been thrown up by coughing (Ephem. Nat. Cur., dec. ii., ann. i., obs. 80); and still more frequently the lungs have been indurated by scirrhous, or oppressed with steatomatous, or other tumours. In Bonet and other writers, we have also ex- amples of internal oppression, and a diminution of cavity, produced by an excessive magnitude in the substance of the lungs, offering a sort of parabysma of this organ, so as to leave little room, and allow little elasticity for their proper play, t And still more generally the oppressive cause lies without, and the capacity of the chest is diminished by rickets, or a softness of the bones (parostia flexilis), or some accidental 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 lit- tle. It may, perhaps, occasionally palliate some of the distress to which the patient is irrevoca- bly doomed, but it cannot go further. Perfect tranquillity of body and mind, gentle exercise, a light diet, with a total abstinence from flatu- lent vegetables and fermented liquors, and an undeviating habit of regular hours, comprise, perhaps, the whole that can be recommended by the physician, or attempted by the patient. [Where dyspnoea depends on the presence of hydatids, or, as Laennec terms them, acepha- locysts in the lungs, common salt appears most deserving of trial as a means of cure. Sheep which feed in salt meadows are exempt from * Bonet. Sepulch., fib. ii., sect, i., obs. 33. Also, valuable observations on this subject, by Laennec, p. 373, 2d edit. t Sepulc, lib. ii., sect, i., obs. 57, 58. Ruysch, obs. 19, 21. Eph. Nat. Cur., dec. i., ann. i., obs. 6. Id., dec. ii., ann. x., obs. 175; and Laennec on Diseases of the Chest, chap, on Hypertrophy of the Lungs, p. 146, 2d edit. Gen. III.—Spe. 1] DYSPNCEA CHRONICA. 277 the rot and staggers, which are occasioned by the development of two species of vesicular worms in the abdominal viscera and brain. If attacked, a removal to such meadows generally cures them. Salt water baths have appeared to Laennec (Op. cit., p. 377) to benefit patients afflicted with analogous complaints. It is not necessary, he says, that the hydatids should be expelled, to effect a cure : it suffices if they be deprived of their vitality, after which their liquid is absorbed, the cyst shrinks into a small compass, and, upon cutting into the tumours, we find the hydatids quite flattened, and some- times stratified with layers of albuminous and friable matter.] Sawyers and hewers of freestone or other fossil masses; glass-cutters, china-manufac- turers (See Hastings on Infl. of the Mucous Membrane of the Lungs, p. 273), lapidaries, and workers upon metals, are often subject to dyspnoea, from having the lungs loaded with fine pulverulent particles, detached from the materials on which they are employed, and floating in the atmosphere that surrounds them. And to these may be 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-dres- sers. This affection is so nearly similar to the variety 0 of dry cough, on which we have treated already, that it is only necessary to refer the reader to the remarks there laid down. The cause and mode of treatment are the same ; and the symptoms chiefly differ from a differ- ence 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 atten- tion 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.—(Hec- quet, Maladies des Artisans, torn, 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 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 mag- net, that concentrates the metallic spiculae, and thus prevents them from floating loose in the inspired air. It is an invention of Mr. Abra- hams, of Sheffield, and has justly met with the approbation of the Society for the Encourage- ment of Arts. [The doctrine of diseases of the lungs being produced by the inhalation of dust, and other extraneous particles, was considered by Laen- nec to be destitute of foundation. The dust, he observes, is quite dissimilar from the creta- ceous formation occasionally met with in the lungs. Such productions he correctly regarded as the result of perverted secretion, and he had never met with them, except in dilated branches of the bronchiae, or in the vicinity of old tuber^ culous excavations, cured by the formation of a fistula, or cartilaginous cicatrix. The produc- tion of cretaceous matter, he says, frequently succeeds that of tubercles. Dr. Forbes coincides with Laennec respect- ing the secretion of the chalky matter; but dif- fers from him in believing, with the author of this work, that the habitual inhalation of dust of various kinds is a frequent source of bron- chial inflammation among various kinds, of arti- sans, and more especially, in this country, ne'edle-grinders, leather-dressers, and miners. An immense proportion of the miners in Corn- wall, he says, are destroyed by chronic bronchi- tis, one cause of which is the inhalation of dust.] Exposure to the vapour of mineral acids, or of metallic or other mischievous exhalations, is also frequently found to produce a permanent difficulty of breathing. This affection is pecu- liarly 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 inter- esting picture of whom is given by Diodorus Siculus, in his description of the mines of Ara- bia 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, according to the nature of the mine, with oxydes, sulphurets, or commi- nuted reguline particles of lead, copper,^ anti- mony, silver, arsenic. Metallurgists and the labourers in chymical laboratories are often se- vere sufferers from a like cause. Gold-refiners become dyspnoetic 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.—(Rammazini, de Morbus Artifi- cum.—Ephem. Vratisl.) And Heurnius saw the lungs of a printer, so changed by inhaling an atmosphere impregnated with lead, as to re- semble a shrivelled apple. The treatment of this variety must be regu- lated by the variety of the cause ; but, perhaps, in all cases, a free inhalation of oxygen gas will be serviceable. An inhalation of moderately stimulant vapours, as of an infusion of laven- der, marjoram, and, indeed, most of the verti- cellate plants, or of diluted wine-vinegar, has also proved frequently of use ; to which may be added, a current of the electric fluid passed two or three times a day from the upper part of the spine to the diaphragm. 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 or- gans to their natural action. Galvanism has also occasionally produced considerable, and, 278 PNEUMATICA. [Cl. II—Ord. II. in some instances, permanent relief, after a few applications ; 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 recommended by Dr. Wilson Philip.—(Op. cit., p. 379.) We sometimes find a permanent difficulty of breathing in persons labouring under great torpor or sluggishness of vascular action. The pulse is slow and unresisting ; the muscles are soon fatigued; the mind has little energy; the face is pallid ; the skin cold and soft : the urine scanty, and the extremities cedematous, without any pathognomonic symptoms of dropsy in the chest, or at least any sensible fluctuation in the thorax. It is the dyspncea aquosa of Cullen, and the dyspncea pituitosa of Sauvages. Whatever has a tendency to depress the living power, and particularly in flaccid and atonic habits, will readily lay a foundation for this va- riety of dyspnoea; and hence it is a frequent result of catching cold in the feet, and, still more frequently, of suppressed perspiration. It also occasionally follows chronic catarrhs, and pneumonitis. A tonic and gently stimulant plan, consisting of the warm gums, camphire, and other terebin- thinates, the warmer bitters, the oxydes of 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 ipecacuanha, as operating longer on the moving powers of the chest. Of the terebinthinate tribe, the best, perhaps, is the balsam of copayva, 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 secre- tion of mucus where it has ceased or become deficient; or in producing a healthy discharge where its nature has been changed by morbid action : on which account, this medicine may almost be regarded as a specific in morbid secre- tions of mucous membranes, whether of the lungs, the intestinal canal, or the urethra; as it has often proved highly serviceable in croup. The chief difficulty is in devising a convenient form for its exhibition, since it sometimes ex- cites nausea. The variety of kast moment, perhaps, to the dyspnoetic patient, is that which proceeds from, or is accompanied with, a short, stunted figure, and considerable corpulence, or, at least, obes- ity of the chest. We see persons of this description, significantly described by the collo- quial term pursy, pant, and perspire", and grow fatigued, day after day, upon very little exer- cise, and yet press on without any serious in- convenience to a late period of life ; or, if they sink suddenly and sooner, they yield rather to apoplexy as a result of their general habit, than to the idiopathic affection before us. [Accord- ing to Laennec, this case is in a great measure nervous, and is to be attributed to the great ex- penditure of nervous influence, required to move a mass so disproportioned to the ordinary powers of motion.—(Op. cit., p. 404.)] Ab- stinence from spirits, wines, and fermented bev- erages, a meager allowance of animal food, a soluble state of the bowels, and exercise, rather persevering than violent, will form the best plan for the present ease, and the best guard against threatened mischief. Bleeding has of- ten been tried, but it affords only temporary relief. Sauvages gives us the history of a female, who for two years had been so far suf- focated, that it had often been judged necessary to bleed her three times a day at least, and she had undergone not fewer than two thousand venesections, when she applied to him. 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 per- spiration : by this means she was convalescent in ten days. Dyspnoea has also sometimes been produced by causes somewhat more singular, as common respirable air obtaining an entry into cavities in the chest, or to which it does not naturally be- long. Stoll gives a case of dyspnoea, in which air-bladders, or vesicles, were seated on the sur- face of the lungs.—(Rat. Med., part vii., p. 135.) [This state is particularly described by Laennec (Op. cit., p. 149) in his valuable account of em- physema of the lungs: after mentioning the en- largement of the air-cells, he says, sometimes we observe on the surface of the lungs single vesicles, distended to the size of a cherry-stone, or even larger, quite prominent, exactly globu lar, and apparently pediculated. The term apparently is used, because, on cutting into them, we find that there is no real pedicle, but merely a constriction at the point where the cell begins to rise beyond the surface of the lungs. The dilated cell, in fact, communicates with the adjoining ones and the bronchiae; and the case is not one of a mere-extravasation of air under the pleura. What he calls pulmonary emphysema consists essentially in the dilatation of the air-cells ; and the projection of air on the surface of the lungs, constituting the larger and more prominent vesicles, is a posterior affection, and of slight importance, compared with the dilatation of the cells ; because hopes may be entertained of its removal by absorption, while we cannot well see how nature or art can rem- edy the other morbid alteration, which, how- ever, Laennec does not pronounce absolutely incurable.] Gooch and various others mention examples of air let loose between the lungs and the pleura. In Timaeus we have a specimen of a very extraordinary idiosyncrasy, giving rise to a difficulty of breathing upon an inhalation of the smell of roses.—(Case, p. 216.) The morbid influence of metallic action is not con- fined to vapour locally applied ; for in Schenck we have a case of dyspnoea produced by mercu- rial inunction (Observat. Rar., lib. ii-, p. 63); 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.— (Eph. Nat.Cur., dec. iii., ann. iv., obs. 30.) [According to Laennec (Op. cit., p. 151), some of the air-cells of the lungs of subjects Gen. III.—Spe. 2.] DYSPNCEA I who have long suffered from any kind of dysp- noea, are almost always found preternaturally dilated. In other words, these organs are in a. state of vesicular or pulmonary emphysema, which he distinguishes from the interlobular, well known to surgeons. He looks upon ve- sicular emphysema as being almost always the consequence of dry catarrh, and presenting the same indications of cure. " Frictions with oil are often very useful in lessening the suscepti- bility to be affected by catarrh. In the case of pallid, cachectic subjects, the subcarbonate of iron has occasionally seemed to have a similar effect, and to tend at the same time to diminish the congestion of the mucous membrane, and spasmodic stricture of the bronchiae. In the severer asthmatic paroxysms, it is frequently necessary to have recourse to venesection, in order to relieve the congestion of blood in the lungs ; and it is always proper to diminish the necessity of respiration by means of narcotics.''] * Chronic dyspnoea appears also as a symptom or sequel in various other diseases, or affections of various other organs ; as aneurism, ossifica- tion, 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 ob- vious, that it must, in a greater or less degree, be an attendant on the latter period of preg- nancy. It has also followed occasionally, not only suppressed perspiration, but the suppres- sion of various cutaneous eruptions, and in a few instances, the sudden closure of an issue, or seton, of long standing.! SPECIES II. DYSPNCEA EXACERBANS. EXACERBATING ANHELATION. the disease subject to sudden and irreg- ular EXACERBATIONS ; BREATHING DEEP, STERTOROUS, ACUTE, AND SUFFOCATIVE ; RE- LIEVED BY AN ERECT POSITION. This species admits of most of the varieties of the preceding, which it is hence unnecessary to repeat; and, like it, is often found as a symp- tom in aneurisms, polypous concretions, and other affections ofthe heart and larger vessels ; in parabysma, and other affections of the ab- dominal viscera ; in empyema, dropsy of the chest, worms, peripneumony, bastard peripneu- * Moderate venesection will be found useful in several of the forms of dyspnoea noticed by the author, particularly in that arising from great tor- por or sluggishness of the vascular action.—D. t Riedlin, Lin. Med., 1695, p. 91. There is a form of dyspnoea, noticed by Laennec, and de- scribed by him as a " besoin de respirer," and by Dr. Williams, as a case of " increased want of breath ;" a disorder which the latter physician re- fers to the venous condition of the blood being augmented beyond its natural standard. If not idiopathic, this affection, he thinks, cannot be as- cribed to any distinct disease. It is to be detected only by the absence of the signs of every other EXACERBANS. 279 mony, smallpox, and occasionally in severe ac- cessions of intermitting fevers. I have already, . indeed, stated, that there is scarcely a function with which the action of the lungs is not con- nected, and, consequently, scarcely a disease of any importance in which it does not occa- sionally participate. Whatever be the cause that produces anhelation, or permanent diffi- culty of breathing, in a patient, any accidental augmentation of it, or any sudden excitement of body or mind, or any diseased action of any kind, capable of uniting with the primary cause, directly or remotely, will increase its power, and not unfrequently induce a spasmodic con- striction in the muscles of respiration. And it is this accidental exacerbation, produced irregu- larly by casual and often occult causes, and es- pecially in irritable or nervous temperaments, that peculiarly distinguishes this species from the preceding. In asthma the returns are for the most part strictly periodical, and the inter- vals, perfectly free from difficulty of breathing. In exacerbating dyspnoea the constriction occurs with the utmost irregularity, in the daytime, at night, in hot or cold weather, in a moist or dry atmosphere, and it is hence sufficiently dis- tinguished from asthma. A catarrhal cough will sometimes prove an occasional cause ; several of the varieties of heart-burn, and es- pecially cardialgia syncopalis, still more fre- quently ; other causes are, indigestible food, a fit of hysterics, or any violent commotion or agitation : while, as already observed, the occa- sional cause is often beyond the power of de- tection. When the constrictive paroxysm makes its attack, it must be immediately opposed by an erect position, without which suffocation would often instantly ensue ; and by the most power- ful antispasmodics. Tincture of opium, ether, and ammonia, are what I have chiefly trusted to, and have uniformly found far more to be depended upon than castor, or any other odor- ous antispasmodics, in whatever quantity given. A large blister to the chest should also be im- mediately applied ; and, if the paroxysm do not yield soon, sinapisms to the feet. Upon its ces- sation, the gum-ammoniac mixture, or a solu- tion of asafoetida, with camphorated tincture of opium, will be found a convenient guard against fresh attacks, provided due attention be paid to the state of the bowels, which ought indeed to form an early consideration. Issues have been recommended as a preventive of the paroxysm, where its approach has been expected, and I cause : when, therefore, a dyspnoea occurs, while pure air is found to penetrate freely into every part of the lungs, and the diseases, which modify the state of the bronchial membrane and its secre- tion, have not existed, the disorder, as Dr. Will- iams conceives, must be necessarily referred to an unusually venous or carbonized state of the blood ; the result, perhaps, of " an excessive formation of those secretions, which are, in relation to the blood, defective in carbon" (Cyclop, of Pract. Med., art. Dyspncea), as, for instance, urea. Bel- ladonna, stramonium, and conium, are the medi- cines which Laennec preferred for the relief of the " besoin de respirer."—Ed. 280 PNEUMATICA. [Cl. II—Ord. II have sometimes thought them of efficacy. For this species, however, perhaps the most effect- ual means of relief are to be derived from the application of the voltaic battery, as already proposed for anhelation 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 animals, whose eighth pair of nerves had been divided, exhibited the op- pressed breathing and accumulation of phlegm that characterize 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 dimin- ishing the accumulation of phlegm in the lungs. In proper asthma, 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 nerves of the respirable organ are alone in a morbid condition, and not the brain or spinal marrow ; yet, in the former, they are still capable of being recalled to a state of healthy activity, or of becoming sufficiently cleared to form a passage for the supply of nervous influence to the lungs, which effect he supposes to be obtained by the use of the voltaic machine. The American pathologists have found great benefit from various preparations of the lobelia inflala, or Indian tobacco, which certainly pos- sesses powerful antispasmodic and expectorant virtues ; and has hence a fair claim to more ex- tensive trial than it has yet received. The or- dinary 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, RECUR- RENT ; ACCOMPANIED WITH A WHEEZING SOUND AND SENSE OF CONSTRICTION IN THE CHEST ; WITH COUGH AND EXPECTORATION.t Asthma, as already observed under dyspnoea, is closely connected with the latter, and particu- larly with its second species, characterized 'by what might be strictly called asthmatic exacer- * A Treatise on the Materia Medica, &c, bv John Eberle, M. D., 2 vols., 8vo., Philadelph., 1822. Also Dr. Andrew's Report in Glasgow Med. Journ., vol. i., p. 177. t " A difficulty of breathing, recurring in parox- ysms, after intervals of comparative good health, and usually unaccompanied by fever."—(Forbes in Cycl. of Pract. Med., art. Asthma.) The great- er number of writers agree in meaning by asthma " a disorder of the respiratory organs, character- ized by intermittent or remittent dyspnoea, the attacks of which usually occur during the night, bations, and which I have hence denominated dyspncea exacerhans. The definition of the disease now offered, while it shows the proximity of the one to the other, is sufficient, if I mistake not, to form a marked and accurate distinction. The vulgar term for the complaint in our own language is bro- ken-wind ; which, as scientific precision is sel- dom 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, although occasional instances of this have occurred, par- ticularly 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 hereditary. Asthma afflicts both sexes, but is more com- mon in the male than the female. It makes its appearance in individuals of every variety of constitution, a necessary result, as Dr. Forbes remarks, of its frequent dependance on other diseases of accidental occurrence ; but what are called nervous temperaments are those in which the disorder occurs with remarkable frequency, and the same observation may be made with respect to plethoric individuals, with a full hard pulse, a short neck, high shoulders, a great deal of fat, and a voluminous head. It is supposed to be more common in temperate climates, than in either the very cold or the very warm re- gions of the earth, t Frank found it more com- mon in Poland than Italy.—(Frank, Med. Univ. Prax., torn, vii.) The paroxysms of asthma are frequently pre- ceded by languor, flatulence, headache, heavi- ness over the eyes, sickness, pale urine, dis- turbed rest, and a sense of straitness, fulness, and anxiety about the prsecordia. " When the evening approaches," says Dr Bree (Inquiry into Dis. Respiration, sect, iv., p. 46), who un- happily describes from his own history, " the weight over the eyes becomes more oppressive, and the patient is very sleepy. Frequently, 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 attempted, with attended by circumstances, which are noticed more or less in all cases, where there is some ob- stacle to the mechanism of respiration."—Jolly, Diet, de Med. et de Chirurgie Pratiques, art. Asthme, 1829.—Ed. * Asthma, according to the definition commonly given of it, is sometimes considered to be less a disease of old persons, than of adults not so far advanced in years; for the dyspnoea, and disturb- ance of the respiratory functions, often noticed in aged individuals, are mostly dependant upon or- ganic diseases of the heart, or great bloodvessels, as M. Rostan has satisfactorily proved.—Ed. t The prevalence of asthma seems to depend more upon the humidity of the atmosphere than upon its high or low degree of temperature. It is more likely to affect individuals on the seaboard than in the interior, and is seen in Boston and New-York more frequently than in Philadel- phia.—D. Gen. IV] ASTHMA. 281 some violence, and with great uneasiness of the abdominal 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 the first and deepest sleep: the cause of which has not been rendered-very manifest, though I do not think it beyond the reach of explanation, and especially in consti- tutions 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. Respi- ration is also so much of a voluntary action, that although it continues during sleep, and when the wiTl is not exerted, 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 recum- bent position of the body, when the muscles of respiration are destitute of the stimulus of vo- lition. When the disease indeed has once estab- lished 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 distressing tightness about the chest, as if he were bound with cords : his anx- iety 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 bedclothes. 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 intermitting; the abdomen is distended with flatulence ; the stomach is faint, and often rejects with great violence a slimy and frothy material of a greenish or yel- lowish 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 ef- fort to excrete, with a harsh and dry cough that brings up nothing more than a little clammy or frothy mucus. And in these cases, the fit usu- ally 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 expiration of tough viscid mucus commences, and gradually becomes copious and affords relief. It is occasionally mixed with blood from* the severity of the struggle ; but the * Dr. Forbes has known a poor patient, in such circumstances, not merely remain by the open win- dow, but lean over it, resting on the sill, with the arm hanging on the outside, for several nights together, and even in winter.—(Cyclop, of Pract. Med., art. Asthma.) Exposure to cold during a paroxysm-of asthma rarely causes any imme- diate or subsequent ill consequences, a fact which appears to Dr. Forbes to prove how profoundly and extensively the nervous system is involved in the attack.—Ed. larger the discharge of either, or of both, the more the bronchial vessels are relieved. It is often, however, many hours before a par- oxysm of this kind very sensibly subsides ; and the patient generally feels some degree of con- striction during the whole of the ensuing day; and is fortunate, if the next night be passed without a similar fit. The tendency to such returns usually continues for several nights ; in severe cases, for a week or fortnight. Sir John Floyer, who, from describing his own sufferings, has given us one of the best historical accounts of the disease that has ever been written, men- tions 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 as- sault, 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, "maybe carried on to old age, if super- vening diseases do not destroy the patient, or disturb the operations of nature, by which a re- covery from the paroxysm may be obtained."* But it rarely makes a first attack without sub- jecting the constitution to subsequent returns ; and frequently, by the debility which it hereby produces, lays a foundation for tubercular phthisis, dropsies of the chest or abdomen, aneurisms of the heart, and various other fatal diseases [which, however, according to the editor's rea- soning, should generally be considered as causes, and not as effect? of the disturbance of respira- tion]. While it occasionally happens, even where none of these Jake'place, that the mucous glands of the bronchiae become relaxed, an ha- bitual excess of secretion ensues, and a trouble- some dyspnma 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 awaking, and is only relieved by a long labour of severe coughing. This overloaded state of the bronchiae and air- cells, from too large a secretion of mucus, is in- deed, at the time, an original exciting cause of the disease; and has by some writers, and es- pecially in our own day by Dr. Bree, been sup- posed to be the chief cause. The exciting causes, however, are numerous, and it is difficult to say which is the chief; nor always easy to ascertain them satisfactorily. Yet they may all be resolved into an irritation of some kind or other, existing within the cavity * Bree*s Inquiry, &c, sect, vi., p. 71. Asthma hardly ever proves fatal as asthma, that is, in the paroxysm ; but, as Dr. Forbes has very correctly explained (Cyclop, of Pract. Med., art. Asthma), its frequent recurrence not merely aggravates the pathological states in which it has originated, but leads directly to the production of other diseases. " The most common of these," he says, " are em- physema ofthe lungs, dilatation of theheart, hydro- thorax, and other forms of dropsy. But," adds this well-informed physician, "if asthma is rarely fatal, it may be said to be almost as rarely cured, if this epithet is applied only to the entire and permanent removal of the disease. It is, however, frequently susceptible of great mitigation and retardation of the paroxysms."—Ed. 282 PNEUMATICA. [Cl. II.—Ord. II. •f 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 dis- ease, 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 removed by removing the primary disorder on which it is dependant.f [The ancients confounded, under the name of asthma, several varieties of dyspncea, arising from different organic diseases, and which they very incorrectly regarded as nervous affections. To Corvisart and RostanJ belong the merit of having thrown a great deal of light on those varieties, in particular, which depend upon or- ganic diseases of the heart and large blood- vessels.] Whether the suffocative tightness o{ the chest be the result of a spasmodic stricture of the bronchial vessels, spreading thence to the mus- cles of respiration, or produced by an infarction of these vessels from a superabundant effusion from their exhalants, is a question of a very different kind. Willis first started the former opinion, which has flowed in a regular current, or with little opposition, through Floyer, Hoffmann, and Cullen, to the present day. [Its possibility has lately received important corroboration from the anatomical researches of Reisseissen (F. D. Reisseissen Ucber den Bau der Lungen., Berl., 1822), who has Ascertained the existence of a set of completely circular fibre* around the bronchial ramifications, beginning at the point where the cartilaginous circles terminate. - Laennec (Op. cit., p. 408) has also verified the correctness of this observation upon branches of less than a line ia diameter; and he remarks that, althciugh it be difficult to follow the muscular fibres to a greater distance, analogy leads us to admit their existence, certainly in the smaller branches, and, perhaps, even in the air-cells. Adopting this view of the subject, he conceives that the spas- modic contraction bf these fibre* may take place in such a degree as to prevent the transmission of air to a great portion of the kings. It is also further maintained by Laennec, that the study of respiration, by means of auscultation, furnishes * On this part of the subject, what Willis has stated is put, as Dr. Forbes has rightly observed, in pithy terms:—"Asthmatics can bear nothing violent or unusuaL From excess of heat or cold, from any great bodily exertion, or mental emotion, from change of .season or weather, from errors, even of a sfight kind, in the non-naturals, and from a thousand things besides, they fall into fits of dyspnoea."—De Med. Op., p. 209.—*Ep. t Among the predisposing causes may be enu- merated hereditary transmission; malformation of the chest; small size of the glottis; excessive ir- ritability of the bronchial membrane; and all dis- eases which directly affect it, as catarrhs, bron- chitis, &c. But of all the predisposing causes of asthma, dyspepsy is the most frequent.—Ed. X L. Rostan, Mem. sur cette question: rasthme des vieillards est-d une affection nerveuse?— Paris, 1809. us, both in health and disease, with proofs of the lungs possessing an inherent power of action. This author is too intelligent, however, to refer asthma exclusively to the operation of any single uncombined cause.] Dr. Bree has lately pro- posed the second doctrine above specified, and supported it with great ingenuity and learning ; .illustrating and fortifying his views by numer- ous references to unquestionable facts, and the opinions of earlier writers. The same principle, or at least ft modification of it, has been adopted by Dr. Parry, who places the vascular turges- cence in the mucous membrane lining the bron- chial cells. Admitting the former hypothesis, the thoracic convulsion is a diseased action from the begin- ning, and under every degree and modification, and is so regarded by its advocates : while Dr. Bree only, allows it to be so when the convul- sive action is violent; contending that in its commencement it is altogether a remedial effort, an instinctive attempt to expel the serum or mucus that clogs the bronchial vessels. And he hence accounts for the pathognomonic wheez- ing, which he does not think the idea of a spas- modic stricture of these vessels is sufficient to explain; as also for the general inefficacy of opium and antispasmodics, to whatever extent they may be carried. I have already stated, that an excessive se- cretion from the exhalants of the bronchi* may be an exciting cause in many cases, and partic- ularly in a relaxed and debilitated conditio^ of the bronchial vessels in consequence of former attacks. But, notwithstanding the masterly man- ner 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 Floyer, that " the lungs do not appear to be much op- pressed 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 always very little, and sometimes no mucus whatever, excreted from the beginning to the end of the paroxysm. It may, indeed, be maintained, that the secretion is absorbed, but this is to beg the question, for we have no proofs of such an absorption. Tha 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 estahjish the fact in those particular cases. And even here we are left in total dark- ness, 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 foroed it into the vessels in which it has been found on dissection. How far the suffocative convulsion may originate in a spasm of the bronchiae, as contended for ky Dr. Cullen, we have no means of determining mani- festly. That it may exist, however, as well as a spasm of the alimentary canal, no one has been bold enough to deny ; that it must produce that strangling constriction or straitness which is a pathognomonic sign of asthma, where it does Gen. IV.—Spe. 1.] ASTHMA SICCUM. 283 exist, can be as little doubted ; and I find it ex- tremely difficult to ascribe the disease to any other state of the bronchiae, in all cases of dry or nervous asthma, in which, as there is little or no discharge from tha lungs, we have full ground for inferring, that there is little or no accumula- tion within them. " It is not, however, intend- ed," says Dr. Bree, " to deny the possible ex- istence of this spasm, but to object to it as a proximate cause ; and to state the imprudence of depending upon it as an important indication in practice."—{Inquiry, Sec, sect, vii., p. 106.) Yet it does not appear to me, that the practice suggested by the one opinion needs to be so much at variance with that suggested by the other, as this passage would seem to intimate. For, if acids prove a beneficial mode of treat- ment, and that benefit be ascribed by the uphold- er of the muculent hypothesis to the astringent power of the acid, by which the flow 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 irrita- bility, and allays all muscular irregularities. [Laennec (Op. cit., p. 405-407) has divided the form of asthma, in which no organic lesion is discoverable, info two kinds; in one, when the chest is examined with the stethoscope, the respiration is very sonorous, like that of chil- dren ; and hence he calls the disease asthma with puerUe respiration* In this instance, the patient constantly feels the want of a more ex- tensive respiration than what he enjoys. The dyspnoea is frequently very intense, and is some- times so aggravated by the slightest motion, that the patient is condemned to a life of inactivity.. Laennec ascribes the disease to the state of the nervous system. He has never met with this species of asthraa, except m persons affected witb chronic mucous catarrh. The other form of asthma noticed by Laennec as unconnected with organic disease, is what he names, with other writers, spasmodic asthma.] Dr. Bree's division of the disease is founded upon causes, rather than upon symptoms; and be has hence divided it into the four following species :—Firstly, those eases, being most nu- merous and common, which are produced by the irritation of effused serum in the lungs. Sec- * Dr JForbes has given the following explana- tion of what is revealed by the stethoscope, which "conveys scarcely any respiratory sound during inspiration, except an indistinct hollow sort of murmur, altogether unlike the usual respiratory sound, and so slight as to leave it doubtful if the impression conveyed to the ear is really a sound or vibration. Expiration, however, is distinctly marked over the greater part of the chest; not, indeed, by the sound of healthy respiration, but by a ioud, sibilant, or dry sonorous rhonchus, cor- responding with the loud sighing wheeze, audible by the naked ear. This rhonchus is often exactly like the sighing of wind through crevices; and sometimes the tone and key of the sound approach nearer those of a moan than a sigh. The sounds are perceptible during expiration over the whole chest, even in the extreme points of the lungs ; and equally so in patients, whose respiration is nearly inaudible in the intervals of the paroxysms." —Cyclop, of Pract. Med., art. Asthma.—Ed. ondly, those produced by the irritation of aerial acrimony in the lungs. Thirdly, those depend- ant on irritation in the stomach, or some of the abdominal viscera, and fourthly, those depend. ant upon habit. [The author of the present work has not ad- verted to the valuable writings of Laennec on this subject, who shows that the most common cause of dyspncea, when of sufficient severity to be termed asthma, is a dry catarrh inducing emphysema of the lungs, that is to say, a pre- ternatural dilatation of the air-cells. In some rare cases, where the progress of oedema of the lungs is very slowy asthmatic symptoms may also be produced. These morbid states have been amply verified by morbid anatomy.] As the definitions, under the present classifi- cation, are founded upon a principle of symp- tomatology rather than of etiology, it will not be. in my power to adopt Dr. Bree's 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 to limit the genus; and which will be wide enough to embrace his fourth, or those cases of the disease which, whatever be their sympto/ns, depend on an established habit: while the third species of Dr. Bree, comprising cases in which asthma is not an idiopathic af- fection, 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 affections included under it being alone to be remedied by remedying the primary disease on which it is dependant. 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 con- venient to contemplate the genus asthma, as comprising, and limited to, the two following species : I. Asthma Siccum. Dry Asthma. Nervous Asthma. 2. -------Humidum. Humid Asthma. Com- mon Asthma; SPECIES I. ASTHMA SICCUM. DRY ASTHMA. NERVOUS ASTHMA. PAROXYSM SUDDEN, VIOLENT, AND OF SHORT DURATION; CONSTRICTION HARD, DRY, SPAS- MODIC ; COUGH SLIGHT ; EXPECTORATION SCANTY, AND ONLY APPEARING TOWARDS THE CLOSE OF THE FIT. This is the proper convulsive or nervous asthma of Willis, Hoffmann, Floyer, and Aken- side. Its predisposing cause we are sometimes capable of developing; for we can trace the disease to a morbid structure of the chest, to an irritable condition of the bronchial vessels, or parenchyma of the lungs, produced by a pleuri- tis, or a succession of severe and protracted winter coughs, or to an hereditary source. Of the occasional causes, however, we are often in great ignorance ; and mostly so where the dis- ease appears in its simplest character, and to- 284 PNEUMATICA. [Cl. II.—Ord. II. tally unconnected with any other affection. In some instances, it evidently follows the sudden repulsion of cutaneous eruptions ; in others, the sudden cessation of oedematous swellings in the extremities of cachectic patients ; and, not unfrequently, the inhalation of deleterious ex- halations : most of which we have already no- ticed as occasional causes of dyspnoea, and dry or humid cough. So that it is probably a mere difference in the constitution or habit that ren- ders these causes capable of producing one of these diseases rather than another. And hence dry asthma, like the preceding, as thus diversi- fied by its occasional causes, may be contem- plated under the following varieties :— a Simplex. Simple nervous asthma. 0 Metastaticum. Repelled eruptions. y Phlegmaticum. A cachectic frame. 3 Vaporosum. Deleterious exhalations e Organicum. Organic misformation. Without any obvious cause1 or connexion with any other af- fection. From retropulsion of some cutaneous af- fection. From repelled oedema of the extremities in phlegmatic or ca- chectic habits, with a scanty secretion of urine. From inhaled fumes of metals, especially of lead and arsenic; of sulphur, charcoal, nitric acid, and oth- er deleterious or poisonous substan- ces. From organic de- rangement of the walls or contents of the chest. The first of these varieties constitutes the second species of Dr. Bree, who supposes the unknown and exciting cause to reside in some " subtile acrimony always present in the at- mosphere in a greater or less degree, and ready to be inspired."—(Inquiry, &c, p. 192.) It is at least difficult to disprove this opinion ; but, admitting the fact, we can make little use of it, and are nearly as muoh in the dark as ever. It is a position of far more general assent, that this modification of asthma is more likely to occur " in proportion as the habit is disposed to the condition called nervous."—(Op. cit., p. 191.) The paroxysm, indeed, frequently makes its attack under those circumstances, which are most apt to try the strings of a nervous temper- ament. A sudden emotion of the mind will give rise to it; an alteration of the wind, a change of residence, or a meal that disagrees with the stomach ; and often there is a consid- erable evacuation of pale urine : while on the contrary, as already observed, it more usually makes its attack without any one of these har- bingers, or any other that can be traced out. The small quantity of viscid mucus that is ex- creted through the whole of the struggle, proves evidently, that the inner membrane of the bron- chial vessels is in a state of peculiar dryness ; and leads us to conceive, that, at the onset, it was nearly or altogether destitute of its lubri- cating fluid. It is on this account that the cough and wheezing are both slight. [According to Laennec, an attack of purely nervous asthma is rarely fatal, and indeed is hardly ever so, without previously giving rise to congestions of blood, and other consequences of the disorder of the respiration and circula- tion induced by it: and, in these consequences, he observes, prejudiced minds may see the causes of the disease. He has met with many cases, however, in which it was impossible, after the most minute research, to find any organic lesion whatsoever, to which the asthma could be attributed. An instance of this is given by M. Andral in the case of a fatal suffocation, following the suppression of a discharge from an ulcerated leg.—(Clin. Mid., torn, ii., obs. 20.) M. Guersent records the cases of two children who died in a few days of a remitting dyspnoea, attended with dry cough and precordial anxiety, in whose bodies no obvious lesion could be found after death.—(Diet, de Med., torn, iii., p. 126.) Laennec is convinced that, in the greater num- ber of- asthmatic cases, depending on dry ca- tarrh and pulmonary emphysema, the asthmatic paroxysm can be induced equally by the super- vention of a fresh catarrh, and by a deranged state of the nervous influence, occasioning.pjil- monary spasm, or an increase of the necessity of respiration, and sometimes by both causes at once. He believes, in fact, that few cases are owing to any one of these causes ; and that, in old men particularly, several are frequently con- cerned. • Of this kind are debility ; ossification of the cartilages, and immobility of the ribs; rheumatism- affecting the walls of the chest; and, perhaps, also, the tenuity of the air-cells, and of all the pulmonary vessels in advanced life. With the exception of the different kinds of catarrh, the occasional causes of the attacks' of'asthma are almost always such as are calcu- lated to produce immediate and evident disturb- ance of the nerves ; a strong mental emotion ; venereal excesses ; the influence of light and darkness ; retrocession of gout; certain odours, such as those of tuberose, heliotrope, stored apples, &c. ; changes of the atmospheric elec- tricity, and other less appreciable conditions of the atmosphere. We find that the greater num- ber of asthmatic patients cannot remain with im- punity in a low, close apartment, although con- taining much more air than they could consume in twenty-four hours; and although it is con- stantly, but insensibly renewed by the doors and chimneys. Some cannot bear any person to go before them, or any thing to be brought close to them, without experiencing a sense of suffoca- tion ; while others are never more subject to dyspnoea than in the midst of a large plain.*] * See Laennec on Diseases of the Chest, &c, 2d edit., p. 412. Dr. Henderson notices a dis- order in India, exactly corresponding to our spas- modic asthma, and which appears to attack poor individuals, whom accident has deprived of their usual daily allowance of opium. The disorder Gen. IV.—Spe. 1.] ASTHMA SICCUM. 285 Cases of the species of asthma before us, and even of humid asthma, occurring upon a sudden disappearance of scabid, herpetic, and other cutaneous eruptions, are so com- mon, that it is hardly worth while to dwell upon them. They are especially noticed by Sir John Floyer, and have rarely escaped the attention of any pathologist since his day. And that this is an actual cause of the disease, is perfectly manifest from the subsidence of the latter as soon as such eruption has been re-excited. A sudden disappearance of gout in the hand or foot, or of an habitual discharge, as that of the hemorrhoidal vessels, has operated in the same manner, while a renewal of these affections has proved an equal remedy. But those of relaxed and phlegmatic habits are peculiarly affected by such transfers of morbid action, particularly when the feet and ankles are habitually oedematous, and accus- tomed to enlarge towards night. Chronic or exacerbating dyspncea is a frequent attendant upon such a state of corporeal debility ; and hence we have reason to expect asthma also : for further information upon which subject the reader may turn to what has already been ob- served under dyspncea chronica. It is not surprising that asthma should be produced by the inhaled fumes of metals. and other mineral substances, since we see it also frequently occasioned in constitutions prone to the complaint, by clouds of common smoke or dust. And Dr. Percival informs me that he has met with two cases in which slight apo- plexies were concomitants of asthma, produced by concentrated fumes of nitrous acid ; here again leading to the same train of causes we have already noticed, as laying a foundation for chronic dyspnoea. To this subdivision, also, belong such cases of asthma as proceed from fogs and mists, es- pecially those of populous and extensive towns, which many asthmatics are obliged to abandon, as soon as November makes its appearance, for a drier and less hazy atmosphere. The coats of the bronchiae seem to be constringed by the inhaled vapour ; and hence the suffocating feel- ing. Where, however, the internal tunic of the bronchiae is habitually dry and irritable, the moisture of such an atmosphere cools and softens the harsh membrane, and the patient longs for such a situation, instead of flying from it. And hence the reason why fogs are poisonous to some asthmatics, and healthy to others. It is also probable that the altered gravity of the atmosphere, in these cases, and the larger and smaller doses of oxygen inhaled in every inspiration, produce some influence that proves beneficial or injurious, according to the habit or actual state of the air-vessels. And hence again, while some asthmatics can only attacks them with such violence, that, unless a sufficient quantity of this narcotic be provided for them, they die in a few hours.—(Edinb. Med. and Surg. Journ.) This fact amounts to a convincing proof of the correctness of the term nervous asthma.—Ed. live in a mountainous situation, others find their only relief in lowlands and valleys. An impregnation of the atpiosphere with odorous essences, has also been found in a few cases of uncommon idiosyncrasy, or where the air-vessels have been peculiarly sensible, a suf- ficient cause of the asthmatic paroxysm ; which has hence been produced by the smell of musk, and in one instance, related by Timaeus, by that of roses.—(Cas. 216.) And, in consequence, it is not to be wondered at, that more pungent, and perhaps acuated corpuscles should produce a like effect. Dr. Scott, of Northumberland, has given cases of the greatest danger and ex- tremity, occasioned by accidentally inhaling the effluvia of ipecacuanha while pulverizing.— (Edin. Med. Comment., vol. iv., p. 75.) Another and a very frequent cause of both species of asthma, but more particularly the asthma siccum, is some organic derangement of the walls or contents of the chest. Gibbosity is one of the most common of the present group of causes. Lommius asserts, after Hippocrates (Aph. xlvi., sect. 6), that if a person become gibbous before puberty, in consequence of asthma, he bUes.—(Obs. Med., lib. ii., p. 146.) On which Dr. Bree has well observed, that the authors have here substituted cause for effect (Inquiry, &c, p. 24), since it is rather the gibbosity that produces the asthma, than the asthma that produces the gibbosity. An osse- ous, and consequently rigid condition of the cartilaginous extremities of the ribs and ster- num ; ossifications of the pericardium, the valves of the heart, or the coronary arteries ; pressure upon the lungs produced by a dropsy of the chest, or of the pericardium ; by an empyema ; by vomicae or indurated tumours of whatever kind in the substance of the lungs ; an inordi- nate magnitude of the lungs themselves ; have all been found occasional causes of asthma, and are among the most formidable to be attacked. Haller, Bonet, Morgagni, and others, who have been peculiarly attentive to structural diseases and their effects, have recorded numerous in- stances of this kind. And the later examina- tions of M. Rostan have added other morbid changes to those already noticed, in the heart indeed as well as in the lungs. In the first of these, he has very frequently found that partic- ular kind of thickening of the left ventricle of the heart, to which the French have given the name of active aneurism : and, in the second, besides the morbid lesions already noticed, ad- hesions between the lungs and the pleura ; ef- fusions of serum into the cavity of the chest; and a general change of structure in the lungs, giving them a semblance of the organ of the liver. Several of these appearances are most probably effects of the disease, though by M. Rostan uniformly regarded as causes. [It was strongly suspected by Laennec (Op. cit., p. 404), that in some rare instances of asthmatic dyspnoea, an imperfect paralysis of the diaphragm* and other muscles of inspiration * When asthma is combined with some material imperfection or disease of the organs of circula- 286 PNEUMAICA. [Cl. II.—Ord. II. was concerned. Rostan gives an instance of asthma connected with ossification of the di- aphragm.] The general treatment of this distressing affection is still a matter of discussion. A con- siderable distinction is necessary in the two species under which it makes its appearance ; and hence it will be more advantageous to defer the consideration of this subject, till we have noticed somewhat more at large the history of humid asthma, so that the plan proper for the one may stand in contrast with that proper for the other. SPECIES II. ASTHMA HUMIDUM. HUMID A S THMA. COMMON A S THMA. paroxysm gradual ; INGRAVESCENT, pro- tracted ; CONSTRICTION HEAVY, HUMID, LABORIOUS J COUGH SEVERE ; EXPECTORA- TION COMMENCING EARLY ; AT FIRST SCANTY AND VISCID, AFTERWARD COPIOUS, AND AF- FORDING GREAT RELIEF. This is the ordinary form under which the asthmatic paroxysm shows itself; and the trivial name of humid or humoral was given to it by earlier writers, most of them advocates of the humoral pathology, from an idea that an acrid humour was hereby discharged from the general mass of the blood, and consequently that the expuition was to be encouraged as much as possible ; the suffocative struggle being regarded as an instinctive or remedial effort of nature to restore the system to a state of health. Like the preceding species, it very generally appears without any obvious cause or connexion with any other affection. In some cases, how- ever, it seems to be the result of a plethora, or, as Dr. Cullen expresses himself, a " turgescence of the blood, or any other cause of an unusual fulness and distention of the vessels of the lungs."—(Pract. of Phys., part ii.,book iii., chap. vi., sect. 1384.) And sometimes, as in old age, or after long-continued and repeated catarrhs, it is produced by an excess of serum or mucus flowing inordinately from a weakened and re- laxed state of the bronchial exhalants or mucous glands : thus offering us three varieties as follow: a Simplex. Without any manifest Simple humid asthma. cause or combination with any other affec- tion. tion and respiration, it is often difficult to offer a positive opinion whether the latter circumstance is not consecutive, and gradually induced by the repeated attacks of the asthma. Then, we may also conceive that various morbid affections and organic diseases in asthma, are sometimes acci- dental attendants on it—not at all concerned with it either as a cause or an effect. Questions of this kind, as M. Jolly has well observed, are some- times involved in difficulties which have not yet been obviated by pathological anatomy.—(Diet, de Med. et de Chir. Pratiques, art. Asthme.) No doubt, in a vast number of examples, in by far the greater number of cases, asthma is only a symp- tomatic disorder.—Ed. 0 Plethoricum. From plethora. y Atonicum. From local atony. From plethora, or the suppression of some accustomed sanguin- eous evacuation. From a debilitated and relaxed condition of the excretories of the air-vessels, as a con- sequence of chronic and neglected ca- tarrhs, Or of old age. We also meet with examples of the humid as well as of the dry asthma, as a symptom or sequel of many other diseases : as gout, hypo- chondrias, hysteria, parabysma, and syphilis. I have already observed that the attack of the present species is more severe, as well as of longer duration than the preceding ; as though the patient were contending with two hostile forces instead of with one—a diminished diam- eter of the vessels, and infarction from a sur- plus of viscid mucus : and thus both the exciting causes co-operate, which have been contended for singly by the leaders 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 oc- curs as in the preceding species without any in- creased discharge of mucus, is unquestionable ; that it occurs with such increased discharge, is equally incontrovertible. But whatever be the source of the aggravated distress endured in humid asthma, after some hours of suffering the patient feels less anxiety, breathes more leisurely and with less labour, and, with a growing freedom of expectoration, acquires general relief and tranquillity. Yet such is the irritable state of the affected organs, that even on the second day " no change of posture is made with impunity, and particular distress affects him if he engage in the fatigue of dressing while the stomach is empty. During the day, if no particular hurry occur, the breath- ing becomes generally more free till the even- ing : an inexperienced asthmatic even flatters himself that his disease is leaving him ; but he finds at the approach of night that he must sus- tain a new attack. The paroxysm recommences with the usual symptoms, and the night is passed nearly as the former ; but the sleep is more per- fect, 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 expectorated mucus is more copious and digested ; strength of pulse and vigour of action increase ; and good-humour again enlivens the mind."—(Bree, Inquiry, &c, sect, iv., p. 48.) In treating asthma, our attention must be Gen. IV—Spe. 1. & 2.] ASTHMA. 287 directed to the paroxysm itself, and to the na- ture 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.* 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. Never- theless, bleeding demands a nice discrimination, and is rarely to be recommended in either spe- cies. The relief it affords, even in dry or con- vulsive asthma, is very temporary ; and Dr. Cullen allows that it cannot be persevered in without undermining the constitution, and lay- ing a foundation for dropsy. Dr. Bree regards it as a doubtful opera tion in the first species, or that, to adopt his own lan- guage, produced by aerial irritation, and as al- ways 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 dyspnoea remained in the intermission, than was common after former paroxysms. In old people, who have been long used to the disorder, it is certainly injurious."t Purging, beyond the intention of keeping the bowels regularly open, has seldom proved bene- ficial. When, indeed, the disease is secondary, and depends evidently upon an overloaded liver or 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 pow- erful alvine irritation will exacerbate the spasm of the chest, instead of diminishing it. * " The treatment of asthma, like that of all periodical diseases, consists of two parts; that proper in the paroxysm, and that in the interval."— (Forbes, in Cyclop, of Pract. Med., art. Asthma.) As the same physician justly observes, when the treatment of asthma is spoken of, that of its chronic forms is generally signified ; for what is called acute asthma is either a variety of bronchitis, or a violent congestion of the pulmonary mucous mem- brane, both cases requiring to be treated on prin- ciples applicable to such pathological states, with little regard to the spasm which complicates it. These are truths to which all practitioners must subscribe.—Ed. t Inquiry, &c, p. 245. According to Dr. Forbes (Cyclop, of Pract. Med.), it never puts an end to the paroxysm, much less does it cure the disease ; and its habitual employment, in an affection of frequent recurrence, cannot fail to be highly inju- rious. It is indicated in the early attacks of young and robust subjects; in cases of great general plethora ; in Tits of great violence, in which the pulmonary circulation is much impeded, and the brain, or other important organs, are likely to suf- fer in consequence.—Ed. In exciting nausea or vomiting, however, we may be less cautious ; for each has been found highly advantageous in both species of idio- pathic asthma. The first, by diminishing gen- erally 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. [This practice has the sanction of Riverius, Akenside, Sir John Floyer, and Laennec, who says, that it acts on the nervous system, and is often followed by an immediate alleviation of the paroxysm.*] Blistering may also be made use of, but, like setons or issues, can only be of ulterior advan- tage, for the fit must be of far more than ordi- nary length if it continue till the blister has produced vesication. It may, however, go far to prevent or shorten a relapse on the ensuing night ; and especially when the disease is con- nected with an asthmatic habit. Sir John Floyer is said, during his residence at Lichfield, to have found great benefit in his own case by the use of very strong coffee. And the practice was afterward followed by Sir John Pringle, as he informs us, with equal success. " On reading the section on coffee, 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 without milk or sugar." Sedatives and antispasmodics, given alone, have rarely been attended with any decisive advantage. They have occasionally afforded relief in the first species, but have had little effect in the second; and, by heating the sys- tem unnecessarily, have often augmented and prolonged the paroxysm. Dr. Bree, in relating his own case, which was that of humid asthma, tells us, that, in the access of a paroxysm, he took four grains of solid opium, which produced nearly an apoplectic stupor for two days. A few hours after trying the opium, 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 headache and a * Laennec on Diseases of the Chest, &c, p. 418, 2d edit. Dr. Forbes approves Of a dose of ipecacuanha when the paroxysm supervenes to a full meal, or occurs in a person having an habit- ually sluggish and loaded stomach; but he does not consider emetics generally useful. (Cyclop. of Pract. Med.) Akenside's practice consisted in giving 9j. of ipecacuanha in the paroxysm to In- duce vomiting, which, he assures us, gave great relief; and, in the intervals, he gave gr. v. every morning, or gr. x. every alternate morning, these doses proving equally useful, whether they ex- cited vomiting or merely nausea.—Med. Trans., vol. i. 288 PNEUMATICA. [Cl. II.—Ord. II. countenance more turgid than usual; the pulse being at first strong and quick, and afterward sinking into great weakness. The paroxysm showed itself four hours earlier than usual the next day. He tried it in smaller doses during several subsequent fits, but in no instance without great general mischief, and witfi little or no local benefit.* Much of this deleterious effect may have de- pended on idiosyncrasy. Sedatives and nar- cotics, if employed at all, should be combined with diaphoretics. In this form, they often prove a very powerful remedy : and one of the best preparations of this kind is the compound powder of ipecacuanha. A universal glow and diapnoe, as it has been called, or breathing moisture on the surface, are among the most favourable symptoms of the disease, under whatever form it makes its appearance. Anti- spasmodics and narcotics, as musk, castor, valerian, cardamine, camphire, and the fetid gums, may, perhaps, be employed successfully when the disease is chiefly dependant upon a morbid habit ; but even here they will derive a great advantage from a union with diaphoretics, as the neutral salts, and small doses of ipecac- uanha, or antimonial powder. The hyoscyamus has often succeeded, as a narcotic, where opium has failed: but, like the latter, it should not be trusted to by itself in either species of the complaint. [Laennec conceives, that narcotics may act, not merely by lessening the necessity of respi- ration, but also by overcoming the spasm of the lungs. The following, he says, have been par- ticularly approved of: opium, belladonna, phel- landrium aquaticum, aconitum, napellus, colchi- cum, tobacco smoked or taken internally, cicuta, dulcamara, hyoscyamus, and the smoking of stramonium. The cases in which he particu- larly recommends narcotics, are those seem- ingly attended with an extraordinary necessity for respiration, and a spasm of the lungs. Besides narcotics, certain substances which act powerfully on the stomach, or nervous sys- tem, have been tried, as the distilled water of lauro-cerasus, the nux vomica, tincture of can- tharides, the arsenical solution, and the prussic acid. Laennec found the laurel-cherry water and diluted prussic acid ease the breathing, though less certainly than narcotics. The- same, he says, is true of the nitric, sulphuric, and acetic ethers.—(Op. cit., p. 416, 417.) With respect to the lobelia inflata, so much commended in America (Eberle's Mat. Med,, Philadel., 1822 ; Dr. Andrew, Glasgoio Journ., vol. i.), Dr. Forbes has found it temporarily * Many cases of asthma being connected with a state of the bronchial membrane, analogous to inflammation, do not seem likely to admit of ben- efit from narcotics. Hence, Dr. Forbes is of opin- ion, that it is only in cases of pure nervous asthma, or in those symptomatic dyspnoeas, simulating asthma, which depend on organic disease of the heart, &c, that opium and other narcotics and antispasmodics are at all likely to prove useful. In the hysteric asthma, the good effects of opium were long ago recognised by Willis.—See Cyclop. of Pract. Med., art. Asthma.—Ed. successful in certain spurious cases, produced by hydrothorax and disease of the heart; and even in the catarrhal asthma, he has known it check the paroxysm, if given at the commence- ment of the attack ; yet he estimates its claim to efficacy below that of stramonium. Where the urine is small in quantity, and of a pale hue, and particularly where the disease is connected with a pituitous or phlegmatic habit, diuretics have been found serviceable. Dr. Ferriar combined them with opium. 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 dependance as the expectorants, when ju- diciously selected and administered. In every kind of idiopathic asthma, these may be em- ployed with advantage. Among the fetid gums which have been em- ployed for this purpose, ammoniac has acquired the greatest degree of popularity: but, its power is inferior to that of asafoetida, the vir- tue of which is to be judged of by the de- gree of its offensive odour. Both these, how- ever, 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 consid- erable degree of irritability and much quick- ness of pulse, we may prefer several of the oleraceous, and especially the mucilaginous demulcents : but oily demulcents are always to be avoided. Of all the medicines, however, which act on the excernents of the lungs, the squill is 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 intes- tinal canal, and to attemper it with opium or some other guard, if it produce much influence in either of these ways ; except, indeed, in the case of asthma connected with the phlegmatic habit, which is the only modification of the dis- ease in which this collateral influence is found to be of advantage. Squills have also a pecu- liar 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 humid asthma, we are not to discontinue it on this account, but only to mod- erate its use. Many practitioners, indeed, em- ploy it directly as an emetic medicine, and pre- fer it to ipecacuanha. In asthma it may, in some habits, be allowed to supersede it; but in no other disease that I recollect ; for it is rougher in its action, and more offensive in its taste. Where, however, the lungs seem to be af- fected only secondarily, and the source of the disease lies in an infarcted and torpid state of the liver or some other abdominal organ, squills, and indeed expectorants in general, GfiN. IV.—Spe.1 &2.] ASTHMA. 289 will be found less serviceable, than in idiopathic cases. And hence we should prefer the seneka- root, which has often been found of great suc- cess^ after calomel, or whatever other cathartic may be judged most proper, has been pre- viously made use of. Seneka-root, indeed, is in itself a sort of general evacuant ; for while it increases very largely the discharge of mu- cus, 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 benefit in many cases of both species of asthma, but, with whose mode of action we are so little acquainted, that it has been explained on very different principles by different pathologists ; I mean the acids, both mineral and vegetable. These principles we have not room to examine ; nor is it necessary ; since, if they be really beneficial, it is of little moment whether they act as sedatives in allay- ing irritation, or as tonics in invigorating the relaxed bronchial exhalants. The vegetable seem more efficacious than the mineral acids, probably because, in consequence of their be- ing less corrosive, the patient can take them in larger quantity; and the vegetable acids ob- tained by fermentation, seem more useful than the native. Yet these have rarely been given alone ; for, by uniting them with diaphoretics, as small doses of ipecacuanha, or with narcotics, the remedial power of each has been augmented ; and the latter are not only rendered more effi- cacious, but are borne with less mischief after- ward. 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 humid asthma, after emetics, he prescribes a draught composed of an ounce of distilled vinegar, and from one to three grains of ipecacuanha, in a sufficient quantity of pure water, to be taken every four hours, as a means of determining to the surface of the body, and of promoting absorption and exhalation. And as a means of taking off irri- tation and exciting the secernents of the bron- chiae, 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 henbane with six minims of the acid and ten of tincture of squills in the form of a draught, and repeat- ing it every three or four hours during the par- oxysm. And he tells us that " Many patients, who had taken the most powerful antispas- modics, have assured me, that none had been so useful; and two gentlemen now under my direction inform me, that it is the only medi- cine that has ever given them relief in the par- oxysms."—(Inquiry, &c., p. 285.) I cannot say that I have found it thus pre-eminently ser- viceable ; but it has often been of decided benefit. And I know of no medicine that suc- Vol. I.—T ceeds so well in preventing the mischievous effects of opium, and even in adding to its se- dative power ; or that is so valuable an adjunct in almost all antispasmodic preparations, and especially where ether, camphire, and other terebinthinates are employed ; or that tends so effectually to take off" all excess of pungency from the more heating expectorants. As 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 be- tween the intervals, has much more to be said in its favour. Dr. Bree tried it in his own per- son, but did not obtain success. His was a case of humid asthma. But in the first species, and particularly where habit has given inveter- acy to the recurrence of the paroxysms, and where the general constitution is vigorous, there is no single remedy likely to be of more value. [In Dr. Wilson Philip's " Inquiry into the Laws of the Vital Functions," will be found various observations, tending to prove the util- ity of galvanism in one form of asthma.] Wherever asthma may be supposed to be dependant upon plethora, tonics can have no claim to be employed till after such a condi- tion has been removed; and then, perhaps, the best medicine will be the mineral acids. [When the asthmatic paroxysms have a strongly-marked periodical character, cinchona, according to Laennec, frequently diminishes their severity, and sometimes stops them altogether.] Peruvian bark is often found to overload the stomach, especially in dyspeptic patients, with whom I have found columbo agree better, occa- sionally combined with carbonate of soda.* But the best tonics are the metallic oxydes, [and of these the subcarbonate of iron, given in doses from a scruple to a drachm, is praised by Dr. Bree and Laennec. The latter speaks particularly of its benefit in pallid relaxed habits, and both in the dry asthma and the nervous.— (On Diseases of the Chest, &c, p. 418.)] Inhalations cannot well be tried during the paroxysms, but they have been very generally had recourse to in the intervals, and have con- sisted of very different vapours. When pneu- matic medicine was at the height of its popu- larity, much benefit was supposed to be derived from the use of oxygen and hydrogen, and dilute chlorine gases. Dr. Beddoes was pecu- liarly 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 * Dr. Forbes believes that bark possesses no specific powers in checking the return of the com- mon asthmatic paroxysm; but, that it occasion- ally acts beneficially in two classes of cases; first, when the asthma is complicated with ague ; and secondly, when the stomach or general system is in a state in which a tonic of this kind is bene- ficial.—Ed. 290 PNEUMATICA. [Cl. II—Ord. II to be cured in this manner hi the present day ; oxygen gas is now rarely adverted to by asth- matics or their medical attendants ; and the remedy, from having been extolled beyond its proper level, has fallen back into an unmerited disregard. Dr. Ferriar has spoken in more sober terms of the benefit of hydrogen in the first species ; and I 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 recovery to this remedy, rather than to other means he had been employing at the same time. Warm aromatic fumes have been also tried ; as prophylactics, obtained from various sub- stances. The smoking of tobacco has very extensively been recommended ; the leaves of the scandix odorala 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 a nar- cotic power, and whatever benefit they produce is hence, perhaps, chiefly derived ; but either this narcotic power, or the stimulating power with which it is so intimately united, has at times been found to bring on a difficulty of swallowing. Another process has lately been adopted in France, but of the issue of which we have not yet received any satisfactory information. It consists in a revival of the impregnated aqueous injections of Stephen Hales (Hamostatics, ii., 74, 75), with a view of determining how far such impregnating materials may reach the lungs and be thrown off by the bronchial exha- lants. Magendie (Physiologie, torn, ii., p. 291) and Nysten have been chiefly engaged in these researches, and they have ascertained that alco- hol, ether, camphire, and most of the other vol- atile antispasmodics, together with the gases, are in this manner conveyed to the lungs, and transpire from the surface of their air-cells. Issues, setons, and even cauteries, have been long in repute as useful drains or revellents ; and under this character, are highly successful in the relief of asthma. And where the disease has appeared upon a sudden check of the cuta- neous eruption, or a sudden cessation of any habitual evacuation, I can unite in this recom- mendation of Macbride (Med. Observ. and Inq., vol. vi., art. ii.) and Reidlin.—(Lin. Med., 1695, p. 91.) 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 espe- cially, has for this purpose been very generally employed in France, under the name of icorce de Garou.—(Essai sur V Usage et les Effels de I'Ecorce de Garou, par M. Archange le Noi, Paris, 1767.) 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 dis- tance 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 irri- tated the rectum by small doses of aloetic ca- thartics. The issue discharged copiously for six weeks, during which time the patient con- tinued free from all attack : I then suffered it to heal slowly, still continuing the -aloes ; and about a month afterward was informed, that the habitual discharge had returned. She had no paroxysm after this for upwards of two years. Pontifex relates a case, in which a corpulent asthmatic patient, who suffered severely from frequent fits of this disease, was accidentally infected with the itch. As the eruption ex- tended, 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 eruption was hereby repelled ; but he was immediately attacked with an asthmatic fit, which returned twice within the space of a month. M. Pontifex advised him to have re- course to his former cure, by using the bed- clothes of one infected with the itch. This advice he followed ; a few days after which the scabid eruption made its appearance, when he was again perfectly liberated from his asthma.* The diet should be light and cordial, without being stimulant, and the food be of a solid, rather than of a liquid kind. All flatulent fruits and vegetables should be avoided ; but oranges, the alliaceous esculents, and the aromata may be allowed in moderation. Hot liquors should be sedulously abstained from ; and the beverage consist chiefly of coffee, ginger-tea, and acidu- lated waters. Where asthma is dependant upon some pri- mary affection of another kind, it can only be effectually treated by removing, or palliating, the original disorder.! * Recueil d'Obs. de Mefiecine des Hopitaux Militaires, par M. Richard de Hautesierck,, &c, torn, ii., 4to., Paris, 1774. t The most recent pathological views of this disorder sustain the opinion that its dominant cause is often an emphysematous condition of the lungs. In regard to the treatment of this disease, regard must always be paid to the doctrines of plethora. Several American writers, as Thatcher, Eberle, and others, agree as to the value of the datura stramonium in lessening the violence of th* paroxysms of asthma. Very lately, an ointment, made from veratria, has been used with great suc- cess against neuralgic irritation and spasmodic distress, and in controlling difficult respiration, accompanied with cough : clinical results may- prove veratria to be efficacious in the treatment of asthma.—See Turnbull, on the External Appli- cation of Veratria. As asthma appears in parox- ysms, much may be done in the way of prevent- ing its attacks. For this purpose, cold bathing and cold affusions, and a strict attention to diet, will be found very beneficial. Finally, in many - cases, where remedies are of hUle avail, a change of air and scene will often relieve the patient.—D. Gun. V.] EPHL GENUS V. EPHIALTES. INCUBUS. SIGHING, SUFFOCATIVE ANHELATION, WITH IN- TERCEPTED UTTERANCE, AND A SENSE OF SOME EXTERNAL WEIGHT PRESSING HEAVILY ON THE CHEST ; TRANSITORY. Ephialtes, incubus, nightmare, which are the common names in Greek, Latin, and Eng- lish, for the present genus of diseases, though not exactly of the same meaning, import a sudden sense of an oppressive and suffocative weight on the chest, threatening strangulation, and rendering the person attacked incapable of changing his position. Ephialtes, from ld\- \op.ai, signifies " to leap upon ;" incubus, from incubo, " to lie upon ;" and the term mare, in our compound nightmare, imbodies the looser idea contained in the Greek and Latin denom- inations, and signifies a hag, goblin, demon, er 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 suf- ficiently expressed in the foregoing definition. If the generic definition be correct, as I trust it is, there can be no doubt that ephialtes be- longs to, or should be ranged inclose connexion with, the family of anhelations, under which it was usually classed by the earlier writers ; and, indeed, continued to be so till the time of Dr. Cullen, who has strangely removed it to that of vesania, 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 consti- tution ; particularly among those who are pre- disposed to hypochondrias or low spirits. Oth- ers, 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 fa- tigue 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 is to be ascribed, for the most part, to the actual state of the stomach, or the sensorium, or both :—more generally, in- deed, 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 respi- ration should be thus singularly affected by the state of the stomach and the sensorium, and T 2 LTES. 291 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 dysp- noea, should mostly recur under similar cir- cumstances, 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 instantly 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 healthful digestion, the ordinary action of the stomach is equal to its own demand: but the moment it labours under any degree of de- bility, or, in consequence of its being overloaded, or loaded with indigestible materials, its ordi- nary action is not sufficient, it becomes neces- sary 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. 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; every organ contributing its proportion, and among others, the lungs. And if this demand, on the part of a feeble or overloaded stomach, should occur in a system, in which the general weakness of the respiratory organs is considerable ; 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, more- over, it should be exhibited during sleep, in which the will itself, and most, sometimes in- deed all, of the faculties of the mind are in a state of suspension, from a cause I shall here- after have occasion to explain ; almost every thing will co-operate to impede respiration, to lower the tone of the respiratory muscles, and consequently to excite in them irregular and spasmodic action ; in one word, to lay a found- ation for all the symptoms which characterize ephialtes : the mind, sympathetically disturbed and hurried in the midst of sleep, imaging to itself, at the moment, from the terrible sensa- tion induced, as terrible a cause for its produc- tion, 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. Now, in revery, the will, as indeed all the faculties of the mind^may be as abstracted du- ring the day, as they are suspended in sleep duringthe night: and from the peculiar strength and vivacity of the train of ideas or mental emo- tions that constitute the revery, the same sud- den exhaustion may take place, and the same inordinate demand upon the common stock of sensorial power, distributed throughout the sys- tem 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 292 PNEUMATICA. [Cl. II.—Ord. II. 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 re- cumbent 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. [Although the fore- going hypothesis, respecting the cause of incu- bus, displays much ingenuity, the editor need scarcely observe, that what is stated amounts to nothing more than conjecture, liable to the very same objections which have subverted most other theories on the subject. Were it true, hardly any dyspeptic person with weak lungs, who eats too freely, could ever escape an attack of nightmare after going to bed. Yet this is quite repugnant to common expe- rience. The disorder has sometimes been im- agined to proceed from a stagnation of the blood in the sinuses of the brain, or in the ves- sels of the lungs, or from too great a determi- nation of blood to the head. The horizontal posture during sleep, and the pressure of the stomach upon the aorta in a supine position, have been fancied to be sufficient to produce an unusual distention of the vessels of the brain ; while, by others, the weight of the heart pres- sing on the left auricle and large pulmonary veins, has been suspected to produce the op- pression and sense of weight and suffocation in the breast.—(See Bond, on Incubus, 1753.) As Dr. Whytt has observed (On Nervous Disorders, chap. 6), however, if these opinions were true, every person that lies upon his back, especially after a full meal, ought to suffer a degree of nightmare. Dr. Bateman considered it prob- able, that the seat of nightmare was chiefly in the stomach. The sympathy of this organ with the head, heart, lungs, and diaphragm, he says, is so- remarkable, that there can be no difficulty in referring the several symptoms of incubus to a disagreeable irritation of the nerves of the stomach. A heavy or flatulent supper undoubt- edly aggravates the nightmare in persons pre- disposed to it. Persons are mostly attacked while lying upon their back, because in this position the viscera make greater pressure on the diaphragm, and inspiration is less easy. The nightmare takes place only in sleep, be- cause the strange ideas excited in the mind, in consequence of the disordered feelings of the stomach, are not then corrected by the exter- nal senses ; nor do we then, by an increased respiration, or other motions of the body, en- deavour to shake off any beginning uneasiness about the stomach or breast. The nightmare generally occurs in the first sleep, and seldom towards the morning, because at the earlier period the stomach is more loaded with food, and digestion is less advanced. It may be re- marked, however, that neither a horizontal pos- ture, sleep, nor heavy suppers ever produce the nightmare, at least, in any considerable degree, unless the person be already predisposed to the complaint by the particular condition of the nerves of the stomach. As far as practical considerations are concerned, there may not be any very important difference between our au- thor's views and those of Drs. Whytt and Bate- man, since he represents the imposition of too much work on the stomach as the exciting cause. And it is only in his rationale, that he lets his imagination take a random flight. With respect to his hypothesis of the cause of the daymare, it may be noticed, that the case which he has inserted as an illustration of it, could not be connected with revery or abstrac- tion of the mind, as it always took place sud- denly, and at regular periods. Be this as it may, our author describes the two following species of the affection :] 1. Ephialtes Vigilantium. Daymare. 2.--------Nocturnus. Nightmare. SPECIES I. EPHIALTES VIGILANTIUM. DAYMARE. PRODUCED DURING WAKEFULNESS ; THE PRES- SURE SEVERE, AND EXTENDING OVER THE AB- DOMEN J RESPIRATION FREQUENT, LABORIOUS, CONSTRICTED ; EYES FIXED ; SIGHING DEEF AND VIOLENT ; INTELLECT UNDISTURBED. This species is less frequently described by pathological writers than the ephialtes of the night season. Rhodius (Cent i., observ. 54.) however, Forestus (Lib. x., obs. 52), and Sau- vages (Class v., ord. i., Anhelaliones Spasmo- dica, gen. i.), have distinctly marked it ; and a striking example of it occurred some years ago in my own practice. Forestus gives a case that returned periodi- cally 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 difficulty 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 meantime, 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. This case seems to be founded upon a highly irritable or spastic diathesis, and makes some approach towards ecstasis and catalepsy ; but, with that intolerable weight on the chest which peculiarly marks ephialtes. No exciting cause is stated. A predisposing cause I have already hinted at, and shall briefly advert to the treat- ment under the ensuing species. SPECIES II. EPHIALTES NOCTURNUS. NIGHTMARE. PRODUCED DURING SLEEP, AND INTERRUPTING IT WITH VIOLENT STRUGGLE AND TREMOR: I THE PRESSURE ON THE CHEST SEEMING T» Gen. VI.—Spe. 1.] STERNALGIA AMBULANTIUM. 293 BE THAT OF SOME HIDEOUS MONSTER, OR PHANTOM. The sensation is said to be frequently pre- ceded by some fearful dream, as that of an im- placable enemy, known or unknown, in close pursuit of the dreamer, from whose grasp he feels incapable of escaping; or of exposure to some overwhelming danger by sea or land, as that of falling from a steep precipice ; or struggling, amid the ruins of a shipwreck, with rocks and breakers that threaten to dash him to pieces every moment. This I believe is often the case ; and particularly when the state of the brain, rather than that of the stomach, forms the exciting cause. The attack, however, appears to be sometimes slighter, and unaccompanied with such fearful scenes of desperate adventure, or the ma- chinery of hideous and appalling demons or monsters ; for Fortis gives the case of a young woman, who, during the paroxysm, supposed herself to be pressed upon by a man who was very far from being disagreeable to her; yet awoke from this imaginary concubinage with the usual sense of oppression, the voice and breath interrupted, great anxiety, and the face covered with sweat.—(Sauv. Nosol., Meth. i., 631.) And similar cases, according to Craanen, Heurnius, and Forestus, have occurred to men as well as to women. While we are told by Pliny, that the oppression, in his day, was as- cribed to the sports of fauns, an idea rather pleasing than hateful to the imagination; and that the disease was hence denominated faun- gambols, ludibria fauni. The treatment may be stated in a few words. The mind and body should be kept free from all undue fatigue and commotion, and the diet be light, especially towards the evening. The action of the bowels should be kept regular ; and, perhaps, as Dr. Darwin recommends, a mattress or harder bed than usual should be used, and an alarum clock hung up in the room, so that the sleep may be interrupted at short intervals. [The patient should sleep with his head raised on high pillows, and lie on his side. If the functions of the stomach be much dis- ordered, the directions already given for the re- lief of dyspepsy and other affections of this organ should be followed.] These plans will supersede the use of the feeble medicines which were formerly in vogue for the cure of nightmare, as saffron and peony, and will ren- der superfluous all further inquiry into a subject which once exercised the pen of the learned, whether the latter was or was net a specific in the form of an amulet. GENUS VI. STERNALGIA. SUFFOCATIVE BREAST-PANG. VIOLENT PAIN ABOUT THE STERNUM, EXTENDING TOWARDS THE ARMS ; ANXIETY, DIFFICULTY OF BREATHING, AND SENSE OF SUFFOCATION. This disease is described by modern writers under the names of angina pectoris, syncope anginosa, asthma dolorificum or arthriticum, orthopncea cardiaca, and various others of a similar import, that clearly discover its relation- ship to the genera which have just passed in review before us. It has characters, however, sufficiently marked to separate it from all of them, and particularly from those under which it has hitherto been ranked as a species or sub- division. And I have, in consequence, been under the necessity of giving it a new denomi- nation, as well as of assigning it a new place.: and hence the above name of sternalgia (STEPNAAriA); a compound importing " pain about the sternum," which is a striking pathog- nomonic symptom, if not the leading feature of the affection. It is here it differs essentially from syncope and asthma, neither of which terms, therefore, ought to have been appropri- ated to it; while it has still less connexion with angina, in its common sense of quinsy, although this is the name by which, from the time of Dr. Heberden, it has been most frequently denomi- nated. M. Brera, an Italian physician of deserved eminence, but whose work (Delia Sternocardia, Verona, 1810) the author was unacquainted with till after the first edition of the present, has entitled it sternocardia, and M. Portal has preferred this term to angina pectoris. Its chief objection is a derivation from two distinct organs, as the seat of disease. The genus offers us two species :— 1. Sternalgia Ambulan- Acute Breast-pang. tium. 2. ---------Chronica. Chronic Breast-pang. SPECIES I. STERNALGIA AMBULANTIUM. ACUTE BREAST-PANG. SUPERVENING SUDDENLY DURING EXERCISER WITH TENDENCY TO SYNCOPE : RELIEVED BY REST. It is singular that there is no description which will fairly apply to this genus under either of its species, in any of the writings of the Greek, Roman, or Arabian authors that have descended to us. Some few passages have been quoted as possibly referring to it; but, on examination, they will be found too general for the purpose, or evidently intended for some other affection. Such particularly is the asthma pneumodes of Aretaeus, referred to by Swediaur, who has distinguished the disease in his Nosology by the name of pnigophobia. And hence, considering the minuteness with which many of the writers thus adverted to have followed up all the morbid affections of the hu- man frame, and the accuracy with which they have described them, the most reasonable con- clusion is, that, like rickets and several other diseases, it was not known to them, or, in other words, was not in existence. The first glances at it which we are any- where capable of tracing, are to be met with oc- casionally in the works of Morgagni (see espe- cially Epist. xxiii., art. 8, 9), and somewhat 294 PNEUJ more distinctly in the Consultationes Medica of Hoffmann. Dr. Letherland has followed up the inquiry with a curious spirit of research in the Edinburgh Medical Commentaries (vol. iii., p. 180), and has quoted a passage from the works of Poter, which renders it highly probable that this writer was well acquainted with, at least, the first species of the genus, and was aware of its being often fatal. Poter's description of the disease is as follows :—" Respirandi difficul- tas quae per intervalla deambulantibus incidit; sic ut plurimum derepente moriuntur."—(Po- terii Op., Cent. 3, No. 22.) But it is to the late Dr. Heberden that we are indebted for the first full and perspicuous account of sternalgia, or, as he calls it, angina pectoris.—(See Med. Trans:, vols. ii. and iii.) Dr. Cullen has not noticed the complaint, either in his Nosology or in his First Lines ; but he has entered it with the unsatisfactory name of angina pectoris in his " Catalogue of Omitted Diseases." It has, however, been minutely described and well illustrated, both historically and practically, by many modern writers of established reputa- tion, as Dr. Fothergill, Dr. Duncan, Dr. Perci- val, Dr. Darwin, Dr. Macbride, Dr. Hamilton, Dr. Haygarth, and Dr. Parry, most of whom have accompanied their descriptions with a spec- ulative inquiry into the causes of the complaint. Sternalgia rarely attacks the young, or those who are under five-and-forty or fifty years of age. Persons' with short necks, inclined to corpulence, or of a gouty temperament, and es- pecially when indulging a sedative life, are pe- culiarly predisposed to it. The form it first assumes is commonly that of the present spe- cies, by far the most severe, and, as Poter correctly observes, the most frequently fatal: for when the constitution has been for some time habituated to the paroxysms, though it often becomes greatly debilitated by them, and the paroxysms themselves increase in duration, it passes through the attack with less violence and immediate danger. The incipient assault is usually felt while the patient is walking, and especially if he happen to be walking soon after eating, or during the process of digestion. He complains of a new and painful sensation in his breast, spreading up to his arms. At first, perhaps, this extends no farther than to the insertion of the deltoid mus- cle, and more commonly on the left side than on the right; but it soon winds its way to the elbow, wrist, and fingers' ends. In this incipi- ent state, he sometimes loses the pain suddenly and entirely by merely standing still. Yet it rarely continues more than from half an hour to an hour, even under its most severe assault, and where it proves fatal. There is sometimes connected with it a strong feeling of flatulence at the stomach, with momentary ease on eruc- tation. The face, moreover, is often pale, and the body bathed in perspiration. Whatever exercise the person is engaged in when the paroxysm attacks him, he feels that a perseverance in it would produce a total suspen- sion of living power ; and hence, if he be walk- ATICA. x ' [Cl.II—Ord. II. ing, and especially against the wind, he turns from the wind and stands still; when, if the complaint be slight, and in its infancy, it soon vanishes. In one instance, a patient thus attacked,,and who was distinguished for great firmness of mind, had the resolution to continue walking, and found the pain go off after it had affected him from five to ten minutes.—(Parry, Trea- tise on Angina Pectoris.) If, by a like degree of courageous effort, the patient, in struggling for breath, be able to overcome the constriction, he will continue able through the remainder of the fit to make a deep inspiration, though ac- companied perhaps with sighing and some diffi- culty of expiring his breath. In other instances, however, an equal degree of firmness has been exerted in vain. In most cases, the pulse, during this contest, varies but little, yet it is sometimes quickened, and sometimes intermits ; while, in a few instances, the heart palpitates considerably, though less so than in the chronic species. A habit of return is soon induced after a few fits have paved the way ; and when this is effected, the action of walking is not necessary for its production, for it will sometimes be brought on by the most trivial circumstances, as coughing, swallowing, going to stool, or a slight disturbance of the mind. And, in this case, the first species becomes converted into the second. " One," says Dr. Heberden (Med. Trans., vol. ii., p. 61), "has told me that this complaint was greatest in winter ; another, that it was aggravated by warm weather ; in the rest, the seasons were not suspected of making any difference." The pulse is not only little affected, as already observed, during the par- oxysm, but even in the intervals ; being, for the most part, only a little quickened, and seldom exceeding eighty strokes in a minute ; in one instance, even where the semilunar valves of the heart were afterward found ossified, and the ossification had extended to the aorta itself, the pulse, though small, never exhibited irregu- larity.—(Med. Trans., vol. iii., p. 16.) Yet, in a few instances, I have found it not only irreg- ular, but intermittent; and intermittent for some weeks after the paroxysm had ceased to return. In others, it has been strong and vibratory. The cause is very obscure, and the more so as the disease has often been found in persons labouring under different sorts of structural de- rangement about the heart, or in one or more of the organs of respiration, to which it has been ascribed, as soon as such derangements have been discovered ; while, in other cases, nothing of the kind seems to have existed. Thus, the cartilaginous portions of the ribs have sometimes appeared ossified on examination after death ; sometimes the semilunar valves of the heart; and sometimes the coronary arteries : and hence Dr. Wall (Med. Trans., vol. iii., art. ii.) has ascribed the disease to the first or second of these morbid changes, and Drs. Heb- erden and Parry to the third (Treatise on the Syncope Anginosa, commonly called Angina Pectoris), who have been followed by Burns Gen. VI —Spe. 1.] STERNALGIA AMBULANTIUM. 295 and' Kreysig. Dr. Cuming found the heart itself double its natural size, with some kind of morbid change in several of the surrounding organs.—(Case of Diseased Heart, &c, Dublin Reports, vol. iii.) Dr. Haygarth, on one occa- sion, found the mediastinum in a state of sup- purative inflammation, and has hence regarded this as the cause {Med. Trans., vol. iii., art. vi.); while, as the pericardium has sometimes evinced concretions of blood, Dr. Hooper and others have referred the disease to this affection.— (Mem. of the Med. Soc. of Lond., vol. i., p. 19, 21.) Dr. Hosack conceives (Americ. Med. and Phil. Regist., vol. ii., p. 366), "that it most frequently arises from a plethoric state of the bloodvessels, more especially from a dispropor- tionate accumulation of blood in the heart and large vessels ;" an opinion more in accordance with the observation of Dr. John Forbes than any of the others.—(See note in transl. of La- ennec on Diseases of the Chest, 2d edit., p. 692.) Dr. Darwin mentions it as a sort of asthma, producing a cramp of a peculiar kind in the diaphragm, or the other muscles of respiration ; while a very large number of pathologists, among whom may be mentioned Eisner (Ab- handlung iiber die Brustbrdnne, Konigsburg), Benger (Algem, Deutsche Bibl., xxxvi., p. 125), Dr. Butter (Treatise on the Disease commonly called Angina Pectoris, London, 1791), and Dr. Macqueen (London Medical Journal, vol. v.), have endeavoured to account for it as a partic- ular species of gout: and hence Dr. Berger attacked it with gum guaiacum, which, in his paper upon this subject in the Copenhagen Transactions, he asserts to have been particu- larly serviceable. Dr. Latham has, in various instances, found it in persons who, possessed of sound chests and apparently untainted con- stitutions {Med. Trans., vol. iv., art. xvi.), were affected with enlargements of the abdominal viscera, or other diseases seated in these or- gans.* That there is a violent and painful constric- tion of some of the muscles about the sternum during the existence of the paroxysm, and that respiration is hence greatly impeded, is unques- tionable ; and that many of the above misfor- mations of structure, or constitutional habits, may occasion a predisposition to sternalgia, is highly probable ; but they give us little or no information concerning the cause that immedi- * Dr. John Warren, of Boston, states (New- England Journal, vol. i., p. 11) that angina pec- toris may probably be the effect of an incapacity of the heart to empty itself of blood (forced into it in an accelerated circulation) sufficiently fast to maintain the vital functions. Prof. Chapman, of Philadelphia, remarks, " that the disease is a spe- cies of neuralgia, we are entirely persuaded, com- mencing, for the most part, in the pneumogastric nerve, and spreading in different directions as other nerves may become involved. That it is, in many instances at least, derived from irregular gout, which, misplaced thus, operates as an irritant to the nerves, and probably first to those of the stomach, seems highly probable."—See Hays' Cy- cloped. of Pract. Med. and Surgery, Art. Angina Pectoris.—D. ately produces it; while it is by no means un- likely, that several of these morbid changes, thus brought forward as causes, are themselves only effects of so laborious and perilous a strug- gle. And hence we cannot, I am afraid, in our present defective knowledge of the physiology of the disease, do more than adopt the modest opinion of Dr. Bergius and Dr. Heberden, and regard it as dependant upon a cause that has not yet been traced out, but which does not seem to originate necessarily in any structural derangement of the organs affected. The variable state of the pulse, and the oc- casional palpitation of the heart, are best ac- counted for by supposing some such structural disease as we have just seen occasionally ex- ists there. Yet even these symptoms may de- pend upon the habit or idiosyncrasy, and ap- pear to have occurred, in a few instances, in which dissection has discovered no such mani- fest local cause. So far as I have witnessed the disease, it has commenced in the respira- tory muscles with a suffocative struggle, and tense constrictive pain : and it has not been till a minute or two afterward, and where the spastic action has extended in different direc- tions, that the pulse has varied, or palpitation ensued : as though the primary seat of dis- ease was in these muscles, and the heart was only affected secondarily. [Laennec considers angina pectoris as a va- riety of neuralgia of the heart. The doctrine of the disease being always the effect of some organic affection of this viscus, he says, is far from being correct. He has known many indi- viduals, who suffered a few very severe but short attacks of it, and then had. no further re- turn of it. On the other hand, he admits, that it frequently accompanies organic, diseases of the heart. He has examined several subjects, whose cases were attended either with hyper- trophy, or dilatation of the heart; but in none of these instances were the coronary arteries ossi- fied. Andral relates a case, in which, after death, no appreciable morbid change was de- tected in the heart, but there were tubercles in the lungs. He takes the opportunity to ob- serve, that the suspicion of angina pectoris being dependant upon an ossified state of the coronary arteries, is destitute of proof; and the disorder is set down by him as an impairment of, what he calls, the innervation of the heart, —(Andral, Pricis d'Anat. Pathol., torn, ii., p. 345.) Laennec conceives (Op. cit., p. 690), that the site of the disorder may vary. When there is pain both in the heart and lungs, the affection may be chiefly situated in the pneumo- gastric nerve ; when there is merely a sense of stricture in the heart, the disorder may be in the nervous filaments, which the heart re- ceives from the great sympathetic nerve. Other nerves are also simultaneously affected by sympathy, or direct anastomosis.] When the real nature of the disease is thus doubtful, and its causes thus obscure or varia- v. ble, its best mode of treatment must be equally uncertain ; and though I willingly join with Dr. Heberden in thinking, that we ought not to 296 PNEUMATICA. [Cl. II.-Ord II. despair of finding a cure, I am afraid we have not yet found it. Where the temperament is plethoric, or the heart is evidently implicated in the affection, bleeding will often afford some relief. But, in the simplest cases of the complaint, where the pulse is little disturbed, and the heart without palpitation, the use of the lancet has proved injurious, rather than beneficial; and purging has been of as little avail. Antispasmodics and cordials, and especially wine, palliate the symp- toms for a few minutes, but afterward lose their virtue. The mode of treatment which I have found most successful consists in putting the patient immediately in an inclined, rather than a re- cumbent position, with his head raised high. He should instantly take an emetic of what- ever may be given most expeditiously, though the antimonial preparations form the best medi- cine for this purpose, as producing a longer action. As soon as the patient rejects, he may be allowed a little warm water, administered to him sparingly. The diaphoresis, hereby in- duced, should be assisted by a moderate warmth of bedclothes, and particularly by placing the patient between blankets ; and, if the constric- tive pain or difficulty of respiration still outlast the sickness, opium, intermixed with ether, camphire, or other diffusible antispasmodics, should be employed pretty freely. And I may here observe, as a general rule, that, where the common forms of opium, as the extract, wine, or tincture, are found to affect the head, the Lancashire or Cheshire preparation of it, known by the name of black drop, which is a solution of this drug, in verjuice, with, appa- rently, 'some portion of rectified spirit, and, certainly, a liberal combination of aromatics, seems to have less tendency to excite nausea and headache afterward : and, from its being nearly double the strength of the ordinary laudanum, may be used in a much smaller quantity. Mr. Batley's well-known form will also, in many cases, succeed as well.* But it is in the intervals of the fits that med- ical skill and ingenuity are likely to be most effi- cacious. If we find the complaint connected, as it often is, with a morbid diathesis of any kind, as that of gout, with' the sudden suppres- sion of any habitual discharge, as that of the hemorrhoidal vessels, or a chronic affection of any other organ, as the heart, the stomach, or the liver, our attention must be immediately directed to what may thus prove a predisposing cause, which we must endeavour to palliate or remove, according to the nature of the cause we may be fortunate enough to detect. The bowels, in the meantime, must be kept gently open, and a freedom from relapse be secured at night for a week or a fortnight by an opiate pill, or the extract of henbane. As the disease is greatly dependant upon a morbid mobility and weakness of the muscular * At the present time we should commonly prefer the acetate or muriate of morphia; prepa- rations of opium freed from narcotine.—Ed. I fibres, either general or local, a tonic course of medicine and regimen should be instantly com- menced, and unswervingly persevered in. The diet should be light ; all flatulent foods and drinks be cautiously avoided ; the hours be early, and the exercise indulged in be of the gentlest kind. Arsenic, in small doses, is said to have been tried with advantage (Alexander, Med. Comm., Edinb., vol. v., p. 99); but I know nothing of its effects from my own practice; and should prefer the oxydes of many other metals, and particularly those of bismuth, copper, and iron, as more likely to afford a permanent and radi- cal cure. Sir Gilbert Blane has briefly noted a case, in which the disease yielded to arsenic in combination with digitalis and mercury.— (Medico-Chir. Trans., vol. iv. p. 136.) Where the complaint is strictly idiopathic and uncombined, it has often been found to give way to some local irritation or vicarious drain. A sudden flow of blood from the anus has com- pletely removed it. An ichorous or serous dis- charge from the same organ has proved equally successful; as has also an obstinate gleet. And it is hence not to be wondered at, that setons or issues should have been productive of equal service. The latter are to be preferred as the least troublesome ; one should be opened in each thigh, and each incision should be large enough to contain two peas ; which it would be better at first to make of the mezereon bark, as already recommended for the same purpose in asthma. [The prussic or hydrocyanic acid, prepared according to Scheele's formula, and given du- ring the paroxysm, has sometimes proved rap- idly successful; and this, probably, from its power of augmenting action, while it diminishes irritability. Laennec has a high opinion of the usefulness of magnetism, with leeches, blisters to the fore- part of the chest, the cherry-laurel infusion, digitalis, or the fetid gums ; a mild regimen, and the warm or cold bath, according to the season of the year.] SPECIES II. STERNALGIA CHRONICA. CHRONIC BREAST-PANG. THE PAROXYSMS LESS VIOLENT, BUT OF LONG- ER CONTINUANCE ; RECURRING FREQUENTLY WITH GREAT PALPITATION OF THE HEART, EXCITED BY SLIGHT AND OFTEN UNKNOWN CAUSES, AND NOT RELIEVED BY REST. From the observations which have been thrown out at some length in treating of ephial- tes and asthma, it is not to be wondered at that sternalgia should in many habits, where it has once taken a hold, be peculiarly disposed to recur when the body is recumbent, and par- ticularly during sleep : nor even that, in some idiosyncrasies, it should, like the two complaints just alluded to, often originate in such a state of body. If, however, the first attacks do not prove fatal, the disease is often apt to become chronic; Gen. VII.-Spe. 1.] ' PLEURALGIA ACUTA. 297 and to exhibit the symptoms that characterize the present species. The attack is now not only more easily brought on, but requires a longer period of time for its removal. Rest, even if it commence during exercise, has little or no effect, and the paroxysm has at times been protracted not only for some hours, but even for several days, without remission, and occasionally with a considerable degree of dan- ger 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, we meet with far more instances of palpitation of the heart and irregular pulse than in the preceding : and not unfrequently these catenating symptoms become more mani- fest and distressing as the disease becomes more inveterate ; as though the morbid state of the 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 of Medical Cases occurring in his private practice, as contradistinguished , from the diary of his public duty as physi- cian to St. Thomas'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 dis- tress of breathing for five years, and the pulse fluctuated from 20 to 32, never falling below the former, nor exceeding the latter. Nothing gave material relief. Leave was not obtained to open the body after death."* Dr. Fother- gill, in like manner, asserts, not only that the pulse, in his practice, has been irregular and intermitting during the exacerbations, but that it has continued irregular, and even intermit- tent, when the patient has been free from pain and at rest. * Med.-Chir. Trans., vol. iv., p. 136. The late Mr. Robert Bligh, who was attended by Dr. Pinckard and the editor, was attacked in bed nearly every night, for some months previous to his death, with such pain about the heart, palpitations, and difficulty of respiration, that he was always obliged to get up immediately, and walk about, to prevent suffocation. His pulse was generally between 28 and 36, regular and strong, but with a vibratory motion in it. One afternoon he fell down dead. The editor examined his body, assisted by Mr. Hooper, of the London Road. The auriculo-ven- tricular opening of the left side of the heart, and the mitral valves, were much thickened. The lungs were healthy, with the exception of some adhesions to the inside of the chest. In the right bag of the pleura, about a pint of bloody serum was discovered. The liver was prodigiously en- larged, hardened, and of a dark purple ink colour. In the gall-bladder there were about twenty cal- culi ; and, in the left kidney, a good deal of gravel. Experience certainly does not at present justify the inference, that angina pectoris is a distinct disorder, depending upon any determinate series of morbid appearances ; though, in opposition to the conclusion of Laennec and Andral, it may be safely asserted, that it is undoubtedly, in many instances, not simply a functional disorder of the nerves of the heart, but actually connected with or- ganic disease, as exemplified by dissections.—Ed. 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 INFLAMMA- TION. The! last genus of diseases which occurs un- der the present order, is that which has been usually denominated pleuTodyne, for which pleu- ralgia 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 has been given to the former. On a nice and critical examination, it would not be difficult to point out a shade of difference between iXyos and b&ivn, but no such critical distinction has been ever attended to by professional writers, and, as terminations to medical compounds, they are used converti- bly, or as direct synonymes.—(See the Author's Prelim. Dissert, to his Nosology, p. 59.) The difficulty of breathing, noticed in the generic definition, depends altogether upon the acute ache produced by every attempt to inflate the lungs; and though negative characters ought to be avoided as much as possible, both in generic and specific definitions, it is necessary in the present instance to add, " without fever or inflammation ;" since this is the chief feature by which pleuralgia, or " stich in the pleura" is distinguished from " pleuritis, or inflammation 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 country. There are two species, how- ever, that have a fair claim to be regarded as strictly idiopathic. They do not often, indeed, constitute 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 form- ing a distinct genus of the complaints before us ; and Macbride is more to be commended in following his example than Cullen in departing from it. The two species are as follow;— I. Pleuralgia Acuta. Stitch. 2.---------Chronica. Chronic pain in the side, SPECIES I. PLEURALGIA ACUTA. STITCH PAIN SUDDEN AND TEMPORARY : SUPERVENING ON MUSCULAR EXERCISE : BELIEVED BY PRES- SURE. This species is found most frequent among 298 PNEUMATICA. [Cl. II.—Ord. II. boys, who are engaged in any violent exertion, and particularly in hard running. It is pro- duced by too great and sudden a distention of the fine bloodvessels of the pleura, from undue propulsion of the blood. It is relieved by a handkerchief, or any other tight bandage. It gradually subsides on rest, or even slackening the pace. When this is not the case, bleeding and other evacuants are in- stantly necessary ; together with warm relaxing liniments, and anodyne fomentations. It is from this forcible distention of the mi- nute vessels of the pleura that Van Swieten, Sauvages, and Macbride distinguish this species by the name of pleurodyne a spasmate ; thus making a distinction between spasma and spas- mus ; and understanding by the former, that voluntary stretching or straining which takes place in any vehement exertion, contraction, or extension of a muscle, as in striving, bearing heavy burdens, or running. In the language of M. de Sauvages (Nosol. Method., Cl. v., Ord. ii., Gen. xi), " Spasma non est spasmus, sed distractio, divulsio, qualis accidere solet a ve- hement musculi nisu, contractione, extensione ; ut inter luctandum, onera gestanda, currendum." This species is occasionally met with as a symptom in flatulence, hysteria, and hypochon- drias : in all these eases, however, though the disease or symptoms are the same, the exciting cause is very different. There is here evidently a nervous or irritable temperament, and a ten- dency to spastic action. [With regard to the hypothesis of stitch de- pending upon an immoderate propulsion of the blood into the vessels of the pleura, it seems to be unsupported by any kind of evidence ; nor is the editor aware that mere distention of blood- vessels will in any other instance satisfactorily account for an att ck of acute pain. The stitch, which is so common to young persons in their active sports, is generally a pain fixed nearly to a point either within one of the hypochondria, or under the false ribs, and is too circumscribed to admit of being explained by the supposed im- moderate distention of the bloodvessels of the pleura, even if such distention could account for the sudden pain.] SPECIES II. PLEURALGIA CHRONICA. CHRONIC PAIN IN THE SIDE. PAIN PERMANENT : AUGMENTED BY PRESSURE : INABILITY OF LYING ON THE SIDE AFFECTED. This species is more diffused than the first, and accompanied with a considerable degree of irritation ; whence pressure, instead of dimin- ishing, augments the pain. The cause is there- fore of a different kind from any of those already noticed, and is perhaps most frequently 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 ceaseless tendency to irritation, is kept up. This species has also often been produced by a fractured rib, or some other lesion of the chest; or by some internal malformation, or other structural disease in the organs of the same cavity. Dr. Percival, 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. Chronic pleuralgia may also,follow from an inflammation of the pleura ; or from transferred gout or rheumatism. It is peculiarly apt to take place under every disease, which, by lower- ing the tone of the system, renders it generally irritable and subject to irregularity of action; as is the case in worms, syphilis, and phthisis. The opposite extreme of plethora has, more- over, not unfrequently been found to produce it. Most of these, however, may be regarded as mere symptomatic affections. Among the gen- uine 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, which still more frequently occurs, and is productive of far severer effects, by the absurd, though fashiona- ble use of tight stays, which, while; they under- mine the health, generally coop up and distort the chest into a shape equally ungraceful and unnatural. This barbarous custom cannot be too strongly inveighed against: for though the imprisoned young female may, by-dint of habit, and where little exercise or exertion is required, be able to obtain a sort of triumph over the primary mischief of adhesions hereby produced, yet may she pave the way for an obstinate cough, phthisis, and lateral curvature 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. In attempting either to cure or to palliate the present species of pleuralgia, we must direct our eye as nearly as possible to its cause. If the affection be symptomatic, we must combat the original disease. If idiopathic, bleeding from the arm will generally be found requisite, and freely, if we suspect plethora ; but locally by cupping or leeches, if it be from the mis- chievous habit of dress we have just reprobated, and the constitution, as is mostly the case, be relaxed and delicate. Here also dry cupping has been frequently found serviceable. Under all circumstances, a loose dress should be in- sisted upon. Blistering will often afford relief, and the discharge should be rendered perma- nent ; but a seton or an issue will generally suc- ceed better than a blister. Electricity by draw- ing sparks, has also proved frequently of use. [Laennec's opinion of magnetism has been noticed under the first species, where the other remedies in which he confides are also briefly mentioned.] Quiet rather than exercise is de- manded, and the ablest course of internal med- icines will be that which is best calculated to take off irritating and irregular action, as baric, valerian, snake-root, conium, and the various preparations of the hop. CLASS III. H^MATICA. ' DISEASES OF THE SANGUINEOUS FUNCTION. ORDER I. PYRECTICA. FEVERS. " II. PHLOGOTICA. INFLAMMATIONS. « III. EXANTHEMATICA. ERUPTIVE FEVERS. " IV. DYSTHETICA. CACHEXIES. CLASS III. PHYSIOLOGICAL PROEM. In treating of the very important and exten- sive range of diseases included under the pres- ent class, let us first take a brief survey of the sanguineous function, which is the immediate theatre of their operation, and the means and instruments by which it is maintained. This comprehensive subject maybe most con- veniently discussed under the three following divisions :— I. The Machinery of the Sanguineous System. II. Its Moving powers. III. The Nature of the Fluid Conveyed. I. The importance of the blood to the gen- eral health of the animal system, and its exist- ence in every part of almost every organ, have been known in every country in which medicine has been studied, from the first dawn of its cul- tivation. It is not necessary to retrace the wild and idle hypotheses, that were started in ancient times to account for the means by which this universal flaid travels from one part to another, and appears in every quarter. It is enough to observe, that till the great and transcendent doc- trine of the circulation of the blood was com- pletely established, the acutest physiologists wandered about in darkness and uncertainty, seldom satisfying themselves, and still more rarely the world around them. The opinion, indeed, of a circulation of the blood through the system, was loosely started by various writers, even of very-early times; but, under every modification, it was found to be accompanied with so many difficulties, as always to be dropped almost as soon as it was revived, and rarely, till the middle of the seventeenth century, to show itself to any effective purpose. Hippocrates guessed at it; Aristotle assented to it; Servetus, or Servede, who was burnt as a heretic in 1553, imperfectly taught it by point- ing out the smaller circulation, or that through the lungs ; and our own illustrious countryman, Harvey, about a century afterward, gave a fin- ish to the inquiry, by establishing the larger cir- culation, or that over the whole frame.* The principal proofs of a circulation of the blood offered by Harvey, and those, indeed, on which we chiefly rely in the present day, are deduced from the disposition of the valves at the origin of the two great arteries ; from the mechan- ism of the valves in the veins ; and from the arrangement of those of the heart; from the possibility of draining an animal of its blood by opening either an artery or a vein; from the range of the arteries and the veins, and from what occurs when either the arteries or veins are opened, compressed, tied, or injected. All the valvular contrivances, to which a reference * Dr. J. R. Coxe, of Philadelphia, has lately ex- amined Harvey's claims, with a view to show that instead of discovering the circulation ofthe blood, he merely " attached more firmly the cementing links of an extensive chain which time had rusted, and possibly, also, has added slightly to its more full perfection." Dr. Coxe supports his views by numerous quotations, from authors existing prior to Harvey, which evince much learned research.— See his Inquiry into the Claims of Dr. Wm, Har- vey to the Discovery of the Circulation of the Blood, &c, Philadelphia, 1834—D. 300 PHYSIOLOGICAL PROEM. [Cl. Ill has been made, prevent the blood from taking any other course than what the present doctrine of the circulation inculcates. If we open an arte- ry, the blood that jets from the puncture flows in a direction from the heart: and in a direction to the heart if we open a vein. A compression or liga- ture upon an artery, puts a stop to the blood that flows from above the ligature ; but the same upon a vein puts a stop to the blood from below it, in which direction the vein immediately be- comes distended. In like, manner, an acid liquor, injected into the veins, coagulates the blood in the direction towards tbe heart, proving that the venous blood is everywhere travelling in this course. While an examination by the microscope of the vessels of the half-transparent textures of frogs, and other cold-blooded animals, confirms the view laid open by these phenomena, and shows to us a continual flow of the blood from the heart into the arteries, thence into the veins, and thence to the heart again ; thus com- pleting the circular career. The arteries, therefore, generally speaking, terminate in veins; but by no means the whole of them, for many are exhalant or secretory, and terminate on the surface of membranes and other organs by minute orifices ; which no microscope, however, has yet discovered, but whose exist- ence we have every reason to believe, as we perceive a perpetual oozing of fluids, whose flow we cannot otherwise account for, into all the cavities of the body ; which keeps their surfaces moist, and makes motion easy. While, accord- ing to M. Magendie, whose experiments, how- ever, seem to want confirmation, other minute arteries terminate in lymphatics, which he makes as much a part of the sanguiferous system as the veins ; the lymphatics conveying the more atten- uate part of the arterial blood, slightly tinged of an opaline or rose-coloured hue, though some- times of a madder-red ; such as the fluid which oozes upon puncturing the lymphatics, or the thoracic duct, after a long fast. It is not neces- sary to examine into the correctness of this hypothesis in the present place, as we shall have occasion to notice it more at large when treating of the excernent system, which will be found to embrace both the absorbent and secretory ves- sels. It should be remarked, however, that, in M. Magendie's hypothesis, the veins, and not the lymphatics, are the absorbents of the body. ■—(Pricis Elimentaire de Physiologie, torn, ii.) Omitting then, for the present, the consider- ation of the lymphatics, the machinery, by which the circulation of the blood is principally effect- ed, consists of the heart itself, the arteries, and the veins. The heart, in the more perfect classes of ani- mals, as mammals, birds, and most, though not all, amphibials, is a very compound organ; for in all these the blood, when received from the veins, is first sent from this central organ to the lungs to be duly aerated, or, according to Mr. Ellis's hypothesis, to be unloaded of its excess of carbon, and is afterward returned from the lungs to the same organ before its general cir- culation over the system commences. These classes, therefore, are said to possess a double circulation. And as the heart itself consists of four cavities, a pair, composing what is called an auricle and a ventricle, belonging to each of the two circulations; and as each of these pairs is divided from the other by a partition, these classes are also said to have not only a double circulation, but a double heart; a pulmonary and corporeal circulation and a pulmonary and corporeal heart. [The division of the circulation into two parts, the great aortic, systemic, or corporeal, and the less, or pulmonary one, has generally been adopt- ed since the time of the illustrious Harvey. Bichat conceived, however, that a division, founded on another principle, was preferable for the purpose of illustrating the objects of the blood's motion. The blood in one portion of its course is remarkable for its bright scarlet hue; in another, for its dark colour. In the first, it is flowing from the lungs to all parts of the body; in the second, it is returning from these parts to the lungs. The first is Bichat's circulation of red blood ; the second, his circula- tion of black blood (Anat. Gin., torn, ii.); a dis- tinction, that at once gives a prompt introduc- tion to the knowledge of the purposes of the circulation.] The heart, in which the chief impelling power of the two vascular systems resides, is situated in the chest, between the lungs, and upon the diaphragm, by all the motions of which it is in- fluenced. [The texture of the heart is fleshy, but very dense and compact, consisting of pack- ets of fibres, more or less oblique, and variously contorted. The lesser ventricle, which has to propel the blood to a much greater distance than the right, is more fleshy and strong than the latter, which has merely to send the blood through the lesser or pulmonary circulation. When the chest and pericardium are opened in a living animal, the heart may be seen beating; the action of the auricles and ventricles alterna- ting ; that is to say, the two auricles contract together, and then the two ventricles. When the stethoscope is applied to the region of the heart, the distinct sounds of the action of the ventricles and auricles may be heard. At the instant when the pulse is perceptible in the arte- ries, a dull sound is audible, and directly after- ward a clearer sound, similar to the noise of a valve. The former arises from the action ofthe ventricles ; the latter from that of the auricles.* * See Laennec, Traite de l'Auscultation, &c, torn, ii., p. 403, edit. 2. Some experiments made by Dr. Stokes and Mr. Hart, and of which an ac- count is given in the Edin. Med. and Surgical Journal for October, 1830, p. 269, led them to con- clude that Laennec was mistaken in his opinions respecting the impulse of the heart. " It is not, as he states, produced during the systole, but dur- ing the diastole of the ventricle. In point of fact, the pulse in the extremities, and the impulse of the heart, arise from one and the same cause ; in the artery from its diastole, and, in the ventricular por- tion of the heart, from the same cause. This ex- plains satisfactorily the want of coincidence be- tween the impulse of the heart and the pulse at the wrist."—(Op. cit., p. 271.) The observations of the same experimenters lead to the following Cl. III.] PHYSIOLOGI The blood is returned from the greater circu- lation by the two large ven* cavae into the right auricle. At the same moment, it is poured into the left auricle from the pulmonary circulation by the four pulmonary veins. The auricles be- ing thus filled with blood, contract, when the blood, partly thrown back into the veins, produ- ces by its reflux from the right auricle, a pulse, sometimes visible in the internal jugular veins of thin persons (Magendie's Physiology by Mil- ligan, p. 360 ; and Mayo's Outlines, p. 67), but the main part of it is propelled into the right ventricle. The auricles then become relaxed, and the ventricles act, and drive back into the auricles such blood as happens to be situated behind the tricuspid and mitral valves, the valves placed at the communications between the auri- cles and ventricles, while the rest is thrown by the right ventricle into the pulmonary artery, and by the left into the aorta. All regurgita- tion from these two great trunks is now impeded by the operation of the semilunar valves, placed at their commencement.] The heart is loosely surrounded by a dense and fibrous membrane, named from its situation, pericardium, possessing little sensibility, closely connected with the diaphragm, and reflected over the heart and its large vessels. Physiolo- gists commonly represent its use to be that of confining the heart in its proper post; and of lubricating it, in its state of unceasing activity, with a peculiar fluid, denominated liquor peri- cardii, secreted from the capillary arteries of its internal surface. In a state of health, this fluid is small in quantity and of a reddish hue, some portion of the red parts of the blood being inter- mixed with it; but, in a morbid state of the membrane, it is apt to accumulate, change its properties, and lay a foundation for various complaints.—(See Boslock's Elem. System of Physiology, vol. i., p. 363, 8vo., 1824.) [With respect to the considerable effect im- puted to the pericardium in regulating the mo- tions of the heart, and preventing this organ from leaping out of its place, as the expression is, one or two facts, brought to light by dissection, have materially weakened, if not quite subverted the hypothesis. A few instances have occured of the heart being found without any pericardium whatever, or any device to answer its purpose. Dr. Baillie has recorded a singular instance of this in a man, aged about forty, who died of an accidental complaint, without seeming to have suffered from the deficiency.—(See Baillie's results :—1. That, in a state of health, the impulse of the heart precedes that ofthe arteries. 2. That the interval between the impulse of the heart and the pulse in the arteries is in the direct ratio of the distance of the vessels from the centre of the circulation. 3. The pulsations of arteries in differ- ent parts, but at equal distances from the heart, are synchronous. 4. The greater the distance, the longer will be the interval. 5. That, although the actual pulsations depend on the-systole of the left ventricle, yet the diastole of the vessels does not occur synchronously in all parts of the body, but is progressive. In the production of the sounds of the heart, as audible with the stethoscope, Dr. Stokes and Mr. Hart consider that two causes are [CAL PROEM. 301 Works by Wardrop, vol. i., p. 44.) Many ex- amples are met with, where the bag of the peri- cardium and its reflected layer on the heart are completely adherent together, without any particular effect on the action of the latter viscus. A similar case to that in Dr. Baillie's works, is reported by M. Littre.—(Hist, de I'Acad. des Sciences, 1712, p. 37.) The circumstances which have most influence in fixing this organ, are, its situation between the two lungs, which enclose it nearly on every side ; and its connex- ion with the large bloodvessels. When, as an able physiologist has observed, we take into consideration the relative impor- tance of the heart and brain, as far as regards mere animal existence, we shall be.led to de- cide in favour of the former. In incubation, as the immortal Harvey pointed out, a beating point, a " punctum saliens," as he expresses it, which is the rudiment of the future heart, pre- cedes the formation of other parts of the body, and is visible for some time before any trace of the brain can be distinguished. Acephalous foetuses have been known to attain their full size in the womb, and even to have lived for a short time after birth, and then died from not being able to effect those changes, which are incidentally necessary to an existence of any duration. For example, a regular supply of nutritious matter is essential to the support of life ; this can only be supplied by the introduc- tion of food into the stomach by the act of de- glutition ; but this act, at least in the higher animals, cannot be performed without the inter- vention of the nervous system.—(See Bostock's Physiology, vol. i., p. 335.) The sides of arteries are divisible into sev- eral strata of dissimilar substances, techni- cally named coats or tunics. Mascagni, like the older anatomists who preceded him, repre- sents both the arteries and veins as having four coats (Prodromo, pp. 61-64); but, his external one (ascitizia) is merely the cellular membrane that connects the vessels to the adjoining parts. —(K. A. Rudolphi, Elem. of Physiol., vol. i.r p. 90.) According to Rudolphi, and the gen- erality of modern anatomists, all vessels have at least two coats, and the arteries three. Some writers, indeed, reckon only two proper arterial coats, and describe every arterial tube, exceeding one line in diameter, as visibly com- posed of one adventitious and two essential substances.—(See Edinb. Med. Journ., vol. xviii., p. 258.) The three arterial coats are concerned. If, as they endeavour to show, Laen- nec's first sound, or that coinciding with the im- pulse, be produced during the diastole of the ven- ticle, it must be produced by this cause, and the contrac- tion of the auricle. To the production of the sec- ond, on the other hand, attributed by Laennec to the contraction of the auricles, the contraction of the auricles and the dilatation of the ventricles appear neces- sary. With respect to the phrase diastole ofthe ves- sels, employed by Dr. Stokes and Mr. Hart, it would perhaps have been better to have substitu- ted the term pulsation, as the experiments of Dr. Parry tend to prove, that there is no true dilatation or diastole in the arteries accompanying the pulse as will be presently noticed. 302 PHYSIOLOGICAL PROEM. ' [Cl. III. now generally called external, middle, and in- ternal; denominations adopted by Dr. Jones, in his excellent work on hemorrhage ; or elas- tic, muscular, or fibrous, and membranous. By Bichat, the latter tunic was styled the common membrane of the system of red blood, as it is not restricted to the arteries, but extends over the inner surface of the left ventricle and auri- cle of the heart, and lines the pulmonary veins, and, in short, the whole track of the scarlet blood. In examining arteries, one of the first things observable is, that the sides of the large arte- ries are thick and elastic, so that, when these vessels are transversely divided, the section pre- sents a regularly circular aperture.—(Haller, Elem. Physiol., torn, i., p. 37.) Elasticity is rather obscure in the greater number of the textures of the animal body, a more prevalent feature of which is softness ; yet it is very con- spicuous in the arteries, and one thing that particularly marks their difference from veins, keeping their sides apart, even when they are empty. In fact, the arteries and some cartila- ginous passages, like the windpipe, and the meatus auditorius of the foetus, are the only tubes which are sufficiently elastic to remain open of themselves. It is to the elasticity of the arterial parietes that must be ascribed the sudden return of their naturally pervious condi- tion, after their cavity has been momentarily effaced by compression, and the quickness with which an artery that has been bent straightens itself again. According to Bichat, this prop- erty is also manifestly concerned in the sort of locomotion which the arteries undergo from the influx of blood into them. If a tortuous arte- rial trunk be exposed in a living animal, the whole of it will be seen to rise up at each pul- sation, quit its place, and straighten itself. As soon as an anatomical injection is thrown into the vessels of a very thin, diminutive subject, a locomotion of all the tortuous branches of the face becomes perceptible through the integu- ments. If the arteries had not a firm, elastic texture, they could not thus yield to the impulse communicated to them. The abdominal branch- es of the vena porta?, having no valves, may be injected like the arteries ; but nothing re- sembling the above locomotion, is observable when the fluid is impelled into them. Bichat frequently made arterial blood circulate in veins by means of curved pipes, adapted to the ves- sels of a living animal; for instance, to the carotid and external jugular vein ; yet, though a kind of pulsation, synchronous with that of the heart,—an evident rustling,—could be felt in the veins, thus injected with arterial blood, no real locomotion was discernible.—(Bichat, Anat. Gin., torn, i., p. 289.) The internal coat of the arteries, though ex- tremely thin, and even semitransparent, is very close in its texture, endued with little elasticity (Hunter on the'Blood, p. 117), and gives to those vessels their smooth polished lining. It does not exhibit the dun yellow colour of the middle coat; nor has it any fibrous appearance, being everywhere perfectly level and slippery.— (Soemmerring, De Corp. Hum. Fab., torn, v., p. 57.) According to the experiments of Dr. Jones, it is elastic and firm in the longitudinal direction; but so weak in the circular, as to be very easily torn by a force applied in that direc- tion.—(On the Process of Nature in suppressing Hemorrhage, &c, 8vo., Lond., 1805.) In the dead body, Bichat noticed that it seemed to have an unctuous fluid upon it, which he con- ceived, however, might not be the case in the living subject. It is of folds of the internal coat of the arteries, that the semilunar and sig- moid valves are formed at the origins of the aorta and pulmonary artery, the important uses of which valves have been already cursorily stated. The same membrane also forms the various ridges at the commencement of the arterial branches. It is very feebly united to the middle coat ; and, according to Bichat, there is no cellular tissue between them. The morbid changes to which it is subject, prove its vascularity. Indeed, during life, it is particu- larly connected with arterial diseases. Thus its inner surface becomes the seat of adhesive inflammation, whenever the blood is prevented by a ligature from passing along it, or the oppo- site sides of the vessel are gently held in con- tact for a certain period. In elderly persons it is als»o noted for its singular tendency to ossify. Bichat calculated, that, in every ten individuals past their sixtieth year, the arte- ries of at least seven have earthy incrustations on them. These ossifications, which never affect the middle coat, always begin upon the external surface of the inner coat, being lined by a thin pellicle, which intervenes between them and the circulating blood, and is plainly the internal coat itself. These calcareous de- positions in the arteries are not regulated by the laws of common ossification, the cartilaginous state rarely preceding them. The earthy mat- ter is always deposited in detached plates, or scales, and the whole artery is seldom converted into one continued solid tube. Thus the por- tions of the internal coat, between the scales, were considered by Bichat as so many articular bands; the arteries thus ossified being com- posed of numerous pieces, moveable upon each other, and capable, in a certain degree, of yield- ing to the impulse of the circulation. While these earthy plates continue thin, the inside of the artery retains its natural smoothness ; but, when they acquire thickness, they project into the cavity of the vessel; the thin pellicle breaks at their circumference ; and they then adhere merely to the fibrous coat. The middle coat, which is the thickest, con- sists of several layers of firm, compact fibres, considered by Hunter, Jones, and many other physiologists, as fleshy or muscular. It is some- times called the fibrous coat, and often the mus- cular. Bichat names it the proper membrane of an artery, and observes, that it is very appa- rent in the large arteries, but less perceptible in their ramifications, where it is gradually lost.* * Anat. Gener., torn, i., p. 270. Yet, according to Hunter's experiments, the smaller the arteries are, the more contractile and muscular they be- come in relation to their size; while, compara- Cl. III.] PHYSIOLOGICAL PROEM. 303 Its fibres have a circular direction ; being, how- ever, rather obliquely connected, and interlaced with each other, than complete circles. Ac- cording to Jones, they are of a peculiar nature, well supplied with nerves, and in form and dis- position like muscular fibres, but different from them in possessing a remarkable degree of elas- ticity. They also differ from muscular fibres in being of a yellowish dun colour ; in not having the same taste when boiled (Rudolphi's Elem., vol. i., p. 80 ; J. J. Berzelius, Animal Chym., p. 25); and in having no fibrine as one of their constituent parts. With respect to the colour of muscular fibres, a red colour is pecu- liar only to those of vertebrated animals, and, even in amphibia, they appear very pale, and, in numerous fishes, still paler. Many of the lower animals, as, for instance, the actinse, possess a, manifest power of contraction; yet, as Dr. Bostock observes (Physiol., vol. i., p. 399), their substance is quite as unlike that of the muscles of warm-blooded animals, as the transverse fibres of the arteries are alleged to be. The non-muscularity of the middle coat of an artery, therefore, must not be inferred from the mere circumstance of its not corre- sponding in colour to the muscles of the human body. Such physiologists as consider the middle coat of the arteries to be muscular, among whom are Haller, Walther, Hunter, and Soem- merring, build their opinions upon various grounds, some of the firmest of which were explored by Mr. Hunter. It is also argued, that the fibres become soft and grayish in the small arteries, and assume much of the appear- ance of those in the intestines; that, notwith- standing the dryness, resistance, elasticity, and fragility of the arterial fibres, not more differ- ence really exists between them and the mus- cular fibres, than between those of different muscles ; and that the muscularity of arteries is proved by their functions. With such state- ments Beelard joins another, which disagrees with the researches of Berzelius ; namely, that he has detected a proportion of fibrine in the middle coat of the arteries.* Dr. Jones represents the elasticity of an artery as so particularly inherent in the middle coat, that, if this coat were separated from the two others, it would retain its cylindrical form, while they would collapse. This statement is certainly not applicable to the largest arteries, the outer coat of which possesses very consid- erable elasticity, and perhaps even a greater degree of it than the middle one. tively speaking, the proportion of elastic matter is most abundant in the great arteries.—Ed. * Beclard, Additions a 1'Anat. Gen., p. 78. According to Cuvier, the middle coat of the arte- ries, which is fibrous in man and the horse, is de- cidedly muscular in the elephant. Dr. Wede- meyer, summing up all the objections made to the doctrine of the muscularity of the arteries, states, that, whereas the true muscular fibre is reddish, soft, extensible during life, and very brittle after death, the fibrous coat of the arteries is, on the contrary, yellowish, firm, hard, and very elastic even after death; that its vasa vasorum do not The external coat of the arteries is often de- scribed as condensed cellular membrane. Its texture towards the middle doat is close and smooth, but, more externally, it is open and rough, in consequence of the cellular substance by which it is connected to an additional cov- ering named the arterial sheath. The external coat is remarkable for its density, whiteness, and great elasticity. If an artery be surrounded with a tight ligature, the middle and internal coats will be completely divided, while the ex- ternal coat will remain entire. Hence, the strength of an artery must depend in a great measure upon this coat, and its importance may be conceived from the fact, that it encloses and transmits the vasa vasorum, by which the artery itself is nourished. The sheath of arteries is merely the lamel- lated cellular substance that forms around them a sort of .canal. On one side it is connected to their external coat by numerous filaments of cellular membrane ; while, on the other, it is continuous with the common cellular substance. It does not exist where arteries are covered by serous membranes. Other arteries are like- wise destitute of it, apparently in consequence of there being no cellular membrane in their vicinity, as in the brain. In the limbs, it is generally very compact; but, in some other situations, it is quite lax, as around the sper- matic arteries.—(Beclard, op. cit., p. 79.) According to Bichat, although the cellular tissue forms the external coat of the arteries,. and serves for the insertion of the arterial fibres, it is not continued into their interstices ; a peculiarity, he says, in which the arterial tissue differs from that of muscles, veins, &c. This absence of cellular tissue he also remarked be- tween the middle and internal coats ; though the observation disagrees with the statements of Haller, Soemmerring, and others. It is to the want of cellular substance in the proper arterial tissue, that Bichat refers a great deal of the fragility by which it is characterized ; the difficulty of arterial dilatations ; the freedom of arteries from fat, anasarca, hydatids, cysts, and various tumours, to which the cellular membrane is liable.—(Anat. Gin., torn, i., pp. 285-287.) Arteries are furnished with minute arteries and veins of their own, technically named vasa vasorum, and without the agency of which the nutrition, growth, and morbid states of the ar- terial system would defy all rational explanation. These small nutrient arteries originate from the neighbouring ramifications, and not from the artery itself, to which they are distributed. One distribute themselves as in the muscular fibre; that it does not contain any fibrine; that it is not excited to contract by galvanism, or any other irritant; and that, in its extreme liability to the deposition of calcareous matter between itself and the inner serous coat, it shows its resemblance to white fibrous tissue in other parts of the body, as well as its difference from true muscular tissue, between which and serous membranes calcareous matter is rarely secreted.—See Untersuchungen fiber den Kreislauf des Bluts, &c, Hannover, 1828— Ed. 304 PHYSIOLOGICAL PROEM. [Cl. 111. exception to this arrangement is pointed out by Bichat : the aorta, at its commencement, gives off the coronary arteries, which, besides supply- ing the heart, ramify on that great vessel. Absorbent vessels are very manifest around the large arteries, for instance, the crural. The enlargement of the cavities of arteries, as the body, limbs, and other parts increase in size, implies the continual performance of ab- sorption in the arterial structure. Other power- ful arguments in support of this inference may be drawn from various pathological facts, espe- cially from the liability of arteries to ulceration. According to Soemmerring (De Corp. Hum. Fab., torn, v., p. 59), all the arteries have nerves, which also appear to him to be smaller and fewer in the large trunks, than in the branches of middling diameter. Hence he con- cludes, that the more minute arteries are, the greater is their proportion of nerve in relation to their size. He states, that the vertebral artery, and the large mesenteric branches in thin subjects, can be seen without any difficult preparation, surrounded by a beautiful network of nerves. Lucae asserts that he has followed the nerves even into the substance of arteries. The late Mr. Wilson also succeeded in tracing filaments of nerves into the arterial coats. " I can have no doubt," he remarks (On the Vas- cular System, p. 155), " of nervous filaments communicating with the packets of muscular fibres, as there is sufficient proof, in the action of blushing, that these fibres are much influen- ced by emotions of the mind." The heart and larger arteries receive but few nerves directly from the cerebrospinal portion of the nervous system, their nerves being principally supplied by the ganglionic system of the great sympa- thetic, which appears to have the organic or nutritive functions of life more especially under its influence. The two divisions of the nervous system are, however, intimately connected by the numerous brancbes which the great sym- pathetic receives from the spinal marrow, and by a few smaller branches coming from the brain. In an experiment made by Sir Everard Home, the great sympathetic nerve was irritated in the necks of dogs and rabbits, and a temporary increase of pulsation is said to have been there- by produced in the carotid arteries.—(Phil. Trans., 1814.) In experiments of this kind, the physiologist should be careful not to con- found the general disturbance of the circulation from the pain and agitation, with a local aug- mentation of the pulse of a particular artery from the effect of the irritation of the nerve or nerves, by which it is supposed to be influenced. The veins are membranous tubes, like the arteries, but differ from these vessels in having a thinner and less fibrous texture, and in being often furnished with valves, which, in the arte- rial system, are nowhere found, except at the roots of the aorta and pulmonary artery. The veins are nearly destitute of that texture, which is seen in the middle coat of the arteries, and are consequently to be regarded as little more than simply elastic tubes. As Soemmerring remarks, it is only in the large trunks of the veins that any fibrous appearance can be traced. —(Op. cit., vol. v., p. 328.) Their office is to return the blood to the heart, after it has served the purposes for which it was sent from the two ventricles of that organ. Their action is, therefore, entirely mechanical, and the blood is transmitted by them (as far, at least, as they themselves are concerned) upon hydraulic prin- ciples.—(Bostock's Physiol., vol. ii., p. 403.) That the large veins have longitudinal fibres is generally admitted ; but the transverse or circu- lar* ones ascribed to them by Marx (Diatribe de Structura atque Vita Venarum, Carlsr., 1819) seem to Rudolphi to be nothing more than cellular membrane. He has never seen distinct circular fibres in the veins of the human subject, nor even a single one in the vena cava of a horse.—(Elem. of Physiol., vol. i., p. 90.) The force with which the veins resist any power tending to tear them is much greater than might be expected from their apparent tenuity. Their area is much larger in proportion to, their sides than that of the arteries ; and, according to the experiments and calculations of Wintringham, the proportion which the thickness of the arterial coats bears to that of the venous tunics, is in the largest trunks as fifteen to one. The veins also bear greater distention than the arteries without bursting. In Wintringham's experiments, the vena cava inferior sustained a column of water weighing 176 lbs., while the aorta, in the same situation, was burst by a column of 158 lbs. 11 oz. The iliac vein was to the artery in this respect as 1034 to 1000. But in the vessels of the viscera, the arteries exceeded the veins, and, in an old dog, the aorta was stronger than the vena cava. In the living subject, however, the veins are found more liable to dilatation and rupture than the arteries. They yield more readily, and admit of greater dilatation. The inner coat or lining of veins is thinner, more dilatable, and less brittle than that of arteries. Ossification never takes place in it; and as all what Bichat calls the common membrane of the black blood is of the same nature, the tricuspida! valve, with the semilunar or sigmoid valve of the pulmonary artery, and the lining of that vessel, never exhibit bony deposites, which are so common in the corresponding parts of the system of red blood. The valves of the veins are produced by folds of the internal coat. In the larger trunks they are generally arranged in pairs, as at the entrance of the internal jugular into the subclavian in the large veins of the leg and arm, and the vena azygos. Three valves situated together are sometimes observed, but not frequently. Sol- itary valves are frequently seen in the smaller veins. The size of the valves is proportioned to that of the vessel, but they are not always large enough to close it completely. The valves are chiefly found in veins which have a perpen- dicular position, as in the limbs, penis, testicle, and the vena azygos. They are particularly * " We have ascertained, by very minute dissec- tions, that the veins have no circular fibres."—See Doane's Meckel, vol. i., p. 127. Cl. III.] PHYSIOLOGICAL PROEM. 305 numerous in the limbs and cutaneous veins, and very scarce in the viscera. There are no valves from the right auricle down to the iliac veins ; none in the hepatic, venal, uterine, cerebral, or coronary veins, excepting the single one at the mouth of the coronary in the auricle itself. Ac- cording to Haller, there are none in the small veins generally, the diameter of which is less than one line. The valves begin in the iliac veins, where, however, they are not numerous ; and they are found in such branches of the hypo- gastric veins as do not come from the uterus and bladder. The effect of the valves in com- pelling the blood to run in one direction in the veins is manifest. They lie close to the side of the vessel, and make no resistance to the blood's natural course; but when that fluid is repelled in the vein, it lifts up the loose edge, and causes the margins of the two valves to form a partition in the cavity of the vessel. Hence the blood cannot retreat farther than the situation of the first pair of valves ; consequently any portion of a venous trunk has to sustain Only the quantity of blood contained between the two valves which bound it. Had it not been for this arrangement, the whole column of venous blood, when its return to the auricle was impeded, would have pressed on the minute veins with a degree of force which the coats of these vessels could not have resisted. The necessity of such a structure arises out of the comparatively slow motion of the venous blood, the absence of an impelling agent at the com- mencement of the venous circulation, and the degree in which it is influenced by the force of gravitation. In consequence of the valves, all pressure must have the effect of sending the blood on towards the heart. For the same rea- son, the swell of the muscles, when they act, must promote the venous circulation. The coats of veins are furnished with minute arteries and veins, not essentially different from the nutrient vessels of the arteries. Their ex- halants and absorbents are calculated to be few ; and their supply of nerves much inferior to what the arteries possess. The following are some of the considerations which led Mr. Hunter to believe the arteries muscular as well as elastic. When the inside of the arteries and veins of the alligator and turtle is inspected, he says, fasciculi of muscular fibres can be plainly seen.—(On the Blood, p. 118.) But in order to prove the point, he had recourse to experiments, in which he contrasted the action of the arteries with that of simple elastic substances. " Action in an elastic body," he observes, " can only be produced by a me- chanical power ; but muscles acting upon an- other principle can act quickly or slowly, much or little, according to the stimulus applied ; though all muscles do not act alike in this re- spect. If an artery is cut through, or laid bare, it will be found that it contracts by degrees, till its whole cavity is closed ; but if it be allowed to remain in this contracted state till after the death of the animal, and be then dilated beyond the state of rest of elastic substances, it will only contract to the degree of that state. This it Vol. I.—U will do immediately ; but the contraction will not be equal to that of which it was capable while alive. " The posterior tibial artery of a dog being laid bare, and its size attended to, it was obser- ved to be so much contracted in a short time, as almost to prevent the blood from passing through if, and, when divided, the blood only oozed from the orifice. " On laying bare the carotid and crural ar- teries, and observing what took place in them, while the animal was allowed to bleed to death, these' arteries very evidently became smaller and smaller: "•When the various uses' of the arteries are •considered ; such as their forming different parts of the body from the blood ; their performing the different secretions; their allowing at one time the blood to pass readily into the smaller branches, as in blushing, and at another pre- venting it altogether, as in paleness from fear ; and if to these circumstances we add the power of producing a diseased increase of any or of every part of the body ; we cannot but conclude that they are possessed of muscular powers." Certain experiments to which Mr. Hunter had recourse, led him to infer, that the large arter- ies are most elastic, and the small ones most muscular. He injected the uterus of a cow, after it had been separated from the animal more than twenty-four hours, and he allowed it to stand another day, at the end of which the larger vessels had become much more turgid than they were when first injected ; and the smaller arteries, he says, had contracted so as to force the injection back into the larger. He regarded this as a proof that the muscular power of the small arteries is superior to that of the large ones, and that they retain it longer after their detachment from the rest of the system. The latter character is one that Mr. Hunter par- ticularly ascribed to all the involuntary muscles, to which class the arterial fibres belong.—(Op. cit., p. 115.) Nothing can differ more widely than the rela- tive spissitude and power ascribed to the elastic and muscular arterial coats, compared with each other in different parts of the circulating course. As the heart is the salient point of the circula- tion, and pours forth about two ounces of blood at every jet, the greatest force is exerted against the arteries that immediately issue from the heart. Here, therefore, we find the greatest resisting power ; for, in the aorta and pulmonary artery, the elastic tunic is stronger than the muscular, by which contrivance these vessels are never too much dilated by the action of the heart in its contraction, or, as the Greeks call it, systole. In like manner, this tunic becomes stronger at the bending of the joints, and con- tinues so through the whole length of the curve ; and the same provision takes place at the sharp angles made by a trunk and its branch, or at an angle formed by the division of one trunk into two. As the arteries, however, recede from the heart, the blood, resisted at every step by the elastic tunic of the canal it flows through, progressively loses its impetus, and a less elastic power becomes necessary, and is actually pro- 306 PHYSIOLOGICAL PROEM. [Cl. III. vided. At a considerable distance, therefore, from the heart, in whatever direction the arter* ies ramify, their muscular tunic soon balances their elastic, and gradually becomes superior; till at length, in the capillary arteries, it is nearly, if not altogether, the only tunic of which the canal consists : whence the ease with which these vessels collapse on some occasions, as from loss of blood, or the exercise of terror, or any other depressing passion ; and the equal facility with which they open in other cases, as in the sudden blush of shame or modesty. [Many of the phenomena which Mr. Hunter and other distinguished physiologists refer to the muscularity of the arterial system, Bichat ascribes to a property which he terms contrac- tility of tissue, that is to say, a property de- pending upon organization, and not upon life. He takes a view of such contractility as opera- ting in the transverse and longitudinal direc- tions. In the former it is- much more strongly marked than extensibility. He observes, that as soon as an artery ceases to be distended with blood, it evidently shrinks. Hence :—1. The conversion of the umbilical artery and ductus arteriosus, after birth, into ligamentous impervious substances. 2. The obliteration of an artery all the way from the place of a liga- ture to the point at which the first collateral branch goes off. 3. The diminution of the calibre of an artery between two ligatures, as soon as the blood between them is discharged by a puncture. 4. In experiments upon dogs, into which blood was transfused, with the view of causing an artificial plethora, Bichat found that the diameter of the arteries was nearly double what it was in dogs of the same size, after profuse hemorrhage. The same differ- ence, he says, may be noticed in two animals of equal size, when one has been killed by hem- orrhage and the other by asphyxia. 5. These experiments left no doubt in Bichat's mind of the fulness and smallness of the pulse, an artery being really more or less bulky according to the quantity of blood which it contains.—(See also Hunter, op. cit., p. 124.) There is a limit, however, beyond which the vessel cannot be extended; but, from a deficiency of blood, it may contract to such a degree as to represent as it were but a thread. Mr. Hunter calculated the degree of con- traction that takes place in the different arteries of-an animal bled to death. He subjected to very careful admeasurement the arteries of a horse killed in this manner, and whose muscles had all been allowed Co contract equally, whence " we might reasonably presume that the vessels, at least such of them as were furnished with muscles, would also be contracted, the stimulus of death acting equally upon muscles in every form and every situation." He removed from the carcass sections of the aorta, iliac, axillary, carotid, crural, humeral, and radial arteries, with the precaution of not altering in the least their texture, or state of contraction. He measured them when slit open, so as to learn their greatest degree of contraction, He then stretched them transversely, and measured them when elongated as much as possible. Lastly, he measured them a third time, in the state to which they recovered by their own powers. He found that the power of recovering was greatest near the heart, and gradually diminished to- wards the extremities of the body. This was owing, as Mr. Hunter supposed, to the exten- sion haying entirely destroyed the power of muscular contraction, which is comparatively greatest in the small arteries, while the degree of contraction which actually took place after such extension, proceeded from elasticity, which is most abundant in the larger trunks. Here what Mr. Hunter imputes partly to muscularity and partly to elasticity, Bichat would refer to contractility of tissue. The lat- ter is of opinion, that most physiologists have confounded this kind of contractility in the ar- teries with irritability, the difference of which is shown by its always ceasing a few hours after death, whereas the contractility, spoken of by Bichat, takes place after death, though in a less marked degree. Mr. Hunter, who, as we have seen, refers all contractility of the arteries to muscularity and elasticity, relates some experiments, the ten- dency of which isto prove that they have no muscular power of contraction in the longitu- dinal direction. In the first experiment, a longi- tudinal section of the aorta ascendens, measur- ing two inches, after having been stretched and allowed to contract again, measured the same length. The same thing was observed in por- tions of the carotid and humeral arteries. " These experiments," Mr. Hunter says, " ap- pear to be decisive, and prove, that the muscular power acts chiefly in the transverse direction; yet, it is to be observed, that the elastic power of arteries is greater in the longitudinal than the transverse direction. This appears to be intended to counteract the lengthening effect of the heart, as well as that arising from the action of the muscular coat; for the transverse contraction of that coat lengthens the artery, and therefore stretches the elastic, which again contracts upon the diastole of the artery."— (Loc. cit., p. 128.) Many of Mr. Hunter's observations embrace the subjects of the vital properties of the ar- teries ; as, for instance, whenever he reasons about the disputed question of their muscularity. Bichat, after considering the elasticity, extensi- bility, and contractility of tissue, or the proper- ties which he believed to depend on the struc- ture or organization of arteries, offers some in- teresting reflections on their vital properties. First, he inquires, whether animal sensibility exists in them I The application of a ligature to an artery, he says, sometimes produces pain ; but more frequently not. The latter statement the editor deems incorrect, or, at least, repug- nant to what he has noticed in the practice of surgery. Nor can Bichat's observation be rec- onciled with what he presently says about the great sensibility of the inner coat of the arter- ies. However, as he admits that they some- times give pain when tied, this affirmative proof of their sensibility is all that can be required. ICAL PROEM. 307 Cl. III.] PHYSIOLOG He states, that, in whatever manner the carotid of a dog be irrjtated, whether with a scalpel, acids, alkalis, &c, the animal never betrays signs of pain. With regard to the inner cOat, however, he found, that, although the injection of a mild fluid, like water, at the temperature of the animal, caused no uneasiness, the injec- tion of a stimulating fluid like ink, diluted acids, wine, &c, excites very acute pain.—(Anat. Gin., torn, i., p. 295.) Animal contractility, as Bichat terms it, or (as it might be expressed) contractility under the influence of the brain, and resembling that of the voluntary muscles, is stated by this au- thor not to belong to the arteries. Such con- tractility, he asserts, could only depend upon a connexion between these vessels and the brain ; yet irritation of this organ, producing convul- sions of parts subject to the will, has no effect upon the arteries ; and opium, which, in a cer- tain dose, paralyzes those parts, leaves the ves- sels unaffected. Another assertion made by Bichat is, that, if the spinal marrow be exposed, irritated, and compressed, the action of the arteries is neither increased nor diminished, even though the voluntary muscles be at the same time convulsed or paralyzed from it. On the other hand, the experiments of Dr. Philip contradict Bichat on this interesting point, and show that the motion of the blood in the capil- laries is influenced by stimulants, applied to the central parts of the nervous system; which circumstance, if established as a fact, must de- pend upon the contractile power of those ves- sels.—(Exp. Inquiries, &c, p. 291, 292, 2d edit.) In direct opposition to the result of Sir Everard Home's experiment, already mentioned, Bichat found the arteries to be quite unaffected, either by irritation of the cerebral nerves, which accompany them, or by that of the ganglionic nerves, which are irregularly and abundantly distributed upon their external surface. He even tried galvanism without any effect. The same physiologist represents the arterial system as destitute of what he calls organic sensible contractility, or that kind of contrac- tility which, in his system, is classed as one of the properties of organic life, and illustrated in the action of the heart, intestines, &c. In whatever manner an artery be irritated in the living body, he asserts that it constantly re- mains motionless. Even when the arterial coats are stripped off layer by layer, either in a living animal, or one recently killed, none of that trembling and palpitation is perceived, which occur in the fibres of organic muscles under similar circumstances. The conclusion to which Bichat's experiments lead him is, that during life the arteries have no contraction that is under the vital influence, and he refers all the circumstances usually brought forward to prove the contrary, to contractility of tissue. Thus, he observes, when an artery is tied at two points, and opened in the interspace, it empties itself of the blood contained in it, as well as of any other fluid accidentally placed in it. The same thing also occurs, when only one ligature is so applied, that it intercepts the influence of the heart. The dependance of these circumstances upon contractility of tissue, he argues, is so much the fact, that, as long as the artery is free! from putridity, they take place in the dead sub- ject. If an artery be filled, and then opened, it empties itself by contracting. The contrac- tion produced by defect of extension, is what Bichat regarded as a test of contractility of tis- sue ; irritability, or organic sensible contractil- ity, always implies the operation of a stimulus. Bichat describes organic sensible contractility, or tonicity, as plainly existing in arteries. In those which pulsate, he says, it is restricted to the purposes of nutrition ; but, as soon as the influence of the heart on the motion of the blood ceases, which (according to his theory) is probably at the beginning of the capillary sys- tem, then the organic insensible contractility begins to have effect, not only upon the nutri- tion of the coats of the vessels, but also upon the circulation within them. Indeed, in this physiologist's views, the circulation in the small vessels is altogether maintained by their tonic power, the heart having absolutely no concern with it. Bichat represents the arteries as endued with organic sensibility, which he says is never sep- arated from the organic insensible contractility. In the large trunks, however, where it is only necessary for their nutrition, it prevails in a very obscure degree. It is by the organic in- sensible contractility, and the organic sensibility, that Bichat would solve many of the difficul- ties attending the comprehension of the process of secretion. What Mr. Hunter and numerous modern physiologists would ascribe to the ac- tion of vessels, Bichat refers to those two rather imaginary properties of the minute arte- ries. The difference seems, after all, to con- sist rather in words than meaning. The following is a summary ofthe principal ar- guments, respecting the muscularity of arteries : 1. When arteries are stimulated in living animals with a sharp instrument (Verschuir, De Arter. et Venarum Vi Irritabili, p. 17), strong acids,* or electricity (Birker, De Nat. Hum., p. 45, Lugd. Bat.), the portion of the vessels so stimulated is declared by the subjoined ex- perimenters to contract. On the other hand, the contraction of an artery on its being pricked, variously stimulated, or even galvanized, is posi- tively denied by Bichat,t who ascribes the * Zimmermann, De Irritabilitate, p. 24. Larry, in Vandermonde's Joum., torn, vi., p. 7. Ver- schuir, op. cit., p. 19. t Wedemeyer's experiments support the doc- trine of Haller and Bichat, that the greater arter- ies do not possess irritability, or vital contractility. With a battery of fifty pairs of plates, Wedemeyer galvanized the carotid artery, and the thoracic and abdominal aorta, sometimes during life, sometimes immediately after death, caused in various modes, and the artery was sometimes left in connexion with the heart, and sometimes removed from the body; but its result was always the same : he never could remark any contraction. Neither could he excite any contraction with mechanical stimulants. Wedemeyer could not perceive that galvanism produced any contraction of the arteries of the umbilical cord and placenta, as asserted by 308 PHYSIOLOGICAL PROEM. [Cl. Ill- change produced by acids to a kind of crispa- tion, attended with chymical injury of structure, whereby the vessel is for ever prevented from resuming its pristine diameter, which it would do, if the contraction depended on mere stimu- lation. But in opposition to him, we have again the galvanic experiments of Giulio and Rossi, and that of Sir E. Home, who, as we have noticed, produced violent throbbing in the carotid by applying alkali to the great sympai- thetic nerve.* 2. Arteries are said to be capable of a peris- taltic motion. The editor is not acquainted with the facts on which Soemmerring (De Corp. Hum. Fabricd, torn, v., p. 66), founds this state- ment ; unless it refer to Dr. Whytt's exploded hypothesis of an oscillation in the minute vessels. 3. The doctrine of the contractile power of the capillaries has received important corrobo- ration from the experiments of Drs. Wilson Philip, Thomson, and Hastings. These gen- tlemen placed the web of a frog's foot in the microscope, and distinctly saw the capillaries contract upon the application of such stimulants as cause the contraction of the muscular fibre. Dr. Hastings found, also, the large arterial trunks, and even the veins, contract, as Ver- schuir and others had previously noticed. Dr. Thomson has seen the arteries contract in such a degree, on the application of ammonia, that their cavity appeared to be quite effaced. On the contrary, the muriate of soda always caused a dilatation of them. 4. Arteries are alleged to pulsate very differ- ently in different parts. With reference to strength and fulness of the vessels, the editor's own observations enable him to corroborate this fact; but he has never known an artery of one part of the body beat more slowly or quickly than the rest of the arterial system. The oc- currence, however, is mentioned by writers as a fact. An increased flow of blood to any par- ticular organ, whether in health or disease, is Osiander. The apparent contraction of the aorta under electricity, he says, is nothing else than in- creased pulsation, arising from the action of the electric fluid on the heart, which is excited to in- creased action. Oesterrheicher has observed in fishes alternate contraction and dilatation of the bronchial artery. Wedemeyer has made the same observation ; but says that this may easily be ac- counted for, because, near the origin of the vessel at the heart, distinct muscular fibres may be traced, not at all like the hard fibrous coat of the arteries in general. The same structure, he says, is particularly conspicuous in the torpedo. On the other hand, Cuvier's statement, that the fibrous coat of the arteries in the elephant is plainly muscular; and BeclardTs, that the same tissue in the arteries of the human subject, actu- ally contains fibrine; must not be forgotten in forming a judgment on this contested point. * Oesterrheicher explains this fact on a differ- ent principle: if a nerve, supplying any vessel, be divided, and then stimulated at the end farthest from the brain, the artery does not pulsate with greater force; and hence, if its pulsation is in- creased when the nerve is not previously divided, this arises from nothing else than the increased action of the heart, caused by the pain inflicted an the animal,—Ed. inexplicable, unless some change in the diam- eter, or action of the vessels supplying it, be taken into the account. 5: In one case upon record, the pulse of the arteries of a paralytic arm was quite indistin- guishable ; while, in the other arm, it was full and strong.—(Hoffmann von der Empfindlichkeit, &c.,$842.) Here hv is argued, that, if the pulse had depended upon the heart alone, it would have been as strong in the paralytic as in the healthy limb. Some highly instructive ex- amples of the entire want of pulsation in the arteries of paralytic limbs are recorded by Dr. Storer,* by whom, however, this effect is de- scribed as exceedingly uncommon. 6. Another argument is derived from the operation of local stimulants in producing in- flammation. The lachrymal ^gland, when the eyes are irritated, or when it is itself affected through the mind, pours fourth tears. The sal- iva is more copiously secreted from the effect of stimulating medicines, or of the sight and smell of victuals. 7. It is argued also, that, as the nerves of arteries are quite evident and abundant, these vessels must be connected with the brain, and be influenced by affections of the nervous sys- tem. Putting out of the present consideration the results of experiments, in which the effect of stimulating the nerves of arteries was ex- amined, and about which the flattest contradic- tions prevail, let us only recollect the quick ac- tion of blushing ; the instantaneous paleness of fear ; the influence of the mind over the secre- tions ; and the sudden distention of the corpora cavernosa from mental causes; and we can scarcely fail to conclude, that the arteries are : under the influence of the nervous system. 8. One important argument in favour of the contractile power of the arteries, is derived from cases in which the circulation was carried on, although the heart was either wanting, defect- ive in its structure, or more or less ossified Examples of the first kind are recorded by Hew- ■ son {Exp. Inq., vol. ii., p. 15) and Brodie (Phil. Trans., 1809, p. 161), and of the latter by A. Burns, and other writers. According to Mr. A. Burns, the left ventricle of the heart may be so ossified, that, it can have no share in propelling * Trans, for Improvement of Med, Knowl., vol. iii., p. 448. Such cases seem to affect very much the doctrines maintained by Wedemeyer and others, that all the phenomena of the arterial pulse may be imitated exactly, when life has been for many hours extinct, by impelling water into the vessels by successive jets from a syringe; that the pulse is owing entirely to the impulse communi- cated by the heart, in consequence of which the artery is partly dilated, and partly made to shift : its place ; that all the phenomena of the circula- 1 tion may be referred to the elastic contractility of the arterial coats, and that the greater arteries, therefore, contribute to move the blood forward ' only by restoring, through their elastic reaction, the force expended in dilating them. The power of arteries to contract beyond the point to which their elastic materials will bring them, as demon- strated by Hunter, is here also to be remembered, as not admitting of explanation without reference to a vital contractility.—Ed. Cl. Ill] PHYSIOLOGICAL PROEM. 309 the blood into the arteries. Yet the circulation is continued through all parts of the body. And, from what happens in cases of ossified arteries, he infers, no doubt with considerable exaggeration, that the circulation can be much better conducted without the action of the ven- tricles, than without the reaction of the arteries. The cases of ossified heart reported by Mr. A. Burns are highly interesting.—-{On Diseases of the Heart, p. 129, &c.) Drs. W. Philip and Hastings{ Treatise on the Mucous Membrane, Introd., p. 51), in their ex- periments, -saw the circulation in the small ves- sels continue for some time after the heart had been removed from the body ; a circumstance hardly explicable without the admission of an action in the vessels themselves. 9. It is decidedly proved, that, during life, an artery can contract below its middling diameter, or that width to which its mere elasticity would reduce it. How can this be effected, but -by muscularity 1 10. Arteries, empty at the moment of death,: and even contracted below their middling diam- eter, recover their ordinary size as soon as the vital influence is completely exhausted. Their muscular power is then annihilated, and their elasticity predominates.—(See Experiments in Hunter on the Blood, p. 116, &c.) From the tenour of all that has been said, the existence of a power of contraction in the minute vessels can hardly be doubted, what- [ ever may be the opinion espoused respecting the muscularity of the arterial trunks. Some physiologists, not exactly agreeing with Mr. Hunter, may yet be disposed to consider the' latter simply in the light of a mechanical or hydraulic system, and the capillaries as the phys- iological or vital organs.* The wisdom with which the structure of the body is contrived, is most convincingly exem- plified in the vascular system. We have in- stances of it in the universal situation of the arterial trunks in the direction of the flexion of the joints, whereby they are hindered from being overstretched, and are protected from external injury; in their occasional tortuosities, by which they are enabled to adapt themselves to the continually changing positions of organs, with- out suffering from extension ; and in their anas- * See Bostock's Physiology, vol. i., p. 403. Dr. Marshall Hall inclines to the opinion, that the cap- illaries are rather passive than active canals, through which the blood is circulated by the im- pulse of the arteries, the absorbing action of the veins, and also by capillary attraction He fully admits, however, the contractility of the small ar- teries.—(On the Circulation, &c.) Galvanism would appear, from the investigations of Dr. Reuss, of Moscow, and those of M. Dutrochet, Mr. Faust, Dr. Mitchell, and Dr. Stevens, to ex- ercise a locomotive influence on the circulating fluids. For information on this curious question, see Nouvelles Recherches sur l'Endosmose et l'Exosmose &c, parM. Dutrochet, 1828; Faust's Experiments, &c, on the Endosmose and Exos- mose of Gases, and the Relation of these Phenom- ena with Respiration; Amer. Journ. of Med. Sci- ence, vol. vii., Nov., 1830 ; Stevens on the Healthy and Diseased Properties of the Blood, &c—Ed. , tomoses, or frequent communications with one another, by which the necessary supply of blood to parts is rendered secure, when any particular trunk is temporarily obstructed by pressure, or permanently obliterated by this and other causes. After having divided, and ramified to a con- siderable extent, and in a manner generally re- sembling the branching of a tree, the arteries, both of the greater and lesser circulations, ter- minate in the general capillary system. The exact point at which the arteries end and the capillaries begin, cannot be demonstrated. Ac- cording to Bichat, it is where the blood ceases to be at all under the influence of the heart, and the circulation is first maintained altogether by a contractile power of the minute vessels, to which he allots the mysterious term of insensi- ble organic contractility. But this imaginary limit would not satisfy many physiologists, par- ticularly those who argue that the action ofthe heart always extends its effect to the capillaries, as well as the arteries in general. Anatomists commonly describe the arteries as terminating in excretory tubes, exhalants, veins, •&«.; but, in reality, the capillary system constantly inter- venes between those vessels and the arteries. The microscopic investigations of Dr. Marshall Hall into the action of the capillary vessels tend to show, that they are a network of pellucid vessels, differing from the small arteries in the circumstance of their subdividing without be- coming smaller ; and freely anastomosing with each other, like nervous plexuses, forming thus, as Bichat always inculcated, an intermediate system of vessels between the arterial and ve- nous system.* As already obseived, while the large arteries are regarded by some physiolo- gists as merely mechanical tubes, the minute ones, or capillaries', are known to be the part of the vascular system, in which all the impor- tant objects of the circulation are mainly pre- pared and accomplished, as nutrition, secretion, the oxydation of the blood, its decarbonization, &ct] * On the Circulation of the Blood, by Marshall Hall, M. D. Wedemeyer's account of the struc- ture and disposition of the minute vessels is con- tained in his " Untersuchungen fiber den Kreis- lauf des Bluts," 1828 ; or in the 100th No. of the Edinb. Med. Journ., July, 1829. ■f- With regard to exhalant pores, Dr. Wede- meyer objects to the notion that they are visible and organic, or, as he explains the term, endowed with a species of contractility, by means of which they retain certain substances, and discharge others. He maintains, that if any such pores existed, they would be perceptible with the aid of the micro- scope ; and he considers that all the phenomena of exhalation may be produced through invisible pores, or the interstices between the ultimate par- ticles which form the organic tissues, and may be explained by the phenomena of capillary attrac- tion, as modified by the action of the nervous sys- tem on textures. In these views, as has been correctly noticed (Edinb. Med. and Surg. Journ. for July, 1829, p. 87), he approaches closely to the theory which M. Dutrochet has founded on his discovery of endosmose and exosmose. (See op. cit., No. 99.) Magendie's experiments tend to establish the fact, that the exhalants do not terminate in open orifices, but that exhalation and 310 PHYSIOLOGICAL PROEM. [Cl. III. I have observed, that the force with which the blood is at first projected from the heart, is progressively diminished by the resistance it en- counters in the thick and powerfully elastic tu- nic of the trunks or large arteries into which it is immediately propelled. There are two other causes which co-operate in producing a progres- sively diminishing force. The first is the short angles against which the blood has to strike at the origin of all the different branches ; and the next, and most important, is the larger diameter of the general mass of the arteries, compared with that of the heart, or the arteries from which they immediately proceed ; the range of the diameter augmenting in proportion to the increase of the ramifications. From experi- ments, indeed, made by Mr. John Hunter on the carotids of camels and swans (On Blood, Inflammation, &c, part i., sect, viii., p. 170), the very same arteries appear gradually to widen from the end nearest the heart to that most re- mote from it. From all which he concludes, that the aggregate diameter of the arterial sys- tem forms a cone, whose apex is at the heart. And he concludes also, and most correctly, that this conic proportion is most obvious, increases most rapidly, and spreads with its broadest base in infants, or rather in the foetus ; for here the main trunks ofthe arteries are extremely short, while the capillaries are very large, and from the obliteration of many vessels in subsequent life, more numerous than at any other period. It is highly probable, indeed, that while the aorta in childhood is not a fourth part of the size of the same vessel in an adult, the aggregate of the capillaries of the former possesses a di- ameter more than four times as large as the aorta in the latter. We may hence, in some degree, account for the difference in the quickness of the pulse at different periods of life. In early infancy it beats as much as 140 strokes in a minute ; to- wards the end of the second year it is reduced to 100 ; at puberty it is only 80 ; about virility 75 ; and after sixty years of age seldom more than 60 in a minute. For reasons connected with^the preceding, it is more frequent in per- sons of short stature, those of strong passions of mind, those of great muscular exertion, and in females. From the increasing diameter of the bloodvessels as they diverge from the heart, the blood has a greater space for moving forward, and is able to move with more freedom; and hence one reason for the empty state in which the arteries are found immediately after death : a second reason is, that the tunics of the veins, possessing little or no elasticity, read- ily dilate to the distentive power of the blood as it moves forward : a third, and indeed the principal reason, as sufficiently proved by Dr. Carson, is the natural elasticity or resilience of the lungs, which, by keeping them after death in a state of dilatation, allows the blood to ac- cumulate here as in the vacuum. And hence, again, the reason of the accumulation of blood, secretion take place through the thin coats of. the vessels.—Ed. which is usually found in the chest after death, as well as the empty state of the vessels. This vacuity of the arteries after death was one of the objections urged very forcibly by the ancients against the circulation of the blood, oi even its following at all the course of the arter- ies ; and which Dr. Harvey very unsatisfac- torily replied to, by asserting, contrary, indeed, to fact, that the heart continues to contract for some time after death, and even after it has received blood ; for it is generally found loaded with blood.—(Carson " On the Vacuity of the Arteries after Death;" Med. Chir. Trans., vol. xi., part i.) The pulmonary artery, which receives from the heart the blood returned into it from the veins, bears a very close proportion to the diam- eter of the aorta (Hunter, p. 133), which sends the blood from the heart over the whole of the larger oirculation. The aorta possesses more strength, but their elasticity is nearly equal, and the measure of each, on being slit, is about 3$ inches: and hence there can be little doubt, that the quantity of blood sent back to the heart is on an exact balance with that which flows from it. It is not, however, at any time the identical blood, which is thus returned to the heart; for every organ takes from the gen- eral current, as it visits it, such parts and such principles as it stands in need of to support the wear and tear of its own action ; while another considerable portion is thrown off, as we have already observed, in the form of secretions or exhalations, from various emunctories that open externally or into internal cavities. But the drain which is hereby produced on the arterial blood, is compensated by the various fluids col- lected from every part by the absorbent vessels, and by the flow of the chyle from the digestive organs ; both which are poured into the thoracic duct, and finally intermixed with the returning current of venous blood a short time before it reaches the heart; and, in this manner, the bal- ance of arterial and venous blood is maintained. With respect to the actual quantity of blood contained in the entire system, our means of determination are so inexact, and consequently the calculations, or rather the conjectures, that have been offered upon the subject, are so stri- kingly discrepant, that it is not easy to reach a satisfactory conclusion. It is only necessary to state a few of the different opinions that have been offered, to show the absurdity of several of them. Muller and Abeildgaard estimate the weight, even in an adult, at very little more than eight pounds (Blumenb. Elem. Phys., p. iv., sect.' 6); Borelli at twenty ; Planch at twenty-eight ; Haller at thirty ; Dr. Young at forty (Phil. Trans., 1809, p. 5.); Hamberger at eighty ; and Keil at one hundred. Blumen- bach states the proportion in an adult healthy man to be as I to 5 of the entire weight of the body. Yet, little reliance can be placed on this last mode of determination, on account of the great diversity, in point of bulk and weight, of adults, whose aggregate quantity of blood is in all probability nearly alike. The mean num- bers, as those of Baron Haller and Dr. Young, Cl. HI.: PHYSIOLOGICAL PROEM 311 making the amount from 301b. to 401b., appear most reasonable ; and, perhaps, fall not far short of the sum intended by Blumenbach. The subject requires further examination, and a nicer estimate. II. There is another question, which has also, in all ages, greatly occupied the attention of physiologists, but upon which we still remain in a very considerable degreee of indecision ; and that is, the moving powers employed in the circulation; or, in other words, the projectile force by which the blood is sent forward.* [Harvey, Haller, Spallanzani, Legallois, Par- ry, and Magendie maintain, that the sole moving power of the blood is the action of the heart. Pecquet, Barlholine, Bohn, Senac, Verschuir, Zimmermann, John Hunter, Blumenbach, Soem- merring, Langenbeck, Tiedemann, Beelard, Sir E. Home, Dr. Hastings, and Dr. W. Philip infer from their researches, that the circulation does not depend on the heart alone, but is also supported by muscular contraction of the arte- ries. Darwin, Bichat, Richerand, and probably Meckel, deny that the greater arteries possess vital contractility, or contribute to the propul- sion of the blood, but assign to the smaller * In the Am. Journal of Med. Sciences, No. 22, p. 348, Dr. Robinson, of Petersburg, Va., has recorded an interesting case of malformation, which may throw additional light on the action of the heart. In a newborn and full-grown infant, the two clavicles, the sternum, and the costal car- tilages were deficient; and the cavity of the tho- rax was exposed to view. The pericardium was absent, and the motions of the heart were observed for fifteen or twenty minutes; this organ was then removed from its attachments, opened, and thrown into a basin of cold water. It however still con- tinued to beat, with less force, but with perfect regularity. The conclusions drawn by Dr. R., from seeing and touching the heart, are as fol- low :—" Systole and diastole are the natural muscular actions of the heart. The force of the diastole is equal to, if not greater than, the force of the systole. There is no pause between auri- cle and ventricle, either in diastole or systole: the action passing from base to apex with great velocity; perhaps accelerated, certainly not retarded. There is not only no pause between the diastole and systole, but the latter almost seems to appear before the former vanishes: thus presenting the appearance of one compound action, in which all the parts concerned co-operate perfectly. The diastole always precedes the systole in the natural order of action. Similar actions in similar parts of the different sides are always synchronous. The time of action, including systole and diastole, is less than the time of the pause. The pause succeeds the systole of the organ. The impulse of the apex against the side of the thorax is caused by the diastole of the auricles, especially the left; for, as the distance of the axis of the heart from the diaphragm must be increased by the increase of its transverse diameter in diastole, and as it is firmly tied down at its base, this increase of dis- tance of the axis can be effected only by its turn- ing on the distended auricle—as each action of the heart is performed by a convulsive jerk, the force of the impulse is naturally accounted for. There is in the heart a vis insita, or vis propria : this is demonstrated by its perseverance in action so long, after its entire separation from all influ- ence of the brain, nerves, and ganglions."—D. arteries and capillary vessels a vital contrac- tility, through means of which the blood is first attracted, and then propelled, and ascribe to the circulation in them a nearly complete independ- ence of the influence of the heart. Others, as Carus, Treviranus, Dollinger, and Oesterrhei- cher, are led by their inquiries to believe, that neither the larger arteries, nor the capillary ves- sels, contribute by their contractions to the progress of the blood ; but, that the blood moves chiefly through means of its vitality, ,or an in- herent power of motion, and that its movement, as thus effected, is materially supported by the action of the heart alone.*] The heart forms the salient point of motion, and with its systole or contraction the circula- tion commences. But what is it that excites the heart to contract 1 One of the most com- mon answers to this question, in the writings of physiologists, is, the flow of the blood into the ventricles. But this is merely to argue in a circle ; for the question still returns, what is it that makes the blood flow into the ventricles ? Others have referred the cause to an immediate impulse from the brain. Now, in contractions of the voluntary muscles, there is no doubt of the existence of such an "impulse, for we are conscious of it, and assent to it; but we are nei- ther conscious of, nor assent to, any thing of the kind in respect to the contraction of the heart ; and are perfectly sure that no such power of the will takes place during sleep. It is a mere as^ sumption; and an assumption which can only apply to a part ofthe great animal kingdom, even during wakefulness ; for, as it is only in mam- mals and birds that the nerves can be thus in- fluenced in their passage to the heart, the pos- tulate does not account for the contraction or dilatation of the heart in other classes of an- imals. Mr. John Hunter ascribes this action of the heart, or rather the whole career of the circu- lation, of which he regards the action of the heart as a single and ordinary link in the gen- eral chain, to what he calls a stimulus of ne- cessity ; by which he seems to mean, an instinc- tive power, dependant on the general sympathy of the system, which in every part is craving or demanding such an alteration ; or, in other terms, is uneasy without it. His words are as follow:—"The alternate contraction and relax- ation of the heart constitutes a part of the circulation ; and the whole takes place in con- sequence of the necessity, the constitution de- manding it, and becoming the stimulus. It is rather, therefore, the want of repletion, which makes a negative impression on the constitu- * See Wedemeyer's Untersuchungen fiber den Kreislauf des Bluts, &c, Hanover, 1828 ; and Edinb. Med. and Surgical Journ., No. c, July, 1829, in which a detail of the contents of Wede- meyer's treatise will be found; the first part of which treats of the part performed by the greater arteries in the , circulation; the second, of the movement of the blood in the minute arteries and capillaries; the third, of the movement of the blood independently of mechanical actions; and the fourth, of the phenomena of capillary attraction in the animal system.—Ed. 312 PHYSIOLOGICAL PROEM. [Cl. III. tion, which becomes the stimulus, than the immediate impression of something applied to the heart. This we see to be the case, wher- ever a constant supply, or some kind of aid, is wanted in consequence of some action. We have as regularly the stimulus for respiration, the moment one is finished an immediate de- mand taking place ; and if prevented, as this action is under the influence of the will, the stimulus of want is increased. We have the stimulus of want of food, which takes place regularly in health, and so it is with the circu- lation. The heart, we find, can rest one stroke, but the constitution feels it; even the mind and heart are thereby stimulated to action. The constant want in the constitution of this action in the heart, is as much as the constant action of the spring of a clock is to its pendulum, all hanging or depending on each other."—(On Blood, p. 149.) Mr. Hunter's " Treatise on the Blood" is a work of such sterling merit, so rich in its facts, and so valuable in its remarks, that, notwith- standing a few nice-spun and chimerical specu- lations that occasionally bewilder it, there is no book on physiology which a student ought to study more assiduously. Yet I am much afraid, that the language now read has no great deal of meaning in it; and that it does little more than tell us, that the heart contracts because it contracts, or, rather, that the circulation takes place because it takes place. Few physiologists indeed seem to have adopt- ed this opinion : and hence a far more plausible and intelligible hypothesis has been since of- fered. This consists in supposing the heart to be stimulated by the oxygen of the blood intro- duced into it in the lungs by the process of res- piration. Such was the favourite opinion of Dr. Darwin; and such appears to have been the opinion of Blumenbach, who was so fully persuaded of the oxygenized state of the blood when first received by the heart and poured into the arteries, that he expresses a desire of changing the terms arterial and venous blood for oxygenized and carbonized. That oxygen, if introduced into the blood, would stimulate the heart, there can be no doubt, from numerous experiments which prove that a very small quantity of any foreign body whatever, even an- ounce or two of solution of gumarabic, infused into the blood by opening a vein, will not only stimulate the heart, but the stomach, intestinal canal, and other organs, with which the heart readily sympathizes.—(De Chirurgid Infusoria renovendd. Aut. J. M. Regnaudot, 8vo., Lugd. Bat., 1779.) [Wheth- er the gumarabic thus injected into the veins would stimulate the preceding viscera, requires proof; but various experiments of M. Magendie show, that it would produce death on another principle ; namely, that of obstructing the cap- illary circulation in the lungs. The hypothesis of Darwin is refuted by the fact, that it would at all events only account for the contraction of the left cavities of the heart; since those of the right side, which perform their contrac- tile functions perfectly well, receive blood that has not undergone the oxygenating change of respiration. Mr. Brodie found in his experi- ments on rabbits, that the heart continued un- altered for at least two minutes after that viscus and the great bloodvessels were empty of blood ; and hence he concluded, that its action does not depend upon the presence of the blood in its cavities.—(See Cook on Nervous Dis- eases, Introd-, p. 61.) It should also be rec- ollected, that if the contact of the blood were necessarily followed by the contraction of the heart, this organ would never be relaxed, be- cause, though the quantity of that fluid undoubt- edly varies at different moments in the auricles and ventricles, it is difficult to suppose that they are ever free from it. Senac's doctrine, that the contraction of the heart is caused by the stimulus of the distention of the blood, is also one that cannot now be retained.] But passing by, till this question is settled, the doctrine of the primum mobile, or first moving power of the blood from the heart—by what means is the motion, thus mysteriously commenced, maintained afterward through the whole circulatory course 1 Harvey replied to this question by asserting, that it is maintained by the action of the heart alone, which propels the blood equally through the entire length of the arteries and veins, both which he regarded as tubes alike inert, and in no respect contrib- uting to the propulsive energy. This dictum was at first received with uni- versal assent ; and the mechanical physiologists immediately set to work, in order to calculate the force with which the heart acts at every contraction, in the same manner as they had endeavoured to calculate the force of the stom- ach in the process of digestion. It is not ne- cessary to enter into the detail of these esti- mates. It is sufficient to observe, that, from Michelot to Sauvages, or Cheselden, they all differed from each other as widely as in calcu- lating the quantity of blood in the system ; and that, while Keil estimated the projectile power of the heart at five ounces, and Hales at fifty- one pounds and a half, Borelli fixed it at no less than one hundred and eighty thousand pounds.* There are various facts, however (and sev- eral have been already mentioned in the course of this proem), which sufficiently prove, that the heart cannot be the sole propulsive power through the entire range of the circulation. The two following are also much insisted upon : Firstly, that the pulse, if the systole of the heart were the only projectile force, must take place, not synchronously all over the system, as it is well known to do, except in a few mor- bid cases in which local causes interfere, but subsequently to the contraction of the heart, and successively through the whole line of the arterial tubes, in proportion as they lie more * For some valuable matter on this point, see the Researches of J. L. M. Poiseuille on the Force of the Aortal, or Left Side of the Heart, in Bres- chet's Repertoire Gen. d'Anat., &c, 3me trim- estre de 1828 ; or, the translation in Edinb. Med and Surg. Joum., No. for July, 1829, p. 28.—Ed. Cl. III.] PHYSIOLOGICAL PROEM. 313 remote from the salient point.* And, secondly, that whatever may be the projectile power of the heart, it must altogether cease with the arteries, and cannot reach the veins. And hence arose another hypothesis, which ascribed the propulsive power to a progressive vis a tergo, or a force communicated from the ventricles of the heart to the commencement of the arteries, producing a vibration or alter- nate dilatation and contraction of their tunics through their whole length to the veins; and thus acting in conjunction with the projectile force of the heart itself. In proof of this auxiliary power afforded by -the coats of the arteries, the phenomenon of pulsation was triumphantly appealed to ; which, it was maintained, gave a direct and incontro- vertible evidence, that an alternate dilatation and contraction, or enlargement and diminution in the diameter of the arteries, is constantly taking place. This, by Bichat, is attributed solely to the locomotion of the arterial tubes, propagated to their terminal ramifications, and thence continued to the veins ; but, by most modern physiologists, to a joint power, com- pounded of the action of the heart and the arteries. Bichat's doctrine has of late been incontro- vertibly refuted by one or two very simple ex- periments of M. Magendie.—(Physiologie, torn. ii., p. 320.) Besides which, however, it is now a well-ascertained fact, and one that has been thoroughly elucidated by Dr. Parry of Bath {Exp. Inq. into the Nature, Cause, and Varie- ties of the Arterial Pulse, &c, Bath, 1816), that no increase of size, or indeed change of bulk of any kind, takes place in arteries during either the systole or diastole of the heart's ven- tricles in a state of health. The arteries of animals, to ascertain this point, have been ex- posed in different parts, and to considerable lengths, without evincing the least apparent in- crease of size. And hence it is the pressure of the finger, or of some other substance against the side of an artery that alone occasions pulsa- tion, in consequence of the resistance hereby made to the regular flow of the blood ; the alternating beat being produced by the greater momentum with which the current strikes against the finger or other cause of obstruction during the systole, than during the diastole of the heart. Dollinger confirmed Parry's experiments by laying bare the carotid of a dog before his pupils, which gave to the eye no proof of altered form or motion, though a pulse was distinctly felt by the finger. And, in like manner, a pulsatory motion is always felt by the fingers when ap- plied to a leaden water-pipe while a pump is at work upon it at one end, and alternately giving a fresh pressure to the column of water it con- tains by forcing in a fresh supply : yet the pipe is all this time incompressible. [Sir David Barry plunged his arm into a horse's chest, and found the aorta constantly * This is still maintained to be the fact by 51. Poiseuille, as will be presently noticed.—Ed. full, without any variation of its distention for an instant, though he took hold of it for five minutes, and repeated the experiment. On the other hand, the vena cava was so little dis- tended that it felt like a thin flaccid membrane. (Dissert, sur le Passage du Sang a travers le Cosur, p. 78, Paris, 1827.)] In inflammation, the pulse of the inflamed part in consequence of local excitement is much more frequent than that of the heart or of any other organ. Thus, in a whitlow, the radial artery may give to the finger a hundred pulsa- tions in a minute, while not more than seventy strokes may be exhibited in any other part of the system. The rapidity of the pulse is in this case usually in proportion to the degree of the inflammatory action (Exp. of the Prin. of Pathology, &c, by Daniel Pring, M. D., p. 119, 8vo., 1823) : and hence, if the system should labour at the same time under ten different in- flammations in different parts or organs of a dif- ferent structure, as glands, muscles, and mem- branes, it is possible that it may have so many different seats of pulsation taking place at such different parts at one and the same time, while all of them are at variance with the pulsation of the heart. Even where there is no inflam- mation, such discrepances in the pulse are oc- casionally to be met with, insomuch that Riel gives a case in which the heart, the carotids, and the radial arteries all pulsated differently (Memorabilia Clinica, vol. ii., fascic. 1-6, Hall., 1792) ; and we can hence readily perceive why they should be more frequent and striking under the increased action produced by inflammation, and often, in a debilitated organ, more disposed to irregular action, and particularly irregular contractile action, in its capillaries. [Respecting the correctness of the state- ment, that the pulsations of inflamed parts are often more numerous and frequent than those of the rest of the system, the editor has never seen a case in confirmation of it; and were not the thing asserted by so many men of eminence, he should be inclined to set it down as erroneous. In whitlows, and other cases, the arteries leading to the part affected throb with increased force ; but never, as far as the editor's observations reach, with a quick- ness exceeding that of the action of the heart. However, if the statement made by writers be accurate, physiologists need no longer doubt and dispute about the muscularity of arteries, and even of those which cannot be regarded as capillaries, to which all physiologists impute a contractile power under some name or another.] We are let a little into the mystery of the above-mentioned phenomenon by the curious fact, that some of the arteries possess a higher degree of contractile power than others, and that the capillaries possess the highest measure allotted to any of them. " Indeed, every fact," observes Dr. Bostock (Physiology, vol. i., p. 402), " with which we are acquainted, respect- ing the mechanism and functions of the sanguif- erous system, leads us to the same conclusion, that the large arteries are to be regarded as canals transmitting the blood from the heart, 314 PHYSIOLOGICAL PROEM. [Cl. III. where it receives its great impulse, into the smaller branches ; and that it is chiefly in these smaller branches that it exercises its various functions." We may hence see why the capil- laries are, in many cases, so much sooner ex- cited than the larger canals, and exhibit so much more violence of action : a distinction of high importance in explaining the doctrine of in- flammation, though it has been less attended to by pathologists than it deserves. The hypothesis, therefore, of a vis a tergo, whether dependant upon the heart alone, upon the arteries alone, or upon a combination of the two, has by no means proved sufficiently satis- factory, or been sufficiently supported by evi- dence in respect to the entire circulation. Under no modification does it account for the flow of the blood through the veins. And in regard to the whole of the views which have been thus far examined, Mr. John Hunter, as I have already observed, was so extremely dis- contented, that he placed no more stress upon one part or organ of the sanguiferous system than upon another; upon the heart than upon the arteries ; or upon the arteries than upon the veins; regarding the whole economy as the result of a sort of instinct, to which, as just noticed, he gave the name of a stimulus of ne- cessity ; and which opinion he supported by making an appeal to insects which had no proper heart; to worms, most of which have no heart whatever ; and to monsters which have been born without a [heart; while at the same time he contended that veins, at least the larger, ex- hibit, under certain circumstances, an expansile and contractile power as well as arteries. " I think it probable," says he (p. 187), " that where there is a universal action of the vascular sys- tem, the action of the arteries and veins is alternate : that where the arteries contract, as in many fevers, the veins rather dilate, more especially the larger." And it is hence again highly probable, that in this " universal action of the vascular system," the secernents, or ex- treme arteries, take an important part; and not impossible, though the thing needs proof that they operate, as has been suggested by Dr. Pring,* by a kind of suction, which may be re- garded as a vis a fronte. * Ubi supra, p. 132, 165. With respect to Bichat's doctrine, that the impulsive power of the heart is almost nugatory in relation to the blood in the capillaries, Dr. Wedemeyer does not ad- mit its correctness, observing, that the transmis- sion of the heart's impulse, even to the extreme capillaries, may be inferred from the slight force required to impel water, a solution of indigo, or fresh drawn blood, through them with a syringe, even from a large artery; a force certainly inferior to that with which the blood in the same artery flows through it under the action of the heart during life. This statement, as an able critic has remarked, receives corroboration from the late dis- covery of M. Poiseuille, of Paris, that each mole- cule of blood retains the force it received from the heart, even after it has passed through a long course, and, through many subdivisions of the ar- terial system.—(Edinb. Med. Journ., No. c, p. 88.) That the impulse of the heart extends even to the capillaries is further shown by the effects of deple- Upon the whole, we may conclude with Haller, that the heart exerts a very considerable degree of force in the general economy of the circula- tion, although it is impossible to estimate its power with mathematical precision. And we may reasonably refer the first or arterial half of the general circuit of the blood to this force, if not alone, in conjunction with the aid contrib- uted by the elastic and contractile tunics of the arteries themselves, whether pulsation be a result of these powers alternately exercised, or of mere local pressure.* It yet remains, however, to account for the second half, or that which consists in the pas- sage of the blood through the veins ; and upon this subject, there is one most important and elucidating fact, which, till of late, has never been in any degree brought forward in the course of the inquiry. It is this : that when the heart, by the contraction of its ventricles, has ex- hausted itself of the blood contained within it, a comparative vacuum must follow, and the blood from the venae cavae, or venous system at large, be sucked up into the right auricle.t This ingenious remark seems first to have been thrown out by Dr. Wilson Philip (Inquiry, &c, p. 9, &c.): and Dr. Carson, of Liverpool, taking ad- vantage of it, has constructed a simple and beautiful theory of the projectile powers em- ployed in the circulation, the general principle of which may be expressed in a few words. The heart is supposed to act at one and the same time in a twofold capacity. By the con- traction of the ventricles, it propels the blood tion, or of fainting, on sanguinolent secretions, on redundant secretions, and on hemorrhage.—Ed. * It would appear from Dr. Poiseuille's experi- ments, that the force with which a molecule of blood moves in the carotid or in the aorta, is pre- cisely the same with the force of its movements in the smallest arterial branches: or, in other terms, that a molecule of blood moves with the same force throughout the whole arterial system ; " a fact," says this author, " which I was far from anticipating. It is not easy to account for the uniformity here unfolded. When the heart con- tracts, a wave of blood is pushed into the arterial system, already full of blood. The phenomena that ensue are dilatation of the arteries, and a kind of locomotion of the arterial system, by which its eurvatures tend to straighten themselves. These changes cannot take place except at the expense of the force with which the wave is pro- pelled from the heart. But hardly has the arterial system become dilated, and scarcely have its cur- vatures yielded to the action of the heart, when the arteries, through the elasticity of their coats, contract again, and restore to the force of the blood all the loss it had sustained. In this way, perhaps, we may explain how the intensity of the force communicated to the blood by the heart, is preserved (as the experiments referred to show), even to the last arterial ramifications."—See Edinb. Med. and Surg. Journ. for July, 1829, or Breschet's Repertoire Gen. d'Anat., &c, 1828. t Bichat and Dr. Bostock deny the existence of this suction-power, which, however, has Wede- meyer in its favour, who conceives that the heart has the power of promoting the capillary circula- tion, though only in a feeble degree, by the suc- tion-power of its auricular cavities, or the blood in the veins.—Ed. Ci.. III.] PHYSIOLOGI through the arteries; and by the dilatation of the auricles, it draws it up from the veins. It is at once, therefore, a forcing and a suction pump. The contraction of the heart, and con- sequently its comparative vacuum, are supposed to be considerably assisted by the elasticity of the lungs, and the play of the diaphragm, which we had occasion to notice at some length in our physiological proem to the preceding class, and the great resistance which they jointly af- ford to the atmospheric pressure ; while this very pressure, applied on every part of the ex- terior of the animal frame, contributes in an equal degree to the ascent of the blood in the veins ; for as the column of venous blood is perpetually girt on all sides, and cannot fall back because of the numerous valves with which the veins are furnished, it must necessarily take an opposite or ascending direction. A suction power, however, as existing in any part of the heart, has been positively denied by Sir David Barry ; whose hypothesis transferred it from the ventricles of this organ to the cavity of the thorax, or rather to the great veins con- tained within such cavity. The grand cause of the venous part of the circulation is, with him, " atmospheric pressure, diminished, or en- tirely taken off, around the cardiac ends of the venous tubes, during the expansion of the chest, but unaltered and entire around every other part of their surface, opposed only by the gravity of the fluid acted upon." He has, indeed, suf- ficiently shown, by a multitude of experiments, that the suction operation of the greaj veins is precisely coincident with the instant, in which the animal experimented upon endeavours to form a vacuum in the chest: that the black blood passes through the veins only during the act and time of inspiration ; and that this venous movement is always placed under the influence of atmospheric pressure. There can hence be no doubt that the action of the atmosphere upon the cavity of the chest during the alternating process of inspiration and expiration, exercises a much more powerful effect upon the circula- ting system than has hitherto been taken into the account. But as the pulsation of the heart and arteries may be made to continue with regu- larity, even in mammalian animals, by a forced quiescence of the lungs, for sixty or eighty strokes in succession, in divers for half an hour, and in syncope for a much longer period of time ; iand as a like circle of action is found to prevail in animals below this rank, as in fishes and reptiles, whose mode of respiration is dif- ferent, and does not allow of the same thoracic suction power, Sir David Barry seems to have overrated the assistance which the venous cir- culation derives from this quarter, in concluding, that of all the contributing forces, " the pressure of the atmosphere is by far the most intense in its degree, the most constant in its influence, and the most unvarying in its amount: that, without which, the circulation could not be maintained beyond a few moments."—(Experi- mental Researches, &c, p. 58, 8vo.) It is well observed by Dr. Bostock, that in the healthy state of the system, we respire, upon the aver- ^AL PROEM. 315 age, about twenty times in a minute, while the average velocity of the pulse may be estimated at eighty, so that the heart contracts four times during each act of respiration; and must con- sequently receive the blood during all the various states of distention to which the lungs are sub- ject ; yet we do not perceive that the pulse ex- hibits any corresponding variations, either in its strength or its velocity. And further, we shall find it very difficult to produce any effect upon the pulse by the most powerful voluntary efforts of inspiration or expiration ; yet, in such cases, the capacity of the thorax will certainly undergo a much greater change than it can possibly ex- perience in its ordinary action.* There are, nevertheless, numerous difficul- ties that yet remain to be explained ; such as the proportion of projectile power furnished by the conducting pipes themselves; by what means the want of a diaphragm is compensated in birds and reptiles which have no such organ ; what constitutes the projectile power in animals that have no heart, and consequently no double pump to work with ;t [the mode of contraction * Elementary System of Physiology, vol. ii., p. 56, 8vo., 1826.—The above observations on Sir David Barry's theory were lately found among Dr. Good's papers, and would have been inserted in the last edition of this work, had they been put into the editor's hands early enough for the pur- pose. Wedemeyer infers from an experiment made on a horse, the particulars of which are given in the Edinb. Med. Journ., No. c, p. 89, that, in the natural state of the breathing, the suction-power' must be very insignificant, which, according to Sir David Barry's researches, is exerted upon the venous blood by inspiration. Wedemeyer objects to that author's statements, 1. That the tendency to a vacuum in the chest during inspiration must be completely overcome by the entrance of the air, an elastic mobile fluid, before any material suction-power can be exerted on a heavy inelastic liquid, such as the blood. 2. That the afflux of blood in a tube towards the jugular vein of the horse, was observed by Sir David Barry to cor- respond with inspiration only when the animal was lying, and consequently breathing with un- natural force with one side only of the chest; and that, in the erect posture, no such correspondence is to be observed, unless the animal be excited to violent respiration. 3. That the tendency to a vacuum in the chest cannot account for the move- ment of the blood in the pulmonary veins, which are subjected outwardly to the same power which is supposed to act on the blood within them. 4. That the venous circulation may be kept up in the mammalia by artificial breathing, for twenty- five minutes or longer after decapitation, although, in such circumstances, the chest internally is con- stantly subjected to pressure ; and that in frogs and other cold-blooded animals, the venous cir- culation will continue for hours, after the breath- ing has been annihilated by laying open the chest. 5. That the venous circulation goes on in the foetus, and in many of the lower animals, without any respiratory movements whatsoever. These objections, along with what has been advanced by Dr. Arnott on the subject, seem to an able critic to render the supposed discovery of Sir David Barry exceedingly doubtful. Vid. Edinb. Med. Journ., No. cc.; and Wedemeyer's Unter- suchungeniiberdenKreislaufdesBluts,l828.—Ed. t Diatribe Anatomico-Physiologica de Structural 316 PHYSIOLOGICAL PROEM. [Cl. IH. in the vessels ; since, as there are no valves in the arteries, if the contraction be supposed to take place simultaneously in their whole course, it may appear to some physiologists as likely to have a tendency to propel the blood backwards or forwards. Indeed, Bichat avails himself of the fact, that the arteries have no valves, to strengthen his position, that these tubes cannot be muscular.] There is also another curious fact, which physiology has pointed out, but has never hith- erto been able to explain ; and that is, a direct communication between remote or unconnected organs, apparently, by some other channel than the circulation of the blood. Something of this kind seems to exist between the spleen and the stomach, the former of which has been proved by Sir Everard Home to receive fluids from the cardiac portion of the latter, though we can trace no intercourse of vessels: but the most extra- ordinary example of this kind which at present we seem to possess, is, the communication which exists between the stomach and the bladder. For the experiments of Sir Everard Home, (Phil Trans., 1811, p. 163), and the still more decisive ones of Dr. Wollaston and Dr. Marcet, (Ibid., p. 96), seem to have established beyond a controversy, that certain substances introduced into the stomach, as rhubarb, or prussiate of potash, may pass into the bladder without taking the course of the bloodvessels, and consequently by some other channel; a channel, indeed, of which we know nothing.* This is a subject well worth studying: for if two organs, so re- motely situated as the stomach and the bladder, be thus capable of maintaining a peculiar inter- course, so other organs may possess a like intercommunion ; and, by such means, lay a foundation for those numerous sympathies be- tween distant parts which so often strike and astonish us. M. Magendie's hypothesis, that veins are absorbents, may explain the facts in Sir Everard Home's experiments, but has no bearing upon that of Dr. Wollaston and Dr. Marcet. The discovery of the circulation of the blood has given a great importance to the doctrine of pulsation ; for by the strength or weakness, the slowness or frequency, the hardness or soft- ness, the freedom or oppression, the regularity or irregularity of the beat of the artery against the pressure of the finger, we are now able to determine many momentous facts, relative, not merely to the state of the heart, but of the gen- eral system; and, in many cases, to prognosti- cate upon grounds which were altogether un- known to the earlier cultivators of medicine. atque Vitft. Venarum : a Medicorum ordine Hei- delburgensi praemio proposito ornata.—Auctore Henrico Marx, 8vo., Carlsrhue, 1822. * In some particulars of a remarkable and per- haps quite unique case of taenise, voided from the meatus urinarius, it is stated by Mr. Law, of Pen- rith, who attended the patient, that the turpentine which she took by the mouth found its way into the bladder in twenty seconds. The letter men- tioning this curious fact, was shown to the editor by his friend, Mr. Docker, late of Canterbury.—Ed. And on this account it is, that the Greek physi- cians took but little notice of the pulse, which, even in the days of Celsus, was regarded as a res fallacissima. The pulse is influenced indirectly by the gen- eral state of the body, but directly by that of the heart, or of the arteries, or of both, or of the quantity of blood which the vessels have to con- tain. In an adult male of good health, and not too corpulent, the common standard of the pulse may be fixed at seventy strokes in a minute ; but it varies in different individuals from sixty to eighty, being greatly affected by the temper- ament, and partly b^ the habit of life. In the man of a high sanguine character it rarely sinks below eighty, and is often at ninety ; and in the melancholic, it seldom rises above sixty, and sometimes sinks to forty. In some idiosyncra- sies the discrepance is so considerable, and complicated with other changes than those of frequency and tardiness, that there is no redu- cing them to any rule. Sir John Floyer, who has numerous bright openings in the midst of a generally obscure horizon, set down the stand- ard number of pulses in health at seventy-five, and affirms that they cease altogether at forty, and are followed by a loss of all sense and mo- tion.—(The Physician's Pulse-Watch, &c, 2 vols., 8vo., Lond., 1707.) Lizarri tells us, however, of a person whose pulse was not more than ten beats in a minute. —(Raccolta d'Opusculi Scientifici, p. 265.) Dr. Heberden says, he once saw a person whose pulse, as he was told, did not number in the beginning of his illness above twelve or sixteen in a minute ; though he suspects, in this and all other instances, where it is below forty, that the artery beats oftener than it can be felt; be- cause such low pulses are usually unequal in their strength, and some of the beats are so faint as but just to be perceived ; so that others, probably still fainter, are too weak to make a sensible impression on the finger. He had at- tended two patients, who, in the best health, had always very unequal pulses, as well in their strength as in the spaces between them, but which constantly became regular as the patient grew ill, and gave a never failing sign of recov- ery in their once more returning to a state of ir- regularity.—(Med. Trans., vol. ii., art. ii., p. 29.) In women the pulse is, generally speaking, six or eight strokes in a minute quicker than in men, and hence, many women, of firm health and a lively disposition, have a standard pulse of eighty-five. In a weakly frame, the pulse is usually rapid ; for debility is almost always accompanied with irritability, and the heart partakes of the gen- eral infirmity. In this case, also, from the feebleness with which the heart contracts, the ventricle is but imperfectly emptied, and con- sequently sooner filled again, and sooner stimu- lated to contraction. Hence, in infancy, the pulse is peculiarly quick, and gradually becomes slower as the child increases in strength. Dr. Heberden, who paid particular attention to this subject, estimates the pulse on the day of his Cl III.] PHYSIOLOGICAL PROEM. 317 birth, and while asleep, from a hundred and thirty to a hundred and forty ; and fixes it at lit- tle less than the same rate, or that of a hundred and twenty strokes, for the first month. Du- ring the first year he calculates it at from a hun- dred and twenty to a hundred and eight; du- ring the second, at from a hundred to ninety; during the third, from a hundred and eight to eighty, at which it continues for the three ensu- ing years. In the seventh year it is frequently reduced to seventy-two ; and in the twelfth, to seventy.—(Med. Trans., vol. ii., art. ii., p. 29.) In advanced age, the pulse sinks often consid- erably below sixty strokes in a minute. " I knew one," says Dr. Heberden, " whose chief distemper was the age of fourscore, in whom, for the last two years of his life, I only once counted so many as forty-two pulsations; but they were seldom above thirty, and sometimes not more than twenty-six. And though he seemed heavy and torpid, yet he could go out in a carriage, and walk about his garden, receive company, and eat with a tolerable appetite." I have at this moment under my care a case of still greater anomaly, in which the pulse is never more than thirty, and more commonly, even after walking, not more then twenty-seven strokes in a minute. Mr. Alexander, the pa- tient I refer to, is sixty-five years of age. About six years ago, from the bursting of a pipe for the conveyance of coal-gas, he fell down in a fit of asphyxy, from which he revived with great diffi- culty. The reducing plan was carried too far, and, though he has recovered from the acci- dent, and his head is uniformly clear, he is dys- peptic, and subject to palpitations of the heart. [In September, 1828, a gentleman, named Paine, was confined in the Fleet prison, whose pulse was sometimes as low as thirty, and hardly ever above forty : he suffered a good deal from asthma.] The pulse may be counted with great accuracy up to a hundred and forty or a hundred and fifty in a minute ; and if the stroke be equal, and the wrist slender, so that we can take in more than half the artery by the pressure of two fingers, we can reach a hundred and eighty; Professor Frank gives an instance of two hundred (De Cur. Horn. Morb. Epit., torn, ii., p. 175, 8vo., Manheim, 1792), in a case of complicated car- ditis ; but, beyond this, there is great confusion and uncertainty; and it is difficult, therefore, to understand by what nice mode of measurement Dr. Wendt could distinguish, as he tells us he has done, a pulse of two hundred and forty-three strokes in a minute.—(De Mutatione quadam Pulsus insigni, Erlang., 1778 ; V. Bald. Syll. v.) Sir John Floyer (Op. cit.) sets down a hundred and forty as the amount of " as many pulses as can be counted." The pulse is quickened by very slight excite-> ments, both external and internal. . The stimu- lus of the air, of the light, and of sounds, is suf- ficient to make that of an infant awake fifteen or twenty strokes more frequent than when it is asleep, and beyond their control. The pulse of an adult is usually quickened eight or ten strokes during the digestion of a meal; and running, or any sudden and rapturous emotion of the mind, will double the ordinary scale. The depressing passions, on the contrary, check it, and have sometimes put a total stop to the heart's motion, with a deadly shock, and killed the patient in a moment. There are many drugs that have a like tendency, of which all the simple narcotic poisons afford examples. The digitalis and hyoscyamus are expressly used on account of this property: the prussic acid, and the plants that contain it, as bitter almonds and the leaves of the prunus laurocerasus, when given in free doses, destroy the irritability, and extinguish the pulse instantly ; and this so effectually that the heart, when immediately examined, has been insensible, not only to puncture, but to concentrated acids. As the excitement of the stomach during the natural process of digestion is capable of accele- rating the pulse eight or ten strokes in a minute, there can be no difficulty in conceiving, that it may be still more accelerated by a morbid ex- citement of any other large organ, and particu- larly where the primary seat of excitement is in the sanguiferous system itself. And as, gen- erally speaking, the frequency of the beat is in proportion to the degree of excitement, the pulse becomes a sort of nosometer, or measurer of the violence and danger of the disease : and it measures it equally, whether the return of the beat be below the standard of health or above it. How far, in either case, the pulse may vary from its natural number without great danger, depends upon a multitude of collateral circum- stances, as the age of the patient, his idiosyn- crasy, the peculiar disease he is labouring under, and the strength or weakness of the system. And hence, in addition to the number of the pulse, we should also attend to its degree of fulness, softness, firmness, freedom, and regu- larity ; a critical knowledge of which can only be learned by experience and a nice discrimination. It has been highly injurious, however, to the study of medicine, that this subject has been often too finely elaborated, and the variations of the pulse been ramified into so many divis- ions and subdivisions, and nice unnecessary distinctions, as to puzzle the young and be of ho use to the old. And hence, some of the best pathologists of modern times have been too much disposed to shake off nearly the whole of the encumbrance, and pay no attention whatever to the pulse except in regard to its fre- quency. Among this number was Dr. Heber- den :—" Such minute distinctions of the sev- eral pulses," says he (Med. Trans., vol. ii., p. 20), " exist chiefly in the imagination of the makers, or, at least, have little place in the knowledge and cure of diseases. Time, in- deed, has so fully set them aside, that most of these names of pulses are now as unheard of in practice as if they had never been given." And in forming, therefore, his prognostic of a disease, while he appeals to the pulse merely in respect to its number, he draws his other grounds of decision from the nature of the malady, and the violence of its specific signs. But this is to limit the subject to too strict a 318 PHYSIOLOGICAL PROEM. [Cl. III. boundary ; and to exclude ourselves from what, in many instances, are clear and even leading diagnostics. There are some practitioners, and of very high merit too, whose fingers are no more capable of catching the finer distinctions of the pulse, than the ears of other persons are the niceties of musical sounds. I suspect this was the case with Dr. Heberden, as it was also with the late Dr. Hunter; of whom Mr. John Hunter observes, that, "though he was ex- tremely accurate in most things, he could never feel that nice distinction in the pulse that many others did, and was ready to sus- pect more nicety of discrimination than can really be found. Frequency of pulsation in a given time is measurable by instruments; smartness or quickness in the stroke, with a pavfse, is measurable by the touch, but the nicer peculiarities in the pulse are only sensa- tions in the mind. I think," continues this dis- tinguished physiologist, " I have been certain of the pulse having a disagreeable jar in it when others did not perceive it, when they were only sensible of its frequency and strength : and it is, perhaps, this jar that is the specific distinction between constitutional dis- ease or irritation and health. Frequency of pulsation may often arise from stimulus, but the stroke will then be soft ; yet softness is not to be depended on as a mark of health ; it is often a sign of dissolution; but then there must be other attending symptoms."—(On Blood, part ii., ch. iii., p. 318.) Dr. Fordyce's table of the pulse is, perhaps, unnecessarily complicated ; but the strength or weakness, fulness or smallness, hardness or softness, regularity or irregularity of the pulse, are indications nearly as clear as its frequency or slowness, and, in many cases, quite as diag- nostic ofthe general nature of the disease. Fre- quency and slowness ofthe pulse, taken by them- selves, indicate little more than the degree of irritability of the heart, or the force of the stimu- lus that is operating upon it. The strength and regularity, or weakness and irregularity of the pulse, are as palpable to the finger as the pre- ceding sign, and show, in characters nearly as decisive, the degree of vigour or debility of the heart; and, hereby, except where this organ is labouring under some local affection, the vigour or debility of the system, which a mere varia- tion in the state of the frequency of the pulse will not tell us. A full and a small pulse may be distinguished with almost as much ease as any other property it possesses ; this Mr. John Hunter ascribes to the state of the arteries : but, if I mistake not, it gives us rather a meas- ure of the quantity of blood circulating through the system, than of the muscular strength of the arteries, or of the heart itself; which is often a very important indication, and espe- cially when combined with the preceding signs ; as it will then be our best guide in cases where we have determined upon emptying the vessels as far as we can do it without danger. Hard- ness and softness of the pulse, together with that vibratory thrill which has been called wiri- ness, are not quite so easily learned as its ful- ness and smallness, but a nice finger will readily discriminate them, and practice will point out the difference to every one.* These characters Dr. Fordyce makes dependant, and, I think, with great reason, on the state of the arteries, rather than on that of the heart, or on the quantity of the circulating fluid ; and Mr. John Hunter concurs in the same view. They measure the degree of vascular tone, or power of resistance ; and when the same effect, whether above or below the natural standard, takes place in the capillary arteries, it produces that change in the pulse which he distinguished by the names of obstruction and freedom, but which it is not always easy to discriminate from several of the preceding qualities ; nor is it of great importance, as we have in such cases other symptoms that more strikingly manifest the same fact.f Thus far, perhaps, the doctrine of pulsation may be studied to advantage : but when, beyond this, we come to a distinction between the free and dilated pulse, as proposed also by Dr. For- dyce ; the quick and the frequent, as proposed by Stahl (De Differentia Pulsus ceteris et fre- quentis); and the dicrotic, coturnising, and in- ciduous, proposed by Solano,t as mere subva- rieties of the rebounding, or redoubling, itself a variety of the irregular pulse, we perplex pa- thology with a labyrinth in which the student is lost, and the master wanders to no purpose. * If a pulse be exceeding hard, and at the same time small, then it has been called a wiry pulse ; if a pulse be both hard and large, it is a strong pulse also; if a pulse be small and soft together, then it must be considered as weak.—See Elliotson's Lec- tures, delivered at the London University, pub. in Med. Gaz. for 1831-2, p. 141. T The following useful and practical distinc- tions of the pulse are from the pen of Dr. Miner. " That pulse is said to he frequent, in which there is a great number of attractions and dilatations of the artery in a given time ; and infrequent when there are but few. The pulse is quick, when each con- traction and dilatation occupies but a short time, whether there are many or few in a minute ; and it is slow, when the individual contractions and dila- tations occupy a comparatively long time, whether they are numerous or few in a minute. The pulse is strong, when every dilatation of the artery gives great resistance to pressure ; and weak, when it gives but little resistance. The pulse is considered as full, when a large quantity of blood passes along at every dilatation of the artery ; and it is small, when the quantity that passes at each dilatation is considerable. The pulse is hard, when the artery may be felt like a wire or tense cord, both in its contraction and dilatation; and it is soft, when it is felt only in its dilatation, and easily be- comes imperceptible on pressure. A regular pulse is equal and uniform in frequency, quickness, strength, fulness, and hardness ; under the term irregularity may be included all those varieties of pulse which do not fall unequivocally under some one of the preceding heads."—See Essays on Fevers and other medical subjects by Miner and Tully, Middletown, 1823. See also The Princi pies of Medicine, &c, by Samuel Jackson, M. D., Philadelphia, 1832, p. 488.—D. X Novae Observationes circa Crisium Praedic tiones et Pulsus. Wetsch, Medicinae ex pulsu Vind., 1770; Vienn., 1773. Cl. III.] PHYSIOLOG " Infida," says Professor Frank, "arbitraria et Bequivoca est multorum de pulsibus criticis doc- trina."—(De Curand. Horn. Morbis Epit., torn. i., p. 30.) De Bordeu acquired great reputation in the middle of the last century, for applying the doctrine of pulsation as an index to the diseases of every distinct organ of the body ; whence he not only adopted most of the subdivisions of Solano, but added others, and subdivided them still further. He started it as a new hy- pothesis, which he endeavoured to support by facts and arguments, that every separate organ possesses a principle of life in some measure peculiar to itself, and independent of the rest of the frame ; that each is endowed with a proper function, and susceptible of proper sen- sations and movements ; and that, by the agree- ment and co-operation of all these distinctive powers, the life and health of the entire system are built up and maintained. These principles are developed and defended in his thesis, " De Sensu generice considerato," published at Mont- pelier in 1742. Though arrogating the merit of originality, they are, however, little more than a revival of the ancient doctrine of har- mony invented by Aristoxenus, and at one time very popular in Greece, as we learn from Lu- cretius :— " — Multa quidem sapientum turba putarunt Sensum anrmi certa non esse in parte locatum ; Verum habitum quemdam vitalem corporis esse, ' apmonian' Graiei quam dicunt."* M. de Bordeu, in adopting this hypothesis, sup- posed, further, that an affection of any particular organ will occasion a peculiar variation in the pulse from its natural state ; and, by a careful attention to these changes, he conceived himself capable of ascertaining the seat of the disease, and the channel through which nature was aim- ing at a crisis. He describes, in consequence, an overwhelming multiplicity of organic pulses : but his general division is into superior and inferior pulses ; and this he founds on an observation that the actions of the parts seated above the dia- phragm, and of those below, excite very different impressions on the circulatory system. These views are chiefly given in the most famous of all his publications, entitled " Recherches sur le Pouls, par rapport aux Crises."—Paris, 1756, 8vo. This hypothesis became extremely popular in France and Germany, and excited a considera- ble degree of attention at Edinburgh. It is now, however, little heard of, and is by no means worth reviving. In effect, a voluminous and complicated clas- ification of pulses is rather a proof of an active fancy than of a sound judgment: and though Dr. Heberden and Dr. Hunter may have thought too lightly of this branch of pathognomy, it is better to" adopt their simplicity than the puerile conceits of many more elaborate pulse-makers. The Chinese have a more operose system of pulsations than any that have appeared in Eu- * De Rer. Nat., lib. iii., 98. See the author's examination of this hypothesis, and its resem- blance to others of later date, in the notes to his Translation of Lucretius, book v., 100, and 104. ICAL PROEM. 319 rope : but nothing can be more whimsical than their divisions, though Floyer fell in love with them, and thought them models of wisdom and accuracy. Avicenna treated of the pulse mu- sically ; and Hoffenuffer, pursuing his princi- ples, drew up, in 1641, a musical scale of the pulse, dividing it into musical time, and mark- ing the different beats by semibreves, minums, and crotchets, semiquavers, and demisemiqua- vers ; thus reducing his patient to a harpsichord, and his profession to a chapter on thorough-base. III. [Blood, when first drawn from the ves- sels, is an adhesive fluid, of a homogeneous consistence, of the specific gravity of about 1.050, of a red colour in man and the higher animals, and of the temperature of about 98° in the human subject. Soon after its discharge from the vessels, if- it be suffered to remain at rest,* it begins to coagulate, and, as the process advances, it separates into two distinct parts, namely, a red mass floating in a yellowish fluid. The red part is called the clot, or crassamen- tum, ^nd the fluid part the serum. The aver- age time, requisite for the coagulation of venous blood, is said to be seven minutes ; and the crassamentum has been estimated to amount to about one third of the weight of the serum.— (Bostock's Physiology, vol. i., p. 434.) In the act of coagulation, it is generally believed that an evolution of heat takes place, though the point is yet a contested one ; Dr. J. Davy's in- vestigations (Edin. Med. Journ., No. 95) disa- greeing with those on which the preceding doc- trine is founded, and corroborating the view adopted by Mr. Hunter. The coagulum, or clot, may be deprived of its red colour by repeated ablution in water ; thus showing, as Dr. Bostock observes, that the colouring matter is only mechanically mixed with the substance left behind, called fibrin, and not chymically combined with it. Many causes of sudden death have the curious effect of impeding the coagulation of the blood. This is exemplified in persons rapidly killed by lightning and electricity ; a blow on the^ stom- ach, or injury of the brain; by the bite of a rattlesnake, and other venomous animals; by acrid vegetable poisons, like laurel-water ; ex- cessive fatigue ; and even violent agitation of the mind. In the same cases, Mr. Hunter found a singular coincidence between the want of coagulability in the fibrin of the blood and the loss of contractility in the muscles after death. The body is also disposed to putrefy with unusual quickness. Hence there appears some analogy, if not identity, between muscu- lar contraction, and the coagulation of the fibrin of the blood ; an opinion strengthened, as Dr. Bostock has observed, by the fact that the chym- ical composition of fibrin is similar to that of muscle. From the relation between the coagu- lation ofthe blood and the contractility ofmus * Rest, however, is not essentially necessary to the coagulation of the blood; for if this fluid be shaken in a vial it will still coagulate. Prof. Physic has ascertained by experiment that blood will coagulate also without the contact of air.— See Prof. Horner's Anatomy, voh ii., p. 162.—D. 320 PHYSIOLOG cles, Mr. Hunter appears to have deduced his celebrated hypothesis of the'life of the blood ; a doctrine which embraces the principle that a fluid is capable of organization, and may be en- dued with functions either identical with, or very similar to, those which are the most characteristic of the living animal solid.—(Bos- tock, vol. cit., p. 443.) At the temperature of 160°, the serum itself coagulates, from which a fluid, termed the se- rosity, may yet be obtained by pressure. The coagulated part is albumen, which principle ex- ists also in the serosity, but is suspended by the presence of an alkali. The coagulation of the blood is a circum- stance, not only interesting to the physiologists, but a source of useful information to the medi- cal practitioner ; for certain appearances of the blood, after its coagulation, are a general indi- cation of inflammation, or other disturbance in the system. Thus, when the upper stratum of the coagulum has a yellow buffy look, in conse- quence of the red globules having subsided from it; when its surface is more or less concave, and the quantity of serum in the basin copious ; the blood is said to be sizy, and to exhibit the buffy coat, or inflammatory crust. As, however, the buffy coat frequently occurs, when no inflam- mation nor inflammatory fever exists, the state of the pulse and other symptoms should always be duly considered, and the decision for the further use of the lancet never be founded merely on the look of the blood, without reference to other circumstances in the case.] To speak minutely of the constituent prin- ciples of the blood, would carry us too far into the regions of animal chymistry; and I shall hence limit myself to a very brief analysis of those that are fixed or confinable, having al- ready paid some attention to the gases in the physiological proem to the preceding class. For the first judicious account of these prin- ciples, we are indebted to an elaborate memoir of MM. Parmentier and Deyeux, who arranged them under the following heads :—1. A peculiar aroma, or odour, of which every one must be sensible who has been present at a slaughter- house, on cutting up the fresh bodies of oxen. 2., Fibrin, or fibrous matter, frequently also called coagulable lymph, and gluten. 3. Gela- tin. 4. Albumen. 5. Red colouring matter. 6. Iron. 7. Sulphur. 8. Soda. 9. Water. Still minuter and more exact experiments have since been made upon particular portions of the whole of the blood, especially by Dr. Marcet (Trans. Medico-Chirurg. Soc, vol. ii., p. 370), Dr. Bostock (Id., vol. i.), and Berze- lius (Id., vol. iii.), which confirm the greater part of the preceding results, but have detected a few errors, which it is necessary to notice. Neither the blood of man nor of quadrupeds, so far as it has been examined, contains any gelatin. " The mistake," says M. Berzelius, " arises from the gelatinous appearance of the albumen : I have never been able to detect a particle of gelatin in blood, and, as far as my researches extend, I have found gelatin to be a substance altogether unknown to the economy tCAL PROEM. [Cl. III. of the living body, and to be produced by the action of boiling water on cartilage, skin, and cellular membrane ; substances which are to- tally distinct from fibrin and albumen." It fol- lows, therefore,- that wherever gelatin is found in the animal frame, it is produced by a decom- position and recombination of the particles of the blood by the action of the secernents. But, instead of the gelatin, Dr. Bostock has since discovered in the serosity, or that part which remains when the lymph or serum has parted with its albumen by heat, a distinct sub- stance, which he has denominated, from its quality, uncoagulable matter (Elementary Sys- tem of Physiology, vol. i., p. 476, 8vo., 1824), and which Dr. Marcet has called muco-extract- ive matter. Berzelius has affirmed it to be impure lactate of soda. The sulphur, detected in the blood by Par- mentier and Deyeux, does not exist in a free state, but is a component part of its albumen, as are also its carbon and hydrogen, which, in consequence, have as strong a claim to be con- sidered as constituent principles as sulphur. It is by means of its constituent sulphur, that the albumen of blood, or of an egg, becomes capa- ble of blackening a silver instrument employed to stir it. ( The iron traced in the blood is, in like man- ner, a constituent principle of the red colouring matter, and exists in so intimate a union with it, that it cannot be detected by the best reagents we possess, till the composition ofthe colouring mat- ter is totally destroyed by heat, or some other means. With these explanations, we are now able to proceed to a clear comprehension of the follow- ing brief analysis of the blood, as corrected by the later experiments of Berzelius, supported by those I have just adverted to of Dr. Marcet and Dr. Bostock. Blood is composed of two parts : one, homo- geneous and liquid; and one, only suspended in the liquor, and spontaneously separating from it when at rest. The homogeneous and liquid part consists of much albumen and a little fibrin, both combined with soda, and all dissolved in water. It also contains a small portion of a few other saline and animal substances.* * Dr. Stevens has endeavoured to prove, that the fibrin partly owes its fluidity within the body to its being held in solution by the saline substan- ces contained in the serum ; but, if this hypothe- sis were true, the fibrin, one would expect, ought not to be totally insoluble in solutions of neutral: salts. It seems to be nearly contradicted, indeed, by one of Dr. Stevens's own experiments. " If, at a certain period after coagulation has com- menced, we add muriate of soda, or a saline solu- tion, to the coagulating blood, the moment that the fibrin feels the stimulus of the salt, the whole of it becomes suddenly solid; and," he adds, " I have seen the fibrin of inflammatory blood, which had been drawn during the hot stages of the marsh fever, contract, on the application of salt, with al most as much rapidity as the muscles, when we apply the same stimulus to the fibres in the living body."—Stevens on the Blood, p. 183., Cl. III.] PHYSIOLOGICAL PROEM. 32] The suspended part consists of the colouring matter. It differs from albumen chiefly in its serum. Iron enters as a constituent ingredient into this material, in the proportion specified in the foot-note. It seems to be the colouring prin- ciple ; but cannot be separated from it as long as it continues to be colouring matter. This separation can only be effected by combustion, or by the concentrated acids, both of which agents entirely decompose the substance with which the metal is combined. The iron exists in the form of oxyde, with a small proportion of subphosphate of the same. But the colouring matter cannot be artificially produced by uniting albumen with red subphosphate of iron.* Fibrin, albumen, and colouring matter, have sometimes been considered as modifications of one and the same substance. Each of these three substances yields, when decomposed, but does not contain, earthy phosphates and carbon* ate of lime ; for the entire blood holds in solu- tion no earthy phosphate, except, perhaps, in too small a quantity to be detected. From these earths, it is clear, that the bones derive their earthy supply ; which, however, it is also clear they can only do, as in the case of the formation of gelatin, in consequence of a decomposition of the blood as it arrives at the secernents of the bones. Vauquelin endeavoured to separate the colour- ing matter from the blood by means of sulphuric acid ; but this does not very well answer the purpose. A method, proposed by Berzelius, is much simpler, as well as more effective.—(Ann. de Chim. et de Phys., torn, v., p. 42.) It con- sists in placing the clot or coagulum of blood upon blotting paper, to get rid of the serum as completely as possible. The clot is then to be put into water, in which the colouring matter dissolves, while the fibrin remains unaffected; when, the water being evaporated, the colouring matter is obtained in a separate state. On re- ducing this matter toeshes, about 1.200 of iron can always be separated. It is difficult to determine by what means the iron or the sulphur, or the elementary principles of calcareous earth, obtain an existence, or the means of existence, in the blood. If these materials were equally diffused throughout the surface of the earth, we might easily conceive that they are introduced through the medium of food. But as this is not the case, some re- gions, like New South Wales, at least, on this side the Blue Mountains, containing no lime- stone whatever, and others no iron or sulphur, while all these are capable of being obtained apparently as freely from the blood of the in- habitants of such regions, as from that of those who live in quarters where such materials enter * According to M. Lecanu, blood contains per- oxyde of iron in the proportion of 2.100 in 1000.000. See Ann. de Chim. et de Phys., xlviii., p., 308. The colouring principle is termed haimatosine, 100 parts of which, burnt in the open air, leaves 1.25 of ashes, containing 0.625 of oxyde of iron, and 0.625 of car- bonate and phosphate of lime, phosphate of magne- sia, and subphosphate of iron, blended together.— Berzelius. ■ Vol. I.—X largely into the natural products of the soil,— it is perhaps most reasonable to conclude, that they are generated in the laboratory of the ani- mal system itself, by the all-controlling influence of the living principle. What may be the aggregate quantity of any of these minerals in the mass of blood belong- ing to an adult, has not been determined with accuracy. The amount of the iron has been calculated by Parmentier and Deyeux, upon grounds furnished them by Menghini, at seventy scruples, or very nearly three ounces, estimating the average of blood in the vessels of an adult at twenty-four pounds, which is most probably something short of the mark. Whether iron exists in any other part of the animal frame than the colouring matter of the blood, is in some degree doubtful. Vauquelin seems to have traced it in egg-shells and oyster- shells ; and Mr. Brande thinks he has done the same in the chyle and in the serum, and this as largely as in the colouring matter of the blood, which, after all, he thinks contains only a very minute quantity.* But these experiments are too indefinite, and by no means coincide with those of Berzelius, since confirmed by other chymists. If the experiments of Menghini may be relied upon, human blood contains a larger proportion of iron than that of quadrupeds; quadrupeds have more than fishes ; and fishes more than birds. But, though there can be no longer any ques- tion of the existence of iron as a constituent principle in the blood, we are in total ignorance of the part it is intended to perform. It is, perhaps, the colouring material, though, as I have already observed in the physiological proem to the preceding class, even here we are still very much in the dark, and are overwhelmed with contending hypotheses.! It is probable * Phil. Trans., 1812, p. 112. For additional infor- mation, see Turner's Elements of Chymistry, and Lecanu's Exp. in Ann. de Chim. et de Phs., vii., 48: t The theory of Dr. Stevens is, that the colour- ing matter of the blood is a peculiar animal sub- stance, which has the property of striking a bright red die with salt; and, as salt exists in the serum, that it is the cause of the red colour of arterial blood. The reader will find in the Med. Gazette for 1832-3, p. 881, some valuable observa- tions and experiments on the causes of the colour of arterial and venous blood, by Mr. G. H. Hoff- man. If these experiments can be depended upon they prove, 1. That carbonic acid gas will black- en red colouring matter of blood, suspended in the serum. 2. That atmospheric air and oxygen will restore its red colour. 3. That carbonic acid gas does exist in venous blood. 4. That the air- pump is not competent to extract the whole of the gases with which the blood is impregnated. 5. That air or oxygen, without salt, will not red- den black blood. 6. That salt, without air, will. 7. That blood, without salt, is black. 8. That blood, with excess of salt, and impregnated with carbonic acid gas, is also black, and that its red colour cannot be restored by air, oxygen, or a fur- ther addition of salt. 9. That pure oxygen gas will heighten the red colour of hsmatosine sus- pended in serum, and impregnated with atmo- spheric air. 10. That nitrogen gas does not pos- sess a positive power to blacken red blood. 11. 322 PHYSIOLOGICAL PROEM. [Cl. Jft that the red particles of the blood contribute to the strength of animals to whom they are natural, as conjectured by Mr. J. Hunter, and that the strength of such animals is in propor- tion, or nearly so, to their number. Yet such particles are never found in the blood of sev- eral classes of animals, as insects and worms; and in those in which they are found, they have often no existence in the commence- ment of life ; for they are not discoverable in the egg of the chick, when the heart first be- gins to pulsate ; nor are they, in any animals, pushed into the extreme arteries, where we must suppose the serum reaches. And hence, what- ever their value, they cannot be regarded as the most important part of the blood, or as chiefly contributing to the growth and repair of the system.—(On Blood, pp. 46, 48.) Various attempts have at different times been made to determine the form and measure the diameter of the corpuscles of the blood; but they do not seem to have been accompanied with' very great success. Delia Torre, by apply- ing his microscope, detected the red particles, as he thought, to be flat circles or rings, with a perforation in the centre ; and Mr. Hewson as- cribed to them the same shape, but represented them as hollow or vesicular, with a dot of red colouring matter in the centre instead of a per- foration ; so that, if his description could have been substantiated, they might literally have been regarded as the wheels of life moving on iron axles. Mr. Hewson's hypothesis, however, ex- tended much farther ; for, by a variety of plausi- ble experiments, he persuaded himself, and many others also, that it is the office of the thymus and lymphatic glands to secrete and elaborate these vesicles, which are then carried by the lymphatics and thoracic duct to the arteries, and from the arteries to the spleen, which furnishes them with their coloured axles. Some of these physiological and microscopic divertissements, however, have been long overturned; while the general shape of the corpuscles has been gravely shown by other exquisite analyses to be globular: the diameter of which, as measured by the micro- scopical experiments of M. Bauer, is 1-2000 part of an inch; a dimension, however, which has since been reduced by Captain Kater to 1-5000 part of an inch.* M. Bauer has also ascertained, That carbonic acid and hydrogen gases do. 12. That on macerating the crassamentum in water for an hour and a half, salt is extracted from a stra- tum of the coagulum equal in thickness to that which may, while moistened with serum, be red- dened for the same length of time by exposure to the air. Mr. Hoffman considers it highly prob- able, also, from the results of his investigations, that free oxygen gas does exist in arterial blood. These results tend, in the main, to support Dr. Stevens's theory of respiration; although it is ad- mitted, that some links in the chain of evidence, necessary to establish it, are wanting.—Ed. * Phil. Trans., 1818, pp. 173, 187. Dr. Hodg- kin, who has carefully examined the red particles of the blood with a microscope, denies that they are globular ; and his description of them is differ- ent from that given of them by other experiment- ers.—See Catalogue of Anatomical Museum of Guy's Hospital, Obs. on sect. xi.—Ed. as he thinks, that it is not the centre of the glob- ule that is dotted, but its outline that is surround- ed with colouring matter; so that, instead of being annular wheels with iron axles, they are spherular wheels with iron tires. It is some- what singular that, in the revolution of science, M. Bauer's views are now sinking below the horizon, while those of Mr. Hewson are again ascending into notice ; for the later experiments of M. Provost have restored to the red corpus- cles of the blood their flat circles and points; and divested them of a globular form. MM. Prevost and Dumas believe the colouring matter to be a membrane, by which these corpuscles are surrounded. They pursued a dexterous method of drying the red particles as soon as separated, and found that, when divested of this red matter and rendered colourless, they are of the same size in every animal they examined; being 1-7600 part of an inch,* but that, with the colouring matter, the size differs in different animals ; being 1-3100 of an inch in man, the dog, rabbit, pig, guinea-pig, and hedgehog; in the ass, 1-4200 ; the cat and man, 1-4300 ; the sheep, horse, mule, and cow, 1-500 ; and the goat, 1-700. These particles have a peculiar tendency to form themselves into lines, as ob- served by Sir E. Home ; the lines resembling in every respect the muscular fibre. Fibrin they found also to be a collection of colourless cor- puscles of the same kind as the above : the same corpuscles may be also traced in the white of the egg. Those of a chick, six days after incuba- tion, they found larger than those of a hen ; as also, that those, which in some young animals are circular, afterward become elliptical. Even this last was also observed by Hewson;" and the remarks may lead to some facts connected with inflammation, by which they may be influenced ; as they may be likewise, by the temperature of hot climates. According to a later set of experiments by M. Bauer, the fluid of the blood has a tendency to run into globules from the first and simplest stage of its formation; while, as it becomes more elaborated, the globules assume a larger and apparently a firmer form, till they at length become tinged with the red colouring matter. We have hence three distinct orders of globules ; the first and minutest of which show themselves in the mesenteric glands, and perhaps in the lacteals, white in colour, and floating in a clear, perfectly colourless fluid. The second and mid- dle orders consist of globules, void of colour, found floating in the serum, and which Sir Eve- rard Home has called lymph-globules, and con- ceives to be the material chiefly thrown out in the process of inflammation. The third and * Prof. Wagner, of Erlangen, has repeatedly measured the globules of the blood, and always with the same results. He thinks that they vary in size, being from the three hundredth to the four hundredth of a line in diameter, and that the con- tradictory estimates of authors depend partly on the imperfection of the micrometers employed, and in the want of accuracy in the observations.— See North American Archives of Med. and Surg. Science, No. 2, p. 153.—D. Cl. III.] PHYSIOLOGICAL PROEM. 323 largest order is that of the red globules, the colouring matter of which he supposes to be derived from the changes that take place in the act of respiration. But, though the great mass of the globules, found in the lacteal glands, are of the extreme minuteness just described, he observed that many of them were much larger; that about eight tenths varied from the smallest speck to the size of the lymph-globules ; that about one tenth were of the size of red globules deprived of the colouring matter; and about one twentieth of the size of the red globules with the colouring matter incasing them. And he is hence inclined to think, that the lacteal glands are the cradle, in which the whole receive their form and structure, however elaborated by other combinations afterward. The subject, however, even upon these points, calls for much further attention ;* and we have also still much to learn, not merely in respect to the real difference between human blood and that of quadrupeds, but the real difference be- tween that of any one species of animal and any other. M. Berzelius observes, that " the great agreement in the composition of human and ox blood is remarkable, and explains to us the pos- sibility of the phenomena observed in the experi- ments in transfusion." But we have a clear proof, that the blood of one species of animals differs so much from that of another, either in its principles or their modification, that no bene- fit can result from transfusion, unless from like kinds to like kinds. Thus, according to several interesting experiments of Dr. Blundell, a dog, asphyxiated by hemorrhage, may easily be re- covered by a transfusion of blood from another dog, but is little or not at all relieved, if the blood be taken from man (Transae. Medico- Chir. Soc, vol. ix., p. 86) ; and the experiments of MM. Prevost and Dumas precisely coincide with this doctrine. [In the operation of transfusion, which seems to have been invented, or, at least, perfected by Lower about 1660, the artery of one animal is connected by a tube with the vein of another animal, under which circumstances the first is gradually deprived of its blood, and the second rendered plethoric. If an opening be made in the veins of the latter, its original blood will escape, and be replaced by that of the other animal. At the time when these experiments were made, diseases were supposed to depend upon morbid qualities in the blood; and as transfusion held out the prospect of changing this fluid at pleasure, it was hailed as a most important means of restoring the health, and some individuals actually submitted to have the blood of lambs or calves transmitted into their vessels, for the purpose of being cured of certain diseases, or of having their vigour reno- vated.—(Bostock's Physiology, vol. i., p. 348.) The first experiments performed on the human subject ended fatally; and in France the con- * These accounts of M. Bauer's investigations were found among Dr. Good's MSS. subse- quently to the publication of the third edition of this work, with the place for their intended inser- tion in it marked by the author himself.—Ed. X2 tinuance of the practice was prohibited by law. Dr. Blundell, however, has established the im- portant fact, that the blood of an animal of the same species may be safely transfused ; but, that if the blood of a different kind of animal be em- ployed, great disorder of the functions is occa- sioned, and death generally ensues. With strict attention to this principle, the experiment has now been tried upon the human subject in several instances, and occasionally with decided success.]* Upon the whole, we cannot but regarcT the blood as, in many respects, the most important fluid of the animal machine: from it all the solids are derived and nourished, and all the other fluids are secreted ; and it is hence the basis or common pabulum of every part. And, as it is the source of general health, so it is also of general disease. In inflammation, it takes a considerable share, and evinces a peculiar ap- pearance. The miasms of fevers and exan- thems are harmless to every other part of the system, and only become mischievous when they reach the blood ; and emetic tartar, when introduced into the jugular vein, will vomit in one or two minutes, although it might require, perhaps, half an hour if thrown into the stomach, and, in fact, does not vomit till it has reached the circulation. And the same is true of opium, jalap, and most of the poisons, animal, mineral, and vegetable. If imperfectly elaborated, or with a disproportion of some of its constituent principles to the rest, the whole system partakes of the evil, and a diathesis or morbid habit is the certain consequence ; whence tabes, atrophy, scurvy, and various species of gangrene. And if it become once impregnated with a peculiar taint, it is wonderful to remark the tenacity with which it retains it, though often in a state of dormancy or inactivity, for years or even entire generations. For, as every germe and fibre of every other part is formed and regenerated from the blood, there is no other part of the system that we can so well look to as the seat of such taints, or the predisposing cause of the disorders I am now alluding to ; often corporeal, as gout, struma, phthisis; sometimes mental, as mad- ness ; and occasionally both, as cretinism. [Whether the blood be primarily affected in certain diseases, or chiefly concerned in the transmission of what have been considered hered- itary disorders, as the author has conjectured, are questions very difficult to solve; and the doctrine, if carried too far, would be at variance with some well-established facts, and approved theories, which ascribe the first origin of many complaints rather to an affection of the blood- vessels, absorbents, or nerves, than tq a change of the blood itself. It must not be inferred,, however, that, in disease, this fluid is not sub- * It is proved, by recent experiments, that for- eign substances may sometimes be introduced into the sanguineous system with great benefit. There are several cases recorded in different American journals, where patients, when moribund from cholera, have been immediately benefited, by injecting into the veins a weak solution of the carbonate and muriate of soda.—See note on p. 164—D. 324 PHYSIOLOGICAL PROEM. [Cl. III. ject to alteration, a fact, of which the valuabki observations of Dr. Armstrong furnish convin- cing evidence ;* nor even that it may not be sometimes the primary vehicle of disease into the constitution. Passing over the variations which occur in its quantity, velocity, and distri- bution, subjects on which this able physician has offered many judicious and practical reflections, let us attend to what his experience has taught him respecting the altered qualities of the blood in cases of disease. It differs, he says, in differ- ent persons, and even in the same person under different circumstances. In general, plethora takes place either in strong individuals of firm fibre, or in plump, lax persons. In both cases, there is a superabundance of the red portion of the blood, but the crassamentum is much firmer in the former subjects than the latter. On the contrary, when local plethora affects the mucous textures of pale, thin men, relaxed by seden- tary habits and a spare, slop diet, the red particles are often deficient, and the quantity of fibrin and albumen lessened. A similar effect is well- known to result from copious and repeated blood- letting, the blood becoming thinner and thinner, and the skin paler and more flabby than natural. Indeed, says Dr. Armstrong, the blood is brought into a like condition by protracted disorder, especially where the digestive processes are dis- turbed, as in cases of chlorosis, in some of which he has known the blood flow from the punctured vein like so much thin claret, or very pale red ink. Nor are the red particles alone affected ; for, when rich blood shows the buffy coat on coagulating, it is firm, opaque, and striated generally on the surface ; whereas, in poor blood, it is loose and semi-opaque, like so much ill- strained jelly ; appearances unequivocally Te- vealing that the fibrin itself is more or let«s alter- ed. In several cases where the circulation was much increased in force and frequency, Dr. Armstrong has seen the blood gush from an opened vein with the bright vermilion colour of arterial blood ; while, on other occasions, where its course had been impeded or retarded in the small arteries, it exhibited a dark venous charac- ter. In some examples of fully developed typhus, where the tongue was glazed, dry, and brown, and the lips and cheeks of a dusky or purple hue, he has seen the blood from the temporal artery present a venous colour. The circulation of such blood within the arteries, seems to Dr. Armstrong to be connected with many of the most conspicuous phenomena of the advanced stage of genuine typhus, and dependant upon a specific bronchitis, in which the mucous texture of the bronchial tubes is loaded with dark blood, and smeared with a copious and tenacious secre- tion. The contagions of smallpox, measles, and scarlatina, he says, first operate on the blood, after which the solids are specifically * This will doubtless be admitted by those who have examined this fluid, as taken from patients affected with cholera ; the analyses of eminent chymists prove, that in this disease the quantity of albumen in the blood is somewhat lessened ; the colouring matter is remarkably increased; while the fibrin is excessively diminished.—D. affected, especially the skin and mucous mem- brane of the air-passages. In specific fevers, where the venous blood is not duly converted into arterial from the presence of bronchitis, that fluid emits an unpleasant odour, not unlike the smell of bugs. The blood of those who live on animal food has more azote in it than the blood of persons who live on vegetables. A diet of salted meat likewise produces a change in the blood, as illustrated in cases of sea-scurvy. The circulation of extraneous substances in the blood appears to Dr. Armstrong to be a frequent cause of fever, as he has ascertained to be the fact in relation to mercury. Mental derange- ment he also conceives may sometimes be con- nected with a morbid state of the same fluid.— (See Armstrong's Mor. Anat. of Bowels, &c, p. 6, 4to., Lond., 1828.) From a case reported in the Lancet, No. cexxxviii., p. 909, it would appear that, in diseases of the spleen and fiver, the blood may even acquire an acid quality.] As already noticed, the blood has been sup- posed to be alive ; a belief of very high antiquity, and which has been warmly embraced by Dr. Harvey and many others of the first physiolo- gists of modern times.* It was a favourite opinion of Mr. John Hunter, and runs through the whole of his doctrines. " That the blood," says he, " has life, is an opinion I have started above thirty years, and have taught it for near twenty of that time in my lectures. It does not, therefore, come out at present as a new doctrine ; but has had time to meet with con- siderable opposition, and acquire its advocates. To conceive that blood is endowed with life while circulating, is, perhaps, carrying the ima- gination as far as it well can go; but the diffi- culty arises merely from its being a fluid, the mind not being accustomed to the idea of a living fluid."—(On Blood, p. 77.) The experiments and train of reasoning he urges in favour of this opinion, are highly inge- nious and peculiarly strong. And, though they may not be demonstrative of a vital and ener- getic essence separate from the blood itself, but inherent in its substanee, and controlling its motions, they seem very clearly to show, that the blood is endowed with peculiar powers ; and that, as matter at large is subject to the laws of gravitation, so the matter of the blood is sub- ject to the laws of instinct. We may here add, in favour of Mr. Hunter's opinion, the following two corollaries of Dr. Philip, deduced from a large field of experiments. " The power of the bloodvessels, like that of the heart, is independ- ent of the nervous system.—The bloodvessels can support the motion of the blood after the heart is removed."—(Phil. Trans.,\S\5,v. 445.) Admitting these deductions to be established, the power here referred to, and capable of influ- encing the blood or the bloodvessels, separately from that of the heart and of the nervous sys- * The opinion that the blood possesses vital powers is ably sustained by Dr. Caldwell, of Phil- adelphia, in his Experimental Inquiry on the Vitality of the Blood. See also a Dissertation on the Pathol- ogy of the Human Fluids, by Jacob Dyckman, M. D., New-York, 1814 ; a work of great merit.—D. Cl. III.—Ord. I] PYRECTICA. 325 tem, must be the power of symple life, or of instinct, which is simple life operating by the exercise of its own laws. This view of the subject has of late, however, been carried by Dr. Pring to an extent far be- yond what Mr. Hunter at any time contemplated. For Dr. Pring not only supposes the blood to be ahve, and to communicate life to the sentient and ORDER I. PYRECTICA. FEVERS. HEAT AND NUMBER OF THE PULSE PRETERNATU- RALLY AUGMENTED : USUALLY PRECEDED BY RIGOUR, AND FOLLOWED BY PERSPIRATION : DURING THE RIGOUR, PAINS FIXED OR WANDER- ING : LASSITUDE : DEBILITY OF MIND AND * Principles of Pathology and Therapeutics, &c. By Daniel Pring, M. D., 8vo., 1823. t De Curand. Horn. Morb., Epit. i., p. 2, torn. iv., 8vo., Mannh., 1792. " The word fever, derived from the Latin term febris (a derivative ofthe verb ferveo, signifying, to be hot), is applied to a class of diseases, characterized by morbid heat of the shin, frequency of pulse, and disturbance in the various functions."—Dr. Tweedie, in Cyclop, of Pract. Med, art. Fever. healthful parts of the system, but to its insen- tient and diseased elements as well; and that the matter of animal poisons, derived from the blood, are themselves also living bodies, acting specifically by the vital but discrepant proper- ties they are endowed with. And he thinks that hereby " a distinction may be furnished between the contagious and infectious diseases."* sometimes to be met with, that opposes the gen- eral law, for the most part dependant, I believe, on a great and sudden oppression of the brain; an explanation which withdraws the anomaly, and accounts for the ordinary increase of pulsa- tion as soon as such oppression is removed. Thus, in the yellow fever of Antigua, in 1816, the pulse, as Dr. Musgrave informs us, was, in one instance, under forty-four. " We almost fancied," says he, " this unusual softness might be constitutional: but, on opening a vein, it greatly increased in frequency ; and, after the loss of a considerable quantity of blood, it num- bered eighty, with nearly complete relief from every uneasy sensation."—{Trans. Med. Chir. Soc., vol. ix., p. 133.) In such cases, the heat of the system usually exhibits as little febrile augmentation as the pulse : for, as the former is the result of in- creased action, till such increased action takes place, the heat, as in the first stage of the par- oxysm, may continue even below the natural standard. Ordinarily, however, the heat is con- siderably heightened, insomuch as in some in- stances to reach 108° Fahrenheit, which, how- ever, is the utmost point it has everbeen known to attain in fever. There is a still more curious variation from the general law, which is sometimes, though very rarely, found to take place, of which Schenck gives a single example that occurred in his own practice ; I mean a reversed order of the symptoms of the febrile paroxysm, and an appearance of the sweating stage before the shivering and hot fit.—(Lib. vi., obs. 34.) To provide for these extraordinary and anom- alous incidents by any definition whatever, is beyond the power of language. They must be left to themselves, and will rather confirm than disturb the definition now offered, agreeably to the maxim of the schools—exceptio probat reg- ulam. In dividing fevers into distinct genera, I have taken the line of demarcation from the charac- ter of their duration, as limited to a single par- oxysm ; as composed of numerous paroxysms, with intervals of intermission or perfect apyrexy; as composed of numerous exacerbations, with intervals of remission, or imperfect apyrexy ; and as composed of a single series of increase and decrease, with a mere tendency to intervals of remission, without perfect apyrexy at any CLASS III. H/EMATICA. VOLUNTARY MUSCLES. No complaint is so common as fever ; none in which mankind, whether professional or lai- cal, are so little likely to be mistaken, and yet none so difficult to be defined. In reality, no writer seems to have been fully satisfied with his own definition ; and it is not extraordinary, therefore, that he should seldom have given satisfaction to others. The difficulty proceeds . from the complexity of the symptoms that enter into the character of a fever: the contrariety of many of them to each other in different stages of it; and the occasional absence of seme that, in other instances, appear to constitute its lead- ing features. " Febris," says Professor Frank, " certorurn potivis morborum umbra, quam ipse morbus est."t The nosologist has also two othei difficulties of considerable magnitude to contend with in laying down a clear and perspicuous survey of fevers ; and that is, their division or collocation, and their generic names. But, as I have already pointed out these difficulties, and the means by which they are attempted to be remedied under the present arrangement and nomenclature, in the running commentary to the Order before us in the volume of Nosology, I shall beg to refer the reader to the observations there laid down, and shall subjoin only one or two additional re- marks upon the same subject Although the number of the pulse, as well as the heat, is preternaturally augmented in almost every case of fever, an extraordinary instance is 326 HJ2MATICA. [Cl. Ill—Ord. I. time. Other nosologists have drawn their ge- neric distinctions from other circumstances ; as their disposition or indisposition to putridity ; their inclination to a sporadic or an epidemic character; the vigour and violence, or weak- ness and debility, of their action; or, in the •language of Dr. Darwin, the nature of their in- fluence on the sensitive or irritative fibres of the animal frame. The most obvious mark, however, and that which has been most gener- ally approved, is the character of duration as- sumed in the arrangement before us. To all the rest, there are greater or less objections, which, as I have already examined them in the .comment just referred to, need not be repeated in the present place. Regulated, therefore, by the principle before us, fever admits of the four following genera :— I. Ephemera. J3iary Fever. II. Anetus. Intermittent Fever. III. Epanetus. Remittent Fever. IV. Enecia. Continued Fever. To each of these belong several species, and •to most of the species several varieties, as will be noticed in their respective order. Some slight deviation from the ordinary no- menclature may be observed in the generic names above: but the reader can have no diffi- culty upon this head, as he will find the changes that have hereby been occasioned are in every instance founded upon a principle of cor- rectness and simplification ; and consequently calculated to disentangle rather than to add to his encumbrances, and to facilitate his progress in the labyrinth before him. The term Ephem- era, is, indeed, well known to every one. Ane- tus and Epanetus are Greek terms, importing intermittent and remittent, from avt-n/ti and iira- vlnpi. Enecia, from the same tongue, denotes continued action, and is a derivation from bveicfis. Before, however, we enter upon the practical part of this subject, it appears necessary to make a few remarks upon one or two other questions that have very largely occupied the attention of many pathologists, and especially concerning the proximate and remote causes of fever ; and the tendency, which fever has been supposed to evince, of terminating sud- denly, either favourably or unfavourably, at fixed, periods of its progress. Proximate and remote causes are rather terms of recent, than of ancient writers. In early times, the causes of diseases chiefly contem- plated were proegumenal, or predisponent, and procatarctic, or occasional. Thus, an hered- itary taint, or habitual indulgence in high living, may be regarded as a proegumenal cause of gout; and catching cold, or an unusual exertion of muscular exercise, may form its procatarctic cause : both of which are absolutely necessary ; for, it is clear, that the latter without the for- mer would not produce the malady ; and it is just as clear, that the former might remain harmless in the constitution for years, were it not to meet with-the co-operation of the latter, which is often, on this account, denominated an exciting cause. Generally speaking, the first was regarded as an internal, and the sec- ond as an external cause ; and, in the instance selected, they are so; but they are not so always. To be acquainted with causes of these kinds is always useful ; and, in guarding against the approach of diseases, it is often of the utmost importance : but they give us very little infor- mation upon the real nature of diseases, and the mode of managing them when present. And hence another set of causes have been adverted to, and have of late been chiefly stud- ied, and particularly in the case of fever. " That only," says Gaubius, " deserves the name of a physical cause, which so^ constitutes the disease, that, when present, the disease ex- ists ; while it continues, the disease continues ; when changed or removed, the disease is altered or destroyed." It is this which constitutes the proximate cause, and is, in fact, the essence of the disease, the actual source of all its effects. The remote cause is that which directly pro- duces the proximate ; as a specific virus in syphilis, or a specific miasm in influenza, or epidemic catarrh. In fever we can often trace the remote causes, though we are still too little acquainted with the nature of several of them to be able to re- strict them to a specific mode of action : of the proximate cause, we know but very little at present, and it will probably be long before we shall know much more. Let us, however, begin with the proximate cause, as that which has most excited the at- tention of physicians in all ages. Upon this subject, indeed, a great deal of learned dust has been raised, and a great deal of valuable time consumed. Ancient speculations, for they are not entitled to the name of theories, have been overthrown ; and modern speculations, in vast abundance, erected upon their ruins ; which, in rapid succession, have also had their day and expired. It is an inquiry, therefore, not likely to prove very productive ; yet, as forming a part of medical science, of which no student should be altogether ignorant, it seems neces- sary to take a brief survey of the most popular doctrines which have been advanced upon the subject in different ages. Fevers, then, in respect to their proximate cause, have been conjectured to originate from a morbid change, either in the composition of the blood, or in the tone or power of the living fibre. The first view has given rise to various hypotheses, that rank under the common division of the humoral pathology. The second has given rise to other hypotheses, appertaining to the common division of the fibrous or ner- vous PATHOLOGY. The hypotheses, derived from the one or the other of these sources, that are chiefly entitled to attention, are the following ; of which the first two belong to the former division, and the remainder to the latter. I. That of the Greek schools, founded on the doctrine of a concoction and critical evacuation of morbific matter. II. That of Boerhaave, founded on the doc- Ct,. III.—Ord. I] PYRECTICA. 32? trine of a peculiar viscosity, or lentor of the blood. III. That of Stahl, Hoffmann, and Cullen, founded on the doctrine of a spasm in the ex- tremities of the solidum vivum, or living fibre. IV. That of Brown and Darwin, founded on the doctrine of accumulated and exhausted ex- citability, or sensorial power. V. To which we may add, that fevers have, by some physiologists, as Dr. Clutterbuck, M. Broussais, and Professor Marcus, been iden- tified with inflammation ; and their proximate cause been ascribed to increased action in some particular organ. I. It was the opinion of Hippocrates, that fever is an effort of nature to expel something hurtful from the body, either ingenerated, or introduced from without. Beholding a violent commotion in the system, followed by an evac- uation from the skin and kidneys, with which the paroxysm terminated, he ascribed the com- motion to a fermentation, concoction, or ebulli- tion, by which the noxious matter was separated from the sound humours ; and the evacuation to a despumation or scum which such separa- tion produces, or rather to the discharge of this morbid scum from the emunctories that open externally. Galen supported this view with all the medical learning of his day ; and it is the only explanation of fever to be met with in medical writings, through the long course of three thousand years; in fact, till the time of Sydenham, who still adhered to it, and whose pages are full of the language to which it nat- urally gave birth. It blended itself almost immediately with the dialect of the chymists of the day, notwith- standing the professed hatred of Paracelsus and Van Helmont towards the whole range of Galenic doctrines, and the solemn pomp with which the former had condemned and burnt the entire works of Hippocrates and Galen. And hence, under the influence of chymistry, at this time assuming a soberer aspect, the supposed animal despumation was contemplated as pos- sessed, according to different circumstances, of different chymical qualities and characters ; and particularly as being acid, alkaline, effervescent, or charged with some other acrimonious prin- ciple, too highly exalted, or in too great a pro- portion. This doctrine, considered merely hypotheti- cally, is not only innocent, but highly ingenious and plausible. It is in unison with several of the phenomena of pyrectic diseases, and de- rives a strong collateral support from the gen- eral history of exanthems, or eruptive fevers, in which we actually see a peccant matter, pro- ducing general commotion, multiplying itself as a ferment, and, at length, separated and thrown off at the surface by a direct depuration of the system. There is no writer, perhaps, in our own day, who has carried this view of the subject farther, or even so far, as Professor Frank, who regards typhus, plague, petechial, and all pestilential fe- vers, and, indeed, nervous fevers of every kind, whether continued or remittent, not only as proceeding from specific contagions in the same manner as exanthems, but from contagions pro- ducing a like leaven in the system, and matured and thrown off through the various outlets of the body, by the same process of depuration ; and hence, after describing all the varieties of malignant nervous fevers under the character of pestilential, he tells us "non aliter haec methodus in ipsa peste turn in pestilential!, sic vocati, febre, profuisse visa est; ubi, ma- turo satis tempore, contagh pee cutem expul- sio solicite a medentibus absolvebatur."—(De Cur. Horn. Morb. Epit., torn, i., p. 130, com- pare with the Y p. 127.) So far, however, as relates to exanthems* the opinion is sufficiently correct. But the moment it is brought forward as the proximate cause of fever, properly so called, in which there is no specific eruption, it completely fails. For, first, no explanation is here given as to the means by which any such concoction or fermentation, or multiplication of morbific mat- ter in any way, takes place. Next, there are many fevers produced evidently by cold, fear, and other excitements, as well mental as cor- poreal, in which most certainly there is no mor- bific matter introduced, and wherein we have ho reason to conceive there is any generated internally; while the disease, limited, perhaps, to a single paroxysm, closes, nevertheless, with an evacuation from the skin or the kidneys. And, thirdly, we sometimes behold fevers sud^ denly cured, as Dr. Cullen has observed, by a hemorrhage so moderate, as, for example, a few drops of blood from the nose, as to be incapable of carrying out any considerable portion of a matter diffused over the whole mass of the blood ; while we are equally incapable of con?- ceiving how such diffused morbific matter could collect itself at a focal point, or pass off at a single outlet, or of tracing in the discharge, after the minutest examination, any properties different from those of blood in a state of full health. I have observed that this hypothesis is, how- ever, harmless enough when merely brought forward as a speculation. But it has not al- ways been limited to this point; for it has occa- sionally been advanced as a practical and effi- cient principle ; and the febrile commotion, and particularly the hot fit, has, in treating the dis- ease, been purposely increased, with a view of assisting nature in her curious bud unknown process of expelling the peccant material, and the most dangerous consequences have followed. II. The acute and penetrating mind of Boer- haave, who was born in 1668, was sufficiently sensible of this danger ; and the discoveries which were now taking place in chymistry and physiology, led him progressively to the con- struction of a new theory, which in a few years became so popular as to obtain a complete tri- umph over that of the Greek schools. Leeuwenhoeck, by a delicate and indefatigar ble application of the microscope to animals of a transparent skin, had endeavoured to establish it as a fact that the constituent principles of the 828 ILEMATICA. [Cl. III.—Ord. 1. blood consist of globular corpuscles ; but, that these corpuscles differ in size in a regular de- scending series, according to the constituent principles themselves ; and that each set of principles has its peculiar bloodvessels, pos- sessing a diameter just large enough to admit the globules that belong to it, and consequently incapable, without force, of allowing an entrance to those of a larger magnitude ; and hence, that the bloodvessels possess a descending se- ries as well as the particles of the blood. It was upon this supposed fact that Boer- haave built his hypothesis. He conceived that almost all diseases may be resolved into an in- troduction of any given series of particles of blood into a series of vessels to which they do not properly belong, and he distinguished such introduction by the name of error loci. He conceived, still further, that this heterogeneous admixture is very frequently taking place ; and that its chief cause consists in a disproportion of one Or more sets of the sanguineous princi- ples to the rest, by which their globular form is occasionally broken down or agglutinated ; and hence rendered too thin and serous, or too gross and viscid. The viscidity of the blood he dis- tinguished by the name of lentor ; and to a prevalence of this lentor, or viscidity, he as- cribed the existence of fever ; maintaining, that the general disturbance which constitutes fever proceeds from an error loci of the viscid blood, whose grosser corpuscles, from their un- due momentum as well as superabundance, press forcibly into improper series of vessels, and stagnate in the extremities of the capilla- ries, whence the origin of the cold stage, and consequently of the stages that succeed it, to which the cold stage gives rise (Aph. 756, Comment. Van Swiet., torn ii., p. 528, edit. Lugd. Bat., 4to., 1745); and hence those med- icines which were supposed capable of. dis- solving that tenacity, or breaking down the coalescence of such a state of the blood, were denominated diluents, humectants, and at- tenuants, while those of an opposite character were called inspissants : terms which have descended to our own day, and are still re- tained, even by those who pay little attention to the hypothesis that gave them birth. The system of Boerhaave, therefore, con- sisted of an elegant and artful combination of both the earlier and later doctrines of corpus- cular physiology. Without deserting the hu- jmoral temperaments of Galen, or the constit- uent elements and elective attractions of the alchymists, he availed himself of the favourite notions of the corpuscular pathologists, their points or stimuli, their frictions, angles, and spherules, derived from the Cartesian philoso- phy, which was now exercising as triumphant a sway over the animal as over the material sys- tem, and interwove the whole into an eclectic scheme, so plausible and conciliatory, that all parties insensibly felt themselves at home upon it, and adopted it with ready assent. In the emphatic language of M. Quesnay, it was " la medecine collective." The most triumphant fact in favour of the. Boerhaavian hypothesis is, that the crust in the blood in inflammations, and cauma or inflam- matory fever, is often found peculiarly dense. But, as fevers (and certainly the greater num- ber) are found without any crust; and, as a similar crust, though, perhaps, not quite so dense, exists under other and very different states of body, as in pregnancy and scurvy (porphyra), even this leading appeal has long lost its power of conviction: while the abruptness with which fevers make their assault, from sud- den occasional causes, and in constitutions of every diversity, forbid the supposition that, in such cases, a lentor or sizy crasis of the blood, and especially a glutinosum spontaneum, can have time to be produced, however it may exist occasionally, and be, perhaps, the source of other disorders. The subject, however, has of late been again taken up by Dr. Storker of Dublin, with a view of reviving the humoral pathology in its more important doctrines, and of extend- ing the arguments which have hitherto been urged in its favour.* III. To the period of Boerhaave, in the pro- duction of fever, and, indeed, of all other dis- eases, the human body was regarded as almost entirely passive, a mere organic machine, oper- ated, indeed, upon by some autocrateia, as na- ture, or a vis medicatrix, but in the same manner as other machines, and mostly by simi- lar laws. Its muscles were contemplated as mechanical levers, and its vessels as hydraulic tubes, whose powers were calculated upon the common principles of mechanics and hydrody- namics, and were only supposed to be inter- fered with by the internal changes perpetually taking place in the fluids they had to convey. A new era, however, at length began to dawn upon the world ; a more comprehensive spirit to pervade medical study : the animal frame was allowed to exhibit pretensions superior to the inanimate, and not only to be governed by pow- ers of its own, but by powers which are con- tinually and systematically, from a given point, * Pathological Obs., &c, Dublin, 8vo., 1823. See also Armstrong's Morbid Anatomy of the Bowels, &e, p. 6, et seq., 4to., Lond., 1828; and Dr. Clanny's Lect. on Typhus Fever. According to Dr. Stevens's investigations, when the bodies of persons who died of yellow fever were opened, the heart was found to contain, instead of blood, a dissolved fluid nearly as thin as water, and as black as ink. In both sides of the heart the fluid was equally black, and throughout the vascular system all distinction between venous and arterial blood was completely lost. Dr. Stevens thinks that the blood first loses its solid parts, and be- comes thin; that it then becomes deprived of its saline principles, and turns black and vapid ; and lastly, that it loses its vitality, so as to be- come incapable of supporting life. He regards this diseased state of the blood as the first link in the chain of morbid phenomena which constitute fever, and believes that the aerial poisons, from which all pestilential diseases arise, are attracted with the atmospheric air into the circulation, mix directly with the blood in the pulmonary system, and this poisoned or diseased state of the circula- ting blood is the cause of the subsequent morbid action in the solids.—Ed. Cl. III.—Ord. I] PYREC operating to a preservation of health where it exists, and to a restoration of health where it has been lost or injured. Stahl, who was contem- porary with Boerhaave, and in the university of Halle, in 1694, first started this loftier and more luminous idea—more luminous, though the light was still struggling with darkness —made the mind the controlling principle, and the solidum vivum, or nervous system, the means by which it acted. Fever, on his hy- pothesis, consisted in a constrictive or tonic spasm; in his own language, spasmus tonicus, produced by a torpor or inertness of the brain, at the extremity of the nerves, and counter- acted by the remedial exertions of the mind, the vires medicatrices of his hypothesis, labour- ing to throw off the assailing power; whence the general struggle and commotion by which the febrile paroxysm is characterized. Hoff- mann, who was a colleague of Stahl, took ad- vantage of this new view, followed up the crude and primary ideas of Stahl with much patient and laborious investigation, and soon presented to the world a more correct system, in a more attractive style ; but, apparently, with a disin- genuous concealment of the source from which he had borrowed his first hints. He omitted the metaphysical part of the Stahlian hypothesis, took from the mind the conservative and reme- dial power over the different organs, with which Stahl had so absurdly endowed it; seated this power as a law of life in the general organiza- tion ; separated the nervous from the muscular fibres, the latter of which were regarded as only the extremities of the former by Stahl; allowed a wider range and longer term to the constric- tive spasm of fever, and changed its name from spasmus tonicus to spasmus periphericus ;* giv- ing also to the moving power of the muscular or irritable fibres the name of vis insita, as that of the nervous fibre was called vis nervea. It is highly to the credit of Boerhaave that his mind, in the latter part of his life, was so fully open to the merits of this hypothesis that he admitted the agency of the nervous power, though a doctrine that struck at the root of his own system, of which we have a clear proof in the change which occurs in the fourth edition of his Aphorisms, and particularly aphorism 755, where he lays down the proximate cause of intermitting fevers. Hitherto it had run thus : " Unde post accuratum examen totius historiae intermittentium causa proxima consti- tuitur viscositas liquidi arteriosi." But to this, in the edition before us, is added the following: " forte et nervosi (liquidi) tam cerebri, quam cerebelli cordi, destinati, inertia."—(De Motil Tonico. Theoria Medica vera, Halle, 1734.) It is also equally creditable to the learned Gau- bius, that, though strongly attached to the Boer- haavian school, in which he was educated, and a zealous contender for many of its doctrines, his understanding was alike open to the clearer and simpler views of the chymists of the day, upon * Med. Nat. Systemat., torn. iii. A 1, cap. 4. Bochmer, Diss, de Spasmi Periphenci signo in Febribus continentibus, Hal., 1765. TICA. 329 various points not yet generally adopted, and al- lowed him to become a more thorough convert to their philosophy. The reader may judge of this change in his mind by the following pas- sage : " An et naturae humanae facultas inest, moleculas, acris detritas aut intropressas angu- lis, in sphsrulas tornando, blanditium creandi! Non satis constat speciosam ideam aequaliter in fluidam solidamque acrimoniam quadrare.— Credibilius profectd mixtione chemica magis quam mechanica rotundatione, id opus perfici." —(Pathol., v 298-300.) In effect, there not only Was at this time, but had been for many years antecedently, a general feeling among the culti- vators of medicine, that neither the laws of ani- mal chymistry, nor of the living fibre, had been sufficiently studied for the purposes of a correct pathology: in proof of which it may be suffi- cient to refer to various articles on both subjects, inserted in the Ephemerides Naturae Curiosorum, published at Frankfort, in 1684; and the wri- tings of Baglivi (Specimen de Fibrd Motrici et Morboso) and Dr. Willis (Pathologia Cerebri et Nervorum), and still more particularly to Dr. Gilchrist's elaborate treatise on nervous fevers (Edin. Med. Trans., vol. iv., art. xxiii. ; and vol. v., part ii., art. xlviii.); who, following up the hint thrown out by Boerhaave in the apho- rism just quoted, endeavours to show how well the two ideas of lentor and spasm are disposed to amalgamate in forming the proximate cause of fever; the spasm consisting of a universal muscular tension, and the lentor being united, according to the nature of the case, with inflam- mation, acrimony, or both ; and hence often pro- ducing what he denominates an alternate nisus andRENisus. The materials, however, were now becoming too unwieldy; and the wheels of the machine were clogged by the very forces that were de- signed to increase its motion. Dr. Cullen was well aware of this, and boldly ventured upon a new attempt for the purpose of simplifying and facilitating its progress. For his basis he took the hypothesis of Stahl, as modified and im- proved by Hoffmann : and on this basis erected his stately and elaborate structure, so well known to the medical world, full of ingenuity and daring genius, and which, if it be at this moment crumbling into decay, certainly is not falling prostrate before any fabric of more sub- stantial materials, or more elegant architecture. Dr. Cullen has been accused of the same want of ingenuousness towards Hoffmann, as Hoffmann is chargeable with towards Stahl; and of hav- ing introduced his system to the public with little or no acknowledgment of the sources from which he has drawn. But, surely, no one can bring forward such an accusation, who has read with any degree of attention the preface to his Practice of Physic, in which he gives a full account of Dr. Hoffmann's system in his own words, and pays complete homage to his merit. According to the more elaborated principles of the Cullenian system, the human body is a congeries of organs, regulated by the laws not of inanimate matter, but of life, and superintended by a mobile and conservative power or energy, 330 H^EMATICA. [Cl. Ill—Ord. I. seated in the brain, but distinct from the mind or soul; acting wisely but necessarily, for the general health ; correcting deviations and sup- plying defects, not from a knowledge and choice of the means, but by a pre-established relation between the changes produced and the motions required for the restoration of health; and operating, therefore, through the medium of the moving fibres, upon whose healthy or unhealthy state depends the health or unhealthiness of the general frame : which fibres he regarded, with Stahl, as simple nerves, the muscular filaments being nothing more than their extremities, and by no means possessed of an independent vis insita. The brain, therefore, upon this hypothesis, is the primum mobile; but it closely associates in its action with the heart, the stomach, and the ex- treme vessels. The force of the heart gives extension to the arteries, and the growth of the body depends upon such extension, in conjunction with the nutritious fluid furnished by the brain, and deposited by the nerves in the interstices of their own fibres ; the matter of which fibres is a solid of a peculiar kind, whose parts are united by chymical attraction. All nervous power commences in the encephalon ; it " consists in a motion beginning in the brain and propagated from thence into the moving fibres, in which a contraction is to be produced. The power by which this motion is propagated we name," says Dr. Cullen, " the energy of the brain; and we therefore consider every modification of the motions produced, as modifications of that en- ergy."—(Mat. Med., part ii., chap, viii., p. 349.) He further lays it down as a law of the economy, that the energy of the brain is alternately ex- cited and collapsed, since the Very fibrous con- traction is succeeded by a relaxation : whence spasms and convulsions are molus abnormes, and consist in an irregularity of such alternation. But we must distinguish in this system between the energy of the brain and the vital fluid it sends forth by the nerves : for, while the former rises and sinks alternately, the latter remains permanently the same. It is not a secretion, but an inherent principle, never exhausted, and that never needs renewal.—(Mat. Med., part ii., chap, vi., p. 223.) This hypothesis, in its various ramifications, influenced every part of his theory of medicine, and consequently laid a foundation for his doc- trine of fever. The proximate cause of fever was, in his opinion, a collapse or declination of the energy of the brain, produced by the appli- cation of certain sedative powers, as contagion, miasm, cold, and fear, which constitute the re- mote causes. This diminished energy extends its influence over the whole system, and occa- sions a universal debility; but chiefly over the ex- treme vessels, on which it induces a spasm ; and in this spasm the cold fit is supposed to consist. " Such, however," to adopt the words of Dr. Cullen himself (Prac. of Phys., y xlvi.), " is the nature of the animal economy, that this de- bility proves an indirect stimulus to the sanguif- erous system ; whence, by the intervention of the cold stage, and spasms connected with it, the action of the heart and larger arteries is in- creased, and continues so till it has had the effect of restoring the energy of the brain, of extend- ing this energy to the extreme vessels, of re- storing therefore their action, and thereby espe- cially overcoming the spasm affecting them ; upon the removing of which, the excretion of sweat, and other marks of the relaxation of the excretories take place." This relaxed or perspiratory section of the paroxysm, however, is not regarded by Dr. Cul- len as a part of the disease, but as the prelude to returning health. Yet the fit still consists of three stages : the first, of debility or dimin- ished energy ; the second, of spasm, and the third, of heat. And though Dr. Cullen had some doubts whether the remote cause of fever might not produce the spasm, as well as the atony of the nervous system, yet he inclined to ascribe the second stage to the operation of the first, as he did most decidedly the third to that of the second : and thus to regard the whole as a regular series of actions, employed by the vis medicatrix naturae for the recovery of health. That fever, in its commencement, or earliest stage, is characterized by debility of the living fibre, or, more closely in the words of Dr. Cul- len, by diminished energy of the brain, extend- ing directly or indirectly to the voluntary mus- cles and capillaries, and producing the signa prodroma of Professor Frank (De Cur and. Horn. Morb., torn, i., page 3, 8vo., Mannh., 1792), cannot for a moment be doubted by any one who accurately watches its phenom- ena. And thus far the Cullenian hypothesis is unquestionably correct; as it appears to be also in supposing the cold stage to be the foundation of the hot, and of the excretion of sweat, by which the hot stage is succeeded ; the entire series forming Frank's signa constitu- tiva. But it fails in the two following impor- tant points, without noticing a few others of smaller consequence. The spasm on the mi- nute vessels, produced by debility, takes the lead in the general assault; and, though it forms only a link in the remedial process, is the most formidable enemy to be subdued ; and hence, all that follows in the paroxysm is an effort in the system to overcome this spasm. The effort at length proves successful, the debility yields to returning strength, the spasm is con- quered, and the war should seem to be over. But this is not the fact: the war continues notwith- standing ; there is nothing more than a hollow truce ; debility and spasm take the field again, and other battles remain to be fought. There is nothing in this hypothesis to account for a return of debility and spasm after they have been subdued ; nor to show why spasm should ever in the first instance be a result of debility. " In this system," says Dr. Parr, " the production of spasm by debility is an isolated fact without a support; and the introduction of the vires medi- catrices naturae is the interposition of a divinity in an epic, when no probable resource is at hand." The next striking defect is, that debility is here made a cause of strength ; the weakened action of the first stage giving rise to the increased action and re-excited energy that restore the Cl. III.—Ord. I.] PYRECTICA. 331 system to a balance of health : and here again we stand in need of the interposition of some present divinity, to accomplish such an effort by such means. IV. It is not, therefore, to be wondered at, that this system, with all its ingenuity and masterly combination, should not have proved satisfactory to every one. In reality, it did not for many years prove satisfactory to every one in the celebrated school in which it was first propounded. And hence, under the plastic hands of Dr. Brown, arose another hypothesis, of which I shall proceed to give a very brief outline, together with the modification it re- ceived under the finishing strokes of Dr. Darwin. Dr. Brown, who was at first a teacher of the classics at Edinburgh, and a translator of in- augural theses into Latin, commenced the study of medicine about the middle of life, by a per- mission to attend the medical schools gratui- tously. He was at first strongly attached to Dr. Cullen and Dr. Cullen's system; but an altercation ensued, and he felt an equal ani- mosity towards both. A new and opposite system, if so it may be called, was in conse- quence manufactured and publicly propounded in a variety of ways. It had great simplicity of principle, and some plausibility of feature ; it attracted the curious by its novelty, the indo- lent by its facility, and every one by the bold- ness of its speculations. It circulated widely, and soon acquired popularity abroad as well as at home. Man, according to Dr. Brown, is an organ- ized machine, endowed with a principle of ex- citability, or predisposition to excitement, by means of a great variety of stimuli, both exter- nal and internal, some of which are perpetually acting upon the machine ; and hence the ex- citement, which constitutes the life of the ma- chine, is maintained. Excitability, therefore, is the nervous energy of Dr. Cullen ; and, like that, is constantly varying in its accumulation and exhaustion : yet not, like the nervous en- ergy of Dr. Cullen, under the direction and guidance of a vis conservatrix et medicatrix naturae, distinct from the matter of the organi- zation itself, but passively exposed to the effect of such stimuli as it may chance to meet with, and necessarily yielding to their influence. Upon this hypothesis excitement is the vital flame, excitability the portion of fuel allotted to every man at his birth, and which, varying in every individual, is to serve him without any addition for the whole of his existence ; while the stimuli, by which we are surrounded, are the different kinds of blasts by which the flame is kept up. If the fuel, or excitability, be made the most of, by a due temperature or mean rate of blasts or stimuli, the flame or excitement may be maintained for sixty or seventy years. But its power of supporting a protracted flame may be weakened by having the blast either too high or too low. If too high, the fuel or ex- citability will, from the violence of the flame, be destroyed rapidly, and its power of prolong- ing the flame be weakened directly ; and, to this state of the machine Dr. Brown gave the name of indirect debility, or exhausted excita- bility. If the blasts or stimuli be below the mean rate, the fuel, indeed, will be but little expended, but it will become drier and more inflammable ; and its power of prolonging the flame will be still more curtailed than in the former case ; for half the blast that would be required to excite rapid destruction antece- dently, will be sufficient to excite the same effect now. This state of the machine, there- fore, the author of the hypothesis contra-dis- tinguished by the name of direct debility, or accumulated excitability. Upon these principles he founded the charac- ter and mode of treatment of all diseases. They consist but of two families, to which he gave the name of sthenic and asthenic; the forms produced by accumulated excitability, and marked by direct debility ; the latter occa- sioned by exhausted excitability, and marked by indirect debility. The remedial plan is as sim- ple as the arrangement. Bleeding, low diet, and purging, cure the sthenic diseases ; and stimu- lants of various kinds and degrees, the asthenic. Fevers, therefore, under this hypothesis, like other diseases, are either sthenic or asthenic ; they result from accumulated or exhausted excitability. Synocha, or inflammatory Tever (cauma under the present arrangement), belongs to the first division, and typhus to the second. Let us try the system by these examples. The first symptoms of inflammatory fever, like those of all others, evince, as I have al- ready observed, debility or languid action in every organ, let the debility be distinguished by whatever epithet it may. The vital flame is weak, and scarcely capable of being supported ; and yet the fuel is more inflammable than in a state of health ; the excitability is accumulated. This scheme, therefore, completely fails in ac- counting for the origin or first stage of inflam- matory, or, in Dr. Brown's own language, sthenic fever. Typhus pestilens, or jail-fever, is arranged by Dr. Brown as an asthenic disease ; and, as such, we have reason to expect debility, as characteristic of its entire progress. Yet, what is it that produces this debility 1 The blast or stimulus is here contagion; and the excitability is exhausted by the violence of this blast or stimulus ; but there is no means of its becoming exhausted without increasing the excitement: the fuel can only be lessened by augmenting the flame that consumes it. Yet in typhus, according to this hypothesis, the fuel is expended, not in proportion as the flame is active and violent, but in proportion as it is weak and inefficient. The excitability is ex- hausted, and the debility increases in propor- tion as the excitement forbears to draw upon it for a supply. The blast blows hard, but with- out raising the fire, and yet the fuel consumes rapidly. This scheme, therefore, completely fails in accounting for any stage of low or as- thenic fevers of every description. Dr. Brown, however, was not a man of much practice ; his writings show that he was but lit- tle versed in the symptoms of diseases , his 332 H^MATICA. [Cl. III.—Ord. I. descriptions are meager and confused : and hence, when he comes to assort diseases into the only two niches he allots for their recep- tion, he makes sad work ; and maladies of the most opposite characters, and demanding the most opposite mode of treatment, are huddled together to be treated in the same manner, in many cases with no small risk of the patient. Thus, among the sthenic diseases are associated rheumatism, erysipelas, scarlet and inflamma- tory fever; and, among the asthenic, gout, typhus, apoplexy, and dropsy. The Brunonian hypothesis, nevertheless, offers one principle that is unquestionably founded on fact, and is peculiarly worthy of at- tention ; I mean, that of accumulated excitability from an absence or defect of stimuli; in collo- quial language, an increase of energy by rest. And it is this principle which forms the hinge on which turns the more finished system of Dr. Darwin. Sensible of the objection that weighs equally against that part of the system of Dr. Cullen and Dr. Brown, which represents the energy or excitability of the living frame as capable of re- cruiting itself after collapse or exhaustion, with- out a recruiting material to feed on, he directly allows the existence of such a material; re- gards it as a peculiar secretion, and the brain as the organ that elaborates and pours it forth. The brain, therefore, in the system of Dr. Dar- win, is the common fountain from which every other organ is supplied with sensorial fluid, and is itself supplied from the blood, as the blood is from the food of the stomach. All this is intelligible; but when, beyond this, he endows his sensorial fluid with a men- tal as well as a corporeal faculty, makes it the vehicle of ideas as well as of sensation, and tells us, that ideas are the actual " contractions, or motions, or configurations, of the fibres which constitute the immediate organ of sense" (Zoonom., vol. i., sect, ii., ii., 7), he wanders very unnecessarily from his subject, and clogs it with all the errors of materialism. He supposes the sensorial power, thus se- creted, to be capable of exhaustion in four dif- ferent ways, or through four different faculties of which it is possessed : the faculty of irrita- bility, exhausted by external stimuli affecting simple irritable fibres : that of sensibility, exhausted by stimuli affecting the fibres of the organs of sense: that of voluntarity, ex- hausted by stimuli affecting the fibres of the voluntary organs, acting in obedience to the command of the will; and that of associability, exhausted by stimuli affecting organs associated in their actions by sympathy or long habit. By all, or any of these means, the sensorial power becomes evacuated, as by food and rest it be- comes replenished, often, indeed, with an ac- cumulation or surplus stock of power. In applying this doctrine to fever, he con- siders its occasional causes, whatever they may be, as inducing a quiescence or torpor of the extreme arteries, and the subsequent heat as an inordinate exertion of the sensorial power here- by accumulated to excess; and, consequently, the fever of Dr. Darwin commences a stage lower than that of Dr. Cullen, or in the cold fit, instead of in a collapse of the nervous energy lodged in the brain. Now, allowing this explanation to account for the cold and hot stages of a single paroxysm of fever, like the spasm of Dr. Cullen, it will apply no farther. For, when the sensorium has exhausted itself of its accumulated irritability; the disease should cease. It may, perhaps, be said, that a second torpor will be produced by this very exhaustion, and a second paroxysm must necessarily ensue. Admitting this, how- ever, for a moment, it must be obvious that the first or torpid stage only can ensue ; for the system being now quite exhausted, the quies- cence that takes place during the torpor can only be supposed to recruit the common supply necessary for health ; we have no reason to conceive, nor is any held out to us, that this quantity can again rise to a surplus. Yet it must be farther remarked, that, in continued fevers, we have often no return of torpor or quietude whatever, and, consequently, no means of re-accumulating irritability ; but one con- tinued train of preternatural action and exhaus- tion, till the system is completely worn out. And to this objection, the Darwinian hypothe- sis seems to be altogether without a reply. A still later modification of the Brunonian system (for after all it is such, though the name of Brown is hereby openly despised), has been attempted in France by M. Broussais, and has acquired a very considerable degree of popularity, though a popularity that seems to have little chance of a longer duration than the two forms by which it has been preceded. Throwing out of the catalogue of vital properties the sensibility of Bichat, and indeed all other vital properties whatever but organic contractility, he maintains that this alone is the real source of all diseases whatever, and that no other exists or is wanted. This contractility is the excitability of Brown, and to the excitement that flows from it M. Brous- sais has given the name of irritation or excita- tion, upon a plus or minus degree of which all diseases, as in the hypothesis of Brown, are de- pendant. But he has this great advantage over Brown, that, instead of making the state of ex- citement or depression common to the entire system, M. Broussais limits both to particular organs, and contends, that when an organ is in a state of irritation, or vital erection, to adopt another quaint term from the technology he employs, such effect can only take place at the expense of some other part of the system, the contractility of which is proportionably dimin- ished.—(Exposition de la Nouvelle Doctrine Midicale, &c, Par J. R. A. Goupel, Paris, 1824.) Diseases with him, therefore, proceed, for the most part, from an unequal distribution of excitation or irritation ; and as the doctrine of sympathy is carried to a considerable extent, and plays a very important part in the patho- logical drama, often, indeed, a very ingenious part, the author of the hypothesis obtains an easy and occasionally a correct mode of ac- counting for local diseases that originate in re- Cl. Ill—Ord. I.] PYRECTICA. 333 mote quarters; as, for example, when his fa- vourite gastro-enteritis is the result of a cold, damp atmosphere applied to the skin, or amor- bid condition of the lungs or of the head. So that gastritis or gastro-enteritis, primary or in- duced, is almost every thing with him : all fe- vers are local affections, and, under whatever shape they may appear, their real seat is the stomach, or alvine canal. Among many weak parts of the hypothesis, one of the weakest is its inability of accounting for the chymical changes that are so perpetually taking place in the system during the influence of disease. For as the only source of disease is in the quantity of the efflux of the vital fluids, with- out any change whatever in their quality, it leaves us entirely in the dark as to the origin of scrofula, cancer, all the exanthems, and, in few words, every other specific poison or mor- bid secretion whatever ; the greater part of which, if not the whole, are still referred to a gastric origin, where we are expressly com- manded to look as definitely for the real seat of plague, as for bilious fever, yellow fever, Indian cholera, or dysentery.* It is not necessary to pursue this subject far- ther. Other conjectures, .more or less discre- pant from those now examined, have been offer- ed : but they have not acquired sufficient notice, nor evinced sufficient ingenuity, to be worthy of examination. V. Other pathologists have referred the proxi- mate cause of fever to a morbid affection of some particular organ, or set of organs, associa- ted in a common function. Thus, Baron Haller alludes to several in his day, who ascribed it to a diseased state of the vena cava (Bibl. Med., Pr. i., p. 112); Bianchi pitched upon the liver (Hist. Hepat., p. 112); Swalve on the pan- creas (Pancreas, &c, p. 141), Rahn on the di- gestive organization generally.—(Briefwechsel, band, i., p. 150.) Professor Frank has divided the different kinds of fever between the digestive organs, the arteries, and the nerves, each in a particular state of diseased action ; so that with him all fevers are nervous, inflammatory, or gas- tric.—(De Cur. Morb. Horn. Epitome, torn, v., 8vo.,Mannh., 1792-4.) The Italian pathologists eagerly caught up this view, and modified it in various ways ; and Broussais has of late given it another modification, by placing fever in the mucous membrane of any of the viscera, but chiefly in the mucous membrane of the digest- ive canal; and consequently gastric fever, with Broussais, takes the lead of all the rest, both in variety and vehemence of action : the particular character or intensity of the fever being resolva- ble into the temperament, idiosyncrasy, or other circumstances of the individual.—(Examen, &c, par F. J. V. Broussais, D. M., 8vo., 1821.) Dr. Clutterbuck has still more lately, in our own * See M. Broussais' Examen de la Doctrine Medicale generalement adoptee, et des Systemes Modernes de Nosologic, Paris, 1816. All the above observations by Dr. Good on the theory of Broussais, are new matter in the present edition, lately found among the author's M S S., and marked for insertion in this work.—Ed. country, and with far more reason and learning, brought forward the brain instead of the stomach ; to an inflammation of which organ he ascribes fevers of every kind, regarding them merely as so many varieties of one specific disease, origina- ting from this one common cause.—(Treatise on Fever, 8vo.) But this is to confound fever with local inflammation, the idiopathic with the symp- tomatic affection. In treating of inflammation under the ensuing Order, we shall have suffi- cient opportunities of seeing, that an inflamed state of almost any organ, and especially of membranous organs, or the membranous parts of organs, is sufficient to excite some degree of fever or other, and not unfrequently fever of the highest degree of danger from its duration or violence. And hence, the liver, the lungs, the stomach, the intestines, the peritonaeum, and the brain, have an equal claim to be regarded as furnishing a proximate cause of fever when in a state of inflammation. A very striking objection to Dr. Clutterbuck's hypothesis is, his limiting himself to a single organ as the cause of an effect, which is equally common to all of them. And on this ground it is, that Professor Marcus, of Bavaria, who has contended with similar strenuousness for the identity of fever and inflammation, has regarded all inflamed organs as equal causes; and is hereby enabled to account, which D~r. Clutter- buck's more restricted view does not so well allow of, for the different kinds of fever that are perpetually springing before us, one organ giving rise to one, and another to another. Thus in- flammation of the brain, according to Dr. Mar- cus, is the proximate cause of typhus; inflam- mation of the lungs, of hectic fever; that of the peritonaeum, of puerperal fever; and that of the mucous membrane of the trachea, of catarrhal fever : a view which has lately been adopted by several French writers of considerable intelli- gence, as an improvement upon the hypothesis of Broussais.* The general answer, however, to pathologists of every description who thus confound or iden- tify fever with inflammation, whether of a single organ or of all organs equally, is, that, though fever is commonly a symptom or sequel of in- flammation, inflammation is not uncommonly a symptom or sequel of fevers. And hence, though post-obit examinations, in the case of those who have died of fever, should show in- flammation in the brain, the liver, or any other organ, it is by no means a proof that the disease originated there, since the same appearance may take place equally as an effect, and as a cause : while a single example of fever terminating fatally, without a trace of inflammation in any organ whatever, and such examples are perpetu- ally occurring, is sufficient to establish the exist- ence of fever as an idiopathic malady, and to separate the febrile from the phlogotic divisions of diseases.! * M. Gaultier de Clanbry, vide Journ. Gen. de Medecine, Avr., 1823, and M. Tacheron, Recher- ches Anatomico-Pathologiques sur la Medecine Pratique, &c, 8vo., 3 tomes, Paris, 1823. t " It is too generally imagined, that the pri- 334 HjEM " A fever, therefore,'' to adopt the language of Dr. Fordyce, "is a disease that affects the whole system; it affects the head, the trunk of the. body, and the extremities ; it affects the cir- culation, the absorption, and the nervous sys- tem ; it affects the skin, the muscular fibres, and the membranes; it affects the body, and affects likewise the mind. It is, therefore, a disease of the whole system, in every kind of sense. It does not, however, affect the various parts of the system uniformly and equally ; but, on the contrary, sometimes one part is much affected in proportion to the affection of another part."*—(On Fever, Dissert, i., p. 28.) mary disease which induces fever is essentially local inflammation. The application of this doc- trine to the early stage of fever, we hold to be not ' only at variance with facts, but dangerous as to the practical deductions to which if leads. We know that irritation, far short of inflammation, is sufficient to excite feverish indisposition, more particularly at^ those periods of life at which the vascular system is easily excited by apparently trivial, local, or sympathetic disturbance (for ex- ample, in infancy or childhood, by dentition, or intestinal irritation), and that this feverishness disappears when the cause is removed. The paroxysm of an intermittent is induced by the peculiar effect of a malarian poison; in this dis- ease, the whole phenomena of fever are well marked ; but certainly few will maintain, that the febrile disturbance is the consequence of local inflammation. There can be little doubt that the error alluded to may, in a great measure, be im- puted to the attempts to discover the cause or nature of fever in the various local lesions which are observed in fatal cases. On the other hand, the important fact should ever be kept in view, that the primary disorder, whatever it may be, passes readily into inflammation, and that the lesions which arise in the progress of fever con- stitute the principal source of danger, and are in many instances the immediate cause of death."— Dr. Tweedie in Cyclop.of Pract. Med., art. Fever. * It is singular that Dr. Good, who has stated, with much ability and clearness, the theories of medicine which have successively prevailed,' should have entirely omitted even a cursory notice of our distinguished countryman Dr. Rush, who may be justly ranked among those who have suc- cessfully elucidated, at least, in part, some of the soundest principles of medical practice. On the subject of Dr. Rush's merits as a systematic theorist, we avail ourselves of a supplementary note by Dr. J. W. Francis, in the American edi- tion of Dr. Brewster's Encyclopedia, Vol. xii., p. 741 " Dr. Rush has been noticed as one of the class of modern eclectics, we think, improperly. No author of late times has probably laboured more perseveringly than Dr. Rush in favour of a particular system, and throughout his numerous medical writings traces of his peculiar theory are always apparent. His system may probably be considered a modification of the doctrines of Dr. Brown, but ushered into the world under circum- stances more favourable to its successful recep- tion. In the advantages of preliminary learning and general science, in experimental research and practical acumen, Brown can stand in no compe- tition with Rush: while the greater elaboration of his doctrines by the latter early began and con- tinued to an advanced age; his extraordinary elo- quence as a public teacher, in the then only fre- quented university of the American republic ; and lTICA. ' [Cl. III.—Ord. 1. The result of the whole, as observed at the outset of this introduction, is, that we know little or nothing of the proximate cause of fever, or the means by which its phenomena are imme- diately produced. In the language of Lieutaud, applied to the subject before us, they are too often atra caligine mersa ; nor have any of the systems hitherto invented to explain this recon- dite inquiry, however ingenious or elaborate, answered the purpose for which they were con- trived. * From the proximate cause of fever, let us next proceed to a few remarks upon its remote causes. Dr. Cullen, who has striven so strongly and so ingeniously to simplify the former, has made a similar attempt in respect to the latter. He first resolves all remote causes into debilitating or sedative powers, instead of being stimulant, as they were formerly very generally considered, and as they are still regarded by many patholo- gists, and especially by those who contemplate fever and inflammation as identical. Whether this position of Dr. Cullen be correct or not, it was necessary for him to lay it down and to maintain it, or he must have abandoned his sys- tem of fever altogether, which supposes it to commence in, and be primarily dependant upon, debility. These sedative or debilitating causes he re- duces to two,—marsh and human effluvia ; to the former of which he limits the term mias- mata, and the power of producing intermittent fevers, which, with him, include remittent ; the popularity of his written productions, secured to him an ascendency and duration which the principles of Brown, popular as they once were, never attained. Dr. Rush, however, seldom per- mitted mere theoretical views to mislead his prac- tice; and his contemporaries will bear witness, that his prescriptions were as prudent and judicious, as his speculations were ardent and adventurous. At the present day, when the pretensions of several medical universities in the country pre- sent nearly equal claims, the medical practice in the United States is far too various to exhibit the liveries of any particular sect. More recently, the doctrines of sympathy, as they are termed, have been ably illustrated and defended, in the Phila- delphia school, by Professor Chapman; while the principles of the humoral pathology, as modi- fied by the late researches in physiology, and the results afforded by animal chymistry, are advo- cated by the professor of the practice of physic in the New-York University.—(See Dyckman's Pa- thology of the Human Fluids.) These two theories may be deemed those most current among Ameri- can physicians."—D. * The following observations by Dr. Tweedie agree with those of Andral (Anat. Pathol., torn. ii., p. 211, &c, and Clinique Med.). "In most cases of fever we can discover the existence of certain lesions, but these are too vague or indefi- nite to enable us uniformly to decide on the pri- mary seat of the malady. It is more than proba- ble, that, in what is usually called idiopathic fever, there is alteration either of the solids or fluids, although its precise locality cannot, in every case, be detected; but, without disease in either the one system or the other, we maintain that fever cannot | exist."—Cyclop, of Pract. Med., art. Feyeb. Cl. III.—Ord. I.] PYRECTICA. 335 while, to the latter, he confines the term conta- gions, and the power of producing continued evers. It is true, he has found himself com- pelled to take notice of a few other powers, as cold, fear, intemperance in venery or drinking; but these he is disposed to regard as little or nothing more than sub-agents, or co-agents, scarcely capable of producing fever by them- selves. " Whether fear or excess be alone," says he, " the remote cause of fever, or if they only op- erate either as concurring with the operation of marsh or human effluvia, or on giving an oppor- tunity to the operation of cold, are questions not to be positively answered; they may possibly of themselves produce fever; but, most fre- quently, they operate as concurring in one or other of the ways above mentioned."—(Pract. of Phys., book i., chap, iv., sect, xcvii.) To cold, however, he attributes a power of engendering fever more freely than to the rest; " yet even this," says he, " is commonly only an exciting cause, concurring with the operation of marsh or human effluvia."—(Ibid., book i., chap, iv., sect, xcii.) We shall find, as we proceed, that these com- plemental causes may admit of addition ; as we shall also, that they more frequently exist as in- dependent agents, than Dr. Cullen is disposed to allow. Yet, there can be little doubt, that the chief and most extensive causes of fever are human and marsh effluvia. No great benefit, however, has resulted from endeavouring to draw a line of distinction be- tween these two terms, and hence it is a dis- tinction which has been very little attended to of late years. Miasm is a Greek word, import- ing pollution, corruption, or defilement generally ; and contagion a Latin word, importing the ap- plication of such miasm or corruption to the body by the medium of touch.* Hence, there * A distinction is sometimes made between a contagious and an infectious disease; the former being communicable only by contact with the patient, or with something that he has touched, or some palpable matter that has proceeded from him. Of this kind are itch, syphilis, cowpox, hydrophobia, elephantiasis, yaws, sibbens, the glanders, and, as is sometimes suspected, porrigo, and plague. Infectious diseases are those which a person may contract by merely being exposed to the patient's atmosphere. Some diseases are both contagious and infectious, being capable of propa- gation in both manners, as the smallpox, the chickenpox, scarlatina, and the measles. The earliest suggestion of the different modes in which contagious and infectious disorders are propagated, was made by M. Quesnay, in his Mem. sur les Vices des Humeurs.—(Mem. de l'Acad. Royale de Chir.) This author admits two species of conta- gion :—" The first consists in the communication of diseases, which extend from one body to an- other by their property of multiplying the cause that has excited them, and of multiplying them- selves in other subjects by this augmentation of cause: smallpox is a manifest instance of this species of contagion." Quesnay's second form of contagion is characterized by " the communication of a spontaneous movement, that extends from one body to another susceptible of this move- ment." This he compares to the fermenting of is neither parallelism nor antagonism in their respective significations; there is nothing that necessarily connects them, either disjunctively or conjunctively. Both equally apply to the ani- mal and the vegetable worlds—or to any source whatever of defilement and touch; and either may be predicated of the other; for, we may speak correctly of the miasm of contagion, or of contagion produced by miasm. Hence, the lat- ter term is equally applied by Sauvages to both kinds of effluvia: " Miasmata, turn sponte in sanguine enata, turn extus ex aere, in massam sanguineam delata."—(Nosol. Method., Cl. ii. ; Febr. Theor., sect. 79.) And it is not a little singular, and confirms the force of this remark, that, since the publication of the first edition, in which the remark may be found as at present, M. Monfalcon, an ingenious and learned advo- cate of the Broussais hypothesis, has specifically applied, in direct contravention of Dr. Cullen's explanation, the terms miasm and miasmata to those morbific effluvia alone which are thrown off from the living bodies of men and animals in a state of disease, the influence or pathological action of which on the human frame he denomi- nates contagion: while the effluvia from marshes, swamps, privies, cemeteries, and other sources of decomposing animal and vegetable materials, he simply but specifically distinguishes by the name of marsh effluvium, and their pathological action by that of infection.—(Histoire des Ma- rais et des Maladies causies par les Emanations des Eaux Stagnantes, &c, 8vo., Paris, 1824.) In a work of practical information, it is hardly worth while to follow up the refinements of those writers who deny, and endeavour to dis- prove, the existence of contagion under any form or mode of origin.* Such speculations may be ingenious and very learned, and find amusement for a leisure hour in the closet; but they will rarely travel beyond its limits, and dough, or the extension of putrefaction through flesh. As Baron Dupuytren has explained, in a valuable document on contagious diseases, it ap- pears that some of them are transmitted through the medium of the air; such are measles and scarlatina, after attaining a certain stage. Others are communicated by contact, as, for instance, the itch; some usually require contact and fric- tion : such is the venereal disease. Others, like the cowpox and hydrophobia, need inoculation, or insertion. Some can be propagated only in one manner : such are measles, searlatina, the itch, the cowpox, and hydrophobia. Others may be communicated in several ways, as syphilis and smallpox, the first of which may be transmitted with and without friction, and by inoculation; and the second by inoculation, contact, or the medium of the atmosphere. Dupuytren errs, however, in stating that measles cannot be communicated by inoculation.—See Rapport fait a l'lnstitut en 1825, sur un Mem. de M. Costa relatif a l'Epidemie qui ravagea Barcelonne en 1821.—Ed. * Lasgis, Recherches sur les veritables Causes des Maladies Epidemiques appel^es Typhus, ou de la Non-contagion des Maladies Typhoides, &c, 8vo., Paris, 1813. Maclean's Results of an inves- tigation respecting Epidemic and Pestilential Dis- eases, &c, 2 vols., 6vo., 1817-18. 336 H.EMATICA. [Cl. III.—Ord. I. should they ever be acted upon, would instantly destroy themselves. It is a question of more importance, whether we have yet the means of realizing the distinc- tion between human and marsh miasmata,* which Dr. Cullen has here laid down, and which has been generally adopted, from the weight of his authority. All specific miasmata may be regarded as morbid ferments, capable of suspen- sion in the atmosphere, but varying very con- siderably in their degree of volatility, from that of the plague, which rarely quits the person ex- cept by immediate contact, to that of the spas- modic cholera of India, which works its way, if it be really from a specific poison, in the teeth of the most powerful monsoons, despising equally all temperatures of the atmosphere and all salubrities of district, and travelling with the rapidity of the fleetest epidemy. They are of various kinds, and appear to issue from various sources, but we can only discriminate them by their specific effects. These are most clearly exemplified in the order of'exanthems ; in which, for some thousands of years, they have proved themselves to be of a determinate character in all parts of the world where they have been the subject of observation, differing only in circum- stances that may be imputed to season, climate, and other external causes, or to the peculiar' constitutions of the individuals affected. Thus, the miasm of smallpox has uniformly continued true to smallpox, and that of measles, to mea- sles ; and neither of them has, in a single in- stance, run into the other disease, or produced any other malady than its own. But, can we say the same of the supposed two distinct miasms of marsh and human efflu- via'! It is equally true, that the former has never produced any other than intermittent fever, or the latter any other than continued 1 And is it also equally true, that each of these maladies adheres as strictly to its own character in every age, and every part of the world, as smallpox and measles; and that they have uniformly shown as strong an indisposition to run into each other1! Dr. Cullen's system is built upon an affirmative to these questions. For it, in fact, allows but two kinds of fever, each as distinctly proceeding from its own specific miasm as any of the exanthems. But this is to suppose what is contradicted by the occurrences of every day : which compel us to confess, that, while we cannot draw a line of distinction between marsh and human effluvia from their specific effects, we have no other mode of distinguishing them. Some writers, indeed, have denied that inter- mittents, or rather the intermittents of marsh- * Johnson, Influence of Tropical Climates, &c, pp. 20, 21, 3d edit., 1822. Miasm still denotes, in the common language of the profession, only the exhalations of decaying vegetable matter, which are the exciting causes of intermittent and remit- tent fevers. As Dr. Elliotson has very justly ob- served, however, marsA-miasm is an improper ex- pression : it generally comes from a marsh; but it may arise without the presence of any marsh at all. Hence the term malaria is frequently pre- ferred.—Ed. lands, are produced by a miasm of any kind ; for they deny that any kind of miasm is generated there; and contend, that the only cause of in- termittents, in such situations, is air vitiated by being deprived of its proper proportion of oxy- gen in consequence of vegetable and animal putrefaction, combined with the debilitating heat of the autumnal day, and the sedative cold and damp of the autumnal night.—(Currie, Trans. Amer. Phil. Soc.) But this opinion is too loosely supported to be worthy of much attention. It is sufficiently disproved by the intermittent de- scribed by Sir George Baker, as existing in the more elevated situations of Lincolnshire, while the adjoining fens were quite free from it.— (Medic. Trans., vol. iii., art! xiii.) And, in like manner, the severe and intractable intermittents, of whatever form or modification, that exercise their fearful sway from Cape Comorin to the banks of the Cavery, from the Ghauts to the coast of Coromandel, not unfrequently pass into a contagious type, and propagate themselves by contagion.—(Report on the Epidemic Fever of Coimbatore, by Drs. Ainsly, Smith, and Chris- tie.) We have as much reason to suppose a febrile miasm in intermittents as in typhus ; and, in some instances, they have been found as de- cidedly contagious. " That intermittent fe- vers," says Dr. Fordyce, "produce this matter, or, in other words, are infectious, the author (meaning himself) knows from his own observa- tion, as well as from that of others."* And, notwithstanding that it becomes us to speak with diffidence upon a subject, respecting which we are so much in want of information, I may venture to anticipate, that the evidence to be advanced in the ensuing pages upon the general nature and diversities of fever, will show that there is more reason for believing that the febrile principle, produced by marsh and human effluvia; is a common miasm, only varying in its effects by accidental modifications, and equally productive of contagion, than that it consists of two distinct poisons, giving rise lo two dis- tinct fevers, the one essentially contagious, as contended for by Dr. Cullen. t * On Fever, Diss, i., p. 117. Notwithstanding Dr. Good's arguments, the Cullenian doctrine still prevails. " It appears quite certain," says Dr. Elliotson, " that intermittent and remittent fevers are not contagious." If a person catch a disease by going to see a patient who is labouring under it, this is no proof that the disorder is contagious; for the patient may be in the very spot where he contracted it from local circumstances ; and the visiter goes to the spot, and exposes himself to the same causes. In order to prove that a disease is contagious, there should be a sufficient number of instances of persons going from the place where they contracted the disease to a healthy part, and there giving it to others. On this point the reader will find valuable rules of evidence laid down by Dr. Alison (On Epidemic Fever, in Edinb. Med. and Surg. Journ., vol. xxvii.), and various judi- cious reflections by Professor Elliotson, in his Lec- tures delivered at the Lond. Univ., as published in Med. Gaz. 1831-2, p. 921.—Ed. t Certain difficulties, in the adoption of this view of the subject, will be noticed when inter- mittent fever comes under consideration.—Ed. Cl. III.—Ord. I.] PYRECTICA. 337 In effect, we shall perceive, that this myste- rious subject is capable of being, in some degree, more clearly elucidated and still farther simpli- fied, than it has been by preceding pathologists. In the decomposition of all organized matter, whether ■ vegetable or animal, when suddenly effected by the aid of heat and moisture, .an effluvium is thrown forth'thatis at all times highly^ injurious to the health; and, in a closely cbncen-' trated state, fatal to life itself. ' Thus, we are told by Fourcroy, fhat, in some of the burial grounds in France, whose graves are dug ug sooner than they ought to be, the effluvium from an abdomen, suddenly opened by a stroke of the mattock, strikes so forcibly upon the grave-dig- ger as to throw him into a state of asphyxy, if close at hand; and, if at a little distance, to oppress him with vertigo, fainting, nausea, loss of appetite, and tremors for many hours : while numbers of those, who live in the neighbour- hood of such cemeteries, labour under dejected spirits, sallow countenances, and febrile emaci- ation.* This effluvium is from the decomposi- tion of animal matter alone ; but, the foul and noisome vapour that is perpetually blown off the coast of Batavia, and the stinking malaria that rushes from the southeast upon the Guinea coast, though loaded with vegetable exhalations alone, triumph in a still more rapid and wasteful destruction. The last peculiarly so, as being thoroughly impregnated with destructive miasm, while sweeping over the immense uninhabitable swamps and oozy mangrove thickets of the sul- try regions of Benin, insomuch that Dr. Lind informs us, that the mortality produced by this * Elem. de Chimie, Art. Putrefaction de Subst. Animal., torn. iv. These facts prove nothing more than either the asphyxiating nature, or the gen- eral unfavourable influence of such effluvia on the human constitution, and not the existence of any specific miasm or contagion, capable of bringing on either intermittent or continued fever. On this subject the following observations are cu- rious and instructive :—" That it is vegetable and not animal matter which produces ague, is proved by this circumstance, that no person has that affec- tion from being exposed to the most intense ani- mal exhalations. Thousands of carcasess are an- nually employed in many manufactories, and yet no person is known to contract an ague from them; indeed, so far from it, that the most crowded places generally escape intermittent fe- vers. That part of Rome inhabited by the Jews, and called the Judaicum, is full of animal filth, but it escapes ague, while the elegant streets in the neighbourhood suffer from it very severely. Malaria not being the produce of dead animal mat- ter, or effluvia arising from living bodies, the more men and animals are crowded together, the less access is there for the malaria ; and, indeed, it is generally supposed, that the addition of smoke of every description has a great tendency to prevent it."—(Professor Elliotson's Lect. at Lond. Univ., as published in Med. Gaz. for 1831-2, p. 895.) Further remarks on this point will be introduced when we come to intermittent fever, and here the editor will merely refer to the observations of M. Andouard, Recherches sur la Fievre Jaune, and to various facts adduced by M. Brachet, of Lyons, in confirmation of the truth of the above view.—Ar- chives Gen. de Med., torn, ix., pp. 380, 381,—Ed. Vol. I.—Y pestilential vapour in the year 1754 or 1755 was so general, that in several negro towns, the liv- ing were not sufficient to bury the dead ; and that the gates of Cape Coast Castle were shut up for want of sentinels to perform duty ; blacks and whites falling promiscuously before this fatal scourge. In this case, as in the preceding, the vapour is always accompanied with an intolerable stench from the play of affinities between the different gases that are let loose by the putrefactive de- composition ; ind hence it is impossible to affirm, that the mortality thus produced is the result of any single or specific miasm operating to this effect. But it shows us, that the general efflu- vium from the decomposition of all dead organ- ized matter, whether animal or vegetable, is equally deleterious to health and life. " Its presence," says the judicious Dr. Jackson, " is often connected with something offensive to the senses,—to the smell, and, perhaps, even to the taste. A certain degree of salivation, nausea, sickness, and headache, is often occasioned by the exhalations of a swamp, or the air of an in- fected apartment, but febrile action is not or- dinarily the immediate consequence! To pro- duce fever a space of time is required, different accdrding to circumstances."—(Outline of the History and Cure of Fever, part i., ch. iii., p. 104.) How far the decomposition of dead vege- table matter, though its effluvium prove thus in- jurious to the health of man, may alone be capa- ble of exciting fever of any kind, may, perhaps, , admit of a doubt; -for, in the bogs or peat-moss- es of Scotland, and, still more, those of Ireland, the inhabitants arc exempt from agues, though the ooze extends in immense tracts.* The decomposition, however, to which on the present occasion we are chiefly to direct our attention, is of a mixed kind ; for the marsh and oozy soil of countries that are closely or have been long inhabited, is necessarily a com- bination of animal and vegetable matter. If this decomposition take place slowly, as in cold or dry weather, and more particularly in a breezy atmosphere, not the slightest evil is sustained during its entire process. And hence, in order to render it mischievous, and particularly in order to render it capable of pro- ducing fever of any kind, it is necessary that it should be assisted by the co-operation of certain * The following is the explanation of this cir- cumstance, given by Professor Elliotson:—" There is one description of bog which does not produce malaria ; but then there is no putrefaction; decom- position has taken place in a peculiar manner. The vegetable matter becomes carbonized, and there is not sufficient heat for putrefaction to occur; but, it is said, that when peat-moss is in a certain latitude, and on a certain level, it can pu- trefy, and then, I believe, ague does prevail. That peat-bog does not putrefy is shown by a fact stated on good authority, viz., that animal matter thrown into it will not putrefy ; but, it is said, that where peat-moss is placed in other situations, where it is warmer, and upon a proper level for moisture, it will putrefy and produce ague, just as other kinds of vegetable matter do."—Lect. at Lond. Univ., Med. Gaz. 1831-2, p. 895.—Ed. 336 ILEMATICA. [Cl. III.—Ord. I. agents, many of which we do not seem to be acquainted with, but which, so far as we are capable of tracing them, appear to be auxiliary to the general process of putrefaction, as warmth, moisture, air, and rest or stagnation. The simplest and slightest fever that is pro- duced under the joint influence of these powers, is the intermittent: and we find these produced where their joint influence is but feeble, and where it exists, perhaps, in its lowest stage, as in the favourable climate of our own country ; where we are not frequently overloaded with equinoctial rains, and have not often to com- plain of a sultry sky, or a stagnant atmosphere. Even here, however, we perceive a change in the character of the intermittent at different seasons : for while in the spring it usually ex- hibits a tertian type, in the autumn we find it assume a quartan. And as these can only be contemplated as varying branches of the same disease, we have thus far, at least, reason to re- gard it as produced by. a common febrile miasm, modified in its operation by a variation in the relative proportion which its auxiliaries, known and unknown, bear to each other during the vernal and autumnal seasons : coupled, perhaps, with some degree of change, produced by the same seasons in the state of the human body. If from our own country we throw our eyes over the globe, we shall find in every part of it where the same causes exist, that in proportion as they rise in potency, they produce a fever of a severer kind, more violent in its symptoms, and more curtailed in its intervals, till we grad- ually meet, first with no distinct intervals, and at length with no intervals whatever ; and hence perceive the remittent progressively converted into intermittent and continued fevers. And that here we have still the same miasm, merely modified in its operation by the varied action of its auxiliary powers on the constitution of the individuals it attacks, is as clear as in the former case ; because, in many attacks, we see different individuals, touched by the very same influence, exhibit all the varieties now alluded to, and intermittent, remittent, and continued fevers co-existing in every diversity of violence ; commencing with either of these forms ; keep- ing true to the form with which they commen- ced ; or changing one form for another.* Such, as remarked by M. Deveze, was the course of the fever at Philadelphia in 1793 (Traiti de la Fievre Jaune, &c, 8vo., Paris, 1820); and such, according to M. Berthe, that of the southern * See Sir Gilbert Blane's valuable article on Yellow Fever, in his Select Dissertations, &c, p. 284, 8vo., Lond., 1822. AH these facts may be true without proving that malaria alone will give rise to continued fever, except in a secondary, in- direct manner, when the change of the intermit- tent fever to this type may be explained by refer- ence to morbid visceral alterations, sometimes brought on by intermittent fever, and possibly also in hospitals, by taking into the account the influ- ence of the effluvia from patients congregated in such buildings. A similar mode of reasoning would account for the variation of continued fever to the intermittent or remittent type, when the patient is exposed to malaria—Eb. provinces in Spain, in 1800 (Precis Historique de la Maladie, qui a regnie dans t'Andalusic, en 1800): and such was peculiarly the fact in the highly malignant yellow fever of Antigua, in 1816, as admirably described by Dr. Musgravp. —(Medico-Chirurg. Trans., vol. ix., p. 92.) This last disease first showed itself during sultry weather and a quiet atmosphere, in a swampy part of the island, among a ship's crew lately arrived, but from a healthy vessel, and themselves in good health on first landing. It soon spread widely, and at length indiscrimi- nately in town and country, among all ranks, and conditions, and situations, blacks as well as whites, the oldest settlers as well as the newest comers. In some cases, the head was chiefly affected ; in others, the stomach, the liver, or a still different organ. Hiccough and black vomit were common towards the close of the disease, though many died without it; and re- covery was no exemption from a second attack. Dr. Musgrave asserts further, that during the whole of this fatal epidemy, there was no in- stance of its being received by contagion. The argument, however, which he offers upon this subject is not quite convincing. Yet admitting the fact to be as he states it, we have an addi- tional proof, if proof were wanting, firstly, that when the animal frame has been previously de- bilitated or relaxed, as in the case of a ship's- crew that has been long voyaging in high lati- tudes, and living on salted provisions, it suffers sooner and more severely than where no such relaxation has taken place : and, secondly, that by a long and gradual exposure to the influence of febrile miasm, however produced, whether from the living human body or from dead organ- ized matter, the animal frame becomes torpid to its action, as it does to the action of other irritants. Whence prisoners confined in jails with typhous miasm around them, as well as those who have long stood the climate in the West Indies, receive the contamination to which they are exposed far less rapidly than strangers, and are capable of communicating it from their clothes or persons to fresh men, without being in the least affected by it themselves ; as ap- pears to have been the case in various courts of justice, and particularly at the Black Assize at Oxford, in July, 1577; though Dr. Bancroft has endeavoured to explain this effect in another way.—(Essay on the Disease called Yellow Fe- ver, &c, Lond., 1811.) The argument, however, of Dr. Musgrave upon this point, we have said, is not quite satis- factory ; because he admits that those who were about the patients, and paid no attention to personal cleanliness, did not wholly escape ; but then, says he, they escaped as generally, and were not more frequently affected, than those who never entered the doors of an in- firmary. Now, as all ranks and conditions, blacks and whites, even far off in the country, were affected indiscriminately, we have no rea- son to expect that those whose habits had rendered them peculiarly torpid to the action of the febrile miasm should be more frequently affected than others. The very admission that Cl. III.—Ord. I.] PYREC they were as much so, seems to imply that the febrile miasm was attacking them in some new mode against which they were not guarded by previous habit.- Nor is it easy to conceive by what means the local disorder of the coast could be converted into so extensive an'epidemy, unless through the medium of contagion. I have dwelt the longer upon this subject, because it is desirable to reconcile as much as possible, the conflicting testimony of respectable writers, who; having adopted different theories, are insensibly led to support them by inaccord- ant descriptions of the same disease. In direct opposition to Dr. Musgrave, Dr. Jackson, Dr. Bancroft, and a host of distin- guished writers who think with them, we are told by Dr. Pym, that the Bulam fever, admitted by Dr. Musgrave to be the same as the above, not only is contagious, but is never introduced into any fresh region but by contagion :* while Dr. Rush, -speaking of the yellow fever of Phil- adelphia of 1793, asserts that "there were, for several weeks, two sources of infection, viz., exhalation and contagion. The exhalation," says he, " infected at the distance of three and four hundred yards, while the contagion infected only across the streets. After the ] 2th of Sep- tember, the atmosphere of every street in the city was loaded with contagion." He adds, that a few caught the disease who had it be- fore : thus taking a middle course between Dr. Musgrave, who tells us, that recovery affords " no exemption from a second attack," and Dr. Pym, who affirms that the fever " attacks the human constitution but once." In the fever of Cadiz of the year 1800, Sir James Fellowes, who coincides in the view adopted by Dr. Pym, asserts, not only that it was contagious, and propagated only by contagion, but that the air, " from its stagnant state, became so vitiated, that its noxious qualities affected even animals : ca- nary-birds died with blood issuing from their bills, and in all the neighbouring towns which were afterward infected, no sparrow ever appeared."t I do not remember to have seen this last fact so directly affirmed by any modern writer ; but it is not contradicted in the course of the con- * Observations upon the Bulam Fever, which has of late years prevailed in the West Indies, on the coast of America, at Gibraltar, Cadiz, and other parts of Spain, &c, 8vo., 1815. t Reports of the Pestilential Disorder of Anda- lusia, which appeared at Cadiz in the years 1800, 1809, 1810, 1813, &c, 8vo., 1815. But, on the other hand, the reader should recollect what has happened subsequently with reference to the pres- ent question. In 1821, the city of Barcelona was visited by the yellow fever in a severe and exten- sively-fatal character. Now, if the report of the French medical commission, sent out to investi- gate the nature of this disorder, be considered, and the facts related be admitted, the contagious na- ture of the fever must be recognised. But if the reader afterward turn to the valuable documents collected by Dr. Chervin, he will be convinced that the facts which led the commissioners to in- fer that contagion had been at work, aTe by no means conclusive ; and he will be compelled to attribute the prevalence of the disease to local cir- cumstances.—Ed, 339 troversy, and is in perfect coincidence with the state of the air during the plague in most places (Diemerbr. de Peste, cap. vi. ; Van Swieten, ex prof. Smbait, in sect. 1407), and particularly at Athens, as described by Thucydides (Hist, xi., 52) : TtKpfjpiov 5e t5>v piv roioirdiv ipviduv lirt\firpis traffjg iycvero' Kal o6y/ tu>pZvro ovti aAXwj, ovre iripl toioUtov obSiv. Oi Si kvvcs paWov aloBnaiv iraptiypv tov dirofiaiVovroj, Stu rb ^vvoiairaaBai. Whence Lucretius, who does but little more than trans- late Thucydides : " Nee tamen omnino temere illis solibus ulla Comparabat avis, neque noxia secla ferarum 1 Exibant sylvis; languebant pleraque morbo, Et moriebantur ; cum primis fida canum vis Strata animam ponebant in omnibus aegre : Extorquebant enim vitam vis morbida membris.* "Nor longer birds at noon, nor beasts at night Their native vyoods deserted ; with the pest Remote they languish'd and full frequent died. But chief the dog his generous strength resign'd, Tainting the highways, while" the ruthless bane Through every limb his sick'ning spirit drove." There can be, or rather there ought to be, no question, therefore, that the fever before us was in some regions contagious, or produced from human effluvium; as, in other regions, and under other circumstances, it was produced from marsh effluvium. And though from a prejudice of education that will presently be pointed out, the contrary is still contended for by names of considerable weight, they seem to be over- balanced in number as well as in authority by those who have enlisted themselves on the op- posite side of the question ; of which last it may be sufficient to set down the names of Lind, Clarke, Belfour^ Chisholm, Blane, M'Grigor, and Johnson, from among our own countrymen ; and of Berthe, Bequine, Dalmas, Bally, and Pugnet, among foreigners. The facts brought forward by Sir James M'Grigor upon this subject are deci- sive, indeed, of themselves. And those who are more voracious of proofs may satisfy the most exorbitant appetite by the numerous and conclu- sive narratives collected by Dr. Chisholm, and especially the fever described by Dr. M'Cabe (Edin. Med. and Surg. Journ., Oct., 1819), as prevailing among the Royal York Rangers, sta- tioned at Trinidad. " The causes of this fever in its origin were, excessive heat, marsh ef- fluvia from a marsh of immense extent in the immediate vicinity of Port of Spain, considera- ble labour, and fatigue. Its contagious char- acter superadded to its marshy was produced by an influx of Spaniards from the Spanish- Main, in a deplorable state of misery and wretch- edness. It was among these unfortunate peo- ple that the contagious fever began."—(Climate and Dis. of Trap. Countries, p. 42, 8vo., 1822.) It is probable that Sir James Fellowes and Dr. Pym might contend that, in this quarter, the' fever was imported, and maintained by conta- gion alone, as they have contended was the case- in the yellow fever of Cadiz in the year 1808 £ but, even in this last case, they have completely failed in establishing the question of its supposed? * De Rer. Nat., hb. vi., 1117, 340 ILEM ATICA. [Cl. III.—Ord. 1. importation by a ship's crew from Spanish Amer- ica ; and, as there is no doubt in the mind of those who have not buckled on the armour of controversy, that this fever was the common fever of the Mediterranean coasts, so well de- scribed by Dr. Cleghorn, and which, under dif- ferent names and with different degrees of vio- lence, commits its ravages mostly about the au- tumnal equinox, from the swampy shores of the Nile to the oozy banks of the Tiber, and which is often found as destructive in the Campania as in the East or West Indies, there should be no longer any doubt of the operation of one and the same miasm or febrile principle in all these cases ; sometimes issuing from the effluvia of the living body, and sometimes from that of dead organized matter : generated, to adopt the language of Professor Frank, " tarn in aegrotan- tium variorum corpore, quam in atmosphaera, plurimorum exhalationibus inquinata, favente anni constitutione" (De Cur. Horn. Morb. Epit., torn, i., 8vo., March, 1792); and, consequently, that the whole of that part of Dr. Cullen's sys- tem is erroneous which supposes a different specific principle of fever to be generated in each ; the one distinguished by being limited to the production of uncontagious intermittent fever, and the other to that of contagious con- tinued fever. And it is of the more importance that the error of this doctrine should be pointed out, since it has proved the very groundwork of that altercation which has prevailed upon the subject before us. For the writers on both sides, having equally drunk from the C'ullenian fountain, and being equally impressed with the truth of this doctrine, have only warred with each other in support of Dr. Cullen's distinc- tion ; and, hence, those who have so clearly witnessed the origin of the fever from marsh effluvium, that they have been compelled to acknowledge this as its source, have felt them- selves compelled at the same time to deny that it is contagious; while those who have as clearly witnessed its contagious power, have as forcibly felt themselves compelled to deny that it has sprung from marshy miasm. Dr. Jackson affords us one of the clearest proofs of the truth of this- remark in his late, as Well as in his earlier works. There is n» writer who has more distinctly pointed out the close analogy between the symptoms of the marsh endemic of the West Indies, and contagious fever, as they very frequently show themselves, than he has done ;—" The derangements," says he, " are exteriorly so much alike, that the dis- criminating characters cannot be delivered but with doubt and hesitation; the result of the whole appearances will often determine the judgment, but the symptoms, separately consid- ered, lead to no certainty. The causes of en- demic and of contagious fevers were equally con- nected, under certain conditions, with eruptions en the skin, ulcers of the extremities, diarrhcea, purging, dysentery, or flux, fever of an inter- mitting or remitting form, of a form continued,— Violent and rapid in course, moderate and of or- dinary duration, or slow, lurking, and irregular, ceasing and returning at intervals,;—changing from general to local disease of various descrip- tions, and from local disease to general and formal fever. The general manner of attack,- the course, changes, and duration of endemic and contagious fevers, have great similarity. Cer- tain modes of action or combinations of action prevail more frequently in the one disease than the other, but forms ani modes do not constitute characteristic differences; thus, affection of the stomach and biliary system, vomiting, and yel- lowness, are less frequent in contagious than in endemic fever; yet, they do occur in the former, and sometimes to considerable extent. Affection of the chest, alternating with delirium, or affection of the head, appears to be more common in contagious than in endemic fever; so- likewise is a peculiar maniacal derangement or lively delirium, occurring in the progress to re- covery : yet the frequency of these appearances does not furnish a characteristic mark."—(His- tory and Cause of Feverr pp. 213, 214, 216.> That is to say, all the leading symptoms, which. make and determine the diseases, are the same : and though practically and in fact they run into* each other and are the same, yet speculatively and theoretically they are not the same, and' never can run into each other in the opinion of this valuable writer, because Dr. Cullen has laid? down the dictum, that intermittents must pro* ceed from paludamiasm and be uncontagious,. and contagious fevers from the morbid effluvium of animal bodies alone. Yet, after all, the sub- stantive part of the tenet seems to be relinquish- ed by Dr. Jackson in the following passage, which occurs in his remarks on the yellow fever that ravaged the Spanish coasts in 1800, not- withstanding the firmness with which the Cul- lenian doctrine is ostensibly maintained. " The- case may perhaps be thus explained. The yel- low fever, during the reign of epidemic influence, often strikes like a pestilence by the mere con- course of people in a close place; and if a mass of sick persons be collected into a hospital du- ring the epidemic season, the common emanations^ from the sick bodies, whether saturated with- contagious particles or not, often act offensively on those who enter the circle, and often appear to> be the cause ofthe explosion of a disease, which,. without accessory or changed condition of the medium in which man lives, would have prob- ably remained dormant for a time, and per- haps for ever."'* In the typhus, or the fever that originates in crowded jails, and other thronged and noisome abodes, there is no longer a question concern- ing its human origin, or emanation from sick bodies* and its contagious property ; at leastr among practical writers. Bit typhus does not differ more widely in its- symptoms from some of the modifications of the fever we have just contemplated, than such modifications do from' others of the same fever, varied by the varying power of its co-operating agents.—(Caizerques, Mimoires sur la Contagion de la Fievre Jaune, * Remarks on the Epidemic Yellow Fever, &c, on the South Coasts of Spain, p. 44, Londonv, 8vo., 1821. Cl. Ill—Ord. l;g PYRECTICA. 341 Paris.) And hence we have reason to conclude, that typhus also is generated from the same common febrile miasm, modified in its action by influential contingencies. In effect, the yellow fever itself, under pecu- liar circumstances, assumes something of a typhous character even in its first origin, and where the source has unquestionably been marsh miasm. The second form of the Andalusian fever, as described by Dr. Jackson, and especi- ally characterized by defective energy, peculiarly exemplifies this remark ; and such was expressly the case with the asthenic remittent at Breslaw in 1757 (Chisholm, Manual of the Climate and Diseases of Tropical Countries, &c, p. 38,1822), as well as in the Island of Edam on the coast of Batavia in 1800, and is still oftener found in the remittent that takes place along the Gambia, after rain in the spring or early part of the sum- mer ; when there is less organized matter re- maining on the surface of the earth to be decom- posed, and what there is has been acted upon by a lower temperature and a shorter duration of beat than in the autumn. " In the month of June," says Dr. Lind, " almost two thirds of the white people were taken ill. Their sickness could not well be characterized by any denom- ination commonly applied to fevers : it however approached nearest to what is called a nervous fever, as the pulse was always low, and the brain and nerves seemed principally affected. It had also a tendency to frequent remissions." The patients were often attacked with a delir- ium, and ran into the open air, where they re- ceived benefit from an affusion of heavy rains upon their naked bodies. The delirium, how- ever, it seems, " soon returned ; they afterward became comatose, their pulse sunk, and a train of nervous symptoms followed ; their skin often became yellow." And even whene the disease commenced with symptoms of great excitement, and an intermittent type, it is so much disposed, under peculiar incidents, as great fatigue, disap- pointment, and short provisions, to run into a typhus fever, as at Walcheren,* and during the retreat of the British army to Corunna, that many nosologists have thought themselves call- ed upon to make this form a distinct variety or even species of fever, which they have usually distinguished by the name of typhus icterodes, or yellow typhus. In like manner, where the yellow fever has commenced originally from contagion, or, in other words, from a decomposition of human instead of marsh miasm, it has been under the very same auxiliaries of filth, poverty, crowded numbers, and a stagnant atmosphere, that give rise to typhus. Thus, the fever of Malaga in * Id. ibid. Here the change of an intermittent fever to typhus is accounted for by the author himself, without any necessity for having recourse to the hypothesis that the infectious principles of malaria from decaying vegetables, and of animal exhalations, may- give rise occasionally either to continued or intermittent fevers. What is stated in the text merely proves, that a person labouring under ague, if exposed to fatigue, disappointment, certain privations, &c.,may become typhoid.—Ed. 1803, uniformly admitted to be of the same kind as that of Cadiz in 1800, spread first, according to Professor Arejula's description, through the narrow, crowded, and offensive lanes of the dis- trict de Perchel; and that of Cadiz itself, ac- cording to Sir James Fellowes, made its earliest appearance in the Barrio de Santa Maria, a part of the town in which the streets are narrower, less ventilated and cleanly, than any other part, and where the poor inhabitants, dirty in their persons, and crowded in filthy rooms, generally live together. It is true, that it was conjectured by many persons, and among others by both these writers themselves, that the contagion did not originate in either of these .situations, but was introduced into them by foreign shipping;; but such a conjecture has, in the first place, ne trustworthy evidence for its support; and, in the second, the mere testimony of the captain of the ship referred to was directly contradicted by the chief physician of the hospital at the Havan- nah,"who was on board the whole time, and was privy to the cases in question. In effect, a cause thus secondary seems tohave been superfluous ; for the local causes, enumerated by Sir James Fellowes and Professor Arejula (Brieve Descrip- cion de la Fiebre Amarilla,j>. 229, Madrid, 1806), appear to have been perfectly adequate. They are, as near as may be, the same as those which operate so fatally on the miserable and crowded cabins of Ireland; and if the fever had shown itself at a cooler season of the year, and the subjects of it had been still more broken down in constitution by mental dejection and low diet, it would probably from the first have assumed a continued and typhous character, instead of a remittent and more energetic. The proofs of- fered upon this subject, from personal and accu- rate observation, by Dr. Jackson and Dr. O'Hal- loran, are in full confirmation of this view ; for there can be no doubt that the fever of 1820 and 1821, which they described, was the same as that of 1800 and 1803. "From an impartial consideration," says Dr. O'Halloran, " of all the circumstances attending the epidemies of Spain in the year 1821, the conclusion is, I think, fairly deducible, that the disease was not, and is not occasioned by im- ported contagion, and that its origin cannot be attributed to the germe of a former epidemic, re- suming original activity from the operation of a peculiar state of atmosphere, without which it would remain dormant, perhaps, for ever. All the towns and cities which suffered from the yellow fever, were, with the exception of Cadiz, filthy in the extreme, disgustingly so, and very objectionable on the score of ventilation, situa- tion, and form of construction ; while the differ- ent towns of Arens, Matero, Badalona, Tarra- gona, Vinaros, Benicarla, Valencia, Aliama, Velez, Malaga, Marabella, Estepona, Vejer, Conil, Puerto Real, Rota, Chipiona, Orcos, and Medina Sidohia,—all of which are in the vicin- ity of the sea, and which, it may be presumed from their relative situations, communicate freely with the theatres of disease, were not affected by the malady. They seldom, indeed, suffered in any other years; because, independent of 342 H^M their localities, being better chosen for health, ..they are comparatively clean."* The febrile miasm, then, generated by a de- composition of human effluvium and of dead organized matter, appears to be essentially the same, modified alone in one Or two .of its qual- ities by the co-operation of the heat, moisture, stagnant atmosphere, and perhaps some other unknown agents, that are necessary to give it birth or activity. The chief difference produced in this miasm .under these distinct modes of origin, is, that when generated by the decomposition of efflu- vium issuing from living human bodies, it is less volatile (Hist, and Cure of Fever, by R. Jackson, M. D., part i., chap, iii.-, p. 102), and -has at the same time a power more directly ex- hausting, or debilitating the sensorial energy, than when generated by the decomposition of dead organized matter. Whence fevers, origi- nating in jails or other confined and crowded scenes, contaminate the atmosphere to sE less distance than those from marshes or other swajnps, but act with a greater degree of de- pression on the nervous system when once received into it. Yet, even the latter have a .definite atmosphere of action, beyond which they lose their power, and an atmosphere of a more limited diameter than we might at first be tempted to conceive : for, we learn from Sir Gilbert Blane, that, in the unfortunate expedi- tion to Walcheren, the crews of the ships in the road of Flushing were entirely free from the endemic of the country, as were also the guard-ships, which were stationed in the nar- row channel between Flushing and Beveland ;— the width of which channel is only about six thou- sand feet.—(Select Dissertations, &c, p. 107.) In whatever mode derived, the remark of my excellent and distinguished friend Dr. Hosack •viii still hold, not indeed that it is altogether ■icapable of taking effect in a pure atmosphere, ■ut that " an impure atmosphere is indispen- •ably necessary to extend the specific poison."f ind I should also fully concur with him and 'rofessor BreraJ hi censuring the application - section, by an accidental wound in the hand, and to excite its specific influence on the body of the anatomist. 7. The miasm of human effluvium is chiefly distinguishable from that of dead organized author's language, 'is denominated atmosphaera koino miasmatica; that portion of air charged with miasmata emitted from and surrounding the body, clothes, bedding, and furniture of persons immersed in the filth of their own excretions, and of those associated in the same family with them, accumulated, long retained, and acted on by an- imal heat, is denominated atmosphera idio mias- matica. Or, in other words, the koino-miasmatic atmosphere is that which is derived from a com- mon or public mass of putrefying matter, expanded to the solar influence ; while, on the contrary, the idio-miasmatic is derived from a personal or pri- vate source, being produced from the filth of indi- viduals and their habitations, and diffused around them only for a small distance/ "In July, 1808, Dr. Hosack, in a letter to Dr. Chisholm of Bristol, England,, proposed a new theory on the laws governing the communication of contagious and infectiou s diseases. Those dis- eases which are communicable from one person to another, and are generally considered of a con- tagious or infective character, are distributed by Dr. H. into three classes. First, such as are com- municated exclusively by contact; as itch, syph- ilis, sibbins, laanda Africana, framboesia, elephan- tiasis, variola, vaccina, and hydrophobia: sec- ondly, such as are communicable by contact and the atmosphere ; as smallpox, measles, chickenpox, hoopingcough, scarlatina, and cynanche maligna : thirdly, those diseases generally communicable only in an impure air; as plague, yellow fever, typhus in its different forms, and dysentery." In 1824, was published the Elements of the Etiology and Philosophy of Epidemics, by Prof. Joseph M. Smith, of New-York. Dr. Smith con- siders the arrangement and terms proposed by Dr. Miller, which we have mentioned above, as the most valuable improvement which has been made in the classification of the remote causes of fever; but he has seen cases of fever arising from the intimate union of both these causes ; from a com- bination of human effluvia with the exhalations of the soil. Dr. S. remarks, that this compound source of disease is highly interesting m a prac- tical and scientific point of view, and is sufficiently distinct and well characterized to be ranked as a genus. He terms it Idio-Koino miasma.—D, 344 H^EM, matter, by being less volatile, and having a power of more directly exhausting or debilita- ting the sensorial energy, when once received into the system. Whence the fevers generated in jails, or other confined or crowded scenes, contaminate the atmosphere to a less distance than the emanations from marshes and other swamps ; but act with a greater degree of de- pression on the living fibre. 8. The more stagnant the atmosphere, the more accumulated the miasmic corpuscles, from whatever source derived ; and the more accu- mulated these corpuscles, the more general the disease. 9. The miasmic material becomes dissolved or decomposed in a free influx of atmospheric air : and the purer the ,air, the more readily the dissolution takes place : whence, e contrario, the fouler as well as more stagnant the air, the more readily it spreads its infection. * 10. Under particular circumstances, and where the atmosphere is peculiarly loaded with contamination, the miasm that affects man is capable also of affecting other animals. * In relation to this subject, it deserves attention, that certain other states of the atmosphere affect different contagious disorders in different ways : " the diffusion of plague, for instance, is favoured by a temperature high within a certain degree ; while it is checked, if not altogether extinguished, by the cold of winter, and likewise by very high temperatures, such as- the heat of certain parts of Africa in summer, as mentioned by AI pinus, and that of the Harmattan winds. Typhus, we know, prevails at low degrees of heat, as likewise do measles and scarlatina ; and so, with regard to contagions in general, we find the effect of tem- perature on them varies in the case of different diseases. A moist and still atmosphere may, if we mistake not, be declared favourable to the propagation of all contagious disorders; while it is sometimes suddenly checked by strong commo- tions in the air, such as storms and hurricanes. But, besides these appreciable atmospheric states, which, in one way or another, influence the dif- fusion and action of the matter of contagion, there are conditions of the air favourable to its diffusion, or otherwise, of the real nature of which we are ignorant, beyond their influence overrhe propagation of the disease. It has occurred to every medical man to see diseases, justly consid- ered contagious, unusually prevalent in one sea- son compared with another, though there may have been no discoverable difference in the atmo-- spheric states to explain this variety in their prev- alence ; and to see them, on the other hand, decline and finally disappear long before individ- uals, susceptible of the contagion, were scarce, and without there having been any appreciable change in the air to account for that in the state of the disease. This atmospheric peculiarity, to which the name epidemic constitution has been as- signed, occasionally appears to possess a limited locality ; for, we find a contagious disease pre- vailing in a town or village, while places in the neighbourhood escape, though there is a constant intercommunion between the infected and healthy districts: or, such a disease may spread exten- sively in one town, while, in another, similar as to the habits and characters of the population, and not remote in situation, it may exist, but be by no means so prevalent."—See Cyclop, of Pract. Med., art. Contagion.—Ed. /TCCA. [Cl. III.—Ord. I. 11. By a long and gradual exposure to the influence of febrile miasm, however produced, the human frame becomes torpid to its action (Br era De' Contagi e della Cur a de' loro Effetti, &.c, ut supra, Padua, 1819), as it does to the action of other irritants : whence the natives of swaihpy countries, and prisoners confined in jails with typhous contamination around them, are affected far less readily than strangers ; and, in numerous instances, are not affected at all. 12. For the same reason, those who have once suffered from fever, of whatever kind, hereby produced, are less liable to be influ- enced a second time ; and, in some instances, seem to obtain a complete emancipation.* It only remains to offer a few remarks upon the doctrine of crises ; or that tendency which fevers are by many supposed to possess, of undergoing a sudden change at particular periods of their progress. A sudden and considerable variation of any kind, whether favourable or unfavourable, occur- ring in the course of the general disease, and producing an influence on its character, is still loosely expressed by the name of crisis. The term is Greek, and pathologically imports a separation, secretion, or excretion of something from the body; which was in truth the mean- ing ascribed to it when first employed, agrees ably to the hypothesis of concoction which we have just considered. The original hypothesis is abandoned; but the term is still continued in the sense now offered. " If the matter of the disease," says Professor Frank, " be ex- pelled by some one convenient outlet in the skin, kidneys, bowels, or bloodvessels, the crisis is simple ; if by several of these at the same time, it is compound; if the whole be carried off at once, it is perfect. If it be carried off at different times, it is a lysis (Op. cit., torn, i., De Febr., p. 26), or resolution." That changes of this kind are perpetually Occurring in the progress of continued fevers, must, I think, be admitted by every experienced practitioner. Nothing is more common than to behold a patient suddenly and unexpectedly grow decidedly better or worse in the progress of a fever of almost any kind, and pass on rap- idly towards a successful or an unsuccessful termination. But the important question is, whether there be any particular periods in the progress of a fever^ in which such changes may be expected 1 Hip- pocrates conceived there were: he endeav- oured to point out and distinguish them by the name of critical days. Asclepiades and Celsus denied the existence of such periods ; and the same diversity of opinion has preyailed in mod- ern times. It is not very easy to determine the point at the present day, and especially in our own country. For, first, fever, like many other com- plaints, may have undergone some change in * An extremely learned paper, on the compar- ative influence of vegetable and animal matter in generating disease, by Prof. U. Parsons, of Prov- idence College, is published in the Am. Journ. of Med. Sa, vol. vii., p. 80.—D. ■Cl. III.—Ord. I.] PYRECTICA. 345 its progress from a like change in the nature of its remote causes, or in the constitution of man. And next, it seems to be generally allowed, that sudden transitions, whether regular or irregular, are more apt to take place in almost all diseases in warm, "than in cold climates. On these grounds, it is probably a subject which will never become of great practical importance at home. Yet, it is well worthy of attention as a question of history, and one that may yet be of great importance to many parts of the world. If we examine the phenomena of the animal economy, as they occur in a natural series, we shall find that they are in almost every instance governed by a periodical revolution. A man in a state of health and regular habits generally becomes exhausted of sensorial power within a given period of time, and requires a periodical succession of rest; his appetite requires a pe- riodical supply ; and his intestines a periodical evacuation. This tendency equally accompa- nies and even haunts him in disease ; he cannot disengage himself from it. Gout, rheumatism, mania, rapidly and pertinaciously establish to themselves periods of return. The hemorrhoi- dal discharge often does this; and the cata- menia constantly. The same occurs in fevers, but especially in intermittents ; for the quotid- ian, the tertian, the quartan, have, upon the whole, very exact revolutions. And, though ac- cidental circumstances may occasionally pro- duce a considerable influence on every one of these facts, whether morbid or natural, the ten- dency to a revolutionary course is clear and un- questionable. Now, although Hippocrates has not appealed to this reasoning, it forms a foundation for his observations : and, when stripped of the perplexi- ties that encumber his writings upon this subject, partly produced by erroneous transcripts, and, in a few instances, perhaps, by his own irresisti- ble attachment to the Pythagorean hypothesis of numbers, he may be regarded as laying down the following as the critical days of continued fever: the 3d, 5th, 7th, 9th, 11th, 14th, 17th, 20th ; beyond which it is not worth while to follow the series ; for it is not often that they extend further. In other parts of his works he regards also the 4th and 6th, and even the 21st, as critical days ; so that in the first week, every day, after the disease has fully established itself, evinces a disposition to a serious change ; in the second week, every other day ; and in the third week, every third day. It is not easy to determine why the 21st day should be a critical day, as well as the 20th. Various conjectures have been offered upon the subject: by some it has been regarded as a mistake in the Greek copy, and by others, as a piece of favouritism in Hip- pocrates for this number, in consequence of its being an imperfect one in the Pythagorean phi- losophy, as the commencement of a septenary. De Haen, with rigid and patient assiduity, has put Hippocrates to the test upon these data; for he has accurately analyzed Hippocrates's own journal of the numerous cases of fever he ,has so industriously collected and recorded, and finds the positions, in most instances, to be strictly justified ; and that out of 168 termina- tions of fever, not less than 107, or more than two thirds, happened on the days denominated critical, not reckoning the 4th, 6th, or 21st, and that the 4th and 6th were very frequently critical. There are a few anomalies ; but it is not neces- sary to notice them, because they are easily referable to accidental causes, similar to those that retard or accelerate the paroxysm of inter- mitting fevers. Now, admitting the Hippocratic table to be true, the continued fever, in its progress, is measured by the various types exhibited by inter- mittent fevers. Thus, the quotidian prevails through the first seven days; there is on each day a slight exacerbation, and no one day is more critical than any other. After this period, the ter- tian type commences, and runs through the ensu- ing week ; the principal changes occur on the 9th and 11th days, and would occur on the 13th, but that the quartan type now assumes its pre- rogative ; and the principal transitions, after the 11th, take place on the 14th, instead of on the 13th ; on the 17th ; and on the 20th. Dr. Cul- len, who has examined this subject with great attention, and simplified it from many of its diffi- culties, directly asserts, that his own experience coincides with the critical days of Hippocrates. Dr. Fordyce, who scarcely does justice to Cul- len upon other points, unites with him upon the present, and justly compliments him upon his ingenious examination and explanation of the Greek distribution of critical days; and Dr. Stoker of Dublin has arrived at a like conclu- sion, after what appears to have been a very patient, discriminating, and extensive inquiry.* It is, nevertheless, admitted on all hands, that the order of succession is far less distinct, as well as less regular, in cold, than in warm cli- mates ; and that it requires a thoroughly atten- tive and practised eye to notice these changes in our own country, or, indeed, in any part of northern Europe. And hence Craanen says, it is lost time to look for them (De Homine); Stoll, that they are only to be found in inflam- matory fevers (Rat. Med., part iv., p. 283); Le Roy, that the supposed critical days have no in- fluence, and can lead to no prognosis or pecu- liarity of practice (Du Pronostic dans les Mala- dies Aigues, 8vo.,Montpel., 1778); and Frank, that nature has fixed upon no one day rather than another, for a solution of fever, nor at any time forbids our attempt at executing a present indication.—(Op. cit., torn, i., 29.) Dr. Jackson, partly from the strength of his attachment to the doctrines of Cullen, and partly from having principally practised in hot climates, is a great advocate for the existence of critical days, and believes them to take place in fevers from hu- man as well as marsh miasm ; though less dis- tinctly, as also less frequently, in the former than in the latter.—(Op. cit., part ii., ch. ix., p. 242.) Why the first week of a fever should * Medical Report of the Fever Hospital, &c. for 1816. Trans, of the King's and Queen's Coll., Dubl., vol. ii., p. 434, 8vo., 1824. 34.6 iLfiMi incline to a quotidian type rather than to a ter- tian, or the second to a tertian rather than to a quartan, we know no more than we do why fevers should ever intermit, or at any time ob- serve the distinctions of different types. We are in-total ignorance upon all these subjects. We see, moreover, that intermitting fevers, whether quotidian, tertian, or quartan, have their paroxysms recur regularly in the daytime ; the quotidian in the morning, the tertian at noon, and the quartan in the afternoon—and that, in no instance, do the paroxysms take place at night: and we see also that, in continued fe- vers, the exacerbations uniformly take place later in the day, than the paroxysms of the latest intermittent.; for these rarely occur later than between five and six o'clock in the even- ing, while the paroxysms of the quartan return commonly before five. Of these interesting and curious scenes we are spectators ; but we are nothing more ; for we are not admitted to the machinery behind the curtains. By some pathologists, the source of these phenomena is sought in the influence of the heavenly bodies, and especially in those of the sun and moon. In ancient times, these lumi- naries were supposed to produce an effect on all diseases, and especially on mania, epilepsy, catamenia, and pregnancy. And when the Newtonian philosophy first illumined mankind. with the brilliant doctrine of universal attrac- tion, Dr. Mead stepped forth into the arena, and revived and supported the ancient doctrine with great learning and ingenuity : and as an inge- nious conjecture and possible fact, of which no practical use could. be made, it was contem- plated till towards the close of the last century : about which time Dr. Darwin, by interweaving it with his new hypothesis, once more endeavoured to raise it into popular notice, and gave it an air of serious importance. Dr. Balfour, of British India, however,'has still more lately brought it forward as a doctrine capable of di- rect proof, and as peculiarly affecting the prog- ress of fevers. His opinion, which he en- deavours to support by weighty facts and ar- guments, is, that the influence of the sun and the moon, when in a state of conjunction, which is named sollunar influence, produces paroxysms or exacerbations in continued fever, in all cases in which a paroxysmal diathesis (for such is his expression) exists; and as this influence de- clines, in consequence of the gradual separa- tion of these luminaries from each other, and their getting into a state of opposition, a way is left open to the system for a critical and bene- ficial change, which is sure to take place, pro- vided the critical disposition is at this time ma- tured. In other words, paroxysms and exacer- bations in fever may be expected to take place (and do in fact take place) at spring-tides, and crises at neap-tides. This is a new view of the influence of the heavenly bodies upon the human frame ; and a view which, though feebly supported by facts, is advanced with all the dogmatism of an estab- lished science. Dr. Stoker, at the particular request of Dr. Balfour, put his doctrines to the lTICA. [Cl. HI.-Ord. I. test of 276 patients between July 6 and Sep- tember 6, 1817, in Dublin. He has candidly given us his tables, and as candidly observes, that " very little coincidence indeed is to be re- marked from a view of these tables."—(Trans. of the King's and Queen's Coll., Dublin, vol. ii., p. 435,8vo., 1824.) There is, nevertheless, more in medical astrology than is, perhaps, generally supposed ; it is an important branch of meteo- rology, and, as such, is well worth studying. Nor can there, I think, be a question in any im- partial mind, that, under certain circumstances, and especially in tropical climates, many dis- eases are influenced by lunation, as we are sure they are, in all climates, by insolation. The concurrent observations of a host of candid and attentive pathologists, who have been witnesses of what they relate, are sufficient to impress us with this belief: but, till we know more fully what these circumstances are, we cannot avail ourselves of their rerriarks, and can only treas- ure them up as so many isolated facts. And hence, in no age or country whatever has the study been turned to any practical advantage, expedited the cure of a disease, or enabled us to transform the type or interval of one kind of fever into that of another. Nor is it any ex- clusive reproach to the art of medicine that it should be so ; for, of all the subdivisions of general philosophy, there is none so little en- titled to the name. of a science as meteorology itself. And, till the naturalist has explained the variations of the barometer, the physician need not blush at being incapable of turning to account the supposed influence of the planets, or of unfolding the origin, or tracing the capri- cious courses, of epidemies and pestilences.* * It is remarked by Dr. Copland, that, since the overturn of the humoral pathology, the doctrine of critical evacuations has undeservedly fallen into disrepute. In our own country, at the pres- ent time, he thinks too little attention is paid to these evacuations, and still less to the periods at which they occur. " In temperate climates, a number of diseases, particularly fevers, run on for certain periods with regularity, and, after an ex- asperation of the symptoms, or some violent per- turbation of the economy, terminate by evacua- tions of different kinds, which tend to remove the train of morbid actions, and to restore the healthy functions. In other cases, the exasperation of the disorder is followed by imperfect evacuations, oc- curring in a regular manner; while, in some, it gives rise to additional phenomena of a danger- ous or fatal character. Hence crises have been de- nominated salutary, complete, imperfect, andfatal."— (Diet, of Pract. Med., art. Crises.) Yet, it has been observed, that the crisis of fever often takes place without sensible evacuation ; notwithstand- ing it is, in a large proportion of cases, preceded or accompanied by some change in the secretions, or by diarrhoea, or hemorrhage. In the progress of fever, the urine exhibits particular changes. In the early stages, its quantity is lessened, but there is no change in its colour or chymical prop- erties. " As the symptoms advance, the urine be- comes darker in colour, but does not deposite a sediment till the fever begins to decline, when it is increased in quantity, and deposites a cloud or sediment on cooling. This urinary deposite, which is sometimes copious, appears in the bottom of Gin. I.—Spe. 1.] EPHEMERA MITIS. 347 GENUS I. EPHEMERA. DIARY FEVER. one series of increase and decrease ; WITH A TENDENCY TO EXACERBATION AND REMIS- SION, FOR THE MOST PART APPEARING TWICE IN TWENTY-FOUR HOURS. This is the simplest form in which fever at any time makes its attack ; and hence, Dr. Fordyce has distinguished it by the name of simple fever. It is probably that which is in- tended by the term essential fever, as used by the French writers. It is, in truth, the basis of all other fevers, which are hence arranged by Eisner as mere species of this.—(Beytrage zur Ficbcrlehre, Konigsh, 8vo., 1789.) For the purpose, however, of entering into the full char- acter, not only of the present, but of all the sub- sequent genera, and their respective species, it is necessary to bear in mind, that the ordinal defini- tion forms a part of that character, and is essen- tially included, in a less or greater degree, in all the subdivisions that appertain to it. The ephemera rarely exceeds a duration of twenty-four hours. Some practitioners, how- ever, have called by this name a fever that has extended to three days ; and Sauvages has ar- ranged this mode of fever under his own genus of ephemera, as has also Professor Frank, dis- tinguishing the proper ephemera by the adjunct simplex, and its elongated form by that of pro- tracta.—(De Cur. Morb. Horn. Epit., torn, i., pp. 156, 185, 8vo., Mannh., 1792.) But this is to confound different species under one generic name. Fordyce asserts, that he has often seen the ephemera commence its attack with all the essential appearances of fever, and terminate in eight, ten, or twelve hours.—(On Simple Fever, Diss, i., p. 33.) And hence, in defining the vessel some hours after the urine has been voided : from its resemblance to brickdust it has been called lateritious, and by evaporation it may be collected in minute crystals of lithate of am- monia. This sediment is by no means peculiar to patients labouring under fever, but is often ob- served in the urine of healthy persons, or in that of others, whose function of digestion is im- paired. In other instances, the sediment is of a pinkish yvhite colour, and to this deposite, which, according to Dr. Wilson Philip, consists of the phosphates of the urine, the term furfuraceous, or branny, has been given. He regards both these urinary deposites as indications of returning health, and particularly of a renewal of a free secretion by the skin, which, in fevers, is generally a fa- vourable symptom. In some fevers, terminating favourably, there is an unusuaj. tendency to sweat, which only exhausts the strength. In these the furfuraceous sediment is observed, but without removing the fever: this is the case in hectic fever."—(Cyclopaedia of Pract. Med., art Fever.) Among other remarks made by Dr. Tweedie, he says, that when the sweating is so profuse as to induce exhaustion, or when it is partial or clammy, it is unfavourable ; and though as a general rule critical sweats should not be interfered with, yet, if the strength be evidently lowered by them, or if there be not a corresponding amendment in the general symptoms, they should, if possible, be ephemera, the symptom of duration ought not to exceed the limit here allotted to it. In this simple shape of the disease, the pa- thognomonic symptoms are few and striking; for, however violent, it is confined to a single paroxysm of three distinct stages, shivering or languor, heat, and perspiration ; each most prob- ably dependant on the other, and ceasing, when true to itself, after having followed up the move- ments of the animal frame through a single diurnal revolution. The cold stage, however, is often scarcely perceptible, and sometimes altogether imperceptible, the general languor taking place without it. The genus exhibits two common and very distinct species ; and If the ephemera sudatoria of Sauvages, the sweating-sickness or English plague of other authors, be regarded as belong- ing to it, as unquestionably it ought, it will then afford us another after the manner following :— 1. Ephemera Mitis. Mild Diary Fever. 2.--------Acuta. Acute Diary Fever. 3.--------Sudatoria. Sweating Fever. SPECIES I. EPHEMERA MITIS. MILD DIARY FEVER. WITHOUT PRECEDING RIGOUR ; LASSITUDE AND DEBILITY INCONSIDERABLE J PAINS OBTUSE, CHIEFLY ABOUT THE HEAD ; HEAT AND NUM- BER OF THE PULSE INCREASED SLIGHTLY ; DRYNESS OF THE TONGUE AND FAUCES J TER- MINATING IN A GENTLE PERSPIRATION. The common exciting causes are, excess of corporeal, and especially,of muscular exertion ; long-protracted study ; violent passion; sup- pressed perspiration ; sudden heat or cold. There are few persons who have not felt this species of diary fever at times, from one or other checked. When moderate diarrhoea comes on towards the termination of fever, it is generally a favourable circumstance, and ought not to be stopped. When there has been a disposition to relaxation of the bowels throughout the disease, which is not uncommon in some epidemics, and at particular seasons, the irritation commonly sub- sides spontaneously. Should it even continue through the period of convalescence, provided it do not interfere with the recovery of the patient, it is only necessary that the diet and general management be regulated. When the diarrhcea appears to retard recovery, and produce gradual emaciation, the practitioner should never lose sight of the possibility of the affection being the re- sult of inflammation of the mucous membrane of the bowels, or of other intestinal lesions, and therefore requiring the most vigilant care. Dr. Tweedie has not met with hemorrhage as a crisis of fever: he has, indeed, seen hemorrhage from the nose, when there was considerable cerebral affection, and always remarked great relief from the evacuation ; but he has never known an instance in which the fever disappeared with epistaxis: In typhoid fevers, hemorrhage from mucous surfaces and from the skin (petechia;) is not unusual; but, according to Dr. Tweedie, they are never critical: they reduce the patient still more, and always indicate a severe, if not a fatal, form of fever. —Ed. 348 HJ2M of the causes just enumerated. When a man has worked himself up into a violent and long- continued fit of wrath, whether there have been reason or no reason, and more especially in the latter case ; when he has taken a long and fatiguing journey on foot, walking with great speed, and suffering beneath great heat and perspiration ; or when he has devoted the whole of the day to a particular study, so profound and abstracting as to exhaust almost the entire stock of sensorial power that can be drawn from other parts of the system at the single outlet of the attention ;—and when beyond this he still urges his abstruse and protracted train of thought into a late hour of the night or the morning—there is a general irritation or undue excitement pro- duced, that simple rest cannot at once allay ; his sleep is short, hurried, and interrupted, if he sleep at all; he yawns, stretches his limbs, turns himself again and again in his bed for an easy, perhaps for a cool place, for his skin is hot and dry ; but for a long time he turns in vain. The morning strikes upon his eyes, but he has had little sleep, and no refreshment : he is indis- posed to leave his bed ; and if he rise, he is still feverish, and unfit for business. He passes the day in disquiet, which perhaps increases to- wards evening ; but at night he feels a moisture breaking forth over his skin, and comfortably succeeding to the heat and dryness that have thus far distressed him ; he recovers, perhaps, even while sitting up ; but if, as he ought to do, he goes to an early bed, a quiet and re- freshing sleep supervenes, and he wakes to the health he before possessed. It is not easy to explain why the febrile par- oxysm should be more disposed to close its career sometimes towards the evening, but more generally later at night, except for the reason, whatever'that reason may be, that all fevers are far more apt to commence their paroxysms in some part or other of the daytime, and espe- cially intermittents, and consequently to drop them as the day declines. Thus the quotidian makes its assault in the morning, the tertian at noon, and the quartan in the afternoon : as though the diurnal revolution were somewhat regularly divided between febrile attack and febrile cessation or truce. It is possible, in- deed, Jhat a fever of any kind may open its onset at any hour; but this is so contrary to the ordinary rule, that Dr. Fordyce affirms, from his own observation, that ten fevers commence in the day to one at night. The species before us forms scarcely a case for medicine: since nature, or that instinctive power which is ever operating to the general welfare of the animal frame, will be usually found competent to its object. So that if any thing remedially is attempted, it should be con- fined perhaps to abstinence from animal food, a slight increase of the peristaltic action of the in- testines by a dose of neutral salts, and to a re- moval of the dry heat of the skin by diluents and 6mall doses of ipecacuanha, which com- bines admirably with most aperients, and in- creases their power, while its own diaphoretic quality continues at least undiminished, and is ITICA. [Cl. III.-Ord. I. often improved. This is now well known, though not a discovery of recent date ; for Gianella, Vater, and various writers of credit, strongly recommended the same from personal experience nearly a century ago.* Gamesters, after sitting up all night, and being worked up to madness by the chances and re- verses of their ruinous stakes, are peculiarly subject to this species. A very cold and wet towel, tied round the temples, seems to give some check to the violent excitement of the brain ; but, in the long run, I have generally found persons who have adopted this practice become debilitated and dropsical, and sink into an untimely grave, or creep on miserably through the fag end of a lingering life, that affords no retrospective comfort, with a hospital of dis- eases about them. But whether this proceed from the practice adverted to, or from the ha- bitual exhaustion which naturally accompanies a course of gambling, may admit of a doubt. SPECIES II. EPHEMERA ACUTA. ACUTE DIARY FEVER. severe rigour; great heat; pulse at first small and contracted, afterward full and strong ; perspiration copious ; great LANGUOR. In a few instances the accession is slightly marked, and there is little chilliness or rigour. The heat that succeeds, however, is always considerable ; the face is red and bloated ; and there are often pungent and throbbing pains in the head, corresponding with the pulsations of the arteries ; though at times the pain in the head is dull and heavy. The high-coloured urine deposites a sediment with a tinge of orange-peel. We cannot always trace the remote causes of this species; but it is usually produced by some morbid affection of the stomach, or of the collatitious viscera. The most obvious and common cause is that of a surfeit, whether of eating or drinking : and there is no great difficulty in interpreting the means by which this cause operates. The stomach, in the ianguageof Mr. J. Hunter, is the great seat of general sympathy, and asso- ciates with almost every other organ in its ac- tion. The digestion of even an ordinary meal is a work of some labour to it, and especially in weakly constitutions ; a greater degree of heat is regularly expended upon it during this process, and unquestionably also a greater de- gree of sensorial power ; both which are taken from the system at large as from a common stock ; and the consequence is, that in infirm habits, a considerable degree of chill and de- bility is felt during this process, and other organs become torpid while the stomach is in a state of increased action. Hence infants and old persons sleep during digestion ; delicate females * Gianella, De admirabili Ipecacoanhae Virtute in curandis Febribus, &c., Patav., 1754. Vater, Diss, de Ipecacoanhae Virtute febrifuga, &c.f Witeb., 1732. Gen. I.-Spe. 3.] EPHEMERA SUDATORIA. 349 feel a coldness shooting over their extremities ; and those of irritable fibres become flushed in the face, and show other signs of irregular action. Now, if this be the case in the digestion of ordinary meals, what disturbance may we not expect during the digestion of a meal that over- loads the stomach, and with which the stomach is incapable of grappling 1 what more especially, when at the same time, by an immoderate use of wine or spirits, the brain becomes exhausted of its energy by the excess of stimulus applied to it I The general chill over the surface, which, in the digestion of an ordinary meal, is only felt by the weak and delicate, is here often felt se- verely, and sometimes amounts to a horripila- tion. The first stage of fever is hence produ- ced ; and as the heat and perspiration are most probably a necessary result of the first stage, a foundation is hereby laid for the entire paroxysm. With the reaction that ensues a greater degree of sensorial power returns; the general frame as well as the brain is roused to an increased energy; the diaphragm and its associate mus- cles instinctively or remedially contract, and the stomach disgorges its contents, or thrusts them forward half digested into the duodenum.* The only and well-known mode of cure con- sists, in the first place, in imitating the above natural process of relief; in unloading the stom- ach of its mischievous freight by a powerful emetic, and the alvine canal of whatever portion of the heating and crapulous mass has passed into it, by a brisk cathartic. The fever hereby excited will often subside in a diurnal revolu- tion, and no tendency to a return of the par- oxysm be produced. If the species before us, however generated, do not subside within this period of time, or a few hours beyond it, the disease becomes a cauma, or inflammatory fever of the continued kind, and consequently belongs to the genus ENECIA. There are, however, a few exceptions to this rule; for Forestus gives a case, in which the paroxysm led to a fatal hectic (Lib. i., obs. 7): and Borelli gives another of equal singularity, in which it kept true to a triennial revolution, returning punctually once every three years.— (Cent, ii., obs. 100.) SPECIES III. EPHEMERA SUDATORIA. SWEATING FEVER. TENSE PAINS IN THE NECK AND EXTREMITIES; PALPITATION ; DYSPNCEA ; PULSE RAPID AND IRREGULAR; HEAT INTENSE; INTOLERABLE THIRST ; DROWSINESS OR DELIRIUM ; EXCES- SIVE SWEAT. I have followed M. de Sauvages in introdu- cing sweating fever, the Ephemera maligna of Borsieri (Inslitut. Med. Pract., 8vo., 4 tomes, Ven., 1782-5), or Burserius, as he is more commonly called, and the sudor Anglicus of most foreign writers, into the present place. Dr. Caius, who practised at the time of its appearance at Shrewsbury, and has written one of the best accounts of it extant, calls it " a contagious pestilential fever of one day. It prevailed," says he, " with a mighty slaughter, and the description of it is as tremendous as that of the plague of Athens." And we are told by Dr. Willis, " that its malignity was so extreme, that as soon as it entered a city it made a daily attack on five or six hundred per- sons, of whom scarcely one in a hundred re- covered." It was certainly a malignant fever of a most debilitating character, but without any tendency to buboes or carbuncles, as in the plague ; though, during some parts of it's career, as fatal. It ran its course in a single paroxysm (Holinshed, vol. viii., 4to., Lond., 1808); the cold fit and hot fit were equally fatal; but, if the patient reached the sweating fit, he com- monly escaped. Hence, the cure consisted in exciting the sweating stage as quickly as possible, and in supporting the system with cordials throughout the whole of the short, but vehement course of the fever. At Shrewsbury, it continued to rage for seven months, and, during that period of time, a thousand fell victims to its violence. But after the discovery of the benefit of the sweating plan, it was certainly far less fatal. It made its first appearance in London in 1480 or 1483: Caius says, in the latter year, first showing itself in the army of Henry VII., on his landing atMilford-Haven. In London, to which, however, it does not seem to have travelled till a year or two afterward, it took up its abode, with various intermissions of activity, for nearly forty years. It then visited the continent, over- ran Holland, Germany, Belgium, Flanders, France, Denmark, and Norway ; among which countries it continued its ravages from 1525 to 1530: it then returned to England, and was observed for the last time in 1551. It commenced its attack with a pain in the muscles of the neck, shoulders, legs, or arms, through which a warm aura seemed to creep in many instances; and after these symptoms, broke forth a profuse sweat. The internal or- gans grew gradually hot, and at length burning, the pungent heat extending to the extremities ; an intolerable thirst, sickness, and jactitation followed speedily, occasionally with a diarrhcea, and always with extreme prostration of strength, headache, delirium, or coma, and a wonderful wasting of the whole body. The sweat was * With respect to the hypothesis, that the heat and nervous influence of the whole system are diminished during digestion, because a part of the general stock is then withdrawn to the stomach, it is scarcely necessary to remark, that it is as improbable as it is destitute of proof. The various circumstances which in the preceding paragraph are fancied to prove or illustrate it, only show that languor, chilliness, and flushings of the face occasionally take/ place during the process of di- gestion, which also sometimes causes a tendency to sleep. These facts, particularly the flushings, constitute so weak a support for the doctrine, that they need no serious refutation. Why should we not here be content with the simple truth, that excesses at table frequently give rise to ephemeral fever 1—Ed. 350 H^MATICA. [Cl. III.—Ord. I. tenacious, saburral, and of an offensive smell; the urine thick and pale ; the pulse quick, often irregular ; and the breathing laborious from the first. The modes of treatment were often pue* riie, and offer nothing instructive. A good consti- tution, and exposure to free air, seem to have been most successful in promoting a cure. Dr. Caius asserts, that a thick noisome fog preceded the distemper, especially in Shropshire, and that a black cloud uniformly took the lead, and moved from place to place ; the pestilence in a regular march following its direction.— There may be some fancy in this : but it is an unquestionable fact, that the most fatal pesti- lences of ancient and modern times have been ushered in by stinking fogs or mists, or some other intemperament of the atmosphere, of which the reader will find various instances in the sequel of this work. The disease is generally, however, supposed to have been produced by inclement harvests and vitiated grain, particularly wheat, which is less hardy than other grains, and sooner infested with albigo (mildew), ustilago (smut), and clavus (ergot or spur). And, in proof that this last was the actual cause, it is observed by Dr. Wil- lan, that the contemporary inhabitants of Scot- land and Wales, who fed on oaten or barley, in- stead of on wheaten bread, were not affected. Nevertheless, whatever was the primary cause, a peculiar miasm or contagion seems to have been generated by the disease itself, which chiefly contributed to its spread and continu- ance. For we are told concurrently by all the writers, that Englishmen, who withdrew from their own country into France and Flanders with the hope of escaping the attack of the disease, fared no better than their countrymen at home : to which Dr. Freind adds, that, while English-^ men abroad were thu§ subject to the contagion, foreigners, and even the Scotch in England, were rarely or never seized with it (Hist, of Physic, vol. ii., p. 533); a feature that has been copied by Dr. Armstrong in his very forcible description of the complaint, which is perhaps better adapted for poetry than for sober prose. " Some, sad at home, and, in the desert, some Abjured the fatal commerce of mankind ; In vain: where'er they fled, the fates pursued. Others,with hopes more specious,cross'd the main, To seek protection in far distant skies ; But none they found. It seemed the general air, From pole to pole, from Atlas to the East, Was then at enmity with English blood: For, but the race of England, all were safe In foreign climes; nor did this fury taste [ed."* The foreign blood which England then contain- Something may, perhaps, be set down to the score of a national diathesis; but, without ex- amining very closely into the accuracy of this wonderful part of its history, we may at least indulge a hope, that this peculiar, most virulent, and fatal contagion, has long since worn itself out, and become decomposed ; though it may be still only latent, and waiting for its proper auxiliaries, once more to show itself in the field. —(Navier, Maladies Populaires, &c.) * Art of Preserving Health, b. iii. It is said, indeed, by Dr. Coste, the learned editor of Dr. Mead's works in French, that the disease continued to manifest itself occasionally as an epidemic in Picardy ; but that, instead of terminating in a single day, it ran on to the third, fifth, and sometimes even to the seventh. It is hence sufficiently obvious, that the two fevers, though possessing many points of resem- blance, are not precisely the same. Yet M. Bellot, in his thesis " An febri putridae Picardii suete dictae, sudorifera!" has maintained Dr. Coste's opinion. GENUS II. ANETUS. INTERMITTENT FEVER. AGUE. PAROXYSM INTERMITTING, AND RETURNING DU- RING THE COURSE OF THE DISEASE ; THE INTERMISSIONS GENERALLY PERFECT AND REGULAR. Under the preceding genus, the remote cause, whatever it consists in, lays a foundation for not more than one paroxysm. In the genus before us, the cause introduces a tendency to a recur- rence of the paroxysm from the first; and, in most cases, with an interval that continues true to itself as long as the disease lasts. I say in most cases, because we shall see presently that, wben intermittent fever has raged very exten- sively, it has not unfrequently established a type of one kind in one person, and of another kind in another; while, in the same patient, quotid- ians have changed to tertians, tertians to quar- tans, quartans to quotidians, and all of them in a few instances to continued fever, in the most capricious and anomalous manner.* Dr. Cullen unites intermittents and remittents into one section of fevers, merely distinguishing them as intermittents with an interposed apyrexy, and intermittents with remission alone ; and, as already observed, he makes it a part of the pa- thognomonic character of both that they are derived from marsh miasm—miasmate paludum orta—as though there were no other cause of their production, whence Dr. Young gives to intermittents and remittents the common name of paludal fever. The only ground, then, assumed for this union of intermittents and remittents, is the supposi- tion, that the cause which generates them is * " In hot climates, and even here, many inter- mittent fevers become remittent, and from being- remittent, they will become continued, unless vigorous measures are adopted, and they may rapidly prove fatal by congestion of the head, thorax, or abdomen. Now and then this may be the case here, from some peculiarity in an epi- demic. We have no idea in this country of what aguish fevers, intermittent or remittent, are in hot climates. In Italy these are called pernicious fevers ; for, as soon as a person is seized, he may fall into a comatose state, from which he never recovers ; and, on inspection after death, the greatest degree of congestion is found in the lungs and head, and also in the abdominal vis- cera."—Professor Elliotson's Lectures at Lond, Univ., Med. Gaz., 1831-2, p. 926. Gen. II.] ANETUS. 351 single, common to the two, and never generates any other fever. Now, although the febrile miasm, issuing from marsh lands, is by far the most common cause of intermittents, it is by no means the only cause; for we find intermittents, like all other species of fever, produced from various sources ; existing in hot countries as well as in cold, in high lands as well as in low lands, sporadically as well as epidemically; sometimes excited by sympathy, sometimes by contagion. Even in tertians, Dr. Cullen is obliged to admit of instances in which other agents are necessary ;~ but then, says he, they are only co-agents, and would not operate alone. " Has potestates excitantes pro parte principii hie admittimus licet neutiquam excitassent, si miasma paludum non antea applicatum fuisset." But this is the very point of controversy; for, in many instances, they produce the disease where marsh miasm cannot be suspected. 1 have seen an isolated case of a regular tertian on the highest part of Islington; and another on the dry and gravelly coast of Gosport, a situation so healthy that all the inhabitants escaped, when, in the year 1765, a most fatal and epidemic fever, originating unquestionably from the miasm of swampy grounds, pervaded the whole Island of Portsea, situate at not more than a mile distant on the other side of the water, and exhibiting, in different individuals, and often in the same per- son, all the diversities of the intermittent, remit- tent, and continued type. Dr. Fordyce affirms, that he has seen an intermittent communicated by infection, meaning the miasm from human effluvium ;* and where the yellow fever has * Dr. Cleghorn, in his work upon the diseases of Minorca, expresses a similar belief. " Dr. Wells, a colleague of Dr. Fordyce at St. Thomas's Hospital, accounts for Dr. Fordyce's opinions by remarking, that he (Dr. F.) fancied that continued and intermittent fevers were mere varieties of the same disease; and, as it appeared in those days, that continued fever was contagious, so he was obliged to maintain that ague was contagious. Dr. Cleghorn's mistake is supposed to have arisen from his having observed, that most of those who were about the sick in Minorca had the disease, forgetting that it did not arise in consequence o emanations from the sick, but from the situation in which they were placed."—(Elliotson's Lec- tures at the Lond. Univ., Med. Gaz., 1831-2, p. 921.) This want of discrimination is evident in much of the argument brought forward by writers in proof of the extension of certain diseases by contagion. In opposition to Dr. Fordyce's hypoth- esis, let us hear what conclusion Dr. Brachet, physician to the Hotel Dieu of Lyons, has adopted, as the result of his investigations:—" I have seen," he remarks, "tanyards situated in the midst of intermittent infection ; and to my inquiries the reply has been, that the disease leaves these places untouched. I attended for a long while the ana- tomical theatres and hospitals, yet never found my fellow-students suffer from intermittent fevers. I have seen the horrors of war bring typhus among us, but not intermittent fever. I have consulted authors: everywhere have I seen typhus arise from the infection of animal mias- mata, and never are intermittent fevers the conse- quence of the crowding of human beings or patients together, or from the action of the putrid emana- Iong existed, or become widely diffusive, this is common. Where it arises from sympathy, or organic affection, the case is still clearer. " Two children," says Mr. J. Hunter, "had an ague from worms, which was not in the least relieved by the bark ; but by destroying the worms they were cured. We have in like manner agues from many diseases of particular parts, more especially of the liver and the spleen, and from an induration of the mesenteric glands."* But one of the most singular and convincing proofs, that the decomposition of marsh land* is not essential to the production of intermit- tent fever, is to be found in the epidemic inter- mittent of 1780, as described by Sir George Baker, and which we shall have occasion to advert to more particularly hereafter ; for, du- tions of animal substances." He then notices that butchers, leather-dressers, fellmongers, and others, whose business exposes them continually to the effluvia of putrid animal substances, do not suffer from intermittent fever. Dr. Brachet then shows how you may at option render the most healthy village the seat of intermittent fever, by forming pools about it, in very hot weather, for the watering of hemp, and then removing them. This he regards as a convincing proof, that intermittent fevers are the product only of emanations from putrefying vegetable substances. He observes, likewise, that intermittent fevers never prevail to any extent in winter, but at the commencement of the warm weather of the spring, or in the autumn. The reason of this is, that the cold of winter pre- vents vegetable matter from putrefying, while the warmth of spring promotes the decomposition of it. The active vegetation which then follows, furnish- es no detritus till the end of summer, when inter- mittents begin again ; a little earlier or later, in different years, according as vegetation may be more or less advanced, and the period when its detritus is blended with stagnant waters.—(See Archives Gen. de Med., torn, ix., p. 380.)—Ed. * On Blood, part ii., chap, iv., p. 411. Here, perhaps, it would be more correct to say, occasion- ally, but without any regularity, from local irrita^ tion. Thus, when matter forms in deep-seated parts, there is frequently one or more rigours, followed by heat, &c.; and when patients have strictures, for which they are using bougies, the same kind of constitutional disturbance is not un- common ; but it has not the regular type of inter- mittent fever; and, even if it had, the case would throw no light on the question, whether common ague can be excited by effluvia from animal sub- stances ? Dr. Elliotson admits, in his Lectures, that sporadic cases, even of ague, which cannot easily be traced to malaria, are frequently met with; but he has no doubt, that, if we could ascertain all the circumstances, we should find, that the individual had a striking tendency to it, and had been exposed to malaria by passing through a market, or some other place, in which there was vegetable matter in a state of decay. The same excellent physician also reminds us, that, though the influence of malaria, is so great, yet, cold and wet, and other causes of debility, will induce ague without the. reapplication of malaria, when a person has once had it. Some- times, too, when malaria has been applied, the disease does not occur till such circumstances as these have taken place. These observations are of great value in accounting for circumstances in the history of ague, which would otherwise leadtr> most erroneous views.r— Ed. 352 H^M ring this, the intermittent harassed very exten- sively the elevated parts of Lincolnshire, while the inhabitants of the neighbouring fens were free from its ravages.—(Med. Trans., vol. iii., art. xiii.) And, in like manner, the dry and healthy climate ofeMinorca is sometimes at- tacked with remittent or intermittent fever, while Sardinia, proverbial for its insalubrity and febrile epidemics, escapes.—(Cleghorn, Disease of Minorca.) " In the year 1812," says Dr. Macmichael, " I was detained several months at Trichiri, a small seaport in the mouth of the Gulf of Volo, in Thessaly. The town is built on a dry limestone rock, but it is notorious for malaria. During my stay here, I made an ex- cursion to visit the celebrated pass of Ther- mopylae, and slept one night near the marshy district in that neighbourhood. On my return, the friends whom I had been waiting for arrived from Athens, and we all embarked on board a Greek vessel, to cruise in the Archipelago. On the following day I was seized with a most se- vere fit of the ague, and, at the same time, a servant belonging to the party suffered a similar attack. It might be said that I had caught my intermittent at Thermopylae, but the servant had not quitted the dry rock of Trichiri, upon which he had remained more than a week."— (New View ofthe Infection of Scarlet Fever, &c., 8vo., 1822.) In like manner, Sir Gilbert Blane informs us, that while the village of Green Hithe, nearly on a level with' the marsh of Northfleet, is unaffected with intermittent fe- vers, the adjacent hills suffer considerably from them : and he refers to other anomalies of the same kind.* To unite remittents, therefore, with inter- mittents, from an idea, of their having a single and common origin, is to depart from the clear line of symptoms into a doubtful region of etiology. If intermittent ought to be separated (as unquestionably they ought) from continued * Select Dissertations, &c, p. 111. Such anomalies may perhaps be explained on principles which leave the Cullenian doctrine as firm as ever. " A certain degree of moisture," as Pro- fessor Elliotson observes, "is necessary for the production of ague by the fermentation and putre- faction of vegetable matter, which gives rise to the exhalations. Hence, in a moderate swamp, you see why dry weather may put a stop to the disease, namely, by putting a stop to putrefaction ; and you also see why, in extremely wet situations, there is often no ague, because too much fluid im- pedes putrefaction ; but this wet, by dry weather, may be reduced to just sufficient swampiness for vegetable decomposition to take place, and mala- ria to be produced. Just as dryness would prevent decomposition, so extreme wetness and moisture will likewise stop it. If the matter which is to be decomposed be diffused in a very large quantity of water, the putrefaction of course ceases, or is not evident; so that some places which were very wet and healthy, have been made unhealthy by being dried just sufficiently for putrefaction to go on vig- orously ; and again, other parts, which were dry, and which never gave out any exhalations, have been caused to do so by a certain degree of moist- ure falling upon them. Thus, you see, that ac- cording to situation, the same additional moisture iTICA. [Cl. III.—Ord. t fevers, so ought remittent to be separated from intermittent. To say that intermittents often run into remittents is to say nothing, for remit- tents as often run into continued fevers ; and it is now an established doctrine, that there is no continued fever whatever without occasional remissions. In effect, all fevers have a tendency to run into each other, and many causes are per- haps common to the whole. The difficulty is in drawing the line ; yet a like difficulty is per- petually occurring to the physiologist in every part of nature ; and equally calls for discrimi- nation in zoology, botany, and mineralogy; and Dr. Parr has correctly observed, that " if a specific distinction can be established in any branch of natural history, it must be in the sep- aration of remittents from intermittents." Vogel unites remittent with continued fevers, to which Cullen, rightly enough, objects ; but the former has as much reason on his side, as the latter has for uniting them with intermittent. Sauva- ges, Linneus, Sagar, and most modern writers, correctly distinguish each from the other. It must nevertheless be admitted, that marsh miasm is by far the most frequent cause of in- termittents ; and hence the frequency and se-^ verity with which they visited our own country in the sixteenth and seventeenth centuries, be- fore the lowlands were artificially drained of their moisture, and, consequently, the atmo- sphere of its taint ; during the former part of which, Dr. Caius tells us, that the mortality from agues in London was such, that the living could hardly bury the dead; and Bishop Bur- net, that at one time, 1558, they raged like the plague. When an intermitting fever or ague is, by the operation of marsh miasm, or any other cause, once introduced into the system, and has once discovered its type, or given an interval of a particular measure between the close ofthe first and the commencement of the second par- oxysm, it continues true, as a general rule, not may produce an ill or a salutary effect. High grounds may, therefore, suffer from the same cause, which removes all unhealthiness from low grounds A certain degree of rain, falling upon high ground will not all remain there, but will roll down ; still, it has moistened the parts suffi- ciently for decomposition to take place above; whereas, when it comes on the low grounds, and there collects, it may be so abundant as to dilute all the vegetable matter, and prevent it from putre- fying, and so put a stop to the unhealthiness of the part."—(Lect. at Lond. Univ., Med. Gaz., 1831-2, p. 845.) Considerations of this kind throw light on various circumstances, which would otherwise be completely perplexing, or lead to erroneous in- ferences. Even supposing no rain at all had fallen on high lands, where ague prevailed, while none existed in lower situations, we are to remember, that the nocturnal dews in many places are nearly equivalent to rain. The fact that malaria is more likely to produce ague when a person has been exposed to it at night, or in a state of health im- paired by fatigue, privations, and other causes, is generally acknowledged. Strangers, also, who visit situations where malaria is present, are more frequently attacked with intermittent or remittent fevers than the natives themselves.—Ed. Gen. II.—Spe. 1.] ANETUS QUOTIDIANUS. • 355 merely to the same measure or extent of inter- val, but to the length and severity of paroxysm, through the whole course of the disease ; the character of the cold stage determining that of the hot, and both together that of the sweating stage ; and the paroxysm ceasing because it has completed its career. But the first in- terval, like the first paroxysm, which regulates the rest, is of different duration in different cases : of the reason of this difference we know nothing ; sometimes it seems to depend upon the season or the temperament of the at- mosphere, operating upon the febrile miasm that is diffused through it, and all who have agues in the same place, or at the same time, have them of the same kind.* Sometimes, on the contrary, it seems chiefly to depend upon the time of life, the idiosyncrasy, or the par- ticular condition of the constitution, for, as al- ready observed, different individuals, even in the same place and under the same roof, ex- hibit different types. But upon this subject we have no clear information. It seems expe- dient, however, to observe, that the fact itself of such regularity of recurrence and interval is an insurmountable objection to the doctrine of M. Broussais, that all fevers consist in an in- flammation of the mucous membrane of the stomach or intestines, as in truth it is to every hypothesis that contemplates fever as a local inflammation of any organ. And hence the doctrine of types is an intractable stumbling- block to all such writers ; who, from the diffi- culty of encountering them, are too apt to ejaculate with M. Monfalcon, " peu importe le type d'une pyrexie" (Histoire des Marais et des Maladies causies par les Emanations des Eaux Stagnantes, 8vo., Paris, 1824); and then dex- terously to reach forward to some point of much easier solution.—(From " It seems," &c., an addition from the author's MS.) Nevertheless, whatever be the cause of these discrepances, it lays a good foundation for di- viding the intermittent genus into distinct spe- cies, and the five following are sufficient to comprise all its principal diversities :— 1. Anetus Quotidianus. Quotidian Ague. 2.------Tertianus. Tertian Ague. 3. ------Quartanus. Quartan Ague. 4. ------Erraticus. Irregular Ague. 5. ------Complicatus. Complicated Ague. As the connexion between all these is pecu- liarly close, and they occasionally run into each other's province ; and, more particularly, as the same mode of treatment is common to the whole, it will be most convenient to defer the general history and praxis, till we have taken a survey * Agues occurring in the spring, are generally tertians and quotidians, and readily give way to proper remedies; while those prevailing in the autumn are more intractable ; and quartan inter- mittents (the most intractable of all) constitute then a more considerable proportion of the cases. Dr. Joseph Brown, in Cyclop, of Pract. Med , art. Fever. " Febris autumnalis Est longa aut lethalis." Vol. I.—Z of these species in their respective definitions, and the varieties they often exhibit. It may, however, considerably assist the stu- dent, and simplify his pursuit in acquiring a knowledge of their characters, to attend to the three following remarks :— - Firstly, the shorter the intermission, the lon- ger the paroxysm. Secondly, the longer the paroxysm, the ear- lier it commences in the day. Thirdly, the more durable the cold fit, the less durable the other stages. Thus, the quotidian has a longer paroxysm and a shorter interval than the tertian ; and the tertian a longer paroxysm and a shorter interval than the quartan. And thus again, while the quotidian has the longest duration, it has the slightest cold stage ; and while the quartan has the shortest duration, it has the longest cold stage. It is also the most obstinate to cure. Each of these species, however, admits of' considerable variations : for sometimes we find the paroxysm protracted beyond its proper pe- riod ; sometimes anticipating, and sometimes delaying its proper period of return. In other cases, we find each of these species catenated with, or giving rise to foreign symptoms or other diseases. And we also meet with a pecu- liar variety of the quotidian ague, in its being sometimes limited to a particular part or organ, in which case it is usually accompanied with very distressing pain. The most irregular of all the species is the fourth, for this is sometimes found to deviate from all the three rules I have just laid down ; but particularly in the greater length of its in- terval, which is sometimes double or even treble that of the quartan, whose interval of seventy- two hours is the longest of the three more dis- ciplined species; it is hence found under the various forms of a five-day, a six-day, a seven, eight, nine, and even a ten-day ague; and sometimes is so extremely vague as to bear no proportion whatever between the violence of its paroxysm, the duration of its stages, and the period of its return. The fifth species is distinguished from the rest by its peculiar complexity, consisting of double tertians, triple tertians, unequal tertians, duplicate tertians, together with as many varie- ties of the quartan type ; the nature and key of which will be more particularly noticed under the species itself. SPECIES I. ANETUS QUOTIDIANUS. QUOTIDIAN AGUE. INTERMISSION ABOUT EVERY TWENTY-FOUR HOURS ; PAROXYSM COMMENCING IN THE MORN- ING ; USUAL DURATION UNDER EIGHTEEN HOURS. The genuine quotidian is of less frequent occurrence than the other species ; but it has a considerable resemblance to that variety of the complicated intermittent, which has generally been denominated a double tertian, and with which it is often confounded. It is distinguish- 354 HiEMATICA. [Cl. Ill—Ord. I. able, however, to an attentive eye, by the regu- larity of its paroxysms, which'are true to them- selves on every return; while, in the double tertian, the alternate paroxysms only are true to each other, as we shall have occasion to observe more particularly in the proper place. The quotidian, like the tertian and quartan, has sometimes been epidemic. The quotidian intermittent is occasionally limited in its attack to a particular part, and is occasionally connected with other affections. It deviates also now- and then from its common rule, in having an imperfect intermission, and in precipitating or procrastinating every subsequent paroxysm ; and hence affords us the following varieties :— o Partialis.- Partial quotidian. 0 Comitatus. Catenating quotidian. y Protractus. Protracted quotidian. & Anticipans. Anticipating quotidian. t Cunctans. Retarding quotidian. In the partial quotidian, the febrile attack is confined to a particular part or organ, and usually accompanied with distressing pain. Under this modification, sometimes one side of the body has suffered, while the other has escaped; sometimes one or both eyes; but more generally the whole or half the head, not unfrequently resembling cases of cephalaea, and particularly that species of it which is called hemicrania. In the catenating quotidian, the disease associates with, or gives rise to, various foreign symptoms or other diseases ; and hence is often found in union with rheumatic affections, par- ticularly lumbago and sciatica. Sauvages quotes a case, in which it associated with daily attacks of a frightful epilepsy.^—(Class ii., Febr. Inter- mit., Quot. Spec, iv.) And Dr. A. Monro nar- rates a similar instance, though less severe, and alludes to several others.—(Edin. Med. Essays, vol. ii., art. xix.) Torti has made a collection of numerous examples of this variety, and has united them into one family, under the name of febres intermittentes comitatae. Galen has de- scribed one or two of them under the name of epiala. In the protracted quotidian, the intermis- sion is inordinately short or imperfect. In the former case, the paroxysm is lengthened beyond the usual period of eighteen hours ; and, in the latter case, it does not so completely subside as to leave the intermission totally clear of fe- brile symptoms. On which last account the Latins describe this variety under the name of quotidiana continua ; and the Greeks under that of amphemerina. In the anticipating quotidian, which is the name given to our fourth variety from Dr. Fordyce, the paroxysm precedes its antecedent period usually by about two hours, and contin- ues the same fore-march at every recurrence ; so that the accession may hereby be thrown into any hour of the day or night. This form is denominated a febris subintrans by Professor Frank and various other writers.—(Op. cit., torn. i, p. 41.) The retarding quotidian, which, like the last, has been particularly noticed and named by Dr. Fordyce, forms a direct «ounterpart to the anticipating; the paroxysm delaying its an- tecedent period usually by about two hours, and continuing the same delay at every recurrence ; so that here also the accession may be thrown into any hour of the day or night. There are few diseases, moreover, in which the quotidian is not occasionally to be found as a symptom; but it occurs especially in hysteria, catarrh, gout, peripneumony, ischury, quinsy, and several species of odontia. SPECIES II. ANETUS TERTIANUS. TERTIAN AGUE. intermission about forty-eight hours : PAR- OXYSM COMMENCING AT NOON J USUAL DU- RATION UNDER TWELVE HOURS. The tertian ague, the tritaeus of the Greeks, occurs most frequently in the spring and sum- mer months; though there is a spurious kind that shows itself in the autumn. The chill, du- ring the cold fit, is intense, with convulsive shivering, rigidity, and gnashing of the teeth. It is, however, of shorter duration than that of the quartan, and sometimes passes off in less than half an hour; and is succeeded first by nausea or vomiting, and afterward by a pun- gent penetrating heat, frequent respiration, ur- gent desire for cold drink, wakefulness and head- ache, sometimes delirium. At length, a moist- ure on the skin, gradually advancing to a copi- ous sweat, breaks forth, the urine commonly de- posites a lateritious sediment, and there is often some looseness of the bowels. The entire paroxysm sometimes ceases in six hours, but more generally extends to eight or ten; if it exceed twelve, as it does occasionally in the au- tumn, the disease forms the spurious tertian I just have alluded to. As the quotidian is mostly common to infants and persons of delicate hab- its, the tertian chiefly affects those of riper years or of firmer fibres, and especially persons of a bilious temperament. It was the opinion of Hippocrates, that the tertian ague, if left to nature, would run itself out in seven paroxysms ; and Vogel adds, that when this is the case, there is usually the appearance of a dry scabby eruption about the lips on the fourth or fifth paroxysm. But the period, pointed out by the former, does not hold in our own day ; and the disease has often continued obstinate in spite of cutaneous eruptions, not only about the lips, but over the body. Sydenham asserts, that, in the autumn, in which, however, a genuine tertian is rarely to be met with, its ordinary natural course is double the term allotted by Hippocra- tes, or rather, that the term of its paroxysms amounts to the space of fourteen days. The tertian exhibits occasionally the two following varieties :— a Comitatus. Catenating tertian. 0 Protractus. Protracted tertian. To both which the explanation already give© Ben. II.—Spe. 5.] ANETUS COMPLICATUS. 355 under the same terms in the preceding species will equally aoply. As an associate disease, it is chiefly to be found united with syncopal and soporose affections, indicating some oppression of the brain ; or with cholera or dysentery, mostly indicating irritation or congestion in the liver. SPECIES III. ANETUS QUARTANUS. QUARTAN AGUE. INTERMISSION ABOUT SEVENTY-TWO HOURS ; PAROXYSM COMMENCING IN THE AFTERNOON; USUAL DURATION UNDER NINE HOURS. This, which is also the quartana of Celsus, is the tetartaeus of the Greek writers. It is rarely found in the vernal season, but is common in the autumnal, in which quarter, also, it is far the most obstinate of all the species, and especially if, as Celsus observes, it show itself only a short time before the commencement of winter. Its chief subjects and sufferers are those of advanced years, and of a melancholic habit; for children and young persons, who principally feel the effects of the two former species, are but little obnoxious to it. It commences usually about, or a little before five o'clock in the after- noon. The cold fit is less vehement than in the tertian, but of longer duration, and will some- times continue for two hours, but usually with- out sickness ot diarrhoea. It yields to a heat that is rather troublesome from its dryness than from its intensity, and which is rarely succeeded by a sensible perspiration. There is a heavi- ness or dulness in the head, rather than acute pain : and often, during the intermediate days, a sense of soreness over the body, as though it had been generally bruised, which strikes through to the bones. It is here also we prin- cipally meet with parabysmic tumours, and es- pecially of the spleen and liver: in the former of which organs they are vulgarly called ague- cakes. The quartan offers the following varieties :— a Comitatus. Catenating quartan. 0 Protractus. Protracted quartan. y Anticipans. Anticipating quartan. o Cunctans. Retarding quartan. Of all which an explanation will be found, by turning to the same varieties under the first species. From the tendency which this species has to affect the abdominal viscera, it is often met with as a symptom in diseases of the spleen, liver, and various adjoining organs. And hence it occasionally interchanges with dysentery, and particularly when the latter is a prevailing or epidemic disease. This remark will also apply to the preceding species, and under the one or the other form was often found exemplified in the fatal dysentery that- ravaged a large part of Ireland in the year 1818 (Cheyne, in Dublin Hospital Reports, vol. iii.), and which still more frequently occurs in tropical climates.—{Climate and Diseases of Tropical Countries, &c., by C. Chisholm, M. D., p. 52, Lond., 1822.) Z2 SPECIES IV. ANETUS ERRATICUS IRREGULAR AGUE. INTERMISSION AND PAROXYSM POSSESSING LIT- TLE REGULARITY : THE FORMER MORE THAN SEVENTY-TWO HOURS. We have already perceived that there is oc- casionally some degree of irregularity in all the preceding species, least of all, however, in the quartan. And hence all the above might, in such instances, be named erratic. But the pe- culiar, character of the present species is, that the duration of the intermission exceeds that of all of them ; on which account it can never be confounded with any of the rest. The chief varieties are the following, which, however, might be considerably enlarged, but it is unnecessary. They are principally taken from Sauvages and Vogel; and, for other au- thorities, the reader may turn to the volume of Nosology :— a Qnintanus. Five-day ague. 0 Sextanus. Six-day ague. y Septanus. Seven-day ague. & Octanus. Eight-day ague. t Nonanus. Nine-day ague. £ Decimanus. Ten-day ague. n Vagus Vague and irreducible. Several of the above have occasionally per- severed with great obstinacy ; in some instances, for upwards of two years without ceasing. The last variety is equally irregular as to the violence of its paroxysm, the duration of its stages, and the period of its return. Several of Sauvages's species of hemicrania may be properly referred to this place, and especially those which by some writers have been denominated inter- mittent larvat^e, or disguised intermittents. SPECIES V. ANETUS COMPLICATUS. COMPLICATED AGUE. PAROXYSMS INTRICATE, MULTIPLICATE, OR BOTH. There are numerous examples of ague, which, to an inattentive eye, are as irreducible to any regular order as those which belong to the last variety of the preceding species, but which, when minutely examined, are found, however intricate, to be composed of types, not that uni- formly resemble each other, but that recur in alternate sets, every set being true to itself, while it differs from that with which it alternates in the duration of its intervals, or of its par- oxysms, or of the time of its accession. And hence, although in some shape or other, most of them return perhaps every day, and are often mistaken for irregular quotidians, they are, in fact, double or triple tertians or quartans, dis- covering their real nature by these alternating distinctions :— The following are the chief varieties :— o Tertianus duplex. The paroxysms of the Double tertian, one tertian occurring in the intermissions 356 ILEMATICA, [Cl. Ill—Ord. I. $ Tertianus triplex. Triple tertian. y Tertianus impar. Double unequal ter- tian. 3 Tertianus duplicatus. Duplicate tertian. t Quartanus duplex. Double quartan. of the other ; and the two sets evincing a difference of duration or of violence. A double tertian, taking place as above ; but one of the sets having regularly two parox- ysms on the day of its return, and the other one alone. The one set evincing a • more perfect, the other a less perfect inter- mission. A single tertian with two paroxysms on the reg- ular day of attack, the intervals being of or- dinary duration. The paroxysms of the • one set occurring in the intermissions of the other, and evin- cing a difference of duration or of vio- lence : with an inter- I val on the third day alone. Consisting of a single quartan with regularly- returning paroxysms ; while each of the intervening days is marked with a slighter or separate attack. Consisting of a single quartan with two par- oxysms on the regular day of attack : the in- tervals being of ordi- nary duration. . Consisting of a single quartan with three par- oxysms on the regular day of attack : the in- tervals being undis- turbed, and of ordi- nary duration. Having thus distinctly noticed the several species and chief varieties of intermittent fever, I shall proceed to offer a few remarks upon its general history and medical treatment. Whenever the accession of an intermittent is violent, be its type what it may, it is sometimes attended with very alarming symptoms, as syn- cope, apoplexy, vehement spasms over the whole system, or a coldness or torpor which threatens death.* Yet, when not violent, nor of very long duration, especially when of the tertian * It once occurred to Dr. Joseph Brown to see a person die in what appeared to be the cold stage of a first fit of ague. Heat applied in various modes, ammonia, ardent spirits, ether, and other stimulants, failed to bring on reaction. The pa- tient lay as cold as marble, and shivering violently, without any pulse at the wrist, and his heart act- £ Quartanus triplex. Triple quartan. ij Quartanus duplicatus Duplicate quartan. k Quartanus triplicatus Triplicate quartan. type, it is often serviceable to the general health, and carries off many disorders of other kinds, Dr. Fordyce affirms (On Fever, Diss, ii., p. 16), that he has seen it of considerable use in curing or alleviating chronic rheumatism, habitual in- digestion, cutaneous eruptions, protracted in- flammations, epilepsies, and hysteria. And his assertion is corroborated by other authorities.— (Salmuth, cent, ii., obs. 14; Ephem. Nat. Cur., dec. iii., ann. iii., obs". 30.) It is to this kind of remedial fever that Professor Frank gives the name of depuratory.—(Op. cit., torn, i., p. 48.) The duration of intermittents is of great uncertainty. The vernal agues generally dis- appear with the advance of summer ; the au- tumnal are more obstinate, and especially the quartan. Where they have remained long, and have become habitual, even their removal must be attempted with great caution; for, when abruptly suppressed, they have been known to lay a foundation for a host of other maladies, often of a more fatal description, as paralysis, various visceral affections, and even sphacelus. Ludolf gives an instance of an eight-day ague (anetus erraticus octanus) continuing for eighteen years ; yet this was probably a double quartan j while we have abundant examples of a con- tinuance of the regular quartan for nine (Eph. Nat. Cur., dec. ii., ann. viii., obs. 45), twelve (Avicenna, canonum i., lib. iv., tr. ii., cap. vi.), eighteen (Madai, Von Weekselfiebern, sect. 144), twenty (Eph. Nat. Cur., dec. iii., ann. ix. and x., obs. 51), twenty-four (Marccllus Donatus, lib. iii., cap. xiv., p. 291 ; Pontanus, De Febr. Conel., lib. viii.), and thirty years (Binninger^ obs. cent, v., N. 64; Wierius, obs., p. 37), and one instance of its lasting for not less than forty- eight years.—(Gabelchover, cent, vi., obs.74.) It is in this species, therefore, that we chiefly meet with those congestions in the spleen which are called ague-cakes, as also with scirrhosities in the liver, pancreas, and other abdominal organs, which by Bonet, Swalwe, Senac, and other writers, have been regarded as causes of the disease, but by Van Hoven, and most pathol- ogists of the present day, excepting, perhaps, Cruveilhier, are more correctly resolved into effects. Schenck gives a case of congenital quartan, or in which it appeared in an infant immediately after birth (Obs., lib. vi., N. 36) ; and Paullini another, in which though not strictly congenital, it appeared in very early infancy.—(Cent, i., obs. 94.) But such examples are rare. Among other singularities, I may observe, that the ac- cession has sometimes been so violent as to destroy the patient in the course of the first paroxysm, of which an instance will be found in Senac (Von Weekselfiebern, b. ii., cap. vi.), while, at other times, it has been so slight and rapid, that the entire paroxysm has run through ing very feebly, for eighteen hours, at the end of which he expired, his intellect having been un- clouded till within a few minutes of his dissolu- tion. The principal morbid appearance discovered was in the liver, which was very much enlarged, had a lobulated appearance, and was gorged with . blood.—Cyclop, of Pract. Med., art. Fever.—Ed. Gen II-] ANETUS. 357 its course in a minute.—{Reil, Mcmorab. Clin., vol. ii., Fasc.) The character of the intermittent seems in a considerable degree to depend upon the age or idiosyncrasy of the individual, and the tempera- ment of the atmosphere. We find, also, that variations more usually take place in the quo- tidian than in any other type, which we should, perhaps, ascribe to its occurring more frequently in early life, when the frame is more irritable ; and to the debility which the constitution suf- fers from this type, above that of any other, in consequence of the greater length of its par- oxysms, and the greater brevity of its intervals, by which means the prostrated strength of the system has no time to rally. In this metropolis, from causes which have not been handed down to us, and which, in- deed, do not appear to have been traced at the time, intermittent fevers were more than ordi- narily frequent from the year 1781 to 1785: and the remarks I have just made apply in an especial manner to all these. As a single ex- ample, let us select those of 1782, as described by Sir George Baker and Dr. Reynolds, in an article drawn up by the former, with an admira- ble combination of learning and liberality, sound critical judgment, and inquisitive research. " The type of the fever of 1781-2," says Sir George, " was either tertian or quotidian; the former being more common in the first part of the winter ; the latter, from the middle of Feb- ruary to the end of June. With respect to the former, nothing occurred to my observation which is worthy of notice"—(Med. Trans., vol. iii., art. xiii.) On the latter, Dr. Reynolds com- municated to him the following information :— The quotidian fevers were irregular in their invasion, and uncommon in their appearance; and no cases resembled each other, except in very few circumstances. The first attack gen- erally commenced with a horror ; but the subse- quent paroxysms, though often beginning with a sense of cold, were chiefly without horror. The intermission was short, and seldom perfect. The symptoms were very severe, and in many cases dangerous, and leaned strikingly to a ty- phous form. Great and sudden oppression ofthe head, anxiety, depression of spirits, a dry, parched tongue, yet less covered with hardened mucus than might be expected ; a pulse low, quick, and intermitting ; bowels variable ; urine dark-red and clear, without any sediment, con- stituted the ordinary signs. Many had a low muttering delirium ; two or three a laborious respiration ; a few spasms and twitchings of the tendons : aphthae appeared occasionally : and one patient exhibited symptoms of violently acute rheumatism. The bark was universally suc- cessful ; and, " I was as much pleased," says Dr. Reynolds, "with its present efficacy, as I was in the year 1781 mortified by its extraordi- nary want of power. Half the quantity of it which I used on that occasion was sufficient on this." In other words, idiosyncrasy and atmospheric temperament were both peculiarly visible, and gave a peculiar character, in the one instance, to particular cases, and, in the other, to the gen- eral disease. In plethoric habits, the head was greatly oppressed with a tendency to delirium. In those of a nervous and irritable disposition, the intermittent was connected with spasms and twitchings of the tendons. And those disposed to rheumatism, had acute arthritic pains. The state of the atmosphere, and the general char- acter of the season, Dr. Reynolds has forgotten to notice ; but we see evidently, and indeed he himself allows, that they give a typhous im- pression to the epidemic ; which, from the same, or from other causes, is also peculiarly distin- guished by the easy victory it yielded to the use of the bark, as that of the preceding year was distinguished by its obstinate resistance to this medicine. If we ascend a, year higher, or to 1780-1, we shall meet with an equal diversity of symptoms. " These fevers" (intermittents), says Sir George Baker, "were in general no other than the common ague ; but in the more inland coun- tries of England, they were often attended with peculiarities extraordinary and alarming. For the cold fit was accompanied by spasm and stiffness of the whole body ; the jaws being fixed, the eyes staring, and the pulse very small and weak. In many cases, delirium was added to spasm, under both which symptoms the pa- tient laboured quite to the end of the paroxysm. And though the senses returned when the fever subsided, yet a convulsive twitching of the ex- tremities continued, even in the intermissions, to such a degree, that it was not possible to distinguish the motion of the artery at the wrist. " This fever had every kind of variety : and, whether at its first accession it were a quotidian, a tertian, or a quartan, it was very apt to change from one type to another. Sometimes it re- turned two days successively, and missed the third, and sometimes it became continual. I am not informed that any died of this fever while it intermitted. It is certain, however, that many country people, whose illness had, at its begin- ning, put on the appearance of intermission, becoming delirious, sunk under it in four or five days. It is a remarkable fact, and very well attested, that in many places, while the in- habitants of the high grounds were har- assed BY THIS FEVER IN ITS WORST FORM, THOSE OF THE SUBJACENT VALLEYS WERE NOT affected by it. The people of Boston and of the neighbouring villages, in the midst of the Fens, were in general healthy, at a time when this fever was epidemic in the more elevated situations of Lincolnshire : and other examples of a like kind have already been noticed.* It is * Sir Gilbert Blane, Select Dissertations, p. Ill, 8vo., Lond., 1822. In orderto form a correct judg- ment of this part of the subject, we should have been informed of the state of the weather, not merely in respect to temperature, but quantity of rain that fell in the different places alluded to. The occurrence of ague sometimes in high situ. ations, while it ceases in lower ones, will admit of explanation on principles already noticed in a preceding note.—Ed. 358 «^M' likewise singular, and worthy of notice, that, in many families, the female servants were nearly exempted from a disease which very few male servants, especially the labourers in the open air, escaped. But the distinguishing character of this fever was its obstinate resistance to the Peruvian bark ; nor, indeed, was the prevalence of the disease more observable, than the ineffi- cacy of the remedy. Though the quantities of the bark usually given were exceeded, the fit was apt to return, rarely altered, either with respect to the time of invasion, or the intense- ness of the symptoms ; and just as if no means had been used to prevent it. A drachm of the bark in powder was frequently administered every second hour, without averting the fit." In casting our eyes over the great diversity of medicines that have been employed for the cure of intermittents,* we shall find that, innumer- able as they are, they may be arranged under two general heads, tonics and antispasmodics; as though, long before the time of Dr. Cullen, his two principles of the disease, debility and spasm, had been uniformly admitted and acted upon. The antispasmodics, consisting chiefly of stimulants, sedatives, and relaxants, have been confined to the term of the paroxysm, with a view to weaken and shorten it; and the tonics, consisting principally of bitters and astringents, have been employed throughout the intervals, with a view of fortifying the system against a recurrence of the attack. In discussing the medical treatment of inter- mittent fevers, it will be sufficient to limit our- selves to these two indications. It was a favourite practice with Bergius to anticipate the cold fit, constituting the accession of the paroxysm, by pungent stimulants, in the hope that, if he could successfully combat this first stage, he should gain a complete victory, not only over the individual paroxysm, but over all future incursions. His favourite medicines for this purpose were garlic, mustard-seed, and capsicum. And he boasts of having, in nu- merous instances, completely succeeded, with each of these ; though he admits that the mus- tard-seed answered best in vernal intermittents, but did not, in general, prove sufficient for the autumnal quartans. The Indian practitioners, I may here observe, employ chakka or ginger, and sometimes the-sison ammi for the same pur- pose, and Dr. Chisholm has occasionally suc- ceeded with scallions.—(Clim. and Dis. of Trap. Coun., &c, 1822, p. 53.) Bergius, however, placed his chief reliance on the capsicum, six grains of which he was in the habit of giving, combined with two scruples of bay-berries in powder, " incipiente primo rigore ;" and of re- peating it every day, at the same hour, for three * Intermittents are sometimes cured merely by diet and regimen. Of twenty-three patients sent to the hospital la Charite, for the purpose of test- ing the efficacy of the misletoe (Ilex aquifolium), M. Chomel states that the disease ceased immedi- ately in seven of them, although no medicine was administered.—See Mem.de l'Acad. Royale de Med., vol. iii.—D. TICA. [Cl. III.—Orb. I. or four times in succession. And he assures us that he has very frequently seen obstinate intermittents removed by this powder, and with- out any relapse. The practice, however, has not been equally successful in other hands ; not even when cap- sicum has been given in a much larger quanti- ty, or exchanged for ammonia, treacle-mustard (clypoela jonthlapsi), or black or white pepper, the latter of which is only the former denuded of its outward tunic, mixed up with brandy or Hollands. They have all, indeed, sometimes answered, but the result is uncertain ; and, as was long ago observed by Van Swieten, if the medicine do not succeed upon a full dose, and especially when combined with ardent spirit, it will often extend its influence to the hot fit, and greatly exacerbate it ; and not unfrequently con- vert an intermittent into a continued fever. Upon the whole, therefore, this plan is not to be recommended, however varied. The least per- nicious material is the ammonia ; but then it is also the least effective. A large draught of cold water has been not unfrequently had recourse to for the same pur- pose, and also, in a few instances, with success. The object is, by taking it about half an hour before the cold fit is expected, to excite a strong reaction and powerful glow over the entire sys- tem against the time when the cold fit returns, and thus to preoccupy the ground ; and, by dis- turbing the regularity of the type, to subdue the intermittent altogether. But this plan has, per- haps, more frequently failed than the preceding : and when the shivering or horripilation produced by the cold water has not been followed with a stimulant effect, as in delicate habits more espe- cially, it has often continued so long as to run into the term of the febrile cold fit, and very considerably to increase its power. Ballonius relates a case in which it proved fatal.* The next division of antispasmodics, which have been directed against the paroxysm, and especially against the rigour with which it makes its onset, is sedatives: and of these the chief have been opiates, which, when given in the form of laudanum, in a dose of from thirty to forty drops at the commencement of the chill, has, in many cases of intermittents, been highly beneficial; diminishing the duration of the stage, and moderating its symptoms. Dr. Trotter says, that he practised this plan with general advantage in an'epidemic intermittent that at- tacked the Vengeance, one of the Channel fleet under Lord Howe ; and adds, that, " if the first dose of opium did not produce a sensible relief * Op., torn, i., p. 193. Venesection has been recommended as a means of shortening the cold stage, and of preventing the hot stage, or lessening its duration and violence. Dr. Mackintosh, in his work on the Practice of Physic, is in favour of such treatment. On the other hand, Dr. Stokes rather disapproves of venesection in the cold stage ; though he admits that it is beneficial in removing the symptoms of congestion about the chest and abdomen.—(Edinb, Med. and Surg. Journ., 1829.) Dr. Elliotson has never seen a case of ague which required venesection in the cold stage.—Lect. at Lond. Univ., Med. Gaz., 1832, p. 2.—Ed. Gen. H] ANETUS. 359 and exhilaration of spirits in half an hour, he re- peated it, and never found it necessary to go beyond a second dose."* Sir Gilbert Blane ad- verts to the same plan, as pursued at Walcheren during the English expedition to that island, and with an equal success.t We have already seen, however, that there is some cause or other, probably the peculiar tem- perament of the atmosphere at the time, that baffles on one occasion the remedy that has best succeeded on another. And hence opium has often failed in other intermittents in every form, but especially when given in the cold fit. And owing to this diversity of effect, Dr. Lind thought it most useful in the hot fit; and asserts that, if administered to the extent of twenty or five- and-twenty drops of laudanum half an hour after the beginning of the hot fit, it produced the ad- vantage of shortening and moderating the heat, calmed the anxiety and headache, which are usual concomitants, expedited the sweating stage, made the paroxysms more regular, and some- times stopped the fever altogether. Other physicians have commenced with re- laxants ; and where these are selected, the anti- monial preparations are to be preferred to ipe- cacuanha. They tend more directly towards the surface, and, where it is useful to excite vom- iting, which is often the case, they act sooner, and maintain the action longer, and hence make a double effort to accelerate the sweating stage. The antimonial preparations differ chiefly from each other by having the reguline part of the antimony they contain in a more or less fusible state ; and their operation will very often vary according to the quantity or quality of the acid they meet with in the stomach ; and hence the different effect of the same preparation in dif- ferent persons, and even in the same person at different times. The most efficacious practice which I have witnessed, consists in uniting relaxants with opiates ; and, where this joint effort is pursued, ipecacuanha may answer as well as any of the preparations of antimony. We cannot have, for this purpose, a more useful medicine than Dover's powder ; and it should be commenced with much earlier than is consistent with the * The administration of opium to arrest the in- vasion of intermittents, is one of long and exten- sive use in the United States. It is largely in- debted for its popularity to the authority of Sir Gilbert Blane. Sixty or eighty drops of laudanum, blended with a few drops of sulphuric ether, or of aqua ammonia, areoften administered a short time previous to the invasion of the cold chill. Many physicians will testify to the efficacy of this treat- ment, and few be disposed to question its efficacy, even in plethoric subjects. Plethora and local con- gestion however should always be considered, and bloodletting may sometimes be found an important preliminary measure. Dr. Gallup (Epidemic Dis- eases of Vermont) strongly condemns the use of opium in every form of intermittent fevers.—D. f Select Dissertations, &c, p. 105, Lond., 8vo., 1822. Dr. Elliotson has given opium with very great success; yet, says he, " if I found great con- gestion of the head or other parts, I would order Weeding in preference to opium." usual practice, so as not taregulate the hot and sweating stages, but to anticipate the cold fit. And we may still farther add to the ingredients of the medicine a full dose of ammonia with great advantage ; for, it is in this form, if in any, that we can employ stimulants with a certainty of doing little mischief, and very nearly a certainty of considerable benefit. In the case of a quartan in St. Thomas's Hospital which had lasted two years, Dr. Fordyce determined upon this plan ; and prescribed a full dose of Dover's powder, with a sweating draught of carbonate of ammonia, two hours before the paroxysm was expected. It succeeded perfectly. A profuse perspiration an- ticipated the period of the cold fit, and hereby entirely prevented it; bark was next given freely, and this obstinate ague was cured in a few days.—(Edinb. Med. Comm., vol. vi., p. 359.) Whatever be the relaxant or sudorific em- ployed, it should be assisted by plentiful pota- tions of warm diluents, and by placing the pa- tient between the blankets instead of in the sheets of his bed : for, I have already had occa- sion to observe, that upon these auxiliary means depend, in many instances, the accomplishment of the object we have in view, without which the most urgent diaphoretic exerts itself to no purpose.* The most important season, nevertheless, for medical operation, is in the intermission of the paroxysms : since, however successful we may be in moderating the febrile attack, it is rarely that we can depend upon any plan which may then be adopted, to prevent a recurrence of the fit. The opinion of mankind seems to have con- curred in most ages, in regarding debility as either the proximate or predisponent cause of intermittents, since almost the only medicines that have been brought forward to guard against the recurrence of their periodic attacks have been tonics, with the sensible qualities of bitter- ness or astringency, or of both. In what way these act upon the moving fibre at any time, and particularly in the diseases be- fore us, we cannot say with any degree of precis- ion. The tone of the moving fibre depends un- questionably in some degree upon the state of the fibrous material itself, but perhaps in a much greater degree upon the state of the nervous influence. We have great reason for believing, that astringents,- in producing tone, act upon the fibrous material itself, for we find them operating in like manner upon animal fibres both in a living and a dead condition. But whether, as Dr. Cullen conjectures, it be the * Dr. Elliotson conceives, that in the cold stage, the plan of surrounding the patient with hot air would be better than putting him into the warm bath, as is sometimes done. Air in any quantity, and of any temperature, may be conveyed undei the bedclothes by means of something like an in- verted funnel, a tube, and a spirit-lamp. Dr. Elli- otson has also a favourable opinion of the useful- ness of friction. The warm drinks which are given, he thinks, should not contain wine or brandy, as such stimuli would be likely to increase the sub- sequent hot stage, bring on delirium, and cause congestion and inflammation of the head and inter, nal organs.—Ed. -360 H^EMj part of bitters alone to act upon the nervous power or living principle, and especially in the very singular manner in which he represents them as acting, is a different question ; and the present is not the place for entering upon it. If we contemplate the brain and spinal mar- row as the sources of nervous energy, we can readily conceive that the component parts of these organs, as well as of any other, may be invigorated by medicines that have a peculiar influence on their structure ; and that conse- quently, such organs may be rendered capable of distributing the nervous power in greater abundance, or of producing it in a more elabo- rate perfection. And we can also readily con- ceive, that such effects may be produced by both bitters and astringents, as well as by medicines that possess some other sensible qualities, though these are the most, obvious in their operation. But should we, with Dr. Cullen, affirm that the same bitter, employed in the same proportion, produces both tone and atony, energy and de- bility ; that it both cures the gout and occa- sions it; that, employed for a certain time it effects the former, and, after such time, the lat- ter; and should we beyond this affirm, with him also, that the nervous energy is not the pro- duction, but an inherent power, of the brain; that it admits neither of increase nor diminu- tion ; is changeable in its state, but unchange- able in its essence; becomes excited and collapsed, or rises and falls in its energy, but experiences nothing of the decomposition or recruit of every other part of the living frame around it; we should travel into a labyrinth of incongruities, and only enlighten ourselves with a will-o'-the-wisp. Dr. Cullen's system, like himself, is a work of no ordinary stamp ; it is full of immortality, but mixed up with weak and perishable materials. Of the remedies appertaining to the one or the other of the two divisions we are now con- sidering, those of astringents and bitters, the cinchona, or Peruvian bark, which unites both qualities in itself, is on every account entitled to our first attention. This valuable medicine, which some practi- tioners are apt to despise or think lightly of in the present day, has never been altogether with- out its opponents; and there are many facts respecting its operation, which, if not altogether anomalous, are of very difficult solution. Peruvian bark, according to the authority of Don Joseph Villerobel, a Spanish physician no- ticed by Badus, was first brought to Spain in the year 1632 ; but here, as in every other country, it had for a long series of years to en- counter the prejudices of the medical profes- sion ; and consequently was very rarely made use of, and unquestionably would have sunk into oblivion but for the activity of the Spanish Jes- uits, who continued- zealously to recommend it, and to import large quantities of it from their brethren in South America. Through these means, it was at last recommended by Pope Innocent X., in 1661, as a medicine perfectly innocuous and salutary; and a Schedula Ro- mana, drawn up under the sanction of the phy- .TICA. [Cl. III.—Ord. I. sician to his holiness, pointed out, in express terms, the time and proportion in which the bark was to be taken. Unfortunately, the time stated was frigore febrili incipiente, " at the commencement of the cold fit:" and it being administered in this manner, with only tempo- rary Benefit, to the Archduke Leopold of Austria, a year or two afterward, it immediately fell into great discredit with a very large and learned part of the medical community of Europe ; and a most acrimonious warfare was instantly waged in every quarter on the subject, in which the combatants on both sides seemed more desi- rous of victory than of truth. In our own country, the bark began to be- come popular about 1655. In 1658, Mr. Un- deTwood, an alderman of the city of London, died while using it, and was instantly reported to have fallen a sacrifice to its power; and so prejudicial was the effect of this rumour, that Cromwell, who was attacked with an ague in the same year, was suffered to languish and at length to die without an exhibition of the bark, his physicians being afraid to make a trial of it, in consequence of the fatal accidents that had so lately accompanied its use : in the words of Morton (Pyretolog., p. 17), "nondum vires cor- ticis in hoc veneno subigendo, saltern hie loci, comprobatae erant." In England, therefore, as well as on the con- tinent, there was a great conflict of opinion. Dr. Prejean, who both preceded and succeeded Dr. Harvey as president of the College of Phy- sicians, appears openly to have advocated its employment in 1658, according to facts adverted to by Sir George Baker in his admirable article on intermittent fevers (Med. Trans., vol. iii., art. xiii.), from which these hints are chiefly drawn up. Dr. Brady, professor of physic at Cambridge, appears equally to have counte- nanced it; as does Dr. Willis, according to his own statement: while Dr. Morton professed himself inexperienced upon its virtues, and Dr. Sydenham was decidedly adverse to its use. Sydenham, however, was a man of reason and liberality. His prejudices, and especially those derived from the hypothesis, that a fever is a fermentation in the blood, raised by nature to throw off some peccant matter at the surface, and which ought not therefore to be checked in its course, however wise it may be to moderate it in its violence, were all at arms against the use of the bark under any circumstances : and the mischievous effects to which he had been an eyewitness in some instances, and its total inertness in more, gave a sanction to suspicion, if it did not justify hostility. But he was de- termined to watch it for a still longer period, through all its variable effects, and to abide by the result when fairly cast up. He soon became sensible that it was, in most cases, a powerful engine ; that in many instances, it was highly serviceable ; and that, in those in which it failed, the miscarriage was rather to be ascribed to some error in handling it, than to a want of power in the drug itself. Sydenham had sufficient ground for this last conclusion. The mode in which it was, at this Gen. II] ANE time, usually administered, was in doses of two drachms given twice in the twenty-four hours ; and, as already observed, the time selected for the purpose was during the existence of the parox- ysm. It is, moreover, highly probable, that it was sometimes considerably adulterated, from the dif- ficulty of obtaining it in any considerable quantity. In 1658, we learn from Sturmius, who warmly patronised its use, that pure bark was so scarce on the continent that twenty doses of the pow- per were sold at Brussels for sixty florins, for the' purpose of being sent to Paris; and that this order so completely exhausted the apothecary's stock, that he himself was incapable of obtaining any even at that price. And hence, for the use of one patient, who was attacked with an obsti- nate intermittent fever in the month of Febru- ary of the same year, he was obliged to wait till the June following before he could obtain a supply.—(Febrif. Peruv. Vindiciarum Pars prior, p. 84, Antwerp, 1659.) Nor was it less diffi- cult to be procured at Brussels than in many other parts of Europe ; for Bartholine, then re- siding at Copenhagan, having received as a great rarity a present of three doses, or six drachms, ofthe powder from some friends who had brought it from Italy, was induced to make a trial of it on a lady who had a quartan fever. Of this small portion, the first dose, or two drachms, was re- jected from the patient's stomach; and, in order to prevent a repetition of this accident, and con- sequently the loss of his entire stock, the admin- istrator macerated his two remaining doses in wine for forty hours, and gave the infusion du- ring two successive paroxysms. The only effect was, that the fever was changed from a double to a single quartan. And here the experimenter was obliged to stop, as having no more materi- als to proceed with.—-(Thoma Bartholini Hist. Anat. et Med., cent, v., hist. 1., Hafniae, 1661.) But, even in 1678, when the same pretext for sophisticating it no longer existed, Morton com- plains that the bark offered for sale was become so inert, corrupt, and adulterated, that it was necessary to increase the proportion from two drachms, to one, two, or even three ounces for a single dose. And, thus given by wholesale, we cannot wonder that still more mischief should result from its abundance than from its scarcity, whatever might be the purity or impu- rity of its quality. To guard against all the evils that seemed to accompany its use, Sydenham proposed to him- self the following regulations :— First, To be peculiarly cautious in the quality of the bark he employed; and to allow of no intermixture, whether from fraud or a view of increasing its virtue. , Secondly, To administer the bark in the in- tervals, instead of in the paroxysms of a fever. Thirdly, To giye it after the rate of two scru- ples every four hours, instead of two drachms twice a day, after the Schedula Romana. Under these regulations, the bark seems to have acquired all the success to which it has at any time pretended; and modern practice has added little to their value. The most important of them is that which TUS. 361 effected a change in the period of exhibiting the bark. But, whether the merit of first suggesting this improvement be due to Sydenham, or to some contemporary of his, we cannot at present very accurately determine. He is, indeed, the only person who openly lays a claim to it, and asserts that he was led to this alteration after deeply pondering the subject—diu multumque apud se agebat: yet Morton, who published his Pyretologia in 1692, only three years after the death of Sydenham, asserts, somewhat loosely indeed, that, during twenty or five-and-twenty years (Pa. 114, 132), he had been in the habit of giving this antidote, as he calls it, in every season of the year, and to persons of all ages and constitutions ; that he had cured every spe- cies of intermittent with it quickly and radically, and had found it more expedient to give it in the intervals than in the fits. While Lister, who was contemporary with botji Sydenham and Morton, and who treats neither of them with respect, directly aqcuses Sydenham, a few years after his death, of having copied his mode of giving the bark from the miserable mountebank Talbor, who was its inventor,—auctoresuo, misero illo, agyrta, Talbor.—(Octo Exercitat io- nes Mcdicinales de Cort. Peruv. exhibendi tempo- re.) Talbor, or Tabor, however, is scarcely open to the stigma of being a mountebank. He con- cealed, indeed, his preparation of the bark, but he had been regularly initiated into a knowledge of medicine by an apprenticeship to an apothecary at Cambridge ; was the most successful, and, therefore, the most popular employer of the bark in his day ; acquired a higher reputation in this line of practice than any other individual what- ever ; was appointed one of the physicians to Charles II., against all the influence of the col- lege ; was specially sent for to Paris to take the Dauphin under his care ; succeeded in curing him, and afterward divulged his arcanum, for a stipu- lated sum, to Louis XIV., by which it was found to be an infusion of the powder of bark in port wine as a cordial. The best foTm of administering it used to be considered its powder, " potissima virtus in toto jacet," says Professor Frank. But it is often found that the stomach will not bear it in this form ; and hence, modern chymistry has been at work to provide various others, the best of which appear to be those which consist of its essential principle, now sufficiently ascertained to be a peculiar bitter alkali, separated from the woody fibre, and neutralized into a salt by means of sulphuric acid. The French chymists have put us into possession of two distinct salts of this kind—quinine and cinchonine, of which the former is the more powerful, and both ap- pear to have been employed with great success in the removal of intermittent fevers, in cases where the stomach has uniformly rejected both the gross powder and the decoction.—(De Cur. Horn. Morb. Epit., torn, i., p. 64.) The dose of the first, for an adult, may vary from two to five grains and half a scruple, and still more has been given without ill effects : of the sec- ond, the dose may be from ten grains to half a drachm. The ordinary ill effects from an over- 362 H^MATICA. [Cl. III.—Ord. I. dose are, nausea, headache, and vomiting.— (Magendie Formulaire pour la Prip. et I'Em. de plus. Midic, p. 49, Paris, 1822.) [It is related by M. Andral that, in some cases of ter- tian ague, M. Lerminier gave between 16 and 17 grains of the sulphate the first day of the treatment. The fever was arrested, and no unpleasant symptom followed. In some other individuals, similarly affected, this medicine, in the dose of only a few grains, produced violent palpitations, oppression, globus hystericus, gid- diness, and fugitive pains in the chest and ab- domen. This he imputes to idiosyncrasy.— (Clinique Midicale, torn, i., p. 488.) But, as Dr. Elliotson observes, quantities that can dis- agree are not required : five grains of the sul- phate, every six hours, is the largest dose that can be jiecessary, at least in this climate ; for, from the reports of Professor Speranza, doses of 12, 24, and 30 grains are common in Italy; and, in one case, 108 grains were given as a dose, before the fever was arrested. The me- dium dose prescribed by Dr. Perrine, of Adams county, in America, is eight grains every hour.— (Edinb. Med. Journ.,.No. xciv., p. 218.) Many cases of intermittent fever in England have been cured with three, two, or even one grain, every six hours.—(Elliotson in Med. Chir. Trans., vol. xii., p. 56.) Every case of ague which the editor has met with in the prisons of the King's Bench and Fleet has yielded to doses of two grains. Dr. Elliotson has also tried the simple quinine, the tonic properties of which he considers as corresponding to those of the sulphate. It never disordered the stom- ach, though given in doses of ten grains every six hours. One fact, adverted to by the same physician, is important, namely, that the fore- going medicines cure cases of intermittent fever which resist bark, even when retained in the stomach and freely administered. In a later communication on this subject, Dr. Elliotson mentions having attended nearly 150 cases of ague, and treated all with the sulphate of qui- nine. Many were combined with so much in- flammation in the abdomen, chest, or head, that venesection was necessary ; some with dropsy, and others with chronic diseases of the lungs or liver; but, every one was cured. Having never found the sulphate of quinine augment inflammation, or interfere with antiphlogistic measures, he has always given it under all cir- cumstances, and adopted with it any other measures required by the symptoms. Some cases, generally quartans, would not yield to less than five grains every four hours ; but this quantity never failed, after being exhibited a week or ten days.* In London, he finds that * In February, 1829, Dr. Elliotson had a patient labouring under quartan ague, which did hot yield to less than 45 grains in the 24 hours. He thought this a very considerable quantity ; but, on his re- turn from the continent in the ensuing October, he found a patient in the hospital, who was taking, by direction of Dr. Roots, a scruple every eight hours, with ten minims of liquor arsenicalis. The case, which was a quartan ague, did not yield to such doses until they were given every four hours, the disease may be generally arrested immedi- ately by the exhibition of ten grains at once, just before or after the paroxysm. Dr. Home, he remarks, found the bark much more suc- cessful after, than before the paroxysm ; and this, also, is his own experience with quinine. He is convinced that the best practice is, first to give ten grains, as soon as the paroxysm is over. Excepting in quartans, this almost al- ways prevents the paroxysm next expected, and, if repeated daily at the same hour, often cures the disease. But, he says, it is some- times necessary, in addition to these ten grains after the fit, to' give small doses every six or eight hours, so as to make the whole quantity in twenty-four hours amount to a scruple or half a drachm.—(Elliotson in Medic. Chirurg. Transac, vol. xiii., p. 464.) From what has been said, it would appear that, the quantity of quinine and cinchonine contained in any one kind of cinchona, is the test of the comparative virtue of the different species ; that the absence of these alkalis in vegetables which have been proposed as substitutes for cinchona, shows their difference, and accounts for their inferior effi- cacy ; while others, in which these alkalis are found, may supplant the cinchona. Thus, the experiments made by MM. Robiquet and Pe- troz prove the existence of an alkali analogous to quinine in the bark of carapa, which has been known in America to cure agues, though they had defied the power of cinchona.—(Quar- terly Journal of For. Med., vol. iv., p. 68.) From the investigations of M. de Martin (Rev. Mid., Septembre, 1827), it appears, that when the sulphate of quinine is finely pulver- ized, mixed with cerate, and then applied to a blistered surface, it is soon absorbed, and thus a cure of intermittents may be performed ; a fact worth remembering in examples where the stomach is very irritable.*] It ought to be known, that one of the best preparations for a successful use of the bark, is calomel in small doses, particularly in inter- mittent fevers. " I have known," says Dr. Baillie, " a good many cases in which bark alone would not cure an ague. In all of these cases, as far as I now recollect, whon a grain of cal- omel was given every night for eight or ten and then the disorder immediately ceased.—(Lec- tures, &.c, Med. Gaz. for 1832, p. 4.) No general rule can be laid down respecting the quantity of sulphate of quinine which may be required.—Ed. * Many persons when taking bark experience nausea, or even vomiting and purging; " and, in all such cases, a few drops of tincture of opium will frequently enable the stomach and intestines to bear it. If it be only the stomach that is dis- turbed, an effervescing draught will answer the purpose, and so will prussic acid. In the case of children, bark may be given in the form of clys- ters, and some persons have been cured, it is said, by its external application, by having it tied in fine muslin or linen, on different parts of the body. I recollect hearing Sir Henry Halford say, that, when he was a child, he had ague, of which he was cured by wearing a jacket of bark. A double jacket was filled with powdered bark, and put next his skin."—Professor Elliotson's Lectures at the London University.—Ed. Gen. II.] ANETUS. 363 nights, bark cured the ague in the course of a few days. This practice I learned from my friend Dr. David Pitcairn."*" But as, under whatever form, in whatever quantity, and at whatever time the bark is given, it is not found to be a specific, not only in every individual, but in every intermittent, we are again driven to a principle I have already ven- tured to lay down, that intermittents of all kinds are occasionally influenced in their character by idiosyncrasies, or the temperament of the at- mosphere. And it is hence of considerable importance to know what other medicines have the strongest claim to attention, when, from accidental circumstances, the best fails of its common effect. This, as we have already had occasion to observe, was the case in the singular intermit- tents that prevailed both in this metropolis and in the country in the year 1787, in which the bark seemed to have no energy whatever, not- withstanding that its genuineness was suffi- ciently tested and proved ; in consequence of which the febrifuge powers of various other medicines were attentively studied and appre- ciated. In some instances other medicines were mixed with bark, and seemed to a certain extent to call forth its proper power ; a mixture of bark and alum answered in some cases, but produced disappointment in others. " The crude sal ammoniac," says Dr. Petrie, who was physician to the hospital at Lincoln, "had not a more certain effect. Several women were cured in a hospital by what is called the Dutch remedy for an ague ; which is compounded of the bark and cream of tartar, each two ounces, and sixty cloves powdered. A drachm and a half of this powder was taken every third hour. Yet this likewise frequently failed. We at last thought that we had fallen on a specific in the powder of bayleaves, plucked from the tree and dried in the shade. From one to two scruples of it were given in the beginning of the cold fit. This powder was very efficacious in preventing the fits in many cases, where the bark, in the largest quantity, had been unsuccessful. But almost all who used it had a relapse in the space of a fortnight, three weeks, or a month. One patient, just at the time the fit was expected, took sixty drops of thebaic tincture. On this he fell into a profound sleep, sweated profusely, and escaped the fever, not only then, but at two successive periods. Eight quartans in the hos- pital, and four in private practice, were entirely cured by one drachm of the theriaca androm- achi, the same of the root of calamus aromat- icus in powder, and fifteen grains of salt of tartar. This mixture was taken in warm ale or wine and water, an hour or two before the fit. Nevertheless" I must confess, that I met with several cases where no medicine prevailed; and many patients, despairing of relief, left themselves to nature ; some of whom went into a pulmonary consumption, jaundice, or dropsy. Many, whom I thought cured of quartans, lately * Lect. and Observations on Medicine, by the late Matthew Baillie, M. D., 1825. Unpublished. relapsed. I have now on the hospital books four patients, ill of quartan fevers, who have received no benefit; and I have no hope left, but in a long course of deobstruent bitters, and tinctura sacra, aided by the approaching sum- mer."—(Med. Trans., vol. iii., p. 165.) Morton's medicine, of one scruple of cham- omile flowers, ten grains of salt of wormwood, and the same quantity of calx of antimony, given every sixth hour, is said to have subdued, in the metropolis, an obstinate tertian in two instances. And Dr. Heberden found, that two drachms of the powder of myrrh, taken just before the time of the expected fit, relieved a patient from an ague, which for a long time had resisted the power of the bark, though taken in very large quantities. The red-bark was now also tried for the first time : it was proved to be of unquestionably superior virtue to that in common use ; but even a moderate dose of it so often oppressed the stomach and excited nausea and vomiting, per- haps produced by its containing a larger propor- tion of resin, that, writing at this very period, Sir George Baker tells us, " I have for some time avoided the use of it." It contains, how- ever, by far the largest proportion of quinine, and is now usually selected for this purpose. In the east a variety of other astringent and bitter barks are also employed both by native and European practitioners, and apparently with considerable advantage; as that called, in hon- our of Van Swieten, Swietenia febrifuga, so warmly recommended by Dr. Roxburgh: that of the bead-tea (Melia Azedarach), and the Tellicherry bark. All these have been now tried in Europe, but with a far less success than in India. Arsenic was also tried, in combination with opium. It is admitted that it often effected a cure ; but was frequently productive of violent vomitings, colic, and dysentery. It seems, however, to have been given at this period in a somewhat rude and unscientific form. " Arse- nic," says the distinguished writer whom I have just cited, " is mentioned in books as a febri- fuge, but it is one of those substances of which we are not as yet so far masters, as to be able, by any art, to render it transferable from the list of poisons to our Materia Medica ; and it cannot be deemed to be a proper remedy for an intermittent fever, while an intermittent fever is less formidable than arsenic." But to this substance we shall have to return presently. The chi^f bitters and astringents that have been called into requisition, independently of those already noticed, are, gentian, casca- rilla, willow-bark, nux vomica, and the leaves of the cherrybay, or Prunus lauro-cerasus; the chief astringents, tormentil, galls, and oak-bark ; the bark of both species of the swi- etenia or mahogany-tree; avens or caryophyllata (the Geum urbanum, Linn.), the Lycopus Eu- ropaus of the same naturalist, called in Pied- mont, where it is supposed to rival the bark, herb China, alum, and several of the metallic oxydes* To all these .a common remark may be ap- plied, that, where they have been of real ser 384 H^EMA vice, it has generally, though not in every in- stance, seemed to arise from their uniting the two qualities of a bitter and an astringent, and that they have rarely answered where there has been only one of these qualities to depend upon. Thus tormentil, one of the most powerful vege- table astringents we possess, and gentian, one of our most powerful vegetable bitters, succeed so rarely alone, that no dependance is to be placed upon them; but when given in combi- nation, they almost rival the virtue of cinchona, and have occasionally succeeded where the latter has failed.' "Joined," says Dr. Cullen, " with galls or tormentil, in equal parts, and given in sufficient quantity, gentian has not failed in any intermittents of this country in which I have tried it."—(Mat. Med., part ii., ch. ii., p. 72.) There is, however, a principle, independently of bitterness and astringency, that seems abso- lutely necessary to enter into conjunction with these, in order to give full efficacy to ahy medi- cine employed as a febrifuge in intermittents ; and a principle that has hitherto eluded all re- search ; [unless it be analogous to that of qui- nine, a principle similar to which has been de- tected in other barks besides the Peruvian.] If the cure depended upon the intensity of a bitter and an astringent quality alone, galls, oak-bark, and mahogany-bark ought to succeed better, not only than a union of tormentil and gentian, or chamomile and alum-, which have also been found very serviceable, but than cinchona it- self ; which every one knows they do not; al- though, when Peruvian bark cannot be obtained, they become desirable substitutes. The nux vomica and Ignatius's bean (Strych- nos nux vomica, and Ignatia amara, Linn.) combine, with an intense bitter, a most active narcotic virtue ; and how far the last may be peculiarly opposed to a recurrence of that spasm on the extreme vessels which consti- tutes the cold fit, it is difficult to determine. M. Bourieu (Hist, de la Soc. R. de Mid., 1776, p. 340) from his own practice strongly recom- mends the latter, and Paulliui (Cent, iii., obs. 45), and Aaskow (Ant. Societ. Med. Hafn., torn, ii.) the former. If Dr. Fouquier's re- mark be well founded, which we shall have oc- casion to notice more at large when treating of paralysis, that these poisons have a power of augmenting energy in debilitated muscular fibres, while they leave those in health unaf- fected, we can account for some part of the success which has been so vauntingly ascribed to them in the case of intermittents. But, notwithstanding that they have been for this purpose before the public for upwards of a cen- tury, the infrequency of their use is a strong argument that they are not much entitled to commendation. " In a very small dose," says Dr. Cullen (Mat. Med., part ii., ch. ii., p. 76), " the faba Sancti Ignatii has the effect of curing intermittent fevers." But whether he reports this from his own practice, or from that of others, we cannot exactly determine : nor does he tell us what is the small dose he refers to. I have tried the nux vomica to the extent /TICA. [Cl. Ill—Ord. I of eight grains in powder every six hours foi an adult under palsy, without any mischievous effect except a slight stupor in the head. And much beyond this we cannot proceed with pru- dence. Hoffmann (Philos.. Corp. Hum. Morb:, p. ii., cap. viii.) gives the case of a girl of ten years of age, who was killed by taking fifteen grains of it, divided into two doses, for an ob- stinate quartan. The lauro-cerasus was at one time, as we are told by Dr. Brown Langrish, a common medicine in his neighbourhood for the cure of agues (Experiments on Brutes; see also Phil. Trans., No. 418, 420), but he takes no notice of the dose or mode of administering it. Its properties are nearly the same as those of bitter almonds; and Dr. Bergius frequently prescribed an emulsion of bitter almonds with success in intermittents, in the quantity of a pint or two daily during the intermission ; and it sometimes cured where the bark failed.—(Mat. Med., p. 412.) This is an authority worth attending to ; and as the same medicines are said to have a peculiar power of resolving visceral obstruc- tions, they have an additional claim to a cau- tious series of experiments. It is known in the present day, that their poisonous property de- pends upon their containing a portion of native prussic acid [and consequently the latter would now generally be prescribed by those who desire to ascertain its power over ague]. The only metallic oxyde really worthy of no- tice is that of arsenic ; for although various oxydes of iron, mercury, zinc, and copper, have been tried, and occasionally extolled, none of them have proved so decidedly beneficial as to render it worth while to try them over, again. Mercury, as we learn from Sir James John- son, was tried extensively some years ago at the Bocca Tigris in the east, on the crews of two ships-of-war, the Grampus and Caroline, in consequence of the stock of bark being ex- hausted. The paroxysms, he tells us, were in- variably put a stop to as soon as the system was saturated; but he adds, that three fourths of the patients thus treated, relapsed as soon as the effects of the mercury had worn off; and this after three, and, in a few instances, four successive administrations, so as to excite ptyalism.—(Amer. Med. Repository, July,1822.) Iron, though of little value in most of its forms, has been said of late to have succeeded completely in that of its prussiate. Dr. Zol- lickoffer has given various instances of this in a foreign journal, and places its powers above those of arsenic or bark. It must be tried, however, upon a much larger scale before it is entitled to an established reputation. The ordinary adult dose is about four grains, two or three times a day, in a little sugar and water. Arsenic, under various forms, has been em- ployed from a very early period.—(Act. Med. BeroL, dec. i., torn, iii.) It is, strictly speak- ing, an oriental medicine, and has been in vogue immemorially in India, and indeed all over the east, but especially among the Tamul practi- tioners, as a most powerful alterant, as we shall have occasion to notice more at large when Gen. IL] ANETUS. 365 treating of syphilis and elephantiasis. It was probably introduced into European practice by the medical students under the brilliant cali- phate of Bagdad ; and seems to have been first appropriated to the cure of intermittents by the Jewish physicians of Poland.—(Gilbert, Adver- sar. Pract. Prim.; Slevogt, Pr. de Permissione Prohib. et Prohibitione Permiss., Jen., 1700.) Ih Sir George Baker's time, we have seen that it was in extensive use, but productive of such veiy different results, tbat, however successful it might prove occasionally, this distinguished pathologist thought it a worse evil than any ague whatever. At that period, however, it does not appear to have been tried in its most commodious forms, which are those of an ar- senite or arseniate of potash. M. Macquer recommends the latter; Dr. Fowler, many years ago, introduced and gave abundant proof of the utility and general commodiousness of the former ; and, under this modification, it has at length found its way into the Pharmacopoeia of the London College, under the name of liquor arsenicalis. Sir Gilbert Blane tells us, that it was used with great success in our unfor- tunate expedition to Walcheren, where the stomach could not retain the bark: but was combined with opium, and, in most cases, with bitters and aromatics.—(Select Dissertations, &c, p. 105, Lond., 8vo., 1822.) The cases of success from the use of this medicine are so numerous, and its employment is now become so general, as to render it un- necessary to advert to particular authorities in proof of its febrifuge power. With many con- stitutions there can be no question that it disa- grees very considerably ; and there are numer- ous instances of its failure : but it is a medicine of real and inappreciable value in many diseases, and in none more than in intermitting fevers. Dr. Fowler advises it to be taken in doses of from two to twelve drops, according to the age and strength of the patient, once, twice, or oftener, in the course of the day: and the di- rections are so broad, and at the same time so much within limit, that no actual harm can occur from following them literally. It will, however, often be found advantageous to com- bine a few drops of tincture of opium with each dose, to guard against the vomiting and griping which it is sometimes apt to excite ; and the bowels should be kept open by warm aperients during its use. Under the French Directory a similar preparation of arsenic formed a part of the political constitution of the day; for an edict was formally published, commanding that the surgeons of the army of Italy should, with- in the course of two or three days, cure the vast number of soldiers suffering from agues caught in the marshes of Lombardy, by the use of this medicine, under pain of military punish- ment.* It is a singular fact, and ought not to be * It is best to begin with two or three drops of the liquor arsenicalis, two or three times a day, and to increase the dose by degrees. As Dr. El- liotson suggests, this medicine should not be given on an empty stomach.—Ed. passed by without notice, that since the estab- lishment of the large copper-works which are now carrying on in Cornwall, the intermitting fevers which used to be almost constantly pres- ent in the neighbouring marshes, are now rarely to be met with in any shape. It should hence seem, that the atmosphere is armed with a specific by becoming impregnated with metallic oxydes or carbonates ; and that Cornwall should be the spot recommended for change of air in many cases of chronic or other obstinate inter- mittents. The result of this general survey is, that the cinchona (including its preparations, quinine and sulphate of quinine) offers by far the best remedy for intermittents of eveiy kind ; that arsenic is its best substitute ; and that, where these fail, as fail they will occasionally, or if particular circumstances should prohibit their use, we must throw ourselves upon such other medi- cines as unite intrinsically, or by combination, a bitter and an astringent principle with a cer- tain proportion of aroma or stimulant warmth.* It is at the same time clear, that a bitter and astringent principle are not the only, nor even the most effectual qualities, for the cure of an intermittent; for the arsenical preparations con- tain neither of these in any prominent degree ; while, as already observed, there are many medicines that possess them in far greater abundance than the bark, which have no claim * Quinine is given so extensively by American practitioners, that little need be said to recommend it to more general use. When employed with prudence, it rarely produces any bad effects, not even in intermittents attended with local determi- nation. It enjoys a supremacy over every article in the materia medica, and seems entirely free from the objections urged to bark. Dr. Eberle, however, remarks (Pract. of Med., vol. i.)," in cases of ague which from long continuance or from some previous malady, are attended with visceral indurations or enlargements, the quinine or bark must be given either after a gentle mercurial course, or in conjunction with mercurial remedies. The blue mass will in general answer best for this purpose, as it is mild, and less apt to pass off by the bowels than calomel." Arsenic must be considered as the most valuable of the minerals for the cure of intermittents. Dr. Mann observes (Medical Sketches), that it succeeded like a charm; and his remarks might be confirmed by quotations from many other medical writers of repute; but it sometimes leads to anasarcous effusions, and even paralysis has been remarked by Currie and others. —(Hosack and Francis' Med. and Phil. Register, vol. ii., p. 36.) According to Dr. Firth, the sulphate of zinc has cured intermittents when the bark and arsenic have failed.—(New-York Med. Rep., vol. x., p. 145.) And Eberle says of it, "I have very rarely failed to arrest the disease as promptly with it as with quinine."—(Pract. of Med., vol. i., p. 81.) The list of vegetable substances employed by American practitioners for the cure of intermit- tent fever is very great.—See Bigelow's Medical Botany, Barton's Collection towards a Materia Medica, Chapman's Therapeutics, Bigelow's Se- quel, &c. Among the remedies in popular use, the strong decoction of coffee deserves notice ; the coffee in powder is highly recommended by some German practitioners.—D. 366 H^M to be put in competition with it as a febrifuge. In effect, of the three species of cinchona used officinally in the present day, the lance-leaved, pale or quilled bark (c. lancifolia), heart-leaved or yellow bark (c. cordifolia), and oblong-leaved or red bark (c. oblongifolia), the yellow, which, as we learn from Mutis and Zea, is the genuine febrifuge of Spanish America, and whose supe- riority to the rest has been abundantly proved in this country as well as on the continent of Europe, is very considerably less bitter and astringent than the red, and not more so than the pale bark : it has less resin than the first, and less gum than the second. Dr. Cullen preferred the red, but Zea's communications upon the subject (Annal. de Hist. Nat., torn, ii., Madrid, 1800) were not then published ; and Cullen was not in possession of the experi- ments by which the statement of the latter has been confirmed. Sir George Baker, as already noticed, found the red bark produce so much oppression and nausea, that he was obliged to discontinue its use. It affords, however, the largest portion of quinine. In administering the bark, little needs to be added to the rules laid down by Sydenham, and copied in a preceding page. Dr. Home has sufficiently shown, not only that the best time for commencing the medicine is soon after the paroxysm, but that it should be discontinued some time before a recurrence of the cold fit, since, if persevered in till its accession, this fit is almost uniformly rendered more violent.— (Clinical Experiments, 8vo., Edin., 1780.) If in the proportion of half a drachm or two scruples to a dose, as recommended by Dr. Sy- denham, or such other quantity as may sit without uneasiness on the stomach, it should not succeed, it should be tried in combination with some aro- matic, or omitted altogether ; and by no means be increased to the enormous quantities some practitioners have ventured upon, who seem to have conceived that they could force the system to yield to its powers, by the overbearing arms of weight and measure. It is singular that Bor- sieri should have so far lost sight of moderation, as to have prescribed occasionally from four to six drachms of the powder in a single draught. In the extremity of the yellow fever such doses have, indeed, been given, and perhaps with advantage ; but opium and old port, in large abundance, have been given at the same time. It will also be judicious to abstain from the use of bark in every instance in which any of the abdominal viscera appear to be labouring under parabysmic enlargements, whether ante- cedently to its employment or during its use ; and, in these cases, to alternate small doses of calomel with whatever tonic may be found to agree best with the system. [Yet, as the editor has already stated, the experience of Dr. El- liotson proves, that the sulphate of quinine may be given beneficially, whether such en- largements be present or not: it has no power of preventing the cure of inflammation, nor does it interfere with antiphlogistic means.] Among the endemic intermittents of the pres- LTICA. [Cl.IH—Ord. I- ent day particularly worthy of notice, are those in the neighbourhood of Rome, and especially about the Pontine marshes, which have often been drained to carry off the decomposing ani- mal and vegetable materials that spread their aria cattiva, as it is called, over the whole of the Campagna. The disease hence produced is named, from its source, malaria. It is also found in like situations, and has the same name, about Syracuse, and other parts of Sicily. M. Rigaud de l'lsle has asserted, that the miasmic particles which infect the air in these places, are heavier than the air in its loftier and lighter strata, and may be separated from it. He has found an elevation of 300 yards, at the Pontine marshes themselves, a complete security from infection ; and he proposes for those who re- side lower to sift the air which they breathe, by wearing a fine silk gauze over the mouth and nostrils.—(Mim. de I'Institut. Roy ale de France, March 24, 1817.) M. Brocchi has successfully employed the same remedy, and hence recom- mends sleeping under a fine moscheto-net in all places where intermittents are endemic.—(Dello Stato fisico del Suolo di Roma, &e., Di G. Brocchi.) GENUS III. EPANETUS. REMITTENT FEVER. SYMPTOMS STRIKINGLY EXACERBATING AND RE- MITTING, BUT WITHOUT INTERMISSION ; ONE PAROXYSM EVERY TWENTY-FOUR HOURS. This genus offers the three following spe- cies, which will be found sufficiently distin- guished from each other by their specific char- acters : 1. Epanetus Mitis. Mild Remittent. 2.---------Malignus. Malignant Remittent. 3.---------Hectica. Hectic Fever. In the last, the remission is perhaps more per- fect than in either of the others : and it serves to show how little foundation there is for refer- ring all remittent as well as all intermittent fe- vers to the individual cause of marsh miasm ; for it would be difficult, though, perhaps, not impossible, to find a single example of a genuine hectic originating from this source.* Marsh * The possibility of hectic fever arising from marsh miasm is a suspicion that may be dis- pensed with, as it is entirely destitute of founda- tion. There may be hectic fever in consequence of visceral disease, that has originated during an ague, and has not yet been cured ; but as for ma- laria being ever itself the cause of hectic, the opinion is groundless. Perhaps, with the excep- tion of remissions, hectic fever has no analogy whatsoever to what is commonly implied by re- mittent fever. As a judicious writer has ob- served, " remittent fever may be considered as holding a middle rank, as to external character, between intermittent and continued fevers ; but, with respect to its nature, the localities in which it chiefly prevails, and the cause whence it prin- cipally, if not solely arises, it bears a closer af- finity to the former than the latter. It may be re- garded more properly as forming the mean degree Gen. III.—Spe. 1.] EPANETUS MIT1S. 367 miasm, however, is the most common cause of the second, perhaps of the first species ; though we shall presently find it probable that even here, and particularly in the second species, hu- man contagion has also occasionally proved a cause, as it assuredly has in those cases of hectic fever, produced by perpetually attending upon, or sleeping with a consumptive patient. SPECIES I. EPANETUS MITIS. MILD REMITTENT. PULSE REGULAR,THOUGH FREQUENT; DEBILITY SLIGHT ; REMISSION DISTINGUISHED BY SWEAT- ING, OR A CLOUD IN THE URINE. This species occurs most frequently among persons of relaxed fibres, debilitated habits, and sedentary occupations ; and is usually preceded by an irregular action of the alvine canal, flatu- lence, abdominal tension, dyspepsy, or some other affection of the viscera of the lower belly ; and is hence called by Professor Frank, as well in the ensuing as in the present species, gastric fever (De Cur. Morb. Horn. Epit., tom. i., Y 50, 99, 8vo.,Mannh., 1792), intermittent, remittent, or continued, according to the type it assumes. It occurs at all seasons of the year, but more fre- quently in the autumn; the ordinary tempera- ment of the season uniting with the patient's infirm state of health, and thus adding an ex- citing to a predisponent cause. Fatigue, cold, or long exposure to the rays of the sun, are also, at this time, powerful concomitants, and quicken the appearance of the disease.* in the scale of periodic or marsh fevers, of which intermittent and yellow fever constitute the ex- treme points. A more intense operation of the febrific cause than is required for the production of intermittent fever engenders remittent, and the more violent the latter, the more remote is its character from that of intermittent; or, in other words, the less perceptible the remissions. That a more powerful action of the morbific cause is demanded for the production of remittent fever, is indicated by the circumstance, that when periodic fevers are prevailing in certain countries, the per- manent residents are often observed to have the disease in the form of ague only, and the mor- tality among them is small; but strangers unha- bituated to the climate and its diseases, suffer from remittents, with a proportionably greater loss of life. In more sickly seasons, remittents will be the prevailing form among both classes of per- sons ; but strangers are more violently affected, and the mortality among them is greater. Its affinity to intermittents is shown, too, by the tendency which it has to pass into that form, and inversely, by the proclivity of ague to as- sume the remitting type."—(Dr. Joseph Brown, in Cyclop, of Pract. Med., art. Fever.) From such facts and reflections an argument might easily be deduced, which would shake very much the hypothesis of malaria, or marsh miasm, and the contagious principle of human effluvia, being capable of exciting similar fevers.—Ed. * Here no reference is made to the commonly re- ceived doctrine, that ordinary remittent fevers spring from the influence of marsh miasm, or mala- ria. Thus, as Dr. J. Brown has stated, remittent is The patient complains of drowsiness, and feels languid; is occasionally chilly, and after- ward flushed, but without perspiration ; for the skin is hot and dry, the thirst considerable, commonly with nausea and a total loss of appe- tite. In the course of the day, but usually to- wards the evening, the pulse quickens, the heat increases, and at length terminates in a sweat, which, however, is sometimes only partial, rarely free and copious, and never critical; for, on its ceasing, the skin is still dry and heated, and the pulse accelerated. Sometimes the ex- acerbation occurs about noon, and sometimes in the middle of the night. If the disease be left to itself, the symptoms augment in severity daily ; the head occasion- ally, but more generally the liver, or^ome other abdominal viscus, gives proof of being loaded and oppressed, and the restlessness is intolera- ble ; or a sudden cholera supervenes, and car- ries off the complaint by a salutary crisis. This species seems to be primarily dependant upon torpitude, or obstruction in some one or more of the chylopoetic organs, and generally yields to a course of active purgatives, among which calomel ought to take the lead. These should be repeated two or three times a week, and the intervals be filled up with mild, diapho- retics. The pulse will generally be found from ninety to a hundred strokes in a minute ; but, as soon as it sinks below this, and the heat and dryness of the skin have yielded to a general softness, columbo alone, or combined with sul- phuric acid, will easily complete the cure; though the disease not unfrequently runs on for ten days or a fortnight.* THE REMITTENT FEVER QF INFANCY, which is generally ascribed to worms, does not essen- tially differ from the present, regard being had to the greater irritability in early life. Worms, there can be no doubt, are sometimes the cause of this infantile fever, but perhaps rarely ; and there is no instance on record of their having been traced in the bodies of those who have fallen victims to it. Dr. Hunter expressly de- clares, that he has often searched in vain. The ordinary cause is crude accumulations in the first passages, whence the digestion proceeds imperfectly; there is great general irritation, with considerable languor: the belly becomes tumid and often full of pain; the food is nau- the endemial fever of warm climates; but it is also met with in temperate regions, and in our own country, especially in seasons of unusual heat, and in those parts of it where, under ordinary tem- peratures, agues are prevalent.—Cyclop, of Pract. Med., art. Fever.—Ed. * Prescribe six grains of calomel, which are to be followed by an active cathartic, and a mixture composed of four grains of tartarized antimony and eight ounces ofcamphire mixture, three table- spoonsful of which are to be given every fifth hour. As soon as the tongue becomes clean, the skin natural, and some impression is made on the disease,* the fourth part of the following mild aperient mixture, given three times a day, will complete the cure :—R. Magn. sulph. 3yj, infus. gentians comp. §vj, acid, sulph. dil. 3]; ft. mist. 3G8 H^MATICA. [Cl. III.—Ord. T. seated : the head is hot, heavy, and often coma- tose ; as though there were water in the ven- tricles, which is sometimes suspected, though without foundation: the skin is pale or livid, with occasional flushes in the cheeks. It is a singular fact, that, if the exacerbation or in- crease of fever take place in the night, there is wakefulness and perpetual jactitation ; if in the daytime, drowsiness and stupor.* Dr. Butter recommends as an aperient, small doses of neutral salts, and, when the bowels have been opened, nitrate of potash; or, if there be considerable irritation, the extract of hemlock. Generally speaking, however, there is such a sluggishness in the peristaltic action of the bowels, as well as in the intestinal se- cernents, tfcat neutral salts will not answer the purpose ; and, in consequence, rather add to the irritation than carry it off. And hence, much stronger purgatives should be employed from the first; as calomel, resin of jalap, or gam- boge dissolved in milk; and it may be safely prognosticated, that, till this plan is had re- course to, the disease will in most instances maintain its ground, if it da not make a fearful advance.t But with a course of brisk cathar- tics, in conjunction with perfect quiet, good ventilation, and light nutritive food, it will usually give way in a week or fortnight.} * " By infantile remittent fever is now commonly understood a species of fever to which children from one year old, up to ten or twelve, are very subject, characterized by one or more daily exa- cerbations and remissions, by pain of the belly, and sometimes'also of the head, and by an unnatural state of the alvine discharges."—Dr. Joy, Cyclop. of Pract. Med., art. Fever. t In this insidious and often fatal form of dis- ease, the first indication is to remove all causes of irritation, and to unlock the intestinal and cuta- neous secretions. For this purpose, to the means mentioned above may be added the employment of small doses of ipecacuanha, alone or combined with rhubarb;- say one or two grains of the former, with some three or four of the latter, administered once or twice a day for a few days, according to the exigencies of the case; the neu- tral salts will also be found useful. In a form of this complaint, the late Dr. Ed. Miller, of New- York (Medical Writings, N. York, 1824), recom- mended small doses of calomel combined with opium; this practice may often be useful where cerebral determination and vascular fulness are absent.—D. } In France, infantile remittent fever is treated as a species of gastro-enteritis. That the secre- tions from the mucous surface of the alimentary canal are in a depraved state, is a fact generally admitted ; but whether in consequence of inflam- mation, is aidisputed point. Dr. Joy expresses his belief, that medicines which slightly increase and modify those secretions, will usually be attended with more success than the sole employment of directly antiphlogistic measures. — (Cyclop, of Pract. Med., art. Fever.) In very obstinate case3, Dr. Hamilton combined calomel with opium and antimony. On the other hand, Dr. Clarke, after the exhibition of an emetic|>and one or two active purgatives, prescribes bark. The editor has seen, in the public services with which he has been connected, many cases of this fever ; and the practice which he has the most favourable SPECIES II. EPANETUS MALIGNUS. MALIGNANT REMITTENT. PULSE SMALL, HURRIED, IRREGULAR ; DEBILITY EXTREME J OFTEN WITH SIGNS OF PUTRES- CENCE. Extreme debility may be inferred from the symptoms of great weakness and irregularity of the voluntary motions; weakness of sensa- tion ; weakness and wandering of the mind ; weakness of the pulse and of respiration ; cold- ness and shrinking of the extremities, and a tendency to faint in an erect posture ; nausea, vomiting, and a total disinclination to nourish- ment ; difficult deglutition, depending upon an atony of the muscles of the fauces ; involuntary excretions, depending upon an atony or paresis of the sphincters. A putrescent state of the fluids may be de- termined from the following symptoms :—pulse quick and tremulous ; heat of the surface sharp and pungent, giving to the finger a peculiar tingling for some minutes afterward ; the skin parched, or soaked with sordid, fetid sweat; the smell offensive to a considerable distance ; the breath hot and fetid ; the mouth aphthous; the tongue clammy, fetid, livid, greenish-black; the lips swollen, puckered, cracked, and purple ; the urine brown or blackish, and offensive ; black discharge, often in profuse quantity, from the stomaph ; the stools blackish, colliquative, very offensive, parted with profusely and in- sensibly ; the mind wandering ; twitching of the tendons ; swelling and tension of the belly ; petechial spots, vibices, and hemorrhages from different parts, without proofs of increased im- petus.* This species may be traced under four va- rieties, each sufficiently marked by its own symptoms :— a Autumnalis. Autumnal Remittent. 0 Flavus. Yellow Fever. y Ardens. Burning Remittent. S Asthenicus. Asthenic Remittent. The autumnal remittent is that which so frequently shows itself in our own country, in the season from which it derives its name, with a strong tendency to assume the tertian or double tertian type: or, in other words, with striking exacerbations every other day, or, where the double tertian is imitated, every day, the exacerbations commencing at noon, and the duration being usually under twelve hours ; the intervals consisting of remissions, which, how- ever, are not always very clearly determined. Where the double tertian type prevails, and the patient has to labour with two distinct sets of tertian exacerbations, it is obvious that one of opinion of, consists in giving at first calomel and James's powder, and a cathartic mixture, followed by small doses of rhubarb and the hydrargyrum cum creta.—Ed. * No writer has given a better account of the fluids in their putrescent state than Dr. Dyckman. —See his Dissertation on the Pathology of tha Human Fluids, New-York, 1814.—D. Gen. III.—Spe. 2.] EPANETUS MALIGNUS. 369 these must take place every day, as il must occur in the remission of the other. Conse- quently, this variety is often mistaken for a quotidian remittent. But a little attention will point out the real nature of the disease. For, while the one set will usually be found dis- tinguished from the other by evincing some dif- ference in its duration or its violence, both will be distinguished from the quotidian by the time of their attack, which is at noon, while the quotidian attacks in the morning ; and by the comparative brevity of the paroxysm, which is always under twelve hours, while that of the quotidian runs on towards eighteen. The perfect apyrexy which takes place in the interval of intermittent fevers, gives the constitution a full power of recovering its energy and recruiting its sensorial supply ; and hence there "is great difficulty in accounting for a re- turn of the paroxysm : I mean in cases in which the patient is removed from the miasmic atmo- sphere ; for otherwise, the cause that com- menced the disease will be present to continue it. Habit may possibly effect this after a re- currence of several paroxysms ; but this will scarcely apply to the second, in which no habit can, with great strictness of language, be said to have taken place. In remittent fevers, how- ever, something of this difficulty is removed ; for the constitution, even during the remissive interval, is still struggling with disease, and has not an opportunity of recovering its sensorial power. There is no perplexity in accounting for a greater tendency to febrile affections in the autumn than in any other quarter of the year : and this, whether we allow the operation of a specific febrile miasm from marshes or not. When the animal frame has for some months been exposed to the stimulus of a high atmo- spheric temperature, and not unfrequently, per- haps, to that of the direct rays of the sun, all its organs become relaxed and debilitated. The nervous energy is diminished, or, in the lan- guage of Dr. Cullen, is in a state of collapse ; a general languor and inertness prevail over every part of the system, and most of the func- tions are performed feebly and laboriously. And hence, if debility be the first stage of the proxi- mate cause of fever, this part of the cause is continually present. But this is not all: the calorific rays of the sun act more powerfully upon some organs than upon others ; and most of all upon the liver. The liver is hence in a state of perpetual irritation ; and an unusual proportion of bile is secreted, a part of which is very generally absorbed and carried into the circulation; and, in tropical climates, so large a part as to form one of the causes of that tawny hue, by which the skin is there char- acterized : and as the greater proportion of the surplus often passes off by the bowels, we see an obvious foundation laid for that variety of diarrhcea which we have already described under the epithet of bilious. The liver, moreover, becomes weakened and torpid in proportion to its degree of excitement, and hence more dis- posed to congestion ; and where congestion or Vol. I.—A a any other obstruction takes place in a largo organ, there is instantly a disturbance in the balance of the circulating fluid; and a disturb- ance which, in so irritable a state of the general system as we are now contemplating, can rarely exist without fever, or a tendency to fever. There is no question that this general dis- turbance of the balance of the circulating fluid and increased excitement of the digestive organs may terminate in actual inflammation in some part of these organs, and especially in their mucous membrane :* and hence those patholo- gists who regard fevers of all kinds as con- sisting in inflammation, contemplate the re- mittent before us as an enteric, or gastric phleg- masia : but this, as we have already had oc- casion to observe, is rather to denominate it from its result than from its essential nature, and to make the cause and effect change places; a remark which will apply to yellow fever, as well as to the present variety. All this mischief is apt to occur in autumns of temperate climates, that are peculiarly dry, and uniform in the range of the thermometer. But it often happens that even in the most tem- perate and healthy climates, like our own, the autumnal months are checkered with sudden vicissitudes of heat and cold : and the pools and rivers are suddenly inundated with equinoc- tial rains, overflow their banks, and cover a wide surface of land with stagnant water. And the animal frame has hence to contend against the dangers of invisible damps, and abrupt changes of temperature, as well as against solar excite- ment : all which become occasional causes of fever, operating upon a state of body already predisposed to its influence. And hence, even without the existence of febrile marsh miasm, we see sufficient causes for a more frequent appearance of fever in the autumn than in any other season of the year : whence, indeed, one reason for its appearing in warm seasons in fleets that are cruising at a considerable distance from ports, as has been justly observed by Sir William Burnet, t But in many districts, perhaps even in some spo- radic cases, we have reason to believe that marsh miasm does co-operate, and itself form the re- mote cause ; and more especially where such cases are frequent, the residence a lowland, and the season hot and rainy. Dr. James John- * The frequency of increased vascularity and ulceration of the mucous coat of the intestines in fever, has been amply proved by dissection.—See particularly Broussais Phlegm. Chroniques ; An- dral's Clinique Medicale, tom. i.; and Bright's Reports of Med. Cases, p. 178 et seq., 4to., Lond., 1827.—Ed. t On the Bilious Remittent ofthe Mediterranean. The occurrence of remittent and intermittent fe- vers in ships, far distant from marshy countries, may appear at first to furnish an argument against the doctrine of malaria, or marsh miasm, being always concerned in the production of such dis- orders ; but those writers who maintain the truth of the latter view would remind their opponents of the malaria frequently issuing from the bilge- water, in which the decomposition of vegetable substances is going on.—Ed. 970 H^EMATICA. [Cl. III.—Ord. I son makes a like distinction betvyeen the causes of the ordinary endemic fevers of the east. " The fever in question," says he (bilious re- mittent), "■frequently arises from atmospheric heat, or rather atmospheric vicissitudes, deran- ging the functions, or even structure, of impor- tant organs ; and is, as Sir James M'Grigor supposes, sympathetic of local affection. Where marsh miasm is added, which is generally the case, then we have the endemic of the place, modified by the peculiar nature of the effluvia, and from which we are not secured but by local habituation to the cause."—(Influence of Trop- ical Climates, &c, 3d edit., p. 105.) In consequence, the symptoms have often a close resemblance in both cases, so much so in- deed, that when both diseases co-exist, it is sometimes found difficult to distinguish them. " The occurrences," says Dr. O'Halloran, "which preceded the appearance of the epidemic of Bar- celona, in 1821, correspond with the oldandrecent observations on a similar subject in other coun- tries ; it almost invariably happening that the yellow fever of Spain is preceded by unusual diseases of various form and force ; more par- ticularly by bilious remittents, which are not unfrequently so aggravated and malignant, that physicians themselves do not venture to define the lines of demarcation between them and the avowed epidemic."—(Remarks on the Yellow Fever of the South and East Coasts of Spain, &.c, 8vo., 1823.) There is still, however, a difficulty in deter- mining why the type of any fever, hereby pro- duced, should be remittent rather than inter- mittent or continued ; and why its declinations should imitate one form of intermitfents rather than another. Pathology has its mysteries as well as every other branch of science ; and let the man who would accuse us of ignorance, because we are incapable of explaining these secrets of nature, first tell us, to adopt the lan- guage of Sydenham, " why a horse reaches his full growth at seven years old, and a man at twenty-one 1 or, why some plants flower in May, and others in June 1 If," continues he, " the most learned men are not ashamed to make an open avowal of their ignorance upon these points, I cannot acknowledge my- self blameable if I modestly forbear reasoning upon a subject quite as difficult, and perhaps altogether inexplicable. At the same time I am persuaded, that the progress of nature is as certain and regular in these cases as in any others, and that the quartan and tertian inter- mittents are as subject to the natural laws, and as much governed by them, as any other occur- rences whatever." The autumnal remittent commences with lassitude, a general soreness over the body, yawning, inquietude, and most of the other concomitants of a febrile incursion. As some of the larger organs have been more affected by the influence of the season than the rest, we find them giving way in proportion. Hence the head is sometimes severely tried with pain or heaviness ; the bowels are overloaded with bile, or the stomach is exquisitely irritable, and rejects whatever is introduced into it. Gen- erally speaking, the stomach, from this symp- tom, suffers more than any other organ ; and, along with the sickness, we have often a very troublesome and debilitating looseness, which resists every attempt to check its course. Some- times, however, the bowels are costive from torpor, and the stomach is but little affected. The violence of the symptoms is commonly in proportion to the violence of the incursion ; but not the duration of the disease : for I have often seen a fever that commenced mildly and insidiously hold on for upwards of three weeks, while another that commenced with great se- verity, and threatened the utmost danger, has softened its aspect in a week, and entirely quitted the patient in a fortnight. The exacer- bation ordinarily takes place at noon, or early in the afternoon, and consists in an increase of heat and pulsation, for there is rarely any pre- ceding chill, and as rarely any salutary moisture when the heat diminishes. The early part of the night is henee peculiarly restless, and no part of it tranquil: the patient dozes perhaps for a few minutes, but without being sensible of sleep, and talks incoherently while dozing ; the images before him being partly furnished from dreaming and partly from delirium. And even during these snatches of unquiet slumber, he is perpet- ually turning from side to side in quest of ease, which no position affords him. Every symptom is obstinate ; laudanum rarely produces sleep, and no sudorific, perspiration ; the coolest and most refreshing drink is rejected from the stom- ach ; and if looseness tease the bowels, it is retained, as already observed, with great diffi- culty. It is hence of little importance what nourishment is offered, and every preparation seems almost equally to fail in supporting the strength of the system. In effect, the debility increases with every fresh exacerbation ; and if no favourable change take place before the fourteenth or fifteenth day, there will always be reason for alarm. The progress of this disease is admirably described by Professor Frank (De Cur. Morb. Horn. Epit., tom i., sect. 100, 8vo., Mannh., 1792), under the name of febris continua gastrica, the remittent form being with him, as with Dr. Cullen, a section of the continued fever. In the case of a young lady in her seventeenth year, whom I lately attended, the attack was slight, and no serious evil was at first apprehend- ed. The pulse was about ninety in a minute, and rather small; the bowels were relaxed, the motions bilious, and the stomach suffered from nausea. A gentle emetic seemed to afford some relief to the stomach, and a dose of rhubarb and calomel to the bowels ; but the fever continued, with a daily and increasing exacerbation, for the most part at mid-day or soon after. The stom- ach again became irritable and sick, and the sickness was again connected with a diarrhoea, but the stools were colourless and watery, and nothing was rejected from the stomach but the diluent food that was swallowed. The skin was now very hot and dry, the pulse from a hundred to a hundred and twenty strokes in a minute, the nights were passed in i.eipetual Gen. III.—Spe. 2.] EPANETUS MALIGNUS. 371 jactitation, or in short and talkative dozings. Opium, rhubarb, neutral salts, diaphoretics, and mild astringents, in almost every form and com- bination, were tried with very doubtful advan- tage, and the first with evident mischief. Ano- dyne injections were of as little avail; but sponging the limbs with cold water, or brandy and water, which was employed as well during the remissive as the aggravated symptoms, di- minished the pungent heat, and for a time afforded some refreshment. Still the fever continued its career; the stomach retained nourishment with difficulty ; the bowels were, daily teased with six or seven watery evacuations ; the pulse was quicker and weaker, and the nights without rest. The heart at length became oppressed with a sense of fulness rather than of throbbing ; the lips were considerably swollen, ragged, and black; a hemorrhage occasionally issued from the nos- trils and the fauces; and the general debility was greatly augmented. Such was the appear- ance towards the eleventh day. The tongue was not much furred ; the pulse, though small, and rarely under a hundred and twelve, was steady ; but the heat was intense, and the thirst unquenchable. The mineral acids in dilution, sometimes singly, and sometimes in the combined form of aqua regia, with acidulated beverages, were now chiefly trusted to, in connexion with farinaceous foods, jellies, and beef-tea; and cold water was permitted in any quantity. This plan was continued till about the eighteenth day ; when every thing allowed being rejected, and every evacuation accompanied with faint- ness, it appeared to me that the plan should be changed ; that the chief cause of irritation was at this time debility; and that a more stimulant treatment should immediately be commenced. My colleagues, for whom I have a high respect, acceded with reluctance, as conceiving that we should only exasperate the febrile symptoms; and that, if the stomach could not retain taste- less things, it would instantly reject wine, or convert it into an acid. The attempt, however, was made ; sound old Madeira was administered by teaspoonfuls, and shortly afterward a small portion of chicken-jelly. Both remained on the stomach ; but the diarrhoea continued ; and for this, as modern preparations had proved of little use, I recommended a scruple of the confectio Damocratis in half an ounce of cinnamon-water after every loose motion. The diarrhcea ceased as by a charm; the erisuing exacerbation was less marked; the night was passed more tran- quilly, and columbo, in small doses of the pow- der, was commenced the next morning, and persevered in. The change of treatment, being thus found to succeed, was adhered to, and the patient slowly, but effectually recovered. It is not often that the autumnal remittent is thus obstinate. But, whether there be sickness or not, an emetic should be administered, as one of the best means of determining towards the skin. And, singular as the advice may appear, it is rather to be recommended where there is little or no sickness than where the sickness is incessant; for, in this last case, the stomach is often so extremely irritable that emetics onlv j Aa 2 exasperate it, and add to the distress. It will also be useful to evacuate the bowels on all occa- sions, though the emetic alone will frequently be sufficient for this purpose, and hence Stoll allows of nothing beyond : for purging, says he^ augments the fever, while an emetic strangles it as at a blow.—(Rat. Med., part i., p. 227.) The use of the lancet must depend upon the circumstances of the particular case. Where the onset is violent, and particularly where the patient is plethoric or of a vigorous habit, it should be employed instantly and freely ; for, without it, from the urgency of the symptoms, there can be little doubt that some large organ or other will soon become locally affected with effusion or congestion, which is always to be avoided as one of the worst symptoms that can occur. And, if we have reason to believe that such local affection exists at the time of the attack, and, more especially, that it is the cause of it, copious depletion will be still more neces- sary ; for, in this case, we have not only to contend with the fever, but to guard against phlogosis or inflammation in the infarcted organ. But, except in such cases, there is no call for the lancet, and we may concede to Stoll that its use is injurious. [According to the observa- tions of Dr. Bright, a tongue with red edges, more particularly when dry, almost- universally indicates in fever great irritation of the mucous membrane of the intestines ; and,' when com- bined with loose, yellow, gritty dejections, gen- erally denotes ulceration, or a state approaching to it. In this state, leeches and blisters may be applied to the abdomen; and the medicine in which Dr. Bright seems to put most faith consists of small doses of ipecacuanha, the hydrargyrum cum creta, and pulv. cretae comp., generally in the proportion of a grain of the first, three of the second, and ten of the last article. The oleum ricini, with a few drops of tinct. opii, he prefers as the safest aperient. Two grains of hydrarg. c. creta, and ten of con- feet, opii, made into pills, and to be taken thrice a day, are also sometimes prescribed, with mucilaginous saline medicines, and ten or fifteen drops of vinum ipecac, to each dose.—(Bright's Reports of Medical Cases, p. 178, &c, 4to., Lond., 1827.)] Copious diluents, and small doses of antimonial powder in effervescing neutral draughts, will ordinarily take off the burning heat of the skin by exciting a breathing moisture ; and, if this can be maintained through the day, the ensuing exacerbation will probably be mitigated in its violence. If not, eight or ten drops of the tincture of digitalis should be added to the antimonial draught, and all ten- dency to sickness be restrained by a few drops of laudanum ; keeping the bowels in the mean time open with some gentle laxative, as rhubarb and the sulphate or supersulphate of potash in combination. Blisters are never of service, ex- cept when topically called for, or as stimulants in the last stage of debility. If the diaphoretic plan fail of effect, and the heat be pungent and augmentive, acids, vegetable, mineral, or both, will ordinarily constitute the best sedatives and refrigerants ; and, where the debility is extreme, n*2 HAMi the stimulant plan should be had recourse to, which is laid down in the preceding case.* One of the severest and most fatal forms un- der which the malignant remittent shows itself is that of the yellow fever, constituting the second variety of the present species; so denominated from the lemon or orange, hue which is thrown over the entire surface of the body, almost from the first attack of the disease, and which gives it a distinctive feature. The heat is here also intense, the thirst extreme, and the vomiting strikingly obstinate, but not, as in the preceding species, consisting of a colourless material, or the food that has been swallowed, but of a yellowish matter at the beginning and through the height of the fever, and of a chocolate-coloured colluvies towards its close. The common remote cause of this fever is unquestionably marsh miasm; and hence it holds a stationary abode in the swampy soils and morasses of the intertropical regions, ex- posed to a high solar heat, and perpetually exhaling a decomposition of animal and vegeta- ble materials : and is found occasionally in all climates that make an approach to the same character; where, in the correct picture of the poet,— " The rivers die into offensive pools, And, charged with putrid verdure, breathe a gross And mortal nuisance into all the air." It is nevertheless a striking fact, that, although such " mortal nuisances" have been exhaled into the atmosphere in all ages within the range of the tropics, the fever we are now entering upon is only of modern date in its malignant form. Whether this be owing to any degree of general change that has taken place in the human constitution, or to a larger accumulation of that mixed animal and vegetable compost which forms the hotbed of the present destruc- tive miasm, or to any other cause, it is difficult to determine. It certainly seems, as Sir Gil- bert Blane has observed, to have some bearing upon the slave-trade, with which it is precisely coetaneous. Smallpox, syphilis,, and rickets, were equally unknown to the ancients ; yet the Gauses of their origin, as, indeed, those of all other epidemic or constitutional diseases, are involved in inscrutable darkness; and, in the language of the poet, —" Noctescunt tenebris caliginis atrae." The yellow fever first showed itself, so far as we have any record of its origin, at Barbadoes, in 1647, whence it spread to various other West * The treatment of the autumnal remittent, as stated above, is perhaps judicious enough for most cases, but it is not so efficient as that generally pursued by American practitioners. Bloodletting, leeches, emetics, cathartics, and calomel, are among their prominent remedies; the febrifuge compound of calomel and James's powder, is much used. Blisters are often applied during the con- tinuance of the active character of the disorder, and after depletion. When the complaint, how- ever, assumes a more malignant and typhoid char- acter, these active remedies must be used with great circumspection.—D. LTICA. TCl. Ill—Ord. I. Indian Islands, and at length made its appear- ance at Boston, in North America, in 1693, to which place it was carried from Martinique by the fleet under Admiral Wheeler. In Europe, its earliest footsteps were traced at Lisbon in 1723 (Sir Gilbert Blane, Select, Dissertations, &c, -p. 284, Lond., 8vo., 1822): after this period, it seems to have declined as well in its violence as in its visits, to the same regions, particularly in respect to North America and Europe. But, in 1793, a new era of its preva- lence commenced; the disease showing itself then and down to the present day with a fre- quency and fatality it had never evinced before, especially in the West Indies and North America. This aggravated form, however, did not manifest itself in Europe till the year 1800, when, after an interval of six-and-thirty years, it appeared at Cadiz in all its' horrors. Since this period, it has visited Cadiz several times, and has hence spread to neighbouring seaport towns in the south of Spain, at short intervals. Among other places in this line of coast, it has repeatedly visited Gibraltar, first in 1804, when more than one third of the garrison and population were carried off; and occasionally since, but with little comparative loss, on account of those pre- cautionary means which had been entirely neg- lected on the first visitation. To what extent the miasm of yellow fever, as it arises from its swampy and putrescent base, may spread, before it becomes dissolved and decomposed in the surrounding atmosphere, it is not easy to determine. " It is probable, however, that, where a tradewind or monsoon sets over a large tract fraught with febrific miasmata, these invisible agents may be carried to a much greater extent than where calms or gentle sea and* landbreezes prevail. This is exemplified in the fever of Corimbatore, and ought ever to be borne in mind by navigators in anchoring ships in the vicinity of swamps, or by generals in pitching tents or stationing troops."—- (Influence of Tropical Climates, &c, by J. Johnson, M. D., 3d ed., p. 148.) It is also satisfactorily proved, that the mod- ification of miasm producing yellow fever does not spread so far, or rise so high, and, conse- quently, is not so volatile, as that producing the ordinary bilious remittent of hot climates ; a feature by which it makes a nearer approach to the miasm of human effluvium, and shows that affinity to it, even from the first, which we have endeavoured to establish in the introductory remarks to the present order. Dr. Ferguson has given us a striking illustration of the truth of this remark, as also of the relative baro- metrical elevations of the respective regions of yellow fever, ordinary bilious remittent, and a pure and healthy atmosphere, in the following passage, in which he is taking a medical per- iscope of the Island of Antigua. " The autumn of 1816 became very sickly, and yellow fever broke out in all its low marshy quarters, while the milder remittent pervaded the island gen- erally. It wa6 the office of the white troops to take the guards and duties of the dock-yards among the marshes below ; and so pestiferous Gen. III.—Spe. 2] EPANETUS MALIGNUS. ' 373 was their atmosphere, that it often occurred to a well-seasoned soldier, mounting the night-guard in perfect health, to be seized with furious de- lirium while standing sentry, and, when carried to his barracks on Monk's Hill, to expire, in all the horrors of the black vomit, within less than thirty hours from the first attack : but, during all this, not a single case of yellow fever, nor fever of any kind, occurred to the inhabitants of Monk's Hill (a rock rising perpendicularly above the marshes to the height of six hundred feet). The result on the ridge (a hill about a hundred feet lower) was not quite the same, but it was equally curious and instructive. The artillery soldiers, seventeen in number, never took any of the night-guards, but they occupied a barrack about three hundred feet above the marsnes, not perpendicularly above them, like Monk's Hill, but a little retired. Not a case of yellow fever or black vomit occurred among them ; but every man, without a single excep- tion, suffered an attack of the ordinary remit- tent, of which one of them died : and, at the barrack on the top of the ridge, at the height of five hundred feet, and still further retired from the marshes, there scarcely occurred any fever worthy of notice."* There is another feature in which the miasm of the yellow fever shows its affinity to the febrile contagion of the human frame, and evinces its less diffusibility ; and that is, in readily attaching itself to whatever bodies it meets with, though to some more than others. Even the leaves and branches of trees form powerful points of attraction, and, where they are in the immediate vicinity of a swamp, retain the contagious matter that rests upon them so effectually, as, in many cases, to keep the sur- rounding atmosphere free from pollution, and be- come a safeguard against febrile attack. " The town of New Amsterdam, in Berbice," says the same writer, " is situated within a short musket-shot to the leeward of a most offensive swamp, in the direct track of a strong trade- wind that blows night and day, and pollutes even the sleeping apartments of the inhabitants with the stench pf the marshes ; yet it brings no fevers, though every one is well aware that it would be almost certain death for a Euro- pean to sleep, or even to remain after nightfall, under the shade of the lofty trees that cover the marsh at so short a distance. All, too, are equally aware, that to cut down the trees would be a most dangerous operation in itself, and would certainly be productive of pestilence to the town." As almost every territory in which the fever hereby produced has committed its ravages has given it a new name, it is as gorgeously arrayed with titles as the mightiest monarch of the east. From the depredations it has committed in the West Indies and on the Amer- ican coast, it has been called the St. Domingo, Barbadoes, Jamaica, and American fever ; and, * On the Nature and History of Marsh Poison, Medico-Chirurg. Rev., Dec, 1821; and compare with Chisholm on Tropical Climates, p. 34. from its fatal visitations on the Guinea coast and its adjoining islands, the Bnlam fever. In British India, it is distinguished by the name of the jungle fever, the Hoogly fever, or endemic of Bengal ; and, still farther to the east, by that of mal de Siam. Nearer home, in the lowlands of Hungary, and along the south of Spain, it is called the Hungarian or the Anda- lusian pestilence. From its rapid attack on ships' crews that are fresh to its influence, the French denominate it fievre matelotte, as the Spanish and Portuguese call it fiebre amo.rilla, and still more frequently vomito prielo, or black vomit, from the slaty or purplish and granular saburra thrown up from the stomach in the last stage of the disease ; while, as its ordinary source is marsh lands, it has frequently been named paludal fever. Its more common name, however, in the present day, and for the reason already assigned, is yellow fever; and, when the attack upon new-comers is slight, seasoning. It is the febris gastrico-nervosa of Professor Frank (Op. cit., vol. i., $ 103), who justly re- gards it as an intense variety of the ordinary autumnal malignant of temperate climates, as already described under this name. From its showing itself in so many parts of the world, and under circumstances so widely different, it is not to be wondered at, that it should often be accompanied with a consider- able diversity of symptoms ; and, consequently, that the paludal fever of one quarter should be regarded by many writers of considerable au- thority as essentially different from that of an- other. But an attentive perusal of the origin and laws of febrile miasm, as I have endeav- oured to explain them, when treating of the remote cause of fever, will, I trust, be suffi- cient to account for all such local distinctions ; and, if not to prove, at least to render it highly probable, that they depend "partly upon the state of the body at the time of attack, but chiefly upon some modification in the powers or qualities of the febrile miasm itself, by the va- rying proportions of the co-operative agents of moisture, heat, stagnant air, and other auxil- iaries which have not yet been detected, in their relation to each other in different places and seasons." How far the yellow fever is capable of origi- nation from any other cause than febrile miasm from marshy lands, or places subject to like decompositions and plays of chymical affinity, we cannot at present determine. Such places, however, are numerous, as damp unventilated stations, stagnant water, thick impervious jun- gles, and woods that arrest the miasm as it ascends; even high and arid hills after heat and rain ; but, above all, a foul state of the hold on board ships, whatever be the cause of such impurity. " Ships," observes Dr. Chis- holm, " containing wine in their holds in a state of decomposition, are generally extremely sickly, and the character of the prevalent dis- ease is that of yellow remittent fever. Several instances of this took place in Fort Royal Bay in the years 1797 and 1798 ; and the situation of the ships in the open bay, far ATICA. [Cl. III.—Ord- L 374 H^EM from the influence of marsh effluvia, precluded a suspicion of the fever from that cause. The ship Nancy, Captain Needs, from Fayal, with a cargo of wine for the army, arrived at Fort Royal, Martinique, in the month of October, 1798 : she met with a gale of wind at sea on the 17th September, and several of the casks, from the motion of the ship, became leaky. The captain was taken sick at sea, and died with every symptom of the highest grade of yellow remittent fever. The mate and several of the crew were attacked with the same com- plaint : they recovered; but a mate, shipped at Fort Royal, fell ill on board and died. The ship lay out in the open bay ; no vessel near her was sickly ; and she herself became very healthy after the cargo was landed."* Heat alone, however high the temperature, is not a cause of the fever before us : there must be moisture ; and, as the result of both, a rapid decomposition and exhalation of organic remains. Provided the air is dry, even trop- ical climates are often found salubrious. " The burning province of CumStta," observes M. Humboldt, " the coast of Cora, and the plains of Caraccas prove, that excessive heat alone is not unfavourable to human life." It has just been observed, however, that even high and arid situations, after heat and rain, may also furnish, by the chymical decom- position of their soil, the specific miasm of yel-^ low fever : and it may here be added, that if, by the violence and redundance of the rain, the swampy low grounds be at the same time over- • flowed, the latter will become an arena of health, while the heights are the seat of disease. Such the hilly ravines of Portugal were occasionally found by the British army, during its occupation of that country in the summer of 1809, when a most destructive remittent suddenly made its appearance, while the overflowed swamps at its feet were more than usually free from dis- ease : " and such is frequently the case," as Mr. Irvine has justly observed, " on the lofty ridges of Sicily, when their fiumari or water- courses, which are ordinarily dry and used for roads in the summer months, are filled and in- undated with sudden torrents of rain. For here the malaria changes its station, and quits the overflowing lowlands for the heights of the primitive hills."t But, whatever be the original source of the fever before us, when once it has established itself and rages with severity, it is now very generally admitted, that the effluvium from the * Essay on the Malignant Pestilential Fever, vol. i., p. 279.—See also Dr. Dickson's Topograph- ical Remarks, &c, sect. iii. t These facts confirm the observations intro- duced in a previous part of this work, in explana- tion of the occasional prevalence of agues in ele- vated parts of the country, or even on hills, while lower situations continue healthy. They also tend to refute the opinion of the identity or affinity of marsh miasm and of contagion from human effluvia to one another, inasmuch as one argument frequently adopted in favour of the latter hypoth- esis is founded upon seeming anomalies in the cir- cumstances under which agues commence,—Ed. body of the affected "is loaded with miasm of the same kind, completely elaborated as it passes off,"—and that the disorder is from this time capable of communicating itself by conta- gion. And, from the statement already given, it appears far more probable, that the fever at Cadiz in 1800, that at Malaga in 1803, and that at both in 1820, had their origin in contagion, or, in other words, in febrile miasm, produced by a decomposition of the effluvium from the human body, than from the same miasm issuing from a decomposition of marsh lands. And, on this account, I have rather preferred the trivial name of yellow to that of paludal fever, which is too limited to express its source in every instance. The yellow fever at Xeres is ascribed by Don J. A. Ferrari entirely to this cause, as produced by importation ; but its pri- mary source he attributes to the decomposition of swampy lands, or other sources of putrefac- tion, which he seems to suppose may exist even in some parts of Spain.—(Edin. Med. and Surg. Journ., July, 1823, p. 369.) In all instances it has a near approach to the autumnal remittent we have just described: Dr. Rush contemplates them as merely different degrees of the same disorder ; but Dr. Bancroft is, as it appears to me, more correct in consid- ering them, after Professor Frank, as " varieties of one disease" (Essay on the Disease Called Yellow Fever, &c, Baltimore, 1811), in unison with the present arrangement. It should be observed, however, that, for the yellow fever to become contagious, it seems necessary that the thermometer should be above 80° of Fahrenheit: since, like the plague, it demands, for the activity of its miasmic cor- puscles, a certain range of temperature, below which it ceases to operate, and its specific par- ticles, perhaps, generally become decomposed. It has never been known in North America, nor in the south of Europe, but at the season of the year in which tropical heats, that is, those of 80° or upwards, prevail; and it has never failed to disappear in winter, even in the mild winter of Spain: though typhus may at the same time hold its full career of malignity.* * Blane, Select Dissertations, &c, p. 314. Is not this a strong fact against the contagious na- ture of yellow fever? The proof of the exten- sion of the disorder by the contagion of human effluvia must be exceedingly difficult, as long as the parties who are imagined to contract the fever from those first affected, are exposed to the influ- ence of the same local circumstances. The no- tion of intermittent and remittent fevers being capable of transmission from one person to an- other by contagion, is, in all probability, as erro- neous as the belief, prevalent in Italy, Malta, and other parts of the south of Europe, that con- sumption is a contagious disorder. When I was at Malta, in 1801,1 wished to procure a lodging for an officer labouring under phthisis, but, owing to the belief universally entertained in that island of the disease being contagious, it was with great difficulty that any family could be persuaded to afford him accommodation. With regard to the malignant remittent fevers so often prevalent on the coast of Spain, it is a fact, that, although the commissioners sent by the French government to Gen. III.—Spe. 2.] EPANETUS MALIGNUS. 375 s From the different impressions produced on febrile miasm under these diversities of origin and adjuncts, we find, independently of other discrepances, that the fever it excites some- times assumes a caumatic or inflammatory cast, sometimes a typhous, and sometimes a syno- chous, or, in other words, begins with the first and runs rapidly into the second or third. And it is in effect into these three subsections that the Andalusian yellow fever has been lately re- stored by Dr. Jackson, in his excellent work on the subject. Generally speaking, the variety before us evinces the last of these characters, as does also the variety we have just treated of: the two varieties that yet remain, will afford ex- amples of a typhous and inflammatory bearing.* t Its ordinary progress, among those who are fresh to the tainted atmosphere, is thus accurate- ly described by Dr. Mosely, who, from its re- semblance to the causus of Hippocrates, de- nominates it endemial causus : a term which has since been adopted by Dr. M'Arthur {Account of the Causus or Yellow Fever of the West Indies, &c), and several others. " When a new-comer is seized with a sudden loss of strength, and a desire of changing, for rest, into every position, without finding it in any, those symptoms, which constitute the endemial causus may be expected. The following day, but sometimes within twelve hours from the first in- disposition, the violence of the disease will com- mence thus :—There will be a faintness, and generally a giddiness of the head, with a small degree of chilliness and horror, but never a rigour. Then immediately will succeed a high degree of fever, with great heat, and strong beating in all the arteries of the body, particu- larly observable in the carotid and temporal arteries ; flushings in the face ; gaspings for cool air ; white tongue, but tinged with yellow, after the retchings have commenced; excessive thirst, investigate the character of the fatal disorder which, in 1821, raged in the city of Barcelona, reported that it was propagated by infection, the doctrine never gained much belief in France, be- cause «t was considered to be sufficiently refuted by other views taken of the same epidemic by Dr. Chervin, whose able researches fully estab- lished the fact, that the propagation of the fever was chiefly, if not entirely, owing to the malaria of the place in which it prevailed, and not to ema- nations from those affected by it.—Ed. * Here it ought to be noticed, that the contagi- ous nature ef typhoid fevers is a disputed point. If you allow the effluvia from too many human beings crowded together in a badly ventilated building to be, as it were, concentrated, you will see fever arise ; but for typhus to be communicated to an- other person from a patient lying in an airy apart- ment, is a circumstance, at all events, so rare, as to be a matter of doubt. Whether the patients, crowded together, have one fever or another, or at first no fever at all, febrile disorders, with change of type if they have previously existed, will gener- ally come on The inflammations and alterations of the mucous intestinal tissues, and other parts, arising in the course of intermittent and remittent fevers, together with the influence of medical treatment, will also frequently account for change of type.—Ed. redness, heaviness, and burning in the eyes; heaviness and darting pains in the head and small of the back, and often down the thighs ; pulse quick, generally full and strong, in some cases, quick, low, and vacillating; skin hot and dry ; sometimes with a partial and momentary moisture ; sickness of the stomach from the first, which increases with the disease ; and, imme- diately after any thing is taken to quench the thirst, retchings succeed, in which bilious matter is brought up ; anxiety, with stricture, soreness, and intense heat about the praecordia; great restlessness ; heavy respiration; sighing ; urine deep-coloured, and but little in quantity. This is the first stage of the fever, and may continue twenty-four, thirty-six, forty-eight, or sixty hours, and this constitutes its inflammatory period. " The second stage begins with an abatement of many of the preceding symptoms, and the rise of others ; sometimes with a deceiving tranquillity, but with perturbation if the patient should fall into a sleep : then a yellow tinge is observed in the eyes, neck, and breast; the heat subsides, and sometimes with a chilliness, but not with that sort of strong rigour which, when it happens, terminates the disease by sweat, or by copious bilious evacuations upwards or downwards. The retchings are violent, and turn porraceous ; the pulse flags, but is some- times high and sometimes soft; the skin soft and clammy ; the urine in small quantity, and - of a dark croceous colour ; the tongue in some cases is dry, harsh, and discoloured, in others furred and moist; there is confusion in the head, and sometimes delirium, with the eyes glassy. This stage of the disease sometimes continues only for a few hours, sometimes for twelve, twenty-four, thirty-six, or forty-eight hours, but never longer. " In the third and last stage ofthe fever, the pulse sinks, and becomes unequal and intermit- tent, sometimes very quick ; frequent vomiting, with great straining and noise, and what is brought up now is more in quantity, and has the appearance of the grounds of coffee, or is of a slate colour. Nothing can be retained in the stomach; difficult breathing;- tongue black; cold clammy sweats; eyes hollow and sunk; yellowness round the mouth and temples, and, soon after, over the whole body." In the earlier remissions, the pulse . often sinks from a hundred and thirty to ninety, and the general improvement is so considerable as to impress the young practitioner with the belief of a salutary crisis. He is soon, however, aroused from his deception, for the exacerbation soon returns with renewed violence ; and, as the symptoms grow more aggravated, they are, in the end, accompanied with subsultus tendinum, black urine, deadly coldness of the limbs, delir- ium, faltering speech, hemorrhage, or oozing of blood from the mouth and nostrils, corners of the eyes and ears; black bloody vomiting and stools ; vibices, hiccough, muttering, coma, death. After the first prostration of strength pro- duced by the symptoms of invasion or accession, | the prodromes of M. Deveze, the disease rung 376 HJEMATICA. [Cl. HI.—Oro. I on violently through its stage of excitement till the sensorial power is exhausted. Through its entire course, till the patient is sinking, the in- tellect is not particularly disturbed, and the organs chiefly affected are the abdominal; those which principally suffer in the malignant autum- nal remittent of our own country, are especially the stomach and the liver. Hence, the intense heat and anxiety about the praecordia, the saffron die of the urine, the yellow teint of the skin, and the vomitings, first of a bilious, and afterward of a chocolate or sanguineous colluvies. In the An- dalusian variety, however, according to Dr. R. Jackson,* the brain is sometimes the first organ affected, and the abdominal organs consecu- tively. In some cases, the disease opens with great vehemence, and rushes forward at once to its acme, constituting the second stage of Dr. Mosely. The patient is sometimes cut off in four-and-twenty hours : and, from the violence so suddenly committed on the liver, its proper function is instantaneously suspended,—and, in- stead of an excessive emulgence ofhigh-teinted bile, a chlorotic secretion takes place, which, forced into the sanguineous system, gives a ghastly lividity to the entire surface. Shortly after which, if the patient live long enough, the gorged bloodvessels of the inflamed and gan- grenous liver itself, and sometimes also of the spleen or stomach (Chisholm, op. cit., p. 36), give way, and repeated tides of dark, granulated grume, like the grounds of chocolate, are eject- ed by the mouth. Dr. Pym has very forcibly described this overwhelming onset of the disease in the fol- lowing terms .•—" There is, at the first attack, a peculiar shining or drunken appearance in the eyes ; the headache is excruciating, and confined to the orbits and the forehead ; has no remis- sions ; when it terminates favourably, is rarely attended with yellowness of the skin, which, if it do take place, is of a very pale lemon colour. It runs its course from one to five days, is at- tended with a peculiar inflammation of the stomach, which, in most cases that prove fatal, terminates in gangrene, or in a diseased state of the internal or villous coat of that organ, ac- companied with a vomiting of matter resembling coffee-grounds, and a livid or putrid appearance of the countenance which it is impossible to describe ; but those wishing to form an idea of it, may see its fac-simile in the countenance of any person with a florid complexion, during the burning of spirit of wine and salt in a dark room, as is practised in the game of snapdragon during the Christmas gambols."—(Obs. upon the Bulam Fever, &c, 8vo., 1815.) In this state, the disease is unquestionably for the most part, though not always, contagi- ous : and, as Dr. Cullen has laid down conta- gion as a distinctive character of fevers origina- ting from human effluvium, in contrast with those originating from the effluvium of marshes, Dr. Pym has endeavoured to draw a line of dis- * Remarks on the Epidemic Yellow Fever, &c, On the south coast of Spain, 8vo., Lond., 1821. tinction between yellow fever in this state of intensity and in its ordinary career ; contending that the former (to which he limits the name of Bulam fever) is in every instance derived from human effluvium, and, consequently, that the two must of necessity be distinct diseases. And to make the distinction still clearer, he has ventured to assert, that the symptom of a more pallid or bloated countenance, together with that of black vomit, or the discharge of coffee-like grounds from the stomach, is peculiar to the con- tagious fever, and is rarely, if ever, an attendant on that produced hy marsh miasm, even in its most impetuous and fatal course. This distinction, however, is in both instances at variance with the history of the disease as it has occurred in most other parts of the world, and, more especially, with respect to the symp- tom of black vomit; which, in its last stage or severer incursions, is common to it from what- ever source derived. Nothing is more frequent in the Andalusian or Spanish variety, where the discharge is sometimes inky-black, like the fluid disgorged by the cuttlefish; and it is thrown forth from the anus as well as the stomach.—(Jackson, op. cit.) Black vomit occurred more especially in the fatal epidemic of Antigua in 1816, which was decidedly an offspring of marsh effluvium. "The island had for some years," observes Dr. Musgrave (Medico-Chirurg. Trans., ix., 92), at whose description we have already glanced slightly,' " been peculiarly healthy ; and the dis- ease first showed itself in a swampy part of it, and amid new-comers, who were sailors, but from a healthy ship, and themselves in good health on first landing. It soon spread widely, and at length indiscriminately among all ranks, and conditions, and situations; among blacks and whites, the newly-arrived, and the oldest settlers in town and country." Nothing was better calculated than this fever, to show that almost all the different kinds of fever that occur to us are capable of issuing from a common source of miasm, merely modi- fied by contingencies ; for, in Antigua, they all occurred in different individuals. The disease sometimes commenced as an intermittent'-or re- mittent, and sometimes in a continued type ; it sometimes ceased in four or five days, which was its usual course, and sometimes terminated in an intermittent. The head was in some cases chiefly affected ; in others the stomach, liver, or some other organ : sometimes the pa- tient died without hiccough or black vomit, though he rarely recovered where these symptoms ap- peared ; Dr. Musgrave recollects but one in- stance. Recovery was no exemption against a second attack. In new-comers, the teint was of a lemon hue ; in native or assimilated consti- tutions, of a deep orange. The state of the atmosphere at the commencement of the dis- ease presented nothing peculiar. To the same effect, Dr. Dickson, in his valu- able official report:—" At Barbadoes and An- tigua, I had generally seen the disease of an ardent and continued form, and did not fully understand why authors talked of a bilious re- mittent yellow fever, until after the capture of Gen. III.—Spe. 2.] EPANETUS MALIGNUS. 377 the French and Danish islands. But the anom- alies of fever, the shades and changes which it assumes, according to the intensity of the ex- citing causes, the state of predisposition, or the spot of residence, could nowhere be more strongly portrayed, than in the destructive epidemic of Mariegalante in the autumn of 18G8, from the most concentrated marsh mias- mata ; where the different types of fever were converted into each other, of the worst and most aggravated species I have ever witnessed. Yellow fever in the continued form; others with comatose remittents or intermittents; the exa- cerbations of which were so violent as to carry off a patient in two or three paroxysms ; while others sunk into a low protracted character of fever, resembling typhus."—(Report, &c, pp. 143, 144.) In the midst, however, of so much discre- pance, there is still much that is concurrent, and quite enough to establish the identity of the two diseases, if an abundance of other evidence to the same purpose were not at hand. The fever of Dr. Pym, specifically characterized by black vomit, is represented as being peculiarly dangerous and fatal; in that of Dr. Musgrave, this symptom only occurred in the most perilous cases. According to the latter, the severest and most deadly attacks were among the new- comers ; the mildest among the natives, or those whose constitutions were assimilated to the climate. The yellow hue of the former (and I have already endeavoured to account for this) was of a deep orange ; that of the latter, a lemon colour. Dr. Pym describes three species of fever as common to warm climates, but which differ from each other in their mode of origin and diagnostic character. In that of least dan- ger, the colour of the surface, he tells us, is of " a very deep yellow;" in that of higher danger, it is of " a deep yellow;" and in the disease before us, which is by far the most fatal, where there is any yellow at all, it is of " a very pale lemon colour;" which is, in effect, the very hue ascribed to- the severest cases of the Antigua fever by Dr. Musgrave, as the "very deep yellow," or "orange," is to the mildest. So that, examined by their external livery, as well as their internal disorganization, there can be no doubt that the two diseases are the same. Dr. Pym appeals peculiarly, as a distinctive character of the Bulam fever, to the deadly and chlorotic paleness exhibited by the coun- tenance in its latest stage, or most fatal incur- sion. But even this only shows that, in such case, the disease makes a mortal attack upon the larger viscera, and especially the liver, from the first ; and demonstrates the proposition I have ventured to lay down, that, in proportion as this organ is severely affected, is its inability to secrete proper bile, or indeed bile of any kind; and, consequently, that if the irritation only reach a certain point, its secernents will be stimulated to emulge a larger quantity and of a deeper hue ; a considerable portion of which will be absorbed into the sanguiferous system, and pro- duce the orange tinge, which, in the description of both these writers, peculiarly marks the dis- ease before us in its less fatal attacks : while, if the febrile incursion be so violent as totally to derange the function, and still more the structure of the liver, no bile will be secreted at all, or, if secreted, less in quantity, and consequently less diffusive in colour ; and hence only convey- ing a chlorotic or livid tinge to the face, which, at the same time, exhibits a bloated fulness from effusion or debility of vascular action. In confirmation of this remark, Dr. Jackson's earlier cases of practice furnish numerous ex- amples ;—" examples indeed," to adopt his own words, " of that form of disease when there is a considerable degree of vascular excitement in the early stage, terminating commonly by deranging the functions of an organ of impor- tance—most frequently the liver or stomach. Yellowness and black-vomiting are common ; and it is more especially to this form, that the name of yellow fever has been applied : but though the yellowness and black-vomiting be common, they are not constant and essential. Determinations sometimes change suddenly; the brain becomes overwhelmed, and stupor and convulsion then cut short the ordinary rapid course."—(Hist, and Cure of Fever, chap, iv., p. 133.) Yet, after all, it is not - denied by Dr. Pym, nor, so far as I know, by any of the writers on the American or Andalusian fever, that the yellow fever from marsh miasm ever evinces either of the symptoms that are so essentially ascribed to the bilious remittent produced by contagion, but only that "it is rarely, if ever," to adopt Dr. Pym's own words, " attended with the fatal symptoms peculiar to the Bulam fever, viz., the black vomiting, and a peculiar bloated appearance of countenance." There would, however, be an almost insur- mountable difficulty in reconciling these differ- ent descriptions of the same disease, in conse- quence of Dr. Musgrave's telling us, very de- cisively, that not a single instance occurred in the Antigua fever of its being received by con- tagion, were there not strong reason for believ- ing that this explicit writer suffered himself to be deceived upon this point; most probably, like Dr. Pym and Dr. Jackson, from too close an attachment to the doctrine laid down by Dr, Cullen, that the fever from marsh miasm does not produce contagion, which is specifically a result of a fever from human effluvium. It is impossible to peruse the history of bil- ious remittents in warm climates, offered from all quarters, without seeing that it may origi- nate from both sources ; each sometimes opera- ting alone, and sometimes in conjunction with the other, as was probably the case at Antigua, and certainly the case in the yellow fever that raged at Philadelphia in 1793, in which, says Dr. Rush, there were, for several weeks, two sources of infection, viz., exhalation and conta- gion. The exhalation infected at the distance of three and four hundred yards, while the con- tagion infected only across the streets. The more narrow the streets, the more certainly the contagion infected. Few escaped it in al- leys. After the twelfth of September, the at- 378 H^M mosphere of every street in the city was loaded with contagion ; and there were few citizens in apparent good health who did not exhibit some mark or other of it in their bodies, particularly a preternatural quickness in the pulse, " which occurred in negroes, as well as in a few who had the disease before." In like manner, the Minorca fever, uniformly originating, as Dr. Boyd observes, in marsh miasm, frequently becomes contagious (De Fe- bre Minorca, &c, 1817) : of which, indeed, he has furnished us with a striking example in his own person: for we are told by Dr. Den- mark that he caught the fever from one of his patients, and nearly fell a victim to it.—(Med- ico-Chirurg. Transact., vi., 301.) But we have had occasion to examine this subject so much at length, in the introductory remarks to the present order, that it is unnecessary to pursue it further, except by introducing the following irresistible illustration :— Sir Gilbert Blane, having been requested by the Board of Admiralty to examine into the dreadful mortality that took place at the Island of Ascension, in the - summer of the present year, 1823, reported, and from the manuscript of this report I was permitted to copy, that the officers and privates of Ascension Island were first stationed there in September, 1821, in number twenty-eight, and continued in such full health as to be without the loss of a man till the arrival of the Bann sloop of war, in May, 1823. The Bann had left Sierra Leone towards the close of the preceding March, at which time the yellow fever was raging there with great mortality, and, at the time of sailing, had had no sickness of any kind on board : but, within a few days after sailing, the yellow fever made its appearance, and continued its ravages till the beginning of June : during which time, not less than ninety-nine men had been attacked by it, and thirty-three cut off, out of a crew of one hundred and seven Europeans and officers, independently of twenty-seven African super- numeraries, none of whom suffered from the disease. Upon the arrival of the Bann at the Isle of Ascension, an unrestricted communica- tion took place between the sick crew and the healthful garrison, the medical officers of the station having adopted the opinion that the yel- low fever is uncontagious. For want of such restrictions, within a few days after the arrival of the Bann, the garrison became affected, now reduced from twenty-eight to twenty-two, in consequence of six men having been ordered to a distant part. And, such was the dreadful mortality with which the disease raged, that, out of this garrison of twenty-two officers and soldiers, not less than sixteen died, being rather more than three fourths of the whole. The medical officers were soon, though too late, con- vinced of their delusion, and most unreservedly admitted the quality of contagion; and that the disease they were called to conteifiplate was genuine yellow fever, will be placed beyond a doubt by the two following symptoms, that the surgeon of the Bann particularly notices as among its other characters :—" the skin tinged ATICA. [Cl. HI.—Ord. 1. with yellow, assuming a deeper and deeper hue," and, " before death, the vomiting of a dark- coloured fluid, like coffee-grounds ;" conjoint symptoms, which, as Sir Gilbert Blane observes, will apply to no other epidemic whatever.* How fin- the tanks or pools of water within the range of the febrile miasm, from whichso- ever of the two sources produced, may become sufficiently impregnated to propagate the dis- ease, has not been sufficiently determined. The Tamul, or native practitioners on the Coroman- del coast, ascribe the epidemic that so often ravages their country to contaminated water as well as to contaminated air, and the able au- thors of the report on the Corimbatore fever incline to adopt this opinion. In France, where, consistently with the popu- lar doctrine of M. Broussais, the disease is supposed to be seated in the mucous texture of the stomach or intestines, and to be dependant on contagion alone,t as its means of propaga- tion, a considerable degree of fancy has of late been indulged in, respecting the origin of this contagion ; and the fancy has been varied ac- cording to the bent of the individual. Thus, M. Moreau de Jonne"s has endeavoured to show, in a work of some learning, but more imagina- tion (Monographic Hist, et Mid. de la Fievre Jaune des Antilles, &c), that the yellow fever, however at first produced, which has eluded his researches, has been perpetuated among Euro- peans, in the manner of plague, leprosy, and syphilis, by a specific poison that has existed immemoriaily among the Indians of St. Domin- go, and was communicated by them to the Spanish fleet, under the command of Columbus, in December, 1493, and from this fleet to all the world in succession, in consequence of the close intercourse which took place between the individuals of the new settlement of Isabella, colonized out of the fleet, and the adjoining na- tives. In answer to which, however, it is suffi- cient to observe, after Dr. Chisholm, that the Spanish writers, Herrera and Oviedo, appealed to in proof of this fact, rather unite in showing, that the Spanish settlers received the disease, in the first instance, from marsh miasm, and then communicated it to the natives themselves : while M. Adouard traces the same contagious poison to an effusion or exhalation from the mucous membrane of the stomach of the indi- * Future experience will decide, whether a fe- ver, corresponding to that now adverted to, will ever arise in Ascension Island, except under cir- cumstances similar to those stated by Sir Gilbert Blane. Fevers affecting the crew of a ship, how- ever, may be looked upon as happening in a situa- tion not the best adapted for ventilation, and where too many persons are congregated together ; under these conditions, no doubt, any prevalent fever may become infectious. The state of the weather and atmosphere, and the localities, to whose in- fluence the military were exposed in Ascension Island, about the period of their being taken ill, are particulars which should be studied in order to arrive at any very certain inference upon the sub- ject.—Ed. t This doctrine is on the decline in France, as already noticed in a previous page.—Ed. Gen. III.—Spe. 2.] EPANETUS MALIGNUS. 370 vidual affected, produced by an engorged or congested state of its vessels, and which, in consequence of the gaseous elasticity of the material thus eliminated, escapes by eructation, and propagates itself by being swallowed, and thus communicated to the stomachs of others ; on the mucous surface of which it commences a like action, and fructifies a like harvest of contagious matter ; the black material which remains behind being, in his opinion, a mere ca- put mortuum, unendowed with any infectious or other mischievous property.—(Relation Hist. et Mid. de la Fievre Jaune, qui a rignee en 1821, a Barcilone, 8vo., Paris, 1822.) There is much truth in this last position, whatever becomes of all the rest. Black vomit has been by many physicians, and was at one time supposed by Dr. Rush, to be vitiated and discoloured bile ; but it is now more generally conceived to be, as already stated, grumous or granular blood, let loose from the liver, stomach, or some other digestive organ, from the violent Commotion of the disease.* Dr. Bancroft af- firms that " it is always insipid;" and we have numerous instances of orderlies in sick rooms, who have had their hands and faces covered with black vomit suddenly ejected from the stomach, which they have taken little pains to wash off, while others have slept in sheets or blankets stained and inundated with its flow, and yet have escaped the complaint. It marks, indeed, the violence of the disease, and is hence, commonly, though not always, accom- panied with the formation of contagious miasm, but in itself it is not a source of contagion. The following instance of disgusting hardihood, though it has been brought forward in proof, not only of the innocuousness of black vomit, but of the uncontagious nature of yellow fever from any source, falls rather within the limit of an exceptive idiosyncrasy, in the-escape with which it was accompanied, than lays any foun- dation for a general rule. A. M. Guyon, of Fort Royal, Martinique, we are told in the Re- vue Medicale, had the bravery to wear, for twenty-four hours, the suit, drenched with sweat, of a soldier who had been labouring under this disease in its worst state; he suf- fered himself to be inoculated in both arms with the yellow matter issuing from suppura- ting blisters : he went into the bed of another patient, who had just died of the disease, while it was soiled with excrement; wore, at the same time, his shirt, soaked through with black sweat and still warm, and himself slept soundly, and sweated through a good part of six hours and a half, which he dedicated to this delectable trial; he exhibited several other feats of the same kind, and crowned the whole by drinking * The effusion of blood into the cavity of the stomach or intestines, it is thought, may occasion- ally depend upon certain states of that fluid itself, by which it is so modified, that it tends every- where to escape from the vessels. According to Andral, this is what happens in some examples of poisoning by absorption, and in typhus, and is the cause of the black vomit in yellow fever.— See Anat. Pathol., tom. ii., p. 151.—Ed. about two ounces of the black vomit discharged from the dead man's stomach—and, neverthe- less, entirely escaped the fever. Admitting the truth of this marvellous story, there is still no great difficulty in conceiving that a man, who was so totally torpid to all delicacy of mental feeling, might, at the same time, labour under a like torpitude of corporeal feeling, and be in- sensible to various irritants that would be sure to affect others.* It is probably owing to an idiosyncrasy, pro- ducing something of the same kind of insuscep- tibility to the action of the contagion of yellow fever, that while the miasmic poison for the most part takes place immediately, it sometimes continues dormant for an irideterminate period. Dr. Jackson has known it remain in this state for two months, and Dr. Bancroft for even nine or ten. The individual who has passed through the disease, is rarely attacked a second time. In the opinion of some physicians, he obtains hereby an immunity at least equal to that afforded by the smallpox.—(Report of the Army Medical Board on Dr. Pym's Observations.) The ex- amples, however, of recurrence are too numer- ous to justify such a comparison; though in most instances where the disease has return- ed, it has evinced a milder character. But this influence on the system, whatever it may amount to, seems to be lost by a short absence from tropical climates ; so that those who re- turn to Europe for a few months, are as open to all the effects of a febrile incursion, as though they had never been within the tropics before. As the larger viscera suffer very differently in different cases of this malady, the appearan- ces on dissection have generally kept pace with the previous indications : for, in some, the in- teguments of the brain, or even its vessels, its substance, and its cavities, have shown marks of inflammatory action, which have not been traced elsewhere ; while in others, whose brain has appeared sound throughout, the stomach and its collatitious organs have been found chiefly affect- ed with congestion, rupture, or, still more fre- quently, an erythematous inflammation, which, in some instances, has spread from the pylorus through nearly the entire range of the intestinal canal. In various other examinations, the chest has exhibited the chief seat of disorganization ; and in others again, the urinary organs.t The mucous membrane of the intestinal canal is by far the most frequently injured organ ; and this has been laid hold of with no small degree of triumph by M. Broussais and his adherents, as affording a manifest proof of the truth of their * In the Med. Chir. Trans, of Edinb., vol. ii., Dr. Ralph has published the History of Yellow Fever, as it appeared in the queen's regiment in Barbadoes in 1816 and 1817. The facts men- tioned by him, in proof of the disease not being communicable from one person to another, are remarkably strong ; indeed, such as leave scarcely any doubt on the subject, as far as the particular fever described by him was concerned.—Ed. f Bally, sur la Typhe Amerique ou Fievre Jaune, Paris, 8vo.—Palloni, Obs. Med. sur la Fievre reg. nante a Livourne, &c—Saveresy, de la Fievre Jaune en general, &c. 380 HAM* favourite doctrine : and that yellow fever can be no other than une gastrite, or, in still later language, une gastRo-enterite. But it should not be forgotten, that most of the gastric symp- toms, and all the severest ones, only occur in the course of the disease, and rarely in a very early part of it; and that they are hence rather to be regarded as effects of overwhelming febrile action upon the delicate and irritable texture of the membrane so severely excited, than as a proximate cause of the fever itself: and the more so, as sometimes the biliary system, the lungs, or the brain are chiefly affected, and the intestinal canal exhibits fewer proofs of suffer- ing than any of these organs. Unfortunately, the practitioners in warm cli- mates have differed as much in their therapia as in their etiology ; for the latter, as might be ex- pected, has greatly influenced the former. Dr. Lind, Dr. Clark, and Dr. Balfour, whose authori- ties were implicitly allowed and submitted to, some fifteen or twenty years since, alarmed at the debility which the system will have to encounter in the second stage of the disease, or as soon as it has run through its inflammatory career, shud- dered at the thought of the lancet, and gener- ally commenced with clearing the stomach and intestinal tube by gentle emetics or purgatives, or both, and immediately had recourse to the bark in as large doses as the patient's stomach could bear, paying little or no regard to the re- missions or exacerbations of the fever: though the last of these physicians chose calomel as his cathartic, and alternated its exhibition with the bark till the disease was subdued, or had effected its own triumph ; at the same time allowing a free use of opium to keep the bark on the stomach, as well as to allay pain and procure rest; to which were occasionally added wine and brandy in considerable abundance, three bot- tles of the latter having sometimes been given to a patient in less than twenty-four hours, and the same proportion continued for several days (M'Cabe, in Edin. Med'and Surg. Journ., Oct., 1819): while recourse was only had to the lancet, where there was obvious proof of very violent local affection. The times, however, have since changed, and by far the more popular plan of late years has consisted in active, profuse, and repeated vene- sections, large and quickly renewed doses of calomel, cold affusion, gestation in pure air, and, as advised by some, the bolder exercise and rapid motion of a cart, spring-wagon, or any other carriage.—(Hist, and Cure of Fever, by R. Jackson, M. D., part i., chap, xi., pp. 267, 270.) It was in this manner that Dr. Rush, regarding the inflammatory impetus as the sole cause of danger, boldly resolved to lay prostrate if possible the morbid Hercules at its birth, by bleeding, according to the state of the pulse, two or three times a day during the first two days, and by following up the same plan as long as a single germe of an inflammatory diathesis should continue manifest. " I paid no regard," says he, " to the dissolved state of the blood, when it appeared on the first or second day of the disorder, but repeated the bleedings after- LTICA. [Cl. HI.—Ord. I. ward, in every case, when the pulse continued to indicate it. It was common to see sizy blood succeed that which was dissolved. The dis- solved appearance of the blood I supposed to be the effect of a certain action of the bloodvessels upon it. The presence of petechiae did not deter me from repeating bloodletting where the pulse retained its fullness or tension." And he affirms, that both petechiae and vibices disappeared in va- rious cases after bleeding. This plan he often pursued through the fifth and even the seventh day, in the course of which period, from a hundred to a hundred and twenty ounces of blood were frequently taken away by six or eight applica- tions of the lancet. His purgative plan was not less alert. Ten grains of calomel and fifteen of jalap, was the force with which he opened his remedial attack, and which he repeated every six hours, till the alvine canal was effectually evacuated. This mode of treatment, he tells us, he was led to by accident; and with it he became as successful as he had been unsuccessful under the tamer and more established method. Under this plan of treatment, the venesection and the calomel were employed on a principle of depletion alone, and of diminishing a real or supposed increased action ; and the former on the principle of a gradual depletion ; Dr. Rush rarely venturing to withdraw more than sixteen ounces of blood at a time, though the venesec- tion was as closely repeated as the patient's strength was conceived to be capable of bearing. Both these remedies have, however, still more lately been employed on different grounds, and under a different mode of management. Blood, 'instead of being taken away gradually and suc- cessively, has by many, and especially by Dr. Jackson, who seems to have introduced the practice, been drawn off, on the accession of the disease, to thirty or forty ounces at once, witfi a view of making a decisive impression upon the system; the same bold use of the lancet being repeated within three hours, if such im- pression be not effected: after which, " such powers are recommended as stimulate to a train of action, congenial to the action of health" (Op. cit., pp. 267, 293): and calomel, instead of being employed as a purgative, has been en- listed as a powerful alterant and deobstruent, and persevered in, to salivation, by doses of from five to five-and-twenty or thirty grains every third or fourth hour, according to circumstances, till this point is obtained; which, however,.is not regarded as important in itself, but as showing that the system is sufficiently under its influence. Dr. Chisholm seems fairly entitled to the hon- our of having first tried and recommended mer- cury with this intention.—(Ibid.) " It ought," says he, "to be a general rule of practice to consider all remittent fevers, within the tropics, as symptomatic of local congestion, and inflam- mation. It is a rule, the observation of which can never be injurious,—almost always posi- tively beneficial,—and the neglect of which is always productive of harm. Under this view, the judicious practitioner will consider the ten- dency to congestion as the object of his main Gen. III.—Spe.2] EPANETUS MALIGNUS. 381 attention, and direct his efforts to prevent it. Upon the whole, then, the treatment is reduced to one sentence :—bleeding to the extent ne- cessary, plentiful alvine evacuation, mercurial ptyalism, and cold affusion" (On the Clim. and Dis. of Trop. Countries,^. 46,47); and he adds, in another part of the same volume, (p. 215) "let it never be forgotten, that, at whatever period of the disease salivation is excited, whether the sup- posed signs of putrefaction have appeared or not, the accession of it is the certain signal of ces- sation of disease, and of returning health." This general plan of Dr. Chisholm has in the present day become highly, and perhaps chiefly popular ; and is powerfully recommended from personal experience of its advantage by Dr. James Johnson (Op. cit., pp. 50, 51, et passim), Sir William Burnett (On the Bilious Remittent Fever of the Mediterranean), Dr. Boyd (De Fe- bre Minorca, &c, 1817), Dr. Denmark (Medico- Chir. Trans., vol. vi.), and a long list of valu- able authorities, who have practised in the one or the other of the Indies ; all of whom, how- ever, combine the use of calomel with copious bleeding; the former being regarded as the " sine quanon," or the " sheet-anchor," by some of them : and the latter being designated by the same terms, by others. On a cursory glance, these diversified modes of treatment appear, in many respects, to be directly hostile to each other, and to establish an utter absence of any one therapeutic princi- ple common to the whole ; but a closer atten- tion to the subject will show us, that there is not necessarily any opprobrium medicorum in the discrepance, except what results from be- coming so exclusively the champion of any one of these respective modes of treatment as to bend every case to its own limits, and thus con- vert it into a bed of Procrustes : for there seems abundant reason for believing, that, in different situations, or under different circumstances, each of these plans has proved equally judi- cious and successful; since we have seen, that the disease, under different incidents and co- adjuvants, has exhibited every variety of vio- lence, and inclined to almost every variety of febrile type. Where there is not much impet- uosity in the onset, no great derangement or prognostic of inflammatory congestion in the larger viscera, where the remissions are regular, and the epidemy is pretty uniform in its charac- ter, large and repeated bleedings, as a general rule, must prove mischievous. They will not shorten the career of the disease, but they will convert the remittent into a continued fever: and we shall in the latter stage of its course stand wofully in need of that strength which we shall have squandered away at first, if we have commenced with profuse venesection. This is more especially the case where the disease makes its attack slowly and insidiously, assuming in some degree a typhous guise, as in the Guzzerat form, described by Mr. Gibson of the Bombay Medical Department (Edin. Med. and Surg. Journ., vol. xi.): in which he tells us, that the debility is so great and instantane- ous, as well as the tendency to putridity, that bleeding is never to be hazarded, except oc- casionally to the robust new-comer;~ and in which, even spontaneous hemorrhages, instead of proving critical, have always seemed to hasten death, and, indeed, without a single exception in his experience, to prove fatal. And it was probably from a survey composed largely of cases of this kind, though in the West Indies, that Dr. Hunter, in a tone still more generally prescriptive, and which will meet with few de- fenders at present, thought himself justified in affirming respecting venesection, that, even " in such cases as seemed most to require it—for example, where the patient was young, strong, of a full habit, and lately arrived from Europe —when the pulse was quick and full, the face flushed, with great heat and headache—and all these at the beginning of the fever—bleeding did no good."—(On the Diseases of Jamaica, p. 118, 3d edit.) Dr. Pinckard, in his " Notes on the West In- dies" (Vol. iii., letter xii., p. 134), has given a very interesting description of his own sufferings under this disease, and of the remedial process to which he had recourse. His attack com- menced in the more common manner, slowly and insidiously, and demanded eight or nine days to reach its acme. His head, stomach, and at last his bowels, were severely affected, especially the first; but his intellect continued sound ; and though the symptoms were vehement, there seems to have been little tendency to that vio- lent visceral inflammation which in the stage of debility is so apt to produce gangrene ; and con- sequently he had no black vomit. He lost twelve or fourteen ounces of blood at the comr mencement of the disease, and took a strong dose of calomel, which considerably relieved the pain in his head and eyes, and diminished the restlessness ; but the thirst, heat, and dryness- of the skin were still intense ; and his weakness became extreme. Affusions of cold water, old hock, opium, and bark, were made use of in profusion, and each seemed to afford great re- lief. Yet, on the subsidence of the fever, he represents his feebleness as most deplorable. Here a freer use of the lancet could have been of no avail, and, had not the author most judi- ciously forbade its further employment, in all- probability, he would never have been the his- torian of his own case. On the contrary, if the disease make its in- cursion with great impetuosity ; if the pulse be full and strong, or even if it be only hard, and there be great tendency to inflammatory conges- tion in any of the larger organs, as the head, the chest, or, as is far more common, the stom- ach, the spleen, and the liver, we cannot well be too bold both in bleeding and purging ; and the plan laid down by Dr. Rush is by no means an exaggeration of what ought to be pursued. It may be, that eight-and-forty or even four-and- twenty hours are the whole we have to work in ; and unless we can completely break down the inflammatory diathesis, the organs mostly affected will in all probability become gangre- nous in a day or two, the oppressed bloodves- sels will give way, and we shall have a chlo- 382 HiEMATICA. [Cl. III.—Ord. I. rotic or livid skin, cold extremities, black vomit, and all the other apparitors of death, before the tamer plan of aperients and diaphoretics could have time to produce the slightest impression on the system. Generally speaking, it will be best to bleed in an erect position, for the sen- sorial excitement, which is what we are chiefly to aim at, is best cut down by syncope, which an erect position will soonest induce ; and we may hence save the expense of several subse- quent bleedings. Dr. Pym speaks with a very just discrimina- tion upon this subject, in observing that, while the Bulam fever, or the disease in its most vio- lent attack, is relieved by free venesection, the yellow fever, more properly so called from the brighter hue on the surface, or, in other words, that which is slighter in its incursion, will not often endure the lancet. Dr. Musgrave's state- ment seems to oppose this assertion, for he dis- tinctly tells us, that " bloodletting in both forms is our sheet-anchor ; the only pillar on which we can securely rest any hope of extensive success." The Antigua fever seems to have exhibited great severity in most instances, and hence called for a courageous course of practice with perhaps few exceptions. Yet the following paragraph proves that it did admitof exceptions, and softens down almost to unanimity a clash of opinion and prac- tice which, after all, is more ostensible than real:—" We have repeatedly," says he, " with success, taken upwards of forty ounces of blood at one bleeding. With equal success we have in several cases renewed the bleeding up to the third, and even the fourth time ; but gener- ally speaking, those which require such reiter- ated evacuation evince an obstinacy not likely '■ to admit of a favourable result under any MODE OF TREATMENT. It MUST ALSO BE RE- MEMBERED, THAT EVERY ONE WHO APPLIES FOR ASSISTANCE IS NOT ALIKE ABLE TO BEAR THIS liberal depletion." It only needs to be ob- served further, that the bowels were emptied, as they ought to be, by calomel or jalap, or some other active purgative ; the head was shaven, and cold ablution preferred ordinarily to cold affusion, because of the fatigue endured under the latter. Bark was then instantly given, and, where the stomach would bear it, in the form of powder. Mercury, with a view of exciting sali- vation, was seldom tried, and not relied upon. In effect, in the milder cases it was not wanted for this purpose, and, in the more urgent, there was no time for its use. There can be no doubt, however, of its being highly advantageous in a great multitude of cases, and of general benefit in various forms of this destructive epidemy. For, whether we con- template the feyer as local or unrestrained, as consisting in violent universal excitement, or, according to M. Broussais, in an inflammation of the mucous membrane of the stomach or du- odenum irritating the bile-ducts, and the liver itself by sympathy ; whether as threatening con- gestion to any of the larger organs, or actually accompanying congestion; there is no medi- cine which, prima facie, affords a better pros- pect of relief than mercury, from its general ac- tion on the excernent system, as well as its specific action on the intestinal canal and the salivary glands. It must, however, be admitted that it is only under a particular condition and tone of the vascular frame that it can at any time be employed with good effect; and hence, not only is a sound judgment constantly de- manded in its application, but much important time is often lost in preparing the system for its remedial introduction. In the case of entonic or strong vascular action, it is necessary, first of all, to lower, and, in the case of atonic or weak vascular action, to raise the living power to the proper standard before ptyalism can be obtained, which is the grand test of its having taken effect ; and hence, to accomplish the former, bleeding, purgatives, and cold affusion, must be first called upon to exercise their re- spective powers, and, in the latter case, tonics and cordials ; upon which last ground, Swediaur (Nov. Nosol. Meth., Syst. i., 28) tells us that the most efficacious plan of treatment consists in giving calomel and columbo, in doses of thirty- five grains each, five or six times a day. It is truly said, indeed, by the advocates for mer- cury, that such other remedies are all valuable adjuvants ; and this is so far from being denied by those who are hostile to the use of mercury, that they affirm, on the contrary, that the benefit ascribed to this medicine, when it has once ob- tained a sway over the system, ought rather to be attributed to these adjuvants themselves, which would have proved still more beneficial had they been left to their own power and in- tention alone. Mr. Gibson, who is a strenuous advocate for the use of mercury upon the prin- ciple now adverted to, very candidly admits both these causes of impediment. "In hotter.cli- mates," says he, alluding to the debilitating province of Guzzerat, " the phlogistic state of the system is adverse to the introduction of mercury : but the prudent abstraction of blood happily reduces it to that standard which is most favourable for its action. In India, however, in fever, the disease in which this is most speedily to be desired, the same means would but in very few cases be admissible : for the debility is so great and instantaneous, as well as the tendency to putridity, that only in the robust new-comer is it, if ever, to be h azarded. It wou Id seem that debility and the plethoric sys- tem are equally inimical to the specific mercurial action. If the patient is fortu- nately invigorated sufficiently to give the mer- cury influence, and before any organ essen- tial to life is injured, by the strictest nursing and attention afterward, the recovery is almost certain, all morbid action yielding from the mo- ment ptyalism is brought on."—(Edin. Med. and Surg. Journ., vol. xi.) Even in cases, however, in which the mer- curial action is fortunately excited, the same intelligent writer tells us that he has frequently met with a very serious evil resulting from the mercury itself; for such, says he, is at times the profusion of the ptyalism, when once induced, that the most disagreeable consequences suc- ceed, and the convalescence is long and preca- Gen. III.—Spe. 2.] EPANETUS MALIGNUS. 383 rious; on which account he laments that we have no Criterion to determine how far we may proceed with the mercurial process, and when we ought to stop. Dr. Bancroft advances much further than this, and asserts that not only has the salivation retarded the convalescence, and produced very troublesome affections of the tongue, mouth, and throat, with other ill conse- quences thus acknowledged by its advocates, but that the salivators, even when they have been free from these evils, have not been more successful than other practitioners ; and he par- ticularly alludes to the admission of Dr. Rush, who was not unfriendly to the mercurial mode of treatment, that, " in the City Hospital (of Philadelphia), when bleeding was sparingly used, and the physicians depended chiefly upon sali- vation, more than one half died of all the pa- tients who were admitted."—(Essay on the Disease called Yellow Fever, &c, Philadelphia, 8vo., 1811.) For like reasons, Dr. Jackson speaks with as little satisfaction of the same practice, not only upon his own experience, but even upon that of Dr. Chisholm himself. Al- luding to the high recommendation of mercury by the latter, he observes, " the detail of his testimonies does not warrant a conclusion so fa- vourable ; for the proportion of mortality in the detachment of Royal Artillery, upon whom this practice is supposed to have been first tried, has perhaps scarcely ever been exceeded in a trop- ical climate. Further, it is a common obser- vation, that, where salivation actually takes place in continued fevers, it seldom shows itself till the violence of the symptoms has evidently abated : hence, a suggestion arises that the ap- pearance of salivation is only an indication of the departure of the disease—no proof exists that the operation of the mercury is the cause of this departure- Such are the remarks which occurred in reviewing different modes of treat- ment in the hospitals of St. Domingo ; to which it will not be superfluous to add an experiment made at the Mole in August, 1796, by Mr. Lind, Surgeon of Jamaica. Out of fifteen cases of fever put under the care of Mr. Lind, on the first day of the disease, and treated with the utmost attention, five died ; in three of whom, salivation actually took place ; five recovered, in whom no salivation took place ; in the other five, who also recovered, salivation was evidently es- tablished ; but, as 13 usual, not till the violence Of the symptoms had begun to abate. Out of four who were put under his care on the second day of the disease, no one died ; but one only was affected by the mercury ; one, brought to the hospital on the third day of the illness, died : mercury was employed, but no salivation took place ; one, on the fourth, likewise died, without marks of salivation ; one, on the fifth—the sali- vation was established, but the disease proved fatal. In none of the above cases were less than ten drachms, and in most not less than two ounces of strong mercurial ointment rubbed into the legs and thighs, with the employment of all other means which seemed calculated to promote the expected effect,"—(History and Cure of Fever, part i., ch. xi., pp. 293, 294.) The question, therefore, to say the least of it, is still open ; and, admitting all that can be said-in favour of employing mercury as a siala- gogue, the evils which flow from the uncertainty of its action, both in respect to time and de- gree, and its frequent inroads upon the consti- tution, even where it has been of use, are seri- ous and important. On the employment of emetics, there is now no longer any question. It is admitted, on all hands, that, in the irritability of the stomach and its collateral organs during this disease, they are generally improper, and almost constantly augment the morbid action ; on which account, even the antimonial sudorifics are of very doubt- ful efficacy, and, whenever ventured upon, should be combined with opium. And, for the same reason, the use of carriage exercise, so strongly recommended by Dr. Jackson, and some of the most distinguished American prac- titioners, even "under the inconveniences of a scorching sun, of clouds of dust, and of a jolt- ing cart" (Ut supra, p. 287), has rarely been put to the test, except in the emergency of the sud- den retreat of an army : and has hardly been al- lowed to enter into the catalogue of ordinary remedies. The general treatment, indeed, may be summed up in few words. Copious bleeding, a free repetition of active purgatives, combined with opium where the ventricular irritation is considerable, in the commencement ofthe fever; frequent sponging, or affusion of cold water, with an interposition of the neutralized salts as diaphoretics, during its progress ; and bark and other tonics, as soon as the febrile commotion begins to subside. The more powerful and vi- olent remedies of repeated bleedings to faint- ness, mercurial salivation, or the stimulants of spirits, ether, and opium, being alone added to the list, according to the circumstances of the individual case. Pure air, by a ventilation of the atmosphere, is, however, a more powerful remedial agent than all the rest put together ; and to this posi- tion I apprehend every class of writers will ac- cede, how much soever they may differ upon other points. The Army Medical Board is, therefore, peculiarly entitled to the gratitude of the country for the great pains it has taken to give improvement to this important object, by an establishment of open and wide-spreading encampments, instead of confined and unper- flated barracks ; and no man can- hear of the desirable success with which this enlightened measure has been attended without exultation. The attempt, as I am permitted to state from the manuscript documents in the possession of the Board, has been made at Barbadoes, Tobago, and Antigua; not more than four individuals being allowed to occupy a single tent, instead of ten or twelve, which is the usual proportion at home : and the success developed in these islands has already become so considerable and decisive, that government has consented that a like trial should be made in all the islands around them. In the affected crew of the Pyramus, distributed by Dr. Hartley into an encampment 384 H^M at Antigua, in the year 1822, not a single case of fever was found to travel from one individual to another. We cannot wonder, therefore, at beholding this able officer anxious, in his report for 1823, that the same plan should be extended to other places, and adopted in other diseases. " In cases of sickness," says he, " and especially in yellow fever, I feel convinced in my own mind, that nothing could prove so beneficial in check- ing the ravages of this disease, as separating the troops ; and particularly by removing them to some distant dry field from the locality of the attack. Nothing could more immediately sub- stantiate the advantages of removing and en- camping a body of men, than the result in the Pyramus's crew," In Barbadoes, where, as I have just observed, the same improvement has obtained a footing, the mortality for the last two years is almost incredibly abated. I have examined the tables subjoined to the annual reports in the office of the Army Medical Board, and have found that, from having been upon an average of seven years, about one in twenty-one of the sick list, in 1822, the mortality was only one in twenty- four ; and, in 1823, only one in thirty-five. In this last year, however, it should be observed, that the hospital list was somewhat enlarged by the occurrence of an influenza unaccompanied with much danger ; yet the aggregate of patients amounted to not more than about a hundred beyond those of the preceding year. I am ready to allow, that several other important regula- tions, for which we are equally indebted to the vigilance and the judgment of the Army Medi- cal Board, may have contributed to this salutary * Under the head of epanetus malignus, Dr. Good has described several forms of fever, which by some clinical writers have been deemed to pos- sess characteristics sufficiently dissimilar to jus- tify a different classification. It is not the province of the editor, however, at any time to interfere with the material arrangement of the book, and more particularly in this instance, as the non-prev- alence of epanetus malignus flavus in the north- em and middle sections of the United States in latter years, has prevented him from observing its nature. He will therefore merely add a few re- marks derived from the writings of American authors, who have had ample experience with yel- low fever, and whose productions, if they had been within reach of Dr. Good, would doubtless have been mentioned in these pages. Many American physicians richly deserve a no- ble reward for their efforts to alleviate public ca- lamity, by their various expositions on the vexed subject of contagion and infection in febrile disor- ders, and particularly in relation to the malignant yellow fever, as it has occasionally appeared in different parts of our country. Disclaiming to espouse with implicit confidence the theoretical views of any writers on the Bulam, the malignant, the pestilential, the yellow, or the bilious remittent fever, or to vouch for the accu- racy of even our most ingenious native authors, the editor will only refer to some particular sources of information, which should be examined by those desirous of a more extensive and better knowledge of yellow fever than is to be found in the text. For additional information in respect to the early appearance of yellow fever, besides the sources VTICA. [Cl. III.—Ord. I. change ; but the greater part of it is still, per- haps, to be ascribed to the new plan of encamp- ing. I cannot give a better description of the adjuvant regulations I am now referring to, than by adopting the words of Mr. Tegart, an en- lightened inspector of hospitals at Barbadoes, who, in his manuscript report for 1823, thus enumerates them, and at the same time confirms the ameliorated health of the soldiers quartered in that station, and to which I have just referred. " The loss in that year," alluding to 1822, or the preceding, " was so comparatively small with former ones, that I hardly hoped to send so fa- vourable a one again. This return, however, ex- ceeds greatly any hopes I could have anticipated; being not one half the average amount of the preceding six years ; and not a sixth part of the yearly loss sustained in the fourteen years ante- cedent to those. There are many reasons for this favourable change : the men are better clothed, better fed, and better looked after by their officers; there are many local improve- ments in the vicinity of the barracks, which for- merly were not much attended to : such as drain- ing swampy and marsh ground; clearing away brushwood and long grass, which harboured mois- ture, and emitted, at certain seasons, noxious ex- halations, producing fever and other diseases, the treatment of which was very different from that of the present day. I believe most sincerely, that we are also indebted for the favourable comparison in the scale of mortality to the im- proved education of medical men, to the dis- coveries in the various branches of medical sci- ence, and to the rationale of medical practice."* The writer of this work cannot avoid adding his already referred to, the reader may consult Hughes' Hist, of Barbadoes, and Towne on Yellow Fever. Dr. Moseley's work on Tropical Diseases contains an able article on the West India Ardent Fever, which he terms the causus of Hippocrates, in which opinion he is followed by some American authors. An excellent tract on the West India Disorder, is that by Dr. Fowle on the Ardent Fever, and the same is true of the treatise by Dr. Warren, on the Disease at Barbadoes. The well-known paper on Yellow Fever by Dr. Lining, of Charles- ton, S. C, in the Edin. Lit. and Phil. Essays, and the remarks on the same subject in the History of South Carolina, by the late American historian, Dr. Ramsay, should also command attention. Dr. Rush's several histories of the Yellow Fever, as it has prevailed in the United States, will be found replete with valuable information.—-(See his Med. Obs. and Inq., 4 vols., 8vo ) Dr. Samuel Brown published an essay on the Yellow Fever of Boston, in J 800. Dr. Colden's account of the Yellow Fever of New-Vork, in 1741-2; Dr. Bayley's remarks on the same disease, as it appeared in New-York in 1795; Dr. John Mitchell's description of the same in Virginia (see Francis and Hosack's Amer. Med. and Phil. Register), and the talented essays of the late Dr. Edward Miller (Med. Writings, New-York, 1814), may be consulted with profit. Professor Potter, of Baltimore, has traced the history of yellow fever from 1607 to 1622. But with the exception of Dr. Rush, no American has written so repeatedly and so largely on this pestilence as Dr. Hosack of New-York. He earnestly contends for its foreign origin, its spe- cific character, and its contagious nature under Gsn. III.—Spe. 2.] EPANETUS MALIGNUS. 385 conscientious assent to the correctness of these views.* There is another variety of malignant remits tent, which has been known to medical prac- certain circumstances;—(See his Medical Essays, 3 vols., 8vo-, New-York, 1824.) Professor Cald- well, of the University of Transylvania, in his appendix to Alibert on Intermittents, has given an account of the yellow fever in Philadelphia, and many valuable articles on the same subject maybe found in the Facts and Observations of the College of Physicians at Philadelphia, and in Additional Facts; also in the Philadelphia Medical Museum of Dr. Coxe, and the Philad Medical Recorder. Papers on the yellow fever have been published also in the Med. and PhiL Register, edited by Drs. Hosack and Francis, in the New-York Med. Re- pository of Drs. Miller, Mitchell, and others, and the New-York Med. and Phys. Journal, edited by Drs. Francis, Beck, and Dyckman. The pecu- liarity of the immunity of the constitution from a second attack of yellow fever was first noticed by Dr. Pym, of London, in 1815, and in June, 1816, Dr. J. W. Francis called the attention of Ameri- can practitioners to this fact, in a letter dated at London.—(See New-York Med. and Phys. Jour- nal, vol. i.) The reappearance of the yellow fe- ver in New-York in 1822, renewed with much ar- dour the controversy concerning its contagious character, and a volume of much research, main- taining its specific nature and contagiousness, was published by Dr. Townsend, New-York, 1822. The publications of Mr. Hardie should also be consulted. He has written distinct histories of the disease, as it invaded New-York in 1795-8,1803-5, and 1822. Other papers on the disease, as it has appeared in the southern and southwestern states, may be found in the different volumes of the Am. Journ. of Med. Sci.,in the Transylvania Journ., &c. The pathology of yellow fever has been ad- vanced by Dr. Physic's account of the results of post mortem examinations, made in 1793; from them, he concludes, that this disease is attended with a high degree of inflammation of the stomach. Dr. Cothrell's analysis of the black vomit may be found in the Trans, of the Am. Phil. Sec, vol. v. Perhaps no writer has described the pathogno- monic signs of yellow fever as distinct from bilious remittent fever, with more philosophical acuteness than Sir Gilbert Blane in his work on the Diseases of Seamen ; and some of our ablest writers, who in their views of yellow fever have confounded diseases of different origins, might consult his work with singular profit. It has justly been remarked, that some forms of bilious remittent fever occurring in the interior of our country, viz., those of great violence and of short duration, resemble the yellow fever very much ; hence the unity of these two forms of dis- ease has been maintained. A paper, pointing out the pernicious tendency of this too hasty general- ization, drawn up by Dr. Norcom, of North Caro- lina, may be found in Hosack and Francis's Am. Med. and Phil. Reg., vol. i., p. 17; it throws light on an intricate subject, and is worthy of a close perusal.—D. * Our author has not spoken of the proposal to cut short the disease by the administration of bark, arsenic, or other antiperiodic remedies, as in inter- mittent fever. Now, with reference to this sug- gestion, Dr. Joseph Brown very judiciously ob- serves, that, in order for it to be tried with safety, the remission must be so perfect as to amount to an actual apyrexia, and the disease would then be identified with intermittent fever; and he has almost uniformly noticed, that the employment of Vol. l.—Bb titioners from the time of the Greeks, though less frequent than the yellow fever, and which, by Hippocrates, has been denominated causus ; as it has by later writers, who have only trans- lated the Greek term, been called febris ar- dens, ardent or burning remittent. From its being usually accompanied with much dis- turbance of the stomach and intestines, it is called by Professor Frank, febris gastrico-in- flammatoria, as the last variety is febris gas- trico-ncrvosa. In Hippocrates, it is briefly de- scribed as a fever, characterized by extreme heat, violent thirst, a rough and black tongue, complexion inclined to yellowish, saliva bilious. There is commonly an acute aching in the head, nausea, great anxiety of the praecordia, with fre- quently a gnawing pain at the stomach. The bowels are unusually costive, particularly at the commencement of the disease. The tongue, mouth, nostrils, and, indeed, the whole surface of the body, are parched, and fiery-hot, whence, indeed, the Greek name for the disease ; the pulse is full and strong; the voice hoarse ; the breathing short and quick, with sometimes a slight cough, and occasionally delirium. It chiefly attacks the young and the vigorous, who bear the attack better than old persons. The causes to which it was formerly ascribed are, long exposure to the heat of the sun, great fatigue from undue exercise or labour, or too heating a diet. It has of late, however, been supposed, and with much plausibility, from its frequent occurrence towards the autumnal equi- nox, and especially from its resemblance to the yellow fever, that, like the latter, its ordinary remote cause is the miasm of swamps and marshes. And if so, it affords us a proof that, under certain modifications, febrile miasm issu- ing from this source may, as I have already sug- gested, produce a caumatic or inflammatory, as well as a synochous or typhous tendency, in constitutions predisposed to this character of fever ;* for the causus is, in fact, whatever be its cause, a vehement inflammatory remittent. It is on this account, that Dr. Mosely conceived the causus of the ancients, and the yellow fever of the present day, to be one and the same dis- ease ; whence he applies to the latter the Greek name of causus. This, however, is not quite correct: for in the real causus, the burn- ing heat is more intense, the thirst more intoler- able ; while the stomach is generally less irrita- ble, and will bear vomiting with advantage : and, in the second stage, the chilliness which, in the yellow fever, is merely accompanied with horripilation, and is a mischievous symptom, in the causus is accompanied with a smart rigour, which often terminates in a copious and salu- tary sweat. The process, moreover, in the causus, generally lasts only four days, and is any antiperiodic in truly remittent fevers not only failed, but invested the disease with a more con- tinued and dangerous character.—Cyclop, of Pract. Med., art. Fever.—Ed. * Deveze, Traite de la Fievre Jaune, 8vo., Paris, 1820. Sayeresy, De la Fievre Jaune en generate, et particulierement de celle qui a regnee a la Mar- tinique en l'an 1803-4. 386 HiEMATICA. [Cl. III.—Ord. I. terminated, when left to itself, by a critical di- aphoresis, vomiting, diarrhoea, or nasal hemor- rhage ; but if the fever be not carried off in this way, it commonly becomes fatal. We have, nevertheless, satisfactory proofs, that though the causus and yellow fever be not the same disease, both often issue from the same febrile miasm, and sometimes run their race conjointly; the difference depending chiefly upon the idiosyncrasy, or the peculiar condition of the constitution at the time of attack. Thus, in- that most formidable assault of yel- low fever which took place at the Mole in St. Domingo, in the autumn of 1796, Dr. Jackson tells us, that "the symptoms of the disease, among a set of men vigorous by nature, and often transgressing the rules of temperance, were ardent and violent, with much vascular ex- citement in the early periods, often subsiding on the third day, and terminating rapidly in black vomiting, and a formidable train of horrors."— (Op. cit., p. 66.) And he has since met with the same form in Spain, which, in effect, constitutes his first division of the Andalusian fever.—(Re- marks on the Epidemic Yellow Fever on the South Coast of Spain, London, 8vo., 1821.) And, hence, Dr. Chisholm informs us, that " the diseases which originally proceed from marsh exhalations, may be so impressed with the action of irregular temperature as to render them highly inflammatory, although the charac- ter and nature of the original are so manifest, as to make a mode of treatment suitable to the two diatheses, or rather the mixed diathesis, prevailing in the system, necessary." And, in proof of his remark, he has quoted several in- stances from the Report of the Army Medical Board, of which that which occurred in the year 1812, at Brimstone Hill, St. Christopher's, is probably most worthy of notice, on account of the topography and general healthiness of the spot, which is described as follows :— " Situation, N. Lat. 17°—soil light"and dry— composition, rock and sand—elevation, six hun- dred feet—distance from the sea, a quarter of a mile. Barracks exposed to currents of air and strong winds, directed on them by ravines. No swamps in the neighbourhood. Change of tem- perature sudden, from 70° to 80° and 90° in the course of a few hours. Rain abundant. Prob- able cause, previous hot dry weather, ill-venti- lated and ill-constructed barracks, some of them bomb-proof. Epidemic cause unknown ; and prevalence of the disease cannot be accounted for." The cause, however, is not difficult to assign ; and, in truth, we have already adverted to it in describing the occasional origin of yellow fever : for, however dry and elevated the situation may be, yet, on the descent of copious and continued rains, such as are here set down, a temporary swamp is very soon produced, and of sufficient power, in hot climates, to generate, even " on a light and dry soil, and a sandy rock," febrile miasm enough for the severest epidemic ; and especially where such miasm receives the col- lateral aid of ill-ventilated barracks, and cur- lents of cold air blowing down long ravines di- rectly upon the troops while in a state of per- spiration ; and producing a sudden abstraction of animal heat, more mischievous, perhaps, within the tropics, than on the banks of the "Cop- per-mine river during the snows of the winter season, where, as Captain Franklin informs us, the Chippewayan Indians find them the most detrimental and destructive to life of all the nu- merous and heavy evils to which they are expo- sed.—(Nar. of a Journey to the Shores of the Polar Sea, dec, p. 249, Lond., 4to., 1823.) The fever continued through the winter, evi- dently in this case kept up by its having become contagious. It was at first confined to one of the barracks occupied by a company of the 25th regiment; and its symptoms are thus briefly but forcibly described :—" Type continued :—thir- ty-four admissions from this company alone : symptoms, in all, of a most unfavourable charac- ter from the first attack; great headache, sick- ness, and vomiting ; pulse full and hard ; eyes in- flamed ; face flushed ; ardent heat of the skin ; in many cases yellowness of the whole body on the second day of the disease. The entire number of cases was four hundred and twenty- two : of which not fewer than one hundred and eighteen died, affording a mortality that treads close upon the heels of that in the plague." In the treatment of this variety, the advocates for copious bleeding and for free doses of calo- mel may shake hands ; for both may be allowed with liberality. The calomel, however, is found most successful when combined with antimo- nials or Dover's powder. Free purging is also to be strongly recommended ; the means, in ef- fect, whatever they are, must be vigorous to be of any avail: for the disease itself is of great vigour and rapidity ; and, unless prostrated at the onset, will soon prostrate the patient. In conjunction with this process, we may also adopt that of Hippocrates, who, in the burning remit- tent of his own day, employed cold applications in every way : the coldest possible drinks ; and the coldest possible clysters, and ablution with cold water applied to every part of the body.— (mpi nu6W, p. 518, lib. 48, 51, p. 419, lib. 37.) Under proper regulations, there is no doubt of the advantage of such a treatment; and the medical process of the continent, as well as that of our own country, throngs with cases in which it has been found serviceable. Marquet recom- mends (Observations sur la Guirison de plu- sieurs Maladies) the application of cold air as well as of cold water; and gives an instance of a rapid cure in one who, in a state of de- lirium, exposed himself naked to the cold of the atmosphere out of doors. And on this account Schaffer advises (Versuche, i., p. 164), that the patient, in any acute fever accompanied with dry burning heat, should be carried forth from his chamber on a mattress, and thoroughly ven- tilated abroad. Dr. Jackson would indeed have him ventilated in any way, even on a cart or wagon, if there be no easier conveyance. In the preceding varieties, the malignant re- mittent has shown a tendency to an inflamma- tory or a synochous career. Under particular circumstances, however, it evinces a like inch- £en. III.—Spe. 2.] EPANETUS nation to a deep nervous depression, sensorial debility, or a typhous character from the first. And this, whether the febrile miasm originate from a decomposition of marsh or of human ef- fluvium ; for the records of medicine furnish us with innumerable instances of both. In the two cases, however, there are' a few slight variations iai the range and mode of its action, the laws of which I have already endeavoured to lay down as far as we are acquainted with them (p. 343); and hence M. Bally, confounding this variety with proper yellow fever, calls the latter the American typhus, and makes two divisions of it, a contagious and an uncontagious, accord- ing to its degree of violence.—(Sur le Typhus d'Amirique, ou Fievre Jaune, &c, Paris, 8vo.) This modification of the disease, therefore, is best distinguished by the name of asthenic REMITTENT. The epidemics of this kind, accompanied with most mortality, are those which arise from a decomposition of human effluvium in the midst of filth, poverty, or famine, great heat and moisture, crowded multitudes, and a stagnant atmosphere : for here we have almost all the auxiliaries of febrile miasm operating for its production. The remittent epidemics of Cadiz and Malaga seem chiefly to have been of this kind ; and they are the common pestilences of dispirited armies, maintaining their ground with difficulty in the midst of great carnage, sur- rounded by the dead and the dying, reduced to short provisions, and worn out by the fatigues of the campaign. The writings of Sir John Pringle are full of examples of this kind : and Professor de Haen has given a striking descrip- tion of the same in his account of the conta- gious epidemy that committed such tremendous havoc throughout the Prussian army, at Bres- law and its vicinity, in the middle of the last centuiy, constituting the disease to which M. de Sauvages has given the name of Tritaeophya Vratislaviensis. It was peculiarly distinguished by irregular action, great debility, and over- whelming dejection of mind. The lipyria, or coldness of the surface, with which the disease opened, rarely yielded to any general reaction, for the extremities seldom became warm, and were often rigid and convulsive ; at the same time that the interior parts burned like a fire ; the head and stomach suffered with acute pain ; there was great anxiety about the praecordia; and so exquisite a soreness over the entire sur- face, that the patient had the greatest dread of being exposed to the contact of the external air, a mere change of the temperature being intoler- able. De Haen himself at length became a prey to the infection, and his attack commenced as thus far stated. On the fourth day, he tells us, all his symptoms were worse, his feet quite chilled, but his hands red, and agitated with convulsive motions ; he had occasional vomit- ings, and was terrified with the image of im- pending death. On the eighth day the pulse was convulsive, and he was continually crying out from his pains. On the ninth, delirium, and a rejection of grumous blood from the stomach. On the eleventh, perspiration and a B b2 MALIGNUS. 387 tranquil pulse, but the voice was broken, the speech was interrupted, and the teeth grated On the twelfth, the jaw was convulsed, there was a sardonic laugh and deafness. On the fourteenth, an icy coldness covered the whole body, accompanied with a cold sweat, but a frequent use of ablutions afforded relief. On the eighteenth, he had a vivid delirium, but fainted on being taken out of bed; which was succeeded by hunger, copious sweats, and pro- found sleep, with an intolerance of noise. At this time, every thing appeared new and extra- ordinary ; a feeling described by many sufferers as soon as the violence of the disease begins to abate, and which Dr. Pinckard has very stri- kingly noticed in his own case. The symptoms varied considerably from this period, and he had still many dangers to contend with. He recov- ered, however, though very slowly, and with numerous drawbacks ; for, on the thirty-sixth day, he had a cholera, and on the forty-eighth, his skin scaled off and he lost his nails. Towards the close of the disease, the skin was covered with a scabid or ichorous eruption, rather than petechiae ; evidently from debility of the capillaries : a fact that has often occurred even in the slighter attacks of this variety of remittent in our own country, when it has occasionally broken out, as in 1765, among the troops stationed in the vicinity of Portsmouth, and is particularly noticed by Dr. Lind. In this last case, it was often suspected to be the itch, to which it had a very near resemblance : and it is highly probable that, in many instances, it was so, and that the acarus scabiei found, in the sores, a convenient nidus for the deposite of its eggs. There are situations, however, in which the febrile miasm, producing this low variety of remittent, is generated by a decomposition of the stagnant matter of humid marsh-lands; such chiefly are the regions about Cape Coast, in Africa, especially when visited by the foul and smouldering harmattan, and about Gom- brow, or, as Sir John Chardin calls it, Bander- Abassi, on the Gulf of Persia (Voyage du Chev- alier Chardin, &c, tom. ix., p. 511-518) : in which last place the mortality is so severe between the months of April and September, that the deaths are ordinarily calculated at nine out of ten of the inhabitants, and this notwith- standing that most of them retire during such period towards the mountains, and all mercan- tile concerns are relinquished ; so that, says the chevalier, " la moisson est fermee, comme un parle." The diseased are commonly removed higher up the country as soon as they sicken ; but, whether removed or not, they usually die in four or five days. There can be no doubt, that, in both these places, the danger of the disease may be aug- mented by the dense and stinking vapour that is perpetually blowing upon them during the pestilential season, the " puantes vapeurs de Ia mer," as Sir John expresses himself, " qui font bondir le coeur la premiere fois qu'on les sent." These, on the African coast, are impregnated from the impenetrable mangrove swamps of the 388 HiEMATICA. [Cl. HI.—Ord. 1. interior of Guinea, and on the Persian, from the saline and sulphurous exhalations of the several adjoining islands, which the winds of the season pass over in their periodical sweep; and the copious disengagement of hydrogen, whose pres- ence the intolerable stench seems to indicate, will account in no small degree for the deficien- cy of living power, which so peculiarly distin- guishes the malignant remittent in these quarters. In the latter region, indeed, some such debilita- ting influence seems to operate habitually : for the ingenious author thus quoted adds, that " the nations carry in their complexion and constitution the proofs of their malignant atmo- sphere, being yellow and ghastly from the age of twenty-one, and decrepit at thirty." Of the destructive power of such vapours, we have sufficient proof from what occurs on the coast of Batavia, and the islands that immediately surround if: for if, by judicious treatment, a patient in this quarter should become convales- cent from an attack of yellow fever, he is still almost certain of falling a prey to the disinvig- orating and deliquescent influence of the noi- some exhalation by which he is surrounded, and especially between sunset and sunrise, un- less timely removed to a more salubrious quarter. We may hence readily conceive how yellow fever may, under certain circumstances, have a strong tendency to the same asthenic character, and run rapidly into a typhous form, or be com- bined with its symptoms from the first. This is, in truth, the hybrid disease of Sir Gilbert Blane, Dr. Lempriere, and Dr. Dickson. " In certain seasons," says Dr. Jackson (Op. cit., 277), "in certain situations, and in certain periods of the year, the character of the en- demic is insidious and malignant. The disease under those circumstances often begins regular- ly as a single tertian ; and two, and sometimes three revolutions pass over without giving any alarm to ordinary observers: but at one or other of the above periods, a paroxysm com- mences with coma, stupor, and suspension of functions, threatening immediate destruction : or, as often happens, the energy of action be- comes less and less distinct in every succeeding paroxysm ; the skin becomes dry, or damp and greasy, the powers of life are overwhelmed, the pulse contracts itself, or becomes apparently weaker and weaker under the use of bark, wine, and the strongest stimulants of the materia medica." His second form of the Andalusian fever of 1820, is precisely to the same effect.— (Remarks on the Epidemic, &c, on the South Coasts of Spain, 1821.) It is to this variety of the endemic of inter- tropical regions, that Dr. Chisholm has given the name of malignant pestilential fever. " It must be kept in mind," says he (Op. cit., p. 167), "that this, the most tremendous of all the tropical diseases, wherever it appears, is the typhus of Europe, grafted on the yellow remit- tent fever of the torrid zone, or of countries whose climate, during part of summer and autumn, possesses the temperature of the torrid zone."—" It is evident," says he in another place (p. 43), " that typhous infection does exist, perhaps does originate, within the tropics. How fraught with mischief, therefore, is that theoretical notion, that such infection cannot exist, cannot originate, and cannot be propaga- ted in hot climates. Let the-young and un- experienced practitioner guard himself against it, and be prepared for it when he meets it." Dr. Chisholm offers a variety of examples in proof of this assertion, to several of which he had been an eyewitness, especially to that which is so well known to have broken out in the unfortunate attempt to colonize the Island of Bulam, in the spring of 1793, and which gave rise to the fever of this name, so strikingly characterized by its asthenic signs. He has noticed others also, of nearly equal demonstra- tion, extracted from the reports communicated to the Army Medical Board of our own countiy. But, perhaps, none offer more striking proofs of this peculiar type than the Edam remittent of 1800, described by Mr. Shields, and that of Trinidad of 1819, described by Dr. M'Cabe. —(Edin. Med. and Surg. Journ., Oct., 1819.) In the former of these, the marks of an extreme debility were often peculiarly impressive from the first. The patient, with little previous notice, was seized with giddiness and cold chills, great sense of weakness, pain over the orbits and in the epigastrium, together with vomiting. He frequently fell down and was insensible during the paroxysm, his body cover- ed with a cold clammy sweat, except the pit of the stomach, which always felt hot to the patea of the hand ; the pulse was small and quick; great torpor in the intestinal canal; the pupil dilated and incontractile ; great despondency at first, then low delirium or insensibility to danger. The patients, while on the island, were carried off in eighteen, twenty-four, thirty, or forty hours: though often, when removed, not till after as many days. So malignant, indeed, was this pestilence, that "almost every one who slept on the island a single night died." The organs chiefly affected were first the brain, and in succession the stomach- and liver. In the Trinidad remittent, so reduced was the vital energy, that it was found necessary, in various instances, to give the patient three bottles of brandy in less than twenty-four hours, and to continue this proportion for several days. The treatment has here varied as much as in yellow fever ; in truth, it ought to vary—not, indeed, according to preconceived and general hypotheses, whose only variance consists in fighting general rules against general rules, but in modifying the plan, whatever it may consist in, to the peculiar case. Bleeding, however, must never form a part of the general practice, how necessary soever it may be in particular instances where atonic congestion may oppress the head or any other large organ. And even in such instances, it will generally be found more expedient to em- ploy calomel in large and repeated doses, than the lancet, unless we see the patient at the very opening of the disease. Under either practice, the bowels must be opened, and kept . open by active purgatives; since, from tha Gen. III.—Spe. 3.] EPANETUS general disturbance of the functionary balance, there is violent action in the abdominal viscera, while the vessels on the surface are entirely torpid. To restore this balance should be our uniform effort: and hence, in conjunction with the above, nothing bids fairer, or has in fact been found more successful, than the use of warm diaphoretics with opium. Cold water as. a beverage, or in the form of injection, has also proved a highly refreshing tonic ; frequent pota- tions of old hock still more so. The bark is a doubtful remedy, for it often sits uneasy on the stomach, and is rejected. It has hence fallen into undeserved disrepute. When, however, it harmonizes with the stomach, and is retained without oppression, itis entitled to all the praise that has been bestowed on it by former writers, and cannot be given too freely. The best prep- aration of it for the present purpose is undoubt- edly the sulphate of quinine. Ablution with cold water has been tried very generally du- ring the malignant remittents of most climates, and always with very great advantage.—(Epi-. demia verna qua Wratislaviam, anno 1737, afliixit. Vide Act. Nat. Curios., tom. x.) SPECIES III. EPANETUS HECTICA. HECTIC FEVER. tfULSE WEAK ; STAGES OF CHILLINESS, HEAT AND SWEAT VARIOUSLY INTERMIXED, AND SOME- TIMES SINGLE ; COLD STAGE EXHAUSTING ; EXACERBATION CHIEFLY IN THE EVENING. The symptoms of this species, except in its sweating stages, are far less violent, and conse- quently its duration is far longer, than that of either of the preceding. Nothing, however, can more fully prove its complexity and irregularity, than the different characters given of it, and the different places allotted to it by different authors. Sauvages and Sagar introduce it into the list of continued fevers : Linnaeus, Crichton, and Parr, into the present division, or that of remitting and exacerbating fevers : Boerhaave regards it as of a mixed nature, a continued intermittent. "Febris hectica," says he, "est referenda ad febres continuatas intermittentes." Vogel and Cullen degrade it into a mere symptomatic af- fection. " As I have never," says the latter, "observed a fever of this kind except when symptomatic, I could not consent to admit it into the list of idiopathic fevers, which alone ought to be enumerated." Those who have adopted Dr. Cullen's opinion, have usually contemplated it as a mere effect of absorbed pus. Dr. Heberden seems to think it dependant upon a local cause, but that irrita- bility in any diseased organ, which cannot be brought into a healthy state, will excite it as effectually as pus introduced into the system.* * The late Dr. Thomas Young, when a boy, had every symptom of tubercles in the lungs, accom- panied by hectic fever ; but they never attained the stage of suppuration.—See his Practical and Historical Treatise on Consumptive Diseases, de- i HECTICA. 389 On the contrary, Galen, Mr. John Hunter, and Dr. Willan contend, that hectic may be, and often is, a strictly idiopathic affection. The second of these valuable writers regards hectic fever as of two sorts, symptomatic and idio- pathic.—(On Blood, part ii., chap, ix., sect. 1.=) The first he ascribes entirely to local irritability, and opposes the idea that it is ever produced by absorbed pus. His argument is, that if ab- sorbed pus be capable of producing it in one instance, it ought in every instance: but this we know is not the case ; for we have had large buboes and even empyemas removed by absorption suddenly, and yet no hectic has taken place. He does not think that more pus is absorbed during the existence of hectic fever, than when no such fever is present: but, admitting that this should be the case, he would rather ascribe the increased absorp- tion to the hectic constitution operating upon the abscess or sore, than to the abscess or sore operating upon the constitution ; in which case the hectic diathesis is the cause, and the increased absorption is only the effect. So that, even here, he regards the hectic as a pri- mary or constitutional disease. As a symptomatic affection, however, he re- fers it lo a general irritability of the constitu- tion, produced by sympathy, in consequence of " some incurable local disease of a vital part, or of a common part when of some magni- tude ;"* and which becomes incurable from two causes ; firstly, because, though the local irritation is small, the constitution is bad, and does not dispose the parts to a healing state z and, secondly, because, though the constitu- tion is good, the local irritation is so considera- ble, that it cannot muster up a sufficiency of remedial energy to subdue it; and hence, while sympathizing in the irritable action, falls a prey to its own efforts. Yet, says he, it is possible for hectic fever to be an original disease of the constitution; for the constitution may fall into the same mode of action without any local cause whatever, at least that we know of. And in this manner he accounts for its existence as an idiopathic af- fection. And, in effect, nothing is more com- mon than for hectic fever to exist in patients in duced from Original Observations, and collected from Authors of all Ages, 8vo., 1815.—Ed. * The period at which the commencement of hectic fever takes place from local irritation or disease, and also the severity of it, are influenced very much by the seat of the original affection, as well as by its nature and extent. " The system will much more readily sympathize with an ab- scess, or other disease of a vital organ, such as the lungs, heart, liver, stomach, intestines, mesen- teric glands, or kidneys, than with a. similar dis- order, existing in the muscular or cellular tissue, near the surface of the body." Diseased lungs will more quickly bring on hectic symptoms than diseased joints; though, the power of joints to repair some of their injuries and morbid changes, being very inferior to those of many other parts, their diseases are often tedious, and frequently in- curable, so that we cannot be surprised to find them often associated with hectic disturbance of the system.—Ed, 390 H/EM whom we can trace no local cause whatever : and, in all such cases, we must either indulge in a gratuitous hypothesis, and throw our suspicions at random upon the lungs, or the liver, or the kidneys, or the heart, or the mesenteric glands, or whatever other organ a few casual symptoms may suggest to the fancy : or we must at least act upon the principle of its being an idiopathic affection, even though we should refuse, in terms, to admit that it is so. " I willingly subscribe," says Dr. Percival of Dublin, in his manuscript comment upon the author's Nosology, " to idiopathic hectic, and have known it to last three months without any pulmonary affection, and then to break out in the lungs."* There seems, indeed, great reason for admit- ting, with Dr. Stoll (Protect., p. 19), a hab- itus phthisicorum, a hectic diathesis or tem- perament, the features of which are, for the most part, strongly marked, and are to be found in a fair skin, blue eyes, yellow hair, lax fibre, and sanguine disposition. And, wherever this exists, it is probable that most of the causes of other fevers, operating upon it, will produce a hectic. + And we can hence readily account for the examples cited by different authors of its being produced by diseased actions or affec- tions of the heart, stomach, mesentery, fiver, pancreas, lungs, or brain ; by a suppression of various exanthems, or other eruptions, or of va- rious habitual discharges, natural or morbid; by other fevers; by chronic inflammations or abscesses. It is well known to be a common eequel to the measles, occasionally so to the * With regard to this case, the editor fully coin- cides with the remark made on it by Dr. Joseph Brown. " From the extreme difficulty of detect- ing the presence of tubercles in their unsoftened state, even with the improved method of diagnosis now employed, is it not reasonable to conclude, that these bodies had existed in the lungs unde- tected, and produced the fever; since we find this affection, which of all is most frequently attended with hectic, ultimately displaying itself by mani- fest signs ?" Some years ago Dr. Brown saw a case of apparently idiopathic hectic, which proved fatal: on examination of the body, small abscesses were found in the muscular substance ofthe heart. —Cyclop, of Pract. Med., art. Fever, p. 246.—Ed. t These are the commonly described emblems of a scrofulous habit in which tubercles, and other forms of local disease, are frequent. Instead of adopting the author's hypothesis, and that of idiopathic hectic, it would be more correct to re- gard hectic fever as a protracted constitutional disturbance, excited and kept up by some local ir- ritation or disease, which is either not immediately curable, or totally incapable of relief. Mr. Hunter considered hectic fever as the remote consequence of a local injury or disease, contrasting it with sympathetic inflammatory fever, which he sets down as the immediate or earlier effect on the system. He also divides hectic fever into two kinds; one depending upon a disease which would be curable, if the constitution had strength enough to bear the struggle ; the other arising from a dis- ease that is absolutely incurable. When Mr. Hunter speaks of spontaneous hectic fever, he seems to mean really nothing more, than that the Cause of it is not apparent.—Ep, \TICA. [Cl. Ill —Of». i smallpox, and, in a few instances, to rosalia, or scarlet fever. It may, hence, be a result of dyspepsy; and one case is said to have been produced by eating bacon, which remained un- digested in the stomach for a term of eighteen months, when it was disgorged by sickness, and the hectic symptoms disappeared.—(Arnold, Diss, de Hecticd Stomachid, 1743.) And it is hence possible that hectic fever may occasion- ally spring, like other remittents, from febrile miasm.* The character of the disease is well given by Mr. John Hunter in the following words :— " Hectic may be said to be a slow mode of dis- solution ; the general symptoms are those of a low or slow fever, attended with weakness, but more with the action of weakness than real weakness ; for, upon the removal of the hectic cause, the action of strength is immediately produced, as well as every natural function, however much it was decreased before. The particular symptoms are, debility ; a small, quick, . and sharp pulse ; the blood forsaking the skin ; loss of appetite ; often rejection of all aliment by the stomach ; wasting ; a great readiness to be thrown into sweats ; sweating spontaneously when in bed; frequently a constitutional pur- ging."—To which he adds, " the water clear." There is, in reality, much difference of opinion upon this last point. Dr. Heberden has ob- served, that the same irregularity which accom- panies most other symptoms of the disease, at- tends this also; that the urine is equally clear or turbid in the exacerbations and the intervals ; sometimes clear in the first and turbid in the second; and sometimes turbid in the first and clear in the second ; while Dr. Duncan, from long and assiduous attention, asserts, that the urine is peculiarly distinguished by a natural furfuraceous separation. Such is the character it has usually exhibited in my own practice ; though, where authorities thus clash, it is not a symptom to be depended upon as a pathog- nomonic. From the frequent approaches which the hectic makes towards a perfect apyrexy, it is sometimes apt to be confounded with an inter- mittent ; but there is rarely any remission in which the pulse is not at least ten strokes in a minute quicker than it ought to be.; and by this it is sufficiently distinguishable, as it is also by the greater irregularity of its different stages, and, indeed, of all its symptoms. It is owing to this last feature that, some- times, the exacerbation commences with a chilly fit, and sometimes without; and that, where there is a chilly fit, sometimes it is immediately succeeded by heat, but sometimes by perspira- tion, without any intervening hot fit; while oc- casionally the cold fit only leads to heat, or even terminates singly without either heat or perspi- ration. Hence the exacerbations must vary in duration : but even where every stage is pres- * Hectic fever may follow visceral disease, brought on by other fevers, but certainly it cannot be correctly stated to be in any instance directly brought on by febrile miasm,—Ep. Gen. TV] ENE ent, and succeeds in regular order, the duration of the entire exacerbation is almostequally un- certain, insomuch that it is seldom that three exacerbations of equal length recur in succes- sion. The remissions will sometimes extend to ten or twelve days, without a single intervening pyrectic symptom: and sometimes the cold or the hot fit, or the sweating, will be renewed several times in the same day. Yet, let the per- spiration appear whenever it may, the patient is never relieved by it, but is as anxious and rest- less during its continuance as in the heat or chill. Dr. Heberden (Trans, of the College, vol. ii., art. i., p. 6) has sometimes seen a hectic at- tack persons who seemed in tolerable health, in a sudden and violent manner, like a common in- flammatory fever : and, like that, in a little time bring them into imminent danger of their lives ; after which it has abated, and afforded hopes of recovery. But the hopes have been deceitful; for, the hectic has still been fed by some lurk- ing mischief; some concealed local disease ; and, resisting the power of medicine, has grad- ually undermined the patient's health and de- stroyed him. More commonly, however, hectic fever com- mences slowly and insidiously, and is not sus- pected for some months: and the only symp- toms noticeable are, lassitude upon slight exer- cise, loss of appetite, and a wasting of the flesh. But, if these symptoms be connected with a gen- eral increase of pulse, so that the artery beats from ninety to a hundred or a hundred and twenty strokes in a minute, there will be real ground for apprehension. This is one of many diseases, in which the art of medicine has hitherto laboured in vain to strike into any direct track of cure. The real cause is commonly involved in great and impenetrable obscurity, and we can do little more than attack single symptoms as they make their appearance. Where the disease is evidently symptomatic, the case must depend upon curing, or, if incu- rable, upon removing, when this can be accom- plished, the part affected. When idiopathic, we must combat, as far as we are able, the irritable diathesis ; and, above all things, en- deavour to strengthen, without increasing, ihe action of the machine. The best sedatives as well as tonics are acids, and of these the vege- table will usually be found preferable to the mineral, since, on account of their corrosive property, the latter can only be taken in small quantities. They abate the febrile heat, di- minish the restlessness, and frequently succeed in checking the night-sweats. And if, as is often the case, the patient be tormented with pains in the limbs or joints, resembling rheuma- tism, and preventing him from sleeping, we may combine the acids with opium. The bowels must be kept regular by gentle laxatives, and the neutral salts seem to answer this purpose better than most others. It will, however, be convenient to vary them occasionally, and some- times to exchange them for the senna confec- tion, or some other aperient. :cia. 391 Stimulants rarely answer any good purpose ? and, in many instances, evidently heighten and accelerate the exacerbation. ' The Peruvian balsam has been given advantageously with nitre ; but myrrh is a medicine of fairer prom- ise ; and beyond these, we can scarcely ever venture to proceed. The fighter bitters are certainly serviceable in many cases, and may conveniently be em- ployed in combination with the acids ; but bark, though tried in numerous instances, and with great perseverance, has not been found success- ful. Dr. Heberden, however, says, that he never saw it do any harm in the hectic fever, and his opinion is confirmed by that of Sir Ed- ward Hulse, after having prescribed it for forty years. Yet neither of them ever obtained proofs of any beneficial result.* A light and regular diet, regular hours, and gentle exercise, are coadjutants of great im- portance. When the disease is dependant upon some local affection, the Bath waters have often afforded a palliative degree of relief; but in idiopathic cases, they usually augment the fever, aggravate the patient's sufferings, and hasten his death. GENUS IV. ENECIA. CONTINUED FEVER. ONE SERIES OF INCREASE AND DECREASE ; WITH A TENDENCY TO EXACERBATION AND REMISSION, FOR THE MOST PART APPEARING TWICE EVERY TWENTY-FOUR HOURS. We now enter upon the important genus of continued fevers, or those which run their course, not indeed without any change or rel- axation whatever, as many of them were sup- posed to do formerly, and were distinguished by the term continentes, but with occasjonal and slight fluxes and refluxes, which bear the same proportions to the exacerbations and remissions of the epanetus, as these do to the paroxysms and intervals of the anetus, or intermittent. When there are two tides or fluxes within the twenty-four hours, the one occurs in the morn- ing, and the other in the evening. The last is always the most distinct ; and takes place usually between five and six o'clock, which is somewhat later than the latest of the par- oxysms of genuine intermitting fevers ; that of the quartan, which is the latest of the whole, usually occurring before five o'clock. It should also be farther observed, that, where continued fever discovers but one augmentation in the twenty-four hours, it is always that of the even- ing. Dr. Fordyce attempts to show that, even in a state of the firmest health, we constantly discover some tendency to a little febrile affec- tion every evening; this he calls the natural evening paroxysm of fever; and to this habit * The lighter preparations of bark, as the sul- phate of quinine, and the infusum cinchonae, are often found to be eligible tonics in hectic cases; yet they cannot be expected to accomplish much good, if the cause of the constitutional disturb- ance continue undiminished, or unremoved.—Ed. 392 HJEM he ascribes the existence of an evening increase of continued fever. The genus thus defined and characterized, includes the three following species :— 1. Enecia Cauma. Inflammatory Fever. 2.-------Typhus. Typhus Fever. 3. —----Synochus. Synochal Fever. Sauvages draws a line of distinction between these three from their respective duration, as well as from their more essential symptoms, affirming that the cauma terminates in a week at the farthest ^ the typhus in two, though sometimes protracted to three weeks ; while the synochus reaches beyond the second, and often beyond the third week. As a general rule, this remark is worth keeping in mind; but, the deviations from it, in all the species, are too frequent to enable us to lay hold of it in as- signing their specific character. SPECIES I. ENECIA CAUMA. INFLAMMATORY FEVER. HEAT GREATLY INCREASED ; PULSE QUICK, HARD, AND STRONG ; URINE RBD ; DISTURB- ANCE OF THE MIND SLIGHT. This species has been distinguished by a variety of names by different nosologists and other medical writers; the chief of which are, imputrid synochus, which is that of Galen ; imputrid continued fever, which is that of Boer- haave ; imputrid continent, which is that of Lommius ; sanguineous continued fever, which is that of Hoffmann; and synocha, which is that of Sauvages, Linnfcus, Cullen, and most writers of the present day. Of these, Synocha, for. reasons stated in the comment to the Noso- logical Synopsis, is the worst; it has no clear or correct etymological meaning; it has been nsed in different senses by different writers, and approaches so nearly to synochus, used as ex- tensively by most of the same writers, as to create a perpetual confusion in the minds of young students; and the more so, as the dis- ease before us is expressly denominated syno- chus by Vogel, while most writers employ this term to import a different species of fever. On all which accounts, I have judged it right to exchange synocha for cauma, a term already employed for the same purpose by Dr. Young, and which, derived from, xatia, " uro," is ety- mologically significant of the character of the disease it designates. The common English term, inflammatory fever, is excellent; and is, in truth, a direct translation of the Greek term cauma. Dr. Fordyce denominates it general inflammation: by which he clearly intimates, that this species of fever bears a near resem- blance to the symptomatic fever produced by the local affections called phlegmasia?, or phlo- gotica, which constitute the next order of the present class, to which the term inflammations is now commonly limited ; but which Dr. For- dyce would distinguish by the term " local in- flammations." In effect, inflammatory fever and the fever ATICA. [Cl. III.—Ord. I. of inflammations bear the same relations to each other, as the idiopathic and symptomatic hectic : in both, there may be a general or a local remote cause; but, the influence upon the constitution will be the same, whatever be the source of excitement. It has been doubted, however, whether cauma or inflammatory fever ever exists without a local cause ; and Dr. Cul- len, who does not allow that hectic fever is ever found without a local cause, distinctly affirms, that he has never seen inflammatory fever ex- isting under the same circumstances ; whence Dr. Clarke, of Newcastle-upon-Tyne, who has too much generalized the subject, has struck inflammatory fever entirely out of the list of diseases, contending, that even the term in- flammatory ought never tb be applied to fever, excepting when fever itself only exists as a concomitant of some local affection :* while Dr. Clutterbuck, as we have already observed, has contended, that this local cause is at all times, and under every variety of fever, an inflamma- tion of the brain. If, however, a cause of this kind be ever fairly made out, a variety of facts, of late detection, will be far more likely to fix it in an inflammation of the arteries, the arteri- tis of the French writers, who have recently examined the subject at considerable length, especially MM. Portal (Cours d'Anatom. Midic, tom. iii., p. 127, 1804), Dalbant, and Vaidy (Diet, des Sciences Medicates: Journ. Com- plement-, vi., Aout, 1819); and to which Dr. Frank has, indeed, already ascribed inflam- matory fever in one of its forms.—(De Cur. Horn. Morb. Epit., lib. i.,4 118, 8vo., Manheim, 1791.) But the subject is still involved in great obscurity, as it is doubtful whether the change of arterial structure, which has been found after death in many cases of supposed arteritis, has been really an effect of inflamma- tory action. In acute rheumatism, it is proba- bly a frequent cause or concomitant; but this is a question we shall have occasion to return to under that disease. How far either hectic or inflammatory fever may, under particular circumstances of human or atmospherical con- stitutions, occasionally originate from marsh or contagious miasm, it is difficult to determine ; but as Dr. Cullen was peculiarly desirous of reducing all fevers to these two sources ; and as, to say the least, they are not obvious sources of either of the diseases in question, his mind appears to have received some bias from this fact in rejecting them from the list of idiopathic fevers. And as it has already been shown that this decision has laid a foundation for much of that " tug of war" in which many * Observations on Fevers, &c, 8vo., London, 1779. Though Dr, Tweedie does not distinctly represent this fever as being essentially connected with local inflammation, as a cause, he observes, that " it is necessary to bear in mind the local in- flammations which almost invariably arise in the course of these acute fevers, and the effect of such complications on the febrile symptoms."— See Dr. Tweedie's Treatise on Continued Fever and its Modifications, p, 49,12mo., Lond., 1832.— Editor. Gen. IV.—Spe. 1.] ENECIA distinguished members of the profession have of late years been engaged, respecting the na- ture and treatment of particular species of fever, it is highly probable, also, that several of the more recent hypotheses, concerning its proxi- mate cause, have originated from the same spring. Inflammatory fever, as it has often occurred in the author's own practice, and in that of others who have described it, usually commences with the symptoms of an acute ephemera, and may in fact be contemplated as the same dis- ease running on from four or five to about eleven days, without intermission, or a renewal of the cold fit. It commences with a sense of languor and inaptitude for exertion, with a dis- relish for food, which continues for a day, or perhaps two. There is then chilliness and soreness over the surface, with nausea and headache, succeeded in the evening by a great increase of heat, and at night by perspiration, with great thirst, restlessness, and sometimes delirium ; sometimes, in young persons, convul- sions, with a stupid drowsiness. The bowels are usually costive, the urine high-coloured, and the pulse quick and hard. With Dr. Fordyce, the grand pathognomonic symptom of cauma is hardness of the pulse. This accompanies it from first to last, in its simplest and in its severest state. When the disease is mild, it is hard alone; when more violent, it is at the same time full, strong, and frequent. The obstructed pulse is often Con- founded with the hard, and it is not easy to distinguish them without considerable practice. There is rigidity of resistance to the finger in each, but of a different kind. In the hard pulse, it is much firmer and tenser ; and is sup- posed by Dr. Fordyce to result from such ah increase of arterial contraction as to overbal- ance its correspondent dilatation. It indicates, in his opinion, a very high degree of living power, and is peculiarly characterized by a tardy coagulation of the blood when drawn freely into a hemispheric basin, in consequence of whi£fethe red particles have time to subside, and leave the surface colourless, or with a buffy appearance. In the obstructed pulse, on the contrary, the blood coagulates at once; and, the red particles not having time to separate, the surface is of the same hue as the cake below. The disease sometimes terminates abruptly with a critical sweat, or some other evacuation, on the fourth or fifth day; but more usually in- creases in violence, though with occasional declinations, for a week longer; during which time the pulse rises to a hundred, or a hundred and ten strokes in a minute, but continues reg- ular ; the nausea subsides, and the patient will take and retain whatever is offered to him of simple nutriment or medicine ; the thirst is less violent, but the tongue is deeply furred, and the lips are parched. The disease is not often dangerous; and about the eleventh day gradually subsides, or yields to some critical discharge, which is usu- ally that of a free and alleviating perspiration. CAUMA 393 The pulse soon sinks to eighty, and the chief symptom is weakness. During the course of the fever, every organ suffers from its morbid and increasing impetus ; but they do not all suffer alike: for in some parts there is, occasionally, a greater resist- ance to the flow of the circulating fluid than in others, whence that acute pain, which is often complained of in the head or the side : in the latter case, sometimes amounting to pleuralgia. And, not unfrequently, the vessels of one part will give way more readily than those of an- other, and there will be a sense of heaviness and oppression in the head, the heart, or the lungs ; as though some effusion had taken place, which, in some instances, is perhaps actually the case. If the head be much affected, delir- ium is a frequent result, with ravings and vio- lence, rather than the low muttering incoherence of asthenic fevers. From the history already given of the malig- nant causus, or ardent malignant remittent, it appears probable, that inflammatory fever may sometimes be produced from febrile miasm, though it is commonly derived from other sources. Of these, the stimulus of violent pas- sions is, perhaps, one of the most common; and especially upon a vigorous and plethoric habit, which is the usual temperament in which inflammatory fever makes its appearance. Un- due muscular exercise, heating foods, or excesses of any kind in the same habit, are also frequent causes; while another may be found in the suppression of any accustomed discharge, as that of menstruation, epistaxis, or periodical bloodletting. Suddenly suppressed 'perspira- tion is, in like manner, a frequent, perhaps the most frequent cause of any ; especially when the body is very hot, and the change is effected by exposure to a temperature of great cold, ap- plied externally or internally, as that of a cur- rent of cold air, a large draught of cold water, or plunging into a river. Some writers, as Sennert and _ Crichton, have supposed inflammatory fever to be occa- sionally produced by an absorption of bile into the bloodvessels under the excitement of a tropical sun, or of a torrid summer in milder regions; and they suppose that the bile is, in this case, possessed of a more than ordinary degree of acrimony, and that the symptoms are varied by a more pungent heat and more intol- erable thirst, with a more scanty secretion of urine, preternaturafly acrid and high-coloured. That bile of this description is often forced back into the system under the circumstances here supposed, is unquestionable ; as it is also that inflammatory fever is a frequent accompa- niment of this morbid change. But, notwith- standing the above authorities, such fever seems less attributable to the reflux of bile into the blood, than to the insolation or solar excite- ment ; which, by unduly stimulating the liver, has been the cause of an overflow of bilious secretion. How far a more irritant or exalted acrimony may be communicated to bile thus operated upon, or what may be its effect upon the system, admitting it to take place, it is dif» 394 HjEMATICA. [Cl. III.—Ord. I. ficult to determine ; but there is much reason to doubt whether genuine bile in the sanguif- erous system is ever a cause of fever, or stim- ulates the heart or arteries to increased action. For if this were the case, jaundice would always be accompanied with inflammatory fever. In- stead of which, however, we find it accompa- nied with atony instead of entony, or diminished instead of increased power.* Sauvages gives a case, in which inflammatory fever was produced by a mechanical irritation cf the meninges of the brain, by a lodgment of vermicles in the frontal sinus, of which sev- enty-two were discharged during a fit of vom- iting and sneezing, from which time the patient began to recover. These vermicles were most probably the lar- vae of some species of the oestrus, or gadfly, which had crept up into the frontal sinus, after being hatched in the nostrils, in which the pa- rent insect had deposited her minute eggs. This is a very common affection in grazing quadrupeds, and especially in sheep, which are often peculiarly tormented, and sometimes driven almost mad, by the violence of the irritation. Stoll gives a case in which the brain, on ex- amination after death, was found deluged with serum—diluvium serosum.—(Mat. Med., iii., p. 294.) But such an appearance is rather to be regarded as an effect, than a cause of the dis- ease ; as an instance of cephalitis profunda, in consequence of the brain having suffered more than any other organ from the inflammatory impetus. Hence the following varieties are noticeable under the present species : a Plethoricum. Produced in a plethoric Plethoric inflamma- habit by great mental tory fever. or muscular excitement, or heating foods ; Or by a sudden suppression of perspiration, or of other accustomed discharges. 0 Biliosum. Accompanied with an ex- Bilious inflamma- cessive secretion of bile, tory fever. ' absorbed into the san- guineous system. y Pleuriticum. Accompanied with a vio- Pleuritic inflamma- lent stitch or pain in the tory fever. side. 5 Cephalalgicum. Accompanied with aeute Cephalalgic inflam- pain in the head. matory fever. As an inflammatory diathesis constitutes the essence of this fever, the cure must depend altogether upon a reduction of the vascular, and especially of the arterial entony : always bear- ing in mind the possibility, that the disease may suddenly lose its inflammatory character, and rapidly pass into that of a typhus. Regulated by this view, we should generally commence with bleeding and cooling purgatives. There are a few cases, indeed, in which bleeding may * Inflammatory fever in the United States is not unfrequently caused by the action of solar heat, and the influence of sudden vicissitudes in the temperature.—D. be dispensed with, as when the habit is by no means plethoric, and the pulse is obstructed rather than hard ; but these are cases that rarely occur. Diaphoretics, or relaxants, as they are denominated by Dr. Fordyce, may then be cm- ployed with advantage. Of these, the Urtarized antimony, the antimonial powder, or James's powder, are chiefly to be relied upon; and may be given alone, or, which is often better, in saline draughts ; and particularly those formed of the acetate of ammonia. And it may not be amiss to observe here, that the acetate of ammonia is sometimes prepared in the form of crystals, and sits more easily on the stomach in this than in any other shape. When given as a liquid, it is of importance that the solution should retain the carbonic acid gas of ammonia as largely as possi- ble ; and, for this purpose, the union should take place in a strong close vessel. According to Bergman, nearly half the weight of ammonia depends upon the quantity of this gas which it contains : so that in a pint of the solution of the acetate of ammonia, comprising four drachms of the latter, there will be extricated, if made in the manner here recommended, little less than a hundred and sixty cubic inches of air. As the stomach is for the most part but little affected, emetics, if used at all, can only be employed for the purpose of determining to the surface ; but, as we can do this by the antimo- nial and other diaphoretics just referred to, as also by diluent drinks, it is hardly worth while to irritate the stomach in order to accomplish the same purpose. Perfect rest of body and mind, a reclined position, and alight liquid diet, destitute of all stimulants, are also indispensa- ble towards recovery. The air should by all means be kept pure by being constantly renewed, though without a sensible current; the temper- ature coOl; the clothing light, and as often changed as may be necessary to maintain clean- liness ; and the beverage, toast-water, lemon- ade, or cool tea.* * Our author has here omitted all notice of cold affusion, the advantages of which, in theiicute or inflammatory forms of fever, have been acknowl- edged by almost every writer. The effect of it is to diminish the heat of the body, to lower the pulse, and to bring on perspiration and sleep. As a general rule, the sooner the affusion is applied after the irregular chills of the first stage are over, the better, provided the heat of the skin is steadily above the natural standard. Dr. Currie deems the safest time for it to be that when the exacer- bation is at its height, or immediately after the commencement of its declination. At this period the heat rises one or two degrees in the central parts of the body, and still more in the limbs. Dr. Currie, therefore, generally directed affusion to be employed between six and nine o'clock in the evening. It is never to be resorted to when any considerable sense of chilliness exists, notwith- standing the thermometer may indicate an aug- mented temperature of the body. Neither ought it to be adopted when the heat, measured by the thermometer, is less than, or only equal to, the natural heat; nor when the patient is perspiring profusely. Dr. Tweedie informs us, that he has never seen a single case in which cold affusion succeeded in cutting short the fever, though all Gen. IV.—Spe. 2.] ENECIA TYPHUS. 395 After all, however, it is not often that exam- ples of pure inflammatory iever are to be met with in the present day ; and it is contended by very high authorities, and seems to be estab- lished by the medical records of earlier times, compared with those of our own, that it is a dis- ease far less common now than it was formerly ; and that it is seldom, to adopt the words of Mr. J. Hunter, " that physicians are obliged to have recourse to the lancet,* at least to that excess which is described by authors in former times. They are now more obliged," continues the same writer, " to have recourse to cordials, than evacuations; and, indeed, the diseases called the putrid fever, and putrid sore throat, are but of late date. I remember when the last was called Fothergill's sore throat, because he first published upon it, and altered the mode of prac- tice. I remember when practitioners uniformly bled in putrid fevers; but signs of debility and want of success made them alter their practice. Whether the same difference takes place in in- flammation, I do not know, but I suspect that it does in some degree ; for I am inclined to be- lieve that fever and inflammation are very nearly allied, and that we have much less occasion for evacuations in inflammation than formerly ; the lancet, therefore, in inflammation, and also pur- gatives, are mucb more laid aside."—(On Blood, &c, part ii., p. 227.) It is not easy to account for this change in the national temperament. It is common, indeed, to ascribe it to an alteration in our mode of life, which is asserted to be much fuller than that of our forefathers. " We may be said," says Mr. Hunter, " to live above par. At the full stretch of living, therefore, when disease attacks us, our powers cannot be excited further, and we, sink so as to require being sup- ported and kept up to that mode of life to which we have been accustomed." If this be a correct view of the times in Mr. Hunter's day, they have greatly altered and im- proved within less than half a century ; for there the patients so treated felt afterward greatly re- lieved. He sets down the practice as best adapted to inflammatory fever (synocha), and more espe- cially to the fevers of hot climates, which are ac- companied by much greater excitement than those of temperate countries. He advises the practi- tioner, however, to ascertain, in every case, before such a powerful remedy is administered, that there is no visceral inflammation ; " were such a powerful shock given to the system under these circumstances, dangerous and even fatal conse- quences might ensue." On account of these rea- sons, and the manner in which most patients ob- ject to cold affusions, Dr. Tweedie prefers sponging the surface of the body with cold water, or vinegar and water. In winter the fluid used may be tepid, if more agreeable to the patient.—See Dr. Twee- die's Treatise on Continued Fever and its Modifi- cations, p. 187, et seq.; also, Dr. James Currie's Med. Reports on the Effects of Water, cold and warm, as a Remedy in Fever, 8vo., Liverpool, 1798.—Ed. * These remarks cannot certainly apply to this type of disease, as it occurs in the United States. —See Miner and Tully's Essays on Fevers, Mid- dletown, 8vo., 1823.—D. has never been a period, since wines arid fer- mented liquors have been introduced among us, so temperate and sober as the present. Drunken- ness, which was formerly common in our streets, is now rarely met with ; suppers are almost en- tirely relinquished'; and, instead of its being disgraceful, as was the case in " the olden time," for the master of the house to let his guests leave him either sad or sober, nothing is now so dis- graceful as intoxication. It is true, we are got back again to a very free use of the lancet in many instances ; which would seem to show, that we had completed a revolution in our general temperament, as well as our general temperance ; but it is not a little singular, that, while the lancet is still used with comparative caution in inflammatory fever, it is chiefly em- ployed, and often unsparingly, in typhus or putrid fever. And hence, there is more reason, I fear, for suspecting a revolution in the profes- sional fashion, than in national temperament; and that the bold and the timid plans have been alternately introduced and alternately dropped, not so much from any radical change in the con- stitution, as from their being found to fail, be- cause employed as popular means, or under the influence of some favourite hypothesis, on all occasions, without a due degree of clinical dis- crimination, or attention to the habits or symp- toms of individuals at their bedside. SPECIES II. ENECIA TYPHUS.* TYPHUS FEVER. PULSE SMALL, WEAK, AND UNEQUAL ; USUALLY FREQUENT; HEAT NEARLY NATURAL; GREAT SENSORIAL DEBILITY, AND DISTURBANCE OF THE MENTAL POWERS. The term is derived from Hippocrates, who uses it, however, in a sense not exactly parallel with its application in modern times, but rather in reference to that low, muttering, and stupid delirium, which so frequently accompanies the disease. It is, nevertheless, admirably expres- sive of the general nature of the fever to which it was applied at first, and which it designates at present; which burns, not with open violence as the cauma, but with a sort of concealed and smothered flame ; for the Greek term rv\iysed to its action to that state in which it may be rendered fit for absorption, and at the same time conveyed to the mouths of the absorbent vessels. But I have for many years thought that it has also another equally important use ; that, I mean, of assisting in the process of granulation ; and a late article of Sir Everard Home, con- taining the observations of Mr. Bauer upon the germination of plants, and his application of those observations to the growth of the new vessels in animals (Phil. Trans., 1818, pp. 180- 194) seems, if not to have settled the question, " at least to have very considerably favoured this view of it. Having sown a quantity of wheat, for the purpose of noticing the changes which occurred from the first, Mr. Bauer took up every day several grains or plants for examination till they were ripe ; and, in the course of his atten- tion, was much struck with the rapid increase of the tubular hair of the root of a young plant of wheat in its earliest stage of vegetation; and, fixing his view entirely to that part of the plant, he observed small pustules, of a slimy substance, arising under the epidermis in the surface of the young root; and, in a few sec- onds, a small bubble of gas bursting from the root into the slimy matter, which it extended in a moment to the length the hair was to acquire ; when the slimy matter surrounding the gas im- mediately coagulated and formed a canal. He repeated his observations on another plant, whose pubescence consisted of a jointed hair, and observed the same effect; a bubble issued from the young stalk, and extended the slimy mucus to a short distance, forming the first joint, which immediately coagulated and became transparent; and at its extremity a new pustule of the same slimy matter accumulated, into Vol. I.-Ee which, in a short time, the gas from the first joint rushed : and thus, in a moment, a second joint was formed. In the same manner, he ob- served the formation of the hairs of ten or twelve joints take place. Impressed with the importance of these facts, Sir Everard Home immediately began to inquire how far the same course is pursued in the pro- duction of new animal matter. He first ascer- tained, by experiments of Mr. Brande, already noticed in the Proem to the second class of this work, that blood in a state of circulation contains a considerable proportion of air, which, in the process of its coagulation, escapes in the form of carbonic acid gas, and, in its escape, produces bubbles, as in the slime of plants ; and that it escapes equally from the coagulating blood of veins and arteries, from effused serum, and from pus. And, in pursuing the subject, he found that on the coagulation of a drop of blood, placed in the field of a microscope, an intestine motion occurred, and a disengagement of a something took place in different parts of the coagulum; beginning to show itself where the greatest number of globules were collected, and from thence passing in every direction with considerable rapidity through the serum, but not at all interfering with the globules them- selves, which had all discharged their colouring matter. Wherever this extricated colouring matter was carried, a network immediately formed, anastomosing with itself on every.side through every part of the coagulum. When the parts became dry, the appearance of a net- work remained unaltered. In some instances, bubbles were seen to burst through the upper surface of the coagulum ; this, however, did not prevent the ramifications that have been described from taking place. " When this hap- pens," continues Sir Everard, " in living animal bodies, from whatever cause, and in whatever circumstances it takes place, no difficulty re- mains in accounting for its afterward becoming vascular, since all that is necessary for this purpose is the red blood being received into the channels of which this network is formed." He next proceeded to the subject immediately be- fore us. "As the globules of pus," says he, " are similar to those of blood, I made experi- ments upon the fluid in which they are sus- pended, and found inspissation produce the same effect on it as coagulation does on the other ; that a similar network is formed, and apparently by the same means ; since, if pus be deprived of its carbonic acid gas (of which it contains a .large quantity) by exhaustion in the air-pump, no such network takes place." Additional experiments are still necessary upon this interesting subject; but, so far as they go, they seem very clearly to indicate the important and double use to which pus is sub- servient ; that it acts as a solvent upon the dead matter, preparing it for absorption, and as a fomes for granulation and the production of new vessels. Nor let it be observed, in opposition to this conclusion, that we are thus endowing it with incongruous and contrary qualities; and that, 434 HiEMATICA. [Cl. III.—Ord. II. if it be erosive in the one instance, it cannot be nutrient in the other ; for the animal econo- my presents us with various examples of like effects, contrary, indeed, but not contradictory, produced by one and the same secretion on dead and on living matter, for which we need go no farther than to the very common opera- tion of the gastric juice; which, while the most powerful solvent of dead animal matter in the whole range of animal chymistry, is a healthy stimulant to the living stomach, and even to other living organs; and has success- fully been applied externally for this purpose by surgeons, to weak and ill-conditioned ulcers, and employed by physicians as an internal tonic in cases of dyspepsy and cardialgia. SPECIES II. APOSTEMA PSOATICUM. PSOAS ABSCESS. Pain and tension about the loins, shooting down the spine and thighs ; difficulty of standing erect ; fluctuating enlarge- ment along the psoas muscle ; apex of the tumour immediately below the groin. This is one of the most lamentable diseases we can ever be called upon to attend. It com- mences insidiously, and, at the same time, in parts so deeply seated as to render it very diffi- cult to determine the place of its origin ; and hence the psoas muscle itself, the cellular sub- stance interposed between the peritoneum and the loins, the lymphatic glands, and the lumbar vertebrae, have been pitched upon by different writers. It is probable that most of these have formed the primary seat of affection in differ- ent cases, and that the inflammation has sub- sequently spread to one or more of the other parts : and hence, assuming no inconsiderable degree of latitude, M. Chaussier denominates the disease Femoro-coxalgie. [The cellular substance behind the perito- neum, or about the psoas muscle, is now ascer- tained to be the most common seat of the ab- scess in its commencement. When the spine ' becomes carious in consequence of the pressure of an abscess, it has been correctly observed by Mr. Brodie, that the symptoms are different from those which attend a caries of the spine, commencing in the spine itself. For instance, the paralytic affection of the lower extremities is generally absent. Caries of the vertebrae and intervertebral cartilages, however, is some- times the primary disease (Brodie's Path, and Surg. Obs. on Dis. of the Joints, pp. 301, 302, ed. 2), and the abscess the subsequent one. This case would be characterized by the peculiar paralysis of the legs, resulting from original caries of the vertebrae and disease of their lig- aments and cartilages.] The pain attending the formation of lumbar abscess, is at first by no means violent, and the patient thinks lightly of it; it is sometimes felt in the back rather lower than the region of the kidneys ; and gen- erally extends down the thigh. [The testicle of the affected side is frequently retracted, and more or less uneasiness and pain are felt in the course of the spermatic cord. A very little exercise fatigues the patient, who mostly in- clines the trunk forward, and in bed generally keeps the thigh of the affected side bent, a relaxed state of the psoas muscle being the most easy to him. The symptoms frequently con- tinue stationary a long time. At length, a change occurs, indicated by rigours, loss of ap- petite, and followed by considerable acceleration of the pulse. Soon afterward the fluctuating tumour presents itself] From the deceptive manner of its attack, medical treatment, which might have been of essential service at first, is fatally postponed; and the symptoms are re- garded as those of an accidental strain. After the abscess is formed, however, the pain, in most cases, increases considerably, and, in com- mon instances, the matter follows the course of the psoas muscle, and points externally a little lower than the inguinal glands ; or it passes down the thigh, where, however, it is apt to dissever the muscles and form smous ab- scesses. Sometimes, though rarely, the matter passes through the muscles of the back, and is discharged in the loins ; and, in a few instances, it has been known to fall into the cavity of the back part of the pelvis. The abscess, on ac- count of its great extent, is highly dangerous : an extent which it generally attains ere it points externally, or admits of being discharged. Hence, the patient very frequently sinks under a hectic fever, produced by the local irritation ; while in most cases in which it has made a nat- ural opening for itself, it has been found con- nected with so many deep sinuses, which can- not be followed up, that the same effect ensues. [It is a curious fact in relation to this subject, that psoas abscess should rarely be met with in the United States of America. Professor Gib- son saw only four cases of the disease during thirteen years, although professionally connected with extensive hospitals and alms-houses most' of that time. Dr. Physic never met with a case of psoas abscess in America, unconnected with disease of the spine.—(Gibson's Surgery, vol. i., p. 214.) If these statements coincide with the experience of other practitioners in America, they are highly interesting, as affect- ing the question, whether, as is generally sup- posed in England, the psoas abscess is necessa- rily connected with a scrofulous constitution.*] No mode of medical treatment has been found productive of any good purpose ; and the case has been, in a very early stage of the suppura- tion, given over to the surgical practitioner. Yet even here different individuals have pur- sued different lines of conduct. [Kirkland be- lieved that the patient had the best chance of recovery when the abscess was allowed to burst of itself, and discharge itself very gradually by * The German medical authorities seem to sup- port the above opinion, but in America the case is otherwise. Psoas abscess is not unfrequent in the United States; it sometimes exists where no spinal disease can be detected. This opinion is confirmed by the experience of Professor Stevens, Dr. McLean, Dr. J. K. Rodgers, Dr. Cheesman, and by other practitioners of ample experience.—D. Gen. I.—Spe. 3.] APOSTEMA « small outlet. The latter precept has been found to be one of great importance.] Mr. Bell advises an early evacuation of the matter, lest the bones should become injured; while Mr. Abernethy apprehends less danger from its being suffered to remain, and at last evacuates it at different intervals, and by successive oper- ations : by which means the cyst, in which the pus is principally lodged, may have an opportu- nity of contracting ; and this, he thinks, it has a greater -> tendency to do than in abscesses where the inflammation is more violent. He is also attentive to close the opening the instant the matter is discharged, so as to prevent' any increase of the inflammation by an access of air. The real cause of danger does not seem to have been hitherto hit upon ; but it may proba- bly be referred to that tendency to a rapid spread of inflammation over their entire surface, which Mr. Hunter has shown to exist in all internal cavities, and the hazard of which is in propor- tion to the extent of the cavity ; a subject al- ready touched upon in the discussion of puer- peral fever, and which we shall have other opportunities of illustrating as we proceed, par- ticularly in some cases of varicose enlargement of the veins. Now, in the disease before us, we have not, it is true, any natural cavity, but we have an artificial cavity of long standing and large extent, in a highly irritable state, and which is therefore peculiarly predisposed to run into all the fatal effects of large natural cavities, when injured or otherwise rendered imperfect. The author throws out this hint, however, for future and general consideration. [Mr. Crowther relates a few cases in which psoas abscesses were dispersed by the applica- tion of large blisters to the swelling, which were kept open with the savin cerate. The same practice, combined with the occasional employ- ment of emetics, was also recommended by Mr. Abernethy.] SPECIES III. APOSTEMA HEPATICUM. ABSCESS OF THE LIVER. DIFFUSE PULSATING TUMOUR IN THE REGION OF THE LIVER ; PRECEDED BY PAIN, A YELLOW COUNTENANCE, AND SHIVERING. [The ordinary symptoms, besides those spo- ken of in the definition, are, swelling and ten- sion of the right hypochondrium, sometimes extending beyond it; pain in the right side, much aggravated by inspiration or pressure, and occasionally shooting up to the shoulder. In the case recorded by Dr. O'Brien, there was also great weakness of the right arm; a pale, anxious countenance, without yellowness ; pulse 120, small and feeble ; and no vomiting.— (Trans, of Physicians in Ireland, vol. i., p. 44.) Much doubt having been expressed by some physicians, whether true laudable pus could be formed in the substance of the liver, that dis- tinguished pathologist, C. P. A. Louis, investi- gated the question, and, in the dissection of 430 subjects, met with five cases of hepatic ab- scesses, all of which presented genuine puru- HEPATIS. 435 lent matter.* It appears also from his dissec- tions, that the abscesses are frequently encysted, and that the neighbouring portion of the liver is sometimes softer, but sometimes more indu- rated, than natural. In the cases of encysted abscesses, examined by himself, he could not decide positively whether they -preceded, or were the consequence of, a dissolution of a greater or lesser number of tubercles ; but he inclines to the latter opinion. In one very in- teresting case, reported by this author, the patient had voided large quantities of blood from the anus, and, after death, a clot of blood was found in a cyst in the liver ; from which part, il is inferred, the blood had passed into the intes- tinal canal. As no communication could be traced, however, between the cavity and the biliary ducts, the conclusion appears question- able.—(Louis, op. cit., p. 385.) A common complication of abscesses of the liver seems to be a softening and ulceration of the mucous membrane of the bowels, especially that of the large intestines, the same affection of the lining of the small ones not being very frequent, ex- cept in phthisis pulmonalis, and fevers. The mucous coat of the stomach in some cases had red specks on it, was much softened, and, in certain places, incompletely ulcerated. Ab- scesses of the liver are mostly not single, but more or less numerous, t Their general fatality is partly ascribed by M. Louis to the liver not * Louis, Mem et Recherches Anatomico-Pa- thologiques, p. 352, 8vo., Paris, 1826. The fluid discharged from an abscess connected with the liver, by Mr. Caesar Hawkins, was not like com- mon pus, but thick and adhesive, of a dark yel- lowish-green colour, and of a peculiar, though not offensive smell; and, upon being mixed with nitric acid, if appeared to contain biliary matter.—(See Med. Chir. Trans., vol. xviii., p. 100.) In another case the matter was thin, of a light brown colour, and could scarcely be called purulent.—(Op. cit., p. 106.) In these two instances the abscesses were only connected with the liver, and not in it. The punctures were followed by ulceration and sloughing of the skin, hemorrhage, and a destruc- tion of nearly the whole thickness of the abdom- inal parietes. The disease had, in each patient, been preceded by symptoms of inflammation of the liver, and, after death, the cavity in which the matter had collected was so far obliterated, that it was difficult to decide positively where the fluid had been situated. The further particulars of these cases will be found interesting by the patho- logical inquirer.—Ed. t Dr. Stokes mentions, in his lectures (Am. Journ. of Med. Sc, No. xxx., p. 503), a curious fact, that it has often been found impossible to sal- ivate persons labouring under hepatic abscess, so that the presence of matter in the liver, or its absence, may be determined by the circumstance of the patient being, or not being, susceptible to the full effect of mercury. This fact is confirmed by Dr. Marshall, a gentleman of great experience, and very conversant with the diseases of India, who states that he has never known a case in which abscess actually formed in the substance of the liver, in which salivation could be produced; and that when the patient became salivated he be- lieved it to be a proof that there was no inflamma- tion of an intense character, or that no abscess had formed.—D IATICA. [Cl. III.—Ord. II 43J5 H^EM having, perhaps, the power of repairing the mis- chief, as he never observed traces of cicatriza- tion in it. Yet this inference seems to be con- tradicted by the cures which are upon record.— (Louis, op. cit., p. 385-394, 408.)] This is also a very fatal disease, and usually terminates in one of the following ways : Firstly, The substance of the liver is grad- ually and almost entirely absorbed from long- continued irritation; the melancholy accom- paniments of which are, a tedious, icterical marasmus, hectic fever, great anxiety, and a sanious and fetid diarrhcea, which is the fore- runner of death. [In one example, recorded by Dr. O'Brien, the abscess extended over two thirds of the liver, the biliary ducts were nearly annihilated, and all but one sixth of the gall-bladder de- stroyed.* In another case, reported by Pro- fessor Gibson (Surgery, vol. i., p. 211), he says that, upon dissection, the fistulous orifice in the side was traced into the liver, or rather into its remains ; for its substance had disappeared, and nothing of its structure could be found, except a shell, or cyst, somewhat larger than an egg, and filled with brownish matter.] Secondly, The abscess breaks internally, and discharges itself into the belly; by which means the rest of the viscera are affected, and the termination is marasmus, ascites, and disso- lution, t According to M. Louis, this mode of evacuation only takes place in chronic hepatitis. —(Mim. et Recherches Anat. Path., p. 372.) Thirdly, The pus sometimes finds a passage into the biliary ducts, and thence into the intes- tines ; from these it is occasionally thrown into the stomach, and vomited in the form of a dark offensive material: but far more generally it is carried downward, and produces a violent loose- ness. Acids and ascescent medicines may here palliate for a time ; but the issue is always fatal. Fourthly, The enlarged liver becomes, in some cases, united by adhesive inflammation to the peritoneum, and the abscess opens exter- nally ; and, in this case, there is a chance of cure. The openings should be expedited by a caustic or the knife : and the cure will greatly depend upon the nature of the fluid which is discharged. Fifthly, There is reason to believe that, in a few rare instances, the matter is carried off by absorption, when a healthy granulation takes place, and a cure is completed without any opening. This termination is more reasonably to be expected in a constitution otherwise * See Trans, of Physicians in Ireland, vol. i., p. 48. The editor opened the body of a woman about three years ago, where the same morbid changes were noticed. A very small portion of the fundus of the gall-bladder remained, and at least two thirds of the liver were occupied by ab- scesses. The preparation, which is now in his possession, will shortly be sent to the museum of the London University.—Ed. t The ordinary effect of such passage of the matter into the cavity of the abdomen is a rapid and fatal degree of peritonitis.—Ed. sound, and where the liver has not been weak- ened or rendered torpid by any former affection It is hence rather to be looked for in a temper- ate than in a tropical climate, and in youth than in advanced life. [Sixthly, In certain cases, the matter of the abscess has made its way by ulceration through the diaphragm, and been either effused in the chest, or, opening a communication with the bronchiae, been coughed up from the lungs. In hot climates, where acute and chronic hepatitis are very common complaints, abscesses of the liver are often noticed. In Great Britain they do occur, but not very frequently, except in those who^ have returned from a long residence in warm latitudes. The liver may suppurate, how- ever, from other causes besides common hepa- titis, as from blows or injuries of the head,* biliary concretions, phlebitis,t and the presence of worms in the biliary ducts.X In the Surgical Museum of the University of Pennsylvania is a preparation in which the substance and ducts of the liver are filled and perforated in every direction by numerous and very large lumbrici. The patient, a child, fell a victim to the irrita- tion and suppuration.—(Gibson, vol. i.,p. 209.)] When the cure takes place without an open- ing, it is not always an easy matter to deter- mine for a certainty that pus has actually been formed. But sometimes we can trace a fluctu- ation ; and, at other times, the subsidence of the tension, pain, and pulse, after one or two severe shivering fits, may be regarded as suffi- cient indications. In a case of this kind that occurred to me in a young gentleman of about thirteen years of age, the shivering was so con- siderable as to make the teeth chatter ; and within eight-and-forty hours, the pulse sunk from a hundred and forty to a hundred and twenty ; and the abdominal tension and tender- ness were considerably abated ; as was also the distressing cough with which he had almost perpetually been harassed for some weeks. He was put upon a tonic plan of columbo and sul- phuric acid immediately after this change, and recovered gradually. [In India, the rapMity with which inflamma- tion of the liver frequently proceeds to suppu- ration, has sometimes been so great as scarcely * Quesnay, in Mem. de l'Acad. de Chir., tom. i., p. 147. Bertrandi de Hepatis Abscessibus; GSuvres Chir. de Desault, tom. i. Also, a valuable paper by Mr. Rose on depositions of pus, &c. in the viscera, after injuries of different parts, in Med. and Chir. Trans., vol. xiv., p. 251, &c. The fact of abscesses of the liver arising from injuries of the head is doubted, however, by the very eminent pathologist, M. Louis. See his Recherches Anat. Pathol., p. 405. The editor suspects that the fre- quency of the occurrence from this particular cause has been exaggerated by writers. t See Cruveilhier, Anat. Pathol. Andral refers to a case in which an abscess of the liver com- municated with the interior ofthe vena cava; and to another in which the matter made its way into the pericardium.—Precis d'Anat. Pathol., tom. ii., p. 598.—Ed. t See Kirkland's Inquiry into the present State of Medical Surgery, vol. ii., p. 186. Also, Bond, in Med. Obs. and Inq., vol. i., p. 68. Gen. I—Spe. 4] APOSTEMA EMPYEMA. 437 to admit of time for the employment of anti- phlogistic remedies. As Dr. O'Brien observes, this should never be neglected in chronic hepa- titis, even where mercury may subsequently become necessary; and be commends general bleeding, and the use of cupping and leeches. In this country, surgeons rarely open abscesses of the liver in an early stage ; but, in India, the contrary practice is said to prevail, and to be found the most advantageous.*] SPECIES IV. APOSTEMA EMPYEMA. LODGMENT OF MATTER IN THE CHEST. FIXED PAIN IN THE CHEST : BREATHING LABO- RIOUS, BUT EASIEST IN AN ERECT POSITION ; DIFFICULT DECUMBITURE ON THE SOUND SIDE ; FLUCTUATING ENLARGEMENT ON THE SIDE AFFECTED ; DRY, TICKLING COUGH. To the symptoms enumerated in the above definition, Hippocrates adds (fltpi TlndZv, pp. 476, 496) oedema of the feet, hollowness of the eyes, and a gurgling sound on shaking the shoul- der. Of these additional signs, the first two belong rather to the hectic fever that generally accompanies empyema, than to the disease it- self. The last has sometimes been met with in modern times.—(Tricourt, Mimoires de Chi- rurgie, &c.) Dr. Cullen regards empyema as a mere sequel of pneumonia, which, with him, includes inflammation of the pleura, as well as of the lungs; but as it may take place from inflammation of the mediastinum, pericardium, or diaphragm, to say nothing of that from ex- ternal injuries, and as it is often doubtful what particular organ is directly injured, a separate species seems decidedly called for. An empyema is sometimes produced by the bursting of a large vomica of one of the lungs into the cavity of the pleura : in which case, the cough becomes more frequent than before this result, and is either dry, or accompanied with a scanty, frothy, and noisy expectoration. The breathing becomes extremely difficult, with re- peated fainting fits, and the dew of a cold sweat hanging over the throat and forehead ; the cheeks and lips are of an ominous red, while the nails are livid, the pupils dilated, and the sight dim. Tf percussion or the stethoscope be employed, before the vomica has broken, to the part in which the matter is seated, little or no sound will be returned, in consequence of the pressing fulness which exists there ;t but if these meth- * Prof. Homer thinks that hepatic abscess may be managed by opening it even when adhesion to the side has not occurred, provided the liver be attached to the side by one or two stitches, which prevents the effusion of pus into the abdomen.— See Am. Journ. of Med. Sc, No. xxvii., p. 90.—D. f Dulness of sound on percussion, and absence of the respiratory murmur on the diseased side, which remains perfectly motionless. Puerile res- piration in the opposite lung, accompanied with increased action of the respiratory muscles, and frequently a displacement of the heart, descent ods be resorted to afterward, it will be found restored, in a considerable degree, to the part affected, from the hollowness which now exists there, while it will be comparatively found di- minished in the posterior and inferior parts of the chest to which the discharged load is trans- ferred. For the history and relative value of these diagnostics, the reader must turn to the treatment of phthisis.—(Cl. Ill, Ord. IV., Gen. III., Spe. 5.) [Laennec does not seem to approve of the application of the term empyema to the bursting of a large vomica into the chest. " I appre- hend" (Op. cit., p. 448), says he, " no one now considers empyema as the product of a vomica, which has burst into the cavity of the pleura. A softened tubercle may, indeed, discharge its contents in this manner, and may thus become the cause of a considerable effusion, by exciting a chronic pleurisy; but, in such a case, the tu- berculous matter must only be considered in the light of an extraneous body, determining inflam- mation, and consequent effusion, by its mechan- ical or chymical qualities. It is also to this species of pleurisy that we must refer those his- tories of lungs entirely destroyed by suppuration, which we find recorded in the older writers." In this country, however, whatever may be the principal source of this purulent fluid in the cavity of the pleura, the term empyema is em- ployed. In acute pleurisy, besides an effusion of coagulating lymph, a serous fluid is poured out, which is of a light yellow colour and transparent, or with its transparency only slightly lessened by the intermixture of small fragments of concrete pus or lymph. In the latter case, it resembles unstrained whey. The fluid is generally devoid of smell. Many physicians suppose, that, in acute pleurisy, no effusion takes place till after some days; but Laennec declares (Op. cit., p. 423-5), that he has several times observed all the physical signs of effusion ; that is. aegophonism,* and absence of the respi- ration and sound on percussion, in one hour from the commencement of the disease ; and he has seen the side obviously dilated at the end of three hours. On the other hand, he does not remember to have met with a single case, in which the effusion was doubtful under the stethoscope during the first and second day. The utmost that he admits on this point is, that the effusion continues to increase for several days, and that it is only at the end of this time that it becomes too manifest to be overlooked, from the dilatation of the affected side, and the total absence of sound on percussion. He is convinced that the effusion of serum is contem- poraneous with inflammation in all serous mem- branes. The fluid effused is generally absorbed after the inflammation has subsided; and it is only when it remains in such quantities as to occasion very urgent symptoms, that any opera- of the diaphragm, and protrusion of the abdomen. —En. * A tone or echo of the voice, distinguished with the stethoscope; and so named by Laennec, from its having a trembling or bleating sound, like the voice of a goat. 438 HiEMATICA. [Cl. Ill —Ord II tion should ever be contemplated for its dis- charge. The disease which Laennec represents as producing the most common species of purulent empyema, is chronic pleurisy, of which he de- scribes three kinds: 1st, that which is chronic from its origin; 2dly, acute pleurisy, become chronic ; 3dly, pleurisy complicated with certain organic productions on the surface of the pleura, bearing a gross resemblance to cutaneous erup- tions. According to Laennec, chronic pleurisy does not differ essentially in its anatomical charac- ters from the acute : the pleura, however, is generally of a deeper red, and the serous effu- sion is more abundant, and almost always less limpid, being mixed with small albuminous flocT culi. In chronic pleurisy, the extravasated fluids have a more fetid smell than in the acute, and often yield a strong alliaceous odour, anal- ogous to that of gangrene.* The effusion is rendered daily more considerable. The affected side becomes manifestly larger ; the intercostal spaces grow broader, and rise to a level with the ribs, and sometimes even higher. The lung, compressed towards the mediastinum and spine, and retained in this position by pseudo-mem- braneous exudation, is sometimes so reduced in size as not to,be more than four or six lines thick, even in its middle. In this state, the pulmonary tissue is soft, pliant, and dense, with- out any crepitation, more pale than natural, and almost without blood ; yet the alveolar texture very distinct.!] Modern researches prove, that collections of pus in the chest frequently occur without any appearance of ulceration. To such cases Mr. Hewson has several references. " The cavities of the pleura, pericardium, &c," says he, " are * The fluid effused in acute pleurisy is of a pale yellow or straw colour, and generally a little tur- bid, from an admixture of coagulable lymph. In chronic pleurisy, the fluid is not only in larger quantities, but of a eonsistence approaching to that of common pus, and generally mixed with flakes of coagulable lymph. However, as Dr. Townsend has observed, it is not always easy in practice to determine a priori the precise nature of the fluid collected within the chest, as its phys- ical characters are found to vary considerably, even in those cases that most closely resemble each other, in their origin, progress, and symp- toms.—Cycl. of Pract. Med., art. Empyema.—Ed. t As in empyema the matter is usually con- tained in only one side of the chest, its pressure sometimes displaces the heart. The editor has seen several examples, in which a considerable quantity of fluid in the left sac of the pleura has caused such a change in the position of the heart, that its pulsation could only be felt on the right side of the sternum. The pus, however, may be qjfumscribed by the adhesive inflammation, and then this effect will not be produced. In the case lately published by Mr. Woolley, the heart pul- sated on the right side, in a situation precisely corresponding to what it ought to have occupied on the left. This was in a child between five and six years of age, that was cured by paracentesis alone.—(Med. Gaz. for Nov., 1833, p. 318.) Such displacement is one of the least fallible symptoms of a collection of fluid in the chest.—Ed, sometimes observed to contain considerable quantities of pus without the least marks of ul- ceration. In one patient I found three pints of pure pus in the pericardium, without any ulcer either on that membrane or on the heart. In another, the cavity of the pleura of the right side was distended with a pus that smelt more like whey than a putrid fluid, and the lungs were compressed into a very small compass : but there was no appearance of ulcer or erosion, either on these organs or on the pleura; but only under the pus was a thin crust of coagula- ble lymph." We have already made some ob- servations upon this secretion of imperfect pus, and it is not necessary here to dwell upon it. Numerous cases are recorded, in which the contained fluid has disappeared.* It has passed off by the intestinal canal (Kelner, Diss, de Empycmate, Helm., 1670 ; Marchetti, Obs. 82, 89), by the bladder,* and by the vagina (Schlich- ting, Phil. Trans., vol. xlii., p. 70), in the form of pus. It has also been frequently carried off by an opening formed by nature, and the patient has recovered his usual health. This opening has commonly been between the ribs ; most usually between the third and fourth, but in one in- stance we find the abscess pointing and burst- ing under the scapula.—(Hurten, Diss, de Em- pyemale, Argent., 1679.) [The escape of the effused fluid through the intercostal muscles, from gangrene of a portion of the pleura, is regarded by Laennec as very rare. He says that he has only seen one case of it himself, and that M. Recamier has not seen more than two; and with respect to another mode in which the fluid finds vent, namely, in consequence of the for- mation of an abscess in the intercostal spaces, and its rupture both externally and internally, Laennec has only met with a single case of this kind. Andral reports three others. There can be no doubt, from the numerous examples on record, that these events are much more com- mon than Laennec imagined. Dr. Forbes ex- presses his belief, that in cases of chronic pleu- risy, the escape of the matter through the walls of the chest is by no means very uncommon. He has himself met with more than one in- stance of it. Laennec states (Op. cit., p. 435), that a cure has, perhaps, more frequently fol- lowed the evacuation arising from these kinds of abscesses, than from an operation. The cure, however, is not always complete ; as a fistula is apt to, remain, frequently kept up by a caries of the ribs. Morgagni has recorded (De Sed. ct Caus. Morb., ep. xxii., art. 13) a singular case of a double empyema ; a lodgment of pus being form- ed on both sides : and Balme a still more ex- * In the Medical Recorder for 1825, p. 553, Dr. Reese has stated a case of empyema, in which large quantities of pus passed off from the stom- ach and bowels. The patient died ; and on dissec- tion an opening was found in the oesophagus, about an inch and a half from- the cardiac orifice of the stomach, through which the pus had passed.—D. t Buchner, Diss, sistens solutionem Empyema- tis per mictionem pumlentam.—Hal., 1762, N. Act Nat. Cur,, vol. i., obs. 5. Gen. I.—Spe. 4.] APOSTEMA traordinary case, in which the pus entered the cellular membrane, and spread over almost the whole trunk.—(Jour, de Med., tom. lxvi., p.244.) Dr. G. Hawthorn has given an instance of this disease, that for its severity and danger, and particularly for its successful issue, is well worth recording.—(Edinb. Med. and Surg. Journ., No. lxi., p. 513.) The patient was thirty years of age, and the disease had been brought on by exposure to damp night air in a state of intoxication. He suffered greatly from quickness of pulse, incessant cough, oppression, and dread of suffocation. A distinct fluctuation was perceived in about three weeks from the attack ; shortly after which he was a little re- lieved by a discharge of purulent matter effused into the bronchial cells, and expectorated to the extraordinary amount of five or six pounds daily, for many days in succession, a fluid of an in- tolerably offensive smell and putrid appearance. He continued, however, to grow worse and weaker; his feet and legs swelled; his coun- tenance was ghastly, and he had colliquative sweats. About twelve weeks from the attack, the operation was performed; nearly 20 lb. of pus was discharged on the first day and night; and he gradually recovered.* [The evacuation of the matter by the bronchiae is stated by Laennec (Op. cit., p. 436) to be more common than that through the intercostal muscles. The fact, he believes, was first clearly established by Bayle. It scarcely ever occurs but in chronic pleurisy ; though Andral relates one example of it in the acute disease.—(Clin. Midicale, tom. ii., obs. 36.) The symptoms indicating the propriety of an operation are, the dilatation of the affected side ; oedema of the same side and arm ; depression of the liver, and displacement of the heart towards the side free from fluid. Laennec has shown, however, that all these symptoms may be absent; and it even frequently happens that at the very time when an operation is proper, the affected side, although full of pus, is smaller than the opposite one, in consequence of the absorption which has already taken place. But in all such cases, the results of percussion and auscultation leave no doubts respecting the ef- fusion.—(Op. cit., p. 475.) Laennec points out two cases of pleurisy, requiring that an operation should be performed for the discharge of the fluid from the chest. The first is when, in an acute pleurisy, the effusion is very copious from the beginning, and increases so rapidly as to give rise, after a few days, to general or local anasarca, and to threaten suffocation. The second is a chronic case, either in consequence of a pleurisy originally chronic, or of the acute disease changed into this state. In such cir- * A patient under Dr. Croker, of Dublin, was tapped for an empyema, and fourteen pints of pus were discharged from the left cavity of the pleura. In Dr. Archer's case of successful paracentesis of the thorax (Trans, of Dubl. Assoc, vol. ii.), eleven pints of inodorous fluid were drawn off, and in a few weeks the patient was convalescent. The interior ofthe pleura in such cases is almost always lined by a pseudo-membrane, such as constitutes tire cyst of an abscess.—Ed. EMPYEMA. 439 cumstances, when oedema of the affected side has come on, when the long continuance ef the disease, the progressive emaciation and debility of the patient, and the failure of every measure employed to produce absorption, leave nothing to be expected from other means, the operation is warrantable.] When the fluid is discharged by paracentesis, Hippocrates 'irepeatedly urges the surgeon to evacuate it only by degrees (ILrpt fiov^&v, ii., p. 476, 1. 42 ; Utpt r!iv WvoS TlaBZv, p. 536, 1. 15): and Borelli (Cent, i., obs. 72) gives a case in which the patient seems to have sunk under a sudden evacuation. There has also been no small discussion concerning the part of the thorax to which the scalpel may be most ad- vantageously applied. David advises near the sternum (Mem. pour le Prix de I'Acad., x.); Mr. Sharp between the sixth and seventh ribs (Crit. Inquiry, &c, chap, vi.); Mr. Bell wherever the pain or fluctuation may direct.—(Surgery, vol. ii., p. 390.) Mr. Warner, whose success made it many years ago a favourite operation in our country, seems to have been of Mr. Bell's opinion, and varied the point of opening according to the nature of the case. And so little danger did he apprehend from the use of the scalpel,on any occasion, that he not only evacuated in all instances the whole of the matter at once, but in one or two examples, operated where there was neither a polarized pain, nor fluctuation, nor visible discoloration, nor any external sign whatever to direct him to one part rather than to another, or even to determine the real nature of the disease, otherwise than from the specific symptoms laid down in the preceding definition. —{Original Cases and Dissections, &c, by John Forbes, M. D., p. 257, 8vo., Lond., 1824.) In Mr. Warner's cases, about twenty ounces of pus formed the average of discharge at the time of the perforation (Phil. Trans., vols, xlvii., xlviii., Ii., as also his works in their collected form): the patients usually found instant relief; the pain, cough, and quickness of pulse dimin- ishing, and the breathing becoming easier. He dressed the wound with a sponge tent till there was no longer any discharge, and afterward su- perficially ; and, in about six weeks, the patients were cured. In this case, it is perhaps more necessary to keep the wound open than in any other operation ; for otherwise the secreted pus is apt to accumulate, and the operation must be renewed.* [The following remarks by Professor Laennec are interesting :—The place of election, he says, commonly adopted by surgeons for this opera- tion, is the most depending point in the anterior and lateral parts of the chest: a rule that can- not be good always, because the most dependant point varies with the position of the patient. The natural posture of a patient affected with empyema is to lie on the diseased side ; and, in this case, the most depending point is the space * Another case of two successful operations on the same person is related in Horn's Archives for March, 1826; an interval of twenty-two year* elapsed between the operations.—D. 440 H.EM. between the fifth and sixth ribs. Many other reasons, Laennec observes, point out this spot as the best. For instance, we know that the upper lobe adheres to the ribs more frequently than any other part of the lungs, and that the lower lobe is frequently attached to the dia- phragm. On the right side, we know that an enlarged liver frequently reaches as high as the sixth, or even the fifth rib ; and that on both sides the thickest false membranes, and conse- quently adhesions, exist at the junction of the diaphragm with the walls of the chest. Finally, we know that the greatest portion of the effused fluid is collected about the middle of the side. The best point is a little anterior to the digita- tions of the serratus major. Should there chance to be any old adhesions in this point, we shall readily discover them by means of some remains of respiration over their place.* But if, on per- cussion, the sound be dead at this spot, and the sound of respiration be wanting, we may safely make an incision.] Riedlin operated with suc- cess twice on the same person.—(Lin. Med., ann. v., obs. 30.) The matter, when discharged or examined on dissection, has been found of very different con- sistences : sometimes like what Laennec has described; sometimes pure pus; sometimes cheesy ; and sometimes gelatinous. And the mischief to the interior of the chest has, in some cases, been very great. Several of the ribs have been found carious (Heurmann, Ver- mischte Bemerkungen, vol. ii., p. 217); the lung on the affected side totally eroded (Kelner, Diss, de Empyemate, Helmst., 1670) ; and, in one case, the pericardium destroyed as well as the lung.—(Goekel, Gallicinium Medico-pract.) The morbid changes described by Laennec have already been noticed. [Owing to various causes, the operation is generally unsuccessful. 1. The first of these, as specified by Professor Laennec, is the bad condition of the lung itself, which is frequently tuberculous. 2. The irritation of the pleura, by the entrance of air into the chest, has been con- sidered the chief cause of the great and offensive discharge, which too often ensues and destroys the patient. The admission of air into the chest, Laennec admits, must affect the action of the organs contained in it; but its immedi- ate impression, he says, is not on the pleura, which, in acute pleurisy, is covered with lymph, and in chronic with thick pultaceous matter. 3. The greatest impediment to the success of the operation is, in Laennec's opinion, the compres- sion of the lungs against the spine and medi- * Under such circumstances, the place for the incision should be varied. In one case of this description, Laennec, after making an incision through the integuments, over the space between the fifth and sixth ribs, introduced a trocar ; but no fluid came out. The patient died ; and in the post-mortem examination it was found that the in- strument had entered the cavity of the abdomen, after transfixing the diaphragm, which had been pushed upward by an enlarged liver, and had be- come firmly adherent to the seventh rib. A similar accident occurred in Lamotte's practice.—Ed. .TICA. [Cl. Ill—Ord. II. astinum, and the nature of the investing false membrane. The lung, from the long compres- sion, has lost its elasticity and expansibility, the inspired air penetrates it with difficulty, and the original dimensions of the organ are very slowly recovered. Indeed, it never returns to its natural size. Hence, with a view of favour- ing the expansion of the lung, Laennec had it in contemplation to revive the plan of exhausting the air from the chest with cupping-glasses : a plan best accomplished with a syringe, as ad- vised by Mr. Jowett, and formerly recommended by Scultetus and Anel.—(Op. cit., p. 476-479.) SPECIES V. APOSTEMA VOMICA. VOMICA. DERANGED FUNCTION OF A THORACIC OR AB- DOMINAL ORGAN ; SUCCEEDED BY A COPIOUS DISCHARGE OF PUS INTO SOME PART OF THE ALIMENTARY CHANNEL ; AND ITS EVACUA- TION BY THE MOUTH OR ANUS. The specific term is a derivative from the Latin vomo, "to eject," especially from the stomach, but not exclusively so ; and hence, on the present occasion, it is used in the compre- hensive sense in which it is employed by Celsus, who applies it to a bursting of pus from the liver, or any other large internal organ, as well as the lungs.—(De Medecin, lib. iv., cap. viii.) Sauvages follows Celsus in this interpretation, but distinguishes the vomica from the aposteme, by making the discharge from the latter consist of pure pus, and that from the former of a mixed matter, being at first a sort of adipose mucus (mucus quidam adiposus), which at length be- comes purulent. Avenbrugger, to whom we are indebted for the Inventum novum, or method of ascertaining diseases of the chest by percus- sion, takes nearly the same range, or rather car- ries it to a still wider extent, so as to include other depositions than that of genuine pus, and hence divides vomicae into purulent and ichorous, mean- ing by the latter term the reddish yellow fluid occasionally found in a sac from the destruction of a hepatized or scirrhous lung, or other organ.* Boerhaave and Cullen confine vomica to the lungs, and this in a more restrained sense than most writers ; for they limit it to what has been called, though with no great accuracy, occult vomica, " vomicae clausae." Linnaeus and Vogel, on the contrary, while they confine the term to the lungs, explain it by open vomica, " vomicae apertae," in which the pus is thrown forth pro- fusely and suddenly. One termination of the hepatic aposteme may be regarded as a variety of this species; for, as we have observed, it sometimes issues in a discharge of pus by the mouth or rectum. [Dr. Good supposed that pul- monary vomicae consisted in conglobate glands, first enlarged by a strumous congestion, and afterward slowly and imperfectly suppurating. Others have described them as abscesses, the * Inventum Novum ex percussione thoracis humani, ut signo, abstrusos interni pectoris morboa detegendi. Vien, 8vo., 1761. Gen. IL—Spe. 1.] PHLEGMONE COMMUNIS. 441 result of inflammation. On the contrary, Pro- fessor Laennec (Op. cit., p. 354) sets down an abscess in the lungs from inflammation as an extremely rare case ; as at least a hundred times as rare as a true vomica. He represents vomicae as the result of the softening of a tuberculous mass of large size, and that the copious ex- pectoration, usually taking place after their rup- ture, is the secretion from the sides of the large tuberculous excavation.] Vomicae are not, how- ever, always so large as described by this author ; they vary in size from the diameter of a millet- seed to that of an orange. The smallest rarely contain any fluid, and sometimes not even a cavity (in which state, indeed, the editor con- ceives they are only tubercles) ; but they are often highly irritable, and maintain a very con- siderable degree of hectic fever. When ulcera- tion has taken place, and pus is secreted, the irritability frequently subsides ; the pulse im- Droves, the febrile exacerbations are less fre- quent and violent, and the patient flatters him- self he is recovering. The vomica at length bursts and disabuses him ; he sinks gradually from the quantity of the daily discharge, and the confirmed hectic ; or if the disease be seated in the lungs, and the cavity extensive, he may be suffocated by the volume of pus that over- whelms the trachea. Bartholine gives a singular case of an occult vomica of the lungs, that, accompanied with an asthma, produced great emaciation; but was fortunately cured by the wound of a sword, the point of which passed between the ribs and opened the sac. A considerable flow of pus followed, and the patient recovered gradually from the time of the accident.—(Hist. Anat., xiv., cent. 6.) The methods of percussion and mediate aus- cultation are now very generally resorted to on the continent and in our own country, to ascer- tain the existence and extent of this affection when seated in the chest ; the theory and em- ployment of which the reader will find explained at some length, under the treatment of phthi- sis.—(Cl. III., Ord. IV., Gen. III., Spe. 5.) GENUS II. PHLEGMONE. PHLEGMON. suppurative, cutaneous tumour ; tensive ; glabrous; painful ; AT length fluctu- ating, AND BURSTING SPONTANEOUSLY ; THE PUS UNIFORM and genuine. Under the last genus, we took a general sur- vey of the process and economy of suppuration, and noticed many of the most extensive and dan- gerous forms in which suppuration ever presents itself. We are now advancing to inflammatory affections, consisting of tumours of small ex- tent, and either entirely confined to the integu- ments, or dipping but a little way below them. The term phlegmon, from 3 or nj^3 (D0 or boa), importing " to swell," and merely doubled according to the analogy of the language, to give it an in- tense or superlative power, whence bobo, or bubo. Buboes are chiefly found m the inguinal and axillary glands. They are sometimes simple glandular inflammations, unconnected with any constitutional or foreign evil, and require nothing more than the common treatment; but they are often a result of constitutional affection, and very frequently a symptom of lues and pestis, in which cases they can only be cured by curing the specific taint. Mr. Hunter asserts, that he has seen buboes cured by vomits, after suppura- tion has advanced. In an early stage, the inguinal bubo has been confounded with a scrofulous tumour. A nice finger will generally discriminate them with ease. The bubonous tumour is smooth, uni- form, and obtusely painful: the scrofulous is to the touch, and sometimes to the eye, a cluster of small tubercles without pain. of Muhlenberg) as a discutient, and with great success.—D. * Institutes, &c, vol. i., pp. 206, 207. Sir Ast- ley Cooper recommends the sinuses to be injected with a solution of two or three drops of strong sulphuric acid in an ounce of rose-water, and to apply a similar lotion to the bosom by means of linen wetted with it.—(Illustrations of Diseases of the Breast, p. 11.) For the dispersion ofthe hard- ness of the breast, left after milk abscesses, friction with iodine ointment, or camphorated mercurial ointment, or the application of the emplastrum ammoniaci cum hydrargyro, is the common prac- tice.—Ed. SPECIES VI. PHLEGMONE PHIMOTICA. PHIMOTIC PHLEGMON. TUMOUR SEATED IN THE PREPUCE ; DIFFUSE ; OBTUSELY PAINFUL; IMPRISONING THE GLANS, OR STRANGLING IT BY RETRACTION. If, at the attack of inflammation, the prepuce be in its natural state and cover the glans, it cannot be drawn back, and the glans is impris- oned. If it should accidentally have been re- tracted, or be naturally short and truncated, it cannot, after the inflammation has firmly fixed itself, be drawn forwards, and the glans is strangled. And hence the species offers us two varieties :— a Incarcerans. The prepuce protracted Incarcerating phirao- and imprisoning the sis. glans. 0 Strangulans. The prepuce retracted Strangulating phimo- and strangling the sis. glans. The first variety alone is denominated phimosis by some writers, the second being distinguished by the term paraphimosis, or cir- cumligatura. But the inflammation is one and the same, and the same specific name should express it; for the difference is a mere accident. This inflammation, like the last, though often produced by common causes, and hence per- fectly simple, is often, also, the result of a specific virus, as in lues and blenorrhoRa. It arises frequently with great rapidity; the pre- puce is prodigiously distended with effused serum, and the mucous glands of the internal surface secrete an enormous quantity of pus before there is any ulceration or breach of sur- face. If the prepuce be retracted violently, and the glans strangulated, and cold applications and topical bleedings prove ineffectual, it is often necessary to divide the prepuce to set the glans at liberty. And occasionally it is also necessary to perform the same operation when the glans is imprisoned by a protraction of the prepuce : for ulceration is apt to take place under these circumstances in either case, and the matter soon becomes erosive ; as much of it as possible, however, should be washed out with a syringe several times a day, and an astringent solution be afterward injected, consisting of alum dissolved in water in the proportion of about a scrapie to a quarter of a pint. The imprisoning phimosis is said to occur not unfrequently from laborious exertion in a very narrow vagina.—(Essich, in Ziegenhagen An- weisung aUe venerische Krankheiten—zu behan- deln, A. D. B., xcv., 421.) I have not met with this result, but often with a lacerated pre- puce. In many instances of both kinds, relief has been easily obtained by grasping the penis with a very cold hand, and dexterously urging the prepuce forward or drawing it backward, according to the nature of the case.—(Andree, on the Gonorrhoza; Hecker, Von Venerischen Krankheiten, &c.) When the inflammation is very violent, wheth- er in the strangulated or retracted variety, and Gen. III.—Spe. 2.] PHYMA FURUNCULUS. 445 surgical attention has been neglected, gangrene will readily ensue, and an amputation of a smaller or larger portion of the penis may be absolutely necessary. In an instance of an amputation of this kind, recorded by Mr. Jamie- son of Kelso, in the Edinburgh Medical Essays (vol. v., art. xxxvi.), the whole of the glans penis was restored by a process of pullulation : the new shoots having at first been mistaken for fungus, and attempted to be destroyed by esca- rotics. The fresh glans was well shaped and proportioned. [The editor scarcely need ob- serve, that the practice of amputating the penis on account of the risk of mortification from paraphimosis, is entirely relinquished by all the best modern surgeons ; and that even the re- moval of a portion of the prepuce for the relief of phimosis, is much less frequently practised than it used to be. Both cases, when depend- ant on inflammation, generally yield to milder treatment. In paraphimosis that resists com- mon means, an incision through the constriction will often prevent gangrene ; and it is only un- der very particular circumstances, requiring the glans to be immediately exposed, or where the phimosis depends upon a naturally long con- stricted foreskin, or one permanently thickened and lengthened by disease, that the removal of any portion of the prepuce is necessary.] GENUS III. PHYMA. TUBER. imperfectly suppurative, cutaneous, or sub- cutaneous tumour ; the abscess thicken- ed, AND INDURATED AT THE EDGE ; OFTEN WITH A CORE IN THE MIDDLE. Phyma, a Greek term importing a tuber, tu- bercle, or small swelling, from , "produco, erumpo," was used among the Greek and Ro- man physicians with great latitude and no small want of precision : sometimes, as by Hippoc- rates and Paulus of ^Egina, being applied to scrofulous and other imperfectly suppurative tumours; sometimes, as by Celsus and Galen, to tumours perfectly and rapidly suppurative, larger than a bile, but less painful and inflam- matory, and without a core or ventricle : and sometimes by other writers, as Celsus also in- forms us, to fleshy excrescences or warts on the glans penis, which it was then the custom to destroy by caustics. And in consequence of this vague sense of the term, and the latitude of its original meaning, the great body of the Galenists, as Sauvages observes, applied it to protuberances of every kind. mations as its species. This seems to be the most accurate sense ; and as such it is adopted in the present system, and made to include sty, bile, sycosis, and carbuncle ; in all which we find some degree of imperfection in the sup- purative or the ulcerative process of these small abscesses, or in both conjointly ; and hence the pus is foul and sanious, or the walls or edges of the abscess are thick and indurated, or the dead matter is not completely carried off, and re- mains behind in the shape of a core or a fungus, sometimes black and spongy, and sometimes excrescent and granulating. The following, therefore, are the species in- cluded under it: 1. Phyma Hordeolum. 2. -------Furunculus. 3. ------ Sycosis. 4. -------Anthrax. Sty. Bile. Ficous Phyma. Carbuncle Modern writers have been at a loss in what exact signification phyma should be employed. Linneus and Cullen have rejected it. Sauvages and Sagar have used it as the name of a dis- tinct and separate order. Vogel, following the example of Hippocrates and Paulus, has re- duced it to a genus of imperfectly suppurative and glanduiar tumours ; and, as a genus, it thus occurs in Dr. Willan's table of arrangement, including biles, carbuncles, and similar inflam- SPECIES I. PHYMA HORDEOLUM. STY. TUMOUR SEATED ON THE VERGE OF THE EYE- LID J granular; hard; reddish; sore to the touch ; suppuration confined to the POINT. The vernacular term sty, or, as it is some- times written, stian, is to be met with in the earlier writers, who obtained it from the Saxon, in which stihan signifies " a rising, springing up, or ascent;" and hence in Bede's Bible, Mar. iv. 7, slihon tha thornas, " up spring the thorns." Wickliffe spells the old English der- ivation stigh, but Spenser, who uses the word frequently, drops both the last letters of Wick- liffe, as in the following couplet:— " To climb aloft and others to excel, That was ambition, and desire to sty." From the hardness of the margin of the tu- mour, and the imperfection of the suppurative process, Sauvages compares it to a small bile ; and asserts that it is often the'result of a mor- bid state of the stomach ; adding, that he knew a man who uniformly had a sty after drinking ardent spirits. The inflammation, though often very troublesome while it lasts, for the most part readily subsides upon the breaking of the minute abscess, or puncturing it at its apex when mature. SPECIES II. PHYMA FURUNCULUS. BILE. tumour common to the surface ; deep red ; hard j circumscribed j acutely tender to the touch ; suppurating with a central CORE. The bile is a push with a central core ; and like the push is found in persons of an entonic or phlogotic habit, with a peculiar susceptibility of irritation : on which account it often makes its appearance successively in different parts of the body, and sometimes synchronously, so that we meet with a crop at a time. This tumour 446 H^M is therefore chiefly found in persons of high health and in the vigour of youth. [It is a hard, painful, and highly-inflamed tumour, of a conical shape, the base of which is below, and the apex slightly elevated above the level of the skin. The colour of the tumour is of a dusky red, inclining to purple, and its summit is tipped by a whitish pustule or eschar, beneath which is lodged a mass of disorganized cellular membrane, commonly called the core. Although the tumour always suppurates, its progress is slow, and the matter is sanious and ill-conditioned.]—(See Cooper's First Lines of the Practice of Surgery, and Gibson's Institutes of Surgery, vol. i., p. 48.) The existence of a core offers a singularity in this affection that is well worth attending to, and shows that, from some cause or other, the ulcerative part of the process is imperfect. Upon Mr. Hunter's hypothesis, this must de- pend upon a weak action of the absorbents ; but as we have already endeavoured to show that the material to be removed must be pre- pared for absorption, and conveyed to the mouths of the absorbent vessels before absorp- tion can take place, and have suggested that it seems to be the office of the secreted pus to accomplish this purpose, it is probable that, in the furunculus, the pus, from some cause or other, is not quite genuine, and is possessed of a less solvent power than in common abscesses • whence a part of the dead matter remains at tached to the living after the hollow has burst, and is thrown off from the base by sloughing. [In estimating the value of this theory, one fact should be taken into the account; namely, that it is the nature of a bile to produce a central core or small slough of the cellular membrane ; whereas many common abscesses occasion no sloughs whatever, so that the solvent power of their matter on such productions is not in real- ity tried. The idea that the solids are melted down, as it were, into pus, is now completely exploded.] The mode of treatment is simple. The diath- esis should be lowered by purging, and, if ne- cessary, by bleeding. [The best local applica- tions are poultices and fomentations ; and, when the apex of the swelling becomes soft, it may be opened, then poulticed until the core is dis- charged, and afterward dressed with a solution of lunar caustic or a stimulating ointment.] SPECIES III. PHYMA SYCOSIS. FICOUS TUBER. TUMOUR EXCRESCENT, FLESHY ; FIG-SHAPED ; SPROUTING FROM THE HAIRY PARTS OF THE HEAD OR FACE , GREGARIOUS ; OFTEN COA- LESCING ; DISCHARGE PARTIAL AND SANIOUS. The Greeks gave the name of sycosis from vvkov, " a fig," to various tubers and excres- cences, the shape of which was conceived to resemble that of a fig. By Celsus, however, it is limited to a particular kind of inflammatory and imperfectly suppurative tuber of the head ATICA. [Cl. III.—Ord. II. and face. Vogel has understood the term nearly in the same sense; and Dr. Bateman has -hence correctly described it as such in his list of cutaneous diseases. It is seated sometimes on the beard, and sometimes in the hair of the head. In the former case it consists of small tumours, hard, roundish, pea-sized ; commonly in clusters ; oc- casionally confluent, or running into one an- other ; and spreading from ear to ear : the dis- charge is small in quantity, and of a glutinous texture, whence the beard becomes filthily matted. The variety that appears on the head consists of softer tumours of different sizes, and in clus- ters ; they are seated among the hair, and throw forth from a fungous surface an ichorous, copious, and fetid discharge. It is not often that this complaint is connected with any con- stitutional affection : and, offensive as it is, it will generally be found to yield to cleanliness and mild astringents ; of which one of the best is starch-powder alone, or combined with an equal proportion-of calamine.* It makes an ap- proach to one or two of the species of porrigo, but has characters sufficiently marked to keep it distinct, and to determine the present to be its proper station. SPECIES IV. PHYMA ANTHRAX. CARBUNCLE. TUMOUR COMMON TO THE SURFACE ; FLAT ; FIRM J BURNING ; PENETRANT ; LIVID AND VESICULAR ; OR CRUSTY ABOVE, WITH A SORDID GANGRENOUS CORE BELOW ; IMPER- FECTLY SUPPURATIVE. Anthrax is a Greek term correspondent to the Latin carbunculus or carbuncle ; literally a small live coal, so denominated from the red- ness and fiery heat of the inflammation. The specific definition sufficiently points out its relation to the furuncle or bile, especially when the latter assumes an unkindly or malig- nant character, from something peculiar in the part or in the constitution. " The inflammation that produces the carbuncle is, however, of a different nature from any of the former: it is stationary," observes Mr. Hunter, " with respect to place, and is pretty much circumscribed, forming a broad, flat, firm tumour. It begins in the skin, almost like a pimple, and goes deeper and deeper, spreading with a broad base under the skin in the cellular membrane. It * This disease seems also to have been de- scribed by Pliny, under the term " mentagra," " quoniam a mento fere oriebatur," and to have appeared with great violence in Rome about the middle of the reign of Claudius. It is sometimes very protracted in its character, and is also liable to recur from neglect. It is occasionally cured by an ointment composed of equal parts of the sulphur and tar ointments, and at times it will yield to a wash of the solution of the chloride of soda. At the Hospital St. Louis, at Paris, it is treated also with internal remedies, as the muriate of gold, arseniate of iron, &c—D. Gen. III.—Spe. 4.] PHYMA ANTHRAX. 447 • produces a suppuration, but not an abscess ; somewhat similar to the erysipelatous, when the inflammation passes into the cellular membrane : for, as there are no adhesions, the matter lies in the cells where it was formed, almost like water in an anasarca. This inflammation at- tacks more beyond the middle age than in it, and.very few under it. It is most common in those that have lived well. I never saw but one patient of this kind in an hospital. Il appears to have some affinity to the bile ; but the bile differs in this respect, that it has more of the true inflammation, therefore spreads less, and is more peculiar to the young than the old, which may be the reason why it partakes more of the true inflammation."-—(On Blood, Inflam- mation, &c, part ii., chap, iv.) The carbuncle occurs chiefly, perhaps uni- formly, in weakly habits, and hence often in advanced life. But it is not all debilitated per- sons who have inflammations that exhibit this disease : and we have here, therefore, another striking proof of the influence of idiosyncrasy, or a peculiarity of constitution, upon the general laws and progress of inflammation ; or of a pe- culiarity of that part of the constitution in which the inflammation shows itself, and, but for which, the inflammatory stages of the present disease would in all probability succeed each other in regular order, and the anthrax be reduced to the character of a common and benign abscess. Of the nature of this peculiarity we are too often able to trace out little or nothing: but, so long as it continues, we have only a small chance of bringing the inflammation to a successful /ssue. The carbuncle shows itself under -the two following varieties :— a Pruna. With a black crust; and Eschar-carbuncle, oozing an erosive ichor, or sanies. 0 Terminthus. Core or fungus spreading in Berry-carbuncle. the shape and colour of the pine-tree berry. The first of these varieties was called pruna by Avicenna, from its assuming the colour, and often the oval figure of the sloe, or fruit of the prunus spinosa, Linn. The second derives its name from its assuming the figure and blackish green colour of the fruit or berry of the pine-nut, or Ttppivflof of the Greeks, the pinus Abies, Linn., named by the Latins tere- binthus ; whence it has been called terminthus and terebinthus indifferently. As the carbuncle is an inflammation of great weakness set down on a peculiar predisposition, it sometimes shows itself among feeble infants in warm climates. According to Tournefort, in his Travels through the Levant, it attacks them chiefly in the back part of the throat, and proves quickly fatal. He describes it as an endemic in his day, among the islands of the Archipelago. In more advanced life, for the same general reason, we meet with it frequently in those who have debilitated their frames by an excess of good living, and are verging on the feebleness of age. We may hence also account for its appearing in an early stage of the plague, the most debilitating disease in the whole cata- logue.* It sometimes shows itself in great numbers almost on its onset, or m'drop as the Arabians call it, who distinguished carbuncles by the name of jimmerat. . When unconnected with any other disease, a cure has been attempted by local stimulants, as cataplasms of tobacco and muriate of am- monia, which has been a common practice in Russia; or of horseradish (Pare, lib. xxi.,cap. 32), or stone-crop (scdum acre).—(Buchoz und Marquet neueste Heilkunde, Nuremb., 1777.) Cantharides (Riverius, Observ. Med., lent, iv.), camphire ointments, and lotions of zinc or mer- cury, have also been tried. More generally, however, it has been attempted to be destroyed or extirpated. Arsenic was recommended for this purpose as early as the age of Agricola, and has been employed in various forms, from that of orpiment to that of Plunket's caustic ; above all which, however, Le Dran preferred corrosive, sublimate. Riverius used other caus- tics, and Pouteau the actual cautery, which has, indeed, been very successfully and skilfully adopted of late in a variety of similar affections by M. Maunoir. But radical success must, after all, entirely depend upon supporting and giving strength to the system by cordials and tonics : for, if this cannot be accomplished, it is perfectly clear that the predisposition will be neither subdued nor subside spontaneously : that the ulcerations will not heal, and the sys- tem must gradually sink under their constant discharge and irritation. [The practice most approved in modern times is to apply in the incipient stage fomentations and emollient poultices to the part, and to have recourse, at the same time, to antiphlogistic treatment in moderation. For the relief of the pain, opium is freely prescribed. After a short time, the antiphlogistic is exchanged for the tonic treatment, with bark, cordials, wine, and a nutritious diet. An early, free, and deep cru- cial incision should be made in the swelling—a method that is to be preferred to the application of caustic to the skin, on account of the latter not procuring an outlet for the matter and dis- organized cellular membrane with sufficient promptitude. ]t * The carbuncle of plague differs from what is met with in this country by being contagious, at- tacking promiscuously any part of the surface of the body, and the young as well as other persons past the middle periods of life. The common carbuncle, as is well known, has a preference to the posterior parts of the trunk, the nape of the neck, and especially a situation between or over the scapulae.—En. t In Hays' Cyclopedia of Pract. Medicine, part vi., Dr. Reynell Coates, of Philadelphia, has writ- ten an able article on anthrax. Where incisions are required, Dr. Coates advocates the crucial form, as proposed by Dupuytren, and as pursued in several cases with the happiest effect by Dr. C. Drake (N. Y. Med. Rep., iv., s. vi., 462) ; " yet it is evident," Dr. C. observes, " that there must be many cases in which these incisions are inad- 448 H.EMATICA. [Cl. IH.-Ord. II. The carbuncle of cattle is frequently owing to the poisonous sting of various insects ; and hence a similar cause has, by some practitioners, been supposed to exist in mankind. Pallas suspects the furia infernalis ; while others have mentioned the sirex gigas, or large-tailed wasp. It is probable that these may have been occa- sional causes, where there has been a predispo- sition to the disease in the constitution.* GENUS IV. I 0 N T H U S. WHELK. UNSUPPURATIVE, TUBERCULAR TUMOUR ; STA- TIONARY ; CHIEFLY COMMON TO THE FACE. Ionthus (tovOos) is, literally, a " violet or pur- ple eruption, or efflorescence," from lov, viola ; whose colour is frequently that of a whelky or bubukled face. It includes all those firm and indurated pimples, of whatever description, un- connected with fever, and having a subcutane- ous base, with which the face is often disfig- ured, whether solitary, gregarious, or confluent. These may be comprehended under the two fol- lowing species :— 1. Ionthus Varus. Stonepock. 2.------Corymbifer. Carbuncled Face. Rosy-drop. missible or impracticable, owing to the great ex- tent, or to the location of the disease." Dr. C. claims the application of epispastics as purely American. Its author, Dr. Physic, has not found so much benefit from it as he expected. Dr. Beck, however (N. Y. Med. and Phys. Journ, vol. ii., p. 37), thinks them useful, and Dr. Coates remarks, "that the proper period for their employment would seem to be the commencement of the sec- ond stage, and the most suitable cases those in which the extent or location of the tumour inter- dicts the use of the knife, and which show a strong tendency to spread indefinitely, or to be- come complicated with diffuse inflammation ofthe cellular tissue." Dr. Hosack treats anthrax by supporting the strength of his patient by a nutri- tious and stimulating diet, while at the same time he preserves the tone and action of the part, by frequently washing the tumour with spirits or brandy, and by the constant application of a poul- tice composed of bark and yest.—(See Am. Med. and Phil. Register, vol. ii., p. 389.)—D. * The carbuncle of cattle, or the malignant pus- tule, as it is named by foreign writers, is not now believed by them to be occasioned in the manner specified in the text, but is propagated on the prin- ciple both of an epidemic and a contagious dis- ease. It is one of the few disorders which can be extended from the brute creation to man—the malignant pustule, cowpox, hydrophobia, and the glanders (as clearly proved by the researches of Dr. Elliotson; see Med. Chir. Trans., vols, xvi., xviii.), being perhaps the only four cases* which are of this nature. The itch has sometimes been also specified as capable of affecting both man and animals.—Ed. * To this list may be added the milk-sickness, which, in the eastern and southern portions of our country, has often proved so destructive to human life—D. SPECIES I. IONTHUS VARUS. STONEPOCK. tumour red ; hard ; pimply ; distinct ; gre- garious ; sore to the touch ; sometimes oozing a little fluid at the tip. This sort of simple eruption is so common, that there is no one but has seen examples of it; and few who have not at times given exam- ples of it in their own persons. It exhibits two varieties:— a Simplex. Broad-based, bright red, solid. Simple Varus. 0 Punctatus. Tipped with a black dot, and Maggot-pimple, discharging, on pressure, a grub-like concretion of mu- cus. The first, on being firmly pressed with the finger, oozes, at times, a little limpid serum, but no concrete mucus ; and even for this it is ne- cessary to make the pressure harder than for the discharge of the mucus in the maggot pim- ple. The mucus concretes in a follicle, or natural passage, and hence there is less inflam- mation and soreness than in the simple varus : yet the sides and root of the follicle are thick- ened and indurated : and hence the papulous elevation. Gouland's lotion, and a few other empirical cosmetics, as white paint of bismuth or cerusse, alike deleterious in their effects, and apt to produce palsy, are a common resource among the multitude for both these varieties. They, have sometimes succeeded, with little other sacrifice than the exorbitant price which the purchaser has had to pay for them ; but the cure has far more frequently been bought (if there have been a cure at all) at the expense of a ruined constitution, and at the exchange of a temporary local disfigurement for a life of gen- eral ill health. Both varieties are occasionally produced by some internal affection, chiefly of the stomach; as a sudden chill from taking a draught of cold water or cold milk ; or eating cold vegetables, as turnips, cucumbers, and melons, when in a state of great heat and perspiration. Catching cold in the feet has sometimes produced the same effect. These are cases of direct sym- pathy ; the torpitude of one organ being com- municated to another, which is predisposed to associate in its action. They have occasionally yielded to powerful sudorifics, and especially when combined with narcotics, as the compound powder of ipecac- uanha, in strong doses, taken for several nights in succession, the part affected being at the same time wrapped in flannel. They have also yielded to metallic and terebinthinate stimu- lants ; as eight grains of the compound calomel pill, and a scruple of camphire, made into six or eight pills, and taken daily for ten days or a fortnight. But they generally require some local irritant at the same time; as savin ce- rate, the camphire or mercurial liniment, or the stronger liniment of ammonia, used so as to excite blistering. Yet, after they have resisted Gen. V.—Spe. 1.] PHLYSIS PARONYCHIA. 449 these and other preparations, with great obsti- nacy, for years, they have at length vanished beneath a severe attack of fever, or have disap- peared spontaneously. The complaint, how- ever, is occasionally hereditary, and bids equal defiance to time, to fevers, and to medicines. Dr. Darwin, under the name of gutta rosea, has a copious collection of cases in point; some of them drawn from old maids, and others from elegant young ladies, and each duly authenti- cated with initials, to which the reader may turn at his leisure. Among the rest is- that of " Miss L., a young lady about eighteen, who had tried a variety of advice for pimples over the greatest part of her face, in vain. She took rhubarb, five grains, and emetic tartar, a quarter of a grain, every night for many weeks, and blistered her face by degrees all over, and became quite beautiful."—{Zoonomia, cl. ii., i., iv., 6.) SPECIES II. IONTHUS CORYMBYFER, CARBUNCLED FACE. ROSY DROP. TUMOURS CONFLUENT J CORYMBOSE ; MOTTLED WITH PURPLE : OFTEN DISFIGURING THE NOS- TRILS WITH PENDULOUS LOBES. As the preceding species is produced by a sympathy of the excernents of the skin with a torpid state of the stomach, the present is pro- duced by a like sympathy with the liver ; and hence it is proverbially regarded as a proof that those who are thus disfigured have indulged too largely in wine and other spirituous potations. So Shakspeare, in describing the physiognomy of a hard drinker, tells us, that " his face is all bubukles, and whelks, and knobs, and flames of fire ! !" And in like manner, as I learn from Dr. Perceval, the common name for these pro- tuberances in Ireland is grog-blossoms. .The tumours in this species are usually more susceptible of irritation than in the preceding ; or, in other words, the cutaneous vessels are in a state of increased debility ; and hence they are exacerbated by cordials or exposure to heat. As this is, in most cases, an habitual affec- tion, or one of long standing, no change of diet, however desirable, should be made suddenly ; for this would run a risk of producing dropsy, and, perhaps, paroxysms of atonic gout: but a gradual change to a more sober and temperate regimen is highly to be recommended ; and, in the mean time, the patient should have his bow- els kept regularly open with warm eccoprotics ; as the extract of colocynth and myrrh pill; and be put upon a course of equitation, or such other exercises as may recruit the spirits and invigorate the system generally, in which ben- efit the liver will become a chief participant. The tumours may not, perhaps, totally disap- pear, but they will often diminish in magnitude, and assume a healthier hue, or, at least, we shall hereby prevent them from any farther en- largement, and especially from passing into that carbuncular ulceration we have just noticed. Vol. I.—Ff GENUS V. PHLYSIS. PHLYSIS. ULCERATIVE, SUBCUTANEOUS TUMOUR J FLAT ; TENSIVE J GLABROUS ; DIFFUSED ; HOT ; THROBBING J AT LENGTH FLUCTUATING WITH AN ICHOROUS MATTER. Phlysis, from the Greek , "ferveo," was formerly employed in a very indeterminate meaning, to express cutaneous eruptions filled with any kind of fluid, whether purulent or ichor- ous : more generally, however, it had a bearing towards the sense of ichorous or vesicular pim- ples. Dr. Willan has, on this account, correctly limited phlyctaenae, derived from the same root, to this import, in his table of definitions; and such is the restriction of phlysis, and all its compounds, in the present system. Of the genus now offered, there is but one well-ascertained specieS; the paronychia, or whitlow. SPECIES I. PHLYSIS PARONYCHIA. WHITLOW. INFLAMMATION SEATED ABOUT THE NAILS AND ENDS OF THE FINGERS; PAIN ACUTE AND PRICKING, SHOOTING UP THE HAND. Under this species are included the following varieties :— a Cutanea. Effusion immediately un- Cutaneous whitlow. der the skin. 0 Tendinis. Effusion among the ten- Tendinous whitlow. dons. y Periostei. Effusion pressing on the Malignant whitlow. periosteum. In the first variety, the ichor, or pus, is poured forth between the skin and the subja- cent tendons, to which, however, it is limited. In the second, it insinuates itself between the tendons and the periosteum; and in the third, between the periosteum and the bone, which is often in the etate of necrosis. It is to this last, or malignant whitlow, that the term felon is most correctly applied. Similar inflammations are occasionally to be found in the soles of the feet and palms of the hands. They break through the skin or cuticle with difficulty, from their thickness, and hence become diffused, and, in the latter case, sepa- rate the cuticle from the skin beneath. In the whitlow, the acute and lancinating pain complained of arises partly from the thick- ness and inelasticity of the skin about the finger- nail, but more from the hardness of the finger nail itself; both which act like a tight bandage upon the inflamed part, and do not allow it to swell, or give way to the extravasation. In these ca- ses, therefore, we can easily see why the appli- cation of poultices should be of more service than in any other; for they can here act me- chanically, or, in other words, their moisture becomes imbibed by the cuticle, as by a sponge, so that it softens, grows larger in its dimensions, and less rigid in its texture ; while the nail itself 450 HAEMATIC A. [Cl. III.—Ord. II. loses a part of its hardness, and becomes sup- pler. It is in consequence of the peculiar firm- ness of the skin around the nail, that the soft parts below are so often seen pushing out through a very small opening in the skin as soon as this has been effected, and appearing like a fungus, but so exquisitely irritable as to give a more impressive idea of soreness than, perhaps, any other kind of ulceration whatever. All this pro- ceeds from the surrounding belts of the cuticle not giving way to the increase of the parts un- derneath ; whence they are squeezed out of this small opening like paint out of a bladder. It is a common practice to eat away this protruded part by escharotics, as if it were a diseased fun- gus ; but this is to give additional pain without any benefit; for the pressure from below will not be hereby diminished. By continuing the poultice the tumefaction will subside, and consequently the pressure cease.* In the first stage of the complaint, leeches should be applied; and if the inflammation be hereby diminished, it may sometimes be carried off by astringent lotions, or ardent spirits, which exeite the surrounding absorbents to additional action.t Most of the causes of inflammation operate in the production of this peculiar affec- tion. It is also occasioned by an incurvation of the nail (Vicat. Delect. Observ. Prac.) ; pos- sibly sometimes by a caries or morbid state of the subjacent bone, in the tendinous and peri- osteous variety, as ascertained by Siebold(CAi- rurgisches. Taschebuch., xi.); and Mr. John Pearson has shown that it may occasionally re- sult from a syphilitic diathesis, or any other de- praved habit.—(Principles of Surgery, p. i.) It seems, moreover, in some cases, to be produced by the bite or burrowing of the larvae of one or more minute, and, lo the naked eye, invisible insects, hatched on the leaves of various field plants, and especially fescue-grass: and is said to be also occasioned by the bite of the gordius aquaticus, or hair-worm. GENUS VI. ERYTHEMA. INFLAMMATORY BLUSH. RED, GLABROUS, TUMID FULNESS OF THE INTEG- UMENTS J DISAPPEARING ON PRESSURE ; PAIN BURNING,; INFLAMMATION ULCERATIVE ; TER- MINATING IN CUTICULAR SCALES, OR VESICLES ; OCCASIONALLY IN GANGRENE. This genus of inflammation is entitled to a * In a late French periodical, the use of mercu- rial frictions is highly recommended for the cure of P. Paronychia. The writer states that the fin- ger should be rubbed every thirty minutes with some mercufial ointment, and then a dressing of the same should be applied to it. In a few hours the pain is subdued, and the disease arrest- ed.—D. f Whitlows, not far advanced, sometimes admit of being resolved by the external use of the nitrate of silver, with which the skin is to be stained, in the manner advised by Mr. Higginbottom, of Northampton. The editor had rarely seen a whit- low brought to resolution before this practice had been suggested.—(See John Higginbottom on the minute and discriminative attention, not only on account of its violence and tendency to an al- most unlimited spread, but from its having been very generally confounded with an exanthem* or eruptive fever, which, in one or two of its species, it frequently accompanies, but of which it is then a mere symptom. [One of the latest writers on erysipelas (or the erythema of the present author) considers it as merely a particular modification of cutane- ous, or cutaneous and cellular inflammation. If (says he), we were to class these according to their natural affinities, we should place erysipe- las between the exanthemata and phlegmon. It is less diffused than the former; not so circum- scribed as the latter. The exanthemata are confined to the skin; erysipelas affects both skin and cellular structure ; while phlegmon has its original seat in the latter; the skin being secondarily involved. Phlegmon is a more vio- lent inflammation than erysipelas ; but sloughing of the cellular membrane is more frequent in the latter than the former.]—(See Lawrence on Erysipelas in Med. Chir. Trans., vol. xiv., p. 18.) Erythema, from ipevdos, " rubor," is a term of Hippocrates, who uses it as nearly as may be in the sense now offered; and for which many modern writers of our own country have not unaptly employed the vernacular term inflam- matory blush ; since the redness has often very much the appearance of a blush, or glow- ing suffusion of the cutaneous capillaries. For erythema, Celsus and Galen have unfortunately adopted the term erysipelas, whence Duretus, in his Latin version of Hippocrates, has used suffusio erysipelatosa. And hence erysipelas has been made a very common synonyme of erythema by general writers, while the nosolo- gists, with a few exceptions, have limited erysip- elas to that species of exanthem or eruptive fever which is vernacularly known by the name of St. Anthony's Fire ; and have revived ery- thema to express the local affection or peculiar inflammation before us, in which the pyrexy is mostly symptomatic. Frequently, however, as these two disorders have been confounded, from an indiscriminate application of the same name to both, it will not be difficult to draw a distinctive line between Application of Lunar Caustic to Wounds and Ul- cers, 8vo., 1826.) When the disease is not imme- diately relieved by this plan, or other means tried to disperse the abscess, an early opening should be made for the discharge of the matter.—En. * The doctrine of erysipelas being an exanthem, according to Dr. Cullen's definition of the last term, is rather inconsistent. It is correctly ob- served by Mr. Lawrence, that, although the lead- ing characters of the exanthemata are thus ex- pressed " morbi contagiosi, semel tantum in decur- su vitae aliquem afficientes," Cullen has arranged under this order erysipelas, which attacks the same individual repeatedly, and the contagious nature of which is, to say the least, very doubtful.—(See Med. Chir. Trans., vol. xiv., p. 31.) As, however, Dr. Good's definition of exanthemata is " cutane- ous eruptions essentially accompanied with fever," he does not fall into the same kind of contradiction as Cullen did. Gen. VI.] ERYTHEMA. 451 them. Erythema bears the same analogy to phlegmon, as erysipelas does to smallpox. Phleg- mon is local inflammation tending to suppura- tion ; erythema, local inflammation tending to vesication : smallpox is an idiopathic fever pro- ducing a phlegmonous efflorescence. Smallpox is always contagious; erysipelas occasionally so ; phlegmon and erythema have no such tendency. The distinction then between erysipelas and erythema is clear; yet the confusion just no- ticed has been increased by some writers, who have not only used erysipelas in its popular, yet. erroneous signification of erythema, but have also employed erythema in a new and unjus- tifiable sense ; as occurs particularly in Dr. Willan's classification of Cutaneous Diseases ; where, while erysipelas is made to embrace both erysipelas and erythema, as these terms have hitherto been commonly used, erythema is arbitrarily appropriated as the name of another collection of cutaneous erubescences of very different characters, and produced by very dif- ferent causes; some of them primary, others symptomatic affections; some constitutional, and others local; occasionally smooth, papu- lous, tubercular, or nodose; most of which should be distributed under different divisions. Thus introduced and explained, erythema, as a genus, will be found to comprise the seven following species, the first three of which are taken with little alteration from Mr. Hunter :— 1. Erythema CEdema- CEdematous Erythe- tosum. ma. 2. ----- Erysipe- Erysipelatous Erythe latosum. ma. 3. Gangrae- Gangrenous Erythe nosum. ma. 4. ----- Vesicula- Vesicular Erythema. rum. - 5. Anatomi- Erythema from Dis- cum. section. 6. Pernio. Chilblain. 7. Intertrigo. Fret. Most of these depend upon a peculiar irrita- bility of the constitution, or of the part in which the inflammation or erythema appears ; and the common, though perhaps not the sole cause of such irritability, is debility or relaxation. Galen, who justly distinguishes between sup- purative, or, as he calls it, phlegmonous inflam- mation, erythematic (with him erysipelatous), and cedematous, ascribes the first, according to the old doctrine of temperaments, to a preva- lence of the sanguineous diathesis ; the second to that of the bilious ; and the third to that of the phlegmatic or pituitous.—(De Tumoribus, Praternat., tom. iii., xx.) That there is gen- erally a peculiar habit in the last two, and often, as we have already observed, in the first, is so clear as to be indisputable ; but it is by no means equally clear, that such peculiarity of habit is dependant upon the immediate cause Galen has adverted to. The temperaments of the Greek physicians, excepting when in excess, are not inconsistent with the condition of health ; and hence, therefore, in connexion with the temper- ament, there is usually, in the last two inflam- Ff2 mations, a habit of debility or relaxation. And where this exists, the very same stimulus that, in a perfectly healthy frame, would produce a common adhesive or suppurative inflammation, under this state of the system changes the char- acter of the inflammatory action, and urges- on the ulcerative process from the first. It usually commences with great violence, and is peculiarly apt to spread ; the surrounding parts being ea- sily excited to act or sympathize in an action to which they are prone. Hence, continued sym- , pathy is a common, though not a universal ef- fect ; for we sometimes meet with very consid- erable inflammations confined to the part irri- tated, notwithstanding that the irritated part evinces great violence of action. Mr. Hunter has illustrated this difference of effect by refer- ring to a piece of paper under two different states, dry and damp. In dry paper, a blot of ink ap- plied to it wHl not spread, and remains confined to the point of incidence ; in wet paper it spreads easily, being attracted by the surrounding moist- ure, to which it has an affinity. [The distinction proposed between erythema and erysipelas is well founded ; the latter term being restricted by Cullen to a fever that is fol- lowed by the peculiar inflammation of the skin, commonly termed erysipelatous. By erythema, Dr. Good signifies merely the local affection of the skin, whether the consequence of fever or not. The only objection to so true a distinction is its interference with the common meaning of the word erysipelas, now more loosely em- ployed in every medical publication, and at every medical school. Yet who will maintain that a fever, leading to a peculiar inflammation of the skin, ought to be confounded with other cases, in which either no fever may precede the local affection, or a fever of a-very different kind from what precedes the efflorescence of ery- sipelas in Dr. Good's sense of the expression 1 The truth of the latter part of this remark will be illustrated in the history of erythema anatom- icum. Why the author, in his definition of ery- thema, should have introduced the words " in- flammation ulcerative," the editor can hardly understand ; since erythema, or erysipelatous in- flammation, frequently terminates without any ulceration, suppuration, or even vesications. The connexion which the disorder is repre- sented by the author to have with debility as a cause, is another doctrine that does not meet with universal assent. The truth is, that the peculiar state of the constitution or part deter- mining the kind of inflammation, is not known ; but, as erythematous inflammation frequently oc- curs in young and robust persons, as well as the old and debilitated, nothing can be more certain, than that it is not essentially connected with weakness. Mr. Lawrence is quite at a loss to discover in this affection those marks of debility, which some have so much insisted on. Ery- sipelas, like any other inflammation, he observes, may occur in old and feeble persons, and the effects of the disease, when aggravated by in- judicious treatment, or protracted from any cause, will soon weaken the most robust; but, however weak the patient, the local disturbance 452 H.EMATICA. [Cl. Ill—Ord. II. is one of excitement; there is increased activity in the circulation of the part, clearly marked by all the symptoms. Indeed, speaking of the part, be is unable to recognise debility as the cause of any inflammation whatever, and, in reference to the seat of disease, he regards the expressions of passive and asthenic inflammation and ve- nous congestion, *as either unmeaning, or calcu- lated to convey erroneous notions.—(See Med. Chir. Trans., vol. xiv., p. 28.)] SPECIES I. ERYTHEMA CEDEMATOSUM. ' "(EDEMATOUS ERYTHEMA. COLOUR SCARLET ; SPREADING WIDELY AND DEEPLY THROUGH THE CELLULAR MEMBRANE, WHICH OFTEN IMPERFECTLY SUPPURATES, SLOUGHS, AND BECOMES GANGRENOUS. This is the " cedematous inflammation" of Mr. Hunter, who observes that, when the ex- travasated fluid is water, it has very much the appearance of the adhesive inflammation, and probably resembles it more nearly than any other erythema, being of a scarlet colour, but much more diffused. The skin, through the whole range of the in- tumescence, appears glabrous, and the redness vanishes upon a pressure of the finger, but re- turns as soon as the pressure is removed. The extravasated fluid is principally serum, and hence the swelling spreads further than the in- flammation itself. It is very painful, or, rather, very sore : but has less of the sensation of throb- bing than the adhesive inflammation. It is ap- parently limited to the surface, yet it probably goes much deeper ; for the extravasated fluid is in too large a quantity to be furnished by the cells of the cutis alone : but as the swelling and the inflammation do not here keep pace with each other, as in the adhesive description, we have not the same guide to direct our judgment. Coincidently with the remarks already offered, Mr. Hunter observes that " the difference be- tween this and the adhesive inflammation arises, I conceive, from the principle of inflammation acting upon a dropsical disposition, which is al- ways attended with weakness; whereas a greater degree of strength would have produced the adhesive inflammation under the same cause or irritation. And what makes me conceive this is, that, in many cases of anasarcous legs, we have exactly this inflammation come on from distention, which adds to the extravasation of the serum, as well as in most cases of scarifi- cations of cedematous parts to evacuate the wa- ter. When this inflammation takes place, it is much more lasting than the adhesive ; and, I believe, seldom or never produces suppuration : but if it should run into this stage, it is more general, and the whole cellular membrane in the interstices of parts is apt to mortify and slough, producing very extensive abscesses, which are not circumscribed."—(On Blood, part ii., chap, ii., sect, vii., p. 269.) There is no difficulty in determining why cedematous inflammation should rarely, if ever, produce suppuration, and why it should be of longer continuance. Suppurative inflammation is, generally speaking, the process of a healthy part or habit taking place instinctively for the purpose of removing something that is dead, ir- ritating, or otherwise mischievous, and filling up the space hereby produced with sound living matter. In cedematous inflammation, the part or habit is unhealthy and debilitated ; and hence, while there is necessarily less tendency to sup- puration, there is less power of recovery. In some instances the disorder is migratory, of which Dr. Swediaur gives a singular case that had just occurred in his practice. The patient was a robust, sanguineous man of fifty-five years of age, who had for many years laboured under paroxysms of gout, which had returned after cer- tain intervals, but who, at the time, had been free from attack for a longer term than usual. The oedema first suddenly showed itself in the eyelids, and disappeared on the second day, when he complained of pain and swelling in the fauces, with difficult deglutition. This was removed by astringent gargles, when the eye- lids became again oedematous; then the neck, and in a few days, in succession, the fingers of the right hand ; the fingers itched, became exul- cerated, and discharged an acrid humour, and the patient felt well. Some months afterward the same erythema returned, travelled in the same direction, and at last fixed on the feet, which in like manner inflamed, ulcerated, and healed, with a speedy return of general salu- brity.—(Nov. Nosol. Meth. Syst., vol. ii., p. 142.) The general curative intention therefore may be expressed in a few words. It should consist in whatever has a fair promise of giving local or constitutional tone, or both. Hence the benefit of astringent epithems and lotions, whether formed of earths, acids, or metallic oxydes, ap- plied to the part affected; and of stimulants where the action is peculiarly weak, as camphire water, or a solution of the acetate of ammo- nia, with proof spirit proportioned to the degree of torpor. And hence, as .internal medicines, bark, columbo, myrrh, iron, will often be found highly serviceable, in conjunction with a gen- erous diet, pure air, and such exercise as may be taken without fatigue. [When erythema cedematosum is joined with a general tendency to dropsy, the treatment should be chiefly directed against the latter dis- ease. But, when the local affection is called oedematous merely on account of the copious effusion of serum in the part, and is not com- bined with a dropsical state of the constitution, some practitioners adopt antiphlogistic treat- ment, instead of the tonic stimulating plan. Thus, in the beginning of the case, venesection, the free use of leeches, low diet, &c, constitute the practice followed by many surgeons and physicians at Paris for the relief of cedematous erythema.*] * Roche et Sanson, Nouveaux Elem. de Patho- logie, Med. Chir., tom. i., p. 351. Rayer, Trait* des Maladies de la Peau, tom. ii., pp. 221,241; and Lawrence, in Med. Chir. Trans., vol. xiv., p. 49. Gen. VI.—Spe. 2.] • ERYTHEMA SPECIES II. ERYTHEMA ERYSIPELATOSUM. ERYSIPELATOUS ERYTHEMA. COLOUR DEEPISH RED; SUPERFICIAL ; WITH A DETERMINED EDGE IN A SERPENTINE DIREC- TION ; THE PART WHICH HAS PASSED THROUGH THE ACTION HEALING AS THE PART NEXT AT- TACKED BECOMES AFFECTED. This is the " erysipelatous inflammation" of Mr. Hunter ; and is evidently that which symp- tomatically accompanies the erysipelas as an ex- anthem, or eruptive fever. It is more commonly cutaneous, than situated in the deeper-seated parts ; although, in some constitutions, almost every inflammation, wherever it takes place, will run deep as well as wide. The skin, how- ever, appears to be most susceptible of its ac- tion ; for it will spread over a prodigious sur- face of skin, while it rarely affects even the cel- lular membrane underneath ; and in this respect especially, it differs from the preceding species. £This opinion, that erysipelatous inflammation rarely affects the cellular membrane, or goes more deeply than the skin, is now found to be incorrect. It is only in the slightest cases that the disorder is confined to the skin, and, in all oth- ers, an effusion soon takes place in the cellular texture, causing a soft swelling; and this may be considerable, with much tension and a shining surface, when a large part of the body, or an entire limb, is involved.—(Lawrence, vol. cit., p. 3.)]—The extravasation, however, is less, than either in the oedematous or even the ad- hesive inflammation. It appears to support itself by continued sympathy ; for it commonly begins at a point, and spreads in a migratory di- rection, as the part first attacked recovers. This cannot, therefore, be merely constitutional; for, if it were, the parts already inflamed could not recover, while the morbid condition of the constitution disposes the surrounding parts to the same action ; but it affords an idea that, when the parts affected have onCe gone through the action, they lose the morbid disposition and become healthy. This property is not peculiar to the inflammation before us ; the ring-worm and many other cutaneous affections have the same tendency. Mr. Hunter observes, that this inflammation is more common in the summer than in the win- ter, especially in hospitals; and believes, that it takes place more frequently after wounds on the head than any where else. " I have often," says he, " seen it begin round a wound on the scalp, and extend over the whole head and face, the eyelids being very much swelled and the ears thickened ; it has then advanced to the neck, shoulders, and body, creeping along both arms, and terminating at the fingers' ends : the part which attacks the body often descends to both thighs, passes down the legs, and termi- nates at the ends of the toes. And while this is going on, it is as expeditiously cured behind, and the skin peels off from the cured parts." Sometimes, however, it stops suddenly in its course, and assumes a milder character. ERYSIPALATOSUM. 453 If it proceed deeper than the skin into the cellular membrane, it often suppurates, and at times occasions mortification in the cells by which the air is let loose ; and it is this state of the disease that forms the erysipelas phleg-. monodes of Galen (Mat. Med., lib. xiv., cap. ii.), Van Swieten (Comment., tom. ii., $723), and many later writers, who have used erysipelas in the loose manner I have already pointed out, as synonymous with erythema. [In Mr. Law- rence's view of this subject, phlegmonous differs from simple erysipelas (erythema erysipelato- sum) merely in the higher degree and deeper extent of the inflammation, which not only occupies the whole thickness of the skin and subjacent adipose and cellular tissue, but soon proceeds in the latter to suppuration and slough- ing, the skin itself being often involved second- arily in the mortification.]* The effect of this mixture of inflammation produces a strange feel, for it is neither that of fluctuation, nor of crepi- tation ; and as there are no adhesions, the matter finds an easy passage into the common cellular membrane, increasing the same kind of suppuration wherever it goes ; and as mortifi- cation, and consequently putrefaction, follow speedily, the discharge becomes very offensive. As the parts loaded with effusion seldom ulcer- ate, they should be opened early ; for the fluid either gets into the cellular membrane from the want of adhesions, or separates parts that are only attached, as the periosteum from the bone, or muscles from muscles ; while the true sup- purative inflammation, on the contrary, ulcerates briskly, and hence should be allowed to burst, or at least should not be opened early. At the commencement of this inflammation, there is commonly some degree of fever, accom- panied with prostration of strength and dejection of spirits, and especially with loss of appetite. But the fever soon subsides, while the inflam- mation pursues its course; yet since one source of irritation has thus departed, it is less violent, and sometimes assumes a chronic character. As this, like the last, is a disease of weak- ness, the same general tonic plan will be calcu- lated to oppose it; and where there is a ten- dency in the separated skin to crack, absorbent earths or powders should be scattered freely over the ulcerative or oozing parts, to imbibe the acrid fluid as it escapes, or the ulceration will soon become extensive ; and the feeble and inflamed subjacent skin, hereby exposed to the stimulus of external agency, will grow gangre- nous with great speed. Finely pounded starch is a useful powder for this purpose ; as it com- bines a tonic and an astringent with an absorb- ent power; so, likewise, is a mixture of equal parts of starch and finely levigated calamine or rhubarb. The last I have sometimes thought peculiarly effectual in checking the irritation; as the second appears to be in preventing the * Med. Chir. Trans., vol. xiv., p. 9. The phleg- mon diffus of Baron Dupuytren : the diffuse inflam- mation of the cellular membrane of Dr. Duncan.— (See Edin. Med. Chir. Trans., vol. i.) This form of the disorder often commences and makes rapid advances in the subcutaneous cellular tissue.—Eo. 454 HAZM, further spread of the inflamed outline that sur- rounds the separated cuticle. This species of inflammation sometimes at- tacks infants from a very early period after birth; and, what is more singular, they have in a few instances been born with it. In such cases, it appears to be produced by some occa- sional cause, co-operatirig with an erythematic diathesis derived hereditarily. It generally as- sumes the mixed form of phlegmonous erythe- ma, suppurates imperfectly as it takes its course through the cellular membrane, and is often succeeded by gangrene. Its progress is very rapid, from the relaxed state of the infantile fibre ; and from the extrication of air, as soon as gangrene is produced, the tumefied surface has the mixed feel, already noticed, of fluctua- tion and crepitation. It commences usually about the genitals, works its way below towards the thighs and legs, and above towards the ab- domen, and often excites on the peritoneum the same caseous or purulent secretion which is so apt to form on this membrane in puerperal fever. As there is no disposition to adhesion, the fluid spreads in every direction, wherever the ulceration makes a way for it; and hence it has often descended in great abundance into the tunica vaginalis and labia'pudendi. Stimulant epithems of ether, alcohol, and camphorated spirits, applied in the first stage of the disease to the parts affected, have been found the most beneficial practice : they act as counter-irritants, and take off the morbid ex- citement by the production of an artificial and more manageable inflammation. To these ought by all means to be added the use of the bark in any way in which it can be introduced, espe- cially in that of injections, repeated several times a day.* [Mr. Lawrence rejects the notion that the cause of erysipelas is debility, and adverts to various facts to prove, that it is a complaint of an inflammatory character. Hence, the anti- phlogistic treatment is what he particularly rec- ommends. " In contending, however, for the inflammatory nature of erysipelas, and for the propriety of treating it antiphlogistically," he says, " I do not mean to recommend, that meas- ures equally active, and, in particular, that bleeding, whether general or local, are to be employed in all cases. In young persons, in * This species of inflammation, which affects the genitals of children, seems analogous to that noticed by Burns in his Midwifery. Mr. Kinder Wood has also written on it.—(Med. Chir. Trans., vol. vii.) "In this complaint," says Dr. Francis, " ulceration ensues within a few hours after vesica- tion of the part; the ulcer becomes deep and foul; but mortification is rarely seen. In the treatment of it, bark and cordials internally, and stimulating applications externally, have proved serviceable." The late Dr. Richard Bayley and Dr. John Bard, of New-York, treated cases of this kind by tonics generally, and by the local application of the un- guent, basil, nig. The pyroligneous acid, as a wash, may be mentioned as effectual.—(Sherrill, Essay on Epidemics, New-York, 1832.) We have used a solution of the chloride of soda also, with success.—D. lTICA. [Cl. Ill—Ord. II. the robust, and those of full habit, in instances where the pulse is full and strong, or when there is headache and white tongue, in erysipelas of the head, attended with symptoms denoting affection of the sensorium, and more especially in the very beginning of the affection, vene- section will be proper; and it may be neces- sary to bleed largely, and to repeat the evacua- tion, or to follow venesection to the local ab- straction of blood. Under such circumstances, the other parts of the antiphlogistic plan must also be employed ; that is, the alimentary canal should be cleared by an active purgative, which may be followed by salines and antimonials, with the occasional use of milder aperients ; and low diet should be enjoined. Nothing can be more different from such a case, than that of an elderly person, with a small and feeble pulse, in the advanced stage of the disease. The interval between these extremes is filled by numerous gradations, requiring corresponding modifications of treatment. The antiphlogistic plan itself embraces a wide range in point of degree ; from bloodletting, local and general, with purging, vomiting, the free use of mercury and antimony, and low diet, to the exhibition of a mild aperient, with some saline medicine. The treatment of erysipelas, like that of any other inflammation, must be modified according to the age, constitution, previous health, and habits of the patient, and the period of the complaint. In asserting, generally, that the antiphlogistic treatment is proper, I speak of the beginning of the disease, when the original and proper char- acter of the affection is apparent; and I am decidedly of opinion, that, in some shape or de- gree, such treatment will always be beneficial in that stage. In many instances, active anti- phlogistic measures are of the greatest service in lessening the severity both of the local and general symptoms. In others, the administra- tion of calomel with aperients, and of diapho- retics with low diet, will be sufficient. When the affection occurs in old and debilitated sub- jects, the powers of life are soon seriously im- paired, and our efforts must be directed rather towards supporting them, than combating the local affection. I have often seen such pa- tients, labouring under erysipelas of the face in its advanced stage, with rapid and feeble pulse, dry and brown tongue, recovered under cir- cumstances apparently desperate, by the free use of bark and wine."—(See Med. Chir. Trans., vol. xiv., p. 41.) Nothing indeed can be more absurd, than to prescribe one plan, either antiphlogistic or stimulating and tonic, for every case, without any regard to the varia- tion of circumstances.] SPECIES III, ERYTHEMA GANGRENOSUM. GANGRENOUS ERYTHEMA. THE COLOUR DUSKY RED ; SUPERFICIAL ; CUTI- CLE SEPARATED FROM THE CUTIS BY A BLOODY SERUM ; THE CUTIS, WHEN DENUDED, EXHIBIT- ING DARK 3ROWN SPOTS, DISPOSED TO BLISTER Gen. VI.—Spe. 4.] ERYTHEMA VESICULARE. 455 AND SLOUGH ; OCCURRING CHIEFLY IN THE EXTREMITIES. The gangrenous erythema, like the two pre- ceding species, is a frequent companion of de- bilitated or relaxed constitutions, but is mostly to be met with in advanced age, or weakly adolescence, or infancy; and particularly where, in old age, the constitution has been broken down by habits of intemperance and excess ; the circulation is languid, and the blood even in the arteries assumes a venous appearance. The inflammatory stage is in these cases some- times very slight, and the gangrene is ushered in with very little previous affection. Either of the preceding species will pass readily into the present, in a warm, stagnant, and corrupt air ; for the same reason that all hospital wounds run rapidly into the same state under the same circumstances. Local applications are here of far less im- portance than an attention to the general con- dition of the constitution. Stimulants and per- fect cleanliness are perhaps all that are demand- ed under the first head; , while, under the second, pure air, and a steady course of tonic medicines and diet, adapted to the age and habits of the patient, are absolutely indispensa- ble, and can alone furnish any hope of recovery. How far this disease appertains to the ignis sacer of the Roman writers, will be seen under the ensuing species, which forms another sub- division of the same affection. [Gangrenous erythema, or erysipelas, seems to the editor not to merit the rank of a distinct species, because it is an effect of several forms of erythema or erysipelas when they are violent, and it is not the exclusive character of any particular example of the disorder. Bad cases of phlegmonous erysipelas present us with the most severe specimens of gangrenous mischief resulting from the disease ; the hope of prevent- ing which mischief induced Messrs. Hutchison, Lawrence, and others, to have prompt recourse to numerous or extensive incisions in the part affected.]* SPECIES IV. ERYTHEMA VESICULARE. VESICULAR ERYTHEMA. COLOUR PALE RED ; SURFACE ROUGHISH, AND COVERED WITH CROWDING MINUTE VESICLES, * The experience which the editor has now had in the treatment of phlegmonous erysipelas, leads him to prefer numerous scarifications when toe part is merely loaded with serum, and does_not contain purulent matter or sloughs. He finds that from the small punctures or cuts, the quantity of fluid discharged will often be very considerable, and afford great relief. In a case which he is now attending, in Eagle-street, Red Lion Square, three pints of serous fluid flowed out of the small punctures in twenty-four hours. This practice is only necessary, however, when cold applications and antiphlogistic treatment fail to check the com- plaint If matter form, a free and depending open- ing becomes immediately indicated. Cold lotions are much more effectual in arresting phlegmonous erysipelas than warm applications; a fact confirm- FILLED WITH AN ACRID, OFTEN WITH A RED- DISH FLUID ; PROGRESSIVELY TRAILING INTO THE NEIGHBOURING SOUND PARTS. This species admits of two varieties, which have been pointed out from the age of Celsus :— a Benignum. Benign vesicular erythema. 0 Corrosivum. Erosive vesicular erythema In the first, the redness and vesicles ad- vance without a breach of the cuticle, as the part that has passed through the action is heal- ing. In the second, the vesicles break in the part first affected, and the erosive fluid produces tracts of sanious ulceration as the redness ad- vances. Under the present and the preceding species is included the ignis sacer of the ancients ; about which much has been written, but which has been seldom understood, and never hitherto re- ceived a clear methodic position. The author has taken some pains upon the subject, and trusts he will be able to establish the true boun- dary and character of a disease, not more fre- quently described by the physicians, than cele- brated by the poets of antiquity. The common error has consisted in making the ignis sacer, or holy fire, an exanthem or eruptive fever ; an erysipelas or a pestis: or some other idiopathic fever of the same order. There is no doubt, indeed, that, like the erysipe- latous erythema, it has at times been met with as an accompanying symptom in pestis ; and, when we shall come to treat of this disease, a distinct notice will be taken of the variety which such an accompaniment produces, and of -which the plague of Athens seems to furnish us with a tolerable example ; but the ignis sacer, in its genuine and simple state, instead of being marked with a low eruptive fever, has often very little fever of any kind ; certainly nothing more than symptomatic fever, and by Celsus is described as being best cured by an ephemeral, or any other fever which may give increased action to the system ; hereby proving that this, like the entire group of erythemas, is a result of debility. In ancient times, some diseases were sup- posed to be inflicted on mankind by the special interposition of the Divinity or of his ministers ; and to these was assigned the name of sacer, ed by Baron Dupuytren's experience, and, for many years, one that has influenced the editor's practice. The skin more frequently sloughs from phlegmo- nous erysipelas of the lower limbs, than from the same disorder on the head and face; a circum- stance ascribed by Dupuytren to the great depth of the tibial and fibular arteries, and their considerable distance from the skin ; while the temporal and oc- cipital arteries lie directly under the integuments, to which they afford a very free supply of blood. Also, since the cellular tissue chiefly affected lies under the aponeurosis of the tendon of the occipito- frontalis muscle, a reason may be discerned why the disease should produce less injury of the ves- sels supplying the skin of the head. Baron Dupuy- tren, in the whole course of his experience, has seen but one example of sloughing of the scalp from erysipelas.—Ed. 456 H.EMATICA. [Cl. III.—Ord. II. or holy ; though the peculiar crimes for which they were inflicted, or the names of the partic- ular persons who in this manner first drew down the special vengeance of Heaven upon their atrocities, have not been communicated to us. The later term of Saint or Sanctus, as in St. Anthony's fire or St. Vitus's dance, are of parallel origin, and express corporal punishments first inflicted by the agents or supposed agents of the Deity, whose names they respectively bear. Ignis is a term expressive of the heat, redness, acrimony, and erosive power of a dis- ease ; and is hence applied to the present, in common with many other affections. The best description of the ignis sacer that has descended to us from the Roman writers is that of Celsus. He represents it as a genus comprising two species ; the first of which is precisely parallel with the species before us, and the second with the erythema gangranosum, or the preceding; and, in order to prevent any doubt upon this subject, the definitions of both species are here given, as nearly as may be, in the words of Celsus himself:—"It has," says he, " two species ; one (the vesicular erythema of the present system) is reddish, or a mixture of redness and paleness, rough, with approxi- mating vesicles (pustula), none of which are larger than the rest, and which, for the most part, are very small. In these are almost al- ways found a fluid (pus), and often a red colour with heat."—(De Medicina, lib. v., cap. xxviii., sect, iv.) Then follows his description of the two varieties just given ; the benign and ero- sive, in the following words :—" sometimes it trails along, the part healing that was first dis- eased ;" corresponding with the variety a ofthe present system ; and " sometimes the part ulcer- ating ; in consequence of which the vesicles (pustulae) break, and the ulceration keeps spread- ing, and the fluid escapes ;" alike corresponding with the variety 0. Celsus then passes oh to describe his second species, which answers to the character and almost to the words of ery- thema gangranosum, or that we have just con- sidered. " The other species," says he, " con- sists in an ulceration of the cuticle, without depth, broad, sublivid, but unequally so; and the middle heals, while the boundary lines ad- vance ; yet not unfrequently the part that seemed healed again becomes exulcerated; while the neighbouring parts, which are about to receive the disease, grow tumid and hard, and change from a blackish hue; the disease chiefly attacking the legs." In this passage, the words fluid and vesicles are by Celsus named pus and pustulae ; hut that he hereby meant vesicles, and an ichorous fluid, the (p\vKTaivai of the Greeks, is clear; first, because Celsus thus explains the term in an- other section of the same chapter ; and secondly, because in the ignis sacer, which, as we learn from Thucydides and Lucretius, was a symptom in the plague of Athens, the former has given us hour or two afterward, being the eighth day from the accession of the disease, he expired. The pathognomonic blush that spreads over the region of the pectoral muscle has a peculiar feel, that is not easy to be described ; it yields to pressure like a quagmire, or piece of sponge ; and is hence called boggy by Mr. Lizars (Trans. Medico-Chir. Soc, Edin., vol. i., p. 496), and doughy by Dr. Colles.—(Dublin Hosp. Reports, vol. iii., ut supra.) In the case of Dr. Pett, it was found by Mr. Travers (Lond. Med. and Phys. Journ., Feb., 1823, p. 176) to crepitate, a secretion or extrication of air having appa- rently taken place. There is often a consider- able degree of uneasiness in the punctured or abraded spot, which has proved an inlet to the virus, sometimes, indeed, amounting to an ago- nizing and intolerable pain, though without any. visible show of inflammation, or too slight to be regarded. The accession of the fever is usually accompanied with great anxiety and dejection of spirits, and often an unwonted irritability of temper. The nervous and depressing character of the fever is, indeed, obvious from the first, and the patient rarely rallies into any degree of hope or composure, where it proceeds to a fatal termination.* In very many cases, however, its issue is of a happier kind ; and where this occurs, some- times, about the eighth day, a gentle diaphore- sis or diapnoe lubricates the harsh and burning skin, a sound and refreshing sleep succeeds, the pain and inflammation diminish, and the patient advances to recovery in a straight path. But, more generally, an effort is made to form lodg- ments of imperfect pus, bloody serum, or gangre- nous ichor, often of all these combined, in partic- ular parts of the affected side, most commonly indeed in the axilla ; which swells into an enor- * The late Prof. Godman has reported an inter- esting case of this affection, in the person of the late Mr. Adrian A. Kissam, which terminated fa- tally.—Amer. Journ. ofthe Med. Sciences, vol. L, p. 315—D. 460 H^EMATICA. [Cl. Ill—Ord. II. mous bag, and, if not opened by art, bursts spontaneously, and discharges the complicated and pent-up fluid to an amount of several pints ; the whole of the cellular membrane on the af- fected side being broken down into the general mass, with numerous sloughs and skeins of fibres detached from the adjoining muscles and thrown out in loose bundles. The cure is long and doubtful in proportion to the range of the ulceration, and the extent of the gangrene : and the patient is often so much reduced as to be in danger of falling a sacrifice from hectic fever or, some other secondary affection. But when he has reached this stage, he generally succeeds in the end, though the skin over the injured part is considerably shrivelled, from the loss of the cellular texture beneath, and often attached to the subjacent muscles. Such is the progress of the disease when the contagion meets with a habit or constitution favourable to its mischievous action, and which yields at once to its influence. But, as in other contagions, so in the present, we perceive a striking diversity in this respect. The habit or idiosyncrasy of most anatomists, fortunately renders them altogether unsusceptive of its im- pression, and they escape from its arrest. And hence, in all probability, the reason why but few comparatively are ever affected with this fearful complaint, though handling dead bodies for years, and with hands chapped or punctured in various points. There are others who seem to possess con- stitutionally a modified protection, though they cannot escape altogether; in whom the virus finds a less easy course of absorption, and, by being delayed in its progress towards the axilla, opens its assault at the point of contagion, be- comes concentrated, and spreads its chief brunt in that quarter. In this case, the disease com- mences with local, instead of with constitutional symptoms, and the latter are even at last rather a sympathetic sequel, as in numerous cases of simple irritants, than a diacritical part of the disorder. The punctured hand or finger is not only vehemently painful, but svvells and becomes considerably inflamed ; the inflammation char- acterized by heat, redness, pain, and enlarge- ment, gradually shoots up the forearm ; and, if not checked in its progress, ascends to the shoulder, and fixes itself in the axilla, or spreads still further into the side ofthe chest. But the virulence is usually diluted as it widens ; and though the constitution suffers much from symp- tomatic fever, the inflammatory action is often confined to the arm alone, where it seems to aim at forming a chain of abscesses from the hand to the elbow, and sometimes to the shoulder or axilla. This distinction is so clearly marked and closely adhered to, that I have scarcely ever heard or read of a case that proved fatal, where the disease has opened with local inflammation, nor often where it has been accompanied with any great degree of danger : while, on the con- trary, nothing can be more dangerous than the same disease, where the constitutional symp- toms take the lead. And I gladly avail myself of a confirmation of this remark by my dis- tinguished friend, Mr. Travers, published since the preceding edition of the present work, in which it occurs in the same words :—" Inflam- mation is not necessary to the most virulent and fatal action of the poison ; and, in general, I should be disposed to say of these cases, that the symptoms of local inflammation and consti- tutional irritation exist in an inverse ratio of severity."—(Inquiry concerning Constitutional Irritation, &c, p. 203, 8vo., 1828.) In a few instances, a most offensive smell has been found to accompany the diaphoresis which occasion- ally breaks forth over the body. In the case of Mr. Whitlaw, Dr. Duncan describes it as " a profuse, dark-coloured, clammy sweat, of a smell so exceedingly fetid and disagreeable, that it could neither be borne by the patient himself nor by his attendants. It was in such abun- dance as not only to wet his body-clothes, but also the bedclothes, and stained them of a dark colour, so that they could with difficulty be washed white again When the patient awoke out of this state of slumber, in which he had continued during the perspiration, he felt great relief of all the symptoms."—(Trans. Medico- Chir. Soc, Edin., ut supra, p. 505.) The di- aphoresis was in fact critical; and, so far as I have seen, it never occurs but in those that re- cover ; and usually, if not always, is an accom- paniment of the disease where the local symp- toms take the lead, and in a considerable degree concentrate the virus. It must not, therefore, be confounded with that cadaverous smell, which is sometimes emitted from the body a short time before death, and is a melancholy harbinger of that event. The inflammation that most nearly resembles the erythema before us, is that produced by the bite of the more venomous serpents, and espe- cially of the rattlesnake ; and as, in all these cases, a specific virus is universally admitted, analogy, in addition to the reasons already urged, leads us to a like cause in the present instance. The chief difference is in the greater degree of virulence or malignity that character- izes the serpent's fang, and the greater rapidity of its mischief. A bite from the fang of the cobra de capello, or hooded snake, the coluber naja of Linneus, generally destroys life in twenty-four hours, and from the fang of the rattlesnake (crotalus horridus, Lin.) in a shorter time, if no curative means be had recourse to.* * This statement requires to be modified. The bites of venomous snakes are very unequal in their consequences, according to the season of the year and the climate ;. the empty or full state of the poison receptacles at the period when the reptiles bite; the constitution of the bitten person ; the penetration of the fang into a vein; and other in- fluential considerations. We have the authority of Professor Gibson, of the United States, in sup- port of this statement. Instances occur, both among the Indians and the white people who in- habit the mountainous and thinly-settled parts of the American States, of almost instantaneous death from the bite of the rattlesnake. On the other hand, he says, it is certain that many per- sons wounded by this animal have sustained very Gen. VI.—Spe. 5.] ERYTHEMA ANATOMICUM. 461 In both, the local and constitutional symptoms take place nearly simultaneously, and persevere in their double attack. The bitten limb swells instantaneously from the part affected, and the inflammation shoots with great speed up its entire length to the body ; and, if it be the arm, associates the axilla in its malignant career ; and, if life continue long enough, darts down the side over the pectoral muscle, and produces there the same kind of erythema as in the dis- ease before us. The vital principle, however, is, from the first, exhausted suddenly, as though by a stroke of lightning; the blood ceases to flow in the smaller vessels of the swollen part ; the superincumbent skin feels deadly cold ; the action of the heart is so weak that the pulse is scarcely perceptible ; the stomach so irritable that nothing can be retained on it; dejection and horror overpower the mind, and a low mut- tering delirium forms the closing scene. Very powerful stimulants applied instantly may postpone the catastrophe, and sometimes, even in the bite of the rattlesnake, produce a cure ; but if the tide of life be kept moving till the venom has exhausted its malignity, the de- bility is usually so extreme, that the unhappy sufferer too often falls a victim to the local mis- chief, when he has even triumphed over the constitutional assault. A striking example of this occurred a few years ago in St. George's Hospital, in a patient whose progress the present writer watched with deep interest. He took notes on the occasion : but the account has been since given so much more minutely by Sir Everard Home, that he will chiefly copy from his statement.—(Phil. Trans., 1810, p. 75.) The patient, by name Thomas Soper, twenty-six years of age, at- tempted, Oct, 17, 1809, to raise a rattlesnake, confined in a cage in a public show-room in Piccadilly, by irritating him with a footrule, but the snake continued quiet. The footrule was dropped into the cage, and the man had the rashness to introduce his hand to take it away. The serpent instantly seized upon it, and bit it in two places. The bites took place at half past two o'clock P. M.; and the wounded man instantly applied to a neighbouring chymist, who gave him a dose of jalap, as he considered him in a state of intoxication, from the incohe- rence of his language, which was probably the effect of great terror. The hand almost im- mediately began to swell, and he applied for aid at St. George's Hospital by three o'clock, or within an hour after the attack. The swelling had by this time extended half way up his forearm : the skin on the back of the hand was very tense, and the bitten part acutely painful. At four o'clock, the swelling had gained upon the elbow ; and at half past four, the pain had extended to the axilla, and the swelling within a short dis- tance of it: the skin was cold, the pulse beat a hundred strokes in a minute ; the man com- plained of sickness, but his answers were in- trivial injury.—(See Gibson's Institutes of Sur- gery.) The poisons of serpents are well known to be most powerful in hot weather, and the pro- creating season.—Ed. coherent. Ammonia, camphire, and ether were freely administered internally; and the two former were also applied externally. The symptoms continued to augment, with the exception that the patient was collected at times, and expressed a hope of recovery ; but, for the most part, his mind was greatly dejected, and it was often difficult to keep him from faint- ing. The arm was quite cold ; but the swelling extended to the shoulder, and-down the side of the body, producing a fulness with evident ex- travasation of blood, as low as the loins, and giving a mottled appearance to the back on the right side. The surface of the swollen part was very extensively vesicated in the course of the present day (the 18th); there was a tremulous motion of the lips ; the fainting fits were per- petually recurring; his limbs twitched ; his stomach rejected what was introduced into it and the skin of the whole arm had a livid ap- pearance similar to what is met with in a dead body. Brandy and opium were now given him instead of ammonia, but in the ensuing morning his pulse was scarcely perceptible ; his extrem- ities were cold, and he spoke in whispers. He was in this manner kept alive by nutritive and stimulant means ; the constitutional symptoms appeared in five or six days to be diminishing, and the venom to have spent its force ; inso- much that the present writer made a minute on October 25th, that "he seems, upon the whole, to be recovering." He had not, however, strength enough left to cope with the extensive mortification which had taken place in the arm and axilla, and died November 4th, at half past four in the afternoon.* In serpents whose venom is less virulent, a ligature tied a little above the bite, and con- tinued for only an hour, will often prevent the action of absorption, and render the disease chiefly local; in consequence of which, as in the local modification of anatomic erythema, the patient escapes with afar less degree of danger. But the most active and malignant of all the serpentine poisons is that of the rattlesnake. * It is difficult to add much to the important details furnished us concerning the influence of this poison by Sir Everard Home, as given in his history of the case of Thomas Soper. Mr. Home mentions the intellectual powers of the patient to have been materially affected. Dr. Francis remarks (Facts on Med. Jurisprudence, N. Y. Med. and Phys. Journal, vol. ii.), " in com- pany with the late James Inderwick, of the United States navy, I visited, in the year 1812, a young man, Mr. A----, of New-York, who was seriously bitten in the arm by a rattlesnake, that had been kept in confinement for a public show. The ac- tion of the poison, as in the case of Soper, began to manifest its effects within the first half hour, and its local changes, such as great swelling, pain, &c, were also similar to those stated by Sir Everard Home. But in the case of Mr. A----, the mind preserved its wonted functions throughout his whole illness. I have reason to believe, that the action of this poison is primarily through the medium of the sanguineous circulation. When the bite is inflicted in a large vein, its effects are more immediate, and its fatality more certain, than un der other circumstances."—D. 462 HjEMATICA. [Cl. III.—Ord. II. All other serpents have an immunity against each other's bite ; but the rattlesnake not only kills every other, and even its own kind, but, by being so far irritated as to inflict a personal wound, has been found to kill itself. A highly stimulant diet, though most essen- tial in the bite of the more poisonous serpents, does not seem to be of equal use in the eryth- ema before us ; nor, in the slighter cases, has any benefit been found from the use of a liga- ture. The excitant plan has been tried by some, and the antiphlogistic hy others ; but both have often failed, and a remedial mode of practice is still a desideratum.* Considering the great benefit that results from fixing the inflammation in the hand and forearm, it appears reasonable that our first attempt should be to concentrate or recall it towards the punctured or abraded part ; not by destroying the life of such part, as has too often been done by caustics, but by powerful and pungent irri- tants, as camphire, turpentine, or ammonia. Or, if within half an hour or an hour from the date of the injury, by the application of cupping- glasses ; the great benefit of which practice,, in preventing the absorption of poison from venom- ous animals, has been satisfactorily ascertained by Sir David Barry's experiments, as we have already had occasion to remark.—(See his Ex- perimental Researches on the Influence exercised by Atmospheric Pressure, &c, 8vo., 1826.) Our next object should be to counteract the inflam- mation that takes place in the axilla and in the region of the pectoral muscle, by a free use of leeches or cupping-glasses ; while the constitu- tional symptoms should be opposed by opiates and sudorifics. We have already seen the high and critical advantage which has arisen from a general diaphoresis; and the present author has observed more benefit from a free use of Dover's powder acting in this manner and allaying the nervous and constitutional irritation, than from any other medicine whatever. In the mean- while, the diet should be moderately stimulant, and the bowels must be kept duly open. * The Guaco plant (Bejuco de Guaco) has long been considered by the natives of South America a specific for the bites of poisonous reptiles, and more particularly of the rattlesnake. A document published at Caraccas, in 1832, and signed, " Un Amigo de la Humanidad," asserts, that it cures the bites of the most venomous serpents, and even of the viper : and Alibert, in his New Elements of Materia Medica, has stated the mode in which the negroes inoculate themselves with it. The atten- tion of scientific men, however, has but recently been drawn to this medicinal plant, and the ex- periments as yet made with it, are not sufficiently numerous or accurate to enable one to form a cor- rect opinion of its real value. In the Jamaica (W. I.) Phys. Jour., vol. i., p. 234, Mr. Higson, a gentleman well known for his bo- tanical researches, and also for his travels in South America, has published a paper on this subject. He begins by remarking, that " the Guaco plant deserves the greatest attention, and its virtues should be made generally known." He then gives the details of two cases which came under his notice, in which the patients had been bitten by an ekkis, one of the most deadly of its species. SPECIES VI. ERYTHEMA PERNIO. CHILBLAIN. INFLAMMATION OF A CRIMSON COLOUR, SUF- FUSED with blue; obstinately itching; CHIEFLY AFFECTING THE EXTREMITIES DURING WINTER. This species offers us the two following va- rieties :— a Simplex. The cuticle remaining un- Simple chilblain. broken. 0 Exulceratus. Accompanied with ul- Kibe. ceration. The extremities principally affected by the chilblain are the hands and feet; but, in very cold climates, the nose, ears, and lips are af- fected also, and the living power is destroyed as completely as by combustion. So correctly has our great epic poet described the power of se- vere frost:— " The parching air Burns frore, and cold performs th' effect of fire." That the pernio or chilblain belongs to the genus erythema is perfectly obvious, not only from its symptoms, but from the character of the age and constitution in which it is chiefly to be met with, and from the stimulant mode of treatment by which alone it is to be cured. The proximate cause of chilblains is a diminu- tion of the excitability or vital energy of the extreme vessels; and, as such diminution is most readily produced in children, or older per- sons of relaxed fibres, these are most subject to the disease. For, though we often meet with it also in strong and hardy boys, it will usually be found that the last, from the natural vigour and courage of their frames, have braved the cold and rigid reign of the winter season beyond the venture of their schoolfellows. Local stimulants, then, are the only applica- tions that will answer, and particularly those which serve at the same time to defend the weakened organ from the severity of the external air. Hence, oil-skin socks worn day and night are useful, and warm diachylon or Burgundy pitch spread upon leather still more so. For the same reason, embrocations of spirits of tur- pentine, opodeldoc, liquor ammoniae acetatis, or equal, parts of vinegar and spirits of wine, will usually be found serviceable. Linneus recom- These were treated by administering the expres- sed juice of the Guaco internally, and applying the bruised leaves of the same to the wound; and although they exhibited severe symptoms, as swel- ling and delirium, they recovered. He farther re- marks, " I have been thus particular, hoping to dispel some of that skepticism that is so apt to ac- company details savouring of the marvellous; but, on the continent south of us, thousands can vouch for the virtues of a plant, placed by Providence where it is most necessary." Mr. Higson was unable to detect the flowers and fruit of this plant, but thinks he recognises its character in Humboldt and Bonpland's Synopsis Plantarum Equinoctialium, under the generic name Mikania, and species Guaco.—D. Gen. VII.] EMPRESMA. 463 mends bathing the part with diluted muriatic acid; and this has the advantage of being astringent as well as stimulant.* The weak- ened vessels should never be too much dis- tended, and hence, though gentle warmth and stimulants are indispensable, great heat, and especially a near approach to a fire, and more particularly still when very cold, will always be found injurious. When the inflammation be- comes ulcerated, or forms a kibe, warm and ir- ritant dressings will alone succeed in effecting a cure; and, if fungous granulations should ap- pear, which they are very apt to do in all sores accompanied with debility, they must be re- moved by a dressing of the unguentum hydrar- gyri nitrati, or some other mild escharotict SPECIES VII. ERYTHEMA INTERTRIGO. FRET. EROSION OF THE SKIN. COLOUR OF THE INFLAMED PART BRIGHT RED ; CUTICLE ERODED J THE EXPOSED SKIN OOZING A LIMPID AND ACRIMONIOUS FLUID. The fret, or erosion, which frequently takes place in different parts of the skin from an acrid secretion of the exhalants or sabaceous glands, and particularly behind the ears, about the groins, and around the anus, is usually accom- panied with erythematic redness, or inflamma- tory blush; and hence is generally and correctly referred to the present place. It is an erythema with weak vascular action, and often considera- ble irritability in consequence of such weakness. The most common example of this species is that which takes place behind the ears of chil- dren of a delicate habit, or who labour under ir- ritation from teething, or from gross indulgence in luxuries. The discharge is often peculiarly offensive, and hence cannot proceed merely from defective absorption, for it would then be nothing more than saline without fetor. It cannot .be checked too soon ; for if it continue for a few weeks, or perhaps even less, it may acquire a habit, the' suppression of which may run the risk of superinducing some worse dis- ease than itself, as dyspepsy, diarrhoea, or con- vulsions. The organ affected should be kept well washed, to prevent the spread of the mor- bid secretion, and the discharge should be im- bibed by dry and scorched rags applied to the part, or starch frequently dusted over it.—(J. P. Frank, De Cur. Horn. Morb. Epit., tom. iv., p. 113, Mannh, 8vo., 1792.) But the irritability is here best subdued by the tonic and astringent powder of many of the metallic oxydes, par- ticularly that of cerusse, which is one of the most valuable, as well as one of those in most common use. * One part of the tincture of cantharides, and six of soap liniment, equal parts of the liq. plumbi acet. and laudanum, and a mixture of tincture of myrrh and liq. plumbi acet., form common and useful applications to chilblains which have not broken, or assumed the ulcerated state.—Ed. t The eminent operator Lisfranc treats eryth- ema pernio by placing thereon perforated com- presses spread with cerate, and covering these with a thick layer of lint, which must be con- stantly wet with a solution of the chloride of soda or lime.—See Monographic des Dermatoses, par Alibert, tome premiere, p. 41, Paris. 1832.—D. GENUS VII. EMPRESMA. VISCERAL INFLAMMATION. DERANGED FUNCTION OF A VISCERAL ORGAN, MEMBRANOUS OR PARENCHYMATOUS ; WITH LOCAL PAIN ; FEVER MOSTLY A CAUMA ; IN- FLAMMATION MOSTLY ADHESIVE. The genus of diseases upon which we now enter, consists of that numerous collection of visceral inflammations which, from the time of Boerhaave, have been generally distinguished by anatomical terms derived from the organ af- fected, with the Greek term itis added as a suf- fix, as cephalitis, gastritis, carditis, and many others. Itis is sufficiently significant of its pur- pose : it is immediately derived from "tpai, which is itself a ramification from «u, and im- ports, not merely action, "putting or going forth," which is the strict and simple meaning of tu>, but action in its fullest urgency, " violent or impetuous action." As a suffix, therefore, we shall retain it in its common use, and pro- scribe it, to prevent confusion, from the few compounds, or proscribe the compounds them- selves, in which this common use is departed from ; as rachitis, hydro-rachitis, ascites, and tympanites, none of which convey any idea of violent or impetuous action, and some of which are peculiarly marked by a contrary state. This application of a common term in com- position to so large a body of visceral inflamma- tions, and the general use of the term for so long a period as that throughout which it has been employed, is a sufficient proof, that practi- tioners have discovered between these inflam- mations other features of resemblance than the general symptoms of inflammatory disorder. In the prosecution of the subject, we shall find that this is the fact; and I have already ob- served, in the opening remarks upon the present order, that, with a very few exceptions, the in- flammation in all the diseases is of the adhesive kind, and the fever a cauma. With a view, therefore, of simplifying, as far as simplicity may be of real use, the present system will, for the first time, comprise the whole of these under one genus, here distinguished by the name of empresma, or " internal inflammations;" a term, in its simple form, employed both by Hip- pocrates and Galen, and which it seems neces- sary to revive for the present purpose. Many of the organs included under the genus before us, and which we shall presently follow up in their respective order, sympathize with each other, and most of them with the stomach. The necessary consequence of which is, that the constitution is disturbed generally, though in very different degrees, according to the organ affected ; or, in Mr. Hunter's opinion, according to the different degree of its connexion with the stomach. If the heart, the lungs, or the brain be in- 464 H^M flamed, whether primarily or secondarily, as by sympathy, the stomach -is peculiarly influenced, probably from the essential importance of these organs to life itself (as all the vital organs, or those essential to life, maintain a very close de- gree of affinity); and the disease originating in any of these has, in consequence, a more vio- lent effect upon the constitution than the same quantity of inflammation would have if it were not in a vital part, or in one with which the vital parts do not sympathize. The pulse, in such cases, is much quicker and smaller than when inflammation takes place in a common part, as a muscle, cellular membrane, or the skin. The progress, moreover, when the attack is so violent as to prove fatal, is, generally speaking, far more rapid than in other parts ; so that, at its very beginning, it has the same effect upon the constitution, as a farther advance of an inflam- mation in other organs that is equally sure of proving fatal in its result. The debility com- mences early, because the inflammation itself is immediately interfering with actions essential to life ; and, as already observed, the sympathy be- tween these organs is peculiarly close, insomuch so as almost to make any single action common to the whole.—(Hunter, on Blood, &c, p. 325.) In inflammation of the brain, the pulse va- ries, perhaps, more than in inflammation in any other part; and we must rather depend upon other symptoms than upon the state of the pulse. It is sometimes quick, sometimes slow, some- times depressed, sometimes full, according as the disease is characterized by the acute pain, delirium, stupor, or other concomitants. When inflammation is seated in the heart, its action becomes extremely agitated and irregular. When in the lungs, the heart, possibly from sym- pathy, does not seem to allow of a free diastole. If the stomach be inflamed, the patient feels an oppression and dejection through all the stages of the disease. The vital energy, or simple animal life, seems to be impaired and les- sened in the same manner as sensation is les- sened when the brain is injured. The pulse is generally low and quick; the pain obtuse, but urgent and overwhelming ; so that the patient can hardly bear up under it. If the intestines, be affected, the symptoms are nearly of the same kind, especially if the in- flammation be in the upper part of the canal; but, if it be seated in the colon, the patient is more roused, and the pulse is fuller than when the stomach itself is inflamed. If the uterus be the organ attacked, the pulse is extremely quick and low : if one of the testi- cles, the pain is depressing, and the pulse quick without much strength. With the uterus, the testicles, and the intestines, the stomach pe- culiarly sympathizes ; often, indeed, as much as if itself were primarily affected. If we con- trast these species of inflammations with those that attack parts not very essential to life, but with such a degree of violence as to produce universal sympathy and affect the vital func- tions, we shall find that, in the latter, the pulse is fuller and stronger than common; and the blood is pushed further into the extreme ax- j LTICA. [Cl. III.—Ord. II. teries. The attack usually commences with rigour; the patient then becomes somewhat roused, because the action of the part is roused, and the effects on the constitution are not yet such as to impede the operations of the vital or- gans. Much, however, will still depend upon the nature of the parts, whether active, as muscles, or inactive, as tendons ; as also upon the situa- tion of the.same description of part, and espe- cially upon the character of the constitution ; for, if the last be extremely irritable and weak, as in many women who lead sedentary lives, the pulse may be as quick, hard, and small, even at the commencement of the inflammation, as in inflammation of the vital parts. The blood, moreover, may be sizy, but will be loose and flat on the surface. It is singular to observe how very rarely the pancreas is subject to in- flammation, or even to disorders of any kind. " The pancreas," observes Dr. Baillie (Lect. and Obs. on Medicine, 1825), " is upon the whole less liable to disease than any other important gland in the body. I do not recollect that, in private practice, I have met with one case in which there was satisfactory evidence of the pancreas being diseased ; and I have only known of a solitary example of it during the thirteen years in which I was physician of St. George's Hospital." [Now, however, that morbid anat- omy is more extensively and zealously culti- vated than it was thirty years ago, examples of diseased pancreas are more frequently met with. On the whole, however, the pancreas, like the sal- ivary glands, to which it is analogous, is, compar- atively speaking, seldom diseased. This subject is noticed in a preceding part of this volume.] Having premised these general remarks, we are the better prepared for examining the rela- tions which the numerous species belonging to the present genus bear to each other, and satisfy ourselves with a more summary account of sev- eral of them than would otherwise be necessary. These species are as follow :— 1. Empresma Cephalitis. Inflammation of the Brain. 2.--------Otitis.------------of the Ear. 3.---------Parotitis. Mumps. 4.--------Paris thim- itis. Quinsy. 5. ————— Laryngitis. Inflammation of the Larynx. 6.--------Bronchlem- mitis. Croup. 7.--------Pneumoni- tis. Peripneumony. 8.--------Pleuritis. Pleurisy. 9.--------Carditis. Inflammation of the Heart. 10.--------Peritonitis.----------- of the Peritoneum. 11.--------Gastritis.-----------of the Stomach. 12.--------Enteritis.------------of the Bowels. 13.---------Hepatitis. ----------— of the Liver. t>EN. VII.—Spe. 1.] EMPRESMA CEPHALITIS. 465 14. Empresma Splenitis. Inflammation of the Spleen. 15.---------Nephritis. ---- ----- of the 16. 17. 18. Cystitis. Hysteritis. Orchitis. Kidneys. Bladder. Womb. Testicles. of the of the of the SPECIES I. EMPRESMA CEPHALITIS. INFLAMMATION OF THE BRAIN. PAIN IN THE HEAD ; AVERSION TO LIGHT ; FACE MORE OR LESS FLUSHED ; CAUMA. The pathology of cephalitis, or inflammation of the brain, is, in some degree, obscure and difficult, from the difference which occurs in several of its secondary or concomitant symp- toms ; occasioned partly, perhaps, by the dif- ference of its exciting cause, partly by the par- ticular portion of the organ that is primarily or chiefly affected, and partly by circumstances which seem to baffle all research. From this occasional difference of symptoms some nosol- Ogists have endeavoured to establish as many distinct affections, and have hence multiplied a single specific disease into a considerable num- ber of distinct species, and even genera, and treated of it under a fearful host of distinct names: and hence the disease b&fore us has been described, not only under the term cephal- itis, but under those of phrenitis, paraphrenitis, phrenismus, sideratio, siriasis, sphacelismus, typhomania, calentura, and a great many others, which have burdened the medical vocabulary, and perplexed the medical student. The disease may commence in the meninges, or membranes of the brain, or in the substance or parenchyma of this organ. [In its activity, it varies from the highest degree of acute to the lowest degree of chronic or scrofulous in- flammation, and with numerous modifications, by which the different forms pass into one an- other by almost insensible gradations. It may terminate by serous effusion; by the deposition of false membrane ; or by a peculiar softening of the cerebral substance.—(See Abercrombie's Path, and Pract. Researches on Disr ofthe Brain, p. 5, 8vo., Edin., 1828.)] If it were to confine itself strictly to the part first affected, instead of spreading from one part to another, there would perhaps be no great difficulty in determining from the symptoms before us its direct and ac- tual seat; for while membranous and muscular inflammation, before the access of gangrene, is accompanied with an acute and rousing pain, great heat, and a pulse considerably and per- manently quickened, parenchymatous inflamma- tion is rather distinguished by a heavy and often a stupifying pain, a slight increase of heat, and a pulse irregularly quickened, sometimes sink- ing even below its natural standard.—(Hunter, on Blood, &c, p. 288, 289.) Now both these conditions are occasionally Vol. I.—G g found in different cases of cephalitis; and we may hence infer, that in the one instance, the disease is seated chiefly, if not altogether, in the meninges, and, in the other, in some part of the substance of the brain itself, thus pre- senting to us the two following varieties :— a Meningica. Pain in the head acute ; Phrensy. intolerance of light and Brain fever. sound; cheeks perma- nently flushed ; eyes red; watchfulness; de- lirium ; pulse rapid.* 0 Profunda. Pain in the head obtuse ; Deep-seated inflam- cheeks irregularly flush- mation of the ed ; pulse irregu laity brain. frequent; eyes oblique ; Acute dropsy of the sleep heavy, but un- head. quiet;.,and occasionally interrupted by screams. Chiefly common to chil- dren. The above clear and distinctive marks, how- ever, by which the two varieties are separated from each other in exact cases, are not often to be met with ; as each, for reasons already given, is apt to assume something of the character of the other.t And hence they have hitherto * Cruveilhier infers from some cases which he has published, that what he terms " la meningite sous-arachnoidienne de la convexite du cerveau," has for its pathognomonic character a stupor grad- ually increasing to complete coma ; and he is of opinion that headache, exaltation of sensibility, delirium, and convulsions, are frequently entirely absent.—-(Anat. Pathol., 6me livr.) When this affection occurs towards the base of the scull, ac- companied by acute dropsy ofthe ventricles, vomit- ing is set down by this pathologist as usually one of the first and most predominant symptoms, so as often to raise suspicion that the patient's dis- order is in the stomach.—Ed. t The following remarks by Dr. Quain are judi- cious and interesting :—" An examination," says he, " of the structure of the brain, and of the pe- culiarities of the circulation in it, would also lead to the inference, that if the meninges be the seat of inflammation, the contiguous cerebral substance must participate in some degree, in the irritative influence. In other organs, the vessels, after enter- ing them by trunks and branches of various sizes, branch out and ramify in their interior, until they become capillary in their spongy and areolar tissue. But in the brain a different arrangement takes place ; the vessels, after entering at the base of the scull, communicate freely with one another, and then branch out upon the surface of the brain, ramifying in an extended web of cellular tissue (pia mater); in this way they become reduced to so great a degree of tenuity before they enter the substance of the organ, that it may be said to be surrounded by a vascular atmosphere, from which its supplies are derived. Hence it is, that as the meninges and the contiguous cerebral substance are supplied from the same source, each will, more or less, become affected by any inflammatory action set up in the other. M. Bayle, in his Thesis, gives six cases of what he considers chronic arachnitis, and in all of them the arachnoid membrane was thickened, opaque, and resisting, and there was found some serous effusion; but in five of these cases, portions of the cerebral substance were ad- herent lo the membranes, and so much softened 466 H.EM; escaped the attention of almost all our nosol- ogists, even of those who hayjf subdivided in- flammation of the brain into the greatest num- ber of distinct genera or species of disease ; while Vogel expressly declares, that all the most acknowledged symptoms of inflammation of the brain are equivocal, not only as to a dis- tinction of one morbid part from another, but as indicative of inflammation in anj^part ; and Dr. Cullen asserts, in a note subjoined to his generic definition (for he advances the disease to the rank of a genus, and a genus too without a species or a specific character), that there are no symptoms capable at all times of distinguish- ing, with certainty, inflammation of the brain from inflammation of its meninges. On which account, he deviates from the more complicated arrangements of Sauvages, Linneus, and Sagar, and includes several of their genera in his own definition, which runs in more general terms as follows:—"pyrexy severe; pain of the head; redness of the face and eyes ; intolerance of light and sound ; watchfulness ; fierce delirium, or typhomania." There is so much correctness in this remark of Dr. Cullen's, notwithstanding the error of his arrangement, that the present author yielded to it in the first edition of his Nosology, and in- troduced cephalitis, not indeed as a naked genus without a specific character, but as a single spe- cies without enucleating its varieties ; or, in other words, without treating of deep-seated in- flammation, constituting acute internal dropsy of the brain, separately from inflammation of the head generally. It may, perhaps, be doubted, whether acute dropsy of the brain ought to be regarded as an idiopathic inflammation at all, and consequently whether the present is the proper place for it; but the reasons which will immediately be advanced will, I trust, settle this point completely. And as, upon a closer attention to the subject, notwithstanding Dr. Cullen's remark, I am induced to think that there are cases in which parenchymatous or deep-seated inflammation may be distinguished from meningic, I have so far deviated from the first arrangement as to, give these distinctions under the form of the above varieties. as to be brought away with the latter, when an effort was made to detach them: in five of them, the pia mater was injected, thickened, and in- filtrated with serous fluid. MM. Martinet and Parent, in their elaborate monograph on arachnitis, give the results of their examination of 116 cases, published with the expressed design of establish- ing the diagnosis and pathology of arachnitis. But though-these are classed as inflammations of a serous membrane, we find, that in a considerable number of them, the inflammation had extended to the cerebral substance, the vessels of the pia matter being at the same time injected, and its substance thickened and covered with a serous or sero-purulent effusion ; so that, judging from the post-mortem appearances, they were, in fact, mixed cases ; and in strictness, we must refer the symp- toms, or physiological indications presented during life, to the lesion of the cerebral substance, rather than to that of the meninges."—Dr. Quain, in Cyclop, of Pract. Med., art. Inflammation of the Brain.—Ed. .TICA. [Cl. III.—Ord. II. I admit, nevertheless, with Dr. Cullen, that there are no symptoms capable at all times of distinguishing, with certainty, inflammation of the substance of the brain from inflammation of its meninges ; and only contend, that the distinction may be drawn in certain cases in which the disease is simple, and the characters strong and unmixed; and strikingly indicative of membranous or parenchymatous inflammation, according to the general rules just laid down upon this subject.* It is possible, indeed, that meningic inflam- mation may occasionally be still more limited, and exist chiefly or altogether in one of the membranes alone, as the arachnoid; whence some pathologists have set down arachnitis as a subvariety of the meningic form : but, as such minute derivations can never be supported by pathognomonic symptoms, nor lead to any practical utility, I cannot but prefer the exam- ple of Professor Frank, and, indeed, of most of the Italian pathologists, in rejecting them, to that of Pinel and other French writers^ in in- troducing or retaining them. [Dr. Abercrombie, who uses the term menin- gitis to express inflammation of the arachnoid or pia mater, or both, as distinct from inflam- mation of the dura mater, finds that it is not characterized by any uniformity of symptoms. In some cases, it comes on with headache, vom- iting, fever, and impatience of light, but more commonly with a sudden and long-continued paroxysm of convulsions, sometimes preceded by headache and vomiting, sometimes without any warning. In some examples, the convul- sion passes immediately into coma, which after- ward alternates only with a repetition of the convulsion, until death. In other cases there is a recovery from the first convulsion, and the patient appears to be doing well ; but after- ward falls into coma, with or without a recur- rence of the convulsion ; while, in certain other instances, no convulsion occurs till a late period of the disease. On the other hand, inflammation of the sub- stance of the hemispheres is said to be attended with symptoms which also vary considerably, according to the extent of the disease, and the particular part of the brain which is the seat of it. In some cases, headache is followed by * According to Bayle, delirium and progressive paralysis are the invariable accompaniments of chronic meningitis. The delirium is at first par- tial ; it is a monomania, with weakness of in- tellect ; but, after a time, it passes on to the maniacal excitement, and finally subsides into confirmed idiocy. The paralysis does not amount to a total privation of motion and sensation in any particular part ; it is at first slight, but gradually increases, and extends to the whole muscular sys- tem, rendering the gait feeble and vacillating, and ultimately destroying the power of motion. The diminution of sensation is not proportioned to that of motion. Spasmodic movements, with contrac- tion and rigidity of the limbs, sooner or later set in; and, finally, epileptic attacks, which terminate in fatal apoplexy.—Ed. t Recherches sur PInflammation de l'Arach noide, &c, Par P. Duchatelet, M. D., &c, et L I Martinet, M. D., 8vo., Paris 1821. Gen. VII.—Spe. 1.] EMPRESMA CEPHALITIS. 467 high ,delirium, and this by coma. In others, there is a sudden attack of convulsion. A fre- quent form of the disease is characterized by headache, followed by convulsion of one or more limbs : these afterward becoming para- lytic. The disease may be fatal in the inflam- matory stage : that of ramollissement, simple or combined with partial suppuration; that of undefined suppuration; that of encysted ab- scess ; of that or ulceration of the surface of the brain.*] » I believe that a simple and unrestricted ap- pearance of inflammation is more frequently to be.traced in meningic, than in profound or pa- renchymatous cephalitis; or, in other words, that, in primary inflammation of the substance of the brain, the meninges are more disposed to partake of the affection, either by continuous action or sympathy, than the substance of the brain is in primary inflammation of meninges. And hence, those nosologists that describe but a single species or genus of this disease, as it has been often though incorrectly denominated, like Vogel, Cullen, and Parr, lean chiefly to the meningic variety, and define it by characters of great vehemence or acuteness, so as in reality to limit themselves to this variety alone. Yet, as the symptoms do not always, nor even most frequently, mount up to this aggravation, in consequence of the disease more commonly originating, or being more commonly seated, in the substance of the brain itself than in its membranes, they have all been dissatisfied with their respective definitions ; and, instead of en- larging or modifying their terms to meet the dis- tinctive phenomena as they vary according to the seat ofthe disease, have endeavoured to apologize for their own inaccuracy, by representing these phenomena as irreducible and anomalous. The first variety, therefore, exists in the judg- ment and even in the description of all writers, who, where they have not entered into more minute subdivisions, have given it as the gen- eral character of the complaint. The existence of the second variety, or, in other words, the propriety of regarding what has hitherto been denominated acute or internal * See Abercrombie's Pathol. Pract. Researches on Diseases of the Brain, pp. 50, 70. This emi- nent pathologist candidly owns, " that our knowl- edge is not sufficiently matured to enable us to say with confidence what symptoms indicate in- flammation of the substance of the brain, as dis- tinguished from that of its membranes." Yet, as Dr. Quain has pointed out, there are circumstan- ces in which we can indicate, with sufficient pre- cision, the symptoms of cerebritis, as distinguished from any that can, in strictness, be referred to meningitis ; for instance, when the inflammation is isolated, and does not reach the membranes, as where it is seated in the thalamus, or corpus stri- atum. But if the inflammation occur at the cir- cumference of the organ, where the membranes and cerebral substance are in contact, and both are supplied by the same vessels, then, though the inflammation may at the outset be seated in the meninges, it will speedily extend, more or less, to the cerebral substance, and, by complica- ting the lesion, confusethe diagnosis.—(Dr. Quain, in Cyclop, of Pract. Med., art. Inflammation cf Gg2 hydrocephalus as a variety of cephalitis, requires to.be examined somewhat more at length. The absurdity of the usual arrangement of internal hydrocephalus, and of contemplating it as belonging to the ordinary family of dropsies, with which it has scarcely a common symptom, has long been felt by pathologists, and is directly noticed both by Sauvages and Cullen. But the question is, if we remove it from its usual situ- ation, where are we to place it 1 If we do not regard it as a dropsy, in what light are we to contemplate it at all 1 And how are we to reg- ulate our treatment of it 1 The Professor of Montpellier tells us, that, according to its symp- toms, it is to be ranked in the comatose, spas- modic, or some other tribe of diseases : distinctly importing that, in his own opinion, he could not refer it to any single division in his very exten- sive classification. Dr. Cullen's reply is, that it is an evident and idiopathic species of apo- plexia, and ought to take its place under that genus ; and he has hence distinguished it by the appellation of apoplexia hydrocephalica, and in this manner assigned it " a local habitation and a name." In reference to this assignment he observes, however, that, in a.nosological work, it is difficult to collate exactly diseases that, in their progress, assume a changeable' form, and hence to allot a perfectly fitting place to hydro- cephalic apoplexy. "Yet I prefer," says he, " placing this disease under the head of apo- plexy to placing it under that of hydrocephalus (dropsy of the head) ; first, as it differs ex- tremely from the symptoms of sensible (exter- nal) dropsy of the head; and next, as in its proximate cause, and at length in its symptoms, it bears to apoplexy as near a relation as pos- sible." Dr. Cullen evidently regarded the effusion or dropsy in the ventricles of the brain as a mere effect of the disease, rather than as the disease itself; yet the drowsiness, or heavy sleep, or whatever else there is akin to apoplexy, and which he contemplated as the proximate cause of the disease, and consequently as the disease itaelf, is a still more remote effect than even the effusion, for it is probably the mere result of such effusion. In truth, it is only necessary to the Brain.) It is an observation made by the same physician, that if we note the symptoms commonly ascribed to inflammation of the arach- noid membrane, we shall find that several of them must really depend upon a disturbance of the functions of the cerebro-spinal mass, and not of its investments; as, for instance, delirium, spasm, and rigidity of the muscles, convulsions, vomit- ing, stupor, coma, contraction or dilatation of the pupils, strabismus, &c In the great majority of superficial inflammations, it appears to Dr. Quain that there is a mixed lesion, and all that discrep- ance which their progress and symptoms present is explicable, not merely by the extent and de- gree of the inflammation, or by peculiar idiosyn- crasy, but by the fact that, in some of them, the inflammatory action is, for the most part, expended on the membranes; that, in others, the reverse obtains ; while, in a third group, it seems as if concentrated on the vessels of the pia mater, the arachnoid on the one hand, and the brain on the other, being but slightly affected.—Ed. 468 HMm run over Dr. Cullen's specific definition of this disease, to see how very little it has in common with apoplexy. This definition is as follows :— " Apoplexy arising gradually ; affecting infants, and the age below puberty, first with lassitude, feverishness (febriculd), and pain of the head ; afterward with a slower pulse, dilatation of the pupil, and somnolency." The definition in- cludes two stages of disease, if not two distinct diseases, a primary and secondary: and it is only in the second stage or secondary disease, the mere result of the first, that it bears any analogy to apoplexy. The first and leading symptoms are evidently those of pyrexy, which is, therefore, the funda- mental part of the disease; and had not Dr. Cullen been in some degree influenced by sys- tem, he'Vould probably have coloured these symptoms a little more highly, as he might have done without any departure from the truth. And hence, while Dr. Parr, Dr. Young, and a few others, have adhered to Dr. Cullen's view of the subject, the great body of pathologists have been dissatisfied with it, and have cor- rectly carried infernal hydrocephalus over to the class of pyrexies, and regarded it as a fever or an inflammation. Thus, in Dr. Macbride's ta- ble, it occurs as a nervous fever, under the title of febris continua, nervosa, hydrocephalica: and more simply under that of febris hydroce- phalica, in Professor Daniel's edition of Sau- vages ; while Dr. Quin of Dublin, Dr. With- ering, Dr. Rush, Dr. Golis, Professor Martini, and a host of other writers of authority, have contemplated and treated it as an inflammation —an inflammation of the brain—and conse- quently a cephalitis, in the language of Dr. Coindet, Cephalite interne hydrenciphalique (Mimoire sur VHydrencephale, par J. F. Coin- det, M. D., Geneva, 1818); in that of Dr. Go- lis, wasserschlag (Prakt. Abhandl. uber die vor- zuglicheren Krankheiten des kindichen Alters., band, i., Wien, 1815), or water-stroke, from its violence ; the fever being regarded as a mild and somewhat irregular cauma, and the effusion into the ventricles of the brain as a mere effect of the inflammation. This is not the only instance, indeed, in which cauma assumes a mild character. In various other species of empresma it is often found to do the same, of which the reader will find an interesting example under the species laryngitis, a few pages further on: and of which every practitioner is meeting with daily instances in pneumonitis, and especially in inflammation of the parenchyma of the lungs producing suppu- ration. The general organ of the brain, how- ever, seems to have less irritability than almost every other organ when in a state of health, and we often find it to be little irritable in a state of lesion ; since nothing is more common than for a bullet, or the broken point of a knife, sword, or other weapon, to be forcibly driven into it, and buried there for weeks, months, or years (Gooch's Cases; Hoegg. Diss. Observ. Medico-Chir., Jen., 1762), in one instance elev- en years (Majanet, Journ. de Med., tom. xii., p. 65 ; Id., tom. xx., p 553), not only without ATICA. [Cl. III.—Ord. IL danger, but sometimes w,ith little inconveni- ence. *' In the third number of the Medico-Chirur- gical Journal there is an excellent paper upon the subject before us, by Dr. Porter of Bristol, which commences with a very correct patholo- gical view of the disease, minutely coinciding with the present arrangement, and confirming this view by a variety of strongly-marked and well-selected cases. And I am glad to avail myself of Dr. Porter's authority in following up this second variety of cephalitis into a dis- tinct and extended illustration. [The view adopted by the foregoing author- ities and by Dr. Good, receives important cor- roboration from the statements of that distin- guished pathologist, Dr. Abercrombie, who has observed (On Diseases ofthe Brain, p. 19; also, Dr. Mills, in Trans, of Assoc, of King's and Queen's Coll. of Physicians, vol. v., p. 353), that, in the earlier investigations of this class of diseases, too much importance was per- ». haps attached to the effusion, as if it alone con- stituted the disease called acute hydrocephalus. The symptoms were ascribed to the compres- sing influence of the effused fluid, and the practice was directed chiefly or entirely to the promotion of its absorption. It is now, says Dr. Abercrombie, very generally admitted, that the effusion in acute hydrocephalus is to be con- sidered as one of the terminations of inflamma- tory action within the head, though there are certainly other causes from which the serous effusion may arise. Dr. Mills proposes to call the acute species, arising from inflammatory action, hydro-cephalitis.1 In a few words, both varieties not only evince symptoms of inflammation during the progress- of the disease, but anatomical proofs of the same upon dissection after the disease has ter- minated fatally; in the meningic subdivision, the complaint commencing in and being ordina- rily confined to the meninges or membranes of the brain, the bloodvessels chiefly affected with inflammatory action being the meningic branches of the external carotid ; and, in the deep-seated subdivision, the complaint commencing in, and being ordinarily confined to, the posterior part of the brain, the bloodvessels chiefly affected being minute branches of the basilary artery. It is nevertheless possible, and appears often to become a fact, from the anastomoses that are occasionally found between different arteries of the brain, from the continuous spread of morbid action from neighbouring sympathy, or from some unknown cause, that either variety may pass still deeper or wider into the substance of the brain, and make an approach towards the other; and hence the mixed, anomalous, and even contradictory symptoms, by which the specific character is sometimes distinguished (J. P. Frank, De Cur. Horn. Morb. Epit., tom. ii., p.48); a striking example of which, but too long to be quoted, is to be found in the Edinb - Medical Commentaries.—(Vol. ix., p. 164.) " In three cases," says Dr. Sagar, " I bave found suppuration of the brain after death ; in each of which the patient during the progress of Gen. VII.—Spe. 1.] EMPRESMA CEPHALITIS. 469 thedisea se breathed sonorously, but without ster- tor."—(Sysl. Morb- Sympt., Cl. XI., Ord. III., Gen. XII.) Whether, in the case of effusion be- tween the membranes, the fluid be confined,where the disease commences in the meninges, to the space between the dura mater and the arach- noid tunic, and where it commences in a con- tiguous part of the brain, to that between the arachnoid tunic and the pia mater, as asserted by Dr. Porter, I have not been able to deter- mine. We may hence explain why the symptoms of irritation and oppression should so much vary, as we find they do, in different cases ; why there is sometimes no delirium, and at other times a considerable degree ; why the delirium is sometimes furious and impetuous, constituting the delirium ferox of medical wri- ters ; why, in other instances, it is mute or mut- tering, designated by the phrase delirium mite; why there should occasionally be examples of that comatose or heavy stupor to which the Greeks gave the name of typhomania; and why the pain and pyrectic symptoms should vary from great acuteness to a mere disquieting headache and slight increased action : as also why, in a few cases, there should not only be found suppuration, but examples of that molli- faction, or softening of the brain, the Ramol- lissement de cerveau of M. Rouchoux (Diet, de Mid., tom. ii., Paris, 1822) and other French writers, which is more frequently traced in apo- plectic subjects, and of which we shall have to treat when discussing the disease of apoplexy. Except in a few cases, in which it is brought on by the abuse of strong liquors, and, in warm climates, by exposure to the intense heat of the sun (Abercrombie, op. cit., p. 6), phrensy is not often found as an idiopathic complaint, though it is a frequent attendant upon other diseases, as synochus, worms, various exanthems, tricho- ma, hydrophobia, injuries of the brain, and se- vere grief. [The diagnosis of inflammatory affection of the brain, as laid down by Dr. Abercrombie, seems faithful and correct. His account, however, refers to inflammation of the brain, in its several modifications and conse- quences, and not merely to acute cephalitis. In the head : violent headache, with throbbing and giddiness, sense of weight and fulness, stupor, a great propensity to sleep. In many obscure and insidious cases, a constant feeling of giddiness is the only remarkable symptom. In the eye : impatience of light, unusual con- traction or dilatation of the pupil, double vision, squinting, blindness, distortion of the eyes out- wards, paralysis of the muscles of the eyelids, objects seen that do not exist, long-sightedness suddenly changed into ordinary vision. In the ear : transient attacks of deafness, great noise in the ears, or unusual acuteness of hearing. In the speech : indistinct or difficult articula- tion, unusual quickness or slowness of speech. In the pulse : slowness and remarkable varia- tions in frequency. In the mind : high delirium, transient fits of incoherence, peculiar confusion of thought, and forgetfulness on particular topics. In the muscles : paralytic and convul- sive affections. In the urine : frequently a re- markable diminution of the secretion, often joined with a frequent desire to void it* In this important diagnosis, as Dr. Aber- crombie justly remarks (Op. cit., p. 17), minute attention to the correspondence of the symp- toms is of more consequence than any particu- lar symptom. Thus, the peculiar oppression which accompanies a high degree of fever, is not an unfavourable symptom ; but the same degree of oppression occurring- without fever, or with a very slight fever, would denote a head affection of much danger. A degree of head- ache and delirium, accompanying a high fever, would only be symptomatic ; but accompanying slight fever, would indicate a dangerous affec- tion of the brain.] Cephalitis sometimes makes a near approach to mania ; but is easily distin- guished by the nature of the exciting cause, where this can be ascertained, the abruptness of the attack, and the violence of the fever ; added to which there is in phrensy, for the most part, though not always, a hurry and con- fusion of the mental powers, a weakness and unsteadiness of mind, which is rarely or perhaps never to be met with in genuine mania. It sometimes, however, runs into mania, of which Stoll has given a singular instance in a chronic case that continued for nine weeks before it assumed this change.—(Rat. Med., sect, iii., p. 179.) [From circumstances noticed by Dr. Aber- crombie it appears probable, that, in this form of the disease, the inflammation is primarily seated in the membranes of the: brain. Another affection of frequent occurrence, referred by Dr. Abercrombie to this head, is characterized by a peculiar aberration of mind, without any complaint of pain. There is a remarkable restlessness, quickness, and impatience of man- ner, obstinate watchfulness, and incessant rapid talking, the patient rambling from one subject to another, but often without any actual hallu- cination ; he knows persons about him, and answers distinctly questions put to him. The pulse is rapid, but other symptoms of fever are absent. The disease is sometimes mistaken for mania, and set down as not dangerous, though often rapidly fatal. On dissection, the chief appearance is a highly vascular state of * The undisturbed state of respiration, in the great majority of cases of simple cerebral inflam- mation, seems to admit of explanation by Sir Charles Bell's discoveries respecting the origin and functions of the respiratory system of nerves. Large portions of the brain may be destroyed, and extensive regions of the body deprived of sense and motion ; but, as long as that portion of the medulla which gives origin to the nerves of respi- ration continues free from irritation and inflam- mation, the functions of respiration and circula- tion proceed without interruption. When, how- ever, the general inflammation or irritation ex- tends to the medulla, as happens in the paroxysms of convulsions which sometimes occur in cere- britis, the respiration then becomes extremely hurried.—See Dr. Crawford's Obs. in Cyclop, ot Pract. Med., art. Inflammation of the Brain. —Editor. 470 H.EMATICA. £Cl. III.—Ord. II. the pia mater, without any actual result of inr, flammation. A second modification of inflammation of the brain, particularly described by Dr. Abercrom- bie, is-*hat which comes on with a sudden at- tack of convulsion, followed by palsy, and put- ting on the appearance rather of an apoplectic, than of an inflammatory affection. It is gener- ally connected with inflammation of a portion .of the cerebral substance, but may also" occur ,in combination with inflammation of the mem- branes. This modification may also take place in a more chronic manner, in which it continues for months. In such cases ft is'generally dis- tinguished by headache, often confined to one side of the head; loss of memory ; affections of various organs, as the eye, the ear, or the tongue; convulsive affections; palsy of one limb or one side of the body; terminating in coma and death. On dissection, ramollissement or suppuration of a part of the brain is gener- ally met with ; but sometimes the part is of a dark colour, and rather firmer than the sur- rounding parts.—(Op. cit., pp. 7 and 17.) A third modification, noticed by the same physician, most commonly affects children, but sometimes adults. It is usually preceded for a day or two by languor and peevishness, which are followed by'fever, sometimes ushered in by severe shivering. The patient complains of acute pains in some part of the head, with flushing of the face, and impatience of light. In many cases, there is frequent vomiting. The ■pain frequently extends' along the neck, and is sometimes complained of in the arms and other parts of the body. The pupil is usually con- tracted ; the eye is morbidly sensible, and some- times suffused ; the tongue generally white ; the sleep is disturbed by starting and frightful dreams; the bowels are mostly confined ; but frequently they are natural, and sometimes loose. After some days, slight delirium be- gins, or a peculiar forgetfulness shows itself, the patient using one word instead of another, misnaming persons and things, &c These symptoms are followed by a tendency to sleep, soon changing to coma. While these symp- toms are going on, the pulse, which was at first frequent, usually falls to the natural standard, or below it ; the pain becomes less violent ; the eye loses its acute sensibility, becoming dull and vacant, often with squinting and double vision; and these are often succeeded by di- lated pupil and blindness, even before the pa- tient falls into coma. The pulse having con- tinued slow for a day or two, sometimes only for a few hours, begins to rise again, and attains extreme frequency, and occasionally that of two hundred in a minute. Through the whole course of the disease, according to Dr. Aber- crombie, it is extremely unequal in frequency, varying perhaps every minute, and every time it is counted. This remarkable inequality, he says, is not observed in other diseases, except from some temporary cause ; and is, in all af- fections of the head, a symptom deserving mtrch attention. The patient is now perfectly coma- tose, sometimes with paralysis, sometimes with, convulsions ; and, after a few days more, the disease proves fatal. The falling of the pulse, while the child continues in a state approaching to coma, is often the first symptom indicating the alarming nature of the disease. A fourth form of the disease, depicted by Dr. Abercrombie, proceeds with slight headache and febrile disorder, with remissions and aggra- vations for several days, ere the case assumes any decided character. The headache, though not seveHBj is now remarked to be greater than is correspondent to the fever; and while the pulse falls, and the appetite improves, the head- ache continues. After a few more days, the pulse sinks even to the natural standard, while the headache is increased, with an evident tendency to stupor. This instantly marks a head affection of the most dangerous charac- ter, and the patient now lies for several days in a state of considerable stupor, sometimes with convulsions, often with squinting and double vision. The pulse then begins to rise again ; some amendment seems to take place ; but a relapse into perfect coma soon follows, and death takes place in three or four days. A fifth variety, pointed out by the same prac- tical writers, begins with violent headache, but without fever. The pulse is about the natural standard, or even as low as 60. In some cases, the face is flushed ; in others, rather pale. The eye may be natural, or it may be impatient of light, with contracted pupil. There is a look of much oppression, and sometimes there is vomiting. Delirium frequently appears at an early period, and in five or six days passes into fatal coma, the pulse having continued from 70 to 80 through the whole course of the disease. In other cases, the pulse is at first above the natural standard, afterward falls to 60 or 50 ; and at last rises to 120 or 130. In some cases vision is not affected ; in others, squinting and double vision occur; and sometimes these symptoms, after lasting a day or two, cease, yet the disease goes on to its fatal termination. In every case there is more or less delirium, though often slight and transient ; and fre- quently the patient lies in a dozing state, and talks incoherently, but is capable of being roused so as to converse sensibly. This condition, says Dr. Abercrombie (Op. cit, p. 6-13), when not accompanied by fever, is always character- istic of a dangerous affection of the brain.] The remote causes of cephalitis are those of inflammation in general applied to the organ affected ; such as sudden exposure to cold after great heat; cold liquors incautiously drunk in the. same state ; inebriation, and especially from spirits ; exposure of the naked head to the rays of a vertical sun ; violent passions of the mind ; obstructed menstruation ; accidental injuries ; suppressed eruptions of various kinds (Frank, ut supra, tom. ii., p. 51); and several kinds of poison. From some of these causes, the inflamma- tion assumes a chronic character ; is slow in its progress, and obscure in its symptoms. The symptoms, moreover, however connected with a morbid consent in other organs, generally G. Gen. VII.—Spe. 7.] EMPRESMA PNEUMONITIS. 495 times only apparent, and the pulse will become stronger and fuller after bleeding. For the re- moval of any doubt about the propriety of bleed- ing, when the pulse is weak, the stethoscope is mentioned as a most valuable instrument. Ac- cording to Laennec, whenever the pulsations of the heart are proportionally much stronger than those of the arteries, we may bleed with- out fear; but, if the heart and pulse are both weak, the practice generally causes complete prostration of strength. Blisters are employed in pneumonitis by the generality of practitioners, but with very little discrimination. The common error consists in applying them too early, in which circumstance they increase the fever, and do more harm than good. The best physicians seem now to agree, that blisters should not immediately follow the first bleeding, but be kept back till the acute stage has somewhat subsided. With respect to purgatives in cases of pneu- monitis, clysters and gentle laxatives are gen- erally preferable to stronger medicines. The editor has seen two cases very lately, in which the expectoration seemed to be stopped by the operation of active purgatives, and the patients, though already benefited by bleeding, suddenly became worse, and died. As Dr. Forbes has observed, when pneumonia is complicated with gastric inflammation, strong purgatives are highly improper. Refrigerants are frequently prescribed in this disease : one of the most common and useful is nitre ;] which may be combined with the citrate of potash, or made to produce a more certain determination to the skin, by the addi- tion of camphire or of antimonial wine, or by a combination with the citrate or acetate of am- monia. In other countries, emetics have seldom been given except in an early stage of the disease, and then only as a gentle puke ; yet, from my own practice, I can recommend them when the disease has made a considerable advance ; but they must be used boldly, or so as to produce full vomiting, and the action of vomiting must be maintained for an hour, or even two ; and in this way they will often produce a transfer of action of as beneficial a nature as the same process is found to do in purulent ophthalmia; and will, at the same time, peculiarly stimulate the exhalants of the lungs to an increased secre- tion of mucus. [On the continent, the free exhibition of tartarized antimony in pneumonitis has always had some partisans. To Laennec's knowledge, the practice was constantly fol- lowed by M. Dumangin, physician to La Cha- rity, who scarcely ever joined bloodletting with it, and yet his practice was quite as successful as that of Corv^art, who bled much in this dis- ease. Rasori, a modern Italian physician, first revived this method of treatment.—(Storia delta Febbre Petechiale, &c, Milano, 1813.) After venesection, Laennec gives a solution of one grain of tartarized antimony every two hours, repeating the dose six times. After this, if the symptoms be not urgent, and the patient dis- posed to sleep, he leaves him quiet for six or eight hours. But, if the oppression be great, or the head affected, the medicine is continued, the dose being then sometimes increased to a grain and a half, or two grains, or even two grains and a half. Many patients bear the*med- icine without being either purged or affected with vomiting. Most of them, however, vomit two or three times, and have five or six stools the first day. On the following days they have very slight evacuations, and sometimes none at all. As soon as some amendment is produced, we may be sure, says Laennec, that the contin- uation of the remedy will effect a cure, without any fresh relapse ; a point in which this prac- tice is represented to differ especially from that of bleeding. Of forty-seven cases, treated by Dr. Hellis, of Rouen (Clinique Mid. de VHotel Dieu de Rouen, 1826), by repeated emetics, only five were lost, being a proportion some- what less than one in nine. Laennec expe- rienced even greater success with large doses of the medicine. The average number of deaths, under the treatment with bleeding and derivatives, is computed to be one in six or eight cases. When the medicine operates too freely, Laennec joins a small proportion of opium with it.—(Op. cit., p. 250.)] M. Pes- chier, of Geneva, also prefers the treatment with tartarized antimony ; and depends upon it alone, or nearly so, even discarding the lancet; for he gives it in large doses, so as to purge as well as vomit. His usual quantity at first is, according to the age, from six or eight to fifteen grains, dissolved in six ounces of water, which is taken in divided doses, in any diluting drink, in the course of twenty-four hours. And, un- der this plan, he tells us that he cured all his patients, old or young, without exception. He admits, however, the conjoint use of blisters, which ought unquestionably to form a concomi- tant in the general plan ; and the obstinacy of the cough may be alleviated by demulcents, or inhaling the steam of warm water. [The plan of making tartarized antimony the chief means of treatment has not yet gained many advo- cates in England. With Dr. John Forbes, the belief of pneumonia being frequently complicated with gastric affections, influences him much against the practice, the merit of which, how- ever, must be determined by experience.] Opiates have been tried in every form, but have never been found of decisive benefit; if opium be used at all, it should be in conjunction with gum-ammoniac or squills : but, upon the whole, either of these expectorants seem to answer best without opium. [The best, the easiest, and even the natural cure of peripneumony, is expectoration, which ought to be encouraged by all the means in our power. It forms the optima crisis of Stoll, though, as he adds, a crisis too rarely obtained.] Dr. Saunders rec- ommended the extract of the white poppy ; and that of the garden lettuce has since been tried, upon the recommendation of Dr. Duncan; others may have been more fortunate than my- self, but, in my hands, both have proved alto- gether insignificant. If the disease proceed favourably, the pulse 496 HjEMATICA. [Cl. Ill—Ord. II. becomes slower and softer; the yellow, tena- cious, and perhaps bloody sputum, is mixed with points of a whiter matter, which increases with the amendment of every other symptom ; for the cough is less violent and straining, the breathing freer, the skin moister, and the tongue cleaner at the edges. If the progress be less favourable, the expectoration becomes darker and more vis- cid ; the pulse lower, indistinct, and often in- termitting ; a low, wandering delirium super- venes, with subsultus ; and the patient dies, apparently suffocated, from the oppressed ves- sels no longer permitting an expansion of the lungs.* When a salutary expectoration has commen- ced,, it sometimes ceases suddenly, from some unknown cause, or some irregularity in the mode of treatment. This symptom is alarm- ing ; and every means should be instantly taken to bring the discharge back ; such, particularly, as increased doses of the expectorants already noticed, to which may be added the steam of vinegar, alone, or impregnated with the essen- tial oil of aromatic plants, as rosemary. And if a diarrhcea, which sometimes proves a very distressing concomitant, should supervene, it will be best relieved by the pulvis cretae comp. cum opio. Inflammation of the lungs is also occasion- ally found as a symptom or sequel in rheuma- tism, lyssa, or canine madness; various exan- thems, as smallpox, measles, miliaria, and com- monly in phthisis ; in which last it has a very frequent tendency to suppuration, as we shall have to notice when treating of this distressing complaint [Peripneumony, thus forming a com- bination with other disorders, is termed by Laennec latent and symptomatic, being then particularly liable to be overlooked. Besides the cases just now specified, on which it is fre- quently an attendant, some others merit recol- lection : as, for instance, haemoptysis ; different kinds of catarrh ; gout; severe erysipelas ; vio- lent continued fevers; and bad local injuries and important surgical operations.] * The progress of pneumonia to a fatal result is marked by a continued aggravation ofthe dyspnoea, with increasing failure of the strength. The cough becomes less capable of expectorating the sputa, which sometimes retain their viscidity and san- guinolent hue, as long as any are avoided. In the greater number of instances, there is a total suppression of the expectoration for some hours before death; but, in others, it is still excreted, though of a different character. The whole sputa, however, in the latter stages of the disease, are generally scanty. Andral describes sputa as some- times taking place, which consist of a slightly glutinous liquid, and of a reddish-brown colour, resembling liquorice-water, or thin sirup of prunes. Towards the concluding scene, the pulse becomes thready and intermittent; the countenance pallid, cadaverous, and bedewed with a cold sweat; the lips livid, the breathing gasping and convulsive, with a rattle in the throat; the sensorial functions, if entire before, now give way; and the patient dies asphyxiated. Whoever has seen the fatal end of pneumonia, must recognise the fidelity of this description, as given by Dr. C. Williams in the Cyclop, of Pract. Med., art. Pneumonia.—Ed. I The malignant peripneumony, contrary to the true or common inflammatory affection, is generally an epidemic, and may be easiest ex- plained by describing it as an epidemic syno- chus, or typhus, occurring in such situations, at such seasons ofthe year, or in such a-tempera- ment of the atmosphere, as have a tendency to excite inflammation of the lungs. The debility is often so extreme from an early stage of the disease, that the pulse ceases on the pressure of the finger ; and the vascular action is too weak to accomplish expectoration. It is sup- posed by many writers, and especially by Sar- cone and Ludwig, to be a pulmonic erysipelas, by which they mean an erysipelatous erythema. The symptoms are those already described, with a great addition of sensorial debility, and consequently with increased laboriousness of respiration. The disease is usually fatal on the fourth or fifth day ; and if the system be in- cautiously lowered by venesection or a laxative of too much power, it" often takes place earlier ; and has sometimes occurred within twenty-four hours after bleeding. Our attention must here, therefore, be turned rather to the constitutional disease, than to the local affection ; and the plan recommended in typhus is to be pursued on the present occa- sion : for it will be in vain to attempt expecto- ration under circumstances in which the system will probably sink before the usual time arrives for effecting it. Camphire is here a medicine of considerable service, and may be used in conjunction with the aromatic confection, and wine in large quantities. It should be taken freely in the form of pills, rather than in that of julap ; though both may be employed conjointly. Even the bark has a powerful claim to be tried, particularly the sulphate of quinine, as in putrid fever; nor has it been found to produce diffi- culty of breathing. Bark may be advanta- geously combined with the aromatic spirit oi ammonia, which of itself often proves a useful stimulus. If evacuations be necessary, they should be obtained by injections alone. A light breathing perspiration, a free expuition, and a more animated appearance of the countenance, are among the most favourable diagnostics.* * Perhaps there is no part ofthe " Study of Med- icine" more appropriate than the present, to notice a form of disease which at times has prevailed in different and distant sections of the United States with extraordinary fatality. This disorder has been termed the petechial, or spotted fever, the ma- lignant nervous fever, peripneumonia typhoides, the malignant pleurisy, pleurisy of the head, typhus pete- chialis, epidemic pneumonia, &c Though it was first particularly noticed some twenty years since, some authorities state that it was described by Sauvages, Huxham, and others. Dr. Gallup, indeed, thinks that a similar disorder has raged at different times in Europe for the last three hun- dred years. In the Am. Med.- and Phil. Register, vol. i., Dr. BaTd has described it as it prevailed on Long Island in 1749; and in the New-York Med. Repos., vol. ii., Dr. H. Williamson has noticed its occurrence in North Carolina in 1792. In 1806, the spotted fever appeared at Medfield, and for many years it proved a severe scourge to the in- habitants of Maine, Massachusetts, Rhode Island, Gen. VU.-tSpe. 8.] EMPRESMA PLEURITIS 497 The spurious or bastard peripneumony is usually allowed to offer another variety of this disease ; and is described under the name of peripneumonia notha by Boerhaave, Coze, and Sydenham. It is, in many instances, little more than a severe catarrhal affection of the lungs, accompanied with great obstruction, oc- curring in habits of a peculiar kind ; and is hence denominated' by many authors catarrhus suffocalitus, and by Professor Frank, catarrhus bronchiorum-—(De Cur. Horn. Morb., tom. iL, p. 138.) It is characterized by great secretion • and expectoration,.with a mild cauma; and is chiefly found in those of advanced life, or who have weakened their constitution by excesses. Sydenham, however,ihas properly distinguish- ed this malady from catarrh, notwithstanding the close resemblance it bears to it on particu- lar occasions. The following is his description Connecticut, Vermont, New-Hafopshire, and some districts of New-York. It has also existed in some of the' middle, southern, and western states, but our information as to its nature in these states is extremely limited. We would refer those who desire more knowledge of this malady than can be embraced in a brief note, be the treatises of Drs. North, Hale, and* Job Wilson on the Spotted Fever, and to Dr. Yates'essay on the Bilious Epid. Fever. The American medical periodicals contain many excellent papers on the same subject, by Stuart, Hosack, Low, Fuller, Stearnes, Hudson, Dunbar, Hunt, &c Dr. Gallup in his " Sketches of Epidemics," Dr. Mann in his " Medical Sketch- es," and Dr. Thacher in his " American Modern Practice," devote some pages to it. The best ar- ticle, however, on this disease, is the Report made by order of £he Mass. Med. Society, in 1810, drawn up by Drs.Warren, Jackson, and Welsh. The inva- sion of the disease was generally sudden and vio- lent, presenting many of the symptoms mentioned in thetext, although trfey varied excessively, and were so different in individual cases as not to ad- mit of enumeration ; attimes, it was masked with greater depression, and assumed more of a typhoid type; the patient often laboured under extreme congestion and coma; maculoe, vibices, &c, oc- casionally appeared. As to the treatment, the most opposite modes of practice prevailed; in many cases the lancet was fatal, and the same was true of the administration of diffusible stimuli: emetics, cathartics, sudorifics, blisters, &c, were among the most effectual remedies. Bloodletting, although sometimes abused, was often indispensa- ble ; in short, the spotted fever frequently present- ed two entirely different forms, demanding differ- ent modes of treatment; a local inflammation, and a typhoid state of the system. On dissection, the brain was almost constantly diseased, andjn most instances there was an effu.- sion of serous fluid, and of coagulated lymph within the ventricles. ^Theheart and pericardium generally exhibited some appearance of morbid affection, and the same remark applies to the pleura and lungs. By many, thrf causes of this disease were thought to be the vicissitudes of pestilential sea- sons ; and, inasmuch as the disease proved ex- tremely fatal to the American soldiers, in the war of 1812-14, its exciting cause was considered by others to be the unwholesome grain used by the soldieys, and the exposure incident to military life. Both these causes doubtless operated, but the extreme changes in the temperature probably had more effect.—D. Vol. I.—I i of the disease :—" The patient is hot and cold alternately, feels giddy, and complains of an acute pain in the head, especially when there is a teazing cough. He rejects all fluids, some- times from paroxysms of coughing, and' some- times without; the urine is turbid, and of a deep red; the blood appears as in pleurisy. The patient breathes quick and with difficulty ; complains of a general pain throughout the entire breast, and, as he coughs, discovers a Wheezing to the attendants. The cheeks and eyes appear slightly inflamed ; the pulse is small, often intermitting ; and lying low, or on one side, is peculiarly distressing." As the fever is here of no great moment, we may, with considerable advantage, carry our local stimulants to a greater extent, and thus excite the lungs more actively to throw off the burden of mucus with which they are over- powered. Squills, gum-ammoniac, balsam of Peru, and even some of the turpentines, may be tried, and will mostly be found serviceable. The tetradynamia,-as charlock, wild rocket, and mustards of various sorts, and the alliaceous plants, will form useful auxiliaries in the plan of diet. Blistering is highly serviceable ; after which, as soon as the chest is a little unloaded, a regimen- directly tonic should be commenced, by rrieans of bitters, chalybeate waters, a mod- erate portion of wine, gentle exercise, pure air, and the irritation of an issue or seton ; for a common result of this disease is hydrothorax. Perhaps more persons fall a sacrifice to some sequel of the disease than to the disease itself. SPECIES VIII. EMPRESMA PLEURITIS. PLEURISY- ACUTE PAIN IN THE CHEST, INCREASED DURING INSPIRATION ; DIFFICULTY OF LYING ON ONE SIDE ; PULSE HARD ; SHORT, DRY, DISTRES- SING COUGH. As the proper seat of the preceding species is in the substance of the lungs, or the pleuritic membrane that immediately covers their surface, or in both, the proper seat of the present is in the surrounding membranes of the pleura; and as these differ, the difference has laid some foundation for several varieties-; of which the three following may be noticed as matter of curiosity, though the subdivisions lead to noth- ing of practical'importance, as the causes are nearly alike, and the same mode of treatment is applicable to the whole. a Vera. Fever a cauma; pain felt True Pleurisy. chiefly on one side ; the in- flammation commencing in that part of the pleura which lines the ribs. 0 Mediastkia." Heavy pain in the middle of Pleurisy of the the sternum, descending mediastinum, towards its ensiform carti- lage ; with great anxiety ; ♦he inflammation, from its symptoms, being obviously sealed in the mediastinum. 498 H^EMATICA. [Cl. III.—Ord. II. y Diaphragmatica. Painful constriction around Pleurisy of the the praecordia; small, diaphragm. quick, laborious breath- ing : manifesting that the inflammation is seated chiefly in the diaphragm.* We have already pointed out the distinction between true pleurisy and peripneumony ; and observed that, in the former, the cough is dry and commonly without expectoration from the beginning to the end, contrary to what occurs in the latter ; that the seat of pain is fixed, in- stead of shifting from side to side; and that the face is far less flushed and tumid. It must be conceded, however, to Dr. Cullen, who has treated of these affections under one common definition, that the general features of the two have a considerable resemblance; and, with the exception of expectorants, which in pleurisy are of little avail, the mode of treatment already proposed for the former disease, is the same that will be found necessary in the latter: the causes of both are alike, and as peripneumony rarely, though we have reason to believe some- times, occurs without any degree of pleurisy, so it is commonly affirmed that pleurisy rarely occurs without some degree of peripneumony ; in both which cases it has been called a pleuro- peripneumonia. [With all the best informed practitioners of the present day, pleurisy always signifies in- flammation of the pleura, whether attended with stitch, or pain in the side, or not; peripneumo- ny, pneumonia, or pneumonitis, will always stand for inflammation of the lungs, even when accompanied, as it sometimes is, with acute pain in the side; while pleuropneumonia will mean the co-existence of inflammation in both organs. The observations of Laennec fully confirm the facts, that pleurisy and peripneu- mony are very frequently combined; that, in eases where the pleura alone is inflamed, the stitch of the side may be scarcely perceptible, quite transient, or entirely wanting; and, on the other hand, that a violent peripneumony, complicated with a slight pleurisy, may be at- tended with a most severe pain in the side. t The latter symptom is, therefore, not pathog- nomonic of pleuritis. Sometimes, thotjgh sel- dom, the pleura is inflamed on both sides of the chest, so as to constitute what has been termed double pleurisy.X It is indeed, as Laennec states, not uncommon to meet with slight de- grees of pleurisy on both sides of the chest, produced a few hours before death in enteral * Instead of this division, the editor would have preferred that into acute and chronic pleuritis. t Laennec, Op. cit, p. 420. Pneumonia is al- leged more frequently to produce pleurisy, than pleurisy pneumonia.—Dr. Law, in Cyclop, of Pract. Med., art. Pleurisy. X Pleurisy of one side, as Dr. Law observes (.Cyclop, of Pract. Med., art. Pleurisy), is not unfrequently complicated with some disease of the opposite lung, which may either become em- physematous, or the subject of bronchitis, or pneumonia. Another frequent complication of pleurisy is tubercles of the lungs.—Er». acute and chronic diseases; ot with a similar affection that has occurred on one side in the last hours of life, while the other side is violently inflamed. But it is extremely rare to see the pleura of both sides simultaneously attacked with violent inflammation and abundant effu- sion ; and, when such a case does occur, it is almost always speedily fatal.] Like peripneumony, we also find pleurisy an occasional symptom or result of typhus, catarrh, rheumatism, various exanthems, and hyper- trophy or enlargement of the heart.—(Original Cases, &c, by John Forbes, M. D., _p. 222, Svo., 1824.) The pleurisy, however, that is supposed to accompany rheumatism, is often an inflammatory affection of the intercostal or other thoracic muscles alone, since the pain is con- fined to the origin and insertion of the muscles. Where this has been accurately attended to, it has been distinguished by the name of bastard pleurisy; and simply by that of pleuritis by Dr. Frank (Op. cit., tom. ii., p. 126), and those who have regarded genuine pleurisy as a mere modi- fication of pneumonitis, or peripneumonia. Like the preceding species, true pleurisy commences with the usual signs of a febrile attack, as chilliness or shivering, succeeded by heat and restlessness. The pairi, or stitch in , the side, is usually just above the short ribs, ?, and the dyspncea is characterized by the expi- rations being less painful than the inspirations.* The pulse is hard, strong, and frequent; and though the cough is mostly dry and suppressed, there is sometimes a bloody or puriform mucus spit up from the lungs. The patient generally- lies most easily on the affected side, or the back, and cannot turn on the opposite side without a great increase of the difficulty of breathing, t [As soon as effusion takes place, the natural sound of the chest on percussion is lost over the whole space occupied by the fluid; and, with the ■ stethoscope, a total absence or great diminution of the respiratory sound, and the appearance, disappearance, and return of aego- phonism' wiS be detected. When the effusion is considerable, the respiration usually becomes * * puerile on the sound side, and the diseased side is larger than the other.] * The pain, which is acute and severe, is usual- ly restricted to a circumscribed space; and is considerably increased by any attempt to make a full inspiration. In truth, the respiration is quick- ened in pleurisy to compensate for the small quan- * tity of air. that can be inhaled on each imperfect expansion of the chest. The pain is not augment- ed by slight pressure, though it is so by strong. At all events, as Dr. Elliotson remarks, the pleu- risy must be very severe, if the pain be increased by slight pressure. On the other hand, in rheu- matism of the muscles of the chest, the least touch causes pain and soreness. It is also remarked by Dr. Elliotson, that, for the most part, there is pro- fuse sweating in acute rheumatism, such as does not occur in pleuritis. In the latter, the constitu- tion is more disturbed, but the pain is less excru- ciating than in acute rbeumatism.—Ed. f The best medical writers contradict one an- other in their statements about the position in wbich a patient, labouring under pleurisy, finds himself most easy. The truth is,"that some differ- Gkn.VIL— Spe. 8]' EMPRESMA PLEURITIS. 499 Like the preceding species, also, pleurisy ter- minates in resolution, suppuration, and gan- grene. The former is the ordinary and most fa- vourable issue. The last occurs rarely, and Laen- nec has seen only one instance of it from acute inflammation ; but suppuration is by no means uncommon ; in which case, if the abscess do not point outwardly, an empyema will ne- cessarily follow ; and the formation of pus is in- dicated by a remission of the pain, one or more shivering fits, and, in some instancies, a sense of fluctuation. This, however, is a termination far more common to pleurisy from external in- juries, than from internal causes. [The pleura, when acutely inflamed, exhibits a punctuated redness, or an infinity of small bloody spots of very irregular figure. They oc- cupy the whole thickness of the membrane, and leave small intermediate portions retaining the natural white colour. It cannot be doubted (says Laennec), that, during life, the redness was uniform; and that the punctuated ap- pearance and partial whiteness are owing to changes which occur after death. Besides this particular redness, the superficial bloodvessels of the pleura are always redder and more distended than in the natural state. Many consider a ' thickerrinf of the pleura a very common result of its inflammation } but Laennec thinks that, in most cases, where such thickening has been supposed to exist, the appearance was produced by an extensive congeries of miliary tubercles on the outer or inner surface of the pleura, a cartilaginous incrustation on the parts covered by it, or a layer of coagulating lymph on its in- ternal surface. Inflammation of the pleura, he says, is always accompanied by an extrava- sation on its internal surface ; the matter effused being either coagulating lymph, termed a false membrane, or else serosity, or a sero-purulent fluid. The serous effusion is commonly of a light yellow colour and transparent, or with its transparency only slightly interrupted by the in- termixture of small fragments of pus or lymph, so as- to give it the appearance of unstrained whey. In acute pleurisy, it is mostly free from smell. Generally speaking, the more violent the inflammation, the more extensive and thick is the membranous exudation, or layer of coag- ulating lymph. On the contrary, in weak leuco- phlegmatic subjects, we find a great quantity of limpid serum, with a small portion of thin mem- brane often floating in it. In such cases the pleurisy seems to pass insensibly into hy- ence prevails in different cases. Df. Law gives it as the result of his observations, that, generally, as long as the acute lancinating pain of the side con- tinues.the aggravation of it, caused by the pressure, makes the patient put himself either on the oppo- site side or upon his back. When the pain has ceased, and extensive effusion takes place, the position before avoided is now adopted ; because, the effusion having interrupted the function of one lung, a necessity for greatly augmented action de- volves upon the other; and in order to favour this, and to let the muscles have the freest action on the unaffected side of the chest, the patient lies on the diseased side.—See Cyclop, of Pract. Med., art. Pleurisy. I i 2 drothorax. In some rare instances we find a pseudo-membranous exudation, uniting the con- tiguous surfaces of the pleura, without any se- rous effusion. This, as Laennec observes, would be a very common case, if we took into our account those pleurisies which had made some progress towards a cure, the absorption of the fluid being the first step in the sanative pro- cess. But the less common examples to which he alludes above are noticed in persons dying of some other disease, and who were at the same time affected with a slight and partial pleurisy. In these cases we find a white, almdst colourless, semi-transparent exudation, which, while recent, readily allows the parts to be sep- arated, and remains on the surface of each, ex- actly like a thick and moist paste, which had united two leaves of paper. The pleura pulmonalis near the inflamed part is also sometimes covered to a small extent with a layer of lymph of various consistence and thickness. In some cases, we find no serous effusion after death; and Laennec has met with similar examples of partial pleurisy, in which no extravasated fluid could be perceived with the stethoscope. ' Many physicians imagine that the effusion does not occur .till after some time, and even some days. This opinion is pronounced by La- ennec to be incorrect. He has several times observed all the physical signs of effusion, viz., aegophonism, and absence of the respiration and sound on percussion, in one hour from the first invasion of the disease, and he has seen the side manifestly dilated at the end of three hours. The false membrane, or exudation of lymph, is gradually changed into cellular substance, or rather into a true serous tissue, like that of the pleura. The serous effusion is absorbed, the compressed lung expands, and the false mem- brane investing it and the costal pleura becomes united into one substance, which afterward be- comes vascular and organized, and constitutes permanent adhesions. A severe pleurisy, that has terminated by numerous adhesions, renders the part so affected much less liable to subse- quent attacks of the same disease ; and when it occurs, the inflammation and effusion do not eitend to the adherent parts. When pleurisy is simple, the pulmonary tis- sue is free from inflammation, even in the vi- cinity of the inflamed portions of the pleura ; but it is rendered more dense and less crepitous from the compression of the effused fluid. If the extravasation has been very great, the lung becomes flattened and completely flaccid ; it no . longer contains air, or crepitates; its vessels are compressed, and contain little blood ; and the bronchiae are rendered smaller. Yet there is no trace of obstruction, as in pneumonitis ; and if air is blown into the bronchiae, the lungs , expand.—(Laennec, op. cit., p. 421, et seq.) When the effused fluid is tinged with blood, or, what is rare, contains coagula (see Case re- corded by Andral, Clinique, 'Med., tom. ii., obs. 15), Laennec terms the disorder acute hemor- rhagic pleurisy. 500 HJ2MATICA. [Cl. III.—Ord. II. Among the occasional causes of pleurisy enu- merated by Laennec are, inclemency ofthe win- ter ; long exposure to cold after violent exer- cise ; metastasis of gout, rheumatism, and cu- taneous diseases ; blows on the chest; and fracture of the ribs. One of the chief dangers of penetrating wounds of the chest, is inflam- mation of the pleura or lungs. Dr. Law has seen a fatal case of pleurisy produced hy perfo- ration of the pleura, in passing the needle round the subclavian artery for the cure of an axillary aneurism.—(Cyclop, of Pract Med., art. Pleu- risy.) Among predisposing causes are, a slen- der frame, narrowness of the chest, the im- moderate use of spirits, and tubercles in the lungs. In youth and middle life, plethora, vio- lent exercise, intemperance, and cold, frequently bring on pleurisy ; but in old persons, and sub- jects of delicate constitution, who take great care of themselves, it is still more frequent. The worst cases, as Laennec truly remarks, occur in the weakest subjects, and in cachectic habits.— (Op. cit, p. 445, 2d edit.)] Perhaps there is no disease in which profuse bleeding from a,large orifice may be so fully de- pended upon, or has been so generally acceded to by practitioners of all ages and all nations ; the only .question which has ever arisen upon the subject being, whether the blood should be taken from the side affected, or from the opposite. The earlier Greeks recommended the former, the Galenists and Arabians the latter ; and the dispute at one time rose so high, that the medi- cal colleges themselves not being able to deter- mine the point, the authority of the emperor Charles IX. was whimsically appealed to; who, with much confusion to the controversy, died himself of a pleurisy before he had delivered his judgment. He, too, had been bled, and his death was immediately ascribed to the blood having been drawn from the wrong side. At present, from a knowledge ofthe circulation of the blood, we can smile at these nugatory solemnities. It is possible, however, that there are some contro- versies of our own times that have as little groundwork, and at which future ages may smile with as much reason. The blood drawn in this disease has a peculiarly thick, yellowish, tena- cious corium, and is hence specifically distin- guished by the name of the pleuritic corium or coagulum. [Should the pain and fever not yield to the first or second venesection, Laennec very prop- erly recommends it to be followed up by local bleeding, preferring, however, cupping to leeches. As Dr. J. Forbes judiciously observes, one of the many practical advantages of accurate diag- nosis in pleurisy and peripneumony is, the much greater benefit derived from local bleeding in the former than in the latter disease. He believes we are accustomed to trust too much to general, and too little to local bleeding in this disease, and that both, combined in moderation, are greatly preferable to either in excess.—^See note in Laennec, p. 479, 2d edit.)] Purgatives should be used freely; blistering the side is very generally beneficial after bleed- ing has been tried and repeated, and should be accompanied with diluents and diaphoretics.- [Blisters"should not be applied in too early a stage, as they are then apt to increase the fever and pleuritic affection. In this disease, as well as in pneumonitis, Laennec prescribes tartarized antimony freely, and states that it speedily sub- dues the inflammatory action, and obviates the necessity of abstracting profuse quantities of blood.] Opium may also be employed with less caution than in peripneumony, and is a most valuable medicine, joined with calomel, as rec- ommended by Dr. R. Hamilton.* For promoting the absorption of the effused fluid, the latter medicines, acetate of potass, digitalis, with mer- curial inunction, and blisters, are the best means. When the accumulation increases so as to form dropsy, paracentesis of the chest may become necessary.t The heart and pericardium are sometimes apt to associate in the morbid action, as well as the lungs themselves. This is particularly the case in the second variety. Dr. Perceval, in his manuscript commentary on the Nosology, has given me a striking example of this, in a * Dr. Elliotson enumerates bleeding, mercury, starvation, and purging, among the remedies in- dicated for the relief of this as well as other in- flammations. Mercury is now, indeed, univer- sally acknowledged to be one of the most powerful means of subduing inflammation of the serous membranes in general.—Ed. t Sometimes the affected side of the chest seems more expanded than the other ; and if the effusion be in the left pleura, the heart may be so displaced, that it pulsates to the left of the ster- num. An accumulation of fluid in the right pleura may push down the liver in an extraordinary rflan- ner, so as to cause an appearance in the abdomen, as if that viscus were enormously enlarged, where- as there may not be the slightest disease of it; a mistake which often took place before auscultation began to be employed, but which, with the valu- able aid of the stethoscope and percussion, will hardly happen again. The want of a hollow sound on percussion, even without aegophonism, which prevails only while the quantity of fluid is moder- ate (see EUiotson's Lectures), will, with attention to the history ofthe case, render the diagnosis of fluid in the chest sufficiently clear. When ef- fusion takes place, there is a dead sound on per- cussion, and no respiratory murmur is heard. Dr. Elliotson observes, that the part of thethest where we should first listen for aegophonism, is from about one to three fingers' breadth from the lower angle of the scapula to the nipple, because it is below this point that the fluid generally accumulates ; and, if the whole lung be covered with effusion, still the thickness ofthe body of the fluid is always less at the posterior part of the chest. If the lung has been so compressed that it will not expand, and the fluid has been absorbed or let out, and no more has formed, the ribs on that side fall, and lie closer together than natural; the shoulder on that side becomes lower than the other ; and the muscles, especially the pectoral, waste. Even the spinal column at length inclines, in some cases, to the affected side. These circumstances were first well described by the celebrated Laennec. Dr. Elliotson, in his Lectures, gives an excellent ac- count of them, with the particulars of a case, in which a chronic pleuritis, terminating in such changes, had been mistaken for phthisis cured by means of muriate of lime.—Ed. Gen. VII.—Spe. 9.] EMPRESMA CARDITIS. 501 patient who complained of excruciating pain in the region of the heart, with dyspnoea, not at all relieved by copious and repeated bleedings. After death, a slight effusion was discovered in the pericardium: but the mediastinum was more inflamed than the membrane of the heart. The treatment of this variety ought not to differ from that of the preceding. The cerebrum is, however, still more dis- posed to associate in the morbid chain of ac- tion than the heart. And hence, when any of the varieties of pleuritis, and particularly the last, are combined with an affection of this or- gan, and produce delirium, the disorder was formerly distinguished by the terms paraplvre- nesis and paraphrenitis ; terms derived appa- rently from the peripatetic philosophy, which supposed the seat of the priv, or soul, to be the praecordia ; whence this region was denom- inated fpcve;; while, as Hippocrates supposed its seat to be in the brain, phrenitis, with a lamentable confusion of terms, was, as we have already remarked, applied to an inflammation of this last organ, and continues to be very generally so applied in the p'resent day. It is in the last variety that the head is most commonly affected: probably from the general sympathy which the diaphragm holds with the lungs and the stomach, and the close com- munity of action between both these organs and the brain. The breathing is here peculiarly dis- tressing and anxious, the diaphragm being the muscle chiefly concerned in respiration, which now takes place without its aid. The hypo- chondria are drawn inwards, and kept at rest as much as possible : the patient is tormented with hiccough and sickness ; and there is a pe- culiar tendency to spasmodic action ; whence the angles of the mouth are often involuntarily retracted: there is a sardonic laugh on the countenance, a sense of tightness like the stric- ture of a cord at the pracordia, and convulsions wander from one part of the system to another. Professor Frank mentions a case in which all these symptoms were present, and which was consequently supposed to be, and was treated as, a diaphragmatic pleurisy, but which on dis- sectionjCfor it proved fatal) was ascertained to be a case of intestinal worms, the diaphragm showing no manifest affection. It is highly probable, however, that the diaphragm was here influenced by sympathy, and that the dietinct- ive symptoms were the result of such irrita- tion. The treatment should be as in the pre- ceding varieties. SPECIES IX. EMPRESMA CARDITIS. INFLAMMATION OF THE HEART. PAIN IN THE REGION OF THE HEART, OFTEN PUNGEWT ANXIETY ; PALPITATION ; IRREGU- LAR PULSE. The symptoms in the definition sufficiently distinguish this species from the preceding. At the same time, it must be acknowledged, that carditis, like pleuritis, has many signs in common with pneumonitis; which may readily be conceived from the vicinity and close con- nexion of the thoracic viscera with, each other, and particularly from the very strong sympathy with which they co-operate. Dr. Cullen affirms, indeed, that he has often met with cases of car- ditis evincing no other symptoms than those of pneumonitis, and Dr. Frank concurs in the same testimony. Vogel's definition i$, founded altogether upon this view, " Cordis inflamma- tio fere ut in peripneumonia." I have hence been at some pains to draw a line of distinction ; and I think it may be found in the symptoms now delivered as the specific character of the disease. We may add to these symptoms, that there is sometimes, though not always, groat difficulty of breathing, generally some degree of cough, but without expectoration, and a per- petual tendency to fainting; and that if deli- quium take place, and the patient do not soon recover from it, it proves fatal.* Portal asserts, that the organic pain is accompanied with an increase of heat, which often spreads to the surrounding regions. This is Portal's acute modification of the disease : but he also notices an obscure or latent modification, in which its symptoms are but little conspicuous, and what- ever exists of them are ascribed to some other disease. The spirit, he tells us, is here sud- denly subdued and broken ; the pulse is slow, soft, and feeble : there is little pain in the heart, and little or no palpitation. Fainting, never- theless, is a frequent appendage, and is pecu- liarly apt to lead astray. This, however, can hardly be called an idiopathic disease. Portal has drawn his description entirely from post- obit appearances in those who hawe died of" se- vere atonic typhus, or of plague; and observ- ing, as Chicoyneau had before him, occasional proofs of suppuration and gangrene of the heart, he has inferred the previous existence of carditis, and has ascribed the almost instantaneous sink- ing of the patient to a rapid march of inflam- mation in this.organ, notwithstanding it was not manifestly accompanied with its ordinary indications, t * Abercrombie, Contributions to the Pathology of the Heart.—Trans, of the Medico-Chir. Soc. of Edin., vol. i., 1824. t Memoires sur la Nature et le Traitement de plusieurs Maladies, par A. Portal, tom. 4me., 8vo., Paris, 1819. One case, the fatal result of which had been preceded by several of the'symp- toms frequently rtoticed in pericarditis, was opened by Andral. The following is a sketch of the dis- order :—In the midst of a good state of health, sudden dyspncea; pain not lery acute about the heart; tumultuous beatings of this organ; very frequent, irregula* pulse ; increasing suffocation, and death. Nothing wrong was detected about the pericardium and substance of the heart, its anriculo-ventricular openings, the mouths 6f the great arteries, or its vessels ; but the internal sur- face of its left cavities were of a bright red colour. No other morbid changes. In another example, where the patient was seized with pleurisy, and died, after having suffered for three weeks pain about the heart, dyspnoea, and palpitations, and where each contraction ol the ventricles Was to% 502 H^MATICA. [Cl. III.—Orp. II. [The obscurity in the diagnosis of pericar- ditis is still generally acknowledged. Dr. Ribes continues to assert, that it has no group of dis- tinguishing symptoms. Sometimes, their as- semblage would lead one to suspect an extrav- asation in the pericardium, and dissection afterward reveals only a partial pleurisy, with matter effused exclusively in the pleura.— (Andral, Clinique Midicale, tom. ii., p. 483.) Sometimes great dyspnoea, augmenting until death, with a regular pulse, and without pain, shall be the only sign of an affection of the per- icardium, with fluid effused in its cavity.—(Id., torn, iii., p. 438.) In another instance, where a tuberculated state of the lungs is ascertained, and yet the respiration is little oppressed, a se- vere dyspnoea suddenly comes on, and proves rapidly fatal; dissection disclosing a purulent collection in the pericardium.—(Ibid., Case fol- lowing that last cited; see Andral, tom. iii., obs. 9.) There has been no pain ; but aneu- rismal symptoms have occurred, which the post- obituary examination has not explained the cause of. Such is the influence of disease of the pericardium over the organ which it en- closes, that it has occasioned appearances of complaints which had no existence ; and the symptoms of chronic inflammation of the mem- brane may assume a form resembling that of organic disease of the heart. On other occa- sions, palpitations are the main effects, and the other local symptoms afford no information. In Andral's twelfth case, there was pain at the bottom of the sternum, and in the region of the heart; obscurity in the pulsations of this organ ; but strength and regularity in the pulse : dis- section showed a stratum of coagulating lymph in the pericardium. Several times in the course of the disease, the dyspncea and general anxi- ety subsided with the pain.* No modern pathologist has investigated the characteristic symptoms of pericarditis with greater discrimination-than M. Louis. The ca- ses which he witnessed and verified by dissec- tion show, that the symptoms most to be de- pended .upon aye, a more or less acute pain in the pracordia, taking place suddenly ; accom- panied with oppression and palpitations in a greater or less degree; irfegularily, or inter- missions of the pulse, sooner or later followed by an obscure, dull sound in the region of the heart on 'percussion, while the rest of the chest lowed by a dull, grating sound, Andral found no lesion, but a vivid red colour of the valves of the aorta, the texture of which was thickened. In certain cases of organic disease of the heart, where great redness of the whole of this organ, or parts of it, is found after death,*riot ascribable to putrefaction, and where the patients are suddenly seized with alarming symptoms, connected with exasperation of the disease of the heart, and die in the midst of these aggravated symptoms, Andral suspects that the catastrophe is referrible to the organic disease becoming complicated with acute inflam- mation.—See Clinique Medicale ; and Anat. Pa- thol., tom. ii., p. 279.—Ed. * F. Ribes, de PAnatomie Pathologique, con- sideree dans ses vrais Rapports avec la Science des Maladies, torn, i., p. 88, Paris, 1828. yields a clear resonation. When all these symp- toms are combined in a person previously well, the existence of pericarditis may be inferred. If the pain were absent, and the other symp- toms occurred, the diagnosis, according to M. Louis, would be hardly less clear ; for the only doubt would be between pericarditis and hydrops pericardii, and this last disease is formed less quickly, and without all the series of symptoms above detailed. In a chronic case, more diffi- culty would be experienced.* The anasarca and coldness of the lower ex- tremities, in cases recorded by M. Louis, ap- proximate them to other affections of the heart, and make an additional line of division between this disease and those of other organs.t] In carditis, adhesions have been occasionally found to a very considerable extent between the heart and pericardium, even where little incon- venience had been felt during life ; from which we may, at least, collect, that the extent of motion of these two parts on each other is not very great. A purulent kind of fluid has at times also been detected on the outer surface of the heart, without the slightest appearance of ulceration either of the heart or pericardium ; and, as the same sort of secretion has often been traced, without ulceration, in other cavi- * Dr. Latham mentions two cases, which were supposed to be marked inflammation of the brain; yet this organ was found, after death, perfectly sound in each example, and the heart affected with intense pericarditis.—(Med. Gaz., vol. iii., p. 209.) Andral relates a similar case.—(Clinique Med., tom. iii., p. 444.) Cases so anomalous as these Dr. Hope considers rare. The principal symptoms of pericarditis, enumerated by the latter physician, are, acute inflammatory fever; a pun- gent, burning, lancinating pain in the region of the heart, shooting to the left scapula, shoulder, and upper arm, but rarely descending below the elbow, or even quite to it. The pain is increased by full inspiration, and especially by pressure between the precordial ribs, and by forcing the epigas- trium upwards, underneath the left hypochon- drium ; inability of lying on the left side; dry cough; hurried respiration; palpitation of the heart, the impulse of which is sometimes violent, bounding, and regular, though its beats ,may be unequal in strength; at other times its action is feeble, fluttering, and irregular; pulse always frequent, and generally at first full, hard, jerking, and often with a thrill; dyspnoea; a constrained position, any deviation from which brings on a feeling of suffocation ; extreme anxiety ; constant jactitation, &c. As many of these symptoms at- tend other complaints, it must be confessed that they would leave the diagnosis obscure.—Ed. t P. C. Louis, Mem. Anat. Pathologique, p. 274, Paris, 1826. The observations on pericarditis in this work are highly important Dr. Elliotson, in describing a case of dilatation and attenuation of the ventricles, and disease of the aortic valves, as proved by dissection, mentions that the symp- toms were, universal dropsy ; difficulty of breath- ing ; loud action of the ventricles, and a bellows sound at the apex of the heart. These things, he says, frequently occur in persons under thirty, and they also generally occur in consequence of peri- carditis, and pericarditis as the result or attendar.t of rheumatism.—See Clin. Lect, Lancet, 1830-31. p, 488.—Ed, Gen. VII.—Spe. 9.] EMPRESMA CARDITIS. 503 ties, Mr. Hewson, as we have already seen, first suspected, and Mr. Hunter afterward en- deavoured to establish, that this fluid is nothing more than coagulable lymph thrown forth from the vasa vasorum, but changed in its nature in consequence of passing through vessels in a state of inflammatory action. And it was this discovery, and the hint thus founded upon it, that gave rise to the doctrine now so generally admitted, and apparently so well sustained, of a distinct secretion of pus, in many cases, without ulceration.* The causes of carditis are often obscure: where we can trace them, they are for the most part those of pneumonitis ; and the mode of treatment needs not essential vary. Dr. Frank gives an interesting case of violent carditis, brought on by terror in a prisoner condemned capitally. The inflammation proved fatal ; but, on dissection, was found not to be confined to the heart. [Inflammation of the heart appears to be a rare affection,! and, as Laennec remarks, it is * In the bodies of persons who died of pericar- ditis, Laennec frequently found the heart softened, and of a very pale colour, which he compared to that of a dead leaf. According to Andral, there is, in such cases, rather a flaccidity of the heart than a true softening of it.—(Anat PathoL, tom. ii., p. 300.) Dr. Elliotson has given some inter- esting particulars of an instance of pericarditis, joined with hypertrophy of the left ventricle. The svmptoms were, dyspnoea; violent and ex- tensive palpitation; beatings of the heart, 160 in a minute ; violent pain about this organ, darting to the clavicle and shoulder, and back to the scap- ula ; extreme tenderness on pressure over the heart. The impulse and sound of the heart's ac- tion were perceived very extensively over the chest. The sound, which was that of the bellows kind, occurred with the pulse at the wrist, when the heart struck the side. The pulse was often irregular, very small, and at times hardly distin- guishable ; a symptom alleged by Dr. Elliotson to be common in pericarditis. There was a great and extensive dulness of sound on percussion over the cardiac region, which did not arise in this case from effusion in the pericardium. There was also great cough without expectoration; the legs were anasarcous, and the belly dropsical. The patient was bled in the arm, cupped freely, and put under the influence of mercury. Some relief followed; yet the heart yielded the same sound, and the signs of hypertrophy, and dilatation, and obstruction, as before. As the patient was get- ting up to take some food, he suddenly expired. On dissection, hypertrophy and dilatation of the left ventricle, and -universal adhesions of the peri- cardium to the heart were noticed, some of which were ancient, others recent. The neighbouring pleura had suffered, and bands were seen between the lungs and pericardium, and lungs and cos- tal pleura.—See Clinical Lectures, in Lancet for 1830-31, p. 427.—Ed. t The redness of the substance or lining of the heart, frequently observed in the dissection of bod- ies more than twenty-four or thirty hours after death, in warm or damp weather, is not an indica- tion of carditis, but merely a change that has fol- lowed dissolution.—(See Andral, Anat. Pathol., tom. ii., p. 276.) In animals poisoned by the oxy- mtrriate of mercury, the lining of the heart is studded with red spots.—Ed. consequently very imperfectly known, both in a practical and pathological view. Our author enu- merates merely some of the symptoms of pneu- monitis, or pleurisy, joined with palpitation, ir- regularity of" pulse, and tendency to fainting. Yet these characters can hardly be received as pathognomonic; because, as Senac observes, (Traiti du Cctur, tom. ii., ch. vii.), they are ex- tremely uncertain ; and, with respect to palpi- tation, although its presence may lead us to suspect that the heart is affected, yet it is prob- ably only a hypothetical opinion, since, in that inflammation which arises from wounds of the heart, palpitation does not occur. What Corvisart describes as inflammation of the heart, seems to Laennec to have been in real- ity pericarditis, conjoined with a paleness, and sometimes also with softness of the substance of the heart.—(Laennec, Op. cit., p. 621.) In- deed, as Dr. J. Forbes remarks, carditis, properly so called, has been almost universally confounded with pericarditis. He has never seen an une- quivocal case of inflammation of the muscular substance of the heart, Yet he has no doubt of its occasional existence, from the statements of Dr. Baillie, and from uloers and abscesses having been met with in that substance.* There seems sometimes to be an increase in the action of the vessels of the heart, which, though short of inflammation, is sufficient to give thickness to its walls, and considerable magnitude to its general substance : and hence, a frequent origin of enlargement of the heart M. Bayle has published an interesting case, which appears to belong to this kind of morbid struc- ture. The patient was a young man of delicate constitution and limited intellect. He was at- tacked in 1819 with mental derangement; and, in a few months afterward, seemed to labour under a general oppression in every organ, un- der which he died in a few days. The mem- branes of the brain were infiltrated and thick- ened ; the heart was twice and a half its natural size ; the aorta and pulmonary artery, as well as various other vessels, gave evident proof of a direct inflammatory action.—(Obs. d'Artirite, Bibliotheque Midicale, Sept., 1821.) There is often a slow or chronic inflammation subsisting in a portion of the heart, which does not betray itself by any peculiar symptom ; for abscesses in the substance of the ventricles, and ulcers on the external surface, are occa- sionally found after death, without any symp- * Of universal carditis, with effusion of pus generally throughout the muscular tissue, Dr. Hope believes (Cyclop, of Pract. Med., art. Peri- carditis), that there is not more than a single in- stance on record, and that occurred to Dr. La- tham. " The whole heart," says Dr. L., " was deeply tinged with dark-coloured blood, and its substance softened; and here and there, upon the section of both ventricles, innumerable small point6 of pus oozed from among the muscular fibres. This was the result of a most rapid and acute inflammation, in which death took place after an illness of only two days."—Med. Gaz., vol. iii., p. 118. Portal and Chicoyneau are alleged, how- ever, in the text (see p. 501), to have seen proofs of suppuration and gangrene of the heart—Ed. 504 HJ2MATICA. [Cl. III.—Ord. It toms of previous inflammation.—(Morgagni, epist. xxv., art. xvii. ; Bonet, tom. i., p. 849.) SPECIES X. EMPRESMA PERITONITIS. INFLAMMA TION OF THE PERITO- NEUM. pain and tenderness of the abdomen, espe- cially on pressure, or in an erect pos- ture ; with little affection of the sub- jacent viscera, or abdominal walls.* The inflammation may be seated in the peri- toneal membrane lining the cavity of the abdo- men, or in its extension to the mesentery or omentum. And hence Dr. Cullen has noticed the three first following varieties, [to which modern experience has added a fourth] :—- a Propria. The inflammation taking the Proper inflamma- general range of the per- tion of the peri- itoneum ; pain extreme, toneum. often pungent, with little or no relief from stools. 0 Omentalis. With a more sensible swel- Inflammation of ling in the region of the the omentum. omentum. y Mesenterica. Pain more deeply seated, Mesenteric in- and more immediately in flammation. the mesenteric region: external tenderness less than in the preceding va- rieties.' Chronica. Progress slow and insidi- Chronic perito- ous ; pulse accelerated ; nitis. little or no tension of the abdomen; sense of prick- ing, or slight tenderness in the belly ; bowels gen- erally costive, sometimes loose. * " Pain, tumefaction, and tenderness of the abdomen on pressure, are the most prominent symptoms which characterize this affection du- ring life ; and increased vascularity, thickening, ef- fusions of coagulable lymph, of serum, of pus, or blood, are the principal local effects produced by it. These elementary features, accompanied in general with more or less of pyrexia, will exist in different degrees and combinations, in every va- riety of age, sex, or constitution; modified, how- ever, by circumstances, derived partly from the nature of the cause, and partly from the condition of the patient at the time of the attack. Perito- nitis may assume either the acute or chronic form. It may exist as a sporadic disease, or prevail as an epidemic. It either presents itself openly, with a numerous group of well-marked symptoms, or creeps on in a latent state, with scarcely one of its characteristic features. It may be limited in its extent to a small portion of membrane, or spread over a large surface. It may run its course un- combihed with any other affection, or be compli- cated with various diseases. There is no period of life exempt from its attacks, &c : pursuing the same course, and exhibiting similar effects in all, it yet presents a vast variety of symptoms in in- dividual cases, principally according to the organ whose peritoneal covering is the chief seat of the inflammation."—Dr. MacAdam, in Cyclop, of Pract. Med., art. Peritonitis.—Ed. It is singular that Dr. Cullen, after distinctly characterizing this species in his Nosology, and following it up into three subdivisions, each of which, with him, forms a separate species, as the general disease does a genus, should take no other notice of the entire complaint in any form, except what is expressed in the following laconic remark :—" Among the inflammations of the abdominal region, I have given a place in our Nosology to the peritonitis ; comprehending under that title, not only the inflammations af- fecting the peritoneum lining the cavity of the abdomen, but also those affecting the extensions of this membrane in the omentum and mesen- tery. It is not, however, proposed to treat of them here, because it is very difficult to say by what symptoms they are always to be known ; and further, because when known, they do not require any remedies besides those of inflammation in general." This remark is by far too sweeping. If the diseases referred to have no specific symptoms by which they can be known, they have no more claim to be admitted into a system of symptomatic nosology, than into a treatise of practice. Dr. Cullen is right in assigning them a place in the former; and he is, therefore, ne- cessarily wrong, in banishing them from the lat- ter ; and the more so, as the treatment ought, in some degree, to vary from that of enteritis, to which his general observation seems chiefly to refer. The true peritonitis occurs, as we have al- ready observed, as a symptom in puerperal fever ;* and, as we have treated of it at some length under that disease, it is the less neces- sary to be minute in our account at present. Puerperal fever, indeed, is sometimes, though not quite correctly, made a variety of perito- nitis ; for it is a disease of a peculiar kind, pro- duced by peculiar causes, and is only connected with peritonitis as ihe latter enters as a symp- tom into its general character, and may hence take the name of puerperal peritonitis, to dis- tinguish it from idiopathic. [Acute peritonitis generally begins with chills and shiverings, though these are occasionally slight, and sometimes not at all observable. The pulse becomes quick and frequent; the urine is scanty and high-coloured; there is considerable thirst; and the general affection, called fever, ensues. These symptoms are at- tended from the very beginning with a sense of heat and pain in the abdomen ; at first, gener- ally confined to one'part, though sometimes more diffused. This pain is much increased by pres- sure ;+ or, in other words, there is a great ten- derness or soreness of the belly ; but it is not * From what is stated in the notes upon puer- peral fever, the reader will see that peritonitis is not a constant or an essential part of the disorder.—Ed. t In order to judge whether the tenderness de- pends upon a real increase of sensibility, the hand should be laid flat on the centre of the abdomen, and then pressed successively on every part of it. Care should be taken not to make pressure with the ends of the fingers; for thus pain may be ex« cited where there is no disease.—Martinet's Pa- thology, by Quain, 3d ed., p, 68. Gen. VII.—Spe. 10.] EMPRESMA PERITONITIS. 505 accompanied by any inclination to go to stool. The pulse is at least 100 in a minute, and small; yet the tongue is not much altered at first from its natural appearance. In the course of twenty-four hours, however, the pain and tenderness on pressure increase, so that sometimes even the weight of the bed- clothes becomes intolerable, and the pulse rises to 120 or 130 in a minute. At this time, the tongue begins to be covered with a cream- coloured mucus, and, though it is moist, there is great thirst. A considerable degree of tension and swelling*now takes place over the whole ab- domen, and the patient finds most relief from pain by remaining motionless upon the back, with the knees in a small degree elevated. Along with these symptoms, you will frequently notice sin- gultus, nausea, and vomiting; at first, of the ordinary contents of the stomach, and afterward of bile ; though such gastric disturbance is still more characteristic of enteritis, and may not al- ways accompany simple peritoneal inflammation. ■The tension of the belly continues to increase to the sixth, seventh, or eighth day ; on one of which days, unless proper measures have been taken to remove the disease, the patient most commonly expires. Previously to death, the pain often suddenly ceases, and the change may be mistaken for amendment; but, if the symp- toms be minutely examined, the pulse will be found to be sinking and increasing in rapidity ; the patient's strength is also sensibly diminish- ed, the countenance collapses, cold clammy sweats break out, the extremities lose their warmth, and, at length, a laborious respiration manifests the concluding struggle of life. A favourable prognosis, however, is to be de- duced from a gradual cessation of the pain, especially when it is accompanied by a diminu- tion of tension and soreness, and when, at the same time, the pulse becomes fuller and less frequent, the skin less parched, soft, and moist, the respiration less laborious, and the counte- nance more open and expressive of ease. Inflammation of the peritoneum may be dis- tinguished from colic by the permanency of the pain and the frequency of the pulse, as well as by the tenderness on pressure, even before any tension of the abdomen has taken place ; and by the absence of any inclination to go to stool, when the pain is severe.* It is not so easily distinguished from inflammation of the bowels, or enteritis. In this latter disease, however, there is obstinate constipation, and frequently vomiting ; while the pain is more acute, and not so much aggravated by external pressure.-—(See Bate- man's art. Peritonitis in Rees's Cyclopadia.)] In the specific definition it is stated, that peritonitis occurs " with little affection of the subjacent viscera or abdominal walls." In ef- fect, it often happens that these are not at all influenced, and, whenever they are, it is only secondarily; and hereby peritonitis is suffi- * " Colic may be distinguished from peritonitis by the absence of fever; the pain being relieved by pressure; the state of the pulse; and the sud- denness of the attack."—Dr. MacAdam, op. cit. —Ed. ciently distinguished from puerperal fever. " If the peritoneum," says Mr. Hunter (On Blood, &c, p, 244), " which lines the cavity of the ab- domen, inflames, its inflammation does not affect the parietes of the abdomen ; or if the perito- neum covering any of the viscera is inflamed, it does not affect the viscera. Thus, the peri- toneum shall be universally inflamed, as in the puerperal fever, yet the parietes of the abdomen, and the proper coats of the intes tines, shall not be affected : on the other hand, if the parietes of the abdomen, or the proper coats ofthe intestines are inflamed, the peritoneum shall not be affected." [The researches of Bichat into the tissues of which the various organs consist, confirm Mr. Hunter's opinion, that inflammation of the peri- toneum may exist alone, and independent of the subjacent parts. In fact, the organs are com- posed of several tissues of different natures and structure, and their affections also differ according as this or that tissue happens to be primarily attacked; and the disorder never fixes on all the three coats of the stomach and bowels at once, but first begins in one of them. When the affection is acute, only a single tissue is generally found altered, the others continu- ing unchanged. Frequently, when the perito- neal covering of an intestine is acutely inflamed, the mucous membrane is remarkably pale.— (MacAdam in Cyclop, of Pract. Med., art. Peri- tonitis.) Not only may the peritoneum be inflamed without the subjacent organs being similarly circumstanced, but such inflammation actually has no essential dependance upon or connexion with those organs. Hence the view sometimes adopted, of gastritis, enteritis,"cystitis, &c, be- ing an inflammation seated exclusively in differ- ent portions of the serous membrane connected with the stomach, bowels, and bladder, is errone- ous, inasmuch as it is supposed that the cases depend upon the corresponding organs. Inflam- mation of the serous abdominal membrane is never exactly restricted to a single viscus, the surrounding portion of the membrane continu- ing healthy, but is propagated over a greater or less extent of the peritoneum.—(See Bichat, Anat. Generate; Legons d'Anat. Pathol, et Diet. des Sciences Mid., art. Peritonite.) Numerous dissections of persons destroyed by peritonitis prove, that the whole or only a part of the peritoneum may be inflamed, with- out the subjacent organs being concerned. In many instances, the muscular and mucous tis- sues of the stomach and intestines were found unaffected, even when gangrene had beo-un to show itself in the peritoneum. In general, the marks of inflammation are stronger, in propor- tion as the disorder is more advanced and vio- lent. Sometimes the membrane seems as if it were very minutely injected; while in other cases, as Bichat remarks, the redness is hardly discernible, the blood having escaped by the col- lateral vessels. Bayle, Broussais, and others, have seen as consequences of acute peritonitis :—1. Redness, thickening of the serous membrane, and here and there sloughs penetrating into the mucous coat. 506 H^MATICA. [Cl. III.—Ord. II. 2. A solid exudation of unorganized coagulating lymph, in the form of false membranes, uniting the surfaces of the peritoneum. 3. A fluid ef- fusion, sometimes turbid, sometimes limpid or reddish. More or less of a sero-purulent fluid was almost always remarked on the surface of the intestines in various places. Broussais also noticed red coagula on the reddened and thick- ened peritoneum, unaccompanied with any fluid blood ; masses of fibrin, destitute of the colour- ing particles of the blood ; and, lastly, pure blood itself, when the effusion was considerable. Gan- grene is a much rarer termination, and, accord- ing to Dr. Abercrombie, slight and partial, and al- ways accompanied by a deposition of false mem- brane. It more frequently occurs, when enteritis coexists with inflammation of the peritoneum. Most examples of peritonitis terminating fa- vourably, leave after them organized adhesions. In general, little gas is found in the bowels; and it is not to it, therefore, that the great dis- tension of the abdomen, remarked before death, can be ascribed.* One remarkable effect of inflammation of the pertioneum is, to lessen its transparency, and render it even quite opaque.] From what has been said, it appears that the membranous tunics of the different viscera do not, therefore, always hold an equal intimacy of ac- tion. And it would be interesting to follow up the discrepance, and draw a scale of their readi- ness, or inaptitude, to sympathize with the vis- cera which they cover. The membranes of the brain, as we have already seen, are so peculiarly disposed to partake of the inflammatory action of the parenchyma, as to render solitary inflamma- tion of the one or of the other a rare occurrence. In the lungs and in the heart, the play of rela- tionship is far less conspicuous, and in the vis- cera of the abdomen it rarely takes place. And it is owing to this circumstance, that we are able so generally to draw the line between in- flammation of the peritoneum and of the intes- tines, from the pain being much more superfi- cial in the former than in the latter case, and, in many instances, not accompanied with sick- ness, or any other disturbance of the alvine ca- nal. Portal is too little disposed to admit this distinction, and seems to think that idiopathic inflammation of the peritoneum is by no means a common disease, and that, when it does exist, its manifestation is far from being clear.t But this is to render a general rule universal, and to * Tension and tumefaction of the abdomen are constant and characteristic symptoms of peritonitis. According to Dr. MacAdam, they do arise in the early stages from a tympanitic distention of the intestines, though at a later period of the affection, they may be caused by effusion in the peritoneal eavity. In individuals with strong abdominal mus- cles, the swelling is not very manifest in the early period of the disorder, though the hardness is con- siderable.—Cyclop, of Pract. Med., art. Peritoni- tis ; Chomel, Diet de Med.—Ed. » t Mem. sur la Nature et le Traitement de plu- sieurs Maladies, torn, iv., 8vo., Paris, 1819. The most important diagnostic symptom between per- itonitis and enteritis is, the sensibility of the ab- domen to pressure. In peritonitis, pain is excited by a very slight degree of pressure, which would sweep away from it the exceptions that chiefly establish its proof. The causes are those of inflammation in gen- eral, as cold, residence in damp situations, the abuse of intoxicating liquors, external injuries, ulceration and rupture of some portion of the alimentary canal, and consequent extravasation of the contents of the stomach or bowels,* and a morbid transfer of action ; and, in a few cases, sympathy with the adjoining organs, as in puer- peral fever. [Peritonitis is alleged to be more common in adults than children; in women than in men ; and in sanguine and plethoric in- dividuals than in others, t] The treatment is, in like manner, that of in- flammation in general, particularly that of e. enteritis. Bleeding, both general and local, should be carried into effect copiously and with all possible speed ; [nor should the practitioner be deterred from the use of the lancet by the seeming prostration of strength and feebleness of the pulse, which are not uncommon symp- toms at the very onset of the disease, especially when the peritoneum of the stomach and bowels participates in the inflammation. Under such circumstances, bleeding will be followed by a rise in the pulse, diminution of the general weakness, and subsidence of pain.—(See Pem- berton on Diseases of the Abdominal Viscera, chap, i.)] But purging, though at all times of service in inflammatory affections, is less impe- riously demanded than in inflammation of the intestines, except where the peritonitis is puer- peral, and the system affected generally ; in which case we have already observed, that cal- omel should be given liberally at the com- mencement of the complaint. [It should be understood, however, that the bowels should always be kept open, and that this should be effected with as little irritation as possible. In ordinary cases, castor-oil, small doses of sul- phate of magnesia, and emollient clysters, are produce little or no inconvenience in enteritis. The action of the diaphragm in full inspiration, or coughing, does not produce so much suffering in enteritis; neither does motion of the body or ab- dominal muscles.—Dr. MacAdam, op. cit.—Ed. * See Abercrombie on Pathology of the Stom- ach, &c, Edin. Med. Journ., No. Ixxviii.; Dr. Crampton and B. Travers in Med.-Chir. Trans., vol. viii.; Lewis in Archives Gen. de Med., Jan., 1823 ; also, Dr. Stokes in Cyclop, of Pract. Med., art. Peritonitis, from Perforation ofthe Serous Membrane. t Dr. MacAdam in Cyclop, of Pract. Med. This intelligent physician arranges the causes into the mechanical, the chymical, and the vital. The mechanical causes include all injuries inflicted on the abdomen, by falls, blows, wounds, pressure of the gravid uterus, enlarged ovaries, or other mor- bid growths, extra-uterine conceptions, &c The chymical causes include all extravasations into the peritoneal cavity, not quickly absorbed, whether of blood, urine, bile, chyle, or feces. The vital causes comprehend all aberrations of healthy ac- tions, transmission of morbid action from a part previously affected to the peritoneum, or exten- sion of inflammation from a contiguous organ or tissue to this membrane. This arrangement seems judicious and well founded.—Ed. Gen. VII.—Spe. 10.] EMPRESMA PERITONITIS. 507 the most proper means for this purpose.*] Warm stimulant fomentations may be advantageously applied to the abdomen, and blisters in succes- sion. [The application of a blister should be deferred till the constitutional effects, produced by the inflammation, are partly removed by bleeding.] After a very free use of leeches, I have found more benefit in applying a large folded flannel wrung out in simple hot water, or water impregnated with aromatic herbs, over the whole of the abdomen, and letting it remain there for many hours or till dry, wrapped over with a broad calico or flannel swathe that sur- rounds the entire body. All we can possibly aim at, in applications of this kind, is a continu- ation of moist warmth, as in a common poultice ; and this is obtained more easily, and with infi- nitely less fatigue to the patient or danger of giving him cold, than in the ordinary way of applying fomentations. When the bowels have been well opened, opiates may be given with freedom, and especially in union with ipecacu- anha, or antimonials, to determine to the surface. When the inflammation commences or is seated in the omentum or epiploon, the pain is more limited, and points rather towards the superior and middle region of the abdomen, a little above and below the navel; though it sometimes inclines to the right or left hypo- chondrium. The peritoneum itself does not readily pass into a secretion of genuine pus ; and still less so the omentum, which, where ulcera- tion takes place, generally evinces a foul and sanious secretion. Sauvages gives a striking example of this in a woman, who was at first attacked with an acute lancinating pain in the umbilical region; and had a tumour formed to- wards the right hypochondrium about the size of a man's fist, which by degrees occupied the whole abdomen. By an application of emollient cataplasms, the pain and general swelling were diminished in the course of three days ; but a fluctuation in the abdomen was next detected, like that of an ascites ; in consequence of which, a trocar was introduced into both sides of the abdomen, and a putrid ichorous fluid was dis- charged, which induced the operator to enlarge the opening ; when sloughs of the omentum, al- ready separated,- came away with an intolera- ble stench, and with about two pounds of what Sauvages calls ichorous water. But the skill of the surgeon was overpowered by the disease, and the patient fell a victim to it.—(Nosol. Med., Class III., Ord. III., XVI.) The mesentery has but a small degree of sen- * Many judicious practitioners are not afraid, however, of prescribing calomel very freely in peri- tonitis. Thus, Dr. Mac Adam recommends giving from five to ten grains of calomel, joined with one or two of opium, directly after the local bleeding; and this dose to be followed up by smaller ones every three or four hours. After the second or third dose of calomel, the bowels are to be opened with castor-oil and clysters. If vomiting be ur- gent, Rochelle salts, with the supercarbonate of soda, in a state of effervescence with lemon juice, may be given in repeated doses so as to produce a moderately laxative effect.—Dr. Mac Adam in Cyclop, of Pract. Med., art. Peritonitis.—Ed. sibility, and hence, as well as from the greater depth of the seat of the disease, mesenteric inflammation is only discoverable by pressure. If the affection be strictly mesenteric, the symp- toms are mild and gentle; but this is a rare case, and chiefly occurs when the glands are obstructed, and any accidental irritation is ap- plied to them. Most commonly it is catenated with inflammation of the spleen, liver, or intes- tines. The chief point of tenderness or presr sure is the navel; though, in the commence- ment of the disease, the pain seems to shoot upward from the back ; the bowels are often obstinately confined.—(J. P. Frank, op. cit., tom. ii., p. 188.) The medical treatment will be the same as in hepatitis or splenitis : though bleeding, in general, effects but little benefit. [It is to Dr. Pemberton, M. Broussais, and Dr. Gregory, that the profession is indebted for the best descriptions of chronic peritonitis. The disease advances very slowly and insidiously, manifesting itself only by occasional superficial pricking pains over the abdomen, without the patient feeling any inclination to go to stool ; or, as Broussais says, by a sort of constant sen- sibility in the abdomen, often not distinguisha- ble but by the touch. The pulse is somewhat accelerated, with considerable thirst, white tongue in the morning, and a pallid, doughy countenance. There is no tension of the abdo- men, as in the acute species ; on the contrary, the skin and abdominal muscles seem to sit loosely upon the peritoneum, which feels like a tight bandage underneath them ; or, as Brous- sais states, the abdomen is slightly swelled and elastic, which symptom increases towards the evening. The appetite and digestion often re- main undisturbed ; but, in other instances, there are vomitings, which Broussais suspected to happen chiefly when the peritoneal coat of the stomach was affected. The same writer also speaks of the feeling of a ball moving about in the belly, and tending towards the throat; re- ferred by him to the mass formed by the agglu- tination of the bowels and thickened mesentery, moveable in the effused fluid. In time, the bowels become agglutinated to- gether, or fluid is effused, so as to produce dropsy. The symptoms are all equivocal, and not one of them pathognomonic. The disease is sometimes the result of protracted acute peri- tonitis. Old age; a delicate, feeble constitu- tion ; occupations confining the abdomen in an habitual state of compression ; unhealthy, damp, cold stations, and the rigour of intermittent fe- ver, according to Broussais, are among the chief causes of chronic peritonitis. By Broussais, chronic inflammation of the peritoneum is regarded as inevitably fatal. The treatment, therefore, in his view, can only be palliative. When any degree of active perito- nitis is suspected to prevail, he recommends antiphlogistic remedies, and moderate stimula- tion of the skin. But when there is no pain, and the symptoms are less marked, he recom- mends blisters, sudorifics, and the tincture of squills and cantharides, with a nourishing diet, 508 H.EMATICA. [Cl. III.—Ord. IL Emetics and purgatives he considers useful only when some incidental complication calls for them. On the other hand, Dr. Pemberton's treat- ment consists in the prohibition of animal food and fermented liquors, and keeping the patient strictly on milk and vegetable diet, with small bleedings once or twice a week, generally by leeches or cupping. The bowels are to be kept open with small doses of sulphate of magne- sia or castor-oil. Dr. Pemberton differs from Broussais in not regarding chronic peritonitis as totally incapable of cure.*] SPECIES XI. EMPRESMA GASTRITIS. INFLAMMATION OF THE STOMACHA burning pain at the pit of the stomach, increased on swallowing ; rejection of every thing; hiccough; emaciation; op- pression AND DEJECTION OF MIND ; FEVER A SYNOCHUS. If to this species we add the ensuing, or empresma enteritis, we shall have a general type of fever, according to the doctrine of M. * Children of a scrofulous habit are subject to one variety of chronic peritonitis, characterized during life by great tenderness of the abdomen on pressure, with occasional paroxysms of acute Cain, at first coming on only once or twice a day, ut afterward becoming more frequent, after which the child appears quite lively, and free from indisposition. At first the pain is limited, but af- terward extends over the whole abdomen, which, in the early stages, becomes swollen and tense, but afterward subsides. The pulse is generally about 100, with some strength and fulness ; the tongue clean; appetite irregular, but generally good, and frequently voracious ; some thirst; the bowels free, the evacuations unusually large in quantity, and peculiar in appearance, consisting generally of a whitish-brown matter. This state may continue for six weeks or two months, with progressive emaciation, until diarrhoea, attended with petechiae, puts a period to the child's life. Disseetion exhibits the mesentery, bowels, and peritoneum, united together into one mass; the peritoneum thickened, and containing large masses of scrofulous matter; the intestinal mu- cous membrane perforated by ulcerations, which form numerous communications between the con- volutions of the bowels; and the intestines and abdominal cavity containing matter resembling that which was passed during life by stool. The disease is generally fatal. The treatment recom- mended by Dr. Gregory consists of leeches and fomentations in the early stage, followed by purga- tives, mercurial alteratives, tonics, chalybeates, and absorbents. Laudanum is the only means of relieving the pain.—See Gregory on Scrofulous Inflammation of the Peritoneum, in Med. Chir. Trans., vol. xi., p. 262; and Dr. MacAdam in Cyclop, of Pract Med., art Peritonitis.—Ed. t Gastritis, a term commonly used to express an inflammation of all the tunics of the stomach, with the exception of its serous covering; but, says Dr. Stokes, as it is now generally believed that this diseased action commences in the mu- cous membrane and glands, the term is employed to designate an inflammation of the internal tunic, which may or may not affect the remaining tis- sues.—See Cyclop, of Pract. Med., art, Gastri- tis.—Ed. Broussais, and that which is commonly re- ceived in the present day throughout France: for we have already observed, that this cele- brated teacher regards fevers of all kinds as an inflammatory affection of some part or other of the alimentary canal; or, to give a close copy of his own words, " all the essential fevers of authors," says he, " may be referred to gastro- enteritis, simple or complicated; and all the acute examples of this inflammation, in its ag- gravated form, proceed to stupor, typhomania (fuligo), lividity, fetidity, and prostration ; and represent what have been called typhus, putrid or adynamic fever, or those in which the irrita- tion of the brain is considerable, whether it amount to inflammation or not, whether it pro- duce delirium, convulsions, ccc, or take the name of malignant, nervous, or ataxic fevers." —(Examen des Doc. Med., &c, Par. J. F. V. Broussais, Prof, de Mid., cxxxviii., cxxxix., translated by Hays and Griffith, Phila., 1833.) Having already entered into the question, whether fever be essentially dependant upon inflammation of any particular organ, as the head, the alimentary canal, the liver, or the pancreas, for all have had their respective advo- cates, and having pointed out the pathogno- monic distinctions between idiopathic fever and organic inflammations, it is not necessary to return to any detailed consideration of this sub- ject. But we ought to add, that there seems more foundation for M. Broussais' opinion in France, than perhaps in any other country ; since inflammatory affections of the alimentary canal, in some part or other of its length, or under some modification or other, often indeed accompanied with ulceration, appear to be more common in Paris than in any other town or re- gion in Europe, or perhaps in the world. To what cause this is owing has not been very clearly pointed out ; the diet is perhaps chiefly concerned ; the water has also been denounced ; but there are various auxiliaries which are not so easily detected. The fact, however, admits of no question : for the observations of MM. Prost, Petit, Serres, and others, concur in proving that by far the greater number of febrile attacks in France, whether sporadic or epidemic, are combined with some modification of gastritis or enteritis, and. very generally show symptoms of diarrhoea and dysentery. But that, even in Paris itself, idiopathic fever and inflammation of the ali- mentary canal are distinct diseases, has been sufficiently established of late by the valuable post-obit examinations of M. Andral ; which have been conducted upon a very extensive scale for the express purpose of settling this disputed question. This excellent and inde- fatigable investigator was selected by M. Ler- minier, physician to the hospital of La Charite, for the purpose of providing cases and dissec- tions for a valuable system of Clinical Medi- cine, that has now been in part published. In pursuit of this branch of study, he has been particularly attentive to the state of the ali- mentary canal through its whole course in pa- tients who have died of fevers of almost every Gbn. VII.—Spe. 11.] EMPRESMA GASTRITIS. 509 type and modification ; and he has found, that although, as already observed, this organ, in some part or other, has often given proof of inflammatory action, yet that, occasionally, there has been no such effect whatever, and very frequently none sufficiently violent or ex- tensive to become the cause of dissolution, or even of any serious evil to the living frame.. In thirty-eight individuals, eleven only presented traees of gastric inflammation sufficiently dis- tinct to warrant the opinion, that they had in- fluenced the symptoms observed during life. In thirty persons, red patches, eruptions, or ulcers were found in the small intestine ; but in fourteen only did these lesions appear to bear any proportion to the severity of the symptoms. In the great intestine the alterations were more rare, and less vehement, than in any other por- tion of the canal. On comparing the lesions observed in the three great divisions of the canal, the following results were obtained :—In five patients, the entire tube was exempt from every lesion of consequence. In seven others, they appeared too inconsiderable to exercise any influence on the state of the disease. And where the affec- tion was more strictly and manifestly inflamma- tory, the effects were extremely diversified. In some cases were found eruptions of varied form and character, occasionally running into ulcera- tion. In other cases, the mucous membrane was studded with large patches of inflamma- tion, and the subjacent cellular tissue was ad- vancing to a gangrenous state. In several in- stances, the ulcers were detached, and assumed a carbuncular appearance.—(Andral, Clinique Midicale, tom. i., Paris, 8vo., 1823.) In most of these examples, there can be no question of the existence of idiopathic gastritis or enteritis : but the simple fact of the existence of numerous instances of fever, and fever too so violent as to prove fatal, without any such accompaniments, together with the certainty that inflammation and even gangrene of particu- lar parts ofthe alimentary canal are, in numerous instances, effects instead of causes of fever, are a sufficient ground for regarding fever and in- flammation either of this or any other kind as distinct diseases,.and prove a complete subver- sion of Broussais' hypothesis. Inflammation of the stomach may be either of the adhesive or the erythematic character; the latter is the more common (J. P. Frank, De Cur. Horn. Morb. Epit., tom. ii., p. 250) ; and the species hence offers us two varieties, with considerably different symptoms ; which are chiefly, indeed, the result of the peculiar na- ture of the fever that accompanies this inflamma- tion, already stated to be a synochus, or fever commencing with caumatic, but terminating in typhous symptoms. For this kind of fever it is not difficult to account We have often had occasion to state, that the stomach is the com- mon centre of sympathy ; it is also an organ of acute sensibility ; and it is hence impossible for it to suffer from inflammatory action without suffering severely, and without extending jts effects very widely. a Adhaesiva. The pain very acute; the Adhesive inflam- fever violent. mation of the stomach. 0 Erythematica. With an erythematous blush, Erythematic in- extending to and visible flammation of in the fauces ; pain more the stomach. moderate ; fever less vio- lent ; pulse low and quick. Dr. Cullen seems to have been the first wri- ter that distinctly pointed out the nature of these two varieties, which he has unnecessarily ad- vanced to the rank of species, and later writers have justified the expediency of a distinction. This distinction, as already remarked, is pro- duced by the nature of the accompanying fever ; and, consequently, in a considerable de- gree, by the nature of the constitution in which the disease occurs. The fever is perhaps in every instance a synochus, the cause of which we have just stated ; but, while in a firm and robust habit the febrile course has, compara- tively, but little tendency to pass from the en- tonic action with which it commences into a dangerous languor and atony, in relaxed and irritable habits it is apt to run into this stage * almost from the first, and the synochus degen- erates rapidly into a typhoid character. In both varieties the causes are alike ; as ex- ternal or internal cold suddenly applied in a heated state of the stomach, acrid substances, or excess in eating. The acrid substances chiefly recorded are jalap, and other drastic purgatives taken in excess; sulphuric acid; corrosive sublimate ; and very large doses of nitre, or quantities swallowed by mistake, as an ounce, or an ounce and a half, of both which we have, an example in the Journal de Mede- cine.—(Laflize, tom. lxxi.; Souville, torn, lxxiii.) It is also said to have sometimes been pro- duced by a severe paroxysm of chololithus (Call- schmied, Pr. de Mgro inflamm. ventr. demortuo calc, &c, Jen., 1757); and occasionally to have followed trichosis Plica, the matted hair of Poland.—(De la Fontaine, Chirurg. Mid.) A sudden chill, from swallowing cold water or some other fluid when the body is heated, is a frequent cause : as is also repelled gout, indi- gestible food, and especially ardent spirits drunk profusely. The symptoms are sufficiently detailed in the specific definition. , Several of them are those of cardialgia ; but, in the latter, there is neither fever nor vomiting. The most decisive signs are a permanent local pain, and general emacia- tion ; and these, as M. Chardel has justly ob- served (Monog. des Degen. schirr. de t'Estomac, 8vo., Paris, 1808), increase with the prolonga- tion of the disease, till both become extreme, and even opium will scarcely relieve the former, in whatever quantity administered.* In a few cases, the food is not rejected for several days ; and as the bowels are constipated, and the di- gestion is imperfect, it remains in the stomach, * General emaciation can only be expected in cases which are chronic, and of longer duration than the acute form of gastritis.—Ed 510 H.EM and forms a tumour sensible to the pressure of the hand, which, upon rejection, disappears. The presence of this tumour is peculiarly char- acteristic of an inflamed state of the pylorus, as its absence is of the same state of the cardia; for, in this last case, the contraction of the cardia renders deglutition extremely difficult, and the food is for the most part rejected with- out reaching the stomach.* From the close sympathy of the stomach with other organs, the disease has sometimes been accompanied with delirium, and in a few instances with hydrophobia. Where the^inflammation is violent, it destroys in a few days. If no fatal symptom occur within the first week, it terminates for the most part favourably. Shiverings and a remission of pain are, as usual, marks of suppuration.! Of the adhesive variety Mr. Cruickshank has given a good illustration in the case of a young lady who died after two or three days1 illness, before which she had been in perfect health. " I was called in," says he, " but she was dead before I got to the house. From her history I was at a loss to account for her death ; but on opening the abdomen a day or two after, I found the contents of the stomach in that cavity; that they had produced peritoneal in- flammation, and killed. On examining the stom- ach, I found a hole in it large enough to admit the end of my finger. This hole had been formed by absorption of part of the substance of the stomach from scrofulous ulceration : its edges had adhered by inflammation to the under surface * Dr. Good does not seem to have been aware, that jnflamed muscular fibres are not so much dis- posed to contract as when they are healthy. This fact, which was distinctly mentioned by Desault, is confirmed by later observations. However, the disease called gastritis is seated chiefly in the mucous membrane, and is extremely rare in the acute and idiopathic form.—(See Abercrombie's Pathol, and Pract, Obs. on Diseases of the Stom- ach, &c, i., p. 13, edit. 2.) This physician con- fesses that he has never seen a case of this nature (p. 15). Dr. Stokes also says, inflammation of the stomach in its highest degree is rarely met with, except in cases of corrosive poisoning. From such examples he infers, that the symptoms would be " intolerable thirst, constant nausea and vomiting, precordial distress, sunk countenance, extraordi- nary prostration, fever."—(Cyclop, of Pract. Med.) It is conceivable, however, that the action of a corrosive poison on the stomach might lead to other consequences than those of simple inflammation : the local effects would be more rapid, more cer- tainly fatal, and the immediate effects on the sys- tem different.—Ed. f It seems as if the general symptoms, as well as the effects of the inflammation on the stomach itself, were liable to variety. In a case recorded by Mr. Annesley, in his work on the Diseases of India, the early symptoms were acute pain in the stomach, increased by pressure, with slight fever, and no vomiting. On the fourth day vomiting began, and the patient died on the seventh. The coats of the stomach were found thickened, and its in- ternal surface minutely injected. And, in another instance related by the same gentleman, and which was fatal in seven days, the symptoms were, in- cessant vomiting and hiccough, with fever of a tertian type, but no complaint of pain. The mu- cous coat was covered with small ulcers.—Ed. ATICA. [Cl. III.—Ord. II. of the small lobe of the liver. This inflamma- tion was evidently raised by the powers of the body to prevent the accident-which happened . and if no violent vomiting had taken place, and torn this adhesion at this particular time, she might have lived for years, notwithstanding the ulcer."—(Anat. ofthe Absorbent Vessels, p. 122.) In many cases of this kind the inflammation is chronic, and indeed of long standing ; for the diseased parts of the stomach exhibit great thickening and induration. Where the inflam- matory action proceeds very slowly, it is often astonishing to find how little the general health, or even the local state of the stomach, is dis- turbed. For, as in the case before us, it pro- ceeds without being suspected till the ulcer is complete, the external tunic gives way, and the contents of the stomach are evacuated; which irritate, as a foreign body, in whatever situation they are lodged, excite a new and ac- tive inflammation, and destroy in a few days. This indeed is the usual termination, whatever be the progress. Yet the march of the disease is not always thus quiet or deceitful; for it is often preceded by many or all the ordinary con- comitants of dyspepsy, as acidity, eructations, flatulence, and oppression of the stomach after eating; often, indeed, accompanied with emacia- tion and debility, and not unfrequently with hae- matemesis ; by which last signs it is chiefly to be distinguished from idiopathic indigestion. The death, however, is commonly sudden, within a day or two, or even a few hours, from the cause just stated. M. Chardel (Op. cit,) has given various examples of this form : M. Gerard (Perf. spon. de I'Estomac) and Dr. Abercrombie, others. —(Edin. Med. and Surg. Journ., vol. xxi., p. 1.) [It is observed by the latter writer, that acute inflammation of the stomach is not a common , disease in this country,* and when it does oc- cur, the symptoms are so severe and well-defined as immediately to indicate the nature of the affection.! But the stomach is liable to inflam- matory action in a chronic form, which often advances so slowly and insidiously, that the dangerous nature of it may be overlooked, until it reaches that stage in which it assumes the characters of organic and hopeless disease. In the early stage, the prominent symptoms, in * The same remark will equally apply to this country ; though it deserves to be noted, that dis- sections have demonstrated the stomach ,to be more frequently than any other organ the seat of the immediate ravages of yellow fever, as it has pre- vailed in the United States.—D. t Acute idiopathic inflammation of the mucous coat is a rare disease in this country. As Dr. Abercrombie observes, it is from the action of poisons that we chiefly meet with inflammation of that coat of the stomach ; but such cases can- not be regarded as necessarily exhibiting the same symptoms which would accompany the idiopathic form of the disorder.—(On Dis. of the Stomach, &c, p. 13.) In fact, we know that each poison is productive of symptoms peculiar to itself, and hence, in this point of view, our author's defini- tion cannot but be imperfect. According to my own judgment, it would have been more consistent with the plan of this system to have treated here only of idiopathic gastritis.—Ed. Gen. VII.—Spe. 11.] EMPRESMA fact, merely indicate derangement of the func- tions of the stomach, and are consequently very apt to be included under the general term dyspepsy.] Gastritis in its acute form has often been represented in a more dangerous light than it deserves to be ; for, in neither variety, under this modification, is it frequently attended with fatal effects under judicious treatment. In the true adhesive form, copious and repeated vene- sections have been very generally recommended, and have often been found of the highest ad- vantage, particularly in robust and vigorous habits.* To be, however, of any decided avail, this plan of treatment should be commenced early ; for the fever is so apt to pass into a typhoid form, that, after the first two or three days, too much inroad will generally have been made upon the constitutional strength to allow the use of the lancet. If acrid poisons or excess of eating be the cause, an emetic should be administered ; but otherwise this, as well as all other stimu- lants, should be avoided. Gentle cooling laxa- tives,! a blister applied after bleeding to the pit of the stomach, mild nutritive drinks (Dr. Stokes particularly recommends cold ones, such as iced water, iced lemonade, &c), nutritious injections, and, if the pain or sickness be ex- treme, doses of a drachm of the sirup of white poppies, and perhaps about five grains of nitre in an emulsion of gumarabic or spermaceti, will generally be found the most successful plan. It is, however, extremely difficult to get any medicine to remain on the stomach ; and hence the best preparation is that of pills. [In idio- pathic inflammation of the internal surface of the stomach, or when that surface becomes in- flamed in the progress of dysentery, gout, or other diseases, Dr. Cheyne has often directed entire abstinence from medicine of every de- scription, and from fluids even of the blandest nature, until the inflammation has been remo- ved by bleeding, blistering, fomentations, &c. The infl*med stomach, he observes, is often incapable of retaining even a spoonful of water, and at first, every description of medicine pro- duces an aggravation of sickness, vomiting, and general distress. After one or two days, calo- mel, in doses of one grain, may be repeated every hour, or four or five grains, and half a grain of opium, given every third or fourth hour, alternating these medicines with a solution of Rochelle salts and soda, to which lemon-juice may be added. But before these remedies be employed, he particularly enjoins a previous re- duction of the inflammation.—(Dublin Hospital Reports, vol. iv., p. 266.)] If gangrene take * In a weak subject, or where an acute attack supervenes on achronic gastritis, Dr. Stokes deems general bleeding almost inadmissible. " The great remedy," says he, " is the appUcation of leeches to the epigastrium, which should be done freely and repeatedly, until decided relief be obtained." —Cyclop, of Pract. Med., art. Gastritis.—En. t " The bowels, which are commonly confined," says Dr. Stokes, " are to be relieved by enemata; but on no account is purgative medicine to be given by the mouth." GASTRITIS. 511 place, all further exertion will be in vain; and we may determine its presence by a sudden cessation of pain, coldness about the praecordia, and languid or intermitting pulse, which are its sure attendants. Under the chronic form we have just noticed, Dr. Abercrombie has found sulphate of iron, in the proportion' of two or three grains three times a day, a valuable and decisive remedy, and it is well entitled to at- tention. [The utility of leeches and counter- irritation on the epigastrium, with a strict regi- men, is universally acknowledged, and the supe- rior success of this practice in the cure of many cases of dyspepsy from chronic gastritis, is a fact attested by all the most judicious prac- titioners.]* Upon the erythematic variety, the follow- ing remarks of Mr. Hunter are too valuable to be omitted; and they are the more valuable, as they apply to disorders of other internal cavi- ties besides the stomach. " There is,'" says he, '' an inflammation which attacks internal * A peculiar species of gastritis occurs in some parts of America, particularly in Ohio, Tennessee, Illinois, Missouri, North and South Carolina, and Georgia, that merits a passing notice. By some practitioners it is called sick stomach, but it is more generally known by the term milk sickness. Although some physicians, with Dr. Wnght (see Western Med. and Phys. Journ., 1827), consider this disease as the common autumnal fever of the country, yet the majority of them believe that it presents an additional instance of the influence of animal disease on the human constitution; and that it arises in the human subject from eating food prepared in some manner from animals which are affected with a disorder of the same char- acter : and experiments have been made, and facts are numerous, proving in the most direct manner the conveyance of the disease from one animal to another by milk. Among the symptoms of this disorder, as de- tailed by Dr. Yadkin (Transylvania Journal of Medicine, vol. i., p. 318) the following are the most remarkable :—" After the use of milk, butter, or recently slaughtered meat, the individual is at- tacked with a distressing sense of burning in the epigastrium,followed by vomiting, with insatiable thirst. These symptoms are uniformly pathogno- monic, and continue throughout the complaint. The bowels are constipated; the pulse, at first natu- ral, becomes in the sequel small, tense, vibratory, and often irregular. Epigastrium tender to the touch; body hot, extremities cold ; the patient's breath has a peculiar odour, sui generis, which is indescribable. The symptoms of the chronic form of the complaint are, a slight burning in the stom- ach, continued, and distressing; occasional vom- iting ; general debility ; costive bowels ; sullen countenance; intellectual dulness." In the treatment of this disease, Dr. Y. observes, that cathartics are the sheet-anchor; and he pre- fers calomel, the operation of which is to be as- sisted by stimulating enemata, until free catharsis is induced, and then the patient may be considered as convalescent. Venesection, blisters, and cold affusions to the extremities, are also useful. The chronic form of the complaint is to be treated with calomel in minute doses, given to salivation, epi- spastics, castor-oil, sulphur, and the alkalis.—(See M'Call in the Med. Recorder, vol. vi., p. 254 ; and L. Beck, in the New-York Med. and Phys. Journ., vol. ii.)—D. 512 ha:m canals, which is classed with the erysipelatous ; but how far it is the same I do not know. It is certainly not the suppurative. Whatever it is, it may be considered in some of its effects to be in direct opposition to the adhesive and suppurative inflammations ; for where the ad- hesive most readily produces adhesions, there the erysipelatous does not, as in the common cellular membrane ; and where the adhesive seldom takes place, excepting from extreme vio- lence, there this inflammation (if erysipelatous) has a tendency to produce adhesions, as in canals or outlets. It also opposes in some degree the suppurative, in being backward in producing suppuration, even in those places where sup- puration most readily takes place, such as canals and outlets; for there, as above observed, it more readily throws out the coagulating lymph. Whatever the inflammation may be, it is cer- tainly attended with nearly the same kind of constitutional affection. The fever in both ap- pears to be the same, viz., accompanied with debility, languor, &c—(On Blood, cVc, p. 270.) The erythematic inflammation of the stomach comes on more insidiously than the adhesive ; and is best characterized by the inflammatory colour of the fauces, for it usually spreads to these, and the fewness and rapidity of the pulse. The inflammation often extends through a great part of the alvine canal, as well as the oesoph- agus ; and, after a subsidence of the sickness, produces diarrhoea, and mucous discharges from the bowels. It is sometimes so gradual and tardy in its progress as to produce little fever, or even local disturbance, for many days or even weeks. If this variety of gastritis be excited by acrid or poisonous substances, the stomach-pump should be used, or a brisk emetic be exhibited with as much speed as possible ; and afterward such antidote as the character of the poison may point out: opposing acids to alkalines, and alkalines to acid erosives, and the most active stimulants to narcotics. When the cause is internal, mild, diluent, and cooling drinks are to be employed freely. The infusion of roses will often prove one of the most serviceable medicines we can make use of; blisters should be applied and repeated, and the bowels kept open with laxative clysters. Inflammation of the stomach is also found in the one or the other of its varieties, as an oc- casional symptom in aphtha, measles, smallpox, and other exanthems, tetanus, and hydrophobia, We may here observe, that the pancreas is also sometimes, though rarely, affected with in- flammatory action ; and that, in this case, the symptoms are a combination of empresma gas- tritis and e. hepatitis. There is pain and dis- tention in the epigastrium, with frequent vomit- ing. There is also a defined tumour seated higher than the liver, and generally more polar- ized, but always accompanied with some degree of jaundice, from its pressure on the bile-ducts. The affection often yields to depletion by cup- ping, brisk purgatives, and blistering.* * Perceval, in Trans. King's and Queen's Col- [Cl. III.—Ord. II.' SPECIES XII. EMPRESMA ENTERITIS. INFLAMMATION OF THE BOWELS. griping pain in the belly ; tenderness, and vomiting ; fever a synochus. In inflammation of the stomach, the pain is seated higher, and is rather burning than gri- ping ; this last, also, has usually some degree of hiccough, and great dejection of mind : neither of which belongs to inflammation of the intes- tines ; and it is by these characters that the two are to be distinguished from each other. Stoll adds, that intestinal inflammation is also accom- panied with a suppression of urine ; but we can- not rely upon this as a specific symptom. Our opening remarks upon gastritis, in respect to the nature of that disease in France, apply to the present as well. Enteritis also exhibits two varieties :— a Adhaesiva. Pain very acute ; fever vio- Adhesive inflam- lent ; vomiting frequent; mation of the and costiveness obstinate. bowels. 0 Erythematica. Pain more moderate ; fever Erythematic in- less violent; little vomit- flammation of ing ; and diarrhoea, instead the bowels. of costiveness. Of these varieties the former is more fre- quent in this species, as the latter is in the pre- ceding.—(Frank, ut supra, tom. ii., § ccxxxviii., p. 250.) The causes of both, as also of the accom- panying fever being a synochus, may be under- stood from the remarks already offered upon gastritis ; the intestines partaking in a very con- siderable degree ofthe character of the stomach. [Medical writers do not always agree respect- ing the meaning of the term enteritis. Some imply by it an inflammation of the several tunics which form the intestinal canal ; while others signify an inflammation of the mucous mem- brane that invests the bowels from the pylorus to the anus. The inflammation, however, some- times extends from the mucous coat to the others, so as to affect the whole thickness of the intestines. The inflammation may also be either acute or chronic.—(See Diet, des Sciences Mid., tom. xii., p. 359.)] To the causes enumerated under gastritis, may be added some natural or accidental organic mischief in some part or other of the intestinal canal, as ventral, inguinal, or other hernias, or introsusceptions of various kinds ; or infarctions from coprostasis, scybala, or enterolithus. The plica polonica, or matted hair, is said by De la Fontaine, to be a cause of this species, as other writers affirm it to be of gastritis. The progress of the first variety usually commences with a sense of coldness or shiver- lege, Dublin, vol. ii., p. 128, 1824. To all who de- sire a correct knowledge of affections of the mucous membrane of the stomach, the editor strongly recommends the Memoir by M. Louis, entitled " Du Ramollissement, &c de la Mem- brane muqueuse de l'Estomac"—Mem. Anat. Pathol., Paris, 1826. ATICA. Gen. VII.—Spe. 12.] EMPRESMA ENTERITIS. 513 ing, and an uneasiness in some part of the belly, at first remitting or intermitting, but gradually acquiring permanency, and rising into an acute pain. The pain now spreads over the whole abdomen, which is tense and tender to the touch, though less so than in peritonitis ; there is great flatulence, accompanied with occasional spasms that shoot backward to the loins, usually ob- stinate costiveness, and unconquerable vomiting, though sometimes diarrhcea and tenesmus. The pulse is small, hard, and frequent, but has some- times been soft; the tongue dry ; thirst ex- treme ; urine high-coloured, small in quantity, and discharged with difficulty ; the breathing is laborious ; and from the contraction of the ab- dominal musdes, the patient is perpetually bend- ing forward.—(Ucpl Viovo&v, iii., p. 491.) If no beneficial change take place, all these symptoms become aggravated ; instead of feculent stools, there is an ineffectual straining, with a small mucous discharge ; and with the increase of the retching, the feces burst through the valve of the colon, and are occasionally thrown up from the stomach. At length the torture suddenly diminishes, and the patient appears to have ob- tained relief; but his pulse intermits, his face grows pale, his extremities cold, convulsions succeed, and he sinks in death.* The general termination, therefore, when un- fortunate, is that of gangrene ; for it is rarely that the inflammation runs into a suppurative state. If, in the course of the first two, three, * Inflammation seems to destroy the action of the muscular fibre. Thus, intestine which has been highly inflamed, is generally found in a state of great distention, showing the complete loss of its healthy muscular action ; and if the disease has gone on until the intestine has either become ruptured, or has given way by ulceration, it is found to have fallen together like an empty bag; whereas, healthy intestine, when it is empty, con- tracts uniformly into a round cord. When we find gangrene, we have reason, in general, to con- clude, that inflammation has existed in the mus- cular coat; but each of the coats may be inflamed separately, and give rise to important differences in the symptoms.—(See J. Abercrombie's Pathol. and Prac Researches on Dis. of the Stomach, &c. p. 7, ed. 2, Edin., 1830.) The following are the general symptoms of inflammatory affections ofthe digestive tube, as described by Dr. Stokes:—In- digestion ; anorexia ; vomiting; thirst; jaundice ; tympanitis ; constipation ; alteration of the fecal discharges in quality or quantity ; pain; tenderness on pressure ; contraction of the features ; morbid state of the tongue ; dryness of the skin and con- junctiva; suppression ofthe urine ; stupor ; delir- ium ; headache ; prostration; accelerated and tho- racic respiration; fever. " We shall find," says he, " that the greatest variety in the combinations of these symptoms may occur, principally arising from the following circumstances: the intensity and extent of the inflammation ; the situation of the disease, both as to the different parts and tis- sues of the tube ; the complications with other dis- eases ; the different degree of excitability of the nervous system in different individuals. Thus, when the inflammation is extensive and severe, occupying both the stomach and intestines, we may nave the worst forms of bilious and gastric fevers ; when it occupies the duodenum, jaundice is a common symptom; and the disease may occur . Vol. I.— Kk or even four days, a free feculent discharge can be procured from the bowels, the vomiting and pains will gradually diminish, the pulse abate in quickness, and the patient be in the way of recovery. In treating this complaint, it is hence of the utmost importance to procure free evacuations, for the cure depends almost entirely upon our success in this respect. Yet the difficulty is often very great, and increased from the ten- dency of the stomach to reject whatever medi- cines are introduced into it Most practitioners commence with bleeding, which they urge very copiously, and repeat every six or eight hours, according as the pulse will bear the lancet The remarks we have made upon this practice, under gastritis, will apply to the present species. If the disease occur in a patient of a hardy and vigorous habit, and particularly if we have an opportunity of employing venesection within the first day or two, we shall commonly find it of essential service : but if we do not -succeed, we shall assuredly hasten the stage of gangrene, and abbreviate the term of remedial operations. And hence, unless free bleeding can be employ- ed early, and the constitution evinces a tolerable portion of vigour, there is no inflammation in which the lancet is less likely to be serviceable, or may become more mischievous. To local bleeding, even under the conditions we are now supposing, there is less objection ; but we have less chance of benefit from it than in peritonitis.* with or without fever; in the small intestine, a slight inflammation is often nearly latent, or only pointed"out by a little swelling or pain ; while in the coecum or. colon, the disease produces all the varieties of diarrhcea and dysentery. When the upper portion ofthe tube is engaged, constipation is a common symptom ; when the lower, there- verse takes place. If the mucous membrane alone is engaged, pain and costiveness are often absent; but, when all the coats are in a state of acute ir- ritation, we may find the most violent symptoms of peritonitis and ileus, with contractions, intusus- ceptions, &c. The complication of the disease with other affections also produces great varieties. Thus, when it occurs in the advanced stages of phthisis, diarrhoea is often the only symptom ; or, when complicated with erysipelas, or pneumonia, its most prominent indication is an extraordinary prostration. The different degrees of excitability of the nervous system cause the greatest irregu- larity of symptoms: in the child, acute enteritis is commonly mistaken for inflammation of the brain ; in the adult, a circumscribed irritation will in one case be accompanied by violent delirium, while, in another more severe, this symptom shall be com- pletely absent."—Ed. * Modern practitioners speak more decidedly in praise of bleeding than our author has done. Thus, Dr. Stokes gives it as his advice, that the lancet should never be neglected; and that, if the vio- lence ofthe disease continue unsubdued, venesec- tion should be frequently repeated. After the first bleeding, Dr. Abercrombie recommends smaller quantities of blood to be taken away. The great efficacy of general bleeding alone in reducing in- flammation of the mucous membrane is consider- ed, however, by Dr. Stokes, to be a well-establish- ed fact; but when the disease has been in the small intestine, he has always found the greatest advantage from local bleeding. If the symptoms 514 H^EMATICA. [Cl.III.—Ord.II. From the first, therefore, we must attempt eathartics. If the stomach will retain the milder, as castor-oil, neutral salts, or senna, these are by far the most advisable; as our ob- ject should be to diminish, instead of increasing the irritation of the intestines. But, in the first species, this is rarely the case ; and we must hence, without loss of time, apply to those that are more active ; as calomel in combina- tion with the colocynth pill; assisting their op- eration by injections frequently repeated, and in as large quantity as the bowels will retain. It does not necessarily follow that the irrita- tion of these more active purgatives will add to the inflammatory irritation ; nor do we always, or even commonly, find any such effect. For, firstly, the operation of the two irritations is very different; and, by exciting the former, we may even diminish or take off the latter by a transfer of action, in the same manner as we take off inflammation from any other organ by the application of a blister to some neighbour- ing part. Secondly, the direct effect of the ca- thartic is to restore a natural action, the peris- taltic action of the intestines, which it is the direct effect of the inflammatory action to op- pose. And, thirdly, we find, in fact, the bene- ficial influence of such a practice, not only gen- erally, but almost uniformly, and are incapable of accounting for it upon any other principle. Opiates would be desirable through the whole' course of this disease, but that, in their general intention, they add to the costiveness if given alone, and retard the effect of purgatives if given in conjunction with them. Nevertheless, if af- ter copious bleeding the costiveness should be intractable, and the flatulence and spasmodic pains very distressing, it will be better to trust for a few hours to two or three grains of opium alone, and withhold the purgative plan for the present. [Opium is frequently useful in quiet- ing the sickness, and in enabling the stomach to retain laxative medicines.] Dr. Baillie recom- mends as a general rule, " the inflammation to be subdued, or at least much lessened, before any active purgative be administered."—(Lec- tures and Obs. on Medicine, 1825.) But we have already stated the principle on which pur- ging and bleeding may be combined from the first in ordinary cases. [The editor's experience leads him to place more reliance on early and free bleeding, and less on premature purging, than the author. The excessive constipation of the bowels is in general merely an effect of the inflammation, and is often attacked with active purgative med- icines, as if it were the primary object, and the source of all mischief. The inflammation is to be subdued by bloodletting from a large orifice to an extent which must be various, and repeat- ed or not, according to the constitution of the patient, and the violence of the symptoms. do not yield at once to this treatment, the leeches are to be repeated, and a large poultice applied over the belly. The bowels are to be gently open- ed by the mildest laxatives, and emollient injec- tions should be frequently given.—Cyclop, of Pract. Med., art. Entbritis.—Ed. Purgatives given by the mouth are not generally successful, when the inflammation has not been previously checked by local and general bleed- ing and blistering. Dr. Gregory used to re- mark, in his,lectures, that a purgative had often been known to operate as soon as a blister ap- plied to the belly began to rise ; and this obser- vation is still more commonly verified after free venesection.*] Fomentations and blisters to the- abdomen form a regular course of the therapeutic plan, and have, no doubt, been occasionally service- able ; but, like local bleeding, they are less so in the present disease than in peritonitis. And, where fomentations are advisable, I prefer the epithem of a folded flannel wrung out in hot water, and confined with a swathe, as already recommended in peritoneal inflammation, to all other fomentations whatever. Injections of warm water alone forcibly thrown up the rectum in as large a quantity as the bow- els cam be made to contain, are moreover often found of essential benefit, and are generally to be preferred to the warm bath, which, by adding to the debility, has accelerated the approach of gangrene. After the bowels have been freely emptied, diaphoretics, and especially combined with opi- ates, will be the best plan we can pursue ; and if the stomach become quiescent, the patient should drink freely of diluents.! There is a singular fact noticed by Rhodius (Cent, ii., obs. 69), which sometimes occurs in this disease, and is peculiarly worthy of notice, as sustaining our hopes to the last: and it is this; that occasionally, in the extreme moment of a seeming mortification, a sudden revolution takes place, and stools are evacuated; and this, too, after the extremities have begun to grow cold, and an apparently deadly languor has * Bateman on Enteritis, in Rees's Cyclopaedia. Also, Edin. Med. Surg. Journ., vol. i., p. 64. When enteritis is joined with diarrhoea, the warm bath, leeches, a blister, anodyne injections, and small doses of pulv. ipecac, comp., with or with- out rhubarb, are some of the remedies commonly resorted to. In the early stage, astringents are pernicious.—Ed. ! For allaying the vomiting, the common prac- tice has been to give effervescing draughts of the carbonate of soda or ammonia, with or without a few drops of the tinct. hyosciami to each draught; the region of the stomach being sometimes fo- mented with the decoction of poppy-heads. Dr. Stokes has found nothing sb efficacious as the application of a dozen leeches to the epigastrium, and the liberal use of iced water, or even ice, which may be given ad libitum. In the more advanced stages of the disease he has constantly applied leeches to the epigastrium, though in smaller num- ber, and has seen what has been called the typhoid state disappear after their use. He has also ap- plied a small blister to the epigastrium, and after- ward sprinkled the surface with a little of the ace- tate of morphia, according to the plan suggested by M. Lembert in tetanus, hydrophobia, and some other cases, where the patient may not be able to swallow medicine at all.—See Lecons Orales de Clinique Chir., faites par M. le Baron Dupuytren, torn ii., p. 608, 8vo., Paris, 1832.—Ed. Gen. VII.—Spe. 12] EMPRESMA ENTERITIS. 5lS overpowered the frame. In such case, we must snatch the patient from impending death by a free use of wine, and warm generous cor- dials ; closely attending, at the same time, to a copious discharge from the bowels, of which, with the liberal plan now recommended, we need not be afraid, and which we should be ex- tremely cautious of checking by opiates. From the less threatening character of the symptoms, as they show themselves in the erythematic variety, this affection often ex- hibits a fallacious appearance, and is misunder- stood. " Saepe," says Professor Frank, " nee febris in pulsibus umbra ; ardor, dolor, ad in- testina aut nullus, aut certenonvehemens ; nee fere ulla tarn diri morbi phaenomena observan- tur."—(Op. cit, tom. ii., p. 254.) Its real na- ture, however, is as we have explained it above : and, from the debility superinduced, ascites has occasionally followed rapidly. It has been well ascertained, that the seat of this variety is some- times in the external coat of the intestines, and it is said, by some writers, that this is the most common seat. It is not easy to determine upon this point: nor always, at its commencement, whether the inflammation be of the one variety or the other ; the modifying causes being, in some constitutions, and some seasons of the year and temperaments of the atmosphere, so nicely bal- anced as to leave the course doubtful. In distinct and simple examples of erythe- matic inflammation, bleeding ought unques- tionably to be abstained from ; and acids, and the milder tonics, and bitters, as infusion of roses, cascarilla bark, and cinchona, supply its place. We have said, that in enteritis there is less pain and tension to the touch than in perito- nitis. It is singular, that at times there should be little or none whatever on pressing the abdomen. " Gastro-enteritis," observes M. Broussais, " exists without any painful point, when the inflammation is not vehement in the stomach and duodenum ; and pressure of the belly does not produce uneasiness."—(Examen, &c, prop, exxxvi., Par. F. J. V. Broussais.) M. Petit speaks nearly to the same effect, though he modifies the opinion ; affirming, " that if the belly be pressed a little deeply at its lower part, especially towards the right, be- tween the spine of the ilium and the navel, the patient is sensible of pain, and at times makes complaint of the pressure, and exhibits the same by his countenance."—(Traitide la Fievre En- tero-Mesentirique, &c.,p. 131.) Yet, even in ulcerations of the mucous membrane, there is not always much uneasiness. " Nothing," says M. Andral, " is more common than an ab- sence of every kind of pain in cases in which numerous ulcerated spots cover the inner sur- face either of the ileum, or of the coecum, or of the colon ; while we frequently see patients complaining of sharp abdominal pains, where the gastro-enteric mucous membrane is not in- flamed."—(Andral, Clinique Midicale, tom. i., 8vo., Paris, 1823.) The last of these writers has lately favoured the world with a valuable and extensive rjnge of examinations into the state of the alimentary Kk2 canal inpatients who have died of gastritis and enteritis; and we are hence enabled to arrive at some calculation of the comparative frequency of inflammatory-action in different parts of the canal. Ulcerations, he observes, may take place in every part, from the cardiac orifice to the anus ; but they are not in all places equally common. They are rare in the stomach, and still more rare in the duodenum and jejunum: they are very frequent in the lower third of the small intestine, and they are again less frequent in the different parts of the great intestine. These conclusions are drawn from the follow- ing observations, comprising seventy-one dis- tinct cases of disease :— In ten individuals ulcerations were found in the stomach ; in one in the duodenum ; in nine in the jejunum ; in thirty-eight in the lower part of the ileum ; in fifteen in the coecum ; in four in the ascending colon ; in eleven in the trans- verse colon ; in three in the descending colon; in one in the rectum. I have said that enteritis is sometimes a result of hernias. It has also, occasionally, been produced by a forcible protrusion of a part ofthe intestinal canal through the anus; of which a singular instance is given in the Medical Trans- actions, vol. iv., in a paper communicated by Dr. Latham. The part of the prolapsed intes- tine was very considerable, and the injury was occasioned by the passage of the wheel of a cart over the loins ; a portion of the mesentery was protuded with that of the gut; gangrene supervened to the inflammation, and the pro- lapsed mesentery and intestine were cut off above the line of gangrene; the latter to a length of not less than fifty-seven inches. The patient, who was a boy, recovered ; had motions regularly from the truncated extremity of the remaining intestine ; and was able afterward to walk twelve or fourteen miles a day. He had no power, however, of retaining his feces.* * Enteritis, a formidable disease in its idiopathic form, is also found to supervene in the course of other affections. Thus, it is daily noticed as a complication of fever. From what has been sta- ted in a previous part of this work, however, when it occurs in typhus, it is not the cause, but simply a consequence of that fever ; though, as Dr. Stokes has justly said, it is not the less important with reference to the prognosis and treatment. Com- pared with other affections, both acute and chron- ic, the frequency of intestinal disease must strike every observer. Andral declares, that in the great majority of diseases of other parts, a derangement either in the functions or structure of the intesti- nal canal will occur; and that, in chronic diseases, whatever be their nature, it is extremely rare for the digestive tube to escape alteration.—(See Cyclop, of Pract Med., art. Enteritis.) In this country, where it is so usual to attribute many complaints to affections of the liver, it is, as Dr. Stokes observes, of great importance that the re- lation of cause and effect between irritations of the upper part of the intestinal tube, and derange- ments ofthe hepatic function, should be carefully studied. " It is true, that gastro-duodenitis may exist without jaundice, or that hepatic inflamma- tion may arise independent of disease in the mu- cous membrane; but, it is equally true, that the symptoms of gastro-duodenitis, both acute and 516 H^M SPECIES XIII.' EMPRESMA HEPATITIS. INFLAMMATION OF THE LIVER. TENSION, SORENESS, AND PAIN IN THE REGION OF THE LIVER ; PAIN ABOUT THE RIGHT SHOULDER ; FELT ESPECIALLY WHEN LYING ON THE LEFT SIDE ; SHORT, DRY COUGH. Inflammation of the liver, which may in general be sufficiently known by the above characters, has also two varieties, dependant upon its rapid and violent, or more tardy and obscure march. a Acuta. In which the above symp- Acute inflammation toms are clearly mark- of the liver. ed, and the character of the disease is deci- sive. 0 Chronica. In which the specific Chronic inflamma- character is obscure; tion of the liver, and the existence of the disease suspected from a previous expo- sure to its causes, in connexion with an occa- sional recurrence ot the pathognomonic symp- toms, accompanied by a slight degree of fe- ver. Next to the lungs and the brain, no organ more frequently has an hereditary predisposition to disease than the liver; and Frank has wit- nessed families suffering in consequence of it, as well in the acute as in the chronic form of in- flammation.—(Op. cit, tom. ii., p. 268.) The acute variety commences with the or- dinary symptoms of visceral inflammation; chilliness, succeeded by heat, frequent pulse, and a furred tongue : the bowels are irregular, mostly costive ; the evacuations little tinged with bile, the urine often saffron-coloured ; the skin is dry, the thirst extreme, with occasional sickness. No physiologist has yet been able to explain the cause of the pain so generally felt in the right shoulder. It is, however, sympathetic of other affections of the liver, as jaundice, or chololithus, as well as hepatitis ; and hence it should seem to be produced by almost any mor- bid excitement of this organ, whether frorh in- flammation, or the obstruction of gall-stones. [In several cases of hepatitis, reported by M. Louis, and the nature of which was verified by dissection, there was no pain in the right shoul- der. Hence, this distinguished pathologist is disposed to doubt whether it be a symptom truly chronic, are those commonly received as indic- ative of hepatic disease ; and that this last af- fection may commence by inflammation in the di- gestive tube." If any doubt exists as to the diag- nosis, Dr. Stokes considers it better to give the patient the advantage of that doubt, and to treat him for gastro-duodenitis, before we have recourse to the hazardous plans usually recommended for hepatic disease. The reader will find much val- uable information on the subject of enteritis, in Dr. Stokes's Observations.—Ed. LTICA. [Cl. III.-Ord. II. appertaining to the complaint, and suspects that, perhaps, when it does occur, the hepatitis is complicated with disease of the right lung, or pleura.*] The cough, which is often very dis- tressing, is easily accounted for from the vicinity of the diaphragm to the seat of disease, and its sympathy with the liver. The sickness of the stomach is from the same cause. The disease is sometimes accompanied with a jaundiced colour of the skin, and Sauvages and Sagar have made such a colour a specific symptom ; but it is not always that the bile re- gurgitates, and, hence, such an appearance ought not to be enumerated among the pathognomonic characters. Even where it exists, it is 'not a distinct symptom of hepatitis ; for, to say nothing of proper jaundice, the feces, as Dr. Latham has well observed, may be light-coloured, and the eyes, skin, and urine peculiarly yellow, from the pressure of an indurated pancreas upon the bile- ducts, and an obstruction of their course.! [Out of five cases of hepatitis, detailed by M. Louis, four were attended with yellowness of the skin and pain in the right hypochondrium, but ten- sion of the same part was remarked only in two. The concurrence of all these three symp- toms actually characterizes hepatitis; but one or two of them alone accompanying an acute disorder, M. Louis thinks, have little validity ; for, with respect to the yellowness, it frequently takes place in such case without any hepatitis ; and as for the pain, it may depend upon so many causes, that it is not a very conclusive symptom. When, however, pain in the right hypochon- drium and jaundice arise from chronic diseases, M. Louis has never seen the latter effect without an accompanying inflammation of the liver.—(Louis, Mem. Anat. Pathol., loc. cit)] The ordinary remote causes are, suddenly suppressed perspiration, especially from cur- rents of cold and damp air, and excess of spir- * Mem. et Recherches Anat. Pathologiques, p. 403, Paris, 1626. Dr. Stokes also represents pain in the right shoulder as an extremely rare symp- tom ; a point on which he coincides with Andral and Dr. Mackintosh.—(Clinique Med. and Elem. of Pathol, and Pract. of Physic, vol. i.) The ed- itor has observed, however, that, in the chronic he- patitis, so frequent among the free living inmates of the great prisons which he attends, pain in the right shoulder is commonly complained of. In acute hepatitis, tenderness and swelling of the liver are also usual symptoms, the latter being ea- sily detected when the bowels are empty ; yet, as the observations of M. Louis prove, it is not a constant symptom.—Ed. ! From a table of cases of hepatitis, drawn up by Dr. Stokes, from the records of Andral, Louis, and the Meath Hospital, it appears that no expla- nation can be given of the reason for the presence or absence of jaundice, from any consideration of the state of the alimentary canal. We find, in the list referred to, cases of hepatitis with jaun- dice, in which that canal was free from disease ; and the same symptom with gastro-intestinal in- flammation ; and with respect to the cases without jaundice, the stomach and bowels were healthy in s-.--.ie, and diseased in others.—See Cyclop, ol Pract. Med., art Liver.—En. Gen. VII.—Spe. 13.] EMPRESMA ituous potation : though often the cause is too obscure for detection. [Hepatitis is most com- mon in the male sex, and is rarely met with in persons under the adult age.] Dr. Saunders, and with some plausibility, suspects the acute variety is owing to an in- flammatory state of the hepatic artery, and the chronic to a like state of the vena portae. Winslow ascribes both to an inflamed state of the ramifications of the vena portae,* which, in his opinion, constitute the seat of the dis- ease ; while Cullen refers us to the hepatic artery alone, and limits the seat of inflamma- tion to its extremities. Dr. Heberden is not inclined to believe that the liver is primarily af- fected, but only influenced by a phlogistic diath- esis, or preceding inflammatory fever. If the inflammation originate in the perito- neal covering, the pain, as in most other cases of membranous affection, is peculiarly pungent, like that of pleuritis ; the fever is-severe, the tension very considerable, the pulse frequent, strong, and hard, the urine generally high-col- oured. When the substance of the liver is primarily affected, the pain and pyrexy are far less acute, and especially at first; but they in- crease with the progress of the disease, or, in other words, as it extends to the peritoneal investment, the pain not only darting to the right shoulder, but sometimes as far as the throat and clavicle.! Where the symptoms are most severe, and we have reason to suspect that the disease is confined to the peritoneal covering, the dura- tion is often short, and the termination is in most cases that of resolution. But when less active, and seated in the parenchyma, it gener- ally tends to suppuration ; and if the convex side of the liver be the part affected, a tumour is visible externally, the cough becomes aggra- vated, and there is a difficulty of breathing.J * The inflammation and abscess of the liver, so common in phlebitis, are referred by Cruveil- hier to the passage of pus, along with the circula- ting blood, into the minute ramifications of the vena portae, in which it produces obstruction and irritation.—Ed. ! The effects of hepatitis vary according to the intensity, duration, and situation of the disease. In general, the first visible effect is the production of increased vascularity of the parenchyma. In a more advanced stage, a softening of the sub- stance of the liver is also observed, and there may be a deposition of pus or lymph on the serous sur- face. In this respect, according to Dr. Stokes, there is a great difference between the liver and the lung, as we seldom meet with pneumonia without serous inflammation, while the reverse often obtains in hepatitis ; a consideration of vast importance in the surgical treatment of the dis- ease.—(Cyclop, of Pract. Med., art. Liver; also, Annesley's Dis. of India, vol i., p. 406.) The rarity of adhesions in hepatitis, even after the for- mation of matter, is a fact which had been ob- served by Drs. Graves and Stokes, before Mr An- nesley's work made its appearance.—See Dublin Hospital Reports, vol. v.—Ed. X Abscess of the liver, as an effect of acute he- patitis, is very frequent in India, but rather un- common in temperate climates. In relation to L HEPATITIS. 517 If adhesions have preceded the suppuration, the pus points to the skin, and the abscess opens on the surface ; but, if it break internally, it generally proves fatal by "inducing a hectic ; though sometimes, in consequence of fortunate adhesions below, the abscess discharges itself into the hepatic duct, and the pus is carried off by this channel. It has, occasionally, by the same means, made its way into the stomach and intestines, where the abscess has been very large: in which case, however, immediately upon the bursting of the abscess, the patient throws off, by sickness or tby purging, a large mass of most offensive matter, and often dies in a few hours. In like manner, the pus has occasionally formed an empyema in the thorax ; and, in a few instances, has been discharged from the lungs.* The progress to a state of gangrene is some- times very rapid, and especially in the swamps of the East and West Indies. Dr. Chisholm gives a striking example of this in a gentleman who, being "heated and profusely perspiring after violent exercise, lay down and slept in this state in a current of cool air. He awoke soon after in the most excruciating torture in the right hypochondrium, and with great tume- faction of the whole abdomen. In two days he was dead." The liver was found greatly enlarged, and reduced in many parts to a state similar to that of rotten cork.! suppuration of the liver, as it presents itself in our latitude, the reader will find the most inter- esting information in the writings of M. Louis (Recherches Anat. Pathol, Paris, 1826), and those of Drs. Graves and Stokes.—(Dublin Hospital Reports, vol. v.) The matter may be either dif- fused or in the form of numerous minute abscesses, or in that of one or more large accumulations, sometimes encysted; on other occasions merely bounded by the softened and yellow hepatic sub- stance.—E D. * Dr. Stokes has known abscess of the liver make its way, 1. Through the diaphragm into the lung ; 2. Into the duodenum ; 3. Into the cav- ity of the peritoneum. Dr. N. R. Smith, of the United States, relates a case, in which an abscess of the liver burst into the pericardium. With re- spect to the thorax, then, as Dr. Stokes has ex- plained, the abscess may open into the lung, pleura, or pericardium^and, with reference to the abdo- men, into some part of the alimentary canal, the peritoneal cavity, the gall-bladder, the vena cava, or kidney.—See Cycl. of Pract. Med., art. Liver. ! Climate and Diseases of Tropical Countries, p, 64, 8vo., London, 1822. Mr. Annesley, who alleges that he has made as many post-mortem examinations of subjects destroyed by liver dis- eases as any writer on the diseases of warm cli- mates, never met with an instance of gangrene of the liver; and he suspects, therefore, that the appearances which have been taken for gangrene, have been merely that black, congested, and soft- ened state of the organ, which is sometimes ob- served in the more acute attacks of hepatitis.— (On Diseases of India, vol. i., p. 435.) Andral met with one clear case, however, of gangrene of the liver, the only example he ever saw; a sut ficient proof or the rarity of such an occurrence. Here, as Dr. Stokes observes, is another circum- stance, in which the pathological relations of the liver differ remarkably from those of the lungs, 518 HJEMATICA. [Cl. III.-Ord. II. The disease sometimes terminates in indura- tion, which "bears an extent in some measure proportioned to the range of the preceding in- flammation, and may often be felt by applying the hand to the region of the organ. This, however, is a more frequent result of the sec- ond or chronic variety. In order to induce acute hepatitis, it is necessary that the organ of the liver, at the time of attack, should be in a state of at least moderate health and vigour ; for it is in this condition only that inflammation running through its regular stages can take place ; and hence the acute variety is found far more frequently in temperate than in intertropical climates ; and, in the latter, more frequently among new-com- ers than among those that have been long habit- uated to the climate, and whose livers have been weakened and relaxed by the greater heat of the sun : " Among the men of the eighteenth regi- ment," says Mr. Christie, who was stationed at Trincomalee, and had the care of the entire gar- rison in 1798, " I found, for the first six or eight months, the disease was much more frequent, much more violent in its symptoms, showed more tendency to suppuration, and was more sudden in its crisis, than with the Company's European troops, who had been long in India, although the latter were the mftst debauched. Among the natives, hepatitis does not often oc- cur : out of a thousand native troops, I did not, in the course of three months, meet with more than two cases of liver complaints, which is comparatively a very small proportion."—(Let- ter to the Editor of the Med. and Phys. Journ., May, 1798.) There is, however, a striking dis- tinction between the state of the bowels, as affected by this disease in hot and in temperate climates. In the latter it is rarely we have any diarrhoea, and often an obstinate costiveness, the evacuations being mostly untinged with bile. In the former, from the higher degree of irrita- tion that prevails, and the greater extent of its range, a bilious flux is so frequent as to be al- most a pathognomonic symptom ; and as the gorged vessels are apt to give way from debility, this is sometimes intermixed with blood. In our own climate, bleeding at the com- mencement of the disease is generally found serviceable, and ought to be prescribed as speed- ily as possible; and be repeated, generally or locally, as the violence of the symptoms may require, and the strength of the constitution allow. Frank advises leeches to the hemor- rhoidal vessels, or to the hypochondrium ; but the lancet is alone to be depended upon.* in which gangrene is not an unfrequent occur- rence.—Ed. * Dr. Stokes's experience would lead him to say, " that general bleeding has not the same marked influence over hepatitis that it has over peripneumony, but appears principally useful in preparing the patient for local depletion, which seems to have the most direct influence on the disease. We have seen a case where upwards of one hundred ounces of blood were drawn at dif- ferent times, and in which no apparent effect was produced on the inflammation, until local bleeding Free purging, with calomel and Epsom salts, should immediately follow ; and mercury be at the same time introduced into the system by the stomach or by inunction, or by both. [Drs. Pemberton and Saunders gave the preference to saline purgatives ; Dr. James Currie to mer- curial ones, and especially to calomel. With respect to inunction, or an attempt to affect the constitution generally with mercury in the early and highly inflammatory stage of hepatitis, it was disapproved by the latter eminent physician, who used calomel at first only as an evacuant*] From the costiveness that usually accompanies the disease, it is rarely necessary to unite the mercury with opium ; though, .where it irritates the bowels, the latter should unquestionably be given ; as it should also to allay the cough, where this symptom is very distressing and pre- vents sleep. The mercurial course, as recom- mended by Sir James M'Grigor (Med. Sketches), should be steadily persevered in, not only in hot climates, but in temperate, till a salutary change has been effected, or salivation has been freely excited. It will often be found, however, that the patient will bear a long continuance of the mercurial plan without any affection of the mouth, and will gradually and insensibly improve under it; the soreness and tension subsiding, the cough diminishing, the pulse becoming slower, and the heat and dryness of-the skin yielding to a pleasant moisture ; all of which are prognos- tics of a favourable issue. In hot climates, however, little benefit is obtained from mercury till it has produced ptyalism ; while, such is the still greater degree of torpitude under which the absorbents, as well as the excretories of the liver labour, that it is often almost impossible to excite this effect by the boldest practice. " I have myself," says Dr. J. Johnson, " taken cal- omel in twenty-grain doses, three times a day, without experiencing the slightest inconvenience from the quantity ; nay, I often found large doses sit easier on the stomach, and occasion less irritation in the bowels, than small ones. At this time, too, I was using every exertion, by was performed. In a robust adult, not less than thirty leeches should be applied, after the general bleeding, to the most painful part of the side," &c—Cyclop, of Pract. Med. * Twenty or thirty years ago, it was frequently stated, that mercury ought not to be given in acute inflammation of the liver, because it stimulated the organ; but that it was proper in chronic he- patitis. This doctrine is no longer respected in practice : mercury', given so as to bring on ptyal- ism, is generally conceived to be just as useful in acute hepatitis, as in any other form of active in- flammation.—(See Elliotson's Lectures at Lon- don Univ., as published in Med. Gaz. for 1833, p. 482.) And Dr. Stokes observes, that, after the employment of general and local bleeding, the production of ptyalism appears to be the most powerful means of subduing the disease. He ad. mits, however, that it is often difficult to excite ptyalism ; and that the more severe the hepatitis is, the greater is this difficulty. As the best mode of ensuring the favourable action of mercury, he recommends the inflammatory condition of the organ to be diminished, as far as possible, before its exlfibition.—Ep, Gen. VII.—Spe. 13.] EMPRESMA HEPATITIS. 519 inunction, to forward the ptyalism, yet it was several days before I could produce any effect of this kind."—(Influence of Tropical Climates, &c, 3d edit., p. 174.) The application of large blisters over the hyp- ogastric region in succession is recommended by most practitioners, but I have not found them successful; and have evidently derived more benefit from fomentations, epithems, and the warm bath. Diaphoretics should certainly form a part of the curative process ; and they combine admi- rably with the mercurial treatment, particularly the antimonial preparations. Cooling, diluent, and even acidulated drinks, should be taken co- piously ; the diet consist chiefly of light farina- ceous foods ; and the chamber be well ventilated. If, from sudden shiverings, and remission of the quickened pulse, we have reason to believe sup- puration has taken place, columbo, the mineral acids, and, above all, the bark, where it can be re- tained, should be given freely ; the cinchona, at least in the proportion of from half a drachm to a drachm, five or six times a day ; and this whether the abscess be likely to burst externally or inter- nally ; and, if the former, the direction should be encouraged by maturating cataplasms, and the abscess be opened as speedily as possible.* The discharge is sometimes very considerable in quantity, and amounts to several pints ; the pus is occasionally found pure, but more gener- ally intermixed with coagulable lymph, or some viscid, yellow fluid. It is at times lodged in different sacs, and hence subsequent tumours ensue, and subsequent openings are necessary.! It is not always, however, even after suppu- * The adhesion of the liver to the peritoneum, in cases of hepatic abscess, a circumstance so es- sential to the safety and success of the operation, is alleged to be rare. If such adhesion should not exist, the matter would pass into the cavity of the peritoneum, and cause an almost certainly fatal inflammation of it To obviate this risk, Dr. Graves has proposed that an incision should be made over the most prominent part of the tumour down to the peritoneum, without dividing this membrane. The wound is to be kept open with plugs of lint, and poultices are to be applied. The desired adhesions will then form, and the matter soon make its way out through the incision.—(See Dublin Hospital Reports, vol. iv.) Dr. Graves gives one instance of the success of the practice, and Dr. Stokes has seen two others. The pas- sage of the matter of an abscess of the liver into the cavity of the pleura or peritoneum, is, no doubt, generally fatal; yet, in the Report of the Meath Hospital, a case is recorded in which death from peritonitis was apparently prevented by the opiate and stimulating treatment, first proposed by Dr. Graves in certain cases of peritonitis. In a case also of double abscess of the liver, related by Dr. Stokes (Cyclop, of Pract. Med.), the pa- tient lived eight days after the rupture of the sec- ond abscess into the peritoneum, and it was evi- dent, on dissection, that the process of cure had commenced, the gelatinous effusion in many places having assumed an appearance of layers, and presenting large bloodvessels in its interior.—Ed. ! Recueil d'Observations de Medecine des H6- pitaux Militaires, &c, art. par M. Boucher, tom. ii., 4to, Paris. ration has taken place, that the abscess must necessarily open in any direction ; for, when we have full reason to believe that such a result has occurred, the fluid may be carried off by ab- sorption, and the organ be restored to a sound state. [A softening of the liver has been noticed by several observers, and among others by M. Lallemand (Troisieme Lettre sur I'Enciphale, p. 351), in a case of very acute hepatitis attend- ed with abscess. But M. Louis conceives, that, in the present state of our knowledge, a soften- ing joined with increased intensity of the red colour of the liver, cannot be deemed a certain proof of inflammation, unless the organ contain at the same time pus, or the patient had, while living, icterus and pain in the right hypochon- drium. In fact, as these two symptoms took place in four out of the five histories recorded by him, he believes they are rarely wanting.— (P. Ch. Louis, Mem. Anat. Pathologiques, p. 407.)] Dr. Chisholm found this disease on one occa- sion contagious. It was at Grenada, in the winter of 1786, in districts peculiarly exposed to the influence of chilling northerly winds, and possessing large tracts of marsh. The disease was lamentably mortiferous, though the symp- toms were insidious rather than violent. It usu- ally destroyed in the course of six days; and the deaths were calculated at one in every six.* In chronic hepatitis, all the specific symp- toms, as already observed, show themselves ob- scurely. The pulse is something quicker than usual, and there is an obtuse pain in the region of the liver ; but such as would not perhaps be noticed, if it were not inquired into, and the organ pressed upon, and connected with a sud- den quick expiration after an attempt to inspire deeply : and there is also an indistinct uneasi- ness generally, though not always, about the right shoulder ; all the- symptoms becoming exa- cerbated at a certain period of the day, com- monly about four o'clock in the afternoon. But, in conjunction with the proper hepatic symp- toms, the most obvious are those of dyspepsy and atrophy; the appetite fails, the stomach is capricious, the animal spirits flag, and the flesh wastes away. The bowels are generally costive, and the stools often clay-coloured, though not always ; and there is usually a sallowness on the skin, or a dirty greenish hue, which Dr. Darwin, from its resemblance to the colour of a full-grown silk-worm, has denominated bomby- cinous. The disease slowly advances to sup- puration, or terminates in a scirrhous induration ; but, in many instances, and especially after a habit of hard eating or drinking, is the index of a broken-up constitution. Excess in eating and drinking, or indeed in any other voluptuousness, is the common cause of this variety of hepatitis in temperate regions,! * Climate and Diseases of Tropical Countries, &c, p. 66, 8vo., Lond., 1822. The circumstances mentioned in the text make it'very clear that the disorder was not truly contagious, but epidemic. —Ed. ! In this country, chronic hepatitis is more com. 520 0 H.EM AT1CA. [Cl. III.-Ord. II. though it sometimes follows obstinate quartans. It is, however, a more frequent affection in hot climates, where, as already observed, it is far more apt to occur than the preceding variety. And it is on this account that we see so many persons returning annually to our own coun- try, from the East or West Indies, with en- larged livers, irregular fever, indigestion, cos- tiveness, fulness in the right hypochondrium, white stools, yellow complexion, dry cough, dis- turbed sleep, and dejected spirits ; occasionally some of these symptoms being wanting, and oc- casionally others. In all such cases, the organ is torpid, yet irritable, and the cure must depend upon our ability to give it fresh tone and vigour. The general congestion is most effectually re- moved by smaller doses of calomel than advised in the acute variety, so as to produce an alter- ant effect, and gently excite the sluggish secer- nents into a state of renewed activity. Though here also ptyalism is aimed at, in hot climates, yet in a milder degree than in the acute variety.* And, in conjunction with these, we are to em- ploy warm aromatic bitters; and, where they agree with the stomach, the mineral acids. Dandelion, as recommended by Boerhaave and Bergius, has often been found serviceable. Dr. Pemberton paid much attention to its virtues, and had often seen it of decided advantage in incipient scirrhosities of the liver and other ab- dominal organs ; and strongly recommended it in doses of half a drachm of the extract twice a day.—(Treatise on the Diseases of the Abdomi- nal Viscera.) We cannot, however, always depend upon this preparation, and hence, as a general rule, it will be more advisable to employ the decoction. Where there is an evident tumour on the right side, a seton should be in- troduced over it. In slighter cases, which have nevertheless compelled a return from India after a residence of eight or nine years, I have found all the symptoms vanish before a steady use of Plum- mer's or the blue-pill, taken every night for a month ; and the Cheltenham air and waters, for the same period of time afterward. Where a chronic inflammation of the liver has terminated in a scirrhus of the whole organ, or of a great part of it, the blood is obstructed mon than acute.—Bateman, in art Liver, Rees's Cyclopaedia.—Ed. * Before employingmercury, Dr. Stokes applies twelve leeches to the region of the liver every third or fourth day, until the pain and tenderness are removed. Afterward he resorts to counter- irritation, with repeated blisters, or antimonial ointment. If these means do not succeed, he endeavours to affect the system gently with mer- cury, for which purpose he prescribes a small dose of calomel, or blue-pill, combined with Do- ver's powder, to be taken at night, or mercurial inunction over the region ofthe liver. When any thing in the state of the constitution forbids mer- cury, Dr. Stokes speaks favourably of the nitro- muriatic bath, or of sponging the surface of the body with this fluid. Frictions with the ointment of the hydriodate of potash on the right hypo- chondrium, and the internal exhibition of iodine, are also sometimes employed with benefit.—Ed. in its circulation, congestion takes place in other organs, and we often meet with very extensive hemorrhages from the lungs, nostrils, stomach, or anus. These discharges are rarely, perhaps never, of service in chronic cases, and only contribute to weaken the system. But, in acute cases, constituting the first variety, by diminish- ing the phlogotic action, they are often of very essential use. [Disease of the liver not uncommonly brings on a cough, which is sometimes so prominent a symptom, as to lead the practitioner to suppose the seat of disease to be-in the lungs.*] SPECIES XIV. EMPRESMA SPLENITIS. INFLAMMATION OF THE SPLEEN. heat, fulness, and tenderness in the sple- nic REGION J WITH PAIN UPON PRESSURE. Of the use of the spleen, as observed in the Physiological Proem to the first class, we know little or nothing. It secretes no peculiar fluid, except what serves to produce a change in its own blood, which is of a dark livid colour, and coagulates with difficulty. It is commonly sup- posed to be an organ auxiliary to the liver ; and it is unquestionably subject to all its ailments : voluptuous living, however, and even the heat of a torrid sun, affect it less; but obstinate ter- tians and quartans more, and render it sooner congestive and scirrhous. Inflammation of the spleen, together with the symptoms given in the definition, is accompanied with the usual pyrectic signs ; and often with a pain extending over the whole of the abdomen, but particularly in the left side, and shooting from the diaphragm to the left shoulder. There is also not unfrequently a dry, short cough, and sense of constriction in the praecordia, sickness or nausea, and a discharge from the rectum of black or livid blood, from a rupture of some of the splenic vessels. It is, however, a rare com- plaint. "The spleen," observes Dr. Baillie, " is much less subject to inflammation than many other of the abdominal viscera. I do not recollect a strongly-marked case of it in my practice ; and I have never met with an abscess in the spleen in all the dead bodies which I have examined."! The common causes of in- flammation of the spleen are the same as those of the liver ; and the treatment need not essen- tially vary, as the progress and terminations of the disease are not different. In India, where it is more common than in temperate climates, * See Dr. Brooke's Case and Obs. on Liver Cough, in Trans, of the King's and Queen's Col lege of Physicians, vols. iii. and iv. ; and Sii Thomas Moriarty's Communication in the latter volume. ! Lectures and Observations on Medicine, 1815. Unpublished. Notwithstanding these remarks, abscesses of the spleen,!; and these of different kinds, have been met with by other anatomists, as may be learned by reference to the additions made to the subject of parabysma splenicum.—Ed. X This remark of the editor is confirmed by occasional dissections in this country.—D. Gun. VII.—Spe. 15.] EMPRESMA NEPHRITIS. ' 521 the native practitioners use acupunctures and scarifications. The splenalgia, or pain in the spleen, of many writers, is for the most part a slight attack of this disease, with some small degree of fever. For further observations on diseases of the spleen, see Parabysma Splenicum. SPECIES XV. EMPRESMA NEPHRITIS. INFLAMMATION OF THE KIDNEYS. PAIN IN THE LOINS ;* FREQUENT MICTURITION ; VOMITING J NUMBNESS OF THE THIGH ON THE AFFECTED SIDE ; RETRACTION OF THE TESTI- CLE. The general causes of this species are what- ever obstructs the flow of the fluids in the ves- sels of the kidneys ; as a wound, contusion, tumour, strain of the muscles of the back that press on the kidneys, excess of horse-exercise, various acrids conveyed to the kidneys by the course of the circulation. It is, however, most frequently met with as a secondary disease, re- sulting from calculous matter blocking up the tu- buli nriniferi, or from calculi formed in the pelvis of the kidneys, and obstructing that cavity or the canal of the ureters, concerning which we shall have to treat under the genus lithia, embracing calculous concretions in the urinary passages.! The symptoms enumerated in the specific def- inition are sufficient to indicate the presence of nephritis, though the numbness and retraction of the testicle are common to calculi in the ureters, or body of the kidney, even when there is little inflammation present. In the case be- fore us, however, the skin is usually hot and dry,! the body costive, and motion, and even * Usually experienced only on one side, and de- scending, along the ureter to the bladder; fre- quently a good deal of uneasiness is also felt in the glans penis. The numbness is in the inner part of the thigh, in the course of the anterior crural nerve. The testicle is often swollen and tender, as well as retracted.—Ed. ! Nephritis may be produced by cold, like any other inflammation, but it is rarely an idiopathic disease ; it is more frequently the result either of mechanical violence, or of the action of turpentine or cantharides on the kidneys ; or of stones lodged in it; or of a disposition perhaps to gout.—See Elliotson's Lectures, delivered at Lond. Univ., as published in Med. Gaz., p. 722, 1833.—Ed. X Dr. Cullen inserts pyrexia as a part of his def- inition of nephritis, and, according to the editor's judgment, very correctly ; for, as Dr. Carter ob- serves, all the other symptoms are common to both nephritis and nephralgia : indeed, the pain in the latter affection may be much more intense than in inflammation of the substance of the kidney, and quite as severe as when its capsule is inflamed; but the pulse is little, if at all affected, and the other signs of inflammatory fever are absent. But if, with the symptoms of the local affection, we find a frequent, hard pulse, a loaded tongue, great heat and dryness of skin, we may at once pronbunce the disease to be nephritis.—(See art. Nephral- gia, &c, in Cyclop, of Prac. Med.) In a rheumat- ic affection of the loins, the pain is usually felt on both sides, extending to the hip, and, if down an erect position, are accompanied with con- siderable uneasiness. By the last sign we may distinguish the disease from an inflammation of the psoas, or almost any other adjacent muscle ; while the immediate seat of pain separates it from colic, even when it is attended, as it is occasionally, with ventral gripings. When the disease is violent, the urine is dis- charged in small quantity, and of a pale hue. And hence, if the urine become higher coloured, be secreted in a larger proportion, and be at length thick and mixed with mucus, a gradual relief may be expected to follow, and the cure will be effected by a copious flow. The disease sometimes passes off also by a metastasis. But if the symptoms be protracted beyond the seventh day, and there be stupor or heaviness in the organ, instead of acute pain, with fre-, quent returns of chilliness and shivering, we have reason to expect that an abscess will en- sue : in which event the pus may be discharged into the pelvis of the kidney, the abdomen, or, in case of adhesions, externally through the in- teguments and the skin. The first is the most favourable issue, next to that of resolution ; the last is often succeeded by a cure, but an evacu- ation of pus into the cavity of the abdomen rare- ly. In some instances the suppuration has been so considerable as to destroy the substance of the affected kidney entirely, and leave nothing but the external membrane.* Yet there are cases in which a patient has recovered even in this state, and the office of secretion has been performed by the sound kidney alone. Gangrene occasionally ensues,! and it is indi- cated by a sudden remission or cessation of pain, after great violence of vascular action; accompanied with cold sweats, a sinking pulse, discharge of black urine, and other symptoms of approaching dissolution. Generally speaking, the cases of complete recovery are but few, though the patient often lingers, and even with an occasional prospect of recovery, for many months, or even years. "The formation of matter," observes Dr. Baillie, " will sometimes be suspended for several months, and patients will recover in a considerable degree their gen- eral health. The disease will return, either from imprudence in diet or exercise, or without any known cause, and the patient will become as ill as ever. It very rarely happens that a the thigh, not in the course of the anterior crural nerve, but in that of the sciatic nerve.—(See El- liotson's Lectures at Lond. Univ., Med. Gaz., p, 721, 1833.) There is no frequent desire to make water, no pain in tfte course ofthe ureter, no en- largement, no tenderness, no retraction ofthe tes- ticle.—Ed. . '• * The editor was once required to sound a patient in a case of this description, attended with symptoms very much resembling those of stone in the bladder. The patient was under the care of Dr. Smith and Mr. Baker of Staines. The former gentleman published some of the particulars of the disease in one of the volumes of the Lond. Med. Gaz. The quantity of matter was very consider- able.—Ed. ! See a Case by Dr. Turner, in the 4th vol. of the Trans, of the College of Physicians.—Ed. 522 H.EMATICA. [Cl. III.—Ord. II. patient permanently recovers from this disease, and I do not at present recollect an instance of it."—(Lectures and Obs. on Medicine, 1825.) In attempting a cure of nephritis, we should commence with copious bleeding, and we may most conveniently apply cupping-glasses to the region ofthe kidneys. Saline purgatives should follow; and then oleaginous or mucilaginous emulsions, with small doses of nitrate of potash, or tincture of digitalis. The last has often proved highly serviceable in taking off the arte- rial action that maintains the inflammation, and at the same time in augmenting the urinary se- cretion. The loins should at the same time be covered with a large folded flannel wrung out in hot water, and confined, as already described in the case of peritonitis ; and copious emollient injections should be frequently thrown up the rectum, and suffered to remain there as long as the patient may be able to retain them. The rest of the treatment and regimen should be that of inflammation in general.* SPECIES XVI. EMPRESMA CYSTITIS. INFLAMMATION OF THE BLADDER. PAIN AND SWELLING IN THE HYPOGASTRIC RE- GION J PAINFUL OR OBSTRUCTED DISCHARGE OF URINE J TENESMUS. The bladder is often irritated and inflamed by the lodgment of a calculus in it, by viscid substances that pass into the circulation, and par- ticularly by cantharides, ardent spirits, and tere- binthine essences or balsams. Idiopathic in- flammation is not a frequent disease ; yet it oc- casionally occurs ; for the bladder is subject to the common causes of inflammatory affection. Its exterior serous coat, its muscular coat, and its internal mucous membrane may all be affect- ed ; or the inflammation may affect the muscular or mucous coat separately.! [Cystitis is some- times brought on by gonorrhoea, the inflamma- tion of the lining of the urethra extending to the mucous membrane ofthe bladder.] If the lower part of the bladder be chiefly affected, the pain will extend to, and take the course of the perinaeum. If the seat be in the neck of the organ, there will be a retention of urine with a constant urgency to evacuate ; if in the fundus, the urine will flow stillatitiously, and without ceasing; the bladder will give a feeling of being constantly full ; and the patient * I believe the best practitioners of the present day do not administer digitalis-nitrate of potash, and other diuretics, in cases of nephritis. With respect to purgatives, Dr. Elliotson prefers those of calomel. The warm bath is also more efficient than partial fomentations. In the event of sup- puration, the treatment is to be regulated by the principles applicable to suppuration in general. Anodynes will be required, and uva ursi may be tried, though its virtues are rather doubted by many members of the profession.—Ed. ! In some observations on inflammation of the bladder, inserted by Mr. Coulson in the Med. Gaz. for 1833, an attempt is made to lay down the par- ticular symptoms which characterize both these varieties of cystitis.—Ed. will be perpetually and fruitlessly striving to empty it. In this affection there is usually great restlessness and anxiety, with cold ex- tremities, vomiting, wildness of the eyes, deliri- um, and other marks of great general irritation. Much heat and smarting are generally experi- enced in the urethra; the patient is troubled with continual tenesmus, and pressure on the hypogastric region occasions violent suffering. The disease runs its course with rapidity, and subsides, or destroys the patient, in a few days.* It terminates, like all other inflammations, most favourably by resolution. But if this do not take place, it passes on to suppuration or gangrene ; the diagnostics of both which are those already noticed in the preceding species. If suppuration take place, the pus may be dis- charged by the urethra, which is its happiest outlet; or it may follow the course ofthe ulcera- tion, and be emptied into the cavity of the ab- domen ; or, if adhesions have been formed with the subjacent cellular membrane, it may work its way in a sinuous direction, and find an open- ing in some part of the perinaeum. Of the last two terminations, the first is almost always fatal; and the second is extremely troublesome and tedious, though a cure is usually affected at last. Repeated bleedings, aperients, and relaxants, with copious emollient injections, suffered to re- main in the rectum as long as possible, form the chief part ofthe plan of cure. Blood should be drawn both generally and locally, and a large bladder about half full of warm water be kept constantly over the pubes. The warm bath has also been frequently of essential service.! * When the lining of the bladder is inflamed, the disease is very likely to be mistaken for stone. The following are the considerations specified by Mr. Coulson, as indicating the difference of one case from the other:—" The uneasiness in the bladder, frequent desire to make water, and the passage of blood with the urine, are symptoms of stone, as well as of this complaint. But in stone the pain is principally experienced after the blad- der has been emptied; whereas, in acute inflam- mation of the mucous membrane of the bladder, the pain is most intense when the bladder is full, and subsides when it is empty: in stone, larger quantities of blood are passed than in this disease, and the urethra is seldom so irritable."—Med. Gaz. for 1833, p. 666.—Ed. ! To the remedies which are mentioned in the text for affections of the bladder, may be added the buchu. This plant (the agusthosma crenatum of Wildenow, the diosma crenata of Thunberg) has long been used by the Hottentots at the Cape of Good Hope for a variety of diseases, and was thus brought to the notice of the English and Dutch physicians, who have recently employed the buchu in Great Britain "and on the continent. Very lately it has awakened the attention of prac- titioners in the United States. Dr. Francis in- forms me that he first became acquainted with this medicine from information given him by Dr. M'Lean, who had used it in a complex case with great success. Profiting by his remarks, Dr. F., within the last four years, has prescribed buchu tea in a number of cases of chronic catarrh of the bladder, of retention of urine in consequence of Gen. VII.—Spe. 17.] EMPRESMA HYSTERITIS. 523 When the urine is actually suppressed, it is usually evacuated by a catheter ; but I would strenuously recommend, instead of this, a siphon formed upon the plan of that employed by Mr. Jukes for the stomach, and already described under dysphagia constricta (Class I., Ord. I., Gen. III., Spe. 1), with an elastic bottle attach- ed to its outer end, and a stopcock adapted to it; so that, being introduced in its contracted Or vacuum state, it may readily be converted into a powerful suction-pump by merely turning the valve. This instrument may also be rendered of great importance in another way ; for by charging it with an emollient or anodyne fluid, when the bladder is empty, we may get such preparations to come immediately in contact with the inflamed surface of the bladder, in any degree of strength that may be advisable.* SPECIES XVII. EMPRESMA HYSTERITIS. INFLAMMATION OF THE WOMB. PAIN, SWELLING, AND TENDERNESS IN THE HYPOGASTRIC REGION; HEAT, PAIN, AND TEN- DERNESS IN THE OS UTERI J VOMITING ; PULSE RAPID. This species offers us two varieties, accord- ing to the condition of the organ at the time of attack :— a Simplex. - The organ unimpregnated. Simple inflam- Pain permanent, circum- mation of the scribed, throbbing ; fe- womb. ver a cauma. weakness or diminished energy of this organ, &c. —and in most cases with the happiest results. It seems to possess several advantages not belonging to the remedies generally used. The buchu leaves are best given in an infusion made by pouring a pint of boiling water on an ounce of the leaves ; which quantity may be taken in twenty-four hours. This article is mentioned satisfactorily in the ex- cellent Dispensatory ofthe United States, by Pro- fessors Wood and Bache, of Philadelphia (second edition), 1834.—See also Manuel de Matiere Med- icale, par H. M. Edwards and P. Vavasseur, p. 362, Paris, 1831—D. * The plan of appeasing an inflamed bladder by injecting any kind of fluid into it, is one that is now renounced by all men of experience. On this point 1 will quote a short statement made by Mr. Coulson, in speaking of inflammation of the mu- cous membrane of the bladder :—" Some recom- mend the injection of oil and opium, and other sub- stances, into the bladder, by means of a gum-elastic catheter ; and in one of my patients this plan had been suggested by an eminent physician, prior to the patient being placed under my care; but no benefit was derived from this treatment. In fact, the pain and irritation which are experienced from the introduction of instruments into the bladder in these cases, are so considerable as to deter me from employing this plan."—(Lond. Med. Gaz. for 1833, p. 666.) This gentleman found some bene- fit produced by the decoction of pareira brava, after the severity of the pain had been subdued by other means ; though he pronounces it to be more applicable to the chronic form of the complaint. He adds, hyosciamus, opium, lime-water, with sirup of poppies, may from time to time be ad- ministered.—Ed. 0 Puerperarum. The organ having lately suf- Puerperal in- fered childbirth. Pain less flammation of acute, less circumscribed , the womb. flow of urine difficult; fe- ver a synochus or typhus. The first of these is produced by cold, or any of the other ordinary causes of inflamma- tion, and terminates in resolution, suppuration, scirrhus, or gangrene. The most ordinary ter- mination is that of resolution, the next that of scirrhus, sometimes running into cancer : both which are far more common to women who have never been impregnated than to those who have had families, but rarely appear before menstrua- tion, from the natural quiescence of the organ in this state.—(J. P. Frank, de Cur. Horn. Morb. Epit., tom. ii., $ 922, p. 217.) [One symp- tom is constant, viz., pain in the hypogastric re- gion, which is increased by the slightest pres- sure, or on the patient's making a deep respira- tion. The urine is generally voided with diffi- culty, and in small quantities; and, as the rec- tum participates in the irritation, a distressing .tenesmus is experienced. The bowels are mostly irregular, the tongue white, apd the pulse rapid, small, and what some practitioners term wiry. The pain frequently extends with great severity to the loins, and sometimes shoots down the thigh ; and, as the stomach sympa- thizes, there is generally vomiting.] All the ordinary means already noticed for subduing inflammation, both general and local, should here be put into effect without loss of time ; as, copious and repeated venesection, leeches, aperients, emollient injections, both into the rectum and uterus itself, and fomentations or epithems to the hypogastrium. The disease is sometimes relieved by a sudden flow of the menses, with hemorrhage or genuine blood.* * Inflammation of the womb is sometimes at- tended with another disease, which has been much overlooked : we allude to inflammation of the ovary, which might very properly be introduced into this genus under the term Empresma Ovaritis. Among the causes of this disease may be men- tioned, inflammations of the uterus or of the peri- toneum, difficult labour, repeated abortion, the in- dulgence in sexual intercourse before the proper period, shortly after parturition, or when conva- lescent from diseases of the uterus, disappoint- ment in marriage, &c. The most prominent symptoms of ovaritis are, pain in one or both sides ofthe abdomen, increased by pressure; this pain is more severe, also, when the patient walks, but is much less in lying down : sometimes, also, the affected ovary becoming en- larged, a tumour is observed in the side diseased. Ovaritis is sometimes resolved, sometimes it be- comes chronic, and sometimes it terminates in suppuration ; the pus collects in an abscess, which opens in the anterior wall of the abdomen, in the Fallopian tube, the vagina, the peritoneal cavity, the bladder, and even into the intestines; it emerges through the vulva, the urethra, or the anus, or it remains incarcerated in a cyst. Mad. Boivin thinks that the adhesion of the inflamed ovaries to the adjacent parts seems to prevent conception, the development of the fetus, and to be a very common cause of abortion. Ovaritis requires to be treated, like other inflam- mations, by bleeding, leeches, warm mucilaginous 524 H.EMATICA. [Cl. Ill—Ord. II. The second variety, in which the symptoms are alike, but less acute, is usually, though not always, a result of suppressed lochia, or vio- lence sustained during labour, particularly from the use of instruments : the inflammatory action from this cause often extends down the vagina, which is hot, reddened, tense, and tender to the touch ; and sometimes the same effects descend so low as to be manifest externally. Bleeding is here to be avoided,* and the inflammation to be attacked with gentle laxatives, diaphoretics, and, where there is much irritability, camphire and opiates ; fomentations and injections being employed at the same time. It is a singular but well-ascertained fact, that the spleen, from some unknown cause, is pecu- liarly apt to sympathize with the action of the womb, and at times to run into an equal degree of inflammation, suppuration, or even gangrene ; and especially in females of a high nervous tem- perament. And so common is this fellowship of action, that most of the cases of diseased spleen related by Morgagni, are accompanied with an account of some mischief existing in the womb or its appendages. It is, however, to M. Gastellier, of the Hospice de la Maternife, at Paris, that we are chiefly indebted for a knowl- edge of this peculiar sympathy, and especially in the case of uterine inflammation after child- birth. " La rate," says he, " en a 6t6 souvent frapp^e, mais une fois entr' autres elle a €t€ entierement d^truite, entierement fondue : il n'en restoit aucune trace, sinon un foyer de fluide sanieux, dans la region, et en place de cet organe." This passage from M. Gastellier is quoted by Dr. Ley, in a case of a similar kind which lately occurred to himself in the Westminster Lying-in Hospital.—(Med. Trans., vol. v., art. xx.) In this case, the preceding labour seems to have been perfectly natural, and without any difficulty whatever. On the third day after- ward the disease seems to have commenced, indicated by intense pain over the whole of the abdominal region, with a slight sense of fulness, but without any considerable degree of tension. The patient sunk suddenly seven or eight days subsequently, and at a time when she was sup- posed to be in a state of improvement. On ex- amining the body, the peritoneum and intes- tines exhibited little morbid affection of any kind, and the disease was found limited to the uterus and spleen; the peritoneal covering of both was slightly inflamed, but the internal structure of both had Undergone a very extensive de- struction. The whole surface of the uterus, when stripped of its tunic, was found to have as- sumed a gangrenous appearance, was extremely irregular, of a dark, livid hue, and gave forth a highly offensive vapour. The texture of the fomentations, and calomel. For further details on this disease, see Boisseau, Nosographie Organ- ique, tome troisieme, Paris, 1829, p. 803; Nou- veaux Elem. de Pathol. Medico-Chirurgicale, par Roche et Sanson, tome premiere, Paris, 1828.—D. * There does not seem to be any sound reason for this caution ; bloodletting may often be considered as an effectual auxiliary to our means of relief.—D. spleen was so changed as to resemble an ex- tremely soft piece of sponge, and its cells were filled with an intimate mixture of pus and gru- mous blood.* SPECIES XVIII. EMPRESMA ORCHITIS. INFLAMMATION OF THE TESTICLES. PAIN AND SWELLING OF THE TESTICLES ; NAU- SEA OR VOMITING ; DEPRESSION OF SPIRITS ; PULSE QUICK, SOMEWHAT LOW.! Inflammation of the testicle has generally been expressed by the absurd and unmeaning name of hernia humoralis ; which, however, in its earliest use, applied to only one stage of the disease, namely, the suppurative, and imported an abscess or collection of pus in any part of the scrotum ; and, in this sense, the expression occurs in Heister and Dionis, being precisely synonymous with the empyocele of the Greeks. I have revived the Greek term orchitis, not only as being far more precise, but as accordant with the general termination of the specific names of the diseases appertaining to the present genus. The inflammation seems commonly to com- mence in the tunica vaginalis, and to pass sec- ondarily into the substance of the testis. Dr. Swediaur contends, that the testis never swells in the first instance, and that the disease al- ways begins in the epididymis.! The causes * Hysteritis puerperarumis, in fact, the disorder commonly, but improperly, called puerperal fever, and described in a former part of this volume, p. 414. Experience has now fully proved, that this disease is not necessarily and essentially perito- nitis. This fact is clearly established by the evi- dence adduced on the subject by M. Tonelle, Dr. Conquest, and Dr. Lee. Dr. Conquest does not think, however, that the morbid appearances are always sufficient to account for death ; for some- times he has only found a Fallopian tube, or an ovary inflamed. In other cases, hysteritis, uterine phlebitis, gangrene of the uterus, and agglutina- tion of all the pelvic viscera, are noticed in post- mortem examinations. For further information respecting the morbid appearances, see ante, p. 414, et seq. An excellent account of the different views taken by different men of eminence of the nature and best mode of treating puerperal fever, is given in Ryan's Manual of Midwifery, p. 635, ed. 3. His description might be much enriched by a notice of the valuable observations of Doctor Lee.—Ed. ! The pulse is quick and hard ; the skin is hot; the patient is constipated; and if blood be drawn from the arm, it presents a buffy covering, and its surface is cupped or excavated.—Ed. X According to Sir Astley Cooper, the first symp- tom of orchitis, when it arises from sympathy with the urethra, is an irritation of the membranous or prostatic portion of that canal, as if some drops of urine still remained in the beginning of the ure- thra ; and this is succeeded by a tenderness in the spermatic cord at the abdominal ring, and by swel- ling and pain in the epididymis. The testicle next swells, and attains a considerable size, becoming at the same time so tender, that the pressure of the thigh against it can hardly be endured. Its weight is also much increased; the pain and swelling ex- Gen. VIII.j OPHTHALMIA. 525 are irritation in the urethra, or external injuries. The most common source of irritation is a gon- orrhoea [which usually stops, or undergoes a con- siderable diminution, as the testis begins to swell.] Bleeding, leeche6, puncturing the veins of the scrotum (Sir Astley Cooper, op. cit, p. 27), the recumbent posture, laxatives, and cold lotions, with a suspensory bandage, form the curative process.* [After two or three days, fomentations and poultices are the best appli- cations.!] Yet we have already observed, that, when all local applications have proved inef- fectual, the inflammation has been removed by vomits, in consequence of the close sympathy between the testis and the stomach. This was a frequent practice of Mr. John Hunter (On Venereal Disease), and especially when the inflammation was the result of gon- orrhoea. It was successfully employed for the same purpose, and is hence strongly recom- mended by Rhases (Continent., lib. xi.), and is a common mode of treatment on the continent, particularly in Germany : after which opiates are often had recourse to, as well externally as internally. It may be worth remarking, that the affinity or play of action which thus pre- vails between the testis and the stomach, does not appear to be the common bond of union that is exhibited between the stomach, as the gen- eral centre of sympathy, and most other parts of the system ; but a fellowship of a peculiar kind, and which, in fact, does not terminate in the stomach, but extends to the upper extremity of the alimentary tube, and exercises a very high degree of influence over the parotid glands, as is well known in e. parotitis, and has been al- ready noticed in discussing that disease. In treating of e. hysteritis, I have had occasion tend along the cord into the inguinal canal; and a good deal of uneasiness is felt both in the groin and the lumbar region, especially when the in- flamed testis is suffered to hang down unsupported. In severe cases, nausea and vomiting sometimes occur. It is remarked by Sir Astley Cooper, that. the epididymis swells more in proportion than the testis, the globus major and minor being more affected, however, than the body of the epididymis, and the former generally very perceptible in front of the spermatic cord. In some cases the pain is pe- riodically and severely increased by spasms of the cremaster muscle.—See Obs. on the Structure and Diseases of the Testis, by Sir Astley Cooper, Bart, 4to., Lond., 1830, p. 9. * Tepid fomentations of vinegar and water, one part of the former mixed with four of the latter, will often be found very useful: the slippery elm- bark poultice is one of the best local applica- tions.—D. ! Sir Astley Cooper, op. cit., p. 28. This ex- cellent surgeon finds, that there are some consti- tutions in which depletion will not succeed in re- lieving orchitis, and, when the pulse is jerking, the patient irritable, and the part painful, he deems it the best practice to give the submuriate of mer- cury, with the compound powder of ipecacuanha. When matter forms, he recommends it to be dis- charged by puncture, as the tunica albuginea ul- cerates slowly. Frequently the abscess is in the testis itself; often in the epididymis; and oc- casionally in the spermatic cord.—Op. cit., p. 30. —Ed. to glance at the existence of a like sympathy between the' uterus and the spleen: and the physiologist who has time for such pursuits, and judgment enough to guide him to a correct dis- crimination, would be engaged in no unthrifty employment, if he were to follow up, and ar- range in a regular classification, these specific and mysterious relationships which single or- gans hold with single organs, and which are subordinate to the general harmony of the en- tire machine.* GENUS VIII. OPHTHALMIA. OPHTHALMIA. INFLAMMATION OF THE EYE. PAIN AND REDNESS OF THE EYE OR ITS APPEN- DAGES; intolerance of light ; flow of TEARS OR OTHER DISCHARGE.^ Ophthalmia, from the Greek term (tyflaX^d?,, " oculus," is obviously of very extensive import, and, from its radical signification, may be applied to any morbid affection of the eye, unless lim- ited by common consent. Now, although a sort of common consent has been given, so as to re- strain the term to inflammatory action, such con- sent has not been universally acceded to; and hence ophthalmia has been used in very different senses by different writers. Thus Sauvages, •Linneus, and Sagar employ it as expressive of any ache of the eye, without reference to pyrexy or inflammation. Among all these, therefore, it occurs under their class dolores, and runs parallel with cephalalgia, or cephalaea, ache or pain in the head. By Vogel, Cullen, and Macbride, it is limited fo inflammatory affections of the eye ;. the two former arranging it as a genus, and the latter as a species. By Dr. Parr and Dr. Young it is also arranged as a species, and limited to a phlogotic action ; the second denominating it ophthalmitis, consonantly with the common ter- mination of names importing inflammatory dis- eases of a particular description of internal mem- branes and organs. In the present system ophthalmia assumes a middle rank : it is limited to inflammatory ac- tion accompanied with organic pain, but is ar- ranged as a genus. It might possibly have been placed as a species under the preceding genus, empresma ; but it has various characters pecu- liar to itself, as well in regard to its symptoms, as to the particular parts of the organ affected, which seem to entitle it to the rank of a distinct genus. And, thus explained, its real meaning will be found in the generic definition ; the symptoms of-inflammation common to the order, and entering into the ordinal definition, being * It is remarked by Sir Astley Cooper, that when an acute inflammation of the testicle is sym- pathetic with the urethra, it rarely advances to suppuration ; and he extends the same observation to other sympathetic inflammations. But, when orchitis is the effect of mechanical violence or vi- cissitude of temperature, suppuration may happen, though not frequently. The symptoms are then ag- gravated, and rigours occur.—Op,cit, p. 11.—Ed, 526 H^EMATICA. [Cl. III.—Ord. II. always understood as a part ofthe generic char- acter. [Yet, if the words of the definition be strictly adhered to, and no inflammations in the eye be regarded as species of ophthalmia, unless attended with redness and intolerance of light, certain cases, generally admitted to be such by the best modern practitioners, will be excluded. As Mr. Lawrence has correctly noticed, it is impossible to reduce into one description the characters of the various inflammations affecting the several structures of the eye. The truth of this must be evident, when it is recollected that the eye and its appendages exhibit, within a very small compass, a great variety of textures. We find in the visual apparatus, specimens of each of the three divisions of membranes, the mu- cous, the fibrous, and the serous ; the conjunc- tiva, the sclerotica, with the cornea, and the surfaces containing the aqueous humour, cor- responding respectively to each of those classes. It contains also nervous, muscular, and glandu- lar parts ; and, besides these, several tissues of peculiar structure, to which there is nothing analogous in other parts ofthe body ; as the iris, the ciliary body, the choroid coat, and the trans- parent media. Each of the latter has its own characteristic structure ; the cornea, the crys- talline lens, the capsule of the lens, and the vit- reous humour, resemble each other in being transparent. What similarity of character can we trace between inflammations of the conjunc- tiva, cornea, iris, and retinal Inflammation of the external tunics differs widely from that of the internal. Hence the attempt to embrace all these affections under one head, name, or defi- nition, will only lead to confusion. It may be argued, indeed, that several textures of the eye are frequently inflamed together ;. yet the af- fection mostly begins in one, and, if duly treated, may often be wholly or principally restricted to it.* As, in a work of this kind, it can hardly be desirable to enter into a minute description of cases usually regarded as belonging to the de- partment of the surgeon, the editor conceives * As Mr. Middlemore has well observed, the study of the diseases of the eye is peculiarly inter- esting ; for in consequence of the superficial situ- ation of some of its textures, and the transparency of others, an opportunity is frequently afforded of actually witnessing the morbid process. When the pleura is inflamed, we may infer, from existing symptoms, that serum is effused, that lymph is de- posited, or that pus is secreted, as a consequence of such inflammation; but, if the conjunctiva, or any of the superficial textures of the eye are dis- eased, we can not only see their precise patho- logical state, but the product of such morbid con- dition.—(See Lectures on Dis. of the Eye, as pub- lished in Med. Gaz. for 1832-3, p. 136.) "Many of the diseases of the eye, and, generally speak- ing, those of chief importance, are very obscure in their symptoms on cursory examination, and, at the same time, rapidly destructive in their prog- ress ; and, unless they are very promptly de- tected, they may arrive at that degree which no remedies will then affect. To detect, therefore, the degree of inflammation, as well as the particular texture inflamed, affords, in many instances, the only chance of preventing the loss of vision." —Middlemore, op. cit—Ed. that a notice of the following species of oph- thalmia will suffice, the arrangement being founded on the structure and parts of the eye chiefly affected. 1. Ophthalmitis. Inflammation of the whole Eyeball. 2. Ophthalmia Ex- Inflammation of the Ex- terna, ternal Tunics. 3.----------In- Inflammation of the inter- terna. nal parts of the Eye. These species, with their varieties, will em- brace as much of the subject as can be expected in a work of the present description, rather em- bracing physic than surgery. Staphyloma, ec- tropium, and entropium, which were arranged in the early editions as species of ophthalmia, though frequently attended with a greater or less degree of inflammation of the organ, are never considered by an«y of the best practitioners of the present day as ophthalmiae. It is therefore only on the principle of their being often as- sociated with a degree of ophthalmia, that their admission into the present genus can be at all justified. The editor, therefore, with some re- luctance, suffers them to remain annexed to the foregoing species, and in the place assigned them by the author.] 4. ------ Staphy- Protuberant and Opaque loma. Cornea. 5.------Ectropi- Everted Eyelid. um. 6. —----Entropi- Inverted Eyelid. um. For the diseases affecting the sense of vision, and unaccompanied with inflammation, the read- er must turn to the ensuing class Neurotica, Order IL, in Vol. II. SPECIES I. OPHTHALMITIS. INFLAMMATION OF THE WHOLE EYEBALL. inflammation seated in no particular tex- ture OR COAT, BUT AFFECTING MORE OR LESS ALL THE TISSUES OF THE EYE ; INCREASED SECRETION OF TEARS. When this general inflammation of the globe is fully developed, it is characterized by very considerable pain, increased external redness, more or less swelling of the part, increased lachrymal discharge, following, however, an earlier stiffness and dryness of the eye, and by redness and swelling of the upper eyelid. The pain is by no means confined to the front of the eye ; but is deep-seated, and extends to the surrounding parts, as the brow, cheek, temple, and back of the head. The redness is at first inconsiderable, and seated in the sclerotic coat ; but the conjunctiva soon participates in it, and the distention of its vessels produces the bright scarlet redness which conceals the faint pink colour of the sclerotica. The conjunctiva then begins to swell, and a deposition of lymph takes place, not only in the texture of the membrane, but in the loose cellular tissue that unites it to Gen. VIII.—Spe. 1.] OPHTHALMITIS. 527 the sclerotica. This bright scarlet elevation of the conjunctiva, projecting beyond and surround- ing the cornea, firm, of considerable breadth, and acutely sensible, is technically called che- mosis. The access of light is very offensive to the patient; the pupil contracts to exclude it; and the eyelids are spasmodically closed. As the slightest attempt also to exert the organ produ- ces severe pain, the patient keeps it as com- pletely as possible at rest.—(A Treatise on the Diseases of the Eye, by William Lawrence, p. 74, 8vo., Lond., 1833.) In the second stage, various alterations of structure are noticed. The iris becomes changed in colour, its brilliancy declines, and it no long- er exhibits its usual motions in the varying degrees of light The pupil contracts, and loses its clear black colour. The cornea becomes more or less opaque, and vision is lost. The alteration in the cornea, and in the state of the pupil, as Mr. Lawrence well observes, would account for imperfection or loss of sight; but the latter often occurs while the cornea is suf- ficiently clear for the transmission of light, and the pupil still open: hence, the evil is then to be ascribed to the mischievous effect of the in- flammation on the structure ofthe retina ; which effects, also, no doubt, generally exist, when the above specified causes of the interruption of the passage of light into the eye are present When the inflammation has attained its greatest violence, ectropium of the lower eye- lid takes place, and a portion of the anterior surface of the eye projects in a denuded state, like a piece of red flesh. To continue Mr. Lawrence's matchless de- scription, here, however, considerably abridged, the mucous membrane of the eyelids becomes the seat of inflammation equally violent with that of the conjunctiva of the globe, becoming red as well as the skin, and the consequent swelling forms a large convex protuberance on the upper eyelid. The pulse is quick, hard, and full; the face flushed ; headache is experi- enced ; the skin is hot and dry; the tongue white ; the appetite lost ; the patient restless, and his nights sleepless. The disorder, if not checked, is now attended with aggravation of all the general and local symptoms ; the pain becomes throbbing, rigours occur, and suppuration of the eyeball follows ; the cornea turns of a dull white, and then yel- low colour. The agony is not relieved by the formation of matter, but continues for some days, until the cornea bursts, and the contents of the abscess are discharged, generally with the vitreous humour and crystalline lens. Mat- ter is discharged for a time ; the tunics of the eye collapse, shrink into the orbit, and the ori- ginal form of the organ is completely lost. When the disease does not proceed so far, the cornea becomes opaque, and remains so; the pupil is either closed or very much contracted, and the aperture filled by a newly-formed adven- titious substance. Vision is either completely, or in a great degree lost; but the form of the eye remains. | The most favourable termination that can be expected, is the recovery of the organ, with the cornea clear, and the pupil open; still, in this case, as Mr. Lawrence has observed, the retina has generally suffered so much, that more or less of imperfection of vision is produced. The present species of ophthalmia is charac- terized by its commencing, at one and the same time, in the external and internal tunics of the eye. Internal inflammation may spread to the external coats, or external inflammation may extend inwards ; but, in this affection, both sets of parts are simultaneously attacked. The prognosis, as delivered by Mr. Lawrence, is short and instructive. If the affection be seen early, and actively treated, you may expect to arrest it, and to prevent a change of struc- ture in the organ, and consequent injury or loss of sight. But if the inflammation be fully de- 'veloped, it can hardly be controlled, so as to preserve the powers of the organ unimpaired. When chemosis. is actually established, the cor- nea clouded, the colour of the iris changed, and the pupil contracted, the patient will certainly lose his sight. With respect to the causes of ophthalmia in general, our limits will permit us only to give a brief enumeration of them. Accidental wounds ; surgical operations ; and direct injury of the eye by various extraneous substances, mechanical or chymical stimuli, coming in contact with it; immoderate use of the organ ; the influence of various states of the atmosphere ; dense winter fogs ; currents of cold wind blowing directly on the eye; exposure of the organ to vivid light, or its employment in the examination of lumi- nous shining bodies. To use- Mr. Lawrence's words, as the eyes are parts of an organic sys- tem, connected with the rest by vessels and sup- ply of blood, by nerves, and by reciprocal sym- pathetic influences in health and disease, the re- mote and predisposing causes must be the same for them as for the rest of the body. One of the most important of these is fulness of habit, and, more technically, a plethoric condition of the system, arising from excess, or imprudent indulgence in the quantity or quality of food and drink. These indulgences produce and keep up an unnatural excitement, under which acci- dental circumstances more readily occasion dis- ease, and that disease partakes more of the acute inflammatory character. The effects of all excesses at table will generally be aggra- vated, if combined with the unhealthiness of sedentary occupations in close and crowded dwellings. Another predisposing cause is the suppression of some habitual discharge, as that of menstruation. When, as Mr. Lawrence ob- serves, we consider that, in a large portion of the community, all these predisposing circum- stances are united with the direct exciting in- fluence of excessive or injurious exertion of the organ, we shall cease to wonder at the numer- ous instances of inflammation in all the textures of the eye, that daily present themselves to our observation.* * The annexed passage from Mr. Lawrence's work is introduced as conveying, in a small com 528 H^MATICA. [Cl. IU.—Ord. II. In the treatment of all inflammations of the eye, the removal of the cause forms one of the most important and early indications ; not, how- ever, that we have it in our power always to trace the precise cause, or, when it is known, to remove it. Its removal, also, will not inva- riably prevent the disorder from making advance, though certainly it is one of the most likely means of having this desirable effect. Thus, if ophthalmia be excited by the lodgment of any extraneous matter, as a small insect, a particle of gravel, sand, &c, between the eyeball and lid, the extraction of such foreign body must scarcely require any knowledge of surgery to make its necessity plain to any common under- standing ; the removal of it in particular cases, however, demands surgical skill. The follow- ing directions, given by Mr. Lawrence, deserve to be recollected. In order to discover and re- move any minute substance that has insinuated itself into the eye, you should first look atten- tively at the exposed surface of the organ in a good light; if you discover nothing there, you should proceed to depress the under lid, and bring the lower surface of the globe into view, by desiring the patient to look up to the ceiling. If you still find nothing, direct the patient to look in the opposite direction, and raise the upper lid, so as to bring into view the superior surface of the globe. In most instances, the extraneous substances lodge in the concavity of the upper eyelid, and cause exquisite pain. When they are thus situated, you must evert pass, a great deal of useful information :—" The common or idiopathic inflammation, is distinguished from the specific or sympathetic inflammations, by the following circumstances :—1st, The principal symptoms, that is, redness, pain, swelling, intol- erance of light, and lachrymal discharge, are equally developed, and present a correspondence in degree. In the specific inflammations, one symp- tom is commonly predominant over the rest. In- tense external-redness is seen in catarrhal ophthal- mia, Often without pain or intolerance of light; in scrofulous cases, the highest intolerance, with hot and acrid lachrymation, and spasm ofthe pal- pebral muscles, with hardly perceptible redness ; in the arthritic and syphilitic, severe pain in the eye and its neighbourhood, with the other phenomena in a slight degree. In the forms just enumerated, the swelling is inconsiderable in comparison to the particular symptoms now pointed out; but is ex- cessive in the purulent and gonorrhoeal ophthal- miae. 2dly, The symptoms commence at the same time, and in an equal degree, and continue in this equal proportion to each other throughout. Each symptom also exhibits this uniformity in degree and extension. The redness occupies equally the whole surface of the organ. In catarrhal and strumous cases it is partial, consisting in distention of some fasciculi; of vessels, or confined to some part of the organ. In syphilitic, rheumatic, and arthritic oph- thalmias, the redness is in the sclerotic coat, and usually forms a zone round the cornea. The pain in ophthalmitis occupies the whole globe and or- bital region. In other ophthalmiae, it is often less in the eye itself than in the parts round the orbit. 3dly, The course of the complaint is very regular, proceeding, when it has once begun, to its full de- velopment, unless it should be interrupted by aotive treatment. In the other ophthalmiae, the complaint altogether, or particular symptoms, of- the lid. Take the cilia between your finger and thumb, and draw the lid downwards and forwards ; press with a probe steadily against its upper part; then carry the ciliary margin upwards and backwards ; you thus turn the lid inside out, and immediately see whether any extraneous body lodges there* Particles of metal, imbedded in the cornea, should be re- moved with a cataract-needle. Another indication is to protect the eye from injurious external influences'. Thus, as Mr. Lawrence has observed, employment of the inflamed organ irritates it, and increases the inflammatory disturbance. The eye should therefore remain perfectly at rest; and even in slighter inflammation, active exertion of the organ should be discontinued, as in reading, writing, &c, although passive exercise of it may be permitted. This rule applies to the sound eye, when the other is the seat of violent inflammation. In the worst cases, the patient should be kept in a darkened room ; but, in general, it will be sufficient to moderate the light by the ordinary Venetian blinds, and to protect the eye by the common pasteboard shade, covered with green crape or silk. The inflamed eye should never be exposed to cold air, in windy, rainy, or damp weather, and great vicissitudes of temperature should be avoided. The preceding measures are only to be re- garded as auxiliaries to the grand plan to be adopted for stopping the inflammation. To use Mr. Lawrence's expressions, it becomes neces- sary to institute early, and to follow up steadily, ten undergo increase or diminution ; in some, re- missions, and in others, complete intermissions are observed. In catarrhal cases, the patient is often free from complaint during the day; the symptoms return in the evening, and are again diminished or lost in the morning. The symptoms of syphilitic ophthalmia undergo a marked diminution during the day, and show themselves again in severe nocturnal paroxysms. Scrofulous patients, on the contraiy, suffer in the day, and are greatly relieved towards the evening. In these cases, too, recover- ies and relapses occur suddenly, and succeed each other frequently. 4thly, True ophthalmitis is at- tended with considerable constitutional disturb- ance of inflammatory character, while the sympa- thetic ophthalmiae are generally without fever, even in many instances where the inflammation runs high."—See Treatise on Dis. ofthe Eye, by Win. Lawrence, p. 78.—Ed. * See Lawrence on Diseases of the Eye, p. 99. "The directions given in books respecting extra- neous substances in the eye, are in general of lit- tle use. Beer is tediously minute in describing every variety of matter by which the eye can be injured, and in laying down rules of treatment (Lehre, b. i., § 158); but he does not even mention the simple proceeding of everting the upper eyelid, which enables us to give the necessary relief in the majority of cases. Injections of water, milk and water, and mucilaginous fluids, under the lids and over the surface of the eye, are recommended : these are of no use, and, indeed, can only add to the irritation which already exists. If any injec- tion could remove the foreign body, the flow of tears which its presence excites would be suffi- cient ; when it sticks to the concavity of the up- per lid, injections are wholly ineffective."—Op. cit., p. 101.—Ed. Gen. VIII.—Spe. 2.] OPHTHALMIA EXTERNA. 529 bold and decisive antiphlogistic treatment, for the purpose of preventingany injurious changes in an organ, the perfect state of which is essen- tial to the comfort and enjoyment of life. The disease must be arrested in its early stage, on account of its tendency to bring on the deposi- tion of opaque matter, and to destroy the trans- parency of the pellucid textures of the eye. The pleura may become opaque, or adherent, without serious inconvenience ; but the cornea cannot be deprived of its transparency, or the' iris be rendered motionless (or misshapen by adhesions), without the functions of the eye be- ing permanently injured or destroyed.—(Mid- dlemore's Lects., Med. Gaz. for 1832-3, p. 136.) Here local bleeding alone will rarely suffice ; and the patient must be bled freely from the arm. In cases of inflammation affecting the entire globe of the eye, in inflammation of the external proper tunics affecting both eyes, or where it is very severe in one, general bleeding should be resorted to. Mr. Lawrence states, that a single large bleeding will, in. general, be sufficient; but he is not inclined to measure the quantity of blood to be taken by ounces, but by the effect produced upon the system. He bleeds till the circulation decidedly feels the loss, and, in severe cases, where the eye is in danger, till fainting is produced. The next mode of taking blood, in point of efficacy, Mr. Lawrence considers to be cupping, either from the back of the neck or the temple, especially the latter, from which part blood can be obtained quickly, and in large quantity. Blood may be drawn by leeches applied as near to the eye as possible. The eyelids would be the best situation, were not this practice apt to produce an ecchymosis, that causes for a few days an unpleasant appearance. Copious bleed- ings by leeches, or cupping-glasses, are usually recommended from the temples ; but it has been suggested, that the former may be employed with inconceivably more advantage, if applied directly to the mucous lining of the lower eye- lid. We learn from Dr. Crampton, that this method has been pursued with almost universal success in the most severe cases in the Royal Military Infirmary at Dublin ;* and it is said to have the great advantage of not being followed by that erysipelatous affection, which so often follows the application of leeches to the external surface of the eyelids, or even to the temples. This mode of using leeches may deserve more extensive trial. In Mr. Lawrence's opinion, opening the tem- poral artery is less advantageous and convenient than cupping. We sometimes do not get blood enough in this way, and sometimes there is difficulty in stopping the bleeding. In active inflammation, the practice of scarifying the con- junctiva is decidedly condemned by him, and he thinks that there are very few cases of chronic ophthalmia in which it is beneficial. The bowels are also to be cleared out by an * Crampton on the Application of Leeches to Internal Surfaces; Dublin Hospital Reports, vol. iii., p. 223, &c. Vol. I—L 1 active purge of calomel, combined with rhubarb, extract of "colocynth, or jalap, and followed by senna, salts, &,c. Antimony and nitre may afterward be given to keep up perspiration, and aperients to maintain regularity of the bowels. In all severe cases, the patient should be re- stricted to fluid, or spoon-diet; and, in milder attacks, fermented liquors and animal food ought not to be allowed. After these measures have been adopted, blisters may be applied to the back of the neck, or behind the ear. Mr. Lawrence is of opinion, that, in active inflammation, they should never be applied nearer to the organ than these situations. Large doses of tartarized antimony have been recommended, with the view of keeping up nausea and vomiting, and thus suddenly check- ing the progress of inflammation of the eye. It seems to have been practised by Dr. Dobson, of Kirkham, as long ago as the year 1773.—(Edin. Med. Com., iii., p. 411.) While, however, Mr. Lawrence admits, that the plan diminishes the heart's action, lessens the force and frequency of the pulse, and certainly so far diminishes the degree of any local inflammation, he deems the remedy severe, and not to be depended upon. After the abstraction of blood, and the evac- uation of the alimentary canal, calomel may be given in doses of from two to five grains, alone, or combined with a small quantity of opium, and repeated every six or eight hours. The free exhibition of calomel, after depletion, is observed to have a very favourable effect in pre- venting the changes of structure, so frequently produced by inflammation.—(Lawrence on Dis. ofthe Eye, p. 111.) This distinguished surgeon has little confi- dence in local applications ; but he does not object to the use of saturnine collyria, or fomen- tations, the choice being regulated by the pa- tient's feelings. SPECIES II. OPHTHALMIA EXTERNA. INFLAMMATION OF THE EXTERNAL TUNICS OF THE EYE. INFLAMMATION SEATED IN THE EXTERNAL TU-. NICS, ATTENDED WITH INCREASED LACHRY- MAL DISCHARGE, IF IN THE SCLEROTICA AND CONJUNCTIVA UNITEDLY ; BUT WITH MUCOUS, OR PURULENT DISCHARGE, IF THE INFLAMMA- TION BE OF A SPECIFIC CHARACTER, AND AFFECT PRIMARILY AND CHIEFLY THE CON- JUNCTIVA. As, under the term external ophthalmia, may be comprised all inflammations affecting chiefly, or primarily, the outer coats of the eye, the proper tunics, as well as the conjunctiva, and sometimes the eyelids, it is here proposed to notice the following varieties : a Ophthalmia exter- Inflammation of the exter- na communis. nal coats of the eye. 0 Ophthalmia catar- Catarrhal, or mucous in- rhalis. flammation of the con- junctiva. y Ophthalmia puru- Purulent inflammation of lenta. the eye. 539 H.EMATICA. Cl. III.—Ord. H. & Ophthalmia Gluti- Affecting the conjunctival nosa. Psor-oph- lining and edges of the thalmia. eyelids. The first variety, as Mr. Lawrence has ob- served, which is common, or simple inflamma- tion in subjects otherwise healthy, varies con- siderably in degree, from slight congestion of the conjunctiva to acute inflammation of the same membrane, with chemosis, and similar in- flammation of the sclerotica and cornea. Un- der its various degrees and forms, it has been designated by different names. Taraxis de- notes the slighter cases ; ophthalmia angularis refers to a particular seat of the disorder; xerophthalmia denotes the dryness of the organ in a particular stage of the affection ; and che- mosis is its most violent or dangerous form, on account of the particular swelling of the con- junctiva often attending it, and described in the foregoing section. Common ophthalmia may be seated in the conjunctiva only, or in the sclerotica and cor- nea. Although both cases may, without impro- priety, be called external inflammation of the eye, they are very different in their symptoms, progress, termination, and treatment. Simple inflammation of the conjunctiva is, generally speaking, an unimportant affection. In consequence of its loose texture, the vessels of the membrane yield readily; there is little pain or inconvenience ; and no danger to the organ. The firmer textures of the sclerotica and cornea yield to distention with pain and slowness ; their vessels do not easily recover, so that inflammation is with more difficulty sub- dued ; and the implication of the cornea, with the ready transition of inflammation to the iris, exposes the organ to serious danger. The symptoms of inflammation affecting the external proper tunics of the eye, are redness, pain, intolerance of light, increased lachrymal discbarge, with more or less febrile disturbance. To pursue Mr. Lawrence's valuable descrip- tion, the redness begins on the front of the globe, immediately round the cornea, where it forms a red zone. Numerous bloodvessels may be seen advancing from the posterior part upon the sclerotica, and branching out into numer- ous ramifications, which are at length lost in the red zone. In inflammation of the conjunctiva, the redness commences in the circumference, the, anterior part being at first comparatively free from it, and the sclerotica retaining its natural white appearance. The character of the red teint differs remarkably in the two cases. The vessels distended in sclerotic inflammation, or sclerotitis, as it is frequently termed, are those seated immediately upon the sclerotic coat; they are therefore ..covered by the con- junctiva, and, being seen through that mem- brane, are of a dark rose-red, and sometimes almost of a livid hue, which forms- a striking contrast to the bright scarlet teint of the ves- sels distended in conjunctival inflammation. The zone, seen around the cornea in the early stage, is also of a rose or pink colour. The redness is uniformly diffused through the scle- sotic coat; and, when the inflammation is con- siderable, a dense arrangement of vessels may be noticed, lying under the conjunctiva, and occupying the whole surface of the sclerotic coat. In inflammation of the conjunctiva, the vessels are not only of a bright scarlet colour, but lie nakedly on the surface of the membrane. When inflammation, without being very violent, is seated in the conjunctiva and sclerotica at the same time, the marked difference in the situation and teint of the two orders of vessels is very manifest. When the sclerotic coat inflames, the con- junctiva soon participates in the affection ; and the cornea, without becoming opaque, assumes a kind of dull appearance. Other common symptoms are, a sense of stiffness and dryness in the eye in the early stage of the disorder; a burning or aching pain in the organ ; a sense of tension, or pressure of it; and a feeling as if sand or gravel were in contact with it, and pain shooting to the back of the orbit and side of the face. Intolerance of light is a marked symp- tom from the commencement of sclerotic in- flammation, and forms another striking contrast. between this affection and conjunctival inflam- mation ; for, in the latter, the patient generally opens the eye freely, and experiences no pains from the access of light If the inflammation proceed further, the cor- nea first becomes grayish, and, when chemosis occurs, it turns white, cloudy, and then yellow ;. a thick, viscid matter, that cannot be discharged by puncture, being deposited in its texture. An effusion of a similar nature also frequently takes place in the anterior chamber, constituting the case termed hypopium. Sometimes the cornea. is perforated by ulceration ; the aqueous humour escapes ; the iris becomes adherent to the opaque cornea, with or without prolapsus; and vision is lost. Inflammation of the external proper coats, then, is distinguished by the redness be- ing originally seated in the sclerotica; by the discharge being lachrymal, not mucous ; by the pain and intolerance of light; and by the changes. occurring in the cornea. In conjunctival inflam- mation, there is increased mucous discharge ■ little or no pain, nor intolerance of light, except at first; and seldom any affection of the cor- nea. According to Mr. Lawrence, the degree of danger to the eye will depend on the ques- tion, whether the inflammation extends to the cornea ; and, if it docs, on the degree of that inflammation. If the cornea be not involved, there is no risk ; or, if the affection of that part be slight, we need not apprehend any injury of vision. The degree of sclerotic redness in the early stage is a criterion, from which we may form an opinion, whether it will be severe or otherwise. If the case proceeds to chemosis ; if the cornea becomes gray or white ; or, if matter be deposited in its texture, sight will be more ot less impaired. With regard to the treatment, it should con- form to the directions given under the first spe- cies of the present genus ; the extent and rigour of the antiphlogistic measures being regulated by Che degree and violence of the inflammation. The distinct nature of catarrhal ophthalmia, Gen. VIII.—Spe. 2.] OPHTHALMIA EXTERNA 531 and its origin from atmospheric causes or pecu- liarities, are expressed, as Mr. Lawrence has well observed, in the terms cold or blight, under which it is often popularly mentioned. The expression, mucous ophthalmia, designates the increased mucous discharge, which is one of its most striking characters. It is inflammation of the.conjunctiva, either of the globe, or of the eyelids, or of both, caused by cold, and it cor- responds to catarrhal affections of other mucous membranes, as those of the nose and its sinuses, of the fauces, trachea, and lungs. Catarrhal inflammation frequently goes through all these parts, and commonly so in influenza. The symptoms of catarrhal ophthalmia, as described by Mr. Lawrence, are at first stiff- ness and smarting; some uneasiness on expo- sure to light; and external redness. When fully developed, the disorder is characterized by redness, increased mucous, not lachrymal dis- charge ; inconsiderable pain, and no intoler- ance of light. The redness is superficial, and of a bright scarlet colour; and at first gen- erally in-patches, the whole surface not becoming uniformly red, till the disorder is fully developed. The redness begins at the circumference of the globe, and gradually advances towards the cor- nea ; but, in the commencement, it is confined to the palpebral conjunctiva. Sometimes little ecchymoses appear on the conjunctiva, and some- times small vesicles, called pustules, generally situated near the edge of the cornea ; but there is nothing like chemosis. When the lachrymal discharge, noticed in the very commencement, stops, its place is supplied by increased secretion of mucus from the in- flamed membrane itself. This is at first thin, afterward becomes thicker, assuming a whitish or yellowish appearance, and sometimes resem- bling pus; Whenever catarrhal inflammation of the eye is at all considerable, the eyelids par- ticipate in the disorder; and a pain and sense of weight are felt about the frontal sinuses and antrum, with headache, disordered stomach, foul loaded tongue, and other febrile symptoms. In the daytime the redness is less; there is no pain nor intolerance of light; but, in the even- ing, the disorder undergoes an exacerbation.* Catarrhal is distinguished from purulent oph- thalmia by its much milder character ; and Mr. Lawrence thinks that they differ rather in de- gree than in any other essential point, unless it should be proved, which he thinks is not yet the case, that purulent ophthalmia is contagious. As the affection is not a serious one, and does not produce injurious consequences to the organ, venesection is not in general necessary; but, * There are exceptions to this statement; a young lady in Bedford Place, whom the editor is now attending (Dec. 1833) for catarrhal oph- thalmia, is always considerably better in the even- ing. This fact is noticed by Mr. Middlemore :— " Sometimes," says he, " the uneasiness occa- sioned by catarrhal ophthalmia is increased du- ring the day, and much relieved during the night; or, if that be not the case, there will be a distinct remission and exacerbation of the symptoms at reg- ular intervals. "—Med. Gaz. for 1833, p. 314.—Ed. L I 2 in a young subject of full habit, with both eyes severely attacked, a full bloodletting would be proper. In ordinary cases, cupping and leeches will suffice. An active aperient, and, if the tongue be foul, an emetic, will advantageously follow the loss of blood. Saline and sudorific medicines may then be given, and occasional purgatives. The patient is to be kept warm, take plentifully of diluent drinks, and no animal food, nor fermented liquor. The pediluvium, or warm bath, may be useful, and perhaps, after a few days, a blister on the nape of the neck. Where the case seems to depend on a disor- dered state of the alimentary canal, an emetic, and an active purgative containing calomel, or the latter alone, followed by mild aperients and low diet, will often suffice, without the abstrac- tion of any blood. The best local applications are fomentations. The sticking of the eyelids together during the night should be prevented by inserting a little of the unguentum plumbi* between the tarsal edges in the evening. The eye will not require a shade, unless the light be strong and offensive. Cool air will also be pleasant to the patient's feelings, and tend to remove the sensation of sand in the eye.! Purulent ophthalmia of adult subjects, the third variety of external inflammation of the eye, here to be treated of, is a case of the most acute kind, attended with an increased secretion, which, in colour and consistence, resembles pus. The affection begins in the lining of the eyelids ; extends to the mucous surface of the globe ; and, when violent and not checked, it soon attacks the cornea. The whole texture of the conjunctiva then swells and becomes thicker ; its vascular texture is developed ; and its surface acquires an intensely bright red col- our. The mucous surface is rendered villous, pulpy, granular, like the secreting surfaces of the alimentary canal ; and, from the secreting surface, thus developed, flows the puriform dis- charge. This form of disease does not, like others, produce suppuration within the eye.! * R-. Liq. plumbi acet. 3SS; ung. cetacei sj. Misce. ! Some practitioners resort to stimulating ap- plications; thus Mr. Melin dropped into the eye a solution of the nitrate of silver, four grains to the ounce of distilled water twice a day.—(Report of Ocular Diseases, &c, Lond. Med. Phys. Journ., vol. liii., p. 184.) Dr. Ridgway used a stronger solution, ten grains to the ounce. Mr. .Mackenzie also puts a large drop of a solution of the nitrate of silver into the eye, in the proportion of from two to four grains to the ounce; foments the eye twice a day with a collyrium of gr. j of the oxy- muriate of mercury in eight ounces of water; and applies to the edges of the eyelids, at night, an ointment, containing gr. iss of red precipitate to the drachm.—(See Mackenzie's Practical Treatise on Diseases of the eye, p. 334.) Mr. Guthrie em- ploys the nitrate of silver ointment, ten grains to 3J. These stimulating local applications are al- leged-to supersede the necessity for bleeding. Mr. Middlemore says, however, that he cannot recommend the ung. nigrum for catarrhal ophthal- mia.—Lect. on Dis. of the Eye, Med. Gaz., p. 316. X Dr. Vetch never saw the formation of pus in the chambers of the aqueous humour from puru- 532 H^EMATICA. [Cl. III.—Ord. IL The changes in the cornea are sloughing, ulcer- ation, and opacity. The sloughing and ulcera- tion often expose the anterior chamber, causing prolapsus of the iris, loss of the humours, and collapse of the tunics, so that not only the func- tion, but the very form of the eye is destroyed. The affection has been described under va- rious names ; as purulent, Egyptian, and con- tagious ophthalmia. In the first stage, there is redness of the pal- pebral conjunctiva, with some stiffness of the eyelids ; and a little whitish mucus is seen on the membrane ; but this stage is seldom seen by the surgeon. The disease soon extends to the globe, in what may be called its second stage ; and now we see it marked by high vas- cular action, and bright redness, great tumefac- tion of the membrane, and profuse discharge. Frequently, there are red patches, apparently of ecchymosis. The swelling of the conjunc- tiva on the globe often raises it in the form of chemosis, which is sometimes so considerable as completely to hide the cornea. At this pe- riod the whole eyelid swells, from an effusion of serum in its texture. At first, a stiffness is felt in the eyelids and globe ; and then a sen- sation is experienced, as if sand or gravel were in the organ. As the inflammation extends to the globe*, the pain becomes severe and excru- ciating ; and is deep-seated in the eye, often with throbbing of the temples and headache. " I have seen (says the younger Dr. Frank) the bravest soldiers- cry like children for a whole night; and have heard them declare, that they would readily allow the affected eye to be torn out, if they could hereby get rid of the pain."— (De Peste, Dysenteria, et Ophthalmia J&gyp- tiaca, 8vo., Vienna.)- In the third stage, there is a gradual remis- sion of the symptoms-: the swelling, pain, and discharge are lessened; the external oedema ceases ; and the swelling of the conjunctiva being no longer counterbalanced, the palpebraa are everted, especially the lower. A thickened and granulated state of the lining ef the eyelids, with consequent opacity and vascularity of the cornea, are remote effects of the inflammation when it becomes chronic. Some unnatural redness of the membrane, with slight swelling, and a little discharge, often con- tinues for a long time ; and there is a great ten- dency to relapse. If the cornea retain its natural transparency, we may expect to arrest the inflammation by vigorous treatment; if it be dull, and deep- seated pain in the eye and head announce ex- tension of inflammation to the globe, the event is doubtful. This is the disease concerning which so much has of late years been written by French and English surgeons and physicians; whieh lent ophthalmia (On Dis. of the Eye, p. 64); and a similar remark is made by Mueller (Erfahrungs- satze, p. 68; see also Lawrence on Diseases of the Eye, p. 180). Yet, Mr. Middlemore speaks of suppuration of the eyeball as one of the occa- sional results of the disorder.—See Med. Gaz. for $833, p. 410.—Ed. [ proved so extremely destructive to the armies of both nations in their respective expeditions to the banks of the Nile ; and the real nature and cure of which have been discussed in mod- ern times with no small degree of acrimony in our own country, but at the same time with much benefit to the public, from the facts and the ingenuity which the controversy has brought to light. There appears little doubt, however, that it has occasionally existed even in our own day, in ships-of-war, antecedently to the expe- dition to Egypt, of which Sir Gilbert Blane has given two examples (Select Dissertations,-&cr p. 215), though it does not seem to have been a subject of much attention at the time. This disease was at first ascribed to the minute and glassy spiculas of the sands of the Egyp- tian plains. But it has since been referred, either to a peculiar miasm generated in marsh- lands, or to sleeping on damp or swampy ground, with insufficient covering, and surrounded by a moist atmosphere. And as these causes exist in other parts of the world than in Egypt, the disease is noticed in Other countries, and, as we shall presently remark, appears to have beers known in former times. The most contested points, however, in the history of the disease, are, whether, after the disorder has been once produced by the above, or other unknown causes, the matter secreted by the conjunctiva be con- tagious or not] and whether the extensive spreading of the affection afterward should not be imputed to this circumstance, rather than to> epidemic causes-] [The generality of practitioners now incline to the affirmative on both these questions. In a former edition of this work, it was observed by Dr. Good that the matter is impregnated with a specific contagion ; and hence the dis- ease i3 propagated with great rapidity between those who come in contact with each other by sleeping together, or using the same towels. He had known it to be caught by a surgeon's assistant, merely in consequence of syringing the eyes of a patient; a part of the discharge having, from the force of the syringing, spirted into one of the assistant's eyes,, which was for some days in a state of danger. Sir Patrick M'Gregor (Trans, for the Improvement of Med. Knowledge, vol. iii.), in the account which he has given of this affection, as it occurred in the Royal Military Asylum, mentions three in- stances in which the nurses of the establish- ment caught the disease, either while syringing the eyes of patients, or frem having employed sponges used by the children. It is curious to find, however, that AssaliniT and all the surgeons who accompanied the French expedition to Egypt, never entertained any belief of the contagious nature of the dis- ease. Not long since, Mr. Lawrence also re- garded the doctrine of contagion as involved in doubt. In support of the opposite view he re- marks, that in all cases where collections of individuals labouring under it have been sep>- arated or dispersed, as when troops are dis- banded, and go into civil life, the complaint is put a stop to, and does not extend itself. Nsw„ Gen. VIIL—Spe. 2.] OPHTHALMIA EXTERNA. 533 if it were contagious, and capable of producing a like disease in others, we should suppose that this would he the veiy way to spread it all over the country ; but we find it the most effectual mode of putting a stop to the disorder. There is no dissemination of the complaint in the families or districts to which the soldiers, or other persons so afflicted, return. Yet, in op- position to this statement, it is to be remem- bered, that the extraordinary and increased prevalence of purulent ophthalmia in the army and elsewhere in this country, since the return of our troops from Egypt in 1801, is ascribed to the importation of the infection by soldiers labouring under the disease. If a healthy regi- ment also enter barracks which have been quit- ted by another corps, more or less afflicted with the complaint, experience proves that the new-comers are almost sure to suffer. If the facts of inoculation by contact, mentioned by Sir Patrick M'Gregor, Mr. Middlemore (Lec- tures on Dis. of the Eye, in Med. Gaz. for 1833, p. 410), and Dr. Good, be unimpeach- able, such affirmative amounts to a proof of the infectious character of the disorder, and cannot be in the slightest degree invalidated by the re- sult of Mr. Mackesy's (Edin. Med. and Surg. Journ., vol. xii.) bold experiment of applying to his own eyes a rag, soaked in the purulent discharge from the eyes of three of his pa- tients, but without contracting the disease. Mr. Lawrence does not, however, venture so far as to assert, that purulent ophthalmia is not contagious; but merely that it is a point re- quiring further proof. He considers, that there is abundant evidence that the disease arises from other causes than from the application of matter from the eyes of one individual to those of another. Many patients went to the Oph- thalmic Infirmary, in whom he could trace no connexion whatever with persons labouring un- der the same affection, and yet they had de- cided purulent ophthalmia. According to his experience, purulent inflammation may be pro- duced by the action of common causes, without the application of any morbid matter to the eye. But, when it is once produced, it is capable of propagating itself, under particular circum- stances, in a way which we cannot easily dis- tinguish from a contagious propagation. When individuals are crowded together in great num- bers in confined habitations, sleeping in the same rooms, and using the same linen and the same utensils, and not carefully attending to personal cleanliness, deleterious influences on human health are known to be produced, though their nature and mode of action are obscure. The bad effects are increased by unwholesome diet, insufficient clothing, and inadequate ventilation. Hence, the only instances ofthe disorder spread- ing extensively and virulently, have been in barracks, ships, schools, prisons, and work- houses.* * " If contagion exist," says Mr. Lawrence, " it must be very different from that of smallpox, scarlet fever, or measles; much less active and certain. At the same time, when I look to the in- stances in which the affection has prevailed exten-. In the treatment of purulent ophthalmia, two indications present themselves : the first is, to check the inflammation by antiphlogistic means; the second is, to restore the altered texture of the conjunctiva to its natural state by the use of astringents. In this manner, not only may the ulceration of the cornea and other destructive effects on vision be prevented, but, as Mr. Law- rence observes, you will also avert that chronic thickening and granulation, which are so ob- stinate and troublesome.] The earliest mode of treatment pursued by the French, as we learn from the account of Dr. Antonio Savaresi, as well as of Dr. L. Frank, consisted in little more than the general treat- ment of the common acute ophthalmia; as bleeding from the jugular vein or temporal artery, blisters, saline purgatives, anodyne lo- tions, and a low diet. The bleedings, however, do not appear to have been very copious. And yet the first writer tells us, that, by this pro- cess alone, he was so fortunate, that, out of a thousand or thereabouts, who were confined to the French military hospitals in Egypt under his care, not more than two lost their sight completely, though some others suffered the loss of one eye. In the hands of our own army practitioners, the plan of treatment, thus limited, completely failed; and the bleeding, which was almost solely depended upon, was carried, from the first day of the attack, and repeated for several days afterward, to as great an extent, not only as fainting, but as life itself would allow. The first accounts we had of this practice seemed to show that it was in the highest degree success- sively ; when I see how the disease has gradually spread through large bodies of men, and how ef- fectually its progress has been arrested in so many cases by insulating the diseased, and preventing all intercourse between them and the healthy, I feel fully satisfied that the disease is contagious under cer- taincircumstances and conditions."—(On Diseases of the Eye, p. 200.) Mr. Middlemore makes the fol- lowing inferences:—1st, That contagion alone will not, except in very rare instances, produce this form of purulent inflammation of the eye, but requires to be aided in its operation by constitutional sus- ceptibility, want of cleanliness, disordered health, exposure to a brilliant sun, or the damp night air, or to dust, or to peculiar conditions of the atmo- sphere, &c. All, or any of these circumstances, he thinks, will ensure the operation of contagion. 2dly, Purulent ophthalmia may arise without the aid of contagion, as occurs in many instances of relapse, and in some of those cases in which one eye becomes affected as soon as the other has nearly recovered; and, finally, the disease has occurred to a ship's crew during their voyage, whose eyes were not affected at the commence- ment of the voyage, nor until some time afterward and who had no communication with the men of any other vessel until the completion, or nearly the completion of their voyage.—(See Med. Gaz. for 1833, p. 411.) It seems manifest, then, that the disease may begin as an epidemic, and, under cer- tain circumstances, at least, propagate itself also by contagion. In the same way, the Asiatic chol- era is now commonly believed to extend itself, both as an epidemic and as an infectious disease. —Ed. 534 H.EMATICA. _; [Cl. III.—Ord. II. ful :* but later experience has not justified the representation, and the extensive lists of blind pensioners supported by the Chelsea and Green- wich Hospitals, are a sufficient proof that the success of the evacuating plan was considerably exaggerated. A free abstraction of blood by leeches applied to the conjunctive tunic itself, does not appear to have been tried till of late by Dr. Crampton, in the Dublin Hospital, where it seems to have been of very decided ad- vantage when employed in the first stage of the disease. [Although bleeding seems not to have been invariably capable of checking the disease, the reason of this may perhaps have depended upon its not being combined with the seasonable em- ployment of other judicious measures, and the impossibility of invariably removing soldiers from those influences by which the disease is kept up. Certainly, at the present day, and in this metropolis, purulent ophthalmia is treated with great success, which is in a great measure ascribed to free bleeding in the early stage. Mr. Lawrence recommends copious venesec- tion, so as to produce syncope, as the first pro- ceeding.! If the symptoms remain urgent, he advises the bleeding to be repeated. Subse- quently, cupping may be practised on the tem- ple, or numerous leeches applied round the eye, and jrepeated. Mr. Middlemore prefers placing them close to the tarsal margin of the lower eyelid. Cold or tepid washes should be used. Brisk purgatives in the first instance, and after- ward milder aperients, will be necessary, with low diet and rest. After these plans have been adopted,'blisters are to be employed.-. Such means are to be repeated and continued till the oedematous swelling of the eyelids, the che- mosis, and the pain are reduced. The con- junctiva will now grow paler, and assume a re- laxed and flabby appearance, the discharge still continuing in abundance. In this stage, astringent lotions are to be applied to the organ, tonic medicines prescribed, and a betteT diet allowed. Mr. Lawrence pre- fers, at first, a solution of alum, and afterward one of the nitrate of silver, or the undiluted liquor plumbi acetatis. Two or three drops of either of the latter liquids should be introduced between the eyelids twice or thrice a day, and the eye may be bathed occasionally in the inter- vals with the alum lotion. The ung. hydrarg. nitrat. may also be applied to the edges of the eyelids at night. Mr. Guthrie, as is well known, is in the habit of using a strong ointment, com- posed of 10 grs. of the nitrate of silver, mixed with a drachm of lard, or the ung. cetacei, in nearly every form and stage of inflammation of the conjunctiva, attended with increased dis- charge from its surface. As an early applica- * Account of the Ophthalmia which has ap- peared in England since the return of the British army. By J. Vetch, M. D. ! " If the symptoms be severe, and the patient tolerably strong, bleed until the pain is relieved, the chemosis diminished, and the sense of tension and throbbing removed."—Middlemore, in Med. Gaz. for 1833, p. 411.—Ed. tion, however, it is disapproved of by Mr. Mid- dlemore, though he admits that the Stimulating plan is extremely useful, as soon as the acute symptoms are subdued.—(See Med. Gaz. for 1833, p. 412.) Then also, bark, cascarilla, and dilute sulphuric or nitric acid, with occasional aperients, are the hest medicines. At first sur- geons should carefully watch the effect of astringents ; for, if the pain continue after their use, with an increase of redness, they must be left off, and antiphlogistic measures be resorted to again,. When the cornea is in a sloughing or ulcer- ating state, accompanied with debility, the pa- tient should have wine, porter, good diet, and the sulphate of quinine, and use local astrin- gents.] The late Mr. Saunders was the first in the present day to discover that the blindness which is so apt to follow, even after the first attack of virulent inflammation has subsided, proceeds from the friction upon the transparent cornea of innumerable irritating granulations, as he de- nominated them, thrown forth from the surface of the tunica conjunctiva that lines the interior of the palpebrae, and which become a new source of inflammation, less violent, indeed, but as fatal in its effects ; and the disease has hence been very correctly divided into two stages, that of primary and that of secondary or apparently granulating inflammation. Mr. Saunders en- deavoured to cut the disease short in its first stage by exciting nausea, and maintaining it for a considerable period of time, so as to lower the living power, and hereby take off the in- flammatory action. And where the disease had proceeded to what he called the granulating stage, he removed the minute caruncles from the tunica conjunctiva by cutting them off with a pair of scissors, and afterward applied a so- lution of nitrate of silver to prevent their sprouting again. Instead of the nauseating pro- cess employed in the first stage, Sir William Adams boldly prescribed active and powerful vomiting, continued for eight or ten hours, by giving two grains of tartar emetic at first, and continuing one grain every half hour afterward, through the whole of this period; by which violence a change of action, or new but more manageable excitement, is often produced in the eye, and the disease is stopped in the course of ten or twelve hours from its onset. [The editorneed scarcely observe, that, though most in- flammations may be checked by the emetic treat- ment, the plan is severe, and less to be de- pended upon, than free bleeding and other an- tiphlogistic remedies.] Where the second or granulating stage has commenced, Sir William Adams used to cut away the diseased surface of the conjunctiva, instead of the granulating points alone ; by which the morbid action is destroyed, not only with less pain, but far more radically and effect- ually ; and he afterward employs a solution of alum, instead of a solution of nitrate of silver, as the latter is hereby rendered unnecessary ; not to mention that the agony it excites is often intolerable, and that a new inflammation has Gen. VUL—Spe. 2.] OPHTHALMIA EXTERNA. 535 followed, in some instances, almost as dangerous as the original inflammation itself. Emetics, indeed, have long been occasionally made use of as a means of relieving inflammation in the eyes, but not in the particular kind before us, nor perhaps at any time of the inflammation with the precise object in view proposed by Sir William Adams. Stoll, for instance, em- ployed them successfully in periodic ophthalmiae (Nat. Med., part ii., p. 102); and Dobson, as al- ready observed, in ophthalmiae of a like chronic kind, accompanied with nervous debility ; the bark being interposed between their repetition. —(Med. Comm. Edin., vol. iii, p. 444.) The nearest approach, however, to this practice, which I have met with on medical record, is Dr. Dobson's case, already noticed in the fore- going pages. Yet, though the emetic plan carried to this extent, and employed for the express purpose just stated, does not appear to have been had recourse to in this form of ophthalmia till our own day, it has been very clearly shown by those who have critically and historically ex- amined into the subject, that this very affection was long ago known to the world, and has been rationally as well as successfully treated in dif- ferent ages. As the Greeks were much better acquainted with Egypt than ourselves, it is hardly to be supposed that it could have escaped their notice, and it has hence been suggested, with much probability, that it is referred to by them under the term pladarotis (Galen. Isag., 215, c. 6, vol. v., fol. 1542); while it is ingeni- ously affirmed by a learned critic of our own day to have been described by the old surgeons of our own country under the expressive appella- tion of the mulberry eyelid.—(Quart. Journ. of For. Med., vol. i., p. 403.) There can, how- ever, be no question that the ophthalmia before us was well known to them under whatever name described ; and that even the granula- tions of the second stage, as they are incor- rectly denominated, and which are rather en- larged and indurated cryptae of the conjunctiva, had not only been noticed by them, but were even removed by some of the most approved methods of modern surgery ; since it is ex- pressly recommended by Read, who flourished nearly a century and a half ago, that, " if they be thick and gross, they must be cut away dex- terously with the point of a lancet, and after- ward let the place be touched with a little fine salt, alum, or copperas-water."* This, how- ever, is not mentioned with a view of deducting from the merit of Mr. Saunders or of Sir Wil- liam Adams; since the practice, and even the name of its original inventor, seems to have been long lost sight of in the annals of chirur- gical science, and consequently the revival of such a practice, and a detection of its benefits, are as much a discovery now as it was in the time of Read. [At the present day, the practice * Short but exact Account of all the Diseases incident to the Eyes, Lond., 2d edit, p. 96,1706. See also Quarterly Journ. of Foreign Med., ut supra. of cutting away the granulations is less fre- quently adopted than that of touching them with nitrate of silver or sulphate of copper; experi- ence having proved that they are more apt to grow again after the use of the knife or scissors than after that of astringents* or mild escha- rotics. The eversion of the eyelid, frequently remaining after an attack of purulent ophthalmia, may also be speedily cured by touching the sur- face of the thickened conjunctiva with these applications, which have the effect of restoring to it a healthy surface. The plan, however, is only right in the perfectly chronic stage, or rather a stage subsequent to those of the original complaint. With respect to the purulent ophthalmia of new-born children, it usually comes on within a week from birth. Both eyes are mostly affected, but they are not first attacked exactly at the same time. In the first stage, it is confined to the mucous lining of the eyelids, which are re- marked to adhere together when the child wakes. Their edges are redder than natural, especially at the corners ; and the access of light to the eye produces pain, and makes the child shut it. If at this period the eyelids be everted, their lining will be found to be red and villous, and a little white mucus will be seen lying on the in- side of the lower eyelid. In the second stage, the inflammation extends from the palpebral conjunctiva to that covering the eyeball; the vascular congestion and red- ness are much augmented; the eyelids swell and become red even externally; from the in- flamed membrane there is a copious secretion of purulent fluid, which glues the edges of the eyelids together, and then accumulates under the latter parts, or pours out over the face, stain- ing the cap and linen. As the light is very painful, the child keeps the eye constantly shut, even if the swelling of the eyelids should not already close it. In this second stage, the whole of the conjunctiva is swollen, of a uni- form bright scarlet colour, and presents a villous surface. It is further remarked by Mr. Law- rence, that the close adhesion of the membrane to the tarsi prevents the palpebral conjunctiva from swelling much; but the loose folds be- tween the lid and the globe become greatly enlarged, forming red tumid rolls, finely granu- lated. These folds, pressed on by the orbicu- laris, evert the tarsi, causing ectropium of one or both eyelids. This eversion particularly takes place when the child cries, or the surgeon at- tempts to examine the eye by separating the eyelids. Sometimes the upper eyelid is so swelled that it hangs completely over the lower. During the night, the eyelids become so ad- herent to each other that they cannot be opened in the morning till after they have been soaked with warm water. When they are separated, the eye is completely concealed by the dis- charge ; we wipe it away with a soft rag, and * Mr. Lawrence gives the preference to solutions of alum, sulphate of copper, or lunar caustic, or the liquor plumbi acetatis.—On Dis. of the Eye, p. 216—Ed. 536 H.EMATICA. [Cl. III.—Ord. II. there is still enough to cover the globe and hide the cornea. If the disease should not be checked, it extends to the cornea, and thus may reach the interior of the globe. Some one or more of the following changes are now pro- duced : general or partial sloughing of the cornea ; ulceration or opacity of the same part; adhesion ofthe iris to the inflamed or ulcerated* cornea, or suppuration of the eyeball, which last occurrence, Mr. Middlemore says, has been denied by Mr. Saunders on very insufficient grounds.—(Middlemore's Lect: on Dis. of the Eye, as published in Lond. Med. Gaz. for 1833, p. 508.) In the third stage, there is a gradual abatement and cessation of all the symptoms; the redness, swelling, and dispharge are dimin- ished ; the child opens the eyes more readily to the light; and no ectropium takes place. The opportunity of seeing whatever changes may have been produced by active inflammation is now afforded. When the complaint is severe, the infant be- comes restless, and its bowels are disturbed; and the sloughing stage is attended with pale- ness and debility. With regard to the causes of purulent oph- thalmia in infants, it appears, that in a large pro- portion of instances, the mother is affected with some kind of vaginal discharge, to, which the child's eyes have been exposed during parturi- tion. Hence the natural inference is, that the disorder is excited by the actual contact of the matter: and the tolerably regular appearance of the disease on the third day corroborates this notion. Indeed, some facts mentioned by Mr. Lawrence and Mr. Middlemore* also tend to confirm this view of the subject. Yet, the former observes, purulent ophthalmia is often seen in children of healthy mothers, or mothers who at least declare themselves to be free from any kind of discharge. A declaration of this sort, however, coming from a woman whose child is attacked about three days after birth, is of course incorrect. Whatever may be the fact with regard to contagion being an exciting cause of,.this purulent ophthalmia, Mr. Lawrence ad- verts to other circumstances, which undoubtedly promote its occurrence. He says, that it is most frequent and destructive in weakly children, and such as are exposed to bad air, cold, insuf- ficient clothing, and deficient, nutrition. It is more frequent in premature children than in those born at the full time; in twins than in single children ; in newly-born infants than older children; and in those than in adults. It is more frequent in damp and cold than dry warm weather; and among the children of the poor than those of the upper classes. In the Foundling Hospitals of Paris, Vienna, Petersburgh, andMos- * Lond. Med. Gaz. for 1833, p. 508. " All in- fants," says he, "are subject to the same change of residence, exposure to light, and to cold, &c, although only a small portion, it is presumed, are destined to pass, in their exit from the uterus, through a canal moistened with morbid secre- tions." The conviction of Mr. Middlemore is, that this disease is produced by the contact of morbid vaginal secretions.—Ed. cow, which receive all infants presented, the dis- ease is particularly prevalent and unmanageable. When the cornea remains clear, the prognosis is always favourable ; but if this membrane has sloughed, or ulcerated extensively, loss of sight is unavoidable. Even if the cornea be of a dull white, or has begun to lose its transparency, ' vision may be lost or injured, as it is most likely that ulceration and prolapsus of the iris, or per- manent opacity will ensue.] I cannot say that in any instance that has fallen within my own range of practice, I have seen all the benefit from the use of Bates's powerful and stimulant astringent, known by the name of aqua camphorata, which Mr. Ware ascribes to it. I have known it at times check the discharge, but do almost as much mischief from the pain it excites, and the irritation pro- duced by very long fits of restlessness and cry- ing, which are sure to follow. The plan that has proved most effectual, in my own course of observation, is to syringe the eyes thoroughly, so that the whole of the puru- lent discharge may be washed out, with a solu- tion of alum in water, in the proportion of not less than a grain to an ounce : to continue this syringing three times a day, to keep the bowels open, scarify the gorged vessels of the con- junctiva where it can be done, or apply leeches to their under surface, and surround the fore- head lightly and loosely with folded linen, wetted with a lotion of an ounce of the liquor ammoniae acetatis mixed with seven ounces of water, and kept cold in a bucket of ice. [Mr. Lawrence has seldom found it necessary to use more than one leech, which he applies to the red swelling of the upper eyelid : even this, he says, some- times renders the infant quite pale. In the most robust children, he would not advise more than two leeches ; one to each eyelid, or to the upper eyelid of each eye.] The child, in order to receive the full benefit of the solution of alum, should have its head laid flat between the knees of the operator, with the face uppermost : the lids should be separated from each other by the fingers, or, if necessary, as it almost always is, by the assistance of a blunt silver spatula, or some other blunt instrument, and the point of the syringe, loaded with the astringent lotion, should then be introduced between them and con- vey its contents all around: the syringing being repeated till the whole of the collected matter is washed away. The pain produced by the use of this solution is trifling, and the child ceases to cry almost as soon as the operation is over. [In the early stage, Mr. Lawrence prefers a saturnine lotion made with rose-water. He also directs the bowels to be kept open with castor- oil or magnesia ; and when the inflammation is active, and the tongue white, he lets the pur- gative medicine be preceded by a grain or two of calomel. He does not approve of blisters for young children. The agglutination of the eyelids is to be pre- vented, and the exit of the discharge promoted, by frequently bathing them with tepid water, or milk, and applying a little lard, or fresh butter, to their edges. Gen VIII.—Spe. 3.] OPHTHALMIA INTERNA. 537 The inflammatory stage having been subdued, astringents are to be employed. Mr. Lawrence uses a solution of alum, in the proportion of from two to ten grains of alum to each ounce of water, according to circumstances. This lotion is to be carefully injected under the eyelids, three or four times a day, so as to cleanse out all the purulent secretion ; and, in the intervals, a piece of rag, wetted with the same wash, may be la,id over the eye. If the alum lotion ceases to have effect, a solution of nitrate of silver, in the proportion of two grains to each ounce of water, may be dropped into the eye two or three times a day.*] If, when the inflammation begins to subside, an ulcer be detected on any part of the cornea, and especially if it be over the pupil, a solution of nitrate of silver, in the proportion of a grain to an ounce of water, should be dropped into the eye night and morning after the syringing is over, and the eye be kept open for about half a minute, so that the solution may not be wiped away suddenly by the closing of the lids, but may fairly lie upon the ulcer and float over it for this period of time. The sulphate of quinine should also be given, dissolved in a small quan- tity of water, to as great an extent as the infant can bear it [or the extract of bark, broken down and blended with milk, may be prescribed, as advised by Mr. Lawrence] ; and if looseness be produced, it should be checked by a drop or half a drop of laudanum in each draught. Prus- siate of potash is also a very good astringent for contracting the area of the ulcer, and expediting the healing process ; and may be used instead of the solution of the nitrate of silver, in the form of an ointment, by means of the unguentum ce- tacei. By a careful perseverance in this pro- cess, I have not only seen ulcerations on the cornea heal speedily, but, in one or two instances, without leaving any cicatrix to impede vision, even where the ulceration has been seated over the pupil. [The varieties of purulent ophthalmia said to arise from metastasis of gonorrhoea from the urethra to the eyes,! and from the inadvertent application of the urethral discharge to the eye- lids, hardly require a particular description in a work of this nature.] S Ophthalmia glulinosa, so called in the pres- ent work, is the psor-ophthalmia of Plenck and * The practice of using powerful stimulants in the early stage is strongly condemned by Mr. Mid- dlemore. "Let the acute stage pass by; let the secretion become diminished; and the tense, florid state of the conjunctiva be exchanged for a compar- atively pale, flabby appearance of that membrane, and then," he admits, " either the undiluted liq. acetatis, or the strong nitrate of silver ointment (ten grains to a drachm), may be advantageously employed."—See Middlemore's Lect. on Dis. of the Eye, as pub. in Med. Gaz. for 1833, p. 511.—Ed. ! This particular cause, which is admitted by Richter, Scarpa, and Beer, is rejected by Mr. Law- rence, because " gonorrhceal ophthalmia may oc- cur while the discharge from the urethra contin- ues, and since it does not take place when that discharge is stopped."—On Dis. of the Eye, p. 229; see also his Treatise on the Venereal Dis. of the Eye.—Ed. Mr. Ware [the idiopathic inflammation of the glands of the eyelids, of Beer, and the catarrhal inflammation of the eyelids, of various modern writers] ; and consists in an inflamed state of the small sebaceous glands, whose ducts, ar- ranged in a row on the edge of each eyelid, pour forth a viscid matter that incrusts and hardens. [It appears to Mr. Lawrence, however, that the mucous membrane is the primary seat of the disease, and that the Meibomian glands, if dis- eased at all, are affected secondarily.—(Law- rence on Dis. ofthe Eye, p. 158.)] During sleep, when the lids have been for some time in con- tact, the matter glues them together so firmly, that they cannot be separated without many a painful effort. This matter, instead of being mild and lubricant, as in health, is now not only viscid, but acrimonious and erosive; whence the eye is irritated, and the edges of the lids ulcerated ; and the complaint is apt to become chronic, and will sometimes last for years, or even for life, in which state it is termed lippitudo. The disease is not unfrequently produced by smallpox and measles ; occasionally by com- mon ophthalmia from cold or any other causes, and in a few instances, though rarely, from a sty. Sometimes it appears to be the result of a scrofulous habit. [In the acute stage, cupping or leeches, tepid lotions, mild ointments, and active aperients, are called for, followed up, if necessary, by a blis- ter.] In the chronic stage, it is best attacked, and perhaps only to be cured, by such local stimulants as may excite a new action or in- flammation, that may be more manageable. The practice of M. St. Yves was here very bold : he touched the ulcers on the edge of the eyelid with lapis infernalis, and thus cauterized the mor- bid surface. The unguentum hydrargyri nitratis, or the older form entitled unguentum hydrargyri nitrati, has of late been used with equal success, and with far less danger of injuring the ball of the eye. The best way of using it is to take up a little of it with a camel-hair pencil, and apply it along the edge of each eyelid.* Or a drop of spirits, as vinum opii, ether, or Riga balsam, may be allowed to fall into the eye in the same manner, and be repeated daily. [Be- sides local applications, the compound calomel pill, and other alterative and aperient medicines, are frequently necessary.] SPECIES III. OPHTHALMIA INTERNA. INFLAMMA TION OF THE INTERNAL PARTS OF THE EYE. ACCOMPANIED WITH LESS EXTERNAL APPEAR- ANCE OF DISEASE THAN THE PRECEDING SPE- * Other applications in common use are Janin's ointment, composed of Armenian bole and tutty, of each 31J. white precipitate 3J. and lard gss. ; Sin- gleton's, or the golden ointtnent, the active ingre- dient in which is orpiment, or the sulphuret of arsenic ; and ointments containing the red precip- itate in various proportions. Mr. Mackenzie puts I from twelve to twenty grains of it to an ounce of lard.—See Practical Treatise on Dis. of the Eye, p. 138—Ed. 638 H.EM. CIES ; ITS COMMENCEMENT AND PROGRESS FREQUENTLY INSIDIOUS J AND OFTEN ATTEND- ED BY LITTLE OR NO EXTERNAL REDNESS. [Inflammation may be confined to one of the internal structures, or all of them may be in- volved. The close connexion between the dif- ferent internal parts and their common vascular supply, is sufficient to account for the exten- sion of inflammation from one to another. If inflammation commences in the iris, it readily extends to the ciliary body, choroid coat, vitre- ous humour, and retina. On the other hand, it may spread forward to the anterior part of the eye, so that a case of iritis often involves in its progress the greater part or the whole of the internal tunics, and also the external parts. In- flammation, beginning in the retina, spreads in like manner to the vitreous tunic, choroid, iris, &c.—(Lawrence, op. cit, p. 268.) Mr. Law- rence treats of four varieties of internal oph- thalmia ; namely, inflammation of the anterior and posterior chambers of the eye ; inflamma- tion of the iris ; inflammation of the internal tunics generally ; and inflammation ofthe poste- rior tunics of the eye. As this work is not designed to convey a minute account of ophthalmic surgery, the first variety must here be omitted, and our remarks confined to a Iritis. Inflammation of the iris. 0 Inflammatio tunicar- Inflammation of the cho- um internarum oculi. roid coat and retina. As in the arrangement of inflammation of the eye adopted in this edition, inflammation of the iris is classed as a variety of internal ophthalmia, and not as a species, no particular definition of it is placed as a leading head at the beginning of this section. Yet, as that inserted by Dr. Good is correct and instructive, it may be as well here to repeat it] Inflammation commencing in the iris ; colour of the part changed to green or reddish ; fibres less moveable, and shooting dentiform processes into the pupil; pupil irregularly contracted and grayish. Dr. Schmidt, of Vienna, to whom we are chiefly indebted for an accurate description of this species, has denominated it Iritis (Ueber Nachstaar und Iritis nach Staaroperationen, Wien, 1801); and under this name it has of late years been described by many practical sur- geons in our own country. The termination, however, is unclassical, and if the derivative be retained, it should unquestionably be iriditis, instead of iritis ; but ophthalmia iridis is better, as the disease is very clearly a species of a con- nective genus of diseases, rather than a distinct genus itself. It is the more singular, however, that iritis should ever have been used by its in- ventor, as the Germans have long employed the more correct relative compounds of iridotomia iridectomia, and irirfodyalysis. The exact change of colour which the in- flamed iris assumes, first in its less, and then in its greater circle, depends upon the peculiar colour it possessed when in health. If this were grayish or blue, the morbid hue will be ATICA. [Cl. III.—Ord. II. green; if brown or black, It will be reddish. The grayish or cloudy appearance of the pupil is produced by the secretion of coagulable lymph, which spreads over it in a fine flake like a cob- web. If the inflammation do not yield to the curative treatment, a yellowish-red tubercle forms in some part of the surface of the iris, commonly where the greater and less circles of the membrane meet; it enlarges, projects still forwarder, and is distinctly seen to be an ab- scess, which at length bursts and discharges its contents into the anterior chamber. [Iritis is an adhesive inflammation; that is, an inflammation attended with deposition of new matter, indiscriminately called by the not very precise term of coagulable lymph. The chief character of the affection is this effusion of lymph, either into the texture of the iris, or in distinct masses on its surface, or in a more or less fluid form. This effusion of coagulable lymph, besides changing the colour and general appearance of the iris, impairs and destroys its motions; frequently renders it adherent to sur- rounding parts ; alters the form and size of the pupil ; and obstructs that aperture, so as to pro- duce more or less impairment of sight. But, though the inflammation is called adhesive, and the substance effused is commonly lymph, it ap- pears, pus may be poured out from the inflamed iris, or, at all events, a fluid of a yellowish colour, that sinks to the bottom of the anterior chamber, and cannot be distinguished from pus ; and where the inflammation is violent, even blood itself may be effused.—(Lawrence, op. cit, p. 285.) In the beginning, there is some intolerance of light; the sclerotic coat participates more or less in the inflammation ; and there is conse- quently a greater or less degree of increased sensibility. If the inflammation be not relieved by proper treatment, Mr. Lawrence finds that an opposite state succeeds, or dimness of sight, caused by other changes which now take place in the pupil and cornea. From the commence- ment there is generally more or less pain, which varies in degree according to the acute- ness of the attack, and often extends around the orbit, and sometimes to the front or back of the head. The pain is often characterized by noc- turnal exacerbations. In the enumeration of the symptoms of iritis, however, what most particularly deserves notice is the redness, which appears in the form of a zone around the cornea, and consists of the ves- sels on the forepart of the sclerotica. In the beginning, a pale pink Hush of sclerotic redness is perceptible, and, although the conjunctiva is not altered, the trunks of the vessels of the sclerotica may be observed to be in a state of distention. If the affection continue to increase, the inflammation spreads from the iris to the corpus ciliare, choroid coat, and retina, with in- crease of pain and fever, and ultimately with irrecoverable loss of vision. At the same time, the mischief is propagated forward, the cornea becomes more opaque, the conjunctiva more in- flamed, and great external redness is added to all the other symptoms. Gen. VIII.—Spe. 3.] OPHTHALMIA INTERNA. 539 After the active inflammation at length abates, the permanent disorganization and changes of structure remain; as general adhe- sion of the iris to the cornea, with opacity of the latter, and even staphyloma ; or adhesion of the edge of the pupil to the capsule of the lens ; a motionless contracted state of the pupil, &c A change of colour in the whole iris, with considerable contraction of the pupil, and an opaque substance in it, with intense external redness, great and deep-seated pain, and com- plete insensibility to light, are circumstances denoting, according to Mr. Lawrence's experi- ence, a hopeless case. When the inflammation is recent, confined to the iris, and unattended with permanent changes of structure in the iris, cornea, or retina, or adhesions, and irregularity of the pupil, the prognosis is favourable.] This distressing affection sometimes follows an operation for the cataract; in which an irri- tation is often excited, either by endeavouring to press out the lens through too small a wound in the cornea, by suffering some pieces of the lens to remain in the posterior chamber, or from too frequent an exposure of the internal surface to the air, by unnecessarily raising the flaps ofthe cornea. And the disease was hence, in our country, till of late, most absurdly de- nominated secondary cataract. [It also origi- nates from accidental injuries, and irritation, and immoderate exertion of the eye. Iritis is particularly apt to occur in certain states of the constitution, and, as Mr. Lawrence mentions, it has even been doubted whether there is any such thing as idiopathic iritis, ex- cept as the result of direct mechanical injury. The unhealthy condition of the constitution, promoting attacks of iritis, are those produced by morbid poisons, as in syphilis, or those oc- curring in individuals who are subject to gouty and rheumatic complaints. Iritis is rare, in young subjects, in whom these states of the system do not exist] Where a patient is labouring under an ar- thritic diathesis, and is accidentally affected by a common ophthalmia, this species is apt to be in- grafted upon it. It is also an accompaniment of several cutaneous eruptions, especially those connected with an abuse of mercury. The medical treatment should consist in free venesection, leeches, active purgatives, and low diet: blisters are then to be applied succes- sively to the temples, behind the ears, and on the nape of the neck. [The body is to be kept perfectly at rest, as well as the organ; and the eye protected from all injurious external influ- ences. According to Mr. Lawrence, local ap- plications cannot be of much service in so seri- ous an affection of parts comparatively internal. Tepid washes, he says, will perhaps be most soothing; but cold applications may be used if the patient prefer them. The foregoing antiphlogistic measures will moderate the violence of the inflammation ; but the effusion of lymph proceeds, and the above- mentioned alterations of structure are the re- sult. For the stoppage of this destructive action, the free and prompt use of mercury is necessary, which not only stops the further de- position of lymph, but promotes the ' absorption of what is already effused. Two, three, or four grains of calomel, joined with one fourth or one half of a grain of opium, should be given every eight, six, or, in urgent cases, every four hours. When calomel disagrees, the blue-pill or mer- curial frictions may be employed.] Whether iritis be a primary affection, or con- nected with other diseases, even with syphilis, or induced by the action of mercurial prepara- tions, Mr. Travers estimates mercury as almost a specific remedy. [Belladonna is also to be used for preventing that contraction of the pupil, to which there is such a powerful tendency in iritis. If the in- flammation be violent, Mr. Lawrence smears the moistened extract upon the eyebrow ; when the organ is less irritable, he drops a solution of the extract between the eyelids. This part of the treatment is of the greatest importance, not only in preventing further contraction of the pupil, but because the influence of belladonna on the iris is so great, that, where adhesions have already taken place, if the effusion be very recent, the contraction of the iris will elongate the masses of effused lymph, stretch them out, and often completely liberate the margin of the pupil. The case, however, must be recent, and the belladonna assisted with the operation of mercury.] Mr. Travers distinguishes also inflammation in the iris from that in the cornea, by regarding the latter as suppurative, and leading to an abscess, and the former as adhesive alone. And he tells us, that inflammation of the cornea so strictly maintains this character, that if it spread to the iris, and in this case become merely secondary, it still preserves its adhesive power. This species is also sometimes a concomitant of cutaneous eruptions, decidedly not syphilitic ; and especially of those produced by a very ex- tensive use of mercury; constituting what has been denominated by some writers erythema mercuriale, and hydrargyria, as we shall take occasion to notice under syphilis. In the syphilitic or arthritic affection, how- ever, a particular attention must be paid to the primary disease, since otherwise no local rem- edies can be of any avail. Inflammation of the internal coats of the eye is a disease that has generally been overlooked by writers, and scarcely discriminated by prac- titioners. We have seen, that inflammation commencing in the iris, may extend to the in- ternal coats of the organ, and even to the whole of the eyeball; but sometimes those coats be- come primarily inflamed. The leading symptoms of the first stage are, a dull, deep-seated pain in the organ, aggravated by light, or exertion of the eye ; impaired vis- ion ; with originally, and often throughout, but little external redness. The pain soon extends to the brow, occiput, and other parts of the head. The pupil may be- either rather con- tracted, with a quick motion of the iris, or somewhat dilated, with sluggish motion of the latter part. The former, according to Mr. ATICA. [Cl. 111.—Ord. II. 540 H^M Lawrence, is the earlier state, denoting excite- ment of the retina ; the latter a later condition, indicating more advanced changes, attended with loss of sensibility in the nervous structure. The disorder is accompanied with febrile symp- toms. As the disease proceeds, more sclerotic redness show's itself round the cornea ; the iris changes colour and expands ; and the sight be- comes weaker and weaker, and is soon lost; after which misfortune the patient is troubled with various false luminous appearances. In the second stage the iris closes, and pro- jects in a convex form towards the cornea ; and hypopium is produced by the effusion of matter in the anterior chamber. Complete amaurosis, suppuration, and collapse of the eyeball, and closure of the pupil, are the result of bad cases. Greatly impaired vision, produced quickly, with pupil still clear, and not much contracted, Mr. Lawrence says, may be restored ; but if sight should have been totally lost before the pupil has closed, or, if that opening be much contracted, and vision gone, there is no hope. The treatment should be antiphlogistic, and followed up by the prompt and free use of mercury, combined with the local employment of belladonna. Bleeding and other antiphlo- gistic means mav check the inflammation ; but, unassisted by mercury, they are not adequate to prevent those changes in the retina which lead to blindness. SPECIES IV. OPHTHALMIA STAPHYLOMA. PROTUBERANT EYE. PROTUBERANCE AND PARTIAL OR COMPLETE OPACITY OF THE CORNEA ; OR AN UNNATURAL PROTUBERANT STATE OF SOME PART OR PARTS OF THE SCLEROTIC COAT; SIGHT ABOLISHED OR IMPAIRED. - The term staphyloma is derived from cra- art Grippe.) Tozzetti's Cronica Meteo- rologica Toscana, a work referred to by Cullen in relation to influenza, was published, however, in 1323.—Ed. the end of November, after which they abated, but the fever still remained the same-as it was before the catarrhs appeared ;" meaning that it then returned to its essential character : " al- though," he continues, "it was neither quite so epidemic, nor accompanied with quite the same symptoms ; since these incidentally depended upon the catarrhs." , Influenza, however, as we shall have occasioa to show presently, has not only occurred in the autumn, but in every season ofthe year, whether hot, cold, damp, or temperate ; and when there has been apparently nO other 'constitutional dis- temper with which it could unite itself. The chief returns of the disease which have been re- marked in this country since the above of Syden- ham, are those of 1732, 1762, 1775, 1782, 1803, and 1831 : the duration of the epidemy was in every instance from a month to six weeks. That the disease is an epidemy, cannot be doubted for a moment: yet this is to advance but a very little way towards a knowledge of its origin Or remote cause ; for we have still to inquire into the nature of epidemics, their sources, diversi- ties, and means of diffusion; often, as in the case of spasmodic cholera, in the very teeth of periodical winds and other meteorological phe- nomena that we might fairly conclude, if we did not know the contrary, would irresistibly Oppose their progress, or disintegrate their principles, and consequently abolish their power.* Dr. Sydenham, with the modesty which peculiarly belongs to himself, and always characterizes real knowledge, freely confesses his ignorance upon the subject, though he is rather disposed to ascribe them to "some occult and inexplica- ble changes wrought in the bowels of the earth itself, by which the atmosphere becomes con- taminated with certain effluvia, which predis- pose the bodies of men to some form or other of disease ;" while Hippocrates, who had pur- sued the same recondite subject with an equally indefatigable spirit upwards of two thousand years before, resolves them, with a devotional feeling which would do honour to the philosophy of the present day, but which the philosophy of the present day has not always evinced, into a present divinity, a providential interposition ; for such, as Galen informs us, is the actual meaning of his TO 6EI0N (De Prognos., lib. i.), and not some unknown and latent physical principle of the atmosphere, as various expositors have con- ceived :—" non enim quaecunque causas habent incognitas et abditas divina vocamus ; sed ubi admirabilia videntur duntaxat."—(Comment, in Progn. Hipp.) An epidemy, however, or state of the atmo. sphere capable of producing any general disorder, whether originating specially or in the ordinary course of nature, may depend upon an intem- perament, or inharmonious combination of the elementary principles of which it consists, or upon some foreign principle accidentally com- bined with it, and which has of late years more * Like cholera, the influenza has also generally extended itself from the east towards the west, and from the south towards the north ; which is a curious coincidence.—Ed. Gen. IX^-Spe. 2.] CATARRHUS EPIDEMICUS. 545 especially been called a miasm or contamina- tion. It is possible, that both these. may be causes of different diseases ; and,,-in this case, the term epidemy might be more correctly lim- ited to those which issue from the first cause than from the second : and Dr. Hosack has en- deavoured thus to limit it. But as it is rarely that we can distinguish between the two, and especially as the term has been very generally applied to diseases arising from both sources, it •is not worth while to alter its common significa- tion. In the disease before us, many writers have endeavoured to trace it to the first of the above causes, and particularly to the atmosphere's being in a state of negative electricity; and Weber, fully confiding in this cause, has rec- ommended, somewhat whimsically, the use of socks made of the most powerful non-conduct- ors, as oiled silk, or paper covered with seal- ing-wax, as a certain prophylactic.—(Rahn, Briefwech. mil seinen ehemaligen Schulern, band. ii., Zurich, 8vo., 1787.) Others, without un- dertaking to determine in what the atmospheric inteniperament consists, have regarded it as a mere exciting cause of catarrhs, or, in other words, as merely rendering the body more sus- ceptive of the ordinary causes of this disease, and hence converting a sporadic into a general distemper. More commonly, however, catarrh, as well as other epidemics, has in modern times been con- templated as dependant upon the second of the aerial causes just adverted to, namely, the ex- istence of a specific miasm, or morbid principle of a peculiar kind, in the atmosphere, distinct from any change in the combination of its proper elements ;* and hence, Professor Frank (Op. cit, p. 118-19), after adverting to the "inambi- ente nos aere mutatio," adds, " non sine magna latentis contagii suspicione." There is much, indeed, to support this opinion ; for in many cases, as in intermittent and remittent fevers, we can manifestly trace such an origin ; and, as we have already shown that contagions and miasms are often identic or nearly so, the for- mer may be brought forward as abundantly con- firming the same view. This identity, or approach to identity, be- tween contagidns and miasms, is closely con- nected with the present subject, and must be a little examined into for its clear elucidation. In treating of the origin and laws of febrile miasm we observed, that it is of two distinct modifications, or proceeds from two distinct sour- ces ; that, in its ordinary course, it first appears as the result of a decomposition of dead organ- ized matter, operated upon by the common aux- iliaries of putrefaction; but that afterward, " du- ring the action of the fever thus produced, the effluvium from the living body is loaded with miasm of the same kind, completely elaborated as it passes off, and standing in no need of the decomposition of the effluvium for its formation; * See especially De Mertens, Observ. Med., torn, ii., p. 4; and Simmons, Lj^nd. Med. Journal, 1788, part iv. Vol. I.—M m under which form it is commonly known by the •' name of contagion." I may now add, that, as primary febrile miasm is not the only miasm generated in the atmo- sphere, so it does not seem to be the only miasm that gives rise to contagion : that both are very numerous in their kinds, and that specific con- tagions are, though perhaps not always, yet far most generally, a result of tepecific miasm pro- duced as above. This^seems especially to be the case in respect to influenza; for though most individuals labouring under it are evidently affected from an atmospheric taint, many, as we shall show presently, appear, as in the case of remittent or typhus fever, to receive it from personal contagion : nor is there, in fact, any reason why a puriform discharge from the mu- pous membrane of the nostrils may not be con- tagious, as well as a puriform discharge from the mucous membrane of the eyelids in ophthalmia, or from the urethra in blenorrhoea, or, as we shall shortly have to notice, from the rectum in dysentery. Among dogs and horses we pe**. ceive the same disease, in many instances highly' and extensively contagious, and accompanied with so violent a degree of fever as to be pecu- liarly dangerous, especially to the young of these kinds. In South America, in particular, this affection is so violent, that half the dogs pupped there are supposed to die of it while sucklings. Whence, in common language^ it is called em- phatically the distemper, though vulgarly, the snaffles, or rather snuffles, from the state of the nostrils. In nosology, it is commonly called catarrhus caninus. Generally speaking, ^Specific miasms and con- tagions, capable of affecting one kind of animals, are incapable of affecting any other kind ; or, at least, rarely extend their influence any farther. In a few febrile pestilences, quadrupeds and birds seem to have been fellow-sufferers with mankind, as we have already had occasion to notice under epanetus malignus, or malignant remittent fever. But this is not common ; and, in some instances, is well known to have de- pended upon the general dearth of a country, or the insalubrity of the preceding harvest. A few of |jhe exanthems, as cowpox, are capable of propagation from one species to another j. but * the greater number of them are not, or only with great difficulty. When a putrid fever has broken out among a ship's crew, the live stock* has never been known to suffer from it: and it has happened occasionally, when large numbers of sheep and hogs have been stowed in a ship for-the purpose of exportation, sometimes the former have been attacked with infectious fever, and sometimes the, latter; but the sheep have never communicated it to the hogs, nor the hogs to the sheep, nor either of them to the ship's crew. " It seems to be a general law of nature," ob- serves Sir Gilbert Blane, " at least among the mammalia, that accumulation and stagnation of the exhalations of the living body produce dis- ease. The glanders of horses arise only in large stables, and the distemper of dogs in kennels. During the American war, it was proposed to send live sheep from England across the Atlan- 548 FLEMATICA. [Cl. III.—Ord. II. tic. In a few weeks, in consequence of being crowded in a ship, they all died of a febrile dis- order."—" In the expedition to Quiberon in 1795, several horse-transports had their hatches shut for a length of time in a storm, by which means eight horses were suffocated. Those which survived became affected with the glanders soon after they landed. Professor Colman saw twenty of them under this disorder ; a consid- erable number had been previously destroyed." —(Med.-Chirurg. Trans., vol. iv., p. 89, 475.) It does not appear, that, in either of these in- stances, the respective disorders were commu- nicated from one genus or species of animals to another. That the catarrh tefore us possesses not only an epidemic character, but is dependant on at- mospheric influence, is established by so many well-known proofs, that it is hardly worth while to give ectopics. Of a dozen persons in per- fect health in the same room, ten have often been attacked as nearly as possible at the same time. Inihe influenza of 1782, three families, consisting of seventeen persons, arrived on the same day at a hotel in the Adelphi, all in per- fect health. The next day they were all af- fected with the symptoms of the reigning dis- ease.—(Med. Trans., vol. iii., p. 59.) In an hospital containing a hundred and seventy per- sons, more than a hundred were on one occa- sion attacked within twenty-four hours ; and few of the remainder escaped afterward. We have said, however, that the middle-aged, the strong, and the robust, are affected soonest, and suffer most severely, while the young and the old are less susceptive of its influence. In proof of this we may advert to the fact, that healthy and well-disciplined soldiers suffer pe- culiarly. In 1782, this was especially the case at Aberdeen : at Dublin, there were, at the same period, seven hundred soldiers confined under it in their barracks at once, and incapable of doing their duty (Dr. Hamilton, Mem. Med. Soc. of Lond., 1782); while at Utrecht, the number amounted to not less than three thousand. On the contrary, out of seven hundred boys in Christ's Hospital, during the same epidemy, only fourteen had the disease, and all of them B£ the slightest manner.* The proofs of communication by personal contagion are not less decisive. " The first," says Dr. Hamilton, describing the influenza of 1782, " who were seized with it at Norwich were two men lately arrived from London, where it then continued to rage. A sergeant of gren- adiers in the 10th regiment of foot went to Lon- don on furlough : the disease then raged in the capital. He returned in a few days to St. Al- bans, affected, and communicated it to the peo- ple in whose house he had his billet. This was the first of its appearance there, and from thence it spread rapidly all over the town."! * Med. Trans., vol. iii., p. 56. It has been al- ready noticed, that when the influenza visited this country in the spring of 1833, old persons suffered with peculiar severity, so that many of them were cut off.—Ed. * Mem. Med. Soc. of Lond., ut supra. The Dr. Cullen in his Synopsis has followed the more striking returns of influenza, from the fourteenth century down to the present times ; or rather from the Cronica Meteorologica Tos- cana of 1323, by Targioni Tozzetti, to Saillant's Tableau des Epidemies Catarrh-ales. " In all these instances,".says he, " the phenomena have been much the same : and the disease has al- ways been particularly remarkable in this, that it has been the most widely and generally spread- ing epidemic known. It has seldom appeared in any one country of Europe, without appeal- ing successively in every other part of it." And, in some instances, the infection has passed the Atlantic with little or no remission of its sever- ity, and attacked Americans who had not had the slightest intercourse with Europeans. And hence we are capable of tracing it at sea as well as on land. In the epidemy of 1782, Lord Howe sailed in the month of May with a fleet for, the Dutch coast; and Admiral Kem- penfelt for that of France. The crews of both fleets were, well on sailing : but, in the same month, both were attacked very generally, and the latter was obliged to return home. The previous state of.the.air, with respect to any of the sensible qualities of heat, cold, electricity, or damp, seems to have exercised but little power. Influenzas, as already observed, have recurred at every different season, in every state of the barometer, thermometer, and hy- drometer. Thus the influenza of 1762, one of the seve- rest on record, producing effects which contin- ued, in many instances, for two or three years afterward, was preceded by weather uncom- monly warm ; while in that of 1767, being the next in rotation, which was also very severe, though productive of less durable mischief t® the constitution, the weather was remarkable for being unusually cold.—(Dr. Heberden, Med. Transact., i., art. xviii.y We know nothing of the country from which the disease has at any time taken its rise ; but it has frequently seemed to proceed from north to south, though it has occasionally travelled from west to east. That of 1781 and 1782 is said to have originated in China, and to have travelled through Asia into Europe ; whence it crossed the Atlantic, and arrived the ensuing year in America. But this assertion wants confirmation. If we allow its materies to depend upon specific miasm floating in the atmosphere, we can only account for its preserving its agency so long, and operating in such distant theatres, by supposing that its par- ticles are with great difficulty dissolved or de- composed in the air, even when in its purest state or highest degree ef agitation by tempest. Of the specific miasms we are a little acquainted with, some seem to dissolve or lose their power opinion on this point, delivered by the author of the art. Influenza in the Cyclop, of Pract. Med., is, that the disorder generally arises from, and is propagated by, some general cause, subsisting in the atmosphere ; " but that it is probable a limited propagation also takes place, by personal inter- course, under the influence, and during the prevalence, ofthe epidemic constitution."—Ed. Gen. X.] DYSENTERIA. 547 much more readily than others, and hence spread their influence through very confined peripheries; while others are only dissoluble in a pure at- mosphere, and consequently retain all they: viru- lence in an air already saturated with other for- eign elements. The chief influenzas that have visited Eu- rope within the last three centuries, occurred in the following order of time :—1510 ; 1557 : 1580; 1587; 1591; 1675; 1709; 1732-31 1743; 1762; 1767; 1775; 1781 and 1782; since which period, the return of the disease has been little noticed in respect to extent or violence.* The remedial treatment needs not detain us long, notwithstanding the violence with which the disease makes its assault. Bleeding, as we have already observed, is rarely required, and, from the debility so soon induced, should be avoided, except in urgent pleuritic pains, which are not common. It was tried copiously by many practitioners in 1782, but they soon reverted to the cautionary track of Sydenham. Quiet, diluent drinks, and the promotion of that easy breathing perspiration which Chenot has distinguished by the name of diapnoe, will usu- ally be found sufficient, if the bowels be kept free from confinement.! If the chest be much loaded, an emetic will afford the best relief. And, if the cough be troublesome, and the breathing laborious, both which, however, are generally alleviated by an emetic, small doses of ipecacuanha, with or without oxymel of squills, will promote an easy expectoration, and take off the sense of oppression. Dr. Cullen joined these with opium, and was particularly attached to the use of Dover's powder in all catarrhal af- fections, asserting that there is no disease in which opium has been found more useful.! But it generally agrees better in common catarrhs than in influenza. The subsequent debility may be removed by a free use of the bark, gen- tle exercise, pure air, cold bathing, and a liberal regimen ; which last, indeed, should be con- * The influenza of 1831, which occurred subse- quently to the author's decease, was generally mild in its character, though almost universal; for it seems to have appeared in both hemispheres, in India as well as the United States of America. About a month before the epidemic cholera broke out in Warsaw it prevailed in that city, and in the spring and autumn it also swept over great part of England, Scotland, and Ireland. Late in the autumn it attacked Paris, the south of Spain, Gibraltar, and Italy, with more severity than the British Islands.—See art. Influenza, in Cyclop. of Pract. Med.—Ed. ! Strong purgatives are generally objected to in cases of influenza, on account of the tendency to a morbid state of the mucous coat of the bow- els, usually accompanying the complaint.—Ed. X Mat. Med., part ii., ch. vi. At the commence- ment of the disease opiates are frequently found hurtful, increasing the febrile heat, aggravating the headache, and stopping the expectoration ; but in the decline of the complaint, they may be more advantageously given. Our author has not noticed blisters, which often afford great relief. A solution of gum ammoniac, with oxym. of squills, is in these cases a valuable medicine.—Ed. M m 2 tinued through the disease itself. The cough occasionally produced remains sometimes as a sequel, long after the other symptoms have dis- appeared : and, in this case, opium with cam- phire, or the resinous balsams, or the extract of hemlock, or of hyoscyamus, prepared in a steam-heat, often affords essential relief, and es- pecially at night; yet it has not been found that even the symptom of a cough has proved any impediment to the use of thejbark, or even that of cold bathing, or been augmented by the prac- tice, as influenza has rarely terminated in phthisis, and, according to Dr. Carmichael Smith, is less disposed to produce this complaint than a common catarrh.* GENUS X. DYSENTERIA. DYSENTERY. BLOODY FLUX. inflammation of the mucous membrane of the larger intestines ; griping and te- nesmus ; frequent and often bloody de- jections ; the feces irregularly dis- CHARGED. Dysentery is far more frequent in the autum- nal months than in any other season of the year. The animal frame is at this time generally re- laxed and debilitated by a long exposure to the stimulus of a high atmospherical temperature, and, in many cases, to that of the direct rays of the sun. The digestive organs and intestinal canal necessarily partake of this debility, and are more easily irritated and thrown out of the order of health, than at any other time. Hence diarrhoeas and colics, and that hepatic flux which by some writers has been regarded, but erroneously, as a variety of dysentery. And hence, also, proper dysentery ; which, in a par- ticular state of the intestinal canal, is excited, rather than any of the jest, by causes that are perhaps common to the whole. These causes may be direct or sympa- thetic : and, as most of these are peculiarly incidental to hot climates, we may readily per- ceive why dysentery should be more prevalent in them than in other situations. The direct causes are chiefly those of diet; and may consist of any sudden application of cold to the stomach very much below its actual tem- perature, as drinking cold water or eating con- * The reader will find much information in re- gard to the epidemic catarrhs and other diseases which have prevailed extensively in the United States, contained in Webster's Hist, of Pest. Dis- eases, Mitchell and Miller's N. York Med. Reposi- tory, Coxe's Phil. Med. Museum, Chapman on Epi- demics, in the Phil. Journ. of Med. Sc, Yandell's Transylvania Journ. of Medicine and the Asso- ciate Sciences, Hosack and Francis's Am. Med. and Phil. Register, the New-England Journal of Medicine and Surgery, Barton's Med. and Phys. Journal, the Am. Journ. of Med. Sc, the works of Dr. Rush, Williams's History of Ver- mont, Belknap's History of' New-Hampshire, Chalmers on the Weather and Diseases of South Carolina, Ramsay's History of South Carolina, Gallup on the Epidemics of Vermont, the Collec- tions of the Mass. Historical Society, &c. &c.—D. 548 HiEMATICA. [Cl. III.—Ord. II. fectionary ices when in a state of considerable heat; eating flatulent herbs, unripe or sub-acid fruits, and especially to excess ; or food of little nourishment and difficult of digestion; drink- ing impure water, and especially when impreg- nated with the, decomposing elements of animal or vegetable substances. In this last case, as well as in one or two ofthe preceding, the disease is often endemic, and extends to almost every one who is under the influence of such a cause ; of which a striking example occurred, not many years ago, among the soldiers stationed in the old barracks at Cork. While the disease was raging with great violence, it was observed by Mr. Bell, the temporary surgeon, that the troops were supplied with water contaminated by an influx from the public sewers, and rendered brackish by an intermixture with the tide. He instantly changed the beverage, and had the barracks supplied by water-casks from a spring called the Lady's Well, when the disease al- most immediately ceased.—(Dr. Cheyne in Dublin Hospital Reports, &c, vol. iii., p. 11.) We meet with various examples of a like kind. Thus Rolander, while residing with Lin- naeus, wa6 repeatedly attacked with this affec- tion, which he ascribed to drinking stagnant water contained in a cistern of juniper-wood. In this cistern wars discovered a species of acarus, which Linnaeus, who was fond of re- solving almost all diseases into an animalcular origin, immediately regarded as the source of the complaint, and specifically distinguished by the name of acarus dysenteria.—(Amcen. Acad., vol. v., p. 82, et alibi.) The sympathetic causes are those which operate on the intestines through the medium of other organs, chiefly of the skin or the rungs ; as exposure to currents of cold air when the body is heated; wet clothes and wet feet, producing, like the last, a sudden suppression of perspiration. And hence a damp marshy soil, or sudden changes in the atmosphere from hot and dry to cold and moist. And as in the autumnal months we find the bowels apt to be directly affected by water contaminated with peculiar impurities, we have reason to believe that they are also apt to be affected by air con- taminated in a particular manner, though we cannot easily trace the specific nature of the taint. And hence the disease assumes an epi- demic, as in the former case an endemic range. But the autumn, which thus peculiarly fa- vours the origin of dysentery and other intes- tinal affections, gives a like tendency, as we have already seen, to various fevers, and espe- cially to bilious and intermittent. With all these dysentery is particularly disposed to com- bine, by which the disease is rendered far more complicated; or excites in them a transfer of action, so as to turn aside, in many instances, their regular tenour, and run away with their violence. When dysentery is accompanied with atonic fever, and a copious discharge of mucous, puru- lent, bloody, or filmy matter, evidently the re- sult of intestinal ulceration, it is frequently pre- sumed to be contagious ;. but whether the matter of contagion is thrown forth from the body of the sick, or from the putrescent recrements, has been a disputed point. But the grand question is, whether dysentery ever exists without conta- gion ? or, in other words, whether, when the disease exists without those virulent symptoms which are deemed indicative of contagion, it is entitled to the name of dysentery'! Dr. Cullen, who, if he did not first start this controversy, has followed it up with a more peremptory opinion than perhaps any other writer, has contended for the negative of the question ; and has hence not only arranged the disease under his class pyrexije, but genetically distinguished it by his character of pyrexia contagiosa : asserting in his Synopsis that he has never met with more than one species ; and still more distinctly in his First Lines, that "the disease is always contagious," and that the con- tagion is probably at all times specific—(Part i., book v., chap, ii., sect, mlxxv.) [On the other hand, Sydenham makes no mention of any contagion attending the epi- demic dysentery which he has described ; and Willis, who speaks of the same epidemic, ex- pressly asserts that it was not contagious. Although Dr. Bateman believed dysentery te> be contagious in camps and hospitals, he neves found the disease, as it occurs in this metrop- olis, to partake of this character. He states that the disease was common in London in a sporadic form in the autumn of 1808 ; yet, that he never once knew it to pass to a second person in any family, while its origin could be- often satisfactorily traced to exposure to cold and moisture. He was therefore disposed to con- sider Cullen's doctrine as erroneous.—(Rees's Cyclopadia, art. Dysentery.) The epidemic dysentery which prevailed at Glasgow in the autumn of 1827, and which has been described by Mr. Brown, is also stated by that gentleman not to have been infectious.—(Glasgow Med. Journ., vol. i., p. 55.)] Dr. Parr and Dr. Young make a nearer ap- proach to the general opinion of Dr. Cullen, than any other nosologists that I am acquainted with. They regard the disease as an inflam- matory affection ; but differ from Dr. Cullen, inasmuch as they do not believe it to be essen- tially and at all times contagious : the former limiting himself to the expression that it is generally so; the latter, that it is often so. The earlier nosologists, however, have laid little or no stress on either the pyrectic or the contagious character ofthe disease ; and hence in Sauvages, Linnaeus, Vogel, Sager, and Macbride, it occurs as a genus under the division, not of fevers, but of fluxes, without any notice of fever or contagion, except as a distinctive symp- tom in some of their species. The practitioners in warm climates, and even the monographic and clinical writers of our own country to the present moment, are as little agreed upon the subject of a specific contagion. Pringle, Hunter, Harty, Balfour, and Chisholm, contend strongly for the existence of such a principle ; the last of whom asserts that " few diseases are more apt to become contagious."— Gen.X.] DYSENTERIA. 549 (Climate and Dis. of Trop. Countries, p. 54, 8vo., 1822.) Johnson, Ballingall, Barnpfield, and Dr. L. Frank, either deny it altogether, or have not met with any instance of it in their own practice. [Dr. Renton also, in his description of the dysentery of Madeira, distinctly affirms, that " the disease is certainly not contagious. The lower orders of the inhabitants, its principal victims, live huddled together in close crowded sties ; but (says Dr. Renton) I have never seen two cases in the same family at the same time." —(See Med. Chir. Trans, of Edinburgh, vol. ii., p. 376.)] So in the late alarming attacks of this disease in Ireland, it was not regarded as contagious at that time at Cork by Dr. Barry (Dublin Hospital Reports, &c,vol. iii., p. 10), or at Limerick by Dr. Perston (Id., p. 81): while Dr. Halloran, practising also at Cork (Id., p. 9), observes, that it was obviously con- tagious on many occasions; Dr. Poole that it was contagious at Waterford (Dublin Hos- pital Reports, &c, vol. iii., p. 7); Mr. Dillon that it was the same at Clonmell (Id., p. 5); and Dr. Cheyne, to whom we are indebted for the best, as well as the most extensive, clini- cal history of this disease, that it was at Dub- lin in some cases contagious, and in some not: being decidedly so when connected with continued fever ; and uncontagious in its sim- ple form, or when combined with an inter- mittent. This last opinion harmonizes most with the present author's experience : and es- pecially when the disease has been epidemic or endemic. This view has the full countenance of another very able and experienced writer of our own day, Dr. O'Brien, of Dublin. He has never found the disease decidedly contagious ; but supposes it may become so when the disease is epidemic, and the accompanying fever, in camps or other crowded stations, assumes a malignant or typhous form (Obs. on the Acute and Chronic Dysentery of Ireland, &c, Dublin, 1822); being, in effect, the opinion offered concerning it many years ago by Dr. Harty.—(Obs. on Simple Dys- entery and its Combinations, 8vo.) In truth, we meet with a like associate pro- cess in influenza, from an inflammatory affection and increased secretion in the mucous mem- brane of the nostrils, instead of in that of the colon : for we have already seen that the dis- ease, at first simply epidemic or atmospherical, at length becomes contagious, and'is capable of communicating its like to whatever distance the patient may be removed from the line of tainted atmosphere. And we are hence enabled to enter fully into the following variety of causes, traced out on the spot by Dr. Cheyne in the late extensive call upon the whole of his judg- ment and talents. " I have analyzed ninety- eight cases. Thirty-three arose during recovery from fever : fifteen while the fever was in prog- ress : fifteen from cold, or cold and wet: four from indigestion. The rest were doubtful: but many had been, exposed to febrile contagion, and nine in close communication with patients labouring under dysentery : four had been nurses in wards where the disease had occurred : four had slept with dysenteric patients, of whom one had used the same night-chair."—(Medical Re- port, &c, p. 18.) We may here readily sub- scribe to his own language, and say, " it has rarely fallen to the lot of a physician in civil life, possessing all the advantages of books, and of consultation with skilful and experienced colleagues, to witness dysentery uponsuch a scale." [In a later paper on the subject, Dr. O'Brien speaks of one of his patients, who supposed that he caught the disease either by lying near another person affected with dysentery, or by using the same night-chair. One other instance occurred, Dr. O'Brien remarks, in which a tol- erably strong presumption at least existed of the propagation of the disease by contagion ; viz., the case of Kelly, the whole of whose family, amounting to six in number, were at- tacked ■ in succession. But Dr. O'Brien has met with no other strong or probable instance of the communication of the disease by conta- gion.*] Dr. Cheyne tells us, that Dr. Prevost, of Geneva, at that time one of the clinical clerks of the Whitworth Hospital, conceived he had con- tracted the disease he was then labouring under in the dissecting-room, where he spent much of his time hanging over the bodies of those who had died of dysentery.—(Dublin Hosp. Rep., vol. iii., p. 18.) When the disease has run through its acute stage with great severity, but without destroy- ing the patient, and not unfrequently, perhaps, when it has been something less severe, but unskilfully treated, it assumes a chronic char- acter, exhibits symptoms peculiar to itself, and, as Sydenham observes, will continue to afflict the patient for several years. In this case, the structure of the liver, as well as that of the in- testines, is almost always injured. If the lesion be not considerable, the patient may at length recover ; but very generally the termination, though protracted, is still fatal. Dr. L. Frank, indeed, regards it as even more fatal than in the acute form. It is not always that the disease under this shape is a sequel of acute dysentery, and espe- cially among those who have predisposed them- selves to it by an antecedent life of intem- perance. Dysentery has, on this account, of late years, by many writers, both at home and abroad, been divided as a genus into the two species of acute and chronic, the pyrectic form being contemplated as a variety of the acute division:— 1. Dysenteria Acuta. Acute Dysentery. 2.----------Chronica. Chronic Dysentery. * Trans, of King's and Queen's College of Phy- sicians, vol. v., p. 227, Dublin, 1828. Dr. Elliot- son observes, that the sporadic cases which are occasionally met within this country among per- sons who have returned from hot climates, are certainly not contagious. Without denying that the disease may be contagious in warm countries, he expresses his belief that it is not so in England. —Lectures at the Lond. Univ., as published in Med Gaz. for 1833, p. 555.—Ed. 550 ILEMATICA. [Cl. III.-Ord. II. posing cause of an atmosphere varying rapidly from heat to cold, and from moist to dry; but by what means this exciting cause operates upon the larger intestines rather than upon any other cavity, or produces the symptoms of dysentery rather than those of diarrhoea, cholera, or colic, we seem to be incapable of determining. We perceive, however, in the events of every day, that sudden chills on the surface are possessed of a revellent power, and throw the action which is lost on the skin on various internal organs, and especially on cavities of mucous membranes, which, in consequence of this excitement, be- come inflamed, and pour forth an additional secretion. Such is especially the case in rheu- matism and catarrh, both which terms are derived from the same Greek root, and import defluxion. And, from this common character, the three diseases have by some pathologists been con- ceived to be so much alike, that dysentery has been regarded as an intestinal rheumatism by Caelius Aurelianus, Akenside, Stoll,and Richter; and is actually set down by Dr. Parr as a spe- cies of catarrh, in his nosological classification. We also see why dysentery, like catarrh, may be either sporadic or epidemic; as also why, in each case, it may be either slight, and pass off without any serious evil in a few days, or ac- companied with great inflammatory action and continued fever ; thus giving rise to the two fol- lowing varieties :— a Simplex. Feces often discharged Simple acute dys- without considerable entery. pain; of a natural qual- ity and affording ease : abdominal tenderness unheeded. 0 Pvrectica. Stools frequent: in every Pyrectic dysentery. way diversified, both Dysenteric fever in colour and consist- ence : severe pain in the abdomen : fever considerable, mostly a synochus. SPECIES I. DYSENTERIA ACUTA. ACUTE DYSENTERY. FECES DISCHARGED WITH DIFFICULTY, MOSTLY IN SMALL QUANTITIES, AND ALTERNATING WITH MUCOUS OR BLOODY DEJECTIONS; PAIN OR TENDERNESS IN THE ABDOMEN-: TERMI- NATING WITHIN A MONTH. We have already observed, that the atmo- spheric temperaments chiefly calculated to pro- duce severe bowel complaints are those of summer and autumn ; when the liver is excited to a larger secretion of perhaps more pungent bile, from the greater heat of the weather ; the skin is exposed to more sudden transitions from free to checked perspiration; and the exhala- tions that rise so abundantly from marshes and other swamps too often give an epidemic char- acter to the atmosphere, and lay a foundation for intermittent and remittent fevers : and we may hence see why dysenteric and other bowel affections, like intermittents, were far more common in our own country about a century ago than they are at present; the soil being more generally drained, and the atmosphere less humid. We have here also sufficient ground for local and general affection, and may readily see how it is possible, from the operation of one of these causes singly, or of two or all of them jointly on an irritable state of the intestines, for all or any of the local symptoms to be produced which enter into the generic or specific definition of the disease before us ; as also how it is possible for these symptoms to be combined with fevers and other disorders of various kinds and various degrees, so as to render the complaint peculiarly complicated and dangerous ; though we have not yet been able to find out what are the precise causes, that, operating locally, produce the dis- tinctive symptoms of dysentery, rather than those of diarrhcea, cholera, or any other irritation or spasmodic action of the intestinal canak This may, perhaps, sometimes depend upon idiosyn- crasy, sometimes upon accident, and, in the se- verer cases, upon contagion or a specific miasm. The symptoms, however, already noticed, suf- ficiently point out the general seat of the dis- ease : the tormina or griping pains, the region most affected by them ; and the costiveness or nodules of feces that are dejected, the exist- ence of spasmodic constriction in or about the colon, or the upper part of the large intestines. And while such is the state of the canal above, the excessive straining or tenesmus, accom- panied with a discharge of simple or bloody mucus, shows as distinctly the existence of great irritation in the sphincter or its vicinity. In some cases, one of these parts is more af- fected, and in some another: and hence the origin of most of the disputes concerning the precise spot of the disease. The ordinary exciting cause, however, of acute dysentery, under all its varieties of fixa- tion, there can be little question, is suppressed perspiration, or a sudden chill applied to the surface, acting in conjunction with the predis- • These are the two varieties under which acute dysentery is described by Sydenham, who in- deed limits himself almost entirely to these forms of the disease, since, though he notices the second species, or chronic dysentery, he merely glances at it in a kind of postscript to his chapter. _ Yet his description of both is so accurate, and his general mode of treatment so judicious, that they have received the sanction of the most approved pathologists from his own day to the present. As the local inflammatory action is more usually traced in the colon than elsewhere, Stoll (Rat. Med., part iii., pp. 294, 326) and various other writers have fixed upon this intestine as its proper seat; and hence Dr. Ballingall has distinguished it by the name of colonitis* Although, in dysentery, the primary seat of inflammatory action is the intestines, yet the functions of the skin and of the liver are from * In the Diet, de M£d. it is described under the name of colite.—See tom. v.—Ed. Gen. X.—Spe. 1.] DYSENTERIA ACUTA. 551 the first, as well as throughout the whole course of the disease, considerably disturbed by sym- pathetic excitement. The liver, however, suf- fers in many instances, not only on this account, but from a continuous spread of the inflamma- tory action through the medium of the biliary ducts, and becomes injured in its organization as well as in its function. Some pathologists, as Dr. Chisholm, conceive that they can trace this extension of the inflammatory process to the liver by particular symptoms, as a fixed pain at the stomach, a constant headache, and fre- quent dejections at the commencement of the disease ; and they have consequently given us a distinct division of it, under the name of hepatic dysentery. It is sufficiently ascertained, how- ever, that the structure of the liver has been often considerably affected, and even destroyed, when neither these or any other peculiar symp- toms have presented themselves ; and hence it is a distinction which can be made no use of. A frequency of dejections at the commencement is rather an anomalous fact than a pathogno- monic sign: while, as to the other two indica- tions, it is admitted by Dr. Chisholm himself, that they are " apparently not characteristic symptoms;" in other respects, says he, "the disease does not seem to differ from the idio- pathic or common dysentery." Some writers, however, as Piso (Discours sur la Nature, &c des Maladies accompagnees de Dysenterie, 1623) formerly, and Dr. James John- son in our own day (Influence of Tropical Cli- mates, &c, edit. 3, p. 197), have carried this view of the subject considerably farther than my late learned and venerated friend Dr. Chis- holm ever intended; for they have boldly re- versed the general opinion that has prevailed, and especially since the days of Sydenham, and contended that the liver itself forms in every instance the primary seat of the disease, the in- testines being only affected secondarily. Whence the latest of these two distinguished authors has ventured a scoff at the pathology of Sydenham, " who," says he, " it is our firm belief, never examined a dead body after he left his academical studies ; at least he has given us no indication of pathological knowledge in any of his works." —(Med.-Chirurg. Rev., March, 1823, p. 830.) I value Dr. Johnson's friendship, and have an equal value for his talents ; but I cannot concur with him in thus tearing from the temples of an illustrious countryman the wreaths of honour he has so deservedly earned, and which have been bestowed on him by our best foreign as well as domestic judges, from Boerhaave and Sauvages, in the middle of the last century, to the younger Frank in the present day. His language, in- deed, is tinctured with the prevailing errors of the humoral hypothesis, which at that period it was impossible altogether to avoid, and which is again rising into notice in some quarters ; but, sifted of this, his pathological doctrines are those of the present day, to which in the main they have given rise ; and better stand the test of dissection than those of Dr. Johnson himself. " His observations," says Dr. Bostock, " will fee commonly found to be correct, although his hypotheses arc too often fallacious."—(Physiol- ogy, vol. i., p. 448, 8vo., 1824.) These " ob- servations" teach us, in few words, that dysen- tery is an inflammatory affection of some part of the larger intestines, which, in its idiopathic and milder state, subsides without serious evil in a few days; but which, occurring in the autumn, is apt to associate itself with whatever febrile epidemy is then prevalent, to become a far more important and complicated malady, and to ravage over a much larger field of organ- ization ; the fever aggravating the dysentery, and the dysentery the fever ; while, not unfre- quently, a metastasis ensues, and the fever is thrown upon the intestinal canal, and expends its violence topically : during which vehemence of action a peccant material (the contagious prin- ciple of Dr. Cullen) is elaborated in the consti- tution and thrown out on the surface. To op- pose all which, he lays down a therapeutic plan which evinces an equal degree of judgment; and consists in bleeding, purging, diaphoresis, and opium ; in other words, in taking off con- gestion and inflammatory action, in allaying irri- tation, and restoring to the circulatory system its proper balance. It may perhaps be said by some modern writers, that he did not always carry these principles far enough. Possibly not in every instance ; but this must altogether depend upon the severity of the disease. And we have a proof, in his own success, that he carried them far enough in general; while his great merit consists in the establishment of such principles, and in squaring a correct line of practice to a correct pathology. It may also be objected, that calomel does not appear to have entered into his list of deobstruents. That he did not use it among other cathartics, shows evidently that his cathartic catalogue might have been improved; but to have employed it as a sialagogue, and to have depended upon curing the disease almost exclusively, as his loudest oppo- sers have endeavoured to do, by ptyalism—how- ever valuable such a process may be in a few in- stances, would not, I fear, have added to his rep- utation, or increased the number of his followers. Had the animadversion, indeed, which I have thus felt it my duty to notice, been delayed but a few months, it is most probable that it would not have been advanced at all. For while the learned writer who has made it had already to struggle with perhaps a majority of the most judicious tropical writers, in denying the exist- ence of contagion at all times, and regarding the very opinion as absurd (Influence of Tropical Climates, edit. 3, p. 223), he would have found in the admirable treatises on dysentery which have since been furnished us from Ireland, not only that this opinion, as already observed, seems to have a firm foundation Under particu- lar circumstances, but that his favourite doc- trine, that the liver is the primary seat of the disease, is completely unhinged; as also that his favourite plan of treatment has as little suc- ceeded here as it did in India under Dr. Bal- lingall, or, as Dr. Frank informs us, it did in his hands in Egypt during the occupation of that country by the French army. 552 H^M The diagnostics of the first variety, or simple acute dysentery, unaccompanied with the pre- vailing fever of the season, are thus accurately laid down by Sydenham :— " But frequently there is no appearance of fever ; for the host of gripings take the lead, and the dejections follow. The gripings are always severe, and a sort of painful descent of the bowels accompanies every evacuation. The discharges are chiefly mucus, but an excremen- titious stool sometimes intervenes without con- siderable pain. The mucous stools are gener- ally streaked with blood ; but, in some cases, there is no such appearance through the whole course of the disease. Nevertheless, if the stools be frequent, mucous, and accompanied with gripings, the disease may as justly be call- ed a dysentery as if blood were intermixed with them." These constitute the ordinary symptoms of the simple variety. And to the same effect Dr. Cheyne :—" When dysentery was unconnected with continued fever, which apparently was often the case, there was nothing peculiar in its origin. The patients generally assigned cold, damp, fatigue, hardships, indigestible food, as the causes of their disease, which began with confinement of the bowels, chills, pyrexia, tor- mina, unsatisfactory stools, and tenesmus."— (Dublin Reports, vol. iii., p. 18.) It is correct- ly observed by Dr. Chisholm, that, " when, after the straining has continued for a few days, the stools are intermixed with blood, the blood never thoroughly combines with the slime or mucus so as to produce a uniform colour" (Cli- mate and Diseases of Tropical Countries, p. 54), but, as Sydenham observes, " appears distinctly or in streaks." It is remarked by several of the practitioners in India, and especially by Mr. Bampfield, that the dejections are more frequent during the night, and especially towards morning, than at any other period of the twenty-four hours : and that the attacks and relapses of the disease are more common at new and full moon, than at any other period of the lunar revolution: and the influence of the heavenly bodies is referred to as the cause of these peculiarities.—(On Tropical Dysentery, 8vo., 352, 1819.) The remark does not seem to be sufficiently estab- lished. In its most favourable course, the symptoms gradually subside in a week or ten days, and sometimes even sooner, the skin becoming soft and moist, and the circulating fluid recovering the natural freedom of its current. If the symp- toms augment, all the local mischiefs of ulcera- tion and gangrene follow, which we shall have to describe presently, or the disease will become CHRONIC In the second variety, or dysenteric fe- ver, as it is called by many writers, all the pre- ceding symptoms are highly aggravated, and others are superinduced by the action of the fe- ver itself. The preceding variety may occur at any sea- son of the year, though, for reasons already Stated, the disease, under every form, is most lTICA. [Cl.III— Ord. II. frequently to be met with in the estival and autumnal months : it is very rarely, however, that the pyrectic variety is to be found in any other than these two seasons ; nor even in these, unless there be some endemic or epidemic fever prevailing, with which dysentery can combine. Of its readiness to do this, and even to con- vert almost all the other diseases of the season into its own form, so forcibly pointed out by Sydenham, the late ravages in Ireland have furnished us with the most undeniable proofs. " The bilious fever of the autumn," says Dr. Cheyne, " continued till near the termination of winter ; consequently it existed as long as the dysentery was prevalent in the hospitals and the House of Industry, or the symptoms were often exchanged for those of dysentery, the irritation from the mucous membrane of the stomach and small intestines probably extending to the large." —(Dublin Reports, vol. iii., p. 17.) And again, " dysentery was sometimes converted into fever, while, vice versa, fever was converted into dys- entery : in short, these forms of disease were convertible the one into the other ; so that the opinion of Sydenham, that dysentery is a febris introversa, or turned in upon the intestines, re- ceived support from our observations. And it is not unreasonable to suppose, that as these patients in my wards, in common with most of the poor in the city, had been exposed to the contagion of fever ; this contagion, according to the condition of the system at the time of its application, or some other modifying circum- stance, may have produced at one time fever, at another dysentery."—(Id., p. 19.) And so of other diseases as well as the pre- vailing fever of the season. " In early autumn, cases of cholera degenerated into dysentery, and, in the spring following, symptoms of dys- entery accompanied the measles, then epidem- ical in many parts of Ireland."—(Id., p. 16.) It is from the peculiar tendency which dys- entery has to unite with other diseases, and especially fevers, or to convert them into its own nature, that many pathologists of consider- able name have regarded it as nothing more than fever with a peculiar " local mode of action," to adopt the language of Dr. Jackson. And they hence endeavour to show that, when dependant upon a cause of endemic fever, it is often intermittent ; when dependant upon a cause of contagious fever, it is contagious {Jack- son, Hist, and Cure of Fever, parti., ch. xiii., p. 324); and, when dependant upon a cause of typhus fever, it is malignant or putrid ;—in the language of Dr. Balfour, as applied to the dys- entery of India, a "putrid, intestinal, remitting fever."—(On Sol-lunar Influence, p. 17.) Most of the French writers of the present day describe dysentery as essentially an atonic or adynamic disease, and hence peculiarly apt to fall into this last form: and Dr. L. Frank rep- resents this as the form it assumed, with little deviation, among the French army in Egypt, and believes it to be the ordinary form of hot climates.—(Consult., fix., T. H., p. 135.) And we can hence see, where there is much fibrous debility with but little fever, and especially Gen. X.—Spe. 1.] DYSENTERIA ACUTA. 553 where this is produced by poverty of diet, that it may occasionally connect itself with that kind of scorbutic affection which appeared some time ago among the convicts of the Millbank Peniten- tiary, and laid a foundation for such a form of the disease as was long ago denominated dys- enteria scorbutica by Cirigli and Brambilla (Phlegm., tom. ii., p. 337), and has been dis- tinguished by the same name, in our own day, by Mr. Bampfield.—(Practical Treatise on Trop- ical Dysentery, &c, 8vo., 1819.) In the pyrectic variety, therefore, the fever is found to vary according to the diathesis or surrounding circumstances. The functions of the liver and skin are disordered from the com- mencement, and continue so till the termination. In the dysentery at Dublin, in the autumn of 1818, the skin was obstinately dry, hot, and pungent; and, "judging," says Dr. Cheyne, " by the appearance of the stools, the biliary secretion was often suspended for many days." —(Op. cit., p. 22.) Scybala were here never found in the discharges, nor often in the intes- tines ; and they by no means appear so frequent as have been represented by many writers ; in- somuch, indeed, that it has of late been doubt- ed by some authorities whether they are ever to be traced at any time or in any country. Dr. Johnson has freely imbibed this doubt (Johnson, op. cit, &c, p. 223, et passim) : Dr. Ballingall tells us that " it is comparatively a rare occur- rence in India (Practical Obs. on Fever, Dysen- tery, and Liver Complaints, &c, 2d edit., Edin., 1823): while Dr. Chisholm speaks of them, on the contrary, as an ordinary symptom, and particularly adverts to the case of one pa- tient under his care, who, " on the tenth day of the disease, after a paroxysm of excruciating torture, attended by cold sweats and deliquium, spontaneously discharged at three evacuations a quantity of scybala sufficient to fill a common- sized chamber-pot."—(Climate and Diseases of Tropical Countries, &c, p. 56 ; see also Cleg- horn on the Diseases of Minorca, p. 252.) There is hence no reason to question their oc- casional formation, notwithstanding they are rarely to be traced on many occasions in the dysentery of any climate : their production, in- deed, is easily accounted for, from the spasmodic constrictions which so often run through a very considerable range of the intestines : and there is hence, prima facie, more reason for anticipa- ting than for not expecting them. Mr. Pack, who had formerly witnessed them in the Medi- terranean, was surprised at not meeting with the same appearance at Kilkenny, in the epi- demy of 1818, and could not avoid adverting to the dissimilarity of the disease in this respect in these distinct quarters.—(Dublin Reports, &c, ut supra, p. 20.) The patient, on going to stool, whatever be the discharge that ensues, has always a feeling of something remaining in the bowels which ought to be dejected ; while the dejections themselves, according to the extent and vio- lence of the inflammatory action and its effects, evince every combination of materials : being in consistency watery, like beef-washings, slimy, mucous, purulent, bloody ; in hue, drab-colour- ed like flummery, bright green like conferva, and, after opium and calomel, deep green; sometimes pitchy (O'Brien on Dysentery, p. 58), and extremely fetid : and sometimes load- ed with shreds of detached membranes ; while occasionally a feculent motion is thrown down, of a natural colour, and nearly of a natural spis- situde. Meanwhile, to adopt the description of Sydenham, the strength is much exhausted, the animal spirits dejected ; there are all the signs of an ill-conditioned fever; intolerable sick- ness and excruciating pains, and a deadly cold- ness of the extremities ; insomuch that the dis- ease, in many instances, and especially when unskilfully treated, endangers the patient's life much earlier than in most other acute diseases. But, if the patient should escape death in this way, still numerous symptoms of different kinds succeed. Sometimes, in the progress of the disease, instead ofthe membranous shreds which are usually mixed with the stools at the com- mencement, pure blood, unmixed with mucus, is profusely discharged at every evacuation, which of itself threatens death, as manifesting an erosion of some of the larger vessels of the intestines. Sometimes a fatal gangrene seizes the intestines. Towards the close of the dis- ease, aphthae frequently affect the interior of the mouth, and generally foreshow imminent death. The rapidity with which acute dysentery, when connected with fever, rushes on to destruc- tion, is particularly noticed by Dr. Cheyne, who ascribes the fatal issue in this case to the vio- lence ofthe fever itself, rather than to the prop- er dysenteric symptoms : though he adds, that sometimes sudden death ensued from an escape of the contents of the intestines into the cavity of the peritoneum, in consequence of ulceration. —(Ubi supra, p. 20.) The afflux of hot acrid matter alluded to by Sydenham is not unfrequently derived from the liver, and indicates a very morbid condition of this organ ; and to the same effect Dr. John- son :—" We sometimes see a partial, ill-condi- tioned sweat on the surface, which is produc- tive of no benefit; while from the liver an oc- casional gush of vitiated bile, like so much boil- ing lead, throws the irritable intestines into pain- ful contortions, and then the tormina and te- nesmus are intolerable."—(Influence of Tropical Climates, ut supra, p. 194.) There is occasion- ally, at this time, a formation of black vomit, the stomach discharging frequently a dark fluid; with a precipitate like coffee-grounds.—(Dub- lin Reports, vol. hi., p. 32.) Dr. Chisholm observes, that the principal signs of the disease having extended to the liver are, a " pain at the pit of the stomach and a headache, a considerable anxiety at the prae- cordia, and a sensation as of a continued pres- sure in the right hypochondrium, with frequent stools, composed of a fluid like the washings of raw meat."—(Ubi suprn, p. 59.) But he ad- mits, as we have already noticed, that these are not idiopathic, and, consequently, are not to be depended upon for this purpose. They prove, however, that the disease has made an exten- 551 H^EMATICA. [Cl. III.—Ord. II. sive inroad upon the constitution. Not unfre- quently the lungs themselves are affected, not merely in their function, but in their structure : for their respiration, observes Dr. Cheyne, was sometimes suddenly suppressed in the advanced stages ; there was pain in the chest, a teasing, dry cough, showing a translation of the disease to the lungs ; an exudation of puriform mucus in the cavity of the bronchia being detected on dissection.—(Supra, p. 25.) " A harsh, dry, opaque, dirty-looking skin ; a florid, clear, varnished tongue; vigilance; a hollow eye, and pallid, wasted, faded cheek; pains in the knees ; cramp in the legs ; fits of dyspnoea ; tendency, to oedema and ascites—be- longed to the more advanced stage, but not to the last, which was characterized by extreme emaciation, supine posture, involuntary stools, a thin reddish secretion, flowing without check ; sordes on the teeth; hiccough; tendency to delirium ; difficulty of swallowing ; thread-like pulse."—(Supra, p. 23.) The mortality is often dreadful. At Clon- mel, in 1818, where, however, it was far less severe than in many other parts of Ireland, Mr. Dillon calculated the deaths at one in ten ; at Cork, during the same year, Dr. Barry estima- ted it at one in three at the least. "I never," says he, " witnessed so fatal a disease," And to the same effect, in general terms, Dr. Cheyne, while practising at Dublin: " I had often witnessed obstinate cases of dysentery, but I had not formed an adequate conception of the horrors of that disease, until I saw the patients who were congregated in the wards of Whit- worth Hospital." [Sir James M'Grigor, in his Account of the Diseases of the Army in the Peninsifla, mentions that, in three years, the loss from the ravages of dysentery was 4717 ; and Dr. O'Beirne (See Trans, of King's and Queen's Coll. of Physicians, vol. iv., p. 407, Dub- lin, 1824), calculates that the number of cases was 40,000. According to Desgenettes, dysen- tery made more havoc among the French troops in Egypt than the plague ; for while, in a given period,. 1689 were carried off by the plague, 2468 perished from dysentery.] Post-obit examinations were made in the dissecting-room ofthe Whitworth Hospital upon a very extensive scale, and gave evident proof, first, that the primary and chief seat of the disease was the intestines ; though the liver often participated in the general lesion; and, secondly, that the intestinal canal was very va- riously diseased, according to the length or se- verity of the attack, or the peculiarity of the patient's constitution. In some cases, the canal was prodigiously distended ; in others, the coats were greatly injured, but without any thickening ; in others, again, they were considerably thickened, as well as otherwise diseased. " Where distention prevailed, the small intes- tines were in a few instances found to be not less than seven, and the large not less than nine inches in circumference. Where the intestinal coats were without in- crassation, the inflammation ofthe mucous mem- brane was sometimes still very extensive, and reached from the stomach to the rectum ; be- ing, however, more obvious as the larger intes- tines were approached; though occasionally this last intestine was still pretty sound for three or four inches above the sphincter. The vas- cularity of the mucous membrane was some- times increased without abrasion or ulceration; sometimes the same part was covered with co- agulable lymph ; sometimes simply abraded of its epidermal coat; sometimes partly ulcerated, and irregularly exposing the muscular coat; the intervening portions being of a natural ap- pearance. Where the intestinal coats were thickened, the mischief seems to have been generally more severe ; the infernal surfaces were often rugose as well as ulcerated, exposing the muscular fibres more extensively, which often hung in shreds as if sphacelated. The process of thick- ening, moreover, belonged to the more protract- ed cases, and often measured the duration of the disease.—(Medical Report, &c, pp. 28, 34.) This incrassation is traced chiefly in the colon, which Dr. Chisholm has found sometimes a quarter of an inch thick, and full of minute abscesses, and small steatomatous excrescences. (Climate and Diseases of Tropical Countries, p. 56.) These last appearances are particularly noticed by Dr. Cheyne, but described differ- ently : "they are not," says he, " small ulcers, but minute pinholes formed out of the enlarged ducts of mucous glands; they were found very numerously, but especially in the rectam and lower part of the colon." By Dr. Baillie they are described as excrescences resembling warts. —{Morb. Anat., fascic iv., pi. iii., p. 73.) "The liver," says Cheyne, " in a majority of cases, was sound, but often otherwise. In two cases there were abscesses ; and in many, great sanguineous congestion."—(Medical Re- ports, &c, p. 36.) To a like effect Dr. O'Bri- en, writing from the same capital at a later pe- riod : " Generally," says he, " the liver was un- affected ; though the gall-bladder was always distended with deep-brown or dark-yellow bile."—(Observ. on the Acute and Chronic Dys- entery of Ireland, Dub., 1822.) Both these ap- pearances were particularly observed by Dr. Chisholm in the West Indies, thus again har- monizing the nature of the disease in climates of different temperatures. " Where the colon was thus diseased, it was prodigiously distended with air. All the rest of the intestinal canal was healthy, the liver was equally so ; but the gall-bladder was of a most uncommon size, and full of yellow bile."—(Climate and Diseases, &c, p. 57.) The same undeviating show of mischief in the intestinal canal, with only an occasional appearance of morbid structure in the liver, occurred to Dr. Ballingall in India, and to Dr. L. Frank in Egypt : so that the real source of the disease can be no longer a mat- ter of doubt. " The dissection of every sub- ject," says the former, " who died of dysentery in the regimental hospital of Penang (with one solitary exception), proved the disease to con- sist entirely in an inflammatory affection of the Gen. X.—Spe. 1.] DYSENTERIA ACUTA. 555 large intestines, without a trace of disease in the structure of the liver."—(Pract. Obs. on Fe- ver, Dysentery, and Liver Complaints, &c, Ed- inb., 1823.) [In a late essay (See Trans, of King's and Queen's College of Physicians, vol. v., p. 249, Dublin, 1828) on the present subject, Dr. O'Bri- en has recorded the dissections of twelve dys- enteric patients. The summary is as follows : liver diseased in six ; spleen in three ; small in- testine (chiefly ileum) inflamed, or ulcerated on its mucous surface, in eight ; great intestine diseased in twelve ; gangrenous in one ; much contracted in two ; ulcerated and inflamed in all; colon and rectum parts most diseased.] The medical treatment of dysentery has given rise to much warfare of opinion, Not, however, in slight cases of the simple acute disease ; for such usually give way in a short time to the ordinary evacuants and sedatives. " In cases," says Dr. Cheyne, " not attended with much fever or pain, and in the first few days of disease, a purgative in the morning, ten grains of Dover's powder in the afternoon, and again at bedtime, with low diet, restored many." ■—(Medical Report, &c, p. 42.) Sydenham generally commenced with bleed- ing, gave an opiate at night, and a pretty ac- tive purgative in the morning : the purgative consisting of a drachm and a half of rhubarb, two drachms of senna, with half an ounce of tamarinds, infused in a sufficient quantity of wa- ter, with manna and sirup of roses. The pur- gative was repeated twice every other day, and in every instance followed up with an anodyne of sixteen or eighteen drops of his own potent laudanum, to take off whatever additional ex- citement the purgative might produce. The same anodyne was constantly given with a warm diaphoretic, every night and morning, even on those days when the aperient was not employed. Where this was insufficient, the sedative was repeated every eight hours t& the amount of twenty-five drops at a dose, and a perspiration was still further attempted to be promoted and maintained by drinking freely of whey or the white decoction, and the use of warm emollient injections ; the perspiration being continued for at least twenty-four hours at a stage, the only bev- erage allowed in the meanwhile being tepid milk. The tormina and bloody stools usually gave way after the third or fourth injection. But where the morbid secretion ran into a chronic charac- ter, he varied the form and intention of the in- jection ; and, with a view of introducing a new and less unhealthy action, compounded it of half an ounce of Venice turpentine dissolved in a pint of cow's milk, which was thrown up daily ; thus anticipating, in a very considerable degree, the modern practice of obtaining the same effect by the balsam of copayva, which is only a terebinthinate of another kind. The principles of this practice it is not easy to improve upon ; though they have since been modified and often extended with considerable advantage. As a general rule, the lancet was had recourse to with too much timidity ; though its present indiscriminate and lavish employment forms an extreme that ought equally to be avoided. Where the fever is considerable, the pulse hard and full, and particularly where there is much general pain and tension over the belly, indica- ting an inflammatory diathesis, blood should be drawn copiously and with all possible speed, and repeated as long as the same symptoms may require ; for here we have no time to lose ; the inflammation may run rapidly into gangrene, and the patient sink from mortification or loss of blood in a day or two ; perhaps in a few hours. There is nevertheless no disease that requires the exercise of a sounder judgment upon this point than dysentery ; as the fever, if not typhous from the first, has a general ten- dency to pass into this type. [The statement of Dr. Renton, who has given a description of dysentery as it appears in Madeira, corroborates the necessity of great caution ; for he says that he was once in the habit of using the lan- cet freely and repeatedly, and of trusting to it and other antiphlogistic means ; but every case so treated terminated fatally.*] In his cathartic plan, Sydenham would have been considerably aided by the use of calomel; of all the purgative deobstruents the most val- uable ; and the more so, as exercising its evacua- ting power over all the secernents of the body. It has of late, indeed, been most extensively employed in quite a different way, and for a very different object; that, I mean, of curing by a specific action upon the immediate seat of in- flammation ; being persevered in for this pur- pose in doses of from five or ten to twenty or twenty-five grains, two or three times a day; assisted, where there is much torpor of the ab- sorbents, by mercurial friction, and continued till ptyalism is produced, which, as in the case of yellow fever, is the alleged test that the con- stitution is sufficiently loaded with it, and that the disease is about to give way. It is impossible to contemplate the conflicting opinions which are given us respecting this mode of treatment by the monographic writers on tropical diseases, without astonishment: and the only mode of reconciling them is, to sup- pose that the constitution is very differently af- fected by the use of mercury under different circumstances ; and that, while in some epi- demics and sporadic cases it produces all that benefit which a priori we should expect gener- ally, in others it entirely fails, or even proves mischievous. Dr. Jackson, Dr. Ballingall, and Mr. Bampfield, feel justified in employing-calo- mel merely as a purgative ; while the second, though he regards it as of the highest impor- tance in chronic dysentery, found even ptyalism itself unsuccessful in the acute form. Dr. John- * Edin. Med. Chir. Trans., vol. ii., p. 381. In acute dysentery, a decidedly antiphlogistic plan is rec- ommended by Dr. Elliotson:—" It may be neces- sary to bleed vigorously in the arm ; to apply leech- es freely and repeatedly to the abdomen ; to give mercury, and get the mouth sore ; to apply cata- plasms of hot moist bran to the abdomen," &c—< Lect. at Lond. Univ., as published in Med. Gaz. for 1833, p. 556.—Ed. 55G H^MATICA. [Cl. III.—Ord. II. son esteems it of high importance as a purgative, but of the utmost moment as a sialagogue. He unites it occasionally with bleeding, with ano- dynes, with diaphoretics, or with all; but each of these is subsidiary to its powers, and may often be dispensed with.—(Influence of Tropical Dis- eases, &c, p. 202.) Mr. Annesley unites it in the same manner, but takes every method in his power to prevent it from becoming a sialagogue. In any of the diseases for which he prescribes it, as fevers, dysentery, and liver-complaints, he gives it in scruple doses in each. " I never wished," says he, " to see the mouth in the least degree affected. Whenever this happened, I considered the salutary effects of calomel inter- rupted, because its use must be then discontin- ued ; and it was my object to act upon the se- cretions of the intestines, to diminish muscular action in the intestinal canal, and not in the most remote degree to act upon the salivary glands." —(Practical Observations on the Effects of Cal- omel on the Mucous Surface, &c, Lond., 1825, 8vo.) Mr. Cunningham, late surgeon to the Sceptre in the East Indies, boldly employs it alone, and regards every thing else as impeding its course. He does not even stand in need of alvine aperients of any kind, and prefers scruple doses to smaller proportions, because it does not in this form so readily excite the alvine dis- charge, so as to be carried out of the system by stool: and, administered in this way, he fear- lessly asserts, and the tables of his practice seem to justify his assertion, that " it is an al- most certain remedy for dysentery, in hot cli- mates at least." [Dr. Renton, of Madeira, after having given a trial to almost all the various modes, from copious bloodletting down to the oil of turpentine, feels himself justified in stating, after some years' experience, that, in the treat- ment of the dysentery of that island, " mercury, given boldly and perseveringly, until the mouth becomes decidedly affected, is the remedy chiefly entitled to confidence."—(Renton, in Edin. Med. Chir. Trans., vol. ii., p. 377.) His plan is to give calomel every three or four hours, until the gums become sore.] And, finally, for it is not worth while to pursue the discrepance further, Dr. L. Frank assures us, that, in his practice, the large doses of calomel given so generally by the English surgeons in India, proved dangerous in the French army in Egypt; and that the plan most successful in his hands, was that laid down by Sydenham, which consisted, says he, in removing irritation by gentle aperients, the use of emollient injections, mucilaginous and diluent drinks, diaphoretics, and laudanum. Sydenham employed laudanum as a cordial and diaphoretic, as well as a sedative; so as to take off that fearful depression of the animal spirits by which dysentery is so peculiarly char- acterized, and to give a breathing moisture, and consequently a refreshing coolness, to he parched and burning skin, as well as to allay local irritation ; his chief auxiliaries for the last purpose being diluent3, tepid injections, and the warmth of the bed. Modern practice has greatly improved upon this plan, by combining some relaxant with the opium; and, in many instances, by premising an emetic, which, inde- pendently of its often exciting a perspiration, which nothing else can accomplish, has the ad- ditional benefit of emulgmg the meseraic or mesenteric vessels by the act of vomitiort. The antimonial preparations form the best emetics for this purpose, whether the glass of antimony, at one iime so powerfully recommended by Sir George Pringle (Edin. Med. Essays, vol. v., art. xv.), tartarized antimony, or Dr. James's powder. Sir George Baker, Dr. Adair, and Dr. Saunders, concurred in strongly recommending the emetic tartar as a diaphoretic or relaxant; the first alone, the second with calomel, and the third with opium ; all which, nevertheless, have, in our own day, often yielded to Dover's powder, which is certainly entitled to a very high degree of praise. Much, however, of the benefit to be derived from Dover's powder, as a sudorific, depends upon its proper ad- ministration, and the care taken to promote its influence by a proper adjustment of clothing. Dr. Cullen advises, that the patient should, from the first be wrapped in a flannel shirt, and laid between the blankets alone, by a removal of the linen sheets, so that he may be sur- rounded by nothing but a woollen covering. Mr. Dewar's recommendation (Obs. on Diar- rhoea and Dysentery) of a broad flannel swathe or Cumberland bound round the abdomen, is, however, better entitled to practice, as it affords support as well as warmth : Sir James M'Grigor found it very useful.* Dr. Darwin amuses us with a singular mode of producing the same result, and one which, if continued long enough, might probably prove as powerful a revellent as any of those already noticed, but which we should not always rec- ommend, nor find our patients disposed to carry into effect. " Two dysenteric patients," says he, " in the same ward of the Infirmary at Edin- burgh, quarrelled, and whipped each other with horsewhips a long time, and were both much better after it."—(Zoonom., cl. ii., i., 3, 19.) If the flux of blood, or any other morbid ma- terial, continue and be considerable, and espe- cially if there be still an intermixture of sanious grume and shreds of membranes, evidently pro- ving vascular disintegration and the approach of gangrene, astringents and tonics must enter into the plan of treatment. And, in this case, great benefit has been obtained from mineral acids, in union with sulphate of zinc or with opium. The former combination was a favourite med- icine with Dr. Moseley, who, ofthe mineral acids, preferred alum, and varied the proportions ac- cording to the strength or age, the degree of costiveness or of hemorrhage, of the patient : sometimes giving two or three grains of each at a dose, to be repeated three or four times a day ; where the hemorrhage is considerable, increas- * Medico-Chir. Trans., vi., 433. Dr. Elliotson has not a favourable opinion of the emetic plan, neither has he ever been able to discover the soothing effects of ipecacuanha. He has not judged it necessary to give preparations of anti- mony.—Ed. Gen. X.—SrE. 1.] DYSENTERIA ACUTA. 557 ing the alum ; and, where feculent evacuations were required, diminishing it, or even omitting it altogether. The preparation is valuable, as it unites a powerful metallic tonic, which is a true character of the sulphate of zinc, with an acid which has the singular virtue of proving astringent to the sanguineous and secernent system, while it produces little effect upon the peristaltic motion, and by some physiologists is thought rather to quicken it. Dr. Adair em- ployed alum alone ; but it is greatly improved by the addition of the sulphate of zinc. Dr. Jackson recommends either, or both conjointly ; and both himself and Dr. Moseley employed injections at the same time, composed of a so- lution of acetate of lead, and apparently with great benefit. [Whether small doses of the sulphate of copper, joined with opium, would prove as useful in these cases as they were found by Dr. Elliotson (Med. Chir. Trans., vpl. xiii., p. 451, &c) to be in chronic diarrhcea, future experience must determine : they should not be given on an empty stomach, as they would be likely to produce vomiting ; but after breakfast. The smallest dose is a quarter of a grain ; the largest, three grains.] A like beneficial effect, however, has been derived from uniting the mineral acids with laudanum. The sulphuric, though the pleasant- est to the taste, is more apt to irritate the bowels than the nitric. But the best mode of giving the latter, is by combining it with muri- atic acid in the proportion of two thirds of the former to one of the latter, imitating hereby the chrysulea of Van Helmont, or the aqua regia of later chymists, the nitro-muriatic acid of the present day, in doses of two drops of the nitric, one of the muriatic, and ten minims of lauda- num, intermixed with infusion of roses or that of the more powerful astringents, logwood, cat- echu, and gum kino. I have employed this medicine with peculiar advantage, not only in dysenteric, but in many other loosenesses and hemorrhages of the bowels, increasing the pro- portion of the acid or the laudanum as the urgency of the symptoms requires.* When, however, the thirst is considerable, and acidulous drinks are called for, we may for this purpose use the sulphuric acid as the most grateful ; though, in this case, the citric acid will usually be preferred, and the patient may be allowed to exercise his choice. Yet the one or the other of the above compounds should be continued, without any alteration in consequence of such a beverage.! * See likewise Th. Hope's Obs. on the powerful Effects of a Mixture of Nitrous Acid and, Opium in curing Dysentery, Cholera, and Diarrhoea.— Edin. Med. and Surg. Journ., No. lxxxviii., p. 35. ! Many of the eminent physicians in different parts of the United States have recommended active antiphlogistic means in the treatment of dysentery : these embrace bleeding, mercurials, the saline cathartics, and the milder aperients. As the hepatic system is sometimes deranged in this disease, emetics, and particularly ipecacuanha combined with antimony, have been used by some to unlock the biliary secretions : blisters are em- ployed by many practitioners, who apply them Since the second edition of this work, the medical world has been favoured with the opinion and practice of Dr. Baillie, in a printed but unpublished volume of his writings. And if there be individuals who object to the prac- tice of Sydenham on account of its defective energy, they will have infinitely more reason to accuse this eminent physician of tameness. He recommends bleeding, indeed, as what is fre- quently of service, but local alone and by leeches ; as cathartics, " mild purgative medi- cines, of which," says he, " I think castor-oil upon the whole the best;" and opiates and astringents to be delayed till "natural fluid motions" have been obtained.—(Lectures and Observations on Medicine, 1825.) Never was man more suspicious of the powers of medi- cine, or more entitled to the character of an ex- pectant physician, than this eminent pathologist. As the disease declines, there will often be found a very considerable degree of debility, and a chronic diarrhcea, with occasional discharges of blood, from the excoriated state of many of the minute bloodvessels of the mucous mem- brane of the intestines, or perhaps from a simple relaxation of the mouths of the capillaries. And in this situation, and especially where the disease has assumed a highly malignant charac- ter, many of the bitters of the Materia Medica, as the cinchona, columbo, simarouba, or extract of chamomile ; and, perhaps, the Nerium anti- dysentericum of Linnaeus may be resorted to, in connexion with acids, with great advantage. They have, indeed, occasionally been given from the first; and in a few very slight cases and very infirm constitutions, the practice may have succeeded ; but as a general rule it is highly rash, and has rarely been tried without repentance. In conjunction with this process, the very great tenderness of the interior of the larger in- testines, from erosion or abrasion, will often, for a long time, demand peculiar local atten- tion ; and demulcent or bland oleaginous injec- tions, as the infusion or oil of linseed, or olive- oil with a little wax and soap dissolved in it, to- gether with a grain or two of opium if there should be much pain (the whole not to exceed three or four ounces in quantity), will often be found of great assistance. Opium alone, in the form of a small pill or sup- pository, as recommended by many practition- ers, will be generally found too harsh ; and, where there is much tenesmus, it will.be im- early, and the compound powder of ipecac, and opium (Dover's powder) is prescribed very gener- ally. When dysentery exists as an epidemic, the depletory method of treatment must be pursued with great care ; the physician ever regarding the rapid manner in which the powers of life are pros- trated and destroyed by this typhoid condition of the system. Prof. Geddings, of Baltimore, has recently pub- lished some remarks on the use of nux vomica in dysentery. From some experience with this drug, Dr. G. considers it as a useful adjuvant, to be used after suitable depletion, and especially when the disease is veiging to a chronic form.—See N. A. Archives of Med. and Surg. Science, Baltimore, vol. i, p. 128—D 558 H^MATICA. [Cl. III.—Ord. II. ossible to retain it. The only mode in which have found it useful in this way is to rub it into an impalpable pulp with a little of the oil or-butter of the cocoanut, and to mould it into small pastils of a sufficient consistency to bear the touch. In long-protracted and chronic cases, lime- water, drunk freely, has occasionally also proved useful. The coat of the intestinal canal is here, however, sometimes very considerably thickened and indurated. And in such cases, the best remedy we can have recourse to is mercury. The liberal and experimental practice pur- sued at the Dublin and various other hospitals in Ireland, during the late severe attacks of epi- demic dysentery, and its general though often dis- crepant effects, may be appealed to in confirma- tion of the mode of treatment thus far laid down. Such was the fatal ravage of the disease, that no one plan, hitherto devised, offered more than a very unsatisfactory success ;—and hence al- most every plan was tried in its turn. From the treatment by mercury much was at first expected; and in many cases it seems to have been of use ; but it "did not succeed," says Dr. Cheyne, " so well as I expected. Cal- omel, tried in every proportion and distance of time, often failed with me and my colleagues." —(Repmt, &c, p. 41.) And he adds shortly afterward, " Mercury could not be depended upon, and did not relieve in numerous instances where the mouth was affected ; and sometimes seemed to increase the disease."—(Id., p. 45.) And even where the symptoms distinctly pointed out a morbid organization of the liver, the result of this treatment was unsatisfactory. " Mer- curial frictions," says Dr. Cheyne, " were tried in all the forms over the region of the liver ; but the advantages were not so extensively ben- eficial as I had reason to suppose, from finding that in every dissection the liver was in its structure more or less destroyed."—(Id., p. 89.) Venesection and opium seem to have been more beneficial. " The lancet," he further adds, " has repeatedly afforded great temporary relief where ulceration seemed to have taken place; and the relief proved permanent from blisters, mild aperients, and anodynes. Where the lancet was not allowable, leeches were also highly useful."—(Id., p. 47.) Free venesection, we ate told in another place, often procured a large feculent stool, where even purgatives failed. In conjunction with a blister, it often removed even the alarming symptom of dyspncea when timely applied.—(Id., p. 26.) Dr. Cheyne's sheet-anchor seems to have been opium, and to this he shows as strong an attachment as Sydenham, who only preferred the liquid to the solid form of this medicine, as he expressly tells us, on account of its more easy sub-action. Dr. Cheyne, however, carried his practice here, as well as in bleeding, to a considerably larger range, at least in severe and alarming cases. " The mercurials,", says he (p. 44), " with opium, sometimes seemed to answer: but in future I should chiefly depend upon opiates in doses of four or five grains, as this seemed chiefly to arrest the progress of in- flammation, diminished agony, and sometimes proved of permanent benefit." In less violent assaults, he at length fell back still more fully into the practice of former times. "In the middle stages," he tells-us, "I pre- ferred to the treatment of mercurials, the old proceeding; venesection, purgatives (chiefly the saline), bath in the evening, diaphoretic at night. This was frequently successful in an early stage." The blood drawn on the first use of the lancet, was from thirty to forty ounces or more ; which was repeated as often as ne- cessary. With the saline purgative was often intermixed emetic tartar, to act on the stomach as well as ori the bowels; and to these were added, in more violent cases, emollient injec- tions, and, as already observed, blistering. Castor-oil, so highly prized by many writers, rarely acted kindly, and very frequently aggra- vated the tormina and tenesmus. It succeeded best when united with opium. Generally speaking, injections did not answer so well as was expected. The most successful were the terebinthinate clysters—the Venice turpentine of Sydenham being merely exchanged for the oil of turpentine or the balsam of copay- va. The local action was hereby frequently changed and meliorated. And even the griping property of castor-oil was softened, instead of augmented, by combining it with the rectified oil of turpentine. The other kinds of injections chiefly employed, were diluted solutions of nitrate of silver and acetate of lead: the last united with opium. This combination was in high repute, on ac- count of its decided success in various cases. Dr. Barker has since improved upon the princi- ple, by giving to the joint materials the form of pills ; under which modification it seems to have been still more effectual. The ordinary astringents, in addition to the above, were, the chalk mixture, or infusion of catechu combined with laudanum. In protracted cases, the medicines chiefly had recourse to were Dover's powder, small doses of ipecacuanha, and calomel. [The generality of army surgeons consider small doses of ipecac- uanha serviceable. The utility of this medicine, and of small doses of hydrarg. cum creta, has been noticed by Dr. Bright.—(See Bright's Re- ports, p. 176, 4to., Lond., 1827.)] The treat- ment, where the disease ran into a chronic form, we shall notice presently. [Dr. O'Beirne has related several cases in proof of the great efficacy of fomenting the ab- domen with an infusion of tobacco, made by pouring two quarts of boiling water on two ounces of Virginian leaf-tobacco, and allowing it to stand for twenty minutes before use. To- bacco .clysters, owing to the irritable state of the rectum, were not found to answer. Dr. O'Beirne usually lets the use of the fomenta- tion be preceded by a mild purgative, like castor- oil ; and, indeed, he lays it down as a good gen- eral rule, that purgatives should be continued with the fomentation, until perfectly natural and feculent discharges be permanently established. The fomentations were sometimes repeated more Gkn. X.—Spe. 2.] DYSENTERIA CHRONICA. 559 than once in the day, and generally not discon- tinued, until some disturbance of the stomach and head had been experienced.—(Trans, of King's and Queen's College of Physicians, vol. iv., p. 386, &c)] SPECIES II. DYSENTERIA CHRONICA. CHRONIC DYSENTERY. STOOLS FREQUENT, LOOSE, "AND FECAL:'OFTEN WITH LARGE DEJECTIONS OF PURE OR GRU- MOUS BLOOD, AND ESPECIALLY WHERE THERE IS SEVERE TENESMUS ; MORBID PROGRESS SLOW AND INSIDIOUS ; MOSTLY WITH HECTIC FEVER. The genuine symptoms noticed under the preceding species, are for the most part rapid and violent : and, when they have run through their course, if the constitution generally, or the alvine organs more particularly, be reduced to a state of extreme debility and relaxation, the disease, instead of yielding to a return of health, is extremely apt to pass into the present species of dysentery. But it not unfrequently happens, that the causes of the disease are feeble and slow, though persevering in their mode of action ; or that the organs on which they operate locally are al- ready in an infirm or undermined state, so as to possess scarcely energy enough, to evince any vehemence of excitement; and in either of such cases, chronic dysentery is produced without the intervention of acute, and becomes a primary malady. The causes are chiefly a repeated exposure to a cold, damp air, and especially in warm weather, by which the perspiration of the skin becomes frequently and suddenly suppressed; and an habitual irritation of the alvine canal, by a daily indulgence in highly stimulant food, and partic- ularly spirits. In this speciest he inflammatory action spreads insidiously from one organ to another, till all the viscera subservient to the digestive process are implicated in a common chain of disease ; and especially the liver, which is usually, indeed, in a state of great irritability and weakness from the first; as are also the mesenteric glands. Hence, the symptoms must vary according to the progress of the disease, and the extent of the structural injury, from a simple relaxed state of the bowels, producing diarrhoea, uniformly ac- companied with a greater or less degree of te- nesmus, to a permanent ulceration, pouring forth purulent matter, or a more compound colluvies, sometimes watery like the washings of raw flesh, sometimes coagulated like dirty cream, and sometimes black and tenacious as pitch ; and in most cases intolerably fetid.—(O'Brien on Dys- entery of Ireland, p. 58, Dublin, 1822.) Oc- casionally, indeed, there is a dejection of sordid pus in considerable abundance, in consequence of the bursting of an abscess that has been long forming in the liver or some other organ, and has discharged its contents immediately or in- termediately into the intestinal canal.—(R. W. Bampficltl on Tropical Dysentery, &c, p. 3, Lond., 8vo., 1819.) And we may hence see abundant cause for those colliquative sweats, dry, distressing cough, and other symptoms of hectic fever, which so frequently accompany this form of dysentery. Chronic dysentery may, therefore, in its sim- plest and mildest state, be regarded as a gleet of the larger intestines, produced, as urethral gleet is, by a morbid relaxation of the mucous glands of the part affected, and accompanied with that sort of irritation which is the usual cause of increased secretion in debilitated or- gans. If the irritation be of any considerable extent over the intestinal canal, the peristaltic action is often permanently excited, and we have then an obstinate and weakening diarrhcea, pain at the pit of the stomach, with loss of appetite, and other dyspeptic symptoms. If the same irritation ramify, whether by sym- pathy or continuous action, to the liver, we often find this organ also stimulated to a very consid- erable excess of secretion ; when there is a fre- quent flow of bilious fluid from the rectum, sometimes nearly pure, but more generally de- praved, and intermixed in its passage with other materials, constituting that variety of the dis- ease which, by practitioners in the east, has been often denominated bilious or hepatic flux.—(Curtis on the Diseases of India.) Not unfrequently, however, the discharge from the rectum is pure or depraved blood, in- stead of bile ; the relaxed and debilitated capil- laries of the organs chiefly affected pouring forth this fluid in great abundance by anastomosis, or a gangrenous erosion of the tunics of larger ves- sels. This case is correctly denominated bloody flux. In the late epidemic dysentery in Ireland, Dr. O'Brien included all those cases under the pres- ent species which ran on to a longer period than six weeks, and were accompanied with little or no fever. The most numerous sufferers were the aged and infirm, who had previously laboured under diseases of the liver, or some other ab- dominal organ. From the extensive range of the morbid ac- tion, the impoverished state of the constitution, and, consequently, its difficulty of rallying, it is not often that a patient recovers from this form of the disease, when it has once passed from its mild or simple stage into a severer or more complicated course ; and, on this account, Dr. L. Frank has asserted that it is essentially more fatal than the acute species. Post-obit dissections have given nearly the same appearances as we have already noticed; there is abrasion or ulceration of the mucous membrane of the intestines ;—the colon is very generally found thickened and contracted through its whole extent, but particularly in its lower flexure. The smaller intestines are rarely traced in a state of ulceration; but patches of a deep-red colour are found in scattered plots, and especially on the ileum. The liver is not ' always affected in its structure, though more frequently than in the acute form : the gall- bladder is usually distended with deep-brown or 560 HiEMATICA. [Cl. III.—Ord. II. dark-yellow bile, evincing a paresis or obstruc- tion in the cystic duct. The therapeutic intentions are here to change the nature of the morbid and irritable action ; to diminish the exhausting discharges ; and to give tone to the languid and impoverished frame. For the first purpose, the most effectual med- icine is calomel, either alone or intermixed with opium. " If, in treating of the acute form of flux," says Dr. Ballingall, " I have refrained from an indiscriminate, and, as I conceive, un- merited commendation of this powerful medicine, it is only in hopes of being able to urge its em- ployment with double force in the form of disease now under consideration ; and to recommend an implicit reliance on it in the chronic form of flux ; to ascribe to it an almost unlimited power in the disease ; and to express an opinion that it will seldom disappoint our most sanguine hopes." Its effects in India, where torpitude and con- gestion are more frequent and more excessive than in cooler climates, seem to give full sanc- tion to this unqualified recommendation, and authorize its employment in large doses. In our own country, though very far from affording universal success, it is of pre-eminent impor- tance ; but, as it requires a long perseverance in its use, it will be found an error to load the system with it suddenly. In Ireland it was most beneficially employed in the form of the blue-pill, combined with opium and a minute appendage of emetic tartar.* Here, too, the terebinthinate preparations may frequently be had recourse to with some con- fidence ; as may, also, for the same purpose of improving the local action, the essential oil of turpentine and the balsam of copayva. As an aperient, oil of castor may generally be employed with'less excitement of griping than in the acute form : but, whatever laxatives are had recourse to, they should always be of as mild a character as possible ; and hence rhubarb in combination with small doses of calomel or Epsom salts, is often preferable to castor-oil. By keeping the bowels free from irritation in this gentle manner, we indirectly check the morbid discharges of whatever kind by which the disease is so peculiarly distinguished. And, where more direct and powerful means are ne- cessary, the compound chalk mixture with opium, various preparations of kino or catechu, or the acetate of lead, in solution or pills, or small doses of the sulphate of copper, joined with opium, may be tried.! * In the Peninsula mercury was found by Sir James M'Grigor to be injurious, except when the liver was diseased.—See Med. Chir. Trans.—Ed. ! A valuable paper on Chronic Dysentery, by Dr. S. K. Mitchell, is published in the Am. Journ. of Med., &c, vol. ii., p. 323. From numerous cases occurring in his own practice and that of his friends, Dr. M. feels confident that "most cases of chronic dysentery are remediable by the exclusive use of mucilage without sugar, and of the blue-pill given in from three to five grain doses, not more fre- quently than once in twenty-four hours, nor less frequently than once in forty-eight hours. Some The diet should be bland and nutritious, com- posed chiefly of milk, as recommended by Sir John Pringle, or of vegetable mucilages, as rice, arrow-root, sago, and salep. And, as soon as the local irritation has manifestly subsided, a more cordial and tonic plan should be entered upon; animal food be allowed; the warmer bitters and metallic corroborants be prescribed, as cascarilla, columbo, sulphate of zinc ; and such exercise and change of air as may best comport with the patient's constitution and sta- tion in life. Dr. O'Brien judiciously recom- mends him to try a warmer climate if his home be the British Isles, and a colder if he be a resident between the tropics. In all situations, he must be especially careful to avoid sudden changes of temperature, and particularly a cold, damp atmosphere, and maintain a healthy ex- citement on the skin by flannel socks worn on the feet, and flannel swathing around the body.* GENUS XI. B U C N E MI A. TUMID LEG. TENSE, DIFFUSE, INFLAMMATORY SWELLING OF A LOWER EXTREMITY ; USUALLY COMMENCING AT THE INGUINAL GLANDS, AND EXTENDING IN THE COURSE OF THE LYMPHATICS. This genus is new to nosological classifica- tions : but it is necessary, in order to include two diseases which have hitherto been regarded by most writers as totally unconnected, and treated of very remotely from each other ; but which, though occurring under very different circumstances, are marked by the same proxi- mate cause, in most instances affect the same organs, and demand the same local treatment. They consist of the following species :— 1. Bucnemia Sparganosis. Puerperal tumid leg. 2.---------Tropica. Tumid leg of hot climates. As the present genus is new, it has been ne- cessary to distinguish it by a new name ; and, cases, of course, require depletion by venesec- tion, &c, and some occasionally demand the use of means to unload the intestines ; but com- monly the mucilaginous diet and blue-pill af- ford almost immediate relief, and soon effect a cure." The same treatment has been pursued with success by other practitioners.—D. * If there be any tenderness about the abdomen, Dr. Elliotson recommends leeches to be put on the anus and front of the belly, for the alleviation of the tenesmus, which may then depend upon in- flammation. When this symptom arises merely from irritation, he approves of an injection of forty or fifty drops of laudanum, mixed with not more than four ounces of a solution of starch, or with what Sir James M'Grigor found afford great re lief in the Peninsula, a solution of the acetate of lead. Dr. Elliotson has not found it necessary to prescribe mercury in the kind of chronic dysen- tery met with in England ; but he speaks favour- ably of the plan of applying straps of adhesive plaster round the trunk, and a flannel bandage over them.—See Lect. at the Lond. Univ., as pub- lished in Med. Gaz. for 1833, p. 558.—Ed. Gen. XI.—Sfe. 1.] BUCNEMIA SPARGMJOSIS. 561 on this account, the author has made choice of that of Bucnemia, from 0ov, a Greek augment, probably derived from the Hebrew y^ or ;-m3 " to swell, augment, or tumefy," a particle com- mon to the medical vocabulary ; and the Greek noun Kvtjjtn, " cms," or " the leg," literally, therefore, " bulky or tumid leg." SPECIES I. BUCNEMIA SPARGANOSIS. PUERPERAL TUMID LEG. THE TUMID LIMB PALE, GLABROUS, EQUABLE, ELASTIC, ACUTELY TENDER ; EXHIBITING TO THE TOUCH A FEELING OF NUMEROUS IRREG- ULAR PROMINENCES UNDER THE SKIN; FEVER A HECTIC ; OCCURRING CHIEFLY DURING THE SECOND OR THIRD WEEK FROM CHILDBIRTH. The tumid leg of childbirth has mostlv been contemplated as a very different affection from that of hot climates, and has rarely been treated of in connexion with it. In the present author's first edition of his Nosology, the ordinary ar- rangement was so far adopted, that the two spe- cies were placed remotely from each other, though a distinction between elephantiasis and the tumid leg was strongly enforced. The tumid leg of lying-in women has been described by different authors under a variety of names, as phlegmasia dolens, phlegmasia lactea, ecchymoma lymphalica, and by Dr. Cullen as anasarca serosa; few of which express the real nature of the affection, and some of them a source obviously erroneous. By Dioscorides it was denominated sparga- nosis, from oirapydw, " to tumefy and distend :" tumeo et distentus sum, as rendered by Scapula ; and, as the term is sufficiently expressive, it has been preferred on the present occasion. By most writers, till within the last twenty or thirty years, the swelling has been ascribed ei- ther to a suppression of the lochia, or a redun- dance of milk, and a morbid deposition in con- sequence of such redundance. Mauriceau re- garded it as a metastasis of the lochia, and Pu- zos as a metastasis of the milk ; whence the French practitioners call it, to the present day, depot laileux, or lait ripandu; and the Ger- mans milchstreichen. A minuter attention to the subject, however, has sufficiently shown that this complaint has seldom any connexion with the milk, perhaps never. It has occurred where the breasts have been destitute of milk, and where they have overflowed ; where suckling has been relinquished, and where it has been continued. It is not long since that I was con- sulted by a young woman labouring under it, who was suckling her infant, without any com- plaint of the breast whatever. It is as little influenced by the state of the lochia as by that of the milk. It attacks wo- men of all ranks and of all habits, the healthy and the diseased, the lean and the corpulent, the sedentary and the active, the young* and * A case of this kind, occurring in a young wo- man, is mentioned by Hazeltinc—(See Comm. to the Mass. Med. Soc. vol. iii., Boston, 1819.)—D. Vol. I— N n the middle-aged. It also occurs in all situa- tions, and has never perhaps been known to ap- pear in any other part of the body than the lower extremities. My esteemed friends Dr. Hosack and Dr. Francis, of New-York, have, however, ingeni- ously contended that it has also been found in the upper* as well as in the lower limbs, and in males as well as in females ; and they especially appeal to one case communicated to them by Dr. Heermans of Ontario, which, could it be re- lied on, would go far to settle the question ; but, as it appears to me that this, like various simi- lar cases that have occurred to the present au- thor, was an instance of erratic or metastatic rheumatism rather than sparganosis, we are not at present authorized to deviate from the ordi- nary character assigned to the disease, or to generalize it in the manner which this more ex- tended view of its occurrence would demand of us. Other local affections, indeed, make an ap- proach to it, of which Dr. Denmark has de- scribed one that occurred in a male, which, how- ever, he prudently avoids calling a phlegmasia dolens, contenting himself with saying that it resembled it;- while Dr. Davis, as we shall have to observe presently, seems to have mistaken for this complaint an inflammation of one of the larger veins in the pelvis or its vicinity. [The editor is happy in having here an oppor- tunity to remark, that Dr. Davis only attempted to show the grounds he had for thinking that phlegmasia dolens was essentially connected with inflammation and obstruction of the iliac veins ; and he has undoubtedly proved by dis- section, that, in some particular instances, cor- responding, as he judged, though not as our au- thor believed, to the latter disease, those veins were inflamed and obstructed. Whether such affection of the veins exists in all or most cases of phlegmasia dolens, can only be determined by further pathological investigations.! In the meanwhile it may be right to mention, that Dr. Davis's view has already received material sup- port from three cases recorded by M. Velpeau, in all of which the sacro-iliac symphysis on the diseased side was more or less affected; ac- companied with purulent effusions in the peri- toneum, and about the genital organs; and a mixture of pus and coagulated blood in the veins of the limb, with evident traces of inflammation of their coats in two of the cases. It is true, that the alteration of the sacro-iliac symphysis * In Mr. Fraser's case, the left thigh and arm were considerably larger than the right—See Edin. Med. Journ., No. xc, p. 17.—En. ! In the case reported by Mr. Fraser, no traces of disease were found in the iliac vein ; and he is inclined to regard phlegmasia dolens as a modifi- cation of diffuse inflammation ofthe cellular mem- brane, as described by Dr. Duncan. On the other hand, Dr. Lee proposes to substitute the term crural phlebitis for phlegmasia dolens; " as it has been demonstrated by the researches of recent pa- thologists, that the swelling of the affected limbs, and all the other local and constitutional symptoms of this affection, invariably depend on inflammation of the iliac and femoral veins."—Cyclop of Pract, Med-, art. Phlegmasia dolens.—Ed. 562 H^MATICA. [Cl. III.—Ord. II. is regarded by Velpeauas the occasion of all the other disorder, and so far he differs from Dr. Davis ; yet the fact of the veins being inflamed and obstructed, in the examples alluded to, is certainly an important coincidence with what was noticed in the cases adduced by Dr. Davis.* Neither does it appear to the editor that satis- factory proof has been given, that phlegmasia dolens is exclusively a disease of the female sex. He visited, in the military hospital at Cam- bray, in 1816, a soldier who was under the care of Dr. Booty, and was afflicted with a swelling of one of the lower extremities, which that gentleman, an army practitioner of considerable merit, confessed that he knew not how to dis- criminate from phlegmasia dolens. Had the editor had no difficulty in joining the author in the supposition, that any eminent physician could have mistaken rheumatism for phlegmasia dolens, he should yet have had to overlook the foregoing facts, as well as the interesting case of inflammation of the iliac and femoral vein, related by Dr. C. Forbes.—{Med. Chir. Trans., vol. xiii., p. 296.) "The morbid appearances observed in this instance," he says, " were very similar to those which have been described by Dr. Davis. Had the subject of the disease been a woman in the puerperal state, would it not," he asks, " have been considered phlegmasia dolens?" This example, be it observed, is an additional corroboration of the statement re- specting the condition of the veins. A peculiar swelling of the lower extremity coming on after fever, and corresponding very much in its char- acter and progress to phlegmasia dolens, was lately described by Dr. Tweedie, who points out its differences from common oedema of the limb, and represents it as an inflammation of the cellular tissue.]! * In January, 1823, several cases and dissec- tions were published by Bouillaud, in which the crural veins were found obliterated in women who* had had a swelling of the lower extremity after delivery. Although these cases were printed four months before Dr. Davis's paper was read, " it does not admit of dispute," says Dr. Lee, " that Dr. Davis was the first wbo proved by dissection, that phlegmasia dolens depended on inflammation of the iliac and femoral veins."—(See Cyclop, of Pract. Med., art Phlegmasia dolens.) The numerous cases and dissections of which Dr. Lee has since published the histories in the Med. and Chir. Trans., and in a recent work on the " Pa- thology and Treatment of some of the most im- portant Diseases of Women," offer a still more complete explanation of the subject; demonstra- ting that if inflammation be excited in the uterine branches of the hypogastric veins, it may spread from them to the iliac and femoral veins, and by the morbid changes induced in them, give rise to all the usual symptoms.—Ed. ! Edin. Med. Journ., No. xcvii., p. 258. In the spring of 1833, a case of chronic dysentery in a man came under the observation of Dr. Macann, in which phlegmasia dolens took place before death. On dissection, the common iliac, the ex- ternal iliac, and femoral veins of the left side, were found to be completely obstructed, and their coats extensively disorganized by inflammation. The preparation is in the possession of Dr. Lee, to whom it was given by Dr. Forbes. In the male I In about twelve or fourteen days after de- livery, accoiding to the common course of the disease, the patient complains of pain in the groin of one side, accompanied with the general train of pyrectic symptoms, but without the pre- cursive shivering. The part affected soon be- comes swelled and distended, the swelling usu- ally extending to the labia pudendi of the same side, and down the inside of the thigh to the leg and foot; in a day or two, the limb is double its natural size, is hot, exquisitely tender, and moved with great difficulty. It has not, how- ever, the ordinary external signs of inflamma- tion, but is hard, smooth, glabrous, pale, and equable, except where the conglobate glands are situate, which are corded and knotty, as in the groin, the ham, and the back and fleshy part of the leg. There is occasionally an uneasi- ness in the loins, and in the region of the pubes on the same side. The swelling has some- times appeared as early as twenty-four hours after delivery, and sometimes not till five weeks afterward. The accompanying fever, which is of a hectic form, usually declines about the fourteenth or twenty-first day, but in some cases runs on for six or eight weeks, and the patient becomes greatly emaciated. The first appear- ance of improvement takes place about the groin, where the disease commenced, the pain and tumour gradually subsiding in this quarter, and the amendment spreading in a continuous line.* Sometimes, though rarely, both sides are af- fected simultaneously, and, in a few instances, the sound leg has exhibited something, though a less degree, of the same complaint, as the dis- eased leg has improved. The improvement ia very slow; and, in many cases, the affected limb continues weak, and with morbid enlarge- ment through life. [Velpeau's opinion, that the origin of the disease is connected with an alteration of the sacro-iliac symphysis, has been already noticed.] Dr. Whyte, M. Caspar, and Mr. Trye, concur in deriving the disease from some affection of sex, the disease may commence either in the hem- orrhoidal, vesical, or other branches of the internal iliac veins, in consequence of inflammation, or organic changes of structure in one or more of the pelvic viscera. It arises, however, much more frequently from inflammation, excited in the su- perficial veins of the leg, and extending upwards to the great venous trunks of the thigh and pelvis, as exemplified in several examples collected by Dr. R. Lee, from the practice of Sir Astley Cooper and others. Phlegmasia dolens seems to the editor, then, not to be precisely synonymous with crura] phlebitis but an occasional effect of it.—Ed. * Dr. Mann, of Boston, states the following curious fact in regard to bucnemia. He was called in consultation to a case of this disorder, where the attending physician, supposing the swelling contained some fluid which required to be evacuated, had made an incision through the skin and adipose substance of the enlarged limb, in order to discharge its contents : " herein," adds Dr. M., " he was not only disappointed, but, to his mortification, the incised part became gangrenous: a sphacelus ofthe whole limb soon followed, which terminated fatally in about ten days after the op- eration,"—Comm. Mass. Med. Soc, vol. ii.—D. Gen. XL—Spe. 1.] BUCNEMIA SPARGANOSIS. 563 the lymphatics of the distended side. Dr. Whyte refers it to an extravasation from the lymphatic vessels ruptured by the pressure of the child's head : Professor Caspar, to a mixed inflammation of the absorbents and cellular membrane (Comm. de Phlegmasia dolente, 8vo., Halle, 1819) ; and Mr. Trye, to inflammation of the lymphatic glands. Dr. Ferriar ascribes it to inflammation of the side affected generally ; and Dr. Hull to a joint inflammation of the muscles, cellular membrane, and inferior sur- face of the cutis seated in the affected part, and an effusion of coagulable lymph, the large blood- vessels, nerves, lymphatic glands, and -glands imbedded in them at times participating in the inflammatory action. The last, if not the real cause, would be sufficiently plausible if the in- flammation be supposed to commence in the lymphatics, instead of being merely extended to them. As it is, Dr. Hull's hypothesis has been adopted and enlarged by Dr. Hosack, who re- gards the complaint, as an inflammatory disease, '' not merely affecting the limb,but the whole sys- tem," commencing, not in the groin or pelvis, but about the calf of the leg ; not limited to the lym- phatics or even to females, but common to both sexes, and to every part of the affected limb ; sometimes appearing in both limbs at the same time ; and where depletion is not actively em- ployed, occasionally, like gout and rheumatism, transferred from one limb to another: produced usually by a suppression of the natural excre- tions, exposure to cold, stimulating drinks, and other means of excitement. To the disease thus described Dr. Hosack has given the name of cruritis (Obs. on Cruritis, or Phlegmasia Dolens, 8vo., New-York, 1822), not quite clas- sically formed ; as partaking of two distinct tongues, and not quite applicable to an affec- tion so variable as to seats, and so migratory even when it once shows itself. The disease is ably described, and followed up with the hand of a master, but it is not, as it appears to me, the disease before us, and belongs rather to our next genus. Mr. Davis has probably thought the same ; for he has entirely stripped the tumid leg of the unrestrained license of attack allowed it by Dr. Hosack, and of its migratory spirit afterward : has restrained it to the female sex, and to the immediate neighbourhood of the pelvis. |' The proximate cause," says he, " of the disease called phlegmasia dolens, is a violent inflam- mation of one or more of the principal veins within, and in the neighbourhood of the pelvis, producing an increased thickness of their coats, the formation of false membranes in their in- ternal surface, a gradual coagulation of their contents ; and occasionally a destructive sup- puration of their whole texture : in consequence of which, the diameters of the cavities of these important vessels become so gradually dimin- ished, sometimes so totally obstructed, as to be rendered mechanically incompetent to carry for- ward into their corresponding trunks the venous blood brought to them by their inferior con- tributing branches."—(Med. Chir. Trans., vol. xii., part ii., p. 3.) Here again we have a very accurate descrip- tion of a disease by no means uncommon, which, moreover, is supported by a variety of cases, most of which have unfortunately a history of their dissections appended to them, containing a clear manifestation of the nature of this very fatal inflammation, and for the most part of the formation of a false membrane within the af- fected vessel. But if the present author have succeeded in truly delineating the disease before us, either in his specific definition or his diag- nostic description, it must be obvious to every reader who will compare them with the ap- pearances laid down by Dr. Davis, that two different inflammations are referred to in the respective statements, the symptoms of which cannot possibly co-exist ; that the very fatality of that described by Dr. Davis is of itself a suf- ficient proof of a clear and very striking distinc- tion :* and that, though both occasionally take place soon after childbirth, the enlargement he has treated of is far less a phlegmasia dolens than a particular variety of venous inflamma- tion, the phlebitis of several authors : for a striking example of which, proceeding from an obscure cause, and extending over the arm in- stead of over the leg, I may refer to Dr. Dun- can's interesting case, in the Transactions of the Edinburgh Medico-Chirurgical Society.! It gives us the same general swelling over the entire limb; rather phlegmonous than erythe- matous ; but, to adopt the author's xiwn simile, still more resembling an anasarcous affection, yet without pitting. It gives, moreover, the same fatal result; and, on examination after death, develops the same thickening of the coats of the vein, and the same obstruction from morbid secretions. And to show still further how little foundation there is for this doctrine, we have in the very next article in the same volume, composed by the same indefatiga- ble author, various cases of diffuse inflammation of the cellular membrane without any affection of the neighbouring veins, so closely approach- ing the general character of the sparganosis be- fore us, that he finds a difficulty in calling them by any other name, and appears greatly inclined to adopt Dr. Hull's hypothesis of the disease.— (Trans. Medico-Chir. Soc. Edin., vol. i.,p. 582.) There is apparently as little reason for the hypothesis of Dr. Denman, who, while regarding it as an inflammation of the lymphatics, refers the inflammation to an absorption of some acri- monious matter secreted by the uterus ; for the * As Dr. Davis's main object was to record the appearances on dissection, the circumstance of his having brought forward only fatal cases must not be received as a proof of the general or com- mon fatality ofthe disease.—Ed. ! Case of Inflammation of the Cephalic Vein, which terminated fatally, vol. i., p. 439. The swelling, named by Dr Good bucnemia sparganosis, and more commonly by other writers phlegmasia dolens, Ss to be regarded as an occasional effect of the obstruction and disorganization of the femoral and iliac veins by phlebitis. On this ground the editor cannot regard the proposed name of crural phlebitis, as a substitute for phlegmasia dolens, as correct.—Ed. 564 ILEMATICA. [Cl. Ill—Ord. II. disease has occurred where there has been no more morbid action of the uterus than of the mammae ; and all the secretions have proceeded healthily and in their proper quantity.* The cure is to be attempted first by a free application of leeches all along the course of the limb, poppyhead fomentations, or, what is better, a swathe of flannel wrung out in hot water applied over the whole extent of the limb, surrounded by a loose bandage of sheeting. To this plan should be added purgatives of con- siderable activity, and where the irritation is considerable, free doses of Dover's powder. General bleeding is rarely, though sometimes necessary. As soon as the inflammatory symp- toms have a little subsided, local stimulants may be had recourse to, so as to excite the torpid absorbents to increased action : of which the most useful in tbe author's hands has been the liniment of ammonia with laudanum. The laudanum, on a cursory view, may seem to add to the vascular torpor; but it tends to take off the pain and soreness that still remain, and thus enables the tranquillized vessels the more easily to recover their tone. Yet what- ever application of this kind is employed, it should be accompanied with gentle friction, con- tinued for half an hour or more, if the limb is able to bear it; for the friction itself is of es- sential service, and tends, perhaps, even more than any other local stimulant, to restore the limb to a healthy action. Mr. Trye advises, for the same purpose, the use of mercurial ointment; and others that of small doses of calomel. But neither have proved decidedly useful; while in some instances of great debility, they have evidently produced mis- chief. The chronic weakness is to be removed by a continuance of the friction, bathing with sea-water, or, which is much better, bathing in the sea itself, an elastic flannel bandage, horse- exercise, pure air, and, if necessary, general tonics and astringents. [Dr. Lee has not seen any benefit produced by mercurial and iodine applications ; and, at the commencement, he relies chiefly on the free abstraction of blood by leeches applied above and below Poupart's liga- * The views of American writers on the nature of bucnemia sparganosis differ as much as those of European authors. In a paper of some extent (N. A. Med. and Surg. Journal, vol.iv.), Dr. Huston considers the disease " as consisting in a complete engorgement of the whole lymphatic system of the affected limb, produced by an inflamed condi- tion of the different conglobate glands, through which the chief lymphatic vessels have to pass, on their way from the affected part to the thoracic duct" Eberle (Practice of Med.) entertains the same belief. Dewees doubts the accuracy of the views of Davis in assuming the disease to be analogous to phlebitis (Practice of Physic). Dr. Jameson, of Baltimore, considers it " as but a va- riety of an extensive group of inflammations, the peculiar characteristic of which is, a tendency to the effusion of serum or watery fluid."—(Amer. Med. Recorder, vol. xv., p. 66.) Dr. Francis's paper (New-York Med. and Phys. Journal, vol. i.) mentions several instances of bucnemia, attended with peculiar circumstances ; among others, an example of the disorder affecting a male subject; ment, in the direction of the femoral and iliac veins. In a case recorded by Dr. Sims, great relief was derived from puncturing the swelling in different places with a needle.—(Dr. R. Lee's art. Phlegmasia dolens, in Cyclop, of Pract. Med.)] SPECIES II. BUCNEMIA TROPICA. TUMID LEG OF HOT CLIMATES. the tumid limb hard, livid, and enormously misshapen; skin at first glabrous, after- ward THICK, SCALY, AND WARTY ; SUCCES- SIVELY BULGING AND INDENTED : OCCURRING CHIEFLY IN TROPICAL CLIMATES. This species is intended to comprise that singular disease, known in the West Indies, and generally over Europe, by the name of Barbadoes leg, from its being indigenous to the Island of Barbadoes. Yet it is not in Barba- does alone that it makes its appearance ; for it is of high antiquity, as well as of very wide range, in hot, and especially in tropical climates ; and constitutes the genuine dal-fil fiojl c\iV or elephant-leg of the Arabians, being so de- nominated from its livid, tumefied, scaly, mis- shapen appearance. As the Arabic dal or daul- ^ Ixall s\ii 's uterany elephantiasis or ele- phant-leg, and as the Greeks distinguished an- other and very different disease by the name of elephantiasis, the Greek translators of the Arabian writers were very generally betrayed, from the unity of the name, into a confusion of the two disorders, as we shall have occasion still further to observe when treating of proper elephantiasis under the fourth order of the present class : and the confusion has, in a con- siderable degree, descended to our own times, insomuch that many writers of the^ present day continue to jumble the elephantiasis, or ele- phant-/^, of the Arabians, with the elephan- , tiasis, or elephant-sAiw, of the Greeks, arid to describe them as a common affection, though an instance of the transfer of the complaint from one limb to the other in the same lying-in female; another case also, in which the same female be- came affected with it in four successive labours; at each recurrence it attacked the same limb, the right; in another case, where bucnemia appeared in the arms. According to Dr. Beck, Ferriar was the first author who remarked that this disease might appear in the upper extremities, and Carus has mentioned instances of its occurrence there. Cailister takes the same view of its seat, as ex- isting sometimes in the upper limbs : the opinion of Dr. F., therefore, that other parts than the lower extremities may become its seat, has the concur- rent testimony of several eminent men in its be- half ; and very recently, Otto, in his Handbuch der Pathol. Anat., vol. i., has sanctioned the same belief. American practitioners generally treat this dis- ease with great activity, by bloodletting and other depletory means. Dr. Dewees has found it ne- cessary to bleed six or seven times before the com plaint yielded—D. Gen. XL—Spe. 2.] BUCNEMIA TROPICA. 565 no two complaints can be more unlike : the former being a mere local malady, produced ac- cidentally, and confined to the individual who labours under it; and the latter a constitutional disease, in every quarter hereditary, and in most quarters contagious. The Arabians, however, had the disease called elephant-skin, the elephantiasis of the Greeks, by themselves called juzam (*'&~> as well as the dal-fil, or elephant-leg, the disease before us. And, as the malady called leprosy, and by the Arabians beras \ftj,, was supposed by many physicians, as well Arabian as Greek, to terminate frequently in juzam, or proper ele- phantiasis, the disease before us has occasion- ally also been confounded with leprosy as well as with elephant-skin, and all the three affec- tions have been huddled together by many wri- ters into one common disease. Even Dr. Schil- ling, a late practitioner of considerable merit at Surinam, has not escaped this last error; for he describes the tumid leg under the name of leprosy ; confuses its earliest symptoms and appearance with those of the leprosy of the Greeks, and especially with those of the lepra or lepriasis Candida, and then distinguishes ele- phantiasis, the disorder he professes to be the immediate subject of his pen, as a peculiar branch of leprosy, merely varied by its com- mencing in the feet, instead of in any other part of the body; and, carrying on the confusion, he next interprets the tumid leg, or disease be- fore us, as a mere variety of elephantiasis.— (G. G. Schillingii de Lepra Commentationes, 8vo., Lugd. Bat, 1776.) For a distinct and more correct account of this species, we must turn to the writings of Dr. Hillary (Works, vol. i., p. 549, 4to. edit., 1799) and Dr. Hendy, who have judiciously separated it from both the leprosy and the elephantiasis of the Greek writers, and treated of it as an individual malady : the former under the name of " Barbadoes leg," and the latter under that of the " Glandular Disease of Barbadoes." It is singular, however, that Dr. Hendy should have adopted the erroneous idea, that the dis- ease before us is not only endemial to Barba- does, but that it is to be found nowhere else ; and that patients who migrate from this island for a cure are almost sure to obtain one, unless in a chronic or inveterate stage of the disease, to whatever quarter they direct their course. It has been known immemorially in India, and is by the oriental writers, and even by Sir William Jones, justly distinguished from the juzam, which he tells us must not be con- founded with the dal-fil, or swelled legs de- scribed by the Arabian physicians, and very common in that country. It is also indigenous to the Polynesian Isles, where it takes the name of yava-skin, as being supposed to originate from drinking the heating beverage called yava ; and, like the gout among ourselves, is regarded in a sort of honourable light.* * Cases of bucnemia tropica have occurred also The tropical bucnemia, like the puerperal, is occasioned by an effusion of coagulable lymph into the cellular- membrane under the skin of the part affected, in consequence of inflamma- tion of the lymphatics of the lower limb, and especially of the inguinal glands ; the cause of which is at present quite unknown. [The doctrine, that the disease essentially consists in an inflammation of the lymphatic vessels and glands, may be said now to be on the decline. In fact, we commonly see these organs inflamed, both in warm and cold climates, without any consequences resembling bucnemia tropica. Dr. Graves ( Trans, of the King's and Queen's College of Physicians, vol. v., p. 65) notices various circumstances amounting very nearly to a complete refutation of the opinion. Thus, he particularly adverts to a passage in Dr. Hillary's work, from which it appears that the disease sometimes attacks the arm, scalp, ears, back part of the neck, the loins, &c Enormous chronic growths' of the integuments and cellular membrane sometimes affect the arm, penis, and scrotum, even in this country; the disease closely resembling the Barbadoes leg, and examples of which had been seen by Mr. Chevalier.—(See Med. Chir. Trans., vol. ii., p. 71.) It is obvious, as Dr. Graves has remarked, that, in such parts, the swelling could not have arisen merely from glandular inflam- mation ; and as, from various # facts which he has brought forward, it is proved that inflam- mation of the skin and subjacent cellular tissue is in itself capable of producing a swelling, in all other respects similar to that of Barbadoes leg, he is inclined to think that a more accu- rate investigation of the subject would have induced Dr. Good to modify the opinion he has delivered on the subject. As far as the point can be decided by a refer- ence to cases very similar to the Barbadoes leg, which have occasionally taken place in Great Britain or Ireland, the editor certainly joins Dr. Graves in the belief, that the disease does not arise from, or essentially consist in, disease of the lymphatic glands or vessels. In the highly interesting example of an extraor- dinary enlargement of the right lower extremity, recorded by Mr. Chevalier, and which occurred in an English woman in this metropolis, no change in the absorbent glands could be de- tected after death, either at the groin or within the pelvis.—(Op. cit, vol. ii., p. 67.) In a very similar case, related by Dr. Graves, and which happened in a young man, twenty-five years of age, admitted into the Meath Hospital, " the swelling had commenced many years before his admission into the hospital, and had attained its enormous size gradually, and without the least pain or inflammation of the skin, the sub- jacent adipose tissue, or inguinal glands." Dr. Graves has no doubt, that, as in Chevalier's case, the tumefaction arose from an extraordi- nary growth of the skin and subjacent adipose in natives of the United States who have never visited a tropical climate.—See Hosack's Med. Essavs, vol. iii., p. 99.—D. 566 H^2MATICA. [Cl. IH.-Ord. II. membrane, quite independently of inflamma- tion.* The diseases described by Mr. Chevalier and Dr. Graves, seem to the editor to correspond to the enormous growth of the scrotum, so com- mon in Egypt and other warm countries, yet sometimes met with in France, this country, and other parts of Europe.! Dr. Graves is of opinion, that the example which he has pub- lished is entirely different both from phleg- masia dolens and the Barbadoes leg, which affec- tions, he says, arise from inflammation. It certainly appears, that some extraordinary en- largements ofthe lower extremity have depended upon a chronic growth and thickening of the integuments and cellular tissue, no inflammation having occurred, at all events, until the disease was far advanced. Yet, in other instances, a similar alteration of the skin and cellular mem- brane has been preceded either by an attack like that of phlegmasia dolens, as happened in Mr. Chevalier's example, or by fever, and heat and redness of the skin, as illustrated in one curious modification of the disease, described by Dr. Graves, and, as it seems, by no means uncommon in Ireland, where it affects the arms, perhaps, more frequently than the legs.] In the tumid leg of hot climates, the skin, instead of maintaining the paleness of the first species, very soon becomes suffused with a deep red or purple hue ; while the saburral fluid that exudes from the cutaneous exhalants, con- cretes, as its finer parts fly off, into rough and sordid scales, and the skin itself becomes enor- mously thickened and coriaceous. The effusion is usually preceded by a febrile paroxysm, induced by the glandular inflamma- tion just noticed ; and which, from the first, discovers a tendency to recur, though often at irregular periods, so as to resemble an erratic intermittent. Every fresh attack adds consid- erably to the effusion, and consequently to the morbid size of the limb, and exacerbates every symptom ; and hence the greater severity of this species than of the former, and the monstrous disfigurement of the leg and foot by which it is * Trans, of the King's and Queen's College of Physicians, vol. v., p. 5C. A woman died in La Charite in 1820, with what Andral calls elephan- tiasis of one of her lower extremities, but which, probably, corresponded to the cases arranged by Dr. Good under the present title. The muscles were found, after death, reduced to a. few pale, slender fasciculi; but the cellular substance was converted into an enormous mass, very hard, and including in some places cells filled with a serous fluid. At certain points it had all the physical qualities of cartilage.—(Anat. Pathol., torn' i., p. 277.) The same author has also seen an extraor- dinary ossification of the layers of the intermus- cular cellular tissue, in the leg of a subject that died with bucnemia. The muscles were in the state of atrophy. The osseous matter, which was deposited in the spaces between the layers of mus- cles, was blended, in the deeper part of the limb, with bony vegetations arising from the periosteum. —Vol. cit, p. 297. ! See the editor's Diet, of Practical Surgery, art. Scrotum, published by Harper & Brothers, New-York, 1834. distinguished. In many instances, also, the in- flammation extends to the surrounding as well as to the descending parts ; and hence the scrotum, like the pubes in puerperal bucnemia, is often peculiarly affected and distended to an enormous magnitude ; while, occasionally, the glands of the axilla participate with those of the groin, and the forearm becomes also enlarged. In a few instances, the disease is said to have commenced in the axilla; but such cases are very rare, and not well established. In this manner the disease at length assumes a chronic character: the monstrous size and bloated wrinkles of the leg are rendered per- manent ; the pain, felt acutely at first, subsides gradually, and the brawny skin is altogether in- sensible. Yet, even from the first, except du- ring the recurrence of the febrile paroxysms, the patient's constitution and general functions are little disturbed: and he sometimes lives to an advanced age, incommoded only by car- rying about such a troublesome load of leg ; which, however, as we have noticed already, is regarded in the Polynesian Isles as a badge of honour. In our own country, the disease is rarely met with but in its confirmed and inveterate state, after repeated attacks of fever and effusion have completely altered the organization of the in- teguments, and rendered the limb altogether incurable. In this state, the distended skin is hard, firm, and peculiarly thickened, and even horny ; while the muscles, tendons, ligaments, and bones are, for the most part, little affected. [Most of the cases noticed in London are in Africans. The editor has seen one or two such examples in St. Bartholomew's Hospital. The most remarkable of these was published in one of the early volumes of the Medical and Phys- ical Journal.] In this advanced stage, the disease seems to be altogether hopeless : nor in any stage has the practice hitherto pursued been productive of striking success. This has'consisted chiefly in endeavours to alleviate the febrile paroxysms by laxatives and diaphoretics, and subsequently to strengthen the system by the bark. It would be better, perhaps, by active and repeated bleed- ings, as well general as local, and powerful pur- gatives, to endeavour to carry off the whole oi the first effusion as quickly as possible ; and then to direct our attention to a prevention of the paroxysms to which the constitution appears to be peculiarly subject, after a single one has taken place, by prohibiting exposure to the damp air of the evening, and by the use of tonics. An original and chronic affection of this kind, in which the integuments of the legs were much thickened, the limbs swelled to such an extent as to prevent the patient from walking, and in- crusted with such a vast quantity of brawny scurf and scales, that handfuls of them miwht be taken out of his bed every morning, was suc- cessfully attacked many years ago by° a mistake of one plant for another. The case is related by Dr. Pulteney ; and the patient, who had been recommended to swallow a table-spoonful of the juice of the water-parsnip, with two Gen. XII.] ARTHROSIA. 567 spoonfuls of wine, every morning fasting, was erroneously supplied with half a pint of what afterward appeared to be the juice of the roots of the hemlock-dropwort (ananthe crocata, Lin.): the first dose produced such a degree of vertigo, sickness, vomiting, cold sweats, and long-continued rigour, that it almost proved fa- tal. So strong, however, was the patient's de- sire of relief, that, with the intermission of one day, he repeated the dose with a slight diminu- tion in the quantity. The effects were still vio- lent, though somewhat less alarming ; and he persisted in using half the quantity for several weeks. At the end of a month he was very greatly improved, and, shortly afterward, the whole of his symptoms had nearly left him.— (Phil. Trans., vol. Ixii.) Amputation of the affected leg has some- times been made trial of, but apparently without any success. Dr. Schilling informs us, that in some, a locked jaw takes place about the sev- enth day from the operation, which is soon fol- lowed by tetanus, and ends in death; that, in others, fatal convulsions ensue immediately ; and that those who survive the operation, have wounds hereby produced that will not heal; while the disorder, still connected with consti- tutional causes, often seizes on the other foot.— (G. G. Schillingii de Lepra Commentationes, 8vo., Lugd. Batav., 1776.) And, in this last as- sertion, he is corroborated by one or two cases related by Dr. Hendy.—(On the Glandular Dis- ease of Barbadoes, 8vo., 1784.) [In the modification of the disease repre- sented by Dr. Graves as common in Ireland, and as following fever and repeated attacks of a kind of inflammation, more like erysipelas than any thing else, he suggests the following treatment. When the case is not of very long standing he recommends, during the febrile par- oxysms, antiphlogistic treatment, purgatives, leeches repeatedly to the inflamed parts, and cold lotions. During the intermissions, rest, moderately tight bandages, bark, and, if it fails, arsenic. The moment the inflammatory parox- ysms recur, the antiphlogistic plan is to be re- sumed.]—(Dr. Graves, in Trans, of the King's and Queen's College of Physicians, vol. v., p. 46.) GENUS XII. ARTHROSIA. ARTICULAR INFLAMMATION. inflammation mostly confined to the joints ; severely painful ; occasionally extend- ing to the surrounding muscles. Arthrosia is a term derived from ap9p6u, " to articulate," whence arthrosis, arthritis, and many other medical derivations. The usual term for the present genus of diseases, among the Greek physicians, was arthritis, which would have been continued without any change, but that for the sake of simplicity and regu- larity, the author has been anxious to restrain the termination itis to the different species of the genus empbesma. Arthritis, then, among the Greeks, was used in a generic sense, so as to include articular in- flammations generally. But as almost every sort of articular inflammation has, in recent times, been advanced to the rank of a distinct genus in itself, it has frequently become a question, to which of them the old generic term should be peculiarly restrained. And hence some writers have applied and limited it to gout; others have made it embrace both gout and rheumatism ; others again have appropriated it to white swel- ling ; while a fourth class of writers, in order to avoid all obscurity and dispute, have banished the term altogether. Now gout, rheumatism, whether acute or chronic, and white swelling, however they may differ in various points, as well of symptoms as of treatment, have striking characters that seem naturally to unite them into one common group- Gout and rheumatism are so nearly allied in their more perfect forms, as to be distinguished with considerable difficulty ; and in many in- stances, rather by the collateral circumstances of temperament, period of life, obvious or un- obvious cause, antecedent affection or health of* the digestive function, than from the actual symptoms themselves. Stoll maintains that they are only varieties (Rat. Med., part iii., p. 122-137 ; v., p. 420) of the same disease : Bergius, that they are convertible affections. White swelling, in one of its varieties, is now uniformly regarded as a sequel of rheumatism, or the result of a rheumatic diathesis; while the other varieties cannot be separated from the species. From the close connexion between gout and rheumatism, Sauvages, and various other no- sologists, distinguish some of the cases of dis- guised gout by the name of rheumatic gout. Mr. Hunter warmly opposed this compound ap- pellation ; for his doctrine was, that no distinct diseases, or even diseased diathesis, can co-exist in the same constitution. And, as a common law of nature, the observation is, I believe, strictly correct ; one of the most frequent examples of which is the suspension of phthisis during the irritation of pregnancy. But it is a law subject to many exceptions ; for .we shall have occa- sion, as we proceed, to notice the co-existence of measles and smallpox ; and I had not long since under my care, a lady in her forty-ninth year, of delicate health and gouty diathesis, who was labouring under a severe and decisive fit of gout in the foot, which was prodigiously tumefied and inflamed, and had been so for several days, brought on by a violent attack' of lumbago,* to which she was then a victim, and which rendered her nights more especially sleepless and highly painful. The constitutional disease had in this case been roused into action by the superadded irritation of the accidental disease ; and the two were running their course conjointly. It is also * Lumbago is so common in gouty subjects, that the editor is inclined to believe it is as frequently met with in them as in rheumatic patients. He cannot, therefore, regard the above case as de- cidedly proving the co-existence of gout and rheu- matism m the same individual 568 H^EMATICA. [Cl. Ill—Ord. II. a striking fact, that one of the severest illnesses that attacked Mr. Hunter's own person, and which ultimately proved to be disguised gout, podagrala rvata, he suspected, in its onset, to be a rheumatic ailment The case, as given by Sir Everard Home, in his life of Mr. Hunter, is highly interesting and curious, as showing the singular forms which this morbid Proteus sometimes affects, and the various seats it oc- cupies ; as also, that a life of abstemiousness and activity is no certain security against its attack ; for Mr. Hunter had at this time drunk no wine for four or five years, and allowed him- self but little sleep at night. Arthrosia, therefore, as a genus, may, I think, be fairly allowed to emfajeace the following spe- 1. Arthrosia Acuta. 2.-------Chronica. Acute Rheumatism. Chronic Rheumatism. 3.-------Podagra. Gout. 4.-------Hydarthrus. White Swelling. SPECIES I. ARTHROSIA ACUTA. ACUTE RHEUMATISM. PAIN, INFLAMMATION, AND FULNESS, USUALLY ABOUT THE LARGER JOINTS AND SURROUND- ING MUSCLES ; OFTEN WANDERING ; URINE DEPOSITING A LATERITIOUS SEDIMENT ; FEVER A CAUMA. The disease varies in respect to violence of the fever, and seat of the pain. The varieties, determined mostly from the last feature, are as follow :— a Artuum. Pain felt chiefly in the joints Articular rheu- and muscles of the extrem- matism. ities. 0 Lumborum. Pain felt chiefly in the loins ; Lumbago. and mostly shooting up- wards. y Coxendicis. Pain folt chiefly in the hip- Sciatica, joint, producing emaci- ation of the nates on the side affected, or an elon- gation of the limb. S Thoracis. Pain felt chiefly in the mus- Spurious pleurisy, cles of the diaphragm, often producing pleurisy of the diaphragm. The common remote cause of articular rheumatism, as of all the other varieties, is cold or damp applied when the body is heated : though it may possibly be produced by any other cause of inflammatory fever, where the consti- tution has a peculiar tendency to a rheumatic action. This tendency or diathesis seems to exist chiefly in the strong, the young, and the active; for, though it may attack persons of every age and habit, these are principally its victims. We may hence, as well as from its symptoms, prove rheumatism to be an inflam- matory disease. " Even in the weak and ema- ciated," observes Dr. Parr, " the pulse is hard, the blood coriaceous, and bleeding often indis- pensable." [Rheumatism is seldom met with in very young children, and, out of one hundred rheumatic patients, ninety are above the age of sixteen. The following is the result of what was noticed in relation to this point by M. Chomel, in La Charite\ Out of seventy-three patients attacked by rheumatism, thirty-five were between the ages of fifteen and thirty ; twenty-two between thirty and forty-five ; seven between forty-five and sixty ; seven were turned sixty ; and only two were under fifteen. Daily experience proves that both sexes are subject to rheumatism. If women more fre- quently escape from it, owing perhaps to their less robust constitutions, and their being gener- ally less exposed to cold and damp than the other sex, they are still known to be particularly liable to it when, after being tenderly brought up, they are exposed to the exciting causes; and their tendency'to be attacked by it is known to be increased by interruption of the menstrual discharge. Hence, also, women between the ages of forty and fifty frequently suffer from it. Rheumatism is not so prevalent in certain fami- lies as gout ; in other terms, it is less hereditary. Yet, though the disease can hardly be called he- reditary, an individual born of rheumatic pa- rents will certainly be in greater risk of suffer- ing from the complaint than another person whose parents were quite healthy. According to a fable kept by M. Chomel, out of seventy- two rheumatic patients, thirty-six had rheumatic parents, twenty-four had healthy parents, and twelve could furnish no information on the sub- ject] How far the observation of Sir C. Wintringham is true, that those who have suffered amputation are susceptible of this dis- ease more than others (Comment, de Morbis quibusdam, art. 79), the author cannot say from his own practice ; but it is the remark of a phy- sician who was not accustomed to form a hasty judgment [The generality of writers, down to the be- ginning of the present century, admit that the seat of rheumatism may be either in the muscles or the fibrous tissues, so called by Bichat, con- sisting of the capsules of the joints, fibrous sheaths, the periosteum, and other fibrous mem- branes, the aponeuroses, tendons, and liga- ments. This is the doctrine of Riviere, F. Hoffman, A. Leroy, and Pinel; to whom is to be added M. Chomel. Among those who be- lieve that rheumatism may be seated indiffer- ently, either in the muscular system or the fibrous, some conceive that the disease never extends to the muscles but secondarily, and that it always first attacks the fibrous or ligament- ous structures. Dr. Clutterbuck, in his lectures, even defines rheumatism to be an inflammation ofthe ligamentous structure, connected with the different joints, and covering the muscles at- tached to them ; which is in fact the theory of Bichat. Dr. Scudamore, who regards the ten- dinous portions of the muscles as the seat of rheumatism, believes that, if the muscular fibres were inflamed, they would be affected with swelling, which is not the case, while an in- crease of volume is always observable in the fibrous structures attacked. In opposition to tho Gen. XII.—Spec. 1.] ARTHROSIA ACUTA. 569 hypothesis of Dr. C. Smyth, that the essential seat of rheumatism is in the muscles, Dr. Scud- amore does not consider the permanent weak- ness of these organs, the diminution in then- size, the imperfection of their action, and the pain following their contraction, as proofs of the inflammation having its seat in the muscular fibres ; but only as the consequences of the im- pairment of the synovial and tendinous struc- tures, and of the extension or disturbance of these textures in a state of inflammation, when- ever the muscles are put in action. Acute rheumatism chiefly attacks the fibrous parts of the large joints of the shoulder, hip, knee, elbow, &c, and the muscular aponeuro- ses.* This inflammation is not in reality attend- ed with much swelling of the texture essential- ly affected, the density of which prevents any considerable effusion of lymph into its intersti- ces. It is true, however, as Dr. Clutterbuck has remarked, that a good deal of swelling often attends acute rheumatism; but this is owing to the extension of the inflammation into the sur- rounding cellular texture.] A few years ago, the proximate cause of rheumatism was imputed to inflammation of the arteries themselves of the muscles and tendons; in short, to an immediate arteritis. Some ca- ses and dissections, in support of this doctrine, were brought forward in France by M. Barde (Obs. communiquies a la Sociili de Mid.), and MM. Dalbant and Vaidy (Diet, des Sciences Mid. Journ. Compl., vi., Aout, 1819); but the anomalous diseases to which they refer have not been generally received as examples of rheu- matism. In the case related by Mr. Barde, the heart, all the larger arteries, and even the venae cava, gave evident proofs of inflammatory action. Their coats were thickened, hardened, of a dark-red colour, in some parts covered with a whitish purulent matter, and in some the inte- rior tunie was destroyed : the heart itself being considerably enlarged and inflamed. [The foregoing hypothesis of arteritis being the proximate cause of acute rheumatism, is suf- ficiently refuted by the consideration, that, if il were true, rheumatism would always accom- pany arterial inflammation, which is not the fact. If another argument were required to subvert the opinion, it might be readily found in the fly- ino- and very wandering nature of rheumatic pains, which pass, as Bichat (Anat. Gen., torn. ii., p. 263) expresses himself, with astonishing quickness, from one situation to another. Brous- sais, in his Lecons Pathologiques, thus accounts for rheumatism : " When," says he, " the ac- tion of the skin is diminished, it is determined to another part; and here it is to the capsules or articular ligaments, the textures around the joints, that the irritation is determined."] In the general course of acute rheumatism, * The parts are generally hot and red, and fre- quently the pain is situated in the theca of the tendons : Dr. Elliotson has noticed red streaks in the direction of the latter parts.—Lect. at Lond. Univ., as published in Med. Gaz. for 1833, p. 852.—Ed. its peculiar inflammation does not continue long enough in any one organ to injure the structure ofthe arterial tunics; often, in effect, as in gout, we witness its disappearance in a moment, and find it migrating to some other part of the body. As a general rule, it may be asserted, that rheumatic inflammation does not tend to sup- puration. [It is one of the characters of the fibrous system hardly ever to suppurate. Bi- chat believed that rheumatic inflammation never ended in the formation of an abscess, though coagulable lymph might be sometimes effused round the tendons affected.] In a few rare in- stances, the contrary has been known to take place (Morgagni, De Sed. et Cans. Morb., eg, lvii., art. 20; Med. Comment. Edin., vol. iv., p. 198); and, in one or two cases, I have my- self been a witness to an extensive abscess. But the general rule is not disturbed by such rare exceptions. The inflammation, therefore, is of a peculiar kind. There will often, indeed, be effusion, and the limb will swell consid- erably ; but the effused fluid is gradually absorb- ed, and the swelling not unfrequently, though not always, is accompanied with an alleviation of the pain. Sometimes the pains take the precedency of the fever; but, in other cases, the fever ap- pears first, and the local affection does not dis- cover itself till a few days afterward.* There is no joint, except perhaps the extreme and mi- nute1 joints of the fingers and toes, but is sus- ceptible of its attack, although it usually com- mences in, and even confines itself to, the larger. Among these, however, it frequently wanders most capriciously, passing rapidly from the shoulders to the elbows, wrists, loins, hips,knees, or ankles, without observing any order, or ena- bling us in any way to prognosticate its course ; always enlarging the part on which it alights, and rendering it peculiarly tender to the touch. The urine is often at first pale, but soon be- comes high-coloured, and deposites a red sedi- ment. It may be distinguished from gout by being little connected with dyspepsy, commen- cing less suddenly, evincing more regularly-mark- ' '"* ed exacerbations at night, but less clear remis- sions at any time : to which we may add, its attachment to the larger, rather than the small- er joints ; and its connexion with exposure to cold and damp. It runs on from a fortnight to three weeks ; and the average of the pulse ia rarely under a hundred. The fever is generally accompanied with copi- ous and clammy sweats [often of an exceedingly ^ sour smell] ; but the skin still feels tense and "' harsh ; nor does the sweat issue freely from * Acute rheumatism presents a state of active fever, accompanied with inflammation of the fibrous tissues about the joints. One point1 not entirely decided is, whether the fever is the cause or the effect of the inflammation ? Sydenham adopted the first of these views, which has found an able advocate in Dr. Barlow (Cyclop, of Pract. Med., art. Rheumatism), who endeavours to" prove (a fact generally acknowledged) that the state ofthe constitution is what principally claims I regard in the treatment of acute rheumatism —Ed. 570 H^M the immediate seat of pain. It seems to be an ineffectual effort of the remedial power of na- ture to carry off the complaint : for it is by this evacuation alone that we can at length succeed in effecting a cure. But the perspiration will be always found unavailing, so long as it contin- ues clammy, and the skin feels harsh, and there is a sense of chilliness creeping over the body, or any part of it, during the perspirable stage. The exacerbation, which regularly returns in the evening, increases during the night, at which time the pains become most severe ; and are then chiefly disposed to shift from one joint to another.* [Acute rheumatism is not, generally speaking, attended with danger. Sometimes, however, it induces inflammation in parts of great impor- tance to life ; seemingly, in consequence of their partaking more or less of the ligamentous or fibrous tissue. The periosteum is a structure that is frequently attacked; and hence those aching pains in the bones by which patients are severely tortured. The pericardium is another organ to which rheumatic inflammation is fre- quently directed: the case being indicated by great pain in the region of the heart, and great disorder in the action of this viscus. Some- times the dura mater, another fibrous membrane, suffers ; the patient being afflicted with severe headache and delirium, and often falling a victim to the disease. There is also no doubt, that the pleura and diaphragm are very liable to acute rheumatic inflammation; and surgeons most experienced in diseases of the eye, recog- nise a species of rheumatic inflammation to which that organ is subject, and which has its seat in the sclerotic coat, whose fibrous texture is well known. Frequently it affects the loins, producing lumbago; the muscles at the back of the neck, the face, or any other part, where fibrous membranes, aponeuroses, ligaments, ten- dons, or perhaps muscles, are situated.] Where fever is violent, and especially where the frame is robust, our only effectual remedies are copious bleeding and the use of diaphoret- ics : by the former, which will often demand repetition, we take off the inflammatory diathe- sis ; and by the latter, we follow up the indica- tion which nature herself seems to point out, and endeavour, by still farther relaxing the ex- tremities of the capillaries, to render that effect- ual, which, without such collateral assistance, is, as already observed, for the most part exert- ed in vain, and with an unprofitable expenditure of strength. The most useful diaphoretic is Dover's powder ; and its benefit will often be increased if employed in union with the aceta- ted ammonia, and sometimes if combined with * When the disease subsides, the parts do not desquamate and itch, as they do after gout; but they merely cease to be hot, swollen, and inflamed. (Dr. Elliotson's Lectures.) Rheumatism does not begin, like gout, particularly in the night- time ; and it arises from an evident exciting cause, exposure to cold, or cold and wet, which is not the usual occasion of gout. In the latter disease, you have not, in the early stage, the same tenden- cy to profuse and often sour perspirations.—Ed. .TIC A. [Cl.III.-Ord.II camphire. Aperients are useful to a certain ex- tent ; but they have not been found so service- able as in various other inflammations. Small doses of calomel have occasionally, however, seemed to shorten the term ofthe disease, though they have not mueh influence in diminishing the pain. To obtain this, Dr. Hamilton has com- bined calomel with opium; and, in his hands, it appears to have been successful. Opium alone is rather injurious ; nor has any decided benefit resulted from other narcotics, as hyos- cyamus, hemlock, and aconite. No constitution is invulnerable to the attack of rheumatism, although the young and the vig- orous fall most frequently a prey to its torture. Hence not unfrequently we meet with it in per- sons of weak and irritable habits, who will not bear the lancet with that freedom which gives any chance of its being useful. Local bleeding is here to be preferred, but it cannot be depend- ed upon ; since, though the pain may diminish, or even totally subside, it is in many cases only to make its appearance in some other quar- ter.* Here also, if in any case, we have rea^ son to expect benefit from uniting stimulants with diaphoretics, as ammonia, camphire, and the r§sinous gums and balsams. In such habits, and particularly if opium should disagree with the system, it may be worth while to try the rhododendron (r. Chrysanthum, Lin.). This plant is a native of the snowy summits of the Alps and mountains of Siberia ; and in Rus- sia, as we learn from Dr. Guthrie, is employed very generally, both in gout and rheumatism, with a full assurance of success, a cure seldom failing to be effected after three or four doses (Med. Comment., vol. v., p. 434): in conse- quence of which, it has formed an article in the Materia Medica of the Russian Pharmacopoeia for nearly a century. Dr. Home tried it upon a pretty extensive scale in the Edinburgh Infir- mary, and found that it acts both as a powerful diaphoretic and narcotic ; and is at the same time one of the most effective sedatives in the vegetable kingdom. In most of the cases it retarded the pulse very considerably, and, in one instance, reduced it to thirty-eight strokes in a minute. It has also the advantage of occa- sionally proving aperient. But it sometimes produces vertigo and nausea ; and, as a general medicine, is not to be preferred to Dover'^ powder ( Clinical Experiments, Histories of Dis- sections, 8vo., Edin., 1780), or even the anti- monial powder with opium, where the latter can be borne without inconvenience. It is possible also in habits of this irritable kind, if in any, that we are to look for that ex- traordinary and decisive benefit from a free use of the bark at an early period of the disease, which we are told has been obtained. Contem- * Dr. Elliotson finds that free local bleeding gen- erally answers better than venesection; and he observes, that whether leeches or cupping be em- ployed, great benefit will result from applying cold lotions as long as the temperature ofthe part is higher than it ought to be.—See his Lectures at the Lond. Univ., as published in the Med. Gaz. for 1833, p. 853.—Ed. Gen. XII.—Spe. 1.] ARTHROSIA ACUTA. Sfj plated as a highly acute inflammatory affection, nothing could at first sight appear to be more inconsistent with all rational practice than the use of such a medicine, and every one must feel predisposed to coincide with Dr. Cullen, when he tells us, in reference to acute rheumatism, " I hold the bark to be absolutely improper, and have found it to be manifestly hurtful, especially in its beginning, and in its truly inflammatory state."—(Mat. Med., part ii., ch. ii., p. 100.) Yet, in direct opposition to such feelings and such assertion, we find the bark freely prescribed from the onset of acute rheumatism, apparently with success, by Dr. Morton, who seems first to have recommended it for this purpose, Sir Edward Hulse, Dr. Hugh Smith, Dr. Fother- gill, Dr. George Fordyce, and Dr. Haygarth of Chester.* Dr. Fordyce affirms distinctly, that, at the time of writing, he had for fifteen years relinquished bleeding in favour of the bark; and that, during this period of time, he had not above two or three patients out of several hundreds for whom he had prescribed it; and had rarely met with any instance of a metastasis, a very common occurrence when he was in the habit of employing copious bleeding.—(On Fever, dissert, iii.) I have also tried the bark in various instances from an early period of the disease, and when the bowels were free from confinement: but I have rarely met with success, and have often, like Dr. Cullen, had reason to think it injurious. [When a trial of bark is judged proper, the sulphate of quinine is a convenient preparation that should not be forgotten. Indeed, it has already been recommended by Dr. Whiting (see Lond. Med. Phys. Journ., Feb., 1826) and others.] The above remarks will apply to the other * Clinical Hist, of Diseases, 1805. On this point Dr. Elliotson has the following remarks:—" You will not find in Haygarth's work any authority for such practice. You will find in his book ac- counts of the successful treatment of rheumatism by bark ; but then, it was not till he had evacua- ted the patient upwards and downwards, and em- ployed the antiphlogistic plan. After that, it is said that it prevented the disease from recurring. 1 have not had occasion to use bark, for 1 have found the disease give way 'to antiphlogistic means, colchicum, and mercury.' The two best internal medicines are, without doubt, colchicum and mercury. Colchicum here, as in the case of gout, generally does no good till it purges; and when once it purges the patient thoroughly, the disease usually gives way. It should be given as in gout, with magnesia. As soon as it purges, it is right to desist, and also as soon as its effect ceases. If you give a dose of one, two, or three minims of hydrocyanic acid with the colchicum, it sits better on the stomach." In obstinate cases, instead of going on with colchicum, Dr. Elliotson exhibits mercury, and makes the mouth tender. "If you do this in the first instance, instead of giving colchicum, the success is about the same. Colchicum may gripe, and mercury may make the mouth sore, so that you may not be able to continue them, and you may then leave off the one, whichever it may be, and exhibit the other ; or, if you begin with one, and find it does no good, you may exhibit the other."—Ed. varieties of acute rheumatism as well as to the first, that which affects the joints generally, and is the most common form under which the dis- ease shows itself: yet the few following obser- vations, more immediately directed to the other varieties, may not be altogether unprofitable. Lumbago has sometimes been confounded with nephritis, or a calculus in the kidneys or ureters ; but the proper nephritic affections are distinguished by some irregularity in the secre- tion of urine, and, as we have already had oc- casion to observe, with a numbness shooting down the thigh, and a retraction of either testicle. Rheumatism of the hip-joint was called among the Latins ischios, from io-^/oj, the Greek term for hip ; which was afterward corrupted into isciatica or sciatica ; a word that has occa- sionally found its way into the dramatic poetry of our own country, as in Shakspeare's Timon, "—The cold sciatica Cripple our senators, that their limbs may halt As lamely as their manners." This variety, at its onset, has sometimes been mistaken for a phlegmonous inflammation of the psoas muscle. But in the latter there is, from the first, less tenderness to the touch, but much more enlargement, and the pain shoots higher into the loins. In sciatica, indeed, the whole limb, instead of continuing to swell, soon wastes away, and the emaciation extends to the nates of the affected side, so that the muscles have neither strength nor substance ; while the thigh seems elongated. When acute rheumatism attacks the pleu- ra,* or any of its duplicatures or appendages, it exhibits many of the symptoms of pleurisy or peripneumony. But here, also, as in every other case of rheumatism, we have much greater tenderness upon pressure than in phlogotic in- flammation, while the pyrectic symptoms are considerably less, and often highly dispropor- tionate to the pain that is endured, so that the degree of pain and that of fever become no measure for each other. There is this peculiar character belonging to the three last varieties, that though they are less disposed to wander generally than the first, they are peculiarly apt to run into each other's proper field, and to affect the stomach, which, in consequence, becomes sometimes enormously flatulent and expanded, with a sense of heat like that of a burning coal. If the back or loins be pressed hard to obtain ease, the pain is trans- ferred to the side or stomach; and if the pres- sure be followed up into the side, it returns with violence to the back or hips ; or the breathing * is impeded, and can only be carried on in an erect position.—(Cartheuser, Diss, de Lumba- gine rheumatica, Fr., 1755 ; Scheid, Diss, de Lumbag. rheumat., Arg., 1794.) Generally speaking, however, in these three varieties the disease is less erratic than in the first, and particularly in lumbago and sciatica. And it is owing to this fact that the loins and * This case is most commonly believed not to affect the pleura at all, but merely the muscles or fibrous tissues of the parietes of the chest.—Ed. 572 H^EMATICA. [Cl.I1I.-0rd. II. the hip, from having been more uniformly affect- ed, are often so long, even after the complaint has subsided, before they recover any degree of tone, so that the patient is frequently a cripple for many months ; and still suffers from chronic rheumatism. Local applications, which are rarely of service in the first or articulate variety, as the pain is so apt to wander from every joint to every joint, may in all these be frequently employed with more advantage ; and where general and copi- ous bleeding may be contra-indicated, leeches or cupping have often afforded considerable relief. The compound camphire liniment, as an elegant rubefacient, is perhaps more frequently employ- ed than any other medicine of the same tribe, but it dries too soon upon the skin, and heats and stimulates without exciting moisture ; and hence it is less useful than camphire dissolved in oil, or oil united with ammonia. In all these applications, however, the friction with a warm hand is of itself highly serviceable, and should be long persevered in and frequently repeated And on this account, essential advantage has often been derived in cases of lumbago, or where the rheumatism has fixed itself between the shoulders, from a waistcoat of the coarsest brown paper, worn close to the skin, which ex- cites a gentle moisture, both by its perpetual friction and the stimulus of the tar with which it is so largely impregnated. [After the acute stage of lumbago, great benefit may often be derived from the Burgundy pitch plaster, or emplastrum picis comp. Dr. Clutterbuck has sometimes succeeded in relieving lumbago by half a grain of elaterium, followed by a grain or two of opium : it generally excites both vomit- ing and purging. Of course, one would only have recourse to such treatment in a case at- tended with great severity and obstinacy.*] Blisters seem rarely to be of all the advantage we should expect; but the vesication from sinapisms succeeds better than that from canthar- ides. The burning of moxa is a favourite rem- edy on the continent, but has been little tried in our own country, and is more suited for the chronic form ofthe disease. The tartar emetic ointment has been also frequently made use of, and sometimes with success : it gives a perma- nent irritation, but the exulcerations it produces frequently prove foul and troublesome. Dr. Perceval of Dublin, in a manuscript note to the volume of Nosology, tells me that, in sciatica, he has known the pain removed by a sweating course of James's powder, after a considerable emaciation of the nates. Bark and gentle stimulants, as guaiacum, bardana, and seneka, may be used with advan- tage, with a liberal regimen and chalybeate waters. Sulphureous fumigation has also of late * In severe lumbago, Dr. Elliotson has recourse to cupping on the loins, and gives a large dose of opium (three grains), which is followed by half a drachm of vinum colchici every eight hours.—(See Clinical Lect, Lancet, 1830-31, p. 492.) I have always found an active purgative one of the best incipient measures, whatever may be the rest of the treatment.—Ed. been very extensively employed on the continent, and partially in our own country, in the cure of both the present and ensuing species, and, ac- cording to the testimony of those who have em- ployed it, with great success. M. Gales, of Paris, who seems first to have tried it, affirms, that of sixty-five patients who were submitted to it, twenty-five were cured, thirty-two much relieved, while only eight received no benefit. Mr. Wallace, who has also tried it at Dublin on a large scale, does not speak so decisively of its benefit in these complaints as in cutaneous eruptions.—(Obs. on Sulphureous Fumigation, as a Remedy in Rheumatism and Diseases of the Skin, Dublin, 1820.) SPECIES II. ARTHROSIA CHRONICA. CHRONIC RHEUMATISM. PAIN, WEAKNESS, AND RIGIDITY OF THE LARGER JOINTS AND SURROUNDING MUSCLES ; INCREAS- ED BY MOTION J RELIEVED BY WARMTH ; LIMBS SPONTANEOUSLY OR EASILY GROWING COLD ; FEVER AND SWELLING SLIGHT, OFTEN IMPER- CEPTIBLE. Concerning the proper position, and, in some sort, the nature of this disease, Dr. Cullen con- fesses himself at a great loss. In his Synopsis, he arranges it as a sequel of acute rheumatism, and so explains it in his definition : yet he gives it a distinct name, that of Arthrodynia, for the express purpose, as he tells us, of having a dis- tinct name at hand for any one who may choose to regard it as a separate genus; and whoever is so disposed is at full liberty, he adds, as to any objection of his own. Yet, in his First Lines, he takes a different view, and perhaps a more correct one, than either of the above. Chronic rheumatism, instead of being a mere sequel of acute rheumatism, or a distinct genus, is here made a separate species of a common genus. " Of this disease," says Dr Cullen, " there are two species, the one named the acute, and the other the chronic rheumatism." And in his subsequent description of the latter, instead of the universal assertion in his earlier work, " pro sequela rheumatismi acuti rheuma- tismum chronicum dictum semper habeo," he modifies it by the word commonly. " The chronic," says he, "is commonly a sequel of the acute rheumatism."—(Aph. ccccl.) There can be no doubt, indeed, that it is so ; but as in many instances it is a distinct disease, characterized by symptoms of its own, and de- manding a very different treatment, it ought certainly to be arranged as a distinct species. Chronic rheumatism has as many, and near- ly the same varieties, as the acute. It becomes fixed in the loins, in the hip, in the knee, but seldom in the thorax. Its symptoms are in most respects like those of acute rheumatism, only that there is little or no fever ; so that, while the general heat is very considerable, and the pulse usually upwards of a hundred strokes in a minute in the acute species, the skin in the chronic species seldom exceeds its natural tem- perature, and the puke is rarely quicker than Gun. XII.—Spe. 2.] ARTHROSIA CHRONICA. 573 eighty strokes; the joints are less swollen, and of a pale, instead of a reddish hue, cold and stiff, and roused with difficulty to a perspiration, and always comforted by the application of warmth.* The disease continues for an indefinite period, and sometimes only terminates with life itself. The affected joint is occasionally debilitated in the utmost degree, so that when the acute pain is not present, the weakness resembles that of a stroke of palsy. Cold, the common cause of the acute rheu- matism, is also a common cause of chronic, even where the acute species has not preceded: and violent strains and spasms may be enumerated as other causes. But, in these cases, the con- stitution must be peculiarly disposed to rheu- matic action. Every symptom proves most distinctly that the present is a disease of debility ; and the mode of treatment must be founded upon this idea. Hence, stimulants of almost all kinds are found serviceable. Warm active balsams and resins, as those of copayva, cubebs (See Dr. Crone's Obs. in Edin. Med. Journ., No. lxxix., p. 305), and guaiacum,* essential oils of all kinds, from resinous substances, as turpentine and am- ber ; from aromatic or pungent plants, as cam- phire and mustard, and especially cajeput, the green distilled oil from the leaves of the mela- leuca leur.odendron, are all employed in their turn ; sometimes alone, where they combine a sedative with a stimulant power, as camphire and cajeput, and sometimes in union with opium, which often proves a very valuable addition. Most of these are also powerful diuretics ; and, as acute rheumatism is best and soonest removed by warm sudorifics, so chronic rheu- matism seems to be chiefly relieved, and, in- deed, radically cured, by diuretics of-a like stim- ulus. Hence, horseradish and garlic are often found serviceable, and turpentine still more so, which, in truth, forms the basis of the greater number of the medicines just enumerated. How far the arum, or dulcamara, may be specifically entitled to this character, I cannot determine from my own practice. They are both intro- duced into the table of diuretics by Dr. Cullen, and are highly commended by many physicians * Occasionally the symptoms will be like those of acute rheumatism, only less violent. In gen- eral, however, the sweating does not continue, and the parts are not above their natural temper- ature, as they are in acute rheumatism. "It is sometimes rather difficult," says Dr. Elliotson, " to make an accurate diagnosis. If the disease has been acute rheumatism at first, you will find there has been sweating."—Lectures at Lond. Univ., in Med Gaz. for 1833, p. 852.—Ed. t One of the best stimulants in cases of chronic rheumatism is the ammoniated tincture of guaia- cum. This is a medicine given in various doses, from thirty drops to a drachm at a time; and Dr. Elliotson has known patients who took 3VJ. three or four times a day. Sometimes, says he, it purges, and sometimes it produces the nettle-rash; but, " when internal stimulants are necessary in rheu- matism, I think this is one of the best."—Lec- tures at Lond. Univ., &c.—Ed, of great celebrity for their arthritic virtues. But it is possible that, whatever virtues of this kind they possess, are rather derived from their stimu- Jating the excretories generally, and rousing the entire system, than from their acting specifical- ly upon the kidneys. The colchicum autumnale, which has sometimes [the author might have said, very frequently] proved serviceable, has more decided pretensions to a diuretic charac- ter.* Local stimulants are here of more service than in the preceding species. The moxa has been more generally used on the continent for chronic than for acute rheumatism, and is cer- tainly more entitled to a trial. It is peculiarly recommended by Larrey.—(Recueil de Mimoires de Chirurgie, &c, 8vo., Paris, 1821.) In our own country, however, practitioners have far more generally had recourse to cataplasms of ammonia, cummin, and mustard-seeds, occasion- ally intermixed with euphorbium or canthar- ides ; or, in their stead, have made use of fric- tion, and, which is far preferable, the vapour- bath, brine, warm-bathing, and have afterward kept the joint well-clothed with flannel, and sent through the organ small shocks of electricity, or roused it by the stimulus of the voltaic trough. Sulphureous fumigations, or the ap- plication of sulphur in a gaseous form, as first employed by Dr. Gales of Paris, are in common use on the continent, and have occasionally been employed with success in our own country. And, when every thing else has failed, the pa- tient is usually advised to. try, what, perhaps, it would be better that he should try at first, the mysterious agency of the Bath waters. The arsenic solution I have never tried in this complaint! It is strongly recommended by Dr. * Dr. Good, among the numerous medicines specified by him as having been recommended for chronic rheumatism, makes no mention of mercu- ry. Whether the parts are hotter than they should be or not, Dr. Elliotson finds obstinate cases, es- pecially such as are attended with exacerbation of the pain in the night, give way to mercury when they will not yield to any other medicine. All men of experience know how frequently pains in the bones, from syphilis, are supposed at first to be merely chronic rheumatism, and how quickly mer- cury sometimes relieves them.—Ed. ! Generally speaking, the arsenical solution is used with reluctance by Americans: its action on the stomach, and its peculiar influence in caus- ing pain in the limbs, &c, have-beenjepeatedly ob- served ; in some extremely obstinate cases, how- ever, it may be found serviceable, but we should begin with half the dose prescribed by our author. Among external applications, few remedies can compare with the oil of cajepnt, which may be rubbed on the affected part in combination with olive-oil or camphorated liniments carded cotton is often far more soothing to the painful limb than flannel; strips of oiled silk and of caoutchouc have also been highly recommended. The late work on Neuralgic Affections by Mr. Teal, has enlarged our views of the mysterious nature of rheumatism: he contends that rheumat- ic affections, and even neuralgia itself, frequently depend on an irritation, or a partial degree of in- flammation, at the origin of the spinal nerves : and hence, he observes, we may sometimes trace the 574 HiEMATICA. [Cl. III.—Ord. II Bardsley (Medical Reports), and, in his hands, it seems often to have succeeded It may be commenced in doses of ten drops, and gradually increased to double this quantity, and should be united with a few drops of laudanum if it sit uneasy on the stomach by itself. The colchi- cum wine and vinegar have certainly been em- ployed with great and decided benefit in chronic rheumatism, to which they are more adapted than to the acute form of the disease.* In many of the eastern parts of the world, and particularly in China and Japan, a mode of treatment for various acute muscular and ner- vous pains has been in immemorial use, under the name of zin-king, or needle-pricking, and consists in pushing from two to five or six fine- ly-pointed gold or silver needles, at a small distance from each other, into the seat of pain, to the depth of from half an inch to an inch, or something more. This has of late been tried, under the name of acupuncture, in France, by M. Berlioz (Mimoire sur les Maladies Chron- iques, les Evacuations Sanguines, et VAcu- puncture, Paris, 1816), and other practitioners, chronic sufferings of rheumatism to spinal disor- der. Acting on this belief, Dr. J. K. Mitchell, of Philadelphia, has applied cupping-glasses over the spinal region, and soon removed pains of a rheumat- ic nature. The same practice has been successful- ly followed by Dr. R. H. Thomas, of Baltimore.— (N. A. Archives of Med. and Surg., &c.,vol. i.,p. 189.) Dr.Eberle remarks, "it would appear, that in many cases of fixed pain simulating rheumatism, one or more ofthe vertebrae ofthe spine are very ten- der to pressure, and that if in such cases leeches or cups be applied over the diseased portion ofthe spi- nal marrow, almost immediate removal of the rheu- matic pains will be effected."—(Practice of Medi- cine, vol. i.) As a dernier resort, the waters of the White and Salt Sulphur Springs, and the Warm Springs of Virginia, which are highly recommend- ed by Dr. M. Page, of Richmond, the Bluelick and Harrodsburgh Springs in Kentucky (Yandell, in Transylvania Journal of Medicine, vol. v., p. 375), or the Avon mineral waters in the state of New- York, may often be used with advantage.—D. * Dr. Elliotson adds his testimony in support of the excellent effect of arsenic on chronic rheuma- tism. The stomach will bear it better, if hydro- cyanic acid be given with it or just before it. Dr. Good's first doses of the arsenical solution are greater than what practitioners usually venture upon. It is best to begin with two or three min- ims, and increase the quantity gradually: few patients can bear above seven or eight minims. Although there may be no danger in the oedema sometimes caused by this mineral, Dr. Elliotson regards the circumstance, when it occurs, as a sufficient reason for discontinuing it Were any gastritic affection to be produced by arsenic, per- severance with the medicine would, of course, be dangerous. When the disease assumes an in- termittent form, Dr. Elliotson gives either arse- nic or a large dose of bark or quinine, either just before a paroxysm is expected or afterward, or smaller doses in the intervals. He also speaks very favourably of the effects of a narcotic, given in a full dose just before the pain is about to be- gin ; as, for instance, one grain of stramonium, re- peated in two or three hours if necessary, and the head remain unaffected. Were the medicine to excite drowsiness, giddiness, or delirium, ane met- ic would be proper.—Ed. and in our own country by Mr. Churchill (A Treatise on Acupuncluration, &c, Lond., 1828), for various affections of the above character, but particularly in severe chronic rheumatism, and, according to the accounts published, with considerable and almost instantaneous relief. The puncture produces little or no pain, and should be followed by no hemorrhage. A single puncture is often found sufficient to remove the ache,though it shoots occasionally to some neigh- bouring part; in which case, the same process is to be followed up to the seat of metastasis, when it is usually found to vanish altogether. The needle, when introduced, is suffered to re- main in each puncture for about five minutes be- fore it is withdrawn, and, in this part of the world, is commonly made of fine steel. [Dr. Elliotson has employed acupuncture very exten- sively : his experience confirms the observation of Mr. Churchill, that it is chiefly useful in the rheumatism of fleshy parts, and in chronic cases. Like the same writer, he also finds one needle, left an hour or two in a part, more efficient than several applied but a few minutes. Of forty- two cases thus treated, thirty were cured : and the other twelve, being more or less acute, were not adapted for it, and yielded to antiphlogistic treatment.—(See Med. Chir. Trans., vol. xiii., p. 467.) Some writers would attempt to ex- plain the modus operandi of acupuncture on the principle of counter-irritation ; but M. Pouillet has endeavoured to show by experiments that electro-magnetic phenomena take place in the operation.—(See Journ. de Physiologic Expir., par F. Magendie, tom. v., art. i.)] When the disease is limited to the extremi- ties, whether of the arms or legs, flannel ban- dages have often been found highly serviceable ; and they should be applied with as much tight- ness as the patient can bear without inconve- nience.—(Trans, of King's and Queen's Col- lege, Dublin; Dr. Gratton, vol. i., p. 169, 1817.) SPECIES III. ARTHROSIA PODAGRA GOUT. PAIN, INFLAMMATION, AND FULNESS, CHIEFLY ABOUT THE SMALLER JOINTS; RETURNING AF- TER INTERVALS, OFTEN PRECEDED BY, OR AL- TERNATING WITH, UNUSUAL AFFECTIONS OF THE STOMACH, OR OTHER INTERNAL PARTS; UNSUPPURATIVE. The origin of the term gout, or goutte, in French, is little known, or rather is almost for- gotten. Among the ancients, most diseases ac- companied with tumefaction were ascribed to a flow of some morbid fluid or humour to the part affected, which was ealled a rheum or defluxion ; and the rheum or defluxion was denominated cold, hot, acrid, saline, or viscid, according to the nature of the symptoms. The Arabian writers ascribed even this cause to various diseases of the eyes, which were hence called gutta se- rena, and gutta obscura, " clear or cloudy drops, or defluxions," according to the external appear- Gbn. XII.—Spe. 3.] ARTHROSIA PODAGRA. 575 ance. Rheumatism and gout were alike attrib- uted to the same origin: and, as the terms rheuma and gutta were used in medicine synony- mously, both importing defluxion, the old opin- ion is still verbally preserved, and has de- scended to us in the names of rheumatism and gout, though the old pathology has been aban- doned. " We have still," says Dr. Parr, " the treatise of Carpinati, published at Padua in 1609, De Gutta, seu Junctuarum dolore ; but the term may be traced to Valescus de Tarenta, who wrote his Commentary early in the fifteenth century ; and Schneider, in his Liber Catar- rhorum Specialissimus, published at Wittenburg in 1664, usually denominated the sixth volume, and peculiarly scarce, describes the gout as a catarrh."—(Med. Diet., App.) [The term, how- ever, is still more ancient, and was used by Ra- dulphus, a Dominican of the thirteenth century, who writes, " cum gutta, quam podagram, vel arthriticam vocant, frequenter vexareter."] The resemblance between gout and rheuma- tism is so close, that the one is often mistaken for the other; and both by Bergius were regard- ed as convertible ; yet, while the former chiefly fixes on the small joints, the latter attacks the large ; and the first is often hereditary, while the second is rarely or never so. Gout is far more connected with a dyspeptic state of the stomach than rheumatism : its incursions are, for the most part, more sudden, its nocturnal exacerbations less striking, but its remissions much clearer. While rheumatism mostly be- gins in the shoulder or elbow, gout always be- gins in the foot or ankle. Gout, moreover, is a far more complicated complaint than rheumatism; and hence there is no disease to which the human frame is sub- ject, that has led to such a variety of opinions, both in theory and practice, many of them direct- ly contradictory to each other, as the gout; and I may add, there is no disease, concerning the nature and treatment of which physicians are so little agreed ; so that, to this moment, it consti- tutes perhaps the widest field for empiricism, and the hottest for warfare, of any that lie with- in the domain of medical science. Shutting the door to disputation and unfound- ed theory as far as we are able, let us, in as few words as possible, attend to the clear and estab- lished history of this disease as we would to that of any other, and draw our pathology and our mode of practice from the principles which it will be fairly found to inculcate. In the first place, it is admitted on all hands, or at least with exceptions so few as scarcely to disturb the general consent, that gout, in what- ever way it shows itself, is a disease of the sys- tem ; or, in other words, is dependant upon a peculiar diathesis or state of the constitution. And next, it is as commonly admitted, that this diathesis is in some instances original, and in others hereditary or derived. There are many persons in whom this complaint makes its appear- ance, who can trace no such affection in their ancestors ;* and as such persons are specially * From some tables published by Sir Charles distinguished by a habit of indolence, luxury, and indulgence, and particularly in the pleasures of the table, it is from this habit that the gouty diathesis is supposed to originate. There are others who, though exhibiting a life of great reg- ularity and ahstemiousness, afford proofs of the same diathesis in occasional paroxysms to which it gives rise ; and such persons are almost al- ways capable of tracing it hereditarily. For the diathesis, having once established itself, keeps its hold on the system, and is propagated from race to race, whatever be the manner of life of the individual, or the general state of his consti- tution ; though there can be no question, that those descendants are most subject to its parox- ysms who indulge in the excesses that laid its first foundation. A gouty diathesis, thus produced, may remain quiescent, and not discover itself for many years, till it meets with some occasional cause of ex- citement, when it shows itself by a sudden and painful disturbance of some part of the system ;* but a disturbance of a very different kind, as well as affecting very different organs, accord- ing to the temperature, constitution, manner of life, or some incidental circumstance of the in- dividual : where the general health is sound, fixing on one or more of the extremities, in the form of a peculiar but very acute inflammation, that runs through a regular paroxysm and grad- ually subsides ; and, where the health is infirm, and the general form debilitated, exciting great derangement in some internal organ or set of organs, and particularly those of digestion; or shifting from one form to another, and thus proving itself, under every form, to be the same disease, and laying a foundation for the three following varieties :— a Regularis. Pain, swelling, and inflam- Regular fit of mation of the affected joint gout. considerable and acute; continuing for several days, often with remis- sions and exacerbations ; then gradually resolving, and leaving the constitu- tion in its usual or im- proved health. Scudamore, it appears that in a given number of gouty individuals, the majority acknowledged no hereditary claim to the disease. Yet we are not to imagine, from the result of this estimate, that, in a large proportion of cases, the predisposition is not received by children from their parents : the fact is familiarly known and universally acknowl- edged.—Ed. * " A state of plethora, absolute or relative," as Dr. Barlow observes, " precedes every accession of gout, and is the principal, if not the immediate cause of it. The intensity and duration of theparox- ysm, too, are dependant on the degree of plethora prevailing, although other circumstances may con- tribute to prolong the attack. But, notwithstand- ing this, gout is not simply plethora leading to or ending in local inflammation. There is some- thing more from which gout derives its distinctive character, and this ideal, at least unexplained ex- istence it is, which constitutes the essence of gout."—Cyclop, of Pract. Med., art. Gout.—Ed. 576 HAM 0 Larvata. Disguised and lurking in the Disguised; lurk- constitution, and produ- ing atonic gout, cing derangement in the digestive or other func- tions, with only slight or fugitive affection of the joints. y Complicata. The disease fixing on some Retrograde ; re- internal organ instead of cedent; mis- on the joints ; or suddenly placed gout. transferred from the joints after having fixed there ; producing in the internal organ affected debility or inflammation, according to the state of the constitu- tion. The predisposing cause of a gouty diathesis, when it first forms itself in an individual, is ple- thora, or the state of the system produced by full living and indolence. An entonic state of the vessels, joined with plethora, may be set down as the predisposing cause to acquired gout; and this hypothesis seems consistent with the fact of the common occurrence of gout in strong robust individ- uals. When it has been transmitted heredi- tarily, it is more disposed to show itself in men of robust and large bodies, of large heads, of full and corpulent, and especially gluttonous habits, or whose skin exhibits a coarser surface, in consequence of being covered with a thicker rete mucosum. [The middle and advanced periods of life are more disposed to gout than the early periods. Thus, it does not commonly attack men until after the age of thirty-five, and generally not till a still later period.* When the gout does appear in more early life, it seems to be in indi- viduals in whom the hereditary disposition is exemplified, and to whom the exciting causes have been strongly applied. According to Hip- pocrates, eunuchs are not liable to gout, nor boys previously to venery ; but these opinions are probably not very correct; since, with re- spect to the latter, the disease is well known to oe almost peculiar to an advanced period of life ; and the eunuchs, who, in the time of Hippoc- rates, were chiefly Persian slaves, were, in all likelihood, confined to the strict discipline and the frugal and temperate lives enjoined to all, and therefore not exposed to the most active causes of gout. For Galen, in his Commentary upon this observation of Hippocrates, tells us, that, in his time, the remark was no longer true, " owing to too much indulgence on their part in an indolent, as well as intemperate mode of life;" and the remark is confirmed by modern expe- rience. There is a Greek epigram, literally sig- nifying, " Of limb-relaxing Bacchus, and limb- relaxing Venus, is born a daughter, the limb- relaxing Gout." And a similar doctrine is con- tained in the adage, " Bacchus pater, Venus mater, et Ira obstetrix Arthritidis." While, * When the predisposition is strong, however, it may commence much earlier. The editor has seen several instances of it in persons not more than twenty years of age.—Ed. ATICA. [Cl. III.—Ord II. says Dr. Bateman, this fact is confirmed on the one hand, by the testimony of ages, in the af- firmative, it is corroborated also, on the other hand, by observation, in the negative. Dr. Cul- len remarks, that gout seldom attacks those who are employed in bodily labour, or who live much upon vegetable aliment, or take no wine or fermented liquors. Indeed, the gout is said to be altogether unknown where these liquors are not used, as among the common people of Turkey. According to Van Swieten, some peo- ple, who, after being in comfortable circumstan- ces, have been reduced to labour for their suste- nance, and to exchange a luxurious table and indolence for a spare diet and activity, have never suffered from gout again. He mentions particularly the instance of a certain priest, who enjoyed a rich living, and had been an old and constant sufferer from gout, but, happening to be taken by the pirates of Barbary, he was kept constantly at work in the galleys for two years ; " which had this good effect, that afterward, when he was ransomed from captivity, having lost all his troublesome and monstrous fatness, he never once had a fit, though he lived several years after the event." Various similar exam- ples are related by Schenckius.—(Obs. Med. Rarior., lib. v., p. 659, ed. 1644.) In a word, as Dr. Bateman remarks, much exercise, which will often counteract the influence of intemper- ance, will, when combined with temperance, counteract even the hereditary disposition to the disease. Women are not very liable to gout, probably from their more regular and abstemious mode of living; but those females whom it attacks are generally of robust and full habits. It is said to be very rare before the cessation of men- struation, which, as Dr. Bateman thinks, only implies, that it is generally a disease of advanced life. For Dr. Cullen [First Lines, &c, §494) has observed, that robust females are often at- tacked before the menses have ceased ; and he knew of cases where it occurred in females whose courses were more abundant than usual.*] The podagric diathesis must be distinguished from the paroxysms to which it gives rise, and which constitute the only manifest indications of its existence. The paroxysms of gout are excited by certain occasional causes, some of which are obvious, and some doubtful, or altogether unknown ; but, without the co-operation of these, the gouty dia- thesis may remain unnoticed, or quiescent in the body for years, or, perhaps, through the whole term of a man's life. And hence we often see an individual, whose ancestors have been noto- rious for this complaint, pass the whole of his days without betraying any marks of it, while it * Bateman, in Rees's Cyclopaedia, art. Gout. For this relative immunity of females from gout, they seem indebted to their greater temperance, and also to the facilities which the female consti- tution possesses of throwing off redundances by natural outlets. Dr. Gregory observed in his prac- tice, that such women as suffered from gout had antecedently been subject to profuse hemorrhages, and were generally plethoric through indolence and high feeding.—Ed. Gen. XII.—Spe. 3.] ARTHROSIA PODAGRA. 577 appears in one or more of his children, perhaps in their yery boyhood. The occasional causes are numerous; for, where the diathesis exists strongly, almost any thing that is capable of producing a general dis- turbance in the system, or of throwing it off the balance of ordinary health, is sufficient to be- come a cause ; and this, whether the incitement be of an entonic or an atonic character. And hence, paroxysms in different individuals are often produced by intoxication, or excess of eating; violent emotions of the mind, particu- larly the depressing passions, as grief and ter- ror ; sudden exposure to cold when the skin is in a state of perspiration; wet applied to the feet; great labour of the body ; severe applica- tion of the mind, especially when protracted, so as to break in upon a due allowance of sleep: cold, flatulent fruits, and often acidulous liquors ; a sudden change from a spare to a full, or from a full to a spare diet; excessive evacuations of any kind ; and, occasionally, a sudden cessation of such as are habitual.* The more violent the attack of a paroxysm, and the longer its continuance, the more the diathesis is confirmed, and the oftener the at- tack is renewed. On which account, it is of great importance to alleviate and abridge the paroxysms as much as possible, and especially when they are as yet new to the system. Whether particular climates or countries are more disposed to favour the existence of gout than others, separate from the occasional causes just adverted to, may be doubted.! Such an opinion, however, has prevailed among the vul- gar, as well as among many of the more learned in most ages. Thus, among the Greeks, it was a popular belief, that Attica was the hotbed of gout, as Achaia was of ophthalmia : whence Lucretius, " Atthide tentantur gressus, oculeique in Achaeis finibus."! Gout clogs the feet in Attica, the sight Fails in Achaia. And thus, too, in more recent times, we are told that China (Le Conte, Nouvelles Mimoires sur I'Etat present de la Chine, Paris, 1696), and even some of the German provinces, are ex- empt from the attack of gout, while, in our own country, it exercises an almost irresistible sway. The last assertion is true enough ; but we are not driven to the variable nature of our climate to account for the fact. Thus far we can proceed safely, respecting * The doctrine that lowering the diet, or that a change from a full to a spare diet, will excite gout, is one that the editor has never seen a confirma- tion of; and if it were true, he thinks that the well- fed gouty priest, taken by the Barbary pirates, and made to work in the galleys, as mentioned by Van Swieten, ought, at all events, not to have been cured by low living and hard labour. In Scotland there is an old saying, that any man may free him- self from gout by working for, and living on, six- pence a day.—Ed. ! Gout is by no means common in very hot cli- mates ; and the summer in this country materially diminishes the number of cases.—Ed. X De Rer. Nat, vi., 1117. Vol I.—0 0 the general pathology of this Proteus disease. But the moment we enter upon the field of its proximate cause, we are bewildered in a hope- less labyrinth, without a thread to guide our en- tangled footsteps amid the growing darkness. There has, indeed, been no want of attempts to explain the subject; but thus far, they have been attempts alone ; ingenious conjectures, rather than enucleated facts. Thus some, among whom was the learned Boerhaave, resolved the proxi- mate cause of gout into a morbid texture of the nerves and capillaries ; and others, into a pecu- liar acrimony of the fluids ; respecting the na- ture of which, however, those who adopted this view were never able to agree ; several of them, like Hoffmann, affirming it to be a tartaric salt, several a bilious salt, several again an acid, and several again an alkali. This morbid material, in whatever it consists, was supposed to be separated from the system, and thrown off' during the continuance of the paroxysm, which, consequently, it became the duty of the physician to encourage. And by some pathologists it was held, that the morbid matter thus despumated has, in various instances, proved contagious, and this not to man only, but to other animals as well: thus M. Pietsch in- forms us, that he has known dogs affected with the same disease by licking the ulcers^ that have followed upon a fit of gout, accompanied with what he erroneously calls chalk-stones. Dr. Cullen has taken great pains, in a series of nine consecutive arguments, to prove the error or absurdity of most of these opinions : and then he proceeds to establish his own; which consists in regarding the proximate cause of a gouty diathesis as dependant upon a certain vigorous and plethoric state of the system ; and the proximate cause of a gouty paroxysm as produced by an occasional loss of tone in the extremities, often communicated to the whole system, but especially to the stomach, succeeded by a powerful reaction in the same quarter, which constitutes the pain and inflammation, and is an effort of the vis medicatrix naturae to restore the tone thus injured.—(Pract. of Phys., part i., b. ii., chap, xiv., dxxxiii.) But, by this hypothesis, we gain as little as by any of the preceding. It is obviously a mere extension of the Cullenian doctrine of. fever to the disease before us, and is chargeable with the same in- congruity : for here, as in fever, the stage of strength or increased energy is made to depend upon the stage of weakness; as the weakness or loss of tone is made dependant upon a pecu- liar vigour and plethoric state of the system. There is, indeed, no great difficulty in conceiv- ing how loss of tone may follow excess of en- ergy ; but by what means recovered energy is to be a result of loss of tone, is a problem of more laborious solution. One of the marks by which a regular par- oxysm of gout is said to be distinguished from that of rheumatism, is the suddenness of its onset. This is true, as Sydenham Has correctly observed, with regard to the general course of regular gout, in which the constitution is in other respects perfectly sound. But in other cases 578 H^EMATICA. [Cl. III.—Ord. II. the fit is often preceded by certain prodromi, which those who have suffered from it before very sufficiently understand, and uniformly take as a warning ; such as a coldness or numbness of the lower limbs, alternating with a sense of pricking or formication along their entire length ; fre- quent cramps of the muscles of the legs ; a crassament in the urine (Butler, Nadcre out dekkingc der menschelyke Wafers, Harlem, 1697); slight shiverings over the surface ; lan- guor and flatulence of the stomach ; and some- times a pain over the eyelids, or in some other organ.—(Eph. Nat. Cur. Dec, i., ann. iii., obs. 252.) The paroxysm is said by Dr. Sydenham, who has drawn its picture to the life, to show itself most commonly in January or February ; but I have known it occur so often towards the close of the summer, and in the autumn, and have * attended so many patients who have never had it except in the latter seasons, that the rule does not seem to be in any way very well estab- lished. The first attack is usually in one of the feet, most commonly about the ball or first joint of the great toe ; it commences at night, or du- ring the night, and there is sometimes, though not always, a slight horror, succeeded by a hot stage. The local pain and swelling increase in violence, the joint assumes a fiery redness, and the whole body is in a state of great restless- ness. The symptoms remit sometimes towards the next morning, yet occasionally not till the morning, after; but they still return during the night, though in a more tolerable degree, for three or four days, or even a week: when the inflammation subsides, as by resolution; the foot almost instantly recovers its vigour, as though nothing had been the matter with it ; and if the patient have been antecedently indis- posed, he enjoys, as on recovering from an ague, an alacrity of body and mind beyond what he has experienced for a long time before ; the constitutional indisposition disappearing with the paroxysm At the commencement of the disease the return of it may be annual, or not oftener than once in three or four years ; but it is perpet- ually encroaching on the constitution, so that the intervals gradually become shorter, and the attacks more frequent and of longer contin- uance : whence, as Dr. Cullen has justly ob- served, " in an advanced state of the disease, the patient is hardly ever tolerably free from it, except perhaps for two or three months in the summer." Nothing can be more specific, more true to itself, or more distinct from every other kind of inflammation, than that of the disease before us, when thus exhibited in a regular fit; the inflammation of erythema does not differ more from that of phlegmon than both these, and, in- deed, every other, from that of gout: it never suppurates, never ulcerates when simple and genuine, however violent may be the attack, and though, to the eye of inexperience, the skin may seem to be on the point of bursting ; while, in the midst of the severest pain, there is a sense of numbness, weight, and want of energy ;; insomuch that, if the pain could for a moment be forgotten, the limb would feel paralytic-; and, though the muscles which move the limb be not affected, they raise it or drag it along like a dead load. If the inflammation run through its course where it first fixes, it subsides by a resolution that leaves no external discoloration, or inter- nal weakness or disability ; and if it make a transfer from one extremity to another, it passes with inconceivable rapidity ; the limb now af- fected being loaded with all the vehemence of the inflammatory action, and that lately the seat of pain being all of a sudden restored to perfect soundness. It is rarely, however, that any metastasis takes place on its first appearance in a healthy constitution ; nor indeed till after various or- gans, or the entire habit, have been weakened by repeated assaults. We have already ob- served, that it is the nature of the disease to weaken the habit in this manner till the system is completely broken down. In this case, the paroxysms, though much longer and more fre- quent, are less violent and painful than at first; but there is no joint exempt from its incursion, nor perhaps an internal organ that does not suffer from induced weakness : so that, in the language of Sydenham, " the patient exists only to be wretched and miserable, and not at all to taste of the happiness of life." [In the inveterate and protracted form of the disease, the joints remain not only weak and stiff after the termination of the fit, but they become at length so contracted and disabled, that, although the patient can stand, and per- haps walk a little, yet it is very slowly, and with great lameness and difficulty. In many persons, though not in all, this immobility of the joints is further increased by the formation of concre- tions of a chalky appearance on the outside of them, and for the most part immediately under the skin. The secretion or deposition of this matter is characteristic of the disease, being the consequence of gouty inflammation alone. It seems to be deposited at first in a fluid form, but afterward becomes dry and firm ; in which state the concretions have the appearance of a friable earthy substance, and have been erro- neously called chalk-stones. By the investiga- tions of Dr. Wollaston, however, it has been ascertained, that they contain no calcareous or earthy matter ; but consist of lithic or uric acid combined with soda, forming what the chymists term the lithate or urate of soda. These con- cretions occur principally about the joints of the toes and fingers, in little nodules, which Syden- ham compares to crabs' eyes; but sometimes they appear about the larger joints, where they occasion a whitish swelling almost as large as an egg, which becomes gradually inflamed and red. There is an instance of a very large con- cretion of this nature, recorded in the surgical works of Sir E. Home. But perhaps the most curious case is that related by Mr. Watson : the patient, who was a martyr to gout, had so extensive a deposition of urate of soda, that the concretions not only enveloped the joints of his great toes, formed tumours on his legs, and Gen. Xll.—Spe. 3.] ARTHROSIA PODAGRA. 579 rendered the synovia of the large joints as thick as cream, but "the joints of the finger3 were swelled and knotty, every knot being a lump of chalk ; and I was told (says Mr. Watson) that, when he played at cards, he used frequently to score up the game with his knuckles."* It is singular that our authort with his very exten- sive information on all subjects connected with medical science, should have fallen into the error of describing gout-concretions as really- composed of lime.] It seems probable, that urate of soda has sometimes been thrown off by the skin. I have seen, says Swediaur, an inveterate case, in which the patient, labouring under a paroxysm of several months' duration, had the entire sur- face of the body covered every morning with a white powder, as though he had been dusted •with flour.—(Nov. Nosol. Meth. Syst., i., p. 218.) Thus far we have -followed up the progress of, a regular attack of gout in a constitution otherwise healthy and vigorous. But the same diathesis exists in systems of delicate and in- firm health, and where there is a want of suffi- cient energy to work up a fit of inflammation, and throw it off at its appropriate outlets. And in such case, as soon as it becomes roused into action by any of the causes of excitement al- ready enumerated, it constitutes the second variety, assumes the guise of various other diseases, as dyspepsy, hysteria, hypochondrias, palpitations of the heart, vertigo, hemicrania, with several modifications of palsy or apoplexy. The stomach and bowels, however, form the chief seat of affection ; the appetite is fastidious or o'estroyed; a spasmodic stricture or painful oppression is felt in the epigastric region, or the stomach is distended almost to bursting with flatulence ; nausea, eructations, vomiting, and all the symptoms of indigestion follow, and are alternated with severe colic or costiveness. In the meanwhile, the disease shows itself, at times, in one or more of the joints, in slight and fugitive pains, as though making an inef- fectual effort to kindle up a paroxysm of proper inflammation, but which there is not energy enough in the system to accomplish; whence the articular pains cease almost as soon as they appear, and the visceral derangement is re- newed ; sometimes slowly subsiding after a continuance of several weeks, and sometimes wearing out the entire frame, and terminating in abdominal or cellular dropsy. It sometimes happens, however, that while the general constitution of a podagric patient is * See Medical Communications, vol. i., art. 3. Two or three years ago, the editor saw a lady in the Fleet Prison, not more than thirty years of age, and the mother of several children, who was in such a state from deposites of urate of soda around almost all her joints, that her limbs were ot little or no use to her. She had resided a con- siderable time in France; but had always been abstemious in her mode of living. When her knees were bent and extended, a rattling noise was produced, like what would arise from shaking a bag of marbles.—Ed. Oo2 tolerably sound, one or more of the internal organs form an exception to the general rule, and are less healthy than the rest. And as, upon an excitement of gouty inflammation in a gouty habit, the inflammation seizes ordinarily upon the weakest part of the body, it makes its assault upon such organ rather than upon the hands or the feet; or, if it commence in the latter, is readily transferred to it ; con- stituting the third of the varieties before us, and which has usually been called retro- grade or misplaced gout. And if the general system should at the same time be below the ordinary tone of health, when the paroxysm is thus excited by the force of some occasional cause, the organ affected may evince great lan- guor and painful inertness, as in the second va- riety, rather than acute inflammation, as in the first. The sensation in the stomach, instead of being that of a fiery coal, is that of a cold lump of lead ; in the head, it changes from madden- ing pain to oppressive horror, in which the pa- tient suddenly starts from sleep almost as soon as he has begun to doze, from the hideonsness of the ideas that rush across the mind and form the distracting dreams. The fit is sometimes transferred to the blad- der ; in which case, there is acute pain at the neck of the organ, strangury, and a discharge of thin acrid mucus from the urethra.* The rectum has also been occasionally the seat of metastasis, and has evinced various species of affection, as simple vehement pain, spastic con- striction, or hemorrhoidal tumours. When thrown upon the lungs, it mimics the symptoms of a peripneumony. [The following observations by Dr. Bateman appear valuable. Many errors have probably been committed, in considering almost every species of indisposition that occurs in gouty habits as arising from the gouty diathesis. We remember to have heard this point strenuously insisted upon by the able Professor of Physic in the University of Edinburgh, Dr. Gregory. Many of the symptoms above enumerated are obviously connected with the impaired functions of the stomach, and occur in dyspepsy or indi- gestion. Such are various hypochondriac sen- sations ; the palpitations of the heart, often proceeding from over-distention of the stomach with flatus, by which the heart is mechanically pressed upwards; cramps in different parts of the body, which are often relieved by a discharge of wind of the stomach : difficulty of breath- ing, often arising from the distention of the stomach, which impedes the descent of the diaphragm ; and the headache, giddiness, &c , which are daily observed to be connected with * "Not unfrequently there is a nephritic at- tack ; an attack of inflammation of the kidneys, and a deposition of lithic acid, or some compound of it. Occasionally these things take place with the gout; occasionally they take place only du- ring the intervals ; but a deposition in the urine, and a fit of gout, where there is deposite in the joints, are frequently very closely connected."— Professor Elliotson's Lectures, see Med. Gaz. for 1833, p. 822—Ed. 580 H^MATICA. [Cl. III.—Ord. II. impaired digestion. On the other hand, in- flammatory disorders of the lungs and other viscera, congestions in the head, inducing head- ache, somnolency, vertigo, &c, and ultimately various degrees of paralytic and apoplectic dis- ease, not essentially different, in any respect, from the same affections in habits free from a gouty diathesis, have probably been suffered to go on, and to prove fatal, under the notion that they were gouty, and the proper remedies have been therefore neglected.*] In applying the art of medicine to the cure or alleviation of gout, our attention must be directed to the state of the patient during the paroxysms, and during their intervals; and particularly to the state of his constitution or previous habits, which, according to their character, may demand a different and even an Opposite mode of man- agement. Let us commence with the paroxysmal treatment; and, first of all, with that of the inflammatory attack, as it shows itself in a reg- ular fit of the disease. It was formerly the belief, as we have already seen, that a gouty paroxysm was an effort of nature to throw off from the constitution, and thereby restore it to a state of perfect health, some peccant matter forming the proximate cause of the distemper; and it was hence also con- ceived in addition, to adopt the language of Sydenham, that the more vehement the fit, the sooner it would be over, and the longer and more perfect the intermission. And, in this view of the subject, there can be no question, that the wisest plan must have been that of leaving the paroxysm to run through its reg- ular course without interruption. Yet, as this hypothesis has long fallen into discredit, we are not in the present day prevented, on such ground, from endeavouring to subdue the inflam- mation of a gouty paroxysm by the ordinary means resorted to in inflammations of any other kind, as bleeding, purgatives, sudorifics, local astringents, and even refrigerants. But a very general objection has since been taken to this plan on another ground; and that is, the great danger of repelling the disease to some internal organ of more importance, and thus of convert- ing a regular paroxysm into a case of retro- grade or atonic gout. And, in consequence of this apprehension, the practice, even in the hands of many of our most celebrated physicians, has, * See Bateman in Rees's Cyclopaedia, art. Gout. In this view Dr. Barlow also concurs. " A paroxysm of gout," says he, " can be regarded only as a constitutional disturbance of an inflam- matory character, attended with local inflamma- tion of a peculiar kind, in one or more joints, running a determinate course, and, in the earlier accessions, terminating in health for the most part, within a very few days. Such being the character of simple gout, there is no reason why the complications so much dwelt on should be considered as specially belonging to it, or regarded otherwise than as accidents arising from pecu- liarity of constitution, contingent derangements of health, or the lesions or morbid tendencies en- tailed by preceding accessions."—See Cyclop, of Pract. Med., art. Gout.—Ed-. for a long period, been in the highest degree vague and vacillating. Sydenham prohibited equally purging and sweating of every kind, whether gentle or copious, and only allowed bleeding where the patient was young and vig- orous, and on the first or second paroxysm: while of cold applications he. takes no notice whatever. He admits, however, the use of laudanum where the pain is very acute : trusting chiefly for the cure of the disease to an alterant regimen and apozems to be resorted to in the intervals. Dr. Cullen allows bleeding with the same restriction as Sydenham, though he recommends the ap- plication of leeches to the inflamed part, as at all times a safer practice than the use of the lancet. Of cathartics and sudorifics he takes no notice, otherwise than as these may enter into the general course of antiphlogistic regi- men ; he is decidedly adverse to the use of cold ; and thinks that warm bathing and emollient poultices, blistering, burning with moxa, cam- phorated and aromatic oils, induce the inflam- mation to shift from one part to another, and consequently tend to repel the inflammation from the-extremities to some more important organ: while opium, though it affords relief in present paroxysms, occasions them to return with greater violence; and therefore he obsorves, by way of conclusion, " The common practice of committing the person to patience and flan- nel alone, is established on the best foundation." —(First Lines of the Practice of Physic, aph. DLXIX.) Now, as we have already seen that the gout, after it has shown itself in paroxysms, is never idle ; that one paroxysm, in the opinion of Syd- enham, Cullen, and every other physician, hast- ens on another, renders its intervals shorter,, and its durations longer; and progressively saps all the energies both of mind and body, and renders life itself a burden ; it is of serious importance to inquire, whether this fear of a repulsion, how- ever well founded in some instances, be not allowed too generally 1 whether it be not pos- sible to draw a definite line between the form of the disease in which it ought to operate, and that in which it ought not! and whether in the latter, case we may not derive all the benefit from a full use of a reducing process, which is obtained in other inflammations accompanied with a like degree of constitutional vigour 1 From the history of this disease, as it has already passed before us, we may draw this general corollary ; that the specific inflammation of gout, or whatever other morbid character it may evince, when once excited by some occa- sional cause into action, has a peculiar tendency to fix and expand itself upon the weakest parts of the system, and, where several parts are equally weak, to pass in sudden transitions from one part to another, though transitions are rare where the system is sound. In healthy constitutions, the weakest parts are the extremities ; and hence, in such consti- tutions, these are the parts, as we have already seen, in which the gout uniformly opens its as- sault. Here it commences, and here it runs through its course, seldom migrating, or, when Gen. XII.—Spe. 3.] ARTHROSIA PODAGRA. 581 it does migrate, only passing from one extremity | to another : as from foot to foot, or one of the feet to one of the hands ; and limiting itself to these quarters, because they are the weakest parts of the system. In unhealthy habits, however, the extremi- ties are not the weakest parts of the system, but perhaps the stomach, or the heart, or the head, or the lungs, or some other organ ; while sev- eral of these organs may, moreover, be equally debilitated, according to the idiosyncrasy, or to accidental circumstances. And, true to the general rule, we see the gouty principle, when roused into action in habits of this kind, fixing itself from the first on one of those important viscera, rather than on the extremities; or roaming from one to another, on its alternating its course from these organs to the extremities, or from the ext«emities to these organs. And as metastases are rare where the system is sound, they become frequent in proportion as it loses this character, and especially in proportion to its debility in particular parts. These are rules which we cannot too closely study and commit to memory, and they seem to point out to us the line of distinction between that form of the disease in which we ought to entertain a prudent fear of revulsion, and that in which we may safely act without any such fear whatever. They directly lead us to two states of constitution that require a very different, and in many instances a very opposite mode of treatment; and seem to settle the important question before us, under what circumstances it may be expedient to employ a palliative plan, and under what a cooling and reductive 1 Let us commence with the first of these two states, forming a regular but violent fit of gout, as it shows itself in a sound constitution, and inflicts its torture on the hand or the foot. Guiding ourselves by the laws just laid down, there seems no reason why, instead of " com- mitting the person to patience and flannel alone," we should not pursue the evacuating and refri- gerant means employed in entonic inflammations of any other kind, and have cause to expect a like success ; such as bleeding, so strongly rec- ommended by Dr. Heberden, and allowed oc- casionally by Sydenham, and emptying the bow- els, relaxing the skin generally, and cooling the fiery heat of the affected limb by cold water or any other frigorific application.* With a trans- fer of morbific matter we have now no longer to contend. Yet, even where such a cause is ad- mitted, as in most exanthems, the plan thus proposed is, in many instances, pursued without hesitation. Thus, in measles, cathartics and * " In simple gout, we know of no good reason why the treatment applicable to the same degree of general fever and local inflammation, occurring from other causes, should not be employed : its general safety and efficacy we can faithfully attest, nor are we aware of any peculiar caution being required beyond what the accompanying state of the constitution and the attending symptoms must necessarily suggest. In all diseases, however in- flammatory, the state of the constitution requires to be taken into account in judging of the activity | venesection are not only in general use, but often indispensable ; in the height of malignant scarlet fever, we sponge or wash the entire sur- face of the body with cold water ; and in small- pox, not only purge freely, but expose the pa- tient to the coldest atmosphere of the winter season. In weakly habits or idiosyncrasies, or inci- dental debilities of particular organs, we have admitted that a metastasis, as we have already seen, is a frequent result, and peculiarly marks the character of gouty inflammation ; and here, indeed, refrigerants, violent purgatives, and ven- esection ought to be most sedulously abstained from ; and not unfrequently, the best practice we can adopt is that of " committing the person to patience and flannel alone." But what I am anxious to establish is, that, agreeably to the laws which regulate the progress of gout, a metastasis in sound and vigorous constitutions is rarely to be expected, and perhaps never takes place except from one extremity to another. In order that some internal organ may become the seat of transferred gout, it is necessary that it should possess a weaker action than the part from which the inflammation is to be transferred : but the parts of weakest action in a sound and vigorous constitution are the extremities them- selves ; and it is probably because the living en- ergy is, in all the extremities, upon a balance, that in a sound frame a metastasis, even from one extremity to another, is a rare occurrence. [In the foregoing argument, the doctrine that the weakness or weak action of any part is what disposes it to be affected by a metastasis of gout, is only asserted, and by no means proved. The abundance of fibrous and ligamentous structures about the foot and hand may seem to many pathologists a better reason for these parts be- ing so disposed to gouty inflammation, than the hypothesis of weakness.] As far as I have seen, the inflammation of a regular fit of gout subsides gradually, though rapidly, under the treatment now proposed, without any repulsion whatever. In a few in- stances, during the use of a cold pediluvium, or shortly afterward, I have known patients speak of a peculiar kind of aura creeping over them and through them, and exciting an undefinable sense of glowing, which has lasted for a few minutes, without any inconvenience at the time, or even any change in the pulse ; and certainly without any ill effect afterward. But, it may be replied, there is no resisting facts. The cases are innumerable in which great mischief has resulted from the depleting and the refrigerant plan ; and, as we cannot of practice that may be safely ventured on; and the same consideration is needed in gout; but, assuredly, none is due in this respect to the im- puted essence of gout, nor to the apprehension of interfering with it, whichhas been too long suffer- ed to paralyze the efforts of the practitioner."— Dr. Barlow in Cyclop, of Pract Med., art. Gout. These sentiments should never be forgotten with reference to the treatment of gout; and they seem to the editor to be supported both by reason and experience.—Ed. 582 HjEMATICA. [Cl. III.-Ord. II. always tell that all the internal organs are or are not in a state of sound health, it is most prudent to abstain from a practice which may prove highly injurious in case of a mistake. The answer to this remark is, that here, as well as in every other disease, professional judgment is to be called into exercise, and the practitioner is to draw largely upon that skill and discrimination which it was the object of his education to bestow upon him: and thus be- stirring himself, he will rarely fall into an error. That mischief has resulted, and frequently, from the use of the plan before us, cannot be denied by any one ; but that great and essential good, and an easy and-rapid cure, have been also in hundreds of instances effected, must be-admitted as readily.- No clear distinctive line, however, has hitherto, so far as I am acquainted with, been acted upon, or even laid down ; and hence it is rather to be ascribed to a want of discrim- ination upon this subject.that the evils adverted to are chargeable, than to any mischief in the plan itself. Yet it may be doubted whether the injury produced, even by an injudicious use of evacuants and refrigerants, amounts to a thou- sandth part of that entailed on the constitution by allowing the gout to make its inroads tacitly and unresisted ; till by degrees it triumphs equally over all the powers, as well of the body as of the mind, and, in the forcible language of Syd- enham, " The miserable wretch is at length so happy as to die."* Of the benefit produced by the external use of cold water, the author can speak from a trial of several years formerly upon his own person, and is only anxious that others should partici- pate in what has proved so decisive a comfort to himself. It is his duty to state, however, that, apparently owing to too much exertion of mind in the composition of this work, the gout has since appeared, accompanied with a more irritable state of the general frame than had hitherto been manifested. On this last occa- * " If the character of gout, in its simplest form and highest intensity," as Dr. Barlow remarks, " be unequivocally inflammatory, it is difficult to con- ceive why its various shades and modifications should be otherwise regarded. The. differences are not greater than are continually met with in several other diseases ; nor, when they do occur, is there any difficulty in referring the peculiarities to the particular constitution, the effects of previ- ous disease, and other contingent circumstances, amply sufficient to account for them. These cir- cumstances may, and in numberless instances do, require that the appropriate remedies of inflam- mation should be applied with caution, but they can by no means warrant the principles of treat- ment founded on the inflammatory nature of gout being wholly reversed, as is too often witnessed. There has been too much disposition, arising from timidity, ignorance, and false theory, to transfer to simple active gout the cautions and the apprehen- sion of interference, which the contemplation of the complex and less active modifications has given rise to." In the correctness of these obser- vations the editor fully concurs : the principles here inculcated ought to have their proper weight in the practice of every man who wishes to treat this disease with success.—Ed. sion, therefore, he did not venture upon the cold bath, but confined himself chiefly to the wine of colchicum, with very frequently a full dose of magnesia ; and, by this simple plan alone, he has again been able to obtain a restoration of heaith, and the full enjoyment of foot-exercise. Yet the bolder practice before us is by no means of modern invention, however it may have become a subject of warm controversy in the present day. An active evacuant plan, both by venesection and purging, has never ceased to be in use among many practitioners, and is particularly alluded to by Sydenham, though with a view of entering his protest .against it, as injurious to a free discharge of the peccant matter, which, in his opinion, required to be carried off; while, with respect to the external use of «old water, not to mention that it seems to be alluded to by several of tj|e Greek writers, and especially by Hippocrates (Aphor., sect. v., p. 25), it has descended in a stream of rec- ommendations from Zacutus Lusitanus (De Medicorum Princip. Hislorid, lib. iii., Amsterd., 1641), in 1641, to Kolhaas (Bahlmge.r, Neue.r. Mag., band, v., p. 521, 1788), and Keck (Ab- handlungen und Bcobachlungen, Berl., 1789), in 1788 and 1789. Bartholin speaks of the use of snow as a common application in 1681 (De Usu Nivis medico, 1661, 8vo.), and Pechlin both of snow and cold sea-water towards the close of the same century.—(Observ. Physico- Med., Hamb.. 1691, 4to.) But this treatment, I am ready to admit, has often been employed rashly, and sometimes with great and even fatal mischief. It ought never to be ventured upon except, as already stated, where the constitution is decidedly sound and vigorous ; for, though I subscribe to much of Dr. Kinglake's therapeutic plan, I cannot agree with him that a gouty paroxysm is a mere- ly local affection. The treatment before us should be limited to those who are in full vigour, and perhaps entony of health ; and is especially to be avoided where the stomach is dyspeptic, the lungs asthmatic, the heart subject to palpi- tation, the head to nervous pains or drowsiness ; or where there is any known disability in any other important organ.* Yet even here we need not, I think, con- demn the sufferer to the torture till cured by patience and flannel; for it will often be in our power at least to palliate his pain, and not un- frequently to expedite his cure, without any risk whatever of affecting his general state of health. Leeches may, in many instances, be applied where venesection would be of doubtful expediency ; a liniment of oil of almonds, im- pregnated with opium, rubbed on the tumefac- tion with a protracted and very gentle friction, I have often found highly serviceable in miti- gating the pain ; and epithems of tepid water, * Though Dr. Elliotson approves of the use of a spirituous tepid lotion, he thinks that no medical practitioner is justified in recommending cold ap- plications, as they may bring on apoplexy, violent gastrodynia, or an affection of the heart, and the speedy death of the patient.—See Lectures in Med. Gaz. for 1833, p. 851. Gen. XII.—Spe. 3.] ARTHROSIA PODAGRA. 583 as recommended by Dr. Scudamore, alone or mixed with a portion of ether or alcohol, formed by cloths wetted with the fluid, and applied to the inflamed part, renewable as they become dry, in many cases prove a grateful substitute for cold water; and are preferable to poultices, warm water, or even vapour-baths, which too generally relax and weaken the joint, and pre- vent it from recovering its elasticity, after the paroxysm is over, so soon as it otherwise would do. At the same time, the body should be cooled with gentle aperients or injections ; and, while drenching sweats are avoided, which never fail to be injurious, the breathing moisture or diap- noe should be imitated, which often breaks forth naturally in an early part of the morning, and is sure to afford relief after a night of distraction. Nor should opium be omitted where the pain is very acute ; for, while it affords temporary ease, it diminishes the duration as well as the vio- lence of the paroxysm. Dr. Cullen, in his Practice of Physic, seems disposed to postpone the use of this medicine till the paroxysms have abated in their violence ; for, when given in the beginning of gouty paroxysms, he asserts that it occasions the fits to return with addi- tional fury. Yet, it should never be forgotten, that it is a law in the history of gout, and one to which we have already adverted, that the frequency and vehemence of the ensuing par- oxysms are measured by the violence of those that have preceded. In the meantime, the regimen should be light and unirritant, and the diet below the standard to which the patient has been accus- tomed ; though, to guard against a metastasis to the stomach, we must be cautious that we do not reduce it too much. His beverage should be cool and unsumulant; Sydenham allows him sound table beer, and, if he have been accus- tomed to stronger malt liquors, such a drink may be conceded to him. His chamber should be well ventilated, and his dress light and easy. In the two ensuing varieties, constituting atonic and retrocedent gout, we have apodagric diathesis grafted upon an unsound frame; the unsoundness being general or local: and, how- ever fearless we may be of the disease fixing on any internal organ in the preceding variety, we have here a constant apprehension that it may do so, and, in many cases, see it commence in such organs. In atonic gout, our uniform attempt should be to produce a transfer from the part on which it has seized, and fix it in the extremities : in retrocedent gout, on the contrary, to render the vacillating attack on the extremities more per- manent, and prevent it from shifting to any other quarter. To obtain the first intention, we have to strengthen, and even stimulate the system gen- erally, by warm tonics and a generous diet, and,' above all things, to take off the severe suffering in whatever it may consist, from the affected'organ ; for the longer the fit continues there, the weaker the organ will become, and the less capable of any instinctive remedial ex- ertion. At the same time, we may solicit the paroxysm to the extremities by putting the feet into warm water. In atonic gout, the sufferings, though widely different, according to the seat of the disease, are almost insupportable. In the head the pain is maddening, or the disorder is accompanied with great horror, or mimics the stupor of an apoplexy : in the stomach there is a faintness like that of death, with the sense of a cold lump of lead lodged within it; or there is a gnawing or a burning agony, or a spasmodic stricture which cuts the body in two, and renders breath- ing almost impossible ; often also accompanied with a rapid and sinking palpitation of the heart. It is of importance, before we proceed, to determine accurately that these anomalous symptoms are really those of gout; of which we have chiefly to judge from the general char- acter of the patient's constitution, his hereditary predisposition, habits of life, and the ailments to which he has been previously subject In most cases during the paroxysm, and especially where the stomach is affected, the warmest cordials are necessary, as brandy, the aromatic spirit of ammonia, the tincture of ginger or of capsicum, or, what is still better, usquebaugh. And it is always advantageous, and especially where the bowels are confined, to add to it some warm aperient, as aloes or rhubarb. Most of our family gout-cordials are made upon this principle, and judiciously consist of some active aperient, and the hottest aromatics dissolved in ardent spirits. And the patient who is subject to these attacks, should never be without hav- ing something of this kind at hand, since the paroxysm often makes its onset without any warning. Yet he should resolutely forbear having any recourse to any such medicine, ex- cept in the time of necessity ; for an habitual indulgence in any of them will still farther de- bilitate the affected organ, and indeed the entire system ; and hence quicken the returns of the paroxysm, and render the stimulant antidote less ayailing. The best aperient, and at the same time stimulant medicine that I know of for this purpose, is the essential oil of turpen- tine ; which, as uniting the powers of an active cathartic and a camphorate cordial, gives us all the qualities we are looking for. I do not know that this valuable medicine has ever yet been brought into general practice in any form of gout; but I may venture to predict, that those who try it, in the modification before us, will seldom have to repent of their experiment. The dose should be about six drachms, swal- lowed unmixed. Most of the preparations of ether contained in the current Pharmacopoeia of the London College, may be employed with benefit in the variety before us, and particularly in that icy coldness of the stomach, accompanied with a numbness of the limbs and a rapid palpitation of the heart, under which it occasionally exhibits itself. Phosphorus itself has sometimes been ventured upon in this case, in the proportion of two or three grains to a dose, dissolved in double 584 H^MATICA. [Cl. HI.-Ord. If. the proportion of ether ; but I have never em- ployed it, and cannot speak of its good effects. Musk seems, in many instances, to have been of decided advantage, if given in sufficient doses, as well in gouty affections of the head as of the stomach. The case related by Mr. James Pringle is strikingly in its favour (Phys. and Lit. Essays, vol. ii., art. xii.), and seems to have induced Dr. Cullen to make trial of it in similar instances, who found it produce sudden relief, by free doses repeated after short inter- vals ; and this where the lungs, as well as the head and stomach, were the seat of transferred disease.—(Mat. Med., part ii., ch. viii.) External irritants may also be beneficially employed at the same time, and particularly those of rapid action, as the compound cam- phire liniment, sinapisms, and the burning of moxa, or coarse flax, as recommended by Hip- pocrates : at the same time the extremities, as already advised, should be plunged in the warm bath. But our sheet-anchor is opium ; and it should be given freely, and in union with some prepar- ation of antimony, so as to act towards the surface generally, and thus restore to the living power its interrupted equilibrium. Small doses of opium will here be of no avail; and we may generally repeat or increase the quantity to a large amount with perfect safety. " In a case of the gout in the stomach," says Dr. Cullen, " I have by degrees gone on to the dose of ten grains twice a day ; and, when the disease was overcome, the dose of opium was gradually di- minished, till, in the course of two or three weeks, it was none at all: and in all this no harm appeared to be done to the system. We frequently find that when a strong irritation is to be overcome, very large doses may be given without procuring^sleep, or showing any of those deleterious effects that, in other cases, appear from much smaller quantities. All this appears from the practice now well known in tetanus, mania, smallpox, gout, and syphilis."—(Id., part ii., ch. vi.) In retrocedent gout, the same plan is to be pursued where the attack has actually shifted from the feet or hands to some internal organ. But where it still lingers in the extremities, though with slight pain and inflammation, and frequent cessations, as though it were on the point of removal, we should increase the morbid action by local irritants applied to the joint, as camphire, ammonia, blisters, sinapisms, or the moxa; and at the same time prescribe a light, but generous diet, with rather more wine than the patient is in the usual habit of taking ; carefully avoiding all violent cathartics, and keeping the bowels moderately open with rhu- barb, aloes, or the compound colocynth pill. In gout, however, the intervals of the dis- ease are of as much importance to be attended to as its paroxysms : and here, also, the mode of management under the first form should dif- fer essentially from that under the second : for, though the occasional causes may in many cases be the same, they have in the former to operate upon a vigorous, perhaps upon an entonic scale of power, and in the latter upon a scale deci- dedly reduced and atonic. In every variety, all known occasional causes must be equally avoided. Where the diet has been too rich it must be lowered, and where too spare and abstemious, made more liberal. In- dolence and a sedentary life must give way to regular exercise ; and over-exertion of body or mind, to repose and quiet. In the young, robust, and corpulent, whether the disease result from too great indulgence at the table, or an habitual taint, it may be requisite to abstain from animal food, wines, and fermented liquors, altogether ; but where the sufferer has passed considerably beyond the zenith of life, and the luxuries of the table have become habitual, his ordinary fare should be reduced or diminished, rather than entirely commuted. And, in every change, it is better to proceed slowly, than to rush rap- idly from one extreme to another : since nothing has so great a tendency to prepare the internal organs for gouty paroxysms, as such sudden and violent transitions. The bowels should be kept in regular order, and the hour of rest be early. A due and unswerving attention to these general rules of the hygiene will often be suf- ficient to keep those free from all disturbance of the gout for many years, and perhaps for the whole of their subsequent life, who have only known it in the form of a few regular parox- ysms. But where the system, and especially the digestive function, are weak, and the patient has had anticipations of atonic or recedent gout, or has actually suffered from its assaults, it will be necessary to superadd a course of invigora- ting medicines. There are three classes of remedies that gen- erally pass under this name ; stimulants, bitters, and astringents. The first increase the action, the two last augment the tone. Stimulants can rarely be employed alone, except in cases of emergency ; for a lax state of fibres will bear little increase of action, without, at the same time, suffering an equal increase of debility. But they may often, and in the case of gout perhaps always, be combined with astringents and bitters with great and decisive benefit. Upon this subject, however, I have already treated so largely under limosis dyspepsia, oi indigestion, that it is only necessary to refer the reader to that part of the work for the pres- ent purpose. Most of the celebrated specifics for preventing a return of gout have been formed of these classes of medicines in combination, and espe- cially of bitters and aromatics ; and it is sin- gular that, although the variety of them which nature offers to us is almost infinite, they have been employed with little change from the time of Galen and Ccelius Aurelianus in the second century, to that of Sydenham in the seven- teenth. The famous powder purchased by the second Duke of Portland, who distributed its re- ceipt for general use, from the service it ap- peared to have rendered him, is formed for the most part of the very same ingredients, mod- ified either from the Greek writers, Ccelius Au- relianus and ^Etius, or from Dr. Sydenham's Gen. XII.—Spe. 3.] ARTHROSIA PODAGRA. 585 prescription ; though it is a simplification of the latter, by omitting severalof the articles that enter into his composition, one or two of which had better be retained. In this reduced form, it con- sists of equal parts of the five following mate- rials, finely powdered and intimately commixed : birth-wort, gentian, germander, ground-pine, and the tops and leaves of the lesser centaury. The dose is a drachm taken fasting every morn- ing for three months ; after which it is to be reduced to three quarters of a drachm for three' months longer ; then to half a drachm for the remainder of the year ; and, after this, the same dose is to be continued every other morning only, through the next twelve months : by which time it is presumed that a cure will be accom- plished. The real effect of this and similar medicines is very doubtful, and the doubt arises from the gradual mischief which a gouty diathesis has a tendency to produce in the corporeal system; and the benefit which the exact and abstemious regimen that is prescribed during the use ofthe Portland or any other course of bitter tonics, is calculated to afford of its own accord. In some instances, such medicines seem to have pro- duced little or no effect of any kind: in others, the joint result of remedy and regimen seems to have been highly salutary; while, in others again, the patients, though free from open and decided fits of the gout, appear to have sunk gradually under complaints more distressing and fatal than the gout itself, as dyspepsy, fewness of spirits, and dropsies of almost every part, es- pecially hydrothorax, ascites, and anasarca. Now, it is possible that the regimen alone may have produced the good where good has been experienced, and the gouty diathesis the evil, where evil has followed ; or that the bitter tonics themselves may have done both, accord- ing as the individual to whom they have been administered has been in a proper or improper state of body for a trial of them. They are not to be used indiscriminately; for, while the re- laxed and debilitated, those who are subject to atonic and retrocedent gout, may have recourse to them with great advantage, they will be sure to prove injurious to those of high entonic health, and who are distinguished by attacks of gout in regular but vehement paroxysms. Some bitters, even among those in common use, may possess more of the sedative and nar- cotic principle than others ; and, where this is the case, though such may be fittest for em- ployment in the first instance, they ought to be dropped for others of a different kind, as orange- peel, bark, columbo, and serpentaria, as soon as all local irritation has ceased. The strongest bitter we are acquainted with is the nux vomica, and the narcotic quality of this is known to every one. Opium possesses it in a still higher decree. It has of late been suspected to exist in wormwood, and been distinctly traced in the hop and some of the lettuce tribe. Dr. Cullen, however, has taken a different view of this subject. He supposes all bitters to possess a deleterious quality of some kind or other, and that, in all gouty persons, they have a power of warding off fits of this disease ; but that, from this deleterious property, when long persevered in, they weaken the stomach and other organs of digestion to which they at first gave tone, and thus ultimately induce the dis- eases we have just noticed, and which are too apt to follow upon a debility of these viscera. And, in proof of this opinion, he tells us of the fate of nine or ten persons who had been liable for some years before to have " a fit of a reg- ular or very painful inflammatory gout, once, at least, and frequently twice, in the course of a year ; but who, after they had taken the Port- land powder for some time, were quite free from any fit of inflammatory gout," and, having completed the course prescribed, " had never a regular fit, nor any inflammation of the extrem- ities, for the rest of their life. In no instance, however," continues Dr. Cullen, " that I have known, was the health of these persons tolerably entire. Soon after finishing the course of their medicine, they became valetudinary in different shapes, and particularly were much affected with dyspeptic, and what are called nervous complaints, with fewness of spirits. In every one of them, before a year had passed, after finishing the course of the powders, some hy- dropic symptoms appeared, which, gradually increasing in the form of an ascites or hydro- thorax, especially the latter joined with anasar- ca, in less than two, or at most three years, proved fatal."—(Mat. Med., part ii., ch. ii.) As Dr. Cullen gives us no account of any mischief that has followed the use of bitter ton- ics in constitutions marked by general debility and atonic gout, the evils he has described seem, on his own evidence, to be limited to those whom we have already cautioned against the employment of such a course. No proper classification or line of distinction seems to have been drawn or adhered to ; which would prob- ably have presented us with very different re- sults if it had been, and have superseded the clashing and unsatisfactory explanation of atonic effects uniformly produced by a continuance of tonic medicines. The subject, however, requires to be further examined by a more accurate classification of gouty patients who may be put under the in fluence of medicines of this kind ; and I throw out the hint for this purpose. Yet, that a per- severing course in bitter tonics does hot uni- formly prove in any way injurious to those who engage in it, is, I think, demonstrable from the daily use of table beer in almost every family throughout the country, and its appearing to be one of the wholesomest beverages we can adopt. Dr. Darwin, indeed, ventures to ascribe part of the mischief produced by highly-spirited malt liquors to some noxious quality in the hops they contain ; but the stronger and headier malt '•*#• liquors are uniformly prepared with a much smaller proportion of hops than the weaker, and especially than those which go under the name of table beer. For the only point aimed at by the employment of hops is to prevent an ace- tous fermentation, which is effectually guarded against by the larger proportion of spirit con- 586 HJEMATICA. [Cl. III.—Ord. IL tamed in ale and strong beer, but which every one knows would soon take place in table beer if it were not powerfully impregnated with this grateful bitter. And hence the remark of Dr. Darwin seems to have no foundation whatever, since the stronger bitter affords a beverage pro- verbially wholesome, while the weak bitter is that which proves injurious. There have also, in all ages, been offered to the public specifics for the sudden cure or re- moval ofthe paroxysm when present, as well as for preventing its return hereafter. Lucian, in his Tragopodagra, gives us, with great humour, a list that occupies a page, of such as were chiefly in vogue in his day ; and the catalogue is certainly not diminished in our own. Those that have acquired the highest reputation appear to have been composed of some species of helle- bore, or of meadow-saffion ; the first of which is among the remedies quoted by Lucian ; though it is probable that the pi'av 'EAAE'BOPOY ofthe Greeks was a different plant from either the white or black hellebore of modern dispensa- tories. The favourite specifics of the present day are M.-Husson's Eau medicinale, and the vinum colchici, or wine of meadow-saffion. The ex- act components of the former are kept a secret ; though its basis is well known to be either the one or the other of the above plants, most prob- ably the meadow-saffron. The effects of the Eau medicinale and of the colchicum wine do not essentially differ ; for, after taking about sixty drops of either, the pulse becomes slower, and at length sinks, in about twelve hours, from ten to twenty strokes in a minute below its natural number, at which time the inflammation subsides. The action of both medicines is ac- companied with great languor and a deadly nau- sea or sickness, which terminates in vomiting, or a discharge from the bowels, or both. If the dose be in a small degree in excess, the symp- toms are syncope, cold sweat, extreme pros- tration of strength, violent vomiting and purging, a wiry and almost imperceptible pulse, or a state of utter and very alarming insensibility. And, in some constitutions, these effects have fol- lowed from the use of even a common dose. Sir Everard Home made several trials of the colchicum wine on a dog, both by the stomach and by infusing it into his jugular vein. From thirty drops he recovered in about seven hours ; from sixty drops, in eleven ; but a hundred and sixty drops, thrown into the jugular vein, killed him, after having suffered great agony, in five hours. On opening him, the stomach, smaller intestines, and colon, were highly inflamed.— (Phil. Trans., 1816, art. xii., xiii.) And it is hence obvious that this medicine, like many other emetics and cathartics, acts rather upon the stomach through the medium of the circu- lation, than on the system through the medium of the stomach. It is possible that the colchi- cum may act by a specific power on the peculiar inflammation of a regular fit; yet, as other in- testinal irritants have occasionally produced a like effect, and particularly the graliola offici- nalis (hedge-hyssop), and ranunculus flammula, the disappearance of the paroxysm may also be ascribed to a transfer of action to the stomach and intestines. Generally speaking, specifics operate by a secret and inexplicable power, as the bark in intermittents, the vaccine virus in shielding the constitution against smallpox, and mercury in syphilis : for, though a ptyalism gives proof that the system is impregnated with the last, there are few practitioners so attached to the Cullenian doctrine in the present day, as to contend that the venereal virus is carried off by the salivation, since we are perpetually be- holding it carried off under the influence of mer- cury without any salivation whatever. Yet, admitting that the colchicum has a spe- cific power over a "regular inflammatory par- oxysm of gout, it is clear that it has no such power over the gouty diathesis, since the par- oxysm has never been so removed as not to re- turn again. And it hence becomes a serious question, whether the mischief produced in the constitution by the employment of so active a medicine, in the large doses recommended by some practitioners, be not greater than the tem- porary good obtained by the suppression of the inflammation 1 From the rapidity and force of the operation, it is clear that they ought never to be tried, or never without the utmost caution, except in the first variety of gout, or where the system is firm and healthy, and the disorder shows itself in a regular fit. And as it is highly desirable, for reasons already stated, to restrain the vio- lence of the paroxysm, shorten its duration, and carry it oft' as soon as possible, the use of the one or the other of these medicines may be ju- dicious, so long as the system is able to recover itself with speed from their influence, and pro- vided the patient limit himself to the smallest dose that will answer the purpose. Yet these medicines, from too little attention to their real effects, and from a mistaken idea that they are equally a specific for gout under every form, have not often been confined to the entonic variety, nor employed with sufficient dis- crimination in the second and third varieties of the disorder, in which the system, and par- ticularly the digestive organs, are in a state of chronic debility ; and the inflammatory fit, when it shows itself in the hands or feet, is in- complete and evanescent. In all such cases, such medicines, without the superintendence of much practical caution and judgment, can- not fail to do serious injury to the constitution. They have a tendency to increase the ventric- ular weakness, and hereby to leave the system more open to all the miseries which gout is so perpetually entailing. And hence the reason of the very general complaint among those who have tried these remedies, that, although they remove the fit at the time, they shorten the in- tervals, and render their frames more obnoxious to relapses. In my own person, I have never exceeded forty drops of the colchicum wine, prepared after the form of the Royal College ; and I have seldom failed to find this servicea- ble, though I cannot affirm that it has been uni formly so. Gen. XII.—Spe. 4] ARTHROSIA ] The remarks of Dr. Lucas upon this subject are well worthy of attention, and, as being of- fered since the first edition of the present work, may be quoted as confirming the author's views. Having contended for a specific principle in gout, which he thinks obvious from the peculiar acid smell of the perspiration, and the deposite of urate of soda concretions, he proceeds as follows :—" I am much strengthened in this opinion by the effects of the Eau medicinale and other gout medicines of the day in procu- ring summary relief in the first instance, at the expense of more frequent visits of the disorder, till at length it is constantly present, and in some form or other proves fatal. The inflam- mation here is probably cured before the mor- bid matter can be thrown off, which, therefore, shortly renews its attack, while the powers of the constitution generally give way under this unsuccessful conflict: for it does not appear how the cure of inflammation, abstractly con- sidered, can be too rapid, if effected with safety to the organization."—(On the Principles of In- flammation and Fever, 8vo., 1822.) It hence follows, as already observed, that our great ob- ject in the employment of' these medicines should be to moderate the inflammation, without trenching on the strength of the constitution.* Where the inflammation has subsided, and weakness alone remains, and an inability to use the limb without pain, I have at times found the support of a compressing bandage produce considerable comfort.t IYDARTHRUS. 587 SPECIES IV. ARTHROSIA HYDARTHRUS. WHITE SWELLING. COLOURLESS SWELLING, CHIEFLY OF THF. LARGER JOINTS : INFLAMMATION SLOW, AND DEEP- SEATED : PAIN FIXED AND SEVERE : IMPER- FECTLY SUPPURATIVE : PEVI-R A HECTIC. This inflammation, like that of rheumatism, attacks the larger, rather than the smaller ar- ticulations. Yet, as the joints are uniformly the seat of its assault, and it frequently runs through its course without the production of genuine pus, however severe its symptoms and fatal its termination, it has a manifest relation to the two preceding species, and ought to be arranged under the same genus. The ordinary occasional cause is a strain, or some other injury to the joint affected ; but this cause does not equally operate in all persons to the production of such a result; and it is hence obvious, that there is, as in the case of gout and rheumatism, a predisposition or peculiar diathesis favouring the origin of hydarthrus, ex- isting in some individuals, to which others are strangers. And we find this predisposition showing Itself also, as we have already seen, in the podagric diathesis, both in persons of a strong, robust, and entonic state of health, and in persons of relaxed and inelastic fibres, par- ticularly in those who inherit a scrofulous taint. And hence the disease exhibits itself under dis- tinct forms, seals itself in different parts of the joint, and demands different jnodes of treatment. [In the foregoing editions of this work the author took his description of white swellings chiefly from the writings of Mr. B. Bell, and adopted the very hypothetical division of the disease into entonic and atonic, meaning by the former case the rheumatic white swelling of several other writers, that most frequently takes place in young plethoric people, " possessing that firm elasticity of health and fibre, which, upon the application of accidental causes, gives rise to rheumatism, as well as this variety of hydarthrus." The atonic white swelling was, in our author's opinion, a name suited for that was as well understood as it is now. The prac- tice of applying cold air Or cold affusions to the gouty surface or extremities, has fewer advocates in this country than abroad ; and too many in- stances might be cited, where their employment has not only aggravated pain, but induced a fatal metastasis. American physicians sometimes give the colchicum in combination with a solution of tartarized antimony. In this way a more advan- tageous action of the medicine on the skin is often secured. Opium must lie administered with cau- tion, particularly if plethora "or local determina- tion to important organs exists ; in such cases, it were better to repeat venesection; after which, the well-known Dover's powder is to be preferred, The Eau medicinale has sometimes partially mit- igated an attack of gout with us as elsewhere; but it has also been detrimental. Carded cotton to the part affee'ed is much more grateful and soothing than flannel, and the cajeput-oil, blended with some stimulating liniment, is among the best embrocations.—D. * Colchicum rarely proves beneficial, unless it produce either nausea, copious perspiration, or purging, or all these effects together. Hence, the common practice is to give the vinum colchici in half'-diachm doses, every four or six hours, joined either with magnesia or the sulphate of magne- sia, so as to determine its action to the bowels. Modern practitioners seem to be acquiring every day greater and greater partiality to colchicum as a means of relieving gout; and, while the appre- hension of various evils from its free employment is not universally allowed to be well founded, its action in shortening the paroxysm of the disease, as soon as nausea or purging is brought on by it, is very generally acknowledged. In cases of ac- tive gout, occurring in a full habit, itis best always to let bleeding and a purgative of calomel and an- timony precede the exhibition of colchicum. Dr. Spillan, of Dublin, prefers a tincture of the seeds, of which 3L, 3iss., or 31J., may be given at night, and repeated, if necessary, the next morning. This quantitv, he says, will generally purge, brisk- ly ; but if it fail, a third dose the following night will be sure to succeed.—(See his Supplement to Pharmacopoeia.) The editor, instead of encoun- tering this risk of losing so much time, prefers giving the wine of colchicum in a mixture, con- taining magnesia, or the sulphate of it. Colchi- cum purges, allays pain, and lowers the pulse, and, when we know these facts, we need not trouble Ourselves with an inquiry, whether it has a spe- cific power over gout or not.—Kd. X The American profession is much indebted to Dr. Rush for his enlightened views on the cause and treatment of gout, published many years ago, which induced practitioners to adopt a depletory plan of treatment, by bloodletting, purgatives, bfisters, &c, even long before the nature of gout 588 H.EMATICA. [Cl. III.-Ord. II. variety which commences in the cancelli of the bones. It is rather extraordinary that Dr. Good should have preferred this principle of di- vision, and selected the epithets entonic and atonic, which involve us at once in conjecture and hypothesis, instead of a division of the subject founded upon facts demonstrated by dis- section, and a choice of names, calculated to express, as correctly as possible, the particular texture chiefly and primarily concerned in each variety of white swelling, and the nature of the morbid changes. When it is considered that our author was not unacquainted with the val- uable researches of Mr. Brodie, the course adopted seems the more singular. The editor, not feeling that it would be right, in the pres- ent state of surgical knowledge, to repeat the author's description of white swelling, has been obliged to introduce a short sketch of the sub- ject arranged on other principles. Hydarthrus is divisible into the following va- rieties :— a Membranae syno- White swelling commen- vialis. cing in the sy no vial mem- brane. 0 Cartilaginum.-------commencing in the cartilages. y Ossium. -------commencing in the bones. The term white, swelling has been com- monly applied to enlargements of the joints, in consequence of the colour of the skin being often not at all changed, even in very advanced periods of the disease. As it expresses what is generally true, the name can hardly be found fault with on the ground of its conveying any erroneous notion; yet, it is objectionable on another principle, which is, that it is applied to several diseases of the joints, which are of very different characters in every other respect, thus tending to keep up a want of scientific discrimination, which conduces to a great deal of confusion and obscurity in practice. The texture of the joint, principally and primarily concerned in the disease, and the nature of such disease, form, as we have already re- marked, a better and more useful basis of no- menclature. The synovial membranes of the joints consti- tute bags, without any external opening ; in this respect resembling the peritoneum, the pleura, and the pericardium, to which Mr. Bro- die conceives it also bears some analogy, both in its functions and diseases. At all events, experience proves, that it is frequently the seat of inflammation ; it is in fact one of the fibrous textures, particularly pointed out by Bichat and other writers, as a common situation of rheumatic inflammation. The consequences of its inflammation, as enumerated by Mr. Brodie, are, first, a preternatural secretion of synovia ; 2dly, effusion of coagulable lymph into the joint; 3dly, in other cases, a thickening of the membrane; a conversion of it into a gris- tly substance ; and an effusion of coagulable lymph and serum into the cellular texture, by which it is connected to the external parts. In the museum of the London University are sev- eral specimens of adhesions of the folds of the membrane to each Other, the result of previous inflammation. Unless the disorder arise from mechanical injury, inflammation of the synovial membrane rarely terminates in suppuration. When the disease is unchecked, it may lead to ulceration of the cartilages ; but he thinks that where this change is combined with inflamma- tion of the synovial membrane, the affection of the cartilages is mostly the primary one, and that of the membrane the consequence of the formation of an abscess in the joint* The symptoms are pain in the joint, frequently very severe at one particular spot, and followed in a day or two by swelling. At first, the swel- ling arises entirely from fluid in the cavity of the joint; but afterward the synovial mem- brane becomes thickened, or lymph is effused on its outer or inner surface ; the fluid in the joint is, therefore, less .easily felt, and the mo- bility of the joint itself diminished. As the swelling is chiefly produced by the distended state of the synovial membrane, its shape is not that of the heads of the bones, and is mod- ified by the resistance it meets with in certain directions from ligaments and tendons. The disease is less frequent in the hip and shoulder than in the more superficial joints. After in- flammation of the synovial membrane has sub- sided, the fluid is absorbed ; and in some in- stances the joint regains its natural figure and mobility ; but in other cases swelling and stiff- ness remain, and the patient is very liable to a recurrence of the disease, whenever he is ex- posed to cold, or takes much exercise Some- times the inflammation not only lingers in the part, but extends to other textures, and at length the cartilages ulcerate, suppuration is estab- lished, and the articular surfaces are destroyed. Inflammation of the synovial membrane sel- dom attacks young children, but is very fre- quent in adults : a feature in which it exhibits a resemblance or relationship to the rheumatic inflammation of fibrous textures in general. Indeed, it is this species of white swelling that is particularly implied in the descriptions given by many writers of the form of the disease to which they apply the epithet rheumatic Mr. Brodie further remarks, it may occur as a symp- tom of gout or rheumatism ; or of derangement of the health by syphilis, or the unskilful use of mercury. In other examples the affection of the joint is quite local, being produced by a sprain or contusion, an extraneous cartilaginous body in the joint, or, what is still more usual, by exposure to cold. When the case has arisen from the ill effects of mercury, Mr. Brodie recommends sarsapa- rilla ; when from rheumatism, opium conjoined with diaphoretics, and the colchicum, which is also particularly useful where the complaint is connected with gout. But when several joints * See Brodie's Pathological and Surgical Obs. on the Diseases of the Joints, pp. 16 and 19, 2d edit, Lond., 1822. A different view of this point is adopted by Mr. Key.—See Med. Chir. Trans., vol. xix.—Ed. Gen. XII.—Spe. 4.] ARTHROSIA HYDARTHRUS. 589 are simultaneously attacked, he deems the moderate use of mercury the most successful practice. In all cases, however, Mr. Brodie has found topical treatment the most important. In the acute stage of the inflammation, he has recourse to leeches and even venesection ; aperient med- icines ; saline draughts and diaphoretics ; and, when the swelling and tension are very great, he prefers fomentations and poultices, but, under other circumstances, cold lotions. In the chronic stage, perfect quietude of the joint, leeches or cupping, repeated several times, and a cold lo- tion, are the means advised. When the inflam- mation has somewhat yielded he applies large blisters, and, if necessary, repeats them from time to time ; a plan which he finds more effec- tual than that of keeping a single blister open with the savin cerate. In a further stage, when the inflammation has yielded still more, he em- ploys strong liniments, containing a proportion either of lin. ammoniae, tinctura cantharidum, or sulphuric acid. The remaining stiffness will be removed by friction with the hand alone, or camphorated mercurial ointment; free exercise of the limb ; or by allowing a column of water to be pumped on the joint from a height, as is practised at the watering-places. Another form of disease affecting the syno- vial membrane, and commonly classed as a white swelling, is that in which the membrane is con- verted into a thick pulpy substance, of a light brown colour, intersected by white membranous lines. As the disease advances, it leads to ul- ceration of the cartilages, caries of the bones, wasting of the ligaments, and the formation of abscesses. According to Mr. Brodie's investi- gation, the disease is slow, but, in the end, the joint is invariably destroyed. The case is rarely seen in any other joint than the knee. The disease commences with a slight stiffness and tumefaction, without pain. At last, the motion of the joint is generally seriously im- paired ; though, in some cases, a certain degree of it remains. The swelling is less regular than that produced by inflammation of the synovial membrane, and is soft and elastic, as if arising from fluid. The patient suffers no pain until abscesses form, and the cartilages ulcerate, at which period hectic fever usually comes on, and the patient gradually sinks, unless the limb be amputated. Mr. Brodie deems this form of the disease in- curable. All that can be done is to check its progress by rest and cold lotions; and to alle- viate the pain attending ulceration of the carti- lages by fomentations and poultices. In the end, the limb must he sacrificed for the preser- vation of life ; at least, until some new treat- ment, capable of restoring the natural texture of the synovial membrane, be discovered. From eertairi accounts published of the effects of iodine, employed internally and externally, it would seem to deserve a fair trial. Mr. Buchan- an, of Hull, applies the tincture to many white swellings, both in the acute and chronic stages, with surprising success, according to the state- ments contained in his late publication.—(Es- say on Diseased Joints and the Non-union of Fracture, 8vo., Lond., 1828.) One species of the disease, vulgarly denomi- nated white swelling, appears, from the re- searches of Mr. Brodie, to commence in the articular cartilages ; and this change is found to be the primary one in a large proportion of the cases in which the hip-joint is concerned.* Ul- ceration of the cartilages of the knee is attended with one remarkable difference from inflamma- tion ofthe synovial membrane , viz., in the for- mer, the pain is at first slight, and gradually _ becomes very intense, which is exactly the re- verse of what happens in the latter. Neither is there, for a considerable time after the disease has begun, any evident swelling, and when this does show itself, it arises from a slight degree of inflammation in the cellular membrane on the outside of the joint, and seems greater than it really is, owing to the wasting of the muscles. No fluctuation is perceptible, as where the sy- novial membrane is inflamed; nor is there the peculiar elasticity which accompanies the con- version of that membrane into a thick pulpy sub- stance. However, in a few cases, the synovial membrane is secondarily affected, and the sy- novia or pus may collect within the joint. If the disease proceed, abscesses generally form, the ligaments are destroyed, and the joint becomes dislocated. The editor has seen several cases, in which the head of the tibia has been drawn into the ham ; and melancholy examples of the luxation of the thigh-bone from the acetabulum, in consequence of this disease in the hip, may be seen daily in the streets of every city and town in Europe. In the treatment of primary ulceration of the cartilages of the joints, Mr. Brodie attaches con- siderable importance to keeping the part mo- tionless. It is this disease, for which he finds caustic issues particularly useful. In the early stage, local bleeding, venesection, and the warm bath, are sometimes serviceable; but stimula-- ting plasters are inefficacious, and friction al- ways hurtful. Another form of white swelling takes place so often in persons with decided marks of scrof- ula about them, that it is generally regarded as a scrofulous disease. It originates in the can- cellous structure of the bones, and ulceration consequently takes place in the cartilages of the joint, and the disease then follows nearly the same course as when it has commenced with ulceration of the cartilages. The heads of the bones of the affected joint at first become un- usually vascular, and deprived of their due pro- portion of lime, while, at first, a transparent fluid, and afterward a yellow cheesy substance, is deposited in their cancelli. As the caries of the bones advances, inflammation takes place in the cellular membrane on the outside of the * From some researches undertaken by Mr. As- ton Key, it would appear that ulceration of car- tilages is preceded by the formation of a vascular substance by the synovial membrane, which sub- stance is the organ by which the cartilaginous tis- sue is removed.—See Med. Chir. Trans., voLxix. -Ed. 590 H^MATICA. [Cl. HI.—Ord. II. joint. Hence, a puffy and elastic swelling in the early, and an oedematous one in the ad- vanced stage of the disease. At length an ab- scess is formed in the joint, and, making its way by ulceration through the synovial mem- brane, bursts externally, after causing numerous- sinuses in the soft parts. In the last stage of the disease, the bones, instead of being preter- naturally vascular, become less so than in the healthy state ; a circumstance to which Mr. Lloyd has imputed the exfoliations which some- times occur.—(Oi Scrofula, p. 123.) According to Mr. Brodie's observations, the disease is often met with in children; and is rarely seen in individuals past the age of thirty. The hip and shoulder are less liable to it than many other joints. As it is connected with a particular diathesis, it sometimes affects several joints at the same time, or recurs in others after the one originally attacked has been cured or removed. In this form of white swelling, a de- gree of pain in the joint, generally not a very distressing one, precedes for some time the oc- currence of swelling in the soft parts. When the cartilages ulcerate, the pain increases; but it is not severe until an abscess has formed, and the parts over the abscess become distended and inflamed. When the abscess bursts, a thin pus, with portions of substance resembling curd, is discharged. " I conceive all such collections of matter," says Mr. Hunter, " to be of a scrof- ulous nature : they ^re most common in the young subject, and seldom found in the full grown, or old. The suppuration is not proper pus, nor the swelling proper inflammation."— (On the B'ood, &c, p. 391.) Sinuses then gen- erally remain, at the bottom of which diseased bone may be felt with a probe. In the worst cases, the patient either dies hectic, or is obliged to submit to amputation. In others, a curative process ensues ; and the disease terminates ei- ther with or without anchylosis, according to the extent of the destruction of the articular sur- faces. In the complicated joints of the foot and hand, the chances of recovery are found by Mr. Brodie to be even less than in larger joints. With respect to the treatment, the plain con- nexion of the disease with scrofula implies that such general remedies as are calculated to im- prove the state of the constitution, cannot fail to be proper. Loss of blood seems to Mr. Bro- die less useful in this form of white swelling than in some others. He has also seldom known any benefit derived from blisters and liniments ; issues and setons, though serviceable, he has only found so in an inferior degree. Cold lo- tions check the extension of the disease to the soft parts, and retard the formation of abscesses. He lays much stress on the advantages of keep- ing the joint perfectly quiet, or as far as it can be done with due regard to health. Hence, he is an advocate for mechanical contrivances for this purpose ; and as far as the editor can judge, this seems to be the principle chiefly aimed at by Mr. Scott in the mass of plasters, bandages, pasteboard, &c w'th which he surrounds the dis- eased joint and limb.* When abscesses are forming, fomentations and poultices are to be em- ployed. When suppuration ceases, and a ten- dency to anchylosis begins, Mr. Brodie applies round the limb strips of linen, spread with soap cerate. As for the means of improving the health, the pure air of the seacoast; nourishing plain diet; steel medicines ; mineral acids ; and, in children, occasional mercurial purgatives ; with the benefit arising from being a good deal in the open air in summer, are those principally recom- mended.—(Brodie's Pathological and Surgical •Obs. on the Joints, 8vo., Lond., 1822.) Some practitioners are partial to the counter- irritation arising from the application of tartar- emetic ointment to the integuments of the dis- eased joint; some prefer setons ; some caustic issues; and others the moxa. But, in numer- ous examples, all plans seem to fail. Whether the high praises now bestowed on the iodine, as a remedy for white swellings, will be justified by general and impartial experience, time will soon determine. As our author remarked in his last edition] no medicine acts so directly on the absorbent system as iodine ; and we are in- formed by Dr. Gairdner, that M. Maunoir, of Geneva, has in one case of a very decided char- acter, and in which even amputation had been advised, after a failure of every other means, found the use of the ointment of iodine, to- gether with the tincture, completely succeed ; so as not only to remove the tumour, but to re- store as free a motion to the affected joint as was possessed by the sound knee. The dose of the tincture contained one twelfth of a grain of iodine at its utmost. The patient was eight years of age.—(Essay on the Effects of Iodine, &c, pp. 49, 64, 8vo., 1824.) [The most en- couraging accounts of the effects of iodine in the cure of white swellings hitherto published, are those of Mr. Buchanan of Hull, who applies the tincture\ with a camel-hair brush to the in- teguments, by which it appears to be rapidly absorbed, t] * See Surgical Obs. on the Treatment of Chronic Inflammation, 8vo., Lond., 1828. The merit of first suggesting this principle of treatment the editor believes due to the late Mr. Cruttwell, of Bath. t R Iodina? 3J., Spir. Vinos. Rect. |iij fl. Tine tura. X See an Essay on a New Mode of Treatment for Diseased Joints; and the Non-union of Frac- ture, 8vo.,Lond., 1823. Although iodine applica- tions are frequently useful in the treatment of chronic diseases of joints, the editor does not find their power so great as some writers represent. Cl. III.—Ord. III.] EXANTHEMATICA. 591 ORDER III. EXANTHEMATICA. ERUPTIVE FEVERS. CUTANEOUS ERUPTIONS ESSENTIALLY ACCOMPA- NIED WITH FEVER The term Exanthemata among the Greeks, from tSZavQita, "effioresco," " per summa erum- po," " to effloresce, or break forth on the sur- face," imported cutaneous efflorescences or eruptions generally. It has since been limited to express cutaneous eruptions accompanied with fever, a boundary assigned to it by Sau- vages, Linneus, Vogel, Sager, Macbride, Cullen, and various others, and this, in effect, is its gen- eral meaning in the present day. Dr. Cullen, however, in his note on Exanthemata, thinks it worth considering whether the word should not be restrained to eruptions (he does not say febrile eruptions) produced alone by specific contagion ; " eruptiones a contagione specifica. ortae ;" while Dr. Willan has still more lately narrowed it, so as to include those eruptions only which fall within the meaning of the English term rash, whether febrile or not febrile. The two last senses of exanthemata, or exanthe.matica, are new and singular. Dr. Cullen, however, has not followed up his own suggestion into his own classification ; while Dr. Willan has not always continued strictly true to his own views and definition, as I have observed in the running comment introductory to the present order in the volume of Nosology, to which the reader may turn, for a fuller exam- ination of this subject, at his leisure. The term, therefore, in the present work, is employed in its common and current sense, so as to include all cutaneous eruptions in which fever exists as an essential svmptom ; whether accompanied with or destitute of contagion ; which last is a doubtful, and perhaps an inap- propriate ordinal character : doubtful, because we cannot very precisely tell where to draw the line ; and inappropriate, because it is a char- acter that applies to diseases of very different kinds, and scatteied over the entire classifica- tion, as dysentery and influenza, in which there is fever without cutaneous eruption ; itch, and many varieties of tetter, in which there is cuta- neous eruption without fever; and blennor- rhea or clap, in which there is neither fever nor cutaneous eruption. The genera included in the order are distinguished by the nature of the eruption, as consisting of red, level, or nearly level patches or pimples filled with a thin ichor- ous fluid ; of pimples filled with a purulent fluid ; and of foul, imperfectly sloughing tumours ; and hence consist of the four following :— I. Enantifesis. Rash Exanthem. II. Emphlysis. Ichorous Exanthem. III. Empyesis. Pustulous Exanthem. IV. Anthracia. Carbuncular Exanthem. Each of these, with the exception of the third, comprises several species ; and all concur in evincing the existence of morbid and specific poisons in the blood, acting the part of animal ferments,* converting the different fluids into their own nature, exciting the commotion of fever, and being eliminated on the surface, as the best and most salutary outlet to which they can be carried, by the very fever which they thus excite. The whole is a wonderful circle of morbid and restorative action, evincing the most stri- king proofs of that instinctive or remedial power of nature, whose presence in every part of every living frame, whether animal or vegetable, is continually discovering itself; and which, under the general control of an infinite and omniscient Providence, is perpetually endeavouring to per- fect, preserve, and repair the individual, and to multiply its species. We have many times had occasion to ob- serve, that wherever any diseased action is ta- king place internally, there is a constant effort exhibited in the part, or in the s\stem gener- ally, to lead it to the surface, where it can do least mischief, rather than let it spread itself on the deep-seated or vital organs, where its effects might be fatal. Mr. John Hunter was peculiarly fond of dwelling on this admirable economy-of nature, and of illustrating it from the course pur- sued in inflammations of every kind (On BUod, Inflammation, &c, pp. 236, 450, 467), which, to obtain this beneficial end, often wind their way outwardly through a multiplicity of super- incumbent organization, instead of opening into some momentous cavity in the interior, from which it is perhaps only separated by a thin membrane. But there is no part of pathology in which this display of a final cause, of an oper- ative intention admirably adapted to the end, is more striking, than in the order of eruptive fevers. It is by means of the fever that the disease works its own cure ; for it is hereby that a gen- eral determination is made to the surface, and the morbid poison is thrown off from the system. But the fever may be too violent; and, from accidental circumstances, it may also be of the wrong kind ; both which facts occasionally oc- cur in inflammations, and require the art of medicine for their correction. When a febrile poison, producing a cutaneous eruption, is generated or has been conveyed into the blood, a small degree of fever is sufficient to throw it upon the skin ; and if it exceed the proper extent, the specific virus will be multi- plied, and the fever itself may become a source of real danger. It was formerly the practice to encourage the fever by cardiacs, a heated at- mosphere, and a load of bedclothes, from an idea that we hereby solicit a larger flow of mor- bific matter from the interior to the surface The fact is unquestionable ; for be the exan- them what it may, the skin will hence, in al- most every instance, be covered with eruption. But it did not occur to the pathologists of those times, that the morbid virus was an animal fer- ment capable of multiplying itself by accesso- ries : and that heat and febrile action, beyond * This language must be understood only in a figurative sense.—Ed. 592 H^EMATICA. [Cl. III.—Ord. III. a very low medium, are among the most pow- erful accessories we can communicate. And hence the advantage of the modern practice of applying cold water in scarlet fever, and cold air in smallpox, with a view of mitigating the fever that often accompanies these diseases : for, by diminishing the febrile violence, we do not, as "was formerly imagined, lock up the con- tagion in the interior of the system, but pre- vent it from forming afresh and augmenting there. But the fever, though the natural mode of cure, may not only be too violent, but it may be also of the wrong kind. And here, again, the whole scope of professional skill is often de- manded. Some of the morbid poisons we are now ad- verting to have a natural tendency to excite a fever of one description, and others of another. Thus the fever of smallpox and measles is or- dinarily inflammatory ; that of scarlet fever may commence with an inflammatory type, but it has a strong tendency to run into a typhous form : while that of pemphigus and plague is typhous from the beginning. Much also, in this respect, will depend upon accidental circumstances, as the constitution of the year, and the prevailing epidemic ; the con- stitution of the patient, his habit of life, or he- reditary predisposition. For under the control of these, we sometimes see an eruptive fever, having naturally a typhous turn, restrained in its tendency ; and, on the contrary, a fever with an inflammatory turn, as in smallpox or measles, converted into a malignant or a typhous. Yet the general intention pursued by the instinctive or remedial power of nature, is one and the same : and it is the duty of the medical practi- tioner to watch over that intention, and co-op- erate with it; to moderate the natural means when in excess; to quicken them when defi- cient ; and to correct them when deflected by accidental circumstances.* * In the very beginning of acute exanthematica, congestions of different mucous membranes exist almost constantly, and, as Andral observes, it is a remarkable fact in the history of these diseases, that in each of them the congestion has a deter- minate situation; in scarlet fever, the mucous membrane of the pharynx; in measles, that ofthe air-passages; and in variola, that of the stomach. —(Anat. Pathol., tom. ii., p. 224.) Exanthematica are not to be regarded merely as cutaneous dis- eases ; they are rather affections of the whole sys- tem, extending their effects to internal organs as well as the surface. In measles, as Dr. Elliotson remarks (Lancet for 1830-31, p. 393), the mucous membrane of the nostrils, the conjunctiva, the mu- cous membrane of the air-passages, often down to the very air-cells, nay, occasionally the substance of the lungs and the pleura, and even the intes- tines, are much affected. In smallpox there is great affection of the larynx, such as frequently destroys life ; a great affection also of the epigas- trium ; the stomach is particularly tender, and is really inflamed from the first. In scarlet fever the eyes and nose are not much affected, but the in- side of the mouth, the soft palate, the pharynx, and the tongue, suffer intensely, and sometimes in such a degree, that their condition is mainly concerned GENUS I. ENANTHESIS. RASH EXANTHEM. ERUPTION OF RED, LEVEL, OR NEARLY LEVEL PATCHES ; VARIOUSLY FIGURED ; IRREGULAR- LY DIFFUSED ; OFTEN CONFLUENT ; TERMI- NATING IN CUT1CULAR EXFOLIATIONS. The term enanthesis is derived from the Greek iv, "in, intra," and avBiut, " floreo,"— " efflorescence from within or from internal af- fection." Whence the term stands opposed to exanthesis, which, in the present system, con- stitutes a genus under the sixth class, and com- prises such efflorescences as are merely super- ficial or cutaneous, and not necessarily con- nected with internal or constitutional affection. Enanthesis is here, therefore, used to express fever accompanied with rash, the latter word being employed in the broader of the two senses assigned it by Dr. Willan, as importing red, irregular, confluent patches; whether simple, as in the case of scarlet fever ; compounded of papulae, small, acuminating elevations of the cu- ticle, not containing a fluid, as in the case of measles ; or existing in the form of wheals, as in that of nettle-rash. And hence enanthesis, as a genus, furnishes us withthree species :— 1. Enanthesis Rosalia. Scarlet fever. 2.----------Rubeola. Measles. 3.----------Urticaria. Nettie-Rash. SPECIES I. ENANTHESIS ROSALIA. SCARLET FEVER. RASH, A SCARLET FLUSH, APPEARING ABOUT THE SECOND DAY ON THE FACE, NECK, OR FAUCES ; SPREADING PROGRESSIVELY OVER THE BODY; AND TERMINATING ABOUT THE SEVENTH DAY : FEVER A TYPHUS. This is the scarlatina of most modern writers, a barbarous and unclassical term that has unaccountably crept into the nomenclature of medicine upon the proscription of the original and more classical name of rosalia, which it is the author's endeavour to restore. Upon this subject I must refer the reader to the running comment in the volume of Nosology, where he will find it explained at full length. At present it is sufficient to observe that al- though, since the introduction of searlatina, its use has been generally tolerated, no classical scholar has been satisfied with the term, while several have peremptorily refused to adopt it. Dr. Morton had so mortal an aversion to the term, that he preferred the error of blending in producing death. There is sometimes sickness in this disease ; an inflammation of the stomach and intestines; the mucous membrane of the ali- mentary canal is affected below the pharynx, so that there is tenderness in the epigastrium ; and sometimes there is inflammation within the head and within the chest, as well as within the ab- domen.—Ed. Gen. I.—Spe. 1.] ENANTHESIl scarlet fever with measles, and of arranging the varieties of the two diseases under the common generic name of morbilli, to employing scarla- tina. De Haen appears to have had nearly as great a dislike to it.—(Med. Contin., tom. i., cap. vii.) Dr. Huxham for a long time eluded the term by using febris miliaris rubra, or maligna, for some of the varieties of scarlatina, and febris anginosa miliaris for Others : Dr. Heberden has still more lately exchanged it for febris rubra ; and Thiery, in direct allusion to the original name, calls it expressly mal de la rosa (Recueil Periodique, vol. ii., p. 337); Ploucquet employs porphyrisma, as Borsiero or Burserius had made use of purpura before him ; Dr. Willan continues scarlatina, but thinks it necessary to apologize for its continuance. " The denomination scarlatina," says he, "was first applied to this disease by British writers : however offensive the term may be to a classical ear, it cannot well be displaced, having obtained admission into all the systems of nosology. Another age will correct and refine the lan- guage now used in subjects untouched by the masters of physic"—(Cutaneous Diseases, p. 253.) It is singular that Swediaur, with all his love for Greek terms, and the determination with which he set out to give every genus a Greek name, should, while ranking this disease as a genus, still retain the objectionable term.— (Nov. Nosol. Meth., syst. i., 164.) It will not be the present author's fault if the correction so generally called for in the case before us should be postponed to another age, or the error complained of be chargeable on future nosologists. In saying that " the denomination scarlatina was first applied to this disease by British wri- ters," Dr. Willan can only mean that it was by British writers first applied technically, and in- troduced as a professional term into the Medical Vocabulary : for the term itself is Italian, and was long as a vernacular name in use on the shores of the Levant before it was imported into our own country. Scarlet fever, measles, and smallpox seem, indeed, equally to have reached us from the east, and to be diseases of comparatively modern origin. [It has been suspected that the first of these contagions came originally from Africa. In Europe, it first broke out in a severe form in Spain in 1610, and it raged at Naples in 1618. In 1689 it appeared in London, and in 1735 it spread gradually, but slowly, over the American continent.]* Some writers fancy that they can distinguish a few traces of one or two of the foregoing disorders in the works of Paulus ^Egina, and other Greek physicians; but the passages referred to are too general and unpre- cise to establish any such conclusion. No such diseases are described ; and had they existed at the time, a few determinate and scattered * See Gregory's Elements of Physic, p. 126, edit. 2. Prosper Martianus, an Italian physician, who gave a description of the disease as it pre- vailed in Rome about the middle of the seven- teenth century, is said to be, if not the first, among the earliest writers on scarlatina.—Ed. Vol. I.—P p S ROSALIA. 593 hints, which may apply to other diseases as well, could not have been the whole to which they would have given rise. The names, indeed, by which they were at first known, as variola, rubeola, or rather rubiola, rosalia, and even morbilli, evidently point to the school of Cor- dova, and lead us to the Arabian or Saracenic physicians for our first account of them. And it is not to be wondered at that in such ac- counts we should meet with some degree of confusion and many inaccuracies, and should perceive that as measles were for a long time confounded with smallpox, so scarlet fever was with measles ; whence it is difficult in one or two instances to determine what is the precise species of disease referred to by Avicenna, Ali Abbas, and Rhazes; for, while they seem to allude to the scarlet fever, we are not sure that they mean it. On this account it is that rosalia, rossalia, and rubeola, alike derived from the colour of the efflorescence, are, among the earliest writers who used these terms, applied equally to scarlet fever and measles ; and when some distinction was at length attempted by the introduction of the word morbillo, or morbilli, in like manner a Spanish or Cordovan diminutive, the line of distinction not being accurately drawn or ad- hered to, this term was also erroneously applied to both ; and the confusion became more intri- cate. So rougeole, which among the French writers is the common name for measles, im- ported also at one time scarlet fever: and this so generally, that when in process of time physicians became sensible of the difference be- tween the two maladies, and it was necessary to establish distinct terms, we learn from Che- venau, that among the Marsellois, rougeole was at first appropriated to the scarlet fever, while the measles were denominated senapion.* And in this manner both diseases continued in every country, till within the last half century, to be regarded and even treated of with but little dis- crimination ; sometimes as different species, sometimes as a common species, and some- times as varieties of a common species. And hence, even in our own country, we find them united in several of their varieties, not only in the writings of Dr. Morton, but still more lately in those of Sir William Watson. Since, however, they have been considered, and most correctly, as different diseases, another extreme has been run into; for rosalia itself has been broken into, subdivisions that are in no respect worth contemplating separately ; one or two of which, as we shall perceive presently, have themselves been elevated by some pathol- ogists into the rank of distinct maladies. For all the purposes of perspicuity, it will be suffi- cient to study it under the two following va- rieties :— * Observ. Med., p. 454. In 1778, Dr. Withering published an Essay on Scarlet Fever, a second edition of which appeared in 1793; to this author Dr. Bateman assigns the merit of having first ac- curately described scarlatina as a distinct disease. But Withering seems to have been anticipated by Plenciz, who published in 1776.—Ed. 594 HiEMATICA. [Cl. 111.—Ord. III. a Simplex. Fever moderate, and termi- Simple scarlet fe- nating with the rash ; lit- ver. tie prostration of strength; slightly contagious. 0 Paristhmitica. Fever severe ; throat ulcer- Scarlet fever with ated ; rash later in its ap- sore throat. pearance, and less exten- sive ; often changing to a livid hue : highly contagi- ous. Children are by far the most frequent subjects of both these varieties, and communicate the disease readily to each other. They are both occasionally epidemic, and in this form occur most usually at the close of the summer. " The scarlet fever," observes Sir Gilbert Blane, " very rarely affects adults. The great majority are under puberty ; some between twenty and thirty ; a few between thirty and forty. Only one case above forty has occurred to my own observa- tion."* Public schools may be one cause of the greater frequency of the disease in our own day. The anticipating symptoms are those of fever [restlessness, anxiety, depression of spir- its, chilliness, pain in the head, soon followed by heat, thirst, and sickness]. About the second day from the beginning of these complaints in the first variety, numerous specks or minute * Select Dissertations, &c, p. 213, &vo., Lond., 1822. The late Earl of Exmouth died of scarlet fever at the age of forty-nine; and Mr. Squib, the auctioneer, in Saville Row, has also very recently fallen a victim to the same disease at the age of forty-five. Both these cases happened in the autumn of 1833. In order to determine the rela- tive frequency of scarlet fever in the sexes at dif- ferent ages, Dr. Tweedie selected from the register of patients admitted into tlie London Fever Hos- pital 200 cases, in the order of their admission. The following table gives the general results:— Age. Males. Females. Total. From 6 to 10 7 8 15 10 to 15 8 15 23 15 to 20 - 17 40 57 20 to 25 . 14 39 53 25 to 30 8 21 29 30 to 35 6 10 16 35 to 40 1 2 3 46 1 0 1 42 0 1 1 48 0 1 1 57 - .0 I I 62 138 200 As Dr. Tweedie explains, however, the table is not complete, the number of children under six years of age who take the disease not being ascer- tained, in consequence of no children under that age being received into the above institution. The list shows, however, the great majority of females at every age, and (putting out of consideration cases in children under six years of age) proves, in opposition to Sir Gilbert Blane's statement, that the majority of those who are seized with scarlatina are not under puberty. For if the young children under six years of age be taken into the calculation, no doubt Sir Gilbert Blane's repre- sentation would be found to be correct. Dr. Tweedie's list, however, is exceedingly instruc- tive, and certainly exhibits a much larger propor- tion of cases in individuals past puberty than would ka-ve been expected ^-Ed, patches of a vivid red colour appear about the face and neck ; and within twenty-four hours, a like efflorescence is diffused over the surface of the body, and occasionally even tinges the inside of the lips, cheeks, palate, and fauces. Sometimes the efflorescence is continuous and universal ; but more generally on the trunk of the body there are intervals of a natural hue between the patches, with papulous dots scat- tered over them.* There is an exacerbation in the evening, at which time the rash is most florid, as it is least so in the morning. In some cases that have occurred to me, it has only shown itself in the daytime in the form of scat- tered patches, or even specks, though the skin has been very generally roughened and rendered anserine from a more than usual determination of blood to the cutaneous papillae. Yet even in these cases, the pathognomonic efflorescence has appeared in a later or less degree in the evening. On the fourth day, .the disease is at its height. On the fifth the eruption begins to decline ; the interstices widen, and the florid hue fades. On the sixth the rash is very in- distinct, and is wholly gone on the seventh. On the eighth and ninth the cuticle is seep peeling off. The pulse during the eruptive stage is usually very quick and feeble ; the tongue is covered with a whitish fur in the middle, often inter- spersed with scarlet points from an elongation of the turgid papillae ; while the sides of the tongue are of a dark red. The face is con- siderably tumefied; and there is great anxiety and restlessness, with a sense of tingling oi itching in the skin, and sometimes at night a slight delirium. Though the fever is in most cases moderate, it sometimes runs high, but in the present variety is rarely alarming. In many cases, indeed, the eruption appears and passes through its course with little inconvenience of any kind from fever, itching, or restlessness. Sauvages, and Cullen, who has eopied Sau- vages' definition, represent the efflorescence as not taking place till the fourth day after the at- tack. Dr. Heberden, on the contrary, fixes it on the first or second day (Med. Trans., vol. iii., p. 397); Dr. Willan " usually on the second day." This last is the ordinary period, and as such I have entered it in the definition. It i3 obvious, however, that the interval observes some variety; though not a little of the appa- rent difference may be ascribed to the different * When the eruption has begun a short time, there generally can be no doubt of its true nature. Minute red points appear upon the lace and neck ; they soon become innumerable, run together, and within twenty-four hours form continuous patches over the. trunk and extremities. The colour is a bright scarlet, not seen in measles, nor in any other disease, and most vivid at the flexures of the joints and in the loins. The skin, cursorily ex- amined, seems smooth ; but if it be inspected with care, it will be found to present minute asperities like those of the cutis anserina. The small points of the skin become a little inflamed, so that the roughness depending upon them had not the coarseness felt in the measles.—See Elliotson's Clinical Lect. in Lancet for 1830-31, p. 393u—Ees. Gen. I.—Spe. 1.] ENANTHESIS ROSALIA. - 595 stages of the disease in which a physician is first consulted, and his inability of fixing very accu- rately the commencement of the febrile incur- sion. Dr. Plenciz, on this account, pursues a middle course, and avails himself of an allow- able latitude : " About the second or third day," says he, " and sometimes later, the red, une- qual eruption makes its appearance."—(M. A. Plenciz, Med. Vindom. Tractatus de Scarla- tina, 1776.) Generally speaking, the more vio- lent the attack the sooner the efflorescence is thrown forth ; and hence, during a severe and extensive range in Newcastle-upon-Tyne in 1778, Dr. Clark tells us that, where it began with great vehemence, the eruption was often observed on the first day ; but commonly it did not make its appearance till the second or third, and sometimes not till the fourth. We have seen that rosalia has been often confounded with measles, to which, indeed, it bears, in many cases, no small degree of re- semblance. The following distinctive charac- ters, therefore, may be of use to prevent a mis- take. The efflorescence of the measles does not appear till two days later than that of scarlet fever ; and, though it consists at first of broad patches amid the general suffusion of red, stig- matized with interspersed dots, the dots are of a deeper colour, and are never lost in the efflo- rescence. It commences, moreover, with symp- toms of a severe catarrh [the eyes have a watery, tender appearance; and the patient sneezes and coughs ; the face is flushed, and the head very heavy. Frequently, however, the cough does not come on during the first three or four days]. Such symptoms do not belong to scarlet fever; and the measles are without that restlessness, anxiety, and depression of spirits, by which the latter is peculiarly distin- guished. [In the early period of scarlet fever, there is this difference between it and smallpox : in the last, there is frequently intense pain in the loins, and great tenderness of the epigastrium ; symp- toms not appertaining to scarlet fever. If a person, therefore, be taken ill suddenly, and an eruptive disease be suspected, and yet there is no violent pain in the loins, and no extreme ten- derness of the stomach, there is no reason to apprehend smallpox.—(Elliotson's Clin. Lect. in Lancet for 1830-31, p. 392.)] From the great determination of blood to the cutaneous vessels, an effusion of coagulable lymph sometimes takes place in the papulous elevations, which is not entirely absorbed by the time the efflorescence subsides; and hence there is occasionally, though not often, an ap- pearance of vesicles, sometimes nearly empty, and sometimes nearly filled with a pellucid fluid, according as the effused serum has been more or less carried off. I have seen them exh»blt the semblance of minute chickenpox ; and they have been thus noticed by many writers, par- ticularly by Dr. Rush (Medical Inquiries and Observations, p. 123, Philadelphia), Dr. With- ering, and Dr. Plenciz : the last of whom com- pares them to white miliary spots; and ex- pressly states, that he observed them on the sixth or seventh day from the commencement of the eruption, chiefly in the hands and feet :• in other words, at the time when the turgid cu- ticular vessels had contracted, and the efflores- cence was on the decline. On examination, he farther tells us, that they appeared to be nothing more than cuticular elevations filled with mi- nute bubbles of air. More correctly, perhaps, they were quite empty, the effused serum being carried off by absorption. M. de Sauvages has made this form ofthe disease a distinct species, as scarlet fever with him constitutes a distinct genus (Tractat. de Scarlatina); and as the ef- fused fluid, when its finer parts are first absorbed, occasionally appears thick and opaque, and has some resemblance to minute pustules of small- pox, he has distinguished it by the name of scar- latina variolodes. There is another peculiarity which the disease sometimes exhibits, and to which the attention of the profession has of late been particularly called by Dr. Maton.—(Med. Trans., vol. v., art. xi.) The disorder, in the case alluded to, showed itself in a large family, and evinced all the common symptoms of a mild rosalia ; and, like rosalia, it proved itself contagious, for every member of the family, elder or younger, to the number of eight, received it in succession. But its singularity was the great length of interval between the time of exposure to the attack, in those who sickened nearest to each other in the order of its descent, and any sen- sible effect on the system; which, instead of being, as in ordinary cases, four, five, or six days, was, upon an average, not less than twenty-one days ; varying, in different individuals, from sev- enteen to twenty-six days. And, on this ac- count, in conjunction with one or two other signs of minor importance, Dr. Maton, though he at first regarded the disease as a modifica- tion of rosalia, was afterward inclined to believe it a new complaint, requiring a distinct desig- nation. Yet, if we reflect how often a similar, or nearly similar retardation takes place in par- ticular families after inoculation from either the smallpox or cowpox, in which we have a much more definite period to calculate from, we shall rather, perhaps, be justified in adopting Dr. Ma- ton's first view of the disorder, and contempla- ting it as a rosalia modified by a peculiar family temperament, or some other accidental control. In the paristhmitic variety, or that accompanied with sore throat, the eruption is always later in its appearance than in the simple form ; in a case I shall have to quote from Dr. Perceval, not less than eight days later; though I have never known it protracted to so late a period as in the modification noticed by Dr. Maton, where the febrile symptoms have taken place as early as usual from the time of exposure. The efflo-' rescence in the measles, however, sometimes evinces a like procrastination, and has appeared as late as the twenty-first day.—(Buchholz Tode Med. Chir. Bibl., band i., p. 86.) In the second or paristhmitic variety, the morbid virus is chiefly directed to the fauces, instead of to the surface of the skin generally, 596 ILEMATICA. [Cl. III.—Ord. III. It is the scarlatina Scptorrhepes of Swediaur. And hence, in some cases, the cutaneous efflo- rescence is very slight, and consists of a few scattered patches of flush, instead of a diffused sheet. The rash, moreover, appears later by a day or two, sometimes even a week; probably delayed by the same cause that interferes with its general spread over the skin, being the local irritation about the throat. [It comes and goes, and when the disease inclines to terminate, the termination is not complete at once ; but the desquamations will sometimes continue for weeks.] If the throat be minutely inspected, this last symptom will be found to commence very early; for though no complaint is usually made of uneasiness in the throat previously to the febrile symptoms, yet, if it be closely exam- ined, the velum pendulum palati will be found redder than natural, and sometimes the uvula will appear to be a little inflamed, the pulse being at this time only slightly disturbed, or flurried rather than feverish.—(Dr. Sims, Me- moirs of the Med. Soc. of Lond., vol. i., p. 394.) Dr. Willan asserts, that this takes place as one of the first effects of the contagion, and de- scribes it as " a dark-red line, extending along the velum pendulum palati and the lower part ofthe uvula."—(Cutaneous Diseases, loc. cit, p. 269.) Gradually, however, the tonsils be- come enlarged, and exhibit a florid redness on their surface which extends over the whole range of the palate, its velum pendulum, the uvula, and the posterior part of the fauces ; the tongue assumes a high-red colour,* the papillae over its entire surface are greatly elongated, and very tender to the touch ; there is often a con- siderable stiffness in the muscles of the neck and lower jaw ; the throat is rough and strait- ened from the second day of the eruption ; and deglutition is performed with difficulty. All the common symptoms are more violent; there is more shivering at first, and afterward more intense heat of the body,t the temperature of which rises to 107°, 108°, or 111°; the fever is severer, accompanied with nausea, vomiting of bile, and languor ; considerable in- quietude and anxiety, headache and delirium ; evidently proving a copious determination to the head, as well as to the fauces. The pulse is feeble, the respiration quick; the throat becomes excoriated, and throws off a large quantity of minute, superficial, whitish sloughs, which inter- mix with the increased flow of viscid mucus, and augment the difficulty of swallowing. The sloughs generally separate about the fifth or * In the mildest form ofthe disease the tongue is red ; but if there be much inflammation of the mouth, the tongue is not only red, as if the mucus upon it were sprinkled with grains of Cayenne pepper, but the papilla are so elongated as well as red, that they project considerably through the mucus.—(See Elliotson's Clinical Lectures, op. cit.) "The disease attacks the interior of the mouth and fauces, and it even affects the conjunc- tiva."—Id. in Med. Gaz. for 1833, p. 101.—Ed. t Even in the mild form of the disease, where the throat is scarcely affected, the heat is very aatense — Elliotson, op. cit.—E», I sixth day, or at the decline ofthe efflorescence ; but sometimes they remain a day or two longer. This is the ordinary course ; but, in many cases, the symptoms run still higher; and the disease is alarmingly dangerous from its irrup- tion. The pulse is small, indistinct, and irreg- ular from the first; there is a stupid, heavy coma, or violent delirium, with deafness ; the ulcerations in the throat are deeper and broader, and covered with dark instead of with whitish sloughs ; the tongue is lined with a black, chappy crust, and is exquisitely tender; the breath is fetid ; the rash, extensive from the commence- ment, assumes a livid hue, with intermixed patches of ghastly paleness ; and death ensues shortly after the seventh day, sometimes on the sixth. The affection of the throat, in this last and most virulent attack, bears so near an approach to the malignant paristhmitis, and its peculiar symptoms commence so early, that some pathol- ogists of great authority, and particularly Dr. Cullen and Dr. Withering, have regarded it rather as a variety of paristhmitis or cynanche than of rosalia, whence, in Dr. Cullen's Sy- nopsis, it occurs under the designation of cy- nanche maligna. But, asthe scarlet or crimson eruption must be contemplated as a pathogno^ monic symptom, this is to give us two distinct diseases, with the same essential signs ; and Dr. Cullen has done this ; for, while he places this most virulent form of rosalia under his genus cynanche, he continues it, in the less vir- ulent form under which we have just described it, as a subdivision of his genus-scarlatina. The distinction, however, is altogether unnecessary, and leads to no advantage, either pathological or practical. With the exception of a higher degree of danger in the one than the other, from the fever assuming the character of a more ma- lignant typhus, both forms of the disease are the same ; they are equally produced by a spe- cific virus ; equally contagious, and at times ep- idemic ; accompanied with a similar rash ; de- mand a like mode of treatment; and even, ac- cording to Dr. Cullen's own admission, so fre- quently run into each other as to be extremely difficult of discrimination. In consequence of which, few later writers have allowed any such distinction whatever. De Haen, therefore, had reason to say, as he does, apparently in refer- ence to Dr. Cullen's arrangement, that different and improper names have been affixed to scarlet fever by different writers ; but that varieties in climate or constitution produce the distinctions under which it has been described. Dr. Withering, however, who was contempo- rary with Dr. Cullen, embraced and strenuously supported his view ; contending that, in scarlet fever with sore throat, the fever is inflamma- tory, and, in sore throat with scarlet fever, it is putrid. Yet, in describing the treatment of this inflammatory fever, he seems to have lost sight of his critical characteristic ; for he tells us that its nature is debilitating or sedative rather than entonic ; and condemns both purging and bleeding, as the pulse will not allow of these evacuations. Gen. 1.—Spe. 1.] ENANTHESIS ROSALIA. 597 In endeavouring still further to lay down the distinctive characters of the two, he observes, after Dr. Fothergill, that the angina gangranosa (sore throat with scarlet rash) usually commen- ces in the winter or the spring, and chiefly at- tacks persons of delicate habits, as women and children ; while the scarlatina anginosa (scarlet rash with sore throat), on the contrary, usually commences'in the summer or autumn, and com- monly fastens upon the vigorous and robust. The scarlet rash, however, of Newcastle-upon- Tyne in 1778, seems to have reversed this rule in its most essential point; for Dr. Clarke, to whom I have just referred, and who has given a very minute and interesting history of this epidemy, tells us, that it made its first appear- ance in June, extending from Newcastle over many towns and villages in the neighbourhood ; that it was most frequent in August, Septem- ber, and October, declining about December ; and that it raged chiefly among children and young persons, although a few adults exposed to the contagion did not escape.* Dr. Clarke therefore concludes, that both these diseases proceed from the same specific contagion, and ought rather to be considered as distinct forms of the same exanthem, than as distinct affec- tions. It is accurately, also, observed by the same writer, that the epidemy of 1748, which Dr. Fothergill has so ably described under the name of putrid sore throat, is essentially the same as that noticed by Dr. Cotton in his letter to Dr. Mead, and which he then denominated scarlet fever, from an objection to any alteration of the name in common use. The subject ought not to be closed without adding the following note from Dr. Perceval's manuscript comment on the author's volume of Nosology, already noticed on many occasions. It adds a high authority to the present arrange- ment of this form of the disease ; and contains one or two remarks, which very agreeably dis- play the observant tenour of the writer's mind. , " Cynanche tonsillaris and maligna I con- sider with you as a species of rosalia. All have ! been produced by the same specific contagion, which in one instance was imported here (Dub- lin) from England in a Pandora's box, containing plumed soldiers which had served to beguile the convalescent hours of a young family, and were sent by them as a present to their quondam play- mates in this capital. We have had no severe | visitation of rosalia in this place for upwards of ten years. In some instances, besides, I have traced the progress of contagion from England, and believe it loses something of its ferocity by the way. Do you think it comes from the con- tinent 1 A remarkable case occurred to me of rosalia paristhmitica, characterized most dis- tinctly with symptoms of what is called cynanche maligna. This, with sunk pulse, great pros- tration of strength, and haggard countenance, ran a course of seven days without eruption ; * Observations on Fevers, especially those of the continued type, and on the Scarlet Fever attended with ulcerated sore throat, &c, 8vo., 1779. during which time it was treated with wine and bark, which removed the affection of the throat. On the eighth day, after a rigour, a fever super- vened of rather an inflammatory type, with a rosalia eruption. After proper evacuations, the patient recovered." That rosalia, under every form, is contagious, and sometimes epidemic, is now admitted with- out a question ; and for the later appearance of the efflorescence in the paristhmitic than in the simple variety, I have endeavoured to account. But, whether some countries are more disposed to favour its appearance in the form of an epi- demy than . others, and particularly, whether under this form it be more common to England than to Ireland, as hinted at by Dr. Perceval, I have no data to determine. There are three modes by which this, or in- deed any other disorder, may become epidemic, using the epithet in its general sense, as import- ing a disease, of whatever sort, that contami- nates the atmosphere of a district or neighbour- hood. It may proceed from a specific miasm, generated from local or accidental circum- stances in the atmosphere itself, as in the miasm of intermittent and often of remittent fevers; from a like miasm generated in the body of a sick individual, and communicated to the at- mosphere, as in typhus; or from a peculiar temperament in the atmosphere, predisposing the entire population that inhale it to a common morbid affection. Of any specific miasm origi- nating in the atmosphere, and producing rosalia, we have no proof whatever: but we have abundant proof of its issuing from the bodies of those who are sufferers under it ;* and, if I mistake not, of a peculiar temperament or con- stitution of the atmosphere in a particular dis- trict or season, that predisposes to its general production ; for it often becomes common to many families so simultaneously, that they have had no power of communicating it directly or indirectly to each other. And hence, howeyer it may be favoured by external concurrent cir- cumstances, we have good reason for believing that the miasm is always ingenerated ; and that * It is not exactly known how long a person is capable of communicating the contagion after he has had the disease; perhaps, according to Dr. Elliotson, not longer than two or three weeks, unless desquamation of the cuticle proceed ; and then the exfoliations appear to be so impregnated with the poisonous secretion of the skin, that they may give the disease as long as they con- tinue to be formed. How long they may retain the infection, after separation, seems uncertain. The contagion of scarlet fever often continues very long in a house or hospital into which a case has'been admitted. Thus, Dr. Elliotson mentions a patient with scarlet fever, who was admitted into a particular ward, and, for nearly two years afterward, all the children and young»men placed in the same ward took the fever, though the ward had been thoroughly whitewashed and cleaned.— (See Lancet for 1830-31, pp. 392-394.) The fact communicated to our author by Dr. Perceval, of the transmission of the contagion from England to Ireland in a box of toys, exemplifies its tenden- cy to adhere a good while to articles which have been handled or worn by patients.—Ed. 598 HjEMATICA. [Cl. III.—Ord. HI. the disease, when communicated, is always by specific contagion. We may hence account for its being in a pure and healthy, or unpredisposing atmosphere, but slightly infectious : for, in treating of the laws of febrile miasm, which, under different circum- stances, originates both within and without the living body, we had occasion to observe, that when generated in the former manner, it ap- pears to be less volatile than when in the latter, and less readily impregnates a periphery of pure air; whence the infection of typhus, which is commonly derived from this source, may be more easily avoided than that of intermittents or even remittents. The miasms of all the ex- anthems seem subject to the same law, as they also probably issue from a specific affection of the living body ; and hence all of them are comparatively confined in the range of their actions, though some radiate their influence to a much greater distance than others, and are not so soon dissolved or decomposed. We may hence, also, see why the contagion of rosalia is received much more readily at some periods than at others. Nothing is more com- mon than for a sporadic case of rosalia to occur in a family without communicating itself to the surrounding children, although no pains may have been taken to keep them separate ; while, a few months afterward, it may possibly be re- ceived from a neighbour's house, merely by an accidental visit for a few minutes. In the one case, there was no predisposition in the habit to receive the complaint; in the other, the al- tered state of the atmosphere has, perhaps, pro- duced such a predisposition in a very high de- gree, and prepared the way for the disease to become a very general epidemy. * What this peculiar state of the atmosphere is has not yet been very accurately ascertained. It does not seem to depend altogether upon the season ; though, commonly speaking, rosalia is more frequent towards the close of the summer, the common harvest-time of all debilitating dis- eases ; and we also perceive that it is usually checked, at all periods, by a cold, dry, and bra- cing air, and hence is less frequent in the win- ter. But, with these exceptions, it has been found to range as an epidemy nearly equally from February to November, and sometimes through the whole of this term without ceasing ; or only slackening its career when a keen dry breeze has sprung up from the north or the east. We see, also, another peculiarity in this dis- ease, and that is in its ordinary limitation to children ; and we see this character accompany it equally, whether the disease be sporadic or epidemic. Or, in other words, we beho\d the predisposing state of the atmosphere observing * Independently of atmospheric influence, there are constitutional peculiarities which render some individuals insusceptible of the contagion of scar- let fever. Many persons are in this state, not merely adults, but children; and, though much exposed to the disease, never catch it. Scarlet fever is not by any means so unfailing a visiter, either of children or adults, once in their lives, as ithe meaeles and smallpox.—Ed. the same restriction as the disease itself when it operates independently of any such predispo- sition. Adults, indeed, do not entirely escape, but their attacks are rare, and, for the most part, less violent* The remote cause of rosalia, then, i» a spe- cific virus, or a specific miasm generated in the living body. Of its occasional or exciting causes, separate from the predisponents just adverted to, we know nothing. It has sometimes seemed to follow a cold, and, at others, a surfeit of the stomach ; but, as these are perpetually taking place without producing such effect, and as ro- salia has often occurred where nothing of the kind could be traced, we can lay very little stress upon such casualties.. All exanthems and nearly all fevers produce an influence on the system that renders it less susceptive of the same complaint for a certain period of time afterward: yet the period varies, from the plague, which exempts but for a few weeks, to the smallpox and measles, which usually extend the exemption to a term equal to that of a man's life ; in consequence of which these disorders, except in a few anomalous cases, never appear but once in the same individual. Scarlet fever seems to hold a middle range. It renders the system far less susceptible, and, perhaps, for several years ; but the influence, in many individuals, wears off by degrees, and does not protect the whole of a man's subse- quent life. Yet, as rosalia is a disease of chil- dren and young subjects rather than of others, it is not often that persons suffer from it a sec- ond time, though examples of such a recurrence are occasionally to be met with.-f- [Hahnemann is well known to be an admirer of what is termed homoceopathia, according to which doctrine diseases should be opposed by remedies, the effects of which are similar to the diseases for which they are given. Having ob- served that small doses of belladonna produced heat and dryness in the throat, and cutaneous affections, he conceived that belladonna might prove a preservative against scarlatina. About ten years after this suggestion had been made, Berndt put it to the test of experience in an epidemic scarlatina that prevailed in Custrin in 1818 and 1819, and, out of 195 children who were freely exposed to the infection after being put under the influence of belladonna, only 14 took the disease. It would appear likewise, from the statements of Dr. Dusterberg, that bel- ladonna has the power of rendering the consti-^ * This is contrary to the result of the editor's observations, which coincide with the statement made by Dr. Tweedie :—" It has been generally observed," says he, " that scarlatina proves more severe to adults than to children ; and that when it attacks pregnant or puerperal women, it is often fatal."—Ed. t P*-. Elliotson believes, that its recurrence in the same person is more frequent than that of smallpox or measles. In two thousand cases, however, Dr. Willan never knew it to take place in the same individual a second time. The extreme of infancy is least liable to rosalia, as well as measles.—See Lancet for 1830-31, p. 392; and Med. Gaz. for 1833, p. 100.—Ed. Gen. I.—Spe 1.] ENANTHESIS ROSALIA. 599 tution, for a time, insusceptible of the contagion of rosalia. During the epidemic prevalence of this disorder at Giitersloh in 1820, he gave daily to such children as had not been attacked from ten to twenty drops of a solution of three grains of extract of belladonna in three drachms of canella-water ; and be assures us that none of the children who had continued this medicine a week were attacked with rosalia, though con- tinually exposed to its contagion. It is also stated that every child that did not take bella- donna, and was exposed to the contagion, had scarlet fever.—(Hufeland's Journ. der Prac- tischer Heilkunde, 1822.) Whitewashing, clean- liness, free ventilation, and the use of the chlo- rides, should never be omitted in dwellings where scarlet fever has prevailed. The linen of the sick should always be put, as soon as removed, into water containing the chloride of soda or lime.] Rosalia is at'all times a disease of debility; it prostrates both the body and the mind, but it has, in manycases, a peculiar tendency to weaken the absorbent system, and incapacitate it for car- rying off the fluids that are exhaled into the in- ternal cavities of the body, and hence to produce dropsy. This calamitous sequel usually creeps en insidiously and without suspicion, and does not distinctly show itself till the twelfth or four- teenth day, and often considerably later, when the patient and his friends are flattering them- selves that all danger is over. It commences with a peevishness, and a feeling of drowsiness and increased weakness and languor : the face is found to swell, and the urine to decrease in quantity, and to assume a somewhat bloody ap- pearance, like the washings of flesh. The leuco-phlegmacy of the face extends gradually to the hands, feet, abdomen, and scrotum, till the whole body becomes puffed up. " I have known these swellings," says Dr. Perceval, " to attack all the cavities, the ventricles of the brain not excepted, and in one instance fatally, upon an eruptive affection so slight as hardly to be no- ticed. The child was not confined, but went out, and was exposed to air.* This last hint should not be dropped in vain ; for the torpitude produced on the mouths of the absorbents by a sudden or injudicious exposure to cold air, on recovering from rosalia, is one of the most common causes of this lamentable re- sult : and hence we see, also, why it should be more common in winter than in summer, and in children than in adults, from the greater deli- cacy of their age.f Dr. Withering confirms * If rosalia be severe, there may ensue dis- charges from the meatus auditorius, sore ears, sup- purations in the parotids, and absorbent glands ol the neck; pulmonary disease, and diarrhoea; or the fever may be followed by chronic pustular dis- eases of the skin, called rupia and ecthyma, but which, as Dr. Elliotson observes, are much more common after smallpox. After rosalia simplex there is often a tendency to anasarca, which usu- ally shows itself at the end of the second week, after the decline of the rash.—See Professor El- liotson's Lect. at Lond. Univ., as published in Med. Gaz.—Ed. | Dr. Elliotson does not adopt our author s ny- the instance just offered by Dr. Perceval, that it is occasionally to be found after the mildest form of the disease ; but adds, that it follows chiefly its malignant or worst species. The curative treatment need not long detain us. In slight cases of the simple variety, we may say, with Dr. Sydenham, that the disease hardly calls for medical assistance of any kind. When the fever is mild, it forms, as we have already observed in respect to exanthems of all kinds, the natural means of cure, by determin- ing the specific poison to the surface. An emetic may assist this determination, and has hence been almost always found -serviceable ; and, if the bowels be confined, an aperient may follow ; but violent purging will add to the irri- tation, and distract the remedial course that is taking place.* In the paristhmitic variety, the determination, instead of being to the skin generally, is power- fully deflected to the throat and head, and the fever is alarming from its violence. The thera- peutic intention is here to counteract this de- termination of the febrile action, always having regard to the nature of the fever, as well as to its severity- Bleeding is the most direct and obvious means of reduction ; but it is open to the same objection as in typhus ; with the additional fact that we have here to deal chiefly with children, who have at all times less surplus of strength to spare than adults. Dr. Plenciz is, however, a strenuous advocate for the use of the lancet, and Dr. Armstrong has recommended it still more lately. Where the head is manifestly oppressed from congestion, it may be risked as a mode of local relief, and may be so far of ser- vice ; but it is a risk at all times, and ought by no means to form a part of the general curative plan. With the exception of typhous miasm, there is nothing that so much exhausts, or rather, perhaps, suppresses the sensorial power, as the miasm of rosalia ; nor is there any evacu- ation that adds so immediately to the direct debility of the system as venesection, and con- sequently, none that ought to be so studiously pothesis of a torpitude of the absorbents : for, though he admits that the dropsical swellings fol- lowing rosalia are most frequent in winter and in cold damp weather, he believes that they are al- most always of an inflammatory nature. As in other inflammatory dropsies, he says, the face is affected the very first. He believes, that when effusion occurs in the chest, there is inflammation or sub-inflammation of the pleura ; and so, with respect to the abdomen, there is peritonitis ; and, with respect to the head, arachnitis.—En. * At the present day, emetics are not so gen- erally given in rosalia as they were some years ago. It is now ascertained that, in simple cases, little more is necessary than mild aperients, except keeping the patient cool, and purifying his cham- ber by the occasional admission of fresh air, and sprinkling it and the bedclothes with a solution of the chloride of lime or soda, which may also be introduced into the vessels used for the pur- poses of nature. This practice is particularly recommended by Dr. Elliotson (Clinical Lect., op. cit., p. 395), with a view of lessening fetor, and preventing the extension of the contagion.—Ed. 600 H.EM. avoided as a general rule. And hence, often as the practice has been introduced by different individuals, it ha3 never been common or estab- lished. Even Dr. Withering, who denominated the fever inflammatory, rigidly abstained both from bleeding and purgatives, and confined him- self, in the onset of the disease, to emetics.* Vomiting, which has just been recommended in the first species, is still more necessary in the present; for it not only tends to take off the dry burning heat of the skin, by relaxing it, but unloads the fauces of the mucous and serous fluids that gorge and distend them. Dr. Withering prohibited purgatives as well as bleeding. But, in doing this, he discovered still further the trammels of hypothesis; for while he conceived that emetics tend directly to throw off the matter of contagion from the organ in which he supposed it to be chiefly con- centrated, he conceived at the same time that purgatives, on the contrary, only promote its diffusion along the course of the intestinal canal. This reasoning, however, cannot be allowed: the system should not be weakened by their violence, but their use can rarely be dispensed with. Calomel, as operating upon all the excretories, is commonly to be preferred to any other cathartic, or may be conveniently com- bined with rhubarb. The great inquietude that characterizes this disease has induced many practitioners to try opium ; but it rarely affords relief in any form or combination, arid generally renders the head worse. Ammonia is in every respect a far more useful medicine ; it takes off the languor, and stimulates the secernents, especially those of the skin, without quickening the pulse. In the form of subcarbonate, it should be given in doses of half a scruple, dissolved in a large spoonful or half an ounce of water, every three or four hours :t and, in this way administered, it has a highly beneficial and powerful effect upon the local inflammation of the throat. Oc- * Account of the Scarlet Fever in 1778, 8vo. No one can entertain a doubt- that, when the symptoms indicate inflammation in the head, chest, or abdomen, the practitioner should not dispense with bleeding ; nor should he be deter- red by any unreasonable fear of typhus and debili- ty from employing the lancet, when the symptoms above alluded to are serious and pressing. The internal inflammation is then the principal source of danger, and leaves no alternative. The debility must be combated when it arrives. If the inflam- matory symptoms run high, Dr. Elliotson approves of venesection ; but, in general, he deems topical bleeding sufficient, and praises the good effects of fresh air, the lowest possible regimen, cleanliness, few clothes, and keeping open the bowels. It is only when inflammation of important organs comes on that he is an advocate for general bleeding, find- ing that any local inflammation in ordinary parts will only require topical bleeding.—Ed. t If the disease show a very considerable gan- grenous tendency in the throat, if the pulse be very soft and feeble, Dr. Elliotson recommends the same treatment as in typhus fever. " Among the internal stimulating medicines which it is necessary to give at the last," says he, " carbon- ate of ammonia is one of the best, with the excep- TICA. [Cl. III.—Ord. Ill casionally also, and in the intervals, we should employ some of the acids, whether vegetable or mineral, which are always grateful to the pa- tient, and seem, more than any other internal means, to diminish the burning heat of the skjn. But our chief dependance for this purpose must be upon Dr. Currie's bold and happy plan of employing cold water freely. Sponging will rarely be found sufficient, or rather will rarely be found of equal advantage with affusion ; the fluid may, indeed, in this case, be dashed against the patient till the heat is subdued, and the process be repeated as fast as it returns. The refreshment is often instantaneous, and operates like a charm ; and seems to show, not merely a refrigerant, but an exhilarating power ; the skin immediately becoming softer and moister, as well as cooler. [One caution is requisite, how- ever, viz., only to apply the cold water when the patient is not perspiring, and when the skin is parched and hot.]* The throat must, in the meanwhile, be de- terged with antiseptic gargles of oxymel and port wine, port wine negus, of chloruret, or chloride of soda and lime, and tincture of myrrh, or any of those already noticed under malignant paristhmitis ; or fumigated with the vapour of mineral acids, t Blisters may also be applied with good effect. Dr. Withering objects to them ; but general experience is in their favour. In severe cases, Dr. Plenciz (Tractat. de Scarlatina) had recourse to the aurum fulmi- nans, as recommended by De Haen (Rat. Med. Continuata, tom. i., part 1, 8vo., Vienna), and speaks, warmly of its success. Its design was to operate on the bowels and bladder, and it was given in combination with calomel, rhubarb, and squills. I have never tried it, nor can I very clearly trace out the path by which any benefit may be expected from it. Wine and nutritious food may be allowed (chiefly, as the editor conceives, in the advanced, or typhoid stage), but somewhat less freely than in malig- nant quinsy. The convalescent state requires tion, perhaps, of wine." All impartial practitioners must agree with this eminent professor, that ammonia has no peculiar power over the dis- ease.—Ed. * If the eruption recede prematurely, Dr. Elli- otson advises the warm bath, and friction, with stimulating applications, unless the patches be prevented from coming out by inflammation of any internal parts ; then stimuli are to be avoided, and leeches employed.—See Elliotson's Lect. de- livered at Lond. Univ., as published in Med. Gaz. for 1833, p. 131.—Ed. t Gargles of the chloride of soda or lime are now generally preferred. When there are dark- coloured sloughs on the throat, which cannot be removed as portions of lymph can, the gargle should be made stronger than that for other cases, in which Dr. Elliotson recommends two ounces of the common solution to Ibss. of water. When the patient is unable to employ them properly himself, as is the case with children, and with other individuals severely ill, they should be thrown over the affected parts of the throat with a syringe. Cold or even iced drinks will be found very grateful, as relieving the excessive heat of the throat and mouth.—Ed. Gen. I.—Spe. 2.] ENANTHESIS RUBEOLA. 601 great care ; and, on account of the tendency to dropsical swellings, a damp cold atmosphere should be especially avoided.* [Dr. Paul has lately detailed an interesting case (Edin. Med. Surg. Journ., No. xc, p. 55), in which the disease, besides being remarkable for its severity, exhibited the peculiarity of petechiae and profuse hemorrhages coming on in the convalescent stage : under these circum- stances, the good effects of the sulphate of quinine were particularly manifest.t] * Dr. Ryan was called to a patient who had been convalescent from scarlet fever a month, at the end of which time he went out at two o'clock, on a cold day in the spring, and returned in a short time completely anasarcous, and died at two next morning.—(Manual of Midwifery, p. 685, ed. 2.) The anasarca and dropsies following rosalia seem to Dr. Elliotson to be most advantageously treat- ed with purgatives and leeches. In all cases pur- gatives are recommended, and topical bleeding also, if there be local dropsy. In intense cases he even sanctions bleeding from the arm.—(Clinical Lectures, op. cit.) While Dr. Good regards the anasarca and dropsical effusions, consequent to ro- salia, as depending upon torpitude of the lymphat- • ics, caused by injudicious exposure to cold damp air, Dr. Elliotson refers them to a degree of inflam- mation in the parts or cavities affected. Andral supposes them to be connected with the interrup- tion of cutaneous perspiration, produced by the extensive efflorescence on the surface of the body ; but this doctrine is hardly tenable, when it is recollected that no such consequence usually arises from erysipelas and other affections of the skin, however extensive. With respect to wine, ammonia, and nutritious food, as recommended in the text, they can only be allowable after all ten- dency to inflammatory action in the system is over, and the patient is in a very low debilitated state.—Ed. t On the subject of Enanthesis Rosalia, we have been favoured by Dr. J. W. Francis, of this city, with the following remarks :— "However various," says Dr. Francis, "may be the methods of cure in rosalia adopted by dif- ferent physicians, all admit the serious character of the disease, and its too often fatal termination. In the United States it frequently appears epi- demically, in places of diversified condition, in populous cities, and in scattered villages; in the pure air of the country, and in the vitiated atmo- sphere of a crowded and heterogeneous popula- tion ; and it would be difficult to assert in which sort of location it often proves most destructive. Its fatality, as recorded in our annual bills of mor- tality, is truly alarming, and seems to reflect little credit on the skill of our most competent pre- scribes ; in the city of New-York alone, during the past six years, no less than fifteen hundred have perished by it. Were greater accuracy exer- cised to ascertain from what particular causes this vast destruction of human lives by this pestilen- tial disease occurred, some adventitious circum- stances might doubtless be found, which would plead in extenuation of the inefficient results of the best efforts of medical skill. Indeed, this spe- cific disease may rage in the boudoir of the rich as well as in the hovel of the needy. Neverthe- less, the mixed population of New-York, the mass of foreign and indigent poor, who, with their de- praved habits and vitiated morals, annually scatter themselves among its better inhabitants, may with great truth be enumerated as of these aggrava- ting causes. The scarlet fever appears sporadi- SPECIES II. ENANTHESIS RUBEOLA. - MEASLES. RASH IN CRIMSON, STIGMATIZED DOTS, GROUPED IN IRREGULAR CIRCLES OR CRESCENTS J AP- PEARING ABOUT THE FOURTH DAY, AND TER- MINATING ABOUT THE SEVENTH ; PRECEDED BY catarrh; FEVER A CAUMA. Of the earliest accounts we possess of mea- sles, by the Arabian writers called al-hasbet, calry at all times among us ; but the seasons of its greater prevalence, those in which it often assumes the type and potency of an epidemic, are the lat- ter part of the autumn and in the winter months. There are exceptions to this rule, however, in the records of its appearance elsewhere. Dr. Calla- ghan, in his account of the epidemic anginosa which prevailed at Pittsburgh, Penn., in 1830, tells us, that it commenced with the setting in of warm weather, about the middle of May, the thermom- eter ranging from fifty to seventy-two degrees, with southerly winds and frequent showers.— (Am. Journal of Med. Science, vol. viii.) Profes- sor Williams, in his history of the disease as it occurred in Deerfield, Mass., in the years 1830 and 1831, mentions that it prevailed extensively through New-England, and that in many towns it was very mortal. At intervals, it continued to prevail from June, 1830, to the time of his writing, November, 1831. The month of May, 1830, was cold and uncomfortable.—(Am. Joum., vol. ix.) For the greater part, it occurs most extensively after seasons of extreme moisture and great vari- ations of temperature: early infancy and youth are most liable to it; but examples at times pre- sent themselves of the infant of a few weeks of age, as well as the advanced adult, being subjected to its influence ; recently, one of our periodicals contains an account of its fatal occurrence in an adult aged eighty. With old subjects it is often severest in its attacks: I have seen it in both classes, and its formidable recurrence in the per- son of a middle-aged man, after an interval of seven years. The immunity of the constitution from a second attack is probably less than from that of measles. It almost always has proved fatal to the pregnant female. " That scarlet fever depends upon a specific contagion is admitted by all, I believe, who tolerate a contagious principle in any disease. The dis- tinguished Dr. Dewees is the only American writer of repute who seems to doubt its conta- gious character : at least he affirms he has never seen any decided proof that it has communicated itself in any one instance. Nevertheless, in ac- tual practice, he says it will be safest to act under such a conviction. For my own part, I think we are brought to the alternative of rejecting in toto the doctrine of contagion in every form of febrile disease, if it is not allowed to be a means of dif- fusing scarlatina. In private families 1 have known the several members to become affected from an individual case : Dr. McLean tells me he has attended nine members of one family, who were attacked in succession by it: and we need not advert to its sweeping malignity when it has prevailed in hospitals, alms-houses, public schools (as at Ackworth), and other places where many persons are congregated. " The luminous history of rosalia, and of its distinctive features, given in the text, supersedes all minute detail on that head: and the division of scarlatina into the simplex, anginosa, and ma- ligna, is so universally adopted, that for practical 602 H^EMATICA. [Cl. Ill—Ord. III. <£X^sl!' t^e origin of the name of rubeola, and the frequency with which it was at first mistaken for rosalia, some notice has been taken purposes it may as well be preserved, though somewhat at variance with the disposition of the subject in the detail by Dr. Good. It is usually from the third to the sixth day after exposure to the contagion that the complaint manifests itself. On the second or third day of the disease, the fe- brile irritation is considerable; but it may be so on the very first; sometimes we encounter no fever whatever throughout the whole course of the complaint; sometimes the efflorescence puts on its peculiar character almost at the invasion of the disease ; and at other times we scarcely can perceive any cutaneous discoloration during its entire existence: sometimes we encounter scarlet fever followed by sore throat; at other times sore throat is followed by scarlet fever: the nature of the former type is perhaps more gener- ally inflammatory, that of the latter more of a ty- phoid character. Accidental causes may however vary this circumstance, and the most malignant type may arise in the course of a case which at first was of an inflammatory form ; while occasionally the latter may halt in its career, and lose its most alarming features. Such is the varied aspect of this Protean disease : an acknowledged febrile complaint, at times without symptoms of fever : an eruptive one, with, at times, no development of cutaneous disorganization. The duration, also, of scarlet fever, exhibits an extraordinary differ- ence in different subjects, according to its type, the predominance of certain symptoms, and the accidental occurrence of peculiar circumstances. In its mildest variety it may continue for some six or ten days; in its aggravated form it may as speedily terminate, or last as many weeks : and the sequels of the disease, when it has commit- ted its most serious ravages, have occasionally been to destroy the equilibrium between the ab- sorbent and secretory systems, incurable deafness, &c &c One of the most lamentable instances of this last sort which I can bring to recollection, was that in the person of the late mathematician and geographer, John Eddy, of this city. " The treatment of rosalia must therefore be regulated by many concurring circumstances : in its simplest form it is often almost supererogation to interpose art where nature is so judicious in her operations: in other cases, mild aperients, sudorifics, simplicity in diet, and attention to clean- liness, may often suffice. In its complex form with sore throat, our indications are of a more discriminating order, and challenge our severest judgment and most effective capabilities. I think I have already noticed the prominent circum- stances which should be kept in mind when called to a case of scarlet fever. A difference in patho- logical opinions must necessarily lead to a corre- sponding difference inOur curative means; as, for instance, whether we deem the existing state of disordered action to depend mainly upon the as- thenic or sthenic diathesis, upon debility or in- creased energy. Too exclusive an adherence to either belief has been the prolific source of evil: the practice of viewing scarlatina as a disease of debility, has induced many to recommend, early, bark, wine, alcohol, and the diffusible stimuli, with cordial nourishment, after the method of the older alexipharmic prescribers, and to dep- recate all antiphlogistic medicines. After this manner, in order to support the strength, have many epidemical 6r pestilential disorders at vari- ous periods been treated; I need not add with under the last species. In its perfect form, it is unquestionably contagious from a specific miasm, though we shall presently have to notice one variety that is inactive in this respect. Like what pernicious results. On the other hand, without due consideration of the specific charac- ter of scarlet fever, of the laws which regulate febrile infection, and of the uniform influence which diseases of such origin have in their ten dency to induce a greater expenditure of the vital powers, other prescribers have urged, even in the advanced state of the complaint, the antiphlo- gistic method by copious bleedings, emetics, dras- tics, cold affusion, and other potent agents; on the ground that all the morbid phenomena depended upon an active inflammatory diathesis. Of the consequences of such a pathology we have too many fatal examples. " In the treatment of scarlet fever, let us ever recollect the specific nature of the cause of the disease; the variable aspect of the complaint while it runs its course; and its uncertainty as to duration; how specious its promises of proving mild or severe, simple or complicated; and be impressed with the facts which pathological inves- tigation has furnished us. Several writers have recorded the diseased appearances which post- mortem examinations present Beside the various conditions, the results of morbid action, exhibited in the mouth, throat, and contiguous glands, in- flammation, or its consequences, in different and distinct parts, the mucous membrane has been found thickened, effusions of tenacious matter obstructing the passages and air-cells of the lungs; an engorged state of those organs, and sometimes of the liver ; a surcharged condition of the peri- toneal lining; and often, in the brain, a preter- natural vascularity, arachnitis or serous effusion between the arachnoid and pia mater, or in the ventricles. The early appearance of a copious efflorescence may be pronounced a favourable harbinger of the character of the disease ; its deficiency is often the cause of severer symptoms; when it is suddenly repelled we must prepare to encounter increased evils on the affections of the throat, and more unmanageable local congestions of the brain or viscera. " Scarlet fever, therefore, is in its nature essen- tially inflammatory; but we must bear in mind the disposition which it has, even in its milder form, but especially in its more aggravated type, to partake of the typhoid character: its forming or active stage is of brief duration, say some three or four days ; while after that period, in common with other disorders of specific febrile contagion, it assumes a tendency towards a typhoid disease. Our active means of relief ought therefore to be regulated by this important circumstance, and be early enforced ; and these, I need hardly repeat, are ever to be regulated by the fact, that if we prostrate the energies of the system too much, we run the greater hazard of encountering augmented difficulties, protracted recovery, and an uncertain cure. " Emetics stand conspicuous among our effi- cient means of relief; they unload the mucous surfaces of the fauces and neighbouring parts, and by their general relaxing influence, lessen heat, and arrest internal congestion. Cathartics, administered so as to occasion a pervious state of the primae viae, diminish in several ways the sources of irritation, and unless given to an im- moderate extent, are not to be dreaded either as transferring diseased action, or as causing greater prostration. Laxatives or mild aperients may perhaps suffice; but an occasional dose of calo. Gen. I.—Spe. 2.] ENANTHESIS RUBEOLA. 608 rosalia, also, it is at times epidemic, and proba- bly from the same cause,—a general predispo- sition in the population of the affected district mel, united with pulvis purgans, some few grains of calomel alone, or with rhubarb, followed by salts or magnesia, or the infusion of senna and marina, will in most instances be all that a just discrimination asks. Long ago Tozzetti (Burse- rius) was more than once surprised to find that diarrhcea in this disease, both at its outset and du- ring its progress, proved salutary. Bloodletting from the arm, and leeches to the throat, are so of- ten serviceable, that they may be fairly enumer- ated among our most approved aids; and the ap- prehensions of evils which some of the best writers on the history of this disease entertained some twenty or thirty years ago, are demonstrated to be untenable by an improved pathology and the results of modern practice. Indeed, nature is not backward in some instances in anticipating the physician by a salutary hemorrhage from the nose. When inflammation of the throat runs high, and a greater disposition to cerebral congestion exists, venesection will be found indispensable. . Anti- monials, either as James's powder, or in the still more manageable form of the tartar-emetic solu- tion, exercise a salutary power : their agency in diminishing the action of the heart and circula- tion, in controlling febrile irritation, and equal- izing the functions of the economy, is the best recommendation for their use. Blisters have their advocates : but the application of them ought to be early, within the first day or two after the dis- ease manifests itself; and then local determina- tions would plead hardest for their service. In- deed, the condition of the surface in scarlet fever seems too often obnoxious to the action of can- tharides, and even when cerebral pressure occurs, I would have them to act upon the more remote fiarts. Like remarks apply to sinapisms, stimu- ating embrocations, &c A powerful means of arresting the malignant or ulcerous condition of the throat, is the application of the lunar caustic in weak solution, delicately pencilled over the af- fected surface. This practice has been pursued in numerous instances by Dr. Hugh McLean, of this city, for thirty years past, with gratifying results. " Soon after the philosophical Currie, of Liv- erpool, first published his Medical Reports on the use of cold water in fevers, his suggestions were adopted with an ample confidence of their saving efficacy in the management of scarlet fever ; the extremely high temperature created in this dis- ease, it was inferred, would be speedily reduced by cold aqueous ablutions, and striking instances of the efficacy of the plan occasionally occurred. But this means of controlling inordinate heat in scarlet fever with safety and promptitude, is not at present looked upon in the same favourable light as formerly : in milder cases of the disorder, cold ablutions are unnecessarily severe; and in aggravated cases, they must be abandoned on the score of inducing more alarming congestions. Many, I believe, have paid the forfeit of existence by the injudicious application of cold water: hence American physicians more generally, at the present day, employ tepid spongings of water, or of vinegar and water. I must advert to another error of practice, which it will be admitted we have detected at no small sacrifice of human life ; I allude to the preposterous design of inducing salivation in scarlet fever, in order the better to secure the safety of the sufferer. The use of mercury to its warrantable extent I have endeav- oured to specify. As in a majority of febrile dis- or country to receive its contagion, perhaps to originate it, from some peculiar but unknown temperament or constitution of the atmosphere. eases where there is local disorganization and gen- eral fever, it is extremely hard to create any sensible mercurial influence on the salivary glands ere the disorder has obtained a prominent sway, so in scarlet fever we have, I think, two powerful obstacles to our securing the wonted benefits of mercury: inordinate fever, which is too general yet to allow the stimulating effects of mercurials, and the local mischief of disorganization in some essential part, which equally forbids its employ- ment: in fine, the disease is too rapid in its march to be checked by the slow progress of salivation. The mortality of scarlet fever would be more within our control, and cease to be the topic of such consternation, were this heroic practice less popular. This at least is my opinion, founded upon a tolerably ample survey of the subject. "I forbear to dwell upon the medicinal and di- etetical measures to be adopted for the purpose of renovating the system after the acute and ac- tive course of scarlet fever is passed through. It. is so analogous to that demanded by typhus as to supersede at this time further minuteness. " The anasarcous and other dropsical conditions which are not uncommon consequences of scar- latina, challenge an additional observation. This uncertain disease is still further characterized by the uncertainty of its manner of termination. Dropsical effusions occur sometimes when the eruptive appearances have not been fairly devel- oped ; and they are liable to ensue when the erup- tion has been suddenly repelled. They may follow even when the eruption has been ample and pre- served its wonted characteristics. I am inclined ' to infer, that from the inefficient action of mer- cury, by its adding to the irritability of an already grievously harassed system, it also frequently is the source of these effusions. Be this as it may, we find almost invariably great tenderness over the whole abdomen, the evidence of sub-acute inflammation. We therefore have our indications well pointed out: bloodletting in some instances, in others free leeching over the abdominal region; diuretics, as squills, nitre, cream of tartar, the lytta, &c I have in this position of affairs given the ela- terium in doses of one sixth or one fourth of a grain, blended with the cream of tartar, two or three times a day. This hydragogue cathartic has re- lieved the oppression by copious alvine dischar- ges ; and, this object accomplished, we may pro- ceed as in a passive state of the system. " 1 have said nothing of opiates in scarlet fever; the indications for their employment must be like unto those which influence us in the management of general fever. Plethora, general or partial, may render them very doubtful adjuvants to our sources of cure: but this exception applies not with the same force to the compound powder of ipecacuanha. " The greater prevalence of scarlet fever within late years compared with a prior period, and its extraordinary fatality, have led me to communi- cate to you these cursory observations. I know of no prophylactic ; and we are left to combat it. True indeed, in Germany, the belladonna is as- serted to be preventive; and yet in that country, where this discovery is so lauded, scarlet fever is at this day more rife and fatal than ever. In this opinion I am fortified by the learned Dr. Wm. Leo- Wolf.—(See his Abracadabra, &c, New-York, 1835.) I may be excused from noticing the homoeo- pathic treatment—assuredly the advocates of this system among us have no special reasons to boast 604 ILEMATICA. [Cl. III.—Ord. III. [It has generally been supposed that measles are not contagious before the eruption has ap- peared ; but certain facts lately recorded tend to prove that this opinion is not correct*] It occurs under the three following varieties : a Vulgaris. Rash slightly prominent, ex- Common Mea- tending over the mouth sles. and fauces; harsh, dry cough, inflamed watery eye. 0 Incocta. Rash running its regular Imperfect Mea- course, with little fever or sles. catarrhal affection; afford- ing no certain security against the common or regular disease. y Nigra. Rash about the seventh or Black Measles. eighth day assuming a black or livid hue, inter- spersed with yellow; pro- longed in stay; and accom- panied with extreme lan- guor and quickness of pulse. The only predisposition or excitiug cause of rubeola that we are acquainted with, is the pe- culiar constitution of the atmosphere just re- ferred to. And, under the influence of this cause, the first variety usually shows itself as an epidemic ; generally commencing in the month of January, and ceasing soon after the summer solstice. There seem, however, to be some other exciting causes than a peculiar state of the atmosphere or of the season; for we meet with a few scattered cases of it in almost every month of the year, evidently proving an ingenerate origin, and that the atmosphere is not auxiliary to its diffusion, from its continuing to be merely scattered ; yet possessing its ordi- nary principle of contagion, which only appears to be less generally active, because there is a less general predisposition, in those who have never undergone it, to be acted upon. It occurs most usually in children, though no age is altogether exempt from it [and it is gen- erally more severe in children than adults]. As rosalia is accompanied with a typhoid fever,f rubeola is accompanied with a catarrhal; and hence, the opening symptoms consist of some degree of hoarseness, with a harsh dry cough, and frequently uneasy respiration; the eyelids are tumefied, the vessels of the conjunctiva tur- gid and inflamed, the cheeks are wet with a flow of acrid tears, and the nostrils loaded with serum, that excites an almost perpetual sneez- ing ; the head aches or is drowsy ; and the stom- ach, from sympathy, rejects its contents. On the fourth day the rash makes its appearance, of their triumphs. The infinitesimal practice of- fers a problem for mathematical scrutiny, and I leave it with you."—D. * See Rust's Mag., Feb., 1827. It is both a con- tagious and an infectious disease.—Ed. t This statement, as a general one, cannot be received as correct; rosalia may become typhoid ; but is not necessarily so in all, or even the major- ity of cases.—Ed. and assumes the character described in the spe- cific definition. The stigmatized and pathogno- monic dots are sometimes at first attended by so general a flush as to be lost in them, and to give the appearance of scarlet fever. I have already noticed several signs by which the two diseases may be distinguished, and the following may be added to the number. In scarlet fever, there is no cough, the eyes do not water, and the eyelids are not red and swelled. In measles, the papula? are more acuminated, of a crimson instead of a scarlet hue, and do not appear till two days later than those of scarlet fever * In smallpox the fever abates as soon as the eruption makes its appearance. In scarlet fe- ver this is by no means the case, and as little so in measles ; the vomiting, indeed, subsides ; but the cough, fever, and headache grow more violent ; and the difficulty of breathing, weak- ness of the eyes, and indeed all the catarrhal symptoms, remain without any abatement till the eruption has completed its course. In rosalia we have also seen, that the sooner the efflorescence breaks forth after the febrile attack, the slighter and more favourable the disease. The same occurs in rubeola. The ordinary period we have already stated to be the fourth day, but it occasionally appears on the third, when the patient commonly escapes with but little inconvenience.—(Van der Haar, Waar- neemingen.) A few rare examples may be found of its exceeding, instead of anticipating, its prop- er term ; and this so considerably, that Buch- holz gives us an instance of its not appearing till the twenty-first day : thus precisely rivalling the singular anomaly of scarlet fever already quoted from Dr. Maton.—(7 ode Med. Chir. Bibl., h. i., p. 86.) On the third or fourth day after the eruption first appears, the redness diminishes, the spots fall off in branny scales, which sometimes, how- ever, are scarcely perceptible for their minute- ness and tenuity-; leaving a slight discoloration on the skin, with considerable itching. On the ninth day from the beginning, where the prog- ress has beefi speedy, and on the eleventh where it has been slow, no trace of measles re- mains. The eyes, however, in many cases, con- tinue still inflamed, and the cough is followed with severe peripneumonic symptoms, which may terminate in phthisis. Yet these sequela? rarely occur, except where the treatment has been improper, or there is a predisposition to consumption from a strumous state of the lungs or some other phthisical diathesis. If, on inoculation for smallpox, rubeolous con- tagion should have been previously received into the system, the variolous action will generally be, though not always, suspended till the measles have run through their proper course, when the inserted virus will resume its power, and the va- riolous eruption follow in its due order. This * The crescent, or semicircular form of the patches in measles, attended with tenderness of the eyes, cough, &c, will generally leave no doubt about the nature of the disease. It is on the face that the characters of the eruption can be most plainly seen.—Ed. Gen. I.—Spe. 2.] ENANTHESIS RUBEOLA. 605 quality of suspension, however, is not peculiar to the measles. " I have known," says Dr. Perceval in his manuscript comment on the pres- ent species, " bex convulsiva yield the pas to variola, and then resume its station." In like manner, consumption is generally suspended during the entire course of pregnancy, and re- commences its inroad on childbirth. Measles in their more perfect form, which is that we are now contemplating, may be said, as a general rule, to occur but once in the course of a man's life ;* for though, as Dr. Baillie ob- serves (Trans, of a Soc for the Impr. of Med. and Chir. Knowledge, vol. iii.), a few instances of a second attack are to be found, exceptio probat regulam, they are so rare as rather to maintain, than disturb the law.—(Roberdiere, Recherches sur la Rougeole, Paris, 1776.) The cases described by Dr. Baillie, however, are very striking, and show a family, rather than an individual susceptibility. His first narration is that of five brothers and sisters, who had it in succession a second time, with one excep- tion, after an interval of six months ; the ex- cepted case affording an interval of twenty-one years. His next narrative is that of two sisters, who had a repetition of measles after an inter- val of four months. Dr. Willan asserts that he k never met with an instance. The anomaly is unquestionably less frequent than in scarlet fe- ver, and shows that the influence produced by the rubeolous action on the habit is more rooted and effective. In its ordinary course, measles is a disease unaccompanied with danger. It is in fact a ca- tarrhal fever with a specific eruption. The fe- ver, as we have observed already respecting ex- anthems in general, is necessary to a certain ex- tent, for the purpose of throwing the virus upon the surface : as inflammation in a certain extent is necessary to produce healthy suppuration. But a small degree of pyrectic action is in both cases sufficient; for if this be exceeded, the natural means of cure itself becomes the disease, rather than the morbid condition it is intended to remove. In all instances the extent of the eruption will depend upon the fever, whenever the latter is in excess. And hence our attention is to be mainly directed to the fever itself; for, by di- minishing the fever, we necessarily diminish the eruption also. In measles, therefore, the reme- dies we have already enumerated for a catarrh, are those we are to have recourse to. An emetic is always useful on the incursion of the dis- ease ; and should be succeeded by cooling ape- rients and demulcents, the skin being kept moist, and its heat subdued by mild diaphoretics. Dr. Cullen recommends bloodletting during every period of the disease ; and it has often been practised at its commencement.+ It is * Few individuals escape the measles: the in- disposition to it is less frequent than that to small- pox.—Ed. + " It is always necessary to observe carefully whether there is peripneumonia, or bronchitis, or pleuritis, and to treat it just as if no measles were present; to take blood from the arm or jugular rarely, however, that this can be called for, ex- cept in the case of pneumonic inflammation ; and as such an affection does not commonly ap- pear till the close of the measles, we should, generally speaking, as recommended by Syden- ham, reserve bloodletting till this period, and not exhaust the patient's strength beforehand ; and the more so, as even here the fever has sometimes proved a synochus, and terminated in a typhous form, as particularly noticed by Sir William Watson in the children of the Found- ling Hospital in 1763 and 1768, who gives to this modification the name of putrid measles (Medical Observations, vol. iv.; Hoffman. Opp., torn- ii-, p. 67); if, indeed, this were an ex- ample of the genuine disease, of which there is some doubt; though there is little doubt, that in a few constitutions the disease has taken this turn. " In a charity-school where measles pre- vailed," says Dr. Perceval, in commenting on this species as given in the Nosology, " typhous infection was introduced ; hence the variety a changed to y." Itis highly probable that some such accidental cause occurred in producing Sir William Watson's modification. Exposure to cold, so peculiarly serviceable to smallpox, has, from a supposed analogy, been recommended also in measles by some rash practitioners, and adopted by others. All fair analogy, however, is against the practice: the fever in measles is directly catarrhal, and the analogy should be drawn, not from smallpox, but from catarrh, in which exposure to cold would, in the opinion of every one, be absurd and mischievous; nor can any thing be so like- ly to produce pneumonic inflammation, which, in truth, is most commonly the result of careless- ness upon this very point. The room should be large and airy, free from currents of cold, but not hot; the drink warm, the food light, diluent, and in a liquid form. If the cough be trouble- some, it will be useful to breathe the steam of warm water, not through an inhaler, but over a large basin, with the head covered with a flan- nel large enough to hang over its edges; and by this means, the inflamed eyes will also have the benefit of the relaxing vapour. If the op- pression of the chest, pain, and coughing should return, as they are apt to do on the disappear- ance of the eruption, venesection or cupping must again be had recourse to, however they may have been employed antecedently. Opium does not, in this case, afford the relief we might expect: it increases the heat and restlessness, but rarely conciliates sleep. A supervening diarrhoea proves the most favourable crisis, and should be very cautiously corrected. And where it does not take place naturally, it may be wise to imitate it by gentle laxatives. From a peculiarity of constitution, or some accidental influence exercised over it at the vein, or apply leeches, &c. One would not pay great attention to these symptoms before the erup- tion occurs; but if they be severe, when the erup- tion comes out, blood should be taken. Moderate purging is proper, and low diet."—Dr. Elliotson's Lect. at Lond. Univ., as published in Med. Gaz, for 1832-33, vol. xi., p. 70.—Ed. 606 ILEMATICA. [Cl. III.—Ord. III. time, the rubeolous rash is sometimes found to run through its regular course with little fever or catarrhal affection, as though it were a. simple cutaneous eruption, and without appearing to afford an immunity to the individual against a future attack ; constituting our second species. This has usually been called, and especially by the German writers, spurious measles ; but as it occurs most frequently when the genuine measles are epidemic, and is doubtless a result of their contagion, it is less properly a spurious than an imperfect or immatured rubeola ; and I have hence, exchanged the term spuria for in- cocta. Dr. Willan denominates it rubeola sine catarrho; but, as the genuine measles them- selves, capable of affording emancipation, have sometimes appeared with very slight catarrhal symptoms, incocta seems preferable. " Some," says Dr. Heberden, " have been so fortunate as to have the measles appear after suffering so very little from fever, or any of the preparatory symptoms, that they could hardly say they had ■ been ill." In this case, the constitution is pro- tected by a natural insusceptibility of the dis- ease ; which is the best protection that can be enjoyed. In the case of imperfect measles, it is only operated upon by some temporary in- fluence : and hence, as soon as this influence ceases, the common susceptibility • returns. The THIRD VARIETY, Or BLACK MEASLES, seems to consist in an intermixture of dark, dis- coloured, or petechial spots from effused blood, with the proper rubeolous rash. It is found chiefly in persons of debilitated and relaxed fibres : and the dark patches will sometimes re- main for ten or twelve days after the commence- ment of the eruption, with no other symptoms of fever than a quicker pulse and an increased degree of languor. It is rarely of serious con- sequence, unless a typhous infection be accident- ally communicated, as mentioned by Dr. Perce- val, and usually yields with ease to an infusion of bark with sulphuric acid. Inoculation has been tried for the measles by employing the acrid serum from the eyes, or from minute vesicles that sometimes appear be^ tween the patches of the rash. Dr. Home, not being able to obtain a contagious ichor from either of these quarters, drew blood from a tur- gid cutaneous vein, where the eruption was most confluent, and, impregnating a dossil of cotton with it, he applied the cotton to a wound made in the arm. It has occasionally succeeded, but more frequently failed ; nor doe,s it seem to operate with any certainty in producing a mild modification; for many of the cases of inocu- lated measles have been quite as severe as we might reasonably have expected from a natural attack. It is, in truth, a very unnecessary cau- tion in a disease which, in its ordinary range, excites so little alarm, and never leaves any blemish, like the smallpox, on the skin. [While the editor coincides with the author on the question of inoculating for the measles, he deems it proper to mention that it is a point on which much difference of opinion has pre- vailed. This inoculation was performed with seeming advantages by Home and Horst, and it has been recommended by Vogel, Perceval, Brown, Monro, and Tissot. On the other hand, it has been condemned by Cullen, Girtanner, Rosenstein, Vaidy, and Montfalcon. In 1822, it was again tried by Professor Speranza (Bib- liolheca Italiana, Agoslo, 1825 ; also Ed. Med. Journ., No. xc, p. 218), of Mantua, in many instances, all of which proved mild. A slight cut was made into one of the most vivid of the large spots with a lancet, the point of which was covered with the blood effused. With this, some small punctures were made in the arm, and a bandage applied.] SPECIES III. ENANTHESIS URTICARIA. NETTLE-RASH. RASH IN FLORID, ITCHING, NETTLE-STlNG WHEALS ; APPEARING ABOUT THE SECOND DAY ; IRREGULARLY FADING AND REVIVING, OR WANDERING FROM PART TO PART J FEVER A MILD REMITTENT. This, like the last species, is rather a troub- lesome than a dangerous complaint,* though it is always attended with some slight disorder of the constitution, as headache, drowsiness, coldnesj, and shivering, succeeded by great heat, and a white fur on the tongue. But the stom- ach seems chiefly to suffer ; and hence there is not unfrequently pain and sickness in this or- gan, with great languor, faintness, and anxiety. And, as a sympathetic affection, the eruption has often followed any violent disturbance of the stomach alone, as surfeit, cold cucurbita- ceous or other indigestible vegetables, mush- rooms, crab-fishes, shrimps, herrings, muscles, t cupreous or other mineral poisons, introduced into the stomach by mistake. The exciting cause, however, of genuine idiopathic nettle-rash, is usually concealed from us ; for it often makes its appearance without any of these irritants, or, indeed, any other that we are acquainted with ; and hence Dr. Heberden was inclined to believe that the skin itself is often the chief seat of the disorder, and that the stomach and the system only suf- * Rubeola, on account of its tendency to bring on inflammation of the bronchial membrane, lungs, or pleura, is a more serious disorder than urticaria. The latter rarely proves fatal ; but many children die of measles. An examination of the bills of mortality in some months of the year, would afford ample proof of what is here stated.—Ed. t Other articles of food might be mentioned as producing urticaria—for example, strawberries, some kinds of honey, cherries, fresh pork, and goose; also fish, at some particular seasons, es- pecially mackerel, oysters, &c. Alibert (Monogr. des Dermatoses, vol. i., p. 128) mentions its occur- rence in a butcher, after skinning the body of an emphysematous cow ; the vapour which escaped from the ntestines and cellular tissue suddenly caused all the phenomena of urticaria, which was very stubborn : and Gibert (Manuel des Maladies speciales de la Peau, p. 19) states instances where it has been caused by affections of the mind.—1>. Gen. I.—SrE. 3.] ENANTHESI fer secondarily.* He has hence contemplated it as a modification of lichen, closely connected with the prickly heat of the West Indies, the es3era, or rather eshera U-i] of the Arabian writers. The resemblance is close ; but there are characters by which the two diseases may be distinguished with tolerable ease. In nettle- rash, the efflorescence is in scattered wheals, with few papulae ; in lichen, in scattered papula?, with few wheals. In the latter, the itching is more mordicant and aculeate ; the eruption, in- stead of terminating in a few days, runs on to an indeterminate period, and, however irritating, produces little or no fever, and but a slight con- stitutional affection of any kind. In Sauvages, on the contrary, nettle-rash is treated of as a scarlet fever under the name of scarlatina urticata. But its character, as given in the specific definition, is sufficient to distin- guish it from any form of rosalia, which has no wheals, or elevated beds with a defined outline, and no sensation of stinging. The nettle-rash occurs chiefly in summer, and more frequently among persons of the plethoric or sanguine habit, especially those who indulge too freely in eating and drinking. In children it seems sometimes to be connected with teething, or irritation of the bowels. The eruption commonly takes place at night, after the febrile symptoms just noticed have pre- vailed for about thirty or six-and-thirty hours: and, on this account, the Arabians elegantly and correctly denominated the coloured wheals \j\\ {» j\\j (benat-allil), " offspring or daugh- ters of the night." By the length of the precursive symptoms, the idiopathic diseaseis distinguished from the sympathetic affection, so closely resembling it, which is occasioned, as already observed, by crapulence, or substances introduced into the stomach that disagree with it. In this last case, the general swelling and eruption take place immediately, and subside as soon as the occa- * Med. Trans., vol. ii., p. 173. According to Dr. Elliotson's observations, the most frequent cause of urticaria is the application of cold, especially when the body is heated. It is perhaps sometimes induced by sudden heat. It will fre- quently arise from an emotion of the mind, or from certain ingesta. In some, almonds and the kernels of various fruits will occasion it, or rather the skin of such kernels, in consequence of its containing hydrocyanic acid, which will now and then have the same effect. So intense is the idiosyncrasy of some persons with respect to its excitement by muscles, that Dr. Elliotson heard of a woman in whom urticaria was induced by one teaspoonful of water in which muscles had been boiled. In some people, he says, malt liquor, white wine vinegar, and common spirits will pro- duce it. Many persons on taking copayva become covered with nettle-rash.t He has known it ex- cited by sulphate of quinine, opium, and subcar- bonate of iron in treacle.—Ed. t Dr. Hewson, of Philadelphia (N. A. Med. and Surg. Journal, vol. v.), has mentioned a case of this kind.—D. 3 URTICARIA. 607 sional cause is removed. Wheals of a similar appearance are sometimes1 found, with other pe- culiarities, as of a whiter hue, or' interspersed with small tubercles, or of very small diameter, except when they unite in clusters : some of these sorts trouble the skin permanently; others vanish and reappear several times in the course of the day ; others subside for a week or two, and then rally and reoccupy their sta- tions. But all of them are of chronic dura- tion, are little accompanied with fever, and cannot be considered correctly as varieties of the idiopathic disease. They occur, however, as such, in Dr. Willan's treatise. A cooling regimen, and subacid diluents, with a free exposure to pure air, generally succeed in effecting a cure of nettle-rash, without any other medical treatment. A gentle laxative or two, however, should be added to the domestic means,* and, if the itching be very troublesome, it may be often allayed by the use of campho- rated vinegar, t Dr. Willan describes a single case in which urticaria proved fatal.—(Cutaneous Diseases, p. 401.) The patient was a man of about fifty years of age, who had impaired his constitution by hard labour and intemperance. The pre- cursive symptoms were all violent, and the sickness and languor were followed by fainting- fits ; and he had great pain in the stomach, which was increased by pressure. The fever was considerable, and soon attended with de- lirium. While the rash was most vivid, his in- ternal complaints abated ; but he gradually got worse, and died on the seventh day. Here, however, the urticaria seems to have been only symptomatic. It afforded him relief, and of- fered the only chance of a recovery. X * About four years ago, a lady in Charlotte-street, Bloomsbury, was attacked with severe pain in the stomach, occasional sickness, and febrile symp- toms, followed by an affection of the skin, which her family supposed was erysipelas; but it turned out to be urticaria. In this case emetics and pur- gatives may be said to have failed; for, though they gave partial relief, it was only temporary, and every night fresh wheals came out, and the febrile symptoms underwent an exacerbation, until bleeding was practised, which at once stop- ped the disease. The editor particularly noticed, in this instance, how very rapidly changes oc- curred in the look of the eruption ; so that, while he was in the room, the rash in some places would almost fade away, or change its appearance and form, and assume an increased redness. Dr. Elliotson, in his valuable lectures, relates several facts, showing the efficacy of venesection as a means of relieving urticaria. If the cause be in the stomach, he does not object to an emetic.—En. t The local applications preferred by Dr. El- liotson for alleviating the itching, are the chlorides of soda and lime, and lotions containing prussic or nitric acid.—Ed. X This affection may be intermittent, a case of which is mentioned by Cazenave as accom- panying a quotidian intermittent fever: it was cured by Fowler's arsenical solution, after other means had failed. Prof. Dewees seems to have been the first who recommended this remedy for this purpose. Quinine, however, is generally preferred.—D. 608 H^MATICA. [Cl. III.—Ord. III. GENUS II. . EM PHLYSIS. ICHOROUS EXANTHEM. ERUPTION OF VESICULAR PIMPLES FILLED PRO- GRESSIVELY WITH AN ACRID OR COLOURLESS, OR NEARLY COLOURLESS FLUID J TERMINA- TING IN SCURF, OR LAMINATED SCABS. Th% term emphlysis is derived.from the Greek tH or iv, "in, intra ;" and not un- frequently led to serious and even fatal conse- quences, by putting those who have had the disease off their guard against variolous infec- tion. And where this error has been commit- ted, and the smallpox has afterward been re- ceived, it has led to a second mistake, by in- ducing the patient to believe that he bas had the smallpox a second time. The two diseases, indeed, were long con- founded by physicians of the highest character : they were regarded alike by Morton ; and even in Sauvages, varicella is described under the name of variola lymphatica.} This, however, is a subject we shall further examine into under should generally afford immunity from the latter disease to those who have once had it. The cow- pox, however, is far milder than smallpox, and strictly a contagious disease, not, like the latter, infectious.—See Dr. Elliotson's Lect. at Lond. Univ., as published in Med. Gaz., vol. xi., p. 305. —Ed. * Little Smallpox. t See upon this subject the remarks under Em- pyesis Variola, or Smallpox, Gen. III., Spec. 1, of the present Class and Order. 618 II.EMATICA. [Cl. HI.-Ord. III. smallpox.* Suffice it for the present to ob- serve, that varicella is adequately ascertained to originate from a peculiar specific contagion; and the characters by which it is sufficiently distinguished from smallpox are, that its fluid, except in a few anomalous cases, is limpid throughout; the disease, in short, is vesicular ; and that, as early as the third or fourth day from the eruption, it concretes into crusts, which are thrown off without indenting the cutis ;t while, in smallpox, the fluid consists of pus as soon as formed, and does not concrete into crusts till the seventh day, and often much later. Like the smallpox, it does not attack the same person a second time, excepting in a few anomalous constitutions, that establish rather than oppose the general rule. " I wetted a thread," says Dr. Heberden, " in the most concreted pus-like liquor ofthe chickenpox which I could find, and, after making a slight incision, it was confined upon the arm of one who had formerly had it: the little _wound healed up immediately, and showed no signs of any infection."—(Medical Transactions, vol. i., art. xvii.) In the ordinary course of the first three vari- eties, the pyrectic symptoms are so slight as not to require medical attention; and sometimes there is no fever whatever. The eruption makes its appearance chiefly on the back, and is often confined to it; and the number of vesicles varies from 20 to 200. I have sometimes, how- ever, known the eruption preceded by almost as severe febrile signs of shivering, sickness, head- ache, and pain in the limbs, as that of smallpox, but the symptoms have always subsided when the vesicles have appeared. In this case an active purge should be ad- ministered, succeeded by some diluting drink ; and the patient should be confined to a quiet, spacious, and well-ventilated room, with a cool dress, till the febrile symptoms have left him. For the fourth variety I am entirely indebted to the observant and indefatigable eye of Dr. Heberden ; for it has never occurred to me, nor is it to be found in the table of the Nosologists. " This disorder," says he, " is preceded for three or four days by all the symptoms which forerun the chickenpox, but in a much higher degree. On the fourth or fifth day the erup- tion appears, with very little abatement of the fever ; the pain likewise of the limbs and back still continues, to which are joined pains of the gums. The pocks are redder than the chicken- pox, and spread wider, and hardly rise so high, at least not in proportion to their size. Instead * Gen. III., Spe. 1, of the present Order, Empy- esis Variola. With regard to the question, wheth- er varicella is only a mild and modified form of smallpox, Dr. Elliotson thinks that we are not in possession of all the information required to en- able us to deliver a positive opinion.—Ed. t After this disease Dr. Elliotson has frequently seen ecthyma, and rupia, and pitting take place, in the same manner as after smallpox. He had the smallpox himself, and was not pitted at all; but the chickenpox came afterward, and left several pits.—See Lect. at Lond. Univ., as published in Med. Gaz., vol. ii., c 308.—Ed. of the little head or vesicle of the serous mat- ter, these have from four to tenor twelve. They go off just like the chickenpox, and are distin- guished from the smallpox by the same marks ; besides which, the continuance of the pains and fever after the eruption, and the degree of both these, though there be not above twenty pocks, are, as far as I have seen, what never happen in the smallpox."—(Med. Trans., ut supra.) SPECIES V. EMPHLYSIS PEMPHIGUS. VESICULAR, OR BLADDERY FEVER. VESICLES SCATTERED OVER THE BODY J TRANS- PARENT; FILBERT-SIZED; WITH A RED IN- FLAMED EDGE, BUT WITHOUT SURROUNDING BLUSH OR TUMEFACTION ; ON BREAKING DIS- POSED TO ULCERATE J FLUID PELLUCID, OR SLIGHTLY COLOURED; FEVER A TYPHUS. The term pemphigus is derived from the Greek wt^'^' " flatus, bulla," and hence infla- tion, bladder, bubble. The idea of flatulence, however, is seldom connected with this disease in modern medicine, though very generally in ancient. The term, in the sense in which it is now commonly understood, was perhaps first employed by Sauvages, and has since passed into common use. It is still doubted by many, whether pemphigus is entitled to be considered as a distinct and idiopathic disease ; and whether all its varieties and modifications may not re- solve themselves into certain peculiarities of erysipelas" or pompholyx, the latter of which consists of similar vesicles, or bullae, without fever; or into mere symptoms of typhus or plague. Gulbrand appears to have been of the former opinion ; and. hence he has denomina- ted the disease erysipelas vesiculdre (Act. Soc Med. Hafn., tom. i.) : Dr. Cullen seems to have been of the latter at the time of drawing up his definition, and still later, at that of drawing up his First Lines, in consequence of which he dis- misses it, in a single paragraph, as an affection concerning which he can say nothing. But the fourth edition of his Synopsis contains a sub- joined note, which intimates that his opinion was altered in consequence of having seen a patient shown him by Dr. Home, and who was labouring under this disease, as an idiopathic affection, at the time. And when to this we add the authority, not merely of the earlier wri- ters, Bontius, Seliger, and Langhans, but of Frank, Withers, Clarkson, Christie, Ring, Braune, and Dr. Stewart of Aberdeen, it would be unpardonable not to allow it a distinct place in a general system of nosology.* * Pemphigus may make its appearance as an idiopathic disease, or as sympathetic of some vis- ceral inflammation; oritsbulkB may occur during the course of other diseases, more especially those of the skin, principally erysipelas, herpes, pru- rigo, scabies, and varicella. It is asserted by some writers, that the bullae of pemphigus are occa- sionally found on the mucous membrane of the stomach and intestines. Rayer admits the occa- sional existence of bulla? on the mucous mem- Gen. II.-Spe. 5.] EMPHLYSIS PEMPHIGUS. 619 Upon a careful rev;ew i', appears to offer the three following varieties, which run parallel with those of Dr. Willan, though not exactly taken from him :— a Vulgaris. Vesicles appearing on the Common vesicu- second or third day, occa- lar fever. sionally not till the fifth or sixth ; in successive crops: often extending over the mouth and intes- tinal canal; fluid, on burst- ing, yellowish ; some of the vesicles livid, with a livid base. 0 Glandularis. Preceded by tumefaction Glandular vesic- of the neck and throat ; ular fever. vesicles chiefly seated on the fauces and conglobate glands; occasionally pro- ducing abscesses ; highly contagious. y Infantum^ Vesicles irregularly oblong, Infantile vesicu- with livid edges and com- lar fever. monly flattened tops; ap- pearing successively on different parts of the sur- face of infants a few days after birth; on breaking, purplish. We shall have occasion to observe, under variola, that Frank, who made a different di- vision of pemphigus, undertook to include under it varicella, crystalline, and hornpox, and many of the forms of disease which have been de- nominated spurious smallpox. The first variety, or common pemphigus, is the pemphigus major of Sauvages, a very marked case of which is given in a communi- cation of Dr. David Stewart to Dr. Duncan of Edinburgh.—(Edin. Mtd. Comment., vol. vi., p. 79.) It appeared on a young private of the seventy-third regiment, who had for a fort- night or three weeks antecedently been unwell from a sudden retrocession of measles, pro- duced by an exposure to cold, and afterward to a damp unventilated apartment. He was re- ceived into the hospital at Aberdeen April 15, at which time he complained of headache, sick- ness, oppression about the praecordia, thirst, sore throat, difficulty of swallowing ; his tongue was foul, his skin hot, pulse from 110 to 120, rather depressed. The whole surface was in- terspersed with vesicles of the size of an ordi- nary walnut; especially the breast and arms. In the interstices, the appearance of the skin was natural ; and the distance from one vesicle to another was from half an inch to a hand's breadth or more. The disease did not seem to be contagious, as the patient was a solitary instance of it, both where he resided before and brane of the mouth, but denies their existence in the stomach and intestines. The case recorded by Dr. Dickson disagrees with Rayer's view, though it was certainly unconfirmed by any post- mortem examination, the patient having recov- ered.—Dr. Corrigan in Cyclop, of Pract. Med., art. Pemphigus.—Ed. after his reception into the hospital. His chief medical treatment consisted in bark and port wine, with acidulated drinks ; many of the ves- icles broke, and discharged a bloody and most offensive ichor; the cutis, upon a rupture of the vesicles, was for the most part sound, of a deep-red hue, and in some places livid. A new cuticle was gradually produced : and on April 27, being twelve days from his reception into the hospital, he was dismissed perfectly cured. In this case the bullae do not seem to have reached below the throat in an internal direc- tion, nor lower than this region in the severer case described by Seliger. In the first instance the vesicles appeared abruptly, and had burst and were healed in seven or eight days. In Seliger's case they issued more gradually, and. in successive crops, ran through a longer period, and were not healed till the twenty-first day.— (Ephem. Act. Nat. Cur., dec i., ann. viii., obs. 56.) Dr. Frank gives a case of a like kind, that continued to migrate over different parts of the body for sixteen days, accompanied with difficulty of breathing, subsultus, and pain at first in the region of the liver, but afterward in the chest, assuming the guise of peripneumony. —(De Cur. Horn. Morb. Epit., tom. iii., p. 266.) In a case apparently of the same kind, published by Dr. Dickson, there is evident proof of the disease having extended from the fauces through- out a considerable part of the alimentary canal: here also the vesicles appeared in successive crops, especially on the ninth,, tenth, and thir- teenth days, each crop continuing four or five days before it burst; the fever was accom- panied with delirium, but abated on the fifteenth day on the appearance of the catamenia, and the bullae healed in succession without any trouble.—(Trans, of Royal Irish Acad., vol. i., 1787.) None of these appear to have been con- tagious.* I cannot speak of pemphigus from personal knowledge ; but in all the above instances, the fever was of a low or typhous type ; and the disease seems to have approached the nature of erysipelas, and was treated successfully by the means usually employed for the latter.t For what little knowledge we possess of the second or glandular variety, the contagious pemphigus of Dr. Willan, we are chiefly in- debted to Dr. Langhans, a Swiss physician, who observed it in the spring and through the summer of 1752, in the lowlands of his own * In the abdominal viscera, the changes most frequently observed in fatal cases of pemphigus are redness, softening, and ulcerations ; the ordi- nary effects of gastro-enteritis.—Dr. Corrigan, op. cit. t According to Dr. Corrigan, the fever which sometimes precedes or accompanies the bullae of pemphigus, makes no approach to the regularity of the fevers of measles or scarlatina ; but is, on the contrary, very irregular in its nature and dura- tion. It may be a short inflammatory fever, or of a low typhoicf type, or it may assume the characters of an intermittent. The period of the fever, when the eruption occurs, seems also to be equally un- certain.—See Cyclop, of Pract. Med., art. Pem- phigus.—Ed. 620 H^MATICA. [Cl. III.—Ord. III. Country.—(Act. Helvet., tom. ii., p. 260.) It commenced with a sense of tension in the fau- ces, and a slight pain spreading behind the ears to the anterior part of the thorax, accompanied with the symptoms that mark the first stage of fever, but not succeeded by a hot fit. A green- ish bilious matter was sometimes thrown up from the stomach, and the pulse was feeble. The neck swelled externally and internally about the fauces, bullae were observed ofthe size of a filbert, producing little pain, and containing a yellow ichor of an offensive smell. Soon after- ward similar vesicles were found scattered spa- ringly over the body and limbs, which, if not broken or opened, collapsed on the second, third, or fourth day, and dwindled into whitish crusts. During this period the tumour of the neck often suppurated, or other suppurating tumours formed in some of the conglobate or conglomerate glands, as the parotid, axillary, or inguinal; and the virus of the disease being thus discharged by different outlets on the surface of the body, the patient recovered. But if, before this trans- lation to the surface, there were a sense of weight and anxiety about the thorax, a large abscess was formed internally, and on its burst- ing the patient died from suffocation. Or, if the matter lodged in the external vesicles were by accident repelled before any glandular sup- puration took place, he died almost as suddenly. M. Langhans compares this disease to syphilis, but apparently with little reason ; and Dr. Cullen and Dr. Frank, with not much more, to rosalia paristhmilica. The cause, like that of the sweating sickness, is altogether unknown, and like this disease also, after having ravaged with great fatalityfdr a certain but a shorter pe- riod of time, happily for Switzerland, and per- haps for all Europe, it vanished, and has been heard of no more. Sauvages, indeed, quotes a description of pemphigus from Thiery, which, by some writers, has been supposed to be the same ; but the account is so brief, and at the same time so loose and indistinct, that it is im- possible either to arrange or reason about it. The glandular pemphigus of Switzerland, ac- cording to M. Langhans, was both contagious and epidemic ; so contagious, indeed, as to spread through numerous families with great rapidity, and so malignant, that all persons af- fected by it died. This last assertion, however, compared with what follows, appears to be a little overcharged ; for the author proceeds, as already observed, to point out under what cir- cumstances patients recovered from it; and lays down a remedial process, which, "though at first," says he, " I employed it with anxiety and hesitation, I can now with pleasure recom- mend to all persons labouring under the com- plaint, with the most sanguine hone that it will effect a speedy cure." This successful practice, as in the sweating sickness, consisted in exciting a strong deter- mination to the surface by active sudorifics ; and at the same time supporting the strength with camphire and other cardiacs. He com- menced his process, however, by venesection, which was sometimes repeated, and where there was danger of an abscess in the lungs, unques- tionably with great judgment. The infantile pemphigus* appears, as al- ready noticed, most commonly a few days after birth; but in one case adverted to by Dr. Willan, as late as ten months after this period. The vesicles show themselves on the neck, upper part of the breast, abdomen, groin, scrotum, and inner parts of the thighs. They arise succes- sively, break, and expose a surface that heals with difficulty, and more generally enlarges its boundary, and wears out the little patient with pain, restlessness, and want of sleep. Warm cordials, as camphire and the aromatic confec- tion, with a little port wine negus, form the best means of supporting the strength ; and laudanum must be had recourse to where the want of sleep requires it. SPECIES VI. EMPHLYSIS ERYSIPELAS. ST. ANTHONYS FIRE. VESICATION DIFFUSE ; IRREGULARLY CIRCUM- SCRIBED ; APPEARING IN A PARTICULAR PART OF THE BODY, CHIEFLY THE FACE, ABOUT THE THIRD DAY ; WITH TUMEFACTION, AND ERYTHEMATIC BLUSH : FEVER USUALLY AC- COMPANIED WITH SLEEPINESS, OFTEN WITH DELIRIUM. In describing the genus erythema, I endeav- oured to point out a distinctive line between that inflammation and erysipelas, which are so often intermixed and confounded even by good writers ; and observed that the first bears the same analogy to phlegmon as the last to small- pox. Phlegmon is local inflammation tending to suppuration; erythema local inflammation tending to vesication : smallpox is an idiopathic fever producing a phlegmonous efflorescence ; erysipelas an idiopathic fever producing an eryth- ematic efflorescence. Smallpox is always con- tagious : erysipelas occasionally so : phlegmon and erythema have no such tendency. [The plan of classing erysipelas with the ex- anthemata does not receive the universal sanc- tion of medical writers. In particular, Mr. Lawrence does not concur in its propriety. " If we were," says he, " to construct a natural arrangement of diseases, we should, perhaps, find sufficient reason for separating erysipelatous affections altogether from the febrile exanthe- mata. The latter form a natural order, well characterized by the fever preceding the local disease, by their origin from a single specific cause, namely, contagion, by their regular periods of efflorescence and decline, their definite dura- tion, and by their generally affecting an individual only once in his life. Erysipelas (here, it is to be observed, Mr. Lawrence uses the term in the sense of the author's erythema) arises from various causes, among which it is doubtful whether contagion is to be included ; it is often * Sometimes named gangrenous pemphigus ; it is the rupia escharotica of Bateman and Biett. Dr. Corrigan describes, under the name of chronic pem- phigus, what Bateman calls pompholyx diutinus, and Alibert dartre phlyctenoide confiuente.—Ed. Gen. IL—Spe. G.] EMPHLYSIS ERYSIPELAS. 621 not preceded by fever ; its course is various and uncertain, its duration indefinite, and it attacks the same individual repeatedly."—(Med. Chir. Trans., vol. xiv., p. 34.) Now, although the erysipelas of Dr. Good is, in imitation of Cullen, restricted to the febrile disorder that is followed by erythema, or erysipelatous inflammation, as an effect, it must be admitted that it wants many of the striking features pointed out by Mr. Lawrence as characterizing exanthemata in gen- eral. At the same time, the distinction of erysipelas as a fever leading to erythema, or erysipelatous inflammation, as a Tegular event, ought undoubtedly to be discriminated from other cases, in which the local affection comes on first, and whatever disturbance of the system ensues is merely the effect of it.] The varieties of this species are very differ- ently given by different writers ; by many of whom they are multiplied most unnecessarily. Dr. Cullen makes even the herpes Zoster, or shingles, a variety : but this is strangely to con- fuse simple cutaneous diseases with idiopathic fevers. For that erysipelas, when genuine, is an idiopathic fever, dependant upon or produc- tive of a specific virus, is clear, because it has often, though not generally, been found con- tagious, and is capable of propagation by in- oculation. " When the acrimonious lymph," observes Dr. Willan, " contained in the phlyc- taenae or vesications of a genuine erysipelas is inoculated or casually applied to any slight wound in a person otherwise healthy, it pro- duces febrile symptoms, with a red and painful, but diffuse swelling, analogous to that of the disease from which the virus was derived."— (On Cutaneous Diseases, p 514.) And he has added a case, in which the mother of a young girl, severely affected with this disease, appears to have received it in consequence of having nursed her. Dr. Wells has strengthened the doctrine of its contagious property by a variety of facts and cases, that can scarcely, I should think, be read by any one without conviction.—(Trans, of a Soc. for the Impr. of Med. and Chir. Knowledge, vol. ii., p. 213.) One of his examples ex- tends to four individuals, who received the dis- ease in succession, after direct contact or near approximation with each other ; and another gives us a like chain of not less than six in descent, all of whom, indeed, he did not attend personally, but the history of whom, as com- municated to him by one of the affected, was confirmed by Dr. Pitcairn, who had been con- sulted by two of the rest, and was privy to the general fact. Dr. Pitcairn also communicated to Dr. Wells the following highly important statement in addition :—" A lady, immediately after delivery, was attacked with a fever, which was accompanied with an affection of her skin somewhat like erysipelas ; her child, about three days after its birth, was seized with that species of erysipelas the French call la gelure, which first appeared about the pudenda, and afterward extended itself to other parts of the body, among the rest to the face. Both the lady and her child died, after a few days' illness ; and about eight days after the death of the child, the lady's mother and servant-maid, both of whom had at- tended it during its illness, were attacked with erysipelas of the face, from which both of them recovered." The opinion of Dr. Baillie, as communicated to Dr. Wells on another occa- sion, is to the same effect; to which Dr. Baillie seems to have been more especially led, by having observed in " a part of the years 1795 and 1796, that the erysipelas of the face was much more frequent in St. George's Hospital than he had ever before known it to be : that many persons were attacked after they came into the hospital, and that the number in a par- ticular ward was much greater than in any other."* This last remark seems to give some counte- nance to the further opinion that erysipelas be- comes occasionally an epidemy, or operates through the medium of the atmosphere, as well as by direct contact ; though, whether the at- mosphere, in this case, be impregnated with the specific miasm of the disease, or merely predis- poses the body to a more ready generation of it, has no more been determined than in the case of various other exanthems that evince a like power. Dr. Parr asserts broadly, " we have four times seen it epidemic; and more than once we have had reason to suspect that it was communicated by infection."t At first sight it might seem easy from these accounts to subdivide erysipelas into the two varieties of contagious and uncontagious ; but, * See also " Cases illustrating the Contagious Nature of Erysipelas, and its connexion with a severe Affection ofthe Throat," by J. Stevenson, M. D., in Edin. Med. Chir. Trans,vol. ii. t Diet, in verbo. The doctrine of erysipelas being contagious is much more doubted at the present day than that of its being sometimes epi- demic, and prevailing extensively in particular situations, seasons, and,states of the atmosphere. Some of the cases published by Dr. Stevenson, of Arbroath, to illustrate the contagious nature of erysipelas (see Edin. Med. Chir. Trans., vol. ii., p. 128, et seq.), appear to the editor to be only an epidemic form of sore throat, sometimes involving the larynx, as described by Bretonneau, and no- ticed in this work, under the head of bronchlem- mitis. The possibility of any textures, except those of the integuments, being truly the seat of erysipe- latous inflammation, is doubted by Mr. Lavyrence. The editor, however, will not venture to deny Mr. Hunter's position, that, when there is a tendency to this form of inflammation in the habit, every inflammation, whether external or internal, may partake of its character in some respects, and he, for instance, more disposed to spread. Mr. Hunt- er's opinion, perhaps, has received some support from three cases mentioned to the Medical and Chirurgical Society of Edinburgh, by Dr. Aber- crombie, Dr. Hay, and Mr. Bryce, where the in- flammation appeared to have spread from the fauces to the external surface, the part of the skin first affected having been, in the first two cases, at the orifice of the nostrils, and, in the last, at one of the lachrymal ducts.—(See Edin. Med. Chir. Trans , vol. ii., p. 135.) The facts published by Dr. Wells, and some others by Mr. Bury, of Farnham (Med. Gaz., July, 1833), are among the strongest adduced in support of the occasionally contagious n?.t.ure of erysipelas.—Ed. 622 H^M- as it is most probable that the power of com- munication depends alone upon the peculiar diathesis of the person who receives it, as being endowed with a susceptibility Of the disease not possessed by others, we can make nothing of this discrepance : and shall hence examine it under the following varieties, founded upon other circumstances :— a Locale. Limited to a particular part; Local erysip- cuticle raised into numerous elas. aggregate distinct cells ; or the cells running into one or more blebs or large blisters. 0 Erraticum. Travelling in successive patch- Erratic erysip- es from part to part : the elas. earlier patches declining as new ones make their ap- pearance. Local erysipelas generally exhibits itself on one side of the face, or on one of the limbs. In the former case, the disease begins with coldness and shiverings, which alternate with irregular flashes of heat, and other symptoms of pyrexy. Dull aching pains are felt in the head, neck, and back. The swelling usually appears in the course of the second night or the third day; though I have sometimes known it take place within a few hours after the attack : the redness disappearing when pressed upon by the finger, but returning as soon as the pressure is removed. The eruption fixes on one side of the nose, or the cheek, temple, or forehead ; is of a dark-red colour, smooth and soft, and attended with a sensation of heat and tingling. The redness and swelling extend gradually over the affected side of the face; and spread, in some cases, to the scalp, and to the side of the neck, or the upper part of the breast. Hence the face appears much disfigured ; the mouth is drawn to one side ; the eyelids are turgid, and close up the eye ; the fever increases, and is often attended with delirium. On the fourth and fifth day vesications arise on idfferent parts of the diseased surface, especially about the centre; but with an increase rather than a diminution of the fever. The vesicles or bullae are of different sizes, and have an irregular base. The fluid contained in them is at first clear and watery ; it afterward becomes straw-coloured or opaque, occasionally slightly livid, without losing its transparency. The cuticle gives way in a few places', and the fluid oozes through the cracks. About the eighth or ninth day, and sometimes sooner, the redness changes to a brown or yellowish hue, the bullae subside, and the cuticle dries and desquamates, or scales off. Occasionally, both sides of the face are affected at the same time; but sometimes the morbid half is separated from the sound by an exact line drawn across the forehead, down the mid- dle of the nose to the chin. The fever subsides about the eighth or ninth day, but sometimes after its cessation it returns suddenly with as much violence as at first, and continues two or three days longer. A sanious fluid, approaching the nature of pus, is sometimes found in parts of the vesication : and from this circumstance lTICA. [Cl. HI.—Ord. Ill Dr. Cullen has distinguished one variety of the disease by the name Sf erysipelas phlegmonodes : and has been copied by Dr. Willan. " A cir- cumscribed cavity," says Mr. Pearson, "con- taining laudable pus, is never seen in the legiti- mate erysipelas.* Where a purulent effusion happens in any considerable degree, it affords, when the part is examined, a sensation similar to that excited by a quagmire or morass. In that sort of suppuration which sometimes su- pervenes to erysipelas, the cellular membrane suffers great injury, and not uncommonly the part is in a gangrenous condition."—(Principles of Surgery, $ 289.) When the head is the seat of disease it oc- casionally swells to an enormous magnitude, and when the case is attended with delirium, it sometimes proves fatal. [Often, particularly when the head is the seat of erysipelas (says Mr. Lawrence), the sensorium is principally af- fected, and there is pain and oppression of the head, sleepiness, coma, or delirium. The tongue in such cases becomes dry and brown ; but this is frequently owing principally to the circum- stance of the patient breathing entirely through the mouth ; the pulse is rapid and feeble, and there is great loss of muscular strength ; in short, the symptoms at length are those called typhoid. In other cases, the circulation and the nervous system are not much affected ; but there are many indications of disordered stom- ach and bowels, to which the origin of the local affection must be ascribed. But, as the same gentleman has remarked, the local symp- toms are preceded and accompanied by fever, which always varies in its character, according to the constitution, age, and general state of health. In the young, strong, and those of full habit, it is decidedly of an inflammatory char- acter ; and blood drawn from a vein exhibits the buffy coat in a greater or less degree. In phlegmonous erysipelas, the general and local symptoms are more violent than in simple erysipelas ; the redness is deeper, and the tumefaction more considerable ; the whole depth of the adipose and cellular textures be- ing loaded with effusion, so that an arm or leg appears of twice the natural size.—(Lawrence, in Med. Chirurg. Trans., vol. xiv., pp. 6-9.) As this form of the complaint frequently does not vesicate, and often arises from local injuries, * The opinion that true pus is never formed in phlegmonous erysipelas is contradicted by daily experience ; but that the pus is very seldom con- tained in a circumscribed cavity is a fact particu- larly noticed by Mr. Hunter. Yet, in phlegmo- nous erysipelas, as Mr. Lawrence has pointed out, matter is frequently deposited in small separate collections, dispersed irregularly in the cellular texture. While erysipelas is what Mr. Lawrence calls simple, that is^ confined to the skin, and does not materially affect the subjacent cellular mem- brane, suppuration does not take place. " It may, however," says Mr. L., " become more severe at one point; and thus we occasionally see the for- mation of abscess under the skin towards the de- cline, or after the appearance, of the general erysipelatous redness."—Med. Chir. Trans., vok xiv., p. 5.—Ed. en. II.—Spe. 6.] EMPHLYSIS ERYSIPELAS. 623 perhaps it cannot properly be classed with St. Anthony's fire, or the erysipelas of our author ; but rather belongs to his cases of erythema.] The disturbance of the constitution is generally less violent when the erythema appears in the extremities, than when it attacks the head. The limbs most affected.are the legs, in which, probably from their depending situation, the vesications fill rapidly, and break within twenty- four hours from their first appearance. Sal- mouth relates a case in which the intumescence extended over the entire frame (Cent, i., obs. 32): but this is extremely rare, excepting under the second or migratory form, in which it trails over different parts in succession, till the whole body has been affected. In the erratic variety, the complaint usually, and particularly in adults, begins its attack in the face, and spreads in succession to the extremities, the patch first formed heal- ing as fresh ones appear below. Sometimes, however, other parts are seized first ; and per- haps more frequently so when this variety shows itself in infants ; for here the parts about the navel are usually first affected, and the disease winds downward to the sexual organs, which are often very considerably tumefied and in- flamed. What, however, is usually denomi- nated the infantile erysipelas, is more com- monly a variety of gangrenous erythema, pro- duced, in many instances, by the want of clean- liness, pure air, and nutritive food. The in- flammatory blush soon assumes a livid hue, and is sometimes covered with or surrounded by petechiae : the cuticle is separated to a con- siderable extent from the cutis, breaks, and ex- poses a foul and ulcerating surface that almost immediately passes into a state of gangrene. In some instances, nevertheless, these cuta- neous efflorescences are probably accompanied with a true erysipelatous fever ; for, in lying-in hospitals, the disease is said to have proved occasionally contagious. The erysipelas cedematodes and e. gangra- nosum of Dr. Willan appear to be misnamed, and consequently misplaced. They are more accurately erythemata, and have already been described under the species erythema cedema- tosum and e. gangranosum. The usual causes are cold, intemperance, suppressed perspiration, and the other common excitements of fever operating upon an erythe- matic diathesis, and producing therefore this peculiar efflorescence in connexion with the febrile attack. In almost every instance, there is evidently a diminished vascular action ; and hence we meet with the disease far most fre- quently in persons of delicate habits, women, children, and those who have long resided in warm climates. In one instance, it has occur- red to me in a strong hearty man, of plethoric form and sanguineous temperament, well known to the world as a public character; but in this case the diet had, from the patient's boyhood, been exclusively that of vegetables. [In the preceding paragraph our author is speaking, it is to be remarked, not of the causes of the erysipelatous inflammation, but of the fever which induces it as a regular effect, and to which he particularly restricts the term ery- sipelas. In this particular instance, whatever excites the specific fever, whatever state of the constitution imparts to the general disturbance of the system the peculiarity of its being al- ways followed by the erythema, or erysipelatous inflammation of the skin, must be considered as the cause of the disease. This cause we know not, unless it be admitted, which is not com- monly believed, that St. Anthony's fire either depends upon contagion, or, as Dr. Good has said, the usual causes of fever operating upon an erythematic diathesis. The inquiry, there- fore, if pursued further, would be into the foundation for the doctrine of contagion, and into the circumstances producing an erythe- matic diathesis, or, in plain language, a dispo- sition to erysipelatous inflammation. It is cer- tain that the fever to which Dr. Good restricts the name erysipelas, is frequently connected with disorder of the liver and stomach.] It has occasionally happened, and especially where the disease has occurred as an epidemy in some of the high and healthy villages of North Britain, in the heat of a dry summer or autumn, that, instead of diminished vascular action, there has been such a degree of entony and caumatic fever as to call for free venesec- tion from the first, and of this form a few stri- king examples have been communicated to the author. So, on the contrary, the smallpox and measles, though ordinarily accompanied with cauma, occasionally evince a typhous type, and demand a tonic plan of procedure. The mode of treatment may be expressed in few words. Venesection was formerly recom- mended as a part of the ordinary plan, and has been so of late by a few writers. Yet this is to act without discrimination, and to mistake the exception for the general rule. Passing by the modification just adverted to, and those oc-> casional congestions in the larger organs, and especially in the head, which, even in typhus, and still more in such forms of erysipelas, de- mand a prompt and repeated use of bloodletting, I can conceive very few ordinary cases, in which the lancet has a chance of being service- able ; while the application of leeches always exasperates the efflorescence. As a general plan, we should first cool the body by gentle laxative^, and instantly have recourse to a tonic plan. The bark given largely, as long since warmly and judiciously recommended by Brom- field (Med. Communications, ii., 4) and Colly (Id., ii., 3), has rarely failed of success. Dr. Fordyce was in the habit of giving it, in a dan- gerous state of the disease, in the proportion of a drachm of the powder every hour. He tried it for twenty years, and with growing con- fidence. Where, however, there is much even- ing or night exacerbation, it may temporarily be dropped for some warm diaphoretic, as cam- phire, with small doses of James's powder, or the spirit or compound spirit of sulphuric ether, in saline draughts made with the subcarbonate of ammonia. If the head be much affected, it should be lightly covered with linen wetted 624 H.EMATICA. [Cl. Ill—Ord. III. constantly with vinegar and cold water, or equal parts of water and the solution of ace- tated ammonia : and, if the vesications ooze, they should be frequently dusted with finely- powdered starch, or a powder consisting of half starch and half calamine. The diet should be light and of easy digestion. Opiates have rarely succeeded in procuring sleep ; and have generally added to the mental irritation. [From the foregoing observations it appears, that the author was much under the influence of the doctrine, that the fever, called by him erysipelas, and all kinds of erysipelatous, or, as he terms it, erythematic inflammation, are es- sentially connected with diminished vascular action and debility. Hence his general prefer- ence to tonic and stimulating remedies. After what has been explained under the head of erythema, in a previous section of this volume, p. 450, et seq., it is unnecessary to insist upon the fact, that the local affection is always of an inflammatory nature ; that, abstractedly viewed, it requires antiphlogistic treatment; but that, whether this plan should be adopted or not, must depend upon the stage of the disease, the patient's strength and age, and the type of the fever, whether caumatic or typhoid. Strong, young, and plethoric persons are more frequent- ly attacked with the fever, here implied by erysipelas, than our author's remarks would lead us to suppose : and in all such examples, anti- phlogistic treatment, including general and local bleeding, purgatives, low diet, &c, is indicated. The application of leeches to erysipelatous parts is found to be perfectly safe. The editor has frequently seen five or six dozen leeches put on the head and face in the course of the first week of the disorder. Nor should free and even repeated venesection be omitted, when the pa- tient is young, strong, or plethoric. An emetic is also frequently of great service in the begin- ning of the disease, particularly when there is a bitter taste in the mouth, attended with head- ache and derangement of the stomach. Emetics must not be employed at random: when the tongue is red, and the thirst excessive, they do harm ; when there are no symptoms of disorder of the stomach, they are neither hurt- ful nor beneficial; but when there is bitterness in the mouth, the tongue has a thick white or yellowish fur upon it, without any subjacent or surrounding redness, and the patient has nausea and eructations, which have the smell of sul- phurated hydrogen, emetics are really of great service.—(Andral, Anat. Pathol., tom. ii., p. 224.)] GENUS III. EMPYESIS. PUSTULOUS EXANTHEM. ERUPTION OF PHLEGMONOUS PIMPLES ; GRADU- ALLY FILLING WITH A PURULENT FLUID ; AND TERMINATING IN THICK SCABS, FREQUENTLY LEAVING PITS OR SCARS. Empyesis is a term of Hippocrates, and is to he found in the fifth book of his Aphorisms. It is derived from the Greek lp.irv6io, or i/*irv/o>, " suppuro." The Greek writers also use, and perhaps more generally, ecpyesis, from hnvdia, of similar meaning. The same distinction be- tween the terms is made in the present system, as between emphlysis and ecphlysis : the former being limited to signify pustular eruptions pro- duced by internal and febrile affection, and the latter to signify those that are merely cutaneous or superficial, or with which inteQpal affection is not necessarily associated. The genus empyesis contains not more than a single species that has yet been discovered, and that is— Empyesis Variola. Smallpox. SPECIES I. EMPYESIS VARIOLA. SMALLPOX. PUSTULES APPEARING FROM THE THIRD TO THE FIFTH DAY ; SUPPURATING FROM THE EIGHTH TO THE TENTH : FEVER A CAUMA : CONTA- GIOUS. When the smallpox first made its appearance in the world, we know not. There is no sub- stantial ground for believing that the disease was known to the Greeks or Romans, It has been thought, indeed, by some persons, that the former have glanced at it under the name of anthrax or» anthrace (Hahn, Variolorum Anti- quitates i Gracis eruta, 1734); but the idea is too wild for serious refutation. It is far bet- ter ascertained that it existed in Asia, and es- pecially in China, for an incalculable period before it was known in Europe; and, from the accounts Of the Jesuits, to which we shall have to refer more particularly presently, it is highly probable that the, art of inoculation was prac- tised throughout the Chinese empire before the natural contagion had reached the European shores. About the middle of the sixth century (Mead, De Variolis, p. 3), it is supposed to have been conveyed by trading vessels from India to Arabia ; and there is no question that the triumph of the Arabian or Saracenic arms introduced it from Africa into the Levant, Spain, and Sicily. The pathognomonic characters of the genuine smallpox are, pus in the eruptions, and a power of propagating itself both by contagion and in- oculation. Perhaps, however, there is no exan- them that is so much affected by accidental influences as the smallpox. Idiosyncrasies of various kinds seem to take off all predisposition to the disease, and to render the body inert to its virus ; so that many persons possess a natu- ral exemption, and pass through life without ever suffering from it.* There are other * A striking occurrence, forcibly illustrating this position of the author, took place on board the well-remembered Jersey prison-ship. In this loathsome receptacle, which was specially appro- priated for the confinement of American prisoners, more than one hundred and twenty men were imprisoned, who had never been affected with smallpox either naturally or by inoculation, and Gen. III.—Spe. ].] changes introduced into the constitution from numerous causes, which, though they do not take off all predisposition to the disease in every individual to whom they are applied, afford an entire exemption in many cases, and exercise so controlling a power in others, that the general character of the disease, whenever it makes its attack, is greatly modified, and, for the most part, greatly mitigated ; so that the accompany- ing lever is considerably less violent, the secre- ted fluid, instead of being a creamy pus, is a limpid ichor, desiccating in three or four days, and so far imperfect in its elaboration as to be less capable of propagating itself by contagion or inoculation, or of affording an absolute security against a reproduction of the disease in future: whence many persons, from the wri- tings of the Arabians to those of our own day, are said to have suffered from smallpox, not only twice, but even three or four times in suc- cession. In these accounts, mistakes have, perhaps, often been committed as to the species or even genus of the eruption ; but, in various instances, the disorder has been so narrowly watched, and the judgment of the physician who has described it been so sound and unimpeacha- ble, as to leave no fair ground for doubt upon the subject. Of the nature of the constitutional peculiari- ties that are thus capable of controlling the exanthein, and deflecting it from its ordinary course, we know nothing; and of the causes themselves, which appear to be numerous, we know only a few. The virus of cowpox, intro- duced into the system, is now satisfactorily ascertained to be one of these causes, and ap- parently one of the most powerful. In most cases it affords, as we have already seen, an entire exemption ; and, where it does not alto- gether take off the predisposition, it generally succeeds in giving the disease that modified and mitigated character which has been just noticed. The virus from the ulcerated heels of horses labouring under the disorder called grease (Jen- ner, Inquiry into the Causes and Effects of the Variola Vaccina, 1798), seems also capable, as we shall observe hereafter, of producing a simi- lar control. And, as in most of the more ex- tensive epidemics of smallpox, in every age since its first appearance, we have had numer- ous examples of such modified and imperfect eruptions, varying in almost every diversity of manner from each other, as well as from the regular pustules, but evidently produced by associating with patients affected with the last, and not unfrequently by inoculation itself from pure pus—examples in which neither of these causes have been present—we are compelled to admit, that there are numerous other causes existing, perhaps other diseases existing as yet of that number less than two thirds were at- tacked with the disease, which, however, proved extremely fatal. One would naturally expect, that in such a place the specific virus of smallpox would act with much more violence. This fact was* communicated to Dr. Francis by the late Philip Freneau, of New-Jersey, one of the pris- oners.—D. Vol. I.-Rr EMPYESIS VARIOLA. 625 causes, to which the bodies of those who exhibit such modifications, or anomalous and imperfect sorts, have been previously exposed, and are indebted for so modifying a control, of which also, at present, we know nothing. Rhazes has given . numerous examples of these diversities or aberrations of smallpox, or Al-gridi, as he denominates them, though the more common name was Al-jedder ,jjjl ', and hence the remarks of John of Gaddesden, " notandum quod variolae sunt duplices, propriae et improprise.—(Ros. Anglie, p. 1044.) The impropri.35 it is often difficult to follow up or arrange, in consequence of their discrepances, and especially their resemblances to other kinds of eruption. More commonly they approximate the form and general character of pemphigus or varicella (chickenpox), and have no doubt often been mistaken for the one or the other, espe- cially the latter, of which the severe variolous epidemies that have of late years, after a long dormancy, spread over Edinburgh (Account of the Varioloid Epidemic, by John Thomson, M. D., 8vo., 1820), Caithness-shire, and various other parts of Scotland, as well as over many parts of the continent, afford striking examples; as has also the late variolous epidemic among the inhabitants of Columbo, and the Kandyan provinces at Ceylon, as related by Mr. Marshall.* Many of the cases of this kind, described or collected by Dr. Thomson, to whose indefati- gable zeal the profession is under an irremuner- able obligation, are peculiarly striking; as they consist of families, the different branches of which, receiving it in succession from each other, evinced in turn almost every variety to which the smallpox can make any fair preten- sion, distinct, confluent, crystallized or varicel- lous, and horny; and all of which, in many in- stances, manifested a power of regenerating and propagating the disease in its purest or pustular form, though this was often lost in several of them. The following case, con- tained in a letter from Mr. John Malloch to Dr. Thomson, is peculiarly entitled to atten- tion. " No case of smallpox had occurred in this town for nine years till last winter, when an idle boy, who was in the habit of wandering about the country, frequenting markets, &c.f happened to be at a house where some of the inmates were said to be ill of smallpox. He himself had been vaccinated some years before. On his return home he was seized with febrile symptoms, and confined for two or three days to bed, when an eruption similar to chicken- pox made its appearance. Immediately the fever abated, and in a few days more he left his bed and attended a cattle-market, half a mile's distance from the town, without experiencing any bad consequences. About a week after- ward one of his master's children was taken * Some Account of the Introduction of Vac- cination among the Inhabitants of the Interior of Ceylon, and of an Epidemic Smallpox which pre- vailed in the Kandyan Provinces in 1819. By Henry Marshall, Surgeon to the Forces. 626 H.EMATICA. [Cl. HI.—Ord. III. ill, and went through the regular stages of small- pox in a mild manner ; then a second similarly. A third suffered in a very alarming degree from the confluent kind ; a fourth was rather worse than the two first; and the youngest, of eight months bid, had what, if the other cases had not occurred, I would, without hesitation,,have called chickenpox : for there was little or no fever, and the pustules were filled with a wa- tery fluid, which was not converted into the purulent appearance of smallpox. None ©f these children had undergone vaccination."— (Variol. Epidem., p. 333.) It is very singular that in the Kandyan epi- demic described by Mr. Marshall, while several cases made a very near approach to varicella, all of them so far deviated from the ordinary character of the variolous secretion as to be de- void of a creamy and consistent pus, and rarely to exhibit more than a whey-like matter, wheth- er the eruption were distinct or confluent, or the fever mild or severe. In other respects, Mr. Marshall observes, the disease did not materi- ally differ from the description given of the smallpox by systematic writers. For some days the eruption was papular; it then became vesic- ular, each vessel having a depressed point in the centre. During the early stage of the ves- icles they contained pure lymph ; subsequently they became less pellucid, and assumed a whitish hue ; and, when matured, they contain- ed the above whey-like fluid. " In no instance," says he, " that came under my observation, did the contents of the vesicle assume a yellow eolour and thick consistence, as is stated to oc- cur in smallpox in Europe." These, it should be observed, were not cases that had been preceded by vaccination. Many such occurred, but the eruption was here of a still different and more modified, and even a more mitigated kind, still showing the control- ling power of the vaccine fluid. This eruption, indeed, was occasionally severe, but uniformly appeared after two or three days' fever. For the most part, it was confined to the fore or the upper part of the body, ranging from one or two to thirty papulae, and was remarkably uni- form in its progress. It consisted of elevated hard pimples, containing a vesicle of pure lymph at their apex. These, by the fourth, fifth, or sixth day, reached their full size, and were soon followed by desquamation. It not unfrequently happens, that, in danger- ous cases, the papulae do not rise kindly, but assume the form of stigmatized dots, while the surface is circumfused, generally, with a bright- er or deeper efflorescence, according to the nature of the habit; under which circumstances the disease makes a near approach to rubeola, and has at times been mistaken for it. Of this form, also, the late Ceylonese epidemic, as de- scribed by Mr. Marshall, afforded various in- stances. " There were a few cases," says he, " where the skin assumed a measly appear- ance. Under this description of the disease, the surface of the body resembled wet brown or blotting-paper. The fever continued with- out abatement,, and frequently little or no erup- tion appeared. I am not aware that a single case of this kind recovered." And where, in the confluent variety, the secreted ichor (for the inflammation is seldom suppurative) is peculiarly virulent, we frequent- ly meet with trails of vesicular and fiery eryth- ema spreading over different parts of the swollen body, not unlike, in appearance, to the ignis sacer of that variety of plague which the an- cients peculiarly distinguished by the name of anthrace, and which in the present classification is denominated erythematous plague.—(See Gen. IV., Spe. 1, Var. y of the present Order.) And the resemblance is still more close, when this form of confluent smallpox is combined with bubonous or other ulcers : of which ex- amples are frequent in hot climates, as in the epidemic attack of smallpox at Aleppo, descri- bed by Dr. Russell. " If the sick," says he, " survived the eleventh day, few of them escaped corrosive ulcers with carious bones, or hard swellings in the glandular parts."—(Oct., 1742.) Even in the colder temperature of our own country, the same miserable train of symptoms has sometimes shown itself, as observed by Dr. Huxham, " variolae epidemicae interdum crudo diffluunt ichore, qui subjectam carnem erodit, im6 et nonnunquam ipsa gangraena. afficit."— (Julio, 1744.) It is not very surprising, therefore, that the smallpox, on its first discovery, and, indeed, foir long afterward, should, according to the variety it assumed, have been confounded with all these diseases, and especially with the measles and chickenpox—from their originating, or, at least, being first noticed about the same period, and consequently being equally new diseases. Hence we are told by Rhazes, that Aaron of Alexan- dria, who wrote on this disease as early as a. d. 620, arranged the smallpox, measles, and an- thrace, or erythematous plague, as products of one common specific contagion.—(Rhaz. De Vari- olis et Morbillis, in Continent., lib. xviii., cap. viii., 1486.) The last was, indeed, soon thrown out of the list, but the two former continued to be contemplated by most writers as one and the same disease for eight centuries after the era of Aaron. With respect to the smallpox and chicken- pox, there has been more difficulty. A con- test of no ordinary magnitude arose in early times upon the subject, in support of which, every nation in Christendom, as in the Holy Wars, for many ages sent forth its champions, and the conflict has been of a still longer dura- tion than the Holy Wars themselves. In the midstr therefore, of all this confusion of diseases, nothing can have been more called for than a judicious attempt to distinguish the one from the other, and to lay down their respective landmarks ; and hence, those who have engaged in such an undertaking have ever been entitled to the warmest thanks of the profession. Khazes, in this respect, may be said to have taken the lead. He carried at once the an- thrace, or erythematous plague of Aaron, to a distinct genus from al-gridi, or the smallpox ; and though he continued this last and. measles. n. III.—Spe. 1.] EMPYESIS VARIOLA. 627 <£x*£isJ|' (a' hasbet, rather than al-hasba, as commonly written), under the same genus, he arranged them as distinct species, and conse- quently regarded them as separate diseases ; while._ to the smallpox, thus disentangled and simplified, he assigned pretty nearly the same varieties as have been allotted to it by the most discriminating writers of the present day ; for he very accurately describes the distinct, the confluent, and the limpid or vesicular, including the crystalline and horny ; and treats of the dis- ease under the opposite characters of benign and malignant.—(Rhaz. De Variol. et Morb. See also Mead's Works, vol. ii., p. 163, edit ed. 1765.) Unfortunately, the limpid or lymphatic small- pox was incautiously denominated chickenpox, by way of distinction from the purulent, by many writers of great authority and talents, as Morton (Treatise upon Smallpox, Lond., 1694), Gideon Harvey (Treatise on Smallpox and Measles, Lond., 1696), Mead (De Variol. et Morb. ex Rhaz., Lond., 1766); while, which was more common, varicella or waterpox in all its varieties, was designated by the term variola, though re- garded as having no real claim to such a term, and hence discriminated from the genuine dis- ease by the adjunct spurious or bastard variola, of which Van Swieten furnishes us with a stri- king example. For after having noticed under his description of variola the stcenpochen (stone- pox), waierpochen, and windpochen (Comment., Aph. 1381, vol. v., p. 11, edit. Lugd. Bat, 4to.), all of which he distinctly characterizes by the name of spurious variola, and observed that he has seen them as frequently epidemic as the genuine smallpox, occasionally, indeed, running a race with the latter, and sometimes succeed- ing it, he dismisses them altogether, and pro- ceeds with the history of the genuine disease in all its modifications : telling us that, like Dr. Mead, he had met with the crystalline variety, as well in the confluent as in the discrete form, occasionally, indeed, intermixed with the pus- tular : and that, under this variety, was reckon- ed by the best writers the siliquose, or that which consists of soft and empty vesicles, but which, are sometimes at last filled with pus.— (Comment., ut supra; Aph. 1398.) In much of this he is followed by Sauvages, who, how- ever, regards varicella by name as a distinct variety of smallpox ; while with Hoffmann (Opp., sect, i., cap. iii., p. 293, ed. Gen. 1740), he separates it from the crystalline or lymphatic variety, which he makes synonymous with horn or cornoidal pox (spitzpochen), and waterpox.— (Cl. Ill-, Ord. IL, Gen. II.) A more pointed discrimination, therefore, be- came necessary, and a still stricter attention to the specific characters by which smallpox and chickenpox are distinguishable. This was suc- cessively undertaken by Fuller (Exanthemato- logia, p- 167, Lond., 1730), Borsiero (Burserius) (Institut. Med., torn, ii.), Hosty (Mercure de France, Janv., 1769), Heberden (Med. Trans., i , 427), and Willan ; and has been so far ac- complished as to have satisfied the profession * R r 2 generally, although it has not, perhaps, at any time, set the question altogether at rest in the mind of every one. Of late years, however, the learning and acute- ness of many pathologists seem to have put us in no small danger of going back into all the confusion which existed in former times ; not in any respect from ignorance of the real nature of the eruptive diseases towards which their at- tention has been turned, but from a scientific desire to generalize and simplify them. About thirty years since, Professor Frank, of Milan, dissatisfied with the ground of that gen- eral composure of mind which seemed to have taken place on the subject, commenced a new agitation, and undertook to show that chicken- pox (varicella), crystalline, and hornpox, and in general all those forms of exanthem, which,- since his time, have been called, though with no very classical term, varioloid diseases, be- long to pemphigus as a genus, under which also he places pompholyx. This genus he divides into two species, p. amplior, importing the or- dinary form of the disease," arid p. variolodes: " eamque," says he, alluding to this variety, " aut vesicularem (variola spuria emphysrmati- ca), aut crystallina (aquosa, varicella auctorum), aut solidescentem (variola spuria verrucosa, acuminata, sicca, dura, ovalis auctorum) appel- lari vellamus."—-{De Cur. Horn. Morb. Epit., tom. iii., p. 264.) It is not necessary to follow up his argument, since, however well supported, it has for some time been sinking into disrepute ; though, amid the versatilities of opinion and conjecture which have of late distinguished the medical world, it is riot impossible, that, like many far more obsolete doctrines, it may yet revive and have its day again. It is necessary, however, to advert to it as forming one of the first and best supported deviations from the gen- eral concurrence of opinion that had for some time been entertained upon the subject, In the variolous epidemic which prevailed du- ring 1816 at Montpellier, the eruption seems to have presented almost all the diversified forms under which it is ever to be traced, in respect to shape and number of pustules, the nature of their fluid, the length of time which they require in order to be exsiccated into scales or scabs, and in the duration and severity of the eruptive, as well as in the absence or presence of the secondary fever. The chickenpox (whether pemphigus or varicella), as is often the case, appears both to have preceded and to have ac- companied the genuine variola; and the two were in many instances so closely intermixed and alternated, as to render it a work of no ordinary difficulty to draw a line of demarcation. " Never, perhaps," says Professor Berard, who, in conjunction with Dr. de Lavit, has given an interesting history of this epidemic (Essai sur les Anomalies de la Variola et de la Varicella, Paris, 1818), "did the symptoms of chickenpox so nearly resemble those of the smallpox, nor these diseases more fully assume the characters of each other." The result was, that, although at the commencement of the epidemy they con- templated the two diseases as perfectly distinct, 62b ILEMATICA. [Cl. III.—Ord. III. ut running a common race, they were at length inclined to regard them as identic, for reasons highly plausible, and which they advance with great modesty ; and thus again enlisted chicken- pox under the banner of variola. And since this time, Professor Thomson, of Edinburgh, from an attentive observation of like coinci- dences in the late variolous epidemy in Scot- land, to which we have already adverted, has not only felt inclined to draw the same conclu- sion, but has, with great industry and force of argument, endeavoured to establish an identity of species between these two eruptions by a copious reference to their history, and the prog- ress of the contest to which they have given rise, as developed iii all the standard authorities, foreign as ^well as domestic, from the accredited date of their origin to the present day.* It is not a little singular, and tends in the strongest light to show the discursive powers of human genius when aided by the resources of learning, that, at the very moment of this new attempt to combine diseases which have of late years been regarded as distinct, or as claimed in various forms by another genus, Dr. Willan, who had laboured hard to support and rivet such distinction, was engaged in the more arduous task of establishing the identity of smallpox and plague in that variety ofthe latter which makes the nearest approach to smallpox, and which we have already referred to under the name of erythematous. His researches, which have been published posthumously by his learned relative Dr. Ashby Smith, f are written with an amenity and antiquarian interest that fuHy entitle them to a place in every medical library, whatever becomes of the question itself, and have, un- doubtedly, brought conviction home to the minds of not a few. So that, if the whole of these elaborate lucubrations could maintain their ground, plague, smallpox, chickenpox, pem- phigus, and, perhaps, cowpox, greasepox (Thom- son, ut supra, pp. 146, 387 ; Willan, ut supra, p. 69, note 75), measles, and scarlet fever, would all be resolvable into one common malady, and derivable from one common virus. While, as another learned attempt has been set on foot by a third body of pathologists, of no mean authority or pretensions,:):.to show that plague itself, in this case the primary and original source of them all, does not exist in any shape, nor ever has ex- isted, as a specific disease ; and is nothing more than a typhous or malignant fever with an ac- cidental appendage of efflorescences, eruptions, or tumours of various kinds, modified by a host of contingencies (to which, indeed, Dr. Frank is * Historical Sketch of the Opinions entertained by Medical Men respecting the Varieties and Sec- ondary Occurrence of Smallpox, &c, in a Letter to Sir James M'Grigor, &c, 8vo., London, 1822. t Miscellaneous Works of the late Robert Wil- lan, M. D., &c, comprising an Inquiry into the Antiquity of the Smallpox, Measles, and Scarlet Fever, &c, 8vo., Lond., 1824. X Heberden, Observations on the Increase and Decrease of Different Diseases, particularly the Plague, 8vo., 1821.—Hancock, Researches intothe Laws and Phenomena of Pestilence, &c, 8vo., 182L also a party in his first volume, p. 136), the whole system of pyretology seems, in the present day, to have some chance of being concentrated into a marvellously small compass, and, for the benefit of future students, may perhaps be engraven on a silver penny. But, where the landmarks of diseases are thus successively broken down one after another, till no guiding-post is left, how is the young student to make his way over the trackless common before him 1 This view of the subject might easily be car- ried still further : for, after Dr. Willan had per- suaded himself that the erythematous plague of the ancients was nothing more than the vesic ular and confluent variety of smallpox, he per- suaded himself still further, that the distinct and coherent form of this disease is, in many cases, synonymous with their phlyzaciae, lichenes, and ecthymata (Will., ut supra, p. 53) ; thus melt- ing down a multitude of other eruptive affec- tions into the same crucible. Had he lived longer, indeed, it was his intention to have un- folded in a similar way the history of syphilis, which, like all'the preceding complaints, he con- ceived to be of immemorial origin, and, appa- rently, to have had a close fellowship with them. —(Miscellaneous Works, p. 87; foot-note by Dr. Ashby Smith.) [The leading arguments of Dr. Thomson are, first, that all the cases he had seen of varicella occurred at the same time, and in direct con- nexion with smallpox, sometimes appearing to originate in it, sometimes to produce it; sec- ondly, that he had never witnessed chickenpox in those whose disposition to- variola had been extinguished by an attack of the varioloid dig- ease ; and, thirdly, that chickenpox is very rare among those who have not been vaccinated. To these apparently strong.arguments it is answered, that Dr. Thomson disregarded the true charac- ters of chickenpox, as determined by the latest and best authors, and confounded with it the vesicular form of the varioloid disease; that though the diseases sometimes alter their char- acters so as to resemble one another very much, yet, when the term chickenpox is restricted to the unequivocal and most frequent variety of it, described by Mr. Bryce, then it will be found, first, that by natural infection chickenpox never gives rise to any thing else but chickenpox; secondly, that by inoculation it never causes the varioloid disease or smallpox ; thirdly, that when it is traced ramifying throughout a family or a district, it reproduces itself in the same form, and with the same mildness, equally in the inoculated, the vaccinated, and the unpro- tected ; and, fourthly, that it reproduces itself as often in its mild form among the unprotected as among the protected, even when it prevails so much as to be accounted epidemical; where- as, all the facts hitherto collected show that when the true varioloid disease prevails epi- demically, its form in the unprotected is very often peculiarly malignant.—(Edin. Med. Journ., April, 1820, and January, 1828.)] It must be conceded to Professor Thomson, that it is often peculiarly difficult, sometimes perhaps unconquerably so, to distinguish bv the Gen. HI.—Spe. 1.] EMPYESIS VARIOLA. 629 superficial appearance the nature of the fever, or even the mark that remains on the skin after- ward, chickenpox from smallpox ; and especially, which is what he particularly alludes to, that modification of smallpox which is so apt to fol- low vaccinia or cowpox, where the latter has only given the constitution a check, and not an utter exemption. But these approximations are only to be traced in extreme modes of the two diseases, and where they make a considerable divergence from their right and proper course ; for, in a pure or perfect state of smallpox and chickenpox, whether we regard them as distinct diseases, or as mere varieties of one common species, there is no difficulty whatever. And even in their widest departure from such state, and their closest approximation to each other, as well in unity of time as of character, they do not more intimately coincide than in the case of various other diseases, of whose distinction there never can be a question. Thus, in idio- pathic epilepsy and intestinal worms, the symp- toms are often precisely the same ; and the ex- istence of the second, at first only conjectura- ble, is at last only ascertainable by the action of anthelmintics. But worms may also be ac- companied with all the symptoms of a genuine hectic, as may this latter with all those of a quotidian or a tertian ague. So measles have often been confounded with rosalia or scarlet fever, and miliaria with eczema, or heat-erup- tion ; and it is one of the most important parts of nosology to point out the distinctive marks of such analogous diseases, though a part in which it has not always succeeded. As there are some disorders that render the constitution less disposed to smallpox than others, of which the cowpox furnishes us with an example, there are also some that render it more so. In like manner, we find the measles generally superinduce catarrh, and very frequently prepare the way for hooping-cough ; insomuch that all these maladies become synchronous. So the chickenpox not unfrequently lays a foundation for the smallpox, and the smallpox may, per- haps, in persons of a particular habit, lay a foun- dation for the chickenpox; or even the atmo- spheric intemperament of either of these dis- eases, when epidemic, may call the other into play ; so that both, as we frequently see, co- exist, not only in the same place, but even on the same person. In truth, the same constitu- tion of the atmosphere often favours the growth and spread of various diseases equally ; and hence, rubeola, varicella, rosalia, and catarrhs, are not unfrequently coincident. [Here it deserves notice, however, that Dr. Mohl, who has favoured the world with a valu- able publication on the present subject, has never seen chickenpox in families where small- pox prevailed at the same time, or recently be- fore ; that he has twice or thrice, indeed, seen in such circumstances an eruption resembling chickenpox, but never a disease corresponding exactly with its characters, as they will be pres- ently laid down. On the other hand, Dr. Liider alleges that he has seen chickenpox produced by the variolous contagion; but his strongest proof, when carefully examined, amounts to nothing. The eruption was preceded by fever of three days' duration : it assumed at first the papular form, and it seems not to have become vesicular till the third day after it appeared. We shall presently find that this description does not by any means correspond with the descrip- tion of an unequivocal case of chickenpox.— (Edin. Med.' and Surgical Journ., No. xciv., p. 185.)] The two diseases before us have marks, if I mistake not, so strictly essential as-to render it highly incorrect and unscientific to contemplate them as mere modifications of a common ex- anthem ; which, moreover, in various cases, by throwing the practitioner off his guard, might lead to a very erroneous treatment and a dan- gerous exposure of the person. If these be not to be found in the ordinary distinctions that have been pointed out by Dr. Heberden, Dr. Willan, and other monographists, as resulting from the form and duration of the pock, the con- sistency of its fluid, and the integrity or dip of the skin after the eruption is over, we must look beyond the obvious symptoms to the intrinsic properties of the respective matters eliminated, and the influence of the two diseases on the con- stitution in future. And here I think we shall not look in vain. I. The matter of smallpox is capable of re- producing smallpox by inoculation. It con- tinues true to its own specific character, and possesses this power to -infinity. The matter of chickenpox is not capable of reproducing small- pox by inoculation ; nor is it often capable of reproducing even its own kind. It will sometimes excite an irritation around the puncture, but it seldom seems to proceed farther. Nor, indeed, does it always irritate locally : for we have al- ready seen that Dr. Heberden, with all his efforts to obtain this effect, found that " the little wound healed up immediately, and showed no signs of any infection."—(Med. Trans., vol. i., art. xvii.) Of the two cases described by Dr. Willan, the first, indeed, affords an example of regular local specific action ; " for the vesicle on the inoculated part went through its ordinary course ; and, twelve days after the incision, he observed further, that two small red eruptions appeared on the shoulder, and soon became vesicular;" but, in the second case, even the local irritation appears to have been nearly as trifling and unspecific as in the case of Dr. Heb- erden ; on the third day after inoculation, " the small scratches made by the lancet were discern- ible, but not inflamed." On the fourth, " they were scarcely visible." On the fifth, "a red- ness with some degree of hardness and eleva- tion appeared at the places punctured, but sub- sided again on the following day." On the eighth, " no vestige remained of the inocula- tion." It should be observed, however, that, twelve days after the use of the lancet, two small gnat-bite-like spots appeared on the patient's side, which became vesicular, and that, two days after this, '" a considerable number of vesi- cles, with surrounding redness, appeared on his body ; but there were not any on his face." On 630 H^MATICA. [Cl. III.—Ord. III. the next day " he was free from indisposition, and no further eruption took place." The whole of which general eruption, in consequence of the imperfect action exhibited on the arm, was rea- sonably ascribed to contagion received antece- dently to inoculation; the patient, who was a boy of nine years old, having been the constant playmate of his brother, from whom the fluid was taken, and who had caught the disease at school.—(On Vaccine Inoc, p. 98, 4to., 1806.) From this slightness of irritability in the fluid of the varicellous vesicle, many practitioners have supposed that it is nothing more than an increased secretion of the serum of the blood, like that which takes place in " any blister pro- duced by scalding or cantharides."^(Brown's Inq. into the Anti-Var. Power of Vaccination, p. 223.) This, however, is hardly to be ad- mitted ; but it is impossible to reflect upon the readiness with which most cutaneous eruptions, whether merely superficial or constitutional, are capable of propagating themselves by inocula- tion, as cowpox, plague, syphilis, psoriasis, por- rigo, and scabies, in all its Torms, as well as smallpox, without a conviction that the fluid of the varicellous vesicle is, at feast, one of the most inert of the whole, and consequently some- thing widely different from that of the smallpox. The power of propagation possessed by genu- ine smallpox, moreover, is not only, in direct opposition to the power Of chickenpox, peculiar- ly active, but runs through all its varieties, each of which, however deflected from the standard of perfection, has a tendency, though not an equal tendency, to reproduce the same disease, and to model it after such standard: and hence we have a thousand instances of discrete purulent smallpox, generated by inoculation from the confluent or crystalline varieties.—(Frewen, Es- say on Inoculation, 1749 ; Willan, On Vaccine Inoculation, p. 55.) Not, indeed, that the lat- ter is always as sure in its action, for it often fails from its imperfection; but, wherever it evinces specific power enough to operate, it re- produces the genuine disease, and mostly with a completely matured pustule. In effect, it is rarely that the fluid in the confluent smallpox becomes thoroughly matured or purulent; and yet it is seldom that this has been found unavail- ing. II. An incursion of natural smallpox protects the system against the recurrence of small-pox, and an incursion of natural chickenpox against the recurrence of chickenpox; but neither of these affords the slightest security against the other. This protection, indeed, is not univer- sal, and hence we have, in both diseases, a few examples of secondary or even ternary affection ; but the rule holds generally, and is not funda- mentally disturbed by such anomalies. And hence a full proof that the intrinsic qualities of each virus is distinct, and consequently that the diseases themselves are so. III. The matter of cowpox, which affords a like protection to the system against smallpox, affords no protection whatever against chicken- pox. On the contrary, according to many wri- ters, it seems rather to pave the way for chick- J enpox;—if all the anomalous eruptions which have been regarded as chickenpox since the in- troduction of vaccination have been fairly enti- tled to this appellation, instead of to that of spu- rious smallpox, as they were formerly called; since such eruptions appear of late years to have been more frequent than ever. But of the real nature of several of these we are, perhaps, to the present moment, in a considerable degree of ig- norance. They may, perhaps, be of later origin than either the smallpox, cowpox, or measles, and they may possibly wear themselves out sooner, and give way to other eruptions, of which ( at present we know nothing. " For it seems de- ducible," says a learned and highly venerated friend of the author, " that there is not a secre- tion or exhalation of the human body which may not be so vitiated as to produce diseases com- municable to others by contact or respiration, under various fortuitous circumstances of con- centration and stagnation, application and ac- tion ; so that there may be new maladies await- ing our species, which are still to develop them- selves under the endle§s combination of the in- cidents of human life through endless ages to come."—(Select Dissertations, by Sir Gilbert Blane, Bart., &c, p. 214, 8vo., Lond., 1823.) By the facility with which some of these are capable of producing fresh crops of their own nature in inoculation, they seem to be distinct from varicella; and from their forming no pro- tection against the smallpox, they are evidently distinct from the latter, notwithstanding their frequent approximation to it in duration, and the external qualities of the pustule. These are marks uncontested, I believe, by finy party ; and they are sufficiently different to establish a clear distinction in the nature of the two eruptions, and consequently to separate the diseases from each other. [The diagnosis between smallpox and chick- enpox is much better understood at present than it was some years ago. Whoever has attended to the account given of varicella by Mr. Bryce and Dr. Abercrombie, will perceive that the ma- jority of previous authors had included under that designation some varieties of eruptive dis- orders, which it is impossible to distinguish from the common forms of modified smallpox. And, although many, or rather most cases of the kind, may be proved to have been cases of the varioloid disease, it is at least highly probable that some of them have been cases of chicken- pox, but in one or other of its irregular forms, to the occurrence of which it is liable, as well as every other exanthematic disorder. In defining the disease, however, the leading place must be assigned to its most frequent and regular form; and it is obviously to this form alone that we must confine all observations on its origin and conta- gious nature. A great deal of attention has been paid to this subject by Mr. Bryce, Dr. Abercrombie, and the reviewer of Dr. Thomson's work.—(Edin. Med. Journ., April, 1820.) And the result has been, says the critic, whose words we are now quoting, that in opposition to the opinion of Dr. Gen. III.—Spe. 1] EMPYESIS VARIOLA. 631 Thomson regarding the impossibility of distin- guishing chickenpox from smallpox, or of imbodying in words the idea currently enter- tained of a pure case of the former disease, we are now in possession of a minute and faith- ful delineation, which no one can be at a loss to apply in practice. The proper unmodified chickenpox is distinguished, first, by the erup- tive fever being generally slight; whereas that of modified smallpox is generally sharp, and of several days' duration ; secondly, by the erup- tion being vesicular from the beginning, or at least from an early period of the first day, not papular, as the vesicular form of the varioloid disease always is for a day or more; thirdly, by the absence of a tubercular basis when the vesicles are fully formed—the vesicles of the chiekenpox being hardly accompanied with any swelling around them ; while those of modified smallpox are, in thefirst instance, elevated on solid tubercular bases ; fourthly, by the great thinness and fragility of the cuticle covering the vesicles. In applying these characters, two precautions must be observed : on the one hand, the eruption must be seen as early as the second or third day, because, at a later period, the chickenpox eruption sometimes acquires a tuber- cular base, and the varioloid loses it; and, on the other hand, the judgment must be directed by the general eruption, not by the appearance of a few vesicles differing from the generality. Besides these characters, the critical writer ad- verts to some others of importance pointed out by Dr. Mohl* and Dr. Liider. 1 According to the latter, the varioloid eruption is formed in the true skin, as is shown by the hard elevated base which remains after the lymph is removed by puncture and pressure. On the other hand, chickenpox is situated in the cellular tissue be- tween the skin and cuticle. This may be per- ceived, as Mr. Bryce formerly pointed out, by opening a vesicle, and examining its edge after the lymph has run out: no excavation or eleva- tion will be perceived, but a surface level with the surrounding skin. Dr. Mohl agrees with Mr. Bryce and Dr. Abercrombie, as to the rapidity with which chickenpox assumes its proper vesicular struc- ture. He had never seen it on the first day; but, on the second, he has uniformly found it vesicular. He adds another character, not al- ways present however, namely, itchiness of the eruption. And he has given a minute descrip- tion of the crusts, which he says are character- istic, being irregular, uneven, opaque, of a pale brownish or yellowish colour, formed of the lymph and collapsed cuticle, and falling off, as Dr. Monro pointed out, not in a single piece, like the crusts of variola* but in small fragments.— (Edin. Med. and Surgical Journal, April, 1820, and January, 1828.) Both Dr. Mohl and Dr. * De Varioloidibus et Varicellis, Copenhagen, 1827. Said by the Edinburgh Review to be, per- haps, the best epitome on the subject. f Versuch einer kritischen Geschichte der bei Vaccinirten beobacht. Menschenblattern, nebst (Jntersuchun. fiber die Natur, &c dieser Krank- heit, Altona, 1824. Liider, it appears, have furnished a criterion, which Dr. Thomson himself admits would, if established, show the fallaciousness of his views. " I do not think," says Dr. Thomson, speaking of his hypothesis, " it can well be set aside, till it shall be proved that chickenpox occurs gen- erally in persons who have not had smallpox, or cowpock, and prevails epidemically, without cases of smallpox occurring among them." It is no wonder, says the reviewer, that the records of medicine should have supplied no such ex- ample, seeing how imperfectly chickenpox was, till of late, distinguished, and still more how seldom, till lately, a district of country cOuld be said to be without smallpox. But the political condition of Prussia and Denmark has enabled both our authors to present Dr. Thomson with examples of the most unequivocal nature. From the year 1809 (says Dr. Mohl) till 1823, there was absolutely no smallpox in this city ; while, during that period, , chickenpox was observed every year': and on that account, there is not a Copenhagen physician who entertains any doubt of the specific difference between the two dis- eases. Between November, 1823, and March, 1825, while smallpox raged in Copenhagen, chickenpox still prevailed sporadically, but with- out our having ever seen them arise from vari- olous contagion, or produce variola. When again the smallpox ceased, during the fine sum- mer months of 1825, chickenpox nevertheless continued to occur frequently. Next year, when the smallpox epidemic returned, Dr. Mohl had frequent opportunity of seeing chickenpox, but still always under circumstances which more and more convinced him that it originated in a peculiar contagion, quite distinct from small- pox.—(Edin. Medical Journal, No. xciv., .p. 168 ; also, Dr. Liider"s Treatise, p. 120.)] That smallpox is not identic with any of the varieties of the loemus or plague, properly so called, of the Greek writers, is still more easily capable of proof. The variety peculiarly fixed upon by Dr. Willan, is that which was often dis- tinguished by the name of anthrage, the eryth- ematous form of the present classification, in which the body is " covered over with trails of vesicular erythema, producing deep, sanious, and gangrenous ulcerations as it spreads, often to a loss of one or more limbs." In this last there is, indeed, some resemblance to confluent smallpox, as it sometimes shows itself in cases where the fluid is yellowish, trans- parent, and immatured. But there is no resem- blance whatever to the pustular discrete small- pox ; and hence Dr. Willan is under the neces- sity of supposing that the latter are alluded to i by the ancients under some other term, and con- stituted with them another and widely different disease. " As the angina maligna," says he. " was for many ages thought generically different from the scarlatina febris, so was the conflu- ent vesicular smallpox deemed a principal branch of the loimos or pestilential fever : while the distinct and coherent variola, with yellowish pustules and a. moderate fever, were ranked with phlyzacia, ecthymata, lichenes agrii, &c. This may be traced up to Hippoc.- 632 H^EMATICA. [Cl. III.-Ord. ILL through the practice of miscreants, who, by means of small poisoned needles, communica- ted, on being paid for it, the horrid infection so extensively, that no computation could be made of the numbers that perished."—(Hist. Rom., lib. Ixii.) Dr. Willan notices this passage of Dion, and very adroitly endeavours to turn it to his own account. "This absurd report," says he, "is very analogous to the calumnies against our early inoculators." The inoculators, however, in every other part of the world, when employed upon smallpox, succeeded, in every instance, in triumphing over such calumnies : they were up- held by the force of truth; they pointed to the favourable result of their practice, a result which it was impossible to deny; and hence there is no nation, in ancient or modern times, barbarous or civilized, Asiatic, African or Euro- pean, as we shall have to observe hereafter, wherever variolous inoculation was introduced, but became gradually sensible of its benefit, and hailed it as an incalculable blessing. Why was not the same triumph obtained by inocula- tion for the disease before us in Greece and Rome 1 Why, but for the reason alleged by the historian—that, instead of an incalculable bles- sing, it proved an exterminating curse, and thus gave a clear manifestation, that this disease was not the smallpox1? Fourthly, that the anthrace, referred to by Dr. Willan, was not smallpox, but a variety of the proper loemus or pestis, is clear from its exist- ing in the same quarter of the globe in the pres- ent day, and being expressly described as such by pathologists of the highest authority, of whom it may be sufficient to mention Dr. Alexander Russell, whose account of this form of plague, as it appeared before his eyes, we shall advert to in its proper place ;* and who was also as ac- curate an observer of smallpox, which he has in like manner represented as it occurred to him ; but who never once dreamed of regarding the two diseases as identic (On the Diseases at Alep- po, ch. iv.), or possessing any near connexion. Dr. Willan, however, relies mainly upon Rhazes, who seems unquestionably to have en- tertained some ideas upon this subject in unison with himself; for, apparently misinterpreting a few loose passages of Galen in the same way as Dr. Willan has done, and particularly where Galen is treating of phlegmonae, erysipelata, herpetes, and ionthi (Tr. de Compos. Med., sec. loc. de Prognos. a Pulsibus, lib. ii.; and De Usu Partium, lib. ix.), he tells us that the smallpox and measles were known to Galen six hundred years before his own era. In answer to which, however, it may be sufficient to quote the following admission on the part of the Greek translator of Rhazes's Treatise on the smallpox and measles (al-gridi and al-hasbet), written in the tenth or beginning of the eleventh century, % and dedicated to the reigning emperor, and which he entitles vepl AotpiKTjs, " on the pesti- lence ;" for by this name, adopting the vulgar rates :—he, as well as Galen, speaks of pem- phigoid fevers, fevers with phlyctaenae, and the anthraces, as pestilential and malignant: and of another set of fevers, in which appear critical, inflamed, and suppurative tubercles or pus- tules."-—(Miscellaneous Works, ut supra, p. 59.) Now the term AOIMOS, or pestis, was em- ployed among the Greeks and Romans, like Our own derivative pestilence, in two very differ- ent senses, a strict or particular, and a loose or general. Under the first it always imported, as plague or pestilence does in our own day, one and the same specific disease ; under the latter, it was applied to various sorts of disease pos- sessing any high degree of malignity, whether among mankind or among brutes, as the word pestilence is still used among ourselves. But it is immeasurably difficult to adopt the view of this subject taken by Dr. Willan, for the follow- . ing reasons :—- First, we have no description whatever of any such disease as smallpox in the writings of any of the Greek or Latin physicians : and all that Dr. Willan or any one else can accomplish upon this point, is to glean a few incidental pas- sages which may be supposed to allude to it in different places or volumes. Now, if the smallpox existed among the Greeks or early Romans at all, it must have existed as a com- mon and popular "disease ; and it is impossible to suppose, that, among pathologists so minute in their attention to other diseases, and the de- scriptions they have given of them, as Hippoc- rates, Aretaeus, Galen, and Celsus, they should not have described smallpox also at large, and assigned some fixed and specific name to this, as well as to apoplexy, cardialgia, catarrh, and opisthotonos, instead of leaving us to seek for it at random under the names of loemus, anthrace, eulogia, and various other affections. Secondly, as the smallpox, if it existed among the Greeks at all, must have had a frequent ex- istence, and its varieties of discrete and con- fluent, mild and malignant, must have been known to every one, it is impossible, that Hip- pocrates or Galen could have made that separ- ation between such varieties as Dr. Willan is obliged to suppose; and have contemplated them as distinct diseases, of very different ori- gins, and destitute of all generic connexion whatever. Thirdly, inoculation for the plague was occa- sionally tried in ancient times, as it is in our day, and especially for that particular variety of the plague which Dr. Willan especially adverts to as making the nearest approach to the small- pox, and always with the same result. Instead of producing a milder disease, as in the latter case, it uniformly proved fatal. The last at- tempt of this kind appears to have taken place in the reign of the Emperor Commodus, a. d. 189, and is thus described by Dion Cassius, in his narrative of the plague which overran so large a portion of the Roman territory at this era, and which is admitted by Dr. Willan to have been the modification of plague now allu- ded to :—" Many died in another way, not only at Reme, but over newly the whole empire, * Gen. IV., Spe. 1, of the present Class and Order. ~SpE- J] EMPYESIS VARIOLA. 633 meaning of the term, he denominates these dis- eases :—" It is confessed by all persons con- versant with the writings and laborious re- searches of Galen, that nothing which pertains to medical science, or the cure of diseases, has escaped his penetration. With regard, how- ever, to the pestilence (Aoi/uki)), he is less ex- plicit than on other subjects: he speaks of it cursorily, or in connexion with analogous com- plaints, but he does not anywhere slate distinctly the symptoms or appropriate mode of treatment in it:—strange, that he who first organized the medical art, and defined what had been left in- determinate, should have but slightly noticed a disease to which every man is born liable." But the most powerful opponent of Dr. Wil- lan upon the whole of this subject, is Dr. Willan himself: who, only a few years before, gave us his opinion upon it in the following form ; and it is not a little singular to observe how directly it is controversive of that we have thus far contemplated, wliile it does not appear that any new facts, or additional evidence of im- portance, had sprung up before him to produce such a change of sentiment. On his referring to this celebrated treatise of Rhazes, " he takes it," says Dr. Willan, " for granted, that the smallpox and measles were known to Galen more than six hundred years before his own time, being misled by some in- correct translation of Galen's works into the Arabian language. The passages which he quotes have certainly not the least relation to the diseases above mentioned (smallpox and measles). Indeed, no description of them, nor the slightest collateral hint, appears in the writings of the Greek physicians, which could lead us to suppose they had any knowledge on the subject. Some modern writers have held a contrary opinion, maintaining that Hippocrates and his successors applied to the measles and smallpox the denominations of exanthemata, ec- thymata, eczemata, erysipelata, herpetes, an- thraces, &c. Now, some of these terms have been strictly defined, and in a way which admits of no such application : the rest are left indefinite, and always intended" to express, generally, erup- tions on the skin, yet have they not been appro- priated to any particular form of them. A con- troversy founded on materials so slight and un- satisfactory, was carried on with ardour during a part of the last century, but need not at this time be revived, when it is nearly consigned to oblivion."—(On Cutaneous Diseases, p. 251, 4to., Lond., 1808.) In the midst of all this diversity of opinion there is one point at least clear, and universally admitted : I mean, that the earliest distinct de- scription of the disease which has descended to modern times is that of Rhazes. It is contain- ed in his Almansor, which was composed about the end of the ninth or the beginning of the tenth century; and in this he quotes from an Alexandrian physician, of the name of Aaron, who had written on the same subject as early as the year 622. Yet it is very singular that neither Rhazes nor Aaron, so far as their writings have reach- ed us, make mention of the contagious property of the disease, chiefly accounting for its produc- tion by an ebullition of the blood, which they thought particularly incident to the age between childhood and youth. And it is equally singu- lar that it should be asserted by Aaron, as it was also by Avicenna, that the same person is liable to a return of it a second, or even a third time, pracipue cum sanguis sit acutus. Has the disease undergone any change since this period, so as to render those who have not had it more susceptible of its influence, and those who have had it less 1 In the descriptive part of the dis- ease, little is to be added to Rhazes's statement, and, what is more singular, he recommends the cool treatment. Unfortunately, however, the doctrine of concoction and despumation of the humoral pathologists spread afterward so widely, and was so generally supported, as to put to flight this correct and rational view of the sub- ject ; and every attempt was made, by warm clothing and the warm bath, to mature-the pec- cant matter, and drive it in as large a quantity as possible to the surface ; by which the slight- est cases were violently exasperated, and too often rendered fatal. The more severe the disease, the sooner the pustules show themselves, thus completely re- versing the law of scarlet fever ; a remark for which we were first indebted to the sagacious eye of Sydenham. And hence, in the confluent variety, the eruption appears on the second or third day, while, in the distinct, we have seldom any traces of it till the fourth, and often not till the fifth day. If a patient have accidentally become impreg- nated with the contagion of the measles before inoculation or being exposed to the contagion of the smallpox, the latter, as we have already ob- served, will, generally speaking, be retarded in its progress, and not make its appearance till the measles have run r through their course, upon the common law, that the constitution is only affected with one disease at a time. But to this common law we have already pointed out various exceptions ; and as gout and rheu- matism sometimes co-exist, the measles and smallpox occasionally co-exist also. In the year 1769, Mr. King, of the Foundling Hospital, Dublin, inoculated forty-three children of the establishment. On the fourth or fifth day after- ward, sixteen of them sickened with the measles, and went through the disease regularly ; yet the progress of the smallpox was not retarded or al- tered ; for the pustules of the latter disease ap- peared as those of the former died away; and both complaints were of a mild character : a like coincidence occurred in the ensuing year, and with a like favourable termination.—(Edin. Med. Comment., vol. iii., p. 443.) In this case, the common law of retardation seems to have been interfered with by some peculiar constitution of the atmosphere ; for the effect was general to all who were under the influence of rubeolous contagion. In other cases we have a like interference with the com- mon law of variola, from the idiosyncrasy of in- dividuals, or some temporary but equally occult Q3\ H.EMATICA. [Cl. III.-Ord. Ill power, operatiftg upon the system. There are some persons who seem to possess a natural immunity to its influence, and pass through life without ever being infected, though they may have purposely exposed themsetves to the most contaminated atmosphere. There are others, who, though incapable of being affected at one time, lose their emancipation at another. " I know an old nurse," says Dr. Huxham, " and one apothecary, who for many years attended persons, and a great number too, in the small- pox, and yet never had them; nay, many that have industriously endeavoured to catch this in- fection, by frequenting the chambers of the sick, have done it without effect; and yet some of these persons, some months or years after, have been seized with the smallpox."—(Treatise on Fever, Smallpox, &c) But not only does the susceptibility of the dis- ease vary in flegree at different times and in dif- ferent persons, but the irritability of the body be- neath its influence. Thus, among fifty persons who receive it at the same time, and undergo the same regimen, we may perhaps have as many degrees of violence ; some dying beneath its se- verity, some escaping, though with great peril, and indelibly seamed and scarred, and others evincing little fever, and a very slight eruption. The present author caught it casually in London, when a child about six years old, and passed through it with scarcely any disturbance, and not more than twenty scattered pustules. In like manner we find, under inoculation, that while some persons throw forth a full crop, and suffer considerably from fever, others have scarcely any febrile symptoms, and no more eruption than the pustule on the puncture ; the disease, in this case, exhibiting the same change as occurs in inoculated cowpox, compared with the exanthem as received casually from the cow. It was at one time doubted, whether this slight appearance afforded protection for the future. There is now no longer any doubt upon this sub- ject. But we may go beyond this, and reason- ably conjecture, that those who have passed through the disease with but little inconvenience, are even less exposed to future attacks than persons who have had it in the confluent form, and whose faces are marked with its ravages. For as the degree of violence depends, where there is no error in the treatment, upon the de- gree of irritability which the constitution mani- fests under the contagion, and as the irritability and susceptibility march with an equal step, he is most likely to have a renewal of the suscep- tibility, in process of time, who bears the most evident marks of a greater susceptibility ante- cedently. It had indeed been conceived by very dis- tinguished pathologists, that the smallpox can never be had a second time, notwithstanding various assertions in support of this fact; and the argument is thus ingeniously put by Dr. Heb- erden, who was himself a disbeliever :—" It would be no extravagant assertion to say, that here in England not above one among ten thou- sand patients is pretended to have had it twice ; and whenever it is pretended, it will always be as likely that the persons about the patient were mistaken, and supposed that to be smallpox which was an eruption of a different nature, as that there was such an extraordinary exception to wr&t we are sure is so general a law."— (Med. Trans., vol. i., art. xvii.) This remark is forcible, but the actual occur- rences are in many, perhaps most of the in- stances appealed to, still more so. For, from the cause I have just pointed out, those who have had a repetition of smallpox have gener- ally, if I mistake not, been able to exhibit proofs of a prior attack in pits or scars on the face or some other part of the body, manifesting the violence with which the disease ran its course, and consequently the strong predisposition of the constitution towards it, and irritability under its influence. " It is remarkable," says Sir Gilbert Blane, " that almost all the well-au- thenticated cases of second smallpox have been of those persons who, in the first instance, had undergone it in its most severe and dangerous forms."—(Select Dissertations, &c, p. 209, 8vo., 1822.) Louis XV. of France afforded a clear exemplification of this in 1774; and an- other still more striking is given, for the ensu- ing year, in the Memoirs of the Medical So- ciety (vol. iv., 1775), in which, though the first attack was peculiarly severe, the second was more so, and proved fatal. The medical repos- itories are rich in cases of this kind, some of them so striking and so well established as to prohibit all doubt whatever : and, in the two or three instances which it has fallen to my lot to witness, I have traced the same character ; for pits from the prior attack have been visible, while the genuineness of the existing attack was in one instance substantiated by the test of inoculation. In some instances this strong constitutional predisposition runs through every branch of the family, of which Dr. Barnes of Carlisle has given us a striking example in five individuals, sons or daughters of the same pa- rents, who, having all caught the smallpox nat- urally in the summer of 1818, from which most of them suffered smartly, caught it again in Feb- ruary, 1822, and had it also smartly, though not quite so severely as on the first attack. In both series of affection, the individuals varied in the degree of fever and range of pustules ; but in every instance, whether of the first or second series, the eruption was pustular. This account is given in the seventy-sixth number of the Ed- inburgh Medical and Surgical Journal (vol. xix., pp. 376-378); and the very next article in the same number affords an instance of a family diathesis of the same kind, in four individuals, sons or daughters of the same parents, who were attacked nearly simultaneously with small- pox after having undergone vaccination, which seems to have passed through its course satis- factorily, at different intervals, varying from six to two years. A fifth child, which had not been vaccinated, received the smallpox at the same time, and passed through it in much the •pame manner, but rather more mildly than one or two of the other instances. The eruption was in every instance distinct and pustular, • "I-—Spe. 1.] EMPYESIS VARIOLA. 635 though, in one or two, a few vesicles were in- terspersed. That erroneous statements upon the subject of a recurrence of smallpox have been very numerously given to the world, is unquestiona- ble ; among which we can find little difficulty in placing that of Borelli, containing the history of a woman who recovered from seven distinct attacks of smallpox, and died on the eighth; the antecedent eruptions having doubtless been those of some other exanthem or cutaneous ef- florescence ; but cases thus clear and incontro- vertible are sufficient to establish an occasional departure from the general law, and teach ns to look without a scoff upon the assertion of Rha- zes and Avicenna, and the far earlier one of Aaron, that the disease occasionally occurs a second, and, in some instances, where there is a strong predisposition to it, even a third time. A like deviation from the ordinary path of procedure, impresses us in the history of other exanthems. The same gerieral law prevails very strikingly in measles and scarlet fever ; but we have also a law of exception ; and the exceptions in one disease seem to hold a steady proportion to those in another. They are most frequent in scarlet fever, fewer in measles, and still fewer in smallpox. In plague, the general immunity lasts but for a few weeks ; yet some who have recovered seem to be protected for a much longer time, and several for life. In in- fluenza, it extends through the whole duration of the existing epidemy, but the susceptibility recovers itself against the next visitation. In some remittents, as yellow fever, the patient continues little susceptible for many years, per- haps for the whole of his natural existence : in intermittents, the susceptibility, on the con- trary, is very generally increased ; for the man who has once suffered from an ague, catches it again more readily than another. A high degree of fever is not necessary to emancipate the system in any exanthem, and consequently not in smallpox. It is upon this principle that inoculation takes its stand in vac- cinia, as well as variola. Febrile commotion, as we have observed already, though necessary to throw the morbid poison to the surface, is only necessary in a small, and sometimes an al- most imperceptible degree ; and if it be urged beyond this, the morbid poison will be increased in quantity, the ferment will acquire a wider assimilation, and hence the fever and the erup- tion always maintain a balance. Provided the entire system submits to the influence of the contagion, the emancipation is always as per- fect under a small product as under a large ; and it is wonderful to observe how completely this influence extends through every part of the system, often indeed without any disturbance whatever, upon a deposite of the minutest par- ticle of variolous contagion under the cuticle ; for we are perpetually witnessing cases, or rather were, when variolous inoculation was more frequent, in which a full change has been operated on the entire frame, though the only pustule has been that excited at the puncture ; and the individual, before liable to the disease, is become liable no longer. And that the blood itself, and therefore every particle of the blood, is equally influenced in such circumstances, and even charged with the nature of the virus, is obvious from the frequent communication of the disease from a pregnant woman to the foetus ; and this too at times where the mother is no sufferer from the disease herself. A remarkable example of this last fact is given by Dr. Mead in the following words :— " A woman who had formerly had the smallpox, and was near her reckoning, nursed her husband who had caught it. At her full time she was delivered of a dead child, whose body was cov- ered over with pustules; a manifest sign that it died of the smallpox before it was brought into the world."—(De Variolis, cap. iv.) Mau- riceau has another case or two to the same ef- fect (Sur la Grossessc, et I'Accouchement des Femmes, obs. 600, et 576) ; and others have since occurred.* In these cases there is no assimilation or multiplication of morbid leaven ; and influence is indubitably exercised, and that, too, over the entire current of blood, for it could not other- wise reach the foetus ; yet without any sensible effect on the mother. What is the nature of this influence 1 Is it by an infinitesimal division of the minute drop of contagion inserted into the skin, or that received by the breath 1 What- ever be the way, it enables us to be less sur- prised at the mode by which family taints, as gout, scrofula, and phthisis, are transmitted from generation to generation. t Unborn infants do not always receive the smallpox under the same circumstances, nor in every instance even where the pregnant mother sickens with the disease. Sir George Baker, who was indisposed to credit these singulari- ties, refers to two instances, in which the moth- ers, having been inoculated, had-passed through the eruption favourably, and brought forth in- fants, both of whom, three years afterward, were also inoculated with good effect.—(Med. Trans., vol. ii., art. xix.) From all which we collect, and we can do no more, that a like va- riation occurs before birth, as we have just ob- served occurs afterward; and that different individuals, or even the same individual under particular circumstances, evince a different de- gree of susceptibility ; so that the contagion, though resisted at one time, is readily received at another. There is another feature in the physiology of smallpox that is peculiarly worthy of notice ; and that is the power which all deep-seated organs possess of opposing a lodgment of the pustulous inflammation on their own surfaces, * During the prevalence of the varioloid in New-York in 1622, a highly interesting case oc- curred : the patient, a young married lady, had been vaccinated when a child : she was affected with varioloid disease six weeks before her ac- couchement, and was delivered of a dead child, which was covered with smallpox pustules. Smallpox was communicated by inoculation with virus taken from these pustules.—(See Hosack's Essays, vol. iii., p. 472.)—D. 636 H^EMATICA. [Cl. III.—Ord. Ill, and driving it altogether externally, where it can do least mischief. Dissections have abun- dantly shown,- that the viscera and cavities of the interior are never affected with the erup- tion : except such as, like the skin, are exposed to the approach or ingress" of air, as the nose, mouth, trachea and its ramifications, and the entrance of the meatus auditorius. As a gen- eral rule, pustules are never found in the rec- tum ; but, if there be any prolapse, that part of the rectum which concurs in the exposure will share in the common fate of the external parts.* To what extent variolous contagion is capa- ble of radiating, as it issues into the atmosphere from a diseased body, has never been satisfac- torily determined. In laying down the general rules of febrile miasm I ventured to state, that contagion or miasm, generated in the living body, does not appear to be very volatile in any instance, and soon dissolves in a pure atmo- sphere. The contagion of smallpox seems fully to be governed by this law. When smallpox was more frequent than at present, medical prac- titioners, though passing casually from house to house, were rarely, if every accused of commu- nicating the disease ; and Dr. Haygarth has appealed to an evidence of facts in proof, that the sphere of variolous contagion does not in- clude a diameter of fifteen hundred feet, and probably not a hundredth part of such a di- ameter. As the susceptibility of smallpox varies so considerably in different individuals, it is not to be wondered at that "the irritability of the sys- tem to its influence should vary also, and con- sequently that there should be some difference in the period of time between the supposed communication of the disease and its appear- ance by any manifest tokens. Upon the whole, the interval may be calculated to vary from six to twenty-one days in the natural smallpox; and in the inoculated, which anticipates the ac- tion a day or two, from four days to eighteen. The writers on this disease have subdivided it into an endless multiplicity of forms ; but the four following varieties are sufficient to in- clude the whole : a Discreta. Distinct smallpox. 0 Confluens. Confluent smallpox. y Degener. Crystallized-pox. Hornpox. S Inserta. Inoculated smallpox. The pathognomonic characters of the first variety, or distinct smallpox, are the follow- * Andral asserts (Anat. Pathol., tom. ii., p. 225), that variolous pustules have never been noticed in the bowels, though enlarged follicles have sometimes been mistaken for them, especially in children, in whom these organs are always con- siderably developed. In what are called putrid or malignant cases, the disease, according to An- dral, is complicated with gastro-enteritis more or less severe, that has, On the one hand, modified the eruption, and, on the other, reacted upon the centres of the nervous system. After death the digestive tube presents changes, which vary in different instances from slight congestion to com- plete ulceration.—Ed. ing :—Pustules pea-sized ; distinct, distended, circular ; the intervening spaces red ; the fever ceasing when the eruption is complete. The disease opens its battery with the usual signs of a febrile cold fit, accompanied with vomiting, and some degree of soreness in the throat* About the fourth, sometimes on the third day, the eruption begins to appear on the face, neck, and breast, in minute flea-bite spots (papulae), which multiply every night for the ensuing four days, when there is usually a pretty full crop of them over every part of the body, though the face is, in almost all cases, far more covered than any other part; and that, accord- ing to Camper, in the proportion of five to one.+ The head, face, hands, and wherever else the pimples show themselves, gradually swell, and the eyelids are often so much distended as to close the eyes and produce blindness ; the spaces between the pimples are reddish, and continue to grow redder as the pimples become pustules and ripen ; the fever is of the caumatic or in- flammatory kind, and the suppuration is com- plete on the eighth day, or thereabouts. On the eleventh, the inflammation and pustules manifestly abate, and the latter, measuring the diameter of a pea, dry away by degrees and scale off, and wholly disappear on the fourteenth or fifteenth day, with the exception of those on the extremities, which, as they come out later, commonly continue a short time longer.^ Such is the ordinary course : but the symp- toms vary greatly in severity according to the degree of fever and extent of the eruption, which, as already observed, hold a pretty accu- rate balance. Where the pimples are few and scattered, there is but very little indisposition ; but where they are very numerous, though still distinct, the soreness, swelling, and febrile heat are very distressing: and, under this form, the progress of the disease has often been divided * The patient is first of all generally seized with languor, drowsiness, vomiting, and pain of the head and loins. The pain in the loins, the sickness, and a tenderness of the epigastrium, present themselves in a strongly-marked degree among the incipient symptoms of smallpox.—Ed. + Les Avantages de l'lnoculation, &c, Paris, 1782. The small red spots (papulae) rise, as Dr. Elliotson describes, into elevated pimples, and these again into hard tubercles (tuberae). The pimples become pellucid, and, on the fifth day, counting from the first attack of feverishness, headache, &c, they become pustules, with opaque, white, purulent contents, and those which are large are generally depressed in the centre.—See Lect. at Lond. Univ., as published in Med. Gaz., vol. xi., p. 273.—Ed. X According to Dr. Elliotson's description, it is on the eighth day that the face swells, and the eyes begin to be closed from inflammation, if there be much eruption. On the eleventh the pustules are at thp;r height, as full and numerous as they will be; ana tne swelling of the face, the running of the mouth, and inflammation of the fauces, subside, and then the hands and feet swell; first the hands, and afterward the feet. Dr. Good has omitted to mention, in his general description, what is termed the secondary fever, which occurs when the suppuration of the pustules is complete about the tenth or eleventh day.—Ed. en III.—Spe. 1.] EMPYESIS VARIOLA. 637 into four stages, an incursive, an eruptive, a ma- turing, and declining or scabbing (Frank, op. cit, torn, iii., p. 159), at each of which it discovers an exacerbation of pyrectic symptoms. And when the patient is an infant, itis at these times, and especially on the incursion of the disease, occasionally attacked with a convulsion fit, or perhaps several in succession.* The grand principle in the treatment of small- pox, as of all the other exanthems that have passed before us, is to moderate and keep un- der the fever ; and, however the plans that have been most celebrated for their success may have varied in particular points, they have uniformly made this principle their pole-star; and have consisted in different modifications of fresh air, cold water, acid liquors, and purgative medi- cines : heat, cordials, and other stimulants hav- ing been abundantly proved to be the most ef- fectual means of exasperating the disease, and endangering life. Dr. Mead seems to have been almost indif- ferent as to thekind of purgative employed, and certainly gave no preference to mercurial prep- arations. His idea was, that all were equally beneficial that would tend to lower the system : " Indicium," says he, ".certe satis manifestum, quamcunque materiae diminutionem, femitem igni suhtrahendo, huic morbo apprime convenire." And, in this manner, he accounts for the mild- ness of the malady after any great evacuation, natural or artificial; after acute diseases, im- moderate catamenia, childbirth, and salivation. Mercury, however, appears to have a specific influence upon the action of variolous matter ; perhaps, as in the case of syphilis, upon the quality of the matter itself: for though, when considerably diluted with water, it is still capa- ble of propagating the disease by inoculation, yet Von YVensel has shown satisfactorily that when triturated with calomel it loses its energy, and in inoculation becomes inert and useless. Mercury has hence been denominated, in Ger- many, remedium pancreston, and has certainly supported its character as the best correcter of the smallpox we are acquainted with, from a period antecedent to the introduction of inocu- lation into Europe to the present day. " Phy- sicians who attend hospitals," says Sir George Baker, "have frequently observed the smallpox to be particularly mild in those patients who have happened to receive the infection soon after a mercurial ptyalism ; and inoculation is said to have been a much more successful practice in some of our American colonies since the use of calomel has been there introduced into the prep- arative regimen." When given as a purgative, it is usually mixed with the powder or resin of jalap, and in this manner acts more briskly. * On this subject the following remark by Dr. Elliotson is no doubt very correct:—" It is said that one fit forebodes a mild disease, whereas sev- eral forebode a severe disease ; but I should sup- pose that if the child had no fit at all, it woild forebode something still better. When the erup- tion is taking place, if the individual be an adult, there is frequently a great tendency to profuse sweating."—Ed. Exposure to fresh and cold air is nearly, if not altogether, of as much service as calomel ; and hence the advantages of a cool capacious room. Cold water is usually prescribed in large draughts for the same purpose, and very gener- ally proves highly refreshing. The acids, and especially the diluted mineral acids, have a pe- culiar influence in diminishing the extent of the eruption ; insomuch that some inoculators have been bold enough to prophecy the number of pustules a patient would produce under a given quantity of the acid. Whether any one of the acids has an intrisic power beyond the rest has never been sufficiently put to the test of in- quiry ; nor is it clearly ascertained in what way they operate towards the present effect. They are an excellent refrigerant in fevers of all kinds ; but, in smallpox, there seems to be a something beyond this power, and they probably restrain the process of assimilation. Lemonade may conveniently form the com- mon drink during the fever; or a solution of cream of tartar in water, which, as. tending to keep the bowels gently open, will be preferable. When the fever is considerable, the purgative should be repeated at each of its exacerbating stages ; and if convulsion-fits arise, the spas- modic irritation is best removed by laudanum.* The pathognomonic characters of the con- fluent variety are the following : pustules confluent,flaccid, irregularly circumscribed; the intervening spaces pale ; with great debility. In this variety the eruption assumes, at first, the appearance of a general efflorescence, with- out any distinctive points ; innumerable pimples, however, show themselves about the third day, being a day or two sooner than in the discrete variety. They soon coalesce from their throng- ing number, and become filled, not with pus, but a yellowish serum, for this variety seldom sup- purates regularly, t, The fever is violent, and exhibits a synochus or typhous type ; and, in- stead, of subsiding on the appearance of the eruption, as in the distinct variety, generally in- creases. The head is oppressed, the eyes in- flamed, the brain comatose or delirious. After the eighth day, the detached pellicle, covering a large secretion of this virulent fluid, becomes brown, and not yellow as in the distinct sort. Peculiar to the confluent smallpox are saliva- tion in adults, and a looseness in children ; the former always attends, the latter more rarely. The spitting begins as soon as the eruption ap- pears, or within a day or two afterward: the saliva is at first thin, and easily and plentifully * The utmost cleanliness ; plenty of clean linen ; a mild antiphlogistic diet, in the first instance ; cold or tepid ablution, if the body be hot; wash- ing the patient and room with the chlorides; bleed ing in adults, if the head be much affected, or, at any rate, the application of leeches ; and aperient medicines, are the means of relief specified by Professor Elliotson.—(See Lecture delivered at London University, as published in Med. Gaz., vol. xi., p. 279.) When debility comes on, he rec- ommends wine and stimulants.—Ed. f Frequently petechiae, vibices, and ecchymoses are seen between the pustules—red, dark-coloured spots of various sizes.—Ed. 638 H-EM discharged; but towards the eleventh day, which is the period of the greatest danger, it becomes viscid, and is discharged with great difficulty : the looseness in children, however, continues beyond this period.* When the disease terminates favourably, the swelling of the face about this time begins to abate, and that of the extremities commences. But if the constitution be incapable of counter- acting the weakness under which it is suffering, or the mass of disease with which it is oppres- sed, and particularly the exacerbating or sec- ondary fever, as it is called, which takes place at the stage of maturation, the cuticle suddenly becomes flattened, the features sink, the pus- tules are depressed ; the coma increases, flea- bite spots are sprinkled over the body, suc- ceeded often by hemorrhages ; the pulse flut- ters, and the patient expires ; usually, as al- ready observed, about the eleventh, but some- times not till the sixteenth day. In the commencement of this variety, the same reducent plan is to be pursued as already rec- ommended in the preceding variety; and the affusion of cold water may be added to a free use of fresh and even cold air. Bleeding is a doubtful remedy, and its propriety must entirely depend upon the constitution or habit of the in- dividual, and the' nature of the prevailing epi- demy. In a state of high entonic health, and firm elastic fibre, it may be allowed, and per- haps repeatedly : but we should always bear in mind, first, that the plenitude of the disease does not so much depend upon the strength or weakness of the frame, as upon its suscepti- bility of the contagion, and irritability beneath its action ; and next, that in confluent smallpox the process of maturation does not take place kindly or perfectly, and that the fever, often a synochus, has always a tendency to run into a typhus, particularly when the temperament of the atmosphere predisposes to this type. On this account, it will often be found necessary, and particularly towards the stage of maturation, to support the tone of the system instead of reducing it. Camphire offers us one of the medicines for this purpose ; and may be given in solution, or in the form of pills. The latter is generally the most convenient, as it can thus be taken in a larger quantity, and needs not in- terfere with ammoniacal neutrals, ethereal com- pounds, the acidulated decoction of cinchona, or the same tonic in a more powerful form. If, indeed, on the accession of the secondary fever, the pulse should suddenly sink, the pustules flatten, and the surface turn pallid or purple, wine must be added to the other remedies, blis- ters or sinapisms applied to the feet or legs; and, if a diarrhoea should supervene, opium be administered; though, in the earlier stages of the disease, this last symptom should be very cautiously interfered with. Some part of the secondary fever may probably be set down to * Sometimes there is bloody urine, or blood in the motions. Blindness, phthisis, and diarrhoea, ending in ulceration of the intestines, are more frequent consequences of V. confluens than of V. discreta.—Ed . KTICA. [Cl. 111.—Ord. III. the score of the absorbed virus, now thrown back upon the blood from every part of the sur- face : and, to disarm this source of exacerba- tion, it may be convenient to open the pustules as they ripen, and let them discharge their con- tents externally. And, to save the face as much as possible from those exulcerations of the true skin that terminate in pits and scars, a piece of fine linen or cambric, over which some ceta- ceous cerate has been spread, should be applied. Smallpox, then, may well be contemplated as a fearful disease. It is so at all times from the uncertainty of its prognosis, but especially when it assumes a severe character.* And it is so, moreover, not merely on account of its own ravage, but of the tendency it produces to sub- sequent evils, after its own course has subsided. In many cases, the constitution is incapable of recovering from the general disturbance and de- bility it has introduced, and hence atrophy, dropsy, and hectic are by no means uncommon results. But it more frequently proves mis- chievous by stirring up some hereditary taint that might otherwise lie quiet through life; and, in this way, becomes an exciting cause of scrof- ula, consumption, and gout. The horn or crystalline-pock it is only ne- cessary to notice, as forming a somewhat sin- gular departure from the usual course of the disease, though not often accompanied with danger, or distinguished by an overloading erup- tion. Its pathognomonic characters are set down in the Nosological Synopsis as follows :— pimples imperfectly suppurating, ichorous or horny, and semi-transparent. From some unknown cause, the variolous fluid is, in this variety, secreted and thrown upon the surface in the form of lymph, and is never exchanged for that of pus. As the finer partof the fluid is absorbed, it loses its pellucidity, and the vesicular pimples appear whitish, and preserve this hue till they dry and peel off. This is particularly the case in persons of a fair and delicate skin ; but, where the skin is darker or coarser, they become brown, hard, and horny : and hence it is always in this way that the pres- ent variety terminates among negroes. When- ever smallpox occurs a second time, it usually shows a tendency to this modification. It is not a little singular, that Professor Frank should have separated this form ofthe dis- ease from smallpox, and made it, together with varicella, as already observed, a modification of pemphigus,—(De Cur. Horn. Morb. Epit., tom. iii., p. 264.) What landmark can the student find when the boundaries of diseases are thus disastrously broken up 1 The fourth variety under which smallpox is to be found, is the artificial modification known by the name of inoculation : a most important * Tfie late Mr. Alcock drew Dr. Elliotson's at- tention to the fact, that the mucous membrane of the larynx and trachea is frequently much inflamed in smallpox, and that there is an effusion of a very thick tenacious mucus from it, such as produces a degree of obstruction in those tubes, that may have some considerable share in occasioning tha [ fatal result of the disease in children.—Ed. Ghn,IIL-Spe.].j EMPYESIS advantage to mankind before they were ac- quainted with the equal or nearly equal protec- tion afforded by the virus of cowpox ; when, m the language of Professor Frank, "ad illud tandem se reductos viderunt; ut victas huic pesti manus traderent, et sic, quasi daemoni, quo sibi esset propitior, sacrincarent"— (Op. cit, tom. 101; p. 334.) Its peculiar characters are thus described in the volume of Nosology ;—orange-coloured are- ola about the puncture ; pain in the axilla about the seventh day ; disease mostly mild ; and the purulent discharge sometimes confined to the punctured parts. This mode of communicating the fiisease, like the natural disease itself, appears to have reached Europe from the east, and especially from China ; where, according to the statements of the Jesuits, (Lettres Edifiantes et Curieuses, &c, passim), it has been practised immemori- ally by perhaps the simplest and best means of communication that has hitherto been devised, —that of a needle charged with the contagious matter of a pustule, and introduced transversely under the cuticle. From China the discovery appears to have travelled into India, and thence to Asia Minor. It is not easy to conjecture how it arrived among the ancient native tribes of Africa, as we know so little of their arriving there themselves. It shows, however, that the disease itself is of very high antiquity, though it does not seem to have travelled in a very early period of the world into Europe ; unless, in- deed, we ascribe to it various sources of ori- gin, which is accompanied with the difficulty of our not knowing where to stop the moment we embrace such a doctrine ; for if we once in- dulge in a plural number, there is nothing to pre- vent Our carrying such number on to infinity. That the disease, however, has from an early period existed in Africa, and has also been counteracted by the employment of a rude kind of inoculation, is now clear from the narrative of Mr. Campbell, whose veracity will not lightly be called in question ; and who tells us, that he found both the smallpox and the practice of in- oculation in use among the Marootzee, or in- habitants of the city of Kurreechane, about a degree and a half to the northward of De la Goa Bay, or 24|° south latitude. Here the rivers, which before ran westward, were found to flow towards the east, evidently proving, that he had reached the loftiest point of this part of the continent. The natives, it seems, have a tra- dition that they procured the variolous matter, or rather learned the art, from a people to the northeast called Mahalatyela, who ride upon elephants. They make the incision between the eyebrows. The Booshuanas, however, in- oculate also for the smallpox.—(Travels in South Africa, &c, 2 vols., 8vo., 1822.) The first employment of inoculation in our own country seems to have been the result of some fortunate observation, made, like that of cowpox inoculation, in the rudest parts of it; for the practice of " buying" the smallpox, which was in fact a communication of the disease by in- sertion was prevalent in Wales at a very early VARIOLA. 639 period, and appears to have been also occasion- ally resorted to in the Highlands of Scotland, from an antiquity nearly as remote ; of which abundant proofs are to be found in various arti- cles in the Philosophical Transactions.—(See vol. xxxii., years 1722-3, and especially Dr. Williams's account.) All such practice, how- ever, and even the knowledge of it, seems to have been confined to the remote quarters in which it accidentally arose, as late as the year 1721, when Lady Mary Montague, who had wit- nessed its success in Turkey, and had had a son successfully inoculated there, submitted an in- fant daughter to the same process at this time in London. Yet, so little acquainted with its! suc- cess were the public, and even the medical pro- fession at this period, and so cautious in giv- ing it credit, that an experiment of its effect was ordered to be made in the same year on six condemned criminals, all of whom were fortu- nate enough to recover, and who thus redeemed their lives. This gave countenance to further attempts; yet the innovation, like that of inoc- ulation from cowpox, was sharply and pertina- ciously opposed, and not more than seven hun- dred and sixty-four persons, according to Dr. Jurin's calculation, were inoculated all over England from 1722 to 1727.* Unfortunately, the practice of treating the dis- ease with cordials and a hot regimen at this time prevailed, and was too generally applied to the inoculated as well as to the natural pro- cess, by means of which the former was often rendered a severe, and, in many cases, a fatal disease ; though it was impossible for the dull- est intellect to be altogether insensible to its high comparative advantages. By degrees, however, the refrigerant and reducing plan ob- tained a triumph, and the triumph of inocula- tion was a synchronous step. Yet half a cen- tury afterward the exploded plan was still per- severed in by some practitioners, and it is in- structive to mark the comparative mischief that still accompanied it. " I found," says Sir George * The bold experiment of inoculation for the smallpox was received very differently in North America. About the time this practice was in- troduced into Great Britain, Dr. Zabdiel Boylston, of Boston, Mass., adopted inoculation at the sug- gestion of Cotton Mather, who informed him of the Turkish practice. Inoculation was first per- formed in Great Britain, on Lady Montague's daughter, in April, 1721; and on the 27th of June ensuing, Dr. Boylston inoculated first his own son, then thirteen years old, and afterward his two negro servants, in which he was completely successful. " This had the happy tendency," says Dr. Thacher, " not only to confirm in his own mind the safety and utility of inoculation, but in some degree to quiet the fears of others. In 1721 and the first part of 1722, Dr. Boylston inoculated two hundred and fifty-seven persons, and thirty- nine were inoculated by other persons in Boston and its vicinity ; of this number six only died, and several of these were supposed to have taken the infection before inoculation. In the same pe- riod, 5759 took the disease in the natural way, of whom 844 died."—See Boylston's account ofthe practice of Inoculation in America, in Thacher's American Biography.—D, 640 HiEMATICA. [Cl. III.—Ord. III. Baker, writing in 1771, " that in the counties of Essex, Norfolk, and Suffolk, many thousands of people, of all ages and constitutions, and some of them of every apparent disadvantage, had been inoculated with general good success : whereas, at Blandford, in Dorsetshire, out of three hundred and eighty-four persons who were inoculated, thirteen actually died, and many others narrowly escaped with their lives from the confluent smallpox."* This gives us a di- rect mortality of something more than one in thirty; and it is almost needless to add, that, in the successful districts here alluded to, the cooling plan was prevalent, and at Blandford that of hot beds and a warm regimen. Even this result, however, with all its fatality, offers a wonderful improvement upon the march of natural smallpox ; in which one out of every three or four have been computed to die among adults, and one out of every seven among in- fants ; while, wherever the cooling and reducent plan has co-operated with inoculation, the casual- ties are not more than one in five or six hundred. Yet, great as is the intrinsic advantage of in- oculation, even upon its lowest scale, there is one evil which has always accompanied it, and which, in a nation so justly proud of its civil lib- erties as Great Britain, it is almost impossible to provide against; and that is, the wider dif- fusion of variolous contagion through the atmo- sphere by the indiscriminate use of inoculation in all places. And hence it has been very for- cibly observed in our own day, by those who have written most warmly in favour of vacci- nation, that smallpox inoculation is upon this ground a greater public evil than good; since the multitude who will not consent to be inoc- ulated, receiving the natural disease more gen- erally than they otherwise would do, the total mortality is greater than before inoculation was had recourse to. I was at first induced to think, that this statement was a little too highly col- oured for a particular and present purpose. But, on turning to Baron Dimsdale's tables of calcu- lation drawn up nearly fifty years ago, I find him arriving at the very same conclusion; and we may fairiy affirm, that the deaths from small- pox, since the introduction of inoculation, have increased in consequence of the more extensive diffusion of variolous contagion in the propor- tion of fourteen or fifteen upon every hundred. The bills of mortality indeed give us something more than this. By what means variolous contagion, received by a puncture, becomes so much milder than when received from the atmosphere, is a prob- lem that has never been satisfactorily solved. Something is unquestionably due to the prepar- atory process of purgatives and a reducent regi- men ; but as the. same mildness of character does not obtain in the natural disease, where the same preparation has been submitted to an- tecedently, some other power must be sought for. Under inoculation, and with the usual pre- * Med. Trans., vol. ii., art. xix. Compare M. Gatti's Nouvelles Reflexions sur la Pratique de PInoculation, Paris, 1770. cautions, the eruption is commonly distinct and widely scattered ; yet the most striking charac- ter in the inoculated form is, that when the erup- tion is full, and even confluent, the secondary fever, so alarming in the natural disease, is here for the most part slight, and sometimes alto- gether absent. This exacerbation is usually as- cribed to an absorption of the contagion from the pustules ; but the feature before us shows, that there must be a something distinct from absorption, though perhaps acting in union with it Is the virus from the first less irritant, and less capable of exciting much secondary fever, for the very reason that it was less capable Of exciting much primary 1 It is on this account that variolous inoculation may be submitted to without danger, by feeble infancy, advanced age, and even cachectic habits in every stage of life ; and that the season of the year does not seem to be a matter of great importance. Pregnant women, however, ought never to be exposed to it, nor infants, where there is a choice, till after the irritation of teething. The operation is perfectly simple: the nee- dle, originally employed in the east, is as good an instrument as any, though the lancet is gen- erally preferred. It is only necessary to deposite a minute drop of the contagion under the cu- ticle, or at least to make such a wound as may give forth a single drop of blood. It is prefer- able to take the fluid before the pustule suppu- rates ; as afterward it seems to partake of the nature of common pus as well, and produces a larger circle of inflammation, and,, on this ac- count, also, it cannot so fully be relied on. The puncture does not so completely disappear as in that with vaccine fluid, but it is often scarcely visible for three or four days. At this period a minute papula may be traced, a little itching is felt, and sometimes there is a slight inflamma- tion. On the sixth day, a pain and weight are felt in the axilla, proving that the lymphatics of the arm have become affected, and that the virus is conveyed into the system. On the sev- enth or eighth day, the precursive symptoms of transient shiverings, headache, and pain in the back are perceived, and immediately followed by the eruption itself; though mostly, in this mild form of the disease, the only eruption, as in the inoculated vaccinia, is the pustule on the puncture, or a few which directly surround it. Where the disease spends itself in this manner, the local efflorescence commonly spreads over a larger area than otherwise, and the adjoining lymphatics participating in the irritation, the ten- derness and sense of weight are increased in the axilla. Where the symptoms are unfavourable, there is a purplish, instead of a rosy inflamma- tion, or a narrow, deep-red circle surrounding the puncture, with a dip or depression in the pustule.* The treatment is to be the same as that al- ready pointed out for the natural disease ; but * Dr. J. D. Fisher, of Boston, has published an excellent work on the smallpox, in which the dif- ferent stages of this disease, &c, are illustrated by coloured plates.—D. Gen. iv.] ANTHRAC1A. 641 it should vary with the habit, constitution, or age of the individual. Sufficient attention was not always given to this remark formerly : for the preparatory regimen was a bed of Procrus- tes, to which every one was alike compelled to adapt himself. Sir George Baker openly com- plained of this inconsistency in his own day (Med. Transac, vol. ii., p. 282); but notwith- standing his censure, it was very generally con- tinued.* GENUS IV. ANTHRACIA. CARBUNCULAR EXANTHEM. eruption of tumours imperfectly SUPPU- RATING, WITH INDURATING EDGES, AND, FOR THE MOST PART, A»SORDID AND SANIOUS CORE. The present genus, denominated anthracia, from avOpaZ, " a burning coal," by its definition embraces two diseases of very different spe- cific characters, though closely according in their generic marks. These are, 1. Anthracia Pestis. Plague. 2.---------Rubula. Yaws. There have been, however, and still continue to be, great disputes among the nosologists as to the proper station of both these species, many contending that plague ought not to be regarded as an exanthem, and most writers having hith- erto contemplated yaws as an impetigo, or some other dysthetic affeetion. Dr. Cullen has ex- pressed a doubt whether the first should not be removed from the order of exanthems into that of fevers ; Vogel has actually introduced it into this last order ; Willan has rejected it from the exanthems. Parr arranges it as an exanthem in his article Nosology, having pre- viously, like Willan, rejected it from that di- vision in his article Cutanei Morbi. In his re- marks subjoined to the article Nosology, he again acknowledges that " on reflection it ap- pears improper" to introduce it into the list of exanthems ; and, in his article Pestis, he as- serts more roundly that " there is no foundation for arranging plague among the exanthemata, and that it should be reduced to the asthenic * As, in smallpox, the inflammation frequently extends to the eyes, opacity of the cornea, staph- yloma, and blindness may be the consequences, especially when a pustule has formed on the eye itself. The smallpox frequently leaves the con- stitution in a state in which scrofula is disposed to arise ; the glands of the neck or mesentery en- large, or phthisis comes on. Frequently, says Dr. Elliotson, it leaves after it rupia and ecthyma, diarrhcea, and chronic inflammation of the mucous membrane of the intestines. For the prevention of pitting, various plans have been suggested. In the hospital at New-Orleans, in 1830, Dr. Picton kept the smallpox patients ex- cluded from the light, and not one of them exhib- ited a pit or mark on the body.—(See Am. Journ. of Med. Sc, vol. x., p. 119.) Pricking the pustules with a fine needle has been favourably spoken of. Mr. George, of Kensington, has published some observations in favour of covering the pustules of confluent smallpox, situated on the face, with cal- amine.—See Med. Gaz., vols. x. and xi.—Ed. Vol. I.—S remittents." Sauvages, Linneus, Sagar, and Macbride, have entered it in the order in which we have placed it in the present system. „ In a few words, there appears strong and al- most incontrovertible reason for thus placing it. The fever, as will presently be shown, is erup- tive, and as specifically so as that of any of the exanthems ; it is contagious like most of them, and, although frequently occurring oftener than once in a man's life, we have the concurrent testimony of all the writers who have been eye- witnesses of its effects, that it renders every one less susceptible for a certain period after- ward, and some for the whole term of their existence. With respect to yaws, the diversity of opinion has been quite as considerable as that respect- ing plague. Generally speaking, it has been placed in the loose and indeterminate class which has been distinguished by the name of cachexies ; Sauvages and Sagar arrange it in the order tubera of this class; Cullen in that of impetigines. These writers take little or no notice of any kind of febrile features that accompany it, whether specific or sympathetic' Dr. Young pays as little attention to the febrile symptoms by which it is said to be distinguished, and, at the same time, transfers it from the di- vision of cachexies (cacochymia, as he denomi- nates them) to the order of paramorphiae or structural diseases. Dr. Winterbottom and Dr. Dance, on the contrary, contend that a slight fever is its primary symptom ; and Dr. Ludford, to whom we are indebted for, perhaps, the best history which has yet been given of this disease, describes it as a proper eruptive fever, totally unconnected with diet, lues, or any other taint in the blood ; commencing with alternations of shivering and heat, lassitude, want of appetite, and pains in the • head and loins to so great a degree as to prevent sleep ; the fever and every inconvenience diminishing after the eruption, and the appetite returning. So that, like smallpox, it appears to have a regular accession, height, and decline, and, as already observed, may be propagated by inocu- lation, and is never known to occur a second time. Hence Parr, who seems to have long wavered in his opinion concerning the real na- ture of this disease, regarding it at one time as a pustulous exanthem, and afterward as a mere cuticular intumescence, returned at last with a decided mind to his first opinion, and again as- serts that " the detail of symptoms shows that the disease is truly exanthematous." This view of the subject will therefore aburv dantly justify the present arrangement of both these diseases, support their pretensions to the character of carbuncular exanthems, and conse- quently develop the nature of the connexion of yaws with plague, under a nosological method founded on the principle of symptoms. In their individual or specific characters, they are, in- deed, highly discrepant; but this is not sufficient to call for a separation, while they agree in the common outline that may form the basis of a generic division. The tall and stately acacia of Egypt, and the delicate sensitive plant of oui * 642 ILEMATICA. [Cl. III.—Ord. lit. own green-houses, belong to the sahie genus in botany, however inaccordant they may appear to the eye of an ordinary spectator. SPECIES I. ANTHRACIA PESTIS. PLAGUE. TUMOURS BUBONOUS, CARBUNCULAR, OR BOTH ; APPEARING AT AN UNCERTAIN TIME OF THE DISEASE : EYES WITH A MUDDY GLISTENING ; FEVER A MALIGNANT TYPHUS, WITH EXTREME INTERNAL HEAT AND DEBILITY ; CONTAGIOUS.* It is happy for us that, in describing this dreadful scourge, we are under the necessity of referring to foreign countries, or to remote periods in the history of our own, before the great advantage of public cleanliness and ven- tilation in our streets was sufficiently attended to, or even known. The earliest visitation of the plague that occurs in English history was in the year 430 ; the last time it appeared as an epidemic was in 1665, and the last notice of it in the bills of mortality was in 1679. In Edin- ' burgh it has not prevailed subsequently to 1645, long since which period it has repeatedly rav- aged all the continent of Europe, east, west, north, and south.t From the diversified and clashing accounts that are given of this disease by different wri- ters and eyewitnesses in different ages, or dif- ferent parts of the world, we are justified in laying down the three following varieties, which, while they offer the chief points of discrepance, will be found in their explanation to reconcile the seeming discordances of estab- lished authorities. a Fructifera. .The disease extending to Common plague. about the fourteenth day; * " The difficulty of presenting a definition appli- cable to all cases may be conceived from the fact, that the disease varies greatly in its appearance in different instances ; insomuch, that even fever is by no means invariably present; and, in rapid cases, death terminates their course before a suf- ficient time has elapsed to admit of the formation of buboes and carbuncles."—(Bateman, in Rees's Cyclop., art. Plague.) The following is Dr. Jo- seph Brown's definition :—" An exanthematous disease, consisting of buboes, carbuncles, and pustules, white, livid, oi black, distributed in va- rious parts of the body, and generally attended with malignant and very fatal'fever."—Cyclop, of Pract. Med. t Marseilles, which had previously suffered twenty severe visitations in the course of seven- teen centuries, was ravaged by it again in 1720. Moscow suffered cruelly from it in 1771 and 1772 ; and it prevailed at Noja, in the Neapolitan terri- tories, as late as 1815 and 1816. It appeared in the Lazaretto of Venice in 1818 ; and at Gressem- berg, in Silesia, in 1819. In the year 1813 it raged at Malta. With these exceptions, it has of late generally been confined to the northern parts of Africa, the reputed land of its origin, and to those portions of Asia and Europe which are, or have been, under the dominion of Turkey.—See the art. Plague, by Dr. Brown, in Cyclop, of Pract. Med.—Ed. and relieved by the ap- pearance of the eruption. 0 Infructifera. The eruption imperfect or Uneruptive plague, suppressed ; transferred to some internal organ ; or superseded externally by stigmata and vibices. y Erythematica. The body covered over with Erythematous trails of vesicular erythe- plague. ma, producing deep, sa- nious, and gangrenous ulcerations as it spreads, often to the loss of one or more hmbs. The whole of these varieties have sometimes been exhibited in the same epidemic ; the last, however, is the least frequent, whether alone or in conjunctiori with the rest. All of them ap- pear to have been present and intermixed in the Aleppo plague of 1660-1-2, so clearly and stri- kingly described by Dr. Patrick Russell, phy- sician at the time to the British factory estab- lished at that city ; for he speaks of the pesti- lential eruptions appearing under the form of buboes, carbuncles, or other exanthemata; among which last he takes particular notice of an erysipelatous redness, forming streaks of a reddish purple or livid colour, intermixed with vibices and wheals, or large blue and purple spots, the maculae magnae of authors ; while, in some cases, he observes that an extraordinary concurrence of these eruptions took place, which, however, was chiefly remarked among children under ten years of age. In the Barbary plague of 1799 and 1800, so fully and excellently described by Mr. Jackson (Account of the Empire of Morocco, &c, 4to., 1809), who was an eyewitness to its effects,— the first and second of the two varieties here offered, the fructiferous and infructiferous, were intermixed, while the erythematic seems to have been absent. It was probably absent also in the plague of Moscow of the year 1771, as it is not noticed by Dr. Mertens, who gives a full description of both the other modifications. In the London plague of 1665, all of them seem to have occurred occasionally ; the first and the second, however, most frequently, examples of which are to be found in Hodges, Sydenham, Sir Gideon Harvey (City Remembrancer, passim), and indeed all the writers; while, in allusion to the last, Sydenham compares the inflammation of the plague, as it often appeared, to that of an ignis sacer, by which he means an erysipelas ; in which nature, he tells us, expels the matter of the disease from the blood to slightly ele- vated tumours dispersed over the surface in broad red patches : only that this ignis, says he, is more violent than the ignis sacer (Febris Pestilens, et Pestis Opp., sec. ii., class ii.):— " ignis noster isto sacro longe divinior est." They seem also to have co-existed in the Nea- politan plague, or rather that of Noya, in 1815, for the police regulations,* as well as the med- * Giomale di tutti Atti, Discussioni, e Deter- minazione della Sopra-intendenza Generale e Su- Gen. IV.—Spe. L] ANTHRACIA PESTIS. 643 ical descriptions, have a reference to each of these in very distinct terms.* In the plague of Athens, on the contrary, as described by Thucydides and Lucretius, we are not sure of the existence of buboes, as not be- ing distinctly noticed, though probably included in the inflammations that are stated to have fall- en upon the privities (tu alSota), while the last two varieties were perpetually intermixed ; the chief eruption, however, being that of the vesic- ular erythema, the sacer ignis, or holy fire, as observed by Sydenham. In consequence of which, Thucydides tells us, that " the surface of the body was neither violently hot nor wan ; but reddish, livid, and covered over with an ef- florescence of minute vesicles and ulcers,"— . 123.)] Mr. George Smith, surgeon of the Russian Imperial Land-Cadet corps of nobles, was twice a sufferer from the plague at Bucharest in the year 1772, as I think, and had the rare privilege to recover from both assaults. But that an ex- emption for a considerable term of time is here- by very generally obtained, is established by in* numerable examples, of which M. Mathias Degio, one of the surgeons attached to the same establishment, affords us a striking instance in his own person. " Perceiving," says Dr. Guth- rie, " the gentlemen of his profession condemn- ed, in a manner, to death, if punctual in their duty, he had the resolution-to inoculate himself for the plague, in a full confidence of its effica- cy ; and.ever afterward found himself invulner- able, while his companions around him were falling victims to its fury."—(Guthrie on the Plague, &c, in Edin. Med. Commen., vol. viii., p. 348.) And to the same effect we are inform- ed by Dr. P. Russell, that, in four thousand four hundred cases of infection, he only met with twenty-eight of a well-ascertained renewal of disease.—(Treatise, &c, p. 190.) [The contagion of the plague, like that of typhus, and unlike that of smallpox, may infect a person a second time, though his chance of being so attacked is very considerably diminish- ed. Dr. Bancroft says, " Two cases of rein- fection, or second attacks of plague, fell under my observation in Egypt; one occurred in Mr. Webster, then an assistant surgeon, and the other in a soldier of the 27th regiment, each of whom had a bubo : they were, however, but slightly indisposed, the weather having become hot. Dr. Buchan had a second attack, but with only a small carbuncle, as he informed me. Dr. Price had also a second attack, without either a bubo or carbuncle, but, according to his own account, with a violent affection of the head and nervous system. In general (he adds), I think second attacks are milder than the first, though Dr. Price informed me of his having seen a lad, who, under such an attack, died on the second day. Pugnet says, that reinfections, when they occurred, were most frequent in persons who had been mildly treated by the first attack ; and that several of these had the disease very vio- lently the second time, immediately after using the bed or blanket of persons who had died of it."—(Bancroft on Yellow Fever, &c, p. 599.) Looking at the general tenour of the evidence on the point before us, it may be concluded that a second infection is not a common event, at least during the same epidemic. In above 120 pestilential cases recorded by Diemerbroeck, 648 H,EM there are only two in which the patients had been infected twice during the same season.— (De Peste, lib. iv., hist. 37, et 45.) Thucydides, in his account of the plague at Athens, mentions, " that those who recovered had much compassion on those who were dying ^and those who lay sick, as having known the misery themselves, and were now in a secure condition, for it never seized the same person twice, so as to be fatal." This confidence of the convalescents in their security (which is not usual in cases of the true plague when epidemic), is sometimes regarded as a confirmation of the suspicion, that the plague of Athens was the smallpox ; against which inference, however, our author has zealously adduced every reason that it is possible to urge.] Of the efficacy of inoculation from the virus of a bubo there can be no question, and we have hence a sufficient proof of the specific character of the eruption ; but it is not always a successful efficacy ; and even where it is so, as the extent of the immunity is not sufficiently ascertained, inoculation for the plague is by no means to be recommended. We are told by Sir John Webb of a bold experimenter, in the person of a young physician and hospital sur- geon attached to the British army at Rosetta in 1802 ; who, to determine the question whether the bubonous virus of the plague be or be not a specific and propagable poison, inoculated him- self at El-Hamed, on January 3d, twice by fric- tion from the matter of a bubo, and once on the ensuing day, by incision. He was attacked with rigour and other symptoms of fever on the even- ing of the 6th of the same month, which proved t6 be the plague, became delirious on the 8th, and continued in this state till the evening of the 9th, when he expired.—(Med. Trans., vol. vi., art. viii.) I gladly avail myself of this authentic narra- tive of the Director General of the Ordnance Medical Department, in confirmation ofthe gen- eral statement here offered ; and as containing, if a feeling of high esteem and friendship have not unduly biased my judgment, one of the most valuable documents we possess on the sub- ject, particularly in respect to the best practical means of opposing the influence of this desolating scourge upon a large scale. Sir John Webb's narrative embraces the his- tory and progress of the plague, as it appeared in the British army employed in the conquest of Egypt in the years 1801, 1802, and 1803, during the whole of which time he was present, and actively engaged in arresting its course : and it justifies us in drawing the following con- clusions :—Firstly, that the disease is specifi- cally contagious. Secondly, that the atmo- sphere of contagion is very limited, and that hence it is by no means difficult to avoid being infected. Thirdly, that the disease makes its attacks with very different degrees of malignity, at different seasons of the year, and on different constitutions. And, fourthly, that those who reside in a place in which the plague exists, and have been gradually inured to the influence of the pestilential miasm, are less disposed to be ATICA. [Cl. III.—Ord. III. affected by it than those who are fresh to its •poison ; and, as in the case of the jail-fever, may carry about them, in their clothes, effluvium enough to infect those who come within its at- mosphere, while they themselves remain in a state of health. The first position is sufficiently proved, not only by the test of inoculation just adverted to, but by numberless other facts, of which one of the most forcible is the following. A lieutenant of the 10th regiment of foot, residing in Alex- andria, was attacked with the disease, and con- veyed within the boundary of the quarantine. A rent having been made in a moscheto curtain, it was taken without his knowledge, by John Lee, a private, and servant to the lieutenant, who prevailed on the sentinel to let him pass, in direct violation of orders, to another private of the same regiment, of the name of William Bower, to be repaired ; after which, Lee im- mediately carried it home, and, at his own re- quest, accompanied his master into the pest- hospital, and attended him till he recovered. On the fourteenth day after this visit of Lee to Bower, the latter was taken ill with very sus- picious symptoms, which, on the idea that it was an attack of plague, could be accounted for by no one. till the application to repair the mos- cheto curtain was recollected by the patient. The suspicions were confirmed on next morn- ing, and in the evening he died. So long, however, as the line of separation was faithfully maintained, and the sound and the diseased were thus kept distinct, there was scarcely an instance in which the disease broke out among the former. I say scarcely an in- stance, because an anomalous case or two oc- curred occasionally. But such was the judg- ment and the vigilance exerted from first to last, that the Board of Health were able to trace al- most every instance of fever to the source from which it was derived, notwithstanding the diffi- culty of maintaining a rigid and permanent pro- hibition of all communication whatever. And hence it is most probable, that the few excep- tions to the general fact proceeded from a dis- obedience of orders which the Board were not able to detect. In general, Sir John Webb observes, that the course of the disease is nearly the same every year, and equally varies in different seasons of the year. In Egypt it commences in Novem- ber, at which time it rages with its mostly dead- ly malignity, " and those who are affected by it sink into the grave almost without complaint." It continues its ravages with little abatement through the winter and the earlier part of the spring, when, as the weather becomes warmer by the approach of summer, its attacks are less frequent, its symptoms much milder, and it sub- sides into a manageable malady ; still, however, retaining the characteristic test of glandular affection : and, on the 24th of June, the Turkish government announces to the public its suppo- sed cessation by a discharge of cannon ; the at- mospheric temperature being now acquired, in which the matter of plague ceases to operate. Sir John, however, with great judgment, en- • IV.—Spe. L] ANTHRACIA PESTIS. 649 tertains doubts of its entire cessation, even then or at any time ; and brings a proof or two of its existence during the period of official emancipa- tion. In few words, he conceives the plague to exist in Egypt as the smallpox exists in Eng- land ; only, from a greater regularity in the at- mospheric changes of the country, evincing a greater regularity of epidemic flux and reflux, operated upon at the same time by contingen- cies often difficult to be developed ; and hence equally varying in violence and extent. That the miasm of plague, like that of typhus, is sometimes inert upon those habituated to its influence, is obvious from the following fact. " When our pest establishment at the camp was broken up, I discovered that the Arab servants who had been employed in it had secreted a great part of the clothing of the men who had died of the plague ; some of which they wore with great satisfaction and perfect impunity." I have noticed this effect of habit in the prece- ding view of the plague at Mogadore : and to the same cause Sir John Webb ascribes it that the Chasseurs Britanniques, on their first arrival at Alexandria from Trieste, suffered far more se- verely from the disease than the troops that had been stationed there for some months.* [Dr. L. Frank {De Peste, Dysenteria, et Ophthalmia Mgypliaca, Vindob, 1820) has published several striking examples of the sud- den disappearance and occasional inertness of plague contagion. The French army arrived at Cairo in 1798, only thirty days after the ces- sation of a severe plague ; and though, in the hospitals, the beds, clothes, &c, of the Mama- lukes were made use of, not a single case of plague occurred during that year. Upon this subject, as Dr. Winterbottom has noticed, Dr. Wolmar informs us, that about the summer solstice the south winds and sirocco, which had prevailed during the time of the plague, ceased, and were succeeded by north and northeast winds. A heavy dew fell every night, and the disease disappeared. The Europeans, many Christian merchants, and the Cophts, now opened again their enclosures, and many days were passed merely in visiting. The Turks, also, visited to congratulate each other, and to renew their commercial ties. The Europeans and native Christians paid visits of condolence to the Turks in their houses ; on which occasion they seated themselves, without dread, upon sofas covered with cotton, which, but a few days before, would have infallibly communicated to them the plague ; though, at this time, such an occurrence was not heard of—a sufficient proof how great the influence of the atmosphere is over this disease.f Moreover, soon after the battle of the pyramids, Bonaparte and his staff * Compare Dr. Patrick Russell's Treatise on the Plague, book i., chap. iv. (Aleppo), p. 19,4to., 1791. + Enrico di Wolmar, Abhandl-ueber die Pest, Berlin 1827. This work, according to Dr. Win- terbottom, is extremely interesting, and contains the author's remarks on the plague, made during four epidemics, which occurred in a residence of fourteen years at Cairo and Constantinople.-See Edin. Med. Journ., vol. xxx., p. 64.—Ld. occupied the quarters of Murad Bey ; in which, a short time previously, sixty men had died of plague, yet none of the French suffered from contagion. Pugnet also informs us, that Bona- parte, in order to lessen the fears of the soldiers, used to touch the bodies infected with plague. Upon this subject, Desgenettes more particular- ly says :—" Se trouvant (le g^neral-en-chef) dans une chambre etroite et tres encombree, il aida a soulever le cadavre hideux d'un soldat, dont les habits en lambeaux etoient souffles par l'ouverture d'un bubon abscede."—(Hist. Mid. de I'Armie d'Orient, p. 49 ; and Winterbottom, in Edin. Med. Journ., vol. xxx., p. 331 )J How slightly the disease makes its assault upon some constitutions may be inferred from the case of one of the sailors of the Major transport, who was attacked towards the end of March with an inguinal bubo, but was other- wise in perfect health. " The man," says Sir John Webb, " declared he had had it three days, and attributed it to cold. I was, however, sat- isfied, after a careful inquiry into his case, and an examination of his leg and thigh of the same side, that it was an effect of pestilential conta- gion, but in its mildest form. He was there- fore placed in a separate tent, and a gentle aperient was administered, which was all the medicine he required. On the 2d of April I found the swelling had begun to diminish, which it continued to do until it entirely disappeared."* The following description is of a different character. It is written with a touching sim- plicity that does credit to the author's heart, and will not be read without feeling by the most torpid. " As I approached the beach to exam- ine them (the sick and suspected of the Major transport), the first object that presented itself was a young woman supported in a chair (Fran- cisca Kennis,) moaning under oppressive dis- ease. She stared wildly about, qnite insensible to every object around her, and there was a muddy glistening in her eyes, which I had seen described but had never before observed. Her husband stood over her in the deepest distress, and held a lovely infant to her breast, who tran- quilly sucked the poison that soon afterward destroyed him. I feared, at first, that force would be necessary to separate the father from his wife and child, but he at length yielded to entreaty, and was removed from the infection, though too late to save his life. She was con- veyed to the pest-hospital, where she soon ex- pired ; and the child was confided to an Arab, who fed and watched over it with the greatest care. On the 28th of March, the fifteenth day after the separation took place, the infant was attacked with plague, and languished until the * Where buboes or carbuncles constitute the main symptoms, the patients are sometimes able to walk about and follow their usual employments, unless prevented by the degree of inflammation in the groin. Among the French soldiers whom Bonaparte led into Syria, several, while ill of plague, were able to march a considerable time. —(See Fodere in Diet. Des Sciences Med, vol xii., p- 77.) Similar facts are recorded by Diem- erbroeck.—Ed. 650 '-•" H^MATICA. [Cl. III.—Ord. III. 14th of April, when death terminated its suffer- ings." Upon an average, from a table of the general return of the loss sustained by the British army from the plague, during the conquest and evac- uation of Egypt, from the 8th of March, 1801, to the 8th of March, 1803, comprising just two years, it appears that the whole number of sick was 660 :—of whom 361 died, and 299 were discharged cured: making the deaths rather more than half the number attacked. And fur- ther, that of the above 660, 612 were seized between March 8th, 1801, and June 30th, 1802, being nearly sixteen months ; and only 48 be- tween July 1st, 1802, and March 8th, 1803, including the remainder of the time : a result which reflects a very high degree of credit on the means resorted to on the occasion, and on the vigilance and activity with which they were carried into execution : 361 being the entire loss sustained from this fatal scourge operating through a period of two years: while in the French army in the same quarter, as we learn from M. Desgenettes, not more than one in three of those that suffered were fortunate enough to recover; and, according to Dr. L. Frank, not more than one in five. Such is the history of plague, as it has shown itself in different ages and parts of the world, collected from the writings of unimpeachable eyewitnesses of its progress. In the midst of many discrepances, it exhibits a sufficient iden- tity of character; and I have dwelt upon it the more largely, because, from the time of Dr. Cullen to the present day, its discrepances have been chiefly attended to. And hence, while some writers of respectability have attempted to di- vest it of one, and others of another of its pecu- liar and most striking attributes, as that of con- tagion,* or that of atmospheric influence (Sir Brooke Faulkner; Tally, Hist, of Plague in the Islands of Malta, Goza, Corfu, &c, 8vo., 1821), some, and especially Professor Frank (J. P. Frank, De Cur. Morb. Horn. Epit., torn. i., p. 136, 8vo., Mannh., 1792), have been equally inclined to sweep the whole away at once, and to reduce it to a mere modification of typhus, or some other fever of great malignity ;t on which account, in Swediaur's Nosology, it is placed next to typhus in the class of continued fevers, instead of in that of exanthems; and is distinguished by the name of loimopyra.—(Nov. Nos. Med. Syst., i., 23.) From its history, then, let us endeavour to collect its pathology, or the laws by which it is * Laessis, Recherches sur les veritables Causes des Maladies Epidemiques, &c, 8vo., Paris, 1819. Lange, Rudimenta doctrinae de peste. Magirus, Von der Pest. Maclean, Results of an Investiga- tion respecting Epidemic and Pestilential Dis- eases, including Researches in the Levant con- cerning the Plague. t Dr. W. Heberden, Observations on the In- crease and Decrease of different Diseases, partic- ularly the Plague, 8vo., 1801. Dr. Hancock, He- searches into the Laws and Phenomena of Pesti- lence, &c, 8vo., 1821. Dr. L. Frank, De Peste, Dysenteria, &c, 8vo., Vienn., 1822. governed, and which connect it with or separ- ate it from other exanthems. In the first place it is obvious, that the plague, like many other febrile eruptions, is un- der the occasional influence of various con- comitant circumstances that give a considerable diversity to many of its features. Its proper fever is an acute typhus; but even this, by the constitution of the individual, or the peculiar state of the atmosphere, sometimes changes to a remittent, and even to an inflammatory type. So the measles and smallpox, whose proper fever is a cauma, sometimes change, as we have al- ready seen, into a typhus or synochus. The final end of the fever in plague, as in other ex- anthems, is to restore the body to health by throwing the morbid ferment to the surface in a specific way. And, as in other exanthems also, a very small degree of fever is requisite for this purpose. And hence we find, that, wherever the disease runs through its progress kindly, the fever is slight in degree and short in continuance; and the specific eruption shows itself in its perfect character. Dr. Frank the younger tells us of a patient, who even danced and was merry at the very time when he had a bubo forming in the right axilla.—(De Peste, Dys- enteria, &c, 8vo., Vienn.) In the smallpox we sometimes find scarcely any eruption, and very little disturbance of the system ; and the same benign disposition is occasionally found to attend the plague ; for the soldier who is struck while in the ranks with a sudden shock, or m'drop, as the Arabians call it, and is taken to the hospital on one day, has, in a few instances, by proper treatment, passed through the febrile assault in three or four hours, and resumed his station the day after (Edinburgh Med. Commentaries, vol. iii., p. 352): the disease, in such cases, evin- cing the same rapidity of attack and recovery which we have already noticed in that tre- mendous and fatal scourge, the spasmodic chol- era of India. Next, the proper eruption of plague is that of buboes ; and where these alone arise, and in their proper period, the disease is not accompa- nied with much danger. They are always a favourable sign, and seem to afford the longest indemnity against future attacks. When the fe- ver is more considerable, carbuncles, the jim- merat CHJM^^p- of the Arabians, are thrown out at the same time over different parts of the body ; and there is in this case always great debility, which is probably the cause of their appearance, and a considerable degree of dan- ger. And, if the fever run still higher, the dan- ger will be proportionably increased, the proper eruption of buboes may perhaps be suppressed, and carbuncles alone be found highly malig- nant, and secreting a most acrid and corrosive ichor, which, as it oozes and spreads about, oc- casionally forms extensive trails of painful and distressing sores. But the fever is often still more acute, and especially, for a reason we shall presently notice, when the disease first appears among a people ; and the danger may be imminent from the first Gen. IV.—Spe. 1.] ANTHRACIA PESTIS. 651 shock. The typhous symptoms are here of the most malignant nature : there is a sudden and almost utter exhaustion of sensorial power with- out the smallest means of recruit: all the larger viscera are disturbed in their functions ; the head, the heart, the lungs, the stomach, and the liver: some overwhelmed with congestion, others sinking and powerless, as though the morbid virus were translated from the surfaee to themselves ; the only active principle through- out the entire system being that of fever itself, which increases with the increase of the general mischief, and, like a house on fire, gathers fuel from the downfall of the fabric All the symp- toms of putrefaction make an early appearance, and appear at the same time under these cir- cumstances : the animal spirits fail and are de- spondent ; the respiration is anxious and feeble ; the stomach faint and sinking, or the brain com- atose ; purple stigmata and vibices are scat- tered over the body, and the patient is destroyed by the incursion of the eruptive fever, as often happens in the smallpox, before the specific tokens have time to show themselves. Of the primary source of plague we are in as much uncertainty as in respect to that of any other exanthem : it appears, however, to have a just claim to a higher antiquity than any of them ; for we have already seen that it was known in an early era to the Greeks, and that histories of it, as it has shown itself in different ages and countries, have descended in a regular stream of Greek, Arabic, Roman, and neoteric writers down to our own day. We might, indeed, if it were necessary, ascend to a far remoter period, and prove its existence in the earliest ages of the Jewish history, for it is very frequently referred to in the Pentateuch under the name of deber (-ot), (Exod. v., 3, et alibi), and is more particularly described in the pro- phetic writings as deber mizraim (ci];a "m or -OT tonXD -p-O), (Amos iv., 10), the PLAGUE OF EGYPT, THE PLAGUE PROCEEDING from Egypt ; thus pointedly adverting to what was equally regarded as its indigenous soil by the Greeks (Lucr. vi., 1139, who quotes from Thucydides) and Barbarians, as well as by the Jews ; while the carbuncular variety is also peculiarly distinguished and characterized by the name of Shechin perech (j-p3 VTVff)' (Exod. ix., 9), " burning carbuncle," and Shechin Mizraim (pnt£* Q'TVD); (Deut. xxviii., 27), car- buncle of egypt. That, like other exanthems, it consists in and is propagable by a specific virus, is unquestionable ; for we have already seen that it has often been put to the test of inoculation ; and, like most other exanthems also, it appears to be dependant for an extensive spread upon the same accessories as give rise to febrile miasm or contagion, and which, as before noticed, are, for the most part, the com- mon auxiliaries of putrefaction. Whether any combination of these be capable of originating it of themselves, either without or within the human body, or whether it be only propagable by a stream of hereditary descent from primary matter communicated from place to place, is a problem to the present hour, though it is probable that the principle which in this respect governs most of the other exanthems, as measles, small- pox, and scarlet fever, governs the miasm of plague also : for all of them, while derivable by communication with the affected, seem at times to have assumed the form of epidemics. In deducing the more obvious laws that regu- late febrile miasm, I observed at some length, that, whenever originating from the human body itself, this miasm does not seem to be very vol- atile, and is soon dissolved or decomposed in an atmosphere of pure air : and we have since had occasion to apply the same remark to the spe- cific miasms of all the preceding exanthems. I have now to observe that it applies especially to that of plague, whose sphere of infection in pure air seems to be more limited than any of the rest; on which account, indeed, it has been held by many who have practised in the field of this disease to be communicable by con- tact alone. Such, in truth, seems to be the surest way of communication, and may, in all common cases, be regarded as a way altogether irresistible : but it is not the only way. In the pure and healthy air of Malta, during the visita- tion ofthe plague in 1813, it was almost the only mode of transmission ; and hence the readi- ness with which it was subdued by the rigid line of quarantine which was so wisely proposed by the medical officers, and enforced by Sir Thomas Maitland. But several of the most intelligent residents on the spot, and even Mr. Tully himself, who, in his work on the subject, has held up cpntagion as the sole means of prop- agation, have admitted to me, in conversation, that the disease might be received by the breath of the infected, without contact, upon a very close intercourse. Sir B. Faulkner's opinion upon this point is in perfect union with MfwTully's : " It is communicated," says he, " only by con- tact or close association with the person or thing infected."—(Minutes of Evidence before the Select Committee of the House of Commons.) And, in consequence, they admit that the air, even in its purest state, may become a vehicle of communication, though to a very short dis- tance, and probably for a short period after being impregnated; since, as already observed, the miasm of plague dissolves in pure air with great rapidity.* When, however, the atmosphere is stagnant, or already loaded with foul effluvia of any other kind, especially such as proceed from the filth of close or crowded rooms, or the putrescent decomposition of animal or vegetable substances, no modification of febrile miasm, as we have had reason to state antecedently, dissolves readily; and consequently the seeds of such disease may continue floating for a considerable period of time, and be driven by currents to some distance in full possession of their specific mischief; and * Whether the plague can be received by means of respiration, must yet be regarded as an unset- tled point. The celebrated Omodei observes : " A tutti e noto che il valoroso Valli, ricco d'esperi- enza su di questa materia, sosteneva non essere contagiosa l'aere respirata dagli appestati."—Peste di Smirne del 1781.—Ed. 652 H^EMATICA. [Cl. III.—Ord. III. hence, even a sporadic fever may be converted into an epidemic. It is in this way that plague appears in many cases to have extended itself; for it would be unjust to the character and good sense of a cloud of intelligent witnesses, to deny that this disease sometimes also assumes the form of an epidemy. But I believe it would be found a universal fact, that it has never exhibited itself in this form, except when aided by the above auxiliaries. Thus much is certain, that it has always raged with most violence, and to the greatest extent, in cities and districts where the atmosphere has been least pure, the human frame most debilitated, and the tendencies to putre- faction strongest and most multiplied, as in times of famine or any other general distress, and in the close and squalid quarters of the poor of every city into which it has found an entrance, if it have not even originated there This fact, indeed, is so common, that while many writers have contended that plague can only be propagated by actual contact, others, of equal authority, have maintained that the dis- ease is altogether an epidemic, as directly de- pendant upon the state and constitution of the air as any epidemic whatever, and that to at- tempt to cure it by a mere interdict of commu- nication between individual and individual is equally weak and wicked. The view now taken of the disease is calculated to reconcile these conflicting opinions, and to bring into a state of amity the most sturdy adversaries in the contest* In enforcing the line of quarantine at, Malta (Treatise on the Plague, by Sir Arthur Brooke Faulkner, M. D., 8vo., 1820), Sir Brooke Faulkner most wisely took especial care to en- force at the same time a rigid attention to puri- fication of every kind ; and I shrewdly suspect that, without the latter, his cordon would have been but of little avail. Thus far, the ordinary course of plague does not essentially vary from that of most of the ex- anthems already considered. The general laws of any one are those of the whole : they are all deflected, and exhibit some variety of features by particular circumstances ; but each, to an attentive eye, gives sufficient proofs of identity in the midst of every modification, and is specifi- cally distinguished from the rest. There are two or three properties, however, which, if not peculiar to the plague, are indented »uponit far more strikingly than upon any other "■ The principal difficulty in the way of an un- qualified admission of the contagious nature of the plague, is the complete and often speedy eradica- tion of the disease, in a place where no particular means of purification have been employed for the removal or destruction of the contagion. " But," as Dr. Bateman observes, "this difficulty is not insurmountable, as might be illustrated bv a refer- ence to the progress of those contagious" diseases which admit of no dispute, such as the smallpox and measles. For even these are only widely epi- demic and severely fatal at particular seasons, when circumstances that are not always cogniza- ble give a peculiar virulence to the contagion, or a predisposition to the human constitution to receive its influence."—(Rees's Cyclop., art. Plague.) disease of the same order, or perhaps of any order whatever: and we will next proceed to a brief examination of them. The ordinary mode of infection, on exposure to an exanthematous patient, is by inhalation or deglutition ; probably by the former; for vario- lous contagion has been swallowed in the way of experiment without producing any influence. How far any other virus, besides that of the plague, is receivable by the pores of a sound skin, is to this hour a matter of doubt. In the case of plague, however, there ought not to exist the shadow of a doubt; for though the miasm is probably communicable within the sphere of its activity, by the mouth or nostrils, direct contact or absorption by the skin forms the ordinary means of its conveyance. Upon this point, almost all the writers of authority, who have been professionally engaged in oppo- sing its progress, are concurrent. And hence again, whatever obstructs or corrugates the mouths of the cutaneous absorbents becomes a certain anti-loimic Oil seems to do this most effectually ; it was accounted " the sovereignest thing on earth" in the last pestilent ravage at Noya, where the physicians, inspectors, and commissaries uniformly wore oil-skin caps, man- tles, masks, and gloves.—(Giornale ditutti Atti, Discussioni, &c, Napoli, 1816.) At Malta, it was in equal favour : and Mr. Tully has informed me, that there was no instance of an attendant on the infected having received the contagion so long as he was regular in thoroughly rubbing himself with oil, wearing a dress soaked in oil, or a covering of oil-skin. And to the same ef- fect is the evidence of Sir Brooke Faulkner, physician to the forces at Malta in 1813, before the Select Committee of the House of Com- mons, June 14, 1819, who, in answer to the question, " How were the military attendants preserved?" replied, "With respect to the pest- hospital in which I attended, they were in my opinion preserved by wearing a dress of oiled silk, which prevented the possibility of any con- tact of infected matter with the skin, and prob- ably also by its promoting free and copious perspiration, and in consequence preventing ab- sorption."^ Copy of Minutes, &c Asal so Sir A. B. Faulkner's Treatise on the Plague, &c, Appendix, p. 16, 8vo., 1820.) To the same effect it has been asserted by Mr. Baldwin, of Cairo, that among upwards of a million of inhabitants carried off by the plague in Upper and Lower Egypt during the space of four years, not a single dealer in oil, so far as he could learn, had fallen a sacrifice to it.— (Travels, &c, chap, xvii.) A similar remark is made by Mr. Jackson, respecting the crolies or labourers in oil-warehouses during the Barbary plague. In that of London in 1665, it is spe- cially observed by Baynard and most of the writers, that the trades chiefly exempted were those of oilmen, fishmongers, tanners, barge- men, and watermen : the first three evidently protected by the greasy viscidity that covered the hands and dress generally ; and the last two by living separate from the scene of contam- ination, as though cut off by a quarantine. Gen. IV.—Spe. 1.] While, on the contrary, it has been quite as gen- erally remarked, that the description of persons most exposed to infection are bakers, cooks, and smiths, the pores of whose skin are kept in a state of perpetual irritation and relaxation from their respective employments. How far an habitual exposure to the miasms of other exanthems tofpefies the skin to their action, or whatever other organ affords them an inlet; or how far the system at large may be thus torpefied, has not been determined with any degree of satisfaction. That stimulants of most kinds have a tendency to produce such torpitude and inirritability is unquestionable ; and that the miasm of jail fever has occasionally done it, will not soon be forgotten in the courts of judi- cature of our own country. It is hence prob- able, that the effluvium of exanthems in gen- eral is possessed of a like power. But in the case of plague, the fact seems to be unequivo- cally and most strikingly established; for we find in every country, after it has raged for a certain number of weeks or months, that the dis- ease is both caught more sparingly, and exer- cises far less violence, at least upon those that have been exposed to its aura; for upon new- comers, or strangers, it still retains its virulence. The history of almost every plague may be taken in confirmation of this remark; but it is particularly established by numerous facts al- ready quoted from Sir John Webb and Mr. Jack- son. It is highly probable, that if the corps of troops which, after the mortality had subsided at Mogadore, arrived there from the city of Tero- dant in the province of Suse, where the plague had been raging and had subsided, had remain- ed at Terodant, it would have continued to es- cape. But it lost its immunity by an exchange of contaminated for pure air in the course of its journey, and the organs having acquired their wonted irritability and susceptibility, were as open to infection as those of fresh persons. The acquisition then of a growing torpitude to the action of the pestilential effluvium beneath a habit of exposure to its influence, seems un- questionable ; and puts us in possession of one means of the progressive subsidence of this tre- mendous scourge, after having occupied a town or district for a certain period of time. But there is an additional cause of its cessa- tion, which is equally striking, and forms another of the peculiar features of this complaint. As a particular state of the atmosphere, such, for instance, as its being saturated with foreign corpuscles from decomposing animal filth, ren- ders it a bad solvent of pestilential miasm, and consequently a ready vehicle for the spread of the disease, a particular state of the atmosphere of some other kind seems to possess a power of dissolving the effluvium instantaneously, in many cases, and of diluting or disarming its vir- ulence in others. Of the immediate nature of this atmospheric change, we are in a consider- able degree of ignorance, but of the general fact there is not a quarter of the world that does not furnish us with examples: so that, all of a sud- den the scourge that had hitherto been sweep- LA PESTIS. 653 ing off one or two thousand inhabitants of a city every day, either totally vanishes, or drops its mortality, and only continues in a form so mild as to excite no alarm. Dr. Hodges notices this sudden change very particularly in the plague of London. " In the beginning of November," says he, "people grew more healthy, and many came into the city without fear ; so that in De- cember they crowded back as thick as they fled : and such confidence was now inspired, that many went into the beds where persons had died, before they were cold, or cleansed from the stench of the diseased ; for the nature of the dis- order was changed."—(Loimol., p. 27.) "Even the physicians themselves," says another eye- witness of the same pestilence, "were sur- prised : wherever they visited, they found their patients better. Either they bad sweated kind- ly, or the tumours were broken, or the car- buncles went down, and the inflammation round them changed colour, or the fever was gone, or the violent headache assuaged, or some good symptom was in the case : so that in a few days whole families that expected death every hour were revived and healed, and none died at all out of them."—(Journal by H. F., p. 250.) Alpinus speaks in the same manner of the sudden decline of mortality in the plague of Egypt: " In the month of June," says he, " to whatever degree pestilence may be raging in Egypt, as soon as the sun enters Cancer, it ceases entirely." And Dr. Russell confirms this remark as follows :—" It is agreed on all hands, that about the 24th of June, at Cairo, there is a remarkable sudden alteration in the conta- gious property of the plague, as well as in the malignity of the disease itself, to whatever cause it is to be ascribed : and Alpinus's remark, that at the same time it ceases, the furniture in in- fected houses suddenly loses all power of com- municating the disease to the inhabitants, so that health and tranquillity are at once restored, agrees in some measure with the general expe- rience of other places in Turkey, where, it is well known, houses or goods undergo little or no purification."—(On the Plague, b. iii., ch. v.) Mr. Bruce speaks to the same effect:—" The Turks and Moors, immediately after this day, expose in the market-places the clothes of the many thousands that have died of the plague during its late continuance; and though these consist of fur, cotton, silk, and woollen cloths, which are stuffs the most retentive of the in- fection, no accident happens to those who wear them, from their happy confidence." And we are hence able to enter more fully into the meaning of a passage already quoted from Sir John Webb, in which he tells us, that, on the approach of summer, the plague subsides into a manageable malady, and that, on the 24th of June, the Turkish government announces to the public its supposed cessation by a discharge of cannon. Unless, therefore, we withhold, most unjust- ly, all belief in this accumulation of unimpeach- able evidence, it seems impossible not to admit that the state, or, to speak more definitely, the ANTHRAC 654 HiEMATICA. [Cl. III.—Ord. III. temperature of the atmosphere is connected with the decline of the plague, and consequent- ly with its previous progress; and that, as already observed, it cannot maintain its energy, nor perhaps exist under an atmospheric heat of 60°,* nor above that of 80° ; while its depend- ance upon a specific miasm seems equally clear from its occasionally commencing in the health- iest, as well as in unhealthy seasons ; though most frequently, and most fatally, in the latter. In the plague of London, as we have already seen, the disease followed a malignant epidemy ; in that of Athens, the preceding year had been so peculiarly healthy, that mankind seemed to have acquired an exemption from complaints of every kind. In that of Egypt it makes a regular return, whatever be the constitution of the sea- son. Dr. L. Frank, in one place, ascribes the diminution of the fatal power of the plague to a periodical return of the north wind : but he af- terward observes, that winds, at times, or even moisture, seem to have little influence upon it. That the change in its degree of activity is connected with the change which takes place in the temperature of the atmosphere, is unques- tionable ; and it is highly probable, that it is dependant upon this alone. That below 60°, or in the cold of the winter months, the miasmic corpuscles lose their volatility, and gradually become decomposed; while above 80°, as in the summer months of Egypt and Arabia, they become almost immediately dissolved ; so that clothes and bedding, however loaded with them, are rendered harmless. And hence the reason why it has never been known either in the tropical or arctic regions. Respecting the proper plan to be pursued, there is still some controversy. Early, copi- ous, and even repeated venesection was at one time, and by very high authorities, recommend- ed in this disease, and especially by Sydenham at the commencement of the plague of London, in 1665 and 1666, before the appearance of any eruption. Like Dr. Rush, in North America, respecting the yellow fever, he was stimulated by the bold determination of quelling this for- midable enerhy in its very onset, and before it should have made a fatal breach in the consti- tution. This practice, however, has been far less successful, and therefore less persevered in, with regard to the plague, than with regard to the yellow remittent. Dr. Mergens says, he would never advise its being resorted to ; and even Sydenham hesitated as he became more experienced. " But though," says he, " I ap- * The only fact with which the editor is ac- quainted, in opposition to this doctrine, is that of Mindererus, who was an eyewitness of the plague of Ismail, during the most severe winter ever remembered there.—(Account ofthe Turkish Em- pire. ) Dr. Winterbottom, in noticing the differ- ences between the plague and yellow fever, says, that the former can maintain itself in excessive degrees of cold, while, on the contrary, a changea- ble temperature, inclining to cold, is destructive of yellow fever.—See Edin. Med. Journ., vol. xxx., p. 340. prove, and have often experienced the utility of bleeding, yet, for several reasons, I prefer the dissipation of the pestilential ferment by sweat, because sweating does not in the same degree prostrate the patient's strength." Bloodlet-" ting and purgatives, Dr. L. Frank assures us, prove equally hurtful in the plague of Egypt. During the plague at Noya, the doctrines of Dr. Brown were in high vogue, and the disease was divided into sthenic and asthenic; free bleeding and large doses of calomel being pre- scribed for the former ; and acids, opium, ether, and other stimulants for the latter. But, in general, the medical practice was here as con- fused and inconsistent as the precautionary means ofthe police were excellent and effective, so that Romani was right in affirming that, after all, their real alexipharmic was to be found in God alone.—(Ricordi sulla Peste, da F. Ro- mani, M. D., Napoli, 1816.) Wherever there is great and threatening congestion in a large or vital organ, early bleeding should certainly be employed ; and is, in such cases, wisely rec- ommended by the elder Frank.—(De Cur. Horn. Morb. Epit., tom. i., p. 136.) But the practice must form an exception to the general rule, and not the rule itself. In general, as Dr. Bancroft says, very bad effects have result- ed from this evacuation. The use of external cold by the application of sheets of pounded ice to the body generally, has been also tried, but with no satisfactory re- sult. It has, indeed, been chiefly confined to Russia, under the vigilant eye of M. Samoilo- witz. How far it might succeed in warmer cli- mates is uncertain, but ablution with cold wa- ter offers a fairer promise. [According to Dr. Bancroft, however, the unsuccessful trials of the cold bath in Egypt afford no encourage- ment to repeat them.] A brisk emetic, given at the commencement of the attack, has often proved of the utmost advantage. M. Degio, to whom I have already adverted, affirms that he has seen men suddenly cut down by the disease when on duty, as though shot by a musket ball, so completely recovered by an emetic given instantly, as to be on duty again within twenty-four hours afterward.* If the nausea and bitter taste in the mouth be not re- moved by a first emetic, a second, and even a third are often prescribed ; and where the symp- toms are urgent, at a distance of not more than four or five hours from each other. And this plan is found to produce far less exhaustion than that of purging, which the patient is often unable to support After evacuating the stomach, and hereby exciting a determination towards the skin, the cutaneous action is to be maintained by active and cordial sudorifics, which, indeed, constitute the ordinary plan of the present day. For cor- dials, there is the utmost necessity : the debility is, from the first, extreme and threatening, and * Substance of notes taken at the Russian army during the prevalence of the plague.—See Edin. Med. Comm., vol. viii, p. 352. Oen. IV—Spe. 3,] the vascular action must be supported at all adventures. Even Sydenham, who at one time hes.ltated as to the use of them upon theory, in which he did not often indulge, was obliged to admit their beneficial effects, though he regard- ed the practice as hazardous. With respect to sudorifics, the concurrent voice of all physi- cians in all countries is in their favour. Dia- phoresis is, indeed, the evacuation that relieves most certainly and most effectually ; and it should be maintained by warm, diluent, and supporting drinks. James's powder employed without cordials does not appear advisable. It was very largely administered at Moscow, but according to Dr. Mergens, with no particular advantage. In many cases the warmer opiates, as the opiate confection, have been found ser- viceable, assisted with camphire and ammonia, and blisters repeated in succession. As oils of all kinds, applied to the surface of the body, have been found a good preservative against the absorption of the contagious miasm, it has been also had recourse to, and employed in the same manner as an antidote when the disease is present, and particularly in the east, where the zeit jagghy , ^cl; (^^v> \, °r olive- oil, has been regarded almost as a specific. Mr. Baldwin affirms, that he made use of it in this form very extensively at Cairo, and with great success : and it is usually employed in Barbary and at Constantinople. The French physicians, however, do not seem to have relied much upon its virtue. M. Sotira suggests, that Mr. Baldwin's benevolence in the distribu- tion of oil for this purpose was occasionally abused, and the cures by oil exaggerated and multiplied by those who wished to have oil gratis. Assilini, however, inclines to a belief that it may be useful: it is most pointedly rec- ommended by Father Louis of Padua, director of the hospitals at Smyrna: and quite as strong- ly by Dr. Pauvini of Palermo, who had prac- tised indeed at Malta, but whose work was reprinted during the plague at Noya, and gave a character to the medical practice pursued in that city.* The application should be accompa- nied with a long-continued friction ; and, when successful, is followed in about half an hour by a perspiration profuse and general, and which affords immediate relief. Sir Brooke Faulkner admits its sudorific power, but is by no means friendly to its use : believing that even by this very power it has often proved highly injurious. Yet he does not speak from much personal ac- quaintance with its effects ; but tells us that " a gentleman who superintended the health of one of the districts of Valetta assured him that, although he had constant opportunities of see- ing oil frictions used by those under his imme- diate orders, he was satisfied that it was not merely useless as a defence, but hurtful to the general health, by the debility which succeeded to the profuse perspirations which it occasioned." ANTHRACIA PESTIS 655 * Chiara Dimostrazione de veri Preservativi della Peste e de Remedj, &c, del Sacerdote P. Pauvini, Dottore in Medicina, &c, Palermo, 1813. [Pugnet says, that oil frictions, so extensively employed by the French physicians in Egypt, were not only useless, but caused anxiety and disturbance to the sick ; and that of fifteen pa- tients to whom they were applied, under Dr. Carrie, one recovered with difficulty, and all the rest died ; and that where they seemed to do good, the disease was always mild. With so much reason to doubt of their efficacy, there is a strong objection to their use, arising from the very great danger of communicating the disease to the person by whose hands they may be applied.—(Bancroft on Yellow Fever, &c, p. 623.)] Sir Brooke, in the passage of his book above referred to, estimates its prophylac- tic virtue as low as its remedial (Treatise on the Plague, &c, pp. 231, 232), and is thus far in a state of direct antagonism, not only with Mr. Tully, who was afterward inspector of quarantine on the same station, but with him- self at the time of delivering his evidence be- fore the Select Committee of the House of Commons ; an extract from which we have al- ready quoted. Dr. L. Frank employed oil, according to his own statement, with great and decided success. In his hands it proved a most salutary sudorific ; and to sudorifics he principally trusted. He used it in the form of friction, six ounces at a time, and a single fric- tion a day. In the remissions of the fever, the bark is used in great abundance, commonly intermixed with port, or other generous wines. During the fatal plague which depopulated the whole of Western Barbary in 1799, the Emperor Sidv Soliman is said to have had the disease twice, and in both cases to have derived his cure from a free use of the bark ; in consequence of which he was never afterward without a large supply of it. When buboes or carbuncles appear, they are always to be promoted and matured by warm cataplasms. [With respect to the management of buboes, although it may be right to promote their sup- puration by emollient cataplasms, where a natu- ral tendency to that issue is evident, it is fully ascertained that there is no danger in favouring their dispersion by the usual means, when they show a disposition to recede. Dr. Bancroft says, " I know that the sudden retrocession of buboes, previous to suppuration, and while other symptoms indicating danger subsist una- bated, is often followed by death. But, this mortality is not in such cases produced by any change in the bubo itself, or by the retention of any matter which ought to be discharged, but by such an extreme diminution of the living power, or other injurious effects of the disease, as is incompatible with the continuation of a suppurating process, and also with the patient's recovery ; and, therefore, this retrocession is to be considered not as the cause of death, but as an indication and consequence of that condition of the patient, from which death necessarily re- sulted ; and, on the other hand, when these glandular swellings rise and suppurate favoura- bly, they indicate such a state of the living pow- er and of the system as is likely to overcome the 656 H.EMATICA. [Cl. III.—Ord. III. disease, without the supposed benefit of an evacuation of morbid poison by that suppura- tion. The same reasoning appears applicable to carbuncles, though in their gangrenous state, and, when not surrounded by concentric infla- med rings, they Tequire hot stimulant applica- tions, and afterward such as will promote a suppuration, and a separation of the carbona- ceous crust."—{Bancroft on Yellow Fever, &c, p. 617.) These observations are important, as connected with the theory, prognosis, and treat- ment of the disease.] Camphire, smoking tobacco, fumigation with gum sandrac, and the vinegar of the Four Thieves, are still largely employed as preven- tives. But the contagion, as we have already observed, is not peculiarly active, and the best prophylactics are cleanliness, pure air, freedom from actual contact, a liberal diet, and cheerful spirits. I may add that vaccination has been repeatedly tried ; but has answered no good purpose. Sir Brooke Faulkner, indeed, gives a striking example of its failure, for " in a nu- merous family," says he, " who had been re- cently vaccinated, the whole fell* sacrifices to the prevailing contagion, with the exception of the parents, who had never undergone the op- eration."—(Treatise on the Plague, p. 233.) [In relation to this part of the subject, the editor mentions with admiration the name of Valli, who, as Dr. Winterbottom observes, " appears to have been a man of a cultivated mind, and overflowing with ardour for his pro- fession. Being an enthusiastic admirer of vac- cine inoculation, and imagining that the preva- lence of natural smallpox and plague was in- fluenced by a kind of mutual repulsion between the two diseases, he flattered himself with having discovered a specific for the latter dis- ease in the vaccine matter. To prove the truth of his opinion, he went to Constantinople, and shut himself up in a pest-house, from which he narrowly escaped with life. He made many experiments by inoculating with mixtures of smallpox, vaccine, and pestilential matters, which he promised to publish, but which it is feared are lost. Dr. Valli inoculated himself with impunity with a mixture of vaccine and plague matter. In consequence of these trials, a nostrum was advertised for sale as a preven- tive of plague ; but it is not clear that Dr. Valli had any concern in it, at least, not from sordid motives. But an apothecary at Constantinople was accused of preparing, as a specific for plague, an ointment, composed, it was pretend- ed, of plague and vaccine matter. The apothe- cary was strangled, as a 'just reward for his knavery. Dr. Valli ultimately went to the Ha- vana to investigate yellow fever, the contagious nature of which he denied, where he died a few days after his landing, and where the Medical Society of that city have erected a monument to his memory. A republication of Valli's works on plague, now out of print, with a bio- graphical sketch of the author, would, as Dr. Winterbottom says, be an interesting present to the medical world.—(Edin. Med. Journ., vol. xxx., p. 332.)] SPECIES II. ANTHRACIA RUBULA. YAWS. tumours numerous -and successive ; gradu- ally increasing from specks to the size of a raspberry ; one at length growing larger than the rest; core a fungous excrescence: fever slight:* occurring only once during life j contagious. The term kubula, by which this disease is distinguished in the present work, is derived from the Latin rubus, "a blackberry or rasp- berry," in French framboise, whence the com- mon but barbarous name of frambasia, quite as objectionable as that of scarlatina; and which the author has thus attempted to exchange for a euphonious and strictly classical term, in per- fect concordance with the ordinary law of di- minutives, which seems to prevail through the general nomenclature of exanthematous dis- eases, as rubeola, variola, varicella. Perhaps morula, from morus, a mulberry, a diminutive used in an approximating sense by Plautus, might have been somewhat more appropriate, since the eruption seems to bear a nearer re- semblance to small mulberries than to raspber- ries. But as this last plant has laid a founda- tion for the vernacular name both on the Afri- can and American coast, on the former of which it is called yaw, and on the latter pian or epian, both importing raspberry; and as the earliest writers have, upon this authority, denominated it framboise or frambasia, I have not felt my- self at liberty to deviate from the original idea. Swediaur has denominated it thymiosis, but with less attention to the external character of the eruption. He arranges it, indeed, under the division of cachectic ulcers, and has made it synonymous with the synochus of the Greeks, as described by Celsus (Lib. vi., cap. iii.); to which it has only a few casual resemblances, while in its essential signs it is widely different. —(Nov. Nosol. Meth. Syst., vol. ii., p. 180.) The disease, as it occurs in Africa and Amer- ica, exhibits some diversity, and lays a founda- tion for two varieties, as follow :— a Guineensis. Attacking infants and young African Yaws. persons chiefly; and sub- siding as soon as the erup- tion appears. 0 Americana. Depascent; and destroying American Yaws. progressively both mus- cles and bones, t * It is alleged by Mr. David Mason, that fever, so far from being necessarily connected with yaws, seldom occurs, and perhaps never, except as an adventitious disorder. Hence he prefers the arrangement of yaws in the class tubera, as adopt- ed by Sauvages, and not Dr. Good's classification of it with Exanthematica.—See Edin. Med. and Surg. Joum.. No. cvi., p. 54.—Ed. t Mr. David Mason's observations, published in the Edin. Med. and Surgical Journal, No. cvi., he informs us, refer to the African variety of Dr. Good; but he thinks that there is no good founda- tion for the division into the African and American kinds. The disease, he believes is of a uniform Gen. IV.—Spe. 2.] ANTHRACIA RUBULA. In the precursory remarks to the present ge- rms, I have stated the reasons for introducing this species into the list of exanthems, or fe- brile eruptions ; and the history of the disease will still further show, that it could not with pro- priety have been placed under any other divis- ion. It is singular, that we have no decided account of this malady among the early writers • nor, indeed, any account whatever till after the appearance of syphilis; whence, as several of its symptoms, and especially where the bones become affected, bear a resemblance to those of syphilis, yaws have been supposed by some wri- ters to be a species of lues, and especially of that which in Scotland is denominated sibbens or sivens, of which we shall treat in the ensuing order: but the eruptive fever and consequent efflorescence, the indemnity from a second at- tack, as well as other symptoms, draw a suf- ficient line of distinction.* The first variety will often run through its course favourably without any medical assistance whatever : and is, indeed, often rendered worse by the injudicious interposition of it. This seems to be the primitive form, and that under which it chiefly shows itself in Guinea, and some other parts of Africa, where, as just ob- served, it is vernacujarly called yaw, or morbus Eubulus. It commences, like the other exanthems, with the ordinary symptoms of fever, although they are usually more tardy in their progress. Hence the precursory symptoms are languor, debility, headache, loss of appetite, rigour, and pain in the back and loins, which continue for a few days, with evening exacerbations. To these succeeds the specific eruption; consisting of successive crops of papula?, at first not larger than a pin's head, but increasing in size with every series, till they acquire the magnitude of a raspberry or mulberry. The smaller papulae become real pustules, and discharge an opaque whitish fluid when broken, and concrete into dense scabs or crusts. The larger are fungous excrescences, and, in their granular surface, as well as in their size and colour, bear a near resemblance to the fruit from which they derive their name. These sprouting tumours have but little sensibility, and suppurate very imperfectly; discharging rather a sordid ichor than a matured pus. They originate in scattered groups over different parts of the body, but are chiefly found, like the erup- tion of plague, in the groins, parotid glands, axillae, and about the arms and pudenda : though they often disfigure the neck and face. The colouring matter of the hair, wherever they are seated, is obstructed in its secretion, and, as in old age, the hairs themselves, from a brown or a nature, the malignant and anomalous symptoms sometimes presented«by it being^the result of in- ternal constitutional, or accidental external cir- cumstances,—Ed. * Speaking of yaws, Mr. Mason observes :—" It has some resemblance to syphilis, being slow in its progress, and only communicable by contact; but its after-effects are not so destructive, and it leaves the constitution invulnerable to future in- fection."—Edinburgh Med. and Surg. Journ., No. cvi., p. 51.—Ed. Vol. I.—Tt 657 black, become a dead white. Dr. Thomas, who has given a very accurate account of this va- riety, apparently from personal knowledge, ob- serves that, " in general, the number and size of the pustules are proportioned to the degree of eruptive fever. When the febrile symptoms, are s ight, there are few pustules; but they are mostly of a larger size than when the complaint is more violent and extensive."—(Pract. of Phys., p. 643, edit. 1819.) The duration ofthe eruption is uncertain, and seems to depend considerably upon the state of the habit, and its power of promoting their ma- turity. They sometimes acquire full perfection in four or five weeks, and sometimes demand two or three months. In their progress to this state, there is usually some one that appears larger and more prominent than the rest, and is called the master-yaw. It is, in truth, a broader and more sloughy fungus, and discharges a larger portion of erosive sanies, which, if not washed off as it issues, will spread widely, and sometimes work its way to an adjoining bone, and render it carious. When the. tumours point from the soles of the feeff,, they cannot press through the thickness of the skin, and hence form imperfectly, and produce highly elevated calluses, which are called tubba or crab-yaws: and often very much impede the power of walking. As soon as the eruption has attained its height, the tumours, when the dis- ease proceeds favourably, become covered with crusts or scabs, which fall off daily in whitish scales; and, in the course of a fortnight, the skin is left smooth and clean; the master-yaw alone remaining and demanding attention. In attempting the cure of this disease, the first step should consist in separating the patient from his associates, to whom he will otherwise assuredly communicate it by contagion. He should then take freely of decoction of sarsa- parilla or some other warm diluent. And it is highly probable that the warm aperient bolus, composed chiefly of a scruple of sublimed sul- phur and five grains of calomel, as recommended by an anonymous writer (Edin. Med. Essays, vol. v., part ii., art. lxxvi.), may be found ser- viceable, continued every night. [In a good practical paper on yaws, Loeffer recommends sarsaparilla; and, for the purpose of promoting the eruption, small doses of ipecacuanha, camphirfe, warm baths, friction, and blisters.*] The mas- ter-yaw must be attacked with escharotics ; for it is to be destroyed in no other way. The cal- lous tumours on the soles of the feet (termed crab-yaws) should be softened by warm water, or cataplasms of some gentle stimulant; and, when on the point of breaking, are best subdued by a slight application of the actual cautery. The diet should be nutritious and liberal, so as to support the strength during the progress of the disease. And, under this mode of treat- ment, it is rarely that a patient fails to do well.t * Meckel's Neues Archiv. der Pract. Arzeney- knnde ; Richter's Chir. Bibl., vol. xii., p. 340; and Winterbottom's learned paper in Edinburgh Med. Journ., vol. xxx., p. 322. •f The following is Mr. Mason's description of 658 H^EMATICA. [Cl. III.—Ord. Ill Mercury was at one time given in great abun- dance frfm the commencement of the com- plaint, under an idea that it would prove as beneficial as in the case of lues. But it is now sufficiently known to be productive of great mischief, and particularly when carried, as it used to be, to a state of salivation. It retards the cure, and generally aggravates the symp- toms. It is often given in small doses as an alterative, when the disease is on the decline, and perhaps with advantage; but it ought never to be employed in any otber form. When the excrescences discharge a sordid ichor, they may also be stimulated with the ni- tric-oxyde mercurial ointment: but the natives themselves, who rigidly abstain, also, from the internal use of mercury, employ, instead of this, a liniment of the rust or subcarbonate of iron and lemon-juice, which proves a very useful ap- plication ; though probably a solution of sulphate of zinc might answer better. And during the maturation of the eruption, they excite a pro- fuse sweat by what may be called a warm air- bath, which consists in putting the patient into a cask with a fire at the bottom in a brazier or small firepan ; the top being covered over with a blanket. Under this mode of treatment, a cure is said to be often effected in three weeks, and the funguses thoroughly healed.—(Ejlin. Med. Comm., vol. ii., p. 90.) The second, or American variety, is a far more terrible complaint; or rather is the same complaint in an exasperated and chronic form ; and hence, though incomparably slower in its progress than the plague, is accompanied with a carbuncular eruption, quite as mischievous and disgusting, and more certainly fatal in its issue. It was first distinctly described by M. Virgile, of Montpellier, who had practised with great reputation at St. Domingo. There can be little doubt of its being imported into the West In- dies along with the slaves from the African coast; and is here called, as already observed, pian or epian, precisely synonymous with the African term yaw: the master-fungus being named mamma-pian, or mother-yaw, as sup- posed to be the source or supply of the rest. The fungous berries, in this form, precisely correspond to the carbuncle already described under the trivial name of terminthus, which consists of a " core or fungus, spreading in the shape, and assuming^ the figure and blackish- green colour, of the fruit or berry of the pine- nut, or terminthus of the Greeks."* And it the crab-yaws:—" Like the other yaws, they seem to arise from the true skin; but, being confined during their growth by the hardened cuticle, its resistance, together with the pressure in walking, creates intolerable pain, and inability to move ex- cept in a singular and awkward way, whimsically fancied to resemble that of the movements of a crab, whence the origin of the term. As the tubercles enlarge, the upper covering gives way, and they appear above the surface in the shape of granular yaws. They are easily removed by pa- ring away the hardened skin around them, cutting off the projecting tubercle, and touching its root freely with caustic. Ft seems that the dangerous practice of keeping the feet immersed in a medi- cated and nearly boiling bath for nine days, is sometimes tried in the West Indies : Mr. Mason has known of some instances in which the method proved fatal.—Ed. * Cl. III., Ord. II., vol. i. Several ofthe febrile eruptive diseases are capable of affecting the same person only once during life; but, according to Mr. Mason's belief, the yaws is a solitary instance of a slow chronic disorder, producing similar con- stitutional changes, tending to future exemption. The time that elapses between the inoculation with yaw matter and the first appearance of a yaw tubercle on the spot where the matter was inserted, was found to be about three weeks. A dry scab was first formed, that remained station- ary, and under it the yaw fungus became percep- tible at the end of about three weeks, and soon afterward other tubercles appeared on the body. In the instances referred to by Mr. David Mason (Edin. Med. Journ., No. cvi.), there wa3 no obvi- ous constitutional disturbance. The following is the description given by him of the American yaws:—" The first appearance of this disease is usually indicated by a foul ulcer, variously and fortuitously situated, and which is ultimately as- certained to be the spot of inoculation, the skin having been previously broken, either by accident or design. At an early stage this sore resembles a simple cutaneous ulcer, and only becomes sus- picious by not healing with the use of common dressing. In a short time, however, the edges be- come spongy, and of a whitish colour. The poi- son now begins to act on the constitution, and, in most cases, circular patches of minute papula appear in various parts of the skin, giving it a granular appearance. In time some of these pap- ulae enlarge, become elevated, and covered with a crust. When this scab is cautiously removed, the whitish, spongy, granular yaw is distinctly seen. When the tubercles are left to themselves they attain a considerable size, and a diameter for them of two inches is not uncommon. They are easily destroyed by caustic, without any mark or depression being left. For a few days the spot is distinguished by a deeper black colour than the surrounding skin, but it gradually fades into the natural colour. Mr. Mason has never seen a yaw tubercle on a mucous surface ; sometimes at the angles of the mouth, but not on the lips, or in the nostrils. All ya*r tubercles, he says, are com- posed of irregular circular segments, cutting each other more or less acutely, and forming waving lines around the base. The summit is often flat and depressed in the middle. Those of the straw- berry shape are considerably elevated, and exhibit an irregular granular surface. In some parts, where the tubercles are numerous, they unite in clusters. Occasionally they appear in the form of a ring or semicircle, with a depression of sound skin in the middle. Whatever be their figure, they all discharge the same sort of matter, which is con- densed into a similar scab, and which, being cau- tiously removed, shows the dingy granular surface underneath. Among healthy negroes, exposed to the simple action of the yaws, Mr. Mason no- ticed little constitutional disturbance. A tingling or itching sensatjpn in the sjtin, and slight pains in the joints, were common, but not constant symptoms. The mother-yaw, or that caused by inoculation, which generally ulcerates, sometimes gives considerable pain. As the disease advances, and the yaws become large and numerous, the constitution shows more evident signs of disorder, debility, emaciation, &c; but never, in ordinary circumstances, causing confinement, or, under proper care and regimen, depressing the spirits. Gen. iv.—Spe. 2] ANTHRACIA RUBULA 659 has hence been conjectured, but without suffi- cient foundation, that the disease of yaws is referred to by Galen and Dioscorides under this name. The erosive secretion from the carbuncles of this variety generally, but especially from the mother-yaw, spreads widely, and, in its mean- dering, destroys all the surrounding parts, not excepting the bones.* [Conradi is wrong in asserting that the pains in the bones affect only negroes, and not Europeans.—(Grundriss des Pathol., b. ii., 826.) Dr. Winterbottom knew a European in Africa, a slave-dealer, who was dreadfully tormented with pains in his bones, in consequence of yaws.t] Nothing can exceed the revolting scene of a yaw-house, or hospital for the reception of slaves suffering under this disease, in the West Indies. " Here," says Dr. Pinckard, " I saw some of the most striking pictures of human misery that ever met my eyes. Not to commiserate their sufferings is impossi- ble, but their offensive and wretched appearance The eruption continues more or less numerous, until the disease is entirely extinguished, occa- sionally increasing and diminishing without any apparent cause. Towards the termination, the large tubercles often disappear, and a few others, after a considerable time, come out. Yet, during this interval of apparent recovery, the skin is sel- dom free fron» clusters of small papular yaws, which sometimes remain for weeks or months af- ter every return of the larger yaws has ceased."— See Edm. Med. Journ., No. cvi., p. 57.—Ed. * This does not agree with "Mr. Mason's de- scription, who informs us that the morbid secre- tion produces no immediate change on the sur- rounding skin, unless the cuticle happen to be broken.—(Edin. Med. Journ., No. cvi, p. 56.) He bears witness, however, to the bones of the legs and arms becoming affected with simple enlarge- ment ; to the extension of ulceration down to the periosteum ; and to the bones becoming carious. These affections of the bones seem, like those of syphilis, often to continue for years after the other symptoms have ceased, and, in some instances, to prove fatal. The membranes of the nasal cavi- ties sometimes ulcerate, and the adjacent bones be- come diseased, followed by frightful and incurable ulceration of the nose, palate, and throat.—Ed. t Edin. Med. Journ., vol. xxx., p.*323. As al- ready noticed, Mr. David Mason denies that the American form of the disease is necessarily con- nected with fever, and maintains that, when fe- brile disturbance is present, it is only an adven- titious circumstance. From his investigations, it appears that the poison or infectious matter of yaws is never, under any circumstances, conveyed through the medium of the atmosphere. Actual contact or inoculation is essential to the produc- tion of the disease. With the design of avoiding any labour, the negroes in Jamaica, he says, often purposely inoculate themselves, and mothers their children about, the period of weaning, as is done also in Africa. Yet, according to Mr. David Ma- son, it is proved by experience that this disease is not milder in childhood, but, on the contrary, more unmanageable, and liable to be conjoined with in- fantile disorders, and to prove dangerous. Al- though the disease is often propagated by inten- tional inoculation, no doubt it is in numerous instances communicated by the accidental con- tact of the matter with an abraded part of $e creates a sense of horror op. beholding them, Of all the unsightly diseases which the human body is heir to, this is perhaps the worst. Some of these diseased and truly pitiable objects were crouching upon their haunches round a smoky fire ; some stood trembling on their ulcerated limbs ; others, supporting themselves by a large stick, were dragging their wretched bodies from place to place ; while many, too feeble to rise, lay shivering with pain and torture upon the bare boards of a wooden platform."—(Notes on the West Indies, vol. ii., letter xxii.) Dr. Pinckard adds, that, " unhappily, this most odi- ous distemper has not hitherto been found with- in the power of medicine : that it often exists for years, and, even where it sooner yields, its removal is more the effect of time and regimen than of medical treatment." This view of the case is too generally true; but, from the length of time which, under the best treatment, is required to effect a cure, it seldom happens that these miserable wretches receive all the attention which their situation deserves ; and they are rarely sufficiently heed- ful of personal cleanliness, which, even alone, is of the utmost importance. This, with a gen- erous diet to support the strength, pure air, reg- ular hours of rest, and such exercise as can be used without 'fatigue, with warm balsamic ap- plications to the sores, have not unfrequently succeeded where the bones have not become extensively carious. But the latter stages of the disease are horrible when it proves fatal; for the pains are excruciating, the debility ex- treme, and the bones are covered with foul exostoses and corrupt ulcerations.* It is happy for the European inhabitants of the West Indies that they are less liable to this miserable malady than their slaves; probably from using a better diet, and being more atten- tive to cleanliness. As yaws is communicated * Mr. Mason suspects, from what he has ob- served, that the mother-yaw might not only be healed by means of caustic, but the constitutional disease prevented, by inoculation before the sys- tem has been tainted. The aggravated effects of the disease he refers to neglect, and to acci- dental unfavourable states of the general health. An ample supply of nourishing diet, frequent bathing, and moderate or equable warmth, seem to him to be requisite in the treatment. He is also in favour of tonic and diaphoretic medicines. Mercury, he says, affords no decided benefit, and, in alterative doses, is prejudicial. The plan which he prefers consists in frequent ablution in the tepid bath; clean linen and clothing ; decoction of sar- saparilla, with small doses of tartarized antimony; and, in a later stage, tonic medicines, especially preparations of iron, with full diet, and a liberal allowance of animal food. Anasarcous debility and functional derangement of thedigestive organs. require frequent calomel purges, chalybeates, and proper diet. As a topical application, he com- mends the nitrate of silver, with which he not only destroys the crab-yaw, but others of long standing, which often linger in the skin after all signs of constitutional disease have ceased ; and its effect on them was still more immediate and complete. Before the caustic is applied the scab must be removed, in order to let the caustic touch the spongy granular substance.—Ed. 666 HiEMATICA. [Cl. III.—Ord. III. in the same way as the venereal disease or the itch.it is just, as much endemial in Africa as lues or itch is in this country. Were it not for the circumstances adverted to, Bertrandi's be- * Winterbottom, in Edin. Med. Journ., vol. xxx., p. 322. On this point the following observations are made by Mr. Mason :—" There is no founda- tion for Dr. Darwin's observation, that the yaws is hereditary; nor is it exclusively confined to the negro or African race. Neither Europeans nor Creoles are invulnerable, although it occurs very rarely among them. These classes, and also peo- ple of colour, view the disease with peculiar dis- lief, that negroes are more disposed to this dis- ease than whites, perhaps might not be correct. The same exposure might produce the same effects in the European as in the negro.* gust; and as they are not exposed to intermingle with the infected, but are careful to avoid such intercourse, nor have the same motives which so often prompt negroes to inoculate themselves and their offspring, we may find, in these considera- tions, sufficient ground for the above exefhption. Something, however, may be allowed to the Eu- ropean constitution being less susceptible of yaws than the African."—Op. cit, No. cvi.—Ed. END OF VOL. I. NATIONAL LIBRARY OF MEDICINE NLM 03E77emb 5 NLM032779465