H; ! }%, n**' ■',' n;! !;]>!i & ^X V^SrV V«^X \MrV ^n V.V r-\^\. y^r-i X.V r • THE STUDY OF MEDICINE. M '" BY JOHN MASON GOOD, ]T > M.D. F.R.S. F.K.S.L. **"" ^ MEM. AM. PHIL. 80C. AND F.l.S. OF PHILADELPHIA. IMPROVED FROM THE AUTHORS MANUSCRIPTS, AND BY REFERENCE TO THE LATEST ADVANCES IN $Ji£8{olo0£, $atnoioas, antr practice. BY SAMUEL COOPER, PROFESSOR OF SURGERY IN THE UNIVERSITY OF LONDON, ETC. SJJCT H 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. II. NEW-YORK: PUBLISHED BY HARPER & BROTHERS, NO. 8 2 CLIFF-STREET. 18 35. «( : > v" r W8 [Entered, according to Act of Congress, in the year 1835, by Harper & Brothsm in the Clerk's Office of the Southern District of New-York.] .#-, ■"• \ ► r hi *v Y • CLASS III. H^EMATICA. DISEASES OF THE SANGUINEOUS FUNCTION. ORDER IV. DYSTHETICA. CACHEXIES. ORDER IV. DYSTHETICA. CACHEXIES. MORBID STATE OF THE BLOOD OR BLOODVES- SELS ; ALONE, OR CONNECTED WITH A MOR- BID STATE OF THE FLUIDS, PRODUCING A DISEASED HABIT. The words ordinarily used to import the dis- eases meant to be comprehended under the present order, are cachexia and impetigo, or, , as the Greeks expressed it, Xu>j, lues, or lyes. None of these, however, exactly answer, and that on two accounts: first, because the order <^ is limited to those depravities which seem to originate or manifest themselves chiefly in ves- sels or fluids of the sanguineous function ; and, secondly, because no very definite sense has hitherto been assigned to either of these terms, and they have ' in consequence been used in very different meanings, by different writers, . from the time of Celsus to our own day. Upon this subject the author has dwelt at large in his volume of Nosology, and it is not necessary to add to the remarks there offered. The word dysthetica has hence been adopted for the purpose of avoiding confusion, and is justified by the eusthesia and eusthetica (EYXOESIA) and (EYXGETIKA) of Hippocrates and Galen, importing a " well-conditioned habit of body," as their opposite, dysthetica, from the same root, imports " an ill-conditioned habit," but a habit, as just observed, originating in, or dependant upon, the organized parts or fluids of the sanguineous function. Thus explained, it will be found to embrace the following genera:— I. Plethora. Plethora. II. Haemorrhagia. Hemorrhage. III. Marasmus. Emaciation. IV. Melanosis. Melanose. V. Struma. Scrofula. King's Evil. VI-. Carcinus. Cancer. VII. Lues. Venereal Disease. VIII. Elephantiasis. Elephant-skin. IX. Catacausis. Spontaneous Ignescence. X. Porphyra. Scurvy. XI. Exangia. . Vascular Divarication. XII. Gangraena. , Gangrene. XIII. Ulcus. Ulcers. A 2 GENUS I. PLETHORA. PLETHORA.*" complexion florid ; veins distended; undub sense of heat and fulness ; oppression of the head, chest, or other internal organs. Plethora is seldom ranked as a disease, and hence seldom treated.of in a course of medical instruction. From what cause this omission proceeds I know not, nor is it worth while to inquire. That it is aif important omission, will be obvious to every student before he has been six months in practice ; for there will probably be few affections on which he will be sooner or more frequently consulted. Yet, the subject has not always been neglected by nosologists ; for plethora, as a genus, occurs in the classifi- ' cations both of Linnaeus and Sagar. In a state of'health, the quantity of blood produced from the substances that constitute our common diet, bears an exact proportion to the quantity demanded by the vascular system in its ordinary diameter and the various secre- tions which are perpetually taking place in every part of the body. But the quantity of blood produced within a given period of time ' may vary ; and the diameter of the bloodvessels, or the c*all of the different secernent organs, may vary ; yet, so long as a due balance is maintained, and the proportion of new-formed blood is answerable to the demand, the general- health continues perfect, or is little interfered with. Thus, a man exhausted and worn down by shipwreck, or by having lost his way in a desert, or who is just recovering from a fever, will devour double the food and elaborate double the quantity of chyle, in the course of four- and-twenty hours, to what he would have done in the ordinary wear of life : but the whole system demands this double exertion-; the dou- ble supply is made use ofK and the general har- mony of the frame is as accurately maintained as at any former period ; there is no accumula- tion or plethora. It should also be observed, that in this case, the same remedial or instinctive power that stimulates the sanguine organs to the formation of a larger proportion of blood, stimulates also the bloodvessels to a diminution of their ordi- HvEMATICA nary capacity, and lessens the activity of the secernents; and hence the difficulty to which the animal machine is reduced is ajso met-an- other way, and a balance between the contained fluid and the containing tubes is often pre- served as completely during the utrrTost degree -•f exhaustion as in the fullest flow, of healthy ■plenitude. ."' We sometimes, however, meet with cases m which an increased supply of blood is furnishel whemnosuch increase is wanted, and the ves- sels remain of their ordinary capacity. And we also sometimes meet with cases in winch, from a peculiar diathesis, the capacity of the vessels is unduly contracted, while no change takes place in the ordinary supply of blood.' It rs evident that in both these contingence"s, there must be< an equal disturbance of the balance between the substance contained 4ind the sub- stance containing, and that the measure of the former must be too large for the measure of the fetter. In other words, fliere must be in both eases an excess of fluid, or a plethora, though from very different, and what are usually re- garded as opposite, causes : and hence it has proceeding from an actual surplus of blood Being denominated a plethofa ad molem, or a plethora in respect to its general mass or absolute quarjj tity ; and that proceedingwom a diminished ca- pacity of the vessels being denominated a ple- thora ad, spatium, or a plethora in respect to the space to be occupied. It is possible, however, for both these causes of plethora to exist at the same time, and for ' the vessels to evince a contractile habit or dia- thesis, while the blood is produced in an inor- dinate proportion. And this, in truth, is by no means an' uncommon state of the animal frame ; for, where the excess of blood is the result of a highly vigorous action or entony of the organs of sanguification, we often see proof of the same entony or highly vigorous action through the whole range of the vascular system, and, in- ^*fMMped, of every other part of the machine ; the pulse is full, strong, and rebounding ; the mus- cular fibres firm and energetic, the complexion florid, the whole figure strongly marked. We have here the sanguine temperament ; and this kind of plethora has hence been called the San- guine Plethora. But we often meet with an inordinate forma- tion of blood in a constitution where the vas- cular action is peculiarly weak, instead of being peculiarly vigorous ; the muscular fibres are re- laxed, instead of being firm ; and the coats of ihe vessels readily give way, and become en- Jarged, instead of being diminished in their di- ameter ; and where, instead of entony, or excess of strength, there is considerable irritability, or deficiency of strength in the organs of sanguifi- cation. Yet though the cause is different, the result is the same ; the vessels, notwithstanding their facility of dilatation, at length become distended, and a plethora is produced which has been de- nominated a plethora ad vires; or a plethora as it respects the actual strength of the system. ' §ol. nr.—obd. iv. The pulse is here indeed full, but frequent, and feeble ; the vital^actions are languid ; the skin smooth and soft, the figure plump, but inexpres- sive; all which are symptoms of debility of the living power, or rather of that peculiar diathe- sis which has been distinguished by the name of the serous, phlegmatic, or pituitary tempera- ment ; and hence this sort of plethqpra has been commonly denominated Serous Plethora. We have hence a foundation for the two following very distinct species of this affection, the names of which are derived from their prox- imate causes. 1. Plethora Entonica. Sanguine Plethora. 2.-------Atonica. Serous Plethora.* SPECIES I. PLETHORA ENTONICA. SANGUINE PLETHORA. pulse full, strong, rebounding : muscular fibres firm and vigorous. Sanguine plethora is more common to men; serous to women. It is the disease of man- been distinguished by different names; that,jhood, of the robust and athletic. Plethora of this kind must be distinguished from obesity ; in effect, they are rarely found in conjunction, foi the entony, or excess of vigorous action, is com- mon to every part of the animal frame ; and hence, though it is probable that a larger portion of animal oil is secreted than in many other conditions of the body, yet itjs carried off by the activity of the absorbents, and there is no leisure for its accumulation in the cellular mem- brane. And hence, persons, labouring under sanguine plethora, are rather muscular than fat, and their distended veins lie superficially, and appear to peep through'the skin. In this state of the bloodvessels, slight ex- citements produce congestion in the larger ves- sels or organs. The head feels heavy and com- atose ; the sleep is disturbed by tumultuous dreams ; the lungs labour in respiration ; and the muscles feel a want of freedom or elasticity in exercise. If fever arise, it will assume the inflammatory type ; and a slight excess in feast- ing or conviviality will endanger an apoplexy, f The cure, however, is not in general accom- * Dr. Barlow distinguishes plethora into absolute and relative (Cycl. of Pract. Med., art. Plethora) ; the former term implying that the redundance of blood exceeds what the healthy state of the indi- vidual constitution would require or bear; the* latter, that its quantity, without being absolutely excessive, is so in relation to the deficient powers of the constitution to disuse of it. But as these varieties of plethora do not comprise the whole subject, he notices a third condition of the blood, which takes place when, under moderate nutrition, there is defective excretion. In this state the sys tern is oppressed, not so much by the quantity of nutriment, or the labour of disposing of it, as by the load of excrementitious matter with" which the blood is overcharged..—Ed. t Instead of saying that plethora is " the parent of pure inflammation" (Cyclop, of Pract. Med.) it would be more correct to regard it as creating a predispositiqii to inflainmatory disorders.__Ed. Gkn. I.—Spe. 2.] PLETHORA ATONICA. 5 panied with much difficulty ; and far more easily effected in this species than in the ensuing: for the entonic power may readily be lowered by venesection and purgatives ; and its dispo- sition to return may commonly be prevented by the use of refrigerants, as nitrate of potash, or other neutral salts, and an adherence to a re- duced diet and liberal exercise ; at Jhe same time it should be observed, that, where the plethora depends dpon a sanguineous tempera- ment or phlogistic diathesis, venesection, though rightly employed at first, should be repeated with great caution, as it will tend to generate in the system a periodical necessity for the same kind of depletion, and consequently promote the disease it is designed to cure.* SPECIES II. PLETHORA ATONICA. SEROUS PLETHORA. PULSE FULL, FREQUENT, FEEBLE : VITAL AC- TIONS LANGUID J SKIN SMOOTH AND SOFT ; FIGURE PLUMP, BUT INEXPRESSIVE. The general pathology we have already treated of: and the reasons given under the last species for the usual appearance of sanguine plethora in persons of a spare and slender make, will explain the plumpness of figure and glossi- ness of skin which so peculiarly mark the spe- cies before us. In the first, there is great and universal vigour and rapidity of action ; the se- cretions are all hurried forward in their elabo- rations, and carried off as soon as produced. In the second, there is little vigour or activity of any kind, and Whatever is eliminated is suf- fered to accumulate. Hence costiveness is a common symptom ; the ankles are cold and pituitous ; and the animal oil, when once separ- ated and deposited in the chambers of the cel- lular membrane, remains there, becomes aug- mented, and produces corpulency and sleekness. The inertness of the body is communicated to the mind ; every exertion is a fatigue ; and the mind thus participating in the inertness of the body, the countenance, though fair and rounded, is without expression, and often vacant. Debility is always a source of irritability; * An increase of bulk and a florid complexion, as Dr. Barlow observes, in which so many exult as evincing sound health, and which they endeavour by all the aids of good living to promote, should not be a source of unmixed congratulation; be- cause they predispose to consequences by which both health and life may be forfeited. " Up to this period, however, disease cannot be said to have commenced, however it may have approached; and reduction of diet, with free bowels, and in- crease of active exercise, would suffice for getting back to sounder health, without any need of medi- cal interference. When abatement of healthful energies becomes evinced by a low and oppressed pulse, diseased actions may be said to commence; and when the stage of irregular action ensues, sensible progress may be considered as made to- wards the establishment of febrile action and in- flammatory disease." Medical aid and active dis- cipline now become indispensable.—See Cyclop. of Pract. Med., art. Plethora—Ed. and hence there is great irregularity, and a seeming fickleness in many of the symptoms by which thA species of plethora is characterized, and the results to which it leads. The bowels, though usually quiescent and costive, are some- times all of a sudden attacked with flatulent spasms, or a troublesome looseness. The appe- tite is languid and capricious ; the heart teased with palpitations, the chest with dyspnoea and wheezing; the head is heavy and somnolent; the- urine pale, small in quantity, and discharged' fre- quently; In this species, as in the last, we are com- pelled to begin with cupping or the use of the lancet. But though the distended and overflow- ing vessels demand.an abstractionpf blood, it should never be fdrgotten, that the relief, hereby afforded is only temporary ; and that*, as the disease is, in this case, an effect of debility, we are directly adding to the cause as often as we have recourse *to the lancet. Our leading ob- ject should be to give tone to the rakfced fibres ; and to take off the morbid tendejfJKo the pro- duction of a surplus of blood by^Sunteractihg the irritability which gives rise to it. • Our attack must be made upon the entire habit, which, as far as possible, should undergo a total change. The diet should be nutritious, but perfectly simple,, and the meals less frequent, or less abundant, than usual; the sedentary life should give way to exercise, at first easy and gentle, but by degrees more active, and of longer extent or duration. Tonics, as bitters, aftringents, and sea-bathing, may now be employed with advan- tage ; and the muscular fibres wilf become firmer as the cellular substance loses its bulk. The whole, however, must be the work of time ; for although in morals it Is a wholesome principle, that bad habitscannot toq>Jp4edily be thrown off, it is a mischievous,doctrine in med- icine. Health being the middle term between excess and deficiency, every day is giving us a proof, that, where either of these extremes has become habitual., the system can only be let up or let down by slow degrees, so as to reach and rest at the middle point with certainty and without in- convenience. Professor Monro has furnished us with several very striking examples of this fact: and particularly among those who had acquired a habit of drinking very large quantities of spirit- uous potation. A man of this description, who had broken both bones of one leg, and was put, for a more speedy recovery, upon a diet of milk and water and water-gruel, was hereby thrown into a low fever with an intermitting pulse, twitch- ing tendons, and delirium ; during which he got out of bed and kicked away the box in which his leg was confined. A by-stander and friend of the patient's, of the same irregular habit, ven- tured to tell the professor, that he would cer- tainly kill him if he did no* allow him ale and brandy ; since, for several years antecedently, he had been accustomed to both these as his common drink : a little of each was, in conse- quence, permitted him, but the patient's friends did not tie him down to this little ; for, extend- ing the grant of an inch to an ell, they instantly gave the man a Scots quart of ale and a gill of 6 H^MATICA. [Cl. Ill— Okd IV. brandy, which was his usual allowance for the evening: he slept well and sound; the next morning was free from delirium and fever ; and, by a perseverance in the same regimen, obtained a speedy cure without the least accident * GENUS II. HAEMORRHAGIA HEMORRHAGE. FLUX OF BLOOD WITHOUT EXTERNAL VIOLENCE. The term haemorrhagia, or hemorrhage, is derived from the Greek alpa, " sanguis," and ^iiyvvfii, ",rumpo." Dr. Cullen has adopted the same name for an order of diseases ; but few parts of his arrangement are more open to ani- madversion, and in fact have been more ani- madverted upon, than the present. The order of hemorrhages, or fluxes of blood, ranks in Dr. Cullen's system under the class pyrexiae, or febrile diseases. Pyrexy, however, is only an accidental sy«nptom in idiopathic hemorrhages of any kind, and has hence been omitted by all, or nearly all, other nosologists in their defini- tions : while Dr. Cullen himself has found it impossible to apply it to many hemorrhages, among which are all those that are called pas- sive ; and he has hence been obliged to transfer the whole of these to another part of his sys- tem, notwithstanding- their natural connexion with the active, and to distinguish them by the feeble name of profusions, instead of by their own proper denomination. Blood, from whatever organ it flows, may have two causes for its issue. The vessels may be ruptured by a morbid distention and impetus/; or they may give wayi'from debility and relaxa- tion,' their tunics breaking without any peculiar force* urged against them, or their exhalants admitting the flow of red blood, instead of the more attenuate serum. + To the former de- * Edin. Med. Ess., vol. v., part n., art. xlvi. With regard to the treatment of plethora from in- adequate excretion, Dr. Barlow has remarked, that a constitution naturally feeble, especially if insufficient exercise be taken, sends the blood to the surface too languidly for proper exhalation from the skin to take place. The best preventive of this diseased condition seems, to him, to be exercise, slighter degrees of which would also be the most effectual cure. Dr. Barlow is likewise an advocate for warm bathing, combined with frictions, and other means of softening and de- taching hardened cuticle. The Russian vapour- bath, so accurately described by the late Dr. Clarke, appears well calculated for establishing a healthy state of the cutaneous functions.—Ed. t On this subject some judicious observations are made by M. Andral (Anat. Pathol., torn, i., p. 338), who cautions the practitioner not to con- found discharges of blood from mucous mem- branes with other affections, of which a degree of inflammation is necessarily a part. In hemor- rhage, there may, indeed, be determination of blood to the part ; but it seems as if the fluid, in- stead of accumulating in the vessels of the mu- cous membrane, escaped as soon as it reached them, owing to some unknown modification of them. There may also be a passive fulness of them, as in obstruction of the venous circulation. scription of hemorrhages, Dr. Cullen has given the name of active ; to the latter that of pas- sive.) The distinction is sufficiently clear ; and, undef the names already employed in the pre- ceding genus of this system, will lay a founda- tion for the two following species :— 1. Haemorrhagia Ento- Entonic Hemorrhage. nica. 2---------Atonica. Atonic Hemorrhage. SPECIES I. HAEMORRHAGIA ENTONICA. ENTONIC HEMORRHAGE."' ACCOMPANIED WITH INCREASED VASCULAR AC- TION ; THE BLOOD FLORID AND TENACIOUS. As the outlets of the body are but few, and all of them communicate with numerous organs, we cannot always determine with strict accu- racy from what particular part the discharge flows. We have, however, sufficient reason for the following varieties :— a Narium. Entonic bleeding at the nose. 0 Haemoptysis. ------- spitting of blood. y Haematemesis.-------vomiting of blood. <5 Haematuria. ------- bloody urine. c Uterina. ------- uterine hemorrhage. £ Proctica. ------- anal hemorrhage. The great predisponent cause of active hem- orrhage, wherever it makes its appearance* is plethora or congestion. . A plethoric diathesis will, however, only predispose to a hemorrhage somewhere or other; and hence there must be a distinct local cause that fixes it upon one particular organ rather than upon another.* But an unusual flow of blood to, or fulness of the vessels, is not essentially concerned in every kind of hemorrhage \, for the qualities of the blood may be so altered, that the natural cohesion of its par- ticles to one another may be weakened, and then it may readily escape from the vessels, producing hemorrhage, quite independent of irritation, in several parts of the system at the same time. This is what is observed in scurvy and typhoid fevers, and in every case where attention to causes, and the look of the blood itself, afford a conviction that this fluid is materially altered. —Ed. * The reader will find many valuable observa- tions on internal hemorrhages in the Lumleian Lectures, delivered at the College of Physicians in May, 1832, by Dr. Watson, and published in the Medical Gazette, vol. x. He espouses the doc- trine that, in a great majority of instances, the escape of the blood is not dependant upon rupture of the vessels, but is effused through those pores or outlets which afford a passage to the natural fluids of the part, and to which we apply the name of exhalants. These hemorrhages by exhalation he divides into the idiopathic, or such as are inde- pendent of any discoverable change of texture in any part of the body; and the symptomatic, or those which are connected with organic disease; and this latter class is subdivided into two species • the first including cases in which the hemorrhage is dependant upon disease in the part from which the blood proceeds: and the second, those exam- ples in which the disease is situated in some other part, capable of influencing the circulation in the Gen. II.—Spb. 1.] HAEMORRHAGIA ENTONICA. 7 The chief local cause is a greater degree of debility in the vessels of such organ, than belongs to the vascular system generally.'. But there are other and more extensive causes that operate upon some organs, and which con: sistfin an unequal distribution of the blood, and its peculiar accumulation in some vessels rather than in others.\ Thus, some organs acquire de- velopment and perfection sooner than others,-of which the head, peculiarly large, even in in- fancy, furnishes us with a striking example ; and, in the promotion of such development, the flow o£ the blood is directed with greater force and in greater abundance. And hence while the coats of tire bloodvessels in this organ are yet tender, and destitute of that firmness which they derive from age, we have reason to expect hemorrhage as a frequent occurrence, and par- ticularly from the vessels of the nostrils; be- cause there is in the nose, for the use of the olfactory sense, a considerable network of blood- vessels expanded on the internal surface of the nostrils, and covered only by thin and weak in- teguments. And on this account, we see why young persons are so much more subject to bleedings from this organ, than those in mature life. Haemoptysis, or spitting of blood, takes place more commonly a few years later, and when the animal frame has acquired its full growth, and, consequently, the vascular system its full extent or longitude. Antecedently to this, the impetus and determination of blood are greater in the aorta and its extreme ramifi- cations than in the pulmonary artery, because more of the vital fluid is demanded for the pro- gressive elongation of the very numerous arte- ries that issue from the former : and conse- quently, a greater tendency to plethora exists in this direction till the age of about fifteen or eighteen, than in the direction of the lungs. Till this period of life, therefore, we have no reason to expect hemorrhage from the respira- tory organs. When this term, however, has arrived, the bias is thrown on the other side : and, the vessels of the corporeal and of the pulmonary circulation being equally perfected, the tendency to accumulation will be in the latter, in consequence of their shorter extent. This tendency will continue till about the age of thirty-five ; which is exactly correspondent with the observation of Hippocrates, who has remarked, that haemoptysis commonly occurs between the age of fifteen and that of five-and- thirty. We have explained why it does not often occur before fifteen ; but what is the rea- former, by reason of some intelligible connexion between them, either of structure, or function, or mutual relation. Dr. Watson adverts to the fact, that hemorrhage by exhalation occurs much more frequently from the mucousmembranes, than from any other tissues of the body ; and also to the re- markable circumstance, that hemorrhage from the brain differs from most other internal bleedings, in not taking place by exhalation, but from actual rupture of a bloodvessel. This is attempted to be accounted for, partly by a reference to the struc- ture and arrangement of the cerebral arteries, but chiefly by the consideration of their great hability to disease.—Ed. son of its seldom occurring after the latter period 1 Dr. Cullen has ingeniously explained it in the following manner. The experiments of Sir Clifton Wintringham, he observes, have shown, that the density of the coats of the veins, compared with that of the arteries, is greater in young than in old animals ; from which it may be presumed, that the resistance to the passage of the blood from the arteries into the veins is greater in young animals than in old ; and while this resistance continues, the plethoric state of the arteries must be perpetu- ally kept up. The very action, however, of an increased pressure against the coats of the ar- teries gradually thickens and strengthens them, and renders them more capable of resistance ; whence in time they come not only to be on a balance with those of the veins, but to prevail over them ; a fact which is also established by the experiments just adverted to. After thirty-five, therefore, the constitutional balance becomes completely changed, and the veins, instead of the arteries, are chiefly sub- ject to accumulation. The greatest congestion will usually, perhaps, be found in the vena por- tarum, in which the motion of the venous blood is slower than elsewhere ; and such congestion alone will frequently act upon the neighbouring arteries, and induce what may be called a re- flex plethora upon them, in consequence of their inability of unloading themselves : and hence the chief origin of hsematemesis, anal hemor- rhage, and various other hemorrhages from the abdominal and pelvic organs.* All these organs, however, are exposed to hemorrhage from incidental causes, as well as * The following conditions are specified by An- dral, as liable to bring on hemorrhage from the mucous membrane of the digestive tube (Anat. Pathol., torn, ii., p. 150):—1. A mechanical ob- struction of the circulation in the vena portse. 2. Irritation of the mucous coat of the stomach and bowels. Thus, certain corrosive poisons, taken into the stomach, will be followed by haemate- mesis, and strong drastic medicines will occasion hemorrhage from the bowels. 3. Sanguineous congestion, neither of a mechanical kind, as in the first case, nor the result of irritation, as in the second. The blood simply accumulates at a cer- tain point, and makes its escape, and that is all that can be ascertained. 4. Certain states of the blood itself, making it disposed to quit its proper channels, as exemplified where particular poisons are absorbed ; in typhus, and also in yellow fever, with black vomit. 5. Lastly, blood in the cavity of the stomach and bowels may have got there by being swallowed, as happens when an aneu- rism of the aorta bursts into the oesophagus. In hasmatemesis, the blood is usually poured out by a kind of exhalation ; the bleeding from ulceration of any considerable artery, or vein, being comparatively rare. Three examples of the latter occurrence are quoted by Dr. Watson (Med. Gazette, vol. x., p. 434); one from the Journ. Heb- domadaire for May, 1830; a second from Dr. La- tham's patients in St. Bartholomew's Hospital; and a third from the practice of Dr. Clark. In all these cases, there had been marked symptoms pf gastric disorder for some time previously to the hemorrhage, and two of the subjects had been habitual drunkards. -Ed. 8 H.EMATICA. [Cl. Ill—Ord. IV. that constitutional change which has a tendency to produce the disease vicariously. , Thus, liemorrhage in all of them is occasion- ally produced by violent exertion, as great mus- cular force, vehement anger, or other passions or emotions of the mind ; severe vomiting, or coughing ; suppressed evacuations of various kinds, especially hemorrhoids of long standing, catamenia, habitual ulcers, issues-, or chronic eruptions of the skin : * as also by the wound of a leech swallowed accidentally.1; But in this la9t case it is probable, that the living principle of the stomach is in a state of weakness, as in all other cases in which exotic worms are found to continue alive under its action : since we know that this action, when in full vigour, is sufficient to destroy oysters, frogs, slugs, leeches, and various other cold-blooded animals in a short time. Haemoptysis is also said by many writers to have been produced by leeches accidentally taken into the stomach by a draught of water.t But it is probable, that in this case there is a deception ; and that the blood, dis- charged by coughing from the trachea, has first passed into it from the stomach and mouth. Local stimulants are also an occasional cause. s Thus the vessels both of the kidneys and rec- tum have been excited to hemorrhage by%n in- judicious use of aloes, terebinthinate prepara- tions, and pungent alliaceous sauces. And the former by cantharides, whether applied exter- nally or internally : for Schenck and other wri- ters have given examples of haematuria excited in irritable constitutions by vesicatories alone j Occasionally, however, all the various kinds of hemorrhages before us have assumed a dif- ferent character, and proved salutary and criti- cal. Thus, cephalitis has often ceased suddenly on a free and sudden discharge of blood from the nostrils ; pneumonitis, from what has been deemed an alarming haemoptysis : visceral in- farctions, from a liberal evacuation of the hem- orrhoidal vessels ; a jaundice has been carried off by a profuse haematuria, || and fevers of vari- ous kinds have instantly yielded to a sponta- neous appearance of any of them. Such hemorrhages, however, though salutary in their onset, must be cautiously watched ; since, if not checked when they have accom- plished their object, they are apt to pass into a chronic or periodic form. Hence, many persons have monthly discharges from the rectum; others from the nostrils; others, again, occa- sional or periodic, from the lungs ; and a few from the stomach. IT Tulpius gives a case of chronic haemoptysis that continued for thirty years ;** and there are other instances of much longer duration, tt * Percival's Essays, n., p. 181. t Galen, De Loc. Affect., lib., iv., cap. v. Rive- rius, Observ. Med., cent, iv., obs. 26. t Galen, De Loc. Affect., lib, iv., cap, v. Bo- relli, cent. i„ obs. 24. § Schenck, lib. vii., obs. 124, ex Langio. Hist. Mort. Uratislav,, p, 58. || Schenck, obs., lib. iii., serm. ii., n. 258. IT Rhodius, cent, ii., obs. 94, ** Lib. ii., cap. ii. ft N, Act. Nat. Cur., vol. i., obs. 1. There is also another reason for an early at- tention to spontaneous hemorrhages, and that is, the profuseness of the discharge which some- times takes place, and the alarming exhaustion which follows. Dr. Banyer* gives a case of this sort, in which the discharge was from the bladder : Biichner, another case from the same organ, in which it amounted to not less than four pounds :t and other writers bring examples of its having proved fatal. The largest quantities, however, are usually lost from the nostrils. Ten, twelve, and up- wards of twenty pounds have been known to flow away before the hemorrhage has ceased. Bar- tholin mentions a case of forty-eight pounds ;} Rhodius another of eighteen pounds lost within thirty-six hours ; $ and a respectable writer, in the Leipsic Acta Erudita, a third, of not less than seventy-five pounds within ten days ;|| which is most probably nearly three times as much as the patient possessed in his entire body at the time the hemorrhage commenced. In the Ephemera of Natural Curiosities is a case in which the quantity indeed is not given, prob- ably from the difficulty of taking an account of it, but which continued without cessation for six weeks.*$ In ACTIVE HEMORRHAGES FROM THE NOS- TRILS, the epistaxis of many writers, the dis- charge is usually preceded by some degree of local heat and itching; and occasionally by a flushing of the face, a throbbing of the temporal arteries, a ringing in the ears, or a pain or sense of weight and fulness in the head. Yet, not unfrequently, the blood issues suddenly without any of these precursories ; for, as we have al- ready observed, the arteries, distributed over the Schneiderian membrane, are very numerous and superficial, and a very slight irritation is often sufficient to rupture them. That insola- tion, or exposure to the direct rays of the sun, a cold in the head, or cold applied to the feet or hands, coughing, or sneezing, especially upon the use of sternutatories, an accidental blow upon the upper part of the nose or forehead, or a jar of the entire frame, as on stumbling, should be sufficient to produce this effect, can easily be conceived ; and these, in truth, are the common occasional causes : but it is singu- lar that it should follow, in some highly irri- table idiosyncrasies, upon such very trivial ex- citements as have been noticed by many pathol- ogists. Thus, Bruyerin** gives an example in which the nostrils flowed with blood upon smelling at an apple; Rhodius.tt upon the smell of a rose ; and Blancard.JJ upon the ringing of bells : and when we find the same effect produced by various emotions of the mind, as terror, anger, and even a simple excitement of the imagination,^ we may readily trace by * Phil. Trans,, vol. xlii. t Miscell. 1728, p. 1496. t Anat. Renov., lib. ii., cap. vi. $ Cent, i., obs. 90. || Lib. 1688, p. 205 f Dec. i., ami. iii., obs. 243. ** De Re Cibaria, lib, i,, cap, 24, tt Cent, hi., obs. 99. H Collect. Med. Phys., cent, vi., obs, 74. <)<) Rhodius, cent, i., obs. 89, Gen. II.—Spe. 1.] HAEMORRHAGIA ENTONICA. 9 by what means the philosophers and poets of the eastern world, and even some of those of the western, were led to regard the nose as the seat of mental irritation, the peculiar organ of heat, wrath, and anger ; and may discover how the same term fix (ap or aph) came to be em- ployed among the Hebrews to signify both the organ and its effect, the nose and the passion of anger to which it was supposed to give rise. We have already observed, that the quantity of blood discharged by a spontaneous hemor- rhage from the nostrils, is sometimes enormous. This, however, is a more common result of pas- sive than of active hemorrhage ; and is more usually found in advanced than in early life : the two stages in which nasal hemorrhage chiefly shows itself. And where it frequently returns, if is apt, like the hemorrhoids, to form a habit of recurrence that cannot be broken through with- out danger, except by an employment of evacu- ants, or some other drain.* If it be evidently connected with entonic ple- thora, or accompanied with the local symptoms just enumerated, it will afford a more effectual relief than bleeding in any other way, and should not be restrained till it has answered its pur- pose. Even a small portion of blood, not amounting to more than a table-spoonful or two, when thus locally and spontaneously evacuated, has afforded, on some occasions, a wonderful freedom and elasticity to an oppressed and heavy head : and, when more copious, has prob- ably prevented an apoplectic fit, as it has often formed a salutary crisis in inflammation of the brain, or fevers in which the brain has been much affected. But when these reasons do not exist, the bleeding should be checked by astringent appli- cations. Cold is the ordinary application for this purpose, and it commonly succeeds without much trouble. Cold water may be sniffed up the nostrils, or thrown up with a syringe ; but the exertion of sniffing, or even the impetus of the water alone, where a syringe is employed, sometimes proves an excitement that more than counterbalances the frigoric effect. .Independ- ently of which, there is an advantage in leav- ing the blood to coagulate on the ruptured orifice of the vessel, which these methods do not allow. By means of a syringe, however, we can throw up, when necessary, astringents of more power than cold water, as vinegar, or the sulphuric acid properly diluted, or a solu- tion of sulphate of zinc, copper, iron, or lead ; after which we should force up tents of lint moistened with the same, and particularly with extract of lead diluted with only an equal quan- tity of water, as high as we are able, with a probe or small forceps, so as to form a tight compress : the styptic agarics can be rarely used to advantage. The face may, at the same time, be frequently immersed in ice-water, or water artificially chilled to the freezing point ; and the temples, or even the whole of the head, be surrounded with a band or napkin moistened * J. P. Frank, De Cur. Horn. Morb. Epit., torn. i?i., lib. vi, part iii. 8vo. Vienna?, 1821. with the same, and changed as soon as it ac- quires the warmth of the skin. When tents are used, they have sometimes been dipped in moistened powder of charcoal, which, of" itself, has proved an excellent styptic. Cold applied to the back sometimes succeeds, but often fails; it is more certain of success when applied to the genitals. Emetics have occasionally been of service, and are recommended by Stoll.* The princi- ple upon which they may be presumed to apt will be noticed under haemoptysis. The bleed- ing has sometimes been checked by a sudden fright,t probably from the cold sweat that so often attends such an emotion: and Reidlin gives a case in which it was cured by sneez- ing ;t but this was probably a case of atonic hemorrhage, in which the spasmodic action might assist in corrugating the mouths of the bleeding vessels. It is rarely necessary, or even proper, in this variety of hemorrhage, to employ any internal astringent or other tonic ; but if this discharge should be excessive, and produce debility, the same plan may be resorted to as will be recom- mended under the ensuing species. In HAEMOPTYSIS, Or SPITTING OF BLOOD, it is not always easy to determine from what vessel, or even from what organ, the bleeding proceeds: for the blood may issue from the posterior cav- ity of the nostrils, or from the fauces, as well as from the lungs. If, however, from the first, it will cease upon bending the head forward, or lying procumbent, and will probably flow from the nose: if from the second, we shall com- monly be able to satisfy ourselves by inspection. Blood from the stomach is of a darker colour, thrown up by vomiting, and betrays an inter- mixture of food. If the haemoptysis be from the lungs, and belong strictly to the present species, and more especially if it be a result of entonic plethora, the blood will be chiefly thrown up by cough- ing ; and the discharge will be preceded by flushed cheeks, dyspnoea, and pain in the chest. There is usually, also, a sense of tickling about the fauces, which often descends considerably lower: Salmuth asserts, that he has known it extend to the scrobiculus cordis.} These symp- toms, moreover, indicate that the blood flows from a branch of the pulmonary, rather than of the bronchial artery. The blood is here of a florid hue, and the hemorrhage sudden and often copious. If a branch of the bronchial artery give way, the flow of blood is usually much slower, and smaller in quantity ; there are no precursive symptoms, the blood is rather hawk- ed or spit up intermixed with saliva, and, from being longer in its ascent, is of a darker colour. From its lodgment, however, in the air-vesicles, it becomes a cause of irritation, and a frothy cough ensues, sometimes accompanied with a little increase of the pulse and other febrile * Rat. Med., part iii., p. 21. t Panarol. Pentecost., v., obs. 27. i Linn. Med., ann. i., obs. 24. § Cent, iii., obs. f ATICA. [Cl. IH.-Ord. IV. 10 H^Eft symptoms, as a feeling of heat and some degree of pain in the breast, which subsides after the ejection, and returns if there be a fresh issue. If the structure of the lungs be sound, we have no reason to prognosticate danger. On the contrary, it often affords great relief to a gorged liver, and has proved critical in ob- structed menstruation.* Excreted with the sputum, it is frequently serviceable, as we have already observed, in cases of asthma, pleurisy, and peripneumony. But if it have been pre- ceded by symptoms of phthisis, or a strumous diathesis, there is a great reason for alarm ; for we can have little hope that the ruptured ves- sel will heal kindly and speedily, and have much to fear from the fresh jets by which the extrav- asated blood becomes deposited, and forms a perpetual stimulus in an irritable organ. The general pathology has been already laid down. ■ The incidental causes are, misformation of the chest; undue exertion of the respiratory muscles, whether in running, wrestling, singing, or blowing wind instruments ; excess in eating and drinking ; or a violent cough. As a symptom or sequel, it occurs in wounds, phthisis, or the suppression of some accustomed discharge. In active hemorrhage from the lungs, vene- section is one of the most important steps to- wards a cure ; and the blood should be drawn freely at once, rather than sparingly and repeat- edly ; though a second and even a third copious use of the lancet will often be found expedient. Emetics have been recommended, but they are of doubtful effect. They augment the vascular volume by relaxing the capillaries ; but they stimulate locally by the act of rejection. Dras- tic purgatives are avoided, because of the strain- ing ; but the straining in vomition is greater and more direct. Dr. Brian Robinson of Dublin, who was one of the most strenuous promoters of this mode of practice in his day, accounted for the bene- fit of emetics by the constriction which he con- ceived they produce upon the extreme vessels everywhere ; but, to act thus, they should ra- ther nauseate than vomit; for in nausea we have great vascular depression, and a cold and general collapse on the surface ; while vomiting is known to rouse the system generally and de- termine towards the surface. Upon the recom- mendation of Dr. Robinson, Dr. Cullen followed the plan in several cases : " but in one instance the vomiting," says he, " increased the hemor- rhage to a great and dangerous degree ; and the possibility of such an accident again happening * In the Lumleian Lectures for 1832, Dr. Wat- son related some striking examples, in which the menstruation, as one might say, took place for several years through the lungs, without any ap- parent injury of the general health. Among the patients of the celebrated Hoffman was a woman, who, for eight years, remained subject to a bleed- ing from the nose, which came on regularly every month, a few days before the menstrual period, and ceased upon the flowing of the catamenia. Then the direction of this periodical discharge was changed ; and, for six years more, instead of epistaxis, she suffered haemoptysis, and afterward this was exchanged for hajinateinesis.—Ed. has prevented all my further trials of such a remedy."* Nauseating has on this account been preferred on the continent to full vomiting in hemorrhage from the stomach, and indeed various other organs, as well as from the lungs ; and ipecacuanha in small doses has been gener- ally preferred to the metallic salts, as more manageable ; half a grain, or even a quarter of a grain, being given every quarter of an hour, for many hours in succession, t In general, however, we shall find it as suc- cessful and far less distressing to employ mild aperients and sedatives. The first, and par- ticularly neutral salts, are alone of great bene- fit, and their action should be steadily main- tained. Sedatives are of still higher impor- tance, and especially those that reduce the tone of the circulation, as nitre and digitalis. The first, in about ten grains to a dose, should be given in iced water, and swallowed while dis- solving ; the dose being repeated every hour or two, according to the urgency of the case. If there be much cough, it must be allayed by opium and blisters. Local astringents we can- not use, and general astringents are here mani- festly counter-indicated, however useful in pas- sive hemorrhage : though it should be recol- lected that, when an active hemorrhage from the lungs is profuse and obstinate, the vessels lose their tone, and fall into a passive state. In h^ematemesis, the blood is evacuated from the alimentary canal at either extremity, whether that of the mouth or of the anus ; for the term is used thus extensively by the Greek writers. In both cases it is discharged in ac- tive hemorrhage with a considerable expulsive effort; and the discharge is preceded by tensive pain about the stomach ; and accompanied with anxiety and faintness. The quantity discharged from the stomach is in most cases larger than what is discharged from the lungs, and of a deeper hue : it is also thrown up by the act of vomiting, and usually intermixed with some of the contents of the stomach. And hence there is no great difficulty in determining as to the source of the hemor- rhage..): Haematemesis, however, is far more frequently a disease of atony than of entony, and hence, chiefly belongs to the next species. Its usual exciting causes, when it occurs under an entonic character, are concussion or other external violence, as a shock of electricity,* some strong emotion of the mind, as rage or terror, vomiting, or pregnancy. It has also occasionally been found to afford relief in sup- pressed catamenia, or been vicarious of it. The pathology we have already given : the blood may proceed from the spleen, the liver, * Mat. Med., part ii., ch. xix., p. 470. t Keck, Abhand. und Beobach. Med. Wochen- blatt, 1783. No. xlix. t The blood, which comes from the lungs, is commonly florid, and mixed with bubbles of air, frothy; that which proceeds from the stomach is usually dark-coloured, coagulated, or grumous and mingled with fragments of the food, with mu! cus or bile—Dr. Watson in Lumleian Lectures for 1832.—Ed. $ Percival's Essays, vol. ii., p. 181. Gen. II.—Spe. 1.] HAEMORRHAGIA ENTONICA. 11 the pancreas,* the stomach itself, or the smaller intestines ; and the mode of treatment should be as already advised for haemoptysis. [From the effects of that insidious disease, chronic in- flammation of the stomach, an haematemesis is sometimes produced, that rapidly cuts off the pa- tient.—(Dr. Abercrombie, in Edin. Med. Journ., No. Ixxviii., p. 2.) Haematemesis is also one of the earliest symptoms of scirrhus or cancer of that organ; taking place long before the commencement of ulceration, as well as in the ultimate stages of the disease. Then, as Dr. Watson conceives (Med. Gaz., vol. x., p. 436), it may be owing to a breach in some vessel of magnitude, though he represents it as being more commonly a general oozing or exhalation from the ulcerated surface.] In hematuria, the blood is evacuated at the urethra, and the evacuation is preceded by pain in the region of the bladder or kidneys, and accompanied with faintness. The blood is sometimes intermixed with urine, but occasion- ally flows pure and uncombined: and, in this last state, the disease is called by Vogel sty- matosis, and the bleeding is supposed to pro- ceed from the bladder rather than from the kidneys ; that from the latter being smaller in quantity, and remaining a longer time in the passages, and consequently of a darker colour. There is some ground for this opinion ; for, when the bladder is the seat affected, there is far more local pain and faintness than when the affection is in the kidneys. Hippocrates, in- deed, has observed, that when the blood flows pure, copiously, and suddenly, and without pain, it proceeds from the kidneys, but, when it is small in quantity, and of a blackish colour, and accompanied with much heat or pain, or both, its source is the bladder. But this remark, in- stead of opposing, tends rather to corroborate, the preceding ; for, according to both views, the seat of disease is distinguished by the greater or less degree of uneasiness that attends the discharge ; and this whether the quantity dis- charged be larger or smaller. It is not often, though sometimes, an entonic disease, or an active hemorrhage. Its exciting * The statement with respect to the blood pro- ceeding from the spleen, liver, or pancreas, is not correct. Disease of these organs may lead to haematemesis, or exist simultaneously with it; but the source of the blood is in the vessels of the mucous coat of the stomach itself. As Dr. Watson has observed, a great majority of cases of hemorrhage from the stomach are symptomatic. That which depends upon incipient cancer of the stomach, while it is by no means of rare occur- rence, is also more frequently obscure than other instances. In general, an attention to symptoms, and the past history of the patient, will readily elucidate haematemesis from the action of corro- sive poisons ; from the rupture of an aneurism ; from the influence of scurvy, or purpura; from cancer of the stomach in its advanced stages; from organic diseases of the liver, spleen, or heart; from an attack of yellow fever ; from sup- pressed or imperfect menstruation; or from the pressure of the gravid uterus.—See Dr. Watson's Observations, as published in Med. Gaz., vol. x., p. 439.—Ed. cause is frequently a stone in the bladder, or a violent blow on the kidneys, or on the bladder, especially when the latter is full. It is also said by Schenck (Lib. vii., obs. i., 24), and other wri- ters, to be occasionally produced by cantharides, whether employed externally or internally.* In connexion with the general course of treat- ment already recommended in the preceding varieties, the compound powder of ipecacuanha may here be employed with great advantage : for the pain and irritation are often intolerably distressing, and, on this account, demulcent drinks are frequently found to produce consider- able relief. In uterine hemorrhage, the blood is dis- charged from the womb with a sense of weight in the loins, and of pressure upon the vagina. This is the menorrhagia of most of the nosolo- gists, and is often, but very erroneously, de- scribed as an excess of the menstrual flux. It is, in truth, a real hemorrhage or issue of blood, instead of menstrual secretion, which is often entirely suppressed, though sometimes a small but inadequate portion is intermixed with the uterine bleeding : and hence Hoffman has prop- erly denominated it uteri hemorrhagia. It oc- curs both in an entonic and an atonic state of the vessels, and especially of the general sys- tem : and, from the remarks offered under Ple- thora, it is not at all to be wondered at that * Hist. Mort. Uratislav., p. 58. The editor has known haematuria occur in several cases in which cancerous disease of the neck of the uterus had extended by ulceration into the bladder. In one woman, whom he lately attended in Bos- well-Court, Devonshire-street, the bladder would sometimes become so full of coagulated blood, that a retention of urine used to be induced, in which the catheter had little effect, unless intro- duced much further than usual. He has also known profuse haematuria arise from a cancerous disease of the bladder ; a case that was remark- able as having been attended with a spontaneous fracture of the left thigh bone and one rib. The particulars have been published in the Trans, of Med. Chir. Society, vol. xvii. M. Andral men- tions a very curious example of haematuria.— (Anat. Pathol., torn, i., p. 339.) It took place in an old woman who had a cancer of the stomach. A fortnight before her death, numerous purple spots appeared on her skin, and a remarkable quantity of blood was daily voided with her urine. Red spots occurred on the conjunctiva, and one of them, rendered very prominent by the blood under it, formed a purple ring round the cornea, like what is observed in chemosis. On opening the body, numerous ecchymoses were found in the cellular texture on the outside of the peritonaeum and the pleura, on the inside of the cavities of the heart, and in different parts of the alimentary canal. The urinary passages contained a bloody fluid, which might also be pressed out of the ma- millae of the tubular substance of the kidneys. No blood was anywhere found, except what was of a purple colour, and quite liquid, without any appearance of coagulum. A similar case is re- corded by M. Stoltz.—(Archives de Med., torn. xv.) The patient, in the latter instance, was a pregnant woman, and it is curious that ecchymo- ses, resembling those noticed in most textures of her body, were also found in the lungs, pericar- dium, heart, and vessels of the foetus.—Ed. 12 H.EMATICA. [Cl. III.—Ord. IV. every night, and persevered in till the period of relapse ; when I have often found that there has been neither tension nor spasms, that the loins have continued easy, and the hemorrhage has yielded to the natural secretion. In hemorrhage strictly anal, the flux of blood issues chiefly from the hemorrhoidal ves- sels, and, as these are large, and but little sup- ported by any surrounding organization, they readily give way both in an entonic and atonic state of the frame, and particularly in case of plethora upon very slight excitements, as in straining to expel hardened faeces, taking cold in the feet, or walking a little too far. Irritants introduced by the mouth have also proved a fre- quent cause of this variety of hemorrhage ; as an injudicious use of aloes, terebmthinate prep- arations, or even pungent alliaceous sauces. The irritation of piles is also a very common cause, and hence by some writers anal hemor- rhage is only treated of as a symptom of that variety of this last disease, which is known by the name of bleeding piles. But this is highly incorrect, as anal hemorrhage often occurs, and very profusely, where no piles have ever been experienced. This power of hemorrhage, when active, as it is called, or in an entonic habit, is usually preceded by a sense of weight and pain within the rectum, and sometimes by a load in the head. And it has often, as already ob- served, proved critical and salutary, and carried off congestions from the abdominal viscera. It is, however, peculiarly apt to become profuse, and to establish an order of recurrence, and hence must be overpowered by the reducent and sedative plan, recommended in most of the preceding varieties, and particularly in that of haemoptysis. The aperients employed, how- ever, should here be peculiarly mild and alter- ant ; and sulphur, which does not readily dis- solve in the course of the intestinal canal, and often reaches the rectum in an unmixed state, is one of the best, and is often found strikingly serviceable. All stimulant foods, moreover, must be especially avoided; and the ordinary drink should be water, soda-water, or lemonade. Here also we are able, as in the case of hem- orrhage from the nose, to employ local astrin- gents, though it would be improper to use those that act generally, so long as plethora or an en- tonic habit continues. The patient may sit in a bidet of ice-water, or water cooled artificially to the freezing point, or may use a cold hip- bath, and have injections of cold water, or as- tringent lotions, as of alum, zinc, or even lead, thrown up the rectum; the latter of which should be in such proportions as to remain there for half an hour or an hour. hemorrhage should in both conditions take place from the uterus very frequently, and, perhaps, more so than from any other organ. For reasons we shall have occasion to explain in a subsequent part of this work, the uterus, from the period of the completion of the female form, is stimulated, once in every lunation, to the secretion and elimination of a peculiar fluid, which exhibits the colour, though it is deficient in many of the properties, of blood ; and for this purpose the uterine arteries are, at such seasons, peculiarly turgid and irritable. There is hence always a tendency on such occasions to a hemorrhage in this quarter in females of a firm and robust texture, and of a plethoric habit. But if, from cold or any other cause, the uterine secernents do not at these seasons fulfil their office, and throw forth the proper fluid, the ute- rine arteries will be inordinately gorged; the reg- ular stimulus will be greatly augmented ; pain, tension, and spasm will extend over the loins, and the extremities of the vessels be ruptured, or their mouths give way by anastomosis, and a considerable hemorrhage be the consequence. . This is the ordinary period in which uterine hemorrhage takes place, though it may occur during any part of the interval between the catamenial, terms, upon any of the occasional causes that operate upon other organs, and form the preceding varieties ; as it is well known to occur at times, with great violence, during preg- nancy and in childbed. When we come to treat of diseases apper- taining to the sexual organs, we shall have to notice some singular cases of precocity in fe- male infants, and especially that of a regular menstruation. It is upon this principle alone that we can account for uterine hemorrhage in new-born infants, of which the medical records give several examples, and especially the Ephe- merides of Natural Curiosities. In suppressed menstruation, uterine hemor- rhage affords relief to the spasms and pains that harass the loins, and the headache and difficulty of breathing which have usually preceded the lumbar distress. But the discharge may be im- moderate, and become habitual. And it is hence best to be upon our guard, and to use venesection as a substitute, and to prevent or diminish the spasmodic action by gentle aperi- ents and the sedatives already recommended in haemoptysis, after which the case will become a disease of suppressed menstruation alone, and must be treated according to the method recom- mended under that malady ; for a restoration of the catamenial secretion is its natural cure. I may observe, however, that, when the suppres- sion of this secretion has been of some stand- ing, and a uterine hemorrhage has periodically taken its place, accompanied with distressing pains in the whole circle of the pelvic region, we can sometimes suddenly restore a healthy action to the organ by a plan of anticipation. For this purpose, I have prescribed venesection about ten days before the return of the monthly paroxysms, and having thus taken off plethoric impetus, I have, a few days afterward, recom- mended the hip-bath to be used in a tepid state SPECIES II. HAEMORRHAGIA ATONICA. ATONIC HEMORRHAGE. accompanied with general laxity or de- bility, AND WEAK VASCULAR ACTION ; BLOOD ATTENUATE, AND OF A DILUTED RED. ' Though the effect in this species is the same as in the preceding, the proximate cause, as Gen II.—Spe. 2.] HJ2M0RRHA well as the more obvious signs, are directly opposite. The general pathology has been given in the introductory remarks to the genus, and the more common organs from which the hemor- rhage proceeds are the same as already noticed under the preceding species ; and hence the varieties of that may be regarded as those of the species before us. When plethora is the remote cause, which it often is, it is atonic plethora, or plethora of de- bility ; but whatever has a tendency to loosen or enervate the tone of the solidum vivum, or living fibre, will lay a foundation for this kind of hemorrhage. It is hence a characteristic disease of advanced age, as entonic plethora is of youth and adult life ; and often takes place in those whose vigour is reduced by meager or innutritious food, close confinement, without exercise, in a foul and stagnant atmosphere, or immoderate indulgence in the pleasures of wine or sexual intercourse. Hence, too, its frequent occurrence, as a symptom, in tabes, atrophy, struma, scurvy, and low fevers.* The characters of the several varieties of this species, as distinguished from those of the preceding, are as follow; for it is not necessary to put the varieties themselves into a tabular form:— In hemorrhage from the nostrils, the blood flows without heat or headache. In that from the respiratory organs it is usually produced without even the exertion of coughing, and is often accompanied with a scir- rhous or calculous affection of the lungs ; the countenance is pale and emaciated. In HEMORRHAGE FROM THE ALIMENTARY CA- NAL, the blood is discharged without tensive pain : though there must necessarily be an ex- pulsive effort; and, from the inanition hereby produced, some degree of nausea and faintness. When evacuated by the urethra, there is, for the same reason, faintness, but little or no previous pain. The most singular and severe examples of hemorrhages from the urethra are those that have occurred during coition ; some- times intermixed with semen, sometimes instead of it, and sometimes immediately after emission. The individuals have been generally persons of highly irritable and delicate habits ; and who have weakened themselves by too free an indul- gence in pleasures of this kind. Numerous in- stances of this sort of hemorrhage are given in the Collections of Medical Curiosities, and espe- cially in several of the German Ephemerides.t * The more correct principles, on which the fact is accounted for by Andral, are adverted to in some of the notes in the preceding pages.—Ed. t The employment of caustic bougies, or the rough introduction of instruments into the ure- thra, occasionally causes profuse hemorrhage. The editor is attending a man at this time (Nov., 1830), who was cut for the stone in Guy's Hos- pital about twenty years ago, and who is voiding a considerable quantity of blood from the urethra, in consequence, as he states, of slipping down with his thighs widely and very forcibly separ- ated. Haematuria atonica may attend typhus fe- ver, smallpox, and purpura hemorrhagica. When entirely passive and unaccompanied by inflamma- 3IA ATONICA. 13 There is little pain in atonic hemorrhage from the uterus : and it generally occurs at the natural cessation of the menstrual flux, or within a few years afterward. As a concomi- tant, hemorrhage from this quarter is also fre- quently found in a scirrhous, cancerous, or other morbid states of the uterus, in whatever period of life these may occur ; which, however, they do most usually after the age of forty or fiftv. Atonic hemorrhage from the anus ordi- narily takes place spontaneously, with little or no pain ; but commonly with varices or con- gestions of the hemorrhoidal vessels, and is very apt to produce a habit of recurrence. In all these varieties, venesection must be had recourse to sparingly, and never, unless where we have satisfactory evidence of atonic plethora or congestion. It may sometimes be requisite to use the lancet in nasal hemorrhage, for the head may feel oppressed and drowsy : and it will still more frequently be necessary in hemorrhage from the uterus ; but the blood extracted should rarely exceed seven or eight ounces ; and, in all other varieties, as a general rule, it will be better to withhold our hand, and to proceed at once with a tonic plan of treat- ment. Into this plan we may, in the present species, freely admit the use of general astringents, in conjunction with their local application, how- ever objectionable in the preceding; for a lax- ity and inelasticity of the fibrous structure are among the chief symptoms we have to oppose : and hence the mineral acids and metallic salts may be had recourse to with great advantage, along with bitters ; and, with a few exceptions, we cannot well err in the selection. The prep- arations of iron may be rather too heating in haemoptysis, and perhaps in all atonic hemor- rhages accompanied with much irritability. One of its mildest and best forms is that of a subcar- bonate ; and perhaps the best mode of obtain- ing it in this form is by the celebrated compo- sition of Dr. Griffiths. The myrrh is also in his preparation a useful article for the present purpose, and we shall rarely do better than em- ploy it. In the London Pharmacopoeia, it is given under the name of mistura ferri composita. From the manifest power of opium to restrain most evacuations, it has often been employed in hemorrhages. It does not appear, however, to have any direct effect in checking the discharge ; and in entonic hemorrhages, and especially when employed early, has been highly mischie- vous. But where, in haemoptysis, there is a perpetual cough from irritation, or in uterine hemorrhages a frequent recurrence of spas- modic pains, it has been tried with considerable success. And the same remark will apply to hyoscyamus, and various other narcotics, which seem to be only useful on the same account. Cinchona, which is peculiarly objectionable in the preceding species, may here be had re- tion, the exhibition, of turpentine in small doses, from twenty to twenty-five drops, every six hours, should be adopted, and the system supported.— See Elliotson's Lects., delivered at Lond. Univ., m Med. Gaz. for Aug., 1833.—Ed. 14 HAEMATIC A. [Cl. Ill— Obd. IV. course to with considerable promise. It seems, however, to be chiefly serviceable in uterine hemorrhage, where the disease depends upon a laxity of the extremities of the vessels, which are therefore readily opened by every irritation, applied to the system or to the diseased part. Whether in this case it acts altogether as a bitter, as supposed by Dr. Cullen, or partly also as an astringent, it may be difficult to de- termine ; but the question is not of importance. For other general roborants to which it may be necessary to have recourse, the reader may turn to the treatment of limosis dyspepsia, or indigestion (Class I., Ord. I., vol. i., p. 98); and he may govern the patient's diet and regi- men by the general plan there laid down. The local astringents and refrigerants al- ready recommended under the former species, may be here employed with even less reserve : and where the bleeding has become chronic, which it is far more likely to do than in entonic hemorrhage, or has been so profuse as very considerably to exhaust the system, a little wine or some other cordial should be administered as soon as we are consulted: for, however small the vessel that is ruptured, its orifice is incapable of contracting from a total loss of tone ; and hence a diffusible stimulus gives it the irritation it stands in need of, and forms a salutary constringent. A striking case of this kind has already been given in treating of accidental hemorrhages from extracting teeth; and it is not long since, that the author was requested to attend in a similar hemorrhage from the nose. The patient was a lady of about fifty years of age, of slen- der and delicate frame, who had for some years ceased to menstruate. The bleeding had con- tinued incessantly for three or four days, during which she had been restrained to a very low diet, and allowed nothing but toast and water for her common drink. She was faint, felt sick, and had a feeble pulse, and must have lost many pounds of blood, though no exact meas- ure had been taken. I gave her instantly a free draught of negus made with port wine, prescribed camphire mixture with the aromatic spirit of ammonia, had the nostrils syringed with equal parts of tincture of catechu and water, and applied a neckerchief wetted with cold water round the temples, directing it to be renewed every ten minutes. In half an hour the hemor- rhage ceased, and, on the ensuing day, I found no other symptom than weakness, for which a nutritious but inirritant regimen was prescribed. A few days afterward the* hemorrhage returned from sneezing or some other incidental stimulus, and was restrained, as I was told, for I did not see her, by a recurrence to the same plan. I recommended, however, carriage-exercise, and an excursion to the seacoast, which was imme- diately complied with, and there was no recur- rence of the disease. To effect the same intention, I have occa- sionally advised cardiacs combined with astrin- gents in haematemesis, where the discharge of blood has been profuse, and has continued for some days, and the patient has become consid- erably exhausted: and I do not recollect an instance in which the plan has proved unfriend- ly. In like manner, in very great faintness or deliquium produced by a copious and protracted hemorrhage from the uterus, I have had the vagina injected with equal parts of port wine and water acidulated with sulphuric acid, and have found it equally successful. The acetate of lead is also a preparation which, in all such, cases, ought to be tried in- ternally. It was at one time greatly out of fa- vour, from the writings of Sir George Baker, and the concurrent opinion of Dr. Heberden. Of the mischievous effects of various prepara- tions of this metal when employed internally, the former has given numerous examples, and concludes with the following corollary : "that lead taken into the stomach is a poison . I do not say ex proprietate naturae et tota substantia ; but which is capable of doing much more hurt than good to the generality of men in all the known ways of using it; and, consequently, that it cannot be avoided with too much caution."— (Med. Transact., vol. i., p. 311.) In corrobora- tion of which Dr. Heberden tells us, that its good effects are by no means so certain as its mischief; and, in most cases, would be far overbalanced by it. In the form of an acetate, however, all its evils seem to be subdued by a combination with opium ; for the first distinct knowledge of which the medical world is indebted to the penetration and judgment of Dr. Reynolds, who tried it, in this state of union, in various cases, with the most perfect success, and without the least unfavourable symptom whatever, whether of pain or even costiveness. He also employed with equal benefit the old tinctura saturnia, and the sugar of lead: of the former, giving eighteen drops with three drops of laudanum to a dose, and repeating the dose every four hours in a little barley-water; of the latter, giving one grain with three drops of laudanum mixed into a pill with conserve of roses; to be re- peated every six hours. And, under both forms, he employed these materials with great and unalloyed advantages in hemorrhages of most sorts, especially uterine, pulmonary, and nasal. —(Med. Transact., vol. iii., art. xiii.) Dr. Latham (vol. v., art. xxi.) has since con- firmed this practice of Dr. Reynolds in its full- est degree, and even extended its range; and so little inconvenience has he found from the use of the acetate, that he has employed it " in doses of a grain three times a day for six, eight, and ten weeks successively; usually, but not always, combining it with opium or conium; without any other precaution than desiring the patients to obviate any costiveness by oleum ricini or confectio sennae." He has occasion- ally given two grains of the acetate as an even- ing dose ; once, in consultation with Dr. Rey- nolds, five grains ; and mentions another case in which he was concerned, where ten grains a day were taken without any inconvenience. By a mistake for sugar, a young woman, respecting whom he was consulted, swallowed at one time about two drachms of it, yet without any serious evil: the fauces and oesophagus were consider- ably constringed, and this seems to have been Gen. III.] MARASMUS. 15 the chief mischief; for the bowels were opened by oleum ricini and other purgatives in the course of the day, and the patient was not at all worse for the accident on the ensuing morning. Imboldened by these facts, Dr. Latham has employed the same medicine in other diseases in which irritant astringents and tonics seem re- quisite, as in colliquative diarrhoeas and hectic perspirations, and more especially in that semi- purulent expectoration which too often termi- nates in pulmonary ulceration and consumption : and, as he confidently assures us, with great ad- vantage. And he hence concludes, that what- ever deleterious properties may appertain to lead in some of its salts and oxydes, nothing perni- cious exists in its acetate ; in the process for which, he conceives it either to be more com- pletely freed from arsenical or other poisonous minerals than in its other forms, or rendered innocuous by the addition of the acetic acid. It only remains to be added, that where en- tonic hemorrhage has occurred so profusely, or has continued so long, as to reduce the system to an atonic state, it then becomes a disease of debility, and is to be treated as though origina- ting under the present species. GENUS III. MARASMUS. EMACIATION. GENERAL EXTENUATION OF THE BODY, WITH DEBILITY. Marasmus is a Greek term, derived from napaivw, "marcesco," " marcescere reddo." It was long ago used collectively to comprehend atrophy, tabes, and phthisis ; and in employing it therefore in the present system as a generic name, we only restore it to its earlier sense. The generic character is common to all these subdivisions; for each is distinguished by a general emaciation of the frame, accompanied with debility, and consequently forms a species to marasmus as a genus. With these species the reader, however, will now find two others united; m. anh/Emia, to which I shall advert presently, and m. climac- tericus : the last from a high authority, with which I fully coincide ; and which is intended to imbody that extraordinary decline of all the corporeal powers, which, before the system falls •a prey to confirmed old age, sometimes makes its appearance in advanced life without any suf- ficiently ostensible cause, and is occasionally succeeded by a renovation of health and vigour, though it more generally precipitates the pa- tient into the grave. Extenuation or leanness is not necessarily a disease; for many persons who are peculiarly lean are peculiarly healthy, while some take pains to fall away in flesh, that they may in- crease in health and become stronger. But if an individual grow weaker as he grows lean- er, it affords a full proof that he is under a mor- bid influence ; and it is this influence, this con- junction of extenuation with debility, as noticed in the definition, that is imported by the term marasmus, and its synonyme emaciation. It is curious to observe how much more ea- sily the body wastes under a disease of some organs than of others ; and it would be a sub- ject of no small moment to inquire into the cuuse of this, and to draw up a scale of organs effecting this change, from the lowest to the highest degree. Dr. Pemberton, in a work of considerable merit, published many years ago, threw out some valuable hints upon this subject, which it is to be lamented that he did not after- ward follow up to a fuller extent. The follow- ing passage is well worthy of notice, and aptly illustrative of what is here intended. " Let us take," says he, " the two cases of a diseased state of the mesenteric glands, and a diseased or scrofulous affection of the breast. In the former, we shall find there is a great emacia- tion ; in the latter, none at all. In an ulcera- tion of the small intestines, great emaciation takes place: in scirrhus of the rectum, none. In a disease of the gall-bladder, which is sub- servient to the liver, the bulk of the body is diminished; but in a disease of the urinary blad- der, which is subservient to the kidneys, scarce- ly any diminution of bulk is to be perceived. In an abscess of the liver, the body becomes much emaciated; but in an abscess of the kidneys, the bulk is not diminished. "If we examine into the function of those parts, the diseases of which do or do not occa- sion emaciation, we may perhaps be led to the true cause of this difference of their effect on the bulk. In order, however, to understand more clearly how the functions of these parts bear relation to each other, it may be necessary to premise, that the glands of the body are divi- ded into those which secrete a fluid from the blood for the use of the system, and those which secrete a fluid to be discharged from it. The former may be termed glands of supply ; the latter, glands of waste. " The smaller intestines, in consideration of the great number of absorbents with which they are provided for the repair of the system, may be considered as performing the office of glands of supply. The large intestines, on the con- trary, may be considered as performing the of- fice of glands of waste ; insomuch as they are furnished very scantily with absorbents, and abundantly with a set of glands which secrete or withdraw from the system a fluid which serves to lubricate the canal for the passage of the feces, and which itself, together with the feces, ia destined to be discharged from the sys- tem. The glands which secrete a fluid to be employed in the system, as well as the glands of direct supply, may be considered the liver, the pancreas, the mesenteric glands, perhaps the stomach, and the small intestines ; and the glands of waste are the kidneys, breasts, exha- lant arteries, and the larger intestines." The first set are, in fact, the general assemblage of the chylific organs ; and it is upon their di- rect or indirect inability to carry into execution their proper function, that the first of the species we are now about to enter upon, that of atro- 16 H^EM phy, is founded in all its varieties. How far these remarks will apply to the other species of the present genus is not quite so clear. The seat of the third and fourth may be doubtful, perhaps variable ; that of phthisis, or the fifth, admits of no debate. Are the lungs to be re- garded as an organ of waste or of supply ■? The question may be answered in opposite ways, ac- cording to the hypothesis adopted respecting the doctrine of respiration. They throw off car- bonic acid gas. Do they introduce oxygen or any other vital gas into the circulating system 1 As an organ of waste, we cannot, upon the prin- ciple here laid down, account for the emaciation which flows from a diseased condition of them. If it can be substantiated that they are an organ of supply, they confirm and extend the princi- ple. Will this principle, moreover, apply in dropsy, in which there is even more emaciation than in phthisis 1 The subject is worth enu- cleating; but we have not space for it, and must proceed to arrange the five species that apper- tain to the genus before us :— 1. Marasmus Atrophia. Atrophy. 2.--------Anhaemia. Exsanguinity. 3.--------Climactericus. Decay of Nature. 4.--------Tabes. Decline. 5.--------Phthisis. Consumption. Most of these follow in regular order, as ge- nera or species in most of the nosological ar- rangements, and are set down as subdivisions of macies or marasmus. By Dr. Cullen, phthi- sis is regarded as a mere sequel of haemoptysis, upon which we shall have to observe in its proper place ; while atrophia and tabes are given as distinct diseases under the ordinary head, only that for macies or marasmus he employs marcores as an ordinal term. The common dis- tinguishing marks are, that atrophy is emaciation without hectic fever; tabes, emaciation with hectic fever; and phthisis, emaciation and hec- tic fever coupled with pulmonary disease. And such, with the exception of phthisis, is the dis- tinction continued by Dr. Cullen in his Synop- sis. But, in his Practice of Physic, he informs us that his views upon this subject had under- gone a change, not only in respect to the sub- divisions or varieties of these two diseases, but as to the diseases themselves. " I doubt," says he, " if ever the distinction of tabes and atro- phia, attempted in the Nosology, will properly ap- ply ; as I think there are certain diseases of the same nature, which sometimes appear with and sometimes without fever."—(Vol. iv., part iii., book i., sect. 1618.) This is written in the spirit of candour that so peculiarly characterizes this great man. But I cannot thus readily con- sent to relinquish a distinction which has re- ceived the sanction of so many observant pa- thologists, and which appears to me to have a sufficient foundation. It is difficult, undoubt- edly, to assign a proper place to all the varieties or subdivisions of these species; but this is a difficulty common to many ^frher diseases equal- ly ; for we perceive fevers, nervous affections, and. those of the digestive organs perpetually running into each other in different varieties, yet ATICA. [Cl. IH.-Ord. IV. we find it convenient to arrange and describe them as distinct diseases. And, with the cau- tion attempted to be exercised in respect to the species before us, I trust that the reader will not discern a greater transgression of boundary in the present, than in various other cases of general allowance. SPECIES I. MARASMUS ATROPHIA. ATROPHY. complexion pale, often squalid ; SKIN DRY AND WRINKLED ; MUSCLES SHRUNK AND IN- ELASTIC ; LITTLE OR NO FEVER. The specific is a Greek term deduced from a privative, and rpfyw, "nutrio," and is literally, therefore, innutrition ; a designation peculiarly significant, as the disease, in all its forms or varieties, seems to be dependant on a defect in the quantity, quality, or application of the nu- trient part of the blood ; and thus lays a found- ation for the three following varieties :— a Inopiae. Blood innutritious from scar- Atrophy of want, city or pravity of food. B Profusionis. Blood deprived of nutrition Atrophy of waste, by profuse evacuations. y Debilitatis. Nutrition not sufficiently in- Atrophy of de- troduced into the blood by bihty. the chylific organs, or not sufficiently separated from it by the assimilating. In order that the body should maintain its proper strength and plumpness, it is necessary that the digestive organs should be supplied with a proportion of food adequate to the per- petual wear of its respective parts: for this wear, as we all know, produces a waste ; and hence the emaciation sustained by those who suffer from famine, in which there is no food in- troduced into the stomach, or from a meager or unwholesome diet, in which the quantity intro- duced is below the ordinary demand. It is this condition that forms the first of the subdivisions or varieties, the atrophy of want, under which the species before us is contemplated in the present arrangement. But the ordinary demand may not be sufficient for the body, or some part of it maybe in a state of inordinate wear and waste, as in very se- vere and protracted labour, in which the supply is rapidly carried off by profuse perspiration, or in rupturing or puncturing a large artery, in which the same effect is produced by a profuse hemorrhage. Any other extreme or chronic evacuation may prove equally mischievous, as an excessive secretion from the bowels, from the vagina, from the salivary glands, from the breasts ; as where a delicate wet-nurse suckles two strong infants. And hence the origin of the second of the above varieties, or the atro- phy of WASTE. Now, in all these cases, wherever the sys- tem is in possession of an ordinary portion of health, there is a strong effort made by the di- gestive powers to recruit the excessive expen- vitca. Gen. III.—Spe. 1.] MARASMUS ATROPHIA. 17 diture by an additional elaboration of nutriment; and the instinctive effort runs through the en- tire chain of action to the utmost reach of the assimilating powers, or those secernents with which every organ is furnished, to supply itself with a succession of like matter from the com- mon pabulum of the blood. Hence, the stom- ach is always in a state of hunger, as in the ease of famine, profuse loss of blood, or recov- ery from fever; all the chylific organs secrete an unusual quantity of resolvent juices, an al- most incredible quantity of food is demanded, and is chymified, chylified, and absorbed almost as soon as it enters the stomach ; the heart beats quicker, the circulation is increased, and the new and unripe blood is hurried forward to the lungs, which more rapidly expand them- selves for the purpose, to be completed by the process of ventilation: in which state it is as rapidly laid hold of by the assimilating powers of every organ it seems to fly to, and almost in- stantly converted into its own substance. Such is the wonderful sympathy that pervades the en- tire frame; and that runs more particularly through that extensive chain of action which commences with the digestive and reaches to the assimilating organs, constituting its two ex- tremities. So long as the surplus of supply is equal to the surplus of expenditure, no perceptible degree of waste ensues ; but the greater the demand the greater the labour, and the turmoil is too violent to be long persevered in. The excited organs must have rest, or their action will by degrees become feeble and inefficient. And if this take place while the waste is still continu- ing, emaciation will be a necessary consequence, even ia the midst of the greatest abundance ; and hence, an explanation of the variety of emaciation before us, constituting the second. Thus far we have contemplated the animal frame in a firm and healthy constitution: and have supposed a general harmony of action per- vading every link of the extensive chain of nu- trition, from the digestive organs to the assim- ilating powers. But we do not always find it in this condition; and occasionally perceive, or think we perceive, that this necessary harmony is intercepted in some part or other of its ten- our : that the digestive powers, or some of them, do not perform their trust as they should do, or, that the assimilating powers, or some of them, exhibit a like default; or, that the blood is not sufficiently elaborated in its course, or becomes loaded with some peculiar acrimony. And hence another cause, or rather an assemblage of other causes, competent to the disease be- fore us. It is from the one or the other of these sour- ces that we are in most, perhaps in all cases, to derive the third modification of this disease, which is here distinguished, for want of a better term, by that of atrophy of debility. The disease under this form is often very complex, and it is difficult to trace out what link in the great chain of action has first given way. Most probably, indeed, it is sometimes one link, and isometimes another. But, from the sympathy Vol. II.—B which so strikingly pervades the whole, we see at once how easy it is for unsoundness in one quarter to extend its influence to another, till the disease becomes general to the system. Yet I am much disposed to think that the atro- phy so conspicuous in feeble habits, and the feeblest periods of life, as infancy and old age, commences most usually at the one or the other end of the chain, and immediately operates by sympathy on its opposite. This remark is in consonance with a very common law of life, by which impressions are more powerfully and more readily communicated from one extreme of an organ to another, than they are to any of the intermediate points. It is hence the will oper- ates instantly on the fingers, the stomach on the capillaries of the skin ; and that the irrita- tion produced by a stone in the bladder is felt chiefly in the glans penis. And hence the close correspondence which we have already seen to prevail between these two extremities of the nutritive function in the case of want and hunger. Where atrophy is connected with a morbid state of the digestive organs, we have a little light thrown on the nature of the disease, but not much. For first, indigestion does not ne- cessarily produce this effect, since it is no un- common thing for dyspeptic patients to become plethoric, and gain, instead of lose, in bulk of body. And next, the morbid state of these or- gans may be a secondary, instead of a primary affection, and be dependant upon a general heb- etude, or some other unsound condition of the assimilating powers, constituting the other end of the chain ; and hence exercising a strong- er sympathy over them than over any interme- diate organs whatever : as the digestive organs themselves, if the disease should have originated in them, may exercise a like sympathy over the assimilating, powers, and hence produce that general extenuation which, as we have just ob- served, is not a necessary consequence of dys- pepsy. It is at least put, I think, beyond a doubt, that more than one set of organs are connected in the atrophy of debility. Where this atrophy takes place in infants at the breast, or young children, it is ushered in by a flaccidity of the flesh, a paleness of the countenance, sometimes alternating with flushes, bloated prominence of the belly, irregularity of the bowels, pendulousness of the lower limbs, general sluggishness and debility, and, where walking has been acquired, a disinclination to motion, with fretfulness in the day, and rest- lessness at night. There is at first no perceptible fever, no cough, nor difficulty of breathing : but if the disease continue, all these will appear as the result of general irritation, and the skin will become dry and heated, and be covered over with ecthyma, impetigo, or some other squalid eruption. The breath is generally offensive ; the urine varies in colour and quantity; and, in infants at the breast, the stools are often ash-coloured or lien- teric, or greenish, loose, and griping. The appe- tite varies ; in some cases it fails, in others it is insatiable. 18 H^EMATICA. [Cl.HI.—Ord. IV. Where these symptoms or the greater part of them occur to an infant at the breast, it becomes us, in the first place, to be particularly atten- tive to the manner in which it has been nursed, in respect to cleanliness, purity of air, warmth, and exercise ; we have next to turn our atten- tion to the nurse's milk ; and afterward to an examination whether the infant is breeding teeth, or has worms, or there be any scrofulous taint in the blood. For the last we have no immedi- ate remedy ; the rest we must correct as we find occasion. And if we have no reason to be satisfied upon any of these points, it may still be advisable to change the milk. It is not easy to de- tect all the peculiarities of milk that may render it incapable of affording full nutrition : and there is reason to believe, that one infant may pine away on what proves a healthy breast to another. I have given this advice in some dilemmas, and have often found a wonderful improvement on its being followed. In children on their feet, who are confined to the filth and suffocating air of a narrow cell, the common habitation of a crowded family from Sunday morning to Saturday night; or who are pressed into the service of a large manufactory, and have learned to become a part of its machi- nery before they have learned their mother- tongue ; there is no difficulty in accounting for the atrophy that so often prevails among them. The appetite does not here so much fail as the general strength ; their meals are, perhaps, doled out at the allotted hours by weight and measure : but still they are falling victims to emaciation ; and are affording proof, that air and exercise are of as much importance as food itself; that there are other organs than those of digestion, upon which the emaciation must de- pend : and that, unless the supply furnished by the food to the bloodvessels be sufficiently oxy- genized by ventilation, and coagulated by exer- cise, the blood itself, however pure from all in- cidental defect or hereditary taint, will never stimulate the secernents of the various organs to which it travels to a proper separation of its constituent principles, and a conversion to their own substance. In all these cases, therefore, the proximate cause seems to be lodged principally in the as- similating powers of the system ; and whenever the digestive organs grow infirm also, it is rather by sympathy with the former than by any pri- mary affection of their own. There is a singular case of atrophy quoted by Sauvages, to which he has given the name of lateralis, and which unquestionably belongs to this variety. It occurred in a young child, and took possession of just one half the body ; the left side, from the axilla to the heel, being so completely wasted, that the bones seemed only to be covered with skin, while the right side was fat. Under the influence of topical anti- spasmodics, and sudorifics continued for seven years, the writer of the account tells us that he began to get better—" melius habere caepit."— (Nos. Med., cl. x., ord. i.; Ex. Collect. Acad., torn, iii., p. 693.) In. the atrophy of debility, common to old age, the cellular membrane, that is, the part contain- ing, as well as the parts contained, seems rather to shrivel away, in many cases to be carried away, by absorption, and the muscular fibres to become dried up and rigid, rather than loose and flabby. In this case, the assimilating pow- ers seem to have done their duty to the last, and, like an empty stomach when loaded with gastric juice in a moment of sudden death, to have preyed upon and devoured themselves: since it is probable, that nearly all the animal oil, and more than half the bulk of the muscles and of the parenchyma of many of the organs, is carried off in the same manner ; for, that all these are capable of being converted into a like sub- stance is clear, since all of them are transform- able into adipocire by a chymical action after death, and into a steatomatous material by a morbid action of the living power, while every other organ continues in good health ; and there are many facts that lead to the conclusion that all, under the circumstances before us, are ca- pable of yielding a common substitute for the natural food of the system. Here, therefore, we are to look for the proximate cause of the disease towards the other end of the chain, or among the chylific viscera. And we shall not in general look in vain. Not, indeed, that we shall always, or even commonly, find it in the stomach or in the liver, for the appetite may not fail, though its demand is but small and is ea- sily satisfied; and it probably digests what is introduced into it. Yet here the greater part of the food rests ; or rather, most of it passes through the intestines, and very little goes into the lacteals ; insomuch that many of our most celebrated anatomists have thought, as I have had occasion to observe (vol. i.,. p. 228, Para- bysmaMesentericum), that the mesenteric glands of old people become obliterated ; while Ruyscb contended, that mankind pass the latter part of their lives without lacteals, and that he himself was doing so at the time of writing. The mode of treatment needs not detain us. Where the disease depends upon a want of wholesome food, or of food of any kind, the cure is obvious : where upon profuse evacuations, it falls within the precincts of some other disease, and is to be governed by its remedies. And where the cause is an infirm condition of any part of the chain of nutritive functions, from the chylific to the assimilating organs, the same tonic course of medicine that may be advisable in the one case, will be equally advisable in the other. The bowels should be kept in a state of regularity ; mercurial alterants may sometimes be required, though less frequently than under one or two varieties of tabes ; the different preparations of iodine will often exercise a healthful stimulus, and prove the deobstruent that is stood in need of; the bitters and astrin- gents enumerated under dyspepsy may also be had recourse to, according to the peculiarity of the case ; and cleanliness, fresh air, exercise and cold-bathing will complete the rest. The atrophy of old age is to be met by the richest foods, wine, and the warmth of another persoa sleeping in the same bed. Gen. Ill—Spe. 2] MARASMUS ANHAEMIA. 19 SPECIES II. MARASMUS ANHAEMIA. EXSANGUINITY. FACE, LIPS, AND GENERAL SURFACE GHASTLY PALE ; PULSE QUICK AND FEEBLE ; APPETITE IMPAIRED ; ALVINE EVACUATIONS IRREGULAR, BLACK, AND FETID, OCCASIONALLY WITH SE- VERE GRIPINGSJ LANGUOR AND EMACIATION EXTREME. The specific name for this disease is some- times written anaemia, but incorrectly ; for the aspirate ought to be retained, and is so, indeed, in common usage, as in anhcemous, vulnerary or styptic, from the same root; enharmonic; er- rhine; cachexy; amphemera; anthelmintic. The most striking peculiarity of the affection is, that the bloodlessness of the exterior precisely cor- responds with that of the interior ; since dissec- tions show that the largest and deepest vessels are nearly as destitute of blood as those on the surface.* It is in this ghastly pallor of the whole exterior, as directly expressive of the same condition within, that this disease chiefly differs from the atrophy of want, of waste, and of debility, which constitute the different modi- fications of the preceding species. The disease itself ha6 often been referred to, and at times described by the old writers, as Becher (Dins. Resoluito casus practici Anosmia, Sanguinis miros fructus reprcesentantis, Leid., 1663), Albert {Diss. De Ana-mid, Hall., 1732), and Janson (Diss. De Morbis ex Defeclu Liquidi vitalis, Lugd. Bat., 1748); and still more lately by Hoffman, De Haen, and Isenflamm. Sever- al of their cases, however, are confounded with the different forms of the preceding species, and consist of nothing more than an exhausted state of the bloodvessels, from hemorrhage or other profuse evacuations, in one case, indeed, from hemorrhoids.—(Robin, Journ. de Medecine, torn. xxxii., p. 48.) And hence Lieutaud and Isen- flamm undertook, in the middle of the last cen- tury, to distinguish the real disease from those which were thus confounded with it; tracing out the separate causes and symptoms, and marking them by different names; as anamia chlorosis, and anosmia consecutiva, which were the appellations of Lieutaud (Precis de la Mide- cine Pratique, 1761) ; and a. vera, and a. spuria, which were those of Isenflamm. These dis- tinctions, however, seem to have made less im- pression on the world of medicine than they ought to have done : for we find M. de Sauvages, in the first edition of his Nosologia Methodica, published subsequently to Lieutaud's Summary, * The blood may be so diminished in quantity, that it seems, during life, to forsake the surface, which is only pervaded (to use Andral's expres- sion) by a kind of serosity; and, after death, no blood is found, not only in the arterial trunks, great veins, and right cavities of the heart, but in the several capillary networks, all of which seem remarkably pale. In this state, completely desti- tute of blood, are found all the membranous and parenchymatous tissues, as the brain, the lungs, the liver, the kidneys, the alimentary canal, and the texture of the heart and muscles.—See Andral, Anat. Pathol., torn- i.,p. 80.—Ed, following Strach and Ramazzini in describing anaemia, if, indeed, he has described it at all, as a modification of spurious chlorosis, or pallor, under the name of chlorosis rhachialgica.— (Nos. Med.,c\.x.; Cachexia, ord. vi.; Icleritia, gen. xxxv.; Ramazzini De Morbis Artific., cl. i., ii.) Of late years, however, something more of light and far more of eorrect description have been thrown upon this very extraordinary mala- dy by the contributions of several writers, and particularly of Professor Halle, of Paris, and Dr. Combe, of Edinburgh.* Nothing can be more different than the occupations, habits, and modes of life, of two distinct classes of in- dividuals, who are hereby brought forward as the subjects of anhaemia. And yet the close resemblance, and, allowance being made for in- cidental circumstances, we may say the identity of the symptoms exhibited in situations so per- fectly unlike, furnish an adequate proof of an identity of disease, t The most strictly idiopathic example, and the one most free from influential incidents, is that of Dr. Combe.—(Case of Anaemia; Transact. of Med. Chir. Soc. of Edin., vol. i., p. 194.) The patient was forty-seven years of age, was born in the country, and for the most part had been occupied in agricultural employments : he was married, but without a family ; was leading a regular and temperate life; had enjoyed per- fect health ever since childhood, and had never been blooded. At the time of his applying to Dr. Combe for advice, he had been unwell for about two months, or something more ; his chief complaint having been loss of strength, uneasi- ness in the head, and a sickly complexion. " I was much struck," says Dr. Combe, " by his peculiar appearance. He exactly resembled a person just recovering from an attack of syncope. His face, lips, and the whole extent of the sur- face, were of a deadly pale colour : the albu- ginea of his eye bluish . his motions and speech were languid : he complained much of weak- ness ; his respiration, free when at rest, became * Professor Samuel Jackson, of Philadelphia, considers anhaemia under four divisions : complete and incomplete ; general and local or partial; un- der each division he has made some very pertinent remarks :—When anhaemia becomes a complica- tion superadded to other affections, an epipheno menon, as it was formerly expressed, the treat- ment of the original disease must be modified by this circumstance.—See Hays's Cyclop, of Med., art. Anemia.—D. t A general anhaemia may come on without any discoverable cause. Andral noticed its existence in the bodies of several individuals who died drop- sical, and in whom no alteration whatever of the solids Could be traced.—(Clinique Med., torn, iii., p. 558, et suiv.) The restriction to a diet not suf- ficiently nutritious, the habitual respiration of im- pure, damp air, deprived of the sun's influence, and which prevents the elaborating functions of the skin and lungs from being duly performed, a dis* ease that affects the direct or indirect organs of haematosis, are the circumstances adverted to by Andral as capable of producing a more or less complete general anhaemia.—See Anat. PathoL, torn, i., p. 81.—Ed. 20 H^MATICA. [Cl. HI.-Ord. IV. hurried on the slightest exertion : pulse eighty, and feeble : tongue covered with a dry fur; the inner part of the lips and fauces nearly as colour- less as the surface." His bowels were very ir- regular, though generally relaxed: the stools very dark and fetid; urine copious and pale : appetite impaired, and latterly a rejection of al- most every kind of food ; constant thirst; no pain referable to any part, nor any determinable derangement of structure. These symptoms continued with little varia- tion for about three months, with the exception that, for a short time, he appeared to be impro- ving. Yet, upon the whole, the disorder gained ground ; the feeble pulse was easily excited ; a copious perspiration followed any exertion ; the veins on the arms and neek could be felt on making pressure, but the colour of the blood did not appear through the skin. At one time, an affection of the liver was suspected ; at another, from the thirst and great flow of urine, paruria mellita; but none of these indications were sta- tionary. Tonics- did no service, nor a sea-voy- age, which was tried, nor the use of a chalyb- eate spring. He grew gradually weaker, con- tinued to lose flesh ; but, with a strong resem- blance to the delusive confidence of phthisis, his spirits remained for the most part undepres- sed, and he still looked forward to a speedy re- covery. Meanwhile all the symptoms were de- teriorating, and the constitution was evidently sinking under their pressure. In about six months from the period of his application for re- lief, the oedema extended over his face and up- per extremities, evident marks presented them- selves of effusion into the chest, and he died with all the symptoms of hydrothorax. The body was examined thirty-six hours after death. The waxy pallor of the surface remain- ed unchanged : the subcutaneous fat was scanty, of a pale yellow, and semi-fluid. Not a drop of blood escaped on dividing the scalp: the dura mater was pale, presented few vessels, and those empty. The pia mater was equally pale, ks bloodvessels contained a pale serum and a considerable quantity of air. The lateral sinuses were moderately filled with a pale fluid blood ; the arteries at the basis were empty. The sub- stance of the brain was very soft and pultace- ous, mapped with very few vessels. The lungs were of a pale gray, without any marks of grav- itated blood. The heart, when cut into, was of a pale colour, and did not tinge the linen when rubbed upon it; it appeared like flesh macerated many days in water. The right ventricle contained a pale coaguhim. The left side was wholly empty. The coronary arteries were sound. The inner coat of the aorta was of a fine red colour for some inches, without any turgescence or ossification. All the valves were sound. A considerable moisture bedewed the viscera of the abdomen. The liver was of its proper size and structure, but of a light brown colour ; there was no exudation of blood on cutting into its substance. The spleen was the only viscus of its usual colour : it was very soft, and its contents, when pressed, turned out as from a sac. The kidneys were nearly blood- less : the pancreas of a pale reddish hue. The stomach and intestines were perfectly sound, thin, showing no vessels, and transparent. The muscular substance throughout the body was, like that of the heart, very pale, and exuded no blood, but only a pale serum when cut into. The arteries were universally empty, as were also the jugular, humeral, and femoral veins. The lower cava alone, about the bifurcation, with the exception of the lateral sinuses, con- tained any appreciable quantity of blood. Besides these appearances, about three pounds of a lemon-coloured serum was found effused in the thorax, and a considerable ossification, about an inch long, rough and irregular, was traced imbedded in the plicae of the dura mater near the vertex, being almost the only morbid deviations, with the exception of those that re- late to the sanguineous system ; the first of which Dr. Combe justly regards as a mere con- sequence of the disease ; while he thinks it may admit of a doubt whether the second had any connexion with the bloodless state of the sys- tem. In truth, it seems to have been an inci- dental concomitant. It is impossible to coneeive a more total ex- haustion of the vital fluid from the entire sys- tem, than this singular case presents to us ; and instead of wondering at the deadly waxiness of the complexion, the feebleness of the pulse, the utter debility and emaciation which this in- carnate ghost must have presented, the greater and almost the only wonder is, how the living principle could so long have remained attached to so exhausted a receiver, and the sensorial power have derived its means of recruit; at a time, too, when all the functions, in the midst of their feebleness, were urged on by the force of the morbid excitement to the performance of double duty: the pulse was quickened; the animal spirits were maintained above the standard of sober health; the peristaltic action, though ir- regular, for the most part accelerated, the per- spiration redundant, and the urine often profuse. The post-obit examination, while it unveils little or nothing of the proximate cause of the disease, discloses to us most manifestly the in- road that had been made upon the general sub- stance of the frame for the want of a due sup- ply of nourishment, and how completely every organ had been living upon itself, and the whole had been living upon the remnant of the blood almost to its last drop. The fault does not, therefore, so much seem to have been in the secernent system, or assimilating powers, as in the lacteals, or digestive function : in the com- mencement, rather than in the termination of the chain. It was the opinion of Ruysch, as we have late- ly had occasion to observe, that this commen- cing part of the catenated organ of supply gradu- ally loses its power with the advance of years, and that, in old age, it entirely ceases to act: so that being himself, at the time of writing, in this very season of life, he conceived he was then living, and had been living for a long period, upon himself: upon such nourishment as the .fat, blood, flesh, parenchyma, and even brain, Gen. III.—Spe. 2.] MARASMUS ANHAEMIA. 21 can produce when melted down by the action ©f the absorljents. And he further conceived that, from the little wear and tear which usually takes place in old age, the flame of life might be kept burning for a considerable term by the fuel hereby supplied ; the growing emaciation being a pretty correct measure of the material consumed. How far such may have been the fact with Ruysch himself, or with any other person in the ordinary advance of life, we need not at pres- ent examine: but something very like it ap- pears to have occurred in the extraordinary malady before us. We have seen that the di- gestive function was habitually impaired, and that at length food of all kinds was rejected from the stomach ; and we shall find by other in- ' stances presently, that the stomach, under the ' influence of this disease, seems to be always, even at the best estate, capricious or fastidious.* : But the lacteals seem to have participated in ; the same infirmity ; and to have laboured under an atony or paresis so considerable, though in- visible to the eye of the anatomist, as to have transmitted whatever aliment might have been subacted very imperfectly, or not at all, into the course of the circulation. And hence, while the blood actually in existence was perpetually drained off in support of the different organs and their respective functions, a small quantity only of an unelaborated fluid was able to reach the heart and larger arteries, which were, in consequence,- pale and empty, or only partially supplied with a thin, watery, and scarcely tin- ged liquid. And, in confirmation of this idea, we shall find in the sequel of our examination, that the mesentery, in various instances, gives proof of disturbance, and appears enlarged, even to an external examination, while the hypochon- ; dria are free from such affection. Such then seems to have been the proximate cause, though undeveloped by dissection, if we may be allowed to hazard a conjecture upon a subject involved in so much obscurity. Yet the exciting cause seems still more effectually to elude our penetration : for the constitution of the individual seems to have been strong and hearty, and every thing in his situation, occupa- tion, and habits of life, apparently concurred in promising him a long continuance of health. In various cases of the disease, however, that; have occurred, we have some degree of insight into the occasional, as well as into the proxi- mate cause. And I now particularly allude to the endemic appearance of this complaint at Auzain near Valenciennes, as described by Pro- fessor Halle. + * After speaking of the effects of a scanty quan- tity of blood in the system, upon the nervous sys- tem, respiratory organs, &c, Andral observes, that digestion is likewise disturbed, because, after the stomach has received food, the regular per- formance of that important function requires that the stomach shall become the seat of sanguineous congestion, which, in persons labouring under anhaemia, cannot take place.—See Anat. Pathol., torn. i.,p. 82.—Ed. t Journ. de Medecine, Chirurg. Pharm., &c. Par MM. Corvisarl, Leroux, et Boyer.tom. ix.,p. At Auzain is a large coal-mine, reaching to two or three adjoining villages. It was in one of the galleries of this mine that the complaint made its appearance, and to this it was confined, though no difference had hitherto been detected between the contaminated gallery and the rest. It is of the same depth, being a hundred and twenty fathoms from the level ground, and ex- cavated in the same manner, but is longer, and hence does not so readily admit of an efflux of pure air. Its temperature is 64° Fahrenheit: it exhales an odour of sulphuretted hydrogen gas, which renders respiration difficult Some caustic mineral, perhaps some metallic salt, ap- pears to be dissolved in the water that drips from the mine, as it produces blains or blisters on any part of the body to which it is applied. Yet the water has been occasionally drunk to allay thirst, and the mine had been worked for eleven years without any such complaint as that before us : and it is hence obvious, that some new combination of vapour, incapable of detec- tion by the senses, had found vent into the at- mosphere of the gallery; or some new mineral substance had become dissolved in its percola- ting water, which had a direct power of loosen- ing and destroying the tone of the restorative system, at the commencement of its chain. The symptoms, in their general features, were strikingly similar to those we have just described; and seem only to have been modi- fied by the ^peculiarity of the exciting cause, being often, though by no means always, ac- companied from the first with severe gripings, and more violent affection of the abdominal vis- cera, and hence more rapid in their progress. Dr. Combe is inclined to think from these symptoms, that this disease was not a strict idiopathic anhaemia, but a modification of rha- chialgia, the colic of lead or arsenic, and that it is hence more nearly allied to the chlorosis rhachialgica of Sauvages, than to the anhamia chlorosis of Lieutaud. But in no instance do I find the back-bone ache, or spine-ache, from which rhachialgia derives its name, and by which, together with an extension of this aching over the upper and sometimes the lower ex- tremities, with a strong tendency to paralysis, it is specifically distinguished. Neither indeed is the colicky pain itself to be regarded as a pathognomonic sign, or necessary attendant: for of the four patients who were sent for ex- amination and treatment from Auzain to Paris, while two suffered from it, the other two were without any such symptom. Nor did the treat- ment usually found most serviceable in rha- chialgia, prove of much, if indeed of any, benefit in the anhaemia of Auzain; so that the medical superintendents, who had at first em- braced this idea, found themselves obliged to abandon such a course, and the view of the disease on which it was founded, and to regard it as a direct exemplification of idiopathic an- haemia. At the time of opening their correspondence 3, Paris, An xiii.—See a translation of this in the Edin. Journ., vol. iii., p. 170. 22 H^W with the School of Medicine at Paris, fifty Eatients, all belonging to the same gallery, had een attacked with the disorder, three of whom had died, and the number of patients was almost daily increasing, notwithstanding that the gallery was at this time shut up. Some of the sufferers had been ill for fifteen, others for twelve, others for eight months : and many were recent cases. It was obvious, however, that those were the most unfortunate subjects, and exhibited the highest degree of severity, who had .been at- tacked while actually employed in the gallery : while those who did not complain till it was closed, passed through it, not indeed with speed, but in a more favourable way. So that the disorder seemed capable of being divided into two distinct states or varieties, an acute and a chronic. The general symptoms under the former, in- dependently of those of colic, were pallor of skin, great emaciation, weak, feeble, quick, contracted pulse palpitations of the heart, anhelation, extreme debility, so as to render walking difficult; bloated countenance, habitual perspiration, especially at night ; stools black or greenish. These symptoms often continued without much change for many months, some- times for upwards of a year ; when they were united, manifestly from augmented weakness, with headache, frequent faintings, intolerance of light and sound. Where colic was an accompaniment, there was much griping pain in the stomach and in- testines, inflation of the abdomen, and at times, towards the close, purulent stools. Four patients were selected out of the aggre- gate body to be sent to the School of Medicine at Paris for examination and advice. They were all young ; their ages being from sixteen to twenty-one.- one of them had worked in the mine for six years, the others for ten or eleven ; and as they had all been ill for nearly a twelve- month, it is obvious that they had been attacked while labouring in the gallery ; and were hence regarded as having received the complaint in its acute state. We have already observed, that, of these four, two had experienced colicky pains from the first, and two had not been troubled with them. The pulse varied from seventy to a hundred and four strokes in a minute, but the stroke was extremely feeble and scarcely per- ceptible ; the least excitement, moreover, would accelerate it almost beyond the power of counting. The stomach appears to have been generally capricious ; they could relish food if allowed to exercise a choice; but one of them was subject to frequent vomiting; and in all the digestion was manifestly imperfect, as the food was par- tially discharged with little change, intermixed with black or greenish feces. The mesentery, as we have already observed, seemed consider- ably enlarged to the touch, but was destitute of pain on pressure: nor did the enlargement extend to any other region. So extreme was the weakness, that none of these patients were able to walk more than a [Cl. Ill— Okd, IV. few steps without palpitation of the heart, and being compelled to sit down, and especially on mounting a staircase. Yet the same delusive hope, the same eparsis, or mental elation, that often accompanies consumption, and appeared, as we have already observed, in Dr. Combe s patient, was generally conspicuous in the cases before us. Even the death of one of them did not seem to destroy this enviable feeling. " We were afraid," says Professor Halle, " lest the melancholy fate of the first patient should have had an influence on the minds of his com- panions ; but we had here no difficulty to en- counter. The hope that the opening of his body would put us upon a more successful mode of treatment predominated in their minds, with- out taking away their regret for his loss." It is thus that we sometimes meet with a few cordial drops intermixed with the bitterest cup of suffering, and enabling the patient to support his trial, not only with composure, but with an elevated spirit. The individual who thus fell a sacrifice, seems to have been attacked with more than ordinary severity at the very onset of the dis- ease : and was one of those who had to con- tend with the pains of colic in addition to the specific symptoms. Mercurial inunction was early tried, but abandoned in a few days, from its being found to augment the pulse and in- crease the tendency to fever. When he reached Paris he had been ill for eleven months, having previously been employed in the mine for a period of eight years. He at length gave mani- fest proofs of hectic fever, the remissions of which became gradually shorter, till at length the fever assumed a continued type. But, though the skin was burning hot, it did not lose its paleness, nor was the slightest blush dis- cernible on the tongue, the lips, or the con- junctiva : a remark which is indeed equally applicable to all the rest. He seems to have sunk under the pressure of debility alone ; his most prominent symptoms at last being those of great difficulty of breathing, a feeble and in- termitting pulse, and cold extremities. The appearances on dissection were, as nearly as may be, those of Dr. Combe's patient, as we have already described them. The parenchymatous viscera were all pale, diminishr ed, and shrivelled, with the exception of the heart, which preserved its natural size. Even the spleen, which, in the preceding case, re^ tained its proper colour, and does not seem to have had its siz.e much interfered with, was here of a reduced magnitude, and of the same spongy softness which the preceding case dis- closed. The almost utter bloodlessness of all the ves- sels, however, formed the predominant feature. " In the three cavities all the vessels, as well arteries as veins, were destitute of coloured blood, and contained only a small quantity of serous fluid. No blood was found in the aorta as far as its crural subdivisions, nor in the accompanying veins, nor in the system of the hepatic vessels, nor in any of the sinuses of the brain. Upon making a deep incision into the ATICA. Gen. HI.—Spe. 3.] MARASMUS CLIMACTERICUS. 23 flesh of the thighs, a small quantity of liquid and black blood flowed out; but none issued from a cut in any other part whatever. The flesh of the muscles which cover the thorax was exceedingly red, but that of the extremities much less so. And we are told that the same destitution of blood which distinguished this case, occurred also in all the other dissections that were made at any time ; so that the want of colour in the interior precisely corresponded with that of the surface, and of the whole capil- lary system. " This condition, therefore," ob- serves M. Halle, "maybe regarded as peculiarly dependant on the disease ; as exhibiting itself by manifest signs during its entire progress; and as reaching its height when it is on the point of terminating, and has reached its last stage." From the extensive spread of the malady, there was a pretty ample opportunity of putting various plans of treatment to an effective test; and the opportunity was not neglected. Mercury, as we have already observed, did not seem to answer. Two cases recovered under its use; but, in general, it produced febrile excitement, and hence no credit was given to it even in the instances of restoration. Emetics, sudorifics, acids, sedatives, tonics, and stimulants were all tried simultaneously, or in succession. But by far the most successful, as, indeed, the most rational plan, and that most corresponding with the nature of the proximate cause we have endeavoured to illustrate, con- sisted in a combined employment of the two last of these classes, stimulant and tonic medi- cines, with a free use of opium where the tor- mina required it, and the employment of gentle laxatives on the return of constipation. The best stimulants appear to have been camphire and ether; the best tonics, bark and iron.* While this plan was continued the patients generally improved in strength, lost their pal- pitation on walking, and evinced a slight return of colour ; and in every instance in which this process was discontinued at too early a period, they appear to have relapsed ; and only to have renewed their advantage upon a return to the same treatment. The diet was generous and nutritious, and altogether harmonized with the pharmaceutic intention. SPECIES III. MARASMUS CLIMACTERICUS. DECAY OF NATURE. CLIMACTERIC DISEASE. GENERAL DECLINE OF BULK AND STRENGTH, WITH OCCASIONAL RENOVATION, AT THE AGE OF SENESCENCE, WITHOUT ANY MANIFEST CAUSE. For the groundwork of this species of ma- rasmus, I am entirely indebted to Sir Henry Halford's elegant and perspicuous description of * The subcarbonate, in doses of one or two drachms, three times a day. In the anhaemia con- nected with enlarged spleen, preparations of iron are extremely beneficial. This fact is mentioned by Tomassini, in his Clinical Reports.—Ed. it in the Medical Transactions. The disease has hitherto never appeared in any nosological arrangement, but it has characters sufficiently distinct and striking for a separate species. In several of its features, it bears a strong resem- blance to the marasmus or atrophy of old age, described under the first species : but it differs essentially in the instance which it affords of a complete rally and recovery: and, if the train of reasoning about to be employed in developing its physiology proves correct it will be found to differ also in its chief seat and proximate cause. The ordinary duration of life seems to have undergone little or no change from the Mosaic age, in which, as in the present day, it varied from threescore and ten to fourscore years. In passing through this term, however, we meet with particular epochs at which the body is pe- culiarly affected, and suffers a considerable al- teration. These epochs the Greek physiolo- gists contemplated as five. And, from the word climax (kXi'/ujI), which signifies a gradation, they denominated them climacterics. They begin with the seventh year, which forms the first climacteric ; and are afterward regulated by a multiplication of the figures three, seven, and nine, into each other ; as, the twenty-first year being the result of three times seven ; the for- ty-ninth, produced by seven times seven; the sixty-third, or nine times seven ; and the eighty- first, or nine times nine. A more perfect scale might perhaps have been laid down; but the general principle is well founded and it is not worth while to correct it. The two last were called grand climacterics, or climacterics em- phatically so denominated, as being those in which the life of man was supposed to have con- summated itself; and beyond which nothing is to be accomplished but a preparation for the grave. With the changes that occur on or about the first three of these periods we have no concern at present, and shall hence proceed to that which frequently strikes our attention as taking place about the fourth, or in the interval be- tween the fourth and fifth. This change is of two distinct and opposite kinds, and it is neces? sary to notice each. We sometimes find the system, at the period before us, exhibiting all of a sudden a very exr traordinary renovation of powers. The author has seen persons who had been deaf for twenty years abruptly recover their hearing, so as in some cases to hear very acutely : he has seen others as abruptly recover their sight, and throw away their spectacles, which had been in habit- ual employment for as long a period ; and he has seen others return to the process of dentition, and reproduce a smaller or larger number of teeth to supply vacuities progressively produced in earlier life. Under the genus Odontia, in the first class and first order of the present sys- tem, several of these singular facts have been already noticed, and examples given of entire sets of teeth cut at this period. That the hair should evince a similar regeneration, of which instances are also adduced in the same place, 24 H^EMATICA. [Cl. Ill—Okd. IV. and of which Forestus affords other examples (Lib. xxxi., obs. 6), is, perhaps, less surprising, since this has been known to grow again, and even to change its colour, after death.' But 1 have occasionally seen several of these singu- larities, and especially the renewal of the sight and hearing, or of the sight and teeth, occur sim- ultaneously. And hence Glanville spoke cor- rectly when he affirmed that "the restoration of gray hairs to juvenility, and renewing exhausted marrow, may be effected without a miracle." On the other hand, instead of a renovation of powers at the period before us, we sometimes perceive as sudden and extraordinary a decline. We behold a man apparently in good health, without any perceptible cause abruptly sinking into a general decay. His strength, his spirits, his appetite, his sleep, fail equally, his flesh falls away, and his constitution appears to be breaking up. In many instances this is, perhaps, the real fact, and no human wisdom or vigilance can save him from the tomb. But, in many ex- amples also, it is an actual disease in which medical aid and kindly attention may be of es- sential service, and upon an application of which we behold the powers of life, as in other dis- eases, rally; the general strength return ; the flesh grow fuller and firmer ; the complexion brighten ; the muscles become, once more, broad and elastic ; and the whole occasionally suc- ceeded by some of those extraordinary renova- tions of lost powers, or even lost organs, to which I have just adverted. The subject is obscure, and it is as difficult, perhaps, to account for either of these ex- tremes—for the sudden and unexpected decline as for the sudden and singular restoration. That the decline, however, is a real malady, and not a natural or constitutional decay, is perfectly obvious from the recovery. And hence Sir Henry Halford, in reference to the period in which it occurs, and by which, no doubt, it is influenced, has emphatically denominated it the Climacteric Disease. Under the first species the author observed, that the great chain of the organs of nutrition extends from the chylific viscera to the assimi- lating secernents ; that these form the ends of the chain ; that a powerful sympathetic action runs through the whole : but that this action is more powerful between the one end of the chain and the other, than between any of its interme- diate links. He observed farther, that, in the atrophy of old age, the failure of action seems to commence and to be chiefly seated at the chy- lific or chyliferous end, and that the assimilating secernents exhibit the same failure only after- ward and by sympathy: that the lacteals be- come generally, and sometimes altogether oblit- erated, while the assimilating process is sup- ported by an absorption, first of the animal oil deposited in the cellular membrane, then of this membrane itself, and, lastly, of much of the * Eph. Nat. Cur., passim. The growth of the hair after death is a manifest impossibility, unless it be assumed that vascular action, circulation, deposition, and secretion, can continue after the extinction of life.—Ed. i muscular and parenchymatous structure of the general frame. In the disease before us, the reverse of all this seems to take place ; and for its origin we must look to the assimilating powers constituting the other end of the chain. The patient falls away in flesh and strength before he complains of any loss of appetite, or has any dyspeptic symptoms ; which only appear to take place afterward by sympathy. And that the mesentery and lacteals are not paralyzed and obliterated, as in the atrophy of old age, is in- controvertible, from the renovation of power and reproduction of bulk that form an occasional termination of the disease. In watching carefully the symptoms of this malady when totally unconnected with any con- comitant source of irritation, either mental or bodily, we shall often perceive that it creeps on so gradually and insensibly, that the patient him- self is hardly aware of its commencement. " He perceives," to adopt the language of Sir Henry Halford, " that he is tired sooner than usual, and that he is thinner than he was ; but yet he has nothing material to complain of. In pro- cess of time, his appetite becomes seriously impaired ; his nights are sleepless, or, if he gets sleep, he is not refreshed by it. His face be- comes visibly extenuated, or perhaps acquires a bloated look. His tongue is white, and he suspects that he has fever. If he ask advice, his pulse is found quicker than it should be, and he acknowledges that he has felt pains in his head and chest, and that his legs are disposed to swell; yet there is no deficiency in the quan- tity of his urine, nor any other sensible failure in the action of the abdominal viscera, except that the bowels are more sluggish than they used to be." Sometimes he feels pains shooting over dif- ferent parts of the body, conceived to be rheu- matic, but without the proper character of rheu- matism ; and sometimes the headache is accom- panied with vertigo. Towards the close of the disease, when it terminates fatally, the stomach seems to lose all its powers ; the frame be- comes more and more emaciated ; the cellular membrane in the lower limbs is laden with flu- id ; there is an insurmountable restlessness by day, and a total want of sleep at night; the mind grows torpid and indifferent to what for-. merly interested it; and the patient sinks at last; seeming rather to cease to live than to die of a mortal distemper. Such is the ordinary course of this disorder in its simplest form, when it proves fatal, and the powers of the constitution are incapable of co- ping with its influence. Yet it is seldom that we can have an opportunity of observing it in the simple form, and never perhaps, but in a patient whose previous life has been entirely healthy, and whose mind is unruffled by anxiety. For if this complaint, whatever be its cause, should show itself in a person who is already a prey to grief, or care, or mental distress of any kind, or in whom some one or more of the lar- ger and more important organs of the body, as the liver, the lungs, or the heart, has been weak- ened or otherwise injured bv accident or irreg- Gen. III.—Spe. 3.] MARASMUS CLIMACTERICUS. 25 ularitv, or is influenced by a gouty or other morbid diathesis, the symptoms will assume a mixed character, and the disease be greatly aggravated. It is these accidents, indeed, that for the most part constitute the exciting cause, as well as the most fearful auxiliary, of the dis- ease ; for, without such, it is highly probable that the predisposition might remain dormant; and that many a patient who falls a sacrifice to it, would be enabled to glide quietly through the sequestered vale of age to the remotest limit of natural life, and at length quit the scene around him without any violent struggle or protract- ed suffering, with a euthanasia sometimes, though rarely attained, but ardently desired by us all. Sir Henry Halford has remarked, that the disease, according to his experience, is less common to women than to men. The author's own experience coincides with this observation. And we can be at no loss to account for the difference, when we reflect on the greater expo- sure of the latter than of the former, to those contingencies which so frequently become oc- casional causes or auxiliaries, and which, at the period now alluded to, strike more deeply and produce a much more lasting effect, than in the heyday and ebulliency of life. There are some events, however, that apply equally to both sexes, and which very frequent- ly lead to this affection ; as, for instance, the loss of a long-tried and confidential friend ; of a beloved or only child ; or of a wife or husband assimilated to each other in habits, disposition, general views, and sentiments, by an intercourse of perhaps thirty or forty years' standing. This last, as it has occurred to me, is a more marked and more frequent cause of excitement than any other. I have seen it in some instances operate very rapidly: and have my eye at this moment directed to the melancholy fate of a very excellent clergyman, between fifty and sixty years of age, the father of ten children, who were all dependant upon him, and whose bene- fice would have enabled him, in all probability, to provide for them respectably had he lived ; but who, having lost the beloved mother of his fam- ily while lying-in of her tenth living child, was never able to recover from the blow, and fol- lowed her to the grave in less than three months. I have at other times seen the same effect produced as clearly and decidedly, though with a much tardier step, and unaccompanied with any sudden shock. I attended not long since a lady in Edgeware Road, who died of a con- sumption at the age of fifty-four. Her husband, though not a man of keen sensibility, had atten- tively nursed her through the whole of her lin- gering illness, and had lived happily with her from an early period of life. He was aware of her approaching end, and prepared for it: and, in a few weeks after her decease, seemed to have recovered his usual serenity. Not long afterward, however, he applied to me on his own account. I found him dispirited, and lo- sing flesh; his appetite was diminishing, and his nights restless, with little fever, and alto- gether without any manifest local disorder. The emaciation with its accompanying evils never- theless increased, the general disease became confirmed, and, in about five months, he fell a sacrifice to it. Occasionally, however, where the climacteric temperament, if I may so express myself, is lurking, a very trivial accidental excitement proves sufficient to rouse it into action. " I have known," says Sir Henry Halford, " an act of intemperance, where intemperance was not habitual, the first apparent cause of it. A fall, which did not appear of consequence at the moment, and which would not have been so at any other time, has sometimes jarred the frame into this disordered action. A marriage, contracted late in life, has also afforded the first occasion to this change." It has in some instances followed a cutaneous eruption, of which the ensuing case will afford a very striking example, and show in the clear- est colours the general want of tone, which, under this morbid influence, prevails throughout the system. Most of my readers of this metropolis have heard of, and many of them have perhaps had the pleasure of being personally acquainted with, the late James Cobb, Esq., Secretary to the East India Company, the history of whose life, from his intimate and extensive connexion and correspondence with the most brilliant and distinguished characters of the age that have figured either in political or fashionable life, and more especially from his own fine taste and commanding talents, and his unwearied efforts to patronise merit in whatever rank it was to be found, ought not to have been with- held from the world. In November, 1816, this gentleman, then in his sixty-first year, and blessed with one of the firmest and most vigor- ous constitutions that I have ever known, ap- plied to me for an erysipelatous affection of the face. It was troublesome, and for nearly a fortnight accompanied with a slight fever, and a good deal of irritation. It subsided at length, but left a degree of debility which called for a change of air, and relaxation from public duty. He made a short excursion to France, and re- turned much improved, but evidently not quite restored to all the strength and elasticity he formerly enjoyed. Insensibly, and without any ostensible cause, he became emaciated, walked from Russell Square to the East India House with less freedom than usual, and found his carriage a relief to him in returning home. His appetite diminished, his nights were less quiet, and his pulse a little quickened. At one time he complained of an inextinguishable thirst, and voided an unusual quantity of urine, so as to excite some apprehension of paruria mellita. But the urine evinced no sweetness, and both these symptoms rapidly disappeared under the medical treatment laid down for him. The general waste and debility, however, continued to increase ; his natural cheerfulness began to flag occasionally, and exertion was a weariness. At this period an inflammation commenced suddenly on the left side of the nates, which 26 njEM soon produced a tumour somewhat larger than a goose's egg, and suppurated very kindly. Sir Gilbert Blane and Sir Walter Farquhar were now engaged in Consultation with myself, as was Dr. Hooper afterward. It was a doubt- ful question, what would be the result of this abscess 1 It might be regarded as an effort of nature to re-invigorate the system by a critical excitement; and, in this view of the case, there was reason for congratulatipn. But it was at the same time obvious, that if the strength of the system should not be found equal to this new source of exhaustion, and could not be stimulated to meet it, the abscess might prove highly unfavourable. The tumour was opened, and about a quarter of a pint of well- formed pus discharged : but the morbid symp- toms remained without alteration, and the cavity seemed rather disposed to run into a sinus along the perinaeum than to fill up. The open- ing was enlarged, but no advantage followed : it was evident there was too little vigour in the system to excite healthy action. The ab- scess was alternately stimulated with tincture of myrrh, a solution of nitrate of silver, and red precipitate ; but the surface continued glassy, with a display of pale and flabby granu- lations, that vanished soon after they made their appearance. Mr. Cline was now united in con- sultation, and concurred in opinion, that the wound was of subordinate importance, and would follow the fortune of the general frame. The issue was still doubtful, for the constitu- tion resisted pertinaciously, though upon the whole the disorder was gaining ground. Yet, even at this time, there was not a single organ we could pitch upon, with the exception of the abscess, that gave indication of the slightest structural disease. The lungs were perfectly sound and unaffected; the heart without palpi- tation ; the mind in the fullest possession of all its powers ; the head at all times free from pain or stupor, even after very large doses of opium and other narcotics : the bile was duly secreted ; the urine in sufficient abundance ; and the blad- der capable of retaining it without inconveni- ence through the whole night. The pulse, however, was quick, the stomach fastidious, and the bowels irregular, sometimes costive, and at others suddenly attacked with a diarrhoea that required instant and active attention to prevent a fatal deliquium. The wound con- tinued on a balance : there was energy enough to prevent gangrene, but too little for incarna- tion. A clearer example of the disease before us cannot be wished for or conceived. Unfortu- nately, its progress, though retarded by the arms of medicines, was retarded alone. One of the last recommendations was a removal into the country ; but Mr. Cobb was now become so debilitated and infirm that this was found a work of some difficulty, and required contri- vance. His Royal Highness the Duke of Sus- sex, however, being kind enough to accommo- date our patient with the use of his easy and convenient sofa-carriage, for as long a period as he might choose, he proceeded without iTICA. [Cl. IH.-Ord. IV. much fatigue to a house provided for him on the borders of Windsor Forest. The distance was now become too considerable for me to attend him statedly, and I visited him but once or twice afterward. He continued, however, to decline gradually, and, in about a month from the time of his going to Windsor, sunk sud- denly under a return of the diarrhoea. In the progress of this disease, medicine will generally be found to accomplish but little. The constitutional debility must be met by tonics, cordials, and a generous diet: and a scrupulous attention should be paid to such contingencies of body or mind as may form an exciting cause, or aggravate the morbid diathe- sis if already in a state of activity. Conges- tions must be removed where they exist, and every organ have room for the little play that the rigidity of advanced life allows to it: and where aperients are necessary, they should consist principally of the warm and bitter roots or resins, as rhubarb, guaiacum, and spike- aloes. In many instances the Bath water, and in a few that of Cheltenham, will be also found of collateral use ; and especially where we have reason to hope that a beneficial impression has been made on the disease, and that the system is about to recover itself. The last remark I shall beg leave to offer, I must give in the words of Sir Henry Halford himself. If not strictly medical, it is of more than medical importance ; and I have very great pleasure in seeing it put forth from so high an authority, and finding its way into a professional volume. " For the rest," says he, " the patient must minister to himself. To be able to contemplate with complacency either issue of a disorder which the great Author of our being may, in his kindness, have intended as a warning to us to prepare for a better ex- istence, is of prodigious advantage to recovery, as well as to comfort ; and the retrospect of a well-spent life is- a cordial of infinitely more efficacy than all the resources of the medical art."* SPECIES IV. MARASMUS TABES. DECLINE. GENERAL LANGUOR ; DEPRESSION OF STRENGTH, AND, MOSTLY, OF SPIRITS ; HECTIC FEVER. Tabes is a Latin term, of doubtful origin. The lexicographers derive it from the Greek ttiku), " macero," varied in the Doric dialect to 7-dncw,—whence Scaliger makes a compound of rai«5/Jios, " macerans vita," " a consuming life, or life of consumption;" and supposes that such a word existed formerly, and that tabes is * In the medical writings of Dr. Rush may be seen a paper of peculiar interest, entitled, "An account of the state of the Body and Mind in Old Age, with Observations on its Diseases and their Remedies." Many of the remarks of Dr Rush are particularly applicable to this species of ma rasmus. Dr. Rush puts much stress upon rir cumstances connected with hereditary predispo Gen. III.—Spe 4.] MARASMUS TABES. 27 a derivative from it. This is ingenious, but nothing more. Tab-eo or tab-es, is most prob- ably derived from the Hebrew jxn (tab), liter- ally " to pine away or consume ;" which is the exact meaning of the Latin terms. Tabes is sufficiently distinguished from atro- phy by the presence of hectic fever; from cli- macteric decay, by the tendency to depressed spirits, as well as its appearing at any age; and from consumption, by the local symptoms of the latter. Its ordinary causes are commonly supposed to be an absorption of pus into the blood, or the introduction of some poisonous substance, as quicksilver or arsenic ; or a scrofulous taint; or an irritation produced by excess in libidinous indulgences ; thus laying a groundwork for the four following varieties :— a Purulenta. B Venenata. y Strumosa. S Dorsalis. Purulent decline. Decline from poison. Scrofulous decline. Decline of intemperance. In the first of these varieties, the ab- sorbed pus may be contemplated as acting the part of a foreign and irritating substance,* and as acting upon a peculiarity of constitution : but, unless the latter be present, pus will rare- ly, if ever, be found to produce a tabid frame : for, as already observed under hectic fever, if absorbed pus be capable, independently of idio- syncrasy, of inducing a decline in one instance, it ought to do so in every instance ; yet this we know is not the case, since buboes, empye- mas, and other apostemes and abscesses of large extent, have been removed by absorption, and yet no tabes has accompanied the process. It is said to occur more frequently where an ab- scess or a vomica is open ; in consequence of pus becoming more acrimonious by the action of the air. But this supposition is altogether gratuitous : and where hectic fever accompanies a sore or open abscess, it is more probably from increased irritation on the edges or internal sur- face of the cavity, as already observed when treating on psoas abscess. In tabes venenata, Dr. Cullen conceives that one cause of emaciation is produced by an absorption of oil from the cells of the cellular membrane into the blood, for the purpose of in- viscating the acrimonious spiculae of the poison- ous substance. This, however, is mere hy- pothesis, without a shadow of proof; and by far the greater number of poisons that enter the blood, whether by deglutition or inhalation, act by a chymical rather than by a mechanical * Armstrong, Diss, de Tabe Purulenta, Edin., 1732. Pus, when absorbed into the circulation from common abscesses, is thought by Cruveilhier (Anat. Pathol.) to undergo some change by the action of the absorbing vessels on it, which change prevents it from having hurtful effects on the con- stitution ; whereas, if pus be introduced directly into the circulation, without being acted upon by the absorbents, it causes capillary venous phle- bitis, visceral abscesses, and severe and fatal con- sequences ; but no disorder resembling what Dr. Good calls tabes purulenta.—Ed. power. Let them, however, act as they may, the hypothesis is not necessary to account for the emaciation; for the offensive matter with which the blood is hereby contaminated, is alone sufficient to excite and maintain the hec- tic ; as the hectic is alone sufficient to wear away the strength and substance of the sys- tem, and produces the waste. It is a disease, as Scheffler has observed, chiefly common to miners and mineralogists (Von der Gesundheit der Bergleute, Chemnitz, 1770) ; and, next to these, is to be found, perhaps, most frequent- ly, among the labourers in chymical laborato- ries. There are other poisonous irritants which are altogether ingenerate or hereditary, that, by their perpetual stimulation, ultimately produce the same effect; as those of chronic syphilis, cancer and scurvy. A more common cause, however, than any of these, is to be found in a state of the sys- tem which has apparently a very near relation to that of scrofula, though it is difficult pre- cisely to identify them. The variety from this cause is hence frequently treated of un- der the head of scrofula or struma ; but as it is peculiarly connected with a morbid condition of one or more of the organs of nutrition, in- cluding those of digestion and assimilation, and is uniformly accompanied with emaciation, irrita- tion, and some degree of hectic fever, it more properly falls within the range of the genus marasmus than that of struma, and constitutes a peculiar variety of decline. Of all the contaminations that lurk in the blood, and are propagable in a dormant state, that of scrofula shows itself sooner than any of the rest. It is curious, indeed, to observe the different periods of time that hereditary diathe- ses of a morbid kind demand for their maturity, unless quickened into development by some in- cidental cause. Scrofula very generally shows itself in infancy; phthisis, rarely till the age of puberty; gout, in mature life; mania, some years later ; and cancer still later than mania. Scrofula runs its course first, and becomes dor- mant, though rarely extinct; phthisis travels through a term of fifteen or twenty years, and if it do not destroy its victim by the age of thirty-eight, generally consents to a truce, and is sometimes completely subjugated. All the rest persevere throughout the journey of life ; they may indeed hide their heads for a longer or shorter interval, but they commonly continue their harassings till the close of the scene. When the strumous taint is excited into ac- tion in infant life, it generally fixes itself upon the chylific or chyliferous glands, especially when they are in a weakly state ; most com- monly upon the mesentery, and to this quarter it often confines itself; insomuch that " I have frequently," says Dr. Cullen, " found the case occurring in persons who did not show any ex- ternal appearance of scrofula ; but in whom the mesenteric obstruction was afterward discovered by dissection."—(Practice of Physic, part iii., book i., § 1606.) It is supposed by Dr. Cullen, and by most pathologists, that the emaciation is, 28 HjEMATICA. [Cl. Ill —Ord. IV. in this case, produced invariably by an obstruc- tion of the conglobate or lymphatic glands of the mesentery, through which the chyle must neces- sarily pass to the thoracic duct. That an ob- struction thus total may occur is not to be alto- gether disputed, because the lymph has been found stagnated in its course by such an ob- struction of lymphatic glands in other parts ; but I have already observed that it is an inter- ruption of very rare occurrence (Vol. i.,p. 228, Cl. I., Ord- II., Parabysma Mesentericum); so rare that Mr. Cruickshank affirms he never saw such a stagnation on the dissection of any mes- enteric case whatever. And that scrofulous en- largement of the glands of the mesentery does not necessarily produce a total obstruction is certain, because children in whom mesenteric enlargement can be felt in the form of knots protuberating in the abdomen, have lived for a considerable number of years, sometimes ten or twelve, and have at last died of some other dis- ease. And hence it is perhaps more frequent- ly the hectic fever, kept up by the local irrita- tion of the mesentery, and the scrofulous taint in the blood, that produces the emaciation in this case, than the pressure of a scrofulous in- farction. " The mesenteric decline," says Dr. Young, " is generally preceded by more or less of a headache, languor, and want of appetite. It is more immediately distinguished by acute pain in the back and loins, by fulness, and, as the disease advances, pain and tenderness of the abdomen. These symptoms are accompanied or succeeded by a chalky appearance, and want of consistency in the alvine evacuations, as if the chyle were rejected by the absorbents, and left in the form of a milky fluid in the intestines; and the functions of the liver were at the same time impaired, the natural tinge of the bile be- ing wanting. The evacuations are also some- times mixed with mucus and blood ; and are at- tended by pain, irritation, and tenesmus, some- what resembling those that occur in a true dys- entery. Occasionally, also, there are symptoms of dropsy, and especially of ascites ; as if the absorption of the fluid, poured into the cavity of the abdomen, were prevented by local obstacles : the absorbent glands, which are enlarged, being rendered impervious, and pressing also on the lacteals and lymphatics which enter them and pass by them." The appetite is generally good, and often ravenous ; probably produced by some remote irritation acting sympathetically on the stomach : as that of the mesentery, or^ more likely that of the assimilating powers that con- stitute the opposite end of the chain of nutrient organs, and which, from their morbid excite- ment, produce a morbid waste, and demand a larger supply than they receive. As worms are easily generated, and multiply in the digestive organs when in a state of debility, they have often been found in a considerable number in this disease, and have sometimes been mistaken for the cause of the malady instead of the effect.— (Chesneau, lib. v., obs. 27.) Balme gives a case in which they were equally discharged by the mouth and anus.—(Journ. de Med., 1790, Sept., •No. i.) In the strumous enlargements are oc- casionally found calcareous concretions; and similar concretions are sometimes discovered in the lacteals and the liver.—(Histoire de VAcad. des Sciences, &c, 1684.) Where the irritation or inflammation is considerable, the intestinal canal is peculiarly apt to unite in the morbid action, producing, with many of the symptoms we have just noticed, hectic fever, and forming what has often been called the febris infan- tum remittens. The decline from an intemperate indulgence in libidinous pleasures has been denominated tabes dorsalis, from the weakness which it in- troduces into the back, or rather into the loins. It is a disease of considerable antiquity ; for we find traces of it in the oldest historical records that have reached our own day; and it is par- ticularly described by Hippocrates under the name of *eiSI2 NJ1TIA2 (rLspi tSv tBvos Ila&Sv, Opp., p. 539, as also Iltpi Novadv ii., Opp., p. 479), literally " humid tabes," from the fre- quent and involuntary secretion of a gleety mat- ter, or rather of a dilute and imperfect seminal fluid. He explains it to be a disorder of the spinal marrow, incident to persons of a salacious disposition, or who are newly married, and have too largely indulged in conjugal pleasures. He represents the patient as complaining of a sense of formication, or a feeling like that of ants creeping from the upper part of his body, as his head, into the spine of his back; and tells us, that when he discharges his urine or excrements, there is at the same time a copious evacuation of semen, in consequence of which he is inca- pable of propagating his species, or answering the purpose of marriage. He is generally short- breathed and weak, especially after exercise; he is sensible of a weight in his head, his mem- ory is inconstant, and he is affected with a fail- ure of sight, and a ringing in his ears. Though without fever at first, he at length becomes se- verely feverish, and dies of that variety of remit- tent which the Greeks called leipyria, a sort of causus or ardent fever, attended with great cold- ness of the extremities, but with a burning fire and intolerable heat within, an insupportable anxiety and unconquerable dryness of the tongue. This description is fully confirmed by Professor Frank in his history of the miserable condition of two young men who had induced the same disease by a habit of self-pollution, one of whom, together with extreme emaciation, suffered ex- cruciating pains in every limb from head to foot, was incapable of standing, and subject to epilep- tic fits ; while the other, after a long career of acute suffering in various ways, was at length seized with a hemiplegia.—(De Cur. Horn. Morb. Epil., torn, v., p. 259.) From this sketch it is obvious that the dis- ease is one of great danger, though it is occa- sionally combated with success. In the H6pi- tal des Enfans Malades at Paris, the fatal cases are calculated by M. Guersent, one of the phy- sicians to the establishment, at from five to six in every hundred of boys, and from seven to eight in every hundred of girls, whose names enter in the tables of mortality.—(Diet, de Med Gen. III.—Spe. 4.] MARASMUS TABES. 29 art. Carreau.) Upon the treatment, we shall offer a few remarks towards the close of the species. Dr. Cullen does not think that the quantity of seminal fluid discharged by undue indul- gence can ever be so considerable as to account for this general deficiency of fluids in the body, and the debility that accompanies it, and adds, that we must therefore seek for another expla- nation of these evils. " And whether," says he, " the effects of this evacuation may be ac- counted for either from the quality of the fluid evacuated, or from the singularly enervating pleasure attending the evacuation, or from the evacuation's taking off the tension of parts, the tension of which has a singular power in sup- porting the tension and vigour of the whole body, I cannot positively determine ; but I apprehend that upon one or other of these suppositions, the emaciation attending the tabes dorsalis must be accounted for."—(Pract. of Physic, part iii., b. i., $ 690.) It is not difficult to trace this result in a less doubtful and more direct way. The sexual or- gans, both in males and females, have a close and striking sympathy with the brain. Morbid salacity is no uncommon cause of madness, as we shall have occasion to observe hereafter. Ir- ritation of the uterus shortly after childbirth, is a still more frequent cause of the same mental affection. The testes are not capable of secre- ting their proper fluid till the sensorial organ has acquired, or is on the point of acquiring, maturity, so that both become perfect nearly at the same time ; the mere apprehension of fail- ure, when in the act of embracing, has at once, in a variety of instances, unnerved the orgasm, and prevented the seminal flow so effectually, that the unhappy individual has often required many weeks, or even months, before he could recover a sufficient confidence to render the op- eration complete ; while, as Dr. Cullen has cor- rectly observed, the evacuation itself, even when conducted naturally, produces a pleasure of a singularly enervating kind. It is in truth a shock that thrills through all the senses ; and hence, in "persons of an epileptic temperament, has been known, as we shall have occasion to observe more fully hereafter, to bring on a par- oxysm while in the act of interunion. It is hence easy to see, that an immoderate excitement of the generic organs, and secretion of seminal fluid, must weaken the sensorial powers even at their fountain ; and consequent- ly that the nervous and muscular fibres through- out the entire frame, and even the mind itself, must be influenced by the debility of the sen- sorium. This we might suppose if there were no chronic flux from the seminal vessels. But when we consider the effect often produced on the general frame by the discharge, or rather the irritation, of a single blister ; or, which is per- haps more to the purpose, of a small seton or issue, we can be at no loss to account for all the evils that haunt the worn-out debauchee, and especially the self-abuser, from involuntary emissions of a seminal fluid, however dilute and spiritless, in connexion with the dreadful debil- ity we have just noticed, and which is the cause of this emission. The nervous irritation which results from this debility, is the source of the hectic by which the miserable victim is de- voured ; and hence the heayy terrors and insup- portable anxiety, corporeal as well as mental, the sense of formication and other phantasms, the flaccidity of the back and loins, the wither- ing of the entire body, the constant desire of erection, with an utter inability of accomplish- ing it, which haunt him by day and by night, and throw him into a state of despondency. A fearful picture, which cannot be too often before the eyes of a young man in this licentious me- tropolis, in order to deter him from plunging into evils to which he is so often exposed.* Even where sexual inability has not taken place, the system, by an habitual excess of libid- inous indulgence, is not unfrequently roused and kept up to such a state of excitement as to pro-r duce hectic fever and great debility, or other de- rangement of the spinal cord. Of this we shall hereafter have to give a most appalling exam- ple (when treating of paraplegia) in a young de- bauchee, who, at the age of forty-five fell a sacrifice chiefly to this enervating propensity, after refusing to take the warning that a con- stitution naturally feeble and rachetic was well calculated to offer; but which might, by care and prudent nursing, have held out to the or- dinary term of old age. The upper limbs were; for years before his death, motionless and rigid ; and the spinal marrow, through a considerable portion of its length, was found disorganized and liquescent. Much of the medical treatment it may be proper to pursue, has been anticipated in sev- eral of the preceding species. The first variety, in which the decline is de- pendant on the stimulus of an abscess or sore, or the introduction of pus into the circulation, can only be cured by a cure of the local affec- tion. The strength may in the meanwhile be supported by a course of inirritant tonics, as cinchona and the mineral acids, nutritious diet, gentle exercise, and pure air. And, if stimu- lants be at any time employed with a view of acting more directly on the morbid irritation, and changing its nature, they should be limited to the milder resins, as myrrh, or the milder terebinthinates, as camphire, and balsam of copayva. In decline from the inhalation of metallic or other deleterious vapours, if Dr. Cullen's hy- pothesis were established, that the emaciation is the mere result of the vis medicatrix natures, and produced by an absorption of oil from the cellular membrane for the purpose of sheathing the minute goads of the poison, it would be our duty to follow up this indication, and employ inviscating demulcents, both oils and mucilages. But this practice has rarely been productive of any success ; and we have much more reason * Lewis's Essay upon the Tabes Dorsalis, Lond., 1758. Brendal, Diss, de Tabe Dorsali, Goett, 1748. Swediaur, vol. i.,p. 251. Sperrna- crasia Asthenica. HvEMATICA. [Cl. III.-Ord. IV. to expect benefit from a use of the alkalis, which, by uniting with the metallic salts, if they still exist in the circulation, may disengage their acid principle, reduce the metallic base to a harmless regulus, and, by the new combination hereby produced, form a cooling, perhaps a se- dative neutral. The first step, however, is to remove the patient from the deleterious scene to an atmosphere of fresh air, then to purify the blood, whether we employ the alkalis or not, with alterant diluents, as the decoction ofsarsa- parilla, and afterward to have recourse to bit- ters, astringents, and the chalybeate mineral waters. In strumous decline, the mode of treatment should run precisely parallel with that for most of the species of parabysma, or visceral tur- gescence, already laid down under their re- spective heads, and particularly with that for mesenteric parabysma, to which the reader may turn. In the treatment of tabes dorsalis, or decline from intemperate indulgence, our attention must be directed to the mind as well as to the body : for it is a mixed complaint, and each suffers equally. A summer's excursion with a cheer- ful and steady friend, into some untried and picturesque country, where the beauty and nov- elty of the surrounding scenery may by degrees attract the eye, and afford food for conversation, will be the most effectual step to be pursued if the symptoms be not very severe. The hours should be regular, with early rising in the morn- ing ; the diet light, nutritive, and invigorating, and a little wine may be allowed after dinner ; since it will almost always be found that the patient has too freely indulged in wine formerly ; and he must be let down to the proper point of abstinence by degrees.* The metallic tonics will commonly be found of more use than the vegetable, with the exception of iron, which is generally too heating : though the chalybeate waters may be drunk, if sufficiently combined with neutral salts. The local cold bath of a bidet should be used from the first, and after- ward bathing in the open sea. If the disease have made such an inroad on the constitution that travelling cannot be ac- complished ; if the mind be overwhelmed, the back perpetually harassed with pain and feeble- ness, and the nights sleepless with hectic sweats and a frequent involuntary discharge, two grains of opium, or more if needful, should be taken constantly on going to bed; diluted acids, vege- table or mineral, should form the usual beverage, and a caustic be applied to the loins on each side. Hippocrates recommends the actual cau- tery, and that it should descend on each side of the back, from the neck to the sacrum. Savin bougies have been prescribed by some writers as a topical stimulus ; but a bidet of cold water is preferable ; with injections of zinc or copper, at first not rendered very astringent, but gradu- ally increased in power. * See Wichmann, De Pollutione Diurnst, fre- quentiori, sed rarius observata, Tabescentiae causa, Goett., 1782. SPECIES V. MARASMUS PHTHISIS. CONSUMPTION. COUGH : PAIN OR uneasiness in the chest, chiefly on decumbiture : hectic fever : delusive hope of recovery. Consumption, or phthisis, as it is sometimes called by old medical writers, is by Dr. Cullen contemplated as nothing more than a sequel of haemoptysis, instead of being regarded as an idiopathic affection ; and his species, which are two, can only be viewed, and so appear to have been by Dr. Cullen himself, as separate stages in the progress of the complaint; his first spe- cies being denominated phthisis incipiens, and characterized by an absence of purulent expecto^ ration ; and his second phthisis confirmata, dis- tinguished by the presence of this last symptom. This, however, is a very unsatisfactory as well as a very unscientific view of the subject, and evidently betrays the trammels of Dr. Cuk len's classification ; since he seerxs only to have placed the disease in this position because he could find no other to receive it: for he ad- mits, in his First Lines, that "phthisis arises also from other causes besides haemoptysis."—■■ (Part i., book iv., ch. i., sect. 852.) No man of experience can doubt that phthisis occurs, or at least commences, more frequently without hemorrhage from the lungs than with it, and consequently that haemoptysis ought much rather to be regarded as a symptom or sequel of phthi- sis, than phthisis of haemoptysis. " Haemoptysis," observes Dr. Young, in a work that has the rare advantage of combining great research and learning, comprehensive judgment, and a study of the present disease in his own person, "is usually enumerated among the exciting, or even among the more re- mote causes of consumption ; but, in a healthy constitution, haemoptysis is not materially for- midable ; and it is conjectured that, when it appears to produce consumption, it has itself been occasioned by an incipient obstruction of a different kind."—(Treatise on Consumptive Diseases, p. 45.) So that, on a concurrence of the two, we may commonly adopt the opin- ion of Desault, and call it an haemoptysis from consumption, rather than a consumption from haemoptysis.—(Sur les Mai. Yen., la Rage, Phthisic, &c, Bord., 1733.) Of the three varieties we are about to de- scribe, we shall find haemoptysis a frequent cause of the second, but rarely of either of the others. These varieties I have taken from Dr. Duncan's valuable " Observations" on consumption : they are evidently drawn from a close and practical attention to the disease, and are as follow :—■ a Catarrhalis. Catarrhal consumption. B Apostematosa. Apostematous consumption. y Tubercularis. Tubercular consumption.* * The editor prefers considering no case as true phthisis that is not accompanied with tubercles If once this criterion be deviated from, the pathol' ogist is obliged to confound diseases which hav not the slightest analogy to one another Cruoaic Gen. III.—Spe. 5.] MARASMUS PHTHISIS. 31 In the first variety the cough is requent and violent, with a copious excretion of a thin, offensive, purulent mucus, rarely mixed with blood; generally soreness in the chest, and transitory pains shifting from side to side. It is chiefly produced by catching cold, or the neg- lect of a common catarrh.* In the apostematous variety the cough re- turns in fits, but is dry : there is a fixed, obtuse, circumscribed pain in the chest, sometimes pul- satory ; with a strikingly difficult decumbiture on one side ; the dry cough at length terminates in a sudden and copious discharge of purulent matter, occasionally threatening suffocation; the other symptoms being temporarily, in a few rare instances, perhaps, permanently relieved. In the tubercular variety the cough is short and tickling ; and there is an excretion of the watery whey-like sanies, sometimes tinged with blood ; the pain in the chest is slight; and there is mostly an habitual elevation of spirits. Usually the result of a scrofulous diathesis. In Dr. Duncan's observations, consumption or phthisis is introduced as a genus, and conse- quently the varieties now offered are reckoned as so many species; yet as the tubercular may run into the apostematous variety, and the ca- tarrhal into both, according to the peculiarity of the constitution and other concurrent cir- cumstances, and more especially as a common cause may produce all of them in different idio- syncrasies, the present subdivision will perhaps be found the most correct. Dr. Wilson Philip has formed another variety (with him species) of consumption, to which he has given the name of Dyspeptic Phthisis, and which he supposes to be produced by a previously diseased state of the digestive or- gans, in which the lungs ultimately participate. "Drunkards," says he, "at that time of life which disposes to phthisis, frequently fall a sac- rifice to this form of the disease ; and those who have been long subject to severe attacks of dyspepsy, and what are called bilious com- plaints, are liable to it. What is the nature of the relation observed between the affection of the lungs and that of the digestive organs, in this species of phthisis 1 Is the one a conse- quence of the other, or are they simultaneous catarrh may partially resemble phthisis in symp- toms ; but its nature is totally different, and this, notwithstanding it may sometimes even lead to the production of tubercles, or real consumption, where the constitution is so disposed. As for apostematous consumption, it is only a particular stage of the tubercular. With respect to the spe- cies described by Bayle, under the name of gran- ular, ulcerous, calculous, cancerous, and with mela- nosis, Laennec observes, that the first is a mere variety of the tubercular; the third is a partial gangrene of the lungs ; and the three others are affections which have nothing in common with tubercular phthisis, except that they have their seat in the same organ.—See Laennec on Dis- eases of the Chest, &c, 2d edit., p. 272, tr. by Forbes.—Ed. * Broussais's History of Chronic Phlegmasiae, or Inflammations, translated from the French by Drs. Hays & Griffith, vol. i., Philad., 1832. affections, arising from a common cause 1 They are not simultaneous affections, for the one al- ways precedes the other. In by far the majority of cases in which both the lung9 and digestive organs are affected, the affection of the digestive organs precedes that of the lungs. In some instances, we find the affection of the lungs the primary disease ; but, in these, the case does not assume the form above described, but that of simple phthisis ; and the hepatic affection, which is always the most prominent feature of this derangement in the digestive organs, does not show itself till a late period of the disease, and then little, if at all, influences the essential symptoms."—(Trans, of Medico-Chirurg. Soc, vol. vii., p. 499.) These remarks show clearly that dyspeptic phthisis is a sequel of a prior disorder, rather than an idiopathic affection ; and, as such, needs not be pursued further in describing the present species. If it outlast the primary malady, or this disease, as is sometimes the case, is con- verted into it, the digestive organs recovering health, and the lungs appearing to concentrate the morbid action in themselves, it is then re- duced to a case of simple or idiopathic phthisis of the one or the other of the varieties now offered. It would, however, be tedious, and of no practical use, to notice the different ramifica- tions into which consumption has been followed up by many pathologists. Among modern wri- ters more especially, it has been very unneces- sarily subdivided : thus Bayle gives us six spe- cies, derived from supposed organic causes (Recherches sur la Phthisie Pulmonaire, Paris, 1810), of most of which we can "know nothing till the death of the patient ; Portal fourteen (Obs. sur la Nat. et le Traite. de la Phthisie Pulm., 2 torn., 8vo., Paris, 1809), the first two of which, the scrofulous and plethoric, are pe- culiarly entitled to attention, while the rest are drawn from other diseases with which it is often complicated, or of which it is a sequel. In Morton and Sauvages, the divisions and subdi- visions are almost innumerable. The Greek pathologists are not chargeable with the same error; for in general they treat of the disease under two branches alone, phthisis and phthoe : the first importing abscess of the lungs, or the apostematous variety of the present classifica- tion ; and the second, ulceration of the lungs, embracing perhaps the greater part of the other two. The terms are those of Hippocrates, and they are thus interpreted by Aretaeus.—(Morb. Chron., i., 10.) Of the varieties here noticed, by far the most frequent is the tubercular ; concerning which it is necessary to offer an explanation, as the term tubercle has been used in very different senses by different writers, and as the morbid change it imports has been derived from very different sources. The term, considered etymologically, is a di- minutive of tuber, a bump or knot of any kind ; in the present work phyma ; and has hence been conveniently applied to minute prominences generally; though, when accompanied with u> 32 H^MATICA. [Cl. III.—Obd. IV. flammation, they are usually called papula or pimples, and when filled with a limpid fluid, vesicles : and if the vesicles, or rather the ve- sicular cysts, be supposed to possess an inde- pendent or animalcular life, hydatids. There is not an organ of the body but is ca- pable, as well in its substance as its parenchyma, of producing tubercles* of some kind or other; and occasionally of almost every kind at the same time ; for Bonet, Boerhaave, and De Haen, as well as innumerable writers in our own day, have given striking examples of clus- ters of cystic tubers, or enlarged tubercles, of every diversity of size, existing both in the ab- domen and in the thorax, formed in the interior of their respective viscera, or issuing from the surface of their serous membranes, some of which are filled with a limpid fluid, others with a gelatinous, a mucous, or a puriform, and others again with a cheesy, pulpy, or steatoma- tous mass. It is not improbable, that even a certain de- gree of inflammation itself is often favourable to the growth and general spread of tubercles. In their origin they seem to be single cysts, or often perhaps single follicles, but as they enlarge, the interior is at times divided by reticulations of vessels, or membranous bands, or distinct cells, thus exhibiting almost every variety of the animal structure ; while the external tunic usu- ally becomes stouter, sometimes duplicate, and at times cartilaginous, t _______ * In whatever organ the formation of tubercu- lous matter takes place, " the mucous system, if constituting a part of that organ, is, in general, either the exclusive seat of this morbid product, or is far more extensively affected with it than any of the other systems or tissues of the same organ."—(See Carswell's Illustrations of the Ele- mentary Forms of Disease, fasc. i.) In the lungs he exhibits the tuberculous matter formed on the secreting surface, and collected within the air-cells and bronchi; in the intestines, within the isolated and aggregated follicles ; in the fiver, within the biliary ducts and their extremities; in the kidneys, within the infundibula, pelvis, and ureters : in the uterus, within the cavity of that organ and Fallo- pian tubes; and, in the testicle, within the tubuli seminiferi, epidydimis, and vas deferens. The formation and subsequent diffusion of tuberculous matter are also described, by Dr. Carswell, as taking place likewise on the secreting surface of serous membranes, particularly the pleura and peritoneum, and in the numerous minute cavities of the cellular tissue. The accumulation of it in the lacteals and lymphatics, both before and after they unite to form their respective glands, he finds to be often very considerable. Dr. Carswell has also given representations of tuberculous mat- ter in the substance of the brain and cerebellum, in accidental cellular tissue, and in the blood ; and adverts to its occasional formation in acci- dental products.—Ed. t Some of the opinions here delivered are not universally admitted; the productions to which several pathologists now restrict the name of tubercle, being, in fact, less diversified than those described in the text. Thus Andral defines those of the lungs to be of a pale yellow colour, mostly of a globular form, and of infinitely various sizes ; at their commencement firm, but brittle ; afterward softening; and, in a later stage, changing into a substance which is not homogeneous, but consists of whitish friable masses, suspended in a sero-pu- rulent fluid.—(Anat. Pathol., torn. i„ p. 408.) The round form of the tubercular substance is consid- ered by Professor Carswell as quite an accidental circumstance. The tubercle assumes the form of a shut or open globular sac, if confined to the se- creting surface, and of a solid globular tumour of various sizes, if it fills completely the cavity of the air-cells; and, for similar reasons, it presents in the bronchi a tubular or cylindrical form, having a ramiform distribution, terminated by a cauliflower arrangement of the air-cells. In the mucous fol- licles, its shape is similar to that which-it receives from the air-cells. The granular arrangement of tuberculous matter in the lungs, is ascribed by Dr. Carswell to its accumulation in contiguous cells; and the lobular character, to its being confined to the air-cells of a single lobule.—(See illustrations of the Elementary Forms of Disease, fasc. i.) Their derivation from obstructed follicles and inflam- mation, is a doctrine which Andral, as well as Laennec, rejects, as a general proposition, which, indeed, in relation to inflammation as a cause, it is right to say, the words of Dr. Good would by no means countenance. The sequel of the text will show that, on this point, he inclined to the opin- ion of Bichat. In the text, however, cysts of nearly every kind, simple and complicated, with fluid, fatty, or fleshy contents, and contents of va- rious other sorts, are all comprised under the term ; a view not adopted at the present time, when so much light has been thrown upon the subject by the researches of MM. Lombard, Laennec, Andral, Armstrong, Cruveilhier, Carswell, and other dis- tinguished cultivators of morbid anatomy. Al- though a tubercle assumes different appearances in its different stages, its transformations are less numerous than Dr. Baron and M. Dupuy (Traite de l'Affection Tuberculeuse, 8vo., 1817) imply in the hypothesis which they maintain, that a tuber- cle is at first a transparent vesicle, or hydatid. The following is Dr. Carswell's definition of tubercle, or rather of the tuberculous matter, which con- stitutes the essential anatomical character of those diseases to which the term tubercular is now ex- clusively restricted. Tuberculous matter, says he, is a pale yellow, or yellowish-gray, opaque, unor- ganized substance, the form, consistence, and com- position of which vary with the nature of the part in which it is formed, and the period at which it is examined. He describes it as an unorganized se- cretion, or as a cheesy-looking material without any trace of organization. When the process of softening takes place in tubercular matter, it is clear, as Dr. Carswell observes, that the change cannot originate in the inorganic substance itself. " After having become firm, it may be converted into a granular4ookingpulp, or pale grumous fluid of various colours, from the admixture of serosity, pus, blood, &c, which have been effused or se- creted by the tissues subject to its irritating influ- ence. The pus and serosity pervade the sub- stance of the tuberculous matter, loosen and de- tach it. These changes are further promoted by atrophy, ulceration, or mortification of the sur- rounding or enclosed tissues, the bloodvessels of which have been compressed or obliterated by the tuberculous matter." Dr. Carswell considers the doctrine, that the softening of tubercles always begins in their centre, as extremely incorrect. Ac- cording to his researches, when tuberculous mat- ter is formed in the lungs, it is generally contained in the air-cells and bronchi. " If, therefore this morbid product is confined to the surface of either, or has accumulated to such a degree as to Gen. III.—Spe. 5.] MARASMUS PHTHISIS. 33 In many cases the cysts or niduses of tuber- cles possess so little energy of action,* as never to exceed the size of small shot, or to consist of more than an insipid fluid, rendered glairy or caseous by an absorption of the finer particles of the material effused or secreted ;t but which, by being united with a few corpuscles of red blood, or of carbonaceous matter, become not unfrequently of a black or chocolate hue, the melanosis of Bayle, but not that of Breschet and Laennec ; and which, by other unions or other changes, produced, perhaps, by the anom- alous operation of the still inherent principle of life, furnish us with all those appearances which dissections bring to light on the surface or in the substance of the lungs, or whatever other organ may chance to be affected. Many writers conceive that, for the growth of tubercles, it is absolutely necessary that in- flammation should take place, and that the whole of the new matter must be supplied from the sanguiferous system immediately: a doctrine rather upheld by Mr. Hunter's followers than by himself, and directly opposed, as Bichat has justly observed (Anat. Gen., torn, iv., p. 517), by the absence of all the signs of inflammation in by far the greater number of passing cases, at least till the morbid growth has fully established itself, and operates by mechanical pressure or some other excitement. While other physiolo- leave only a limited central portion of their cav- ities unoccupied, it is obvious that, when they are divided transversely, the following appearances will be observed —1. A bronchial tube will resem- ble a tubercle having a central depression, or soft central point, on account of the centre of the tube not being, or never having been occupied by tuber- culous matter, and of its containing a small quan- tity of mucus or other secreted fluids. 2. The air- cells will exhibit a number of similar appearances, or rings of tuberculous matter grouped together, and containing in their centre a quantity of similar fluids. When the bronchi or air-cells are com- pletely filled, the tuberculous matter presents no such appearances."—(Professor Carswell's Illus- trations of the Elementary Forms of Disease, fasc. i.) Softening, he says, most frequently be- gins at the circumference of firm tuberculous mat- ter, where its presence, as a foreign body, is most felt by the surrounding tissues.—Ed. * In the lungs, the idea of encysted tubercle appears to Dr. Carswell erroneous, the distended walls of the air-cells being commonly mistaken for cysts. He admits, however, that tuberculous matter is sometimes encysted, but not until it has undergone changes preparatory to its ultimate re- moval from the organ in which it is formed.—Ed. t The common pulmonary tubercle is most in- durated in its early stages, and the change which it afterward undergoes is a softening or dissolution, which Andral refers to the effect of the pus se- creted around it. An increased hardness of the tubercular matter, after its first secretion, has not yet been proved, with the exception of a few in- stances, in which a large proportion of phosphate and carbonate of lime is deposited in the substance of the tubercles. According to M. Andral, this happens chiefly in cases where these bodies have for a long time ceased to have any serious effect upon the constitution. In this respect, the earthy transformation is quite the converse of the process by which a tubercle is softened.—Ed. Vol. II.—C. . gists have limited such morbid growths to the operation of the absorbent system, or to minute bladders containing a limpid fluid which they have called hydatids ; the term being sometimes employed as a mere synonyme of bladders or turgid vesicles of serum, in the language of Boerhaave, "hydatids, sive vesiculae sero tur- gentes" (Epist. Anat. ad Fred. Ruysch, p. 82); and at other times importing a parasitic animal- cule forming a subdivision under the genus taenia of Linneus, and of which we have already spoken under turgescence of the liver.—(Vol. i., Cl. I., Ord. III., Gen. IV., Spe. 1.) [With regard to the important question, whether tubercles of the lungs are the product of inflammation, the subject is one concerning which some of the greatest men in the profes- sion are yet divided. " If," says Laennec, " we question any practitioner, ignorant of morbid anatomy, but who is a man of observation and free from prejudices, he will give it as his opinion, that the symptoms of phthisis very rarely super- vene to acute pneumonia. Even in the cases where this sequence is observed, it is impossible to say whether the pneumonia has given rise to the tubercles, or whether these, acting as irrita- ting bodies, have not excited the pneumonia." The latter view was adopted by a late eminent physician of this country ; for; he distinctly ob- serves, that the number and the increase of the size of tubercles frequently create irritation in their vicinity, so that a consequent inflammation of the surrounding texture is not an uncommon circumstance.—(Armstrong's Morbid Anat. of the Bowels, &c, p. 16, Lohd., 1828,4to.) The solution of the question by a reference to patho- logical anatomy, Laennec deems far more sim- ple, since it is certain, that we very rarely find tubercles in the lungs of those who die of pneu- monia, and that the greater number of con- sumptive subjects exhibit no symptom of this disease during the progress of their fatal malady, nor any trace of it after death. Many of these have even never been affected with it during the whole course of their lives. If tubercles were merely a product of acute peripneumony, we should be able to ascertain the different steps of the transition of the one into the other, which is not the case. It is said that chymical analysis discovers no difference between the softened matter of tubercles and true pus :* in * As already observed, the softening of tubercles is ascribed by Laennec, Andral, and Carswell, to the effect of suppuration around them; in other words, the tubercular matter dissolves in the pus. [f this explanation be correct, though disagreeing with the admission of Andral, that the softening of tubercles often begins in their centre, it is not surprising that the analysis of suppurated tuber- cles should resemble that of purulent matter. But the analysis of a solid tubercle is different, being, according to M. Thenard, animal matter, 98.15; muriate of soda, phosphate of lime, carbonate of lime, 1.85; with some traces of oxyde of iron. There are tubercles, however, the analysis of which is still more different from that of pus; viz., those which contain a very large proportion of phosphate and carbonate of lime, and which are generally such as have existed a long while, with- 34 H^MATICA. [Cl. III.—Ord. IV. like manner, Laennec replies, it discovers none between the albumen of the egg and the secre- tion of certain cancers. These facts only prove the imperfection of chymistry, and not the iden- tity of the matters in question. In almost all their physical characters, tubercles differ from pus. After the complete evacuation of a soft- ened tubercle, its contents are never renewed; while the sides of an abscess, after it is opened, are well known to continue to secrete pus. Laennec admits that acute pneumonia and tu- bercles occasionally coexist; but the complica- tion is rare, when the great frequency of both diseases is taken into consideration. In nine- teen twentieths of the cases of this complication, the tubercular affection evidently precedes the other ; and we may therefore infer, either that the tubercles are the occasion of pneumonia, or that the diseases, although co-existing, have no etiological relation to each other. Laennec concedes, however, as a matter of no evil con- sequence in practice, and of no importance in theory (although he thinks it supported neither by direct experiment nor positive observation), that in the small number of cases where phthisis is seen to arise during the convalescence from acute peripneumony, the inflammation may sometimes accelerate the development of tu- bercles, to which the patient was disposed from some other cause, of the nature of which we are ignorant, but which is assuredly different from inflammation.—(Op. cit., p. 291.) Accord- ing to M. Andral, if the disposition to tubercles be very strong, the slightest local congestion of blood will give rise to them ; wherever such congestion takes place, the same product ap- pears, or the tubercular diathesis is produced. If this disposition be less strong, it is requisite for the formation of a tubercle, that the conges- tion of blood should be so considerable and permanent, as to amount to inflammation. But, when there exists no such predisposition, the most intense and the longest inflammation will not produce a tubercle.—(Andral, Clinique Med., torn, iii., p. 13.) The latter admission is virtually an acknowl- edgment, that the formation of tubercles de- pends essentially upon a peculiar diathesis. Against the idea of tubercles being simply the out any serious effect on the system. They con- sist of animal matter, 3 ; saline matter, 96. These are the only kind of pulmonary tubercles which can be said to become more indurated with time. Professor Carswell observes, that the chymical composition of tuberculous matter varies not only at the different periods at which it is examined, but in different animals, and probably in different or- gans. . In man, he says, it is chiefly composed of albumen, with various proportions of gelatin and fibrin. The most important fact relating to this part of the subject is, " that either from the nature of its constituent parts, the mode in which they are combined, or the condition in which they are placed, they are not susceptible of organization, and consequently give rise to a morbid compound, capable of undergoing no change that is not in- duced in it by the influence of external agents."— See Professor Carswell's Illustrations of the Ele- mentary Forms of Diseac-e, fasc. i.—Ed. effect of inflammation, Dr. Armstrong instances the following fact: in many cases, where tuber- cular points are scattered over the pleura or per- itoneum, the serous membrane is transparent up to these points, and only becomes reddened or opaque when the tumour has enlarged so as to produce local irritation. The tubercle, he admits, is probably connected with effusion of fibrin, but, according to his observations, such effusion is not necessarily connected with inflam- mation.—(Armstrong's Morbid Anatomy of the Bowels, &c, p. 17, 4to., Lond., 1828.)* The ancients ascribed to inflammation all kinds of scirrhi, tumours, and tubercles. In the course of the eighteenth century, this doctrine encoun- tered opposition; but it was not till M. Bayle directed his powerful mind to the subject, that many positive facts were collected in formidable array against the hypothesis. On the other hand, the celebrated Broussais (Exam, des Doclr.Mid., 1816) has continued to be an active defender of the ancient opinion ; and, as far as tubercles of the lungs are concerned, he can still boast of distinguished partisans, among whom be it sufficient to mention the name of Alison. The cases which this gentleman has seen, and which seemed to him to furnish the best evidence on this point, have occurred, he says, in young chil- dren. From them he has been led to think, that when the constitutional tendency to them pre- vails, tubercles may form in very different cir- cumstances, and probably with various rapidity. He has little doubt, that they do often form without being preceded by inflammation of such a character as to be detected by symptoms during life ; and that, in the lungs at least, the inflam- mation, of which the undeniable marks are so often found along with them after death, has really often been posterior to ihem in date. But he has also been led to believe that it is not merely, as Laennec states, a possibility, but a real and frequent occurrence, that inflammation, acute or chronic (to which he would add febrile action), however produced, becomes, in certain constitutions, the occasion of the development of tubercles.—(Edin. Med. Chir. Trans., vol. i, p. 407.) The cases which seem to Dr. Alison to con- firm the doctrine, that tubercles sometimes form in consequence of inflammation, he arranges under two heads :— 1. The first consists of cases in which the tubercles did not cause death, and were found on dissection in an incipient state, but so imme- * A late American writer, Dr. Morton, adduces much able reasoning to prove, " 1st. That tubercles are an altered secretion of the albuminous halitus, proper to the cellular tissue forming the paren- chyma of organs. 2d. That inflammation is not necessary to their development. 3d. That the cel- lular tissue which envelops and intersects tuber- cles, sooner or later takes on inflammation and secretes pus, by which process the tubercular matter is eliminated and an abscess is formed "— See Illustrations of Pulmonary Consumption its anatomical characters, causes, symptoms and treatment, with 12 plates, drawn and coloured from deljlm, 183!-D Ge°rge M°rt0n>M- D > PbU° Oen. Ill—Spe. 5.] MARASMUS PHTHISIS. 35 diately succeeding to the symptom, and so closely connected with, or even passing by in- sensible degrees into, the undeniable effects of inflammation, that it was impossible to suppose their formation independent of it. 2. The second consists of examples in which children, previously in good health, or at least unaffected with any pulmonary complaint, have been seized with well-marked inflammatory symptoms, generally from a known cause, cer- tainly adequate to that effect. These symptoms have lasted some time, and been manifestly dangerous to life,—have subsided very imper- fectly,—the children have passed into the state of phthisis, r>_nd died within a few months ; and, on dissection, tubercles have been found in va- rious stages of progress, but with little or no other appearance which could be considered either as the effect of the inflammation known to have existed, or as the cause of death. In a paper of later date,* Dr. Alison strength- * Edin. Med. Chir. Trans., vol. iii., p. 274. The expression, "in certain constitutions," employed by Dr. Alison, is an important limit to the doctrine. With this understanding, there is no material dif- ference between his views and those of Laen- nec and Andral. The latter pathologist dis- tinctly affirms, that irritation alone will not ne- cessarily give rise to tubercles, which are fre- quently formed without any irritation that can be perceived. Without the concurrence of other causes, mere irritation will not account for their production.—(Anat. Pathol., torn, i., p. 438.) Like many other writers, he ascribes much to peculiar- ity of constitution. Tubercles, he says, are par- ticularly apt to form in individuals whose skin is very white, and, as it were, shrivelled, without any traces of colouring matter in its capillary net- work ; and whose cheeks exhibit a red patch, making a singular contrast to the dead white of the rest of the face. The colouring matter is also deficient in the eyes, which retain the blue colour of infancy ; and the hair is of a fight hue, and its quantity small. The muscles are slender and flabby, with little strength of contraction. The blood is serous, and poor in fibrin and colouring matter; and the mucous secretions predominate. In persons of this diathesis, sanguineous conges- tions readily take place in the skin and mucous membranes ; and, when once produced, do not terminate, but continue in a chronic form, and are frequently followed by ulcerations, and various disorganizations very difficult of cure, and often needing remedies of an opposite nature to such as are termed antiphlogistic. These individuals seem to retain in adult age several traits which appertain to infancy, considered both in its healthy and diseased state; and the development of their organization is impeded. This kind of constitu- tion may be formed without the influence of any manifest external cause. In other instances it ap- pears to be acquired: a residence in an impure air, or such as is not renewed often enough; the crowding of many persons together; absence of the sun's rays; an habitually damp atmosphere; food of a quality inadequate to repair the strength of the system; and various excesses, which ex- haust the strength and nervous influence, and injure nutrition, are enumerated by Andral as so many causes which, at the same time that they render the blood so poor as to account for the state of the skin and muscles externally, give a chronic character to every inflammatory complaint, and a ens, by additional facts and observations, the proposition that, in certain constitutions, inflam- mation, acute or chronic, but most generally chronic, does frequently and directly lead to the deposition of tubercles. The first fact to which he adverts is, that tu- bercles are very seldom found in the bodies of children who are stillborn, or die very shortly after birth. — (Denis, Recherches d'Anat. el de Physiologie Pathologiqucs sur plusieurs Mala- dies des Enfans nouveau-nes.) Velpeau and Breschet had frequently sought for tubercles in the foetus, but could never find them ; and though Orfila and West have seen them, it was only in small number.* Dr. Alison therefore infers, that in most of the numerous cases where tu- bercles are found in the bodies of young children, the diseased actions by which they are formed originate after birth, parents transmitting to theh offspring only the tendency to this kind of dis eased action, and very seldom the actual disease' Dr. Alison next quotes the observation of Magendie, that in those cases where he had detected tubercles of the smallest size, and ap- parently in the earliest stages of the bodies of young children, they were surrounded by cir- cumscribed vascularity. This Dr. Alison has also observed, not uniformly, but in many cases. Lastly, Dr. Alison, in support of his views, ad- verts to the frequency of phthisis in masons, as is supposed from the irritation of the particles of sand inhaled; and to certain experiments by Dr. J. P. Kay, in which the introduction of a globule of mercury into the trachea? of rabbits led to the production of clusters of tubercles in the lungs, each tubercle containing in its centre a small particle of mercury. As for these experi- ments, and others recorded by Cruveilhier [Anal.- Pathol.), the editor thinks that they merely show that the particles of mercury, like other extraneous bodies, led to the effusion of lymph around them, by which they became en- cysted, just as a leaden shot or bullet has fre- quently been observed to be, when it has been lodged in the lungs for some time previously to death. The same process happens in all other parts, so as to circumscribe extraneous bodies. tendency in every organ to the tubercular secre- tion. It is not to be supposed, however, that tu- bercles form only in these constitutions ; and An- dral admits that it is not uncommon for phthisis to destroy persons of dark complexion, very black hair, and a muscular system strongly developed. We know, indeed, that so far is a dark complex- ion from being a certain protection from phthisis, that the blacks of Africa, when brought to this climate, are particularly liable to the disease ; though here the disposition to it may be set down as acquired. At this present time (Dec, 1830), the editor has a patient with phthisis, in the King's Bench, whose complexion is remarkably dark, and his hair black. However, he believes with M. Andral, that the natural disposition to tubercles is most frequent in the above description of sub- jects, and especially the tendency to their simul- taneous production in several organs.—Op. cit., p. 434—Ed. * One or two additional cases of this kind are recorded in Lloyd's work on Scrofula. The prep- arations are in Mr. Langstaff's museum.—Ed. 36 H^MATICA. [Cl. III.—Ord. IV. The analogy between these cases and others in which tubercles are produced extensively throughout the lungs, by a process m which frequently the presence of no extraneous body can be suspected, certainly does not seem very eVAefew years ago, Dr. Baron brought forward an hypothesis, founded upon the hydatid basis. Waving the question of the animalcular origin of the hydatid, as contended for by Dr. Jenner and others, and resigning the critical meaning of the term tubercle as a diminutive substantive, he employs tubercle, vesicle, and hydatid as nearly synonymes. Tubercles in their incipient state being with him "small vesicular bodies with fluid contents" (Inquiry illustrating the Nature of Tuberculated Accretion, &c, p. 214), the hydatids of his friend Dr. Jenner, and vesi- cles being parallel with both, and distinguished from tumour as follows :—" I would employ the word tubercle to denote those disorganizations that are composed of one cyst, whatever may be its magnitude or the nature of its contents ; and by tumour I would understand those morbid structures that appear to be composed of more than one tubercle." From this source Dr. Baron derives tumours of almost every kind, varied merely by the pe- culiarity of the constitution, or the concomitant circumstances of the organ in which their vesic- ular or hydatid form first makes its appearance ; and hence ramifying into encysted tumours, however diversified in their contents,-^-whether limpid, gelatinous, cheesy, pultaceous, medul- lary, or steatomatous,—sarcomatous tumours, scirrhous tumours, cartilaginous tumours, can- cer, and the fungus haematodes. He limits their. formation to the absorbent system alone, con- ceiving the sanguiferous to have little or nothing to do with the morbid productions; and upon this point it is that he is chiefly in a state of challenge with the ablest supporters of the Hunterian doctrines. According to Dr. Baron, the tubercle "may be pendulous, or imbedded in any soft part, or it may be found between the layers of mem- branes, and wherever the textures are of such a nature as to admit of its growth. It may be so small as to be scarcely visible, or it may ac- quire a very great magnitude. Single tubercles are often seen in a viscus, while all the rest of the organ is free from disease, and its functions are performed in an uninterrupted manner. But it is evident that the same state of the system, whatever that may be, which ealls one tubercle into existence, may generate an indefinite num- ber : that they may be diffused through the whole of a viscus, leaving nothing of its original texture ; or they may occupy any portion of it, or extend to the contiguous parts, and involve them in the same form of disease."—(P. 216.) If the organ or the general constitution be not much predisposed to a generation of tuber- cles, a few may remain for a long time inert, and without any multiplication whatever ; but there is often a particular diathesis that favours such a complaint, and facilitates its being called from a latent state into an active manifestation by a thousand little accidents ; and which, when once excited, encourages the growth of tuber- cles in great abundance, and finds a rich and ready soil for them, not in one organ only, but in every one. A case, strikingly illustrative of this form of the disease, is recorded by Mr. Langstaff—(Med. Chir. Trans., vol. ix.) [Some valuable observations, lately published by Dr. Abercrombie (Edin. Med. Chir. Trans., vol. i., p. 682), are very unfavourable to the hy- pothesis that tubercles consist of hydatids. A chymical examination of the mesenteric glands affected with tubercular disease, he found to present some curious results. When a gland, having a soft fleshy appearance, is-^lunged into boiling water, it instantly contracts considerably in its dimensions, its textures become much firmer, and its colour changes from that of flesh to an opaque white or ash-colour. By boiling for a short time, it loses a great part of its weight; but a residuum is left, which has increased much in firmness during the boiling, has lost entirely the flesh colour, and exhibits the appearance, consistence, and properties of coagulated albu- men. The part that is lost seems to consist partly of water, but chiefly of the muco-extrac- tive matter ; sometimes, but not always, there is a mixture of gelatin ; and, in some 'specimens, the coagulated part gave traces of fibrin, but in small quantity. According to Dr. Abercrombie's report, the proportions of these ingredients varied exceed- ingly in different specimens, and apparently in different periods of the disease. In the softest state, glands which were considerably enlar- ged, lost by boiling about five sixths of their .weight; the remaining one sixth being a firm mass, with the appearance of the firm white tubercle, and the properties of coagulated albu- men. Glands, examined in a more advanced stage of the disease, lost by boiling perhaps from two thirds to one half. Portions in the semi-transparent, cartilaginous state, lost about one fourth, leaving three fourths of their weight in the same state of firm, opaque, albuminous coagulum. The white, opaque, tubercular mat- ter lost a still smaller proportion, and what was left was a firm white substance, resembling coagulated albumen. The same results were obtained from an examination of the white tu- bercle of the lungs, the tubercular disease of the bronchial glands, tubercles of the liver, cer- tain tumours of the brain, and of similar masses in other situations. As the mesenteric and lymphatic glands, ap- proaching the healthy slate, do not exhibit any traces of albumen, Dr. Abercrombie infers, that the deposition of this substance in them is a morbid process, and that there is good ground for conjecture that this deposition of albumen is the origin of tubercular disease. The tuberculated disease of the peritoneum, on which so much of Dr. Baron's hypothesis is founded, presented, in Dr. Abercrombie's ex- periments, characters considerably different from those of tubercles of the lungs, or of the tuber- cular disease of the lymphatic glands. The specimens presented an irregular surface, eleva* Gen. Ill—Spe. 5.] MARASMUS PHTHISIS. 37 ted into variously-shaped nodules of a semi- pellucid appearance and firm texture. By boil- ing in water, these nodules were nearly dis- solved, leaving only a small central part, to which they seemed to have been attached, and which had undergone little or no change during this first boiling. The part that was dissolved seemed to consist entirely of the muco-extract- ive matter, and the part that remained was the same substance in a more concrete state, with a small trace of albumen. In all Dr. Aber- crombie's examinations, this substance seemed remarkably different from what is observed in the proper tubercle. They both differ, how- ever, from the contents of a hydatid, which consist of water, holding in solution about one hundredth part of saline matter, and one fortieth part of muco-extractive animal matter ; a fact weighing heavily against Dr. Baron's hypoth- esis.* The researches of Dr. Armstrong taught him that the vesicular appearance of a tubercle is an accidental occurrence, dependant on the texture of the part in which it is placed ; a fact agreeing with Dr. Carswell's investigations. Thus, tu- bercles in their origin may have the vesicular appearance in the lungs ; but if minutely ex- amined, he says they will be found to be the extremities of the bronchial tubes, or air-cells, into which the peculiar deposite constituting tubercle often takes place. He has frequently examined them in a strong light, and never found them to be, strictly speaking, vesicles, 'though the tubercular points have been in many cases extremely minute, t Dr. Baron attempts to prove that tubercles are essentially hydatids, and that the progress of tubercular disease is precisely the reverse of Laennec's description ; and that, instead of passing from an indurated to a softened and fluid state, they are first simple vesicles of fluid ;t and that they generally pass through a * Dr. Carswell has always found tuberculous matter in scrofulous glands ; and, when the cutis is pale, and they happen to lie directly under it, they are almost completely filled with this morbid product. " When, therefore, enlarged glands, in a scrofulous patient, ultimately disappear, we may conclude, almost with certainty, that we have witnessed the cure of a tubercular disease."—See Illustrations of the Elementary Forms of Disease, fasc. i.—Ed. t See Morbid Anatomy Of the Bowels, &c, p. 16 Dr. Armstrong's belief that tubercles are ori- ginally the extremities of the bronchial tubes, or air-cells, may have been derived from the fact, that tubercles are sometimes situated in the sub- stance of the parietes of the air-cells, and of the minute ramifications of the bronchiae. Matter, like that of tubercles, has been found, however, in cavities lined by mucous membrane, after ul- ceration has taken place. Mucous follicles and lymphatic vessels have been occasionally remark- ed to contain a similar substance.—(Andral, Anat. Pathol., torn. L, p. 419.) The cellular tissue is, then, not the only nidus for tubercles.—Ed. t According to Professor Carswell, tuberculous matter does not acquire its maximum of con- sistence until an indefinite period after its for- mation : and he states that it is frequently found in j process of inspissation, until they become quite hard, in which state, he says, there is the strong- est reason for believing that they do not sub- sequently soften ! This theory seems to Dr. Forbes incompatible with the best established facts, and susceptible of ready refutation by any person versed in modern pathology. Dr. Baron, as a critic has remarked, has betrayed not only a singular misapprehension of the pathology of the diseases of which he treats, but actually not a due acquaintance with the natural history of hydatids themselves, on which all his opinions repose.- He reproaches Laennec with indulging in unnecessary minuteness in his description of tubercles ; forgetting, in his zeal for the hydatid doctrine of disease, that nature's forms may be very diversified, and that it is the privilege of theory only to be just as simple as the theorist could desire. Real instances of hydatids in the lungs are extremely rare, Andral having'met with only four or five cases among six thousand subjects.* its primitive state, in the bronchi, air-cells, and other situations, resembling a mixture of soft cheese and water.—(See Illustrations of the Ele- mentary Forms of Disease, fasc. i.) M. Cruveil- hier believes, that previously to the period when a tubercle presents itself as a firm substance, it has a less advanced stage, in which it exists in a fluid form. In his experiments to produce tuber- cles artificially in animals, on an examination of their bodies at the very commencement of the disease, he found, close to the white bodies, which were already indurated, other productions, which differed from them only in having less consistence, and being in a state of fluidity. In the human lungs, filled with tubercles, M. Andral has also seen dispersed, throughout the interior of those viscera, white points, consisting of a liquid matter, like a small drop of pus. Yet he is of opinion, that the doctrine of M. Cruveilhier has not been sufficiently proved; and that the above appear- ances are only accidental, and not constant; and that, however minute a tubercle may be, it is mostly met with in a solid shape. At all events, there is one great difference between M. Cruveil- hier and Dr. Baron, inasmuch as the former does not suppose that hardened tubercles cannot soft- en—Ed. * Laennec on Diseases of the Chest, note by Dr. Forbes, 2d edit., p. 298. Andral, Clinique Med., torn, iii., p. 93. In another publication (Anat. Pa- thol., torn. L, p. 408), the latter author mentions, that he has seen only a single instance of trans- parent vesicles in the human lungs, accompanied by tubercles ; but he has met with this association more than once in phthisical horses, and, in some of these examples, the fluid of the vesicle became turbid, and surrounded by a white opaque cyst. His inferences are, that the transparent vesicles observed in a few uncommon cases, in the vicinity of tubercles, are an accidental complication. If they were the original form of tubercles, they would be more frequently noticed. They may sometimes secrete, instead of their usual contents, a peculiar matter, the physical qualities of which may have more or less resemblance to those of a tubercle ; but this is no proof of the latter having been always preceded by a serous cyst, and secre- ted from it. As well might it be argued, that a tubercle is always secreted by a mucous follicle, or lymphatic vessel, because a substance like that of tubercle has been occasionally observed within 38 H^EMATICA. [Cl. III.—Ord. IV. When the morbid action commences m the abdominal organs, it far more readily passes into those of the chest, than when it commences m the chest, into those of the abdomen ; instances of which have been sufficiently noticed under the complicated species of Parabysma.—(Vol. i., Cl, I., Ord. II., Gen. IV., Spe. 7 ) These, how- ever, are extreme examples ; for, in most cases of tubercular phthisis, the disease has made far less progress at the time of its proving fatal, and is often confined to the seat of the lungs alone, and even to an evolution of tubercles of minute size and uniform simplicity of contents, mostly consisting of a whey-like or cheesy material. A certain but low degree of inflammatory action, however, seems to favour a more rapid forma- tion of fresh tumours, and an enlargement of those already in existence ; and the same may be observed of the accompanying hectic fever. If this be decided and considerable, the disease may run its course in four or five months, and sometimes sooner. If the hectic be undecided and only occasional, the disease may play about the system for some years, and at length prove equally fatal. If the inflammatory action exceed the low degree we have just adverted to, ulcer- ation and suppuration usually follow, and the tu- bercular form passes into, or is united with, the apostematous. M. Louis, like his friend M. Laennec, refers every case of phthisis to a tubercular origin; and where the predisposition to the formation of such growths is very predominant, he has traced them, in post-obit dissections, to a still wider range than the example furnished by Mr. Langstaff: in various instances, indeed, over al- most every viscus of the abdominal, as well as of the thoracic cavity. In one or two of these, he has even found the tubercular structure to have been far more manifest and elaborated than in the lungs, and especially in the stomach, the mesenteric glands, the ileum or jejunum, but rarely in the duodenum. But he positively as- serts that he has never traced these morbid ap- pearances in other parts, without some kind of manifestation of them in the lungs : and he hence concludes, that a development of tubercles in this last organ is essential to their formation else- where. So far as he has examined, however,— and his field of observation has been very ex- tensive, as well as closely followed up, in the Hopital de la Charite,—phthisis has seldom limited its structural ravages to the region of the lungs. Tubercles, or ulcerations, have usually been detected elsewhere on dissection ; often, indeed, in the trachea, larynx, and epiglottis, and occasionally in the pharynx and oesophagus, as well as in the stomach. And when the hectic has been active, there is scarcely an organ but what he has found at times entering more or less into the general circle of action ; as the large intestines, the liver, the spleen, the peritoneum, the lym- phatic glands, the aorta, and even the brain. The heart, and the urinaiy organs, have usually escaped with less structural injury than any others.—(Recherches Anatomico-Pathologiques sur la Phthisie, par P. Ch. A. Louis, Paris, 8vo., 1825.) ' With one exception out of 350 dissections, whenever M. Louis found tubercles in the lungs, he always found them in other organs.* In a few instances, however, Laennec found tuber- cles to commence in other parts, especially in the mucous membrane of the intestines, and in the lymphatic glands, their formation in the lungs having been secondary.—(Laennec, op. cit., p. 285.) The occurrence of tubercles in various organs without the presence of any in the lungs, has been noticed by M. Andral more frequently than by M. Louis. Such cases are more com- mon in children than adults. In the former, there is a disposition to tubercles in a larger number of parts at once ; and the organs most frequently affected in them are not the same as in the adult subject. The parts which are most frequently the seat of them in the adults are, first, the lungs, and then the small intestines : in children, first, the bronchial glands ; secondly, the mesenteric glands; thirdly, the spleen; fourthly, the kidneys ; and fifthly, the intestines, &c. In children under fifteen, tubercles are least frequent between the first and second years of their age ; and most common from the end of the fourth until the commencement of the fifth. —(Anat. Pathol., torn, i., p. 424.)] Phthisis, as already observed, is a disease of high antiquity, as well as of most alarming fre- quency and fatality. So frequent, indeed, is it, as to carry off prematurely, according to Dr. Young's estimate, and the calculation is by no means overcharged, one fourth part of the in- habitants of Europe (On Consumptive Disea- ses, ch. iii., p. 20) : and so fatal, that M. Bayle will not allow it possible for any one to recover who suffers from it in its genuine form.—(Re- cherches sur la Phthisie Pulmonaire, Paris, 1810.) I can distinctly aver, however, that I have seen it terminate favourably in one or two instances, where the patient has appeared to be in the last stage of disease, with a pint and a half of pus and purulent mucus expectorated daily, exhausting night-sweats, and anasarca; but whether from the treatment pursued, or a remedial exertion of nature, I will not undertake such parts. Transparent cysts are very common in the diseased lungs of pigs, where they even ex- ceed tubercles in number ; and it seems to M. An- dral, that this fact is the chief ground of the opin- ion that tubercles commence in the shape of hy- datids. He also warns us not to mistake the de- position of tubercular matter around hydatids (an instance of which he met with in a rabbit) for the conversion of vesicles into tubercles.—Ed. * Recherches sur la Phthisie, &c, p. 179. In the 350 post-mortem examinations mentioned in the text, M. Louis found tubercles in various or- gans besides the lungs, in the following propor- tions :—In 2-3 of subjects, small intestines ; in 1-9 large intestines; in 1-4, mesenteric glands • in 1-10 the cervical glands; in Ml, the lumbar glands ; m 1-13, the prostate ; in 1-14, the spSn in 1-20, the ovaries ; in 1-40, the kidneys • I-3T0' the womb ; 1-350, the brain; 1-350, the cereal lum ; 1-350, the ureter. M. Louis makes nn m«" tion of tubercles in the testis, which are common . fo7mdShmStheffi^aDb0Ut ** SKd Gen. III.—Spe. 5.] MARASMUS PHTHISIS. 39 to say. Dr. Parr affirms that he has witnessed six cases of decided phthisis recover spontane- ously. [Previously to the knowledge of the true na- ture of tubercles, and while consumption was considered simply as a consequence of chronic inflammation and suppuration of the pulmonary tissue, phthisis was deemed curable, at least, when properly treated before it had made too much progress. But, says Laennec, it is now the general opinion of all well-informed patholo- gists, that the tubercular affection, like cancer, is absolutely incurable. The observations con- tained in the treatise of M. Bayle, as well as Laennec's remarks on the development of tu- bercles, prove how illusive the idea is of curing consumption in its early stage. Crude tu- bercles tend essentially to increase in size, and to become soft. Nature and art may re- tard, or even arrest their progress, but neither can reverse it. But, while Laennec admits the incurability of consumption in the early stages, he is convinced, from a great number of facts, that, in some cases, the disease is curable in the latter stages, that is, after the softening of the tubercles, and the formation of an ulcerous exca- vation.* * Laennec on Diseases of the Chest,T2d edit., p. 299. In Dr. Carswell's Illustrations of the Ele- mentary Forms of Disease, fasc. i.,the reader will find some particularly interesting facts, con- firming Laennec's views of this part of the sub- ject ; for he has traced the several steps of the curative process in the bronchial glands, in indi- viduals who had recovered from scrofula and phthisis, but died some time afterward of other diseases. He has found in these glands a greater or less quantity of a substance resembling putty, or dry mortar, the consistence of which was some- times equal to that of sandstone or bone, and presented spiculae, which had excited inflamma- tion, ulceration, and perforation of the lining of the bronchi or trachea with which they were in contact. A direct communication was thus formed between the cavity of the air-tubes and the dis- eased glands, through which the cretaceous bod- ies passed; and they were rejected along with the expectorated fluids. Dr. Carswell has seen several examples of cure of tubercular disease of the bronchial glands in the mannerjust described. When these glands have discharged the whole of their contents, they are found atrophiated, and converted into a fibrous tissue, which fills up the external orifice of the perforated tube. The acci- dental opening now contracts, becomes obliterated, and leaves in its place a puckered depression or cicatrix, seen on the internal surface of the air- tube. Dr. Carswell adds, that similar appear- ances, indicating the removal of the serous and albuminous parts of the tuberculous matter, and the condensation of its earthy salts, have frequent- ly been observed in the lungs of persons whose history left no doubt of theirhaving been affected, at some period of their lives, with tubercular phthisis. For a particular description of the changes referred to, as leading to this fortunate amendment, the reader is advised to consult Cars- well's Illustrations of the Elementary Forms of Disease, fasc. i. It appears, that if the bronchi remain pervious, the tubercular matter is gradu- ally removed by expectoration; and, if they are closed, it is removed by absorption.—Ed. Eight or ten cases of cicatrization of the lungs after tubercles are recorded by Andral.—(Clin- ique Med., torn, iii., p. 382.) The learned trans- lator of Laennec's work is of opinion, however, that this author has exaggerated the frequency of recoveries in this way ; and that he has con- sidered certain appearances as signs of cicatri- zation, which were probably owing to other causes. Dr. Forbes considers it likely, that simple pneumonia, or pleuro-pneumonia, may give rise to many of the slighter deviations from the natural structure, considered by Laennec as tubercular cicatrices.—(See note in translation of Laennec, p. 311, 2d edit.; also, Louis, Re- cherches, &c, p. 36.) Notwithstanding what has here been advanced, many experienced prac- titioners still incline to Bayle's opinion, that tubercular consumption is incurable ;, the dis- ease, however, may be retarded, and patients may live with it sometimes thirty or forty years.] The ordinary period of the consumptive di- athesis has been stated to be from the age of eighteen to that of thirty-five, occasionally an- ticipating the first, and overpassing the second of these limits: the mean term of its proving fatal has been fixed at about thirty ; and the an- nual victims to its ravages in Great Britain, Dr. Woolcombe has calculated at fifty-five thou- sand.—(Remarks on the Frequency and Fatality of different Diseases, &c, 8vo., Lond., 1808.) During the last half century, it is said to have been considerably on the increase ; but this is, perhaps, chiefly owing to the greater' number of infants of delicate health who are saved from an early grave by the introduction of a better system of nursing than was formerly practised ; yet who only escape from a disease of infant life to fall before one of adolescence or adult years. And, for the same reason, sav- ages rarely suffer from consumption, as they only rear a healthy race, and lose the sickly soon after birth. The question, however, concerning the actual range of the consumptive diathesis, or in other words, at what period of life consumption is most frequent, is still open to inquiry. It was a com- mon doctrine among the Greek physicians, and it has very generally descended to our own day, that phthisis rarely occurs before fifteen or after thirty-five years of age ; and Dr. Cullen has en- tered into an ingenious argument to show why it should be so. Yet the tables that have been kept in most parts of the world seem to indi- cate the contrary ; or that, at least, as many die of this disease, and even originate it, after thirty- five or forty years of age, as antecedently to this period. One of the first pathologists who ap- pears to have called the public attention to this general concurrence of the tables and bills of mortality, is Dr. Woolcombe ; and he particu- larly adverts to the proportions observed in the Dispensary of Plymouth, as being the chief source from which he drew his calculations. He tells us, that of seventy-five deaths from consumption, which occurred within the range of this establishment, ten took place before the age of fifteen, sixteen between fifteen and thirty, and forty-nine above the age of thirty ; twenty- 40 HiEMATfCA. [Cl. III.—Ord. IV. three of these forty-nine, moreover, being above the age of forty.—(Op. cit, &c, p. 75.) Dr Alison (On the Pathology of Scrofulous Diseases; Transact, of the Medico-Chir. Soc. Edin., vol. i.) has given the result of various other tables, most of which are in consonance with Dr. Woolcombe's. Thus Bayle, in his Treatise on Consumption, notices a hundred cases above fifteen years of age, all of which terminated fatally in the hospital of La Charite at Paris, and after the following proportions : thirty-three below the age of thirty, and sixty- seven above it, of whom forty-four were up- wards of forty.* So Haygarth, in his account of the deaths from phthisis in the course of two years at Chester, makes the total a hundred and thirty-five ; of which twenty-five occurred before the age of fifteen, forty-two between fifteen and thirty, and sixty-eight above thirty; forty- four of these last being above forty.—(Phil. Transact., Ixiv., lxv.) "In the practice of the New Town Dispensary at Edinburgh, Dr. Ali- son tells us, there have been fifty-five deaths from phthisis in the last two years; of these, eight occurred before fifteen years of age, thir- teen between fifteen and thirty ; thirty-four after thirty ; and of these last, twenty-four after forty." So in Sussmilah's table of deaths at Berlin in 1746, out of six hundred deaths from phthisis, two hundred and fifty-one are stated to have oc- curred before fifteen years of age, seventy-three between fifteen and thirty, and two hundred and ninety-six above the age of thirty ; two hundred and thirty of which occurred after the age of forty. In this last table, a greater number of deaths took place within the first fifteen years than in any fifteen years afterward. And a like surplus occurs in the calculations at Warrington record- ed by Dr. Aikin : the proportions being twenty- four below the age of fourteen, thirty-six be- tween fourteen and fifteen, and the same num- ber above the age of forty-five.—(Phil. Trans., vol. liv.) While at Carlisle, as we learn from Dr. Heysham, out of two hundred and four- teen deaths, fifty-nine anticipated the age of fifteen, sixty took place between this period and thirty, and ninety-five above the age of thirty; sixty-one of these being above that of forty, t The general result, therefore, seems, at first eight, to oppose in a very striking degree the doc- * Bayle, p. 42. Of 223 deaths from phthisis, re- corded by Bayle and Louis, 21 occurred between the ages of 15 and 20, 62 between the ages of 20 and 30, 56 between those of 30 and 40, 44 between those of 40 and 50, 27 between those of 50 and 60, 13 between those of 60 and 70.—See Laennec, tr, by Forbes, note, p. 352.—Ed. t Milne, on Annuities, vol. ii., p. 464. After pu- berty, Andral has calculated that tubercles are most common in men between the age of 21 and 28; but that females are most liable to the disease ere they attain their 21st year.—(Anat. Pathol., torn, i., p. 429.) These estimates, it is to be ob- served, refer only to the periods of the existence of the disease, and not to the time of life in which the greater or lesser number of deaths takes place from it. The latter is a very different question; be- cause numerous consumptive patients linger many years. Dr. Elliotson observes, that in this country trine of the Greek schools, and those who have followed them; and to show that the age from fifteen to thirty is most exempt from consump- tion, while that above thirty, or even forty, to the close of life, is most distinguished by fatal- ity from this disease, though the period below fifteen is also seriously invaded by it. But the doctrine of the Greek schools relates to idiopathic consumption as the product of a phthisical diathesis ; or, in other words, affirms that this diathesis, when not called into action by accidental excitements, is most disposed to show itself between the ages of fifteen and thirty-five. And, thus modified, it is probable that the doctrine holds good to the present day, notwithstanding the apparent contradiction of the tables now adverted to. For, with respect to the cases of consumption that anticipate the age of fifteen, by far the greater part of them are secondary, instead of primary or idiopathic affections, and follow as sequels of a strumous habit that has previously shown itself in a mor- bid condition of the mesentery or some other organ, with which the lungs at length associate in action ; though, but for such an incidental ex- citement, they would probably have remained quiescent for several years longer. In many in- stances, indeed, they are to the last rather ta- bes strumosa, strumous or mesenteric decline, than phthisis or consumption properly so called, though included in the bills of mortality or other tables under this last name. And as we have already observed, that variolous and vaccine in- oculation carry various sickly infants through the period of infancy, who would otherwise have fallen victims to the smallpox, yet who, a few years afterward, from the same sickliness of constitution, sink beneath the assault of decline or phthisis, we see sufficient reason for the great- er number of early deaths in our own day from what is ordinarily called consumption, and what often is strictly so, though of a secondary or catenating, instead of a primary or idiopathic kind, than was known to the Greek authorities, whose doctrine relating to idiopathic phthisis alone is not hereby interfered with. The ob- servations of M. Louis, to which we have just ad- verted, and which seem to have been made and persevered in with great accuracy, are directly coincident with these remarks, and support the calculation of the Greek school. "The num- ber of individuals who die of phthisis," says this attentive pathologist, " is more considerable between the ages of twenty and forty than be- tween forty and sixty, although the general mor- tality is less in the first than in the second of these periods." And, in support of this asser- tion, he subjoins the following table as the re- sult under his own eye :— Age. l\o. oj Deaths. Age. From 15 to 20 - 11 From 40 to 50 20 - 30 - 39 50 - 60 30 - 40 - 33 60 - 70 scrofula is more likely to occur in the luntrs be tween the ages of 18 and 30, than at anv other time of life.—See Lect. at Lond. Univ as nnhli«h ed in Med. Gaz. for 1833, p, 231.-Ep, pUbllsh" Gen. III.—Spe. 5.] MARASMUS PHTHISIS. 41 And in effect the proportions, as arranged by M. Bayle, do not essentially vary when given in his own tabular form, instead of being gener- alized, as they are by Dr. Alison, in the refer- ence just quoted. In this form they occur as follows :— A No. of ° ' Deaths. From 15 to 20 - 10 20-30 - 23 30-40 - 23 ASe £°- °f Age- Deaths. From 40 to 50 - 21 50-60 - 15 60 - 70 - 8 In respect to the exuberant cases that occur in later life than thirty, they are, for the most part, far less a result of a phthisical diathesis than of an accidental exposure to causes pecu- liarly operating upon the lungs, and exciting them to a morbid action, so as to produce the disease, whether there be any hereditary taint or predisposition to consumption, or whether there be none. These causes are chiefly the habitual influence of a higher degree of heat or of cold, and espe- cially the latter, than is consistent with that eu- thesy or perfection of constitution on which sound health depends ; and particularly the mis- chievous influence of a temperature perpetual- ly varying from high degrees of heat to those of cold ; and a like mischievous exposure to irri- tating gases, or spicular dust, perpetually in- haled in various chymical or handicraft occupa- tions. Above thirty years of age, the stations of mankind are usually fixed, and whether healthy or unhealthy, they cannot easily be aban- doned. If, then, we examine the kind of consumption which takes place above this age, we shall find it, in by far the greater number of cases, con- fined to the lower classes—to those engaged in the occupations just noticed, or who have injured themselves by intemperance ; while the classes above them, who have passed safely through the period of from fifteen to thirty or forty years of age, and are free from the incidental excite- ments alluded to, rarely add to the number of deaths from consumption; and may be regarded as having, in a considerable degree, lost what- ever predisposition they had to the disease in an anterior stage of life. Thus again confirm- ing the correctness of the earlier and more com- mon doctrine upon this subject, which refers chiefly to consumption as issuing from a phthis- ical diathesis. Hence a material difference is very generally discernible in the nature of the disease as oc- curing in earlier life, or during the natural range of the predisposition, and as occurring from inci- dental excitements afterward. The first is usually, though not always, of the tubercular variety ; the last, as usually of the catarrhal or apostematous, most commonly of the catarrhal modification, originating from habitual irritation and repeated and neglected inflammation, not at first of an unhealthy character, for the most part more active than tubercular inflammation ; and, where suppuration does not take place freely, leading to a dark-hued or hepatized in- duration. The causes of phthisis, then, are of two kinds; the predisponent, and those that excite the predisposition into action, or operate even where there is no predisposition whatever. Of the nature of the predisponent cause, we know little more than that it appertains to a peculiarity of constitution, which will be noticed presently.* The exciting or occasional causes are very numerous, as mechanical irritation of the lungs from swallowing a piece of bone ; the dust of metallic or other hard substances per- petually inhaled ; frequent and sudden changes of temperature, or exposure of the body to cold when in a heated state and unprepared for it; overaction in speaking, singing, or playing on a wind instrument; the irritation of various other diseases, as worms, scrofula,t syphilis, or mea- sles ; too rapid a growth of the body ; and va- rious passions perpetually preying upon the individual, as mortified ambition, disappointed love, home-longing (R. Hamilton, in Duncan's Med. Comm., xi., p. 343), when at a remote dis- tance from one's friends and country. Examples of consumption from a mechanical irritation of the lungs are peculiarly numerous, and they furnish cases of every variety of the disease, according to the habit or idiosyncrasy, though the apostematous is less frequent than the rest. So common is this complaint among persons employed in dry grinding, or pointing needles in needle-manufactories, that Dr. John- stone, of Worcester, informs us they seldom live to be forty, from the accumulation of the dust of the grindstones in the air-cells of the lungs, and the irritation and suppuration which follow. —(Mem. Med. Soc, v., 1799, p. 89.) Itappears to be little less common among knife and scythe- grinders, whence, according to Dr. Simmons, the disease thus originating is called the grind- er's rot (Pract. Observ. on the Treat, of Con- sumptions, 8vo., 1780); and Wepfer gives an account of its proving endemic at Waldshut, on the Rhine, where there is a cavern in which mill-stones are dug and wrought: the air is al- ways hot, even in the winter, and a very fine dust floats in it, which penetrates leathern bags, and discolours money contained in them. " All the workmen," says he, " become consumptive if they remain there for a year, and some even in a shorter time ; and they all die unless they apply early for assistance."—(Observationes de Affect. Capitis, 4to., Schaff, 1727-8, quoted by Young on Consumptive Diseases, p. 206.) And hence, Dr. Fordyce had much reason for regard- ing the dust of the streets of London as a se- * Many would escape the disease were it not for their being exposed to wet and cold, for want of proper lodging and clothing. These circum- stances, together with unwholesome food, are well known to create a tendency to, and even to excite, scrofulous diseases in general, among which must undoubtedly be placed tubercular phthisis. It is alleged, says Dr. Elliotson, that formerly in Scot- land the people were all dressed in woollen, and phthisis was rare among them; but that since thej have changed it for cotton, the disease has become very prevalent in that country.—Ed. t Tubercular phthisis is considered, by the most accurate pathologists of the present day, as a scrof • ulous disease itself.—Ed. 42 H^EMATICA. [Cl. III.-Okd. IV nous cause ,„ of pulmonic disorders (Trow, of Soc. for the Impr. of Med. and Chir. Knowl- edge, vol. i., p. 252), though it is a cause hat has been much diminished since the introduc- tion of paving and watering.* As these are causes that operate at all ages, consumption among such persons occurs at all ages also ; in patients, however, beyond forty, it may for the most part be regarded as a strictly original dis- ease, the consumptive diathesis having by this time, as already observed, gradually lost its In- fluence. And it is on this account that Dr. Alison regards the tubercular or strumous form as rarely taking place after the age of thirty-five or forty (Edin. Medico-Chir. Transact., vol. i., 1824), thus confirming the ancient, and indeed the common opinion, how much soever opposed by the tables we have already referred to. A lodgment of some fragment of a bone even in the oesophagus has, in like manner, been a fre- quent cause of phthisis, which has often been protracted through a long period of time. Thus Claubry gives a case of this kind which had con- tinued for fourteen years, and the patient seem- ed to be in the last stage of a consumption, when he was fortunate enough to bring up the piece of bone spontaneously, in consequence of which he recovered, though for the preceding four years he had laboured under an haemop- tysis.—(Sedill. Journ. Gen. Med., xxxiv.,p. 13, 1809.) Mr. Holman describes a similar case that had run on for fifteen years, accompanied with cough, haemoptysis, and hectic diarrhoea; and which was also speedily relieved in conse- quence of the bony fragment, three quarters of an inch in length, and apparently carious, being suddenly coughed up after the discharge of a pint of blood.—(Land. Med. Journ., vii., p. 120.) A moderate use of the vocal organs, as of any other, tends to strengthen them, and to enable public speakers, singers, and performers on wind-instruments to go through great exertion without inconvenience, which would be extreme- ly fatiguing to those who are but little practised in any of these branches ; but the labour is often carried too far, and the lungs become habitual- ly irritated, and haemoptysis succeeds. I have known this terminate fatally among clergymen ; who have lamented, when too late, that in the earlier part of life they spent their strength un- sparingly in the duties of the pulpit.t Hence, Dr. Young observes from Rammazini (On Con- sumptive Diseases, p. 264), that public speak- ers, readers, and singers are most liable to pul- monary diseases, and that Morgagni and Val- salva have confirmed the observation. Cicero himself felt it necessary, as he tells us m his book on orators, to retire from the forum for two years, during which he travelled into Asia, and afterward returned with renewed vigour to the duties of his profession; and Moliere died of haemoptysis, immediately after performing, for the fourth time, his Malade Imaginaire.—(Van Swieten, Aph. iv., $ 1201, p. 49.) Many diseases have a peculiar tendency to excite phthisis, from their close connexion with the lungs, or affinity to hectic fever, which is one of its most prominent symptoms. Thus, neglected catarrhs form a frequent foundation, and measles for the same reason. [This hypothesis of the origin of consumption from catarrh is very ancient, but not at present universally admitted. In most phthisical cases, as Laennec allows, the first symptoms are ca- tarrhal ; but, as he also acknowledges, we find very large and very numerous tubercles in sub- jects who exhibit no signs of catarrh. If it be said that the tubercles are the product of for- mer catarrhs, Laennec replies, that they exist in persons who have not had catarrh for years, or even at all. Pulmonary catarrh is, indeed, often the first symptom of tubercular phthisis : this, however, may have existed long in a latent state ; since we find, on examining the chest of such persons, all the physical signs of tubeicles, and sometimes even of tubercles already ex- cavated. On the other hand, thousands of per- sons have catarrh several times every year, and yet very few of them become phthisical—(Op. cit., p. 293.) Some arguments and facts against the doctrine of tubercles being a consequence of pleurisy, peripneumony, and catarrh, are no- ticed by M. Louis. Of eighty phthisical sub- jects, into whose previous history he had partic- ularly inquired, only seven had ever been affected with pneumonia, and four of these had been per- fectly free from any pectoral affection for sev- eral years before the invasion of phthisis. He notices the fact, mentioned by Laennec, of tu- bercles being most frequent in the upper lobes, while peripneumony most commonly occupies the lower. He adds, that pneumonia rarely af- * The diminution of the supposed cause, and the undiminished frequency of consumption, seem to contradict Fordyce's hypothesis.—Ed. t On this subject Dr. John Ware, of Boston, very justly remarks (Med. Dissertations, Boston, 1820), " The most obvious cause of this liability to pulmonary disease in clergymen is the great and long-continued exercise of the lungs, required in the performance of public worship. To this, as the peculiar duty of the profession, our attention is apt to be principally and almost exclusively de- voted ; we are too ready to consider it as a suf- ficient cause in itself; and to avoid examining the influence of other circumstances. It is not found lhat members of other professions who are in the habit of exerting their lungs, are more liable than the average of mankind to pulmonary disease. We do not hear of any extraordinary proportion of deaths from consumption among lawyers, public actors, public singers," &c.—" The reason I be- lieve to be this, that the duties of the profession are only occasional, and occur at too great inter- vals to allow the formation of a habit; while at the same time they are sufficiently difficult to over- exercise, fatigue, and exhaust the organ. They are from the first as long and laborious as they ever will be, and there is no opportunity for that slow and gradual increase which enables one to acquire strength and facility of exertion."—" Oc- casional extraordinary exertion, carried to the point of fatigue, and then omitted until the fatigue is entirely removed, can only have the most inju- rious effect, and it is exactly in this way that the lungs are exercised in preaching. They are wearied by the services of the Sabbath, and are then suffered to remain perfectly at rest through the interval of the week."—D. Gen. HI.—Spe. 5 ] MARASMUS PHTHISIS. 43 fects both lungs, while phthisis almost always does so ; and that the former is most common in men, while the latter is so in women. The same remarks, he says, apply to pleurisy and ca- tarrh, with this addition, that in cases of chronic pleurisy, he has found as many tubercles in the lung of the sound as in that of the diseased side. Out of the eighty cases of phthisis above alluded to, only twenty-three had been partic- ularly subject to catarrh.—(Louis, Recherches, &c, p. 503, et seq.; also, Forbes, in note to transl. of Laennec, p. 323, 2d edit.)] Whether the tubercles found in the substance of the lungs, in the tubercular variety of con- sumption, be, in every instance, strictly scrof- ulous, may admit of a doubt ; that they are so in many cases is unquestionable ; and hence scrofula becomes very generally an exciting, and not unfrequently, perhaps, a primary cause of this disease.* The tendency of the syphilitic poison to pro- * In Great Britain, where strumous habits are admitted to exist much more extensively than in the United States, the connexion between scrofula and consumption ought not to be questioned. In this country scrofula is rare when compared with Great Britain, and yet the mortality by consump- tion is nearly the same as there. To what cir- cumstances is this to be attributed 1 To the ex- traordinary vicissitudes in the climate, " to the mis- chievous influence of a temperature perpetually varying from high degrees of heat to those of cold." Consumption too is evidently increasing among us, and within the city of New-York the weekly num- ber of deaths from this disease within the last five years, has risen from 18 to 36; a ratio of one hundred per cent., while the increase in population is not more than ten per cent.; thus, notwithstanding the improvements in medicine, our treatment is not much more successful than it was formerly: this in- crease may be ascribed partly to the modified habits and manners of our people, especially in the larger cities, where greater errors of life prevail; to impru- dence in dress, improprieties in diet, and the ex- cesses and indiscretions which mark the extremes of society, the rich and the poor. The truth of this remark will be readily seen by comparing the mortality by consumption at the present time with that which prevailed about a century ago. Dr. Colden, speaking of the climate of New-York some ninety years since, remarks, " the air of the country being almost always clear, and its spring strong, we have few consumptions or diseases of the lungs. Persons inclined to be consumptive in England, are often Perfectly cured bv our fine air." —(Am. Med. and Phil. Reg., vol. i., p." 309.) If these premises be allowed as correct, we have strong reason to think that inflammation is the more com- mon cause of consumption, and to regard with more favour than many eminent writers abroad, the principle of the entonic or acute character of the disease. Dr. Rush was unguardedly led into an error in stating that the Indians are exempt from pulmonary disease ; an acute observer, onejvho re- sided long among those "sonsof the forest," re- marks, that consumption is one of the common causes of death among them-—(See Hunter on Diseases of the Indians, in the N. York Med. and Phys. Journal, vol. i.) Nine deaths from the same cause have occurred in the family of the celebrated Indian chief Red-Jacket.—(See Francis on the Mineral Waters of Avon.) The liability of blacks to consumption is well known.—D. duce phthisis has been noticed by almost every writer from the time of Bennet, who particular- ly dwells upon it (Vestibulum Tabidorum, 8vo., 1654, Leyd.); but whether this would be ade- quate to such a purpose without an hereditary predisposition is uncertain.* And the same re- mark may be made respecting worms, which Morgagni has stated to be a very common cause.—(De Morb. Thoracis, lib. ii., Ep. Anat. xxi., 43.) Indeed, any habitual irritation in any part of the alimentary canal, seems capable of exciting a sympathetic action in the lungs : and hence Wilson, in Dr. Duncan's Annals, gives a case of hectic in a child produced by swallow- ing a nail two inches long, which remained in the stomach fifteen months, and was then thrown up, and succeeded by a recovery of health.t Rapid growth is always attended with debil- ity ; and, where there is a predisposition to con- sumption, it often becomes its harbinger. Rich- erand relates a case of this kind that terminated fatally, the individual having grown more than an English foot in a year.—(Sedill. Journ. Gen. Med., xx., p. 255.) I have known a still more rapid growth, without any other inconvenience than that of languor; but, in this case, there was no phthisical predisposition. Where the chest labours under any misfor- mation, we can readily trace another cause of excitement, and are prepared to meet the ex- amples that from this source so frequently oc- cur to us in practice. But it is less easy to explain by v.'hat means persons otherwise de- formed, and particularly those who have had limbs amputated, should be more liable to con- sumption than others ; yet this also is a remark that has been made by Bennet.t Of all the occasional or accidental causes of phthisis, however, frequent and sudden vicis- situdes of temperature are probably the most common (Broussais, ut sup. •; Hastings, Essay on Bronchial Inflammation); so common, in- deed, and at the same time so active, as often to be a cause of consumption in constitutions where we cannot trace any peculiar taint or pre- disposition whatever. Several hundred cases of phthisis from this cause, among which were many fatal ones, occurred in the channel fleet that blockaded the port of Brest in April, 1800. The summer was hot and dry, the duty severe, * " The varieties termed scorbutic, venereal, &c. are all essentially tuberculous, differing only from the common species by the cause (perhaps gra- tuitous) to which the development of the tuber- cles is attributed."—(Laennec, p. 272?) No modern practitioner of any judgment now believes in the existence of a form of phthisis depending upon and kept up by the syphilitic poison.—Ed. t Vol. i., 1796. Our author here, and in some other places, seems not to have made an adequate distinction between phthisis and hectic fever.— ED. t Tabid. Theatr,, p. 99. Perhaps some expla- nation of the circumstance, if true, might be de- duced from the consideration that most amputa- tions, in this country at least, are done for scrof- ulous diseases of joints, and consequently on in- dividuals of strumous diathesis; in whom alone, probably, tubercles of the lungs ever form,—Ed, 44 H^EMATICA. [Cl. III.—Ord. IV the sailors, wet with sweat, were **&«**/**: posed to currents of air at the port-holes; and little time was allowed for refitting. Hence, the most frequent examples of con- sumption are to be found in countries which are most subject to changes of temperature. In Great Britain it is calculated that this disease carries off usually about one fourth of the inhab- itants ; at Paris, about one fifth ; and at Vi- enna, one sixth: while it is by no means com- mon in Russia, and still less so in the West In- dies ;t for it is checked in both regions by the greater uniformity of the atmosphere, whether hotter or colder.% It is a singular fact, and not well accounted for, that of all places which have hitherto been compared, the proportional mortality from consumption appears to have been the greatest at Bristol; and this, not among its occasional visiters, but its permanent inhabi- tants ; and yet, as though in defiance of expe- rience, this very place has been chosen as the great resort of consumptive persons.—(Young, ut supra, p. 42.) Nor does its mineral water seem entitled to any higher compliment than its atmosphere. Dr. Beddoes affirms, in direct terms, that it is of no manner of use.—(Manual of Health, &c, 12mo., Lond., 1806.) Heat,- when above the range of health and entony, is often found a cause as well as cold, though it does not act so manifestly or so rapid- ly. But of its power of action, we have a clear proof in the greater frequency and fatality of consumption among the native troops of hot cli- mates during the fatigues of war, than among * Trotter's Medicina Nautica, vol. iii., p. 325. While Laennec partly admits the truth of the statement respecting the effects of vicissitudes of temperature, he observes, that too light clothing, and the impression of cold, when the body is heat- ed, much more frequently give rise to catarrhs, peripneumonies, and pleurisies, which are not fol- lowed by the tubercular disease; so that he con- cludes that phthisis, when it follows these com- plaints, has been merely accelerated by them, the tubercles having previously existed. In opposi- tion to Dr. Trotter's account, Laennec says, that most naval surgeons whom he has conversed with, inform him that they had scarcely ever known a man become phthisical in the course of a long voyage, and that they had frequently seen sailors who had pulmonary complaints at the time of put- ting to sea, return benefited or cured.—Op. cit., p. 352.—Ed. + If we examine the official records of mortality, we shall find that consumption annually destroys its thousands in the United States also. The sta- tistical tables of Dr. Emerson, of Philadelphia, pre- sent the following as the relative number of deaths by consumption in the principal cities of the union. Deaths by consumption in proportion to the whole mortality—New-York, 1-5,23; Boston, 1-5,54; Baltimore, 1-6,21 ; Philadelphia, 1-6,38. Number of deaths in proportion to the population—New- York, 1-39,36; Baltimore, 1-39,17; Boston, 1,44-93; Philadelphia, 1-47,86. The number of deaths by consumption in the city of New-York during the last seven years, is nearly eight thousand.—D. t Woolcombe (Dr. W.), remarks on the Frequen- cy and Fatality of Diseases, 8vo., London, 1808. Southey (Dr. H. H.), Observations on Pulmonary Consumption, 8vo., Lond., 1814. Europeans who have just been inured to the climate, and have for a less period of time been under the influence of its relaxing agency. " We know at least," observes Dr. Alison, "that a great majority of the inhabitants of these cli- mates, both negroes and Hindoos, are unusual- ly prone to scrofula when they come to temper- ate climates, and even suffer from it, in some instances, in their own, where Europeans are nearly free from it. I was favoured by Dr. Fergusson, lately inspector of hospitals in the Windward and Leeward Islands, with a perusal of the report of the deaths and chief diseases occurring in the army in these colonies, in each quarter, from March, 1816, till March, 1817, dis- tinguishing the deaths among the white and black troops."—(Trans. Medico-Chir. Society Edin., vol. i., p. 397.) According to these re- ports, the average strength of the army, for the entire year, consisted of seven thousand three hundred and thirty-seven whites, and five thou- sand seven hundred and seventy-two blacks : out of which there died of fever, whites, one in 15.3; blacks, one in 151.8: of dysentery, whites, one in 21.4; blacks, one in 58.9 : but of pulmonic disease, whites, one in 89.1 ; blacks, one in 45. "Fever, therefore," remarks Dr. Alison, " caused ten times as great a mortality among the white troops as among the blacks, and dysentery nearly three times as great; but pulmonary complaints caused twice as great a mortality among the blacks as among the whites. The deaths from this cause were one in 10.9 of the whole mortality among the whites ; and one in 2.06 of the whole mortality among the blacks. The pulmonic disease among the black troops was almost exclusively phthisis, which attacked them chiefly in the more eleva- ted situations of the interior of the islands, where the heat is least oppressive, and where the Europeans were most free from the diseases which, to them, are in that climate most fatal."— (Trans. Mcd.-Chir. Soc. Edin., vol. i., p. 398.) On this account we can readily see whence, in numerous instances, a residence in the warm- er regions of Europe proves remedial to oc- casional visiters from colder and less genial coun- tries, although the tables of mortality do not show a much greater immunity from consump- tion among the natives than exists in higher latitudes. Negroes and Hindoos are by no means exempt from this disease ; and we shall presently have to notice, that the southern bor- ders of the Mediterranean give proofs of a fre- quency and fatality that would be sufficient to deter strangers from trying those coasts as a cure, did not daily observation justify our recom- mending them to patients of a more northerly origin.* * An exact comparative view of the degree in which consumption prevails in different parts of the world, has not yet been satisfactorily obtained According to Laennec, the complaint is very rare among the natives of high mountainous countries particularly the Alps. Dr. Forbes thinks it toler' ably well made out, that, in the most northern parts of Europe, particularly Russia, and still morp conspicuously between the tropics, the disease is Gen. III.—Spe. 5.] MARASMUS PHTHISIS. 43 Where a consumptive diathesis has once originated, it is often very evidently transmitted to succeeding generations ; and there is great reason to believe that the disease is in a certain degree contagious. M. Portal, and a few other pathologists of distinction, have doubted or de- nied that it possesses any such property ; but the apparent instances of communication among near relations and close attentive nurses, and especially between husbands and wives, who have fallen victims to it in succession, are so frequent, that its contagious power has been ad- mitted by most practitioners, and in most ages. Aristotle appeals to it as a matter of general be- lief among the Greeks in his day (Problem, sect, i., 7); and it has since been assented to in succession by Galen, Morton, Hoffmann, Vogel, Desault, Morgagni, Darwin, and most modern writers.* I have myself been witness to various cases which could not be ascribed to any other cause ; and Dr. Rush has given an account of a con- sumption manifestly contagious, which spread from the proprietors of an estate among the ne- groes, who were neither related to the first vic- tims, nor had been subjected to fatigue or anx- iety on their account, and among whom it scarcely ever makes its appearance.—(Medical Inquiries and Obs., &c, vol. i., 8vo., Phila., 1789.) The disease, however, is but slightly contagious, admitting it to be so at all; and seems to demand a long and intimate commu- nion, as, for instance, that of sleeping or con- stantly living in the same room, to render the miasm effective. [Respecting the contagious nature of phthisis, the editor must take this opportunity of observ- ing, that a belief in it is not entertained in this country : Laennec distinctly affirms, that the disease does not appear to be contagious in France. When the great frequency of con- sumption, and other pulmonary complaints con- founded with it, is fairly considered, the exten- sive co-existence of such cases, or their con- tinual succession, or seeming transmissions from one individual to another, can be very well ac- counted for, without unnecessarily resorting to the doctrine of contagion. If one fourth or one fifth of the population die phthisical, such events considerably less prevalent than in more temperate climates. It is extremely prevalent in every part of Great Britain, Germany, France, Italy, Spain, and in the islands and on all the coasts of the Mediterranean sea. Laennec believed the inhabi- tants of maritime situations to be less liable to consumption than those who reside away from the sea; but in England this is not found to be the fact.—See note by Dr. Forbes, in Laennec's Trea- tise, p. 324—Ed. * In Languedoc, Spain, Portugal, Italy, and Malta, phthisis is yet regarded as contagious. When the editor was in the latter island, many years ago, a consumptive person could hardly pro- cure a lodging for money; and in Spain and Por- tugal, the clothes of persons who die with con- sumption are burned by the civil authorities. Mor- gagni was so frightened about its contagiousness, that he would not open the bodies of those who died of it.—Ed. must of course be frequent. Is it meant to in- sinuate that all phthisical diseases are conta- gious, notwithstanding the wide difference in their nature, even as viewed by the author of the present work 1 Or is it intended to limit the doctrine exclusively to tubercular consump- tion 1] The diathesis strictly consumptive is usually associated, in the language of Hippocrates (Epidem., v., p. 1142) and Aretaeus (Chron., Diss, i., 10, 12), with a smooth, fair, and ruddy complexion, light or reddish hair, blue eyes, a long neck, a narrow chest, slender form, and high shoulders, or, in the words of Hippocrates-,. • shoulders projecting like wings, ana a sanguine disposition. In some instances, however, the skin is dark, and the hair almost black.* Ac- cording to Dr. Withering and Dr. Darwin, the most constant irlark of a consumptive habit is an unusual magnitude of the pupil, to which some have added long and dark eyelashes ; but this last character seems loose and unestablish- ed. It is a remark far better supported, that the teeth are peculiarly clear, and the eyes ex- ceedingly bright; and that both become more so when the disease has once commenced its inroad ; the former assuming a milky whiteness, and the latter a pearly lustre. Professor Camper, and most physicians ■with him, affirm that this appearance accompanies all the varieties of the disease ; but Dr. Foart Simmons limits it to the tubercular alone, and conceives it to be a distinguishing characteris- tic of this form of the disease, or of a predispo- sition to it. And he remarks further, that, of those who are carried off by tubercular phthisis, the greater number will be found never to have had a carious tooth.—(Practical Obs. on Con- sumption, 8vo., London, 1779.) The earliest symptoms of phthisis, in what- ever manner excited, are insidious, and show themselves obscurely. The patient is, perhaps, sensible of an unusual languor, and breathes with less freedom than formerly, so that his respira- tions are shorter and increased in number. He coughs occasionally, but does not complain of its being troublesome, and rarely expectorates at the same time ; yet, if he make a deep in- spiration, he is sensible of some degree of un- easiness in a particular part of the chest. These symptoms gradually increase, and at length the pulse is found quicker than usual, particularly towards the evening ; a more than ordinary per- spiration takes place in the course of the night; and if the sleep be not disturbed by coughing, a considerable paroxysm of coughing "takes place in the morning, and the patient feels relaxed and enfeebled. This may be said to form the first stage of the disease ; and it is the only hopeful season for the interposition of medical aid. The malady is now decidedly established, * Nearly two thirds of the consumptive patients seen by Dr. S. G. Morton, have had dark eyes and hair, and sallow or dark complexions, and many of the remainder had reddish hair and a sandy complexion.—(See his Illustrations of Pulmonary Consumption, &c, Philadelphia, 1834.)—D- 46 H^EMATICA. [Cl. III.—Ord. IV the cough increases m frequency, and from be- ing dry is accompanied with a purulent mucus, varying, according to the peculiar modification of the disease, from a watery whey-like sanies, occasionally tinged with blood, to a sputum of nearly genuine pus : which, as Aretaeus has well observed, may be livid, deep black, light brown, or light green ; flattened or round ; hard or soft; fetid or without smell.* In many cases it is very scanty; and we may also add, with Aretaeus, that, in some consumptions, there is no expectoration at all : for in the apostematous variety, the sufferer has sometimes died before the vomica has broken. The uneasiness in the chest, only perceived at first on making a deep inspiration, is now permanent, and attended with a sense of weight ;t the hectic fever has as- sumed its full character; the patient can only lie with comfort on one side,*which is usually the side affected ; and the breathing, as Bennet has remarked, is frequently accompanied by a sound like the ticking of a watch. The strength now fails apace; the pulse varies from about a hundred to a hundred and twenty or thirty ; the teeth increase in transparency, and the scleroti- ca of the eye is pearly-white ; " the fingers," to continue the elegant description of Aretaeus, as given by Dr. Young, " are shrunk, except at * In the earliest stage of the disease, according to Dr. Forbes's valuable description, the cough is either quite dry, or attended by a mere watery, or slightly viscid, frothy, and colourless fluid. This, on the approach of the second stage, gradually changes into an opaque, greenish, thicker fluid, intermixed with fine streaks of a yellow colour. At this period, also, the sputa are sometimes in- termixed with small specks of a dead white, or slightly yellow colour, varying from the size of a pin's head to that of a grain of rice. After the complete evacuation of the tubercles, the expec- toration puts on various forms of purulency ; but frequently assumes one particular character, which has always appeared to Dr. Forbes pathognomonic of phthisis, although he says it has been noticed by other pathologists in simple catarrh. This ex- pectoration consists of a series of globular masses, of a whitish yellow colour, with a rugged woolly surface, and somewhat like little balls of cotton or wool. They commonly, but not always, sink in water. They are most common in young scrofulous subjects, in whom the disease is hered- itary. At other times, in cases where these glob- ular masses are observed, and also in those in which they have not appeared, the expectoration assumes the common characters of the pus of an abscess, with an occasional tinge of red, and sometimes more or less fetor.—See Laennec, by Forbes, note, p. 352, 2d edit. t The researches of M. Louis tend to support the opinion, that the pain in phthisis depends upon slight chronic pleurisies, which occasion the adhesions found after death, and not upon the tubercles.—(Recherches, &c, p. 205.) As, how- ever, one direct effect of tubercles in the lungs is to lessen the capacity of these organs for the air of respiration, and to diminish that surface by which the purposes of breathing are accomplished, it is difficult to conceive this approach to suffocation, slow as it is, unattended with more or less un- easiness and pain. The tubercular matter itself, being unorganized, cannot, of course, be suscepti- ble of pain.—Ed. the joints, which become prominent : the nails are bent for want of support, and become pain- ful ; the nose is sharp, the cheeks are red, the eyes sunk, but bright, the countenance as if smiling; the whole body ^ is shrivelled ; the spine projects, instead of sinking, from the de- cay of" the muscles; and the shoulder-blades stand out like the wings of birds." The third stage is melancholy and distressing, but usually of short duration. It commences with a depressing and colliquative diarrhoea; but, till this period, and occasionally indeed through it, the patient supports his spirits, and flatters himself with ultimate success, while all his friends about him are in despondency, and find it difficult to suppress their feelings. The voice becomes hoarse, the fauces aphthous, or the throat ulcerated, with a difficulty of swallow- ing. Dropsy, in various forms, now makes its approach; the limbs are anasarcous, the belly tumid, or the chest fluctuating ; and the oppres- sion is only relieved by an augmentation of the night-sweats or of the diarrhoea; for it is generally to be found, that the one set of symp- toms is less as the other is greater. " A few days before the patient's death, he is frequently unable to expectorate from apparent weakness, and sometimes dies absolutely suffocated: but much more commonly the secretion of pus, as well as the expectoration, has ceased : as if the capillary arteries had lost their power, or the fluids of the system were exhausted. There is also sometimes a degree of languid delirium for some days, and occasionally a total imbecility for a week or two : though, in general, the faculties are entire, and the senses acute, the patient being perfectly alive to the danger and distress of his situation, and retaining, even when his extremities are becoming cold, a con- siderable quickness of hearing and feeling. The closing scene is often painful, but it sometimes consists in the gradual and almost imperceptible approach of a sleep which is the actual com- mencement of death."—(Young on Consumptive Diseases, p. 28.) [One very frequent symptom is not noticed in the preceding account: the editor alludes to a sore oppressive sensation in the throat, attended with a feeling as if an extraneous mass were lodged in the larynx, and generally accompanied by more or less difficulty of swallowing. In numerous cases seen by him, this symptom occurred a few days before death: it depends upon ulceration within the larynx, which is often noticed on dissection. In the dissections performed by M. Louis, the mucous membrane of the trachea was found either red, or somewhat thickened and softened, in one fifth of the cases, and ulcerated in rather less than one third, while the larynx and epiglot- tis were ulcerated in one fifth. According to Bayle, the proportion is one sixth, and to An- dral, three fourths. The ulceration of the larynx and more particularly of the trachea and epiglot- tis, is deemed by M. Louis peculiar to phthisis Dr. Bright says, it is generally betrayed bv the hoarseness of the voice, and the clanging sound which accompanies the cough. The most usual Gen. III.—Spe. 5.] MARASMUS PHTHISIS. 47 seat of it, he observes, is immediately below the rima glottidis, where it begins with one or two very small round ulcers, which soon extend, and become irregular in form, assuming the appear- ance of superficial abrasion. The situation and extent, however, vary a little : sometimes the epiglottis itself is ulcerated, and, occasionally, small independent ulcers take place in the mucous membrane of the trachea, two or three inches below the larynx. When the ulceration in the larynx has taken place early, it has not unfrequently, according to Dr. Bright, drawn the attention both of the patient and the prac- titioner from the more important seat of disease; for the irritation and uneasiness occasioned by it is more forced upon the attention than the inconvenience and dyspnoea, seldom amounting to pain, which accompany the tubercular deposite in the lungs.—(See Bright's Reports of Medical Cases,p. 149, 4to., Lond., 1827.)] Such is the common progress and termination of the disease ; but it varies considerably in the character and combination of its symptoms, and particularly in the tardiness or rapidity of its march, according to the habit or idiosyncrasy of the individual, or the variety of the disease it- self. Where the constitution is firm, and the hereditary predisposition striking, it commonly assumes the apostematous form, and runs on to the fatal goal with prodigious speed, constitu- ting what among the vulgar i3 called, with great force of expression, a galloping consumption. In this case, the activity of the lymphatic, and, indeed, of every other part of the general system, is wonderful: the whole frame is in a state of estuation, and greedily preying upon itself. The animal spirits are more than ordinarily recruited, and all is hope and ardent imagination ; the secernents play with equal vigour, and the skin is drenched with moisture; the bronchial ves- sels are overloaded with mucus, vomica after vomica becomes distended with pus, and the bowels are a mere channel of looseness. The absorbents drink greedily ; and animal oil, cel- lular membrane, parenchyma, and muscle, are all swallowed up ■ and carried away, till every organ* is rapidly reduced to half its proper * This statement should be qualified : it is true, as Laennec explains, that the greater number of phthisical subjects, before they die, fall into that extreme degree of emaciation, from which the Greeks derived the name of the disease. This emaciation is strongly marked in the adipose cel- lular membrane and muscles, but, with the ex- ception of the heart, not at all in the internal organs. The intestines may appear contracted, but this is chiefly owing to their containing very little air. The brain, nerves, genital organs, spleen, pancreas, and other glands, present no marks of emaciation. The bloodvessels usually seem dwindled, owing to the quantity of the circulating fluid having been reduced by copious evacuations and low regimen. The bones are not at all shortened; but Laennec thought that he had frequently noticed, in pro- tracted cases, a diminution of their diameter, and their specific gravity is certainly lessened. The narrowness and contraction of the chest are known to everybody.—(See Laennec, by Forbes, p. 286, 2d edit.) With regard to the heart, the statement of Andral is different from that above given; for weight and bulk, and the entire figure becomes a shrivelled skeleton. So swift was the prog- ress of the disease in the case of the Dutchess de Pienne, that M. Portal informs us she died in ten or twelve days from the first alarm. If, before this, an extensive vomica burst suddenly and with a wide opening into the trachea, or larger bronchial tubes, suffocation follows instantly. If its aperture be small, a purulent matter, often diversicoloured, is ex- pectorated in the course of a violent fit of coughing: the expuition then ceases for a few days, and, at times, with an apparent relief to the patient; but it returns in a short time, and is always ushered by an increase of the febrile state for the preceding four-and-twenty hours. The breath now becomes tainted, and is offen- sive to by-standers ; the appetite is lost, and the lightest foods and most desirable dainties produce a sense of increased languor and anxiety. The patient becomes daily more emaciated : all the symptoms just noticed are exacerbated, till, at length, a supervening colliquative diarrhoea first diminishes, ^nd then totally suppresses the expectoration, and the sufferer turns himself un- expectedly on his back, and, in a very few days afterward, draws up his legs, and, in this position, usually expires suddenly. [A tuberculous cavity sometimes opens into the pleura. In the cases recorded by M. Louis, the rupture was indicated by an instantaneous acute pain at one point of the chest, with dysp- noea and extreme anxiety, followed by the com- mon symptoms of acute pleurisy, and death within a period varying from one to thirty-six days. " In every case of this kind," says Dr. Forbes, " the diagnosis derives unerring cer- tainty from auscultation and percussion." In five of the eases described by M. Louis, the perforation took place opposite the angle of the third and fourth ribs of the left side, and it did the same in a case attended by Dr. Forbes.— (See Laennec, by Forbes, p. 341 ; and Louis sur la Phthisie, ch. vii., p. 446.)]* On other occasions the ma^ch of the con- sumption is remarkable for its tardiness. This is particularly the case with the tubercular variety, when not quickened in its pace by re- turns of haemoptysis. Hoffmann gives instances of two or three who lived under the disease for he observes, that although, in several diseases which carry off the patients in a very emaciated condition, the heart partakes of the atrophy of the rest of the muscular system, this is not constantly the case, and the hearts of many consumptive per- sons, who die in the extreme of marasmus, are quite free from atrophy. If, in such a case, the heart should appear diminished in size, it is be- cause, being empty of blood, it has contracted; its cavities are small, hut its parietes are of their natural thickness.—Andral, Anat. Pathol., torn. ii., p. 288.—Ed. * Dr. Morton, in his valuable Illustrations of Pulmonary Consumption already cited, has figured a case (PI. viii., ix.), in which pus passed between two ribs, infiltrated into the muscles of the back where a large abscess formed, by which the spinous processes of several vertebras were exposed.—D. 43 HjEMATICA. [Cl.Ill—Ord. IV. thirty years :* and in the Edinburgh Communi- cations is the case of an individual, who passed nearly the whole of a long life under its in- fluence, who was consumptive from eighteen to seventy-two, and died of the complaint at last. Of two hundred cases, however, selected by M. Bayle, a hundred and four died within nine months, which may hence be regarded as the mean term. Dissections concur in showing, in almost every instance, an indurated and ulcerated state of the lungs, while the changes thus exhibited vary greatly in the morbid structure they de- velop ; the more obvious of which, though perhaps constituting the two extremes of these changes, are the white and the dark-coloured or hepatized knobs. The first seems to move for- ward to a state of inflammation with a slow and pausing step, and forms the basis of the tuber- cular variety before us. The second is more rapid and uniform in its action, and constitutes the catarrhal or purulent modifications. While, not unfrequently, we meet with both these appearances intermixed in every possible pro- portion. Yet we perceive, concurrently with the diagnostics of the disease, that its most fre- quent form is the tubercular; so much so, indeed, that M. Laennec has confined his at- tention to this variety alone, and will hardly admit of any other.—(De VAuscultation Me- diate ; ou Traitk du Diagnostic des Maladies des Poumons, &c, 2 tomes, Paris, 1819.) The tubercles are found indiscriminately in all parts of the cellular texture of the lungs, but more abundantly at the upper and posterior parts. As already observed, they exhibit every diver- sity of size ; are often very minute, but more generally consist of those circumscribed nodules or indurations which Wesser has called gran- dines. They are whitish and opaque, like small absorbent glands, but sometimes more trans- parent, like cartilage, with black dots in their substance. They augment by degrees, till they are half an inch or more in diameter; but in general, when they have acquired the size of large peas, they begin to soften in the centre, and then open by one or more small apertures into the neighbouring bronchia?, or remain for a longer time closed, and constitute small vomicae, containing a curdy half-formed pus. Occasion- ally, as we have stated, they are found to unite into large abscesses.t [Whatever be the form under which the tubercular matter is developed, it presents at first, according to Laennec,J the * In 1828, a person named Robert Jeffries, aged 56, died in the Fleet prison, who had had a cough and shortness of breath for thirty years, and whose lungs were found, after death, filled with tubercles and abscesses.—Ed. t Young, ut supra. Portal, Observations sur la Nature et le Traitement de la Phthisie. Bayle, Recherches sur la Phthisie Pulmonaire, Paris, 1810. t On Diseases of the Chest, by Forbes, 2d edit., p. 272. Andral objects to Laennec's view, that if a tubercle necessarily began as a grayish semi- transparent granulation, this would be found in every situation where tubercles are met with. But, he asks, have such granulations ever been appearance of a gray, semi-transparent gran- ulation, which gradually becomes yellow, opaque, and very dense. Afterward it softens, and gradually acquires a fluidity nearly equal to that of pus. It is then expelled through the bronchiae, and cavities are left, vulgarly called ulcers of the lungs, but which Laennec designated tubercular excavations. ] Now as we have before observed from Dr. Baillie, that nothing like a gland is to be found in the cellular membrane of the lungs in a sound state, constituting the seat of these tubercles,* and as scrofula selects for its abode a glandular structure, tubercular consumption cannot perhaps with strict propriety be called a scrofulous disease ; yet as the untempered fluid contained in the tubercles resembles that of scrofula, and, more especially, as this variety of consumption is very generally found in con- stitutions distinctly scrofulous, the analogy be- tween the two is extremely close, and has often led to a similar mode of treatment. M. Portal, indeed, contends that glands exist in great num- bers through the whole structure of the lungs, but rather from analogy than from demonstration. And to the same effect M. Laennec ; " The noticed in lymphatic glands, in which a tubercle can be examined in every stage of its progress 1 Have they ever been seen in the brain, liver, spleen, or the cellular tissue under mucous or serous membranes, or between the muscles ? The small, grayish, irregularly globular bodies, dis- persed sometimes over the free surface of serous membranes, he contends, are as different as pos- sible from ordinary granulations of the lungs. As for the grayish granulations, sometimes noticed on the surface of mucous membranes, they seem to Andral to be merely enlarged follicles. At the same time, he admits that tubercular matter may be Jormed within granulations of the lungs. —Anat. Pathol., torn, i., p. 411.—Ed. * This doctrine does not coincide with Andral's observations, whose researches lead him to con- sider tubercles as a secretion, which may take place indifferently, either in the ultimate bronchial tubes and air-cells, in (he cellular tissue interposed between these, or in the interlobular cellular texture. He inclines to the opinion, adopted also by Professor Carswell, that the tubercular matter is at first liquid, and afterward becomes solid ; and that a congestion, and even inflammation, are often concerned in giving rise to their production. " Observation proves," says he, " that the tuber- cular matter may be deposited on the surface of the mucous lining of the bronchiae or air-cells, or in the cellular tissue uniting together the different parts of tfie lung." M. Magendie, and subsequently M. Cruveilhier, promulgated the opinion, that tubercular matter might be formed in the ulti- mate ramifications of the bronchiae; and Andral confirms its truth by various facts, and, among others, by the appearances found in the lungs of a glandered horse. Andral also proves, by dissec- tion, that tubercles may sometimes occur primarily in the lymphatic glands within the lungs; and he relates two rare instances, in which the tubercular matter tilled the superficial lymphatic vessels of the lungs, and, m one of the cases, the lymphatics of other parts, and likewise the thoracic duct- (See Clinique Med., torn, iii., p 13-'?(n Tho corroboration of Andral's views by Professor Cars well's observations, as given in his Tlln^LY of the Elementary Forms of D^ase flsc f'T3 been noticed in the foregoing pages.—En. rs PHTHISIS. 49 Gen. III.—Spe. 5.] MARASMU tubercles in the lungs," says he, " differ in no respect from those situated in the glands; and which, under the name of scrofula, after being softened and evacuated, are often followed by a perfect cure:" Here, however, the hollows are not incarned or filled up with a new material, but have their surfaces covered with a semi- cartilaginous membrane, which, as they thus heal, leave as many sound fistulse as there were formerly tubercles. In some cases; proper abscesses or larger vomicae are found without any trace of tubercles : and especially when the disease has rapidly fol- lowed peripneumony, or taken place in persons of robust or plethoric habits. And when the catarrhal symptoms have been striking, and, in the increasing hoarseness and free discharge of muculent pus, have evinced extensive inflamma- tion on the surface of the trachea, M. Portal has found the whole extent of the tube lined by a crust resembling bone. In some instances, the lungs, from the accretion of new matter, have weighed not less than five or six pounds, which is nearly four times their ordinary weight; but, in others, they have been so reduced as, in the language of the same writer, to leave "a vacant Space" in the chest; or, in that of M. Bayle, "to be shrivelled into leather." On this ac- count, breathing would be impossible, if it were „ not that the lungs in a state of health are capa- ble of containing ten times as much air as is received by an ordinary act of inspiration ; and hence are capable of losing a very large portion of their capacity without suffocation. In some cases, one lung has been entirely destroyed, and the office of respiration maintained by the remaining lung alone for many years.—(Boneti Sepulchr., lib. i., sect, ii., obs. 167; Parotti, Raccolti d'Opuscoli Sciennfwi, xlvi., p. 275.) In other cases, blood, and even pin6 have been thrown up from time to time in considerable quantities without the least trace of ulceration, or breach of continuity in the membrane, or any part of the structure of the lungs.—(De Haen, Ratio Med., i., xi., p 60; Willan's Reports, 1796, March 20.) [Laennec has particularly invited the atten- tion of practitioners to the successive develop- ment of tubercles in different parts of the lungs, as very important in a therapeutical point of view. Tubercles, he says, begin to show them- selves in the first place, almost always in the top of the upper lobes, more particulaily the right; and it is in these points that tubercular excavations of large size are most commonly met with. M. Louis coincides with Stark in stating, that such excavations are nearer the posterior than the anterior part of the lungs. According to Laennec, it is by .iO means un- frequent here to meet with cavities of this kind, when the rest of the lungs is quite sound, and does not contain a single tubercle ; but, in this class of cases, the symptoms have only been equivocal, and the patient has died of some other disease. It is much more usual, how- ever, to find one single excavation and several crude tubercles, in a pretty advanced state, in the upper part of the lungs; and the remainder of Vol,. II—D these organs, though still crepitous, and in other respects sound, crowded with innumerable tu- bercles of the miliary kind, extremely small, semi-transparent, and hardly any of them with the yellow speck in the centre. This secondary crop of tubercles Laennec represents as being produced about the time when the first set be- gin to Le softened. A third, still later crop, composed of crude miliary tubercles, with some yellow points in their centre, is situated still lower , and, finally, the basis and inferior edge exhibit the most recent formation of all.—(Op. cit.,p. 282.) The preceding account, given by Laennec, of the greater frequency of tubercles in the right than the left lung, does not agree with the state- ments of other distinguished pathologists. Of thirty-eight cases, in which M. Louis found one upper lobe wholly disorganized, twenty-eight were on the left side ; of eight cases of perfora- tion, seven were on the left side ; and of the seven cases in which the tubercles were con- fined to one lung, five were on the left side.— (Recherches sur la Phthisie Pulmon., p. 7, et seq.) According to Stark, the left lungs are more frequently affected than the right; an ob- servation agreeing with the researches of Dr. C. Smyth.—(See note by Forbes in Laennec, p. 283.) The secondary production of tuber- cles is not confined to the lungs ; and, at the period when the first crop is being softened, others make their appearance in various other organs. In fact, it is observed by Laennec that it is very rare in phthisical subjects to find these bodies only in the lungs ; they almost always exist at the same time in the coats of the intes- tines, where they give rise to ulcers, which be- come the cause of the colliquative diarrhoea so often accompanying phthisis.^-(Op. cit., p. 284.) With respect to the origin of intestinal ul- cers, as described by Laennec and Dr. Bright, Andral admits that it may be the case in some instances but he contends that it is not so in all; for he has examined the bodies of several phthisical subjects, where the intestines pre- sented an infinite number of ulcers, yet without any appearance countenancing the idea that they had originated in tubercles under the mu- cous membrane.—(G. Andral, Anat. Pathol., torn, ii., p. 95,) In five sixths of the cases ad- verted to by M. Louis, the small intestines were more or less ulcerated. The ulcers were also nearly as frequent in the large intestines, the whole, or a great portion of the mucous mem- brane of which, in one half of the cases, although often red and thickened, was as soft as mucus. In only three cases did M. Louis find the large intestines universally healthy.—(Louis, Recher- ches Anal. Pathol, sur la Phthisie, p. 175, Pa- ris, 1825.) In sixty-seven cases out of a hun- dred, Bayle also found the intestines in a state of ulceration; while Andral's dissections* con- * Andral, Clinique Med., torn, iii., p. 306. In his latter publication he remarks, that in phthisis the digestive canal is so commonly unsound, that this state may be considered, in some measure, as one of the elements of phthisis, and almost a constitu 6463 50 H.EMATICA. [Cl. III.—One. IV firm all these reports by the fact, recorded in his most valuable work, that the intestines were perfectly sound in only one fifth of all the nu- merous cases under M. Lerminier in La Char- he. The morbid changes in the mucous mem- brane of the intestines in phthisis are particu- larly noticed by Dr. Bright. They are denoted, he says, by unequivocal symptoms during life, and are traced in two different forms after death; " sometimes giving proof of a diffused irritation along the Whole membrane from the pylorus to the termination of the rectum, evinced by in- creased vascularity, or by the appearance of in- numerable minute black specks, which give a general gray colour to all the parts where they are most frequent; and sometimes affording evidence of a more severe affection, by the for- mation of numerous ulcers, which are found sometimes in the upper part of the duodenum, frequently dispersed along the whole course of the small intestines, but usually most abundant about the valve, and through the whole extent of the colon. These ulcers, as found in the small intestines, are usually, in the first place, very small and circular, and appear to originate from round, opaque, white bodies, about the size of half a sweet pea ; but, whether these are al- together morbid tubercles, or are only enlarged mucous glands, it is no easy matter to decide. Certain it is, that they are most generally placed in that part of the circumference of the intes- tines which is most distant from the mesentery, and where the mucous follicular structure is most developed."—The ulceration of the large intestines is, according to Dr. Bright, most con- spicuous about the coecum and valve of the co- lon, where it also begins, as in the small intes- tines, by opaque deposites ; but the disease pro- ceeds to a much greater extent, sometimes in- volving the coecum in one continued ulcer, and occasionally, though rarely, affecting the lining of the vermiform process itself. In the colon, the ulcers are generally oval, with elevated edges, and more or less distributed along the sides of the longitudinal bands. They are fre- quently found as low as the sigmoid flexure, and sometimes even in the rectum. They appear to Dr. Bright occasionally to undergo a healing process, their tubercular edges becoming soft- ened down, and their flattened edges adhering ent part of it. In about four fifths of consumptive patients who die in an advanced stage of this dis- ease, the intestines are found seriously affected. Ulcerations are the most common change in them, and ordinarily situated at the end of the small in- testines, and in the coecum. Varying in number, shape, and size, and occupying (though not con- stantly) the follicles of Peyer, they are produced most frequently without pain, and occasion mere- ly a more or less copious looseness. Even in the very commencement of phthisis, it is not uncom- mon to observe slight marks of intestinal irritation, alternations of constipation and diarrhoea, the lat- ter gradually becoming permanent, like the lesion on which it depends.—(Anat. Pathol., torn, ii., p. 222.) The great opportunities which I have had of observing the progress of phthisis in the branch- es of the public service with which I am con- nected, lead me to recognise fully the truth of these valaable observations.—Ed. to the parts denuded by ulceration ; but he states that this is not a frequent occurrence, because the more usual course of phthisis is to go on from worse to worse till it terminates in death ; and little attempt is made by practitioners to change the condition of the intestines, while they consider the more urgent disease to be in another organ.—(Reports of Medical Cases, p. 151, 4to., Lond., 1827.) Sometimes, when phthisis is accompanied by numerous ulcerations of the intestinal canal, one of them makes its way completely through the bowel, and the imme- diate cause of the patient's death is peritonitis. —(G. Andral, Anat. Pathol.T torn, ii., p. 106.) The inflammation thus excited in the peritoneum is generally acute and rapidly fatal; but some- times of a chronic character, with symptoms of slower progress. Thus, Andral says, be can never forget the case of a consumptive young man, from whose navel, one day, an ascaris lumbri- coides was discharged. He lived several weeks after the occurrence, the fistulous opening daily emitting a small quantity of matter resembling what the intestines usually contain. Examina- tion of the body after death disclosed the exist- ence of chronic peritonitis, with numerous pseu- do-membranes, between which were formed sev- eral worms of the above kind, floating in the extravasated matter, some of which issued from the navel every day.—(Op. cit., vol. cit.,p. 114.) Besides the morbid appearances already men- tioned as often complicating phthisis, are to be enumerated a softening of the mucous coat of the stomach, and frequently a general attenua- tion of all its coats ; but, according to Andral, it is not usual to meet with ulcerations or tuber- cles in it (Andral, Anat. Pathol., torn, ii., p. 222), an increased vascularity and softened state of the brain, and disease of the absorbent glands of the bronchiae and mesentery. In phthisical persons, the cartilages of the ribs and larynx are observed to become prematurely ossified.—(An- dral, Anat. Pathol., torn, i., p. 300.) Many ingenious experiments have been in- vented to distinguish between pus and mucus, in order to determine the actual nature of the disease. Such trials may gratify the curiosity of the pathologists, but from the variable and frequently complicated nature of the expectora- tion, as well in the most dangerous as in the earlier stages of the complaint, we can derive little assistance from this distinction. Mr. Hunt- er, as»a test, employed muriate of ammonia, having observed that a drop of pus, united with a drop of this fluid, is rendered soapy, while nei- ther blood nor mucus is affected by it.—(See Apostema Commune, vol. i.,503.) Mr. Charles Darwin— " ™ eu ""stride puer ! si qua fata aspera rumpas Tu Marcellus eris"— proposed a double test of sulphuric acid and a solution of pure potass. If, on the addition of water to pus dissolved in each of these seoar- ately, there be a powerful precipitation the matter made use of is determined to be Pus • if there be no precipitation in either, it is mucus But the simplest and truest character of nus as was first observed and described by Sir Ever'aid Gen. III.—Spe. 5.] MARASMUS PHTHISIS. 51 Home, is, that it is a whitish fluid composed of globules contained in a transparent liquid ; that it does not coagulate by heat; and is only con- densed by alcohol. The presence of the glob- ules, as remarked by Dr. Young, may be easily determined by putting a small quantity of the liquid between two pieces of plate-glass. If it be pus, we shall perceive, on looking through it towards a candle placed a little way off, the ap- pearance, even in the daytime, of a bright cir- cular corona of. colours, of which the candle will be the centre ; a red area surrounded by a circle of green, and this again by another of red ; the colours being so much the brighter, as the glob- ules are more numerous and more equable. If- the substance be simply mucus, there will be no rings of colours ; though a confused coloured halo may sometimes be perceived by the mixture of mucus with blood or some other material. As, however, consumption is by far more fre- quently a tubercular than a strictly purulent dis- ease, and, perhaps, more generally fatal under the former than under the latter modification, the distinction here sought for is of less impor- tance. It is of more consequence to ascertain whether morbid excavations from any cause, ul- cerative or tubercular, have taken place at all; and to this point the attention of physicians has been peculiarly directed, for the purpose, if pos- sible, of obtaining a criterion. It is now well known that M. Avenbrugger of Vienna suggested, more than half a century ago, the possibility of determining whether there were such morbid hollows, or other diseased condition of the chest, by the means of percus- sion by the hand (Inventum Novum ex Percus- sione Thoracis Humani, Vienna, 8vo., 1761): and that M. Corvisart was so much impressed with the importance of the suggestion, that he not only translated Avenbrugger's work on the subject from the German into the French tongue, but recommended his method warmly in his Clinical Lectures, and employed it so generally in his practice as to obtain for it a considerable degree of reputation. There is no doubt of its giving us a correct information at times: but the whole process is accompanied with difficul- ties which we shall notice presently, and its ap- plication is also of limited use. To remedy these evils, M. Laennec, from an early period of his life, conceived it possible to attain the same end, and with much greater exactness, by an acoustic instrument.* His mind was directed * De l'Auscultation Mediate, ou Traite du Diagnostique des Maladies des Poumons et du Coeur, 2 torn., 8vo., Paris, 1819. Two years pre- viously, M. Donble had brought out his Semei- ologie Generale, in which he mentions ausculta- tion as a method peculiar to himself.—(See torn. ii., p. 31.) In the history of auscultation is a cu- rious passage in Hook's Posthumous Works, p. 39, who, though not of the medical profession, actually foretold, as Dr. Elliotson has observed, the invention and uses of the stethoscope. The following short biographical notice of Avenbrugger is from the pen of Dr. Forbes :—Avenbrugger was born at Graets in Styria, in 1722. He gradu- ated at Vienna, and afterward became physician in ordinary of the Spanish nation, in the Imperial to the fact, that if the ear be applied to one end of a beam of wood, we may distinctly hear the scratch of a pin when made at the other end : and, taking advantage of this hint, he first made a roll of a sheet of paper, wound up close, and well tied, when " applying," says he, " one end of it to the region of the praecordia, and placing the ear at the other end, I was as much surprised as gratified on hearing the heart beat more clearly and distinctly than I had ever done by a direct application of the ear itself." And hence he foresaw that the same instrument might also be employed to ascertain a variety of modifi- cations in the pulsation of the heart and the larger arteries. Having .experimented upon a series of sub- stances, he found that bodies of such a density as folded paper, wood, or cane, were best calcu- lated for the purpose; and he at length fixed upon a cylinder of wood of a foot long, and an inch and a half in diameter, with a bore or canal in the centre three lines in diameter. To render this instrument more portable, he made it divis- ible in the middle, like a German flute, the parts, however, being united by a screw. When this cylinder, to which he gives the name of a stethoscope, is applied to the chest of a healthy person in the act of speaking or singing, nothing is heard but a kind of low mur- muring, more distinct in some parts of the chest than in others : yet where an ulcer or other morbid excavation exists in the lungs, a very singular change takes place ; for the voice of the invalid is no longer heard by the disengaged ear, but comes entire to the observant ear that is applied to the end of the cylinder opposite to that affixed to the chest. This phenomenon M. Laennec ascribes to the greater degree of strength which the vocal sound exercises in a cavity of wider calibre than the bronchia? them- selves. And the opinion is rendered probable as the same phenomenon occurs when the cyl- inder is applied to the trachea or larynx. To this apparent transfer of the voice to the chest, the experimenter has given the awkward name of pectoriloquism, or mediate auscultation of the voice. And as the same instrument, or with slight variations, is capable of determining the morbid changes that take place in the breathing or contraction of the heart, he hence employs it in like manner to obtain a mediate ausculta- tion of the respiration, or of the pulsation of the heart, or the aorta. For the first of these two purposes, however, the canal should be Hospital in that city. In Ersh and Puchelt's Lit- eratur der Medicin, he is recorded as the author of two other works, relating to madness, one in Latin, published in 1776, and the other in Ger- man, in 1783. In the same record, Avenbrugger is stated to have died so late as the year 1809, in the 87th year of his age. The Inventum Novum was first translated into French in 1770, by Ro- ziere ; but the subject attracted little attention till a second translation was published by Corvisart in 1808. The only English translation came out in 1824, with a selection of Corvisart's Commen- taries, and additional notes.—-.See Original Cases, &c, by John Forbes, M. D., 1824; and art. Aus- cultation, in Cyclopaedia of Pract. Med.—Ed. 52 H^EMATICA. Cl. III.—Ord. IV. gradually widened at the end applied to the chest, in a funnel-form, to an ascent of about an inch, and then suffered to return suddenly to its general calibre. For the second purpose the canal should be entirely obliterated, which may be easily done by a plug of the same kind of wood; the pulses being propagated through the cylinder by vibratory chords.* Percussion and auscultation are used simultaneously by many physicians in France ; they were so by Laennec himself; and their comparative pretensions have been ably esti- mated in the same country by Dr. Colin (Des Diverses Methodes d'Exploration de la Poitrine, Paris, 1824), as they have in our own by Dr. Forbes.—(Original Cases, &c, 8vo., Lon- don, 1824.) The diseases in which the former method is chiefly employed, are phthisis, dropsy of the chest, chronic pleurisy, chronic peripneumony, emphysema of the lungs, pneumo-thorax, or a morbid communication of the interior of the lungs with the thoracic cavity, and hypertrophy of the heart, or a morbid enlargement of its substance. In the use of this kind of exploration, the patient should be in a sitting posture, the points of the fingers brought close together may be employed, or the flat of the hand, and either upon the naked chest or with the body linen drawn tight over it. The action of percussion is applied, as circumstances may direct, to the forepart of the chest, the sides, or the back. In the first of which cases, the patient is to hold his head erect, and throw back his shoul- ders, that the chest may be protruded, and the skin and muscles drawn tight over its bones, by which the sound is rendered most distinct. In striking the lateral parts of the chest, the pa- tient is to hold his arms across his head, so that the walls of the thorax may become tense, and the sounds rise distinct, as in the former in- stance. If the back be operated upon, the pa- tient is for the same reason to bend forward, and draw his shoulders towards the anterior part of the chest, hereby rounding the dorsal region. The degree of percussion is to be va- ried according to the subject and the place ; so that a more powerful impulse is to be em- ployed in a fat or robust, than in a slender and emaciated subject; for the stroke that is suffi- cient to educe a clear sound in the latter case, may draw forth none in the former. The amount of the sound must depend upon the general sum of the hollow contained in the chest, as in striking a cask, to which M. Aven- brugger very forcibly compares it. And hence, to determine whether this amount be more or less than it ought, it is necessary we should be- come first acquainted with its character in a healthy state, and accustom ourselves to the * De 1'Auscultation Mediate, &c.,par R. T. H. Laennec, 1818. For a particular description of the construction of the stethoscope, consult Dr. Wil- liams's Rational Exposition of Physical Signs, ed. 2, 1833. The best maker of stethoscopes that he has been able to meet with, is Grumbridge, turner, 42 Poland-street, Oxford-street.—Ed. percussion of those who are well. Its changes from this standard are of three kinds: it may be greater or stronger than natural; dull or ob- scure ; or totally wanting. The first takes place where the cavity or hollow is enlarged, as in emphysema of the lungs, which, so to speak, resembles a cask comparatively empty, or rather containing a large volume of air : the second in oedema of the lungs, severe catarrh, or the earlier stage of peripneumony; in which the interior is more than usually occupied with dense matter: and the third in a tuberculated or he- patized state of the lungs, or when they are crowded with any other morbid secretion or in- duration, so as to be choked up, and leave no room for resonance. The chief difficulties attending the diagnostic of percussion, are the long habit required for its use before it can be employed with any ad- vantage, and the peculiar tact or address with which the stroke must be applied to produce its proper effect : the limited power of our having recourse to it in many cases of females, on the score of delicacy ; and its occasional uselessness, perhaps deception, in other cases. Thus it is altogether unavailing in patients pos- sessing much corpulence ; and, although it af^ fords a pretty clear indication in hydrothorax, when the chest is but partially loaded, and hr peripneumony, before suppuration has taken place, yet as no sound is yielded when the chest is quite full of fluid, and a very different sound to what was at first elicited when a vomica has burst, both these diseases may be mistaken in their most important stage. In nervous coughs, asthmas, dyspnoeas, and polypous con- cretions about the heart in young subjects, M. Avenbrugger himself admits the total ineffi- ciency of his method. The diagnostic of auscultation has some advantage in most of these respects. It is employed, as we have already observed, for three distinct purposes; as a test of the voice, of the respiration, and of the action of the heart and aorta. When employed for the first purpose, or that of determining the state of the voice, it affords, under different circumstances, four different kinds of measure : as that of its degree of in- tensity, which M. Laennec has denominated resonance; its articulation, to which, as above stated, he has given the name of pectoriloquism; its suppression, or under-tone, which, from its supposed resemblance to the voice of goats, he has called agophomsm; and its vibratory clink, distinguished by the name of metallic tinkling. The first of these tests, when existing in a higher tone than natural, is supposed, for the most part, to indicate a certain degree of indu- ration in the substance of the lungs. The sec- ond, or that of pectoriloquism, we have already noticed : it is a measurer of tubercular excava- tions communicating with the bronchia. The third indicates, in the opinion of M. Laennec a flattening of the bronchial tubes. And the fourth a morbid communication of the interior of the lungs with the cavity of the chest Where the stethoscope, or chest-sound, is Gen. Ill—Spe. 5.] MARASMUS PHTHISIS. 53 employed as a measure of the respiration, it runs parallel with the modifications of percus- sion, and determines its intensity, its atony, and its absence ; and detects also its combination with foreign sounds. Under the first modifica- tion it strikes the ear like the strong and sono- rous breathing of children, into which the ac- tion of the trachea greatly enters ; and on this account, the present modification is distin- guished by M. Laennec by the name of puerile, or tracheal. It occurs especially in cases in which an entire lung, or a considerable portion of both, is rendered impervious to air, and par- ticularly in acute diseases. The modifications of a weak or absent respiration upon the use of the cylinder indicate a general obstruction in the respiratory organ, and only vary in the de- gree or extent of such morbid change ; and hence, as in the parallel modifications of per- cussion, they become tests of certain different stages of hydrothorax and peripneumony. The foreign sounds with which the cylinder detects the respiration to be occasionally combined, are various kinds of rale or rattle, to which the in- ventor of the present method has given the name of crepitous, and subcrepitous, mucous, sonorous, sibilous. The first, or crepitous rat- tle, is denominated from its resembling in sound the crepitation of salt in a heated vessel, or that emitted by frying butter. It is supposed to be a pathognomonic sign in peripneumony on' its first attack, and occurs sometimes in haemop- tysis. The subcrepitous is an under-sound of the same kind, and indicates an oedematous state of the lungs. The mucous rattle is that pecu- liar kind of stertor called" the dead rattles" by the vulgar of our own country, though in a less degree of intensity. It is produced by a trans- mission of the breath through fluids accumu- lated in the trachea or bronchiae, and measures the extent of such accumulation in catarrhal phthisis, haemoptysis, and other important dis- eases. The sonorous and sibilous rattle are of less importance as diagnostics, and exhibit con- siderable ramifications in their character. The former gives sometimes a loud, and sometimes a deep snore, and sometimes the cooing of a' wood-pigeon ; the latter consists of a whizzing, or whispering tone, or of chirping like that of birds, often alternately ceasing and renewing its murmur. Both descriptions indicate some par- tial obstruction of the bronchial tubes ; the lat- ter perhaps of the smaller cells. But the method of mediate auscultation is also employed to determine the degree of the strength and action of the heart. And it is supposed to do this in four distinct ways : by measuring the extent of the pulsation; its shock or impulse ; its sound; and its rhythm. In a healthy person, of moderate stoutness, and well-proportioned heart, the action of this last organ, upon an application of the stetho-. scope, is not found to extend beyond the range of the cardiac region, or the space comprised between the cartilages of the fifth and seventh ribs, and under the lower end of the sternum. It is, however, often traced, in a state of dis- ease, through the whole of the left or the right side of the chest, as well as in the region pos- terior to them : which is generally owing to the feebleness of the heart, and the extenuation of its walls. It may therefore be taken as a gen- eral rule, according to M. Laennec, that a per- ceptible extent of the heart:s action is in the direct ratio of its .thinness and weakness, or inversely to its substance and power. A wide range of sound is often, indeed, traced when the heart is enlarged ; but in this case its walls are often morbidly slender ; and the enlarge- ment consists in a mere dilatation of its ventri- cles. And hence this diseased extent of action is often traced in particular kinds of a hyper- trophy of the organ. The heart is also frequently found to be here- by affected in the shock or impulse of its stroke. The stouter and thicker the walls of the heart, the more violent is the impulse, in- somuch that, as we have already had occasion to observe, the bed-clothes have sometimes been seen to be hereby elevated. This impulse is peculiarly caught hold of by the stethoscope : and is in some cases so energetic as even to lift up the observer's head, and to give an un- pleasant shock te his ear. In proper hypertro- phies, therefore, or such enlargements of the heart as are opposed to the preceding, in which the natural cavities are not much interfered with, and the augment consists altogether in a thickening of the parietes, we have reason to expect the present effect; which, in like man- ner, becomes a pathognomonic sign of such a disorder, and indicates its existence. -The stethoscope, also, measures the sound of the heart's pulsation. When the action of the heart is peculiarly violent, as in vehement palpitations, the individual himself becomes sensible of a peculiar souad, as well as of an increased impulse ; and it has, indeed, in a few rare cases, been heard at a distance from the patient's person. Now, the application of the stethoscope heightens the sound of the pulsa- tion considerably at all times, insomuch that, in its ordinary tenour of health, it communi- cates a certain degree of sonorous vibration, which cannot be perceived otherwise ; the sound, however, produced by the contract on of the ventricles, and which is accompanied by the stroke of the pulse, being much clearer than that produced by the contraction or systole of the auricles, so that there is at all times to the ear of the experimenter a double or alter- nate sound, consisting of a louder volume suc- ceeded by a lower. The seat of this double sound, in a state of health, is the cardiac region, to which it is limited ; but in a state of disease it spreads much wider, and is heard distinctly in other places. The sound, moreover, varies from the standard of health both in intensity and in hebetude. Where the diameter of the heart is enlarged by a dilatation of its cavities, while its walls are weakened and rendered thin- ner, the sound is loud and distinct; but where, on the contrary, its walls are considerably thickened and enlarged, the cavities remaining but little disturbed, the sound is morbidly dull or obscure; and where the same organic thick- 54 H.EMATICA. [Cl. III.—Orb. Vf. ening exists in considerable excess, ^ contrac tion of the ventricles produces a mere shock or impulse without any sound whatever. The sound, moreover, is not only varied m its intensity, but in its vibration from a natural state It is sometimes accompanied with a peculiar hissing, like that of a pair of bellows, and is in this state either continuous or inter- mittent, indicating, according to M. Laennec, a spasm or some other temporary and partial ob- struction of the first organs of the circulating system. At other times, the accompanying noise is like that of a rasp or file ; which is always permanent, and evinces a permanent ob- struction in some of the orifices of the heart. And in one or two instances, Dr. Colin has ob- served it combined with a crackling like that of new leather, which he supposes to be a pathog- nomonic indication of an inflammation of the pericardium, from fcis having traced this affec- tion in a person who died during its existence. The stethoscope is also supposed to detect in a peculiar degree the rhythm or relative du- ration and succession of the ventricular and au- ricular contractions. These are sometimes al- ternated with considerable but irregular inter- missions, and sometimes far too rapid in their succession: both which changes from the rhythm of health indicate that kind of organic affection which is dependant upon delicacy of constitu- tion, and is often congenial. They do not, however, augur the existence of any dangerous or even very serious malady. It appears from this general outline, that the method of mediate auscultation may be ad- vantageously applied in one or all its forms to a detection of various important diseases of the chest, and especially to the different varieties of phthisis; that it may be more generally em- ployed than that of percussion, since corpules- cency will seldom prove a bar to its use ; and that it is often more definite in its results.* Notwithstanding, however, all the ingenuity that it evinces, it must often be found an im- perfect guide in deciding on the actual state of a disease, or even indicating the disease itself, to say nothing of the long and repeated expe- rience which is absolutely necessary to its be- ing employed with precision. For, fir^t, it gives us a very doubtful kind of information concerning the existence of tubercles or vomica till they have actually broken, and produced numerous excavations, and consequently is of little use in the earlier stages of the disease.* Next, as it has been observed by M. Laennec himself, that some persons have an habitually relaxed state of some of the bronchial vessels, from hooping-cough or chronic catarrh, or a few * The following information is derived from Professor Elliotson's Lectures :—It is only when the tubercles increase to a certain size, and ap- proximate so as to form a mass, that you can ex- pect any symptoms that are discernible by the ear. You will easilv see that this must be the case, when you consider that, in the first instance, the tubercles which constitute this disease are exceed- ingly small and few, leaving a large portion of pulmonary structure perfectly healthy. The parts in which the symptoms cognizable by the ear are first noticed, are those below the clavicle, and this even before the tubercles have softened; but, when they have become sufficiently large and numerous to occupy some space, you will not find, on striking the part under which such deposite ia situated, the hollow sound of health, but a degree of dulness. In proportion to the size of the tu- bercular deposite, is the dulness of the sound. Then, if you listen with the stethoscope, and make the patient speak, you will find the voice resounds there in an unnatural way, because the solid substance of the. tubercles is a much better medium for the conveyance of sound than the loose structure of the healthy lung. The sound, therefore, where the tubercles exist, is louder than elsewhere. Y ou will likewise perceive what is termed bronchophony ; the same sound you hear on putting the stethoscope over the large bronchiae. But it is to be remembered, that the voice natu- rally sounds louder under the clavicle than else- where, on account of the large tubes being there, and consequently you should not depend on this symptom alone ; but, to justify a decided infer-. ence that the bronchophony depends upon tuber- cular deposition, it should be united with the dead sound on percussion. Dr. Elliotson very properly also advises a careful comparison of the sounds perceptible on each side of the chest. When the tubercular mass softens, and a portion is dis- charged, so that the cavity is emptied, or nearly so, a new symptom presents itself, viz., pectorilo- quy, or pectoriloquism; for, as the bronchial tubes enter this cavity, you hear with the stethoscope the same sound as is heard on putting it over the trachea. If you make the patient cough, you hear a mucous rattle ; and, in proportion as more and more of the tubercular matter is spit up, and mere mucus remains in the cavity, the gurgling sound becomes louder and more distinct. In thin persons, pectoriloquy under the clavicles is natural, though no tubercles may exist: it should be heard decidedly mother parts of the chest to be sufficient evidence of the disease. When pectoriloquy is established, the dull sound on percussion ceases: The tubercular solid mass, which gave the dull sound, no longer exists ; and the part being now excavated, yields the same hollow sound as in health. It is to be remembered, says Dr. Elliot- son, that though you have pectoriloquy, and alarge space which ought not to be there, yet the phe* Stethoscope, 8vo., Paris, 1824. J. Hope, M. D., nomenon does not show the nature of the cavity on the Diseases of the Heart and Great Vessels, and it is only from the general symptoms that vou Lond., 1832. John Elliotson, M. D., on Diseases are satisfied it is the cavity of the phthisis A * For an extensive practical application of this method, see Andral's Clinique Medicale, ou Choix d'Observations Recueillies a la Clinique de M. Lerminier; Medecin de l'Hopital de la Charite, Deuxi&me Partie, Maladies de Poitrine, 8vo., Paris, 1824; also Colin, des Diverses M^thodes fl'Exploration de la Poitrine, &c, 8vo., Paris, 1824. John Forbes, M. D., Original Cases, with Dissections and Observations, illustrating the Use of the Stethoscope and Percussion in the Diag- nosis of Diseases of the Chest, &c, 8vo., 1824. P. A. Piorry, de la Percussion Mediate, et des Signes Obtenus a l'aide de ce Nouveau Moyen d Exploration dans les Maladies des Organes Thoraciques et Abdominaux, 8vo., 1828. Lis- franc, Mem. sur des Nouvelles Applications du of the Heart, fol.—Ed. part of the lungs is sometimes separated by^gan- Gen. III.—Spe. 5.] MARASMUS PHTHISIS. 55 minute excavations in the organ of the lungs, without any serious deviation from a state of ordinary health; as also that patients occa- sionally recover from the tubercular species of consumption, and have the interior of the hol- lows or fistulae hereby produced not filled up, but lined with a semicartilaginous membrane, thus effecting a natural cure,—the phenomenon of pectoriloquism will here be as distinct as in a morbid state of the pulmonary organ, and consequently may often lead the practitioner astray. And, lastly, as the stethoscope is lim- ited, or nearly so, to the ulcerative forms of phthisis, the disease may exist in the catarrhal variety, and still elude its power. For these and other reasons, little dependance is placed on this instrument by M. Rostan, and still less by M. Fodere ; nor is it likely to obtain a very extensive use in our own country.* [It has grene, and a cavity will remain ; so that you may here have pectoriloquy; but the nature of the case is denoted by the fetor of expectoration, sudden extreme debility, &c. In chronic bronchitis the bronchial tubes may be very much enlarged at one spot; and here, also, there may be pectoriloquy ; but the general symptoms of phthisis will be ab- sent. N o reliance is to be placed on the ear alone; the symptoms which are audible, are only to be taken in conjunction with those which are gen- eral. Certainly, a very wrong view is taken of auscultation, when it is regarded as superseding the necessity of attending to the whole of the symptoms. As Dr. Elliotson further explains, a person may be labouring under ulceration of the lungs, and yet he may not afford the sign of pec- toriloquy. If the cavity be near the surface of the chest, and the walls of the cavity be very thin, and if the bronchial tubes that open into the cavity have mouths so small as to bear no proportion to the cavity itself, you may have a large cavity, and yet no pectoriloquy at all. Here is another instance of the fallacy of observations made by the ear alone, to the exclusion of the other symptoms. The walls of the cavity must be of a certain thickness for pectoriloquy to be produced, and the bronchial tubes, opening into the cavity, must bear a certain proportion to it; but, when the cavity is near the surface of the lung, and only covered by pleura, there will he no pectoriloquy. If, however, you had seen the patient before the cavity became so large as to be out of proportion to the bronchial tubes opening into it, and before the sides of the cavity had become so thin, you would have had pectoriloquy. When the excava- tion is very large indeed, you will sometimes hear the metallic tinkling, a silvery-ringing sound, when the patient coughs, speaks, or breathes. The metallic tinkling, however, as Laennec ob- served, is heard also whenever a communication is formed between the air-cells and the cavity of the pleura. In the first stage of phthisis, nothing is to be learned from the ear; and as the case proceeds, the case is generally clear enough with- out the information to be derived from this source; but, when it is questionable whether the disease be bronchitis or phthisis, the existence of pecto- riloquy in the latter affection, previously to the excavation becoming too large, will prove the true character of the complaint, and serve for the dis- crimination of one case from the other.—See Pro- fessor Elliotson's Lectures at the Lond. Univ., as published in Med. Gaz. for 1833, p. 227.—Ed. * The editor does not coincide in this remark ; but he believes, that, for the elucidation of many also been employed to ascertain the existence of pregnancy, by catching the sounds of the pulsations of the foetal heart, and of the move- ment of the blood in the utero-placental arteries.] Such is the general history of phthisis. The pathology and practice are in a most unsatisfac- tory and unsettled state : nor can any thing be conceived more contradictory than the writings upon both these subjects. Boerhaave regarded consumption as a local disease, or conversion of all the blood and chyle into pus by means of an erosive ulcer seated in the lungs : Stahl as a general disease, unaffected by pus or any other acrimony. The latter ascribed consumption to the very abundant use of bark which was then prevailing in Europe ; while Morton regarded bark as his sheet-anchor in effecting a cure. Consumption, according to Brillouet and many other writers, is identic with scrofula, and is only to be cured by tonics, alkalis, corrosive sublimate, or other mercurial alterants employ- ed for the cure of scrofulous affections.—(Journ. de Med., 1777.) According to Cullen, though it has an apparent connexion with scrofula, the analogy affords us no assistance in the treat- ment, and the remedies for the one are of no avail in the other. Dr. Rush contemplated it for the most part as an entonic or inflammatory disease, and par- ticularly in its first stage, though it is sometimes accompanied with a hectic, or even a typhus fever. And hence his principal remedies were, salivation, or bleeding, which he sometimes prescribed fifteen times in six weeks ; emetics, nitre in large doses, a milk and vegetable diet, walking in cold air even during an haemoptysis, and afterward severe exercise. The hardships of a military life, says he, have effected cures in a multitude of cases of confirmed consump- tion ; and a riding postman has been relieved more than once by the pursuit of his occupa- tion.—(Med. Inqu.ir.and Observ., i., 8vo., Phil., 1789; ii., 1793; v., 1802.) This bold practice excited many followers, and was tried with variable success upon a large scale. But a practice of an opposite kind, equally bold, and which soon became equally popular, was pro- posed at the same time by M. Salvadori, of Trent.—(Del. Morbo-Tisico, 2 vols., 8vo., Trent, 1787.) Consumption, in the view of this pa- thologist, is an atonic, instead of an entonic disorder from the beginning—a disease of direct debility, and not of inflammation ; and hence is only to be cured by an active plan of stimulants and roborants from the first. The patient's diet is to consist of copious meals of meat and wine, and his chief regimen to be that of climbing ambiguous cases in the practice both of physic and surgery, the stethoscope will always be a val- uable instrument. Its use in the examination of tumours, suspected to be of the aneurismal kind, but attended with obscurity, is generally recog- nised For ascertaining doubtful fractures, and sometimes the presence of a calculus in the blad- der, the stethoscope has also been recommended. —See Lisfranc, Mem. sur les Nouvelles Applica- tions du Stethoscope; or Alcock's Translations and Dr. Ferguson's Obs. in Dublin Trans., vol L-~ Editor. 56 ILEMATICA. [Cl. III.—OtLV. IV, hills, or precipitous steeps, in the morning, as quickly as he is able, till he is out of breath and bathed in sweat, and then augmenting the per- spiration by placing himself near a large fire. Mr. May, who adopted the same general princi- ple, seems to have postponed the gymnastic part of the process till the symptoms were al- leviated, and to have called in the aid of medi- cines which Salvadori regarded as superfluous. May's medicinal means were emetics, bark, and laudanum night and morning; and for diet, he prescribed soup, meat, wine, porter, brandy and water, eggs, oysters, with proper condiments. Swinging was interposed twice a day, and horse- exercise was to complete the cure.—(Lond. Med. Journ., ix., 1788.) Many later writers believe consumption to be very generally produced by a habit of drinking vinegar daily to improve the figure : and Desault relates a case in which this effect was produced in the course of a month.—(Sur les Maladies Veneriennes, la Rage, et la Phthisie, 12mo., Bord., 1739.) Galen recommends vinegar as the best refrigerant we can employ: and Dr. Gregory, in 1794, gave the case of a patient, who recovered by using three dozen lemons daily. Dr. Beddoes felt justified in declaring fox-glove a cure for consumption as certain as bark for agues (Essay on the Causes, Early Signs, and Prevention of Pulmonary Consump- tion, 1799); Dr. Barton, of Philadelphia, has never known but one case cured by it, though others may have been palliated (Collections for a Materia Medica, 8vo., Philadelphia, 1798) ; and Dr. Parr asserts roundly, that it is more in- jurious than beneficial.—(Med. Diet, in verb., Phthisis, vol. ii., p. 410.) Contradictory, however, as are these state- ments with each other, they are chiefly so, as being either too highly coloured or too indis- criminate. We have already considered phthi- sis under three varieties or modifications, chiefly in respect to its being deep-seated or superficial; the apostematous lying lowermost, the tubercular somewhat higher, and the catar- rhal on the surface. But each of these, as it occurs in different constitutions, or under dif- ferent circumstances, may exhibit very different symptoms, and demand a very different, and perhaps an opposite mode of treatment. And hence, most of the principles on which the pre- ceding opinions and modes of practice are found- ed, may derive authority from particular ex- amples of success ; and are so far correct, though, perhaps, none of them will apply to the whole. So considerable, indeed, are the shades of distinction from this multiplicity of causes, that every separate case of consumption should be allowed to speak for itself, and must call for much deviation from the widest line of treat- ment we can ever propose to ourselves under the form of general rules. [Whether tubercular phthisis be ever really curable, is yet a contested point. It is certain, however, that the progress of the disease may be checked, and that some patients will live thirty years or more, without sinking under its effects. From various cases which Laennec has reported, this distinguished pathologist con- cludes that tubercular phthisis is not beyond the powers of nature, though he admits that art possesses no certain means of accomplishing a cure. We may be well assured, he says, that a disease is irremediable, when we find employ- ed in its treatment almost every known medica- ment, however different, or even opposite in ef- fect ; when we see new remedies proposed every day, and old ones revived, after having lain long in merited oblivion ; when, in short, we find no plan constant but that of giving palliatives, and no means persevered in but such as are proper for fulfilling indications purely symptomatic. With respect to what our author denominates catarrhal phthisis, if it be unattended with tu- bercles, the frequency of its cure is as undoubt- ed as its total difference from a case of tuber- culated lungs. But the apostematous phthisis, spoken of in the preceding pages, seems to im- ply either an abscess in the lungs from some cause not essentially connected with tubercles, or else the effect of that process by which pul- monary tubercles become more or less dissolved, and converted into a fluid exhibiting many of the qualities of pus. Apostematous phthisis, in the first of these meanings, must often admit of cure ; but, in the second, the frequency and even the possibility of cure are matters of dis- pute. After a careful perusal of the facts re- corded by Laennec, in illustration of the mode in which nature sometimes cures phthisis, or re- pairs tubercular excavations, and after an im- partial consideration of Professor Carswell's ob- servations (Illustrations of the Elementary Forms of Disease, fasc. i., 4to., 1833), the edi- tor conceives that the absolute incurability of apostematous phthisis must not be positively as- serted, though the extreme rarity of a cure is as certain as any fact whatsoever in the whole mass of medical knowledge,* According to Laennec, and with reference to the ascertained progress of tubercles, as detail- ed in the foregoing pages, the following are the most rational indications :— 1. As soon as we have ascertained the ex- istence of the disease, our aim should be to pre- vent the formation of the second set of tuber. cles ; as, in this case, says Laennec, if the pri- mary tubercular masses be not extremely large or^ numerous, which they very seldom are, a cure will necessarily take place after they are softened and evacuated. * The following is Professor Elliotson's opin- ion on the important question of the curability of tubercular phthisis:—"I am quite sure, on ac- count of the succession of tubercles, that persons rarely recover; and I doubt whether the cavities heal so often as Laennec thought they did." The puckering and subjacent induration, noticed by Laennec as proofs of cicatrization of the lunes are not considered by Dr. Elliotson to furnish un- equivocal evidence of the fact, because similar an- pearances are commonly observed in the livX under circumstances where there could have beer! no suppuration and ulcerations See Lee: »t Lond. Univ., as published in Med. Gaz for lfi^ EoS^^^"*"1 at the ^conS Gen. III.-Spe. 5.] MARASMUS PHTHISIS. 57 2. The second indication should be to pro- mote the softening and evacuation, or the ab- sorption of the existing tubercles. These indi- cations being comprised in the following ones, considered by the author of the present work, though expressed in different language, the edi- tor does not find it necessary to deviate from the arrangement preferred by Dr. Good.] The general intentions by which practitioners seem to have been guided in the midst of all the above contrarieties of practice, are the en- suing :— I. To take off the inflammatory action. II. To correct the specific cause, or phthis- ical diathesis. III. To support under debility. IV. To subdue the local irritation, and im- prove the expectoration. V. To excite a change of action. I. If the patient be of a robust habit, and in the prime and vigour of life, and if the symp- toms indicate considerable inflammation, wheth- er in the lungs or bronchiae, such as, in the former case, fixed pain and weight in the chest, increased by lying on one side, with a dry but troublesome cough ; and in the latter, a general soreness rather than pain in the chest, frequent and violent cough, with a copious excretion of a thin, offensive, and purulent mucus ; and, in both cases, with a full and strong pulse, the fe- ver, though remissive, making an approach to- wards a cauma, constituting the plethoric species of Portal, and the inflammatory of Dr. Rush, our object in both these cases should be to di- minish vascular action by every means in our power. Venesection should be had recourse to with all speed : and though we shall seldom be called upon so closely to follow the steps of Dr. Dover as to repeat the operation fifty times in succession (Ancient Physician's Legacy to his Country, 8vo., Lond.) before we desist, it may be necessary to follow it up rapidly to the third, fourth, or fifth time. Portal, in the catarrhal variety, bled a man, seventy-eight years old, three times, with the happiest effect.* [With regard to bleeding, Laennec does not consider it as a means of curing, or even pre- venting phthisis, but only as calculated to allay the inflammatory affections with which it is sometimes complicated. Laennec, as we have already explained, conceived that inflammation had little share in the production of tubercular phthisis, and he positively asserts that bleeding can neither prevent the formation of tubercles, nor cure them when formed.—(On Diseases of ike Chest, p. 362, 2d edit, by Forbes.) The * The patient may occasionally have attacks of inflammation, and suffer violent stitches in the side, with aggravation of the cough. Under these circumstances a few ounces of blood may be taken away, or the chest may be cupped and blistered. You have then, as Dr. Elliotson observes, to treat the case as one of inflammation of the chest, in a constitution of little power.—(See his Med. Lect. at Lond. Univ., as published in Med. Gaz. for 1833, p. 235.) If the patients be seized with hemorrhage, it is often necessary to treat them in the same way, and keep them on low diet.—Ed. latter part of the proposition is more generally admitted than the former; and the celebrated Broussais declares, that, in putting a stop to catarrh, a mild peripneumony, and pleurisy, by very active treatment at their onset, the occur- rence of phthisis may be rendered very rare, whatever be the constitutional predisposition of the patient.—(Doct. Med., p. 686.)] Immediately after the use of the lancet, we should employ small doses of ipecacuanha or an- timonial powder, so as to maintain a nausea till the pulse is lowered. Where the symptoms ap- proach to peripneumony, the latter is to be pre- ferred ; where they lean to an inflammation of the mucous membrane of the bronchiae, the former, of which three or four grains may be given three or four times a day, and will often prove expectorant, and unload the mucous folli- cles of the air-cells. The bowels should, in the meantime, be thoroughly opened by neutral salts, or uniting three or four grains of calomel with the nauseating powder : and after this, the fox-glove may be prescribed. Van Helmont first employed this last medicine as a specific for scrofula; but the only specific influence we know it to possess is on the kidneys, and on the action of the heart and arteries. It is for this last effect that we look to it in the present in- stance ; the only effect, in all probability, that renders it of any advantage in consumption. In catarrhal phthisis, it seems sometimes, however, to improve the character of the exspuition : but this is, perhaps, a collateral result of the dimin- ished action of the arterial system. When a sufficient inroad has thus been made upon the inflammatory diathesis, we may content ourselves with an administration of the cooling neutrals, of which the nitrate of potash is one of the best. It may be given in almond emul- sion in the proportion of a scruple to half a pint; and, if the cough be still troublesome, may be conveniently united with some light narcotic, as the extract of hyoscyamus or white poppy, The diet and general regimen are points of great importance ; but upon these we shall have to speak presently. It is not often, however, that phthisis com- mences with the inflammatory action we have been contemplating. Its ordinary march is un- ostentatious and insidious ; and it takes posses* siori of the fair and delicate, rather than of the firm and athletic frame, and chiefly in those possessing this figure who can trace the disease in their ancestors. II. Of the proximate cause of this predisponent diathesis we know nothing : it is generally sup- posed to have a near analogy to that of scrofula ; and when called into action, it commonly shows itself in the form of the tubercular variety ; the tubercles themselves, though not occurring in a structure strictly glandular, bearing a consider. able resemblance to scrofulous indurations. And on this account, as there are various medicines and a particular regimen that seem to have a beneficial effect upon a scrofulous habit, the same have often been resorted to for the cure of consumption. Thus, sea-water, the alkalis, almost all the metallic salts, and esDecially those 58 HiEMATICA. [Cl. III.—Ord. IV. of mercury, have been repeatedly tried, but apparently with very doubtful success Mr Spalding gives the case of a patient who had taken nearly two pounds of potash and soda, intermixed like common salt, with his ordinary food ; and, he states, with considerable benefit, after fox-glove, sulphuric acid, and bitters, had been successively found to disagree (American Med. Repository, vol. v., p. 220); and Dr. Trotter affirms, that among seamen in scrofu- lous consumption, as he calls the tubereular, salt and salt diet have proved of eminent service, but that the most effectual remedy is cinchona with sulphur.—(Medecina Nautica, vol. ii., p. 359.) Yet, though serviceable in particular cases of tubercular consumption, this class of medicines is far less efficacious than in strumous affections ; and the remark of Dr. Cullen, which he has confined to two or three varieties of them, may be extended to the whole. " In scrofula," says he, " the remedies that are seemingly of most power are, sea-water, and certain mineral waters ; but these have generally proved hurtful in the case of tubercles of the lungs. I have known," he adds, " several instances of mercury very fully employed in certain diseases in per- sons who were supposed at the time to have tubercles formed, or forming, in their lungs : but though the mercury proved a cure for those other diseases, it was of no service in preventing phthisis, and, in some cases, seemed to hurry it on."—(Pract. ofPhys., vol. ii., sect. 907,p. 293.) Nor have any other metallic salts been of more use than those of mercury. Dr. Roberts has had the spirit and perseverance to run through the whole range of such erf them as can in any way be thought applicable to this com- plaint; and has also had the candour, after a sufficient scale of trial in St. Bartholomew's (a candour how seldom to be met with !), to confess that none of them were administered with suc- cess. The experimental list consisted of silver in its nitrate ; lead in its superacetate, combined with opium, for counteracting its deleterious effects, zinc, in its sulphate and oxyde ; and the precipitate from the sulphate of potash, combined with myrrh ; arsenic in the neutral salt formed by a combination with potash ; man- ganese in its white oxyde, in doses of ten grains every six hours : cobalt in its black oxyde, in doses qf from one grain to four; ammoni'ated copper, and muriate of barytes. And with a like want of success, he tells us, in addition, were employed the vegetable narcotics aconite, hyoscyamus, stramonium, belladonna, as also toxicodendron. * We may hence, I think, nearly * Med. Trans., vol. iv., p. 129. Professor Cars- well has traced abundance of tubercular matter in scrofulous lymphatic glands : and since swellings of this kind are sometimes cured, he regards the circumstance as a consideration against the infer- ence, that tubercles of the lungs are absolutely incurable.—(See his Illustrations of the Element- ary Forms of Disease, fasc. i., 4to., Lond., 1833.) The tubercular substance being unorganized, can- not itself be affected or influenced by medicine; and hence no doubt one principal difficulty in the attempt to cure phthisis.—Ed. conclude with Dr. Cullen, that " the analogy of scrofula gives no assistance in this matter." —(Pract. of Phys., vol. ii., sect. 907.) And it is probably on this account, that M. Fodere has treated of tubercular and scrofulous con- sumption as two distinct forms of the disease.— (Legons sur les Epidemies et VHygiene Pub- lique, torn, ii., Paris, 1823 ) The preparations of iodine have a fair claim to attention here, as well as in scrofula, though great caution is necessary in employing them ; while it is only where the affection is pretty evidently tubercular that we have any reason to expect success from their use ; and even here, only in an incipient state of this variety. I have found a local application of the ointment re- lieve the cough and pain in the side, in some cases, more effectually than the tartar-emetic eruption. And if the erythema hereby produced should prevent a continuance of the applica- tion,* we may substitute the form of pills or of tincture ; giving half a grain of the iodine, in either mode of preparation, two or three times a day. [From the remarkable power of iodine in removing bronchocele, and reducing the size of diseased lymphatic glands on the surface of the body, the employment of it for the dispersion of pulmonary tubercles, as Dr. Forbes observes, was at once prompted and justified by the fairest analogy.! But, says he, there exists so material a difference between tuberculous diseases of the lungs and bronchocele, or enlargement of the external glands, notwithstanding their seeming analogy, as renders the efficacy of iodine in the former disease more than problematical. He considers it, however, as deserving of further trial.] This part of our subject, however, ought not to be closed without briefly adverting to the practice of giving very small doses of tartar- emetic, dissolved in a large body of some simple menstruum, and continuing it for an almost in- definite period of time. Dr. Balfour dissolves two grains in six ounces of water, and prescribes an ounce of this mixture, that is, a third part of a grain of the tartarized antimony, to be taken every hour, and a smaller quantity where this is found to nauseate. M. Lenthois, in his Methode Preservative, first directs a grain of tartarized antimony to be dissolved in eight tablespoonfuls of distilled water, and then six or eight pints of water, and sometimes not less than twelve, to be added. The solution, thus weakened, is em- ployed by the patient for common drink in every case and stage of consumption, either alone or with some other drink at meals, or occasionally with wine. [Tartarized antimony was strongly recommended by Dr. Jenner (Letter to Dr. Parry, 1822), hut Dr. Forbes says that he has tried it, as well as setons, blisters, &c, without any benefit.] III. Although in consumption we can avail * For its other troublesome effects, see Vol TI Cl. VI., Ord. I , Gen. II., Spe. 1, Emphyma Sari coma Bronchocele, p. 315. t See Baron's Illustrations of the Inquiry re- spectmg Tuberculous Diseases, p. 220, and Gaird- ner on the Effects of Iodine, 1824. Gen. HX-Spe. 5.] MARASMUS PHTHISIS. 59 Ourselves but little of the treatment which ap- plies to scrofula, and know nothing whatever of the nature of its specific cause, we see enough to convince us that consumption, in its general character, is, like scrofula, a disease of debility ; and that wherever it exhibits an excess of vas- cular action, it is merely in consequence of being planted upon a plethoric or entonic tempera- ment.* And hence another principle, con- spicuous in most of the remedial plans to which it has given birth, is that of supporting the sys- tem while labouring under its influence. This principle is well founded, but of difficult application ; and, like the opposite principle of reduction, has been often carried to an extreme. During the last century, Salvadori in the Tyrol, and, in the present day, Dr. Stewart of Edin- burgh, are justly chargeable with having done this by a very general allowance of nourishing diet, in conjunction with pure or diluted wine, bark, steel, and other tonics ; exercise on horse- back, and affusion with vinegar and cold water. In its ordinary course the disease itself is not only peculiarly prodigal of animal strength, but extremely protracted in its duration; while the fever, though remissive, rarely subsides alto- gether, or allows any interval of which we can avail ourselves. In some instances, however, it does allow such interval, and especially where it has con- tinued for a long period, and has broken down the general vigour of the frame ; in which case, Moreton occasionally found the inflammatory form with which it commenced converted into a low intermittent, sometimes assuming the quotidian, but more generally the tertian type ; beginning with cold fits, and succeeded by in- tense heat and profuse sweats, which exhausted the patient, though they left him in high spirits dufing the intermissions. And in such instan- ces, it is possible that the tonic and stimulant plan of bark, wine, and even high-seasoned dish- es, with cold air, cold bathing, and active exer- cise, so warmly eulogized by the writers just referred to, as well as by many others, may oc- casionally prove successful; and particularly' where the disease is of the apostematous or catarrhal variety, and there is no constitutional taint to oppose at the same time. And it is here also, if anywhere, that the bustling and violent exercise, so strenuously recommended by Dr. Rush and Dr. Jackson, have a chance of proving beneficial. Dr. Chisholm tells us that, in particular cases, he found both these plans of decided service.—(Climate and Diseases of Tropical Countries, &c., 8vo., p. 112, Lond., 1822.) But these are plans which cannot be brought into general practice; and, in supporting the strength of the system, we are ordinarily com- pelled to pursue a very different course : a doc- trine, in a few rare instances, admitted even by Dr. Stewart himself. The first means by which we are to aim at * Excess of vascular action sometimes depends upon phthisis being conjoined with various degrees of inflammation in the chest.—Ed. accomplishing this is of a negative kind; and consists in saving the frame as much as possible from the profuse exhaustion it is daily sustain- ing, by calming the febrile irritation, and check- ing the colliquative sweats, which, as already observed, are never of a critical kind. " I have sometimes succeeded very decidedly," says Dr. Young in a note to the author, while the first edition was printing, " in checking the sweats by Dover's powder; but I do not know that the progress of the disease has been much retarded by this palliation." Bleeding, however plausible and even advan- tageous when the pulse is full and strong, and the pain in the side acute, can rarely be allowed when the frame is delicate and irritable, and the pulse small and weak. Where the local dis- tress is considerable, it may be had recourse to as a palliative, but never carried beyond a few ounces, nor repeated without great hesitation. To emetics there is less objection, but vom- iting is here to be preferred to nauseating. The latter, though it lowers the pulse, produces considerable fatigue and distress. The former emulges the bronchial glands, and diminishes the local irritation by transferring it, through the means of a general glow and moisture, over the system at large. The dose may be repeated three or four times a week, ,and should have its oower limited, as nearly as may be, to a single inversion of the stomach. In the selection of emetics, some judgment is required; for those should be carefully avoided which, like the antimonial preparations, produce loose evacuations, and excite considerable sweat- ing. The ipecacuanha is, perhaps, one of the simplest and the best. Dr. Simmons, however, preferred the sulphate of copper, giving first of all half a pint of water to the patient, and then the blue vitriol from two grains to twenty, ac- cording to his age and strength, dissolved in an additional cupful of water. In general he found, that the moment the emetic reached the stomach it was thrown up again, upon which the patient was ordered to swallow another half pint of water, which was sufficient to take off the nausea.—(Practical Observations on the Treat- ment of Consumption, dec.) [Besides the use of ipecacuanha as one of the best emetics in phthisis, it is an important medi- cine for palliating the diarrhoea, under which many patients sink. This complaint, it is true, is often quite incurable, being connected with morbid changes in the bowels, already described in the preceding pages ; but whatever benefit it does admit of will be derived from small doses of ipecacuanha. Thus, Dr. Bright says, when the disorder of the mucous membrane of the bowels is a prominent feature in phthisis, the purging may often be diminished, and the stools rendered natural in appearance, by giving the patient two grains of ipecacuanha three times a day.—(Reports, &c., p. 152.) The editor can add his testimony in favour of the practice, espe- cially when the ipecacuanha is made into a pill with four op five grains of the confectio opii.] The reason that prohibits nauseating, pro- hibits also the use of fox-glove : for though the 60 H^MATICA. [Cl. HI.—Ord. IV. pulse mav be diminished, nothing more is ob- tained, and even th.s is obtained at too great an expense of sensorial power in the degree of de- bility we are now contemplating: and the remark will apply to most of the narcotics, whether of the umbellate or solanaceous order. The neu- tral salts answer better, and especially nitre ; and there is no modification of the disease in which this may not be given, and will not prove an excellent refrigerant as well as sedative. The general error, however, has been in admin- istering it too freely, as in doses of fifteen grains or a scruple ; in which case it becomes a direct irritant, and does much more harm than good. Seven or eight grains at a time, as already ob- served, is a far better proportion, and even in this quantity it will answer best if considerably dilu- ted. It is often united with narcotics; but these are never found of use, unless they pal- liate the cough or local distress ; for otherwise they increase the heat and quicken the pulse. Most of the acids may also be employed for the same purpose, and with equally good effect. They may, indeed, be regarded in the joint char- acter of sedatives, refrigerants, and astringent tonics : and have hence every claim to atten- tion. The mineral have been most commonly in use; but, from their erosive quality, they can- not be thrown in sufficient abundance into the -circulating fluids : and, on this account, the veg- etable are to be preferred; and, of the vegeta- ble, the fermented acids, which, though some- what less grateful than the native, seem to be more effectual as tonics. The acetous acid was employed freely by Galen, diluted with water, -who regarded it as the best refrigerant we can select. It is continued to the present day among the Moorish physicians at Tunis, and, according to the late M. Orban, with decided sueeess. He observed its effects, during three months, upon one patient who appeared to be labouring under a confirmed phthisis from a neg- lected catarrh. The quantity of vinegar drunk in the course of every twenty-four hours, was seven fluid ounces intermixed with seven times as much rain-water, and sweetened with two ounces of refined sugar. This apozem was ac- companied with astringent and tonic pills, com- posed chiefly of alum and sulphate of iron, of each of which two grains and a half were taken daily. The diet allowed was very slender, and consist- ed of nothing more than vermicelli or millet, boiled in water, and seasoned with a little oil and salt. Of this, only two meals in the four- and-twenty hours were allowed for several weeks. And, on the patient's becoming very costive under its use, the Moorish physician paid no attention to the symptom, but told M. Orban that a constipated state of the bowels was the best symptom that could occur, and that the more strikingly this prevailed, the more certain he was of a cure. M. Orban* left his patient in * Med. Trans., vol. v., art. xviii. This treat- ment with vinegar falls under the head of what is called the empirical practice. The account is al- together unsatisfactory : the case is called a con- firmed phthisis: but was it of the tubercular kind ?—Ed. a state of convalescence bordering on perfect health; and, on his return to France, pursued the same plan, with the exception of the iron, which he omitted as too stimulant, and found it, in many cases, eminently successful, though not in all. It has since been tried in our own country, and has often proved equally advan- tageous. Dr. Roberts has paid particular at- tention to its effects; and, upon a pretty ex- tensive scale, has been satisfied with them. One of his cases was of a very unpromising as- pect, and consisted of a young gentleman, seven- teen years of age, whose elder brother had died of phthisis. The cough, which in the morning was very considerable, was accompanied with expectoration sometimes streaked with blood ; a confirmed hectic preyed upon him, and the night-sweat was so profuse that his hair was drenched with it. " My patient," says Dr. Roberts, " was at once relieved by the use of the acid, and in a short time so lost his com- plaints, that, by advice, he discontinued the remedy."—(Med. Trans., ut supra.) The acetic and acetous acid seem to have been employed indiscriminately; over which the citric, which was also tried, did not seem to have any advan- tage. The acetous was usually given in half- ounce doses, with an ounce of infusion of cas- carilla, and a little mucilaginous powder or sirup, the dose being repeated three or four times a day. From these facts, as well as from a host of others of the same kind that might be adduced, the acetous acid appears to be a powerful seda- tive. It diminishes action generally, checks night-sweats, restrains haemoptysis, retards the pulse, and produces costiveness. In haemop- tysis, I have carried the use of the acetous acid much farther than was prescribed by Dr. Rob- erts, and with manifest and unmixed advantage. The proper astringents have also not unfre- quently been employed in phthisis for the same negative purpose of producing strength by check- ing the exhausting discharges of sweat, pus or mucus, blood, and often diarrhoea ; but they have rarely proved successful. Some degree of benefit seems occasionally to have been derived from the use of oak bark, several of the agarics (De Haen, Rat. Med., torn, ii., 567 ; Dufresnoy, in Corvisart, Journ. Med., cent, vii., 531, 1804) given in the form of lozenges, and the acetate of lead ; * but they have far more generally been employed without success, or with more mis- chief than advantage. The most direct means of supporting the system would be by those tonics that unite an astringent with a bitter principle ; but we have * Ewell in Sedilot's Journ. Gen. Med., xliv.; Hildehrand, id., xxxvi. Frequently the largest doses of opium, such as will produce great stupor, and astringents in doses that even overload the stomach, will not succeed in checking the diar- rhoea. Frequently there is ulceration of the intes tines, and then the sulphate of copper is recom mended by Dr. Elliotson. It has a tendency to produce sickness; but this may be subdued hv hydrocyanic acid. In the event of this not an swenng, we may try ipecacuanha m small doses' joined with opium, as already mentioned —Ed Gen. III.—Spe. 5.] MARASMUS PHTHISIS. 61 already observed, that the system i3 usually, and particularly in the beginning and at the height of the disease, in too high a degree of irritation for a convenient use of any medicines of this kind; though where the complaint has lasted for many months, and appears to be rather of the tubercular or catarrhal, than of the apostematous variety, these may sometimes be employed with great success. The Angustura bark generally agrees belter than the cinchona ; and to this myrrh and iron may at such times be added in increasing doses, and particularly as prepared in the mistura ferri composita of the London College. In the tubercular variety, the cinchona seldom agrees in any stage : Dr. Cul- len conceives never ; and tells us that, even where the disease has assumed something of an intermittent character, quotidian or tertian,— and he has, on this account, been tempted to try it in free doses,—he has in no instances succeeded so as to establish a complete cure. " For in spite," says he, " of large exhibitions of the bark, the paroxysms, in less than a fort- night or three weeks after they had been stop- ped, always returned, and with greater violence, and proved fatal." In the latter stages of the apostematous variety, and especially where the vomicae are small and in perpetual succession, he thinks, however, it may be of service in restoring a healthy action, and promoting a se- cretion of genuine pus. In this last case, and here perhaps only, we may venture with success on the use of the cold bath. In a more irritable state or stage of the complaint, the tepid bath may occasionally prove serviceable; and, where it does so, should be repeated three or four times a week, or even oftener. Of the effect of the banos de tierra of the once-celebrated Solano de Luque, I can- not speak from personal knowledge. It consists in burying the patient up to the chin in fresh mould. It would be most obvious to suppose that this was designed to act as a tonic, and check the undue tendency to perspiration by a protracted chill, but that Van Swieten tells us the smell of fresh earth is serviceable, and ap- proves of it on this account. It has since been recommended by Dr. Simmons and M. Pouteau. Before, however, the hectic, or the general irritability of the system, has so far subsided as to render tonics advisable, our chief depend- ance for giving support to the system must be upon diet and regimen. The diet should be of the lightest kinds, and in very small proportion, and with long inter- vals of rest; for some degree of exacerbation, in the stage of the disease we are now contem- plating, is always produced by the process of digestion. Under limosis expers we have al- ready seen how very small a portion of food is necessary for the support of life, when neither mental nor muscular exercise is made use of; and though hectic fever itself is a source of very great exhaustion, this exhaustion will be less in proportion as we produce less excitement, whether from eating or any other cause. And hence the most cautious physicians, from the time of the Greeks to our own day, have concur- red in recommending food in small quantity, as well as of the lightest materials. It is not merely the stomach and its collatitious organs that are hereby put at rest, but the circulating system, the assimilating powers, the brain, and the in- testines. The food itself should consist principally of milk and the farinaceous parts of plants, if it be not limited entirely to these : and upon a diet of this kind, in conjunction with temperate air and exercise, the Greek physicians placed their only hopes of a cure. Whether it be necessary to pay that strict attention to the different kinds of milk which we find inculcated by many wri- ters of established reputation, I cannot fully de- termine. Galen recommends woman's milk as lightest of all, then ass's, next goat's or ewe's, and lastly cow's (Opp., torn, vi., 130, 131, edit. Basil., 1542); and Van Swieten adopts the recommendation of Galen.—(Comment., torn. iv., sect. 1211, edit. Lugd. Bat., 1764.) Mare's milk has since been proposed as preferable to all these : but the analyses published by differ- ent chymists vary so much from each other, that it is difficult to come to a conclusion. If the experiments of Stipriaan may be depended upon, mare's milk contains most sugar, and least cream, butter, or caseous matter; and woman's milk most sugar, and least butter and caseous matter, next to mare's, with most cream, next to sheep's.—(Crell's Chemische Annates, sect, viii, p. 138, 1794.) Whence mare's milk should be the lightest of the whole, but less nutritive than woman's. According to Parmen-- tier, however, ass's milk contains less propor-^ tion of caseous matter than any of the rest. Peculiar properties may sometimes be given to milk by the food fed upon ; and hence Galen endeavoured to render it more astringent, by placing the animal that was to furnish it in pas- turage enriched for the purpose with agrostis,- lotus, polygonum, and melyssophyllum. And as the patient became convalescent, and could bear a richer nutriment, he was allowed to sail down the Tiber and use the cow's milk of Stabiae, which was peculiarly celebrated for its excel- lence. When ass's milk cannot conveniently be ob- tained, its place may be supplied with what has been called artificial ass's milk ; which is a mix- ture of cow's milk and animal mucilage, dilu- ted in a farinaceous apozem, rendered slightly sweetish and aromatic by eryngo. The ordi- nary form consists in boiling eighteen contused snails with an ounce of hartshorn shavings, of eryngo-root, and pearl-barley, in six pints of water, to half its quantity, and then adding an ounce and a half of sirup of Tolu. Four ounces of this are usually taken morning and evening, with an equal quantity of fresh milk from the cow.—(Med. Trans., vol. ii., p. 341.) The chief foods which have been allowed in the general treatment of consumption in its earlier and middle stages, in conjunction with milk and the farinacea, are the vegetable and animal mucilages, but particularly the former. And of these, that obtained from the Iceland liverwort haa been held, and deservedly so, in 62 ILEMATICA. [Cl. III.—Ord. IV. the highest degree of estimation ; for, to an ali- ment of sufficient nourishment, it adds a tonic power by its bitterness ; yet a power that so far from increasing vascular action, seems rather to quiet it ; as though the bitter principle were itself in possession of something of the sedative quality of the hop, Ignatius's bean, or some other plant that decisively unites the two. In supporting or recruiting the strength, a due attention to air and exercise is also of high im- portance. The advantages offered by the first are those of a mild, dry, and equable atmo- sphere ; and, probably, these are the whole. If the patient's own country give him these, he need not wander from home. If it do not, he must create an artificial atmosphere in his own chamber, or set of chambers, by keeping the thermometer at from 60° to 65° of Fahrenheit, and confining himself to this temperature ; or he must seek the atmosphere he stands in need of in a foreign climate. The disadvantage of the former is, that though he may support the requisite temperature, he cannot conveniently obtain a sufficient change of air, nor so well avail himself of the various exercises that might be useful to him, as if he were at liberty to go abroad. Hence a change of abode has been recom- mended in all ages to those whose native soil is subject to considerable and sudden atmospheri- cal variations, though pathologists have by no means agreed upon a meteorological standard. For the patient's residence in our own country, the southwestern boundary of the Cornish coast, and particularly Penzance, seems to offer the best asylum : and where a foreign climate is rec- ommended, it should lie between thirty and forty degrees of latitude : if lower than this, the dis- ease, and especially where ulceration has taken place, seems to be exacerbated instead of di- minished, and, consequently, its fatal issue to be quickened (Sir G. Blane, Observations on the Diseases of Seamen, 8vo., 1785) ; notwith- standing that to the natives consumption is little known within the tropics. In Great Britain, the annual mortality from this disease in 181-1, when the population was calculated at 23,353,000, seems to have amount- ed to 55,000, being a proportion of 1 in 224. In Geneva, from a very exact register, M. Prevost Moulton estimates it at 1 in 521.— (Chisholm, on Tropical Climates, p. 234.) Generally speaking, however, a change of climate or of local situation has been determin- ed upon too late ; and hence has not been at- tended with all the benefit that might otherwise have been reasonably hoped for. On which ac- count many pathologists have considered it as of little importance, if not more injurious than staying at home, though the most celebrated spots should be selected. Thus Dr. Carmichael Smyth asserts, that Madeira is unfavourable to the consumptive when the lungs are materially injured, notwith- standing the mildness and equability of its cli- mate.* Nice and Naples are said to be equally Account of the Effects of Swinging in Pul- unfnendly from the neighbourhood of mountains; and Dr. Southey's inquiry has led him to con- clude that, in Malta, Sicily, and other islands in the Mediterranean, phthisis, though a rare dis- ease among the natives, does not appear to be retarded in those who visit them for a cure.* M. Portal dissuades from all such trials by af- firming that there is no dependance to be placed upon them, since he has seen the disease ac- celerated in Englishmen, or those of other north- ern nations, by a visit in quest of milder air to the south of France ; while, in the natives of Languedoc or Provence, it has been restrained by a removal to Paris.—(Obs. sur la Nature et le Traitement de la Phthisie Pulmonaire,- ii., p. 358.) Nor are the observations of M. Fodere much more encouraging to a trial of any part of France: as he expressly tells us that, in the provinces on the borders of the Mediterranean, phthisis commits the most horrible ravages; while, out of 62,447 deaths which took place at Paris in the years 1816, 1817, and 1818, thir- teen thousand eight hundred and eighteen fell victims to diseases of the chest.—(Lecons sur les Epidkmies et I'Hygiene Publique, torn, ii., 1813.) The whole of this, however, only shows us that very great care is necessary in ascertaining the state and stage of the disease, the patient's constitution, and the local features of the situa- tion that may be proposed for his residence' and we have already shown how it is possible for a mild and relaxing climate to prove reme- dial to strangers, while it may even become a predisponent cause of phthisis to natives. Where, in the commencement of the disease, there is great irritability or an inflammatory diathesis ; or, in its advance, the strength of the constitution is greatly reduced ; and especially where an obstinate diarrhoea has supervened, the fatigues of journeying and of a sea-voyage, and the necessary relinquishment of many of those minuter, but still important conveniences, to which the patient has been accustomed at home, will more than counterbalance all the advan- tages he might derive from the possession of a milder and more equable atmosphere. The topography of the situation about to be chosen is of equal importance ; for if it be strong- ly marked by lofty cliffs or mountains,! the air will seldom circulate freely, but rush in currents in some parts, and be obstructed and become stagnant in others. Such is the state of Hast- ings on the Sussex coast of our own country, monary Consumption, &c, 8vo., 1787. In Ma- deira the thermometer commonly ranges from 60° to 75° ; and, in the greatest extremes, seldom ex- ceeds these limits by more than 5°.—See Journ. of Morbid Anatomy, Ophthalmic Medicine, &c , vol L, p. 103.—Ed. * Obs- °n Pulmonary Consumption, 8vo., 1814. Phthisis was common enough among the in- habitants of Malta and Minorca when the editor formerly visited those islands as an army surgeon. —En. t Laennec observes that, though phthisis is un- frequent in mountainous countries, it runs a verv rapid course when it does occur in them —On Diseases of the Chest, p. 368, 2d edit, by Forbes Gen. III.—Spe. 5.] MAHASMUS which would otherwise form an excellent asy- lum for those who are subject to pulmonary af- fections, and cannot remove far from their native abodes. The shore is skirted by two enormous cliffs of sandstone, that rise between two and three hundred feet in perpendicular height. The old town is built in a deep ravine opening towards the northeast, that lies between them, and the new town immediately under the cliffs, fronting south and west; and hence, while the air is rushing in a perpetual current through the former, it becomes stagnant, heated, and suffo- cative in the latter.* On this account, it has been uniformly found that small islands, with- out any great boldness of feature, enjoy the most equable temperature, and, when within the range already pointed out, form the most favourable situations for consumptive cases. Madeira, in some of its positions, is one of the best foreign stations in the winter season; but from its mountainous face, and the snow, sleet, and cold winds to which it is occasionally liable, catarrhal affections, and even genuine consump- tion itself, are, according to Dr. Gourlay, not uncommon to the natives ; and in removing to it, therefore, it will be necessary to select a spot of sufficient elevation, and equally sheltered from the meteorological evils of currents, tem- pests, and suffocative heat. And, however for- tunate a patient may be in procuring such a res- idence at Madeira, he will, in all probability, succeed still better, and obtain a greater choice of desirable situations, at Nice, Pisa, or even Hieres ; and might be more comfortable at Villa Franca than even at any of these, if the town were now of sufficient extent and population to offer him the conveniences he will always want, and especially that of a roomy and excellent lodging-house, which, in the present decayed state of this town, is not a little difficult to be obtained. The depth of the bay, and the very abrupt elevation of the hills that rise in a most beautiful and romantic amphitheatre behind it, enable the patient to make a considerable range without exposure to sudden currents. The east is its only unsheltered quarter, and, from the evils attendant on occasional chills, he must sedulously avoid this. But we have already shown that a high de- gree of heat habitually applied to the body, as in intertropical regions, as a source of debility and irritation, may itself call forth a latent con- * For a more inviting account of Hastings, as a place of resort for invalids, see Harwood's Cu- rative Influence of the Southern Coast: or the Journal of Morbid Anatomy, &c, by Dr. Farre, vol. i., p. 121. Laennec considered maritime situa- tions as exhibiting a less prevalency of consump- tion ; but Dr. Forbes, who has resided long on the southern coast of England, deems the opinion un- established by proof. During a residence of five years at Penzance, Cornwall, a place much fre- quented by consumptive patients on account of the mildness and equability of its temperature, Dr. Forbes had extensive opportunities of observing the effect of change of climate on phthisis ; and he says, that, in the greater number of cases, the change was not beneficial.—Transl. of Laennec, 2d edit., pp. 324 and 367. 3 PHTHISIS. 63 sumptive predisposition into action, and become a source of phthisis, as well as a temperature of unfriendly cold. The variety in this case, as we have already observed, is almost always the tubercular, and often combined with a strumous diathesis, if it do not originate from it The change must here, therefore, be to a cooler in- stead of to a warmer temperature ; to an atmo- sphere of a more refreshing and invigorating power ; to a climate still mild, but less exciting, equable in its thermometer, and tonic in its general influence.* After all, the most equable of temperatures is that of the sea itself: and hence many patients who feel inconvenience from a residence on the seaside, are almost instantly relieved by sailing a few miles distance from it. This has often been resolved into the exercise of sailing, or the sea-sickness which in many instances is- hereby excited. It is, nevertheless, a distinct advan- tage from either, and resolvable into the explana- tion just stated. Sea-sickness, however, is of unquestionable service in many cases, and particularly in those in which a protracted nausea by other means has already been recommended. The exercise of sailing is useful on another and a very differ- ent account All motion without eixertion, or with no more exertion than gives a pleasurable feeling to the system, which the Greeks expres- sed by the term aeora, instead of exhausting, tranquillizes and proves sedative. It retards the pulse, calms the irregularities of the heart, produces sleep, and even costiveness. Hence sailing on the Tiber was a common prescription among the Roman physicians, and many con- sumptive patients have found great benefit from long voyages, in which they have suffered no sea- sickness, and have been exposed to many vari- eties of atmospherical temperature. Hence, too, the well-known advantage of exercise in a swing,, or in a carriage, on horseback, or even on foot, as soon as these can be engaged in with comfort; the organs of respiration, like those of every other kind, deriving strength, instead of weakness, from a temperate use of them. Gymnastic medicine, however, seems by many pathologists to have been carried to an extreme; and especially by Sydenham, who employed horse-exercise in all stages of thedis- * The following remarks by Dr. Clark deserve attention :—" A change of climate having been decided on, the particular situation to be selected becomes a question. Professor Laennec's deci- ded preference of a maritime residence is not, per- haps, founded on very extensive experience. Cer tain it is, however, that as well in this country as on the continent, the places usually resorted to by consumptive invalids are on the seacoast, or at no great distance from it. In almost every case, when the removal to a milder climate can be ef- fected by sea, this means is much preferable to a journey by land. In some cases, the good effects produced by a voyage are very remarkable."—(See Laennec, by Forbes, 2d edit., p. 368.) No doubt, as Dr. Forbes has explained, change of climate often fails, hecause tried too late ; and some decep- tion prevails respecting such cases as are benefit- ed, and which are frequently only specimens of chronic catarrh, or chronic bronchitis.^—Ed. 64 I-LEMATICA. [Cl. III.—Okd. IV. ease, and roundly affirms, that neither mercury in syphilis, nor bark in intermittents, is more effectual than riding in consumptions.—(Opp., p 629 ) Nor is carriage-exercise, says he, by any means to be despised, though not equal to that of the saddle. Hoffmann and Baglivi adopt- ed the same opinion, and laid it down in terms nearly as unqualified. Where phthisis is a secondary disease, and dependant upon some obstruction of the digestive viscera, exercise of this kind may, in many instances, be employed as in important co-operation with other means, even from the beginning ; and to such cases of consumption Desault judiciously limits it. In the present day, it has been revived by Dr. Stewart under a variety of ingenious modifica- tions, and appears in many cases to have afford- ed relief : but the constitutions of mankind must strangely have altered since the days of Syden- ham, if the severity of horse-exercise could at that period have been employed as a specific remedy in consumptions of every kind. Stoll did not find it so in the middle of the last cen- tury ; for he tells us, that, if a consumptive pa- tient mount his horse, he will ride to the banks of the Styx as surely as if he were in a pleurisy. —(Rat. Med., i.) And Stoerck died consump- tive, though in the habit of riding, killed by an haemoptysis apparently produced by this exer- cise.—(Quarin, pp. 162, 163.) IV. Another part of the curative process in the disease before us has consisted in endeav- ouring to subdue the local irritation, and im- prove the secretion from the lungs. This has been chiefly attempted by fumigations, medicated airs, expectorants, and sedatives. Bennet was strongly attached to the first of these, and thought they proved peculiarly de- tergent, and enabled the patient to throw up a more laudable discharge with increased facility. He sometimes employed aromatic herbs im- mersed in hot water, over which the patient held his head, surrounded with cloths to confine the vapour, which was thus inhaled with every inspiration. But he seems to have placed more dependance on an inhalation of the fumes of various terebinthinate resins, as frankincense, styrax, and turpentine itself, mixed into a pow- der or troche with a few other ingredients, and burnt on coals: to which he sometimes added a considerable proportion of orpiment. And such was the success ascribed to this practice, that Willis, not many years after, resolved the great- er exemption of certain parts of England and Holland from coughs and consumptions, to the turf and peat fires which the inhabitants were in the habit of using, and the arsenical princi- ple which was intermixed with the material. In our own day, terebinthinate fumigations have been very extensively tried, in consequence of the warm recommendation of Sir Alexander Crichton,* who thought he had perceived great and decisive advantage from the aroma of pitch * Practical Observations on the Treatment and Cure of several Varieties of Pulmonary Consump- tion ; and on the Effects of the Vapour of Boding Tar in that Disease, Lond., 8vo., 1823. and tar diffused through rope manufactories, ships, and other places where these articles are in perpetual use. I have tried this repeatedly by heating a tin vessel of tar over an oil or spirit-lamp, and thus impregnating the atmo- sphere of the chamber with the powerful vapour that arises. In doing this, however, we must be careful not to burn the tar ; for in such case the room will be filled with an empyreumatic smoke, that will greatly augment the patient's cough instead of diminishing it: and it will be also advisable, as recommended by Dr. Paris (Pharmacologia, vol. ii., p. 339, edit. 1822), to - add about half an ounce of subcarbonate of pot- ash to every pound of tar, for the purpose of neutralizing its pyroligneous acid, the fume of which will otherwise ascend and prove irritating. In those states of the disease in which ter- ebinthinates, as myrrh, benzoin, or copayva, may be taken internally with a prospect of suc- cess, this kind of fumigation will sometimes prove useful also, and it is hence far better adapted to the tubercular and catarrhal than to the apostematous variety. In a chronic state of the first two I have sometimes thought it serviceable, but I have more frequently used it without any avail. The experience of Dr. James Forbes, who has tried this remedy upon an ex- tensive scale, very closely coincides with these remarks. Of nineteen cases of phthisis, of which he has given us an account, it neither cured nor improved any ; on eight it had no ef- fect ; and mischievously suppressed the secre- tion, injured the breathing, and increased the disease in eleven. In cases of chronic catarrh, where the secretion constitutes the disease, and tonics and astringents are useful, it often suc- ceeded. Of thirty-two cases narrated, it had no mischievous effect on any; no effect what- ever on eighteen; improved six, and cured eight.—(Remarks on Tar-Vapour, by James Forbes, M. D., 8vo , 1822.) Pneumatic medicine, which about thirty years ago was in the highest popularity, does not ap- pear, when candidly examined, to have been more successful. Oxygen gas has, in almost every instance, proved so stimulant, and so much increased the signs of inflammatory ac- tion, that, though it has seemed occasionally to afford a momentary relief in a few cases, it has rarely been persevered in more than a fortnight, by which time it has often suppressed the usual expectoration, and produced an haemoptysis.— (Fourcroy, Annates de Chim., iv.,p. 83, 1790.) There was much more reason and ingenuity in recommending an inhalation of hydrogen inter- mixed with common air than of oxygen, since the effect of this gas in destroying the irrita- bility of the living fibre is known to every one ; and it was hence a plausible conjecture, that, by being applied immediately to the seat of the disease, it might sufficiently subdue the inflam- matory impetus, change the action of the ulcer- ated surface, improve the secretion, and annihi- late the hectic. The experiment has been tried at home and abroad upon a pretty extensive scale, by employing different proportions of hy- drogen, so that the patient has twice a day Gen. III.—Spe. 5.] MARASMUS breathed from a pint to a quart of gas at a time, diluted with from twelve to six times its meas- ure of common air ; and, making every allow- ance for an exaggeration of statement in those who have most warmly engaged in the practice, it seems difficult- not to concede that it has proved serviceable in various cases. A combination of hydrogen with common air seems, indeed, to be beneficial in various other modes of application ; but whether by lowering the ordinary stimulus of common air, or by di- rectly diminishing and exhausting the nervous influence communicated to the lungs, it is not easy to determine. In either way, however, it has an equal tendency to indispose them to in- flammatory action. Thus Clapier relates a case of confirmed consumption cured by an habitual residence in a coal-mine (Journ. Med., xviii., 59), and expressly states that the matter expec- torated soon began to assume a more healthy appearance, and was excreted more freely. It is, in like manner, a common remark, that the miners of Cornwall are more generally exempt from phthisis than most other persons (Southey, Observations on Pulmonary Consumption, 8vo., 1814), and that butchers, who are perpetually engaged in slaughter-houses, and surrounded by a vapour impregnated with hydrogen, possess an equal emancipation. It is probably to this cause, if to any, we are to ascribe the benefit which Bergius found consumptive patients de- rive from a residence in cow-houses (Neue Schwed. Abhandl., 1782, part iii., p. 298), and which was, not long since, a fashionable mode of practice in our own country.* Expectorants and demulcents have also very generally been employed for the same purpose —that of subduing the disease by exciting a healing action in the tubercles or ulcerations, indicated by improvement in the exspuition. Of the general nature and mode of action of these classes of medicines, we have already spo- ken at large in discussing the treatment of cough and asthma : and our remarks, therefore, upon the present occasion, will be but few. Where the irritation is considerable, and ac- companied with much increase of vascular ac- tion, as in the" commencement of the apostema- tous and catarrhal varieties, the best demul- cents, and, indeed, the only medicines of this * Of late years the inhalation of iodine and chlo- rine has been extensively tried. When iodine is employed, it is only in a minute quantity, and mixed with hydriodate of potassa. Dr. Elliotson informs us, that he has seen more mitigation from the chlorine than the iodine; but he has never seen a case cured by either of them. He has known a single drop of tincture of iodine, put into a pint of fluid, produce great irritation ; but chlorine is borne much better: the mitigation afforded by it, how- ever, is but temporary. The following is the mode of using it recommended by Dr. Elliotson :—Into three quarters of a pint of water, drop four or five minims of a saturated solution of chlorine ; but he considers it best to begin with one or two minims, and to increase the quantity gradually, in propor- tion as the patient can bear it.—See Lect. at Lond. Univ., as published in Med. Gaz. for 1833, p. 236. —Ed. Vol. II.—E 3 PHTHISIS. 65 kind we can employ as palliatives, are the veg- etable mucilages, as of tragacanth, quince- seeds, or gumarabic. Where it is necessary to diminish the general action, these may be united with small doses of ipecacuanha, or of squills, which have the double power of exciting nausea, and unloading the mucous follicles of the bronchiae as expectorants. And, where the cough is very troublesome and the pain acute, they should be united with narcotics, as opium or hyoscyamus. In a more advanced stage of the disease, and through the entire course of the tubercular va- riety, except where haemoptysis is present, the expectorants, more properly so called, have often been employed with advantage. One of the oldest of these is sulphur, and, perhaps, one of the best: from its not readily dissolving in the first passages, it is carried to the rectum, and skin sometimes, with little alteration, and hence gently stimulates both extremities, loosens the bowels, and excites a pleasing diapnoe on the surface." It is in this way it appears to be ser- viceable in an inflammatory or tubercular state of the lungs. It was in high repute among the Greek and Roman physicians, who, when em- ploying it as an expectorant, usually combined it with yelk of egg; and it has maintained its character to the present day. In the tubercular or scrofulous variety, as it is often called, it has frequently been united with some other prep- aration, as diaphoretic antimony, with which it was joined by Hoffmann, dulcamara by Videt (Medecine Expectante, torn, iii., p. 237, 8vo., Lyons, 1803), and cinchona by Dr. Trotter.— (Mcdicina Nautica, vol. iii., p. 325.) The vulnerary balsams and resins, however, have been more generally had recourse to, but ought rarely, perhaps never, to be employed in an early stage of the disease. Their action is common, and depends upon their possession of a terebinthinate principle, and hence they might be used indiscriminately, but that some of them are less stimulant and heating than the rest. Myrrh and camphire are among the least irritant, and may often be employed when we dare not trust to any other. Copayva, though of some- what greater balsamic pungency, has often been found essentially useful. Marryatt was peculi- arly attached to it: he gave twenty drops of it night and morning upon sugar, and asserts that, when an ulcer has been formed, it ought never to be omitted (Therapeulica, Lond., 1758); and Dr. Simmonds appears to hold it in nearly as high an estimation.—(Pract. Obs. on the Treat- ment of Consumption, Lond., 1780.) Many of the remedies already enumerated under the present head act with a sedative in- fluence, and of opium we have already spoken. But there is a medicine which immediately be- longs to the present place, not yet noticed, that has of late years been strongly urged upon the public in the warmest terms of panegyric, and by many celebrated writers been regarded as a specific in consumption ; and that is, the prus- sic or hydrocyanic acid. M. Magendie has been highly sanguine concerning it in France.—(Re- cherches sur VEmploi de VAcide Prussique, &c, 06 H^EMATICA. [Cl. III.—Oxd. IV. parF. Magendie, D.M,&c., 8vo., Pans, 1819.) MM. Brera, Manzoni, and Borda (Storia delta Fcbre Petecchiale ii Ginova, &c.) in Italy, and Dr. Granville in our own country (Observations on the Internal Use of the Hydrocyanic Acid in Pulmonary Complaints, &c>; yet not a single case of actual cure in confirmed phthisis has hitherto been advanced by any of them. We have already noticed this powerful medicine as a most valuable subduer of nervous irritation in periodic nervous cough and hooping-cough, and there can be no question that it will often be found capable of acting in the same manner in phthisis. But, from the greater degree of de- bility and relaxation in this last than in the pre- ceding diseases, we have more to fear from the mischievous effects of the prussic acid, which cannot always be guarded against, and which M. Magendie admits to have taken place occa- sionally with very fearful apprehensions, such as vomiting, diarrhoea, great depression of spirits, prostration of strength, and even syncope. And hence, if it be employed as a palliative at all, it should be in the earlier stages of the disease ; for, in the latter, where it is most wanted, it is altogether unsafe, and must yield to most of the forms of opium. And the same remark may be made concerning aconite, another of the fa- mous counter-stimulants of the present Italian school of medicine, and with which M. Borda tells us he has sometimes snatched the patient from the jaws of death. V. The last part of the general therapeutic process, which has been attempted in most ages, has consisted in endeavouring to diminish or carry off the local affection by a transfer of ac- tion. Blisters have very generally been applied for this purpose to the back or the chest. Their service is temporary, but often very efficacious, and they ought never to be neglected. It was formerly the custom to render them perpetual by the use of savin ointment or some other eschar- otic. But it is less painful and more beneficial to let the skin heal, and renew them after short intervals. Setons, issues, and caustics, however, where the constitution is not very delicate, nor the habit very irritable, have proved far more pow- erful revellents, on account of their more vio- lent stimulus and greater permanency of action. The actual cautery, though much abstained from in modern practice, from its apparent, and, indeed, real severity, was in almost universal use in ancient times ; and, in the mode described by Celsus, was undoubtedly a very formidable operation. When the disease, says he, has taken a deep root, the cautery must be applied under the chin, in the throat, twice on each breast, and under the shoulder-blades ; and the ulcers must not be healed as long as the cough continues. The obvious intention is to produce a revul- sion, and hence, by transferring the morbid ac- tion to a part of less importance, to allow the lungs to return to a healthy condition. Such transfer may, by these means, in some cases be rendered total, though, in general, the morbid I irritation is only partially, instead of entirely, carried off. There are other means, however, by which it seems to be removed altogether, although they are seldom put into our hands. Thus M. Bayle's fifty-third case is that of a medical man who was fully prepared to meet his fate, and resolved to take no medicine what- ever. At this time a severe rigour from an un- known cause attacked him, succeeded by a sweating-fit so profuse, that his linen was changed two-and-twenty times in a night, and even this was not sufficient. The paroxysm proved critical, and the disease was thus carried off by an ephemera. Sir Gilbert Blane gives an account of a like singular and salutary change excited by a hur- ricane at Barbadoes in 1780, which produced such an effect on the air or on the nerves of the sick, that some who were labouring under in- cipient consumption were cured by it: while others who had reached a more advanced stage were decidedly relieved, and freed for a time from many of their symptoms.—(Observations on the Diseases of Seamen, 8vo., Lond., 1785.) No affection seems to keep a consumptive diathesis in so complete a state of subjugation as pregnancy. Most practitioners have seen cases in which a female has dropped all the symptoms of phthisis upon conception, and has continued free from the disease till her delivery. Suckling does not seem to continue the truce ; but, if she conceive again shortly afterward, she renews it: and there have been instances in which, from a rapid succession of pregnan- cies, the suspension has been so long protracted, that the morbid diathesis has run through its course and entirely subsided, leaving the pa- tient in possession of firm and established health. As one disease, therefore, or state of body, is well known to have a frequent influencaupon another, and consumption is found to be thus influenced by various affections, it is a question well worth inquiring into, whether there be any malady of less importance, which, like cowpox over smallpox, by forestalling an influence on the constitution, may render it insusceptible of an attack of phthisis 1 Dr. Wells, not many years ago, very ingeniously engaged in an inquiry of this kind, and, finding that it was common for the consumptive in Flanders to remove to the marshy parts of the country where agues were frequent, began to think, not indeed that agues might give an exemption from consumptions, but that the situation which produced the for- mer might prove a guard against the latter. And, so far as his topographical investigations have been carried, and they have extended over some part or other of all the quarters of the globe, this opinion has been countenanced ; for he has discovered that, wherever intermit- tents are endemic, consumption is rarely to be met with, while the latter has become frequent in proportion as draining has been introduced__ (Trans. Medico-Chir. Soc, vol. iii., p 471 \ The later inquiries of Dr. Southey do not sud port this hypothesis, but the question is yet unsettled, and well worth pursuing- and Mr Mansford, who practises in the interior of Som." Gen. IV] MELANOSIS. 67 ersetshire, has still more lately published a work, which, though not written as a defence of Dr. Wells's opinion, indirectly confirms it, by endeavouring to prove that a low, inland situation, like the vales of his own country, is far better calculated as a residence for consump- tive patients than the air of mountains, or of the seacoast.—(Inquiry into the Influence of Situation on Pulmonary Consumption, by J. G. Mansford, &c, 8vo., 1818.)* * As the pathology of consumption is not yet fixed, so too the treatment, of this disease varies with different physicians : the assumption that the forming stage of phthisis is, in many cases, of an inflammatory character, has led the profession in the U. States to a more active method of relief in early periods, than is sanctioned by the practice of Europe : phthisis has generally been considered in this country as allied to pneumonitis, bronchitis, &c, and as requiring the use of the lancet, purga- tives, antimonials, &c, during the first stage, which practice is warmly advocated by Dr. Hosack (Es- says, vol. ii.): few however would imitate the ex- treme depletory practice of Rush; bloodletting has its limits. In regard to purgatives, morbid anatomy has so often shown an inflammatory condition of the mucous membrane of the ali- mentary canal, that the milder cathartics seem more appropriate than drastic purgatives. Antimonials, in the earlier stages of the disease, are almost universally recommended, and Dr. Bal- four's practice of tartar-emetic ointment is ex- tremely popular. Practitioners differ widely as to the remedial powers of digitalis : while it is much extolled-by some as lessening the activity of the heart and arteries, it is rejected by others as in- creasing the debility and irritability. Dr. Eberle's estimate of its value seems to us to be just: " that Under careful management, and in conjunction with a well-regulated diet and proper attention to the cutaneous functions, much good may be de- rived from its employment in incipient phthisis." " Tar fumigations, employed as directed in the text, have been found highly serviceable by Amer- ican practitioners. In regard to iodine, a gentle- man of ample experience, Dr. Morton of Pliiladel- pliia, remarks (Illustrations of Pulmonary- Con- sumptions), that "in a large number of instances, it has appeared, especially in incipient consump- tion, to arrest or suspend the tubercular secretion, and with it the hectic, marasmus, cough, dyspnoea, and other urgent symptoms ;" and again," in a ma- jority of cases, even in the second stage of phthi- sis, 1 have been much gratified with the results ; thus, it often relieves the dyspnoea, improves the complexion, and restores the appetite, even when the advanced progress of the disease precludes all hope of recovery." Dr. Rush urges salivation as important in treating pulmonary consumption ; we are aware that the American journals contain some interesting reports in which this plan of treatment has been successful, but there are habits of body, peculiarities of temperament, and other circumstances, whicb, in some cases of phthisis, would forbid it The respiration of cold air was proposed as a remedy in pulmonary diseases by the late Dr. C. Drake, of New-York. He states," that its sensible effects were tolerably uniform. The most con- stant effect on the pulse was to render it fuller: when it was pretematurally frequent, it commonly rendered it slower; it very generally mitigated the cough, diminishing its frequency, and rendered the expectoration freer and easier." For a view of the E2 GENUS IV. MELANOSIS.* MELANOSE. SECRETION OF A BLACK MATERIAL, MORE OR LESS INSPISSATED ; STAINING OR STUDDING THB VISCERAL AND OTHER ORGANS.+ The tubercles and tubers of struma chiefly originate in the texture of the glands, espe- cially the lymphatic, and are often confined to them. There are other tubercles, as those of mesenteric tabes, that spread rapidly into dif- ferent textures, and sometimes originate in them. But there are none that seem to com- mence or extend over so large a field as those we are now about to describe, or so seriously to affect the constitution.% There is not, in- deed, a single organ of the simplest or most complicated kind, from the cellular texture to the unravelled elaboration of the brain, which is not occasionally loaded with them; while, in various parts, the black pigment, which gives them their hue, is found diffused in extensive sheets, without tubercles, or the pulpy matter that fills their cysts ; transforming the natural colour of the organs, to which it is conveyed, into its own morbid jet. [The most frequent seat of true melanosis, however, is found by Dr. Carswell to be the serous tissue, more especially where this tissue constitutes tho cellular element of organs. Here the mela- notic matter accumulates in the cells, and forms tumours of various sizes. Its formation, as a secretion, is still more conspicuous in the loose cellular tissue, and especially on extensive se- rous surfaces.] The last change has hitherto been found chiefly in the bones, but sometimes also in the membranes, and even the parenchyma of organs, constituting, in the language of M. Breschet, a false membrane or membranous expansion on the surface of the mucous and other textures; and it is hence possible that examples may hereafter be met with of a generally diffused, as well as a generally tubercular, form of the disease. But as the second, with a few local exceptions, is the only mode under which it has hitherto appeared,^ we have at present but one apparatus employed by Dr. Drake, see the Am. Journ. of Med. Sc, vol. iii., p. 53.—D. * Melanose, Laennec; Melanoma, Dr. Cars- well ; Black Cancer, Baron Dupuytren. t " True melanosis consists in the formation of a morbid product of secretion of a deep brown or black colour, of various degrees of intensity, un- organized, the form and consistence of which pre- sent considerable variety, solely in consequence of the influence of external agents."—(Dr. Cars- well, in Illustrations of Elementary Forms of Dis- ease, fasc. iv.)—Ed. % If we advert to tubercular diseases of the lungs, peritoneum, spleen, and some other organs, and at the same time recognise them, with many of the best modern pathologists, as scrofulous af- fections, some of our author's doctrine, as here laid down, will appear incorrect.—Ed. $ Since the period when this was written mela- nosis has been investigated with considerable at- tention, and our knowledge of its nature has beeu 68 HiEMATlCA. [Cl. III.—Ord. IV. species of the genus, which we shall proceed to describe under the name of Melanosis Tnbercularis. Tubercular Melanose.* SPECIES I. MELANOSIS TUBERCULARIS. TUBERCULAR MELANOSE. THE BLACK SECRETION PULTACEOUS, IN EN- CYSTEDt TUBERCLES, PEA-SIZED OR WALNUT- SIZED, SCATTERED IN GKOUPS OVER MOST OF THE ORGANS ; CHIEFLY BELOW THE SURFACE, SOMETIMES UPON IT : FEVER MOSTLY A HEC- TIC : GREAT DEBILITY.t It is singular that this very striking disease should not have been traced, or rather, perhaps, not have attracted much of the attention of much extended. We are now aware that it pre- sents itself in various forms, which have been treated of with great ability and discrimination by Professor Carswell, in his Illustrations of the Ele- mentary Forms of Disease, fasciculus iv., Lond., 4to., 1834. He divides melanotic formations into two kinds, the true and spurious. Thus, when these formations or products depend on a change taking place in that process of secretion, whence the natural colour of certain parts of the body is derived, or, in other words, when they constitute what is called an idiopathic disease, he considers them as belonging to the first kind; and, when they originate in the accumulation of a carbona- ceous substance, introduced into the body from without, the action of chymical agents on the blood, or the stagnation of this fluid, he includes them in the second kind.—Ed. * Four varieties, or species, are described by Professor Carswell, namely,—1. Punctiform. 2. Tuberiform. 3. Stratiform. 4. Liquiform. The tuberiform, which is by far the most common, corresponds to Dr. Good's melanosis tubercularis, or the melanose en masse of French pathologists, Tuberiform melanosis agrees with the " concre- tions melaniques;" punctiform with the " mela- nose infiltree ;" stratiform with the " melanose membraniforme;" and liquiform with the " mela- nose liquide" of Laennec, Breschet, Andral, and other writers. It was Breschet who applied the term liquid melanosis to one of the varieties.—Ed. t " Tantot la matiere est enkystee, tantot elle n'est contenue dans aucun reservoir; et elle paroit etre exhalee a la surface des tissus, ou epanchee dans une cavite."—(Breschet.) "La melanose en masse peut etre entouree d'un kyste, ou en e'tre d^pourvue. Le premier cas est infini- ment plus rare que le second."—(Andral, Precis d'Anat. Pathol., torn, i., p. 451.) Laennec's dis- tinctions of encysted and unencysted melanosis are of much less importance than similar distinc- tions in relation to cancer; in fact, cysts are rarely met with, and, when they are present, consist of such a cellular loose tissue, that they have little effect as boundaries to melanotic humours.— (Blandin, Diet, de Med. et de Chir. Pratiques, art. Melanose.) According to Dr. Carswell, mela- nosis is perhaps never found encysted in com- pound tissues or organs, as the brain, lungs, liver, or kidneys; whereas it is always so in the cellu- lar and adipose tissues, and sometimes also on the surface of serous membranes.—See Illustrat. of the Elementary Forms of Disease, fasc. ivP-ED. t In the majority of cases, melanosis does not produce great constitutional disturbance. We find it sometimes attaining considerable magni- pathologists, till a few years back, at least m the nosology of man. For it has been long observed in many kinds of quadrupeds, as the dog, cat, hare, but especially the horse, and, among the veterinary surgeons of France, has obtained the name of charbon, or maladie char- bonneuse. It is, however, to the ingenious anatomical researches of MM. Laennec and Bayle (See Journ. de Med. de Cmvisart, &c, torn, ix., p. 368) that we are indebted for our first knowledge of the disease as it exists in man,* and for the very appropriate generic name Of MELANOSIS,* Or MORBID DENIGRATION, by which it is now generally distinguished. [The colour of melanosis varies from dark yellow to brown, deep blue approaching to black, and to complete black, which is the most com- mon. It is readily detected by its peculiar shades of colour in any organ containing it; more especially as the surrounding tissues are lighter coloured, and form a contrast with it. No smell proceeds from it, a circumstance dis- tinguishing it from gangrene, which always emits a very offensive odour ; nor has it any particu- lar taste, a character which belongs to it in common with most other morbid formations. The minute texture of melanosis is little known : if we except the cyst, no vessels nor nerves have been discerned in it; and it seems as if it were an inorganic substance deposited in or upon various parts. The melanosis described in the definition prefixed to this article by Dr. Good, is the most common or the tubercular va~ tude in the liver, and in the common cellular tis- sue, without giving rise to any functional derange- ment sufficient to excite the suspicion of its ex- istence ; it may merely occasion a degree of un- easiness by its mechanical effects on the contig- uous parts.—Ed. * Breschet assigns the honour of having first described this organic affection to Dupuy tren, who declared, when MM. Bayle and Laennec (Bulletins de la Soc. de l'Ecole de Med., No. ii., 1806) published their observations, that lie had for several years described the disease in his lectures. Some controversial papers on this point maybe seen in Corvisart's Journ., torn, ix., p. 360 and 441, and torn, x., p. 89 and 96. An allusion to the disease, however, may be traced in the writings of Morgagni, Bonetus, and Haller. In Epist. iv.. No. iv., De Sedibus et Causis Morb., Morgagni informs us, that in one body which he opened, the lungs looked as if they had been stained with ink ; and in another place, he describes the lungs as having been found indurated and black. In a dropsical patient, the liver, after death, was also black.—(Epist. vii., No. xi.) In Haller's Opus- cula Pathol., obs. xvii., notice is taken of an ex- ample hvwhich the lungs were found not filled with pus, but with a matter as black as ink; and of another case, in which the author met with black matter in the cavity of the chest.—Ed. t Breschet says, however, " Cette designation ne se trouve ni tres-rigoureuse ni tres-exacte, car on voit plus souvent ces matieres etre jau'nes- brunes, couleur de suie ou de bistre, que verita- blement noires. • Cependant j'en ai rencontre qui etoient parfaitement noires, et qui coloroient les tissus de lin et le papier, comme le fait la solution aqueuse de l'encre de la Chine."—See Jnnm a*. Physiol., torn, i, p. 354.—Ed. n> ** Gen. IV—Spe. 1.] MELANOSIS T riety of it, but it presents itself in other shapes.* The melanotic deposite takes place in three distinct forms: 1st, Very much divided and suspended in liquids; hence the black tinge of the serous fluid of certain cavities, and espe- cially as frequently presented by the serosity of the peritoneum, when the liver, bowels, stom- ach, or uterus, are the seats of cancerous dis- ease, t Breschet, Andral, and Cruveilhier, de- scribe a melanotic secretion from the surface of a mucous membrane, or the cavity of the stomach; but, in doing so, it seems to Professor Carswell that they have mistaken the black discoloration of the blood, produced by the ac- tion of the gastric juice on this fluid, when ef- fused, for true liquiform melanosis.—(Op. cit., fasc. iv.) 2dly, As a very thin layer spread over serous membranes, the stratiform or mem- braniform melanosis. In this case it sometimes exhibits a fine glossy black colour, resembling that of Indian-ink. The layers are more. or less extensive ; and M. Merat has seen the whole of the peritoneal coat of the intestines covered with them. The matter is adherent to the serous membranes, which are almost the only ones upon which it assumes this form ; but they are not at all altered by it, being neither thickened nor otherwise affected ; and it is re- marked, that individuals who die with this mod- ification of melanosis do not fall victims to it, but to other organic changes. Layers of black matter are noticed on some portions of the mu- cous system, as on the tongue in typhoid and other fevers ; and Meiat even conceives that such appearance is a specimen of one kind of melanosis. 3dly, Melanosis most frequently assumes a globular shape, or the form of a tu- bercle, varying from the size of a millet-seed to that of an egg, or even a larger body. Its shape is moulded by the containing parts ; and hence it is in general less symmetrically spher- ical in soft parts, and more regularly globular * This form is exemplified occasionally in most of the organs of the body, and also sometimes on serous surfaces, as the pleura and peritoneum. In compound organs, the disease is generally a single swelling; but in the cellular and adipose tissues there is an aggregation of tumours, producing tu- berculated masses. In the liver, lungs, and kid- neys, according to Dr. Carswell, the tuberiform melanosis is always combined with the punc- tiform.—Ed. t Breschet, in Magendie's Journ., torn, i., p. 359. Laennec takes no notice of the fluid vari- ety. Indeed, as he describes melanosis as a tissue, he could not regard a liquid as meriting the name. But other pathologists, who look upon melanosis as a simple deposite of unorganized colouring matter, have no more difficulty in conceiving its fluid than its solid state. The liquiform variety of true melanosis has in general been confined to natural or accidental serous cavities. Dr. Cars- well has never seen it in man, as a product of se- cretion, but has met with it in consequence of the dertruction of melanotic tumours, and the effu- sion of their contents into the serous cavities, the walls of which they had perforated. The acci- dental serous cavities in which it is found are those which constitute cysts, particularly in the ovaries.—Ed. JBERCULARIS. 6S in such as are firm. 4thly, A fourth variety is that in which the disease is diffused through certain tissues, the " melanose infiltree" of Laennec, the " punctiform melanosis" of Cars- well.*] The cause, progress, diagnosis, and mode of treatment of tubercular melanosis, are at present obscure and unsatisfactory. The individual la- bouring under it frequently exhibits, when he first applies for help, a considerable degree of febrile excitement, debility, and oppression in the thorax or abdomen ; most commonly about the pleura or in the loins. Every case of melanosis that came under the observation of Dr. Armstrong was accompa- nied by more or less chronic bronchitis, which, however, he admits, is not sufficient of itself to produce melanosis, as numerous examples of it take place without any traces of the latter affec- tion.—(Mori. Anat., &c, p., 25.) [Melanosis is alleged to be more frequently combined with carcinoma than with any other disease ; but, as Dr. Carswell observes, there is no similarity between these two diseases, their anatomical, physical, and chymical characters being totally different. Several varieties of the former (re- garded as such in Dr. Carswell's classification.) are highly organized, while melanosis itself is an unorganized substance, injurious only from its quantity, the number of organs which it af- fects, its situation, and mechanical operation. In Dr. Carswell's work may be seen representa- tions of melanosis, combined with fibrous, car- cinomatous, and erectile tissues.] The above, however, are not always the introductory symptoms ; for the disease some- times commences with catarrhal or rheumatic affections after exposure to cold, succeeded by shivering fits.* The patient seems generally unwell for the first five or six weeks after this attack ; but when it has once firmly established itself, and evinced the thoracic or abdominal signs just adverted to, it proceeds with a rapid * The punctiform melanosis appears in minute points or dots, grouped together in a small space, or scattered irregularly over a considerable extent of surface. Such appearances are most frequently seen in the liver, the cut surface seeming as if it had been dusted over with soot or charcoal pow- der. When examined with the aid of a leas, the black points sometimes present a stellated or peni- cillated arrangement, which, in some cases, can be distinctly seen to originate in the ramiform ex- pansion of a minute vein, filled with melanotic matter. At other times, this matter appears to be deposited in the molecular structure of this organ, consisting of the most minute points disseminated throughout the acini of the liver, of various depths of shade, terminating in black.—See Carswell'-s Illustrations of the Elementary Forms of Disease, fasc. iv.—Ed. t Melanosis often produces, at its first forma- tion, no disturbance of the health, and the exist- ence of the disease is frequently not suspected previously to dissection. However, several pa- tients were cut off by the disorder who had a sallow complexion, excessive debility, and more or less oedema, being in a state very similar to the advanced stage of scurvy.—See Magendie's Journ., torn, i., p. 365.—Ea 70 H.FMATICA [Cl. HI.—Ord. lv- and fatal step, and in about a fortnight, he falls a victim to the hectic fever, perspiration, ema- ciation, and debility by which he is jointly as- saulted : the prodromi or incursiye symptoms, whether affecting the loins or chest, usually giving way before the closing scene arrives, and deceiving the sufferer, and sometimes even his medical attendant, into a belief that he is improving; when he suddenly sinks from debil- ity alone. If the patient be examined accurately at this time, a few tubercles or clusters of tubercles may occasionally be felt under the skin, espe- cially that of the abdomen or of the breasts. And sometimes also a cyst, much larger than the rest, may be found projecting, and even forcing its way externally through the integu- ments. In a few instances this larger cyst ul- cerates, of which a striking example occurred to M. Breschet in 1821, and is particularly no- ticed by Mr. Cullen. In the right groin of the patient, who was a female, an ulcerative surface was perceived about as large as a crown piece, the bottom of which consisted of the ordinary black material of the disease before us, jetty as China ink, of the consistence of cream above, but much more inspissated below, where it was in contact with the cellular texture. There were sufficient proofs that it was not a mere Bloughing sore ; among which it may be ob- served that it was destitute of fetor, and that in its immediate vicinity, as well as in other parts of the body, as was afterward ascertained by opening into them, there was a crop of de- fined melanotic tubers of different forms and diameters. One of the best marked instances upon rec- ord is the following, which occurred to Profes- sor Alison in the Royal Infirmary, Edinburgh. The patient's name was Rachael Bruce, and she was admitted on the third of June.—(Trans. of the Medico-Chir. Soc. of Edin., vol. i., p. 275, 1824.) She complained of severe pains shooting down from the loins to the inferior extremities, and to the abdomen. She had sim- ilar pains in the right shoulder and arm, in- creased in the night-time, or by motion. She had become weak and emaciated since her com- }>laints began, and was liable to shivering, fol- owed by flushing and profuse perspiration, which increased her debility without relieving her pains. The abdomen was swelled, but did not fluctuate on percussion, and the distention va- ried in degree at different hours of the day. She had thirst, with scanty, high-coloured urine, not coagulating by heat. The integuments of the abdomen were flaccid ; and a hard, move- able tumour could be felt in the iliac and hypo- gastric regions. She was also liable to parox- ysms of dyspnoea during the night. Her appetite was impaired. She had a bad taste in the mouth, with white and dry tongue. Her bowels were reported to be regular ; but she had occasional nausea. She stated her complaints, which were of five or six weeks standing, to have commenced, af- ter exposure to cold, with shivering and pain, and stiffness of the loins, and of the hip and knee-joints of the left side. The enlargement and induration of the abdomen had been re- marked only during the last fortnight. Up to June the 20th, being seventeen days from the time of admission, the symptoms con- tinued with little variation. On the 21st were perceived several small painful tumours on the integuments of the abdomen, which she de- clared to have existed from the commencement of her illness. She was on -this day examined by a skilful accoucheur, who reported the tu- mour felt in the hypogastric region to be uncon- nected with the uterus. On the 24th a copious sweating, with involuntary discharge of urine, was added to the other symptoms. From this moment there was great debility, with decided hectic fever; and a tendency to sloughing of the sacrum. On the evening of the 7th she had vomiting of a dark-coloured matter, and soon afterward died. The course is usually more rapid : and in the case of John Houston, a shoemaker, admitted into the same infirmary under the care of Dr. Home, extended only to thirteen days. His chief symptoms at the time of admission were those of pleurisy, with a severe cough and dif- ficult expectoration. The bladder was also af- fected ; and on the eighth day he was troubled with painful hemorrhoidal tumours, probably produced by the action of repeated purgatives. The other symptoms gradually diminished, but the debility increased. On the twelfth day, as we learn from a diary of the symptoms and treatment, furnished us by Sir Andrew Halli- day, his pulse was 112; heat 98| Fahrenheit ; he was allowed a beefsteak, and a quarter of a pint of sherry. On the ensuing night he made complaint of great weakness ; his pulse- quick- ened to 140, and he died at four in the morn- ing.—(London Medical Repository, vol. xix., p. 442.)* The treatment is yet to be learned ; and the cases before us afford little instruction upon the subject. The first was resisted by little more than palliatives, as leeches, laxatives, anodynes, and Dover's powder. The second unfolds a bolder plan, though the patient still sooner reached his end. It consisted in venesection to sixteen ounces, two days in succession, and powerful purgatives, at first often repeated, of calomel, jalap, and sulphate of magnesia, &c. * A case of melanosis, affecting the parotid gland, is recorded by Dr. Valentine Mott, in the Am. Journ. of Med. Sc, vol. x., p. 16. The de- scription is accompanied with a coloured engra- ving of the melanotic body, which was extirpated. On dividing the tumour longitudinally, not a ves- tige of the original organization of the gland could be observed. The inner surfaces had the appear- ance of firm tar, and imparted a black colour to the fingers when touched. After the operation, the patient seemed to do well; but in about a month several tumours appeared on the scalp. a dark spot showed itself in the integuments of the diseased side of the face, the knee swelled and hectic supervened. The patient died fifty' three days after the operation. No examination of the body could be made, but Dr. Mott is confident that the disease was constitutional melanosis —D. Gen. IV—Spe. 1.] MELANOSIS TUBERCULARIS. 71 But this was not long continued, no benefit ap- pearing to issue from it; and it yielded to seda- tive mucilages and a tonic diet. In reasoning speculatively, we should speak with great modesty. But admitting the mate- rial which forms the tubercles to be a peculiar secretion, and that the constitutional excitement consists mainly in this new and stimulant ac- tion, perhaps it may, in future cases, be found useful to combine the two intentions of allay- ing the peculiar irritation, and, at the same time, urging the secernents to a renewal of their proper action ; or, in other words, to em- ploy the conjoint force of sedatives and counter- irritants ; which may be effected by a union of opium, or Dover's powder, with the tincture of iodine. The great and beneficial influence which the latter is well known to exercise in many cases over strumous tubercles, should in- dicate its use on the present occasion. And it is also not improbable, from the approach which the disease seems occasionally to make to the more irritant cases of phthisis, in its excitement of the chest and its hectic fever, that the hy- drocyanic acid might at times, with great ad- vantage, take the place of all other sedatives. Such coincidences of symptoms, moreover, show us clearly the place which melanosis should oc- cupy in a general nosological arrangement.* Before hazarding a syllable upon the physiol- ogy of this very extraordinary disease, it is re- quisite to put the reader into possession of the general appearances afforded by post-obit exam- inations ; and the case already alluded to, as un- der Professor Alison's care, is admirably adapted to this purpose, if put into an abridged form. The body evinced great and general emacia- tion, and various small dark-coloured tumours, perceptible during life, were still distributed over it. In the mammae, these were largest and most numerous : they were traced in cysts, and imbedded in the cellular substance; and when cut into were found to contain a deep black-col- oured matter, of a soft and pulpy consistence. Within the abdomen, most of the cellular and adipose textures had disappeared. The perito-. neum lining the parietes was of a blackish colour, and the black matter was irregularly deposited in striae and spots upon the inner side of the mem- brane, which had lost much of its natural trans- parency. The omentum presented a similar appearance, and several globular shining tumours of a black colour were appended to it, which, when cut into, poured out a similarly coloured fluid. Spots and tubercles of a like kind were traced in the serous or% outer membrane of the intestines, and between the folds of the mesen- tery. The ovaria were several times as large as their natural size, seated in front of the uterus, and occupying the lateral iliac regions. * When a melanotic tumour is so situated as to admit of being removed with a knife, this is the proper practice. In the human subject such an operation has been done for the extirpation of the eye affected with this extraordinary disease. Me- lanotic tumours have often been successfully re- moved from horses.—SeeArchiv.Gen.de Med., Juin, 1628, p. 180.—Ed. Their external surface had a dark, shining, lobula- ted appearance, with numerous ramifications of vessels upon the peritoneal covering; beneath which black matter was irregularly deposited in spots, giving a mottled appearance to the whole. When cut into, their substance was uniformly black. The cellular texture still retained its consistence, and vessels containing red coagula- ted blood could be traced through it. Several distinct cysts or cavities were found in their substance, which poured out a black liquid when opened. The kidneys, liver, spleen, and the mucous or interior membrane of the stomach and intestines, were all free from black matter, although it was deposited in the cellular tissue connected with these organs. On uncovering the breast-bone and scull-cap, it was observed that the whole texture of the sternum, the an- terior portion of the ribs, and a great part of the parietal and occipital bones, were black, more brittle, and of softer consistence than natural, but without enlargement or ulceration. The periosteum was nearly natural, but the whole inner table of the scull, when removed from the dura mater, was of a darker hue than natural, and in some places whore the black matter was deposited in irregular patches of the bone, there were corresponding stains on the surface of the dura mater. The substance of the brain was healthy, but a few. black stria? were discernible in the membranes, and the tunics of several of the vessels. A large quantity of serum was effused under the arachnoid membrane and in the ventricles. Within the thorax, the costal pleura and surface of the lungs were studded with black tubercles like those of the integuments, while some of them were larger. The substance of the lungs was dark, and some minute tuber- cles were imbedded in it, and like spots were noticed beneath the pericardial coverings of the heart, which contained some coagulated blood in its cavities, and was softer than usual. It should further be observed, that in a few places in the present subject, but more gener- ally in others, the black material varied con- siderably from its ordinary degree of consistence, and instead of being pulpy or nearly solid, was a fluent liquid ; and that several of the tuber- cles were filled with a white and brain-like sub- stance, while those that surrounded them were of a deep jet. The first opinion formed respecting the na- ture of these enlargements by MM. Bresclfct and Laennec was, that the dark material was con- gested blood that had escaped from the capil- lary vessels into the cellular substance by a rup- ture of their coats, or by anastomosis from relax- ation. But this conjecture was soon found un- tenable, as it was sufficiently ascertained that the material is a distinct secretion, and is now supposed to be a secretion sui generis. Nor is another opinion of M. Laennec's much more tenable, which advances that the black material evinces different stages of elaboration; that when first thrown forth it is pultaceons or nearly solid, and in a state of crudity, but that it grad- ually matures, and advances to a state of ra- mollissement or fluidity. For it is well observed 72 HvEMATICA. [Cl. III.-Ord. IV by Dr. Cullen, that, were this true, we should expect to find the largest cysts or reservoirs in the highest state of liquefaction, and the small- est in the highest state of solidity ; the contrary of which is usually the course pursued. [Mr. Fawdington (Case of Melanosis, with General Observations on the Pathology of this interest- ing Disease, 1826), however, follows Laennec in placing the stage of fluidity posterior to that of solidity. At first it seems difficult to con- ceive how the melanotic matter can be originally deposited in any other than a liquid form ; and if in a solid state, how from its organic nature it can undergo the process by which it is after- ward softened. Yet, that tubercles of the lungs are first solid and afterward soften, though their substance has no organization, is the general belief.*] It is also justly remarked by Dr. Cullen of Edinburgh, that the characters of tubercular me- lanosis completely distinguish it from cancer and fungus haematodes; since it is well known to exist without local pain,t and to propagate itself by cysts and boundary lines, while both the others are accompanied with severe lancinating pains, and burst through every bond, and ex- tend their ravages in every direction. [Dr. Armstrong, in noticing the opinion that melanosis, like tubercle, scirrhus, and fungus, is associated with an organized affection sui gene- ris of the solids, takes the opportunity to remark, that in all the cases examined by him, the dis- ease seemed to be nothing but a secretion, sometimes occurring in textures otherwise ap- parently natural, sometimes in those chronical- ly inflamed, and sometimes co-existent with either scirrhus or fungus.—(Armstrong's Morbid Anatomy, &c, p. 24, 8vo., London, 1828.) It is a peculiar feature in the nature of melano- sis, that the animal textures are never, strictly speaking, converted into it, unless it be proved that the oily matter of the cellular tissue under- goes this change ; and even on this supposition * M. Blandin supports Laennec's view by ob- serving that melanotic tumours may change into a softened state, particularly when they are sit- uated near the surface; the skin becomes thin and ulcerates, and from the surface of the sore is discharged a glutinous black matter, which is characteristic of the disease. A case exemplifying these changes was seen by M. Blandin in the Sal- Eetriere, and the particulars of it were published y B,+jschet.—(See Journ. de Physiol. Experi- ment, torn, i., p. 354.) The old woman, the sub- ject of it, and who is referred to in our text, had melanotic tumours in the right groin, thigh, and breasts. It seems that the part, after having ulcer- ated, will sometimes form granulations and heal. This fact was illustrated in ahorse, from which M. Damoiseau removed a melanotic tumour, as rela- ted by M. Trousseau.—Archives Gen., &'c Juin 1828, p, 180.—Ed. t " Comme elle (la melancse) paroit etre abso- lument insensible, les visceres ou elle existe ne ma- nifestent aucune douleur, meme a la pression; s'il y a de la douleur, onpeut affirmer, que cette lesion organique n'y est pas seule. La melanose serait entierement sans inconvenient, si elle ne ge"nait pas par sori volume des visceres essentiels."—Diet. des Sciences Med., torn, xxxii., p. 185.—Ed. it would be the conversion of an inorganic se- cretion rather than of an organic issue, into me- lanosis. On the contrary, the new matter is de- posited in the substance of the textures or or- gans, or between their component fibres. These circumstances, together with its appealance in several of the bones, where it seems to have oc- cupied the situation of the marrow,* would give some countenance to the notion that melanotic matter was a diseased modification of the adi- pose secretion. To this idea, however, an ob- jection is presented in the melanotic masses found occasionally in the liver, spleen, and sub- stance of the kidneys. Its occurrence in the pancreas forms little or no valid objection ; for the quantity of adipose cellular substance with which the portions of this gland are connected, might be regarded as the primary matrix of the morbid deposition.—(Edin. Med. Journal, No. xc, p. 162.) All this, however, is only conjec- ture ; but the following observations respecting the anatomical distribution and preference to certain textures exhibited by melanosis, seem to be founded upon the careful consideration of facts. First, The cellular tissue and adipose mem- brane are both most abundantly and most gener- ally the seat of the melanotic deposition ; that is to say, of the tubercular melanosis. The subcutaneous and intermuscular cellular tissue is a common situation of it; as well as other parts of great laxity, where the cellular mem- brane is abundant, as in the genital organs, around the rectum, within the pelvis, and on the forepart or at the sides of the spine. Secondly, The delicate cellular .tissue which connects the serous membrane to contiguous parts and to the enclosed organs, presents this melanotic deposite nearly in the same, if not in a greater degree, than the common cellular mem- brane. This was particularly noticed in the case recorded by Mr. Fawdington. In Dr. Home's patient, though the pleura was studded with melanose tubercles, no mention is made whether they were upon or under it; but as the lungs are described as extensively occupied by melanotic masses, there is reason to infer that this is meant of the cellular tissue beneath the pleura, and connecting that membrane to the pulmonic lobules. In like manner, when, in the same case, the substance of the heart is said to be affected; when, in the case of Rachael Bruce, spots are said to have been noticed be- neath the pericardiac coverings of the heart; and when, in Mr. Fawdington's case, the surface of the heart is described ^s covered with melan- ose spots, chiefly subjacent to the pericardium ; little doubt can be entertained that the tissue of melanotic infiltration is the subserous and in- termuscular structure. Infiltration of the abdom- inal subserous cellular tissue is particularly re- marked in the case of Rachael Bruce, related by Dr. Cullen and Dr. Carswell, and also in Mr Fawdington's examples. Next to the cellular * Breschet states, however, that he has never seen melanosis in the central cavities of the bones m the synovial membranes, nor in cartilaaes-See Magendie's Journ., torn, i., p, 364 e Gen. IV.-Spe. 1.] MELANOSIS TUBERCULARIS. 73 and adipose tissue, several of the internal organs, termed parenchymatous, are most frequently the seat of the disease. Thus, not only the lungs (which, indeed, by the French writers are deem- ed the most common situation*), but the liver, the spleen, and the kidneys, are stated, in the case of Houston, to have been occupied with melanotic masses. In Mr. Fawdington's case, the liver, pancreas, spleen, and kidneys, were extensively affected ; while in Dr. Alison's case, though the substance of both mammae and of both "ovaries was completely melanosed, the liv- er, spleen, and kidneys were exempt from the disease. When melanotic tubercles take place in the liver, they are frequently of considerable size, and sometimes as large as an egg. Lastly, It is to be observed, that, in the case of Houston, one of the ribs and a part of the clavicle were melanosed. In that of Rachael Bruce, a part of the inner table of the scull was darker than natural, and the surface of the bone was stained with particles of black matter. A great part of the parietal and occipital bones was black, less consistent and more brittle than natural; and similar changes were observed in the sternum and sternal ends of the ribs. Ac- cording to Breschet, the parts of bones connect- ed with the muscles are most commonly affected. Some textures seem either quite exempt from melanosis, or only to be very slightly affected by it. Thus the nerves, the proper arterial tis- sue^ and muscular fibre, are scarcely ever the seat of it; and it is doubtful whether the serous and mucous membranes ever become penetrated by the melanotic deposition^ The above critic errs, however, in setting down the skin as rarely or never affected. In the cutaneous texture, says Breschet, melanoses are common ; and he has found an infinite number of small black tu- mours, resembling grains of cassia, situated in the skin, and appearing to originate from the rete mucosum. An example of this kind, which was seen by Breschet, is recorded by Alibert, who denominates it cancer melani.—(Magendie's Journ., torn, i., p. 361 ; and Alibert, Nosologic, &c.) It ought to have been mentioned, that melanosis often attacks the lymphatic glands, the eye, and fat of the orbit; and that traces of it are frequently met with, as Dr. Armstrong confirms, in various diseased structures.] We have reason to conclude that the dis- ease before us is at first local, or commences in a particular organ; and that, from the general sympathy of the secernent system with the part where it first appears, it ramifies in every direction, over the most solid and compact, as well as over the most loose and yielding tex- * " Le poumon est, de tous les visceres, celui ou on les voit le plus frequemment."—Diet, des Sciences Med., torn, xxxii., p. 185. t This is true, notwithstanding, as Breschet re- marks, " les vaisseaux sanguins sont parfois en- toures de ces tumeurs, et le vaisseau est cache au milieu de la inatiere melanique." X See Edin. Med. Journ., No. xc, p. 15?; also Dr. Cullen and Dr. Carswell, in Edin. Med. Chir. Trans., vol. i.; and Fawdington's Case of Mela- nosis, 1826. tures; accumulating and forming reservoirs where there are cells or other hollows for its reception, and spreading as a jet, die, or sheath on the surface, or through the parenchyma, where these are not. [The doctrine of the disease being at first local, is liable to several objections : first, the great disorder of the health frequently preceding the melanotic formation ;* secondly, the great extent of the affection, and the many internal organs found after death studded with melanotic tubercles; thirdly, some peculiarity of con- stitution appears requisite, from the curious cir- cumstance that the disease, when it occurs in horses, is chiefly observed in such as have a white or gray coat.t] What is the nature of the black die or pig- ment, and by what means is it produced 1 Much more attention to the subject is neces- sary, before any satisfactory reply can be given to this question. The material to which it seems most nearly to make an approach, in temperate climates, is the black pigment of the choroid membrane, and perhaps that which is supplied from the rete mucosum as a colouring matter for black hair. Both these are evidently productions of the secernent system. They are indeed small in quantity; but if we turn our eyes to the intertropical climates, we shall find the same, or a like jet pigment, thrown forth over the entire surface, and continued by a permanent supply, as the die antecedently furnished is carried off. And if we attend to the curious economy which takes place in this subject respecting the children of negroes, we shall also find this material produced in very large abundance in a short time : for the infants * This is not, however, a constant circum- stance: many patients with melanosis have not suffered at first much constitutional disturbance ; and Dr. Carswell, we know, ascribes the injurious effects of melanotic formations principally to their mechanical pressure on the neighbouring parts : they are not themselves organized.—Ed. f See G. Breschet, in Magendie's Journ. Exper, de Physiologie, torn. i., p. 355. " The much greater frequency of melanosis in the gray and white than in the bay, brown, or black horse, is a circum- stance which may be noticed here as favourable to the theory which ascribes the origin of this dis- ease to the accumulation in the blood of the car- bon which is naturally employed to colour dif- ferent parts of the body, as the hair, rete mucosum, choroid, and other parts."—(See Carswell's Illus- trations of the Elementary Forms of Disease, fasc, iv.) Remarkable examples of melanosis in the horse are recorded by MM. Goyer and Rodet (Journ.de Med. Veterinaire, torn, ii., p. 273); and MM. Trousseau and Le Blanc relate other in- teresting facts of the same kind.—(Archiv. Gen. de Med., Juin, 1828.) Speaking of the melanosis being principally seen only in white or gray horses, M. Blandin observes:—" On dirait que chez eux la matiere colorante s'est, pour ainsi dire, refugiee dans ces tumeurs."—(Diet, de Med. et Chir. Pra- tiques, art. Melanose.) Occasionally, however, melanosis is met with in horses of other colours, and both Rodet and Andral have noticed it in those of a bay colour. In the horse, melanotic tumours are most liable to form under the tail, whence they extend into the pelvis.—ED 74 H.EMATICA. [Cl. III.—Ord. IV. of negroes, as we shall have occasion to observe more at large when treating of epichrosis or mactjlar-skin,* are nearly fair when firstborn, and only become coloured with the black effusion a few weeks afterward ; which at first gives little more than a tawny hue, but gradually advances to a jet. We shall also have occasion to notice, in the same place, that this black die, like the pig- ment in melanosis, is on some occasions secreted in the form of a finer and more fluent liquid, and in others in a more inspissated state, and united with a coarser material, constituting the rete mucosum of Malpighi; who, moreover, gave it the name of rete from a belief that he was able to trace in it something of a fibrous structure ; an idea that has not been realized by Cruick- shank or any later anatomist. And it is not a little singular, that as in melanosis we some- times meet with a few patches or tubercles of the preternatural secretion destitute of its colouring die, and presenting a variegated appearance of black and white mosaic, so, in the distribution of the natural pigment of the negro over the surface, we sometimes meet with the same casual obstruction to the flow of the black die, producing that marbled skin which gives the individuals the name of piebald negroes. [According to the researches of Breschet and Cruveilhier, when the black matter of melanosis is not concrete, but liquid, or when it is deposit- ed in layers on the surface of a serous or mu- cous membrane, the minute bloodvessels are filled with a black of precisely the same kind as that exhaled.t Dr. Armstrong suggests, that as melanosis is frequently combined with chronic bronchitis, the venous character imparted to the whole mass of blood by this last disease may facilitate the dark and peculiar secretion of the first dis- order. He observes, that the secretion peculiar to melanosis varies in colour from a dark brown to a deep blue or green black. It is sometimes spread, like so much paint, under the serous membrane of the intestines, for instance, or diffused through the substance of the spleen; while, in other cases, it is circumscribed in dis- tinct patches, as in the parenchyma of the lungs, liver, or kidneys ; in short, being occasionally found thus diffused or limited in most organs.— (Morbid Anatomy of the Bowels, &c.,p. 24.)] The chymical analyses of MM. Barruel and Lassaigne show that melanotic tumours consist, first, of coloured fibrin ; secondly, of a blackish colouring matter, soluble in weak sulphuric acid, and in a solution of subcarbonate of soda, which become reddish ; thirdly, of a small quantity of albumen; and, fourthly, of a chloruret of * Vol. ii., Cl. VI., Ord. III., Gen. X., Spe. 2, 6, and comp. with the introductory note to Gen. IX., Trichosis. t When melanotic matter is found in bloodves- sels, it is chiefly in the venous capillaries, and " under circumstances which show that it must have been formed in these vessels."—See Pro- fessor Carswell's Illustrations of the Elementary Forms of Disease, fasc. iv.—Ed sodium, subcarbonate of soda, phosphate of lime, and oxyde of iron. The principles of melanosis, therefore, nearly resemble the con- stituent elements of the blood.* It is homoge- neous, opaque, and destitute of any particular smell or taste. Thenard ascertained that it contains a very large proportion of carbon. When exposed to the air, it putrefies slowly, t GENUS V. STRUMA SCROFULA. INDOLENT, GLANDULAR TUMOURS, FREQUENTLY IN THE NECK ; SUPPURATING SLOWLY AND IMPERFECTLY, AND HEALING WITH DIF- FICULTY J UPPER LIP THICKENED ; SKIN SMOOTH ; COUNTENANCE USUALLY FLORID. The Greeks denominated this disease XOIPAE, the nosologists of recent times scrofula, thus literally translating the Greek, and. importing swine-evil, swine-swellings, or morbid tumours to which swine are subject. Celsus employs struma, which was common in his own day, and has well described the complaint under this name, which is therefore selected on the present occasion. It is probably derived from orpuifia, "congestion," or "coacervation," as of straw in a litter, feathers in a bed, or tumours in a body ; in which last sense Cicero elegantly em- ploys the metaphor in the phrase " struma civitatis," " the scrofula or king's evil of the state." The medical dictionaries and glossaries concur in deriving struma from the Latin struo, but the terminating syllable of the noun should rather prove it to issue from a Greek source. Other animals are subject to this disease besides man. It is, as already observed, from the frequency of its appearance among swine, that the Greek name, as well as the more recent one of scrofula, is derived. Among horses we meet with it at least as often, when it is called farcy ; under which modification it is propagable by transfusion of blood from the diseased horse, not only to other horses, but to asses also, as * Dr. Foy instituted a comparative analysis ot medullary, scirrhous, and melanotic substances, and found them to contain albumen, fibrin, and salts, having for then basis soda, potash, and lime; also oxyde of iron, which was in rather greater proportion in the first two diseases than in melan- osis ; and in this latter alone he detected a highly carbonized principle, probably altered carbon, which constituted nearly a third of the morbid mass.—(See Archives Gen. de. Med., Juin, 1828.) The colouring matter of melanosis is generally thought to bear a considerable analogy to the colouring matter of the blood.—Ed. t A singular appearance lately presented itself to the American editor, who, in company with Dr. Benj. Drake of New-York, examined the body of a rhinoceros to ascertain the cause of its decease which was found to be pulmonary congestion' The small intestines, which were thirty feet in length, presented in nearly their whole course minute black dots, resembling what is termed punctiform melanosis. Whether this appearance was natural or the result of disease, we are not prepared to say.—D. Gen. V—Spe. 1.] STRUMA V has been lately proved by Professor Coleman at the Veterinary Institution. Sauvages, who has many species under the generic character, has two for the forms now referred to. The por- cine species he denominates scrofula Chalasis, and the equine s. Farcimen. As it is not the intention of the present work to notice the diseases of other animals, other- wise than by an occasional and incidental glance, we shall proceed to a contemplation of the present genus under the single species of 1. Struma Vulgaris. King's Evil. The strumous and mesenteric decline, in the present classification atrophia strumosa, is often introduced as a second species; but, tbough nearly allied to the present genus, it has so much closer a connexion with all the sub- divisions of the genus marasmus, and especially with that of atrophia, that the former is evidently its proper place, and we have accordingly treated of it under that genus.* SPECIES I. STRUMA VULGARIS. KING'S EVIL. TUMOURS CONFINED TO THE EXTERNAL CON- GLOBATE GLANDS ;t PEA-SIZED OR CHESTNUT- SIZED ; APPEARING IN INFANCY OR YOUTH ; SUBSIDING ON MATURE AGE ; HEREDITARY. Scrofula, though not a contagious disease, is unquestionably hereditary,^ and hence very generally dependant upon a peculiar diathesis. Yet, like many other hereditary diseases, it is also occasionally generated as a primary affec- tion, without any hereditary taint that can be discovered. I had very lately a gentleman under my care, who has been greatly afflicted with it for many years, and is now chiefly labouring under its sequelae; for the sores, which are in different glands and joints, and some of which have affected the bones, are healing; yet, of eight brothers and sisters who have reached the middle of life, he is the only one who has discovered any tendency to such complaint, nor is it to be traced through any part of the family lineage as far as it can be ascended. * Tubercular diseases of the lungs, spleen, and peritoneum, are regarded by many pathologists of the present day as scrofulous affections: so are particular diseases of the eyes, bones, and joints, and likewise some chronic abscesses, of which one of the most remarkable examples is the psoas, or lumbar abscess. A tendency to the formation of abscesses in a very slow and sometimes hardly perceptible manner, unpreceded by any very ob- vious exciting cause, is a common occurrence in scrofulous individuals. We sqe, then, how im- perfect is Dr. Good's definition of scrofula, and how much more comprehensive it might have been made.—Ed. t The editor is at a loss to understand why the deep-seated lymphatic glands, which are often the seat of scrofulous disease, should be excepted. X Kirkland, On the Present State of Surgery, vol. ii. Kortum, Comment, de Vitio Scrofuloso, Lemgoviae, 1789. Baumes, sur le Virus Scrofu- leox, &c. TLGARI9. 75 When it occurs as a primary or ingenerated affection, it is by no means always limited to any particular temperament or habit of body. The individual just noticed is of moderate stature, brown complexion, dark brown hair, and ruddy face: and I am still occasionally attending a lady who has long been subject to the same complaint, without any trace of hered- itary predisposition, of a sallow countenance, dark eyes and hair, and of rather tall and slender make. But, where scrofula appears hereditary, and especially where it does not show itself very early, it is often accompanied with a pecu- liar constitution.* " It most commonly," says Dr. Cullen, " affects children of soft and flaccid flesh, of fair hair and blue eyes, smooth skins and rosy cheeks : and such children have fre- quently a tumid upper lip, with a chop in the middle of it; and this tumour is often consider- able, and extended to the cohimna nasi and lower part of the nostrils." And it is a further remark of Dr. Cullen, but which I have not found to hold very generally, that, where it takes place in children whose parents have givenno signs of it, the latter have nevertheless evinced much of the habit and constitution by which the disease is ordinarily characterized. From all this we have a clear proof that king's evil is a disease of debility, operating by a spe- cific influence on the circulation, and particularly on the lymphatic system.—(Gam, Kranken ges- chichten, p. 121.) Whether this influence be the result of a specific matter is by no means so clear, however common the opinion. It is also a general helief that this specific matter is, from the first, a specific irritant or acrimony. But this, at least, is a mistake; for the disease is accompanied throughout with diminished, instead of with increased irritability (Richler, Chir. Bill., band viii., p. 501); and hence the power producing it must be of a sedative, rather than of an exciting or acuating quality. And it is in this diminution of irritability that scrofula differs from all other atonic diseases, since the debility and irritability generally augment in like proportion, and maintain an equal march. Early life is peculiarly characterized by an abundance of albumen, as its maturity is by an abundance of fibrin. Dr. Parr ascribes the scrof- ulous diathesis to a redundance of albumen at this period, together with an excess of oxygen and a deficiency of azote, evidenced by the florid hue of the countenance. By this hypothesis he obtains a sort of lentor in the circulating system, and accounts for the origin of scrofulous tumours by arguing that, since the mobility of the lym- phatic system is peculiarly affected and dimin- ished, the viscid fluids will be most disposed to stagnate there, and particularly in the lymphatic * The numerous disordered conditions of the function of nutrition evinced in scrofulous per- sons, are certainly independent of one another: all of them proceed from a cause that is manifested to us by the existence of those modifications of nutrition and secretion, the assemblage of which makes what is termed a scrofulous constitution. —See Andral, Anat. Pathol., torn, i., p. 5, 8vq.. Paris, 1829.—ED, 76 H.EMATICA. [Cl. III.—Ord. IV. .glands, as they must necessarily stagnate most where the impelling power is least.* It is here, indeed, rather than in any other modification of tubers or tubercles, that we find most to oppose to the opinion of those physiolo- gists, as M. Broussais and Dr. Alison, who as- cribe the origin of all tubercles to the existence of a higher or lower degree of inflammation. Yet it is singular that, at the same time, we here meet with proofs of the most advanced state of a living action in the morbid growths them- selves, the most perfect specimens of vascularity and sensation, and particularly where they origi- nate in a glandular texture, which is their proper seat. This living property, however, they do not seem capable of retaining long; for they soon run through their career of vitality, and become decomposed. Such was the short-lived date, according to the first physiological poet of Rome, of those monster-growths which sprang in the infancy of the world, but were soon cut off by Nature, as incongruous with her laws and hateful to her survey. " Caetera de genere hoc monstra, ac portenta, creabat: Nequidquam ; quoniam Natura absterruit auctum; Nee potuere cupitum aetatis tangere florem, Nee reperire cibum, nee jungi per Veneris res."t These sprang at first, and things alike uncouth; Yet vainly ; for abhorrent Nature quick Check'd their vile growth ; so life's consummate flower Ne'er reach'd they, foods appropriate never cropp'd, Nor tasted joys venereal. As occurring in early life, when, as we have already observed, there is a peculiar abundance of albumen, with a comparatively less portion of fibrin or coagulable lymph, it is highly probable that a morbid deposition of albumen forms the commencement of the strumous tuber. And such, indeed, seems to be proved by the chymi- cal tests to which Dr. Abercrombie has put them.—(Trans. Medico-Chir. Soc. Edin., vol. i., p. 686.) It is at first, perhaps, deposited in a soft state, and involved in the structure of the gland, the part being in other respects vascular and organized, and probably capable of perform- ing its functions. As the disease advances the proportion of albumen seems to increase, while, at the same time, it assumes a more concrete and structural figure, and evinces a vascular and sensitive character. " In this first state of en- largement," says Dr. Abercrombie, " these glands * The doctrine of Andral is exactly the reverse of this : a morbid state of the lymphatic glands is most frequent at the period of fife when the nu- trition of these organs is most active. This, says he, affords a confirmation of the general law, in virtue of which the frequency of the disease of every organ is in a direct ratio to the development of its structure and action.—(Anat. Pathol., torn ii., p. 449, 8vo., Paris, 1829.) Then, what are we to think of the hypothesis of stagnation in the lymphatic glands, when we find, from the experi- ments of Becker, that when they are diseased, quicksilver peryades them in the freest manner ? —Ed. t Lucret., De Rer. Nat., v., 845. present, when cut into, a pale flesh-colour, and a uniform, soft, fleshy texture. As the disease advances, the texture becomes firmer and the colour rather paler. In what may be regarded as the next stage, we observe portions that have lost the flesh-colour and have acquired a kind of transparency, and a texture approaching to that of soft cartilage. While these changes are going on, we generally observe, in other speci- mens, the commencement of the opaque white structure, which seems to be the last step in these morbid changes, andjs strictly analogous, in its appearance and properties, to the white tubercle of the lungs.* In a mass of consider- able size we can sometimes observe all these structures, often in alternate strata ; some of the strata being composed of the opaque white mat- ter ; others presenting the semi-pellucid appear- ance ; while in other parts of the same mass, we find portions which retain the fleshy appear- ance. In the most advanced stage, the opaque, white, or ash-coloured tubercular matter is the most abundant, and this afterward appears to be gradually softened, until it degenerates into the soft cheesy matter or ill-conditioned suppuration so familiar to us in affections of this nature." The morbid growth, therefore, as it recedes from its more vascular and vital elaboration, gradually subsides into the simple pretension of coagulated albumen, of which it consisted at first. In the second stage, the part is probably susceptible of active inflammation and healthy suppuration, or suppuration making a near approach to that of a healthy character. In its closing stage it seems incapable of healthy action, and only passes into that peculiar state of softening which arises from a simple decomposition of the tubercular organization. We have already described at some length the probable origin of tubercles in other textures, chiefly in the serous and mucous membranes of - organs, and in the structure of the lungs. The remarks now offered will enable us in some de- gree to judge in what respect the tubercles of proper glands, as those of the lymphatics and the mesentery, are assimilated to these, and in what respects they differ from them. The subject, however, is still open to inquiry, and * In the section on tubercular phthisis, refer- ence has been made to Dr. Carswell's observa- tion that the same kind of substance as constitutes tubercles in the lungs has been traced in scrofu- lous lymphatic glands. According to Andral, the latter organs rank as parts of the body in which tubercular matter is most commonly detected. At present this deposite is supposed to take place in the substance of these organs; but Andral con- ceives it probable that future researches may trace its seat to be within the lymphatic vessels which communicate together in these organs. In fact, cases have come under his notice, where tubercu- lar matter was found in the thoracic duct, and in several of the absorbent vessels.—(Anat Pathol torn, i., p. 451.) This view seems, however to disagree with the assertion, that mercury will readdy pass through the vessels of diseased lym- phatic glands. We are yet in want of precise in formation respecting the state of the absorbent vessels in the glands, when these latter are in va nous conditions of disease.—Ed. Gbn. V—Spe. 1.] STRUMA VULGARIS. 77 much remains to be accomplished before a full and satisfactory result is likely to be obtained. Be the proximate cause of scrofula, however, what it may, as the remote cause is of a debil- itating kind, we can readily see what are likely to prove occasional and co-operative causes, or those calculated to call the remote cause into a state of activity. They must consist of every thing that directly lowers and reduces the tone of the living fibre, and puts the system out of that state of firm and vigorous elasticity which is the best prophylactic against the disease, and keeps the scrofulous diathesis most effectually in a state of subjection. And hence we find the common debilitating powers of cold, damp, meager or unwholesome food, want of cleanliness, and a close and suffocating atmosphere, the most usual incidental sources of strumous affec- tions.—(E. A. Lloyd's Treatise on Scrofula, &c, 8vo., Lond., 1821.) But for these, a scrofulous predisposition might remain dormant in the constitution through the whole of life ; and descend to and disorder the next generation, without having in the least disturbed the present. But the moment any of these occasional causes become adjuncts with the scrofulous diathesis, scrofula, rather than any other disease they are also calculated to pro- mote, will make its appearance and commence its ravage. And hence the frequency of this disease in large manufacturing towns, and in higher and colder latitudes than 45°. Heat, as a relaxing and debilitating power, tending to produce languid action, is also a fre- quent cause whenever applied in excess and habitually ; and particularly where, like cold, it is combined with sudden variations of tempera- ture. Scrofula is known to be particularly fre- quent in Hindoos, Hottentots, and negroes, when they come to temperate climates ; and especially in the children of settlers in intertropical regions, upon their quitting such.regions for countries of a milder temperature. [The unusual frequency of phthisis among ne- groes and Hindoos, and even among mulattoes and half-caste people, in this climate, is, as Dr. Alison observes (Edin. Med. Chir. Trans., vol. i., p. 399), generally admitted. At the same time he grants, that, as the black population of tropical countries have other peculiarities besides that of being brought up in hot climates, we are not entitled to ascribe their scrofnlous tendency exclusively to this circumstance. Yet, says he, when we connect the facts above stated with the enervating influence produced by long residence in hot climates on European constitutions, so strikingly shown in the different forms assumed by fever and by hepatitis in the old settlers and the newly-arrived Europeans ; and this, again, with the facts already adduced to show the con- nexion of general debility with scrofula; it seems to Dr. Alison extremely probable, that this part of the constitution of negroes and Hindoos is very much owing to the long-contin- ued application of heat in early life, and partic- ularly to this cause acting on many generations in succession.] The influence of excessive cold, however'is much more rapid than that of excessive heat, and far more obvious to the sense. Yet it is often sustained with impunity where the consti- tution is firm, and the cold rarely subject to vicissitudes ; and especially where there is no other debilitating cause to contend with, as the depressing passions, a sedentary occupation, scanty and innutritive diet, damp and impure air, or any kind of personal neglect or unclean- liness. And it is on this account, we meet with a far smaller proportion of scrofula in early life among the peasantry of higher latitudes and mountain scenery, as that of Scotland and Swit- zerland, than among the mechanics of crowded and warmer cities. " I was told," says Dr. Alison, " by one of the physicians of the Hopital des Enfans Malades, at Paris, where upwards of five hundred children die annually, whose bodies are almost uniformly opened, that he believed nearly one half of the bodies he saw opened had scrofulous tubercles in some part or other." This is indeed a higher aggregate than is to be found in the metropolis of our own country, and obviously includes mesenteric or strumous tubers, of which we have treated al- ready, as well as every other modification of scrofula. But the same writer calculates, from data furnished by Dr. Perceval, that the pro- portion of scrofulous fatal ca.ses among children at Manchester, at the time Dr. Perceval wrote, generalizing them as above, could not be less than a third of the whole infantine mortality ; while at Waverton, a country parish near Ches- ter, it appears from the same documents that the deaths from scrofula in children under five years of age, did not amount to a fourth part of this proportion. In the bordering village of Reyton, the difference appears to have been still greater ; for the whole mortality of children under five years of age in this last parish, com- pared with the same period of parallel mortality at Manchester, was only as two to seven ; not more than one seventh part of the children born in this village appearing to die before they had attained their fifth year. " I examined lately," says Dr. Alison, " a register, which I know to have been kept with great accuracy for nearly four years, of the deaths of a country parish in Scotland, that of Rafford, near Forres, the popu- lation of which parish is almost exactly a thou- sand persons. Of forty-two deaths that had occurred in that time, two only, or one in twenty- one, were below the age of two ; and three only, or one in fourteen, below that of five years :" while in the town of Manchester, to which we have just referred, Dr. Perceval assures us, on an average of twenty years, that the proportion of deaths- under two years to the whole deaths was lto2.9.—(Perceval's Works, vol. iii., p. 107.) To add any thing further is unnecessary. Scrofula is manifestly a disease of weak vascu- lar action, and is sure to be found in abundance with other diseases, issuing from the same soil, consociate, to whose fatality it largely adds. Extreme heat and cold, though powerful pre- disponents, are far more injurious when flowing in irregular vicissitudes, than when in a uniform tenour; and the mischievous effect of the latter 78 H.EMATICA. [Cl. III.-Ord. IV is often counteracted where combmed with the tonic powers of a pure and dry atmosphere, a regular plan of diet and exercise, the salubrious exhalations from growing vegetables, and the grateful stimulus of their odours m village scenery. . [And, as Dr. Alison has judiciously remarked, those who suffer most from the agency of cold, as a cause of disease in general, are by no means those who are most frequently exposed to it; but those whose previous condition is such as to favour its operation on the body, and particu- larly those in whom the circulation, either from the state of the constitution or accidental cir- cumstances, is feeble and easily depressed. The same well-informed physician elsewhere ob- serves, that what is true of the production of disease in general by exposure to cold, seems to be true of the production of scrofulous diseases in particular; but with these limitations :— 1. That scrofulous action appears to be excited almost solely in the earlier periods of life. 2. That, for the production of this kind of dis- eased action, there appears to be required, be- sides other conditions, a certain peculiarity of habit, not understood, but, manifestly, in Dr. Alison's opinion hereditary. 3. That the con- stitutional debility which disposes to scrofulous disease from cold, appears to be more perma- nent and habitual than that which disposes to other diseases resulting from this cause.] For the reasons just urged, scrofula has at times been called into activity by local inju- ries, the depressing influence of severe grief, or a sudden reverse of worldly prosperity. It is also sometimes joined with or follows rickets ; and is frequently a sequel of severe febrile dis- ease, smallpox, yaws, measles, syphilis, scarla- tina, several obstinate cutaneous affections, and the long use of mercury. But though scrofula usually commences m the lymphatic glands, it often extends beyond them: as gout, that ordinarily shows itself at first in the small joints, and rheumatism, that begins in the large joints, spread not unfre- quently to the membranes and the muscles. I have said that, under the influence of the scrof- ulous diathesis, the circulating system is weak- ened generally; and hence also we frequently find the eyes, the mucous glands of the nose, the tonsils, and even the joints and bones, suc- cessively yielding to its influence.* The disease for the most part shows itself early in life, though rarely before the second,! and commonly not till the third year of infancy ; from which period it continues to prey on the * Sometimes the disease commences in the eyes, joints, spleen, lungs, peritoneum, or other organs, and the lymphatic glands may either es- cape, or be affected only secondarily. For this and otheT reasons, the editor regards the definition at the head of the present section as liable to ob- jections.—Ed. t When the mother has been scrofulous, tuber- cles in the lungs, and strumous disease of the kid- neys, have been sometimes, though rarely, noticed in the foetus or stillborn infant.—See Lloyd, op. cit., p. 23.—Ed. system till the seventh, when, in ordinary cases, it gradually subsides and disappears. If the predisposition be not considerable, the attack is sometimes postponed till after the seventh year, and has occasionally been retarded till the age of puberty, after which, however, we have very seldom any first manifestation of the disease. The first tumours we meet with are usually upon the sides of the neck, below the ears, or under the chin ; and confined to the lymphatic glands in these parts. The tumours are, per- haps, two or three in number, moveable, soft, and slightly elastic, of a globular or oval figure, without pain or discoloration of the skin. In this state they continue for a year or two ; after which they grow larger and become more fixed, and acquire a purplish redness. They then give that feeling of greater softness, and at length of fluctuation, to which we have just adverted; after which the skin, in one or more of them, becomes paler, and a peculiar liquid is poured forth at several small apertures, apparently like immature pus, but growing daily less purulent, and at length assuming a cheesy or curd-like form.* The tumour, or cluster of tumours, then subsides, but others rise in the neighbour- hood ; and in this manner the disease proceeds, fresh tumours forming, chiefly in the course of the spring, as the older disappear, and the same process is continued for several years; after which the ulcers heal spontaneously, with puck- ered and indelible indentations, provided the dis- ease terminates favourably; but if not, other parts of the system, as we have already observed, become tainted with the morbid influence, and add to the sum of distress. If the attack fall upon the eyelids, they become inflamed, are swollen and red, and pour forth from their mi- nute glands an erosive but viscid secretion, which glues them together at night, so that in the morning they are opened with difficulty. The adnata partakes of the irritation, which is at length communicated to the whole globe of the eye, and not unfrequently to the cheek, from the acrid discharge that flows down. An un- sightly lippitude, and eversion of the lower eye- * According to Mr. Wardrop, " the matter has at first a firm curdy consistence, and, as the pro- cess advances, some portions become more fluid ; until, ultimately, the suppurative cavity contains a matter partly curdy, partly punform, and partly serous. When this matter is removed by ulcera- tion of the parietes of the cavity containing it, an irregular-shaped cavity remains in the substance of the gland. While the swelling of the part di- minishes, the sides of this cavity become covered with a curdy yellow incrustation, more or less firm, and from its surface a puriform matter is se- creted. This incrustation prevents the formation of granulations, and is the cause of scrofulous cav- ities not healing up; while it is by the separation of this crust, in consequence of laying open these abscesses, that granulations form and heal up the cavity. " The incrustation covering the internal surface of the scrofulous abscess, when of very long stand- ing, acquires a surface which resembles a mucous membrane, from which the puriform fluid is se- creted."— Baillie's Works, by Wardrop vol ii Preliminary Obs., p. 33. ' Gen. V—Spe. 1.] STRUMA VULGARIS. 79 lid are hence a very common result of a scrof- ulous attack on this organ. In like manner the disease, in this unfavour- able and aggravated state, often makes its as- sault on the limbs, and fixes on the ligaments, cartilages, or even the bones themselves ; and particularly whenever any injury occurs to a joint. An indolent tumour first shows itself, which tardily advances in magnitude with a kind of smothered inflammation, and at length opens on the surface from one or more minute ulcerations, which discharge the sanious kind of fluid we have already noticed. And it is here we perceive how nearly scrofula is related to hydarthrus, or white swelling; and how readily the former may become a cause of the latter, as already observed under that species. If the strumous diathesis be excited by the fracture of a bone, the broken ends unite with great diffi- culty, and sometimes not at all. A specific tu- mour forms in the seat of the injury, the soft parts are often affected with a weak inflamma- tion, and ulcerate slowly, and the bone is ren- dered carious. If the injury occur in the mid- dle of a cylindrical bone, an exfoliation may take place- in a long course1 of time ; but if at its ex- tremity, it will become spongy, enlarged, and disorganized. If a cure be at length effected, the enlargement will remain and the articulation be lost; yet amputation will be of no use while the part continues under the influence of the scrofulous taint.* [The susceptibility of scrofula, inherent in different parts, is said to be altered by age: " Thus, in children, the upper lip, eyes, glands of the neck, and those of the mesentery, are generally the parts first affected ; the lungs, bones, and other parts being subsequently at- tacked.—(Lloyd on Scrofula, p. 5.)] In the worst and severest stage of the dis- ease, the entire system appears to be contami- nated ; hectic fever ensues, and sometimes tu- bercular phthisis, which gradually puts an end to the contest. [The urine of scrofulous subjects is said to contain less phosphoric acid than the urine of healthy persons, and an increased quantity of phosphate of lime. This earth is also some- times found after death in the lymphatic glands, in the thoracic duct, and in the substance of the viscera.J] In attending to the cure, we must not be un- mindful of the principle we have endeavoured to establish, that scrofula is a disease of debility, principally affecting the lymphatic system, ac- * This is not quite correct, as no stumps gen- erally heal more favourably than those resulting from the amputation of scrofulous joints.—Ed. t Pinel, Nosogr. Philosophique. We know from the researches of Dr. Carswell, that tubercu- lar matter, the same kind of unorganized deposite as is found in tubercles of the lungs, is also some- times detected in scrofulous glands ; and, as these are sometimes cured, the fact has been adduced as an argument in favour of tubercular phthisis not being absolutely incurable.—See Dr. Cars- well's Illustrations of the Elementary Forms of Disease.—Ed. companied with diminished irritability.* And it hence follows that our chief dependance must be upon a tonic and stimulant plan, so modified as to meet the patient's age, idiosyncrasy, and manner of life. An old hypothesis is, that scrofula depends "upon an acrimony in the system, and hence se- datives and narcotics have found a place among the most celebrated of its remedies ; while, as the chymical character of the acrimony has been also pretended to be developed, and has been declared to be a specific acid, another class of remedies had recourse to has been the alkalis. That the latter are often of considerable ser- vice, ought I think freely to be admitted; but we have assuredly no proof that they become beneficial as correctors of acidity. They are gentle stimulants, admirably adapted to the de- bilitated and indolent condition of the vascular system they are intended to excite ; and hence, in whatever form they are given, have a chance of doing good. And it is to this principle we are, perhaps, to resolve all the advantage that has been stated by different writers, and in dif- ferent ages of the world, to have resulted from the use of burnt sponge, burnt cuttlefish, shells of all kinds, burnt hartshorn, and even burnt secundines, which last were at one time in high request, and are to be found as a sovereign remedy in Schroeder's Pharmacopoeia.—(Lib. v., p. 288.) All these have in our own day de- servedly yielded to the carbonate of soda and subcarbonate of ammonia; which, in a more elegant and concentrated form, offer whatever virtues may be contained in the older medicines : and still more lately to iodine, not long ago de- tected by M. Courtois in kelp and other salt- worts ; for a more particular account of which medicine the reader may turn to the treatment of bronchocele.—(Vol. ii., Cl. VI., Ord. I., Gen. II., Spe. 1, Emphyma Sarcoma Bron- chocele.) The author has, at this moment of * How contrary this theory ie to that entertained by some other writers, may be seen by a reference to Crowther's work on white swelling, &c, ed. 1808. A still later author remarks :—" In scrof- ulous disease there is generally what is termed a delicate state of the health, great nervous irrita- tion, greater susceptibility than natural; so that certain external agents, as cold, &c, applied to the body, produce unusual effects; and there is al- ways more or less disorder of the digestive organs ; and, upon accurate investigation, this state of the system will always be found to have existed for some time previous to the appearance of the dis- ease in any particular part."—(Lloyd on Scrofula, p. 32.) The editor believes that we know nothing about the proximate cause of scrofula; and that the digestive organs cannot be essentially con- cerned in the production of the disease, is as clear as the fact pointed out by Mr. Lloyd, that scrofula sometimes affects the foetus in utero. The disor- der of these organs, in many examples, is certainly only an effect; yet it is not here intended to deny the possibility of the origin of scrofula being pro- moted by derangement of the functions of the di- gestive organs. But that something else is requi- site appears certain, as these organs are frequently disordered without a single symptom of scrofula showing itself.—Ed. 80 H^EMATICA. [Cl. HI—Ord. IV. Writing, among other patients who have been ben- efited by this plan, a lad about thirteen years of age, with weak eyes, inflamed and irritable con- junctiva, and such an enlargement of the parotid glands* as to make them nearly meet, so that the mouth opens with uneasiness. He has now applied the ointment of iodine for three weeks, and at the same time taken half a grain twice a day in the form of a pill, and is essentially im- proved in every respect. [Iodine may be said to be the medicine to which the generality of medical practitioners are turning their attention as a means of curing various forms of scrofulous disease. Its extraordinary power in dispersing many strumous swellings cannot be doubted; but whether it possess any specific power for the correction of the scrofulous diathesis, still re- mains to be proved.!] Lime-water and the muriate of barytes,t which last was thought by Dr. Adair Crawford to be nearly a specific, if they have any pretensions whatever, can only derive them from the general principle of their being stimulants, and espe- cially of the lymphatic system. And the same may be observed of petroselinum, sarsa, meze- reon, balsam of sulphur, and calamus aromaticus. Muriate of soda, or common sea-salt, posses- ses a like character, and has undoubtedly been found of far more use in many cases. It has hence been employed very freely, both inter- nally and externally. In the latter case gener- ally through the medium of the bibulous marine plants, which contain it in a larger proportion, and have been applied to the strumous tumours in the form of epithems, as sea-wrack (fucus vesiculosus), sea-tang (alga marina), and sea- oak (quercus marina). The mineral waters of every description have in like manner been had recourse to, chalybeate, sulphureous, and saline ; and perhaps, as Dr. Cullen observes, with nearly a like reputation and success ; though it is by no means improbable * The editor believes that this case must have been either a bronchocele, or a general enlarge- ment of the lymphatic glands on each side of the neck and behind the jaw; for, besides the fact that the parotid gland is seldom or never the seat of scrofula, the extension of the disease under the chin seems to prove that the disease could not have consisted in the parotid.—Ed. + The strongest facts on record proving the use- fulness of iodine in scrofulous diseases, are those published by Dr. Lugol (Mem. sur PEmploi de l'lode dans les Maladies Scrofuleuses, 8vo., Paris, 1829), who employs this medicine, however, in a greater variety of ways and forms than we have taken the trouble to do in this country. Instead of the tincture, he prescribes an aqueous solution of iodine of different strengths, with a proportion of the hydriodate of potash in them. He also ap- plies iodine in the form of baths, lotions, and col- Syria ; sometimes also as a stimulating or rubefa- cient application ; and, in particular cases, as an escharotic. Whoever wishes to give iodine a fair trial in scrofula, should prescribe it in Lugol's manner, whose formulae may be seen in his work. —Ed. X This article is highly recommended by Dr. Williamson.—See Potter's Med, and Phil. Lyce- um, Baltimore, 1811.—D. that some waters may prove a more remedial stimulant or alterant to some constitutions, and others to others. And we thus possess a more plausible reason for their being advantageous than that offered by Dr. Cullen ; namely, that, " if they are ever successful, it is the element- ary water that is the chief part of the remedy" (Practice of Physic, vol. iv., 1752); which, he tells us in another place, " may be of use by washing out the lymphatic system." Stimulant external applications, besides sea- water, have also been tried, and undoubtedly been often found serviceable ; as a long con- tinued friction of the hand over the scrofulous 'protuberances, mercurial or ammoniacal plas* ters, or the-convenient form in the London Phar- macopoeia that combines both these ingredients ; irritant ointments, especially those containing iodine, the aura of voltaism, or moderate shocks of electricity. The means of this kind, however, to which we have recourse, whether external or internal, should always be gentle at first, however we may venture upon augmenting them afterward. If we stimulate violently, we shall do mischief rather than good, and add to the debility in- stead of diminishing it. Scrofula is a strictly chronic disease ; it never has been, and never can be cured rapidly ; and wherever any bene- ficial influence has been produced upon it, it has always been, as in the use of alkalis and of mineral waters, by lenient means and patient perseverance. But we have to increase the power as well as to take off' the irritability ; and hence tonics seem to be as much demanded as stimulants, and have in fact been as generally made use of. It is very singular, that, of this class of med- icines, the only two which Dr. Culien has thought it worth while to notice, are bark and coltsfoot; of the first of these he speaks very doubtfully ; while he seems to depend more on the second than on any other remedy whatever. This opinion he expresses in his Practice of Physic, published in 1783; but in his Materia Medica, published six years afterward, he gives it the same high character, and tells us that he was induced to try it in scrofulous cases upon the testimony and recommendation of Fuller. He employed both an expressed juice of the fresh leaves, and a decoction of the dry ; but preferred the former, of which he gave " some ounces every day," and affirms that " in several in- stances it had occasioned the healing up of scrofulous sores." He admits, however, that neither of them was, in some trials, sufficiently effectual. The metallic salts have been, more generally used, and have at least acquirer! a higher repu- tation ; though, with the exception of calomel, I do not know of any of them that can appeal to any decided testimonies in proof of their suc- cess ; and even calomel may perhaps be regard- ed rather as an alterant or mild stimulant, than as a tonic. Salivation has always done harm ■ and, on this account, mercury in every form must be given in minute doses. Combined with some preparations of antimony, and partic- Gen. VI.] CARCINUS. 81 ularly with the precipitated sulphuret, as in Plum- mer's pills, it is said to have been chiefly ser- viceable. But in my own practice, I have not found this medicine of any manifest service in the present disease. The acids have also been tried, but are of little or no avail. Upon the whole, however, the tonic class of medicines has thus far proved considerably less decisive and important, in the treatment of scrofula, than we might fairly have conjectured. Yet a tonic regimen of sea-air, sea-bathing, lib- eral exercise, and a diet somewhat generous, is of the highest consequence in promoting im- provement, and ought by. no means to be dis- pensed with. The infirmary at Margate is on this account a noble institution, and cannot be too liberally supported. Of the specific benefit of narcotics, as hem- lock, henbane, foxglove, solanum, asclepias, vin- cetoxicum, and many others, I have yet to be persuaded. They may possibly be of some use in quieting the irritation occasionally pro- duced by congestion and mechanical pressure where the tumours are peculiarly indurated and large, and in such cases may assist in softening and diminishing them. And they may, perhaps, operate in the same way where, in the latter and more malignant stages of the disease, the se- cretion is become virulent, the open ulcers irri- table, and a foundation is hereby laid for hectic fever. But I can conscientiously say, with Dr. Cullen, that they have often disappointed me, and have not seemed to dispose scrofulous ul- cers to heal. The local applications, like the internal rem- edies, should be slightly stimulant ; and, where the tumours have broken, usually consist of digestive ointments combined with the caustic metallic salts of mercury, zinc, or copper, and of digestive lotions of a dilute solution of alum or nitrate of silver. These are well calculated to coincide with the general intention; but we must not expect a sound cure till the morbid impression is set at rest in the constitution, or utterly extirpated from it. [Those who espouse the hypothesis that in scrofula there always is more or less disorder of the functions of the digestive organs, and pri- marily of no other important function, of course renounce all faith in specifics, and consider the principal indication to be that of improving the state of those functions by attention to diet, and by keeping the bowels regular, and the hepatic secretions natural. - The editor believes that more good may be effected in scrofulous cases by endeavouring to rectify any obvious defect in the constitution, or, in other words, to im- prove the health in general, than by trying the effect of various medicines, supposed to have a specific power over the disease. On this very principle, however, iodine, carbonate of soda, blended with rhubarb or columbo powder, and other alteratives and tonics, will frequently be proper, as well as small doses of the blue-pill, the compound calomel pill, and the compound decoction of sarsaparilla ; with occasional mild purgatives, so much confided in by those prac- Vol. II—F titioners who believe the cause of scrofula to be essentially connected with disorder of the di- gestive organs,]* GENUS VI. CARCINUS. CANCER.f SCIRRHOUS, LIVID TUMOUR, INTERSECTED WITH FIRM, WHITISH, DIVERGENT BANDS, FOUND CHIEFLY IN THE SECERNENT GLANDS ; PAINS ACUTE AND LANCINATING ; OFTEN PROPAGATED TO OTHER PARTS ; TERMINATING IN A FETID AND ICHOROUS ULCER. Of this genus there is but one known spe- cies : for the division into occult and open, or * Struma is comparatively of rare occurrence in the more northern portions of the United States; the official report of deaths by this disease in the city of New-York for the past five years, amounting only to sixty-five; but in the southern country the case is far different, and there this malady proves a complete scourge to the black population, who in the northern states also appear more disposed to it than do the whites; among the latter, it seems to affect foreigners rather than Americans, and to be often called into action by the confined air of narrow and dirty habitations, by unwhole- some diet, &c. The treatment of scrofula is conducted on the principle that the disease is often constitutional; the popular idea that the muriate of barytes was useful, has led many to our mineral springs, and more particularly to that of Ballston in the state of New-York, inasmuch as chymical analyses had shown that this compound of barytes was a con- stituent part of these mineral waters. Chalyb- eates, more particularly the carbonates and phos- phates of iron, are now commonly prescribed, at- tention being previously paid to the digestive or- gans. Iodine, also, has many firm friends with us.—D. t One of the heterologous formations, as they are termed by Professor Carswell, in his Illustra- tions of the Elementary Forms of Disease. The essential character of the heterologous formations, he founds on the presence of a substance which does not enter into the original composition of the body. When the heterologous deposite is col- lected at numerous points, in the shape of a hard, gray, semitransparent substance, intersected by a dull-white, or pale straw-coloured, fibrous, or con- densed cellular tissue, the disease is usually termed scirrhus. When it assumes a regular lob- ulated arrangement, so as to present an appear- ance similar to a section of the pancreas, it consti- tutes Nonpancreatic sarcoma of Abernethy. For other varieties, named by the French tissue lardaci, mat- ure colloid, and cancer gdlatiforme, or ardolaire, con- sult Dr. Carswell's work. In order to trace the precise seat, origin, and mode of formation of can- cer, it is necessary, as this excellent pathologist observes, " to catch the disease, as it were, at the earliest period of its formation; that is to say, when the heterologous substance of which it con- sists has just been deposited, and has not effaced the particular texture or structure of the part in which it is contained. Investigated in this its first stage, we ascertain, with greater or less facil- ity, that this substance becomes manifest to our senses, either as a production of nutrition or secre- tion. In the former case, it is deposited in the same manner as the nutritive element of the blood enters into the molecular structure, and assumes Si H^MATICA. [Cl. Ill— Ord. IV. indolent and ulcerative, introduced by Hippoc- rates, and continued to the time of Boerhaave, is unnecessary in pathology, and incorrect in a nosological arrangement; as the distinctions it contemplates are nothing more than so many stages or modifications of the same disease in different habits, or affected by different con- comitants. This species is what is generally described under the name of 1. Carcinus vulgaris. Common cancer : and it is not necessary to alter the term. SPECIES I. CARCINUS VULGARIS. COMMON CANCER. TUMOUR BURNING, KNOTTY ; WITH DARK, CAN- CRIFORM VARICES ; ULCER, WITH THICK, LIVID, RETORTED LIPS. There is a soft, fungous, and bleeding ulcer, possessing the name of fungus hsematodes, which has by many writers of celebrity been supposed to be of a cancerous origin ; and, under their au- thority, it has been so regarded in the author's volume on Nosology : but as it seems to differ from cancer in its constitutional influence, and in some of its local characters,* it is better to contemplate it as a malignant ulcer of a pecu- liar kind ; and in the present work it is referred to that genus accordingly.! The term carcinus (xapicivos) is Greek, and imports a crab; the disease being thus call- the form and arrangement of the tissue or organ into which it is thus introduced. In the latter, it makes its appearance on a free surface, after the manner of natural secretions, as on serous surfaces in general. Proceeding still further in our re- searches, we find this substance existing not only fn the molecular structure, and on the free sur- face of organs, but also on the blood of the venous and capillary divisions of the vascular system." —Professor Carswell, op. cit.—Ed. * One fact, mentioned by Dr. Carswell, is ex- ceedingly curious and important in relation to these malignant diseases:—" Numerous examples," says he, " might be given of scirrhus, medullary sar- coma, and fungus haematodes, originating in the same morbid state, and passing successively from the one into the other, in the order in which I have named them. Indeed, we often meet with all the varieties which I have enumerated of both species, not only in different organs of the same individual, but even in a single organ."—(See Illustrations of the Elementary Forms of Disease, 4to., fasc. ii., Lond., 1833.) One evening, at the London Uni- versity, Sir Astley Cooper lately mentioned to Dr. Carswell and the editor, that he knew of a case in which a lady, whose breast had been removed, and was found to have the true scirrhous texture, after- ward died of fungus haematodes in the same situ- ation.—Ed. ! The fungus haematodes of Hey, is the medul- lary sarcoma of Abernethy, the matiere ciribriforme, or enciphaloide of Laennec, the spongoid inflamma- tion of John Burns, and the soft cancer of several other writers. As it is not till an advanced stage of the disease that any fungus or ulceration occurs, medullary sarcoma is one of the best of these terms. Fungus haematodes is, at all events, totally inap- plicable, until the morbid mass projects through the skin and bleeds; and even then it is not truly a fungus, but a soft medullary substance.—Ed. ed from the cancriform or crab-like ramifica- tions of the dark distended veins of the cancer- ous tumour. The question is of some conse- quence, whether cancer be a constitutional or a local, whether an hereditary or merely an occa- sional disease. Much has been said, and well said, on both sides. Till of late years, the dis- ease was generally regarded as a constitutional affection, and will, for the most part, therefore, be found in the division of cachexies, from Sau- vages to Macbrider though Dr. Cullen has intro- duced it into his class locales; and since his time, many of the best writers of the present day, arhong whom are Dr. Baillie and Mr. Ab- ernethy, concur in regarding it as local alone. If the disease be merely local, it is difficult, and perhaps insuperably difficult, to say why a blow on a conglomerate gland, as the breast for ex.- ample, should sometimes produce a cancer, but more generally not; or what that power is that excites the cancerous action in one person, from which another, or perhaps a hundred others, re- main free upon an application of the very same injury to the same organ. A blow on the knee often produces a white swelling, but ten thousand children receive blows on the knee without any such effect following. In this case we resolve the difference of result, without a controversy, into the presence or absence of a scrofulous con- stitution ; and without this view of the subject we should find ourselves at a loss for an answer. And unless we apply the same reasoning to can- cer, we shall ever, I fear, remain at an equal loss* The cases, moreover, in which cancerous tu- mours are found in other parts of the body, after one or more than one has been extirpated, lead us by an easy thread to the same conclusion, provided the tumour has been removed in an early stage of the disease, and before ulceration has taken place ; for it is possible that the spe- cific matter of a cancer, generated and matured locally, may be absorbed and deposited on the organs which are afterward affected.* But if the extirpation have taken place before the for- mation of the specific matter, it is not. easy, ex- cept by a constitutional diathesis, to account for any subsequent appearances.! * The impossibility of communicating cancer from one person to another by inoculation with the matter of cancerous ulcers, is a strong fact in op- position to this last hypothesis. The existence of a specific cancerous matter, or virus, is denied by M. Roux, as the editor conceives, upon very suffi- cient grounds.—Ed. ! Dr. Carswell joins our author in considering cancer as a constitutional disease :—" It may," says he, " be regarded as a law, that the speciality of a morbid product, of the nature of those I am now treating of (carcinoma, &c), is entirely inde- pendent of any local agency whatsoever. The trite, but important remark, that handreds and thousands of individuals are dairy affected, for ex- ample, with inflammation, without this local dis- ease being followed by any other than its usual effects, places in the clearest light the necessity ot a previously existing modification of the economy as the immediate and essential condition of the special- ity of the heterologous formations, when they occur in conjunction with inflammation."—See Illustrations of the Elementary Forms of Disease, fasc ii—Eta. Gen, VI.—Spe. 1.] CARCINUS VULGARIS. 83 It is still stronger in proof of an hereditary predisposition, that various membersof the same family have exhibited the same disease, either simultaneously or in succession ; and that the descendants of those who have been afflicted with it, seem to have more frequently suffered from it than others. It is not necessary to ad- vance individual instances in support of these positions, though it may be noticed, in passing, that Bonaparte died of a cancer in the stomach, his father of a scirrhous pylorus.—{Account of the last illnes*, decease, Sec. of Napoleon Bo- naparte, by Archibald Arnot, 1822.) The same remarks have been made upon a general survey of the disease in most ages ; and the. doctrine of an hereditary influence, in consequence, de- scended to us as a result of such remarks from the time of the Greeks and Romans. Since the first and second editions of the pres- ent work, in which these remarks occur as now again presented to the reader, they have received no inconsiderable degree of confirmation by the publication of Sir Astley Cooper's Lectures on Surgery, in which the same line of pathology is pretty closely adopted. With respect to the constitutional character of the disease, he tells us, from numerous dissections, that " it seldom happens, when a tumour of-this kind exists in the breast, that only one is found, for there are generally several smaller, in different parts of the glandular structure," and that not only the glands in the axilla, but those above the clavicle are changed in their internal appearance from the deposite of a scirrhous secretion resembling that in the breast, and that most of the viscera, in different cases, participate in the same morbid change, especially the lungs, the liver, the uterus, the ovaria; while in proof of its hereditary in- fluence, he observes as follows :—" There are sometimes several persons in the same family who will be affected with this disease. A phy- sician had three relations, sisters ; the first of whom had a scirrhous tubercle of the breast, of which she died. A second had the disease, which was removed by Mr. Lucas senior; the disease returned, and she died. The third had applied to me, for a very painful swelling in the breast. They were unmarried. Therefore," continues he, " in a family in which one is af- fected, the first dawn of complaint should be carefully watched, and the general health be well attended to in others."—(Tyrrel's edition, vol. ii., pp. 183, 186, 189, 8vo., 1825.) How far a predisposition to cancer, whether original or derived, may manifest itself by exter- nal signs, I am not able to determine. Such an outward character is by no means constant in the list of hereditary diseases. It is, perhaps, generally Visible in those that affect the mind, but far less so in those that affect the body. In phthisis, the predominant diathesis has a striking exterior; in scrofula, the outward and visible sign is far less distinct, though such a sign seems to p evail generally: in gout, there is no spe- cific exterior that we can depend upon. Dr. Parr, however, has conceived that cancer has its outward character as well as phthisis, and that it is indelibly marked in the complexion : F 2 " for we have found," says he, " cancers more frequent in the dark cadaverous complexions, than in the fairer kind. The complexion we mean is distinct from the darkness of the atra- bilious "or melancholic habits : a blue teint seems mixed with the brown, and is chiefly conspicuous under the eyes, or in the parts usually fair. This may, perhaps, be a refinement without founda- tion, but we think we have often observed it. There is certainly no constitutional symptom by which it can be predicted, if, in women, a scanty and a dark-coloured catamenial discharge be not a prognostic of the future disease. Cancer has certainly been traced in females of the same family ; and those who have escaped suffer from irregular anomalous pains, and different, often unaccountable complaints."—(Medical Diet, in verbo.) The picture thus ingeniously drawn is worth bearing in mind, but I have never been able sufficiently to appropriate it; and, in the last two or three cases of cancerous breasts that have occurred to myself, the patients have been of fair complexion, and light hair ; one of them, indeed, peculiarly so ; the lady was about fifty, and had a large and very handsome family, all of whom were so fair as to make a near approach to the phthisical exterior, though none of them have ever exhibited its pathognomonics. Cancer has also been imagined by many prac- titioners of high respectability to be contagious, of whom we may mention Bierchen, Sinnert, and Gooch ; but there seems no sufficient ground for the continuance of such an opinion. Inocu- lation has been said to have produced the com- plaint-: but this is contrary to the results of later investigations ; for M. Alibert inoculated both himself and several of his pupils, without any other effect than that of local inflammation, and even this did not always ensue.—(Maladies de la Peau, &c.) The discharge from cancers has been swallowed by dogs without any mis- chief. The parts most usually affected by cancer are the excretory glands, and especially those that separate the fluids to be employed in the animal economy, rather than those that secern the ex- crementitious parts of the blood. The lymphatic glands are seldom primarily affected, though they may become so secondarily, that is to say, in consequence of the effect of a neighbouring cancerous tumour or ulcer upon them; but whether this is on the principle of irritation or absorption, is not quite clear. " I never yet," says Mr. Pearson, " met with an unequivocal proof of a primary (cancerous) scirrhus in an absorbent gland."—(Principles of Surgery, &c, vol. i., p. 209, &c.) And hence we behold a striking difference between the nature of cancer and scrofula. But, though the secernent glands are most open to the attack of cancer, any part of the body may become its seat. We meet with it, however, chiefly in the breasts of fe- males, the uterus, the testes, the glans penis, the tongue, stomach, cheeks, lips, and angles of the eyes. The diseased action commences in the minuter vessels, and the .adjacent parts are affected in consequence. Women are more subject to cancer than men, 84 H.EMATICA. [Cl. III.—Ord IV. and in these the mammae and the uterus are the organs most predisposed to its influence. Celi- bacy, as well as the cessation of the menses, conduces to its production or appearance, and hence antiquated maids are mostly affected with it, and, next to these, mothers who have not suckled their children; for we may lay it down as an axiom, in the language of Dr. Parr, that a milk abscess never becomes a cancer. Then follow women who are past child-bearing, and, lastly, women who have borne children, and suckled them with their own milk, and males incidentally exposed to its occasional causes. To which we may add that, when cancer occurs in men, it is chiefly in the lips, and, when in children, in the eyes.* Of the remote cause of cancer we know noth- ing. While scrofula has been supposed by some to be the result of an acid acrimony, can- cer has by others been supposed to be produced by a peculiar alkali. Dr. Crawford, from a se- ries of very curious experiments upon the matter of cancer, thought he had ascertained this to consist principally of hepatized ammonia, and found that this matter effervesced with sulphuric acid.—(Phil. Trans., vol. lxxx., 1791.) Plouc- quet, however, affirms that it sometimes effer- vesces with alkalis as well.—(Init. Biblioth., torn, ii., p. 202.) The taste discovers nothing ; for to the tongue it is insipid and mawkish rather than acid or alkaline. Yet Parr, laying hold of Crawford's experiments, has boldly ventured to assert that the remote cause, or rather the cause of the cancerous diathesis, consists in an excess of ammonia, with a redundant development of sulphur. When it was popular in the Linnaean school to resolve almost all diseases into the irritation of worms, grubs, or insects existing parasitically in different organs of the body, cancer was by some theorists supposed to depend upon a like cause ; and the hypothesis has been since adopt- ed by several writers in our own country, as Mr. Justamond, who ascribed it to the larvae of a particular species of insects, and Dr. Adams, who referred it to hydatids.—(Observations on Morbid Poisons.) Vermicles, or the larvae of insects, have at times been found in the open ulcer of a cancer, as in the fetid discharge of many other malignant ulcers. These, as in other cases, have undoubtedly proceeded from eggs deposited in the sore as a nidus, though the worm or insect'that has so deposited them has never been detected.! Such appears to be the * The cases which used a few years ago to be set down as cancers of the eyes of children, are now well ascertained to be in reality examples of fungus haematodes.—Ed. ! The great attention now paid to morbid anat- omy has dispelled for ever these sports of the im- agination. In cancer there is a deposite of what is termed heterologous matter, quite different from any of the normal tissues. The carcinomatous sub- stance may exist in the molecular structure of or- gans or on free surfaces, and in the blood, and it always forms by f&4 the greater bulk of the disease. When the carcinomatous matter is deposited on free surfaces, the fibrous tissue is not often met foundation of this hypothesis, which we have no authority for carrying further, and which is rarely advocated in the present day. The occasional or exciting causes are numer- ous, but to account for their efficiency, it seems indispensable, as we have already observed, to suppose the existence of a cancerous predispo- sition or diathesis, since we see the same causes acting in innumerable instances daily without betraying any tendency to such a re- sult. Where this is present, it may be pro- duced by an external injury upon any of the parts most susceptible of cancer; by an indu- rated and chronic tumour incidentally inflamed or irritated ; an accumulation of acrid filth in the rugae of the skin, which is a frequent eause of cancer in the testes, and particularly among chimney-sweepers ; the hard and pungent pres- sure of a wart or corn in an irritable habit, of which the medical records offer various exam- ples ; the general disturbance produced in the system by a severe attack of smallpox, or several other exanthems ; a sudden suspension of a periodical hemorrhoidal flux, and a cessation of the menses ; and, when in the stomach, by a previous life of ebriety or irregular living. With these, severe cold seems also to co-operate, as the disease is generally admitted to be both more frequent and more virulent in the high northern latitudes than in the southern regions of Europe. When cancer takes place in the breast, it usually commences with a small indolent tu- mour that excites little attention. In process of time this tumour is attended with an itching, which is gradually exchanged for a pricking, a shooting, and at length a lancinating pain, a sense of burning, and a livid discoloration of the skin. And however difficult it may be to de- termine the precise point of time in which the scirrhus first becomes converted into a cancer, where these symptoms are united there can be no risk in calling the tumour by the latter name. Adhesive bands are now formed in the integu- ments, which become puckered, while the nip- ple is drawn inwards by suction, and, in some instances, completely disappears; the tumour rises higher towards the surface, and feels knot- ty to the finger, at the same time that the sub- cutaneous vessels are distended with blood, and show themselves in dark, cancriform varices. The march of the disease may be slow or rapid, for it varies considerably in its pace ; but at with as an anatomical element of the disease; but the serous tissue is frequently present, and may form either a capsule or interior cyst, filled with gelatinous, albuminous, or other fluids. However, in the molecular structure, the quantity of cellular and fibrous tissues which intersect a scirrhus in various directions may be very considerable. In dense organs, like the breast, uterus, ovaries, liver, walls of the stomach, &c.r these tissues are often very abundant.—(See Dr. Carswell's Illustrations of the Elementary Forms of Disease, fasc. iii.) According to this author's investigation, the blood- vessels seen in scirrhus are only branches belong- ing to the neighbouring tissues, and which have become enclosed within the morbid substance .—Ed. Gen. VI.—Spk. 1.] CARCINUS VULGARIS. 85 length the integuments give way in a few points to the ulcerative process, and a small quantity of caustic ichor, or of lymphatic fluid tinged with blood from eroded vessels, is thrown forth, sometimes with a short and deceitful relief (Prysschriften Uitgegeven door het Genoottch. ter bevondering der Heelkunde, Amsterdam, 1791): the ulcerative process in the meantime advancing and spreading more widely and deep- ly, till a considerable extent of surface becomes exposed, and a broad excavation is scooped out, with a discharge of a peculiar and most offensive fetor.* Here again the ulcer sometimes affords a delusive hope of recovery by its granulating; but the granulations are soft and spongy, and not unfrequently bleed, from the loose texture of the new vessels, or their erosion by the can- cerous matter. It is rarely, moreover, that they extend over the entire surface of the sore ; for, more generally, while one part is covered with them another part is sloughing, and each of the parts runs alternately into the action of the other.! And, not unfrequently, the lym- phatic vessels become affected as high up as the axilla, and in their course betray a few smaller tumours. But whether this be a mere result of contiguous sympathy or of cancerous taint is uncertain. Cancer, as we have already ob- served, rarely, if ever, commences in lymphatic glands, but they, at length, partake of the dis- ease in the course of its ravages; and hence all such suspected tumours are prudently re- moved when the knife has been resolved upon. Where the disease has spread widely or con- tinued long, some of the muscles of respiration participate in the irritation, and the breathing is performed with difficulty.X When cancer attacks the uterus, it is known by tensive lancinating pains in this organ shoot- ing through the region of the pelvis, indurations in the part sensible to the touch, a preceding and immoderate leucorrhoea or menstruation, * C. Bell on the Diseases comprehended under the name of Carcinoma Mammas.—See Medico- Chir. Trans., vol. xii. ! Both in cancer and fungus haematodes slough- ing is a common occurrence, and arises from va- rious causes, such as the pressure of the morbid substance on the veins, the irritation of it on the neighbouring tissues, or even the constriction of a portion of the disease by a narrow opening in a fascia, through which it protrudes. " Congestion, hemorrhage, softening, and sloughing," as Dr. Carswell observes, " take place in both cases of carcinoma. In scirrhus, however, they originate in the vascular system of the tissues included within the carcinomatous matter; but are not, on that account, less frequent and destructive than those which arise in the proper and collateral cir- culation in cephaloma (fungus haematodes). In general the softening is less complete, the hemor- rhage not so considerable, and the sloughing more extensive in the former than the latter."—(See Dr. Carswell's Illustrations, fasc. iii., 4to., Lond., 1833.) Nerves, he says, have never been detected in either of these diseases, as a new formation. -Ed. X This probably depends on the absorbent glands under the sternum becoming diseased. Hence likewise the cough that usually takes place in the advanced stage of cancer of the breast.—Ed. sometimes both. The ulcerative process, as far as we are acquainted with it, is the same as already described; and as soon as it has work- ed to the surface of the organ, there is a sanious, or bloody, or mixed discharge, characterized by the peculiar stench of the disease. By degrees the labia swell and become oedematous, and if, as sometimes happens, the inguinal glands be obstructed, the oedema extends down the thigh, and the ulceration proceeds often to the bladder and rectum.—(Clarke, Obs. on the Diseases of Females, &c, 8vo., 1821.) Cancer in the vagina, which, however, rarely takes place, can easily be felt; and in the rec- tum, the distinction is not difficult. The nature of the discharge, and the other symptoms just noticed, are sufficient to decide its existence. It is still more obvious in the penis. None of these symptoms assist us in deter- mining its presence in the stomach : and hence, how confidently soever it may be conjectured from the marks of an acute and burning pain, tenderness of the epigastrium upon pressure, nausea, and rejection of food, and even an of- fensive fetor in the breath, the disease ean sel- dom be completely ascertained till after death. It is sometimes accompanied with vomiting, and sometimes not; and ordinarily the absence of vomiting is an unfavourable sign, as it has often been found to proceed from an induration of the coats of the stomach generally, which has_rendered it incapable of contracting, or from a cancerous ulceration and enlargement of the pylorus (Mem. sur le Vom., par Ml Piedagnel, &c. ; Journ. de Phys. Exp., par M. Magendie, 1821, Paris), which, upon the slightest pres- sure, readily admits the contents of the stomach into the duodenum. There is here, however, usually habitual nausea, though without vom- iting. The progress of cancer in the testicle is often slower than in many other parts. In chimney- sweepers we can trace an obvious cause, which is that of soot lodged in its rugae, and irritating as well from its own acrimony, as from that of the perspiratory fluid with which it comes in contact and forms a union. A painful ragged sore, with hard rising edges, is first produced; or sometimes a little indurated wart; which, from inattention, increases in size, is repeatedly rubbed off by the exercise of climbing, enlarges and deepens its sphere of irritation, grows more malignant, and at length is converted into a real cancer, and affects the whole scrotum, or the body of the testis. In whatever part of this complicated organ, however the disease com- mences, it is progressively communicated to the rest; the scirrhosity increases in size and hardness, till the tumour often acquires an enor- mous and irregular magnitude, studded exter- nally with numerous protuberances, and the shape of the testis, even before ulceration, is entirely lost. In the progress of the disease the spermatic cord becomes affected, and the taint or irritation is communicated more or less to the viscera and lymphatic glands of the abdomen. From the cancerous effect of a highly irritable wart or crack on the scrotum of chimney-sweep- 86 H.EM. ers and smelters of metals, we may derive some idea of the formation of cancers on other super- ficial parts of the body from a similar beginning. These most frequently occur on the lips, nose, or eyelids ; and oftener from a crack than from a wart. The edges of the sore become hard, and one or more tumours issue from thern, which increase in size, and gradually evince a cancer- ous character. On the tongue the same disease sometimes shows itself, and more usually commences with a small wart or pimple near the tip, which har- dens by degrees, grows highly irritable and ma- lignant, and spreading its influence througlrthe entire organ, swells it to a prodigious size, and renders it of a scirrhous induration. These local tumours are seldom entitled to be called cancers on their origin. They are almost always produced, as Mr. Earle has justly ob- served, by local irritation, and exacerbated by a continuance of the same cause ; and hence they rarely give much trouble on extirpation, and per- haps never endanger the constitution. A chronic malignancy may, however, convert them into genuine carcinomata.—(Medico-Chir. Trans., vol. xii., art. xxii.) Cancer is said, in a few instances, to have terminated spontaneously. De Haen gives us one example of this (Epist. De Cicuta\ p. 43), and Parr affirms that he has seen six cases of the same in his own practice. But he adds, in proof of its being a constitutional affection, that in every case the cure was followed by some other disease, as an enteritis, fixed pains in the limbs, a sciatica, or an apoplexy; in one of these cases the apoplectic attack occurred twice, and the last was fatal.* In general, however, a cure is rarely affected but with the knife or caustic, the use of which it does not belong to the present course of study to explain. Yet the progress of the complaint may perhaps be arrested; and we are often able, without cutting, to render it at least tolera- ble for a series of years. In an early stage of the disease relief may often be obtained by topical bleeding, as with leeches; and topical refrigerant applications, as saturnine lotions, or sheet lead in very thin layers, as the linings of tea-packages, an application which has of late been brought forward as something new, but which was employed long ago, and may be found recommended in many of the older journals of established reputation.! The diet should be limited to the mildest nutriment, and wine be sedulously avoided. At this period, indeed, * Diet, in verb., vol. i., p. 329. The termination of carcinoma in mortification, from obliteration of veins, is stated by Professor Carswell as far from being a rare occurrence.—Ed. ! Eph. Nat. Cur., dec. i., ann. iv., v., obs. 161. It is on the principle of diminishing the supply of blood for the nutrition and growth of cancerous tu- mours, that the frequent local abstraction of this fluid, the application of cold, the use of the liga- ture and compression, have been recommended as the most effectual means of arresting or retarding their progress.—Professor Carswell, op. cit., fasc. iii.—Ed. /TICA. [Cl. III.—Ord. lV. whatever can prevent or lessen inflammation should be seriously studied and adhered to. Pouteau relates the particulars of a cure pro- duced by rigid abstemiousness alone, the patient taking nothing whatever but water for a period of two months.—(Nuovo Metodo per curare si- curamente ogni Canchero coper to, &c, Venezi, 1750; 02uvres Posthumes, torn, i.) As, however, the disease advances, and as- sumes more of a chronic character, the activity of the smaller vessels may be gently urged, in order to relieve or prevent congestion. And, where the irritation is not great, we may by degrees apply gentle stimulants also externally, and let the saturnine lotion be superseded by the acetated solution of ammonia, tar-water as rec- ommended by Quadiro, or the application of mercurial ointment, combined with a small por- tion of camphire, to the surrounding parts. The internal medicines which have been chiefly trusted to for the cure of cancer, are the lurid and umbellate narcotics and the min- eral tonics : the former apparently for the pur- pose of taking off irritation, and in some in- stances correcting the specific acrimony ; and the latter for supporting the living power, and thus enabling the system to obtain a triumph over the disease by its own instinctive or reme- dial energy. Of the first class, the chief have been the belladonna and hemlock, and particularly the latter, which appears to have been most prom- ising. When Dr. Stoerck of Vienna published his work upon the successful exhibition of hem- lock in cases of confirmed cancer, many of which were vouched for by the Baron Van Swieten, every practitioner was eager for ex- amples upon which to try the experiment for himself. Solanum had been in vogue, but was just sinking into disrepute from its numerous failures ; and corrosive sublimate was the medicine chiefly confided in at St. Thomas's Hospital. Dr. Akenside, who was at this time prescribing the corrosive sublimate in the hos^ pital with what he thought a gratifying success, immediately exchanged it for the conium, or cicuta, as it was then called. He tried it upon a large scale in every stage and modification of the disease, and at first with the most sanguine expectations ; but his hopes gradually failed him as he advanced in the career of his experi- ments, and he was compelled to make very great drawbacks upon Dr. Stoerck's commenda- tion of the medicine. He allows it, however, a certain portion of merit, and his account is drawn up with a degree of candour which en- titles it to the fullest confidence, and appears to deal out the real truth. In recent states of the disease, where there was no ulceration, or none of any depth, he asserts that it often pro- duced a favourable termination, and gives nu- merous examples to this effect. But in invet- erate cases, where the cancerous ulcer had made considerable progress, its benefit was very questionable : it operated often for a verv few days like a charm, diminished the pains, and improved the discharge ; but suddenly it failed to do the slightest good any longer, unless the Gen. VI.—Spe. 1 ] CARCINUS VULGARIS. 87 dose was very largely increased, upon which a like beneficial effect followed, but unfortu- nately of equally transient duration. The dose was in many instances again increased, and continued to be so, till at length the symptoms produced by the cicuta were as mischievous as those of the cancer itself, and Dr. Akenside was compelled to abandon it.—(Transact, of the Coll. of Phys. of Lond., vol. i., art. vi., p. 64.) We are hence in some degree prepared for the contradictory accounts of its effects. De Haen asserts that it affords neither cure nor relief of any kind (Rat. Med., ii., 37); Bier- chen, that it aggravates real cancer, though sometimes serviceable in scrofula ; and Lange, that it is altogether inefficacious.—(Diss, dubia Cicuta vexata, Helmst., 1764.) Fothergill is friendly to its use (Works, vol. ii., passim); and Bell (On Ulcers, part ii., sect, viii.) and Fearon (On Cancers, passim) recommend it both externally and internally, alone or in com- bination with opium. For this discrepance of judgment, we have in some measure endeavoured to account. Yet the advocates of the medicine have doubtless, in some instances, suffered themselves to speak of it in exaggerated terms ; and it is highly probable that in others, where it has seemed altogether inefficacious, the hemlock, whether in powder or extract, was administered in an imperfect state. Dr. Cullen gives a striking example of this last fact in a lady, who, being very particular in the use of this medicine, em- ployed the powder as mostly to be depended upon, and weighed out her own doses, begin- ning with a small quantity at a time, and pro- ceeding gradually till she took sixty grains at once. By this period her parcel of the powder was exhausted, and she had derived no bene- ficial effect. She supplied herself, however, with another parcel, and being warned that different samples were rarely of the same strength, she reduced her first dose of the new plan to a scruple : yet even this nearly killed her; for in ten or fifteen minutes she was af- fected with sickness, tremour, giddiness, delir- ium, and convulsions. Happily, the sickness proceeded to a vomiting, and the poison was re- jected. But of the fresh supply she was never afterward able to take more than five or six grains at a dose, notwithstanding she had taken sixty grains of the preceding without any mis- chief.—(Mat. Med., vol. ii., part ii., ch. vi., p. 264.) Yet the quantities pretended to be given by some practitioners are far beyond this last amount. Thus, Dease informs us that he gave an ounce and a half of the powder every twenty-four hours (Introduct. to the Theory and Pract. of Surg., i.), and performed a cure; and Rostard, that his ordinary allowance was six drachms of the extract for the same pe- riod, which is a still higher proportion.— (Journ. de Mid., torn, xxxviii., p. 36.) Warner gave a drachm and a half, and thought it an enormous quantity, without mischief.—(Treatise en the Eyes, passim.) Upon the whole, the balance of experiments seems very much to confirm the candid report of Dr. Akenside. Schaeffer and many others contend, that even its beneficial influence is nothing more than a result of its narcotic power; but it does seem, in some instances, to act as a discutient, and to improve the quality of the secretion as well as to relieve the pains. Dr. Cullen advances further, and tells us that he has found it, in several cases, make a consid- erable approach towards healing the sore; " Though I must own," says he, " that I was never concerned in a cancerous case, in which the cure of the" sore was completed."—(Mat. Med., loco citat.) Of the other narcotics, chiefly of the solana- ceous order, that have been employed, it is hardly worth while to speak particularly. The same uncertainty has accompanied their use : and some of them, as aconite and dulcamara, have been rather supposed to effect whatever temporary benefit has flowed from their employ- ment by the general disturbance they produce in the system, whereby a transient stop is put to every other anomalous action, than by their sedative power. Of the metallic oxydes that have been brought into use, the only ones it is necessary to notice are those of mercury, iron, and arsenic. The first has been uniformly found mischievous when carried to the extent of salivation. Loss asserts, that by this means he cured a cancer of the nose and face (Observ. Med., b. iv., Lond., 1672); but this was probably a spurious disease of zaruthan, as it has been called by some writers. It has more generally been em- ployed as a gentle stimulant or alterant. Many practitioners have preferred the corrosive sub- limate in small doses, but the submuriate is a far better preparation. And even this is given with more advantage in the form of Plummer's or the compound calomel pill, than alone; a form that conveniently unites a mild stimulant with a mild relaxant. To this, if the pain be acute, should be added a small quantity of opium ; at the same time carefully guarding the bowels against constipation by any convenient aperient, if the pill itself should not prove suffi- cient. Iron has been tried in almost every state of combination. The ferrum ammoniatum appears to have been the most successful, and is still the most popular. Under the name of flores martiales, it was introduced for this purpose before the public as far back as the middle of last century, by Francis Xavier de Mars, ob- tained, however, by a very uncouth and operose process. Dr. Denman was particularly attached to this metal, in whatever form administered ; and broadly affirms that, after having employed almost all the medicines recommended for this disease in every different stage, he has never found any of them possess the pretensions of iron ; and that the rest may be generally re- garded as totally unavailing.—(Observations on. the Cure of Cancer, p. 77.) Its greatly stimu- lant power rather recommends it to us on the present occasion, than proves an objection ; for it is the kind of stimulus we stand in need of to 88 fLEMATICA. [Cl. Ill— Ord. IV". excite a new local action. It is said tdproduce a very speedy mitigation of pain, an improved discharge, and a less fetid smell; and, even in hopeless cases, to render the disease less ma- lignant and distressing : unfortunately, however, its effects, like those of conium, have rarely been found permanent; and it has closed its career as a palliative, rather than as an antidote. But of all the medicines of this class, arsenic has acquired the highest and most extensive reputation. This is a strictly oriental remedy, employed, as we shall have occasion more fully to observe when treating of elephantiasis, for every impurity of the blood. Who first ven- tured upon it in Europe for the disease before us, is not very satisfactorily known. It was common in the time of Hildanus, who ascribes its introduction into practice to the monk Theo- doric, who. flourished about the beginning of the eleventh century.—(Cent, vi., obs. 81.) It has formed the basis of almost all the secret remedies for cancer which have at any time been current, whether external or internal, from that of Fuschius, in the fourteenth century, who united it with soot and serpentary, to that of Richard Guy, who wrote upon .the disease (Es- say on Scirrhous Tumours and Cancers, 1759) in the middle of the last century, and whose boasted arcanum was found to be a composition of arsenic, sulphur, hogsfennel (peucedanum officinale), and crows-foot (ranunculus sylves- tris.)—(Richter, Chir. Bibl., band v., p. 132.) Of the real effects of arsenic, as of several of the preceding medicines, we labour under great obscurity from the discrepant reports which have been communicated. Le Febure, with a host of practitioners antecedent to and contemporary with himself, employed it both externally and internally, and regarded it as a specific.—(Remede eprouvepour guerir radicale- ment le Cancer occulte, et manifeste ou ulcirk, 8vo., Paris.) Smalz thinks it serviceable.— (Seltene chirurgische und medicinische Vorfalle, Leips., 1784, 8vo.) Schneider (Chir. Ges- chichte, Theil. v.) and Justamond declare it to be useless, though the latter employed it locally as an escharotic. Hildanus (Account of the Methods pursued in the Treatment of Cancerous and Scirrhous Disorders, Lond., 1780) and De- bus (Dissert. Observat. et Cognit. nonnulla Chi- rurg., fasc. vi.) assert it to be injurious; and Schenck (Observ., lib. ii., N. 304) and Meibom (Blumenbach, Bibl., band viii., p. 724) give examples of fatal effects from its employment. Fatal effects, indeed, it is easy to produce, provided a sufficient degree of caution be not employed in experimenting upon it. And, in truth, it is not till lately that any very conve- nient form has been devised for trying its vir- tues without a risk of mischief; but the arsen- ical solution of the London College, for which we are indebted to Dr. Fowler, has given us a preparation of this kind. Yet, even with this advantage, we cannot boast of any certain suc- cess in the use of arsenic. It acts very differ- ently on different constitutions, though, gener- ally speaking, it proves beneficial, and in some cases may produce a radical cure. But more commonly, like the preparations of hemlock and iron, it unfortunately loses its effect as soon as the habit has become accustomed to its in- fluence, and the cancerous action resumes its victorious career. And perhaps the only power that is capable of neutralizing cancer, or keep- ing it permanently in subjection, is the exist- ence of a predominant diathesis of some other kind. How far the remark may have been made antecedently I know not, but from a pretty close attention to the subject within my own sphere of observation, I have been led to con- clude that cancer does not often make its at- tack upon those who are constitutionally subject to gout, and seems to be restrained by its in- fluence. The list of external applications is still more numerous than that of internal. We have al- ready glanced at the local treatment before ul- ceration has taken place. After this period sedative applications do not succeed, and mod- erate stimulants alone seem to afford any ma- terial degree of relief. In fact, the inflamma- tion has now acquired much of the character of a malignant erythema, and requires warmer applications than phlegmonic sores.* Yet a cure is rarely to be effected, except by the caustic or the knife. When the poison was sup- posed to be of an acid character, a solution of the alkalis was employed to correct it. It was afterward conceived to be of an alkaline nature ; and various acids, and particularly the carbonic acid gas, were regarded as the best antagonists. Who first employed it for the present purpose is not known ; but it stands recommended as early as 1776, in an article of Magellan, in- serted in Rosier's Journal; and an easy and convenient mode of application has lately been contrived by Dr. Ewart of Bath. Dr. Craw- ford, however, for the same purpose, preferred a lotion of muriatic acid diluted with three or four times its weight of water. Carminati and Senebier applied the gastric juice of animals ; but poultices of carrots or charcoal have been in more general reputation. [A solution of the chlorides of lime or of soda, has also been of late years employed.] All these have a considerable influence in correcting the oppressive fetor, and keeping the sore clean; but whether they go beyond this has been doubted. Yet even this is of great importance, since such an effect must necessarily give some check to the spread of the ulceration, afford solace to the patient, and probably im- prove the nature of the discharge itself. And hence many writers have been sanguine enough to expect an entire cure from such processes ; and others have given accounts of such cures nearly accomplished, but which seem seldom, if ever, to have been rendered complete. Fomentations of hemlock and various other narcotics have been also had recourse to, and sometimes tepid baths of the same, in which * The editor has known the liquor opii sedati- vus preferred, in some instances, to every other dressing; and, on other occasions, nothing was found to afford so much ease as the simple ung. cetacei.—Ed. Gen. VII] LUES. 89 the patient has been ordered to sit for twenty minutes at a time; and temporary benefit has sometimes followed the use of these means ; but they have often been tried with as little avail as the suckling of toads, which was at one time a fashionable remedy, and esteemed of great importance, the animals being feigned to expire in agonies as the poison of the ulcer was drawn out, and its surface assumed a better aspect. Bouffey, whf was a witness to their use, tells us, and probably with some truth, that they did more harm than good (Journ. de Mid., torn, lxii.), and dealt out more poison than they took away. The era of this invention is un- known, but it was still in use about half a cen- tury ago in our own country, if we may judge from one of the private letters of Junius to Woodfall, who, alluding to the princess dowager of Wales, at that time afflicted with a cancer that destroyed her in January, 1772, asserts that " she suckles toads from morning till night."—(G. Woodfall's edition, vol. i., p. *241.) One of the best detergents appears to be arsenic* finely levigated, and sufficiently reduced in strength by a union with calamine or some other ingredient. It is also one of the best caustics, in a simple or more concentrated state, and was freely employed as such by Mr. Justa- mond. Guy's powder, which we have already noticed, is used externally for the same purpose.! [Mr. Carmichael some years ago strongly recommended the application of preparations of iron to ulcerated cancers, and gave a very in- teresting account of the good effects which he had seen arise from them. The plan has been repeatedly tried in this country, but its success here has not corresponded with that stated to have resulted from it in Ireland. When a medicine or application proves successful in the hands of one surgeon, and unsuccessful in those of another of equal skill, the inference is, that, if the medicine or application in each case be undoubtedly of similar qualities, but its effects different, the cases themselves cannot precisely correspond in their nature. No doubt, many alleged specifics for cancer have obtained their repute by the circumstances of their having * In consequence of many patients having fallen victims to the absorption of arsenic from the sur- face of cancerous and other anomalous sores, few modem practitioners now venture to apply pow- dered arsenic to carcinomatous ulcers.—Ed. ! Baron Dupuytren uses arsenical applications, prepared so as to modify the diseased surface, without acting as a caustic. The formula of the powder which he applies is 4 parts of arsenical acid and 96 of the submuriate of mercury in every 100. Occasionally the proportion of arsenic is increased to 5 or 6 in 100. When the baron uses a liquid, or paste, he merely blends the above powder with distilled water, or gumarabic pow- dered and moistened. When, however, the lotion is employed, 6, 8, 10, or even 12 parts of arsenic may be the proportion of it to the calomel. It is chiefly for phagedenic or inveterate ulcerations about the nose, lips, and face, that Baron Dupuy- tren has recourse to this heroic remedy, as he calls it.—See Lecons Orales de Clinique Chirurgicale, torn, iv., p. 471, et seq., 8vo., Paris, 1834.—Ed. cured tumours and ulcers which only some' what resembled, but were not really cancers.] We have already observed that sheets of lead, among other preparations of this metal, were applied to the cancer about forty or fifty years ago, and bound over it with some degree of pressure. But a pressure of a much severer kind, together with the use of the same metal- lic sheeting, was employed a few years ago by Mr. Young, a fair and impartial trial of whose plan, however, by other surgeons, has completely proved that it is generally more hurtful than beneficial. After all, when the cancerous character of the tumour is once decidedly established, little dependance is to be placed upon any plan but that of extirpation with caustic or the knife. The actual cautery, as employed by M. Mau- noir, of which we shall have to speak more at large when discussing the genus Ulcus, may, perhaps, be most advantageously made use of in small cancers of the face ; but the knife is the preferable instrument where the organ is large and extensively affected: Mr. Bell ad- vises an early performance of the operation; Mr. Pearson, that we should wait till the extent of the disease has fully unfolded itself, so that no morbid part may be left behind.* Yet some parts may be doubtful even at last, and, wher- ever there is the least suspicion of this, they should unquestionably be removed along with the more decided portion of the morbid struc- ture. Even this remedy, however, can only apply to exterior organs, or to organs that can be brought down to the surface ; for the uterus has been occasionally extirpated with success, but, far more frequently, without any benefit, per- haps from the operation having been postponed till too late.! In all other instances, the prac- tice is melancholy from the first. The die is cast; and all we can hope to accomplish is to postpone the fatal result, to mitigate the suffer- ings of the day, and soften the harsh passage to the tomb. GENUS VII LUES. VENEREAL DISEASE. ULCERS ON THE GENITALS, INGUINAL BUBOES, OR BOTH, AFTER IMPURE COITION ; SUCCEED- ED BY ULCERS IN THE THROAT, COPPER- COLOURED SPOTS ON THE SKIN, BONE-PAINS, AND NODES. The term lues is derived from the Greek \iu>, " solvo, dissolvo"—"to macerate, dissolve, or corrupt;" and, agreeably to the common rule * The maxim of every surgeon of judgment in the present day, is to recommend the removal of every truly cancerous disease as soon as its nature is manifest. This proves the general inefficiency of all medicines and local applications, and the dangers resulting from delay.—Ed. f In cancers of the rectum Lisfranc has suc- ceeded in extirpating the diseased structure with perfect relief to the patient. In a memoir read by 90 H^EMATICA. [Cl. Ill— Ohd. IV. of expressing the power of the Greek u by a Roman y, should be written lyes, as in the case of Lyssa and Paralysis, both of which are derived from the same root; but lues has been employed so long and so generally, that it would be little less than affectation to attempt a change, and in allucinatio, or hallucinatio, from the Greek aAtfw, or &\v primo traxit cognomina morbus : Syphilidemque ab eo labem dix^re coloni." One of the earliest German writers who as- cribed the disease to the return of Columbus, is Leonard Schmauss, a physician of Strasburg, whose works were published in 1518 ; but neither his history nor his arguments are in any degree satisfactory: while his countryman, * See especially Meiner, Sitten des mittel Alten. Stuinf, Schweitzer Chronik, lib. xiii. Stettler, Schweitzer Chronik, lib. vii. Sprengel, Uesehichte der Arneykunde, theil. ii. Matern Berlen, a clergyman of Ruffach, and an eyewitness of the disease on its first appear- ance, assigns it a very different origin ; and, in his history of the Italian expedition of Charles VIII., declares it to have been a punishment inflicted by the Almighty on this monarch and his subjects, in consequence of his having car- ried off the Dutchess Anne of Bretagne from the Emperor Maximilian, to whom she had been betrothed. Among the Spanish writers, there are two chiefly who ascribe the origin of syphilis to an American source ; while others, by their silence upon the subject when detailing the particulars of the return of Columbus, give sufficient evi- dence that they disbelieved the report. Of the two who thus contributed to spread it, one of them, Goncalvo Hernandez de Oviedo, affirms that it was conveyed into Italy by Cordova's fleet, which, however, did not arrive in Italy (Messina) till May 24, 1495, and, consequently, not till two years after the disease had existed there. The other is Sepulveda, who, in a his- tory of America, written in a good Latin style, towards the middle of the sixteenth century, roundly asserts that " ex Barbaricarum mulie- rum consuetudine Hispani morbum contraxe- runt." But as this writer does not, like his contemporary Fracastorio, enter into the partic- ulars of the controversy, his assertion can go no farther than to the weight of his own indi- vidual opinion in a controverted case. Among those who have been most full in their accounts of the voyages of Columbus and the discovery of America, we may certainly reckon Antonio de Herrera. He fixes the return of Columbus at the period above specified ; and is very particular in detailing the order sent to Lisbon to him, on the moment of his arrival, to follow the Spanish court to Barcelona, to which city it was then removed ; the highly honour- able reception the great navigator received ; the preparations which were immediately made for his second voyage ; the speed with which these preparations were accomplished; and the in- structions given to him on the occasion. Yet not a hint is added that his crews were un- healthy, that the new recruits had any dread of the plague, to which, had he brought it home, they must have known they were about to be exposed, nor a single instruction to be provi- dent of their health in this respect. He took leave of the royal pair with every mark of dis- tinction, the whole court accompanying him to his house, as well at the time as when he quit- ted Barcelona. " Despidose," says Herrera, " de los Reyes, y aqual dia le acompano toda la corte de palacio a su casa, y tambien quando salio de Barcelona."—(Hist. Gen. de las Ind. Occ, decad. i., lib. Ii., ch. v.) Linnasus stands alone in arranging syphilis as an exanthem, along with smallpox and measles. He thought himself justified, from the fever which occasionally accompanies the copper-col- oured spots on the skin, in an advanced stage of its secondary symptoms ; or perhaps from the fever which, on the first appearance of the dis- ease, unquestionably accompanied it, and uni- 92 H^EMATICA. [Cl. III.—Ord. IV. formly preceded the eruptions. For it is an ex- traordinary fact, to which all the contemporane- ous writers bear witness, that syphilis, when it first broke forth upon the world, and, indeed, as it is described in Fracastorio's poem, was not only called the plague, but was, in truth, a spe- cific fever, attended with most violent putrid symptoms, together with carbuncles, buboes, and other glandular abscesses, which discharged a malignant sanies often fatal, and even when recovered from, leaving the most melancholy marks of its ravages. And hence, in many places, the infected were as much exiled from the community by a line of circumvallation drawn around them, as in the case of plague. In Scotland, indeed, they were strictly prohibited all medical assistance, and in- humanly left to the effects of their own licen- tiousness : for Mr. Arnot gives the copy of an order from the privy council of Edinburgh, which equally banished to the Island of Inchkeith those who were affected with the disease, and those who undertook to cure it.* By degrees, however, the disorder appears to * History of Edinburgh, by Hugo Arnot, Esq., 4to., 1789. With reference to the origin of syphi- lis, the editor is skeptical about the correctness of the doctrine which attempts to refer the first com- mencement of the complaint only to one source. Is it rational to believe that all the syphilitic mis- chief that has scourged the various cities, king- doms, and generations of the world, has arisen from the amours of a single unfortunate individual in whom the virus was first produced ? Are we to fancy that the disease never had but one pri- mary source ? and that it is to the mysterious con- coction of the poison in one individual alone, that all quarters of the world are under obligations for the gift of the venereal disease ? No doubt syph- ilis must have had a beginning, like every thing else ; but probably it has had numerous beginnings. Various considerations would lead us to expect (what is, indeed, the fact), that in every country where the population is numerous, and promiscu- ous sexual intercourse exists, the venereal disease would be prevalent. Mr. Travers has conse- quently declared it to be his belief, that if all the syphilis in the world were to be now annihilated, a never-failing source of the disease would still re- main, in the action of the matter of superficial or gonorrhoeal ulcers of the penis on the human con- stitution.—(See his Pathology of the Ven. Dis- ease.) In relation to this part of the subject, Mr. Wallace also considers it not in opposition to the general laws of nature, that the venereal disease may have arisen on different occasions spontane- ously.—(See Treatise on the Ven. Disease and its Varieties, p. 8, 8vo., Lond., 1833.) At the same time he adds :—" No cases have occurred to me, nor have I heard or read of any, in which the evi- dence was quite satisfactory, that a deranged state of general health, or simple local irritation, or other accidental causes, either local or constitu- tional, ever produced by their influence on the system any effects which resembled in their series or order the constitutional symptoms of the ve- nereal poison."—(P. 12.) The question, however, more immediately under our consideration is, not whether this poison exists at all, but, admitting the reality of its existence, whether it has had one or numerous origins ? and whether it can originate under the circumstances adverted to by Mr. Trav- ers ?—Ed. have assumed a chronic form, and at length so far changed its nature, as to make its attack without fever, and to remain local except from absorption. It seems still, indeed, to be con- tinuing its course of melioration, notwithstand- ing the assertion of Dr. Swediaur (Beobach- tungen, &c, p. 172), that it has not assumed a more mitigated character at present than in former times ; for very severe cases are now much rarer, not only in private practice, but even in public hospitals, than they were thirty or forty years ago. It is possible that this change may have been produced by two causes ; firstly, by the virus wearing out its own strength and becoming milder as it descends to different individuals and generations, and has to cope with the force of sound constitutions, and, perhaps, also, with a perpetual instinctive power or vis medicatrix naturae, constantly labouring to subdue it: of which we shall hereafter have occasion to offer other examples than the present. And, second- ly, it is also highly probable, that the frequent and indeed universal use of mercury for its ex- termination has succeeded, as a specific, in softening its violence, in the same manner as we know the virus of cowpox succeeds in giv- ing a milder character to smallpox, even where it does not altogether answer as a prophylactic. Syphilis shows itself under two distinct sets of symptoms, local and constitutional, the latter of which is commonly, but not always, a sequel of the former. In which way soever it is produced, it is usually by means of impure coition; though we shall have occasion to show presently, that syphilitic matter coming in contact with any part of the surface of the body, where it is ca- pable of burrowing and meeting with a little mucus, sweat, or, perhaps, any other natural secretion, is capable of assimilating it to its own nature, and hence of introducing the disease into the system by absorption, and consequently without any breach of surface. And hence, as other parts than the sexual organs may be a medium of communication, no local symptoms may in some instances ensue, and the constitu- tional signs be the first to manifest themselves. The earliest ordinary mark, however, that in- fection has taken place, is the appearance of one or more minute pimples of a peculiar kind, which are called chancres ; having a hard inflamed base, of a pale red hue, and irritable apex, which next opens with a small eyelet, becomes ulcerated, and discharges a small portion of limpid virus, that produces fresh chancres wherever it spreads. In the common mode of infection, the chancre shows itself on the pre- puce, glans, and orifice of the urethra in men, and about the labia, nymphae, clitoris, and lower- most part of the vagina in women. This mark sometimes appears as early as the third or fourth day after coition, more generally, however a few days later; and in some instances, where the cutaneous absorbents possess little irrita- bility, not till a lapse of several weeks. The chancre occasionally degenerates into a hard and irritable wart, with which the genitals are Gen. VII.—Spe. L] LUES SYPHILIS. 93 frequently studded, sometimes as low down as the anus. Another local symptom is the formation of a bubo in one or both groins, evidently produced by an absorption of the virus first deposited, or, as is more commonly the case, multiplied in the ulcerated chancre, communicated to the lym- phatics, and hence to the inguinal glands, which, in consequence, become inflamed and tumefied. The tumour, when first perceived, is small, but hard, fixed, and diffused, with a somewhat ob- tuse pain. It enlarges gradually, and becomes more acutely painful, so as to render walking troublesome ; and, if not opened by the lancet, generally bursts by the time it has reached the size of a pullet's egg, and discharges a copious quantity of pus from a single hollow. In a few instances the suppurative inflammation does not follow, and the tumour, as it augments, acquires considerable induration. Sometimes, also, the inflammation extends by sympathy to the spermatic cord, which is in- flamed and rigid through a great part of its course, while the testes themselves are tender and considerably swollen. And occasionally, from sympathy also, or an entrance of a part of the received virus into the urethra, its mucous membrane becomes inflamed, and pours forth a considerable secretion of pus or purulent mucus, resembling that of blennorrhoea, or gonorrhoea, as it is commonly called, or the discharge from the eyes in purulent ophthalmia. This was at one time mistaken for a genuine gonorrhoea, and the two diseases were very gen- erally regarded as only different modifications of one and the same species. And some prac- titioners continue to be of the same opinion still, notwithstanding all the facts that have been adduced in proof of their being distinct maladies, produced by distinct kinds of conta- gion.* The local symptoms of syphilis, chancres, and buboes, are perpetually occurring without gonorrhoea, and gonorrhoea without chancres and buboes. Insomuch that there are not wanting practitioners who affirm that they never occur together, unless the two venoms are re- ceived simultaneously. And there is no doubt that this assertion is true in regard to a genu- ine gonorrhoea; but, from the cause already stated, a large flow of pus or purulent matter, and a general irritation and enlargement of the body of the penis, in appearance strongly resem- bling the symptoms of a genuine gonorrhoea, sometimes coincide with the primary signs of a syphilis, of which a very marked case occurred to the author not long ago, which he showed to an eminent surgeon of the metropolis, who had antecedently been incredulous upon this point. And hence a like admission of Professor Frank, who, however, does not speak very decidedly * Thus, in an enumeration of the morbid states or actions produced by the direct application of the venereal poison, we find included, by one of the latest writers on the subject, " an increased and morbid secretion from the diseased surface of the urethra, constituting the state commonly called gonorrhoea."—Wallace, on the Ven. Disease, p. 45, 8vo., Lond., 1833.—Ed. upon the subject; and has strangely placed syphilis not only with gonorrhoea, but with leu- corrhcea, mucous piles, hernia humoralis, and a variety of other diseases, under one and the same indistinct genus, to which he has given the name of medorrhcea.—(De Cur. Horn. Morb. Epit., torn, v., p. 149, Mannh., 8vo., 1792.) But the clearest and most incontrovertible proof of dis- tinction between the two complaints immedi- ately before us is, that in no instance whatever has a simple gonorrhoea, unconnected with bubo or chancre, produced those secondary or consti- tutional symptoms to which the proper local signs of syphilis are sure to lead, if not cor- rected in their progress.* These symptoms are, a progressive soreness and ulceration of the tonsils, uvula, palate, and tongue; the voice being rendered hoarse, and the swallowing difficult. The ulcers about the fauces are of a distinctive character, being foul and rugged, with an excavated centre covered with a brown or whitish slough, and surrounded with a hard, red, elevated, and erythematous outline. Sometimes the mucous membrane of the con- junctive tunic of the eyes next suffers in the same way, and displays an inflamed surface, with ulcerations on the eyelids and angles of the eyes.! The skin is in various parts covered over with copper-coloured spots, which at first desquamate in scurfs, afterward in scales, and still later in scabs ; each of which leaves a foul ulcer, that gradually grows deeper, and dis- charges an offensive fluid As the disease advances, irregular pains shoot through the limbs, and are felt so severely at night as to prevent sleep. By degrees they strike into the bones, which become diseased, and in many places swell into nodes, which at length grow carious : while the ulcerations about the fauces spread at the same time, or even before this, to the adjacent bones of the palate and nostrils, which are gradually eroded and carried away ; so that the speech is rendered nasal and imperfect, and the nostrils are flattened to the level of the cheeks. Finally, the countenance grows sallow, the hair falls off, the appetite is lost, the strength decays, and a low hectic preys upon the system, and at length destroys it. It is not easy to say how long the matter of syphilis, when once communicated, may remain limited to the local symptoms of chancres or * The earlier American physicians generally believed that gonorrhoea and lues syphilis arose from two distinct poisons, and necessarily de- manded different modes of treatment; that mer- cury was indispensable to cure the latter, while it was unnecessary, if not pernicious, in treating the former. This opinion, however, was somewhat questioned when the treatise of John Hunter was published in this country ; and his authority is so great, that some still maintain the identity of all venerea] poisons.—D. ! Among the secondary symptoms Dr. Good should have mentioned iritis, which is a far more unequivocal effect of syphilis than the affections of the conjunctiva and eyelids, to which he has alluded.—Ed. 94 H.EM buboes, or continue inert in the System where no local symptoms have taken place ; or what period must intervene before a patient may be pronounced safe after having exposed himself to contamination. We have already seen that the primary or local signs generally manifest them- selves within four or five days ; and, where the constituiion has become infected without them, we have reason to expect the appearance of the secondary symptoms soon after three weeks, or from this time to six months : and if this latter interval have passed without the slightest man- ifestation of mischief, locally or generally, we have little reason to fear for the issue. It has been said, however, that the poison has lurked unperceived for several years; yet it is rarely that such an assertion is made, except for the pur- pose of excusing some fresh infection. I should, indeed, have been disposed to think it had never been made otherwise, but that Dr. Hahnemann has referred to an instance or two to the con- trary, in which he places full confidence (Un- terricht fur Wundarzte vher die Venerischen Kiankheilen, 8vo., Leips., 1789); and particu- larly that the late Mr. Hey of Leeds, whose authority is indisputable, has offered it as his opinion, formed from a variety of cases that had occurred to him during an extensive practice of nearly threescore years, that a man may com- municate the disease after all the symptoms have been removed, and he is judged to be in perfect health ; and that a mother who has been once affected may convey it, notwithstanding an apparent cure, to two, three, or four children in succession, each of whom he supposes will have it in a milder form than the preceding one ; as though it were gradually ceasing in the consti- tution, though it still continues to show some degree of activity.* * Facts illustrating the Effects of the Venereal Disease, by William Hey, Esq., F. R. S., 1816. The doctrines here adverted to, particularly that of the poison lurking unperceived in the constitu- tion for many years, and that of a man in perfect health, or without any perceptible ailment about him, being able to communicate the disease to a woman, may be considered as now having few advocates. As the disease may be transmitted from the mother to the foetus through the medium of the blood, a suspicion has frequently been en- tertained that it is likewise communicable through the medium of the natural secretions, the saliva, milk, semen, &c. With respect to the foetus, we may infer that it receives the infection by means of the circulating blood, in the same manner as the mother herself receives her secondary symp- toms; but, with regard to the saliva, semen, and milk, it is difficult to pronounce how far these se- cretions will serve as means for the transmission of the disease, till the power of the secondary symptoms in general to do so is better made out. The editor believes with Mr. Travers, that none of the natural secretions of a contaminated indi- vidual can communicate the disease to other per- sons. The following statement in this gentleman's work (Pathology of the Ven. Disease) is interest- ing : a man who has syp'hilis in the secondary form, provided he be free from all affections of the genitals, will communicate no taint to his progeny any more than to his wife; but a healthy wet-nurse, getting a sore nipple, in consequence of suckling a VTICA. [Cl. III.—Ord. IV. It is obvious, however, that in syphilis, as in various other diseases produced by the absorp- tion of a specific virus, different constitutions are differently affected, and that some are far more susceptible of the morbid action than oth- ers. In many instances it is received by simple contact alone, and through an unbroken skin. It is generally, perhaps, thus received in the ordinary course of connexion ; but still more evidently thus in other cases, and by other or- gans : for it has been very frequently caught by sucking the nipple of an infected wet-nurse ; by infected saliva communicated in kissing; by drinking out of a cup that has previously been used by a syphilitic patient (Reid, Diseases of the Army, &c.; Griiner, die Ven. Anst. durch gemeinschaff. Trinkge., Weissenfels, 1787); and it is said to have been produced by receiving infected breath, and lying in a bed which had been antecedently occupied by a person labour- ing under the disease (Horstius, opp. ii., p. 315): in some of which cases, however, it seems ne- cessary to suppose the existence of a cut or crack, or some other breach of surface in the skin, and particularly about the lips, with which the syphilitic virus must have come into union. And it is hence easy to conceive how much more readily it may be communicated by the insertion of an exotic tooth (Watson, Medical Transactions, vol. iii., p. 325), by bleeding or scarification with an infected lancet (Girlanner, die Venerischen Krankheilen, «&c, p. 165), or by the attendance of an infected midwife (Act. Nat. Cur., vol. vii., obs. 75; vol. ix., obs. 94),* who has sometimes given the complaint both to the mother and the child.! A very melancholy instance of infection is re- lated by Dr. Barry of Cork, communicated by a woman who was in the habit of drawing the pocky child, and having secondary symptoms, will communicate the disease to the foetus of which she may become pregnant. This, we see, is agree- able to the usually received opinions, that the blood will contaminate the embryo though all genital sores may be absent, and though the party cohabiting with the woman is actually beyond the sphere of the influence of the disease in her. As far as the present state of our knowledge of the subject reaches, we may conclude that the dis- ease is only communicable through the medium of a purulent fluid, and not an ordinary secretion, with the exception of the mode of its transmission to the foetus, which receives the infection through the circulation, and may therefore be regarded as under the same circumstances with respect to the secondary effects of the disorder as the mother her- self.—Ed. * In the Westphaelischer Anzeiger, a case is stated where leeches, having been applied to a syphilitic patient, and afterward to an infant, the latter was affected with lues.—D. ! The faith to be put in several of these alleged modes of infection must be regulated by the well- established fact, that the venereal disease cannot be communicated unless the infectious matter be directly applied and lodged upon some part of the body of the person who catches the disease. The communication of the disorder through respiration, or by sleeping in a bed in which a venereal patient has previously lain, would not generally be credited by surgeons of the present time.—Ed. Gbn. VII.—Spe. L] LUES S^i breasts of puerperal patients; and who, upon examination, was found to have chancres on the lips and roof of her mouth, probably caught from some impure person in the course of her voca- tion. From the numerous engagements of this woman, the disease had spread very widely ; and the rapidity of its progress was as striking as the manner of its communication. " The nip- ple," says Dr. Barry, "first became lightly in- flamed, which soon produced an excoriation, with a discharge of a thin liquor ; from whence red spreading pustules were dispersed round it and gradually spread over the breast, and, where the poison remained uncorrected, produced ul- cers. The pudenda soon after became inflamed, with a violent itching, which terminated in chancres that were attended with only a small discharge ; and in a short time after, pustules were spread over the whole body. It finished this course, with all these symptoms, in the space of three months. The disorder made a quick and rapid progress in those who first re- ceived it, they not being apt to suspect an infec- tion of this nature in their circumstances. The husbands of several had chancres, which quickly communicated the poison, and produced ulcers in the mouth, and red spreading pustules on the body. But some of them escaped, who had timely notice of the nature of the disease, before the pudenda were affected. Some infants re- ceived it from their mothers, and to the greatest part of them it was fatal."* * Edin. Med. Essays, vol. iii., art. xxi., p. 297. The real nature of the disease here spoken of is very ambiguous, and much doubt must be enter- tained respecting its syphilitic character; for, ac- cording to received opinions, it is not the ordinary course of the venereal disease to be communicated through the medium of any other secretion than the matter of a chancre, nor to attack the pudenda secondarily, after the infection has been originally communicated through some other quarter. Ac- cording to Mr. Hunter, the matter of secondary ve- nereal sores cannot impart the disease. However, it should be noticed, in opposition to the doctrine of the venereal disease being only communicable by the application of the matter of a chancre to the body of the person who catches the disease, that many cases are recorded of infants contracting the complaint, as was supposed, through the milk of infected nurses; and that other examples are related, in which most severe effects, resembling those of the worst forms of syphilis, have followed the transplantation of a tooth. In such instances, if the disease communicated were truly venereal, they were of course transmitted through the me- dium of the milk and the secretions of the mouth ; but it is not a view in which the editor places any confidence. Various statements in the writings of Mr. Evans and the late Dr. Hennen, tend also to prove that the matter of true chancre in one person does not always communicate to another individual a sore of the same character; that the common secretions of the genitals, in unclean fe- males, will cause in other persons who have con- nexion with them, sores of a very anomalous and infectious nature; and that several individuals who cohabit with a particular female that has, perhaps, merely a discharge, as ascertained by careful examination, may have, in one example, a true chancre; in a second, a superficial ulcer with elevated edges; in a third a clap, without any l'PHILIS. 96 Where a wet-nurse and the infant she suckles are both affected, and there is a doubt which has communicated it to the other, collateral cir- cumstances will assist us much : but where the one, as is usually the case, has constitutional symptoms, and the other only local, the former must have had the disease the longest, and con- sequently have been the source of contamina- tion.* Such, however, i6 the insusceptibility of some idiosyncrasies, that the matter of syphilis, like that of smallpox, seems to have no effect upon them, and they are proof against its activity. I once knew a young physician, who, finding him- self to be thus naturally protected, fearlessly, and for the sake of experiment, associated him- self with females in the rankest state of the dis- ease, and escaped in every instance. In like manner, Schenck (Obs., lib. vi., N. 21) gives us a case of an infant rendered syphilitic through a diseased father, while the mother remained un- affected ; and Mauriceau and other writers give cases of infants which have been fortunate enough to avoid infection, though born of syphi- litic mothers (Mauriceau, ii., p. 100, 377 ; Epft. Nat. Cur., cent, iii., iv., obs. 18); while Pallas asserts that the Ostiacks have a general immu- nity from the disease, under whatever form it offers itself.—(Reisen, iii., p. 50.) sore ; and in a fourth, no ulceration, discharge, nor any complaint whatever. These facts certainly tend to prove that the nature of the complaint may be very considerably modified by some inexplicable peculiarity, either in the constitutions of different individuals, or in the state of the parts to which the infectious matter is applied.—Ed. * The hereditary transmission of lues will hard- ly be questioned, even by the most skeptical; and linical practice might controvert the opinion of Mr. Travers, that none of the natural secretions of a contaminated individual can communicate the disease to other persons. We have good au- thority for stating the following case, which oc- curred in the practice of the late Dr. Post, of New- York. A gentleman, who deemed himself cured of syphilis, married : his child exhibited the dis- ease soon after birth, and imparted it to the wet- nurse, whose character was beyond suspicion; the wet-nurse infected another female who drew her breasts, in consequence of which she was treated by mercurials, and was subjected to a surgical op- eration for an affection of her upper lip. The vision of the wet-nurse was impaired by the dis- ease. In Dr. Hosack's Medical Essays, vol. ii., several cases are recorded of the communicability of syphilis to the foetus in utero. In speaking of the remarkable fact that Dr. Denman never saw a decided instance of a child born with venereal dis- ease, Dr. Francis remarks, " The diseased mother may affect the foetus while in utero ; the diseased infant may, by sucking, infect the nurse ; the in- fected nurse may, in turn, communicate the com- plaint to the infant suckling at her breast. All this has occurred where the organs of generation, both male and female, were unaffected." " I have had under my care three cases of the venereal disease communicated to the foetus in utero : two of these cases occurred where the genital system appeared in a perfectly sound state; in the other, there were ulcers of the labia and constitutional dis- ease."—See Francis's Denman, 3d edit., New- York.— D. 96 H^EMATICA. [Cl. III.—Ord. IV And, after all, the symptoms that character- ize the disease, as well in its first as its second stage, are at times so nearly approximated by those which are occasionally traced in the sec- ond species of this genus, syphiloid lues or spu- rious syphilis, that it is often extremely difficult to distinguish them, and we are obliged to enter minutely into the history of the case, in order to assist our decision. It was regarded by Mr. Hunter as a pathog- nomonic character of syphilis, firstly, that it never ceases spontaneously ; secondly, that it is uniform and progressive in its symptoms ; and thirdly, that it is only to be cured by mercury. And such were the doctrines of a few of his warmest advocates, almost down to the present time.* How far these characters may have applied to it on its first appearance in Europe, under the influence of European excitements, and when the general constitution of European nations was fresh to its virus; or how far such charac- ters may have descended to the middle of the last century, not long after which Mr. Hunter was so deeply engaged in drawing up those mas- terly views of this disease which he at length gave to the public in 1786, it maybe difficult to determine. But to maintain any one of these doctrines without much modification, and espe- cially as criteria of genuine syphilis in the pres- ent day, after the wide field of experiments which has been opened to us, both at home and abroad, would be the height of incredulity. For we have hundreds and perhaps thousands of proofs, that instead of " never ceasing sponta- neously," it has occasionally disappeared with- out any other care than that of cleanliness and a reducent diet; that instead of being uniform and progressive in its symptoms, it has occa- sionally retrograded, or disguised itself under a variety of peculiarities, according to the influ- ence of habit, climate, or idiosyncrasy; and that, instead of being only to be cured by mer- cury, various other modes of treatment have been quite as successful; while, in numerous cases, mercury has added to the virulence of the disorder, and introduced many of those very symptoms which have usually been regarded as indicative of its secondary stage. Insomuch that it has been almost as seriously made a question in France, whether there is any such disease as syphilis,! as it has been in our own country, whether there ever was such a disease as plague: the former being as much resolved into local uncleanliness or constitutional irrita- tion, as the latter has been into some modifica- tion of typhus with incidental influences. This, however, is to run from one extreme of opinion to another ; and all we can fairly collect from such a collision of facts and opinions, is a confirmation of the conjecture I have already * The late Mr. Rose had the merit of establish- ing more accurate views of the nature of this Pro- tean disorder, especially with regard to the points which are here specified.—Ed. ! See the anonymous but ingenious pamphlet, " Sur la Non-existence delaMaladie Venferienne," Paris, 8vo., 1811. ventured to throw out, that syphilis, like many other diseases, is capable of being greatly modi- fied by contingent or habitual concomitants, or that it has actually changed its character, and is in a progressive course of melioration. In truth, it is well known that Mr. Hunter him- self found at times the secondary symptoms of syphilis intractable to a mercurial course, and had the candour to acknowledge as much. Dr. Adams, indeed, with all his warmth of attach- ment to the Hunterian code of doctrines, has given an impressive case of this very kind, in which, in spite of the mercury, the disease car- ried its assault from the first to the second or- der of parts, by which is meant the bones. But then this anomaly is accounted for by their in- geniously telling us, that if a constitutional dis- position to the disease be formed, the mercury cannot cope with it till such disposition comes into action; which seems, as Mr. Guthrie has justly observed, to mean nothing more, in plain language, than that " the disease cannot be pre- vented in certain constitutions from running its own course, when it may at last be cured." Of all the profession, the medical officers of the British army seem to have been first im- pressed with the expediency of re-examining and revising the established doctrines upon the sub- ject before us, from having observed that mer- cury is little used in Southern Europe, especial- ly fn Spain and Portugal, and that syphilis is there suffered in a very considerable degree to take its natural course; or at most to be treated locally as ordinary sores, and constitu- tionally with only herbaceous diluents or diapho- retics ; while the primary symptoms evidently vanish under this simple remedial course, and secondary symptoms are at times not more com- mon than where mercury is had recourse to and solely depended upon. Mr. Rose, surgeon to the Coldstream regiment of guards, was deter- mined to put the question to a test, and upon such a scale as might lead to something of a decisive result. He forbore, in consequence, about the year 1815, to employ mercury for the cure of any case of syphilitic affection, or sus- pected to be such, among the soldiers of his own regiment; and soon sufficiently perceived, that though the cure did not advance so rapidly as under a judicious use of mercury, it nevertheless in every instance did advance ; that it was not more severely followed by secondary symptoms or a syphilitic dysthesy, than where mercury is trusted to as a specific ; and that, of course, it was without the risk of those mischiefs to the general health, which mercury is so well known to introduce where it disagrees with the consti- tution.* Having persevered in this mode of treatment, in his own opinion very successfully, for a pe- riod of nearly two years, he communicated its * Many facts tending to show that syphilis is curable without mercury, might be seen in the large work entitled the Aphrodisiacus of Lusitanus and others, edited by Boerhaave, and published more than a century ago. The voyages of Don Ulloa contain evidence of the kind influence of climate in this disease.—D. Gen. VII.—Spe. 1.] LUES SYPHILIS. 97 result to the public (Med. Chirurg. Trans., vol. viii., p. 349, 1817), with a long list of well-di- versified cases and observations that cannot fail to make an impression on every one who reads them. The experimental course laid down by Mr. Rose was soon adopted by others, and, on va- rious occasions, carried into establishments which afforded ample space for a satisfactory examination. It was tried in other battalions of the guards, as well in France as at home ; was introduced into the York Hospital at Chel- sea, and various other hospital establishments, as at Dover, Chatham, and Edinburgh. " From these hospitals," says Mr. Guthrie, " I have seen the reports of nearly four hundred cases which have been treated with the same result, as far as regards the cure of primary ulcers ; each ulcer appears to have run a certain" course, which, as to extent, was much the same as in one of the same appearance where mercury was supposed to be necessary, and, at an indefinite period of time, to have taken on a healing ac- tion, and, in the greater number of instances, skinned over rapidly, leaving a mark or depres- sion showing a loss of substance. With us, where the ulcer had the characteristic appear- ance of chancre, dry lint alone was generally applied to it. Where these signs were less prominent, a variety of applications were used. But there were a great number of sores, both raised and excavated, on which no application made the least favourable impression for many weeks. They did, however, yield at last to simple means, after remaining for a consider- able time nearly in the same state, several of them having become sores of a large size pre- vious to or in the first days of their admission. If they were ulcers without any marked appear- ance, and did not amend in the first fortnight or three weeks, they generally remained for five or seven weeks longer ; and the only difference, in this respect, between them and the raised ulcer of the prepuce was, that this often remained for a longer period, and that ulcers possessing the true characters of chancre required in general a still longer period for their cure, that is, from six or eight, to ten, twenty, and, in one case, to twenty-six weeks, healing up and ulcerating again on a hardened base. Those that required the greatest length of time had nothing partic- ular in their appearance that could lead us to distinguish them from others of the same kind that were healed in a shorter period. Neither were any of these ulcers followed by a greater number of buboes, nor did they suppurate more frequently than in the same number of cases treated by mercury. On the contrary, the ul- cers were not so frequently, on the average, fol- lowed by them, neither did they so often sup- purate. But this may also be attributed to the antiphlogistic means employed both generally and locally for their relief."—(Medico Chirurg. Trans., vol. viii., p. 557.)—And to this it may be added, that M. Cullerier, the first surgeon in the Venereal Hospital at Paris, has been for years in the habit of demonstrating to his pupils the possibility of curing every kind of ulcer that Vol. II.—G falls under his notice without mercury. He usually, indeed, has recourse to this medicine afterward, but for the mere purpose of guard- ing against secondary symptoms. It is very candidly admitted, however, by Mr. Guthrie, that although these experiments give the strongest proof of the possibility of curing venereal ulcers without mercury, yet that a much longer period of time is required for the cure. " I have every reason," says he, " to be certain, from former experience, that almost all these protracted cases would have been cured in one half or even one third of the time, if a moderate course of mercury had been resorted to after common applications had been found to fail." The result of this inquiry therefore should by no means induce us to relinquish the use of mercury as of specific influence in general prac- tice ; but it is of great importance as offering solid consolation to those who may be labouring under the disease with an idiosyncrasy or acri- tude of constitution that forbids the use of this specific, and converts it into a poison, instead of receiving it as a remedy. It is admitted, also, that the cases of second- ary symptoms occur more frequently in the cure of primary symptoms without mercury than where the last has been had recourse to. Upon the former plan of treatment, Mr. Guthrie cal- culates the secondary symptoms to occur about once in ten times ; in the latter, once in about fifty-five times. But it is singular that, in the former case, the secondary symptoms are for the most, part far milder than in the latter, the bones being rarely if ever affected. " Inso- much," says Mr. Guthrie, " that some of my friends, of great talents and experience, have been induced from this to suppose, that the greater severity of symptoms which are frequent- ly met with have been caused by the exhibition of mercury in the first instance, which aggrava- ted the constitutional disease." Mr. Guthrie, however, ascribes this more lenient show and course of the symptoms to the stricter antiphlo- gistic means resorted to in the simple than in the mercurial treatment, and endeavours to prove that mercury has no tendency to produce any such aggravation, except when injudiciously employed, or it does not harmonize with the idiosyncrasy, or actual state of the constitution. It has been asserted, indeed, that in Portu- gal, where, as we have already observed, mercu- ry is rarely hada recourse to, both the primary and the secondary appearances are much more virulent than in England, or under a course of mercury : that the local ulcers are far more apt to slough and become gangrenous, and to run into that encircling phagedaenic sore about the glans which has been vulgarly denominated black lion, and that a greater proportional num- ber of British soldiers, and even officers, suf- fered irremediable injury from syphilis during the Peninsular war than are in the habit of suf- fering in this degree at home. These facts have been especially noticed by Dr. Fergusson in a valuable paper on the subject (Med.-Chir. Trans., vol. iv.), and they are virtually admit- ted"by Mr. Guthrie, who, however, ascribes the 98 HJEMATICA. [Cl. III.—Obd. IV. malignity, m every instance, to the accidental circumstances of change of climate and intem- perance of habit, rather than to the absence of mercury. " I do not think," says he, " the dis- ease which the troops contracted in Portugal was in the slightest degree more violent than the same kind of complaint at home, neither do I place the least reliance on what has been said by others about a distemper called the black lion of Portugal, which I do not believe exists. But I perfectly coincide with him (Dr. Fergus- son) in opinion that the change from the climate of Great Britain to that of Portugal in the sum- mer, with the different mode of life, does act most powerfully on our northern constitutions, and disposes strongly to inflammatory affections. It is this that rendered the same kind of wounds more dangerous to the British soldiers than to the natives, and it was to this disposition, in- creased by the greatest irregularity of conduct and often by intemperance, a vice the natives are not addicted to, that we were indebted for the mutilations which ensued from the venereal disease." The following calculation of results seems to be a fair expression of the general facts, and, in the present state of the question, they are too important to be omitted. They comprise the conclusion of the same able writer's remarks upon the subject. 1. "Every kind of ulcer of the genitals, of whatever form or appearance, is curable without mercury. This I consider to be established as a fact, from the observations of more than five hundred cases which I am acquainted with, ex- clusive of those treated in the different regi- ments of guards, and which occurred in conse- quence of promiscuous intercourse. 2. " Secondary symptoms (and I exclude tri- fling pains, eruptions, or sore throats), that have disappeared in a few days, have seldom followed the cure of those ulcers without mercury, and they have, upon the whole, more frequently fol- lowed the raised ulcer of the prepuce, than the true characteristic chancre of syphilis affecting the glans penis. _• 3. "The secondary symptoms in the cases alluded to, amounting to one tenth of the whole, have hitherto been nearly confined to the first order of parts, that is, the bofes have in two instances only been attacked^ and they, have equally been cured without mercury. 4. "As great a length of tifne has elapsed in many of these cases without tr\f occurrence of secondary symptoms, as is considered satisfac- tory where mercury has been used, viz., from six to eighteen months. *^^r 5. " The primary sores were of everyTde-. scription, from the superficial ulcer of the pre- puce and glans to the raised ulcer of the pre- puce, the excavated ulcer of the glans, and the irritable and sloughing ulcer of these parts. In the inflam'matory stage, attended by itching, scabbing, and ulceration, they were treated, for the most part, by antiphlogistic and mild reme- dies ; in the latter stage, when the ulcers were indolent, whether raised or excavated, by gen- tle stimulants. 6. " The duration of these stages is very different, is often increased by caustic and irri- tating applications, and is much influenced by surgical discrimination in the local treatment. 7. " The last or indolent stage often contin- ues for a great length of time, especially in the excavated chancre and raised ulcer of the pre- And it appears to me that in these par- puce. ticular cases, a gentle course of mercury, so as slightly to affect the gums, will materially short- en the duration of it, although in, others it is occasionally of no service. 8. " Although the secondary symptoms do for the most part yield to simple remedies, such as venesection, sudorifics, the warm bath, sar- saparilla, &c, without much loss of time, that is, in the course of from one to four or six months, yet, as in the primary ulcers, a gentle course of mercury will frequently expedite, and in particular persons and states of constitution is necessary to effect a cure ; and that a repeti- tion of it will even in some cases be requisite, to render it permanent."* There is yet one singular feature which re- mains to be noticed before we close the history of syphilis, and which, so far as I know, has never yet been fully brought before the public eye, although established by many of the best reports in the possession of the Army Medical Board ; and that is, the great difference which exists in the facility with which syphilis, and, I may add, the affections that make a near ap- proach to it, as bastard syphilis and gonorrhoea, are propagated in the East, compared with theis propagation in the West Indies. These re- ports have been submitted to me by the friend- ship of the director general; and the chief conclusion I have been able to draw from them —and it is a conclusion that Dr. Gordon, who was kind enough to go over these reports with . me, has long since arrived at from the same documents—is, that every two regiments in the East Indies furnish, at least, as many cases of both genuine and doubtful syphilis, as are fur- nished by the whole army in the West Indies. But the following tables will give the reader an opportunity of calculating for himself, and will show that the difference is^sometimes much greater. The report from the (,whole of the West Indies for the .year 1823 is as follows :— Cases of syphilis unaccompanied with secondary symptoms Doubtful or bastard syphilisj Simple buboes - ' Annual number of. cases for the whole of the West Indies in 1823 16 15 5 36 Now, the report from the 1st oLjjoval regi- meftf?ralone, for the same year, stationed at Trincomalee, gives 177 cases of syphilis, with- outany subdivision into genuine and doubtful. In like manner, during a preceding year, while the 12th regiment of light dragoons furnished the following report— * Medico-Chir. Trans., vol. viii, p. 576. Also R. Carmichael's Essay on Venereal Diseases, and the Use and Abuses of Mercury in their Treat- ment, ed. 2, Lond., 1825.—Ed. Gkn. VII.—Spe. 1.] LUES SYPHILIS. 99 syphilis Secondary symptoms -Doubtful ulcerated penis - 44 - 6 - 5 Buboes - - - - 2 Cachexia syphiloidea -Gonorrhoea '- 7 - 26 Hernia humoralis - 15 105 the report for the same year from the whole of the West Indies, gives Cases of syphilis - . - 41 Buboes ... 29 Hernia humoralis - - 40 110 From the uncertainty which still prevails re- specting the specific nature of several of the above affections in the minds of many practi- tioners, they are returned as of a common fam- ily ; and however unscientific such an arrange- ment may be in itself, it at least enables us to draw a more satisfactory general conclusion, as showing that none of the forms of disease which, in the widest latitude of the term, can be referred to a syphilitic origin, are here kept back. I was, in effect, not a little surprised at find- ing how few reports respecting syphilis have been sent home from the West Indies, com- pared with those from the East, till Dr. Gordon convinced me, from the nature of those which have been received, of the difficulty of making out any such reports whatever in particular years ; and pointedly directed my attention to a remark in one of them, transmitted by Mr. Te- gart, a highly intelligent inspector of'hospitals at Barbadoes, as though offering an apology for the scantiness of his returns upon this subject. " One gentleman, Mr. Taylor, of much learn- ing, and great experience in this island, who has resided here nearly thirty years,.says that in that long period he has only seen two cases of primary disease. The fact is," continues Mr. Tegart, " that syphilis is almost unknown in this country :" alluding to the West Indies generally. To what then are we to ascribe the wonder- ful contrast presented to us in these two colo- nies of the same empire 1 Is syphilis regulated by some such law as that of plague, which, as we have already observed, seems incapable of existing iii' an atmospheric temperature above 80°, or much below 60° ; and hence has never been able to obtain a footing in Abyssinia or the south of Arabia, while it has rarely appeared earlier, as an epidemy, than June or July, in our own country 1 or is it affected by any other meteorological influence 1 The question is of no small moment: for if it be either the atmo- spherical temperature or temperament of the West Indies that produces so striking and ben- eficial an effect upon the specific poison of syph- ilis, it may be found that the "best asyfum we can provide, even for those who are actually la- bouring under the disease, and in its rankest form, is the same quarter: so that Barbadoes G2 and Jamaica may in process of time become as general a resort for syphilitic patients, as Ma- deira or the south of France for consumptive. Till we are further acquainted, however, with the cause and nature of these discrepances than we are at present, we must continue to provide for syphilis the best means of cure we may be able to do at home. And in pursuing this object it is not to be wondered at, from the observations already offered, that 'plans of very different kinds, and medicines of very different classes, should not only be had recourse to in our own day, but should have been adventured upon at all times, even when the disease may be supposed to have raged with a far greater de- gree of malignity than at present. From the number and repugnance even of those that have acquired any considerable de- gree of reputation, there is no small difficulty in reducing them to any thing like an intelligi- ble classification. Yet, upon the whole, we may observe that the medicines which have been chiefly had recourse to, or have been found most serviceable in curing syphilis or arresting its progress, are narcotics, diluent diaphoretics, diuretics, drastic purgatives, and those which introduce a large portion of oxygen into the system. Of the narcotics, recourse has been chiefly had to opium, conium, solanum, and belladonna, manifestly upon the principle of their being se- datives, and hence rendering the system inirri-i table to the syphilitic virus. This some of them accomplish in a very considerable and desirable degree; and particularly opium, which has been mostly trusted to, and tried upon a wider scale than any of the rest. It moderates and alleviates every symptom; and, from a cause not well ascertained, may be taken in very large doses with less inconvenience in syphilis than in almost any other disease. From its pallia- tive effects, it has been supposed by many prac- titioners capable of producing a radical cure ; and numerous histories to this purpose have been published by those whose judgments have been unduly prejudiced in its favour. On these histories it is not necessary to enlarge : they have been long before the world, and have call- ed forth other trials, which have not proved equally successful. Narcotics in general, and opium beyond the rest, add considerably to the efficacy of other means, and particularly of mercury ; but of themselves they are not com- petent to remove the complaint, and conse- quently are not to be depended upon.* The list of warm and diluent diaphoretics * As, from what has been said in the foregoing pages, every form of the venereal disease seems to admit of a spontaneous cure, without the specific influence of any medicine whatsdfrs%|the question about opium should rather relate to^its useful or injurious effects on the disease than "to- its power of curing it; and if the disorder will get well of itself when no opium is given, and will not do so when this medicine is exhibited, the conclusion must absolutely be that opium is injurious, and prevents the .cure. No doubt our author did not mean to maintain, this doctrine.—Ed. 100 H^MATICA. [Cl. Ill —Ord. IV. that have been employed as remedies in syphi- lid lis are very extensive ; but it may be sufficient to enumerate the following : mezereon, guaia- cum, sarsaparilla, saponaria, bardana, smilax, and one or two species of asclepias, or swallow- wort. All these are supposed to be serviceable by exciting a determination to the skin, and throw- ing off the syphilitic poison, as various other poisons are thrown off, from the surface; and in very warm climates many of them are said to operate a radical cure, though the statements to this effect are rarely such as we can depend upon. * They have all had their day, and the only one at present in much request is sarsaparilla, of the actual amount of whose virtues it is difficult to speak with precision. Like the lobelia syph- ilitica, or blue cardinal-flower, which is a pur- gative plant, it owes its earliest reputation to . the American tribes ; and when first imported into Europe by the Spaniards, about the year 1563, it had the character of being a specific for the venereal complaint. From being ex- tolled, however, too highly,—for it never ful- filled this character in the old world,—it has since sunk, like many other useful medicines, into a very unmerited contempt, insomuch that Dr. Cullen allows but eight lines to its history and qualities, in the course of which he tells us that if he were to consult his own experience he would not give it a place in the Materia Medica, as he has never found it an effectual medicine in syphilis or any other disease.— {Mat. Med., part ii., chap, v., p. 200.) The London College, however, have evinced a dif- ferent opinion, for they have adopted it under various forms: and Professor Thomson, of Edinburgh, has been so highly satisfied with its antisyphilitic powers, that he has for some years relinquished the use of mercury altogether, in favour of a mode of practice which consists chiefly in the employment of sarsaparilla.— (Edin. Med. and Surg. Journ., No. liii., p. 84.) Upon a very large scale, he has met with very great success ; though, like Mr. Rose, he can- didly acknowledges that the secondary symp- toms of the disease have required a longer time to be overcome under the new treatment than they would under a mercurial. There is also a much more powerful objection to its use; namely, that the secondary symp- toms are in many cases apt to return soon after the new treatment has been relinquished, or other symptoms not essentially different. The fair pretensions of sarsaparilla appear to be those of a mild stimulant and diaphoretic. It is hence in many cases a useful auxiliary to mercury : * Now, however, that the curableness of the ve- nereal disease without any medicine, or with only such as are Quite inert, and destitute of any spe- cific power, is considered to be an established fact, the doubts here expressed concerning the subsi- dence and effectual dispersion of venereal com- plaints under a course of warm diaphoretic medi- cines, are quite inconsistent with the view which the author has taken of what was made out by Mr. Rose's investigations.—Ed. bat I have chiefly found it succeed in chronic cases, where the constitution has been broken down, perhaps equally, beneath a long domina- tion of the disease, and a protracted and appa- rently inefficient mercurial process. In con- nexion with a milk diet and country air, and with a total abandonment of mercury, I have here often found it of essential importance, and have seen an incipient hectic fall before a free use of it in a week. Its best form is the old one of the decoction of the woods, of which three or four pints should be taken daily. In France the same plan has been long in general use, and has been found equally success- ful. On account of the dearness of sarsaparilla, when genuine, M. Etienne Sainte-Marie has been induced to try the carex arenatia, or German sarsaparilla of our old dispensatories, as Gled- itch of Berlin had done before him ; and though he does not, like Gleditch, regard it as more ef- ficacious, he affirms, after employing it for ten years, that it is at least of equal value.—(Mith. pour guirir les Mai. Ven. invit., &c, Paris, 1818.) The syphilitic poison has also been often at- tempted to be thrown out of the body by exciting the excretories of some other organ than those of the skin, or in conjunction with them. Thus the flammula Jovis, or upright traveller's joy, the clematis recta of Linnaeus, which acts pow- erfully both on the surface and on the kidneys, is said to have been employed with great advan- tage, and was at one time in high and extensive estimation. It was given in the form of an in- fusion of the leaves ; and Dr. Stoerck, with his usual liberality, assigns it an extravagant praise, informing us that it effectually subdues all the secondary symptoms of inveterate headaches, bone-pains, nodes, ulcerations of the throat, and cutaneous eruptions.—(Libell. quo demonstr. herb. vet. diet, flamm. Jovis posse tutd exhiberi, Vienna, 1769.) The lobelia syphilitica of the American In- dians has a still fairer claim to notice. It is a drastic purgative, uniting something of the stim- ulant and narcotic powers of tobacco, to which it has some resemblance in its taste. In the simple life and inirritating diet of the American tribes, it is possible that it may have proved as successful as it is stated to have been; but it has completely failed in Europe.* Of the antisyphilitics whose influence seems to depend on their being loaded with pxygen, the principal are the mineral acids and the metallic oxydes. Of the first, the nitric has chiefly been made a subject of experiment in our own country, though the sulphuric has been employed abroad. —(Crato., epist. v., p. 293.) Its general ef- fects are, as we might expect them to be, tonic and sedative ; whence the appetite is increased, a greater rigidity or firmness is given to the liv- • \-nCCOr??g lu th,e ^St luformation, the lobelia is still used by the Indians. The ravages of this disease among them, however, have recently led them to employ mercury. Barton savs Aw Mat. Med ), that the antisyphilitic powers of lobe I ha are no longer credited.—D. Gsn. VII.—Spe. 1 ] LUES SYPHILIS. 101 ing fibre, and a greater density to the coagulable lymph: the action of the bowels, and even of the bladder, being diminished. Besides these, it has a particular effect on the mouth, approach- ing to that of ptyalism, for the gums are ren- dered slightly sore, the mouth and tongue be- come moist, and in India and other warm cli- mates a real salivation is said to ensue. Under this change, the syphilitic symptoms assume a better appearance, and especially those that be- long to the primary set; but we have no deci- ded case in which a perfect cure has been ac- complished in our own country,* though Dr. Scott affirms that in India this has been com- mon. The acid he was in the habit of employ- ing was a direct aqua regia, as already noticed in the treatment of jaundice (Cl. I., Ord. II., Gen. I., p. 205.;) and with the internal use of this he combined that of the acid bath, as there also particularly specified. His object was to effect a cure without incurring any of the evils so fre- quent upon a mercurial course ; and to this ob- ject the proposed plan has, in his opinion, given complete success. It would have been happy for the world if this success had been perma- nent and universal; but the plan has since fallen in its reputation, not much less in India than in Europe. The metallic oxydes have offered a large field for experiment; and almost all the metals have been had recourse to in rotation, as cop- per, iron, antimony, mercury, arsenic, and even gold. The pretensions of arsenic are certainly con- siderable : it forms the ordinary medicine em- ployed in syphilis by the cabirajahs or native Indian physicians, who depend upon it as a spe- cific. They give it in the form of white arse- nic, in combination with black pepper, as we shall notice more at large when treating of ele- phantiasis, for which also it is esteemed a pow- erful remedy. The only auxiliary is a cathartic ef manna dissolved in a decoction of nymphaa Nelumbo. Of the effects of any of the preparations of gold, we know but little. Many of" them were in high repute formerly as a cure for various cachexies, and are said to have been used with success in syphilis.—(Agricola, Comment, in Pappium, Num., 1643.) They have since been tried in France,! and also in this country.} Antimony, and perhaps a few other metals, are useful auxiliaries: but, in fact, the only * As syphilis in most of its forms, if not all, has been fully proved to admit of a spontaneous cure, we should be obliged to suppose the nitric acid to be not only useless, but an impediment to the cure, if our author's statement were substantially true. This is not, however, suspected ; nor can there be any foundation for the suspicion, while Mr. Rose's facts continue to dispel various prejudices concern- ing the incurable nature of the disease without the aid of mercury.—Ed. ! See the Report of A. S. Duportal, M. D., and Th. Pelletier, Apoth. Annates de Chimie, torn. Ixxviii., p. 38. Delpech, Chir. Clin.,4to., 1823. ± See a paper by Mr. R. D. Forster, on the Em- ployment of the Chloride of Gold and Soda in Syphilis, published in Lancet for Feb., 1834.—Ed. metal, and I may add the only medicine, on which we can confidently rely for a general cure of syphilis in all its stages, in our own climate, is mercury.* This has been tried from an early period in almost every variety of preparation ; and, pro- vided a sufficiency of it is introduced into the system, in every variety it has been found to succeed ; so that, in the present day, the pecu- liar form is regarded of less importance than on its first use ; though we may observe, that it seems to be most rapidly efficacious in those forms that introduce the largest proportion of oxygen into the system. And as it operates chiefly, like most other medicines, through the medium of the circulation, when it once becomes mixed with the current of the blood, it is equally efficient in the cure of a recent chancre and a chronic ulceration of the throat. Mercury is a universal stimulant, and in- creases the action of all the secretories at one and the same time ; for it operates simultane- ously on the intestines, the skin, the salivary glands, and even the bladder ; though it displays itself chiefly by ita action on the salivary glands. It has also, when given in moderate doses, con- siderable pretensions to a tonic power, though this is overwhelmed by its stimulant effects when the dose is considerably increased. It seems, therefore, to unite most of the virtues of the preceding remedies, excepting the seda- tive ; and hence it is greatly improved by the addition of opium and camphire, which give it the quality it stands in need of. Independently, however, of its combining in itself many of the virtues of the preceding rem- edies, mercury seems also to possess some spe- cific virtue unknown to the rest; for we can as- sociate all the general qualities by a combina- tion of different medicines without producing the same result. Mercury, indeed, to these gen- eral qualities adds that of peculiarly stimulating the salivary glands, which the other remedies employed in syphilis do not at all, or never in an equal degree ; but that its specific power as an antidote does not depend upon its being a sialagogue is clear, because, while it has some- times excited salivation without effect, it has at other times produced a perfect cure without any salivation whatever; for, in some idiosyn- crasies, the salivary glands are not affected by its irritation. Dr. Cullen, however, who had a mortal aver- sion to considering any medicine in the charac- ter of a specific, denies that mercury is a spe- cific in syphilis, as he does also that it is an an- tidote to the disease. It is in vain to point out to him its specific influence upon the salivary glands, or its specific action upon the mouth; * The preparations of gold and platina have been tried with perseverance by M. Cullerier, but without success. They are difficult to manage on account of their activity, and also of the fa- cility with which they are decomposed. In this country, too, results have not warranted the reliance placed on them by Chrestien.—See Eb- erle's Am. Med. Review, vol. i.; also Dyckman's edition of the Edinburgh Dispensatory.—D. 102 H^EMATICA. [Cl. III.—Ord. IV. he denies the whole, and contends that mercury might travel, and perhaps would travel for ever in some other direction, were it not for the friendly interposition of the ammoniacal salts of the blood, which he fancies to have a close af- finity with mercury, as he supposes they have also with the salivary glands ; in consequence of which, they take the mercury by the hand, and introduce the one stranger to the other (Mat. Med., part ii.,, chap, xvii., p. 443-450); thus solving the difficulty like divinity in the catas- trophe of a drama. The result of the whole, in the opinion of Dr. Cullen, is, that mercury cures the venereal disease, not by producing any change in the state of the fluids, but entirely by giving a stimulus to the excretories at large, by whatever contrivance it reaches them, and thus increasing the excretions, and washing out the poison from the body. That It does this is highly probable ; but this alone is not sufficient, for fresh poison is con- tinually forming by the process of assimilation, or the conversion of some part of the fluids it comes in contact with into its own nature ; since, if it were not so, and the minute drop of virus that excited the disease at first remained without any increment, there.can be no question that such a general scouring of the system would be unne- cessary, and tha^the ordinary evacuations would be sufficient to throw it off. And hence we have not only to carry away the poison that is actually present in the vessels, but to prevent the formation of new. Now it is in this power of prevention that the specific virtue of mercury seems to consist; and this it is that renders it paramount to all other remedies in the cure of syphilis. It is not only an evacuant, but an antidote : for, as we have already seen, it quickens the action of other re- medial means when united with them, and far more speedily effects a cure even by itself than any of them. By what means, however, it be- comes an antidote, or exerts its specific power, we know not. The matter of a chancre, mixed up with a quantity of Plenck's gummy solution of mercury, has been applied to a sound person without occasioning either a chancre or any other syphilitic symptoms. And it has hence been supposed that mercury neutralizes the syph- ilitic virus, and produces a third and harmless substance ; as it has been further supposed, that it is by the disengagement of the oxygen which the various preparations of mercury introduce into the system, that this effect is accomplished. All this is ingenious, and may be true ; but the evidence does not come home to the conclusion. Even the experiment with chancrous matter and the mercurial solution has not been satisfactorily performed; and if the result were as here stated, the matter, while it has no power of assimilating the solution into its own nature, as it has the fluids of the human body, may only have been rendered inert by simple dilution. [Instead of these chymical hypotheses, the be- lief most commonly adopted by modern practi- tioners is, that mercury excites a new and pecu- liar action in the system, whereby the syphilitic action is destroyed. This, however, is only a theory ; and though it originated with Mr. Hunt- er, it should be regarded rather as an attempt- ed than a well-proved explanation of the modus operandi of mercury.] We have said that, provided a sufficient quan- tity of mercury be introduced into the system, the particular preparation is of no great impor- tance. Van Swieten preferred the oxymuriate, and every one followed his example. The cal- cinated mercury came next into popularity, and triumphed over every other form. It was the leading article of most of the secret remedies that were sold for the complaint, and especially of Keyser's pills ; the receipt for which was pur- chased with great formality by the French gov- ernment, with an express provision not to make it public till the inventor's death.* These pills, however, which consisted of nothing more than mercury calcined by needlessly operose elabo- ration and mixed up with manna, were found in many cases to irritate the bowels, even when uni- ted with aromatics and opiates ; and hence they gradually yielded on the continent to Plenck's solution, which still holds a considerable sway. In our own country it is now most usual to employ the mercurial pill, or calomel, either alone or together with mercurial ointment. Yet, whatever plan is preferred, much caution is ne- cessary in carrying it into effect; for the older practitioners, who employed larger doses, fre- quently did as much mischief to the constitution by the antidote as it had received by the infec- tion. If calomel be employed, about two grains a day will commonly be found sufficient, guard- ed when necessary by a grain of opium ; and if the ointment be preferred, half a drachm of the strong mercurial ointment may be rubbed in night and morning. If the disease be not se- vere or of long standing, it will not be necessa- ry, with a little management, to produce saliva- tion, which in most instances may be regarded only as a test that the system is thoroughly im- pregnated with the medicine ; but, in chronic cases, we ought not to be satisfied without it. In the course of the present work—and the observation is applicable to other doctrines than those of medicine—we have often seen that ex- tremes lead to extremes: and hence, while many practitioners have been reviving the at- tempt to cure syphilis entirely without mercury, others have revived that of attacking it with very large doses. The last has chiefly been confined to those who have been employed in warm climates, and been friendly to the same practice in dysentery and yellow fever. In syphilis, however, they seem to have been some- what more successful than in the other diseases, doubtless from the more decidedly specific in- fluence of mercury over the former. The dose, with these gentlemen, is the usual one of a scruple, which in our own climate is repeated daily for three or four days in succession; but in warmer climates, four or even five times in u • i?a P"Pe8» .ou f^ules de M. Keyser, par Richard de Hautesierck. Recueil d'Observations Je Medecine desHopitaux Militaires, &c , Paris, Gun. VII.-Spe. 2.] LUES SYPHILODES. 103 twenty-four hours. In various cases the effects on the stomach and bowels are severe, and in all cases a considerable degree of nausea is ex- cited, and the appetite is entirely suppressed. But, upon the whole, the bowels and general system are for the most part less affected than might be supposed ; ptyalism is often excited in two or three days, and a constitutional improve- ment speedily shows itself. So that, Where the treatment does not disagree with the idiosyn- crasy, the cure is rapid and perhaps radical; the individual being usually set at liberty in a fort- night or three weeks.* But such a practice must not be attempted indiscriminately, and should indeed be used with great caution : for it has fallen to the author's lot to know of not a few instances, in which the constitution has been so completely broken down by the very onset of this energetic plan, as to require not two or three weeks, but many months, before the patient was re-enabled to take his station in society ; to say nothing of the virulence which has been added to all the symptoms of the case, whether prima- ry or secondary, in dyscrasies or idiosyncrasies which are hostile to the use of mercury. There can be no doubt, indeed, that a long perseverance even in small doses, under like circumstances, will not unfrequently produce as lamentable an effect. But, in this case, we can hold our hand much more easily on the first appearance of mis- chief. In all cases of the use of mercury, but partic- ularly in cases of salivation, care should be taken to avoid cold, and flannel should be worn next the skin. It is also of importance that the diet should be light and simple, as the pulse is usually accelerated, and, by a stimulating regi- men, would be so much quickened as to do se- rious mischief. Mr. Hunter lays no stress on this point, but it ought by no means to be neg- lected. If a bubo have formed in the groin, the mer- curial ointment is best rubbed in a little below it, as it would increase the inflammation if ap- plied to the tumour itself. In about a week or ten days the mouth will become slightly sore, when the further use and proportion of the oint- ment or other preparation must be regarded by the violence or duration of the complaint. An injudicious use of mercury, or indeed any use of it in highly irritable habits, will some- times excite a very troublesome erythema, that spreads itself in trails or patches over the whole surface ; commonly, however, commencing about the genitals and lower limbs. It is accompanied with a painful tenderness and itching of the skin, and as the erythema meanders onward, the trails or patches first observed heal as new ones make their appearance. We have already glan- ced at this affection under the vesicular species of erythema. Mercury must in this case be desisted from, the bowels be loosened with some gentle aperient, and the irritability opposed by * Dr. S. A. Cartwright of Mississippi has em- ployed calomel in this manner in many cases of syphilis, where small doses of mercury had been used without success.—See his Essay on Syphilis in the Am. Med. Recorder, vol. viii.—D. sedative and mild cardiacs, as camphire, guaia- cum, and sarsaparilla ; and particularly by the mineral acids.* SPECIES II. LUES SYPHILODES. BASTARD-POX. the generic ulcers indeterminate in their characters ; symptoms irregular in their appearance; usually yielding spontane- ously ; variously affected by a course of mercury. I have already observed, at the opening of the present genus, that the species before us is de- signed to include a multiplicity of affections, which, in many of their signs, have a close re- semblance to syphilis, but differ from it in the progress of the symptoms, as well as in the means that are necessary for a cure.! Such affections are of high antiquity, far higher, indeed, than those of syphilis, and some of them appear to be glanced at in the sacred records. A few of them may perhaps have arisen in much later times, and may be arising at present.— (Pearson, Obs. on the Effects of var. art. of the Mat. Med. in the Cure of L. Ven., 2d ed., p. 53.) By Celsus the subject is touched upon scientifi- cally : it has been taken up in modern times by Mr. Hunter with that spirit of inquiry which pe- culiarly distinguished him, and has since been pursued by Mr. Abernethy (Surg. Obs. on Dis. resemb. Syphilis, Lond., 1810), Mr. Carmichael, and various other surgeons and physiologists, with a kindred comprehension and genius : and the track which they have traced out in Eng- land is precisely parallel with the march which M. Etienne Sainte-Marie has of late yeaTs pur- sued in France, conceiving himself, according to his own account, to have been the original dis- coverer of these distinctions ; which is the more extraordinary, since this writer, as we have al- ready had occasion to observe, believes in the exploded doctrine of the identity of syphilis, and what is commonly called gonorrhoea.—(Milh. pour guirir les Mai. Ven., &c, Paris, 1818.) The subject, however, is still in its embryo. Mr. Hunter considered his own remarks rather as hints for others to prosecute than as a com- * In the U. States, syphilis is generally treated by mercurials; and although some practitioners believe that it can be cured without this class of medicines, but very few have adopted the non- mercurial practice. The preparations of mercu- ry most used are calomel, blue-pill, and corrosive sublimate. The latter remedy, notwithstanding the violent opposition of Mr. John Pearson of the Lock Hospital, London, is too well known, and has proved too efficacious, to be invalidated even by him. An able view of the Medical History and Curative Action of Mercury, by Dr. J. W. Francis, will be found in the Am. Med. and Phil. Register, vols. iii. and iv.—D. ! Many of these cases would be arranged by Mr. Wallace as degenerations of syphilis.—See his Treatise on the Venereal Disease and its Va- rieties, p. 60, where he enters into the considera- tion of what he terms the " degenerations of pri- mary syphilis."—Ed. 104 H^EMATICA. [Cl. III.—Ord. IV. plete account of it. And though Mr. Abernethy has accumulated facts and cases, and ably illus- trated them with observations that sufficiently establish these hints, and give something of a body to the outline, we are still in want, as we have already seen, of distinctive characters, and cannot determine with any degree of accuracy, whether the wide group of complaints that fall within the present range of contemplation are mere varieties of a common species produced by a common poison, or distinct species dependant upon distinct poisons, as discriminable from each other as all of them are from proper syphilis. Under the last species, we had occasion to notice Mr. Hunter's pathognomonic criteria of genuine syphilis : first, that it never ceases spon- taneously ; secondly, that it is uniform and pro- gressive in its symptoms ; and thirdly, that it is only to be cured by mercury. Could this view of the disease be strictly sup- ported, we should have a tolerably distinctive character by which to discriminate the prece- ding from the present species ; but sufficient proof has been offered, that not one of the three points holds good with a considerable degree of modification, whether in respect to the primary or secondary symptoms of these maladies. Very ingenious attempts have since been made to distinguish these diseases, not by their general march and mode of cure, but by their immediate and prominent signs ; that of the true syphilitic chancre in the first stage, and those of the peculiar nature of the spots, the nodes, or the ulcers, in the second. But the close ap- proach to syphilis, at times, of misaffections, whose history, when minutely investigated, has clearly proved them to have issued from other sources than syphilis, has in a great measure levelled all such landmarks, and nearly left us in extreme cases without a clew. It is after all, therefore, rather from the gen- eral history of the different examples in all their bearings, than from the individual symptoms, that we can alone arrive at any sound or satis- ' factory means of referring them to a syphilitic or a different origin. If we can strictly rely upon the assertion, or know, as a fact, that there has been no impure connexion; if we cannot perceive that there has been any primary ulcer; if we find that the symptoms, whether primary or second- ary, readily give way spontaneously, or by other remedies than mercury; or if we have proof from the first that they are exasperated by this last medicine, whatever be the approximation of such symptoms to those of genuine syphilis, we may rest pretty well assured that the disease is syph- iloid, rather than syphilitic lues. In the first case, indeed, unquestionably so, and nearly unques- tionably so in the second and third. It is well known that constitutional derange- ment, in an irritable habit or idiosyncrasy, will often follow from other local causes of various kinds, and often from what is ordinarily of very slight import. It is hence that the general health in some persons suffers from such cuta- neous eruptions as rose-rash, herpes, or itch. Gonorrhoea has perhaps at times, as we have already remarked, affected the constitution in like manner, and even thrown over the skin spots that have been mistaken for those of genuine syphilis. And there is hence reason for believing, that even an incidental and un- specific irritation of the prepuce or the glans may, in the same way, occasionally so far simu- late the march of the same disease, as to ex- hibit a very close semblance to the raised ulcer, or the excavated chancre, or even the phage- daenic slough ; or, passing by these first symp- toms, that it may mimic as closely those of the second stage of the disease. And as it is now pretty generally admitted on all hands, that morbid and irritative secretions of various kinds, independently of those of syphilis or even gonor- rhea, are thrown forth and accumulate in the sexual organs of contact, we can trace a variety of sources of both local and constitutional affec- tion, which, issuing from the same seat, may assume something of a family character ; to say nothing of those more wonderful resemblances of the secondary symptoms of syphilis which have sometimes been found to occur without any previous local contagion, and in the most unspotted purity of single life. A consideration, therefore, of such diseases, or varieties of diseases, as are thus found to approximate the general character of syphilis, though issuing from sources widely distinct, and possessing, in the midst of such approximation, a few discriminative marks, perhaps at all times, and under all circumstances, however they may hitherto have eluded the prying eye of the pa- thologist, is evidently called for, and it is the object of the present subdivision to imbody them, as far as the footsteps of observation will at present allow. We have thus far, however, followed them into their extremes, in which alone their symp- toms appear merged in those of syphilis ; for, in the greater number of cases, a distinction is not very difficult, either in the local or the constitu- tional attack. In illustration of these remarks I might refer to the observations of those who have been at- tentive to the subject on a large scale, but I refer more particularly to the collection of cases which Mr. Abernethy has printed in the work already alluded to. The disease ordinarily commences with local symptoms, though not always; but the local symptoms have a less resemblance to those of genuine syphilis than the constitutional by which they are succeeded. A few foul and highly irri- table sores are unexpectedly discovered on the genitals, commonly larger than chancres, and less thickened and indurated, about the size of a sixpence, and frequently sprouting with fungous granulations. Rarely, but very rarely, they have the guise of a true chancre ; so rarely, in- deed, that of the twenty cases contained in Mr. Abernethy's book, the fifth is the only one that answers to this description. These are some- times succeeded by buboes and sometimes not. And where buboes take the lead, they run their course more rapidly, and with more violent inflammation, than in the true disease and spread to a greater number of circumjacent Gen. VR-Spe. 2.] LUES SYPHILODES. 105 glands. These mostly, if not always, heal by the ordinary means without mercury, or consti- tutional symptoms of any kind. But, not un- frequently, in a few weeks or months, they are followed by a soreness and ulceration of the tonsils, copper-coloured spots over the body, and nodes or swellings of the periosteum in various bones ; and sometimes these symptoms change their order of succession, or appear single. In a few instances the constitutional symp- toms take the lead and the local follow, of which Mr. Abernethy's fourth case affords an example. The patient here perceived first of all a small ulcer on the breast near the nipple, after having suckled a nurse-child about four months. It was of the size and shape of an almond, and was ascribed to the child's having a sore nose and lips. A gland in the axilla soon swelled and subsided, but, in about two months, the patient had a severe febrile attack, accompanied with a sore throat; from this she soon recovered, but had shortly afterward a copper-coloured eruption scattered over the body, and upon the disappearance of this, white blisters about the pudenda, which gave her pain in walking. About a week afterward her husband found a sore on the penis, covered by a black scab, of about the size of a sixpence, with a base neither hard nor thick, but with the surrounding skin much in- flamed. Another formed in the course of the lymphatics towards the groin; the inguinal glands enlarged, and one of them suppurated; and an eruption of a papulous erythema, ushered by a few febrile symptoms, followed in about three weeks. The sores were twice touched with lunar caustic, and, as well as the bubo, were afterward washed with calomel in lime- water : they gradually healed. Both patients recovered, the wife with little assistance from mercury, having taken only a few compound calomel pills with small doses of nitric acid; the husband without mercury altogether, except that a dose of calomel was once administered with other aperient drugs as a purge.* * These cases resemble some others quoted by the author under the preceding species as syphi- litic ; but against which inference the editor has mentioned a few considerations which occurred to him at the time of reading them. With regard also to the present examples, set down as syphi- loid, the conclusion that they were not venereal cannot be maintained by the mere fact that they got well with little or no mercury, for, as already explained, all forms of the venereal disease are generally curable without mercury, though this often accomplishes the cure with greater expedi- tion, and diminishes the frequency of secondary symptoms. When we read in Mr. Abernethy's Observations on Diseases resembling Syphilis, p. 44, that " the fictitious disease, in appearance, so exactly resembles syphilis, that no observation, however acute, seems to be capable of deciding on its nature ;" and when we find him admitting, at p. 54, that all his reasoning is founded " upon the presumption that diseases which sponta- neously get well are not syphilitic," we are com- pelled, in the present more accurate state of our Knowledge upon the latter point, to confess that Mr. Abernethy completely failed in making out In all these cases we meet with a virus that seems to be more active and irritating than that of genuine syphilis, but which, while it pur- sues, though with much irregularity, the same general path, runs through its course much more quickly, and is more effectually coped with by the natural strength or remedial instinct of the constitution. And hence, all that we are here called upon to do in the way of treatment is to support the general vigour and second the instinctive effort. This is best to be accom- plished by tonics and gentle stimulants, and, where necessary, by sedatives. The mineral acids are the best means of supplying the first intention; camphire, the decoction of the woods, and the compound calomel pill, where small doses of mercury do not irritate, the second; and opium the third, though to this last it will rarely be necessary to have recourse at all. The distinction between these affections and genuine syphilis is frequently difficult, but of importance ; since, as a full use of mercury seldom seems to do good, and often does seri- ous mischief in the former, such a plan has a chance of overwhelming the constitution with a second disorder instead of freeing it from a first. To this family of maladies we are probably to refer the disease which, for a century or two, has been known in Scotland by the name of sibbens, or sivens, literally rubula, or raspberry eruption, and which seems to be a variety of lues, rendered hybrid by passing through a con- stitution already contaminated with genuine rubula or yaws.* The local symptoms have a much nearer resemblance to those of bastard- pox than of genuine syphilis, but in its consti- tutional progress, after the ordinary affection of the fauces, the disease has a tendency to throw forth over the surface an eruption of tubercles, which speedily degenerate into fungous ulcers resembling yaws, rather than an eruption of copper-coloured spots; which tubercles some- times show themselves also in the throat itself. The constitutional disease spends itself chiefly on the surface, and the bones are rarely affected. With these exceptions we may agree with Dr. Gilchrist (Account of a very infectious Distem- per, &c.) and Mr. Hill, of Dumfries (Cases in Surgery), that it has not a symptom which does any peculiarities in his cases to justify their being denominated pseudo-syphilitic. When we are told of a disease being exactly like syphilis in appear- ance, we ought first to be informed what is the precise appearance of syphilis itself; for it presents itself in so many shapes, and has so many varie- ties, or degenerations, as Mr. Wallace terms them, that they form a very obscure and complex sub- ject. Frequently no judgment of any value can be given about the nature of a sore, suspected to be venereal, merely from the look of it, without any reference to other particulars in the history of the case. On this point there are some inter- esting remarks in Mr. Wallace's Treatise on the Venereal Disease, p. 84, et seq.—Ed. * Some few cases of sibbens occurred in 1819-20 among the ditchers employed on the grand canal between lake Erie and the Hudson. The per- sons affected were last from Canada, and were natives of Scotland or Ireland.—D. 106 ILEMATICA. [Cl. III.—Ord. IV. not accompany the lues venerea (meaning syphilis) through all Europe; that both are equally infectious ; both only communicated by sexual intercourse or other familiar contact; and both beneficially treated by mercury, which, they affirm, is the only remedy to be depended on. Mr. Hill tells us that it was introduced into the vicinity of Dumfries about the year 1772, "by some pocky soldiers, who, to pre- vent their debauching in town, were disposed through the neighbouring villages." Even upon liis own showing, however, a much looser and blander exhibition of mercury than is sufficient for the cure of a confirmed syphilis,* will effect this in sibbens; for he adds, that " by the em- ployment of a mild preparation of this metal he has cured numbers without confining them to their houses, even in frosty or snowy weather." It is probable, therefore, that sibbens might be eradicated by other means as well; but these gentlemen, notwithstanding the peculiarity of many of its- symptoms, regarded it as a genuine syphilis, and, in consequence, did not direct their attention to any other mode of treatment.! GENUS VIII. ELEPHANTIASIS. ELEPHANT-SKIN. SKIN THICK, LIVID, RUGOSE, TUBERCULATE ; INSENSIBLE TO FEELING ; EYES FIERCE AND STARING; PERSPIRATION HIGHLY OFFENSIVE. The Greeks denominated this disease ele- phas, or elephantiasis, because the skin of persons affected with it resembles that of the elephant in thickness, ruggedness, insensibility, and dark hue. Thus applied, therefore, the term imports elephant-skin, in the same manner as the same national school denominated dan- druff pityriasis, or bran-skin, from the skin, under this disease, resembling branny scales ; and an- other sort of scaly malady, ichthyiasis, or fish- skin, from the resemblance of the skin when thus affected to the scales of fishes. There are, however, two diseases of a very different kind, which occur in the translations of the Greek and Arabic writers under the name of elephas, elephantia, or elephantiasis; that im- mediately before us, and the thick leg of Bar- badoes and other hot climates : and as the for- mer of these has also, by many of the Arabian writers, been called lepra, or leprosy, and espe- cially black leprosy, though as distinct from genuine leprosy as it is from the thick leg ; and as the common term lepra has been continued * When it is recollected that the venereal dis- ease does not absolutely require mercury for its cure, but may be cured without it, the criterion here adverted to must be extremely fallacious —Ed. ! In the treatment of syphiloid affections, and in cases where mercury, through injurious man- agement or peculiarity of constitution, has proved detrimental, Plummer's pill will be found an effec- tual alterative. Carmichael's Essays on the Ve- nereal Disease contain satisfactory evidence of the valuable properties of antimonials in managing syphiloid disorders.—D. in the translations of such writers, and copied from them by writers of our own times, an almost impenetrable confusion has been thrown around the whole of these diseases ; and they have, even by modern writers, been strangely huddled together, and contemplated as mere modifications of one and the same malady, or as having some other connexion which does not in reality exist. My attention was particularly called to this subject several years ago by an application from Dr. Bateman, who was then preparing his work on Cutaneous Diseases for the press, to assist him in unravelling it from the thorny maze in which it was at that time enveloped ; and as the following letter from him, written in conse- quence of my acceding to his request, shows the real difficulty of the case, and is highly creditable to the activity of his mind, the reader will be obliged to me for introducing it. " In order to give you the least trouble pos- sible in the research which you were good enough to promise to make for me this morning, I wish to state, in a few words, the object of my inquiry. I believe the proper tubercular elephan- tiasis of the Greeks was called juzam or alju- zamby the old Arabians (dsjuddam and madsjud- dam by the moderns, according to Niebuhr.)— (See Avicen., quart, iii., or lib. iii., fen. hi., tract. iii., cap. i.) " If so, do the other Arabian writers also designate the proper elephantiasis by the same appellation 1—For instance, is it used by Haly Abbas 1* " Again, what is the Arabic term applied to the thick leg (which most of the translators call elephantiasis, but which the translator of Haly Abbas calls elephas, thus distinguishing it from elephantia)?—The thick leg is described by Haly Abbas (Theorice, lib. viii., cap. xviii.), by Avicen (Lib. ii., fen. xxii., tract, i., cap. xvi. or xviii.), by Rhazes (Ad Almanzor, lib. ix., cap. xciii.), and by Avinzoar.—(Lib. ii., cap. xxvi.) The translators of the other works in these places used the word elephantia. " Thus, the proper elephantiasis is called ele- phantia by (the translators of) Haly Abbas, and lepra by (the translators of) Avicen, Rhazes, and Avinzoar. And the thick leg is the elephas of the former, and the elephantia of the latter. My chief inquiry is, whether the difference is only among the translators, or whether there is likewise a want of uniformity in the nomencla- ture of the original writers. " En passant, I may observe, that some far- ther confusion has arisen among the translators respecting another leprous disease, as it has been called, which the Arabians seem to have con- sidered as having some affinity with the proper elephantiasis (juzam), but yet is materially dif- ferent in its symptoms ; and which they have denominated bar as or barras, and albaras, and which appears to accord accurately with the leuce of the Greeks, and the vitiligo (species ! Theorice lib. viii., cap. xv., and Practice, caD iv. In which passages the translator has used t T t Elephantia'and not LePra» hke the other Gen. VIII.] ELEPHANTIASIS. 107 3) of Celsus. If the Hebrews did not ap- ply the term (translated) leprosy to several affections of the skin (such as the scaly lepra Graecorum, the psoriasis of Dr. Willan, and the leuce, which I suspect they did), this leuce or baras would seem to be the unclean leprosy de- scribed in Leviticus, chap, xiii.* " If your knowledge of the oriental languages will enable you, together with your knowledge of these diseases, to disperse some of the thick mist in which the translators have enveloped them, I should be exceedingly glad to partake of a little of your light." The substance of the author's reply to this letter, already given in a note to the volume of Nosology, but which ought not to be omitted on the present occasion, was as follows :— The Greeks became first acquainted with the elephantiasis from their casual intercourse with Egypt. To this quarter Lucretius, adopting the eommon opinion, ascribes its origin :— " Est Elephas morbus, qui propter flumina Nili, Gignitur jEgypto in media, neque praeterea us- quam."! High up the Nile, mid Egypt's central plains, Springs the Black Leprosy, and there alone. Arabia, however, seems rather to have been the prolific source of this terrible scourge than Egypt; if we may judge from what seems high- ly probable, namely, that this is the disease with which Job was afflicted in Idumea, a part of Arabia, as described in the sacred poem that bears his name under the appellation of njHX VJJi "the stroke of the scourge," and which affords, without question, the most ancient rec- ord in the world, composed in a mixed lan- guage of Arabic and Hebrew; and if we add to this the still more powerful argument, that the Arabic name of the disease has extended itself all over the east, and is almost the only name by which it is known in Egypt, Persia, and India, in all which regions the disorder is about equally common. Yet the Arabic name is not elephas or elephantiasis, but juzam f*[t>-! literally " disjunction, amputation," vulgarly in- deed, and more generally pronounced and writ- ten judam *|<^** , from t>>-, a root which im- ports "erosion," "truncation," "excision;" ev- idently referring to the destructive character of the disease, and the spontaneous separation of the smaller members, as the fingers and toes, when severe in its progress. The Arabians, however, have a malady, but of a very different kind, to which they also give the name of elephas, or elephant af- fection, in their own language lioll^J/j dal fil, * This is the opinion of two learned old Ger- mans, Leon. Fuchs, in his Paradoxa Medicinae, lib. ii., cap. xvi.: and Gregor. Horst, in his Epist. to Hopner, inserted in his Observationes Medici- nales, lib. viii., obs. xviii. And Sennert seems to be of the same opinion, Pract. Med. lib., v., part i., cap. xl. f De Rer, Nat., vi., 1112. which is literally morbus elephas, and which they sometimes contract to iljc fil, or elephas, alone. It is the " swelled, tumid, or Barbadoes leg of modern writers, the bucnemia tropica of the present system." And, on this account, when learning, and especially medical learning, found an asylum during the dark ages at the splendid courts of Bagdat, BassQrah, and Cor- dova, and the best Greek writers were trans- lated into Arabic, or the best Greek and Arabic into Latin, two different diseases were found to possess a like name ; for the Greeks, notwith- standing that they had elephantiasis to signify juzam, could only translate dal fil by elephantia- sis also. And hence arose that confusion of the two maladies which has continued to the pres- ent moment, notwithstanding the wide distinc- tion between them, the one being a tubercular affection of the whole body, while the other is a scaly affection of only particular parts, and com- monly of not more than a particular limb. The leprosy, properly so called, the leuce (XivKt)) of the Greeks, and the baras or beras • jOJ of the Arabians, was by many of the Arabian physicians, and very generally among the people, supposed, in various cases, to termi- nate in juzam or elephantiasis, as though this also was nothing more than a different stage or degree of the same disease. And hence another error and perplexity in medical study. Alsaha- varius thus unites them, and they are jumbled together or explained alike in nearly all the oriental dictionaries ; in which beras or lepro- sy, and juzam or elephant-skin, are, almost without an exception, regarded as convertible terms. This oriental confusion of two very different diseases was readily copied by the Latin translators, till at length both in the east and west, beras or lepriasis, though literally scale-skin, became a sort of family name for almost every disfigurement of the skin, whether tubercular or scaly, cutaneous or constitutional. And on this account, elephantiasis and leprosy, and several other diseases even in the nosology of Linnaeus, are included under the term lepra ; all which the disciples of this school, extending a principle very widely adopted by them, ascribe to animalcules drunk in with the common bever- age of water, especially the gordius marinus. The author ought not to conceal Dr. Bate- man's acknowledgment of this communication, and his assent to its explanation, contained in the following opening of a letter received a few days afterward:— " I thank you sincerely for your ready and interesting communication, which satisfactorily explains the point respecting which I was the least able to obtain satisfaction from the trans- lators, viz., that the Arabians had applied the term elephant (elephas, according to the able translator of Haly Abbas), or fil, as you state, to the swelled leg. This is some apology for the appropriation of the Greek term elephan- tiasis (though it actually denoted a different dis- ease) to the Arabian thick leg ; but the appro- priation of lepra, which is never mentioned by 108 H^EMATICA. [Cl. Ill—Ord. IV. the Greeks but as a 'superficial, rough, and scaly affection,' to the tubercular juzam, has un- fortunately misled and confused us for a thou- sand years." Dr. Bateman adds, that he apprehends the term elephantiasis had also a reference to the magnitude and duration of the disease, inde- pendently of the appearance of the skin. And it is very probable, as the malady was likewise sometimes denominated leontiasis, that the formidable and frightful aspect of the patient labouring under it may have been hereby com- pared to the general exterior of both the ele- phant and the lion : for while Aretaeus tells us, in describing it, that " it is disgusting to the sight, and in all respects terrible like the ele- phant," Avicenna affirms, " it renders the coun- tenance terrible to look at, and somewhat of the form of the lion's visage." The necessity of that stricter investigation into the nature of genuine elephantiasis, thus anxiously desired by Dr. Bateman, will be the more obvious when the reader learns, that in the classical work of Professor Frank it is arranged as a species of lepra ; as are also ichthyiasis, and various other cutaneous affections, that should take their station in distinct quarters.—(Op. cit., torn, iv., p. 211, 1792.) Besides the elephantiasis of the Arabians, we have a disease of the same kind, or which seems to be of the same kind, common to some parts of Italy, and another common to some parts of Spain; both which seem, indeed, to have issued from the Arabian stock. And hence elephantiasis, as a genus, offers us the three following species:— 1. Elephantiasis Arabica. Arabian elephanti- asis. 2. -----------Italica. Italian elephantia- sis. 3.-----------Asturiensis. Asturian elephan- tiasis. SPECIES I. ELEPHANTIASIS ARABICA. ARABIAN ELEPHANTIASIS. BLACK LEPROSY. tubercles chiefly on the face and joints : fall of the hair except from the scalp : voice hoarse and nasal : contagious and hereditary. This species, which is the oldest of the three, is also the most inveterate: for we do not know that the Italian species is contagious, though, like the Arabian, it appears to be he- reditary ; while the Spanish is, perhaps, neither contagious nor hereditary. In some parts of the world, indeed, even the present species is said not to be contagious, though all the writers concur in its being heredi- tary in every quarter.* Thus Dr. Schilling, * Dr. Kinnis mentions two patients whom he saw in the Isle of France, and who " stood in the relation of mother and daughter. The husband of the former had been dead eight or nine years: he had long been afflicted with palsy and dropsy, to which, only two years before he died, was su- while he admits the latter effect, asserts that it is not contagious in Surinam, and Dr. T. Heberden asserts the same of this disease in Madeira. " I not only," says he, " am a daily witness of communication between lepers and other people without the least ill conse- quence, but know several instances where a leprous husband (afflicted with the Arabian lep- rosy or elephantiasis), married to a sound wife, has cohabited with her for a long series of years, and had several children by her, without her having contracted the least symptom of the disorder, although the children have inherited it; and vice versa between a leprous wife and sound husband."—(Med. Trans., vol. i., p 35.) That the disease, however, is contagious as well as hereditary in India and Arabia, we have the concurrent testimony of all the medical wri- ters of both countries, native as well as foreign ; so that there can be no doubt upon the subject. And hence the Madeira and Surinam juzam should seem to be a variety of the oriental, in- fluenced by peculiarity of climate or some other incidental cause. This severe malady, wherever it shows itself, is sometimes slow in its growth, and continues many years without deranging the functions of the patient, yet great deformity is advancing upon his external make. The alae of the nose become swelled and scabrous, and the nostrils are preternaturally dilated ; the lips are tumid ; the external ears, particularly the lobes, are en- larged and thickened, and beset with tubercles. The skin of the forehead and cheeks grows dense and hard, and forms large and prominent rugae, especially over the eyes ; the hair gener- ally, except on the head, falls off; the voice be- comes hoarse and obscure ; the external sensi- bility is obtunded or totally abolished, so that pinching or puncturing gives no pain. The tu- bercles at length begin to crack and ulcerate ; ulcerations appear in the throat and nostrils ; the breath is intolerably offensive ; the palate destroyed ; the nose falls off; the fingers and toes, from the increased depth and virulence of the ulcerations, become gangrenous, and separ- ate, and drop off one after another. [In the cases noticed in the Isle of France, the palms of the hand were seldom tuberculated, but had a dry, smooth, shrivelled appearance, as if the fat had been absorbed from under the skin. The backs of the hands, and more particularly peradded elephantiasis. Her daughter was at- tacked about the time of her husband's death ; she herself about two years afterward ; and one of her sons had since fallen a victim to the disease. Her father was a Frenchman, her mother and ma- ternal grandfather Creoles, and none of them was ever affected." Another patient is stated to have inherited the predisposition from the family of his maternal grandmother, who was never attacked herself, but lost two sisters and three nieces from the disease. None of his other relations, for three generations back, were ever known to have been affected. Dr. Kinnis saw his mother, with three other children, in the best health. She and her mother were Creoles, her grandparents Europe- ans.—See Edin. Medical Journal, No lxxxi d 290.—Ed. ** v' 11 bn. VHI.-Spe 1.] ELEPHANTIA of the fingers, were swollen, thickened, flabby, and beset with oblong tubercles, impeding the motion of the joints. One patient had lost four toes of the right foot, excepting a single pha- lanx, which three of them still possessed ; and another had lost two phalanxes of the little finger. In one case the terminal bone of the great toe was exposed and dry ; in another there was a circumscribed gangrenous spot on the fourth toe ; and in most of the cases there were open indolent sores on the backs of the fingers, the bend of the ankle joints, the soles of the feet, or about the toes; sometimes su- perficial, and of a red colour; sometimes foul, discharging little, surrounded with hard, irregular edges, or overgrown with morbid cuticle.—(Dr. Kinnis, Edin. Med. Journ., No. lxxxi.,p. 288.)] The mental powers suffer less than in the two other species ; the dreams, however, are greatly disturbed, the manners, for the most part, mo- rose and melancholy, and sometimes there is an inextinguishable desire of sexual intercourse.* The disease is also known in the high north- ern latitudes of Norway and Iceland. In the last place it is peculiarly prevalent, produced, as Dr. Henderson justly observes, by the ran- cidity of the food usually fed on, wet woollen clothes, an insalubrious air, and want of clean- liness. It is called " Likthra," or " Putrefac- tion :" and an hospital is established for it in each of the four quarters of the island. It seems to be here both infectious and hereditary. " In its primary stage," says Dr. Henderson, " its symptoms are inconsiderable. A small reddish spot, scarcely larger than the point of a needle, breaks out at first about the forehead, nose, corner of the eyes, and lips ; and in pro- portion as it increases, other pustules make their appearance on the breast, arms, armpits, which generally dry up in one place and break out in another without pain, till the disease has considerably advanced, when they cover almost the whole body, give the skin a scabrous ap- pearance, stiffen it sometimes in shining scales, which fall off like dust, sometimes in malignant tumours and swellings. The patient in the meantime labours under lassitude of body, an- aesthesia, and lowness of spirits." The miser- able progress is nearly a transcript of the de- scription just given. The patient is so worn out with fatigue and melancholy as to be often tempted to make away with himself. He sur- * According to Dr. Kinnis, who has given an interesting description of elephantiasis as it ap- pears in the Isle of France, the wasting of the genitals, represented by Dr. Adam as attending the disorder in Madeira, did not take place in a single individual of the other island; " the testi- cles in males, and the breasts in females, being constantly of their natural size. With regard to the functions of these organs," says Dr. Kinnis, " neither the wonderful salacity ascribed to the miserable victims of this loathsome disease by some authors, nor the utter extinction of the ve- nereal appetite said to characterize them by oth- ers, existed in any case. One of the female pa- tients, who had been affected with the disease only two years and a half, affirmed, that though she had ceased to menstruate from its commence- .SIS ARABIC A. 109 renders one part of the body after another to the insatiable malady, " till at length," says Dr. Henderson, " death, the long wished-for deliv- erer, comes suddenly and puts an end to hi» misery."—(Iceland, or the Journ. of a Residence in that Island, vol. i., p. 295, 8vo., Edin., 1818.) Mr. D. Johnson, of the Bengal establishment, ascribes the disease in India to nearly the same causes as Dr. Henderson in Iceland. It is found principally among the poorer castes^ and " at- tacks chiefly such people as have their feet and hands frequently in cold water or earth, such as the peasants in the low marshy countries of Bengal and Orissa, Dobys (washerwomen) and Mollies (gardeners) in the upper provinces of India; and I conceive that cold and poorness of blood cause the circulation in the extreme capillary vessels to become too languid; the consequence is, a gradual decay or depolution of these parts." This writer admits that the disease appears in hereditary descent, but, as the different trades and occupations of the na- tives descend hereditarily also, he has some doubt whether the latter may not be the sole cause of its appearing in successive generations, instead of a family taint.—(Misc. Obs. on certain Indigenous Customs, Diseases, &c. in India.) There seems to be a variety of this disease, in which a tumour of a larger size than the rest seats itself in the inguinal glands, sometimes in both groins, and is subject to a regular paroxysm of inflammation once in about every fourth month, preceded by shivering, and accompanied with a smart febrile excitement. These symp- toms usually subside in three or four days, and leave the tumour as before. But, not unfre- quently, that on the one side or On the other, rarely or never on both sides, advances to sup- puration, and produces a troublesome sore. Dr. Adams met with cases of this kind in Madeira, and Dr. Kinnis has since observed the same in the Isle of France (Obs. on Elephantiasis as it appears in the Isle of France, Edin. Med. Journ., Oct., 1824, p. 289): thus giving the dis- ease an approach towards bucnemia tropica. The cure is extremely difficult, but a course of warm diaphoretics succeeded by tonics, and especially the metallic tonics, seems to have con- stituted the most successful plan. Hence a free use of sarsaparilla, mezereon, or guaiacum, has been found beneficial, and mercurial alteratives still more so, though salivation appears to have ment, or to experience her former sexual propen- sities, she had yet suffered a miscarriage about twelve months before I saw her, and continued to cohabit wfth the person by whom she was kept. Another was the mother of two young children, one of whom I saw at the breast: she cohabited with a black," &c.—(Dr. Kinnis, in Edin. Med. J ourn., No. lxxxi., p. 289.) In an example detailed by Mr. Lawrence, in the Med. Chir. Trans., the testes were unnaturally small and soft; and in four cases seen by Dr. Bateman, the venereal de- sire was lost. From the evidence collected on this point, we may conclude with Dr. Joy (Ency- clop. of Pract Med., art. Elephantiasis), that the affection of the mammary and seminal glands, like the femoral tumour, is at most only an occa- sional complication.—Ed. 110 H^EMATICA. [Cl. Ill—Ord. IV. been uniformly mischievous. Even the lobelia has had its advocates, and, upon the ground of its proving salutary in syphilis, it has probably also been sometimes serviceable in elephantiasis. Dr. Schilling endeavours to increase the deter- mination to the skin, by advising the use of the warm bath and gentle exercise, and embrocating the body with spirits of wine or rum, or expo- sing it to a vapour-bath of mastic, olibanum, benzoin, or lavender. In India the cabirajahs, or native physicians, after bleeding and purging, immediately apply to the metallic tonics, and particularly to the white oxyde of arsenic, which they give, as in the case of syphilis, and indeed of various other impuri- ties of the blood, in the form of pills; mixing the arsenic, which, in Hindostanee, is sane hya, and in Arabic, shucc, with six times its weight of black pepper into a mass with a little water ; so that each pill may contain about two thirds of a grain of arsenic and four grains of pepper, which is to be taken twice a day: and this med- icine is regarded almost as a specific antidote. It has no doubt proved often successful: and I have known various cases in our own country in which it has been found equally so in the form of the arsenical solution. In this quarter of the globe, however, Mr. Playfair has of late years revived the use of one of the species of asclepias or swallow-wort. In Europe, the a. Vincetoxicum was formerly in high favour as an alterant and alexipharmic, and was often denominated contrayerva Germano- rum: but its virtues were not sufficient to sup- port its character. The swallow-wort employed by Mr. Playfair is the a. gigantea, a native of the east, and appears, from an account lately published by Mr. Robinson (Medico-Chirurg. Trans., vol. x.), to be possessed of more active and possibly more salutary qualities. It is the mudar or midaur of Hindostan, a shrub not yet systematically arranged, but found on all the un- cultivated plains of India, producing a milky juice, which is the part employed medicinally, not only in this complaint, but in various her- petic affections, by being applied to the skin.— (Misc. Obs., &c., by Daniel Johnson, Esq.) The tonie found most useful by Dr. T. Heber- den in Madeira was bark, which, however, has not proved of equal success in other places, or in the hands of other practitioners ; but he em- ployed it in connexion with that course of exter- nal stimulants which has been found generally serviceable, and probably not a little contributed to its wonderful efficacy in the various cases he refers to, and particularly one of a confirmed and chronic attack. " I have," says he, " in this island experienced the use of the bark in four or five leprous patients with success. One had a confirmed elephantiasis ; the others were only incipient, having no other symptoms than florid or livid tubercles in the face and in the limbs. The confirmed elephantiasis was attended with livid and scirrhous tubercles, which had over- spread the face and limbs ; the whole body was emaciated ; the eyebrows inflated ; the hair of the eyebrows fallen off entirely; the bones of the nose depressed; the alae nasi tumefied, as likewise the lobes of the ears ; with a suffusion in both eyes, which had almost deprived the pa- tient of his sight. There was a want of sensa- tion in the extremities, and a loss of motion in the fingers and toes." For upwards of seven years, Dr. Heberden had used every medicine he could think of to relieve this patient, but in vain. Antimonials and mercurials of almost every kind, neutral salts, the warm diaphoretics, as sassafras and sarsaparilla, warm baths and medicated baths, were alike fruitless. On May 2d, 1758, he made his patient commence an electuary of powder of bark, with a third part bark of sassafras root, inspissated with sirup ; and of this the quantity of a large nutmeg was ordered to be taken twice a-day. The patient at the same time had his arms and legs bathed with an embrocation, consisting of an ounce of lixivium of tartar and two drachms of spirit of sal-ammoniac, inter- mixed with half a pint of proof spirit. By the latter end of May the tubercles were consider- ably softened; by June 28th, they were dis- persed ; a red scurfy efflorescence alone remain- ing behind, which in ten days lost its florid hue and peeled off, leaving the cuticle sound and clean. " The patient," says he, " gradually re- covered the sensation in his legs and arms, and the use of his toes and fingers; the hair has grown again on his eyebrows ; and the only re- mainder of the distemper which I can perceive is, that the nose continues somewhat flatter, from the depression of the bones. The suffu- sion is quite cured, and the patient is tSaapxos Kai evxpoos,* of a healthy skin and colour." SPECIES II. ELEPHANTIASIS ITALICA. ITALIAN ELEPHANTIASIS. TUBERCLES CHIEFLY ON THE BODY AND LIMBS, SOMETIMES DESQUAMATING : GREAT TENSION OF THE SKIN : VERTIGO : BURNING, LANCINA- TING PAIN IN THE HEAD : MELANCHOLY, AT FIRST REMITTING, AFTERWARD FIXED, TER- MINATING IN ALIENATION OF MIND : HERED- ITARY. For a knowledge of this species we are al- most exclusively indebted to the Italian physi- * Med. Trans., ut supra. Mr. Robinson repre- sents the disease as presenting itself under two forms in Hindostan; one characterized by the dropping off of the fingers and toes, the insensi- bility of the skin, and the extreme torpor of mind and body ; the other by tubercles, ulceration of the palate, and affections of the cartilages and bones of the face, together with the frequent occurrence of the oblong glandular tumour in the groin. The mudar, so useful in the first variety, is injurious in the second, which is benefited by arsenic — (See Med. Chir. Trans., vol. x.) Iodine might be tried both externally and internally. Rayer rec- ommends exciting a slight degree of inflammation in the diseased skin with ammoniacal liniments tincture of cantharides, or ointment of the hydri- odate of potass. If they produce too much irri- tation, they are to be used alternately with the warm bath.—Ed. Gen. VIII.—Spe. 2.] ELEPHANTIASIS ITALICA. HI cians, who have generally given it the name of pellagra or pelagra. The first writer upon the subject appears to have been Francis Frapolli, a physician of Milan, whose work, " In morbum vulgo Pelagram dictum," was published at Mi- lan in 1771, and who expresses himself doubt- ful whether the disease, though not antecedent- ly described, is not referred to occasionally by earlier writers, although he does not think that the pilarella, as the syphilis was called when it proved depilatory to the chin and eyebrows, was the disease in question, notwithstanding this seems to have been an extensive opinion at the time. The next tract of any note upon the sub- ject was published at Venice in 1784, by G. M. d'Oleggio, under the title of " A Theoreti- cal and Practical Treatise on the Diseases of Vernal Insolation, commonly called Pellagra."* But the best account we have received of this complaint is from the pen of Dr. Jansen, of Ley- den, which appeared in 1788, and asserts that it is endemic in the Milanese territory.—(De Pellagra morbo in Mediolanensi Ducatu en- demio.) It is, in truth, common to both the Milanese and Venetian territories, as well as to other districts widely differing in soil and tem- perature ; and can scarcely therefore be referred to either of these sources. There is little doubt of its being hereditary, but not contagious ; and it does not seem to have existed earlier than the middle of the last century.! It is com- monly ascribed, as we have observed above, to the heat of the sun's rays (J. P. Frank, op. cit., torn, iv., p. 43) after the chill of winter, and is hence called mal del sole, which we have just seen was the view taken of it by D'Oleg- gio ; while by Odoardo it is attributed to a scrofulous habit (D' una spezia particolare di Scorbuto, Venet., 1776), and by Videmari and others, who have too much limited themselves to the nature of the eruption, to an impetiginous impurity.—(De quddam Impetiginis specie, 8vo., 1790.) But none of these explanations seem to rest on any very solid foundation; and, upon the whole, we have more reason for regarding it as produced by the debilitating causes of hot, confined air, want of cleanliness, and bad diet, operating in many cases upon a diathesis hered- itarily tainted. It is found chiefly among the Milanese and Venetian peasantry, whose hovels are full of wretchedness, and rarely makes its appearance till after the age of puberty. Ali- bert, in his " Diseases of the Skin," has denom- inated it, but with little accuracy, Ichthyosis Pellagra.—(Desc. des Mal. de laPeau, p. 175.) The first symptoms of the disease are general languor, listlessness, gloom, feebleness, and stu- por in the legs, and hence unsteady walking, vertigo, and confusion of ideas. Domeier, an- other writer upon the subject, extends the stu- por of the legs to the entire frame, and asserts that anaesthesia is a characteristic symptom of * Tratto teoretico-praticodelle malattie dell'in- solato di primavera volgarimente dette della Pel- lagra. ! Paralleli fra la Pellagra ed alcuna malattie, che piil lo rassomigUano, del F. Fanzago. Pado- va, 1792. this species.—{Baldinger, Journ., vol. xxvi., p, 9.) But this assertion is not confirmed by the history of other pathologists, though the lan- guor and inertness are often very great, as well as universal. These symptoms usually take place-in the spring ; and as the summer approaches, a sense of tension, burning, and itching is felt in every external organ except the head, followed by an eruption of rosy papulae, scattered over the skin generally,* which terminate in tubercles of a shining red colour. After some days the tu- bercles desquamate, and the skin appears at first red, but soon recovers its natural colour. As the summer, however, advances, every symp- tom commonly subsides, and the strength is re- newed with the winter ; but the symptoms return with increased violence with the return of the spring, and this for several years in succession. But if the symptoms do not thus subside, they soon become even on the first attack considera- bly exasperated, and form a second stage of the disease, in which the itching grows more pun- gent ; the heat more fiery; the skin harder, cracked, and chapped ; the debility is greater ; the mental functions are disturbed generally ; the appetite is irregular ; the sleep broken with acute pain in the head and spine, soon followed by delirium. The cutaneous affection how di- minishes, but the nervous symptoms are greatly augmented. The vertigo increases ; the patient is sad and loves solitude, and melancholy delir- ium alternates with furious mania. The tae- dium vitae is insupportable, and self-murder is a frequent consequence. Strambi remarks, that those who labour under this disease have the greatest tendency to drown themselves, " as by a hallucination," says he, " opposite to that of hydrophobia."—(De Pellagra, Obs., ann. i., ii., iii., Mediol., 1785.) Coercion is at last neces- sary; and a diarrhoea, dysentery, or dropsy, closes the dreadful scene, if the patient do not sink earlier from corporeal and mental exhaus- tion.! Dr. Holland tells us that at one time * Dr. Holland says:—"The local symptoms very generally show themselves, in the first in- stance, early in the spring, at the period when the mid-day heat is rapidly increasing, and when the peasants are most actively engaged in their labours in the fields. The patient perceives on the back of his hands, on his feet, and sometimes, but more rarely, on other parts of the body ex- posed to the sun, certain red spots or blotches; which gradually extend themselves, with a slight elevation of the cuticle, and a shining surface, not unlike that of lepra in its early stage."—See Med. Chir. Trans., vol. viii., p. 321. ! Besides exhibiting, at different periods in the same individual, many varieties in the appearances of the skin, as erysipelas, lepra, psoriasis, elephan- tiasis, and ichthyosis, it is liable to terminate in the production of several constitutional or general derangements of the system,—tetanus, chorea, epilepsy, convulsions, dropsy, melancholia, mania, marasmus, &c. " Hence," as Dr. James John- son has observed, " we see written over the beds in the Milan Hospital the various diseases to which pellagra forms the adjective, as atrophia pellagrina, phthisis pellagrina, hydrops pellagri- ns, paralysis pellagrina, mania pellagrina, dec."— 112 HiEMATICA. [Cl. III.—Ord. IV. in the lunatic hospital at Milan, of five hundred patients more than one third were Pellagrosi (Medico-Chir. Trans., vol. viii., part ii., p. 326); and he also informs us, that morbid dissections have thrown little light on the pathology of this disease; that the liver and spleen have at times evinced indurations and enlargements ; and tra- ces of disease have been occasionally seen in the intestines and mesenteric glands; but by no means constantly, and rather as effects than causes of the disorder. The treatment needs not essentially diffeT from that of the preceding species. Pure air, habitual cleanliness, warm bathing, and a nu- tritious diet, with such tonics, whether vegeta- ble or mineral, as best agree with the constitu- tion, have proved most successful where the disease has not advanced beyond the reach of recovery. At Milan, the lichen Islandicus is one of the most popular remedies. [Antimonials are also in repute, and attention is paid to the diarrhoea with which the disease is frequently accompanied. Bloodletting is rarely practised, except when mania or some local in- flammation comes on. In some instances, ac- cording to Dr. Holland, the cutaneous affection forms the principal indication of the complaint for several successive years; being renewed every spring, and disappearing again in the au- tumn. In other cases, he says, where it has been found possible to remove the patient to a new situation and mode of life, the disease is still further arrested in its progress. " It rarely happens, however, that these means can be prac- tically adopted ; and the constitutional malady is generally so far established in the third or fourth year, that little hope remains of benefit- ing the patient, either by medicine or change in the mode of life."] SPECIES III. ELEPHANTIASIS ASTURIENSIS. ASTURIAN ELEPHANTIASIS. TUBERCLES CHIEFLY ON THE HANDS AND FEET ; CRUSTACEOUS, DESQUAMATING : CONTINUAL TREMOUR OF THE HEAD AND UPPER PART OF THE TRUNK : BALDNESS OF THE SCALP, AS WELL AS OF OTHER PARTS : GLOOM AND TER- ROR OF MIND. This species agrees in many of its symptoms with the Italic, and it is only worth while to notice the points in which they differ. Upon the whole, we may observe, that all the species coincide in being founded on an exhausted con- stitution, in the general character of the tuber- cles, and in their fatal termination by dropsy, atrophy, or some other asthenic disease. The Arabian species attacks the face, the roots of the hair, and the palate-bones, before the remain- ing parts on which it preys are diseased, and the affection of the skin increases with the in- crease of the other symptoms. In the Italian species, the affection of the skin diminishes as the nervous and mental commotion augments. Change of Air, or the Pursuit of Health, p. 75.— Editor. The pellagra also is distinguished by thick urine, double vision, and a peculiar mouldy smell of the sweat. In the Asturian species the crus- taceous tubercles are peculiarly painful, highly fetid, more deeply furrowed with cracks, and more disgusting to the sight; attacking the head as well as other parts indiscriminately, and destroying the roots of the hair. The mind is less affected than in the last, and with mel- ancholy and terror rather than with raving de- lirium. This species constitutes the Asturian leprosy of Thiery, Vandermonde, and Sauvages ; but genuine leprosy is rarely a constitutional com- plaint ; and the present is its proper place. As the tubercles desquamate, the skin appears of a glossy leprous red, and the disease is hence called by the Spaniards Mal de la Rosa. The causes are, extreme poverty and its at- tendants, filth, bad diet, and crowded unventila- ted rooms in the deep and swampy valleys of the country, almost impervious to the rays of the sun ; and hence the medical treatment and gen- eral regimen recommended under the preceding species, will here afford the fairest promise of success. GENUS IX. CATACAUSIS. CATACAUSIS. GENERAL COMBUSTIBILITY OF THE BODY. The peculiar state of the constitution which lays a foundation for the present genus of mor- bid affections, is of a very singular and myste- rious kind ; and the only medical work that has referred to it in our own country, antecedently to the author's own system of Nosology, is Dr. Young's Medical Literature, in which it is no- ticed under the Greek name here applied to it, derived from ncaraxa/u, " exuro." One species only has hitherto been discovered as belonging to it ; which, from the peculiar habit under which it occurs, may be distinguished by the name of 1. Catacausis Ebriosa. Inebriate Catacausis. SPECIES I. CATACAUSIS EBRIOSA. INEBRIATE CATACAUSIS. THE LIVING BODY INFLAMMABLE IN CONSEQUENCE OF A LONG AND IMMODERATE USE OF SPIRITU- OUS LIQUORS : THE COMBUSTION EASILY EX- CITED, OR SPONTANEOUS. In this wonderful malady, the art of medicine can be rarely of any avail; since the mischief is, in almost all instances, only to be discovered after a cessation of life, and the destruction of some part of the body by an actual flame or fire, in many instances spontaneously issuing from its surface. There may be some diffi- culty in giving credit to so marvellous a diathe- sis ; yet examples of its existence, and of its leading to a migratory and fatal combustion, are so numerous and so well authenticated and press upon us from so many different coun- tries and eras, that it would be absurd to with- 'HYRA. H3 Gen. X.] PORP hold our assent. In almost every instance, the combustion seems to have taken place in fe- males, advanced in life, and immoderately ad- dicted to spirituous liquors.—(Bartholin, Act. Hafn., i., obs. 118.) In some cases, the heat that has set them on fire appears to have origi- nated in themselves; in others, to have been communicated by a stove, or a candle, or a stroke of lightning (Fouquet, Journ. de Med., torn, lxviii.); but in no case has the fire or flame hereby excited in the body been so powerful as essentially to injure the most com- bustible substances immediately adjoining it, as linen or woollen furniture. The body, in sev- eral instances, has been found actually burning, sometimes with an open flame flickering over it; and sometimes with a smothered heat or fire, without any open flame whatever : while the application of water has occasionally seemed rather to quicken than to check the igneous progress. This is the more extraordinary, as the human body, in every other state we are acquainted with, whether of health or disease, is scarcely at all combustible of itself, and cannot be re- duced to ashes without the assistance of a very large pile of fagots or other fuel, as universal experience in this very ancient mode of sepul- ture, and the history of martyrs who have been condemned to the flames, abundantly testify. The event has usually taken place at night, when the sufferer has been alone ; and has commonly been discovered by the fetid, pene- trating scent of sooty films, which have spread to a considerable distance ; the unhappy subject has in every instance been found dead, or more or less completely burnt up; the burnt parts being reduced to an oily, crumbly, sooty, and extremely offensive matter. " I confess," says M. Pierre-Aime-Lair (Journ. de Physique, an. viii.), " that these accounts at first appeared to me to be worthy of very little credit; but they are presented to the public as true, by men whose veracity is unquestionable. Bianchini, Maffei, Rollin, Le Cat, Vicq d'Azyr, and other men distinguished by their learning, have of- fered certain testimony of the facts. Besides, it is not more surprising to meet with such in- cineration, than a discharge of saccharine urine, or an appearance of the bones softened to a state of jelly." Those who are desirous of pursuing this cu- rious subject farther, and of entertaining them- selves with the very extraordinary histories connected with it, as also of examining the va- rious hypotheses by which they have been ac- counted for, may consult the Philosophical Transactions (see especially vols, xliii., xliv.), which contain numerous examples ; as also a variety of foreign journals of established repu- tation, referred to and cited in the running com- mentary to the author's volume of Nosology.— (Ploucquet, Littirat. Mid.; Dupont, de Corporis Hum. Incendiis Spontaneis.) We have not space to enter into these separate cases, though many of them are highly interesting; but in a general course of medical study, the phenome- non ought not to be passed by : it forms one of Vol. II— H the most curious links in the long chain of mor- bid affections, and equally demands our atten- tion as pathologists and physiologists.* GENUS X. PORPHYRA. SCURVY. LIVID SPOTS ON THE SKIN FROM -EXTRAVASATED BLOOD : LANGUOR, AND LOSS OF MUSCULAR STRENGTH : PAINS IN THE LIMBS. Porphyra is in Greek what purpura is in Latin, literally, " the purple or livid disease." The latter has been very generally made use of; but the former is here preferred on two accounts. First, that of technological sim- plicity,—the names of the genera under the' present system being uniformly of Greek origin. And secondly, because the Latin purpura has been used in senses so numerous, so vague and unconnected, that at this moment it con- veys no definite idea whatever. " The term purpura," observes Dr. Bateman, most cor- rectly, " has been employed by different wri- ters in so many acceptations, that some ambi- guity would perhaps have been avoided by dis- carding it altogether; for some authors have used it as an appellation for measles, others for scarlet fever, for miliaria, strophulus, lichen, nettle-rash, and the petechias of malignant fe- vers ; while formerly it was applied to petechial spots only by Riverius, Diemerbroeck, Sauva- ges, Casson, and some others."—(Synopsis of Diseases, p. 102.) The usual synonyme for purpura is scorbutus; but to this there are still stronger objections. For, as a term, it is neither Greek nor Latin, nor any language whatever ; but an intolerable barbarism, derived, as is commonly supposed, from the German compound schar-bocke, liter- ally " aggregate-pox," " cluster-pox ;" but more likely from sckarf-pocke, " violent," or " vehe- ment-pox ;" or schorf-pocke, " scurf," or " scur- vy-pox," to which the inventor has endeavoured to give a sort of Latin termination. Independ- ently of which, scorbutus, as employed at pres- ent, only indicates a particular species of scur- vy ; and could not, therefore, without impi ecis- ion, be used in a generic signification. The sense here expressed by porphyra, runs, as nearly as possible, parallel with the range assigned by Dr. Willan to purpura. " With Riverius and some other authors," says he, " I propose to express by the term purpura an efflorescence consisting of some distinct pur- * Cases of catacausis ebriosa are recorded in several American periodicals. A paper on the subject may be found in the Am. Med. Recorder, vol. v. The author of it, Dr. J. K. Mitchell of Philadelphia, maintains " that combustible gases are generated in the systems of drunkards by the decomposition of alcoholic potions; that these gases, and even the identical spirituous liquors, are distributed to every pait of the system, and that these gases inflame spontaneously, just like gases out of the body, without the aw of-fire "—See also the Elements of Med. Jurisprudence, by Prof. J. R. Beck and Trotter on Drunkenness,—D. I'M H^EMATICA. [Cl. Ill—Ord. IV. pie specks and patches, attended with general debility, but not always with fever." And again : " Cases of the purpura seem to have beea studiously multiplied in periodical publica- tions, and in medical or surgical miscellanies. I consider it under all the forms described as pertaining to the scurvy, though it is not always attended with sponginess of the gums, and a discharge of blood from them, according to the definition of scorbutus in nosology."—(On Cu- taneous Diseases, Ord. III., p. 453.) Porphyra, in its present signification, is in- tended to include every description of petechial eruption and spontaneous ecchymosis, not de- pendant on fever as their cause, in which case these affections are only symptomatic. The genus, thus explained, will associate under its banners the three following species:— 1. Porphyra Simplex. Petechial Scurvy. 2.-------Haemorrhagica. Land Scurvy. 3. -------- Nautica. Sea Scurvy. SPECIES I. PORPHYRA SIMPLEX. PETECHIAL SCURVY. SPOTS NUMEROUS, BUT SMALL AND FLEABITE- SHAPED : CHIEFLY IN THE BREAST, ARMS, AND LEGS : PALENESS OF VISAGE. Pulicose or petechial spots were at one time supposed to be, in every instance, the result of debilitating and putrid fevers. Riverius is per- haps the earliest author who distinguishes be- tween simple petechiae and petechial fevers. Vascular debility or relaxation is, however, the predisposing cause in both cases.—(Plumb, Practical Treatise on the Diseases of the Skin, p. 100, 8vo., 1824.) They necessarily, indeed, accompany each other, and, wherever they ex- ist in any considerable degree, they lay a founda- tion for those minute extravasations which con- stitute the present species ; and which may take place either from occasional ruptures of the weakened coats of the minute subcutaneous bloodvessels, in consequence of their being in- capable of resisting the impetus of the blood that flows through them ;. or from the mouths of many of them, which should give forth only the finer and limpid particles of the blood, yielding and allowing an exit to the red globules. Both these may follow atonic fevers ; but the usual remote causes, in the species before us, are severe labour with innutritious or spare diet, and especially with impure air ; an empoverished state of the system from a sudden and profuse loss of blood ; a sedentary and inactive life, or some chronic and exhausting disease, by which the general strength has been broken down. To these Riverius adds suppression of the cata- menia, and a certain mild ebulliency of the blood in boyhood—levem quandam sanguinis ebullitionem—a phrase, apparently importing an excess of sanguineous temperament; from both which, he tells us, he has frequently seen the disorder originate. And he is confirmed in the last by a case hinted at by Dr. Perceval in his manuscript comment on the author's Nosology, in which he observes, under the present spe- cies, that " in a young lady of a full habit and florid complexion, if the skin of the face or neck were touched, even slightly, blood oozed from the pores." The disease seems also to be produced at times by some unknown cause ; of which Cul- len has given a striking instance in his Materia Medica. " The patient," says he, " was a wo- man who had lived very constantly upon vege- table aliment, and had not been exposed, so far as could be judged, to any febrile or putrid con- tagion ; and yet, without a feeling of" any other disorder, was affected with numerous petechiae over the whole surface of her body. After these had continued for some days, without any symptoms of fever, she was affected with swell- ed and bleeding gums, with fetid breath, and much thirst; and, in the course of a week or two more, almost every symptom of a putrid fe- ver came on, and in a few days proved fatal." It is possible in this case, that the brain may have lost its energy, and the blood become em- poverished by too low a diet, though the history is not given with sufficient fulness to speak with much decision upon this point. The fever was evidently produced by the irritability of weak- ness, and necessarily ran into a typhous type from the same cause. The disease, as it commonly shows itself, ap- pears under two forms, which may thus be de- scribed as varieties :— a Pulicosa. Exhibiting from the first a Simple pulicose pulicose or fleabite ap- scurvy. pearance. 3 Urticaria. The fleabite spots preceded Nettle-wheal by reddish, rounded, and scurvy. nettle-sting wheals, but without the nettle-sting itching; fugacious and migratory. The first variety is not only produced by debility, but attended with languor and pains in the limbs, and chiefly affects women and chil- dren, in consequence of their greater laxity of fibre. The second variety may possibly be ac- companied with more constitutional affection ; for there is usually a loss of appetite, and an oedematous swelling of the hands and ankles, while the spots are brighter at night and darker in the day, evidently proving great irritability in the capillaries, and especially towards the pe- riod of the natural evening paroxysm of fever. This variety often continues for five or six weeks. Better diet, freedom from hard labour, pure air, sea-bathing, the mineral acids, and other tonic medicines, afford a pretty certain process of cure. SPECIES II. PORPHYRA HEMORRHAGICA. LAND SCURVY. SPOTS CIRCULAR, OF DIFFERENT SIZES; OFTEN IN STRIPES OR PATCHES, IRREGULARLY SCAT- TERED OVER THE THIGHS, ARMS, AND TRUNK - Gen. X.—Spe. 2.] PORPHYRA HEMORRHAGICA. 115 OCCASIONAL HEMORRHAGE FROM THE MOUTH, NOSTRILS, OR VISCERA: GREAT DEBILITY AND DEPRESSION OF SPIRITS. This species, the morbus maculosus Werl- holfii of the German writers (Gesch. eines gliich- lich geheilten Morbus Maculosus Werlholfii, von Dr. Marquett, &c, Magdeburg), is sometimes marked by febrile paroxysms, with variable intervals, but usually occurring in the evening. It has no regular or stated termination. Dr. Willan has found it run on, in different cases, from fourteen days to a twelvemonth and up- wards. It is met with at every period of life, but chiefly affects persons of a weak and delicate habit, often children, principally women. y The precursive symptoms are lassitude, faint- ness, and pains in the limbs, so that business, or even company, is found fatiguing. After this, there are often shiverings, nausea, and vomiting. The purple eruption, for the most part, appears first on the legs, and afterward, at irregular periods, on the thighs, arms, and trunk of the body ; the hands and face generally remaining free. The" spots, however, are fre- quent on the interior of the mouth, and particu- larly the tonsils, gums, and lips,where they are sometimes raised or papulated. It is here the first hemorrhage commonly issues, though, as the disease advances, blood flows also from the nostrils, lungs, stomach, intestines, and uterus; all which organs, together with the heart, are sometimes found studded with spots on their surface, on examination after death.—(Edin. Med. and Surg. Journ., July, 1822.) The hemorrhage is often profuse, and cannot easily be restrained, and is accompanied with anasar- cous swellings. It sometimes precedes the pur- ple spots, but more commonly takes place a few days afterward. It is this rapid erosion or ulceration of the bloodvessels, and consequent discharge of blood, often accompanied with diarrhoea or dysentery, where the intestines associate in the complaint, by which land scurvy is chiefly distinguished from sea scurvy, and acquires the distinctive name of hemorrha- gic ; since, though these symptoms may also occur in the latter, they do so rarely, except in the last stage of the complaint.* * There is no sponginess of the gums, as in common scurvy, nor are the limbs affected in the manner often exhibited in the latter disease. Rayer, in his Traite des Maladies de la Peau, torn ii., has described purpura under the name of hemaeelinose (derived from al/io, blood, and Kfi>pa>v is "mentis compos," or "in one's mind." It is here used, as among the Greeks, generically alone, in the ordinary sense of insanity ; and is designed to include the two following species:— 1. Ecphronia Melancholia. Melancholy. 2. ---------Mania. Madness.* Each of these species has been regarded by many nosologists as forming a" genus of itself, for which there seems to be no just reason. Dr. Cullen has thus arranged them in his Synopsis ; but has given them a different arrangement and a very subordinate place in his Practice of Physic, so that, in the two works, he is in this respect altogether at variance with himself. In both, his order is entitled vesaniae, which, in the first, includes fatuity, mania, melancholy, and sleep-disturbance (oneirodynia), as distinct ge- nera ; but, in the last, takes for its genera de- ness, and differs from mania, as chronic rheuma- tism varies from that which is acute, that is, in being accompanied with a'more moderate degree of the same symptoms : manalgia; the symptoms of which are taciturnity, downcast looks, a total neglect of dress and person, and insensibility to heat and cold. Dr. Rush treats also of derange- ment of the memory, fatuity, incubus, somnam- bulism, illusions, revery, the derangement of the passions, the morbid state of the sexual appetite, and of the disorders of the moral faculties. Dr. T. Y. Simons (Observations on Mental Alienation, &c, Charleston, 1828) considers in- sanity under various grades, as, 1st, Mania, a total hallucination on all subjects, or a total perversion of the intellectual faculties, accompanied with furor. 2. Melancholia, a total or partial hallucina- tion, accompanied with extreme dejection, fear, and false apprehensions. 3. Monomania, a false reasoning or conception on one subject, which, when it completely overcomes the other opera- tions of the mind, produces either melancholia or mania, according to the cause and the tempera- ment of the individual. 4. Hypochondriasm, a continued apprehension of the physical health, re- gardless of worldly affairs, connected with dys- peptic symptoms.—D. * The word mad is stated by Dr. Armstrong to be derived from the Gothic word mod, which sig- nifies rage; and the word mania, which the Greeks apply to madness, has the same signification. Melancholy etymologically signifies black bile. Hence, in the ancient writers, the term mania is applied to that form of madness in which there is excessive excitement of the system, with violent emotions of the mind; and the term melancholia, to that form in which the body and mind are de- pressed. Hence, also, the terms high madness and low madness. Insanity, from insanus, unsound, and derangement, from the French derangement, signifying disorder, are common names for mad- ness. The word lunatic was originally applied only to patients who had lucid intervals, and who were supposed to be under the influence of the moon, idiocy signifies the condition of those who are imbecile from their birth, or become so in consequence of injury or disease of the brain. Delirium, derived from the Latin words delira, out of the track, is now generally restricted to the wanderings attendant upon fever.—See Arm- strong's Lectures on the Morbid Anatomy, Na- ture, and Treatment of Acute and Chronic Dis- eases, edited by Joseph Rix, p. 703, 8vo., Lond. 1834.—Ed. 17Q NEUR lirium, fatuity, and oneirodynia. He contem- plates delirium, moreover, as of two kinds ; one combined with fever, and one without : the lat- ter, he tells us, is what we name insanity ; and under this latter kind alone, the apyrectic delir- ium or insanity, running synonymously with the present genus ecphronia, he proceeds to treat of melancholy and, mania as species or subdi- visions of it : throwing back the other kind of delirium to the class of fevers, as unconnected with the subject before him. So that, properly speaking, Dr. Cullen's order of vesanioe should run parallel with the present order phrenica; the genera of which should be delirium and fa- tuitas ; while mania and melancholy should be the species of delirium or the first genus. Crichton, Parr, Young, Pinel, and most of the German writers, contemplate these diseases under the same sort of specific subdivision. Parr, indeed, in his article mania, asserts that both constitute nothing more than varieties of one common species : yet, with an inconsisten- cy which; among much that is excellent, is too frequently met with in his Dictionary, he changes his opinion in the article nosology, makes ve- sania the genus, and arranges melancholia, ma- nia, and even oneirodynia, as separate species under it. The distinguishing characters, as the two spe- cies are contemplated by the generality of no- sologists, are clear. In melancholy the aliena- tion is restrained to a few objects or trains of ideas alone ; in madness it is general ; in refer- ence to which distinction M. Esquirol has ex- changed the term melancholy for that of mo- nomania. And it hence follows, that gloom; gayety, and mischievousness may equally exist under both species ; according as these propen- sities are limited to a single purpose, or are un- confined and extend to every thing. Occasion- ally, however, among ancient writers, we find melancholy insanity limited to insanity accom- panied with gloom or despondency, without any attention to the universality or partiality of the disease : for an undue secretion of melancholia, which is only a Greek term for black bile or choler, was supposed to be a common cause of mental dejection, and where it became habitual, to produce a low or gloomy temperament; to which the term melancholic has continued to be applied to the present day. And hence the vul- gar sense of the term, which is in unison with this view, is at variance with the technical and pathological. Yet the pathologists themselves have not been uniformly true to their own import: for even Dr. Cullen, who has followed the tech- nical signification in his Synopsis, by defining melancholy as "insania partialis sine dyspep- sia," sometjmes adopts the colloquial meaning in his Practice of Physic, and hereby betrays a confusion which rarely belongs to him ; while Sir Alexander Crichton has given himself over completely to the popular, or, as he would per- haps call it, the ancient interpretation of the terms ; distinguishing mania, not by the gener- alization of the delirium, but by its raving fury or elevated gayety; and melancholy, not by a limitation of the delirium to single objects or )TICA. [Cl. IV.—Ord. I. trains of ideas, hut by its concomitant dejection and despondency. There seems to be an equal incorrectness, though of a different kind, in M. Pinel, whose book is, nevertheless, of great merit. Delirium or wandering is made a pathognomonic symptom in his definition of the genus ; in other words, a want of correspondence between the judgment and the perception : and consequently this symp- tom should be found in every species which he has arranged under it. M. Pinel, however, has given us one species which has no such symp- toms, and which is purposely intended to include cases of what he calls mania without any such discrepance ; on which account he has denom- inated it mania sans dilire. All such cases, however, are reducible to modifications of rage or ungovernable passion, and ought by no means to be confounded with mania; the judgment being, in these instances, not at variance with the perception, but overpowered by the predom- inant fury or passion that has been excited. They all belong properly to our next genus ; under which they will be considered. Much difficulty has also been felt in defining ecphronia or insanity, so as to draw the line be- tween real disease and habitual waywardness or oddity ;* and hence, while some definitions are so narrow as to set at liberty half the patients at Bethlem or the Bicetre, others are so loose and capacious as to give a strait waistcoat to half the world. M. Dufour undertook, with great learning and ingenuity, to prove that, as all our knowledge of an external world is derived from the action of the external senses, while mental sanity depends upon the soundness of these senses, mental in- sanity is alone to be referred to a diseased con- dition of one or more of them. And, in proof of this, he gives the case of a person who lost his senses because he could not be persuaded that the objects he saw in consequence of an incip- ient cataract arose entirely from that complaint. " When he found that he could not remove the dark web which appeared to him to be constant- ly floating before his eyes, he fell into such fre- quent fits of violent passion that he became quite insane. But as soon as the disease was com- pleted he became more tractable, and submitted to the operation like a reasonable man." * The following are distinctions insisted upon by Dr. Conolly, between eccentricity and insani- ty :—" The man who is merely eccentric can, if he exert himself, act rationally, and leave off his eccentricity ; the lunatic cannot. The eccentric man also commonly justifies his eccentricity more speciously and more calmly ; or perhaps laughs at it himself; the madman seldom justifies his pe- culiarities with much skill, is provoked by contra- diction, and is very seldom capable of joining in a laugh which is raised against himself."—(Inquiry concerning the Indications of" Insanity, p. 139.) Dr. Conolly acknowledges, however, that there are cases on its boundary-line, between eccentri- city and madness, which seem to bid defiance to aU definition; but generally resolvable into the effects of habit in confirming trifling actions, at first performed on some insufficient ground of reasoning.—Ed. Gen. I.] ECPH But this only shows us that " Ira furor brevis est," or else that the insanity was caused, not by the cataract, but by the frequent fits of violent pas- sion. Thousands of persons have had cataracts in every form, and other external senses than the eye diseased in every form, and have been born defective in several of these senses, with- out the least mark of insanity ; while other per- sons, apparently in the most perfect possession of all the five senses, have been stark mad. Hence, the doctrine of M. Dufour boasts of few advocates in the present day. In insanity or delirium without fever, it is far more obvious that there is a morbid condition of the judgment, or of the perception, or of both. Mr. Locke, and after him M. Condillac, refers it to the former alone, and characterizes mad- ness, in the general sense of the term, by false judgment; by a disposition to associate ideas incorrectly, and to mistake them for truths ; and hence, says Mr. Locke, " madmen err as men do that argue right from wrong principles."— (B. ii., ch. xi., § 13.) Dr. Battie, on the con- trary, refers madness to the latter faculty alone, and characterizes it by false perception; but the perceptions in madness seem, for any thing we know to the contrary, to be frequently as correct as in health, the judgment or reasoning being alone diseased or defective.* It is difficult to say which of these two ex- planations of madness is most imperfect. It is sufficient to observe, that neither of them, taken alone,describes a condition of the faculties strict- ly morbid, and consequently neither of them de- fines madness. For we are daily meeting with thousands of mankind who are under the influ- * Of those lunatics whose intellectual faculties are manifestly disordered (says Dr. Prichard), there is always a considerable proportion in whose minds it is impossible to trace any particular hal- lucination, or erroneous perception, or recollec- tion. The rapid succession of thoughts, the hur- ried and confused manner in which ideas crowd themselves into their mind in a state of incohe- rence, or without order or connexion, is in very many instances among the most striking phenom- ena of madness. There are likewise cases of a different description, in which the intellectual fac- ulties appear to have sustained but little injury, while the feelings and affections, the moral and active principles of the mind, are strangely per- verted and depraved; the power of self-govern- ment is lost or greatly impaired ; and the individ- ual is found to be incapable, not of talking or rea- soning upon any subject proposed to him, for this he will often do with great shrewdness and volu- bility, but of conducting himself with decency and propriety in the business of life. His wishes and inclinations, his likings and dislikings, have all undergone a morbid change ; and this change ap- pears to be the originating cause, or to lie at the foundation of any disturbance, which the under- standing itself may have sustained, and even in some instances to form throughout the chief char- acter or constituent features of the disease.—(See Cyclop, of Pract. Med., art. Insanity.) Whether these morbid changes, however, in the inclina- tions and wishes, likings and dislikings, are strict- ly the originating cause, may very well be dis- puted.—Ed. RONIA. 171 ence of false judgments, who Unite incongruous or discrepant ideas, and draw from false asso- ciations right conclusions, yet whom we never think of regarding as out of their senses. While, on the contrary, if false perceptions be sufficient to cdnstitute madness, every man is insane who mistakes at a distance a square for a round tower, the bending azure sky that terminates an extensive landscape for the sea, or the distant rumbling of a heavy wagon over the streets for a peal of thunder : and we should none of us be safe from such a charge for a single day of our lives. Dr. Cullen seems to have embraced Mr. Locke's view of the subject; for his definition of insanity (vesaniae) in the latter editions of his Synopsis is, " injured functions of the mind in judging (mentis judicantis) without pyrexy or coma." Dr. Crichton, on the contrary, seems rather to adhere to Dr. Battie's view, though he enlarges and improves upon it; and hence his definition is, " general derangement of the mental faculties, in which diseased perceptions are mistaken for realities ; with incoherent lan- guage and unruly conduct." Diseased is certainly a better term than false, which is that of Dr. Battie ; but " unruly con- duct" does not essentially belong to madness, even under this excellent writer's own explana- tion ; for of the three species which he compre- hends under this disease as a genus, viz., mania furibunda, mania mitis, and melancholia, while the last, as he afterward illustrates it (Of Men- tal Derangement, book iii., ch. iii., vol. ii.), evinces these symptoms only occasionally, he expressly tells us of the second, that the dis- eased are " all happy, gay, and cheerful ; that good-humour characterizes this insanity, and hence the patients are in general very tracta- ble."—(Id., book i., ch. v., pp. 181, 182, vol. i.) But the chief objection to Sir A. Crichton's definition of insanity, is his limiting it, in respect to the mental faculties, to the power of percep- tion, while the judgment remains totally unaf- fected. " In regard to lunatics," says he, in another place, " and men who are of a sound mind, the faculty of judging is the same in both ; but they have different perceptions, and their judgments therefore must be different." Now, if the faculties of perception, attention, and memory be liable to derangement, as the same writer admits, and there be " a general derangement of mental faculties in insanity," there seems no sufficient ground for exempting the faculty of judgment. And a little attention to the history of an insane patient will, I think, sufficiently support the opinion of Mr. Locke and Dr. Cullen upon this point, and show that this, if not the faculty chiefly diseased, labours under at least as much disease as that of per- ception. We have already observed, in the proem to the present class, that all the powers of the mind are as liable to be affected with diseases, and diseases of various kinds, as those of the body ; and that either the body or the mind may be enfeebled at the same time in the whole of its powers, a few of its powers, or in a single 172 NEUROTICA. [Cl. IV.—Ord. I. power. A sound mind supposes an existence of all the mind's feelings and intellectual powers in a state of vigour and under the subordination of the judgment, which is designed by nature to be the governing or controlling principle. And, thus constituted, the mind is said to be in a state of order or arrangement. It often happens that this order or arrangement is slightly broken in upon by natural constitution or some corporeal affection ; but, so long as the irregularity does not essentially interfere witfi the mental health, it is no more attended to than slight irregulari- ties or disquietudes of the body. Yet, whenever it becomes serious and complicated, it amounts to a disease ; and the mind is said, and most correctly so, to be deranged or disordered. This derangement may proceed from a mor- bid state of any of the intellectual or any of the impassioned faculties of the mind ; for the per- ception may not correctly convey the ideas we receive by the external senses, or the judgment may lose its power of discriminating them, or the memory may not retain them, or the ima- gination or the passions may be in a state of unruly excitement—all which will lay a founda- tion for different kinds or genera of diseases, and, in fact, form the foundation of those appertain- ing to the present order. Now, an attentive examination into the habits of an insane person will show, first, that the judgment and the perception are both injured during the existence of insanity ; and next, that though, from a violent or complicated state of the disease, the morbid condition often extends to some other, or even to all the other mental faculties, yet it does not necessarily or essen- tially extend to them ; for a madman may be fu- rious or passionate, yet every madman is not so ; his memory may fail, or his attention be incapa- ble of fixing itself, or his imagination be wild and extravagant, but these do not always oc- cur. The faculties, however, of the judgment and the perception are affected in every case, though they are not always equally affected at one and the same time ; for the morbid power seems, for the most part, unaccountably to shift in suc- cession from the one to the other, so as alter- nately to leave the judgment and the perception free, or nearly free, from all estrangement what- ever ; the disease being, however, always ac- companied with irregular remissions, and often with such a diminution of sensibility that the patient is uninfluenced by the effects of cold and hunger, and very generally insusceptible of fe- brile miasm. Thus, a madman will often mistake one per- son who is introduced to him for another, and, under the influence of this mistake, will reason correctly concerning him ; and although he may have been for years his next neighbour, will ask him when he came from China or the East In- dies, by what ship he returned home, and wheth- er his voyage has been successful—in all of which the error may be that of the perception alone. But if, as is frequently the case, the patient address his visiter by his proper name, he gives a ground-for believing that he perceives him aright, and that the error is that of the judg- ment, which thus unites incongruous ideas, ap- plying a visionary history to a real and identified person. At another time, he may from the first perfectly recognise the individual so presented to him, and, to prove his recollection and the correctness of his perception, may rapidly run over a long list of his relations, and a long string of anecdotes respecting his former life ; after which he may suddenly start, and, looking at the visiter's walking-stick, tell him that that drawn sword will never save him from destruc* tion, nor all the men that slept with him in the same bed the night before—that his rival is now pushing forward with all speed on a black horse with a large army behind him, and that to-mor- row he will fight and lose his crown.* In such a case, and it is by no means an ex- treme one, the perception and the judgment travel soundly and in harmony at the outset of the interview, but they soon separate and aban- don each other as far as the east and west. It is not always easy to say whether the first par- oxysm of insanity that thus suddenly displays itself is limited to the one faculty or the other, or is common to both. For, if the perception suddenly wander, the judgment has a new train of ideas presented to it, artd must necessarily take a new direction. Yet it is difficult to con- ceive how the judgment can be thus abruptly led astray, if it continue sound ; and hence it is more probable that the judgment itself is at * The definition of madness adopted by Dr. Con- olly is, " a loss or impairment of one or more of the mental faculties, accompanied by the loss of comparison."—(Inquiry concerning the Indications of Insanity, p. 114.) The cases of Nicholai and Dr. Bostock prove that persons may be conscious of the appearance of phantoms and other illusions, and know them to be false, if the foregoing gen- tlemen, as Dr. Conolly remarks, had for one mo- ment lost the power of comparing, they must have believed the illusions to be real; and "from the moment of such belief they must have been mad, and the same so long as the belief remained." Dr. Conolly introduces the following observations in his illustration of his theory:—"In a fever, the patient's bed will seem in flames; or voices will whisper in his ear; or the smell of a banquet as- sail him; or his sense of touch seem opposed by moving bulky bodies; or the sense of sight will be harassed by the rapid succession of imaginary fa- ces, already spoken of, appearing and disappearing in endless trains and variety. If we talk with pa- tients thus affected, some will tell us, in a very quiet way, that they are thus tormented. Others will seem confused, and make a visible effort of sight and hearing before they tell us how they are troubled; and others will tell us what they see and what they hear, with an expressed belief, on their part, of the reality of what we know to be delu- sions. Of these three classes of patients," says Dr. Conolly, " the last are in a state of delirium; the second are approaching to it; the first are in a state of sound mind." In another part of his interesting publication (p. 123), Dr. Conolly admits that it is not always easy to determine, in the case of the insane man whether his sensation or his attention be impair- ed ; but the effect remarked, which may arise from either impairment, is the want of power of comparing one object with another, and thi= in such cases, produces the insanity.—Ed Gen. I.] ECPHI fault, and admits a train of ideas which, how- ever congruous to themselves, are incongruous to those furnished by the faculty of perception ; or both may equally wander and accompany each other in the visionary scene, as they at first as- sociated in the real. It is obvious, however, if I mistake not, that both faculties are affected in the derangement of insanity, jointly or in irregu- lar succession.* How far a morbid state of the mental facul- ties may in any case depend upon the mind it- self, as distinct from the sensorium or instru- ment by which it is connected with the body, it is impossible for us to know till we become acquainted with the nature of this connexion, and perhaps also with the essence of the mind, which, in our present state of information, seems to be a hopeless subject of inquiry. But we may possibly obtain some insight into the man- ner in which correct ideas of perception are changed in their nature and rendered incorrect or incongruous by a diseased judgment, by at- tending to a process ofvariation that is frequent- ly occurring in perfect sanity and acuteness of mind; " The ideas we receive by sensation," says Mr. Locke, in adverting to this process, " are often in grown people altered by the judg- ment without our taking notice of it." And he explains this position by observing that, when a ball of any uniform colour, as of gold, alabaster, or jet, is placed before the eye, the idea there- by imprinted in the mind is that only of a flat circle variously shadowed, with different degrees of light and brightness coming to the organ of * According to Dr. Conolly's views and argu- ments, which are replete with truth, each of the faculties of the mind may be impaired, and impair- ed without insanity ; at the same time, when the impairment of them, or any one of them, is such as to bring on inability to perform the act of compar- ison, or is accompanied by the loss of this faculty, insanity is the direct and inevitable result. The decisions are then no longer correct, the judgment no longer sound, and the actions no longer rational. —(See Inquiry concerning the Indications of Insan- ity, p. 170.) And, in a subsequent part of the work, when speaking of cases in which the sensations are morbid, Dr. Conolly justly observes, that, in numerous instances, the hallucination of the sense arises from an imagination previously over-excited ; that over-excitement is disease, but not madness ; it produces a hallucination, but, if the hallucina- tion is known to be a hallucination, still there is no madness; if it is mistaken for reality, then the man is mad.—(P. 307.) Dr. Conolly gives from Shak- speare a fine illustration of the struggle between sanity and insanity. When the dagger first ap- pears to Macbeth, although apparently sensible that it is a delusion, he attempts to seize it; and failing to do so, says,— " I have thee not, and yet I see thee still. Art thou not, fatal vision, sensible To feeling, as to sight ? or art thou but A dagger of the mind, a false creation, Proceeding from the heat-oppressed brain V " The exercise of one sense to correct the sus- picious evidence of another, the comparison, and the questioning which follows, are very striking. As Macbeth proceeds, it will be observed that he is struggling to exercise the comparison, which will prevent his belief in the delusion; and that ONIA. 173 sight. " But, having by use been accustomed to perceive what kind of appearance convex bodies are wont to make in us, what alterations are made in the reflections of light by the dif- ference of the sensible figures of bodies, the judgment presently, by an habitual custom, al- ters their appearances into their causes ; so that from that which truly is variety of shadow or colour, collecting the figure, it makes it pass for a mark or figure, and frames to itself the per- ception of a convex figure and a uniform col- our."—(Human Underst., book ii., ch. ix., § 8.) ■ And the same change occurs still more con- spicuously in looking at an engraving or a picture, in which the only idea presented by the eye to the perception is that of a plane variously shaded or coloured, but which the judgment im- mediately changes and multiplies into other ideas of life and motion, and running streams, and fathomless woods, and cloud-capt moun- tains. And if in a sane state we find the judg- ment capable of thus varying the ideas of per- ception presented to it, we can have no great difficulty, I think, in conceiving by what means such a variation may be produced, and may ram- ify into incongruities of great extravagance in a judgment deranged by disease. Nor is there much difficulty in conceiving how the paroxysm should be subject to remis- sions or even intermissions more or less regu- lar, or the derangement be limited, as we fre- quently find it, and especially in melancholy, to particular subjects or trains of ideas. For, first, all diseases have a tendency to remissions or in- when he becomes fully able to do it, he triumphs over the delusive appearance. The struggle is be- gun in the lines already quoted; it is continued in the following:— " ' I see thee yet, in form as palpable As this which now I draw. Thou marshall'st me the way that I was going; And such an instrument I was to use. Mine eyes are made the tools o' the other senses, Or else worth all the rest.' " Here we observe that the delusion is power- ful, but that Macbeth compares it with the reality of his own dagger; he is evidently connecting the appearance with the cause of it; with his actual intentions, and mentally accounting for it by asso- ciating it with his hidden thoughts; yet he reasons with himself concerning the possibility of the evi- dence of his eyes being finer and truer than any other evidence, or the greater probability that by his state of commotion, and his disturbed feelings, his eyes are made ' the tools o' the other senses.' In this state of agitation the vision assumes some variety, while it maintains its distinctness ; but the words which follow show us that the mental process, the reasonings, the comparisons which Macbeth has made, effect a triumph over the de- lusion :— " ' I see thee still; And on thy blade and dudgeon gouts of blood, Which was not so before.— There's no such thing. It is the bloody business, which informs Thus to mine eyes.' " These passages, and the comment on them by Dr. Conolly, certainly present a beautiful illustra- tion of some of the doctrines concerning insanity contained in his valuable publication.—Ed. 174 NEUROTICA. [Cl. IV—Ord. I. termissions; but those connected with the brain or nerves more than any others, as is evi- dent in hemicrania, epilepsy, hysteria, and pal- pitation of the heart. And, next, there is no man in a state of the most perfect sanity whose judgment is equally strong and exact upon all subjects, and few whose judgments are not man- ifestly influenced and led astray by partialities or peculiar incidents of a thousand kinds : in- somuch that we dare not, on various occasions, intrust to a man of the strictest honesty and the clearest head a particular subject for his decision, whom we should fly to as our coun- sellor upon every other occurrence. And it is not, therefore, very extraordinary, that in a mor- bid state of mind, and particularly of that fac- ulty which constitutes the judgment, there should be an aberration in some directions or upon some subjects which does not exist upon others. The corporeal indications differ as much as those of the mind, and generally as being gov- erned by the latter. We have hence sometimes, as an opening symptom, an extraordinary flow of high spirits ; at others extreme terror. The countenance is pale and ghastly, and strongly expressive of inward emotion ; the speech hur- ried and tremulous ; and the extremities be- dewed with a cold sweat. In other instances the eye glares malignantly; the face is flushed, and evinces a dreadful ferocity ; the objects of terror become objects of vengeance ; and the pa- tient is furious. In some there is an unusual degree of suspicion, and an anticipation of evil, and a belief in imaginary plots or conspiracies. In others, great irascibility and malignity, and a desire to commit some act of desperation, ven- geance, and cruelty. All this is often combined with headache, giddiness, throbbing of the tem- ples, or impaired vision. There is little or no sleep, for the mind is in a state of too much ex- citement ; though at times the patient lies list- less, and refuses to be roused.—(Annual Re- port of the Glasgow Asylum for Lunatics, .1821.) Concerning therefore the remote or even the proximate cause of the disease, we have yet much to learn. From the view we have taken in the proem of the close connexion between the mind and the brain, it seems reasonable to conceive that the remote cause is ordinarily de- pendant upon some misconstruction or misaf- fection of the cerebral organs ; and hence every part of them has been' scrutinized for proofs of so plausible an hypothesis, but hitherto to no pur- pose whatever. The form of the cranium, its thickness, and other qualities; the meninges, the substance of the brain, the ventricles, the pineal gland, the commissures, the cerebellum, have all been analyzed in turn, by the most dexterous and prymg anatomists of England, France, Germany, and Italy, but with no satis- factory result. The shape or thickness of the scull has been started, indeed, as a cause, by many anatomists of high and established reputa- tion ; but the conjecture has been completely disproved by others, who have found the very structures supposed to be most certain of pro- ducing madness, exist in numerous instances with perfect soundness of intellect. A particu- lar shape of the scull seems, indeed, to be often connected with idiotism from birth or soon after birth, but with no other species of mental de- rangement whatever. Morgagni engaged in an extensive course of dissections upon this subject, and pursued it with peculiar ardour ; and his results are given in his eighth epistle, from the second to the eighteenth article. In some cases the brain was harder, in some softer, than in a healthy state ; occasionally the dura mater was thicker, and was studded with soft, whitish bodies on the sides of the longitudinal sinus. ' This sinus itself sometimes evinced polypous concretions ; and the pineal gland, or several of the glands in the plexus choroides, were in a diseased state. Dr. Greding (Vermischle Medicinische und Chi- rurgische Schriften, Altenb., 1781), with a like spirit of investigation, arrived at a like diversity of facts. Meckel found the brain denser and harder than usual (Hist, de I'Acad. Royale des Sciences, &c, Ann. 1760, Berol., 4to., 1761); Dr. Smith (Med. Observ. and Inquir., vol. vi.) descried a bony concretion, and Plenciz and several others represent the brain as bony or calculous in various parts ; while Jones, in the Medical Commentaries, found it softer than usual, with a thickening of the membranes and a turgescence of the ventricles. From all which, nothing precise or pathognomonic can be col- lected, since all such morbid appearances have been traced under other diseases as well as under insanity. M. Pinel is firmly decided upon this point; and after a very extensive course of investiga- tions, he asserts, with respect to the cranium, that there are no facts yet clearly established which prove the faculties of the mind (except in the case of idiotism) to be in any degree in- fluenced by its size, figure, or density : while with respect to the contents of the cranium, " I can affirm," says he, " that I have never met with any other appearances within the cavity of the scull, than are observable on opening the bodies of persons who have died of apoplexy, epilepsy, nervous fevers, and convulsions :" and his successors M. Esquirol and M. Georget con- cur in the same remarks. The last, after hav- ing examined three hundred lunatics on their de- cease, to settle the point before us, thus con- cludes : " Toutes les alterations que nous avons observees sur les alienees de la Salpetriere sont consecutives au deVeloppement de la folie, ex- cept6 celles des cerveaux d'idiotes, qui sont primitives et liees a l'etat intellectuel." The observations of Haslam are nearly to the same effect: for they concur in showing that, except in so considerable a misformation of the scull or its contents as to induce idiotism from an early period of life, as in the case of cretinism, nothing decisive can be obtained in reference to insanity from any variations of appearance that have hitherto been detected.* * From the dissections recorded by Dr. Haslam his own inference is, that madness is always cobh Gen. I] ECPHRONIA. 175 The dissections of Greding extended to not fewer than two hundred and sixteen maniacal patients, the whole of whom, however, died of disorders unconnected with their mental ail- ments: three of the heads were exceedingly large, two exceedingly small; some of the scull- bones extremely thick, others peculiarly thin ; in some, the frontal bones were small and con- tracted ; in others, the temporal bones com- pressed and narrow. In a table containing an aggregate of the patients received into the lunatic asylum at Bicetre during a considerable part of the French revolution, from 1784 to 1792, by far the greatest number admitted were between the ages of thirty and forty : next, those between forty and fifty; next to these, patients between twenty and thirty; then those from sixty to seventy; nected with disease of the brain or its membranes. Indeed, he expresses a decided opinion that in- sanity is not a disease of ideas, and is among the first who in modern times have regarded it as con- nected with disease of the brain or its membranes. —(See Obs. on Madness and Melancholy, &c, p. 238, &c.) A similar opinion had been previously deliveredby Dr. Marshall.—(See Morbid Anatomy of the Brain in Mania, &c.) According to Gre- ding, the pia mater and arachnoid membrane were hardly ever sound. The same fact was noticedby Dr. Haslam in thirty-seven out of thirty-eight dis- sections ; also by J. Werzel, of Mentz (Obs. sur le Cervelet, &c, trad, par M. Breton, Paris, 1811); and Chiarugi, of Florence (Delia Pazzia, &c, in Firenze, 1794). M. Bayle considers chronic me- ningitis, a form of meningeal inflammation essen- tially and primarily chronic, as the most frequent pathological cause of mental derangement.-(Traite des Maladies du Cerveau, &c, Paris, 1826.) The frequency of disease of the brain in insane persons is confirmed by the researches of M. Calmeil.— (De la Paralysie consider^ chez les Aliened, &c, Paris, 1826.) Dr. Conolly also agrees in " ascri- bing mental disorders to corporeal disease ; not to any specific corporeal disease, but to any disease capable of disturbing the functions, or impairing the structure of the nerves:" yet he adds, " we do not find in insanity, as in consumption, such in- variable disorganization or impairment as would account for the long continuance of the malady, or for the small proportion of cures."—(An Inquiry concerning the Indications of Insanity, p. 14.) When insanity proceeds from adversity, domestic calamity, and other external influences on the mind, and especially when the alteration of the mind is suddenly produced by such causes, the connexion of the mental change with any organic or visible disease must be, at least in the first in- - stance, beyond all suspicion, unless disturbance of the innervation and circulation, and other func- tional disorders, not necessarily accompanied by change of structure, be comprehended under the denomination of corporeal diseases. As Dr. Uwins observes,—"Who shall pronounce upon the pre- cise nature of that change in the sentient organi- zation, when unexpected intelligence instanta- neously destroys a keen appetite? when madness occurs as the immediate result of some heart- rending disappointment ? when the whole man is thoroughly and in a moment revolutionized by a change of scene and circumstance? or when faith in a physician at once breaks down the strong- holds of hitherto confirmed disease?"—On Dis- orders of the Brain and Nervous System, p. 11, 8vo., Lond., 1833.—Ed. and lastly, those from fifteen to twenty ; below which we have no account of any admission whatever. Hence different stadia of life seem to exercise some control, and the period most exposed to the disease is that in which the in- fluence of the passions may be conceived to be naturally strongest and most operative. "Among the lunatics confined at Bicetre," says M. Pinel, " during the third year of the repub- lic, and whose cases I particularly examined, I observed that the exciting causes of their mala- dies, in a great majority of instances, were ex- tremely vivid affections of the mind; as un- governable or disappointed ambition, religious fanaticism,* profound chagrin, and unfortunate love. Out of one hundred and thirteen mad- men, with whose histories I took pains to make myself acquainted, thirty-four were reduced to this state by domestic misfortunes ; twenty-four by obstacles to matrimonial unions which they had ardently desired to form ; thirty by political events connected with the revolution; and twenty-five by religious fanaticism" Those were chiefly affected who belonged to profes- sions in which the imagination is unceasingly or ardently engaged, and not controlled in its ex- citement by the exercise of the tamer functions of the understanding, which are more suscepti- ble of satiety and fatigue. Hence the Bicetre registers were chiefly filled from the professions of priests, artists, painters, sculptors, poets, and musicians: while they contained no instances of persons whose line of life demands a pre- dominant exercise of the judging faculty : not one naturalist, physician, chymist, nor geome- trician. But there are other organs that also betray very prominent signs of diseased action in in- sanity as well as the brain, as those of the epi- gastrium and the adjoining regions : and hence other physiologists have sought for a remote or even a proximate cause of the malady in these, rather than in the encephalon. This was the case among several, though not the majority, of the Greek physicians, as we have seen already ; and it is to this quarter that M. Pinel refers the proximate cause in almost every instance in our own day. It is here he supposes the disease to commence, and contends that the affection of the brain and of the mental faculties is sub- sequent to the abdominal symptoms, and alto- gether dependant upon them ; and, in proof of this, he adverts to various dissections which have shown a considerable derangement, not only in the function, but even in the structure of one or more of the abdominal organs, and particularly a displacement of the transverse colon. But this is to give a weight to the morbid ap- pearances occasionally manifested in these or- gans, above what is allowed to like misforma- tions in the cranium. Yet there can be no doubt that, in most cases of insanity, the brain * According to Dr. Burrows, there are five times as many females insane from this cause as males.— See Commentaries on the Causes, Forms, Symp- toms, and Treatment, moral and medical, of In- sanity, 8vo., 1828.—Ed. iwg JNfcUK and epigastrium suffer jointly ; and that the dis- ease may, and often does, commence in some structural or functionary affection of the abdom- inal organs, is perfectly clear from the fre- quency of this complaint during pregnancy and in childbed: its being connected with a pecu- liar state of the genital organs, as we shall pres- ently have occasion to show, and its following upon a sudden suppression of the menstrual or hemorrhoidal discharge. Nor is it difficult to account for this associa- tion of influence from the extensive distribution of the par vagum, and more particularly of the intercostal nerve over the abdominal viscera : on which account a like sympathy is by no means uncommon in various other disorders. Thus, while a concussion or compression of the brain produces nausea, sickness, and constipa- tion, worms are frequently found to excite con- vulsions or epilepsy. The fair result of the whole inquiry appears to be, that insanity, in every instance, to adopt the language of Sir A. Crichton, "arises from a diseased state of the brain or nerves, or both" (Of Mental Derangement, vol. i., p. 138); but that in many instances this diseased state-is a primary affection, and in others a secondaiy, dependant upon a morbid condition of the epi- gastric or some other abdominal organ : for, in whatever this morbid condition may consist, and whatever symptoms it may evince, it is not till the sensorium has by degrees associated in the chain of unhealthy action, that the signs of in- sanity are unequivocal. And, in like manner, dyspeptic and other abdominal symptoms are not unfrequently brought on by a previously dis- eased state of the mind: and it is hence pecu- liarly difficult, and perhaps in some cases alto- gether impossible to determine, where we are not acquainted with the incipient symptoms, whether melancholy or hypochondrias has origi- nated in the state of the abdominal viscera or of the cranium ; or, in other words, whether the one or the other be a primary or a secondary affection. * The ensuing passage conveys Dr. Conolly's mode of viewing one part of this mysterious sub- ject, which has defied, and, as Dr. Good states, will continue to defy, all attempts at a satisfactory explanation :—" The manifestation of the mind must depend upon, and be modified by, the de- velopment of the brain in each individual. The same intellectual light may be given to all; but, in some, obscured by a gross organization; and in others, more happily organized, shining forth more brightly. Itself out of the reach of physical injury, it works by physical instruments; and the exact- ness of its operations depends on the growth, ma- turity, integrity, and vigour of its instruments, which are the brain and nervous system. If the nervous agents of sensation are unfaithful, the mind receives false intelligence, or transmits its orders by imbecile messengers; if the seat of thought, the centre of intellectual and moral gov- ernment, is faultily arranged, the operations of the understanding are impeded and incomplete."— (See An Inquiry concerning the Indications of Insanity, p. 62.) The editor cannot, discover the agreement between the tenour of these observa- tions, and the doctrine to which the author of the OTICA. [Cl. IV.—Ord. I. When, however, we are made acquainted with the history of the incipient symptoms, we have a tolerable clew to guide us; and for the most part may safely decide, that the region primarily affected is that which first evinces mOrbid symptoms; and hence, while we shall have little scruple in assigning the origin of most cases of hypochondriacism to a morbid con- dition of one or more of the digestive organs, we need have as little in assigning the greater number of cases of mania to a primary mis- affection of the brain or the nerves. In what that misaffection consists is a ques- tion that has never been settled to the present hour; and from our total unacquaintance with the nature of the connexion between the brain and the mind, it never will be in any very satis- factory manner.* The morbid changes, indeed, which we have already seen are frequently to be traced in the structure of the brain, show very sufficiently that a considerable degree of diseased action has been taking place there; but as these changes are often found in other dis- orders of the head as well as in mania, and more especially as we cannot tell whether they have preceded or been produced by such action, they give us little information as to the nature of the diseased action itself. Dr. Cullen has offered a series of ingenious arguments to prove that mania consists in some inequality in the excitement of the brain (Prac. Phys., vol. iv., Aph. 1562), or of the nervous power (Id. 1544), and, in most cases, in an in- creased excitement. Dr. Cullen's idea of the nervous power, as we have already had occa- sion to observe, is very far from being explicit: for he defines it " a subtile very moveable fluid, included or inherent in a manner we do not clearly understand, in every part of the medul- lary substance of the brain and nerves." While, in other parts of his writings, he represents it as never either recruited or exhausted, and thus conceives it to possess qualities beyond the ordinary endowments of living matter. Yet his general principle appears to be well found- ed, and Sir Alexander Crichton has availed him- foregoing excellent work inclines, that mental dis- orders may be ascribed to any corporeal disease capable of disturbing the functions, or impairing the structure of the brain. The incongruity which is here manifest, depends upon the term mind be- ing made to signify also the soul. But the intel- lectual organization and functions certainly con- stitute a very different subject from that of the theological doctrines of our immortal nature. Hence, also, the following passage cannot be cor- rect :—" Nay, so dependant is the immaterial soul upon the material organs, both for what it receives and what it transmits, that a slight disorder in the circulation of the blood through different portions of nervous substance, can disturb all sensation, all emotion, all relation with the external and living world; can obstruct attention and comparison; can injure and confound the accumulations of the memory, or modify the suggestions of imagina- tion." The statement is not accurate in relation to the soul; but unobjectionable, perhaps, if ap- plied to the mind. Our souls, it is to be hoped, will exist, when our brain, nerves, circulation, &c, are no more.—Ed. Gkn. I.] ECPHRONIA. 177 self of it in giving a fuller explanation of this highly probable hypothesis : and, after appealing to the doctrine which has already been advanced and. supported in the preceding pages of the present work, that the nervous power is a pecu- liar fluid secreted in the medullary substance of the brain or the nerves, he endeavours to show that the cause of insanities is a specific morbid action of the vessels which secrete the nervous fluid in the brain (Of Mental Derangement, vol. i., p. 174); and which may hereby be altered not only in quantity but in quality.* From the quickness of the external senses, the irascibility, heat of the skin, flushed coun- tenance, and uncommon energy which maniacs evince, we have reason to believe this morbid action to be, for the most part, a preternaturally increased action; and we are hence able to ac- count for the various exacerbations and remis- sions which it evinces, sometimes periodically, and sometimes irregularly. Yet as the health of the faculties of the mind must depend upon a healthy energy of the vessels, too scanty a se- cretion of nervous fluid must be as effectual a cause of mental derangement as too copious a flow ; and hence torpor of the vessels of the brain may prove as certain a cause of a wander- ing mind as entony, and, consequently, typhus fever may become a source of delirium as well as inflammatory. And as the various secretions can only be elaborated from the blood, and are often affected by its condition, we may see also how madness may be a result of acrid narcotics and other poisons introduced into the blood by absorption, or a transfusion of blood from ani- mals of a different nature, of which Dionis has given some very striking examples. That there is a tendency not only to an in- creased secretion of sensorial power in the head in most cases of insanity, but to an accumula- tion of it from all parts of the body, and espe- cially from the surface, is clear from the patient's * Id., vol. i., p. 169. With respect to the hy- pothesis here laid down, the editor has already de- livered his opinion in the Physiological Proem. That the brain is an organ receiving a very great supply of blood; that its vessels are large and nu- merous ; that an increased determination of blood to the brain, or, on the contrary, a diminution of the quantity conveyed to it, must have an effect upon the cerebral functions; that the vessels se- crete from this blood the medullary and cortical substances, the fluid in the ventricles, and every kind of matter composing the various tissues of the brain; and that the perfect or imperfect state of the intellectual and nervous powers is intimately dependant upon the condition of the circulation within the head, are facts of which no doubt can be entertained. But when the venturesome phys- iologist proceeds farther, and first assumes the existence of a nervous fluid as synonymous with sensorial or nervous power, represents it as a se- cretion, and mental derangement as arising from its altered quality or quantity; he is getting out of his depth, and only contenting himself with an hypothesis, which, if it were admitted, would, after all, not render the subject at all more intelli- gible. Instead of the " secretion of the nervous fluid," it might be better, therefore, to read, " the production of nervous or sensorial power."—Ed. Vol. II.—M diminished sensibility to external impressions, and his being able to endure the severest winter's cold, and a fasting of many days, without incon- venience or indeed consciousness. But that there is, in some cases, a diminished secretion of this fluid, producing a general debility of the living fibre, is also clear from the great tendency manifested by some maniacs, whose brain gives no proof of increased excitement, to a gangrene in their extremities, and, where they are un- cleanly, about the buttocks. The insensibility from this cause is sometimes so considerable as to affect not only the diffuse organ of feeling, but some of the local senses as well. And hence some patients lose their hearing, and others are capable of staring at the meridian sun without pain, or any change in the diameter of the iris.—(Blumenb., bibl. i., p. 736.) Some- times, however, the increased secretion of sen- sorial power is so considerable as not only to affect the head, but to augment the corporeal sensibility generally. And hence Hoffmann makes accumulated sensation an ordinary symp- tom of this disease (Opp., Suppl. ii., 2), mista- king the exception for the general rule : and Riedlin gives us an instance of a maniac, who, instead of calling for and being able to endure large quantities of snuff', sneezed and was con- vulsed on smelling the mildest aromatics.* It is a melancholy reflection, that insanity is often the result of an hereditary predisposition. This, indeed, has been denied by a few writers, but their opinion has unhappily been confuted by the concurrent voice of those who have thought differently, and the irresistible evidence of daily facts. Mysterious as the subject is, we have perpetual proofs that a peculiarity of mental character is just as propagable as a peculiarity of corporeal; and hence wit, madness, and idiot- ism, are as distinctly an heirloom of some fam- ilies, as scrofula, consumption, and cancer of others.i In most of the latter we have already observed that something of a constitutional make or physiognomy is often discernible ; and the * Lin. Med., 1696, p. 29. Such occurrences are only accidental accompaniments of insanity, by no means essential to it, or even indicative of its existence. Were the contraiy view adopted, the modern Romans, who are greatly annoyed by a perfumed handkerchief, might be set down as lunatics, as well as others whose sense of smell is so inconveniently acute, that they almost " die of a rose in aromatic pain."—Ed. t In six sevenths of the cases which have come under the observation of Dr. Burrows, hereditary- predisposition was traced. He does not consider that the several forms of insanity tend to transmit each its own kind from one generation to another; but, on the contrary, that they mutually transmit one another, so that mania, melancholia, and hyp- ochondriasis, may be all remarked in different individuals of the same family. He admits, how- ever, one exception to this rule in the instance of suicidal insanity. Probably, hypochondriasis may be another exception. Dr. Burrows does not con- sider hereditary insanity more difficult to cure than other forms of it, which statement dis- agrees with what is commonly believed.—See Commentaries, &c, and Edin. Med. Joum., Ha. xcviii., p. 123. 178 NEUROTICA [Cl. IV—Ord. I. same is contended for by many authorities in the disease before us. Yet, if we examine the marks accurately, we shall find that they merge, for the most part, into the common symptoms of a sanguineous or melancholic temperament: either of which constitutions exercises such a control over the disease as to give it a peculiar modification, whatever be the nature of the ex- citing cause, which is, in truth, of little impor- tance to the constitutional turn the malady may take, though well worth attending to in the moral treatment. " The violence of the mani- acal paroxysm," observes M. Pinel, " appears to be independent of the nature of the exciting cause ; or, at least, to be far more influenced by the constitution of the individual, and the peculiar degree of his physical and moral sensi- bility. Men of a robust constitution, of mature years, with black hair, and susceptible of strong and violent passions, appear to retain the same character when visited by this most distressing of human misfortunes. Their ordinary energy is augmented to outrageous fury. Violence, on the other hand, is seldom characteristic of the paroxysms of individuals of more moderate pas- sions, with brown or auburn hair. Nothing is more common than to see men with light- coloured hair sink into soothing and pleasurable reveries ; while it seldom or never happens that they become furious or unmanageable. Their pleasing dreams, however, are at length over- taken by and lost amid the gloom of an in- curable fatuity. Those of the greatest mental excitement, of the warmest passions, the most active imagination, the most acute sensibility, are chiefly predisposed to insanity. A melan- choly reflection !—but such as is calculated to call forth our best and tenderest sympathies." It has long been a current opinion, that in- sanity is a disease more common to our country than to any other : and this opinion has of late been rendered more seriously alarming by the following assertion of Dr. Powell, secretary to the commissioners for licensing lunatic estab- lishments, and which is given as the result of his official tables of returns from 1775 to 1809 inclusive, divided into lustra or periods of five years each. "Insanity appears to have been considerably upon the increase : for if we com- pare the sums of two distant lustra, the one be- ginning with 1775, and the other with 1809, the proportion of patients returned as having been received into lunatic-houses during the latter period, is to that of the former nearly as > 129 to 100."—"The facts also," says he, u which present themselves to the observation of the traveller, whatever direction he may take through this country, and all the local informa- tion which we receive upon the subject, supply us, as I am led to think, with sufficient proof, that the increase must actually have been very considerable, though we cannot ascertain what has been its exact proportion."* The first part of. this opinion, or that which * Med. Trans., vol. iv., p. 131, art. Observa- tions on the Comparative Prevalence of Insanity at different Periods. regards insanity as a disease peculiarly prev- alent in England, does not seem to rest on any established basis ; for, calculating with Dr. Powell, that the number of lunatic paupers, and those received into public hospitals, which, under the act of parliament, are not cognizable by the commissioners, together with those neg- lected to be returned, compared with the returns entered into the commissioners' books, bear the proportion of three to two, which is probably far above the mark, Still the aggregate number of insane persons for the year 1800, contrasted with the general census for the same year, will only hold a ratio of about 1 to 7300 ; while if we take with Dr. Burrows the proportion of suicides committed in foreign capitals as a test of the extent to which insanity is prevalent in the same towns, which is nevertheless a loose mode of reckoning, though it is not easy to ob- tain a better, we have reason to conclude that insanity is comparatively far less frequent among ourselves than in most parts of the continent : the suicides of Paris, Berlin, and Copenhagen, as drawn from tables collected by Dr. Burrows for this purpose, being, in proportion to the rel- ative population of London, as 5 to 2 for the first, 5 to 3 for the second, and 3 to 1 for the third.—(Inquiry into certain Errors relative to Insanity, &c, p. 93, Svo., 1820.) Nor does the idea that insanity is an increas- ing disease in our own country appear to rest on a stabler foundation. Taking Dr. Powell's result as drawn from full and incontrovertible data, and comparing the supposed march of the disease with the acknowledged march of the population, although the former may possibly be said to have overstepped the latter by a few paces, the difference will hardly justify the as- sertion, that " insanity is considerably upon the increase." And if we take into view the inten- sity of interest with which this subject has, for the last twenty years, been contemplated by the public, the operation of those feelings of human- ity which have dragged the wretched victims of disease from the miserable abodes of prisons and neglected workhouses, and placed them under the professional care of the superintendents of licensed establishments, and, above all, the aug- mented number of such establishments in con- sequence hereof, and the great respectability of many who have the management of them, thus giving the 'commissioners returns which, by the power of the act of 26 Geo. III., they could not otherwise have been in possession of, we mav, I think, fairly conclude, that this apparent over- step, be it what it may, in the march of insanity beyond that of the population of the country, is a real retrogression. At this conclusion we might, I think, fairly arrive, even if the data selected by Dr. Powell were full and incontrovertible ; but he himself has candidly admitted that, instead of being full and incontrovertible, they " are subject to nu- merous inaccuracies, and that any deductions which may be made from them must be imper- fect." It is still more consolatory to learn, that the direct deductions from the parochial and dis- trict establishments are not only in accordance Gen. I.—Spe. 1.] ECPHRONIA MELANCHOLIA. 179 with Dr. Powell's, but such as seem to show that a retrogression, instead of an advance, has actually taken place. Dr. Burrows has indus- triously collected many of these, and, as far as they go, they lead to such an inference almost without exception.—(Inquiry, &c, ut supra, p. 66, et alibi.) Yet it is probable that even this inference does not give us the precise fact, and that it is as chargeable with an error on the favourable side, as the opposite account is on the unfavourable ; since the increase of licensed houses, whose returns seem to have swelled the list of the commissioners beyond its proper ag- gregate, has been considerably supported by a transfer from the establishments which have thus fallen off. And hence, allowing the error on the one side to compensate that on the other, we are brought to the conclusion which, after all, appears more natural, that the career of in- sanity is only varied in its uniformity by tem- porary contingencies, but that it is by no means a prevalent disease in our own country.* * Dr. Burrows thinks that climate does not ap- pear to be an exciting cause of insanity; but it cannot be denied, he adds, that the seasons are so; and that, when the thermometer is highest in temperate regions, the number of insane is great- ly augmented. Thus, in Paris, on taking the aver- age of nine years, the number of insane increased in May, arrived at its maximum in July, and grad- ually decreased till January, when it was at its minimum. Dr. Burrows also remarks, that the species of insanity termed suicidal always pre- vails most in the hottest season. From registers published in the cities of Westminster, Paris, and Hamburgh, suicides are most frequent in June and July ; in short, whenever the thermometer ranges near 84° F. Hence, he concludes, that it is not climate, but a high temperature, which exposes the intellectual functions to derangement. It would seem, at first view, from many circum- stances, that females are more liable to insanity than males. Dr. Rush remarks, that women, in consequence of the greater predisposition impart- ed to their bodies by menstruation, pregnancy, and parturition, and to their minds by being much alone in their families, are more predisposed to madness than men. Yet, according to the statis- tics given by Dr. Burrows (if we except large cities, as Paris, Lyons, Milan, &c, where immorality and habits prejudicial to the female prevail), the majority of the insane are men. In the Royal Asylum at" Charenton in France, from January 1, 1815, to January 1, 1823, 1453 lunatics were ad- mitted ; of these there were 847 males, 606 fe- males. Of 2507 insane admitted to the Parisian hospitals, 1095 were men, and 1412 were women. At Lyons, the proportion was, men 60, women 150. In England, the number of lunatics con- fined in private houses from 1812 to 1824, was 7804: of these, 4461 were males, and 3343 fe- males. But, according to an analysis published of the Pauper Lunatic Asylum in the county of Middlesex, including the metropolis, in 1827, the proportion was stated to be, men 307, women 546. In Scotland, in 1818, the proportion was, men 2311, women 2339. In the Dublin House of In- dustry in 1824 and 1827, nearly the same number of both sexes were admitted. The same was true of Zurich in 1823. In Germany, the men exceed. In Vienna, in 1812, the number of men insane was 177, of women 94. In Berlin, in 1816, the num- ber of insane males was 242, of females 177.— M 2 SPECIES I. ECPHRONIA MELANCHOLIA. MELANCHOLY. THE DISCREPANCE BETWEEN THE PERCEPTION AND THE JUDGMENT LIMITED TO A SINGLE OB- JECT, OR A FEW CONNECTED OBJECTS, OK TRAINS OF IDEAS : THE WILL WAYWARD AND DOMINEERING. We have already stated, that whatever be the exciting cause of mental alienation, the symptoms are in every instance greatly modi- fied by the prevailing idiosyncrasy ; and hence, though a love of solitude, gloom, fear, suspicion, and taciturnity, are the ordinary signs of the present species, these signs often yield to symp- toms widely different, and sometimes even of an opposite character; and we hence become possessed of the four following varieties:— a Attonita. Mute, gloomy, retiring mel- Gloomy melan- ancholy. choly. B Errabunda. Roving, restless melancholy, Restless melan- evincing a constant desire choly. to change the abode. - y Maievolens. Morose or mischievous mel- Mischievous mel- ancholy, occasionally ter- ancholy. minating in suicide, or the injury of others. (Burrows's Comment on Insanity,p. 241, London, 1828.) We must regret the imperfect statements of the number of insane in the United States. Dr. A. Brigham of Hartford, taking the ascertained number of insane in Connecticut as the basis of his calculation, estimates the whole number in the United States to be 50,000; which is certainly very large, and probably exceeds the true amount. —(See Remarks on the Influence of Mental Cul- tivation on Health, by Amariah Brigham, Hartford, 1832.) According, however, to the reports of the Bloomingdale Asylum, New-York, the number of insane in that institution, including those re- maining at the end of December, 1830, and those admitted and discharged during part of 1831, was 98; in 1832 and 1833, 216; of whom 145 were males, and 73 females ; in 1834, 103; of whom 67 were males, and 36 females. Dr. Burrows asserts that indulgence in ardent spirits is the cause why insanity prevails most among males, and in the U. States we have un- fortunately too many instances of this truth. Dr. Rush remarks, that on inquiring in regard to the insane confined in the Pennsylvania Hospital, he found that one third of the whole number had be- come deranged from intemperance. The most frequent cause of insanity, says the report of Dr. Woodward, the able superintendent of the Luna- tic Asylum at Worcester, Mass., is intemperance ; and we have reason to think the same is true as respects the inmates of the Lunatic Asylum at Bellevue and at Bloomingdale. If these facts be well founded, and there is rea- son to think they are, philanthropists have cause to be gratified with the salutary results which must follow from the extension of the temperance system in the United States; an abstinence from alcoholic drinks would diminish the number of the insane at least one half: hence, with the present exertions of the friends of temperance, insanity must be comparatively on the decrease in this country.—D. OTICA. fC'L. IV.—Ord. I. 180 NEUR S Complacens. Self-complacent and affable Self-complacent melancholy; occasionally melancholy. rejoicing in a visionary superiority .of rank, sta- . tion, or endowment. The same variety of symptoms, as chiefly modified by the prevailing temperament, are noticed by Fracastorio. " The phlegmatic," says he, " are heavy; the sanguine lively, cheerful, merry, but not witty ; the choleric are in rapid and perpetual motion, impatient of dwelling upon any subject. An acuteness of wit belongs to most of the varieties, but not to all."—(De Intellectione, lib. ii.) And hence Diodes, in opposing Galen for holding, after Hippocrates, that gloom and terror are pathog- nomonic signs of melancholy, observes, " Upon serious consideration I find some patients that have nothing of these qualities, and others that exhibit every diversity of feeling ; for some are sad without being fearful, others fearful without being sad ; some neither, and some both." Besides these modifications there is another of a very peculiar kind, noticed by Dr. Spurz- heim, in order to show that the faculties of the mind are double, and that each hemisphere of the brain contains a distinct set. As I have never met with an instance of this variety, I must describe it in his own words. " Tiede- mann," says he, "relates the example of.one Moser, who was insane on one side, and who observed his insanity with the other. Gall at- tended a minister who, having a similar disease for three years, heard constantly on his left side reproaches and injuries, and turned his head to that side in order to look at the persons. With his right side he commonly judged of the madness of his left side, but sometimes, in a fit of fever, he could not rectify his peculiar state. Long after being cured, if he happened to be angry, or if he had drunk more than he was accustomed to do, he observed in his left side a tendency to his former alienation."— (Physiognomical System, &c, p. 144, 8vo., 1816.) It may appear strange to those who have not studied the subject with much attention, that persons who are possessed of a diseased, or even defective judgment, should at any time be of quick and lively apprehension, and thus be witty without being wise. But the faculty of wit is dependant not so much on the judgment as on the imagination, and particularly on the memory; on the possession of a large stock of ideas stored up for ready use, and brought forth with rapidity. " And hence," says Mr. Locke, " some reason may perhaps be given of that common observation, that men who have a great deal of wit, and prompt memories, have not always the clearest judgment or deepest reason. For wit lying most in the assemblage of ideas, and putting those together with quick- ness and variety, wherein can be found any re- semblance or congruity, thereby make up pleas- ant pictures and agreeable visions in the fancy ; judgment, on the contrary, lies quite on the other side; in separating carefully, one from another, ideas wherein can be found the least difference, thereby to avoid being misled by similitude, and by affinity to take one thing for another."—(On Human Understanding, book ii., chap, xi., sect. 2.) And hence we may easily account for that gayety and those ebulli- tions of a vivid fancy, which so often assume the character of wit in persons whose minds are deranged, and especially in the sober faculty of the judgment. Mirth and wit, however, though sometimes found in the present species of insanity, are by no means its common characters : but, on the contrary, as we have already observed, a love of solitude, gloom, and taciturnity, and an in- dulgence in the distressing emotions of the mind. And hence, whenever hypochondriacism merges into actual insanity, it almost always takes this form ; as melancholy, from a sort of natural connexion, between the two, often as- sumes many of the symptoms that essentially appertain to the hypochondriac disease ; the morbid state of the brain influencing the abdom- inal organs in the latter case, as the morbid state of the abdominal organs influences the brain in the former. The disease shows itself sometimes suddenly, but more generally by slow and imperceptible degrees. Among the earliest symptoms may be mentioned headaches, frequent attacks of giddiness, sudden confusion of ideas, a great disposition to anger, violent agitations when irritated, and an uncommon sensibility of nerves, whereby the patient is apt to be carried to as great excesses from causes of joy as from those of grief. There is a desire of doing well, but the will is wayward and unsteady, and produces an inability of firmly pursuing any laudable ex- ertion, or even purpose, on account of some painful internal sensation, or the perverseness of the judgment, led astray by false or erroneous ideas which command a firm conviction in the mind.—( Crichton, of Mental Derangement, pas- sim.) And if the disease occur in a person possessing that temperament which has been conceived to predispose to it, and was by the Greeks denominated melancholic, the external signs become peculiarly marked and prominent : " the patient," says Hippocrates, in his book on insanity, " is emaciated, withered, and hol- low-eyed, and is at the same time troubled with flatulence and acid eructations, with vertigo and singing in the ears, gets little sleep, and when he closes his eyes is distracted with fear- ful and interrupted dreams." The first variety most commonly com- mences with this character, and creeps on so gradually that it is for some time mistaken for a mere attack of hypochondriacism or lowness of spirits (Falret, de VHypochondrie et du Suicide, passim, 8vo., Paris, 1822), till the mental alien- ation is at length decided by the wildness of the patient's eyes, the hurry of his step whenever he walks, his extraordinary gestures, and the fre- quent incongruity of his observations and re- marks. The first stage of the disease is thus ad- mirably expressed by Hamlet :—<:I have of late but wherefore I know not, lost all my mirthj foregone all custom of exercise ; and, indeed, it Gun. I.-Spe. 1.] ECPHRONIA 1 goes so heavily with my disposition, that this goodly frame, the earth, seems to me a steril promontory ; this most excellent canopy, the air, look you, this brave o'erhanging firmament, this majestical roof, fretted with golden fire, why it appears no other thing to me than a foul and pestilent congregation of vapours." But while the external world is thus in gen- eral falsely recognised by the perception, or falsely discriminated by the judgment, the mind is so completely possessed by some particular trains of imaginary ideas, that the attention is perpetually turned to them, and the judgment mistakes them for substances; and, so far as it is sensible of surrounding objects or scenery, is perpetually blending the vision with the real- ity. It is not that the patient's ideas are in- congruous with themselves, but with the world around him ; for the remarks of the melancholy man,-when his attention is once correctly fixed, are for the most part peculiarly shrewd' and pointed. But in the gloom that hangs over him under the variety we are now contemplating, he can rarely be brought into conversation, seeks for solitude, sits moping in one continued posture from morning till night; or, if he walk at all, seeks for orchards, back lanes, and the gloomiest places he can find. " One of the chief reasons," says Hippocrates, in his epistle to Philipoemenes, " that induced the citizens of Abdera to suspect Democritus of craziness, was, that he forsook the city and lived in groves and hollow trees, upon a green bank by a brook- side, or by a confluence of waters, all day and all night."* Sauvages, under the variety of melancholia attonita, gives an extreme case of the present modification, though not from personal knowl- edge. " The patient," says he, " never moves from place to place, nor changes his posture; if he be seated, he never stands up ; if standing, he never sits ; if lying, he never rises. He never moves his feet unless they are pushed aside by a by-stander; but he -does not shun * A gentleman residing in a part of the coun- try with which Dr. Conolly is well acquainted, easy in his circumstances, and not unhappy in his family, conceived an aversion to interchanging a word with anybody whatever. He would avoid people whom he saw approaching, or leave the room when they entered it. He generally had his hands clasped before him, and used to deal much in short exclamations, such as " Lord have mercy upon us'." " What a wicked world this is !" and so forth. Yet this man, when circumstances compelled him into conversation, wanted none of the powers, and had lost none of the information requisite for performing his part in it with credit. His aversion to meeting or speaking to people was a mere aggravation of what nervous persons are very subject to : but there appeared also to be in him an inaptitude of the nervous system to be so acted upon by ordinary impressions as to attend to them; but when the impression was increased, his faculties, and especially his attention, were roused into healthy action, and consequently he was not insane, according to the principles laid down by Dr. Conolly.—See Inquiry concerning the Indications of Insanity, p. 124.—Ed. [ELANCHOLIA. 181 the presence of man; if asked a question he does not answer, and yet appears to understand what is said. He does not yield to admonition, nor pay any attention to objects of sight or touch ; he seems immersed in profound thought, and totally occupied by foreign matters. Yet at times he is more awake ; if food be put to his mouth, he eats ; if liquor be presented, he drinks." M. de Sauvages then adds, that this rare modification of the disease occurred once to Dr. James, physician to the Elector of Sax- ony, in a man about thirty years old, who was terrified with the thought that the Deity had condemned him. It continued for four months, during the autumn and winter, but the patient was at length restored to his right understand- ing.—(Nosol. Med., class viii., ord. 3.) Grief, and particularly for the loss of friends, discontent, severe disappointment, the dread of some real or imaginary eviL a violent and long- continued exertion of any of the passions, and deep uninterrupted study, have frequently proved accidental causes or accessories of this variety of melancholy, where the peculiarity of the constitution has formed a predisposition, and have sometimes produced it even where no such predisposition can be traced. M. Magen- die met with a singular exemplification of this from a cause few would expect, though not dif- ficult of solution. The patient, an intelligent and agreeable man, though of a highly nervous temperament, had the misfortune, at the age of thirty-six, to meet with various crosses in busi- ness, and to have his wife become deranged in her confinement with her first child. All his energies were devoted to the recovery of his wife, whom he accompanied in travelling, which was recommended to her ; he nursed her with tender assiduity, and was a witness to all her sufferings of body and mind. In time she re- covered ; but he himself, instead of giving way to joy, fell into a state of the most distressing melancholy—believed himself ruined, pursued by the officers of police, and about to take his trial for some heinous offence. Upon every other subject his mind was sound. We have already observed that the sudden cessation of any habitual drain, or other corporeal irritation, has occasionally proved a cause of melancholy ; and we here find that there is at times as much danger in a sudden cessation of mental as of corporeal irritation ; the excited mind being as little capable of bearing the change in the one instance as in the other. And hence, whenever such an effect occurs in an irritable frame, the individual should be instantly roused to some new pursuit, that may swallow up, though more agreeably, the whole of the surplus of sensorial power that has habitually been produced. In the state above described M. Magendie's patient continued many months, when, from some un- known cause, the disease upon the mind was thrown upon the motific fibres, and he was at- tacked with a chorea ; the intellect recovering its powers as the muscles of locomotion were more and more thrown into the most ridiculous but involuntary gesticulations. He was restored from this, and to perfect health, by the use of 182 NEUROTICA. [Cl. IV.—Ord, t tonics, and especially the sulphate of quinine.— (Magendie, Journal de Physiologie, Avr., 1822.) Other excitements by which the present spe- cies is produced, are immoderate exercise, inso- lation, or long exposure to the direct rays of the sun, sudden transitions from heat to cold, pow- erful stimuli applied to the stomach. In the case related by Sauvages, the disease appears to have proceeded from a heated ima- gination exercised upon false views of religion : and perhaps there is no cause more common or more operative, especially in timid minds ; and more particularly still where the conscience is alarmed by a review of a long catalogue of real delinquencies, and a dread of eternal reprobation. Few persons have given a more striking ex- ample of this than the Abbe de Ranee" when first touched with remorse for the enormity of his past life, and before the disturbed state of his mind had settled into that turn for religious se- clusion and mortification which produced the appalling austerities of La Trappe. " To this state of frantic despair," says Dom Lancelot in his letter to La Mere Angelique of Port Royal, " succeeded a black melancholy. He sent away all his friends, and shut himself up in his man- sion at Veret, where he would not see a crea- ture. His whole soul, nay, even his bodily wants, seemed wholly absorbed in a deep and settled gloom. Shut up in a single room, he even for- got to eat and drink : and when the servant re- minded him that it was bedtime, he started as from a deep revery, and seemed unconscious that it was not still morning. When he was better, he would often wander in the woods for the entire day, wholly regardless of the weather. A faithful servant, who sometimes followed him by stealth, often watched him standing for hours together in one place, the snow and the rain beating on his head; while he, unconscious of them, was wholly absorbed in painful recollec- tions. Then, at the fall of a leaf, or the noise of the deer, he would awake as from a slumber, and wringing his bands, hasten to bury himself in a thicker part of the wood; or else throw himself prostrate, with his face in the snow, and groan bitterly." The same causes operate in the production of roving or restless melancholy, forming the second variety, and exhibiting a modification which often depends obviously upon a difference of idiosyncrasy, though the cause is not always to be explained, and under the operation of which the patient has a constant desire to change his pursuit or his residence. And hence, while Al- bert Durer is entitled to the approbation he has so long received for his admirable picture of melancholy, under the guise of a pensive female leaning on her arm with fixed looks and neg- lected dress, Shakspeare has equally copied from nature in his description of the beautiful and in- teresting Ophelia, who, instead of shutting her- self up from the world, and seeking silence and solitude, is represented as peculiarly busy and talkative, and unwittingly divulging the fond se- cret of her distraction to every one she meets, as well in verse as in prose. Sadness is the prevailing colour of the mind; but it is often, as Jaques expresses it, " a most humorous sad- ness," so blended with sallies of pleasantry and wit, that is impossible to listen to them without smiling, notwithstanding the gravity of the oc- casion. " Humorous they are," says Burton (and, unhappily for himself, no one knew how to describe the disease better), " beyond all meas- ure ; sometimes profusely laughing, extraordi- narily merry, and then again weeping without a cause ; groaning, sighing, pensive, and almost distracted. Multa absurda fingunt et a ratione aliena (Frambes. Consult., lib. i., 17); they feign many absurdities, void of all reason : one sup- poseth himself to be a dog, cock, bear, horse, glass, butter. He is a giant, a dwarf, as strong as a hundred men, a lord, duke, prince. Many of them are immoveable and fixed in their con- ceits ; others vary upon every object heard or seen. If they see a stage-play, they run upon that for a week after ; if they hear music or see dancing, they have naught but bagpipes in their brain; if they see a combat, they are all for arms ; if abused, the abuse troubles them long after. Restless in then thoughts and actions, continually meditating,— ----'velut aegri somnia, vanae Finguntur species;'—— more like dreamers than men awake, they feign a company of entire fantastical conceits : they have most frivolous thoughts, impossible to be effected; and sometimes think verily that they hear and see present before their eyes such phan- tasms or goblins they fear, suspect, or conceive ; they still talk with and follow them. ' They wake,' says Avicenna, ' as others dream.' Though they do talk with you, and seem to be very intent and busy, they are only thinking of a toy ; and still that toy runs in their mind, what- ever it be ; that fear, that suspicion, that abuse, that jealousy, that agony, that vexation, that cross, that castle in the air, that crochet, that whimsey, that fiction, that pleasant waking dream. If it be offensive, especially, they cannot forget it; they may not rest or sleep for it ; but still tormenting themselves, Sisiphi saxum volvunt sibi suis." How melancholy a reflection, that the writer of this spirited description should have drawn many of its features from himself; and that the work from which it is copied, engaged in for the purpose of diverting his thoughts, and replete with genius, learning, and the finest humour, should only have exasperated the disease, and urged the pitiable patient, as there is too much reason to fear, to an untimely end ! " He com- posed his book," says Mr. Granger, " with a view of relieving his own melancholy ; but it in- creased it to such a degree that nothing could make him laugh but going to the bridge-foot, and hearing the ribaldry of the bargemen, which rarely failed to throw him into a violent fit of laughter. Before he was overcome with this horrid disorder, he, in the intervals of his va- pours, was esteemed one of the most facetious companions in the university." The third variety, in which the alienation assumes a morose or mischievous character, is Gen. I.—Spe. 1.] ECPHRONIA MELANCHOLIA. 183 perhaps the most common Form under which the disease makes its appearance. Sometimes the patient is extremely passionate, and will quarrel furiously with every one alike, in whatever tone or manner he is addressed, and expresses him- self with great violence of language, occasion- ally with gross unqualified abuse, but occasion- ally also in a style of repartee that never was evinced in a sane state. More generally, how- ever, he selects his objects of resentment; which are, for the most part, unaccountably taken from his nearest relations and kindest friends. Against these he haTbours the blackest suspicion and jealousy, believing that they are haunting him to take away his money or his life, or to put him to torture. He loads them with every term of the deadliest hatred, or scowls at them with con- tempt, and denounces them as fools and idiots. Under the distressing influence of this horrid form of the disease, the mother abominates her infant family, and the wife her husband; the most chaste become lascivious ; and lips which have hitherto uttered nothing but the precepts and the language of piety, become grossly pro- fane, and are the vehicles of oaths and impu- dence. The unhappy individuals are, at the same time, not only sensible of what they say or do, but occasionally, sensible of its being wrong, will express their sorrow for it immediately after- ward, and say they will not do so again. But the waywardness of the will, and its want of control by the judgment, urge them forward in spite of their desire,' and they relapse into the same state almost as soon as they have express- ed their regret. Mr. Locke has, with great ability, pointed out the proper distinction be- tween these two faculties of the desire and the will, and has exemplified'it by the chastisement with which an indulgent father frequently finds himself called upon to visit an offending child, and which he wills to perform, though his desire is in the utmost degree reluctant. The disease before us is pregnant with examples of the same kind, and strikingly shows the correctness with which this great master of his subject analyzed the human mind. We have already observed that the peculiar turn or modification of the malady depends in general far less upon the immediate and exciting cause, than upon the constitutional temperament, or some operative principle which we cannot always develop. And in proof of this it may be hinted that I have drawn the principal linea- ments of the description just laid down from the case of a lady of about sixty years of age, re- specting whom I was lately consulted, and whose exciting cause has been, manifestly, suppressed grief for the death of an only son, and separa- tion from a daughter who was the remaining solace of her advancing years, in consequence of her having married a gentleman whose sta- tion is in a remote part of the globe. Possess- ed by nature of a high and commanding spirit, and of a peculiar degree of energy and activity, she effectually succeeded, by a violent internal struggle, in subduing the pangs that at first suf- focated her; and has for several years talked of her daughter, and her daughter's children, for the latter has since become a mother, with- out emotion. But with the loss of fine feel- ing for her daughter, she has lost, at the same time, all fine feeling upon other subjects ; and her judgment has sunk amid the general wreck. The love of her nearest relations has turned to contempt or hatred; the ardour and animation of her mind, which restrain her from taciturnity and retirement, have rendered her forward and invective ; rational expostulation has yielded to sudden and unmeaning fits of violence and blows, and the voice of piety to exclamations that would formerly have shocked her beyond endurance. She, too, is often sensible of her doing wrong, and, in letters of great sobriety and excellence, often complains of her own conduct, and the burden she is become to her friends ; but the intervals of sanity are only of a few hours' du- ration, and with all her calmness, she is sure to relapse.—(Compare with the Report of the Glas- gow Asylum for Lunatics, 1821.) For many months she was intrusted in her own house to the control of a professional female attendant, who, with great dexterity, at length succeeded in obtaining a due degree of authority over her without personal restraint; and, under the regi- men of perfect quiet and seclusion from the world, she seemed to be in a fair way of recov- ery ; but the mischievous fondness of her near- est relations has since removed this faithful watchwoman, and her senses have again been bartered for her liberty. The symptoms most afflictive to the relations of the patient in this variety of insanity are the tendency to behold them with indifference or even violent aversion, and to utter exclamations and employ language of the most offensive kind to a serious and a delicate ear; and it is the symp- tom apparently most unaccountable to those who have not studied the disease with much atten- tion. I have already remarked that, in insanity, the corporeal sensibility is greatly diminished, but it is not more so than the moral sensibility ; and as the moral sensibility disappears, all moral restraint disappears also: and for the reason that the insane man has little, feeling of cold or hunger, he has also little feeling of decency or religion. In the present variety, the worst pas- sions are in a state of exeitement, and the lan- guage most freely employed is the language of the passion that predominates; and there being no longer any moral restraint, it is em- ployed in its utmost vehemence and coarseness. And as the fond affections have given way to the irascible, it should seem to follow, of course, that the greater the love or friendship formerly, the greater the hatred at present. There is one consolation, however, though a small one, that we may reap from this distres- sing contemplation, and to which the friends of the sufferer should not be indifferent. It is that, with this blunted sensibility of mind, the patient has no pain from a consciousness of his degra- ded condition. And it is singular to observe, what may also contribute to alleviate the dis- tress of the sympathizing heart, how completely ftis unconsciousness prevails even after a pa- tient's restoration to health, so that few look 184 NEUROTICA. [Cl. IV.—Orv. 1. back upon what they have undergone with the horror that would be expected; while many, even in the apprehension of a relapse, contem- plate it, and turn their eye to the abode of mis- ery where they were lately inmates, without dread. The fourth variety, or self-complacent melancholy, is perhaps less frequent than any of the rest; hot it occurs- occasionally, and is often accompanied with at high-eoloured and ruddy complexion, and other marks of a san- guineous habit: " Such persons," says Burton, " are much inclined to laughter, are witty and merry, conceited in discourse, pleasant, if they be not far gone, and much given to music, dan- cing, and to be in women's company." Aristotle gives the case of an inhabitant of Abydos, who, labouring under this variety of the disease, would ait for a whore day as if he had been upon a stage, listening to visionary actors ; some- times acting himself, and occasionally clapping his hands and laughing as overjoyed with the performance.—(Lib. de Reb. mir.) Such per- sons have not unfrequently thought themselves called upon to undertake some desperate adven- ture, and are exquisitely elated with the new and lofty character they are about to embrace. These stimulant feelings are not unfrequently connected with erroneous ideas of religion, and excite in the mind of the patient a belief that he is supematurally endowed with the power of working miracles, or undergoing the severest mortifications without injury. The German Psychological Magazine is full of examples of this kind; and, among others, relates the case of a gens-d'armes of Berlin, whose name was Gragert, of a harmless and quiet disposition, but rather of a superstitious turn of mind. From poverty, family misfortunes, and severe military discipline, he brought on a series of sleepless nights, and a mental disquietude that, according to his own report, nothing could dissi- pate but a perusal of pious books. In reading the Bible, he was struck with the book of Dan- iel, and so much pleased with it, that it became his favourite study ; and from this time the idea of miracles so strongly possessed his imagination, that he began to believe he could perform some himself. He was persuaded more especially that, if he were to plant an apple-tree with a view of its becoming a cherry-tree, such was his power that it would bear cherries. He was discharged from the king's service and sent to the workhouse, where he conducted himself calmly, orderly, and industriously for two years, never doing any thing that betrayed insanity; at which time Dr. Pike examined him, that he might be discharged and sent to his family. He an- swered every question correctly, except when the subject conclpied miracles: in regard to which he retained his old notions ; adding, how- ever, at the same time, that if he found, upon trial, after he was at home, that the event did not correspond with his expectation, he would read- ily relinquish the thought, and believe he had been mistaken; and confessed that he had al- ready removed one error in his mind in this way ; for there was an old woman whom he had at one time considered as a witch, but whom he afterward discovered, upon trial, to be no such thing. Upon the medical treatment of diseases of this kind, we shall not have to say much; but as the plan chiefly advisable for the present species is equally advisable for the ensuing, il will be most expedient to reserve the discussion of it till the latter has been described in its order. SPECIES II. ECPHRONIA MANIA. MADNESS. the discrepance between the perception and the judgment general; great ex- citement of the mental, sometimes of the corporeal powers. This species appears under almost infinite varieties of character, of which, however, it may be sufficient to mark the following, modified for the most part by the predisposing causes that we have already noticed, as modifying the pre- ceding species :— a Ferox. Furious and violent madness. B Exuhans. Gay and elevated madness. y Despondens. Gloomy, despondent madness, S Demens. Chaotic madness. The exciting causes, like the predisposing, are chiefly those already enumerated under ecphro- nia melancholia: as sudden and violent men- tal emotion ; bad passions indulged habitually ; false views of religion, especially the dread of reprobation and eternal punishment; sudden re- verse of fortune, whether from bad to good, or from good to bad; preying anxiety, or lurking discontent; deep protracted study, unrelieved from week to week by an interchange of exercise or society, and breaking in upon the hours of sleep ; unkindly childbed ; a suppression of vari- ous periodical evacuations ; and sometimes even a virtuous restraint of sexual orgasm in a vig- orous constitution, without taking purgative or other means to reduce the irritative entony. Of these one of the most frequent causes is that of childbed, and recovery from childbed, though it is not always easy to develop the immediate mode by which this change in the constitution acts upon the brain; for it has occurred not only where there has been some organic affection from puer- peral fever, a sudden cessation of the lochia, or a sudden relinquishment of nursing, but where the recovery has been unattended with a single unfa- vourable symptom, and the mother has ardently persevered in the office of a nurse. It shows us, however, very sufficiently, how strong is the chain of sympathy between the brain and many remote organs of the body, and especially those subservient to the function of generation. M. Esquirol, not long ago, communicated a paper to the Societe de Medecine upon this im- portant subject, enriched with the results of the Hospital de la Salpetriere, for the years 1811 12, 13, and 14. During these four years eleven hundred and nineteen women were admitted labouring under mental derangement: of whom • ninety-two (nearly an eleventh part of the whole> Gen. I.—Spe. 2.] ECPHRONIA MANIA. 185 had become deranged after delivery, during or immediately subsequent to the period of suck- ling. In the higher ranks of society, the pro- portion of puerperal maniacs he calculates to be not less than a seventh of the whole. Of the above 92 cases, 16 occurred from the first to the fourth day after delivery ; 21 from the fifth to the fifteenth; 17 from the sixteenth to the sixtieth day; 19 from the sixtieth to the twelfth month of suckling : and in 19 cases it appeared after voluntary or forced weaning.* Of the above 92 cases, 8 were-idiotic, 35 mel- ancholic, and 49 maniacal. The respective ages' were as follows : 22 from 20 to 25 years; 41 from 25 to 30 years ; and 12 above 30. Fifty- six out of the ninety-two were entirely cured, and thirty-eight of these within the first six months. Fright was the most frequent cause. —(Quart. Journ. of For. Medicine, No. i., p. 98.)t I have said that a virtuously restrained orgasm, in a full habit, and where no steps have been taken to reduce the entonic vigour, has occa- sionally induced mania. There is a curious in- stance of the powerful effect of such a state re- lated by Kemnesius in his history of the Council of Trent, which, though it did not terminate in madness, proved quite as fatal. In the year 1419, Rossa, nephew to the King of Portugal, and archbishop elect of Lisbon, was taken seri- ously ill at Florence. His physicians told him that his disease proceeded from an excessive irritation of the genital organs, and that he would certainly die unless he committed forni- cation or married. With a courage worthy of a happier issue, he resolved on death, and met it without breaking bis Vow of celibacy.—(Kem- nes. Concil. Trident., part iii. ; De Calibatu Sa- ccrdotum.) The following instance, however, will prove that mania itself is sometimes the consequence of the same firmness of mind. A clergyman of exemplary character, and one of the most dis- tinguished preachers I have the pleasuie of be- ing acquainted with, was, many years ago, very unexpectedly attacked with a paroxysm of mania, the cause of which it seemed impossible to un- fold. He recovered in about six months, and returned to a regular and punctilious discharge of clerical duty. He is a man of exquisite taste, warm imagination, exalted and highly cultivated * In the New-York Med. Journal, vol. i., p. 280, Dr. McDonald, physician to the Bloomingdale Asylum for the insane, has published some obser- vations on puerperal mania, and concludes, " That young women are much more obnoxious to this malady than those more advanced, and that the susceptibility of females to it diminishes in about the same ratio that their years increase; that wo- men are more liable to this disease at the first than at subsequent parturitions ; that an heredi- tary predisposition to insanity exists in less than one sixth of the cases; that moral causes are co-operative only; that puerperal insanity is one of the most curable forms of mental disorder."—D. + There is a greater predisposition to madness, says Dr. Rush, between twenty-five and fifty, than at any of the previous or subsequent years of hu- man- life.—D. mind. With these qualifications, in less than a year after his recovery, he married his maid- servant, and the world imagined he was gone or going out-of his senses a second time. A con- fidential statement of his situation soon proved to myself that nothing could be more prudent or praiseworthy than the step he has thus taken, and which had excited so much astonishment among his friends. He was fully convinced, he ~said, though he had never communicated it to any one, that the cause of his unfortunate mal- ady was a genital irritation, exciting to a con stant desire of matrimony, which he was not in a situation to comply with, and which compelled him to exercise from day to day a severe restraint upon his feelings. On being fully restored to health, he found the same morbid propensity be- ginning to return. I felt, said he, it would again drive me mad if I did not relieve it, and my principles forbade me to think for a moment of relieving it immorally. To what respectable family could I now offer myself, having so lately been discharged from private confinement 1 The servant who lived with me was a very excel- lent young woman; her disposition was amia- ble, her mind well capable of cultivation, and her form and manners by no means unpleasing ; and hence, after mature deliberation, I deter- minecLupon marrying her, if she herself would venture upon so perilous a risk. He married her accordingly ;—has ever since, for upwards of twenty years, enjoyed an almost uninterrupted share of health, and has been more than ordi- narily happy in his family. Other examples of a like kind are to be found in Paullini (Cent, iii, obs. 14), Martini (Osservazioni, ch. ii., 10), and Vogel (Beobachtungen, p. ft): but it is unne- cessary to copy them. And hence, castration has been often advised and submitted to, and occasionally with success. It is from a like sympathy of action between the brain and other parts of the body that we meet with instances of the one or the other spe- cies of disease before us, produced occasionally, and perhaps in habits of great sensibility, by suppressed irritations of much smaller moment; as cutaneous diseases,* a suppressed hemor- rhoidal flux (Santacrux, De Melancholia, p. 29 ; Lentilius, MiscelL, i., p. 36), or an ulcer of long standing suddenly dried up.—(Forestus, lib. x., obs. 24.) Furious mania, constituting the first variety, sometimes makes it attack very abruptly, and commences with the patient's being sensible of some indescribable movement in his head, which excites him to loud and sudden shrieks, at the same time that he runs up and down the room and mutters something to himself that is alto- gether unintelligible: though the symptoms, even in this abrupt and violent attack, admit of much diversity. More commonly, however, the disease is the work of time ; and its growth is thus admirably described by Dr. Monro in his reply to Dr. Bat- tie :—" High spirits, as they are generally term- * Act. Nat. Cur., vol. viii., obs. 28. Descottes Journ. de Med., torn. lxvi. Petit, OZuvres nos- , thumes, torn. iii. * 186 NEUK ed, are the first symptoms of this kind of disor- der. These excite a man to take a larger quan- tity of wine than usual, and the person thus afflicted, from being abstemious, reserved, and modest, shall become quite the contrary, drink freely, talk boldly, obscenely, swear, sit up till midnight; sleep little, rise suddenly from bed, go out a hunting,-return again immediately, set all his servants to work, and employ five, times the number that is necessary. In short, every thing he says or does betrays the most violent agitation of mind, which it is not in his own power to correct. And yet, in the midst of all this hurry, he will not misplace one word, or give the least reason for any lone to think he im- agines things to exist that really do not, or that they appear to him different from what they do to other people. They who but seldom see him admire his vivacity, are pleased with his sallies of wit and the sagacity of his remarks ; nay, his own family are with difficulty persuaded to take proper care, of him, till it becomes abso- lutely necessary from the apparent ruin of his health and fortune." This picture is drawn from a rank of life something above that of mediocrity, but its gen- eral features of ebullient spirits, and hurry and bustle, and " much ado about nothing," will apply to every rank. Such a person, says Sir A. Crichton, in allusion to the present descrip- tion, cannot be said as yet to be delirious, but that event soon follows, and he has then the symptoms common to the disease, symptoms which only differ from a difference in the train of thoughts which are represented in his mind. He begins to rave, and talk wildly and incohe- rently ; swears as if in the most violent rage, and then immediately afterward bursts into fits of laughter ; talks obscenely ; directs offensive and contemptuous language against his relations and those around him; spits at them ; destroys every thing that comes in his way ; emits loud and discordant screams ; and continues this con- duct till he is quite exhausted. The state of rest which follows is generally short and sleep- less ; the patient is obstinate ; he will not speak a word, and clinches his teeth if any thing be offered him to swallow ; or else cunningly pre- tends to drink a little, but immediately squirts it out on the person who offers it. Instantly he again breaks out into all the wild and extrava- gant language and actions he committed before. If kept in strict coercion, he has often so much command over himself as to behave mildly and modestly ; and were it not for the general ex- pression of his countenance, and the peculiar glistening appearance and rapid movement of his eyes, he might impose on many of the by- standers, and make them imagine that the phren- sy was over- The length of the paroxysm and of the interval varies greatly in different indi- viduals.* But, generally speaking, the more vio- lent the fit the sooner it ceases, from exhaus- tion ; and hence sometimes it ceases in a day or two, and sometimes runs on to a month or * The paroxysm is accurately and powerfully described by Spenser, Fairie Queen, b. ii., cant. iv., xv. DTICA. [Cl. IV—Ord. I. even more ; returning at the distance of a few weeks, or at certain periods of the year. In the second variety, or elevated mad- ness, the passions, and especially the irascible ones, are less busy, and the imagination is chiefly predominant, and at work without ceasing. It is here we most frequently trace something of the ruling pursuit of their former lives, so that the covetous man is still conversant about pur- chasing lands and tenements, and amuses him- self with perpetually augmenting his posses- sions ; while the devotional character is forever engaged in a routine of prayers, fastings, and ceremonies, visions and revelations, and fancies himself to be inspired and lifted into heaven.* The phantoms are all of a pleasurable kind, and mostly such as afford the deluded sufferer a vast opinion of his own rank or talents. Donatus gives a case of a lady at Mantua, who conceited she was married to a king, and would kneel down and affect to converse with him as if he were present with his attendants ; and if she found by chance a piece of glass in the street, she would hug it as a jewel sent her from her royal lord and husband.—(De Hist. Med. Mirab., lib. ii., cap. i.) He relates another case, from Seneca, of Senecio, a madman of considerable wealth, who thought himself and every thing about him great; that he had a great wife, and great horses, and could not endure little things of any kind ; so that he would be served with great pots to drink out of; great hosen, and great shoes bigger than his feet : "Like her," says Burton, " in Trallian, that supposed she could shake all the world with her finger, and was afraid to clinch her hand lest she should crush the world to pieces like an apple."— (Anat. of Melancholy, part i., sect. 3.) Yet even here the train of thoughts or ideas which occupy the mind of the maniac, in many instances throw no light whatever on the nature or origin of the complaint ; and we can still less avail ourselves of them than in various cases of melancholy. This is particularly observable in the third VARIETY, Or DESPONDENT MADNESS ; for though this modification of the disease may occasionally be produced by suspicion, terror, or a guilty conscience, it is far more frequently the result of a melancholic idiosyncrasy, or a debilitated state of the constitution at the time of the at- tack, in consequence of which the sensorial fluid is secreted* perhaps even less freely, instead of more so, than in a condition of health ; so that the patient sinks by degrees into a state of in- sensibility ; unless he should be roused with false courage, and find means to put an end to his existence before this period arrives. In dementia, or chaotic madness, this state of sensorial exhaustion and consequent insensi- bility are still more obvious, though there is, perhaps, less constitutional tendency to the de- * In some instances, the person labouring un- der this variety of elevated madness has imagined himself to be the Messiah.—D. t As this expression is quite an improbable hy- pothesis, it would be better to exchange it for " sensorial power is generated."—Ed. Gen. I— Spe. 2] ECPHRONIA MANIA. 187 pressing passions. The judgment here is more diseased and weakened than in any other form, and none of the kindred faculties assuming a para- mount power, there is a general anarchy and con- fusion in the ideas that flit over the sensory, with- out connexion or association of any kind. And hence Pinel has admirably characterized it as consisting in a " rapid succession or uninterrupt- ed alternation of insulated ideas and evanes- cent and unconnected emotions ; continually re- peated acts of extravagance; complete forget- fulness of every previous state; diminished sen- sibility to external impressions : abolition of the faculty of judgment; perpetual activity without object or design, or any internal sense of its taking place."—(De I'Aliination Mentale, ch. iii., iii., $ 176.) These maniacs are often ungovernable except by means of coercion ; but they are more easily re- strained than those who are in a state of phrensy. They are intractable, and neither listen to entrea- ty or to menaces. Fear of corporeal punishment, however, makes them obey. They willingly avoid the light, burying themselves under the bed- clothes, or under the straw of their cells. They are totally regardless of decency and cleanliness, and, from some strange motive, are often found smearing themselves over with their excrement. For the most part, they have little appetite, and refuse the food offered them; yet a sense of hunger seems sometimes to return with great keenness, when they W1U greedily devour their feces. Of the nature of the ideas that take place in the sensory, and are expressed by an unintelligible muttering, we know nothing fur- ther than that, from the screams and bowlings with which their jargon is accompanied, there can be no doubt that they are often excited by painful sensations of body or mind. It is happy for those who suffer under this as well as under the preceding form, that they rarely sustain a long conflict; the exhaustion of sensorial power by repeated paroxysms soon leading to a total torpitude, and consequently a death of the sensorial organ ;* though there are instances in which a paroxysm of more violence than usual has produced a favourable change, and suddenly restored the patient to his senses. In gloomy madness, in which there is often a chronic affection of some of the abdominal or- gans co-operating with a diseased condition of the brain, we find least to justify hope ; the pa- tients generally become weakened by fresh par- oxysms, and often sink into a state of idiotism. The first variety, on the contrary, if the con- stitution have not been seriously broken down by intemperance, or the patient be not suddenly * " Death of the sensorial organ" seems by no means an eligible expression, as it may be under- stood to signify that the brain, in the case here described, dies first, and the rest of the system per- ishes afterward, in consequence of the death of the sensorial organ. In the examples referred to, the violence of the paroxysms may be said to de- range the functions of the whole nervous system disturb all the operations of the animal economy j and thus bring on debility, various forms of dis- ease, and speedy dissolution.—Ed. carried off by the violence of the attack on its commencement, will often work its own cure by its own ardour ; and will gradually soften into a more sober state from simple mental fatigue. While in the milder and more pleasurable mod- ification of the second variety, in which the production of sensorial power is upon the whole perhaps less than in a condition of sanity (since, though the stimulus of the disease may tend to increase it a little, the total privation wh'ch the patient enjoys of all the vexations, and anxieties, and wearing vicissitudes of real life, reduce it to a moderated and even tenour it could not otherwise possess), nothing is more common than for maniacs to continue to a very advanced age. I am at this moment interested in the case of a clergyman who has reached his ninety- sixth year, and has been in a state of quiet in- sanity for more than half a century. For the most part, those are most easily as well as most rapidly cured, whose insanity, of whatever kind it be, has been produced by ac- cidental causes, as intoxication, sudden transi- tion from cold to heat, retention of habitual dis- charges, or a revulsion by a transfer of morbid action from other organs. And hence the com- parative facility with which a cure is effected in insanity after childbirth. While, on the con- trary, those are least likely to obtain a perma- nent recovery who possess an hereditary taint; the disease may indeed leave them for a time, but, the predisposition remaining, they common ly fall victims to fresh attacks after intervals of a year or two, or even of a few months. " Mania and melancholy," says Dr. Greding, writing while he was physician to the work- house at Waldheim, "have continued half a year with some, and remained forty years and upward with others, among whom one patient Only in this workhouse attained the age of eighty- five."—(Vermischte Schriflen, ut supra, &c.) The chance of recovery is considerably great- er upon the first than upon any subsequent at- tack, and especially if the disease have not ex- ceeded three months' duration when the patient is first put under medical treatment. If it have at this time lasted a twelvemonth, the prospect of success is diminished by half; if two years, not above a fourth part as many recover; and if more than two years, the expectation is small, though, where the second year is not much ex- ceeded, a cure is by no means to be despaired of* The treatment of ecphronia has generally been discussed under the two heads of medical and moral. Both have undergone a very great improvement within the last twenty or thirty years : the first by being considerably simplified ; the second, by being more thoroughly studied and raised to a higher degree of importance.t * The instructive volume of Dr. Rush, " On the Diseases of the Mind," mentions many cases of most of the prevalent forms of mania. Knapp's Life of the late Thomas Eddy contains the inter- esting particulars of the case of Count Renauld St. Jean d'Angely, from the pen of Mr. Colden. This distinguished French orator died of mania.—D. t When a medical practitioner is consulted »• 188 NEUK Nothing can be more injudicious than the or- dinary routine of medical treatment, which, till within a few years, was equally employed in almost all the larger lunatic establishments in our own country and on the continent, especially at Bethlem, the Hospice d'Humanit£, and the Hotel Dieu ; and which consisted in a course of venesections, emetics, and purgatives, ad- ministered in every case indiscriminately, and often, indeed, without even the personal inspec- tion of the consulting physician or other super- intending medical officer ; and if, to these means of cure, we add the occasional use of bathing in various forms and various temperatures, we shall very nearly have exhausted the merely medical process that till of late was ordinarily had recourse to. Upon the cruel and disgusting scenes which, from the late parliamentary inquiry and the re- port of the committee which followed, are well known to have occurred not long ago in the largest and most celebrated receptacle of luna- tics in this metropolis, it is now unnecessary to dwell. But from the official communication of M. Esquirol to the French government con- cerning the residences for lunatics throughout France, it is perfectly clear that we have not transgressed in a greater degree than our neigh- bours. Filth, straw, and dirty rags, were all specting a person suspected to be insane, his whole duty, as Dr. Conolly explains, resolves it- self into two parts:—rl. To determine whether the individual in question be of sound mind. 2. To give an opinion respecting the treatment re- quired, and especially concerning the necessity of restraint, and the degree and nature of such restraint. The aid of medicine is required in most cases of disturbed mind ; personal restraint may be re- quired in many; but the degrees of it which are required in different cases vary, as the cases them- selves vary, from the slightest to the most com- plete ; and complete restraint is very rarely re- quired. Whether the person ought to be confined at all will rest, as Dr. Conolly very properly insists, upon the consideration, whether the degree or character of the mental disturbance is such as to make the patient dangerous to himself or others, either as regards person or property.—(See Dr. Conolly's Inquiry concerning the Indications of Insanity, pp. 365, 386, &c.) This talented writer adverts to the frequency of cases in which patients become more and more susceptible of all impres- sions, and more and more irritable, in consequence of habitual indulgence in diet which disagrees with them. Certain articles of food, or of drink, which produce a temporary disturbance of the whole system, are taken so frequently, that the body and mind are never left quite free from their effects. During the early stage of such cases, restraint may be productive of a complete cure ; and even when insanity has become declared, but has not long existed, it will recede and disappear, if the habits which are destroying the mind are resolutely broken. The cure depends partly upon physical, and partly upon moral treatment; and Dr. Conolly gives it as his opinion, that both may often be better administered out of an asylum than in it. Long-continued superintendence and occa- sional restraint are necessary; but seclusion, con- finement among lunatics, deprivation of property, long separation from friends, are quite uncalled for and improper.—Op. cit., p. 393.—Ed. OTICA. [Cl.IV—Ord. I. these miserable beings possessed in many de- pots to mitigate the coldness of the air, and the dampness of their paved, crammed, and suffoca- ting cells. And in some instances they had neither straw nor rags, and were perfectly naked, except from a layer of dirt. " J'ai vu," says M. Esquirol, with just indignation, " un mal- heureux imbecile, tout nu et sans paille, couch£ sur le pave. Exprimant mon etonnement d'un pared abandon, le concierge me repondit que l'administration ne lui passait, pour chaque in- dividu, qu'une botte de paille tous les quinze jours. Je fis remarquer a ce barbare que le chien qui veillait a la porte des alienes etoit loge plus sainement, et qu'il avoit de la paille fraiche et en abondance. Cette remarque me valut un sourire de pitie. Et j'etois dans une des grandes villes de France."—(Des Etablissemens des Alienes en France, et des Moyens d'ameliorer le Sort de ces Infortunis, Paris, 1819.) It is satisfactory, however, to know, that a more ju- dicious and discriminative practice has in all these asylums been introduced since the above period, and that it has been followed by an abundant success.* Admitting the proximate cause of insanity to be in most cases an increased action of the vessels secreting the nervous fluid [or supply- ing with blood the organs by which the senso- rial power is produced], venesection and ca- thartics, and a general reducent regimen, seem indicated as an ordinary means of relief; and are unquestionably called for when the pulse is full and strong, and the temperament is san- guineous : and the success which has so fre- quently accompanied this practice, stamps it with the highest sanction it can receive. But there is great reason to believe, that even where the demand for bloodletting is unequivocal, it has been carried to a mischievous extent, and ruined its own benefit. Thus Plater made a point of repeating it once a week, and some- times had recourse to it for seventy weeks in succession.—(Observ., lib. i., p. 86.) Much caution, however, is necessary even in the first trial; for as a sound intellect depends apparently upon a certain degree of excitement in the sensorial vessels, and a certain quantity of the fluid secreted [or intellectual power generated], derangement may take place also, * In Dr. Conolly's Inquiry into the Indications of Insanity, many judicious reflections will be found on the disadvantages of the common system of lunatic asylums. Every humane mind will also incline to his opinion, that it is not every form of mental derangement that justifies confinement in such establishments. A man may fancy his legs to be butter, and take all due care of them, with- out injury to himself, his family, his property, or the property and persons of others, and no one can have a right to interfere with him.—(Op. cit., p. 305.) He may, on seeing his doctor, address him as if he were Jesus Christ; or he may fancy that a princess is in love with him, and do many ex- travagant things in consequence of the delusion ; yet his conduct will not justify restraint, unless his mental disorder lead him to neglect his affairs and his family, or to inflict injury either on others or on himself.—Op. cit., p. 384.—Ed. Gen. I.—Spe. 2] - ECPHRONIA MANIA. 189 as we have already observed, from diminished in- stead of from increased action, and diminished in- stead of increased secretion or production. And such we have reason to believe is the cause of de- lirium whenever it occurs in profuse hemorrhage and ift typhus fevers : in all such instances, a reducent plan must necessarily lend to augment instead of to carry off the disease. And hence, the patient's general habit and temperament, the nature of the exciting cause, the probability of visceral congestion, the violence or mildness of the maniacal symptoms, the progress they have made, and the length of time he has laboured under them, are all to be taken into considera- tion before we can determine upon the expe- diency of bleeding even at first. And if, when we have decided upon its propriety, no benefit be produced from a second or a third repetition, we have no encouragement to proceed further, and should withhold the lancet altogether. To a series of purgative medicines there is less objection, provided they are not rendered too violent. The abdominal viscera, it has al- ready appeared, form in many instances an im- portant link in the morbid chain of action, and are sometimes the primary cause of the dis- ease : and it is hence of great moment that they should be effectually cleared of any mat- ter that may irritate or clog them up. But be- yond this, by keeping up such an increased ac- tion in the abdominal region as the organs may bear without debility, we may diminish or change the morbid action in the head by remote sym- pathy, or entirely withdraw it by a revulsion. A spontaneous diarrhoea has been known in va- rious cases to carry off the disease as by a charm: and the use of this class of medicines is the more necessary, as the bowels of mani- acal patients are apt to be extremely costive. If the black hellebore of the ancients, which appears to have been a different plant from that of the modern dispensatories, were ever entitled to half the antimaniacal virtues ascribed to it, it was most probably upon the obvious ground of its being a purgative attenuant and deobstruent. Dr. Dubuisson has lately revived the use of the modern black hellebore in various species of mental alienation, as chronic mania, melan- choly, and hypochondriacism : in all which he speaks of its effects, after an extensive trial, as highly successful. He has given it also in ev- ery form, as that of powder, decoction, watery extract, and tincture ; but prefers the extract as least irritating.—(Des Vesanies, ou Mala- dies Mentales, Paris, 1816.) His opinion, how- ever, is not supported by the result of general practice, and appears to be by far too sweeping and indiscriminate. Spleissius, nevertheless, affirms that in his hands, when given freely, it proved sedative and produced sleep.—(Annotat. in Zapat. MirabiL, p. 136.) Upon no other description of medicines can we place any rational dependance. Emetics, narcotics, and other sedatives and antispas- modics, have been tried for ages in every form and in every proportion ; sometimes alone, and sometimes in conjunction with blisters and the warm or cold bath. There are instances in which they have all appeared to produce some benefit; but the far greater number, in which they have failed, prevents us from placing any reliance upon them. Of the narcotics, the chief-that have been had recourse to are opium, aconite, belladonna, and the stramonium. Far more mischief than good seems to have followed from the use of all of them, with the exception of the first, which would probably be found a remedy of high value if we could duly discriminate the proper states or modifications of the disease for its use. Dr. Cullen's experience of it in mania he admits to be small, but he has cor- rectly estimated its general effects in telling us that, in some cases, he found it useful in moder- ating the violence of the disease, but that in others he found it manifestly hurtful. A mo- nographist upon this malady could not, perhaps, be engaged more usefully, than in turning his attention to the peculiarities which produce this difference. On the continent, it has also been given sometimes alone ; but, more usually, in conjunction with nitre or camphire, or both; but in all these forms, also, with variable success. —(Fribourg, Coll. Soc. Med. Hafn., ii., p. 176.) Upon what ground St. John's wort was ever advanced to the rank of a powerful sedative I know not; but in this class it at one time took the lead, and held it for ages. Its antispasmodic powers were regarded of so high a character as equally to put to flight hysterics, hypochon- driacism, and madness of every kind, and es- pecially that which was formerly described un- der the name of dasmonomania (Abrah. Mayer, Archive der Practischen Arzneykunde), whence, indeed, its technical name of hypericurn, or fuga daemonum, under which it was also celebrated. It occupied a place in a late edition of the Pharmacopoeia of the London College, and was at one time noticed as an antispasmodic even by Dr. Cullen, who rejected it, however, most deservedly, in his maturer courses of lectures. Its only sensible qualities are those of a slight resinous bitter, not worth the trouble of ex- tracting. Camphire is a sedative far better entitled to attention, and appears to have been tried with more extensive success than any other medicine of the same tribe. It has been given alone, and in union with other sedatives, chiefly with opium, nitre, and the mineral acids, none of which, however, seem to have improved its powers. Berger, Fischer, and Herz, speak fa- vourably of its effects abroad ; and, in our own country, it has had equal commendations from physicians of distinguished talents. Dr. Mead thought highly of it; Sir Clifton Wintringhain tells us that he found it, given to the amount of half a drachm in the evening, diminish the phrensy, procure sleep, and produce perspira- tion. Unfortunately, however, here, as in the case Of opium, we have so many proofs of its utter inefficacy, as to render us at present inca- pable of placing any dependarice upon it in any quantity or with any auxiliary. Dr. Cullen had a patient who began with five grains for the night's dose, and advanced it gradually to thirty, 190 NEUROTICA. [Cl. IV.—Ord. I. without any benefit, though without any increase of the pulse. At this time it was carried by accident to forty grains, which produced syn- cope, and nearly proved fatal. The patient, how- ever, recovered from the accidental symptoms, but unhappily no impression was made on the con- stitutional disease.—(Mat. Med., vol. ii., p.294.) The warm and cold bath have also had their votaries, but no certain benefit appears to have been derived from either. The last may be use- ful as a tonic in a state of convalescence, but has rarely produced real benefit during the prog- ress of the disease. Weber, however, thought it useful, and published several cases to this ef- fect.—(Obs. Med., fascic. i., p. 26; see also, Act. Med. Berol., dec. i., vol. vii., p. 61.) From an idea that the disease consists in an undue determination to the head, or an undue excitement of the vessels supplying the organs of sensorial power, Wendt (Nachricht, Von dem Klinischcn Institut. zu Erlangen, 1783, 8vo.) surrounded the head with cataplasms of pounded ice in the form of a nightcap ; and Dan- iel, with a still more ingenious spirit of adven- ture, applied cataplasms of the same kind to the head, while the body, with a view of encour- aging a revulsion more effectually, was plunged into a warm bath. The process will be found described in his Beytrage zur Medicinischen Gelehrsamkeit, published in quarto at Halle in 1749. And I mention the fact as an act of jus- tice to the author, since the same process has of late years been revived in France and in our own country as a new discovery. Daniel thought it highly beneficial; and by its recent revivers it was at one time held up as a specific ; but whatever success may, in a few rare instances, have attended it, the practice has not been able to work itself into public favour; and a sober attention to its effects does not seem to justify its further continuance. M. Pinel was at one time favourable to an employment of jets of cold water directed upon the head, while the body was immersed in tepid water ; but his suc- cessor, M. Esquirol, is decidedly of opinion that it is injurious ; and in many cases has induced disorganization of the cerebrum, and rendered the madness incurable.* After all, we have chiefly to depend on mor- al treatment. Firmness on the part of the attendant, with conciliatory manners, has done wonders ; but a sense of authority must be main- tained, though occasional severity should be ne- cessary for this purpose : yet it will rarely be needful to exceed the coercion of the strait waistcoat. It is needless to add, that the diet should be of the simplest kind, that every thing which can tend to produce excitement should * The treatment of mental disorder must be determined in a great measure by the cause of the affection. That cause will probably be found to be " one of those producing temporary >n? quali- ties of mind, but the operation of which has, in the case of the insane person, more deeply af- fected the understanding. Some stimulus may have been withdrawn, or some emotion may have acted too much as a stimulus. Disease, or age, may have produced disturbance or debility. If be prohibited, and that, in public institutions, the patients should be divided into proper classes. Amusements of every kind that may engage the attention and encourage exercise in the open air, without rousing the passions or producing fatigue, should be promoted by every contri- vance that can be thought of. And if the turn or previous occupation of the patient point to any particular pursuit, and especially to handi- craft trades, and those that employ the mind without exhausting it, as that of sawing, garden- ing, bookbinding, or watchmaking, he should be enabled to pursue it according to his own desire. The desire itself is a favourable symptom, and has often led to the most beneficial results. Judicious conversation and cheering advice are also of great importance ; and regular daily attendance on religious services in the bosom of a private family, or with a few patients of a like standard in a public institution, may be al- lowed, where the disease has assumed a con- valescent shape, and the service is performed soberly and dispassionately.—(Report of the Glasgow Asylum for Lunatics, 1820.) This will at first, perhaps, be only of use as promoting a habit of moral order and quietism; but every good man will indulge the hope, that it may afterward introduce into the mind the higher blessing of spiritual peace and consola- tion. Yet the attempt must not be begun too soon, and in no case till the patient has acqui- red not only a spirit of subordination, but of tran- quillity. Before this period, nothing can be so absurd as to attempt devotional instruction of any kind ; for the subject of religion can only be addressed to the reason, or to the passions : the former of which does not exist in a state to be influenced ; and the latter of which, if they could be influenced at all, would only add to the excitement and increase the disease. The clear duty of the priest and of the physician is in this case one and the same : it is to bring the mind home to the world around it ; to draw it down and fix it upon things of time and sense, instead of rousing it to things invisible and eter- nal ; to enable it to behold God in the materi- alities of his works, instead of urging it to a con- templation of him in the spiritualities of his word. To instigate to an abstract and elevated com- munion with his Creator a madman, who is inca- pable of holding an intercourse upon ordinary topics with his fellow-creature, is to cure a frozen limb by pouring boiling water upon it, or to teach the Optics of Newton in a nursery. In many cases, the cure mainly depends upon withdrawing the patient's mind as much as pos- sible from every former scene and every former companion ; in setting before him a new world, and giving an entire change to the current of the undue exercise or the too great neglect of any one faculty, as of the attention, the memory, or the imagination, has brought on the malady, the object must be to excite or to sooth, to rouse or to restrain such faculty ; or if the irregularity seems dependant on some bodily inaptness or dis- order, to this, of course, attention must be imme- diately given."—See Dr. Conolly's Inquiry con- cerning the Indications of Insanity, p. 388.—Ed. Gen. I.—Spe. 2.] ECPHRONIA MANIA. 191 his recollections and ideas. There are particu- lar cases, however, and perhaps particular pe- riods of the disease, if we could accurately hit upon them, in which the sudden admission of a well-known friend or relation, and a sudden recall of the mind to its former images and hab- its, tend to produce a most salutary excitement, and disperse the maniacal cloud like a dream. Dr. Gooch has given an interesting illustration of this remark in the case of a lady, twenty- eight years of age, of a good constitution but susceptible mind, who fell into a state of melan- choly, in the ordinary sense of the term, a few months after a second childbirth, and at length became furious. " She was now," says he, " put under the care of an experienced attend- ant, separated entirely from her husband, chil- dren, and friends ; placed in a neat cottage sur- rounded by agreeable country (it was the finest season of the year), and visited regularly by her physician. For several weeks she manifested no improvement; sometimes she was occupied with one notion, sometimes with another; but they were always of the most gloomy description. At length it became her firm belief that she was to be executed for her crimes in the most pub- lic and disgraceful way; every noise she heard was that of the workmen erecting the scaffold ; every carriage, the officers of justice assem- bling at the execution. But what affected her most deeply was, that her infamy had occasion- ed the disgrace and death of her children and husband, and that his spirit haunted her. As soon as the evening closed, she would station herself at a window at the back of the cottage, and fix her eyes on a white post that could be seen through the dusk ; this was the ghost of her husband; day and night he was whistling in her ears. Several weeks passed in this way. The daily reports varied, but announced nothing happy. At length her husband became impa- tient, and begged to have an interview with her, thinking that the best way to convince her he was not dead was to show himself. This was objected to. He was told the general fact, that patients are more likely to recover when com- pletely separated from their friends; and that if she saw him, she would say it was not himself but his ghost. But the husband was obstinate, and an interview was consented to. When he arrived at the cottage he was told that she had had a tolerable night, was rather more tranquil, but that there was no abatement of her gloomy notions. ' As soon as I entered the drawing- room, where she usually spent the day' (I copy his own statement, which I have now before me, and which he wrote down at the time of the occurrence), ' she ran into a corner, hid her face in a handkerchief, then turned round, look- ed me in the face, one moment appearing de- lighted at the thought that I was alive, but im- mediately afterward assuming a hideous ex- pression of countenance, and screaming out that I was dead, and come to haunt her. This was exactly what Dr.----had anticipated, and for some minutes I thought all was lost. Find- ing that persuasions and argument only irritated and confirmed her in her belief, I desisted, and tried to draw off her attention to other subjects. It was some time since she had either seen me or her children : I put her arm under mine, took her into the garden, and began to relate what had occurred to me and them since we parted. This excited her attention; she soon became interested; and I entered with the utmost mi- nuteness and circumstantiality into the affairs of the nursery, her home, and her friends. I now felt that I was gaining ground, and when I thought 1 had complete possession of her mind, I ventured to ask her, in a joking manner, whether I was not very communicative for a ghost. She laughed. I immediately drew her from the subject, and again engaged her attention with her children and friends. The plan succeeded beyond my hope : I dined, spent the evening with her, and left her at night perfectly herself again.' He went the next morning in a state of intense anxiety to know whether his suecess had been permanent; but her appearance at the window with a cheerful countenance soon re- lieved his apprehensions. While he was there, Dr----came in. He went up stairs without knowing the effect of the interview, and came down, saying, ' It looks like magic !' With the view of confirming her recovery, she was or- dered to the seaside to bathe. As soon as the day of her departure was fixed she began to droop again, the evening before it she was very low, and on the morning of her setting off was as bad as ever. This state continued for sev- eral weeks, in spite of sea-air and bathing ; and ceased as suddenly as it had done before, appa- rently in consequence of interviews with friends, calculated to remove the apprehensions by which her mind was haunted. She has since then continued perfectly well, and has had an- other child, without the slightest threatening of her former malady."—(Med. Trans., vol. vi.)* * On the medical treatment of mania we would remark, that whether the results of American prac- tice be more or less favourable than those abroad, yet that neither in our public nor private institu- tions have those afflicted with insanity ever ex- perienced such harsh and injurious treatment as the late parliamentary reports have brought to light. The moral treatment of the insane was adopted at the Bloomingdale Asylum about twenty years since, and was warmly advocated by the late Thos. Eddy (See his Hints and Life, by S. L. Knapp, New-York, 1834); and if philanthropists have relied more upon it than on medical treat- ment, we have cause to be gratified with the ben- efits they have conferred on the cause of humanity. Perhaps a more active mode of medical practice is generally pursued by American physicians in the acute forms of insanity than is recommended in the text; and this would seem to be justified by the results. The following remarks, however, de- serve attention. Dr. Francis observes, " There is another circumstance I can hardly al- low to be passed over on this occasion without a remark, and which, I think, has been a concur- ring cause of the too hasty and too general adop- tion of moral management, as of itself alone the essential means of cure of maniacal subjects. The delirium of inebriety, and the more advanced forms of diseased action denominated delirium tre- mens, have inadvertently been confounded with idiopathic mania; and inasmuch as the right use of 10TICA. [Cl. IV—Okd. I. 192 NEUF This was a bold venture, and the physician must be of a temper more than ordinarily san- guine who would predict a like success upon every similar attempt. Yet we have already had occasion to observe, that puerperal insanity is more easily recovered from than most other forms of the disease.* reason is for the most part, in those cases, resto- red by mere abstraction from noxious potation, which is effectually secured by confinement, moral management, without other aid, has been allowed an undue weight in the curative process of genuine mania. I am aware that permanent cerebral disorganization may arise from intemper- ance in drink, as dissection has repeatedly shown; but the neglect of a distinct pathognomonic differ- ence between the ravings of inebriety or delirium tremens, and mental derangement, strictly so con- sidered, has led to gross miscalculations in our prognosis. As alcoholic insanity is engendered in every country where drunkenness prevails, it is perhaps more frequently seen in our mixed popu- lation than in that of Europe. Hence we have sometimes been led to pronounce hastily and er- roneously that our success in the management of lunacy is greater than that of other nations. We, however, must be supplied with more extensive and more accurate tabular views of the comparative results of practice in different institutions abroad and at home, before we can come to a satisfactory conclusion on this contested head. It is cheering to the feelings of the philanthropist to know, that by remedial measures, much more is accomplished at the present day than was at a former time imagined practicable."—D. * In the foregoing talented observations, Dr. Good has omitted to notice a subject which has been most eloquently treated of by Dr. Conolly, namely, the many circumstances which, in places for the reception of lunatics, retard or prevent the patient's return to the full enjoyment of reason. In particular, Dr. Conolly adverts to the neglect of making a proper classification of the inmates of such establishments. " There is," says he, "sometimes a mere separation of the rich from the poor ; or of the noisy from the quiet; or of the paralytic and idiots, or, at the best, of convales- cents from the rest. Even this case is not com- mon. Not only so long as it is neglected, but so long as one lunatic associates with another luna- tic, supposing the cases to be curable, so long must the chances of restoration to sanity be very mate- rially diminished. Convalescents should not even associate with convalescents, except under the strict watching of persons of sound mind: they can hardly assist, and they may retard, recovery of one another."—(Inquiry concerning the Indica- tions of Insanity, p. 28.) Dr. Conolly also points out a class of patients for whom a lunatic asylum is a most improper place, viz., those who become affected with various degrees of weakness of in- tellect. In such persons there is little or no ex- travagance, still less is there any thing in their condition to render their liberty dangerous. As this infirmity of mind is diversified by intervals of amendment, it is clear that confining such indi- viduals with lunatics is the most likely thing both to afflict them and to shut out every hope of restoration to mental strength. The maxim which Dr. Conolly everywhere inculcates is, that re- straint, with reference both to the person and to the management of affairs, can never be justified, ex- cept by probable danger to the person of the patient or to others, or to his property or the property of others.—(P. 430.) GENUS II. EMPATHEMA. UNGOVERNABLE PASSION. THE JUDGMENT PERVERTED OR OVERPOEWRED BY THE FORCE OF SOME PREDOMINANT PAS- SION ; THE FEATURES OF THE COUNTENANCE CHANGED FROM THEIR COMMON CHARACTER. The term empathema is derived from the Greek -n&Qvpa, " passio," " affection," whence ifiiradfis, " cui insunt affectus seu perturbationes ; affectu percitus vel commotus." We have already had occasion to observe, that the various faculties of the mind are just as lia- ble to be separately diseased as those of the body : for, as the faculty of digestion may be im- paired, while that of respiration or secretion re- mains in perfect health; so may the perception or the judgment be injured, while the memory or the imagination continues in its former activity. It is the same with the pathetic faculties. These, I have stated, are to the mental part of the hu- man frame, what feelings, properly so called, are to the corporeal: and hence both may be excited pleasurably or painfully ; they may be in morbid excess or in morbid diminution ; and their influence may equally vary, according to the peculiarity of the passion or the sense affect- ed. Each will therefore furnish a distinct di- vision of diseases : the first constitutes the ge- nus before us ; the second will be found in the ensuing order. The present genus, however, has never hith- erto been properly arranged or digested. Pinel is constantly describing the species that belong to it in his general remarks and illustrative cases, but allots no place to it in his nosologi- cal arrangement, with the exception of the third species ; which, as I have already observ- ed, he has irregularly ranked as a subdivision of mania, under the name of manie sans delire ; although he admits that the judgment and per- ception, and, indeed, all the reasoning faculties " If an insane man believes that he has commu- nication with angels, or is an emperor, or a gen- eral, his happiness may be very harmless ; he may require no restraint. But, in the angelic revela- tions made to him, he may be ordered to kill his children; or, in his capacity of emperor or gen- eral, he may put his supposed subjects or soldiers to death. The disposition to do this may arise suddenly, and nothing but watching and superin- tendence can lead to a discovery of it. Yet, to restrain this poor man at all times from walking about the fields, or partaking of any of the com- mon enjoyments of society of which he is capa- ble, because such a thing may happen, is not to be justified. Unless he is known to be mischievous, it is unnecessary and cruel. A man must not be made a prisoner for life because he chooses to wear a coat the wrong side outwards, or a pointed hat. It may be more necessary to protect him from others, than others from him; and therefore an asylum to him may be what its name imports, —a sanctuary and a refuge ; but unless he is dis- posed to injure others or himself, he must not be subjected to severe restraint. If he has property, and can take care of it, no one ought to touch that property on account of his peculiar dress "—Oo. cit.,p. 430— Ed. ^ Gbn, II.-Spe. 1.] empathema entonicum. 193 of the mind, are in most cases undisturbed. In like manner, Sauvages has incorrectly merged the whole family into a single species under the genus mania, to the utter confusion of both. It is not a little singular that Dr. Crichton, who has written so excellently on the diseases of the passions, and has illustrated his observa- tions with such a variety of examples, should, both in his " Inquiry into the Nature of Mental Derangement," and in his " Synoptical Table,'' either have assigned no place to these diseases, or have transferred them, like Sauvages, to in- sanity, under his nomenclature, delirium; al- though, as I have just remarked, the perception and the judgment (a diseased condition of which is usually appealed to as constituting pathog- nomonic symptoms of insanity) are, for the most part, strikingly clear in empathema, and often peculiarly acute. This last faculty, indeed, is frequently pervertedby the prevailing emotion or passion of the hour ; as where a man, under the influence of despair, reasons himself into the lawfulness and expediency of suicide ; but the argument, though deflected, runs still in a right line ; or, in other words, consists of cor- rect reasoning built on a perception of false ideas as its premises, of which we have, had various examples in the philosophical suicides of Germany. In the greater number of cases, however, the judgment, instead of being per- verted, is merely overpowered by the impas- sioned emotion ; there is neither false judgment nor false perception. Ungovernable passion, or empathema, never- theless, though not strictly insanity, is as much a mental derangement as insanity itself. " Ira furor brevis est," is as clear a truth as is to be found in the whole learning of the Roman empire ; and hence the elegant and fanciful mind of the Greeks added the term mania to that expressive of any pas- sion or emotion whatever, when in a state of | violence or misrule, as doximania, erotomania, chrysomania ; and, in this sense, mania is often used in the colloquial language of our own day. For poetry or vernacular speech, mania, thus employed, is intelligible enough; but it is not sufficiently correct for medical or physiological purposes, under which predominant passion must necessarily be distinguished from delirium. The genus empathema has three species : the first characterized by the rousing power of the prevailing passion ; the second, by its depres- sing power; the third, by symptoms different from both, and which will be explained in its order. 1. Empathema Entoni- Impassioned Excite- cum. ment. 2. —-------- Atoni- Impassioned depres- cum. sion. 3.-----------Inane. Hairbrained passion. SPECIES I. EMPATHEMA ENTONICUM. IMPASSIONED EXCITEMENT. THE PREDOMINANT PASSION ACCOMPANIED WITH Vol. II.—N INCREASED EXCITEMENT, ARDOUR, AND ACTIV- ITY ; EYE QUICK AND DARING ; COUNTENANCE FLUSHED AND TUMID. The varieties are innumerable : the chief are as follow:— a Lstitiae. B Philautiae. y Superbia?. 6 Gloriae famis. e Iracundiae. { Zelotypiae. Ungovernable joy. Self-love. Self-conceit. Pride. Ambition. Anger. Jealousy. ' All these, and, indeed, all other passions whatever, are as much direct and indirect stim- ulants to the mind, as provocative foods or drinks are to the body. Employed occasionally, and in moderation, both may be of use to us, and are given to us by nature for this purpose : but when urged to excess, they throw the sys- tem off its healthy balance, rouse it by excite- ment, or depress it by exhaustion ; and weaken the sensorial vessels by the wear and tear they produce. As those we are now contemplating are at- tended with increased action, they have some few symptoms in common, how widely soever they may differ in others ; of which the chief are, an augmented temperature and an acceler- ated pulse. If carried to such a degree that the judgment loses its power, or, in other words, the man has no longer any command over him- self, they betray themselves by their effect on particular features and particular organs, ac- cording as the emotion is of a painful or a pleas- urable character, or as the pain or the pleasure predominates in those cases which partake of - both. There are some organs, however, that seem to be equally affected under a vehement excite- ment of whatever may be the prevailing passion, as the brain, the heart, and the lungs ; for head- ache and apoplexy, palpitation and anhelation, are alike common to sudden fits of extreme joy, terror, and rage. The thoracic effects are, in- deed, the most striking; and hence it is that the praecordia has been more generally suppo- sed in all ages and countries to be the seat of mental emotion than the encephalon; and the state of the heart as light and jumping for joy, oppressed and breaking with grieJ, or black and bilious with hatred, has been more commonly appealed to than that of the animal spirits; though the latter is the cause, and the former the mere effect. It may be thought, perhaps, that the vulgar character of the heart, as indicative of hatred or revenge, is merely figurative, and has no foun- dation in nature. But this is not the case : for anger, when long indulged, is well known to af- fect the functions of the liver, and has often laid a foundation for jaundice, and consequently for a deeper colour as well as other properties of the blood that circulates through the heart; a fact so well known, that the seat of anger has, in the poetical language of most countries, been transferred to this organ, and bilious or choleric and irascible are convertible terms in the popu- lar language of our own day. 194 NEUR We have endeavoured to account for the dif- ference of effect produced by the sensorial fluid in the different organs of local sensation, by sup- posing some degree of change to take place in the nature of this fluid by the action of the re- spective sentient nerves at their origin or ex- tremity.* It is possible that other changes may take place in the sensorium, from the influence of peculiar mental impressions, and that certain classes or ramifications of nerves may be more affected by particular impressions than others. And we may hence account, not only for the sympathy of the liver with the sensorium when urged by anger, but for that of other organs, un- der other impassioned excitements ; and this not merely whether pleasurable or painful, but according to the peculiarity of the pleasure or the pain which forms the source of incitation. Thus, while anger stifnulates the liver, fear has a tendency to produce a diarrhoea and inconti- nence of urine ; grief disorders the stomach, and affects the lachrymal glands ; sudden fright di- vests the muscles of locomotion, and produces palsy ; while mirth throws them into involun- tary action, and compels a man to leap, laugh, and sing. This, however, is to digress ; for our present business is to contemplate the mental, rather than the corporeal, effects of the passions, when urged to excess, or intemperately pro- tracted. The instances of derangement produced by a sudden fit oji immoderate flow of joy are numerous, and not difficult to account for. As this impassioned emotion, when indulged with a rampant domination over the judgment, is a direct stimulus of a very powerful kind, acting not only on the nerves but on every part of the body, it cannot take place without producing great sensorial exhaustion, and consequently cannot be persevered in without remissions of languor and lassitude, like the effects of intoxi- cation from strong wine or spirits. The mis- fortune is, that when the elevating faculties of the mind, and especially the imagination, are once let loose by the operation of this passion, and both run wild together, the mental excite- ment will sometimes continue after the strength of the body is completely prostrated. And when this strength is sufficiently recruited for the external senses to convey once more to the per- ception true and lively impressions of the ob- jects that surround them, the perception, which has been also morbidly affected by the violence of impassioned paroxysms, will not receive or convey them in a true state, and a permanent derangement is the consequence. Cardan (De Sapientia, lib. ii.) gives the case of an artisan of Milan, who, having had the good luck to find an * This and other hypotheses, founded on the presumed existence of a sensorial fluid, may sat- isfy readers disposed to be content or pleased with conjecture; but until the reality of such fluid be proved, they can only be regarded as sports of the imagination. It is fortunate, however, that the occasional reference made to them in the text does not impair the generally valuable character of the author's matter.—Ed. )TICA. [Cl. IV—Ord L instrument that formerly belonged to Archime- des, ran mad with a fit of transport into which he was hereby thrown : and Plutarch, in his life of Artaxerxes, has a like story of a soldier, who, having had the high honour of wounding Cyrus in battle, became so overjoyed that he lost his wits from the moment. Boerhaave (De Morb. Nerv., lib. ix., cap. 12) and Van Swieten (Com- ment., torn, iii., p. 144) relate cases of epilepsy that followed from the same cause. Occasionally, the exhaustion of sensorial pow- er hereby produced is so sudden and total, that the whole nervous system seems instantaneous- ly to become discharged of its contents, like a Leyden vial loaded with electricity when touched with a brass rod, and death takes place at the moment. There are various instances on record, in which a like fate has followed upon the injudicious production of apardon to a culprit just on the point of his being turned off at the gal- lows. Valerius Maximus relates two anecdotes of matrons, who in like manner died of joy on seeing their sons return safe from the battle at the lake Thrasis ; the one died while embracing her son ; the other had been misinformed, and was at that moment lamenting his death. The power of surprise was added, therefore, in this case, to that of joy, and she fell even before her arms could clasp him.—(Lib. ix., cap. 12.) Marcellus Donatus, Pechlin, and other collect- ors of medical curiosities, are full of incidents of this kind : and a case not very unlike occur- red a few years since to the present author, in the person of an intimate friend and most exem- plary clergyman. This gentleman, who had con- sented to be nominated one of the executors in the will of an elderly person of considerable property with whom he was acquainted, receiv- ed, a few years afterward, and at a time when his own income was but limited, the unexpected news that the testator was dead, and had left him sole executor, together with the whole of his property, amounting to three thousand pounds a year in landed estates. He arrived in London in great agitation; and on entering his own door dropped down in a fit of apoplexy, from which he never entirely recovered ; for though he regained his mental, and most of his corpo- real faculties, his mind was shaken and rendered timid, and a hemiplegia had so weakened his right side that he was incapable of walkino- far- ther than a few steps. Could this passion be employed as a medi- cine, and administered with a due regard to time and measure, from its powerful influence on the whole system, there can be no doubt that it might be made productive of the most beneficial effects. And there is hence no rea- son for hesitation in admitting many of the wonderful cures which are reported to have been occasionally operated by its sudden incur- sion. Corineus gives the case of a tertian ague thus removed; Lory that of a stricture of the pylorus with incessant vomiting (De Melancho- lia, torn i. p. 37); and Trellian, what we should less have expected, a radical cure of melancholy.—(Lib. xli., p. 17.) In the second variety we have noticed the Gen. II—Spe. 1] EMPATHEMA ENTONICUM. 19S predominance of self-conceit. The ordinary feeling here is still of a pleasurable kind, but never amounts to the paroxysms of the prece- ding ; its effects, therefore, on the soundness of the mind are more gradual, but in many instan- ces quite as marked. It is a vain and prepos- terous estimation of one's personal powers or endowments, accompanied with so immoderate a love of one's own self on this very account, as to make the possessor blind to every instance of superiority in another person, and hence to save him in a considerable degree from the pain he would otherwise endure ; for the self-con- ceited man is not easily mortified or humiliated, and hence not easily cured of the malady. " A wise man," says Mr. Mason in his Treatise on Self-Knowledge, " has his foible as well as a fool: but the difference between them is, that the foibles of the one are known to himself, and concealed from the world ; the foibles of the other are known to the world, and concealed from himself. The wise man sees those frail- ties ip himself which others cannot: but the fool is blind to those blemishes in his character which are conspicuous to every one else."— (Part i., chap, vii.) It was under the influence of this disease that Menecrates, as we learn from JElian, became so mad as seriously to be- lieve himself the son of Jupiter, and to request of Philip of Macedon that he might be treated as a god. But it is not always that the man thus deranged falls into such good hands as those of the Macedonian monarch ; for Philip, humor- ously determining to make the madman's disease work its own cure, gave orders immediately that his request should be complied with, and invited him to a grand entertainment, at which was a separate table for the new divinity, served with the most costly perfumes and in- cense, but with nothing else. Menecrates was at first highly delighted, and received the worship that was paid to him with the greatest compla- cency ; but growing hungry by degrees over the empty viands that were offered him, while every other guest was indulged with substantial dain- ties, he at length keenly felt himself to be a man, and stole away from the court in his right senses.—(Lib. xii., cap. 51.) The passion of pride has a close affinity to that of self-conceit: but is less confined to self- endowments, and is a relative as the former is a personal vanity. The proud man may indeed have the same preposterous estimation for some supposed gift of person, but the grasp of the passion does not terminate here ; for he carries the same estimation to every thing that in the remotest degree appertains to him, and is hence as vain of his birth, or family connexions, his wealth, his estates, his country, his office, his honour, or his religion ; and he is hence open to more numerous mortifications, and is in fact more frequently mortified, than the mere egotist. Examples of a deranged mind from ungoverna- ble pride are to be found in every rank of life ; but as those in the loftiest have the cup of in- toxication most frequently offered to them, and drink deepest of its contents, it is here, among kings, and courtiers, and prime ministers, and commanders, that we are to look for the most striking instances of this malady. Many a crown won by good fortune, and which might have been preserved by moderation, has been lost by the delirium of pride and vain-glory; of which the history of Demetrius of Macedonia furnishes us with one of the most memorable examples: who, in his disgraceful fall, was obliged to aban- don, among the other idols of his heart, the un- finished robe which was to have hung over his shoulders, containing a magnificent embroidery of the sun, the moon, and all the stars of heaven, designed to have represented him as the sov- ereign lord of the whole. There is, however, another kind of madmen, to adopt the words of Burton (Anat. of Melanch., parti., sect, ii., vol. i., p. 189), opposite to these, " that are insensibly mad, and know nothing of it; such as affect to contemn all praise and glory, and think themselves most free when they are most mad: a company of cynics, such as monks, hermits, and anchorites, that contemn the world, contemn themselves, contemn all titles, honours, offices, and yet, in that contempt, are more proud than any man living. They are proud in humility, proud in that they are not proud. They go in sheep's russet, many great men that might maintain themselves in doth of gold, and seem to be dejected; humble by the outward carriage, when as inwardly they are swollen full of pride, arrogance, and self-conceit. And therefore Seneca adviseth his friend Lucil- ius, in his attire and gesture, his outward actions especially, to avoid all such things as are most notable in themselves; as a ragged attire, hir- sute head, horrid beard, contempt of money, coarse lodging, and whatever leads to fame that opposite way."—(Epist. \.) When the passion of pride is united with that of ardent desire after something beyond us and above us, it constitutes the next feeling of am- bition : and hence this also is an inflating emo- tion, a tympany of the mind, and may be called prospective vanity, as pride is relative vanity, and self-conceit personal. It is the more dan- gerous to the understanding, in consequence of the double force with which it overpowers the judgment; and hence the slave of inordinate ambition is far more restless, and in a far higher degree of excitement, than the slave of either of the other two kinds of vanity ; and as, being dependant upon a greater number of con- tingencies, he is most of all open to reverses and downfalls. Examples are not necessary, and would be a waste of time. Whenever the stimulant ideas or thoughts that are connected with any one of this train of passions pass over the mind, the blood, as is justly observed by Sir A. Crichton, rushes with impetuosity to the head, the sentient principle is formed in preternatural quantity, and the excite- ment is at last so often renewed, and increases to such a degree, as to occasion an impetuous and permanent delirium. But when the ex- pectations and high desires which pride or van- ity naturally suggests are blasted; when these passions are assailed by poverty, neglect, con- tempt, and hatred, and axe unequal to the contest 196 INH.U.K.I they now and then terminate in despondency, or settled melancholy.—(Of Mental Derangement, book iii', ch. ii.) But if such be a frequent effect of the stir- ring passions of a pleasurable kind, it is not difficult to conceive that those accompanied with pain, as the passion of anger, and all its compounds, suspicion, revenge, and especially jealousy, must make a much wider inroad upon the domain of a well-ordered mind, and intro- duce confusion and derangement. Nor is the effect confined to the head ; for a stimulus thus violent affects the entire system, and, as we have already observed, has a peculiar sympa- thetic influence on the liver ; producing in many instances a diseased secretion of bile, and alter- ing it in a very short period, not only in its quantity but in its quality. At the same time, every vessel is exhausted of its irritability; and the whole strength is so prostrated as occasion- ally to lead on to obstinate faintings, convul- sions, and death. The expressions and gestures are always violent and offensive, and are similar to those of maniacal rage ; the eyes are red and inflamed, the countenance is flushed, swollen, and distorted, and the person is ungovernable. Such was the case, in 1392,. with Charles VI. of France ; who, being violently incensed against the Duke of Bretagne, and burning with a spirit of malice and revenge, could neither eat, drink, nor sleep for many days together, and at length became furiously mad as he was riding on horse- back, drawing his sword, and striking promis- cuously every one who approached him. The disease fixed upon his intellect, and accompanied him to his death. In jealousy, as in ambition, there is a com- bination of irritating passions, and the combina- tion is still more complicated ; for it is a com- pound of suspicion, hatred, eager desire of re- venge, occasionally intermixed with love. To hot climates it appears to be endemic ; and there is not, perhaps, an eastern dynasty that does not offer numerous examples of its sanguinary phren- sy and diabolical career. It is not often, however, that any of the va- rieties of this species terminate in permanent insanity, although the case of Charles VI. of France forms an exception to the general rule. As moral treatment appears to be of more ben- efit in the preceding genus than medical, it is almost the only treatment that can be recom- mended in ungovernable passion; though the violence of the excitement should unquestiona- bly be reduced by venesection and purgatives. After this, time and perfect quiet must be chiefly depended upon : yet judicious conversation, and more especially a judicious choice of subjects, may accomplish much. A deaf ear is generally turned to the precepts of the moralist; but if attention can be obtained for them, Epictetus and Mason's Self-Knowledge, Pascal's Thoughts, and Lord Bacon's Essays, will furnish valuable remedies ; and so also, and of a much more powerful op- eration, will the still better penned ethics of a book, which, in every Christian country, should be uppermost in the mind without any sugges- tion. Moral castigation, however, if not too [Cl. IV.—Ord. I. sudden or severe, is that which generally works most effectually ; and few madmen of this kind have been able to meet a serious reverse of for- tune, or condition of life, without being the bet- ter for it, if not destroyed by its first shock. Self-conceit, which is a mere product of self- ignorance, is best removed by an acquaintance with the world, and especially with men of real talents and genius, in which sphere the man who labours under it will soonest learn his own emptiness, and the means of remedying this defect. And hence the advantage of a public education over a private one; in which talents are brought into a fair competition with talents, and every one learns to appreciate his powers, not by the standard of his own vanity, but by the stamp of merit that has passed the mint. SPECIES II. EMPATHEMA ATONICUM. IMPASSIONED DEPRESSION. the predominant passion accompanied with diminished excitement, anxiety, and love of solitude : eye fixed and pensive ; countenance pale and furrowed. The mental emotions productive of these effects, are at least as numerous as those which harass the frame by increased excitement. The following may serve as examples :— a Desiderii. Ungovernable Love. 8 Auri famis.-----------Avarice. y Anxietudinis. -----------• Anxiety. 8 Moeroris. ----------- Heartache. t Desperationis.-----------Despondency. As increased sensorial excitement produces various symptoms in common, whatever be the nature of the governing passion at the time, there are also various symptoms common to de- creased sensorial excitement under each of these depressing passions : as a greater or less degree of torpor in every irritable part, especially in the circulating and absorbent systems ; whence paleness of the countenance, coldness of the extremities, a contraction and shrinking of the skin and general surface of the body, a retarda- tion and smallness of the pulse, want of appe- tite, deficiency of muscular force, and a sense of languor which overspreads the whole frame. The ardent desire which is distinguished by the name of longing, is directed towards ob- jects of various kinds that are absent, and equally relate to places and persons. It is a painful and exhausting emotion, as compounded of hope, love, and fear, and peculiarly agitates the pracordia; and hence the striking and beau- tiful apothegm of the wise man,—" Hope de- ferred maketh the heart sick." It is felt by children at a distance from home, and who are eager to return to the embraces of their parents ; by foreigners who have a strong and inextin- guishable love for their country, and are anxious to return to the scenes and the companions of former times ; and by the youthful pair who have-vowed an eternal attachment, and are sure that they cannot live without each other, but whose union is opposed by bars that are felt to be insurmountable. And hence the present va- 3TICA. Gen. II—Spe. 2.] EMPATHEMA ATONICUM. 197 riety includes the three modifications of home- sickness, country-sickness, and love-sick- ness. The first is for the most part transitory; the second, the heimwehr of the Germans, has sometimes, and especially among the Swiss, when their manners were simpler, and their do- mestic virtues and feelings much stronger, than they seem to have been of late years, produced not only a permanent melancholy but hectic fe- ver. Yet it is to the third that our attention is chiefly called on the present occasion, from the greater frequency of its occurrence, and the more severe and tragic effects to which it has led, where obstacles have arisen in its progress. We have, on the present occasion, nothing whatever to do with the gross passion of concu- piscence, which is as different from that of pure and genuine love as light from darkness. The man of lust has indeed his love, but it is a love that centres in himself, and seeks alone his own gratification; while the passion we are now speaking of puts self completely out of the field, and would voluntarily submit to every pain, and sacrifice even life itself, in promoting the hap- piness of the beloved object. Yet, constituted as we are by nature for the wisest and best of purposes, a pure corporeal orgasm still inter- weaves itself with the sentimental desire, though subordinate to it in virtuous minds, and the flame is fed from a double source. " Nuptial love," says Lord Bacon, " maketh mankind ; friendly love perfecteth it; but wanton love corrupteth and embaseth it."—(Essays, No. x.) What it is that first lights up this flame is of no importance to the present subject. A pe- culiar cast of form or of features, acknowledged by all to be moulded according to the finest laws of symmetry, and productive of a high de- gree of external grace or beauty; or a figure, or a manner, that to the eye of the enamoured beholder gives token of a mind adorned with all he can wish for ; or an actual knowledge, from long acquaintance, of the existence of such in- ternal cultivation and excellence, may be equal- ly causes of the same common effect. And hence this is of little or no account; for the passion being once excited, the judgment runs a risk of being overpowered by its warmth and violence; and the moment it is overpowered, the new train of ideas that are let loose upon the mind are of a romantic character; and as soon as any obstacle starts up as a barrier in the vista of hope, instead of being damped or re- pressed, they grow wilder and more vivid, till at length the sensorial system is worn out by the vehemence of its labour; and though the ex- citement is really less than at first, because there is less vascular vigour for its support, it is still greater than ever, compared with the weak- ened state of the sentient organ. Yet love-sickness itself, whatever mischief it may work in the corporeal frame by sleepless nights, a feverish pulse, and loss of appetite,* and however, from the exalted state of the ima- * Schurig. Gynealog., p. 94. Horstius, An Pul- sus aliquis amatorius concedendus? Bilizer, De Natura Amoris, Gioss. 1611, 4to. gination and the increased sensibility of the body, it may transpose the reality of life into a kind of visionary existence, and so far produce mental derangement, rarely leads to direct insan- ity, so long as there is the remotest hope of the attainment of its object. But if hope be sud- denly cut off by an inexorable refusal, the inter- vention of a more fortunate rival, the conceal- ment of the object of adoration, or any other cause whatever, the mind is sometimes incapable of resisting the shock thus produced by the con- current yet opposite powers of desire and de- spair ; and in a moment in which the judgment is completely overwhelmed, the love-sick ma- niac calls to his aid the demoniacal passion of revenge, and, almost at hazard, determines upon a plan of murder directed against his rival, his mistress, or himself. The story of Mr. Hack- man and Miss Rae will at once, perhaps, occur to the recollection of most of the author's read- er's in proof of this assertion. He himself had some acquaintance with the former ; and is con- vinced, from what he knew of him, that nothing but a paroxysm of insanity could have urged him to so horrible an act. The operation of the passion of avarice, when it has once obtained an ascendency over the mind, is altogether of a different nature from that of the preceding variety, though it often produces a wider and more chronic alienation. It has not a stirring property of any kind belonging to it, but benumbs and chills every energy of the body as well as of the soul, like the stream of Lethe: even the imagination is rendered cold and stag- nant, and the only passions with which it forms a confederacy, are the miserable train of gloomy fear, suspicion, and anxiety. The body grows thin in the midst of wealth, the limbs totter though surrounded by cordials, and the man vol- untarily starves himself in the granary of plenty, not from a want of appetite, but from a dread of giving way to it. The individual who is in such a state of mind must be estranged upon this point, how much soever he may be at home upon others. Yet these are cases that are daily occurring, and have been in all ages: though perhaps one of the most curious is that related by Valerius Maximus of a miser who took ad- vantage of a famine to sell a mouse for two hundred pence, and then famished himself with the money in his pocket.—(Lib. vii., cap. vi.) And hence the madness of the covetous man has been a subject of sarcasm and ridicule by moralists and dramatic writers in every period, of which we have sufficient examples in the writings of Aristophanes, Lucian, and Moliere. There is another mental feeling of a very af- flictive, and too often, like the last, of a chronic kind, which is frequently found to usurp a do- minion over the judgment, and to imbitter life with false and visionary ideas, and that is, a habit of anxiety, or preying care ; which not only drives the individual who possesses it mad, but runs the risk of doing the same to all who are about him, and are harassed with his com- plaints and discontents. This is sometimes the effect of a long succession of misfortunes or vexatious troubles; but seems in some persons 198 NEUROTICA. [Cl. IV—Ord. I.' to depend on a very high degree of nervous sensi- bility, united with a choleric or melancholic tem- perament.* Their age, wealth, or situation in life is of no importance ; and though their digestive powers are good, and they are not hypochon- driacs, they are always apprehensive and full of alarm, and flee from every appearance of joy as they would from an apparition, or even sooner. In the language of Burton, who knew too well how to describe them, " the old are full of aches in their bones, croups, and convulsions ; dull of hearing, weak-sighted, hoary, wrinkled, harsh, so much so that they cannot know their own selves in a glass ; a burden to themselves and others. If they be sound, they fear dis- eases ; if sick, weary of their lives. One com- plains of want, a second of servitude, another of a secret or incurable disease, of some deformity of body, of some loss, danger, death of friends, shipwreck, persecution, imprisonment, disgrace, repulse, contumely, calumny, abuse, injury, con- tempt, ingratitude, unkindness, scoffs, scouts, unfortunate marriage, single life, too many chil- dren, no children, false servants, unhappy chil- dren, barrenness, banishment, oppression, frus- trated hopes, ill success; "' Caetera de genere hoc, adeo sunt multa, loqua- cem, Delassare valent Fabium.' "' In the meantime,' continues the younger Democritus, ' thus much I may say of them, that generally they crucify the soul of man, at- tenuate our bodies, dry them, wither them, rivel them up like old apples, and make them as so many anatomies.' "—(Anat. of Melancholy, part i., sect, ii., subs, x.) Nothing can be more different than this con- stitutional pining, and the pains produced by heartache, or the reality of severe grief. The former is talkative and querulous ; the latter is dumb, and flies from company. The sensorial exhaustion is so considerable, that the mind, with its attention upon the full stretch, has scarcely strength enough to collect the train of ideas on which alone it resolves to dwell ; and hence all conversation is irksome., the presence of a friend disquieting, and the deepest solitude is anxiously sought for. And not unfrequently the discharge of nervous power is so consider- able and sudden as to produce a general torpor of the brain ; which, if it do not happily termi- nate in quiet sleep, is the inlet of apoplexy. Even in the former case, the inirritability of the nervous fibres continues to .such an excess, that the suf- ferer has no natural evacuation for perhaps sev- eral days, feels no hunger, cannot be persuaded to take food, is incapable of sighing, and sheds no tears. And hence the appearance of tears and sighing are good omens, and are correctly regarded as such; since they show that the * One position maintained by one of the latest writers on mental derangement is, that mere ner- vousness and insanity are absolutely identical; or, in other terms, that nervous derangerrients differ " in measure more than in kind."—Dr. Uwins on the Disorders of the Brain and Nervous System, pp. 5,24, &c, 8vo., Lond., 1833.—Ed. generatl orpitude is giving way in the organs that most associate with this painful emotion of the mind, to a slight return to irritability. As soon as the flow of the sensorial principle is a lit- tle increased, the praecordia struggles with great anxiety, and the heart is overloaded and feela ready to break or burst, whence the name of heartache, so appropriately applied to this va- riety of suffering. Sometimes, also, hysteric flatulence oppresses the respiration, and convul- sions, and not unfrequently death itself, ensue. Of this last effect Erndtl has given numerous in- stances.—(Relatio de Morbis anno 1720 War- savia curalis, Dresd., 1730.) But if recovery should take place, it is usually long before the judgment re-assumes its proper sway in the mind, and the temporary derangement altogether ceases. At times, indeed, this never returns, and the pitiable sufferer only lives through the shock to endure the severer evil of confirmed insanity ; of which Shakspeare has given us an admirable copy in the character of King Lear, finely imagined to be a result of filial ingratitude. Despair makes a near approach to heartache in the overwhelming agony it produces, and its pressing desire of gloom and solitude ; but, gen- erally speaking, the feeling is more selfish, and the mind more hurried and daring. Despair, as it commonly shows itself, is utter hopelessness from mortified pride, blasted expectations, or a sense of personal ruin : heartache is either hope- lessness from a sense of some social bereave- ment, or relative ruin. The gamester, who cares for no one but himself, may rage with all the hor- ror of despair ; but the heartache belongs chiefly to the man of a warmer and more generous bo- som, stung to the quick by a wound he least ex- pected, or borne down, not by the loss of for- tune, but of a dear friend or relative, in whom he had concentrated all his hopes. The well-known picture of Beverley is drawn by the hand of a master, and he is represented as maddened by the thought of the deep distress into which his last hazard has plunged his wife and family ; but if his selfish love of gaming had not triumphed over his relative love for those he had thus ruin- ed, he would not have been involved in any such reverse. While Beverley was in despair, it was his wife who was broken-hearted. The sources of this most agonizing emotion are innumerable ; and from the total shipwreck of all hope on which it is founded, there is no pas- sion of the mind that drives a man so readily to an act of suicide. To live is horror : the infu- riated sufferer feels himself an outcast from God and man; and though his judgment may still be correct upon other subjects, it is completely overpowered upon that of his actual distress"; and all he thinks of and aims at is to withdraw with as much speed as possible from the present state of torture, totally regardless of the future, or falsely satisfying himself by a perversion of his judgment that there is no crime in his doin, " abstraho, retraho, avoco, abduco;" and is in use among the Greek writers. The subject is almost, if not altogether, new to nosology, and has seldom been dipped into by physiologists. Dr. Darwin occasionally touches upon it in various parts of his " Zoonomia," and Dr. Crichton in his " Inquiry into the Nature of Mental Derangement;" and it is well de- scribed and illustrated by La Bruyere in his " Characters :" but it yet remains to be analy- zed, and reduced to a nosological method, and examined in a pathological view. A few lead- ing ideas on this subject have already been thrown out by the author, in his comment upon the present definition in the volume of Nosol- ogy ; and of these he will avail himself in treat- ing of it more at large. In order to our becoming acquainted with the existence of surrounding objects, or of an ex- ternal world, as it is called by psychologists, three things are necessary : sound external senses; a secretion of the nervous fluid (or, as it might be perhaps more correctly expressed, a due maintenance of the nervous and sensorial ener- gy), apparently under different modifications, whereby they are made capable of being roused or excited by the different objects addressed to them ; and an exercise of the faculty of atten- tion to the impressions which are thus produced. The will has, or ought to have, a power of cal- ling this, as well as every other faculty of the mind, into a state of exertion, or of allowing it to be indolent; and it is chiefly upon this want of power, or the same power intensely exerted, that the phenomenon of revery depends ; thus giving rise to the three following species of men- tal aberration:— 1. Aphelxia Socors. Absence of Mind. 2.-------Intenta. Abstraction of Mind. 3.-------Otiosa. Brown-study. In the first of these the attention is truant, and does not yield readily to the dictates of the will: in the second it is riveted, at the instiga- tion of the will itself, to some particular theme unconnected with surrounding objects : and in the third it has the consent of the will to relax itself, and give play to whatever trains of ideas are uppermost or most vivacious in the sensory. SPECIES I. APHELXIA SOCORS. ABSENCE OF MIND. TRUANT ATTENTION ; WANDERING FANCY ; VA- CANT OR VACILLATING COUNTENANCE. This is an absence, or vacuity of mind, too taken by themselves, the practitioner must not attach great importance."—See Inquiry concern- ing the Indications of Insanity, p. 405.—Ed. common at schools and at church ; over tasks and sermons ; and there are few readers who have not frequently been sensible of it in some degree or other. In reading books in which we are totally un- interested, composed in a tedious and repulsive style, we are almost continually immersed in this species of revery. The will does not ex- ert its power: the attention is suffered to wan- der to something of stronger attraction ; or the imagination is left to the play of its own nuga- tory ideas ; and though we continue to read, we have not the smallest knowledge of the ar- gument before us ; and if the subject to which the train of our thoughts is really directed be of a strikingly ludicrous character, we may pos- sibly burst into a laugh in the middle of a dis- course of great gravity and seriousness, to the astonishment of those around us. This is a common case, and may lead to great embarrassment. We have nevertheless thus far supposed that the will does not exert its power, and sufficiently rein in the attention to the sub- ject addressed to it. It not unfrequently hap- pens, however, that the will, for want of a proper habit, has lost its power, either wholly or in a very great degree, and cannot, with its utmost energy, exercise a due control over the atten- tion ; and it also happens in other cases, from a peculiarity of temperament or morbid state of body, that the faculty of the attention itself is so feeble, that it is incapable of being steadily directed for more than a few minutes to any ob- ject of importance whatever, with all the effort of the will to give it such direction. The. mind, under either of these conditions, is in a deplorable state for all the higher pur- poses of reflection and knowledge for which by its nature it is intended ; since it is upon the faculty of attention that every other faculty is dependant for its vigour and expansion : without it the perception exercises itself in vain; the memory can lay up no store of ideas ; the judg- ment draw forth no comparisons ; the imagina- tion must become blighted and barren; and where there is no attention whatever, the case must necessarily verge upon fatuity. In early life, the attention, like every other faculty of the mind, is weak and wandering, is often caught with difficulty, and rarely fixed upon any thing. Like every other faculty, however, it is capable of being strengthened and concen- trated ; and may be made to dwell upon almost any object proposed. But this is a work of time, and forms one of the most important parts of education : and, in the course of this discipline, it should not be forgotten that the faculty of at- tention, when it first shows itself, is more readily arrested by some subjects than by others, and that it is hence of great moment to ascertain those subjects, and to select them in the first instance. The habit is what is chiefly wanted ; and the quicker this is acquired, the more time we gain for transferring the same habit to other and perhaps more valuable purposes afterward. This is a point seldom sufficiently consideerd in the course of education; and, for want of such consideration, far more than half the time Gen. IV—Spe. 2.] APHELXIA of many boys becomes an entire blank, and is lost; and not a few suffered to remain block- heads in the particular department to which their hours of study are directed, who might discover a considerable capacity and genius if the de- partment were changed for one more adapted to their own taste, or, in other words, more attract- ive to their attention. There is a very singular instance of habitual absence of mind related by Sir A. Crichton, in a young patient under the care of Dr. Pitcairn and himself, which, though some other circum- stances appeared to have combined with it, is ascribed considerably to the error of education we are now speaking of, that of not duly study- ing the peculiar bent of a mind in many respects singularly constituted, and drawing forth and strengthening the faculty of attention, which was in an especial degree weak and truant, by an employment of such objects and pursuits as were most alluring. This patient was a young gentle- man of large fortune, who, till the age of twenty- one (and he does not seem to have been much more at the time of describing his case), bad en- joyed a tolerable share of health, though of a deli- cate frame. In his disposition he was gentle and calm, but somewhat unsociable. His absence of mind was extreme, and he would sometimes willingly sit for a whole day without moving. Yet he had nothing of melancholy belonging to him ; and it was easy to discover by his coun- tenance that a multiplicity of thoughts were con- stantly succeeding each other in his imagination, many of which were gay and cheerful; for he would heartily laugh at times, not with an un- meaning countenance, but evidently from mental merriment. He was occasionally so strangely inattentive, that, when pushed by some want which he wished to express, if he had begun a sentence, he would suddenly stop short after getting half way through it, as though he had forgotten what else he had to say. Yet, when his attention was roused and he was induced to speak, he always expressed himself in good lan- guage and with much propriety ; and if a ques- tion were proposed to him which required the exercise of judgment, and he could be made to attend to it, he judged correctly. It was with difficulty he could be made to take any exercise ; but was at length prevailed upon to drive his curricle, in which Sir Alexander at times accom- panied him. He at first could not be prevailed upon to go beyond half a mile ; but in succeed- ing attempts he consented to go farther. He drove steadily, and when about to pass a carriage, took pains to avoid it: but when at last he be- came familiarized with this exercise, he would often relapse into thought, and allow the reins to hang loose in his hands. His ideas seemed to be for ever varying. When any thing came across his mind which excited anger, the horses suffered for it; but the spirit they exhibited at such an unusual and unkind treatment made him soon desist, and re-excited his attention to his own safety. As soon as they were quieted, he would relapse into thought: if his ideas were melancholy, the horses were allowed to walk 6low ; if they were gay and cheerful, they were Vol. II.—0 INTENTA. 209 generally encouraged to go fast.—(Of Mental Derangement, vol. i., p. 281.) Perhaps, in this case, something might have been owing, as supposed by Sir A. Crichton, to an error in the mode of education ; but the chief defect seems to have been in the attentive fac- ulty itself, and its labouring under a natural im- becility, which no mode of education could en- tirely have removed. We have had frequent occasions to observe that the powers of the mind vary in different individuals as much as those of the body: and we have already offered exam- ples of weak or diseased judgment, weak or diseased perception, and weak or vehement im- agination. In the case before us, the mental dis- ease seems to have been chiefly confined to the faculty of attention ; and we shall presently have to notice a similar imbecility of the memory, and even of all the mental faculties conjointly.* SPECIES II. APHELXIA INTENTA. ABSTRACTION OF MIND. THE ATTENTION WOUND UP AND RIVETED TO A PARTICULAR SUBJECT; WITH SYMPATHETIC EMOTION OF THE MUSCLES AND FEATURES CONNECTED WITH ITS GENERAL DRIFT. In this species the faculty of attention, in- stead of being feeble or contumacious to the will, is peculiarly strong, and vehemently ex- cited, and acts in perfect co-operation with the will itself. And in many instances the senso- rial energy maintained is so great, and demands so large a supply of sensorial power, as appa- rently to exhaust the entire stock, except, in- deed, the reserve which is in almost all cases instinctively kept back for the use of the vital or involuntary organs. And hence all the ex- ternal senses remain in a state of torpor, as though drawn upon for their respective contri- butions of sensorial power in support of the pre- dominant meditation : so that the eyes do not see, nor the ears hear, nor does the flesh feel; and the muser may be spoken to, or conversa- tion may take place around him, or he may even be struck upon the shoulders, without any knowl- edge of what is occurring. Abstraction of mind may be produced by va- rious causes, but the following are the chief, and form two distinct varieties :— a Aphelxia a pathe- From some overwhelm- mate. ing passion. B Aphelxia a studio. From intense study. Of the first variety we have already of- fered abundant examples in the two preceding * The absent man cannot spread his attention over many things at once: it is concentrated on one subject, or one train of thought; and the most trivial thoughts are sufficient for its exclusive oc- cupation. He therefore commits a thousand ex- travagances ; puts on his friend's hat; loses his way in his native town; goes to bed in the mid- dle of the day, because he finds himself in his bed- room ; or forgets his own name when he knock* at a person's door.—See Conolly on Insanity, p. 121.—Ed. 210 NEUROTICA. [Cl. IV.—Okd. L genera : and especially in the cases of ungov- ernable joy or rapture, grief and despondency ; unci?r the influence of which the affected per- son is often as much lost to the world around him, as if he were in a profound sleep and dreaming; and only hears, sees, and feels the vivid train of ideas that possess themselves of his mind, and rule it as a captured citadel. To these alone the attention is directed ; here it ex- hausts all its power, and the will concurs in the exhaustion ; insomuch that the patient is said in some cases to have stared at the meridian sun without pain (Blwmenb., bibl. i., p. 736); and in others to have been undisturbed by the discharge of a cannon.—(Darwin, Zoonomia, iii., i., ii., 2.) We meet with like proofs of this variety of revery in many cases of intense study, and es- pecially upon abstract subjects, as those of pure mathematics, in which all the reasoning and more serious faculties of the mind, as the per- ception, the memory, and the judgment, as well as the attention, are jointly called into action, and kept equally upon the stretch. Of the power of this variety of revery in rendering an individual torpid and almost dead to all around him, we have a decided instance in Archimedes at the time of his arrest. When the Roman army had at length taken Syracuse by strata- gem, which the tactics of this consummate en- gineer prevented them from talcing by force, he was shut up in his closet, and so intent on a geometrical demonstration, that he was equally insensible to the shouts of the victors and the outcries of the vanquished. He was calmly drawing the lines of a diagram when a soldier abruptly entered his room, and clapped a sword to his throat. " Hold, friend," said Archimedes, " one moment, and my demonstration will be fin- ished." The soldier, surprised at his uncon- cern at a time of such extreme peril, resolved to carry him before Marcellus ; but as the phi- losopher put under his arm a small box full of spheres, dials, and other instruments, the sol- dier, conceiving the box to be filled with gold, could not resist the temptation, but killed him on the spot.* SPECIES III APHELXIA OTIOSA. BROWN-STUDY. LEISURELY LISTLESSNESS ; VOLUNTARY SURREN- DER OF THE ATTENTION AND THE JUDGMENT TO THE SPORTIVE VAGARIES OF THE IMAGI- NATION ; QUIESCENT MUSCLES ; IDLE GRAVITY OF COUNTENANCE. The attention is equally summoned into ac- tion and dismissed at the command of the will. It is summoned in the last species : it is dis- missed when a man voluntarily surrenders him- * If the attention be much engrossed by one ob- ject, it is necessarily withdrawn from others; and although readily transferred in general from one set of objects and ideas to another set of objects and irfeas, it is sometimes so tenacious of one set as to refuse, as it were, to turn to a succession. We self to ease and listlessness of mind; during which period, moreover, in consequence of this indulgence in general indolence, the external senses themselves unite in the mental quies- cence, and a smaller portion of nervous energy is probably generated, for the very reason that a smaller portion is demanded ; and hence the active senses without are as vacant and unstrung as the active senses within, and as blunted to their respective stimuli. The first playful ideas that float over the fancy in this case take the lead, and the mind relaxes itself with their easy and sportive flow. It is the studium inane of Darwin (Zoonom., iii., i., ii., 2 ; and again, iv., ii., iv., 2), who seems, however, to have in some degree misapplied the name, or to have con- founded the aberration with that of ecphronia or alusia. Cowper has admirably described it in the following verses :— "Laugh, ye who boast your more mercurial powers, That never feel a stupor, know no pause Nor need one : 1 am conscious, and confess^ Fearless, a soul that does not always think. Me oft has fancy, ludicrous and wild, Soothed with a waking dream of houses, towers, Trees, churches, and strange visages, express'd In the red cinders, while with poring eye I gazed, myself creating what I saw. Nor less amused have I quiescent watch'd The sooty films that play upon the bars Pendulous, and foreboding in the view Of superstition, prophesying still, [proach. Though still deceived, some stranger's near ap- 'Tis thus the understanding takes repose In indolent vacuity of thought, And sleeps and is refresh'd. Meanwhile the face Conceals the mood lethargic with a mask Of deep deliberation, as the man Were task'd to his full strength, absorb'd and lost." In the indolent mind such indulgence is a disease ; and, if not studiously watched and op- posed, will easily become a habit. In the stu- dious and active mind it is a wholesome relax- ation ; the sensory, in the correct language of the poet, " sleeps and is refreshed," grows fer- tile beneath the salutary fallow, and prepares it- self for new harvests. This is more particularly the case where, in conjunction with an attention " screwed up to the sticking-place," and long continued there, a spirit of ardent emulation is at the same time stirring, and distracted between the hope and fear of gaining or losing a distinguished honour or re- ward. I have seen this repeatedly in young men who have been striving night and day, and week after week, for the first prizes of our Eng- lish universities; some of whom have indeed succeeded, but with a hectic exhaustion that has been recovered from with great difficulty ; while others, in the full prospect of success, have been compelled to relinquish the pursuit, and to degrade. read that when Sir Joshua Reynolds, after being many hours occupied in painting, walked out into the street, the lamp-posts seemed to him to be trees, and the men and women moving shrubs__ See Dr. Conolly's Inquiry concerning the Indica tions of Insanity, p. 119.—Ea "«*«•<» Gkn. V.] PARONIRIA. 211 Yet even without this conflict of feeling, where the attention alone has been too long di- rected to one or to a variety of recondite sub- jects without relaxation, the mind suffers con- siderably, and its powers become shaken and confused ; of which we have an interesting ex- ample in the case of Mr. Spalding, a scholar of considerable eminence in Germany, as drawn by himself, and communicated to the editors of the Psychological Magazine.—(Crichton's In- quiry into Mental Derangement, i., 237.) His attention, he tells us, had been long kept upon the stretch, and had been still more distracted by being continually shifted from one subject to another, when, being called upon to write a re- ceipt for money paid him on account of the poor, as soon as he had written the two first words, he found himself incapable of proceeding farther. He strove all he could, and strained his attention to the utmost, but to no purpose ; he knew the characters he continued to make were not those he wished to write, but could not discover where the fault lay. He then desisted, and partly by broken words and syllables, and partly by ges- tures, made the person who waited for the re- ceipt understand that he should leave him. For about half an hour a tumultuary disorder reigned in his senses, so that he was incapable of re- marking any thing very particular, except that one series of ideas of a trifling nature, and con- fusedly intermixed, forced themselves involun- tarily on his mind. At the same time his ex- ternal senses continued perfect, and he saw and knew every thing around him. His speech, however, failed in the same manner as his pow- er of writing, and he perceived that he spoke other words than those he intended. In less than an hour he recovered himself from this confusion, and felt nothing but a slight headache. On ex- amining the receipt on which the aberration first betrayed itself, he found that, instead of the words " fifty dollars, being one half-year's rate," he had written " fifty dollars, through the salvation of Bra—" the last word being left un- finished, and without his having the least rec- ollection of what it was intended to be.. GENUS V. PARONIRIA. SLEEP DISTURBANCE. THE VOLUNTARY ORGANS CONNECTED WITH THE PASSING TRAIN OF IDEAS OVERPOWERED BY THE FORCE OF THE IMAGINATION DURING DREAMING, AND INVOLUNTARILY EXCITED TO THEIR NATURAL OR ACCUSTOMED ACTIONS; WHILE THE OTHER ORGANS REMAIN ASLEEP. Paroniria, from -napa and Hvtipov, signifies " depraved, disturbed, or morbid dreaming." So in Dioscorides (vol. ii., p. 127), Svadvtipos signi- fies " tumultuosis et malis somniis molestans." In treating of the genus ephiai.tes, or night- mare (Vol. i., Cl. I., Ord. II., Gen. V.), I endeav- oured to explain its course and nature ; and here- by pointed out the essential distinction which ex- ists between that disease and the present, and the impropriety of uniting the species which be- long to both of them under one head, as Dr. Cullen has done in his genus oneirodynia; since, with the exception of their occurring in the night, and during sleep, and therefore involunta- rily, they have little or no connexion or resem- blance, in cause, symptoms, or even mode of cure. The three following species are so clearly and decidedly of one and the same family, as to prevent all dispute in their present position. They are here, however, associated for the first time in a genus distinct from ephialtes. 1. Paroniria Ambulans. Sleep-walking 2.--------Loquens. Sleep-talking. 3.---------Salax. Night-pollution. The nature of these singular affections, and the means by which they are produced, have never yet been explained ; and rarely, so far as I know, has any explanation been attempt- ed. To understand them fully, it would be necessary for us to enter into a minute devel- opment of the physiology of sleep and dream- ing, which the limits of the present work will not allow. On some future occasion, the au- thor may perhaps follow it up into such a de- tail ; but a few general remarks must suffice for the occasion before us. In sleep, accompanied with dreaming, the fac- ulties of the mind bear a pretty close parallel with those of the body, as to the effect produced upon them. Some of them, as the will, the perception, the judgment, are in a state of gen- eral torpitude, like the voluntary organs of the body ; while the memory and the imagination, like the vital or involuntary organs r>f the body, are in as high activity as ever. Hence, the sensory is as much crowded with ideas as at any time ; but, destitute of a controlling power, they rush forward with a very considerable de- gree of irregularity, and would do so with the most unshapeable confusion, but that the habit of association still retains some degree of in- fluence, and produces some degree of conso- nance and proportion in the midst of the wildest and most extravagant vagaries. And hence that infinite variety which takes place in the character of our dreams ; and the greater reg- ularity of some, and the greater irregularity of others. Hence a combination of thoughts or ideas, sometimes only in a small degree in- congruous, and at other times most frantic and heterogeneous ; occasionally, indeed, so fearful and extravagant as to stimulate the external senses themselves into a sudden renewal of their functions, and consequently to break off abruptly the sleep into which they were thrown. Now, as the stimulant force of our ideas in dreaming is often sufficient to rouse the exter- nal senses generally, and to awake us all of a sudden, it may be of such a kind, and just of such a strength, as to excite into their accus- tomed action the muscles of those organs or members only which are more immediately con- nected with the train of our dreams or incohe- rent thoughts, while every other organ may still remain torpid. And hence the muscles chiefly excited being those of speech, some persons 212 NEUROTICA [Cl. IV.—Ord. I. talk, or the muscles chiefly excited being those of locomotion, other persons walk in their sleep, without being conscious, on their waking, of any such occurrence.* And by the same means we may easily account for the third species of the genus, or that which consists in dormant and involuntary salacity. SPECIES I. PARONIRIA AMBULANS. SOMNAMBULISM. SLEEP-WALKING. THE MUSCLES OF LOCOMOTION EXCITED INTO THEIR ACCUSTOMED ACTION BY THE FORCE OF THE IMAGINATION DURING DREAMING. In profound sleep, all the faculties of the mind, as well as all the voluntary organs of the body, are in a state of inactivity or torpitude, and the only organs that preserve their active tenour are the involuntary ones ; so that, in this state, there is neither thought nor idea of any kind. In dreaming, some of the mental faculties only sleep or are torpid, while the others, like the involuntary organs of the body, continue wakeful or active : the somnolent fac- ulties, we have already observed, are the will, the perception, and the judgment ; the wake- ful are the memory and the imagination. It would not be difficult, if we had time, to show why the involuntary organs do not require rest, or, in other words, become torpid like the voluntary ; nor why the will and the judgment sooner associate in the general sleep of the ex- ternal senses than the imagination; but this would carry us too far into the subject of ani- mal physiology. There are two physiological remarks, however, which it is necessary to make, in explanation of the morbid affection immedi- ately before us. The first is, that sleep is a natural torpitude or inertness, induced upon the organs of the body (with the exception of the involuntary), and the faculties of the mind by fatigue and exhaustion. And the next is, that, in the production of sleep, it is not neces- sary that all these powers of body and mind should have been equally exposed to exhaustion : for such is the effect of association and habit, that as soon as one faculty or organ feels fatigue or becomes exhausted, the rest participate in the same condition, and the sleep or torpitude becomes common to the whole. It is hence the body is made drowsy by mental study, and the mind by corporeal labour ; that muscular exer- cise wearies all the senses, and the exertion of the senses wearies the muscles: though there tan be no doubt that the general tendency to .sleep is also partly superinduced by the indirect exhaustion sustained by the organs or faculties that have been less employed, in consequence of the share of sensorial energy which, as from a common stock, they have themselves con- tributed towards the support of the more active and hence more debilitated powers. * Hennings, von den Triiumern und Nachtwand- lern, Weimar, 1784. Horst, De Natura, Differ- cntiis, et Causis eorum qui dormientes ambulant, &c., Leipe., 1593, 8vo. Now it sometimes happens, either from dis- ease or peculiarity of constitution, that all the external organs of sense do not associate in the general action that has taken place, or yield alike to the general torpor to which it gives rise ; and that the auditory, the optical, or some other sense, continues awake or in vigour while all the rest are become inert; as it does also, that such particular sense, like the muscles of particular members, as observed a page or two above, is awakened or restimulated into action in the midst of the soundest sleep, by the pe- culiar force and bent of the dream, while the rest still sleep on and are unaffected. If the external organ of sense thus stimula- ted be that of sight, the dreamer may perceive objects around him, and be able to distinguish them: and if the tenour of the dreaming ideas should as powerfully operate upon the muscles of locomotion, these also may be thrown into their accustomed state of action, and he may rise from his bed, and make his way to what- ever place the drift of his dream may direct him, with perfect ease and free from danger. He will see more or less distinctly in propor- tion as the organ of sight is more or less awake : yet, from the increased exhaustion, and, of course, increased torpor of the other organs, in consequence of an increased demand of sen- sorial power from the common stock, to supply the action of the sense and muscles immedi- ately engaged, every other sense will probably be thrown into a deeper sleep or torpor than if the whole had been quiescent. Hence, the ears may not be roused even by a sound that might otherwise awaken the sleeper. He may be insensible, not only to a slight touch, but a severe shaking of the limbs; and may even cough violently without being recalled from his dream. Having accomplished the object of his visionary pursuit he may safely return, even over the most dangerous precipices, for he sees them distinctly, to his bed ; and the organ of sight being now quite exhausted, or there being no longer any occasion for its use, it may once more associate in the general inactivity, and the dream take a new turn, and consist of a new combination of images.* * A remarkable instance of somnambulism oc- curred in 1833-4, at Springfield, Mass., in the per- son of Jane C. Rider, and was observed by Dr. L. W. Belden, of that town, from whose statement (An Account of Jane C. Rider, the Springfield Somnambulist, Springfield, 1834) we quote the following particulars:—The mother of Miss R. died suddenly of disease of the brain. Ths young lady, when these attacks commenced, was in her seventeenth year, and of a full habit. A small spot on the left side of her head has, from her earliest recollection, always been tender or pain- ful on pressure, and much more so whenever she suffers from headache, with which she is occa- sionally affected. During the paroxysms of som- nambulism, this spot is frequently the seat of in- tense agony. Her eyes are extremely sensible to the light. The first paroxysm of somnambulism appeared in June, 1833 ; from this she was relieved by an emetic ; in a month, however, she was again af- fected, and the paroxysms recurred at different Gen. V.-Spe. 1.] PARONIRIA AMBULANS. 213 Somnambulism occurs in many persons with- out any manliest predisponent cause, though it- is generally connected with a considerable irri- tability of habit. A morbid state of the stom- ach, where this habit exists, has very frequently proved an exciting cause ; of which Dr. Yeates' has given us an example in the case of a young gentleman of ten years of age.—(Med. Trans., vol. v., art. xxviii., p. 444.) He was of a del- icate frame, often troubled with sickness ; some- times ejected his food undigested, after having lain two days in his stomach: his bowels were costive, and the stools were dark, offensive, and ill formed. The sympathetic symptoms were frequent headaches, with occasional stupor, gen- eral coldness of the skin, and limpid urine. Af- ter being in bed for about two hours, he was wont to start up suddenly, as if in a fright, dart rapidly into the middle of the chamber, or of the room adjoining, and walk about with much agita- tion. In this state he would run over quickly, but incorrectly, the transactions of the day ; and he once attempted to spell a word which in the. daytime he had spelled wrong, in doing which he jnmbled a number of letters together. When spoken to he would make a rational re- intervals until February, 1834. From the 6th to the 13th of December she had from one to three paroxysms daily. " At first they occurred only in the night; and generally soon after she went to bed. As the disease advanced, they commenced earlier ; she then fell asleep, or rather passed into the stats of somnambulism in the evening, sitting in her chair. At a still later period, the attacks took place at any hour during the day or evening. After she began to be affected in the daytime, the fit seldom commenced when she was in bed. The duration of the fits varied from a few minutes to forty-eight hours. " The state of somnambulism was usually pre- ceded by a full, heavy, unpleasant feeling in the head ; sometimes by headache, ringing in the ears, cold extremities, and drowsiness. To a spectator she seemed as if going to sleep ; the respirations became long and deep ; her attitude and the mo- tions of her head resembled those of a person in a profound slumber. During the fit, the breath- ing, though sometimes natural, was often hurried, and attended with a peculiar moan. The pulse was at times accelerated, but generally it did not vary much from the natural standard. Occasion- ally the whole system was thrown into violent agitation, and she appeared like a person in hys- terics. The eyes were generally closed, but at times they were open, and the pupil was then con- siderably dilated. These different states of the eye seemed to occasion no difference in the power of seeing—she saw apparently as well when they were closed as she did when they were open. All attempts to rouse her during a paroxysm were unsuccessful. She heard, felt, and saw; but the impressions she received through the senses had no tendency to waken her. " At the termination of a paroxysm she sunk into a profound sleep. The frown disappeared from her brow; the respirations again became long and deep; she soon began to gape and rub her eyes; and in fifteen or twenty minutes from the first appearance of these symptoms she opened her eyes, and recollection was at once re- stored. " Her manner differed exceedingly in different ply ; and, in one of his sleeping perambulations, he called for an epitome of the History of Eng- land, which he was in the habit of reading. The nurse brought him a book, but not the one he called for: on perceiving the difference he immediately threw it from him with great vio- lence, and with expressions of anger and disap- pointment. On these occasions his eyes were wide open, though he did not seem conscious of seeing, nor of his situation at the time. It was, says Dr. Yeates, a perfect state of dream throughout, though partaking of the acts of the waking state, for he would avoid objects walk- ing about the room. His face was quite pallid at the time. In this case, much of the nervous hurry and agitation seems to have depended upon the de- bilitated and irritable state of the patient's frame. But where the affection proceeds from idiosyn- crasy, or where there is no disturbance of the general health, the dreamer often proceeds far more coolly and collectedly ; and the eyes, in- stead of being wide open, as though staring, are often not more than half unclosed, in some cases even less than this ; which has given oc- casion to marvellous stories of somnambulists walking over dangerous places, or avoiding dan- paroxysms ; sometimes she engaged in her usua occupations, and then her motions were remark- ably quick and impetuous—sfie moved with aston- ishing quickness, and accomplished whatever she attempted with unusual celerity. She attended to her domestic occupations, and was sometimes employed in sewing, reading, writing, &c. In the intervals of reading or talking, and even when thus engaged, her nods, her expression of coun- tenance, and her apparent insensibility to sur- rounding objects, forced on the mind the convic- tion that she was asleep. Occasionally she was cheerful, but generally she was petulant and irri- table. How far she was sensible to the presence of surrounding objects, it is very difficult to de- termine. Indeed, facts seem to prove that she was not in every paroxysm alike in this respect. In the early stage of her complaint she appeared to take little notice of persons unless they were connected with her train of thought; but at a la- ter period she seemed to comprehend more of what transpired in her presence. She recollected du- ring a paroxysm circumstances which occurred in a former attack, though there was no remem- brance of them in the interval. She occasionally imitated the manners, language, arid sentiments of those around her with great fidelity; though in her natural state she had no imitative powers, and could even sing accurately and agreeably, although when in health she can do neither." The most remarkable feature, however, of this curious case, was the extraordinary power of vis- ion attending the earlier paroxysms. Although her eyes were carefully covered by a white hand- kerchief folded so as to make eight or ten thick- nesses, and the spaces below the bandage filled with strips of black velvet, yet she read, played backgammon, gave answers as to the colours of different objects presented to her, &c, &c, with the utmost precision. She took a pencil, and while rocking in a chair wrote her own name, each word separately, and dotted the i. In this case the disease evidently depended on a derangement of the digestive organs, and was cured by appropriate remedies.—D. 214 NEUROTICA. [Cl. IV.—Ord. T. gerous objects, with their eyes completely shut all the time.*" The remedial treatment which it may be ne- cessary to pursue we shall defer till we have briefly noticed the succeeding species, as the same treatment will apply to the whole. SPECIES II. PARONIRIA LOQUENS. SLEEP-TALKING. THE MUSCLES OF SPEECH EXCITED INTO THEIR ACCUSTOMED ACTION BY THE FORCE OF THE IMAGINATION DURING DREAMING. It is not necessary to dwell upon this spe- cies, as we have already explained the general principles of the inordinate action in the prece- ding pages. As the train of ideas which form the dream, when peculiarly lively and immedi- ately connected with the organs of locomotion, may stimulate those organs into their accustom- ed activity, and thus give the dreamer a power of walking without consciousness ; in like man- ner, if a similar train of dreaming ideas be im- mediately connected with the organs of speech, these may also be equally influenced, and the dreamer be able to talk without being conscious of it, or having any recollection of such exer- tion when he awakes. And as, for reasons al- ready specified, the».organ of sight is sometimes in the same way roused from a state of sleep or torpitude to a state of wakefulness, while, all the other external senses continue somnolent, or from idiosyncrasy, or some local or accident- al cause, do not join in the general repose, but continue vigilant during its dominion, the organ of hearing may be roused in the same manner* or exhibit the same anomaly; and in this case the dreamer, who, under the influence of the last species of affection, is able to see as well as to walk, is able, under the present, to hear as well as to speak. + Examples, in- * It seems to Dr. Uwins, that the phenomena characterizing that remarkable condition of the brain and nerves which leads to sleep-walking, might be adduced in favour of the principle that one series of organs may be active while another is dormant. It is well known, says he, that the perceptions are so exceedingly acute in sleep- walkers as to enable them to pass over narrow bridges, &c, the contemplation of which they have shuddered at when awake. " Is not this su- perior adroitness referrible to the suspended agen- cy of other parts of the brain, rather than to a positive augmentation of power in the parts in ex- ercise ? And is not this the pivot or main-spring upon which aberration turns and depends ? Wake a sleep-walker, and he is immediately alive to his danger; prove to a maniac the untenable nature of his assumptions, and he is directly conscious of, or awake to, all his insane wanderings."—Dr. Uwins on those Disorders of the Brain and Ner- vous System usually called mental, p. 31, 8vo., London, 1833.—Ed. t Dreaming seems to Dr. Uwins to differ from the condition of actual madness, inasmuch as there are in it no correctives against aberration from the senses: " when these are called into ex- ercise, all the lofty conceits and wild combinations deed, are given, in which a by-stander, obtain- ing some clew into the train of thoughts of which the dream is composed, has been able not only to keep up an irregular conversation, but, by dexterous management, and the artful assump- tion of a character which he finds introduced into the dream, to draw from the dreamer the profoundest secrets of his bosom, the dreaming ideas generally consisting of those on which the dreamer is most employed when awake, or which lie nearest his heart. I have never met with a case of this kind in my own practice, but it is given as a fact by various physiologists from the time of the Greeks and Romans to our own day.* SPECIES III. PARONIRIA SALAX. NIGHT POLLUTION THE SEXUAL ORGANS EXCITED INTO VENEREAL ACTION BY THE FORCE OF THE IMAGINATION DUKING DREAMING. By Sauvages this affection is absurdly placed among the species of gonorrhoea, which, with great looseness of generic character, is defined "passio, cujus praecipunm symploma est fluidi puriformis vel seminiformis effluxus stillatitius ex urethra." This definition is, indeed, wide enough to embrace the affection before us ; but the absurdity consists in intermixing a natural discharge, produced by the ordinary orgasm, with morbid discharges, in which, in most cases, there is no orgasm whatever. Dr. Cullen, how- ever, has continued to assign the same place and the same name to the present species, and this with still greater inconsistency : since he has struck out of his definition of gonorrhoea the epithet seminiformis, and confined it to a " fluxus humoris ex urethra prater naturam." So that he has been obliged to break his own bounds, to introduce this natural flux into the place he has allotted it. And hence, in laying down the treat- ment of gonorrhoea in his Practice of Physic, he tikes no notice of his gonorrhoea dormienlium, as though feeling that it was altogether a differ- ent, subject. We have already observed, that whatever part of the animal frame is immediately connected with the tenour of the somnolent vision, it is often roused, under particular circumstances, from the general sleep or torpitude in which it had participated, and becomes wakeful, while every other part perseveres in the common re- pose. During sleep, moreover, our ideas are often more lively and operative than during of the dreamer are in a moment over ; while they continue in the mad, despite of the sensual infor- mation ; nay, the workings of the brain seem oc- casionally to change these sensual guards against aberration into actual ministers of misconcep- tion."—On Dis. of the Brain, &c, p. 31.—Ed. * The lectures on moral philosophy of Dr. Sam- uel S. Smith, the late president of Princeton Col- lege, contain many valuable remarks on the causes of the morbid phenomena adverted to by Dr. Good when treating of paroniria.—See likewise ih.0 I ingenious work of MacNish on sleep.—D. Okn. V—Spe. 3.] PARONIRIA SALAX 215 wakefulness, and this on two accounts; first, because from the uninterrupted activity of the involuntary organs, there is a more ready secre- tion of sensorial as well as of most other fluids in a state of perfect tranquillity ; and next, because the ideas that predominate at the time are not broken in upon or weakened by exterior impres- sions and disturbances. It is on this account, when the faculty of the judgment is stimulated into activity instead of the ear or eye, or the motory powers, a man has sometimes been able to solve difficulties in dreaming which proved too hard for him when vigilant. And to this effect Dr. Spurzheim : " Somnambulists," says he, " even do things of which they are not ca- pable in a state of watching; and some dream- ing persons reason sometimes better than they do when awake."—(Physiognomical System, p. 175, 8vo., Lond., 1815.) A singular and amu- sing instance of this occurred not many years ago to a very excellent and justly celebrated friend of the author's, the Reverend William Jones, of Nayland, Suffolk, who, among other branches of science, had deeply cultivated that of music, to which, indeed, he was passionately attached. He was a man of irritable tempera- ment, ardent mind, and most active and brill- iant imagination; and was hence prepared by nature for energetic and vivid ideas in his dreams. On one occasion during his sleep he composed a very beautiful little ode of about six stanzas, and set the same to very agreeable music ; the impression of which was so firmly fixed in his memory, that, on rising in the morning, he sat down and copied from his recollection both the music and the poetry. It is hence not difficult to conceive, that mem- bers so irritable as the sexual organs, when once the imagination leads energetically to the subject of concupiscence, should occasionally participate in the vision and prove their sympa- thy by the result. In some morbid states of the body, and espe- cially when accompanied with local irritation, produced by inflammation, fibrous entony, the debility of old age, or a habit of vicious indul- gence, a seminal flux has sometimes taken place without any connexion with the dream, and sometimes without either erection or tumes- cence ; but this does not constitute the affection immediately before us ; in which the stimulant power lies in the sensory, and is propagated from that organ to those of generation. The Roman poet, who so admirably unlocked the nature o? things to his contemporaries by following the footsteps of nature herself into most of her deepest recesses, directed his at- tention to this subject, among other physiologi- cal facts, and has elegantly explained it in the above manner; adducing at the same time an- other instance of the influence which the ideas of dreaming sometimes exercise over the organs connected with them, derived from the evacua- tion of the bladder, which frequently takes place in children, whose dream is directed to this nat- ural want, and who image to themselves the or- dinary vessel employed for such purpose aa at hand'for their use {,De. Rer. Nat., iv., 1020) :— " Pueri saepe, lacum propter, seu dolia curta, Somno devinctei, credunt se extollere vestem; Totius humorem saccatum corporis fundunt; Quom Babylonica, magnifico splendore, rigan- tur. Turn, quibus aetatis freta primitus insinuantur, Semen ubi ipsa dies membris matura creavit, Conveniunt simulacra foris e corpore quoque, Nuncia praeclari voltus, pulchrique coloris, Qui ciet inritans locaturgida semine multo, Ut, quasi transactis saepe omnibus rebus, pro- fund ant, Fluminis ingenteis fluctus, vestemque cruen- tent." In the medical treatment of all these species of paroniria we must never lose sight of this principle, that although in many instances their predisponent cause is a peculiar idiosyncrasy or habit, their exciting cause is in all cases gen- eral or local irritation; and that this irritation is of two very opposite kinds, which it also be- comes us very particularly to attend to, namely, that of entony, or excess of power, and that of atony, or deficiency. It is to the former that Lucretius alludes, and which is by far the most common exciting cause; and where this exists, our first indication is to reduce the superabundant vigour by venesection, purgatives, laborious exercise, and a limitation to a plain and spare diet. While, on the con- trary, where the exciting cause is debility, our attention should be directed to a tonic course of medicines, and particularly to those tonics which prove sedative at the same time that they strengthen the system. Several of the mineral acids are entitled to this character, and espe* cially the sulphuric ; and a still greater number of the vegetable bitters, and particularly the ex- tracts of hop and lettuce. Dr. Cullen, indeed, as we have already observed, supposes a seda- tive power to exist in all the' bitters, though not equally in all. How far the prussic acid might be usefully employed for this purpose, I cannot say from personal practice. Our next object of attention should be to pre- vent all undue accumulation of the sensorial principle during sleep; and this may be accom- plished in two very distinct and opposite ways. The first is the use of a hard mattress, with so small a covering of clothing that the sleep may be somewhat less sound than ordinary, and con- sequently more easily broken off. For the force of our dreaming ideas will always be in propor- tion to a certain degree of soundness in our sleep ; I say a certain degree ; because if the fatigue, or exhaustion, or torpitude be extreme, the sleep will become profound or lethargic, all the faculties of the mind will participate in it, and, as already observed, there will be no ideas or dreaming whatever. And hence the second mode of preventing an accumulation of sensorial and especially of irri- table power will be the employment of narcot- ics till the morbid habit is destroyed ; for these, when carried lo a sufficient extent, diminish vas- cular action, and consequently take off sense and motion so completely as to extinguish the vital principle altogether; and hence not only to sup- press ah power of dreaming, but even life itsoi£ 216 .NEUROTICA [Cl. IV—Ord. I. I had lately under my care, for the last spe- cies, a very modest and regular young man, who was a student of Christ's College, Cambridge ; and was alarmed at the idea of having his con- stitution undermined by its continuance. He was rapidly growing, of slender make, and of a relaxed habit. Nitre, which has been so often recom- mended as a sedative, in this case did no ser- vice ; but, under the use of a pill composed of one grain of opium and five of camphire, taken nightly, and draughts of myrrh and infusion of columbo acidulated with sulphuric acid, he lost the tendency in a fortnight, after having been subject to the discharge for many weeks. His bowels were kept at the same time constantly stimulated by the pill of aloes and myrrh, and the cold bath formed a part of his regimen. Pa- gini and De Cazelles (Journ. de Medecine, torn. lxxiv.) have recommended electricity; but the author has never tried its effects, having uni- formly succeeded without it.* Where either of these species, but partic- ularly the two former, are connected with a morbid state of the stomach, the disease must be attacked in this quarter ; as it was with great judgment and a favourable issue in the case quoted from Dr. Yeates, GENUS VI MORIA. FATUITY. DEFECT OR HEBETUDE OF THE UNDERSTANDING. Moria is a Greek term, from ui&pos, " stultus, fatuus." It is here limited to its proper signifi- cation. Vogel employs it, though with a differ- ent termination (morosis instead of moria), in the same or very nearly the same sense ; but he is almost the only medical writer that does so. By Nenter and Sauvages, m6ria is used to denote melancholia complacens (self-complacent melan- choly), while by others it is employed synony- mously with ancea or idiotism. To complete the confusion, morosis (amentia morosis) is the name given by Sauvages to mental imbecility (moria imbecillis), though, as already observed, he had just before used moria in the sense of melancholy. It is precisely in the signification now offered, that the term is employed by Eras- mus in his celebrated treatise entitled " Moria Encomium," or " The Praise of Foily," which he dedicated to Sir Thomas More, Mora, moror, morosus, morositas, are derived from this common source; and uniformly im- port " waywardness, tardiness, dulness, imped- iment ;" though the lexicographers, not having hit upon the right path, have wandered in differ- ent directions without being able to satisfy them- selves. In Sauvages and Sagar morositates are * In the entonic state of paroniria salax, we are often obliged to employ the usual antiphlogistic remedies. When it depends on an opposite con- dition, which is more frequently the case, we rely on bark, iron, chalybeate waters, country air, and agreeable society. Blisters to the perineum are often serviceable, and so too with cold hip-baths. Opium, tobacco, and other narcotics are thought by some to possess an anti-aphrodisiac power.—D, in fact " corporea moria?," defects or hebetudes of the bodily faculties. The preceding genera are founded upon a morbid perversion or misrule, a diminished or excessive excitement, of one or more of the powers of the mind, operating upon the mind itself or upon the body. The present is founded upon a natural or permanent dulness or hebe- tude of one or more of the same powers, pro- ducing a deficiency in the understanding, which, however, may be regarded as the general frame or constitution of the mind, in the same manner as the body is the general frame or constitution of the organs which form its separate parts. Moria, thus explained, will be found, as a genus, to embrace the two following species :— ] - Moria Imbecillis. Imbecility. 2.-----Demens. Irrationality. SPECIES I. MORIA IMBECILLIS. MENTAL IMBECILITY. THE DEFECT OR HEBETUDE PARTIAL, OR CON- FINED TO PARTICULAR FACULTIES OF THE UN- DERSTANDING. We have already observed that all the facul- ties of the mind are as subject to a diseased disturbance as the organs of the body; and hence all of them are liable to be affected by the present species. The whole of the varieties, therefore, under which mental imbecility is ca- pable of being contemplated, might form an ex- tensive list: but it will be sufficient to confine ourselves to the four following :— Dulness and indocility of the ap- prehension ; torpitude and poverty of the imagination. Feebleness or failure of the memory. Weakness and undue pliancy of the judgment, with a facility of being duped. Instability and irresolution of the will. a Stupiditas. Stupidity. B Amnesia. Forgetfulness y Credulitas. Credulity. S Inconstantia. Fickleness. In stupidity, there is generally a dulness in several of the faculties besides the apprehension and the imagination; and sometimes, perhaps, in all of them: but then it originates in these, and the rest are for the most part only seconda- rily dull, as not being furnished with a sufficient number of ideas, or in sufficient rapidity for their use. Thus the judgment of a heavy or stupid man is often as sound in itself as that of a man of capacious comprehension ; and more so, per- haps, for a reason we have already observed under alusia facetosa, or crack-brained wit, than that of a man of facetious quickness of parts: but the heavy man requires time and patience to collect his ideas, and compare them with each other; for they are neither furnished to him in a free current from his memory or his imagina- tion, nor does he readily apprehend or lay hold of them as they are offered from external objects to his perception, which, in effect, is little more than a synonyme for the apprehension—the ap- Gen. VI.—Spe. 1.] MORIA IMBECILLIS. 217 prehension being the perception in a state of exercise or exertion. There is hence a mate- rial difference in physiology, though perhaps little in practice, between ignorance and stupid- ity. The former is want of knowledge from want of its ordinary means ; and by the use of such means may perhaps soon be gotten the better of: the latter is dulness in the use of such knowledge as by ordinary means has been ac- quired, and exists in the sensory, though in a state of stagnation or dormancy. Mr. Locke has made the same distinction, though he has justly enough observed, that for all practical purposes, the man of stupidity had almost as well be without his knowledge as with it. " He," says this admirable writer, " who, through this default in his memory, has not the ideas that are really preserved there ready at hand when need and occasion call for them, were almost as good be without them quite, since they serve him to little purpose. The dull man, who loses the opportunity while he is seeking in his mind for those ideas that should serve his turn, is not much more happy in his knowledge than one that is perfectly ignorant. It is the business of the memory to furnish those ideas which it has present occasion for ; and in the having them ready at hand on all occasions, consists that which we call invention, fancy, and quickness of parts."—(Essay concerning Hum. Underst., b. ii., ch. x., sec. 8.)* Stupidity or dulness of apprehension may be idiopathic ; but it may also proceed from want of education, or education irregularly conducted ; for all the faculties of the mind, like the muscles of the body, become invigorated and are ren- dered more alert by a well-disciplined exer- cise. And hence stupidity is a natural result of idleness ; as it is more particularly of idleness in conjunction with an undue use of wine and fermented liquors, which have a proverbial power of besotting the understanding. It is also pro- duced temporarily or habitually by various cor- poreal diseases ; as hemicrania, chronic inflam- mation or dropsy of the head, gout in the head, and sometimes repelled cutaneous eruptions or habitual discharges. Stupidity, like wit, is propagable ; and hence we frequently see it run from one generation to another; and not unfrequently it forms a dis- tinctive mark in the mental character of dis- tricts or nations : in many cases, indeed, where they border closely on each other. The Dutch have at least as much solid sense as their neigh- bours, the French ; but they are certainly less quick, or, in other words, they have a duller fancy and apprehension. Bceotia, in respect to chorography, was merely separated from Attica by Mount Cithaeron; but in respect to genius, the two countries were as far apart as the poles. So, in the Pacific Ocean, the natives of Otaheite * As stupidity sometimes depends on mechani- cal causes, so, too, after the operation of the same causes in stupid persons, the mind sometimes manifests more energy. The celebrated Pere Mabillon was considered as stupid till a tile fell upon his head: he then began to display great abilities.—D. learn every thing with facility ; the natives of New South Wales have no aptitude, and learn nothing. The residence of a few missionaries among them for a short term of years has nearly civilized the former : the actual possession of the country for a far longer period by a British public and a British government, with a perpetual inter- course and the kindest encouragement, has made little or no impression upon the latter. A failure of memory, however, which forms the second species of mental imbecility before us, is a far more severe evil than dulness of per- ception with poverty of imagination ; for as all the sources of information to which we have been privy cannot be always immediately before us to excite the perception, we must necessarily draw upon our recollection for those which are not so, and whose ideas or impressions we stand in need of. And hence the memory is the great storehouse of intelligence ; and in one sense at least the Platonic doctrine is univer- sally true, that " all knowledge is reminiscence." There are some minds in whom this faculty has been peculiarly retentive, as that of Newton, who made it answer the purpose of intuition ; and of Pascal, who is said never to have forgotten, till his health failed him, any thing he had ever done, read, or thought of.* Retention of memory, however, is a different property from that of quickness. They may and often do co-exist, but they are also found sep- arate ; for there are many persons who can well catch hold of an entire song, an entire ser- mon, or a series of speeches in parliament, and can recite them almost, if not altogether, verba- tim immediately afterward, but who lose all rec- ollection of them in a day or two ; while there are others who are obliged to pause over the subject submitted to them, or to have it repeated for several times before they can get it by heart, yet who, when they have once fixed it in the memory, retain it as long as they live. Mr. W. "Woodfall, the celebrated reporter of the parlia- mentary debates, was an instance of the former of these talents in regard to his powers of ap- prehension ; the well-known Jedediah Buxton of the latter ; though it should be remarked, that Mr. Woodfall retained with as much ease as he first fixed speeches in his memory. Failure of memory takes place in a variety of ways.f It is sometimes general, and extends to every subject; but it is frequently far more * Actors, who are compelled by their profes- sional pursuits to cultivate the memory, often pre- sent remarkable examples of the powers of appre- hension and retention of this mental faculty. Hodgkinson, a celebrated comedian, was able, by three or four readings, to recite the contents of a newspaper without error. The distinguished Dr. S. L. Mitchill could repeat, in earlier life, an en- tire sermon which he had heard a few hours pre- viously.—D. t The curious case related by Major Elliot of West Point, N. Y., merits attention :— " The patient was a young lady of cultivated mind, and the affection began with an attack of somnolency, which was protracted several hours beyond the usual time. When she came out of it, she was found to have lost every kind of acquired 218 NEUROTICA. [Cl. IV.—Ord. I. manifest on some subjects than on others. Sal- muth mentions a case in which the affected per- son had forgotten to pronounce words, but could nevertheless write them.—(Cent, ii., obs. 41.) Mr. J. Hunter was suddenly attacked with a singular affection of this kind in December, 1789, when on a visit to the house of a friend in town. " He did not know in what part of the house he was, nor even the name of the street when told it, nor where his own house was : he had not a conception of any thing existing beyond the room he was in, and yet was perfectly conscious of the loss of memory. He was sensible of im- pressions of all kinds from the senses, and there- fore looked out of the window, although rather dark, to see if he could be made sensible of the situation of the house. The loss of memory gradually went off, and in less than half an hour his memory was perfectly recovered."— (Sir Eoerard Home's Life, prefixed to his Trea- tise on the Blood, Inflammation, (See, 4to., 1794.) This might possibly be connected with a gouty habit, to which Mr. Hunter was subject, though not at this time labouring under a paroxysm. The late bishop of Landaff, Dr. Watson, gives a singular case of partial amnesia in his father, the result of an apoplectic attack. " I have heard him ask twenty times a day," says Dr. Watson, " ' What is the name of the lad that is at collegeV (my elder brother); and yet he was able to repeat, without a blunder, hundreds of lines out of classic authors."—(Anecdotes of the Life of Ric/iard Watson, D. D., Bishop of Landaff.) And hence there is no reason for discrediting the story of a German statesman, a Mr. Von B., related in the seventh volume of the Psychological Magazine, who, having called at a gentleman's house, the servants of which did not know him, was under the necessity of giving in his name ; but unfortunately at that moment he had forgotten it, and excited no small degree of laughter by turning round to a friend who accompanied him, and saying, with great earnestness, " Pray tell me who I am, for I can- not recollect."* knowledge. She immediately began to apply her- self to the first elements of education, and was making considerable progress, when, after several months, she was seized with a second fit of som- nolency. She was now at once restored to all the knowledge which she possessed before the first attack, and without the least recollection of any thing that had taken place during the interval. After another interval she had a third attack of somnolency, which left her in the same state as after the first. In this manner she suffered these alternate conditions for four years, with the very remarkable circumstance that during one state she retained all her original knowledge, but during the other that only which she had acquired since the first attack. During the healthy interval, for in- stance, she was remarkable for the beauty of her penmanship; but during the paroxysm wrote a poor, awkwTard hand. Persons introduced to her during the paroxysm, she recognised only in a subsequent paroxysm, and not in the interval; and persons whom she had seen for the first time du- ring the healthy interval, she did not recognise du- <"b- the attack."—D. * The lat>p Hon. Thomas Law of Washington From severe suffering of the head in many fevers, a great inroad is frequently made upon the memory, and it is long before the convales- cent can rightly put together all the ideas of his past life. Such was one of the effects of the plague at Athens, as we learn from Thucy- Qldes : to&s 6e xai Xi'/dti tXdpBavc irapavTiica avaarav- ruj ruv Tavruv 6/ieiuj xal iiyv6tjaav a^aj n airoiii, Kal rove cnTiiiclovs '■ " and many, on recovery, still experienced such an extraordinary oblivion of all things, that they knew neither themselves nor their friends." A few years ago a man with a brain-fever was taken into St. Thomas's Hospi- tal, who, as he grew better, spoke to his attend- ants, but in a language they did not understand. A Welsh milk-woman, going by accident into the ward, heard him, answered him, and con- versed with him. It was then found that the patient was by birth a Welshman; but had left his native land in his youth, forgotten his native dialect, and used English for the last thirty years. Yet, in consequence of this fever, he had forgotten the English tongue, and suddenly recovered the Welsh.* Boerhaave, however, gives a still more extra- ordinary instance of oblivion in the case of a Spanish tragic author, who had composed many excellent pieces, but so completely lost his mem- ory in consequence of an acute fover, that he forgot not only the languages he had formerly learned, but even the alphabet; and was hence under the necessity of beginning to read again. His own poems and compositions were shown to him, but he could not be persuaded that they were his production. Afterward, however, he began once more to compose verses, which had so striking a resemblance to his former writings, that he at length became convinced of his being the author of them.f city, the brother of Lord Ellenborough, was a re- markable instance of this peculiarity. He fre- quently was unable to give his name when calling at the postoffice for letters: yet on other occa- sions, as in respect to past events and on business of importance, his powers of memory were strong and acute.—D. , * In a case occurring under the notice of Dr. John Ware of Boston, where the patient had suf- fered excessively from sea-sickness, the memory of recent events was entirely lost. The gentle- man could recollect distinctly what had occurred several years before, but retained no trace what- ever of what had happened a few months previous to his illness—See Am. Journal of Med., Sc (Sec vol. v., p. 379.—D. t Pralect. Acad.in Instit. Med. ex edit. Haller, torn, iv., p. 463. See also Crichton of Ment. De- rangement, i., 370. Dr. Uwins considers the very condition of madness as implying some sort of for- getfulness, or forgetfulness of something, which, were memory to recall, the hallucination would be over. " Both in actual dreams and in the day- dreams of madness, we bring together into one point of time the most extravagant alibis, and join in conversation with those who have paid nature's great debt many years before. The portions of the brain implicated, if they tell us nothing but the truth, but at the same time do not tell us the whole truth, lead to all these misconceptions as to time, and place, and circumstance. How they do this, and how they leave that undone, constitutes the Gen. VI—Spe. 1.] The memory may also be prematurely impair- ed (for in age it is a natural defect)* by various other causes. Idleness or inattention will do it, as in the case of stupidity, as will also an over-exertion of the faculty, injuries of the head, rheumatic or gouty pains in it, dyspeptic mala- dies, various narcotic poisons, prostrating hem- orrhages or want of food, and libidinous indul- gence.—(Dissert, de Memoria Lasione ex nimis Vener. Usu, Alt., 1695.) Dependant upon this last cause, Sir Alexander Crichton has given a single example of what may be called perverse oblivion in an old at- torney, nearly seventy years of age, who, though married to a lady much younger than himself, kept a mistress, whom he visited every night. He was suddenly seized with great prostration of strength, giddiness, and forgetfulness ; but the last was of a peculiar kind, and consisted in the mistaking the name of one thing for that of another; vo that, if he wanted bread, he would ask for his boots; and though enraged at the latter being brought to hiin, he would still call out for his boots or shoes. In like manner, if he wanted a tumbler to drink out of, it was a thousand to one but he would call for the ordi- nary chamber utensil; or, if this were wanted, he would call for a tumbler or a dish. This gentleman, however, was cured of the complaint by large doses of valerian and other cardiacs. In credulity, constituting the third varie- ty of the imbecility before us, the faculty of the judgment is the chief seat of disorder. It is unquestionably more generally to be found among ignorant people, than those whose minds are well stored with the elements of knowledge ; but as we also frequently perceive among the former a most obstinate and wilful incredulity, and among the latter extraordinary proofs of the present failing, it cannot be regarded as alto- gether an effect of a general want of ideas : it is in reality a hebetude or indolence of the judg- ment or power of ratiocination, which induces a man to take things upon trust, and allow others to think foi him, not for want of ideas, but for want of comparing one idea with another, those of probability with those of improbability, and fairly striking the balance ; in, consequence of which, under the influence of this mental osci- great and still unsolved problem in mental philos- ophy.''—Uwins on Mental Disorders, p. 44.—Ed. * The impairment produced by age is not so much ins;viity as imbecility or fatuity: the mem- ory fails, but it only fails with the other mental powers. " Musicians have told me," says Dr. Conolly, "that as they became old, they found they could not play the music learned in later years without having the music before them ; but could still go through long compositions learned in early life without the book, and without the mis- take of a note. The susceptibility to sensations and emotions is diminished; the attention is less excited by them ; they make a weak and fading impression on the memory. Those things which yet excite more attention are better remembered, even in old age. Old men, Cicero remarks (De Senect.), do not commonly forget where they have deposited their money."—See Inquiries concern- ing tli defective memory, which he names dysasthesia interna, and ranks in the same list or genus with defect of the external senses. Sauvages, and after him Sagar and Cullen, have applied oysaesthesiae to a morbid state of the corporeal senses generally ; whence anaesthesia should, in their hands, have expressed atony or total inac- tivity of these senses generally. But while aysaesthesiae extends to all the senses, anaesthe- sias is by the same writers limited to the single sense of touch, with no small perplexity to the young student. In the Physiological Proem to the present class, we have taken so full a survey of the connexion which exists between the brain and the corporeal senses, by means of the nerves, that it is not necessary to say more upon the subject at present; and I shall only therefore further observe, in these preliminary remarks, that where one of the senses is deficient, and especially where naturally deficient, the rest have very frequently been found in a more than ordinary degree of vigour and acuteness ; as though the sensorial power were primarily de- rived from a common source, and the proportion belonging to the organ whose outlet is invalid, were distributed among the other organs, t t Trinckhusius, De Caecis, sapientia ac eru- ditione, claris mirisaue caecorum quorundam. ac- 222 NEUROTICA. [Cl. IV.—Ord. II. The genera, under the order before us, are taken in a regular series from the corporeal senses themselves in a state of morbid action, and are in number six; of which the first five are derived from the five external senses, and the last from a diseased state of particular branches of the nerves distributed over the frame generally, for the common and pleasurable feeling of health in the different organs through which they are dispersed. I. Paropsis. II. Paracusis. III. Parosmis. IV. Paragusis. V. Parapsis. VI. Neuralgia. Morbid Sight. ------Hearing. ------Smell. ------Taste. ------Touch. Nerve-ache. GENUS I. PAROPSIS. MORBID SIGHT. SENSE OF SIGHT VITIATED OR LOST. Paropsis is literally " diseased or depraved vision," from xapa, male, and Htptc, visas ; as paracusis, " diseased or depraved hearing," from Vrapa, and a/covr). The ophthalmic monographists, by making every variety of affection a distinct disease, have most unmercifully enlarged the list under this genus.—(Campiani Raggionamenti sopra tulti i Mali degli Occhi descrilti, &c, Genoa, 1759.) To say nothing of Campiani, Taylor has in this manner mustered them at two hun- dred and forty-three (Catalogue of two hundred and forty-three Diseases of the Eyes, Edin., fol., 1749), while Plenck has contrived to multiply them to nearly six hundred.—(Doctrina de Mor- bis Oculorum, 8vo., Vienna, 1783, 2d edit.) Upon a comprehensive view of the subject, it will, I think, be found, that this formidable num- ber may be reduced to the twelve species fol- lowing :— 1. Paropsis Lucifuga. -------Noctifusa. 2. 3.-------Longinqua. 4.-------Propinqua. 5.-------Lateralis. 6.-------Illusoria. 7.-------Caligo. 8. -------Glaucosis. 9.-------Cataracta. 10.-------Synizesis. 11.-------Amaurosis. 12.--------Strabismus. Night sight. Day sight. Long sight. Short sight. Skew sight. False sight. Opaque Cornea. Humoral Opacity. Cataract. Closed Pupil. Drop Serene. Squinting. tionibus, Gerae, 1672. Meckren. Observ. Med. Chir., cap. xx. Whether the principle adverted to in the text be true or not, the editor will not undertake to say; but it is more certain that an- other principle is generally concerned, resolvable into habit or practice. Thus, a blind man, whose eyes cannot apprize him of danger, or convey to him any kind of information, is habitually all at- tention with his ears; just as the organ of touch, in a deaf and dumb person, is, from necessity, continually exerted, and brought by habit to ac- quire a nice power of feeling and discrimination, far superior to what is enjoyed by the generality of mankind.—Ed. Most of these fall rather within the province of the ophthalmic surgeon than that of the phy- sician ; but as their general nature ought to be known to every practitioner, we shall proceed to give a glance at each of them in their order. The maladies of the eye dependant on inflam- mation, and constituting ophthalmia, have been already treated of in Class III., Order II., H^e- MATICA PHLOGOTICA. SPECIES I. PAROPSIS LUCIFUGA. NIGHT SIGHT. VISION PAINFULLY ACUTE IN A STRONG LIGHT; BUT CLEAR AND PLEASANT IN A DEEP SHADE OR THE DUSK OF THE EVENING. The specific term lucifuga is so distinct as at once to point out the general nature of the affection, while constituting a very prominent symptom. The author, however, has found a necessity for introducing this new name, not more from its own clearness than from the confusion which has taken place among earlier writers in distinguishing the disease by two directly opposite terms, nyctalopia and hemera- lopia, according as these terms have been used in a literal or a technical and implied sense. The Greeks called it by the former name, literally night sight, in consequence of the person la- bouring under it being only able to see at night or in a deep shade ; while nyctalopia has been used by most modern writers in the opposite sense of night-sightac/ie, agreeably to the tech- nical and implied meaning of opia when applied pathologically ; in which case it always imports diseased vision, as though a contraction of" the term paropia or paropsis*; whence nyctalopia has necessarily been made to import day sight instead of night sight, or that imperfection of vision in which the eye can only see in the day, or whenever there is a strong light. And hence hemeralopia, the opposite to nyctalopia, has been used with the same confusion and contra- diction of signification ; by the Greeks import- ing day sight, being taken naturally or literallv ; by the moderns day-sightache, and consequent- ly night sight, being taken technically or by im- plication ; and hence Sauvages, " Gracis heme- ralopia ; neotericis nyctalopia." It is the lus- citas of Beer (Lehre von der Augenkrankheiten, als Leitfaden zu seinen (iffcntlichen Vorlesungen entwurfen; Twey bando, 8vo., Wien, 1817); the day blindness of various other writers. The disease is dependant upon a peculiar ir- ritability of the retina, produced by two very different causes ; a sudden exposure to a strong- er light than the eye has been wont to sustain, and a deficiency of the black pigment which lines the choroid tunic. If the iris be weak and torpid, it is enlarged ; if strong and contractile, diminished. From the first cause, this disease is common to those who live almost constantly in dark cav- erns or chambers, as mines, dungeons or dark prisons, or who have recently had a'cataract depressed or extracted, the growth of which Gen. I.—Spe. 2.] PAROPSIS NOCTIFUGA. 223 has still more effectually excluded the light from the retina. And in all these cases we find it accompanied with a perpetual nictitation, from the sympathy which prevails between the retina and the orbicular muscles of the palpebrae. Ramazzini asserts that this complaint is com- mon to the peasants of Italy who are employed in agriculture; but in whom he is able to trace no other peculiarity than a considerable enlarge- ment of the pupil.—(De Morbis Artificum, &c.) It is not difficult, perhaps, to assign a reason for such an affection among these people, though Ramazzini is silent upon the subject. The sky of Italy is peculiarly bright, its atmosphere par- ticularly clear, and its temperature relaxingly warm. The peasants of Italy, therefore, are exposed to the joint operation of almost every cause that can produce habitual debility in the iris, and irritability in the retina. And we find these causes acting with renewed power at the time when the disease chiefly makes its attack, which we are told is on the return of spring, or rather at the vernal equinox, when a double flood of day breaks on them. And such is the dim- ness it produces, that the peasants lose thcj: way in the fields in the glare of noon ; but on the approach of night they are again able to see distinctly. It is hence necessary for them to keep for some weeks in the shade, or in com- parative darkness, till the eyes recover their proper tone ; and the weakness, and consequent- ly the disease, subsides. And hence Ramaz- zini tells us that in the course of the suc- ceeding month, or in other words, after they have taken due care of themselves, the peasants recover their sight. The glare of the sun in tropical regions, and especially where reflected from bright chalk-hills, has often produced the same effect. A deficiency of the black pigment is occasion- ally found in persons of a fair complexion and light hair ; and as the retina is hereby deprived of the natural shade that softens the light in its descent upon this very sensible membrane, its morbid irritability is not to be wondered at. Al- binoes, who are without the common pigment that lies between the cuticle and cutis in other persons, are always deficient in this also : and hence are painfully sensible to light. Indeed, they are hardly able to open their eyes in a strong sunshine ; they contract their brows, and keep the eyelids nearly closed during the day ; but no sooner does twilight come, than they are able to see quite distinctly. In old persons the same deficiency of black pigment is sometimes traced, but without painful vision ; for at this time of life the optic nerve is become more ob- tuse. In horses, this want of pigment consti- tutes what is culled a wall-eye. [There are many states of the organ in which vision is very imperfect, even to blindness, in the strong light of the day; and much better sight is enjoyed in twilight and the dusk; but Mr. Lawrence has never seen such a state as an amaurotic affection, or what is here called night sight, dependant on disease of the retina or optic nerve. In central leucoma of the cor- nea, in incipient opacity of the lens, in partial central opacity of the capsule, in contractions of the pupil from prolapsus iridis, or adhesion of the pupillary margin, connected with either of the former circumstances, the patient will see best in a weak light, and find vision very imper- fect in a strong glare. The enlargement of the pupil in the former, and its contraction in the latter state, sufficiently account for this differ- ence. On the same ground, sight is much im- proved in some of these circumstances by the use of belladonna. In strumous ophthalmia, the intolerance of light often amounts to blindness during the day ; the symptoms remitting in the evening, at which period the eyes are opened, and the patient sees well. Unnatural sensi- bility to light is the form which sympathetic affection of the retina sometimes assumes.— (See a Treatise on the Diseases of the Eye, by Wm. Lawrence, p. 570, Svo., Lond., 1833.) Acuteness of night vision is natural to various animals that prowl in the dark ; as cats, lynxes, lions, and perhaps all the feline genus ; which save their eyes from the pain produced by broad daylight, by a closer contraction of their pupils than mankind are able to effect; expanding them gradually as the night shuts in, till, by the extent of the expansion, they are able to see much better than mankind in the dark. Owls, bats, cockroaches, moths, sphinxes, and many other insects, have a similar power. Where the disease proceeds from an accident- al irritability of the retina, sedative applica- tions, as the tincture of belladonna and inter- nal sedatives, as hyoscyamus and conium, have often proved serviceable, and the more so when combined with the bark. In old age, or an early deficiency of the black pigment that covers the choroid tunic, medicine has very little chance of success ; and all we can hope for is to afford occasional relief by palliatives, if the irritation be violent, or accompanied with inflammatory symptoms. SPECIES II. PAROPSIS NOCTIFUGA. DAY SIGHT. VISION DULL AND CONFUSED IN THE DARK ; BUT CLEAR AND POWERFUL IN BROAD DAYLIGHT. This species, the nyctalopia of neoteric au- thors, or night blindness, is said to be endemic in Poland, the West Indies, Brazils, and the intertropical regions generally.—(Haulesierck, Recucd d'Obs. de Midecine, i., ii.) Its cause is precisely the reverse of that of the preceding species, and proceeds from too great instead of too small an habitual exposure to light, whence the retina becomes torpid, and requires a strong stimulus to raise it. At noontide, therefore, it is sensible to the impressions of objects ; but does not clearly discern them in the shade, or towards the close of day. [Hence the pres- ent complaint is rarely met with, except in cli- mates or situations where the light is very pow- erful. Between the tropics, as Mr. Lawrence observes, the full glare of a vertical sun in an unclouded sky, and the strong reflection of the fcOTICA. [Cl. IV.—Ord. II. 824 NEUI Bolar rays from the sea, or from a sandy soil, produces an excitement of the retina to which we are wholly unaccustomed in our latitudes ; although, in some parts of Europe, analogous influences exist in a sufficient degree to cause the affection. Europeans in the West Indies, and particularly soldiers and sailors, who are much exposed to the sun, often have the com- plaint. In all the cases which Mr. Lawrence has seen, the disease commenced in the East or West Indies, and was brought to England. In the commencement, the person can see by moonlight, or when the room is lighted by a candle ; but as the disorder proceeds, he can see nothing after sunset; and in the morning, vision returns. There is no, change of appear- ance in the eye, and, of course, if the patient can see perfectly during the day, the organ can have undergone no important change. At first, a slight increase of irritability is remarked ; but as the disorder increases, the pupil becomes rather dilated, and the case is alleged to termi- nate sometimes in amaurosis. The feeble light of night and twilight does not impress the reti- na, after it has been so strongly excited in the day, sufficiently for perfect vision.—(See Law- rence's Treatise on the Diseases of the Eye, p. 569.)] Day sight is said to be endemic in some parts of France (Mem. de la Soc. Royale de Med., 1786) ; and particularly in the neighbourhood of Roche Guyon, on the banks of the Seine. And so general is its spread there, that in one village we are told it affects one in twenty of the inhabitants, and in another one in ten, every year. It makes its attack in the spring, and continues for three months ; sometimes, though in a slighter degree, returning in the autumn ; and there are individuals who have had annual returns of the complaint for twenty years in succession. - It passes off, after having run its course, or rather, perhaps, after having been treated with due medical attention, without any inconvenience, excepting a weakness in a few eyes that renders them impatient of wind and strong light. The soil is here a dazzling chalk, and the keenness of the first reflected light, after the dreariness of the winter, is prob- ably one cause of so general an evil. [Accord- ing to M. de Hautesierck, the disorder at one time prevailed extensively among some French troops stationed in Belleisle, under a combina- tion of local peculiarities calculated to act pow- erfully on the retina, and at a season of the year favourable to their influence.—(Recueil d'Obs. de Mid. des Hopitaux Militaires.)~\ Perhaps however, there is no part of the world in which this disease is found more commonly, or more decidedly, than in Russia : but then it is rarely found except in the Russian summer, when the eye is exposed, almost without intermission, to the constant action of light, as the sun dips but little below the horizon, and there is scarcely any interval of darkness. The malady, again, mostly makes its appearance at this time among the peasants, who protract their hard labour in the fields from a very early to a very late hour ; and at the same time exhaust and weaken them- selves by their daily fatigue. The sight is soon restored by rest, a proper shade, and bathing the eyes with an infusion of any bitter and astrin- gent vegetable. Dr. Guthrie, in the Memoirs of the Medical Society of London, from which this account has been taken, gives also an ex- ample of the disease having appeared suddenly, a few springs before, in a detachment of Russian soldiers ; who, being ordered to attack a Swe- dish post, at the moment of its incursion, had nearly destroyed one another by mistake. These men had been harassed by long marches, and been exposed night and day to the piercing glare of an uninterrupted scene of snowy mountains ; both which causes had concurred in producing this effect. Sir Gilbert Blane has found it occasionally occur in scorbutic patients ; but no such diseases appeared in the Russian soldiery. Hens are well known to labour under this defect natural- ly ; and hence they cannot see to pick up small grains in the dusk of the evening, and so employ this time in going to roost : on which account the disease is sometimes called hen-blindness. [All practitioners who have had opportuni- ties of witnessing this disorder, concur in deliv- ering a favourable prognosis. When it is rec- ollected that Mr. Bampfield (see Med. Chir. Trans., vol. v.), a naval surgeon, saw in the East Indies about three hundred cases, and that they were all easily cured without any perma- nent injury of sight, no doubt can be entertained of the generally favourable result of proper treat- ment, in which the avoidance of the cause of the affection is one of the most important things to be observed.] Tonics and gentle stimulants have been much recommended. The bark may be freely em- ployed internally, and blisters externally, with the vapour of camphire, ether, or carbonated am- monia ; and a few drops of the tincture of opi- um, the citrine ointment, or a minute portion of prussiate of iron, also in the form of an oint- ment, occasionally applied to the ball of the eye. In most of the endemic cases it seems to be an intermittent, as the preceding species appears to be occasionally ; and in such circumstances, a free use of the bark used to be the plan chief- ly depended upon. [Of late years, however, in consequence of the great and decided success with which Mr. Bampfield cured every case by means of blisters on the temples, and aperient medicines, this practice is now generally pre- ferred. With it, Mr. Lawrence has occasional- ly associated cupping from the temples or nape of the neck.] When the sight is once stimulated by the full light of the day, it occasionally becomes pe- culiarly acute and vivid. Plenck asserts, that he has known some men labouring under this disease evince so high an excitement of vision as to be able to distinguish the stars at noon. Dr. Heberden has communicated a singular case of this species, which it will be best to give in his own words.—(Med. Transactions, vol. i.) " A man about thirty years old had in the spring a tertian fever, for which he took too small a quantity of bark, so that the returns of Gen. I.—Spe. 3.] PAROPSIS LONGINQUA. 225 it were weakened without being entirely remo- ved. He therefore went into the cold bath; and after bathing twice, he felt no more of his fe- ver. Three days after this last fit, being then employed on board of a ship in the river, he ob- served, at sunsetting, that all objects began to look blue, which blueness gradually thickened into a cloud; and not long after he became so blind as hardly to perceive the light of a can- dle. The next morning, about sunrising, his sight was restored as perfectly as ever. When the next night came on, he lost his sight again in the same manner; and this continued for twelve days and nights. He then came ashore, where the disorder of his eyes gradually abated, and in three days was entirely gone. A month after he went on board another ship, and after three days' stay in it the night blindness re- turned as before, and lasted all the time of his remaining in the ship, which was nine nights. He then left the ship, and his blindness did not return while he was upon land. Some little time afterward he went into another ship, in which he continued for ten days, during which time the blindness returned only two nights, and never afterward." I have observed that nyctalopia noctifuga is often an intermittent affection. In the present case it was distinctly of this nature, and evinced a decided quotidian type. We are not acquaint- ed with the exciting cause of this intermittent; but we know that when once a circuit of ac- tion has been established in a weakened and irritable habit, it adheres to the system with al- most invincible tenacity, and is recalled with the utmost facility upon a repetition of such a cause. And hence the uniform return of the affection on shipboard, where it commenced, till a cure was obtained.* SPECIES III. PAROPSIS LONGINQUA. LONG SIGHT. VISION ONLY ACCURATE WHEN THE OBJECT IS FAR OFF. This is the dysopia proximorum of Cullen, the vue tongue of the French. In both the preceding species the morbid af- fection seems chiefly to appertain to the retina ; in the present species it belongs chiefly to the iris, which is habitually dilated, and not easily stimulated to a contractile action. " For it is well known," observes Dr. Wells, " to those who are conversant with the facts relating to human vision, that the eye in its relaxed state is fitted for distant objects, and that the seeing of near objects accurately is dependant upon muscular exertion." * Dr. Davenport remarks, that " this disease is frequently, perhaps commonly, sympathetic of dis- ordered stomach or derangement of the biliary or- gans." Three instances have been observed by him where p. noctifuga was congenital. In two of these the occurrence of oblique vision was no- ticed during the usual nocturnal paroxysm.—See the Boston Med. and Surg. Journal, voL xi., p. 415—D. Vol. II.—P The species offers three varieties, as follow :— a Vulgaris. Iris relaxed, but moveable ; Common long cornea mostly too flat. sight. 3 Paretica. Iris incontractile, pupil un- Unalterable long changeable, from partial sight. paralysis. y Senectutis. Cornea less convex ; relax- Long sight of ation and hebetude coin- age, mon to all the powers of the eye. The first variety is common to every pe- riod of life, in which the iris is affected with an habitual relaxation. [The truth of the fore- going statement, that long sight is dependant on the state of the iris, is not very manifest. No doubt, the pupil is often large ; but it may be questioned whether this may not be only an ef- fect of the infirmity ; for nothing is more cer- tainly established than that this defect of vision, as well as the opposite one, called short sight, is principally occasioned by a peculiarity in the refractive powers of the eye. In long-sighted persons the rays of light are not collected in the proper place, the focus in which they would meet being behind the retina. Like short sight, it is, as Mr. Lawrence has observed in his Lec- tures, " merely consequent upon some circum- stances in the transparent media of the eye, which, in all other respects, is perfectly natural. Now the eye being in a great part of its func- tions a mechanical instrument, must be subject- ed to mechanical laws ; and we find that a given configuration of the transparent media, a certain relation of them to each other, and their position at a determinate distance from the reti- na, are necessary to the formation of a distinct picture upon that nervous expansion. There is a certain distance from the eye which is called the point of distinct vision, at which we can see objects in all their details with perfect clearness. Every eye, considered as an optical instrument, has its point of distinct vision. The latter, therefore, varies in different persons, and is gen- erally different in the two eyes of the same in- dividual. Objects are not so distinctly seen when moved nearer to or further from the eye than this point. In ordinary well-constructed eyes, the distance ranges from fifteen to twenty inches." Too flat a configuration of the cornea or crystalline lens, too little distance between the retina and the lens, or too weak a refrac- tion of the rays of light, from insufficient densi- ty of the humours and transparent media, total loss of the crystalline lens by operations for cat- aract, may be so many causes of long sight. It has been remarked by Mr. Wardrop, that when people advance in life, the cornea gradually loses its convexity, perhaps from the humours of the eye being diminished. The change, how- ever, is not absolutely restricted to old persons ; for the same writer speaks of a girl eight years of age, the cornea of whose eyes was observed to be remarkably flat, and her vision very imper- fect from her infancy. In subjects much en- feebled by considerable evacuations, by numer- ous bleedings, or by disease, the quantity of the 226 NEUROTICA. [Cl. IV—Ord. 11. aqueous humour diminishes, the convexity of the cornea is lessened, and they can only see objects at a distance.—(See Wardrop's Essays on the Morb. Anat of the Human Eye, p. 115 ; Portal, Anatomie Midicale.) The ingenious ex- periments of Sir Everard Home and the late Mr. Ramsden, recorded in the Philosophical Trans- actions, prove, however, that the sphericity of the cornea is altered according to the distance at which objects are viewed. Hence, an impair- ment of this power, of accommodation in the eye may sometimes be concerned in the present in- firmity, -as well as in the opposite one of near sight. In the present, the faculty which the eye has of adapting itself to near objects is pre- sumed to be defective.]* The second variety constitutes the disease called immutability of sight by Dr. Young (Phil. Transact., year 1793); and is admira- bly described by Dr. Wells in the Philosophical Transactions, in an interesting case of a young person, about thirty-five years of age, whose ret- ina was as sensible to the stimulus of light as ever; yet who, from a paresis or permanent dilatation of the pupil, saw near objects with considerable confusion, but remote objects with perfect accuracy. The power of moving the up- per eyelid was also lost. It was -an extreme case of the disease before us, complicated with partial paralysis of the adjoining muscles, and may be imitated by applying the tincture of bel- ladonna. It was easily remedied by the use of spectacles with convex glasses, by means of which the patient was able to read without dif- ficulty in a printed book, whose letters he was scarcely able to distinguish from each other be- fore the spectacles were applied. The third variety, or that produced by old age, constitutes the presbytia and presbyopia of medical writers, from npiaflvs, senex, and takes place in various degrees. The rays of light unite into a focus too late ; that is to say, they strike the retina before they have conjoined into a fo- cus ; and the focus which they are calculated to form would be situated behind the retina. [The eyes undergo certain changes in age, which have the effect of diminishing their refractive power. Persons after fifty, and sometimes be- fore that age, generally find that they cannot distinguish near objects so well as they have been accustomed to do. The rays of light are more divergent the nearer the object is to the eye : and the further it may be, the more do they approach to the parallel direction ; conse- quently, a greater refractive power is necessary in the former than the latter case. Far-sighted persons can see distant inscriptions, or distin- guish the hour by a distant church clock, when they cannot read a common print held in their own hands, or,see the figures and hands of a watch. The custom of old persons to hold'a * See Farther Observations on Vision, by Dr. Hosack, published in the Trans, of the Royal So- ciety for 1794: in this paper the author attributes to the action of the external muscles of the eye its power of accommodation to objects of different focal distances. On this principle Mr. Ramsden formed his artificial eye.—D. book or letter a long way from their eyes, and to draw back their heads, in order to be able to read it, when they have not their spectacles at hand, is familiarly known.] In the present, as in the other varieties of this affection of the eyes, the best remedy for sup- plying the deficient convexity of the cornea, as well as the deficient irritability of the iris, is con- vex spectacles ; adapting their power to the pre- cise demand of the eye, and increasing it as the . demand grows more urgent. They should be of that power which will en- able the patient to see without straining the or- gan, and should only be worn for reading, wri- ting, or the examination of near objects. SPECIES IV. PAROPSIS PROPINQUA. SHORT SIGHT. VISION only accurate when the object is near. This (the myopia of many writers) is in most respects an opposite disease to the preceding; for it not only produces an opposite effect, but proceeds, in the main, from an opposite cause. In the former, the iris is for the most part re- laxed and weakly ; here it is sound, often too much contracted : in the former, the cornea is in almost all cases too much flattened ; in the present, it is too convex or polarized. The best palliative, therefore, is spectacles of an opposite character to those recommended under the pre- ceding species ; and with these we must satisfy ourselves till age brings us a natural relief, by taking off the entony and depressing the cornea. Unfortunately, however, this is a relief that does not always continue for many years, since the excess of tone becomes too much lowered as the age advances, and the sight grows imperfect from this cause. Mice are said to have this kind of vision nat- urally, and hence one of the technical names for it is myopia or myopiasis, literally " mouse- sight." [The explanation of the infirmity -is, that rays of light are collected too soon, and brought into a focus before they reach the retina. Although a sound eye never discerns remote objects so clearly as near ones, inasmuch as the rays of light entering the eye from a distant thing are always fewer in proportion to its distance from the organ, yet a short-sighted eye sees objects at even a very small distance very indistinctly. The degrees of short sight are various : some individuals cannot discern things which are be- yond two inches from their eyes. In the worst form, the person squints in examining an object with care ; for he is compelled to put it so close to the eyes that the visual axis of the two eyes ' cannot be made simultaneously to bring it within their scope. This defect of vision depends upon the refractive powers being too strong, the eye- ball being too long, or the impairment of that faculty by which the eye accommodates itself to distant as well as to near objects. The pre- mature formation of a focus within the eye some- Gen. I.—Spe. 6.] PAROPSIS ILLUSORIA. 227 times depends on the great convexity of the cor- nea ; a state which is always promoted by the humours being very abundant in the eye. Hence the reason why a short sight is most frequent in young persons; why it sometimes decreases with age ; and why any accidental causes increasing or diminishing the quantity of humours in a sound eye may render it sometimes rather short- sighted, and sometimes oppositely disposed. It is a common opinion, that persons who are short-sighted from too great a convexity of the cornea always have objects depicted upon their retinae in a larger and plainer way than is the case in the eyes of other individuals. This cir- cumstance, which does not appear to be well founded, is ascribed to the strong refractive powers of the eye. According to Mr. Law- rence, there is no ground for the notion that a near sight is strong sight. Another thing gen- erally promulgated by writers, and already men- tioned here, does not coincide with this gentle- man's observations. " The eye, in progress of age," he says (op cit., p. 580), "becomes pres- byopic, and it might be supposed that this natu- ral change in the organ would remedy the ex- cess of refractive power in the near-sighted, and enable them to dispense with their concave glasses : but this is not the case; the near- sighted continue so in old age." As this ac- count disagrees with that given by Richter (An- fangsgr. der Wundarzn., b. iii., p. 487), and other men of great experience in disorders of the eye, it is noticed here as one meriting fur- ther investigation. Besides great convexity of the cornea, other causes of short sight are gen- erally enumerated ; as too great convexity of the lens; preternatural density of the transparent parts of the organ ; too great a space between the cornea or lens, and the retina; or a loss of the power by which the eye accommodates itself to the varying distances of objects. On this subject there is an interesting passage in Mr. Lawrence's Treatise, in p. 578. " It may be a question," he says, "whether this state of the eye depends upon the habits of the individual. I am inclined to think that the habitual mode of employing the organ has some influence. In persons of a literary and studious character, who use their eyes much in reading or writing, and in others who are constantly occupied on minute objects near the eye, we observe that the sight is frequently myopic. I remember once attend- ing a book-sale, at which I was struck by the number of persons wearing spectacles : having counted them, I found there were twenty-three gentlemen in the room, and that twelve of the number had spectacles on. Mr. Ware en- deavoured to ascertain the proportional number of the near-sighted in the different ranks of society, and he consulted the surgeons of the different regiments of Guards in and about Lon- don, at that time comprehending about 10,000 men; and he was informed that near-sighted- ness was almost unknown among them; not six individuals had been discharged, nor six re- cruits rejected, on this account, in twenty years. He pursued the investigation at the Military Asylum at Chelsea, containing 1300 children, P2 among whom only three were near-sighted. He then made some comparative inquiries of the heads of colleges at Oxford and Cambridge, and found near-sightedness very prevalent in all those institutions. In one particular instance, where the society consisted of 127 members, thirty-two either wore spectacles or used hand-glasses.— (Ware's Tracts on the Eye, p. 201, &c.) From these facts, together with the well-known far-sightedness of sailors and country people, we may infer that the habitual mode of employing the eyes has a decided influence in rendering them either myopic or presbyopic. Near-sight- edness is not observed early in life ; you never see persons trying to use glasses until towards the age of fourteen, or from that to eighteen." Mr. Lawrence admits, however, that the defect may exist previously without being noticed, as very young persons do not attend minutely to the state of their sight, or compare accurately their own vision with that of others. The only assistance which a near-sighted per- son can obtain is from concave glasses, which should be such as will enable him to see distant objects distinctly, without producing any sense of painful exertion in the eye. As there is great reason to believe, with Mr. Lawrence, that the optical powers of the eye accommodate them- selves to the circumstances under which vision is habitually exercised, near-sighted persons should not wear spectacles constantly, but only at periods when such aid is particularly re- quired.—(See Lawrence, op. cit., pp. 579-580.)] SPECIES V. PAROPSIS LATERALIS. SKEW SIGHT. SIGHT ASKEW. vision only accurate when the object is placed obliquely. In this species the patient can only see in an oblique direction, in consequence of some partial obfuscation of the cornea (usually, perhaps, from scratches or slight scars), or of the humours through which the light is transmitted, or from a partial paralysis of the retina. This must not be confounded with strabismus, or squintincr, as it sometimes has been, but which proceeds, from a different cause, and' is accompanied with dif- ferent phenomena. In skew sight, or lateral vision, the axis of the eye affected usually coin- cides with that of the sound eye, though it runs somewhat obliquely, to avoid the obstruction in the tunic. In strabismus the two axes do not coincide, and the judgment is formed from the strongest eye alone. If, however, in lateral vision, the obstruction be such as to make the optical axis of the affected eye at variance with that of the sound eye, squinting must be a necessary consequence of the disease. SPECIES VI. PAROPSIS ILLUSORIA. FALSE SIGHT. IMAGINARY OBJECTS FLOATING BEFORg THB 228 NEUROTICA. [Cl. IV—Ord. II. SIGHT ; OR REAL OBJECTS APPEARING WITH IMAGINARY QUALITIES. This species, thus defined, clearly includes two varieties, as follow:— a Phantasmatum. Appearances of objects Ocular spectres. before the sight that have no real existence. B Mutationis. Real objects apparently Ocular transmuta- changed in their natu- tions. ral qualities. Both these varieties offer a very numerous family of distinct illusory perceptions, which re- quire to be noticed in their order. Of the ocular spectres, constituting the first variety, one of the most frequent forms is that of dark spots. These are the musca volitantes of many authors; and are " some- times," says Dr. Young, "if not always, occa- sioned by an opacity of some of the vessels of the vitreous humour near the retina. They are seen in a full light, and cannot, therefore, as Sauvages has justly remarked, be caused by any thing in the anterior part of the eye ; and they may often be observed to change their form with the motions of the eye; which they could not do if they did not depend on some floating sub- stance. Their apparent change of position, when we attempt to follow them with the eye, is a necessary consequence of the motion of the eye itself which contains them."—(Delius, Diss. Phantas. ante oculos volitantia, Erlang, 1751.) If, however, these phantasmata depended upon vascular opacity of any kind, it is difficult to account for their mobility. And hence De- mours is perhaps nearer the mark, in ascribing them to small portions of Morgagni's humour that have acquired an increase of density, weight, and refractile power, without losing their trans- parency.—(Traiti des Maladies des Yeux, p. 409.) And in this view of their formation Mr. Guthrie coincides.* Another form these ocular spectres exhibit is that of net-work ; hence called suffusio reti- cularis by Sauvages, and visus reticularis by Plenck. This is sometimes permanent, some- times transitory ; and is probably, as conjectured by Sauvages, produced by a morbid affection of the arteriolae of the retina. A third form is that of sparks : and hence called by Sauvages suffusio scinlillans. It pro- ceeds generally from a blow, or excess of light. * Lectures on the Operative Surgery of the Eye, p. 211, 1823, 8vo. Mr. Lawrence is of opinion, that the immediate cause of muscae voli- tantes has not yet been satisfactorily explained. The notions of partial pressure on the nervous structure, by distention of vessels in the retina or the choroid, or by inequality in the surface of the latter membrane, he regards as purely conjectural. The explanation derived from minute particles supposed to be floating in the aqueous humour, seems to him to have no belter foundation.—(See Lawrence's Treatise on the Diseases of the Eye, b. 567.) We know that muscae volitantes are an early symptom in amaurosis ; and probably in all cases they depend upon functional derangement of the retina, temporary or permanent. Such dis- order may be combined with organic disease.—Ed. The eye is also troubled with an imaginary sense of dazzling, constituting the marmoryge of the Greek writers. Its usual cause is sup- posed to be a plethora of the minute vessels of the eye. Sometimes, from the same cause, the ocular spectres assume an iridescent appearance; or exhibit, in splendid succession, all the colours of the rainbow. This Sauvages calls suffusio colons. It is occasionally a regularly intermit- tent affection, or returns at stated periods, and particularly in the evenings; and occasionally the morbid appearance is confined to a single colour. Dr. Heberden has given a curious ex- ample of an affection of this kind in a lady of advanced age, who took lodgings on the eastern coast of Kent, in a house that looked immediately upon the sqa, and was of course very much ex- posed to the glare of the morning sun. The curtains of the bed in which she slept, and of the windows, were of white linen, which added to the intensity of the light. When she had been there about ten days, she observed one evening, at the time of sunset, that first the fringes of the clouds appeared red, and soon after the same colour was diffused over all the objects around her, and especially if the objects were white, as a sheet of paper, a pack of cards, or a lady's gown. This lasted the whole night; but in the morning her sight was again perfect. The same alternation of morbid and sound sight continued the whole time the lady was on the coast, which was three weeks, and for nearly as long after she left it; at which time it ceased suddenly and entirely of its own accord. Ex- cess of light upon a delicate and irritable habit appears to have been the cause of this singular affection. The retina was too strongly excited to throw off the impression easily ; and that of the red rays of the descending sun constituting the last impression communicated, remained after the sun itself had disappeared. The circle of action may be easily accounted for by a uniform return of the same cause. The second variety of false sight, or that in which real objects appear changed in their natural qualities, is by Plenck denominated, in consequence of such change, metamerphopsia. Sometimes the change exhibits error of form ; and the objects appear too large, too small, cut in half, or distorted. Sometimes error of motion : in consequence of which they seem to be dancing, nodding, or in rapid succession. Sometimes error of number : and then they appear double, triple, or otherwise increas- ed or multiplied; constituting the diplopia of Sauvages and many other writers. Sometimes error of colour ; in which case one hue is mistaken for another, as red for green, or green for yellow, or every hue appears alike. Examples of this imperfection are not unfre- quent. Mr. Scott has given a singular instance of it (Phil. Trans., vol. lxviii., 1778, p. 611) and Dr. Priestley another.—(Id.,lxvii., 1777, p! 260.) The last is especially worthy of notice, as in some degree a family defect; and wa3 communicated to Dr. Priestley by Mr. Huddart, Gen. I.—Spk. 7.] PAROPSIS CALIGO. 229 of North America. Of five brothers and two sisters, all adults, three of the former were af- fected with it in a greater or less degree ; while the remaining two and the two sisters possessed perfect vision. One of the brothers could form no idea whatever of colours, though he judged very accurately of the form and Other qualities of objects; and hence he thought stockings were sufficiently distinguished by the name of stockings, and could not conceive the necessity of calling some red and others blue. He could perceive cherries on cherry-trees, but only dis- tinguished them, even when red-ripe, from the surrounding leaves, by their size and shape. One of the brothers appears to have had a faint sense of a few colours, but still a very imperfect notion ; and upon the whole, they seem to have possessed no other distinguishing power than that of light and shade, into which they resolved all the colours presented to them; so that dove and straw-coloured were regarded as white, and green, crimson, and purple, as black or dark. On looking at a rainbow, one of them could distin- guish it as consisting of stripes, but nothing more. Dr. Nicholl, of Ludlow, has published two papers* on the imperfection of vision producing a delusive appearance of colours. His cases were hereditary, and not symptomatic of amau- rosis. In one, the imperfection seems to have been confined to one or two colours alone. The patient could easily distinguish the green of the grass, or the leaves of the trees ; but like those in Mr. Huddart's statement, he confounded with the green the red fruit or flowers which hap- pened to be intermixed with it. The false sight in this case was also connected with paropsis ionginqua; for the patient saw objects at a greater distance than other people, and more distinctly in the dark. The irides were here also gray, with a yellow tinge round the pupil, f The causes of these varieties are not always assignable: many of them, however, are the same as have been pointed out under the variety * Transact, of the Medico-Chir. Soc, vols. vii. and ix. For additional facts on this subject, con- sult Glasgow Med. Journ., voL it, art. 2. t The following observations on the cause of this curious infirmity, are delivered by Mr. Law- rence :—" This peculiarity, which is an original defect, and not a pathological condition, is seated, according to the opinion of Drs. Gall and Spurz- heim, in the sensorium. They conceive that the function of the eye is limited to the receiving cer- tain impressions, but that the judging of these im- pressions, the power of understanding the rela- tions which colours bear to each other, is the function of the sensorium; and they assign this faculty to a particular part of the brain. It is cer- tain that an eye may he excellent for the general purposes of vision, and capable of distinguishing the minutest objects, and yet the individual may not be able to judge of colours. The latter power, with the accurate perception of the harmony of colours, and their various relations to each other, is a higher endowment: indeed, only a few per- sons possess it eminently."—(See Treatise on Dis- eases of the Eye, p. 574.) The incapacity of dis- tinguishing colours, viewed as an original defect, and one seated in the organization of the brain, must be incurable.—Ed. of ocular spectres. Diplopia, or errors of num- ber, have often been occasioned by long expo- sure to severe cold ; sometimes by local spasm, sometimes by hydrocephalus.—(Justi, Baldin- ger, N. Mag., bande xi., p. 446.) Baumer gives a case produced by a wrong position of the pu- pil.—(Act. Hafn., i., art. xxvii.) Raghellini an- other caused by a double pupil.—(Lettera al S. Coechi sopra I' offesa delta vista in una Donna, Veneta, 1748, 1479.) In Letin is a singularly complicated example of objects seen triply.— (Lib. ii., obs. 20.) The chief diagnostic of many of these illu- sions is their mobility (Guthrie, Lectures, &c, ut supra, p. 212), which distinguishes them very decidedly from the fixed spots perceived in the eye, and which depend on an opacity of the lens. They are well known frequently to precede amau- rosis. Sometimes, however, when they have reached a certain point, they cease to become more troublesome, or rather, from habit, to be troublesome at all, and are little attended to: for if amaurosis do not soon follow, there is no reason for expecting it; a consolation of no small moment, as no certain remedy has hitherto been discovered. , In other cases, and especially where the mis- affection is not structural, but dependant upon an entonic or an atonic condition of the optic nerve, muscular fibres, or bloodvessels, benefit has been derived in the first instance from local bleeding, blisters, and sedatives ; the sedatives being employed both generally and topically :* and in the last instance from stimulant collyri- ums and general tonics. Many of these varieties of false sight, and especially ocular spectres, are also found as symptoms in several species of dinus, syspasia, syncope, plethora, cephalitis, dyspepsy, and va- rious fevers : some few of the filaments of the great sympathetic passing off, at its origin within the cavernous sinus, to the orbit, and uniting with the lenticular ganglion.—(Cloquet, Traiti d'Anat. Descriptive; Bloch, Besch. des funftcr Nervenpaares, &c, Leip., 1817.) SPECIES VII. PAROPSIS CALIGO. OPAQUE CORNEA. dimness or abolition of sight, from opacity of the cornea or spots upon its surface. The Latin term caligo sufficiently explains the nature of the disease, by importing "dim- ness, darkness, cloudiness, obscurity.1' In old English, this opacity, as well as the pterygium, was denominated a " web of the eye," from its giving the idea of a film spreading across the sight; whence Shakspeare in King Lear, " This is the foul fiend Flibbertigibbet: he gives the * Several forms of paropsis illusoria, or false vision, depend on a disturbed state of the digest- ive organs or on plethora. Hence, too, some one of them is more apt to occur when the tone of the system has become impaired by previous ill- ness, by a long course of inebriation, or by excess in eating and drinking, and also by great efforts of mind.—D. 230 NEURC web and the pin : squints the eye, and makes the hare-lip." The pin is a variety of the synizesis, "closed or contracted pupil." [Surgeons usually divide common opacities of the cornea into four varieties or kinds :— a Nebula corneas. Superficial opacity. 0 Albugo. Deep-seated dense opacity. y Leucoma. A white cicatrix. i Arcus senilis. Circular loss of transparen- cy, extending in old age from the margin of the cornea. The first or simple opacity, or nebula cornea, as it is often termed, is a diffused cloudiness of the whole or a part of that membrane, without any distinct or circumscribed boundary. Hence it is always greatest in its centre, and gradually diminishes towards its circumference. The iris and pupil are discernible through the dimness, and the patient yet has a degree of vision. It rarely extends to the deep lamellae of the cor- nea, but is generally restricted to a cloudiness or milky thickness, arising from the albuminous secretion effused under the corneal conjunctiva, or in the texture of this delicate membrane itself. When this superficial cloudiness of the cor- nea is accompanied with active inflammation of the eye, the treatment must be regulated by the principles applicable to ophthalmia in general. The disease is mostly attended with groups of turgid, knotty vessels in the conjunctiva. If this be the case, another indication presents itself besides that of diminishing inflammation ; namely, to reduce the enlarged vessels; and if that be impracticable, to cut off all communica- tion between the trunks of the most prominent of them in the conjunctiva, and the branches im- mediately distributed to the nebulous portion of the cornea. For the first purpose, Scarpa rec- ommends the unguent, hydrarg. nitrat. and as- tringent collyria; for the second, the excis- ion of a fasciculus of the enlarged vessels.* These measures may often be proper; but in Scarpa's practice the cause of the affection is not much considered ; and if the treatment were regulated with reference to it, some of the plans which he proposes1 would not be needed. As a nebulous state of the cornea generally arises from inflammation or irritation, and is kept up by it, whatever removes the cause will also dis- perse the cloudiness of that membrane. Thus, the nebula is often dependant on the irritation of hard fungous granulations on the inside of the eyelid, a sequel of purulent ophthalmia : now, if these granulations are removed, the nebula soon disappears without any other pro- ceeding. The first indication, when inflamma- tion is present, is to put a stop to it. If we do this, and wait a little, we shall find that the opa- city will diminish of itself. Afterward, coun- * This practice is not approved by Mr. Law- rence : he has little confidence in its efficacy, and objects to it also on the ground that the vessels of the cornea are derived from the sclerotica, and not from the conjunctiva. Scarpa means, how- ever, the vessels visibly extending to the opaque part of the cornea to be partially removed by ex- cision, without any reference to their origin.—Ed. OTICA. [Cl. IV—Ord. tt. ter-irritation by issue, or seton in the temple, with attention to diet, and the state of the stomach and bowels, will be proper. Then the absorption of the opaque matter may be promo- ted by collyria containing the nitrate of silver in the proportion of two grains of it to one ounce of distilled water at frrat, the strength being gradually increased. It may be dropped into the eye, or applied to the opaque part with a camel-hair pencil.—(See Lawrence on Diseases of the Eye, p. 371.) Albugo and leucoma are deeper opacities of the cornea, arising from previous severe ophthal- mia, or an ulcer or wound of the cornea. The term leucoma is particularly applied to the pearl- coloured opacity, produced by the cicatrix of a wound or ulcer. In these deep opacities, the texture of the cornea is often so disorganized that they cannot be removed ; for they do not consist merely of an effusion of a thin milky secretion, but of a dense lymph, which insinuates itself between all the lamellae of the cornea, and becomes inseparably connected with them. When an albugo is recent, however, its disper- sion may be attempted by applying the ung. hy- drarg. nitrat. to it, and bathing the eye with a col- lyrium made of rose-water, and two grains of the nitrate of silver to each ounce of it. The leucoma occasioned by a cicatrix is evidently incurable. The arcus senilis, or that opacity formed in persons of advanced years round the whole or part of the margin of the cornea, and some- times extending considerably towards the pupil, so as to lessen the sphere of vision, is the effect of old age, and absolutely incurable. It comes on without any pain or uneasiness, and at length renders the texture of the cornea, in the part which it occupies, entirely impervious to light. This opaque circle, Mr. Lawrence observes (op. cit., p. 369), is not situated at the very margin of the cornea, but there is generally a transpa- rent rim which intervenes between it and the sclerotic coat. In some cases, the opacity is very narrow; and in other cases, it becomes much broader ; but he has never seen it inter- fere with vision, a sufficiency of the centre of the cornea for this purpose being left transparent. He describes it as a natural change in the part, from causes independent of disease. It shows itself, he says, much earlier in some cases than others; being occasionally seen between the ages of thirty and forty, but generally later. He compares it to the opaque knots which take place in the internal coat of the larger arteries of old persons.] In newly-born infants spots on the cornea are occasionally met with, which soon vanish spon- taneously (Farr, Med. Commen., ii., 30): prob- ably, the rays of light acting as a salutary stim- ulus upon the occasion. SPECIES VIII. PAROPSIS GLAUCOSIS. HUMORAL OPACITY. dimness or abolition of sight from opacity of the vitreous humour. Glaucosis is a Greek term, from y\av>cls, "blu- Gen. I—Spe. 9] PAROPSIS CATARACTA. 231 ish or greenish feinted," from the common colour of the obscurity. It was also called by the Greeks glaucoma, and by the Romans glaucedo. Glaucosis is here preferred to glaucoma, because the final oma imports usually, and, for the sake of simplicity and consistency, ought always to import, external protuberance; as in staphyloma, sarcoma, and various others noticed in detail in the volume of Nosology. [It is remarked by Mr. Lawrence that the term glaucoma was formerly given to cataract, but is no longer so applied. We use it now to denote.j certain change of the vitreous humour conse^dnt on inflammation of that part of the eye, attended with an alteration in the colour of the pupil. The first symptom of glaucosis, as our author prefers to call it, is a pain in the head, usually situated over the brow. In con- junction with this pain, the patient begins to complain of dimness or of weakness of the sight; and, if the eye be now examined, the pupil pre- sents a greenish, muddy-green, or yellowish- green colour, instead of its natural deep-black. In a strong light, the appearance resembles a yellowish metallic reflection from the bottom of the eye. At the same time, the pupil is gener- ally rather dilated, and the motions of the iris sluggish. The state of vision is different in dif- ferent instances : in some, an alteration of the pupil is distinctly produced, and yet the eye- sight may be tolerably perfect; while in other cases vision is entirely lost, with apparently no more discoloration of the back part of the eye, or change of the pupil, than in the former in- stance. Glaucosis has of late years generally been regarded as an inflammation of the vitre- ous humour, the texture and colour of which are changed. As the retina lies close upon this humour, there is no difficulty in accounting for their both being inflamed; and whether they both suffer from the commencement or not, if the inflammation of the vitreous humour be not checked it will involve the retina, and produce such changes in its structure as to render the eye permanently amaurotic. The eyesight be- comes gradually worse and worse ; the discolo- ration behind the pupil grows more and more con- siderable ; and the iris becomes more and more sluggish, until it is at last motionless, and vis- ion is entirely lost. The lens also is sometimes attacked, and with it the iris propelled forward, so that, as Mr. Lawrence remarks, it is no uncom- mon thing for cataract to occur subsequently in an eye originally attacked by glaucosis. Glaucosis, the precise causes of which are not known, occurs chiefly after the middle period of life, and in persons not of the most healthy char- acter. It appears to Mr. Lawrence to be mere- ly a chronic form of what is sometimes termed arthritic inflammation of the deep part of the eye ; but he particularly mentions that it does not occur more frequently in gouty and rheu- matic persons than in others ; so that the ex- pression arthritic cannot be very eligible. In glaucosis, the colour of the pupil is green, or yellowish-green; and if the eye be viewed laterally, no discoloration can be seen ; but in cataract, the pupil looks gray, or of a grayish white, and it remains so, whether it be regarded laterally or not. The loss of vision in glaucosis is not in direct proportion to the change of col- our of the pupil; for, with an inconsiderable change of this kind, vision may be entirely de- stroyed or very seriously impaired. But in cataract there is a direct proportion between the state of the opacity or change of colour, and the injury to sight. In cataract, vision is best in a weak light ; but in glaucosis, sight is most perfect in a strong light.—(Lawrence, op. cit., p. 393.) It is not yet decided among pathologists, whether the opacity in this disease be seated in the delicate membranous septa of the tunica hyaloidea, or in the fluid contained in the cells of the vitreous humour; or whether both are al- tered. Beer, in dissecting a glaucomatous eye, found the vitreous humour immediately sur- rounding the foramen of Soemmerring much more deeply coloured than the rest of it. Were this fact corroborated by further observations, we might perhaps infer that this is generally the original seat of the disease, and that the morbid changes extend from this point.* Beer delivers a most discouraging prognosis, asserting that nothing will prevent glaucosis from terminating in amaurosis. All practical writers seem to agree that we possess no means of removing the opacity of the vitreous humour ; but Mr. Lawrence is of opinion that the disease may be checked, and any degree of sight now enjoyed preserved, by having recourse to suit- able treatment. There is, he says, a decided congestion about the brain and orbit, and the removal of that congestion is attended with con- siderable benefit. Hence, he recommends an- tiphlogistic remedies ; cupping ; active purga- tives ; alterative doses of mercury ; a regulated diet; and repose of the eye. By such means, he has known cases kept for two or three years stationary.] SPECIES IX. PAROPSIS CATARACTA. CATARACT. DIMNESS or abolition of sight, from opacity OF THE CRYSTALLINE LENS. The cataract, as it is now called, was by old English writers named pearl eve, or pearl in the eye, and is so denominated by Holland, * G. Frick, on Diseases of. the Eye, p. 220, 2d ed. by Welbank, 1826. Mr. Mackenzie observed the following changes in eyes affected with glau- coma:—1. The choroid coat, and especially the portion of it in contact with the retina, was of a light brown colour, without any appearance of pig. mentum nigrum. 2. The vitreous humour was in a fluid state, perfectly pellucid, colourless, or slightly yellow. There was no trace of hyaloid membrane. 3. The lens was of a yellow or am- ber colour towards its centre, its consistence firm, and its transparency perfect, or nearly so. 4. In the retina, no trace of limbus luteus, nor of the foramen centrale.—See Glasgow Med. Journ., vol. iii., p. 259; and Mackenzie's Treatise on Diseases of the Eye.—Ed. 232 NEUROTICA. [Cl. IV—Obd. II. the faithful translator of Pliny. Cataracta, as a Greek term, is usually derived from narap'p'daoia, " to disturb, destroy, or abolish." Karo^d/crns or KarapdKTvs, however, was employed by the Greek writers themselves to signify a gate, door, or loophole, and the bar which fastens it, and becomes the impediment to its being open- ed. And it is probably from this last sense that the term cataract was first applied to the disease in question, as forming a bar to the eyes, which were called the loopholes or windows of the mind by various philosophers, as we learn from Lu- cretius, who thus closes his opposition to their view:— " Dicere porro oculos nullam rem cernere posse, Sed per eos animum ut foribus spectare reclusis Difficile est."* To deem the eyes, then, of themselves survey Naught in existence, while the interior mind Looks at all nature through them, as alone Through windows, is to trifle— Whence, perhaps, Shakspeare, in the speech of Richmond:— " To thee I do commend my wakeful soul, Ere I let fall the windows of mine eyes." The Greeks themselves, however, called this disease indifferently hypochyma, apochysis, and hypochysis. The earlier Latins, suffusio : while cataracta seems first to have been made use of by the Arabian writers, and was probably intro- duced into the medical nomenclature by Avi- cenna. Yet the more common name among the Arabians was gutta obscura, as that for amaurosis was gutta serena; the pupil, in this last species, being serene or transparent. The Arabians, who had adopted generally the humoral pathology of Galen, conceived both these diseases to be the result of a morbid rheum or defluxion falling on a particular part of the visual orb ; in the one case producing blindness with obscurity, whence the name of an obscure rheum or gutta; and in the other without ob- scurity, whence the contrary name of a trans- parent or serene rheum or gutta. But as vari- ous other diseases, and particularly of the joints, were also supposed to flow from a like cause, and were far more common, the terms gutta and rheuma were afterward emphatically applied and at length altogether limited to these last complaints, whence the terms gout and rheuma- tism, which have descended to the present day, as the author has already had occasion to ob- serve under arthrosia podagra. For gutta the Arabian writers sometimes employed aqua; and hence cataract and amaurosis are descri- bed by many of them under the names of aqua obscura and aqua serena; and the former, by way of emphasis, sometimes under the name of aqua or arqua alone. The opacity producing a cataract may exist in the lens alone, the capsule alone, or in both; thus laying a foundation for the three following varieties:— o Lenticularis. The opacity existing in the Lenticular cat- lens itself, and confined to aract. it. * De Rer. Nat., iii., 260. B Capsularis. Capsular or membranous cataract. y Complicata. Complicated cataract. The opacity confined to the capsule, or membrane of the lens. The opacity common to the lens and its capsule. We are told moreover by Richter (Von der Ausziehung des Grauen Staars, Gott., 1773, 8vo.), of a cataract of the humour of Morgagni, or the interstitial fluid which lies between the capsule and the lens : whence this has also been copied by Plenck, Beer, and Sir William Ad- ams, into the list of modifications ; but rather as a possible than an actual case ; for none of these practitioners give a single example of such a variety ever having occurred to them with certainty, though Beer suspected it in one case. —-(Lehre von den Augenkrankheiten, band ii., sect. 56.) [Mr. Lawrence doubts the separate existence of this as a distinct species of cataract. How, he asks, could we determine that this fluid was opaque, and the lens transparent 1 Can it be supposed that it could undergo this change, and the capsule and lens remain transparent 1 He thinks, therefore, that in a practical considera- tion of the subject, this kind, of cataract might be safely omitted.] Cataract is sometimes accompanied with a sac, enclosing a small body of pus or ichor, and is probably the result of the inflammation that produced it. In this case it forms the cataracta capsulo-lenticularis cum bursa ichorem conti- nente of Schmidt.—(Ueber Nachslaar und Iritis, &c, Wien, 1801.) Beer affirms that this sac is commonly seated between the lens and pos- terior part of the capsule, and very rarely be- tween the former and the anterior part.— (Lehre von den Augenkrankheiten, band ii., p. 301, 1813.) Professor Beer seems to have refined a little too much in his divisions and subdivisions of cataract; for he not only assigns a distinct place to the Morgagnian and this pustular cystic, but to a cystic form without pus, to a siliquose, and a trabecular; while he further partitions the capsular into two separate forms, according as it is before or behind the lens itself, thus giving us a catalogue of nine distinct forms of what he calls the true cataract, while he allots four other subdivisions to what he denominates the spurious cataract: meaning hereby some other obstacle to vision, the seat of which is without the crystalline capsule, between its anterior hem- isphere and the iris. [The most striking circumstances observable in cataract are an opaque body placed behind, or even filling up the pupil, and the impaired state of vision which is the result of that change. In both these respects it agrees in its incipient stage with glaucoma and some forms of amaurosis ; but as the treatment is essen- tially different in these several affections, it is very necessary to discriminate them accurately In incipient cataract we can do little or noth- ing ; we must wait until the opacity has become complete before we perform an operation: but Gen. I.—Spe. 9.] PAROPSIS CATARACTA. 233 in the early state of amaurosis we must take means to arrest the affection ; for if we should leave the case to itself, under the supposition of its being a cataract, loss of sight would be inevitable and irremediable. The diagnosis of cataract from other affections, Mr. Lawrence, therefore, very properly represents as an im- portant subject; and in doubtful cases we shall be much assisted by the influence which the belladonna has in dilating the pupil, and afford- ing as clear a view as possible of what lies be- hind that opening.—(Op. cit., p. 397.) The situation of the opacity is the best ground of distinction between glaucosis and cataract: in the latter it is very near the pupil; but in glaucosis, and also amaurosis, the discoloration of the pupil is much more deeply seated; it looks as if it were at the back of the eye ; and hence, when the eye is viewed laterally in glaucosis, no opacity is perceived. The dis- coloration cannot be seen unless the surgeon look directly into the pupil; it is also equally diffused, and sometimes the opacity has a con- cave appearance. The following observations, by the same sur- geon, are highly valuable to the practitioner. In cataract, the opacity begins generally in the centre of the pupil; consequently it is more dense in the centre, and less so towards the sides. Hence, some light passes through the circum- ference of the pupil, enabling the patient to see objects laterally, when he cannot see them di- rectly in front of the eye. Dilatation of the pupil, by exposing the margin of the lens, which is sometimes transparent when the centre is opaque, and at all events is much thinner, and therefore less densely opaque, improves vision considerably, especially in incipient lenticular cataract. Such patients see best in the dusk or twilight, or when the pupil has been artifi- cially dilated by the belladonna. They see best when their back is turned towards the window. These circumstances particularly distinguish cases of cataract from those of glaucoma and amaurosis ; for, in the latter affections, the sen- sibility of the retina being impaired, the indi- vidual generally sees better in strong lights, and his sight is not improved by belladonna. In the commencement of cataract, objects seem as if surrounded by a mist or fog ; the pa- tient fancies that there is something interposed between his eye and the object at which he is looking ; while the haziness or cloudiness in- creases gradually in proportion to the degree of opacity. A cataract patient sees a lighted can- dle as if it were involved in a cloud, which be- comes thicker as the opacity proceeds, and ul- timately shrouds the flame so completely that its position only is discernible. To an amauro- tic patient the flame of a candle would appear as if scattered into rays, like a star, or surround- ed by a halo, or confused with prismatic col- ours. In cataract, the sight is impaired in pro- portion to the degree of opacity; but there is no such direct ratio in glaucosis and amaurosis ; for, with only a slight greenish discoloration of the pupil, there may be a considerably impaired state of vision, such as the opacity would not account for; indeed, sight may be entirely de- stroyed when there is only a trivial change in the colour of the pupil. With respect to the iris and figure of the pupil, Mr. Lawrence observes, they are not gen- erally affected by cataract, or at any rate, not in the early period of its formation. The iris con- tinues to move as usual, and the pupil retains its circular shape. In some cases, indeed, where the bulk of the lens is increased, this body presses against the iris and impedes its motions ; but this happens chiefly in soft cataracts, and not in the early stage of them. In cases of cata- ract, the margin of the pupil represents a black circle, formed by the uvea, in consequence of the white or grayish-white ground which the opaque lens constitutes behind that opening.— (Lawrence, op. cit., p. 399; also, Beer, Lehre, dec, b. ii., p. 281.)] Cataracts are of different colours and of dif- ferent degrees of consistency, from circumstan- ces influencing the morbid action with which we are but little acquainted; and as little with the occasional causes of such action, though old age seems to be a common predispo- sing cause. They are therefore black,* white, leaden-hued, ferruginous, amber; as they are also fluid or milky, soft, firm, hard, horny, and even bony. They are not unfrequently the re- sult of an hereditary taint, adhering to generation after generation, and appearing either congeni- tally, or by a very general predisposition after- ward. All ages are subject to cataracts; children are even born with them ; and they may occur at any age, from infancy to the remotest period of life. Perhaps elderly persons are most sub- ject to the complaint, especially from fifty, sixty, or upwards.+ Cataracts are never hard in young persons ; you will never meet with a hard lens below the age of puberty. They are not always hard in old persons ; you may have soft cata- racts in such, and hard ones during the middle period of life.—(Lawrence, op. cit., p. 410.) Mr. Pott inculcated what experience has am- ply confirmed, that when the opaque crystalline is perfectly dissolved, so as to form a soft cata- ract, it is somewhat enlarged; and that when such dissolution does not take place, and a hard cataract is produced, the crystalline is in some degree lessened. The hard cataract has also * The occurrence of black cataract is still a matter of dispute. Dupuytren, with his vast ex- perience, has never seen a case of it.—See his Clinical Lectures on Surgery, translated by Doane, New-York, 1833, p. 39. t The following table is compiled from the ob- servations of Drs. Mannoir and Fabini. Of 612 cases of cataract, 14 were between 1 and 10 years of age. 16 " " 11 " 20 I li 23 " " 21 " 30 I M 21 " " 31 " 40 t (1 62 41 " 50 < l£arf " consido, coeo, coalesco ;" and was used among the Greek grammarians, before it obtained an introduction into the medical vocabulary, to sig- nify (he coalescence of two or more syllables- into one [The pupil may be simply contracted or closed; or these changes may be combined with opacity of the lens or capsule, with an ad- ventitious membrane in the pupil, with adhesion of the iris either to the capsule (synechia poste- rior) or the cornea (synechia anterior), with pro- trusion of the iris, displacement of trie pupil, or opacity of the cornea. All these conditions of the eye are the consequence of severe inflam- mation, either external or internal. As Mr. Lawrence correctly observes, it must also be recollected, that this serious inflammation may not have confined itself to the production of the foregoing evils, but extended its effects to the nervous structure of the eye, or to other parts of the organ. Hence, says he, it is necessary to ascertain correctly whether the loss of vision is produced by the changes of the pupil only, be- fore a decision is made about an attempt to form an artificial pupil.] This species exhibits two varieties :— a Simplex. Simple closure of the pupil. Simple closed pupil. * M. Dupuytren has made a number of experi- ments to ascertain the value of this operation. Of twenty-one individuals operated upon by him in this mode, seventeen recovered their sight. For many valuable remarks on the nature and treatment of cataract, see his Clinical Lectures on Surgery, trans, by Doane, New-York, 1833. 238 NEUROTICA. [Cl. IV—Ord. II. 9 Complicata. Closure of the pupil corn- Complicated clo- plicated with cataract, sed pupil. opaque cornea, or other changes specified above. The pupil sometimes becomes closed or oblit- erated from a gradual contraction, and at length coalition, of the muscular fibres of the iris, unat- tended with any other change or impairment of the eye. In all these cases, it is a simple ob- literation OF THE PUPIL. It is COMPLICATED when the obliteration is combined with an opa- city of the cornea, with a cataract, with adhe- sions of the iris to the cornea or capsule of the lens, &c. When the disease is an effect of in- flammation, it forms the atresia iridis of Dr. Schmidt of Vienna, who further subdivides it into complete, incomplete, and partial, according as the vision is totally destroyed, impaired, or confined to a part of the pupil.—(Ueber Nach- staar und Iritis nach Slaaroperationen, 4to., Wien, 1801.) The natural shape of the human pupil is cir- cular, this being the natural form of the fine fringe of the iris by which it is surrounded. But in a few instances the fringe or rays of the iris have evinced a different figure, and the pupil, in consequence, has been found oblong or heart- shaped.—(Eph. Nat. Cur. Dec, iii., ann. vii., viii., obs. 21.) The first has occurred most fre- quently, and according to Albinus, has some- times preceded loss of vision.—(Anat. Acad., lib. vi., cap. 3.) Bloch gives an instance in which the disease was congenital and heredi- tary.—(Medicinische Bemerkungen, p. 1.) If the iris contract irregularly, sometimes only a few of its fibres spread across the pupil, while others are retracted : and hence we have ex- amples of double or more than double pupils, though of smaller dimensions than the natural circle. Solinus gives an instance of two pupils hereby produced (Vide Marcel. Donat., lib. vi., cap. 2, p. 619), and Janin of not less than five. —(Mimoires. dec.) Medicines in this disease are of little avail. In the first variety, an external application of the tincture of belladonna, or a solution of stra- monium, which is said to answer the same pur- pose,* has occasionally effected a cure by de- stroying the contractile action ; and so have di- lute solutions of brandy, camphire, or sulphate of zinc, by their tonic or stimulant power. When the disease does not yield to this mode of treat- ment, or consists of the complicated variety, it belongs manifestly to the art of surgery, and its removal must be sought for in books on that sub- ject : among the best of which may be men- tioned, Mackenzie's Treatise on Diseases of the Eye, Lawrence's work on the same subject, Mr. Guthrie's Lectures on the Eye, and Beer's Essay on Staphyloma and Artificial Pupil, pub- lished in 1804,t and his Doctrine of the Diseases * Annual Report of the Liverpool Institution for Diseases of the Eye. By Alexander Hannay, M. D., 1822. t Ansicht der Staphylomatoien Metamorphosen des Auges, und der Kunstlichen Pupillenbildung. Also, particularly, G. J. Guthrie on the Operations for the Formation of an Artificial Pupil, 8vo., Lon- of the Eye, published in 1817.—(Lehre von den Augenkrankheiten, &c, ut supra.) According to the nature of the coalition, Beer employs three varieties of operation ; incision, excision, and separation ; which he distinguishes by the names of corotomia, corectomia, and coro- dialysis. The first is the simplest, and that most usually had recourse to. In the second, an incision being made with a cataract-knife, close to the edge of the cornea, and not larger than the third part of its circumference, the iris, if it protrude, is laid hold of with the hook ; or, if no protrusion take place, the hook, introduced through the incision, is made to lay hold of the pupillary edge of the iris, which drags it through the wound when a sufficient portion of it is re- moved with a pair of scissors. In the third method, which is that originally proposed by Dr. Reisinger, the operation is performed with a double hook or hook forceps.* SPECIES XI. PAROPSIS AMAUROSIS. DROP SERENE. DIMNESS OR ABOLITION OF SIGHT, RESULTING FROM AN AFFECTION OF THE NERVOUS STRUC- TURE OF THE EYE, WHETHER SEATED IN THE RETINA, OPTIC NERVE, OR BRAIN ; AND WHETHER DIRECTLY THE RESULT OF ORGANIC CHANGES IN THOSE PARTS THEMSELVES, OR INDIRECTLY THE EFFECT OF THEIR SYMPATHY WITH DISORDER OF OTHER ORGANS. This is the gutta serena of the Arabic writers, whence the term "Drop Serene," of our own tongue ; terms we have already ex- plained under paropsis cataracta. Milton is well known to allude to this affection in his beautiful address to light, as he does also to the cataract, by him called suffusion, as the Latins call it suffusio; but it is singular that, in the course of this allusion, he seems doubtful as to which of the two diseases he ought to ascribe his own blindness :— " Thee 1 revisit safe, And feel thy sovereign vital lamp; but thou Revisit'st not these eyes, that roll in vain To find thy piercing ray, and find no dawn. So thick a drop serene has quench'd their orbs, Or dim suffusion veil'd."* The term amaurosis is derived from the Greek duavpds, "obscurus, caliginosus, opacus." The most common cause is a paralysis of the retina, usually in conjunction with a paralysis and dilatation of the iris. Occasionally, how- ever, this is rigidly contracted. From the dif- ferent degree in which the disease presents it- self, and from its assuming at times an in- don, 1819; and Lawrence's Treatise on Diseases of the Eye, p. 452 et seq., 8vo., Lond., 1833 * See also D. Weller's Treatise Ueber kiinst- liche Pupillen, und eine besondere Methode diese fertigen; published in Langenbeck'a Neue Biblio- thek, b. n., st. 4. See also Dr. Schlagintweit Ueber den gegenwartigen Zustandder kunstlichen Pupillenbildung, &c, Miinchen, 1818 t Par. Lost, iii., 21. Gen. I.—Spe. 11.] PAROPSIS AMAUROSIS. 239 termittent type, it has three principal varie- ties :— a Perfecta. Attended with total blind- Complete amau- ness. rosis. B Imperfecta. With vision impaired, but Incomplete am- not altogether destroyed. aurosis. y Intermittens. With periodical cessations Intermittent am- and returns. aurosis. Plenck makes a distinct disease of an unal- terable pupil, with or without injury of the vis- ion, under the name of mydriasis. When ac- companied with injured vision, it is evidently a variety of amaurosis; and it is questionable whether an unalterable pupil is ever to be traced without defective vision. It is probably to the cases attended with con- traction of the pupil, that Shakspeare chiefly al- ludes by the term pin or pin-eye, the pupil being sometimes contracted to nearly the diameter of a pin's head ; though the synizesis is equally en- titled to the name. I have quoted one example already under P. Caligo, which he calls web-eye ; another is contained in the following couplet:— ----"Wish all eyes Blind with the pin and web." [Tn the former editions of this work, the au- thor made the state of the pupil the ground of two of his varieties of amaurosis. When the pupil was dilated, the amaurosis was termed atonic ; when contracted, spasmodic. Thus the iris was more attended to than the real seat of the disease, and incidental changes were mis- taken for essential ones, and considered to be absolutely dependant upon atony and spasm. These errors the editor is happy to have the opportunity of expunging ; and in their place he has substituted the two varieties of perfect and imperfect amaurosis, as cases admitted by every modern writer on diseases of the eye, and the distinct consideration of which is highly useful in practice. The intermittent amaurosis, the third variety adopted by the author, remains ; though the principal examples of it are com- prised in the subjects of day blindness and night blindness. Other better founded and more prac- tical distinctions than those formerly given by our author, are the organic, and the sympathetic or functional; the former depending upon a dis- eased state of the retina or optic nerve ; the latter consisting of a suspension of the functions of the nervous structure of the organ of vision, in consequence of the influence of the disease or disorder of some other part of the body on the eye. This last case is also sometimes denomi- nated symptomatic amaurosis, being the mere ef- fect of another disease, which is the primary one. In this point of view, the loss of vision or paral- ysis of the retina from various organic changes affecting the whole eyeball, as hydrophthalmia, fungus haemrtodes, &c, may be considered as a symptomatic amaurosis. Besides the impor- tant division of this disease into the perfect and imperfect, organic and functional varieties, some others, not noticed by our author, cannot be overlooked by the practitioner, because they make very considerable differences in the prog- nosis. The further distinctions here alluded to are those of recent and inveterate, and of com- plicated amaurosis. Amaurosis is generally characterized by a very dilated state of the pupil, which is frequently not affected by any degree of light that is made to fall upon the retina. Sometimes the pupil is extraordinarily contracted. Hence, as already stated, the varieties formerly selected by the author of this work were badly chosen; be- cause they were founded, not upon any intelli- gible differences in the condition of the retina, but upon incidental states of the iris. His sec- ond or spasmodic variety, indeed, as far as the definition went, might have signified rather syni- zesis, or impediment to vision from great and permanent contraction of the pupil. In amau- rosis the pupil seldom retains its circular form, but becomes more or less irregular or angular. Neither does it commonly exhibit the clear ap- pearance of a sound eye, but a grayish or dark green hue, resembling what is observable in the eye of a horse. In certain examples, a whitish or greenish-yellow spot is perceptible apparently in the fundus of the eye, and a little to one side of the visual axis, with a splendid disk, like the tapetum of sheep, or the coloured choroid of fishes. Another change in the pupil, noticed by Beer and all the most correct writers on amau- rosis, is an alteration in its position : it is most- ly drawn towards the internal and superior por- tion of the eye. The iris is in general very sluggish, or absolutely motionless ; but in a few cases it preserves its usual power of motion (Caldani ad Haller, vide Richter, Nov. Comm. Soc. Goett., torn, iv., p. 79 ; Hey, Med. Obs. and Inq., vol. v.), and sometimes acts with great- er rapidity than in a healthy eye. Amaurosis is ordinarily preceded by certain defects in the sight, and illusive appearances before the eye. One of the most important is what is termed by writers the visus interruptus. Thus, in reading, it seems to the patient as if syllables, words, or whole lines were deficient; and he is obliged to move the eye or head ere he can discern what seems wanting. If he look upon any other ob- ject he will seldom see the whole of it, unless he make a similar motion of his eye or head. On other occasions, he will see the whole of the ob- ject when it is held in a particular direction, but he loses it again as soon as this is altered. A common precursor of amaurosis is an ap- pearance as if motes or small bodies were inces- santly moving about in front of the eye. This is the visus muscarum, or musca volitantes of sur- gical writers. When it is a dark-coloured speck that the patient fancies to interrupt his sight, it receives the technical name of scotoma; for ap- pearances of this kind may be either single or very numerous, and of diversified shapes. They are most troublesome when the patient looks at very bright or light-coloured surfaces. In in- cipient amaurosis every object frequently ap- pears to the patient as if it were surrounded by a zone of variegated colours; but sometimes things have a different look, seeming as if they were 240 NEUROTICA. [Cl. IV.—Ord. 11. enveloped in a mist, gauze, or network. In many cases, single objects appear to be double: this defect of vision is termed visus duplicatus, and proceeds from impairment of the faculty by which the axis of vision in each eye is made to adapt itself to the object looked at. Amaurosis may present itself as an uncom- bined local affection of the optic nerve or retina, or as conjoined with some other disease of the organ or general system. Among the local complications are to be noticed cataract, fungus haematodes of the eye, glaucosis, cirsophthalmia, hydrophthalmia, exophalmus, atrophy, paral- ysis of one or more muscles of the eyeball or lids, ophthalmitis, &c. The general complica- tions especially meriting enumeration are, dis- eases of the nervous system, the debility from typhoid and other fevers, hydrocephalus, organic and functional diseases of the abdominal viscera, worms, pregnancy, and diseases of the brain and cranium. Amaurosis is not restricted to any particular age or sex. Perhaps, on the whole, persons of middle age are most liable to it. Children are less liable to the disease than adults, but con- genital cases are upon record. In Germany, an opinion prevails, that dark-coloured eyes are more frequently attacked by amaurosis than those of light colour. A tendency to the disor- der is produced by pregnancy, by every kind of immoderate exertion of the eyes on small or shining objects, a full habit, and whatever has the effect of keeping up a great determination of blood to the head and eyes. Mr. Lawrence considers organic amaurosis as not essentially different from a very slow insidious inflamma- tion of the retina, and not a disease of debility, as represented by numerous writers. His opin- ion on the pathology of amaurosis, of course, has great influence on the practice which he partic- ularly inculcates ; and which, in the early stage, is generally antiphlogistic ; in the second, mer- curial.—(See Treatise on the Diseases of the Eye, 8vo., 1833.) The doctrine most usually adopted, however, refers a certain class of cases to debilitating causes ; as typhoid fevers, profuse discharges or evacuations, excessive venery, the suckling of infants, &c That particular articles of food or medicine will produce amaurosis sympathetically, is am- ply proved. It is true, that in some of the ex- amples of this fact we are obliged to suppose the existence of an idiosyncrasy ; as when a per- son is affected with blindness whenever he takes chocolate or bitters, which have not the slight- est effect upon the sight of other persons. The sympathy of the eyes with the stomach and in- testines is often illustrated in cases of worms, which, according to the admission of every wri- ter, are not an unfrequent occasion of amaurosis. A child has been known to become amaurotic from accidentally swallowing a bead, and to re- gain sight on the foreign body being voided by means of an emetic. In Germany and Italy, indeed, the opinion that amaurosis is very fre- quently prevalent on gastric disorder has been entertained to a great and perhaps an unwarrant- able extent; we say unwarrantable, because in this country, experience does not furnish evi- dence of the efficacy of the treatment which the doctrine naturally points out, and which, in the hands of Schrmicker, Richter, and Scarpa, has proved remarkably successful. Beer himself had little faith in the opinion, except in relation to the amaurosis from worms ; and in this me- tropolis, repeated trials of the emetic practice have not created an impression in its favour. The great influence of hereditary disposition in producing amaurosis has been remarked by all the most correct observers. Beer ih partic- ular adverts to the frequent examples of this fact, and mentions a certain family, in which all the females who had not had children became amaurotic about the period of the cessation of the menses; and what is very remarkable, it is stated that this had been the case through three generations. One form of imperfect amaurosis, named am- blyopia senilis, is ascribed by Beer to deficiency of the pigmentum nigrum. This case is com- monly attended with a tremulous or vibratory motion of the globe : the admission of light pro- duces great uneasiness, and vision is seriously weakened. It is usually met with only in old persons; but sometimes occurs in others after fevers, and in the last stage of consumption.— (Vetch on Diseases of the Eye, p. 144.) Al- though it is declared to be incurable, the power of vision may be very usefully assisted with cyl- indrical shades, goggles, and other contrivances calculated to absorb light. An amaurosis rarely cured, is that arising from blows on the eyebrow, or injury of the frontal nerve. All cases, likewise, depending upon organic changes in the eye itself, optic nerve, brain, or orbit, do not admit of relief. The prognosis in every instance of complete amaurosis is unfavourable. The functional and sympathetic forms of the complaint are generally more easy of cure than the organic ; but whether they can be relieved or not, will depend upon the circumstance whether the original com- plaint in another part of the body, with which they are connected, can itself be removed or not. The length of time that the loss of sight has pre- vailed, will also materially influence the prog- nosis. Generally speaking, amaurosis that has been formed recently and suddenly, but without violence or immoderate previous inflammation of the eye, is more easily cured than that which has come on with great slowness. The disease is absolutely incurable, when accompanied by any change in the shape and dimensions of the eyeball. When amaurosis affects only one eye, unless it be from sympathy with a neighbouring part,* as a carious tooth, the other eye is in great danger of being also attacked. The occasional mobility of the iris in this disease, and a moder- ate dilatation of the pupil, are no proof that the amaurosis will be more easily cured ; for the iris often regains its mobility without the least im- * See Wardrop's Essays on the Morbid Anato- my of the Eye; and Frick on Diseases of the Eye by Welbank, p. 150, 2d edit. Gen. I.—Spe. 11.] PAROPSIS AMAUROSIS. 241 provement in vision, and sometimes the eyesight may improve, though the iris continue sluggish or even motionless. The treatment of amaurosis must of course be regulated by the view taken of the cause of the disease. Thus, notwithstanding the fact that emetics have not proved as successful in this country as they have abroad, they should be prescribed when bilious disorder of the gastric organs is evidently present, and unaccompanied with much determination of blood to the head. Richter has recorded the case of a priest who became suddenly blind in a fit of passion, but recovered his sight immediately after taking an emetic. Schmiicker cured many cases by a combination of the emetic and antiphlogistic practice, and the evidence of Scarpa is strongly in favour of the same method. In general, it is to be taken into the account, that emetics and bleeding have been assisted with the simultane- ous exhibition of purgatives, so that it would be assuming too much in numerous examples to refer the success of the practice altogether to the emetics. Purgatives are, on the whole, in far greater repute for their good effects on am- aurotic disorders, than the free employment of tartarized antimony. They are particularly in- dicated when there is much disorder of the pri- ma3 viae, when the disease is attended with ha- bitual costiveness, and any manifestly increased determination of blood to the brain and eyes. This state may be presumed to exist whenever amaurosis is connected with the suppression of any accustomed discharge, as of the menses, bleed- ing from piles, secretion of matter from an old ul- cer, &c The origin of the greater number of cases of amaurosis, that is to say, of those which directly affect the retina or optic nerve, is ascribed by Mr. Lawrence to vascular excitement, to con- gestion, or even a slow inflammation of the ner- vous structure constituting the seat of vision. His practice, therefore, in such instances, is at first decidedly antiphlogistic, comprehending lo- cal and general bleeding, purgatives, low diet, &c., afterward followed up by the free use of mercury, aided with blisters or a seton. This mode of treatment, however, he recom- mends to be graduated according to the violence of the attack, the constitution, age, and strength of the individual, and other circumstances. It must not be supposed, he observes, that all am- aurotic patients require to be bled and salivated. When we meet with the affection in the form of active inflammation of the retina, more espe- cially in young and vigorous individuals of full habit, where there are obvious marks of local vascular congestion and constitutional excite- ment, the antiphlogistic treatment cannot be too active or too quickly followed up. Amaurosis often comes on in a slow and very insidious manner in persons of enfeebled constitution: the organ suffers from habitual excessive exer- tion, at the same time that the constitution is depressed by residence in confined dwellings, bad air, by sedentary occupations, unwholesome diet, costiveness, and other hurtful influences. In the treatment of a thin, pallid, feeble woman, who had destroyed her health by close confine- Vol. II.—Q ment to needlework, less active measures would be required. Emptying the alimentary canal, perhaps, taking away a little blood by cupping, or by leeches to the temples, and then using mercury in the alterative manner, with mild aperients, would here be the best plan. Mr. Lawrence recommends a few grains of Plum- mer's pill to be given every night or every sec- ond night, and the bowels to be kept open with occasional doses of electuary, castor-oil, or rhu- barb and magnesia. The blue-pill, he says, may be taken in combination with aloes or the com- pound extract of colocynth. It may be neces- sary to persevere with the mercury, slowly in- creasing the dose until the mouth is slightly affected. A nutritious diet without stimuli, good air and exercise, and repose of the organ, Mr. Lawrence deems important auxiliaries. With these means may be joined a succession of mod- erate sized blisters. After mild antiphlogistic means, and the alimentary canal has been clear- ed, it may be expedient to combine tonics with aperients, as rhubarb with bark, columba, or cascarilla, and allow a generous diet, with a lit- tle porter and wine. Dr. Frick has seen much benefit from mercury or calomel in those cases of incipient amaurosis which come on with deep- seated pain in the head and orbit, more particu- larly when such pain is found to intermit.—(On Diseases of the Eye, 2d edit, by Welbank, p. 153.) Although modern practitioners place little re- liance on the real utility of various local stimu- lating applications in the treatment of amaurosis, and not much more on electricity, galvanism, and several internal medicines, once supposed to have a specific effect in removing blindness, the editor has considered it right not to suppress the following remarks delivered by the author, as they bring before us many plans which have oc- casionally been strongly recommended.] Sternutatories demand attention: they are best formed of turbeth mineral, with about ten times its proportion of mild snuff, or any other light powder. The vapour of ammonia, ether, or camphire, mixed with hot water, has sometimes also afforded benefit; as has probably the use of moxa frequently repeated, so warmly recom- mended by Baron Larrey. " By this remedy," says he, "not only has the progress of amau- rosis been arrested, but in some cases removed, even where the blindness was complete."—(Rec. des Mem. de Chirurgie, &c, Paris, 8vo., 1821.) Professor Beer is minute in describing the modifications that proceed from plethora, and a morbid state of the digestive organs ; but gives a still more copious detail of that which depends upon local rheumatism, and which he hence calls the rheumatic amaurosis. In this he re- marks, that the pupil is perfectly clear, and the iris unalterable, slightly dilated, and thrust a little nearer the nose and the eyebrow than naturally, so as to be in a small degree dis- placed inwards and upwards. The tears flow on slight occasions, and the light is often troub- lesome, accompanied with an aching pain in the eyeball. The movement of the eye is im- peded, and more in one direction than in others. 242 NEUR< This modification rarely proceeds to perfect blindness. The rheumatic form is frequently treated with success, and principally by diaphoretics. Beer employs guaiacum and camphire combined du- ring the day, and Dover's powder at night; and with these he has recourse also to blisters, placed in succession behind the ear, on the temple, and over the eyebrow, so as to maintain a catenation of counter-irritative actions. Both this and the plethoric modification, in which local bleeding is of the utmost benefit, are fre- quently hurried on to a complete development of disease and a total insensibility of the retina by stimulants, and particularly by galvanism and electricity. Where it has followed repelled eruptions, it has also been occasionally found to yield to setons and blisters, or a restoration of the sup- pressed efflorescence ; and as in other diseases, what has sometimes proved the source of its production, has been found its best remedy; so that the cause has become the cure. Thus, it has at times yielded to the violence of a fever, to that of a sudden blow on the head, to a strong light, to a paroxysm of convulsions. Electricity, and especially voltaism, has proba- bly been serviceable in some instances ; at least, the assertions to this effect are very numerous, though in various cases both these have some- times been altogether unsuccessful, and, as just observed, sometimes highly mischievous. Nor is the magnet without its recommendations, having been applied to the upper part of the spine, while minute bags filled with iron filings were placed on the eyes.—(Wurkung des Kunsllischen Magnets, &c, pp. 24, 25 ; Hell. v. Nootnagel, 1, c, $ 22 ; Eph. Nat. Cur. Dec, ii., ann. v., obs. 247.) The chief dependances, besides these, have been on camphire, cajeput, musk, mercury, iron, bark, arnica, and exter- nally the Pulsatilla nigra. Collier employed the flowers of arnica in decoction (Dr. Layard, Phil. Trans., 1757-8, vol. 1., p. 747) in the proportion of about half an ounce to a pint of the strained liquid, which may be taken in a day or a day and a half. Richter, Schmucker, and other German writers, declare it to be of no avail. The pulsatilla is certainly better entitled to attention. "I would recommend it," says Dr. Cullen, with his usual liberality, " to the attention of my countrymen, and particularly to a repetition of trials on that disease, so fre- quently otherwise incurable, the amaurosis. The negative experiments of Bergius and others are not sufficient to discourage all trials, considering that the disease may depend upon different causes, some of which may yield to remedies, though others do not."—(Mat. Med., vol. ii., part ii., chap, v., p. 216.) When dis- tilled with water, it gives forth a terebinthinate substance resembling camphire,which necessarily possesses a stimulant, and hence a medicinal power. Whence the euphrasia officinalis, or eye-bright, obtained the character it once pos- sessed as a specific in this disease, it is difficult to say. By Hildanus and Lieutaud, however, it was chiefly confined, even in its zenith of )TICA. [Cl. IV—Ord. II. popularity, to the. amaurosis of old age. Its chief sensible quality is that of being a mild astringent. Rue, which rivalled it at one time, and by Milton is put upon a level with it, has far better pretensions when used externally in the form of a potent infusion ; for it unites the prop- erties of volatile pungency and bitterness: both which, as concentrated in strong chamomile tea, I have occasionally found highly serviceable in an incipient state of this disease, produced by weakness; though, as already remarked, none of these should be employed in several forms of the disease. With respect to narcotics, the aconite has been chiefly popular in Germany: it has been strongly recommended by many writers of repu- tation, and has sometimes been given by gradual augmentation to the amount of a drachm daily.* Chevillard combined the use of antimonials with blisters; but cold applied externally, and cold bathing, as recommended by Warner, is much entitled to our attention. Dr. Powell relates a case of sudden loss of vision, preceded by an acute cephalaea, in which an emetic was found, during the act of vomiting, abruptly to restore sight to the right eye (for both were affected), with a sensation as if a flash of lightning had taken place, but the vision was soon again lost. More than a twelvemonth afterward, the patient returned to emetics; when, after the use of the second, the pupils of the eyes recovered the power of dilating and contracting on exposure to light, and preserved it till death ; but the power of vision was not re- stored. During the whole of this case of blind- ness, the sense of hearing was peculiarly acute. —(Trans. Med., vol. v., p. 226.) The discov- ery of Dr. Bock, that a few nervous filaments, appertaining to the great sympathetic nerve, are thrown off while this nerve is within the caver- nous sinus, and entering the orbit unite with the lenticular ganglion, may account for these re- mote influences ; the ear, as is frequently the case, sympathizing with the morbid state of the eye, either directly or reversely.*—(Beschreibung des fufnten Nervenpaares und seiner Verbin- dungen mil anderen Nerven, &c, von D. A. Carl Bock, Leipsic, 1817.) SPECIES XII. PAROPSIS STRABISMUS. SQUINTING. optic axes of the eye not coinciding on an object. This disease, in colloquial language now called squinting, was formerly denominated goggle-eye, whence the word goggles is still ap- plied to the glasses which are used by persons affected with the complaint. The French called * Beobachtungen und Untersuchungen, &c , band ii., Nuremb., 17G7. All faith in the virtue of these medicines against amaurosis, is at the present day totally abandoned.—Ed. f Dr. Hays has published an extremely judicious article on amaurosis, in the American Cyclopedia of Practical Medicine, vol. i. See likewise Cop- land's Dictionary of Practical Medicine, p. 50 — D. Gen. I.-Spe. 12.] PAROPSIS STRABISMUS. 243 these glasses masques a louchette, literally squinl- ina-guards. The technical term strabismus, is derived from the Greek orpafidj, " tortus ocu- !is," or " sight-twisted." The optic axis is an imaginary line passing from the centre of the vitreous humour, lens, and globe of the eye, to the* object of vision. In perfect vision, the optic axis of the one eye is in unison with that of the other ; and conse- quently, they converge or coincide at the same point; and the object which would otherwise appear double, as being seen by each eye, is contemplated as single. In order to this coinci- dence the muscles of each eye must constantly assume the same direction, their position and configuration be precisely alike, and the sight be of an equal power and focus : a deviation from each of which postulates must necessarily pro- duce squinting, or an inaccordant action of one eye with the other. From common and early habit we acquire an equal command over the muscles of both, and are able to give them any direction, or power of direction, and to fix them upon any object we please. And such is the force of habit, that they at length involuntarily associate in the same action, and it is difficult for us to give to the one eye a different direc- tion from that of the other ; or in other words, to make their optic axes diverge instead of con- verge. In persons born blind no benefit can be derived from this unity of action, and hence it is never attempted; and the muscles being never- subjected to discipline, the eyeballs roll at random, and wander in every direction. In consequence of which, one of the most difficult tasks to be acquired by such persons, after ob- taining sight, is that of keeping their eyes fixed, and giving the same bearing or convergent line to each. And hence, again, they see things double at first, and in a state of great confusion. When one eye is naturally stronger, or of a more favourable focus, or more frequently em- ployed, than the other, as among watchmakers and jewellers, the latter, from comparative neg- lect, relapses into an undisciplined state, and less readily obeys the control of the will. Its muscles do not assume the same direction as those of the eye employed; and if they do, in the two former cases, the object still appears double ; and hence the neglected or weaker eye wanders and stares at one or at various objects, while the eye relied upon is fixed upon some other. And it is this divergence of the optic axes, this inaccordance of direction, or looking at different objects at the same time, that consti- tutes the present disease.* * When the axis of the eyes of persons who do not so.uint, and sometimes also of amaurotic indi- viduals, are directed in different fines, objects are seen double: squinting persons, however, do not see objects double. Yet the principal reason as- signed for the singular phenomenon, that the ima- ges impressed upon the two eyes excite only one image in the mind, is, that the two images fall upon corresponding points of the retina. The Crobability therefore is, that in a squinting person, oth eyes do not see the object looked at. In many cases, as Sir Everard Home has remarked, " this is pretty evident to a by-stander, who is able Q2 It is obvious, therefore, that strabismus may have three varieties :— a Habitualis. From a vitiated habit; or Habitual squint- the custom of using one ing. eye, and neglecting the other. 8 Atonicus. From debility of the affect- Atonic squinting, ed eye, whence the sound eye possesses a different focus and power of vision, and is alone trusted to: in consequence of which . the weak or neglected eye insensibly wanders as al- ready stated.* y Organicus. From the eye being differ- Organic squinting, ently constructed in form or position.* The first of these varieties constitutes the nystagmus of Dr. Plenck, and its cause is suf- ficiently obvious. In the second, the sound eye is alone trusted to, because it is the only eye on which any dependance can be placed; and hence the weak eye, neglected by the will, wan- ders insensibly, as in the preceding order we have seen that any one of the mental faculties will wander in like manner under the same want of discipline. [It has been ascertained by experiment, that in individuals who have a confirmed squint of this kind, one of the eyes is too imperfect to see distinctly. Of this, how- ever, the patient is not always conscious, as was evinced in a young lady whose case is re- to determine that the direction of one of the eyes differs so much from that of the other, that it is impossible for the rays of light from any object to fall on the retina of both, and therefore that one eye does not see the object. The same thing may be proved in another way. For since a small de- viation in the direction of either eye from the axis of vision produces double vision, any greater de- viation must have the same effect, only increasing the distance between the two images, till it be- comes so great that one eye only is directed to the object. In squinting, there is evidently a greater deviation from the axes of vision than in double vision, and the object does not appear double ; it is therefore not seen by both eyes."—Phil. Trans., vol. lxxxvii., 1797.—Ed. * Besides the hypothesis here adopted in ex- planation of the mariner in which strabismus is produced, others have been suggested. M. de la Hire conceived that the defect might arise from the more sensible part of the retina not being placed in the axis of the eye, but at some distance from it, on one side or the other ; and that, conse- quently, not the axis, but this more sensible part of the retina, is turned towards the object on which the axis of the other eye is fixed, so that both axes are not directed to the same point. A case of this description would of course be abso- lutely incurable. Dr. Darwin's observations rather tend to show the possibility of such a form of strabismus; but both this hypothesis, and that of obliquity of the crystalline lens, are mostly con- sidered to have been refuted by Dr. Jurin. Buffon refers the cause of squinting to an inequality in the goodness or in the limits of distinct vision in the two eyes ; a doctrine, the truth of which is at present generally admitted. The exclusive adop- tion of any one hypothesis will obviously not ex- plain all the varieties of strabismus,—Ed. 244 NEUROTICA. [Cl. IV.—Ord. 11. lated by Sir Everard Home. Neither she her- self nor her friends believed that any defect of the eye existed ; and upon being asked if she saw objects distinctly with her eyes, she said, certainly, but that one was stronger than the other. To ascertain the truth of this, he cover- ed the strong eye, and gave her a book to read ; when, to her astonishment, she found she could not distinguish a letter, or any other near object. More distant objects she could see, but not dis- tinctly : when she looked at a bunch of keys in the door of a bookcase about twelve feet from her, she could see the bunch of keys, but could not tell how many there were. The obscurity of vision in one eye, then, is the cause of this common species of squinting, and may occasion this irregularity in the following way. The ob- scure image being so imperfectly formed in the weak eye as to excite little attention in the mind, the use of the eye, and its uniform direc- tion to the same object with the other, may have been neglected from the beginning; for as distinct vision was obtained at once by the perfect eye, the end was answered, and there- fore there was no necessity for any exertion of the other ; or, in the effort to get rid of the con- fused image, the muscles may have acquired an irregular and unnatural action. Under either of these circumstances the eye is directed towards the nose, because, as Sir Everard Home remarks, this direction is determined by the superior force of the adductor muscle.] In the third variety, the difference of form or position respects the situation or figure of the one eye compared with the other, or of the particular parts of the one eye compared with those of the other : in con- sequence of which the one is favoured, and the other thrown into disuse. [Dr. Porterfield has pointed out two cases referrible to this variety, or rather, constituting two distinct varieties themselves. One depends upon an oblique po- sition of the crystalline lens within the eye, by which the image of an external object is refract- ed out of the line of the axis of the eye ; and the other from an oblique position and greater protuberance of the cornea, producing a similar effect.*] In this last variety a complete cure is hardly to be expected. In the second it is attended with considerable difficulty ; and in the first is rather to be accomplished by what, in mania, we have called moral treatment, than by medi- cine. A constant and resolute exertion on the part of the patient to obtain a command over the weak or irregular eye is of absolute neces- sity, while the neglected eye itself, if weak, * Edin. Essays, vol. iii., art. xii. " The eye may be turned inwards or outwards, towards the nose or towards the temple, the one case being termed strabismus convergent, the other strabismus divergens. The deviation is not always confined to one eye ; in some cases both are affected, the patient appearing sometimes to squint with the right eye, and at other times with the left. If the sound eye be covered, and the patient be directed to look at any object, the squinting eye resumes its proper position, and can be moved in any direc- tion in obedience to the will; but there are in- stances in which this cannot be done."—See should be strengthened by tonics and gentle stimulants. Goggles, though often recommend- ed, are seldom serviceable, and especially to children ; for although the sight must hereby be restrained in each eye to a common line, the child will still use the sound eye alone, and leave the irregular eye unemployed. It is a better plan to affix some object near the orbit of the affected eye at such a distance, that it may constantly catch and draw off the pupil from the inner angle to the outer. [If squinting has not been confirmed by long habit, and one eye be not much worse than the other, Dr. Darwin recommends a piece of gauze, stretched on a circle of whalebone, to cover the best eye some hours every day, so as to reduce distinctness of vision in this eye to a similar degree of imper- fection to what exists in the other eye.] But the method that I have myself found by far the most effectual, is to blindfold the sound eye with a blink for a considerable part of every day, and thus force the affected eye into use and a subservience to the will. I recommend this simple plan most strongly, and especially in the case of children ; and may venture to predict that it will be sure to succeed in the first varie- ty of the disease, that of habit, and frequently in both the others. [The same plan, which was first suggested by Dr. Jurin (see Smith's Op- tics, Rem., p. 30), is recommended by Mr. Law- rence, who mentions, however, that the squinting eye has sometimes been cured by it, but the op- posite one has then become affected. As stra- bismus, says he, occurs from so many causes, of course the treatment cannot be uniform. A close investigation, with the view to discover the particular cause, is a necessary preliminary to any remedial measures. When this has been accomplished, the course of treatment will be obvious ; or we shall see, perhaps, that the de- fect cannot be remedied. In the forms of stra- bismus arising from accidental irritation affect- ing the sensorium or alimentary canal, the treat- ment will of course turn upon the removal of the cause. When strabismus and double vision oc- cur in the commencement of amaurotic affection, they will disappear if we succeed in removing that disorder. The squinting which is produced from change in the pupil and cornea, will hard- ly admit of relief.—(Op. cit., p. 575.) Dr. Darwin mentions a singular case of squinting, in which the patient was equally ex- pert in the use of either eye, but viewed every object presented to him with only one eye at a time, and always with the eye on the side oppo- site the object. Thus, if the object was present- Lawrence on the Diseases of the Eye, p. 574. In the junior school of the London University, there is at the present time (May, 1834) a boy, who squints with one eye when he looks at near ob- jects, and with the other when he looks at distant ones. Here it is manifest that the power of ac- commodation to distances is different in the two eyes ; and consequently, that when this boy is look- ing at near objects, the eye adapted only to distant objects cannot preserve any harmonious move- ment and position with respect to the other eye, which alone is now employed.—Ed. 0«K. II.] PARACUSIS. 245 ed on his right side, he viewed it with his left eye ; and when it was presented on his left side, he viewed it with his right eye. At the same time, Dr. Darwin found that he turned the pupil of that eye which was on the same side with the object in such a direction, that the image of the object might fall on that part of the bottom of the eye where the optic nerve enters it, and where it would of course excite no impression ; and this insensible portion of the retina Dr. Dar- win ascertained, by some ingenious experiments, to be four times greater in this patient than in ordinary persons. When an object was held directly before the patient, he turned his head a little to one side, and observed it with but one eye ; viz., with that most distant from the object, turning away the other in the manner just men- tioned ; and when he became tired of examin- ing it with that eye, he turned his head the con- trary way, and observed it with the other eye alone with equal facility; but never turned the axis of both eyes on it at the same time. For remedying this curious example, in which there was no defect in either eye, but merely a depraved habit of using both eyes separately, Dr. Darwin says, " a gnomon of thin brass was made to stand over his nose, with a half circle of the same metal to go round his temples ; these were covered with black silk; and by means of a buckle behind his head, and a cross- piece over the crown of his head, this gnomon was managed so as to be worn without any in- convenience, and projected before his nose about two inches and a half. By the use of this gno- mon, he soon found it less inconvenient to view all objects with the eye next to them, instead of the eye opposite to them. " After this habit was weakened by a week's use of the gnomon, two bits of wood, about the size of a goose-quill, were blackened, all but a quarter of an inch at their summits. These were presented for him to look at, one being held on one side of the extremity of this black gno- mon, and the other on the other side of it. As he viewed these, they were gradually brought forwards beyond the gnomon, and then one was concealed behind the other. By these means, in another week, he could bend both his eyes on the same object for half a minute together. "By the practice of this exercise before a glass almost every hour in the day, he became in another week able to read for a minute to- gether with his eyes both directed on the same objects : and I have no doubt, if he has patience enough to persevere in these efforts, he will in the course of some months overcome this un- sightly habit.—(Phil. Trans., vol. lxviii., pp. 86-89.) GENUS II. PARACUSIS. MORBID HEARING. SENSE OF HEARING VITIATED OR LOST. Paracusis is a term of Hippocrates, derived from irapaKovv, " perperam, depravate, vitiose audio." The mechanism of the ear is as com- plicated as that of the eye, and is admirably adapted, in all its parts, to the perfection of the sense which constitutes its function. Its lobes, its entrances, its openings, its various drums, its minute and multiplied foramina, its delicate bones, all contribute to one common effect. Even the surrounding bones, and, still more than this, the teeth, are in no small degree aux- iliary to the same object, as the experiments of M. Perolle, given in the fifth volume of the Tu- rin Transactions, have abundantly established ; as they have also, that bone in general is a far better conductor of sound than air, alcohol, or water. We may hence learn one very important use of the four minute bones deposited in the posterior chamber of the tympanum, the loss of any one of which impairs the hearing, and in some in- stances, has produced total deafness ; of which we have a striking proof in the case of a lad who had parted with the incus on one side, and both the incus and malleus on the other, by means of an ulcerated sore throat that opened a passage from the fauces into each ear, and through which the bones were discharged. The tympanum, on the boy's recovery, seems not to have lost its vibratory power; for be was sensi- ble of violent or sudden sounds, but altogether insensible to conversation, and apparently as deaf in the ear that had only parted with the incus, as in that which had parted with both bones.* From the complicated organism of the ear, it follows necessarily that, like the eye, it must be subject to a great variety of diseases; while many of the diseases of the one sense must bear a striking analogy to those of the other. Thus, painful and obtuse hearing and deafness may be well compared with painful and obtuse vision and blindness. As the eye is sometimes af- fected with illusory objects, so is the ear with illusory sounds ; and as, when the optic axes do not harmonize, as in strabismus, the same ob- ject may be seen double, so may the same sound be heard double when the action of the one ear is inaccordant with that of the other. And hence it is not at all to be wondered at that a peculiar degree of sympathy should exist between these senses, and the state of the one be frequently affected by that of th^ other. Bartho- line gives a case in which deafness and blindness alternated with each other (Epist., cent, iv., No. xl.); and we shall presently have to observe, that a temporary srfection of the eyes may sometimes be proceed by particular noises. As the organ of the ear, however, is less ex- * Phil "Trans., vol. ii., No.l., 1761. The editor has se<5n one case in which a boy who was re- ported to have lost all the ossicula of one ear, was not completely deaf from it; though certainly his hearing on that side was dull. Sir Astley Cooper is acquainted with another example of the same kind. According to Mr. Mayo, the stapes is, so strictly applied to the membrana fenestras ovalis, that the loss of this bone necessarily produces in- curable deafness by injuring the labyrinth.—Out- lines of Human Physiology, 2d edit., p, 415, 8vo., Lond. 1828. 246 NEUROTICA. [Cl IV.—Ord. II- posed than that of the eye, we are far less ac- quainted with the immediate seat of its diseases, and even with the exact bearing which every particular part sustains in the general phenome- non of hearing. It was at one time supposed that the nicest power of discriminating sounds, or in other words, that accuracy of distinguish- ing which constitutes what is called a musical ear, is seated in the cochlea; birds, however, whose perception is exquisite, have no cochlea. It has since been conceived by Sir Everard Home, that it is the membrana tympani in which this fine feeling is peculiarly lodged (Phil. Trans., year 1800), and that it depends upon the muscularity of this membrane ; yet the same feel- ing has remained, and in a high degree, in persons whose membrana tympani has been ruptured. —(See Bell's Anatomy, vol. iii., p. 180, Lond., 1820 ; and Buchanan's Physiological Illuslra-, tions of the Organ of Hearing, p. 14, London, 1828.) [Sir Charles Bell does not conceive that the cochlea, or any part of the organ, par- ticularly conduces to the bestowing of a musi- cal ear, although it is by hearing that we are capable of the perceptions of melody and har- mony, and of all the charms of music. It would seem, says he, that this depends upon the mind, and is not an operation confined to the organ. It is enjoyed in a very different degree by those whose simple faculty of hearing is equally per- fect.] Paracusis as a genus includes the following species :— 1. Paracusis Acris. Acrid Hearing. 2.--------Obtusa. Hardness of Hearing. 3.--------Perversa. Perverse Hearing. - 4. •--------Duplicata. Double Hearing. 5.--------Illusoria. Imaginary Sounds. 6.--------Surditas. Deafness. SPECIES I. PARACUSIS ACRIS. ACRID HEARING. hearing painfully acute, and intolerant OF THE lowest sounds. This occurs occasionally as an idiopathic af- fection in nervous and highly irritable idiosyn- crasies, and beai<3 a striking analogy to that acritude of sight which we have noticed under paropsis lucifuga. It is the hypercousis, or, as it should rather be, the hyperacusis, of M. Itard, who also regards it as an idiopathic affection in various cases.—(Traite des Maladies de I'Oreille tt de VAudition, 2 tomes, 8vo., 3>aris, 1821.) It depends upon a morbid excitement, some- times of the whole of the auditory oi^ans, but more generally of some particular part, %s the tympanum or the labyrinth, and especially the cochlea, or some of the internal canals. \n many instances it seems confined to the branches of the nerve ; and Bonet gives an instance of it from the very singular cause of a triple au- ditory nerve formed on either side (Sepulchr., lib. i., sect, xix., add. obs. 7), in which case there is sufficient ground for its idiopathic ori- gin. It is found more frequently, however, as a symptom of earache, headache, epilepsy, otitis, cephalitis, and fevers of various kinds. The sensation is sometimes so keen as to ren- der intolerable the whisperings of a mere cur- rent of air in a room, or the respirations of per- sons present, while noises before unperceived become highly distressing. I have at this moment before me a most impres- sive description of this effect in a letter from a young lady of about twenty-eight years of age, of an irritable habit, great genius, and a highly cultivated mind, who about a twelvemonth ago was attacked with a cephalitis which proved severe and alarming. The mental powers are rendered more acute, and the external senses, especially those of hearing and seeing, strangely sympathize with each other. " You think me," says she in this letter, " unfit for study; but study I must, whether I am fit for it or not, oth- erwise my mind preys upon itself, and no power can prevent my thinking, which is almost as bad as reading. Last night I was kept awake for some hours by so powerful an excitement of the brain, that I really thought it would have taken away my senses. The pain is very acute, but I do not mind that so much as the distraction which accompanies it. It usually comes on with a most painfully quick hearing. I feel as if the tympanum was stretched so tight as to make the least sound appear almost as loud as thun- der ; and a loud noise is just as if I received a blow quite to the centre of the brain. This really is not imagination, but actual sensation. Moreover, a noise affects my eyes so much, that I am obliged to darken my room when at any time I am under the necessity of hearing any thing like a noise : a loud sound affects my eyes, and a strong light my ears. They seem to act reciprocally. My head is certainly not so bad, nor any thing like it, as it was at Clifton, but still the sudden attacks I have from over-exer- tion of the mental powers, or upon any other ex- citement, make me always fearful I shall lose my senses." Injections of warm water, or a few drops of almond-oil dropped into the ear, will occasionally afford relief. But cold water, and cold applica- tions about the ear, and even pounded ice where there is no tendency to a periodic rheumatism, by directly inducing torpitude, will at times have a better effect; laudanum may also be intro- duced into the ear, and a blister be applied to its immediate vicinity. SPECIES II. PARACUSIS OBTUS. HARDNESS OF HEARING. hearing dull and confused, and demand- ing a clear and modulated articulation. This may proceed from organic defect; from local debility, in which case it is called nervous dea*ness ; or from some accidental obstruction in the external tube or passage, as that of mu- cus, wax, sordes, or any other extrinsic body; or, in the internal or Eustachian tube, from mu- I cus, inflammation, or ulceration and its conse- Gen. II— Spb. 2.] PARACUSIS OBTUSA. 247 nous part it possesses; and a like inunction will be found the best means of destroying in- sects. Atonic or nervous deafness will often bid defiance to our utmost exertions, but it will sometimes yield to local stimulants and tonics : of the former are alcohol, ether, camphorated spirits, essential oil of turpentine combined with olive-oil, and the tinctures of the gum-resins, as myrrh, amber, kino, balsam of Tolu, and blis- ters about the ear ; of the latter, cold water, and solutions of alum, sulphate of zinc, or other metallic salts. [When hardness of hearing depends upon a deficiency of cerumen, Mr. Buchanan recom- mends warmth and stimulant applications. Two drops of the subjoined formula* he advises to be applied to the interior parts of the tube every night at bedtime, and a table-spoonful of the mixture, the composition of which is given be- low^ to be taken at the same time. If the pa- tient be costive, the pilulse rhei comp. are also to be prescribed. When the wax is deficient in quality, or deficient both in quantity and qual- ity, Mr. Buchanan, with the view of improving the state of the digestive organs, gives two table-spoonfuls of an infusion of quassia, with rhubarb and magnesia. The patient should re- side in a dry airy place ; take regular exercise ; use the warm bath at bedtime once or twice a week ; and immediately after getting into bed take pulv. ipecac, comp. 9j. and hydrarg. sub- 1 mur. gr. ij. Mr. Buchanan directs the under- written injection^ to be used every second or third day. He speaks also favourably of bath- ing the feet in warm water, and a light nour- ishing diet, with a glass of port wine after din- ner. Sometimes he applies blisters behind the auricle, or uses them and an antimonial embro- cation^ alternately.—(See Th. Buchanan's Illus- trations of Acoustic Surgery, p. 60 et seq., 8vo., Lond., 1825.) Where hardness of hearing is habitual, and cannot be radically cured, we can only endeav- our to diminish the evil by advising the use of a hearing-trumpet, which is, in fact, an instrument formed upon the principle of imitating the cav- ities of the labyrinth of the ear itself, and the object of which is to collect a large body of sono- rous tremours, and send them to the tympanum in a concentrated state by means of a conver- gent tube, or in other words, to increase as much as possible the vibratory power of the sound. Now sound is well known to be prop- agated in straight lines, and hence persons par- tially deaf will always hear most distinctly when directly opposite the speaker. For the same reason the trumpet itself should be formed as nearly as possible in a straight line ; though we are sometimes, for the sake of convenience, obli- ged to deviate from this direction, and to bend the tube into the segment of a circle, by which quences.* It is also found occasionally as a symptom or sequel in various fevers, in hemi- plegia, apoplexy, otitis, lues, and polypous ca- runcles or concretions in the passage of the ear; and has followed on drinking cold water during great heat and perspiration of the body, of which several examples are given in the Ephemerides of Natural Curiosities. Among the cases of organic defect, one of the least common is atre- sia, or imperforation ; yet Albucasis (vide Mar- cell. Donat., lib. vi., cap. ii., p. 619) gives us an instance of this, as does Bartholinet and Henc- kel.—(N. Anmerk-, ii.) And among the more singular obstructions of an accidental kind may be mentioned insects and the grub of insects or worms. Bartholine mentions a leech which was once found to have burrowed in the ear ; and Walker a small stone which had unac- countably become lodged there, and was dis- charged by a fit of sneezing.! •The cure must depend upon the nature of the cause. All foreign bodies must be carefully re- moved or destroyed, and the cavity of the ear be washed by means of a syringe. Accumula- tions of wax may be softened by oil of almonds and alcohol, which will dissolve whatever resi- * R Acid. Pyrolign., Sp. iEther. Sulph., 01. Terebinth, a a M. t R Tinct. Colchici 3iij., Aq. distillat. ^vj. X R- Acid. Pyrolign. 3ij., Aq. distillat. jvj., M. ft. injectio. § R 01. Sabinae ^ss., Antim. Tart. 3j., Ung. Cetacei jiij., Misce. * That hardness of hearing sometimes depends on deficiency of the ceruminous secretion within the meatus auditorius, is a fact of which most surgeons are perfectly aware. It is a cause, how- ever, that does not appear to have received the author's notice. The ceruminous lining of the meatus auditorius is regarded by Mr. Buchanan as very essential to perfect hearing; and he has termed it the " ceruminous tubular circle." " With- out this provision," says he, "the undulations would affect or strike upon various parts of the membrana tympani irregularly, and produce con- fused vibratory action. And hence we find, in pa- tients divested of this secretion, almost total ina- bility to partake of the pleasure of a conversa- tional party, where the news, politics, or other matters are discussed by the generality of the company; more especially if an argument ensue, in which a part of the discussion is taken by each individual." Mr. Buchanan compares the effect of the " ceruminous tubular circle," in absorbing what he calls the resilient pulsations of sound, to that of the pigmentum nigrum in the eye, which absorbs the superabundant rays of light, and pre- vents them from being reflected so as to injure the retina, or render vision indistinct.—See Bu- chanan's Physiological Illustrations of the Organ of Hearing, p. 21, 8vo., Lond., 1828. t Hist. Anat., cent, vi., n. 36. The editor of this work has seen a child which was born en- tirely destitute of both auricles, and with the places of the meatus auditorii covered by the common integuments. In this case the hearing was dull, but not annihilated. X Observ. Medico-Chirurg., xx., 8vo., 1718. I once removed two pebbles from the ears of a child after they had remained there a twelvemonth, having been introduced by another child in play. The little patient was, at the time of my seeing him, in considerable pain; inflammation had at- tacked each meatus auditorius, and there was complete deafness. I succeeded in bringing out the pebbles by throwing warm water into the meatus with some considerable force by means of a syringe. I recommend surgeons to prefer this simple expedient to more painful, and dan- gerous, and less efficacious measures.—Ed. 248 NEUROTICA. [Cl. IV.-Ord. II. some degree of power is always lost. The metal of which the tube is made should be that which is found most sonorous, or, in other words, which most completely reflects instead of ab- sorbing the sound ; and while the funnel or large aperture is as wide as possible, the extreme end of the pipe cannot be too small. M. Itard has found that a parabolical figure has no advantage over a conical or pyramidal tube ; but that the tube is assisted in producing distinctness of sounds by an insertion into it of slips of gold- beater's leaf, at proper distances, in the manner of partitions.—(Traite de Maladies de I'Oreille et de I'Audition, 2 tomes, Paris, 1821.) SPECIES III. PARACUSIS PERVERSA. PERVERSE HEARING. the ear only sensible to articulate sounds when excited by other and louder sounds intermixed with them. This is a very extraordinary hebetude of the organ, though it has occasionally been met with in most countries. AVhere it exists, the ear, as in other cases of imperfect hearing, requires to be roused in order to discriminate the articulate sounds addressed to it, but finds the best excite- ment to consist in a great and vehement noise of almost any kind.—(Feiliz in Richter Chir. Bibl., band ix., p. 555.) It consists, according to Sauvages, who seems to judge rightly con- cerning it, in a torpitude or paresis of some parts of the external organ, which, in consequence of this additional stimulus, convey the proper sounds addressed to them beyond the mem- brane of the tympanum, in the same manner as the drowsy, or those who are sluggish in wa- king, do not open their eyes, or admit the light to the retina, unless a strong glare first stimu- lates the exterior tunics. It seems, however, sometimes to depend upon an obstruction of the Eustachian tubes. Under the influence of this species, it occa- sionally happens that particular sounds or noises prove a better stimulus than others, though equally loud, or even louder; as the music of a pipe, of a drum, or of several bells ringing at the same time. Holder relates the case of a man who never heard but when he was beating a drum (Phil. Trans., 1668, No. xxvi.); and Sauvages a similar case of a woman, who on this account always kept a drum in the house, which was constantly played upon while she was conversing with her husband. The latter gives another case of a person who was always deaf except when travelling in a carriage, du- ring which time, from the rauling of the wheels, he was perfectly capable of hearing and enga- ging in conversation. And Stahl gives an in- stance of like benefit derived from the shrill tones of a pipe.—(Colleg. Casual., N., Ixxvi.) In ordinary cases of practice, if we can once hit upon a stimulus that succeeds in giving tem- porary tone to a debilitated organ, we can often avail ourselves of it to produce a permanent benefit, and sometimes a complete restoration, by raising or lowering its power, continuing its power for a longer or shorter term of time, or modifying it in some other way, so as to adapt it to the particular exigency. And it is hence probable, that if any of these sonorous stimuli were to be employed medicinally, and with a due respect to length of time and acuteness of tone, they might in some instances be made the medium of obtaining perfect success. Dr. Birch, indeed, gives an instance of such success in a person who only heard during the ringing of bells ; and who, by a permanent use of this stimulus, recovered his hearing altogether.— (Hist., vol. iv.) Voltaism may here also be employed in many cases with a considerable promise of advantage ; and especially in connex- ion with the ordinary routine of general and local tonics and stimulants, as cold, and cold bathing, pungent masticatories and injections, bark, valerian, alone or with ammonia, and a free use of the siliquose and coniferous plants as a part of the common diet. SPECIES IV. PARACUSIS DUPLICATA. DOUBLE HEARING. the action of the one ear inaccordant with that of the other ; sounds heard doubly, and in different tones or keys. This pravity of hearing depends upon an inaccordance of the auditory nerve on the one side with that on the other ; so that the same sound produces on each side a very different effect, and is consequently heard, not homoto- nously, or in like tones, but heterotonously, or in separate and unlike. And hence this species of morbid hearing, as I have already observed, has a considerable parallelism with that of stra- bismus or squinting, in which the optic axis of the one eye is not accordant with that of the other, whence the same object is seen double, and often in a different position. Sauvages has given two or three very curious examples of this affection. A musician, while blowing his flute, heard two distinct sounds at every note. The sounds were in different keys, and con- sequently not in harmony ; and as they were heard simultaneously, the one could not be an echo of the other. On another occasion he was consulted by a person who for several months had been troubled with a hearing of two distinct voices whenever he was spoken to ; the one at least an octave higher than the other, but not in unison with it, and hence producing a harsh and insupportable discordance. This affection is mostly temporary, and, as jiroceeding altogether from a morbid condition of the auditory nerve, has been cured by blisters and other local stimulants. From not being attended to, however, in due time, it has some- times assumed a chronic character, when it is removed with great difficulty ;■ and in a few in- stances it has been connected with a constitu- tional irritability of the nervous system, in which case a plan of general tonics must co- operate with local applications. [Mr. Buchanan does not coincide with the author respecting the cause of paracusis dupli- Gen. II.—Spe. 6.] PARACUSIS SURDITAS. 249 cata, but ascribes its symptoms to an imperfect secretion of cerumen in only one ear.—(See Buchanan's Physiological Illustrations of the Organ of Hearing, p. 24, Lond., 1828.) In this view of the case, nothing more need be said on the treatment than what has already been stated under the head of paracusis obtusa. If some observations published by Sir Everard Home be correct, double hearing may some- times arise from another cause, not ad- verted to by Dr. Good. " An eminent music- master (says he), after catching cold, found a confusion of sounds in his ears. On strict attention, he discovered that the pitch of one ear was half a note lower than that of the other ; and that the perception of a single sound did not reach both ears at the same instant, but seemed as two distinct sounds following each other in quick succession, the last being the lower and weaker. This complaint distressed him for a long time, but he recovered from it without any medical aid. In this case (Sir Everard Home observes), the whole defect appears to have heen in the action of the ra- diated muscle (of the tympanum), exerted nei- ther with the same quickness nor force in one ear as in the other, so that the sound was half a note too low, as well as later in being im- pressed on the organ."—(Phil. Trans., 1800.) This case seems to be very similar to those above cited from Sauvages. Mr. Buchanan expresses his doubts about the reality of the alleged cause, which he suspects might be a de- fective state of the ceruminous secretion.] SPECIES V. PARACUSIS ILLUSORIA. IMAGINARY SOUNDS. internal sense of sounds without exter- nal CAUSES. This is in most instances strictly a nervous affection, and bears a striking analogy to parop- sis illusoria, or that illusory or false sight in which unreal objects, of various forms, colours, and other sensible qualities, appear before the eyes. The morbid state is often confined to the auditory nerves, or some of the branches alone ; yet it is not unfrequently the result of a peculiar irritability that extends through the whole of the nervous system. And occasionally it proceeds from an obstruction of one or both the Eustachian tubes. M. Itard ascribes it to two other causes : a peculiar state of the blood- vessels, local or general, and an impeded motion of the air in the tympanal cavity (Traite des Mal. de V Oreille et de V Audition, 2 tomes, 8vo., Paris, 1821); [Mr. Buchanan, to the imperfect secretion of cerumen.—(Physiological Illustra- tions of the Organ of Hearing, p. 23.)] The sounds hereby produced differ greatly in dif- ferent persons, and sometimes in the very same person at different periods; but it is sufficient to contemplate them under the three following varieties, all which the French express by the term bourdonnements:— a Syrigmus. A sharp, shrill, successive Ringing or tink- sound. ling. B Susurrus. An acute, continuous, his Whizzing. sing sound. y Bombus. A dull, heavy, intermitting Beating. sound. Heister recommends, in cases arising from a debility of the local nerves, to fumigate the ears with the vapour of a hot vinous infusion of rosemary and lavender ; and where a spasmodic affection of the inner membrane may be sup- posed to follow such debility, he advises a simultaneous use of diaphoretics internally. If it proceed from an obstruction of the Eustachian tubes, in consequence of spasm or inflammation, the fumes of tobacco drawn into the mouth, and forcibly pressed against these tubes by closing the lips and nostrils, and then urgently sniffing the vapours upwards to the palate, have often proved serviceable, by taking off the irritability on which the spasmodic or inflammatory action is dependant. Stimulating the external ear by blisters or aromatic injections has sometimes availed, though not often. Chronic cases are extremely difficult of cure ; though I had lately an elderly lady for a patient, who after having at different times suffered from each of these modifications of illusory sounds for several years, and tried every remedy that could be sug- gested in vain, at length lost the distressing sensation by degrees, and without the assist- ance of any medicine.* SPECIES VI. PARACUSIS SURDITAS. DEAFNESS. TOTAL INABILITY OF HEARING OR DISTINGUISH- ING SOUNDS. In the preceding species, the sense of hear- ing is in various ways depraved or impaired ; in the present, it is altogether abolished, and may proceed from causes which offer three distinct varieties of affection : a Organica. From organic defect or im- Organic deafness, pediment. 3 Atonica. From local debility or relax- Atonic deafness, ation. y Paretica. From nervous insensibility. Paretic deafness. The organic defect or impediment may exist in the outer or inner entrance, or in the cavity of the ear. The outer entrance has in a few instances been imperforate (Cels de Med- ian, lib. vii., c. 8 ; Buchner, MiscelL Phys. Med., p. 318, 1727), but far more generally blocked up with indurated wax, excrescences, concretions, or some other substance. The inner entrance or Eustachian tube has been sometimes also found imperforate on both sides, but more frequently obliterated by ulceration (Haller, Elem. Phys., torn, v., p. 286), or * The treatment suggested by Mr. Buchanan has already been briefly noticed under the head of Paracusis Obtusa. 250 NEUROTICA. [Cl. IV.—Ord. II. closed by the mucous secretion of a catarrh, or the pressure of the tonsils, in whatever way morbidly enlarged. If the defect or impediment exist in the cavity of the ear, its precise nature can seldom be known during the life of the patient, and if known would rarely admit of a remedy. It often consists of a malformation of the helix ; and, as we have already seen under parotitis, in a loss of the articulation or sub- stance of one or more of the tympanal bones. Atonic deafness, or that dependant on lo- cal debility or relaxation, may be superinduced by a chronic cold, abruptly plunging the head into cold water in a heated state, a long expo- sure to loud and deafening noises, or the sud- den and unexpected burst of some vehement sound upon the ears (Schulze, Diss, de Audi- tus Difficultate, sect. 23), as that of a cannon or a thunderclap (Borelli, Observ., cent, iv., Paris, 1656), where the constitution is in a state of great nervous irritability : in which state, moreover, it has in a few instances been pro- duced by a violent fright.—(Eph. Nat. Cur., cent, ix., obs. 6.) It has also proceeded from an atony of the excretories of the outer ear, in consequence of which there has been neither wax nor moisture of any kind. And it has fol- lowed as a sequel upon various fevers and in- flammations, especially cephalitis and otitis, rheumatic hemicrania, and other nervous head- aches, repelled gout, and repelled cutaneous eruptions. Paretic deafness may be regarded in many cases as nothing more than an extreme of aton- ic deafness; and almost all the causes produ- cing the one, when operating with greater vio- lence or upon a feebler frame, may also produce the other. It has not only been induced sud- denly by loud sounds and violent frights, but by a vehement fit of sneezing, and from sympathy, by the use of powerful sternutatories (Eph. Nat. Cur., dec. ii., ann. ix., obs. 26); the olfac- tory nerve hereby becoming insentient through all its branches. Deafness has often been transmitted heredi- tarily ; of which numerous instances are to be found in Hoffmann (Consult, et Respons., cent. i., cas. 40), Morgagni (De Sed. et Caus. Morb., epist. xlviii., art. 48), and other writers of es- tablished reputation. The most usual causes of total deafness are beyond the power of the medical art to relieve ; and hence the disease runs very generally through the whole period of life. Where the cause is an imperforation of either of the pas- sages, an opening has been often effected with success. Many other impediments, as of indu- rated wax, or infarction from inflammation, are in general removable still more easily ; and some obstructions have been suddenly carried off by a fall, or other violent concussion of the head. The great difficulty, however, is in getting at such impediments when they are formed in the tympanal cavity. The perforation of the mas- toid process, recommended by Riolanus, has been practised occasionally with success, and especially by the Swedish anatomists, Jasser and Hagstrcem. But the difficulties are so con- siderable, that the plan has usually been super- seded by a puncture of the membrane, or by injecting the Eustachian tube, as first proposed by an unprofessional artist, Guyot of Versailles, and since followed up successively by Cleland, Petit, Douglas, and Wathen. Of late, hew- ever, even this has been dropped ; though now once more revived in France by M. Itard, and in Great Britain by Mr. Buchanan.—(Engraved Representation of the Anatomy of the Human Ear, &.C., Hull, 1823.) In deafness from atonic relaxation, almost all the stimulant and tonic methods pointed out under the preceding species have been tried in turn, occasionally with palliative success, some- times altogether in vain. The fumes of tobacco sniffed up the Eustachian tubes from the mouth, in the manner described under the last species, were recommended by Morgagni (Epist. Anat., vii., art. 14; Eph. Nat. Cur., dec. i., ann. vi., obs. 110) and many other writers of earlier times, and have occasionally been found bene- ficial in our own day; the spasm or other ob- struction of the fine tubes ceasing of a sudden, and with the sensation of a smart snap, that almost startles the patient. And as sight has sometimes been restored in amaurosis by a vio- lent fever or a flash of lightning, so has deaf- ness from atony, approaching to paralysis, been recovered by a like fever or a thunderclap (Bresl. Samml., 1718, p. 1541); ordinary causes be- ing thus transferred into extraordinary modes of cure. Among the stimulants most useful, where the deafness is dependant upon debility of the mem- brane of the tympanum, or the nerve of hear- ing, have been the aura of voltaic electricity, applied two or three times a day for half an hour or longer each time, and persevered in for many weeks, a series of blisters continued for a long period, and a diluted solution of nitrate of silver. Yet a chronic ulcer forming in the ear, and discharging plentifully, has often proved still more effectual. Mr. Gordon relates a case of total deafness, produced suddenly in a soldier in good health by plunging overhead into the sea ; which, af- ter a long routine of medicines had been tried in vain for three months, yielded to the use of mercury as soon as the mouth began to be af- fected. A gentle salivation supervened, his hearing was gradually restored, and in six weeks from its commencement, he returned to his duty perfectly cured.—(Edin. Med. Comm., vol. iii., p. 80.) The excitement of the sali- vary glands seems in this case to have ex- tended by sympathy to the Eustachian tubes, or whatever other parts of the organ of hearing were diseased. "When the Eustachian tubes are imperforate or irrecoverably closed, which may commonly be determined by an absence of that sense of swelling in the ears which otherwise takes place on blowing the nose violently, Riolanus, and afterward Cheselden, proposed a substitute for the canal by making a small perforation through the membrane of the tympanum ; and Sir Ast- ley Cooper has boldly put their recommenda- Gun. III.—Spe. L] PAROSM tion to the test. The artificial opening does not destroy the elasticity of the membrane, and it has hence been occasionally attended with success; and perhaps would be .always, if it were to be limited, as M. Itard (Traiti des Maladies de V Oreille el de VAudition. &c, 2 tomes, Paris, 1821) has shown it ought to be, to a permanent obstruction of the Eustachian tube, unaccompanied with inflammation or any other cause of deafness. And it is from a wan- ton application of this remedy to other cases that it has so often been tried in vain since Sir Astley Cooper's successful sanction. GENUS III. PAROSM IS. MORBID SMELL. SENSE OF SMELL VITIATED OR LOST. This is the parosmia and anosmia of many writers ; from vapa, " male," and Sfa, " olfaeio," analogous with paracusis and paropsis : anos- mia, however, will not include one of its spe- cies, and the present termination is preferred on account of its analogy with that of the par- allel terms. Under this genus may be arranged the three following species:— 1. Parosmis Acris. Acrid Smell. 2.--------Obtusa. Obtuse Smell. 3.--------Expers. Want of Smell. SPECIES I. PAROSMIS ACRIS. ACRID SMELL. SMELL PAINFULLY ACUTE OR SENSIBLE TO ODOURS NOT GENERALLY PERCEIVED. Generally speaking, the sense of smell in all animals is in proportion to the extent of the Schneiderian or olfactory membrane with which the nostrils are lined, and over which the branch- es of the olfactory nerves divaricate and ramify. And hence this membrane is much more exten- sive in quadrupeds and birds, which chiefly trust to the sense of smell in selecting their food, than in man j for it ascends considerably higher, and is for the most part possessed of numer- ous folds or duplicatures. It is hereby the hound distinguishes the peculiar scent thrown * Over the whole of the Schneiderian mem- brane, branches of the fifth nerve are distributed. In the human subject, the first or olfactory nerve does not spread so extensively, but goes princi- pally to the septum narium and upper turbinated bone. M. Magendie has ascertained the effect of the separate division of the first and fifth nerves in animals ; and has thus more correctly demon- strated how much of the impression received by the nostrils belongs to smell, properly so called, and how much to touch. " It appears that upon the division of the first nerve, the animal remains as sensible as before to the disagreeable impres- sion of odours which act pungently. A young dog thus mutilated, appeared conscious of an un- pleasant impression when ammonia, acetic acid, oil of lavender, or Dippel's oil, was held to its nose. On the other hand, after the division of the 3 ACRIS. 251 forth from the body of the hare, and the domes- tic dog recognises and identifies his master from all other individuals. Yet the nerves of smell are not only spread in great abundance over the olfactory membrane of all animals possessing such an organ, but they are distributed so near the surface as to be almost naked ;* and hence in every class they are easily and hourly excited into action, being covered with little more than a layer of bland, insipid mucus, thin at its first separation, but gradually hardening by the access of air into viscid crusts, and which is expressly secreted for the purpose of defending them. From this nearly naked state it is, that they are stimulated by aromatics, however finely and impalpably di- vided ; whence the violent sneezings that take place in many persons in an atmosphere in which only a few particles of sternutatories or other acrid olfacients are floating : and hence also the rapidity with which a sympathetic action is ex- cited in the neighbouring parts, or in the system at large, and the refreshment which is felt on scenting the pungent vapour of carbonate of ammonia, or vinegar, or the grateful perfume of violets or lavender, in nervous headaches or fainting-fits. The fetid odours are well known to affect the nostrils quite as poignantly as the pleasant, and to produce quite as extensive a sympathy ; and hence the nausea, and even in- testinal looseness, which often follow on inhaling putrid and other offensive effluvia. Under peculiar circumstances, however, the ordinary apparatus for smell possesses an activ- ity, and sometimes even an intolerable keen- ness, which by no means belongs to it in its natural state. M. Virey, who has written a very learned treatise upon the subject of odours, asserts that the olfactory sense exists among savages in a far higher degree of activity than among civilized nations, whose faculty of smell is blunted by an habitual exposure to strong odours, or an intricate combination of odours, and by the use of high-flavoured foods. And he might have added, that this sense, like every other, is capable of cultivation, and of acquiring delicacy of discrimination by use ; that sava- ges, many of whom make an approach to the life of quadrupeds, employ it, and trust to it in a similar manner; and that this is perhaps the chief cause of the difference he has pointed fifth, the first nerve remaining entire, an animal is not affected by the presence of the substances above mentioned." But a dog that survived the division of. the fifth rierve for a considerable period, would at times, when food was offered to it rolled up in paper, unrol the paper, and expose and eat the food although at. other times he appeared to want the power of distinguishing by smelling the presence of objects placed near it. " Pungent odours seem to offend the nose upon the same principle that they irritate the conjunctiva of the eye; their acrid impression, without their scent, being perceived when the influence of the first nerve is artificially destroyed." The first nerves, therefore, constitute the organ of smell.—See Mayo's Outlines of Physiology, p. 412, 2d edit.; and Magendie's Journ. de Physiol. Exp., torn, iv., p. 173.—Ed. 252 WKUK( out. It is in like manner relied upon by persons who are deprived of one or two of the other external senses, as those of sight or hearing, or both : not merely in consequence of more fre- quent employment, but from the operation of the law we have already pointed out, that where one of the external senses is destroyed or con- stitutionally wanting, the rest, in most cases, are endowed with an extraordinary degree of energy ; as though the share of sensorial pow- er naturally belonging to the defective organs were distributed among the rest, and modified to their respective uses. One of the most in- teresting examples that I am acquainted with of this transfer of sensorial power, is to be found in the history, first given to the public by Mr. Dugald Stewart, of James Mitchell, a boy born both blind and deaf; and who, having no other senses by which to discover and keep up a connexion with an external world than those of smell, touch, and taste, chiefly depended for information on the first, employing it on all oc- casions, like a domestic dog, in distinguishing persons and things. By this sense he identi- fied his friends and relatives ; and conceived a sudden attachment or dislike to strangers, ac- cording to the nature of the effluvium that es- caped from their skin. " He appeared," says Mr. Wardrop, who has also published an account of him, " to know his relations and intimate friends by smelling them very slightly, and he at once detected strangers. It was difficult, however, to ascertain at what distance he could distinguish people by this sense ; but from what I could observe, he appeared to be able to do so at a considerable distance from the object. This was particularly striking when a person entered the room, as he seemed to be aware of such entrance before he could derive infor- mation from any other sense than that of smell. When a stranger approached him, he eagerly began to touch some part of the body, com- monly taking hold of his arm, which he held near his nose ; and after two or three strong in- spirations through the nostrils, he appeared to form a decided opinion concerning him. If it were favourable, he showed a disposition to be- come more intimate, examined more minutely his dress, and expressed, by his countenance, more or less satisfaction ; but if it happened to be unfavourable, he suddenly went off to a dis- tance, with expressions of carelessness or dis- gust."* The Journal des Sgavans for 1667 gives a eurious history of a monk who pretended to be able to ascertain, by the difference of odour alone, the sex and age of a person, whether he were married or single, and the manner of life to which he was accustomed. This, as far as the fact extended, may possibly have been the result of observations grafted upon a stronger natural sense than belongs to mankind in gen- eral, and is scarcely to be ranked in the list of diseased actions. But among persons of a * History of James Mitchell, a boy bom blind and deaf, &c.; by James Wardrop, F, R. S., 4to. edit., 1813. 3TICA. [Cl. IV—Ord. II. highly nervous or irritable idiosyncrasy, I have met with numerous instances of an acuteness of smell almost intolerable and distracting to those who laboured under it; which has fairly constituted an idiopathic affection, and some- times nearly realized the description of the poet, in making its possessors ready at every moment to " Die of a rose in aromatic pain." Mr. Pope seems to have written this line as a play of fancy at the time, but the writings of various collectors of medical curiosities abun- dantly show that he has here described nothing more than an occasional and sober fact. Thus M. Orfila gives us an account of a celebrated painter of Paris, of the name of Vincent, who cannot remain in any room where there are roses without being in a short time attacked with a violent cephalaea, succeeded by fainting (Sur les Poisons, torn, ii., Cl. v., sect. 972); and M. Marrigues informs us that he once knew a sur- geon who could not smell at a rose without a sense of suffocation, which subsided as soon as the rose was removed from him ; as he also knew a lady who lost her voice whenever an odorifer- ous nosegay was applied to her nostrils.—(Journ. de Physique, year 1780.) We have observed that a keen stimulation of the olfactory nerves is often productive of a very powerful sympathetic action in other organs. There are few persons who, on inhaling the fine particles of black hellebore and colocynth while in the act of being pounded, would not feel their effect on the intestines by a copious diarrhoea; but where the acuteness of smell exists which constitutes the present disease, whether limited to particular odours, or extending to all odours equally, the sympathetic action is sometimes of a very singular description. M. Valtain gives the history of an officer who was thrown into convulsions and lost his senses by having in his room a basket of pinks, of which, nevertheless, he was very fond. The flowers were removed, and the windows opened, and in the course of half an hour the convulsions ceased, and the patient recovered his speech. Yet, for twelve years afterward, he was never able to inhale the smell of pinks without fainting.—(Hygiene Chi- rurgicale, p. 26.) And M. Orfila relates the case of a lady, forty-six years of age, of a hale constitution, who could never be present where a decoction of linseed was preparing, without being troubled, in the course of a few minutes afterward, with a general swelling of the face, followed by fainting and a loss of the intellect- ual faculties; which symptoms continued for four- and-twenty hours.—(Sur les Poisons, loc. citat.) The predisponent cause of the species before us is a nervous or irritable habit. The occa- sional causes are, local irritation from a slight cold, in which the contact of the air alone, as inhaled, often produces sneezing ; or excoriation of the mucous membrane of the nostrils, from the use of sternutatories in those not accustom- ed to them. It is often the result of idiosyn- crasy ; and perhaps at times, as in paracusis aens, of a superfluous distribution of olfactory Gen. IV] PARAGEUSIS. 253 nerves. As a symptom, it is often found in ophthalmia and rheumatic hemicrania. Where the disease is connected with the habit, the nervous excitement should be diminished by refrigerants and tonics, as the shower-bath, bark, acids, neutral and several of the metallic salts. And where it is chiefly local, we may often pro- duce a transfer of action by blisters in the vicin- ity of the organ ; or relax the Schneiderian mem- brane, and moisten its surface by the vapour of warm water. The sniffing up cold water will also prove serviceable in many instances, by in- ducing torpitude at first, and additional tone afterward. Dr. Darwin advises errhines fo first of these purposes, that of exhausting excitability and blunting the sense. SPECIES II. PAROSMIS OBTUSA. OBTUSE SMELL. SMELL DULL AND IMPERFECTLY DISCRIMINATIVE. This is often a natural defect, but more fre- quently a consequence of an habitual use of sternutatories, which exhaust, weaken, and tor- pify the nerves of smell, just as exposure to a strong light weakens and impairs the vision, and sometimes destroys it altogether. To those un- accustomed to sternutatories, the mildest snuffs will produce such an excitement as is marked by a long succession of sneezing, which is noth- ing more than an effort of the remedial power of nature to throw off the offending material; while those who have habituated themselves to snuff for years, can hardly be excited to sneeze by the most violent ptarmics. The evil is here so small, that a remedy is seldom sought for in idiopathic cases; and in sympathetic affections, as when it proceeds from catarrhs or fevers, it usually, though not always, ceases with the cessation of the primary disease. It is found also as a symptom in hysteria, synco- pe, and several species of cephalaea, during which the nostrils are capable of inhaling very pungent, aromatic, and volatile errhines, with no other effect than that of a pleasing and refreshing ex- citement. Where the sense of smell is naturally weak, or continues so after catarrhs or other acute dis- eases, many of our cephalic snuffs may be rea- sonably prescribed, and will often succeed in removing the hebetude. The best are those formed of the natural order verticillata?, as rose- mary, lavender, and marjoram : if a little more stimulus be wanted, these may be intermixed with a proportion of the teucrium Marum; to which, if necessary, a small quantity of asarum may also be added ; but pungent errhines will be sure to increase instead of diminishing the defect. SPECIES III. PAROSMIS EXPERS. WANT OF SMELL. TOTAL INABILITY OF SMELLING OR DISTINGUISH- ING ODOURS. Tms species is in many instances a sequel of the preceding; for whatever causes operate in producing the former, when carried to an ex- treme, or continued for a long period, may also lay a foundation for the latter. But as it often occurs by itself, and without any such introduc- tion, it is entitled to be treated of separately. It offers us the two following varieties:— a Organica. From natural defect, or Organic want of accidental lesion, injuri- smell. ous to the structure of the organ. B Paralytica. From local palsy. Paralytic want of smell. The first variety occurs from a connate destitution of olfactory nerves, or other struc- tural defect; or from external injuries of various kinds ; and is often found as a sequel in ozaenas, fistula lachrymalis, syphilis, smallpox, and por- phyra. The second is produced by neglected and long-continued coryzas, and a persevering indulgence in highly acrid sternutatories. The author once knew a very beautiful and elegant young lady, who had from birth so total a want of smell as not only to be incapable of perceiving any difference in the odours of dif- ferent perfumes or flowers, but of sweet and corrupt meats, and who could inhale very pow- erful errhines without sneezing. Though this affection seemed to have been connate, and de- pendant upon a natural imperfection of the nerves of smell, the Schneiderian membrane had something of the thickening which is ordinarily produced by catarrhs, and the lady always spoke as though under the influence of a slight cold. When this affection is a sequel of local irrita- tion, as from a coryza or catarrh, warm stimu- lating vapours, as of vinegar or frankincense, are often useful. If produced by syphilis, the fumes of cinnabar may be inhaled -by the nos- trils, or a sternutatory may be used, composed of t.urbeth mineral and ten times the quantity of any mild and light powder, as orris-root. GENUS IV. PARAGEUSIS. MORBID TASTE. SENSE OF TASTE VITIATED OR LOST. Parageusis is derived from napa, "male," and ytiut, "gustum praftbeo," whence xapayivat, and consequently irapayttois. The author has preferred, with Vogel, the present termination to parageusia, as analogous to the names of the preceding genera of the order before us. In the senses of taste and smell there is a considerable association. The young lady I have just noticed, who was- destitute, or nearly so, of the sense of smell, was equally destitute of that of taste, and could not distinguish by this crite- rion between beef, veal, and pork ; and conse- quently, in respect to all these, had no preference. The chief organ of taste is the tongue; but this is not the only organ, nor is it absolutely necessary for an existence of the sense. The Philosophical Transactions give us examples of persons who possessed a perfect taste after the 254 NEUROTICA. [Cl. IV—Ord. II. tongue had been wholly destroyed ; and Pro- fessor Blumenbach, in his Comparative Anato- my, affords us a similar example in an adult whom he visited, and who was born without a tongue. Consonant with which, many insects appear to have a faculty of taste, though they have no organ of a tongue ; and among these the gustatory function is supposed by Professor Knoch to be performed by the posterior pair, of palpi or feelers ; while, on the other hand, there are many animals possessing a tongue who do not use it as an organ of taste. All birds pos- sess a tongue, for even the pelican, which has been said to be tongueless, has a rudiment of this member ; yet there are but few birds, com- paratively, that taste or are able to taste with this organ. Parrots, predaceous and swimming birds, are an exception to this remark ; for they possess a soft thick tongue, covered with papil- lae, and moistened with a salivary fluid, and select that food which is the most agreeable. Yet, in by far the greater proportion of birds, we do not find the tongue appropriated to this purpose. In many of them, indeed, it is stiff, horny, and destitute of nerves. The tongue of the toucan, though sometimes several inches in length, is scarcely two lines broad at its root: it has throughout the appearance of whalebone, and its margins are fibrous. The tongues of the woodpecker and cock of the woods are equally hard and horny : in themselves they are short, and in a quiescent state lie backward in the mouth, and are covered with a sort of sheath issuing from the os hyoides or the oesophagus: but they possess a mechanism which renders them extremely extensile, and capable of being thrust forward to a considerable distance. That of the woodpecker is sharp-pointed, with barbed sides, and is darted with great rapidity out of the mouth to an extent of some inches ; by which means it follows up such insects as the animal is in pursuit of through all their crannies in the bark of trees, sticks them through with its apex, and in this state drags them out for food. The chameleon has a tongue of a some- what similar kind, which in like manner an- swers the purpose, not of taste, but of preying for food. It is contained in a sheath at the lower part of the mouth, and has its extremity covered with a glutinous secretion. It admits of being projected to the length of six inches ; and is used in this manner by the animal in catching its spoil, and especially in catching flies. It is darted from the mouth with wonder- ful celerity and precision ; and the viscous se- cretion on-its extremity entangles minute ani- malcules, which constitute another portion of its food. The tongue, when it forms an organ of taste, as in man, is studded, and especially on its upper surface and lateral edges, with innumer- able nervous papillae, issuing from a peculiar membrane that lies beneath, and has a near re- semblance to the skin in other parts, but is softer and more spongy. Its external tunic or cuticle is an exquisitely fine epithelium, which is moistened, not by an oily fluid like that of the Burfacc of the body, but a peculiar mucus. We have here, therefore, a more exquisite sense of touch than on the general skin, whose papillae are not only smaller but dry. There can be no question, also, that the sen- tient fluid with which they are supplied is dif- ferently modified from that of the skin ; and hence the provinces of the two senses, though they occasionally approach each other-rare still kept distinct; and the tongue becomes a dis- cerner of eertain qualities which the slun can- not discriminate, as sour, sweet, rough, bitter, salt, and aromatic* Thus much we know ; but we do not know the cause of that different effect, or in other words, of that variety of tastes which different substances produce upon the papillae of the tongue, and which constitute their respective flavours. It was supposed by the Epicureans, and the doctrine has descended to the present day, that all this depends upon the geometrical figure of the sapid corpuscles ; and particularly so with respect to saline bodies, which are cubic in sea-salt, prismatic in nitre, and equally diver- sified in vitriol, sugar, and other crystals. It is sufficient, however, to annul this explanation, to observe, that many crystals of very different forms are alike insipid; while others of the same, or nearly the same shape, posfcess very different flavours ; as also that the flavour in any of them continues the same, even where we are able to change the figure ; as, for example, by rendering common nitre cubical. The cause of flavours, therefore, appears to reside in the ele- * Instead of this hypothesis of a modification of the nervous fluid, modern discoveries teach us rather to seek in the different nerves with which the tongue is supplied for an explanation of the cause of the peculiar and diversified faculties which it enjoys; as, for instance, the power of motion, the power of common sensation or touch, and the power of taste. "In man," as Mr. Mayo has observed, " the apparent sense of taste is the tongue and palate ; the same surfaces have an ex- quisite sense of touch; and an attentive examina- tion shows that the latter occupies a larger sur- face than the former, and is, indeed, the only sense with which the palate is endowed. " Upon the surface of the tongue, again, the sense of taste is very partially distributed, being restricted to the papillae fungiformes. The largest of these are found upon the dorsum of the tougue, while the smaller and more numerous are situated along the sides and towards the tip of the tongue. They are vascular and erectile, and shoot up when the tongue is touched by a sapid substance."__ (See Outlines of Human Physiology, p. 406, 2d edit.) It is clear, however, that if some facts to which the author of the Study of Medicine has adverted be correct, either the sense of taste must be more extensive than here represented, or else that, under particular circumstances, other parts than those specified must acquire a gustatory power. The ninth pair of nerves, which are dis- tributed to the muscles of the tongue, are merely the nerves of motion; while those of taste and sensation appear to be, first, the gustatory branch of the ganglionic portion of the third division of the fifth, which is distributed not merely to the muscles of the tongue, but to its mucous surface and to two of the salivary glands; and secondly the glosso-pharyngeal nerve, which sends branches to the surface of the root of the tongue —Ed Gen. IV.—Spe. 1.] PARAGEUSIS ACUTA. 255 mentary principles of substances that lie beyond the reach of our senses. But the variable condition of the peculiar covering of the papillae of the tongue, together with the condition of the adjoining organs which concur in the purpose of the tongue, as also the changeable nature of the saliva and of the sub- stances lodged in the stomach, all concur in in- fluencing the taste, and giving a character to the flavour. And hence the same flavours do not affect persons of all ages, nor of all temper- aments ; nor even the same person at all times. In general, whatever contains less salt than the saliva, seems insipid. The spirituous parts of plants are received, in all probability, either into the papillae themselves, or into the absorbing villi of the tongue ; and hence the rapid re- freshment and renovation of strength, not easy to be accounted for otherwise, which these stimulating materials produce, even when they are not taken into the stomach. It is from the diversity of flavours by which nature has distinguished different substances, that animals are taught instinctively what is proper for their food: for, speaking generally, no aliment is unhealthy that is of an agreeable taste ; nor is any thing ill-tasted that is fit for the food of man. We here fake no notice of ex- cess, by which the most healthy foods may be rendered prejudicial, nor of mineral preparations, which are not furnished by nature, but prepared by art. And hence the wisdom of Providence incites man to select the nutriment that is best fitted for his subsistence, equally by the pain of hunger and the pleasure of tasting. Man, how- ever, is often guided by instruction and example, as well as by his own instinct: but animals, which are destitute of such collateral aids, and have to depend upon their instinct alone, dis- tinguish flavours, as we have already observed they do smells, with a far nicer accuracy than mankind ; and, admonished by this correct and curious test, abstain more cautiously than man himself from eating what would be injurious. And hence herbivorous animals, whose vege- table food grows often intermixed with a great diversity of noxious plants, are furnished with much longer papillae and a more delicate struc- ture of the tongue than mankind, as they are en- dowed also with a more accurate sense of smell; both which, indeed, they jointly rely upon for the same purpose. The sense of taste, therefore, which possesses so close an analogy to that of smell, is subject to a similar train of specific diseases, and con- sequently the genus parageusis must contain three following species :— I. Parageusis Acuta. Acute Taste. 2.----------Obtusa. Obtuse Taste. 3.---------Expers. Want of Taste SPECIES I. PARAGEUSIS ACUTA. ACUTE TASTE. TASTE PAINFULLY ACUTE, OR SENSIBLE TO VOURS NOT GENERALLY PERCEIVED. The sense of taste, like that of sight, sn or hearing, is capable of acquiring a higher de- gree of accuracy by use : and hence those who are in the habit of tasting wines by this organ perceive a variety of flavours, or modifications of flavour, which another person, not versed in such trials, is insensible of. We also perceive that the nerves of taste, like those of every other sense, become exhausted, and consequently tor- pid, by much labour and fatigue. And hence the nicest discriminator, after having tried a va- riety of wines, spirits, or other pungent savours in quick succession, is far less capable of judg- ing concerning them, and has at last little more than a confused perception of gustatory excite- ment. Morbid acuteness' of taste, however, varies essentially from accuracy of taste : for, under particular states of irritation, pungent savours, of whatever kind, give equal pain to the tongue, which at the same time is altogether incapable of distinguishing between them. This painful acuteness may proceed from two causes : a morbid or excessive sensibility in the nerves of taste, or a deficient secretion of the peculiar mucus that lubricates the lingual papil- lae ; in consequence of which the latter are ex- posed in a naked state to whatever stimuli are introduced into the mouth. The former is some- times found, though for the most part only tem- porarily, in highly nervous and irritable constitu- tions, and especially during a state of pregnancy; the latter in certain morbid conditions of the stomach, accompanied with great thirst and a parched tongue. Both these causes, however, very frequently coexist; as in ulcerated sore throats, or other excoriations of the mouth, in which the papillae are in a state of the keenest excitement, while the tongue is sore, either from a defective secretion of mucus, or from its being carried off by a morbid and augmented action of the absorbents as fast as it is formed. In this state of diseased action, moreover, it not unfrequently happens that the mucus itself is secreted in a morbid condition ; and the palate, instead of being soft and smooth, be- comes harsh and rugous or furrowed, exquisite- ly irritable, and intolerant of the slightest touch or the mildest savours. I have sometimes met with this distressing affection, apparently as an idiopathic ailment, or at least unconnected with any manifest disease of the stomach or any other organ; and seemingly induced by a rheumatic pain from carious teeth. It is, however, far more frequently a symptom of dyspepsy, por- phyra, and chronic syphilis. In treating this affection, we should in the first instance direct our attention to the state of the stomach, and clear it of whatever sordes may probably be lodged there. This may some- times be done by aperients, but it will be the surest way to commence with an emetic. The local symptoms may, in the meanwhile, be relieved in two ways. First, by changing the nature of the morbid action, or exhaustinc the accumulated sentient power by acid or lJ astringent gargles, or a free use of the coldest water alone ; for which purpose also sage leaves 1, | and acrid bitters have often been employed with 256 NEUROTICA. [Cl. IV.—Ord. II. advantage. And next, the naked and irritable tongue may be sheathed with mucilages of vari- ous kinds, and thus a substitute be obtained for its natural defence. And in many cases, both these classes of medicines may be conveniently united. When the affection is a symptom of some other disease, as in the case of syphilis and scurvy, it can only be cured by curing the pri- mary malady. Carious teeth, if such exist, should be extracted; and if the palate be rugous or spongy, scarification should be employed. SPECIES II. PARAGEUSIS OBTUSA. OBTUSE TASTE. TASTE DULL AND IMPERFECTLY DISCRIMINATIVE. This species rarely calls for medical attention. It occurs sometimes idiopathically, and seems to be dependant on a defective supply of nerves, or nervous influence, subservient to the organ of taste. I have seen it under this form in various instances ; and as already observed, have found it connected in a few cases with obtuseness of smell. The patient has not been altogether with- out taste or smell, but both have been extremely weak and incapable of discrimination. In the case alluded to at the commencement of this genus, the individual could distinguish the smell of a rose from that of garlic, and the flavour of port wine from that of mountain or madeira ; but she could not discriminate between the odour of a rose and that of a lily, nor between the taste of beef, veal, or pork, and consequently gave no preference to either of these dishes. As a symptom, this affection occurs in almost all the diseases that are accompanied with hebe- tude of smell, as catarrh, hysteria, and several species of cephalaea. SPECIES III. PARAGEUSIS EXPERS. WANT OF TASTE. TOTAL INABILITY OF TASTING OR DISTINGUISH- ING SAVOURS. As an utter want of smell is sometimes a nat- ural or congenital effect, so in a few instances is an utter want of taste ; and unquestionably from the same cause, an absolute destitution of nerves Or nervous power subservient to the gusta- tory organ. This default is altogether immedi- cable : as is also for the most part the same when a result of palsy, general or local; though here stimulant gargles or masticatories, as mustard- seeds, horseradish, pyrethrum, and camphire, have sometimes succeeded in restoring action to the torpid nerves. When, however, it occurs, as it sometimes does, from a long use of tobacco, whether by smoking or chewing, or of other acrid narcotics, these stimulants will be of no use. In fevers, various exanthems, and inflamma- tions, this species exists temporarily, partly per- haps from a diminished or-morbid production of sensorial power, but chiefly from a conversion of the mucus of the tongue into a dry, hard, or tough and viscid sheath. And where there is much increased heat and action, the epithelium or cuticle of the tongue itself becomes often pe- culiarly thickened and coriaceous or leathery. Acids, in the form of gargles, are the pleasantest means of removing this morbid substance, but they will often succeed best if rendered viscid and converted into a soap by mixing with them a little almond-oil, which may at the same timo be sweetened with honey. GENUS V. P A R A P S IS. MORBID TOUCH. SENSE OF TOUCH OR GENERAL FEELING VITIATED OR LOST. Parapsis is derived from the Greek terms, irapa and aTtrouai, " perperam tango." The com- mon technical name for the genus is dysaesthe- sia, but not quite correctly; since this wcrd, as we have already had occasion to observe, is also employed to express morbid external sensation of any kind, whether of touch, taste, smell, sight, or hearing: while by Dr. Young it is equally applied to one at least of the faculties of the mind, as in dysasthesia interna, which he characterizes as " a want of memory, or confu- sion of intellect." This genus embraces three species as fol- low :— 1. Parapsis Acuta. Acute Sense of Touch or General Feeling. 2. ------Expers. Insensibility of Touch or General Feeling. 3.------Illuso- Illusory Sense of Touch or ria. General Feeling. [The skin is the principal seat of touch ; though modifications of this sense are said to reside in various mucous surfaces, and in the voluntary muscles. The power of distinguishing with the finest discrimination the tangible properties of bodies is certainly in the hand, and especially in the extremities of the fingers. " The nerves," says Mr. Mayo (Physiology, p.,402, 2d edit.), " which minister to the sense of touch, are the posterior roots of the spinal nerves, the large di- vision of the fifth, the nervi vagi, and the glosso- pharyngeal nerves. The body, the neck and occiput, and the limbs, are supplied by the spi- nal nerves; the face, temples, and fauces, by the fifth; the pharynx and oesophagus by the nervi vagi and glosso-pharyngeal nerves. It is remark- able, that the nerves of touch have ganglions near their origin."] SPECIES I. PARAPSIS ACUTA. ACUTE SENSE OF TOUCH. THE SENSE OF TOUCH PAINFULLY ACUTE, OR SEN- SIBLE TO IMPRESSIONS NOT GENERALLY PER- CEIVED. This species of morbid sensibility shows it- self under almost innumerable modifications ■ but the four following are the chief:— Gsn: V.—Spe. 1.] PARAPSIS ACUTA. 257 a Teneritudo. Soreness. B Pruritus. Itching. y Ardor. Heat. 6 Algor. Coldness. In the first variety, or that of soreness, there is a feeling of painful uneasiness or tenderness, local or general, on being touched with a degree of pressure that is usually unaccompanied with any troublesome sensation. This is often an idiopathic affection ; but more generally a symp- tom or sequel of fevers in their accession or first stage, inflammations, or external or internal violence, as strains, bruises, and spasms. It is not always easy to account for this feel- ing, and perhaps the cause is in every instance more complicated than we might at first be in- duced to suppose. It occurs where there is distention of the vessels, where there is contrac- tion of them, and where there is neither. Wher- ever it exists, however, it is a concomitant of debility, and may in many instances be regarded as the simple pain of debility, the uneasiness of an organ thrown off from its balance of health. The general health of the body depends in a very considerable degree upon the harmonious co- operation of its respective organs ; insomuch, indeed, that this harmony of action, as we had occasion to observe in the Physiological Proem prefixed to the present class, was supposed, by a distinguished school of ancient philosophers, and is still supposed by many physiologists of the present day, to constitute the principle of life itself. Regarded as a universal principle, the hypothesis is unfounded, though in many re- spects beautiful and plausible. Yet, notwith- standing that the life of the animal frame does not altogether depend upon an harmonious co- operation of the whole of the organs that enter into its make, much of the comfort of life has such a dependance ; and we trace the same principle in the minutest and comparatively most trivial parts of the animal functions, as mani- festly as in the largest and most complicated or- gans. Where every portion of a member, how- ever subordinate in itself, as a toe or a finger, works well or healthily, there is a feeling of ease and comfort; but wherever it works ill or with difficulty, there is a sense of disquiet, and, un- der peculiar circumstances, of tenderness or soreness. A change in the diameter of a ves- sel, whether by dilatation or contraction, provi- ded it be moderate and gradual, is accompanied with no uneasy sensation whatever; but if it either be violent or sudden, a feeling of soreness is a certain result. Warmth, gentle friction, and stimulants, as spirits, balsams, and essential oils, are of gen- eral advantage, wherever the kind of tenderness we are now describing occurs, and is uncon- nected with inflammation. The sense of itching, which may be defined a painful titillation, local or general, relieved by rubbing, is commonly a result of some mechani- cal or morbid irritant applied externally or inter- nally to the part affected; though sometimes, unquestionably, dependant upon a morbid sensi- bility of the nerves of feeling themselves. If the summit of the nerves or their extreme points Vol. II.—R be alone touched, the effect is tickling or tit- illation, as in the vellication of the skin by a feather; if it descend a little below the summit, it is accompanied with a vibratory feel which we call tingling, as when the beard of barley- corns creeps unobserved by us up the arms ; and if it reach still deeper, it is combined with a sense of piercing which we call pricking, as when the keen .hairs of several species of doli- chos or cowhage are handled or blown upon the skin by a light breeze. In many cases all these modifications of itch- ing are the effect of some acrimonious secretion on the surface of the body, or of an acrimonious change in the common matter of perspiration, in consequence of its lodging in the cutaneous fol- licles longer than it should do. The papulous efflorescences we shall have to treat of under the third order of the sixth class, will afford abun- dant examples of both these causes of itching, apparently produced by, or closely connected with, a morbid sensibility of the cutaneous nerves themselves. For the present we can do noth- ing more than refer generally to various species of exormia, as lichen and prurigo ; and of ec- pyesis, as impetigo and scabies. It is, more- over, highly probable, that the disorder called fidgets is sometimes chiefly dependant on a morbid sensibility of the summits or extreme ends of the cutaneous nerves. This affection is also found as a very trouble- some symptom in pernio and other cutaneous inflammations, as likewise in urticaria and other rashes. The sensations of heat and cold may be ex- plained at the same time. An easy and pleas- urable warmth depends, in a state of health, upon a moderate temperature of the atmosphere, which cannot he very accurately laid down, be- cause, from habit or constitution, or some other circumstance, different persons enjoy very dif- ferent temperatures. Now it is the well-known property of heat and cold to disturb the temper- ature, whatever it may be, that affords ease and comfort to the nerves of feeling; and to produce disquiet as they either raise or depress it. And this both of them do in two distinct ways. Heat is a strong irritant, and even if it made no change in the bulk of a living organ, or the jux- taposition of its particles, like all other irri- tants, it would still excite a troublesome feeling, amounting at length to acute pain, if raised to a considerable range beyond the ordinary scale. But it does, in every instance, excite a change in the bulk of living organs and the juxtaposition of their particles ; for it enlarges the former in every direction, and only does this by separating the particles from each other ; in which forcible and sudden divellication we have a second source of the troublesome and acute sensation which so constantly accompanies a temperature when carried very considerably above the point of health.* * The effects of heat upon the human body are partly influenced by the state of the innervation at the period of its application. This is illustrated by a fact mentioned in Mr. Earle's Essay on 258 NEUROTICA. [Cl. IV.—OrD. JI. Heat, as an idiopathic affection, occurs chiefly in plethoric and irritable habits. In the former it is relieved by bloodletting, and evacuants of neutral salts ; in the latter by mild diaphoretics, and afterward cold bathing and other tonics. As a symptom it is found also in the second stage of fever, in inflammation, and entonic em- pathema. Cold is also a strong irritation, though it acts by the opposite means of heat. When the at- mospheric temperature is too high, it is a pleas- ant and reviving agent, inasmuch as it both re- duces the heated medium, and restores the par- ticles of the affected organ from a state of dis- quieting tenseness to their usual scale of approx- imation. If the cold be pushed farther, it may go a little beyond this, and still be pleasant and healthful; for the organ or the general system may be in a state of morbid relaxation, and con- sequently, in their actual scale of approach, the living particles may be too remote for the pur- poses of high elasticity and vigour. And it is in such a condition as this that cold chiefly shows its stimulant power, and is so generally resorted to as a tonic. But if the agency of cold be car- ried farther than this, it produces uneasiness to the nerves of feeling by a process precisely the reverse of that we have just shown to be pursued by heat, and consequently in a twofold manner. First by sinking the warmth of the organ, or of the system, below its scale of ease and comfort; and next, by forcing the living particles into too close and crowded a state, and not allowing them sufficient room for play. Cold, as an idiopathic affection, is chiefly lo- cal, and most common to the head and feet. It is temporarily relieved by warmth and stimulants, and particularly by the friction of a warm hand ; and, where it can be used, the exercise of walk- ing. It is permanently relieved by the warmer tonic's, as sea-bathing and aromatic bitters. Considerable mischief has often been produ- ced by a sudden exposure of the feet to severe cold, and especially in delicate and irritable hab- its, unused to such applications: as colic, ce- phalaea, catarrh, fevers of various kinds, and, in a podagral diathesis, gout. But the application of severe and sudden cold to the head or stom- ach by drinking ice or cold water, and especially when the individual is heated and perspiring, has been followed with more alarming effects, and even with death itself. Mauriceau relates an instance of death produced during baptism, by applying to the head the water of the baptismal font.—(Tom. ii., 348.) But this must be a rare occurrence; while the fatal effects of drinking ice or iced water in a state of heat are innumer- able. It is observed by Dr. Fordyce (On Simple Fever, p. 168), and the observation is quoted Burns :—A lady met with a comminuted fracture of the clavicle, and severe injury of the shoulder, producing paralysis of the arm; and it was noticed, after the accident, that she could not put her hand into moderately warm water without redness, vesi- cation, and the other usual consequences of the application of high degrees of heat, being imme- diately excited.—Ed. and called curious by Dr. Darwin, " that those people who have been confined some time in a very warm atmosphere, as of 120 or 130 de- grees of heat, do not feel cold, nor are subject to paleness of their skins, on coming into a temperature of 30 or 40 degrees; which would produce great paleness and painful sensation of coldness in those who had been for some time confined in an atmosphere of only 86 or 90 de- grees." The cause is not difficult of explana- tion. The sensorial power is exhausted, and the nerves of feeling rendered torpid, by a long exposure to the heat of 120 or 130 degrees, and the turgid capillaries, whose dilatation produ- ces the general blush, lose their power of con- striction or collapse; while in a heat of 86 or 90 degrees neither of such effects takes place. Cold, as a symptom, is found in the first stage of fever, in syncope, hysteric syspasia, nausea, and atonic empathema; in all which the affec- tion is general. SPECIES II. PARAPSIS EXPERS. INSENSIBILITY OF TOUCH OR GEN- ERAL FEELING. the organ of touch totally impercipient of objects applied to it. Under this species, by some writers denom- inated amblyaphia, we may mention the two fol- lowing varieties :— a Simplex. Confined locally or generally Numbness. to the organ of touch : sometimes accompanied with uneasiness. B Complicata. Complicated with insensibility Complicated in- in several of, or all the other sensibility. senses. Occasional and local numbness is common to most persons. A tight bandage, or accidental pressure of one limb upon another, by obstruct- ing the communication or activity of the nervous influence, will often produce this, when the limb is commonly and emphatically asserted to be asleep. A very slight motion, however, takes it off, when the irregular transmission of the sensorial power, on its first return, produces a sense of pricking, as though a ball of needles were in the limb, and pushing in every direction. Where such numbnesses, however, occur without pressure or any manifest cause, they well deserve watch- ing and resisting by tonics or stimulants, local or general; for they clearly show a tendency to paresis, if not to paralysis. But there are some persons who possess by nature a numbness, or privation of the sense of feeling, in particular organs or parts of the sur- face, which appears to depend on a natural des- titution of the nerves of touch wherever such insensibility is to be found. And hence they are able, in such parts of the body, to prick or cut themselves, or to run pins to any depth below the skin, without pain. I have seen several stri- king examples of this peculiar affection. Some- times the numbness has been limited to a single limb, but common to the whole of it, as the hand for example, which at the same time has pos- Gkn. V—Spe. 3.] PARAPSIS ILLUSORIA. 259 sessed a full power of motion. Sometimes the insensibility has been universal, or extended over the whole surface. Lamarck relates a case in which this want of feeling was confined to the arm; but at the same time was so complete, that the man who laboured under it had no pain during the progress of a phlegmon; and who, on another occasion in which he broke his arm, felt nothing more than a crash, and merely thought he had broken the spade, he was at work with. Dr. Yelloly has described another inter- esting case in the third volume of the Medico- Chirurgical Transactions. The patient, aged 58, had been first affected in Jamaica about three years before, and the affection had become permanent. " The hands," says Dr. Yelloly, "up to the wrist, and the feet half way up the legs, are perfectly insensible to any species of injury, as cutting, pinching, scratching, or burn- ing. The insensibility, however, does not sud- denly terminate ; but exists to a certain degree nearly up to the elbow, and for some distance above the knee. He accidentally put one of his feet, some time ago, into boiling water, but was no otherwise aware of the high temperature, than by finding the whole surface a complete blister on removing it. The extremities are in- sensible to electrical sparks taken in every vari- ety of mode."* As an example of the second modification, or insensibility in the organ of touch, complica- ted with insensibility in several other senses, we may mention the following, which Sauvages has copied from the Academy Collections :— "The patient, a delicate young man, was sud- denly in the morning deprived equally of speech and of the sense of touch, without any assign- able cause or premonition. Punctured and pricked in different parts of his body, in his head, neck, back, shoulders, breast, arms, abdo- men, he felt nothing whatever, and even laughed at the singularity of the phenomenon ; as, with the exception of numbness and cutaneous in- sensibility, he laboured under no kind of disease. The complaint continued two days, and seemed to have yielded to venesection." Insensibility of touch, either simple or com- plicated, is also felt as a symptom in apoplexy, palsy, catalepsy, epilepsy, syspasia, and syncope. Where the numbness js complete and con- stitutional, it lies beyond the reach of medicine ; where it is recent and less extreme, it will often yield to friction alone, or with camphorated oil or spirits ; to heat, especially that of the warm bath ; ether, ammonia, and water, and the vol- taic stream, or small shocks of electricity. SPECIES III. PARAPSIS ILLUSORIA. ILLUSORY SENSE OF TOUCH. imaginary sense of touch, or general feel- ing, IN ORGANS THAT HAVE NO EXISTENCE. This is the pseudaesthesia of Ploucquet; and * In the case mentioned in the note to page 258 of the present volume, a paralytic state of the arm rendered it extraordinarily susceptible of the in- fluence of heat.—Ed. R2 ■■" X...V ■• is frequently found among persons that have suffered amputation ; who, for a long time after the loss of the separated limb, have still a sense of its forming a part of the body, and suffer in idea the same kind of pain, or other inconvenience, they endured before its removal. It proceeds from the close sympathy which peculiarly prevails between the extremities of the living fibre in all organs whatever, and which, as we have already had occasion to show, ex- tends also between the terminating links of va- rious chains of action that run into organs at a considerable distance from each other. Of the first we have an example in the constrictive pain produced in the glans penis, when the neck of , the bladder is irritated by the lodgment of a calculus upon it. So, if the fauces or upper end of the oesophagus be tickled by a feather, the stomach at the lower end will be excited to nausea and sickness ; and if the stomach itself feel suddenly faint and enfeebled, the rectum will at the same time give way, and involunta- rily discharge its contents. Of the second kind of sympathy, or that which shows itself between remote organs engaged in a common chain of action, we have a striking instance in the swel- ling of the mammae on the irritation of the ute- rus in pregnancy ; and we had occasion to point out another equally striking, when treating un- der the last class of several species of maras- mus, in which the chylific and assimilating or- gans, constituting the two extremities of the great chain of the nutritive function, maintain, on various occasions, a wonderful harmony both of energy and weakness.* And hence, in a diseased limb, the pain which originates in the part affected is often extended, or even transferred, by sympathy, to its tendi- nous extremities, where the morbid impression remains in many instances long after the dis- eased portion of it has been removed. Nor is this protraction of the impression to be won- dered at; for we are perpetually witnessing cases in which, when a morbid impression has once been established, it continues to manifest itself in the same manner. Thus, when dust has been blown into the eye, a sensation of pricking is just as much felt in the conjunctiva for some hours after the dust has been washed out, as when it was actually goading the tender tunic : and in like manner, when an ague has been once generated in the animal frame by an exposure to marsh miasm, the patient will be still subject for many weeks, or perhaps months, to the same return of febrile paroxysm, how widely soever he may remove from the tainted region, and thus free himself from the cause of the disease. In the case before us, the illusory feeling be- comes fainter by degrees, and as the affected fibres return to a healthy condition. And if in the meantime it be very troublesome, it may generally be relieved by a moderate use of nar- cotics. A like imaginary sensation is occasionally felt * Vol. ii., Cl. III., Ord. IV., Gen. III., Spe. 1, Marasmus Atrophia; and Spe. 3, M. Climacce- ricus. r " 260 NEUROTICA. [Cl.IV—Ord. H. as a symptom in hypochondrias, and va other mental affections ; in which ideas of and distress are mistaken for realities, and duce as severe a suffering.* GENUS VI. NEURALGIA. NERVE-ACHE. ACUTE SENSIBILITY AND LANCINATING PAIN IN THE COURSE OF ONE OR MORE BRANCHES OF NERVES IN AN ORGAN ; MOSTLY WITH AN IRREGULAR MOTION OF THE ADJOINING MUS- CLES ; RECURRENT IN SHORT PAROXYSMS, WITH INDETERMINATE INTERVALS OR REMIS- SIONS. The term neuralgia, from "tSpoj, "nervus," and SKyoi, "dolor," has been for many years * The history of Caspar Hauser, the individ- ual who, as is well known, was kept in a dungeon, separated from all communication with the world, from early childhood till about the age of seven- teen, and who was found at Nuremberg in 1828, presents a most wonderful instance of morbid ex- altation of the senses of seeing, hearing, tasting, and feeling. His biographer, the eminent Feuer- bach, remarks as follows:— " As to his sight, there existed in respect to him no twilight, no night, no darkness. This was first noticed by remarking that at night he stepped everywhere with the greatest confidence ; and that in darkplaces he always refused a light when it was offered to him. He often looked with astonishment or laughed at persons, who in dark places, for instance, when entering a house or walking on a staircase by night, sought safety in groping their way or in laying hold on adja- cent objects. In twilight, he even saw much better than in broad daylight. Thus, after sun- set, he once read the number of a house at the distance of 180 paces, which in daylight he would not have been able to distinguish so far off. To- wards the close of twilight, he once pointed out to his instructor a gnat that was hanging in a very distant spider's web. At a distance of certainly not less than sixty paces, he could distinguish the single berries in a cluster of elderberries from each other, and these berries from black currants. It has been proved by experiments carefully made, that in a perfectly dark night he could distinguish different dark colours, such as blue and green, from each other. " When at the commencement of twilight a com- mon eye could not yet distinguish more than three or four stars* in the sky, he could already discern the different groups of stars, and he could distin- guish the different single stars of which they were composed from each other, according to their mag- nitudes and the peculiarities of their coloured light. From the enclosure of the castle at Nuremberg, he could count a row of windows in the castle of Marloffstein; and from the castle, a row of the windows of a house lying below the fortress of Rothenberg. His sight was as sharp in distin- guishing objects near by, as it was penetrating in discerning them at a distance. In anatomizing plants, he noticed subtle distinctions and delicate particles which had entirely escaped the obser- vation of others. " Scarcely less sharp and penetrating than his sight was his hearing. When taking a walk in the fields, he once heard, at a distance compara- tively very great, the footsteps of several persons, s employed with great accuracy to express a divis- i ion of diseases which will probably hereafter be - found to be peculiarly numerous, and in some modification or other, to appertain to most of the organs of the animal frame. The term neuralgia has of late been employed by various nosologists to express this group of diseases, especially by Professor Chaussier of Paris, and Dr. Meglin of Strasburg. Yet, till of late, only the neuralgia of the face seems to have been known to any pathologist: M. Chaus- sier, however, has added the second of the pres- ent species, under the name of neuralgia plan- taris. Since the publication of the volume on Nosol- ogy, I have been consulted on a very striking disease of the same kind, occurring, with a few local peculiarities of feature, in the female breast; and we are hence put into possession of another and he could distinguish these persons from each other by their walk. He had once an opportunity of comparing the acuteness of his hearing with the still greater acuteness of hearing evinced by a blind man, who could distinguish even the most gentle step of a man walking barefooted. On this occasion he observed that his hearing had formerly been much more acute; but that its acuteness had been considerably diminished since he had begun to eat meat; so that he could no longer distinguish sounds with so great a nicety as that blind man. " Of all his senses, that which was the most troublesome to him, which occasioned him the most painful sensations, and which made his life in the world more disagreeable to him than any other, was the sense of smelling. What to us was entirely scentless, was not so to him.—The most delicate and delightful odours of flowers, for instance the rose, were perceived by him as in- supportable stenches, which painfully affected his nerves. " What announces itself by its smell to others only when very near, was scented by him at a very considerable distance. Excepting the smell of bread, of fennel, of anise, and of caraway, to which he says he had already been accustomed in his prison,—for his bread was seasoned with these condiments—all kinds of smells were more or less disagreeable to him. When he was once asked, which of all other smells was most agree- able to him ? he answered, none at all. His walks and rides were often rendered very unpleasant by leading him near to flower-gardens, tobacco-fields, nut-trees, and other plants which affected his ol- factory nerves; and he paid dearly for his recrea- tions in the free air by suffering afterward from headaches, cold sweats, and attacks of fever. He smelt tobacco when in blossom in the fields at the distance of fifty paces, and at more than one hundred paces when it was hung up in bundles to dry, as is commonly the case about the houses in the villages near Nuremberg. He could dis- tinguish apple, pear, and plum-trees from each other at a considerable distance, by the smell of their leaves. The different colouring materials used in the painting of walls and furniture, and m the dying of cloths, &c, the pigments with which he coloured his pictures, the ink or pencil with which he wrote, all things about him wafted odours to his nostrils which were unpleasant or painful to him. If a chimney-sweeper walked the streets, though at the distance of several paces from him, he turned his face shuddering from his smell. The smell of an old cheese made him feel Gem. VI] NEUI species, making the entire number three that have now exhibited themselves under precise and determinate characters. These species, therefore, are as follow :— 1. Neuralgia Faciei. Nerve-ache of the Face. 2.--------Pedis. Nerve-ache of the Foot. 3.--------Mammae. Nerve-ache of the Breast. unwell, and affected him with vomiting. The smell of strong vinegar, though fully a yard dis- tant from him, operated so powerfully upon the nerves of his sight and smell as to bring the wa- ter into his eyes. When a glass of wine was filled at table at a considerable distance from him, he complained of its disagreeable smell, and of a sensation of heat in his head. The opening of a bottle of champaign was sure to drive him from the table or to make him sick. What we call unpleasant smells were perceived by him with much less aversion than many of our per- fumes. The smell of fresh meat was to him the most horrible of all smells. When Professor Daumer, in the autumn of 1828, walked with Cas- par near to St. John's churchyard, in the vicinity of Nuremberg, the smell of the dead bodies, of which the professor had not the slightest percep- tion, affected him so powerfully that he was im- mediately seized with an ague, and began to shudder. The ague was soon succeeded by a fe- verish heat, which at length broke out into a vio- lent perspiration, by which his linen was thor- oughly wet. He afterward said that he had never before experienced so great a heat. When on his return he came near to the city gate, he said that he felt better; yet he complained that his sight had been obscured thereby. Similar effects were once experienced by him (on the 28th of Septem- ber, 1828), when he had been for a considerable time walking by the side of a tobacco-field. " Professor Daumer first noticed the peculiar properties of Caspar's sense of feeling, and his sus- ceptibility of metallic excitements, while he was yet at the tower. Here a stranger once made him a present of a little wooden horse and a small mag- net, with which, as the forepart of the horse was furnished with iron, it could be made to swim about in different directions. When Caspar was going to use this toy according to the instructions he had received, he felt himself very disagreeably affected; and he immediately locked it up in the box belonging to it, without ever taking it out again, as he was accustomed to do with his other playthings, in order to show to his visiters. When he was afterward asked why he did so, he said that that horse had occasioned him a pain which he had felt in his whole body and in all its members. After he had removed to Professor Daumer's house, he kept the box with the magnet in a trunk; from which, in clearing out his things, it was accidentally taken and brought into notice. The idea was suggested thereby to Professor Daumer, who recollected the occurrence that had formerly taken place, to make an experiment on Caspar with the magnet belonging to the little horse. Caspar very soon experienced the most surprising effects. When Professor Daumer held the north pole towards him, Caspar put his hand to the pit of his stomach, and drawing his waist- coat in an outward direction, said that it drew him thus; and that a current of air seemed to pro- ceed from him. The south pole affected him less powerfully; and he said that it blew upon him. Professor Daumer and Professor Herrmann made afterward several other experiments similar to these, and calculated to deceive him; but his feel- ings always told him very correctly, and even | ALGIA. 261 There can be little doubt that other organs besides these are subject to the same misaffec- tion ; and it is not improbable that accident or a minuter investigation of the subject may show that almost every part of the body may become a seat of neuralgia. * M. Recamier has of late met with a painful and intractable disease of the though the magnet was held at a considerable distance from him, whether the north pole or the south pole was held towards him. Such experi- ments could not be continued long, because the perspiration soon appeared on his forehead, and he began to feel unwelL "In respect to his sensibility of the presence of other metals, and his ability to distinguish them from each other by his feelings alone, Professor Daumer has selected a great number of facts, from which I shall select only a few. In autumn, 1828, he once accidentally entered a store filled with hardware, and particularly with brass wares. He had scarcely entered before he hurried out again, being affected with violent shuddering, and saying that he felt a drawing in his whole body in all directions.—A stranger who visited him, once slipped a piece of gold of the size of a kreutzer into his hand, without Caspar's being able to see it: he said immediately that he felt gold in his hand.—At a time when Caspar was absent, Pro- fessor Daumer placed a gold ring, a steel and brass compass, and a silver drawing-pen, under some paper, so that it was impossible for him to see what was concealed under it. Daumer di- rected him to move his finger over the paper without touching it; he did so; and by the dif- ference of the sensation and strength of the at- traction which these different metals caused him to feel at the points of his fingers, he accurately distinguished them all from each other, according to their respective matter and form.—Once, when the physician, Dr. Osterhausen, and the royal crownfiscal, Brunner, from Munchen, happened to be present, Mr. Daumer led Caspar, in order to try him, to a table covered with an oil cloth, upon which a sheet of paper lay, and desired him to say whether any metal was under it; he moved his finger over it and then said, there it draws! ' But this time,' replied Daumer, ' you are nev- ertheless mistaken; for,' withdrawing the pa- per, ' nothing lies under it.' Caspar seemed at first to be somewhat embarrassed; but he put his finger again to the place where he thought he had felt the drawing, and assured them repeatedly that he there felt a drawing. The oil cloth was then removed, a stricter search was made, and a needle was actually found there.—He described the feeling which minerals occasioned him, a kind of drawing sensation which passed over him, accompanied at the same time with a chill, which ascended accordingly as the objects were different, more or less up the arm; and which was also at- tended with other distinctive sensations. At the same time, the veins of the hand which had been exposed to the metallic excitative, were visibly swollen. Towards the end of December, 1828, when the morbid excitability of his nerves had been almost removed, his sensibility of the influ- ence of metallic excitatives began gradually to disappear, and was at length totally lost."—D. * The editor has seen several examples of neu- ralgia of the arm, which arose from injuries of the thumb or fingers. M. Ribes has recorded a case of neuralgia of the external sciatic popliteal nerve, which disorder gradually extended its par- oxysms of violent pain, with convulsions of the | muscles, over the greatest part of the body. It 262 NEUROTICA. [Cl. IV—Ord. II. uterus, which he has regarded as of this kind, and has denominated uterine neuralgia, though he does not speak of it with much decision.* The corporeal senses which have hitherto passed within the range of our observations as the seats of different genera of diseases, are ex- ternal, and serve to convey impressions peculiar to themselves. It is, however, sufficiently known to every one, that there is not an organ in the body but is possessed of nerves productive of a very different kind of sensibility from any of these; less distinct perhaps and elaborate, but the index of its weal or wear, its comfort or dis- quiet ; and which may be sufficiently expressed by the name of general feeling. It is possible, indeed, that this general feeling may in some de- gree be differently modified in every organ ; but as the distinctions, whatever they may be, are not nice enough for us to trace out and arrange, as they are in the local senses, it is sufficient for all the purposes of pathology to regard this feeling as common to all the sentient organs, and con- sequently as one and the same. We have already taken some notice of it in the proem to the present class, and have observed that it has been described by some pathologists under the name of camesthesis, and by the Germans is denomi- nated Gemeingefiihl, or general feeling. Dr. Hubner published an inaugural dissertation on this subject in 1794, in which he enumerates its properties at some length.—(Commentatio de Caneslhesi Dissert. Inaug. Medica ; Auctore C. F. Hubner, 1794.) I have never seen this treatise, but Sir Alexander Crichton, who has, describes it as a very ingenious production. It is these nerves of general sensibility that seem to constitute the seat of disease in the three species we are now about to enter upon, and consequently indicate that the present rs their proper place in a system of physiological nosology, t SPECIES I. NEURALGIA FACIEI. NERVE-AC HE OF THE FACE. LANCINATING PAINS SHOOTING FROM THE REGION OF THE MOUTH TO THE ORBIT, OFTEN TO THE EAR, AND OVER THE CHEEK, PALATE, TEETH, AND FAUCES ; WITH CONVULSIVE TWITCH1NGS OF THE ADJOINING MUSCLES. This is the trismus maxillaris or t. dolorifi- eus of M. de Sauvages, for it is not necessary arose from a gunshot wound of the upper third of the leg, and resisted various medicines, the moxa, &c.; but was very materially relieved, though not completely, by the division and excision of a por- tion of the above nerve.—See Magendie's Journ. Exper. de Physiol., torn, ii., p. 343. See also cases of neuralgia in various situations, by Dr. Evans, in Edin. Med. Journ., No. lxxix., p. 278. * Tableau des Maladies observers a l'Hotel- Dieu, dans les Salles de Chniques, &c Par L. Martinet, Revue Medicale, &c, 1824. t Dr. Good's prophecy, "that accident or a minuter investigation of the subject may show that almost every part of the body may become a seat of neuralgia," is fully verified. In addition to those species of neuralgia mentioned by Dr. Good and the London editor, Itard has observed to make a distinction between them, as Sauvagea himself has done ; by Dr. Fothergill it is denom- inated dolor crucians faciei. As the French give the name of tic to trismus or locked-jaw, they distinguish this first species of neuralgia, affecting the nerves about the jaw, by the name of tic doloureux, by which term the disease is, perhaps, chiefly known even in our own country in the present day. I shall have occasion to observe more at large, under the genus tris- mus, that the word tic is commonly supposed to be an onomatopy, or a sound expressive of the action it imports; derived, according to some, from the pungent stroke with which the pain makes its assault, resembling the bite of an insect; but according to Sauvages and Soleysel, from the sound made by horses, that are perpetually biting the manger when labour- ing under this peculiar affection. We do not, however, appear to be acquainted with the real origin of the term. From the symptoms by which this complaint is distinguished, it is not difficult to decide con- cerning both its seat and nature. The char- acter of the pain is very peculiar, and its course corresponds exactly with that of the nerves. The second branch of the fifth pair is perhaps more frequently affected than either the first or the third. But the portia dura of the seventh pair, which is distributed more extensively upon the face, under the name of pes anserina, is more frequently the seat of affection than any of the branches of the fifth pair seem to be ; which is a matter of no small regret, as it is difficult for any operation to reach this quar- ter effectually, although it is a difficulty which we shall presently find has, in one instance at least, been encountered and surmounted. When, however, the disease is seated in the seventh pair of nerves, we can be at no loss ]to decide concerning it, in consequence of the course and divarications of the pain, which com- mences with great acuteness in the forepart of the cheek, towards the mouth and alae of the nose, sometimes spreading as high as the fore- head, and ramifying in the direction of the ears. At other times, the forehead, temple, and inner angle of the eye on the side affected, and even the ball of the eye itself, form the chief lines of pungent agony, while, from irritation of the lachrymal gland, the eye weeps involuntarily. In this case we may reasonably suspect the dis- ease to be seated in some part of the superior maxillary nerve, constituting the second branch of the fifth pair. And it is hence obvious, that the radiation of the pain must vary accord- ing to the nerves or nervous twigs that are affected.* neuralgia of the ear; Siebold that of the intercostal nerves; Chaussier and Jadelot in the first lumbar nerve; Francis and Barras in the spermatic nerve; and Cotugno and Chaussier in the anterior crural nerve. Boisseau has described a still greater number of neuralgic affections.—See his Nosographie Organique, vol. iv., p. 714.—D. * Some practitioners, remembering that the portio dura is only a nerve of motion, consider it doubtful whether this nerve is ever truly the seat 1 of neuralgia. One of Dr. Elliotson's patients, Gen. VI.—Spe. 1.] NEURALGIA FACIEI. 263 The disease has been occasionally mistaken for rheumatism, hemicrania, and toothache : but the brevity of the paroxysm, the lancinating pungency of the pang, the absence of all in- tumescence or inflammation, the comparative Shallowness, instead of depth, of its seat, and its invariable divarication in the course of the facial nerves or their offsets, will always be sufficient to distinguish it from every other kind of pain. Of its exciting causes we know but little. It seems sometimes to have been produced by cold, and sometimes by mental agitation, in per- sons of an irritable temperament. But it has been found in the robust as well as in the deli- cate, in the middle-aged as well as in the old. In a few cases the irritation has been local, of which Mr. Jeffreys has given a very striking in- stance in a young woman, who, when only six years old, fell down with a teacup in her hand, which was hereby broken, one of the cheeks lacerated, and a fragment of the teacup imbed- ded under the skin. The wound healed, though slowly and with difficulty ; the buried fragment of the teacup was not noticed, and consequently was not extracted. From an early period, a violent nervous pain returned nightly, and one side of the face was paralytic. These dreadful symptoms were endured for fourteen years : at the end of which time an incision was made through the cicatrix down upon what was then found to be the edge of a hard substance, and which appeared, when extracted, to be the piece of the teacup above noticed. From this time the neuralgia and paralysis ceased ; the af- fected cheek recovered its proper plumpness, and the muscles their due power.* It is possible, as suggested by M. Martinet, that as a symptom, it may sometimes occur in what he calls, and perhaps correctly, an inflam- mation of the nerves, or a thickening of the neurilemma in some particular organ, of which he has given various examples, accompanied with a reddish or even violet tinge, and studded with minute ecchymoses. + But that this is not however, complained of the disorder not only in the cheek, but in the course of the portia dura from the stylo-mastoid foramen. Two, or even all the three branches of the fifth pair may be affected, and the pain may extend also to the other side of the face. Dr. Elliotson has known it extend down the neck to the shoulder, and along the in- side of the arm to the ends of all the fingers and the thumb. Various nerves of the legs, arms, fin- gers, or toes, are occasionally the seat of the dis- ease ; and an intercostal, a lumbar, and even the spermatic nerve, have been attacked. The pain does not always shoot in the course of the nerve, but frequently in the opposite direction.—See Cyclop, of Pract. Med., art. Neuralgia.—Ed * Lond. Med. and Phys. Journ., March, 1823, p. 199. Sir Henry Halford mentions the case of a lady who suffered violent tic doloureux till an apparently sound tooth was extracted, on account of the attacks being frequently preceded by unea- siness in it: an exostosis was found at its root. Another case was relieved by an exfoliation of a portion of the antrum.—Ed. f Memoire sur l'lnflammation des Nerfs, &c. the only, or even the ordinary proximate cause, is clear, since, in the cases alluded to, pressure upon the part is intolerable, while in idiopathic neuralgia it is commonly consolatory, and con- siderably diminishes the agony. Andre appears to have been the earliest writer who remarked this painful affection with accuracy ; and he succeeded in removing it per- manently by applying a caustic to the infra-or- bitary or maxillary branch of nerves in one case in which a previous division of the nerve by the scalpel, as practised by Marechal, had produced only a temporary cure. Andre, who resided at Versailles, published his account in 1756, whimsically enough inserting it in a treatise on diseases of the urethra. A few unsatisfactory experiments and operations were given to the public in the course of the next fifteen years, chiefly by French practitioners, from which little of real value is deducible. In 1776, Dr. Foth- ergill, in the fifth volume of Medical Obser- vations and Inquiries, communicated a very full and elaborate description and historyof the dis- ease : since which time M. Thouret and Pujol have each published a valuable paper on the same subject, in the Memoirs of the Society of Med- icine of Paris, containing various cases col- lected and described with great minuteness; and we have already adverted ta the more re- cent publications of Dr. Meglin and Professor Chaussier. It has of late been suspected, that in some cases, at least, of this disease, the seat of irrita- tion might be at the origin instead of at the ex- tremity of the nerve ; an idea that has arisen from the powerful sympathetic action mani- fested by the eye and the stomach* forming the boundaries of the chain, upon which subject we shall have to speak at large when treating the genus entasia in the ensuing order " The nerves," remarks Dr. Parr, " that supply the eye externally, and the slight connexion of the intercostal with the brain, are nearly from the same spot in the cerebrum, and it did not seem improbable in the case alluded to, that the dis- ease may have really been at the origin of the nerves, although felt as usual at its extremity." Dr. Parr was in consequence induced to try arsenic, and in one instance, he tells us, with a decidedly good effect. It is also said to have 1824. Also, cases by Evans in Edin. Med. Journ., No. lxxix., p. 282. * Dr. Elliotson assures us that he has never seen one case of neuralgia referrible to disorder of the digestive organs.—(See Cyclop, of Pract. Med., art. Neuralgia.) Where inflammation is obvious, whether rheumatic or not, he approves of local bleeding, mercury, colchicum, and antiphlogistic treatment in general. Should these means fail, he recommends anodynes to be added to them. When the complaint is rheumatic, but inflamma- tory, he approves of stimulants, internal and ex- ternal, especially ammoniated tincture of guaia- cum, a generous diet, tonics, mercury, and all modes of counter-irritation. In some cases, warm temperature and warm clothing seem essential; in some, the warm water or steam bath; and in others, the cold bath, followed by friction, answer best.—Ed. 264 NEUKt been since found serviceable in a few other cases. In Mr. Thomas's hands, however, we shall presently perceive that it completely failed. Mercury is also reported to have occasionally proved successful, and especially when carried to the extent of salivation ; though in numerous instances it has been tried even to this last effect without any benefit whateyer. [Some cases of facial neuralgia have been cured by ap- plying a drop or two of the oil of croton to the tongue.—(Med. Chir. Review, Sept., 1821.) The effect on the nerve was almost instanta- neous. Bark, and the sulphate of quinine,* have also been tried with various results.] When, about thirty years ago, animal magnet- ism was a fashionable study in France, it was had recourse to for this disease among others, and had its day of favour as a popular remedy. —(Edin. Med. and Surg. Journ., July, 1823.) Of late, however, neuralgia has been attempted to be cured in France by an external use of acetic ether ; while in Germany Dr. Meglin has employed pills composed of the extract of hen- bane,! and sublimed oxyde of zinc, and according to his own statement, with great success. But, beyond controversy, one of the most valuable medicines that have hitherto been tried is the subcarbonate of iron, for the first use of which, so far as I know, we are indebted to the late Mr. Hutchison,^ of Southwell, who commonly employed it in doses of a drachm three times a day. [Dr. Borthwick, however, has found the last * Obs. de Neuralgie sus-orbitaire droite, guerie par le Sulfate de Quinine, par M. Piedagnel. Magendie, Joum. de Physiologie Exper., torn, ii., p. 124. t The best anodyne narcotics for trial in cases of neuralgia, are the acetate, muriate, or sulphate of morphine, and the extracts of stramonium and belladonna. The editor has known great relief produced by the application of a plaster to the in- teguments covering the painful nerves, which was composed of one or two drachms of the extract of belladonna and an ounce of soap cerate.—Ed. X Cases of Neuralgia Spasmodica, &c, by B. Hutchison, &c, 8vo., Lond., 1825. Numerous examples of the utility of subcarbonate of iron are now on record, and Dr. Elliotson adduces his tes- timony in favour of its efficacy in chronic neural- gia. When there is debility, and especially pale- ness, iron in full quantities operates much more effectually, he says, than quinine. Should no structural nor mechanical cause, and no inflam- mation, be present, and should the disease be of the exquisite character, he deems iron the remedy most worthy of trial. Although the doses spe- cified in the text sometimes succeed, it is found that children will often take an ounce or six drachms every four hours. If given in twice its weight of treacle, Dr. Elliotson finds that it rarely constipates; but the bowels must always be kept open during its employment, for otherwise it is apt to accumulate in the intestinal canal in large masses.—(See Cyclop, of Pract. Med., art. Neu- ralgia.) Ice applied to the parts has sometimes been of service.—See Med. Chir. Trans., vol. xiii., p. 252; and Cyclop, of Pract. Med. Also, Crawford, in Med. Chir. Review; Dr. Belcher's case of neuralgic amaurosis, successfully treated by the carbonate of iron.—Edin. Med. Journ., No. lxxxvi.,p. 37.—Ed. OTICA. [Cl. IV.—Ord. II. plan so successful, and his confidence in it is such, that he regards the point now almost set- tled in practice, " that iron will relieve, if not cure, tic doloureux (neuralgic affections, gener- ally speaking), as certainly and as speedily as quicksilver, in particular forms, will relieve and cure the lues venerea." The dose which he gives in severe cases, is one drachm and a half four times a day.—(See Edin. Med. Journ., No. lxxxiii., p. 297.)] The instances of success appear to be very numerous, though this also, like all other medi- cines, has often failed. But there is another energetic medicine, which has also a fair claim to attention from a very different property— that of subduing the sensibility; and this is piussic acid. Mr. Taylor, of Cricklade, Wilts, has made repeated trials of this powerful seda- tive in various cases, and apparently with more rapid relief than is afforded by the carbonate of iron. He commenced his career with a drop of Scheele's preparation, in twenty-four hours, in divided doses ; but as he grew better acquainted with the effects of the medicine, he gave a drop for a dose at first, and then increased the dose to two drops, repeating it three times a day. In one or two instances he has carried the quan- tity, by a gradual augmentation, to twenty-four drops a day, in the course of a month's use ; and very often to five and six drops a day, by adding a drop to every day's account.—(Edin. Med. and Surg. Journ., July, 1823.) Time alone must determine whether the cures thus obtained will prove as permanent as those ef- fected by the tonic power of the subcarbonate of iron. To induce ease, however, under any circumstances, and for any period of time, in the midst of so much torment, is an invaluable blessing. In effect, neither narcotics nor tonics, nor any other class of medicines hitherto employed, can be in every case depended upon for a radi- cal cure, though some of them, and particularly the subcarbonate of iron, are worthy of high commendation. "My father," says Dr. Perce- val of Dublin, in his manuscript .comment on the present author's Nosology, " was subject to neuralgia faciei for several years, and used a variety of medicines without relief. He was worse in close damp weather, and much worse when his mind was occupied. At length he had an issue inserted in the nucha, kept his bowels free with James's analeptic pills, and exchanged a town residence for the country. In this situa- tion he soon threw off the disease, from which he was free for a considerable time before his death." Change of scene, a transfer of morbid action, and a recruited cheerfulness of spirits, are valuable auxiliaries in the present as in every other nervous affection; but I much question whether these alone have ever operated a cure. A spontaneous cure is the work of time alone; and time, though often a long and te- dious period is requisite, will generally accom- plish it, and probably did so in the case before us. The fact is, that the nervous system in every part, and every ramification, becomes gradually torpefied by excess of action ; and as Oen. VI.-Spe. 1] NEURALG the eyes grow blind and the nostrils inolfacient by strong stimulants applied to them, so the nervous twigs of every kind, after a long series of irritation from the present disease, become exhausted of power and obtuse in feeling: and it is probably by hastening this state, that the most active stimulants and the warmer tonics produce whatever benefit is tobe ascribed to them. [In the treatment of various cases of neural- gia, Baron Larrey was very successful with the moxa, which he repeated the application of ac- cording to circumstances. Delpech used the actual cautery, and after the separation of the eschar, kept up a discharge for a long time.] How far acupuncture or needle-pricking, the zin-king of the Chinese, which we have already described under chronic rheumatism, might be useful, has not yet been determined. It has at least a fair claim for experiment, before having recourse to a curative attempt by the knife. This radical cure consists in a division of the affected branches, provided they can be followed home. Dr. Haighton completely succeeded, some years ago, in a case in which he divided the sub-orbital branch of the fifth pair ; and Mr. Cruickshank and Mr. Thomas more recently in a case of considerable complication, and where the affection was evidently not confined to the different branches of any single nerve. This last case is given by Dr. Darwin, whom the pa- tient had intermediately consulted, in the second part of his Zoonomia, and is one of the most interesting sections of the work. The patient, a Mr. Bosworth by name, was between thirty and forty years of age. When he first applied to Dr. Darwin, he complained of much pain about the left cheek-bone. Dr. Darwin sus- pected the antrum maxillare might be diseased ; and as the second of the grinding teeth had been lately extracted, directed a perforation into the antrum, which was done, and the wound kept open for two or three days without advan- tage. Afterward, by friction about the head and neck with mercurial unguent, he was for a few days copiously salivated, and had another tooth extracted by his own desire, as also an in- cision made in such direction as to divide the artery near the centre of the ear next the cheek, which gave also a chance of dividing a branch of the affected nerve; but without success. When the pain was exceedingly violent, opiates were administered in large quantity; bark being used freely in the,intervals, but without effect. The pain spread in various directions from a point in the left cheek a little before the ear, sometimes to the nose, and forepart of the lower jaw, and sometimes to the orbit of the eye on the same side ; the under part of the tongue being at times also affected. It re- turned on some days many times in an hour, and continued several minutes ; during which period (it is well worth observing, as showing the con- nexion between an irregular sensitive and an irregular motive power in the same muscles) the patient, says Dr. Darwin, seemed to stretch and exert his arms, and appeared to have a ten- dency to epileptic actions, so that his life was rendered miserable. The complaint gradually [A FACIEI. 265 grew worse, and Mr. Bosworth removed to London, for the purpose of again putting himself under Mr. Cruickshank's care, and of submitting to any operation he should recommend. The pain was now intolerably acute and almost un- remitting ; and opiates afforded him little or no relief, though taken to the quantity of six tea- spoonfuls of laudanum at a time. The opera- tion of dividing the diseased nerve was therefore determined upon. " As the pain," says Mr. Thomas, in his let- ter to Dr. Darwin after its completion, " was felt more acute in the left ala of the nose and the upper lip of the same side, we were induced to divide the second branch of the fifth pair of nerves as it passes out at the infra-orbital fora- men. He was instantly relieved in the nose and lip ; but towards night the pain from the eye to the crown of the head became more acute than ever. Two days after, we were obliged to cut through the first branch passing out at the supra-orbital foramen: this afforded him like relief with the first. On the same day the pain attacked, with great violence, the lower lip on the left side, and the chin: this circum- stance induced the necessity of dividing the third branch, passing out at the foramen men- tale. During the whole period, from the first division of the nerves, he had frequent attacks of pain on the side of the tongue ; these, how- ever, disappeared on division of the last nerve. " The patient was evidently bettered by each operation: still the pain was very severe, pas- sing from the ear under the zygoma towards the nose and mouth, and upwards round the orbit. This route proved pretty clearly that the portio dura of the auditory nerve was also affected, at least the uppermost branch of the pes anserina. Before I proceeded," continues Mr. Thomas, "to divide this—Mr. Cruickshank had operated hitherto—I was willing to try the effect of arsenic internally; and he took it in sufficient quantity to excite nausea and vertigo, but with- out perceiving any good effect. I could now trust only to the knife to alleviate his misery, as the pain round the orbit was become most vio- lent ; and therefore intercepted the nerve by an incision across the side of the nose, and also made some smaller incisions about the ala nasi. To divide the great branch lying below the zygomatic process, I found it necessary to pass the scalpel through the masseter muscle till it came in contact with the jaw-bone, and then to cut upwards: this relieved him as usual. Then the lower branch was affected, and also divided : then the middle branch running under the parotid gland. In cutting this, the gland was consequently divided into two equal parts, and healed tolerably well after a copious dis- charge of saliva for several days. " I hoped and expected that this last opera- tion would have terminated his sufferings and my difficulties; but the pain still affected the lower lip and side of the nose, and upon cough- ing or swallowing his misery was dreadful. This pain could only arise from branches from the second of the fifth pair passing into the cheek, and lying between the pterygoideus in. 266 NEUROTICA. [Cl. IV—Ord. II. ternus muscle and the upper part of the lower jaw. The situation of this nerve rendered the operation hazardous, but, after some attempts, it was accomplished." This finished the series of operations, and restored the afflicted patient to perfect health. I have dwelt the longer on this interesting case, because it seems to show, first, that there is occasionally no certain cure but in the use of the knife ;* secondly, that a delay in per- forming the operation only affords time for the disease to spread from one branch of the affected nerve to another, and even to different branches of nerves in a state of contiguity ; and thirdly, that the disease betrays the spasmodic character of the diathesis when minutely watched, even in cases in which this character is most obscure. Dr. Darwin objects, properly enough, to arran- ging this disease as a trismus, " since no fixed spasm," says he, " like the locked-jaw, exists in this malady." He adds, indeed, that in the few cases he has witnessed, there has not been any convulsion of the muscles of the face ; but in Mr. Bosworth's case he has expressly noticed the morbid stretching of the arms, and the ten- dency to epileptic actions. Its proper place, however, seems to be where it is now arranged. SPECIES II. NEURALGIA PEDIS. NERVE-ACHE OF THE FOOT. RACKING AND LANCINATING PAINS RANGING ABOUT THE HEEL, AND TREMULOUSLY SHOOT- ING IN IRREGULAR DIRECTIONS TOWARDS THE ANKLE AND BONES OF THE TARSUS. This is the neuralgia plantaris of Professor Chaussier; who mentions a very decided case of it, to which Dr. Marino, a physician of Pied- mont, had been long subject. It commenced, he tells us, in early life; was relieved by the mineral waters of Vivadio, and still more by the pressure of a tight bandage. With advan- cing years it became less severe, the cause of which we have already explained in the prece- ding species, but never ceased altogether. It al- ternated with other nervous affections, and was at length complicated with convulsive asthma. In calling the attention of the medical pro- fession to this species, by introducing it into the volume of Nosology, so long ago as the be- ginning of 1817, I had my eye directed to a very marked case, which had then lately oc- curred to me in a clergyman of this metropolis, about forty-five years of age, but otherwise in firm health and cheerful spirits. He had for many years been a victim to it. The paroxysms were short, and of uncertain recurrence, but so acute as nearly to make him faint, and at length compelled him to relinquish the duties of the ulpit, for which, from his zeal and eloquence, e was admirably qualified, but where he had frequently been obliged to break off with great abruptness from the unexpected incursion of a * As this expression may induce young practi- tioners to promise too much from the operation, the editor deems it right to mention that the knife has frequently failed. fresh paroxysm. The pain usually extended up the calf of the leg towards the knee, and rami- fied towards the toes in an opposite direction; and was usually compared by himself to that of scalding verjuice poured over a naked wound. The tibial branches of the popliteal nerve, and particularly the plantar twigs, seem in this spe- cies to have been the part chiefly affected, though it is probable that some of the offsets from the peroneal branch associated in some instances in the morbid action. Every therapeutic process that the art of medicine in the hands of the most experienced physicians of this metropolis could devise, was in this case tried, in a long and tedious succes- sion, in vain. Sometimes external and some- times internal preparations, or a tight ligature, appeared to afford a temporary alleviation, and to protract the intervals: but never any thing more. Tt was in consequence proposed by a surgeon of great eminence to amputate the leg, which was at one time on the point of being submitted to, though protested against by the present author on two accounts. First, the uncertainty whether the morbid condition of the nerve might not be seated chiefly in its origin instead of in its extremity, in which case am- putation could be of no avail; and secondly, the chance, that in process of time the keen sensi- bility of the affected branches would be worn out and obtunded by the violence of the action. Such was the undecided and miserable condi- tion of this patient at the time of noticing his case on the publication of the author's volume of Nosology. Since this period, the prediction that the disease would gradually wear itself out has been completed : the paroxysms are now slight and tolerable, and the intervals much longer: and the patient has for nearly a twelve- month been able to resume the duties of his profession without any interruption. SPECIES III. NEURALGIA MAMMAE. NERVE-ACHE OF THE BREAST. SHARP, LANCINATING PAINS, DIVARICATING FROM A FIXED POINT IN THE BREAST, AND SHOOT- ING EQUALLY DOWN THE COURSE OF THE RIBS AND OF THE ARM TO THE ELBOW ; THE BREAST RETAINING ITS NATURAL SIZE, COMPLEXION, AND SOFTNESS. About the year 1820,1 was requested by Mr. Blair to examine a young woman, then eighteen years of age, who for more than two years had been subject to a painful disorder of the breast, that seemed equally to defy all parallel and all modes of treatment. On examining into the na- ture of the symptoms, I found them as descri- bed in the preceding definition. The organ was full-formed, soft, and globular, without the slightest degree of inflammation or hardness. When the paroxysm of pain was not present, it would bear pressure without inconvenience; but during the pain, the whole breast was acute- ly sensible. The paroxysms returned at first five or six times in the course of the day, and were short and transient : but as the disease Gen. VI.—Spe. 3] NEURALG1 became more fixed, it became also more severe and extensive ; for the agonizing fits at length recurred as often as once an hour, and some- times more frequently ; and, from being com- paratively concentrated, the lancinating shoots darted both downward in the course of the cir- cumjacent ribs, and upwards to the axilla, whence they afterward descended to the elbow, below which I do not know that they proceeded at any time. These fits were at length so frequent and vehement as to imbitter her whole life, and incapacitate her from pursuing any employment; for it frequently happened, that if she attempted needlework, her fingers abruptly dropped the needle a few minutes after taking hold of it, from a mixture of pungent pain and tremulous twitching. The twitching or snatches in the shoulder, for it at length reached to this height, were at one time so considerable as to give the patient an idea, to use her own words, that something was alive there ; while, though the lacinating pain did not descend below the elbow, a considerable degree of trepidation reached oc- casionally to her fingers' ends. Her general health was in the meantime unaffected, and she was regular in menstruation.* I had no hesitation in regarding this as a non- descript species of neuralgia; and as little in communicating my fears that no plan of medi- cine we could lay down would be more than palliative, even if it should prove thus far bene- ficial, and that we must trust to time alone for a cure, and that obtuseness of sensibility, which I have already noticed as a common conse- quence of high nervous irritation, continued till the organ becomes exhausted and torpefied. Every remedial process was nevertheless tried in series for the purpose of obtaining re- lief, if not full success. Bleeding, local and general, frequently and profusely repeated ; pur- gatives of all kinds ; tonics and antispasmodics of every sort; the hot and cold bath ; electri- city and galvanism in every form ; rubefacients, blisters, setons, issues, and whatever else could be suggested, were enlisted into service in suc- cession. But every thing was equally without avail; nor do I know that even a temporary re- lief was obtained by any of these. Narcotics of all kinds proved impotent: drowsiness, indeed, and a comatose stupor, were hereby in various instances obtained, but the interval of wakeful- * Many good practical observations on this sub- ject will be found in Sir Astley Cooper's Illustra- tions of the Diseases of the Breast, chap. ix.,part L, 4to., Lond., 1829. "The breast," says he, " is liable to become irritable without any distinct or perceptible swelling, as well as to form an irrita- ble tumour composed of a structure unlike that of the gland itself, and which, therefore, appears to be a specific growth. Both states of disease, in the greatest number of examples, occur in young persons from the age of 16 to 30 years. I have never witnessed it prior to the commencement of puberty."—(P. 76.) The suffering increases very much just as menstruation is about to take place; it is somewhat relieved on-the evacuation occur- ring, and decreases on its cessation. An opera- tion, when there is no distinct tumour, must be en- tirely out of contemplation.—Ed. I MAMMAE. 267 ness was as much as ever tormented with the same racking paroxysms. From the powerful influence of nux vomica in many cases of ner- vous affection, to some of which we shall have occasion to advert hereafter, I had some hope of producing a slight impression on the nerves affected ; but the hope proved illusory : the pa- tient took it in infusion as far as to about eight grains at a dose three or four times a day, till her head was intolerably confused, and every other part became numb ; but the paroxysms were intractable. The poor sufferer, whose relations were inca- pable of affording the resources of private prac- tice, tried one dispensary after another, and at length one of the largest hospitals of this me- tropolis, without the smallest benefit, and from each was discharged as incurable. About six months since, however, being nearly four years from the commencement of the disease at home, and having utterly relinquished all medical means, with the exception of a seton under the breast, which was not dried up, she began to think herself rather better, and has continued to improve ever since, till a week ago, when her mother came to inform me she was worse again. This intelligence greatly surprised me, till I learned that the seton was now quite healed. It has since been opened, and there is a hope of her again improving.* * Since the time of Fothergill, neuralgia has been noticed by many physicians and surgeons in this country. Prof. James Jackson, of Boston, seems to have been the first who wrote at any length on the subject, and according to him, little attention was paid to it prior to his publication in 1813: the remarkable case of the late Dr. Jones of New-York, who died from neuralgia, had how- ever already appeared in the Phil. Med. Museum of 1809, and Dr. Hosack remarks, that he had re- peatedly encountered this disease many years be- fore.—Am. Med. and Phil. Reg., vol. iv. At the present day it is unfortunately not uncommon, and seems to be more frequent in females than in males. In regard to treatment, although the division of the nerve may at times prove successful, yet sur- gery must surrender her claims to the physician in removing this calamity. From carefully exam- ining the recorded cases of neuralgia, if we except those from mechanical injury we are led to con- clude that in many instances it is constitutional, and hence that the treatment must be conducted with reference to the whole system. Among par- ticular remedies, the datura stramonium is in more repute among American physicians than conium or belladonna, and the arsenical solution is some- times employed with success. Dr. Hosack has on several occasions prescribed the volatile tinc- ture of guaiacum with good effect. Dr. James Jackson, pursuing the suggestions of Fothergill. has administered three hundred grains of conium in six hours: the patient was cured. The carbon- ate and phosphate of iron, so warmly recommend- ed by Hutchison, are frequently given with it. Dr. Francis has found that sulphate of quinine re- lieved, in many cases, where the narcotics had failed: his practice is recommended by Roche and Sanson.—See their Nouveaux Pathol. Med. Chirurg., vol. ii. Veratria has been employed by Dr. Turnbull in many instances.—(See Turnbuil on Veratria.) And recently some curious cases have been published in the London Lancet, show- 268 "*v" Thus far was written in the first edition of this work. The patient, under the kindness of Sir William Blizard, obtained an entrance into the Margate Sea-bathing Infirmary, and, after five or six weeks' use of the marine bath, re- turned home—not indeed entirely free from pain, but in comfortable ease, and able to re- sume the use of her needle. About six months afterward, however, the complaint returned with as much violence as ever, and again the most powerful tonics and antispasmodics were tried in vain. The subcarbonate of iron, in the ORDER III. CINETICA. DISEASES AFFECTING THE MUS- CLES. IRREGULAR ACTION OF THE MUSCLES OR MUS- CULAR FIBRES : COMMONLY DENOMINATED SPASMS. Having, in the Physiological Proem to the present class, glanced, as far as our space would allow, at the disputed question concerning the nature of muscular irritability, or contractility, to adopt the language of Dr. Bostock, and its af- finity with sensorial or nervous influence, it is only necessary at present to take a very brief view of the general character and mode of ac- tion of muscles, as they appear to the naked eye in a massive form, or in other words, as compo- sed of an almost infinite variety of minute fibres. A muscle, thrown into action, increases in absolute weight, in density, and in power of re- sistance. It is also said to increase in absolute bulk, but the experiments on this subject are contradictory ; the middle or belly of the mus- cle, indeed, is at this time evidently enlarged, but then its length appears to be proportionally diminished. [The ventricular portion of the heart, removed from a large dog immediately af- ter the animal had been hanged, was immersed in warm water, contained in a glass vessel which ' was closed below with a ground glass stopper, and terminated above in an open vertical tube one third of an inch in diameter. The venl^U cles continued alternately to contract and dilate for a considerable length of time, during which the water stood at the same level in the tube, totally unaffected by the varying condition of the muscular fibres.—(Mayo's Anal, and Phys- iolog. Commentaries, vol. i., p. 12.)] Muscles constitute the cords, as bones do the levers of the living frame ; and in most cases the muscles ing that magnetism sometimes has a powerful effect.—D. * Cases of Neuralgia Spasmodica, &c, by B. Hutchison, &c, 8vo., London, 1822. Sir Astley Cooper considers equal parts of soap cerate and extract of belladonna, or a poultice with solu- tion of belladonna and bread, the best applications. Covering the breast with oil-silk, or hareskin, he has also found tranquillize the part, by exciting perspiration from it. " As constitutional reme- dies, the submuriate of mercury, with opium and conium, should be given for a time, with an occa- sional aperient; and then, the medicme which I )TICA. [Cl IV.—Ord. III. fullest doses employed by Mr. Hutchison, was had recourse to, and steadily persevered in, but to as little purpose as every other medicine. She has now again returned to the Margate In- firmary, where I hear she has again found bene- fit. In various cases, however, even in this spe- cies, I have reason to believe that the iron has proved as successful as in neuralgia faciei. And Dr. Alderson has given another example in a very striking instance of mammary neural- gia, but in an older and less irritable period of life.* grow tendinous, as the bones do cartilaginous, towards their extremities, by which means the fleshy and the osseous parts of the organs of motion become assimilated, and fitted for that in- sertion of the one structure into the other upon which their mutual action depends : the extent and nature of the motion being determined by the nature of the articulation, which is varied with the nicest skill to answer the purpose in- tended. Whether, however, the substance of tendons consists of the same fibres as the belly of a muscle, but only in a state of closer approx- imation, and possessed of finer vessels, which do not admit the introduction of red blood, or whe- ther they form a distinct system of fibres, merely attached to those of the muscles, is at present undecided. It is certain that tendons possess nothing of the peculiar structure of muscles, and seem to be more nearly allied to the simple solid. —(Bostock's Physiology, p. 67, 8vo., 1824.) It appears singular, at first sight, that the ten- dinous fibres, which thus seem to be compacted into a firmer and more substantial cord than those of the muscles, should be sometimes bro- ken by muscular exertion, while the muscular fibres remain uninjured ; yet this unquestionably depends upon their greater rigidity, and, conse- quently, inability of yielding to the force by which they are opposed. And hence the bones themselves are sometimes broken in the same manner as by a violent jerk, or a sudden spas- modic contraction, of which we shall presently meet with examples, especially in the patella, the ribs, and the arms. The muscles them- selves, however, are occasionally ruptured by a like irregular violence and excess of power, as the recti abdominis in tetanus, and the gastroc- nemii in cramps. Muscular action, then, consists in a mutual attraction and concentration of the constituent fibres and muscles, in a manner peculiar to liv- have prescribed with most advantage in lessening the irritability of the part, is as follows :—R. Ex- tracti conii, extracti papaveris a a. gr. ij.; extracti stramonii e seminibus gr. ss. M. ; ft. pil." The above pill may be given twice or three times during the day; but if the gr. ss of the extract of stramonium be found too powerful, half that quan- tity may be tried. When the menses are obstructed, Sir Astley Cooper prescribes the carbonas ferri, the ferrum ammoniatum, or the mist, ferri comp. combined with aloes. He also recommends a hip- bath of seawater.—See Illustrations of the Dis- eases of the Breast, pp. 79,80.—Ed. Cl. IV—Ord. III.] CINETICA. 269 ing matter; for we cannot imitate it by any combination or action of mechanical fibres. It is not, however, a contraction in every dimension, since in this case the muscular volume would be diminished; but in length only, attended with a proportional increase of bulk, so as to preserve the absolute volume unchanged, or nearly so. It is easy to conceive, from these few remarks, that the force exerted by muscular contraction may be enormous ; but by the mechanical phy- sicians it was calculated in the most extravagant manner, from premises in many instances wholly chimerical. Thus Borelli estimated the force with which the heart contracts, in order to carry forward the circulation of the blood, to be equal to not less than 180,000 lbs. at each contrac- tion ; while Pitcairn, applying the same specu- lation to the function of digestion, conceived that this process is accomplished by a muscular exertion, divided equally between the stomach and the auxiliary muscles that surround it, amounting in the stomach alone to the force of 117,088 lbs., for which, "had he assigned five ounces," says Professor Monro, " he would have been nearer the truth."—(Monro, Comp. Anat., Prefl, p. 8.) Yet we do not want these vision- ary calculations to prove the wonderful power possessed by muscular fibres ; the facts we have already adverted to, and others we shall have to notice in the course of the present order, are sufficient to establish their astonishing energy, without having recourse to unfounded hypothe- ses or exaggerated statements. In general, says Dr. Parr, in a very excellent article upon this subject (Med. Diet, in verb., Musculus), it appears that the force with which a muscle contracts is in proportion to the num- ber of its fleshy fibres, and the extent of the surface to which these fibres are attached ; but its degree of contraction, or the extent of its motion, is in proportion to their length. The limits of contraction differ ih the long and in the circular muscles : for the former do not contract more than one third of their length, but the circular fibres of the stomach, which in their utmost dilatation may be expanded to a foot in circumference, may, after much fasting, be reduced to the circle of an inch. It must, however, be added, that in circular muscles no fibres pass completely round ; bundles of fibres are collected and end at different points, while some begin where others end. Each may therefore admit of only a limited contraction, while the dilatation just mentioned may be the sum of the whole. The action of muscles never intermits, and is only diminished in the sleeping state ; though, where the sleep is profound and lethargic, the diminution amounts to almost a cessation, ex- cept in the involuntary organs. When the muscles are not exercised (to use the words of Haller), " the vis insita is very slightly ex- erted ;" but we can still trace its influence by the position which the limbs assume, and dis- cover the relative strength of the antagonizing muscles. Thus we find the flexors stronger than the extensors ; for, during sleep, the head falls forward, and the body, legs, arms, and fin- gers, are slightly bent. The cause of this ad- ditional strength is easily explained: for the flexors have stronger and more numerous fibres, their insertion is farther from the centre of their motions, and under a larger angle, which must increase when flexion has begun. This superi- ority of the flexors bends the foetus in the womb into a round ball. The same superiority of power continues, though in a less degree, after birth, and hence frequent pandiculations are re- quired to give activity and energy to the exten- sors, which they again lose in advanced age. On awakening from a sound sleep, the same yawnings and stretchings occur from the same cause ; and Bethel fancifully refers the crowing of the cock, and the fluttering of his wings, to a similar purpose. It is always useful in dis- eases to examine the position of the limbs du- ring sleep, particularly the sleep of children. If they deviate from the ordinary degree of flex- ure to a more straight position, there is gener- ally some irregularity in the state of tone, and of course in the vital influx. The irritability or contractility of a muscle is a very different power from that of elasticity. The latter always depends upon simple reac- tion, and is never a source of actual energy : it merely restores, in a contrary direction, the force which had been impressed, and the effect which it produces can never be greater than the amount of the cause. But in muscular con- traction, the mechanical effect produced is infi- nitely greater than the mechanical cause produ- cing it, as, when the organ of the heart, recently detached from the body just dead, is slightly scratched in its inside by a needle, it will con- tract so strongly as to force the point of the nee- dle into its substance.—(Fordyce, Phil. Trans. r 1788, p. 80.) But the chief proof of the dif- . ference between the two is, that the irritable power of a muscle is often excited without any mechanical cause at all, and from the mere in- fluence of the will, which has no effect upon the simple elasticity of organs. Hence, while contractility belongs to the muscular structure alone, elasticity appertains to many other sub- stances as well, whether animal, vegetable, or even metallic. Muscles also have their elasti- city, but the principle is altogether of a differ- ent kind, though often confounded with the pre- ceding by modern pathologists ; and particularly in their use of the term tonicity (Bostock, Phys- iology, p. 168, 8vo., 1824), which is often em- ployed with little precision, and frequently means nothing more than this common principle of elas- ticity, to which indeed.it seems directly to be applied by Dr. Cullen. The muscles of the body may be divided into two grand classes ; voluntary or animal, and involuntary or automatic. In the former we meet with some that aTe peculiarly remark- able for strength and continuity of contraction, as the greater part of the round muscles ; and others as remarkable for mobility and vacilla- tion, among which we may place most of the long muscles. These properties are strikingly exemplified in a state of disease, and call for particular attention; the muscles characterized 270 NEUROTICA. [Cl. IV—Ord. III. by mobility presenting examples of atonic or agitatory spasm while those that are conspic- uous for continuity of action, are chiefly subject to rigid or entastic spasm. Continuity of exertion, however, is generally less evident in the voluntary than in the invol- untary muscles, of which last some organs, as the heart, continue their efforts through life without intermission ; though all of them relax, or remit, occasionally or periodically. For this greater permanency and regularity of action they are indebted to the peculiar provision which has been made for their supply of nervous pow- er ; for while the voluntary muscles are fur- nished in a direct line from the sensorium, whence indeed the close connexion they hold with it, the control the will exercises over them, and their catenation with the prevailing emotion of the moment, the involuntary muscles are de- pendant chiefly On the intermediate or gangli- onic system described in the proem to the pres- ent class, and are more remotely connected with the sensorium : they are in consequence far less influenced by the variable impulses of the men- tal faculties, and are placed beyond the juris- diction of the will. And hence the tenour of their action is more equable, more permanent, more uninterrupted, and less subject to fatigue or weariness. But as these organs are by no means free from the power of injury or diseased action, they are also subject at times, in common with the voluntary organs, to those abnormal motions which are ordinarily denominated spasms : and it is not a.little curious to observe the uniform tendency which different spasmodic affections manifest towards some organs or functions, rather than towards others. Thus the vital function, in which the heart and lungs are such prominent agents, is chiefly disturbed by palpi- tation and syncope; the natural, or that in which the abdominal organs so generally co-operate, by hysterics ; and the animal, extending through the range of the 'voluntary organs, by tetanus and epilepsy. In the prosecution of the pres- ent order, indeed, we shall see that this does not hold universally ; that epilepsy, for instance, is often a disease rather of the stomach or in- testines than of any other organ, and that the heart is sometimes affected with rigid instead of with clonic spasm: but the rule holds gen- erally, and is not essentially shaken by these casual exceptions. Dr. Cullen has contended, that in all spas- modic affections the brain is the actual seat of disease, and that they consist in some morbid modifications of its energy. " The scope and purpose of all that he has said," he tells us, "is to establish the general proposition, that spasmodic affections, whether they arise prima- rily in the brain or in particular parts, do con- sist chiefly, and always in part, in an affection and particular state of the energy of the brain : and that the operation of antispasmodic medi- cines must consist in their correcting this mor- bid or preternatural state in the energy of the brain, by their correcting either the state of preternatural excitement or collapse, or by ob- viating the too sudden alteration of these states." This proposition seems rather to follow from Dr. Cullen's singular doctrine concerning the mutable condition of the energy of the brain, and the immutable nature of the nervous pow- er, which is propagated from it by vibrations, than from the clear face of facts before us. Spasms, in many instances, are altogether lo- cal ; they are confined to particular muscles, or particular sets of associate muscles, and have no effect on the brain whatever, so as to dis- turb its energy; of which we have examples in hiccough, priapism,* chorea, and often in pal- pitation. They depend upon some irritation ex- isting not at the origin but at the extremity of the nerves : and where such is their source, even though the chain of morbid action should at length reach the brain and affect its energy, as in convulsions from teething, epilepsy from worms, or some palpitations from ossific or poly- pous concretions, all the antispasmodics in the world will afford no relief, so long as the local cause of irritation continues to operate ; while, the moment this is removed, where it is capable of removal, as by the use of a gum-lancet or active anthelmintics, all the powers of the brain become instantly tranquillized ; its faculties are rendered clear, its energy is re-invigorated, and its motive power or sensorial energy is distrib- uted in an uninterrupted tenour. The greater number of spasmodic affections, therefore, do not so much depend upon the. state of the brain as of the living fibres that issue from it, and maintain a correspondence with it ; for the stream may be vitiated while the fountain is untouched. We have seen, indeed, in the pro- em to the present class, from the concurrent results of various physiological experimenters, that although, while the organ of a brain exists, it exerts a certain influence over the principle of muscular motion, this principle is far less de- pendant upon the encephalon than that of gen- eral feeling or of the local senses; that it is found abundantly in animals totally destitute of a brain ; and that, hence, those possessing a brain may be excited not only into abnormal and spasmodic, but even into a continuation or reproduction of regular and natural motions of various muscular organs after the brain has been separated from the spinal chain, by stimuli ap- plied to this chain, or even by the artificial breath of a pair of bellows. We have seen, also, that the nervous fila- ments of the .muscles are of two kinds, sensific and motific; the former proceeding from the cerebellum, or the posterior trunk of the spinal cord, to which it gives rise, and the latter from the cerebrum, or anterior trunk of the same double cord ; and as these two sets of filaments do not necessarily concur in the same affection, it is obvious that the muscles of a limb, or of the whole body, may be thrown into the most violent agitation, or the firmest rigidity, without * This cannot be explained by the action of any muscle, and consequently is not a spasmodic af- fection.—Ed. Gbn. I.—Spe. 2.] ENTASU much, or perhaps any degree of painful emotion or increased sensibility. And we can hence readily account for the little complaint that is made by patients upon this subject, on their be- ing freed from a severe paroxysm of tetanus, convulsion-fit, or hysterics. The following are the genera of diseases which will be found to appertain to the present order : I. Entasia. Constrictive Spasm. II. Clonus. Clonic Spasm. III. Synclonus. Synclonic Spasm. GENUS I. ENTASIA. CONSTRICTIVE SPASM. IRREGULAR MUSCULAR ACTION, PRODUCING CON- TRACTION, RIGIDITY, OR BOTH. Entasia is derived from the Greek hraoii, " in- tentio," " vehementia," "rigor," from ivretvu), " intendo." By many nosologists the genus is called tonos, or tonus, which is here dropped in favour of the present term, because tonus or tone is employed by physiologists and pathologists, in direct opposition to irregular vehemence or rigidity, to import a healthy and perfect vigour, or energy of the muscles ; and by therapeutists to signify medicines capable of producing such or similar effects. The genus entasia includes the following species:— 1. Entasia Priapismus. Priapism. 2.-------Loxia. Wry neck. 3. ------- Rhachybia. Muscular Distortion of the Spine. 4. ------- Articularis. Muscular Stiff-joint. 5. ------- Systremma. Cramp. 6. ------- Trismus. Locked-jaw. 7.------Tetanus. Tetanus, 8. ------ Lyssa. Rabies. Canine Mad- ness. 9.------Acrotismus. Suppressed Pulse. SPECIES I. ENTASIA PRIAPISMUS. PRIAPISM. PERMANENT RIGIDITY AND ERECTION OF THE PE- NIS WITHOUT CONCUPISCENCE. The specific term is derived from the name of Priapus, the son of Venus and Bacchus, who is usually thus represented in paintings and sculptures, but with a concupiscent feeling. Galen applies the term also to females, as im- porting a rigid elongation of the clitoris without concupiscence. Spasm is, in all instances, a disease not of vigour, but of debility, with a high degree of irritability ; and there is no case in which this is more striking than in the present species. It has been found occasionally in infancy; but it is far more frequently an attendant upon advan- ced years. It has sometimes also followed cold, and especially local cold, clap, dysury, and the use of cantharides. It has at times been a result of free living, and particularly hard drink- ing. The spasms consist in a stiff and perma- 1 LOXIA. 271 nent contraction of the erectores penis,* uncon- nected with any stimulus arising from a fulness of the vesiculae seminales. Dr. Darwin says he had met with two cases where the erection, producing a horny hardness, continued two or three weeks, without any ve- nereal desire, but not without pain. The easi- est attitude was lying upon the back with the knees bent upward. The corpus cavernosum urethrae at length became soft, and in a day or two the whole rigidity subsided. One of these patients had been a free drinker, had a gutta rosacea on his face, and died suddenly a few months after his recovery from the present com- plaint. It is singular that this spasm should sometimes continue after death ; at least we have accounts of such cases in Marcellus Dona- tus and other writers, t As the disease is a case of both local and general debility, its cure is in most instances difficult. Antispasmodics and tonics are the only medicine that promise relief, as camphire, opium, bark, warm aromatics, warm bathing, cold bathing: but the whole are often tried without effect. [In the case which surgeons most frequently meet with, namely, that excited by the irritation of ulcers and excoriations about the glans, or by gonorrhoea attended with chordee, the most effectual treatment is the antiphlogistic, com- bined with antispasmodics. This is quite incon- sistent with the notion of the complaint being connected with debility, a notion that has no foundation, except the author's hypothesis of the cause of spasm.] SPECIES II. ENTASIA LOXIA. WRY NECK. PERMANENT CONTRACTION OF THE FLEXOR MUS- CLES ON THE RIGHT OR LEFT SIDE OF THE * That the author has fallen into an error in rep- resenting priapismus to be a species of constrictive spasm, cannot be doubted; because erection of the penis is not really produced by the action of the erectores muscles, as they are termed, but by the injection and distention of the glans, corpus spon- giosum urethrae, and corpora cavernosa, with blood. " Each of the crura penis gives attachment at its origin to a tolerably strong muscle, named the erec- tor penis, probably because, when a power capable of producing the effect indicated by that name was sought by anatomists, this muscle seemed to be their only resource. At present the name appears very ill adapted, since the muscles in question ob- viously draw the penis downward and backward, instead of upward and against the pubes. Those who explain the erection of the penis by the com- pression of its vein, should find out a power capa- bleof elevating the organ against the bone, and of carrying it forward."—(See Rees-'s Cyclopaedia, art. Generation.) In fact, mechanical pressure of the vein will not produce erection.—En. t Dr. Francis remarks, " that in cases of severe parturition, when the head has been greatly com- pressed, the child is often born with a strong erec- tion of the penis." In instances of sudden death, where opium has been taken freely, the penis is sometimes found erect.—D. 272 NEUROTICA. [Cl. IV—Ord. III. NECK, DRAWING THE HEAD OBLIQUELY IN THE SAME DIRECTION. The term loxia is derived from the Greek, X^Aj, "obliquus, tortus;" whence loxarthrus in surgery, an obliquity of a joint of any kind, without spasm or luxation. By the Greeks, however, the term was specially applied to the joints or muscles of the neck. This disease, in its genuine form, proceeds from an excess of muscular action, particularly of the mastoid muscle on the contracted side. But we frequently meet with a similar effect from two other causes : one in which there is a disparity in the length of the muscles opposed to each other, and consequently a permanent contraction on the side on which they are short- est ; and the other in which, from cold or a strain, there is great debility or atony on the side affect- ed, and consequently an incurvation of the neck on the opposite side, not from a morbid excess, but an overbalance of action. This species, therefore, offers us the three following varieties :— ■ Dispars. From disparity in the length Natural wry of the muscles opposed to neck. each other. B Irritata. From excess of muscular ac- Spastic wry tion on the contracted side. neck. y Atonica. From direct atony of the Atonic wry muscles on the yielding neck. side. The first variety is mostly congenital, though sometimes produced by severe burns or other injuries. And a like effect occasionally issues from a cause that may be noticed in the present place, though not connected with a morbid state of the muscles,—a displacement of the mus- cles, from an incurvation in the vertebrae of the neck ;* by which, though the antagonist mus- cles be of equal length and power, those on the receding side of the neck are kept on a perpet- ual stretch, while those on the protruding side are in a state of constant relaxation. The other two varieties are commonly the result of cold, or inflammation, or a strain; often by carrying too heavy loads on the head. M. Boyer gives instances of the disease produced by moral causes : and Wepfer relates the case of a man who had a wry neck, occasioned by a convulsive action of the muscles on one side of the neck, which appeared whenever he was tormented by chagrin, but ceased as soon as he was restored to a state of mental tranquillity.—(Traiti de Maladies Chirurgicales, &c, torn, vii., 8vo., Paris, 1821.) The cure must depend upon the nature of the cause-. In colds and strains, warmth, the fric- tion of flannel, and the stimulus of the ammonia or camphire liniment combined with opium, will be found most serviceable, as tending to dimin- ish pain, and restore action to the weakened * In almost every instance, the change in the bones is the consequence of the long-continued action of the preponderating muscle. This doc- trine, which is maintained by Jorg, is now gener- ally admitted.—Ed. organ. In direct spasms the same process will also frequently be found useful; but the appli- cation of cold water will often answer better. [About four years ago the editor was consulted by a gentleman at Clapham, whose right sterno- cleido mastoideus muscle was not only affected with permanent and rigid spasm, but had at- tained a vast increase of bulk and force. Under the direction of Dr. Babington, Mr. Brodie, and Sir Charles Bell, the patient had tried various narcotics, ammoniated copper, and different local applications, without benefit. A seton in the nape of the neck, and friction over the muscle with camphorated mercurial ointment, was now suggested, with a course of the compound calo- mel pill, combined with hyosciamus and conium, and occasional purgatives; but the patient had not courage to begin the plan. In this case, the wry neck was evidently associated with consid- erable disorder of the nervous system; and the patient could only lift a glass to his mouth by using both hands for the purpose.] Where the antagonist muscles are of unequal length, the case lies beyond the reach of medical practice ; and if relieved at all, can only be so by a sur- gical operation. If the cervical vertebrae be in- curvated, but the bones sound, the disease may not unfrequently be made to yield to a skilful application of machinery by the hands of an in- genious surgeon. It sometimes happens, how- ever, that the bones in this case are soft and occasionally carious, and the slightest motion of the head is attended with intolerable pain. Setons have here been found serviceable, with an artificial support of the head ; but this kind of affection is often connected with a constitu- tional softness of the bones, of which we shall have to treat in the first order of the sixth class, under the head parostia flexilis. SPECIES III. ENTASIA RHACHYBIA. MUSCULAR DISTORTION OF THE SPINE. PERMANENT AND LATERAL CURVATURE OF THE SPINE, WITHOUT PARALYSIS OF THE LOWER LIMBS : MUSCLES OF THE BACK EMACIATED ; MOSTLY WITHOUT SORENESS UPON PRESSURE. Distortion of the spine is produced in va- rious ways ; and it is chiefly owing to a want of due attention to this fact, that so much con- fusion has of late prevailed respecting the real L nature of the particular case to be treated, and the particular treatment that ought to be adopted. The disease, under this general name, was first introduced before the public with any con- siderable degree of notoriety by Mr. Pott, as connected with a palsy of the lower extremities, and as dependant upon a scrofulous diathesis; which at length fixed itself upon some part of the vertebral column, softened or rendered ca- rious the bones that became affected, and hereby necessarily produced crookedness, and a morbid pressure upon the right line of the spinal marrow. This is a case that often happens, and a like effect occasionally occurs in a very early period of life from a rachitic instead of a scrofulous Gbn. I.—Spe. 3.] ENTASIA RHACHYBIA. 273 diathesis ; though from the greater facility with which the principle of life is able to adapt itself to deviations from the ordinary laws of health at this latter period than afterward, a paralysis of the lower extremities is less common,* and even the mischiefs incidental to a misformation of the chest less fatal. So that, while the disease of a humpback can rarely take place in puberty or later life without a serious injury to almost every function, we often find it occur in infancy with- out making much encroachment on the general health. In all cases of this kind, the malady is prima- rily and idiopathically an affection of the verte- bral bones; and there is always to the touch a mollescence in their structure, or a manifest soreness and ulceration. And from the pecu- liar contour of the vertebral column, the distor- tion is always from within outwards, forming what has been called an angular, in contradis- tinction to a lateral curvature. So that the characters of the osseous gibbosity are suf- ficiently clear and specific. But the muscles of the vertebral column and their appendages, the ligaments and cartilages into which the latter are inserted, are of as much importance to its healthy contour as its bones. And hence any morbid affection of these several structures may as essentially in- terfere with the natural curve of the spine, and the wellbeing of the constitution, as a disease of the vertebral bones. It is possible that these are all affected in par- ticular instances, sometimes separately, some- times jointly (Copelo.nd on the Spine, p. 15) ; but there can be no doubt that the muscular fibres of the neck, back, and loins, those on which all the complicated movements of the vertebral column depend, and which compose more than three hundred distirJct muscles in the * Scrofulous caries of the corpora vertebrarum, whether in adults or children, most frequently af- ter a time causes paralysis of the lower extremi- ties, though exceptions are met with. In rickets, where the spine may be said to be deformed rather from imperfect development of the bones than from disease of them, palsy of the legs is not pro- duced, however great the lateral curvature of the back. Cruveilhier, in his Anatomie Patholo- gique, livr. iv., gives us the particulars of a case in which no paraplegia existed, though not less than five of the dorsal vertebrae had been totally annihilated by disease, and the alteration in the shape of the vertebral column was such, that the upper half formed over the lower an extremely acute angle, which, from what is demonstrated in the engraving, would have been still more acute if it had not been prevented by the eleventh and fifth dorsal vertebrae touching each other. The intervertebral foramina were all preserved, though more or less deformed, contracted, or displaced backwards. In those which were most diminished the corresponding intercostal nerves must have been compressed, and consequently, the action of the intercostal muscles impaired, and an asth- matic affection been the result. The engraving shows how nature in this ^instance contrived to maintain the integrity of the vertebral canal, and the spinal cord uncompressed, in the midst of such a deviation of the spine from its normal shape. Although five of the vertebrae were de- Vol. II.—S whole, are most frequently thus enfeebled, either in part or in their entire range ; though an en- feebled state of any of these organs must pro- duce an inability of preserving the spine in its natural sweep and equilibrium. And where dis- tortion proceeds from this cause, the indications are in most cases as clear as where it is the re- sult of a diseased condition of the bony struc- ture ; for first the morbid curvature, instead of being from within outwards, takes place later- ally, the crookedness being manifestly on the right or the left side, according as the muscles on the one side or the other overpower the ac- tion of their antagonists; there is little or no soreness upon pressure, unless indeed the bones or their cartilages should ultimately become affected from the protracted state of the disease ; and the distortion being less abrupt or angular than in the ossific gibbosity, the lower limbs are not affected with paralysis. The distinction, therefore, between the os- seous and the muscular distortion of the spine, is clear and definite ; and so far as regards the pe- culiar character of the curvature, was minutely noticed by the Greek writers, who identified the first by the name of lordosis or cyrtosis, ac- cording as this curvature was anterior or poste- rior, and the second or the lateral curvature by the term hybosis, from bSb; (hybos), incurvus. It is from this term that the author has derived the name which he has ventured to assign to the present species—rhachybia—as an allowable contraction of rhachyhybia, literally spinal in- flection. Swediaur has denominated it, from the same source, hyboma Scoliosis.—(Tom. ii., p. 740.) The distinction is very accurately pointed out by Mr. Pott, who,—while he affirms that " the ligaments and cartilages of the spine may be- come the seat of the disorder (scrofula) without molished, anchylosis took place, and the medulla suffered no pressure adequate to the production of paralysis of the lower parts of the body. A beautiful preparation, illustrative of an equally extensive destruction of the bodies of the verte- brae, and of as sudden a bend of the spine, may be seen in the anatomical museum of the London University. Cruveilhier also gives the particu- lars of the body of a child ten years old that was brought to his dissecting-room, in which only a few vestiges of the third, fourth, fifth, sixth, sev- enth, eighth, ninth, tenth, and eleventh dorsal vertebrae were left. According to this patholo- gist, diseases of the vertebra] column, like those of every other part of the osseous system, are seated, not in the osseous tissue itself, but in the adipose cellular or medullary tissue occupying its interstices. When this cellular tissue in- flames, sometimes it pours out pus in abundance, constituting an abscess; sometimes in scanty quantity, which admits of being entirely absorbed. The cells of the osseous tissue being distended by the development of the cellular tissue, and de- prived of the materials of nutrition, may be com- pletely absorbed; and thus Cruveilhier accounts for the total disappearance of the texture of bone, without a vestige of it being left. The reader is probably aware, that Cruveilheir's doctrine is, that all disease is seated in the cellular tissue of organs, the other tissues being only liable to atro- phy and hypertrophy.—Ed. 274 NEUROTICA. [Cl. IV—Ord. Ill any affection of the vertebrae," in which case " it sometimes happens that the whole spine, from the lowest vertebra of the neck down- wards, gives way laterally, forming sometimes one great curve to one side, and sometimes a more irregular figure, producing general crooked- ness and deformity of the whole trunk of the Body, attended with many marks of ill health ;" —yet admits that paralysis of the lower limbs never accompanies cases of this sort, so far as his experience had extended, nor even that un- tempered and misshapen structure of the spine which occurs at birth or during infancy from a rachitic softness of the bony material. " I have never," says he, " seen paralytic effect on the legs from a malformation of the spine, how- ever crooked such a malformation might have rendered it, whether such crookedness had been from the time of birth, or had come on at any time afterward during infancy.—None of those strange twists and deviations which the majority of European women get in their shapes from the very absurd custom of dressing them in stays during their infancy, and which put them in all directions but the right, ever caused any thing of this kind, however great the deformity might be. The curvature of the spine which is ac- companied by this affection of the limbs (i. e. that which takes place from a diseased condi- tion of the bones themselves subsequently to childhood, and from a supposed scrofulous di- athesis), whatever may be its degree or extent, is at first almost always the same ; that is, it is always from within outwards, and seldom or never to either side." Now it has unfortunately happened, that as Mr. Pott's remarks were written chiefly to ex- plain this last form of spinal distortion, and ad- dressed to the single cause of scrofula, the hints he has given respecting distortions from every ether cause have been too often forgotten ; and the moment a young female is found to have a tendency to a vertebral distortion of any kind, it has too generally been taken for granted that the bones were in a diseased state, or on the point of becoming so ; that the patient was la- bouring Tinder the influence of a strumous diath- esis, whieh was manifesting itself in this quar- ter ; and all the severe measures of caustics or setons, with an undeviating permanent confine- ment to a hard mattress, or inclined plane, for many weeks or months, which a strumous affec- tion of this kind calls for and fully justifies, has been improvidentry had recourse to, with a great addition to the sufferings of the patient, and, in many instances, no small addition to the actual disease which has been so unhappily mis- understood. Mr. Baynton seems justly chargeable with having adopted this general view of the sub- ject, and extending it indiscriminately to every case. Mr. Wilson, who, though he conceived the disease to originate in a rachitic rather than a strumous diathesis, and had recourse, as we shall observe presently, to a different mode of treatment, seems to have stretched his parallel hypothesis over the same extent of ground. And Mr. Lloyd, who has lately favoured the profes- sion with a valuable work on the same subject, in like manner contemplates every case of spinal distortion as issuing from a common, and that a strumous cause ; to which cause also it has since as uniformly been assigned by Dr. Jarrold. —(Inquiry into the Curvature of the Spine, &c, 8yo., 1824.) Mr. Lloyd, correctly indeed, dis- tinguishes between the angular and the lateral curvature ; and with equal correctness observes, that " in the former there is always some de- struction of some portion of the vertebral col- umn, and often, for a considerable time, progres- sive destruction of bone, cartilage, and ligament; and the vertebrae undergo precisely the same changes as the extremities of other bones in scrofulous diseasesof the joints :" while he adds that "in the latter there is no destruction of parts, but merely an alteration of structure;" that " a wasting of the muscles always attends it in a greater or less degree ;" and that " it has been supposed by some authors that the cause of the curvature is entirely in the action of the muscles. But although," he continues, " this may be and most probably is the imme- diate cause, I am much more inclined to be- lieve that the primary cause is in the vertebrae ; that scrofulous action is set up in them, which increases their vascularity, and softens their texture." Here, then, is a distinct recognition of the two forms of morbid distortion of the spine to which I am anxious to direct the attention of the reader : and each of them is allotted its pe- culiar seat and diacritical signs ; the bones with manifest injury of the bones, and the muscles with manifest injury of the muscles. The resl is matter of mere hypothesis, and needs not urge us into a discussion. So obvious and so much more common indeed is muscular than osseous distortion of the spine, that other pathologists, from this fact chiefly, have contended that this is the only form of the disease in its commencement. Such was the opinion of the late Mr. Grant, of Bath, and such is the opinion of Dr. Dods, of the same city, in an interesting tract he has lately published on this subject (Path. Obs. on the Rotated or Con- torted Spine, 8vo., Lond., 1824); while Dr. Harrison refers its origin to " the connecting ligaments of the vertebrae." " These," he ob- serves, " get relaxed, and suffer a single verte- bra to become slightly displaced ;" in conse- quence of which, he adds, " the column loses its natural firmness, other bones begin to press unduly upon the surrounding ligaments ; they in turn get relaxed and elongated, by which the dislocation is increased,'and the distortion per- manently established. The direction becomes lateral, anterior, or posterior, according to cir- cumstances ; but the malady has in every in- stance the same origin, and requires the same mode of cure."—(Lond. Med. and Phys. Journ., No. eclxiv.) There is much ingenuity in this explanation, and I have no doubt that it is a correct expres- sion of various cases of vertebral distortion. It chiefly fails, like the osseous hypothesis in toc- wide a spirit of simplification, and in allowing no Gen. I.—Spe. 3.] ENTASIA RHACHYBIA. 273 other origin in any instance, than that which forms the keystone of its own pretensions. Ad- mitting the disease to commence in the con- necting ligaments, the associating muscles must soon be involved in the mischief; while, if it commence in the latter, the ligaments which unite them to the bones cannot long continue unaffected. So that the question is merely one of primogeniture, and imposes little or no differ- ence in the mode of treatment. Nay, even the bones themselves, by being irregularly pressed upon, may at length suffer in such parts from in- creased absorption, become thinner and more spongy, or even ulcerate and grow carious; so as in process of time to give a direct proof of osseous or angular contortion, though induced instead of taking the lead. One of the chief difficulties, in cases where we have no reason to apprehend a morbid state of the bones, consists in accounting for the change that seems to take place in the relative position of several of the vertebrae or their pro- cesses ; and especially in the greater elevation or prominence of their transverse processes on one side, while those on the other are scarcely perceptible. And it is in truth chiefly to solve this question, that most of the hypotheses of" the present day are started in opposition to each other. The idea of an actual dislocation of the vertebral bones, which enters into that of Dr. Harrison, would sufficiently account for the fact, if such a dislocation could be unequivocally shown. But while the change of position does not seem in any instance to amount to a com- plete extrusion of a vertebra from its seat of ar- ticulation, the ease and quietude with which, under judicious management, it often seems to recover its proper position, and to evince its proper shapes, are inconsistent with the phe- nomena that accompany a reduction of luxated bones in every other part of the body. The explanation, therefore, has not been felt satisfactory to a numerous body of pathologists; and Dr. Dods has hence offered us another so- lution, which is also highly ingenious, and may perhaps in the end be found correct in those cases in which the miscurvature is very consid- erable, and especially where it becomes double or assumes a sigmoid figure. He supposes, in the first place, that the whole disease in its ori- gin is seated in the extensor muscles of the back, or that part of them to which it is confined : more especially in the quadratus lumborum, sacro-lumbalis, and longissimus dorsi. He sup- poses next that the right hand being habitually more exerted than the left, the effect of such surplus of force, in consequence of our throwing the body towards the left to preserve its centre of gravity, and hence strongly contracting the muscles of this side of the spine, must fall in a greater degree upon those muscles, and more dispose them " to suffer disorganization and be- come contracted;" and he hence accounts for the greater frequency of contortion on the right side than on its opposite. He then proceeds to account for the single or double curvature which the contortion effects, by remarking that the morbidly contracted muscles of the left side, in overcoming the action of the muscles of the right, do not drag the vertebrae forward towards themselves in a direct line, but rotate the verte- brae to which they are attached, because of the angles formed relatively between the vertebrae and the pelvis (the points of origin and insertion of these muscles), and the force of their con- traction acting upon moveable, horizontal, or transverse levers, namely, the transverse pro- cesses of the vertebrae.—(Op. cit., p. 93.) Morbid curvation of the spine, therefore, in the opinion of Dr. Dods, does not consist in an evulsion of separate vertebrae from their natural course and position, but in a twist of a great part of the entire column, by which means the morbid lateral flexure is nothing more than the natural sigmoid sweep of the vertebral chain, wrested more or less round to one side, as by the turning of a corkscrew. Whatever displacement is met with in the ribs, or the other bones of the chest, is neces- sarily a result of the first deviation from the line of health. " All the ribs," he observes, " have a double attachment to the vertebrae : one, by their heads to the bodies of them ; and the other, by their tubercles to the transverse processes. When the vertebrae, then, are made to rotate upon each other in the manner described, by the permanent contraction, and this, for exam- ple, to the right side, which is the more frequent direction they take, from the causes noticed, they by this movement push out or backward the heads of the ribs of the left side, and force their sternal extremities considerably forward, because of the quick circular turn which the ribs make between their angles and their points of attachment to the vertebra?, and the very small motion, from such a formation of them, requi- site here to produce them. Together with this movement of the ribs, which produces the pro- jection of the left side of the chest in front, they are also made, from their double attach- ment to the vertebrae, to fall down and approxi- mate, or, as it were, overlap each other, at their angles. This causes that hollowness or sinking in of the left side of the chest behind. The fal- ling down of the ribs here described appears to me to be in part owing, also, to the permanent con- traction of the sacro-lumbalis muscle, which is in- serted into all their angles. While these move- ments take place with the ribs on the left side of the body, the very opposite, of necessity, hap- pens to those on the right. By the rotatory movement of the vertebrae, the ribs on the right side have their heads, contrary to those on the left, drawn inward, and their sternal extremities made to recede backward, while their double connexion with the vertebrae causes them, con- trary also to those of the left side, to be raised up and separated from each other at their angles. This rising up and separation of the ribs at their angles is what produces the projection of the right side of the chest behind." From this general change of position, and particularly the twist of the ribs, Dr. Dods ac- counts for the unnatural situation of the scapulae, and in many instances, of the clavicles and the sternum, with the falling down of the right shoul- 276 NEUROTICA. [Cl. IV.—Orb. HI. der. He observes, moreover, that though the contortion of the spine most frequently takes place to the right side, yet that it occasionally takes place to the left; that the whole column is not always moved round, but only a part of it; and that hence, instead of a profile of three morbid flexures brought into view, which inva- riably follows in the former case, we have often a profile of only two : and that where the mus- eles of both sides of the column become con- tracted from position, which sometimes takes place, the greater number of the vertebral joints acquire an anhylosis, and the body is arched backwards. There is much ingenuity through the whole •f this explanation, which plausibly accounts for that ridgy line of projection so frequently felt on the left side of the loins when the morbid curvation is on the right, ascending nearly to a level with the spinous processes, while there is not only no such ridge on the opposite side, but even no appearances of the transverse processes. Upon the hypothesis before us, these processes are conceived to be equally elevated on the one side and depressed on the other, which gives us the two phenomena of an unnatural and ridgy prominence in the former line, and of an unnat- ural disappearance, in the latter. The hypothe- sis nevertheless (for at present it cannot be en- titled to a higher appellation) requires further elucidation and support; and after all, can never altogether reach the precise object at which it aims,—that of establishing itself at the expense of every other view, and especially of subvert- ing the doctrines of a diseased action of the other moving powers or their appendages, the ligaments of the Spinal muscles, or the cartila- ges into which they are inserted ; a morbid con- dition of which is often capable of proof from the very limited area of pain and tenderness to which, on pressure, the disease seems to be con- fined : to say nothing of the affection of the ver- tebral bones themselves, in which, as already observed, spinous distortion sometimes com- mences, though from a very different source, and in which, even when derived from the source now contemplated, it sometimes terminates. There can be no doubt, however, that the spinal distortion of the present day is a disease far more frequently of the muscles and their ap- pendages than of the bones, and is the result of a want of equilibrium between the antagonist forces on the one side and on the other of the ?ertei>ral column, as well those of the trunk as of the back; in consequence of which this col- umn is deranged in its natural sweep, and either twisted or deflected in particular parts, or in its whole length : all the other changes in the gene- ral figure, and deviations from the general health, being dependant upon this primary aberration. It is hence a disease of muscular debility, or irregular, and henccclonic, action in the fibres of the yielding muscles, and an inability to resist the encroachment that is made on them by their more powerful antagonists. The complaint almost invariably shows itself from the age of puberty to that of mature life, *hough sometimes later; and is nearly limited to females, and, among females, to those of deli- cate habits, and who are especially disciplined in the false and foolish rules for obtaining a fine figure. It is hence a perpetual inmate in our public female schools, and is by no means an unfrequent attendant upon domestic education. The progress of the disease may be so easily collected from the physiological survey we have already taken, that only a few words in addition will be necessary. The complaint first shows itself by a general Iistlessness and aversion to muscular exertion of any kind, and an unwonted desire to lounge and loll about. No signs of constitutional dis- ease, however, are as yet manifest; the nights are not disturbed, the appetite does not fail, the evacuations are regular, and the pulse unaffect- ed. There is soon after a sense of weariness, and even at times uneasiness, about the back, and especially the loins ; and if the muscles of these parts be minutely examined, several of them will give proof of flaccidity and emacia- tion. If no steps be taken at this time to arrest the disease in its march, or if the steps taken be injudicious or inadequate, the vertebral col- umn will soon be involved in the morbid action ; and especially, as Mr. Ward observes, " on the occurrence of any particular disturbance to the constitution" (Pract. Obs. on Distortions of the Spine, Chest, and Limbs, p. 36, 8vo., 1822) : its numerous joints will lose their nicely-adjust- ed poise ; they will in various parts be left too loose on the one side, and dragged too rigidly on the other; and the elegant contour of the spinal chain will progressively be broken in upon. All the other changes, whether upon the gen- eral form or the general health, which progres- sively take place in the advance of the disease, are entirely consecutive upon the symptoms be- fore us, and may be anticipated by any one. From the morbid contest which is thus contin- ually going on between the antagonist muscles, their internal Organization must necessarily be- come greatly affected, and the growing debility, which is manifest in the contractile and exten- sile power of their aggregate fibre, will enter into every part of every separate fibril, and affect their vis insita. The debility and irregular ac- tion of one muscle will spread by sympathy or association to various others ; and from the de- rangement of the bones of the spine and the chest, the functions of respiration and digestion, and consequently, in a greater or less degree, all the other functions of the body, must be inter- fered with in their respective powers, so that there is scarcely any other disease but may fol- low ; and the frame will become generally ema- ciated. As the proximate cause is debility of the ex- tensor muscles of the back or loins on either side, the occasional cause will consist in what- ever has a tendency to produce such debility. Too rapid growth is a frequent source of this complaint; a casual strain of the muscles on either side is a source not less common • chlo- rosis, or any other constitutional weakness, may lead to the same effect; and assuredly the use of stiff and girding stays, or any other part of Gkn. 1.—Spe. 3.] ENTASIA RHACHYBIA. : 277 that fashionable compression which is designed, in the school-discipline of the present day, to mould the form into a somewhat different and more graceful shape than perhaps the niggard hand of nature has intended—such as back- boards, braces, steel bodices or steel crutches, spiked collars, neck-swings, and even education- chairs. The tendency of all these to produce deformity where it does not exist, and to aggra- vate it where it does, is forcibly pointed out by Dr. Dods; who nevertheless seems to censure, with rather more acrimony than needful, the whole system of school-drilling education, as practised in many of our most fashionable es- tablishments. A course of discipline for giving grace and elegance to the growing form, if con- ducted with judgment, devoid of rigorous com- pression to the expanding organs, and allowing a sufficient alternation of relaxation and ease, so far from being injurious to the health and strength of the general frame, has a natural tendency to invigorate it. But the greater fre- quency of the lateral distortion of the spine in our own day compared with its apparent range in former times, together with the increased co- ercion and complication of the plan laid down in many of our fashionable schools for young ladies, seems clearly to indicate that some part at least of its increased inroad is chargeable to this source : and the following remarks of Mr. Pott upon the various instruments applied to a grow- ing girl in order to prevent a crooked shape, have a wider claim to attention in the present day than when they were first given to the world. " These," says he, " are used with de- sign to prevent growing children from becoming crooked or misshapen; and this they are sup- posed to do by supporting the backbone, and by forcing the shoulders unnaturally backward. The former they cannot do; and in all cases where the spine is weak, and therefore inclined to deviate from a right figure, the latter action of these instruments must contribute to, rather than prevent, such deviations, as will appear to whoever will with attention examine the mat- ter. If, instead of adding to the embarrass- ment of children's dress by such iron restraints, parents would throw off all of every kind, and thereby give nature an opportunity of exerting her own powers ; and if, in all cases of mani- fest debility, recourse were had to friction, bark, and cold bathing, with due attention to air, diet, exercise, and rest; the children of the opulent would perhaps stand a chance of being as stout, as straight, and as well-shapen, as those of the laborious poor." The simple fact is, that the system of disci- pline is carried too far, and rendered much too complicated ; and art, which should never be more than a handmaid of nature, is elevated into her tyrant. In rustic life we have health and vigour, and a pretty free use of the limbs and the muscles, because all are left to the im- pulse of the moment to be exercised without re- straint. The country girl rests when she is weary, and in whatever position she chooses or finds easiest; and walks, hops, or runs, as her fancy may direct, when she has recovered her- self ; she bends her body and erects it as she lists, and the flexor and extensor muscles are called into an equal and harmonious play. There may be some degree of awkwardness, and there generally will be, in her attitudes and move- ments ; and the great scope of female discipline should consist in correcting this. With this it should begin, and with this it should terminate, whether our object be directed to giving grace to the uncultivated human figure or the uncul- tivated brute. We may modify the action of muscles in common use, or even call more into play than are ordinarily exercised, as in various kinds of dancing ; but the moment we employ one set of muscles at the expense of another, keep the extensors on a full stretch from day to day, by forbidding the head to stoop, or the back to be bent, and throw the flexors of these organs into disuse and neglect, we destroy the harmo- ny of the frame instead of adding to its elegance, weaken the muscles that have the dispropor- tionate load east upon them, render the dejected muscles torpid and unpliant, sap the foundation of the general health, and introduce a crooked- ness of the spine instead of guarding against it. The child of the opulent, while too young to be fettered with a fashionable dress, or drilled into the discipline of our female schools, has usually as much health and as little tendency to distor- tion as the child of the peasant: but let these two, for the ensuing eight or ten years, change places with each other; let the young heiress of opulence be left at liberty, and let the peas- ant-girl be restrained from her freedom of mus- cular exertion in play and exercise of every kind ; and instead of this, let her be compelled to sit bolt upright in a high narrow chair with a straight back, that hardly allows of any flexion to the sitting muscles, or of any recurvation to the spine ; and let the whole of her exercise, instead of irregular play and frolic gayety, be limited to the staid and measured march of Mel- ancholy in the Penseroso of Milton— " With even step and musing gait;" to be regularly performed for an hour or two every day, and to constitute the whole of hercor- poreal relaxation from month to month, girded moreover, all the while, with the paraphernalia of braces, bodiced stays, and a spiked collar ; and there can be little doubt that, while the child of opulence shall be acquiring all the health and vigour her parents could wish for, though it may be with a colour somewhat too shaded and brown, and an air somewhat less elegant than might be desired, the transplanted child of the cottage will exhibit a shape as fine, a de- meanour as elegant, as fashion can communicate ; but at the heavy expense of a languor and relax- ation of fibre that no stays or props can com- pensate, and no improvement of figure can atone for. Surely it is not necessary, in order to acquire all the air and gracefulness of fashionable life, to banish from the hours of recreation the old rational amusements of battledoor and shuttle- cock, of tennis, trap-ball, or any other game that calls into action the bending as well as the ex- 278 NEUROTICA. [Cl. IV.—Obd. III. tending muscles, gives firmness to every organ, and the glow of health to the entire surface. Such, and a thousand similar recreations, va- ried according to the fancy, should enter into the school-drilling of the day, and alternate with the grave procession and the measured dance, for there is no occasion to banish either; al- though many of the more intricate and ventur- ous opera dances, as the Bolero, should be but occasionally and moderately indulged in ; since, as has been sufficiently shown by Mr. Shaw, " we have daily opportunities of observing, not only the good effects of well-regulated exercise, but also the actual deformity which arises from the disproportionate development that is produ- ced by the undue exertion of particular classes of muscles.—(On the Nature and Treatment of Distortions, &c, p. 15, Lond.,8vo., 1823.) It may be observed," continues the -same excel- lent writer, "that the ligaments of the ankles of some of the most admired dancers are so un- naturally stretched, that in certain postures, as in the Bolero dance, the tibia nearly touches the floor. So bad, indeed, is the effect occasionally produced [by a frequent stretching of the liga- ments, that the feet of many of them are de- formed ; for the ligaments which bind the tar- sal and metatarsal bones together become so much lengthened by dancing and standing on the tips of the toes, that the natural arch of the foot is at length destroyed."—(Inquiry into the Causes of the Curvature of the Spine, &c, ut supra, p. 119.) Such, then, are the best preventive means against muscular or ligamentous distortion of the young female frame, and especially of the vertebral column, in conjunction with pure air, plain diet, and well-regulated hours of rest. If, notwithstanding such means, a tendency to crookedness on either side should manifest it- self, evidenced by the symptoms already pointed out, no time should be lost in making an accu- rate examination of the spinal chain: and if such tendency should be accompanied with pains about the pelvis and lower extremities, our attention should be particularly directed to the state of the vertebrae seated in the centre of the different flexures of the column, but especially of the lumbar, for it is probable, in this case, that one or more of them may be in a state of inflam- mation. Where this is the case, the usual means of taking off inflammatory action, and especially depletion by cupping-glasses, should be instant- ly'had recourse to. But where the cause is de- bility alone, and a want of equilibrium between antagonist sets of muscles, rest, reclination, gen- eral tonics, especially myrrh, steel, and in many cases the sulphate of quinine, sea-bathing, and, in effect, whatever may tend to introduce a greater firmness of fibre and general vigour of onstitution, constitute the best plan of treat- ment. To these should be added a series of friction, and especially of shampooing or manipulation, applied down the whole course of the spine, and partic- ularly that part of it where the distortion is most evident; and it may be of advantage, as propo- sed by Dr. Dods, to direct the course of the ma- nipulation in a particular manner to such trans- verse processes of the vertebrae as appear pecu- liarly elevated, so as artfully, and by insinuation, to assist in restoring them to their proper posi- tion. It will also be found expedient in most cases to smear the hand with oil, or some other unctuous substance, in order to prevent the fric- tion from irritating or excoriating the skin. Those who ascribe the disease to a strumous diathesis in every instance, have of course a medical treatment of their own adapted to this view of the case. Such is the practice of Dr. Jarrold, who has lately written a treatise upon this subject containing many valuable hints, but who limits the seat of the malady to the in- tervertebral cartilages, as he does its cause to a strumous taint. His Materia Medica, therefore, for the present purpose, is nearly restricted to burnt sponge and carbonate of soda. " Conceiv- ing," says he, that " there might be some rela- tion between it and bronchocele, I have made use of similar remedies."—(Inquiry into the Causes of the Curvature of the Spine, &c, ut supra, p. 119.) To which he occasionally adds, when the debility is considerable, twenty drops of nitric acid daily. And with this simple pro- cess he tells us that he has been so successful in a restoration of health, strength, plumpness, and uprightness, that " medical treatment is sel- dom further required, unless the appetite and di- gestion be impaired." Not acceding to this causation, I have not tried the plan ; which seems here to have been far more successful than in bronchocele itself; even when the more powerful aid of iodine is called into co-operation, which it is singular that Dr. Jarrold does not appear to have had recourse to. To all the confederate means, however, of recumbency, friction, shampooing, pure air, and occasional exercise, he is peculiarly friendly : and as these have of themselves effected a cure in the hands of various other practitioners, it is not improbable that Dr. Jarrold is far more in- debted to such confederates than he is aware of, and that his auxiliaries have been of more service to him than his main force. It has been made a question of some impor- tance, which is the best position for a patient to rest in who is labouring under the complaint before us, or has a striking tendency to it; as also what is the best formed couch for him to recline uponl All seem to agree that the couch should be incompressible, or nearly so, in order that the weight of the body may be equally instead of une* qually sustained, and not one part elevated and another depressed ; and hence a mattress is judged preferable to abed, and a plain board is by many esteemed preferable to a mattress. It is also very generally agreed, that the board or mat- tress should form an inclining plane, so that the body, placed directly on the back, may be kept perpetually on the stretch: while Dr. Dods maintains, in opposition to this general opinion, that the line should be horizontal, or even cur- ved ; that a position on the back is by no means necessary ; and that a posture of extension can.- Gen. I.—Spe. 4] ENTASIA ARTICULARIS. 279 not fail of being injurious, and adding to the strength or extent of the disease. Either of these opinions may be right or wrong, according to the nature of the case ; and hence neither of them can be correct as X uni- versal proposition. Ease and refreshment are the great points to be obtained ; and whatever couch or whatever position will give the lar- gest proportion of these, is the couch or the po- sition to be recommended, whether that of su- pine extension or relaxed flexure.* Dr. Dods, who refers all kinds of lateral dis- tortion to debility of the fibres of the extensor muscles, prescribes an extended position in every instance ; and as already observed, recom- mends a curved relaxing couch in its stead, so that the patient may sink into it at his ease, in- stead of being put upon the stretch. The ad- vice is good so far as the opinion is correct, and the disease is dependant upon debility of the ex- tensor muscles alone ; for here nothing can af- ford so much ease to the patient as such an in- dulgence. But it is not to be conceded that the fibrous structure of these muscles forms the seat of the disease in every case, and conse- quently the recommendation will not always ap- ply ; for the flexor muscles may be affected,, or the debility be seated in the extensor ligaments, or the vertebral cartilages with which they are connected. I have at this moment under my care a lady just of age, who for four years past has been labouring under a slight affection of lat- eral distortion, feeling much more of it when- ever she suffers fatigue, or is affected in her spirits. A position strictly supine, and some- what extended, upon a hard mattress or a level floor, is the only posture that affords her ease, and takes off the sense of weight on the spine and oppression on the chest. She has often tried other positions, but in vain. To this, therefore, she has uniformly recourse after din- ner, and occasionally, at other times in the day as well. Pure country air has also been of great service ; but above all things, sea bathing. She has just returned from an excursion around the Devonshire coast. The first day's journey, though in a reclined position in an open landau- let, with every attention that could afford ease and accommodation, proved so fatiguing, and produced so much pain in the spine, that it was doubtful whether she would be able to proceed. A better night, however, than was expected, ca- pacitated her for another trial, and the fatigue was considerably less : on the third or fourth day she had an opportunity of beginning to bathe ; and by a daily perseverance in the same, was enabled, soon after reaching Teignmouth, to engage in long walks, climb its loftiest hills, and enjoy the entire scenery : her appetite became almost unbounded, and her flagging spirits were restored to vivacity. It is hence perfectly clear, that while that position and that mode of dress are most to be * The figures of several machines, invented by Dr. Wm. Grigg, and which have proved extremely useful in treating distortions of the spine, may be seen in the Boston Med. and Surg. Journal, vol. Si., p. 228.-D. recommended which afford the highest degree of ease arid comfort, gestation, pure air, sea- bathing, and every other kind of tonic, whether external or internal, are also of the utmost im- portance ; and that perfect and continued rest, in whatever position it be tried, is far less effica- cious than when interrupted by such motion as can be borne, though with some degree of fatigue, and the other tonic auxiliaries just ad- verted to. In extreme cases, indeed, such ex- ercise as is here adverted to should be postponed till the debilitated and, most probably, irritable organs, have lost some part of their disease ; yet the motion of friction or manipulation by a skil- ful and dexterous hand may still be adverted to, and should supply its place : and although the use of tight and girding stays cannot he too much reprobated as applied to growing girls in the full bloom and health of nature, and may well be accused as an occasional cause of the deformity before us; yet there is much sound- ness of judgment in Mr. Shaw's recommenda- tion of a dress of this kind, capable of giving support without cramping the form by too close a lacing, in cases where the complaint has in any considerable degree established itself, and the mischief is not now to be warded off, but to be prevented from becoming worse. In this case stays may not only be allowed, but " they should be made sufficiently stiff and strong to sustain the weight, which the muscles that have been deteriorated by want of action are unable to support."—(Further Illustrations on the Lat- eral or Serpentine Curvature of the Spine, &c, 8vo., 1825.) This, indeed, is the only mechan- ical aid that should be allowed; and if applied with caution, and without an uneasy restraint, they will often be found an auxiliary of great value. SPECIES IV. ENTASIA ARTICULARIS. MUSCULAR STIFF-JOINT. AND RIGID CONTRACTION OF ONE ARTICULAR MUSCLES OR THEIR PERMANENT OR MORE TENDONS. The joints of the limbs are as subject to muscular contractions as the neck, and in many instances from like causes: the following are the varieties of affection hereby produced :— a Irritata. From excess of action in Spastic stiff-joint. the muscles contract- ed. B Atonica. From direct atony in the Atonic stiff-joint. yielding muscles. y Inusitata. From long confinement Chronic stiff-joint. or neglect of use. Besides the ordinary causes of cold, inflam- mation, and strains, by which the first and sec- ond variety are produced, the former has some- times followed a sudden fright.—(Starke, Klin. Instil., p. 32.) Frcind, also, mentions a case in which it has been cured by a fright ( Vit. Ga- briel); and Baldinger.one in which it disap- peared on the revival of a suppressed eruption which had given rise to it.—(N. Magazin., band xi.^78.) Rheumatism has often produced it, ana particularly the second variety, in the joint of the knee and thigh-bone. In a case of the latter kind, it was success- fully attacked by Richter (Chir. Bibl., band x., 219) with a cautery of a cylinder of cotton. In this and the third variety, much benefit is often derived from repeated and long-continued fric- tion with a warm hand, or with some stimulant balsam or liniment. In an obstinate contraction of the fingers succeeding to a fractured arm, Dr. Eason relates an instance, in which the rigidity suddenly gave way to a pretty smart stroke of electricity after every other means had failed ; and the patient had the use of his fingers from this time.—(Edin. Med. Comment., v., p. 84.) Such exercise, moreover, or exertion of the limb, should be recommended, as it may bear without fatigue. The cold bath, as an anti- spasmodic, has sometimes been serviceable in the first variety,* and more frequently, as a tonic, in the second. Most men exhibit proofs of the third va- riety, or chronic stiff-joint, from a neglect of using many of their muscular powers : for nearly a fourth part of the voluntary muscles, from be- ing seldom called into full and active exertion, acquire a stiffness which does not naturally be- long to them; while many that by exercise might have been rendered perfectly pliant and obedient to the will, have lost all mobility, and are of no avail. Tumblers and buffoons are well aware of this fact, and it is principally by a cultivation of these neglected muscles that they are able to assume those outrageous postures and grimaces, and exhibit those feats of agility, which so often amuse and surprise us. It is a like cultivation that gives that measured grace and firmness, as well as erect position in walk- ing, by which the soldier is distinguished from the clown ; and that enables the musician to run with rapid execution, and the most delicate touch, over keys or finger-holes that call thou- sands of muscular fibres into play or into quick combinations of action, which in the untutored are stiff and immoveable, and cannot be forced into an imitation without the utmost awkward- ness and fatigue. SPECIES V. ENTASIA SYSTREMMA. CRAMP. SUDDEN AND RIGID CONTRACTION AND CONVOLU- TION OF ONE OR MORE MUSCLES OF THE BODY, MOSTLY OF THE STOMACH AND EX- TREMITIES : VEHEMENTLY PAINFUL, BUT OF SHORT DURATION. Systremma, literally "contortio, convolutio," " globus," is derived from avarpifu), " contor- queo," " convolvo in fascem." Stremma, the * In an example of this kind, brought on by a wound of one of the fingers, the editor applied a succession of blisters to the back of the hand and wrist; and the patient, a woman residing at Wey- bridge, was very soon enabled to extend her fingers again. 3TICA. [Cl. IV.—Ord. in. primary noun, is an established technical term for " strain, twist, wrench ;" and the author has hence been induced to add the present term to the medical vocabulary in the sense now offered, for the purpose of superseding and getting rid of crampus, which has hitherto been commonly employed, though at the same time commonly reprobated, as a term intolerably barbarous, de- rived from the German krampf. The proper Latin term is, perhaps, " raptus nervorum;" whence opisthotonia or opisthotonos is denomi- nated by the Latin writers " raptus supinus." But raptus is upon the whole of too general a meaning to be employed on the present occa- sion, unless with the inconvenience of another term combined with it. The parts chiefly attacked with cramp are the calves of the legs, the neck, and the stomach. The common causes are sudden exposure to cold, drinking cold liquids during great heat and perspiration, eating cold cucurbitaceous fruits when the stomach is infirm and incapable of digesting them, the excitement of transferred gout, and overstretching the muscles of the limbs; in which last case it is an excess of reaction produced by the stimulus of too great an exten- sion. Hence many persons are subject to it, and especially those of irritable habits, during the warmth and relaxation of a bed, and particu- larly towards the morning, when the relaxation is greatest, the accumulation of muscular or irritable power most considerable, and the ex- tensor muscles of the legs are strained to their utmost length, to balance the action which the flexor muscles have gained over them during sleep. Cold night-air is also a common cause of cramp, and it is a still more frequent attend- ant upon swimming, in which we have the two causes united of cold and great muscular exten- sion. An uneasy position of the muscles is also in many cases a sufficient cause of irritation; and hence we often meet with very painful cases of cramp in pregnant women, down the legs, or about the sides, or the hypogastrium. When the hollow or membranous muscles are affected, they feel as though they were puckered and drawn to a point; the pain is agonizing, and generally produces a violent perspiration ; and if the stomach be the affected organ, the dia- phragm associates in the constriction, and the breathing is short and distressing. If the cramp be seated in the more fleshy muscles, they seem to be writhed and twisted into a hard knot; and a knotty induration is perceivable to the touch, accompanied with great soreness, which con- tinues for a long time after the balance of power has been restored. In common cases where the calves of the legs are affected, an excitement of the distressed muscles into their usual train of exertion is found sufficient; and hence most people cure themselves by suddenly rising into an erect po- sition. I have often produced the same effect, and overcome the reaction without rising, by forcibly stretching out the affected leg by means of other muscles, whose united power over- matches that of the muscle that is contracted. Warm friction with the naked hand, or with Gen. I.—Spe. 6.] ENTASIA TRISMUS. 281 camphorated oil or alcohol, will also generally be found to succeed. A forcible exertion of some remote muscles, which thus collects and concentrates the irritable power in another quar- ter, will also frequently effect a cure ; and it is to this principle alone, I suppose, we are to refer the benefit which is said to arise from squeezing strenuously a roll of brimstone, which suddenly* snaps beneath the hold. The brimstone snaps from the warmth of the hand applied to it; but its only remedial power consists in affording a something for the hand to grasp vehemently, and thus excite a sudden change of action. Where the stomach is affected, brandy, usque- baugh, ether, or laudanum, affords the speediest means of cure; and it is often necessaiy to com- bine the laudanum with one or other of the pre- ceding stimulants. Here also the external ap- plication of warmth, and diffusable irritants, as hot flannels moistened with the compound cam- phire liniment, are found in most cases pecu- liarly beneficial. Exciting a transfer of action to the extremities, as by bathing the feet in hot water, or applying mustard sinapisms to them, is frequently of great advantage ; as is the use of hot, emollient, and anodyne injections, whose palliative power reaches the seat of spasm by sympathetic diffusion, and often affords con- siderable quiet. Here, also, the patient should be particularly attentive to his diet and regimen, confining himself to such viands as are most easy of digestion, and least disposed to rouse the stomach to a return of these morbid and anoma- lous actions; for a habit of recurrence is soon established, which it is difficult to break off. In pregnancy, where the crampy spasms are often migratory and fugitive, the position should frequently be changed, so as to remove the stimulus of uneasiness by throwing the pressure upon some other set of muscles; and if the stomach be affected with gout, opium, rhubarb, chalk, or aromatics, should be taken on going to rest. The best preventives when the cause is con- stitutional, are warm tonics, and habituating the affected muscles to as much exercise as their strength will bear : and hence the same forcible extension used in swimming which produces cramp the first or second time of trial, will rarely do so afterward. Cramp is also found as a symptom, and as one of the severest symptoms of the disease, in various species of colic and cholera; in which cases it must be treated according to the meth- ods already pointed out under those respective heads. SPECIES VI. ENTASIA TRISMUS. LOCKED-JAW. PERMANENT and rigid FIXATION OF the mus- cles OF THE lower jaw. This disease is by the French writers called tic. The technical term is derived from the Greek rpl^u, "to gnash or grind the teeth;" which, like the French synonyme, is supposed by the lexicographers to be an onomatopy, or a word formed from the sound that takes place in the act of gnashing. In truth, it was to a disease in which morbid gnashing formed a symptom, that both the Greek and French term were originally applied ; for the trismus of the old writers consisted, not of a ri- gid, but convulsive or agitatory spasm of the lower jaw; an affection comparatively trifling, and rarely to be met with, and when it does oc- cur, appertaining to the clonus of the present system of nosology, the clonic spasm of authors in general. And the use of trismus or tic to im- port a state of muscle directly opposed to that which it first indicated, is another striking proof of the incongruous change which is perpetually occurring in the nomenclature of medicine, for the want of established rules and principles to give fixation and a definite sense to its respect- ive terms. Dr. Akerman is the only writer of reputation I am* acquainted with in recent times who has used trismus in its original intention, or rather, who has united its original with its modern meaning. For he employs the term generical- ly; and arranges under it the two species of trismus tonicus, being that now under consider- ation, and trismus clonicus, or the disease it ori- ginally denoted. But this arrangement is uncall- ed for and inconvenient, and has not been re- ceived into general use ; the term trismus being, with every writer of the present day, limited to the first of these two species alone, notwithstand- ing the origin of the word. And hence, as it is so generally and completely understood, there would be an affectation in changing it for any other. The Germans call it kinnbakkenzwange, which is precisely parallel with the locked-jaw of our own tongue. Dr. Cullen, in the first edition of his Nosolo- gy, made trismus and tetanus, our next species, distinct genera ; but he altered his opinion be- fore the publication of his First Lines, and re- garded them as nothing more than degrees or varieties even of the same species. " From the history of the disease," says he, " it will be evi- dent, that there is no room for distinguishing the tetanus, opisthotonos, and trismus or locked- jaw, as different species of this disease, since they all arise from the same causes, and are al- most constantly conjoined in the same person." —(Pract., of Phys., book iii., sect, i., chap, i., § 1267.) In consequence of which, in the later editions of Dr. Cullen's Synopsis, in which the supposed error is attempted to be corrected, the disease is introduced with a very singular de- parture from nosological method : for first, teta- nus is employed as the term for a distinct genus, defined " a spastic rigidity of many muscles ;" and next, under this generic division are given no species whatever, but two varieties of degree alone ; to the first of which is again applied the name of tetanus, defined " the half or whole of the body affected with spasms," and to the second that of trismus, defined " spastic rigidity, chiefly of the lower jaw." Passing by this irregularity of method, the proper view of the subject seems to lie in a 282 NEUROTICA. [Cl. IV.—Ord. III. middle course ; in contemplating trismus and tetanus, not as distinct genera, or mere varie- ties of a single disease, but as distinct species of a common genus; and under this view it is contemplated in the present arrangement. Tris- mus bears the same relation to tetanus as syno- chus does to typhus: the two former, like the two latter, may proceed from a common cause and require a similar treatment; and the first may terminate in the last. But trismus, like sy- nochus, may run its course alone, and continue limited to its specific symptoms. And as Dr. Cullen has thought proper to make synochus and typhus distinct genera, he ought at least to have ranked trismus and tetanus as distinct species. Trismus is found in all ages, sexes, tempera- ments, and climates. In warm climates, how- ever, it occurs far more frequently than in cold ; and chiefly in the hottest of warm climates. Dr. Cullen observes, that the middle-aged are most susceptible of the disease, men more so than women, and the robust and vigorous than the weakly. Other animals are subject to this complaint as well as man, particularly parrots ; and from many of the causes (Bajon. Abhand- lungen von Krankheit. auf der Inset Cayenne, &c.) that affect the human race. These causes, for the most part, are chilliness and damp operating upon the body when heated, and hence sudden vicissitudes of heat and cold ; wounds, punctures, lacerations, or other irrita- tions of nerves in any part of the body ; whence it has not unfrequently followed venesection when unskilfully performed (Delaroclte, Journ. de Med., torn, xv., p. 213; Forestus, lib. x., obs. iii.; Schenck, obs. 1., i., N. 250), and still more frequently amputation, worms, or irritation in the stomach and bowels, especially in those of in- fants. We have thus the three following varie- ties offered to us, which, however, chiefly differ in symptoms peculiar to the period of life in which the disease is most disposed to show it- self, or in the interval between the casual ex- citement and the spastic action :— a Nascentium. Attacking infants during the first fortnight after birth. Locked-jaw of infancy. B Algidus. Catarrhal lock- ed-jaw. Occurring at all ages, after exposure to cold and damp, especially the dew of the evening, the symptoms usually appearing within two or three days. y Traumaticus. Occurring as the conse- Traumatic lock- quence of a wound, punc- ed-jaw. ture, or ulcer, with'partic- ular frequency in hot cli- mates ; and rarely appear- ing till ten days or a fort- night after local affection. The pathology is highly difficult, if not mys- terious, and has hence been purposely avoided by most preceding writers. Dr. Cullen express- ly avows that he " cannot in any measure at- tempt it."—(Pract. of Phys., book iii., sect, i., chap, i., § 1269.) There is one principle, how- ever, to which I have frequently had occasion to direct the reader's attention, which will help us in a considerable degree to develop some- thing of its obscurity, and to account more espe- cially for so remote a separation between the seat of primary irritation and that of spasmodic excitement, which constitutes, perhaps, its most embarrassing feature. The principle I allude to is the sympathy that prevails throughout the whole of any chain of organs, whether continuous or distinct, engaged in a common function, and which is particularly manifest at its extremities ; so that let a morbid action commence in what- ever part of the chain it may, the extremities in many instances become the chief seat of distress, and even of danger. We had occasion to notice this law of the animal economy when treating of parapsis illusoria, or that imaginary sense of feeling and of acute pain in a limb that has been amputated and is no longer a part of the body, which we referred to the principle before us ; and farther noticed, by way of illustration, the pain often suffered at the glans penis from the mechanical irritation of the neck of the blad- der by a calculus. So, irritating the fauces with a feather excites the stomach, and even the diaphragm, to a spasmodic action, and the con- tents of the organ are rejected. Irritating the ileum, as in ileac passion, produces the same ef- fect upon the stomach and oesophagus; at the same time that the other extremity of the canal is attacked with rigid spasm, and consequently with obstinate costiveness : while in cholera both extremities are affected in a like way, and we have hence both purging and vomiting. It is to the same principle we are to ascribe it, that when the surface of the body is suddenly chill- ed, as on plunging into a cold bath, the bladder becomes irritated, and evacuates the contained urine : and in treating of marasmus we had oc- casion to show, that while in one of its species the disease seems to commence in the digestive, and in another in the assimilating organs, consti- tuting the extreme ends of a very long and com- plicated chain of action, it very generally hap- pens, that at which end soever the decay com- mences, the opposite end is very soon affected equally. In a continued chain of nervous fibres, how- ever, this principle of sympathy, which induces remote parts, and particularly remote extremi- ties, to associate in the same morbid action, is peculiarly conspicuous. Hence, if a long muscle be lacerated in any part of its belly, the tendi- nous terminations are often the chief seat of suf- fering. As the ulnar nerve sends off twigs from the elbow to supply the forearm and fingers, a blow on the internal condyle of the humerus gives a tremulous sensation through the forearm and hand : and as the ulnar nerve itself is only an offset from a plexus or commissure of the cer- vical nerves, which also give a large branch to the scapula, a paralysis of the ring or little fin- ger has sometimes been removed by stimulating the scapular extremity by a caustic applied at the internal angle of the scapula. In inflam- mation of the liver, a severe pain is often felt at the top of the shoulder; and in palpitation of the heart, at the left orifice of the stomach. Gen. I.-Spb. 6.] ENTASIA TRISMUS. 283 Both these are to be accounted for by recollect- ing that the radiations of the phrenic nerve ex- tend in an upper line to the shoulder, and in a lower to the diaphragm, which constitutes its extreme points; and that one of its branches passes over the apex of the heart. Now as the under surface of the diaphragm participates, from its contiguity, in an inflammation of the liver, the top of the shoulder suffers, as forming the extreme point of the phrenic chain by which these organs are connected; and as the upper surface of the diaphragm is in direct contact with the left and very sensible orifice of the stomach, an uneasiness at the apex of the heart becomes the cause of irritation to this orifice in consequence of its connexion with the dia- phragm, and hence, of necessity, with the lower branch of the phrenic nerve at its extreme dis- tribution. These remarks apply with particular force to the disease before us, and many others of the same class with which it has a close analogy, as tetanus, lyssa, and hemicrania. And although, from the intricacy of the intersections and decus- sations with which various nerves pursue their radiating courses, it is impossible for us, in many instances, to determine why one line of connex- ion suffers while another remains unaffected; yet in most instances we may be able, by an accurate survey, to trace the catenation, and hence to obtain some insight into the physiology of these exquisitely curious and complicated dis- orders. In mapping the nervous ramifications which give rise to trismus or locked-jaw, we must re- gard the ganglionic system, consisting of the various branches of the intercostal trunk, ani the numerous branches which unite with it from the whole line of the spinal marrow, as consti- tuting the centre; and as from this centre we perceive ramifications radiating in every direc- tion to the face, the entire length of the back, the upper and lower limbs, and the thoracic and abdominal viscera, we see a foundation laid, even by a continuous chain, for an association of re- mote parts and even extreme points in morbid changes, though we may not be able, satisfacto- rily perhaps, in any instance, to trace out the in- dividual line by which the diseased action is carried forward, and to separate it from other lines with which it is inextricably interwo- ven. Thus, in the case of trismus nascen- tium, forming the first variety under the present species, the irritation of the nerves of the stom- ach, which is very clearly the primary seat of disease in most cases, is propagated directly to the central branches of the ganglionic system by the tributary offsets which the stomach receives from it. But we have already observed, that the chief contribution to this grand junction canal is derived from the intercostal nerve itself. In the first instance, an arm from the trigeminus or fifth pair of nerves, two branch- es of which radiate upwards, constitute the maxillaris superior and maxillaris inferior, and are lost in the muscles of the jaws : so that the upper extremity of the nervous line distribu- ted over the stomach is the nerves of the jaws themselves; while various branches of the fifth occasionally unite with the portio dura, or respi- ratory trunk of the seventh pah, which divari- cates not only to the diaphragm, but over all the muscles that have the remotest connexion with the respiratory system. And hence, agreeably to the law of the animal economy we have just pointed out, the muscles of the jaws, forming this extremity in the chain of morbid action, are the organs in which we may expect an irritation of the nerves of the stomach in various instances to manifest itself most strikingly. In like manner we may account for the second and third varieties of trismus, or that produced by a chilly dampness or irritative vio- lence applied to the upper or lower extremities : for as these are all supplied by nerves from the vertebral source, which, we have already re- marked, gives off branches from every aperture in the spine to the ganglionic system, and as this system, at its upper end, terminates in the maxillary branches of the fifth pair of nerves, the muscles into which these nerves are distrib- uted constitute one extreme point of a long chain of nervous action, while those of the up- per and lower limbs constitute the other. And hence the same law which produces a spastic fixation of these muscles in certain irritations of the stomach, may reasonably be expected to operate with like effect in certain irritations of the upper and lower limbs. And as the inter- costal nerve, at its first rise from the common source of itself and the maxillary branches, re- ceives also, in its progress, offsets from the sixth, seventh, eighth, and ninth pairs of cere- bral nerves, as well as from all the vertebral, and as all these, in consequence of such an in- terunion and decussation, are sending forth branches over the muscles of the back, the chest, and the thorax, there is no difficulty in conceiving, when a rigid spasm has once commenced in the lower jaw, why it should be propagated through any of the muscles apper- taining to these parts of the system, or even originate in them from any of the causes that excite locked-jaw, and hence lay a foundation for tetanus as well as trismus, both as a primary and a secondary disease. And I have touched upon this subject now, that we may not have to repeat the present explanation when treating of tetanus in its proper place.* * See Cloquet, Traite d'Anatomie Descriptive. Bock Beschreibung des fiinften Nervenpaares und seiner Verbindungen mit anderen Nerven, vorzug- lich mit dem Ganglien Systeme, Leips., 1817. The whole of the above hypothesis is only an at- tempt to explain the origin and extension of teta- nic disorders, by the intricate communications of the nerves of different parts of the body. The view of the pathology of tetanic affections enter- tained by Dr. Elliotson is, that they depend upon a peculiar state of that part of the brain, or spinal marrow, which is immediately connected with the nerves of the voluntary muscles. The mind is unaffected, and so is sensibility. The disorder appears to be an affection of the voluntary mus- cles through the medium of the voluntary nerves, and those parts of the brain and spinal marrow with which they are connected.—See Dr. Elliot. 284 NEUROTICA. [Cl. IV.—Ord. Ill- Bajon should place one of its chief residences at Cayenne (Bajon, Abhandlung von Krank- heit. auf der Insel Cayenne, &c, Erp. 1781), or that Akerman should assert it to be endemic in Guinea. In the second variety of the disease, or that proceeding from cold or night dew, the symptoms often appear within a day or two after exposure to the exciting cause. It is not common that the spasm extends to the muscles of the chest or back, so as to produce tetanus, though there is often an uneasy sensation at the root of the tongue, with some difficulty in swallowing liquids after their introduction into the mouth; the disease thus making an approach towards lyssa, or canine madness, in its symptoms, as we have just endeavoured to show that it does in its physiology. According to the observations of Baron Larrey, indeed, this approach is in many instances very considera- ble ; for he informs us, that on post-obituary examinations he has often found the pharynx and oesophagus much contracted, and their in- ternal membranes red, inflamed, and covered with a viscid reddish mucus. Dr. Hennen, however, does not place much dependance upon any such appearances : he admits, nevertheless, that they are to be traced occasionally, though he ascribes them more to an increased flow of blood, consequent on increased action, than to any other cause.—(Principles of Military Sur- gery, 246.) In thia variety, from the slighter nature of its attack,' the patient not unfrequently recovers by skilful medical treatment, and there are un- questionably instances of spontaneous recovery (Briot, Hist, de la Chirurgie Militaire en France, &c, 8vo., Besancon, 1817), though cases of this kind are very rare. The intellect remains unaffected, there is little quickness of the pulse, sometimes none whatever, and little or no disorder of any kind, though the bowels are usually very costive. If the patient pass the fourth or fifth day, we may begin to have hopes of him; for the spasmodic constriction will then frequently remit or intermit; but as, even in the last case, it is apt to return at un- certain intervals, there is still a considerable danger for many days longer. When, as in the third variety, the disease proceeds from a nerve irritated by a wound* or In the simplest state of trismus, indeed, there is some degree of stiffness found at the back of the neck, and even in the sternum. The dis- ease in some cases, shows itself with sudden violence, but more usually advances gradually; till at length the muscles that pull up the jaw become so rigid, and set the teeth so closely together, that they do not admit of the smallest opening. In tropical climates, for Dr. Cullen's remark that it is most common to the middle-aged, only applies to the temperate regions of Europe, children are particularly subject to'this com- plaint, and with a few peculiarities, which, though producing no specific difference, are suf- ficient to establish a variety. The disease in this case is vulgarly known by the absurd name of falling of the jaw. It occurs chiefly be- tween the ninth and fourteenth day from birth ; seldom after the latter period. Without any febrile accession, and often without any per- ceptible cause whatever, the infant sinks into an unnatural weariness and drowsiness, attended with frequent yawnings, and with a difficulty, at first slight, of moving the lower jaw, which last symptom takes place in some instances sooner, in others later. Even while the infant is yet able to open its mouth, there is, occasionally, an inability to suck or swallow. By degrees, the lower jaw becomes rigid, and totally resists the introduction of food. There is no painful sensation ; but the skin assumes a yellow hue, the eyes appear dull, the spasms often extend Over the body, and in two or three days the disease proves mortal. The ordinary cause is irritation in the intes- tinal canal. Hence viscid and acrimonious me- conium frequently produces it; as worms are said also to do some months after birth. It seems, moreover, in some instances, to have followed from irritation in tying the navel-string,* its not being properly attended to afterward, in which case, though the stomach may be affected by contiguous sympathy, the disease makes a near approach to the third or traumatic variety. Yet the appearance of the spastic ac- tion is as early as where the stomach is prima- rily affected. In cold and even mountainous countries, this variety is also sometimes found. " I am in- formed," says Dr. Cullen, "of its frequently occurring in the Highlands of Scotland; but I never met with any instance of it in the low country."—(Loc. citat.,y 1281.) Whether, ac- cording to the conjecture of this celebrated writer, it is more common to some districts than to others, has not been sufficiently deter- mined. " It seems," says he, " to be more frequent in Switzerland than in France." Hot climates, however, constitute its principal do- main ; and hence it is not very surprising, that son's. Lectures on Medicine, as delivered at the Univ. of London, and reported in Med. Gaz. for 1832-3, p. 470.—Ed. * Two cases of trismus, arising from this cause, have occurred in the practice of Dr. Francis ; in one of these there was considerable hemorrhage from the cord.—D. * Trismus traumaticus sometimes follows sur- gical operations, and very frequently lacerated wounds of the fingers, toes, and other tendinous parts. The editor has seen several cases of it brought on by gunshot injuries, amputation, cas- tration ; and he knew of one instance in which it was induced by the amputation of a cancerous breast. In warm climates it occurs from very slight causes, and hence is much more frequent in them than in temperate and cold countries. A wound will sometimes not produce the disease till the person is suddenly exposed to cold, and then he will have it immediately. Last autumn, the editor saw an example of this in a farmer, who had met with a lacerated wound of the scalp, by being thrown from his horse : from this accident he was recovering in the most favourable way ; but on going out into the cold air, at the end of a Gen. I.—Spe. 7.] ENTASIA TETANUS. 285 a Anticus. Tetanus of the flexor mus- Tetanic procur- cles. The body rigidly vation. bent forwards. 0 Dorsalis. Tetanus of the extensor Tetanic recurva- muscles. The body ri- tion. gidly bent backward. y Lateralis. Tetanus of the lateral mus- Tetanic transcur- cles. The body rigidly vation. bent laterally. 8 Erectus. Tetanus of both the poste- Tetanic inflexi- rior and anterior mus- bility of the cles. The body rigidly body. erect. The first of these varieties is the empros- thotonos of early writers ; the second the opis- thotonos ; the third the pleurosthotonos of authors of a later date ; the fourth the proper tetanus of Dr. Lionel Clarke and a few others. To these varieties it has been usual to add the singular disease called catochus ; which by Sau- vages, Cullen, and various other authorities, is regarded as closely connected with this species. It has a near affinity to it unquestionably, and hence, out of deference to concurrent opinions, it was suffered to stand as a variety of tetanus in the first edition of the author's Nosology; but with a note intimating that it seems rather to belong to the genus carus of the fourth order of the present class, and to be a modification of the species ecstasis, under that genus : and as this appears to be its proper place, it will now be found arranged there accordingly. The general physiology, so far as it seems capable,of elucidation, has been already given under the preceding species; the proximate cause being that of a peculiar irritation of a cer- tain chain or association of nerves, chiefly oper- ating with the greatest violence at the two ex- tremities of the morbid line. This irritation seems, in many instances, to consist in inflam- mation ; and hence is made a common cause by many of the most valuable writers of the pres- ent day. Professor Frank seems first to have started the idea, and he has been followed in succession by Dr. Saunders of Edinburgh, Dr. Chisholm, Dr. James Thomson, and Dr. Aber- crombie, who have been upheld in Italy by MM. Brera, Rachetti, and Bergamaschi, and in France by M. Esquirol. Bergamaschi* advan- ces, indeed, so far as to maintain, that where sore, the spasmodic symptoms are much later in showing themselves ; and sometimes do not make their appearance till eight or nine days aftej-ward, occasionally, indeed, not at all till the wound is healed. The disease is more dan- gerous in proportion to the delay ; the adjoining muscles of the face become more affected, and, as is already observed, the spasms often shoot downward into the back or chest, and trismus is complicated with tetanus. The breathing is nasal and abrupt, the accents are interrupted and slow, and uttered by the same avenue ; the muscles of the nose, lips, mouth, and the whole of the face, are violently dragged and dis- torted, and the patient sinks from nervous ex- haustion and want of nutriment, the jawbone being set so fast that it will often break rather than give way to mechanical force. The disease, from this cause, is generally fatal; and we are indebted to the ingeniousness of Sir James M'Grigor and Dr. Hennen for a confession that, whatever remedies wore em- ployed in the British army, whether in India or in Spain, the mortality was nearly the same. But as the treatment of the present variety and the ensuing species should be founded on a like principle, we shall reserve this subject till we have entered upon a distinct history of the latter. SPECIES VII. ENTASIA TETANUS. TETANUS. PERMANENT AND RIGID FIXATION OF MANY OR ALL THE VOLUNTARY MUSCLES ; WITH IN- CURVATION OF THE BODY, AND DYSPNOEA. Tetanus is derived from riralvia, which itself is a derivative from rclva, " tendo, extendo." Like trismus, it is a term common to the early Greek writers, among whom it was used synon- ymously with opisthotonos and emprosthotonos, though the two latter were afterward employed to express two distinct modifications of the dis- ease. From peculiarities in the seat or mode of its attack, this species offers us the four following varieties:— fortnight, when the wound was nearly healed, he was attacked with trismus, which soon assumed the form of universal tetanus, and he died in about six or seven days from the commencement of the disorder. Tetanus occurs in all conditions of wounds; in some of a healthy, and others of an unhealing appearance: sometimes also when they are almost, or even entirely, healed up. It oc- curs, too, whether the wound be large or small. Dr. Elliotson had a case of tetanus, as severe as any he ever saw, where there had been merely a contusion of the thumb. There was no pain, no irritation; the nail was separated and loose, but under it all was dry, and no secretion was going on. A case is mentioned in the Trans, of the Lond. Med. Society, in which the disease occurred after a burn, at the time when there was merely a dry scab on the leg, and no inflammation around it; nay, as Dr. Elliotson observes, the dis- ease has sometimes declined and ceased, while the wound every day grew worse and worse. In Egypt, the wounded of the French army were found by Larrey to be safe from traumatic tetanus, if they were "not attacked by it before the sixteenth day. Sir Gilbert Blane has known the disease commence at all periods of a wound between the second day and the end of the fourth week. In Spain and Portugal, Sir James M'Grigor found the twenty-second day the limit. Dr. Murray re- lates an instance in which a midshipman trod on a rusty nail one evening at nine o'clock; and, after exposing himself to the cold night air in keeping watch, had tetanic symptoms on the following morning at eight o'clock.—(See Lond. Med. Gaz. for 1832-3, p. 623.) In hot countries the disease has been known to follow a local injury directly after its occurrence.—Ed. * Osservazioni Medico-pratiche sul Tetano. Giornale di Medicina practica del Sig. Cons, e Prof. Cav. V. L. Brera. 286 NEUB wounds themselves, of whatever form, are the remote cause, a neurostenia,"as he calls it, or inflammatory affection of the nerves, is still the proximate cause; extending itself from the wounded part, by the nervous extremities, to the spinal marrow and the brain, or, vice versd,fxom the brain to the spinal marrow and principal nerves, and thence to the parts that are subser- vient to locomotion. Dissection, however, is very far from giving proofs of such inflamma- tory change in every instance ; while in many cases the disease is of too fugitive a character, and makes its seizure or its disappearance too rapidly, for the more measured progress of in- flammation.* The exciting causes are also for the most part those of trismus ; though it appears in infancy far less frequently, unless as a concomitant of that disease. Damp and cold, therefore, and simple nervous irritation from woundst or sores in hot climates and crowded hospitals, are the chief sources of its production ; and where these accessories exist, terror seems to be a powerful auxiliary, and has alone, in some instances, been sufficient for-its production. "Passion or ter- ror," says Dr. Hennen, " after wounds and op- erations, has been known to produce the disease in some ; and sympathy, though a rare cause, in others." It is said also to have been produced by insolation or exposure to the direct rays of the sun (Pathol., lib. v., p. 372); and has un- questionably followed, as M. Magendie and nu- merous other French authors (Desportes, Raf- fenean, Fonquier, Dupuy) have abundantly shown, from various irritant narcotics, as strych- nine, or the active principle of nux vomica, as * Dissections reveal no appearance of any regu- lar or constant description in the bodies of persons who die of tetanus. In most cases nothing re- markable is met with; and hence the best modern pathologists all agree, that when morbid changes are noticed, they are not essential, but incidental. Sometimes there are traces of inflammation of the spinal marrow ; though if the weather be hot and the body not examined promptly, the coverings of the spinal marrow will look red, though no inflam- mation may have existed in it.—Ed. t Dr. Armstrong mentions that one of his friends, who had had extensive experience in hot climates, never knew a case of tetanus occur without local injury; and he was led to believe that such was the fact by a careful examination of the whole sur- face of the body.—(See Lectures on the Morbid Anatomy, Nature, and Treatment of Acute and Chronic Diseases, p. 742, 8vo., Lond, 1834.) There can be no doubt, however, that many cases of te- tanus are idiopathic, and not traumatic, because we know that the latter are infinitely more diffi- cult to control, and more frequently fatal. Dr. Armstrong states that the local injuries which most frequently produce tetanus are those which are accompanied with friction. Lacerated or punctured wounds of tendinous parts, injuries of the fingers, thumb, or toes; dislocations, especially compound ones; burns, scalds, and ulcers, may be exciting causes of traumatic tetanus; and what is remarkable, the disorder may come on, as al- ready noticed, when the wound or sore is healing, or nearly healed. It may be produced by the ir- ritation of a seton, an issue, the partial division of a nerve or the inclusion of it in a ligature.—Ed. DTICA. [Cl. IV.-Ord. III. also from galvanism, when raised to a sufficient power for the purpose. Lateral tetanus is very rarely to be met with, and seems to be rather a chronic than, an acute malady. Fernelius, who first described it (Med. Obs. and Inq., vol. vi.), gives a case in which it occurred annually, but only in the win- ter, during which season the patient had two or three paroxysms daily : the head was first at tacked with a peculiar vibratory feeling, which gradually descended to the neck, with a sensation of cold ; and by the time it reached the scapula was immediately succeeded by symptoms of opisthotonos, and afterward of lateral contrac- tion ; during which the mind and external senses were unaffected, but the flexor muscles were so firmly fixed, that no antagonist force of the by- standers was able to overpower the contortion. Nor are the other varieties nearly so frequent as trismus, except where they form a subsequent part of the general chain of morbid action. My observant friend, Dr. Hennen, confesses that, during the whole period of his superintending the British hospitals in Spain, he never met with but one case of emprosthotonos, and even this he describes as an incurvation that rather ap- proached it than constituted the disease itself. " It was observed," says he, " at the same time and in the same hospital, with the various de- grees of trismus : rigid spasms of almost every muscle of the body, and violent periodical con- vulsions, all from similar injuries to that in which it was produced."—(Military Surgery, p. 247, 8vo., Edin., 1820.) From the complicated manner, indeed, in which tetanus shows itself, and its anomalous attack upon different sets of muscles at the same time, it seems in many instances to put all the subordinate divisions of classification at defiance. It is, in truth, for the most part, a mixed dis- ease, affecting various and opposite sets of mus- cles ; and this in many cases so equally, that the spastic action of the flexors just balancing that of the extensors, "the patient," to adopt the language of Dr. Lionel Clarke, " seems often to be braced between opposite contractions." It is to this form, indeed, that this last very intel- ligent writer has limited the name of tetanus, as that to which it applies most emphatically. Like Dr. Hennen, he asserts that he had never seen a single case of genuine emprosthotonos ; and that of the other two varieties of which he treats, the opisthotonos and proper tetanus, the former occurs most frequently.* In opisthotonos, or tetanic recurvation, the symptoms sometimes show themselves sud- denly, but more commonly advance slowly and * According to Baron Larrey, who had extensive opportunities of seeing tetanus while he was ser- ving with the French army in Egypt, it appears that in that country, when the wound was in the back, tetanus commonly assumed the form of opisthoto- nos ; but if the wound happened to be in the ante- rior part of the trunk, and tetanus followed, the latter was generally in the shape of emprosthoto- nos. Sir Gilbert Blane published two cases, where the side of the body on which the local injury was situated became the seat of tetanic disorder.__Ed. Gen. I.—Spe. 7.] ENTASIA TETANUS. 287 imperceptibly, the patient mistaking the uneasy stiffness which he feels about the shoulders and cervical region for a crick in the neck, produced by cold and rheumatism. The stiffness, how- ever, increasing, he finds it impossible to turn his head on either side without turning his body : he cannot open his jaws without pain, and he has some difficulty in swallowing. A spastic and aching traction now suddenly darts at times towards the ensiform cartilage, and thence strikes through to the back, augmenting all the previ- ous symptoms to such a degree, that the patient is no longer able to support himself, and is com- pelled to take to his bed. The pathognomonic symptom in this variety is the spasm under the Bternum, which is perpetually increasing in ve- hemence ; and instead of returning, as at first, once in two or three hours, returns now every ten or fifteen minutes. Immediately after which all the host of concomitant contractions renew their violence, and with additional severity : the head is forcibly retracted, and the jaws snap with a fixation that rarely allows them to be af- terward opened wide enough to admit the little finger. This vehemence of paroxysm may not, perhaps, last longer than for a few minutes or even seconds ; but the spastic action prevails so considerably, even through the intervals, that it is difficult for an attendant to bend the contorted limbs into any thing like an easy or reclined position.* The breathing is quick and laborious ; and the pulse, though calm and less hurried, small and irregular. The face is sometimes pale, but oftener flushed; the tongue stiff and torpid, but not much furred ; the whole counte- nance evinces the most marked signs of deep distress ; and swallowing is pertinaciously ab- stained from, as accompanied with great diffi- culty, and often producing a sudden renewal of the paroxysms. The last stage of the disease is truly pitiable. The spasms return every minute, and scarcely allow a moment's remis- sion. The anterior muscles join in the spastic action, but the power of the posterior is still dominant; and hence, while every organ is lit- erally on the rack from the severity of the an- tagonism, the spine is more strongly recurvated than ever, and forms an arch over the bed, so that the patient rests only on the back part of the head and on the heels., During the exacer- * One symptom, very characteristic of the dis- ease, is the pain at4the scrobiculus cordis. As Dr. Elliotson observes in his invaluable Lectures on the Practice of Medicine, it is a pain not increased pressure, but a sudden, violent, sharp, stabbing l^in ; it may be more or less constant, but at peri- ods u is exceedingly severe. Then the spasmodic rigidity of the muscles is constant, not convulsive ; not a spasm alternating with relaxation. The pe- culiar posture into which the body is drawn in opisthotonos, emprosthotonos, and pleurosthoto- nos, and the closed or nearly closed state of the jaw in trismus, without any inflammation, or any organic disease near the part to account for such closure, are all so many circumstances throwing light on the diagnosis. There is no terror in this disease, no excitement of mind, no morbid corpo- real sensibility, no fear of noise, light, a current of air, &c, as in hydrophobia.—Ed. bation of the spasms, the lower extremities, even while they continue rigid, are so violently jerked that the utmost attention is necessary to prevent the patient from being projected from his bed: and Desportes gives a case, in which both the thigh bones were broken from the violent con- traction of the flexor muscles during a moment- ary remission of the extensors (Hist, des Mala- dies de St. Domingue, ii., p. 171); similar re- sults to which we shall have occasion to notice hereafter. The tongue is in like manner darted spasmod- ically out of the mouth, and the teeth snapped suddenly and with great force ; so that unless a spoon covered with soft rags, or some other in- tervening substance, is introduced between the teeth at such periods, the tongue must be mis- erably bitten and lacerated.* The exertion is so laborious, that the patient sweats as in a hot bath; and the heat has in some instances been raised to 110° Fahrenheit. The pulse is at this time small and irregular; the heart throbs so violently that its palpitations may be seen ; the eyes are sometimes watery and languid, but more commonly rigid and immoveable in their sockets ; the nostrils are drawn upward, and the cheeks backward towards the ears, so that the whole countenance assumes the air of a cynic spasm or sardonic grin, while a limpid or bloody froth bubbles from the lips. There is sometimes delirium, but this is not common: the patient is worn out under this laborious agony in a few hours; though mo»e usually a general convulsion comes to his relief, and he sinks suddenly under its assault. In the erect tetanus, in which there is a balance of spastic action between the anterior and posterior sets of muscles, the progress of the disease is not essentially different. The march of the spastic action, however, varies in some degree, as we have already observed, in almost every instance, from trismus to tetanus, and from one modification of tetanus to another : yet the course we have now described is that which chiefly takes place where the disease ad- vances in something of a regular and uninter- rupted progress. Its danger and duration are commonly to be estimated from the degree of violence of the incursion. Where this is very severe, the patient rarely survives the third day, and is sometimes cut off on the second, or even in six-and-thirty or four-and-twenty hours. But where the attack is less acute, the patient may continue to suffer for a week before he reaches his tragic termination. If he have strength enough to survive the ninth day, he commonly recovers; for the paroxysms diminish in vio- lence, the intervals of remission are longer, and the muscles being generally more relaxed, he is able to take a little nourishment. Through the whole period there is an obstinate costiveness ; partly from want of food in the stomach, but chiefly from an association of the mouths of the * The muscles of the fingers are observed to remain unaffected, even in the latest stage of the disorder. Sometimes, but not invariably, the- sphincter ani is so violently contracted that it is difficult to administer a clyster.—Ed. 288 NEUROTICA. [Cl. IV.—Ord. III. intestinal excernents in the spasmodic constric- tion.* The general principle of cure is far more ea- sily expressed than carried into execution. It is that of taking off the local irritation, wher- ever such exists, and of tranquillizing the ner- vous erethism of the entire system. The first of these two objects is of great importance in the locked-jaw or trismus of infants ; for by re- moving the viscid and acrimonious meconium, or whatever other irritant is lodged in the stom- ach or bowels, we can sometimes effect a speedy cure without any other medicine. Castor-oil is by far the best aperient on this occasion, and it may be given both by the mouth and in injec- tions. But if this do not succeed, we should have recourse to powerful anodynes; and of these the best by far is opium, which should be administered from three to five drops in a dose, according to the age of the patient. Musk and the host of antispasmodics have been tried so often with so little succes, that it is not worth while to put the smallest dependance upon them; nor has the warm or cold bath produced effects sufficiently general or decisive to allow us to lose any time in trusting to their operation. They may be employed, however, as auxilia- ries ; but our sheet-anchor must be opium; which, if the spastic action have made much advance when we first see the patient, should instantly be employed in conjunction with the prescribed aperient. By taking off the con- striction from the -intestinal canal, and thus re- storing and quickening the peristaltic motion, it may even expedite the dejections. In trismus or tetanus from wounds or sores, the local irritation is not so easily subdued ; nor is its removal of so much importance, though in no case of small moment. But generally speaking, the spastic action is in these instan- ces as much dependant upon constitutional as upon topical irritability ; and when it has been once excited it will run through its career, whether the local cause continue or not. It is owing chiefly to this fact, that the best and most active plan of cure so often fails of success; and the most cautious practitioners hesitate in their prognostications, whatever be the march of symptoms, for the first four or five days. "From the state of the pulse," says Dr. Hen- nen, " I have derived no clew to either the proper treatment or the probable event: it has, in the cases I have met with, been astonish- ingly unaffected. From the state of the skin, I have been left equally in the dark. Sweating, which some have imagined critical, I have seen during the whole course of the disease, and at- tended with the most pungent and peculiar smell; while in others it has never appeared * If tetanus arise from a wound, the result is generally fatal. It is an observation made by Dr. Parry, that in tetanus, if the pulse be not above 100 or 110 on the fourth or fifth day of the attack, the patient mostly recovers; but that when the pulse is quicker than this in the early stages, the issue is commonly unfortunate. The danger gen- erally lessen? in proportion to the protracted dura- tion of the disorder.—Ed. at all: and suppuration, which is generally in terrupted, I have seen continue unaffected by the spasms. Even the process of healing, which, it would be reasonable to conclude, should be altogether put a stop to, has gone on apparently uninfluenced by the disease : and in the most severe case I ever saw, which occur- red after a shoulder-joint amputation, sent into Elvas from before the lines of Badajos, the life of the patient and the perfect healing of the wound were terminated on the same day." So powerfully does the constitutional irritability op- erate in many cases after the disease has once displayed its hideous features, and render the local treatment of subordinate importance. In numerous instances, however, a change in the condition of the wound has produced a ben- eficial result; and hence various means have been resorted to for the purpose of effecting such a change, as local bleeding, anodyne appli- cations to allay the morbid sensibility, resinous, terebinthinate, or mercurial stimulants to excite a new action, and amputation of the diseased limb. The first of these three plans is the or- dinary mode of practice, and in full plethoric habits it has sometimes proved favourable ; the second plan seems to have been very generally employed by Baron Larrey, who occasionally used stimulants of a far higher power, as pen- cilling the wound with lunar caustic, or an ap- plication of the actual cautery. It is upon this principle of counter-irritation that advantage has sometimes been derived from needle-punc- turing, of which the periodical journals have lately furnished us with various examples (Lon- don Med. Repos., vol. xx., p. 403, case fur- nished by Mr. Finch); and, by the French pa- thologists, from an employment of strychnine or the active alkaline part of nux vomica, where the disease has not been primarily induced by this irritant.—(M. Coze, Remarques sur la Nux Vomique, &c.) Amputation seems to have an- swered in a few cases, if we may give full credit to those who have chiefly tried and recommend ed it ;* but it is at best a clumsy and desperate kind of remedy ; and for reasons already as- signed, must be often altogether inefficient if it do not add to the constitutional erethism. The general treatment has consisted in a free use of opium, salivation, the hot or cold bath, and wine or ardent spirits, in some in- stances so far as to produce intoxication. Dr. Cross gives a case in which, after other medi- cines had been used in vain, and every hope seemed to fail, the patient was inebriated with spirits, and kept in this state for ten days, with * Silvester, Med. Obs. and Inq., i., art. i. White, Med. Obs. and Inq., ii., art. xxxiv. Mr. Liston amputated in a case of tetanus from laceration of a branch of the median nerve distributed to the thumb; but though partial relief followed, the pa- tient died. After the operation, it was wished to let the stump bleed for a time; but not more than eight ounces of blood could be thus obtained, and only one vessel was tied. " Could this arise " says Mr. Liston, " from the coats of the vessels partaking in some measure of the general rigidity and contraction ?"—See Edin. Med. Journ No lxxix., p. 292.—Ed. ' Gen. I.—Spe. 7.] ENTASIA TETANUS. 289 the result of a perfect recovery.—(Thomson's Annals of Philosophy.) A generous use of wine appears to be almost indispensable,* and considering the ordinary constitution in which the disease occurs, the difficulty of supporting the system by common means, and the great sensorial exhaustion which is perpetually taking place, it is far from difficult to explain in what manner it operates beneficially ; but intoxication is a frantic experiment, and where it succeeds once, we have reason to apprehend it would kill in a hundred instances. The warm and the cold bath have each of them a much better claim to attention ; and their Vo- taries are so equally divided, that it is no easy matter to say which is most strongly recom- mended. The latter demands more general strength-in the system than the former; but neither of them is to be depended upon except as an auxiliary. The cold bath has the author- ity of Dr. Lind in its favour (Essay on Dis- eases in Hot Climates, p. 257), and has in some instances been tried with success in America.— (Tollman, Amer. Pliil. Trans., i., xxi. ; Coch- ran, Edin. Med. Comm., vol. iii., p. 183.) Mercury, in various forms, has been had re- course to from a very early period ; and on the authority of Dr. Stoll, has occasionally been used for the purpose of exc*iting salivation. On what ground it has been carried to this extent I do not know, except it be that a pretty free flow of saliva from the mouth spontaneously has, by many persons, been regarded as a fa- vourable sign. The disease, however, does not seem to be accompanied with any symptom that can be called critical; and it is hence probable, that this spontaneous flow of saliva is nothing more than a result of the violent action and al- ternating relaxation of all the parts about the fauces. Nevertheless, salivation, where it has been accomplished, is said by many writers to have been serviceable, though I know of no practitioner who has relied on it alone. And, in reality, such is the rapidity with which both trismus 2nd tetanus usually march forward, where they have once taken a hold on the system, that we have seldom time to avail ourselves of this mode of cure, were its pretensions still more decisive than they seem to be. It is most suc- cessfully employed after copious venesection, and in conjunction with opium. Opium, indeed, in every stage and every varie- ty of both tetanus and locked-jaw, is the remedy on which we are to place our chief, if not our only dependance ; but to give it a full chance of success if should be administered in very free doses, and it is not easy for us to be too free in its use. In the Edinburgh Medical Com- mentaries (vol. i., p. 88) we have a case, in which five hundred grains were taken within seven- teen days, which is about thirty grains a day : and in the Edinburgh Journal (Edin. Med. and Surg. Journ., No. lxxi. ; Mr. Barr's case) an- * In Hosack's Essays, vol. ii., reference is made to a number of instances of tetanus cured by the use of wine. Dr. H. gives also the details of a case treated by himseli, and with success, in which the quantity of wine used was three gallons.—D. Vol. II.—T other case, in which, after smaller doses along with calomel, the practitioner at last gave a drachm of solid opium at one time. This, how- ever, proved too high a dose ; for the induced stupor was accompanied with very laborious res- piration, and nearly an extinction of the pulse ; and the patient was obliged to be roused by stimulants. He recovered ultimately. Yet, in the West Indies, opium is often carried, with the most beneficial effects, to as great an ex- tent as this, though not at once. Thus Dr. Gloster of St. John's, Antigua, gave to a ne- gro, labouring under tetanus from an exposure to the night air, not less than twenty grains every three hours, in conjunction with muskr cin- nabar, and other medicines ; and continued it with but little abatement for a term of seventeen days, in the course of which the patient took five hundred grains of this narcotic. For the first six days, little benefit seemed to be effect- ed ; but after this period the symptoms gradu- ally declined under the same perseverance in the medicine, and in thirteen days more, they were so much diminished that no further assist- ance was thought necessary.* If there be any thing which adds to the seda- tive power of opium in this disease, it is sudo- rifics, and particularly ipecacuanha. And upon this subject Dr. Latham has given a valuable paper in the Medical Transactions, in which he offers examples of failure in the use of James's powder, when used either alone or in alternation with opium ; but of full success by uniting the two powers of the narcotic and the sudorific, though he afterward preferred ipecacuanha to James's powder, and prescribed it in the form of the compound powder of this name. He gives cases in which he employed this compound in very severe attacks, and sometimes in what seemed to be its last stage of the disease, with an immediate arrest of its symptoms, and pro- gressively a perfect restoration to health. His doses consisted of ten grains, repeated every three or four hours. In no instance was there any unusual inclination to sleep, how long so- ever this treatment was continued, which, in one case, was for a fortnight; nor was there any degree of sickness, nor any other inconveni- ence, except that of a perspiration, troublesome from its excess.—(Med. Trans., vol. iv., art. iv.) It is only necessary to observe further, that, during the treatment either of trismus or teta- nus, a very particular attention should be paid to ventilate the chamber with pure air ; and es- pecially to purify the air of close and crowded hospitals, without which no plan of treatment in the world can be of any avail. We should also remove, if possible, the costiveness, to * In the West Indies one hundred drops of lau- danum are sometimes given as the first dose, and repeated every two hours, with an addition of one third to every succeeding dose. This plan is com- bined with the free use of mercury, an allowance of wine and ardent spirits, the employment of the warm bath, and attention to remove constipation. Dr. Morrison has given a favourable report of the effect of this practice, even in traumatic teta- nus.—Ed. 290 NEUROTICA. [Cl IV.—Ord. III. which the bowels are so peculiarly subject, by some gentle aperient: for it sometimes hap- pens, not only in infantile trismus or tetanus, but in that from obstructed perspiration, or cold and dampness, that the primary cause of irrita- tion is seated in the bowels ; while, whatever accumulation takes place in this quarter during the course of the disease, may add to and ex- acerbate the general erethism. At the same time, nothing can be more mischievous than the drastic purges which practitioners are apt to give at the commencement of this disease, consisting of jalap, scammony, and aloes. We have already seen, that the general excitement * The editor freely confesses that he does not participate in the author's aversion to the employ- ment of strong purgatives in tetanus. While Dr. Good condemns them, we find some other physi- cians prescribing them in extraordinary doses, and with decided success. Thus, in an example un- der Mr. Manifold, of Liverpool, on which Dr. Briggs has offered some reflections, half a drachm of calomel, as much scammony, and fifteen grains of gamboge, were given in one dose, followed by a clyster of half an ounce of turpentine and two drachms of aloes. As these powerful means had produced no effect, two drops of the oil of croton in a little treacle were given in the evening, and at the same time a clyster of four ounces of the sul- phate of magnesia in a pint of infusion of senna. In less than an hour afterward a black stool was voided, and relief immediately experienced from the evacuation. By continuing the same active remedies, a cure was effected.—(See Edin. Med. Journ., No. lxxxv., p. 277.) Indeed, the oil of croton, owing to its great efficiency in procuring stools, promises to be a most valuable medicine in tetanus. Dr. Briggs even maintains, in direct opposition to Dr. Good, that the principle on which the utility of purgatives rests-in this disorder, is that of counter-irritation on the bowels ; a theory which we need not investigate too deeply, provi- ded the practice be found to answer. Dr. Good describes opium as the sheet-anchor in the treatment; yet, in almost every case in which the editor has seen this medicine used as the chief or only one, the disease proved fatal. Our author has not delivered any opinion with regard to venesection as a means of relieving te- tanus. Sir Astley Cooper has found it hurtful; and the editor of this work has seen some cases in which he thought that the patient's chances of recovery were rendered worse by it. Dr. Elliot- son states that the bleeding is not at all useful unless the wound is inflamed, or there is some de- cided internal inflammation present, or the patient is in a state of plethora. In consequence of many practitioners suspect- ing tetanus to be dependant upon inflammation of the spinal marrow or its coverings, they have had recourse to blistering the skin in the track of the vertebral column. The efficiency of the plan is far from being well proved. One remedy for tetanus, in favour of which we have now many facts recorded, is tobacco, t Two examples of its efficiency are detailed by Dr. Anderson, of Port Spain, Trinidad. He fomented the jaws, throat, and chest frequently with a strong is so extreme, that the slightest occasional irri- tation, even that of changing the position of the head, is sometimes sufficient to produce a re- turn of the spasms ; and hence there can be nothing more likely to do it than the griping effects of such medicines. And it will be far safer to pass by the constipation altogether, than to attempt to remove it by such dangerous means. The best medicine is castor-oil, which may be given either by the mouth or in the form of injections; and if this do not succeed, we may employ calomel. But the action of the bowels must only be solicited, and by no means violently excited.* t Dr. Skinner, of N. Carolina, has communica- ted a case of tetanus treated successfully by tobac- co injections.—See the Phil. Journ. of Med. and Phys. Sc, May, 1827. Arsenic, also, has been found efficacious by Dr. Holcombe of Virginia.—D. decoction of this plant, and applied cataplasms of the boiled leaves to the lower jaw and throat. The patient was also put into a warm bath, im- pregnated with tobacco, every three hours, and had a clyster of the decoction administered to him twice in twenty-four hours. Purgatives, con- sisting of gamboge, calomel, and ol ricini, were likewise employed.—(See Ed. Med. Chir. Trans., vol. i., p. 187.) An earlier paper, particularly in recommendation of tobacco and the purgative practice, is that of Mr. O'Beirne, who adverts to various opinions and facts communicated on this subject by other previous writers.—(See Dublin Hospital Reports, vol. iii., p. 343, &c) From the share which the state of the medulla spinalis is sometimes conceived to have in the production of the disease, the practice of applying a blister the whole length of the spine has been derived. Dr. Reid is an advocate for this practice and powerful cathartics.—(See Trans, of Physicians of King's and Queen's College, vol. i., p. 122.) Oil of tur- pentine is another valuable medicine in tetanus. It is given by the mouth, and in clysters. The facts in its favour are numerous. It operates with excellent effect on the bowels. Prussic acid and belladonna have been tried in tetanus, and found to do no good. In consequence of the benefit which Dr. Elliot- son had seen the carbonate of iron produce in some examples of St. Vitus's dance, another spas- modic disease, he determined to try it in tetanus ; and the account which he has published of the results of some cases which fell uivier his own observation, and of others which occurred in the West Indies, certainly encourages the hope that this medicine will be a valuable one in the present disorder. The editor has tried it only in one case of traumatic tetanus, but in that it did not succeed ; indeed, the trial was not a fair one, because com- menced in too advanced a stage of the disease. Whether veratria would prove serviceable, as a means of relieving tetanus, is a point which may deserve further investigation. Its external use seems to have great power in mitigating and cu- ring neuralgia, and other nervous affections. From 9j. to 3ij. of it may be blended with ointment, and rubbed on the painful or disordered parts. Dr. Turnbull, some months ago, mentioned to the ed- itor several very extraordinary proofs of the power of veratria, employed in this way, in curing neu- ralgic diseases. In traumatic tetanus, amputation has sometimes been practised, with the view of stopping the dis- order; but the most experienced surgeons disap- prove of the proceeding as useless. The plan of dividing the nerve distributed to the wounded part, has also been done with various results. One of the strongest facts in support of this prac- tice was published a little while ago by Dr. Mur- ray, assistant surgeon in the Honourable East In- Gen. I.—Spe. 8.] ENTASIA LYSSA. 291 SPECIES VIII. ENTASIA LYSSA. RABIES. spasmodic constriction of the muscles of the chest ; supervening to the bite of a rabid animal ; usually preceded by a re- turn of pain and inflammation in the bit- TEN part: great restlessness, horror, AND HURRY OF MIND. The Greek term for rabies was lyssa : and the antiquity of the disease is sufficiently estab- lished from its being referred to several times under this name by Homer in his Iliad, who is perpetually making his Grecian heroes compare Hector to a mad dog, xiva 'Xvaanrtipa, which is the term used by Teucer; while Ulysses, speaking of him to Achilles, says, --------Kparipfi Si i AT'SSA Siovkcv* " So with a furious lyssa was he stung." The author has ventured to restore the Greek term, not only as being more classical, but as being- far more correct than the technical term of the present day, which is hydrophobia, or water-dread; since this is by no means a pa- thognomonic symptom ; being sometimes found in other diseases ; occasionally ceasing in the present towards the close of the career; and though almost always observable among man- kind, in numerous instances wanting, even from the commencement, in rabid dogs, wolves, and other animals. " Constat repetita," says Sau- vages, " apud Gallo-provinciales experientia, canes luposque rabidos bibisse, manducasse, flu- men transisse, ut olim Marologii, et bis Foro- livii observatum, adeoque nee cibum nee potum aversari." The same fact is affirmed of rabid wolves, in a case given by Trecourt in his Chi- rurgical Memoirs and Observations. Dr. James in like manner relates the case of a mad dog, that both drank milk and swam through a piece of water (On Canine Madness, p. 10); and one or two similar cases are said to have oc- curred among mankind ; + though even here a dia Company's service.—(See Med. Gaz., 1832-3, p. 623.) A midshipman in the ship " James Pat- tison," aged fifteen, trod upon a rusty nail, which penetrated the left foot, between the metatarsal bones of the great toe and the adjoining one. Af- ter the accident the patient kept his watch, and was exposed to cold. At eight o'clock on the fol- lowing morning, the symptoms of locked-jaw had commenced. Under the administration of opium the disorder gained ground; Dr. Murray therefore cut down to and divided the posterior tibial nerve, about an inch behind the malleolus internus. Al- though the patient had not been able to speak be- fore the operation, he immediately opened his mouth with an exclamation, and expressed that he felt himself already greatly relieved. The ori- ginal wound was then dilated, and covered with a poultice containing laudanum, and the case had a favourable termination.—Ed. * Iliad, ix., 239. + Fehr. Nachricht von einer todslichen Krank- heit nach dem tollen Hundsbisse, Gbtt., 1790, 8vo. In a case published by Dr. Satterley, the pa- tient had fits of biting, and between these he was perfectly well—even took warm fluids, and had a 60und sleep. It seems, then, as if the disease may T 2 spasmodic constriction of the muscles of the chest, and sometimes of the throat, seems to have been present. Dr. Vaughan, indeed, gives the case of a patient who called for drink through the whole course of the disease, and only ceased to ask for it a short time before his- death. ' I have occasionally met, on the contrary, with a few obstinate cases of hydrophobia, or water- dread, without any connexion with rabies : one especially in a young lady of nineteen years of age, of a highly nervous temperament, which was preceded by a very severe toothache and catarrh. The muscles of the throat had no constriction, except on the approach of liquids, and the patient, through the whole of the dis- ease, which lasted a week, was able to swallow solids without difficulty ; but the moment any kind of liquid was brought to her, a strong spas- tic action took place, and all the muscles about the throat were violently convulsed if she at- tempted to swallow. Similar examples are to be found in Battini, Dumas, Alibert, and several of the medical rec- ords, and particularly one of great obstinacy in the Edinburgh Medical Essays, which was chiefly relieved by repeated venesections (In- flammation of the Stomach, with Hydrophobia, dec, by Dr. J. Innes ; Ed. Med. Ess., i., p. 227), as the preceding case was by large doses of opium. Hydrophobia is therefore too general and indefinite a term to characterize the genus before us, unless we mean to include under it diseases to which it is by no means commonly applied, and which, in truth, have little connex- ion with rabies. Hunauld has, indeed, em- ployed it in this extensive signification, and has hence made it embrace no less than seven dis- tinct species, of which two only are irremedi- able (Discours sur la Rage, et scs Remedes, Chateau-Gontier, 1714, 12mo.); and Svyediaur has followed his example.—(Nov. Nosol. Mcth. Syst., vol. i.,p. 511.) There is, even in the present day, so little satisfactorily known, and so few opportunities of acquiring any practical knowledge concerning the general nature and pathology of rabies, that it might, perhaps, be most prude«c to imitate the example of modesty which Dr: Cullen has set us upon this subject, an in the largest doses referred to (Annalen, ix., p. 33), and Raymond has confirmed his re- marks.—(Med. Observ. and Inquiries, vol. v.) But a late experiment of Professor Dupuytren, of the Hotel Dieu, has given a still more striking and incontrovertible proof of its utter inefficacy, if not in all cases of the disease, in certain states and circumstances. Surlu, a man aged twenty- four, had been bitten by a dog sufficiently proved to be mad, had been cauterized immediately af- terward, and been discharged as supposed to be cured. In about a month from the time of the bite, he was attacked with rabies in its severest symptoms, and conveyed to the hospital. Opium was the medicine determined upon, and as the constriction of the throat prevented it from be- ing given by the mouth, a gummy solution was injected into the veins, for which the saphsena and cephalic were alternately made use of. Two grains of the extract were in this manner thrown in, and the patient was in some degree tranquil- lized for an hour or two : the dose was doubled towards the evening of. the same day. It was repeated at intervals, and at length increased to eight grains at a time. The relief it afforded, however, was never'more than temporary, and he expired on the fifth day from the incursion.* M. Trolliet used it freely in the form of pills, in combination with belladonna; but in no instance had he reason to boast of his success, though he gave in some cases twenty-seven grains of opium, and nine of the extract of belladonna, in the course of twenty-four hours. Professor Brera employed the belladonna, but united it with mercury instead of with opium : his doses were carried gradually to a great extent, inso- much that the patients at length took the pow- dered root of the belladonna to the amount of three drachms a day ; and in about forty-four or forty-six days swallowed seven ounces and a half of this drug, and ten grains of corrosive sublimate, besides rubbing in some ounces of mercurial ointment.—(Mem. Soc. Ital. Scienz., torn, xvii., Modena.) The object was to keep the system as much as possible under the influ- ence of mercury, evidenced by ptyalism, and of the narcotic effects of belladonna, so long as the combination was continued. As a preventive, it seems to have been successful; though sev- eral of the patients appear to have advanced to the first symptoms of acute affection, having had some degree of water-dread, and recurring irri- tation in the bitten parts, the disease did not proceed beyond these initiary steps. But we have no proof of success from this plan after the * Orfila, Traite des Poisons, &c. The extract of belladonna in solution and other narcotics, have likewise been injected into the veins without success.—Ed. 305 NEUROTICA. [Cl. IV.—Ord. III. pathognomonic signs had shown themselves. The warm bath was also combined with, the above practice. In like manner, musk, opium, and belladonna have been all united ; and some- times combined with camphire, oil of amber, in- unction with olive oil,* or bleeding. Musk was also at one time very generally combined with cinnabar, and in this form supposed to be pe- culiarly efficacious. The famous powder em- ployed by the natives of Tonquin, and introduced into this country by Mr. Cobb, on which account it was called pulvis Cobbii, or Tunguinensis, consisted of sixteen grains of musk with forty- eight grains of cinnabar, mixed in a gill of ar- rack. This, taken at a dose, is said to have thrown the patient into a sound sleep and per- spiration in the course of two or three hours : and where it did not, the dose was repeated till such effect was produced. And this medicine also was regarded as a specific during the short career of its triumph, and a bure was commonly supposed to follow the administration of the medicine. The sedative power of several of the prepara- tions,of arsenic, however, had perhaps a fairer pretension than any of these, and especially as, like mercury, it has for ages been employed with decided benefit in Asia in the case of syphilis. Agricola mentions its use in his day (Comment. in Popp., p. 54), but the forms in which it was then employed were rude and incommodious, and they do not appear to have been followed with much success. It is to be regretted, how- ever, that even in the elegant and manageable form of Dr. Fowler's solution, it has not been found to be more efficacious. It has of late years been tried internally in various cases, and particularly, with great skill and in full doses, by Dr. Marcet ; but in every trial it has disappoint- ed our hopes. Applied externally, as a preven- tive to the bitten part, Dr. Linke of Jena thinks it has succeeded ; but as his trials were made on dogs inoculated from the froth of rabid ani- mals after death, no dependance can be placed on them. Under this head I may also observe, that the Prussic acid has occasionally been had recourse to, but without any apparent benefit. In the form of the distilled water of the prunus Lauro- eerasus, it was not long since made a subject of experiment at Paris by Baron Dupuytren, who injected this fluid into the veins of various dogs, and appears to have done so in one instance into those of a man : butjn every case without ef- fecting a cure. There are two or three other remedies, which it is difficult to arrange, but which have also acquired a considerable celebrity in the cure of lyssa ; and hence it is necessary to notice them. The first is the Ormskirk medicine, so called from its preparer, Mr. Hill of Ormskirk, suppo- sed, for the inventor could not be prevailed upon to publish his secret, to consist of the following materials : powder of chalk, half an ounce ; ar- * Vater, Pr. de Olei Olivarum efficaeia contra morsum canis rabiosi, experimento Drc*d;E facto, adstructa, Viteb., 1750. menian bole, three drachms ; alum, ten grains ; powder of elecampane root, one drachm ; oil of anise, six drops. The single dose, thus com- pounded, is to be taken every morning for six times in a glass of water, with a small propor- tion of fresh milk. If this be the real formula, and the analysis of Dr. Black concurred with that of Dr. Heysham in determining it to be so, the inventor seems to have contemplated the specific virus to be an acid, for the basis of this preparation is unquestionably an alkaline earth. And with regard to its occasional efficacy, the latter writer, following the general current of opinion of the day, informs us, that this has been so thoroughly established by experience, that there can be no room to doubt it. Dr. Hey- sham himself, however, admits of various cases in which it failed, while in many instances his successful ones do not afford proofs of an ex- istence of the genuine disease.—(Diss. Med. Rabie Canind, Svo.) The second of the anomalous remedies I have just referred to, might possibly have been in- troduced under the head of the common anti- dotes for the bites of venomous animals ; but as it has reputed powers in some degree peculiar to itself, it is best to notice it separately. This is the aiyssum, or alysma Plautago (madwort plantain), of established reputation in America as a specific for the bite of the rattlesnake, where it seems to rival the imprescriptible claims of the ophiorrhiza Mangos, though its juice is generally given in combination with that of the common horehound—an addition that certainly does not promise much accession to its strength. This species of alyssum has for some ages been a popular remedy for canine madness, es- pecially in the north of Europe : and in a late communication to Sir Walter Farquhar in the Russian tongue, translated and published in Mr. Brande's Journal (Jour, of Sciences and the Arts, No. ix., p. 142), we are told that it still retains its popular sway and reputation over a great part of the Russian empire; and that in the govern- ment of Isola it has never failed of effecting a cure in a single instance for the last five-and- twenty years. The preparation is simple : the root is reduced to a powder, and the powder is to be«aten by being spread over bread and but- ter. Two or three doses are said to be suffi- cient in the worst cases, and will be found to cure mad dogs themselves. The butcher's broom (genista tinclona), and side-leaved scull-cap (Scutellaria laterifolia), have however rivalled the reputation of the plau- tago ; and, in our own day, the first is power- fully recommended by M. Marochetti of Mos- cow, in the St. Petersburgh Miscellanies of Medical Science, as employed with great suc- cess, in the Ukraine ; and the second by Dr. S. Spalding of New-York, who tells us that it has been successful in America in upwards of a thousand cases, not only in men, but in dogs swine, and oxen.* ' * Chymical analyses have showrTthis plant to be nearly^nert-bee N. York Med.Repository, voL Gen. I.—Spe 8.] ENTAbIA LYSSA 307 The next remedy I have lo notice is also of extensive use in the present day, and comes be- fore us with no mean authority. While the medical practitioners of the east are-pursuing their plan of abstracting rabid blood from the system, as the surest means of curing canine madness, the physicians of Finland have under- taken to accomplish the same effect, by intro- ducing rabid blood into the morbid frame. In the second number of the Hamburgh Medical Repository, Dr. W. Rithmeister, of Powlowsk in Finland, has given an article, in which he has collected a multiplicity of striking cases, and various authorities in proof that the blood of a rabid animal, when drunk, is a specific against the canine hydrophobia, even where the symp- toms are most strongly marked. The rabid wolf-dog, or other quadruped, is for this pur- pose killed, and its blood drawn off and collected as an antilyssic ptisan. Dr. Rithmeister's com- munication contains a letter to himself from Dr. S'.ockmann of White Russia, confirming this account, and stating the practice to be equally common and successful in his own country. , I will only add, that a discussion has lately taken place between two Italian physicians of distinguished reputation, Professor Brugnatelli of Pavia, and Professor Valetta of Milan, upon the virtues of chlorine as an antidote for the dis- ease in question. The former has strongly rec- ommended it (Giornalc di Fisica, &c, Pavia, Dec, 1816), and the latter has denied that it is of any use (Bibitoteca Italiana, Gennaj., 1817): in answer, however, to which denial, Professor Brugnatelli has adduced various authenticated facts, by which what he calls the specific pow- ers of the chlorine have been established and verified.—(Giornalc di Fisica, &c, Pavia, Feb- braj., 1817.*) I have thus endeavoured, upon a subject of so much interest and importance, to put the reader into possession of the general history of the practice that has hitherto prevailed ; and he * M. Magendie (Journ. de Physiol. Exper., torn. i., p. 44, &c) conceived, that the sudden produc- tion of an artificial plethora might have the effect of arresting this ungovernable disease, and with this view he injected about a pint of warm w^ter into the veins of a hydrophobia patient; but though the operation relieved for a time the violence of the symptoms, death took place nine days after the experiment. The patient having lived, how- ever, much beyond the usual period after the dread of water had commenced, hopes were entertained that this plan might prove more successful in sub- sequent cases; but experience has now folly shown, that the injection of water into the venous system, is of as little use as every thing else that has hitherto been suggested for the purpose of curing the disorder, after it has been decidedly formed. The guaco, a vegetable matter employed in South America as an antidote for the bites of serpents, has been strongly recommended as a rem- edy for hydrophobia. It has been tried in this country by Dr. Roots, Dr. Elliotson, and others ; and though in one or two instances a temporary amendment followed its exhibition, the patients all died about the usual period, namely, on the third or fourth day from the commencement of decided hydrophobia.—Ed. will at least allow, that if the result be highly un- satisfactory—as most unsatisfactory it is—such conclusion does not result from idleness on the part of the medical profession.* But how are we to reconcile the clashing and contradictory statements which the present analysis unfolds to us 1 This is a question of no easy solution. Yet there are many circum- stances which ought to be borne in memory, and will, in a certain degree, account for such op- posite views and decisions, without rudely im- peaching the veracity of any of the experi- menters. In the first place, it is possible, that the mor- bid poison itself, like that of plague or intermit- ting fever may vary in its degree of virulence, in certain idiosyncrasies, certain countries, or certain seasons of the year; and hence that a medicine which has proved useless in general practice, may succeed in particular persons, par- ticular places, or at particular periods ; or if in- active in itself, may be employed in so much milder a degree of the disease, that the consti- tution may be able, in most or many instances, to triu,mph over it by its own powers alone. s It is a just remark of Celsus, that omnis fere morsus habet quoddam virus (Dc Medicind, lib. v., x.) ; and we have already given proof, that this is particularly the case when the animal that bites is labouring under the influence of vi- olent rage or other sensorial excitement; the symptc-ms incident upon which produce a severe effect upon the nervous system, and often stim- ulate those of the genuine lyssa. And hence there can be little doutt, that these symptoms have often been mistaken for lyssa, and have given celebrity to the medicines employed for their cure, to which they were never entitled. In various cases, as we have already seen, the disease commences almost coetaneously with the external injury, or inoculation; in others, not till months or even years afterward. In some instances, the first symptoms of the dis- ease show themselves in the bitten part, and even this in a very different manner ; for there may be a troublesome sense of numbness, or of irritation ; arid this irritation may be confined to the cicatrix, or travel up the limb, and pro- duce acute pain or spastic action : while, in other instances, there is no local affection what- ever through the entire progress of the malady. Ordinarily speaking, hydrophobia or water- dread is one of the most common as well as one * According to Roche and Sanson, no less than 300 medicines have been proposed as specifics for hydrophobia. The American editor, however, would add but few remedial agents to those al- ready mentioned. Dr. Ramsay of South Carolina recommended the treatment by alkalis, as allu- ded to in a previous page. The sapo or contrecu- libri, another American remedy, has been some- times employed; the seeds of this plant are pre- ferred, but if these cannot be obtained, the leaves may be used. Dr. Becarie of New-Spain, speaks warmly of its efficacy.—See Med. Repository, vol. xvii. The vapour bath has been introduced into practice lately by M. Brisson. He has succeeded in curing upwards of 80 patients with it. It is em- p'.ojed at a temperature of 108° F.—D. 308 ^v* of the severest symptoms of the disease; yet there are instances, even where the rabies has terminated fatally, in which water-dread has not been once complained of. Most commonly again, on an early examination after death, the fauces and parts adjoining are found red and in- flamed ; but we have already observed, that Morgagni dissected patients in whom there was no such appearance whatever : and in two bod- ies, examined after death by Dr. Vaughan, the fauces, oesophagus, stomach, diaphragm, and in- testines, were all in a natural state. There can be Tittle or no doubt, moreover, where many persons are bitten in quick succes- sion by the same rabid animal, that the poison is not equally introduced into all of them. In some cases it may be expended entirely upon the earlier victims, and hence the rest, though bitten, may be free from the virus ; while in others, where the teeth have to pass through various foldings of clothes, it is possible that the virus which still remains may be wiped off in its passage, and the larceration be nothing more than a clean wound from the first. And in all such cases a sanguine experimenter, without al- lowing for. these circumstances, will be apt to persuade himself, whatever medicine he makes use of, that the absence of the disease is owing to the efficacy of the plan or the medi- cine he has prescribed, and which he is hence tempted to hold up to the world as an antidote or specific. Some of these remarks will best explain the very different results of the same mode of treat- ment, in the eleven patients intrusted in 1775 to the care of M. Blaise of Cluny, after having been dreadfully bitten and torn by a mad wolf. The principal remedy was mercurial inunction, though combined with antispasmodics. The mercury was carried on in all of them to saliva- tion, and the treatment continued for above a month, in those that lived-long enough for this purpose. One died with great horror and water- dread about the twelfth day from the injury, and after the mercury had begun to act. A second perished under hydrophobia, furious, and at length comatose, just at the close of a month, his mouth and gums being slightly affected by the mercury. A third died nearly six weeks af- ter the commencement of the mercurial plan, having been taken away by his friends on the eighteenth day, apparently in a state of doing well. The remaining eight, after having exhib- ited greater or less symptoms of spasmodic af- fection, but never amounting to hydrophobia, are said to have recovered, and were discharged ac- cordingly (Mithode eprouvie pour le Traitemcnt de la Rage); but, in a subsequent work, M. Blaise informs us, that even one of these died in a paroxysm of hydrophobia six weeks after his discharge and supposed restoration to health.* * Hist, dela Societe de Medecine, torn. ii. Dr. Elliotson saw two little girls, sisters, who were bitten at the same moment by a dog, and in the same part, namely, the face. One J3f them died, and the sister had the symptoms which commonly nsher in hydrophobia; but, after lasting four or five days, they ceased, and she recovered. Facts DTICA. [Cl. IV.—Ord. III. In all these cases, the success is ascribed to the action of the mercury, and the want of suc- cess to some irregularity or other, committed by the patient while under medical care. The enormities, however, are in general rather far fetched, and not very convincing. Thus, in the last of the above cases, it is ingeniously ob- served, that the man who had been so long discharged as well, four days only before the symptoms of hydrophobia appeared on him, had thrust his arm down the throat of an ox which was said to be mad ; though no proof is offered that the ox was really mad, nor is it pretended that even this reputed mad ox inflicted any bite upon the arm whatever. AVho does not see, that in all these cases, the mercury may have been guiltless of exercising any control? that those who died may have died in consequence of an effective lodgment of the virus in the wound inflicted, and that those who survived may have survived because it obtained no admis- sion to the "bitten part 1 It is moreover highly probable, that a spon- taneous cure is occasionally effected by the strength of the constitution, or the remedial power of nature alone. The fact appears to be, that the disease requires about six or seven days to run through its course, at the expiration of which period the system seems to be exonerated, by the outlet of the salivary glands, of the poison with which it is infested. And hence, if by any means it be able to sustain and carry itself through this period, without being totally ex- hausted of nervous power in the course of so protracted and prostrating a conflict, it will ob- tain a triumph over the disease ; and any pre- scribed medicine made use of on the occasion, will seem to have effected the cure, and will run away with the credit of having done so, till sub- sequent instances dissolve the charm, and prove beyond contradiction the utter futility of its pre- tensions. I have already had to observe, that the contagion of lyssa, though highly malignant, is neither remarkably volatile nor very active, and in every instance perhaps, requires some exciting or predisponent cause to enable it to take effect: but, as it seems to be more inde- composible than any other contagion we are ac- quainted with, it is capable of lying latent and undissolved for months, if not years, till it meets with a cause of this kind. And hence the very long and uncertain interval, which sometimes occurs between the attack of the rabid animal and the appearance of rabid symptoms, has often proved another source of deception; of which we have a singular example in Mr. Nourse's case, related in an early volume of the Philosophical Transactions (No. 445), which states, that a lad, who had been bitten in the thumb by a mad dog, took morning and evening for forty days a drachm of the pulvis antilyssus already descri- bed, and bathed in the sea for ten days in suc- cession. He was in due time reported to be of this kind prove, at all events, that the constitu- tional disturbance, preceding the occurrence of actual hydrophobia, is not absolutely irremediable, and that in this stage, the patient may be saved. Gen. I.-Spe. 8] ENTASIA LYSSA. 309 well, and the cure was altogether ascribed to the specific virtues of the antilyssic powder. He was shortly afterward cut for the stone, from which also he recovered : nineteen months af- ter which operation, however, he was attacked with hydrophobia and'the other symptoms of canine madness, and fell a victim to their vio- lence. Had this patient died under the opera- tion of lithotomy, or from any other circumstance in the interval, the virtues of the antilyssic pow- der would have obtained a complete, and indeed a rational triumph in this instance : and even now, there may be a question whether the ap- pearance of the disease was not retarded by the plan pursued, though its specific power can no ; longer be maintained for a moment. The oc- casional exciting cause which, in this instance, at length gave activity to the dormant virus, is not pointed out to us. But it is difficult, if not impossible, to account without such a cause for the quickening of the lurking seminium of the poison at this time rather than at any other.* And the following valuable remarks of Dr. Per- cival, occurring in his manuscript comment on the author's volume of Nosology, in relation to this subject, are in full illustration of the same opinion. " A wine porter was attended, in Dispensary practice, for a low fever: after a time appeared symptoms of lyssa; and much inquiry elicited the recollection of his having been slightly bitten by a dog six weeks before. In the interval he was convicted of some fraudulent practice in the cellar of his master, to whom he owed great ob- ligation, and was dismissed with disgrace. Anx- iety on this event seemed to produce the fever, which terminated in lyssa. " Lately, an officer in our barracks was bitten by a dog, whose madness being recognised, the bitten part was excised immediately. After an undisturbed interval of two months, he was ad- vised to go to England to dissipate the recollec- tion of the accident: there he exercised himself violently in hewing wood ; felt pain in the hand which had been bitten ; embarked for Ireland ; had symptoms of hydrophobia on board the packet, and died soon after his arrival. " I have lately seen a case of hydrophobia treated ineffectually by most profuse bleeding and large doses of opium. Here too, the bitten part was extirpated by caustic within an hour. The patient was a man of steady mind, nor could any occasional cause be assigned for bring- ing the poison into action, except that a bilious diarrhoea was suddenly checked. " From the varying period of attack we might infer, that the influence of occasional causes is very considerable. In the last patient hydro- phobia supervened exactly five weeks from the time of the bite; he lost a hundred and eight ounces of blood in twelve hours, which sunk * It deserves to be recollected, however, that modern practitioners do not puzzle themselves about the exciting cause, in cases where the syph- ilitic poison first produces constitutional symptoms several weeks or months after the application of the virus, and the formation of a chancre.—Ed. him much; violent perspiration, and at length delirium, attended the water-dread: during the last twenty-four hours he swallowed, and recov- ered his senses; and died slightly convulsed while cutting an egg. These cases seem to point out agitation of mind and feverish excita- tion as powerful occasional causes." In a disease so intricate as lyssa, a very complex treatment is by no means unpardon- able ; but it may fairly, I think, be questioned, whether the complexity and the energy of the means employed to produce a cure may not rather, in some instances, have had an opposite effect, and have hastened and confirmed a fatal I issue. A patient bitten by a mad dog, having in vain tried and persevered in the use of the Ormskirk medicine, was next put under the joint care of Dr. Watson and Dr. Fothergill. Having been bled standing, as long as he could stand, he was next immersed in a warm bath, where he was ordered to remain till he again became faint; a clyster of milk and water, with a drachm of Dover's powder dissolved in it, was injected as soon as he was removed from the bath ; half an ounce of mercurial ointment was at the same time rubbed into the legs and thighs, and three grains of thebaic extract given in the form of pills, two grains being ordered to be continued every hour till he became sleepy. To stand the brunt of a treatment thus vig- orous, would demand no ordinary constitution, even without the co-operation of any disease. But that the wretched sufferer should sink (as he did, in a few hours) under the assault of such a malady and such a mode of cure, cannot be matter of surprise. The whole subject is afflictive, as well in re- spect to its treatment as its progress. But how, after all, is a young practitioner to proceed when he meets with a case of rabies 1 This is a most important question ; and the following remarks, submitted with great deference as the result of some little personal experience and no small degree of reflection, are meant to meet it, and to point out the path which, in the present un- settled state of the subject, it may perhaps be most expedient to adopt. From the whole of the preceding survey it is sufficiently clear that we have no direct specific for the cure of the disease; and hence, what- ever plan we employ, must be palliative only. It appears also, that the disease consists in a poison of a peculiar kind, capable of assimilating some of the animal secretions to its own nature, and that the new matter, or contagion, hereby produced, continues to be eliminated for five or six days, principally, if not entirely, from the excretories of the salivary glands, as the inflam- mation of gout unloads itself on the extremities, and the specific matter of exanthems on the sur- face generally; and that at the expiration of this period, or as soon as such depuration has been effected, the disease abates, and the pa- tient is restored. It appears also, that the dis- ease is one of the most dangerous in the whole catalogue of nosology, and that few patients re- cover from it under any plan of medicine that has ever been devised ; but tliat nevertheless, 310 NEUROTICA. [Cl. IV.—Ord. III. I To obtain and encourage such elimination should indeed be our first object, if we had any means of accomplishing it upon which wc could fully depend. This, however, we have not; but as the quarter to which the virus is directed is the salivary glands, of which, indeed, we have full proof in consequence of the saliva being the fomes of the poison apparently as soon as it be- comes elaborated, and as we have a medicine which possesses a specific influence on this or- gan, and is capable of augmenting its secretion to almost any extent, it seems of the utmost im- portance that, while we endeavour to support the system, and to allay the nervous irritation, we should endeavour at the same time to quick- en the elimination of the morbid matter, by ex- citing the salivary emunctories, and thus prob- ably also carrying it off in a diluter and less irri- tant form. It is difficult to withhold one's assent to all the numerous instances of cure which are so confidently asserted to have followed the use of mercury carried to the point of free saliva- tion. And hence, without allowing this med- icine to be a specific more than any other, we may indulge a reasonable hope of its forming a good auxiliary, and should employ it freely, either ex- ternally, internally, or in both modes simultane- ously, but with as little disturbance tothe patient as possible, till a copious ptyalism is the result, Fever, or inflammatory action, does not ne- cessarily belong to lyssa in any stage ; and the present mode Of treatment is altogether ground- ed upon this principle. Either, however, may become incidentally connected with it, from the peculiar state of the habit or some other cause. Hence, as a preventive, the bowels should be kept moderately open; and when there is any just apprehension of plethora, or a turgid state of the vessels, and particularly of the brain, blood should be drawn freely from the arm, and, if necessary, be repeated. We have already seen that such a state of congestion is some- times produced even at the onset of the dis- ease, and is so forcibly felt by the patient him- self, that he earnestly entreats the medical at- tendant to bleed him. Such entreaty should, perhaps, never be urged in vain ; but the bleed- ings to deliquium, which have of late years been so strongly recommended, are a rash and dan- gerous practice.* Such, in the doubt and darkness that at pres- ent beset us concerning the real physiology of lyssa, seems to be the safest and most promis- ing path we can pursue. Our best time for ac- tion, however, and almost the only time we can improve, is immediately on the infliction of the wound : a tight ligature above which, with the Some patients have recovered under almost every mode of treatment, however incongruous and contradictory to other modes ; and hence, that many cases of restoration must be rather re- ferred to a natural or spontaneous cure than to ihe virtue of medicines. In this state of things, it seems reasonable that our first intention should consist, as in various other kinds of animal poisons communicated in the same manner, in supporting the system gen- erally, and the nervous part of it more particu- larly, so that it may not sink under the violent excitement and augmented secretion which the organ of the nerves has to encounter during so perilous a struggle. And it is to this principle we have to resolve all the benefit which has at any time been found to result from the use of the stimulant theriacas and other cordials of the old practitioners. On this account, ether, am- monia, and camphire have a strong claim on our attention, and especially the two last, as they may be given in a solid form. All the pungent epices belong to the same class, as cardamom- seeds and capsipum, and may be adverted to as auxiliaries; nor should wine or even ardent spirits be refrained from, if the patient can be induced to swallow them ; moderately through the en- tire course of the disease, but liberally and pro- fusely as his strength declines. Our grand ob- ject must be to keep him alive, and prevent a fatal torpitude in the sensorium for a certain number of days, at any expense of stimulants, or of subsequent debility. Wine is profusely given with great success in the bite of the most venomous serpents of the East, and analogy jus- tifies us in proposing it in the present instance. Our next intention should be to diminish, as much as possible, the spastic action of the chest and fauces, and to prevent a return of the exa- cerbations. And to this end as much quiet and composure as we can possibly procure, under so restless a state of body, seerns imperatively called for, and is far more likely to be service- able than the fatigue of taking the patient re- peatedly out of bed for the purpose of plunging him either into a hot or cold bath. And though opium has never of itself, perhaps, produced a cure, it seems advisable to try it in liberal doses; and the more so, as several of the cases already adverted to'afford a direct proof, that it is capa- ble occasionally of producing some degree of tranquillity for a short period. In employing it, however, it seems most reasonable, from analo- gy, to combine it with some diaphoretic, and particularly with ipecacuanha in the form of Do- ver's powder, since at all times the animal frame is most disposed to be quiet and free from irreg- ular actions when there is a general moisture Upon the surface. In many cases of rabies, such a state of body has been found unquestionably favourable ; and in one of the instances already quoted from the Medical Transactions, the bene- fit was so striking, that the practitioner could not avoid regarding it as critical. It is possible, slso, though no great stress can be laid upon this remark, that a part of the virus itself may be herebv eliminated, as in various other cases oi animal prisons. * Instead of persevering in these and other plans, which, when allowance is made for the am- biguous nature of many imperfectly reported re- coveries, and the influence of the remedial pow- ers of nature, cannot be said positively to have done effectual good in a single example, practi- tioners ought undoubtedly to make new experi- ments on the subject. If we always continue in the same path, we shall never discover the long desired object, namely, a method of treatment , which can be depended upon.—Eu. Gen. I.—Spe. 9.] ENTASIA ACROTISMUS. 311 hreble precaution of the cupping-glass, excis- ion and cauterization, may in general be re- arded as an effectual preventive. I do not now, indeed, that the profession is acquainted with any other.* It has, however, been pro- posed in France, to fight off the poison of lyssa by preoccupying the ground with the poison of a viper, upon the principle of combating vario- lous with vaccine matter : and for this purpose it has been suggested, that the part bitten by a mad dog should be again bitten, a little below the wound, as soon as may be, by a venomous serpent, whose virus, from its greater activity, will, in most cases, be certain of taking the lead, and may, it is presumed, guard the con- stitution against any subsequent effects from the wound of the mad dog. I have not, however, heard that this proposal has ever been carried into effect, and the claim of ingenuity is, most probably, the whole it will ever have to receive.i I ought not, however, to conclude without noticing one very extraordinary fact in the economy of morbid poisons, and especially of that before us, which I have had confirmed by the testimony of several veterinary practition- ers entitled to credit. It is, that no dog which has ever had the distemper, as it is called, which is the canine catarrh or influenza, has been known to become rabid spontaneously, though he is capable of receiving the disease by the bite of another dog. If this be true, for which however I cannot fully vouch, we have certainly another instance of morbid poisons mortally conflicting with each other; and it might be worth trying how far inoculation with the mat- ter of canine catarrh might succeed in protect- ing a human subject after the infliction of a rabid bite; though in the dog, perhaps from a stronger predisposition to rabies, it seems to be impotent. In South America, rabies, as already observed, is altogether unknown, and I have hence been anxious to learn, whether the dis- temper be unknown there also ; and in answer to this inquiry, it has been told me, by several intelligent residents in that quarter, that this last disorder is so common and so fatal, that two thirds of the dogs littered there perish of it while pups; a remark which still further con- firms the home-report concerning its influence on rabies, and may partly explain the non-existence of the latter on the shores of the Plata. SPECIES IX. ENTASIA ACROTISMUS. P ULSELESSNESS. failure or cessation of the pulse, often accompanied with pain in the epigastri- um ; the perception and the voluntary muscles remaining undisturbed. Acrotismus is literally " defect of pulse,;' from xpiroi;, "pulsus," with a privitive a pre- * Dr. Marochetti's prophylactic treatment has already been mentioned.—Ed. t By referring to the article "hydrophobia" in the Dictionary of Practical Surgery, the reader will perceive that this expedient has really been Lrtfd—Ed. fixed ; whence the technical term crotophus or crolophium, importing " painful pulsation or throbbing in the temple." Asphyxia is the term employed for this disease by Ploucquet, and would have been used in the present arrange- ment, but that it has been long appropriated to import suspended animation or apparent death ; a total cessation, not of the pulse only, but of sense and voluntary motion. This failure or cessation of pulsation some- times extends over the whole system, and is sometimes confined to particular parts. In ev- ery case, it imports an irregularity in the action of the heart, or of the vessels that issue from it, and, in most cases, an irregularity proceed- ing from local or general weakness, and de- pendant upon a spasmodic disposition hereby produced in the muscular tunic of the vessels. Of this last cause, we have a clear proof in the universal chill and paleness that spread over the entire surface in the act of fainting or of death,"to which fainting bears so striking a re- semblance. Except, however, in the agony of dying, the spasmodic constriction for the most part soon subsides, and the arteries recover their proper freedom and diameter. Yet this is by no means the case always, for in violent hemor- rhages, and especially hemorrhages of the womb, the rigidity has sometimes continued for several days, during the whole of which time the heart has seemed merely to palpitate, and there has been no pulse whatever. Morgagni relates, from Ramazzini, a case of this kind which ex- tended to four days. The patient was a young man of great strength and activity, even during this suppression. The arteries were as pulse- less as the heart; and through the \vhole period he was quite cold to the touch, and without micturition. On the fourth day he died sud- denly.—(De Sed. et Causis Morb., ep. xiviii., Lugd. Bat., 4to., 1767.) Examples, indeed, are by no means uncommon, in which the spasm has existed for three (Pathology, p. 25), four, or even five days (Pelargus, Med. Jahngange., band v., p. 23) before death. Other irritations besides that of weakness, have occasionally led to a like spastic state of the arteries. The stimulus of aneurism of the aorta has produced it in the brachial arteries, so that there has been no pulse in the wrists ;* and gout or some irritation in the stomach has op- erated in like manner on the arterial system to a much greater extent; as has likewise general * The hypothesis of such a degree of spasm as is here referred to, and supposed to be capable of rendering the large arteries impervious, is one that would not be generally adopted by modern practitioners. Many physiologists, perhaps all the most eminent ones, consider the small arteries as possessing the power of becoming completely con- stricted by a kind of action that may be sometimes spastic, but a contraction of the arterial trunks in this degree is a position that could not be so well established. In aneurisms of the arch of the aorta, the occasional interruption of the pulse can be explained on a better principle, and one con- firmed by dissection; namely, the manner in which the disease obstructs or breaks the impetus pf the blood destined for the upper extremities,—Ed, 312 NEUROTICA. [Cl. IV—Ord. III. pressure on the larger thoracic or abdominal or- gans, from water in the chest or cavity of the peritoneum. The causte however, is not always to be traced, and hence Marcellus Donatus has given an instance, which he tells us was unac- companied with any disease whatever (Lib. vi., cap. ii., p. 620), the irritation probably having subsided. Berryatt, in the History of the Acad- emy of Sciences, has furnished us with a very singular example of this disease, which was general as well as chronic, and continued through the whole term of life. In all which cases, however, though the heart itself should seem to participate in the pulselessness, we are not to suppose that it is entirely without any alterna- tion of systole and diastole, but only that its ac- tion is indistinct from weakness or irregularity. In treating of the nature of the pulse in the Physiological Proem to the third class, we ob- served, that it is in some persons unusually slow, and has been found, as measured by the finger, not more than ten strokes in a minute: and that, in many of these cases; the cause of retardation seems to be a spasticity or want of pliancy in the muscular fibres of the heart or arteries, or both, rather than an actual torpor, which is also an occasional cause. I have never met with any case in which the ordinary stand- ard of the pulse was not more than ten strokes in a minute ; but I have at this time a patient, of about thirty-six years of age, whose pulse has not exceeded twenty-four or twenty-six strokes, and has often been below these numbers. He is a captain in the Royal Navy, of a sallow complexion and bilious temperament; till of late he enjoyed good health, but about three years since was attacked with a fit of atonic apoplexy, from which he recovered with diffi- culty. At an interval of a few weeks from ' each other, he had several other fits ; on recov- ering from the last of which he instantly mar- ried a young lady to whom he had for some time been engaged. He has now been married about fifteen months, has a healthy infant just born, and has had no fit whatever. His spirits are good, and he is residing by the seaside, which situation he finds agree with him best. Dr. Latham gives a similar example in a merchant whose pulse, though never intermis- sive, seldom, for ten or twelve years that he had known him, exceeded thirty-two beats in a min- ute ; occasionally was as slow as twenty-two, and at one time only seventeen. " I once," says Dr. Latham, " attended him through a regular fever, when his pulse was not more than sixty, notwithstanding the disease ran on for at least a fortnight with a hot and dry skin, white and furred and parched tongue, and occasional de- lirium."—(Med. Trans., vol. iv., art. xx.) In many of these anomalies there is not only no perceptible pulse, or a veiy retarded one, but often intermissions more or less regular, and occasionally a want of harmony between the stroke in some of the arteries compared with that in others. Reil gives a case in which the heart, the carotids, and the radial arteries all pulsated differently (Memorabilia Clinica, Vol. ii., fasc i., 6, Hall., 1792); and Beggi an- other, in which the acrotism, or want of pulsa- tion, extended over the entire frame, with the exception of the heart, which pulsated violently. —(Opp. Pacchioni, Rom., 4to., 1741.) This species is strikingly exemplified in the biographical sketch of Mr. J. Hunter, drawn up and prefixed to his volume on Blood and In- flammation by Sir Everard Home. Mr. Hunter, for the four preceding years, had annually suf- fered from a fit of the gout in the spring. In the year 1773, this did not return, and having on a particular occasion been greatly affected in his mind, " he was attacked," says Sir Everard Home, " at ten o'clock in the forenoon, with a pain in the stomach, about the pylorus : it was the sensation peculiar to those parts, and be- came so violent that he tried change of position to procure ease ; he sat down, then walked, laid himself down on the carpet, then upon chairs, but could find no relief: he took a spoon- ful of tincture of rhubarb, with thirty drops of laudanum, but without the smallest benefit. While he was walking about the room, he cast his eyes on the looking-glass, and observed his countenance to be pale, and his lips white, giving the appearance of a dead man. This alarmed him, and led him to feel for his pulse, but he found none in either arm. He now thought his complaint serious. Several physicians of his acquaintance, Dr. William Hunter, Sir George Baker, Dr. Huck Saunders, and Sir William Fordyce, all came, but could find no pulse : the pain still continued, and he found himself, at times, not breathing. Being afraid of death soon taking place if he did not breathe, he pro- duced the voluntary act of breathing, his work- ing his lungs by the power of the will, the sen- sitive principle with all its effect on the machine not being in the least affected by the complaint. In this state he continued for three quarters of an hour, in which time frequent attempts were made to feel the pulse, but in vain. However, at last the pain lessened, and the pulse returned, although at first but faintly, and the involuntary breathing began to take place. While in this state, he took Madeira, brandy, ginger, &c, but did not believe them of any service, as the return of health was very gradual. In two hours he was perfectly recovered."—(Sir E. Home's Life of Mr. Hunter, prefixed to the Treatise on Blood, &c, p. 46.) This is one of the most extraordinary cases on record, considering the extensive group of important functions that were jointly affected, and the total freedom of the rest; and nothing can more strikingly prove how close is the sym- pathy that in many instances prevails between discontinuous organs, the chief disease having prevailed in the heart, and the chief pain in the stomach on its upper side. The nature of the pain and the collateral symp- toms seem sufficiently to show that this disease was of a spasmodic kind ; for the deficiency of pulse was subsequent to the pain, and ceased upon its removal, while the deadly paleness of the face gave proof of a constriction of the capil- laries. So far as my own experience has extended, Gkn. H.] CLONUS. 313 such failures of the pulse, whether consisting in a total suspension or a preternatural retardation, and attended with acute or with very little pain, are dependant upon the diseased state of the lar- ger arteries, or the larger viscera of the thorax or abdomen, and generally lead to sudden death. The case of the captain of the navy which I have just related, and which was drawn up while the first edition of this work was in the press, I may now apply to in illustration of this remark ; for I have since been informed by his sister, that while at Swansea, apparently in as good health as he had ordinarily enjoyed for several years, he was attacked with a fit of apoplexy, which carried him off in less than an hour. Such, too, was the fate of Dr. Latham's patient, for we are told, that " one day, when in complete health, as he then considered himself, he dropped down in the street and expired." And so sudden was the decease of Mr. J. Hunter, that feeling him- self unwell while in the course of his professional attendance at St. George's Hospital, he went into an adjoining room, gave a deep groan, and dropped down dead. In all cases of this kind, therefore, the mode of treatment must depend upon the nature of the exciting or predisponent cause, as far as we are able to ascertain it. Where the cause is con- stitutional, a sober, quiet, and regular habit of life, with a due attention to the ingesta and egesta, and particularly to a tranquillized state of mind, will often enable the valetudinarian to reach his threescore and tenth year with cheer- fulness and comfort; but he must content him- self with "----the cool sequestered vale of life," and not form a party in its contentions and its glitter, its bustle and " busy hum." Where the affection appears to be dependant upon a particular state of any one of the larger thoracic or abdominal organs, as the heart itself, the lungs, the stomach, or the liver, our atten- tion must be specially directed to the nature of the primary disease. And, in these cases, it is often essentially relieved by some vicarious irri- tation, as a seton or issue, a regular fit of the gout, a cutaneous eruption, or a painful attack of piles. During the paroxysm itself, the most powerful and diffusive stimulants should be had recourse to, as brandy, the aromatic spirit of ammonia, or of ether, which is still better, and opium in any of its forms. Some persons are said to possess a natural power of thus keeping the heart upon a full stretch, and hereby producing a universal de- ficiency of pulsation, and of simulating death. Of this Dr. Cleghorn and Dr. Cheyne both give an instance. It should be observed, however, that the individuals died suddenly ; and one of them, Col. Townshend, within a few hours, after having maintained this rigidity of the heart for half an hour, at the expiration of which time he con- sented to resuscitate himself, and awoke from the apparent sleep of death. It should hence seem, that the natural energy of the heart sinks gradually, or abruptly, beneath the mischievous exertion, wherever such a power is found to exist. GENUS II. CLONUS. CLONIC SPASM. FORCIBLE AGITATION OF ONE OR MORE MUSCLES IN SUDDEN AND IRREGULAR SNATCHES. The Greek terms k\6vos and ic\6vrioic import " agitation, commotion, concussion." The clo- nic or agitatory spasms form two distinct orders in Sauvages, and a single genus in Parr. The first is unnecessarily diffuse ; the second is too restricted. The two orders of Sauvages are in the present arrangement reduced to two genera, and constitute that immediately before us, and svnclonus, or that which immediately follows. Dr. Cullen seems at one time to have had a de- sire of distinguishing the diseases of both these genera by the name of convulsions ; and of lim- iting the name of spasms to the permanent con- tractions, or rigidities of the muscular fibres, produced by spastic action, constituting the dif- ferent species of the preceding genus. " I think it convenient," says he, in his First Lines, " to distinguish the terms of spasm and convulsion by applying the former strictly to what has been called the tonic, and the latter to what has been called the clonic spasm." Yet the whole are treated of in his nosological arrangement under the common name of spasmi, and even in his First Lines, notwithstanding this distinction, un- der that of " spasmodic affections without fever." These spasmodic affections are, indeed, subse- quently divided into a new arrangement of " spasmodic affections of the animal functions; of the vital; and of the natural:" throughout which an attempt is still made to separate the term convulsion from that of spasm, and apply it to all clonic or agitatory motion of the mus- cles, while convulsio is nevertheless retained in the Synopsis, as the technical name of that single species of disease, which is colloquially called convulsion-fit, and not extended to any others. There is doubtless a difficulty in draw- ing the line between entastic and clonic spasm in many cases, from the mixed nature of the symptoms; but if it be felt of importance to take terms out of their general meaning, and tie them down to a stricter interpretation, such in- terpretation should be rigidly adhered to, or some degree of confusion must necessarily ensue. To understand the real nature of the spasms we are now entering upon, it may be expedient to recollect, that the nervous power appears to be naturally communicated to parts by minute jets, as it were, or in an undulatory course, like the vibrations of a musical cord. But the move- ment is so uniform, and the supply so regular in a state of health and where there is no fa- tigue, that we are not conscious of any discon- tinuity of tenour, and can grasp as rigidly and as permanently with a muscle as if there were no relaxation in its supply of power. To prove the nature of the influx, however, nothing more is necessary than to reduce the muscle from a state of healthy tone to a state of languor, or to wear it down by fatigue ; for, in this condition, all the muscles tremble, and the stoutest man is inca- pable of extending his arm with a small weight 314 NEUR in his hand, or even of raising a glass of wine slowly to the mouth, without a manifest and even a painful oscillation. The flow of the nervous power, in a state of health, is augmented by the application of va- rious stimulants, both mental and corporeal. The ordinary mental stimulus is the will, but any other mental faculty, when violently excited, will answer the same purpose, though the action which takes place in consequence hereof will' in some degree be irregular, as proceeding from an irregular source, and will in consequence make an approach to the character of spasms ; of which a violent excitement of almost any of the passions affords examples sufficiently evident, and especially the passions of fear and anger, under the influence of jvhich it is sometimes found impossible to keep a single limb still. The ordinary corporeal stimulants are the fluids, which are naturally applied to the motory organs themselves. Thus the air which we breathe becomes a sufficient excitement to the action of the lungs; the flow of the blood from the veins a sufficient excitement to that of the heart; while the descent of the feces maintains the peristaltic motion of the intestinal canal. Where these stimulants are regularly adminis- tered, and the organs to which they are applied are in a state of health, the alternations of jets and pauses in the flow of the nervous energy, as we have already remarked, are uniform. But in a state of diseased action, this uniformity is, de- stroyed, and in two very different ways; for, firsts the nervous energy may rush forward with a force that prohibits all pause or relaxation whatever, and this too in spite of all the power of the will; and we have then a production of rigid or entastic spasms, or those abnormal con- tractions in different parts of the body of which the preceding genus furnishes us with abundant examples: and, next, the pauses or relaxa- tions may be too protracted ; and, in this case, every movement will be performed with a manifest tremour. Where this last is the case, moreover, the succeeding jet from the accumu- lation of nervous power that necessarily follows upon such a retardation, must at length take place with an inordinate force and hurry; and the movement in the voluntary muscles, when attempted to be controlled by the will, must be irregular, and often strongly marked with agita- tion, giving us examples of convulsive or clonic spasm. And as, moreover, in such a state of the nervous system or of any part of it, there will often be found a contest between the retard- ing and the impelling powers, the spasm will not unfrequently partake of the nature of the two ; the nervous energy, after having been irregularly restrained in its course, will rush forward too impetuously, and for a few moments without any pause : and we shall have either a succession of constrictive and clonic spasms in the same mus- cle or sets of muscles, or a constrictive spasm in some parts, while we have a clonic spasm in others : and hence those violent and ramifying convulsions which we shall have more particu- larly to notice under the ensuing genus. A sudden and incidental application of any ir- DTICA. [Cl. IV—Ord. III. ritant power whatever to any of the muscular fibres, will throw them into an irregular action, not only in a morbid state when they are most prone to such irregularities, but even in a state of health. Hence the involuntary jerk that takes place in all the limbs when a boat in which we are sailing at full speed gets aground without our expecting it, or we are assailed unawares with a smart slroke of electricity. Now, whenever a forcible and anomalous movement of this kind has once been excited in any chain of muscular fibres whatever, there is a strong tendency in them to repeat the same movement even from the first; and when from accident, or a continuance of the exciting cause, it has actually been repeated, it forms a habit of recurrence that is often broken off with great difficulty. Hence the convulsive spasm of the hooping-cough always outlasts the disease itself for some weeks, and is best removed by the in- troduction of some counter-habit obtained by a change of residence, atmosphere, and even hours. A palpitation of the heart, first occasioned by fright in an irritable frame, has in some cases continued for many days afterward, and in a few instances become chronic. A habit of sneezing has sometimes been pro- duced in the same manner, and followed an ob- stinate catarrh ; after which the slightest stim- ulants, even the sneezing of another person, have been sufficient to call up fresh paroxysms, and, in some cases which I have seen, of very long and troublesome continuance. Hiccough affords us another example of the same tendency to a recurrence of muscular ab- normities. ' This is usually produced by some irritation in the stomach, not unfrequently that of fulness alone : the irritation is by sympathy communicated to the diaphragm, which is thrown into a clonic spasm, and the spasm being a few times repeated, the habit becomes so established as in many instances to be broken through with considerable difficulty. It is to these physiological laws that most of the affections we are now about to enter upon are referrible ; and the concentrated view we have thus taken of their operation, will render it less necessary for us to dwell at much length upon any of them. The genus clonus comprises the six follow- ing species :— 1. Clonus Singultus. Hiccough. 2.------Sternutatio. Sneezing. 3.-------Palpitatio. Palpitation. 4. .------Nictitatio. Twinkling of the Eye- lids. 5. -------Subsultus. Twitching of the Ten- dons. 6.-------Pandiculatio. Stretching. SPECIES I. CLONUS SINGULTUS. HICCOUGH. CONVULSIVE CATCH OF THE RESPIRATORY MUS- CLES, WITH SONOROUS INSPIRATION; ITERA- TED AT SHORT INTERVALS. Thouch the spasmodic action in this affec- Gen. II.—Spe. 2.] CLONUS STERNUTATIO. 315 tion exists chiefly in the diaphragm, the principal seat of the disease is the stomach, when strictly idiopathic ; an observation which was long ago made by Hippocrates, and has in recent times been more copibusly dwelt upon by Hoffmann, but which Sir Charles Bell has been the first to establish by experiments on the nervous system. "Vomiting," says he, "and hiccough, are ac- tions of the respiratory muscles, excited by irritation of the stomach.—(Experiments on the Structure and. Functions of the Nerves; Phil- Trans., 1821, p. 40C.) Debility is perhaps the ordinary remote cause, and irritability, or some accidental stimulus, the exciting. Thus excess of food, and especially in a weak stomach, is often a sufficient stimulus : and hence the frequency of this complaint among infants.* For the same reason, it is occasionally pro- duced by worms, acidity, or bile in the stomach. External pressure on the stomach is another ex- citing cause : and hence it has sometimes fol- lowed an incurvation of one or more of the ribs (Schenck, lib. iii., obs. 49, ex Fernelio), or of the ensiform cartilage (Bond. Sepulchr., fib. iii., sect, v., obs. 8., Appex.)/of the sternum, pro- duced by violence, and pressing on the coats of this organ. The stomach, however, is not at all times the only organ in which the morbid cause is seated, that excites the diaphragm to the spasmodic action. The liver is frequently to be suspected. " I have often," says Dr. Percival, in his manuscript notes on the volume of No- sology, "found hiccough symptomatic of an en- largement or inflammation of the liver on the upper convex side." It also frequently follows strangulated hernia ; and, according to Mr. John Hunter, in numerous instances accompanies local irritation after operations of various kinds. It has sometimes attended the passage of a stone in one of the ureters.—(Darwin, Zoonom., iv., i., i., 7.) The affection is often very troublesome, but it cures itself in ordinary cases, and where the exciting cause is lodged in the stomach ; for the spasmodic action very generally removes the accidental irritant; and if not, the disorder usually yields to very simple antispasmodics, as a draught of cold water, or a dose of camphire or volatile spirits. Where these have failed, a nervous action of a different kind, and which seems to operate by revulsion, has often been found to succeed, such as holding the breath, and thus producing a voluntary spasm of a rigid and opposite kind in the diaphragm; or a vio- lent tit of sneezing. An emetic (Rigaud, Ergo solvunt Singullum Vomitus et Sternutatio'! Paris, 1G01) will sometimes answer the pur- pose ; and, still more effectually, a sudden fright, or other emotion of the mind.—(Ricdlin, Lui. Med., 1696, p. 276.) If these do not prove sufficient, we must call in the aid of opium; and, in the intervals, have recourse to tonics internal and external, the warm bitters, bark, pure air, exercise, and cold bathing. * It is very frequent in drunkards when the stomach is overloaded with spirituous drink.—D. We have already pointed out the tendency which these irregular actions have to form a habit, and the more so in proportion to the gen- eral weakness and irritability of the frame ; and hence, indeed, their arising so readily in the later stages of typhus and other low fevers, and their continuing to the last ebb of the living power. Even where the constitution is possessed of a tolerable share of vigour, hiccough is too apt to become a chronic and periodical affection; and as the frequency of the spasm is also usually increased with the frequency of the se- ries, it has sometimes become almost incessant, and defied every kind of medical treatment that could be devised. As a chronic affection, it has been known to return at irregular periods from four (Bartholin, Hist. Nat., cent, ii., hist. 4) to four-and-twenty, years (Alberti, Diss. Casus Singultus chronici viginti quatuor annorum, Hal., 1743); and as a permanent attack, to con- tinue without ceasing for eight (Riedlin, cent. i., obs. 15), nine (Act. Nat. Cur., vol. v., obs. 108), twelve days (Tulpius, lib. iv., cap. 25), and even three months.—(Schenck, lib. iii., obs. 49, ex Fernelio.) Dr. Parr tell us, that he once knew it continue for a month with scarcely any intermission even at night. "The sleep," says he, "was at last so profound, that the convul- sion scarcely awoke the patient." In a few in- stances it has proved fatal. Poterius mentions one (Cent, ii., obs. xxvii.); and another, pro- duced by cold heverage, occurs in the Ephem- erides of Natural Curiosities.—(Eph. Nat. Cur., dec. iii., an. i., obs. 48.) In the Gazette de Santd for 1817 is the case of a young girl, who had been tormented for six months with an almost incessant hiccough. It ceased during deglutition, but re-appeared im- mediately afterward. The sleep was frequently disturbed. Baron Dupuytren, on being con- sulted, after antispasmodics and the warm bath had failed, applied an actual cautery to the re- gion of the diaphragm, and the hiccough imme- diately ceased; but perhaps terror operated in no slight degree in this mode of cure. SPECIES H. CLONUS STERNUTATIO. SNEEZING. IRRITATION OF THE NOSTRILS, PRODUCING SUD- DEN, VIOLENT, AND SONOROUS EXPIRATION THROUGH THt-IR CHANNEL. Sneezing is a convulsive motion of the res- piratory muscles, commonly excited into action by some irritant applied to the inner membrane of the nose, and not unfrequently, when so ap- plied, to an extremity of almost any one of the respiratory nerves ; in the course of which the air from the lungs is sonorously forced forward in this direction as the lower jaw is closed at the time. "In sneezing," says Dr. Young, " the soft palate seems to be the valve, which, like the glottis in coughing, is suddenly opened, and allows the air to rush on with a greater •316 NEUROTICA. [Cl. IV—Ord. Ill velocity than it could have acquired without such an obstruction."—(Med. Literat., p. 107.) It is a common and rarely a severe affection in its ordinary course. But, from the habit which irregular actions of the irritable fibres are perpetually apt to assume, as we have already explained, and particularly in a relaxed and mo- bile state of them, sneezing has occasionally become a serious complaint. Forestus, Hors- tius, Lancini, and many of the German medi- cal miscellaneous collections, give instances of its having been sometimes both permanent and violent, sometimes periodical, and a few cases wherein it proved fatal; which last termination is confirmed by Morgagni. The Ephemerides Naturae Curiosorum contain one instance, in which the sneezings continued for three hun- dred times in a single paroxysm. The ordinary Irritants, operating immediately on the membrane which lines the interior of the nostrils, are sternutatories, a sharp pungent at- mosphere, indurated mucus, the acrimonious fluid secreted in a catarrh or measles, or a mor- bid sensibility of the Schneiderian membrane it- self. But the severest cases have usually been produced by sympathy with some remote organ, as an irritable state of the lungs, stomach, or bowels. For the same reason, sneezing often accompanies pregnancy and injuries on the head, and sometimes the last stages of low fevers. The benediction, formerly bestowed with so much courtesy on the act of sneezing, is said to have been congratulatory, on account of its fre- quent violence; but we do not seem to be ac- quainted with the real origin of this custom. As sneezing is a symptom of catarrh, if it be repeated for some time with quick succession in an irritable habit that has been frequently af- fected with catarrh, it will sometimes, in the most singular manner, call sympathetically into action the whole circle of symptoms with which it has formerly been.associated, and the patient will seem at once to be labouring under a very severe cold. An instance of this singular sym- pathy has occurred to me while writing. The patient is a lady of about fifty years of age, in good health, but of a highly nervous temper- ament. She began to sneeze from some triflng and transient cause, and having continued to sneeze for five, or six times in rapid succession, her eyelids became swollen, her eyes bloodshot and full of tears, her nostrils discharged a large quantity of acrid serum, her fauces were swollen and irritable, and a tickling and irrepressible cough completed the chain of morbid action. The sneezing at length ceased, aiid, within a quarter of an hour afterward, the whole tribe of sympathetic symptoms ceased also. Sneezing, in its ordinary production, though a convulsive, is a natural and healthy action, in- tended to throw off instinctively from the delicate membrane of the nostrils whatever irritable or offensive material may chance to be lodged there. But when it proceeds from a morbid cause, or becomes troublesome from habit, we should use our endeavours to remove it. That there is nothing of proper convulsion in sneezing is shown, as Sir Charles Bell has justly observed, by the admirable adjustment of the muscles to the object. A body irritating the glottis will call into simultaneous action the muscles of res- piration, so as to throw out the air with a force capable of removing the offending body ; but if the irritation be on the membrane of the nose, the stream of air is directed differently,'and by the action of sneezing, the irritating particles are removed from these surfaces. By the con- sideration of how many muscles require the ad- justment to produce this change in the direction of the stream of air, we may know that the ac- tion is instinctive, ordered with the utmost ac- curacy, and very different from convulsion.— (Of the Nerves which associate the muscles of the Chest in the Actions of Breathing, &c ; Phil. Trans., 1822, p. 305.) When the complaint is idiopathic and acute, or, in other words, when the Schneiderian mem- brane is morbidly sensible, or stung with some irritant material, it may be relieved by copiously sniffing warm water up the nostrils, or throwing it up gently with a syringe, or forcing up pellets of lint moistened with opium dissolved in warm water, the pressure of which is sometimes of as much service as the sedative power of the fluid itself. If this do not succeed, leeches or cold epithems should be applied to the nose exter- nally. But a free and spontaneous epistaxis, or hemorrhage from the nostrils, effects the best and speediest cure, of which Riedlin has given an instructive instance.—(Lin. Med., 1695, p. 148.) Its return has been prevented by blisters to the temples and behind the ears, and fre- quently sniffing up cold water. It has also been attempted to be cured by pungent sternutatories, so that the olfactory nerves may be rendered torpid and even paralyzed by over-exertion ; but this has rarely answered ; for when once a mor- bid habit is established, it does not require the primary cause or stimulus for its continuance. When the complaint proceeds from sympathy, the most effectual mean of removing it is by as- certaining the state of the remote organ with which it associates, and removing the stimulus that gives rise to it. This, however, cannot always be done ; and, in such cases, camphire in free doses will often prove a good palliative, and if this do not succeed, we must have re- course to opium. SPECIES III. CLONUS PALPITATIO. PALPITATION. SUBSULTORY VIBRATION OF THE HEART OR ARTERIES. Palm us or palpitatio is used in very differ- ent senses by different writers. By Cullen and Parr it is limited to a vehement and irregular motion of the heart alone. By Sauvages and Sagar it is applied to an irregular motion " in the region of the heart." By Linneus it is de- nominated "a subsultory motion of the heart or a bowel—cordis viscerisve ;" and by Vogel is defined " a temporary agitation of the heart, a bowel, a muscle, a tendon, or an artery." The first of these views is too contracted, for Gen. II.—Spe. 3.] CLONUS PALPITATIO. 31? palpitations, or quick abnormal beats, are felt almost as frequently in many other organs, and particularly those of the epigastric region. Yet, as in these, it seems in every instance, however complicated with other symptoms, to depend upon a morbid state of the he;.-, t itself, or of the arteries which supply them, or are in their vi- cinity ; the definitions that extend palpitations to other organs than the heart and arteries, as separate from these, appear to be as much too loose and out of bounds as the first definition is too limited. The view now offered takes a middle course : it contemplates palpitation as dependant on a diseased action of the heart alone, or of the lar- ger arteries alone, or of the one or the other as- sociating with some organ more or less remote ; and hence lays a foundation for the three follow- ing varieties :— a Cordis. Palpitation of the heart. 0 Arteriosa. Palpitation of the arteries. y Complicata. Complicated or visceral palpita- tion. The vibratory and irregular action, which we denominate palpitation of the heart, is some- times sharp and strong, in which case it is call- ed a throbbing of the heart, and sometimes soft and feeble, when it is called a fluttering of this organ. Both may possibly proceed from two distinct causes ; the one a morbid irritability of its muscular fibres, or some sudden stimulus applied to it, either external or internal, by which its systole becomes harsh and unpliant, and evinces a tendency to a spastic fixation ; and the other an irregular motion of the entire organ of the heart in the pericardium, by which it literally strikes against the chest: the cause of which we do not always know, though we see it very frequently occasioned by a sudden and violent emotion of the mind, and have rea- son to believe, that it is often a result of the spastic systole or contraction of the heart which we have just noticed. When, however, the substance of the heart is thus irregularly acted upon, and jerked backward and forward from a cause extrinsic to itself, the palpitation is con- fined to the pericardium, and the pulse does not partake of the abnormity. The last is, perhaps, the most common proxi- mate cause of the palpitation of this organ, and we are indebted to Dr. William Hunter for having first pointed it out to us. The heart, in its natural state, lies loose and pendulous in the pericardium ; and when the blood which it re- ceives is, from an irritation of any kind, thrown with a peculiar jerk into theaorta, the moment it reaches the curvature of this trunk, it en- counters so strong a resistance as to produce a very powerful rebound in consequence of the aorta being the first point against the spine : the influence of the heart's own action is now, therefore, thrown back upon itself, and this or- gan, as a result of its being loose and pendulous, is tilted forward against the inside of the chest, between the fifth and sixth ribs on the left.— (t^ee J. Hunter on Blood, p. 146, note.) The rebound of so strong a muscle as the heart against the inside of the chest, must de- pend for its violence, upon the violence of the jerk with which the blood is spasmodically thrown into the aorta : and this has often been so powerful as to be distinctly heard by by- standers.* Castellus has given an example of tliis sonorous effect: and Mr. Dundas has ob- served it in various cases. " The action of the heart," says the latter, " is sometimes so very strong as to be distinctly heard, and to agitate the bed the patient is in so violently, that his pulse has been counted by looking at the mo- tions of the curtain of the bed."—(Trans. Medi- co-Chirurg. Soc, i., 27.) The heart has some- times palpitated with a force so violent as to dislocate (Horslii, ii., 137-139) or break the ribs (Schenck, obs. 215, ex Fernelio), for both are stated to have occurred on respectable au- thorities,! and, in one instance, to rupture its own ventricles.X—(Portal, Mimoires de Paris, 1784.) Upon the wonderful power of the soft parts, or rather of the muscles over the bones, when thrown into vehement spas- modic action, we had occasion to observe in the Physiological Proem to the present order : and hence we have sometimes had examples of the humerus, and other long bones, being broken by a convulsion-fit. A contraction of the left aurico- ventricular opening is sometimes found to pro- duce the phenomenon of a double pulse.— (Hodgson on the Diseases of Arteries and Veins.) I have said, that we are not always acquaint- ed with the remote or exciting causes of the pal- pitation of the heart. Violent emotion of the mind, as already observed, is a frequent excite- ment, and one or two others have been already indicated. The first of these, is perhaps the most frequent cause ; and hence we can readily admit with M. Corvisart, that palpitation, toge- ther with many other diseases of the heart, have been far more frequent in France since the commencement of its late horrible revolution. M. Portal has, indeed, proved this fact by va- rious interesting examples, from which the fol- lowing may be selected, as it is short:—A young lady, who had suddenly learned that her husband had been cruelly murdered by a band of the popular ruffians, was instantly seized with a violent palpitation that terminated in a syn- cope so extreme, that she was supposed to be dead. This apprehension, however, was erro- neous. She recovered; but the palpitation continued for many years ; and she at length died of water in her chest.—(Mem. sur la Na- ture et le Traitement de plusieurs Maladies, tome iv., 8vo., Paris, 1819.) The remote causes are rarely to be discovered till after death, and for the most part seem to consist in a morbid structure of the heart itself, or the pericardium, by which last the muscular * Castellus, P. Vascus. Exercitat. ad affectus Thoracis, tr. ix., Toloso, 1614, 4to. Lettsom, Med. Soc. Lond., vol. i. A Vega, De Art. Med., lib. iii., cap. 8. f The editor has no doubt of the incorreotness of such reports. X Another case of spontaneous rupture of the heart is recorded by Dr. Valentine Mott, in the New-York Medical Magazine.—D. 318 NEURi walls of the heart have either been obstructed in their play, or have had too much liberty of action. The heart has sometimes been found ossified in its general substance, as in the case of Pope Urban the Eighth; and more frequently in its valves or in its connexion with the aorta. It has sometimes been thickened, and has grown to an enormous size, which change of structure has lately been distinguished by the name of hypertrophy, and has been found in one instance of a weight of not less than fourteen pounds.— (Eph. Nat. Cur., dec. iii., ann. iii., obs. 166.) A case occurred to the present author not long ago in a young lady of fourteen, in whom it leached half this weight, and was the cause of a most distressing palpitation, as well as of a gen- eral dropsy. By close confinement and quiet, and the use of elaterium and scarification to carry off the water, she recovered an apparently good share of health ; but the exercise of dancing, a few months afterward, produced a recurrence of all the symptoms in a more violent and ob- stinate degree, and she gradually fell a sacrifice to them. In other cases, the heart has been peculiarly small and contracted, chiefly, perhaps, in the disease of tabes or marasmus ; and consequent- ly there has not been a sufficient capacity for the regular influx of venous blood. The space of the pericardium has often been morbidly diminished by inflammation, or an un- due growth of fat; and hence, again, the heart has been impeded in its proper action; while occasionally it seems to have been filled, or nearly so, with a dropsical fluid. Organic injury from external violence, is also a frequent cause of palpitation. Yet it is sin- gular to observe the severity of lesion which the heart and its appendages will sometimes un- dergo, when the constitution is sound, without affecting the life. M. Latour, who during the French war was first physician to the Grand Duke of Berg, attended a soldier who laboured under a tremendous hemorrhage from the breast, produced by a wound from' a musket that had penetrated this organ. The hemorrhage, how- ever, ceased on the third day, the patient's strength gradually recruited, and suppuration proceeded kindly. It was nevertheless neces- sary to cut several pieces of fractured rib away ; yet the wound cicatrized at the end of three * Diet, des Sciences Medicates, Art. Cas. Rares. The following causes of palpitation are specified by Dr. Hope as inherent in the heart itself:—1. Hypertrophy, and hypertrophy with dilatation. In these affections, palpitation consists in an in- crease both of the force and of the frequency of the heart's action. 2. Dilatation with attenuation. Palpitation in this case consists in an increase of the frequency, but often not of the strength of the beats, though the patient may experience the sen- sation of an increased impulse. 3. Disease of the valves. Palpitation from this cause varies in its characters, according to its nature, situation, and extent of the valvular affection, and according to the presence or absence of hypertrophy, dilatation, or both. 4. Pericarditis, carditis, and inflamma- tion of the internal membrane. 5. Adhesion of the pericardium. Palpitation from this cause is >TICA. [Cl. IV.—Ord. IIF. months, and the only inconvenience that re- mained was a very troublesome palpitation of the breast, that annoyed him for three years. Six years after the accident, he died of a com- plaint totally unconnected with the wound. His body was opened by M. Mansion, chief surgeon of the hospital at Orleans ; and the ball, which had entered his breast, was found lodging in the right ventricle of the heart, covered over in a great measure by the pericardium, and resting on the septum medium.* To these causes may be added a scirrhous or other morbid structure of the lungs, and per- haps of the spleen, liver, stomach, or intestinal canal ; for it is a frequent accompaniment upon most species of parabysma : and, in these cases, appears as a symptomatic affection alone. For reasons already assigned, it is also an occasion- al symptom in hydrothorax ; during which it shows itself in a very violent degree upon men- tal agitation, especially that produced by fright or vehement rage. We should not, however, be hasty in deciding upon any structural affection of the heart, or of any of the larger organs that closely associate with it, nor, in reality, upon any incurable cause whatever. For it has not unfrequently happened, that a palpitation of long standing, arid.which has been regarded as of a dangerous kind, has gradually gone away of its own accord, and left us altogether in the dark. Dr. Cullen gives a confirmation of this remark in the following very instructive case :—" A gentleman, pretty well advanced in life, was frequently attacked with palpitations of his heart, which, by degrees, in- creased both in frequency and violence, and thus continued for two or three years. As tho patient was a man of the profession, he was visited by many physicians, who were very unan- imously of opinion, that the disease depended upon an organic affection of the heart, and con- sidered it as absolutely incurable. The disease, however, after some years, gradually abated both in its frequency and violence, and at length ceased altogether ; and since that time, for the space of seven or eight years, the gentleman has remained in perfect health, without the slightest symptom of his former complaint."— Mat. Med., part ii., chap, viii., p. 357.) A case precisely similar, and in a professional gen- tleman somewhat beyond the middle of life also, violent, and of an abrupt, kind. As physical causes of palpitation, exterior to the heart, Dr. Hope spe- cifies, 1. Acceleration of the circulation by mus- cular efforts. 2. Plethora. 3. Anaemia. 4. Con- vulsive, epileptic, and hysteric fits. 5. Obesity, 6. Obstructions in the lungs from hydrothorax, empyema, pneumothorax, hepatization, bronchitis, &c. 7. Asthmatic bronchial constriction. 8. Acute Laryngitis. 9. Abdominal infarction from enlarged liver or spleen, ovarian dropsy, utero- gestation, &c. Afterward Dr. Hope adverts to palpitation from causes operating entirely through the nervous system.—(See Cyclop, of Pract. Med., art. Palpitation.) Nervous palpitations, as this writer correctly observes, are intermittent, their causes being only occasional, whereas those from organic diseases are continued, their causes being incessant.—Ed. Gen. II.—Spe. 3.] CLONUS PALPITATIO. 319 has occurred to the present author, with a spon- taneous termination equally as favourable. M. Laennec's ingenious method of mediate aus- cultation by the stethoscope, as we have al- ready explained, will often be found of great im- portance in the different forms of this species of disease.* The same alternating spasmodic motion, into which the muscular substance of the heart is oc- casionally thrown by one or other of the causes thus glanced at, seems, at times, to take place in some of the larger arteries, and extends to a greater or less length in proportion to the nature of the cause, or the extent of the morbid irritability by which they are affected, produ- cing the second variety before us. That a morbid irritability may exist in a part of an ar- tery while the rest is free from any such condi- * See Cl. III., Ord. IV., Gen. III., Spe. 5. In nervous palpitations, it was remarked by La- ennec, that " the first impression which the ap- plication of the stethoscope to the region of the heart produces on the ear, shows at once that this organ has not great dimensions. The sound, al- though clear, is not loud over a great extent; and the shock, even when it at first appears strong, has little real impulsive force, for it does not sen- sibly elevate the head of the observer. This last sign," saysLaennec, " appears to me the most im- portant and the most certain of all, when we add to it the frequency of the pulsations—most com- monly from 84 to 96 in a minute." It is stated by Dr. Hope (Cyclop, of Pract. Med., art. Palpitation), that in dilatation of the heart, dulness on percussion indicates enlargement of the organ, further evidenee of which is derived from the impulse being situated lower down than natural. The first sound is short, smart, and clear, resembling, and in dilatation with attenua- tion, becoming identical with the second. In hypertrophy with dilatation, the dulness on percussion is increased over a still greater extent, and the dulness and impulse are also lower down than natural. Both sounds are very loud, and the impulse is much more forcible than in nervous palpitation, very frequently raising the head of the auscultator. In simple hypertrophy the impulse is a slow, gradual, and powerful heaving, very sensibly ele- vating the head. Both sounds are diminished, and in extreme cases almost suppressed. In dis- ease of the valves there is a permanent bellows sawing, or rasping murmur; whereas the murmur in nervous palpitation is only occasional, and of a soft character. If the valvular contraction be great, the action of the heart is irregular. It is further observed by Dr. Hope, that irregularity al- so occurs in nervous palpitation, but it is not ac- companied by those symptoms of an embarrassed circulation, which invariably attend valvular dis- ease. Should hypertrophy, dilatation, or both, coexist with valvular disease, their signs will likewise be present. In nervous palpitation, Dr. Hope finds the pulse to be jerking, but *vith little fulness, strength, and incompressibility. In dilatation it is full and soft; in hypertrophy with dilatation, it is full, strong, and sustained ; and in simple hypertrophy, though less full, it is strong, sustained, and even hard. These and other ob- servations on the diagnosis of palpitation from various causes, as delivered by Dr. Hope, are re- plete with practical instruction, whose Treatise on the Diseases of the Heart is a valuable contribu- tion to medical literature.—Ed tion, is easily conceived, since a like partial ir ritability is often found to exist in organs in which we are capable of tracing it in the most manifest manner. Yet, even in arteries them- selves, we can sometimes ascertain the same to the conviction of our senses ; as, for example, in the case of phlegmonous inflammation ; in which also we fkid it accompanied with the throb, oi alternating spasm and relaxation which consti- tute what is meant by palpitation. . In a healthy and ordinary flow of the blood through the ar- teries, it is very well known, that there is no sensible series of contractions- and dilatations whatever; and we have already observed in the Physiological Proem to the third class, that there is no actual change of bulk of any kind, and that it is the pressure of the finger Or of some other substance against the side of an artery that alone produces a feeling of pul- sation. In a phlegmonous inflammation, how- ever, every one is sensible of a considerable change in this respect; for there is often a veiy smart and vibratory pulsation while the affected part is in perfect freedom, and no finger is ap- plied to it: and that this is a pulsation, uncon- nected with the regular pulsation of the heart, is perfectly clear, because it is frequently less uniform, rarely if ever synchronous with it, and, in most instances, twice as rapid. We have here, therefore, a full proof of a local excess of irritability in an arterial tube, and of a palpi- tation, or alternating spasm and relaxation, as its effect.* Yet inflammation is but one cause of this sub- sultory action, or of the irritability which gives rise to it. With other causes we are not much acquainted ; but we have reason to be- lieve them very numerous, and wherever they exist, the artery operated upon will evince the same kind of vibratory throb, though, in general, the stroke will not be found quite so smart as that which takes place in the pulse of a phleg- mon. It may appear singular, that this abnbr- mal action, whether of the heart or arteries, should evince so much punctuality in its vibra- tions ; but there is often a wonderful tendency to punctuality in all intermissive affections what- ever. We see it in hemorrhoidal discharges, in gout, and above all, in intermitting fevers : and, till the cause of such punctuality is explained in this last instance, it will be in vain to expect an explanation in the case before us. In very irritable habits, or perhaps where there is a morbid sensibility through the whole . of the sanguiferous system, the palpitation will not unfrequently shoot from one artery to an- other ; and one or two cases are given in the Epheinerides of Natural Curiosities (Eph. Nat. Car., dec, i., ann. vi., vii.), in which it appears * The tenour of some of these observations dis- agrees with the results of certain microscopical observations made on parts in a state of inflam- mation. Thus Dr. Thomson of Edinburgh, in his experiments, was unable to discern any alter- nate expansion and contraction of the arteries. The statement about the pulse in an inflamed part not usually coinciding in number and time to the pulse of the left ventricle, is also at variance with other observations.—Et>. 320 NEUROTICA. [Cl. IV—Ord. III. to have been universal. It was so, indeed, in the very irritable organization of that singularly constituted character, J. J. Rousseau, if we may credit the account he gives of himself in rela- tion to this subject: for he tells us, that after a eculiar paroxysm of high corporeal excitement, e became, all of a sudden, sensible of a pulsa- tion in every part of his body, whicW from this time accompanied him without intermission: and he adds, that the throbbing was so distinct and strong, that he was often capable of hear- ing as well as feeling it. The temporal arteries are peculiarly apt to concur in this migratory throbbing, and occa- sionally the carotid : and the throbbing of both is sometimes synchronous with that of the heart, and sometimes successive to it. Mr. Dundas has observed, that this affection of the carotids is most common to persons in the prime of life ; and that, on dissection, the heart is often found enlarged in its size, but without any increase of muscular power ; an assertion collaterally sup- ported by the case of a young lady described un- der the preceding variety. We here also some- times meet with polypous concretions, and very generally adhesions to the pericardium. And it is highly curious and interesting to no- tice the ramifying chain of morbid action, of which the heart sometimes forms the first link. I had lately a lady under my care, of delicate constitution and highly nervous habit, in the third month of pregnancy, who had for several weeks been uniformly attacked in the evening with a violent palpitation of the heart, that con- tinued for nearly an hour or upwards ; it was then transferred to the temples, which throbbed with as much violence and for as long a period of time; vertigo followed, with a tendency to deliquium, immediately after which there was a general reaction in the system ; the skin became heated, and at first very dry ; but the dryness at length yielded to a gentle diaphoresis, which concluded the morbid series ; for the patient at that time becoming tranquil, dropped into a sound and refreshing sleep, and woke free from all these symptoms in the morning. In this case, also, there was a considerable tendency to that universal subsultus or alterna- ting spasm of the arterial system to which we have just adverted: for all the arteries of the extremities pulsated or palpitated whenever ac- cidentally pressed upon by any substance, though it required this additional stimulus to ex- cite spasmodic action. Arterial palpitation, however, is to be found, though not more frequently, still far more alarm- ingly, in the epigastric region, than in the head ; and appears to proceed from some particular excitement of the aorta, the superior mesenteric, or some branch of the cceliac artery. Its beat has here some resemblance to that of an aneu- rism of these vessels, and has often been pro- nounced to be such without the slightest foun- dation, to the great terror of the patient, and consequently to a considerable exacerbation of the disease. It may, for the most part, be easily distinguished from an aneurism by being des- titute of any circumscribed pulsatory tumour that can be ascertained by a pressure of the finger; by a smarter vibration in the arterial stroke ; and by that degree of irregularity in the return of the stroke by which palpitation is dis- tinguished from pulsation. In some cases, in- deed, the line of the affected artery can be dis- tinctly felt and followed up to a considerable length ; and the vibration has occasionally been so strong as to be visible to the eye, even at some distance, when the surface of the epigas- tric region has been exposed to view. " From a good deal of experience upon this subject," says Dr. Baillie, " I am enabled to say, that the increased pulsation of the aorta in the epigas- tric region very rarely depends upon any dis- ease of the aorta itself, or of its large branches in that place ; and that this occurrence is almost constantly of very little importance.'"—(Med. Trans., iv., xix.) This distinguished physiolo- gist tells us further, that he has had an oppor- tunity of examining the state of the arteries in the epigastric region after death, in two persons who had this pulsation very strongly marked, and who died from other diseases. In both ca- ses all the arteries were perfectly free from every appearance of diseased structure. He was also some years ago consulted by an old man upon a paralytic affection ; who afterward spoke to him incidentally concerning a palpita- tion of the kind before us, to which he had been subject for upwards of twenty-five years. The throb, on examination, was distinctly to be felt; and on the patient's first perceiving it, and ap- plying to Sir Cesar Hawkins, Mr. Bromfield, and Dr. Hunter, the two former had declared it to be an aneurism, while the latter, more mod- estly, confessed that he did not know what it was. Dr. Baillie, in the article now alluded to, has imitated the modesty of Dr. Hunter. "It is perhaps difficult," says he, " to ascertain, in many instances, the causes of the increased pul- sation of the aorta in the epigastric region : but, in most cases, it will be found to be connected with an imperfect digestion and an irritable con- stitution.* And hence, whatever may improve the digestion and render the constitution less irritable, will be of use in mitigating the com- plaint : and, above all, will be found highly ser- viceable to remove the patient's anxiety on the subject, whenever it can fairly be done.f It ia here that M. Laennec's stethoscope may be employed as a valuable diagnostic, and will often enable us, better than any other means, to as- certain the real nature of the malady; for an account of which the reader may turn to the re- marks on Phthisis.—(Cl. III., Ord. IV., Gen. HI., Spe. 5.)_________________________________ * Dr. Valentine Mott has written an interesting paper on pulsation in epigastrio, which may be found in the Transact, of the New-York Physico- Med. Society, vol. i.—D. t With respect to pulsation in the epigastrium, useful information will be found in A. Bum's work on Diseases of the Heart, Edin., 1609 ; and in a publication by the late Dr. Albers, of Bremen, entitled Uber Pulsationem im Unterleibe, 8vo., Bremen, 1803. The subject is also introduced into the editor's Dictionary of Practical Surgery. under the Head of Abdominal Pulsations.—Ed. Gen. II.—Spe. 3.] CLONUS PALPITATIO. 321 But the throbbing or pulsatory motion is often communicated to other organs than the sanguif- erous vessels, and forms that variety of affec- tion, to which we have given the name-of com- plicated palpitation. This is clearly de- pendant, in many cases, upon the vicinity or close connexion of such organs with the heart or arteries that form the seat of disease ; and it may also in other cases be produced, as inge- niously conjectured by Dr. Young, by an accu- mulation of fluid in the pericardium or thorax, which transmits a pulsatory motion from the heart itself to whatever other organ or surface of a cavity such fluid may reach ; in the same manner as the fluctuation, produced by a slight blow given to one side of the abdomen when distended with water, is distinctly propagated to the opposite side. In the case of a middle-aged woman, of a rheumatic habit, labouring under symptoms of general dropsy (Med. Trans., vol. v., art. xvii.), " a palpitation," he tells us, " was observed in the right hypochondriac region, and on the right side of the neck, which exhibited a vibratory motion more rapid and less regular than that of the pulse felt at the wrist; and a similar vibration was observable in the heart it- self : the pulsation of the neck was not confined to the jugular veins ; it was more forcible and extensive than it could have been if it had ori- ginated from those vessels ; and it had more the appearance of a violent throbbing of the carotid artery; although, in the axillary artery, the pulse was comparatively regular and natu- ral." Dr. Young found, nevertheless, upon making a strong pressure on the right side of the neck with a single finger, that the motion of the carotid artery was very perceptible, and totally independent of that of the superficial parts, being precisely synchronous with the pulse at the wrist, although it required consid- erable attention to distinguish it from the more irregular palpitation. The symptoms, however, of a dropsy of the chest or pericardium in this patient appear to have been obscure; and at the time when the general hydropic enlarge- ment, which had been much reduced in the course of the autumn, began to increase towards the end of October, the palpitation was consid- erably less, as well as the pulsations in the ab- domen and neck, though the motion of the heart was still fluttering, the pulse at eighty, inter- mitting and very irregular. On the death of the patient, which occurred soon afterward, a con- siderable quantity of fluid was found in the per- icardium, in the right cavity of the thorax, and in the ventricles of the brain, but little or none on the left side of the chest: the heart was in- considerably enlarged, and some of its valves, as also those of the pulmonary artery, which were much ossified, so that a free passage of the blood was impeded. I have said, that palpitation is sometimes de- pendant upon a morbid irritability of the san- guiferous system in general. In some instan- ces, however, we find it rather dependant upon a morbid irritation and debility of the entire frame, and consequently connected with a very irregular performance of many, or all the func- Vol. II.—X tions of the body. Of this highly complicated state of the disease we have a striking exam- ple in Dr. Bateman's history of himself (Med. Chir. Trans., vol. ix., p. 227), which he as- cribes to a poisonous action of mercury, em- ployed on his own person copiously, in the form of an unguent, to relieve an amaurosis of the right eyey and which seems to have produced something of the mercurial erethism described by Mr. John Pearson (Obs. on the Effects of various Articles of the Materia Medicain Lues Venerea, ch. xii.) as taking place in some sin- gular idiosyncrasies, already noticed by us under the head of Syphilis.—(Cl. III., Ord. IV., Gen. VII., Spe. 1.) In thiscase, the heart and arte- ries were equally subject to subsultory and vio- lent motions, sometimes separately, and some- times synchronously, but inaccordantly as to the number of the throbs in a given time, and al- most perpetually accompanied with a most dis- tressing sense of languor and sinking. There was also a very irksome cough, an occasional sense of constriction across the region of the diaphragm, and such a difficulty of respiration as to render an erect position at night impera- tively necessary. Life was, in this case, un- questionably a forced state of being, and all the stimuli of the external senses and of the will seemed necessary to excite the sensorial organ to produce a sufficiency of nervous energy for the mere preservation of life. And hence, du- ring sleep, or as soon as these stimuli were cut off, there was such an increase of languor, ir- regular action of the heart, and sinking as though in the act of dying, that it was at times necessary, notwithstanding the extreme drow- siness of the patient from a previous and long- continued watchfulness, to interrupt the sleep every two minutes ; since by this time or even sooner, the failure of the pulse and the appear- ance of the countenance indicated a superve- ning deliquium. The powers of the stomach, from the repeated paroxysms of the disease, seem to have declined rapidly. Frequent sup- plies of food and cordials, as spiced wine, ap- peared at first serviceable in warding off the languor ; but, at length, nothing but fluids could be taken and retained, without increasing the disturbed action of the heart. Yet so extreme was the sense of sinking and immediate disso- lution, that, on one occasion, after a quarter of an hour's sleep, air was importunately demand- ed, and three glasses of undiluted brandy were drank in five minutes, without much relief: and afterward ammonia and ether repeated every ten minutes for two hours ; when the paroxysm rapidly declined after a copious discharge of "lim- pid urine. The disease continued a twelve- month before the patient felt, in any essential degree, amended : and little benefit was derived from medicines of any kind. It is well known, however, that this acute pathologist and excel- lent man has since fallen a sacrifice to a return of the complaint. In a disease produced by so great a diver- sity of causes, often obscure, and very gener- ally complicated with other affections, it is im- possible to lay down any one plan of treatmeut 322 NEUR( that will apply to every case. Our first en- deavour should be to ascertain, as far as we may be able, whether the palpitation be idio- pathic or symptomatic ; and if the last, while we endeavour to palliate the present distress, our attention should chiefly be directed to the primary malady. If any other morbid state of the stomach or bowels be suspected, this, as far as possible, should be removed ; and if we have reason to suppose hydrothorax, or any other kind of dropsy to be present, the means here- after to be recommended for this tribe of com- plaints should be resorted to from the first. In •pregnancy, the disease will most probably cease upon a cessation of this state of body, and usu- ally, indeed, ceases during the latter months, or after the period of quickening. And, if it seem to be chiefly dependant upon a general irritability of the sanguiferous system, or of the whole constitution, the sedative antispasmodics, tonics, and especially the metallic, quiet of mind as well as of body, regular hours, light meals, pure air, and such exercise as agrees-best with the individual, will often prove of essential ser- vice, and sometimes effect a radical cure. Much of this plan will also be requisite where we have reason to apprehend some structural affection of the heart or larger bloodvessels : and when, from any incidental excitement, the irritation is here more than ordinarily trouble- some, recourse must be had to narcotics. Opi- um is by far the best where it agrees with the system : but its secondary effects are often very distressing, and we cannot employ it. In such cases, we must find out, by trial, what is its best succedaneum : the hop, henbane, hemlock, and prussic acid, have all been essayed in their turn, and sometimes one has succeeded where the rest have all failed. But, upon the whole, the henbane has answered far better and more gen- erally under the author's own hands: and, in one or two instances of great obstinacy, he has known it effect a perfect cure, when all the rest. had been tried in succession and had totally failed. In Dr. Bateman's case, however, which was peculiarly severe and complicated, the henbane, though it seemed serviceable at first, taken in doses of from three to five grains of the extract every night, gradually. lost its effect even when repeated three times a night in doses of five grains at a time. The tincture of hop, in doses of thirty drops every six hours, was next tried, but produced no other effect than a slight drowsi- ness. Musk seemed most successful in draughts of ten grains each; yet even this was of tran- sient duration, and was abandoned as of no use. Where the palpitation is accompanied with a distressing tendency to deliquium, I have occa- sionally relieved it by camphire pills, with the ammoniated tincture of valerian or the aromatic spirit of ether. The disease has occasionally been carried off by a sudden attack of some other complaint, as gout, herpes, diuresis, or the formation of an abscess : and hence, setons and issues have been recommended, and have occasionally proved serviceable. Zacutus. Lusitanus found the lat- )TICA. [Cl. IV.—Ord. III. ter produced a radical cure in palpitation of the heart, which he ascribed to the rapid healing of some chronic ulcers.—(Prax. Hist.,lib. viii., obs. 30.) Schenck advises the wearing a bag of aromatics at the pit of the stomach (Lib. ii., obs. 216); and hence, perhaps, the origin of camphire-bags as a specific for irregularities of the heart of another kind.* SPECIES IV. CLONUS NICTITATIO. TWINKLING OF THE EYELIDS. RAPID AND VIBRATORY MOTION OF THE EYELIDS. To a certain extent, twinkling or winking of the eyes is performed every minute without our thinking of it. It is a natural and instinctive action for the purpose of cleansing and moist- ening the eyeball, and rendering it better fitted for vision. Dr. Darwin has some ingenious re- marks upon this subject. "Whenthe cornea," says he, " becomes too dry, it becomes at the same time less transparent, which is owing to the pores of it being then too large ; -so that the particles of light are refracted by the edges * Our author speaks of idiopathic palpitation; but, according to the editor's view, such a disease has no real existence, palpitation being only a symptom of some other primary affection, either organic or nervous. Thus, it may depend upon organic disease of the heart, aneurism of the aorta, hysteria, chlorosis, indigestion, plethora, utero- gestation, anaemia, or nervous disorder, which pri- mary affections, while they continue, prohibit all effectual relief of the palpitations dependant on them. Hence, inasmuch as several of the pri- mary complaints are incurable, the palpitations themselves must also be incurable. On the mode of treating palpitations arising from plethora we need not here dwell. With regard to those oc- curring in early pregnancy, if they are connected with plethora, the treatment should consist in bleeding the patient, giving her gentle aperient medicines, and making her observe a diet without stimulants. In palpitations from anaemia, Dr. Hope (Cyclop, of Pract. Med.) recommends the exhibition of the preparations of iron with aloes, and especially the pills employed by Dr. Aber- crombie, consisting of two grains of thesulphate of iron, two of aloes, and five of the compound cinnamon powder, in two pills, taken at dinner, and, if necessary, at bedtime also. Dr. Hope speaks favourably likewise of the carbonate of iron, in doses of from one to three drachms thrice a day, and of small doses of the nil. aloes c' myr- rha, and pil. galban. comp. at bedtime. A nutri- tious animal diet, pure air, gentle exercise, the flesh-brush, salt water sponging,, and the shower bath, are likewise commended. For nervous palpitation, Dr. Hope recommends, at first, the lightest hitters, then bark and mineral acids, and afterward, metallic tonics, one of the best of which is the sulphate of zinc in the dose of one grain, with extract of gentian, in the form of a pill, twice or thrice a day. At the same time it is admitted that, in the first instance, a bracing air by the seaside, seabathing, a nutritious un- stimulating diet, and a good regimen in general, are of more importance than medicine ; and that after the continuance of such means for a few weeks, chalybeates will often become extremely serviceable.—Ed. Gen. II.—Spe. 5.] CLONUS SUBSULTUS. 323 of each pore instead of passing through it; in the same manner as light is refracted by pas- sing near the edge of a knife. When these pores are filled with water, the cornea becomes again transparent."—(Zoonom., cl. i., i., 4, 2.) Moist- ure is indeed a frequent cause of transparency in various bodies ; and hence, in dying people, whose eyelids are become torpid and do not nictitate, the cornea is sometimes so dry that its want of transparency is visible to by-stand- ers. So when white paper is soaked in oil, and its pores filled with this fluid, from an opaque body it becomes transparent, and radiates the light that is thrown upon it; air itself is most transparent when as much moisture is dis- solved in it as it will hold; when void of moist- ure, indeed, it forms a dry mist, which is occa- sionally met with in the morning, and through Which distant objects are seen indistinctly; white, on the contrary, when distant objects are seen with perfect clearness, it is a sign of rain. In a mist, distant objects are also seen indis- tinctly ; yet here the moisture is not dissolved in the atmosphere, but merely suspended, and formed by the attraction of cohesion into col- lected spherules. We may hence account for the want of transparency in the air, which is seen in tremulous motions over cornfields on hot summer days, and over brick-kilns, after the flame is extinguished, while the furnace still re- mains light. It is this dryness and want of transparency in the atmosphere over the sum- mits of hot and arid hills, in a bright unclouded sky, as in Italy, which constitute what is called by the painters the blue shade of light, and which is copied in most pictures of Italian scenery. The ordinary use of nictitation is therefore obvious : but there are many persons who wink or twinkle their eyes far more frequently than is necessary for the purpose of moistening the cornea, and in whom it forms an unsightly habit. This has usually been produced at first by some local irritation, as inflammation or dust in the eyes, which quickens the natural action, and, where the stimulus is considerable, renders it irregular and convulsive. If indeed the stimu- lus be very vehement, the nature of the spasm is changed, and the eyelids, instead of irregu- larly opening and shutting with great rapidity, become rigidly closed. We have seen, in many of the preceding spe- cies of diseases, with what ease morbid actions are continued when once introduced into an or- gan : and hence, when any permanent irritation of the eye has excited and maintained for some days or weeks a quick repetition of twinkling, this iterative action will often be found to be- come habitual, and remain after the irritation has subsided. This morbid habit has been sometimes cured by a powerful exertion of the will; but more generally by using one eye only at a time, and closing the other ; the open eye being employed in examining an object for a considerable period with great attention and steadiness. A minute examination of the stars at night through a tel- escope has a like corrective tendency, and may be employed for the same purpose. SPECIES V. CLONUS SUBSULTUS. TWITCHINGS. SUDDEN AND IRREGULAR SNATCHES OF THfl TENDONS. This affection is to the tendinous extremities of the muscles in which the principle of irrita- tion is often apt to accumulate, what palpitation is to the irritative fibres of the heart and arter- ies : and hence, as we have already seen, it is included under the general term of palpitation by Vogel. We witness these starts or twitchings most frequently in extreme stages of debility produced by atonic fevers, and especially just before the act of dying. They are in such cases weak convulsions interruptedly undulating from one limb or part of a limb to another, too feeble to raise the limb itself, although sufficiently power- ful to give slight but transient swellings to the belly of a muscle, and consequently a slight in- voluntary flickering to its tendons. In the or- dinary close of life, they are the precursors of the fatal scene, the harbingers of the dying strug- gle, and generally indicate that the will has lost its hold, and the power of sensation is rapidly ceasing: thus affording another proof, if other proofs v/ere wanting, to those adverted to in the Proem to the present class, that the irritative fibres are capable of maintaining their function, under particular circumstances, for a much later period than the organs of perception and sensa- tion, occasionally, indeed, for some hours after the death of every other part of the body. And as debility and irritability often exhibit a joint march, the subsultory motions are apt to become stronger as the regular motion of the pulse be- comes weaker, and at length work up those ago- nizing convulsions under which the little and loitering flame of life is sometimes extinguished instantaneously. Such twitchings of the ten- dons, however, do not always prove fatal, for they often show themselves where the case is not so extreme ; and hence they may occasion- ally be allayed by cordials, antispasmodics, and warmer sedatives, and are altogether lost in a favourable turn of the disease. It occasionally happens, that the debility pro- ducing these weak convulsive actions is local and habitual: and in such cases they may be seen to agitate and play over a limb, without any influence on the system generally, and with- out much injury to the limb itself. Such a state of nervous constitution may be produced by ac- cident, but it is for the most part strictly idio- pathic ; and there are few practitioners perhaps who have not met with examples of it. Dr. Darwin gives us an instance in the following words : " A young lady, about eleven years old, had for five days had a contraction of one muscle in her forearm, and another in her arm, which oc- curred four or five times every minute ; the mus- cles were seen to leap, but without bending the arm. To counteract this new morbid habit, an issue was placed over the convulsed muscle of her arm, and an adhesive plaster wrapped tight like a bandage over the whole forearm, by 324 NEURi which the new motions were immediately de- stroyed, but the means were continued for some weeks to prevent a return."—(Zoonomia, Cate- nation, sect, xvii., i., 8.) The author has some- times seen it about one of the shoulders, but the extremities are its most usual seat; and he was lately consulted by a lady of a strikingly irritable habit, who was suddenly attacked with it both in her hands and feet, so as to throw her into a considerable degree of alarm. Upon in- quiring into the patient's age and state of health, he was informed, that she was between forty and fifty, that menstruation was on the point of leaving her, and had of late appeared very irreg- ularly, and that she had a considerable oppres- sion in her head. The cause was therefore ob- vious, and the cure was not difficult: for it yielded to a moderate venesection, and an ha- bitual attention to the state of the bowels.* SPECIES VI. CLONUS PANDICULATIO. PANDICULATION. TRANSIENT ELONGATION OF THE EXTENSOR MUS- CLES, USUALLY WITH DEEP INSPIRATION AND A SENSE OF LASSITUDE. This is perhaps the slightest modification of spasmodic actions ; but as it often occurs, as in nausea on the first stage of a febrile parox- ysm, whether the will consents or not, and is frequently and irregularly repeated, it cannot but be regarded as belonging to the present fam- ily on many occasions. The muscles chiefly concerned are the extensors of the lower jaw and of the limbs : the particular kind of pandic- ulation to which the first of these movements gives rise being called oscitancy, yawning, or gaping ; and that produced by the second, stretching. The muscles are excited to this peculiar action by a general feeling of restless- ness or disquiet: and the spread of the action from one muscle or set of muscles to another, is from that striking sympathy or tendency to cat- enate in like movements which we so often be- hold in different parts of the body, without being able to explain. It is possible, however, that the synchronous motion of the muscles of the lower jaw and of the limbs, for it is rarely that yawning and stretching do not accompany each other, may be dependant upon the same line of intercourse, by which trismus so often accom- panies a wound in one of the extremities, and which we have already attempted to illustrate; the irritant power, in the one case, leading to a fixed or entastic, and in the other to a transient and clonic spasm. Pandiculation, considered physiologically, is an instinctive exertion to recover a balance of power between the extensor and flexor muscles, in cases in which the former have been en- croached upon and held in subjection by the latter. A very slight survey of the animal frame will * There is some reason to -think that clonus subsultus occurs more frequently from affections of the knee-joint than from any other local dis- turbance.—D. )TICA. [Cl. IV.—Ord. III. show us that the flexor muscles have in every part some preponderance over the extensors; and that this preponderancy is perpetually coun- teracted by the stimulus of the instinct or of the will. We see it from the first stage of life to the last, and most distinctly in those states in which there is most feebleness, and consequently in which the controlling powers are least capa- ble of exercising and maintaining a balance. In the fetus, therefore, in which the weakness is most pressing, the power of instinct is merely rising into existence, and no habit of counter- poise established in the nascent fabric, every limb, and part of every limb capable of bending, undergoes some degree of flexure, and the en- tire figure is rolled into a ball, as the hedgehog habitually rolls himself even after birth. As the fetus, however, increases in size and age, and the powers of instinct, sensation, and voli- tion become more perfect, this general conflex- ure produces occasionally a sense of uneasiness ; and hence every parturient mother is sensible of frequent internal movements and stretchings of the little limbs of the fetus to take off the uneasiness by restoring some degree of balance to the antagonist powers. After birth, and du- ring wakefulness, the stimulus of the will, di- rected rather to the extensor than the flexor muscles, renders the counterpoise complete for all the purposes for which it may be necessary. But the moment we repose ourselves in sleep, and the will becomes inactive and withdraws its control, the flexor muscles exercise their pre- ponderancy afresh, though in a less degree than in fetal life, since the extensors, from habitual use, have acquired a more than proportionate increase of power. The preponderance, how- ever, when long exerted, still produces some de- gree of disquiet, and hence occasionally during sleep, and still more vigorously the moment we begin "to awake, we instinctively rouse the extensor muscles into action ; or in other words, yawn, stretch the limbs, and breathe deeply, to restore the equipoise that has been lost during unconsciousness. In all these cases, pandiculation is a natural action; it is an effect produced by the will when it is called to the particular state of these two sets of muscles, or by the instinctive or remedial power of nature, which supplies its place when it is dormant or inattentive, to re- store ease to a disquieted organ. But, in an infirm or debilitated condition of the system, it evinces a morbid and convulsive character, and takes place without our being able to prevent it, even when the will uses its utmost effort to resist instead of to encourage it. How far its repetition may be of use in the shivering fit of an ague, or in a nauseating deli- quium of the stomach, it is difficult to say. Yet we are at no loss to account for its frequency of recurrence ; for as the whole system is, in such circumstances, thrown into a sudden prostration of strength, the extensor muscles, in conse- quence of being naturally weaker than their an- tagonists, must become soonest exhausted, and give way with a more than ordinary submission to then power. And hence we behold a painful US TREMOR. 325 Gkn. III.—Spe. 1.] SYNCLON retraction over the whole system, and the pre- ponderance assumes a rigid and spastic charac- ter ; and we may fairly conclude, that much of the yawning and stretching which ensue, is for the purpose of getting rid of the constrictive spasm, though these counteractions themselves often run in the attempt into a spasm of another kind, and become convulsive. Yawning and stretching, then, are among the signs of debility and lassitude. And hence, every one who resigns himself ingloriously to a life of lassitude and indolence, will be sure to catch these motions as a part of that genera] idleness which he covets. And, in this manner, a natural and useful action is converted into a morbid habit; and there are loungers to be found in the world, who, though in the prime of life, spend their days as well as their nights in a perpetual routine of these convulsive movements over which they have no power ; who cannot rise from the sofa without stretching their limbs, nor open their mouths to answer a plain ques- tion without gaping in one's face. The disease is here idiopathic and chronic : it may perhaps be cured by a permanent exertion of the wilh and ridicule and hard labour will generally be found the best remedies for calling the will into action. GENUS III. SYNCLONUS. SYNCLONIC SPASM. TREMULOUS, SIMULTANEOUS, AND CHRONIC AGI- TATION OF VARIOUS MUSCLES, ESPECIALLY WHEN EXCITED BY THE WILL. We have already observed, that clonus im- ports " agitative," or " tremulous motion of the muscles ;" and hence, synclonus means neces- sarily their " multiplied, conjunctive, or com- pound agitation, or tremulous motion." The term is therefore intended to denote a group of diseases more complicated in form, of more ex- tensive range, or more connected with the gen- eral state of the constitution than those of the preceding genus ; and it runs parallel with the clonici universales of Sauvages, as far as they can be said correctly lo belong to this family. The species included under this genus will be found to be the following: 1. Synclonus Tremor. Trembling. 2.---------Chorea. St. Vitus's Dance. 3.---------Balismus. Shaking Palsy. 4.---------Raphania. Raphania. 5.---------Beriberia. Barbiers. SPECIES I. SYNCLONUS TREMOR. TREMBLING. SIMPLE TREMULOUS AGITATION OF THE HEAD, LIMBS, OR BOTH ; MOSTLY ON SOME VOLUN- TARY EXERTION. The proximate cause of this disease is an ir- regular transmission of irritable power to the motory fibres of the muscles that constitute its seat. It is strictly a disease of nervous debility, either general or local: debility pro- duced by sudden exhaustion, as in the case of great muscular fatigue from violent exercise, severe cold, or a vehement exertion of the pas- sions, and particularly of the passions of fear and rage ; or debility produced slowly and in- sensibly by causes of tardy operation, as an in- judicious use of mercury, lead, opium, or other mineral and narcotic poisons; an habitual ex- cess in hard drinking or sexual commerce; and, in some idiosyncrasies, an immoderate indul- gence in tea.* And, as this disease is a result of debility, it necessarily occurs as a symptom on the general spasm and prostration of strength that so peculiarly distinguish the accession of an ague-fit, and the interruption of sensorial power that takes place in paralysis. There are some persons, however, in whom the same convulsive action exists habitually, without any morbid state of other organs, or any other inroad upon the general health. I once knew a lady considerably beyond the mid- dle of life, who was strikingly affected with this complaint, insomuch that the slightest voluntary exertion of any of the muscles threw the head and arms into as great a tremour as if they had been hung upon wires, but who enjoyed at the time, and had for a long term of years continued to enjoy, as perfect health as possible in every other respect; was lively, cheerful, animated, possessed of brilliant powers of conversation, and able to use a more than ordinary portion of ex- ercise without fatigue. The earlier part of her life had been passed in India, but her constitution did not appear to have suffered from this circumstance; and so grad- ual was the attack of the affection, that though she had laboured under it for many years, she could not date its commencement from any given point of time. She at length died at the age of seventy-two or seventy-three, her corporeal powers progressively declining, and laying a foundation for a general dropsy, while her mind continued firm to the last. In all cases of this kind, the supply of nervous energy to the motory fibres of the affected muscles takes place interruptedly, and where the organ or the constitution is in a state of debility, it is also less abundant as well as less uniform. We have already observed, that the nervous energy (or fluid, as the author preferred calling it), in its natural course is transmitted only by waves or vibrations, and consequently with an interpo- sing pause or relaxation after every efflux ; but that the pause is instantaneous, and the supply so regular as to answer the purpose of a per- manent and continuous tenour. In clonic tre- mour, the pauses are, however, prolonged, and for the most part irregular, or untrue to themselves; and the greater the retardation and irregularity, the more marked and alarming the spasmodic shake. In the case just adverted to, there was no other diseased action whatever ; the nervous power was unquestionably supplied in sufficient * It arises also from long indulgence in tobacco, particularly in the form of snuff; it will occasion- ally be caused by the loss of sleep, and is some- times seen in persons of a sanguineous tempera- ment after severe seasickness.—D. 326 NEUROTICA. [Cl. IV—Ord. HI abundance, and the pauses, though prolonged, were uniform; and it was singular to observe the influence the will possessed over the affect- ed muscles under these circumstances, and how completely they were still under its control: for, in consequence of the uniformity of the morbid interruptions, and from the force of habit, I have seen this patient, in the midst of a shaking that threatened every moment to overturn whatever she took hold of, raise a cup brimful of tea, or a glass brimful of wine to her lips by way of experiment, without spilling a single drop. Where the corporeal health is so little inter- fered with as in the present case, a course of medical treatment might perhaps do more mis- chief than benefit. But where the constitution is generally affected, or the muscles that form the seat of the convulsion are manifestly debil- itated, general and local tonics and stimulants may sometimes be tried with advantage, though they frequently fail of producing any good ef- fects. Sea bathing and horse exercise, a gener- ous diet, change of air and scene, may be found useful auxiliaries in the general treatment; and long-continued and daily friction by a skilful rub- ber, ammoniacal embrocations, blisters, setons, and a course of voltaism or electricity, offer the best promise as topical means of relief. The affected limbs may also be put into a train of gradual exertion, for the purpose of obtaining both strength and steadiness : and, to this end, the head or shoulders may be occasionally made to balance an easy weight for a given period of time, and the hands to suspend, or carry a wineglass or tumbler brimful of water. Here also may be recommended the kneading friction, or shampooing of the Egyptians and Turks, which has of late become a fashionable refreshment in the watering-places of our own country ; and there can be no question, that the pungent and exhilarating essential oils which' are applied to and absorbed by the skin after- ward, add considerably to the general efficacy. Something like this the French have long been in the habit of employing under the name of frictions seches.—(Ardouin, Essai sur I' Usage des Frictions Siches, &c) The horse-hair shirts and periodical flagellations of the old Francis- can friars, would probably be found to answer the same purpose. But this is a remedy which is not likely to be revived in the present day, whether from a medical or a moral call. SPECIES II. SYNCLONUS CHOREA. ST. VITUS'S DANCE. ALTERNATELY TREMULOUS AND JERKING MOTION OF THE FACE, LEGS, AND ARMS, ESPECIALLY WHEN VOLUNTARILY CALLED INTO ACTION ; RESEMBLING THE GRIMACES AND GESTURES OF BUFFOONS ; USUALLY APPEARING BEFORE PU- BERTY. The term chorea, from x°pfc» "chorus," " coetus saltantium," is comparatively of modern date in its application to the present disease; nor is it easy to determine satisfactorily who originally employed it. It was first more limft- edly denominated chorea sancti viti, under which limitation it occurs in Sydenham, and is still known in popular language, being called in colloquial English, St. Vitus's Dance, and in colloquial French, Dance de St. Guy. Accord- ing to Horstius, the name of St. Vitus's Dance was given to this disease, or perhaps more prob- ably to a disease possessing some resemblance to it, in consequence of the cure produced on certain women of disordered mind, upon their paying a visit to the chapel of St. Vitus, near Ulm, and exercising themselves in dancing from morning to night, or till they became exhausted. He adds, that the disease returned annually, and was annually cured by the same means. The marvellous accounts of this dance, as re- lated by old writers, are amusing from their ex- travagance.* The paroxysm of dancing, we are told, must be kept up, whatever be the length of the time, till the patient is either cured or killed ; and this also, whether she be young or old, in a state of virginity or of parturition ; and, in the growing energy of the action, we are further told, that stools, forms, and tables are leaped over without difficulty if they happen to be in the way. Felix Plater gravely tells us*, that he knew a woman of Basle, afflicted with this complaint, who on one occasion danced for a month together ;i and the writers add general- ly, that it was hence necessary to hire musicians to play in rotation, as well as various strong, sturdy companions to dance with the patients, till they could stir neither hand nor foot.—(Par- acels. De Morb, Amentium, tract, i. ; Schenck, de Mania, lib. i.) The nearest approach to this kind of gymnas- tic medicine which I am acquainted with in modern times, is a singular case of the same disease, described by Mr. Wood in the seventh volume of the Medico-Chirurgical Transactions. The morbid movements were in measured time, and constituted a sort of regular dance as soon as music was struck up, but ceased instantly upon a change of one time to another, or upon a more rapid roll of the drum, which was the instrument employed on the occasion, than the morbid movements could keep up with. Ad- vantage was taken of the last part of this very singular influence, and the disease was cured by a perseverance in discordant or too rapid time. This form of the disease appears to have a near relation to the tarantismus of Sauvages, which is the carnevaletto delle donne of Baglivi, all of them probably nothing more than modifica- tions of the present. Linneus, and after him * The best history of the dancing mania is that written by Prof. Hecker, which has been trans- cfonf 1835-3) Y D'' B' G' BabinSton> Lon" a JirPt^6"118 A1fnat-,caP- W. A case in which a girl, ten years of age, kept up the most extraor- dinary movements and exercises for five weeks somenmes for fifteen hours a day, is related™ Drl Watt.—(See Med. Chir. Trans., vol. v \ As M Hunter of Glasgow has truely remarked, it is per- haps the most extraordinary case of the kind on 26C80)-iDSee Edm- Medl J'Um'> ^0. kS, P Gen. III.—Spe. 2.] SYNCLONUS CHOREA. 227 Macbride, from the epithet of sanctus, as ap- plied to chorea, or a belief that such affections are induced by the immediate agency of a supe- rior order of beings, have applied to it the name of hieronosos, or '* morbus sacer"—a name, however, which by earlier writers was appro- priated to convulsion-fits. In Galen, chorea seems to be included under a disease which he calls scelotyrbe, literally, "cruris turba or perturbatio,"—" commotion of the leg;" and his description, which is as fol- lows, is extremely accurate. " It is a species of atony or paralysis, in which a man is incapa- ble of walking straight on, and is turned round to the left when the right leg is put forward, and to the right when the left is put forward, or alternately. Sometimes he is incapable of rais- ing the foot, and hence drags it awkwardly, as those that are climbing up steep cliffs." One of the best general descriptions which have been given us of chorea, is the following of Dr. Hamilton, contained in his valuable trea- tise on the utility of purgatives : " Chorea Sancti Viti attacks boys and girls indiscriminately ;* and those chiefly who are of a weak constitution, or whose natural good health and vigour have been impaired by confinement, or by the use of scanty or improper nourishment. It appears most commonly from the eighth to the fourteenth year. I saw it in two young women, who were from sixteen to eighteen years of age. The ap- proaches of chorea are slow. A variable and often a ravenous appetite, loss of usual vivacity and playfulness, a swelling and hardness of the low- er belly, and in general, a constipated state of the bowels, aggravated as the disease advances, and slight, irregular, involuntary motions of dif- ferent muscles, particularly those of the face, which are thought to be the effect of irritation, precede the more violent convulsive motions which now attract the attention of the friends of the patient. " These convulsive motions vary. The mus- cles of the extremities and of the face, those moving the lower jaw, the head, and the trunk of the body, are at different times, and in differ- ent instances, affected by it. In this state the patient does not walk steadily; his gait resem- bles a jumping or starting ; he sometimes cannot walk at all,t and seems palsied : he cannot per- form the common and necessary motions with the affected arms. This convulsive motion is more or less violent; and is constant, except during sleep, when in most instances it ceases altogether. X Although different muscles are * Dr. Heberden states, that only one fourth of his patients were males; which agrees with the result of Dr. Elliotson's experience. The latter physician considers the period of life most subject to chorea to be from three or four years to fourteen. —F,n. + It is observed, that the patients generally walk quickly better than slowly; Dr. Heberden adverts to one individual who could not walk, though he could run.—Eo. X Dr. Elliotson has seen the skin of the chin and breast rubbed off by the perpetual scraping of one on the other. He has known the patient un- able to he on the bed, rolling off it, so that it was sometimes successively convulsed, yet in gen- eral the muscles affected in the early part of the disease remain so during the course of it. Ar- ticulation is now impeded, and is frequently completely suspended. Deglutition is also oc- casionally performed with difficulty.* The eye loses its lustre and intelligence ; the countenance is pale, and expressive of vacancy and languor. These circumstances give the patient a fatuous appearance. Indeed, there is every reason to believe, that when the complaint has subsisted for some time, fatuity to a certain extent inter- rupts the exercise of the mental faculties." Thermaier gives a case in which it was con- nected with a deeply melancholic temperament, and the limbs were in a state of constant snatch- ing and trepidation (Consil, lib. ii., cap. xi.) : but this is a rare concomitant; nor is fatuity a constant sequel of it, even in its most obstinate and chronic form. The present author has met with various instances in which the disease has continued with considerable violence from an early period to old age, without making any in- road whatever on the mind, or even spreading to any other joints, limbs, or muscles than those at first affected. He once knew a man under the habitual influence of this complaint, who was a good orator, always reasoning with great clear- ness, and delivering himself with much anima- tion. The movements of his arms were indeed in ungraceful snatches, and the muscles of the neck frequently evinced a like convulsive start, yet not so as to interrupt the flow of his periods, or to abridge his popularity. He knew another person, for many years severely afflicted with the same complaint, who was an excellent musician, public singer, and composer of music ; and this, too, notwithstanding that he was blind from birth. The person alluded to, is the late Mr. John Printer, of the Foundling hospital. In walking he was always led, 0:1 account of his blindness, and used a staff on account of the unsteadiness of his steps; but, notwithstanding every exer- tion, his gesticulation was extreme, and so nearly approaching the antics of a buffoon, that it was often difficult for a spectator to suppress laugh- ter. Yet, in singing and playing, he had a per- fect command over the muscles of the larynx and of the fingers ; his tones were exquisitely clear and finely modulated; but his neck and head curvetted a little occasionally. He died when about sixty years of age, without ever exhibiting any debility of intellect. + necessary to strap him dowrB These, however, were very severe cases. Except in extreme in- stances, the movements are suspended during sleep.—Lect. on Med. at Lond. Univ., as reported in Med. Gaz. for 1832-33, p. 533 —Ed. * As to feeding patients, Dr. Elliotson observes, that is often very difficult; and it will sometimes require the aid of two or three persons to give them their meals—two to hold them still, and one to catch the favourable opportunity of putting the spoon into their mouths.—Op. cit. t According to Dr. Elliotson, one leg and one foot generally first show the disease. The first symptom usually observed is that of one foot be- ing dragged after the other. The arms are gen- erally more affected than the legs. The face has 328 NEUROTICA. [Cl. IV—Okd. 111. There is a singular form of this disease, which has been called by some writers malleatio, consisting in a convulsive action of one or both hands, which strike the knee like a hammer. In this case the hands are usually open, but some- times clinched. Morgagni (De Sedibus, &c, x., 16) relates a case in which it came on even in the sound hand, if the finger of the affected one were extended. If the motion be forcibly stopped, the convulsion becomes afterward still more violent and general. Where the system is disposed to hysteria, the paroxysm is sometimes extremely vehement, and partakes of the constitutional diathesis, making an approach to epilepsy, but distinguished from it by a continuance of consciousness and sensibility. Dr. White of York has given us a striking example of this mixed affection in a lady forty-two years of age, who " had always a very weak system of nerves," and was rendered speechless for an hour or two upon any sudden surprise. In November, he tells us, she was affected with a fresh paroxysm, which, upon be- ing sent for, he describes as follows :—" She complained of a violent 'pain in the right side of her face, and of universal erratic aches and soreness. There is a scorching heat all over the skin, except from the feet up to the ankles, which are as cold as marble. Pulse not quick- ened, but full ; mouth dry, but no great thirst; body costive, which is indeed her natural habit, so as to oblige her to the frequent use of mag- nesia. She is regular as to the menses, the re- turn of which she expects in five or six days. Appetite good, rather voracious ; but her spirits always low after a full meal, especially dinner. Has a violent pain in the loins, which often shifts from hip to hip ; the teg of the aching side being so much affected with stupor and numb- ness, that she drags it after her in walking. She falters in her speech at times, but this does not continue long. All the muscles of the body evince convulsive motions ; not simultaneously, but successively : thus, her face is first violently affected, then her nose, eyelids, and whole head, which is thrown forcibly backward, and often twitched from one side to the other with exquis- ite pain. From this quarter the convulsive ac- tion removes first into one arm, and then into the other; after which both legs immediately became convulsed with violent and incessant motions, and in this manner all the external parts of her body are affected by turns. She is all the time perfectly sensible, and knows what limb is going to be attacked next, by a sensation of something running into it from the part already convulsed, which she cannot describe in words ; but the foretoken has always been found to be true, though the transition is surprisingly quick. She is easiest in a prone posture. Such," con- tinues Dr. White, " has been her situation up- wards of forty-eight hours, with scarce a mo- ment's remission, by which she complains of very frequently a fatuitous appearance ; the mind is apparently a little affected ; and certainly persons are somewhat childish in this disease.—Lect. on Medicine at the Lond. Univ., op. cit. great and universal soreness. No words can convey an adequate idea of her odd appearance: and I do not in the least wonder, that in the times of ignorance and superstition, such diseases were ascribed to supernatural causes and the agency of demons."—(Edin. Med. Comment., vol. iv., p. 326.) Even Dr. White himself ap- plies to it, perhaps in imitation of Sauvages, the name of hieronosos. The predisponent cause of this disease is an irritability of the nervous system, chiefly depend- ant upon debility, and particularly a debility of the stomach and its collatitious organs. Most of the diseases of children are seated in this quarter; and it is from it that chorea commonly takes its rise, and shows itself in an early period of life ; the ordinary occasional causes being bad nur- sing, innutritious diet, accumulated feces, worms, or some other intestinal irritant.* About the age of puberty, there is another kind of general irritation that pervades the system : and where this change does not take place kind- ly, which is frequently the case in weakly habits, the irritation assumes a morbid character, and is exacerbated by a congestive state of the ves- sels that constitute its more immediate seat: and chorea takes its rise from this cause, t In effect, where the predisponent cause of an irritable state of the nervous system is veiy ac- tive and predominant, a local or temporary ex- citement of any organ, and almost at any period of life, will give rise to the convulsive move- ments of chorea: and hence we find it so fre- quently united with an hysteric diathesis. It has been produced by a fright (Stoll, Rat. Med., part iii., p. 405), by a wound penetrating the brain through the orbit of the eye (Geash, Phil. Trans., vol. liii., 1763), by an improper use of lead, mercury, and some other metals (De Haen, Rat. Med., part iii., p. 202), and by suppressed cutaneous eiuptions.J * Chorea, says Dr. Armstrong, is always pre- ceded by some disorder of the stomach, liver, or bowels; and the affection which takes place in the brain and spinal cord (for both of them are affected) seems to be secondary. " You may al- ways trace its rise to some improper diet. It is very common in children who eat many vegeta- bles, and are subject, to worms." After adverting to its occasional production by the irritation of dentition, Dr. Armstrong mentions the case of a pregnant lady who laboured under chorea; she had a tapeworm, which the doctor dislodged by means of a dose of turpentine, and the chorea ceas- ed.—See Armstrong's Lectures on the Morbid Anatomy, Nature, and Treatment of Acute and Chronic Diseases, 8vo., Lond., 1834, p. 733. t According to Lisfranc and Seire's, this disease depends on an affection and even an inflammation of the tubercula quadrigemina.—D. i Wendt, Nachricht von dem Krankeninstitut zu Erlangen, 1783. "What myriads of different diseases are referred to debility, disorder of the stomach and bowels, suppressed eruptions, dis- charges, &c ! Yet we remain quite in the dark how the effect is produced; why it should hap- pen in one individual and not in another; and why, apparently, the same alleged cause should produce in different persons consequences entirely different? The clew to an explanation of these Gen. III.—Spe. 2.] SYNCLONUS CHOREA. 329 From this view of the general nature and ori- gin of the disease, we can be at no loss to ac- count for the great benefit which has been de- rived from a steady course of brisk purging in recent cases, or those of early life; for this, while it carries off the casual irritation, or un- loads the infarcted viscera, seems at the same time to act the part of a revellent, and to pro- hibit the return of the paroxysm by a new ex- citement. It may appear, perhaps, strange to those who have not thought upon the subject, that where the disease has proceeded from intes- tinal irritation, it should also be carried off by intestinal irritation. But the irritations are of very different kinds : and it is so far from fol- lowing of necessity, that, because one kind of irritation, applied to a particular organ, excites a particular effect in a remote part, another will do the same, that the converse is more com- monly true, and that any other kind of irritation, applied to the same organ, by exciting a new action, will be the most effectual way of taking off or preventing such effect. And it is upon this ground alone that we often endeavour to cure rabies, trismus, and tetanus, by laying open the original wound to a considerable extent, or the application of some new stimulus that may answer the same purpose. The principle being a general one, it does not seem of much consequence what purgative is employed, provided it be sufficiently powerful; though, where worms are suspected, the essen- tial oil of turpentine, from its being a good an- points would convey more information than the often repeated allusion to debility, disordered stomach, &c Dr. Armstrong's pathological view of chorea is, that the disorder first commences in the prima? viae ; and that the brain is next affected, as seems to be proved by the countenance and by the state of the intellect, which, however be it remembered, is not always weakened. Dr. Arm- strong believed the spinal cord to be implicated, because the upper and lower extremities are both affected. " Probably," he says, " the cerebrum, the cerebellum, and the spinal cord, are all af- fected."—(On the Morbid Anatomy, Nature, and Treatment of Acute and Chronic Diseases, p. 734.) M. Magendie details an extraordinary case, in which the power of the will over the muscular motions was at intervals entirely lost; but instead of the muscles being paralyzed, or remaining at rest, they were seized with the most irregular and indescribable movements for hours together. Some light has been thrown on the cause of such anom- alous cases by the experiments which this distin- guished physiologist made on some of the lower animals, rendering it probable that the will is more particularly seated in the cerebral hemispheres, while the direct cause of motion is in the spinal marrow. Hence, he observes, it is readily con- ceived why, in certain cases, these motions are not produced, though commanded by the will; and why, in certain circumstances of a contrary nature, very extensive and energetic motions are developed without any participation of the will.— (Compendium of Physiology, vol. i., p. 201. On these principles, explanations are attempted of the irresistible propensity to move forward and back- ward, and of the quick and continuous rotations to the right or left, &c, occasionally noticed in pa- tients labouring under chorea.—Ed. thelmintic, as well as a good cathartic, will be found one of the best. It seems, indeed, to have been occasionally serviceable where worms have not been the cause, for Dr. Powell relates a case in which he completely effected a cure in a girl of seventeen, by a single dose of a fluid ounce (Transact. Medico-Chir. Soc, vol., v., p. 358): and hence its antispasmodic power may at times co-operate with its purgative quality as well as its vermifuge power. Sydenham, who recommended an alternation of bleeding and purging, probably derived far more advantage from the latter than the former part of his plan :* it has been found peculiarly advantageous in the hands of Dr. Hamilton : and Dr. Parr, who ascribes to Sydenham the first hint he obtained upon this subject, affirms, that having pursued the purgative plan with great activity through sixty cases of the disease, which occurred to him in a course of twenty years' practice, he was successful in the whole of these cases except one ; and that in all but this one, he found the disease yield, not only soon, but with few instances of a relapse.t There is, therefore, no malady whatever per- haps that calls so peremptorily for stimulating the abdominal viscera into increased action ; and as chorea often precedes puberty, or occurs about this period of life, we have another reason for directing an augmented stimulus to the low- er regions of the living frame, and rousing into energy the tardy development of the sexual or- gans. Even blistering the sacrum at this period of life is often attended with success. Dr. Chis- holm (On the Climate and Diseases of Tropical Countries, p. 97, 8vo., 1822) affirms, that he found it so after a total failure of antispasmodics and the purgative plan : and as his patients were all eighteen years of age or below, the success * " If large quantities of blood be drawn, espe- cially in delicate habits, the disease will be inva- riably increased."—Armstrong, op. cit., p. 735. t According to the experience of the late Dr. Armstrong, a due attention to the secretions of the liver, and to the alvine discharges and a reg- ulated diet, with an occasional shower bath, will almost invariably cure chorea, provided the plan be followed up for six weeks, or two or three months. " The best diet for children in chorea is bread and milk in the morning and evening, and a small quantity of animal food with bread in the day. This diet is the best if there be no inflamma- tion in the stomach or small intestines, and then the diet should be very bland, as milk, with some farinaceous food, arrow-root, or thin gruel. Get rid of acidity by an occasional dose of magnesia, or of the carbonate of an alkali. Give calomel every night, in conjunction with rhubarb or jalap; and sulphate of magnesia with infusion of senna, or compound decoction of aloes, or cold-drawn castor oil in the morning. As an alterative, give small doses of blue pill occasionally, not oftener than every second night. When the patient loathes food, but there is no pain on pressure, and the head is not affected, a mild emetic may be admin- istered. If there be inflammation of the stomach or small intestines, apply leeches as long as the tip of the tongue is red, and there is obscure pain on pressure."—See Armstrong on the Morbid Anatomy, Nature, and Treatment of Acute and Chronic Diseases, p. 735.—Ed. 330 NEUROTICA. [Cl. IV—Ord. III. was probably dependant upon the principle here pointed out. But it is necessary to attend to the state of the system generally as well as locally, to take off the constitutional weakness and irritability, as well as the topical irritation, and especially where the disorder has acquired a chronic char- acter. And hence other remedies must be had recourse to as well as purgatives. The German physicians have strongly recommended the use of antispasmodics and sedatives, and especially musk, belladonna, and foxglove, with a view of allaying the irregular action, and Dr. Cullen speaks as decidedly of the benefit of opium.— (Mat. Med., part ii., chap, vi., p. 246.) But the advantage derivable from these seems to be merely palliative ; and the stimulant tonics and alterants promise a better success. The cuckoo-flower or lady's-smock, carda- mine pratensis, so common to the meadows of our own country, was at one time supposed to be of essential service in the cure of this and various other spasmodic affections. Michaelis, who is a great advocate for its use, employed it in the proportion of a drachm every six hours.— (Richter, Chirurg. Bibl., b. v., p. 120.) But it owed of late its reputation in this country chiefly to the recommendation of Sir George Baker, who published five cases of spasmodic diseases, two of them instances of chorea, in which he conceived a most decided benefit was obtained from the use of these flowers. In the hands of later practitioners, however, they have not sup- ported their credit, and have consequently sunk into disuse. The leaves of the Spanish or Seville orange-tree, as a stimulant and tonic bitter, are far more entitled to attention, not only in this, but in various other cases of convulsive spasm. They were first recommended to De Haen by Westerhoef, who, as well as Werlhoff, employed them with considerable success : and they were afterward introduced by Hoffmann as a valuable ingredient into his celebrated stomachic elixir ; and for the same reason formed a part in the com- position of Whyt's stomachic tincture. They were given in the form of decoction, and in that of powder ; in the last case the dose is from half a drachm to a drachm, three or four times a day. The metallic salts and oxydes have been tried in every form. At one time, the most popular of these were the flowers of zinc. Dr. Gaubius first brought them into reputation, and gave to the metal the name of cadmia ; and, according to bis statement, they worked wonders in all clonic affections whatever, chorea, hooping- cough, hysteria, convulsion, and epilepsy; on which account they were afterward employed upon a still larger and more popular scale by the famous empiric Luddemann, under the name of luna fixata.—(Dissertatio Medica inaug. de Zinco, Aut. Jacob. Hart, Lugd. Bat., 4to.) This medicine has, however, by no means been able to maintain its high character; and even Stoll, who once employed it as a favourite, at length abandoned it as good for nothing,* and * The oxyde of zinc is still in great favour with some practitioners, being regarded by them returned to the belladonna in its stead, which he employed in the form of an extract from the juice of the root; giving it from a sixth to a quarter of a grain every quarter of an hour, and, as he affirms, with very great advantage. For the information of practitioners in gen- eral, however, it should be noticed that when the stomach has reached its full dose of the oxyde of zinc, it will still bear a full dose of ammoniated copper in conjunction with it, by which means the metallic power may be very much increased. Thus a delicate stomach will rarely bear more than two grains of either of these without nausea ; yet it has been found that the same stomach will continue at ease un- der a mixed powder of two grains of the former and two and a half of the latter at a dose.* The nitrate of silver seems to have been radi- cally successful in various well-established cases. It has commonly been given in the guise of pills, from one to five or six grains to a dose. [In one interesting example recorded by Dr. Crampton (Trans, of the King's and Queen's College of Physicians, vol. iv., p. Ill), purga- tives were extensively tried, with various other remedies ; but the disorder scarcely remitted under any mode of treatment, until the nitrate of silver was prescribed. Iron had been recommended in chorea, among a multitude of vegetable" and mineral tonics; but until Dr. Elliotson published the results of his experience with it, its powers were not apprecia- ted, nor the possibility contemplated of giving it with advantage when the disorder was accom- panied with headache, vertigo, and a degree of paralysis. The facts which this physician has published in favour of the efficacy of the sub- carbonate of iron, given every six hours in doses of two scruples and sometimes even of half an ounce, blended with gruel, mucilage, or treacle, are calculated to recommend it strongly to the notice of medical practitioners as a remedy of the highest value in chorea. "When the bowels were confined, Dr. Elliotson sometimes gave his patients scammony, calomel, and other pur- gatives ; but, in some of the instances, they were rarely used.—(Med. Chir. Trans., vol. xiii., p. 232, et seq.)] Another remedy entitled to credit in the pres- ent day, is arsenic ; for it is difficult to resist as a more manageable preparation than the sul- phate. It may at first be given in doses of five grains, and gradually increased. According to Mr. Bedingfield, it was so successful in the Bristol In- firmary that he considers it as a specific. Upwards of forty cases occurring there, were, with one ex- ception, cured by it.—See compendium of Med. Practice, p. 51; and Cyclop, of Pract. Med., art. Chorea.—Ed. * Letter from Dr. Odier to Dr. A. Duncan, Edin. Med. Com., iii., p. 191. The sulphate of zinc is a medicine in high repute at the present time for the cure of chorea. Many practitioners prefer its ex- hibition to that of purgatives. With the excep- tion of two cases, however, the late Dr. Armstrong never saw the purgative treatment fail. Sulphate of zinc may be given three times a day, in five- grain doses, gradually increased, and the bowels should of course be regulated.—Ed. Gen. Ill—Spe. 3.] SYNCLONUS BALLISMUS. 331 the evidence from various quarters in which it seems not only to have produced benefit, but to have established a perfect cure. [Mr. Martin prescribed it in one case with success ; and Mr. Salter, of Poole, found it answer in an instance in which the nitrate of silver, and many other medicines had failed. It has also been given with advantage by Dr. G. Gregory.] It is com- monly given in the form of the solution of the London College, in doses of ten drops to a youth of twelve or fourteen years of age three times a day, increasing the dose as there may be oc- casion.* In this disease, however, as in various others, it will often be found, and the remark is well worth attending to, that different remedies are required for different individuals, even where the cause is obviously the same ; and that what produces no benefit in one case, is highly ad- vantageous in another. Camphire in large doses has succeeded where turpentine or the nitrate of silver has completely failed ; and a brisk pur- gative plan has sometimes answered where all the preceding have proved of no use whatever. It is hence we are to account for Dr. Cullen's peculiar attachment to the bark, which he tells us he has found " remarkably useful," and pre- fers to any of the preparations of copper, zinc, or iron (Mat. Med., part ii., ch. ii., p. 112) while Dr. Powell informs us, that in a lady of seventy years of age, of a very irritable habit, attacked for the first time with this complaint in severe paroxysms at night, he found musk, in doses of ten grains every six hours, succeed and produce a cure, when purging, blistering, the ammonia- ted spirit of amber, nitrate of silver, ammonia- ted tincture of valerian, castor, muriated tincture of iron, bark, and opium had all failed.—(Med. Trans., vol. v., p. 192 ; also Maton's Case cured by Musk, p. 188. )t [In a severe example successfully treated by * It would be imprudent to commence with this quantity. It is best to begin with one or two drops for a child six or eight years of age, three times a day, always taking care to administer it after a meal and very gradually increasing the dose ac- cording to its effects. In some of the cases allu- ded to in the text, it was the only medicine pre- scribed ; in others, it had been preceded by pur- gatives.—Ed. t According to Dr. Eberle (Practice of Medi- cine, vol. ii., p. 91), the principal exciting causes of chorea are mental emotions, gastro-intestinal irritation, repelled, chronic, and acute cutaneous eruptions; the suppression of habitual discharges, and unsatisfied or over-excited sexual propensi- ties. Vegetable and mineral poisons, as stramo- nium, mercury, and lead, have also been known to produce this affection. In the treatment, it is highly important to regu- late the alimentary canal by the judicious use of purgatives ; and the state of the vascular system will sometimes require moderate and repeated venesection. This being done, the nitrate of sil- ver will sometimes succeed when other remedies have failed ; and more is accomplished by the con- tinuance of this remedy for several weeks than by giving larger doses for a few days. On the principle inculcated by Dr. Jenner for the use of the tartar-emetic ointment, Dr. Whar- ton of Virginia has lately employed it in a case Dr. Crampton (Trans, of the King's and Queen's College of Physicians, vol. iv., p. 120), where headache was a prominent symptom, leeches were repeatedly applied to the temples, neck, and along the spine, in succession ; the head shaved ; the shower bath employed; and the action of the bowels regulated. In another case treated by Mr. Hunter of Glasgow, a cure was accom- plished by rubbing antimonial ointment into the scalp, and along the course of the vertebral col- umn. —(Edin. Med. Journ., No. lxxxiii., p. 261.) In an instance recorded by Mr. Stuart, the pa- tient was cured by the prussic or hydrocyanic acid, preceded by purgatives.—(Op. cit., No. xciii., p. 271.)] Voltaism or electricity was warmly recom- mended by De Haen. Like the preceding rem- edies, either appears to have been serviceable in some cases; but they are far outbalanced by the instances in which they have failed. It is very possible, that in some instances, a long and punctual discipline of the affected limbs, where the disease is not very severe,Jo regular and measured movements, may progressively recall them to their wonted order and firmness, as a like discipline of the vocal organs in stammer- ing has not unfrequently been found to restore them to a regularity of utterance : and, with this view, the gymnastic exercise of dancing, whose movements are all measured with the greatest nicety, and which was so much depended upon in former times, and asserted to have been so successful, may be well worthy of attention in the present day, provided it be kept within due bounds, and be not carried to the ridiculous ex- treme we had occasion to notice a few pages above.* SPECIES III. SYNCLONUS BALLISMUS. SHAKING PALSY. PERMANENT agitation OF the head or limbs WITHOUT VOLUNTARY EXCITEMENT ; BODY BENT FORWARD, WITH A PROPENSITY TO RUN AND FALL HEADLONG ; USUALLY APPEARING AFTER MATURITY. This is the scelotyrbe festinans of Pro- fessor de Sauvages, and the shaking palsy of Mr. Parkinson.—(Essay on the Shaking Palsy, 8vo., 1817.) The genus Tantarismus of Baligvi seems to hold an equal point between ballismus and chorea, and the species usually arranged of chorea with success.—See Am. Med. Recorder, vol. ix.—D. * Dr. Armstrong saw one case where a strictly regulated diet and every other plan had failed, and which was cured by music. A travelling musician passed by the house, and, while he was playing, the child's parents noticed that its motions were re- markably still; they took the hint, and procured sleep regularly every night by means of music; and the child ultimately recovered.—See Lectures on the Morbid Anatomy, Nature, and Treatment of Acute and Chronic Diseases, p. 736. Iodine has been successfully employed by Dr. Manson and others as a remedy for chorea. It was given in combination with mild cathartics.—Med, Researches, &c., p. 187, &c—Ed. 332 NEUROTICA. [Cl. IV.—Ord. III. under it may be resolved into the one or the other, and are done so under the present ar- rangement. The term Ballismus (BaXXiaubs) is not used in a medical sense by the Greek writers, but occurs in Athenseus and various other authors in the literal sense of tripudiatio, or " tripping, capering, cur- velling on the toes ;" from /3uXX/£o, " tripudio,pe- dibus plaudo;" and is hence well designed to ex- press the characteristic feature of the patient's being thrown involuntarily, when he attempts to walk, " on the toes and forepart of his feet," to employ the language of Mr. Parkinson, " and im- pelled, unwillingly, to adopt a running pace :" or, as Dr. Cullen, who has indiscriminately blended this species with the preceding, expresses it, to " various fits of leaping and running."—(Pract. of Phys., part ii., book iii., ch. iii., 1353.) Ballismus, however, though not found in the writings of the Greek physicians, has been long established as a technical term in the medical nomenclature of later times, in which it has been used, with little discrimination, to import almost all or any of the species that belong to the present genus. Sauvages observes, that while chorea or sce- lotyrbe Sancti Viti attacks the young, ballismus or scelotyrbe festinans attacks those in advan- cing life; and the remark is founded on a just distinction of the characters of the two diseases; though there are other features also of as stri- king a peculiarity, and which are here introduced into their respective definitions. Shaking pal- sy, as it is called by Mr. Parkinson, who has adopted the colloquial name, is by no means a correct designation ; for though in the disease before us there is a weakness of muscular fibre, and a diminution of voluntary power in the parts affected, there is none of that diminution of sensation by which palsy is generally char- acterized. Mr. Parkinson's description of the disease, however, is the best we have hitherto had, and is as follows:— " So imperceptible is the approach of this malady, that the precise period of its commence- ment is seldom recollected by the patient. A slight sense of weakness, with a proneness to trembling, sometimes in the head, but most commonly in the hands or arms, are the first symptoms noticed. These affections gradually increase, and at the period perhaps of twelve months from their first being observed, the pa- tient, particularly while walking, bends himself forward. Soon after this, his legs suffer similar agitations and loss of power with the hands and arms. " As the disease advances, the limbs become less and less capable of executing the dictates of the will, while the unhappy sufferer seldom experiences even a few minutes' suspension of the tremulous agitation : and should it be stopped in one limb by a sudden change of posture, it soon makes its appearance in another. Walk- ing, as it diverts his attention from unpleasant reflections, is a mode of exercise to which the patient is in.general very partial. Of this tem- porary mitigation of suffering, however, he is now deprived. When he attempts to advance, he is thrown on the toes and forepart of his feet, and impelled unwillingly to adopt a running pace, in danger of falling on his face at every step. In the more advanced stage of the dis- ease, the tremulous motions of the limbs occur during sleep, and augment in violence till they awaken the patient in much agitation and alarm. The power of conveying the food to the mouth is impeded, so that he must submit to be fed by others. The torpid bowels require stimulating medicines to excite them into action. Mechan- ical aid is often necessary to remove the feces from the rectum. The trunk is permanently bowed; muscular power diminished ; mastica- tion and deglutition difficult; and the saliva con- stantly dribbles from the mouth. The agitation now becomes more vehement and constant; and when exhausted nature seizes a small portion of sleep, its violence is such as to shake the whole room. The chin is almost immoveably bent down upon the sternum ; the power of ar- ticulation is lost; the urine and feces are dis- charged involuntarily, and coma with slight delirium closes the scene." The remote cause is involved in some obscu- rity. Long exposure to damp vapour, by lying from night to night on the bare earth, in a close unventilated prison, seems to have produced it; and possibly other causes of chronic rheuma- tism : and hence it has frequently supervened on chronic rheumatism itself. Long indulgence in spirituous potation has often given rise to it; and probably any thing that debilitates the ner- vous power.* And on this account miners, and others ex- posed to the daily exhalation of metallic vapours, and especially those of mercury, are frequent and severe sufferers ; of which Hornung has ad- duced many interesting examples from the quar- rymen in Camiola.—(Cista, p. 280.) It has also followed worms in the intestines (Commerc. Liter. Nor., 1743, p. 55); and, in this case, has sometimes assumed a periodical type.—(Act. Nat. Cur., vol. ii., obs. 143.) The part of the nervous organ more imme- diately affected has also afforded some ground for controversy. Bonet ascribes it to a diseased state of some portion of the cerebrum, and has given examples of its being found, on dissection, to contain, in various quarters, proofs of serum, sanies, and other morbid secretions.—(Sepul., lib. i., sect, xiv., obs. 7, 9.) But the misfortune is here, as we have already observed in similar ap- pearances after mania, that it is impossible for us to determine whether these diseased fluids give rise to the disease, or the disease to them. And * Modern writers distinguish the true paralysis agitans from the description of cases here advert- ed to. It certainly possesses many points of sim- ilarity to chorea and mercurial palsy; yet differ- ences are noticed not only from these affections, but from the trembling brought on by the abuse of spirituous liquors, strong tea or coffee, or by mere old age. In these examples the agitation stops if the limb be supported, and none of its muscles put in action ; whereas, in the real shaking palsy, the reverse takes place. The gait is also peculiar; the patient, when he attempts to walk, being un- pelled unwillingly to adopt a rarining pace.—Ed. Gen. IH.-Spe. 4.] SYNCLONUS RAPHANIA. 333 hence Mr. Parkinson seems to pay no attention to them, at least as a cause, and fixes the seat of the affection in the cervical of the spinal mar- row, from which he supposes it to shoot up by degrees to the medulla oblongata. We have already shown sufficiently in the Physiological Proem to the present class, that the nervous fibres which ramify over the extremities, whether sensific or motific, originate from the chain pf the spinal marrow; and we have also shown, in discussing the diseases of trismus, tetanus, and lyssa, how acutely one extremity of a chain of any kind, and particularly of a continuous fibrous chain, sympathizes with another : and there can be no difficulty, therefore, in conceiving, that wherever the cutaneous ends of the nerves of motion are torpified, or otherwise affected by any of the causes just adverted to, the vertebral column must itself very seriously participate in the mischief, and consequently the upper or cer- vical part of this column; and that from this point the disease must ramify to the brain be- fore the general functions of the system become affected, as in its latter stages. The remedial process is not very plainly in- dicated. Vesicatories and other stimulants ap- plied to the neck, or even the dorsal vertebrae, have appeared useful. A seton or caustic, and especially the actual cautery, as practised so generally in France, might possibly be of more avail applied to different parts of the spine. Be- yond this an active purgative system, as strongly recommended by Riedlin, has certainly been found efficacious (Lin. Med., 4695, p. 101) ; and the subcarbonate of iron, the prussic acid, and solution of arsenic, bid as fair for a favour- able result here as in the preceding species.* Starck tried musk, and carried it to very large doses frequently repeated every day (Klin, und Anat. Bcmerkungen); but it does not seem to have produced any decisive success. Friction of the affected extremities, resolutely persevered in by a skilful rubber, with stimulant embrocations of camphire or ammonia, should also be tried in an early stage of the disease, and be alternated with the use of the voltaic trough. Here, too, we may expect to derive ad- vantage from a free use of diaphoretic and alter- ant apozems, as the decoction of the woods, and especially where the disease is suspected to be of a rheumatic origin:—to which may be added a regular course of bathing in the Bath springs. * This statement is far too promising; for the disease does not, like chorea, take place in young, but generally old persons, and is commonly be- lieved to be connected with organic disease of some part of the nervous system. Dr. Elliotson informs us, that he has never been able to cure but one case, and this was a patient not more than thirty-five. As there was pain in the head and giddiness, copious bleeding, blisters, mercury, low diet, and setons were first tried, but without any benefit. Zinc was next prescribed, and, as that did not answer, the subcarbonate of iron was given, which effected a cure. Dr. Elliotson has since tried the latter medicine in four or five other cases of shaking palsy, but without the least ben- efit.—Lectures at the Lond. Univ.—See Med Gaz 1832-33, p. 533.—Ed. SPECIES IV. SYNCLONUS RAPHANIA. RAPHANIA. SPASTIC CONTRACTION OF THE JOINTS : WITH TREMBLING AND PERIODICAL PAINS. Of this species we know little or nothing in our own country. It was first described by Lin- neus, who called it Raphania, from his suppo- sing it to be produced by eating the seeds of the raphania raphanistrum, a wild radish or shar- lock that grows indigenously in our native corn- fields, as well as in the cornfields of most parts of Europe. By other writers, as Herrmann and Camerarius, it has been ascribed to the use of darnel or rye* infested with the spur, or ergot, or some other parasitic plant, which, as we have already observed, is a frequent cause of other very severe complaints, as mildew mortifica- tion (gangrana ustalaginea), and erythema- tous plague (pestis erythematica). All these diseases, however, are so distinct from each other, that though there can be little doubt of their being severally produced by some poison- ous material contained in the patient's food, the poison must be of different kinds, and we do not seem to be acquainted with the cause of this dif- ference ; and hence the question has given rise to much controversy, and been discussed with some warmth on the continent; for, while the greater number of writers refer the disease to the raphania, or spurred rye (secale cornutum), many deny that it is produced by either of these (Wichmann, Beytrdg. zur Geschichle der Kric- belkrankheit, Leips., 1771-8), and Lentin as- cribes it to the honeydew of various plants, con- cerning which we shall have to speak further under paruria mellita. That it is a vegetable poison, however, seems to be admitted by com- mon consent, and it is possible that the poison is not confined to a single plant, j * Abhandlung von der Kriebelkrankheit, &c, Cassell, 177s-8. De Lall. Lolio. temulento, Tu- bing., 1710. t The pernicious effects of blighted rye, when used, as an article of food, have been observed ever since the time of Duhamel. Mann, in his Medical Sketches, "has attributed much of the sickness of the Northern army in the war of 1812-14 to this cause; and we think that suffi- cient evidence has been adduced by writers to place its noxious effects beyond dispute. Messrs. Wood and Bache (U. S. Dispensatory, 2d edition, 1834) speak thus confidently on the subject:— " Terrible and devastating epidemics in different parts of the continent of Europe, particularly in certain provinces of France, have long been as- cribed to the use of bread made from rye contam- inated with the degenerate grain. Dry gangrene, typhus fever, and disorders of the nervous system at- tended with convulsions, are the forms of disease which have been observed to follow the use of this unwholesome food. It is true that ergot has been deemed to be the cause, but accurate inves- tigations made by competent men on the spot where the epidemies have prevailed, together with the results of experiments made upon inferior animals, leave no room for reasonable doubt upon the subject."—D. 334 NEUROTICA. [Cl. IV.-Ord. III. That many poisonous plants have a direct ten- dency to affect the nervous system, and excite entastic or clonic spasm, or a mixture of the two, according to the peculiarity of the poison itself, or of the habit into which it is introduced, we have frequently had occasion to notice al- ready, and particularly under the head of erup- tive surfeit (colica cibaria efftorescens). This is particularly the case with several of the del- eterious agarics or funguses, some of which seem to operate chiefly on the sensific nerves, and produce a general stupor : and others on the motory, and produce palpitations, cramps, or convulsions over the whole system.—(Heber- den, Med. Trans., ii., 218.) It is very proba- ble, therefore, that the cause ordinarily assigned for the present species of disease is the true one. There is an excellent paper upon this sub- ject in the Amoenitates Academics (Tom. vi., art. cxxiii., 1763), furnished by Dr. Rothman, a pupil of Linneus, from which the disease seems to be not unfrequently epidemical, arid always to commence in the autumn. It is found, how- ever, only among the lower orders of the peo- ple, and, in the epidemic referred to, is suffi- ciently traced to impure admixtures with their grain, and the employment of this vitiated grain in too new a state. Dr. Rothman delineates the disease from actual observation, and does not believe it to be a new malady, as generally sup- posed, but thinks he has traced it in the wri- tings of various authors from the year 1596 to 1727 ; which would establish, moreover, that it has been common to other parts of Europe as well as to Sweden. And in confirmation of this we may observe, that Dr. Mercard (Medici- nische, Versiiche. Zweyter Theile., 8vo., Leip- zig) describes a disease very much resembling raphania, that appeared at Stade in the winters of 1771, 1772, which was evidently epidemic, and accompanied with symptoms of fatuity, or that narcotic effect which many deleterious plants are sure to produce. Dr. Cullen, who has generalized far too much his description of chorea in his Practice of Physic, seems to have imbodied this species, as well as the preceding, in the common delin- eation, and hence, when he tells us that "there have been instances of this disease (chorea) ap- pearing as an epidemic in a certain corner of the country" (Part ii., book iii., chap, iii., 1353), there can be little doubt that he al- ludes to the species before us originating from the cause now assigned, although without some such interpretation as the present, the passage is not very intelligible. The disease commences with cold chills and lassitude, pain in the head, and anxiety about the prascordia. These symptoms are followed by spasmodic twitchings, and afterward rigid contractions of the limbs or joints, with excru- ciating pains, often accompanied with fever, coma, or delirium, sense of suffocation, and a difficulty of articulating distinctly. It continues from eleven days to three or four weeks ; and those who die generally sink under a diarrhoea or a paroxysm of convulsions. The warm antispasmodics, as valerian, cas- tor, and camphire, appear to have been em- ployed with decisive success. An emetic, how- ever, given at the onset of the symptoms, as recommended by Henman, would probably cut short the course of the disease and mitigate its violence. This writer advises also blistering or bathing with Dippell's animal oil.—(Abhandl. von der Kriebelkrankheit.) Camphorated vine- gar, as employed by other practitioners, would probably be found a more useful embrocation.— (Nachricht. von der Kriebelkrankheit.) Towards the close of the disease, purple ex- anthems or vesications are said to be sometimes thrown out, which approximate" it to mildew- mortification and the erythematic pestis, both which, as we have already observed, have been traced to a similar cause. SPECIES V. SYNCLONUS BERIBERIA. BERIBERY. BARBIERS. SPASMODIC RIGIDITY OF THE LOWER LIMBS, IM- PEDING LOCOMOTION ; OFTEN SHOOTING TO THE CHEST, AND OBSTRUCTING THE RESPIRA- TION AND THE VOICE ; TREMBLING AND PAIN- FUL STUPOR OF THE EXTREMITIES ; GENERAL CEDEMATOUSINTUMESCENCE. Bontius seems first to have introduced the term beriberi or beriberia into medical nom- enclature, and tells us it is of oriental origin (De Medicind Indorum, cap. i.); and Sauvages has hence copied it into his list of " nomina barbara, seu nee Grsca, nee Latina." Mange- tus affirms, that the disease was known to Eras- istratus, but certainly not under this name. Eustathius, however, has fiipScpi, but in the sense of " concha or ostreum," " conch or shell,"— and tells us that It is a term of Indian origin He might have said, with more propriety, of ori- ental origin, for it is common both in its pri- mary and duplicate form ^3 or jo3. "013 or D'laiD to the Hebrew, Chaldee, Syriac, and Arabic, in which last it is iJ«j| J (befabir), and in all of them is a nomadic term, importing til- lage and its production, wnich is gTain, or pastu- rage and its production, which is sheep, or other cattle ; and hence, probably, the origin of brebis or sheep in the French tongue. The term is said to be applied to this disease in India from the patient's exhibiting, in walking, the weak and tottering step of a sheep that has been over- driven. This disease, though common to various parts of India, is chiefly to be met with in Ceylon and on the Malabar coast [especially in that tract of country reaching from Madras as far north as Ganjam].—(Hamilton in Edin. Med. Chir. Trans., vol. ii., p. 13.) It seems to be produced by sudden transitions of the atmosphere from dry to damp, and from sultry calms to chilling breezes. In these countries it attacks both na- tives and strangers, but particularly the latter. during the rainy season, which commences in November and terminates in March ; through a great part of which, also, the land-winds blow Gem. Ill—Spe. 5.] SYNCLONUS BERIBERIA. 335 from the neighbouring mountains every morn- ing about sunrise with great coolness; and hence, those who sleep abroad, or without suffi- cient shelter, are equally exposed to the influ- ence of a penetrating chill and damp.* [The instances are comparatively rare in which it has occurred at a distance from the sea exceeding sixty or seventy miles.] Fresh troops, partly from their being new to the climate, but chiefly from their want of a sufficient degree of caution, very frequently suf- fer severely from this complaint so long as the rainy season continues. Thus we learn from Mr. Christie, that the 72d regiment was severe- ly attacked with it in the autumn of 1797, not many months after its arrival, and continued to suffer from it till the ensuing spring ; and that the 80th regiment, which relieved the 72d in March, 1797, was equally attacked with it in the ensuing November.+ It is, however, in all such cases, most frequently to be found among those who have previously weakened their constitutions by sedentary habits or a life of debauchery ; and particularly where too free an indulgence in spirits has co-operated with sedentary habits, as among the tailors and shoe- makers of a battalion ; who, in order to give them time to work at their respective trades, are often excused from the duties of the field, and, by their double earnings, are enabled to procure a larger quantity of spirits than other men. And we may hence, in some degree, ac- count for Mr. Christie's remark, that during his stay at Ceylon, he never met with an instance of this complaint in a woman, an officer, or a boy under twenty.J The disease commences with a lassitude and painful numbness of the whole body, the pain sometimes resembling that of formication. The legs and thighs become stiff, the knees are spas- modically retracted, so that the legs are straight- ened with great difficulty, and instantly relapse into the retracted state, whence the patient is apt to fall if he attempt to walk. In some cases, indeed, the motory and sensific power, instead of being distributed to the muscles of locomo- tion irregularly, is not distributed at all, and the limbs become paralytic. And even where the spasmodic action exists, it often travels or ex- tends to those parts of the body, and particu- larly to the chest and the larynx, so that speak- * According to Mr. Wright, who had opportu- nities of making remarks on the disease, as it pre- sents itself on the Malabar coast, it was most prev- alent towards the end of the rainy season, when ' the night temperature was many degrees lower than that of the day.—See Edin. Med. and Surgi- cal Journal, vol. xli., p. 235.—Ed. t " So far as I know," says Mr. Hamilton, " there is no instance on record of an individual being attacked with the disease immediately upon his arrival in India."—Edin. Med. Chir. Trans., vol. ii., p. 21.—Ed. X This agrees with Mr. W. P. Wright's state- ment, that " the periods of infancy and boyhood are exempt; and females are seldom attacked." —See Edin. Med. and Surgical Tmirnal. vol. xli., p. 323—Ed. ing and respiration are conducted with great dif- ficulty. At the same time, the whole of the absorb- ent system exhibits equal proofs of torpitude, the legs first, and afterward the entire surface of the body becomes bloated and cedematous, and all the cavities, particularly those of the chest, are progressively loaded with fluid : and hence, to- wards the close of the disease, where it termi- nates fatally, the dyspnoea is extreme, and ac- companied with an intolerable restlessness and anxiety, and constant vomiting; the muscles are convulsed generally ; while the pulse gradually sinks, the countenance becomes livid, and the extremities cold. Such is the course of the disease as it shows itself at Ceylon, where it seems to rage more se- verely than on the Malabar coast, and where we are told by Mr. Christie, whose account is con- firmed by Mr. Colhoun,* that its progress is so rapid, that the patient is often carried off in six, twelve, twenty-four, or thirty-six hours from its onset, though it ordinarily runs on for several weeks, t Since the first edition of the present work, various important communications have been made to the Army Medical Board upon the sub- ject before us. These, by the kindness of my eminent friend the director-general, I have been enabled to examine, and they concur in supporting the general character of the disorder as given above ; as they do also in affirming, that neither women, officers, nor persons under twenty years of age become the subjects of beribery ; evidently because such individuals are rarely called upon to expose themselves at night, or sleep in the open air. From the complicated nature of the disease, however, and the variety of organs that are linked in the general chain of morbid action, suggestions have often occurred, whether beri- bery be not rather a modification of some other malady than an idiopathic affection ; and espe- cially whether it be not a peculiar form of an- asarca, deflected from its common course by * Essay on the Diseases incident to Indian Sea- men or Lascars on long Voyages, by W. Hunter, A. M., &c. t On the Malabar coast the disease appears in different forms. The first of these is named hy Mr. Wright the severe, or inflammatory, which is generally a first attack, the patient being robust, and dropsical symptoms present, of the kind termed by pathologists acute or arterial. The second is the asthenic, when the patient has been reduced by some previous disease, or by a relapse of it; then the dropsical symptoms resemble those observed after protracted fevers or other debilita- ting causes. The third is the local variety, tfie disease seeming to be confined to the lower ex- tremities, with merely oedema and paralysis of them, unaccompanied by constitutional irritation. —(See Edin. Med. and Surgical Journal, vol. xli., p. 324.) It is admitted, however, that the cases sometimes vary, according to the constitution of the patient and the effect of noxious influences; so that, though he has at first only local symptoms, he may be suddenly attacked by general acute an- asarca.—Ed. 336 NEUROTICA. [Cl. IV—Ord. III. accidental circumstances. The last is more es- pecially the opinion of Mr. Collier, a staff-sur- geon of considerable talents and authority ; and to the same opinion I find Dr. Dwyer inclining, physician to the forces at Kandy in Ceylon. Yet, after having, in his manuscript report, which is a very valuable document, called it incidentally by the name of acute anasarca, he tells us that, from the great diversity of its symptoms, many cases have been referred to apoplexy, carditis, aneu- rism, gastritis, which were purely examples of beribery : and he then proceeds as follows :— " Although allied in many of the symptoms to dropsical affections, it is to be considered dis- tinct BOTH IN SYMPTOMS AND TREATMENT." —(Lord Valentia's Travels, vol. i., p, 318.) And to the same effect, a very able inspector of hospitals in the same quarter, Dr. Farreil, who observes as follows:—" I cannot help thinking still, notwithstanding the weight of his (Mr. Collier's) authority, that the affection commonly called beri-beri is a disease of ex- haustion and debility, occurring chiefly in per- sons of intemperate habits, and labouring under other maladies." In effect, it is not only a dis- ease of exhaustion and debility, but of these properties peculiarly applied to the nervous sys- tem ; the dropsical and apoplectic symptoms only taking place secondarily, and as a result of the general wealuiess. " The more promi- nent symptoms," observes Dr. Dwyer, " were numbness of the extremities, muscular power greatly impaired, walking attended with a con- siderable degree of unsteadiness, pain, tottering, and weakness of the joints ; such instability of gait as resembles a person walking on his heels ; sometimes paralysis. In the latter stages of the disease, when the thxyrax becomes affected, in- creased uneasiness of the epigastrium and vom- iting succeed; dyspnoea and all the symptoms of hydrothorax." At times the spasmodic action spreads, even from the first, to other organs than the limbs, and produces a very striking effect. A sergeant of the 45th regiment, of sober habits, who seems to have nearly recovered from two previous at- tacks at Kandy about a year before, and had left the hospital, was suddenly seized, April 1, 1822, with " an extreme difficulty of breathing, inability to walk or speak much. The muscles of the forehead, face, and nose were in motion at the exertion made to speak or breathe. The corrugations of the latter gave a sharpness of countenance very peculiar, but indicative of great distress and anxiety. The countenance soon became livid ; the pulsations of the heart were loud and fluttering; its strokes against the side could not be distinctly counted. He was bled two pounds without much relief. The appearance of this poor man was very affecting. The blood drawn was sizy; and, upon re-open- ing a vein from a large orifice, he again bled freely ; but, becoming exhausted, it was thought prudent to stop it again. His legs were much swelled, and pitted on pressure. They were covered with small livid spots, as well as other parts of his body, like fleabites, but much larger. He died in half an hour afterward. The thighs and abdomen were but little swelled in propor- tion to his legs, but evidently larger than natu- ral. His arms were emaciated, and no part osdematous. He appeared of stout make." The intumescence of the legs seems to have been a result of debility from the two prior at- tacks ; but it was nevertheless expected, that most of the cavities of the body would have given proof of an hydropic affection ; and I have selected this case as one of the strongest in sup- port of such an opinion : for, in general, though water is traced, sometimes in one cavity and sometimes in another, yet there is seldom much accumulation, and still more seldom such as to produce oppression. Dr. Dwyer took a minute of sixteen cases ; and his remark upon the whole of these is, "water is usually found in some of the cavities, but the organs vary:" and such an observation is alone sufficient to take beribery out of the list of proper dropsies, what- ever other place we may assign to it. An early post-obit examination, however, of the case before us, showed as follows :—"About an ounce of serous straw-coloured fluid escaped in various ways on opening the dura mater. Filling up the gyri on the surface of the brain, we observed a gelatinous transparent matter of some tenacity and consistence ; it looked like a coating of isinglass. In the ventricles there was but very little fluid; in no other part of the cra- nium were indications of pre-existing disease observed." In the thorax there were various adhesions, especially within the pericardium, on opening which seven ounces of a straw-coloured serum were found in it, yet warm. No fluid in the thoracic cavity.—In the abdomen there were few morbid appearances, except in regard to the spleen, which was as large as an ordinary sized liver, and weighed three pounds ten ounces. The liver of its usual size, but had a mottled appearance. Only eleven ounces of serous or dropsical fluid were found in this cavity.* * The morbid appearances observed by Mr. Hamilton, materially differed from those above described. Upwards of an ounce of serum was effused between the pia mater and tunica arach- noidea; and, in two or three places, there were dark red-coloured patches, one of which was ex- ceedingly vascular, and extended into the sub- stance of the brain from a quarter to half an inch. There was likewise found considerable effusion in all the ventricles except the fourth. In the base of the cranium, four ounces of fluid tinged with blood were contained. The lungs were much loaded with dark-coloured blood, and in both cavities of the thorax there was extensive effusion. The heart was healthy, nor did the pericardium contain more fluid than usual. Both its external and in- ternal surface, however, exhibited evident marks of inflammation. The diaphragm was also much inflamed, particularly its right portion. The stomach was healthy. The liver was larger than natural, and gorged with blood, as were also the mesentery and pancreas. The intestines presented nothing remarkable. Traces of con- gestion were remarked in the spinal marrow. From three to four pounds of fluid were found in the cavity of the abdomen, and the cellular tex- ture, nearly all over the body, was anasarcous.— (Edin. Med. Chir. Trans., vol. ii., p. 18.) Mr. Gen. III.—Spe. 5.] SYNCLONUS BERIBERIA. 337 The curative intention is to re-excite the ab- sorbent system and the affected branches of the nerves to a discharge of their proper functions, by a process of diaphoretics and stimulants. Squill pills and calomel are chiefly depended on for the latter, and James's powder for the former; though the compound powder of ipecacuanha seems better calculated for the purpose, as con- taining a sedative admirably adapted for allaying nervous irregularities. On the Malabar coast, it is no uncommon practice to excite perspiration in this complaint by burying the patient in a sand bath ; for which purpose a hole is dug in the sandy soil, into which he is plunged as deep as to his neck, and con- fined there as long as he can bear the heat of the sand that surrounds him. The strength, throughout the whole, is supported by cordials, and in many instances even by ardent spirits diluted for the purpose ; punch is a common drink on this occasion, and the refreshing and sedative power of the acid entitles it to a pref- erence. To remove the numbness and prick- ing or formicative pain from the limbs, friction and stimulant liniments are applied locally, and not unfrequently the legs are plunged into a pediluvium. And where the disease assumes an alarming appearance, and the spasmodic symptoms are very violent, recourse is had to a hot bath, and the strongest cordials and anti- spasmodics, as brandy, sulphuric ether, or its aromatic spirit, and laudanum, which it is some- times found necessary to continue for several weeks. In convalescence, the patients should be re- moved, as soon as may be, to a drier and more equable temperature, .and be put upon the or- dinary plan of tonics, regular exercise, and nu- tritive diet. In milder cases, they generally re- cover with the shifting of the monsoon, which carries off the remote cause of the disease, and brings a change of temperature home to them. [The evident congestion, noticed by Mr. Hamilton in his dissections, made him resolve to try the effects of bloodletting. This was practised freely and repeatedly, after which twenty grains of calomel and thirty drops of laudanum were exhibited, and the patient's body fumigated with the hydrargyri oxydum cinere- um. In an hour and ten minutes, the calomel and laudanum were repeated. In three hours more, the calomel was given again with six Hamilton notices, that the post-mortem appear- ances described by Mr. Ridley (Dublin Hospital Reports, vol. ii.), mark the existence, not only of internal congestion, but of visceral inflammation, in beribery still more decidedly. " Dissections 6how," says Mr. Wright, " that the patient is at times killed by suffocation from the increased pressure of accumulated fluid in the lungs, and, at others, by apoplexy." His other remarks on this subject generally confirm those of Mr Hamil- ton—Ed. Vol. II.—Y grains of gamboge, and the body was exposed again to the fumigation, " which, together with the scruple doses of calomel, and friction over the surface of the abdomen and thighs with the unguentum hydrargyri fortius and liquor ammo- nia;, was repeated every three or four hours, until ptyalism was fully established. Every un- favourable symptom then speedily disappeared. Three other cases treated in the same way, proved equally successful."*] Beribery has not been hitherto described as existing in any other part of the world; and if it should be found, it will probably exhibit a modification of some of the symptoms, accord- ing to the quarter in which it appears. I am induced to make this remark from observing an account (Med. Chir. Trans., vol. ix., art. i., p. 1) of a very singular spasmodic disease by Dr. Bostock, which evidently belongs to the present genus, and seems to be a variety of the present species, assuming a chronic form. The patient, who was in the middle of life, was first attacked with achings in the lower limb on one side, ac- companied with a difficulty and irregularity of motion, which soon spread to the other side, and then gradually to the throat, so as to hinder deglutition, except with great pain and severe exertion: the larynx next became affected, so as to prevent speech, and afterward the back of the neck, the muscles affected being the vol- untary alone. From the spastic rigidity of the limbs, they were both bent and straightened with a like difficulty. The pricking pain, like that of pins, or of a limb awaking from stupor, com- mon to the extremities in beribery, was present here also, though apparently without stupor or oedematous swellings. Yet the intellectual powers were at length affected and weakened ; the failure of understanding gradually increas- ing, but principally showing itself in paroxysms, during one of which the patient died. No cause of the disease could be traced before death, or by dissection afterward. * Hamilton in Edin. Med. Chir. Trans., vol. ii., p. 23. Those practitioners who regard beriberia as a disease of debility, prefer stimulants, deob- struents, and antimonials; while others, who look upon it as an inflammatory complaint, recom- mend bloodletting and evacuants. Mr. Wright is of opinion, that both methods are applicable, if varied according to the peculiar form of the dis- ease, which seems to him to be in many instances of the tril o of idiopathic dropsies, such as, accord- ing to Dis. Parry, Blackall, and other modern writers, are originally caused by increased mo- mentum and disorder of the sanguiferous system, and have a general alliance with inflammation, whatever appearance they may afterward pre- sent. In other instances in which the patient has long suffered from this disease, complicated with abdominal dropsy, Mr. Wright is in favour of sup- porting the patients with cordials, wine, bark, and nourishing diet.—See Edin. Med. and Surgical Journ.. vol. xli., p. 328.—En 338 NEUROTICA. [Cl. IV—Ord. IV. ORDER IV. SYSTATICA. DISEASES AFFECTING SEVERAL OR ALL THE SENSORIAL POWERS SI- MUL TANEO USL Y. IRRITATION OR INERTNESS OF THE MIND, EX- TENDING TO THE CORPOREAL SENSES, OR THE MUSCLES ; OR OF THE CORPOREAL SEN- SES, OR THE MUSCLES, EXTENDING TO THE MIND. The sensorial powers are those which are dependant on the sensorium or brain as their instrument or origin; and are three in number, -—the intellectual, the sensific, and the motory. Thus far we have only contemplated these as they are affected singly, or, where more are af- fected than one, as influencing the rest only sec- ondarily or sympathetically. The diseases of the present order are of a more complicated origin and nature, and affect several or all the sensorial powers conjointly from the first. The order is hence denominated systatica, a Greek compound, from cvviarriut, "congredior, conso- eio." Syncoptica might have been employed, and upon as large a scale, so as to denote in- creased, as well as diminished action, impellen- tia as well as concidentia; but this term is usually limited to express maladies of the latter kind ; and, consequently, might have produced confusion, since the present order, like all the preceding, includes diseases evincing different, and even opposite states of action. The genera appertaining to it are the follow- ing: I. Agrypnia. II. Dysphoria. III. Antipathia. IV. Cephalaea. V. Dinus. VI. Syncope. VII. Syspasia. VIII. Cams. Sleeplessness. Restlessness. Antipathy. Headache. Dizziness. Syncope. Comatose Spasm. Torpor. GENUS I. AGRYPNIA. SLEEPLESSNESS. DIFFICULTY OR INABILITY OF OBTAINING SLEEP. Agrypnia (iypvwh) is a Greek term signifi- cant of the English sleeplessness, by which it is here rendered. The affection is not intro- duced into Dr. Cullen's nosological arrange- ment, and has consequently been omitted by most nosological writers since his time ; but it occurs in the greater number of those who pre- ceded him ; and its claim to be considered as an idiopathic affection is as clear as that of most diseases concerning which there is no dis- pute. The two following species are embraced by this genus:— I. Agrypnia Excitata. ~ Irritative Wakefulness. 2.--------Pertaesa. Chronic Wakefulness. SPECIES I. AGRYPNIA EXCITATA. IRRITATIVE WAKEFULNESS. SLEEP RETARDED BY MENTAL EXCITEMENT J LISTLESSNESS to surrounding objects. On the physiology of sleep and dreaming, we briefly touched under the genus paroniria, or sleep disturbance, in the first order of the present class ; but the subject is of great extent and complexity, and cannot be followed up into any detailed explanation in a work on pathology. At present, therefore, I can only observe, that natural sleep is a natural torpitude of the volun- tary organs of the animal frame, produced by a general exhaustion of sensorial power, in con- sequence of an exposure to the common stimu- lants or exertions of the day. And hence, if such exhaustion do not take place, natural sleep cannot possibly ensue, though morbid sleep un- doubtedly may, as produced by other causes. Now it often happens, that from an energetic bent of the mind to a particular subject, the sen- sorial power continues to be produced, not only in a more than usual quantity, but for a more than usual term of time ; and, in consequence of this additional supply, there is no exhaustion at the ordinary period, and therefore no sleep. Severe grief is often a stimulus of this kind; during which a morbid redundancy of sensorial power continues, followed by a morbid excite- ment of the system generally from day to day, and from night to night, till the frame is worn out by the protracted watchfulness or sensorial erethism. And it is astonishing to witness, in various instances, how long the frame will sup- port itself before it is worn out, or the irritation that prevents sleep sufficiently subsides for its return, and particularly where the mind is labour- ing under the influence of the depressing pas- sions, or of depressing pain. A hemicrania has kept a person awake for three months ;* and a melancholy or gloom on the spirits for fourteen months. Overwhelming joy has often a similar effect, though seldom in an equal degree, or for so long a period of time. The mind may also be intensely directed to some peculiar object of study, and the energy of the will becomes in this case a like stimulus to the production of a fresh or protracted supply of sensorial power, so that the usual exhaustion of the nervous system does not take place at the accustomed period. This is peculiarly the case in a pursuit of the abstract sciences, or those of a more strictly intellectual nature, as the higher branches of the mathematics. * Bartholin, Hist. Anat., cent, i., hist. 64; Schenck, lib. i., obs. 256. The editor once at- tended a young lady, whose complaints consisted in violent palpitations of the heart, cough, and difficulty of breathing, and who was kept almost constantly awake by her distressing sensations for nearly three months. As sitting up or the least exertion aggravated the palpitations, she continually kept her bed. This patient was. one of the last visited by Dr. Good, who recommended a trial of hyoscyamus. This medicine, and many others, were tried in vain; but under Dr. Oke, now of Southampton, and Mr. Taylor, of Farnham, a complete recovery gradually took place.—Ed. Gek. I,—Spk. 2.] AGRYPNIA PERTHES A. 339 Where the determination of the mind to a particular subject is exquisitely intense, whether that subject be a passion or a problem, by far the greater part of the sensorial power is expended at this particular outlet; and consequently the frame at large, with the exception of those organs to which such outlet peculiarly appertains, is so far drawn upon, as a common bank, for a con- tribution of sensorial power, that it labours under a certain degree of deficiency, and hence a cer- tain degree of torpitude, so as to become insen- sible to the world around it; making, in this respect, an approach to the state of mind we have already described under the name of aphelxia intenta, or mental abstraction. The cure of this species of sleeplessness is to be accomplished -by allaying the mental excite- ment by which it is produced. This is best done by recalling the mind from the pursuit that leads it astray, and a free surrender of the will to listlessness and quiet. The perturbation will then subside, the sensorial organs become tran- quillized and inactive, and the habit of refresh- ing slumber resume its influence. But where this cannot be obtained by the mere exercise of the will, we must call opium or some other nar- cotic to our aid, which, by its revellent stimulus, may coincide with the consent of the will, and produce the exhaustion, and consequently the quiet, that is requisite for sleep. SPECIES II. AGRYPNIA PERTJSSA. CHRONIC WAKEFULNESS. SLEEP RETARDED BY BODILY DISQUIET; ATTEN- TION ALIVE TO SURROUNDING OBJECTS. The exhaustion, in which the very essence of natural sleep consists, supposes a perfect qui- escence and inactivity of the sensorial powers. Uneasiness of any kind will become an obsta- cle ; and hence, an aching coldness of the ex- tremities or of any other part will prevent it; an uneasy sensation of the stomach or any other part will prevent it; an absence of the common pleasu- rable feeling with which we ordinarily prepare our- selves for sleep will prevent it: "And, on this ac- count," as Darwin observes, " if those who are ac- customed to wine at night take tea instead, they cannot sleep." And the same evil happens from a want of solid food for supper to those who are accustomed to use it; as, in these cases, there is an irksome or dissatisfied feeling in the stom- ach. And hence, also, too great an anxiety or desire to sleep is another cause of its suspension; for this, as a mental disquiet, will only add to the corporeal disquiet which has produced it; and, as already observed, the emotions of the mind must be as quiescent as those of the body, and the will, instead of commanding or inter- fering, must tranquilly resign itself to the gen- eral intention. Where uneasiness of this kind has been per- mitted to continue for several nights in succes- sion, the sleeplessness is apt to become chronic, and to be converted into a habit. We have hence had examples, as noticed with their appro- priate references in the volume of Nosology, in which vigilance or sleeplessness has continued for a month without intermission (Grilling, cent. iv., obs. 90), for six months (Panarol, Pentecost, v., obs. 4), and even for three years.—(Plinii, lib. v., vii., cap. 51.) Mr. Gooch gives us a singular case of a man who never slept, and yet enjoyed a very good state of health till his death, which happened in the seventy-third year of his age. He had a kind of dozing for about a quarter of an hour once a day, but even that was not sound, though it was all the slumber he was ever known to take.—(Med. and Chir. Observations, dec, 8vo.) The cure of this disease demands a particular attention to its cause ; for if we can get rid of the organic disquiet on which it depends, we shall be pretty sure to succeed in obtaining our object. All irksome chills, and especially those of the feet, should be taken off by a sufficient warmth of clothing ; and the habitual supper, or other indulgence which has hitherto preceded and introduced sleep, should be freely allowed. The lulling sounds of soft and agreeable music, or agreeable reading, have been tried as concomitants, and not unfrequently with success. And narcotic aromas have at times been had recourse to, especially that of the hop, heaped into pillows ; but, so far as I have seen, and I have once or twice witnessed the experiment, with as little efficacy as the pillows of the male fern in cases of rickets, which were once, ac- cording to Van Swieten, in equal estimation for this last complaint. A pediluvium, as recom- mended by Lang (Epist., xlv.), will often be found a much better prescription, or any means which will excite that breathing moisture which is indicative of general ease. Soft, gentle, and general friction, and especially where there is any chill or rigidity upon the limbs, will fre- quently produce the same effect in a very agree- able way; and this, too, without combining it with the external use of opiates, as proposed by De la Prada (Journ. de Midecine, torn, xxxvi.) and various other writers.— (Anscrt. Abhandl., b. l, iv., st. 45.) Mosch was the favourite medicine of Thile- nius (Medicinische und Chirurgische Bemer- kungen, &c), and hyoscyamus of Stoerck (Li- bellulus quo continuantur Experimenta, &c), but a free and exhilarating glass of wine, as pro- posed by Fordyce, will often answer much bet- ter than either of them. In many cases of dis- quiet, and particularly in the stomach and prae- cordia, it might be well to try the hypnotic powers of the nutmeg, as warmly recommended by Dr. Cullen. We have already noticed this reputed effect in the East Indies, which Bon- tius confirmed by his own experience, and which has since been confirmed by practitioners in Europe : and when taken in a large dose, there can be little doubt of its somnolent virtue. In the case recited by Dr. Cullen in proof of this, the person had swallowed more than two drachms by mistake, and the effect was a drowsiness, commencing an hour afterward, which gradu- ally increased to a complete stupor and insensi- bility. After this he was delirious, and contin- ued to be alternately stupid and delirious for 340 NEUROTICA. [Cl. IV.-OkD. If- several hours : but, in six hours from the attack, he was pretty well recovered from every symp- tom.—(Mat. Med., part ii., ch. v.) Where, however, the morbid habit is too rigidly established to give way to any of these means, we must forcibly break through it by the use of opium, till the habit itself be overcome, when all narcotics should be gradually omitted. The wakefulness so common to old people is hardly a disease. They use but little exertion, and hence require but little sleep ; and the inter- nal inactivity is upon a par with the external. A third part of the vessels, perhaps, that took a share in the general energy of the middle of life, is obliterated, and the wear and tear of those that remain are much less. The pulse beats feebly ; the muscles of respiration are less for- cibly distended ; the stomach digests a smaller portion of food, for only a smaller portion is re- quired ; the intellect is less active, the corporeal senses less lively, and a minuter quantity of ner- vous energy produced by the brain and its de- pendencies.' And^ience, though there is far more weakness thin in earlier life, there is a less proportionate demand for exertion, and con- sequently a far smaller necessity for steep. From such a fine of reasoning may we see why sleeplessness should be found as a symptom in excessive fatigue, violent pain of any kind, inflam- mation, fevers, and various affections of the brain. GENUS II. DYSPHORIA. RESTLESSNESS. TROUBLESOME AND RESTLESS UNEASINESS OF THE MUSCLES ; INCREASED SENSIBILITY ; INABILITY 09 FIXING THE ATTENTION. This is the inquietudo of many authors, which the Greeks expressed by the generic term now chosen, importing, literally, " tolerandi difficul- tas," "a difficulty of enduring one's self." It does not expressly enter into the classification ©f Sauvages, nor that of Cullen, but is nearly synonymous with the anxietas of the former, which in the present system becomes a species of this genus. " Molesta scnsatio," says Sauvages, " quae ad jactitationem cogit, sed quomodo ab af- finibus morbis discrepet, dicant qui experti sunt." ., The genus embraces two species, as exhibit- ing restlessness or inquietude, chiefly confined to the sensifie or the irritable fibres ; or as de- pendant upon the state of mind- 1. Dysphoria Simplex. 2. -------— Anxietas. Fidgets. Anxiety. SPECIES I. DYSPHORIA SIMPLEX. FIDGETS. RESTLESSNESS GENERAL, AND ACCOMPANIED WITH A PERPETUAL DESIRE OF CHANGING THE POSI- TION. This is what we mean by the English collo- quial term Fidgets, from fidgety, most probably a corruption of fugitive, though the lexicogra- phers have given us no origin of the term. Bothjmport restlessness, unsteadiness, and per- petual change of place. The proper Latin term is titubatio; and, indeed, most languages have some peculiar term to express this troublesome and irritable sensation, though it has been rarely introduced as a disease into the nosological catalogue. The actual cause seems to consist in an un- due accumulation of sensorial power, which seeks an outlet, so to speak, at every pore, for want of a proper channel of expenditure. Thus every one becomes fidgety who is obliged to sit motionless beneath a long-drawn and te- dious story of commonplace facts totally desti- tute of interest: and still more so when he is eagerly waiting, and fully bottled up as it were, to reply to an argument loaded with sophisms, absurdities, or untruths, and over which he feels to have a complete mastery. So the high-met- tled horse is fidgety that, called out, in full caparison, and still restrained in his career, is panting for the race or the battle. " So the squirrel, "when confined in a cage, feels," as Dr. Darwin has ingeniously observed on this disease, which he calls jactitatio, " a restless uneasiness from the accumulation of irritative power in his muscles, which were before in continual and violent exertion from his habit of life; and, in this situation, finds relief by perpetually jump- ing about his cage to expend a part of his re- dundant energy. For the same reason, children that are constrained to sit in the s'vne place at school for hours together, are liable to acquire a habit of playing with some of the muscles of their face, or hands, or feet, in irregular move- ments, which are called tricks, to exhaust a part of the accumulated irritability by which they are goaded." In the two last instances^ this irritability is simply accumulated for want of a proper outlet, and not from inordinate secretion. In the two preceding cases, of the restrained horse and the restrained orator, there is added to this simple accumulation, for want of disbursement, an ac- cumulation also from inordinate excitement! It is this last source alone that can give the present affection any thing of a morbid charac- ter : and in irritable temperaments this is often the case ; for there is a diseased excess of sen- sorial power produced constitutionally, which is apt, on various occasions, to show itself by a perpetual restlessness or jactitation, as trouble- some to those who are of the company as to those who are afflicted with it. Paulini (Lanx. Sat., dec. ii., obs. 10) observes that worms, and Lentin (Beobacht. der Epidem- ischen Krankheiten, p. 47) that atony alone is a cause ; and hundreds of other sources of irk- some irritation may be added to these ; one of the most common of which is an obstinate and Unconquerable itching, like that of prurigo seni- lis, and especially in a part of the body that we cannot conveniently get at to scratch : and hence ascarides in the rectum or pudendum, into which last organ they have been sometimes found to creep, is a most distressing, and, in some cases, a maddening cause. A course of cooling purgatives, warm bathing, or increased exercise,, will probably be found Gen. IN.—Spe. 2] ANTIPATHIA INSENSILIS. 341 most serviceable in this harassing complaint; with an attention to the primary disease, where it is sympathetic. SPECIES II. DYSPHORIA ANXIETAS. ANXIETY. THE RESTLESSNESS CHIEFLY AFFECTING THE PR-SCOKDIA ; WITH DEPRESSION OF SPIRITS, AND A PERPETUAL DESIRE OF LOCOMOTION. This species, in persons of an irritable or highly nervous temperament, and especially among those inclined to hysteria or hypochon- driacal symptoms, is occasionally to be met with as an idiopathic affection, to which such a tem- perament gives a peculiar predisposition. But we see it more frequently as a feature in the first attack of fevers, in nausea, in various affec- tions of the prascordia, and most powerfully and most distressingly in lyssa or canine madness. It has been ascribed to the want of a free pas- sage for the blood through the heart, in conse- quence of a polypus concretion, or some other obstruction ; to a similar difficulty of its passage through the lungs ; and to a constriction of the vena ports, producing a like impediment in the lower belly; and the anxiety has been denomi- nated precordial, pulmonary, or epigastric, ac- cording to the part affected, which, however, we cannot always trace out. The complaint is particularly noticed by Hippocrates, who distin- guishes it by the name of alysmus (dXvaudf), lite- rally, restlessness or inquietude. It has sometimes, and especially in persons of an acutely irritable habit, been accompanied with great excitement of the nervous system generally, and spasmodic action of some or even all the muscles, displaying, according to the idiosyncrasy, the symptoms of chorea, hypo- chondrias, or lyssa; and has occasionally, as I have reason to believe, been mistaken for lyssa, where the morbid mind has pored incessantly on the recollection of some former scratch or bite of a dog or cat; and, like lyssa, it has some- times terminated fatally, though by no means with a like rapidity. Where the affection is idiopathic, an emetic will be generally found to produce the readiest assistance ; after this, the warmer antispasmod- ics, and, if necessary, nareotics may be success- fully employed, with gentle exercise and a light diet. GENUS III. ANTIPATHIA. ANTIPATHY. INTERNAL HORROR AT THE PRESENCE OF PARTI- TICULAR OBJECTS OR SUBJECTS ; WITH GREAT RESTLESSNESS OR DELIQUIUM. Antipathia (AvrnraOhs, from amvaOto, " natu- ralem repuguantiam habeo") does not occur in Swediaur, nor in Dr. Cullen's classification; but enters into his supplementary catalogue, " Morborum a nobis omissorum quos omisisse fortassis non oportebat;" or, as he expresses it, in another place, or diseases which were either forgotten when the arrangement was settled, or for which no fit place could be found within its limits. It occurs, however, in Sauvages, Lin- neus, Vogel, and Ploucquet, and seems to com- prise two species:— 1. Antipathia Sensilis. Sensile Antipathy. 2----------Insensilis. Insensile Antipathy, SPECIES I. ANTIPATHIA SENSILIS. SENSILE ANTIPA THY. ANTIPATHY PRODUCED THROUGH THE MEDIUM OF THE EXTERNAL SENSES. Very singular examples of both species be- longing to this genus are recorded by the collect- ors of medical curiosities ; while others are of everyday occurrence. Some may be accounted for from early fright, stories told in the nursery, or that incongruous association of ideas in early life, which we had occasion, to notice in the Proem to the present class. But many are of difficult solution, and others altogether inexpli- cable. Under the species before us, we may mention an antipathy produced by the smell of roses, of strawberries, of mint, and some other herbs ; by the sound of music ; or the sight of a drawn sword, which is said to have existed in King James I.; or the rattling of a carriage over a bridge, which continued for some years after mature life in Peter the Great of Russia, who was frightened, while an infant, by a fall from a bridge into the water, and who only overcame the antipathy by resolutely accustoming himself to the object of disgust. The sight of crabs and lobsters, and, still more frequently, of toads and vipers, has pro- duced the same effect; and we have a few in- stancesof its being occasioned by what we should much less expect as a cause, the appearance of bread and cheese, or even bread alone.—(Eph, Nat. Cur., dec. i., ann. i., obs. 144, et in Schol., dec. hi., ann. iii., obs. 149.) The object itself, however, seems to be of little or no importance; the feeling in most of these cases results from an association of such object, whatever it may be, with some painful occurrence in early life, of which it continues to be as much the symbol or expression as letters are of ideas. In many instances, the original occurrence is forgotten; but the impression indelibly remains, and the ob- ject recalls the mind to its influence. There is reason to believe, however, that the antipathy is often the result of idiosyncrasy, or something peculiar in the framework of the individual con- stitution. SPECIES II. ANTIPATHIA INSENSILIS. INSENSILE ANTIPATHY. THE ANTIPATHY PRODUCED THROUGH AN UN- KNOWN MEDIUM. In the preceding species the feeling of antip- athy is excited through the medium of one of the external senses, to which the object of an- 342 NEUROTICA. [Cl. IV—Ord. IV. tipathy presents itself, or with which it is asso- ciated on recollection; for it is the sight, or taste, or smell, or touch, or hearing of such ob- ject, or the idea of such sensible impressions, that alone calls the antipathy into action. There are some persons, however, that are struck with a peculiar and indescribable kind of horror at the presence of an object, which is unperceived by any of these senses, as soon as it comes within the atmosphere of some un- known influence. The presence of a cat has been often known to produce this effect under the circumstances now adverted to ; or when the animal, though present, has been concealed, and not one of the senses has been alive to its presence. Instances of this kind are to be found in most of the collections of medical cu- riosities, as well as in various other works ;* and I have met with several decided instances in the course of my own practice. The affec- tion, in this case, depends unquestionably upon an extraordinary idiosyncrasy; but by what means such an idiosyncrasy is influenced we know not. Sauvages inquires whether the ef- fluvium thrown from the object of aversion into the atmosphere may not, in combining with the fluids of the affected person, produce an irrita- ting and distressing tertium quid, as corrosive sublimate is produced by a combination of mer- cury with oxymuriatic acid. The fact, at pres- ent, appears inexplicable; but it is not more singular than the wonderful power so well known to be possessed by the viverra noctula (common or great bat), which renders it conscious of the presence and position of objects when all its senses are muffled, and which enables it, when flying in this state, to avoid them. This extra- ordinary faculty, to which we adverted in the Proem to the present class, has been called a sixth sense by several naturalists. In all these cases, whether of the preceding or of the present species, the only means in our power of destroying the anomalous or mor- bid impression is by introducing a counter-habit; or, in other words, by gradually inuring the sen- sorium to the influence of the disgustful object. By being familiarized with what at first we most shrunk from, our courage becomes hardened, and the painful impression blunted ; and sights, and sounds, and smells, and the most imminent dangers, that could not at one time be encoun- tered, or even contemplated without fainting, in process of time no more affect us than the roar of a cannon affects the war-horse, or the mountain-tempest the mariner. GENUS IV. C E P H A L M A. HEADACHE. ACHING PAIN IN THE HEAD ; INTOLERANCE OF LIGHT AND SOUND ; DIFFICULTY OF BENDING THE MIND TO MENTAL OPERATIONS. Cephalaea (xtQa'kala, from Kt This is, in most cases, a far more serious form of syncope than the preceding, and is com- monly ascribed to some structural disease of the heart or the large arteries that immediately issue from it, as an ossification of the valves, polypus concretions, an enlargement or thickening of the substance of the heart, an accumulation of water in the pericardium, or an aneurism. Each of these may possibly be a cause in some instance or other; and where, during the par- oxysm, the breathing, though feeble, is anxious and obstructed, the face livid, and the patient Gkn. vii.j SYSPASIA. 353 in the midst of the swoon shows a tendency to jactitation, or an uneasiness on one side or on the other; and, more especially still, where no ordinary exciting cause can be assigned, and it has commonly followed some unusual exertion or hurry of the blood through the lungs, it would be imprudent not to suspect such mischief. But there are causes of a different and much slighter kind that I cannot avoid believing fre- quently operate in the production of. recurrent syncope, and that too with many of the peculiar symptoms just enumerated. And I now allude to any of the ordinary causes of syncope, as set down under the first species, or any other inci- dental irritation whatever, occurring in a con- stitution of great mobility and excitability, or where the heart alone, or in conjunction with the whole arterial system, is peculiarly disposed to that irregular and clonic action which we have noticed under the species palpitation, and par- ticularly under the first and second varieties. In such a frame of body, any sudden alarm, a longer abstinence than usual, a fuller dinner than common, unwonted exercise, and a thou- sand minute excitements of daily occurrence, will often succeed in producing a fainting-fit; and especially where a morbid habit of recur- rence has been once established, and there is a predisposition to return. Atonic plethora is an- other frequent cause in the peculiar constitution we are now considering, and a cause far too liable itself to establish a circle of recurrence, and consequently to give recurrence to the form of syncope before us. There is a singular ex- ample of periodic swooning in the Ephemera of Natural Curiosities (Dec. ii., ann. i., obs. 10), which seems to have been dependant upon this state of body ; and another example, in which it was evidently produced by a return of the term of menstruation, and became its regular harbinger.—(Id., dec. ii., ann. v., obs. 53.) In all cases of this kind, therefore, it is of the utmost importance to study minutely the char- acter of the patient's idiosyncrasy and habit, and not to excite any alarm concerning organic mis- chief, and thus add another excitement to those which already exist, while there is a probability that the affection may be owing to one or other of these lighter and more manageable causes. In the latter case, tonics, cold bathing, equi- tation, regular hours, and light meals, will form the best prescription. Where we are compelled to suspect some organic impediment, or other mischief about the heart, small bleedings, that may anticipate the usual time of the return, camphire, nitre, hyoscyamus, and whatever other sedative may be found best to agree with the patient and diminish the rapidity of the circu- lation, will form the most rational medical plan we can devise; while tranquillity of body and mind, an abstinence from all stimulant foods, and a regular attention to the state of the bow- els, should form a standard rule for the whole tenour of his life.* * In the treatment of syncope, we should re- member that it may arise from two opposite states of the system, from plethora and exsanguinity: the Vol. II.—Z GENUS VII. SYSPASIA. COMATOSE SPASM. CLONIC SPASM ; DIMINISHED SENSIBILITY ; INA- BILITY OF UTTERANCE. Syspasia or syspasis, from avairdw, " con- traho, conyello," literally imports convulsion, in the popular sense of the term, or, in other words, clonus or agitatory spasm, in combination with a greater or less degree of failure of the sensa- tion and the understanding. The term seems wanted as a generic name for the three follow- ing diseases, whose symptoms and, for the most part, mode of treatment, are so discordant, as to establish the propriety of linking them under a common division:— 1. Syspasia Convulsio. Convulsion. 2.-------Hysteria. Hysterics. 3.-------Epilepsia. Epilepsy. The author has entered so fully into the na- ture and principle of clonic or agitatory spasm under the genus clonus, that a very few remarks will be necessary in explaining the pathology of these three species. They are all of them clonic spasms, as expressed in the definition, but com- plicated with other morbid affections, and par- ticularly with those of the two preceding genera: for if we combine clonic or synclonic spasm with different modifications of vertigo or syncope, we shall produce the three species now before us. In explaining the nature of clonic spasm, we noticed the tendency there frequently exists, when the uniformity of the flow of the senso- rial power is once interfered with, to alterna- tions of a hurried and excessive, as well as of a restrained and deficient supply, and consequent- ly to an intermixture of constrictive or entastic spasm with clonic or agitatory, of which palpi- tation, and various other affections of this kind, afford perspicuous examples. In the diseases immediately before us, the proofs of such an intermixture are still more striking ; for there is not one of them but evinces a union of both de- scriptions of spasmodic action, in a high, though not an equal degree of vehemence. In con- vulsion-fit the two kinds of spasm are nearly upon a balance, commonly with a retention of some share of both sentient and percipient power. In hysteria, the spastic or entastic ac- tion, in its sudden and transient irruptions, is more violent than the clonic ; the force exer- cised at this time is enormous, and there is also, in many cases, a small retention of sensation and understanding. In epilepsy, the clonic ac- tion is most conspicuous, and the failure of the mental and sentient faculties generally complete. Of the essence of the nervous power, we have repeatedly stated that we know nothing ; for we can trace it only by its effects : but we are compelled to conceive it to be formed by some particular organ within the animal system, which organ there can be no difficulty in con- former is often the immediate cause when syncope occurs in advanced life, and then moderate blood- letting may judiciously precede or accompany our other remedies.—D. 354 NEUROTICA. [Cl. IV^-Ord. IV templating as the brain singly, or the brain and nerves jointly, which constitute only different parts of one common apparatus. Admitting this, the nervous power may be produced in ex- cess or in deficiency, or be imperfectly elabo- rated, and, however produced, it may be irreg- ularly transmitted, as well by precipitation as by interruption. The means by which these diseased actions take place we have already touched upon; and have shown that the com- mon causes are sometimes mental, sometimes mechanical, sometimes sympathetic, and some- times chymical, as narcotics and other poisons, and repelled eruptions. Now it is in persons of relaxed or debilitated fibres that we find these exciting causes chiefly operative. For in those of high health, full vessels, and a firm constitution, however the circulation may be accelerated, or the nervous power excited, it is rarely that we meet with clonic spasms, or, indeed, spasms of any kind : or, at least, we meet with a far less tendency to such abnormities, than in persons of lax and debilitated fibres, possessing necessarily more mobility or facility of being put into new ac- tions, from the very quality of debility itself. The common predisponent, then, is weakness, particularly of the nervous system; and the common excitement, irritation. The peculiar effect must, however, be modified by the idio- syncrasy ox peculiarity of the constitution, or of collateral circumstances, by which it.may be influenced at the time. And hence the very exciting cause that in one individual may pro- duce hysteria, in another may produce epilepsy, and in a third the more fugitive and less impres- sive attack of syspasia, as convulsion.—(Pritch- atd, on Nervous Diseases, p. 139.) The nature of the idiosyncrasy, or, more par- ticularly, of the individual constitution, is rarely within our control; but the collateral circum- stances are often before us: they constitute the occasional cause of the disease, and should form a prominent point in our attention to its progress. There are, perhaps, few more common causes of weakness than over-distended vessels ; and hence plethora is a frequent occasional cause of each of the diseases belonging to the genus before us, the species actually produced depend- ing, as just observed, upon the influence of other circumstances. Thus, if such plethora take place in a young woman of eighteen or nine- teen, whose menstrual flux has been accident- ally suppressed or retarded, it is most probable, if an irregularity in the nervous system be hereby excited,, that such an irregularity will lead to a fit of hysterics rather than to one of convulsion or epilepsy, since we shall find, as we proceed, that this species of spasm is peculiarly con- nected with an irritable and especially an orgas- tic state of the genital organs. On the contrary, if the plethora produce chief- ly a distension of the vessels of the brain, epi- lepsy is more likely to be the result; in other words, that form of spasmodic action, in which the sensation and the intellect suffer more se- verely than in either of the others. While, if the plethora be general, we have reason to expect that the spasmodic effect will be general also, or, in other words, take the form of convulsion in which no single organ is tried more than an- other. Yet plethora, in a firm and vigorous frame, is seldom found to produce either of these affections, for the resistance of the coats of the bloodvessels is here sufficient to counterbalance the impetus of the sanguineous fluid, and, con- sequently, to prevent an over-distention. And hence, again we see in what manner debility becomes a remote or predisponent cause of the diseases under our consideration. Plethora, thus actingby over-distention, may be regarded as a mechanical stimulus, upon the removal of which, as upon the removal of other mechanical stimuli, the disease will cease. Veneseetion is the most direct means of such removal; but it labours under the inconvenience of being only a temporary remedy. It takes off the occasional cause ; but, by adding to the general debility, it gives strength to the predis- posing cause. The more direct mechanical stimulants are sharp-pointed ossifications formed in the mem- branes of the brain, or arising from the internal surface of the cranium ; splinters of a fractured cranium, or the introduction of some wounding instrument. The occasional causes resulting from mental emotions, we have already been called to notice more than once; as also to show that, while some of these appear to act by instantaneously exhausting the sensorial or- gan of its living principle, others operate by giving a check to the production of the senso- rial power. These modes of action are indeed opposite, but the result, which is a depletion of the nervous apparatus, is the same. And as, in weakly or relaxed habits, there is in every or- gan a greater mobility or facility of passing from one state of action to another than in the firm and robust, we see also why the former should be not only more subject to spasmodic actions from mental emotion, but to sudden changes of mental emotion, and consequently, to caprice and fickleness of temper. SPECIES I. SYSPASIA CONVULSIO. CONVULSION. MUSCULAR AGITATION VIOLENT ; TEETH GNASH- ING ; HANDS FORCIBLY CLINCHED : TRAN- SIENT. In defining convulsion, most of the nosolo- gists represent the faculties of the mind and the external senses as still sound and unaffected. Sauvages says, " superstite in paroxysmis ani- mae functionem exercitio." Vogel distinguishes it, "cum integritate sensuum." Dr. Cullen is more exact than either of these. His words are, " musculorum contractio clonica abnormis, citra soporem," " an irregular clonic contrac- tion of the muscles, bordering on but short of lethargy." The influence of the disease on the sensation and perception varies considerably in different cases,, but, so far as I have seen, the Gen. VII.—Spe. 1.] SYSPASIA CONVULSIO. 355 sensibility is always in some degree diminished, and I have hence ventured to introduce this fea- ture into the generic definition as a pathogno- monic symptom. There are also some other differences that occur in the character of the disease in its dif- ferent attacks, and which have been laid hold of as the groundwork of very numerous subdi- visions by many nosologists. For these differ- ences we cannot always account: but in gen- eral they will be found to depend upon the idi- osyncrasy, habit, or stage of life in which the disease makes its appearance, and to give rise to the following varieties :— a Erratica. The convulsion shifting ir- Migratory con- regularly from one part to vulsion. another. fi Universalis. The convulsion attacking ev- General convul- ery part simultaneously ; sion. occasionally protracted in its stay. y Recurrens. The convulsive paroxysm Recurrent con- returning after intervals vulsion. more or less regular. S Ejulans. The convulsion accompani- Shrieking con- ed with shrieks or yells, vulsion. but without pain. t Puerperalis. Occurring during pregnancy Puerperal con- or labour, usually with co- vulsion. ma, and stertorous breath- ins-. £ Infantilis. Occurring during infancy ; Infantile con- preceded by twitchings or vulsion. startings, and accompa- nied with a blueness about the eyes and upper lip. In the first or migratory variety, the con- vulsion travels, in some instances, so completely from organ to organ, and from one set of mus- cles to another, as to make an entire circle. In the second or universal variety, the convulsion is often accompanied with a peculiar kind of percussion or hammering of one limb against another, or against some other part of the body, resembling the malleation we have already had occasion to describe, and constitu- ting the malleatio of some authors. In the recurrent variety, the intervals are often very irregular; but the ordinary return, where any thing like a regular period is estab- lished, is menstrual or lunary. To this, as also to the preceding, many writers have applied the name of hieronosus or morbus sacer ; which by others, as we have above observed, has been limited to some modifications of chorea. In the fourth or shrieking variety, the muscles of respiration, and especially those of the larynx, appear to be chiefly affected; and the shrill sounds, or yelling to which it gives rise, proceed rather from an involuntary motion of these organs, than from any greater degree of pain that is suffered under this form than un- der any other. In puerperal convulsion, the irritation is supposed by Dr. Bland to derive no peculiar character from the state of the body at the time But it is impossible to shut our eyes Z2 to the close and active sympathy which exists between the sexual organs and the sensorium, and which is peculiarly striking in hysteria; nor to the distinctive symptoms which take place in convulsion from this cause ; in which there is a greater tendency to oppression in the head than in any other modification whatever; the breath- ing is stertorous, and the spastic action particu- larly violent. Convulsions of this kind occur during pregnancy, in the midst of labour, or im- mediately afterward: they rarely, however, take place before the sixth month. Yet, if the irritation were not of a particular kind, we might rather expect it on the first turgescence of the uterus. But we shall have occasion to recur to this subject under the ensuing class.* In infantile convulsion, the mobility of the frame is impressively conspicuous. The clonic motions are exquisitely rapid, and the fingers work and the eyelids nictitate with a quiver that is often difficult to follow up. This constitutes the ecclampsia of Sauvages. In the subsequent stage of teething, as the irritative fibre is somewhat firmer, the clonic vibration is rarely so rapid. Antecedently to the time of teething, the usual causes of excitement are retained meconium, flatulency, and acrimoni- ous food.t * With regard to the treatment of puerperal convulsions, it seems to be settled by the most experienced practitioners in midwifery, that, when the pulse is strong and full, and the frame robust, the copious abstraction of blood in a large stream is the most efficient means of shortening the at- tack. Active purgatives may be given, and if there be difficulty of swallowing, one or two drops of croton-oil may be smeared on the tongue. Dr. Locock also recommends a stimulating purgative injection to be thrown into the rectum, particu- larly one containing turpentine. For the coma- tose or chronic stage, he advises blisters to the head or back of the neck, and the bowels to be kept freely open, turpentine clysters being now of great service. In cases where the patient has been much reduced by previous illness, Dr. Lo- cock recommends bleeding, if employed at all, to be so only with great circumspection; and when admissible, he prefers local bleeding to general. He has a favourable opinion of opium and cam- phire in the latter class of cases, and prescribes it, in the dose of one or two grains with five of camphire, every hour or two, till the proper effect is produced. Dr. Locock approves of emetics only where the attack has ansen from a loaded stomach or indigestible food.—(See Cyclop, of Pract. Med., art. Convulsions.) Respecting the question of delivering females in all cases where the child or placenta still remains in the uterus, the reader should consult the best authorities on midwifery.—Ed. t Beaumes, Des Convulsions de l'Enfance, de leur Cause, et de leur Traitement, &c, 8vo., Par- is, 1805. In the majority of examples, the con- vulsions of young children are symptomatic of some other disease. According to Mr. North, who has written an able work on the convulsions of in- fants, an impending attack is indicated by various symptoms, independently of the existence of any particular disease, and all of which show an in- creased irritability of the system; such are, start- ing at very slight noises, a disturbed sleep, fre- quent fits of crying from trifling causes, and great 356 NEUROTICA. [Cl. IV.—Ord. IV The ordinary excitements of convulsion, how- ever, operate at all periods of life. Though often concealed, they are generally those of clonic spasm. They consist not unfrequently, as we have already observed, in pressure or other irri- tation, from a deformity or some spicular node within the cranium ; and are said by Desessarts (Journ. de Mid., xlvii., 114), to occur most fre- quently in those whose sculls are peculiarly large, or in the language of Morgagni (De Sed. et Caus. Morb., ep. ix., 9), nearly cubical in the occipital region. Pressure, however, or congestion in the brain, from whatever cause, is an occasional source of this complaint. And hence convulsion is a frequent result of severe fright, or any other violent agitation of the mind ; and, like several of the species we have just noticed, it is a fre- quent result of some suddenly-suppressed nat- ural or morbid discharge, or suddenly repelled complaint affecting a remote organ. It has hence appeared on suppressed menstruation, suppressed flow of milk, leucorrhcea, or lochia, suppressed dysentery (Hoefner, Baldinger N. Mag., b. vi., p. 323), the suppressed discharge from an old ulcer (Gruellmann, Diss. Observ. de usu cicuta, Goett., 1782 ; Ephem. Nat. Cur., dec. iii., ann. ii., obs. 74), repelled gout, ex- anthems, and cutaneous eruptions. The usual causes in pregnancy and infancy have been al- ready noticed. Convulsions are also frequently produced by many of the narcotic poisons in a certain degree of strength or activity, and a certain state of the constitution. For, if the dose be very large, or the system much debilitated at the time, the irri- tability will be entirely destroyed, and death will often ensue instantaneously, without any struggle whatever. Thus the distilled water of the leaves or kernels of the prunus lauro-cera- sus, under different circumstances, will produce both these effects; as will also the distilled water of the kernels of various other fruits pos- sessing prussic acid, as those of the black-cher- ry and bitter-almond-tree-; and hence the prus- sic acid itself. And we may hereby understand the remark of Sir Hercules Langrishe, that one peevishness : there is also a frequent fixing of the eyes, an oscillatory motion of the pupils, a mo- mentary contraction, and again a sudden dilatation of them, or a want of consent between them, so that one will contract while the other dilates. The countenance is alternately flushed and pale; sudden animation is followed by as sudden a fit of languor, and irregularity in the breathing. Hic- cough is not unfrequent, and, in many instances, a peculiar blueness about the mouth.—(See North on the Convulsions of Infants, 8vo., Lond., 1826; and Locock in Cyc of Pract. Med., art. Convul- sions.) It was inculcated by Dr. John Clarke, that " in every case of convulsion, the brain is at the time organically affected, either directly or in- directly."—-(See Commentaries on the Dis. of Children.} This doctrine is criticised by Mr. North, who points out the mistakes into which it has led practitioners. So far from admitting that the brain is organically affected in every case, he does not allow that its vessels are even congested, as a matter of course ; and he argues that, when they are so, it is often only a temporary condition, existing merely during the attack.—Ed. ounce of laurel water will occasion more violent and stronger convulsions than five or six ounces. The dose of this water, given by way of poison, to Sir Theodosius Boughton, was a draught- vial full, and consequently about an ounce and a half. The struggling-fit in this case began in a minute and a half, or two minutes after it was swallowed (Gurney's Trial of John Donellan, Esq., folio, pp. 18, 19); it continued for about ten miuutes, when he expired. The spasmodic action produced by these plants is chiefly clonic, which, in effect, is the ordinary action with which life ceases : but there are others that render it of a mixed character, the entastic alternating with the clonic ; and some, in which the rigid or entastic power con- siderably predominates, as in the poisonous juice of the upas tiente, which, though with occasion- al relaxations, fixes the muscles as rigidly as in tetanus, and continues the rigidity till the pa- tient dies. In ordinary cases, however, the mode of at- tack and the progress of the paroxysm exhibit a considerable variation. Sometimes the assault is sudden and without any warning ; but, more generally, there area few procursive Indications,. and especially in patients who are subject to re- turns of it; such as coldness in the extremities, with a dizziness in the head, and floating spectra before the eyes, or a flatulent uneasiness in the bowels, and a tenseness in the left hypochon- drium. In other cases, the patient complains of tremours in different muscles, and a cold aura creeping up the back, which makes him shiver. The struggle itself, I have already said, varies equally in its extent and violence, and I may add, in its duration. The muscles are alter- nately rigid and relaxed, the teeth gnash, and often bite the tongue, the mouth foams, the eye- lids open and shut in perpetual motion, or are stretched upon a full staTe, while the protuberant balls roll rapidly in every direction: the whole face is hideously distorted. The force exerted is enormous, so as frequently to shake the entire room, and overpower the strength of six or eight attendants. In some instances, it has been so violent as to break a tooth, and even fracture a bone.—(Epkem. Nat. Cur., dec. ii., ann. vii.} When the lungs are much oppressed in the course of the contest, the lips, cheeks, and in- deed the entire surface, is died with a dark or purple hue. The paroxysm will sometimes cease in a few minutes, but occasionally lasts for hours, and, after a short and uncertain period of rest, returns again with as much violence as before ; a fact peculiarly common to puerperal and infantile con- vulsions. Great languor commonly succeeds; sometimes headache, vertigo, and vomiting, oc- casionally delirium: but not unfrequently, and especially in infants, there are no secondary symptoms whatever. The treatment of convulsion must apply to the paroxysm itself, and to the state of the x;onsti- tution which gives a tendency to its recurrence. If it proceed from a narcotic or any other poison introduced into the stomach, much bene- fit may often be obtained from the stomach. • Gen. VH.-Spe. 1.] SYSPASIA pump. If the poison be in a liquid form, most of it may hereby be withdrawn, while the re- mainder, or the whole, if it be a powder, may be diluted and pumped up afterward. As there is danger from congestion in the brain, venesection is, in most cases, a good meas- ure of caution, and in many instances is abso- lutely necessary : and hence, where plethora has preceded, and has threatened to become a cause, the disease has often been prevented, and some- times effectually cured, by a spontaneous hem- orrhage from the nose, the ears, or some other organ. But we have often had occasion to ob- serve, that in weak and relaxed habits, bleeding, if frequently repeated, increases the tendency to plethora; and, on this account, how necessary soever at the time, it should be employed with caution, and persevered in with reluctance. Brisk cathartics, introduced into the stomach if possible, and where this cannot be accomplish- ed, in the form of an injection, lower the mor- bid distension almost as effectually, and in some instances directly remove from the system the principal fomes of the complaint. Emetics are of more doubtful effect: they also may occasion- ally carry off the actual cause of irritation, and by powerfully determining to the surface, make a favourable diversion of action. But, in many cases of debility, they have evidently increased the violence and prolonged the duration of the fit. In puerperal convulsions, they are strongly disapproved by Dr. Miguel.—-(Traite des Con- vulsions chez les Femmes Enceintes, &c, Paris, 1824.) The authorities, however, in their favour are numerous and highly respectable. Le Preux (Diss. An Convulsionibus recens natorum Vo- mitoria 1 Paris, 1765), strongly recommends them in early infancy : and Hoeffner asserts, that he has found them highly serviceable where the irritation proceeded from dysentery.—(Bal- ding. N. Mag., b. vi., 323.) Schenck employed them generally with considerable success, and preferred the preparations of copper, and partic- ularly the verdigris, to any other emetic, from their rapidity of action.—(Lib. i., obs. 244.) An- tispasmodics are certainly entitled to our atten- tion, and often succeed in allaying the irregular commotion. Those most commonly resorted to are ammonia, ether, musk, camphire, and vale- rian. The empyreumatic oils, both animal and vegetable, seem to have fallen as much below their proper value in the present day as they were once prized above it. And the same may be observed of the volatile fetids generally, as fuligo, assafoetida, and chenopodium Vulvaria, or stinking arach : the last of which, however, under the older name of atriplex fcetida, seems to have been a favourite with Dr. Cullen. It is not very easy to explain the operation of antispasmodics of this kind. Dr. Cullen refers it to their volatility alone, and hence concludes, that they are useful in proportion as they are volatile ; which is, in fact, to regard them in the light of stimulants. But, beyond this, they seem to possess a sedative power, which probably re- sides in their fetor. Where flatulency or some other misaffection of the stomach is the exciting pause, as is frequently the case in infancy, after 30NVULSIO. 357 opening the bowels, the warmer carminatives of anise, mint, ginger, and cardamoms will often be found sufficient; and where these fail, re- course has been had to opium, hyoscyamus, bel- ladonna, and sometimes St. Ignatius's bean, or M. Wedenberg's favourite medicine in this dis- ease, the extract of stramonium.—(Dissertatio Medica dc Slramonii Usu in Morbis Convulsivis, 4to., Upsaliae.) Cold and heat have also been very frequently resorted to as powerful antispasmodics, and in many cases with considerable success. Heat appears to act by a double power, and especially when combined with moisture, with which it is always most effectual. It both relaxes and stim- ulates ; and hence is admirably calculated to harmonize two alternating and contending states of a morbid rigidity and a morbid mobility, on which the disease depends, and consequently, to restore a healthy equipoise of action. On this account we find warm bathing, and especially in infantile convulsions, of great benefit. It ought not to be forgotten, however, that both effects, as well the stimulating as the relaxing, have a considerable tendency to exhaust and debilitate, and hence the warm bath must not be frequently repeated. The immediate effect of a sudden application of cold, whether by a blast of air or by an affu- sion of water, is a general shuddering, a spas- modic contraction of the entire skin. And hence, where cold, applied in this manner, takes off either clonic or entastic spasm, it is by a re- vulsive power; by a transfer of the spasmodic action from a particular organ or set of organs, to the surface of the body generally; in the same way as blistering the neighbourhood of an inflamed organ takes off the primary inflamma- tion, by a transfer of the inflammatory action to the part where the blister is applied. If the cold excite a general reaction, and the shudder- ing be succeeded by a glow, it becomes a direct and very powerful tonic ; and, in both these ac- counts, is a remedy highly worth trying in hys- terics, convulsions, and even those cases of epi- lepsy in which a suspicion of some structural cause of irritation within the cranium does not form a bar, by prohibiting every thing that may increase the impetus of the blood. In the convulsion fit of infancy the affusion of cold water, so far as I have seen, may be much oftener resorted to with perfect safety, than the fears of mothers will allow ; and be found much more successful in a hot, close, unventilated nursery, than the more popular prescription of a warm bath. And where I have not been able to proceed thus far, and the warm bath has been tried repeatedly in vain, I have frequently succeeded by taking the little infant in my arms, and exposing him naked, or nearly naked, for a few moments, to the air of the window, thrown open to allow it to blow upon him.* The great * Other means specified for the relief of infantile convulsions, are wet cloths, or bladders filled with snow or powdered ice, and cofistantly applied to the scalp; clysters of assafoetida, combined with castor-oil or neutral salts; and chafing the hands and feet with brandy or ether. Should the abdo- 358 NEUROTICA. [Cl. IV.—Ord, IV diminution of sensibility which prevails at such a time, prevents all danger of catching cold ; white, on the contrary, the little patient is usual- ly revived by the sudden rush of the external air, and the fit in many cases, ceases instantly. Cold bathing, when not prohibited by any other complaint, will also be found a useful tonic in the intervals of the attacks, and may conve- niently be employed in conjunction with internal medicines of the same character.—(Y. W. We- del, Liber de Morbis Infantum, cap. xiii.) Of these the metallic salts and oxydes are chiefly to be depended upon, and especially those of iron, copper, arsenic, silver, and zinc. Zinc has had by far the greatest number of advocates, and is generally supposed to have succeeded best in the form of its white oxyde, ten or twelve grains of which are usually given to an adult in the course of twenty-four hours. Mr. Dugaud in- creased the proportion to fifteen grains (Edin. Med. Comment., v., 89); and Mr. Bell, at length, prescribed not less than ten grains at a time, re- peated three times a day.—(Edin. Med. Com- ment., i., 120.) [Dr. Brachet joins the extract of henbane with the oxyde of zinc, giving to children four grains of the former and two of the latter, in divided doses, one of which is taken every three or four hours.] In the hands of the present author, zinc has proved more salutary in the form of its sulphate, which has not unfre- quently succeeded where the oxyde has failed ; the usual proportion which he has employed be- ing a grain three times a day, given in the emul- sion of bitter almonds. Where silver has been made choice of, the usual preparation has been its nitrate, and the dose has begun with a grain given four or five times a-day in the shape of a pill, and gradually increased to eight or ten grains, or as much as the patient's stomach will bear.* men be distended with air, a few drops of sal vola- tile may be given in peppermint water, and the belly rubbed freely with the hand, or with any gently stimulating liniment. A purgative of calo- mel and jalap, or scammony, may be given, if the child can swallow; or an emetic, if any improper article of food has been recently taken. Bleeding is not always right, as a matter of course, though proper when the vessels of the brain are in a ple- thoric state. The jugular vein may be opened, or leeches applied to the temples or behind the ears. Should the child be of an age when dentition is going on, the gums ought to be freely scarified. If the case were one of great irritability of the nervous system, without plethora, we should first endeavour to remove the exciting cause, and when the convulsions still continue, have recourse to an- tispasmodics, assafoetida mixture, ammonia, cam- phire, ether, and musk, and even opium, with cau- tion. When the bowels are very irritable, the pul- vis crets comp. cum opio, in doses of from one to ten grains, according to the child's age, and re- peated every hour or two, until relief is obtained, is an excellent medicine. In some cases, and those not always in very weak children, there is consti- tutionally an exceedingly irritable state of the ner- vous system, leading to convulsions resembling those of an epileptic nature. Here the carbonate of iron, in doses of five grains, mixed with honey, has sometimes proved beneficial.—See Locock in Cyclop, of Pract. Med., art. Convulsions.—Ed. * In particular cases, iron has the advantage of j The virtue of all these, however, seems con- siderably improved by a combination with cam- phire, which has often been found to be advan- tageous even alone. " In spasmodic or con- vulsive affections," says Dr. Cullen, " it has been of service, and even in epilepsy it has been use- ful. I have not, indeed, known an epilepsy en- tirely cured by camphire alone ; but I have had several instances of a paroxysm, which was ex- pected in the course of" a night, prevented by a dose of camphire exhibited at bedtime; and even this, when the camphire was given alone ; but it has been especially useful when given with a dose of cuprum ammoniatum, or the sul- phate or the flowers of zinc."— (Med. Transac- tions, vol. i., art. 19.) The vegetable tonics are little to be depended upon. The bark recommended by Dr. Home, Sumeire, and many other distinguished writers, is rarely of use, except where the paroxysm is periodical : and the cardamine pratensis (lady- smock), sempervivum tectorum (house-leek), and viscus quercus (mistletoe), are hardly worthy of notice in the present day, notwithstanding the specific virtues they were supposed to possess formerly. The cardamine, the aurifi6piov trepov of Dioscorides, is of ancient celebrity, and in modern times has been warmly extolled by the commanding authorities of Mr. Ray, Sir George Baker, and Dr. Home ; the second of whom, as was noticed under the head of chorea, declares himself to have succeeded in its use, not only in cases of convulsion, but of all clonic spasms whatever, and this too when almost every other medicine had failed.—(Auserl. Abhandl. fur Pract. Aerzte., b. x., 13.) The house-leek was employed in the form of an expressed juice intermixed with an equal quantity of spirit of wine, which gives a white coagulum, resembling cream of fine pomatum, that has a weak but penetrating taste, and was supposed, from its ready evaporation, to contain a considerable portion of volatile alkaline salt. The mistletoe has rarely been employed in our own country, except by Dr. Home, who thought he found it serviceable : though it is chiefly in- debted for its fame as a specific in convulsions, to the practice and writings of Colbatch.—(See also Diss, sur le Gui de Chine, Remede Spe- acting as an emmenagogue, and correcting that deficiency and irregularity in the functions of the uterus which are so often the sole cause of the disordered state of the health. Dr. Abercrombie gives a remarkable instance of this power of the sulphate of iron, which, in the dose of three grains thrice a day, combined with a sufficient quantity of aloes to regulate the bowels, effected the cure of a most anomalous convulsive disease, that had been treated ineffectually for six years on the plan of copious depletion and counter-irritation. This case would beconsidered by many, however, rather as one of chorea. In similar cases, Dr. Adair Crawford has prescribed with considerable advan- tage the carbonate of iron, combined with a mix- ture of carbonate of ammonia and tincture of aloes : he recommends it to be given to the extent of one or two drachms in the twenty-four hours, but not more freely, as then it remains accumulated and inert in the bowels,—Ep, Gen. VII.—Spe. 3.] SYSPASIS cifique pour les Maladies Convulsives, Paris, 1719.) It has been given in powder, infusion and extract. SPECIES II. SYSPASIA HYSTERIA. HYSTERICS. CONVULSIVE STRUGGLING, ALTERNATELY REMIT- TING AND exacerbating; rumbling in the BOWELS ; SENSE OF SUFFOCATION ; DROWSI- NESS ; URINE COPIOUS AND LIMPID ; TEMPER FICKLE. Hysteria, from laripa, " the uterus or vulva," or, more correctly, " viscus posterius vel info- rms," evidently imported in an early period of medical science, some misaffection of the womb or other sexual organ: and hence hysteria, among the Greeks and Romans, was also a term by which female midwives were denominated, or those who especially attended to affections of the hysteria or womb. The Latin term ute- rus, although it approaches it in sense and sound, is altogether of a different origin. For this has a direct reference to the use and figure of the uterus as a single organ, and is an immediate derivation from uter, a bag or bottle. With a morbid condition of this organ, indeed, hysteria is in many instances very closely con- nected, though it is going too far to say, that it is always dependant upon such condition: for we meet with instances occasionally, in which no possible connexion can be traced between the disease and the organ ; and sometimes witness it in males as decidedly as in females. It has been contended by various writers, that in this last case, the disease ought to be called hypo- chondrism, the hypochondrias of the present work ; and that hysteria and hypochondrias are merely modifications of a common complaint. Nothing, however, can be more erroneous. These two diseases have often a few similar symptoms, and more particularly those of dys- pepsy; but they are strictly distinct maladies, and are characterized by signs that are peculiarly their own. The convulsive struggling parox- ysms, the sense of a suffocating ball in the throat, the fickleness of temper, and the copious and limpid urine, which are pathognomonic of hyste- ria, have no necessary connexion with hypo- chondrias, and are never found in this disease when strictly simple and idiopathic. While, on the contrary, the sad and sullen countenance; the dejected spirits and gloomy ideas that char- acteristically mark hypochondrias, have as little necessary connexion with hysteria, and are in direct opposition to its ordinary course. Hyste- ria is strictly a corporeal disease, hypochondrias a mental, though it commonly originates in cor- poreal organs, but organs that have a peculiar influence upon the mental faculties, and has not established itself till these participate in the morbid action. Hysteria is a disease of the ir- ritative fibres, hypochondrias of the sentient; hysteria is a disease of early life, hypochondrias pf a later period. Both, however, are diseases of a highly nervous or excitable temperament, | HYSTERIA. 359 and, as such, may cdexist in the same individ- ual : but so also may vertigo or cephalaea with either of them ; which would nevertheless con- tinue to be regarded as distinct diseases, not- withstanding such an incidental conjunction. And hence Mieg (Epistola ad Hcdlerum scripta, No. v.) and various other established writers* upon the subject, have not incorrectly, though perhaps unnecesarily, treated of the disorder before us under the two divisions of male and female hysteria, hysteria virorum or masculina, and hysteria fceminina. Swediaur, who affirms that men may labour under the hysteric passion as well as women, arranges this and hypochon- drism as distinct species of a common genus, to which, with his extravagant fondness for long Greek terms, he has given the name of hyper- kinesia. Hysteria, like all other clonic affections, shows itself most frequently in mobile and irritable temperaments, and particularly during that period of life in which irritability is at its highest tide, as from the age of puberty to that of thirty-five years, seldom appearing before the former, and rarely after the latter of these terms.t The common occasional causes of convulsion, which we have already described, are also those of hysteria ; and hence, disorder of the stomach, or other abdominal organs, mental emotions,:): plethora, and particularly turgescence of the sex- ual region, are among the most frequent; on which account we are told by Forestus (Observ. et Curat. Medic, lib. xxviii., obs. 29, 33) and Zacu- tus Lusitanus (De Praxi Admiranda, lib. ii., obs. 85) that one of the most common causes of hysteria in mates is a retention of semen, as one of its surest cures is an excretion. As every thing, moreover, that disturbs the uniform transmission of the nervous energy, or the other ordinary diameter of the bloodvessels or cavity of the heart, becomes a powerful irri- tant, we may also see why this disease should occur on debilitating, and especially sudden evacuations, and be at no loss to account for its appearing on excessive as well as on suppressed menstruation, and consequently in leucorrhoea. And as the sexual organs lose much of then- orgasm during the period of parturition, we may * Eph. Nat. Cur., dec. ii., ann. iv., obs. 1861; Traite Nouveau de Medecine, &c, Lyons, 1684. t The menstrual period of life, or that between the ages of fifteen and forty-five, may be stated to be the time when this disorder is most disposed to show itself. If it appear at any other age, it is more frequently earlier than later; it is more com- mon to meet with hysterical girls who have not menstruated, than with old women who have done menstruating.—See EUiotson's Lect. at Lond. Univ., as reported in Med. Gaz. for 1832-3, p. 642. —Ed. X " Any woman may have hysteria, if she can have but emotion of mind strong enough." Anger or grief, especially grief for ungratified desire, or, to use a more elegant expression, "disappointed love," is the most common cause. It is during the period of menstruation that all the feelings of women are most active; it is then that they are most likely to fall in love, and to experience sor- rows of all sorts, whether real or imaginary.—See EUiotson's Lectures.—Ed. 360 NEUROTICA. [Cl. IV.—Ord. IV, also see why the disease should attack barren rather than breeding women, particularly young widows, who are cut off from the means of exhaustion they formerly enjoyed ; and, more especially still, those who are constitutionally inclined to that morbid salacity, which has often been called nymphomania, and in the present work, will be found under the genus lagnesis. I have already endeavoured to show by what means, in a habit of great nervous irritability, both clonic and entastic or rigid spasms are pro- duced, and the disposition there frequently exists for them to pass into each other, or to alternate in rapid succession. And we have also seen that the former is most predominant in laxer and more mobile, and the latter in firmer and more vigorous constitutions. There is no frame, how- ever, that may not become a prey to spasmodic action of some kind or other, and hence, there is no frame that may not become a prey, under par- ticular circumstances, to the species of spasmod- ic action we are now describing. These cir- cumstances are very generally concealed from us ; but we uniformly perceive, that the rule we have now adverted to holds true , and that the hysteric spasms will assume more or less of a clonic or of a spastic character, in proportion as the individual is of a more relaxed or of a more vigorous make. And hence the most violent, though the least common instances of hysteric struggle that occur to us, are in young women of the most robust and masculine con- stitution. The paroxysm often takes place without any previous warning or manifest excitement what- ever, and especially where it has established it- self by a frequency of recurrence. Occasional- ly, however, we have a few precursive signs, which rarely show themselves in vain: as a sense of nausea or sickness, flatulency, palpita- tion of the heart, depression of spirits, and sud- den bursts of tears without any assignable cause. The fit soon succeeds, with a coldness and shiv- ering over the whole body, a quick fluttering pulse, and an acute feeling of pain in the head, as though a nail were driven into it. The flat- ulency from the stomach or colon rises in the sensation of a suffocating ball into the throat, and forms what is known by the name of globus hystericus. The convulsive struggle now com- mences, which in women of very mobile fibres is sometimes very feeble, the relaxant alterna- tions prevailing over the contractile; but in other cases, is prodigiously violent, evincing du- ring the contractions a rigidity as firm as in te- tanus, and a force that overcomes all opposition. The trunk of the body is twisted backward and forward, the limbs are variously agitated, and the fists are closed so firmly that it is difficult, if not impossible, to open the fingers ; and the breast is violently and spasmodically beaten. An equal spasm takes place in the sphincter ani, so that it is often found impracticable to introduce a clyster pipe ; and the urine discharged, though copious, is colourless. The muscles of the chest and trachea are agitated in every way, and hence there is an involuntary utterance of shrieks, screams, laughing, and crying, according to the direction the spasm takes, sometimes accompa- nied with or succeeded by a most obstinate and distressing fit of hiccough. When the fit ceases, the patient appears to be quite spent, and lies stupid and apparently lifeless. Yet, in an hour or two, or often much less, she perfectly recov- ers her strength, and has no other feeling than that of a general soreness, and perhaps some degree of pain in the head. It is rarely indeed that an hysteric fit becomes dangerous ; though it has in a few instances terminated in epilepsy or insanity.* The temper is fickle, and the mind is as un- steady as the muscles : " and from hence," ob- serves the sagacious BHrton, who has painted strongly, but from the life, "proceed a brutish kind of dotage, troublesome sleep, terrible dreams, a foolish kind of bashfulness in some, perverse conceits and opinions, dejection of mind, much discontent, preposterous judgment. They are apt to loathe, dislike, disdain, to be weary of every object. Each thing almost is tedious to them. They pine away, void of counsel, apt to weep and tremble, timorous, fear- ful, sad, and out of all hopes of better fortunes. They take delight in doing nothing for the time, but love to be alone and solitary, though that does them more harm. And thus they are af- fected as long as this vapour lasteth ; but by- and-by they are as pleasant and merry as ever they were in their lives ; they sing, discourse, and laugh in any good company upon all occa- sions. And so by fits it takes them now and then, except the malady be inveterate, and then it is more frequent, vehement, and continuate. Many of them cannot tell how to express them- selves in words, how it holds them, what ails them. You cannot understand them, or well tell what to make of their sayings."—(Anat. of Melancholy, part i., sect, iii.) The mode of treatment bears so close a re- semblance to that of the preceding species, that it will be unnecessary to enlarge upon it.t Pun- gent applications may be applied to the nostrils, * In hysteria there are fits of general convul- sions and insensibility, as in epilepsy ; but not a continuance of the insensibility after the convul- sions are over. For the most part, the convul- sions are renewed in the midst of the insensibility. Sometimes, but not always, there is a regular col- lection of sobbing, crying, laughing, and shriek- ing in the midst of the convulsions. The insensi- bility is generally incomplete ; the patient has some knowledge of what is going on around, or, if she have not all the time, yet she has more or less of the time.—See EUiotson's Lectures delivered at the Lond. Univ. as reported in Med. Gaz. for 1832^3, p. 641.—Ed. t Hysteria, like the other species of clonus, is most common in the plethoric, or in persons of a nervous character. Next to derangement in the uterine system, or in the uterus, one of its most frequent causes is a torpid state of the alimentary canal. Hence bloodletting, and active cathartics continued for some time, are among the most effi- cacious remedies. Croton-oil and spirits of tur- pentine have recently gained some reputation, and when a tonic plan is thought expedient, the sul- phate of iron has proved efficacious where the carbonate has failed—D, Gen. VII.—Spe. 2.] SYSPASIA HYSTERIA. 361 ot round the temples, or the face and neck may be sprinkled or dashed with cold water during the paroxysm,* and warmth and the friction of the hand be applied to the feet. The peristaltic action of the bowels should be increased, which can only be done by stimulant and cathartic in- jections, if the contraction of the sphincter ani will allow them to pass. Our chief attention, however, should be di- rected to the intervals. And here the first rec- ommendation is, sedulously to avoid every re- mote or exciting cause. If the menstruation be in a morbid state, this must be corrected as soon as may be, concerning which, however, we shall have to speak in the ensuing class. If plethora be a striking symptom, the lancet should be em- ployed. In robust and vigorous habits, we may bleed freely and have nothing to fear ;+ but in loose and relaxed constitutions, far more caution is necessary, as has been already explained under CONVULSIO. In this last state of body, tonics should also be had recourse to, and many of the warmer sedatives and antispasmodics, as assafoetida, camphire, most of the verticillate plants, and cajeput, which was a favourite remedy with Mieg.—(Epist. ad Haller., ut supra, No. 5.) Valerian has often proved serviceable, but is rarely prescribed in sufficient quantity to pro- duce any good effect."—" It seems," says Dr. Cullen, " to be most useful when given in sub- stance and in larger doses. I have never found much benefit from the infusion in water."— (Mat. Med., part ii., ch. viii.) The ammonia- ted tincture of the London College, however, is an excellent form ; but even here the quantity of the root employed should be double what is prescribed. The cinchona may be usefully uni- ted with valerian, but does not seem to be of much benefit in this disease by itself. X Opium is a doubtful remedy: where the pro- cursive signs are clear, it will often allay the ir- ritation, and thus prove of great value. But it so frequently produces headache, and adds to the constipation, that it is rarely trusted to in the present day. When resorted to, it is best com- bined with camphire.* Where the disease occurs in the bloom of life, and there is reason to apprehend the ordinary orgasm of this age to be in excess, the surest remedy is a happy marriage, t it in doses of from seven to ten drops twice a day. He adds, that he has generally found these forms of medicine less objected to by patients than the mistura ferri composita, although the compound iron pill is taken without complaint, and, in doses of eight or ten grains twice a day, is a valuable tonic. The vinum ferri, or the mistura ferri, with the decoct, aloes comp., is mentioned as a useful combination, when it is desired to promote the ac- tivity of the bowels, or the periodical functions of the uterus.—See Cyclop, of Pract. Med., art. Hys- teria.—Ed. * Sydenham has given a description of a cough dependant on hysteria. In its treatment, he chiefly depended upon opium; but, in a case recorded by Dr. Sinclair, powerful cathartics effected a cure, after the failure of bleeding, opium, antispasmod- ics, and various other means.—Edin. Med. Joum., No. Ixxxii. p. 38.—Ed. t M. Pinel, on instituting an examination of the patients detained in the Salp^triere as epileptic, found a great number of women, several of them young women, who were only hysterical, and yet who were separated from their families and from society.—(Traite des Maladies Nerveuses, torn. i., p. 117.) In referring to this circumstance, Dr. Conolly introduces the following just observations: —" To pronounce a young female patient epilep- tic, is often in its consequences only second to pronouncing her insane : the disease is considered to be incurable, to have a tendency to destroy the understanding, and to be transmissible to offspring; none of which terrible evils are associated with the name of hysteria. The attack of hysteria is commonly less sudden and less violent than an at- tack of epilepsy. Epilepsy is often ushered in by a loud cry; the patient falls violently to the ground ; the muscles of the face are severely con- vulsed ; the eyes are distorted ; the tongue is pro- truded and bitten, and frothy saliva forced out of the mouth. In hysteria there is seldom any incip- ient cry, although the patient may cry or laugh during the paroxysm ; the patient, except in the comatose variety, does not fall suddenly, but feel- ing the approach of the fit, is usually attacked after sitting or lying down; the muscles of the face and the eyes are usually tranquil, and the face is generally flushed; whereas in epilepsy it often has a ghastly paleness. The hysteric pa- tient does not obtrude or bite the tongue, nor is there a discharge of frothy saliva. The epileptic patient does not laugh or shed tears, but is in a state of fixed and intense agony; neither is globus a sensation known to him. During the paroxysm of hysteria, the pupils of the eyes are commonly sensible to light, which is not the case in epilepsy. After the paroxysm, the hysteric patient often re- members all that has passed, which the epileptic patient does not. It may be added, that epilepsy is most common in men, in whom hysteria is rare; and that the character, habit of body, and history of the cases will frequently afford instructive cir- cumstances of difference."—See Cyclop, of Pract. Med., art. Hysteria.—Ep. * The water should be thrown with considera- ble force, and in plentiful quantities. Dr; Elliot- son mentions, that filling the mouth with salt gen- erally succeeds in stopping the fit. If the patient is able at intervals to swallow, we may give her from half a drachm to a drachm of the spiritus am- moniac aromaticus, or of the spiritus aetheris aro- maticus, or foetidus, or of the spiritus aether, sulph. comp., or nitrici, blended with water.—Ed. t When, in such patients, there is pain in the head, that part should be cupped, and active pur- gatives prescribed. Hysteria seems frequently to be combined with habitual constipation.—Ed. X When a tonic plan is judged advisable, Dr. Elliotson considers iron, with cold affusion and cold bathing, the best means of relief. For the ex- treme languor the patient feels, and the sense of sinking experienced in the epigastrium, he prefers the ferrum ammoniatum. When the disorder is attended with trismus, he recommends two or three ounces of oil of turpentine to be thrown up the rectum ; there is usually difficulty in getting a patient in this state to swaUow turpentine, and hence the injection is best. As chalybeate tonics, Dr. Conolly prefers to the carbonate half a grain or a grain of the sulphate of iron in a draught with e few drops of diluted sulphuric acid. If more of the sulphute is deemed necessary, he gives it in a pill with the extractum anthemidis, vel gentians, night and morning. If the tinctura ferri muriatis can be taken without inconvenience, he prescribes 362 SPECIES III. SYSPASIA EPILEPSIA. EPILEPSY. FALLING-SICKNESS. SPASMODIC AGITATION AND DISTORTION, CHIEF- LY OF THE MUSCLES OF THE FACE, WITHOUT SENSATION OR CONSCIOUSNESS ; RECURRING AT PERIODS MORE OR LESS REGULAR.* The Greek physicians gave the name of epi- lepsy, from ciri\au6dvouat, to the present dis- ease, from its " sudden seizure or invasion," which is its direct import: and as the violence of passion or mental emotion to which the Ro- man people were accustomed to be worked up in their comitia, or popular assemblies, from the harangues of their demagogues, was one of the most common exciting causes, it was among the latter denominated morbus comitialis, in the popular language' of our own day, " elec- tioneering disease," in reference to the time and occasion in which it most frequently oc- curred ; or, according to Seneca, because, when- ever the disease appeared', the comitia were in- stantly broken up.—(De Ira, iii., 7.) There are many other names also by which epilepsy was distinguished in former times ; but it is unnecessary to recount them. The general pathology of the two preceding species, and which has been given at some length under the genus clonus, will apply to the present: but it is obvious from the symp- toms, that the muscular power, commonly speak- ing, though not always, is affected to a less ex- tent, and the sentient and intellectual to a much greater, and consequently that the irritative fibres suffer in a smaller degree than the sensific and percipient. Before we enter upon the history of the dis- ease, it will be convenient to remark, that from the different modifications under which it shows itself, it has been subdivided by many nosolo- gists into very numerous varieties, but that the whole may be reduced to the following:— a Cerebralis. Attacking abruptly, without Cerebral epilepsy, any evident excitement, except in a few instances a slight giddiness. In this case, the predisposing cause is external violence or some internal injury, misformation, or disease of the head. 8 Comitata. Catenating with some mor- Catenating epi- bid action of a remote lepsy. part, with the sense of a cold vapour ascending from it to the head, or * " In epilepsy there are fits of a sudden loss of sense, with convulsions of the voluntary mus- cles ; and the loss of sense continues after the convulsions have ceased, so that the person is said to go to sleep after the fit. The fact is, the con- vulsions cease before the loss of sense terminates." —(Elliotson.) GeneraUy, says Dr. Armstrong, epi- lepsy may be defined to be clonic convulsions, fol- lowed by stupor, which after a time return.—See Lectures on the Morbid Anatomy, Nature, and Treatment of Acute and Chronic Diseases, p. 750, 8vo., Lond., 1834.—Ed. )TICA. [Cl. IV.-Ord. IV. some other procursive sign. y Complicata. The limbs fixed and rigid, Complicate epi- with clonic agitation of lepsy. particular organs. The causes of epilepsy, like those of the two preceding species, may be mental or corporeal: but to produce this, rather than either of the others, there must be a peculiar diathesis, which seems to depend upon the state of the nervous system. Where this exists, almost any of the passions or mental emotions, when violent, have been found sufficient to occasion a paroxysm, as anger, grief, fright, consternation ; of all which the records of medicine afford abundant exam- ples. In a like diathesis, any kind of corporeal irritability will often become an exciting cause, whether more or less remote from the head itself; and particularly where it is productive of a preternatural flow of blood into the vessels of the brain. Thus, an irritability in the ear from an inflammation, abscess, or some insect or other foreign substance that has accidentally entered into it, or the sudden suppression of a discharge to which it has been subject, has in various instances produced epilepsy. Hildanus (Cent, i., obs. 4) mentions a case, in which it followed a considerable degree of irritation, ex- cited in the same organ by the accidental intro- duction of a small piece of glass. In like man- ner, an irritable state of the stomach, or intes- tines, or the liver, from chronic inflammation, debility, worms, or the presence of substances that do not naturally belong to it, has proved a frequent origin. Bartholine gives an instance, in which it supervened upon swallowing pieces of glass (Hist. Anat., cent, v., hist. 66), and Widenfield another upon swallowing a needle.— (Diss. Obs. Med. Triga, Goett., 1768.) Con- firmed drunkards are peculiarly subject to this complaint. Particular affections of the uterus are, in like manner, an occasional source of epilepsy as well as of hysteria: and sometimes the latter has run into the former, where the epileptic diathe- sis has predominated. What this diathesis con- sists in, it is difficult to determine, for it gives no external signs: and hence Dr. Pritchard seems to doubt its existence (On Nervous Dis- eases, p. 95, 1822): but it is otherwise no easy matter to determine why a like irritation in the uterus should in one woman produce hysteria or convulsions, and in another epilepsy ; examples of which last occur very numerously in all the medical collections of cases.* Menostation, or a suppression or retention of the menstrual flux, is perhaps the most common of this class of causes; and we may hence see why it should occasionally be excited by a suppression of the lochial discharge. A sudden suppression, in- deed, of discharges of almost every kind, natu- ral or moibid, of long continuance in an irrita- ble habit, has occasionally proved a sufficient source of excitement. * Moranus, Apologia de Epilepsia Hysterica, Orthes., 1626, 4to. Schulze, Diss. Casus Hyste- rico-epileptici Resilutio, Hal., 1736. Eickmeyer, Diss, de Epilepsia Uterina, Ultraj., 1638. NEUR< Gkn.VII.—Spb. 3.] SYSPASIA EPILEPSIA. 363 Hence, also, repelled gout has been a cause, and still more generally repelled eruptions and exanthems, as itch, various species of ecpyesis, smallpox, and in one instance miliaria.* Some- times it has occurred with the regular flow of the menses, and been re-excited by every peri- odical return ; for where the peculiar diathesis exists, the slightest stimulus is often sufficient to call forth the disease. In the case before us, however, the periodical discharge is usually ac- companied with pain in the loins, or other local distress, as has been justly observed by Profes- sor Osiander.t Yet the most frequent cause of epilepsy is seated in the head itself; and has been found, on post-obit examinations, to consist in some morbid structure or secretion in the bones, tunics, or substance of this organ, as tubercles, exostoses, caries, apostemes, natural miscon- struction of the whole or of particular parts, injuries from external violence,! loose calcare- ous earth, hydatids, pus, ichor, and other dis- eased fluids.*} Of these, some are predisponent, others occasional causes ; the former of which will often continue inactive for a long period of time, and, as we have already observed, apper- tain chiefly to the first or cerebral variety. It has been observed, also, that in this modifica- tion the disease often makes its attack suddenly, and without any manifest exciting cause. Yet there can be little doubt that, in every instance, some occasional cause does exist, though, from its acting upon a morbid part of an organ that lies beyond our research, it entirely eludes all no- * BaraiUon, Hist, de l'Acad. Royale de Med., an. 1776, p. 220. Inflammation of the membranes of the brain; certain poisons, as those of lead and the vegetable narcotics; acute hydrocephalus; the stage of smallpox in which the eruption is coming out; and profuse hemorrhage; may all prove so many exciting causes of epilepsy.—Ed. t Uber die Entwicklungs-krankheiten in den Bliithen jahren des weiblichen Geschlechts, theil. i., 58, Gotting., 1817. X Several cases of epilepsy, caused by injury of the head, and relieved by trepanning, are de- tailed by Professor Dudley in the Transylvania Journal of Medicine.—D. § Epilepsy is frequently attended with a curious form of the head; it is very often united with de- ficiency of intellect, with a deficiency of brain, and of course fatuity, or idiocy. Many epileptic pa- tients have a narrow forehead, a low forehead, sloping back. Many persons are idiots, not from there being a deficiency of brain, but the brain is of bad quahty. However, there is one kind of idiocy which depends entirely upon a deficiency of the anterior part of the brain. Where such is the case, it is common for epilepsy to be united with it. It is very common to find a sugar-loaf form of head in epileptic patients. Epilepsy is sometimes united with a large head. A man with hydrocephalus, who had ten pints of water in his head, was epileptic. Sometimes the magnitude of the head arises from a pretematurally thick bone. Epilepsy may also occur in a person that has a most beautifully formed head, simply from some accidental disease in the head.—(See Pro- fessor EUiotson's Lectures, as delivered at the London University, Med. Gaz. for 1832-3, p. 582.) Very often, he adds, you will find the predisposi- tion inexplicable.—(P. 609,)—Ed. tice The organ chiefly affected, as appears from the numerous and delicate dissections of M. Wenzel, is the cerebellum. He tells us, indeed, that he never opened the body of a sin- gle epileptic patient, in which he did not find the cerebellum diseased in some way or other. But then Dr. Prout, who examined the bodies of numerous epileptics in the hospitals of Pans, tells us the same respecting the existence of worms in the intestines (Medecine iclairie par l" Observation et I'Ouverture du Corps, Paris, 1804); while " it is proper to remark," observes Dr. Cook, in his essay on Epilepsy, " that in some instances after this disorder, no marks of disease whatever could be found within the cra- nium, the thorax, the abdomen, or any other part of the body."—(On Nervous Diseases, vol. ii., part 41.) So that, however curious in them- selves, it is only in a few cases such morbid ap- pearances can be turned to any account; while some of them may occasionally, perhaps, be effects of the disease rather than its causes. Dr. Lbbenstein-Lobel, however, thinks that there ought always to be found some marks of dis- ease or other within the cranium ; and there is something humorous in his mode of accounting for their absence. "This is owing," says he, " to an injudicious treatment on the part of the practitioner, or neglect of the patient, by means of which the disease, instead of confining ijself to a particular organ, is thrown over the ner- vous system at large."—(Weser und Heilung der Epilepsie, &e, 8vo., Leipsig, 1818. )t The paroxysm in most cases occurs suddenly, and the patient is, so to speak, cut down at once, and loses all sense of perception and power of motion ; so that if he be standing he falls to the ground with a greater or less degree of convul- sion. X There are a few rare instances of some degree of consciousness and perception through- out the paroxysm (Bresl. Sammlung, 1724, band i., p. 436); but the exceptions-are few, * Obs. sur le Cervelet, et sur les diverses Par- ties du Cerveau dans les Epileptiques, &c, Mentz. Dr. Elliotson, however, has opened persons who died of epUepsy, and nothing wrong was noticed in the cerebellum, or anywhere else.—(See his Lectures as delivered at London University.) In Dr. Carter's account of a lunatic hospital in France, it is stated that one of the physicians of the institution, in thirty dissections of epileptic subjects, found no disease of the brain, but of the medulla spinalis; which observations would agree with the view taken of this disease by Dr. Reid —Ed. t Dr. Otto (N. A. Med. and Surg. Journal) takes the same view of the subject, and prescribes ac- cordingly.—D. X The scream with which epilepsy usually commences, is described as one of the most startling sounds that can be uttered. " A young lady, while in the drawing-room of an eminent physician, waiting the assembling of a consulta- tion summoned to consider her case, was sudden- ly attacked with epilepsy. She uttered a scream so piercing, that a parrot, himself no mean per- former in discords, dropped from his perch, seem- ingly frightened to death by the appalling sound " —Dr. Cheyne in Cyclop, of Pract. Med., art, Epi. lepsy.—Ed. 364 NEUROTICA. [Cl. IV-Ord. IV. and by no means enough to disturb the general rule. Commonly, the limbs on one side are more agitated than those on the other. The muscles of the face and eyes are always much affected, and throw the countenance into various and violent distortions. The tongue is thrust out of the mouth, which discharges a frothy saliva; the lower jaw is strongly convulsed ; the teeth gnash violently upon each other; and as this occurs while the tongue is protruded, it is often most grievously wounded.** During the continuance of the fit, there is generally an alternate remission and exacerba- tion of the symptoms ; though the whole does not usually last long, and is often of shorter du- ration than hysteria. On the cessation of the paroxysm, the patient remains for some time motionless, quite insensible, and apparently in a profound sleep or lethargy. He recovers from this attack sometimes suddenly, but more gen- erally by degrees, and without any recollection of the sufferings he has undergone.! * Dr. Cheyne states, that the patient is often found labouring under a general spasm, more es- pecially of the extensor muscles. In a girl unrter this physician's care, the muscular contractions were so violent, that her arm was observed to be dislocated after every fit.—(Cyclop, of Pract. Med., art. Epilepsy.) Burserius describes a similar case, and another in which the lower jaw was found dislocated after each attack.—Ed. t Portal, Memoires sur la Nature et le Traite- ment des plusieurs Maladies, torn, ii., p. 229. Sometimes the urine and feces are discharged in- voluntarily ; and occasionally there is a discharge of the semen. The hands are generally clinched, and the heart palpitates strongly. The pulse is quick, and respiration short, deep, and irregular. " "When the patient wakes from the state of sopor, he has generally no recollection of what has passed, and perhaps, therefore, there is no suffer- ing. The want of" recoUection of suffering is no proof that there has been no suffering; for we have all suffered enough in cutting our teeth, and we know nothing of it now, and so it may happen respecting more recent events: the fit may be at- tended with more or less suffering, and yet the individual not be aware of it afterward; but," says Dr. Elliotson, " I should think there is no suffering, and for this reason, persons do not suffer in general when they are hung. There is an account in Lord Bacon's works of a person who was hung, and all but killed, and yet he did not suffer. There is a short account of Cowley the poet (which is very scarce), from which it appears that he three times attempted to commit suicide, and one of these attempts was by sus- pension. The account was written by himself, and found among his manuscripts. He there mentions, that he suspended himself over his chamber door in the Temple, and became perfect- ly insensible. He only recollected a flash of light appearing before his eyes. His weight at last caused him to drop on the floor; there he was found, and after a time he recovered. He says, that although he was thus in the jaws of death, and had "become perfectly insensible, yet he had no previous suffering; and therefore, as there was no previous suffering in that state, it is prob- able that there is no suffering in epUepsy. I should suppose that in drowning there is no suf- fering, if it occur at once. Shakspeare's expres- sion is, ' Oh, Lord! methought what pain it was [In one example, recorded by Dr. Burnet (Med. Chir. Trans., vol. xiii.), there was con- siderable dyspnoea, and a remarkable slowness of the pulse, which at times did not exceed fourteen strokes a minute.] Under the first or cerebral variety, or where there is little or no appearance of an oc- casional cause, and the predisponent cause is supposed to exist in the head, the comatose symptoms, and, indeed, the general mischief to the external as well as to the internal senses, are most striking. Yet the effect is even here very different in different individuals. The op- tic nerve affords severe proofs of this. Some- times surrounding objects appear brighter or larger than natural, or both.—(Bartholin, Hist. Anat., cent, iii., hist. 45; N. Samml. Med. Wahrnem., b. iv., p. 229.) Yet, in many cases, the irritability of the nerve or its adjoining muscles has been destroyed, and a paresis, more or less general, has been the result. Hence a perpetual nictitation, strabismus, or blindness, is no unfrequent consequence. Yet, in one instance, a most fortunate and directly opposite effect was produced, for an habitual blindness was removed.—(Ephem. Nat. Cur., cent, i., ii., obs. 130.) Where the muscles of speech have suffered in an equal degree, speechlessness has in like manner followed (Hagendorn, cent, i., obs. 14; Act. Nat. Cur., vol. i., obs. 71); and for the same reason, where the joints have been violently affected with a predominance of rigid over clonic action, they have sunk into an insu- perable contraction.—(Horstius, ii., p. 90.) It is hence not to be wondered at, that the whole system should occasionally be nearly exhausted of its entire stock of sensorial power, and that the paroxysm, as observed by Aretaeus, should terminate in mania, idiocy, or even death itself; sometimes instantaneously, and at other times through the medium of a fit of apoplexy.* to drown;' but there is no reason to suppose there is pain, if the individual go down and do not come up again; but if he come out of the water, the suffering is dreadful."—See ElUotson's Lectures, as delivered at the Lond. Univ.—Ed. * Aretaeus, de Caus. et Sign. Morb., cent, i., 4. The following observations by Dr. Cheyne are re- plete with practical instruction:—" In our endeav- our to determine the species to which a Case of epilepsy belongs, we may proceed as follows :— first, we may inquire into the state of the natural functions, the state of the appetite, digestion, and nutrition, and into the condition of the secretions and excretions; then into the state of the nervous system; and lastly, if the patient is a female, into the functions of the uterus, especially with respect to menstruation. If we are unable to de- tect any affection of the nerves, any local irrita- tion, or disorder of a remote part of the brain, we may with probability consider the case as a speci- men of the epilepsia cerebralis. In this conclu- sion we may repose with more confidence, if we discover that the disease is inherited; that the patient has been liable to vascular congestion in the brain from determination of blood to the" head, increased action in the arterial system within the cranium, &c, flushing in the face, throbbing in the temples, epistaxis, vertigo, dulness or weak- ness of intellect, tightness across the forehead, headache, false perceptions; that there is any Gen. VII—Spe. 3.] SYSPASIA EPILEPSIA. 365 The warning or procursive symptoms by which epilepsy is sometimes ushered, have been most common to the second or catenating variety. The most usual sensation is that of the ascent of a cold creeping vapour from some particular part of the body, of the nature and cause of which we know nothing, but which has often been called an aura epileptica. This hali- tus usually ascends from the extremities, but there is no organ from which it has not issued in different individuals, according to examples accumulated by the collectors of medical curiosi- ties ; as the feet, the hands, the fingers, the thumb, the great toe, the legs, the arms, the hypochondria, the crown of the head. And, in various instances, spots on the face or feet have preceded, and at other times accompanied the paroxysm. We sometimes meet, however, with other harbingers, of quite as singular a character, in the other varieties ; as a heaviness of the eyes, pain, heat, and sparkling, which, by Sir Clifton Wintringham, were regarded as signs that pe- culiarly distinguish the idiopathic from the symptomatic disease.—(Ricardi Mead Monila et Pracepta,permultis notationibus et observation- ibus Ulustraia, torn, i., 8vo.) Sometimes there has been a wild play of phantasms or illusive objects before the sight :* and Portius relates the case of a woman, who was always warned of an approaching fit by the appearance, as it were, of her own image in a mirror.—(Medica Considerationes Varia.) On many occasions, indeed, as Paulini has rightly observed, there is a peculiar overflow of spirits, and a tendency to merriment, as though the mind were entirely thrown off its balance.—(Cent, ii., obs. 13; Brest. Samml., 1724, band, ii., p. 434.) Some- times the patient exhibits sudden starts of run- thing peculiar in the fonn of the head or expres- sion of the countenance; and that the habits of the patient have been such as to produce consid- erable or long-continued excitement of the brain. Paroxysms of epilepsy, which occur late in life in persons who have had apoplexy, or whose dia- thesis is apoplectic, rank under the epilepsia cere- bralis; as also do those cases of not unfrequent occurrence, hi which epilepsy almost invariably leads to an attack of insanity."—See Cyclop, of Pract. Med. art. Epilepsy.—Ed. * Bartholin, Hist. Anat., cent, i., hist. 81, cent. ii., hist. 72. Hagendorn, cent, iii., obs. 12. Also Armstrong's Lectures on the Morbid Anatomy, Na- ture, and Treatment of Acute and Chronic Diseas- es, p. 747, 8vo., Lond., 1834. This latter physician knew a patient who married, and then became re- markably dissipated, and used to go to bed intoxica- ted every night. As he was sitting one day after din- ner, he suddenly started from the table in great alarm, and asked his friends if they did not see any writing on the wall. In a few hours he had his first attack of epilepsy, of which disease he ultimately died. Dr. Gregory, of Edinburgh, used to mention the case of an officer, who, before a fit occurred, always saw an old woman in a blue coat, who approached him, and with a stick which she held in her hand, knocked him down. Such spectral iUusions denote the cerebral variety of the disease. Dr. Armstrong knew a lady who always squinted a day or two before the attack.—Op. cit. —Ed. ning (Boot. De Affectionibus Omissis, cap. vi.; Schenck, obs. i., lib. ii., p. 202) or dancing (Chesneau, lib. i., cap. iv., obs. 4; Eph. Nat. Cur., passim); occasionaUy he is strangely talkative (Eph. Nat. Cur., dec. ii., ann. 6, obs. 229); and, in one instance, exhibited a new and peculiar talent for singing.—(Act. Nat. Cur., vol. v.) Vic-D'Azyr relates the case of a wo- man who had been subject to epileptic fits for twelve years, and which at length became as frequent as four or five times a day. They al- ways commenced with a peculiar sensation in one leg, near the lower part of the gastrocne- mius muscle. A surgeon present on one of these accessions, plunged a scalpel into the part affected, which came in contact with a hard body, that he soon cut out, and found to be a dense cartilaginous ganglion, of the size of a very large pea, that pressed upon the nerve which he divided. The woman had no return of epdepsy.* We have already noticed a simi- lar cause of irritation and mode of cure in a case of neuralgia faciei; and it is highly probable, that under a slight variation of the nervous ere- thism in either instance, the one disease would have been substituted for the other. Under the third or complicated variety, while many of the limbs are rigidly fixed, almost without relaxation, the muscles of other parts are thrown into the most grotesque and ludicrous gesticulations of chorea; and, if the muscles of the chest be affected in this way, the patient appears in some cases to burst into involuntary fits of laughter from their irregular and clonic action.—(Eph. Nat. Cur., dec i., ann. iii., obs. 304.) At the same time, such has been the force of the spastic muscles, as to break one or more teeth, to rupture an artery, or render a vein varicose; and in one case, at least, to burst the left ventricle of the heart itself.— (Johnston, Med. Remarks, &c, vol. ii.) It has been observed, that the epileptic parox- ysm occurs chiefly at irregular periods, and is for the most part of short duration. There are, however, some instances on record of a singu- lar exception to this rule in both cases: for it has occasionally lasted for two or three days, with little or no remission. It has also returned at stated times, and with great frequency ; with the revolution of the morning, or even of the night; in one instance six times in a single day (Tulpius, Kb. i., cap. xi.); and iii another, on the revolution of the birthday of each of the pa- tient's parents (Eph. Nat. Cur., dec. iii., ann. iv., app. 193) : and hence it may occasionally have obeyed lunations, and appeared to be in- * Diet, des Sciences Medicates, art'. Cas Rares. In the Edinburgh Med. Essays, there is likewise an instance of the disease being produced by a small hard body in a nerve, at the lower part of the gastrocnemius muscle. The disease had ex- isted twelve years; but, on this body being re- moved, it entirely ceased. Dr. Curry, of Guy's Hospital, has mentioned an instance, in which the aura epileptica rose from the extremities; yet, af- ter death, a little tumour was found in the head. The case was referred to by Dr. EUiotson, in his Clinical Lectures at St. Thomas's Hospital, in Dec, 1830— En, 366 NEUROTICA. [Cl. IV.—Ord. IV. fluenced by the phases of the moon (Forest., lib. x., obs. 60), while running a regular course from some other cause. In a highly nervous temperament it is not difficult to account for such returns; since the dread of its return alone, when it has once established a circle of action, will form a sufficient source of irritation. In a few instances, it seems to have been heredi- tary,* and perhaps in an equal number congeni- tal, appearing soon after birth, and-mostly pro- duced by a fright of the mother during pregnan- cy. Hildanus gives an example, in which a fright of this kind was occasioned by the pres- ence of an epileptic patient when suddenly at- tacked with a paroxysm (Cent, iii., obs. 8.): and other medical records contain instances of a like effect on the sudden rush of a hare, or some other animal against a pregnant woman. Many persons, habitually disposed to epilepsy, are attacked immediately on waking in the morning from a sound sleep, when we may be inclined to think they would be least liable to such a surprise. Dr. Cullen finds a difficulty in explaining this curious fact. But when we re- flect that epilepsy is a disease of irregular ac- tion, chiefly in a debilitated system, depending, where there is a confirmed diathesis, upon what- ever may disturb the balance of perhaps any of the circulating fluids—and that this balance may be disturbed either by too much as well as too little excitement;—when we reflect, moreover, that during sound sleep there is always taking place a considerable accumulation of sensorial power, and may at times be an excess of it—we shall no longer, I think, be at a loss to account for an adequate cause of this very singular phe- nomenon, t The general mode of treatment proposed for the last two diseases, will apply to the present. The twofold intention is to remove, as far as we * Frid. Hoffm. Diss, de Affectibus haereditariis eorumque Origine, Hal., 1699. App. Suppl., ii., 1., E. 523. Abhandlung fiber die erblichen Krank- eiten, &c, von J. Clund. Rongemont, Frankf., 1794, 8vo. In speaking of a certain hereditary predisposition to epilepsy, Dr. Elliotson observes, " you will find this shown, perhaps, not by broth- ers and sisters, fathers and mothers, grandfathers and grandmothers having had the disease, but by their having had other affections of the nervous system. The same state of the nervous system will frequently not produce the same disease; one shall have epilepsy, and another some other ner- vous affection. When, however, you see these things in different generations, you may class them together, and consider them as the development of an hereditary predisposition."—Lectures deliv- ered at the London Univ., as reported in Med. Gaz for 1832-3, p. 582.—Ed. + On the cause of epilepsy, Dr. Jackson of Phila- delphia remarks (Philadelphia Journal of the Med. and Phys. Sc, vol. xiv., p. 209):—"If direct de- ductions from the symptoms, which are derange- ments of function, will lead us to a knowledge of the organ affected in any disease, and the nature of the organic lesion, we must conclude that the brain is indubitably the seat of epilepsy, and san- guine congestion, suddenly and periodically indu- ced, the character of the morbid lesion" Dr. J. H. Wright, of Bait., states as follows:—"From the result of aU the dissections I have hitherto are able, the exciting cause,* and to allay the habitual irritation of the nervous system. Where plethora manifestly exists, we may use venesection' with great hope of success, and, generally speaking, more freely than in hysteria.t But here also cathartics will be of considerable avail, and, in the hands of Dr. Hamilton, have been found sufficient alone to produce a cure.J To effect this, they should be used freely and maintained steadily, so as to keep up a perpetual counter-irritation in the bowels, which may act as a revellent against the morbid irritation in any other part, and directly carry off whatever irritating matter may exist in the bowels them- selves. Provided this be accomplished, the particular medicine employed does not appear to be a mat- ter of great moment. Colocynth, gamboge, sul- phate of magnesia, and calomel, seem to have been used with almost equally good effects; though in visceral congestion the last should never be omitted. If worms be suspected, and especially the vermicular ascaris, the rectified oil of turpentine should undoubtedly be allowed a preference. Even where worms are not found to exist, this has often proved highly successful, apparently by the revulsive action it excites. As a purgative, it should be given in ounce or ounce and a half doses to an adult; but as an alterant, in smaller doses repeated daily.—(See Dr. Latham, Med. Trans., vol. v., art. xxiii., and compare with his Treatise on Diabetes.) Cold affusion, whether general or confined to the head, has been rarely tried in our own coun- try, but is strenously recommended by many foreign authorities, as well during the paroxysm as in the intervals ; particularly by Dr. Lbben- stein-Lbbel. He employs it, indeed, both in an entonic and atonic state of the frame, only in the former case premising venesection. Under prosecuted, to discover the cause or condition pre- disposing to epilepsy, or the tenour of lesion by which that form of disease had involved a fatal issue, I infer that the sensorial irritations exciting epileptic phenomena, depend on organic degener- ations of the brain or membranes more frequent- ly than is generally admitted."—(Am. Journ. of Med. Sc, vol. ii., p. 45.) Prof. Chapman also contends for its cerebral character.—See his Ma- teria Medica.—D. * Dr. Armstrong saw more benefit derived from removing the exciting cause, than from any thing else. As to diet, he says, simplicity in the kind of food, and moderation in its quantity, is the golden rule. He knew of several cases which were cured by adopting this rule, and avoiding all circumstances which act on the mind and circulation. " A regu- lated diet," he observes, " occasional bloodletting, if the patient be of a full habit, and purgative medi- cines, are the remedies upon which I have the most reliance."—See Lectures on the Morbid Anatomy, Nature, and Treatment of Acute and Chronic Diseases, p. 754, 8vo., Lond., 1834.—Ed. + " If there be an inflammatory state within the head, or the patient be plethoric without inflamma- tion, then, certainly, blood should be taken away." —Elliotson. t With the purgative plan, free bleeding and a blister to the nape of the neck may often be use- fully combined, as in the case related by Mr. Ounn. See Edin. Med. Journ., No. xc, p. 78.—Ed. Gen. VII—Spe. 3.] SYSPASIA EPILEPSIA. 367 particular circumstances it may be useful, but it requires great caution; for even this writer prohibits it where the patient is subject to gout, rheumatism, diarrhoea, or nervous trepidations ; at the period of menstruation, or any other ex- pected discharge, or on repelled eruptions.— (Wesen und Heilung der Epilepsie, &c, 8vo., 1818.) De Haen often employed emetics, and chiefly for the purpose of exciting and maintaining a new action, for which purpose he continued them daily for a week or two. His example was followed at one time, but has long been re- linquished.—(Rat. Med., part v., cap. iv., y 1 ; Eph. Nat. Cur., cent, vi., obs. 58.) Externally, stimulants bave also been tried, and, in various instances, seem to have been at- tended with good success. The spine has been rubbed night and morning with different prepa- rations of ammonia, camphire, cantharides, and the antimonial ointment;* and setons and issues have been applied to different parts of the body, as have also the actual and potential cautery (Ab. Heers, Observ. Var. Locher, Observ. Pract.; Roekard, Journ. de Med., torn, xxv., p. 46), and the moxa. Where the cause of the disease has been suspected to be seated in the head,t they have been chiefly confined to this organ, but where there has been a manifest aura epileptica to the limb or other part of the body from which the vapour has seemed to ascend. And there can be no question that these means have fre- quently proved serviceable, especially in prevent- * See Creighton on the use of Tartar Emetic Ointment in Epflepsy.—(Trans, of the Assoc, of Physicians, Ireland, vol. iv., p. 332.) This gentle- man applied it also to different parts of the body; and he noticed that the eruption produced by it is not confined to the spot on which the ointment is rubbed, but mostly appears in very remote parts; thus proving that its action is in some degree on the constitution.—Ed. t It is seldom that the seat of the local mischief, which causes epilepsy, in those cases which arise from organic derangements within the head, can be exactly ascertained ; and it is not always that, when ascertained, they are within the reach of a surgical operation; yet such cases are On record, and one remarkable instance is related by Dr. Rog- ers of New-York. It was a protracted epilepsy, cured by elevating a portion of the osfrontis, which had been depressed upon the brain fourteen years. —(See New-York Med. and Physical Journ., 1826.) Facts of this kind, and others in which strabismus and other unequivocal signs of affection of the brain take place, are decidedly adverse to Dr. Reid's theory, that epilepsy should be ranked among those diseases to which, what he terms, the spinal sys- tem is liable.—(Trans, of Assoc, of Physicians, Ireland, vol. iv., p. 355.) That epilepsy does not always depend upon the state of the spinal cord, is also proved by the morbid changes in the head, frequently revealed by dissections as the cause of the disease. That they are not merely consequen- ces, is shown by the fact, that when removable, as in the case adverted to, the cure follows. At the same time, what is here stated is by no means in- tended to controvert Dr. Reid's position, that in epilepsy the medulla spinalis is sometimes found in a morbid state, and may be concerned in the pro- duction of the disease.—Ed. ing the recurrence of subsequent fits, where a habit of return has been established. The prac- tice is of considerable antiquity, for, under some modification or other, it is recommended by Ga- len, and many other Greek writers. In later times, it has been chiefly employed by Baron Percy (Pyrotechnie, passim) and by M. Gondret. Schenck has examined, at considerable length, the successful and unsuccessful cases which, in his day, had been published upon the use of cau- teries.—(Observ., lib. i., No. ccxxxiii.) In sev- eral instances, an accidental burn has answered the purpose of a surgical escharotic, and fortu- nately proved a radical cure.—(Eph. Nat. Cur., dec. i., ann. ii., obs. 9.) Professor Zoeffler, of Altona, instead of cauterizing the limb from which the epileptic halitus seems to ascend, has ingeniously tied a tight ligature above the part whence the vapour issues, probably upon the ground of the success with which it is often at- tended in the bite of the rattlesnake and other venomous animals, and, in one or two cases, the ligature seems to have proved quite as favour- able in the present disease.* The general irritability of the nervous sys- tem has been attempted to be overcome by se- datives and tonics. Of the former, the chief have been camphire, cajeput, valerian, hyoscya- mus, stramonium, opium, and digitalis. Stra- monium, like many other medicines, has had a strange alternation of fortune. About a century ago it was esteemed every thing, half a century ago it declined greatly in its reputation, and has of late been once more rising into esteem. Four- teen epileptic patients in the royal hospital at Stockholm were, many years since, treated with pills of stramonium, t Of these, eight are de- clared by Dr. Odhelius, in the official report upon this subject, to have been entirely cured, five had their symptoms mitigated, and only one received no relief. The greater number, on first using this remedy, were affected 1*!th confusion in their heads, dimness in their eyes, and thirst; but these symptoms gradually diminished. Where hyoscyamus has been given, it has been employed both in the leaves and seeds: Dr. Parr preferred the latter, and usually com- bined the seeds with some aromatics, commen- cing with doses of a grain, and advancing them to four or five grains. [One or two cases in favour of the utility of digitalis are recorded (See Edin. Med. Journ., No. xc, p. 19) by Mr. Scott of Liverpool.] The tonics employed have been both vegeta- ble and metallic. Among the former, the mis- tletoe of the oak stood at one time at the head * Speaking of the aura epileptica, Dr. Armstrong confirms the statement of many other writers, that if a tourniquet be applied above the part, the fit will frequently be prevented. He adds, " Some- times, when this has occurred, tumours have been found in the course of the nerves."—See Lectures on the Morbid Anatomy, Nature, and Treatment of Acute and Chronic Diseases, p. 748,8vo., Lond., 1834.—Ed. t Mem. de l'Acad. Royale des Sciences de Stock- holme, traduit par M. Keralio, torn. iii.; Razoux, Diss. Epist. de Stramonio, &c. 368 NEUROTICA. [Cl. IV.—Orb. IV. of the remedies for epilepsy. It was regarded as a specific by Colbatsch (see also Abhandlung von dem Missel, und dessen kraft wieder die Epi- lepsia Altenb., 1776), and most warmly recom- mended by Haller and De Haen.—(Rat. Med. Pract., part vi., p. 317.) It appears, however, of no importance from what tree it is taken, for, as a parasite, it flourishes equally on many, and preserves its own peculiarities on all; and from every tree, so far as late experiments have been made, it is equally inefficacious and futile. In plethoric habits, cinchona will generally do mischief; in the cerebral variety, it can do little or no good; and it is only in a relaxed and mo- bile state of the animal frame that any benefit can be expected from it. Mercury has been tried in almost every form and to almost every extent; sometimes indeed to that of salivation, in which state some prac- titioners pretend to have found it highly useful. As a general plan, however, this can never be advisable : and Muralt admits that, in most cases, where it has seemed to answer, it has only restrained the disease, or prolonged the in- terval, but not effected a radical cure.* Of the preparations of zinc we took notice under convulsion, and the remarks there offer- ed are equally applicable to epilepsy. Such, however, has been the state of exhausted irrita- bility produced by this disease in some instances, that the patient would bear almost any quantity of them. Mr. Johnson of Lancaster gave the sulphate of zinc in doses of five grains twice a day at first, and increased the dose gradually to twelve grains. Thelenius had previously given eight grains of the same daily.—(Medicinische und Chirurgische Bemerkungen, Franc, 1789 ) Arsenic has of late been chiefly employed in the form of the common solution, and, as united with nickel, in the compound of an arseniate.t But the preparations of copper and silver have met with more success than any of the prece- ding. The best form of the first is that of the cuprum ammoniatum; and the Edinburgh Med- ical Commentaries are full of cases that afford proof of its remedial power. The simplest mode of exhibiting this medicine is that of pills, as the pilula carulea of the Edinburgh Pharma- c&pceia, which is nothing more than ammoniated * Hippocr. Helvet., p. 247. Dr. EUiotson is of opinion that there can be no harm in trying mer- cury and iodine, because there may be some dis- ease in the head which these will remove. He is not aware that they do good, except in removing the effects of chronic inflammation.—See his Lec- tures, delivered at the London Univ.—Ed. t See a valuable article on this and similar med- icines in the Edin. Med. and Surg. Journ., No. xix., p. 374. The following are Dr. EUiotson's observations on zinc, tin, and arsenic :—" The sul- phate of zinc has been much praised, as well as the oxyde. I have given it in St. Vitus's dance: you may exhibit it in large quantities (sometimes twenty or twenty-four grains), but I never saw it do good in epUepsy. The oxyde of tin has been much praised, and so has arsenic ; but I have seen rsrsons from taking the latter become epffeptic. do not believe these things are to be depended upon.—Ed. copper made into a pilular consistence by means of crumbs of bread. The patient should begin with half a grain of the metallic salt every night, and increase it to double the quantity if his stom- ach will bear it. The best, and indeed the common preparation of silver for the purpose before us, is its nitrate. Under a more operose and unscientific form, it was employed as early as the beginning of the seventeenth century by Angelus Sala, and after- ward by Boyle and Geoffrey, though for other. complaints rather than the present. Dr. Albers of Bremen has observed, and the remark has since been confirmed by Dr. Roget (Trans. Mcd- ico-Chir. Soc, vol. vii., p. 290), Dr. Badeley (see Epichrosis Pacilia of this Work, Cl. VI., Ord. III., Gen. X., Spe. 6), and numerous other practitioners, that the use of this medicine, if persevered in, gives a peculiar darkness to the colour of the skin, which remains for many months after its discontinuance, in some cases for upwards of two years.—(On the Effect of Ni- trate of Silver, Trans. Medico-Chir. Soc., vol. ix., p. 234.) Dr. Powell tried the nitrate of silver in St. Bartholomew's Hospital upon a large scale, and in two forms, that of pills and that of solution, the solvent being mint-water, which seems best to cover its unpleasant taste. Many of the cases seem to have been strongly marked, and they are given in a communication to the London College* They relate chiefly to young persons of both sexes from nine to fifteen years of age ; in all of whom the medicine proved successful, and is said to have operated a perfect cure. The dose consisted at first of not more than half a grain or a grain of the metallic salt, whether in the form of pill or of solution, given usually every four hours, but this was gradually increas- ed to doses of three or four grains taken at the same distance of time: and the increase was still continued till sickness or some other incon- venience forbade. It is singular, that while the earlier writers complain very generally of the purgative powers of this medicine, and the gri- ping it produces, the modern preparation excites no such effects; not even when it has been car- ried, as it has occasionally been, to the amount of fifteen grains to a single dose in the shape of pills; though it should be remembered, that few stomachs will bear more than five grains in a dissolved state. Dr. M'Ginnis of Portsmouth affirms, that he has employed it repeatedly both in recent and chronic cases, without any percepti- ble effect, in doses of twelve grains; and M. Georget, who, however, does not seem to be much acquainted with its use, has condemned it as a medicine dangerous to the coats of the stomach, t * Med. Trans., vol. iv., art. viii. A casein favour of the nitrate of silver is related by Dr. Williams of Liverpool, though many other potent remedies were also employed, as oil of turpentine, blisters, cold washes to the head, sulphate of zinc, issues, and mercury.—Edin. Med. Joum., No. lxxxv., p. 297.—Ed. t Phys. de Syst. Nerv., torn, ii., p. 401. Accord- ing to Dr. Armstrong, the nitrate of silver some- Gen. VIII.] CARUS. 369 Iron, in all its preparations, offers a far less hazardous remedy, and in some instances, ap- pears to have been attended with considerable success. The best form perhaps is that of the subcarbonate, in the proportion of a drachm three times a day, as already recommended in the case of Neuralgia ; and thus administered, it has occasionally produced a radical cure.* All these tonics seem to operate by taking off the tendency to irregular nervous action, and, consequently, the tendency to a return of the paroxysm, where a habit of recurrence has once been established; for in many instances, such habit alone appears to be as much an adequate stimulus as a similar habit in intermittents : and hence, whatever has a tendency to break through such a habit must have a beneficial effect; fe- vers themselves of various kinds have often done this,t and especially quartans, the most obsti- nate of the whole tribe of fevers ; and the above remark explains their mode of operation in this respect: it is that of introducing a new circle of actions. But the exciting causes of epilepsy are so numerous, and the disease itself so complicated, that it would be in vain to expect success in every instance from metallic tonics, or any one description of medicines whatever.$ The rem- times stops epilepsy, but most frequently fails.— (On the Morbid Anatomy, Nature, &c, of Acute and Chronic Diseases, p. 755.) Dr. Elliotson sel- dom prescribes it: " if it be not given for a long time," says he, "you will not do good; and if it be given for a long time, you run the chance of blackening the patient." He considers it as a medicine calculated to bring on gastritis and diar- rhoea ; points on which he disagrees with the au- thor's statements.—Ed. * Dr. Elliotson has never seen iron do good in epilepsy, except as a tonic, when the patient has been improperly lowered.—Ed. + Hornung, Cista Medica, Norib., 1625, 4to. Augziige aus dem Tagebuche eines ausiibenden Arztes, &c, 1 Samml., Berl., 1791. *" X This is a truth which the practitioner should never lose sight of; for while he is guided by it, he will know what degree of value ought to be at- tached to various allege3 remedies for epilepsy. Professor Elliotson, in his Lectures, after advert- ing to preparations of copper, iron, lead, zinc, tin, and arsenic, and to narcotics, cold affusion, oil of turpentine, &c, as means for the cure of epilepsy, very properly remarks:—" Now all these things may fail, entirely through our not attending to the antiphlogistic regimen. It is possible that cases happen now and then that would yield to some of these remedies; but we neglect to lower the pa- tient. I am quite sure that remedies are com- pletely prevented from doing good, because we do not remove a plethoric state of the system. In some local inflammations, and in many cases of various diseases, it is necessary to lower the sys- tem to a certain point, and then remedies, which would not otherwise be useful, become so. The reason that the disease is so generally intractable, —the reason that so many remedies are so uncer- tain and unsatisfactory,—is veiy evident. This is a disease which arises from every sort of irritation in every part of the body; and the irritation may be structural, may be slow inflammation, or some- thing we cannot remove. If it arose from one cause, it would be a different thing; but it will Vol. II.—Aa- edies must often be varied to meet the varying case. And on this account, it is by no means uncommon to find epilepsy removed by oil of turpentine or some other purgative, that had ob- stinately resisted the most powerful doses of the metallic salts ; while, in some instances, the disease is altogether irremediable.* GENUS VIII. CARUS. TORPOR. muscular immobility; mental or corporeal torpitude, or both. Carus or xdpos, " sopor cum gravedine," is derived from Kdira, " the head," being the or- gan in which the disease is chiefly seated. As employed in the present arrangement, the genus signified by this term will readily include the following species :— 1. Carus Asphyxia. Asphyxy. Suspend- ed Animation. 2. ---- Ecstasis. Ecstasy. 3. ---- Catalepsia. Catalepsy. 4. ---- Lethargus. Lethargy. 5. ---- Apoplexia. Apoplexy. 6. ---- Paralysis. Palsy. Carus, therefore, will be found to embrace, under the present arrangement, a field somewhat more extensive than that allotted to it by most other writers, so as to include several of the species arranged by Sauvages under his two or- ders Leipopsychiae and Comata; to be nearly synonymous with the Defectivi and Soporosi of Linneus ; and still more so with the Adynamia; of Macbride. As a generic sign, the author has preferred the term torpor or torpitude to stupor or sopor, which have hitherto been chiefly made use of for the same purpose ; and this ou two accounts. First, as being of wider signification, since it includes the general idea furnished by both the arise from any cause whatever, physical or men- tal, organic or inorganic, and situated in any part of the body. You will see, therefore, not only that it must be usually an incurable disease, but you will see that there can be no remedy for it."— See EUiotson's Lectures, as delivered at the Lon- don University, Med. Gaz. for 1832-3, p. 614.—Ed. * Dr. Reid mentions two modes in which the convulsions of epilepsy may be stopped. " Du- ring the inordinate struggle," says he, " to perform respiration, the practitioner may abstract some of the force applied to the respiratory organs by at- tracting the exertion in another direction. Thus, while the hands and arms are violently contracted, if the attendants forcibly extend them, and open the fingers, so much exertion is involuntarily made by the patient to oppose this, that the violent oper- ation of the respiratory muscles subsides, the or- gans fall into their natural train of action, the pa- tient draws a heavy sigh, and the paroxysm is at an end. Any unusual irritation," Dr. Reid adds, " may have this effect." The other mode is to let an assistant press forcibly the soft parts of the ab- domen towards the spine with his closed hand. The theoretical explanation of the practice we need not examine, if the plan answer, as Dr. Reid has found it do.—See Trans, of Assoc, of Physicians, Ire- land, vol. iv., pp. 363-365.—Ed. 370 NEUROTICA. [Cl. IV—Ord. IV others: and secondly, because neither stupor nor strpor has been uniformly employed in a de- terminate sense of any kind. Thus stupor is often, perhaps usually, restrained to mental in- sensibility or morbid steep ; while Sauvages has explained it as meaning hebetude of the sense of touch, " molestia quae sensum tactus oflscu- rat;" and Linneus, transient sleep of any part with a sense of formication, '■'■sopor transitorius partis alicujus cum sensu formicationis." In this place, and indeed generally, Linneus makes sopor combine the two ideas of a cessation of motivity and of feeling-, or of irritability and sensibility ; while Cullen objects, and correctly, to this stfained extent of the term, and limits it to the ordinary signification of " sleep, or a sleep-like state." Torpor, or torpitude, in the definition of carus now offered, imports insensi- bility, mental or corporeal, in a frame still alive, and actuated, though often imperceptibly, by the vital principle. The term insensibility would not so well answer the purpose ; it is of too wide a range and too loose a meaning, being often predicated of insentient, unorganized matter, that never possessed the principle of'life. Carus or torpor, thus explained, win equally apply to all the species we have just enumera- ted, some of which are very unconjmon, and a few of which have been supposed doubtful ; though, upon the whole, the authorities are in their favour, and they ought neither to be omit- ted nor merged, as they seem to be by Cullen, m the sweeping name of apoplexy: constitu- ting in his hands a genus that includes a variety of distinct, and in some instances, very different diseases, but which, under his own classifica- tion, Dr. Cullen found it difficult to distinguish or place separately. SPECIES I. CARUS ASPHYXIA. ASPHYXY. SUSPENDED ANIMA- TION* TOTAL SUSPENSION OF ALL THE MENTAL AND CORPOREAL FUNCTIONS. Asphyxy, from a privative, and ofi^ic, "pul- sus," is here used in the general sense of the term, though it has occasionally been employed to import mere failure or cessation of the action of the heart and arteries, which, in the present elassification, is made a species of entasia under the name of acrotismus ; and has already passed in review as belonging to the second order of the present class. * The meaning of the term asphyaia is often more limited than what Dr. Good has assigned to it; being applied only to cases in which the ces- sation of the heart's action proceeds from a par- ticular cause, namely, the interruption of respira- tion, or, to speak more correctly, the interruption of the effect produced by that function on the blood. In this sense, then, asphyxia is the condi- tion of the body consequent to the interruption of the arterialization of the blood, and attended with a suspension of all the powers of sensation and voluntary motion.—See Dr. Roget's Obs. in Cy- clop, of Pract. Med., art. Asphyxia.—Ed. Asphyxy offers us several varieties, from a difference of occasional cause, which produces ;\ like diversity in a few of its symptoms. Sau>: vages, who has made the disease a genus, gives us no fewer than seventeen species or subdivis» ions ; Dr. Goodwin contents himself with three, and denominating the disease melanama, from the blaek colour which the blood ordinarily as- sumes under its influence, distinguishes thern by the names of melanaema from hanging, from drowning, and from inspiration of fixed air. Of these, the first arrangement is unnecessa- rily diffuse and complicated; and the second too limited and not quite correct, since it will pres- ently appear, that the direct cause of asphyxy in hanging and drowning is one and the same. The author has, in consequence, been induced to divide the species into the following table of varieties, forming a middle line between the two preceding arrangements, and including, as he hopes, every modification with which it is of importance to become acquainted:— a Suffocationis. Produced by hanging or Asphyxy from drowning: countenance suffocation. turgid and livid. 3 Mephytica. Produced by inhaling car- Choke-damp, bonic acid or some other irrespirable exhalation: countenance pallid. y Electrica. Produced by a stroke of Electrical as- lightning or electricity. phyxy. Limbs flexible; counte- nance pale ; blood unco- agulable. & Algida. Produced by intense cold. Frostbitten as- Limbs rigid : countenance phyxy. pale and shrivelled. In the first variety, or asphyxy from hanging or drowning, the immediate cause is suffoca- tion, or a total obstruction to the respiration, and is so explained by Bonet, Haller, Lancisi, Petit, and De Haen. The fade, as we have just noticed, is turgid and suffused with livid blood ; and the general symptoms are given with so much truth and emphasis by Shakspeare, in Suffolk's descrip- tion of the body of Henry VI., that I copy them as a guide to the medical student: " See how the blood is settled in his face ! Oft have I seen a timely parted ghost Of ashy semblance, meager, pale, and bloodless; Being all descended to the labouring heart : Who, in the conflict that it holds with death, Attracts the same for aidance 'gainst the enemy, Which, with the heart, there cools, and ne'er returneth To blush and beautify the cheek again. But see! his face is black and full of blood; His eyeballs further out than when he lived, Staring full ghastly, like a strangled man, His hair up-rear'd, his nostrils stretch'd with struggling; His hands abroad display'd as one that grasp'd And tugg'd for life, and was by strength sub- dued."* This description, however, applies more fully to asphyxy from hanging than to that fromdrown- Henry VI., Second Part, Act. III. Gsn. VIII.—Spe. 1.] CARUS ASPHYXIA, 371 ing, in which last there is more flaccidity of the Ihjibs, and consequently less of " struggle and grasp, and tug for life." In both cases, never- theless, the countenance has a semblance of apoplexy, as though there was a congestion of b^od in the head, to which the application of the rope to the neck, in the case of hanging, af- fords some countenance. And hence many eminent writers of earlier times, as Boerhaave, Wapfer, and Alberti, referred suffocation from both the causes before us to apoplexy ; while Cullen made it a subdivision of this last disease : and M. Portal has, still more lately, entered into the same view.—(Observations sur les Effetsdes Vapeurs Mephytiques, Nouv. edit., Paris, 1774.) But in apoplexy there is always oppressive, gen- erally stertorous sleep, which never exists in asphyxy, unless, indeed, the exciting cause has only partially operated, and produced a different disease, or apoplexy instead of asphyxy ; afford- ing us a proof of what in fact we have noticed in a thousand instances already, that different maladies may issue from the same cause ; ac- cording to the degree of its violence, or perhaps the accidental condition or constitution of the patient. In asphyxy, wherever we can trace any sign of diseased action, the lungs are chiefly affected ; in apoplexy, the brain. In the first, the irritability of the system is sudden and total; in the second, it is progressive and partial. In the former, the patient is often restored after all the common symptoms of death have for some minutes, perhaps for nearly an hour, fixed upon him : in genuine apoplexy, this is never the case. The appearances on the dissection of drowned animals are very accurately given by Dr. Curry, and precisely coincide with the distinction here offered. The vessels of the brain were found in every instance free.from distention or any other mtilhid condition, while the lungs were over- loaded. The author has observed that the immediate cause of asphyxy, or, in other words, an occlu- sion of the larynx, may be partial, and, in such case, give a tendency to apoplectic symptoms. And in effect, wherevejp" the larynx or glottis is only imperfectly closed, we meet with such a ten- dency ; and it is on this account that the face of those who die by hanging is more generally tur- gid, and the muscles give proof of more convul- sive action than the face of those who die by drowning ; for in the former case, either from a rigidity in the coats of the larynx, or from the rope not being properly applied, a small current of. air is often capable of moving backward and forward for some time, and particularly in sui- cides, many of whom suffer much before they die, in consequence of applying the rope very bunglingly, and whose cheeks, lips, eyes, and tongue, are peculiarly turgid and prominent. The reason of this may be partly collected from the history already given, in the Physiological Proem to the third class, of the state of the heart in the act of dying. The immediate cause of the contraction or systole of the heart, we ob- served, has not been satisfactorily settled : but vve may safely affirm, that a part of this cause, if not the whole, depends on the change, what- A a 2 ever that change consists in, which takes place in the blood during its ventilation in the lungs, by which it is rendered more active and stimu- lant ; for as this change gradually subsides in those who are in the act of dying, the heart con- tracts more feebly ; and when, with the last ex- piration of air, it ceases altogether, the heart as instantly contracts no more: the consequence of which is, that the lungs, the heart, and the larger vessels in the vicinity of the heart, are usually found filled with blood, the smaller ves- sels empty, and the general surface of the body pale. Now whatever has a power of instanta- neously cutting off inspiration must necessarily produce the same effect: and hence, as we have already observed, the gorged state of the lungs, and the livid hue of the countenance, in most cases of suffocation by drowning; and, conse- quently, the only reason why the lungs are not quite so full, and the countenance more turgid, in most cases of suffocation by hanging, is that, from the inexpert manner in which the rope is usually applied, and the necessary admission of a certain portion of air to the lungs, the heart is for some time able to contract feebly, and to keep up a feeble circulation, while the pressure of the rope on the jugulars prevents a ready return of the blood from the head, and conse- quently accumulates it in all the vessels of the face ; and hence, the more inexpertly this oper- ation is performed, the more turgid these ves- sels must become, and the more apoplectic the general appearance. It is the same, as we shall presently have oc- casion to notice more fully, with persons who are exposed to the action of carbonic acid gas or other mephitic vapours, so far lowered or in- termixed with respirable air as to render them incapable of destroying life instantly ; in which cases there has not only been sometimes a fee- ble prolongation of the circulation, but even a stertorous breathing, and many other symptoms of apoplexy, of which we shall have to speak further under the next variety. There are some of the narcotic poisons that seem to act in the same manner. Given in a full dose, they destroy life instantly ; but in an under-dose the circulation is continued feebly, and apoplectic symptoms ensue. Thus, accord- ing to Mr. Brodie's experiments, infusion of tobacco, when injected into the intestines, and the upas antiar, when applied to a wound, have a power of rendering the heart insensible to the stimulus of the blood, and thus suddenly stop- ping the circulation ; while alcohol, the juice of the leaves of aconite, the woorara, essential oil of almonds, whether applied to wounded sur- faces or taken internally, produce death by de- stroying the functions of the brain, while they act only indirectly on the circulation. In like manner, De Haen gives one instance of apoplectic signs discovered on the dissection of a criminal who had been publicly executed by hanging ; in which the pia mater was found unusually florid, the vessels of the brain turgid, and some degree of serous effusion had taken place under the tunica arachnoides : but in this case he found, also, that the lungs were equally 372 NEUR overloaded, and that the rope had not pressed upon the trachea, but upon the part lying be- tween the scutiform cartilage and the os hy- oides, and consequently that the compression had been imperfect.—(Rat. Med., continual., torn, i., part ii., 8vo.) But, except in cases where the occlusion of the trachea has not been entire, the patient who suffers from asphyxy produced by hanging is as void of apoplectic symptoms as he who suffers the same disease from drowning. In the dogs hanged by way of experiment by De Haen (Ab- handlung uber die art. des Todes der Ertrunke- nen, Ernhcnkten, und Erstiklen, Wien, 1772), and cut down as soon as they were dead, and in those drowned by Dr. Goodwin,* there was an equal absence of apoplectic signs ; and, in truth, wherever an executioner does his duty completely, the death is too sudden to allow of accumulation as its cause. By the double ef- fect, however, of stopping the circulation and obstructing the passage of the air, the public punishment of hanging, when dexterously con- ducted, is probably attended with very little pain. It has been said of late, that another, and indeed a chief cause of the suddenness of the death hereby produced, is to be found in a lux- ation of one of the upper vertebrae. Such an ef- fect may take place at times upon our public scaffolds, on which the hardened criminal jumps from the gallows to produce a rapid result, but it is rarely met with in the private retreat of the more timid suicide, t That a total obstruction to the respiration, moreover, is the chief cause of death in hang- Big, is clear from the cases in which the as- phyxy has been cured by inflation of the hings after the unhappy wretch has been cut down ; and from one or two instances, in which the in- dividual has escaped death from an ossification of the trachea ; of which we have a few curi- ous examples in Bonet and Fallopius (Bond., lib. vii., sect, xii., obs. ii. ; Fallop., torn, i., obs. *i.); and more particularly from the case of In- etta de Balsham, stated by Dr. Plott in his Nat- ural History of Staffordshire ; who having been hung, in the reign of Henry VI., according to the due form of law, was cut down alive, after suspension from nine o'clock on Monday till la- ter than sunrise on the ensuing Tuesday; in consequence of which she received the king's * Connexion of Life with Respiration, or an experimental Inquiry into the Effects of Submer- sion, Strangling, &c, Lond., 1788. t The dislocation spoken of is asserted to have happened in certain executions formerly at Ly- ons, where the executioner used to communicate to the body of the criminal a particular rotary mo- tion, or twist, at the moment of the fall; but at St. Bartholomew's hospital, the bodies of numer- ous criminals executed at Newgate have been dis- sected, and though the state of the cervical ver- tebrae was particularly examined, no luxation was found to have taken place. Respecting the degree of pain experienced by persons who die by fcanging or drowning, an interesting quotation from Dr. EUiotson's lectures has been inserted in the form of a note to Dr. Good's observations on epilepsy in the present volume, p. 364.—Ed. OTICA. [Cl. IV.—Or». IV pardon. Dr. Plott ascribes this extraordinary escape to an ossification of the larynx. " She could not," says he, " be hanged, upon account that the larynx or upper part of her windpipe was turned to bone."—(Hist., p. 292.) It has hence been occasionally proposed to save a criminal condemned to the gallows by introdu- cing a silver cannula into the trachea. It is com- monly reported that such an attempt was in ag- itation among the friends of the unfortunate Dr. Dodd, but we have no reason to believe it was actually tried. The following experiment, however, as rela- ted by Dr. Curry, is also demonstrative as to the . immediate organ through which the attack of death is received in hanging. It was performed at Edinburgh, many years ago, by the senior Dr. Monro, and, in the language of Dr. Curry, "clearly proves that the exclusion of air from the lungs is the immediate cause of death. A dog was suspended by the neck with a cord, an opening having been previously made in the windpipe below the place where the cord was applied, so as to admit air into the lungs. In this state he was allowed to hang for three quar- ters of an hour, during which time both the cir- culation and breathing went on. He was then taken down without appearing to have suffered much from the experiment.* The cord was now shifted from above to below the opening made into the windpipe, so as to prevent the ingress of air into the lungs, and the animal being again suspended, he was completely dead in a few min- utes."! * A case is recorded by Dr. Mahon, in which this expedient was tried by a criminal for prevent- ing the fatal interruption of respiration by the cord.—(Med. Legale et Ponce Med., torn, iii., p. 62.) In the beginning of the last century, a butcher, named Gordon, was condemned to be hanged at the Old BaUey for highway robbery. Having amassed a great deal of money by his dis- honest practices, he tempted a young surgeon, by the offer of very high remuneration, to make an opening low down in the trachea, and then pass a small cannula into it. This was secretly ac- complished previously to the execution. After the body had been suspendedthe usual time, it was taken down, consigned to the relations, and quickly removed to a neighbouring house. The surgeon immediately took some blood from the jugular vein, and tried every means calculated to restore animation. Gordon opened his eyes, gave a deep sigh, but expired a few minutes afterward. The failure was attributed to the great weight of the body, which increased the violence done to the parts compressed by the rope.—Ed. t Observations, p. 71. It was first clearly proved by Bichat, that the primary effect of the circulation of venous blood is on the brain, and that this effect extends, through the medium of the same organ, to the whole nervous system. On this subject the following reflections by Dr. Roget are judicious:—" The first, in point of time, in the series of phenomena consequent upon the sus- pension of the arterializing process, is the affec- tion of the brain. Were this the sole effect di- rectly produced by the want of oxygen, or super- abundance of carbon in the blood, then might as- phyxia be ranged under the head of apoplexy ; and the subsequent failure of the circulation would be Csn. VIII.—Spe. 1.] CARUS ASPHYXIA. 373 Asphyxy from submersion has been very gen- erally accounted for, even by many who have regarded it as an effect of suffocation, by sup- posing the suffocation produced by a rash of the water into the cavity of the lungs, which pre- vents the access of air, and consequently of res- piration. This idea, first, perhaps, advanced by Galen, has been in modern times adopted by Haller, Goodwin, Pouteau, and indeed most physiologists, and attempted to be supported by various experiments on drowned cats. It is now well ascertained, however, that, in many cases from drowning, not a drop of water enters into the lungs ; that where it does enter, the quan- tity is, for the most part, very small; and that, whether small or large, it passes the trachea af- ter death instead of before it, and consequently cannot be a cause of death. The immediate cause, as in the case of suspen- sion, is suffocation. The glottis is extremely ir- ritable : the access of the surrounding water pro- duces a rigid or entastic spasm upon its muscles ; and the rima is as completely closed against the entrance of air as in the case of a cord round the throat. And hence, the suffocation often produced by a very small substance of any other kind accidentally thrust into or stimulating its aperture, as a minute crust of bread, a hair or blade of grass, a peach, or even a grape-stone ; to which last Anacreon is well known to have fallen a victim. How long the living principle may, under these circumstances, remain attached to the animal frame, and afford a chance of recovery, is not as- certained, with any degree of accuracy, even in the present day; and the answer to the question a consequence of the impaired energy of the ner- vous jjpwers which maintain the energy of the heart. But this can scarcely be admitted to be the sole cause of death; because the motion of the heart in asphyxia is arrested much sooner than it ever is in simple apoplexy. We find, indeed, that in the latter disease the heart continues to beat for many hours, or even days, after the destruction of the faculties of sensation and consciousness ; and it appears at length to stop principally in con- sequence of the cessation of breathing, which al- ways takes place when the abolition of the pow- ers of voluntary motion has proceeded a certain length. So that, in fact, it may more properly be said, that apoplexy proves fatal by inducing a state of asphyxia, than that asphyxia is merely a species of apoplexy, as it has been erroneously classed in some systems of nosology."—(Dr. Roget in Cy- clop, of Practical Med., art. Asphyxia.) While this physician admits that a paralytic affection of the pulmonary capillaries, rendering them incapa- ble of transmitting blood through them, is one of the principal causes of the cessation of the heart's action, he considers it very probable that the dim- inution of its energy, occasioned by the circula- tion of venous blood through its substance, con- tributes in a great degree to the same effect. Dr. Roget does not, however, entirely adopt Bichat's views of the latter point. " The cessation of the action of the heart," says he, "was accounted for by Bichat on the supposition that it was itself par- alyzed by the deleterious qualities of the venous blood, which, by entering the coronary arteries, penetrated its muscular substance, and destroyed Us irritability. If we were to admit this doctrine, must, in a considerable measure, depend upon the degree of irritability, or perhaps the idiosyn- crasy, of the individual. M. Brodie is reported to have asserted in his Lectures before the Col- lege of Surgeons, that " when the action of the heart has ceased after the suspension of the breathing, or even has become so feeble as no longer to be able to maintain the circulation, it can never be restored by artificially inflating the lungs." This may be true : but we have innu- merable proofs of a natural restoration of both these organs to healthy action after such action has ceased for many minutes, perhaps for many hours, in Catalepsia or Trance- It has been known, however, from a very early age, that torpitude from drowning may be induced and continue for some minutes, without much danger : since this, as we have already observed, was a common practice among the Greeks and Romans for the cure of lyssa; and was carried by Van Helmont so far, that he would not suf- fer the individual to be raised from under the water till the psalm Miserere had been solemnly chanted, which was the measure of time he al- lowed. If the submersion have not exceeded five minutes, and no blow against a stone or other violence have coincided, persons will usually be found to recover without much diffi- culty. After a quarter of an hour, recovery is not common; and after twenty minutes or half an hour, it is nearly hopeless. Divers, from hab- it, are able to remain under water for three min- utes ; but, according to Dr. Edwards of Paris, this is the longest period.—(De I'Influence des Agens Physiques sur la Vie, &c, Paris, 8vo. 1824.) Young animals require less change of however, this obvious difficulty would present it- self in accounting for the renewal of the contrac- tions of that organ on the re-establishment of res- piration ; namely, that the very power to which it must owe the restoration of its irritability, by the propulsion of fresh arterial blood through its ves- sels, has, on this hypothesis, been itself destroyed; and, therefore, the means of recovering it do not exist. Resuscitation from asphyxia would, if this were true, be impossible. But, since daily experience shows us that the heart may be made to renew its contractions even some time after they have ceased, we are forced to conclude that the organ stUl retains, under these circumstances, a considerable share of irritability, ready to be called into action when a proper stimulus is ap- plied. On the renewal of the action of the pul- monary capillaries, by which means a fresh sup- ply of arterial blood is poured into the left auricle and ventricle, these cavities are urged by their ap- propriate stimulus again to contract and renew the circulation. Arterial blood being thus again diffused over the system, imparts its vivifying in- fluence to all the organs; their suspended func- tions are resumed, and animation is restored."— See Cyclop, of Pract. Med., art. Asphyxia.) In confirmation of these views, Dr. Roget refers to the experiments of Dr. Kay (Edin. Med. and Surg. Journ., vol. xxix.), and of Dr. Edwards (De l'ln fluence des Agens Physiques sur la Vie, part i., chap, i., and part iv., chap, iv.), which tend to prove, that when venous blood is made to circu- late through the substance of muscles, it contrib- utes to support their irritability in a certain degree, although less effectually than arterial blood.—Ed. 374 NEUROTICA. [Cl. IV—Ord. IV respirable air than those that are old. Dr. Ed- wards has known puppies live under water fifty- four minutes, though their voluntary motions had ceased in four minutes alone. The first report of the establishment for the recovery of drowned persons at Paris, divides the cases that had occurred to it into three classes, the first of which includes those that were restored to life, and comprehends twenty- three instances. Of these one recovered after having been three quarters of an hour under water ; four after having been half an hour, and three after a quarter of an hour ; the rest after a still shorter period.—(Detail des Succes de I' Etablissement que la Ville de Paris a faite en faveur des Personnes Noyies, &c, Paris, 1773.) Of twelve dogs drowned by De Haen for the purpose of experiment, not a single one was re- covered, though only confined under water for a few minutes. It is very possible, however, that in these cases, the force necessary to keep them submerged may have considerably added to the extent of the mortality. Among man- kind, where no such force is applied, this emi- nent physiologist conceives, that one in sixteen is no unfavourable average of the portion that recover.—(Rat. Med. Cont., torn, i., part ii.) There are case's, indeed, of recovery from drowning after a submersion of some hours ; but these are rare and wonderful, and some of them altogether incredible : for we have histories of recovery after eighteen hours (Pechlin, De A'eris et Alimentorum Defedu et Vita sub Aquis, Kiel, 1676, 8vo.), four-and-twenty hours (Lepi, Sub- mersos per24horas vitam protrahere posse, Rom., 1670), and even three days (Eph. Nat. Cur., dec. i., ann. vi., vii., obs. 20), while some of the retailers of the marvellous have stated intervals of fifteen days, and in one instance, related with much gravity, not less than seven weeks.—(Id., obs. 125, 130, 192.) From all which, however, we may at least learn the useful lesson of the necessity of redoubling our exertions when call- ed upon for medical aid, and not of despairing very early. Dr. Edwards of Paris instituted some singu- lar experiments on the Batrachian amphibials (reptiles of the Linnean system), and especially on frogs and salamanders, to determine how long the living principle may continue in a state of asphyxy, which afford some light on the subject before us in at least two important points. He has first clearly ascertained, that the rapidity of death depends very considerably upon the tem- perature of the water in which the experiments are made, compared with the actual temperature of the medium in which the animal has been living for some time antecedently : for that frogs, taken in November from an atmospheric temper- ature of 50° and immersed in water of the same temperature, lived from five hours and ten min- utes to eleven hours and forty minutes, being double the length of time they lived in water of the same temperature in summer. Whence it is probable, that the relative speed or tardiness with which a man dies in submersion, depends partly upon the temperature of the atmosphere in which he has lived for several preceding days, compared with that of the water at the time of the accident. And secondly, he has satisfacto- rily established, that frogs and salamanders, de- prived of the heart, continue to live for a longer period in the air, than in water whose air has been withdrawn from it. At the end of four hours, the salamanders which were in the water appeared to be dead, though they manifested some degree of activity on being pinched or agi- tated. At the end of nine hours, however, they were all entirely void of living power; while those which were retained in the air lived for twenty-four or twenty-six hours. The frogs lived four hours under the water, and five out of it. The experiment was varied by suffocating other reptiles of the same kind, their heads being closely tied up in a piece of bladder, instead of cutting out their hearts; and the result was in every instance consentaneous. Dr. Edwards hence concludes, and the conclusion seems well supported, that air has an influence on the econ- omy of animals, independently of its action through respiration ; and that this influence is probably exerted through the medium of the skin.* And we may hence see why recovery from hanging is more frequent than from drown- ing, under like intervals of protraction. • Unfortunately, we have no means of deter- mining whether the vital principle lies latent in the body or has utterly dropped its connexion. Want of heat is no more to be relied on than cessation of the pulse or of breathing : for while in submersion, heat, in consequence of its rapid absorption by the surrounding elements, is one of the first properties of life that disappears, whether the patient recover or not; in death from convulsions and various other sudden causes, it often continues for hours, and some- times even for days after the event, cheating the by-standers with an empty and unfounded hope of a restoration never to take place. The present author was a few years since sent for in haste to a female domestic of Mr. Salmon of Mecklenburgh-square, who however died under a convulsion-fit before his arrival. In the even- ing, nearly twelve hours afterward, he was again requested to attend, as, notwithstanding the body had been laid out from the first and merely cov- ered with a sheet, it still possessed a consider- able degree of warmth. He was sorry to repress a hope which he found fondly and highly cher- ished, but the symptom was illusive, and the heat gradually disappeared. On the decease of a robust and corpulent lady, whom he also at- tended in Bedford-row, and who died of a spasmodic asthma, this symptom continued, or rather showed itself afresh, eight-and-forty hours after death, so that the author was requested to attend at the time the body was on the point of being put into the coffin. In this case, the heat was produced by putrefaction ; for the body was livid and offensive. Bartholine has an example or two of the same kind ; and the Ephemerides, among other cases less marvellous, one in which * Memoires sur l'Asphyxie consideree dans les Batraciens. Paris, 1817 : also, De 1'rnfhienee ties Agens Physiques sur la Vie, &c. Paris, 8vo., 1821. Gen. VIII.—Spe. 1.] CARUS ASPHYXIA. 375 the heat is said to have continued till the fourth day after death : and which should no doubt fall within the solution just given.—(Ephem. Nat. Cur., dec. ii., ann. iv., obs. 18.) As heat has occasionally maintained itself for hours after death, so also has perspiration. Paul- lini mentions a case in which tears flowed from the eyes (Cent, iii., obs. 10, Franc, 1698, 8vo.); Riedlin another, in which the eyes them- selves recovered their brightness (Lin. Med., 1696, p. 203) ; and Hagendorn a third, in which the face swelled and looked red.—(Cent, iii., obs. 46.) In all these cases, we have proofs of a lingering of the irritable principle in particular parts after the sentient principle has totally dis- appeared. And hence, in a few instances, some of the muscles have been thrown into irregular action, the penis has become erect (Eph. Nat. Cur., dec i., ann. ix., x., obs. 34, 158), the jaws have opened and shut, as though masticating (Commerc. Nor., 1732, pp. 82, 90, 173) ; and, as is well known, the heart, when dissected from the pericardium, has leaped from the table.* In attempting a cure of suffocation by sub- mersion, the two grand means by which we are to operate are those of warmth and inflation of the lungs. The body should be quietly con- veyed to a warm and dry situation, and rubbed all over with moderate stimulants, as diluted flower of mustard, or the warmer balsams; while the nostrils are plied with ammonia, and the eyes exposed to a strong light, t But a res- toration of the action of the lungs is chiefly to * The post mortem appearances of drowned per- sons, as stated by different writers, vary. " Upon dissection" says a distinguished authority in medi- cal jurisprudence (Paris and Fonblanque, vol. ii., p. 36), " we shall perceive the vessels of the brain more or less gorged with blood; in the trachea, a watery and bloody froth will be found; the lungs will appear expanded, full of frothy mucus, and generally livid; the right cavities of the heart gorged with blood, the left nearly empty; and it has been sometimes noticed that the blood remains fluid, and follows after every incision by the scal- pel." Orfila believes that a greater or less quan- tity of water is generally inspired during the agony of drowning: he remarks (Diet, de Med., tome xx., p. 25), " I have examined at La Morgue the bodies of many who have been drowned, which had been in the water for a few hours only, and I have frequently found a froth or frothy fluid in the tra- chea and bronchi." Dr. E. J. Cox has rendered it very probable (N. A. Med. and Surg. Journal, Oct., 1826), that water seldom enters into the lungs be- fore the last moments of life, when the glottis loses that organic sensibility which generally pre- vents the entrance of a foreign fluid into the tra- chea.—D. + The Humane Society, in their Report for 183), very properly recommend the wet clothes to be immediately taken off, and the body to be wiped, cleaned, and wrapped in dry clothes or blankets, so as to prevent evaporation, and the effects of ex- posure to a cold medium. The body should then be carried in the recumbent posture on the back, with the head and breast raised. As soon as it has arrived in the room for its reception, it should be stripped and covered with warm blankets. If the mouth and nostrils be obstructed, they must be thoroughly cleansed. The lungs are then to be be aimed at; and for this purpose, a full expira- tion of warm air from the lips of a by-stander should be repeatedly forced into the patient's mouth, and his nostrils held close to prevent its escape by that channel. Inflation may also be attempted by a pair of common bellows ; or, which is far better, if it can be readily procured, by a pair of bellows communicating with a pipe introduced into the larynx, or, as some have rec- ommended, into an aperture made between the rings of the trachea. Stimulating injections of acrid purgatives, or camphire, ammonia, and brandy, or other spirits, have often been intro- duced with success into the rectum, and some- times injections of warm air alone ; and it would be better that the air introduced into the lungs should be also moderately warm. Besides this active process, h may be possible to convey some warm and cordial stimulant, as ammonia, or the compound spirit of lavender, into the stomach by means of a syringe ; or what may probably in this case answer better, by a piece of sponge, impregnated with one of these, fixed to the end of a small rod of whalebone. In the Berlin Transactions is recommended the use of a ven- triculi excutia, or stomach-brush, to produce in- ternal friction in the same manner. There is no family of diseases in which the internal use of phosphorus seems to promise more success. The German physicians have employed it very generally in the last ebb of ty- phus fevers, in apparent death from convulsion (De Phosphori, loco Medicamenti ad sumpti, vir- lute medicd, dec, Anat. J. Gabi, Mentz), and in most cases in which the nervous power has been suddenly annihilated. It is one of the most powerful stimulants we know, and in asphyxy should be given to the amount of two or three grains for a dose, dissolved in ether.* Venesection, and especially that of the jugular vein (Jo. Wences Nachtigal, Dissertatio de Sub- mersis, Vindobon, 8vo.), has been strenuously recommended by physicians of high authority; and wherever there is reason to believe that the drowning has followed a sudden fit of apoplexy, the recommendation is rational enough, provided it can be practised with effect. But, commonly speaking, it is advice to no purpose, for the blood will not flow; and in other cases, if it would, such depletion, we have reason to believe, would do more injury by weakening, than good by removing what is erroneously supposed to be congestion. It may occasionally, perhaps, be serviceable as soon as the living powers begin inflated, and dry warm flannels, bags of warm grains, or bottles or bladders of warm water, ap- plied to the epigastric region, the soles of the feet, and other parts of the body. Bleeding ought never to be employed in this stage of the process; though it may become necessary when the circu- lation has returned, and reaction has taken place. —Ed. * With regard to stomach-brushes and stomach- mops, the editor coincides with Dr. Roget in thinking the proposal of them altogether extrava- gant.—(See Cyclop, of Pract. Med., art. Asphyx- ia.) The commendations also bestowed on the virtues of phosphorus in asphyxy are not entitled to any confidence.—Ed. 376 NEUR to show themselves, but it is rarely to be tried in the first instance. Returning life is first usually discoverable by the symptoms of sighing, gasping, twitching, or subsultus, slight palpitation, or pulsation of the heart; in effect, by a weak or clonic action in most of the organs. Our efforts should here be redoubled, for the feeble spark still requires to be solicited, and nourished into a permanent flame—and has often disappeared from a relax- ation of labour. A spoonful or two of warm wine, or wine and water, should now be given by the mouth as soon as the power of swallowing is sufficiently restored ; which should.be shortly succeeded by a little light, warm, and nourishing food of any kind, with gently laxative clysters, a well-heated bed, and perfect tranquillity. I have dwelt the longer upon this subject, because the general principles of the remedial treatment here recommended apply to most of the other varieties under which asphyxy or sus- pended animation is to be traced ; and the reader who is desirous of following the operative plan into a still minuter detail, will do well to con- sult Dr. Cullen's leter to Lord Cathcart, the president of the Board of Police in Scotland, concerning the recovery of persons drowned and seemingly dead, an able extract of which is given in the Medical Commentaries of Edinburgh.— (Vol. iii., p. 243.) We may observe, however, that in attempting the recovery of those who have been hung, and particularly who have in- expertly hung themselves, bleeding from the jugulars may be more frequently found neces- sary than in attending the drowned, since in the former, as we have very fully observed above, there is a greater tendency to apoplectic symp- toms than in the latter : yet, even here, the quantity abstracted needs not be large. In the second variety of asphyxy, or that from an inhalation of irrespirable auras, death in many cases takes place instantaneously ; and consequently, for reasons already advanced, the general surface of the body, and even the coun- tenance itself, is pale.—(Brukser von den Un- gewissheit der Kennzeichen des Todes.) Yet as the gas is often in some degree diluted with atmospheric air, the circulation, and even the breathing, are occasionally continued for some time in a feeble and imperfect state, and the asphyxy is united with symptoms of apoplexy, or genuine apoplexy takes place in its stead. In Cornwall and other mining regions, these gases are vulgarly called damps, from the Ger- man dampff, " a vapour or exhalation." The direct effect of such gases, when in a concentrated state, is utterly and instantaneously to destroy the irritability and sensibility of the nervous system, of which we have examples perpetually occurring in persons who incau- tiously descend foul beer-casks Or the shafts of mines. By what means, however, such ex- halations, when they have penetrated the lungs, become so rapidly communicated to the nervous system as to prove instantly destructive, we do not seem to be very well informed. Absorption would be the most ready way of accounting for it; but, till the objections thrown out by Mr. 3TICA. [Cl. IV—Ord. IV Ellis against an absorption of oxjrgoB or any other gas by the lungs, and which we have no- ticed in the Physiological Proem to our second class, are more satisfactorily replied to than they appear to have been, it is an hypothesis that can hardly be allowed. In the case of hanging or drowning, it does not seem to be owing to a direct want of irritability that the heart ceases instantly to contract, but as we have already re- marked, to its being deprived of the necessary stimulus, which is no longer afforded by the lungs, however they may act, in providing it. Yet, in the present case, there seems to be not only a cessation of action for want of a proper stimulus, but a total abstraction of both sensific and motific power ; and this as completely in one part of the frame as in another. The gases of the description before us that are found most fatal, are the carbonic acid, hydrogen, nitrogen,* and several of a more com- !>ound kind, which are thrown forth from putre- ying animal and vegetable substances, and especially from cemeteries, on opening fresh graves, in which the process of decomposition is proceeding rapidly, and the concentrated ef- fluvium bursts forth with an intolerable stench. Of the powerful effects of this last exhalation, Fourcroy has furnished us with a very particu- lar and striking account from the narration of grave-diggers examined for the purpose : from which it appears that those who are immedi- ately hanging over a corpse whose abdomen is accidentally penetrated with a pickaxe, often fall down in a state of senselessness and appa- rent death, while persons who happen to be at a little distance, and receive the exhalation in a form diluted with atmospheric air, are attacked with nausea, vertigo, faintness, and tremours, which continue for some hours. The most common of these gases is the car- bonic acid, which is chiefly found in the guise of a torpefying vapour in close rooms where charcoal has been burnt, at the bottom of large beer-casks, or of wells, and in many natural caverns in the earth's surface. Its weight pre- vents it from oscaping readily, even where there is an accession of atmospheric air ; and its want of smell, when pure, prevents it from being de- tected otherwise than by its effects, As it will not support flame, the common and easiest test, where it is supposed to exist, is that of a lighted candle, which is well known to be extinguished immediately, if this gas be present in a quan- tity sufficient to be injurious to respiration. * From the experiments of Sir Humphrey Davy, it would seem that hydrogen and azotic gases have no positively injurious operation on the system. The voluntary respiration of them for a short time is unattended with danger. The deviations from this result, occasionally noticed, are ascribable to an admixture of other gases, particularly that of carbonic acid. The phenomena exhibited by an- imals confined in hydrogen or azotic gas are those of simple asphyxia. They are not kiUed at once by any actively deleterious principle of such gases, as they are when carbonic acid gas, carburetted hydrogen, and certain other kinds of air enter the | lungs.—Ed. Gen. VIII.—Spe. 1.] CARUS ASPHYXIA. 377 Nitrogen and hydrogen, when pure, have probably as little smell as carbonic acid gas; but they are generally combined with other gases, sulphur, carbon, or phosphorus. The first, for- merly denominated phlogistic air, and sometimes mofette, is thrown forth largely during the de- composition of animal matter, and in a small de- gree during that of vegetable matter. Combined with hydrogen, it forms ammonia ; with oxygen, nitric acid. Fourcroy asserts that it possesses a peculiar and distinct odour, resembling that of fishes just beginning to putrefy ; but this is probably at all times produced by its combina- tion with other materials. It seems chiefly con- cerned in giving the greenish colour to parts, and especially muscular parts, in a putrid state. In some gases of this kind, a candle will burn freely. Hydrogen issues also from fecal matter, and in combination with sulphur, phosphorus, and carbon, produces the chief part of the nausea- ting and putrid stench thrown forth from decom- posing animal and vegetable substances. It is emitted in a much purer state from the sides of coal and metallic mines, and often exists in con- siderable abundance without being perceived by the nostrils. If mixed with an equal proportion of oxygen, it may be breathed for about an hour without any great inconvenience. If inhaled beyond this time, or in a more concentrated form, it has a great tendency to occasion the effects we have just noticed, lower the irritabil- ity of the animal frame, and induce stupor or an inclination to sleep. The fumes of mercury, lead, and some other metallic substances, when highly concentrated, seem to operate not very dissimilarly to those of charcoal, and give a check to the mobility of the nervous power at once. The fumes of charcoal are generally inhaled in a diluted form, but they are still highly dele- terious, and produce asphyxy more or less com- plete, according to the degree of concentration, and in some cases according to the strength or weakness of frame of those who are exposed to them. We have a striking illustration of this in the case of two persons communicated by Dr. Babington to the Medico-Chirurgical Society, who had gone to bed in a room in which a char- coal fire was kept up through the whole of the night, with the gas of which the surrounding atmosphere was strongly impregnated. Accord- ing to the principle we have endeavoured to establish, we ought here, from the dilution of the vapour, to expect, that whatever tendency there might be to asphyxy would be united with a tendency to apoplexy. And such we find to have been the fact; for, of these two persons, the younger and less vigorous, a boy of thirteen, died apparently during his steep, and without commotion ; while the elder and more robust, a man of thirty-eight, was found, upon being called in the morning between six and seven, in an apo- plectic state, with a swollen, projecting tongue, suffused and prominent eyes, and laborious breathing.* * The power of resisting the effects of carbon- The patient, if any degree of sensibility re- main, should in this variety be freely exposed to the open air, instead of to a heated atmosphere, as in the preceding : and if he can swallow, acid- ulated liquids should be given him. If insen- sible, cold water should be dashed on his face ; strong vinegar, and especially aromatic vinegar, be rubbed about his nostrils, and held under them, and stimulating clysters be injected, as recommended under the first variety. The lungs should be inflated with the warm breath of a healthy man, or, which is better, with oxygen gas. A proper use of voltaic electricity is also in many instances found highly serviceable. No ad- vantage, however, is likely to accrue from pas- sing the electric aura across the chest, directly through the heart and lungs, which is a common practice. The fluid should be transmitted along the channel of the nerves, from the seat of the phrenic nerve in the neck, to the seat of the diaphragm, or that of the par vagum immedi- ately under the sterno-rhastoid muscles, and that of the great sympathetic nerve, which send forth branches to the heart.* In Dr. Babing- ton's case, the application of voltaic electricity surprisingly increased the power of the muscles of respiration, but appeared rather to diminish the action of the heart. It was hence used al- ternately with a forcible inhalation of oxygen gas, and various external stimulants. Vene- section was tried, but does not seem to have been beneficial. The man recovered in a few days.f M. Portal recommends opening the external jugular vein ; but the blood will rarely flow from any vein, and is still more rarely succeeded by any advantage, even where it is obtained. And if every other remedy fail, he advises bronchot- omy, and a scarification of the feet and hands. J ic acid gas is supposed to be less in youth than in more mature age. The boy referred to in the text was found completely dead; but the man eventuaUy recovered. A similar case is reported by Bourdon, of a woman thirty-five years of age, who resolved to destroy her own life and that of her daughter, a child five years old.—(Principes de Physiologie Medicate, partie ii., p. 650.) Having shut herself up with the little girl in a closet, with a large brasier of burning charcoal, the bodies were afterward found extended on the floor. The mother was soon restored ; but no means were of any avail for the recovery of the child.—En. * Greg. Consp. Med. Theor. Hufeland, Diss. usus Ver. Elect, in Asphyxia, Goet., 1783. t Notwithstanding the text maintains the inu- tility of bloodletting in cases of asphyxia from car- bonic acid gas, the abstraction of a few ounces of blood has in some cases been found useful, co-op- erating with othermeans in relieving the oppressed state of the lungs. Even the instructive case of Dr. Babington (Medico-Chirurg. Trans., vol. i.) proves the value of the practice. In most cases, however, the operation is impracticable. In Rus- sia, where from the mode of burning fuel asphyxia from irrespirable gases is not unfrequent, the com- mon mode of treatment is to rub the bodies with snow; a practice foUowed, it is said, with the hap- piest results.—D. X Obs. sur les Effets des Vapeurs Mephytiques 378 NEUROTICA. [Cl. IV.-Ord. IV. The sprinkling or dashing of water upon the body seems to be useful, by having a tendency to rouse the vessels on the surface to contract.* In the third or electric variety, the whole system appears to be not so much rendered in- irritable to stimulants, as to be suddenly ex- hausted of its entire stock of nervous power, like a Leyden vial upon an application of the discharging rod; in consequence of which the limbs are flexible, the countenance pate, and the blood uncoagulable. The mode in which the electricity is communicated is of little impor- tance ; for, if sufficiently powerful for the pur- pose, real or apparent death is instantaneously produced, whether the stroke flow from light- ning, an electric battery, or a voltaic trough. Upon plants, on the contrary, we often find a stroke of lightning of the same intensity occa- sion very different effects in different kinds or branches of the same plant, in consequence of the variety they exhibit as conducting powers. Upon some, it descends without mischief; in others, it exhausts itself on particular parts, which are withered, as though attacked by a hemiplegia. In the betula alba, or common birch, it never runs along the stem, but confines its stroke to the top alone, beating off the boughs in every direction. In animal life, however, there is also a dif- ference of effect, but only in proportion to the degree of intensity of the electric power that attacks the system; and it is curious to observe the nature of this effect. Small doses of elec- tricity prove a powerful stimulus to the nervous function, increase the flow of sensorial energy, and augment the irritability of the muscles: while a violent shock, as we have just seen, ex- hausts the nervous system instantaneously, car- ries off the entire stock from the animal fabric, and leaves the muscular fibres flaccid and flag- ging. This singular result is extended to the blood, and extended to it in both cases ; for its coagulability, or the firmness of its texture, is increased by the application of small doses of electricity; while the shock of lightning, which renders the muscles lax and uncontracted, ren- ders the blood loose and uncoagulable. It is to this variety of effect that Mr. John Hunter makes a powerful, and certainly a very impressive ap- peal, in proof that the blood, though a fluid, is actuated by the same living principle as the muscular fibres, t sur les Corps de l'Homme, &c, nouv. edit., Paris, 1774 * Throwing cold water on the face and breast is well known to have considerable influence in dis- pelling syncope. The dogs which are made the subject of experiment at the Grotto del Cane, are usually plunged into a neighbouring lake, as a means of" promoting their recovery.—Ed. t But few cases of the effects of lightning on the human body are recorded. Paris and Fon- blanque refer to the dissection of a man killed by lightning in the London Philosoph. Transactions, but it contains nothing remarkable. Mr. Brodie concluded from an experiment on a guinea-pig which was killed by repeated strokes of elec- tricity, that the electric shock did not destroy the irritabiUty of the muscular fibre, nor did it affecl The general principle of medical treatment has been laid down under the first variety. Stimulants of the most active kind should be re- sorted to without loss of time : but of all stimu- lants, that of electricity, or voltaism, seems to be especially called for in the present modifica- tion of asphyxy. I do not know that it has ever been tried to any great extent in the variety be- fore us, on the human subject, but M. Abild- gaard has related a few experiments on other animals that are well worthy of attention. The animals chiefly selected were from the poultry- yard, and consisted of cocks and hens. These the action of the heart. Death took place pre- cisely in the same manner as from a severe injury of the head, and the animal died manifestly from the destruction of the functions of the brain. The facts, that the muscles are relaxed and inca- pable of contraction, that the limbs do not stiffen as in other cases of death, that the blood does not coagulate, and that the body runs rapidly into a state of putrefaction, are well established: yet ex- ceptions occur. Beccaria mentions a case of death by lightning where the body became ex- ceedingly stiff soon after, and in one of Mr. Bro- die's experiments the same occurred in the mus- cles of a guinea-pig. " Dr. Francis," says Dr. T. R. Beck (Med. Jurisprudence, vol. ii.), "mentions that he has seen a case where the muscles im- mediately became extremely rigid." "The mor- bid evidences of death by lightning vary exceed- ingly," says Dr. Francis. " Death may follow from the force of the electric fluid, and no dis- organized appearances externally be observed. The electric fluid may have nearly expended its force, and occasioned partial vesications on the surface of the body; these vesications will some- times exhibit, results like those produced by scald- ing water; sometimes the surface will present groups of vesicular patches, or the epidermis wiU be destroyed; the hair of the body may be scorched. In one case I observed, the common integuments about the anterior and superior parts of the chest were raised; the lesions appeared like the cortical desquamation of a tree, and several fissures or streaks extended to the pubes. In another instance where the individual was de- stroyed by a vivid stroke of Ughtning, which en- tered the crown of his hat, the scalp was torn from its bony attachment, the left eye rooted out, the upper lip torn off, and the left side of" the body denuded to the heel of the left foot; the abdo- men swelled to an enormous extent, and the tongue protruded. In two cases the brain inter- nally appeared overloaded and turgid; the menin- geal covering was surcharged with dark blood; there was arachnitic effusion under the arachnoid membrane; and about an ounce and a half of serous effusion in the two lateral ventricles. In a third case, the brain exhibited no disorganization. In one instance the right side of the heart was sur- charged, whUe the left was nearly empty, and there was a slight degree of effusion in the peri- cardium ; the lungs presented many of the appear- ances seen in asphyxia from charcoal. In one case I have found the bladder considerably dis- tended with urine; in another, quite empty. In four of the cases I have examined, the bodies re- mained flaccid, and ran speedily into incipient de- composition ; the blood seemed dissolved, and would not coagulate, and the cadaverous exhala- tion was very conspicuous; in one, however, an adult black aged about thirty-six, the body stif- fened."—D. Gen. VIII.—Spe. 1.] CARUS ASPHYXIA. 379 were first rendered asphyctic, or apparently dead, by a strong shock of electricity passed through the head ; and afterward recovered by another shock passed through from the chest to the back, the animal instantly walking about as if nothing had happened. M. Abildgaard does not say what interval he allowed between the shocks thus administered : but he observed, that where no second shock was employed, the appa- rent was converted into real death; for the ani- mal, in no instance, showed any tokens of resus- citation : and he observed farther, that if the second shock were thrown through the head like the first, instead of from the chest to the back, the same lifelessness continued, and no benefit whatever was produced.—(Socielatis Med. Hav- niensis Collectanea, &c, vol. ii., art. Teritamina Electrica in Animalibus.)* In frostbitten asphyxy, or that produced by intense cold, the limbs are rigid, and the countenance pale and shrivelled.t This variety is always preceded by an insurmountable desire to sleep, which the utmost exertion of the will is unable to overpower. The steep is, in most cases, fatal, and becomes the sleep of death.— (Rhazes ad. Almans., tract, vi., cap. v., vii.) * Dr. A. H. Stevens of New-York has recorded a case of injury by Ughtning successfully treated by copious venesection: the amount of blood drawn within ten days was about one hundred and twenty ounces.—(See the Medical and Surg. Register, p. 55.) In the case of Frances Gray, detailed by Dr. Paul of Kingston, Jamaica, vene- section was employed three times during the treatment, and with the happiest results.—(See the Jamaica Physical Journal, vol. i., p. 354.) The public journals recently contained the case of a person struck by Ughtning who was restored by pouring cold water on the head for several hours. —D. t Dr. Kellie of Leith, when speaking of the ex- ternal appearance and pathological condition of two persons perishing from cold, remarks: " In re- viewing the appearances observed in the dissection of these two bodies, our attention cannot fail to be arrested by the striking resemblance which the one, in almost every particular, bears to the other; in both we observed the same soundness and freshness of the bodies, in the abdomen the same congestions of the viscera, especially the same re- markable redness of the small intestines from the turgescence of their bloodvessels, the same absence of fetor, putrescence, and tympanites, the same perfection of the other viscera, with the exception of the pancreas in the woman; in the head, the same bloodless state of the scalp, the same tur- gidity of the vessels on the surface of the brain, the same congestion of the sinuses, the same soundness of the cerebral texture, and the same serous effusion, amounting in the one to nearly four ounces, in the other, to about three." Similar ap- pearances have been described by Quelmalz (Progr. quo frig, acrieris in corp. human, affectus ex- pedit, Lipsioe, 1755.) Rosen (Anat., p. 142) found the vessels within the cranium were much dis- tended with blood, and Cappel (Obs. Anat.) ob- served great congestion of the internal viscera. Dr. Kay remarks (Treatise on Asphyxia, London, 1834, p. 309), "perhaps the most remarkable cir- cumstance observed in these post mortem ex- aminations is, the great effusion of serum into the ventricles of the brain."—D. Captain Cook, in the account he has given of his first voyage round the world, has strikingly exemplified this remark in the case of Dr. Sol- ander and Mr. (afterward Sir Joseph) Banks. " Dr. Solander," says he, " who had more than once crossed the mountains which divide Swe- den from Norway, well knew that extreme cold, especially when joined with fatigue, produces a torpor and sleepiness that are almost irresistible ; he therefore conjured the company to keep mo- ving, whatever pain it might cost them. ' Who- ever sits down,' said he, ' will sleep, and who- ever sleeps, will wake no more.' Dr. Solander was the first who found the inclination, against which he had warned others, irresistible, and in- sisted upon being suffered to he down. He soon fell into a profound sleep, from which, however, by the exertion of Mr. Banks, he was awakened. Several others of the party very narrowly es- caped; and two of them slept, and perished from the cold."—(Hawkesworth's Account of Voyages, vol. ii., p. 46.) For these symptoms, and their effects, it is easy to account. Cold, so long as the living power is capable of producing a reaction, is one of the most strenuous tonics we are possessed of, and the glow that accompanies the reaction is felt to be peculiarly vigorous and elastic. But if it exceed this proportion, and no reac- tion ensue, the contraction of the vessels on the surface is converted into a rigid spasm, the blood is driven into the interior, and the surface must necessarily be pale. In this extremity of temperature, moreover, cold, instead of being a tonic, is one of the most formidable sedatives in animal chymistry : it carries off the heat of the body far more rapidly than it can be recruited, and as effectually exhausts it of all its irritable and sensible power. But such exhaustion, as we have already shown under the genus paro- niria, is a cause of stupor or sleep, and a cause so cogent that the will is, in many cases, in- capable of resisting it, and falls a prey to its power. In applying remedial means to this modifica- tion of asphyxy, great caution is necessary re- specting the employment of warmth ; and par- ticularly where the limbs are peculiarly rigid, and under the influence of frost.* In this last case it will be generally found most advisable in the first instance, as in frostbitten limbs, to plunge the body for a few minutes into a bath * " In Siberia,"says Gmelin (Voyage in Siber., trad, en Fr. parKeralio, Paris, 1767, Journ., p. 381), "the frozen, pale, and insensible limbs are first rubbed with snow; as soon as they begin to regain their sensibility, the snow is replaced by warm water. If they have been frozen a short time, the most prompt remedy is to rub them with wool. The Jakrouts employ another process, which the Russians have also adopted; they cover the frozen limb with mud or clay, or with both, to bring back sensation. These substances are used also as prophylactics, and when about to travel in the cold, they cover the hands and face with a layer of them. It would seem too that turpentine, applied to a frozen limb, and then gradually ex- posed to heat, so to be melted in as warmly as possible, is useful."—D. 380 NEUr of cold seawater or salted water, at the same time that warm air may be breathed into the lungs, and the stomach and rectum gently excited by moderate stimulants : for it does not follow that, because the limbs and surface of the body are frozen from frostbite, the central parts have suffered to the same extent. After a short immersion in seawater, the body should be taken out, wiped perfectly dry, laid in flannel in a moderately warm room, and submitted to the friction of warm hands, several persons being engaged in this process simultaneously.* SPECIES II. CARUS ECSTASIS. ECSTASY. total suspension of sensibility and volun- tary motion ; mostly of mental power ; pulsation and breathing continuing : MUS- CLES rigid : body erect and inflexible. There is so close a connexion between the present and the ensuing, and, in truth, most of the ensuing species of the order before us, that they are occasionally apt to run into each other, or to exhibit a few aggregate symptoms. And on this account, they have been very differently arranged by different writers. Sauvages, and most of the continental nosologists, have regarded them as distinct genera. Dr. Mead and Dr. Cullen, as species or subdivisions of apoplexy, and Dr. Cheyne, as the same of lethargy. Dr. Cooke has treated of them more cursorily than those who are acquainted with his talents and learning could wish ; and has so far followed Dr. Cullen as to place them conjointly in a chapter under the head of apoplexy : while Dr. Young, coin- ciding with the view taken in the present work, has arranged the whole as a species, under the generic name of carus. To understand the nature of their distinctive symptoms, and the reason of their occasional combination, it is necessary to bear in mind the remarks offered in the Physiological Proem to the present class respecting the natural division of the nervous ramifications into sensific and mo- tific fibres ; since it happens that some of these diseases are confined to one set, and others to another, while other diseases again extend equal- ly to both. And hence we are able to account for disorders in which the perception or sensibil- ity is abolished, white the irritability continues without much interference : or in which there is * Baron Larrey,in his account of the sufferings of the French army in the Russian campaign, re- fers to numerous examples of soldiers, who were under the influence of exposure to intense cold, falling down completely dead on their entering warm rooms, or approaching too near to the fires of the bivouacs.--(8gii Campagnes ou Mem. de Chir. Militaire, t. iv.) - Caloric should be commu- nicated in the most gradual manner, and this prin- ciple is essentially requisite, not only with the view of restoring animation suspended by cold, but for the purpose of preventing the attack of chil- blains, and of a rapid and uncontroUable species of gangrene, in cases where the effects of intense cold are chiefly restricted to the extreme parts of the body, the feet, hands, nose, ears, &c.—Ed. OTICA. [Cl. IV.—Ord. IV. a disturbed flow or total cessation of the irrita- ble power, with little interference with the per- cipient, and sometimes also with the sentient, as in some cases of paralysis : or in which there is a disturbance or cessation of all these, with the exception of a partial supply of irritative power to the involuntary organs. It will also be ne- cessary to recollect, as we have endeavoured to show in many of the preceding pages, and par- ticularly under the genus clonus, that, where there is a disturbance of the motific or irritative power, this disturbance is of two kinds, one from excess, and one from deficiency; and that, in both cases, there is a great irregularity of action, and consequently entastic or rigid, and clonic or agitatory spasms, exhibiting by their continuation innumerable modifications. All the divisions of the nervous system, more- over, have a natural tendency to sympathize in the same action, however combined or inter- changing ; and hence, in whatever division of it a disease commences, one or more of the other divisions are peculiarly apt to participate in the affection; and the more so, as it is not very common for abnormal actions, when once com- municated, to proceed with much order or regu- larity ; for if trismus and tremour give us exam- ples of such order, tetanus very generally, con- vulsion-fit, epilepsy, and hysteria, furnish proofs of the most capricious alternations of spastic and clonic action, or of their existing in different trains of muscles simultaneously. These remarks peculiarly apply to ecstasy, the species immediately before us, compared with catalepsy or trance, the species that im- mediately follows. In both, the nervous influ- ence contributory to sensibility and irritability is disturbed in its transmission or regularity of ac- tion, but not equally, nor in the same manner; for while the transmission of the sensific prin- ciple seems to be totally suspended, that of the irritable principle continues, though with a stri- king deviation from the uniform tenour of health. Thus far the two diseases agree. They differ in the nature of the disturbance of the motific principle. In ecstasy, this seems to be pro- duced in excess, and irregularly accumulated ; inconsequence of which the muscles are thrown into a rigid and permanent spasm, not incurva- ting the body, as in the different modifications of tetanus, but maintaining it erect from an equal excess of supply to the extensor and flexor muscles. In catalepsy, on the contrary, the motific principle seems to be in deficiency rather than in excess, though it is often irregu- larly distributed; and hence, while some mus- cles appear sufficiently supplied, the action of others, even the involuntary ones, is often pe- culiarly weak. Whence also the limbs, instead of resisting external force, yield to it with readi- ness, and assume any position that may be given to them. In both cases, the torpitude of the external senses appears to extend to those of the mind ; for the patient, on returning to himself, has no recollection of any train of ideas that occurred to him during the fit. Yet we shall find pres- ently, that in a few instances, the power of Gen. VIII.—Spe. 3.] CARUS CATALEPS1A. 381 sight and of judging, and perhaps some other powers, do not seem completely to have failed. It deserves, however, especially to be re- marked, that both these diseases are most com- mon to persons constitutionally disposed to some mental estrangement, as melancholy or revery, hypochondriacism, or morbid elevation of mind ; thus pointing out to us the outlet at which the sensorial power is carried off: for we have al- ready seen, that under intense revery, the exter- nal senses are for the most part inactive or tor- pid to the impressions of surrounding objects during wakefulness; while the mind is alike dead to every thing but the train of ideas which immediately constitutes the subject of the revery. The same tendency to abstraction, though not carried so completely into effect, is often'to be found in Melancholy, and still more so in that species of alusia which, in the present work, is denominated elatio, mental elevation or extrav- agance, and particularly the variety called ela- tio ecstatica, false inspiration, visionary con- ceits. If the person labouring under any of these be attacked at the same time with a gen- eral entasia, or rigid tetanus, erecting instead of incurvating the body, he will be thrown into an ecstasy, constituting the present species. And if instead of an excessive there be a deficient supply of irritable power, and consequently a flaccidity or flexibility of the muscles instead of a rigidity, his disease will be a catalepsy, con- stituting the ensuing species, with this difference alone, that in most cases of the two diseases be- fore us, the faculties of the mind unite in the torpitude of the senses, instead of giving rise to it. I say in most cases, and have kept to the same limitation in the specific definition: for if it be true that one of the causes of both these affections is profound conteamlation or attention of mind, or some overwhelming passion, as we are told by many writers, the mind does not seem in such cases to be without ideas, nor without them in a very energetic degree. And it is to ecstasis under this modification that I am inclined to think we should refer the cato- chus of most of the nosologists, which they ar- range in the same order as, and next to tetanus, and define a " general spastic rigidity without sensibility." Ecstasis is of rare occurrence ; its predispo- nent cause is unquestionably a highly nervous or irritable temperament; the exciting or occa- sional causes it is not easy at all times to deter- mine. For the greater part, they seem to be of a mental character, as profound and long-con- tinued meditation upon subjects of great interest and excitement; and terror or other violent emotions of the mind. It seems also to have proceeded, like most of the spasmodic affections already treated of, from various corporeal irrita- tions, and particularly those of the stomach and liver, suppressed menstruation, repelled chronic eruptions, and plethora; and perhaps occasionally, as hinted by the younger M. Pinel, from an inflammation of the spinal marrow.— (Journ. de Phys. Expir., par F. Magendie, D. M., &e, torn, i., Janv., 1821.) The duration of the fit varies from a few hours to two or three days. The patient rouses as from a sleep, seems languid, and complains of nausea and vertigo ; evidently showing that the morbid supply of sensorial power is exhausted, and that the spasm has ceased inconsequence of such exhaustion. As the disease evidently consists in a disturb- ance of the balance of the sensorial power, or in an excessive production of the irritable, but a deficient or suspended production of the sensific principle, the curative intention should lead us to aim at a restoration of this balance; and hence the remedial process will run so nearly parallel with that for tetanus, that it is only ne- cessary to refer the reader to the treatment already laid down for that disease. Where catalepsy is connected with a morbid state of the liver, mercury given to ptyalism has often proved highly successful. Dr. Chisholm has given a very interesting case of this kind in a young lady of eighteen, of an hysterical di- athesis, and in whom the ecstasy, or parox- ysm of rigidity, was alternated with parox- ysms of mania. " At the end of ten minutes the patient suddenly started up in bed, the mus- cles became at once relaxed, but maniacal dis- traction of mind instantly succeeded. During the maniacal state, now, it was particularly sin- gular that, although she could not articulate a single word, and was evidently unconscious of what she did, yet she sung some very beautiful airs with a sweetness of tone and correctness of measure extremely interesting and affecting : at the end of ten minutes, her head suddenly and unexpectedly dropped, and she fell back into the state of rigidity."—(Of the Climate and Dis- eases of Tropical Countries, p. 160, 8vo., Lond., 1822.) She finally recovered by the use of mercury. SPECIES III. CARUS CATALEPSIA. CA TALEPSY. TRANCE. TOTAL SUSPENSION OF SENSIBILITY AND VOLUN- TARY MOTION; MOSTLY OF MENTAL POWER ; PULSATION AND BREATHING CONTINUING ; MUS- CLES FLEXIBLE ; BODY YIELDING TO AND RE- TAINING ANY GIVEN POSITION. This species is chiefly distinguished from the preceding by the flexibility instead of the inflex- ibility of the muscles. The cause of this differ- ence has been explained under the preceding species, and needs not to be repeated in the pres- ent place. The specific term common to the Greek writers is derived from KaraXauSdvo^ai, " deprehendor," " to be seized or laid hold of," and alludes to the suddenness of its attack. The predisponent and exciting causes are the same as those of ecstasis <£ and the state of the habit or idiosyncrasy alone produces the differ- ence of effect. The countenance is commonly florid, and the eyes open, and apparently fixed intently upon an object, but in most cases with- out perception. Yet here, as in ecstasis, we sometimes meet with examples in which one or more of the senses, mental as well as corporeal, do not associate in the general torpitude. So 382 NEUROTICA. [Cl. IV.—Ord. IV. in paroniria, the sight or hearing continues awake, while the other external senses are plunged into a deep sleep, and in some cases of paralysis, the sentient fibres retain their activi- ty, while those of motion are torpid. The paroxysm commonly attacks without any previous warning, and closes with sighing, or a clonic effort of the nervous power to re-establish its regular flow. Its duration is from a few hours or minutes to two or three days ; and, ac- cording to well-established authorities, some- times for a much longer period. And so com- pletely exhausted of irritable power are some of the organs, and even those of involuntary action, that we have one example in a foreign journal of forty grains of emetic tartar having been given without any effect.—(Behrends, Bal- dtngers N. Magazin, b. ix., 199.) The disease, like the last, is not common. Dr. Cullen never saw an instance of it, except where it was altogether counterfeited, and asserts the same of other practitioners ; which, in fact, he offers as an apology for not knowing exactly where to arrange it. "Therefore," says he, "from the disease being seldom, differently described, and almost always feigned, I can scarcely tell where to place it with certainty; but I am well persuaded that it does not at all differ from the genus apoplexy, and I have hence arranged it as a species of this division." Plethora or pressure of the brain may perhaps be an occasional cause of this, as of most other nervous diseases, in some habits ; but the greater number of cases that have occurred show very clearly that this disease in its genuine form is as distinct from apoplexy as from epilepsy. We have said that both catalepsy and ecsta- sy are most frequently found in constitutions disposed to mental estrangements. Dr. Gooch has given a very interesting case in illustration of this remark, in his paper on puerperal insani- ty, published in the Medical Transactions. The patient was twenty-nine years of age, had been often pregnant, but had only borne one living child ; and was now confined after delivery of a dead child in her seventh month of gestation. " A few days after our first visit," says Dr. Gooch, " we were summoned to observe a remarkable change in her symptoms. The attendants said she was dying, or in a trance. She was lying in bed motionless, and apparently senseless. It had been said that the pupils were dilated and motionless, and some apprehensions of effusion on the brain had been entertained. But, on coining to examine them closely, it was found that they readily contracted when the light fell upon them; her eyes were open, but no rising of the chest, no movement of the nostrils, no appearance of respiration, could be seen; the only signs of life were her warmth and pulse : the latter was, as we had hitherto observed it, weak, and about 120 ; her feces and urine were voided in bed. " The trunk of the body was now lifted, so as to form rather an obtuse angle with the limbs (a most uncomfortable posture), and there left with nothing to support it. Thus she continued sitting while we were asking questions and conversing, so that many minutes must have passed. " One arm was now raised, then the other, and where they were left, there they remained : it was now a curious sight to see her, sitting up in bed, her eyes open, staring lifelessly, her arms outstretched, yet without any visible sign of animation ; she was very thin and pallid, and looked like a corpse that had been propped up, and had stiffened in this attitude. We now took her out of bed, placed her upright, and en- deavoured to rouse her by calling loudly in her ears, but in vain; she stood up, but as inani- mate as a statue ; the slightest push put her off her balance ; no exertion was made to regain it; she would have fallen if I had not caught her. " She went into this state three several times: the first time it lasted fourteen hours ; the sec- ond time, twelve hours ; and the third time, nine hours, with waking intervals of two days after the first fit, and one day after the second. After this, the disease resumed the ordinary form of melancholia ; and three months from the time of her delivery, she was well enough to resume her domestic duties." From the rarity of the complaint and the sin- gularity of several of its symptoms, many physi- cians, who have never witnessed an example of it, are too much disposed, like Dr. Cullen, to regard it in every case as an imposture. The in- stance just given is sufficient to clear it from this charge ; yet the following, from Bonet, is added "in confirmation. George Grokatski, a Polish soldier, deserted from his regiment in the harvest of the year 1677. He was discovered a few days afterward, drinking and making merry in a common alehouse. The moment he was apprehended he was so much terrified, that he gave a loud shriek, and was immediately deprived of the power Of speech. When brought to a court-martial, it was impossible to make him articulate a word: he was as immoveable as a statue, and appeared not to be conscious of any thing that was going forward. In the prison to which he was conducted, he neither ate nor drank, nor emptied the bowels and the bladder. The officers and the priest at first threatened him, but afterward endeavoured to sooth and calm him; but all their efforts were in vain. He remained senseless and immoveable. His irons were struck off, and he was taken out of the prison, but he did not move. Twenty days and nights were passed in this way, during which he took no kind of nourishment, nor had any natural evacuation. He then gradually sunk and died.—(Medic. Seplentrion.,\A>. i., sect, xvi., cap. 6.) The pliability of the muscles to any stimulus that acts upon them is sufficiently evident from both these cases : but it has not been generally observed by pathologists, that the force of the stimulus which is acting upon them at the time of the attack continues afterward, so that the same state of motion or rest is still maintained. In the case of a schoolboy aged eleven years, related by Dr. Stearns (Hosack <$• Francis's American Med. Register, vol. i., art. viii.), the paroxysms returned ten times in twenty-four Gun. VIII.—Spe. 3.] CARUS CATALEPSIA. 383 hours, and never exceeded three minutes at a time. And if it commenced while the patient was walking, the same pace was maintained, though without the direction of the mind. The present author was consulted a few years ago on a similar case by a student of Gray's Inn, about nineteen years of age. Having been attacked with a fit of catalepsy while walking, within a few minutes after having left his chambers, he continued his pace insensibly, and without the slightest knowledge of the course he took. As far as he could judge, the paroxysm continued for nearly an hour, through the whole of which time his involuntary walking continued; at the end of this period he began a little to recover his recollection and the general use of his exter- nal senses. He then found himself in a large street, but did not know how he got there, nor what was its name. Upon inquiry, he learned that he was at the further end of Piccadilly, near Hyde Park Corner, to which, when he left his chambers, he had no intention of going. He was extremely frightened, very much ex- hausted, and returned home in a coach. He was not conscious of any particular train of ideas that had passed in his mind during the fit; but if such there had been, there can be little doubt that, like the visions of a dream, the rem- iniscence of them would have been completely banished by the terror he felt on first recovering his recollection, and finding himself in a strange place, to which he had been irregularly wander- ing through a great number of streets, without consciousness. He had several slighter attacks antecedently, shorter in duration, and, from his being at rest at the time, unaccompanied with a tendency to perambulate. In this case, and in aU of a similar kind, from the power which the patient seems to possess of avoiding danger, the faculty of the will and of sight must be in some degree of activity, however obtunded : bearing a near resemblance to paroniria ambulans, or sleep-walking, with the exception of the suddenness of the attack. Some pathologists, indeed, have noticed a modi- fication in which the powers of deglutition and digestion continue, as well as those of pulsation and breathing, provided the food be thrust into the mouth. If we were right in ascribing the catochus of the ancients to that form of ecstasy in which the mind retains some train of ideas, we shall probably be right also in referring their catoche to this modification of catalepsy; though Galen seems to have regarded the term as a mere synonyme of catalepsy, and iEtius adopted his opinion. Instead, however, of most of the involuntary or- gans being in a joint state of activity, instances have occasionally been known of an apparent cessation of activity in all of them. A critical examination of the region of the heart will most- ly, indeed, give proof of a very feeble flutter, and if a clear mirror be applied to the mouth and nostrils, it will generally be found to have a thin vapour on its face. But even these signs have not always been given : insomuch that the disease has been mistaken for real death : and in countries where the rite of sepulture takes place speedily, it is much to be feared that the unfortunate sufferer has in a few instances been buried alive.—(Pineau sur le Danger des Inhu- mations precipitees, Paris, 1776.) In a case of asphyxy of a singular kind, related by M. Pew, the patient, a female, was peculiarly fortunate in having had her interment postponed for the pur- pose of ascertaining the cause of her supposed death by dissection: for on being submitted to the scalpel, its first touch brought her to her senses, and threw her into a state of violent agitation, the anatomists being almost as much frightened as herself.* So Diemerbroeck re- lates the case of a rustic, who was supposed to be dead of the plague, and was laid out for in- terment. It was by accident three days before he could be carried to the grave, when, in the act of being buried, he showed signs of life, re- covered, and lived many years.—(Tractat. de Peste, lib. iv., hist. 85.) Mathaeus, Hildanus, and the collectors of medical curiosities, are full of stories of this kind; many of them, indeed, loosely related ; but many also possessing every requisite authority for belief; and urging the necessity of waiting for signs of putrefaction before the lid of the coffin is screwed down, or, I should rather say, before the body is removed from its deathbed. We have already observed, that the predis- posing and exciting causes are the same as those of ecstasy, and that the state of the habit or idiosyncrasy alone produces the difference of effect. This distinction has not been sufficient- ly attended to by pathologists in their mode of treatment: and hence one common plan has been too generally laid down and pursued in ec- stasy, catalepsy, lethargy, and even apoplexy, the general treatment being as much confounded as the diseases themselves. Commonly speaking, copious bleedings and purgings have been chiefly trusted to in all of them : and as the present disease, in some cases, arises from plethora, or obstruction, or some irritation of the stomach, it is not to be wondered at that this process should sometimes succeed. But if we have been correct in our pathology, if catalepsy be not only a nervous disease, but a disease of nervous debility, in which the sensorial power is distributed with enfeebled and clonic irregularity, and conse- quently with a necessary disturbance of the balance of the nervous system, it is perfectly clear that a reducent treatment, however ser- viceable in a few cases, cannot be laid down as the proper plan to be pursued in general, nor even in any case as an advisable practice, fur- ther than it may be called for by the contingen- cy of the exciting cause. Stimulants of most kinds will usually be found far more serviceable, particularly in the form of blisters to the head and heart, sinapisms and other rubefacients to the extremities, and injections to the rectum. It is now well known that the simplest sub- stances, as a solution of gumarabic, or merely * Pratique des Accouchemens, &c. Tozzetti's Raccolta de Teorie, Osservazioni e Regole per distinguere e promptemente dissipare le Asphyssie, o Morte apparente, Fiorenza, 8vo., 1772. tOTICA. [Cl. IV—Ord. IV. genuine lethargy and sound healthy sleep; in which sense the former becomes a strictly" ner- vous affection, dependant upon a weak and ir- regular action of the sensorial organ, accompa- nied with a diminished production of sensorial power, and this power, so diminished, irregular-1 ly distributed over its different departments or ramifications; being altogether withheld from the external senses and the voluntary organs, white the supply to the involuntary organs is little interfered with, as in ffie case of common sleep. The faculties of the mind seem also, in most cases, to partake of the torpitude of the external senses ; though, as the whole is a dis- ease of debility, and consequently of irregular action, we can readily account for a few singular cases that have been met with, in which the lethargy has been broken in upon by short re- turns of sensation, or even of speech, or by an irregular flow* of ideas, which the patient is sometimes apt to mistake for sensations. And hence lethargy has been observed under the fol- lowing varieties:— a Absolutus. Without intervals of Genuine lethargy. sensation, waking, or consciousness. fi Cataphora. With short remissions Remissive lethargy. or intervals of imper- fect waking, sensa- tion, and speech. y Vigil. Perfect lethargy of body, Imperfect lethargy. but imperfect lethar- gy of mind : wander- ing ideas, and belief of wakefulness during sleep. 384 NEUE warm water, infused, to the amount of not more than an ounce or two, into the current of the blood, by opening a vein, will not only excite the heart to a more violent action, but affect the stomach and intestinal canal with a like in- creased action by sympathy, producing sickness in the former, and looseness in the latter: and hence Dr. Regnaudot, in an ingenious inaugural dissertation, has thrown out a hint well worthy of being followed up, that such a stimulus may probably succeed in rousing the system generally in the present and most of the preceding species. Electricity or voltaism, in the manner already recommended, may also be tried with a hope of success : and if it be possible to introduce any thing into the stomach by means *of a syringe, brandy, ether, ammonia, camphire, or even phos- phorus, in the form and dose already recommend- ed, may be attempted in rotation. The body in the meanwhile should be kept warm, with a free influx of pure air, and general and perseve- ring friction should often be had recourse to. A steady use of the metallic tonics should be chiefly confided in after the paroxysm is over. SPECIES IV. CARUS LETHARGUS. LETHARGY. MENTAL AND CORPOREAL TORPITUDE, WITH DEEP QUIET SLEEP. Lethargy, from the Greek terms yfjOri and opydj> " oblivio pigra," is distinguished from all the preceding species of the present genus by the apparent ease and quietism of the entire sys- tem : the limbs retaining that gentle and placid flexion which they are wont to exhibit in natu- ral sleep, and the eyelids being consequently closed: by both which signs it is also distin- guished from apoplexy. Lethargy is sometimes produced by conges- tion or effusion in the brain ; by violent mental commotion, as that of fright or furious anger ; by retrocedent gout, or repelled exanthems ; but more generally by long-continued labour of body, or severe exertion of mind. The common causes of sleep, therefore, whether natural or morbid, are in many cases causes of lethargy. The proximate cause, how- ever, of idiopathic lethargy, does not seem to have been sufficiently pointed out; and on this account it has too frequently, like the preceding species, been confounded with apoplexy, and re- garded as a mere modification of it. We had occasion to take a glance at the gen- eral physiology of sleep under the genus ephi- altes, or nightmare, and observed, that its proximate cause is to be sought for in a torpi- tude or exhaustion of sensorial power from the ordinary stimulants of the day. Now it is pos- sible that the same effect may be produced by a defective supply of sensorial power as well as by its exhaustion; and consequently, that the torpitude of sleep may ensue whenever such de- ficient action or energy exists, even where there is no exposure to its ordinary exciting causes. And this it is, as it appears to me, which constitutes the real difference between The first variety has, in some instances, been considerably protracted. We have ex- amples of its continuance for forty days (Plott, Natural History of Staffordshire), and even for seven weeks.—(Bang. Collect. Soc. Med., Havn., ii., 17.) In one instance, it is said to have resulted from insolation, or exposure to the direct rays of the sun; and at length, with great singularity, to have yielded to a large flow of urine, loaded with pus, that fell to the bot- tom.—(Morgagni, de Sed. et Caus. Morb., ep. v., 13, 14, Albertino.) The SECOND variety, or cataphora, is the coma somnolentum of many writers : and is also a frequent accompaniment of many fevers and other diseases of great debility. It occurs at. times, however, as an idiopathic affection; and I was some years ago acquainted with a very singular example, that continued for five years. The patient was a young lady of delicate con- stitution, in her eighteenth year at the time of the attack : her mind had been previously in a state of great anxiety : the remissions recurred irregularly twice or three times a week, and rarely exceeded an hour or two: during these periods, she sighed, ate reluctantly what was of- fered to her, had occasional egestions, and in- stantly relapsed into steep. Her recovery was sudden, for she seemed to awake as from a night's rest, by a more perfect termination of the paroxysm, not followed by a relapse. G«n. Vin.—Spe. 4.] Carus lethargus. 385 A less fortunate case of the same kind is re- lated by Mr. Brewster, and was connected with depressed animal spirits, and probably conges- tion or plethora. The patient was a female servant about the middle of life. The first par- oxysm was preceded by a hemorrhage from the nose, and lasted three days: the next continued six weeks ; during which she occa- sionally swallowed food and had alvine evac- uations. She had two subsequent fitS, neither of which lasted above a few days. Not long afterward, she hung herself.—(Edin. Phil. Trans., 1817.) The third variety, or imperfect lethar- gy, is the typhomania of the Greek writers ; the coma vigil of many later pathologists. It is a frequent sequel upon fevers, or other causes of great nervous debility, in circumstances in which the sensorial power has not recovered its regu- larity of distribution, or stability of balance: during which the patient uniformly assures his physician and his friends, morning after morn- ing, that he has passed a restless and hurried night, without a moment's sleep, while the nurse has been a witness to his having been asleep the whole night long. The mode of treatment must depend upon the nature of the cause, as far as we are able to ascertain it. If this have consisted in any sup- pressed discharge or eruption, we should en- deavour to reproduce it by all possible means. If we have reason to suspect compression on the brain, copious bleedings, purgatives, and other reducents, are imperative. And if, as is more commonly the case, it be a strictly nervous af- fection, and depend on atony and a disturbed production or balance of the sensorial power, the warm nervine irritants, as musk, camphire, valerian, with blisters, sternutatories, and other stimulants, are the means we should have re- course to. These different processes have been pursued in most ages, but unfortunately they have been pursued indiscriminately : and bleeding, purga- tives, and ethers and other diffusible excitants, have been employed on like occasions, or even at the same time. Forestus and Dr. Cheyne, who regarded lethargy as chiefly dependant upon plethora or congestion, seem uniformly to have adhered to a reducent plan ; and Celsus, who contemplated it as a nervous affection, equally confines himself to external and inter- nal pungents, and advises pepper, euphorbium, castor, and vinegar, with the fumes of burning galbanum or hartshorn applied to the nostrils : as also shaving the head, fomenting it with a decoction of laurel-leaves or rue, and after- ward applying sinapisms or some other rubefa- cient epithem. All these are consistent with themselves, how much soever tho writers may differ in their view of the proximate cause. Yet, neither line of conduct can be right as a general practice ; and hence other practitioners have occasionally in- termixed the two, sometimes incongruously; and consequently have done less mischief, as at other times they have done less good. That genuine lethargy is, not unfrequently, a Vol. II —B b strictly nervous affection, and even closely con- nected with an irregular or debilitated state of the mind ; and that a reducent plan is not al- ways calculated to afford it radical relief, how- ever it may give a temporary promise, must, I apprehend, be obvious to mo6t practitioners who have paid a due attention to their own circle of cases; but the following example from Dr. Cooke, bearing a close resemblance in its ter- mination to that already quoted from Mr. Brew- ster, is peculiarly in point, and ought not to be omitted on the present occasion : " A lady about twenty years of age, who had usually enjoyed very good health, was one morning found in a state of profound but quiet sleep, from which she could not be awakened, although the preceding evening she had gone to bed apparently quite well. Various means had been tried with a view of exciting her from this state, but in vain. Under these circumstances, I recommended cupping in the neck ; and after she had lost a few ounces of blood in this way, she opened her eyes, perfectly recovered, and remained through the day quite free from all symptoms of disorder. The next morning, and for several successive mornings, she was found in a simUatstate, from which she was recovered by tn^pame rem- edy, no stimulating external applications produ- cing any good effect. As she was considerably weakened by repeated depletions, it was deter- mined that, on the next recurrence of the par- oxysm, the case should be left to the effects of nature, as long as was consistent with safety. The experiment was tried ; and at the end of about thirty hours, she spontaneously awoke, apparently refreshed, and wholly unconscious of her protracted sleep. On the future returns of these paroxysms, which were frequent, the same plan was adopted, and she awoke after intervals of thirty-six, forty-eight, and*, on one occasion, sixty-three hours, without seeming to have suf- fered from want of food or otherwise. In the early part of the disease, various means were employed without the smallest advantage, ex- cept that, while under the influence of mercury, which produced a very severe salivation that lasted more than a month, she was free from the complaint. For a considerable length of time, these paroxysms recurred: but at length they gradually left her ; and soon afterward she became deranged in mind, in which state I be- lieve she still remains."—'(Treatise on Nervous Diseases, vol. i., p. 372.) When, therefore, there are no symptoms leading to a peculiar cause, it will be advisable to bleed by cupping, once or twice, but not oftener ; to open the bowels and keep them in a state of slight irritation ; to employ blisters or other external stimulants occasionally, and to have recourse to a repeated use of the voltaic trough, sending the line of action from the oc- ciput down the spine, and varying it to the ex- tremities. In the meantime, if the patient can be made to swallow, we should try the effect of musk or camphire, with free doses of the me- tallic tonics, of which the sulphate of zinc, in doses of a grain three or four times a day, offers the best prospect of success. 386 NEUROTICA. [Cl. IV.-Obd.IV. SPECIES V. CARUS APOPLEXIA. APOPLEXY. MENTAL and corporeal torpitude, with pul- sation, and oppressive, mostly stertor- ous, sleep.* There is a considerable difference of opinion among pathologists whether stertor is a neces- sary and invariable, or only an occasional sign of apoplexy. Sauvages, Linneus, Vogel, Sagar, Forestus (Lib. x., obs. 73), Kirkland (Comment., p. 16), Young, and by far the greater number of writers, have arranged it as an essential symp- tom ; and, hence, the present author was in- duced to view it in the same light when he pub- lished his volume of Nosology. He has since, however, met with one or two cases of atonic apoplexy, in which, although the disease proved fatal, the breathing was at no time noisy or ster- torous, though uniformly laborious or oppres- sive : and he has hence been induced to modify the specific character in the manner it stands at the head of the present division ; and thus to approximate it to the opinion of Forestus, Cul- len, and ParJal, who do not regard stertor as a necessarySptex. Dr. Cullen is generally con- ceived to lave omitted this peculiar mark, in consequence' of his having included asphyxy and catalepsy, which have no pretensions to stertor, under the genus apoplexia. But as we shall have to return to this subject when discussing the different forms or varieties under which apo- plexy shows itself, I shall only further observe at present, that Dr. Cooke has, with great judg- ment, steered a middle course in laying down his own definition, which characterizes apo- plexy as " a disease in which the animal func- tions are suspended, while the vital and natural functions continue ; respiration being generally laborious, and frequently attended with ster- tor."! Apoplexy is strictly a disease of the nervous system, dependant upon a suspension of the sensorial power in almost all its modifications, sentient, percipient, and motory, with the ex- ception of a certain portion which still continues to be supplied to the involuntary organs; the faculties of the mind participating in the torpi- tude of the body. In these respects it bears a very near approach to the preceding species of * Another definition is, " Loss of sensation, vol- untary motion, and intellect or thought; respira- tion, and the action of the heart and general vas- cular system, being continued."—Ed. •t On Nervous Diseases, vol. i., p. 166. Apo- plexy is liable to be confounded with syncope and natural sleep. The following are the marks of distinction adverted to by Dr. Clutterbuck (see Cyclop, of Pract. Med., art. Apoplexy) : in syn- cope the respiration is suspended, the pulse is not to be felt at the wrist, the features shrink, and the surface of the body turns pale and cold. In apo- plexy the reverse of all these circumstances takes place. The distinction between apoplexy and nat- ural sleep can only be made by one being able to rouse the person from sleep, however profound, by a certain degree of irritation: this cannot be done, or but very imperfectly, in apoplexy.—Ed. carus ; it chiefly differs in its being generally connected with an oppressed state of the ves- sels of the brain from over-distention or effu- sion : so generally, indeed, that apoplexy is, by almost all the writers on the subject, regarded rather as a disease of the sanguineous than of the nervous system; the morbid action of the latter being supposed to be entirely dependant on that of the former, and consequently only a secondary affection. This view of the subject, however, is by far too limited: for although, in most cases, the more prominent symptoms concur with the ap- pearances on dissection in leading us to com- pression of the brain as the primary cause of the disease, yet we shall find presently, that it has sometimes taken place where no such com- pression seems to have existed, while we have already had occasion to notice a variety of af- fections of the head attended with forcible and severe compression, as inflammation and dropsy of the brain, that have run their entire course without any mark of apoplexy whatever: to which should be added that, while in most other diseases or lesions accompanied with compres- sion of the brain, and a suspension of sentient and motory power as a consequence hereof, such suspension ceases almost the moment the compression is removed, when the nerves of feeling and motion, together with the faculties of the mind, resume their wonted activity, and evince no tendency to a relapse ; in apoplexy, on the contrary, the result is always doubtful; for a palsy of some part or other is a frequent and permanent effect, or the mind suffers in some of its faculties, and a relapse is generally to be apprehended. So that, though compression of the brain, and particularly from a morbid state of the sanguineous and respiratory functions, may be justly regarded as the ordinary efficient cause, there seems to be at the same time some peculiar debility or other diseased condition of the sensorial system* to which apoplexy is pri- marily to be referred, and without which it might not take place ; and which has not been suffi- ciently adverted to by practitioners. Though there can be no difficulty in our affirming that, wherever such a morbid condition exists, com- pression, from whatever cause, will be sure to produce the disease. We may hence see why advancing age should * Perhaps, instead of these ambiguous expres- sions, it might be better to say that attacks of apo- plexy are mostly preceded by disease of the brain or its vessels, without which previous disease the apoplexy would not occur. This remark, how- ever, is liable to exceptions, because we know that apoplexy may be suddenly induced in the most healthy subject, if he take an extraordinary quan- tity of brandy, gin, or other strong spirituous liquor, into his stomach, in an undiluted state. Though apoplexy, in the sense of an effusion of blood in or upon the brain, is not usually occa- sioned by strangulation, especiaUy where the ob- struction of the trachea is complete, it may be pro- duced by it, where the struggle for life is more considerable, in consequence of the interruption of respiration being less effectually accomplished. —Ed. Gkn. VIII.—Spe, 5.] CARUS APOPLEXIA. 387 prove a predisposing cause ; and account for the statement of Morgagni, who tells us that, of thirty cases of apoplectic patients that fell with- in the reach of his observation, seventeen were above the age of sixty, and only five below that of forty.* Hippocrates, on a more general es- timate, calculated that apoplexies are chiefly (nd\wra) produced between the fortieth and sixtieth year.—(Aph., sect, vi., 57.) This, in- deed, is somewhat earlier than we should expect on the ground of advancing age ; but when we take into consideration that it is the precise period in which the mind is most agitated and exhausted with the violent and contending pas- sions of interest, and ambition, and worldly honours, and the blood most frequently deter- mined to the head by this impulse of sudden and irresistible emotions, we shall, perhaps, readily accede to the Hippocratic aphorism as a gen- eral rule. How far apoplexy is occasionally the result of an hereditary influence on the frame, it is not easy to ascertain. Forestus, Portal, and Wepf- fer, refer to decided instances of such facts within their own knowledge : the first, indeed, relates the history of a father and his three sons, all of whom died in succession of this disease ; but as the chronology drops with the second generation, it does not descend quite far enough for the purpose. There is great reason, how- ever, for believing that an hereditary tendency does sometimes show itself; and, as this exists without external or manifest signs, it is probably seated in the sensorial system, and constitutes another of the morbid conditions of this system to which we have referred above, as often giving effect to subordinate causes. There is no difficulty in conceiving how heat may become a predisponent cause, since noth- ing tends more effectually to quicken the action of the heart, drive the blood forcibly into the aorta, and, consequently, overload the vessels of the brain. But cold is said to be a predispo- nent cause as well, and one that operates quite as extensively, while the reason of this has not been at all times very clearly explained. Now, as a hot temperature acts chiefly upon the san- guiferous system, extreme cold acts chiefly upon the sensorial, benumbs the feeling, weakens the muscular fibres, diminishes the sensorial energy, and consequently induces, as we have already seen under one of the varieties of asphyxy, an unconquerable propensity to sleep. And hence, again, in apoplexies produced by severe cold, the primary or predisponent cause is to be sought for in a debilitated state of the nervous system. The Gieek physicians are perpetually alluding to this cause as one of great frequency, and the explanation now given does not essentially vary from that offered by Galen.—(De Loc. Aff., lib. * According to Mr. Hope's paper, read recently before the College of Physicians in London, it would seem that apoplexy is more common and fatal between the ages of forty and fifty, and seventy and eighty, which he thinks may be styled the two apoplectic periods of life. Mr. Hope founds his opinion on the data presented by the records of the St. Mary-le-Bone Infirmary.—D. B b 2 iii., cap. vi.) If, indeed, the cold be exquisitely intense, carus asphyxia is more likely to .be produced than carus apoplexia; for we have already observed, under the preceding species, that the very same cause which, operating in a vehement degree, excites the former, operating powerfully, has often a tendency to excite the latter. The other predisponent causes, so far as they have been traced out, are more obvious to the senses, and, for the most part, more directly referrible to the state of the sanguineous func- tion ; as plethora, corpulence, and grossness of habit, a short thick neck, and the free use of wines and heavy fermented liquors. Dr. Cheyne, indeed, believes the last to be so common a cause, as even to produce the disease without any inordinate indulgence whatever : " the daily use," says he, " of wine or spirits will lead a man of a certain age and constitution to apo- plexy, as certainly as habitual intoxication."— (Cheyne, p. 146.) This may be true as here limited; but then the limitation must be at- tended to; in which case we are only told in other words, that wherever such a kind of sen- sorial debility exists as that which we have al- ready adverted to, the result of age, or habit, or constitution, one man will be as readily led to apoplexy under a moderate use of wine, as another man, destitute of such predisposition, will be under a state of habitual intoxication. With this explanation, however, a moderate use of wine becomes only an accessory, and not a primary cause. How far there may be any other efficient or exciting causes of apoplexy than compres- sion of some kind or other, it is difficult to de- termine, though various cases on record should induce us to suppose there are. Hydatids, tu- mours of almost every consistency, gelatinous, steatomatous, and bony, pus, and indurations of the membranes, have, in various cases, been discovered on dissection, and are generally sup- posed to operate by compression. But in many instances, these appearances seem to have been too minute for any such effect; and can only fairly be regarded as concomitants or allied powers—as local irritants, stimulating and ex- hausting the sensorium, and preparing it for at- tacks of apoplexy against the accession of some superinduced and occasional cause; though, where there exists already a strong predisposi- tion to the disease from hereditary or any other affection, it is not improbable that such local irritants may alone be sufficient to perfect the complaint. And we may hence account for that foTm of apoplexy which is said to proceed from intestinal worms, or some irritation of the stomach, or from teething; and which, conse- quently, occurs at an early, instead of at a late period of life, and has been especially denomi- nated apoplexia infantium. Other organs, how- ever, besides the teeth and the stomach, seem not unfrequently to have given occasion to apo- plectic attacks from irritation, distention, or organic lesion. Thus, according to M. Portal superinducing tumours and congestions have been found in the neck, in the breast, or in the 388 NEUROTICA. [Cl. IV.—Ord. IV. abdomen; ossifications in the thoracic and ven- tral aorta, as well as in the arteries of the upper or lower extremities, in the superior vena cava, and in the right ventricle and valves of the heart, which has also indicated various other changes.—(Portal, Ch. Risultats de I'Ouver- turedes Corps, p. 329.) Most of these morbid actions and appearances, however, are as common to various other affec- tions of the sensorial system as to apoplexy. We have already noticed them in lethargy, con- vulsion, epilepsy, various species of cephalaea, and some forms of insanity : and hence, wher- ever they become causes at all, it is most proba- ble that the disease they immediately produce is regulated by the predisposition of the individ- ual to one, rather than to any other of the above sensorial affections, resulting from family taint, idiosyncrasy, habit, or period of life; and, consequently, that the same exciting or occa- sional cause which in one person would pro- duce apoplexy, in a second would form epilepsy, in a third convulsion, and in a fourth madness. It is highly singular that this view of the subject should scarcely ever have been attended to by physicians; and that, while all the writers have pretended to regard apoplexy as a disor- der of the nervous system, none of them have suffered such ideas to enter fairly into their pa- thology, or in any way whatever into their prac- tice ; the nervous organ being supposed by all of them to be in a state of soundness at the time of the attack; and whatever mischief it suffers to be merely secondary, and consequent upon a morbid state of the bloodvessels, or of some other cause, that as suddenly and effectu- ally interrupts the production and distribution of the sensorial power, as retrocedent gout, mephitic vapours, or narcotic poisons. Now, all these accidental or effective causes of apoplexy Ve well known to be causes, also, of the other nervous affections we have just re- * The following reflections on this subject, by Dr. Clutterbuck, appear interesting:—" The opin- ion that appears to prevail most generally at pres- ent, as to the immediate cause of the suspension of functions that constitutes the apoplectic state, is, that the remote causes of the disease, such as extravasated blood, and accumulation of serum, produce a compression of the cerebral substance, thereby interrupting its functions. But, besides that some of the remote causes of apoplexy have no apparent tendency to make any direct pressure on the brain, it must not be overlooked, that the cerebral substance, being in its nature incompres- sible, cannot, so long as the blood, is contained within its vessels, be exposed to greater pressure at one time than another. It must be in some other way, therefore, than by compression of the substance of the brain, that the remote causes act in producing their effect. It cannot be questioned, that pressure on the brain of any kind, if carried to a certain extent, is capable of interrupting the functions of the organ so as to induce apoplexy; but there is good reason to believe that the pres- sure operates upon the bloodvessels so as to im- pede mechanically the passage of the blood through them; in a word, that interrupted circulation in the brain is the proximate or immediate cause of that tem- porary suspension of the sensorial functions which constitutes the apoplectic state."—(See Cyclop, of ferred to. But if this be the case, how comes it that they should thus vary in their result, and that what in one person and at one period of life should produce apoplexy, should in another person and in another period of life produce lethargy, palsy, convulsions, or epilepsy 1 or that some of them should exist without pro- ducing any of these diseases, or any other dis- ease whatever? It is not, perhaps, possible for us to develop the precise condition of the sen- sorium that leads to any one of these effects rather than to any other; but that there is such a condition, forming a predisponent or remote cause of the specific disease that shows itself, must, I think, be allowed by every one who se- riously considers the subject. Nor is there, in effect, any other means of reconciling the discrepant and opposite opinions that have been held concerning the proximate cause of the disease. This we have stated to be, for the most part, compression, and especial- ly sanguineous compression.* Mr. John Hunt- er was so strenuously attached to this cause, that he would allow of no other; M. Rochoux has followed his footsteps (Did. de Midecine, torn, ii., Paris, 1822); and if a man died of apoplexy from atonic gout, and without effusion, the former distinguished it as a disease similar to apoplexy. He regarded apoplexy and palsy as one and the same disease, merely differing in degree : and he gives us his sentiments very forcibly in the following words :—" For many years," says he, " I have been particularly at- tentive to those who have been attacked with a paralytic stroke forming a hemiplegia. I have watched them while alive, that I might have an opportunity to open them while dead : and, in all, I found an injury done to the brain in con- sequence of the extravasation of blood.—I must own, I never saw one of them which had not an extravasation of blood in the brain, except one who died of a gouty affection in the brain, Pract. Med., art. Apoplexy, p. 126.) This intel- ligent writer then proceeds to show that apoplexy may be brought on by a variety of remote causes, all operating in different ways, but all leading to the same general result—obstructed circulation of the brain. " Whether this be produced by direct external pressure, or by extravasated fluids or tumours within the scull; whether by arterial excitement, and consequent distention, produced by either alcohol, external heat, or mental emo- tions; or whether by any impediment to the return of blood from the brain, by causes influencing the veins; the effect," according to Dr. Clutterbuck's view, "is still the same, and suggests the same general indications of cure; namely, to restore the circulation of the brain." Some part of this writer's doctrine agrees with the opinion of Dr. Abercrom- bie, who refers merely to a derangement in the circulation of the brain, without restricting the immediate cause to one principle alone, as Dr. Clutterbuck has done in the foregoing quotation. A correct theory of apoplexy, inrelation to its im- mediate cause, is certainly of the highest impor- i tance, as leading to the consideration of what ought to be the principal indication in the treat- ment of the disease. Thus, Dr. Clutterbuck's views convince him, that the general indication of cure is to restore the circulation of the brain , by removing the obstructing cause.—En. Gen. VIII.—Spe. 5.] CARUS AP with symptoms similar lo apoplexy."—(Treatise on Blood, &c, p. 213.) In direct hostility to this hypothesis, many other writers of great eminence and experience have contended that compression is no cause whatever, and that an accumulation of blood in the head as a prominent symptom in apoplexy is a doctrine rather than a fact. Of this senti- ment is Dr. Abercrombie, who, after examining the question with much ingenuity, brings him- self to the following conclusion :—" Upon all these grounds," says he, " I think we must ad- mit that the doctrine of determination to the head is not supported by the principles of pa- thology, and does not accord with the phenome- na of apoplexy."* M. Serres, however, a phy- sician of considerable distinction in France, and who followed up this subject for many years by a careful examination of the bodies of persons who died of apoplexy and paralysis, both of the Hotel Dieu and the Hopital de la Pitie, has car- ried his inroad upon the popular doctrine of the day still further ; for he has not only in his own opinion completely subverted it, but has endeav- oured ^to establish another doctrine of a very different character upon its ruins.—(Annuaire Medico-Chirurgicale, Avril, 1820.) To deter- mine the question, he has gone through a long series of experiments upon the brains of dogs, pigeons, rabbits, and other animals, whose crania were trepanned, their lateral or longitudinal si- nuses laid open, and their brains lacerated and excavated in various ways so as to be gorged with effused blood, yet, in none of them did somnolency or any other apoplectic symptom take place. And he hence triumphantly concludes * Treatise on Apoplexy, &c, p. 19. If, how- ever, we consult a later publication of this distin- guished physician and pathologist, we shall find that, whatever may be his opinion respecting de- termination of blood to the head as a cause of apoplexy, he himself brings forward examples of apoplexy from pressure on the veins in the neck, and a consequent distention of the vessels of the brain.—(See Pathological and Practical Research- es on Diseases of the Brain and the Spinal Cord, p. 204, Edin., 1828.) After adverting to cases from strangulation (cases, however, in which the actual suspension of the functions of the brain might be more justly imputed to the transmission Of black or unoxygenated blood to that organ, than to an apoplectic state of it), he notices other ex- amples, " in which persons fall down suddenly in a state of perfect apoplexy, and very speedily re- cover under appropriate treatment, without retain- ing any trace of so formidable a malady. The apoplectic attack, as it occurs in such examples as these," he says, " must be supposed to depend upon a cause which acts simply upon the circula- ting system of the brain, producing there a de- rangement which takes place speedily, and is often almost as speedily removed. What the precise nature of that derangement may be, is a point of the utmost difficulty to determine," &c And again, " the apoplectic attack is generally prece- ded by symptoms indicating some derangement of the circulation in the brain."—^-(P. 205.) Were the editor bold enough to question the accuracy of some parts of Dr. Abercrombie's valuable trea- tise, he should be disposed to say that this author comprehends too many different states of disease in 'OPLEXIA. 389 that extravasation of blood does not produce apoplexy, whether lodged between the cranium and the dura mater, or between the dura mater and the brain: whether the blood occupy the great interlobular scissure, and thus lie upon the corpus callosum; whether cavities be made in the fore, the back, or the middle part of the hemispheres, or run from the one into the other ; or, lastly, whether piercing through the corpua callosum, we reach and fill up the ventricles of the brain. " On whatever animal," says he, " we try these experiments, whether on birds, rabbits, or dogs, the result is the same, and hence apoplexy in man ought not to be ascribed to such effusions." [" A person (says Dr. Abercrombie), previous- ly in perfect health, falls down suddenly, de- prived of sense and motion, and dies after lying for some time in a state of coma. We find on examination a large coagulum of blood com- pressing the surface of the brain, or filling its ventricles, and the phenomena of the disease ap- pear to be distinctly accounted for. Another person is cut off with the same symptoms, and we expect to find the same appearances ; but nothing is met with except serous effusion in no great quantity in the ventricles, or only on the surface of the brain. A third is seized in the same manner, and dies after lying for a consid- erable time in a state of coma, from which nothing can rouse him for an instant; and, on the most careful examination, we cannot detect in his brain the smallest deviation from the healthy structure."]* his view of apoplexy. Thus, his 90th case (p. 212) appears to have been only an example of ascites and hydrothorax, where death was preceded by coma and stertor. But if all diseases which ex- hibit coma and stertor a little before their termi- nation were to be regarded as apoplexies, where would be the limit to this principle of classifica- tion '! The editor would also say, that apoplexy might be characterized by the suddenness with which the fit takes place, whether preceded by other ailments or not, and that no examples ought to be looked upon as apoplexies in which the coma and loss of sense come on graduaUy, as they do in the last stage of fevers and other disorders. Apoplectic symptoms, as a critical writer observes, are known to arise from various states of the brain or its parts. It is now, says he, regarded as most expedient to restrict the appellation of apo- plexy to that state of the vessels of the brain in which they are either excessively distended with blood, or in which this fluid has escaped, either by exhalation or rupture.—(Edin. Med. Journ., No. xc, p. 83.) Dr. Abercrombie's remarks are particularly interesting, however, as proving that apoplexy should not always be ascribed to fulness of the cerebral vessels, or to extravasation, even though some unknown form of derangement of the circulation in the brain may exist.—Ed. * Pathological and Practical Researches on the Diseases of the Brain and Spinal Cord, p. 202, Edin., 1828. In considering the causes of apo- plexy, pathologists must not overlook certain phys- ical conditions of the brain ; as, for instance, its enclosure in an unyielding bony case, whereby it is excluded from the influence of atmospheric pressure. So long as the scull is entire, its cav- ity is always completely filled by its contents, and there can be no alternata contraction and expan- 390 NEUROTICA. [Cl. IV—Ord. IV. How are these discrepances to be reconciled 1 by what means are we to account for it, that pressure may be a cause and may not be a cause 1 and that apoplexy is sometimes found with it and sometimes without it 1 It is the peculiar state of the sensorium or nervous system at the time that makes all the difference—it is the morbid predisposition or debility, or whatever other deviation from perfect health it may labour under at the moment of the application of the exciting cause, that gives an effect which would not otherwise take place ; and something of which in many cases often discovers itself by pro- cursive signs, for a considerable period before the apoplectic incursion. The facts stated by Mr, John Hunter no one can call in question; and we have as little right to question the experi- ments of M. Serres : the error consists in taking an unsound and a sound state of the brain for like premises, and reasoning from the effects pro- sion of the cerebral mass, with a vacuity produced by the former between the scull and the mem- branes of the brain. The contents of the scull, solid as well as fluid, if not absolutely incompres- sible, at least are so by any force that can be ap- plied to them during life, Yet the bloodvessels witliin the head will readily yield to pressure, so as to be emptied of their contents; a necessary consequence of which is a stoppage of the circula- tion in the part so affected, As Dr. Clutterbuck observes (Cyclop, of Pract. Med., art. Apoplexy), the pressure may be made to take place on any part qf the brain, even the most remote from the principal vessels; yet, nevertheless, the pressure, by operating through an incompressible substance, may influence vessels the most distant, so as to im- pede if not wholly interrupt the cerebral circula- tion. From these circumstances, the following important conclusions are drawn ;—No material variation can take place within a short period in regard to the absolute quantity of blood in the brain. No additional quantity can be admitted into its bloodvessels, because the cavity of the scull is already completely filled by its contents. A plethoric state, or overfiilness of the cerebral vessels altogether, though often talked of, can have no real existence; nor, on the other hand, can the quantity of blood within the vessels of the brain be diminished, any more than can wine or other fluid be drawn from a cask without furnishing an equivalent for the portion abstracted from it, by the supply of an equal bulk of air, which, in the case of the brain, can of course find no entrance. No abstraction of blood, therefore, whether it be from the arm or other part of the general system, or from the jugular veins (and still less from the temporal arteries) can have any effect on the blood- vessels of the brain, so as to lessen the absolute quantity of blood contained within them. From the experiments of Dr. Kellie, it was found that in animals bled to death, the brain still contained the usual quantity of blood 4 and in some cases, the superficial veins were found gorged with blood, and the sinuses full; the rest of the body being at the same time blanched and drained of its blood. In a few instances the brain appeared to contain less blood than usual; but then there was found some serous exudation. When the cranium of the animals subjected to these experiments was perforated before they were bled, the brain was as much emptied of its blood as the rest of the body. In two instances of persons that had been hanged, the cellular membrane of the whole head exter- nally was turgid with blood; but nothing peculiar duced on one to those that are found to follow on the other. This, in truth, is an error too often committed ; and hecatombs of quadrupeds and other animals, in a condition of perfect health, are tortured in a thousand ways for the purpose of determining what they never could determine, though the trials were to be repeated to the end of time ; I mean, the effects of certain causes on a diseased state of body in man, from their influence on a sound state of body in brutes. M. Serres's actual examinations of apoplectic patients after death, however, though conducted also upon a large scale, do not seem to afford much countenance to his hypothesis, nor, in effect, to offer any thing out of the common way. In a considerable number of subjects, there was serous effusion, sanguineous effusion, or both; sometimes in the circumvolutions of the brain, sometimes in the ventricles, some- times in all these ; and not unfrequently the ves- sels of the meninges appeared distended with was observed in the state of the vessels of the brain itself. When blood is suddenly or rapidly extravasated anywhere within the scull, the space thus occupied can only be furnished by the com- pression and consequent emptying of the blood- vessels in other parts of the brain ; and in the same degree that this happens, it is evident that the cir- culation of such parts must be interrupted. But in the formation of tumours within the scull, and during the slow accumulation of serum from in- flammation or any other cause, the cerebral sub- stance itself may be absorbed to an extent corre- sponding to the bulk of the tumour, or the quan- tity of serum deposited. The circulation of the brain may then go on uninterruptedly, and thus the apoplectic symptoms be prevented. But, as Dr. Clutterbuck further explains, although, under ordinary circumstances, the absolute quantity of blood contained in the vessels of the brain must remain the same, there may be great differences in regard to its distribution, and the force and ve- locity with which it is moved. Thus, the arter- ies of the brain altogether may be unusually dis- tended with blood ; but in this case the veins will be in the same degree compressed and emptied, and the circulation of the organ proportionally in- terrupted, with a corresponding interruption of functions. Again, as the same writer observes, there may be a partial fulness or distention of ves- sels in one part of the brain only ; but this must be at the expense of the rest of the brain, which will he proportionally deprived of the usual supply of blood. In like manner, there may be great diver- sity with respect to the force and velocity of circu- lation in the brain ; the absolute quantity of blood in the vessels still remaining the same. In this way the functions may be more or less excited, or more or less disturbed. These changes in the state of the cerebral circulation are all independ- ent of the heart. Bloodletting, therefore, how- ever useful in apoplexy, does not become so by diminishing in any degree the absolute quantity of blood in the brain, but by reducing the velocity and impetus of the circulation there, and which it does by influencing the general system. These peculiarities in the condition and circulation of the brain were, as Dr. Clutterbuck notices, long ago demonstrated by the late Dr. Monro, and have been recently confirmed by a variety of experi- ments instituted by Kellie, Abercrombie, and oth- ers, who have drawn from the whole of the inves- tigation the important views and inferences ad- verted to in the foregoing observations.—Ed. Gen. VIII.—Spe. 5.] CARUS AP blood, and the membranes themselves thickened. Such appearances seem to furnish something of a stumbling-block to M. Serres's new doctrine, yet he readily gets over the difficulty by satis- fying himself that in all these cases the effusion did not produce the apoplexy, but the apoplexy the effusion. In other dissections he found some material alterations in the structure of the brain, but without effusion; and as the class of individuals had evinced palsy rather than apo- plexy, he is inclined to think that apoplexy, or that state of the disease in which the stupor is greater and more general, is occasioned by a morbid irritation of the membranes of the brain ; and palsy, or that state in which the stupor is less, by a morbid change in its substance; in consequence of which he proposes to call the first meningic, and the second cerebral apoplexy. In this conclusion, however, there seems to be a striking mistake ; and the very reverse is what we should have expected; for if there be one pathological principle more established than an- other, it is that stupor and dulness of pain ap- pertain to the parenchymatous irritation or in- flammation of an organ, and rousing, restless, and acute pain to its membranous irritation; a principle we have already explained at some length; and whence, indeed, the lancinating pain of pleuritis compared with pneumonitis, and of meningic or brain fever, compared with acute dropsy of the head.—(See vol. i., Empresma Ce- phalitis, Cl. III., Ord. II., Gen. VII., Spe. 1.) There is far more dependance to be placed upon the painful and unjustifiable series of ex- periments performed several years since by M. Rolando upon the brains of animals of almost all kinds ; and which seem to show, as we have already observed, that animals which possess a perfect brain, derive their sensific power and mo- tific power not jointly from the cerebrum and cere- bellum, but separately, the one affording the one power, and the other the other.—(Saggio sopra la vera Strutlura del Cervello, &c, e sopra le Fonzioni de Sistema Nervosa, Sassari, 1809.) Stupor and apoplexy were in all these cases pro- duced, not by a morbid irritation of the mem- branes of the brain, as conjectured by M. Serres, but by a morbid irritation of the substance, while irritation of the membrane took away neither the sensific nor the motific power.* The brain, therefore, may be rendered com- atose by various causes : but we hold, after all, that the grand exciting cause of apoplexy is compression; and this shows itself in various ways, which are well enumerated by Dr. Cheyne in the following passage :—" I mention first," says he, " the remains of an excited state of the minute arteries of the brain and its membranes, this probably being the most important, as it is the most unvarying appearance ; then the ex- travasation of blood, probably the consequence * Dr. Stokes, in his lectures on apopVxy, boldly asserts, that the brain must be a very compressible organ; and Dr. Condie, in an able article on the sub- ject, writes as follows : " We should even be in- clined to adopt the opinion of Cruveilhier, that the brain is eminently compressible."—See Amer. Cycl. of Pract. Med. and Surg., vol. ii.—D. )PLEXIA. 391 of the excited state of the vessels; the tumes- cence of the venous system; the enlargement of the ventricles, partial or general; and lastly, the serous effusion, which is generally found in various parts of the brain, and which would seem to imply previous absorption of the brain."* The concluding sentence in this passage ap- pears to indicate that this correct and discrim- inating pathologist was by no means inatten- tive to that extraordinary change, which is not unfrequently produced in the structure and te- nacity of the brain by various causes of excite- ment; and exists in a more or less extensive demolition of its substance, so that it is some- times found to be pulpy or pasty, and at others, the disorganization having proceeded farther, to be as liquescent or diffluent as soup. Morgagni has collected various examples of these and other modes of disintegration ; Dr. Baillie has occa- sionally adverted to them (Morbid Anatomy, fascic x., pi. iii., p. 213, and pi. viii., 227, 228); and Dr. Abercrombie has brought them into a still more prominent notice by an ingenious pathological explanation of their cause, t But in France the subject has been pursued with pe- * Cheyne p. 24. M. Bouilliaud maintains the doctrine, that chronic inflammation of the cerebral vessels, or a diseased state of their coats, has a principal share in the production of apoplexy. (Recherches, &c, in Mem. de la Soc. d'Emul., torn, ix., Paris, 1826.) The connexion between hemorrhage of the brain and disease of the arterial system has been noticed by Morgagni, Lieutaud, Baillie, Hodgson, and others. In one case of apo- plexy, recorded by the latter writer, a copious effu- sion of blood was found beneath the arachnoid coat at the base of the brain, and to have escaped from an aneurismal sac, as large as a horsebean, com- municating with the basilar artery, where it di- vides into the cerebellic and posterior cerebral branches.—(On.Diseases of Arteries and Veins, p. 76.) In another instance, detailed by the same surgeon, there was apoplectic hemorrhage from disease of the ramifications on the pia mater (p. 26, case iv.). But a full confirmation of cerebral hemorrhage being frequently connected with dis- ease of the vessels of the brain, may be found in the essay of M. Bouilliaud, who has adduced cases on this point from Lallemand, Serres, De Haen, and other eminent authorities. As a critical writer observes, however, this author can claim no other merit than that of stating a fact " which has been familiarly known to us since the days of Willis, which was converted into a solid and substantial principle by Cullen, and which received the most undeniable confirmation from the researches of Portal and Rochoux in France, and from those of Baillie, Cheyne, and Abercrombie in this country. When," says this same reviewer, " it is remem- bered how difficult it is to adduce examples of gen- uine and unequivocal apoplexy from direct impair- ment, of nervous energy, or of what is termed ner- vous apoplexy by Zuliani, Kortum, Kirkland, and Abernethy, it will not be regarded as a proof of too extensive a generalization to maintain, that apo- plexy consists in an affection of the vascular system of the brain only."—(See Edin. Med. Journ., No. xc, p. 88.)—Ed. f Edin. Med. and Surg. Journal, vol. xiv., p. 265. Observations on Chronic Inflammation of the Brain; also, Pathological and Practical Re- searches on Diseases of the Brain, &c, pp. 81, 86, 129, &c, 8vo., Edin., 1829. 392 NEUROTICA. [Cl. IV.-Okd. IV. culiar activity since the publication of the first edition of the present work, and has excited an interest of no ordinary standard. To this change, M. Rochoux has given the name of ramollisse- ment de cerveau, or mollifies cerebri (Recherches sur VApoplexie, 8vo., 1814), and its nature and varieties have since been followed up, and sys- tematically arranged with considerable nicety and precision, by M. Rostan (Recherches sur un Maladie encore peu connue qui a recu le nom de Ramollissement de Cerveau, 8vo., 1820) and M. Lallemand (Recherches Anatomico pathologiques sur VEncephale et ses-dependances, 1821), who have regarded it as an idiopathic affection, and attempted a development of its entire patholo- gy and mode of treatment. Its actual cause is often doubtful; and still more doubtful is it whether it ever exists as a primary disease. That inflammation, consequent on congestion or rupture of the bloodvessels of the brain, is a frequent cause is clear, because the minute and colourless arteries of the part affected are often found striated or infiltrated, as the French call it, with red blood, and a clot of effused blood is traced in the centre. The inflammatory process hereby produced is sometimes violent, and passes rapidly into the suppurative stage, accompanied with severe lancinating pains, and a feeling of constriction round the head, and even delirium; and hence this condition is as common a result of cephalitis as of what we shall presently have occasion to call entonic apoplexy. The soft, pulpy disorganization of the brain is in this case often intermixed with masses of pus, while the general hue of the diseased part is brown ox red- dish, from a diffusion of the red particles of the blood that have been let loose ; and as the extrav- asated blood becomes more or less decomposed and intermixed with the white or gray matter of the brain, and with effused serum, the colour is found to vary considerably through all the diversities of white, gray, yellow, rosy, amaran- thine, deep red, brown, chocolate, and greenish. The gray substance of the brain, however, as less tenacious, is found more generally diffluent and more completely decomposed than the white. More usually, however, the inflammation is far less violent, or it is even chronic ; and the symp- toms are those of an obtuse pain in the head, general oppression, occasional vertigo, with in- distinctness of memory, and confusion of thought, the pulse evincing but little if any change from a state of health. But as these symptoms are common to various other diseases, their pathog- nomonic value is small. There are two other signs, however, pointed out by the French mo- nographists as more essentiaUy distinctive, but which the present writer has never had an op- portunity of noticing : these are a mouse smell or odour issuing from the body of the patient; and a movement of the lips on one side, accom- panied with a rushing or whizzing sound, like what is often exhibited by smokers in the act of smoking tobacco.* For the production of these * These symptoms, justly ascribed to a hemiple- giac state, almost invariably prognosticate a fatal termination of the case.—D. last symptoms, however, it is necessary that the disease should be accompanied with hemiplegia, so that one side of the mouth only is capable of motion. By far the greater number of these symptoms, however, indicate atony rather than entony of action; and hence, though inflammation is not unfrequently a proximate cause, debility, whether consequent upon inflammation or any other mor- bid change, is perhaps a more common cause. Hence in our own country this organic molles- cence has usually been regarded as a gangrene of the brain, and many of the French patholo- gists, and especially M. Recamier, incline to in- terpret it as a result of low atonic or malignant fevers, rather than of phlogotie action. With M. Rostan and M. Lallemand, however, it is ranked as a direct phlogosis, or phlegmasia, not resulting from apoplexy, but necessarily conduct- ing to it and producing it. Yet, as according to their own showing, the leading symptoms are those of turgescence and oppression, with little increase of pulse or other excitement, it should seem to follow that they have in a considerable degree mistaken the cause for the effect, even where inflammation is coexistent. In reality, though there is no difficulty in ac- counting for the extravasated blood, or the vas- cular infiltration, or the depraved colours, which are found in this state of the brain, upon the principle of inflammation, there is a considerable difficulty in explaining upon the same principle the mollification of the diseased area : and it is upon this point that the pathology of the French writers seems chiefly to fail. The real mode of action, as it appears to the present writer, is the same as that which takes place in mollification of the bones, which we shall explain in a subsequent part of this system ; but which, as well as its opposite, fragility of the bones, is always a disease of weakness, local or general. Now we meet with a like deviation from a healthy tenacity of the brain in both these ways ; for we find it sometimes too tough, and indeed almost horny (Morgagni, passim); as well in the gray as in the white compartments, occasionally, indeed, interspersed with masses of bony matter (see the accounts of Duverney> Giro, and Moreschi, especially in Gazette de Santi, Paris, Nov. 11, 1809); and at other times, as in the disease before us, too soft and unresisting; and in both these cases also, if I mistake not, debility will be found the immediate cause, even where inflammation has preceded. The firm and tenacious material which enters so largely into the substance of the brain, and particularly into the white part, is a secretion sui generis, and so long as the secernents and absorbents of this organ maintain a healthy ac- tion, and precisely counterbalance each other, this material will be duly supplied, and in a healthy state, as it is wanted, and duly removed to make way for a fresh recruit as it becomes worn out. But if the organ from any cause be- come weakened in its vascular powers, that weakness will extend to one or both the sets of vessels we are now considering, and the result will necessarily be the existence of brainy mat Gen. VIII.—Spe. 5.] CARUS APOPLEXIA. 393 ter of a depraved and untempered tenacity. In proportion as the compages of the brain becomes Looser and less resistible, effusions of serum and red blood, ulceration, gangrene, and a total dis- solution of the entire substance, must in many cases follow as a natural result, and in the order here stated. And hence, in cancer of the brain, the substance of the organ is always found in a soft or mollescent state. As a further proof that this peculiar change is for the most part a result of debility, it is admitted by both M. Ros- tan and M. Lallemand, that it is by far most fre- quently met with in persons of advanced age ; the former, indeed, asserts roundly, that in the whole extent of his practice he has never met with more than one instance, in which he was suspicious of it at or under the age of thirty, and as examination after death was not here al- lowed him, he does not regard even this case as of any moment.* It is singular that the congestive fluid, instead * The softening of textures during fife is ascri- bed by Professor Carswell to three causes.—1. In- flammation ; 2. obliteration of arteries ; 3. modifi- cation of nutrition. It is laid down as a general rule, that every organ or tissue affected with acute inflammation, undergoes at the same time a dimi- nution of consistence. Dr. Carswell represents the process of softening as being accomplished " under the immediate influence of a mechanical agent on the one hand, and a vital agent on the other. Thus, the effused fluids separate mechan- icaUy the molecules of the tissue, which the ces- sation of nutrition had deprived of their vital prop- erties ; or, in other words, the cessation of nutri- tion deprives the molecules of those properties on which their power of aggregation depends, and in this state they are separated and detached by the effused fluids."—(Illustrations of the Elementary Forms of Disease, fasciculus 5.) Softening from obliteration of arteries occurs only in the brain, and at an advanced period of life. " It is," ob- serves Dr. Carswell, " this kind of softening which was first described by M. Rostan, as a disease sui generis, as entirely opposite in its nature to inflam- mation, and which he Ukened to gangraena senilis. The opinion of this author met with strong opposi- tion from Lallemand of Montpellier, who main- tained that softening of the brain is always the consequence of inflammation." But Dr. Carswell considers the latter view as far from the truth as the former is ambiguous and inconclusive; and he thinks that the real nature of this disease, to which the brains of aged persons are so Uable, has not hitherto been ascertained. It has been conjectur- ed to originate in ossification of the arteries ; yet even M. Rostan, among the great number of cases of softening of the brain detailed in his work, has not given a single instance in which ossification and obUteration of the arteries are mentioned as having been observed on dissection. The coloured engravings contained in Dr. Carswell's publication, illustrative of the softening of various textures, and especially of the brain, are among the finest speci- mens of the power of the pencil to facilitate the comprehension of the morbid changes to which the several textures of the body are liable. The work in which they are published, entitled " Illus- trations of the Elementary Forms of Disease," 4to., Lond., 1833-4, is deserving of every possible en- couragement, and should be attentively studied by every medical man desirous of becoming a good pathologist.—Ed. of proving a material elaborated by the animal frame itself, should sometimes consist of a for- eign material recently received into the stomach. Dr. Cooke has given a case strikingly in proof of this, which I shall offer in his own words :— " I am informed by Sir Anthony Carlisle, that a few years ago, a man was brought dead into the Westminster Hospital, who had just drunk a quart of gin for a wager.* The evidences ol death being quite conclusive, he was immedi- ately examined, and within the lateral ventricles of the brain was found a considerable quantity of a limpid fluid distinctly impregnated with gin, both to the sense of smell and taste, and even to the test of inflammability. 'The liquid,' says Sir Anthony Carlisle, 'appeared, to the senses of the examining students, as strong as one third gin to two thirds water.' "t On examining the different sources of a com- pressed brain, as we have just enumerated them, it will be obvious that they bespeak a very dif- ferent, and indeed, opposite state of vascular ac- tion in different cases ; and that, while some of them necessarily imply a vehement and entonic power, others as necessarily imply an infirm and atonic condition. The external symptoms, from the first, speak to the same effect; and hence, from an early period of time,—as early at least as that of La Riviere or Riverius (Praxis Medica, 8vo., Lugd., 1670)—apoplexy has been contem- plated under two distinct forms or varieties, which have commonly been denominated san- guineous, and pituitous or serous ; as though the former proceeded from an overflow of blood highly elaborated by a vigorous and robust con- stitution, and rushing forward with great impet- uosity ; and the latter from thin dilute blood, or a leucophlegmatic habit, from the relaxed mouths of whose vessels a serous effusion is perpetually flowing forth. Morgagni has en- deavoured to show, but without success, that this distinction was in existence among the Greek writers. It is a distinction, however, that runs not only through his own works, but through those of Boerhaave, Sennert, Mead, Sauvages, and Cullen, and is acknowledged by most practitioners of the present day. The term pituitous or serous, however, has been objected to as not always expressing the actual state of the brain in atonic apoplexy ; since no serum has been found at times in cases where the symptoms of debility have peculiarly led those pathologists to expect it who have employed the distinctive term ; while the cavi- * Dr. Hosack remarks, in a note to his address delivered before the temperance society (Essays, vol. iii., p. 415), " My coUeague, Dr. J. W. Fran- cis, Prof, of Obstetrics and Forensic Medicine in the Rutgers Medical CoUege, who has for more than ten years past been engaged as medical wit- ness and adviser in the Criminal Courts of New- York, states to me, that occurrences of this char- acter have repeatedly come before him upon the examination of the bodies of persons who have died from intemperance."—D. t On Nervous Diseases, vol. i., p. 221. Schrader has a similar case, Observ. Anat. Med., decad. iv., Amsterd., 1674; as also Wepffer, Observ. Medico- Pract., p. 7, Scaph., 1722. 394 NEUROTICA. [Cl. IV—Ord. IV. ties and interstitial parts of the brain have, on the contrary, been sometimes found as much loaded with blood as in what they denominate sanguineous apoplexy. And hence, Forestus and a few other writers have been disposed to exchange the terms sanguineous and serous, for strong or perfect, and weak or imperfect apo- plexy.* How far a modification of this disease, strictly serous, may be said to exist, we shall examine presently ; but that apoplexy is contin- ually showing itself under the two forms of en- tonic and atonic action, seems to be admitted by all. And as the terms sanguineous and se- rous do not sufficiently express this change of condition in every instance, the author, in pro- ceeding to treat of these two varieties, will, for the future, distinguish them as follows :— o Entonica. With a hard full pulse, flushed Entonic apo- countenance, and stertorous plexy. breathing. B Atonica. With a feeble pulse, and pale Atonic apo- countenance. plexy. In entonic apoplexy the fit is, for the most part, sudden and without warning; though a dull pain in the head occasionally precedes the attack, accompanied with a sense of weight or heaviness, somnolency and vertigo. The in- spirations are deeper .than natural; the face and eyes are red and turgid, and blood bursts from the nostrils. On the incursion of the paroxysm the patient falls to the ground, and lies as in a heavy sleep, from which he cannot be roused. The breathing is strikingly oppressive ; though at first, perhaps, slow and regular, increasing in some instances. A case is described by Serres, in which the rupture took place in the substance of the pons Varolii, and the blood made its way into the occipital fossa. 2. The superficial vessels; the blood generally communicating betwixt the dura mater and the arachnoid; but cases are re- corded in which it lay beneath the pia mater, and appeared to have been discharged from the reti- form plexus of vessels at the base of the brain. 3. From ulceration and rupture of one of the arterial trunks. Dr. Mills has described a case in which the hemorrhage was traced to ulceration of the basilar artery, and a similar affection of the inter- nal carotid is described by Morgagni and Serres. 4. From the vessels of the choroid plexus, as de- scribed by De Haen. " This," says Dr. Abercrom- bie, " may probably be the source of the hemor- rhage, when the blood is confined to the ventricle, without any laceration of the substance of the brain." 5. Rupture of one of the sinuses, as in a case described by Dr. Douglas.—(Edin. Med. Ess., vol. vi.) 6. From the rupture of small aneurisms in the basilar artery (Serres), circle of Willis, &c. —(Archiv. Gen. de M6d.) 7. Lastly, Dr. Aber- crombie refers to a very uncommon case (Med. Surg. Reg. of New-York), in which the bleeding took place betwixt the dura mater and the bone, from ulceration of a vessel, produced by caries of the inner surface of the left parietal bone. In the most common form of this disease, or that in which the hemorrhage proceeds from a vessel in the sub- stance of the brain, Dr. Abercrombie supposes the rupture to take place from disease of the artery itself, without any relation to that congestive or hemorrhagic condition, making what he terms simple apoplexy. It consists sometimes of ossifi- cation of the arteries in various places, and some- times of that peculiar earthy brittleness, which Scarpa has described as leading to aneurism ; and the canal of the artery will be found in many pla- ces to be considerably narrowed or contracted at the hardened parts, and sometimes entirely oblit- erated. In other cases, numerous branches of the principal arteries of the brain will be found to pre- sent a succession of small opaque osseous rings, separated from one another by small portions of the artery in a healthy state. Dr. Abercrombie says that this is a very common appearance in the brains of elderly persons. In some other cases, the inner coat of the artery is much thickened, of a soft pulpy consistence, and very easily separated. —(See Abercrombie's Pathological and Practical Researches or. Diseases of the Brain, &c, pp, 239-242.) These observations cannot fail to ba highly interesting.—Ed. * " The distinction which has been proposed," says Dr. Abercrombie, " betwixt sanguineous and serous apoplexy, is not supported by observation. The former is said to be distinguished by flushing of the countenance and strong pulse, and by oc- curring in persons in thef ur of life; the latter by paleness of the countehance and weakness of the pulse, and by affectirif the aged and infirm; and much importance has been attached to this distinction, upon the ground that the practice which was necessary and proper in one case, would be improper and injurious in the other. 1 submit, that this distinction is not founded upon observation; for in point of fact, it will be found, that many of the cases which terminate by serous effusion, exhibit in their early stages all the symp- toms which have been assigned to the sanguineous apoplexy ; while many of the cases which are ac- companied by paleness of the countenance and feebleness of the pulse, will be found to be purely sanguineous."—(Pathological and Practical Re- searches on Diseases of the Brain and Spinal Cord, p. 218, 8vo., Edin., 1828.) The divisions of apo- plexy, laid down by this interesting writer, are ex- ceedingly judicious. He arranges all cases into three classes :—First, those which are immediately and primarily apoplectic; secondly, those which begin with an attack of a sudden headache, and pass gradually into apoplexy; thirdly, those which are distinguished by palsy and loss of speech, without coma.—(P. 208.) However, though the second class of cases are stated to pass gradually into apoplexy, we find, on referring to the details given by Dr. Abercrombie (p. 221), that he only means that the disease is preceded by violent headache, &c, and not that the apoplectic attack itself, when it does come, is not sudden. From the history of such cases he believes, " that they depend upon the immediate rupture of a consider- able vessel, without any previous derangement of the circulation, the rupture probably arising from disease of the artery at the part which gives way. At the moment when the rupture occurs, there seems to be a temporary derangement of the func- tions of the brain, but this is soon recovered from. The circulation then goes on without interruption, until such a quantity of blood has been extravasated as is sufficient to produce coma."—(P. 223.) Ac- cording to the same authority, the source of the hemorrhage, in this class of cases, is exceedingly various. 1. The most common appears to be the rupture of a vessel of moderate size in the sub- stance of the brain, from which the blood bursts its way by laceration either into the ventricles or to the surface, or in both these directions at once. In general, the hemorrhage cannot be traced to particular vessels, though Dr. Cheyne succeeded in" Gen. VIII.—Spe. 5.] CARUS AP frequency, weakness, and irregularity, with the progress of the fit, till at length it becomes, in many cases, intermitting and convulsive. It is in this form of the disease that we chiefly meet with, and are almost sure to find, a snoring or stertorous breathing, which, though not a symp- tom of apoplexy as a species, may be ranked as a pathognomonic character of the particular form before us. And to the same effect, Dr. Cooke and the most celebrated pathologists who have preceded him. " Boerhaave," says he, " meas- ures the strength of the disease by the degree of stertor ; and Portal agrees with him in opin- ion on this subject; observing, that respiration in apoplexy is greatly impeded, and the motions of the breast are very apparent. We hear a noise of snoring or stertor," he says, " which is great in proportion as the apoplexy is strong. In all the cases of strong apoplexy which I have seen, the respiration in the beginning of the par- oxysm was laborious, slow, and stertorous; and in those which proved fatal, this symptom, as far as I can recollect, remained, even when the breathing had become weak and irregular."— (On Nervous Diseases, vol. i., p. 171.) There is also often an accumulation of frothy saliva, or foam, which is occasionally blown away from the lips with considerable force. The skin is about the ordinary temperature, and covered with a copious perspiration or clam- my sweat; the pulse is full and hard, the face flushed, the eyes bloodshot and prominent, and generally closed. The cornea is dull and glassy, and the pupil for the most part dilated. In a few cases, however, there is a tendency to either spastic or convulsive action, spreading sometimes over the limbs, but more generally confined to the muscles of the face ; insomuch that, under the first, the teeth are firmly closed, and deglutition is impeded. And where this state exists the pupil is contracted, as in a synizesis, sometimes, indeed, almost to a point. This last feature has been rarely dwelt upon by pa- thologists, whether of ancient or modern times : but it has not escaped the observant eye of my . accurate and learned friend Dr. Cooke :—" In some instances," says he, " I have seen the pu- pil contracted almost to a point, and a physician of eminence of my acquaintance has likewise observed this appearance of the eyes in apo- plexy : yet, although all writers on the subject mention the dilated pupils, I do not find any one, Aretaeus among the ancients, and Dr. Cheyne among the moderns, excepted, who has noticed the contracted pupil."—(Ibid., p. 174.) The paroxysm varies in its duration, from eight to eight-and-forty hours, and sometimes exceeds this period. Dr. Cooke quotes from Forestus the case of a woman, who being seized with an apoplexy, which he calls forlissima, lay in the fit for three days, and afterward recov- ered. We have already observed, that where it does not prove fatal, it predisposes to a relapse, and often terminates in a lesion of eome of the mental faculties, or in a paralysis more or less general: commonly, indeed, in a hemiplegia, which usually takes place on the opposite side of the body from that of the brain OPLEXIA. 395 in which the congestion or effusion is found on examination to have taken place. " This," says Dr. Baillie, " would seem to show, that the right side of the body derives its nervous influ- ence from the left side of the brain, and the left side of the body its nervous influence from the right side of the brain. It is rarely, indeed, if ever, that some of the turgid vessels of the brain are not ruptured in this form of the disease, and consequently produce an effusion of blood into some part of the organ of the brain." And, ac- cording to the same distinguished writer, the part where the rupture most commonly takes place is its medullary substance near the lateral ventricles, some portion of the extravasated fluid often escaping into these cavities.—(Morbid Anat., p., 227.) Atonic apoplexy is the disease of a consti- tution infirm by nature or enfeebled by age, in- temperance, or over-exertion of body or mind. It has more of a purely nervous character, as we have already observed, than the preceding varie- ty, and is more a rt. " »f vascular debility than of vascular surcharge, and consequently where effusion of blood is found, as it often is, in the present form, the vessels have been ruptured, not from habitual distention or vigorous pletho- ra, but from accidental, often indeed slight caus- es, that have produced a sudden excitement and determination to the head beyond what the vas- cular walls are capable of sustaining. Hence, a sudden fit of coughing or vomiting, a sudden fright, or fit of joy, an immoderate fit of laugh- ter (Aretaus de Sign, et Caus. Diut. Morb., lib. i., cap. 7), the jar occasioned by a stumble in walking, or a severe jolt in riding, have brought on the present form of apoplexy, and with so much the more danger as the system possesses less of a remedial or rallying power in itself. In most of the cases, the effusion detected after death has therefore been as truly sanguin- eous as in entonic apoplexy; and hence a valid objection to the use of the term sanguineous as descriptive of the entonic form alone. " It is," says M. Portal, " an error to believe that the apoplexy to which old men are so much subject is not sanguineous." Daubenton and Le Roy, members of the Institute, died of this precise kind of the disease at an advanced age; and Zulianus describes a case marked by a pate coun- tenance, and a pulse so weak as scarcely to be felt, which, on examination after death, was found to be an apoplexia vere sanguinea: and another in which, after all the symptoms of what is ordinarily called serous apoplexy had shown themselves, extravasated blood was discovered in the brain, without any effusion of serum, or the smallest moisture in the ventricles.—(See also Burser. de Apoplex., p. 82 ; Cooke, ut sup.) It is nevertheless true, that atonic apoplexy is often found with an effusion of serum instead of an effusion of blood, and apparently produced by such serous effusion; and hence, notwith- standing the objections of Dr. Abercrombie, and, in the latter years of his practice, of M. Portal, to serous effusion as a cause at all,* the experi- * The following conclusions of Dr. Abercrom. iOTICA. [Cl,IV—Ord. IV. 396 NEU* ence and reasoning of Boerhaave, and Hoffmann, and Mead, and Sauvages, and Cullen, must not be abruptly reUnquished without far graver proofs than have hitherto been offered: for if it be a question, as Stoll has made it, whether effused serum, when discovered in the brain of those who have died of apoplexy, be a cause of the disease or an effect (Pralect., p. 367), we may apply the same question to effusion of blood. It is possible, indeed, for effused serum to be- come occasionally a cause even of entonic apo- plexy, or that which, from its symptoms, is or- dinarily denominated sanguineous apoplexy ; for it is possible for the exhalants of the brain to participate so largely in the high vascular excite- ment by which this form of the disease is char- acterized, as to secrete an undue proportion of effused fluid into any of its cavities, and thus become as direct a cause of apoplexy as extrav- asated blood. This, however, is not what is generally un- derstood by the term serous apoplexy as distin- guished from sanguineous, and, indeed, ought only to be regarded as an effect of sanguineous distention.* Serous apoplexy, properly so call- ed, is strictly the result of a debilitated consti- tution, and especially of debility existing in the bie, the editor of this work is disposed to adopt as most consonant to facts:— 1. There is a modification of apoplexy which is fatal, without leaving any morbid appearance that can be discovered in the brain. 2. There is another modification, in which we find serous ef- fusion often in small quantity. 3. The cases which are referrible to these two classes, are not distin- guished from each other by any such diversity of symptoms as can be supposed to indicate any es- sential difference in their nature. 4. Without any apoplectic symptoms, we find serous effusion in the brain in an equal, or in a greater quantity, than in the cases of the second modification. 5. It is therefore probable that, in these cases, the effu- sion was not the cause of the apoplectic symptoms. 6. It is probable that the cases of the first modi- fication depend upon a cause which is entirely referrible to a derangement of the circulation in the brain distinct from inflammation. 7. It is probable that the cases of the second modification are, at their commencement, of the same nature with those of the first; and that the serous effusion is to be considered as the result of that peculiar de- rangement of the circulation which constitutes the state of simple apoplexy. In short. Dr. Aber- crombie considers the serous modification as sim- ple apoplexy terminating by effusion.—(On Dis- eases of the Brain, &c, p. 220.) With respect to the impossibility of detecting any morbid appear- ances in some cases of apoplexy, we are not to infer from it that a minute derangement of the structure of the brain, some alteration of its con- sistence, or some diseased action of its vessels, may not frequently have been concerned in the pro- duction of the disease, though overlooked, or not demonstrable, after death.—Ed. * Here, and in the preceding sentence, the au- thor admits one of Dr. Abercrombie's principal con- clusions, somewhat differently expressed, namely, that serous apoplexy is a consequence of some de- rangement in the cerebral circulation, though what this derangement may be is not defined, further than that it is unaccompanied with any visible mor- bid appearances in the brain after death.—Ed. excernent vessels of the brain, whether exha- lants or absorbents.* I say absorbents, because, although lymphatics have not yet been discov- ered in this organ, there must be vessels of some kind or other to answer their purpose, and the extremities of the veins have been supposed thus to act; a supposition which has derived coun- tenance from various experiments of M. Magen- die, to which we shall have to advert in the Proem to the sixth class, and which may at least stand as an hypothesis till the proper system of vessels is detected. Hence, atonic apoplexy rarely makes its at- tack altogether so incontinently as entonic ; and is commonly preceded by a few warning symp- toms. These are often, however, nothing more than the ordinary precursors of other nervous af- fections, as vertigo, cephalaea, imaginary sounds, a faltering in the speech, a failure in the mem- ory or some other mental faculty, and at length a sense of drowsiness, and a tendency to clonic spasms. On the attack of the paroxysm the patient is as completely prostrated as in the en- tonic variety, but the symptoms are less violent, though not on this account less alarming, in con- sequence of the greater debility of the system. The countenance is here pale or sallow instead of being flushed, but at the same time full and bloated ; the pulse is weak and yielding, some- times, indeed, not easy to be felt; and the breath- ing, though always heavy and laborious, not al- ways, as we have already observed, noisy or stertorous. If spasms occur, they are uniformly of the convulsive or clonic kind. The duration of the fit varies, and if the patient recover, he is more liable to a relapse, and more in danger of hemiplegia or some other form of paralysis, than in the stronger modification of the disease. From these remarks on the two varieties of apoplexy we may readily see why this complaint, and its ordinary associate or sequel, palsy, should be about equally common to the poor and to the rich : for frequent exposure to cold and wet, severe and long-protracted exercise, and a diet below what is called for, will often be found to produce the same debilitating effects as ease, indolence, luxury, and indulgence at too sump- tuous a table. And hence, contrary to what * Dr. Clutterbuck regards serous apoplexy dif- ferently from our author. He conceives that no absolute Une of distinction can be drawn between the sanguineous and serous forms of the disease: " they are, in fact, frequently found in combina- tion, or rather to be considered as mere varieties of one and the same affection. Serous accumu- lations in any of the cavities of the body are in most instances the result of membranous inflam- mation ; not, in general, of an acute, but rather of a chronic or protracted description. This pri- mary dependance of serous accumulations, or drop- sies, as they are called, on inflammation, is not al- ways distinctly seen, on account of the mildness of the inflammatory symptoms at first, and their often having passed away without notice, leaving the accumulation of fluid behind. Still there are but few cases in which the connexion of dropsy with inflammation, as its primary source, may not be traced by accurate inquiry. This applies to the brain as much as to other parts."—See Cyclop, of Pract. Med., art. Apoplexy, p. 131.—Ed. Gkn. VIII.—Spe. 5.] CARUS APOPLEXIA. 397 many would expect, Sir Gilbert Blane has ob- served from accurate tables, kept with minute attention, and derived from a practice of ten years in St. Thomas's Hospital, and his private consultations, that " there is a considerably greater proportion of apoplexies and palsies among the former than among the latter:" or, in other words, that these disorders bear a lar- ger proportion to other diseases among the lower classes than among those in high life. " Some cases of hemiplegia," says he, "occur in full habits ; some in spare and exhausted habits. The former, being most incident to the luxuri- ous and indolent, most frequently occur in pri- vate practice, and among the upper ranks of life. The latter occur more among the laborious classes, and among such of the rich as are ad- dicted to exhausting pleasures."—(Trans. Med- ico-Chir. Soc, vol. iv., p. 124.)* In forming our prognostic, a special regard must be had to the peculiar character of the disease. Generally speaking, atonic apoplexy is more dangerous than entonic, for we have here a more barren field to work upon, and nature herself, or the instinctive power of the living frame, has less ability to assist us. As to the rest, in either modification, the degree of dan- ger will be generally measured by the violence of the symptoms. Where, under the first va- riety, the breathing is not much disturbed, the pupil is relaxed, and there is no appearance of spastic action ; where the perspiration is easy, the skin warm rather than hot, the bowels are readily kept in a due state of evacuation, and more especially where there is any spontaneous hemorrhage, as from the nose or hemorrhoidal vessels, and of sufficient abundance, we may * " Apoplexy," according to Dr. Condie (Hays' Cyclopedia, vol. ii.)," is of more frequent occurrence in the male than in the female sex : probably from the former being much more addicted than the lat- ter to excesses, both as it regards the body and mind. Of fifty-one apoplectic patients admitted into the General Hospital of Hamburgh during the years 1828 and 1829, fifteen only were females. In Berlin, in 1829, of six hundred and ninety-nine deaths from apoplexy, four hundred and nine took place in males, and two hundred and ninety in fe- males. In PhUadelphia, during the three years preceding 1835, the number of deaths from apo- plexy was two hundred and nine: of these, one hun- dred and nineteen occurred in males, and ninety in females. M. Serres, however, found that to the particular form of apoplexy termed by him menin- geal (that is, apoplexy without paralysis), females are much more liable than males. Out of forty- one cases of this species which fell under his no- tice, thirty-three were in females, and only eight in males ; and the registers of the Salpetriere and Bicetre make the predominance stiU greater on the side of the female sex." The predisposition to a recurrence of apoplexy is much increased after each attack, and popular opinion seems to countenance the belief that the third attack is almost universally fatal. Cases, however, might be adduced, of individuals sustain- ing ten or more attacks. Richter (Specielle Therapie) inclines to the opinion that apoplexy sometimes prevails epidemi- cally ; and the same belief is entertained by Mor- gagni, Hoffmann, and others.—D. fairly venture to augur favourably. But where the symptoms are directly opposed to these ; where the stertor is deep and very loud (Dolaus, p. 144), and particularly where it is accompanied with much foaming at the mouth (Burser., p. 97); where the teeth are firmly clinched, or a spasm has fixed rigidly on the muscles of deglutition, and the pupil, instead of being dilated, is con- tracted to a point, we have little reason to ex- pect a favourable termination. The great hazard resulting from this tendency to spastic action, and particularly as evinced in a strongly contracted pupil, is thus forcibly pointed out by Dr. Cooke :—" Among the dan- gerous signs in apoplexy, many authors men- tion a dilated state of the pupil of the eye : but the contracted pupil, which I consider to be a still more dangerous appearance, has been scarcely noticed. I am of opinion that this ought to be reckoned among the very worst symptoms of the disease. I never knew a per- son recover from apoplexy when the pupil was greatly contracted. My opinion on this subject is confirmed by that of Sir Gilbert Blane and Dr. Temple."—(Id., p. 280.) Dr. Cheyne, in like manner, regards convul- sions as a source of great danger: while M. Portal, on the contrary, thinks they sometimes announce a diminution of the morbid cause. The latter reasons from the fact, that when, in living animals, a slight pressure has been made on the exposed brain, convulsions have taken place; while, if the pressure be increased in power, general stupor with stertor and difficult respiration have followed, instead of convul- sions ; an ingenious conclusion, but not exactly applicable, since in the one case the brain is in a morbid and in the other in a sound state; whence the premises on which the reasoning is founded are not parallel.* In the treatment of apoplexy, if we be timely consulted during the existence of the procursive signs which have been noticed as occasionally taking place, we shall often find it in our power completely to ward off a paroxysm by bleeding, * The following passage from Dr. Abercrombie's work, in relation to the prognosis, deserves atten- tion :—" From the facts which have been related, we have reason to believe that there is a modifi- cation of apoplexy which is fatal without leaving any morbid appearance, and which probably de- pends upon a deranged condition in the circulation in the brain. We have also seen grounds for be- Ueving that the cases which terminate by effusion are probably at their. commencement in this state of simple apoplexy. We have seen farther, that we have no certain mark by which we can ascer- tain the presence of effusion; and, finally, we have found that even extensive extravasation of blood in the brain may be entirely recovered from by the absorption of the coagulum. These con- siderations give the strongest encouragement to treat the disease in the most active and perseve- ring manner. They teach us also not to be influ- enced in our practice by the hypothetical distinc- tion of apoplexy into sanguineous and serous; and, finally, not to be hasty in concluding that the dis- ease has passed into a state in which it is no longer the object of active treatment."—Pathol, and Prac- tical Researches on Dis. of the Brain, p. 288. 398 NEUROTICA. [Cl. IV—Ord. IV. purgatives, perfect quiet, and, in the entonic variety, a reducent regimen. Where, however, the pulse and other symptoms give proof of weak vascular action and nervous debility, the depleting plan should be pursued with caution, and it will be better to employ cupping-glasses than venesection, and, in some instances, to limit ourselves to purgatives alone. Yet, what- ever be the degree of general debility, if the proofs of compression or distention be clear, as those of drowsiness, vertigo, and a dull pain in the head, it will be as necessary to have recourse to bleeding, either locally or generally, as in en- tonic apoplexy; for such symptoms will assu- redly lead to a fit, unless timely counteracted and subdued. " In the actual paroxysm of apoplexy," says Dr. Cooke, and I quote his words because it is impossible to exchange them for better, " the patient should, if possible, be immediately car- ried into a spacious apartment, into which cool air may be freely admitted. He should be placed in a posture which the least favours determina- tion of blood to the head: all ligatures, espe- cially those about the neck, should be speedily removed, and the legs and feet should be placed in warm water, or rubbed with stimulating ap- plications. These means may be employed in all cases of apoplexy" (Burser., p. 288); and are consequently equally applicable to both the forms under which we have contemplated the disease. The collateral means to be had re- course to require discrimination, and it will be most convenient to consider them in relation to the actual form under which the apoplexy pre- sents itself. In entonic apoplexy, copious and repeated bleeding seems, prima, facie, to offer the most rapid and effectual remedy we can have recourse to: yet the opinions of the best practitioners, as well in ancient as in modern times, have been strangely at variance upon this subject. Hip- pocrates, who regarded apoplexy as chiefly de- pendant upon a weak and pituitous habit, dis- countenanced the use of the lancet, as adding to the general debility: and even where it is ac- companied with symptoms of strong vascular action, he discountenanced it equally, from an idea that the case was utterly hopeless. The authority of Hippocrates has had too much in- fluence with physicians in all ages, and has ex- tended its baneful effects to recent times, and, in some instances, even to our day. Hence Forestus tells us, that in strong or entonic apo- plexy, no courageous plan ought to be attempted, no venesection, no pills: we may, indeed, to please the by-standers, have recourse to the remedia leviora of frictions, and injections, and ligatures round the arms and thighs: " and where," says he, " we have not found these suc- ceed—in rationem sacerdotibuscommiserimus." In our own country, the same timid feeling has been particularly manifested by Dr. Heberden and Dr. Fothergill, but on grounds somewhat different. These excellent pathologists have chiefly regarded apoplexy as a disease of ner- vous rather than of general debility, and have been fearful of adding to this debility by ab- stracting blood, and hereby of almost ensuring hemiplegia, or some other form of paralysis. Hence Dr. Heberden speaks with great hesita- tion concerning the practice, rather than with an absolute and general condemnation of it: he ob- serves, which is true enough, that many persons have been injured by large and repeated bleed- ings, and then lays down his rule not to bleed either in an attack of apoplexy or palsy, if there would have been just objections to taking away blood before the incursion of either.—(Medical Transactions, i., p. 472.) Dr. Fothergill, however, expresses himself still more decidedly against bleeding than Dr. Heberden. He suspects that the weakness it occasions checks the natural effort to produce absorption ; and that even the hard, and full, and irregular pulse, which seems imperatively to call for a very free use of the lancet, " is often an insufficient guide;" since " it may be that strug- gle which arises from an exertion of the vires vita to restore health." And hence, he adds in another place, " I am of opinion that bleeding in apoplexy is for the most part injurious, and that we should probably render the most effectual aid by endeavouring, in all cases, to procure a plentiful discharge from the bowels: as by these revulsions the head is perhaps much more effectually relieved from plenitude, and that without weakening or interrupting any other effort of nature to relieve herself, than by vene- section."* It is singular that, in drawing such conclu- sions from the instinctive efforts or remedial power of nature, where a cure has been effected spontaneously, these distinguished writers have not felt more deeply impressed by the salutary effects of spontaneous and copious hemorrhages, as from the nose, the lungs, and the hemor- rhoidal vessels, which have never perhaps poured forth blood freely without operating a cure ; and that they have not endeavoured to follow these footsteps, as far as they might have done, by substituting an artificial discharge of blood where a natural discharge has not taken place. Other physicians, however, both in ancient and modern times, have not been equally insen- sible to this important fact. Galen, though he always hesitated in departing from the practice of Hippocrates, ventured to deviate from him * Works, vol. iii., p. 208. Dr. Clutterbuck seems to lean very much to the doctrines of Heb- erden and Fothergill; for, in noticing the apoplexy arising from the extravasation of blood in the brain, that form of disease which has attracted the greatest notice, he observes, " this is a case in which bloodletting has been used with little dis- crimination, and often, there is reason to believe, carried to a hurtful excess. It is evident that the remedy can have no direct effect in removing the extravasated blood; nor can it lessen the quantity of blood altogether within the scull," &c—(Cy- clop, of Pract. Med.) To this some writers would reply, that bleeding is proved by experience to be one of the most powerful means of checking in- ternal hemorrhages, and that in apoplexy it is in- dicated on this principle, though it may have no direct effect in promoting the absorption of the blood already extravasated.—Ed. Gen. VIII.—Spe. 5.] CARUS APOPLEXIA. 399 upon the point before us. Aretaeus, Paulus of ^Egina, and Ccelius Aurelianus, carried the remedy of bleeding to a still further extent, and Celsus regarded it as the only means of effecting a cure.—(De Medecin, lib. iii., cap. xxvii.) "The Arabians adopted the practice of the ancients, as far as relates to the employment of bloodletting in the strong apoplexy, and by far the greater number of modern physicians have in tliis respect followed their example In sup- port of this practice we might adduce the opinion of all who have written on the disease : we might quote from the works of Sydenham, Wepffer, Boerhaave, Van Swieten, Morgagni, Baglivi, Sauvages, Tissot, Mead, Freind, Pit- cairn, Hoffmann, Cullen, Portal, Cheyne, and many other eminent modern writers."—(Cooke, ut supra, 292.) As this paragraph is quoted from Dr. Cooke, it is almost superfluous to add his own name to the list of those who strenu- ously recommend bloodletting. A question has been made as to the side from which it may be most advantageous to take blood. Aretaeus drew it from the sound side, wherever this could be distinguished. Valsalva and Morgagni recommend the same; as does also Cullen, observing that " dissections show that congestions producing apoplexy are always on the side not affected."—(Pract. of Phys., vol. iii., p. 184.) Baglivi recommends bleeding from the diseased side, except where blood is abstracted locally. The question appears to be of no great importance; the grand object in general bleeding is to diminish the quantity and momentum of the circulating fluid, to enable the ruptured vessels to contract with greater facility, and to afford time for an absorption of whatever may have been effused. In entonic apoplexy, general and local bleed- ing should go hand in hand; and the quantity drawn should in every instance depend upon the urgency of the symptoms. Dr. Cheyne ad- vises us to begin with abstracting two pounds, and tells us that it will often require a loss of six or eight pounds before the disease will give way. Dr. Cullen, and many other writers, as Mor- gagni, Valsalva, and Portal, have recommended that the opening should be made in the temporal artery or the jugular veins. " In all cases of a full habit," says Dr. Cullen, "and where the disease has been preceded by marks of a ple- thoric state, bloodletting is to be immediately employed, and very largely. In my opinion, it will be most effectual when the blood is taken from the jugular vein; but if that cannot be done, it may be taken from the arm. The opening of the temporal artery, when a large branch can be opened, so as suddenly to pour out a considerable quantity of blood, may also be an effectual remedy; but in execution it is more uncertain, and may be inconvenient. It may in some measure be supplied by cupping and scarifying on the temples or hind-head. This, indeed, should seldom be omitted, and these scarifications are always preferable to the application of leeches."—(Id., vol. iii., p. 182.) In bleeding from the temporal artery, we may safely let the stream flow as long as it will, for in common it will cease before we have obtained enough, and all tight ligatures aboutathe head, or indeed any other part of the body, should be avoided as much as possible. For the same reason Heister advises that on opening the jugular vein* no ligature should be made use of, as the smallest pressure on the part may do harm, by interrupting the circulation of the blood on the external veins of the neck. M. Dejean of Caen, proposed, not long ago, to the Academy of Sciences, to open the supe- rior longitudinal sinus, after raising the bone which covers it, and asserted that he had em- ployed this mode with great success on strangled dogs.t M. Portal and M. Tenon, however, who were appointed commissioners to report on M. Dejean's memoir, agreed that bleeding from the jugular vein is preferable to that from the sinus, as producing the same effect more speed- ily, and with more facility of restraint when a sufficiency of blood has been taken away. What seems to be the fair result the author will give in the words of Dr. Cooke. " General opinion, then, as well as reasoning, appears to be very much in favour of free and repeated evacuations of blood, both general and topical, in the strong apoplexy; and I am persuaded that greater advantage may be reasonably ex- pected from this than from any other practice ; yet I am very much inclined to think that it may be, and actually sometimes has been, car- ried too far. I have seen several cases, and heard of many others, in which very large quan- tities of blood have been drawn without the smallest perceptible advantage, and with an evi- dent and considerable diminution of the strength of the patient."—(Op. cit., p. 311.)$ * The superior utility of opening this vein is questioned by some of the best practitioners. As Dr. Abercrombie justly observes, " the only jugu- lar vein that can be opened is the external jugular, which has very little communication with the brain, and, consequently, bleeding from it is prob- ably much inferior to bleeding from the temporal artery."—On Dis. of the Brain, p. 289. t The plan of trephining a patient, in order to open the longitudinal sinus for the relief of apo- plexy, would be a novelty in operative surgery, equalled only by some of the proceedings of St. John Long.—Ed. X The opinions of Fothergill and of Heberden on the subject of bloodletting have lost their weight. The abstraction of blood, generally and locally, is now advocated by most clinical ob- servers. On this subject Dr. Condie remarks, "the subtraction of blood is unquestionably one of the most efficacious means we possess for the cure of apoplexy. Employed at a sufficiently early period after the attack, it wiU frequently very promptly remove the congestion of the cere- bral vessels, often prevent extensive extravasation of blood, and preserve the substance of the brain from rupture and disorganization. Even at a later period, it wfll in many cases greatly ameliorate the symptoms, prevent the extension of the injury which the brain may have already received, pro- mote the absorption of the effused fluids, and the contraction and cicatrization of the apoplectic cavity. Bleeding, it is true, has been objected to in the treatment of apoplexy by a few respectable 400 NEUROTICA. [Cl. IV.—Ord. It. The next important means to be pursued is that of exciting the bowels by active purgatives. [This, as Dr. Abercrombie justly remarks, is always to be considered a most important and leading point in the treatment; and, " though, in arresting the progress of the disease, our first reliance is upon large and repeated bleeding, the first decided improvement of the patient is gen- erally under the influence of powerful purging."] The particular purgative is of no importance ; whatever wiU operate most speedily and most effectively is what should be preferred in the first instance :* and hence a combination of calomel and extract of jalap will be found among the best: though a free action may afterward be more conveniently maintained by colocynth or sulphate of magnesia. Dolaeus employed calomel so as to excite salivation, from an opinion that all evacuations are useful: and he gives an account of several cures he was hereby enabled to effect, and particularly relates the case of a woman who was in this manner con- siderably relieved, and died on the cessation of the ptyalism.—(Dolaus, p. 149.) The collateral remedies are of less impor- tance, though some of them may add to the general effect. Emetics are of a very doubtful character in the form of the disease before us, though often highly useful in atonic apoplexy.t writers; and its use by others is restricted to cer- tain forms of the disease. The objections, how- ever, that have been made to the general employ- ment of bloodletting in the early period of the at- tack, and its cautious repetition at a more advanced stage, will be found, we apprehend, to be purely hypothetical, and based upon erroneous views of the character of the disease, or to hold good solely against the abuse of the remedy. To say nothing of the concurrent evidence borne in favour of the good effects of bloodletting by the great majority of those medical writers whose opinions on prac- tical subjects are the most deserving of respect, the very symptoms by which the disease is ordi- narily accompanied, the morbid state of the brain revealed by dissection, and the fact that sponta- neous and copious hemorrhages from the nose, lungs, or hemorrhoidal vessels, have either pre- vented the occurrence of the attack, when the most unequivocal symptoms of its approach have been present, or completely removed the disease when it has occurred, aU press upon the atten- tion of the reflecting practitioner the importance and necessity of bloodletting in the treatment of apoplexy."—(See Hays' American Cyclopedia of Practical Medicine and Surgery, vol. ii., art. Apo- plexy.)—D. * The most efficient purgative is the croton-oil; and, as Dr. Abercrombie observes, if the patient cannot swallow, it may be very conveniently in- troduced into the stomach, suspended in thick gruel or mucilage, through an elastic gum tube. The operation should be expedited by strong pur- gative injections.—Op. cit., p. 289.—Ed. t It is much to be regretted that the practice of administering emetics in apoplexy is still pursued by some practitioners. The celebrated and la- mented Spurzheim very justly observes, " wher- ever there is a determination of blood to the he?,d, emetics are contra-indicated; vomiting is admissi- ble only where apoplexy is connected with an overloaded state of the stomach, and then we ought to have recourse merely to tickling the fauces. If They have been given upon the principle of their producing a sudden prostration of strength and faintness : but this is a result of nausea rather than of vomiting; and we cannot answer that the straining will not renew the extravasation, or even rupture a vessel where no rupture has existed.* Blisters and sinapisms promise but little in this form of the disease : they tease and irritate to no purpose when applied to the extremities, and are still more injurious when they are made to cover the scalp; for they effectually prevent the use of epithems of cold water, or vinegar, or pounded ice, which afford a rational chance of producing benefit. + Cordials were in high reputation among the Greek practitioners, from a belief that apoplexy is in almost every case the result of a debilitated and pituitous habit; and the custom has too generally descended to the present day, even where the ground on which it was founded has been relinquished. Stimulants and cordials of all kinds should be sedulously abstained from : and the neutral salts, with small doses of the antimonial powder, or any other cutaneous re- laxant, be employed in their stead : cooling di- lute drinks should be freely recommended ; and if we should hereby be enabled to excite a gen- eral moisture on the skin, it may prove of incal- culable advantage. The curative process under our second va- riety of the disease, or atonic apoplexy, must vary in many points from the preceding. It is here, if at any time, we should pause before we employ bleeding. Yet, as dissections sho w us, that even here also compression, and that too from an efflux of blood, is very general, and, ei- ther from blood or serum, almost constant,— whatever be the degree of constitutional debility, I can hardly conceive of any case in which we should be justified in withholding the lancet, or the patient is insensible and cannot swaUow, there is danger of suffocating him by introducing any liquid into the mouth Vomiting always increases the vascular action: the face becomes turgid and suffused; it gives headache, which can be ex- plained only by the congestion of blood in the ves- sels. Indeed, there is every reason to think that vomiting wfll bring on apoplexy, and convert a slight attack into a hopeless case rather than cure it."—See Observations on Insanity, by J. G. Spurzheim, London, 1817, p. 49.—D. * Dr. Abercrombie says, " antimonials may oc- casionally be useful as an auxiliary, from their known effect in restraining vascular action, pro- vided, in the early stages, they do not occasion vomiting."—(On Dis. of the Brain, p. 288.) In numerous instances, as Dr. Clutterbuck observes, apoplexy is ushered in by vomiting; the disease is then often referred to a disordered state of the stomach as the primary cause; but generally with- out reason, the disorder of the stomach being mostly secondary, and dependant upon the brain. The mistake is important, as leading to the em- ployment of emetics, the use of which is not un- attended with danger.—See Cyclop, of Pract. Med., art. Apoplexy.—Eb. t Many practitioners wul prefer to use warm rather than cold applications in these cases. —D. Gen. VIII.—Spe. G.] CARUS PARALYSIS. 401 the use of cupping-glasses. The argument stands precisely upon the ground of the expe- diency of bleeding in typhus accompanied with congestion : it is in itself an evil; but it is only employed as a less evil to fight against a greater. With it we may succeed : without it, in either instance, the case is often hopeless. Generally speaking, however, local bleeding will here be preferable to that of the lancet; but cupping should always be preferred to leech- es, whose operation is far too slow for the ur- gency of the occasion. The last, however, are recommended by Burserius, and Forestus quotes an instance in which they succeeded by a for- midable application over the entire body.—(Lib. x., obs. 76.) Aretaeus, after abstracting blood by cupping-glasses, recommends also the use of dry-cupping between the shoulders, and the rec- ommendation is highly ingenious, and worth at- tending to.—(De Cur. Morb. Acut., i., 4.) Purgatives, though less violent than in ento- kept in a state of perpetual motion by walking or other exercise, so as to prevent sleep till the narcotic effect is over. An interesting case of this kind is related by Dr. Marcet.—(Med.-Chir. Trans., vol. i., p. 77.) After all, it should not be forgotten, that apo- plexy is in most, perhaps in all cases, not second- arily alone, but primarily a nervous affection, and dependant upon a predisposition to this dis- order in the sensorium itself, if not upon a mor- bid condition of it: and that hence the patient, though we should recover him from the actual fit, will be subject to a recurrence of it. In this view the interval becomes a period of great im- portance, and should be as much submitted to a course of remedial treatment as the paroxysm itself. After entonic apoplexy, the patient should habitually accustom himself to a plain diet, reg- ular exercise, early hours of meals and retire- ment, and uniform tranquillity of mind : and the nic apoplexy, should in like manner be had re- state of his bowels should particularly claim his course to : and as we have less danger to ap- prehend from the use of emetics, they may be given. They have the triple advantage of free- ing the stomach from irritating matters, rousing the system generally, and determining from the head to the surface of the body.* Here also we may use both external and in- ternal stimulants in many cases with considera- ble success. Of the former, ammonia, camphire, electricity and galvanism, rubefacients and blis- ters, may be made choice of in succession, and applied alternately to different parts of the body.t Of the latter, we should chiefly confine our- selves to the warmer verticillate plants, as lav- ender, marjoram, and peppermint, or the warmer siliquose, as horseradish and mustard, or the different forms of ammonia; yet even of these we are debarred by Dr. Cullen. [In France, nux vomica has been employed ; and in Germa- ny, phosphorus. Dr. Abercrombie (Pathologi- cal and Practical Researches on Diseases of the Brain, p. 298) is of opinion that aU stimulants must be used with considerable caution, and that the patient, during their use, should be kept in a very low state by spare living and oc- casional evacuations ; and he cannot agree that the diet in paralytic cases ought to be nourish- ing and restorative.] In that peculiar kind of apoplexy which is sometimes produced by taking immoderate doses of spirits or some narcotic, and especially opium, in which we meet with an almost instantaneous exhaustion of the nervous power, making a near approach to asphyxy, though with a heavy drow- siness and stertorous breathing, the patient should first have his stomach thoroughly emp- tied by an emetic of sulphate of copper; he should be generally stimulated by blisters, and * After the pathological remarks already deliv- ered on the present disease, it seems that the prac- tice of employing emetics must be attended with some risk of producing a renewal of hemorrhage, or even of occasioning a fresh rupture of the weak- ened or diseased vessels.—Ed. t Cajeput oil will be found an admirable exter- nal application.—D. Vol. II.—C c attention. After the atonic variety, the same general plan may be followed with a like good effect, but the diet may be upon a more liberal allowance ; and a course of tonic medicines should form a part of the remedial system. And hence much of the treatment laid down under limosis Dyspepsia (vol. i.) may be pursued here ; together with the use of the waters of Bath, Buxton, and Leamington. SPECIES VI. CARUS PARALYSIS. PALSY. CORPOREAL TORPITUDE AND MUSCULAR IMMOBILI- TY MORE OR LESS GENERAL, BUT WITHOUT SOMNOLENCY. Palsy is a disease which makes a near ap- proach to apoplexy in its general nature and symp- toms, and is very frequently a result of it. It is, however, still more strictly, a nervous affection, and less connected with a morbid state of the san- guiferous or the respiratory organs. In examin- ing it more in detail, we shall find that some- times the motory fibres alone are affected in any considerable degree, while the sentient are only rendered a little more obtuse ; sometimes both kinds are equally torpid, and sometimes several of the faculties of the mind participate in the de- bility, though they are never so completely lost as in apoplexy. The Greek writers contemplated the two dis- eases under the same view, considering them as closely related to each other, or, in other words, as species of the same genus. " The ancients," says Dr. Cooke, who has accurately gone over the entire ground, and taken nothing upon trust, "very generally considered apoplexy and palsy as diseases of the same nature, but different in degree; apoplexy being a universal palsy, and palsy a partial apoplexy. Aretaeus says, apo- plexy, paraplegia, paresis, and paralysis, are all of the same kind ; consisting in a loss of sensa- tion, of mind, and of motion. Apoplexy is a palsy of the whole body, of sensation, of mind, and of motion. And on this subject Galen, 402 NEUROTICA. [Cl. IV.—Ord. IV, Alexander, Trallianus, ^Etius, and Paulus ^Egi- neta, agree in opinion with Aretaeus. Hippoc- rates who in various parts of his works speaks of apoplexy, nowhere, as far as I know, mentions paralysis ; and when he refers to this disease, he employs the term apoplexia. Both Aretseus and Paulus ^Egineta represent him as speaking of apoplexy in the leg. Celsus de- scribes palsy and apoplexy by the general terms resolutio nervorum."—(Treatise on Nervous Diseases, vol. ii., p. 1.) It is only necessary to add, that paresis and palsy were used some- times synonymously ; and that, when a distinc- tion was made between them, paresis was re- garded as only a very slight or imperfect palsy. Palsy and apoplexy, however, are something more than the same disease merely varied in degree ; the one, indeed, may lead to and ter- minate in the other, but they very often exist separately and without any interference; and notwithstanding their general resemblance, are distinguishable by clear and specific symptoms. But if the Greeks approximated them too close- ly, the greater part of the nosologists of modern times, as Sauvages, Linneus, Vogel, Sagar, Cullen, and Young, have placed them too re- motely, by regarding each as a distinct genus : the proper nosological arrangement seems to be that of co-species, as they are ranked by Dr. Parr, as well as under the system before ns. The common causes of apoplexy are usually asserted to be those of palsy : and considering how frequently palsy occurs as a sequel of apo- plexy, the assertion has much to support it; for compression is here also, as well as in apoplexy, a very frequent cause. Yet, as compression does not seem to be the only cause of apoplexy, it is still less so of palsy in all its modifications, and we shall still more frequently have to resolve the disease into some of those causes of general, and especially of nervous debility, which we have already noticed as occasionally giving rise to apoplexy, and which we have more particu- larly illustrated under the genus clonus of the preceding order. Palsy is often preceded by many of the pre- nrrsrve signs of apoplexy; and it commonly commences slowly and insidiously; a single Hmb, or a part of the body, being at first troubled with an occasional sense of weakness or numb- Bess, which continues for a short time, and then disappears. A single finger is often subject to this token, as is one of the eyes, the tongue, or one side of the face-. The nerves chiefly affected are those subser- vient to- voluntary motion, but the accompanying serves of feeling in most eases participate m the torpitude, though not in an equal degree, and sometimes not at all. " I never," says Dr. Cooke, "saw a case of palsy in which sensation was entirely lost :" though such cases seem sometimes to have occurred. The action of the involuntary organs, and especially of the heart amd lungs,, is but little interfered with, though in a few instances something more languid than at a state of ordinary health. And in this re- spect we perceive a considerable difference be- tween paralysis and apoplexy, in which last the heart appears to be always oppressed, and th« breathing laborious. The faculties of the mind, however, rarely escape without injury, and es- pecially the memory ; insomuch that not only half the vocabulary the patient has been in the habit of using is sometimes forgotten, but the exact meaning of those terms that are remem- bered ; so that a senseless succession of words is made use of instead of intelligible speech, the patient perpetually misusing one word for an- other, of which we have given various examples under moria imbecillis, or mental imbecility. And it is hence not to be wondered at that pal- sy should occasionally impair all the mental fac- ulties by degrees, arid terminate in fatuity or childishness. We have frequently had occasion to observe. and to prove by examples, that where any one of the external senses is peculiarly obtuse or deficient, the rest are often found in a more than ordinary degree of vigour and acuteness ; "as though the sensorial power were primarily de- rived from a common source, and the propor- tions belonging to the organ whose outlet is in- valid, were distributed among the other organs." Something of this law seems to operate in many cases of palsy, and is more and more conspicu- ous in proportion to the extent of the disease : for, in hemiplegia and paraplegia, the half of the body that is unaffected has not unfrequently evinced a morbid increase of feeling. Dr. Heb- erden attendecLa paralytic person, whose sense of smell became so exquisite as to furnish per- petual occasions of disgust and uneasiness : and he mentions one case, in which aU the senses were exceedingly acute. It is to this principle we are to resolve it, that where the disease confines itself to the mo- tory nerves of an organ alone, and the sensific are not interfered with, the feeling of the pal- sied limb itself is sometimes greatly increased, and sometimes exacerbated into a sense of for- mication, or some other troublesome itching. " I have seen several instances," says Dr. Cooke, " in which paralytic persons have felt very violent pain in the parts affectedr particu- larly in the shoulder and arm" (Op. cit., p. 5); and the remark, if necessary, might he con- firmed from numerous authorities- Palsy, however, is strictly a disease of ner- vous debility, and where it shows itself exten- sively, the whole nervous system is affected by it. The consequence of which is, as we have already shown in treating of entastic, and partic- ularly of clonic spasm, that the sensorial power in all its modifications is communicated irregu- larly, and its balance perpetually disturbed, so as to operate upon the mind as well as upon the body : whence some parts are too hot and others too cold ; and even the affected limb itself, ac- cording to the nature of the affection, and its limitation or extension to different sets of nerves, will be warmer or colder than its natural tem- perature, and will waste away, or retain its ordi- nary bulk; while the passions of the mind will participate in the same morbid irritability, and evince a change from their constitutional ten- our. Persons of the mildest and most placid Gbn. VIII.—Spe. 6.] CARUS PARALYSIS. 403 tempers will often discover gusts of peevishness and irascibility : and men of the strongest men- tal powers have been known to weep like chil- dren on the slightest occasions. In a few in- stances, however, an opposite and far more de- sirable alteration has been effected. "I had several years ago," says Dr. Cooke, " an oppor- tunity of seeing an illustration of this remark in the case of a much respected friend. The per- son to whom I allude had always, up to an ad- vanced age, shown an irascible and irritable dis- position ; but after an attack of palsy his tem- per became perfectly placid, and remained so until his death, about two years afterward."— (On Nervous Diseases, vol. hi., p. 12.) It is the general opinion, that paralytic limbs are uniformly colder than in a state of health : and Mr. Henry Earle has ably supported this opinion, upon an extensive scale of examination. —(Medico-Chirurg. Transact., vol. vii.) Dr. Abercrombie, on the contrary, in a correspond- ence upon this subject with Dr. Cooke, gives it as his opinion, that the paralytic parts do not become colder than natural; and adds, " that he had long ago observed that they are some- times warmer than sound limbs, but without being able to account for it." The present au- thor has frequently made the same remark, though he has more commonly found them be- low the ordinary temperature. The facts, there- fore, on both sides, are correctly stated; and the discrepance is to be resolved into the na- ture and extent of the sets of nerves that are immediately affected, whether sensific, motific, or both, and into the disturbed and irregular, the hurried or interrupted tenour, with which the nervous influence is distributed.* The learned Pereboom, who has followed Boerhaave and Heister in attaching himself to the apparently correct doctrine of the Galenic school, that the nerves issuing from the senso- rium are of two distinct sorts, one subservient to sensation, and the other to muscular motion, and has so far accorded with the physiology at- tempted to be established in the commencement of the present volume, has divided palsy, which he describes as a genus, into three species ; a nervous, muscular, and nervo-muscular ; by the first meaning that form qf the disease in which there is a deprivation of sense without loss of motion ; by the second, loss of motion while the sensibility remains ; and by the third, loss both of sense and motion.—(Acad. Nat. Cur. Soc. de Paralysi, 8vo., Horna;.) The specific names are here at variance with the physiology ; for, if it be true that muscular motion is as depend- ant upon the nerves as sensation, then palsy af- fecting the moving fibres is as much entitled to be called nervous as palsy affecting the sen- tient. Nor are the few cases to be met with of * According to Dr. Abercrombie, paralytic limbs lose, in some degree, that remarkable power pos- sessed by the living body in a healthy state, of preserving a medium temperature ; and paralytic parts become hotter or colder than sound parts which have been exposed to the same tempera- tore.—Pathological Researches on the Brain, &lc, p. 277. C c 2 privation of feeling, without loss of motion, strictly speaking, to be regarded as palsies. They are rather, as Aretaeus has correctly ob- served, examples of anaesthesia, or morbid want of the sense of feeling, and as such will be found described in the present system under the name of parapsis expers.—(Class IV., Ord. II., Gen. V.) . On this account the present author, in his vol- ume of nosology, thought it better to follow up, though with a considerable degree of simplifica- tion, the subdivisions of Sauvages and Cullen, and to distinguish the disease under the three following varieties, founded upon the line or lo- cality of affection:— a Hemiplegia. The disease affecting and Hemiplegic palsy. confined to one side of the body. B Paraplegia. The disease affecting and Paraplegic palsy. confined to the lower part of the body on both sides, or any part be- low the head. y Particularis. The disease affecting and Local palsy. confined to particular limbs. Some nosologists have transferred to this di- vision the local insensibilities and atonies of the external senses, or parts of them, as though they were idiopathic affections. It is rarely, however, or never, as Aretaeus has justly remarked, that they are not connected with other symptoms and other derangements of such organs and their respective functions: and hence, they rather belong to the second order of the present class than to paralysis, in the strict sense of the term. They are anaesthesias,—v6ooi irapaXi- tikoi or rcapiriKoi, rather than irapd\vatts; and in the system before us are arranged accord- ingly- Hemiplegia, the first of the above varieties of palsy, is far most frequently met with as a sequel of apoplexy, and especially of atonic ap- oplexy, or that in which the energy of the ner- vous system is peculiarly diminished and irreg- ular. The usual exciting causes of apoplexy are in consequence of those of palsy, and need not be enumerated in the present place. In a few instances, however, hemiplegia occurs without preceding apoplexy ; and hence distinctly proves that pressure, or at least such a pressure as is demanded to produce somnolency, is not essen- tially necessary.* Mr. John Hunter, as we have * Dr. Abercrombie's third class of apoplectic cases is that which he terms paralytic. " The leading phenomenon of this class," he says, " is the paralytic attack without coma, or at least with- out that complete and permanent coma which oc- curs in the former classes." He describes the at- tack as appearing under various forms ; the most common of which is hemiplegia with loss of speech; but in some cases the speech is not af- fected ; while mother cases, the loss of speech is at first the only symptom. In some cases again, he observes, one limb only is affected, which is most commonly the arm, though sometimes the leg. Numerous other modifications occur, as pal- sy of one eyelid, or of the orbicularis muscle; 404 NEUROTICA. [Cl. IV.—Ord. IV already observed, was inclined to think that pressure from effused blood was in every in- stance the cause both of this disease and of ap- oplexy ; but in allowing, as he has done, that on one occasion at least he was called to a pa- tient who died of a gouty affection of the brain, "vnth symptoms similar to apoplexy," and with- out any extravasation whatever, he directly yields the point of compression as a universal cause : for if atonic or retrocedent gout may produce apoplexy or palsy without pressure on the brain, so may many other atonic powers, op- erating as effectively on the sensorium. One of the most frequent of these powers is a de- bilitated and paretic state of the liver; and distortion of the eyes ; double vision ; twisting of the mouth, &e Loss of the power of swallowing also occurs occasionally, though more rarely in the cases which do not pass into apoplexy.—(Pa- thological and Practical Researches on the Dis- eases of the Brain, &c, p. 245.) The following are the morbid conditions specified by Dr. Aber- crombie, as connected with these varieties. 1. Many of the cases have a close analogy to simple apoplexy, and-after the patient's death, no partic- alar changes in the brain are found, or only an ef- fusion of serum, often in small quantity. 2. Ex- travasation of blood of small extent. 3. Softening of the cerebral substance. 4. Inflammation and its consequences.—(P. 247.) 5. Induration of a portion of the brain. 6. Empty cysts, from which the extravasated blood has been absorbed. 7. Extensive disease of the arteries of the brain.—(P. 279.) An extraordinary case of intermittent hemiplegia of the left side is recorded by Dr. Elliotson in his clinical lectures.—(See Lancet for 1830-1, p. 556.) The paroxysms usually came on at ten o'clock in the morning, every third or fourth day, and, with a single exception, never with a longer interval; but, on one occasion, the complaint left him for sixteen days. He was forty-eight years of age, and had been subject to this affection for two years and a half. The paroxysms lasted from three to four hours. He had been in the East and West Indies, and had had fever both at Bombay and Ba- tavia. Dr. Elliotson believed that this hemiple- gia was the effect of malaria, and a form of ague, though not attended with shivering, heat, and sweating. On this principle he gave quinine, at first in doses of five grains every six hours, and the quantity was increased to fifteen. Large doses are often required in quartan ague, and Dr. EUiot- son views this as a worse form of disease than quartan, because it occurred every third or fourth day, and the longer the interval between the at- tacks, the greater the difficulty of cure. The practice was successful, whatever may be the truth of the theory. We must agree with Dr. El- liotson, that, at all events, the case amounts to a proof, that paralysis is not necessarily an organic affection; and that hemiplegia does not necessarily arise from effusion, or from compression of any kind. If any compression occurred, it could only be during the fit; but Dr. Elliotson inclines to the theory that it was a disorder of function, induced by a particular poison. Some cases, however, depend upon local affec- tion or injury of the nerves; as the palsy of the deltoid muscle or whole arm, from pressure of the bead of the dislocated humerus on the cervical nerves; palsy of one side of the face from an af- fection of the portio durae, brought on by inflam- mation of the ear of parotid gland, &c—Ed hence those persons are peculiarly subject to this variety of palsy who have spent the earlier part of their lives in an habitual course of intem- perance.* Hoffmann has particularly noticed this cause ; and Morgagni describes the case of a man advanced in years, who was attacked with jaundice and hemiplegia simultaneously ; the jaundice affecting the hemiplegic side alone, which was the right, and that with so much precision, that the nose was of a deep yellow on the one side, and of its proper colour on the other, which were divided from each other as by a ruled line. Other causes are, exposure to the rays of the sun, drinking cold water and bathing in it when heated, repelled eruptions, and chron- ic rheumatism. As apoplexy has its procursive symptoms oc- casionally, so also has hemiplegia, and particu- larly when it is connected with a plethoric hab- it : for, in this case, the veins of the neck and face often appear turgid, there is an obtuse pain in the head, the tongue moves with some diffi- culty, and particularly on one side, the percep- tion and memory become impaired, and the pa- tient feels a tendency to drivel at one corner of the mouth rather than at the other. The on- set, like that of apoplexy, is at last sudden ; and, if the patient be standing, he drops down abruptly on the affected side. The progress of the disease is uncertain ; and depends very much upon the state of the ner- vous system at the time of the attack. If there be no chronic debility, nor other morbid condi- tion of the sensorium, the patient will sometimes recover entirely in a week, or even less ; but if this system, or some particular part of it, be in an infirm state, he recovers only imperfectly; and obtains, perhaps, a thorough or a limited use of the lower limb, while the upper remains immoveable ; or he is compelled to pass through the remainder of a wretched and precarious ex- istence with only one half of his body subservi- ent to his will, the other half being more dead than alive, and withering, perhaps, with a mil- dew mortification.—(See Cl. III., Ord. IV., Gen. XII., Spe. 2.) We have stated that in this disease, as in- deed in all others accompanied with an atonic disturbance of the nervous energy, there is not only a great irregularity in its supply, but a great and confused disproportion in its dis- tribution to different parts of the body. Dr. Cooke (On Nervous Diseases, vol. ii., part i.) and Dr. Abercrombie (Treatise on Apoplexy and Palsy) have collected numerous and highly in- teresting examples, in which the sensific or mo- tific nervous influence was either deficient in some parts, or so accumulated in others, that the most capricious and extraordinary sensations or motions were produced in them. Sauvages gives a case from Conrad Fabricius of what he calls transverse hemiplegia, in which the disease was confined to the arm on one side, and the foot on the other: and Ramazzini speaks of a patient whose leg on one side had lost . * C:J?es °[ "bis kind are unfortunately not rare m the Umted States— D. Gun. VIII.—Spe.6] CARUS FA its feeling, but retained its power of motion, while the other leg had lost its power of motion but retained its feeling.* In some instances, indeed, the entire feeling on one side is said to have been lost, and the entire motivity on the other side (Eph. Nat. Cur., passim.); and, in a few rare examples, persons during the parox- ysms, and even for some time afterward, have felt on the affected side a sensation of pungent heat from cold, and especially polished bodies, and of painful cold from an application"of hot bodies. Where the sensibility is morbidly accumula- ted in a weak limb, as it often is in hemiplegia, sometimes so much as to give a painful sense of formication, cold not only excites action, but becomes almost as pungent an irritant as an ac- tual cautery; in the correct language of the poet— " Boreae penetrabfle frigus adurat."t And hence, in climbing lofty mountains, as the Alps and the Andes, the traveller frequently finds his skin more completely blistered from the sharp cold by which he is surrounded, than by an exposure to an equinoctial sun. On the con- trary, the morbid halitus or perspiration into which the application of hot bodies often throws a limb, in the same relaxed and debilitated state, produces an unusual sense of coldness in conse- quence of the evaporation. And we may hence explain the singular case recorded by Dr. Fal- coner of a gentleman who, after a paralytic at- tack, felt his shoes very hot when he first put them on, and gradually become cool as they ac- quired the warmth of his feet; the reaction and consequent increase of moisture thrown forth from the surface of the feet, producing the difference of sensation. The case of Professor de Saussure (Med.- Chir. Trans., vol. vii., p. 216) is very singular ; he was gradually attacked with an imperfect hemiplegia, which at first showed its approach by perturbed sensations and vertigo, with a feel- ing of seasickness, a sight of objects reversed, a difficulty of swallowing liquids, and a total loss of voice, while the powers of the mind re- mained unimpaired, so that he could watch all his symptoms. Shortly after this the whole of the right side became utterly insensible, the in- sensible part being divided from the sensible by a geometrical line running down the body in a vertical direction: and in about three months * De Morb. Artif., 286. See also Heister, Wahrnehmungen, i., 205. For references to vari- ous other facts of this kind, see Abercrombie's Pathol, and Practical Researches on the Diseases of the Brain, p. 275. " A gentleman," says he, " who was under the care of Dr. Hay, of Edin- burgh, had two paralytic attacks at the distance of eight months from each other. In the first, there was perfect loss of feeling, with only partial loss of motion; in the second, there was perfect loss of motion, with only partial loss of feeling," &c Sir C. Bell's discoveries, and those of C. F. Bellingeri (see Ed. Med. and Surg. Journ., July, 1834), certainly tend to throw light on this curious subject.—Ed. t Virg. Georg., i., 93. 405 more, the insensibility of the right side of the head, accompanied with a debility of all the vol- untary muscles, was transferred to the left, the right reacquiring its antecedent powers ; but all the right side below the head still continu- ing to possess its former torpitude. Here, also, there was a very different sense of heat and cold on the opposite sides ; for, white the left was in- fluenced naturally, the right had the falsified sen- sation just noticed in Dr. Falconer's case, so that in getting into a cold bath or cold bed, the right side had a feeling of heat, while the left side felt cold as it should do. Hot bodies, in like manner, felt cold to the diseased side, appa- rently from the cause just stated. And that this was the real cause seems manifest from the patient's having often a feeling of a cold dew, or of cold water on the surface, and especially over his face, which induced him to wipe him- self as if he had been wet. It is perhaps more singular that, though plunging his right or af- fected hand into cold water gave him a sense of lukewarmness, plunging it into boiling water gave him a disagreeable sensation, but very dif- ferent from that of either heat or cold.* This morbid disturbance and irregular distri- bution of sensorial power is sometimes productive of the most alarming consequence ; for, in a hemiplegic state of the bowels, some parts are in certain cases so acutely sensible, and others so utterly insensible, that while ordinary purga- tives are incapable of exciting evacuations from the torpitude and irresponsibility of the palsied parts, they are sufficient to occasion inflamma- tion, and have actually occasioned it in the parts exacerbated by accumulated sensibility, as cer- tain experiments of M. Magendie have sufficient- ly established. It is owing to the same irregular distribution of sensorial power, where every department of the nervous system participates in the diseased state of the sensorium, that we sometimes behold hemiplegia, and particularly imperfect hemiple- gia, united with other affections of the same system. The symptoms of hypochondriacism are peculiarly apt to associate with it; in which case the bravest hero will often lose all his mag- nanimity, and sit down and weep like a child : and in the celebrated geologist, M. de Saussure, we find a still more complicated instance of hem- iplegia, hypochondriacism, and chorea. The disorder crept on by imperceptible degrees, and was accompanied with various anomalies. Both sides were weakened, but the left suffered chiefly; yet with the aid of a stick he could still drag forward the left leg. By some un- known means he had taken up a morbid notion, * Dr. Abercrombie remarks, that paralysis gen- erally begins in the extreme parts; but he has seen one patient who could write distinctly with his arm supported upon a table, after the arm from the shoulder to the elbow was completely paralytic. In a few hours afterward, the hand was also para- lytic He also quotes a case, related by M. Vel- peau (Archives Gen., 1825), where the right arm was paralyzed from the shoulder to the middle of the forearm, while the hand was not in the least affected.—See Path. Researches on the Brain, p. 277.—Ed. 406 NEUROTICA. [Cl. IV—Ord. IV. very common to hypochondriac patients, of the difficulty of passing through a doorway when wide open without being squeezed to death ; and hence at the very time in which he could cross his room with a tolerably firm step, the moment he reached the door, which was of ca- pacious breadth and thrown open for his passage, he tottered and precipitated his motions with the jerk of a St. Vitus's dance, as though he were preparing for the most perilous leap : yet as soon as he had accomplished the arduous under- taking, he again became collected, and passed on with comparative ease till he had to en- counter another adventure of the same kind, which was sure to try him in the same manner. —(Medico-Chir. Trans., vol. vii., p. 214.) Tul- pius gives a somewhat similar case, in which hemiplegia was united with beribery.—(Lib. iv., cap. 5.) Paraplegia, or the second variety of palsy, has generally been conceived to depend alto- gether upon a diseased affection of the spine in its bones, ligaments, or interior, most frequently in the region of the loins; in consequence of which the spinal marrow becomes pressed upon or otherwise injured independently of any com- plaint of the brain. That this is a common cause is unquestionable, and a cause that often operates long without external signs : for the vertebral extension of the dura mater may be thickened,-or a serous fluid effused, or blood be extravasated within the vertebral cavity ; or a tumour may be formed in some part of it, or the spinal marrow itself may undergo some morbid change. But the best practical observers of the present day concur in opinion that paraplegia, like hemiplegia, is produced still more frequently by causes operating on the brain than confined to the spine. Of this opinion is Dr. Baillie, who ascribes it chiefly to pressure on the brain (Trans. Med., vol. vi., art. ii.), Sir Henry Hal- ford, Sir James Earle, and Mr. Copeland.— (Treatise upon the Symptoms and Treatment of the Diseased Spine.) Some kind of affection of the head, indeed, will commonly be discov- ered from the first, if we accurately attend to all the symptoms ; some degree of pain, or gid- diness, or sense of weight, or undue drowsiness, or imperfection in the sight. And hence many of the causes of paraplegia are evidently those of hemiplegia, operating probably upon a differ- ent part of the brain. This form of paralysis may take place at any age, but it is more frequent as we advance be- yond the middle of life ; and Dr. Baillie has ob- served, that it occurs oftener in men than in women ; for which it is by no means difficult to account, considering the greater hurry and activ- ity of life pursued by the former. The disease in many instances makes an insidious approach. There is at first nothing more than a slight numbness in the lower limbs, with an appear- ance of stiffness or awkwardness in the motion of the muscles ; these symptoms increase by degrees; there is great difficulty in walking, and an inability of preserving a balance; the aid of a staff or the arm of an assistant is next demanded: and the urine is found to flow in a feeble stream, or perhaps involuntarily. The bowels are at first always costive; but as the sphincter loses its power of constriction, the mo- tions at length pass off involuntarily. The dis- ease may continue for years, and the patient at last sink from general exhaustion. It some- times, but rarely, terminates in a recovery.— (Practical Essay on the Diseases and Injuries of the Bladder, by Robert Bingham, 1822.) When an injured or diseased state of the spine is the origin of paraplegia, the complaint shows itself suddenly, or makes its advances in- sidiously, according to the nature of the cause: and for a knowledge of this form of the malady we are chiefly indebted to Mr. Pott,* who, how- ever, does not think that it properly belongs to the species paralysis, though there seems no suf- ficient reason why it should not be so arranged, as in truth it has been by most pathologists from the time of Galen, who seems not only to have understood its nature, but to have contemplated it in this view.—(DeLocis Affeclis, lib. iv., cap. vi.) The disease, however, must not be con- founded with rhachybia, or distortion of the spine from debility of muscular power, of which we have already treated (Cl. IV., Ord. III., Gen. I., Spe. 3) in the present volume. It sometimes happens in hemiplegia, that one or more vertebrae have been pushed by sudden force a little out of their proper position ; and in this case a considerable degree of numbness, together with less motion in one or both the lower limbs, is almost sure to follow, too often succeeded by a paralysis of the sphincters of the rectum and bladder, and consequently an involuntary discharge of feces and urine : and if the luxation should take place in the dorsal or cervical vertebrae, the organs of digestion may all more or less suffer, the respiration become affected, and the spine itself exhibit a consider- able degree of curvature. And the same effects are still more likely to follow, and even to a greater extent and with still more serious mis- chief, from an idiopathic affection of some part of the spinal chain, arising from inflammation, scrofula, rickets, mollification, or caries ; from compression by some effused fluid, or a thicken- ing of its external tunic, or even of the sub- stance of the spine itself; of which last M. Portal has given a singular example.—(Anat. Med., p. 117.) In the last case, the disease for the most part makes its approach slowly, and is often found in weakly and ill-nursed infants. Its precursive symptoms are commonly languor, listlessness, weakness in the knees, and a pale and shrivelled skin. As it advances, there is a difficulty in directing the feet aright when walking, the legs involuntarily cross each other, and the little pa- tient is perpetually stumbling upon level ground, till at length he is incapable of walking at all. In adults, the progress of the disease is more rapid than in childhood. Like hemiplegia, this variety is sometimes connected with a morbid state of the mental * Remarks on that Kind of Palsy of the Lower Limbs which is frequently found to accompany tt Curvature of the Spine, 8vo., 1788 Gen. VIII.—Spe. 6.] CARUS PARALYSIS. 407 powers, and particularly with hypochondriacism, and this too where the disease proceeds from an organic lesion of the spine. Dr. Cooke has an instructive case in illustration of this in an offi- cer of the army, aged forty-five, who had for many years been exposed to the hardships of a military life, particularly to extremes of heat and cold in various climates. " For two or three years previous to the paralytic attack, he had complained that his state of health was de- teriorated, although no precise symptoms of disease could be pointed out either by himself or by his medical friends. His appetite was good, his bowels regular, though inclined to costiveness, and his usual robust appearance was not'diminished. He entertained some fan- ciful notions respecting the state of his health, and from some uneasy sensations about the sa- crum, he supposed that he had internal hemor- rhoids, though no evidence of their existence could be perceived by his physicians, by whom he was considered as hypochondriacal." After having suffered for two or three years, he grad- ually lost the power of walking without some support for one of his hands. He went to Bath, and had the hot water pumped upon his loins: soon after which he complained of pain in the lumbar region, which was followed by a collec- tion of fluid behind the great trochanter of the left side, which burst externally, and was dis- charged daily in considerable quantity. The paraplegia was now complete; the lower ex- tremities being quite useless: the feces and urine, which for a considerable time the patient had with some difficulty retained, came away involuntarily: his strength rapidly wasted; he became much emaciated ; and at the end of three months after his return from Bath he died, retaining the use of his senses and his intellect- ual faculties to almost the last instant of his life. —(On Nervous Diseases, vol. ii., part i., p. 43.) Where the upper part of the spine is affected, the superior limbs are usually divested of mobil- ity or sensibility, or both, while but little dis- turbance, in a few rare instances, takes place in the inferior. The most singular example of this sort that has occurred to the present writer, is contained in a case related by M. Rullier, of Paris.—(London Medical and Physical Journal, July, 1822, p. 80.) The subject was forty-five years of age, and had evinced a slight rachitic tendency from infancy, accompanied, as is often the case, with a considerable precocity of intel- lectual powers ; the dorsal portion of the verte- bral column evincing a little distortion, so as to give some degree of elevation to the right shoul- der ; but which did not proceed further. The patient, from early youth, had indulged himself in every concupiscent indiscretion, and especially in an unbounded and extravagant intercourse with females, which frequently reduced him to a state of exhaustion amounting almost to deli- quium. It was not, however, till the age of thirty-four, that he first began to perceive any serious difficulty in the movement of his arms, which was soon connected with some degree of pain and swelling in the distorted part of the vertebral chain. The complaint made a rapid progress, and the patient in a short time lost the entire use of these limbs, though their sensibility continued to the last, and appeared to grow morbidly acute, as he would not suffer any one to touch them, on account of the pain produced by such contact. He became, indeed, highly irritable in his temper, but could walk a consid- erable distance, enjoyed company and his usual meals, and still retained an immoderate appe- tency for venereal pleasures, with the fullest means of indulging it. Hectic fever, however, now attacked him, with phthisis, and he at last fell a sacrifice to such a host of marshalled evils. On a post-obit examination, the chief organs found to be affected were the lungs, and the spinal marrow at the seat of distortion. The last, indeed, presented a very singular appear- ance. From its origin to the fourth pair of cer- vical nerves, it was quite natural; but from this point, through an extent of six or seven inches in length, the whole substance of the column was reduced to the most diffluent state of molli- fication, like what we have already noticed as sometimes found in the brain: while below this length, the cord appeared again to be firm and uninjured; a few flakes of medullary matter were alone found in the morbid fluid which had usurped its place, but altogether disorganized and uncon- nected. And we here, therefore, behold, to adopt M. Magendie's remarks upon this very marvellous affection, a man enjoying, almost to his last hour, great moral activity, powerful generative faculties, a free movement of his in- ferior extremities, and a keen sensibility of the superior; who nevertheless, for an uncertain, but probably a very considerable period, had been destitute of one third part of the substance of the spinal marrow; and possessed no kind of communication between the cervical and dorsal portions of this cord,* unless we suppose some- thing of the sort to have been maintained by means of the surrounding membranes; a sup- position, however, which is entirely gratuitous, and at most, capable of throwing but little light upon the subject. Local palsy is often produced by the general causes of the other varieties, probably operating in a less degree or more partially on the brain. We have already seen that it frequently takes the lead of the general affection, and appears for some days or weeks antecedently, in an im- perfect movement of the tongue, or of one eye, or of one side of the mouth, sometimes of one or more of the fingers, or of an entire arm. And if, in this incipient state of the disease, proper evacuants or other means be instantly had re- course to, the paralytic tendency may be sub- dued, and the complaint limited to these local affections, and in a few days be entirely removed. This variety, however, is often the effect of * If this were the fact, the case is undoubtedly exceedingly interesting, in a physiological as well as pathological view. However, as a very slight communication between the cervical and dorsal portions of the spinal cord might have existed pre- viously to the dissection, and been inadvertently broken in it, a doubt may be entertained upon this material point.—Ed. 408 NEUROTICA. [Cl. IV.—Ord. IV. other causes tending to destroy the irritability of the nervous system, or particular parts of it; such as exposure to certain metallic fumes, or other means of absorbing metallic particles, espe- cially those of mercury and lead : and above all, exposure to keen blasts of cold and damp air.* This last is perhaps the most common and effectual cause of local palsy, and is peculiarly operative, where the limb or organ so exposed is in a state of relaxation and perspirable moist- ure, whether from previous exercise or great heat of the atmosphere. A palsy on one side of the mouth, of the muscles of one eye, of one of the cheeks, of an arm or a leg, is in this man- ner frequently produced, and becomes at times of very great obstinacy. Occasionally, indeed, the torpitude extends much further than to a single limb, and various organs are involved in its mischief. " A watchman," says Dr. Powell (Med. Trans., vol. v., p. 195), "on quitting his duty after a night of severe cold, was attacked by sudden and violent general pains in his limbs, which soon departed, and left him in a state of universal palsy of the muscles of voluntary mo- tion. He had lost all command over the mus- cles of his limbs or trunk; but the joints were unaltered in their external appearance: they were perfectly flexible: and it gave him no pain if you moved them in any direction. The sphincters also of the rectum and bladder had lost their usual powers of retention, and he passed both stools and urine involuntarily and unconsciously. His circulation was not af- fected in any cognizable degree, and his mind retained its usual powers. . His voice was not lost: the hot bath and other remedies were tried in vain; he died : but on examination, there was no congestion, or effusion, or altera- tion of structure of any kind discoverable." In this case the motific nerves, or those derived from the anterior trunk of the spinal cord, seem to have been alone affected ; and in those slight palsies, induced by sudden cold or damp applied to one side of the face, and commonly known by the name of blights, the nerves that lose their power are branches of the portio dura, the respi- ratory nerve of Sir Charles Bell, white it is rarely that the twigs of the trigeminus, which commonly accompany them for the purpose of conveying sensation, are united in the mischief. In the treatment of palsy, it is necessary to distinguish between its attack and its confirma- tion, and as much as possible to ascertain the nature of its predisponent and exciting cause. Generally speaking, in hemiplegia, and very frequently in paraplegia, and even in local palsy, the causes of apoplexy are those of the present And as, of these causes, compression affection. * The eminent historical painter, Mr. John G Chapman, now of New-York, was once the sub- ject of paralysis particularly affecting his right arm, from the incautious use of spirits of turpentine Spurzheim (On Insanity, p. 32) states, that he has seen several soldiers who, during night, were ex- posed to cold and wet weather, and who in the morning felt stiffness in one of the lower limbs, which by degrees diminished, attacked the whole body, and was succeeded by death.—D. of the brain has appeared to be by far the most frequent in the former disease, so we ought to regard it, and shall generally find it, in the latter. And hence, copious bleeding and purgatives not only recommend themselves to us from the good effects we have already seen them produce in apoplexy, but from the actual and general ad- vantage which has been derived from them in palsy itself. Mr. John Hunter was so fully con- vinced of the benefit of sanguineous depletion, that he made it his unicum remedium, though he aUowed cathartics subordinately. Upon this subject, however, he writes with more force than discrimination. Referring to the stimulant plan pursued by some practitioners, he observes, " This is even carried further than blistering," to which he also objects: "we hardly see a man taken with all the signs of an apoplexy, where a paralysis in some part takes place, or hemiplegia, but he is immediately attacked with cordials, stimulants, electricity, &c. Upon a supposition that it is nervous debility, &e, the poor body is also tortured because it cannot act, the brain not being in a condition to influence the voluntary muscles. We might, with exactly the same propriety, stimulate the fingers, when their muscles are torn to pieces. We ought to bleed at once very largely, especially from the temporal artery, till the patient begins to show signs of recovery, and to continue it till he may begin to become faintish. We should give sa- line purges freely, to diminish impetus, and pro- mote absorption ; then quietness should be en- joined, and as little exercise of body as possible, and especially to avoid coughing and sneezing. Plain food should be directed, and but little of it."—(On Blood and Inflammation, p. 213.) All this is excellent as a general rule ; but the rule must admit of exceptions. In treating of apoplexy, we have noticed it as dependant on two very different and opposite states of the constitution,—an entonic and an atonic. And the same diversities of constitution are to be found in paralysis. Now, under the entonic state, there can be no question, and there ought to be no exception : and the boldness of the practice should be regulated by the nature of the exciting cause. Where this is over-eating or intoxica- tion, eighteen or twenty ounces of blood may be taken away with advantage, at once; in a few hours after, twelve or fifteen ounces more ; and the venesection may be repeated a third or even a fourth time, if necessary. Dr. Cross pursued this active plan in the case of a man thirty-five years old, who became hemiplegic from excess of drinking, and at the same time gave calomel to the amount of twenty-five grains to a dose, and in a few days effected a com- plete cure—(Thomson's Annals of Philosophy, " xhv., p. 121.) And similar instances of No success are to be found in all the writers upon the subject. Even in atonic apoplexy, it has been observed that venesection is occasionally necessary ■ and it may be equally necessary in atonic paralysis ; for here also effusion may take place both of blood and serum : of serum, indeed, more fre- quently from deficiency than from excess of Gen. VIII.—Spe. 6,] CARUS PARALYSIS. 409 vigour; and of blood, from a debilitated state of the vessels, and their greater facility to be ruptured from slight causes, as a violent fit of coughing or sneezing, of joy or terror. Absorp- tion may not easily take place in this state of constitution; but emptying the vessels alone will gain space, by stimulating them to contract their diameter. I cannot better illustrate this, than by the fol- lowing case from Dr. Abercrombie :—" An old and very poor woman, aged about seventy, thin, pale, and withered, having gone out to bring water from one of the public wells, on the morning of the 2d of July, 1818, fell down in the street speechless, and completely paralytic on the right side. Nothing was done till about two P. M., when she was found stupid but not comatose, yet completely speechless and para- lytic : her pulse of good strength, and about ninety-six. She was bled to fifteen ounces. Purgative medicine was ordered, and cold appli- cations to the head : on the 3d she was consid- erably improved both in speech and motion ; but having become rather worse at night, the bleed- ing was repeated, and the purgative medicine continued. From this time she improved grad- ually : at the end of a week she was able to walk with a little assistance, and speak pretty distinctly ; and by the end of another week, she had entirely recovered her former health."— (Treatise, &e,p. 15.) Nothing could be more judicious than this treatment, and the result cor- responded with the views of the enlightened practitioner. There can be no doubt that, in this case, a vessel had been suddenly ruptured : the labour in which the patient was occupied was violent, the season was that of the summer, and the temperature probably very hot : the stupor and state of the pulse equally indicated compression of the brain. Thus far, bleeding may be allowed, and in- deed ought to be imperatively enjoined. But there are some cases in which it is altogether a venture, and others in which it is considered on all hands to be injurious. Even Mr. Hunter himself recoils from the practice where hemiple- gia is apparently a result of retrocedent gout; and if we follow up the spirit of this forbearance, we shall be induced to abstain equally in all in- stances where there is a like diminution of senso- rial power—in all instances of atonic paralysis, let the exciting cause be what it may, where there is no stertor, no stupor, nor vertigo ; no convulsion, nor other irregular nervous action ; and the pulse, instead of being firm, is feeble and intermittent. For it should never be forgotten that, if many patients have recovered after bleed- ing, in suspicious circumstances, others have died after it, and probably in consequence of it, while great numbers have derived no benefit whatever. The advice of Dr. Cooke upon this subject is therefore founded on the truest wis- dom, and cannot be too extensively committed to memory:—" Each individual case must be viewed in all its circumstances, and by a careful consideration of them our practice should be regulated. Before we prescribe bloodletting in hemiplegia, we must investigate the age, strength, general constitution, and habits of the patient, and above all, the actual symptoms of the disease. In early, or even in somewhat advanced life, if plethora and the various symp- toms tending to apoplexy be present, I should not scruple to bleed freely both generally and topically. On the contrary, in great age, debil- itated, leuco-phlegmatic habit, dropsical tenden- cy, &c, I should think it right to abstain alto- gether from this and from every other powerful mode of depletion, unless there be an evident determination to the head, marked by flushing in the countenance, throbbing of the arteries, red- ness of the eyes."—(On Nervous Diseases, vol. ii., part i., p. 141.) In'purging, we may proceed with less re- straint : for even in debilitated and dropsical habits, stimulating the bowels is almost uniform- ly beneficial: should there be serous, or even sanguineous effusion, absorption is hereby pow- erfully promoted ; and if there be none, a bene- ficial revulsion will often be produced, and the stimulus will always be useful. In a very de- bilitated state of the constitution, however, we should choose the warmer in preference to the colder purgatives ; and hence jalap, colocynth, or even aloes, in preference to neutral salts: and it will also be serviceable to combine them with some distilled water impregnated with an essential oil, as mint, pennyroyal, juniper, or rosemary. If we have strong reason to apprehend a san- guineous effusion, emetics ought not to be em- ployed for a few days ; but if we have no ground of such suspicion, they cannot be had recourse to too soon. In low^ir atonic hemiplegia, Stoll first checked the hemiplegia by emetics, and then carried it off by external and local stimu- lants, as cantharides, in conjunction with pills of gum ammonia, myrrh, and aloes.* Such, under different modifications, is the re- ducent course it seems proper to pursue in the general train of paralytic attacks when they first make their appearance. If this course succeed the patient will soon recover, and, with a view of preventing a relapse, an extension of the re- ducent or tonic regimen, according to the na- ture of the case, as we have already noticed in the treatment of apoplexy, is all that we shall have further to prescribe. But this course may not succeed : the disease may prove obstinate and become confirmed; and the practitioner be called upon to proceed further. Having removed, as far as we may be able, all pressure upon the sensorium, and thus given an opportunity of healthful play to its function, our next business is to reinvigorate its general energy, and extend it to the parts which it has ceased in a greater or less degree to actuate. Stimulants, external or internal, or both, have been almost uniformly had recourse to for this purpose : but I cannot avoid thinking that the practice has been too indiscriminate, and, in * Mat. Med., part ii., p. 92. Few of the best modern practitioners venture to prescribe emetics in any examples of paralysis connected with dis- ease in the head.—Ed. 410 NEUR( many cases, far too precipitate. We have ob- served, that in many cases of hemiplegia, there is not only great local inactivity, but great irreg- ularity of action ; a tumultuous hurry of senso- rial power to some parts, with an equal removal of it from others. In all such cases we should proceed gently and palliatively, rather than rap- idly and forcibly : and to do nothing is better than to do too much. We should endeavour to allay the nervous commotion, and restore the agitated system to order by internal and exter- nal quiet of every kind. The patient should be kept as still as possible in a warm commodious bed and a well-ventilated room. His diet should be plain, with the allowance of a moderate quantity of wine, or wine and water. Camphire, musk, valerian, and other warm sedatives, as ammonia, neutralized with citric acid, are here to be chiefly resorted to, if, indeed, we resort to medicines of any kind ; and to these may be added the less stimulant metallic salts, and es- pecially those of zinc and bismuth. The warm bath may be allowed two or three times a week, and, if the nights be restless, the inquietude may be subdued by hyoscyamus. And, as this form of the disease is often connected with great general debility, and a tendency to hypo- chondriacism or lowness of spirits, cheerful and exhilarating conversation, and such occasional exercise in a carriage as may be indulged in with- out fatigue, will form very serviceable auxilia- ries. In Pechlin (Lib. iii., obs. 27) is to be found the case of a person called Peyreske, who is said to have been cured of a palsy accompa- nied with aphonia, by reading some favourite and agreeable authors. This may be an over- statement, or too much stress may be laid on this particular part of the general plan of treat- ment : but there can be no doubt that, in the form of the disease we are now contemplating, a gentle and insinuating amusement of this kind will not be without its effect. This tranquillizing and unostentatious plan I have found to answer wonderfully in many ca- ses of that tumultuous and irregular action de- scribed in the preceding history. But where the case seems altogether confirmed and chronic, and an entire side, or some other extensive part of the body, shows a fixed loss of sense and vol- untary motion, while every other part has re- sumed its healthy function, we may then, with safety, have recourse to the stimulant practice. This will consist of external and internal irri- tants, and Dr. Cullen has given a long and use- ful table of both. Of the former, the chief are friction by the hand or a flesh-brush; stimula- ting liniments prepared of the concentrated acids, or_ the caustic alkalis inviscated in oil or lard to render them less acrid and corrosive; brine, or a strong solution of sea-salt; the essential oils of turpentine, or other terebinthinate sub- stances ; and various vegetable acrids, as mus- tard, garlic, and cantharides, or other blistering insects. The object of all these is the same ; it is that of acting upon the origin of the nervous chain by stimulating it at its extreme end ; and as we have numerous instances of the produc- tion of such an effect in a great variety of cases, •TICA. [Cl. IV.—Ord. IV. particularly in those of trismus and lyssa, or canine madness, the principles of which we have endeavoured to elucidate under these diseases, we have reason to expect a like influence, and of a beneficial instead of a morbid kind, in the applications before us. Generally speaking, however, the irritation produced by the use of many of the siliquose and alliaceous or alkales- cent plants, as mustard, horseradish, and garlic, is more uniformly efficacious than that of can- tharides ; as the irritation excited is more con- siderable and of longer duration. Dr. Cullen tells us, that he has reason to believe the use of liquid styrax in the proportion of one part to two of the old black basilicon, a favourite em- pirical composition, " has been of remarkable service in paralytic cases, and particularly in a debility of the limbs following rickets.* Many practitioners have, for the same purpose, been in the habit of burning moxa, or cotton alone, on different parts of the affected side. Dupuytren employed the former, and Pascal (Journ. de Mid., torn, lxvi.) the latter ; and both, as they tell us, with great advantage. Baron Larrey speaks in terms of high commendation of the first, and especially in spine-cases, or paraplegia. One of his examples is worth rela- ting. The patient had been a sufferer for three years, and had violent and almost permanent pain in the extremities, tremour, emaciation, and sleeplessness ; the spinous processes of the dor- sal vertebrae projected, and were painful on pres- sure. The moxas were applied in pairs, begin- ning from the tenth and eleventh dorsal vertebrae. On the first application all pain was removed; on the second, spontaneous motion was restored ; and, after the use of thirty moxas, the patient walked without support.—(Recueil de Memoires de Chirurgie, &c, 8vo., Paris, 1821.) Others have thought they derived more service from a repeated use of stinging nettles. Some again have employed issues, others setons, others acu- puncture, and others the potential or even the actual cautery. This last mode of treatment, however, is best calculated for that form of hemiplegia produced by a diseased spine. Mr. Pott found caustics applied on each side of the spine peculiarly serviceable, and they have been in common employment ever since his recom- mendation of them. In the rank of external stimulants, we are to arrange electricity and voltaism. From their well-known and extraordinary power of re-exci- ting irritability in the muscular fibres of animals that have been for some time dead, it was very reasonable to suppose that either of these stimuli might be employed with very great advantage : and accordingly we meet with them in exten- sive and popular use from the earliest periods of their having been, if not discovered, at least reduced to scientific management; and have numerous reports of cases in which the former was tried, and in many instances with advantage, * Mat. Med., vol. ii., part ii., cap. v. The editor has not much faith in the employment of internal stimulants, and believes with Dr. Abercrombie, that the practice is hardly safe unless accompa- nied by a low regimen. Gen. VIII.—Spe. 6.] CARUS PARALYSIS. 411 rather before the middle of the last century* In several experiments, both have been found highly beneficial; but in various cases also, both have been made use of in vain, and in a few instances, with apparent disadvantage; and those who were at first most sanguine of' suc- cess, gradually lost their confidence in them. The fact seems to be, that even at this late period of trial, we are greatly in the dark upon the subject, and have not learned to discriminate the exact modifications of the disease, or the exact modifications of electric power in which alone this active stimulus may be employed with advantage : for that, in both forms, it has been occasionally of very high benefit, is by no means to be disputed: and even at times When com- municated by the gymnotus electricus, or elec- tric eel itself, of which a singular example is given in the Haerlem Transactions ;t the pa- tient having recovered the use of the affected side after a hundred strokes from the fish. Upon the whole, as it is a direct stimulus, it appears better adapted to the atonic than the entonic character of paralysis. The stimulus of hot water alone is often ser- viceable in local palsy, especially when it has been produced by cold or damp; and in con- junction with the rubefacients and vesicatories we have just enumerated, or with friction to the part affected by means of the hand or a flesh- brush, and particularly when aided by terebin- thinate or other essential oils, will usually suc- ceed in restoring to the affected muscles their wonted power. But where the palsy is more extensive, as in hemiplegia and in many cases of paraplegia, it has been more usual to recom- mend the stimulus of hot water in conjunction with various active mineral corpuscles held in solution by it: and hence the common resort of paralytic patients in our own country to the wa- ters at Bath, Buxton, and Leamington. Hot baths of this kind are also a direct stimulus ; and as such, are found more efficacious in para- lytics of atonic or dilapidated constitutions, than in those who have suffered from plethoric or entonic fulness, or at least till they have been lowered to the proper standard by a long course of some reducent regimen. Cold bathing is also a stimulant as well as hot bathing, but a stimulant of a different kind, for it acts indirectly instead of directly. The intention with which it is used, is that of forci- bly urging the mouths of the cutaneous vessels into a general entastic or rigid spasm, in order hereby to excite a general reaction, as in the case of the first and second stages of the ague- fit, and thus to draw the torpid muscles into the common range of association. Dr. Cullen seems favourable to this practice under a prudent management. "Cold," says he, "applied to the body for any length of time, is always hurt- ful to paralytic persons : but if it be not very in- * Memoires de 1'Academie des Sciences, 1749, p. 40. Jallabert, Experience sur l'Electricite, Gene v., 1749. f Abhandlungen aus den Schriften der Harle- mer und anderer Holliindischen Gesellschaften, band i., p. 109. tense, nor the application long continued, and if at the same time the body be capable of a brisk reaction, such an application of cold is a powerful stimulant of the whole system, and has often been useful in curing palsy. But if the power of reaction in the body be weak, any application of cold may prove hurtful."—(Pract. of Phys., vol. iv.,mclxvi., p. 190.) It is hence only necessary to add, that while the hot miner- al baths appear best adapted to cases of atonic paralysis, cold affusion or the cold bath may be employed with most success in accidental pal- sies of the plethoric and the vigorous. The ordinary internal stimulants are the min- eral waters we have just adverted to, camphire, and other terebinthinate substances, many of the siliquose and alliaceous plants, as mustard, horseradish, garlic, and onions, and a temperate use of wine : the whole of which, however, are proscribed in all cases by many writers of great eminence, and particularly Dr. Cullen and Mr. John Hunter : and which, if allowed at all, should be confined to the atonic form of paral- ysis, or never be commenced, in any instance of entonic palsy, till the system has been sufficient- ly reduced for the purpose. And where this has been accomplished, such a class of remedies has often been found of essential service* Independently of these, there is a tribe of medicines entitled also to the name of stimu- lants. I mean several of the acrid poisons, as arnica montana, or leopard's bane ; rhus vernix, varnish sumach; and strychnos, nux vomica. All these excite the nervous system to great agitation and spasmodic action ; and if the dose be increased, violent convulsions, alternating with tetanus, are sure to ensue: and hence it has been supposed, that they may be rendered effectual in a restoration of motivity to paralytic limbs. The flowers of the arnica, or doronicum, as it was once called, were chiefly employed, though sometimes the leaves were preferred. Dr. Collin was much attached to the former in palsies of all kinds, and affirms that he has found them very generally successful. He gave them in an infusion or decoction, in the proportion of from a drachm to half an ounce, to a pint of the liquid (Observ. circa Morbos Acutos et Chroni- cos, torn, v., p. 108): and, from his recom- mendation, they were, at one time, very gen- erally adopted, were countenanced by Plenck and Quarin, and experimented upon by Dr. Home.—(Clinical Experiments, Histories, &c, Edin., 8vo., 1780.) The last tried them in six cases, but without much success; and they have not been able to maintain their reputation : nor, from the violence and uncertainty of their effects, is it worth while to revive them. The rhus vernix, or varnish sumach, is chiefly indebted for whatever degree of fame it has ac- quired in paralysis to the recommendation of Dr. Fresnoi. The milky juice of this plant is so acrid as to blister the hands of those who * Dr. S. Calhoun, of Philadelphia, has proposed the use of the tourniquet for restoring the power of muscles debilitated by long-continued inactivity —Phil. Journ. of the Med. and Phys. Sc . vol 1 p. 131.—D. ' ' 412 NEUROTICA. [Cl. IV—Ord. IV gather its leaves, so that they are obliged to wear gloves. The leaves are employed in de- coction and in extract; and appear not only to act powerfully upon the nervous system, but by urine and perspiration ; and hence the plant has a claim to be considered as an active promoter of absorption as well as a revellent, which may, perhaps, render it serviceable in some cases of paralysis from serious compression of the brain. Of its benefit in some other diseases of a spas- modic or -nervous character, and especially in hooping-cough, we have already spoken. Most of the species of rhus or sumach con- tain a like pungent acridity in their milky juices, and hence several others of them have occa- sionally been employed for the same purpose. Dr. Alderson, of Hull, has of late preferred the leaves of the rhus toxicodendrum, poison sumach, or poison oak, as it is sometimes, but improperly called : and, in many cases, he has thought it of considerable benefit. He commences with half a grain of the powdered leaves, which he gives three times a day, and gradually increases the dose to four or five grains, till he finds a sense of tingling produced in the paralytic part, accompanied with some degree of subsultus, or a twitching or convulsive motion.* There are other acrid poisons which have a tendency to produce strong entastic or rigid . spasm, most of which possess an intensely bitter principle, and perhaps derive that difference of effect from the tonic power of this very quality. Of these the chief are the strychnos, nux vomica, and the ignatia amara. Both have hence been employed in paralysis, and the virtues of both seem to be nearly alike ; the former, however, has of late taken the lead upon the recommen- dation of Dr. Fouquier, of the Hopital de la Charite at Paris, who has tried it upon a very extensive scale, and apparently with a perfect restoration of health in many cases; and whose success has been authenticated by similar ex- periments under the superintendence of MM. Magendie, Husson, Asselin, and other patholo- gists. He gives it in the -form of powder, or alcoholic extract: four grains of the first, and two of the last, are a dose, and may be taken from two to six times a day. He also employs it in injections. In half an hour after adminis- tration, the paralyzed muscles have, in various cases, begun to evince contraction : and, what is peculiarly singular, while a spastic contrac- tion is determined to these, the sound parts re- main unimplicated in the action. A frequent effect, unquestionably dependant on the bitter principle of the plant, is that of increasing the appetite, and diminishing the number of the alvine evacuations when in excess. Sometimes it produces a temulent effect, and occasions stu- por and a sense of intoxication, and, when rashly administered, general tetanus, with all its train * Dr. Horsefield, in his inaugural dissertation on the different species of rhus, mentions the effi- ciency of the toxicodendrum in paralytic affections. " In two instances of hemiplegia," says Dr. Eberle, " I have prescribed the saturated tincture of the rhus with unequivocal benefit."—Practice of Physic, vol. ii.—D. of distressing and frightful symptoms. The most powerful form of this medicine is its alka- line basis, to which the French cbymists have lately given the name of strychnine. It has hitherto been chiefly used through the agency of clysters.* Like all other powerful medicines in their first and indiscriminate use, the nux vomica ap- pears sometimes to have been highly beneficial, sometimes mischievous, and sometimes to have produced violent effects on the nervous system, without an important change of any other kind. Dr. Cooke has collected a variety of cases, in which it has been tried in our own country as well as in France, and this seems' to be the gen- eral result. The present author has tried it in various instances, but has never been able, from its tendency to temulency, to proceed much more than half as far as some practitioners have gone, who have gradually advanced it from four grains of the powder to twenty-four, three or four times a day. In the case of the late E. Sheffield, Esq., of the Polygon, Somer's Town, mineralogist to the estates of the Duke of Dev- onshire, and who is well known to have been one of the best practical geologists of his day, the author commenced with two grains alone of the powder given three times daily, as this was a hemiplegia following upon a second fit of atonic apoplexy, with a general debility both of the mental and corporeal powers, the patient being, at the time, rather upwards of sixty years of age. This dose occasioned no manifest effect, and on the third day, August 21, 1819, it was gradually increased to six grains. It now produced a powerful sense of intoxication, but with clonic agitation instead of a tetanic spasm of the paralyzed leg and arm, and great heat down the whoie of the affected side. The powder was continued in this proportion for three or four days, but the stupor and vertigo were so considerable and afflictive, that the patient could not be persuaded to proceed with it any longer, and it was in consequence sus- pended. In the ensuing September 1, he was evidently getting weaker, and recommenced the medicine at his own desire ; the dose was grad- ually raised from four to six grains three times a day : the same clonic effect was produced, with the same sensation of heat through the whole of the affected side, but without a sense of intoxication. The dose was advanced to eight grains, when the head again became af- fected, but without any permanent return of muscular power or sensation in the palsied limbs, or any other effect than a few occasional twitches and involuntary movements. Mr. Sheffield could not be persuaded to persevere any further, and the medicine was abandoned. He contin- ued in the same feeble state for about three months, when he fell a sacrifice to a third apo- plectic attack, apparently of a much slighter kind. I have stated that this was a case of atonic affection, and hence there was no opportunity of * Remarques sur la Nux Vomique considered comme Medicament, par F. M. Coze, &c.; Jour- nal Universel des Sciences Medicates, Nov., 1819. Gbn. VIII.—Spe. 6.] CARUS PARALYSIS. 413 iving full play to the power of the nux vomica. ut so far as I have seen, I think we may come to the following conclusions : First, that when only small doses can be given without seriously affecting the head, as in cases of great general or nervous debility, the effect is a clonic instead of an entastic or tetanic spasm. Secondly, that, under this effect, it is not calculated to do any permanent good, and often produces mischief. And thirdly, that it is most serviceable in en- tonic hemiplegia, after the patient has been suf- ficiently reduced from a state of high energetic health, and especially energetic plethora, to a subdued and temperate state of pulse ; in which state, it may very frequently be employed in doses sufficient to excite strong or entonic spasm.* Nervous agitation, proportioned to the mode of the disease and the strength of the patient, has often been of peculiar advantage; and hence, palsy has occasionally been carried off suddenly by a violent fit of mental emotion, as of anger (Camerar. Memorab., cent, v., No. xxx.; Paulini, cent, iii., obs. 89 ; Schenck, Ob- serv., lib. i., No. clxxxii.) or fright (Diemer- broeck, Observ. et Cur. Med.; Loeffler, Bey- trdge sur Wundarzneykunst, band i.), of both which the examples are very numerous: by a stroke of lightning (Wilkinson's Case of Mrs. Winder, 8vo., 1765); and by fevers.—(Act. Nat. Cur., vol. v., obs. 64; Samml. Medicin- ischen Wahrnehmungen,ba.nAvi., p. 152.) Nor can I do otherwise than think, that one of the most rational and efficacious means of cure in many instances of paralysis, and especially where" no great inroad has been made upon the gen- eral strength of the constitution, would be a journey into the Hundreds of Essex or some other marshy district, for the purpose of obtain- ing a sharp attack of a tertian ague, which would most effectually, and I apprehend at .the least expense, give us all the advantage of entastic spasm and reaction that we could wish for. In * Andral thinks that brucea is much better adapted for medicinal purposes than strychnine. —D. treating of the tertian intermittent, we observed from Dr. Fordyce, that it has often a tendency to carry off a variety of obstinate and chronic diseases to which the constitution has been long subject, and to restore it to the possession of a better and firmer degree of health.* In a few cases, hemiplegia is said to have ceased spontaneously by the mere remedial en- ergy of nature ; in one instance, after ten years' standing, and accompanied with loss of voice. —(Brest. Samml., 1721, pp. 406, 503.) And in a few cases of paraplegia from external in- jury to the spine, where only one or two vertebrae have in a small degree been displaced from their proper position, the same instinctive or remedial power has alone produced a cure, or greatly al- leviated the mischief, by so far thickening the growth of the bones immediately above and be- low, that the chasm has been filled up, and a line of support restored. The best artificial means of obtaining so salutary an action is by a free and laborious process of friction, vellication, or shampooing, with such intermediate exertion or exercise as the patient may be able to take.f It is only necessary to add further, that where local palsyt has been produced by the fumes or minute divisions of lead or other noxious metals, it is almost always accompanied with symptoms of colica rhachialgia, or painter's colic, and is to be remedied by the treatment already laid down under that disease. * As the pathology of paralysis shows the very frequent dependance of this disease upon effusion of blood in the head, and certain morbid changes in the brain and spinal marrow, as causes, the editor has less confidence than the author in the scheme here proposed. ( t See especially, Shaw on the Nature and Treatment of Distortions to which the Spine and the Bones of.the Chest are subject, 8vo., 1823. X In the New-York Med. and Phys. Journal, vol. in., p. 430, Dr. Delafield of New-York has published the details of five cases of partial paral- ysis of the face, which were treated successfully by leeches, cupping, and blistering over the origin of the portio dura, and by the administration of purgatives.—D. CLASS V. GENETIC A. DISEASES OF THE SEXUAL FUNCTION. ORDER I. CENOTICA. AFFECTING THE FLUIDS. " II. ORGASTICA. AFFECTING THE ORGASM. " III. CARPOTICA. AFFECTING THE IMPREGNATION. CLASS V. PHYSIOLOGICAL PROEM. We now enter upon the maladies of that im- portant function by which animal life is extend- ed beyond the individual that possesses it, and propagated from generation to generation. To this division of diseases the author has given the classic name of genetica, from yetvopai, " g'gnor»" whence genesis (yiviait), " origo," "ortus." In almost every preceding system of nosolo- gy, the diseases of this function are scattered through every division of the classification, and are rather to be found by accident, an index, or the aid of the memory, than by any clear me- thodical clew. Dr. Macbride's classification forms the only exception I am acquainted with; which, however, is rather an attempt at what may be accomplished than the accomplishment itself. His division is into four orders; general and local as proper to men, and general and local as proper to women ; thus giving us in the or- dinal name little or no leading idea of the na- ture of the diseases which each subdivision is to include, or any strict one of division between them : for it must be obvious, that many dis- eases commencing locally very soon become general and affect the entire system, as ob- structed menstruation; while others, as abor- tion or morbid pregnancy, may be both gen- eral and local. Under the present system, therefore, a differ- ent arrangement is chosen, and one which will perhaps be found not only more strict to the limits of the respective orders, but more ex- planatory of the leading features of the various genera or species that are included under them. These orders are three ; the first embracing those diseases that affect the sexual fluids ; the second those that affect the orgasm; and the third those that affect the impregnation. To the first order is applied the term cenotica (kcvij)tiko), from Ktyiaais, " evacuatio," " exinani- tio ;" to the second, orgastica (ipydariKa), from dpydfa, " irrito," " incito," and especially libidi- nose ; and to the third, carpotica (Kapndrtita), from /rapirij, " fructUS." Before we enter upon these divisions, it will perhaps prove advantageous to pursue the plan we have hitherto followed upon commencing the preceding classes ; and take a brief survey of the general nature of the function before us, under the following heads :— I. The Machinery by which it operates. II. The Process by which it accomplishes its Ultimate End. III. The Difficulties accompanying this Process, which still remain to be explained. I. One of the chief characters by which ani- mals and vegetables are distinguished from min- erals, is to be found in the mode of their forma- tion or origin. While minerals are produced fortuitously, or by the casual juxtaposition of the different particles that enter into their make, animals and vegetables can only be produced by generation, by a system of organs contrived for this express purpose, and regulated by laws peculiar to themselves. [In perennial plants (see Mayo's Outlines of, Human Physiology, p. 462, 2d edit.), the organs of generation are annually shed and reproduced. In animals, the sexual organs are periodically fitted for the function of generation, either by( their actual enlargement, or by a determination of blood to them at particular periods. In hu^ man beings, the sexual organs are competent to their function during the greater part of life ; from the age of puberty to forty-five or fifty, in females ; to sixty-five or seventy, or even later, in men.] Cl. V] PHYSIOLOGICAL PROEM. 415 Generation is effected in two ways; by the medium of seeds or eggs, and by that of off- sets ; and it has been supposed that there may be a third way, to which we shall advert hereafter; that of the union of seminal mole- cules, furnished equally by the male and the female, without the intervention of eggs, which constitutes the leading principle of what has been called the theory of epigenesis. Many plants are propagable by offsets, and] all plants are supposed to be so by eggs or seeds] As we descend in the scale of animal life, we meet in the lowest class, consisting of the worm tribes, with examples of both these modes of propagation also. For, while a production by ova is more commonly adhered to, the hydra or, polype is well known to multiply by bulbs or] knobs thrown forth from different parts of thej body, and the hirudo viridis, or green leech, by} longitudinal sections, which correspond with the* slips or suckers of plants. In these cases we meet with no distinction of sex ; the same individual being capable of con- tinuing its own kind by a power of spontaneous generation. In other animals of the worm class, we trace examples of the organs of both sexes united in the same individual, making a near ap- proach to the class of monoicous plants, or those which bear male and female flowers distinct from each other, but on the same stock, as the cucumber; thus constituting proper hermaphro- dites, evincing a complexity of sexual structure which is not to be found in any class of animals* above that of worms. Some of the intestinal! worms are of this description, as the fasciola orl fluke, which is at the same time oviparous, the| ovaries being placed laterally. The earthworm propagates its kind by a like organization, as does the barnacle, the lamprey, and even the common and conger eel.—(See Sir Everard Home's paper on some of these animals, Phil. Trans., 1823, art. xii.) The helix hortensis, or garden-snail, is her-l maphrodite, but incapable of breeding singly. In order to accomplish this it is necessary that one individual should copulate with another, the' mate organ of each uniting with the female, and the female with the male, when both become impregnated. The manner in which this amour is conducted is singular and highly curious. They make their approach by discharging sev- eral small darts at each other, which are of a sharp form and of a horny substance. The quiver is contained within a cavity on the right side of the neck, and the darts are launched with some degree of force, at about the distance of two inches, till the whole are exhausted ; and when the war of love is over, its consummation suc- ceeds. The increase is by eggs, which are per- fectly round, and about the size of small peas. There are some animals in which a single im- pregnation is capable of producing several gen- erations in succession : we have a familiar ex- ample of this in the common cock and hen ; for a single copulation is here sufficient to give fe- cundity to as many eggs as will constitute a whole brood. But the same curious fact is still more obvious in various species of insects, and especially in the aphis (puceron, or green-plant louse) through all its divisions, and the daphnia pulex of Moller and Latreille (the monoculus pu- lex of Linnaeus). In both these a single impreg- nation will suffice for at least six or seven gen- erations ; and in both these, likewise, we have another curious deviation from the common laws of propagation, which is, that in the warmer summer months the young are produced vivipa- rously, and in the cooler autumnal months, ovip- arously. It is also very extraordinary that in the aphis, and particularly in the viviparous broods, the offspring are many of them winged, and many of them without wings or distinction of sex ; in this respect making an approach to the working-bees, and still more nearly to the working-ants, known till of late by the name of neuters. For confirmation respecting the generative process which takes place in these two last kinds, we are almost entirely indebted to the nice and persevering labours of the elder and the younger Huber ; who have decidedly proved, that what have hitherto been called neuters, are females with undeveloped female organs, and therefore non-breeders, but whose organs, at least in the case of bees, are capable of development by a more stimulating or richer honey, with which one of them, selected from the rest, is actually treated for this purpose by the general consent of the hive on the accidental loss of a queen- bee, or common bearer of the whole, and in order to supply her place. It is these alone that are armed with stings : for the males, or drones, as we commonly call them, are without stings; they are much larger than the non-breeders or workers, of a darker colour, and make a great buz in flying. They are always less numerous in a hive than the workers, and only serve to en- sure the impregnation of the few young queens that may be produced in the course of the sea- son, and are regularly massacred by the stings of the workers in the beginning of the autumn. The impregnation of the queen-bee is produced by a process too curious to be passed over. It was conjectured by Swammerdam that this was effected by an aura seminalis thrown forth from the body of the whole of the drones or males collectively. By other naturalists it has been said, but erroneously, to take place from an in- termixture of a male milt or sperm with the eggs or spawn of the queen-bee, as in the case of fishes. M. Huber, however, has sufficiently proved that the queen-bee for this purpose forms an actual coition, and this never in the hive, but during a tour into the air which she takes for this purpose a few days only after her birth, and in the course of which she is sure to meet with some one or other of her numerous serag- lio of males. As soon as copulation has been effected she returns to the hive, which is usu- ally in the space of about half an hour, and of- ten bears home with her the full proofs of a connexion in the ipsa verenda of the drone ; who, thus wounded and deprived of his virility by the violence of his embrace, dies almost im- mediately afterward. This single impregnation will serve to fecundate all the eggs the queen 416 PHYSIOLOGICAL PROEM. [Cl. V. will lay for two years at least; Huber believes, for the whole of her life ; but he has repeated proofs of the former. She begins to lay her eggs, for the bee is unquestionably oviparous, forty-six hours after impregnation, and will com- monly lay about three thousand in two months, or at the rate of fifty eggs daily. For the first eleven months she lays none bat the eggs of workers ; after which she commences a second laying, which consists of drones' eggs alone. Of the mode of procreation among fishes, in consequence of their living in a different ele- ment from our own, we know but little. A few of them, as the squalus, or shark genus, some of the skates, and other cartilaginous fishes, have manifest organs of generation, and un- questionably copulate. The male shark, in- deed, is furnished with a peculiar sort of hold- ers for the purpose of maintaining his grasp upon the female amid the utmost violence of the waves, and his penis is cartilaginous or horny. The female produces her young by eggs, which, in several species of this genus, are hatched in her own body, so that the young when cast forth are viviparous. The blenny produces its young in the same manner; in most species by spawn or eggs hatched externally; but in one or two vivipa- rously, three or four hundred young being thus brought forth at a time. The blenny, however, and by far the greater number of fishes, have no external organ of generation, and appear to have no sexual connexion. The females, in a particu- lar season of the year, seem merely to throw forth their ova, which we call hard roe or spawn, in immense multitudes, in some shallow part of the water in which they resid&j where it may be best exposed to the vivific action of the sun's ray ; when the male shortly afterward passes over the spawn or hard roe, and discharges upon it his sperm, which we call soft roe or milt. These substances are contained in the respect- ive sexes in two bags that unite near the podex, and at spawning time are very much distended. The spawn and milt thus discharged intermix ; and, influenced by the vital warmth of the sun, commence a new action, the result of which is a shoal of young fishes of a definite species. Yet, though no actual connexion can be traced among the greater number of the class of fishes, something like pairing is often discernible among many of those that have no visible organs of copulation ; for if we watch attentively the mo- tions of such as are kept in ponds, we shall find the sexes in great tumult, and apparently strug- gling together among the grass or rushes at the brink of the water about spawning time ; while the mate and female salmon, after having as- cended a fresh stream to a sufficient height and shaUowness for the purpose, are well known to unite in digging a nest or pit in the sand of about eighteen inches in depth, into which the female casts her spawn, and the male immediately af- terward ejects his milt; when the nest is cov- ered over with fresh sand by a joint exertion of their tails. The salmon, the sturgeon, and many other marine fishes, seek out a fresh water stream for this purpose : and their navigations are often of very considerable length before they can satisfy themselves, or obtain a proper gravelly bed. The salmon tribe sometimes make a voyage of sev- eral hundred miles, cutting their way against the most rapid currents, leaping over floodgates, or up cataracts of astonishing height; in their endeavour to surmount which they often fail, and tumble back into the water ; and, in some places, are in consequence caught in baskets placed in the current for this purpose. The power of fecundity in fishes surpasses all calculation, and appears almost incredible. It has been said, no doubt in a strain of exagger- ation, that a single herring, if suffered to multi- ply unmolested and undiminished for twenty years, would show a progeny greater in bulk than the globe itself. This species, as also the pilchard, and some others of the genus clupea, as a proof of their great fertility, migrate annu- ally from the arctic regions in shoals of such vast extent, that for miles they are seen to darken the surface of the water. The mode of procreating among frogs does not much vary from that of fishes. Early m the spring, the male is found upon the back of the female, in close contact with her; but no communication is discoverable, although this contact continues for several days ; nor can we trace in the male any external genital organ. After the animals quit each other, the female seeks out some secure and shallow water, in which, like the race of fishes, she deposites her spawn, which consists of smaU specks held to- gether in a sort of chain or string, by a whitish glutinous liquor that envelops them ; and over this the male passes and deposites his sperm, which soon constitutes a part of the glutinous matter itself. The result is a fry of minute tad- poles, whose evolution into the very different form and organization of frogs is one of the most striking curiosities of natural history. In the Surinam toad (rana pipa), this process is varied. The female here deposites her eggs or spawn, without any attention to order ; the male takes up the amorphous mass with his feet, and smears it over her back, driving many of the eggs hereby into a variety of cells that open upon it; and afterward ejecting over them his spermous fluid. These cells are so many nests, in which the eggs are hatched into tadpoles, which are perfected and burst their imprison- ment in about three months. But a volume would not suffice to point out all the singularities exhibited by different ani- mals in the economy of procreation. It is worth while, however, to notice how variously some of the organs of generation are situated in many tribes. In the female libellula, or dragon-fly, the vagina is placed on the upper part of the belly, near the breast. In the male spider, the generative organ is fixed on the extremity of an antenna. In the female ascaris vermicularis, or maw-worm, the young are discharged from a minute punctiform aperture a little below the head, which appears, therefore, to constitute the ascarine vagina. In the snail we find this or- gan placed near the neck, in the immediate vi- Cl. V] PHYSIOLOGICAL PROEM. 417 cinity of the spiracle which serves for its lungs. The tama solium, or tapeworm, throws forth its young from the joints. So some plants bear flowers on the petioles, or edges of the leaves, instead of on the flower-stalk. In like manner, while the mamma: in the hu- man kind are placed on the chest, and made a graceful and attractive ornament, in all quadru- peds they are placed backward, and concealed by the thighs. In the mare, the teats, which are two, are inguinal; in the horse, they are sin- gularly placed on the glans penis. The testes of most animals that possess these organs, and procreate only once a year, are ex- tremely small during the months in which they are not excited. Those of the sparrow, in the winter season, are scarcely larger than a pin's head; but, in the spring, are of the size of a hazelnut. In man, the testis, before birth, or rather during the early months of pregnancy, is an abdominal viscus : about the seventh month, it descends gradually through the abdominal ring into the scrotum, which it reaches in the eighth month. And if this descent do not take place anterior to birth, it is accomplished with great dif- ficulty, and is rarely completed till the seventh or eighth year. Sometimes, indeed, only one testis descends under these circumstances, and occasionally neither. There is a set of barbarians at the back of the Cape of Good Hope who appear to be very generally monorchia", or possessed of only a sin- gle testis; and Linneus, believing this to be a natural and tribual defect, has made them a dis- tinct variety of the human species. Mr. Bar- row has noticed the same singularity : but it is doubtful whether, like the want of a beard among the American savages, this destitution is not owing to a barbarous custom of extirpation in early life. It is commonly believed that the productive power of man is greatly impaired, if not totally lost, by a retention of both testes in the abdomen, as in this situation they are sel- dom completely developed. Mr. Hunter ima- gines never ; and Zacchias and Riolan concur with him. Mr. Wilson met with one case of this kind, in which the generative power was perfect: and M. Fodere boldly affirms that per- sons thus incompletely formed are most re- markable for their vigour, thus strangely im- peaching the ordinary course of nature.* Yet, in the erinaceus or hedgehog genus, and a few other quadrupeds, they never quit the cavity of the abdomen. In the cock, whose penis is di- * When one or both of the testes are retained fn the abdomen, Mr. Hunter conceives that they are exceedingly imperfect, and incapable of performing their natural function. The editor of this work knows of one example in which this was the case. Mr. Lawrence has seen two cases, in each of which one testis remained in the abdomen, and where the circumstances, ascertained by anatomical ex- amination, corroborated the opinion of Mr. Hunt- er. In one the body of the gland was not more than half its usual size; the epididymis, which was very imperfect, ran for about an inch behind the sac of a hernia, which had occurred in the in- dividual, and did not join the body of the testis. Vol. II.—Dd chotomous or two-pronged, they are situated on each side of the backbone. It has been made a question among phys- iologists, whether the seminal fluid is secre- ted by the testes at the moment of the de- mand, or gradually and imperceptibly in the in- tervals of copulation, and lodged in the vesicu- lae seminales as a reservoir for the generative power to draw upon. The latter is a common opinion. It is, however, opposed, and with very powerful arguments, by Swammerdam and Mr. John Hunter. The secretion found in the vesiculae seminales is different from that of the testes in the properties of colour and smell; those of the former being yellow and inodorous, those of the latter whitish, and possessing the odour of the orchis-root, or the down of chest- nuts. On the dissection of those who have naturally or accidentally been destitute of one testis, the vesicula of the one side has been found filled with the same fluid, and as largely as that of the other; and, consequently, the fluid on the vacant side must have been supplied by a secretory action of the vesicula itself. There are no organs of generation that differ so much in their form and comparative size in different animals as these vesicular bags : in the hedgehog they are twice as large as in man, and in many animals they are utterly wanting. They are so in the dog, which continues for a very long time in a state of copulation, and in birds, whose copulation is momentary. They are moreover wanting in most animals whose food is chiefly derived from an animal source, though not in all, as the hedgehog, to which I have just referred, is an example of the con- trary. Mr. Hunter hence concludes that the vesi- culae seminales are not seminal reservoirs, but glands secreting a peculiar mucus, and that the bulb of the urethra is, properly speaking, the re- ceptacle in which the semen is accumulated previously to ejection. Of the actual use of these vesicular bags he confesses himself to be ignorant, yet imagines, that in some way or other, they are subservient to the purposes of generation, though not according to the com- mon conjecture. In a few rare instances, the uterus and vagina have been found double. Dr. Tiedemann met with two instances of this monstrosity. The or- gans constituting one of the cases are preserved to this day in the Heidelberg Museum. The indi- vidual had been pregnant in one of the sets, and The other case presented exactly the same ap- pearances. A third instance, however, concur- ring with that noticed by Mr. Wilson, came to the knowledge of Mr. Lawrence. Both of the testes had remained in the abdomen, but were apparent- ly perfect in their structure, and during the pa- tient's life, had executed then functions in a healthy manner.—(Rees's Cyclopaedia, art. Gen- eration.) It appears, then, that there are excep- tions to the conclusion at which Mr. Hunter and some other physiologists arrived on this interest- ing question; and that more depends upon the size and structure of the testes being natural, than upon their accidental situation.—Ed. 418 PHYSIOLOGICAL PROEM. [Cl. V. the uterus is here larger than that on the oppo- site side, which is of the ordinary size. The woman reached her full time, but died nineteen days after delivery.* The ovaria are to the female what the testes are to the male. They were formerly, indeed, called female testes, and furnish, on the part of the female, what is necessary towards the pro- duction of a progeny. They are, in fact, two spheroidal flattened bodies, enclosed between the folds of the broad ligaments by which the uterus is suspended. They have no immediate connexion with the uterus ; but near them the extremity of a tube, which opens on either side into that organ, hangs with loose fimbriae in the cavity of the abdomen, into which it communi- cates the fimbrial end. This tube is called the Fallopian, from the name of its discoverer.— (Fallop. Observ. Anat., 197.) At the age of puberty the ovaria acquire their full growth, and continue to weigh about a drachm and a half each, till menstruation ceases. They contain a peculiar fluid resembling the white of eggs, once supposed to be secreted by the glandular struc- ture of various small bodies imbedded in them, which have been denominated corpora lutea. By some early writers this fluid was contem- * In August, 1831, Dr. Robert Lee examined the body of a woman who died eight days after parturition, from inflammation of the peritone- um and uterus. She had previously borne sev- eral living children. The uterus was found to be divided into two lateral halves, opening into a common cervix ; the os uteri and vagina present- ing the appearances usually noticed at that pe- riod after delivery. The inner surface of the right half or cornu, which had contained the foetus, was lined by rough irregular flakes of deciduous membrane, or a layer of fibrin of the blood. One ovary and one Fallopian tube were connected with this cornu, and the same was the case with the unimpregnated one. Both ovaries were enlarged, but the right was much larger than the left, and included a distinct corpus luteum. The whole of the surface of the left cornu was coated with a delicate membrana decidua, which formed a shut sac at the cervix, but presented a smooth circular opening at the uterine orifice of the Fal- lopian tube, into which its fibres extended, though to what distance could not be ascertained. Dr. Lee gives reference to a vast number of what are termed bilocular, bicorned, bifid, or double uterus, in all of which, without a single exception, the uterine appendages consisted of an ovary and one Fallopian tube annexed to each cornu of the uteri, and not of two ovaries and two Fallopian tubes, as the expression double uterus would seem to im- ply. This kind of malformation has four varie- ties, which are dehneated by Lauth and Cruveil- hier:—1st. "Where the vagina and the uterus are separated into two cavities by a septum, without any thing unusual in the external configuration of this organ. 2dly. "Where the only remarkable circumstance is the division of the fundus and body of the uterus into two cornua, as exempUfied in an instance lately published by Mr. Adams.— (See Med. Gaz. for 1833-4, p. 898.) 3dly. Where the uterus is bifid, and the cervix and vagina con- tain a septum. 4thly. Where the vagina forms a single canal, with a double os uteri. Morand, Bartholine, Tiedemann, Ollivier, and Dr. Blun- dell, have related cases of double uterus, in which plated as a female semen, forming a counterpart to the semen of males; but it has since been held, and the tenet is well supported by ana- tomical facts, to be a secretion of a different kind,*thrown forth in consequence of the ex- citement sustained by the separation of one or more of the minute vesicles which seem to issue from them as their nucleus or matrix, and which are themselves regarded by the same school as the real ovula of subsequent fetuses : to which subject, however, we shall advert presently. [Women reach the period of puberty one or two years before men; and the inhabitants of warm before those of cold climates. In the hottest regions of Africa, Asia, and America, girls arrive at puberty at ten, and even at nine years of age; in France, not till thirteen, four- teen, or fifteen : while in Sweden, Russia, and Denmark, this period is not attained till from two to three years later.* At the time of puberty in the male, the la- rynx enlarges, the quality of the voice is changed, the beard grows, the chest and shoulders en- large, the generative organs are developed, hair grows upon the pubes, and the secretion of the seminal fluid begins. In the female, the breasts and pelvis enlarge, the uterine organs impregnation had taken place, and the foetus had been retained till the full period ; but, according to Dr. Lee's investigations, none of these authors have alluded to the presence of a deciduous mem- brane in the unimpregnated cornu of the uterus. That such membrane is formed in all similar ca- ses he deems probable, because, in the gravid ute- rus of the lower animals, the membrane which surrounds the product of conception invariably occupies the whole inner surface of both comua. At the same time he candidly explains, that in the examination of the preparation from Dr. Purcell's remarkable case (see Phil. Trans., vol. lxiv., p. 474), no remains of a membrana decidua were no- ticed in either the right cornu, which had been impregnated, or in the left, which had not; though whether this was owing to accidental decompo- sition, or intentional removal of such membrane (as far as the right comu was concerned), cannot now be determined.—(See Med. Chir. Trans., vol. xvii.) The disposition of the deciduous menv brane in the case related by Dr. Lee himself must have rendered superfoetation impossible, and its history is adverse to the speculations of M. Cas- san on the possibility of superfoetation, where a double uterus exists. In this case, also, as in or- dinary pregnancy, where the inner surface of the uterus is lined with the deciduous membrane, Dr. Lee observes, that menstruation must have been suspended.—See Med. Chir. Trans., vol. xvii.—Ed. * The age at which the female Indians of North America reach the period of puberty, has been generally stated by travellers to be the eightefcnth year: but later obseivations have proved this as- sertion to be fallacious. According to M ajor Long (Long's Expedition to the Rocky Mountains), the young squaw has her catamenia in her twelfth or thirteenth year. Hunter states that menstrua- tion does not occur by two or three years so soon as among the whites. Both these late travellers, therefore, fix the period of puberty much earlier than the European authorities.—(See Clinton's Letter, in Francis's Denman, 3d edit, New-York, Cl. V] PHYSIOLOGICAL PROEM. 419 are developed, and a peculiar periodical dis- charge from the uterus commences, which con- tinues, subject to certain suspensions during pregnancy and lactation, as long as the organ is capable of impregnation, or, on the average, about thirty years.]* It is singular to contemplate the very power- ful influence which the secretion, or even the preparation for secreting the seminal fluid, but still more its ejection, produces overthe entire system. On the perfection, and a certain and entonous degree of distention of the natural vessels, ap- parently producing an absorption of the fluid when at rest, the spirits, the vigour, and the general health of man depend. Hence, antece- dently to the full elaboration of the sexual sys- tem, and the secretion of this fluid, the male has scarcely any distinctive character from the female : the face is fair and beardless, the voice shrill, and the courage doubtful. And when- ever, in subsequent life, we find this entonous distention relaxed, we find at the same time languor, debility, and a want of energy both in the corporeal and mental functions. And where the supply is entirely suppressed or cut off by accident, disease, or unnatural mutilation, the whole system is changed, the voice weakened, the beard checked in its growth, and the ster- num expanded : so that the male again sinks down into the female character. These changes occur chiefly where the testicles are extirpated before manhood ; but they take place also, though in a less degree, afterward. In like manner, during the discharge of the seminal fluid in sexual commerce, the most vig- orous frames of the stoutest animals become exhausted by the pleasurable shock: and the feeble frames of many of the, insect tribes are incapable of recovering from the exhaustion, and perish immediately afterward; the female alone surviving to give maturity to the eggs hereby fecundated. The same effect occurs after * Mayo's Outlines of Human Physiology, p. 463. The menstrual discharge may be stated generally to be " the consequence of a peculiar periodical condition of the bloodvessels of the uterus, fitting it for impregnation, which condi- tion is analogous to that of ' heat' in the inferior animals." In Dr. Hooper's work on the Morbid Anatomy of the Human Uterus, there is an exact representation of the uterus of a woman who was instantaneously killed by an accident during men- struation ; and every one must be struck with the resemblance which it bears to the description given by Mr. Cruickshank in the Philosophical Transactions (1797), of the appearances observed by him in rabbits killed during the state of genital excitement, usually called the time of heat. The actual presence of the discharge is the resolution, if we may so term it, of the previous condition of the vessels which separate it; for the uterus is fitted for the purposes of impregnation before the menses begin to flow. An instance in proof of this may be given from the Philosophical Trans- actions (1817), of a young woman who bore two children successively without any previous men- struation ; which function, in fact, did not show itself externally till after the third pregnancy, which ended in a miscarriage.—Dr. Locock in art. Menstruation, in Cyclop, of Pract. Med.—Ed. the same consummation in plants. The stout- est tree, if superfructified, is impaired for bear- ing fruit the next year; while the plants of the feeblest structure die as soon as fructification has taken place. Hence, by preventing fructifi- cation, we are enabled to prolong their duration; for by taking away the styles and stigmas, the filaments and anthers, and especially by pluck- ing off the entire corols of our garden-flowers, we are able of annuals to make biennials, and of biennials, triennials. In many animals, during the season of their amours, the aroma of the seminal fluid is so strong, and at the same time so extensive in its influence, as to taint the flesh; and hence the flesh of goats at this period is not eatable. Most fishes are extremely emaciated in both sexes at the same time, and from the same cause, and are ■ equally unfit for the table. Stags, in the rutting season, are so exhausted as to be quite lean and feeble, and to retire into the re- cesses of the forest in quest of repose and quiet. They are well known to be totally inadequate to the chase ; and hence, for the purpose of maintaining a succession of sporting, they are sometimes castrated, in which state they are caUed heaviers. If the castration be performed whde the horns are shed, these never grow again; and if while the horns are in perfection, they are never shed.* The male and female raindeer (cervus taran- dus) ordinarily cast their horns every year in November. If the male be castrated, the horns will not grow after he is nine years old : and the female, instead of dropping her horns as usual in November, retains them, if gravid, till she fawns, which is about the middle of May. In this case, the usual stimulus necessary for the operation of exfoliation is transferred to another part of the system. And, for the same reason, we often find that a broken bone in a pregnant woman will secrete no caUus, and consequently not unite, till after childbirth. In the former case, the roots of the horns are affected by sym- pathy of the general sexual system, of which in- deed they may be said to form a part, and by their superior size are discriminative of the male sex. In the human race, the strong deep voice, char- acteristic of manhood, is rarely acquired if cas- tration be performed in infancy. There is no animal, perhaps, but shows some sympathetic action of the system at large, or some remote part of it, with the genital organs, when they are in a state of peculiar excitement. The tree-frog (rana% arborea) has, in the breeding season, a peculiar orbicular pouch attached to its throat; the fore-thumb of the common mate toad :s at the same season affected with warts; and the females of some of the monkey tribes evince a regular menstruation. * Otto, in his Handbuch der Path. Anatomie, remarks, " I kept a stag for twelve years, which I had castrated when two years old; it put up yearly, when it shed its coat, new long prickers, which were mostly covered with velvet, and were so brittle that the stag never attempted to strike with them; but if angered, used his fore-feet for weapons."—D. 420 PHYSIOLOGICAL PROEM. [Cl. V. II. The process by which the generative power is able to accomplish its ultimate end, is to the present hour involved in no small degree of mystery; and has given rise to three distinct and highly ingenious hypotheses, that have a strong claim upon our attention, and which we shall proceed to notice in the order in which they have appeared. The first and most ancient of these consists in regarding the foetus in the womb as the joint production of matter afforded in coition by both sexes, that of the male being secreted by the testes, and that of the female by the uterus it- self, or some collateral organ, as the ovaria, which last, however, is a name of compara- tively modern origin, and derived from a sup- posed office which was not contemplated among the ancients. To this hypothesis has been given the name of epigenesis. The seed or matter afforded by the female, was regarded by Hippocrates, Aristotle, and Galen, as the menstrual blood or secretion, which they supposed furnished the substance and increment of the foetus, while the male semen furnished the living principle: Empedocles, Epicurus, and various other physiologists con- tending, on the contrary, that the father and mother respectively contributed a seminal fluid that equaUy co-operated in the generation and growth of the foetus, and stamped it a male or a female, and with features more closely resem- bling the one or the other, according as the or- gasm of either was predominant at the time, or accompanied with a more copious discharge. In the words of Lucretius, who has elegantly compressed the Epicurean doctrine,— " Et muliebre oritur patrio de semine seclum ; Maternoque mares exsistunt corpore cretei. Semper enim partus duplici de semine constat: Atque, utri simile est magis id, quodquomque cre- ator, Ejus habet plus parte aqua, quod cernere possis, Sive virum suboles, sive est muliebris origo."* The distinction of sex, however, was ac- counted for in a different manner by Hippocrates, who supposed that each of the sexes possesses a strong and a weak seminal fluid; and very un- gallantly asserted that the male foetus was form- ed by an intermixture of the robuster fluids of the two sexes, and the female by that of the more imbecile. Lactantius, in quoting the opin- ion of Aristotle upon this subject, adds, fanci- fully enough, that the right side of the uterus is the proper chamber of the male foetus, and the left of the female : a belief which is still preva- lent among the vulgar in many parts of Great Britain. But he adds, that if the mate, or stronger semen, should by mistake enter the left side of the uterus, a male child may still be con- ceived ; yet, inasmuch as it occupies the female department, its voice, its face, and its general complexion, will be effeminate. And, on the contrary, if the weaker or female seed should flow into the right side of the uterus, and a fe- male foetus be begotten, the female will exhibit * De Rer. Nat., lib. iv., 1220. many signs of a masculine character, and be in- ordinately vigorous and muscular.* The doctrine of epigenesis, under one mod- ification or another, continued to be the leading, if not the only hypothesis of the day, till the be- ginning of the sixteenth century, when, in con- sequence of the more accurate examinations and dissections of Sylvius, Vesalius, Fallopius, and De Graaf, the organs which had hitherto been re- garded as female testes, and so denominated, were now declared to be repositories of minute ova, and at length named ovaria by Steno in 1667.—(Elem. Myologia Specim., p. 117.) We now, therefore, enter upon the second of the three hypotheses above alluded to, which de- rives the foetus from rudiments furnished by the mother alone. This hypothesis was ori- ginally advanced by Josephus de Aromatariis, as flowing from these anatomical discoveries, but was chiefly brought into notice by Swam- merdam and Harvey, who established the doc- trine of omne ab ovo. Observing a cluster of about fifteen vesicles in each of the female ova- ria, apparently filled with a minute drop of al- buminous yellow serum, and perceiving that they appeared to diminish in number in some kind of proportion to the number of parturitions a woman had undergone, it was conceived by these physiologists that such vesicles are inert eggs or ovula, containing miniature embryons of the form to be afterward evolved, one of which, by the pleasurable shock that darts over the whole body, but in an especial degree through this organ, during the act of copulation, is in- * De Opificio Dei, cap. xii. Mr. Mayo consid- ers it natural to suppose that the sex of the em- bryo is determined antecedently to impregnation; but, by what facts he is led to this opinion, is not explained. This part of the subject stiU continues a complete mystery, t It is a remarkable fact, as Dr. Bostock has observed (Elem. Syst. of Physi- ology, vol. ni., p. 47), that, although there is no uniform proportion between the number of males and females produced by the same parents, yet that the total number of each sex brought into the world, taking the average of any large community, is nearly the same; or, more exactly, that we have in aU cases a small excess of males. The data that we possess, while they prove that this ex- cess exists in all countries, seem, however, to show that the amount of it differs in different countries. From a very extensive examination made by Hufe- land, the numbers in Germany are as 21 to 20.— (Edin. Phil. Joum., vol. v. p. 296.) The census that was taken in England and Wales in 1821, shows the numbers to be nearly 21 and 20.0664 But, says Dr. Bostock, to whatever cause we may as- cribe the relative proportion, it would appear that the greater number of males who are bom is com- pensated by their greater mortality, whether pro- duced by natural or accidental causes; for we find, among adults, that the number of females rather exceeds that of males.—Haller, El. Phys., lib. xxviii.,p. 1; Jameson's Journ., vol. v., p 20o' —Ed. t Sir E. Home thinks that the development of the sex takes place subsequently to impregna- tion, the ovum being fitted originally to become either male or female.—D. X According to the statistical tables of Dr. Emerson, the proportion in Philadelphia for nine years was as 21 to 19.43 —D Cl. V.] PHYSIOLOGICAL PROEM. 421 stantly thrown into a state of vital activity, de- tached from the common cluster, and in a short time passes into the uterus through the canal of the Fallopian tube, which spontaneously en- larges for the purpose; where its miniature germe is gradually unfolded and augmented into a sensible foetus, partaking of the form and figure of the parent stock. The elementary animal- cule, it was farther asserted by Harvey, may be occasionally impressed with a resemblance in its features to the father from the electric im- pulse given in the genial act to every portion of the solids and fluids of the body, and of conse- quence to the fluid contained in the ovula them- selves : but, reasoning from the length of the vagina in cows and many other animals, and an occasional dissection of the human subject soon after coition, he contended that the male semen never did, nor indeed could enter the uterus, and of course could not add any thing to the embryon in its evolution. Leewenhoeck and Hartsoeker, however, upon a more accurate anatomy of the uterus imme- diately after copulation, discovered, not only that the projected male semen could enter its cavity, but actually did thus enter, and in some in- stances which fell within their notice, had clearly ascended into the Fallopian tubes. And now a new doctrine was started, and one alto- gether opposite to the theory of Harvey. Upon the principle of the former, the father had no im- mediate connexion with his own child ; he could not bestow upon it a particle of his own matter, and the whole production was the operation of the mother. But, in consequence of this later dis- covery, it was contended that the entire forma- tion was the work of the father, and that the mother, in her turn, had nothing to do with it: that every particle of the propelled fluid was a true and proper seminium, containing in itself, like the ovulum of the female upon the hypothe- esis of Harvey, a miniature of all the organs and members of the future foetus, in due time to be gradually evolved and augmented ; and that the uterus, and possibly the ovulum, into which some one of these male semina or seminia is al- most sure of being protruded in the act of genera- tion, offers nothing more than a nest, in which the homunculus or rudimental foetus is deposited for warmth and nutriment. And, as the former hypothesis appealed to the natural economy of oviparous animals during the period of incuba- tion, that of worms and tadpoles was appealed to by the latter : and a very considerable de- gree of life and motion was supposed to be dis- covered and proved by the aid of good magnifying glasses in the simple fluid of the male semen, in- somuch that not less than many millions of these homunculi, or unborn manikins, were pointed out as capering in a diameter not greater- than than that of the smallest grain of sand, each re- sembling the tadpole in shape. Delappius, in- deed, a celebrated pupil of Leewenhoeck, ad- vanced farther; for he not only saw these ho- muncular tadpoles, but pretended to trace one of them bursting through the tunic by which it was swaddled, and exhibiting two arms, two legs, a human head and heart. Such was the dream of the popular philoso- phy on the subject of generation indulged in at the period we are now adverting to, and which continued for upwards of a century. It is truly astonishing to reflect on the universality with which this opinion was accredited, and how de- cisively every anatomist, and indeed every man who pretended to the smallest portion of medi- cal science, was convinced that his children were no more related, in point of generative power, to his own wife, than they were to his neighbour's. It was in vain that Verheyen de- nied the existence of animalcules in the seminal fluid, and undertook to demonstrate that the motion supposed to be traced there was a mere microscopic delusion : it was in vain to adduce the fact of an equal proportion of paternal and maternal features in almost every family in the world, the undeviating intermixture of features in mutes, and other hybrid animals, and the cas- ual transfer of maternal impressions to the un- born progeny, when suddenly frightened in the earlier months of pregnancy. The theory, as it was triumphantly called, of generation ab ani- malculo maris, was still confidently maintained ; and the mother, it was contended, had nothing to do with the formation of her own offspring, but to give it a warm nest and nourishment. At length arose the celebrated and indefati- gable Buffon, who was not inattentive to the facts before him, nor to the absurdities to which some of them had led. He readily accredited the microscopic motion pointed out by Leewen- hoeck in the floating bodies of the male semen, and which Spallanzani has since persuaded hjm- self he has detected, not only in this fluid, Wit in various others of an animal origin (Opusco- It de Fisica, Animate, Vegetabile, &c, vol. ii., 8vo., Milan, 1776), but, instead of admitting them to be animalcules, he regarded them as primordial monads, molecules organiques, of a peculiar activity, existing through all nature, and constituting the nutrient elements of living matter : and upon this principle he founded, not indeed a new hypothesis, but a new edition of that of epigenesis, with so much accessory, and in his view of the subject, important matter, as very nearly to entitle it to the character of an original plan. Like the speculations to which it succeeded, it soon acquired a very high degree of popularity. All organized beings, and hence plants as well as animals, according to the doctrine of M. de Buffon, contain a va3t number of these active molecules in every part of their frames, but espe- cially in the generative organs of both sexes, and the seed-vessels of plants, in which they are more numerous than in any other parts. These organic primordia afford nutrition and growth to the animal and vegetable fabrics; and as soon as these fabrics are matured, and consequently a smaller proportion of such molecules are re- quisite, their surplus is secreted and strained off for the formation of vegetable and animal seeds. The existence of ovula in the female ovaria, im- pregnated and detached at the time of concep- tion, is by this hypothesis declared to be a chi- mera, and their passage into the uterus asserted 422 PHYSIOLOGICAL PROEM. [Cl. V. to be contrary to all observation and fact. The ovaria are once more regarded as female testes, receiving, like those of the male, the surplus of the organic molecules of the body, and secreting them like the latter, for the common purpose of generation. The seminal liquors, thus secerned in the male and female frames, are projected in the act of coition simultaneously into the uterus, and becoming intimately blended there, produce by a kind of fermentation the first filaments of the foetus, which grow and expand like the fila- ments of plants. To render such combination of seminal fluids productive, however, it was contended that their quantities must be duly proportioned, their powers of action definite, and their solidity, tenacity, or rarefaction, symphoni- ous : and the foetus, it was added, would be either male or female, as the seminal fluid of the man or woman abounded most with organic molecules, and would resemble either the father or the mother, according to the overbalance of the respective elements contributed by each parent. It is obvious, from this brief view of the sub- ject, that Buffon, in the planning of this hypoth- esis, did nothing more than avail himself of the anatomical facts of Vesalius, De Graaf, and Harvey, and the supposed discoveries of Lee- wenhoeck, to revive in a new form the doctrine of the Greek schools, and especially that of Epi- curus. The subject, however, was offered to the world with plausible arguments and captiva- ting eloquence, and had soonthe good fortune to meet With powerful and enlightened support- ers in Maupertuis and Needham, who added some improvements, but of no very great impor- tance, to several of M. de Buffon's tenets ; while Haller and Bonet strove hard to revive the hypothesis of female generative power, or that of evolution alone, at first established by Harvey ; or rather to erect an edifice, some- what similar to it, out of the crumbling ruins of the ^primary building; in doing which they ap- pealed to the phenomena of the vegetable cre- ation with considerable research and some de- gree of success. But this revived hypothesis, notwithstanding, has never been very generally followed ; and is now almost, if not altogether relinquished, even in Germany. In like manner, there are several physiolo- gists who have endeavoured to improve the hy- pothesis of Buffon, of whom it may be sufficient to mention Dr. Darwin and Professor Blumen- bach. The alterations, however, are little more than verbal, and consequently of no great im- portance, and chiefly relate to the subordinate doctrine of organic molecules. For the term or- ganic molecules, Darwin prefers that of vital germes, which he assorts into two kinds, or rather maintains are thus formed by nature, as being secreted or provided by male or fe- male organs, whether animal or vegetable ; for in the philosophy of this writer, the two depart- ments tread closely upon each other. In this subdivision of germes, however, the term mole- cule is still retained, but limited to the female character or department: the vital germes or particles, secreted by the female organs of a bud or flower, or the female organs of an animal, being by Dr. Darwin denominated molecules with formative propensities; while those secreted from the male organs of either department, are called fibrils with formative appetences. To the fibrils he assigns a higher degree of organi- zation than to the molecules. Both, however, we are told, have a propensity or an appetence to form or create; as we are told also, that " they reciprocally stimulate and embrace each other, and instantly coalesce; and may thus popularly be compared to the double affinities of chymistry." In the view of Professor Blumenbach, matter is divided into two kinds, possessing properties essentially different from each other ; these are organized and unorganized : unorganized matter is endued with a creative or formative power throughout every particle ; and organized mat- ter with a creative or formative effort, a nisus formativus, or bildungstrieb (Uber den Bildungs- trieb, 8vo., Gottingen, 1791), as he calls it, a principle, in many respects, similar to that of gravitation, but endowing every separate organ, as soon as it acquires structure, with a vita pro- pria. From the first, he traces the origin of the world in the simple and inorganic state of the mineral kingdom ; from the last, the rise of veg- etables and animals. It is only necessary to add further a remark of Mr. John Hunter's, that in plants of all kinds, the seed, properly so called, is produced by the female organization, white the male gives nothing more than the principle of arrangement; and that the same operation and principles take place in many orders of animals.—(Animal Econ- omy, p. 55.) In all these attempts to improve upon the older speculations, there is a great deal that can- not but be regarded as philosophical nugae. The physiological experiments that have been made, and the anatomical facts that have been discov- ered, since the days of Harvey, and particularly during the last half century, though they leave the doctrine of generation still surrounded with many difficulties, have sufficiently established the following positions :— First, that in all ordinary cases, the male se- men enters into the uterus at the time of coi- tion ; and that in those cases in which it does not or cannot enter immediately, from the ex- treme length of the vagina, as in some quadru- peds, or from a greater or less degree of imper- foration of the vaginal passage, it is conveyed there soon afterward, in consequence of its prox- imity of situation. Secondly, that the uterus itself, worked up at this time to the highest pitch of excitement, secretes also some portion of a peculiar fluid, the female semen of the Epicurean philosophers, with which the male semen combines, and which is probably the basis of the membranes soon af- terward prepared for the foetus. Thirdly, that the Fallopian tubes at this period become rigid ; their fimbriae embrace the ovaria ; and consequently form a direct channel of com- munication between the ovaria and the uterus ; that what were formerly supposed to be vesicles are real ovula ; and that one of them, detached Cl. V.] PHYSIOLOGICAL PROEM. 423 by the momentary shock or excitement, bursts from its nucleus or matrix, enters into one of the open mouths of the fimbriae of the Fallopian tube, and in consequence, into the tube itself, by which it is conveyed to the uterus; an ef- fect, however, which does not seem to take place during the act of coition, since the ovu- lum is seldom found, even in the Fallopian tube, till seme time afterward: and that, as soon as the ovulum has thus escaped, the lips of the wound hereby made in the side of the ovary are closed by an external cicatrix, and indented with a small cavity, which forms what is meant by a corpus luteum. Fourthly, that the cervix of the uterus is from this time closed in its canal towards its upper part, so as to prevent a second fcetation by the introduction of fresh male semen ; while the in- ternal surface of this organ becomes lined with a fine coagulable and plastic lymph, being prob- ably the fluid secreted at the moment of inter- course ; which assumes a thin membranous form, and has been called tunica caduca or decidua, and constitutes the uterine ovum or egg of the foetus ; this important part of the process seem- ing to take place about a week after the time of copulation. In the rabbit, Mr. Cruickshank found it as early as the fourth day. Fifthly, that for the better protection and nu- trition of the foetus, the walls of the uterine ovum are multiplied ; and that hence, while the tuni- ca caduca itself possesses a duplicature, which is called tunica reflexa, there are also two other membranes by which the decidua is lined, de- nominated chorion and amnion, both which are filled with peculiar fluids; the fluid of the cho- rion occupying the space between itself and the amnion, which it surrounds ; and the fluid of the amnion occupying the whole of the interior, which is distended with it like a bladder.* Sixthly, that the medium of connexion be- tween the foetus and the mother is the umbilical cord and the placenta, + into which it is distrib- * Dr. William Hunter Was the first who gave just views of the decidua, the membrana exterior ovi of Haller, and showed that it consisted, at least at one period of utero-gestation, of two folds. The chorion he described as the third membrane of the ovum from the second to the fifth month, and as the second membrane after the latter period. It was also Dr. Hunter that divided the placenta into the maternal and foetal portions, which, ac- cording to his views, did not communicate with each other. These accounts received implicit be- lief in the medical schools of England and the continent for nearly half a century.—See Edin. Med. and Surg. Joum., No. cxviii., p. 156.—En. t Rouhault, in the Mem. of the Acad, of Sci- ences for 1714, 1715, and 1716, published descrip- tions of the placenta, which, he maintained, was produced by a thickening of the chorion, while its spongy tissue was formed solely by an assemblage of capillary veins from the umbilical vessels. He also denied that any anastomoses existed between the vessels of the placenta and those of the womb. In 1734, Dr. Simson, of St. Andrew's, undertook to prove that the placenta was formed from the chorion—a doctrine revived by M. Breschet.—(See his Etudes Anatomiques, &c, de l'CEuf dans l'Es- pece Huinaine, &,c, 4to., Pans, 1832.) In 1754, uted; the former consisting of an artery from each of the foetal iliacs, and a vein running to the foetal liver twisted spirally and surrounded by a common integument; and the latter consisting of two parts, a uterine or spongy parenchyma, derived from the decidua, and a foetal parenchy- ma, consisting of a great multitude of exquisitely beautiful knotty flocculi that cover the chorion, and constitute not only an organ of nutriment, but, as was first ingeniously supposed by Sir Edward Hulse, of oxygenation. In both these organs Sir Everard Home appears, by the assist- ance of Mr. Bauer's extraordinary microscopical powers, to have detected a few silvery lines, or rather continuous chains of nerves (Phil. Trans., 1825, Croonian Lecture), and to have shown the probability of there being an order of vessels in these organs, which were peremptorily denied to exist by Haller. These experiments, how- ever, seem to require confirmation.* Seventhly, that about the third week, or as soon as the uterine ovum is thus prepared for its reception, we can trace the first vestige of the embryon, oval in its shape, and resembling a minute bean or kidney, swimming in the fluid Albinus represented the placenta to be formed of bloodvessels, cellular tissue, and membranous in- vestments derived from the chorion.—(Annot. Acad.) See a valuable review of Breschet's work, and of Velpeau's Embryologie, in the Edin. Med. and Surg. Journ., No. cxviii., January, 1834.—Ed. * The structure of the human placenta, and its connexion with the uterus, form a subject that has engaged a great deal of attention, and more particularly at the present time, in consequence of the investigations of Dr. Robert Lee, which lead to so different a view from what was promulgated by the two Hunters. In a communication to the Royal Society, Dr. Lee described certain appear- ances which he observed in the examination of six gravid uteri, and many placentae expelled in natu- ral labour, which seem to him to warrant the con- clusion, that the human jplacenta does not consist of two parts, maternal and foetal; that no cells exist in its substance; and that there is no communication be- tween the uterus and placenta by large arteries and veins. The whole of the blood sent to the uterus by the spermatic and hypogastric arteries, except the small portion supplied to its parietes and to the membrana decidua by the inner membrane of the uterus, appears to Dr. Lee to flow into the uterine veins or sinuses, and, after circulating through them, is returned into the general circulation of the mother by the spermatic and hypogastric veins, without entering the substance of the placenta. The deciduous membrane being,.according to Dr. Lee, interposed between the umbilical vessels and the uterus, whatever changes take place in the fcetal blood must result from the indirect exposure of this fluid, as it circulates through the placenta, to the maternal blood flowing in the great uterine sinuses.—(See Phil. Trans.) With reference to these points, it merits notice, that M. Velpeau ad- mits that Dr. Lee's statement of the large vessels of the womb not communicating with any corre- sponding vessels of the placenta, is perfectly well founded; but he considers Dr. Lee to be erroneous in representing the decidua to be interposed be- tween the womb and the placenta, and, in his own opinion, the chorion adheres directly to the uterine surface, though it is admitted, at the same time, that the uterine sinuses are closed by membranous pulpy matter.—Ed. 424 PHYSIOLOGICAL PROEM. [CL.V, of the amnion, and suspended by the umbilical cord,*ihich has now shot forth from the placen- ta. (Prom this reniform substance the general figuri pallulates, the limbs are protruded, and- the faces takes its rise. III. Uhe chief difficulties that have been felt, as accompanying these positions, and the gen- eral doctrine that flows from them, are the foUow- ing :— First, as to the mode by which the male se- men is conveyed to the ovulum in the Fallopian tube. Secondly, the occasional existence of corpora lutea in the ovaria of virgins, or of those who, from misformation, have been incapable of in- dulging in sexual commerce. Thirdly, the occasional detection of a full-sized foetus in the uterus without any placenta,* um- bilical cord, or mark of an umbilicus. The first of these difficulties was originally started, as we have already observed, by Dr. Harvey, who contended that, in the case of cows, whose vagina is very long, -as well as in various other cases, the semen cannot possibly reach even the uterus; and that hence there is no reason to suppose it ever reaches it. It was not then known that impregnation commences in the Fallopian tube, and that it must also reach this canal as well; which, by Harvey, would have been received as an objection stiU more triumphant. By what means the ejected semen is conveyed into the uterus we do not, indeed, very clearly know, even to the present hour; but that it is so conveyed, and even in animals in which the male organ can by no means come in contact with it, has been proved by incontrovertible facts.t Mr. John Hunter killed a bitch in the act of copulation, and found that the semen was then existing in the cavity of the uterus, in his opinion carried there per saltum. Now, if it reach the uterus, there can be no difficulty in conceiving that it may also reach the Fallopian tubes, which by one end open into the uterus; sucked in, perhaps, as supposed by M. Blumen- bach, by the latter organ during the thrilling orgasm of the moment. Leewenhoeck and Hart- soeker seem indeed to have removed the diffi- culty altogether, by having, in some instances, detected the seminal fluid in the Fallopian tubes themselves4 And there seems great reason to * A curious case of this kind may be seen in the New-York Med. and Phys. Journal, vol. i., record- ed by Dr. Cotton.—D. t The recent discoveries of Dr. Gartner of Co- penhagen, may throw some Ught on this intricate subject. In some of the mammalia, as the sow and cow, the doctor has been able to trace canals or ducts from the vagina to the ovaries.—D. X In May, 1827, Mr. H. Bond, of Philadelphia, was invited by Dr. S. Tucker to examine the body of a female, between 18 and 20 years of age, who had destroyed herself by taking a large quantity of laudanum. She had passed the whole or the greater part of the night in the arms of a young man, and before break of day destroyed herself by swallowing a strong dose of laudanum. Mr. Bond removed the whole of the genito-urinary organs, and took them home for rninute examination.— believe that it has occasionally entered the ova- rium, and even produced impregnation in that organ instead of in the uterus, where an obstruc- tion has been offered to the descent of an ovu- lum into the fimbrial openings of the tube after its detachment: for we cannot otherwise readily account for the formation of foetuses in the ova- rium ; facts, however, well known to occur, and of which Mr. Stanley has given a singular in- stance (Med. Trans., vol. vi., art. xvi.), and Dr. Granville a still more extraordinary example, the foetus at its examination appearing perfect, and four months old.* [It appears now to be fully proved, that " if the canal leading from the orifice of the vagina to the ovaries be interrupted, conception never lakes place. When the interruption results from obliteration of the vagina, the sexual appetite remains unaffected; but when the cause which has produced it is the division of the Fallopian tubes, desire appears to be lost, as well as the capacity of being impregnated." The experi- ments of Dr. BlundeU show that the division of the vagina prevents conception.—(Med. Chir. Trans., vol. x., p. 50.) In several female rab- bits, Dr. Haighton divided the Fallopian tubes, and found that the animals invariably lost the sexual appetite. When the Fallopian tube on one side only was divided, the same result gen- erally ensued. In a few cases, however, the animals thus mutilated admitted the male, and became impregnated; but the horn of the ute- rus, on the side on which the Fallopian tube had been divided, never contained ova.—(See Phil. Trans., vol. lxxxv., p. 108, and Mayo's Outlines, p. 471.)] The second difficulty is also capable of a plau- sible answer, but not quite so satisfactory as the preceding. There can be no doubt that the ovarium is directly concerned in the great business of gen- eration, for it is well known that the operation of spaying or excising the ovaries, corresponds in females to that of castration in males. It takes off not only all power of production, but all desire. And in a recent volume of the Phi- losophical Transactions, there is the case of a natural defect of this kind in an adult woman, who in hke manner had never evinced any in- clination for sexual union, and had never men- Among other circumstances, the foUowing ones were noticed:—" The internal surface of the ute- rus was fined with a matter having the appearance of semen, and giving out strongly the peculiar odour of that fluid, and the neck of the organ was filled with the same matter. One of the Fallopian tubes (the only one examined) seemed to contain a simffar fluid, but the seminal odour was not here well marked. When this matter was removed from the surface of the uterus, the lining mem- brane appeared extremely vascular, hke the con- junctiva in cases of acute ophthalmia, or as if it had been injected with vernulion."—See Lancet for 1833-4, p. 114.—Ed *Pbil. Trans., 1820, p. 101. It is contrary to the anatomy of the parts, to fancy that the semen enters the ovary; nor could we explain, by any such doctrine, the occasional formation of parts of the foetus in the male subject.—Ed. Cl. V] PHYSIOLOGICAL PROEM. 425 struated; and who on dissection was found, with the deficiency of ovaria, to have the uterus only of the size of an infant's, a very narrow pelvis, and no hair on the pubes.—(Vol. for the year 1805, p. 226.) It seems, also, perfectly clear, that in concep- tion, an ovum does really descend from the ova- rium into the uterus within a few days after sexual intercourse has taken place : in proof of which it will be sufficient to quote the following curious historical fact from Sir Everard Home (Id., 1817, p. 252), who appears to have traced its path very accurately:—"A servant maid, twenty-one years of age, died of an epileptic fit seven days after coition, there being circum- stances to prove that she could not have seen her lover after the day here adverted to, nor for many days before. The sexual organs were submitted to dissection: the right ovarium had a small torn orifice upon the most prominent part of its external surface, which led to a cavity fined with coagulated blood, and surrounded by a yellowish organized structure : its inner surface was covered with an exudation of coagulable lymph. A minute spherical body, supposed to be an ovum, was concealed in the cavity of the womb among the long fibres of coagulable lymph which covered its inner surface, and especially towards the cervix. This supposed ovum was submitted to the microscopical powers of M. Bauer, who has made various drawings of it, and who detected in it two projecting points, which are considered as the future situations of the heart and brain." [M. Bauer is stated to have repeatedly veri- fied the preceding observation in animals, and also to have ascertained that the corpora lutea, when the ova are fit for fecundation, burst and expel their contents, and subsequently shrink and disappear. " These interesting observa- tions," says Mr. Mayo (Outlines of Human Phys- iology, p. 466, 2d edit.), " have the advantage of bringing under one theory all the instances of generation with separate organs, by proving that, in the case of mammalia, as in other ani- mals and in plants, an ovum is prepared by the female previously to a fruitful connexion."] What exact period of time the ovum demands to work its way down the tube into the uterus, has not been very accurately ascertained. That it does not descend at once is admitted on all hands; and there can be no doubt that, in differ- ent kinds of animals, a different period is requi- site. Mr. Cruickshank, whose experiments were confined to rabbits, ascertained that in this spe- cies the ovum demanded for its journey about forty-eight hours. In the case just alluded to seven days had elapsed, and consequently a period perfectly sufficient seems to have been given for the purpose, and there can be little doubt that the minute body observed in the cav- ity of the uterus, was a genuine impregnated ovum that had completed its travels. But whence comes it to pass, if the copula- tive percussion felt through every fibre be the cause of the detachment of ova or ovula from the ovaria, that examples should be found of a like detachment, and consequently of a forma- tion of corpora lutea, in cases where no copula- tion has ever taken place 1 Of the fact itself there is no question.* " Upon examining," says Sir Everard Home, " the ovaria of several women who had died virgins, and in whom the hymen was too perfect to admit of the possibil- ity of impregnation, there were not only distinct corpora lutea, but also small cavities round the edge of the ovarium, evidently left by ova that had passed out at some former period, so that this happens during the state of virginity."— (Phil. Trans., 1817, ut supra.) Professor Blu- menbach has met with similar examples. + An endeavour has been made to account for the fact, first, by supposing that the females thus circum- stanced must have been of a peculiarly amorous disposition, and at particular times morbidly ex- cited by a venereal orgasm originating in their own persons alone, without any intercourse with the mate sex. And next, that a high-wrought excitement of this kind may be sufficient to pro- duce such an effect, and to lead to the first and most important step in the generative process. All this is highly ingenious, but we seem at present to want facts to justify us in offering such an explanation. " We cannot doubt," says Sir Everard Home, " that every time a female quadruped is in heat, one or more ova pass from the ovarium to the uterus, whether she receives the male or not."—(Phil. Trans., 1817, ut su- pra.) And to the same effect Professor Blu- menbach, who first launched this opinion in 1788, before the Royal Society (Specimen Physiologia Comparala; Comment. Soc. Reg. Scientia G'ot- lengens, vol. ix., 128) of Gottingen:—"The state of the ovaria," says he, " of women who have died under strong sexual passion, has been found similar to that of rabbits during heat." * The fact of birds laying eggs without the co- operation of the male, which eggs, however, are unproductive, is famiUarly known.—Ed. ■f The minute investigations of the latest physiol- ogists seem to have demonstrated clearly that the appearance of corpora lutea is not conclusive that pregnancy has existed. This important prin- ciple has been supported by many facts from hu- man and comparative anatomy. To the high names mentioned in the text may be added BlundeU, Francis, Granville, Dunglisson, and others. Dr. Francis observes (Notes to Francis's Denman, p. 152), " In my physiological lectures in the Univer- sity of New-York, as Professor of the Institutes of Medicine, in 1817,1 ventured the opinion that the appearance of corpora lutea is not to be deemed decisive of previous pregnancy; I have since found these corpora lutea in two instances where no doubt could exist as to the virginity of the subjects. That undue salacity may induce them, as well as other changes in the ovaria, may be confidently affirmed." Dr. Granville remarks (Graphic Illus- trations of Abortion and the Diseases of Menstru- ation, 4to., London, 1834), " It is inaccurate to state that a woman has been pregnant because a corpus luteum has been found in the ovaria after death, or to calculate the number of children she has borne from the number of corpora lutea so detect- ed. Corpora lutea have been found in the ovaria of very young girls, of unmarried women of the strictest virtue, and in newly-born female infants; and lastly, in steril animals, such as mules."—D. 426 PHYSIOLOGICAL PROEM. [Cl. V. And in confirmation of this he adds:—" In the body of a young woman, eighteen years of age, who had been brought up in a convent, and had every appearance of being a virgin, Valisneri found five or six vesicles pushing forward in one ovarium, and the correspondent Fallopian tube redder and longer than usual, as he had fre- quently observed in animals during heat. Bo- net," he adds, "gives the history of a young lady who died furiously in love with a man of low rank, and whose ovaria were turgid with vesicles of great size." In neither of these cases, however, do we meet with ovula actually detached, and still less with corpora lutea. Add to which, that not only corpora lutea, but de- tached ovula, and even imperfect fcetation, have at times been found in the ovaries of infants of ten or twelve years of age, who can scarcely be suspected of any such erethism: a very curious instance of which we shall have to quote from Dr. Baillie, under the genus Proeotia.—(ClassV., Ord. II., Gen. II., Spe. 2, of the present volume.) I am aware that the same explanation has been adopted by M. Cuvier; indeed it is diffi- cult to adopt any other ; but direct facts in sup- port of it are wanting in him as well as in the authorities just referred to. There is an indi- rect fact appealed to, however, by the last, which is well worth noticing for its curiosity, whatever degree of bearing it may have upon the present question. After observing that a corpus luteum is not positive evidence of impregnation, he adds, nor does the existence of a decidua in the uterus constitute better evidence of the same, since it has sometimes happened that, at each period of painful menstruation, the excitement of the uterine vessels has produced a perfect decidua, not to be distinguished from that be- longing to an ovum. The present author has never met with a case of this kind, but of the fact itself there seems no doubt :* Morgagni has given one striking instance of it in his day (De Sed. et Caus. Morb. Ep.), and Mr. Stanley another in our own.—(Med. Trans., vol. vi., art. xvi.) To explain the origin of such a mem- brane under such circumstances is by no means difficult, as it follows upon the co'mnion princi- ple by which other membranous or membrane- like tunics are produced in other hollow organs in a state of peculiar irritation, of which some curious examples have already been offered under diarrhcsa tubularis.—(Vol. i., p. 137.) The peculiar character of the membrane must necessarily be governed by the character of the organ in which it is formed. Upon the whole, it does not seem to afford much support to the argument in whose favour it is appealed to, and the subject requires further investigation. * Obstetrical writers have generally noticed the formation of this deciduous membrane. " Some- times it is small," says Dr. Dewees, " at other times large, and sometimes it resembles the cavity from which it has been expelled; at other times it will be broken into many fragments."—(Diseases of Females, 4th edition, p. 181.) Dr. Granville, in his beautiful " Illustrations of Abortion and the Diseases of Menstruation," has devoted two plates (xi. and xii.) to these formations.—D. The third difficulty attendant upon the com- mon doctrine of the day, which supposes the foetus to hold its entire communication with, and to derive its blood, nutriment, and oxygen from the mother by means of the placenta and umbilical cord, is founded upon the occasional instances of foetuses of large and even full growth being found in the womb, and even brought forth at the proper period, without any placenta, or at least one of any utility, without any umbilical cord, or even a trace of an umbilicus. Admit- ting the course just glanced at to be the ordi- nary provision of nature, what is the substitute she employs on these occasions 1 tire means by which the bereft foetus is supplied with air and nourishment 1 The advocates of the doctrine of epigenesis, as new modelled by the hands of Buffon and Darwin, triumphantly appeal to these curious deviations from the established order of nature, as effecting a direct overthrow of the doctrine of evolution by an impregnated ovum ; while the supporters of the latter doctrine have too gener- ally cut the question short by a flat denial of such monstrous aberrations. There is little of the true spirit of philosophy in either conduct. Admitting the existence of such cases, they just as much cripple the one doctrine as the other; for, granting the explana- tion which is usually offered by the former, the ordinary machinery of a placenta and an umbili- cal cord becomes immediately a work of super- erogation—a bulky and complicated piece of fur- niture, to which no important use can be assign- ed, and which the overloaded uterus might be well rid of. But, on the contrary, to deny the existence of well-established and accumulated facts, mere- ly because we cannot bend them to our own speculation, is still weaker and more reprehensi- ble. * The kangaroo, opossum, and wombat, * As a great deal of the mystery and obscurity of the process of reproduction in the animal world, and much of the difficulty of explaining several of its phenomena, are naturally connected, as a crit- ical writer justly observes, with the anatomical facts of the new formation at different periods of its progress, it has been always a most essential step in the inquiry to determine the anatomical structure of its different parts. " From this cir- cumstance it has resulted, that all theories of the process of reproduction, framed at periods when anatomy was either little or imperfectly cultivated, and before precision in anatomical inquiry was observed, have been extremely erroneous and fal- lacious. In the class of warmblooded viviparous animals, or those provided at once with a womb and mammae, the union of the sexes, if efficient, gives rise to the formation of a new product, which is, destined to be attached for a definite time to the inner surface of the womb, in one form of exist- ence or vital action, and thence to be separated in order to become the seat of a different and new species of vital action. The new product thus formed, or ovum, as it is generally denominated, if examined at any given time, is found to consist of certain constituent parts, which may be distin- guished into two general divisions ; one, which is the germe or rudiment of the future being, and consequently contains more or less completely the representative form or rudiment of all the parte Cl. V.] PHYSIOLOG all breed their young without either placenta or navel-string. The embryons are enclosed in one or more membranes, which are not attached to the coats of the uterus, and are supplied with nourishment, and apparently with air, from a gelatinous matter by which they are surrounded. Hoffmann gives us the case of a foetus, born in full health and vigour, with the funis sphace- lated and divided into two parts.—(Op. de Pin- guedine.) Vander Wiel gives the history of a living child exhibited without any umbilicus, as a public spectacle (Observ. Cent, post.); and, in a foreign collection of literary curiosities, is the case of a hare which was found, on being opened, to contain three leverets, two of them without a placenta or umbilical vessels, and the other with both.—(Commerc Liter. Norimberg.) Ploucquet has collected a list of several other instances in his Initia (Initia Bibliotheca, Med- ico-Pract. et Chirurg., torn, iii., p. 554, 4to., Tubing, 1794); but perhaps the most striking example on record is one which occurred to the present author in December, 1791, an account of that being, and is destined for a comparative- ly permanent existence; the other certain parts which, either as investments of this rudimental being, or as the medium of its attachment to the inner surface of the womb and its nutrition while there, are Umited in the duration of their existence to the period at which the newly-formed being is detached from the body of its mother. If the ovum, or product of generation thus defined, be examined in any of the mammiferous animals, it is found that the former assemblage of parts cannot be rec- ognised with the same distinctness and perfection in the early as in the latter period of utero-gesta- tion; and that there is a period, even after prolific sexual intercourse, in which it cannot be demon- strated in any form. It is different, however, with the second assemblage of parts. The existence of these can be perceived at a very recent period after impregnation ; and they are beheved on very good evidence, if not to commence, at least to precede the organism of the new body. The great problem in the solution of the principal difficulties of the process of generation is to determine the relation of these two orders of organized parts; to discover how much of the existence and develop- ment of the one depends on that of the other; to unfold the mechanism of their formation, and to understand the nature of the process by which they are produced. It is manifest that it is impossible to attain the last of these objects, without a thor- ough knowledge of the anatomical peculiarities of both assemblages of parts; and it, in any situa- tion, the previous knowledge of the structure of organs be necessary to explain their properties and functions, it is in that of the process of reproduc- tion. There is in this inquiry, however, this pecu- liar difficulty, that the parts are not at all periods after the process of impregnation exactly the same jn appearance and disposition; and it is even un- certain whether they are the same in number. The ovum appears to pass through a succession of stages, in each of which it presents different aspects, and acquires new parts; while some, formerly distinct, disappear, or are blended with others."—(See Edin. Med. and Surg. Jour., No. cxviii., pp. 153, 154.) According to Lobstein, the vesicul umbilicalis, the uses of which are un- known, is restricted to a particular stage of the life of the embryon; and a similar remark applies to the omphalo-mesenteric vessels.—Ed. CAL PROEM. 427 of which he gave to the public in 1795.* The labour was natural, the child, scarcely less than the ordinary size, was born alive, cried feebly once or twice after birth, and died in about ten minutes. The organization, as well external as internal, was imperfect in many parts. There was no sexual character whatever, neither penis nor pudendum, nor any interior organ of gener- ation : there was no anus nor rectum, no funis, no umbilicus ; the minutest investigation could not discover the least trace of any. With the use of a little force, a small shrivelled placenta, or rather the rudiment of a placenta, followed soon after the birth of the child, without a funis or umbilical vessel of any kind, or any other appendage by which it appeared to have been attached to the child. No hemorrhage, nor even discoloration, followed its removal from the uterus. In a quarter of an hour afterward a second living child was protruded into the vagina and delivered with ease, being a perfect boy attached to its proper placenta by a proper funis. The author dissected the first of these shortly after its birth in the presence of two medical friends of distinguished reputation, Dr. Drake of Hadleigh, and Mr. Anderson of Sudbury, both of whom are still able to vouch for the correctness of this statement. On the present occasion, however, it is not necessary to follow up the amorphous appearances any further, as they are already before the public, except to state that the stomach, which was natural, was half filled with a liquid resembling that of the amnios. This subject has been ably discussed by Pro- fessor Monro and Mr. Gibson, t The latter, giving full credit to the few histories of the case then before the world, endeavours very inge- niously to account for the nutriment of the foetus by the liquor amnii, which he conjectures to be the ordinary source of supply, and not the pla- centa. The chief arguments are, that the em- bryon is at all times found at an earlier period in the uterus than the placenta itself; which does not appear to be perfected till two or three months after conception; and, consequently, that the embryon must, thus far at least, be supported from some other source than the placenta; and if thus far, why not through the whole term of parturition 1 That extra-uterine foetuses have no placenta, and yet obtain the means of growth and evolution from the surrounding parts. That tfie liquor amnii is analogous in its appearance to the albumen of a hen's egg, which forms the proper nourishment of the young chick ; that it is found in the stomach and mouths of vivipa- rous animals when first born ; and that it dimin- ishes in its volume in proportion to the growth of the foetus.X * Case of Preternatural Fcetation, with observa- tions : read before the Medical Society of London, Oct. 20,1794. t Edin. Med. Essays, vol. i., art. xiii.; vol. ii., art. ix., x., xi. See also Dr. Fleming's paper, Phil. Trans., vol. xlix., 1775-6, p. 254. X The fluid of the vesicula umbilicalis is re- garded by M. Velpeau and some other physiolo- gists in a similar light, namely, as a nutritious 428 PHYSIOLOGICAL PROEM. [Cl. V. To these arguments it was replied by Profes- sor Monro, that we have no satisfactory proof that the liquor amnii is a nutritive fluid at all, and that in the case of amorphous fetuses, pro- duced without the vestige of a mouth or of any other kind of passage leading to the stomach, it cannot possibly be of any such use : that if the office of the placenta be not that of affording food to the embryon, it becomes those who maintain the contrary to determine what other office can be allotted to it; and that till this is satisfactorily done, it is more consistent with reason to doubt the few and unsatisfactory cases at that time brought forward, than to perplex ourselves with facts directly contradictory of each other. For the full scope of the argument, the read- er must turn to the Edinburgh Medical Essays themselves, or, for a close summary, to the pres- ent author's observations appended to his own case. It must be admitted that the instances adverted to in the course of the discussion are but few, and most of them stamped with some- thing unsatisfactory. Others, however, might have been advanced even at that time on au- thorities that would have settled the matter of fact at once, how much soever they might have confounded aU explanation. But after the his- tory just given, and the references to other cases by which it may be confirmed, this is not neces- sary on the present occasion, as it is now well ascertained that the human embryon is always supported for several weeks in the commence- ment of gestation without a placenta ;* and in various other mammalia, as the mare, ass, camel, and hog, besides those just adverted to, through its entire period. These animals being uniformly destitute of such an organ, the surprise is in some measure removed, which would otherwise be natural on finding a single instance of a like destitution through the whole term of human pregnancy, t It is singular that the subject of aeration, which forms another difficulty in discussing the question, is not dwelt upon on either side, not- withstanding the ingenious conjecture of Sir Edward Hulse, that the placenta might be an organ of respiration as weU as of nutrition, had at this time been before the public for nearly half a century; and it shows us how slow the best founded theories not unfrequently are in obtain- ing the meed of public assent, to which they are entitled from the first. These, however, are only a few of the pecu- liar difficulties that still accompany the subject of generation, to whatever doctrine we attach ourselves. There are others that are more gen- eral, but equally inexplicable. The whole range of extra-uterine foetuses is of this character; often formed, and nourished, and developed,with- out either a placenta or an amnios, and yet some- times advancing, even in the remote cavity of the ovarium, and perfect in every organ, to the age of at least four months, of which we have already offered an example. A great part of the range of amorphous births defy equally all mental comprehension ; particularly the produc- tion of monsters without heads or hearts, some of whom have lived for several days after birth (see for examples and authorities the author's volume of Nosology, p. 538); others consisting of a head alone, wholly destitute of a trunk, and yet possessing a full development of this organ ; a specimen of which was lately in the posses- sion of Dr. Elfes, of Neuss, on the Rhine (Hufe- land, Journal der Pradischen Heilkunde, Apr., 1816); and others again, the whole of whose abdominal and thoracic viscera has been found transposed. X Nor less inexplicable is the generative power of transmitting peculiarities of talents, of form, substance—a kind of oil—like the vitelline fluid of the chick ; and he thinks that it contributes to the development of the embryon until the cord and the vessels are formed, and untU the ovulum is exactly applied to the inner surface of the womb. —(See his Embryologie, &c, Paris, 1833.) In short, the vesicula umbilicaUs seems to him to be analogous to the vitelline sac of the chick, which it resembles in shape, position, its connexion with the intestines, the structure of its parietes, and the quality of its fluid. The theory here adverted to, however, is far from being well established ; and is, perhaps, not better supported than Mr. Gibson's hypothesis respecting the use of the liquor am- nii.—Ed. * This statement is at variance, however, with the result of the investigations of M. Velpeau, who describes the development of the placenta as com- mencing the moment the ovulum enters the uterus, and not, as some writers have represented, three or four months after gestation.—(See his Embry- ologie, ou Ovologie Humaine, fob, Paris, 1833.) How many unsettled points are there in what may be regarded as the anatomical facts appertaining to this difficult subject!—Ed. t See PhU. Trans., 1822, art. xxix., on the Pla- centa, by Sir Everard Home, Bart. M. Velpeau infers that the foetus does not receive from the womb blood completely elaborated, but a fluid of different chymical properties and general constitu- tion, being more serous, less coagulable, and hav- ing much smaller globules.—(Embryologie, &c, Paris, 1833, fol.) However, the editor is disposed to join a critical writer in the belief, that it is phys- iologicaUy erroneous to imagine it necessary for the foetus or ovum to receive blood in any shape from the uterus. " What is the use of the com- plicated but beautiful arrangement of membranes, vessels, and placenta, unless it were that these parts were perfectly competent to derive the ma- terials of blood from the womb, without the inter- vention of actual vascular canals conveying red, completely-formed blood ? Physiologists, in their inquiry, seem to forget or overlook the fact, that the ovum, after fecundation, is a new being, which has received the principle of life, and that, by vir- tue of this principle, it is quite capable of attach- ing itself to any living tissue, and deriving from that tissue the materials of nutriment, as is abun- dantly evinced in Fallopian and also extra-uterine pregnancies, in which the peritoneum serves as a uterine surface for a time."—See Edin. Med. and Surg. Joum., No. cxviii., p. 174.—Ed. X Samson, Phil. Trans., 1674. Smithers, who was executed at the Old Bailey two years ago, for setting fire to a house in Oxford-street, and oc- casioning the loss of life to some of its inhabi- tants, furnished an example of such transposition. The preparation is contained in the Museum of the London University.—Ed. Cl. V.] PHYSIOLOGICAL PROEM. 429 or of defects, in along line of hereditary descent, and occasionally of suspending the peculiarity through a link or two, or an individual or two, with an apparent capriciousness, and then of exhibiting it once more in full vigour.* The vast influence which this recondite hut active power possesses, as well over the mind as the body, cannot, at all times, escape the notice of the most inattentive. Not only are wit, beauty, and genius propagable in this manner, but dulness, madness, and deformity of every kind. [Mr. Mayo supports the opinion, that the phys- ical and moral constitution of the infant have a greater resemblance to those of the father than to those of the mother. The offspring of a black man and a white woman are observed to be darker than that of a black woman by a white. This doctrine, in relation to form, complexion, and moral character, among Europeans at least, has so many exceptions, that its correctness seems doubtful. The following statements, intro- duced into this gentleman's " Outlines of Physi- ology," and closely connected with some obser- vations at the commencement of this preliminary physiological discourse, are highly interesting. Some remarkable instances which have recently attracted notice, seem to show that in the higher animals the influence of the male is extended even beyond a single impregnation. A seven eighths Arabian mare, belonging to the Earl of Morton, which had never been bred from before, had a mule by a quagga : subsequently she had three foals by a black Arabian horse. The first two of these are thus described:—They have the character of the Arabian breed as decidedly as can be expected, where fifteen sixteenths of the blood are Arabian; and they are fine spe- cimens of that breed ; but, both in their colour and in the hair of their manes, they have a striking resemblance to the quagga. Their col- our is bay, marked more or less hke the quagga, in a darker teint. Both are distinguished by the dark line along the ridge of the back, the dark stripes across the forehand, and the dark bars across the back part of the legs. Both their manes are black; that of the filly is short, stiff, and stands upright: that of the colt is long, but so stiff as to arch upwards, and to hang clear of the sides of the neck; in which circumstance it resembles that of the hybrid. This is the more remarkable, as the manes of the Arabian breed hang lank, and closer to the neck than those of most others.—(Phil. Trans., 1821, p. 21.) A similar occurrence to the preceding is mentioned by Mr. Giles respecting a litter of pigs, which resembled in colour a former litter by a wild boar. The explanation of these phe- nomena, preferred by Mr. Mayo, is the supposi- tion that the connexion with the male produces a physical impression, not merely upon the ova which are ripe for impregnation, but upon others, likewise, that are at the time immature. In gal- linaceous birds, in turkeys for instance, it is well known that a single coitus will actually impreg- * See Sir E. Home's Paper on Impressions pro- duced on the Foetus in the Womb.—Phil. Trans., 1825, p. 75. nate aU the ova that are laid during the breed- ing season. The explanation here quoted he deems more reasonable than any supposed influ- ence of the imagination.—(See Mayo's Outlines of Human Physiology, 2d edit., p. 489.)] Even where accident, or a cause we cannot discern, has produced a preternatural conforma- tion or singularity in a particular organ, it is as- tonishing to behold how readily it is often copied by the generative power, and how tenaciously it adheres to the future lineage. A preternatural defect in the hand or foot has, in many cases, been so common to the succeeding members of a family, as to lay a foundation in every age and country for the family name, as in that of Varro, Valgius, Flaccus, and Plautus, at Rome. Seleucus had the mark of an anchor on his thigh, and is said to have transmitted it to his poster- ity ; and - supernumerary fingers and toes have descended in a direct line, for many generations, in various countries. Hence, hornless sheep and hornless oxen produce an equally hornless offspring; and the broad-tailed Asiatic sheep yields a progeny with a tail equally monstrous, often of not less than half a hundred pounds weight. And hence, too, those enormous prom- inences in the hinder parts of one or two of the nations at the back of the Cape of Good Hope, of which examples have been furnished to us in xmr own island. How are we moreover to acceunt for that fear- ful host of diseases, gout, consumption, scrofula, leprosy, and madness, which, originating perhaps in the first sufferer accidentally, are propagated so deeply and 6o extensively, that it is difficult to meet with a family whose blood is totally free from all hereditary taint 1 By what means this predisposition may be best resisted, it is not easy to determine. But, as there can be no question that intermarriages among the collateral branch- es of the same family tend more than any thing else to fix, and multiply, and aggravate it, there is reason to believe that unions between total strangers, and perhaps inhabitants of different countries, form the surest antidote. For ad- mitting that such strangers to each other may be tainted on either side with some morbid pre- disposition peculiar to their respective lineages, each must lose something of its influence by the mixture of a new soil; and we are not without analogies to render it probable that in their mu- tual encounter, the one may even destroy the other by a specific power. And hence, nothing can be wiser, on physical as well as on moral grounds, than the restraints which divine and human laws have concurred in laying on mar- riages between relations; and though there is something quaint and extravagant, there is some- thing sound at the bottom, in the following re- mark of the sententious Burton upon this sub- ject :—" And surely," says he, " I think it has been ordered by God's .especial providence that, in all ages, there should be, once in six hundred years, a transmigration of nations to amend and purify their blood, as we alter seed upon our land ; and that there should be, as it were, an inundation of those northern Goths and Vandals, and many such like people, which came out of 430 GENETICA. [Cl. V—Ord. I. that continent of Scandia and Sarmatia, as some suppose, and overran, as a deluge, most part of Europe and Africa, to alter, for our good, our complexions, that were much defaced with hered- itary infirmities, which by our lust and intem- perance we had contracted."—(Anatomy of Melancholy, vol. i., part i., sect, ii., p. 89, 8vo.) Boethius informs us of a different and still se- verer mode of discipline at one time established in Scotland for the same purpose, but which, however successful, would make, I am afraid, ORDER I. C E N 0 T IC A. DISEASES AFFECTING THE FLUIDS. morbid discharges; or excess, deficiency, or irregularity of such as are natural. This order, the name of which is derived from Galen, and has been explained already, is designed to include a considerable number of dis- eases which have hitherto been scattered over every part of a nosological classification, but which are related to each other, as being mor- bid discharges dependant upon a morbid condi- tion of one or more of the sexual organs. The term employed might have been medorrhcetica, but that medorrhoea, as a genus, has been already employed by Professor Frank of Paris, in a somewhat different, and, as it appears to the au- thor, peculiarly indistinct sense ; as combining, under a single generic name, what seems to be a medley of diseases with no other connexion than locality or contiguity of organs, as mucous piles, fistula in ano, leucorrhoea, clap, gleet, syphilis phimosis, paraphimosis, and what was formerly called hernia humoralis, by him named epidydi- mitis, the orchitis of the present system. The genera under this order are five, and may be thus expressed:— I. Paramenia. Mismenstruation. II. Leucorrhoea. Whites. III. Blennorrhoea. Gonorrhoea. IV. Spermorrhoea. Seminal Flux. V. Galactia. Mislactation. GENUS I. r PARAMENIA. > MISMENSTRUATION. s MORBID EVACUATION OR DEFICIENCY OF THE * CATAMENIAL FLUX. 3 Paramenia is a Greek term, derived from napa, J "male," and /inv, "mensis." The genus is here limited to such diseases as relate to the . menstrual flux, or the vessels from which it issues. This fluid is incorrectly regarded as _ blood by Cullen, Leake, Richerand, and other physiologists; for, in truth, it has hardly any ti common property with blood, except that of be- g ing a liquid of a red colour. It is chiefly dis- e tinguished by its not being coagulable; and J? hence, when coagula are found in it, as in labo- J* rious and profuse menstruation, serum or blood is ^ intermixed with it, and extruded either from c' atonic relaxation or entonic action of the men- p etrual vessels. "It is," observes Mr. John t< sad havoc in our own day, were it ever to be carried into execution. " If any one," says he, " were visited with the falling sickness, madness, gout, leprosy, or any such dangerous disease, which was likely to be propagated from father to son, he was instantly castrated; if it were a woman, she was debarred all intercourse with men ; and if she were found pregnant with such complaint upon her, she and her unborn child were buried alive."—-(De Veterum Scotorum Moribus, lib. i.) Hunter, " neither similar to blood taken from a vein of the same person, nor to that which is extravasated by accident in any other part of the body; but is a species of blood, changed, separated, or thrown off from the common mass by an action of the vessels of the uterus similar to that of secretion ; by which action the blood loses the principle of coagulation, and, I suppose, life." Mr. Cruickshank supposes it to be thrown forth from the mouths of the exhaling arteries of the uterus, enlarged periodically for this pur- pose ; and his view of the subject seems to be confirmed by a singular case of prolapse, both of the uterus and vagina, given by Mr. Hill of Dumfries. In this case, the os tincae appeared like a nipple projecting below the retroverted vagina, which assumed the form of a bag. The patient at times laboured under leucorrhoea ; but it was observed that when she menstruated, the discharge flowed entirely from the projecting nipple of the prolapse : while the leucorrhoea proceeded from the surrounding bag alone.— (Edin. Med. Com., vol. iv., p. 91.)* As this distinction has not been sufficiently attended to, either by nosologists or physiolo- gists, many of the diseases occurring in the present arrangement under paramenia have been placed by other writers under a genus named menorrhagia, which, properly speaking, should import hemorrhage (a morbid flow of blood alone) from the menstrual vessels. And we have here, therefore, not only a wrong doc- trine, but the formation of an improper genus : for menorrhagia or uterine hemorrhage is, cor- rectly speaking, only a species of the genus hae- morrhagia, and will be so found in the present system, in which it occurs in Class III., Order IV. This remark applies directly to Sauvages ; and quite as much so to Cullen, who, in his at- tempt to simplify, has carried the confusion even further than Sauvages. Few diseases, perhaps, of the uterus or uterine passage, can be more distinct from each other than vicarious menstru- ation, lochial discharge, and sanious ichor ; yet * The idea that the menstrual fluid is a secre- tion, is strongly supported by a remark of Spren- gel. He says, " arterias equidem certo capillares e villis fundere sanguinem persuadeor, cum a Kaauw Boerhaavii inde temporibus saepius mani- festa visa fuerit ea origo. Quae arteriae licet et in hoc viscere continuo in venulas transeant, patuli tamen sunt earum fines in viUis massa laxissima cellulosa clausis, e quibus sine laceratione ob im- petum majorem, sanguis expeditius efnaere po- test."—Institut., vol. iii.—D. Gen. I.—Spe. 1.] PARAMENIA OBSTRUCTIONS. 431 all these, with several others equally unallied, are arranged by Sauvages under the genus me- norrhagia, though not one of them belongs to it. While Cullen not only copies nearly the whole of these maladies with the names Sauvages has assigned them, but adds to the generic list leu- corrhoea or whites, abortion, and the mucous fluid, secreted in the beginning of labour from the glandulae Nabothi at the orifice of the womb, and hence vulgarly denominated show or appearance. Menstruation may be diseased from obstruc- tion, severe pain in its secretion, excess of dis- charge, transfer to some other organ, or cessa- tion ; thus offering us the five following species, accompanied with distinct symptoms :— Obstructed Menstruation. 1. Paramenia Ob- structions. 2. —------Diffi- cilis. 3.---------Su- perflua. 4.---------Erro- Laborious Menstruation. Excessive Menstruation. Vicarious Menstruation. --------Ces- Irregular Cessation of the sationis. , Menses. SPECIES I. PARAMENIA OBSTRUCTIONS. OBSTRUCTED MENSTRUATION* CATAMENIAL SECRETION OBSTRUCTED IN ITS COURSE; SENSE OF OPPRESSION; LANGUOR; DYSPEPSY. This species, by many writers called raenos- tatio, appears under the two following va- rieties :— a Emansio. The secretion obstructed on its Retention of accession, or first appearance. the men- The feet and ankles oedematous ses. at night; the eyes and face in the morning. 8 Suppressio. The secretion obstructed in its Suppression regular periods of recurrence. of the men- Headache, dyspnoea, palpitation ses. of the heart. In order to explain the first of these varie- * The amenorrhoea of other medical writers, a term appUed to every example of obstructed men- struation except that resulting from pregnancy. Here, however, it is manifest that a variety of af- fections and many states of the female constitu- tion are disadvantageously confounded together. The non-appearance of the menses in a girl seem- ingly arrived at puberty, is not at all analogous to the natural cessation of them in a woman that has reached the critical period of life; and both these forms of amenorrhoea are essentially different from what originates from some chronic inflammation or an organic disease. Again, the latter is not similar in any respect to the stoppage of the men- ses brought on by impairment of the general health or inertia of the uterus; while the last mentioned instance is entirely of a different nature from that in which the courses are suddenly suppressed by some accidental cause.—See L. C. Roche, in Diet, de Med. et de Chir. Pratiques, torn, ii., p. 135—Ed. TIES, Or RETENTION OF THE MENSES, by PrO- fessor Frank quaintly denominated amenorrhoea (De Cur. Horn. Morb. Epit., torn, vi., lib. vi., part iii., 8vo., Vienna, 1821) tiruncularum, it is necessary to observe that when the growth of the animal frame is completed or nearly so, the quantity of blood and sensorial power which have hitherto been employed in providing for such growth, constitutes an excess, and must produce plethora by being diffused generally, or congestion by being accumulated locally. Pro- fessor Monro contended for the former effect; Dr. Cullen, with apparently more reason, for the latter. And this last turn it seems to take for the wisest of purposes ; I mean, in order to pre- pare for a future race, by perfecting that system of organs which is immediately concerned in the process of generation; and which, during the general growth of the body, has remained dor- mant and inert, to be developed and perfected alone when every other part of the frame has made a considerable advance towards maturity, and there is, so to speak, more leisure and ma- terials for so important a work. We shall have occasion to touch upon this subject more at large when we come to treat of the genus chlorosis : for the present it will be sufficient to observe, that this accumulation of the nervous energy and sanguineous fluid seems first to show itself among men in the testes, and among women in the ovaria; and that from the ovaria it spreads to all those organs that are connected with them either by sympathy or unity of intention, chiefly to the uterus and the mammae; exciting in the uterus a new action and secretion, which secre- tion, in order to relieve the organ from the con- gestion it is hereby undergoing, is thrown off periodically and by lunar intervals in the form of a blood-like discharge, although, when mi- nutely examined, the discharge, as already stated, is found to consist not of genuine blood, but of a fluid possessing peculiar properties. These properties we have already enlarged upon, and have shown in what they differ from those of proper blood: and it is upon this point that the physiology of Dr. Cullen is strikingly erroneous, for not only in his First Lines, but long after- ward in his Materia Medica, he regards the dis- charge as pure blood, and consequently, the economy of menstruation as a periodical hemor- rhage. " I suppose," says he, " that in conse- quence of the gradual evolution of the system at a certain period of life, the vessels of the uterus are dilated and filled ; and that by this conges- tion these vessels are stimulated to a stronger action, by which their extremities are forced open and pour out blood. According to this idea, it will appear that I suppose the menstrual dis- charge to be upon the footing of an active hem- orrhagy, which, by the laws of economy, is dis- posed to return after a certain interval."* * Mat. Med., vol. ii., p. 587, 4to. In refutation of the notion that menstruation depends on a gen- eral plethoric orgasm, Dr. A. T. Thomson, in the second volume of his Elements of Materia Medi- ca, quotes the case of the Hungarian sisters, who were united at the lower part of the back, and hvpd to the age of twenty-two. The same blood 432 GENETICA. [Cl. V.—Ord. I. From the sympathy prevailing between the uterus and most other organs of the system, we meet not unfrequently with some concomitant affection in various remote parts ; as an appear- ance of spots on the hands or forehead antece- dently to the efflux (Salmulh, cent, iii., obs. 18); or, which is more common, a peculiar sensation or emotion in the breasts.—-{Act. Nat. Cur., vol. iii., App., p. 168.) We cannot explain the reason why this fluid should be thrown off once a month, or by lunar periods, rather than after intervals of any other duration.* But the same remark might have been made, if the periods had been of any other kind; and will equally apply to the recurrence of intermittent fevers. It is enough that we trace in this action the marks of design and reg- ularity. The time in which the secretion, and conse- quently the discharge, commences, varies from many circumstances; chiefly, however, from those of climate, and of peculiarity of constitu- tion. In warm climates, menstruation appears often as early as at eight or nine years of age ; for here the general growth of the body advan- ces more rapidly than in colder quarters, and the flowed in the vessels of each, for the abdominal vessels were found after death united at the loins; yet the uterine function was distinct in each of these individuals, differing in its period, and also in the quantity of the discharge. The menses do not coagulate like blood, nor do they, according to modern statements, contain fibrin; though this account does not agree with Mr. Brande's obser- vation, that they possess the " properties of a very concentrated solution ot blood in diluted serum." M. Lecanu found, that blood drawn from the arm of* a woman during the menstrual discharge, con- tains Uttle more than half of the quantity of glob- ules present in it at other periods.—Ed. * The intervals being exactly those of the course of the moon in the revolution of her orbit, they were supposed to be influenced by this planet; but were this the case, the menses ought to corre- spond with one of the phases of the moon's course, which is not the fact. See Dr. A T. Thomson's Elem. of Materia Med., vol. ii., p. 439. The fol- lowing are the ages at which, according to the researches of Mr. Roberton, of Manchester, 450 women began to menstruate in this climate :— In their 11th year 10 In their 16th year 76 12th year 19 17th year 57 13th year 53 18th year 26 14th year 85 19th year 23 15th year 97 20th year 4 One corollary drawn by Mr. Roberton from this table is, that the natural period of puberty in women of this country, instead of being the four- teenth or fifteenth year, occurs in a much more ex- tended range of ages, and is much more equally distributed throughout that range than authors rep- resent. In Mr. Roberton's paper, evidence has been col- lected to prove, in opposition to usual belief, that the age of female puberty in the arctic regions is at least as early as in the temperate zone. In the same document, the reader will also find a state- ment of various circumstances, which appear to Mr. Roberton to have led travellers to form errone- ous conclusions concerning the period of puberty in warm climates.—See Edin. Med. and Surg. Jour- nal for October, 1832, p. 246. atmosphere is more stimulant. In temperate climates it is usually postponed till the thir- teenth or fourteenth year, and in the arctic re- gions till the nineteenth or twentieth.* In all climates, however, when the constitu- tion has acquired the age in which it is pre- pared for the discharge, various causes may ac- celerate its appearance. Among these we may mention any preternatural degree of heat or fe- ver, or any other stimulus that quickens the cir- culation. Mauriceau relates a case in which it was brought on suddenly by an attack of a ter- tian intermittent: and in like manner, anger, or any other violent emotion of the mind, has been found to produce it as abruptly. The depres- sing passions, as fear and severe grief, conduce to the same end, though in a different way ; for here there is rather uterine congestion than in- creased impetus, in consequence of the spastic chill of the small vessels on the surface, which lessens their diameter. Inordinate exercise, or a high temperature of the atmosphere, has in like manner a tendency to hurry on the men- strual tide ; and hence its appearing so early in tropical regions. Dr. Gulbrand, indeed, con- ceives that even an increase in the elasticity or weight of the atmosphere is sufficient to pro- duce a like effect, and refers to a curious fact in proof of this. In an hospital to which he was one of the physicians, a very considerable num- ber of the female patients were suddenly seized with catamenia : which was the more remarka- ble, because several of these had, for a consid- erable time, laboured under a suppression of that discharge, and had been taking emmena- gogues to no purpose; while others had only been free from their regular returns for a few days. On inquiring into the cause, the only one which could be ascertained was a very great augmentation in the weight or pressure of the atmosphere, the mercury in the barometer having attained a height at which it had never been previously observed at Copenhagen, though he does not state the point it had actually reached.—(De Sanguifluxu Uterino,8vo., Hafn.) * In Lapland, according to Linnaeus, women will often menstruate only during the summer months. The difference in the time of life when the menses appear has been mentioned as the rea- son why women in hot climates are almost uni- versally treated as slaves, and why their influence is so powerful in cold countries, where personal beauty is in less estimation. This is an opinion professed by Hume and Montesquieu (Spvrit of the Laws, E. T., b. 16), and is referred to by Dr. Denman :—" In hot climates, women are in the prime of their beauty when they are children in understanding: and when this is matured they are no longer objects of love. In temperate climates, their passions and their minds acquire perfection at, or nearly at the same time: and the united power of their beauty and faculties is supposed to be irresistible."—(Introd. to the Prac. of Mid- wifery, p. 82.) But, as Dr. Locock well observes, the influence of civiUzation seems to have been entirely overlooked in this theory; as otherwise the most chivalrous devotion to the fair sex would be found in the savage inhabitants of the countries of perpetual snow.—See Cycl. of Practical Mad., art. Menstruation.—Ed. Gen. I.—Spe. 1.] PARAMENIA 0 "* It is possible that other general causes may sometimes operate to a like extent; and hence this disease is said by Stoll, and other writers, to be occasionally epidemic,—(Rat. Med., P. iii., p. 48 ; Samml. Med. Wahrnehm., b. ix.,p. 401.) Still much depends upon the idiosyncrasy: some girls are of a more rapid growth than oth- ers of the same climate ; and in some, there is a peculiar sexual precocity, or prematurity of orgasm, that hurries on the discharge before the general growth of the body would lead us to ex- pect it: of which Pecklin gives an example in a girl of seven years of age, who, in the intervals, laboured under a leucorrhoea.* And hence those very early and marvellous stories of preg- nancy in girls of not more than nine years old, which, if not well authenticated, and from dif- ferent and unconnected quarters, might justify a very high degree of skepticism, t The efflux continues from two to eight or ten days ; and the quantity thrown forth varies from four to ten ounces in different individuals : the monthly return running on till the fortieth or fiftieth year, and sometimes, as we shall have occasion to observe hereafter, to a much later period of life. J * Lib. i., obs. 24. In the Med. Chir. Trans., Dr. Wall has published the particulars of a chffd, aged nine years, who had regularly menstruated from the age of nine months, and at two years of age had all the indications of puberty.—Ed. t Haller (Gottl. Eman.), Blumenbach, bibl i., p. 558. Schmid, Act. Helvet., iv., p. 167. Eph. Nat. Cur., dec. iii., an. n., obs. 172. The following case happened in the practice of Mr. Robert Thorpe, and is recorded by Mr. Roberton of Man- chester :—" A girl who worked in a cotton factory became pregnant, as was represented, in her elev. enth year. When in labour she was seized with convulsions, but ultimately, without unusual diffi- culty, was deUvered of a full-grown stiUborn child. Her recovery was perfectly favourable." Mr. Thorpe and the late Dr. Hardie examined the registers of this girl's birth and christening, and fully satisfied themselves that she had really con- ceived in her eleventh year, and that at the time of her delivery she was only a few months ad- vanced in her twelfth year. Mr. Thorpe likewise ascertained that she had menstruated before she was pregnant.—See an Inq. into the Natural Hist. of the Menstrual Functions, by John Roberton, Edin. Med. and Surg. Journal for Oct., 1832, p. 231.—Ed. X In this climate the function of menstruation lasts, upon the average, for about thirty years of the life of woman, beginning at puberty, and end- ing somewhere between forty and fifty years of age, unless interrupted by disease, by pregnancy, or by suckling.—(See Pract. Comp., by Dr. Gooch, p. ii.) It is a popular idea, as Dr. Ramsbotham ob- serves, that some women menstruate during the whole period of utero-gestation : even good physiolo- gists and physicians of discernment have adopted the same erroneous opinion. But such a circum- stance, he remarks, is perfectly impossible; for, upon impregnation taking place, the uterus be- comes lined with a membrane, secreted from its internal surface, which completely closes the ori- fices of the vessels from which the menses flow. It is certainly true, that some pregnant women are subject to occasional attacks of hemorrhage, both from the uterus and vagina, which may last three or four days. This blood has been taken for the Vol. II—E e STRUCTIONS. 433 It is not always, however, that a retention of the menses to a much later date than sixteen, or even twenty years of age, constitutes disease : for sometimes it never takes place at all, as where the ovaries are absent, or perhaps imper- fect ;* or where, instead of precocity in the menstruous fluid; but it is unlike the menses, in- asmuch as it does not return at regular intervals. Although it is impossible for this secretion to con- tinue throughout the whole of pregnancy, the same remark does not hold good with regard to the few early weeks. Dewees is persuaded that women may menstruate till the end of the fourth month, and he supposes that the secretion, in such case, proceeds from the cervix uteri, which before that time is not developed; and Dr. BlundeU says he has repeatedly met with cases in which the catamenia flowed for the first two or three months. Dr. Ramsbotham has a patient who always men- struates once after having conceived, though very sparingly.—(See Med. Gaz. for 1833-34, p. 268, Ramsbotham's Lectures.) When women deviate from the natural law, and menstruate during lac- tation, the milk is observed to be neither suffi- ciently nutritious nor copious.—(lb.) During the large proportion of female life aUotted for men- struation, there is a great Uability to derange- ments of this process in one form or another; and, as Dr. Locock remarks, the time, of the first ap- pearance of the catamenia, and that of their final cessation, are deemed critical periods, when pru- dence requires the system to be taken great care of. The actual flow of the menstrual discharge itself is also looked upon as a tune of great delica- cy, and as demanding pecuUar attention; so that very few diseases can exist, and very few plans of treatment be recommended, without the presence of the menses in some way influencing the nature of the symptoms or the remedies to be applied. It is in this especiaUy that the character of the female constitution in disease is manifested; for, before pu- berty, and after the cessation of menstruation, the female differs but Uttle from the male in the charac- ter of disease, except in those points which may be considered as accidental, such as organic dis- eases of the sexual organs.—(See Dr. Locock on the Pathology of Menstruation, in Cyclop, of Pract. Med., part 14.) Dr. Gooch states that menstruation recurs every month with almost me- chanical regularity. But though it is unquestion- ably true, that in a considerable majority of instan- ces, the catamenia recur monthly,—i. e.. from the cessation of the secretion at one period, to its re- appearance at the next, there elapses an interval of twenty-eight days,—yet " there is a certain pro- portion of women in whom the interval is not four, but three weeks; another smaller proportion, in whom the interval (apparently in no degree ow- ing to disease) is irregular, being in the same wo- man at one time three, at another time four, or six, or eight, or even twelve weeks; and in another, but smaller proportion, in whom the catamenia return regularly every fortnight." In all these varieties, the secretion generally continues to flow from about two to six days : in some three or four days longer.—See Roberton's Obs. in Edin. Med. and Surg. Journ., No. cxiii. for Oct., 1832, p. 252. —Ed. * Sometimes the general health and strength continue unimpaired, the growth of the body pro- ceeds rightly, and the circulation is active; but the mammae are not protuberant; there are no sexual propensities; a slight beard grows on the upper lip; and the general characteristics resem- ble thsoe of a male. In such a case, the proba- 434 GENETIC A. [Cl. V—Ord. I. genital system, there is a constitutional tardi- ness and want of stimulus ; under which cir- cumstances it appeared for the first time, accord- ing to Holdefreund, in one instance, at the age of seventy (Erzdklungen, No. iv.): and in an- other, that fell under the care of Professor Frank, it never appeared, either in the condition of sin- gle or married life, nor had the patient at any time any lochial discharge, though she had pro- duced three healthy children.—(De Cur. Horn. Morb. Epit., torn, vi., lib. vi., part iii., 8vo., Vienna, 1821.) It is only, therefore, when symptoms take place indicating a disordered state of some part or other of the body, and which experience teaches us is apt to arise upon a retention of the menstrual flux, that we can regard such retention as a disease. These symptoms, as already stated in the definition of the disorder, consist chiefly in a general sense of oppression, languor, and dyspep- sy. The languor extends over the whole sys- tem, and affects the mind as well as the body : and hence, while the appetite is feeble and ca- pricious, and shows a desire for the most unac- countable and innutrient substances, the mind is capricious and variable, often pleased with trifles, and incapable of fixing on any serious pursuit. The heat of the system is diffused ir- regularly, and is almost always below the point of health: there is, consequently, great general inactivity, and particularly in the small vessels and extreme parts of the body. The pulse is quick, but low, the breathing attended with la- bour, the sleep disturbed, the face pale, the feet cold, the nostrils dry, the intestines irregularly confined, and the urine colourless. In some in- stances there is an occasional discharge of blood, or a blood-like fluid, from a remote organ, as the eyes, the nose, the ears, the nipples, the lungs, the stomach, or even the tips of the fingers, giving examples of the fourth species. There is also, sometimes, an irritable and distressing cough; and the patient is thought to be on the verge of a decline, or perhaps to be running rapidly through its stages. A decline, however, does not follow, nor is the disease found fatal, although it should con- tinue, as it has done, not unfrequently, for many years: for if the proper discharge do not take I place, the constitution will often in some degree ! accommodate itself to the morbid circumstan- ces that press upon it, and many of the symp- toms will become slighter, or altogether dis- appear. Most commonly, however, when the patient is supposed to be at the worst, probably from the increased irritation of the system pe- culiarly directed to the defaulting organs, a little mucous or serous discharge, with a slight show bilities are, that the ovaries are either absent, or have become so diseased that their functions are entirely lost. A striking instance is related by Mr. Pott, where a precisely similar state was artificially induced by the removal of the ovaries in a young woman; although, previously to the operation, menstruation, and all the signs of puberty, had regularly existed.—(See Locock, m Cyclop, of Pract. Med., art. Menstruation.) —Ed. of colour, is the harbinger of a beneficial change, and is soon succeeded by the proper discharge itself: though it often happens that the efflux is at first not very regular, either as to time or quantity. But this is an evil which generally wears away by degrees. All the symptoms indicate that retained men- struation is a disease of debility, and there can be little doubt that debility is its primary cause :* a want of energy in the secernent vessels of the uterus, that prevents them from fulfilling their office, till the increase of irritability, from the increase of general weakness, at length pro- duces a sufficient degree of stimulus, and thus momentarily supplies the place of strength. The system at large suffers evidently from sym- pathy, t * There are many cases of retained menstrua- tion, which indicate conclusively that the non-ap- pearance of the menstrual fluid may depend on an entonic state of the system. In such instances, an- tiphlogistics, and the free use of the lancet, are among the most serviceable emmenagogues.—D. t Two conditions of body, essentially different, may be connected with the form amenorrhoea, or paramenia, as Dr. Good terms it, now under con- sideration. In one, puberty is delayed, whether from idiosyncrasy, from want of constitutional en- ergy, or from defective organization : in the other, puberty exists ; the ovaria and the uterus are or- ganically matured; but their peculiar function is suspended. Dr. Good might have entered further into the consideration of the causes of obstructed menstruation than he has done ; in particular, he might have noticed the frequent difficulty of im- mediately deciding whether the stoppage of the menses is an original or secondary affection—a cause or an effect—the whole disorder, or merely a symptom. Residence in low, gloomy, damp, marshy places; food of unwholesome quality, and containing but little nutritious principles in it; too low a diet; want of exercise ; labour beyond the strength, and protracted to too late an hour; are so many circumstances, whose prejudicial influ- ence on female youth will prevent their prope* growth, keep them from attaining their strength, and hinder them, though they have exceeded the age of puberty, from possessing the attributes of this enviable stage of life. In women, also, who have already menstruated, similar influences will bring on, first, a diminution of the discharge; then a retardation of its return by two or three days; next, still longer intervals; and at length, complete amenorrhoea. Anaemia, or a deficiency of blood in the system, is another occasional cause of this form of paramenia. Celibacy is likewise generally regarded as giving a tendency to the disorder. Certain it is, that, with many women, sexual in- tercourse promotes menstruation; and, as M. Roche observes (Diet. Med. et de Chir. Pratiques, torn, ii., p. 137), what practitioner has not remark- ed, that numerous other females, whose courses were always difficult or obstructed before mar- riage, menstruated copiously and regularly after that change in their condition. But, according to this author, none of the preceding causes of amen- orrhoea are so powerful as the existence of any serious chronic disease, whatever may be its na- ture, whether chronic gastritis, or chronic pneu- monia, or pleurisy; and so frequent does this spe- cies of cause seem to him, that he pronounces amenorrhoea in most instances tobe a symptom and not a disease. At all events, the observation de- serves to be weU remembered in practice, by G«Nv I.—Spe. 2.] PARAMENIA DIFFICILIS. 43d Yet menostation may take place from a sup* pression of the menses after they have be- come habitual, as well as from their retention in early life, which constitutes the second va- riety of the disease. The causes of this form are for the most part those of the preceding, and consist in a torpi- tude of the extreme or secernent vessels of the uterus, produced by anxiety of mind, cold, or suddenly suppressed perspiration ; falls, espe- cially when accompanied with terror, or a gen- eral inertness and flaccidity of the system, and more particularly of the ovaria. Hence the dis- ease may exist equally in a robust and plethoric habit, and in the midst of want and misery. In the last case, however, it is usually a result of weakness alone ; and on this account, it is sometimes found as a sequel of protracted fe- vers. As this modification of the disease occurs after a habit has been established in the constitution, its symptoms differ in some de- gree from those we have just contemplated. And, as it occurs also both in a state of entony and atony, the symptoms must like- wise differ, according to the state of the con- stitution at the time. If, however, the frame be at the time peculiarly weak and delicate, the signs will not essentially vary from those of the first variety, only that there will be a greater tendency to headache and palpitation of the heart. If the habit be plethoric, and more particu- larly, if the cause of suppression take place just at the period of menstruation, or during its ef- flux, a feverish heat and aridity of the skin usu- ally make their appearance, the face is flushed, and the eyes red, the head is oppressed, and often aches, with distressing pains down the back, occasionally relieved by a hemorrhage from the nose. As the principle which should guide us in the mode of treating both these varieties will also extend to the ensuing species, it will be most convenient to defer the consideration of it till that species has passed in review before us. We shall then be able to see how far a common pro- cess may apply, and to contrast the few points in which it will be necessary to institute a dif- ference. All these, indeed, have by many writers, and especially by Dr. Cullen, been included under the term amenorrhoea, which Professor Frank has lately employed in a still wider sense, so as to embrace, not only those three distinct forms of impeded menstruation, but chlorosis as well.—(De Cur. Horn. Morb. Epit., torn, vi., lib. vi., part iii., 8vo., Vienna, 1821.) which means we shall avoid directing all our rem- edies merely to an effect, and leave the cause it- self unremoved. The action of the foregoing causes of amenorrhoea is always gradual; but that of some others is very rapid, provided the period of menstruation is at hand, or the discharge is actual- ly going on. Such is the impression of cold, wheth- er from wet feet, cold bathing, cold drinks, or ex- posure to cold winds, while the individual is in a state of perspiration.—Ed. Ee2 SPECIES II. PARAMENIA DIFFICILIS.* LABORIOUS MENSTRUATION. CATAMENIA ACCOMPANIED WITH GREAT LOCAL PAIN, AND ESPECIALLY IN THE LOINS ; PART OF THE FLUID COAGULABLE. In the preceding species, the regular efflux is altogether prevented, as we have already ob- served, by a torpitude of the secerning vessels of the uterus, perhaps of the ovaries also. In the species before us there is no actual suppression, but the quantity thrown forth is for the most part too small, and attended with severe and forcing pains about the hips and region of the loins, that clearly indicate a spasmodic constric- tion of the extreme vessels of the uterus. The secretion is hence extruded with great difficul- ty, and is sometimes perhaps of a morbid char- acter : while, from the force of the action, the mouths of some of the vessels give way, and a small portion of genuine blood becomes in- termixed with the menstrual discharge, forming coagula in the midst of an uncoagulating fluid, and thus drawing a critical line of distinction between the two. The spastic action, thus commencing in the minute vessels of the uterus, not only spreads externally to the lumbar muscles, but internally to the adjoining organs of the rectum or blad- der, in many instances, indeed, to the kidneys : and hence an obstinate costiveness and suppres- sion of urine are added to the other symptoms, and increase the periodical misery ; the frequent return of which imbitters the life of the patient, and effectually prohibits all hopes of a family ; for, if impregnation should take place in the in- terval, the expulsory force of the pains is sure to detach the embryon from its hold, and to de- stroy the endearing promise which it offers.t These pains generally recur at the regular pe- riod, but often anticipate it by a day or two, and rarely cease till a week afterward. The dis- ease, moreover, is peculiarly obstinate, and, in some instances, has defied the best exertions of medical science, and has only yielded to time, and the natural cessation of the discharge. We have frequently had occasion to observe, * The Dysmenorrhcea of medical writers in gen- eral. t Denman and Dewees were of opinion that a female thus affected could not have children ; but the contrary is maintained by Morgagni, Ham- ilton, and Burns. Dr. Ryan has known pain at- tend menstruation for months after marriage, yet conception took place. He mentions two cases: in these no portions of membrane were dischar- ged.—(See Manual of Midwifery, p. 329; and Lond. Med. and Surg. Journ., vol. v., 1830.) On this subject Dr. Locock observes, the error has arisen from the facts, that the individuals are par- ticularly liable to abortions at a very early age, which abortions have been supposed to be merely unusually aggravated attacks of the complaint. Nor is the common belief well founded, that preg- nancy is a cure for a previously existing dysme- norrhoea, unless by great care and management the first two or three months are safely passed over. —See Cyclop, of Pract. Med., art. Dysmenor- rhcea.—Ed. 436 GENETICA. [Cl. V—Ord. t. ■ ous menstruation. And sometimes the protru- ■ sive agony has been so severe as to occasion a displacement or retroversion of the uterus, which has been found forced down, enlarged, with the fundus thrown backward, and the indurated mouth facing the lower edge of the symphysis pubis.—(Dr. J. Robertson, Edin. Med. and Surg. Journ., No. lxxiii.) Cold, mental emotion, local injury from a fall, and, above all, a peculiar irritability of the ute- rus itself, are the common causes. The cure of all the forms of paramenia we have thus far noticed is to be attempted, first, by increasing the tone of the system in general, and next, by exciting the action of the uterine vessels, where they are morbidly torpid, or re- laxing them where they are in pain from spas- modic constriction. Both the last, however, are subordinate to the first; for, if we can once get the system into a state of good general health, the balance of action will be restored, and the organs peculiarly affected will soon fall into the common train of healthful order. To give strength and activity to the circula- tion is generally attempted by tonics : to give local action, by stimulants. Both these should be employed conjointly in the two forms of the first species. The astringent tonics, however, are supposed, and apparently with good reason, to be injurious, and in many instances to extend the retardation, or diminish the flow where there is any appearance. Myrrh has long been a fa- vourite medicine; but its power does not ap- pear to be very considerable in mismenstruation, though it undoubtedly acts as a stimulant in phthisis, and has at times, in highly irritable habits, produced haemoptysis. The metallic ton- ics are those on which we can chiefly depend ; and of these, the principal that have been em- ployed are iron and copper. The first requires less care than the second, and has hence been more frequently recurred to, as the safer. It has been given under a great variety of forms; but that of the sulphate, or green vitriol, is one of the best and most readily obtained.* It is often tried in union with myrrh ; and where symptoms of dyspepsy exist, and espe- cially acidity in the stomach, the two have been united with carbonate of soda, a combination which makes the celebrated draught, so weH. known by the name of its inventor, Dr. Grif- fiths. Iron is, by some writers, supposed to show an astringent, and by others an aperient power. In different constitutions it may be said to oper- ate both ways. "If, for example," says Dr. Cullen, " a retention of menses depends upon a weakness of the vessels of the uterus, chalyb- eate medicines, by invigorating the force of the vessels, may cure the disease, and thereby ap- pear to be aperient: and on the contrary, in a and especially under croup and tubular diar rhoea, that where hollow and mucous organs la- bour under a certain degree of irritation, a por- tion of gluten is often thrown forth with the mor- bid secretion that takes place on the surface, and the result is a formation of a new membrane 01 membrane-like substance that lines the cavity to a greater or less extent: the nature of this substance being regulated by the nature of the Orjan in which it takes place. This remark ap- plies particularly to the uterus under the influ- ence of the irritation we are now speaking of; and consequently, a membrane very much re- sembling the decidua, or that naturally elabora- ted by the uterus on impregnation, has been oc- casionally formed, and discharged in fragments,* during the violence and forcing pain of labori- * Morgagni, De Sed. et Caus. Morb., ep. xlviii., 12. Denman, Medical Facts and Obser- vations, i., 12. The expulsion of a membranous substance was observed in dysmenorrhoea by Mor- gagni, who described it as generally consisting of a small bag, containing a fluid, on which account it was usually mistaken at that time for a very early abortion. Afterward the occurrence was more particularly investigated by Dr. Denman, who satisfactorily established the fact, that the membrane was expelled at least as frequently from single as from married women, and that it had the appearance of a triangular cast of the cavity of the uterus, and a resemblance to the membrana decidua. It would seem, according to Dr. Locock, that where a bag containing a fluid was really dis- covered, it must have been an ovum, at an early period of conception, particularly as such women are very liable to miscarry. Dr. Denman supposed that this membrane, though often not noticed, was expelled in every case of dysmenorrhoea. That he was wrong in this conjecture, as Dr. Locock remarks, is now well known; for, though occa- sionally met with, it is by no means common ; and what frequently resembles it at first sight, con- sists merely of a coagula of blood, with the col- ouring matter separated from it. From the sup- position that the membrane is always expelled, and that it consists of coagulable lymph, exuded from the lining of the uterus in consequence of inflam- matory action, has arisen, says Dr. Locock, a most mistaken and pernicious treatment, when universal- ly applied.—(See Cyclop, of Practical Medicine, art. Dysmenorrhea.) Dr. Mackintosh considers smallness of the os uteri the most frequent cause of the disease, but he includes also inflammation of the lining membrane of the uterus, or inflam- mation of the substance of the cervix, and the pres- sure of tumours, as occasional sources of the com- plaint. In every museum are specimens of the os uteri being so narrow as to be scarcely capable of admitting a bristle.—(See Ryan's Manual of Midwifery, 3d edit., p. 330.) Dr. Locock believes, that, in the majority of cases, there is not inflam- mation, but simply irritation of the uterus, the former sometimes taking place, particularly in ple- thoric and robust constitutions. The women most liable to this complaint seem to him to be those ossessing great susceptibility, who are subject to ysterical affections, and who have strong pas- sions and ardent temperaments. Dysmenorrhoea will often occur only at those periods of life when there is great constitutional disturbance, or much mental excitement, as in the early years of men- struation, or shortly after marriage.—See Cyclop. of Pract Med., art. Dysmenorrhoea.—Ed. * At present, the subcarbonate of iron is fre- quently preferred, in doses of one or two drachms, thrice a day. The ferrum tartarizatum is also a good preparation. Steel medicines answer well, when the disease is connected with a deficiency of blood in the system, or the state termed anaBmia. —Ed. Gen. I.—Spe. 2.] PARAMENIA DIFFICILIS. 437 menorrhagia, when the disease depends upon a laxity of the extreme vessels of the uterus, iron exhibited, by restoring the tone of these ves- sels, may show an astringent operation."—(Mat. Med., vol. ii., p. 22, 4to.) The preparations of copper labour under two disadvantages : they are essentially more astrin- gent than many of the other metals, and at the same time more uncertain in their effect. They are perhaps more soluble in the stomach than any other metallic preparations, wherever there is a sufficient proportion of acid for this pur- pose : but, as the quantity of acid in this organ is constantly varying, their effect must Vary also. Dr. Fordyce advises to avoid cupreous prepara- tions when the intention is to strengthen ; but, when we attempt to lessen irritability, he ob- serves that they are extremely useful; and hence their advantage in epilepsy and plethoric hysteria. It is, however, a just remark of Dr. Saunders, that all solutions of metals are seda- tive and ease pain, or in other words, take off irritability, provided the solution be not too strong. The old tinctura veneris volatilis, con- sisting of one drachm of filings of copper, infused in twelve drachms of water of ammonia, is one of the simplest and best preparations of this metal, and forms a good substitute for the cu- prum ammoniacum, or c. ammoniatum of the Edinburgh and London Pharmacopoeias. Boer- haave directs us to begin with three drops as a dose, and gradually to increase it to twenty-four. The chalybeate mineral waters have also been used with considerable success, and the more so as with these are usually conjoined the advan- tages of travelling, change of air, and a new stimulus given to both the mind and body by nov- elty of scene, novelty of company, amusing and animating conversation, and exercise of various kinds. With these may also be combined, in the intervals of» the menstrual season, and par- ticularly before the discharge has appeared, the use of cold, and especially of sea bathing. An unnecessary apprehension of catching cold by the employment of this powerful tonic has been entertained by many practitioners : with proper care, I have never known it occasion this effect; and it should be only relinquished where no re- active glow succeeds to the chill produced by immersion, and the system is hereby proved to be too debilitated for its use. The stimulants to be employed under the first species, in conjunction with a tonic plan, are those that operate generally and locally. The general stimulants should consist of those that do not exhaust the excitability or nervous power of the frame, but rather, by the moderation of their effect, and the constancy of their applica- tion, support and augment it. Exercise, which we have already recommended, will in this view also be of essential service, as will likewise be uniform warmth ; and hence the warmth of a mild climate, and a generous diet, with a tem- perate use of wine. Hence also the benefit of friction and electricity applied directly to the hypogastric and lumbar regions.* * Alberti Diss, de Vi Electrics, in Amenorrhoe- As the depressing passions produce the dis- ease, the elevating passions have been often known to operate the best and speediest cure. It has sometimes suddenly yielded to a fit of joy (Medicin Wochenblatt, 1782, p. 416), and in one instance, from the violence of" the emotion, to a fit of terror.—(Walther, Thes., obs. 37.) We can hence easily see how it may be induced by disappointed love, and removed by a return of hope, and a prospect of approaching happiness. —(Eph. Nat. Cur., dec. i., an. ix., x., obs. 58.) The stimulants, operating locally in this dis- ease, are known by the name of emmenagogues.* In the old writers the catalogue of these is very numerous. Those most worthy of notice con- sist of the warmer gums and balsams, as guaia- cum, asafoetida, turpentine, and petroleum; castor, and the more irritating cathartics, as aloes, and black hellebore. The last is, in most cases, too stimulant upon the whole range of the intestinal canal, though at one time in high fa- vour as an emmenagogue. Aloes is a particu- larly valuable medicine. Dr. Adair gave it in combination with cantharides ; but in this form it will often be found to produce a troublesome irritation of the rectum or bladder, rather than a salutary stimulus of the uterine vessels. The juniperus sabina, or common savin, is am, seu Catameniorum obstructionem, Goet„ 1764. Birch, Considerations of the Efficacy of Electricity in Female Obstructions, &,c, London, 1799. * Professor A.T. Thomson doubts whether there is any medicinal agent which, when taken into the stomach, exerts a directly stimulant influence on the uterus ; though he appears to except savin from this observation, as will be seen in a subse- quent note ; " but a stimulant effect maybe prop- agated from neighbouring parts to the uterine vessels ; hence, some cathartics, which operate chiefly upon the rectum, are found to influence the uterus. When the obstruction of the menses is accompanied with a florid complexion, and the colour of the cheeks is the flush of disease, not the glow of health ; or when a slight cough, with pain in the chest and difficulty of breathing, accom- panies the suppression, bleeding and other anti- phlogistic means must be resorted to before taking into consideration the uterine function; and until the general excitement be subdued, the employ- ment of emmenagogues would be injurious. It is questionable whether, in these cases, any of those substances supposed to act directly upon the ute- rus should be employed. If they can be adminis- tered, they will be most likely to prove beneficial when given immediately after the reduction of febrile excitement. " The employment of emmenagogues is not con- fined to cases of simple obstruction or suppression. In some females, the pain with which menstrua- tion is accomplished imbitters much of life. This either indicates a peculiar state of the organ itself, or it is the effect of disease, or at least the ten- dency to it in the organ itself; not, as is some- times supposed, an increased degree of the irrita- bility of the general system. Some of the sub- stances employed as emmenagogues are supposed directly to lessen uterine irritation, and conse- quently to facihtate the discharge: they are thus closely alUed with sedatives and antispasmodics." —See Dr. A. T. Thomson's Elem. of Materia Med., vol. ii., p. 443.—Ed. 438 GENETICA. [Cl.V—Ord. I. also a valuable medicine, as being both stimulant and slightly aperient, and operating not only lo- cally, but upon the system at large. As the volatile oil, which is the active principle, is dis- sipated by boiling, the extract is a better prepar- ation. It may be given in powder, extract, or essential oil: of the powder, the dose varies from a scruple to a drachm twice or three times a day : of the extract, from half a scruple to half a drachm ; and of the essential oil, from two to four drops. Dr. Home thought highly of it, and Mr. Hetz has praised it in equal terms.— (Briefe, ii., p. 5.) The former declares that, by employing the scruple doses three times a day, he succeeded in three out of five cases.* But the most favourite emmenagogue in his hands was the root of the rubia tinctorum, or mad- der. Of nineteen cases of which he gives an account, fourteen, he tells us, were cured by it. From half a drachm to a drachm was prescribed twice or oftener daily. Dr. Home asserts, that in this quantity it produces scarcely any sensible operation, never quickens the pulse, nor lies heavy on the stomach ; yet that it generally restores the discharge before the twelfth day from the time of its commencement.—(Clinical Experiments, Histories, &.c, 8vo., 1780.) The present author has never tried it: he has been deterred by the very different and even contra- dictory accounts of its effects upon the consti- tution, which have been given by different writers of high authority. White Dr. Home found it thus beneficial in cases of obstructed menstrua- tion, Dr. Parr tells us that it produced a cure in excessive menstruation, but in the former dis- ease effected no change whatever.—(Med. Did., vol. ii., in verb., p. 524.) From its tinging the urine of a red colour, it has been supposed to be a powerful diuretic ; but even this quality it has been incapable of supporting; and yet, in the opinion of Dr. Cullen, this seems to be its only pretension to the character of an emmenagogue. —(Mat. Med., vol. ii., p. 553, 4to. edit., comp. with p. 38 of the same.) Given freely to brute animals, Dr. Cullen tells us that it always dis- orders them very considerably, and appears hurtful to the system. Its direct virtues do not, therefore, seem to have been in any degree as- certained : but let them be what they may, it * Dr. A T. Thomson considers savin, or rather the volatile oil of the plant, to be an energetic em- menagogue. From its activity and mode of ac- tion, and its proneness to produce uterine hemor- rhage, he admits that there is reason for thinking that it is taken into the circulation and carried di- rectly to the organ, on which it exerts a stimulant influence. " This," says the professor, " is not a recent opinion ; for previous to the introduction of the ergot of rye, savin was sometimes employed for the purposes of accelerating parturition and expelling the placenta." As it is apt to excite in- flammation of the uterus, he recommends a great deal of caution in its use, and it seems to him only to be adapted to those cases of amenorrhoea which are attended with a pale countenance, and languid circulation. The doses proposed by him are from five to ten grains of it in substance or from two to six minims of the oil, blended with sugar.—See Elem. of Materia Medica, vol. ii., p. 452.—Ed. has deservedly fallen into disrepute as a remedy for any misaffection of the uterus. The athamanta meum, or spignel, which once rivalled the reputation of madder, seems to have a peculiar influence in stimulating the lower vis- cera, and especially the uterus and bladder, and is no indifferent sudorific. On this last ac- count, it was at one time highly in favour also in intermittents, and was afterward employed in hysteria and humoral asthma. It is very probable that in cases of weak ac- tion, and especially when combined with a stru- mous diathesis, the pills or tincture of iodine, as we shall have occasion to notice them when treating of bronchocele, may be attended with beneficial effects. Dr. Coindet regards this med- icine, indeed, as one of the most powerful em- menagogues we possess ; and even accounts for its advantages in bronchocele from the sym- pathy which the uterus and the thyroid gland manifest for each other.—(Archives Genirales de Midecine, &c, in Rem.) This part of the subject must not be quitted without glancing at a medicine that has lately acquired great popularity in North America as an emmenagogue, and is said to have been em- ployed with unquestionable success. This is spurred rye (secale cornutum), or rye vitiated by being invested with the clavis or ergot, a para- sitic plant, which we have already had occasion to notice, as producing a powerful effect on the whole system, and especially on the nervous part of it, and the abdominal viscera in general. When taken in such a quantity as to be poison- ous, it first excites a sense of tingling or formi- cation, and fiery heat in the extremities, where the action of the system is weakest; to this suc- ceed cardialgia, and griping pains in the bowels ; and then vertigo, an alternation of clonic and entonic spasms in different parts of the body, and mania or loss of intellect. If the quantity be something smaller than this, it excites that pestilent fever which the French denominate mal des ardens, and in the present work is de- scribed under the name of pestis erythematica (Cl. III., Ord. III., Gen. IV, Spe. 1); while, in a quantity still smaller and long-continued, it seems to spend itself almost entirely on the ex- tremities, as being the weakest part of the body, and to produce that species of gangr^ena which is here denominated ustilaginea, or mil- dew mortification.—(Cl. III., Ord. IV., Gen XII., Spe. 2.) It is hence a very acrid irritant, and from its pe- culiar tendency to stimulate the hypogastric vis- cera, seems often, in minute quantities, to prove a powerful emmenagogue. For this purpose an ounce of spurred rye is boiled down, in a quart of water, to a pint; half of which is usually taken in the course of the day, both in obstructed and difficult menstruation, and continued for three or four days. The symptoms produced by it are headache, increased heat, and occa- sional pain in the hypogastrium, succeeded by a free and easy flow of the menstrual fluid. Ad- vantage has been taken of this effect on another occasion; for the same medicine has been pre- scribed in lingering labours, and we are told by Gen. I—Spe. 2.] PARAMENIA DIFFICILIS. 439 Dr. Bigelow, with the best success, as good forcing pains arc hereby very generally produced speedily.—(New-Eng. Journ. of Med. and Surg., vol. v., No. ii.) In this case Dr. Bigelow, instead of a decoction of spurred rye, prefers giving the crude powder, to the amount of ten grains to a dose. Dr. Chapman, indeed, regards this med- icine as chiefly if not solely useful in expediting labour-pains ; for, while he asserts that *„' to the uterus its whole force seems to be exclusively directed, and believes it to be highly beneficial in floodings and other uterine hemorrhages," he tells us, that in repeated trials he has found it of only slender power as an emmenagogue.* We have hitherto regarded the spur in spurred rye and other grain as a clavus, or species of us- tilago. It was formerly, however, conceived to be a disease of the grain itself. M. Decandolle has since described it as a variety of champig- non, under the name of sclerotium, from its ren- dering the grain hard and horny. And M. Vi- rey, in a work reported upon by M. Desfon- taines to the Academy of Sciences of the French Institute, in 1817, has still more lately endeav- oured to revive the obsolete opinion, by con- tending that it is a specific disease of the plant, under which the grain is rendered, not, properly speaking, hard and horny, as is actually the case when infested with the sclerotium, but rather friable, and easily detached. There is something highly plausible and inge- nious in the plan that was at one time tried rather extensively, of compressing the crural ar- teries by a tourniquet, and thus gorging the or- gans that lie above and are supplied from collat- eral branches. By compressing the jugular veins we can easily gorge the head, and endan- ger extravasation and apoplexy. But it appears upon trial, that the tide thus dammed up in the * Therapeutics, &c, vol. ii., p. 19, 8vo., Phila- delphia. In inquiring what pretensions the active principle of ergot has to the character of an emme- nagogue, Dr. A. T. Thomson observes, that " the chief use to which secale comutum has hith- erto been applied is to produce uterine action, to aid the efforts of parturition when these are insuf- ficient for the expulsion of the child. For this purpose it is administered in doses of from 9j. to jss, bruised and mixed in f |ij of water, at short intervals, untfl the effect is produced. Ample ex- perience has proved the efficacy of ergot to expel any substance from the uterus, when it is in a state of complete inactivity during the process of parturition. Now, admitting this to be true, these premises are not sufficient to justify the conclu- sion that it will also aid the menstrual discharge when scanty or suppressed." Dr. Thomson, after examining the theories of its modus operandi, ex- presses his own belief that it has very slender, if any pretensions to the character of an emmena- gogue. " The dose of the secale comutum," he says, " should not exceed thirty grains. The med- icine should be preserved entire in a glass bottle with a ground stopper, and powdered only at the time it is about to be given; and then it may be administered in a glass of wine, which Dr. Balar- dini has found to be preferable to water. Heat and moisture tend to spoil it. It should always be the growth of the year in which it is prescribed."— See Thomson's Elem. of Mat. Med., vol. ii., p. 470.—Ed. case before us is thrown back upon too many organs to produce any very sensible effect upon the uterus. Independently of which, the uterus is not, like the brain, exactly enclosed in a bony box that prohibits a general and equable dilatation of its vessels. In six cases in which Dr. Home made experiment of this remedy, he succeeded but once ; and others have been still less suc- cessful.—(Hamilton, Edin. Com., vol.Si., art. 31 ; Weiz ad Fabric, iv., 98.) Impeded menstruation is sometimes, however, a disease strictly local, and proceeds from the obstruction of the passage by a polypus or other tumour, or an imperforate hymen. In all these cases, the cure must depend upon a removal of the local cause. Emetics have sometimes been recommended ; they rouse the system generally, but have not of- ten been found useful in retention of the menses ; though when employed in cases of suppression, and especially at the regular periods of return, or so as to anticipate such return by a few days, they frequently prove a valuable adjunct. If this period be passed by without any salutary effect, and particularly if at the same time the system labour under symptoms of oppression in the head or chest, venesection to the extent of from four to six ounces of blood will be found a very useful palliative, and will have a tendency to keep up that periodical habit of depletion which will probably prove advantageous against the ensuing lunations. Venesection will also be found useful, and often absolutely necessary, where the suspension has suddenly taken place during the flow of the catamenia, from cold, de- pressing passions, fright, or indeed any other cause.* In treating the second species of paramenia, or difficult menstruation, the stimulant part of the process we have thus far recommended must be sedulously abstained from ; but the rest may be followed with advantage, t Every thing, In cases of paramenia obstructionis, Dr. Chap- man has derived great benefit from using a decoc- tion of the polygala seneca: Dr. Dewees places great reliance on the volatile tincture of guaiacum. Dr. Hosack has relieved a case of ten years' standing, which had resisted the aloetic and mer- curial emmenagogues, by using an injection, per vaginam, of half a drachm of the aqua ammonias, and eight ounces of rain water.—(Med. Essays,vol. ii.) This practice has been followed by Dr. Glon- ninger, and with great benefit.—(New-York Med. and Phys. Joum., vol. iii.) Dr. Lavagna also has succeeded with the same remedy. Dr. London, acting on the suggestions of Hippocrates, who remarked the intimate sympathy between the mammae and uterus, has cured some cases of amenorrhoea by applying leeches to the mammae ; and Dr. Paterson, of Dublin, has attained the same end by irritating the parts with sinapisms. —(See Boston Med. and Surg. Journal, vol. x.,p. 105.)—D. t Practitioners differ much as to the causes and treatment of paramenia difficilis, a disease wliich, although not fatal, is extremely difficult to be removed. Dr. Dewees remarks (Diseases of Females), " There appear to be two distinct states of this affection; one where the mammae sympa- thize with the uterus by becoming tumid and of- tentimes painful, the other where there is no such 440 GENETICA. [Cl. V.—Ord. I. indeed, that has a tendency to produce local ex- citement, and in this respect the conjugal em- brace itself, where the patient is married, must be systematically abstained from.* The diet must be plain, and the bowels kept open with neutral salts, or other cooling aperients. And, to allay the strong spasmodic action on which the severe pains in the lumbar and hypogastric regions depend, it will be found highly advanta- geous, a short time before the expected return of menstruation, to employ relaxants, and espe- cially local relaxants ; and of these, one of the best and pleasantest is the hip-bath, which oper- ates directly on the diseased quarter, and has a tendency to produce the desired effect without weakening the system generally. The ease and comfort of this valuable contrivance are ac- affec'tion." He thinks the former kind is the more manageable. It may occur in two states of the system ; that of general weakness and debility, or its opposite: in the former case, it is seen in those individuals where the bodily strength has been ex- hausted by previous disease, or by long-continued labour in an impure atmosphere. In these cases we must attempt to restore the tonic powers of the system; and the chalybeates, quinine, gener- ous living, moderate exercise in the open air, the tonic mineral water, a change of scene, &c, will be found beneficial. But in the greater number of cases, paramenia difficilis depends on a gen- eral entonic state, attended with preternatural ful- ness of the bloodvessels, and general oppression. In such cases, bloodletting and appropriate cathar- tics are indispensable; leeches may be applied to the loins or to the external organs, to be followed by warm fomentations. Campbell recommends the exhibition of an enema of two drachms of as- afoetida dissolved in twenty-four ounces of warm water, and the injection of warm water into the vagina until the catamenia have ceased, " to sub- due, if possible, that excitement which leads to the effusion of lymph and consequent formation of the membranous and fibrous productions." Os- borne, of Dublin, after the means mentioned above, employs smaU doses of ipecacuanha with opium, belladonna, and the hke, to relax the sys- tem, and to diminish pain and general distress. The above remarks apply more particularly to the treatment during the menstrual period. For a radical cure, Dr. Dewees recommends the vola- tile tincture of guaiacum, to be given with a proper regard to the state of the system. This remedy, Observes Dr. Dewees (Diseases of Females, 2d edit., p. 137), has generally been successful, but a perseverance in the use of it for two or three months is sometimes necessary. Dr. Eberle (Prac- tice of Physic, vol. ii., p. 529) recommends the extract of stramonium, given in doses of one eighth of a grain three times daily, commencing about four days before the expected return of the attack. Iodine has lately been used with some success, particularly by Dr. S. A. Cartwright of Mississippi. He remarks (Am. Med. Recorder, vol. xiv.), " Dr. Thompson, of Louisiana, preceded me in resorting to iodine in deranged menstrua- tion. The success which has attended his prac- tice in cases wherein a variety of other remedies had for a long time failed, is a sufficient proof of the beneficial effects of iodine in re-estabhshing the healthy functions of the uterus, if the proper cases be selected for its exhibition."—D. * Intercourse should be avoided for about a week before the expected attack.—Dr. Locock, in Cyc. of Pract. Med., art. Dysmenorrhea.—Ed. knowledged by almost all who have bad recourse to it. Martini and various other writers recom- mend the cold bath in preference to the hot, and Tissot represents the latter as injurious. But this is to speak without due discrimination. That the cold bath has been found of use in some in- stances is unquestionable : but only where there has been such a degree of energy in the consti- tution as to produce a reaction correspondent to the antecedent rigour. The direct effect of the cold bath is to constringe, and consequently, where a spastic contraction exists already, as is mostly the case from local cr constitutional debil- ity, to increase the evil. But where the constitu- tion is naturally robust, and but little inroad has hitherto been made upon its strength, the latent energy of the system is capable of resisting the sudden shudder; an increased action, and con- sequently an increased and glowing heat, ensue ; the repelled fluids are forced forward ; the blood flows more briskly ; the mouths of the capillary vessels give way in every direction; the mus- cular fibres lose their rigidity, and the suppressed secretions, of whatever kind, recommence. And hence it is that cold bathing may sometimes be serviceable in the disease before us, and warm bathing less useful: but these cases are rare, and warm bathing is mostly to be preferred. Even the hip-bath, however, though it miti- gates the pain, occasionally does nothing more : there is the same paucity of discharge, the same intermixture of coagula, and the same tendency to a return of the disease. In such cases it has been common to abstract eight or ten ounces of blood from the loins by cupping, antecedently to the use of the bath ; and this, by diminishing the spastic constriction, has at times diminished in a still greater degree the distressing pain. But I do not think the hip-bath is in general had re- course to early enough. Instead of waiting till the periodical pains return, as is the common practice, I have found it more advantageous to anticipate this period, and to relax the vessels by employing it for two or three nights before the pains are expected. And where in this and every other way it has failed, or the patient, from great delicacy of constitution, has appeared too much exhausted from its use, I have availed my- self of the same relaxant power in another way, and, with a like anticipation, have prescribed the use of a broad folded swathe of equal width, as already recommended in peritonitis and hepati- tis. The whole should be suffered to remain till the morning, by which time the warmth of the body will be usually found to have evapora- ted all the moisture, though the skin will still be dewy with perspiration from so powerful a sudorific. I have often found this plan succeed still better than the hip-bath; and have never known the patient catch cold, or complain of any chilly sensation from it.* * Where a kind of deciduous membrane has been certainly and habitually expelled, Dr. Lo- cock admits that benefit may be derived from moderate local bloodletting ; but, as a general-prac- tice, he deems it not requisite; and is of opinion that the extent to which it has been carried in many instances has done serious mischief. From Gen I.—Spe. 3] PARAMENIA SUPERFLUA. 441 SPECIES III. PARAMENIA SUPERFLUA. SUPERFLUOUS MENSTRUATION. catamenia excessive, and accompanied with hemorrhage from the menstrual vessels. This species offers us a disease precisely the reverse of the last, not less in the facility with which the mouths of the vessels give way, than in the quantity of the discharge. It exhibits the two following varieties :— a Reduplicata. Excessive from a too fre- Reduplicate men- quent recurrence. struation. B Profusa. Excessive from too large a Profuse menstru- flow at the proper periods. a tion. the character of the constitutions usually affected, the spasmodic nature of the pain, and the success of a very opposite class of remedies, Dr. Locock concludes that the disease is seldom inflamma- tory, but arises from a peculiarly irritable condi- tion of the uterine organs. For relieving the pain during the menstrual period he recommends opium, especially combined with ipecacuanha and four or five grains of camphire.—(See also Rams- botham's Lectures in Med. Gaz. for 1833-4, p. 310.) Immediately before the expected attack, he directs the bowels to be opened by a mfld purga- tive or injection of warm water; and the patient to put her feet in warm water, or use the warm hip-bath. During the attack, if the pulse be full and frequent, the countenance flushed, and pletho- ra prevail, he approves of cupping on the loins, or the application of leeches to the pudenda or groin. He speaks also favourably of a belladonna plaster applied over the sacrum, and of lotions containing belladonna or opium frequently injected into the vagina. Fomentations to the pubes, loins, and perinaeum, are stated to be of great service, and the cautious exhibition of ether, asafoetida, and ammonia, when there is not much feverish excite- ment, receives the same physician's sanction. With regard to the regulation of the general health during the intervals, as already observed, the patient, if married, is to refrain from sexual intercourse for about a week before the expected attack; and she may take inwardly some of the preparations of iron. Dr. Locock prefers equal parts of vinum ferri and the spir. aetheris sulph. comp. (3SS. to jj), given two or three times a day ; or the mist, or pil. ferri comp. One useful combi- nation, he says, is the compound extract of colo- cynth, and the soap and opium pill, in the propor- tion of two grains of each. But he observes, that on the whole, the natural chalybeate waters an- swer better than any artificial preparations. Where iron disagrees, zinc is to be tried. With the ex- ception of senega, recommended by Dr. Chapman of Philadelphia, for cases attended with the ha- bitual expulsion of a membrane, vegetable tonics promise little benefit. Cold hip-bathing, and the injection night and morning of cold saturnine lo- tions into the vagina, are likewise recommended. When dysmenorrhoea and rheumatism have ex- isted in the same patient, guaiacum and colchicum have sometimes cured both disorders.—(See Dr. Locock's Obs. in Cyclop, of Pract. Med., art. Dys- menorrhea.) Dr. Mackintosh, who adopts the theory of dysmenorrhoea being dependant on con- striction of the os uteri, recommends dilating the part with bougies, a practice which, according to Dr. Ramsbotham's report (Med. Gaz., vol. cit., p. The second variety, or profuse menstru- ation, is often technically distinguished by the name of menorrhagia. It is, in effect, the me- norrhagia rubra of Cullen, who makes it a dis- tinct affection from metrorrhagia or hemorrhagia uteri, by confining the latter term to a significa- tion of hemorrhage from other vessels of the uterus than those concerned in separating and discharging the catamenial flux.* We have already observed, that we cannot lay down any general rule to determine the ex- act quantity of fluid that ought to be thrown forth at each lunation, some individuals secre- ting more and others less ; and the measure va- ries from four to eight or ten ounces. + We can only, therefore, decide that the quantity is immoderate and morbid, when it exceeds what is usually discharged by the individual, or when it is associated with unquestionable symptoms of debility, as paleness of the face, feebleness of the pulse, unwonted fatigue on exercise ; coldness in the extremities, accompanied with an oedematous swelling of the ankles towards the night; pain in the back in an erect posture ; and various dyspeptic affections. Either of the varieties may be entonic or atonic, or, in common language, active or pas- sive : but in the first, there is usually a greater degree of local irritability than in the second, so that the secernents are excited, or the ex- tremities of the minute bloodvessels open upon very slight occasions. As the disease may oc- cur under these two different states of body, it may proceed, as Dr. Gulbrand has observed, from an increased impetus in the circulation, a relaxed state of the solids, or an attenuate state of the fluids (De Sanguine Uterino, 8vo., Hafn., 1778): to which he might have added uterine congestion. Increased impetus usually indicates great ro- bustness of constitution, or an entonic habit, and is not unfrequently connected with uterine ges- 310), does not receive the general sanction of the profession.—Ed. * Dr. Mackintosh of Edinburgh, and Mr. Burns of Glasgow, also restrict the name of menorrhagia to cases where, along with the peculiar menstrual secretion, pure blood is expelled ; while other ex- amples, in which the menstrual discharge is mere- ly too copious, are denominated an immoderate flow of themenses.—En. t According to Dr. Locock, the quantity lost is, upon an average, about five or six ounces ; " but," says he, " this is merely a general rule : the ex- ceptions are numerous; and it is only when it be- comes an exception to the individuals ordinary habits, that disease should be considered to exist. The effect of climate in these cases is very remark- able ; and what would be considered a very scanty menstruation in the warmer climates of the east, would be deemed menorrhagia in Lapland. A cu- rious blunder was committed in this respect by Dr. Freind, who stated that the quantity of menstrual discharge in this country averaged about twenty ounces—a menorrhagic excess by no means com- mon ; the mistake arising from his having quoted Hippocrates, without reflecting that the <5iio Kdrvlat 'Attikoi applied only to the females of Greece."—. See Cyclop, of Pract. Med., art. Menorrhagia. -Ed, 442 GENETICA. [Cl. V.—Ord. I. tation ; and in many cases, the accidental causes are cold, a violent shock or jar, or an accidental blow. Under this form, the disease commonly yields to venesection, cooling laxatives, and quiet. Superfluous menstruation from atony, or, in other words, from a relaxed state of the solids, and an attenuate state of the fluids, frequently arises from repeated miscarriages or labours, poverty of diet, and an immoderate indulgence in sexual pleasure. It often proceeds also, and especially in the higher ranks, from a life of in- dolent ease and enervating luxury, producing what we have denominated atonic plethora, lax vessels, easily,distended by a current of blood superfluous in quantity, but loose and unelabo- rate in crasis, and which is reproduced, and per- haps still more abundantly, but at the same time still more loosely, as soon as the excess is at- tempted to be removed by bleeding.* Here, therefore, venesection is almost sure to do mischief; we must restrain every luxuri- ous excess as far as it may be in our power, and we may have authority enough to ensure a com- pliance, which is not always the case ; we must employ, at the same time, the milder tonics, with astringents, as kino, catechu, or sulphate of zinc, and carefully guard against costive- ness by cool unirritating laxatives. The rhatany- root appears also, on the authority of Dr. Rath of Nordhausen, to have been peculiarly service- able in many cases, and particularly in the form of decoction ; an ounce being boiled for ten min- utes in half a pint of water lightly covered.— (Hufeland's Journal der practischen Heilkunde, Jan., 1819.) If the discharge be very consid- erable, astringent injections of cold water, or, which will commonly be found better, of a so- lution of alum or zinc, or cold water with a third part of new port wine, should be had recourse to without fail. Early hours are of especial im- portance, with a due intermixture of moderate exercise, and the use of cold sea-bathing. The Cheltenham waters, as those also of many other chalybeate springs, have often proved servicea- ble, partly from their own medicinal powers, and partly from the greater purity of air and increase of exercise with which a temporary residence at a watering-place is usually accompanied, t * In all severe or protracted cases, resisting the usual means of relief, the best practitioners deem it advisable to make an examination of the actual state of the uterus; because symptoms, closely resembling those of menorrhagia, may arise from organic mischief, particularly ulceration, polypus, and inversion of the womb.—Ed. t On the treatment of paramenia superflua, the able editor of the American edition of Denman's Midwifery makes the following judicious and prac- tical remarks:— " From the beneficial effects which have occa- sionally been produced by nausea in the hemor- rhage following abortion, it might be inferred that a like advantage might arise from the use of emet- ics in menorrhagia; and I have, for several years past, adopted this practice in a number of difficult cases with decided relief, where the ordinary means proved unavailing. The principle is not wholly new; as Frank mentions emetics in the list of those It is a common observation, in moral as well as in physical philosophy, that extremes meet in their effects, or produce like results. There is perhaps no part of natural history in which this is more frequently exemplified than in the sphere of medicine. In the case of apoplexies and palsies, as well as various other diseases, we have had particular occasion to make this re- mark : and in the genus immediately before us, as well as others closely connected with it, we have another striking instance of its truth. " The proportion of the diseases peculiar to the female sex in the hospital," says Dr. Gilbert Blane, speaking from tables accurately kept by himself for this purpose, " is the same as in pri- vate cases; from which it would appear that the unfavourable influence of indolent habits, excessive delicacy, and sensibility of mind and body, in the upper ranks, compensates for the bad effects of hard labour and various privations in the lower orders.* remedies proper for menorrhagia: yet the para- mount refief which is secured in this disease by inducing nausea by small doses of ipecacuanha, repeated within moderate intervals, deserves to be better known. The notion that any peculiar class of remedies possesses a specific action on the ute- rus, is scarcely any longer recognised as therapeu- tical ; and it is probable that other agents of the materia medica may be found in hke manner ser- viceable, as antimonials, from the well-known con- sent which exists between the stomach and the uterus, and from the effects which result to the entire vascular system. I have known the dis- charge disappear after the emetic operation of ipecacuanha; and I have prescribed successfully this article for the same purpose in doses of two, three, or four grains, taken every six hours for sev- eral days. The cases on this subject which have lately appeared from the pen of Dr. Osborne of Dublin, give us strong hopes of having acquired the means of better success than heretofore in the treatment of menorrhagia. Dr. Osborne thus states the results of his experience :—' I began the use of ipecacuanha by ordering a scrapie to be taken as an emetic at night, and I generally directed an acidulous saline purgative to be administered the following morning. The effect produced exceeded my most sanguine expectations. The discharge either ceased within twenty-four hours, or was so much diminished that no more remedies were ne- cessary to ensure its entire removal. In some few cases it recurred within a short time, but when this did happen, it was Only necessary to repeat the emetic once or twice in order to produce a per- manent effect. I met with a few individuals in whom the discharge continued with little altera- tion after the first emetic, but with these I had only to repeat the remedy on the following night; and in one case alone three emetics were taken before the desired effect was produced.'—See Transac- tions of the Association of King's and Queen's College of Physicians in Ireland, vol. v."—D. * Paramenia superflua may occur every ten days, be as copious as on ordinary occasions, and yet the patient be apparently in perfect health. Dewees records an interesting case, where a lady had first menstruated at the age of twelve, and continued to do so every ten days until she was forty, except during pregnancy or suckling. Notwithstanding this peculiarity, she was in very good health. Ex- cessive menstruation is to be considered as a dis- ease when it brings on debility, dyspepsy, hysteria, Gen. I.—Spe. 5.] PARAMENIA CESSATIONIS. 443 SPECIES IV. PARAMENIA ERRORIS. VICARIOUS MENSTRUATION. CATAMENIA TRANSFERRED TO AND EXCRETED AT REMOTE ORGANS. We have already noticed the extensive sym- pathy which the sexual organs maintain with every other part of the system. With the ex- ception of the stomach, which is the grand cen- tre of sympathetic action, there is no organ or set of organs possessed of any thing like so wide an influence. And hence, where, from any particular circumstance, as sudden fright or cold, the mouths of the menstrual vessels be- come spasmodically contracted at the period of menstruation, and the fluid is not thrown forth, almost every organ seems ready to offer it a vi- carious outlet. We have accounts, therefore, of its having been discharged, by substitution, from the eyes, the nostrils, the sockets of the teeth, the ears, the nipples, the stomach, the lungs in the shape of haemoptysis, the rectum, the bladder, the navel, and the skin generally, as more fully explained in the volume of No- sology, to which the reader may turn at his leisure. In effect, there is scarcely an organ of the body from which it has not been discharged under different circumstances.* A very singu- lar case is recorded of its being thrown forth from an ulcer in the ankle of a young woman little more than twenty years of age, and which continued to flow at monthly periods, for two or three days at a time, for about five years : after which, some part of the bone having separated in a carious state, the ulcer assuming a more healthy appearance, and the body becoming plumper and stronger, the vicarious outlet was no longer needed, and the menstrual tide re- turned to its proper channel.+ In all these cases there is a considerable de- gree of uterine torpitude, and commonly of gen- eral debility, while the part forming the tem- porary outlet is in a state of high irritability or and the " Protean symptoms of a complication of these affections."—See Ryan's Manual of Mid- wifery, p. 332, ed. 3.—Ed. * Eph. Nat. Cur., passim. Act. Nat. Cur. Act. Med. Berol. Bertholin. Obs. passim. Cent, passim. Bierling. Thes. Pract. Sennertus, Pract. et Par- alip..lib. iv. t Art. Calder, in Edin. Med. Essays, p. 341. The editor has seen several examples in which the menstrual discharge seemed to be transferred to ulcers. He once visited, with Mr. C. Hutchison, a woman who had an enormous spina bifida, and a sinus in the thigh, from which a bloody discharge took place regularly every month in lieu of ordi- nary menstruation. Ulcers of the kind now refer- red to have had the epithet menstrual appUed to them by Sir Astley Cooper. Baudeloque mentions a woman, aged forty-eight, who had never men- struated, and from the age of fifteen had been at- tacked every month with vomiting and purging, that used to continue about three or four days. The reader wiU find some interesting observations on menstruation, and the consequences of its de- rangement, in Ryan's Manual of Midwifery, ed. 3.—Ed. other diseased action. And hence the remedial process should consist in allaying the remote irritation, strengthening the system generally, and gradually stimulating the uterus to a state of healthy excitement, by the means already recommended. SPECIES V. PARAMENIA CESSATIONIS. IRREGULAR CESSATION OF THE MENSES. CATAMENIAL FLUX IRREGULAR AT THE TERM OF ITS NATURAL CESSATION J OCCASIONALLY AC- COMPANIED WITH SYMPTOMS OF DROPSY, GLAN- DULAR TUMOURS, OR SPURIOUS PREGNANCY. The set of organs that are most tardily com- pleted, and soonest exhausted, are those of the sexual system. They arrive latest at perfection, and are the first to become worn out and de- crepit. In this early progress to superannua- tion the secretory vessels of the uterus grow torpid, and, by degrees, the catamenial flux ceases. This cessation, however, has some- times been protracted to a very late period, and in a few rare instances, the menses have contin- ued nearly, or altogether, through the whole term of life; we have examples of it, noticed in the volume of Nosology, at seventy-eight and even ninety years of age; but the usual term is between forty and fifty, except where women marry late in life, in which case, from the postponement of the generative orgasm, they will occasionally breed beyond their fiftieth year.* On approaching the natural term of the * Childbearing begun at an early age, at sixteen or eighteen for example, rarely goes on through- out the whole of what is usually regarded as the natural period for it. The earlier or later termina- tion of chfldbearing in any country, therefore, as Mr. Roberton observes, will depend upon the aver- age age of marriage which there obtains. In our own country he is led to believe, from facts which he has collected, that the average age of marriage for women is about twenty-one years. Assuming this as correct, he considers the following table as possessing some interest. It is drawn up from the registers of the Manchester lying-in hospital, and shows, on the average of 10,000 instances of preg- nancy at all ages, the proportion of women who conceive above the age of forty :— Of 10,000 pregnant women, 436, or 43 3-5 per 1000, were upwards of 40 years of age. 101, or 10 1-10 per 1000, were in their 41st year. 113, or 11 3-10 - - - - 42d 70, or 7 .... 43d 58, or 5 4-5 - - - - 44th 43, or 4 3-10 - 45th 12, or 1 1-5 - - - - 46th 13, or 1 3-10 - - - . 47th 8, or 4-5 .... 48th 6, or 3-5 .... 49th 9, or 9-10 - . . . 50th 1, or 1-10 - - - - 52d l,or 1-10 .... 53d 1, or 1-10 .... 54th The number of pregnancies, it will be observed, suddenly and greatly diminishes after the age of 45. From the age of 46 to 50, both inclusive, the numbers are nearly equal for each year. Abova 444 GENETICA. [Cl. V.—Ord. f. cessation of the menses, the sexual organs do not always appear to act in perfect harmony with each other, and perhaps, at times, not even every part of the same organ with every other part. In proof of the first remark, we seem occasion- ally to meet with a lingering excitement in the ovaria, after all excitement has ceased in the uterus ; and we have hence a kind of conceptive stimulation, a physcony of the abdomen, accom- panied with peculiar feelings and peculiar cra- vings, which mimic those of pregnancy, and give the individual room to believe she is really preg- nant, and the more so in consequence of the ces- sation of her lunar discharge, while the uterus takes no part in the process, or merely that of sympathetic irritation, without any change in size or structure. On the contrary, we may chance to find the uterus itself chiefly if not solely affected with irregular action at this period : evincing some- times a suppression of menstruation for several months, sometimes a profuse discharge at the proper period, and sometimes a smaller discharge returning every ten or twelve days, often suc- ceeded by leucorrhoea. And not unfrequently the system associates generally in the misaffec- tion, and suffers from oppression, headache, nau- sea, or universal languor. All these are cases that require rather to be care- fully watched than vigorously practised upon ; and the character of an expectant physician, as the French denominate it, is the whole that is called for. The prime object should be to quiet irregular local irritation, wherever necessary, by gentle laxatives, moderate opiates, or other nar- cotics, and to prevent any incidental stimulus, mental emotion, or other cause, from inter- fering with the natural inertness into which the sexual system is progressively sinking. Hence the diet should be nutritive but plain ; the exer- cise moderate ; and costiveness prevented by lenient, but not cold eccoprotics : aloes, though most usually had recourse to, from its pungency, in earlier life, is one of the worst medicines we can employ at this period, as the sulphate of magnesia, warmed with any pleasant aromatic, is perhaps one of the best. If the constitution be vigorous and plethoric, and particularly if the head feel oppressed and vertiginous, six or seven ounces of blood may at first be taken from the arm; but it is a prac- tice we should avoid if possible, from the dan- ger of its being necessarily resorted to again, and at length running into an inconvenient and debilitating habit.* the latter age, the proportion dwindles to one in- stance of pregnancy in 3333.—(See Roberton on Menstruation, in Edin. Med. and Surg. Journ. for Oct., 1832, p. 254.) Dr. Ryan states that he has known a woman delivered in her sixty-third year. —See his Manual of Midwifery, p. 44, ed. 3.—Ed. * This caution against bloodletting will not be much regarded by American practitioners. The beneficial results of occasional venesection, to se- cure as it were a vicarious relief, and thus to guard against that inordinate plethora which so often occurs at the cessation of the catamenia, are well understood, and many formidable symptoms of congestion are relieved by this remedy.—D. The mammae, that constantly associate in the changes of the uterus, and constitute a direct part of the sexual system, are at this time, also, not unfrequently in a state of considerable irri- tation ; and if a cancerous diathesis be lurking in the constitution, such irritation is often found sufficient to excite it into action. And hence, the period before us is that in which cancers of the breast most frequently show themselves. From the natural paresis into which this im- portant and active system is hereby thrown, a certain surplus of sensorial power seems to be let loose upon the system, which operates in various ways. The ordinary and most favour- able mode is that of expending itself upon the adipose membrane generally, in consequence of which a larger portion of animal oil is poured forth, and the body becomes plump and corpu- lent. The most unfavourable, next to the ex- citement of a cancerous diathesis into action, is that of irritating some neighbouring organ, as the spleen or liver, and thus working up a dis- tressing parabysma, or visceral turgescence ; or deranging the order of the stomach and laying a foundation for dyspepsy.* * Dr. Marshal Hall, in his Commentaries on the Diseases of Females, recommends particular at- tention to be paid to the regulation of the bowels, and to diet, air, and exercise, at the cessation of menstruation. When vertigo or drowsines is an effect of it, he is an advocate for the exhibi- tion of purgatives, and the occasional abstraction of blood by cupping on the nape of the neck, or by the application of leeches. The following passage from Dr. Ryan's Manual of Midwifery is so cor- rectly descriptive of subjects connected with this part of the study of medicine, that the editor deems no apology needed for its insertion :—" When men- struation is about to cease, the period is called ' the change or turn of life,' and many important changes take place in the constitution. The breasts collapse, the fulness of habit disappears, the skin shrivels, and loses its colour and softness, and many diseases appear in the womb and breast which had lain dormant for years. However, when this period has passed, women often enjoy better prospects of health and of long life than the other sex. This period is also designated ' the climacteric, the critical time, the critical age,' and often before its arrival the menstruation is irregular, absent for weeks or months ; the abdo- men becomes tumid ; there is loss of appetite in the morning; and the woman considers herself pregnant, which is never the case. According to the statistical reports of Finlaison, Moret, Cha- teauneuf, and Lachaise, no more women than men die between the fortieth and fiftieth year; and Dewees contends that women are not more liable to diseases at this than at any other period of Ufe (meaning, of course, the generality of diseases; for to cancer we know they are certainly more exposed). The cessation of menstruation, how- ever, is often preceded by gradual decrease or in- crease of the fluid, nervousness, and all its Protean symptoms ; or more serious diseases appear, so that moderate purgation is often of the greatest advan- tage. The internal and external orifices of the ute- rusbecome obliterated, partially or totally (Duges); or the cervico-uterine orifice (Mayer); the uterus and ovaries are atrophied or hype'rtrophied; the rugae of the vagina and mucous membrane of the uterus are relaxed, and pour out a mucous dis- charge ; the vulva is flaccid and dilated; there is Gen. IX—Spe. 1.] LEUC0RRHG3A COMMUNIS. 445 GENUS II. LEUCORRHOEA. WHITES. MUCOUS DISCHARGE FROM THE VAGINA, COM- MONLY WITHOUT INFECTION ; DISAPPEARING DURING MENSTRUATION. The term leucorrhoea, from A«i/cdj, " white," and j>iu, " to flow," is apparently of modern or- igin, as it is not to be found in either the Greek or Roman writers, and seems first to have been met with in Bonet or Castellus. This is the menorrhagia alba of Dr. Cullen, so denominated because he conceives the evac- uation to flow from the same vessels as the catamenia ; as also that it is often joined with menorrhagia, or succeeds to it. Its source, how- ever, is yet a point of dispute (Rat. Med., part vii., p. 155): Stoll (De Notis Virginitatis, lib. i., prob. 3), Pinaeus, and various other distin- guished writers, have ascribed it, like Cullen, to the uterus. But as it occurs often in great abundance in pregnant women, in girls of seven, eight, and nine years of age (Heister, Wahrneh- mungen, b. ii., N. 128 ; Hoechstctter, Obs. Med., dec. iv., cas. i., Schol.), and even in infants, it has been supposed by Wedel (Diss, de Fluore albo, Jen., 1743), and most writers of the pres- ent day, to flow from the internal surface of the vagina, or at the utmost, from the vagina jointly with the cervix of the uterus. Morgagni is perhaps most correct, who conceives, and ap- pears indeed to have proved by dissections, that in different cases, the morbid secretion is- sues from both organs ; for he has sometimes found the uterus exhibiting in its internal sur- face whitish tubercles, tumid vessels, or some other diseased indication, and sometimes the vagina.* Frank affirms that he has occasion- ally, on dissection, traced it issuing from the Fal- lopian tubes.+ In the case narrated by Mr. Hill of Dumfries, and noticed under the pre- ceding genus, it was evidently confined to the vagina alone.—(Edin. Med. Comment., iv., p. 91.) When first secreted it is bland and whitish, but differs in colour and quality under different circumstances, and hence affords the three fol- lowing species:— often prolapsus uteri; and the breasts decrease or disappear."—Ed. * De Sed. et Caus. Morb., ep. xlviii., art. 12, 14, 16,17, 18,19, 27 ; ep. lxii., art. 14. Numerous cases are on record, where, in prolapsus uteri, the leucorrhoeal discharge proceeded from the os uteri itself.—(Locock, in Cyclop, of Pract. Med., art. Leucorrhoea.) On the other hand, Dr. Jewel believes that the discharge, in ordinary cases, does not issue from the cavity of the uterus.—Ed. fDe Cur. Horn. Morb. Epit., torn, v., p. 177, Mannh., 8vo., 1792. The simplest form of leucor- rhoea is a mere increase of the natural secretion from the mucous membrane of the vagina. As this membrane is continued to the interior of the uterus and the Fallopian tubes, it is easy to sup- pose that now and then the lining of these organs may become affected, and the leucorrhoea have a more extensive seat.—Locock, in Cyclop, of Pract. Med., art. Leucorrhoea.—Ed. 1. Leucorrhoea Communis. Common Whites. 2.----------Nabothi. Labour-show. 3.----------Senescentium. Whites of ad- vanced life. SPECIES I. LEUCORRHG3A COMMUNIS. COMMON WHITES. THE DISCHARGE OF A YELLOWISH-WHITE COLOUR, VERGING TO GREEN. This species is the fluor albus of most wri- ters : the medorrhoea foeminarum insons of Pro- fessor Frank. It is found in girls antecedently to menstruation, or on any simple local irrita- tion in the middle of life, and hence also, as just observed, during pregnancy. It is said, in the Berlin Transactions, to be occasionally con- tagious (Act. Med. Berol., dec. i., vol. v., p. 85); and I have met with various cases which seem to justify this remark.* It has occurred as the result of suppressed menstruation :f as it is asserted also to have done on a suppressed catarrh (Act. Erud., Lips., 1790, p. 376 ; Raulin, sur les Fleurs blanches, p. 329): and dullness or suppressed perspira- tion of the feet.—(Act. Nat. Cur., vol. viii., obs. 38.) Local irritations, moreover, are fre- quent causes. And hence one reason of its being an occasional concomitant of pregnancy ; as also of its being produced by pessaries inju- diciously employed, by voluptuous excitements, and uncleanliness. It is said at times to exist as a metastasis, and particularly to appear on a sudden failure of milk during the period of lac- tation : a failure which may be set down to tlie- list of suppressed discharges.—(Astruc, de Morb. Mulier., lib. i., cap. 10.) Jensen gives a singu- lar case of leucorrhoea that alternated with a pituitous cough.—(Prod. Act. Hafn., p. 160.> * On this point differences of opinion yet pre- vail. " True leucorrhoea is not infectious; it pro- duces no disease in a man who cohabits with a female labouring under it."—(Ramsbotham's Lec- tures, as published in Med. Gaz. for 1833-4, p. 420.) Where the discharge is purulent or of an acrid quality, sexual intercourse, as Dr. Locock observes, will often bring on a train of symptoms in the male very much resembUng gonorrhoea. " This, when occurring between husband and wife, has often led to much domestic unhappiness^' from the supposition of one party or the other having contracted gonorrhoea from impure con- nexion. It is important to be able to distinguish between gonorrhoea and common leucorrhoea, to. remove or confirm the suspicions ; but it is doubt- ful whether any very accurate diagnosis can be formed. It has been stated, that in a recent gon- orrhoea there is ardor urinae, which does not ac- company leucorrhoea, unless unusually acrid. But how are we to distinguish in a case of this unu- sually acrid leucorrhoea, or where a gonorrhoea is not recent ? The redness and tumefaction of the labia, nymphae, &c, only can be seen in a recent gonorrhoea, and they may be seen in severe cases of leucorrhoea, particularly in those following lo- cal irritation, or possessing more acute inflamma- tory action."—See Cyclop, of Pract. Med., art Leucorrhcea.—Ed. + It is found also in females who menstruate too copiously.—D 446 GENETICA. [Cl. V.—Ord. L It is most frequently found among the weakly and delicate of crowded cities and humid re- gions, of a cachectic habit, and who use but little exercise ; especially about the age of puberty, or who, being married, have borne too numerous a family, or been pregnant in too quick a succes- sion. It is also found among the barren, those who cruelly forbear to suckle their own offspring, or who menstruate too sparingly.—(J. P. Frank, De Cur. Horn. Morb. Epit., torn, v., p. 176.) It is usually accompanied with a sense of languor, and a weakness or pain in the back. And if it become chronic or of long contin- uance, the countenance looks pale and un- healthy, the stomach is troubled with symptoms of indigestion, the skin is dry and feverish, and the feet oedematous. The discharge, in its mildest form, is slimy, nearly colourless, or of an opaline hue, and un- accompanied with local irritation. It afterward becomes more opaque and muculent, and is ac- companied with a sense of heat, and itching or smarting : in this stage, it is of a yellowish" white. But as the disease advances in degree it appears greenish, thinner, more acrid, and highly offensive, and is apt to excoriate the whole surface of the vagina : while there is of- ten a considerable degree of pain in the uterus itself, and even in the loins. Among novices there is some difficulty in distinguishing the discharge of whites from that of blennorrhoea, which we shall describe present- ly. But though the appearance of the two fluids is often similar, they may easily be known by their accompanying signs. In blennorrhoea there is local irritation from the first, and this irritation extends through a considerable part of the meatus urinarius, so as to produce a distres- sing pain in making water ; symptoms which are not found in leucorrhoea.* In the former there is also from the first a swelling of the labia, a more regular though a smaller secretion, and of a more purulent appearance. When the disease is violent or of long con- tinuance, it leads to great general as well as local debility. It has sometimes been followed by a prolapse of the uterus or vagina (Boehman, Diss, de Prolapsu et Inversione Uteri., Hal., 1745); by abortion or miscarriage where there is pregnancy; and by barrenness where no pregnancy has occurred. When it acts on the system at large, it has given rise to cutaneous eruptions of various kinds (Klein, Interpres Clinicus, p. 112), hectic fever (Hippocr. Aph., sect, v.), dropsy, scirrhus, and cancer.—(Raulin, sur les Fleurs blanches, torn, i., passim ; Frank, ut supr., p. 182.) The cure is often difficult: but it is of no small importance to be from the first fully ac- quainted with the nature of its cause and charac- ter, for upon this the proper means to be pursu- ed will mainly depend. And hence it will often be necessary to examine the organs themselves, t * Notwithstanding these diagnostic symptoms, distress about the meatus urinarius, and pain in making water, will often be found in leucorrhoea, particularly when of long continuance.—D. t The following observations by Dr. Locock are If the cause be uncleanliness, a lodgment of some portion of a late menstrual flux, or any other irritating material in the vagina, nothing more may be necessary than frequent injections of warm water : or, if the vagina itself be much irritated, injections of the diluted solution of the acetate of lead: which last will often, indeed, be found highly serviceable where the discharge proceeds from debility and relaxation, produced by a severe labour or miscarriage, forming no uncommon causes ; as they are also no uncom- mon effects. Other astringent injections have often been tried, as green tea, a solution of alum, or sul- phate of zinc, a decoction of pomegranate bark, or a solution of catechu. All these are sure to be of service, as tending to wash away the discharge, and keep the parts clean ; and in many cases they will also succeed as astringents ; nor is it always easy to determine which is to be prefer- red ; for in some cases one answers the purpose best, and in others, another.* Sir Kenelm Digby recommended a local ap- plication of the fume of sulphur (Medic. Exper- iment, p. 65), which may be communicated in various ways ; and so far as this has a tendency to change the nature of the morbid action, by originating a new excitement, it is worthy of attention; but perhaps the diluted aqua regia bath, of which we have spoken under spasmodic jaundice (Ider. Spasmodic, vol. i.), may prove more advantageous. The disease, however, is often highly troub- full of judgment and truth :—" Sir Charles M. Clarke," says he, " has classed the diseases of the female genital organs by the nature of the vaginal discharges which are peculiar to them; and al- though there are many serious objections to such a mode of classification, yet it proves how impor- tant it is to note their several and distinguishing peculiarities. Of the diseases to which females are liable, there is none more common than vagi- nal discharge of one sort or another; it attends most of the uterine diseases, and it is extremely common as the result of either local or constitu- tional disturbance, or of general debility. It is looked upon by the patients themselves as the cause of ill health, or of the symptoms under which they may happen to labour; whereas, in the ma- jority of instances, the discharge itself can only be considered as a symptom, the effect and result of local or general disorder. By practitioners in gen- eral, vaginal discharges have been carelessly at- tended to; there has been one common routine of treatment, without investigation; and it is only when the complaint has been obstinate, that at a later period more minute inquiry has been made, and more rational and scientific plans adopted. So many of the vaginal discharges depend upon ute- rine disorganization, or some alteration in the po- sition of that organ, that it is advisable in every case, where possible, to make a minute examina- tion per vaginam."—See art. Leucorrhoea, in Cyclop, of Pract. Med.—Ed. * Weak solutions of the nitrate of silver are preferred by Dr. Jewel, in the proportion of from one to three grains of the nitrate to each ounce of distilled water. Sometimes he applies the caustic itself to the cervix uteri. At the Lock Hospital, injections, containing 9ij or 38s of the nitrate of silver in every ounce of water, have sometimes been employed.—Ed. Gen. II.—Spe. 2.] LEUCORRHOZA NABOTH1. 447 lesome and obstinate, and hence it has been ne- cessary to employ constitutional as weU as local means. The general remedies that have been had re- course to are almost innumerable. Acids have been taken internally in as concentrated a state as possible, but rarely with much success. The sulphuric acid has been chiefly depended upon: and, in the form of the eau de Rabel, which is that of digesting one part to three of spirit of wine, it was at one period supposed to be almost a spe- cific. The compound, however, has not been able to maintain its reputation, and has long sunk into disuse. Emetics have been found more useful, as op- erating by revulsion, and stimulating the system generally, and on this ground a sea voyage, accompanied with seasickness, has often effect- ed a cure. Stimulating the bowels, and partic- ularly in the commencement of the disease, and where the general strength has not been much encroached upon, has, for the same reason, been frequently found useful, as transferring the irri- tation to a neighbouring organ, and under a more manageable form. And one of the best stimu- lants for this purpose is sulphate of magnesia. Small doses of calomel have been given daily with the same view, but in general, they have not succeeded. Heister, however, recommended mercury in this disease, even to the extent of salivation (Wahrnehmungen, band ii.) ; yet this is a'very doubtful remedy, and even under the best issue, purchases success at a dear rate. A spontaneous salivation has sometimes effected a cure.—(Eph. Nat. Cur., dec. iii., ann. ix., x., obs. 140.) Mr. John Hunter, with a view of changing the nature of the morbid action in its own field, advised mercurial inunctions in the vagina itself. Other stimulants have been recommended, that operate more generally,,and have a pecu- liar tendency to influence the secretion of mu- cous membranes, as the terebinthinate prepara- tions, particularly camphire, balsam of copayva, cubebs, and turpentine itself; and there is reason to believe that the second of these has often been useful. It has sometimes been em- ployed in combination with tincture of canthar- ides : but the latter is in most instances too irritating, whether made use of alone, or with any other medicine. As the acids have not succeeded, neither have other astringents to any great extent. The ar- gentina, or wild tansy (potentilla anserina, Linn.) was at one time in high favour ; it was particu- larly recommended by M. Tournefort, and upon his recommendation very generally adopted. Alum has been supported by a still greater num- ber of advocates for its use ; and kino has, per- haps, been employed quite as extensively. Dr. Cullen asserts that he has tried all these alone without success, but that by uniting kino and alum, as in the pulvis stypticus of the Edinburgh College, he obtained not only a most powerful astringent, but one that had occasionally proved serviceable in the present disease. The anserina has justly sunk into oblivion. The rhatany-root is much better entitled to a trial in the form of a decoction, as already recommended in atonic paramenia superflua: though, from its warmth, united with the quality of astringency, it is a still more promising remedy in the leuconhoea of advanced life. Upon the whole, the best general treatment we can recommend is a use of the metaUic ton- ics, and especially zinc and iron, in conjunction with a generous but temperate diet, exercise that produces no fatigue, pure air, and change of air, cold bathing, regular and early hours, and especially a course of the mineral waters of Tunbridge or Cheltenham. [In chronic leucor- rhoea, the internal and external use of iodine has been tried with benefit (Gimele ,• Omodei, Annali, &c); and Dr. Negri and others have tried small doses of the secale cornutum. It is admitted, however, that its efficacy is less prompt than in cases of uterine hemorrhage.— (See Lond. Med. Gaz. for 1833-4, p. 369.) When the disorder depends upon suppressed menstruation, M. Guibert finds that upon the menstrual discharge being re-established by bleeding, the leucorrhoea ceases at once.—(Re- vue Mid., Juillet, 1827.)* SPECIES II. LEUCORRHCEA NABOTHI. LABOUR-SHOW. THE DISCHARGE SLIMY, AND MOSTLY TINGED WITH BLOOD. In this species the fluid is secreted by the glandulae Nabothi, situate on the mouth of the uterus, whence the specific name. It is the leucorrhcea Nabothi of Sauvages, and the hamor- rhagia Nabothi of Cullen. It is most usually found as the harbinger of labour ; and indicates that the irritation which stimulates the uterus to spasmodic and expulsory contraction, when the full term of pregnancy has been completed, or some accident has hurried forward the pro- cess, has now commenced, and that the pains of childbirth may soon be expected. It is prob- ably nothing more than the usual fluid secreted by the glands from which it flows, augmented in quantity in consequence of temporary excite- ment, and mixed with a small quantity of blood. It is hardly entitled to the name of a hemorrhage, as given by Dr. Cullen, though blood from the ute- rus often succeeds to it, apparently thrown forth in consequence of the violence of the pains. In its ordinary occurrence, it is only worthy of notice as a deviation from the common secre- tions of health, and is rather to be hailed than to become a subject of cure or removal. But there is a state of irritation to which these glands are sometimes subjected that produces the same discharge, and in considerable abun- * When the patient is plethoric, much benefit will sometimes be derived in cases of leucorrhoea from bloodletting. When the pulse is in a proper condition, Dr. Dewees has administered the tinc- ture of cantharides with decided success. This remedy is used until strangury is produced, un- less the disease is arrested before. He remarks, "that it rarely withstands a second strangury." 448 GENETIC A. [Cl. V.—Ord. I. dance, for many weeks or months before labour, and which, for the comfort of the patient, re- quires a little medical advice and attention. The irritation may proceed from plethora and distention, or from a weak or relaxed state of the constitution. If from the former, venesec- tion and gentle laxatives will prove the best course we can pursue : if from the latter, a re- clined position, easy intestinal evacuations, and such sedatives as may sit most pleasantly on the stomach, and produce least disturbance to the head. _______ SPECIES m. LEUCORRHCEA SENESCENTTUM. WHITES OF ADVANCED LIFE. ' THE DISCHARGE THIN, ACRID, FREQUENTLY EX- CORIATING AND FETID. This is usually, but not always, connected with a morbid state of the uterus. It commonly shows itself on the cessation of the menses : and is often chronic and obstinate. The more common diseases of the uterus, with which the discharge is combined, are an incipient cancer, or a polypous fungus. But I have occasionally met with it unconnected with either, and apparently dependant upon a pecu- liar and chronic irritability of the uterus, or rath- er, perhaps, of those glands which secrete the fluid that is poured forth during the act of sex- ual intercourse. A lady, about forty years of age, not long ago applied to me, who had, for more than a twelvemonth, been labouring under a very distressing case of this kind. She had been married from an early period of life, but had never been pregnant. Her general health was good, her temper easy, her imagination pe- culiarly warm and vivid. She had no local pain, and had ceased to menstruate at the age of about thirty-eight. The discharge, at the time I first saw her, consisted of at least from a quar- ter to half a pint daily—thick, slimy, brownish, and highly offensive. Every external and in- ternal remedy that could be thought of appeared to be of only temporary avail, and sometimes of no avail whatever, though she certainly derived relief from injections of the punica granalum, with a fourth part port wine, which for some time checked the discharge and diminished the fetor. In the meantime, the general strength was preyed upon, the loins became full of pain, the appetite failed, and the sleep was disturbed. Accidental circumstances compelled her, even in this debilitated state, to undertake a voyage to India. During its progress, she suffered se- verely from seasickness; but the change hereby produced, or effected by the alteration of climate, proved peculiarly salutary : for she gradually lost the complaint, and recovered her usual health. Hence emetics, change of climate, and the tonic plan already recommended under the first spe- cies, seem to be the best course we can pursue in the species before us.* GENUS III. BLENNORRHCEA. GONORRHOEA. MUCULENT DISCHARGE FROM THE URETHRA OR VAGINA ; GENERALLY WITH LOCAL IRRITATION AND DYSURY; NOT DISAPPEARING DURING MENSTRUATION. Blennorrhoea is a Greek compound of mod- em writers, derived from B\twa, "mucus," and f>iu, " to flow." Sauvages, and after him Cullen, have employed gonorrboea from ydvos, "semen," and beta, as a common term for this and spermorrhcsa, constituting the ensuing genus, and consisting in an evacuation of semen. Cullen, indeed, has extended the term still fur- ther in his First Lines, and hence morbid secre- tion of mucus, all kinds of venereal contagion and seminal flux, are equally arranged as spe- cies of the same generic disease; and tliis, too, under a word which imports the last alone: while, to add to the confusion, this very word, in its vulgar sense, is restrained to venereal con- tagion, which, in its strict meaning, that of sem- inal flux, it signifies just as much as it does abortion or stone in the bladder. It is high time to make a distinction, and to divide the list of Sauvages into two genera. Blennorrhcsa has, indeed, been already employed of late by various writers to denote the first of these genera, and there is no necessity for changing the term. The genus under Muller (Muller, Medic. Wo- chenblatt, 1784, N. Ii., plures species) is subdi- vided into numerous species: but the three fol- lowing include the whole that fairly belong to it:— 1. Blennorrhoea Simplex. Simple urethral running. 2.---------- Luodes. Clap. 3.----------Chromca. Gleet. * Sir Charles Clarke has frequently known leu- corrhoea, attended by the worst symptoms, subside on the removal of the patient into the country, with very Uttle aid from medicine.—Ed. SPECIES I. BLENNORRHCEA SIMPLEX. SIMPLE URETHRAL RUNNING. SIMPLE INCREASED SECRETION FROM THE MUCOUS GLANDS OF THE URETHRA. This definition is given in the words of Dr. Fordyce, and is sufficiently clear and expressive. In effect, the efflux proceeds from mere local irritation, unaccompanied by contagion or viru- lence of any kind, and is chiefly found in per- sons in whom the affected organ is in a state of debility; the occasional causes of irritation being venereal excess, too large an indulgence in spir- ituous liquors, cold, topical inflammation, too frequent purging, violent exercise on horseback, to which various authors add transferred rheu- matic action (De Plaigne, Journ. de Mid., torn. lxxiv.; Richter, Chir. Bibl., b. iv., p. 508 ; Pou- teau, GZuvres Poslhumes, i.); and occasionally, according to Mr. John Hunter, transferred irri- tation of the teeth.—(Natural'History of the Teeth.) The matter discharged is whitish and mild, producing no excoriation, pain in micturition, or other disquiet. It is the mild gonorrhoea of many Gen. III.—Spe. 2.] BLENNORRHCEA LUODES. 449 writers, the gonorrhoea pura of Dr. Cullen, and usually yields without difficulty to rest, emol- lient injections, and very gentle and cooling purgatives. SPECIES II. BLENNORRHCEA LUODES. CLAP. MUCULENT DISCHARGE FROM THE URETHRA OR VAGINA, INTERMIXED WITH SPECIFIC VIRUS: BURNING PAIN IN MICTURITION: PRODUCED BY IMPURE COITION : INFECTIOUS. This is a disorder of far greater mischief and violence than the preceding, and, in contradis- tinction to it, has been very generally denomi- nated the virulent or malignant gonorrhoea. It is the gonorrhoea impura of Cullen. The disease was for many years supposed to be a local effect of that poison which, when communicated to the system, produces syphilis. It is in truth received in the same manner, and by the same organs—its medium of conveyance being that of cohabitation with an infected per- son. We are chiefly indebted to Mr. John Hunt- er for having pointed out the distinction; and there is now scarcely an individual in our own country who has any doubt upon the subject, though there are several who conjecture that it has been derived from the syphilitic venom, changed and softened in its virulence by an in- troduction into different constitutions. These conjectures are harmless, but they have little ground for support. That it is a disease specif- ically different from syphilis, is clear from the following facts. Its appearance did not com- mence till more than a hundred years after that of syphilis ;* it will continue for months without any syphilitic symptoms, which are rarely, in- deed, found connected with it; and where such symptoms have shown themselves, there has been full evidence of a new and different infec- tion, or strong ground for suspicion : the matter of chancre, the pathognomonic symptom of syphilis, when introduced into the urethra, has been found not to produce clap, and the matter of clap inserted under the skin has been proved not to produce syphilis: the common course of mercury, which is the only specific cure for the latter, is a very inconvenient and dilatory way of treating the former; while the local plan, by which the former is conquered with great speed and ease, produces no effect on the latter. It is singular, therefore, that the old and erroneous doctrine of their being one and the same disease should still maintain its ground in France, as it appears to do from M. Sante-Marie's late trea- * As discharges from the urethra have been common from time immemorial, this assertion can hardly be received as correct and certain, inas- much as it is now impossible to form any judgment respecting the particular nature of those com- plaints. From what we know of discharges from the urethra, as they appear at the prese«t day, we have every reason to befieve that some of those referred to by the ancients, must have been capa- ble of communication from one person to another. fc —Ed. Vol. II.—F f tise, as well as various others, on this subject.— (Mithode pour guirir les Maladies Vineriennes invileries, &c, Paris, 1818.) M. Lagneau, indeed, although he acknowl- edges that clap or gonorrhoea may have a differ- ent origin from syphilis, still endeavours to prove the identity of the former and chancres in the greater number of cases, from the fact that va- rious females have been infected with both com- plaints by the same man, and various men by the same female.—(Exposi des Symptomes de la Maladie Venirienne, Paris, 1815.) But this will go no further than to show that the individ- ual, communicating both complaints, was in- fected with both at the same time. What is so common as porrigo galeata or scalled-head co- existing with itch; or dysentery with bilious fever, measles, or any other epidemic that may be prevalent together with itself! It is very possible, indeed, that in a few habits or idiosyn- crasies, the matter of gonorrhoea may^produce' chancres or other local sores, or even be followed by constitutional symptoms very closely mimick- ing those of syphilis: for when treating of this last disease, we shall have to show that such mimicry of symptoms frequently takes place from other impure and local irritants, and with so near a resemblance as to be distinguished with great difficulty from the disease it seems to copy.* We have already pointed out the dis- tinctive characters of the malady before us and syphilis ; and it is sufficient to observe further, that the anomalous symptoms, if they ever fol- low genuine clap, occur not in the ordinary course of its march, but as extreme exceptions to its established habits, and are not to be found once in ten thousand examples.! Some of these facts, indeed, were known to physiologists and reasoned from even before the time of Mr. John Hunter; and hence Baglivi contended that virulent gonorrhoea, as it was then called, may be produced by other acrimo- nies than the syphilitic (De Fibrd Motice, &c), while Zeller, towards the close of the seven- teenth century, affirmed that it may originate in either sex without contact (Diss, de Gonorrhad utroque sexu, Tubing., 1700); and Stoll, in the middle of the eighteenth, that it proceeds from. various causes, of which syphilitic contagion is one.—(Prated., p. 104.) It is due to the merits of Dr. Balfour to observe, that he made the distinction between syphilis and gonorrhoea the * The facts recorded in the writings of Mr, Evans and Dr. Hennen, leave no doubt of the fact that sores of various character have arisen on the genitals after connexion with individuals affected only with clap. Whether any of such sores were true Hunterian chancres is another question, of which a different opinion may perhaps be enter- tained from that of M. Lagneau.—Ed. t Dr. Swediaur enumerates the following spe, cies of blennorrhoea: the syphilitic; the herpetic, leprous; scorbutic; the gouty; the rheumatic; the hemorrhoidal; that produced by some substance taken internally or apphed extemaUy to the ure< thra; and blennorrhoea, a stimulo-mechanico.—« See his Comprehensive Treatise upon the Symp- toms, Consequences, Nature, and Treatment of Venereal or Syptosfijjc. Diseases.—D, 450 GENETICA. [C'L. \ -Ord. I. ground of his inaugural dissertation at Edin- burgh in 1767, which was nineteen years be- fore the publication of Mr. Hunter's celebrated work. It is not easy to account for the primary ap- pearance of this or of any other specific poison, but we see daily that most, perhaps all mucous membranes, under a state of some pecuhar mor- bid action, have a tendency to secrete a virulent and even contagious material of some kind or other, the particles of which are in some in- stances highly volatile, and capable of commu- nicating their specific effect to organs of a like kind, and of propagating their power by assimi- lation after having been diffused to some dis- tance through the atmosphere, which does not at all times readily dissolve them; though, agree- ably to a general law we have formerly pointed out, the more readily, the purer the constitution of the atmosphere.—(Vol. i., corol. 9, p. 344.) We have a manifest proof of this in the mucu- lent discharge of dysentery, in canine catarrh, or the muculent affection in the nostrils of dogs, which is vulgarly called distemper, and in the glanders, possibly also in the farcy, of horses. And although that species of catarrh which we name influenza is probably a miasm, rather de- pendant on some intemperament of the atmo- sphere itself in its origin, than on the tempera- ment of the individual who suffers from it; yet this also becomes a contagion in its progress, and is communicable in consequence of such new property, from individual to individual, after a removal into fresh and very remote atmo- spheres by travelling (see Catarrhus Epidemicus of this work, Cl. III., Ord. II., Gen. IX., Spe. 2); while nothing can be more highly contagious than the discharge from the mucous glands of the tunica conjunctiva in purulent ophthalmai, although perhaps a direct contact is necessary for the production of its effect. In like manner, leucorrhoea, as we have alrea- dy observed, has sometimes seemed to be con- tagious ; for I have occasionally found a kind of blennorrhoea produced in men, accompanied with a slight pain in the urethra, and some diffi- culty in making water, upon cohabitation with women who, upon inspection, had no marks whatever of luodic blennorrhoea or clap; and, in some instances, indeed, were wives and matrons of unimpeachable character. The disease before us, however, has symp- toms peculiar to itself, and undoubtedly depends upon a specific virus. The chief of these symp- toms are described in the definition. They are generally preceded by a troublesome itching in the glans penis, and a general sense of soreness up the whole course of the urethra ; soon after which the discharge appears, on pressing the glans, in the form of a whitish pus oozing from its orifice. In a day or two it increases in quantity, and becomes yellowish; and as the inflammation augments, and the disorder grows more virulent, the yellow is converted into a greenish hue, and the matter loses its purulent appearance, and is thinner and more irritant. The burning or scalding pain that takes place on making water, is usually seated about half an inch within the orifice of the urethra, at which part the passage feels peculiarly straitened, whence the urine flows in a small, interrupted stream : the lips of the urethra are thickened and inflamed, and a general tension is felt up the course of the penis. This last symptom is sometimes extremely violent, and accompanied with involuntary erections ; at which time, if the cells of the corpus spongiosum urethrae be united by the adhesive inflammation, and ren- dered incapable of yielding equally with the cor- pora cavernosa, the penis is incurvated with in- tolerable pain. It is to this state of the penis, in which it bears some resemblance to a hard twisted cord, that the French have given the name of chordee. Under these circumstances, we often meet with a troublesome phimosis ei- ther of the strangulating or incarcerating kind; in consequence of the increased spread of the inflammation. Sometimes it extends to one or both groins, in which case the glands swell and buboes are often formed: sometimes it reaches to the bladder, the inner surface of which pours forth a cheesy or wheyey fluid, instead of its proper lubicrous secretion, which is blended with the urine ; and sometimes the testes parti- cipate in the inflammation, become swollen and painful, and excite a considerable degree of fever. In woman, the chief seat of affection is the vagina ; but as this is a less sensible part than the urethra, the pain is seldom so pungent, ex- cept when the meatus urinarius and the nymphae associate and participate in the inflammation. The disease appears at very different inter- vals after infection, according to the irritability of the constitution. The usual time is about the fourth or fifth day. But it has shown itself within the first twenty-four hours, and has some- times continued dormant for a fortnight. Do- meier lays down the time from the fourth to the fourteenth day (Fragmente uber die Erkentnis venerischer Krankheiten, Hanov., 1790) ; Plenciz fixes it after the tenth.—(Acta et Observaliones Med., p. 139.) Sometimes only a very small discharge takes place, while the other symptoms are peculiarly exasperated. To this state of the disease, some practitioners have applied the very absurd name of gonorrhcea sicca. It was at one time imagined that the puri- form fluid, which is usually poured forth in con- siderable abundance, proceeds from an ulcer in the urethra: but it is now well known T;hat it is not necessary for an ulcer or an abscess to exist for the formation of pus, and the dissection of persons who have died while labouring under this disease, has sufficiently shown that the se- cretion is thrown forth from the internal mem- brane of the urethra, chiefly at the lacunae, with- out the least appearance of ulceration, or even, in most instances, of excoriation. The cure in the present day is simple ; for the venereal clap, like the venereal pox, appears to have lost much of that virulence and severity of character, by passing from one constitution to another, which it evinced on its first detec- tion.* Rest, diluent drinks, and an antiphlogis- * The statement of clap and the venereal dis> Gen. Ill—Spe. 2.] BLENNORRH tic regimen, will often effect a cure alone. But it may be expedited by cooling laxatives and topical applications. The remedies employed are of two kinds, and of very opposite characters ; stimulant and seda- tive. Both, also, are used generally and locally; with a view of taking off the irritation indirectly, by exciting a new action; or directly, by ren- dering the parts affected torpid to the existing action, and thus allowing it to die away of its own accord. Many of these medicines, indeed, as well the local as the general, were at one time supposed to be natural antidotes, and to cure by a specific power : an idea, however, which has been long banished from the minds of most practitioners. The general sedatives that have hitherto been principally employed, are opium, conium, nitre, oily emulsions, and mucilages. The first has often succeeded, but with considerable and very unnecessary inconvenience to the constitution : the others are not much to be depended upon. They may have co-operated with a rigidly re- ducent diet, but have seldom answered alone. Employed locally, some of them, and particu- larly opium, have proved far more beneficial. The best form of this last is that of an injection, rendered somewhat viscid by oil or mucilage. The stimulant process has, however, been found to answer so much more effectually, that it has almost superseded the use of sedatives. Formerly this process, also, was employed generally, and it was supposed, and in many cases sufficiently ascertained, that by strongly irritating some other part, the morbid excite- ment of the urethra would subside, and the or- gan have time to recover its natural action. And hence the intestines were daily stimulated by cathartics, as neutral salts, mercury, and colocynth, which last was at one time regarded as a specific ; or terebinthinates, as camphire, balsam of copayva, and turpentine itself. And sometimes the bladder was treated in the same manner, with diuretics of all kinds, and especial- ly with cantharides. This plan is still continued in many parts of the east, and particularly in Bengal and Java ; where, as we are informed by Mr. Crawford, the common remedy, and one to which the dis- ease in those hot regions yields very easily, is that of. cubebs, the piper cubeba of Linneus. This pepper, well pounded, is exhibited in a lit- tle water, five or six times a day, in the quanti- ease having become milder by transmission from one constitution to another, than they were at their origin, is one that can only be received as a suppo- sition ; for the exact periods of the origin of the venereal disease and of gonorrhoea form a subject involved in considerable obscurity. In the most ancient limes, the genitals were also subject to discharges and ulceration; and at the present day, the venereal disease is believed to be either several different specific disorders, or else several forms of one disease, so disguised and modified by the in- fluence of temperament, climate, mode of living, and other causes, as virtually to form cases that seem to have little resemblance to each other, and to require very opposite modes of treatment.—Ed. Ff 2 IA LUODES. 451 tity of a dessert-spoonful, or about three drachms, as well in the ensuing as in the present species, during which time all heating aliments are to be' carefully abstained from. The cure, we are told, is entirely completed in two or three days, the ardor urinae first ceasing, and the discharge again becoming viscid. A slight diarrhoea is sometimes produced, with a flushing in the face, and a sense of heat in the palms of the hands and the soles of the feet. In a few instances, Mr. Crawford tells us, inflamed testicles have supervened, an affection which yields easily to the common treatment.—(Account of the Piper Cubeba, &c, Edin. Med. and Surg. Jour., No. liii., p. 32.) This plan has of late been exten- sively made use of at home. Mr. Broughton has given us a result of fifty trials under his own eye ; and of these he tells us, that he cured forty-one in less than a month ; that five were relieved; one was cured, but relapsed; and- three failed. He affirms that it does not disa- gree with the stomach, is more easily admissible than balsam of copayva, and is not attended with the evils of injections. He employed the medi- cine two or three times a day; giving, of the powder, from two drachms to half an ounce, and of the wine or tincture from a drachm to half an ounce for the dose.* There is no necessity, however, for subjecting the constitution to so severe a discipline ; for the stimulant process, and particularly that of astringent stimulants, when employed locally, succeeds ordinarily in a few days without any trouble. These consist chiefly of metallic salts in solution, as the muriate and submuriate of mercury, the former in the proportion of three or four grains to eight ounces of water, sulphate of zinc, sulphate of copper, ammoniacal copper, and the acetated solution of lead. The astrin- gent property of most of these, under due man- agement, instead of being found mischievous, gives a check to the morbid secretion, at the same time that it acts as a direct tonic, and rapidly restores the irritated mouths of the ex- halants to their healthy and proper action; and this too without the inconvenience of a second- ary inflammation. A slight solution of alum alone, indeed, in the proportion of one or two grains to an ounce of water, has, for this pur- pose, been often employed with sufficient effica- cy ; though the present author has reason to prefer the sulphate of zinc, which he has usually combined with bote armenic, in the proportion of one scruple of the former and two of the lat- ter to half a pint of water. And he can venture to say, that through a pretty extensive course of practice for upwards of thirty years, he has never known this composition to fail; and has never perceived it produce any of the inconve- * Trans, of the Medico-Chir. Soc, vol. xii., part i., 1822. The cubebs, or Java pepper, as it is termed, still possesses considerable repute for its efficacy in checking gonorrhoeas and gleets, and is in common use. It seems to act as a tere- binthinate, and like other medicines of this class, if it does good at all, the benefit is perceived as soon as the urine begins to have its odour and other qualities changed by the remedy.—Ed. 452 GENETICA. [Cl. V.—Ord. I. niences of stricture or swelled testicle, which were so much, but so groundlessly apprehended, when the stimulating and astringent practice was first introduced.* The addition of the bole may to some practi- tioners appear trifling, but it adds to the power of the zinc, probably by giving an increased body to the solution without diminishing its stimulant effect, which would certainly follow by using oil or mucilage in its stead. The sulphate of cop- per is more irritating than that of zinc, and, in a strong solution, is more likely to produce in- flammation ; and it is on this account chiefly that the author has confined himself to the lat- ter. It is, in effect, by an analogous practice, that several modifications of purulent ophthalmia, and particularly that of infancy, is most success- fully subdued, as we observed when treating of this disease. It is almost unnecessary to add, that the ut- most cleanliness by frequent washing should be maintained from the first appearance of the dis- ease. Where the complaint, however, is improperly treated with stimulants, and particularly astrin- gent stimulants, or where it has continued too long before application for medical assistance, the whole range of the urethra, or some par- ticular parts of it, are apt to become so irri- table as to suffer spasmodic contractions, which commonly pass under the name of strictures, without being so in reality ; and, as we have already observed, this irritation, in some cases, extends to the interior surface of the blad- der, and even thickens it. We have often had occasion to remark, that in fibrous structures and canals, the most sensible parts are their extremities ; and this remark is particularly ap- plicable to blennorrhoea, for the portions of the urethra which suffer most from irritation are the interior membrane of the glans and the prostate, particularly the latter, in consequence of its di- rect connexion with the bladder as well as the urethral canal. On this account, when a patient once labours under spasmodic constrictions from the disease before us, whatever other parts these may exist in, the introduction of a bougie will be almost sure to prove, that there is also a constriction towards the prostate gland. Generally speak- ing, it will be found to originate here, and to occur in other parts of the canal from sympathy. But the case will often be reversed, and while the irritation originates in some other part, or in the bladder, it is by sympathy with these that the prostate itself is affected. Mr. Abernethy has pointed out this double source of spasmodic constriction in the prostate, in the clearest man- ner possible (Surgical Observations on Diseases of the Urethra, p. 194, 8vo., 1810); and the re- marks he has offered upon the propriety of em- ploying or withholding the bougie as an instru- ment of cure cannot be too deeply imprinted on every student's mind; the general principle of which is to persevere in its use wherever it ap- * These inconveniences, however, often arise from the use of lead injections, and hence they are now almost universally abandoned.—D. pears to blunt the sensibility ; and to pass it as high up the urethra as can be accomplished with this effect, if possible, indeed, through the pros- tate into the bladder ; but in every instance to desist where a second or third trial of the in- strument gives more pain than the first, or to con- tent ourselves with passing it as high as can be done without any such symptoms of increased ir- ritation, and there stopping short; and only ma- king an occasional trial when we have reason to hope that the morbid sensibility has still further subsided. M. Ducamp thinks, however, that lit- tle benefit is to be derived from bougies ; and that suffering them to remain in the urethra is sure to increase the irritation.—(Traiti des Reten- tions d'Urine par le Rilricissement de f 'Urethre, &c, Paris, 8vo., 1822.) SPECIES III. BLENNORRHCEA CHRONICA. GLEET. SLIMY DISCHARGE FROM THE MUCOUS GLANDS OF THE URETHRA, WITHOUT SPECIFIC VENOM OR INFECTION : SLIGHTLY IRRITATING ; CHRONIC. This species is a frequent sequel of a clap that has been ill managed, or has lasted long, and produced an obstinate local debility. But it exists also independently of clap, and is oc- casioned by strains, excess of venery, and other causes of weakness. The discharge is for the most part a bland and slimy mucus, not accom- panied with inflammation, apparently proceeding from a morbid relaxation of the mucous glands of the urethra, and at times, like other dischar- ges from debilitated organs, accompanied with and kept up by irritation, and especially irrita- tion produced by a stricture in the urethra prop- erly so called, or a diseased state of the pros- tate gland. In common cases, the disease yields to the local tonics and astringents recommended under the preceding species ; but it is sometimes pe- culiarly irritable, and bids defiance to all the in- genuity of the medical art. A. Castro gives an instance of its having continued for eighteen years.* The stimulants ordinarily employed have con- sisted of copayva, cubebs, or some terebinthinate or resinous balsam in the form of injection; tincture of ipecacuanha, as recommended by Swediaur; infusion of cantharides, a favourite remedy with Bartholine"; or a blister applied to the urethra, as advised by Mr. John Hunter and several other writers. The bougie may here be used, for the most part, more fearlessly than in the preceding spe- cies. Its own simple stimulus, if employed reg- ularly once or twice a day, has often proved sufficient: and where this fails, it may be ren- dered more active by being smeared with tur- pentine, mercurial ointment, or camphorated lin- iment ; or armed with nitrate of silver, where * De Morb. Mul., p. 68. Here it is to be sus- pected, that the disease must have depended upon the presence of a stricture in the urethra.—E». Gen. IV—Spe. 2.] SPERMORRHCEA ATONICA. 453 strictures require it. Even in this species, how- ever, it is a valuable remark of Mr. John Hunt- er, that before we have recourse to any pow- erful application, we should well weigh the de- gree of irritability of the patient's constitution ; for we may otherwise run a risk of exciting a vi- olent local inflammation, or of extending the ir- ritation to the testes or the bladder. Should such an issue unfortunately occur, one of the most salutary injections we can employ is a so- lution of the extract of hyoscyamus in water. Even in chordees which resisted the influence of opium, Mr. Bell asserts that he has found this medicine advantageous, in the quantity of from one to three grains at a time, and repeated three times a day or oftener. Or we may have re- course to a warm hemlock poultice, applied every night, and made sufficiently large to cover the whole of the perinaeum, testes, and penis. I have known this succeed in taking off an ha- bitual irritation, and with it effectually suppres- sing the discharge, on the third application, in two instances of more than a twelvemonth's standing ; and this after stimulants of all kinds, and narcotics of many kinds, and particularly opium, had been tried in succession. The leaves were here employed in a fresh state. In women, this disease is often mistaken for leucorrhoea ; we have pointed out the distinct- ive character under the last species. Yet the mistake is not of essential consequence, as the same treatment will often effect a cure in both. As the vagina, however, is less irritable than the urethra, gleet in females is a less frequent and troublesome complaint than in mates. GENUS IV. SPERMORRHCEA. SEMINAL FLUX. INVOLUNTARY EMISSION OF SEMINAL FLUID WITH- OUT COPULATION. The generic name is derived from (rtrtlpw, "sero," "semino;" whence aspermus, "void of seed," gymnospermus, "having the seed na- ked," a term well known in botany ; and hence also numerous other derivatives of the same kind. Gonorrhoea, which is a direct synonyme, would have been retained as the name for this genus, as it is retained by Linneus, Sagar, and Frank, but from the confused signification in which it has been employed by Sauvages and Cullen ; and from its being usually, though most improp- erly, applied in the present day to blennorrhoea luodes. The genus offers two varieties, as follow :— 1. Spermorrhcea Enton- Entonic Seminal Flux. ica. 2. —--------Atonica. Atonic Seminal Flux. SPECIES I. SPERMORRHCEA ENTONICA. ENTONIC SEMINAL FLUX. INVOLUNTARY EMISSION OF PROPER SEMEN, WITH ERECTION ; MOSTLY FROM AN INDULGENCE OF LIBIDINOUS IDEAS. The usual cause is assigned in the definition, ; and it very strikingly points out the influence which the mind bears upon the body, and the ne- cessity of subjecting the passions to the disci- pline of a chaste and virtuous deportment; since, as there is no passion more debasing than that of gross lust, there is none more mischiev- ous to the general health of the body. It leads the besotted slave straight forward to every other sensuality, and, by becoming at length an es- tablished and chronic disease, stupifies the mind, debilitates the body, and is apt to terminate in hectic fever and tabes. This affection sometimes originates in the body itself; in a local and urgent erethism, pro- duced, as Forestus conjectures (Lib. xxvi., obs. ii.), by a superabundant secretion of seminal fluid in a constitution of entonic health and vig- our. And as, in the former case, the body is to be chastised through the mind, in the present the mind is to be chastised through the body : particularly by purgatives and venesection, a low diet and severe exercise. If, however, the pa- tient be single, as is commonly the case, the pleasantest, as well as the most effectual rem- edy, is to be sought for in marriage. SPECIES II. SPERMORRHCEA ATONICA. ATONIC SEMINAL FLUX. INVOLUNTARY EMISSION OF A DILUTE AND NEAR- LY PELLUCID SEMINAL FLUID ; WITH LIBIDI- NOUS PROPENSITY, BUT WITHOUT ERECTION. Of this species Sauvages gives us two curi- ous examples : one from Deidier, in which the patient was an exemplary monk, who shrunk with horror at the idea of this involuntary self- pollution, as he regarded it: the other a case in his own practice, in which the patient, a most religious young female, was, as he affirms, driv- en almost to madness under the same erroneous contemplation of the disease. From his having included a female under this genus, it should seem that Sauvages inclined to the theory of epigenesis, or that which supposes the male and female to contribute equally a seminal fluid in the act of procreation. It is probable that some local irritation is the usual cause. Professor Deidier himself suspected this in the first of the above cases ; and referred it rather to a calcu- lus in the bladder, sympathetically affecting the prostate gland, than to any idiopathic disease of the vesiculae seminales, or the testes. The pious monk found himself most relieved by scourging his legs : a blister applied to the peri- nasum would probably have relieved him still more effectually. The fluid is a thin degener- ate secretion, apparently from the vesiculae sem- inales, rather than semen itself. It is sometimes found intermixed with blood ; and, in this case, we have a further irritation of a wound or rup- tured vessel. The most common cause of this miserable disorder is a previous life of unre- strained concupiscence : and under the debility hereby produced, the morbid discharge is pecu- liarly apt to flow upon the mere muscular ex citement that takes place on evacua^g the rec« 454 GENETICA. [Cl V — Ord. /. turn; and hence follows hard upon a stool.— (Art. Med. Berol., dec. i., vol. iv., p. 70; WeichmannDe Pollutione, &c, Goet., 1712.) A cure should be attempted by the daily use of a bidet of cold seawater, or of early bathing in the sea, and the internal use of the metallic tonics. The bowels should be kept lax; but the warjn and irritating purgatives should be carefully abstained from. Blistering the peri- naeum, or making a seton in it, has occasion- ally been found serviceable : as has also a local use of electricity.* GENUS V. GALACTIA. MISLACTATION. MORBID FLOW OR DEFICIENCY OF MILK. This includes the greater part of those affec- tions treated of by Dioscorides under the name of sparganosis, which, however, in his arrange- ment, embraced, as we observed under phleg- mone mammas: (Cl. III., Ord. II., Gen. II., Spe. 5), many complaints that have little or no connexion with each other, and particularly one of the species of bcjcnemia, or tumid leg : so that it has been necessary to break up the division, and allot to its different members their proper positions. Galactia is a Greek term, from yd\a, "lac," whence ya\a.KnKo%, " lacteus." It occurs in Linneus and Vogel for the genus now before us, which by Sauvages and Sagar is written galac- tirrhoea, literally " milk-flux," in a morbid sense of the term. The author has preferred galac- tia as more comprehensive than galactirrhoea, so as to allow the idea of a depraved or defect- ive, as well as of a superabundant secretion of milk : all of which are equally entitled to be comprised under one common head, as excess, deficiency, or other irregularity of arterial action in fever. Hitherto, however, from an opposite fault to that of Dioscorides, these affections have been separated from each other by many nosolo- gists, and carried to different heads, sometimes to different orders, and occasionally to different classes ; whence the student has had to hunt for them through every section of the nosologi- cal arrangement. It has already been necessa- ry to make the same remark respecting many of the species of paramenia ; and various other instances will occur to us in the ensuing orders of the class we are now explaining. The flow of milk may become a source of disease, as being out of season, defective in quantity, vitiated in quality, transferred to an im- proper organ, and as discharged from the proper organ, but in the male sex. These differences will furnish the present genus with five distinct species, as follow :— 1. Galactia Praematura. Premature Milk-flow. 2.-------Defectiva. Deficient Milk-flow. 3.-------Depravata. Depraved Milk-flow. 4.-------Erratica. Erratic Milk-flow. 5.------r- Virorum. Milk-flow in Males. * The tincture of cantharides will be found useful as a local and general stimulant when other means have failed.—D. SPECIES I. GALACTIA PREMATURA. PREMATURE MILK-FLOW. EFFLUX OF MILK DURING PREGNANCY. The mammas, which maintain the closest sympathy with the ovaria and uterus, and, in most animals possessing them, are placed in their direct vicinity, and which, in truth, are as much entitled to the character of a sexual or- gan as any organ of the entire frame, participate in the development of the generative function from the first stimulus of puberty. It is then that the breasts assume a globose plumpness, and the catamenial flux commences; when pregnancy takes place, and the uterus enlarges, the breasts exhibit a correspondent increase of swell; and when, shortly after childbirth, the lochial discharge ceases, and the uterus takes rest, the lacteal discharge is secreted, and poured forth in immediate succession. The sympathy continues, however, even after this rest has commenced, for one of the most effect- ual means of increasing the flow of milk from the breasts is a slight excitement of the uterus, as soon as it has recovered its tone : and hence the mother of an infant, living with her husband, and herself in good health, makes a far better nurse, and even requires a less stimulant regi- men, than a stranger, brought from her own family, and secluded from her husband's visits. Of this, indeed, many of the rudest and most barbarous nations, but which are not always in- attentive to the voice of nature, have the fullest conviction ; insomuch that the Scythians, accord- ing to Herodotus, and the Hottentots in our own day, irritate the vagina to increase the flow of milk in their cows and mares. It sometimes happens, however, that this stim- ulus of sympathy is carried to excess, even du- ring pregnancy, and that the lactiferous ducts of the mamma? secrete milk from the ultimate branches of the arteries sooner than it is wanted. If the quantity thus separated be small, it is of no moment; but if it be considerable, some de- gree of debility is usually produced, with rest- lessness and pyrexy. And hence Galen observes, that a premature flow of milk indicates a weakly child (Fragm. ex Aphor. Rab. Mois., p. 34); and the collections of medical curiosities contain various cases, in which it has appeared to be in- jurious.—(Act. Nat. Cur., vol. iv.) Sauvages gives an instance, in which a pint and a half was poured forth daily, as early as the fifth month. Where the constitution is peculiarly robust, even this may for some time be borne with as little mischief as menstruation during pregnancy : but in ordinary cases, the system must be weakened by so excessive and unprofit- able a discharge. There is another instance noticed in the volume of Nosology, in which a pint and a half was poured forth daily at the fifth month. The morbid irritation, however, may general- ly be taken off by venesection, and if this should not succeed, by a few doses of aperient medi- cines. It has sometimes happened that a like pre- Gen. V—Spe. 2] GALACTIA DEFECTIVA. 455 cocity has occurred in young virgins, and that these also have secreted and discharged milk from the proper organ. In many cases this has occurred as a substitute for the catamenial flux, which has been retained or suppressed at the time ;* but more generally it has proceeded from entonic plethora, or a morbid erethism of the sexual organs at the period of puberty (Hip- pocr. Aph., sect, v., § 39; Vega, Comment, in Hippocr., Aph. v., i£» or morbus puerorum. Bonet has followed the oriental ex- tension of the term, and has given instances of its occurring, not only in pubescent, but even adult males: and, in like manner, Sir Gilbert Blane, in his table of diseases under the article chlorosis, observes, that one of his patients affected with this complaint " was a male of seventeen, who had all the characters of this malady, except that which is peculiar to the female sex. He was treated like the others, and recovered under the use of carbonated iron and aloes."—(Medico-Chir. Trans., vol. iv.,p. 140.) It is on this account that the definition of chlo- rosis will be found, in the present work, to vary in some degree from all that have preceded it, so as to render its characters capable of em- bracing the male as weU as the female form of the disease. GENUS II. PRCEOTIA. GENITAL PRECOCITY. PREMATURE DEVELOPMENT OF SEXUAL ORGAN- IZATION, OR POWER. The generic term prceotia or prceotes is copied from Theophrastus, and derived from rpul, " praemature." It is, however, peculiarly applied to premature semination. The genus, as embracing both sexes, com- prises the two foUowing species :— 1. Prceotia Masculina. Male Precocity. 2. ------ Feminina. Female Precocity. SPECIES I. PRCEOTIA MASCULINA. MALE PRECOCITY. premature development of sexual organ- ization in males. Both the mind and body advance, in their ordinary career, by slow and almost impercep- tible steps to maturity; faculty after faculty, and function after function, put forth, acquire strength, and become perfected. But occasion- ally this ordinary course is departed from, and the whole system, as well mental as corporeal, or, which is still more frequent, particular powers or organs, push forward with incredible rapidity. The admirable Crichton, as he is commonly called, and others pre-eminently gifted in the same extensive way, afford in- stances of the first of these remarks ; and those who, in early and even in infant life, have shown a peculiar aptitude for an acquisition of languages, or of music, ornumerical arithmetic, give examples of the last kind. It is not hence much to be wondered at, that a like extraordinary precocity should sometimes exhibit itself in the development of sexual or- ganization and power : and that, from a peculiar degree of local irritation or erethism, the pubes should be found covered with hair, the testes be formed and capable of secreting a seminal fluid Gen. II.—Spe. 2] PRCEOTIA FEMIN1NA. 461 and the penis be susceptible of a concupiscent turgescence and erection. It is not necessary to dwell upon instances of exemplification, which may be traced in great numbers in the writings of physiologists who have been curious upon this subject. Those who are desirous of doing so may turn to the Journal des Scavans for 1688, and the Philo- sophical Transactions for 1745. In the former, Boiset gives an instance of this disgusting anti- cipation in a boy of three years old; in the lat- ter, the subject in the case recorded was two years and eleven months. A simple example at a similar age is well known to have occurred, only a few years since, in a boy who was ex- hibited by his friends for money to medical prac- titioners in this metropolis ; and may be found, together with various others, minutely described in the first volume of the Medico-Chirurgical Transactions.* Two, of late date, are also de- tailed in the 11th and 12th vols, of the same work, by Dr. Breschet and Mr. J. F. South. With respect to moral or even medical treat- ment, nothing can be worse than this very com- mon practice of a public exposure whenever the case occurs among the poor, who are so strongly tempted to make a profit of it. The orgasm is fed by a repetition of examinations, and the pol- luting tide that exhausts and debases the body is at length accompanied, even though it should not be so at first, with a polluting pleasure, that in a still greater degree exhausts and debases the mind. An occasional application of leeches to the seat of affection, cooling aperients, a cool, loose, and unirritating lower dress, with the daily use of a bidet of cold water, or iced water, will form the best plan that can be pursued on such occasions; and, by producing a healthful repression, may enable the unhappy infant to grow up with gradual vigour to the possession of a hearty manhood, instead of sinking, as has been sometimes the case, into a premature and tabid old age at the early period of puberty. * In the year 1748, Mr. Dawkes, a surgeon at St. Ives, near Huntingdon, pubhshed a small tract, called Prodigium WiUinghamense, or an account of a surprising boy, who was buried at Willingham, near Cambridge, upon whom he wrote the following epitaph:—" Stop, traveller, and wondering know, here buried he the remains of Thomas, son of Thomas and Margaret Hall; who, not one year old, had the signs of manhood; not three, was almost four feet high; endued with uncommon strength, a just proportion of parts, and a stupendous voice; before six he died, as it were, of an advanced age. He was bom at this village, October 31,1741, and in the same departed this Ufe, Sept. 3, 1747."—(See also Phil. Trans., 1744-45.) As Dr. Elliotson has observed, this perfectly authentic case removes all doubts re- specting the boy at Salamis, mentioned by Pliny (Hist. Nat., lib. vii., c. 17), as being four feet high, and having reached puberty when only three years old ; and respecting the man seen by Craterus, the brother of Antigonus (Phlegon, De Mirab., c. 32), who, in seven years, was an infant, a youth, an adult, a father, an old man, and a corpse.—(Blu- menbach's Physiology, 4th edit., note, p. 535.) Premature puberty does not appear to be attended with a proportionally early development of the intellectual faculties.—Ed. SPECIES II. PRCEOTIA FEMININA. FEMALE PRECOCITY. premature development of sexual organ- ization IN FEMALES. Under the species of obstructed menstrua- tion, we have observed that this secretion, which commonly affords a proof that the sexual organ- ization is developed, and its function completed, takes place at very different periods of life under different circumstances, chiefly those of climate and peculiarity of constitution : and that, though its ordinary epoch is that of thirteen or fourteen, it has sometimes, under the influence of a trop- ical sun, or a warm and forward temperament, shown itself as early as eight or nine years of age.* There is hence no difficulty in conceiving that, under the influence of the same kind of local erethism we have noticed in the preceding spe- cies, the sexual organization in females may ac- quire a similar precocity to that in males. And so complete has been the development occa- sionally, that we have numerous and well-authen- ticated instances of pregnancy itself occurring at the early age of nine years, on which we shall have to remark more fully in the introductory observations to the third Order of the present Class, when treating of morbid impregnation. This foremarch of nature should be timely checked, for it will otherwise assuredly lead to a very great debility of the system in general, and is usually found to stint the stature, and in- duce a premature old age. And the means of repression may be the same as those already pro- posed for male precocity. The premature development or organization before us does not always seem to be connected with any cupidinous orgasm, or at least, it has occurred under circumstances that render it ex- tremely difficult to entertain any such idea. One of the most singular instances of this kind is a case of extra-uterine foetation published by Dr. Baillie. It consisted of a suety substance, hair, and the rudiments of four teeth, found in the ovarium of a child of not more than twelve or thirteen years of age, with an infantine uterus, and perfect hymen.—-(Phil. Trans., vol. lxxix., p. 71 ; see also New-York Med. and Physiol. Journ., vol. ii.) In this case there can be little doubt that an ovulum, by some peculiar irritation, had been ex- cited to the rudimental process of an imperfect conception, and that it had, in consequence, been separated from its niche, and a corpus luteum taken its place. In the Physiological Proem to * Walther, Thes., obs. 40. In some rare cases the menses have appeared in precocious puberty as early as the third or fourth year. Sir Astley Cooper has recorded an instance of this kind (Trans. Med. Chir. Soc, vol. iv.), and others are reported by British practitioners. In one case, the patient was but three years and a half old (Med. Phys. Joum., 1810); and, in another, but two years of age.—(Op. cit., vol. xxviii.) See Ryan's Manual of Midwifery; or, a Compendium of Gyn- aecology and Paidonosology, 12mo., Lond., 1831, edit. 3, a work replete with useful matter.—Ed. 462 GENETICA. [Cl. V.—Ord. Il< the present Class we have observed, that such chancres are occasionally met with in mature virgins, whose organs have afforded ample proof of freedom from sexual commerce, the ordinary mode of accounting for which is by supposing, that although they have never cohabited with the male sex, they have at times felt a very high de- gree of orgasm or inordinate desire, and that such feeling has been a sufficient excitement to produce such an effect. The author has already expressed himself not satisfied with this expla- nation ; and the case before us can hardly be re- solved into any such cause.* GENUS III. L A G N E S I S. LUST. INORDINATE DESIRE OF SEXUALCOMMERCE, WITH ORGANIC TURGESCENCE AND ERECTION. Lagnesis is a derivative from \dyvns, "libidi- nosus ;" " praeceps in venerem ;" and as a ge- nus, is intended to include the satyriasis and nymphomania of Sauvages and later authors; which chiefly, if not entirely, differ from each other only as appertaining to the male or female sex, and in their symptoms do not, like the pre- ceding genus, offer ground for two distinct spe- cies. The proper species belonging to this ge- nus are the following :— 1. Lagnesis Salacitas. Salacity. 2.--------Furor. Lascivious Madness. SPECIES I. LAGNESIS SALACITAS. SALACITY. the appetence capable of restraint; THE EXCITEMENT CHIEFLY CONFINED TO THE SEX- UAL SYSTEM. In a state of health and civilized society, there are two reasons why mankind are easily capable of restraining within due bounds the ani- mal desire that exists in their frame from the period of puberty tiil the infirmity of age : the one is of a physical, and the other of a moral kind. The natural orgasm of men differs from * One of the most remarkable instances of Pr. feminina known, is recorded by Dr. D. Rowlett of Kentucky, in the Transylvania Journal of Medi- cine, October, 1834. The subject of it, when born, was of the usual size, but in a few weeks after birth her hips and breasts began to grow rapidly, and when twelve months old, the menstrual function was established: this appeared regularly until she became pregnant. At the age of ten years and tlur- teen days she was delivered of a healthy female child, weighing seven pounds and three quarters. The child refused the breast, and was raised by the bottle. Dr. R. remarks: "It is as healthy as is usual for children to be when raised from the bot- tle ; and at the time of taking these notes it weigh- ed eight and three fourth pounds, and its mother weighed one hundred pounds. She was four feet seven inches high, and had the countenance of a girl not exceeding her in years, but is as intelligent as girls usually are at her aze."—D- that of brutes in being permanent, instead of being periodical, or dependant upon the return of particular seasons : and on this very account, is less violent, more uniform, and kept with comparative facility within proper limits. This is a cause derived from the physical constitu- tion of man. -But the power of habit and the early inculcation of a principle of abstinence and chastity in civilized life, form a moral cause of temperance that operates with a still stronger influence than the preceding, and lay down a barrier which, though too often stealthily broken into, yet in the main makes good its post, and serves as a general check upon society. As man rises in education and moral feeling, he proportionally rises in the power of self-re- straint; and consequently, as he becomes de- prived of this wholesome law of discipline, he sinks into self-indulgence and the brutality of savage life. And were it not that the very per- manency of the desire, as we have already ob- served, torpefies and wears out its goad, the savage, destitute of moral discipline, would be at all times as ferocious in his libidinous career as brutes are in the season of returning heat; when, stung with the periodical ardour, and work- ed up almost to fury,-the whole frame of the animal is actuated with an unbridled force, his motions are quick and rapid, his eyes glisten, and his nerves seem to circulate fire. Food is neglected; fences are broken down ; he darts wild through fields and forests, plunges into the deepest rivers, or scales the loftiest rocks and mountains, to meet the object that is ordained by nature to quell the pungent impulse by which he is urged forward (see Crichton on Mental De- rangement, ii., p. 301): " Nonne vides ut tota tremor pretentet equorum Corpora, si tantum notas odor attulit auras ? Ac neque eos jam fraena virum, neque verbera saeva, Non scopuli, rupesque cava?, atque objecta retard- ant Flumina, correptos unda torquentia montes."* The power of restraint, however, ddes not operate alike on all persons, even in the same state of society, and under a common discipline. Period of life, constitution, and habit, produce a considerable difference in this respect, and lay a foundation for the four following varieties of morbid salacity :— a Pubertatis. Salacity of youth. B Senilis.------of age. y Entonica.-------of full habit. & Assueta.-------of a debauched life. The first variety proceeds not so much from organic turgescence as from local irritabil- ity : for it is chiefly found in relaxed and delicate frames, weakened by overgrowth, or a life of indolence and indulgence. The action is new, and where, from whatever cause, the irritability is more than ordinary, a degree of excitement is produced which shows itself constitutionally or topically. If in the former way, hysteria, or chorea, or some other nervous affection, is a very frequent effect: if in the latter, a high-wrought and distressing degree of appetence. It is un- Virg. Georg., lib. iii., 250. Gen. III.—Spk. 2.] LAGNESIS FUROR. 463 der this state that females are said to be capable of separating ovula from their ovaries, and of forming corpora lutea without actual copulation, in the same manner as the ovaries of quadrupeds that are only capable of breeding in a certain season of the year, exhibit during their heat mani- fest proofs of excitement, and especially of florid redness, when examined by dissection. I do not think the assertion concerning women is alto- gether established : but in the case of young men when entering upon, or emerging from pubescence, and of the relaxed and delicate frame just noticed, nothing is more common than in- voluntary erection and seminal emission during sleep, often connected with a train of amorous ideas excited by the local stimulus, as we have already observed under paroniria salax. It is possible that this affection may occasion- ally be a result of entony or plethoric vigour, as well as of atony or delicacy of health : but the last is by far the most common cause. In the first case we have nothing more to do than to reduce the excess of living power by co- pious venesections and purgatives, active labour or other exercise, and a low diet. In the second, it will be expedient in a very considerable degree to reverse the plan. We may, indeed, palliate the topical irritation by the use of leeches and cooling laxatives; but, in conjunction with these, we should employ the unirritant tonics, as the salts of bismuth, zinc, and silver, or the sedative tonics, as the mineral acids, most of the bitters, and the cold bath. By taking off the debility, we take off the irritation ; and by taking off the irritation, we overpower the disease. The salacity of age is a very afflictive mal- ady, and often wears away the hoary form to the last stage of a tabid decline, by the frequency of the orgastic paroxysms, and the drain of sem- inal emissions without enjoyment. It is usually a result of some accidental cause of irritation in the ovaria, the uterus, the testes, or the prostate gland, and has sometimes followed a stone in the kidneys or bladder ; and is hence best reliev- ed by removing or palliating the local irritation by a warm hip-bath, anodyne injections, or cat- aplasms of hemlock, or the other umbellate or lurid plants in common use. Where these do not succeed, our only resource is opium and the warmer tonics. Entonic salacity, or that of a robust and sanguine temperament, is not always so easily remedied as might at first be supposed. Copious venesections, purgatives, and a reducent diet, and this succeeded by a regular use of neutral salts, and especially of nitre, will often, indeed, be found highly beneficial. But the erethism occasionally becomes chronic, and defies the ef- fects of all medicines whatever, and is excited by the slightest sensible causes, or even by the power of imagination (Swed. Nov. Nosol. Syst., i., p. 231); and where there is an excess of ir- ritability in the constitution, and the patient, from a principle of chastity, has sedulously re- strained himself from all immoral indulgences, the nervous system, and even the mind itself, have sometimes suffered in a very distressing degree. One or two examples of this we have already noticed under ecphronia mama, or mad- ness. The natural cure is a suitable marriage, wherever this can be accomplished ; but unless the union be of this character, it will often be attempted in vain. Professor Frank of Vienna, in his System of Medical Polity, relates the case of a lady of his acquaintance, of a warm and am- orous constitution, who was unfortunately mar- ried to a very debilitated and impotent man; and who, although she often betrayed unawares, by her looks and gestures, the secret fire that consumed her, yet, from a strong moral principle, resisted all criminal gratification. After a long struggle, her health at last gave way : a slow fever seized her, and released her from her suf- ferings. The salacity of a debauched life, or lech- ery produced and confirmed by habit, can only be cured by a total change of habit; which is a discipline that the established debauchee has rarely the courage toattempt. Exercise, change of place and pursuits, cooling laxatives, and a less stimulant diet than he will commonly be found accustomed to, may assist him in the at- tempt ; but in general, the mind is as corrupt as the body, and the case is hopeless. He perse- veres, however, at his peril, for with increasing weakness, he will at length sink into all the miserable train of symptoms characterizing that species of marasmus which is usually expressed by the name of tabes dorsalis.—(Cl. III., Ord. IV., Gen. ni., Spe. 4.) SPECIES II. LAGNESIS FUROR. LASCIVIOUS MADNESS. appetence unbridled, and breaking the bounds of modest demeanour and conver- sation : MORBID agitation of body and MIND. Most of the causes of the preceding species are causes of the present, though it shows it- self less frequently at the age of puberty. It is in fact very nearly related to the species sala- citas, though the local irritation is more violent, and the mind participates more generally and in a very different manner. Under the first, the patient has a sufficiency of self-command to con- duct himself at all times with decorum, and not to offend the laws and usages of public morals ; and if, as is rarely the case, however, the mind should at length become affected, it is rather by a transfer of the morbid irritation than an ex- tension of it, so that patients thus afflicted very generally lose the venereal erethism, and show no reference to it in the train of their maniacal ideas. In lascivious madness, on the contrary, this last symptom continues in its utmost ur- gency, all self-command is broken down, the judgment is overpowered, the imagination en- kindled and predominant, and the patient is hur- ried forward by the concupiscent fury like the brute creation in the season of heat, regardless equally of aU company and all moral feeling. As it occurs in males, it is the satyriasis furens 464 GENETICA. [Cl. V—Ord. It. of Cullen; as it occurs in females, it is the nymphomania furibunda of Sauvages.* The pulse is quick, the breathing short, the patient is sleepless, thirsty, and loathes his food ; the urine is evacuated with difficulty, and there is a continual fever. In women, the disease is often connected with an hysterical temperament, and even commences with a semblance of mel- ancholy (Delias, Advers., fascic. i.; Belol, Fu- ror Uterinus, Melancholicus Effedus, Paris, 1621); and I once had an instance of it, from local irritation, shortly after childbirth. The child having suddenly died, and there being no more demand for a flow of milk, the fluid was repelled from the breasts with too little caution, and the uterine region, from the debility it was yet labouring under, became the seat of a trans- ferred irritation. Among females, the disease is strikingly marked by the movements of the body and the salacious appearance of the countenance, and even the language that proceeds from the lips. There is often, indeed, at fir.st, some de- gree of melancholy, with frequent sighings ; but the eyes roll in wanton glances, the cheeks are flushed, the bosom heaves, and every gesture exhibits the lurking desire, and is enkindled by the distressing flame that burns within. In some cases, it has unquestionably proceed- ed from the perpetual friction of an enormous clitoris, making an approach, from its erection, to what Galen calls a female priapism. Biichner, Schurig (Gynacolog., pp. 2, 17), and Zacutus Lusitanus (Prax. Admir., lib. ii., obs. 91), give numerous examples of this ; and Bartholine has the case of a Venetian woman of pleasure, whose clitoris was rendered bony by frequent use, and consequently became a source of con- stant irritation. In hot climates, this kind of enlargement and elongation is by no means uncommon ; and as it becomes a source of uncleanliness as well as of undue excitement, circumcision, or a reduc- tion of the clitoris to its proper size, has been often performed with advantage. The same operation has been proposed for the case before us, and, in some instances, it has succeeded completely. " A young woman," says Richer- and, " was so violently affected with this disease as to have recourse to masturbation, which she '---'----------------------_-------'--------~TS * If a sound opinion can be drawn from the records of crime, lascivious madness would appear to be more common in those males who have pass- ed the bound of threescore years and ten, than at any other period of fife. The foUowing table is compiled from authentic documents: it relates ex- clusively to France, but goes far to estabUsh the above position. Of 1000 offences of a personal nature, or connected with personal violence, the ages, &c, were as follow :■■— Ages. Under 21 years, - 169 21 to 30, .- - 105 30 to 40, - - 73 40 to 50, - - 61 50 to 60, - - 32 60 to 70, - - 14 Above 70, . - 23 Rape on Rape on m f i Adults. Children. l otaL 123 - 292 58 - 163 59 - 132 94 - 155 88 120 166 . 180 318 341 D. repeated so frequently as to reduce herself to the last stage of marasmus. Though sensible of the danger of her situation, she was not pos- sessed of self-command enough to resist the or- gastic urgency. Her parents took her to Pro- fessor Dubois, who, upon the authority of Lev- ret, proposed .an amputation of the clitoris, which was readily assented to. The organ was removed by a single stroke of the bistoury, and all hemorrhage prevented by an application of the cautery. The wound heated easily, and the patient obtained a radical cure of her distressing affection."—(Nosographie Chirurgicale, &c) Where the cause cannot be easily ascertain- ed, we must employ a general plan of cure. If there be plethora or constitutional fulness, venesection should never be omitted; and, in most cases, cooling laxatives, a spare diet, with acid fruits and vegetables, cold bathing, local and general, will be found useful. Nitre has often proved beneficial; and to this may be ad- ded conium, aconite, and other narcotics. Cam- phire is also well worth a trial. From the infuriate state of the mind in most cases of this malady, Vogel has arranged both satyriasis and nymphomania as species of mania. But this is incorrect; the fury of the mind is merely symptomatic. Parr, on the contrary, has ranked it under lagnesis, to which, with great perversion, he applies the term hallucina- tio erotomania, or love-sickness, more properly a variety of empathema desiderii, and which, in the present and most other systems, is there- fore regarded as a mental malady. Love-sickness, however, may sometimes be an occasional or exciting cause, and its symp- toms may be united with the complaint, and even add to the general effect, of which the His- tory of the Academy of Sciences affords an in- stance (Ann. 1764, p. 26); but in itself it is, as we have already shown, altogether a disease of a different kind ; and where it becomes blended with concupiscent fury, it must be from a con- currence of some of the special causes of the latter, either general or local, which we have just pointed out. In males, the disease has led to quite as much exhaustion as in females ; Bartholine gives an example of a hundred pollutions daily. GENUS IV. AGENESIA. MALE STERILITY. inability to beget offspring. The generic term is a compound from a, nega- tive, and ylvonai, " to beget," and will be found to comprehend the three following species, de- rived from impotency of power or energy; an imperfect emission where the power is adequate ; or an incongruity in the copulative influences or fluids upon each other:— 1. Agenesia Impotens. Male Impotency. 2. -------- Dysspermia. Seminal Misemission. 3.--------Incongrua. Copulative Incongru- ity, Among plants we sometimes meet with a like Gen. IV.—Spe. 1.] AGENESIA generative disability, occasionally from imper- fectly formed styles or stigmas, stamens, or anthers ; sometimes from a suppression of farina, and sometimes from a total destitution of seeds : .which last defect is common to bromeliu ananas ; musca paradisiaca, ox banyan ; artocarpus incisa, or bread-fruit-tree ; and berberis vulgaris, or common berberry. SPECIES I. AGENESIA IMPOTENS. MALE IMPOTENCY. IMPERFECTION OR ABOLITION OF GENERATIVE POWER. The species before us is perhaps more gen- erally called by the nosologists anaphrodisia, though this last term has been used in very dif- ferent senses ; sometimes importing a want of desire, sometimes inability, sometimes both; and sometimes only a particular kind of inability, re- sulting from atony alone. The third species has never hitherto, so far as the author knows, been introduced into any nosological arrange- ment, although the reader will probably find, as he proceeds, sufficient ground for its admission. And even the first and second, closely as they are connected by nature, have rarely, if ever, been introduced before under the same common division, but been regarded as distinct genera, belonging to distant orders or even classes, and arranged with diseases that have little or no re- lation to them, of which numerous examples are given in the volume of Nosology. Impotency in males may proceed from two very distinct causes, showing themselves in different ways, and laying a foundation for the following varieties:— a Atonica. Atonic Impotency. ! B Organica. Organic Impotency. In tl.» first of these, there is a direct imbe- cility or want of tone; produced chiefly by ex- cess of indulgence, long-continued gleet,* or a paralytic affection of the generative organs. It has also been occasioned by a violent contusion on the loins, a fall on the nates (Hildan., cent. vi., obs. 59), and sabre wounds of the back of the neck. Of the latter, Baron Larrey saw vari- ous examples in the campaigns of the French armies, f Under the two first of these causes, a cure is often effected by time, and local tonics and stimulants, especially cold bathing: and the same process will frequently succeed where the weakness has followed, a chronic gleet: in which * This cause is not usually recognised, and, in- deed, it is fortunate that impotency is probably never the effect of so common a complaint as an old gleet. Were it otherwise, one half of the male population in London would most certainly be afflicted with impotency in early manhood. Gleets which are attended with and arise from bad stric- tures in the urethra, are accompanied, it is true, with an impossibility of perfect seminal emission; but here the cause is not the gleet, but the ob- struction m the urethra.—Ed. t See Chir. Militaire, &c. Such wounds were observed to bring on atrophy of the testicle.—Ed. Vol. II.—G g IMPOTENS. 465 we may also employ the course of remedies al- ready recommended for this complaint.—(Act. Nat. Cur., vol. v., obs. 59.) Where the impotency results from a paresis or paralysis of the local nerves, or has been brought on by a life of debauchery, the case is nearly hopeless. We have heard much of aph- rodisiacs, but there is none on which we can depend in effects of this kind. Wine, which is the ordinary stimulant in the case before us, will rarely succeed even in a single instance ; and where it has done so, it has increased the debility afterward. It is, in truth, one of the most common causes of the disease itself. Cantharides have often been employed, but in the present day they are deservedly dis- trusted, and flourish rather in proverbs than in practice.* Their effect, as a local stimulant, shows itself rather on the bladder and prostate gland than on the testes, and as a general ir- ritant in increasing the heat and action of the whole system, in which the testes may, perhaps, sometimes have participated. " They are," says Dr. Cullen,J' a stimulant and heating sub- stance, and I have had occasion to know them, taken in large quantity as an aphrodisiac, to have excited violent pains in the stomach, and a feverish state over the whole body."—(Mat. Med., vol. ii., p. 563.) Many of the verticillate plants, as mint and pen- nyroyal, have been tried in a concentrated state for the same purpose, but with different, and even opposite effects, in the hands of different practitioners. To the present hour they are supposed by many to stimulate the uterus spe- cifically, while they take off the venereal ap- petence in males. Upon sober and impartial trials, however, they seem to be equally guiltless of both: and may as readily be relinquished for such purposes as the nests of the Java swallow, which are purchased at a high price as a pow- erful incentive, and form an extensive article of commerce in the east. The best aphrodisiacs are warm and general tonics, as the stimulant bitters, and the metaflic salts, especially the preparations of iron. In China, ginseng has for ages been in high esteem, not only as a general restorative and roborant, but particularly in seminal debilities. Dr. Cul- len appears to have thrown it out of practice, by telling us that he knew " a gentleman a little advanced in life, who chewed a quantity of this root every day for several years, but who ac- knowledged that he never found his venereal faculties in the least improved by it." Local irritants, in many cases, have undoubt- edly been of use, as blisters, caustics, and se- tons. Electricity is said to have been still more * The remedial powers of the tincture of can- tharides certainly deserve to be mentioned in more qualified terms: there are doubtless cases of im- potency in which this article can have little or no good effect; but, on the other hand, it has proved serviceable in so many instances, that full confi- dence is placed in its powers, particularly in the United States, where it has been administered of late years with great, freedom.—See Hosack's Appendix to Thomas's Practice of Medicine.—D. 466 GENETIC A. [Cl. V—Okd. II. extensively serviceable; and friction with am- moniated oil, or spirits, or any other rubefa- cient, is fairly entitled to a trial. Stinging with nettle-leaves (urtica urens) was at one time a popular remedy, and flagellation of the loins (Meibom. de Flagrorum usu in re Venerea) or nates (Riedlin, Linn. Med., 1696, p. 6), or both, still more so. In organic impotency, forming our second variety, the chance of success is generally hope- less. This proceeds from a misformation or misorganization of the parts, either natural or ac- cidental : as an amputated, injured, or enormous penis, or a defect or destitution of the testes.* Plater introduces brevity or exility of the penis (Observ., Mb. i., pp. 249, 250) among the causes, but these evils are generally overcome by habit. An incurvated, retracted, or otherwise distorted form, is also mentioned by many writers ; but such cases seem rather to belong to the ensuing species. An unaccommodating bulk of the or- gan seems to have been no uncommon cause.— (Schung. Gynacolog., p. 226; Wadel, Pathol., sect, iii., p. 11.) Schenck gives an instance of this kind, in which the bulk was produced by the monstrosity of a double penis (Observ., lib. iv., N. 2, 8); and Albinus relates a case of a divorce obtained against a husband from inability to enter the vagina ob penem inormem.—(Dis- sert, de Inspedione Corporis, forensis, in causis matrimonialibus fallacibus et dubiis, Hall., 1740.) A similar litigation with divorce is recorded by Plater.—(Observ., lib. i., p. 250.) It has been doubted, whether a retention of the testes in the abdomen, or in the path of theii descent, will necessarily produce impotency. Swediaur distinctly affirms that impotency is not a consequence, and points out the impor- tance of rightly distinguishing between a real and apparent deficiency, in respect to the one or the other of these two cases.t * Bad strictures in the urethra, a cause already alluded to in a foregoing page, would rank as a case of organic impotency.—Ed. t Nov. Nosol. Syst., vol. ii., p. 351. This point has been already considered in the present vol., see p. 417. In Sir Astley Cooper's Observations on the Structure and Diseases of the Testes, Lond., 4to., 1830, pp. 52,53, maybe found some interesting facts relating to the subject of this part of Dr. Good's work. From these it appears, that a wast- ing of one testis at an early period of life does not deprive the individual of the power of pro- creation. Neither does the removal of one testis always seem to lessen virility. " A gentleman had his testis removed in January, 1821, for an enlargement and great hardness. He recovered in three weeks. His wife, by whom he had al- ready had one chfld, nursed him during his con- finement. In the month of March she proved pregnant, about nine weeks after the performance of the operation." Mr. Headington knew a man who had several children after losing one testicle by an operation. A man, one of whose testicles had been absorbed fourteen years, from wearing a truss for hernia congenita, married, and in due time became a father. It has twice fallen to the lot of Sir Astley Cooper to remove the testicle, where the other had already been lost. In the second case here referred to, the operation was SPECIES II. AGENESIA DYSSPERMIA. SEMINAL MISEMISSION. imperfect emission of the seminal fluid. This is the dysspermatismus, or, as it is usu- ally but incorrectly spelled, dy-spermatismus, of authors. The termination is varied, not merely on account of greater brevity and simplicity, but in conformity with the parallel Greek com- pounds, polyspermia, gymnospermia, aspermia, terms well known to every botanist, and the former of which are elegantly introduced into the Linnean vocabulary. Imperfection or defect of emission proceeds from numerous causes, accompanied with some change of symptoms as appertaining to each, and laying a foundation for the following va- rieties :— a Entonica. The imperfect emission pro- Entonic mise- ceeding from super-erec- mission. tion or priapism. 0 Epileptica. Rendered imperfect by the Epileptic mise- incursion of an epileptic mission. spasm produced by sexual excitement during the in- tercourse. y Anticipans. The discharge ejected hast- Anticipating ily, prematurely, andwith- misemission. out due adjustment. & Cunctans. The discharge- unduly re- Retarding mis- tarded from hebetude of emission. the genital organs; and hence not accomplished till the orgasm, on the part of the female, has subsided. c Refluens. The discharge thrown back Refluent mise- into the vesiculae semi- mission, nates,* or the bladder, be- fore it reaches the ex- tremity of the pepis. performed in Guy's Hospital, in 1801. Four days afterward, the patient informed Sir Astley that he had had, in the preceding night, an emission, which appeared upon his linen. For nearly a twelvemonth, it seems that he had emissions in coitu, or the sensation of them. That he then had erections and connexion at long intervals, but without the sensations of emission. After two years, he had erections very rarely and imper- fectly, and in time the penis became shrivelled and wasted. It would appear, then, that in this case castration led to a cessation of all seminal emission at the end of a few months. The emis- sion, such as it was, also, could only have been of the fluids secreted by the vesiculae seminales and prostate gland.—Ed. * The idea, once prevalent, that the vesiculae seminales were merely reservoirs for the semen, has yielded to the better-founded opinion, that their office is to produce a secretion of their own, which becomes blended with the semen. Mr. Hunter remarked, not only that the fluid contained in the vesiculae seminales was quite different from semen; but that, when the testis on one side had been long removed, the same fluid was still found, on dissection, in the corresponding vesicula sem- inalis. Dr. Good's statement, therefore, respect- ing the reflux of the semen into the vesicuke seminales, must be regarded as erroneous.— Ed. Gen IV—Spe. 2.] AGENESIA DYSSPERMIA. 467 Of the first, or entonic variety, examples are by no means uncommon. Dr. Cockburn gives an instance in a young noble Venetian, who, though married to a fine and healthy young lady, had no seminal emission in the act of union, notwithstanding there was a vigorous erection, while he could discharge very freely in his dreams.—(See a'similar case in Marcel. Donat., lib. iv.", cap. 18.) As no remedy could be devised at home, the Venetian ambassadors, resident at the different courts of Europe, were requested to consult the most eminent physi- cians in their various quarters. The case came in this manner under the notice of Dr. Cock- burn, who, hitting accurately upon the cause of the retention, and ascribing it to the violence of the erection, or rather, to the plethora of the penis, whose distention produced a temporary imperforalion of the urethra, advised purgative medicines and a slender diet, which soon pro- duced the desired issue.—(Edin. Med. Essays, i., p. 270.) I remember, many years ago, a healthy young couple, who continued without offspring for seven or eight years after marriage, at which period the lady, for the first time, became pregnant, and continued to add to her family every year till she had six or seven children; and in pro- fessional conversation with the father, he has clearly made it appear to me that the cause of sterility during the above period was the mor- bid entony we are now discussing. Time, that by degrees broke the vigour of the en- counter, effected at length a radical cure, and gave him an offspring he had almost despaired of. Mr. J. Hunter recommends opium in this case, as the best allayer of the undue stimulus, and nothing can be more judicious; for M. Bauer has shown, by microscopical drawings, that the corpus spongiosum, as well as the cor- pora cavernosa, are divided into cells or trellis- work by an infinite number of fine membranous plates, and that the minute arteries which open into them, and fill them with blood in their dis- tended state, are very numerously attended with nerves (Phil. Trans., communicated by Sir E. Home, Bart., 1820, p. 183), the peculiar excite- ment of which produces the exundation. And hence opium or any other narcotic, by acting as a sedative, and moderating the excitement, must bring down the organ to a desirable scale of tone. The second variety, or misemission from the incursion of an epileptic fit, it is not diffi- cult to account for. Persons who are predis- posed to epilepsy are for the most part of a highly irritable habit; and wherever the predis- position exists, any accidental excitement is sufficient to produce a fresh paroxysm: and hence it is seldom more likely to occur than from the commotion of a sexual embrace. Even death itself has sometimes ensued in conse- quence of the violence of the venereal paroxysm. Examples of epilepsy from this cause, as col- lected in the public medical records, are numer- ous. Among men, one of the most famous in- stances is that of the celebrated Hunnish chief Attila.—{Borelli, Amalth. Med. Hist., p. 161.) Morgagni (De Sed. el Caus. Morb., ep. xxvi., art. 13) and Sinbaldus (Geneanthropia, p. 794) have given examples among women. Hence, a life of matrimony had better be re- linquished by those who are thus afflicted, as well on their own accounts as on that of their descendants. And where marriage is actually effected, sexual commerce should be sedulously abstained from at the periods in which the dis- ease is accustomed to recur, or during the con- tinuance of those signs by which a paroxysm is usually preceded. The third and fourth varieties, or antici- pating and retarding misemission, are put to- gether by Ploucquet under the name of ejacula- iio inlempcsliva (Init. Biblioth., torn, iv., p. 61, 4to.fTubing., 1795), and are equally entitled to this character : while the former is, by Schenck, denominated ejaculalio pramatura.—(Observ., lib. iv., obs. 46.) The anticipating or premature variety evinces great nervous irritability in a delicate or relaxed habit; the plethora of the first or entonic va- riety would produce the best and most effectual cure; but as this is rarely to be accomplished in a constitution of this kind, tonics, a plain but nutritious diet, especially light suppers, and, more especially still, a bidet of cold water be- fore retiring to bed, form the most effectual means of subduing this precession of gener- ative power. In some cases, the afflux has been so quick as to take place even before the vagina has been fairly entered. The fourth or retarding variety forms a perfect contrast to the preceding. It imports a sluggishness either of constitution or of local erethism, in consequence of which the seminal flow does not take place till the orgasm of the female has subsided, and fatigue, perhaps dis- gust, have succeeded to desire. Here, too, general tonics and local stimulants offer the fairest chance of success ; and both sting-nettles (Eph. Nat. Cur., dec. ii., ann. v., App.,p. 794) and flagellations (Meibom. and Riedlin., loc. citat.), as in some cases of organic impotency, are said to have worked wonders. The variety is generally described under the name of brady- spermatismus. The refluent variety is chiefly introduced upon the authority of M. Petit (Mimoires de - I'Academie de Chirurgie, i., p. 434), whose de- scription has been copied by Sauvages. " It consists," he tells us, "in a reflux of the semen into the bladder or vesiculae seminales, on ac- count of the narrowness of the urethra, in con- sequence of which there is no semination during the inter-union, and the semen is afterward dis- charged with the urine." This narrowness is common to those who have suffered from frequent blennorrhoeas, and have hence contracted strictures or indurations in the course of the urethral passage. Deidier adverts to a patient who laboured under a fistula that opened from the vesicula? seminales into the rectum; in consequence of which, though sound in every other respect, whenever he em- braced his wife, scarcely any of the semen es- caped from the penis, nearly the whole passing 468 GENETICA. [Cl V—Ord. n. into the intestine, intermixed with a small quanti- ty of urine; and hence his marriage was steril.* In all these cases, the cure of the impotency must depend upon a cure of the local cause of constriction. The dysspermattsmus urethralis, nodosus, and mucosus of Sauvages, and Cullen, who has copied from him, are all resolvable into this variety, as proceeding from like causes, and producing a hke effect. SPECIES III. AGENESIA INCONGRUA. COPULATIVE INCONGRUITY. the seminal fluid inaccordant, in its con- stituent PRINCIPLES, WITH THE CONSTITU- TIONAL DEMAND OF THE RESPECTIVE FEMALE. All the species of this genus are closely con- nected : yet it is only the first two that have hitherto been noticed by nosologists: nor is there any preceding system, that I am aware of, un- der which even these two have been introduced into the same subdivision. In almost every in- stance, indeed, they have been regarded as dis- tinct genera, belonging to distant orders or even classes, and arranged with diseases that have little or no relation to them. Thus, in Sauva- ges, impotentia, by him called anaphrodisia, oc- curs in the second order of his sixth class, uni- ted with such diseases as " loss of thirst" and "desire of eating;" while jdysspermia, or dys- spermatismus, is carried forward to the third order of his ninth class. In Cullen, these dis- eases occur indeed in the same class, a very improper one, that of locales, but under dif- ferent orders of this class ; impotentia being ar- ranged under the second order, with the morbid cravings of the alimentary canal, and some of those of the mind, as nostalgia; and dyssper- mia being placed under the fifth order, entitled epischeses, or suppressions. The present species is, for the first time, so far as the author knows, introduced into a noso- logical system; and is derived from personal observation, in full accordance with the scat- tered remarks of several other writers and prac- titioners. The principle upon which the species * Tom. iii., consult, i. That the account here given cannot possibly be correct, is quite obvious ; first, because a communication between the vesi- cula seminalis and the rectum will not explain the alleged circumstance of nearly the whole of the semen passing into that bowel instead of along the urethra. This is obvious, even if the vesicula? seminales were reservoirs for the semen, as was once the incorrect supposition ; but now, when it is known that they perform no such office, the in- sufficiency of the explanation is still more mani- fest. Secondly, if urine really passed into the rectum, there must have been a fistula between the cavity of the bowel and that of the bladder; and therefore, in all probability, no such commu- nication between the vesicula seminalis and the rectum; and the fluid, conjectured to be semen, could have been neither the secretion of the testes, nor that of the vesicula seminalis, but possibly some of the mucus of the inner coat of the bowel itself. The patient's infirmity must have been owing to different causes.—Ed. is founded, belongs strictly to the general doc- trine of conception, and has been already ex- plained in the Physiological Proem to the pres- ent class. It will hence be sufficient to throw out a few additional hints, for the purpose of bringing the principle more immediately home to the disease before us, and supporting the propriety of its introduction into the general register. Every one must have noticed occasional in- stances in which a husband and wife, apparently in sound health and vigour of life, have no in- crease while together ; either of whom, never- theless, upon the death of the other, has become the parent of a numerous family; and both of whom, in one or two curious instances of di- vorce, upon a second marriage. In various in- stances, indeed, the latent cause of sterility, whatever it consists in, seems gradually to di- minish, and the pair that was years childless is at length endowed with a progeny. In all this, there seems to be an incongruity, inaccordancy, or want of adaptation, in the constituent princi- ples of the seminal fluid of the male to the sex- ual organization of the respective female ; or upon the hypothesis of the epigenesis, which we have already illustrated, to the seminal fluid of the female. Writers, strictly medical, have not often adverted to this subject, though it is appealed to, and for the most part'with appro- bation, by physiologists of all ages and coun- tries. Sauvages, however, evidently alludes to and admits such a cause in his definition of dis- spermatismus serosus, which is as follows :— " Ejaculatio seniinis aquosioris, adeoque ad gen- esim inepti, quae species est frequentissimum sterititatia virilis principium." He illustrates his definition by a case which occurred to Hague- not and Chaptal, who attributed it to the cause in question, and refers for other examples to Etmuller. Cullen expresses himself doubtfully upon this species, " De dysspermatismo seroso Sauvagesii," says he, " mihi non satis constat." Yet his own gonorrhaa laxorum, in the present system spermorrhaa atonua, and which he ex- plains " humor plerumque peUucidus, sine penis erectione, sed cum libidine, in vigilante, ex ure- thra fluit," makes so near an approach to it, that the physiologist who admits the one can find little difficulty in admitting the other. The re- semblance is indeed close and striking ; in the latter disease, the individual labouring under it emits involuntarily, and without coition, or even erection, but with a libidinous sensation, a pel- lucid fluid, apparently of a seminal character, affirmed positively by Sauvages, from whom Cul- len derives his species, and to whom he refers, to be an " effluxus seminis ;" while, in the for- mer, the same dilute and effete semen, with dif- ficult and imperfect erection, is poured forth during coition. In like manner, Forestus speaks of a proper gonorrhoea, or involuntary emission of the semi- nal fluid, produced ex aquositate (Lib. xxvi., obs. 12), from too watery a condition of the secre- tion : Timaeus, of the same disease occasioned ex semine acri (Cos., p. 188), by a secretion of an acrimonious semen ; and Horuung, of hys- Oen. V—Spk. 1.] APHORIA IMPOTENS. 469 terics occasioned in married women, who are steril from an "immissio frigidi seminis" (Cista, p. 487); an expression adopted from, or at least employed by Ballonius (Opp. i., p. 120), and sup- ported by Schurig (Spermatologia, p. 21) and Ab Heer.—(Observ. Rar., N. 10.) The explanation, however, now offered, takes a more comprehensive view of the subject, by supposing that the seminal fluid may be secre- ted, not merely in a state of morbid diluteness, but under various modifications, even in a state of health, of such a condition as to render it inadequate to the purposes of generation in fe- male idiosyncrasies of certain kinds, while it may be perfectly adequate in those of other kinds. In agricultural language, it supposes that the respective seed may not be adapted to the respective soil, however sound in itself. So Parr tells us, on another occasion, that " in some in- stances, the semen itself seems defective in its essential qualities."—(Diss., art. Anaphrodis- ia.)* Here, again, the mode of treatment must be regulated by a close attention to the nature of the cause. In most cases, whatever will tend to invigorate the system generally, will best tend to cure the sterility : as a generous diet, exer- cise, the cold bath, and particularly the use of the bidet or local cold bath. With these may be combined the warm and stimulant resins and balsams, as guaiacum, turpentine, copayva ; and the oxydes of iron, zinc, and silver. Abstinence by consent for many months has, however, proved a more frequent remedy than any other, and especially where the intercourse has been so incessantly repeated as to break down the staminal strength : and hence the sep- aration produced by a voyage to India, has often proved successful. GENUS V. APHORIA. FEMALE STERILITY. BARRENNESS. INABILITY TO CONCEIVE OFFSPRING. Aphoria (aopia), "sterilitas," " infecunditas," from a, negative, and lood will suffice ; but the depletion must be repeated at distinct intervals if the cough should continue unabated. Gentle laxatives should succeed to the bleeding, and be perse- vered in as the bowels may require. And to these may be added mucilaginous demulcents, united with such doses of hyoscyamus, conium, or opium, as are found best to agree with the state of the constitution. There is little dan- ger, nevertheless, of this cough terminating in consumption, however troublesome and obstinate it may be in itself, for it is rarely that two su- peradded actions go forward in the constitution at. the same time : and hence, whenever preg- nancy takes place in a patient labouring under phthisis, the progress of the latter disease is arrested till the new process has run its course. Derangements of the alvine canal, under some modification or other, accompany most cases of pregnancy, are often very distressing, and by their irritation sometimes hasten on la- bour-pains before their time. These affections are of two very opposite kinds. In some instances, the intestines parti- cipate in the irritability of the uterus, the peris- taltic action is morbidly increased, and there is a troublesome diarrhoea. In others, the larger intestines appear to be rendered torpid, partly by the share of sensorial power which is taken from them in support of the new action, and partly by the pressure of the expanding uterus on their coats. In both cases, piles are a fre- quent attendant, but particularly in the last. The diarrhoea varies in different individuals, from a looser flow of proper feces to a muculent secretion, or a dejection of dark-coloured of- fensive stools, accompanied with a foul tongue and loss of appetite. The first modification re- quires no remedy, and may be safely left to it- self. The second and third import a morbid ac- tion of the excretories of the intestines, and are best relieved by small and repeated doses of rhubarb with two grains of ipecacuanha to each (Burns, Principles of Midwifery, p. 154), and afterward by infusions of cascarilla, orange- peel, or any other light aromatic bitter. The costiveness must be carefully guarded against by such aperients as are found upon trial to agree best with the bowels. Where acidity Vol. II—Hh in the stomach is suspected, magnesia may be employed, and will often prove sufficient: but where this does not exist, the senna electuary, the sulphate of magnesia, or castor-oil, will be found to answer much better. The piles will usually disappear as soon as the bowels are re- stored to a current state : and, if not, they should be treated according to the plan already laid down under proctica marisca.—(Vol. i., p. 195.) Varicose dilatations of the veins of the lower extremities are a frequent, though not often a very troublesome accompaniment of pregnancy. They are chiefly found in women whose occupation obliges them to be much on their feet. Where the affected veins are first perceived to enlarge, the varicose knots may generally be prevented by exchanging the ac- customed erect position for a recumbent one, and using the legs but little. Where the vari- ces are actually formed, the legs may be cov- ered with a bandage drawn only with such mod- erate pressure as to afford gentle support; for, if carried beyond this, we shall only endanger a worse congestion in some other part not equally guarded against. For the rest, the reader may turn to exangia varix, in a preceding part of this work.—(Cl. III., Ord. IV., Gen. XI., Spe. 2.) Pregnancy may also take place during the ex- istence of abdominal dropsy, or even give rise to it, and the general pressure and enlargement may be so considerable as to threaten suffoca- tion. The ascites will be hereby considerably complicated ; but its mode of treatment will be best considered under the latter disease.— (Infra, Cl. VI., Ord. n., Gen. I., Spe. 5.)* SPECIES II. PARACYESIS UTERINA. LOCAL DERANGEMENT OF PREG- NANCY. PREGNANCY DISTURBED OR ENDANGERED BY SOME DISEASED AFFECTION OF THE UTERUS. In the progress of this work, we have seen that, on the commencement and through the course of impregnation, the periodical secretion of the uterus is suspended ; that the organ grad- ually enlarges from its ordinary size, till in the ninth month it measures ten or twelve inches from top to bottom ; and that, in the course of this enlargement, it changes its position, ac- cording to a law that is never departed from in a state of health. In a state of morbid action, however, or from some accidental injury, the uterus does not al- ways maintain its proper position, nor abstain * The constitutional derangement of pregnancy is so frequently relieved by venesection, that many American practitioners are in the habit of bleeding at different periods of gestation. The affections of the digestive system, which sometimes annoy the sufferer to a great extent, are often entirely con- trolled by using prussic acid, given in doses of one drop two or three times a day. Dr. Delafield of New-York, has found this remedy very suc- cessful.—D. 482 GENETICA. [Cl. V.—Ord. III. from throwing forth not only its ordinary and natural secretions, but other fluids of a morbid character; and hence becomes subject to sev- eral varieties of affection, of which it may be sufficient to notice the following :— a Retroversa. Retroversion of the uterus; B Leucorrhoica. The uterus secreting, or ex- citing in the vagina, a se- cretion of leucorrhoea, so as to produce debility. y Catamenica. The catamenia continuing to recur. S Haemorrhagica. Accompanied with hemor- rhage. A retroversion of the uterus may be pro- duced in various ways, though it is seldom found except in pregnancy, and between the third and fourth month of this state. This organ, not- withstanding its appendages of broad and round ligaments, is still left pendulous in the hypogas- trium: and hence, if the fundus or broad and upper part happen, by a scirrhous induration, or pregnancy, or any other means, to acquire a certain bulk and weight, and if at the same time the cervix, or lower and narrow part, be pushed on one side by any accidental force, as that of the bladder when distended, the broad and up- per part will tumble downward, white the nar- rower part ascends and takes its place. It is this which constitutes a retroverted uterus ; but as it occasionally occurs under other stages than that of pregnancy, we have treated of it al- ready under the genus ^doptosis uteri, where we have stated the mode of treatment to be adopted in the case before us. Leucorrhcea is a result of the increased ac- tion excited in every part of the uterus, or of the upper part of the vagina, which is inflamed by continuous sympathy. The mucous dis- charge, denominated leucorrhoea or whites, ap- pears to be secreted from the lower part of the uterus, and the upper part of the latter organ ; and hence any excitement operating on the fun- dus of the womb, may be easily conceived, un- der a particular condition of the cervix of the uterus and the vagina, t>r of the system gener- ally, capable of producing this secretion in con- siderable abundance. When treating of leucorrhoea as an idiopathic affection, we remarked, that where the discharge is excessive, it produces considerable debility of the system generally, and of the sexual and lum- bar regions more particularly ; and that when it becomes chronic, it often degenerates into an acrimonious condition, and occasions great dis- quiet by excoriating the cuticle to a considerable extent. Both these evils are consequent upon its oc- currence in pregnancy, and the first has occa- sionally threatened abortion. They are to be relieved by the remedial process already pointed out under the genus leucorrhcea. A continuance of the catamenial discharge at the regular periods is also, in many cases of delicate habits, a source of great weakness and discomfort, and sometimes endangers miscar- riage 01 premature labour ; in all which instan- ces it ought to be checked by a recumbent posi- tion, and particularly a little before the time in which it may be expected, and by the other means already enumerated under paramenia superflua. It has sometimes continued, how- ever, in strong and vigorous habits, through the whole period of pregnancy without any serious mischief (Hagedorn, cent, ii., obs. 94) ; though even here it has usually been found to produce general debility, and many troublesome dyspep- tic symptoms. Hemman* and several other writers give cases of women who have never menstruated except when in a state of pregnancy ; such is the degree of irritation which the secretories of the uterus occasionally demand in order to be roused into a due performance of their function. So some persons can only see on a full expo- sure to a meridian light, and others can only hear when the tympanum is irritated by the noise of a drum or of a carriage, sufficient to deafen all the world around them. Hemorrhage from the uterus is sometimes connected with this irregular return of the pe- riodical discharge ; as we have already observed, it is not unfrequently in an unimpregnated state of the organ. In both cases, this is usually a consequence of great general debility, and it is hence the more alarming in any period- of par- turition, as risking the loss of the uterine fruit. In the delicacy of habit we are now contempla- ting, bleeding would only add to the debility or predisponent cause ; and we must content our- selves with the plan already recommended un- der atonic hemorrhage of the uterus in a prior class and volume.—(Vol. i., Cl. III., Ord. IV., Gen. II., Spe. 2.) Where the discharge has been induced by external violence or a sudden emotion of the mind, venesection will be the best remedy we can have recourse to, and af- terward thirty or five-and-thirty drops of lauda- num in a saline draught, with two or three grains of ipecacuanha. SPECIES III. PARACYESIS ABORTUS. MISCARRIAGE. ABORTION. premature exclusion of a dead fcetus from the uterus. We have stated, in the introductory re- marks to the present order, that the usual term of pregnancy is forty weeks, or nine calendar months. Within this period, however, the foetus maybe morbidly expelled at any time. If the exclusion take place within six weeks after con- ception, it is usually called miscarriage; if be- tween six weeks and six months, abortion ; if during any part of the last three months before the completion of the natural term, premature labour. Among some writers, however, abor- tion and miscarriage are used synonymously, and both are made to express an exclusion of the foetus at any time before the commencement of * Medicinisch-Chirurgische Aufsatze., Berl. 1778. Hopfergartner, fiber menschliche Entwic ] kelungen, p. 71, Stutg., 1792. Gen. I.—Spe. 3.] P-ARACYESIi the seventh month. At seven months the foetus will often live. It has been bom alive, in a few rare instances, at four months (A. Reyes, Cam- pus Elys. Quest., 90, p. 1164); and has as rarely continued alive when bom between five and six months.—(Brouzet, sur VEducation Midicinale des Enfans, i., p. 37.) The process of gestation may be checked, however, from its earliest period ; for many of the causes of abortion which can operate after- ward, may operate throughout the entire term ; and hence a miscarriage occurs not unfrequently within three weeks after impregnation, or before the ovum has descended into the uterus. In this case the pains very much resemble those of difficult menstruation ; and, with a considerable discharge of clotted or coagulated blood, the tu- nica decidua passes away alone, having also some resemblance to that imperfect form of it which we have already noticed as being pro- duced in' some cases of difficult menstruation, but exhibiting a more completely membranous structure. And here the ovulum escapes un- perceived at some subsequent period, and is probably decomposed and incapable of being traced. In later periods of pregnancy, abortion con- sists of two parts or stages ; the separation of the ovum from the fundus of the womb, and its expulsion from the mouth. Sometimes these take place very nearly simultaneously, but some- times several days, or even weeks intervene ; so that the process of abortion may considerably vary in its duration, and become exceedingly te- dious. In several cases I have known the ovum remain undischarged for upwards of six weeks, and in one case, for three months after its separ- ation, and consequently after the death of the foetus, comparing its size and appearance with the ascertained term of gestation. Through the whole of this period there is an occasional discharge from the vagina, and often temporary disquietudes, and even contractile pains in the uterus. Rut both are of a very dif- ferent kind from those which occur antecedently to the separation of the ovum. The first pains are usually sharp and expulsory, with a free dis- charge of clotting arterial blood ; sometimes in- deed in an alarming, though rarely a dangerous profusion ; the last are dull and heavy, and the discharge is smaller in quantity, dark, and fetid. We may also judge of the detachment of the ovum, and consequently the death of the foetus, by the cessation of those sympathetic symptoms which have hitherto connected the stomach and the mammae with the action of the uterus ; as the morning sickness, and the increasing plump- ness of the breasts, which not unfrequently are so stimulated as to secrete already a small quan- tity of milk. On the separation of the ovum from the fundus of the uterus, all these disap- pear ; the stomach may be dyspeptic, but with- out the usual sickness, and the breasts become more than ordinarily flaccid. The ovum, when at length discharged, comes away differently in different cases. Sometimes the whole ovum is expelled at once ; but more generally it is discharged in detached parts, the S ABORTUS. 483 foetus first escaping with the liquor amnii, or de- scending with its own proportion of the placen- ta, the maternal proportion following some hours or even days afterward. And where there are twins, one of the foetuses, naked or surrounded with its membranes, is usually expelled alone, and the other not till an interval of several hours, or even a day or two ; the discharge of blood ceasing, and the patient appearing to be in a state of recovery ; so that, in cases of early abortion, it is difficult to determine whether there are twins or not. The causes of abortion are very numerous; and some of them are rather conjectured than fully ascertained. They may depend upon the ovum itself, upon the uteru6 itself, or upon the uterus as affected by the nature of the maternal constitution, or accidental lesions.* " The imperfections observable in Ova," re- marks Dr. Denman, " are of different kinds, and found occasionally in every part; and there is usually a consent between the foetus and the shell of the ovum, as the placental part and membranes may be called, but not always. For examples have occurred in which the foetus has died before the termination of the third month, yet the shell, being healthy, has increased to a * Abortion, as Dr. Robert Lee observes, is a frequent occurrence in the early months of preg- nancy, particularly among women of the lower classes of society, who are exposed to much bod- ily fatigue and mental anxiety. It is more likely to occur in plethoric, irritable, and nervous sub- jects ; in women who are affected with constitu- tional diseases, more especially syphiUs ; in those who have deformity of the bones of the pelvis, or some organic disease of the uterine organs. All the chronic diseases, therefore, to which the ute- rus and its appendages are liable, may be consid- ered causes of abortion. The production of polypi in the cavity of the uterus, or of fibro-cartilaginous tumours in its walls, and morbid adhesions of the uterus to the surrounding viscera, may all, by im- peding the regular enlargement of the gravid ute- rus, give rise to premature expulsion of its eon- tents. But, according to Dr. R. Lee, by far the most frequent cause of abortion is in the product of con- ception itself, viz., in a diseased condition of the foetus or its involucra, by which it is deprived of life, and afterward expelled from the uterus hke a foreign body. Sometimes the chorion is thick- ened, opaque, and extremely irregular, or Iobula- ted on its internal surface. In certain cases, the amnios undergoes similar changes. Blood and serum may also collect between these two mem- branes ; and where abortion takes place after the third month, the placenta has sometimes been found much indurated, and of diminutive size, with calcareous matter deposited in its substance. In other instances the placenta has been unusually large, and its vascular structure converted into a soft fatty substance, or it has contained hydatids. Under these circumstances, the umbilical cord has been remarkably slender, and the foetus has ap- peared to perish for want of a proper supply of nourishment, and not from any defect in the sup- ply of its internal parts. Various organic dis- eases of the brain and other viscera of the foetus, by extinguishing its life, make it an extraneous body, for the expulsion of which, efforts on the part of the uterus soon commence.—See Cyclop. of Pract. Med., art. Abortio^.—Ed 484 GEN] ♦ certain size, has remained till the%xpiration of the ninth month, and then been expelled, accord- ing to the genius and constitution of the uterus, though frequently it has been found to have un- dergone great changes, as, for instance, in many cases of hydatids."—(Practice of Midwifery, 5th edit., p. 508, 8vo.) "It is remarkable," says the same author, " that women who are in the habit of miscarry- ing go on in a very promising way to a certain time, and then miscarry, not once, but for a number of times, in spite of all the methods that can be contrived and aH the medicines that can be given; so that, besides the force of habit, there is sometimes reason to suspect that the uterus is incapable of distending beyond such size, before it assumes its disposition to act, and that it cannot be quieted till it has excluded the ovum. What I am about to say will not, I hope, be construed as giving a license to irregularity of conduct, which may often be justly assigned as the immediate cause of abortion, or lead to the negligent use of those means that are likely to prevent it. But from the examination of many ova after their expulsion, it has appeared that their longer retention could not have pro- duced any advantage, the foetus being decayed, or having ceased to grow long before it was ex- pelled. Or the ovum has been in such a state as to become wholly unfit for the purpose it was assigned to answer : so that if we could believe there was a distinct intelligence existing in every part of the body, we should say it was con- cluded in council that this ovum can never come to perfection, and shall be expelled."—(Denman, ubi supra, p. 508.) The causes of abortion of a constitutional or accidental kind are more obvious. They may be internal, and depend upon a relaxed or debil- itated state of the system generally, and conse- quently of the uterus as a part of it; or exter- nal, and depend on adventitious circumstances. Violent pressure, as that of tight stays, by pre- venting the uterus from duly enlarging, is an obvious cause, as is also that of a sudden shock by a fall, or a blow on the abdomen ; violent ex- ertion of every kind is a cause not less obvious, as that of immoderate exercise in dancing, riding, or even walking ; lifting heavy weights ; great straining to evacuate the feces, or too frequent evacuations from a powerful purgative. Violent excitement of the passions, as terror, anxiety, sorrow, or joy. Violent excitement of the ex- ternal senses by objects of disgust, whether of sight, sound, taste, or even smell; or whatever else tends to disturb or check the circulation suddenly, and hereby to produce fainting, will often prove a cause of abortion.* And when once this affection has been produced, the or- gans with difficulty recover their elasticity, and it is extremely apt to recur upon the slight- est causes. Plater gives us an account of four- * One of the best accounts of the cau ses of abor- tion is contained in Prof. T. R. Beck's Med. Juris- prudence ; art. Infanticide, ed. 1825. An ex- cellent summary of them may be found in Ryan's Manual, p. 193.—Ej^ TICA. [Cl. V.—Ord. III. teen miscarriages in succession (Observationes, lib. ii., p. 467); Werlhoff, of five within two years (Opp. iii., p. 718); and Werloschnig, of not less than eight in a single year.—(De Cura- tionibus Verno-autumn., p. 496.) Wolfius re- lates the history of a woman who, in the whole course of her life, suffered twenty-two distinct abortions (Lection. Memor.,p. 418); and Schultz, that of another, who in spite of every remedy miscarried twenty-three times, and uniformly in the third month, probably from an indisposition in the uterus to become distended further, as suggested by Dr. Denman.* Another and a very frequent cause is pletho- ra, and this whether it be from entony or atony. "The uterus," observes Mr. Bums, "being a large vascular organ, is obedient to the laws of vascular action, while the ovum is more influ- enced by those regulating new-formed parts: with this difference, however, that new-formed parts or tumours are united firmly to the part from which they grow by all kinds of vessels, and generally by fibrous or ceUular substance, while the ovum is connected to the uterus only by very tender and fragile arteries and veins. If, therefore, more blood be sent to the maternal part of the ovum than it can easily receive, and circulate and act under, a rupture of the ves- sels will take place, and an extravasation and consequent separation be produced; or even where no rupture is occasioned, the action of the ovum may be so oppressed and disordered as to unfit it for continuing the process of ges- tation, "t Now in atonic plethora, or that commonly ex- isting in high and fashionable life, among those who use little exercise, live luxuriously, and sleep in soft warm beds, although the action that accompanies the pressure is feeble compared with what occurs in the opposite state, the ves- sels themselves are feeble also, and their mouths * " I was recently caUed in attendance on a lady," says Dr. Francis, " who has sustained thir- teen abortions in succession during the past nine years : sometimes the gravid womb freed itself of its contents at the completion of the second month : at several other times the duration of gestation was continued to the fifth and sixth months, and in her last pregnancy to the full termination of the eighth month. Vascular irritation or plethora seemed to be the only cause that could be assign- ed for these accidents. She has never bome a living child."—D. + Principles of Midwifery, 3d edit., 8vo., p. 191. To use the words of Dr. Robert Lee, the placenta adheres to the uterus by means of the deciduous membrane alone, which is directly applied to the openings of the uterine sinuses. If the impetus of the blood in these be increased by an excited state of the general circulation, or by the irritation of the uterus itself, an unusual afflux of blood to these vessels will take place, and the placenta will be forced from its connexion with the uterus, more or less extensively, by the extravasation of blood from the opening of the uterine sinuses between the placenta and uterus. If this happen to a con- siderable extent, the process of gestation will be arrested, and, sooner or later, the ovum will be expelled.—See Cyclop, of Pract. Med., art. Abor- tion.—Ed. Gen I.—Spe. 3.] PARACYESIS ABORTUS. 485 and tunics are exceedingly apt to give way to even a slight impetus ; and hence plethora be- comes a frequent cause of abortion in women of a delicate habit and unrestrained indulgence. Among the robust and the vigorous, however, its mode of operation is still more obvious and direct. An increased flow of blood is here forced urgently into the uterus, which participates ir- resistibly in the vehemence of the action ; so that if the vessels do not suddenly give way, and hemorrhage instantly occur, the patient feels a tensive weight in the region of the uterus, and shooting pains about the pelvis. " This cause," observes Mr. Burns, " is especially apt to oper- ate in those who are newly married, and who are of a salacious disposition, as the action of the uterus is thus much increased, and the ex- istence of plethora rendered doubly dangerous. In these cases, whenever the menses have be- come obstructed, all causes tending to increase the circulation must be avoided, and often a temporary separation from the husband is indis- pensable."—(Burns, ut supra, p. 192.) The general treatment of abortion consists of two intentions; that of preventing it when it threatens, and that of safely leading the patient through it when there is little doubt that it has taken place. The chief symptoms, menacing abortion, are transitory pains in the back, or hypogastric re- gion, or a sudden hemorrhage from the vagina. In all these cases, the first step to be taken is a recumbent position, and when the patient is once placed in this state, we should deliberately examine into the nature of the cause. If there be symptoms of plethora, or oppression, if an accident, or a sudden emotion of the mind, or severe exercise, as of dancing, riding, or even walking, have produced them by disturbing the equilibrium of the circulating system, blood should be immediately taken from the arm, and all irritation removed from the bowels by a gen- tle laxative or injection.* In plethora, indeed, we may go beyond this, and empty the bowels more freely : yet even here our object should be to reduce without weakening."!" In every in- stance, except where plethora prevails, after ab- stracting blood, the next best remedy is a full dose of opium, consisting of thirty or forty drops of laudanum, or more if the symptoms be urgent, and repeated every three or four months till the object is obtained.}; And where the system is * A bad cough is always a dangerous occur- rence in pregnancy. Venesection, hyoscyamus, conium, and prussic acid, are the remedies advised by Dr. Ryan.—(Manual, &c, p. 187.) In dyspnoea from the distention of the abdomen interfering with the action of the diaphragm, he recommends antispasmodics.—Ed. t " Cold applications, and even ice, if it can be procured, should be applied over the pubes."— (See Cyclop of Pract. Med., art. Abortion.) Of course the administration of opium should follow, and not precede, the abstraction of blood.—Ed. X Aaskow, Act. Soc. Med. Hath., torn. i. Even when the case proceeds from plethora, some prac- titioners have recourse to opium as well as the lancet. Thus Dr. R. Lee gives the following ad- vjce ■_« a. dose of laudanum, or of the liquor opii so feeble or emaciated that bleeding is counter- indicated, we must content ourselves with giv- ing sulphuric acid with small doses of digitalis, unless, indeed, there be much tendency to sink- ing at the stomach, and in this case we must limit our practice to the mineral acids and opium, and gently relieving the bowels.* By this plan the pains originating from inci- dental causes are often checked, and the partial separation of the ovum that has commenced is put a stop to. But the remedial process is thus far merely begun ; the patient, for some weeks, must be peculiarly attentive to her diet, which should be light and sparing, and if exercise of any kind be allowed, it should be that of swing- ing, or of an easy carriage. Cold bathing, and especially cold sea bathing, is of great impor- tance ; and where these cannot conveniently be had, a cold hip or shower-bath may be employed in their stead; and if there should still be the slightest issue of blood from the vagina, injec- tions of cold water, or of a solution of alum or sulphate of zinc, should be thrown up the pas- sage two or three times a day ; or an icicle, or a snow^ball, be employed as a pessary. If the habit be peculiarly vigorous and robust, stimulants and softness of bedclothes must be carefully avoided, and the downy couch be ex- changed for a hard mattress. But if the consti- tution be delicate and emaciated, two or three glasses of wine may be allowed daily, and a course of angustura, columbo, or some other bitter tonic, should be entered upon. In either case, however, it is absolutely necessary that sexual connexion should be abstained from for ten days or a fortnight. It has of late been much the custom to con- fine women of a very delicate frame, and espe- cially after they have once miscarried, to a re- cumbent position, from the first symptom of con- ception through the whole term of gestation. In a few cases this may be a right and advanta- geous practice; but in the present day it is em- ployed far too indiscriminately. Among the causes of abortion we have just enumerated, there are many it can never touch, as where the ovum itself is at fault, or there is a natural in- disposition in the uterus to expand beyond a certain diameter. In this last case, if we could be sure of it, a tepid hip-bath, employed every evening about the time the abortion is expected, would be a far more likely means of preventing it: for we should act here as in all other affec- tions where our object is to relax and take off sedativus, is to be given, or a starch and laudanum clyster may be administered, to prevent or quiet the uterine contractions. The superacetate of lead is in these cases a-valuable remedy. Two grains, combined with a quarter of a grain of opium, may be taken every three hours, until the discharge of blood begins to abate."—Dr. R. Lee, op. et. loc. cit.—Ed. * In cases of threatened abortion, Dr. Samuel Jackson of Northumberland, Penn., has derived great benefit from applying blisters to the back, or sacrum, and the utility of his practice is confirmed by reports from other practitioners.—See the Am. Joum. of Med. Sc, vol. ii., p. 299.—D. 486 GEN] tension, in which states we uniformly employ warmth and moisture: commonly, indeed, a bread and water poultice. And hence, in the instance before us, one of the best applications we could have recourse to, would be a broad swathe of flannel moistened with warm water and applied round the loins and lower belly every night on going to bed, surrounded exter- nally with a dry swathe of folded linen. This should be worn through the whole night, and continued for a fortnight about the time we have reason to expect a periodical return of abortion from the cause now alluded to. I was lately requested to join in consultation with an obstetric physician, upon the state of a young married lady of a highly nervous and ir- ritable frame, united with great energy and ac- tivity both of mind and body, who had hitherto miscarried about the third month of gestation, by braving all risks, taking walks of many mites at a stretch, or riding on horseback for half the day at a time. She was now once more in the family-way, and had just commenced the dis- cipline of only quitting her bed for the sofa, to which she was carried, and on which she was ordered to repose, with her head quite flat and in a line with her body, and without moving her arms otherwise than to feed herself; and to con- tinue-in this motionless state for the ensuing eight months. Without entering into the im- mediate cause of her former miscarriages, I ven- tured to express my doubts whether so sudden and extreme a change would not rather hurry on than prevent abortion. But I recommended that all exertion of body and mind should be moderated, that the diet should be plain, the hours regular, that the position should be gen- erally recumbent, and strictly so for a fortnight, about the time in which abortion might be ex- pected. It was over-ruled, however, to perse- vere in the plan already adopted from the mo- ment, and every sedentary relief and amusement that could be devised was put in requisition to support the patient's spirits. She went on well for a week: but at the end of this period be- came irritable, fatigued, and dispirited; and miscarried at about six weeks from conception, instead of advancing to three months, as she had hitherto done. Even in the case of a delicate and relaxed frame, and of a mind that has no objection to confinement, it is well worth consideration whether the ordinary means of augmenting the general strength and elasticity by such tonics as are found best to agree with the system, and such exercises as may be taken without fatigue, par- ticularly any of those kinds of motion which the Greeks denominated aeora, as swinging or sail- ing, riding in a palanquin, or in a carriage with a sofa-bed or hammock—which, as we observed on a former occasion (Marasmus Phthisis, Cl. III., Ord. IV., Gen. III., Spe. 5), instead of exhausting, tranquillize and prove sedative, re- tard the pulse, produce sleep, and calm the irreg- ularities of every irritable organ—may not be far more likely to serve the patient, than a life of unchanging indolence and undisturbed rest, which cannot fail to add to the general weak- :TICA. [Cl. V—Ord. III. ness, how much soever the posture it inculcates may favour the quiet of the uterus itself. We have thus far supposed that there is a mere danger of abortion, and that the symptoms are capable of being suppressed. But if the pains, instead of being local and irregular, should have become regular and contractile before med- ical assistance is sought for, or should have ex- tended round the body, and been accompanied with strong expulsory efforts, and particularly if in conjunction with those there should have been a considerable degree of hemorrhage, our pre- ventive plan will be in vain: a separation has un- questionably taken place, and to check the de- scent of the detached ovum would be useless if not mischievous. Even though the pains should have ceased, we can give no encouragement: for such a cessation only affords a stronger proof that the effect is concluded. If the discharge continue but in small quan- tity, it is best to let it take its course ; to con- fine the patient to a bed lightly covered with clothing, and give her five-and-twenty or thirty drops of laudanum. Bleeding is often had re- course to with a view of effecting a revulsion ; it is uncalled for, however, and may do mischief by augmenting the weakness. But the practitioner often arrives when the discharge is in great abundance, and amounts to a flooding ;. and the patient is faint and sinking, and seems ready to expire. To the inexperienced, these symptoms are truly alarming; and in a few instances, sudden death appears to have ensued from the exhaus- tion that accompanies them. But it rarely hap- pens that the patient does not recover in an hour or two from the deliquium ; and even the syncope itself is one of the most effectual means of putting a check to the discharge, by the sud- den interruption it gives to all vascular action. Cold, both external and internal, is here of the utmost importance : the bed-curtains should be undrawn, the windows thrown open, and a sheet alone flung over the patient; while linen wrung out in cold water or ice-water should be applied to the lower parts of the body, and renewed as its temperature becomes warm, withholding the application, however, as soon as the hemorrhage ceases. Injections should in this case be desisted from ; for the formation of clots of blood around the bleeding vessels should be encouraged as much as possible, instead of being washed away. And for this reason, it is now a common prac- tice to plug the vagina as tight as possible with a sponge or folds of linen, or, what is better, a silk handkerchief, smeared over with oil, that they may be introduced the more easily, and af- terward to confine the plug with a T bandage. This plan has been long recommended by Dr. Hamilton, and has been extensively followed with considerable success. Here, also, Dr. Hamilton prescribes large doses of opium as an auxiliary, beginning with five grains, and con- tinuing it in doses of three grains every three hours, till the hemorrhage has entirely ceased. Opium, however, is given with most advantage where the flooding takes place after the expul- Gen. II] PARODYNIA. 487 sion of the ovum; for if this have not occurred, its advantage may be questioned, since it has a direct tendency to interrupt that muscular con- traction without which the ovum cannot be ex- pelled. And it should be farther observed, that where opium is had recourse to in such large doses as are above proposed, it must not be dropped suddenly, for the most mischievous consequences would ensue ; but must he con- tinued in doses gradually diminishing till it can at length be omitted with prudence. If the flooding occur after the sixth or seventh month, and the debility be extreme, the hands should be introduced into the uterus as soon as its mouth is sufficiently dilated, and the child turned and brought away. And if, before this time, a considerable degree of irritation be kept up in the womb from the retention of the foetus, or any considerable part of the ovum after its separation, one or two fingers should also be in- troduced for the purpose of hooking hold of what remains, and bringing it away at once. Such a retention is often exceedingly distressing, and the dead parts continue to drop away in mem- branous or filmy patches for several weeks, in- termixed with a bloody and offensive mucus. And not unfrequently, some danger of a typhus fever is incurred from the corrupt state of the unexpelled mass. In this case, the strength must be supported with a nutritious diet, a liber- al allowance of wine, and the use of the warm bitters, with mineral acids. It is also of great importance that the uterus itself be well and frequently washed with stimulant and antiseptic injections, as a solution of alum or sulphate of zinc, a decoction of cinchona or pomegranate bark, a solution of myrrh or benzoin, or, what is better than any of them, negus made with rough port wine. The injection must not be wasted in the vagina, but pass directly into the uterus ; and on this account the syringe must be armed with a pipe made for the purpose, and of suffi- cient length. The application of cold then, plugging the va- gina, opium, and perfect quiet, and where the pulse is full, venesection, are the chief remedies to be employed in abortions, or threatenings of abortions, accompanied with profuse hemor- rhage ; and where these do not succeed, and es- pecially after the sixth month, immediate deliv- ery should be resorted to. The process, how- ever, of applying cold, should not be continued longer than the hemorrhage demands ; for cold itself, when in extreme, is one of the most pow- erful sources of sensorial exhaustion we are ac- quainted with. And hence, where the system is constitutionally weak, and particularly where it has been weakened by a recurrence of the same discharge, it may be a question well worth weighing, whether any thing below a moderately cool temperature be allowable even on the first attack? as also whether the application of warm cloths to the stomach and extremities might not be of more advantage 1 for unless the extremi- ties of the ruptured vessels possess some degree of power, they cannot possibly contract, and the flow of blood must continue. And it is in these casos that benefit has sometimes been found by a still wider departure from the ordinary rules of practice, and the allowance of a little cold ne- gus. So that the utmost degree of judgment is necessary on this occasion, not only how far to carry the established plan, but, on peculiar emer- gencies, how far to deviate from and even op- pose it. We have said that the hemorrhage which takes place in abortions, however profuse, is rarely accompanied with serious effects. This, however, must be limited to the first time of their taking place : for if they recur frequently in the course of a single gestation, or form a habit of recurrence in subsequent pregnancies, the blood, from such frequent discharges, loses its proper crasis ; the strength of the constitu- tion is broken down ; and all the functions of the system are performed with considerable lan- guor. The increasing sensorial weakness pro- duces increasing irritability; and hence slighter external impressions occasion severer mischief, and the patient becomes subject to frequent fits of hysteria, and other spasmodic affections. Nor is this all; for the stomach cannot digest its food, the intestines are sluggish, the bite is irregularly secreted, the heart acts feebly; and the whole of this miserable train of symptoms is, apt to terminate in dropsy.* GENUS II. PARODYNIA. MORBID LABOUR. THE PROGRESS OF LABOUR DISTURBED OR ENDAN- GERED BY IRREGULARITY OF SYMPTOMS, PRE- SENTATION, OR STRUCTURE. The generic term is a Greek compound from irapa, male, and (!><5iv or &SU-ivos, " dolor parturi- entis." All the different species of viviparous animals have a term of utero-gestation peculiar to themselves, and to which they adhere with a wonderful precision. Among women we have already said that this term is forty weeks, being nine calendar or ten lunar months. Occasion- ally, the expulsory process commences within this period, and occasionally extends a little beyond it; but, upon the whole, it is so true to this exact time as clearly to show it to be under the influence of some particular agency, though the nature of such agency has never been satis- factorily pointed out. Sometimes the weight of * It is observed by Dr. Ryan (Manual, &c, p. 192), that when abortion occurs during the two first months of pregnancy, we can only distinguish it from excessive menstruation by the blood coag- ulating,—an appearance neyer witnessed in the menses. Abortion is most common in the first three months, women being then more nervous and irritable than in the subsequent stage of preg- nancy. It is also noticed, that consumptive wo- men, who have a great aptitude to conceive, sel- dom miscarry. It is familiarly known, that such women as marry late in life are particularly liable to the accident. With respect to numerous or- ganic diseases of the uterine organs, and of the embryo and its involucra, acting as causes of abortion, practitioners have no means of prevent- ing or removing them.—Dr. R. Lee, in Cyclop, of Pract. Med., art. Abortion.—Ed. 488 GENETICA. [Cl. V.—Ord. III. the child has been supposed to force it down- wards at this precise period, and sometimes the uterus has been supposed to contract, from its inability of expanding any farther, and hence from an irritable excitement produced by the pressure of the growing foetus. By other phys- iologists it has been ascribed to the increasing activity of the child, and the uneasiness occa- sioned by its movements. But it is a sufficient answer to all these hypotheses to remark, that a like punctuality is observed, whether the child be small or large, alive or dead ; unless, indeed, the death took place at a premature period of the pregnancy ; for " no fact," says Dr. Den- man, " is more incontestably proved, than that a dead child, even though it may have become Jiutrid, is commonly born after a labour as regu- ar and natural in every part of the process as a living one" (Pract. of Midwifery, 8vo., 5th edit., p. 255): and hence we can only resolve it into the ordinary law of instinct or of nature, like that which regulates the term of menstruation, or assert still more intelligibly with Avicenna, that " at the appointed time labour comes on by the command of God."* In natural labour, which consists in a gradual enlargement of the mouth of the womb and the diameter of the vagina, so as to suffer the child to pass away when urged from above by a repe- tition of expulsatory contractions of the uterus and all the surrounding muscles,f there is little or no danger, however painful or distressing to the mother. These contractions or labour- pains continue, with a greater or less regularity of interval and recurrence, from two hours to twelve : the process rarely terminating sooner than the former period, or later than the latter ; the ordinary term being about six hours. But unhappily labours do not always proceed in a natural course ; for sometimes there is a feebleness or irregularity in the muscular action that greatly retards their progress ; or a derange- ment of some remote organ that sympathizes with the actual state of the uterus, and produces the same effect; or the mouth of the uterus it- self is peculiarly rigid and unyielding; or the natural presentation of the child's head may be exchanged for some other position ; or the ma- ternal pelvis may be misshapen, and not afford convenient room for the descent of the child ; or there may be a plurality of children ; or, even after the birth of the child, the placenta may not follow with its ordinary regularity ; or an alarm- ing hemorrhage may supervene ; each of which conditions becomes a distinct species of disease in the progress of morbid labour, and the whole of which may be arranged as follows :— 1. Parodynia Atonica. Atonic Labour. 2--------— Implastica. Unpliant Labour. 3- —;------Sympathet- Complicated Labour. . ica. 4.--------Perversa. Preternatural Presen- tation. Cross-iiirth. 5. ---------Amorphica. Impracticable Labour. 6.---------Pluralis. Muciparous Labour. 7.-------— Secundaria. Sequential Labour. SPECIES I. PARODYNIA ATONICA. ATONIC LABOUR. * This inquiry seems, as Dr. Ramsbotham ob- serves, to promise as much usefulness as the ques- tion, why human beings do not grow twenty feet high, or live for five hundred years ?—Ed. t The action of the uterus is involuntary, which is regarded as " a wise provision of nature, be- cause it is most probable that many women would not have fortitude sufficient to bring on labour vol- untarily at the end of the proper term of gestation ; while some might induce action prematurely, either from fear, shame, or other motives. The auxiliary muscles, however, which assist the uterine powers, are, to a certain extent, voluntary ■ so that labour may be said to consist of a mixed action, principally involuntary, but partly volun- tary; and it is m the woman's power to aid the contractions of the uterus by the exertion of her Sa a f,66^' Ramsbotham's Lectures, as pubUshed in Med. Gaz. for 1833-4.—Ed. LABOUR PROTRACTED BY GENERAL OR LOCAL DE- BILITY, OR HEBETUDE OF ACTION. It often happens, in various affections of the system, that a general law is incapable of being carried into effect with promptness and punctu- ality from weakness or indolence of the organs chiefly concerned in its execution. Thus, when vaccine or variolous fluid is properly inserted un- der the cuticle, it remains there in many cases for several days beyond its proper period, in a dormant state, from inirritability or indolence in the cutaneous absorbents ; and in the case of smallpox, even where the fluid has been re- ceived into the system, whether naturally or by inoculation, and has excited febrile action, this action is, in many instances, very considerably augmented from a like indolence or inirritability of the secernents of the skin, which do not throw off the morbid matter sufficiently on the surface. A like want of harmonious action very fre- quently occurs in parturition. The full time has expired—the uterus feels uneasy, and the uneasiness is communicated to the adjoining or- gans, and there are occasional pains in the back or in the lower belly; but either from a weak- ness or hebetude, or both, in the uterus itself, or in the muscles that are to co-operate with it in expelling the child, the pains are not effective, and the labour makes little progress. It often happens, also, in debilitated habits, that while in some parts of its progress the labour advances kindly and even rapidly, the little strength the patient possesses is worn out, and her pains suddenly cease ; or, what is worse, still continue, but without their expulsory or effective power, and, consequently, do nothing more than tease her, and add to the weakness. This exhaustion will sometimes occur soon after the commencement of the labour, or in its first stage, before the os uteri has dilated, and while the water is slowly accumulating over it; but in this stage it is more likely to occur, if the mem- branes should have prematurely given way, and the water have been already evacuated Yet it occurs also, occasionally, towards the close Gen. II.—Spe. 1.] PARODYNIA ATONICA. 489 even of the last stage, and when the head of the child has completely cleared itself of the utems, and is so broadly resting on the perinaeum that a single effective pain or two would be suf- ficient to send it, without any assistance, into the world. In the greater number of these cases, to wait with a quiet command of mind, and sooth the patient's desponding spirits by a thousand little insinuating attentions, and a confident assurance that she will do well at last, is the best, if not the only duty to be performed. A stimulant injection, however, of dissolved soap or muriate of soda, will often re-excite the contractions where they flag, or change the nature of the pains where they are ineffective. After this it is often useful to give thirty or five-and-thirty drops of laudanum, and to let the patient remain per- fectly quiet. It is not certain in what way the laudanum may act, for it sometimes proves a local stimulant, and sometimes a general seda- tive ; but in either way it will be serviceable, and nearly equally so ; for it will either shorten the labour by re-exciting and invigorating the pains, or increase the general strength by producing sleep and quiet.* In America, it has of late been a common prac- tice to employ spurred rye in cases of this kind, as we have already observed under Paramenia diffi- cilis, for which also it is very generally had re- course to ; it being supposed to have a specific power in stimulating the uterus : and the cases adverted to are numerous and authentic, in which it seems to have been serviceable in exci- ting labour-pains under the present affection, t If the pulse should be quick and feeble, with languor and a sense of faintness at the stomach, a little mulled wine or some other cordial may be allowed. If the mouth of the womb be lax and dilatable, and the water have accumulated large- * Here, instead of laudanum, many practition- ers prescribe the acetous solution of opium (Dubl. Pharm.), the liquor opii sedativus, or the acetate or muriate of morphine.—Ed. t Dr. John Stearns, of New-York, was the first American practitioner who publicly proposed the use of ergot to facilitate lingering labour. In his paperin the New-York Med. and Phys. Journ., vol. i., he has succinctly stated the principles which ought to regulate its employment. He re- marks, " The ergot is indicated and may be pre- scribed, 1st, When, in lingering labours, the child has descended into the pelvis, the parts dilated and relaxed, the pains having ceased or being too inefficient to advance the labour, there is danger to be apprehended from delay, by exhaustion of strength and vital energy, from hemorrhage, or other alarming symptoms. 2d, When the pains are transferred from the uterus to other parts of the body, or to the whole muscular system, produ- cing general puerperal convulsions. 3d, When, in the early stages of pregnancy, abortion becomes inevitable, accompanied with profuse hemorrhage and feeble uterine contractions. 4th, When the placenta is retained from a deficiency of contrac- tion. 5th, In patients Uable to hemorrhage imme- diately after delivery. 6th, When hemorrhage or lochial discharges are too profuse immediately af- ter deUvery, and the utems continues dilated and relaxed, without any ability to contract.—D. ly and protrude upon it as in a bag, advantage is often gained by breaking the membranes and evacuating the fluid, for a new action is hereby given to the uteres, and while it contracts with more force it meets with less resistance, and its mouth is more rapidly expanded. But unless the labour should have advanced to this stage, the membranes should never be interfered with ; for their plasticity, and the gradual increase and pressure of their protruding sac against the edges of the os uteri, form the easiest and su- rest means of enlarging in, while the retention of the fluid in this early stage of parturition lu- bricates the inner surface of the womb, and tends to keep offbeat and irritation.* For the same reason, if the mouth of the womb be narrow and have hitherto scarcely given way, the application of the finger can be of no advantage. Every attempt to dilate it must be in vain, and only produce irritation, and an in- creased thickening in its edges : but if it have opened to a diameter of two inches, and be at the same time soft and expansile, advantage should be taken of the pains to dilate it by the introduction of one or two fingers .still further, which should only, however, co-operate with the pains, and be employed while they are acting ; and, by these conjoint means, the head of $he child sometimes passes rapidly and completely out of the uterus. We have said that it is sometimes apt to lodge in the vagina in consequence of the patient's exhaustion, and an utter cessation of all pains, or of all that are of any avail. The patient should again therefore be suffered to rest, and if faint, be again recruited with some cordial sup- port. Generally speaking, time alone is want- ing, and the practitioner must consent to wait; and it will be better for him to retire from his pa- tient, and to wait at a little distance. But if several hours should pass away without any re- turn of expulsory efforts, if there should be fre- quent or continual pains without any benefit, if the patient's strength should sink, her pulse be- come weak and frequent, if the mind should show unsteadiness, and there be a tendency to syneope, and if, at the same time, the head be lying clear of the perinaeum, the vectis or for- ceps should be had recourse to, and the woman be delivered by artificial means. This situation forms a general warrant; but for the peculiar circumstances in which such or any other in- struments should be employed, the manner of em- ploying them, and the nature of the instruments * The advice here delivered agrees with that given by the best modem obstetric practitioners. Thus, Dr. Ramsbotham, in his Lectures, strongly recommends the plan of preserving the membra- nous bag entire as long as possible ; or, at least, until it has performed the whole of the office des- tined for it by nature ; namely, the dilatation of the os uteri, the vagina, and in some degree also of the external parts. When the membranes appear externally to the vulva, we may then suppose that they have done all the good that can be expected from them ; that their remaining entire may pos- sibly be retarding the labour ; and we may in that case venture to rupture them, provided the head present.—See Med. Gaz. for 1833-4, p. 821.—Ed. 490 GENETICA. [Cl. V.—Ord. HI. themselves, the reader must consult such books as are expressly written upon the subject, and should sedulously attend the lectures and the introductory practice which are so usefully of- fered to him in this metropolis.* SPECIES II. PARODYNIA IMPLASTICA. UNPLIANT LABOUR. LABOUR DELAYED OR INJURED FROM IMPLASTI- CITY OR UNKINDLY DILATATION OF THE SOFT PARTS. The tediousness and difficulty of the prece- ding species of labour proceed chiefly from ato- ny or hebetude of the system generally, or of the local organs particularly. But it often happens, that the parts dilate and the labour proceeds as slowly from an implasticity, or rigid resistance to the expansion and expulsory efforts which should take place, according to the law of na- ture, at the fulness of time which we are now supposing to be accomplished, and which is some- times productive of other evils than that of pro- tracted suffering, offering us, indeed, the four following varieties : a Rigiditatis. The delay confined to a sim- ple rigidity of the uterus or outer mouth. B Prolapsa. Accompanied with prolapse. y Haemorrhagica. Accompanied with hemor- rhage. S Lacerans. Accompanied with laceration of the uterus or perinaeum. Rigidity of the uterus may extend to the entire organ, or be limited to the cervix, or os uteri, as it is called after the cervix has lost its natural form, and partakes of the spherical shape of the fundus. When the former occurs, the practitioner meets with severe pains in the loins, shooting round the lower belly, and producing great contractile efforts of the muscles surround- ing the uterus, so as to throw the patient, from the violence of her exertions, into a profuse per- spiration, and induce the attendants to believe that the labour is advancing with great speed, while the practitioner himself finds, on exami- nation, that there is no progress whatever ; that the uterus itself does not unite in the expulsory force, the fluid of the amnios does not accumu- late over the os uteri, nor the head of the child bear down upon it. In other cases he finds that the general organ of the uterus does participate in the common action, and force the head of the child down- ward, but that the mouth of the womb does not dilate or become thinner in consequence here- of; appearing, on the contrary, in some cases, from a peculiar tenderness and irritation, to grow thicker and tenser, and more intractable. * See Dr. Dewees's System of Midwifery ; Dr. Meigs's valuable Translation of Velpeau's Mid- wifery ; Midwifery Illustrated, by J. P. Maygrier, translated from the French by A. Sidney Doane ; Dr. Francis's edition of Denman's Midwifery, &c, &c. And he not unfrequently finds, even where both the body and mouth of the womb are suffi- ciently pliable and co-operative with the com- mon intention, and the head of the child has be- come easily cleared of this organ, that a like ri- gidity and implasticity exist in the os internum, and that the child, having readily worked its way thus far, is fast locked from this circumstance, and cannot get any further; and occasionally the rigidity has been found in some part, and particularly the upper part of the vagina, of which Dr. Davis has given a very striking ex- ample in a young woman parturient for the first time. The contraction was here a spastic ring, bordering immediately on the orifice of the ute- ms ; and so inconsiderable that the forefinger could nor- be made to pass through it.—(Ele- ments of Operative Midwifery, &c, 4to., 1825.) In all cases of this kind, the same means of relaxation should be resorted to as in an irrita- ble or inflammatory tenseness and rigidity of other organs. Blood should be freely abstracted, active purgatives be given by the mouth, and co- pious emollient injections be administered without much aperient virtue, so that they may for some time remain in the rectum and act as a fomenta- tion. And here also it may be advantageous to apply round the loins and lower belly a broad swathe of flannel wrung out in hot water, and to encircle it with an equally broad band of fold- ed linen, in the manner already recommended in PARAMENIA DIFFICILIS. In Dr. Davis's case of contracted vagina, af- ter an abstraction of blood to deliquium, which demanded thirty ounces, sixty drops of Battley's sedative solution of opium were also directed to be given, with great judgment as well as with the most desirable success: for in about five hours the child's head had cleared both the orifice of the utems and the contracted part of the vagina, and was beginning to bear on the os externum; in about three hours after which, the patient was safely delivered of a liv- ing child. In several cases of rigidity, if no means be adopted to subdue the tension, the protrusive force of the surrounding muscles is sometimes so considerable that, as it cannot expel the child by itself, it goes far to expel the child and the uterus conjointly, the latter being thrust down- ward into the outward passage, and its mouth projecting out of the vulva, thus constituting a PARTURIENT PROLAPSE. While the uterus is thus forcibly descending, the attendant should support it, or the head of the child, with two fingers : if the prolapse be complete, the uterus should be returned into its proper place as quickly as possible ; and if this cannot be done, the child must be turned, and delivery take place as speedily as may be. In the violence of this struggle, it sometimes happens, moreover, and particularly where the water has escaped, that some of the vessels give way, or the placenta is partly detached, and there is the additional evil of a profuse hemorrhage to contend with. If this occur in the commencement of labour, venesection should generally be had recourse Gen. II.—Spe. 2.] PARODYNIA IMPLASTICA. 491 to, the patient be kept cool and quiet, and take thirty drops of laudanum. If the labour have advanced and is advancing rapidly, and the hem- orrhage be not very considerable, we may safe- ly trust to nature to complete the process before any serious mischief ensues. But if the patient be debilitated, or much exhausted, or the labour advance slowly, the wdman should be delivered by turning the child, or having recourse to the forceps, according to the progress of the labour, and the position of the child at the time. But there is a far worse evil than any of these, which results from the implasticity we are now considering : and that is, a rupture or lacera- tion, either of the vagina or of the uterus. The causes of laceration are said to be nu- merous, and it often occurs suddenly and with- out any known cause : but if we examine into their general nature, we shall find that, except in the case of brutal force or want of skill, they are almost always dependant on a certain degree of implasticity in the lacerated part of the organ, which prevents it from yielding with the uniform- ity of the other parts, or from a peculiar de- gree of irritability, that renders it more liable to irregular action or spasm : though there can be no question that, in a very few instances, the laceration has commenced from a cut produced by an occasional sharpness of the edge of the ilium. " Those women," observes Mr. Burns, " are most liable to rupture of the uterus who are very irritable, and subject to cramp ; or who have the pelvis contracted, or its brim very sharp, or who have the os uteri very rigid, or any part of the womb indurated. Schulzius re- lates a case where it was produced by scirrhus of the fundus ; and Friedius one where it was owing to a cameo-cartilaginous state of the os uteri."—(Principles of Midwifery, 8vo., 3d edit., p. 361.) Laceration of the fundus of the womb may lake place during any part of the labour, when the pains are violent, and the walls of the or- gan do not act in unison in every part; but the mischief more commonly commences in the cervix, when the head, or the shoulders, or any other part is passing through, and the whole of its circumference does not yield equally.* * " This disastrous occurrence is to be dread- ed,"" says Dr. Ryan, " in all cases of transverse labours, unless timely aid be afforded. It is most common in arm presentations, and in deformities of the pelvis. In a word, in aU cases where the labour is protracted and violent."—(See Manual, &c, p. 287.) When a woman has already borne children, the os uteri generally dilates very readily in subsequent parturitions; but this is by no means universally the case. Dr. Ramsbotham relates the particulars of a woman whom he attended in her first labour, and the child was born naturally in four or five hours. In her second labour, however, the membranes broke early; the pains became ex- ceedingly violent;. the head was forced powerfully against the undilated and rigid os uteri; irregular muscular spasms supervened; and, at the end of about fifty hours from the rupture of the mem- branes, when the os uteri had not acquired a di- ameter larger than a shilling, Dr. Ramsbotham, while carefully examining the parts, felt the os Where the accident occurs in the vagina or perinaeum, it must necessarily take place after the head has descended from the womb, and is pressing upon the substance of these organs, that, like the lacerating os uteri, does not yield equally in every point.* In most cases of an implastic rigidity, whether in the body of the uterus itself, or in its cervix, or in the os externum, there is a considerable de- gree of local irritation, and in many of them a great deal of firm and vigorous action. The parts are not only rigid, but dry, and hot, and tender, and the pulse is generally full, with restlessness and a heated skin. And hence ven- esection is imperatively called for from an early period of the labour : and there are few cases in which the uterus has not acted after- ward with more freedom, and its mouth been rendered laxer, softer, and more compilable. In all such cases, also, an emollient injection sev- eral times repeated will advantageously co-oper- ate in taking off the tension, and increasing the expansibility. Here opium should be avoided, but general relaxants, as antimony and ipecacuanha, given in the neutral effervescing draught, may add to the general benefit. The operator must be abstinent till the parts have yielded, and the tension and irritation subsided; for before this, every application of the fingers will only increase the morbid tendency. The only case in which the use of opium is here to be justified, is where, from the vio- lence of the contractile pains, a considerable and an alarming hemorrhage has ensued, and the state of the os uteri will not allow of the introduction of the hand for the purpose of turn- ing and delivering immediately. In this instance, after venesection and a due administration of emollient and aperient injections, our last de- pendance must be upon a powerful opiate, for the purpose of allaying the irritation, and taking off the pains, t And if the force of the expulsory power thrust down the uterus so as to give danger of produ- cing a prolapse, the practitioner must support the organ during the recurrence of the pains, by introducing two fingers into the vagina for this purpose, and the patient must be kept in a recumbent position, without moving from it; and must be instructed to avoid, as much as possible, every expulsory or bearing-down ex- uteri and the cervix give way on the right side, and the head passed at once into the vagina. Bleeding and opium here had failed to bring about the requisite dilatation of the os uteri. The pa- tient died of uterine inflammation on the fourth day after delivery.—See Ramsbotham's Lectures, as published in Med. Gaz. for 1834, p. 161.—Ed. * The following references to cases of ruptured utems, from falls or blows in the early months of pregnancy, are given by Dr. Ryan, op. cit., p. 441: namely, Phil. Trans., vol. xlv., p. 121; Mem. de l'Acad. des Sciences, 1709; Journ. Med., 1780; Burns's Midwifery, p. 640; Annals of Med., p. 412; Dublin Med. Trans., 1830, "vol. i., New Series, &c. + In cases of rigidity, where the patients were robust, the celebrated Dr. Hamilton, of Edinburgh, employed venesection; but where they were deli- cate, the starch and opium clyster.—Ed. 492 GENETICA. [Cl. V.—Ord. 111. ertion while the pain is upon her. If the ute- rus have actually protruded into the vagina, a reduction must be instantly attempted: and if this cannot be done, no time should be lost in passing the hand through the cervix, as soon as, without force, it can be sufficiently dilated for this purpose, and delivering the child by turning. Laceration generally takes place suddenly; though in irritable habits, cramps or other spas- modic affections are often previously complained of in different parts of the body. Mr. Burns has well described the symptoms that succeed : —" When this accident does happen, the wo- man feels something give way within her, and usually suffers at that time an increase of pain. The presentation disappears more or less speed- ily, unless the head have fully entered the pel- vis, or the uterus contract spasmodically on part of the child, as happened in Bechling's patient. —(Haller, Disput., torn, iii., p. 477.) The pains go off as soon as the child passes through the rent into the abdomen : or, if the presenta- tion be fixed in the pelvis, they become irregu- lar, and gradually decline. The passage of the child into the abdominal cavity is attended with a sensation of strong motion of the belly, and is sometimes productive of convulsions."— (Burns, ut supra, p. 362.) It is not necessary to make a distinction be- tween the parts in which the laceration takes place ; for, whether it be in the fundus or cer- vix of the womb, or in the vagina, except where, as just observed, the position is fixed in the pel- vis, the part presented instantly disappears, and the child slips imperceptibly through the chasm into the hollow of the abdomen, sometimes with a hemorrhage that threatens life instantly, but sometimes with little or even no hemorrhage whatever.* This accident will not unfrequently occur to- wards the close of a labour that promises fair. It is not many years ago when the present au- thor, at that time engaged in this branch of the profession, was requested with all speed to at- tend, in consultation, upon a lady in Wigmore- street, who was then under the hands of a practitioner of considerable skill and eminence. She had, for about eight hours, been in labour of her first child, herself about thirty-eight years of age, had had natural pains, and been cheered throughout with the prospect of doing well, and even more rapidly than usual, under the circum- stances of the case. In fact, the head had com- pletely cleared the os uteri, and was resting on the perinaaum, and the obstetric practitioner was flattering himself that, in a quarter of an hour at the farthest, he should be released from his con- finement, when he was surprised by a sudden retreat of the child during a pain which he ex- pected would have afforded her great relief, ac- companied with an alarming flooding: and it was in this emergency the author of this work was requested to attend. On examination, it was ascertained that a large laceration had * Blood may escape from the vagina, but gen- erally it passes into the cavity of the abdomen, and excites peritonitis.—Ed. taken place in the utems, commencing at the cervix, and apparently on the passing of the shoulders ; but why any part of it should have torn at this time rather than antecedently, there were no means of determining. It is usual, under these circumstances, to follow up the child with the hand through the rupture into the abdomen, and to endeavour to lay hold of the feet, and withdraw it by turning. The hemorrhage had alarmed the practitioner, and this had not been attempted ; and, at the time of the author's arrival, which was about an hour and a half afterward, the attempt was too late, for the pulse wa3 rapidly sinking, the breathing interrupted, and the countenance ghastly ; yet the patient had not totally lost her self-posses- sion, and being informed of her situation, begged earnestly to be let alone, and to be suffered to die in quiet. Where there is little or no hemorrhage, life usually continues much longer, whether the child be extracted or not; mostly about twenty-four hours, though in some cases considerably lon- ger still. Dr. Garthshore attended a patient who lived till the twenty-sixth day, and the Co- penhagen Transactions (torn, ii., p. 326) con- tain the case of a woman who, after being deliv- ered, lingered for three months; and a few marvellous histories are given in the public col- lections of a natural healing of the utems, while the child continued as a foreign and extra-foetal substance in the cavity of the abdomen for many years. Halter has reported a case in which it continued in this state for nine years (Mim. de Paris, 1773); and others relate examples of its remaining for sixteen (Eph. Nat. Cur., dec. i., ann. iii., obs. 12), and even twenty-six years,* or through the entire term of the mother's natu- ral life.t The only rational hope of saving both the mother and the child, is by following up the latter through the rupture, and delivering it by the feet; but where this cannot be done from the smallness of the dilatation of the os uteri, or from the violent contraction of the uterus be- tween the os uteri and the rent, we have nothing to propose but to leave the event to nature, or * Eph. Nat. Cur., dec. ii., ann. viii., obs. 134. Lieutaud mentions examples in which the foetus was retained from ten to forty years. \Y hen the pa- tient sinks, it is generally from inflammation of the bowels and uterus. In some cases, abscesses follow near the rectum, or in the perinaeum, from which the foetus is discharged piecemeal. Dr. M'Kee- ver's work on Lacerations of the Womb and Vagina, published in 1824, deserves praise, as containing a good deal of information on the subject.—Ed. t If the woman is saved, the womb decreases, and returns to its former unimpregnated size; the menses return; and she may become pregnant and even bear children before the expulsion of the extra-uterine foetus.—(Journ. de Med., torn, v., p. 422; Bums, p. 105.) When the child is retained many years in the abdomen, it becomes enclosed in a cyst. In a case of this kind recorded by Dr. Percival, the foetus, at the end of twenty-iwo years, was expelled from the rectum.—(See Ryan's Man- ual of Midwifery, p. 440.) No doubt some of the instances reported as cases of ruptured utems, have been in truth extra-uterine conceptions.—Ed. Gen. II.—Spe. 3.] PARODYNIA SYMPATHETICA. 493 to extract the child by the Caesarean operation. We have just seen that, in a few rare instances, the vis medicatrix Naturae, or instinctive ten- dency to health, has succeeded in healing the wound, and restoring the patient with the foetus still inhabiting the belly. But this result is so little to be expected, that an incision into the cavity of the abdomen has not unfrequently been tried, and in some instances unquestionably with success.* SPECIES III. PARODYNIA SYMPATHETICA. COMPLICATED LABOUR. LABOUR RETARDED OR HARASSED BY SYMPA- THETIC DERANGEMENT OF SOME REMOTE OR- GAN OR FUNCTION. We have often had occasion to observe that, with the exception of the stomach, there is no organ that holds such numerous ramifications of sympathy with other organs as the womb ; and we hence find the progress of parturition dis- turbed, and what would otherwise be a natural, converted into a morbid labour, by the interfe- rence of various other parts of the body, or the faculties which appertain to them. The whole family of varieties which issue from this source are extremely numerous : but the three follow- ing are the chief:— a Pathematica. Accompanied with terror or other mental emotion. B Syncopalis. Accompanied with fainting. y Convulsiva. Accompanied with convulsions. In the pathematic variety, the joint emo- tions which are usually operative upon the pa- tient's mind, and especially on the first labour, are bashfulness on the presence of her medical attendant, and apprehension for her own safety. There is not a practitioner in the world but must have had numerous instances of a total suspen- sion of pains on his first making his appearance in the chamber. And in some cases, the pains have been completely driven away for four-and- twenty hours, or even a longer term. There is nothing extraordinary in this, for two powerful morbid actions are seldom found to proceed in the animal frame simultaneously ; and hence pregnancy is well known to arrest phthisis, and the severest pain of a decayed tooth to yield to the dread of having it extracted, while the patient is on his way to the operator's house. It is hence of great importance, that the be- spoken attendant should familiarize himself to his patient before his assistance is required, and endeavour to obtain her entire confidence : and it is better, when he is first ushered into her presence in his professional capacity, that he should say little upon the subject of his visit, direct the conversation to 'some other topic of general interest, and then withdraw till he is wanted. And if the idea alone of his approach * Progres de la Medecine, 1698,12mo. Abhand- lung der Konigl. Schwed. Acad., 1744. Hist, de l'Acad. Royalo des Sciences, 1714, p. 29, 1716, p. 32. be peculiarly harassing, it is best for him to be in a remote part of the house in readiness, and not to see his patient till her pains have taken so strong a hold as to be beyond the control of the fancy. If her apprehensions for herself be very active, and if there be any particular ground for them, it is most reasonable to enter candidly on the question, and to afford her all the consolation that can be administered. Syncope, in labour, proceeds commonly from a peculiar participation of the stomach in the ir- ritation of the womb, and is hence often con- nected with a sense of nausea, or with vomiting. Occasionally it occurs also from the exhaustion produced by the violence of the pains : and par- ticularly in relaxed and debilitated habits, in which case the fainting fits sometimes follow up each other in very rapid succession, and require very close attention on the part of the practi- tioner and the patient's friends. The usual remedies should here be had re- course to in the first instance ; pungent volatiles should be applied to the nostrils, the patient be in a recumbent position, with the curtains un- drawn, and unless the season of the year pro- hibit, with the windows open; the face, and especially the forehead and temples, should be sprinkled with cold water or ether; and the usual volatile fetids, aromatics, and terebinthi- nates, as camphire, should be given by the mouth; and to these, if necessary, and particularly where the pulse is feeble and fluttering," should be added a glass or two of Madeira, or any other cordial wine, with twenty drops of laudanum. If this plan should not answer, and especially if the fainting-fits should increase in duration and approximation to each other, the patient must be delivered by the process of turning, as soon as ever the 6s uteri is sufficiently dilated to let the hand pass without force. One of the worst and most alarming of the associated symptoms in labour is that of con- vulsions, and these are often connected with fainting-fits, and the two alternate with each other. We have already glanced at them gen- erally under syspasia convulsio, but must dwell upon them a little more at large under the pres- ent modification. Convulsions may occur during any period of gestation; but we are now to consider them as an accompaniment of labour, and as interrupting its progress. Their proximate cause is a pecu- liar irritation of the nervous system as participa- ting in the irritation of the womb ; and hence it is obvious, that the radical and specific cure is a termination of the labour. We cannot always trace the link of this pe- culiar influence of the womb upon the nervous system ; though where there is a predisposition to clonic spasm of any kind, we can readily ac- count for its excitement, and may be under less apprehension, than where it occurs without any such tendency. The occasional causes of faint- ing are the same as of convulsions : and hence they are apt to follow, and particularly in deli- cate or debilitated constitutions, on the fatigue and exhaustion of violent and protracted paina, 494 GENETICA. [Cl. V.—Ord. III. great depression of the animal spirits, and pro- fuse hemorrhage. Sometimes, however, they occur where none of these are present, and where the patient is of a strong plethoric habit of body, and especially if it be her first time of pregnancy; and are accompanied with, or even preceded by, a sense of dizziness and oppression in the head, ringing in the ears, or imperfect vision; the plethora itself thus forming the oc- casional cause. The attendant symptoms are peculiarly vio- lent, sometimes resembling those of hysteria, sometimes those of epilepsy, but more vehement.- Nothing can restrain the spastic force of a wo- man when in parturient convulsions, whatever be her natural weakness. The distortion of the countenance is more hideous than the most ex- travagant imagination can conceive; and the rapidity with which the eyes open and shut, the sudden twirlings of the mouth, the foam that col- lects about the lips, the peculiar hiss that issues from them, the stertor, the insensibility, and the jactitating struggle of the limbs, form a picture of agony that cannot be beheld without horror. The exciting cause is the irritable state of the womb ; and whatever be the predisponent or oc- casional cause, whether a debilitated condition of the nervous system, or a robust and entonic fulness of the bloodvessels, it is obvious that such violence of action cannot take place under any circumstances without endangering a rup- ture of the vessels in the head, and consequently all the mischiefs of apoplexy. It is against this, indeed, that all practitioners, how much soever they may disagree upon other points, most cor- dially endeavour to guard, though it rarely hap- pens that effusion in the brain, and some of its results, do not take place in spite of all their ex- ertions. The first step is to open a vein, and bleed co- piously from a large orifice till the patient faints: and if the operator be expert, the best vein to make choice of is the jugular :* the hair should be immediately removed from the head, and lotions of cold water, pounded ice, or the freezing mixture, produced by dissolving three or four different sorts of neutral salts in water at the same time, be applied all over it by wet- ted napkins, changed for others as soon as they acquire the least degree of warmth. At the same time, a purgative injection should be thrown up the rectum, and five or six grains of calomel be given by the mouth with a draught of sulphate of magnesia in infusion of senna. The paroxysms must, if possible, be put a stop to, the fatal effects they threaten must be anti- cipated, and not a moment is to be lost. This is the general plan ; and it is to be pur- sued under all circumstances, though its extent, and particularly in regard to bloodletting, must be regulated by the strength and energy of the patient. The local mode of treatment seems to be somewhat less decided. * As the only jugular vein that can be opened is the external, and it does not communicate di- rectly with the sinuses of the brain, modem prac- titioners do not so frequently bleed in it as their predecessors were accustomed to do.—Ed. It may happen that at the attack of the fits, the os uteri is merely beginning" to open, or that it is of the diameter of a crown-piece, but pecu- liarly rigid and undilatable. There are practi- tioners who in this case confine themselves to the depleting plan, and only wait for the advance of the labour : but, in the state of the uterus we are now contemplating, they may have to wait for some hours before the labour is so far ad- vanced as to render them capable of affording any manual assistance whatever, while the fits are perhaps recurring every quarter of an hour, and threatening fatal mischief to the brain. And in this case, I cannot but warmly approve of the bolder, or rather the more judicious advice of Dr. Bland, who, after a due degree of depletion, recommends a full dose of opium, for the pur- pose of allaying the nervous irritation generally, and particularly that of the uterus, which is the punctum saliens of the whole. A few hours' rest may set all to rights, if no vessel have thus far given way in the head: for when the next tide of pains returns, it will commence under very different circumstances, in consequence of the reducent course of medicine that has been pursued: and it will rarely be found that the whole body of the uterus is not rendered more lax and plastic, and consequently its cervix, and even the os externum, more yielding and dila- table. But this is not the common course which the uterus takes under these circumstances ; for in by far the greater number of cases, the whole of this organ, the cervix as well as the fundus, is so exhausted in the general contest as to be more than ordinarily relaxed and flaccid, and di- latable with considerable ease : insomuch that, if the muscular power of the system were now concentrated in a common expulsory effort, as in natural labours, the whole process would ter- minate in a few minutes. But unfortunately this muscular exertion, instead of being concentra- ted, is distracted and erratic, and wanders over all the muscles and organs of the system, pro- ducing general mischief instead of local benefit: so that whatever pains there may be, they are of far less use than in a state of harmonious action. This may be easily ascertained by introducing the hand on a return of the paroxysm, when the uterus will be found to contract indeed, but with a tremulous, undetermined sort of force, perfectly different from what it does at any other time. The necessary practice in this case should ap- pear to be obvious and without doubt: the med- ical attendant seems imperatively called upon to introduce his hand into the os uteri as soon as it is sufficiently open for him to do so without force, to break the membranes if not broken al- ready, lay hold of the child's feet, deliver by turning, and thus put an end to the convulsions at once, and consequently to the fatal effects which seemed to await the mother as well as the child. Such was the practice recommended by Mau- riceau upwards of a century since : " La convul- sion," says he, " fait souvent perir la mere et 1'enfant, si la femme n'est pas promptemenl se- courue par I'accouchement, qui est le meilleui Gen. 11.—Spe. 3.] PARODYNIA SYMPATHETICA. 495 remede qu'on puisse apporter a. I'une et a l'autre."—(Traiti des Maladies des Femmes grosses, tom. i., p. 23,4to., Paris, 1721.) This recommendation was adopted generally, and in our own country successively by Smelfie, W. Hunter, and Lowder. And although, in cir- cumstances of so much danger, it was not and could not be always successful, yet it was sup- posed, and with reason, to be the means of sa- ving the life, as well of the mother as of the child, in very numerous instances in which that of one or of both would otherwise have unques- tionably perished. Some forty years after the publication of M. Mauriceau's work, Professor Roederer of Goettingen called this practice in question, and recommended that the patient be left to the natural course of the labour (Ele- menta Artis Obstetrica, Aph. 679, Goet., 1769, 8vo.): and we are told by Dr. Denman that in our own country, Dr. Ross, towards the close of last century, " was the first person of late years who had courage to declare his doubt of the pro- priety of speedy delivery in all cases of puer- peral convulsions. The observation," continues Dr. Denman (Practice of Midwifery, ed. by Dr. J. W. Francis, p. 607, 8vo., 3d edit., 1829), " on which these doubts were founded, was merely practical, and the event of very many cases has since confirmed the justice of his ob- servation, both with respect to mothers and chil- dren." The sweeping extent of this censure seems to show that the practice has often been had re- course to indiscriminately, and without a correct limitation. And the apparent concurrence of Dr. Denman in Dr. Ross's opinion, together with the undecided manner in which he treats of the question in his subsequent pages, has raised up, among the most celebrated obstetric physicians of our own day, various advocates for leaving, in general, to nature, the case of la- bour accompanied with convulsions, or at least till the natural efforts of the mother are found completely to fail; and in this last case, as the child's head may be supposed to have cleared the uterus, to have recourse to the perforator or the forceps, according to the nature of the po- sition. The chief grounds for this proposed delay, as far as I have been able, to collect them, are, that the introduction of the hand into the os inter- num, in the irritable state of the organ we are now contemplating, is more calculated to renew the convulsions than to put an end to them : that a repetition of them, after due depletion has been employed, is not so dangerous as is gen- erally apprehended, and consequently that im- mediate delivery is by no means essential to the patient's safety: and lastly, that we are not sure of putting an end to the convulsions, even after delivery is effected ; since it is well known that they have occasionally continued, and some- times have not commenced, till the process of labour has been long completed. In reply to this it may be observed, that if a repetition of the convulsive fits be not so dan- gerous as is commonly apprehended, a practi- tioner should feel less reluctance in introducing the hand, even though he were sure of exciting a single fit by so doing: and the more so as this single fit might, perhaps, be the means of ter- minating the whole, and, consequently, would be a risk bought at a cheap rate. At the same time it should be observed, that general experi- ence does not seem to justify the remark, that a cautious and scientific use of the hand, where the mouth of the womb is sufficiently dilated, becomes a necessary or even a frequent excite- ment of fresh paroxysms ; and the prediction of such an effect is therefore without sufficient foundation. And if there be a considerable chance, as seems to be admitted, that instru- mental assistance will be requisite at last, and that the forceps, or what, in the probability of the child's being still alive, is ten times worse, the perforator, must be called into action, how much more humane is it, as well as scientific, to employ instrumental aid at first, and thus save the pain and the peril of perhaps many hours of suffering—and particularly when the soft, and supple, and plastic instrument of the hand, may supersede the use of the ruder, and rougher, and less manageable tools of art 1 But the most important part of the question is as to the actual degree of danger induced by convulsions : and to determine this, nothing more seems necessary than to put the whole upon the footing of an impending apoplexy. It is possible that no effusion in the brain may have taken place at the time when the deple- ting plan has been carried into execution ; but if the paroxysms should still recur, surely few men can look at the violence of the struggle which they induce, at the bloated and distended state of the vessels of the face and of the tem- ples, at the force with which the current of blood is determined to the head, at the stertor and comatose state of the patient during the continuance of the fit, without feeling the great- est alarm at every return. And that he does not feel in vain is clear, because in various in- stances the insensibility continues after the par- oxysm is over, accompanies her through the re- mainder of her labour, and is the harbinger of her death. Regarding puerperal convulsions, then, as a case of impending apoplexy, produced by an ex- citing cause which it is often in our power to remove, it should seem to follow as a necessary and incontestable result, that in this, as in every other case in which the same disease is threatened, our first and unwearied attempt should be to remove such cause as far as it may be in our power. The present author's opinion was once re- quested upon a case of this very kind; but it was by the connexions of the patient, who had already fallen a victim to her sufferings. She had been attacked with natural labour-pains, and was attended by a female, who, alarmed by the sudden incursion of a convulsion-fit, sent im- mediately for male assistance. The practitioner arrived, and a consultation was soon held with several others : the os uteri is admitted to have been at this time open to the size of a crown- piece, soft, lubricous, and dilatable. The de- fETICA. [Cl. V—Ord. III. 496 GEN pleting and refrigerant plan was, however, confi- ded in alone, and the labour was suffered to take its course. Expulsory pains followed at inter- vals, but the convulsions followed also, and be- came more frequent and more aggravated ; in about six hours from the time of venesection the patient became permanently insensible ; and as the child's head, completely cleared of the uterus, had now descended into the pelvis, it was determined to deliver her by the forceps, which was applied accordingly ; and, in about an hour afterward, a dead child was brought into the world, whose appearance sufficiently proved that it had not been long dead. The source of irritation had now ceased, and with it the convulsions; but the patient contin- ued comatose still; yet even this effect went off in seven hours afterward, and she revived, and gave considerable hopes of recovery. On the second day, however, in consequence of the accession of milk-fever, the convulsions return- ed, immediately followed with stertor and in- sensibility, and, on the ensuing day, she died apoplectic. To reason from a single instance, whether successful or unsuccessful, is often to reason wrong. Yet it is difficult to avoid conjecturing, that if immediate delivery had here taken place as soon as the sanguiferous system had been duly emptied, and when the state of the uterus was so favourable for a trial, two lives might have been spared, both of which were lost under the course pursued.* It is true, the fits return- ed with the milk-fever, but had the brain been less injured, there would have been far less dan- ger of such return. The cases of Dr. Smellie and of Dr. Perfect concur in justifying such a conjecture : and the following passage of Mr. Bums should be committed to memory by every student and every practitioner. " But this is not all," adverting to the necessity of a free depletion ; " for the patient is suffering from a disease connected with the state of the uterus, and the state is got rid of by terminating the la- bour. Even when convulsions take place very early in labour, the os uteri is generally opened to a certain degree, and the detraction of blood, which has been resorted to on the first attack of the disease, renders the os uteri usually lax and dilatable. In this case, although we have no dis- tinct labour-pains, we must introduce the hand, and slowly dilate it, and deliver the child. I en- tirely agree with those who are against forcibly opening the os uteri: but I also agree with those who advise the woman to be delivered as * It often happens that the os uteri does not di- late during the most violent convulsions, and con- sequently delivery cannot be effected. In such cases the French apply the extract of belladonna to dilate the uterine orifice, and when this fails, the woman and infant being in danger, Boehn rec- ommends incisions through the os uteri. In such a case Dr. Ryan joins Dr. Ashwell in preferring the dilatation of the part with the fingers, as af- fording the mother and infant a much better chance of life. Should the woman die undeliv- ered, the Caesarean operation ought to be perform- ed shortly after death—in about ten minutes, ac- cording to the latter practitioner.—Ed. soon as we can possibly do it without violence. There is, I am convinced, no mle of practice more plain or beneficial. Delivery does not, in- deed, always save the patient, or even prevent the recurrence of the fits, but it does not thence follow that it ought not to be adopted."—(Prin- ciples of Midwifery, p. 359, 3d edit, 8vo., 1811.) SPECIES IV. PARODYNIA PERVERSA. CROSS-BIRTH. LABOUR IMPEDED BY PRETERNATURAL PRESENT- ATION OF THE FCET0S OR ITS MEMBRANES. In the ordinary course of gestation, the foetus is rolled up into as small a compass as possible, with the breast uppermost and the head depend- ent, the legs incurvated, and the arms folded : the placenta rises from some part of the fundus uteri, and the umbilical cord hangs at perfect ease in loose folds, or is sometimes turned loosely round the body, thus forming an ellipse, whose longer axis corresponds to the longer axis of the uterus. Why the head rather than the breast, or indeed any other part of the foetus, should so uniformly constitute the point of pre- sentation, we know not, excepting that it is by far the most commodious point for delivery ; and we can hence only resolve it into one of those striking laws of nature, which are ever aiming at accomplishing the best ends by the best means, and afford an unvarying and unequivocal proof of design, united with benevolence and power.* Here, however, as in every other part of the animal economy, we meet with occasional devi- ations from the ordinary course of nature, and de- viations which are always productive of evil. For it sometimes happens, from incidental causes that are totally concealed frbm us, that some other part of the child is lowermost, or presents itself instead of the head; or that the placenta rises in an unfavourable part of the womb, or that the navel-string hangs down be- low the head, and is constantly in danger of being strangled as the child passes through the sharp bones of the pelvis ; and hence, we have the following varieties of morbid condition under the present species :— a Faciei. Presentation of the face. 3 Natium. ----------- of the breech. y Pedis. -----------of one or both feet. * M. Viery states, that in those pregnant ani- mals of the multiparient kind which he has dis- sected, he always found in the horns of the ute- ms the snouts pointing to the vulva. In a gravid viper which he opened, all the young, eight in number, were placed with their mouths directed towards the external parts. In the egg, the head is always directed to the large end, and that end protrudes first; and the same thing occurs with respect to the ova of fishes. The larvae of insects pass out with their heads foremost; the chrysalis eats through its silky shell; and the caterpillar through its silky covering. Thus we see that na- ture is here regulated by one common law.—See Ramsbotham's Lectures, Med. Gaz. for 1834, p. 465—Ed. Gen. II.-Spe. 4.] PARODYNIA PERVERSA. 497 i Brachials. Presentation of one or both arms. t Transvcrsalis.----------of the shoulder. £ Funis prolapsi. Prolapsed navel-string. ti Placentae. Presentation of the placenta. As it is by no means the object of the pres- ent work to instruct in the manual or artificial operations of the obstetric art, the author must limit himself to pointing out the different mor- bid conditions in which such operations will be found necessary. Their nature, mode of ac- complishment, and effective instruments, are only to be learned by works written professedly on the subject, or, which is infinitely better, by an at- tendance on lectures, and such initiatory practice as the obstetric schools afford. A few general or incidental remarks are all that the author can undertake to add to the above table of morbid presentations. There is no mode of determining what may be the presentation of a child before the com- mencement of labour, and, even at that time, it is most prudent for a practitioner to speak with some hesitation on the subject, till the mem- branes have actually broken, and the position is fully decided. For, though the real presenta- tion is often sufficiently ascertainable through the membranes themselves, and particularly on the natural descent of the head, yet it has oc- casionally happened that, on the breaking of the membranes, the head has receded, and the shoulder or some other part taken its place ; and there are cases in which the opposite and more fortunate change has occurred, of a reces- sion of a presenting shoulder and a descent of the head in its stead.—(Joerg, Hist. Part., p. 90 ; Burns, ut supra, p. 292.) There is hence no foundation for those ap- prehensions which are often entertained by a pregnant woman respecting the misposition of the child, drawn from some peculiar symptom or feeling which she has never been conscious of on former times, as a singularity in the shape of the abdomen, a sense of the child's rising sud- denly towards the stomach, or a numb or pain- ful uneasiness in one leg more than in another. These, and hundreds of other anomalous sensa- tions, have occurred in cases where the pre- sentation has at last been found natural, and the labour has proved highly favourable ; white, on the contrary, it is very rarely, when a cross-birth is detected, that it has been particularly appre- hended by any procursive tokens whatever. And the minds of the timid may hence be com- forted in the midst of all the peculiarities on which they are accustomed to hang with daily alarm. It will rarely be found necessary to have re- course to any mechanical instrument in any of the varieties we have enumerated above ; and in some of them, as the breech and foot present- ations, the expulsory powers of nature generally are sufficient alone, at least till the head de- scends into the pelvis, at which time it will be found necessary, whenever the arms lie over the head, to introduce a finger or two, and gently draw them down. Vol. II—I i Where the face presents, or any other part of the head than the vertex, it was formerly the custom to deliver by turning; but a skilful practitioner of the present day is commonly able, by a dexterous pressure of one or two fin- gers against particular parts of the head, and es- pecially if attempted in an early stage of labour, to give the organ a right direction without in- troducing the hand. On the presentation, however, of a shoulder, or of one or both arms, it will be expedient to turn as soon as possible ; or in other words, as soon as the mouth of the womb is sufficiently dilated for this purpose. It is singular, that while under the old practice delivery by the feet was often endeavoured in face cases, attempts were made in arm and shoulder cases to bring down the head, and reduce the labour to a nat- ural course. This it seems has been done, and may be done, but with so much fatigue and exhaustion to the patient as to run the risk of incapacitating her for any subsequent efforts, if she do not even fall a sacrifice to a flooding, as in a case related by Dr. Smellie. It is by the successful exejtions of Pare and Mauriceau that the better practice of the present day has obtain- ed a triumph over all Europe. Yet'in justice to the obstetric practitioners of ancient Greece, it should be observed, that the modern method is little more than a revival of their own, which unaccountably sunk into disfavour: for we are told by ^Etius that Philomeles discovered the method, at that time in common use, of turning and delivering children by the feet in all unnat- ural presentations. Where, however, the child is small or of premature birth, it may sometimes be taken away without changing the presenta- tion : for the obstetric writers abound in exam- ples of delivery effected under such circum- stances, by pulling down the arm and drawing the head jnto the vagina.—(Gardner, Med. Com- ment., vol. v., 307 ; Baudelocque, sect. '1530 ; Burns, ut supra, 303.) It sometimes happens that the shoulder is so far advanced into the pelvis before the arrival of the practitioner, or from the vehement force of the uterus, that it is impossible to raise or move the child by the utmost power of the oper- ator, and the state of the case seems- to leave the woman without any hope of relief. At this very moment, however, and by these very means, the wise and benevolent law of instinct or of nature is interposing to the relief that is despaired of. This wonderful process, though occasionally noticed by earlier writers, and fore- most of all perhaps by Schoenheider in the Co- penhagen Transactions (Act. Hafn., tom. ii., art. xxiii.), was first fully illustrated and explain- ed by Dr. Denman, who distinguished it by the name of a spontaneous evolution. His ex- planation is best given in his own words :—"As to the manner in which this evolution takes place, I presume that, after the long-continued action of" the uterus, the body of the child is brought into such a compacted state as to re- ceive the full force of every returning action. The body in its double state being too large to pass through the pelvis, and the uterus pressing 498 GENETICA. [Cl. V.—Ord. lit upon its inferior extremities, which are the only parts capable of being moved, the latter are forced gradually lower, making room as they are pressed down for the reception of some other part into the cavity of the uterus which they have evacuated, till, the body turning as it were upon its own axis, the breech of the child is expelled as in an original presentation of that part, and consequently is delivered by nature at the time she least expected it." Dr. J. Ham- ilton, however, has justly observed, that this evo- lution can only take place where the action of the uterus can produce no exertion on the pre- senting part, or where that part is so shaped that it cannot be wedged in the pelvis : and he might have added, where the woman is in full strength, and the uterus is capable .of exercising a strong expulsory power. And hence it is a chance that should never be trusted to, or suf- fered to interfere with the common practice of delivering by the feet, wherever this can be ac- complished.* In all the above cases it is a general rule, and one of great importance, to suffer the water of the amnios to accumulate towards the neck of the womb as largely as possible, and to leave the membranes unbroken as long as may be. A presentation of the funis is another diffi- culty often of considerable moment in the prog- ress of labour, for it is obvious that by a check to the pulsation, either actually taking place, or being greatly endangered in every pain by the violent pressure of the head or of any other part against the mouth of the uterus, or afterward against the sides of the pelvis, and consequently against the funis itself, the life of the child is in imminent hazard, and, without the exercise of considerable skill, may inevitably be lost. If it be possible to return the prolapsed part of the funis round the head as it is descending, or to hook it against the hand or some other part so as to keep it clear of pressure, this ought to be done by all means. But if this be impossible, the child must be turned, as soon as turning is practicable from the dilated state of the os in- ternum : or if the head should have reached the pelvis before the accident takes place, the labour must be accelerated by the patient's using her utmost efforts during every pain; and if she be too much exhausted for concentrating her strength, it must be quickened by the use of the forceps. But if the pulsation in the cord have already ceased, and we have hereby a proof that the child is already dead, the labour is to be suffered to take its natural course. It sometimes happens, however, that after the child is turned, and the head does not follow the body so speedily as could be wished, from the patient being greatly exhausted—and the same frequently occurs in breech cases in consequence * The presentation of the knees has been descri- bed by several authors, but this case is exceedingly rare; Madame Boivin has seen four instances of it, Madame Lachapelle none; Campbell also al- ludes to it in his System of Midwifery. It has been observed by American practitioners, particu- larly by Francis and Dewees. The general indi- cation in these cases is to deliver hy the feet.—D. of the protracted length of the labour in this presentation—there is still a considerable dan- ger to the navel-string, from its pressure between the child's head and the pelvis. This should be remedied as much as possible by giving the funis full play between the pains. But it fre- quently occurs, in spite of the utmost caution, that the pulsation is suspended, and the child is born in a state of asphyxy, and apparently life- less. The common practice in this case is to tie the navel-string as quickly as possible, remove the child from the mother to the warmth of the fireplace, and endeavour to stimulate the lungs into action by breathing forcibly into the mouth while the nostrils are closed. Friction with a warm hand, and with the conjoint aid of some pungent volatile, is at the same time applied actively to the chest; and if this do not succeed, the nostrils are attempted to be roused with ammonia, or the fauces with a teaspoonful of brandy and hot water, to excite sneezing or coughing. All this is well; but there is a great, and I am afraid not unfrequently a fatal error, in thus separating the navel-string, and removing the child from the mother. While it continues united, it has two chances of recovery—that of the action of the lungs, and that of the reaction of the umbilical artery. By removing it from the mother we allow it but one chance, and that in my opinion the feeblest. The expansion -of the lungs is altogether a new process, and, like other new processes, does not always take place with great promptness, even where the child is in full life and vigour, and the umbilical artery in regular pulsation ; for it is sometimes half a minute, or double this time, before the child be- gins to cry, which is the first proof of its respi- ring. But the flow of the blood through the umbilical artery is an established habit, and, like all other habits, has a powerful tendency to recur if we give it time and favour, and must derive an additional tendency from the stimulus of the posterior placental vessels, which are still pul- sating and operating with a vis a tergo. Of the various cases of asphyxy on birth which I have witnessed, by far the greater number have proved fatal when treated in the former way, and successful when treated in the latter; and the explanation here given will readily account for the difference. The placenta itself may also form a preter- natural presentation, and add much to the diffi- culty and the danger of labour. We have said that this rises ordinarily from some part of the fundus of the uterus, though it may originate from its sides, or from some other quarter, for there is no quarter of the womb which may not become its source. Hence it occasionally takes its rise more or less over the mouth of the womb; and while this part of the womb continues qui- escent, it produces no more inconvenience there than anywhere else. But the moment labour commences, or even, in the latter months of par- turition, when any cause whatever irritates the mouth of the womb, and in any degree puts it upon the stretch, some of the placental vessels must necessarily become ruptured, and a hemor- Gen. II.—Spe. 5.] PARODYNIA AMORPHICA. 499 rhage ensue. So long as this is small in quan- tity, and does not frequently return, it will be sufficient to enjoin quiet, a recumbent position, and that the bed be not heated with a profusion of blankets. But if the hemorrhage be consid- erable, whether before the full time of labour "or on its accession, or in any part of it, there is no perfect safety but in delivery, and hereby giving the ruptured vessels an opportunity of closing their mouths. The difficulty is less than a young practitioner might at first expect; for he may be sure from the hemorrhage itself that the os uteri is both ddated and dilatable, since if this did not give way, neither would the vessels which produce the hemorrhage. Upon the whole, the proportion of unnatural deliveries to natural is but few; and of these it is pleasing also to reflect, that the more they are connected with difficulty or danger, the more rare is their occurrence; insomuch that, compa- ring the statements of Professor Naegele of Heidelberg (Uebersicht der Vorfalle in der. G. H. Eutbindungsanstalt zu Heidelberg, &c, 1819) with those of several of the most eminent ac- coucheurs of our own country, as Dr. Bland and Dr. Merriman, we may calculate that a breech case may be expected about once in fifty times, a foot case once in eighty, and the more dangerous presentations of the arm, breast, or funis, scarcely twice in five hundred births.* SPECIES V. PARODYNIA AMORPHICA. IMPRACTICABLE LABOUR, LABOUR IMPEDED BY MISCONFIGURATION OF THE FCETUS, OR OF THE MATERNAL PELVIS. In natural labour, the size of the head is adapt- ed to the diameter of the pelvis it has to pass through : in some children, indeed, the head is rather larger than in others, or has a difference of shape ; and we meet with a like difference in the area of the pelvis : and these circumstances may prolong the labour, though the expulsory powers of the mother will ultimately triumph Over the resistance. But it unfortunately happens that the head is sometimes so enlarged by monstrosity of struc- ture, hydrops capitis, or some other disease, or that the maternal pelvis is so deformed in its make, that the child cannot pass through the passage, and delivery becomes altogether im- practicable. There is, however, an intermediate state be- tween the natural size of the pelvis with a head of a natural size applied to it, and that of abso- lute impracticability from the utter inaccordance of the head to the opening; in which, though the most violent and best-directed pains of the * In 71,045 labours occurring in the practice of Madame Lachapelle and others, 70,111 were nat- ural; in 24,214 cases recorded by Madame Boivin and others, the number terminating naturally was 23,795, unnatural cases 256, delivered with for- ceps 117, with the perforator 31, by symphysioto- my 2, by the Caesarean section 2, by operations not stated II.—D. I i 2 mother may not be sufficient to produce expul- sion, this object may be effected by the assist- ance of instruments co-operating with the natu- ral efforts. What space of pelvis is absolutely necessary to enable a living child at its full time to pass through it, has not been very accurately settled by obstetric writers; some maintaining that this cannot take place where the conjugate diameter is less than two inches and a half, though it may till we reach this degree of narrowness; and others that it cannot take effect under three inches. The difference of the size of the head. in different children on their birth, and of the thickness of the soft parts within the pelvis in different women, may easily account for this variation in the rule laid down. It is clear, however, from the acknowledgment of both par- ties, that if the dimension of the pelvis be much under three inches, delivery cannot be accom- plished without the loss of the child ; and it is also clear that if the head be much enlarged beyond the natural size from any cause what- ever, it cannot pass even through the ordinary dimensions; thus giving us the two following sources or varieties of difficult labour from an amorphous cause:— a A fetu. The foetus deformed by a pre- ternatural magnitude of head, or some other mor- bid protuberance. B Pelvica. The pelvis contracted in its diameter by natural de- formity, or subsequent dis- ease or injury. It is by no means easy to determine what is the actual measurement of the hollow of the pelvis in a living woman, and particularly during the time of labour: and hence, how useful so- everit maybe to be acquainted with what ought to be its precise capacity as taken under other cir- cumstances, the judgment must chiefly deter- mine as to the practicability or impracticability of the passage from a calm attention to the in- dividual case at the time, and particularly where the difficulty proceeds from the form of the child rather than from that of the mother. If, in well weighing the circumstances, the ques- tion remain doubtful, the patient should be al- lowed to proceed with her natural exertions alone, or such only in addition as the hands may be able to afford, till the strength is consider- ably exhausted, and the mind participates in the depression.of the body. And if, at this time, as will probably be the case, the head has de- scended so low as to be in contact with the per- inaeum, and an ear can be felt, it would be im- prudent to delay any longer assisting her with the vectis or the forceps. But the case may not be doubtful, and the passage may be so much contracted as to render all attempts to accomplish delivery by the hands or the ordinary instruments totally ineffectual from the first. In this situation other means must be resorted to, or the mother and the child must both perish, worn out by fatigue, and per- haps-rendered gangrenous in the points of con- tact from irritation and inflammation. 500 ¥, GENETICA. [Cl. V.—Ord. IIL The means on this occasion are the three fol- lowing ; the practitioner may reduce the head of the child by the crotchet or perforator. He may, in a small degree, enlarge the diameter of the pelvis by dividing the symphysis "pubis. Or, he may make a section through the abdo- men into the uterus. The first of these methods is designed to save the mother by a voluntary sacrifice of the child. The two last give a chance to the child, but at an imminent hazard of the mother. Where the difficulty proceeds from a morbid enlargement of the child's head, the question as to which of these three methods of treatment should be adopted ought not to admit of a mo- ment's delay. The child is, perhaps, dead al- ready, or, if not, it is not likely that it would long survive the deformity it labours under, or live so as to render life a blessing : and the life of a sound woman must not be risked, and still less sacrificed, for the chance of saving an un- sound child. The head, therefore, ought to be diminished, and consequently the perforator had recourse to. But there are instances of a deformity of the pelvis so considerable, that the perforator can- not be employed to any advantage : for how much soever the cranium may have been bro- ken down, there may not be breadth enough to extract the child in any way. And this will al- ways be the case where the range of the pelvis is under an inch and a half from the pubis to the sacrum, or on either side. Dr. Osborn as- serts that he once succeeded in removing a child by means of the crotchet, in a case where the widest side of the pelvis was only an inch and three quarters broad, and not more than two inches long (Osborn's Essays, p. 203); which is a capacity so narrow as to throw some doubt upon the accuracy of the measurement in the minds of many practitioners (Burns's Princ. of Midwifery, p. 351), and certainly so narrow as to form an unparalleled case in the annals of the obstetric art. In situations, therefore, of this kind, some other plan must be pursued even to save the life of the mother ; and the only plans that can even be thought of are that of dividing the symphysis of the pubes, and that of the Caesa- rean section. Towards the latter months of pregnancy, there seems to be a disposition in the bones of the pelvis to separate at their symphysis, inso- much that some pregnant women are sensible of a motion at the junction of the bones, espe- cially at that of the ossa pubis.—(Francis's Den- man, p. 98, 484.) This has been known lo anatomists for some centuries, and about sev- enty years ago, for the first time, gave rise to a question, whether advantage might not be taken of this tendency in cases of pelvic contractions, to enlarge the space by dividing the ossa pubis at their symphysis, and thus obtain the same end as is answered by the Caesarean section, with a considerable diminution of risk. The operation seems first of all to have been proposed by M. Louis of the French Academy of Surgery to Professor Camper of Groningen, who tried it first on a dead female body, and found it would afford space, and next on a living pig, which, for some days afterward, was incapable either of walking or standing, but in a few weeks per- fectly recovered. He was then desirous of trying it upon a young woman condemned to death at Groningen, but did not succeed in his request. Not long afterward, however, it was performed with complete success by M. Sigault of Paris upon the wife of a soldier, who had hitherto borne four children, each of which, from the mother's misformation, was obliged to be extracted piecemeal. The section of the cartilage connecting the ossa pubis, enabled the bones to be separated, according to his ac- count, by a chasm of two inches and a half; and yielded a free passage to the child in four minutes and a half. The wife, with her hus- band and child, a few weeks afterward, pre- sented themselves to the members of the faculty assembled in their halL The patient walked steadily, and was found to be perfectly recov- ered.—(Med. Comm. Edin., vol. v., p. 214.) Mr. Le Roy, who was requested to attend on the occasion, tells us that the same operation was afterward performed by two other practitioners on two other women, and, in both cases, with an equally happy termination. He also observes, that although, in an unimpregnated state, the bones of the pelvis cannot be made to separate upon a division of the symphysis to a space of more than an inch, which would be insufficient for the purposes proposed, the additional soft- ness and flaccidity which take place during pregnancy, as well in the bones and cartilages as in the muscles, is so considerable, that a sep- aration of two inches and a half may be easily effected in labour, and was effected in the above cases, while the same bistoury that divided the soft parts, easily also divided the cartilage.— (Recherches Hisloriques et Pratiques sur la Sec- tion de la Symphyse du Pubes, &c, Paris, 8vo., 1778.) In various other parts of the continent, and especially at Mons and in Holland, it has been repeated with complete emancipation both to the child and mother. Dr. J. H. Myers, who witnessed it at Paris, speaks of it in the highest terms of commendation. He says, that the length of the incision does not exceed three inches, and that the whole operation is over in less than five minutes : while, in the Caesa- rean. operation, the wound is necessarily more than nine inches long, the uterus is divided, and the surrounding viscera are uncovered. " I have seen," says Dr. Myers, " the operation twice performed in this capital with every pos- sible success. The last patient, white I am writing, is in the room, coming to show her- self in justice to her operator. It is only eigh- teen days since the operation was performed, and she is in perfect health, and by no me'ans injured by it."—(Edin. Med. Comm., vol vii p. 453.) The operation however, has been decried, and in some instances has certainly failed; but there appears to be some doubt whether, in sev- eral of these cases at least, if not in all, it was conducted with a sufficient degree of dexterity Gen. II.—Spe. 5.] PARODYNIA and skill: for when we are told by one operator thatv after the division of the symphysis, he could not effect an opening of much more than a finger's breadth, and by another, that the ut- most extent of the hiatus was not more than an inch and a half, and compare these remarks with the following assertion of Dr. Myers upon this very point, it is difficult to come to any other conclusion. " The moment," says he, " the division is made, there is an enlargement of the pelvis, I venture to say, to any extent desired : the last I saw was three inehes, accu- rately measured by an instrument called pelvi- melre, contrived by M. Trainel." To which we may add, that M. de Lambon performed the operation twice on the same patient; in the first instance, without injury to the mother: and, in the second, with success to both mother and child.—(Leake's Practical Observatioiis on the Acute Diseases of Women, 8vo.) After these decisive facts in its favour, to which the reader may add others from the vol- ume of Nosology, I cannot but conceive that the prejudice against it, in our own country, has been carried too far. One trial alone has been made among ourselves, and that with an unsuc- cessful issue. But the chief opposition to it seems to have proceeded from the discounte- nance of Dr. Denman, added to certain experi- ments made in relation to it by Dr. William Hunter,* which do not seem to have been con- ducted under circumstances that can fairly call in question the truth of the preceding state- ments. " Immediately," says Dr. Denman, " after the accounts of the operation were brought into this country, wishing, as a matter of duty, to under- stand the ground of the subject, I had a confer- ence with the late Mr. John Hunter, in which we considered its first principle, its safety ; and after the most serious consideration, it was agreed that, if the utility could be proved, there ap- peared from the structure of the parts, or from the injury they were likely to sustain by the mere section of the symphysis, no sufficient ob- jection against performing it. Of its real utility it was, however, impossible to decide before many experiments had been made on the dead body, to ascertain the degree of enlargement of the capacity of the pelvis, well-formed or distort- ed, which would be thereby obtained. Such ex- periments were soon made, and their result pub- lished by the late Dr. Hunter ; and these proved on the whole that, in extreme or great degrees of distortion of the pelvis the advantage to be gained was wholly insufficient to allow the head of a child to pass without lessening its bulk : and, in small decrees of distortion, that the operation was unnecessary, such cases admitting of re- lief by less desperate methods. They proved, moreover, that irreparable injury would be done by attempts to increase the common advantages gained by the section of the symphysis by strain- ing or tearing asunder the ligaments which * See also Osbom's Essay on Laborious Partu- rition, in which the division of the symphysis pubis is particularly considered, 8vo., Lond., 1783. AMORPHIC <" 501 connect the ossa innominata to the sacrum, and to the soft parts contained in the pelvis, par- ticularly to the bladder."—(Francis's Denman, &c, 3d edition, New-York, 1829, p. 486.) Now it did not require these experiments to prove that this operation, or .almost any other, would become mischievous if unskilfully per- formed ; but surely it was something too much to endeavour to set aside the facts and results known to have taken place in very numerous instances in the living body, and to call in ques- tion the veracity of those who made them and those who witnessed them, by facts and results made merely on the dead body, without one single experiment on the body while alive, and in the peculiar circumstances under which alone it is admitted that the facts and results con- tended for could possibly take place. Upon the whole, it is aUcwed in the passage just quoted, as the concurrent opinion of Dr. Den- man himself, Mr. John Hunter, and apparently Dr. William Hunter, and this, too, after " the most serious consideration,"—that " there appears from the structure of the parts, or from the in- jury they are likely to sustain by the mere sec- tion of the symphysis, no sufficient objection against performing the operation." That it will answer in every degree of a contracted pelvis was never asserted by its most sanguine advo- cates, but only in cases where the constriction was somewhat too considerable to allow of the ex- traction of the child by the forceps ; and lastly, it is after all admitted by Dr. Denman himself, that where the life of a child is of more than ordinary importance from public or other con- siderations, and the mother, who is in labour with it, possesses a pelvis so deformed and con- tracted that it cannot pass through the passage in its present state, " there the section of the symphysis of the ossa pubis might be proposed and performed,—being less horrid to the woman than the Cassarean operation, and instead of adding to the danger, giving some chance of preserving the Ufa of the child."* It is perfectly clear, however, that, be the ad- vantages of dividing the symphysis what they may when the pelvis is under certain states of deformity, it is an operation that can never be of any avail where the passage is so narrow that the child cannot be brought away piecemeal even by {he use of the perforator. And, in such circumstances, the only alternative is to leave the patient to nature, in the slender and desperate hope, that the pains may gradually wear away as the parts become habituated to the irritation, and the child, as in many cases of extra-uterine foetation, be thrown out in de- tached fragments by an abscess; or to have * Francis's Denman, ut supra, 487. On the con- tinent, the section of the symphysis of the pubes was repeated with various success. Thirty-six cases are well authenticated, in which fourteen women died, and half the children were stillborn. It has only been performed once in Great Britain; Mr. Welchrnan, the operator, has given the par- ticulars of it in the London Medical Journal for 1790.—See Ramsbotham's Lectures, as pubUsherj in Med. Gaz. for 1834, p. 404—Ed. 502 GENETICA. [Cl. V.—Ord. III. recourse to what has been called the cesarean operation, and deliver by making a section into the uterus through the abdomen. The- love of offspring, or a sense of duty, has been so prevalent in some women as to induce them to submit to this severe trial in cases where the pelvis has by no means been so strait- ened as we are now contemplating. And these motives not being confined to any particular age, the operation is of considerable antiquity, and is particularly -noticed by the elder Pliny, who tells us, that the elder Scipio Africanus and the first of the Caesars were brought into the world in this manner, and adds, that the name of Cae- sar was hence derived " a caso rhatris utero."— (Hist. Nat., lib. vii., cap. ix.) In recent times, one of the earliest cases in which it was sub- mitted to, was that of the wife of a cattle-geld- er at Siegenhausen in Germany, in the be- ginning of the sixteenth century. The child, it seems, was, from its size, supposed to be inca- pable of being expelled in the natural way, and the operation was performed by the cattle-gelder himself. Bauhin, in his Appendix to Rousset, who was a warm supporter of the practice, and wrote in favour of it in 1581, tells us that this woman did well, and bore several children af- terward in the natural way. There are a few other instances related of its having been exe- cuted in a similar way, and with equal success ; particularly one performed in Ireland, by an un- jnstructed midwife, whose instrument was a ra- zor. The case is related by Mr. Duncan Stew- art (Edin. Med. Essays, vol. v., p. 360), who saw the woman a few days after the operation. She was well in about a month. Among regu- lar practitioners, however, it has been generally Opposed on account of its very doubtful result, from the time of Pare and Guillemeau, who warmly resisted its employment. Dr. Hull not long since made a collection of all the cases in which the operation has been performed, both at home and abroad, and calculated them at 231, of which 139, being considerably more than half, had proved successful.—(Translation of M- Baudelocque's Memoir, p. 233.) The Ger- man collections, indeed, give various examples of its haying been repeated several times on the same person ; and M. Trestan narrates the ex- traordinary history of one woman who had sub- mitted to it not fewer than seven times.—(Journ. de Medecine, tom. xxxvi., p. 69.) One of the latest examples is, I believe, the case furnished by Dr. Locker, of Zurich, in which the mother and child were both happily preserved.—(Med. Chir. Trans., vol. ix., p. 69.)* Under this view of the subject, it is singular to obseTve the general fatality, at least to the mother, with which the Cesarean section has been followed in our own country. " There are, I think," says Mr. Burns, " histories of twenty cases where this operation has been performed in Britain ; out of these only one woman has * The Caesarean operation has been performed but seldom in the United States. The most re- cent case, which occurred in the practice of Prof. Gibson, of Philadelphia, was successful.—D. been saved, but ter. children have been pro- served."* At Edinburgh, Mr. Hamilton remarks (Ele- ments of the Practice of Midwifery, 8vo.) that it had been performed five times at the date of his publication: and that, in no instance, had the patient had the good fortune to survive it many days. Of the last case he was an eye- witness, and it was only resorted to after every other means had proved ineffectual : the child was saved, but the mother survived only six-and- twenty hours. This ingenious writer enters with great pertinence into the question to what cause so general a failure is to be ascribed. And while he admits that nervous or uterine irritation from the wound, internal hemorrhage, or an extravasation into the cavity of the abdo- men, may each have an influence, he is disposed to think, that its ill success is principally to be imputed to the effect which access of air is well known to have on viscera exposed and in a state of irritation. Dr. Monro repeatedly found that, in making even a large aperture by incision into the abdomen of animals, if the wound be quick- ly closed, the animahreadily recovers : but that if the viscera be exposed for only a few min- utes to the air, severe pains and fatal convul- sions ensue.+ And hence Mr. Hamilton recom- mends, that, in performing the Caesarean opera- tion, the bowels be denuded as little as possible, and the wound be closed with the utmost expe- dition. This answer, however, is hardly satisfactory : and I am rather inclined to think, that the com- parative want of success at home is owing to the greater reluctance in performing the opera- tion than seems to be manifested in France and Germany ; in consequence of which it is rarely determined upon until the woman is too far ex- hausted, and has an insufficiency of vigour to enable the wounded parts to assume a healing condition. In most of the cases recorded, there does not seem to have been any deficiency of skill ; and particularly in that which occurred about five-and-thirty years since, and was at- tended by Mr. John Hunter and Dr. Ford (Fran- cis's Denman, ut supra, p. 498), and hence the * Princip., ut supra, P- 348. Dr. Ramsbotham, whose lectures have a later date than that of Mr, Burns's work, states, that " out of nearly thirty instances in which this operation has been per- formed in the British isles, in two only has it proved successful, as far as the preservation of the mother was concerned." The latter physician would restrict its performance to cases of pelvic distortion or tumours. In Britain it is never sub- stituted for craniotomy by choice, but only had recourse to when no other mpde of delivery is practicable.—(See Med. Gaz. for 1834, p. 403.) The custom of resorting to it with less delay abroad, is no doubt the reason of its having proved more successful there than in this country, where the woman is usually in a state of extreme danger before the operation is attempted.—Ed. t As the viscera were generally exposed to the air in cases operated upon abroad, which were at- tended with a considerable proportion of success, such exposure will not account for the greater fa» tality of the operation in this country.—Ed. '. II.-Spe. 6.] PARODYNIA PLURALIS. 503 unfavourable issue must be resolved into some other cause. It is happy for the world, and peculiarly so for those who are possessed of a contracted pelvis, and in many cases without knowing it till they are in labour, that a far safer and less painful operation may be had recourse to, where the de- formity is known in due time ; I mean that of a premature delivery. "A great number of instances have occurred," says Dr. Denman, " of women so formed that it was impossible for them to bring forth a living child at the termina- tion of nine months, who have, in my own practice, been blessed with living children by the accidental coming on of labour when they were only seven months advanced in their preg- nancy, or several weeks before their due time. But the first account of any artificial method of bringing on premature labour was given to me by Dr. C. Kelly. He informed me, that about the year 1756 there was a consultation of the most eminent men at that time in London to consider of the moral rectitude of, and advanta- ges which might be expected from, this prac- tice ; which met with their general approbation. The first case in which it was deemed neces- sary and proper, fell under the care of the late Dr. Macauley, and it terminated successful- ly. The patient was the wife of a linen-dra- per in the Strand. Dr. Kelly informed me that he himself had practised it; and among other instances mentioned that he had per- formed this operation three times upon the same woman, and twice the children had been bom living. " A lady of rank," continues the same writer, " who had been married many years, was soon after her marriage delivered of a living child in the beginning of the eighth month of her preg- nancy. She had afterward four children at the full time, all of which were, after very difficult labours, born dead. She applied in her next pregnancy to Dr. Savage, whom I met in consultation. By some accounts she had re- ceived, she was prepared for this operation, to which she submitted with great resolution. The membranes were accordingly ruptured, and the waters discharged, early in the eighth month of her pregnancy. On the following day she had a rigour, succeeded by heat and other symptoms of fever, which very much alarmed us for the event. On the third day, however, the pains of labour came on, and she was, after a short time, deliv- ered, to the great comfort and satisfaction of her- self and friends, of a small but perfectly healthy child, which is at this time nearly of the same size it would have been had it been bom at the full period of utero-gestation ; and it has lived to the state of manhood. In a subsequent preg- nancy, the same method was pursued; but whether the child was of larger size, or the pel- vis was become smaller, whether there was any mistake in the reckoning, or whether the child fell into any untoward position, I could not dis- cover, but it was stillborn, though the labour did not continue longer than six hours. Yet, in a third trial, the child was born living and healthy, and she recovered without any unusual incon- venience or trouble."—(Epist. App. ad Strauss de fostu, Mussipont., p. 298.) It is only necessary to add, that at the time in which the labour-pains will come on after thus rupturing the membranes and discharging the waters, is uncertain, and appears to depend much on the irritability of the uterus. It is sometimes delayed, as in the first trial in the case just noticed, for three days, but the labour has sometimes also been found to commence within a few hours. SPECIES VI. PARODYNIA PLURALIS. MULTIPAROUS LABOUR. LABOUR COMPLICATED BY A PLURALITY OF CHIL- DREN. The fertility of women seems to depend upon various circumstances ; partly, perhaps, the ex- tent or resources of the ovaria, partly constitu- tional warmth of orgasm, and partly the adapta- tion of the male semen to the organization of the respective female. Eisenmenger gives us the history of a woman who produced fifty-one children (Epist. App. ad Strauss de fcetu, Mus- sipont., p. 228) ;* and sometimes the fertility seems tq pass from generation to generation, in both sexes, though it must be always liable to some variation from the constitution of the fami- ly that is married into. I have in my own fami- ly, at the time of writing, a young female ser- vant whose mother bore twenty-three children, and brought them up with so much success, that, at the time of the mother's death, she was the youngest of nineteen then living; and her eldest brother has fourteen children at present, all of whom I believe are in health. But while some women produce thus rapidly in single succession, there are others that are multiparient, and bring forth occasionally two or even three at a time, more than one ovum being detached by the orgastic shock. Three at a time is not common : I have met with but one instance of it in which the children were all alive and likely to live ; and one instance only occurred to Dr. Denman in the course of upwards of thirty years' practice. Four have occasionally, but very rarely, been brought forth together, and there are a few wonderful stories of five, but which rest on no well-authenticated testimony, t Twins are mostly produced at a common birth ; but owing to the incidental death of one of them while the other continues alive, there is * A most remarkable instance of fecundity in the human species, is contained in the London Medical Gazette, vol. i., p. 354. The wife of a Russian peasant brought forth fifty-seven children in twenty-one births. They were all living at the same tune. In the first four labours, she gave birth to four children at each time ; three in each of the next seven labours ; and she afterward was always delivered of twins. By a second wife, the same man had fifteen children in seven labours. —D. t In 18,300 cases at the British Lying-in HospjT tal, no case of triplets occurred. In 20,357 at thp Matemite, there were 3 ; and in 59,354 cases, 19, —See Ryan's Manual of Midwifery, p. 290.—Ed, 504 GENETICA. [Cl. V—Ord. III. sometimes a material difference in the time of their expulsion, and consequently, therefore, in their bulk or degree of maturity, giving us the two following varieties :— a Congruens. Of equal or nearly equal Congruous twin- growth, and produced at ning. a common birth. 3 Incongruens. Of unequal growth, and pro- Incongruous ducedat different births. twinning. In congruous twinning, or ordinary twin- cases, in which there is no great disparity of size between the two, on the birth of the one, it can be pretty easily ascertained that another is still in tiie womb, by applying the hand to the abdomen : for the limbs, and, if the child be alive, its movements, may generally be felt very distinctly, except, indeed, where an ascites is present, and the practitioner must then have re- course to other tokens. There are no precise signs by which a woman or her attendant can determine whether she be pregnant of twins or not. Inequalities in the prominence of the abdomen, peculiarities of in- ternal sensation or motion, slowness in the prog- ress of a labour, have been advanced as signs; but they belong as frequently to' the uniparient as to the multiparient, and hence are unentitled to attention. The claim to priority of birth in a twin case is dependant, not on superiority of strength or any other endowment, but on a closer proximity to the mouth of the uterus alone, and conse- quently, on a greater convenience of position. Though when, on the birth of twins, one is found small and emaciated, and the other plump and strong, we have some ground for appre- hending that the vigorous child has absorbed the greater part of the nutriment afforded by the mother, as we find not unfrequently in plants shooting from the same spot of earth. The general rules that govern in morbid labour of individual children, govern equally in morbid labour of twins. The second child is usually delivered with comparatively few pains and little inconvenience, as the parts have been sufficient- ly dilated by the passage of the first: and, al- though there is commonly some interval between the termination of the one and the commence- ment of the other struggle, it is not often that this interval exceeds half an hour or an hour. It has, indeed, in a few instances, extended to whole days ; in one instance to ten (Hist, de VAcad, des Sciences, 1751, p. 107), and in an- other to seventeen days.—(De Bosetin Verhen- delingen van Harlem, xii., App. No. 6.) But these are very uncommon cases: and, as mis- chief may possibly happen to the womb and to the system at large from a long protraction of * Some practitioners seem not to agree with Dr. Good on this point: the following is the ad- vice delivered by Dr. Ryan. "In all cases, imme- diately after delivery, the hand is to be placed upon the abdomen to ascertain whether another infant be present; and if such is the case, the la- bour should not be provoked for ten or twelve hours, unless some Untoward symptoms occur. I have known a woman delivered of one infant on uterine irritation, it is now the practice to de- liver the second child by art, after having waited four or five hours in vain for a return of expul- sory exertions.* In incongruous twinning we meet, in dif- ferent cases, with every possible diversity in perfection of form and term of expulsion, be- tween the co-offspring. Nor is this to be won- dered at in either respect. We have already seen that a single foetus may die during any pe- riod of parturition, from a variety of causes; and hence we may readily conjecture that one of the twins may die at any period, while the other still thrives and remains unaffected. This twin may remain in the womb, and both be expelled together at the full time. But it may happen, also, from the peculiar irritation of the uterus generally, or the peculiar position of the dead foetus near the cervix, that this organ may be so far stimulated by the death and corrupt state of the fcetal corse and its membranes as to expel it from the body, while the living child receives no injury, continues to thrive, and is maturely de- livered at its proper time. In the latter case, where the dead foetus has been discharged in the second or third month of pregnancy, the mother, not knowing herself lo have been pregnant with twins, has been erro- neously conceived, on the arrival of the second birth, to have produced a perfect child within the short term of six or seven months. In the former case, or that in which the dead foetus remains quiet in the womb through the re- maining term of pregnancy, and both are dis- charged at a common birth, an opinion equally erroneous was formerly entertained in order to account for the apparent difference of the two in growth and size: for it was supposed that the dead and puny, and apparently premature foetus, was conceived some months subsequently to the perfect and vigorous child, and hence had not time to reach it in size and perfection : and to this supposed subsequent conception was given the name of superfcetation. We have reason to believe that such a pro- cess does occasionally take place in some quadrupeds, whose wombs are so formed as to allow of it : but we have already observed in the preliminary Proem to the present class, as also in the introductory observations to the pres- ent order, that in women, from the moment of conception, an efflorescent membrane is formed, which lines the whole cavity of the uterus, and acts as a septum to the ascent of any subsequent tide of male semen ; not to say, further, that the os uteri itself is so plugged up by the secre- tion of a viscid mucus at the time, as to prevent any communication between this organ and the vagina till the period of pregnancy is completed, And hence the doctrine of superfoetation in wo- Monday, and the second on the following Thurs- day, without a bad symptom during the time ; and both infants were born alive. Another case fell under my care, where there was a period of thirty- six hours between the births, and not a pain during the time; the second infant was born dead. The secale comutum had its usual good effects in this case."—See ii anual of Midwifery, p. 192, ed, 3. Gen. II.—Spe. 7.] PARODYNIA SECUNDARIA. 505 men, excepting under very particular circum- stances, has deservedly sunk into general dis- repute.—(Waldschmied, Dissert, de Supcrfazta- tione falso pratensa, Hamb., 1727.) For it is possible, however, as we have already observed, for a second foetation to take place by an addi- tional connexion, within a few hours after the first, and before the formation of the occluding membrane. But in this case the progress of the twins is parallel, and their birth in immediate succession. The cases of this kind, and formerly ascribed to the exploded cause, are by no means uncom- mon. Dr. Maton has given a very decided one of a lady delivered at Palermo of a male child, in November, 1807, and again, scarcely three months afterward, in February, 1808, of an- other male infant, " completely formed."—(Med. Trans., vol. iv., art. xii.) The proportions or powers of the first child are not sufficiently no- ticed : but we are told that both were born alive ; that the elder died when nine days old " without any apparent cause;" and that the younger died also, but after a longer term. In Henchel we have an account of a minute (Neue Medicinische und Chirurgischt Anmer- kungen, b. ii.) and a mature foetus born at the same time : and a similar history is given by Mr. Chapman, with the exception of the time, which varied considerably : the dead and minute foetus, apparently not more than three or four months old, having in this case been born in October, 1816, and the twin, a full-grown child, not till December, just two months afterward.— (Med. Chir. Trans., vol. ix., p. 195.) In this last instance, however, there can be no doubt that the aborted foetus had remained quiet in the uterus for some months after its death before it was expelled ; which in truth is the only way of reconciling its apparent age and size of not more than three or four months at the time of its expulsion, with the full time or nine months of the mother, completed only two months afterward. Nor is a quiet and undisturbing continuance in the uterus after the death of the foetus by any means uncommon, whether the offspring be single or double. We have already given examples of an interval of ten, and even seven- teen days, in the case of twins born equally of full size. But where the growth has been dis- crepant, and the dead foetus has remained behind unsuspected, it has sometimes been several months before expulsion has taken place. Ruysch gives a case in which it was delayed a twelvemonth after the apparent term of its death, and even then discharged without corrup- tion (Thesaur. Omnium Max.): and some of the foreign collections have instances of more than double this time.—(Neue Samml. Wahr- nehmungen, band iv., p. 241.) The present author was once engaged in consultation upon the case of a lady in Bedford Row, who had miscarried of a foetus under three months old, which there was every reason to believe died four months antecedently; as at that time the mother had been attacked with a flooding and rigours, had had various subsequent uterine hemorrhages, and had never been able to quit a recumbent position without producing some return of the bleeding. SPECIES VII. PARODYNIA SECUNDARIA. SEQUENTIAL LABOUR. DISEASED ACTION OR DISTURBANCE SUCCEEDING DELIVERY. In ordinary childbirth, the pains of labour may be said to cease with the expulsion of the foetus : since though sequential, or after-pains, as they are ordinarily called, are not uncommon for a day or two, and are useful in expelling the pla- centa and its membranes, and a few large coag- ula of blood that have formed in the uterus, these last are neither violent nor by any means frequent. It sometimes happens, however, that there is almost as much trouble, and as much pain, and as much danger, after the birth of the child as antecedently, so that the labour itself may be fairly said to be protracted into this sec- ondary stage, which offers the following varieties of morbid affection :— a Retentiva. Retention of the secundines. B Dolorosa. Violent after-pains. y Haemorrhagica. Violent hemorrhage or flood- i5 Lochialis. Inadequate lochial discharge. In about ten minutes or a quarter of an hour after the birth of the child, the uterus recovers its action, and again exerts itself, though with less force, and consequently slighter pain, to ex- pel what is commonly called the after-birth, consisting of the placenta and its membranes ; which, in common cases, are easily separated and thrown off from the sides of the organ. The instinctive or remedial power of nature is just as competent of itself to do this as to expel the child ; but as unquestionable benefit is found from assisting in the expulsion in the latter case, a like degree of benefit is also found in the for- mer ; and the practitioner, by taking hold of the funis, and gently pulling it during the action of a pain, will in most cases be sure of expediting the passage of the placenta without running the least risk of rudely tearing it from the sides of the uterus, and exciting a hemorrhage. It will sometimes however be found, that the funis, instead of being fully inserted at its upper extremity into the body of the placenta, origi- nates alone from a few of its vessels, and that from an incautious tug it gives way, and is drawn down by itself, leaving the placenta be- hind; and consequently putting it entirely out of the practitioner's power to render any col- lateral assistance. It also happens, not unfrequently, from the general exhaustion of the system, or the local exhaustion and torpitude of the uterus, that no expulsory pains of any kind follow at the ordi- nary time, or even for a long period afterward, and consequently, that the placenta is still lying unseparated in the uterus. On a trial instituted by Dr. W. Hunter and Dr. Sandys, in the Middlesex Hospital, it was' found in one case that the placenta, left to the 506 GENET1CA. [Cl. V.—Ord. III. action of the uterus alone, was not rejected till twenty-four hours after delivery ; and as no ill consequences followed this experiment, it be- came soon afterward a practice with many in this metropolis, as it had long before been with still more on the continent, to pay no attention to the placenta, and to leave it to take its course. Great mischief, however, has been in many cases found to ensue from this kind of quietism : for where there is great exhaustion, a sufficiency of natural exertion does not in numerous instan- ces return for three or four days afterward, and sometimes even longer : while the placenta, by remaining in the uterus, keeps up a febrile irri- tation, and what is infinitely worse, by being in many instances partly, though not wholly de- tached, and rendered a dead as well as a foreign substance, the detached part putrefies, and pro- duces a fetor through the whole atmosphere of the chamber, sufficient of itself to render the patient sick, and faint, and feverish, if it do not occasion a genuine typhus. I was lately requested to attend in consulta- tion upon a case of this kind. The patient had had a very difficult labour, and after two or three days of severe suffering, was delivered by the use of the crotchet. She was afterward for a long time in a state of syncope, and the placenta was suffered to remain without any attempt to remove it. She had no expulsory pains for,three days; but very great soreness and some degree of laceration in the soft parts, with such a torpi- tude of the bladder that the water was obliged to be drawn off daily. In about eight-and-forty hours she had a hot dry skin, brown furred tongue, with a quick, small pulse, slight delirium, and occasional shiverings. She was in this state when 1 was requested to see her. The room, which was small, was insupportable from its stench, notwithstanding all the pains taken to maintain cleanliness, and to cover the fetor by pungent odours. I strenuously advised that the placenta should be instantly removed ; but was answered that, as gangrene had already begun, the patient would certainly die, and as certainly sink under the very attempt to bring it away, so that the operator would fall under the charge of having killed her. My reply was, that she would assuredly die if it were not removed, but I was not so certain that she would if it were ; that in my judgment, the fetor rather proceeded from the placenta itself than from the ichorous discharge about the vagina, and gave a token of a very extensive separation, though the patient wanted power to expel it from her body. And I could not avoid adding, that if none of the gen- tlemen present (we made four in all) would ven- ture upon the task, I would take the risk upon myself, though I had long declined the practice, and give the patient this only chance of a recov- ery. This declaration inspirited the rest; the operation was determined upon : the placenta, as I suspected, was found nearly separated through- out, and half advanced into the vagina, and was removed without difficulty. By the use of the cinchona and the mineral acids, with a nutritive regimen, the patient gradually recovered, and is now in a state of perfect health. The modern practice, therefore, of not trust- ing the placenta to the mere powers of nature when these powers are exhausted or inopera- tive, is founded upon a principle of the soundest observation. Four or five hours is the utmost time now usually allowed ; and if it be retained beyond this period, the operator interferes, brings it away by the funis, if the uterus will hereby become sufficiently stimulated,* and if not, or the funis be broken, by cautiously introducing his hand into the uterus, and peeling the pla- centa gradually from its walls by the action of his fingers, t If the uterus, instead of contracting at its fun- dus, should contract irregularly and transversely, so as to form what has been called an hour- glass contraction, the removal of the placenta should take place before this time. In some irritable habits, on the contrary, the after-pains, instead of ceasing gradually, occa- * In the Repertorio di Medicina for May, 1826, published at Turin, Dr. Mojon has communicated a new mode of separating the placenta from the uterus. He removes the blood from the umbili- cal vein, and injects it forcibly with a mixture of vinegar and cold water; if the first injection is not successful, the vein is again emptied, and the same process is repeated. Other practitioners have confirmed the efficacy of this treatment. The committee of the Med. Society at Paris, to whom was referred the memoir of Legras on the subject, close their report by saying, that "the author has proved by facts the safety in all cases of injections into the umbilical vessels after the birth of the child; and also that they are efficient in causing the pla- centa to separate from the uterus, in arresting hemorrhage from a partial detachment of tliis body, and finally, in stimulating the uterus when it is in- ert. It follows also from our views, and from the experiments reported, that the effect of the injec- tions can be regulated by graduating the tempera- ture and quantity of the fluid injected, by rendering it more or less styptic, and by graduating the force with which it is injected. In dangerous hemor- rhages the vessels of the placenta should be rapidly distended, and the cold and styptic fluid should thus be sent even to the surface of the uterus."— See the Journ. Gen. de Medecine et de Chirurgie, &c.,Avril, 1828.— D. + When the placenta is retained an unusual time, Dr. Ryan recommends friction on the abdo- men, grasping the utems, applying a tight roller, dashing cold water on the abdomen, in order to make the uterus contract, and exhibiting the ergot of rye. If these means fail, and hemorrhage or fainting occur, he advises the separation of the placenta by the assistance of the hand, after which its expulsion will be effected by pressing on the uterus and abdomen so as to make the womb con- tract. After the birth of the infant, no practition- er should leave his patient previously to the ex- pulsion of the placenta; for, until this has hap- pened, she is never free from danger.—See Ryan's Manual, &c, p. 291. Also, in another part of the same work, we find the following observations: " The cases which cause a necessity for artificial extraction or separation of the placenta, are hem- orrhage, convulsions, syncope, inertness of the utems, spasmodic contraction of the womb, hour- glass contraction, preternatural adhesion, adhesion of the organ to tbe neck of the uterus, and abor- tion. Some of these require immediate extrac- tion, as hemorrhage, convulsions, and syncope," &c—(P. 611.) Gen. II.—Spe. 7.] PARODYNIA SECUNDARIA. 507 sionally continue with little interruption, and with nearly as great violence as those of labour itself ; and this for many hours after the extrac- tion of the placenta. If such after-pains closely follow the labour, they proceed from a morbid irritation and spas- modic tendency of the uterus alone ; and the best remedy is an anodyne liniment applied, to the abdomen, with an active dose of laudanum, which last must be repeated as soon as the first dose has lost its effect, the bowels in the mean- while being kept regularly open. If such violent pains do not take place till some hours after the evacuation of the placenta, or even the next day, it is highly probable that some large cake of co- agulated blood has formed in the uterus, and be- come a source of irritation. This may often be hooked out by a finger or two introduced for such purpose, and the organ be rendered easy ; if not, an opiate will here be as necessary as in the preceding case. Hemorrhage, or flooding, after delivery, is another evil which the practitioner is not unfre- quently called upon to combat. This is some- times produced by pulling too forcibly at the umbilical cord, and separating the placenta from the walls of the uterus, before its vessels have sufficiently contracted : but the most common cause is an exhausted state of the uterine ves- sels themselves, and a consequent inability to contract their mouths, so that the blood flows through them without resistance. The uterus is at this time so stored with blood of its own, that a prodigious rush will of- ten flow from it without producing syncope or any serious evil upon the general system : for it is only till it has lost its own proper supply, and begins to draw upon the corporeal vessels for a recruit, that any alarming impression is per- ceived. Yet, from the first moment, the attend- ant should be on his guard, and should have recourse to the means already laid down under flooding occurring in the latter months of preg- nancy.* In the present case, however, from the very open state of the mouths of all the uterine vessels that have anastomosed with the pla- centa, the flooding is here upon some occasions far more profuse and dangerous than at any other period, so that a woman has sometimes been carried off in the course of ten minutes, with a sudden faintness, sinking of the pulse, and wildness of the eyes that is most heart- rending.! And, in such a situation, as the liv- ing powers are failing apace, and must be sup- ported at all adventures, while cold and astrin- gent applications are still applied to the affected * Gen. I., Spe. 2, Paracyesis uterina haemorrha- gica; and compare with Cl. III., Ord. IV., Gen. II., Spe. 2, Haemorrhagia atonica uteri. t In cases of this character, the transfusion of blood from the veins of a healthy person into those of the patient, has been recently recommended by Dr. BlundeU, and its efficacy is apparently support- ed by cases occurring in the practice of himself and others. On this operation, Dr. Dewees re- marks as follows:—" We do not hesitate to believe these accounts of success, but we very much doubt whether the patient would have died had the remedy been withheld. We believe this prin- region, we must have recourse to the warmest, the most active, and most diffusible cordials, as Madeira wine or brandy itself in an undiluted state : and if we succeed in rousing the frame from its deadly apathy, we must drop them by degrees, or exchange them for food of a rich and nutritive, but less stimulant description. When the discharge of blood from the uterus ceases, it is succeeded by a fluid of a different appearance, which is commonly called lochia (A, Monro, both the Hunters, and Cruickshank, the *•' ' "'"'" whole of this curious and elaborate economy was completely explained and illustrated towards the close of the preceding century, and the op- position of Baron Haller was abandoned.* The vessels of the absorbent system anasto- mose more frequently than either the veins or the arteries ; for it is a general law of nature, that the smaller the vessels of every kind, the more freely they communicate and unite with each other. We can no more trace their ori- fices, excepting indeed those of the lacteals, than we can the orifices of the exhalants ; but we can trace their united branches from an ear- ly function, and can follow them up singly, or in the confederated form of conglobate glands, till, with the exception of a few that enter the right subclavian vein, they all terminate in the common trunk of the thoracic duct; which, as * The claim to the honour of the discovery of the uses of the lymphatics, produced an acrimoni- ous controversy between Drs. Hunter and Monro. Neither of these great anatomists seems to have been aware that the main facts, the cause of this celebrated dispute, had been distinctly mentioned by M. Noguez, in bis work L'Anatomie du Corps Humain, ed. 2, 1726.—See an account of the Life, &c, of Wm. Hunter, M. D., by S. F. Simmons, M. D., p. 30.—Ed. Gt. VI.] PHYSIOLOGICAL PROEM. 519 we have formerly observed, receives also the tributary stream of the anastomosing lacteals, or the absorbents which drink up the subacted food from the alvine canal, whose orifices are capable of being traced—and pours the whole of this complicated fluid, steadily and slowly, by means of a valve placed for this purpose at its opening, into the subclavian vein of the left side. And as these all perform a common of- fice, are of a like structure, pass through simi- lar glands, and terminate in a common channel, there is strong reason to suppose them to con- stitute a common system ; and hence, as we are capable of tracing up the mouths of the lacteals, we are led to conclude analogically, that the lymphatics have mouths of like kind, and for like purposes, although from their minuteness they have hitherto eluded all detection. By this contrivance there is a prodigious saving of animalized fluids, which, however they may differ from each other in several properties, are far more easily reducible to genuine blood, than new and unassiindated matter obtained from without. Yet this is not all; for many of the secre- tions, whose surplus is thus thrown back upon the system, essentially contribute to its greater vigour and perfection. We have a striking ex- ample of this in the absorption of semen, which, as observed on a late occasion (vol. ii., p. 414, Phys. Proem, supra), gives force and firmness to the voice, and changes the downy hair of the cheeks into a bristly beard ; insomuch that those who are castrated in early life, are uniformly deprived of these peculiar features of manhood. The absorption of the surplus matter, secreted by the ovaria at the same age of puberty, pro- duces an equal influence upon the mammary glands, and finishes the character of the female sex, as the preceding absorption completes that of the mate. So, absorption of fat from the co- lon, where, in the opinion of Sir Everard Home, ijt is formed in great abundance, carries on the growth of the body in youth.* [Many facts and considerations will apprize the physiological inquirer, that the constituent particles of every texture of the body are al- ways undergoing a change ; those which be- come unfit for longer continuance being with- drawn, and new ones deposited in their place. In this manner, an incessant renovation of the * Phil. Trans., 1813, p. 157. These opinions respecting the absorption of the semen, of the re- dundant matter secreted by the ovaries, and fat from the colon, are only to be received as hypothe- ses. We have no proof that the testis ever pro- duces its particular secretion, except for the pur- pose of being collected in the bulb of the urethra during the venereal excitement, and of being ex- pelled at the instant when the orgasm takes place. As for the ovaries, we know of no peculiar matter which it is their office to secrete, unless it be the ovula, which nobody supposes to be habitually absorbed. When the testes or ovaries are want- ing, or have been removed, the influence upon the constitution is probably rather to be ascribed to the imperfection of an essential part of the genital system, than to the interruption of any supposed absorption of the semen, or of any matter secre- ted by the ovaries.—Ed. component matter of the various Organs is kept up during life, to which it is unquestionably quite as essential as any of the other great vital functions, though some of these, in consequence of being more obvious to common notice, may have attracted a greater share of attention. In proof of this statement, we need at present merely observe, that white respiration compre- hends within itself an example of one modifica- tion of absorption without which it would be completely useless, a principal object of the cir- culation is, that all parts may receive from the blood the new materials expressly intended to replace such as are taken away from them by the organs of absorption; and that, if it were not for the absorbent system, by which the cir- culation is replenished, the copious deductions from the mass of blood, caused by the various secretions, and the perpetual deposition of new matter in every texture, would speedily bring our existence to a conclusion. Thus, by the reciprocal and harmonious action of the secern- ing arteries and the absorbents, a change is al- ways taking place in the identity, though not in the nature, of the component matter of every part of the body ; and, what is curious, thi3 change is effected, without the part necessarily undergoing any deviation from its ordinary shape, size, and general appearance. However, during the period of growth, the process is so regulated, that the deposition of new particles exceeds the absorption of the old, and the conse- quence is a gradual enlargement of the body, limbs, and different organs. After this stage of life, whatever increase takes place in the bulk of the body in general, or any of its parts, must originate either from morbid changes of structure, dropsical disease, the formation of tumours, or the accumulation of adipose mat- ter, the absorption of which, in certain consti- tutions, does not keep pace with its secretion. But although the various parts of the body do not enlarge after the stage of life allotted to growth, many of them lose a considerable por- tion of their volume in old age, as is exemplified in the muscular system in general, and in the absorbent glands ; and even in the infant, while nearly every part is receiving an addition to its size, a few organs, like the thymus gland and the renal capsules, are dwindling away. Now, whenever the body, or any parts of it, receive new particles into their composition, in ex- change for the old, as is the case during the whole of life ; or whenever the quantity of con- stituent matter is lessened, and the size of or- gans consequently reduced ; these effects imply the agency of the absorbents, without the co- operation of which the secerning arteries might thicken and increase the volume of parts, but could have no power to produce any of those mu- tations, in which the removal of some of their component particles is an essential branch of the process. The organs usually believed to effect the species of absorption to which we hero refer, are the lymphatic vessels and their glands. Several cavities in the body are naturally moistened with an exhalation of limpid fluid, and those of the joints are lubricated with syno- 520 PHYSIOLOGICAL PROEM. [Cl. VI. via; but these and every other secretion, re- tained for any time within the animal body, are never actually stagnant; for while the arteries are secreting them, the absorbents are actively employed in removing them, so that, in these examples, an uninterrupted renovation is going on, and the quantity of fluid, though continually receiving additions, is prevented by the absorb- ents from becoming too copious. This function is also commonly ascribed to the lymphatics. Another form of absorption, entirely distinct from the two preceding ones, yet not less im- portant, is that by which nutritious fluid, the product of digestion, and well known by the name of chyle, is taken up from the inner sur- face of the small intestines, and conveyed into the venous system near the heart. For the per- formance of this very indispensable function, which, in fact, is the only one whereby the circu- lation is known with any degree of certainty to be replenished, nature has provided a set of ves- sels, named lacteals from their white appearance, which arises from the chyle being seen through their thin and transparent coats. In modem works they are also frequently called chyliferous vessels and nutrient absorbents. One remarka- ble peculiarity of the lacteals is, that they gen- erally absorb only chyle, and perhaps never im- bibe any other substances ; at least, several ex- periments, undertaken of late years in France, tend to establish this point; though it is one at variance with the result of Mr. Hunter's inves- tigations ; a circumstance that will be present- ly noticed again. But whatever decision may be finally made on this subject, it is acknowl- edged by all parties, that the lacteals have noth- ing to do with the removal of the old particles of the body, but only take up those substances which are in contact with the villous coat of the bowels. We have stated that the absorption of chyle by the lacteals is the only process posi- uvely known to be instrumental in replenishing the sanguiferous system ; an observation justi- fied in the present state of physiological science, by the do,ubts entertained concerning the origin and uses of the fluid pervading the lymphatics. The common belief is, that the lymphatics ab- sorb all the old and redundant materials of the body, and also various kinds of fluid within its textures and cavities ; and that, by some unex- plained operation, all these different substances are converted, as soon as they enter into these vessels, into a colourless limpid fluid termed'the lymph. The truth is, that nothing has been de- monstrably and unequivocally proved about the source of this fluid ; and the foregoing hypothe- sis is absolutely denied by those physiologists who particularly espouse the doctrine of venous absorption. However, although the origin of lymph cannot be said to be known with certain-. ty, its course and destination are perfectly un- derstood ; and since the lacteals and lymphatics all terminate in a common trunk, and the chyle and lymph are thus blended together previously to their entrance into the large veins near the heart, there is strong reason for believing that the lymph is concerned in the same function as the chyle. It appears, therefore, that while the exact use of the lymphatics is a questionable point in physiology, the function of the lacteals, —the conveyance of chyle into the sanguiferous system,—is one that is quite undisputed.] Lymphatics accompany every part of the gen- eral frame so closely, and with so much minute- ness of stmcture, that Mr. Cruickshank has proved them to exist very numerously in the coats of small arteries and veins, and suspects them to be attendants on the vasa vasorum, and equally to enter into their fabric. Wherever they exist they are more richly endowed, as we have just remarked, by very numerous valves, than any.other sets of vessels whatever. "A lym- phatic valve is a semicircular membrane, or rather of a parabolic shape, attached to the in- side of the lymphatic vessels by its circular edge, having its straight edge, corresponding to the diameter, loose or floating in the cavity : in consequence of this contrivance, fluids passing in one direction make the valve lie close to the side of the vessel, and leave the passage free : but attempting to pass in the opposite direction, raise the valve from the side of the vessel, and push its loose edge towards the centre of the cavity. But as this would shut up little more than one half of the cavity, the valves are dis- posed in pairs exactly opposite to each other, by which means the whole cavity is accurately closed.''—(Cruickshank, Anat. of Absorb. Ves- sels, p. 66, 2d edit.) The distance at which the pairs of valves lie from each other varies exceedingly. The inter- vals are often equal, and measure an eighth or a sixteenth part of an inch. Yet the interval is, at times, much greater. " I have seen a lym- phatic vessel," says Mr. Cruickshank, " run six inches without a single valve appearing in its cavity. Sometimes the trunks are more crowded with valves than the branches, and sometimes I have seen the reverse of this."—(Loc. citat.) In the absorbent system, also, we meet with glands : their form is mostly circular or oval, and somewhat flattened; but we are in the same kind of uncertainty concerning their use, and in some measure concerning their organi- zation, as in respect to those of the secernent system.* The vessel that conveys the fluid to one of these glands is called a vas inferens, and that which conveys it away a vas efferens. The vasa inferentia, or those that enter a gland, are sometimes numerous ; they have been detected as amounting to fifteen or twenty : and are some- times thrice or oftener as many. They are al- ways, however, more numerous than the vasa efferentia, or those which carry on the fluid to- wards the thoracic duct. The last are conse- quently, for the most part, of a larger diameter, and sometimes consist of a single vessel alone. It is conceived by many physiologists, that the conglobate mass, which forms the gland, con- sists of nothing more than convolutions of the vasa inferentia; while others as strenuously * In man, every lymphatic vessel, before reach- ing the venous system, must traverse a lymphatic gland.—See Magendie's Elementary Compendium of Physiology, translated by Dr. E. Milligan, ed, 2, p 309.—Ed. Cl. VI.] PHYSIOLOGICAL PROEM. 521 contend that they are a congeries of cells, or acini, totally distinct from the absorbent vessels that enter into them. [They are very vascular. Each appears to consist of a soft, fleshy, porous substance, contained in a membranous capsule, the central part being firmer and whiter than the rest. Mercury injected into the vasa inferentia appears to fill a series of cells in an absorbent gland, and then escapes by means of the vasa efferentia. After an injection with wax, the whole substance of the gland seems to consist of convoluted absorbents irregularly dilated, and reciprocally communicating.—(See Mayo's Out- lines of Human Physiology, p. 213, 2d edit.) The use of the absorbent glands is unknown ; but it would seem that, whatever may be their function, it is most important in young subjects, in whom they are larger and contain a greater proportion of fluid than in more advanced life.] As in the case of the secernents, we are also unacquainted with the means by which the ab- sorbents act. This, in both instances, is said to be a vis a tergo,—a term which gives us little information in either instance, and is peculiarly difficult of comprehension in the latter.* In their most composite state they possess a very low degree of sensibility,.and are but little sup- plied with branches from the larger trunks of nerves. Abstruse, however, as the process of absorp- tion is to us at present, we have sufficient proofs of the fact. Of six pints of warm water inject- ed into the abdomen of a living dog, not more than four ounces remained at the expiration of six hours. The water accumulated in dropsy of the brain, and deposited in the ventricles, we have every reason to believe, is often absorbed from the cavities ; for the symptoms of the dis- ease have been sometimes marked, and after having made their appearance and been skilfully followed up by remedies, have entirely vanished ; and the water in dropsy of the chest, and even, at times, in ascites, has been as effectually re- moved. It has been doubted by some physiologists whether there be any absorbent vessels that open on the surface of the body : yet a multitude of facts seem sufficiently to establish the posi- * Dr. S. Cartwright, of Natchez, asserts in his Prize Essay on Absorption, that this power is nothing more nor less than the suction power of the heart extended to the venous radicles, the lym- phatics, and the lacteals. All these vessels ab- sorb in consequence of the absorbing or suction power of the heart, into which they ultimately flow. " The veins, lymphatics, and lacteals, all absorb, and their respective fluids receive their motion, not from any hypothetical power resident in the coats of these vessels, whether vital or physical (a power in either case inexplicable and unique in its character), but from the well-known power which results from an inequilibrium or loss of balance in atmospheric pressure. As an effect of this inequilibrium or loss of balance, the heart, the veins, lymphatics, and lacteals, are endowed with a suction power, which enables them to ab- sorb and give motion to the various fluids of every tissue and organ."—See Am. Med. Recorder, vol. xiii., p. 96.—D. tive side of this question, though it is not fluids of every kind that can be carried from the skin into the circulating system, and hence their power is by no means universal. Sailors who, when in great thirst, put on shirts wetted with salt water, find considerable relief to this dis- tressing sensation. Dr. Simpson, of St. An- drews', relates the case of a rapid decrease of the water in which the legs of a phrenitic pa- tient were bathed : and De Haen, finding that his dropsical patients filled equally fast, whether they were permitted to drink liquids or not, did not hesitate to assert, that they must absorb from the atmosphere. Spirits, and many vola- tile irritants, seem to be absorbed more rapidly than water, and there can be no doubt that warmth and friction are two of the means by which the power of absorption is augmented. " A patient of mine," says Mr. Cruickshank, " with a stricture in the oesophagus, received nothing, either solid or liquid, into the stomach for two months: he was exceedingly thirsty, and complained of making no water. I ordered him the warm bath for an hour, morning and evening, for a month: his thirst vanished, and he made water in the same manner as when he used to drink by the mouth, and when the fluid descended readily into the stomach."—(Anal. of the Absorb. Vessels, p. 108.) The aliment of nutritive clysters seems in like manner to be often received into the system ; and it is said, though upon more questionable grounds, that cinchona, in decoction, has also been absorbed both from the intestines and the skin. Narcotic fluids rarely enter to any considera- ble extent, and never so as to do mischief, re- specting which, therefore, the power of the cu- taneous absorbents is very limited : and there are few poisonous liquids, with the exception of matter containing the venereal vims, that may not be applied with safety to a sound skin. [The skin is pointed out by M. Magendie, as an exception to the general law of absorption by veins in all parts of the body. However, if it be deprived of the cuticle, and the bloodvessels of the surface of the cutis be denuded, absorp- tion takes place from it as well as from every other part. After the application of a blister, if the excoriated surface be covered with a sub- stance, the effects of which upon the animal economy are readily recognised, they frequently become very manifest in a few minutes. Arse- nic, applied to ulcerated surfaces, has often produced death. In order that the variolous in- oculation or vaccination may succeed, every surgeon knows that the virus must be inserted under the cuticle, in contact with the subjacent bloodvessels. But when the cuticle intervenes, unless the substances applied be calculated to attack it chymically, and to • irritate the blood- vessels, M. Magendie asserts that no absorption is perceptible. The opinion is quite at variance with the belief, that when the body is immersed in a bath, it absorbs a part of the fluid ; which supposition has led to the occasional employ- ment of nourishing baths of milk, broth, &c. From a series of very accurate experiments by M. Seguin, it appears that the skin does not ab- 522 PHYSIOLOGICAL PROEM. [Cl.VI. sorb water in which it is immersed. In order to learn whether this was the case with other fluids, he made experiments on persons labour- ing under venereal complaints. Their feet and legs were kept immersed in baths, composed of sixteen pints of water and three drachms of sublimate, each bath being continued an hour or two, and repeated twice a day. Thirteen pa- tients, subjected to this treatment twenty-eight days, exhibited no signs of absorption. A four- teenth presented manifest indications of it as early as the third bath ; but then he had psoric excoriations on the legs. In two others, simi- larly circumstanced, the same thing occurred. In general, absorption took place only in sub- jects whose epidermis was not entirely sound. However, at the temperature of 18° Reaumur, sublimate was sometimes absorbed, but not wa- ter. From experiments made with other arti- cles, it was found that the most irritating ones, and those most disposed to combine with the cuticle, were partly absorbed, while others were not so in a perceptible degree. But, according to M. Magendie, what does not happen from simple application, takes place with the assist- ance of friction. He deems it unquestionable, that mercury, alcohol, opium, camphire, and emetic and purgative medicines, thus penetrate into the venous system. They seem to pass through the pores of the cuticle, or the aper- tures intended for the transmission of hairs, or the insensible perspiration. Besides these ex- periments, some other very conclusive ones, re- lated by M. Segalas, leave no doubt that cer- tain poisonous or highly odorous substances, when applied to an internal membranous sub- stance, or to a wound, or rubbed upon the skin, so as to penetrate the epidermis, pass directly into the blood, through the coats of the bloodvessels.'] This double process of secretion and absorp- tion was supposed by the ancients to be perform- ed, not by two distinct sets of vessels expressly formed for the purpose, but by the peculiar con- struction of the arteries or of the veins, or of both. These are sometimes represented as be- ing porous, and hence, as letting loose con- tained fluids by transudation, and imbibing ex- traneous fluids by capillary attraction. There is, in fact, something extremely plausible in this view of the subject, which, in respect to dead animal matter, is allowed to be true, even in our own day. For it is well known that a bladder, filled with blood and suspended in the air, from a cause we shall presently advert to, is readily permeated by oxygen gas, so as to transform the deep Modena hue of the surface of the blood that touches the bladder into a bright scarlet; and thin fluids, injected into the bloodvessels of a dead body, transude very generally; inso- much that glue dissolved in water and thrown into the coronary veins, will permeate into the cavity of the pericardium, and, by jellying, even assume its figure. And hence, bile is often found, after death, to pass through the tunics of the gali-bladder, and tinge the transverse arch of the colon, the duodenum, or the pylorus, with a brown, yellow, or green hue, according to its colour at the time. The doctrine of porosity, or transudation, was hence very generally supported, till the time of Mr. Hewson, by physiologists of the first repu- tation. Boyle hence speaks, as Mr. Cruick- shank has justly observed, of the porositas ani- malium, and wonders that this property should have escaped the attention of Lord Bacon. Even Dr. Hunter and Professor Meckel be- lieved it in respect to certain fluids or certain parts of the body. The experiments of Hew- son, J. Hunter, and Cruickshank, have how- ever sufficiently shown that, while vessels, in losing life, lose the property of confining their fluids, they possess this property most accu- rately so long as the principle of fife continues to actuate them.* There is moreover another method, by which the ancients sometimes accounted for the in- halation and exhalation of fluids, making a much nearer approach to the modern doctrine ; and that is, by the mouths of vessels ; still, how- ever, regarding these vessels as arteries or veins, and particularly the latter. " The soft parts of the body," observes Hippocrates, " at- tract matter to themselves both from within and from without; a proof that the whole body ex- hales and inhales." Upon which passage Ga- len has the following comment : " For as the veins, by mouths placed in the skin, throw out whatever is redundant of vapour or smoke, so they receive by the same mouths no small quantity from the surrounding air: and this is what Hippocrates means when he says that the whole body exhales and inhales." This hypothesis of the absorption of veins, without the interference of lymphatics, was re- vived some years ago by MM. Magendie and Flandrin, of Paris, who made an appeal to ex- periments which appear highly plausible, and are entitled to a critical examination. The doctrines hereby attempted to be estab- lished are indeed varied in some degree from those of the Greek schools, and are more com- plex. In few words they may be thus express- ed :—that the only general absorbents are the veins—that the lacteals merely absorb the food —that the lymphatics have no absorbent power whatever—and that the villi in the different por- tions of the intestinal canal are formed in part by venous twigs, which absorb all the fluids in the intestines, with the exception of the chyle, which last is absorbed by the lacteals, and finds its way into the blood through the thoracic duct; and that these fluids are carried to the heart and lungs directly through the venae por- tae, whose function it is minutely to subdivide and mix with the blood the fluids thus absorbed, which subdivision and intermixture are necessa- ry to prevent their proving detrimental. M. Magendie further supposes, that the cu- * Notwithstanding the general accuracy of these observations, the experiments of M. Segalas prove beyond all doubt, that when certain substances are placed upon the surface of a wound, the ex- coriated cutis, or an internal membrane in the liv- ing body, they find their way directly into the . blood through the coats of the bloodvessels.—Ed. Cl. VI.] PHYSIOLOGICAL PROEM. 523 tide has no power of absorption in a sound state, either by veins or lymphatics ; but that, if abraded or strongly urged by the pressure of minute substances that enter into its perspirable pores, the subjacent minute veins are thus ren- dered absorbent. He supposes the function of the lymphatics to consist in conveying the finer lymph of the blood directly to the heart, as the veins convey the grosser and purple part: and that they rise, as the veins, from terminal arteries. Proper lymph, in the system of M. Magendie, is that opaline, rose-coloured, sometimes mad- der-red fluid, which is obtained by puncturing the lymphatics or the thoracic duct, after a long fast. It is everywhere similar to itself; and hence differs from the fluid of cavities, which is perpetually varying. He supposes the mistake of confounding the two to proceed from a want of attention to this fact. One of the chief reasons urged for regarding veins as absorbents is, that membranes which absorb actively have, in his opinion, no demon- strable lymphatics, as the arachnoid. But, ac- cording to Bichat, such membranes have no more demonstrable veins than lymphatics; veins are seen to creep on them, but never to enter. The two principal experiments on which M. Magendie seems to rely in proof that the veins, and not the lymphatics, are absorbents, are the following :—First, M. Delille and himself separ- ated the thigh from the body of a dog, that had been previously rendered insensible by opium. They left the limb attached by nothing but the crural artery and vein. These vessels were is- olated by the most cautious dissection to an ex- tent of nearly three inches, and their cellular coat was removed, lest it might conceal some lymphatic vessels. Two grains of the upas tiente were then forcibly thrust into the dog's paw. The effect of this poison was quite as im- mediate and intense as if the thigh had not been separated from the body : it operated before the fourth minute, and the animal was dead before the tenth. In the second experiment, a small barrel of a quill was introduced into the crural artery, and the vessel fixed upon it by two liga- tures. The artery was immediately cut all round between the two ligatures. The same process took place with respect to the crural vein. Yet the poison introduced into the paw produced its effect in the same manner, and as speedily. By compressing the crural vein be- tween the fingers at the moment the action of the poison began to be developed, this action speedily ceased : it reappeared when the vein was left free, and once more ceased on the vein being again compressed. These experiments are very striking, and, on a cursory view, may be supposed to carry con- viction with them ; but the confidence of those who have studiously followed the concurrent ex- periments, and the clear and cautious deduc- tions of our distinguished countrymen, Hewson, both the Hunters, and Cruickshank, supported as they have been by those of Mascagni, and vari- ous other able physiologists on the continent, will not so easily be shaken.* Reisseissen has limited his researches to the lungs, but seems to have established the doctrine of a distinct system of absorbents in this organ, by showing that the veins of the lungs do not absorb, and pointing out the occasional cause of error upon this subject.—(De Fabrica Pulmonum Comm., Berolini, 1822.) We have already observed, that lymphatic absorbents, in the opinion of Mr. Cruickshank, probably in that of all these writers, enter as fully into the tunics of veins and arteries, and even into those of the vasa vasorum, as into any other part of the animal frame : and hence there can be no difficulty in conceiving that the poison, employed in these experiments, might accompany the veins by means of their lymphat- ics. We also observed, that while the lymphat- ics anastomose or run into each other more fre- quently than any other set of vessels, their valves, which alone prevent a retrograde course, and direct the contained fluid towards the tho- racic duct, are occasionally placed at a consid- erable distance from each other, in some instan- ces not less than six inches, and that this length of interval occurs in the minute twigs as well as in the trunks. And hence, admitting that, in the veins that were cut or isolated in M. Magen- die's experiments, such a vacuity of valves inci- dentally existed, there is alsfcio difficulty in con- ceiving by what course the poisons that have al- ready entered into their lymphatics from with- out should, in consequence of" this frequency of anastomosis and destitution of valves, be stimu- lated to a retrograde course by the violence made use of, and be thrown into the current of the blood from within, by the mouths of those lymphatics that enter into the tunics of the veins ; and particularly as the separated vessels were only isolated to a distance of less than three inches, while the lymphatics are occasion- ally void of valves to double this distance. In some cases we have reason to believe, that the lymphatics that enter info the tunics of the lacteals, which M. Magendie admits to be a sys- tem of absorbents altogether distinct from the veins, are equally destitute of valves in certain parts or directions, and communicate by anas- tomosis some portion of the chyle and any sub- stance contained in it to the interior of the ad- joining veins, and consequently to the blood it- self : for the experiments of Sir Everard Home with rhubarb, introduced into the stomach of an animal, after the thoracic duct had been se- cured by a double ligature, show that this sub- stance, and consequently others as well, is capa- ble of travelling from the stomach into the uri- nary bladder, notwithstanding this impediment: and there are certain experiments of M. Foh- mann • (Anatomische Untcrsuchungen uber den Anastomosis der Lymphaliken mit der Venen, Heidelberg, 1821), who has paid great attention to the subject, that seem to prove that such an- astomosis is not unffequent. [The researches of Lippi also exhibit a still greater frequency of * Some observations relating to this statement will be presently introduced.—Ed. 624 PHYSIOLOGICAL PROEM. [Cl. VI communication between the venous and absorb- ent system. He has demonstrated, that the ab- sorbent vessels in the abdomen communicate freely with the iliac, the spermatic, the renal, the lumbar veins, the vena cava, and with branches of the vena portae. He has proved, that they communicate as well by opening di- rectly into the great venous trunks, as into the small veins issuing from the conglobate glands, and also by being continuous with the capillary veins. He has also shown, that several absorb- ent trunks in the belly proceed directly to the pelvis of the kidney, and open into it.—(Lippi, Illustrazioni Fisiologiche e Patologiche del Sis- tema Linfatico Chilifero, Firenze, 1825.) This fact unquestionably tends to corroborate the opinion of Sir Everard Home, that there is a shorter route from the stomach to the bladder, than through the thoracic duct and sanguiferous system. In the singular experiments made with prussiate of potash, by Dr. Wollaston and Dr. Marcet, the blood which was drawn from the arm during the interval of the introduction of this substance into the stomach, and its de- tection in the urine, did not, on being tested, discover the smallest trace of the prussiate, though it was obvious in the fluid of the urinary bladder. [This is perhaps more explicable by the anatomical facts pointed out by Lippi, than by the conjecture depressed by our author in a former edition, namely, the very diffused state of the prussiate in the entire mass of the blood, and its greater concentration when secreted by the kidneys.] There is, however, another mode of account- ing for the result of M. Magendie's experiments, without abandoning the well-established doc- trine of absorption by the lymphatic system. It is a remark which ought never lo be lost sight of, that experiments made upon animals in a state either of great pain or of great debility, can give us, by their result, no full proof of the line of conduct pursued by nature in a state of health. In the dead animal body, the valves of the lymphatic vessels very generally lose all elasticity and power of resistance, and transmit fluids in every direction ; whence, in all proba- bility, that porosity or transudation which we have already observed as manifest, occasionally, in the stomach and intestines, and in various other organs, -on the use of anatomical injec- tions. And hence there can be little doubt, that as an organ makes an approach to the same state of insensibility and irritability, by the se- vere, if not fatal wounds inflicted on it in the course of such experiments as are here alluded to, the valves of its lymphatic vessels make an approach also to the same state of flaccidity, and allow the fluids, whose course they should resist, to pass in any direction. The experiments of a like kind, which have, since M. Magendie's communications, been pur- sued in France by M. Fodere (Journ. de Physiol- ogie, Jan., 1823), and in America by Dr. Law- rence and Dr. H. Coates,* are open to the same * Experiments to determine the Absorbing Pow- er of the Veins and Lymphatics, Philadel. Journ., No, x. objection. They have been made under cir- cumstances of ebbing vitality or excruciating pain, and a few of them on pieces of animal membrane removed from the parent body. It is admitted candidly, however, by the last two physiologists, that the quill experiment of M. Magendie, in most instances, though not in all, failed in their hands. Even this, however, is in every successful result referred by M. Fohmann to the anastomosing connexion, which he has taken much pains to establish, as existing be- tween various veins and lymphatics, and which we have just adverted to.* This altered condition of many parts of the lymphatics in the dead body was sufficiently shown by Mr. Cruickshank, in a course of numer- ous experiments made at Dr. Hunter's Museum, in the spring of 1773. The organs chiefly in- jected were the kidney, liver, and lungs of adult human subjects. In one case, he pushed his injection from the artery to the pelvis and ureter without any rupture of the vessels. In another, he injected the pelvis and ureter from the vein, which he thought succeeded better than from the artery. In three different kidneys, he injected from the ureter the tubuli uriniferi for a consid- erable length along the mamillae; and in one case, a number of the veins on the external surface of the kidneys were evidently filled with the injection. In all these experiments, the colouring matter of the injection was vermilion. In numerous instances, he filled the lymphatics of the lungs and liver with quicksilver ; and from the lymphatics of the liver he was able, twice in the adult, and once in the foetus, to fill the thoracic duct itself.—(Edin. Med. Com., p. 430.) Dr. Meckel! had already shown the same facts by a similar train of experiments, instituted only a year or two before, and the conclusion he drew from them is in perfect coincidence with the explanation now offered. Dr. Meckel's experiments consisted in injecting mercury with great care, but considerable force, into various lymphatics and minute secreting cavities; and he found that a direct communication took place between such cavities and lymphatics, and the veins in immediate connexion with them: and hence he contended that the lymphatics and the veins are both of them absorbents under particular circumstances ; the lymphatics acting ordinarily, and forming the usual channel for carrying off secreted fluids ; and the veins act- ing extraordinarily, and supplying the place of the lymphatics where these are in a state of morbid torpitude, or debility, or the cavity is overloaded. He traced this communication particularly in the breasts, in the liver, and in * The ingenious author of the " Study of Med- icine" has reasoned in this passage with many strings to his bow. If he adopt Fohmann's ex- planation, he must evidently give up the conjec- ture respecting the influence of excruciating pain, and ebbing vitality, in bringing about the results of the experiments in question.—En. t Nova Experimenta et Observationes de fini- bus venarumet vasomm lymphaticorum in ductus, visceraque excretoria corporis humani, ejusdem- que structure utihtate, 8vo. Cl. VI.] PHYSIOLOGICAL PROEM. 525 the bladder ; and he thus accounts for the ready passage which bile finds into the blood, when the ductus choledochus is obstructed, as in jaundice; and the urinous fluid, which is often thrown forth from the skin and other organs upon a suppression of the natural secretion. It follows, therefore, that the experiments of M. Magendie, allowing them to be precisely narrated, are capable of explanation without abruptly overthrowing the established doctrines of preceding physiologists in the same line of pursuit: and we have still ample reason for believing that the economy of absorption is ef- fected by a system of vessels distinct from veins, and, in a state of health, continually holding a balance with the secerning vessels. [The questions, whether the lymphatics ab- sorb ! whether they are the only absorbents of the old particles of the body 1 whether the veins are concerned in this or any other branch of the function wholly or in part 1 and whether the lacteals absorb any other matter but chyle 1— all bear so intimately upon many points in pa- thology and the treatment of disease, that the determination of them in a clear and satisfactory manner is almost, if not quite as desirable, as the settlement of the grand question formerly was about the circulation of the blood. As having afforded a ground for dissatisfac- tion with the doctrine that the lymphatics and lacteals were the only absorbents, it may be right to notice the idea entertained by Bichat, Magendie, and some other physiologists, that the capacity of the trunks of the lymphatic sys- tem seemed inadequate to the conveyance of the vast quantity of matter that must be absorb- ed from the various textures and cavities of the body, either in the shape of old particles needing removal in proportion as new ones are deposited, of redundant fluids, of fat, of chyle, &c.—(See Bichat, Anat. Gin., tom. ii., p. 102 ; Magendie, Pricis Elim., tom. ii., p. 143.) The opinion tended to raise suspicions of there being some other channels of absorption. As the lymphatics are generally conceived to act upon the matter absorbed at the moment of their imbibing it, and to produce in some inexplicable manner, analo- gous to the operation of the secerning arteries, certain changes in it, perhaps, much importance cannot be attached to another argument, broached by M. Magendie, namely, that as the lymph is supposed to be taken up by the radicles of the lymphatics from the surfaces of mucous, serous, and synovial membranes, the cellular tissue, the skin, and the parenchyma of every organ, it is presumed to exist in the different cavities of the body. He argues that, though some analogy may seem to exist between the lymph and fluids met with upon serous and other membranes, in the cellular tissue, &c, these fluids readily differ from it, both in their physical and chymical prop- erties. They also differ from each other; so that he conceives that, if this origin of the lymph were to be admitted, various modifications of it would be found ; yet in all parts of the body it appears to be of one description.—(Pricis Elim. de Physiol., tom. ii., p. 177. M. Magendie observes that, before the proofs upon which the common doctrine of absorption by the lymphatics is founded can justly be re- ceived as valid, much more requires to be made out than has yet been done. The experiments instituted by Mr. Hunter were designed to prove, first, that the lymphatic vessels are absorbents; and secondly, that the veins do not absorb. Now, supposing them to be accurate, which M. Magendie endeavours to show is not the case, he argues, that their number is so small, that it is truly astonishing how they should have been deemed sufficient for the subversion of the an- cient doctrine. Some strong facts having been already stated in support of the doctrine that the veins absorb, or, at all events, that articles absorbed are partly transmitted into the veins, by anastomoses between these vessels and the lymphatics, we need not enlarge upon this part of the subject. We shall therefore conclude with observing, that any impartial physiologist, who attentively considers the results of the nu- merous accurate experiments adduced against those of Mr. Hunter, must arrive at the conclu- sion that the lacteals absorb only chyle, or some of the fluids which happen to be within the ali- mentary canal when no chyle is present there ; that the mesenteric veins take up other substan- ces ; that the small veins in general, and possi- bly the small arteries, convey a portion of the absorbed matter, by a more direct channel, into the venous system, than that of the thoracic duct; and that, though the lymphatics are prob- ably absorbents, the source of the lymph in them is yet a questionable point in physiology, and one demanding much more elucidation than it has yet received.* That the experiments of M. Magendie and others have shaken the Hun- terian doctrine of absorption, notwithstanding our author's partiality to it, must be candidly acknowledged. The process of absorption, in all its forms, indeed, seems to require more or- gans than Mr. Hunter has assigned to it, and to be altogether a more complicated function than he has represented it. The greater skill and accuracy, also, with which experimental physi- ology is now practised, have given the researches of M. Magendie and his colleagues a greater value than those of the immortal physiologist of the preceding century, the glory of his pro- fession and his country. Hence we find, that * M. Magendie observes, nothing affords a more convincing proof of the imperfection of our knowl- edge of the function of absorption than the ideas of physiologists respecting the lymph. This name is given by some to the serum of the blood; by others to the fluid in the serous membrane; by others again, to the serosity of the cellular tissue; while there are others who consider the fluid which flows from certain scrofulous ulcers as lymph. M. Magendie insists on the propriety of restricting the name of lymph to the liquid con- tained in the lymphatic vessels and thoracic duct, because, by admitting other significations, a per- manence is given to an opinion by no means pro- ved; viz., that the fluids of the serous membranes and of the cellular tissue, &c. are absorbed by the lymphatic vessels, and transported by them into the venous system.—See Magendie's Elem. Syst. of Physiology, by Milhgan, ed. 2, p. 306.—Ed. 526 PHYSIOLOGICAL PROEM. [Cl. VI. the opinions of some of the latest writers on physiology are beginning to be materially affected by the facts which have been recently elicited. In proof of this remark, let us merely notice the following passage :—" Of the numerous liquid substances which reach the small intestine, the lacteals appear to absorb chyle only. "The experiments of Hunter went, indeed, to prove the reverse. When a solution of starch and indigo, or milk and water, was injected by Mr. Hunter into the small intestines of sheep and asses, a bluish or whitish liquid appeared to rise in the lacteals. But there is reason to be- lieve that these observations were not made with sufficient exactness. They have been re- peated by M. Flandrin and various physiologists of the present day; and no substance thrown into the bowels, distinguishable by its odour, colour,* or poisonous effects, appeared to enter the lacteals. When Mr. Hunter saw a white fluid rise in the lacteals, after pouring milk into the bowel, we must suppose that some remains of chyle in the small intestine continued to be absorbed ; and where the blue liquid was used, the deception probably resulted from the fol- lowing circumstance. When the lacteals are empty, and are seen against a dusky medium, they appear as blue lines upon the mesentery. I observed this circumstance when repeating the Hunterian experiment upon a rabbit. The lacteals, which, when a solution of starch and indigo was first placed in the cavity of the bowel, were full of chyle, on being examined half an hour afterward, appeared of a clear blue colour ; and those present were, for an instant, satisfied that the indigo had been absorbed : but, upon placing a sheet of white paper behind the mes- entery, the blue tinge disappeared ; the vessels were seen to be transparent and empty. On removing the white paper, they resumed their blue colour."—(See Mayo's Outlines of Human Physiology, p. 223, 2d edit., 8vo., Lond., 1828.) The same writer also believes in the assertion of chyle having been found in the mesenteric veins ; but whether absorbed by these vessels, or poured into them by the lacteals, seems to him not determined. In many places he adverts to the direct termination of lymphatics in the venous sys- tem, without the intervention of the thoracic duct. He also considers it proved, that certain poison- ous and highly odorous substances, applied to internal membranous surfaces or wounds, or rubbed into the skin, find their way into the blood through the coats of the bloodvessels, as exemplified in the experiments of M. Segalas. At the same time, he deems it probable that molecular absorption is performed by the lym- phatics, as taught by Hunter and others.] III. In different periods of life, many of the secretions vary considerably in their sensible * " Chyle never takes the hue of the colouring substances mixed with the food. M. Halle proved the contrary by direct experiments, which I have lately repeated, and with exactly the same results. Animals which I made eat indigo, saffron, and madder, yielded a chyle whose colour was not at all influenced by those substances."—Precis Elem. de Physiol., tom. ii., par F. Magendie.—Ed. properties or relative quantity. Thus the bile of the foetus is sweet, and only acquires a bitter taste after birth. In infancy, perspiration flows more profusely than during manhood : and the testes, which secrete nothing before the age of puberty, at this time acquire activity, and again lose their power in old age. There are also many of the secernent organs that, in case of necessity, become a substitute for each other. Thus, the perspirable matter of the skin, when suppressed by a sudden chill or any other cause, is often discharged by the kid- neys ; the catamenia by the lungs ; and the serum accumulated in dropsies by the intestines. The secretions are moreover very much affect- ed and increased by any violent commotion of the system generally. In hysteria the flow of urine is greatly augmented, while the absorption of bile seems diminished ; and hence the dis- charge is nearly colourless. In violent agitation of the mind, the juices of the stomach become more acid than natural; and sometimes the se- cernents of the skin, and sometimes those of the larger intestines, are stimulated into increased action; whence colliquative perspiration, loose- ness, or both. The heat and commotion of a fever will sometimes produce the same effect, and sometimes a contrary ; the skin being dry, parched, and pricking. And occasionally the dryness has been so considerable as to produce a sudden separation of the cuticle from the cutis ; of which Mr. Gooch relates a singular instance in a patient,'who for several years had once or twice a year an attack of fever, accom- panied with a peculiar itching of the skin, and particularly of the hands and wrists, that ended in a total separation of the cuticle from these parts : insomuch that it could easily be turned off from the wrist down to the fingers' ends, so as to form a kind of cuticular glove.—(Medical and Chirurgical Observations, 8vo.) The same dis- tinguished writer gives as singular an instance of the effects of solar heat upon the skin of an- other patient, who had no sooner exposed him- self to the direct rays of the sun, than his skin began to be affected with a sense of tickling, became violently hot, as stiff as leather, and as red as vermilion.—(Op. citat.) In this case we have an instance of highly excited action in the cutaneous excernents of both kinds, and of the formation of new bloodvessels under the cuti- cle, followed by a conversion of the cutaneous integument into a coriaceous substance. There are some parts of the body that waste and become renewed far more rapidly than oth- ers ; the fat than the muscles; the muscles than the bones; and probably the bones than the skin; for the die of the madder-root, with which the bones become coloured when this root has for some time formed a part of the daily food of an animal, is carried off far sooner than the coloured lines of charcoal-powder, ashes, soot, and the juices of various plants, when in- troduced into the substance of the skin by punc- turing or tattooing it, a practice common among our sailors, and still more so, and carried to a far greater degree of perfection, among the in- habitants of the South Sea Islands. Cl. VI.] PHYSIOLOGICAL PROEM. 527 It has been said, indeed (Bernouilli, Diss, de Nutritione, Groning., 1669, 4to.), that the disap- pearance of madder-colour from the bones, af- fords no proof that the phosphate of lime, in which it was seated, has itself been carried off at the same time ; because the semm of the blood is found to have a stronger affinity for madder than the phosphate coloured by it; and hence will gradually attract and remove it, when the animal is no longer fed with the coloured food. The experiment, however, upon which this latter opinion is grounded, has not been hitherto conducted in such a manner as to be directly applicable to the question ; and if it had been, it would afford no proof that a perpetual, though, in that case, a slower change than the madder would exhibit, is not taking place in the bones : nor are we driven to the effects of mad- der die upon their solid substance as the only foundation for this opinion ; for there is scarcely a bone in the animal system which does not as- sume a different shape at one period of life com- pared with its form at another period : a remark that peculiarly applies to the flat bones of the skeleton, and forms the chief cause of that won- derful change which the lower jaw experiences as the individual advances from middle life to old age, and which often gives a different char- acter to the entire face.—(Gibson, Manchester Memoirs, vol. i., p. 533.) It is from this mysterious power of reproduc- tion appertaining to every part of the system, that we are so often able to renew the substance and function of parts that have been wasted by fevers or atrophy, or abruptly destroyed or lopped off by accident. In the progress of this general economy, every organ and part of the body secretes for itself the nutriment it requires, from the common pabulum of the blood which is conveyed to it, or from se- cretions which have already been obtained from the blood, and deposited in surrounding cavities, as fat, gelatin, and lymph. And it is probable that the several organs of secretion, like the eye, the ear, and the other distinct organs of sense, are peculiarly affected by peculiar stimulants, and excited to some diversity of sensation. In Germany, this idea has been pursued so far as, in some hypotheses, and particularly that of M. Hubner (Comment, de Caneslhesi, 1794), to lay a foundation for the doctrine of a sixth sense, to which, as we observed on a former occasion (vol. ii., p. 151, Physiol. Proem), has been given the name of selbstgefuhl or gemeingefuhl, " self-feeling," or "general feeling." The sen- sations, however, we are at present alluding to, are not so much general, or those of the whole self, as particular, or Umited to the organs in which they originate; and seem to be a result of different modifications of the nervous influ- ence on which the common sense of touch de- pends. In most parts of the system these modi- fications are so inconsiderable as to elude our notice ; but in others we have the fullest proof of such an effect; for we see the stomach evin- cing a sense of hunger, the fauces of thirst, the genital organs of venereal orgasm. And in like manner, we find the bladder stimulated by can- tharides, and the intestinal canal by purgatives; and we may hence conjecture, that every other part of the system, where any kind of secretion is going forwards, is endowed with a like pecu- liarity of irritability and sensibility, though not sufficiently keen to attract our attention. It is hence we meet with that surprising va- riety of secretions which are furnished, not only by different animals, but even by the same ani- mal in different parts of the body. Hence sugar is secreted by the stomach, and sometimes by the kidneys ; sulphur by the brain ; wax by the ears ; lime by the salivary glands, the secreto- ries of the bones, and, in a state of disease, by the lungs, the kidneys, the arteries, and the ex- halants of the skin ; milk by the breasts ; serpen by the testes ; the menstrual fluid by the uterus ; urine by the kidneys ; bile by the liver ; muriate of scda by the secernents of almost every organ ; and sweat from every part of the surface.* Hence some animals, as the bee, secrete honey ; others, as the coccus ilicis, a large store of wax ; others, as the viper and scorpion, gum, which is the vehicle of their poison ; others thread, as the spider and some species of slug; and many silk, as the silkworm and the pinna, or nacre, whence Reaumur denominates the pinna the sea silkworm : it is common to some of the Italian coasts, and its silky beard or bys- sus is worked at Palermo into very beautiful silk stuffs. There are great numbers of worms, in- sects, and fishes, that secrete a very pure, and some of them a very strong, phosphorescent light, so as in some regions to enkindle the sea, and in others the sky, into a bright blaze at night. Many animals secrete air ; man himself seems to do so under certain circumstances, but fishes of various kinds more largely, as those furnished with air-bladders, which they fill or exhaust at pleasure, and the sepia, or cuttlefish, * No doubt, in the process of glandular secre- tion, chymical phenomena take place. Several of the secretions are acid, while the blood is alka- line ; and most of them contain proximate princi- ples, which do not exist in the blood, and must be formed in the glands themselves; but the particu- lar way in which these combinations are effected is unknown. A curious experiment, performed by Wollaston, led him to infer, that a very weak elec- tricity is concerned in the regulation of secretion, and has a marked influence over it. He took a glass tube, two inches long and three quarters of an inch in diameter, and he closed one of its ex- tremities with a bit of bladder. He poured a little water into the tube, with 1-240 part of its weight of muriate of soda; he wet the bladder on the out- side, and placed it on a piece of silver; he then bent a zinc wire, so that one of its ends touched the silver, and the other entered the tube for about an inch. In the same instant, the external sur- face of the bladder gave indications of the pres- ence of pure soda; so that, under the influence of this weak electricity, there was a decomposition of muriate of soda, and the soda, separated from the acid, passed through the bladder. Wollaston thought it not impossible that something analogous might happen in the process of secretion ; but, as M. Magendie justly observes, before this idea can be adopted, more proof of its correctness is re- quired.—Ed. 528 ECCRIT1CA. [Cl. VI.—Ord. I. with numerous other seaworms; and by this power they raise or sink themselves, as they have occasion. The cuttlefish secretes also a natural ink, which it evacuates when pursued by an enemy, and thus .converts it into an instru- ment of defence ; for, by blackening the water all around, it obtains a sufficient concealment, and easily effects its escape. Other animals, and these also chiefly fishes, secrete a very large portion of electric matter, so as to convert their bodies into a powerful battery. The torpedo- ray was well known by the Romans to possess this extraordinary power; and the gymnotus electricus (electric eel) has since been discovered to possess it in a much larger proportion. The genus tetradon, in one species, secretes an elec- tric fluid ; in another, an irritating fluid that stings the hand that touches it; and in a third, a poisonous matter diffused through the whole of its flesh. From the same cause we meet with as great and innumerable a variety of secretions among plants, as camphires, gums, balsams, resins : and, as in animals, we often meet with very different secretions in very different parts of the same plant. Thus, the mimosa nilotica secerns from its root a fluid as offensive as that of asafoetida ; in the sap of its stem an astringent acid; its glands give forth gumarabic ; and its flower an odour of a very grateful fragrance : whfle the milk-tree or cow-tree, the arbol di lache, or palo de vaca, of South America, overflows with nutritious milk from every part. This is one of the many singular plants noticed by M. Hum- boldt, in his voyage to the equinoctial regions. It is a native of Venezuela, and belongs to the natural family of the sapotae ; and its juice, in strict correspondence with its name, is said to possess almost all the properties of cow's milk. M. Humboldt visited the district where it was reported to grow, and found the account true; but tells us that it is rather more viscous than cow's milk, and has a slight balsamic taste. He drank it plentifully in the evening and early in the morning without any unpleasant effects ; and was told that, when in season, the working people use it with their cassava bread, and al- ways fatten upon it.—(Annates de Chimie ct de Physique, Juin, 1823, tom. xxiii., p. 19.) This subject is highly interesting, and might be extended to volumes, but we are already di- gressing too far. There is no part of the body in which the process of secretion is not going forward ; we trace it, and consequently the fab- ric which gives rise to it, in the parenchyma, or intermediate substance of organs, in their inter- nal surfaces and outlets, and on the external surface of the entire frame : thus forming three divisions of prominent distinction, both in respect to locality and to the diseases which relate to them. It is on these divisions that the Orders of the present Class are founded. ORDER I. MESOTICA. DISEASES AFFECTING THE PAREN- CHYMA. GRAVITY IN THE QUANTITY OR QUALITY OP THE INTERMEDIATE or connecting substance of ORGANS ; WITHOUT INFLAMMATION, FEVER, OR OTHER DERANGEMENT OF THE GENERAL HEALTH. The classic term eccritica is a derivative from iKKplvw, " secerno," " exhaurio," " to se- cern or strain off," "to drain or exhaust," and is preferred by the author to any other derivative which KpUia, its primitive, affords, as equally ap- plicable to the two systems of vessels that enter into the general and important economy illus- trated in the preceding Proem. The ordinal term mesotica is derived from uiaos, "me- dius ;" for which parenchymatica might have been substituted, but that there are two objec- tions to the use of the latter: the first is, that rropa is here employed in a different sense from its general signification in the system before us, which is that of " male," or " perperam," in- stead of per or penitus, its real meaning in pa- renchyma ; and, consequently, the double signi- fication would trench upon that simplicity and uniformity which it is the direct object of the present nomenclature to maintain. The second objection is, that the term parenchyma (iraplyxv- pa) is formed upon a false hypothesis, invented by Erasistratus, who first employed the term, and held that the common mass, or interior sub- stance of a viscus, is produced by concreted blood, strained off through the pores of the bloodvessels which enter into its general struc- ture or membranes. The order embraces the five following genera :— I. Polysarcia. Corpulency. II. Emphyma. Tumour. III. Parostia. Mis-ossification. IV. Cyrtosis. Contortion of the Bones. V. Osthexia. Osthexy. GENUS I. POLYSARCIA. CORPULENCY. firm and unwieldy bulkiness of the body, or its members, from an enlargement of natural parts. Polysarcia, from Tro\