LEA & BLANCHARD, HAVE RECENTLY PUBLISHED, MIDWIFERY ILLUSTRATED, BY FRANCIS H. RAMSBOTHAM, M.D., PHYSICIAN TO THE ROYAL MATERNITY CHARITY, AND LECTURER ON MIDWIFERY AT THE LONDON HOSPITAL, ETC. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, IN REFERENCE TO THE Process of Parturition, ILLUSTRATED BY ONE HUNDRED AND FORTY-TWO FIGURES. FIRST AMERICAN EDITION, REVISED. In one large octavo volume. From among numerous commendations of this work of Dr. Ramsbotham, the American publishers append a few, and would particularly call the attention of the medical public to the execution of the numerous plates, which form a most important feature in the volume. The great expense they have incurred in its production calls for an extended sale, which they trust the merits of the work will command. "It is a good and thoroughly practical treatise; the different subjects are laid down in a clear and perspicuous form, and whatever is of importance is illustrated by first rate engravings. As a work convey- ing good, sound, practical precepts, and clearly demonstrating the doctrines of obstetrical science, we can confidently recommend it either to the student or practitioner. "—Edinburgh Journal of Medical Science. " It is the book on Midwifery for students: clear, but not too minute in its details, and sound in its prac- tical instructions. It is so completely illustrated by plates (admirably chosen and executed) that the stu- dent must be stupid indeed who does not understand the dctails.of this branch of the science, so far at least as description can make them intelligible."—Dublin Journal of Medical Science. ... "There is so much in the practice of Midwifery which cannot be understood without pictorial illustra- tions that they become almost essential to the student; but hitherto the expense has proved an impediment to their being employed so much as desirable. The work has only to be knowu to make the demand for it very extensive."—Medical Oaiette. . . "We strongly recommend the work of Dr. Ramsbotham to all our obstetrical readers, especially to those who are entering upon practice. It is not only one of the cheapest, but one of the niOBt beautiful works in Midwifery."— British and Foreign Medical Review. wpII merits."—Dublin Medical Press. •'We most earnestly recommend this work to the student, who wishes to acquire knowledge, and to the nractit'ioner who wishes to refresh his memory, as a most faithful picture of practical Midwifery; and we can with justice say, that altogether it is one of the best books we have read on the subject of obstetrical medicine and surgery."—Medico-Chirurgical Review. .,....•. r -. u. "It is intended expressly for student! and junior practitioners in Midwifery; it is therefore, as it ought to be elementary, and will not, consequently, admit of an elaborate and extended review. Our chief obieci now™ toEstate our decided opinion, that this work is by far the best that has appeared .n this cSv for Those who seek practical information upon Midwifery, conveyed in a clear and concise style. ti?p v^i/e of the work, too, is strongly enhanced by the numerous and beautiful drawings by Bagg, which are in the first style of excellence. Every point of practical importance is ill.strated, that requires the aid of the engraver to fix it upon the mind, and to render it clear to the comprehension of the student."- i" AmS'tte man?'literary undertakings with which the Medical press at present teems, there are few that deserve a warmer reconfmendation at our hands than the work-we might almost say the obstetrical ibrarv cZwZd in a single volume-which is now before us. Few works surpass Dr. Ramsbotham s ,o . r^'onJriiL„onr<> of eettinff ud and in the abundant and excellent engravings with which it is illus- reatedy WeE.lv wifh the^olume the success which it merits, and we have no doubt that before long it rated, we nearuiy «"" "" *.. . ....„.„ ;„ tV>a ui„aAnm Th* illustrations are ai mirab e: they are the much by anatomical accuracy."— The Lancet. THE PRACTICE OF MEDICINE, OR A TREATISE ON SPECIAL PATHOLOGF AND THERAPEUTICS. BY ROBLEY DUNGLISON, M.D., PROFESSOR OF THE INSTITUTES OF MEDICINE, ETC. IN THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA, LECTURER ON CLINICAL MEDICINE, AND ATTENDING PHYSICIAN AT THE PHILADELPHIA HOSPITAL, ETC. CONTAINING THE DISEASES OF THE ALIMENTARY CANAL, THE DISEASES OF THE CIRCULATORY APPARATUS, DISEASES OF THE GLANDULAR ORGANS, DISEASES OF THE ORGANS OF THE SENSES, DISEASES OF THE RESPIRATORY ORGANS, DISEASES OF THE GLANDIFORM GANGLIONS, DISEASES OF THE NERVOUS SYSTEM, DISEASES OF THE ORGANS OF REPRODUCTION, DISEASES INVOLVING VARIOUS ORGANS, &c. &c. In Two Volumes Octavo. " This new work, from the press of Lea and Blanchard, forms a valuable addition to our Medical Literature, and fills up avoid in our libraries, which the numerous improvements in medical science had long since created; and we congratulate the profession in being put in possession of a work on the practice of medicine, in which not only are found the latest and most approved views of Pathology, united with the soundest practical deductions, but which is here interspersed throughout with the most valuable recipes for administering the various medicines suggested. "The object of the author has been, as he states, to incorporate the improvements and modifications incessantly taking place in the departments of Pathology and Therapeutics, so as to furnish those to whom the difierent general treatises, monographs and periodicals are not accessible, with the means of appreciating their existing condition. The examination we have made of the work satisfies ns that in this aim he has been eminently successful, and that he has presented to the profession the most complete work on the Practice of Medicine to be found in any language—for we know of no similar work in which is embodied such an amount of scientific and practical information. Mo one, therefore, who desires to keep himself au nouveau du siecle, will fail to include in his collection a work which thus brings before him the latest views of subjects, in which scientific investigations have lately wrought so many changes. "This is not the place of course, to speak in detail of the merits of such a work. We may there- fore say that the two volumes before us give evidence throughout of extensive research, deep reflec- tion, and abilities for which, indeed, the author's name is always a guarantee; and that we can con- fidently recommend them to all who desire to keep pace with the progress of medical science."— Bait. Pat. " We hail the appearance of this work, which has just been issued from the prolific press of Messrs. Lea & Blanchard, of Philadelphia, with no ordinary degree of pleasure. Compri.-ed in two large and closely printed volumes, it exhibits a more full, accurate, and comprehensive digest of the existing state of medicine than any other treatise with which we are acquainted in the English language. It discusses many topics—some of them of great practical importance, which are entirely omitted in the writings of Eberle, Dewees, Hosack, Graves, Stokes, Mcintosh, and Gregory; and it cannot fail, therefore, to be of great value, not only to the student, but to the practitioner, as it affords him ready access to information of which he stands in daily need in the exercise of his profession, It has been the desire of the author, well-known as one of the most abundant writers of the age, to render his work strictly practical; and to this end he has been induced, whenever opportunity offered, to incorporate the results of his own experience with that of his scientific brethren in America and Europe. To the formei, ample justice seems to have been done throughout. We believe this constitutes the seventh work which Professor Dunglison has published within the last ten years; and, when we reflect upon the large amount of labour and reflection which must have been necessary in their preparation, it is amazing how he could have accomplished so much in so short a time."—Louisville Journal " As a system of Practical Medicine, this work will meet a cordial welcome from all who know the untiring assiduity and laborious habits in the pursuit of knowledge, of the author, who has already presented the public with numerous excellent works, bearing the stamp of originality as well as of profound research. " The object of Professor Dunglison is to present, in as compact a form as was consistent with accuracy and perspicuity, a history of all the affections which properly come under the care of the physician, with all the improvements and modifications which have taken place latterly in Pathology and Therapeutics, so as to enable the student and practitioner • to appreciate their present condition,' and to avail themselves of knowledge scattered about in various journals and mono- '•This task has been faithfully executed, and the work maybe recommended as a good class-book, in which the soundness of the author's views and his freedom from exclusive opinions have enabled him to select from the experience of others those facts and views, which, together with his own experience, were to furnish the proper data for correct descriptions and for sound practical deduc- tions."— New York American. A SYSTEM PRACTICAL MEDICINE COMPRISED IN A SERIES OF ORIGINAL DISSERTATIONS. ARRANGED AND EDITED BY ALEXANDER TWEEDIE, M.D. F.R.S., FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, PHYSICIAN TO THE LONDON FEVER HOSPITAL AND TO THE FOUNDLING HOSPITAL, ETC. WITH NOTES AND ADDITIONS, W. W. GERHARD, M.D., LECTURER ON CLINICAL MEDICINE TO THE UNIVERSITY OF PENNSYLVANIA, PHYSICIAN TO THE PHILADELPHIA HOSPITAL, BLOCKLEY, ETC. THE SECOND AMERICAN EDITION. IN THREE VOLUMES VOL. III. PHILADELPHIA: LEA & BLANCHARD. 1842. Entered, according to the Act of Congress, in the year 1842, by Lea & Blanchard, in the Clerk's Office of the District Court for the Eastern District of Pennsylvania. WQ V.2> C. Sherman, Printer, 19 St. James Street. DIGESTIVE, URINARY, AND UTERINE ORGANS, HAEMORRHAGE, DROPSY, RHEUMATISM, GOUT.—FORMULARY, ETC. CONTENTS OF VOL. III. DISEASES OF THE ORGANS OF DIGESTION. STOMATITIS, OR INFLAMMATION OF THE MOUTH {Dr. Symonds.) Stomatitis aphthosa.—Anatomical varieties.—Aphtha? in infants—in adults.—Stomatitis mercurialis.—Symptoms and treatment.—Stomatitis ulcerosa.—Symptoms and treat- ment .............17 GANGRiENA ORIS. {Dr. Symonds.) Synonymes.—Symptoms.—Causes.—Treatment......21 DISEASES INCIDENT TO THE PROCESS OF DENTITION. (Dr. Symonds.) Local symptoms—in the mouth and gums.—Remote affections—in mucous membranes. Skin.—Nervous system.—Fever.—Causes of difficult dentition.—Treatment 24 GLOSSITIS. (Dr. Symonds.) Symptoms—local—general.—Causes.—Treatment......28 PAROTITIS. (Dr. Symonds.) Specific variety.—Symptoms.—Causes.—Treatment—Common variety.—Its symptoms and treatment -----.......29 ANGINA, OR INFLAMMATION OF THE THROAT. (Dr. Symonds.) ANGINA DIFFUSA. Varieties.—Symptoms.—Causes.—Prognosis.—Treatment ... 30 ANGINA MEMBRANACEA. Description.—Two forms, the sthenic and the malignant.—Causes.—Nature.—Diagno- sis.—Treatment -----......32 ANGINA TONSILLARIS. Superficial and deep-seated.—Symptoms.—Causes.—Treatment 35 HYPERTROPHY OF THE TONSILS, p. 36. (Dr. Symonds.) DISEASES OF THE CESOPHAGUS. (Dr. Symonds.) Structural disease of the oesophagus.—Spasmodic stricture.—Symptoms.—Diagnosis.— Treatment............36 ° CONTENTS. GASTRITIS. (Dr. Symonds.) Anatomical characters of congestion and inflammation of the gastro-enteric membrane. —Redness.—Forms of.—Cadaveric—Physiological. — Morbid. — Congestive. — In- flammatory.—Brown colour.—Slate-gray, black.—Inference from the absence of mor- bid colourings.—Softening.—Induration.—Hypertrophy.—Ulceration.—Effusion.— Symptoms of acute, subacute, and chronic gastritis.—Anatomical characters.—Causes. —Treatment........----<» ORGANIC DISEASES OF THE STOMACH. (Dr. Symonds.) 1. Carcinoma.—Anatomical characters.—Symptoms.—Causes.—Treatment. 2. Soft- ening—Inflammatory—Chemical action of the gastric juice.—Gelatiniform softening. 3. Ulceration—Varieties. —Symptoms. —Treatment. 4. Perforation. —Morbid.— Cadaveric..........---50 DYSPEPSIA. (Dr. Symonds.) Preliminary observations.—Acute dyspepsia.—Two forms.—Symptoms of the first.— Causes and treatment.—Symptoms of the second.—Causes and treatment.—Chronic dyspepsia.—Symptoms.—Local.—General.—Causes.—Nature.—General treatment. —Diet.—Regimen.—Treatment of particular symptoms.—Influence of gastric disor- ders upon other organs..........56 GASTRALGIA. (Dr. Symonds.) Symptoms.—Complications.—Nature.—Causes.—Treatment 67 GASTRORRHG3A. (Dr. Symonds.) Symptoms.—Causes.—Nature.—Treatment.......70 INFLAMMATION OF THE DUODENUM. (Dr. Symonds.) Acute.—Chronic.—Duodenal dyspepsia.—Structural diseases of the duodenum.—Treat- ment of duodenal diseases ----.....-71 ILEO-COLITIS, OR ENTERITIS. (Dr. Symonds.) General observations.—Anatomical characters.—Symptoms.—Acute or Subacute—Di- agnosis from typhoid fever.—Chronic.—Causes.—Treatment.—Acute.—Chronic 74 COLITIS, OR DYSENTERY. (Dr. Symonds.) Symptoms of acute colitis.—Local.—General.—Of chronic colitis.—Diagnosis.__Pro- gnosis.—Causes.—Treatment.........79 INFLAMMATION OF THE CAECUM, p. 86. (Dr. Symonds.) DIARRHCEA. {Dr. Symonds.) Varieties.—Symptoms and causes of each.—Treatment.....g7 CHOLERA. {Dr. George Budd.) Sporadic cholera.—Symptoms.—Causes and Treatment—Malignant or Asiatic cholera. —History .—Causes.—Symptoms.—Prognosis.—Anatomical characters.__Nature- Treatment ............QQ ALVINE CONCRETIONS, p. 112. {Dr. Symonds.) FATTY DISCHARGES FROM THE INTESTINES, p. 113. (Dr. Symonds.) HJ3MORRHOIS. (jDr. Symonds) 1. Hsemorrhois.—Simple.—Nature.—Treatment. 2. Hsemorrhoidal Tumour* — Ana- tomical Varieties.—Mode of Production.—Number, Size, and Appearance —Svmjv toms.—Causes.— Treatment...... . . - 114 CONTENTS. 9 SPASMODIC STRICTURE OF THE RECTUM. (Dr. Symonds.) Symptoms.—Causes.—Diagnosis.—Treatment......119 COLIC. (Dr. Symonds.) Symptoms. — Anatomical characters. — Nature. — Varieties. — Prognosis. — Treat- ment .............121 LEAD COLIC. (Dr. Symonds.) Symptoms.—Nature.—Treatment........126 TORPOR OF THE COLON. (Dr. Symonds.) Nature.—Causes.—Symptoms.—Treatment......127 TYMPANITES. (Dr. Symonds.) Nature.—Complications.—Diagnosis. — Symptomatic tympanites. — Duration. — Treat- ment .............129 PERITONITIS. (Dr. Symonds.) General Observations.—Anatomical characters.—Symptoms. — Diagnosis. — Causes.— Prognosis.—Treatment.—Erythematic Peritonitis. — Puerperal Peritonitis. — Perito- nitis from intestinal perforation.—Symptoms and Treatment.—Chronic Peritonitis.— Anatomical characters. — Tuberculous complications. — Symptoms. — Latency. — Causes.—Prognosis.—Treatment.—Peritonitis of the Caecum.—Symptoms.—Termi- nation.—Treatment -........-- 131 ENTERALGIA, p. 142. (Dr. Symonds.) DISEASES OF THE MESENTERIC GLANDS. (Dr. Wm. Thomson.) Simple acute inflammation.—Tuberculous degeneration.—Calcareous deposition.—Os- seous transformation.—Induration.—Causes.—Complications.—Symptoms.—Diagno- sis.—Treatment...........142 DISEASES OF THE BILIARY ORGANS. GENERAL VIEW OF THE CAUSES OF BILIARY DISEASES. (Dr. Wm. Thomson.) Atmospheric heat.—Diet.—Bodily inactivity.—External injuries.—Alcoholic liquors. —Mercury.—Foreign matters circulating with the blood.—Mental emotions.—Dis- eases of other organs..........149 FUNCTIONAL DERANGEMENTS OF THE BILIARY ORGANS. (Dr. Wm. Thomson.) General description.—Diminished biliary secretion.—Excessive biliary secretion.—Vi- tiated biliary secretion.—Impeded excretion of bile.—General View of the symptoms. Treatment of functional derangements of the biliary organs.—Biliary concretions or gallstones.—Their symptoms and treatment......154 DISEASES OF THE BILIARY PASSAGES. (Dr. Wm. Thomson.) Glands of gall-ducts.—Their enlargement—Inflammation of the mucous membrane of the gall-bladder, ducts, and biliary tubuli.—Collections of pus.—Ulceration and per- foration of the gall-bladder and ducts.—Contraction.—Distension of the gall-bladder, various causes of.—Symptoms and treatment of diseases of the biliary passages 164 INFLAMMATION OF THE LIVER. (Dr. Wm. Thomson.) Hepatic Congestion and Hemorrhage.—Symptoms and treatment—Acute Hepatitis.— Symptoms.—Terminations.—Chronic Hepatitis.—Diagnosis and treatment of Hepa- titis ..............167 VOL. III. 2 10 CONTENTS. STRUCTURAL DISEASES OF THE LIVER. (Dr. Wm. Thomson.) Serous cysts and hydatids.—Adipose degeneration.—Tubercles.—Malignant forma- tions .............179 DISEASES OF THE PANCREAS. (Dr. Wm. Thomson.) Alterations in the pancreatic secretion.—Congestion and haemorrhage.—Inflammation and its consequences.—Hypertrophy.—Atrophy.—Induration.—Cartilaginous trans- formation.—Fatty transformation.—Steatomatous concretions.—Tubercles. —- Serous cysts and hydatids.—Scirrho-cancerous degeneration— Melanosis.—Calculous con- cretions.—Diagnosis and symptoms of the diseases of the pancreas.—Causes.—treat- ment .............19U DISEASES OF THE SPLEEN. (Dr. Wm. Thomson.) Congestion and inflammation. — Purulent formations.—Gangrene.—Hypertrophy.— Atrophy.—Induration.—Softening.—Rupture.—Tubercle.—Serous cysts and hyda- tids.—Symptoms.—Causes.—Treatment ------- 198 DISEASES OF THE URINARY ORGANS. PROPERTIES OF HEALTHY URINE. (Dr. Christison.) Average daily quantity.—Chemical constitution.—Density - 206 FUNCTIONAL DISEASES OF THE KIDNEYS. (Dr. Christison.) Morbid states of the urine.—Variations in the density and solid ingredients.—Sensible qualities.—Urea.—Lithic acid.—Earthy phosphates.—Impregnation with blood.— Albumen.—Sugar.—Bile.—Milk.—Oleo-albuminous matter.—Oleaginous or fatty matter.—Pus.—Spermatic fluid.—Carbonate of ammonia.—Nitric acid.—Oxalate of lime.—Carbonate of lime.—Melanic acid.—Cystic oxide.—Siliceous deposits.—Hy- drocyanic and ferrocyanic acids.—Phosphorus......210 CALCULOUS DISEASES. (Dr. Christison.) GRAVEL. Definition.—Symptoms, general and local.—Condition of the urine.—Varieties of gravel, and their comparative frequency.—Causes and pathology.—Prognosis.—Treat- ment .............216 URINARY CALCULUS. Symptoms.—State of the Urine.—Composition of Urinary Calculi.—Treatment 228 DIABETES. {Dr. Christison.) DIABETES INSIPIDUS. Varieties.—Causes.—Treatment.........234 DIABETES MELLITUS. Definition.—History.—Symptoms.—Characters of the urine__State of the functions of the alimentary canal.—Of the blood and circulation.—Of the cutaneous functions__ Of the function of nutrition.—Pathology and anatomical characters.__Prognosis!__ Treatment -........... 237 DIABETES CHYLOSUS. Symptoms.—Nature.—Treatment ------.. 253 CONTENTS. 11 SUPPRESSION OF URINE. (Dr. Christison.) Symptomatic of various diseases.—Symptoms.—Causes.—Treatment - - 254 ERRORS IN POSITION AND CONFORMATION OF THE KIDNEYS, p. 258. (Dr. Christison.) HYPERTROPHY OF THE KIDNEYS. (Dr. Christison.) INFLAMMATION OF THE KIDNEYS. (Dr. Christison.) Frequency of the disease.—Various forms according to Rayer.—Symptoms of acute ne- phritis—Of simple chronic nephritis.—Complications.—Symptoms and terminations of Pyelitis.—Causes of the several forms of inflammation of the kidneys.—Anatomical characters.—Prognosis.—Treatment ------- 259 GRANULAR DISEASE OF THE KIDNEY. (Dr. Christison.) Recent discovery of this form of renal disease.—Definition.—Primary symptoms of the acute and chronic form.—Characters of the urine.—State of the blood.—Secondary diseases.—Causes.—Prognosis.—Anatomical characters and pathology.—Treatment of the primary disease.—Of the secondary affections ----- 271 OTHER CHRONIC ORGANIC DISEASES OF THE KIDNEYS. (Dr. Christison.) Hyperemia. — Anaemia. — Atrophy.—Tubercles.—Carcinoma.—Melanosis.—Develope- ment of the erectile tissue.—Phlebitis.—Serous cysts.—Hydronephrosis - 287 DISEASES OF THE BLADDER AND URETHRA. (Dr. Christison.) Inflammation.—Vesical catarrh.—Irritable bladder.—Diseases of the prostate gland.— Stricture of the urethra..........290 DISEASES OF THE UTERUS AND OVARIA. DISORDERED MENSTRUATION. (Dr. Ferguson.) General observations on the phenomena of menstruation.—Imperfect puberty—preco- cious—tardy.—Faulty developement.—Suspended menstruation, or Amenorrhea— coexistent with healthy state of the constitution—with organic disease—with consti- tutional debility—with plethora.—Complications—Treatment.—Vicarious menstrua- tion.—Painful menstruation, or dysmenorrhcea.—Symptoms.—Inflammatory and neu- ralgic forms.—Causes.—Prognosis—Treatment.—Excessive menstruation, or menor- rhagia. — Pathology. — Causes. — Symptoms. — Prognosis. — Forms.— Treatment.— Chronic menorrhagia and its treatment.......294 IRRITABLE UTERUS, OR HYSTERALGIA. (Dr. Ferguson.) Symptoms.—Diagnosis.—Prognosis.—Treatment......312 LEUCORRHCEA. (Dr. Ferguson.) Acute and chronic forms.—Symptoms.—Causes.—Treatment ... 314 INFLAMMATION OF THE UTERUS, OR METRITIS. (Dr. Simpson.) Congestion of the uterus, and its treatment—Acute metritis.—Anatomical Characters— Causes.—Symptoms.—Treatment—Chronic metritis. —Various forms. —Ulcerative inflammation.—Suppurative inflammation.—Membranous inflammation.—Inflamma- tory enlargement and induration of the substance and mucous follicles of the uterus. Symptoms of chronic metritis.—Causes.—Treatment.....317 FIBROUS TUMOURS OF THE UTERUS. (Dr. Simpson.) Anatomical characters.—Nature.—Progress.—Symptoms.—Prognosis.—Treatment 326 12 CONTENTS. POLYPUS OF THE UTERUS. (Dr. Simpson.) General description.—Forms,—Symptoms, local and constitutional.—Diagnosis.—Pro- gnosis.—Treatment...........3*9 CAULIFLOWER EXCRESCENCE OF THE UTERUS. (Dr. Simpson.) Pathological Nature.—Symptoms.—Treatment......332 CARCINOMA OF THE UTERUS. (Dr. Simpson.) Description.—Symptoms, local and constitutional.—Treatment - 334 CORRODING ULCER OF THE UTERUS. (Dr. Simpson.) Characters of this ulcer.—Diagnosis.—Treatment......337 OTHER MORBID DEGENERATIONS OF THE STRUCTURE OF THE UTERUS. (Dr. Simpson.) Cartilaginous and osseous Transformation.—Phlebolites.—Hypertrophy and atrophy.— Substances in the uterine cavity -------- 338 INFLAMMATION OF THE OVARY, OR OVARITIS. (Dr. Simpson.) General observations.—Congestion and haemorrhage.—Anatomical characters and ter- mination of inflammation of the ovary.—Symptoms and diagnosis.—Causes and treat- ment .............340 DROPSY OF THE OVARY. (Dr. Simpson.) Simple serous cysts.—Dropsy and dilatation of a Fallopian tube.—Unilocular simple cyst, or dropsy of the ovary.—Ovarian cyst containing hydatids.—Compound or multilo- cular cystic dropsy of the ovary.—Symptoms and Diagnosis.—Prognosis.—Treat- ment .............343 STRUCTURAL DISEASES OF THE OVARY. (Dr. Simpson.) Hypertrophy and atrophy.—Morbid transformations and simple tumours.—Cystic tu- mours containing hairs, &c.—Malignant degenerations.—Symptoms of the preceding ovarian diseases and their treatment........354 HAEMORRHAGE. GENERAL DOCTRINES. (Dr. George Burrows.) Definition.—Preliminary observations.—Spontaneous haemorrhages.—Different tissues from which these occur.—Mode of escape of the blood—by rupture ot vessels, and by exhalation.—Arguments in support of the doctrine of haemorrhage by exhalation. —Spontaneous haemorrhage, a symptom of constitutional disturbance, or of locai disease.—Active and passive haemorrhages.—Symptomatic and sympathetic — Diagnosis of spontaneous hemorrhages.—Characters of the blood eftused —Obser- vations on constitutional haemorrhages.—States of the constitution favourable to them.—Their periodicity.—Vicarious hemorrhages.—Symptoms attending active haemorrhages.—Passive haemorrhages.—Explanation of the cause of the extravasa- tion of the blood in active and passive haemorrhages.—Effects of haemorrhage local and general.—Treatment of constitutional haemorrhages—of periodical—vicarious- active—passive.—Observations on symptomatic and sympathetic haemorrhages — Haemorrhages considered with reference to their seat—into the substance of organs —cutaneous—from serous membranes—from mucous membranes - . 057 CONNEXION OF INFLAMMATION AND HiEMORRHAGE. p. 3?7 (American Editor.) HAEMORRHAGE FROM THE NOSE, OR EPISTAXIS. (Dr. George Burroios.) Symptomatic of constitutional and local disease.— Active.—Passive.__Vicarious.__ • Treatment........--.. -^g CONTENTS. 13 HAEMORRHAGE FROM THE LUNGS, OR HAEMOPTYSIS. (Dr George Burrows.) Definition.—General description.—Sources from which the blood may issue.—Pulmo- nary lesions induced by haemoptysis.—Pulmonary apoplexy.—Causes of haemoptysis. Active constitutional hemoptysis—its symptoms and treatment.—Passive constitu- tional hemoptysis and its treatment.—Vicarious hemoptysis and its treatment- Hemoptysis induced by pulmonary diseases, symptoms and treatment—by cardiac diseases, symptoms and treatment—Hemoptysis resulting from obstruction in the abdominal circulation -......... 381 CONNEXION OF HaEMORRHAGE OF THE LUNGS WITH TUBERCLES, p. 392. (American Editor.) Haemorrhage from the stomach, or HaEmatemesis. (Dr George Burrows.) Etymology.—Symptoms.—Diagnosis.—Prognosis.—Duration.—Influence of age and sex.—Quantity of blood effused.—Its physical characters.—Condition of the stomach in hematemesis. — Causes.—Active constitutional hematemesis. — Symptoms and treatment—Passive hematemesis and its treatment.—Vicarious hematemesis and its treatment.—Hematemesis induced by organic lesions—of the stomach—of other organs.............393 Haemorrhage from the intestines. (Dr. George Burrows.) Symptoms and source of the hemorrhage.—Characters of the effused blood.—Prog- nosis.—Causes.—Constitutional disturbance and structural lesions.—Intestinal hemor- rhage may be active, passive, or vicarious.—Symptoms and treatment of these forms. —May originate in connexion with organic lesions, viz., inflammation of the intestinal mucous membrane.—Ulceration.—Carcinoma.—Diseased liver and spleen.—Symp- toms and treatment of these forms........402 Haemorrhage from the urinary organs, or HaEmaturia. (Dr. George Burrows.) Derivation and signification.—Characters of bloody urine.—Substances taken as food impart a red colour to the urine.—Other deceptive appearances.—Tests for the presence of blood in the urine.—Sources of the blood.—Urethral hemorrhage.— Vesical hemorrhage.—Renal hemorrhage.—Diagnosis.—Causes.— Peculiar states of the constitution.—Local lesions—active—passive—vicarious.—Symptoms and treatment.—Hematuria arising from morbid conditions of the urinary organs.— Symptoms and treatment --------- 406 HaEMORRHAGE FROM THE UTERUS.. (Dr. George Burrows.) Definition.—Active and passive menorrhagia.—Symptoms and treatment.—Occurring during pregnancy and parturition.—Causes and treatment.—Resulting from struc- tural diseases of the uterus .........413 SCURVY. (Dr. Budd.) Historical details. — Causes. — Prevention. — Symptoms. — Anatomical characters.— Diagnosis.—Treatment..........417 DROPSY. GENERAL DOCTRINES OF DROPSY. (Dr. Watson.) Conditions of the system under which dropsical effusions arise.—General pathology of dropsy.—Chemical composition of dropsical fluids.—Remarks on some of the pheno- mena of the effusion.—Prognosis of dropsy.—General principles of treatment.— 14 CONTENTS. Cardiac dropsy.—Indications that dropsy originates in cardiac disease.—Forms of cardiac disease that induce it, and progress of the dropsical effusion.—Renal dropsy. —Peculiar characteristics of this form.—Appearances in the structure of the kidney in renal dropsy.—Relation of renal disease to dropsy.—Condition of the urine—of the blood.—Incidental complications.—Causes of the renal disorganization.—Acute or febrile dropsy.—Nature, symptoms, and causes.—Dropsy following scarlet fever. —Treatment of general dropsy—of acute or febrile dropsy—of chronic general dropsy—of the renal form of chronic general dropsy—of cardiac dropsy—of diet and drinks.......------ 456 CEREBRAL DROPSY, OR CHRONIC HYDROCEPHALUS. (Dr. Watson.) Origin of the disease.—Its progress.—Examples.—Mode of treatment - - 501 THORACIC DROPSY. (Dr. Watson.) Symptomatic of disease of the heart or great vessels.—Rare as a substantial disease.— Physical signs and treatment.—Hydropericardium.—Symptoms and treatment 510 ABDOMINAL DROPSY. (Dr Watson.) Restriction of the term ascites.—Mode of distinguishing ascites from ovarian and other forms of encysted abdominal dropsy.—Exciting causes.—Treatment - 512 SCROFULA. (Dr. Shapter.) Definition.—Description of the scrofulous constitution.—Of the progressive stages of scrofula.—Of the scrofulous ulcer.—Tuberculous deposit in tissues and organs.— Nature of tubercle.—Origin.—Composition.—Modification of other diseases by scro- . fula.—Complications.—Statistics.—Causes.—Prevention.—Treatment - 519 BRONCHOCELE. (Dr. Rowland.) History.—Causes.—Cretinism.—Connexion between bronchocele and cretinism.— Diagnosis.—Treatment.....----- 54s RHEUMATISM. (Dr. William Budd.) Forms.—Acute rheumatism.—Complications.—Rheumatic inflammation of the heart__ Rheumatic pleurisy.—Arachnitis.—Diagnosis.—Pathology.—Causes.—Treatment of acute rheumatism.—Chronic rheumatism.—Description and treatment.—Muscular rheumatism.—Lumbago.—Pleurodynia,—Rheumatism of the muscles of the neck.— Of the muscles of the limbs.—Of the abdominal muscles.—Treatment of muscular rheumatism --------_.._ 55^ GOUT. (Dr. William Budd.) Synonymes.—Symptoms of acute gout—of chronic gout—Gouty concretions —State of the urine in gout—Gouty affections of external structures__of internal organ* — Diagnosis.—Pathology.—Causes.—Treatment.—Prevention - . . 575 WORMS FOUND IN THE HUMAN BODY. (Dr. Arthur Farre.) Parasites.—Origin of worms.—Causes.—Seat.—Symptoms, local and constitutional —. Morbid appearances caused by worms.—General treatment—Classification of worrrw —Particular species.—Acephalocystis endogena.—Acephalocystis multifida.—EchU CONTENTS. 15 nococcus hominis.—Cysticercus cellulose.—An'malcula echinococci.—Diplosoma crenata.—Tenia solium.—Bothriocephalus latus.—Distoma hepaticum.—Polystoma pinguicola.—Trichina spiralis.—Filaria Medinensis.—Filaria oculi.—Filaria bron- chialis.—Tricocephalus dispar.—Spiroptera hominis.—Dactylius aculeatus.—Stron- gylus gigas.—Ascaris lumbricoides.—Ascaris vermicularis - - - 595 FORMULARY. (Dr. Joy.) PRELIMINARY REMARKS ON THE ART OF PRESCRIBING. Difficulty of scientific prescription arising from the extent of knowledge requisite.— Discrimination as to the cases requiring medical aid.—Medicines divisible into simple and compound, officinal and extemporaneous or magistral. —Simplicity of prescription. —Elements of a formula,—the principal ingredient—adjuvant or directive—correc- tive—rival ingredients—newly developed powers.—Excipient, or vehicle, &c. forms of medicines, solid and fluid, powder, electuary, bolus, linctus, pill, mixture.—Drinks, periods at which they should be given.—Arrangement of the several ingredients of a formula.—Errors most apt to occur in extemporaneous prescription.—Domestic mea- sures.—Doses applicable to individual cases, modified by age, temperament, idiosyn- crasy, &c. ------------ 630 EXTEMPORANEOUS FORMULaE. I. Stimulants......650 II. Narcotics......657 III. Antispasmodics.....662 IV. Tonics........664 V. Astringents......669 VI. Diaphoretics ----- 673 VII. Expectorants.....676 VIII. Emetics.......678 IX. Cathartics......681 X. Diuretics ------ 688 XI. Emmenagogues - - - - 692 XII. Antacids......693 XIII. LlTHONTRIPTICS, OR ANTI- L1THICS ------ 695 XIV. Refrigerants .... 695 XV. Demulcents and Emollients 696 XVI. Anthelmintics - - - - 698 XVII. Antiphlogistic, Antisyphi- litic, Alterative, and Deobstruent Remedies 700 XVIII. Alkaloids .....704 GENERAL INDEX TO THE THREE VOLUMES, p. 707. DISEASES OF THE ORGANS OF DIGESTION. STOMATITIS, OR INFLAMMATION OF THE MOUTH. Stomatitis aphthosa.—Anatomical varieties.—Aphthae in infants—in adults.—Stomatitis mer- curialis.—Symptoms and treatment.—Stomatitis ulcerosa.—Symptoms and treatment. Under the generic term Stomatitis (from cVo^a, the mouth)-we shall include three species of inflammatory affections of the mouth, viz., Stomatitis aphthosa, Stomatitis rnercurialis, and Stomatitis ulcerosa. ■', 1. Stomatitis Aphthosa. This form of inflammation of the mouth is distinguished by the appearance of white points or streaks, distinct or confluent, on the surface of the tongue, the interior of the lips, the cheeks, the gums, the palate, and the pharynx. These specks, called indiscriminately aphthae (from cwrrw, accendo), differ consider- ably in their anatomical nature. We shall describe the most important of these varieties. 1. The first, and perhaps the most common form, is an oval or circular ele- vation of the epithelium, having serum beneath it, and corresponding to a cuta- neous vesicle ; whence aphtha? in general are included in the class Vesiculce of Willan and Bateman's system. When the epithelium is broken, and the mu- cous membrane thereby exposed, the latter may secrete pus, and the vesicle is thus converted into an ulcer. 2. In another variety the disease is seated in the mucous follicles, which, swelling with the inflammation and augmented secretion, raise the mucous mem- brane and epithelium above them into round whitish eminences; these aphthae feel hard under the finger, and are often surrounded by a circle of redness. If the disease advances, The epithelium and mucous membrane covering the fol- licle are destroyed by sloughing, leaving an ulcer beneath. Aphthae of this description are generally isolated, but when a great number of follicles are affected they may become confluent. Billard proposes to confine the term "aphthae" to inflammation of the follicles, hut the restriction is inconvenient. 3. We may recognise a third form of aphthae in those white streaks and patches, without any perceptible elevation of the surface, which occur for the most part in persons of advanced age, or at the close of chronic diseases. They vol. in. 3 18 stomatitis aphtha (Varieties). consist of portions of the epithelium which have lost their transparency. They often assume the appearance of small portions of white fur, adhering to the membrane. Sometimes they accompany the vesicular and follicular varieties. 4. The fourth variety of aphthae is distinguished by a soft pulpy matter secreted by the mucous tissue under a peculiar form of inflammation. Whether the pel- licle consists of concrete mucus or of albumino-fibrin has not been satisfactorily determined. This disease very frequently extends into the oesophagus and stomach, and has been observed by Billard even in the small intestine. It is known in France by the term muguet. The distinction of the varieties of aphthae thus sketched is founded on their anatomical characters. But they often co-exist; thus we find the vesicular aphthae, and the inflamed follicles, occurring in the same subject, and as purely local affections ; and in children the pellicular inflammation and the confluent form of the second variety are often so intermixed as to be easily confounded. In a practical point of view it is of less importance to determine, in any given case, the precise anatomical nature of the aphthae, than the state of the general system. In our remarks on this subject we shall find it convenient to speak of the disease, first, as it occurs in the infant, and secondly in the adult. The infant is liable to two forms of aphthae ; the more common being that which occurs in the earliest periods of existence. It begins with an erythema- tous redness of the tongue, on the surface of which may be observed, after a day or two, a number of white points or streaks, consisting either of opaque epithe- lium or of concrete mucus. In mild cases the disease is confined to the tongue and the roof of the mouth, and subsides under appropriate treatment in two or three days. The attention of the nurse is generally first called to the affection by the reluctance of the infant to take the breast, or by its suddenly leaving off after beginning to suck with avidity. The exciting cause is some temporary disturbance in the stomach and bowels, occasioned by the quality of the milk, or by the improper use of other kinds of food. Antacid medicines, such as soda, magnesia, or chalk, with the local application of borate of soda, will generally put an end to the complaint, unless the food continues to be of an irritating nature. When the inflammation extends to the throat, the white points becom- ing confluent, and putting on the appearance of a creamy lining, there is com- monly sickness, soon followed by diarrhcea, and attended with great restlessness and prostration. In this state a small dose of Hydr. c. Creta and rhubarb may- be used at first, and afterwards mucilaginous liquids. The gastric and enteric irritation may be soothed by poultices applied to the abdomen. In some cases it may be necessary to leech the epigastrium, but this practice requires the utmost caution in subjects of so tender an age, and in a disease attended with so much exhaustion. When the vital powers are considerably depressed, we must administer broth, and even small quantities of wine, mixed with arrow-root or rice jelly. The aphthae in such cases require the application of astringent sub- stances diffused in syrup ; five or six grains of sulphate of zinc may be°added to an ounce of syrup of poppy, with which the parts may be frequently touched by means of a camel-hair pencil. This serious form of aphthous inflammation especially attacks children of sickly habit and ill-nourished. It has sometimes prevailed epidemically ; and has also been known to rage in hospitals devoted to young infants. (Dugts.) About the period of the first dentition, or later, infants are subject to aphtha? of the follicular kind, either distinct or confluent; the former connected with transient disorder of the digestive functions, the latter symptomatic of more serious affections, especially febrile attacks, and diseases of the lymphatic svs tem. Although this kind of aphthae is far more frequent at the period above mentioned, our experience leads us to think, with Dr. Evanson, that Billard was in error when he stated that it is never met with before dentition. (See Evan son and MaunseU on Dis. of Children, 2d edit. p. 206.) The local treatment is the same as that recommended for the other forms of aphtha?, while the general measures must depend on the previous or accompanying disorders. stomatitis mercurialis (Symptoms). 19 Adults are by no means so liable to aphthous inflammation as young children. The vesicles described as the first variety, are met with in conjunction with gas- tric irritation, and are not very easy to get rid of. It often happens that they are not discovered till they have been converted into ulcers, and are then scarcely to be distinguished from ulcerated follicles. Our first care must be to ascertain and correct the condition of the stomach and bowels, with which the aphthae are associated. If they fail to subside under treatment thus directed, we must have recourse to local applications. Gargles containing chloride of soda, mineral acids, alum, and tincture of myrrh, &c, are not without use ; but the most de- cisive remedies of this class are the nitrate of silver, and the sulphate of copper, applied in substance to the aphthous ulcers. The confluent follicular aphthae, and those belonging to the third variety, occur in the latter periods of exanthematous fevers, chronic visceral phlegmasia), especially those of the abdomen, the hectic fever of phthisis, and the breaking up of the constitution in carcinomatous or other structural diseases. Their ap- pearance is inauspicious in all cases, but especially in chronic maladies. When they occur in clusters surrounded by redness upon the velum palati, the inside of the cheeks, or on the tongue, the pharynx being but little affected, the prospect is more favourable than when, as frequently happens, the base of the tongue, the palate, and the pharynx present a diffuse whiteness, looking as if they had been smeared with paint. The latter appearance is accompanied by signs of profound debility, a small fluttering pulse, colliquative sweats, and diarrhoea. But even this combination of symptoms is not invariably fatal, at least if the primary affection has been of short standing. The aphthae attendant upon fevers are more commonly met with in autumn, and in humid atmospheres. In Holland an aphthous fever is sometimes epidemic, and the most frequent sub- jects of it are adults, and especially puerperal women. (Guersent.) The treatment consists in using measures for supporting the strength, such as the exhibition of bark, wine, broth, jelly, &c, and in applying detergents and stimulants to the mouth and fauces. Ablution with warm water, whenever the patient's strength will admit of it, should precede the use of gargles. To the substances already recommended for the composition of these gargles, a sedative may be added, in the form of laudanum or syrup of poppy. 2. Stomatitis Mercurialis. The inflammation of the mouth excited by the specific action of mercury is a serious adjunct to the ptyalism produced by this metal. Ptyalism strictly signifies increased secretion from the salivary glands, and it may occur quite independently of mercurial action, as an accompaniment of hysteria, hypochon- driasis, and dyspepsia, but it is then very rarely attended with stomatitis. The affection is generally preceded by an unpleasant taste compared to that of copper or brass, soon after which the patient complains that his teeth feel soft and tender when brought together, and he fancies they are loosened in their sockets. Soon after this, shooting pains are felt in the face, and a stiff- ness in the movement of the lower jaw, caused by tumefaction of the sub- maxillary and parotid glands. The gums are of a deep red colour, and their margins projected, as it were, from the teeth. Here and there we may perceive spots of a dull whiteness caused by opacity of the epithelium. The tongue is swollen, indented at the edges by the pressure of the teeth, and coated with a thick yellow or brownish fur: the breath has a peculiar foetor, and often before the stomatitis is very manifest. In severe cases there is ulceration of the gums, commencing at the margins, and extending to the interior of the cheeks: occa- sionally the tumefaction of the salivary glands is so great as to prevent the mouth from being opened; this, together with the engorgement of the tongue, may become so considerable as to induce suffocation. But without attaining so 20 stomatitis ulcerosa (Symptoms). serious a degree, the stomatitis is productive of great distress, by the imP^" ment to speaking, mastication, and deglutition, as well as by the proluse s - tion of saliva. The patient often complains of it more bitterly than mine internal inflammation, for the removal of which the mercury was adm.nisierea, and he can scarcely refrain from inveighing against his physician,^lor suosi - tuting so loathsome an affection even for a malady which threatenea nis exist- ence. The local symptoms are generally accompanied by levenshness, ana general irritation. , . ~ ,, • a The duration of ptyalism varies with the extent and seventy of the inflam- mation. If ulceration has taken place, the parts seldom recover themselves till several weeks have elapsed; and even without this, it may be almost as long before the spongy state of the gums, and the increased flow of saliva, entirely subside. Ordinarily, however, when there has been only tumescence and sore- ness of the gums, the affection disappears in a few days. The severity of stomatitis holds no direct ratio with the amount of the mercury introduced into the system. The enormous quantities requisite for inducing the specific effects of this metal in some subjects, are no less surprising than the sudden appearance of the affection, when only the most trifling doses have been taken. Some persons have, by idiosyncrasy, a remarkable suscep- tibility of mercurial influence, while others are as strikingly capable of resisting it. The constitutional liability, however, cannot be fairly estimated when inflammatory disease is present, for the most general fact with which we are acquainted as to the specific action of mercury, is, that the readiness with which it takes place is in an inverse ratio with the intensity of the existing disease. Other circumstances, also, very materially affect the result; such as the mode of administration, the state of the bowels, and of the function of the skin, previous bloodletting, &c.; but this is not the place for their consideration. Treatment. In slight cases, very little more is necessary than to enjoin frequent ablution of the mouth, at first with tepid water, and afterwards with a mild astringent gargle, and to secure a free action of the bowels by saline aperients, and of the skin by warm clothing. When the inflammation is more severe, as indicated by a white line of suppuration along the edges of the gums, we must, in addition to the measures just mentioned, employ others of greater activity. If the tumefaction is general, leeches applied under the lower jaw, with fomentations, will afford relief. The best local application in our expe- rience is the nitrate of silver, either in substance, or in a strong solution, (two scruples to an ounce of distilled water,) by means of a small sponge fastened to a proper handle, or a camel-hair pencil. A lotion of chloride of soda will be very useful for correcting the foetor, as well as for its stimulant property. An alum gargle containing laudanum is of service, when the active period of the inflammation has passed by. We have very little confidence in internal medicines exhibited as antidotes, such as sulphur and iodine. The supposed efficacy of the former depends, we believe, on its laxative operation. Opium in repeated doses has proved useful by quietino- the erethism and also, perhaps, by lessening the secretion from the salivary glands. But it must be confessed that the affection is very slightly amenable to treatment excepting as to the progress of ulceration, which may be arrested with tolerable certainty by the nitrate of silver. The practitioner should never neglect to enjoin free ventilation of the patient's apartment, which, indeed, ought to be kept not onlv airy, but cool. ' 3. Stomatitis Ulcerosa. Under this term we shall notice a form of inflammation of the gums wh" h appears in children between the first and second dentition. It is sometim called cancrum oris, or a milder variety of that frightful disease which we shall GANGRiENA ORIS. 21 describe presently, under the appellation gangrcena oris. It would be better to confine both these terms to the latter disease, which is not merely more intense in degree, but distinct in its pathological nature, from stomatitis ulcerosa. This affection begins with inflammation of the outer surface of the gum, and more commonly in the lower jaw; sometimes limited to one side, but more fre- quently extending to both sides. The inflamed part is extremely swollen, and soon surmounted by a line of ulceration at the margin adjoining the teeih. The cheeks and lips become hard and oedematous, so as to impede the opening of the mouth; and this, together with the quantity of mucus and saliva collected between the gum and the cheek, renders it difficult to procure a satisfactory in- spection of the diseased parts. The breath has a peculiar foetor, allied to the taste called brassy or coppery, and quite distinguishable from the odour of gan- grene. There is often considerable flushing of the face and conjunctivae, with heat and tenderness; and the glands below the jaw are enlarged and painful. If the disease be not speedily checked, the ulceration may proceed so far as to lay bare the alveolar processes; but occasionally, we have known it continue in an indolent state for several days, neither advancing nor disposed to heal. In some subjects, the ulcerated surface is very prone to bleed. More or less fever for the most part accompanies the affection, but is sometimes absent. The bowels are costive, and there is no inclination to food. The disease prevails chiefly among the poorer classes of the community, and indicates debility of habit as a predisposing cause. The attack may be often referred to the immediate agency of cold, damp, or disorder of the stomach and bowels. When seen early, the prognosis is favourable, unless the disease has supervened upon some other acute malady, such as fever or scarlatina. Treatment. Though the disease is inflammatory, it is not to be combated by the ordinary antiphlogistic measures. Leeches and cold lotions may be useful in reducing the glandular enlargements, but they cannot be depended upon for stopping the internal ulceration. The best applications for this pur- pose are of the same kind as we have recommended in the other species of stomatitis, such as the strong solution of nitrate of silver, and the mixture of syrup and sulphate of zinc. A linctus made with a drachm of strong muriatic acid, added to an ounce of honey, is an excellent remedy. We can also speak highly of a gargle composed of alum, decoction of cinchona, and tincture of myrrh. The only objection to this, as to certain other gargles, is, that the age of the child often prevents them from being used in sufficient quantity, or with sufficient frequency, to render them really efficient. The internal treatment may be commenced by an emetic, unless the lips and cheeks are so swollen and tender as to render vomiting too distressing an action. After the emetic, a brisk purgative of scammony or jalap, with calomel or Hydr. c. Cret., should be administered. If there is much fever, we may exhibit salines and antimonials, but it is seldom necessary to continue them longer than a day or two. The action of the bowels may be maintained by castor oil, rhubarb and soda. Should the ulceration, after the above treatment, show a tendency to spread, we must exhibit the sulphate of quinine, or decoc- tion of bark, in doses suited to the age of the patient, continuing at the same time the local treatment with undiminished energy. GANGRCENA ORIS. Synonymes.—Symptoms.—Causes.—Treatment. Gangrene of the mouth may be the consequence of any of the forms of stomatitis, but the disease we are about to consider is idiopathic, or gangrene 22 GANGRJ2NA ORIS (Pathology). proper, beginning with that loss of vitality which in inflammatory mortification is the last of a series of morbid changes. The synonymes of Gangrama uns are Cancrum oris, sloughing phagedena of the ?nouth, water-canker, stomacace maligna, nomra, necrosis infantilis. , , Symptoms. The existence of this disease is generally first intimatea ^ an indolent swelling of one cheek, without heat or redness. It is hard to tne toucn, and so little tender or painful, that the patient seems all but unconscious ot it, and but for the enlargement being obvious to the eye, the mischief would pro- bably escape notice altogether in its early stage. Indeed, as it is, the tumetac- tion is occasionally mistaken for affections of a much less serious description. The skin of the cheek has a peculiar glossy or waxy appearance. Ua exami- nation of the mouth, we detect a whitish or ash-coloured eschar, without any inflammatory redness of the surrounding membrane; generally in the centre of the cheek, or in the commissure of this part and the lower jaw. The gums look pale and spongy. There may be a certain degree of languor, dulness, or slight feverishness, but not less frequently there is nothing to call particular attention to the general health. Such are the principal phenomena of the first stage of the disease. As it advances, the slough spreads rapidly over the in- terior of the cheek and lip, and invades the gums. Saliva escapes in great quantity, at first clear, afterwards mixed with a dirty sanious matter which has a horrible fcetor. About the same time the outside of the cheek presents a pale ashy spot, which soon becomes livid and sphacelates. The extension of the disease to the bony structures is evidenced by the loosening of the teeth, which are soon thrown off with portions of the alveolar processes. The fluid dis- charged appears to have a corrosive quality, for the angles of the mouth and the lower lip sometimes become new centres of mortification. We have known both sides of the face attacked in the same individual, and there are cases on record in which all the soft parts of the face, as well as the upper maxillary bones, the palatal, the nasal, and even the ethmoid, were involved in the de- struction. Usually, however, death prevents the lesion from extending so widely. The constitutional disturbance is in many cases far from being proportionate to the severity of the local affection. The pulse is frequent, but weak: the bowels, at first combined, become towards the close of the malady extremely relaxed, and the heat of the extremities is much depressed. Causes. The subjects of gangraena oris are children, usually between two and five years of age, but we once met with it in a girl who had attained her eighth year. It is confined to children of debilitated habit, and is very rarely observed among the richer classes; low marshy situations and rainy seasons appear to increase the predisposition. Not unfrequently gangrrena oris is one of the sequelae of exanthematous fevers. There is no good reason for attributing the disease to the specific action of mercury, though it may have sometimes supervened upon the latter, which, like any other cause of derangement, may have given the first impulse to the morbid process. It has often occurred when not a particle of mercury had been administered. As to the pathology, we have already expressed our belief, that the disease is gangrenous ab origine. Any inflammation that may be found about the part is secondary only, bearing no causative relation to the gangrene. It has been stated that the commencement is often unattended by pain, heat or redness. The swelling is the effect of the retarded circulation in the capillaries and the infiltration of the tissues with serum, or liquor sanguinis. The pressure thus produced is sufficient to explain why the vitality of the central portion is de- stroyed. The mortification extends by contiguity, because the capillary circu- lation in the adjacent parts is necessarily affected by the pressure of the diseased tissue. If they have sufficient vital action, they may only suffer inflammation and suppuration, but it too often happens that the lesion assumes the same ch racter as in the neighbouring part, being influenced by the same state of the gangr^na oris (Treatment). 23 general habit. It can scarcely be doubted that this depraved habit consists mainly in deficient plasticity of the blood. The worst case that ever fell under our notice, occurred in a girl recovering from a mild fever, who had been leeched on the forehead. There had been extreme difficulty in restraining the haemorrhage from the leech bites, in consequence of the incoagulable quality of the blood. The prognosis is from the first unfavourable. Though the child may escape with life, it cannot be saved from disfiguration when the gangrene is once esta- blished. If, however, oedema has been discovered very early, and a vigorous treatment adopted, the danger may sometimes be warded off. Treatment. On the first appearance of the swelling, the cheek should be frequently rubbed with a stimulating embrocation, consisting of camphorated oil and ammonia, and in the intervals should be kept moist with a tepid lotion con- taining muriate of ammonia and spirit of wine. A careful examination of the interior should be made, so that, on the detection of the slightest appearance of an eschar, the part may be touched with the solid nitrate of silver, or strong muriatic acid. If sloughing has already commenced, the nitrate of silver lotion will be the best application. The mouth should be frequently washed out or syringed with a solution of chloride of soda, if only to moderate the foetor. M. Billard recommends, that as soon as the livid spot on the exterior of the cheek shows itself, a crucial incision should be made into the centre of the swelling, and butter of antimony introduced, or still better, the actual cautery at a white heat. (Malad. des Enf. p. 247.) This remedy has been previously much in- sisted on by M. Baron. When the gangrene is complete, we must endeavour to stop its extension by carrot, or fermenting poultices. The medicines to be exhibited are tonics and stimulants, of which carbonate of ammonia in decoction of bark, or quinine combined with camphor, are the most efficient. Wine or brandy may be liberally administered with beef tea; opium is strongly indicated not merely for allaying general irritation, but for the sake of the stimulating influence which it is known to exercise upon diseases of the capillary system characterized by debility. Constipation or diarrhoea must be met by the remedies appropriate to either state. The patient should if pos- sible be placed in a large airy apartment. The gangrenous affections of the mouth in children, are very frequent in certain situations, and are apt to occur after particular diseases. They are very prevalent in some years, among a crowd of children confined in almshouses or asylums, and obey in this respect nearly the same laws as erysipelas. Sometimes they originate In children who are apparently in good health, but in a great proportion of cases they are merely sequelae of diseases affecting the general system, such as measles and small-pox, especially the former exanthema. From the causes which govern its developement, there can be little doubt as to the pathology of the dis- order ; that is, it should be regarded as a disease of the fluids rather than of any solid tissue of the economy; and the local lesion may occur in various other tissues than those of the mouth, especially in the lungs. The gangrene of the mouth is occasionally met with in adults, but rather as a sequel of that of the lungs than as an idiopathic disorder. Mercurial ptyalism favours the developement of gangrene, and during the prevalence of an epidemic disease which passes into gangrene, patients who are salivated are more apt to suffer than those who are not under the influence of this mineral. Its influence, however, is limited, and is rarely sufficient in itself to produce the lesion. The course of the disorder is the same, whether the gangrene first shows itself as a small whitish eschar between the lower incisors, or a shining slough of the cheek; but in the former case it may be reached much more readily by escharotics, and may be sometimes entirely destroyed. When a large portion of the cheek is attacked, it cannot be reached by escharotics, and more or less extensive sloughing is almost sure to take place. In either case there is little pain, and the disease is rarely discovered until the mouth assumes a characteristic gangrenous odour. The slight pain is readily accounted for by the trifling degree of inflammation which 24 diseases op dentition (Local Symptoms). is generally developed, especially if the gangrene has first occurred, when there is no other evidence of inflammatory action than a red circle around the slough : in other cases a sub- acute inflammation precedes the gangrene. The indications for the treatment of any form of gangrene of the mouth are extremely sim- ple. These indications are of course twofold—to modify the general constitution and at the same time to act upon the local mischief. If there is not high fever, the patient will use bark and wine, or at least a quinine solution or syrup; if the excitement be much higher, the mineral acids are better adapted to the case, with occasional doses of rhubarb; but we must remember that gangrene of the mouth, like other diseases of much debility, will often require, or at least be benefited by a tonic and almost a stimulating treatment. The best local applications are the nitrate of silver, if the slough be small in extent; if much larger, the best escharotic is the muriated tincture of iron, applied in the undiluted state; after the progress of the disease is arrested, the ulcer will improve rapidly under an astringent stimulant, such as the tincture of myrrh, or the aromatic wine of the French Pharmacopoeia. G. DISEASES INCIDENT TO THE PROCESS OF DENTITION. Local symptoms—in the mouth and gums—Remote affections—in raucous membranes.—Skin. —Nervous system.—Fever.—Causes of difficult dentition.—Treatment. The developement of organs and functions supplemental to those with which extra-uterine existence commences, is often productive of derangement both in the parts which are the seats of the new action, and in the general economy The local and general disorders attendant upon the first efforts at menstruation upon utero-gestation, parturition, and lactation, would sufficiently exemplify this statement; but the truth of it is perhaps still more forcibly illustrated by the morbid affections incident to the process of teething. To describe the various disorders which have been attributed to dentition, would be tantamount to treating of nearly all the diseases of infancy. So extensive a range of effects may be admitted if we view dentition as a predisposing cause, or as inducing a state of the system which more easily y.elds to the ordinary exciting causes of disease such as vicissitudes of temperature, hygrometric changes of the atmosphere' improper food, &c.: but we must here confine our survey to the morbidEstates' more -mediately referrible to the process in question. Thlse ™L con veniently divided into the local and the remote. y I. Local symptoms. The local disorders of dentition are for the most part of a trivia nature when compared with the sympathetic derangements. Ptval sm one of the most common accompaniments of teething, can hardly be consfderS morbid It occurs not less frequently in infants who cut their Lth with ease than in those with whom the process is more difficult ^t „!l ui 1 !' that the free secretion of saliva relieves X ™,™? I Pr°bable, indeed, mouth and gums are liable. W,ca™ hZveV fSRT^h V^ ^ notion, that the constant humectation of the partSJ.K the general by softening the gums. part fdV0Urs the eruPl1™ of the teeth That the infant suffers from feelings of heat -mrf nr^Koki • . ■ in the gums, is intimated by the plefsure wh chU*t \ * an'tching««»tioii cold substances, such as mLllicboTeT 2d in l£w ■"!• th\apl?,ication of finger These sensations may be ife^^^^ when the gums become swollen from congestion or inflammation, there t Pvi dence of pain and tenderness, not only in the fretfulness of tempe , the fren,!; crying and starting from sleep, but also in the reluctance to take the nS in the sudden retraction of the mouth after it had been applied gre^dT/ ft °r the promptings of hunger. In this state, the child may to noticeTone i'nl H diseases of dentition (Nervous System). 25 thrusting its fingers into the mouth from instinctive attempts at relief, and the next suddenly removing them as if their contact with the gums had occasioned pain. These movements lead us to inspect the gums, which are found red, swollen, and sometimes drier than natural. This condition is most frequent when the teeth are near the surface, but it sometimes occurs even when they cannot be felt by the lancet, and is probably owing to the sympathy between the external parts and the vessels of the dental pulps, the latter being morbidly con- gested from irregular developement. The inflammation of the gums is sometimes quite superficial, being confined to the mucous membrane, and is then apt to show itself in the form of aphthae. (See Stomatitis aphthosa.) II. The remote affections may be grouped under the following heads :—1, the mucous membranes ; 2, the skin ; 3, the nervous system ; 4, febrile affection. 1. The mucous membranes. Irritation of the lining of the nasal passages is denoted by frequent sneezings, and coryza. These catarrhal symptoms, accompanied by suffusion of the eyes and turgescence of the face, often lead to the idea that the infant has taken cold, and sometimes, when viewed in con- nexion with symptoms of general disturbance, such as feverishness, loss of appetite, restlessness, &c, create a not unnatural suspicion that an attack of measles is impending. Sometimes the irritation extends to the air-passages, producing hoarseness, coughs, and wheezing. We have known in particular children these symptoms precede the appearance of almost every tooth, and subside immediately afterwards. Disorder of the gastric membrane is plainly indicated by the anorexia, sickness, and flatulence ; and that of the intestines by diarrhoea, the stools being unnatural in colour and consistence, and by griping pains in the abdomen, the signs of which are screams, with sudden drawing up of the legs and depression of the anguli oris. Painful micturition, and soreness about the glans penis, the labia, and nymphse, betoken irritation of the genito-urinary membrane. The several disorders enumerated are gene- rally transient, but occasionally they degenerate into chronic diseases. Thus coryza becomes ozoena, epiphora runs into ophthalmia, catarrh into chronic bronchitis, &c. &c. But when this happens, there is an unhealthy habit of body, either congenital, or produced by external circumstances. 2. The skin. The cutaneous affections most frequently excited by teething, are papular, as in strophulus and lichen; erythematous, as in intertrigo; squamous, as in pityriasis and psoriasis; vesicular, as in eczema; and pus- tular, as in impetigo and porrigo; or vesiculo-pustular, as in eczema impetigi- nodes. The papular and squamous diseases, for the most part, appear and subside with the successive eruptions of teeth; but the vesicular and pustular oftener remain during the whole period of dentition. 3. Nervous system. Under this head are included the most formidable effects of teething. We shall first notice the local nervous affections, and secondly, those which implicate the cerebro-spinal axis. The local disorders show themselves principally in the form of spasm, affecting both the involuntary and voluntary muscles. As instances of the former, we may specify laryngismus stridulus, and spasm of the sphincters, producing retention of urine, and constipation. The first of these, known by the name of crowing inspiration or spasm of the glottis, is often suddenly fatal. When fully developed, it is characterized by a stoppage of the breathing (during which the child either struggles violently or appears death-stricken), followed by a long crowing inspiration. But approximations to this condition may be noticed, by a careful observer, in children who otherwise give no sign of disorder. Thus a slight sound of the kind alluded to, may be heard when the child wakes up from sleep, or when it has been excited to laughter. It should immediately direct attention to the gums, for teething, though by no means the only exciting cause, is probably one of the most frequent antecedents. Perhaps we ought to place under the spasms of the involuntary muscles, that of the orbicularis palpebrarum, which is not uncommon. It is known by a partial vol. in. 4 26 DISEASES OF DENTITION (FeVCl). closure of one eye, which in these cases, is, we think, more reasonable to be referred to spasm of the orbicularis, than to paralysis of the levator. Local spasms of the voluntary muscles are witnessed chiefly in tne nanas and feet. The flexors of the thumbs and toes are especially liable 10 tne affection. Frequently there is no other token of irritation in the system man the rigid clenching of the thumb in the palm of the hand. Sometimes the flexors of the toes, and those of the carpus, are affected at the same time. These carpo-pedal spasms are occasionally seen in connexion with a pecuhar cedema of the dorsum of the foot and of the wrist, described by Dr. Under- wood and Dr. Kellie; but the two affections may occur independently of each The above local nervous disorders have been separately noticed, because they frequently occur singly, but not less often they are conjoined, and are even associated with the general affection to be next considered. We have distinguished them as local, because they are manifested in detached parts of the body ; but we need scarcely inform the reader, that the irritation, which begins in the nerves of the dental pulp, is transmitted to the spinal marrow, and thence reflected along the nerves of motion. Cerebro-spinal disorder, sympathetic with teething, may show itself under two very serious forms : eclampsia, otherwise called convulsions ; and meningo- cephalitis or acute hydrocephalus. As these diseases so provoked, in no respect differ from those occasioned by other causes, we shall not enter into any description of them in this place. But cerebral disorder of a less formidable nature often occurs in the form of irritability of temper, wakefulness or uneasy sleep, and sometimes of torpor and heaviness. When such symptoms are accompanied by heat of the head, flushing of the cheeks, constipation and fever, the case may be readily taken for one of idiopathic inflammation of the brain, and not unfrequently it is really in the first stage of such disease. But the speedy subsidence of the symptoms after the removal of the irritation in the gums shows that the affection was symptomatic only. 4. Fever. The febrile affection in teething has nothing characteristic. Its elements are a quickened circulation, increased heat, and diminished secretions, especially of the perspiration and urine. It is nearly always attended by some one or more of the mucous or nervous disorders already adverted to. As difficult dentition does not necessarilly give rise to the remote irritations just passed under review, we may inquire in what consists the liability to be so affected? In many cases, the irregular teething itself is only a part of a general fault in the organization, which renders the whole system more or less prone to disorder. In some, the tendency to mucous and cutaneous diseases is shown by the readiness with which they are excited by other causes, such as trifling errors in diet or changes of temperature. In other cases, the neurotic diathesis is strongly marked, and continues long after the work of dentition has been completed. It is not improbable that the afflux of blood towards the head, attendant upon the active nutritive processes in the jaws, may predispose to disorder of the brain. The immediate causes of the irregular developement of the teeth are various. It may be retarded by the unequal ossification of the alveoli. 1 hus Guersent has seen them chsed by plates of bone. (Diet, de Med ) Rapid dentition is more frequently accompanied by disorder than a slower develope- ment; but we cannot easily determine in any given case, whether it r onlva sign of general irregularity of organization, or whether the excess of nutrition in the jaws is directly injurious, by subtracting from the proper decree of action in other organs. It is, however, quite obvious that if the growth°of the teeth is disproportionate to that of the jaws, the rental pulps must be subjected to a pressure which readily accounts both for the local and for the irritations.* remote * The following Table, extracted from Dr. Ashburner'a very interesting Lecture on Dent'f diseases of dentition (Treatment). 27 The treatment of the local disorders of teething is very simple. When there are signs of superficial tenderness, it may be sufficient to moisten the gums frequently with cold water, or to apply the mel boracis by the nurse's finger. Slight scarifications afford relief by the mere bleeding. But when the gums are spread and swollen, and there is reason to consider the growth of the tooth considerably advanced, while its emergence is impeded by the rigidity of the gum and the capsule, no time should be lost in making a free incision, which should be carried downwards till the tooth is felt under the lancet. When made upon a molar tooth the incision should be crucial. The relief ensuing upon this operation is often most striking. It will occasionally be needful to divide the gums even when there are no very obvious indications of local irritation, in cases presenting the sympathetic disorder which have been described above, and which from the absence of other causes we may consider referrible to teething. It is a very common error to suppose that if no redness or swelling of the gums is perceptible, there can be no necessity for lancing them ;—as if the teeth could not as easily produce irritation when low in the jaw as when near the surface. The benefit resulting from the operation under such circumstances would be a sufficient answer to the objection; but we may remark in addition, that if it be allowed that the dental pulps may be the seat of morbid congestion or inflammation, to deny the utility of scarifying the gums for such an affection would be as unreasonable as to declare that no benefit could accrue from leeching the chest in pleurisy, or the abdomen in peritonitis. The diet must be carefully attended to in all cases of irregular dentition. If the infant is robust and plethoric, or disposed to inflammatory attacks, it must be confined to the mother's food, or to milk and farinaceous articles. But we not unfrequently meet with cases of defective developement, in which a more nutritious diet is strongly indicated. Such infants are to be seen among the poorer classes, pale, emaciated, ricketty, with shrivelled features, loose skin, flabby muscles, and enlarged lymphatic glands, while the teeth are in a state of abnormal forwardness. The change produced by generous diet in these subjects, and by a removal from town into the country, will often prove beneficial. The treatment of the secondary disorders of dentition will be considered under their appropriate heads. The irregular growth of the permanent teeth is a frequent cause of disorder both local and remote, and as such should always be borne in mind when we are treating patients during the period of the second dentition. Cases apparently very obscure and anomalous in their pathology, have had unexpected light thrown upon them by a consideration of the relative state of the teeth and jaws. Numerous instances may be found in Dr. Ashburner's lectures (op. cit). (Med. Gazette, 1833-4), exhibits " the approximation to a normal order of eruption of the first dentition:"— Periods. Teeth. 7th month after birth - - - two central lower incisors. 8th " " ... two central upper incisors. 9th " " - two lateral lower incisors. About 9th or 10th - - - two lateral upper incisors. " 12th or 14th - - - four first molars. 16th, 17th, 18th, 19th, or 20th - two upper canine. 22d to 30th.....four last molars.—Author. 29 glossitis (Symptoms—Treatment). GLOSSITIS. Symptoms—local—general.—Causes.—Treatment. Inflammation of the substance of the tongue is far less frequently met with as an idiopathic affection, than as the accompaniment of other diseases. It has been observed in the course of exanthematous fevers, especially small-pox and scarlatina, and as an extension of disease from adjoining parts, as in Tonsillitis and Ptyalism. Membranous inflammation of the tongue does not require a separate consideration, being comprised under the general head of Sto- MATITIS. . . Symptoms. The local symptoms of glossitis are the same, whether it is primary, or only a secondary affection. The organ becomes hot, swollen, and painful towards the tip, the colour of which is of a deeper red than usual. The tumefaction soon extends to the body and the base, producing rigidity and diffi- culty in its movements, both in speech and deglutition. The surface is some- times dry, and in other cases covered with a thick albuminous crust. As the disease advances the tongue acquires so great an increase of volume as to fill the whole cavity of the mouth, and even to project considerably beyond the teeth. By the swelling at the root of the organ dyspnoea is necessarily occasioned, as well as pressure upon the great veins of the neck, to a degree which sometimes threatens apoplexy. The progress of the disease is often frightfully rapid, the most extreme engorgement requiring only a few hours for its production. If the inflammation is idiopathic, it is sometimes preceded by rigors and other symptoms of fever. The pulse at the commencement is quick, full, and hard. The skin also, and the secretions, denote strong phlogistic fever. But when the swelling has begun to impede the respiration, the pulse becomes feebler, and the skin is bedewed with cold perspirations. The disease may subside by resolution, or terminate in suppuration or gan- grene. The anterior part is most liable to gangrene, in consequence of the interruption to the circulation produced by the pressure of the teeth, a pressure which necessarily takes place when the organ is at once swollen and protruded. The causes of glossitis may be those common to all phlegmasia?, but the more specific are injuries inflicted on the organ by mechanical or chemical irritants. The effect of the former is often witnessed in epileptic patients, who have bitten the tongue during the convulsive paroxysm. The sting of insects, such as the wasp or bee, may excite a very alarming form of inflammation. M. Marjolin alludes to the case of a young man (a patient of M. Dupont) who suffered a severe attack after chewing a toad ! (Diet, de Med.) Treatment. This disease must be regarded as dangerous, and requiring very prompt treatment. Blood should be abstracted from the arm, in quantity corresponding to the urgency of the symptoms; but the case must be seen early for this measure to produce much benefit. Local depletion is of the utmost importance; the tongue should be covered with leeches, and should the swelling notwithstanding advance, incisions must be made from the base to the tip care being taken to avoid the ranular arteries. The relief from this treatment is generally very decided. It has the advantage not only of disgorging the capil- laries, but also of giving exit to any collection of pus that may have been formed. As auxiliaries to local treatment we may apply ice to the surface of the tongue' and a blister to the throat and neck. ° ' Purgatives must be freely administered from the commencement, and when the deglutition is too much impeded to admit of their being taken by the mouth pakotitis (Causes of Specific). 29 we must resort to enemata. The enema colocynthidis will be useful under these circumstances. If suffocation is threatened, a surgeon should be at hand prepared to practise tracheotomy. Mr. Benjamin Bell has related a case of glossitis from mercurial action in which the patient's life was saved by the operation. PAROTITIS. Specific variety.—Symptoms.—Causes.—Treatment.—Common variety.—Its symptoms and treatment. Inflammation of the parotid gland may be conveniently considered under two varieties, the specific and the common. 1. Specific Parotitis. This disease, vulgarly called the mumps, is characterized by pain and swelling of one or both of the parotid glands. The local affection is nearly always pre- ceded by slight febrile disturbance. It first manifests itself by fulness and sore- ness at the angle of the jaw, impeding the movement of this part. By degrees the tumefaction extends towards the space between the cheek and ear, and also downwards, involving the submaxillary glands. On the fourth day it begins to subside; and during or after the decline it is not uncommon for the mammae or testes to become painful and swollen. If the turgor of these parts or of the parotid itself is suddenly removed, we have reason to apprehend vicarious disease in the brain. As this form of parotitis usually terminates by resolution, it is probable that the vessels of the glands are in a state of congestion rather than of inflammation. In strumous subjects, the disease is apt to lay the foundation for chronic enlargement and induration of the glands. Causes. Specific parotitis is usually excited by contagion, but it sometimes appears under circumstances which forbid the supposition of such a cause, and yet it may be afterwards propagated in this manner. Analogous observations have been made on other well-known contagious disorders. It seems highly probable that the specific alteration of the blood may be induced by common causes, and that an emanation from this may take place, capable of inducing the same affection in other subjects. That the blood is implicated we infer from the previous constitutional disorder, and from the great tendency to metastasis. But before adopting this inference we must admit first that a tendency to metastasis indicates a diseased condition of the whole system, and secondly that this general fault (in acute disorders at least) has its seat in the blood. Specific parotitis is one of those diseases which seldom occur more than once in the same individual, but many persons escape it altogether. The treatment required is generally very slight. The part should be kept warm by flannel, and no attempt should be made to reduce the swelling by cold lotions. If the patient manifests an anxiety for some medicinal application, we may direct the flannel to be imbued with a weak solution of camphor in oil. The bowels should be gently relieved by laxatives, but violent purgation is to be avoided. The diet should be quite unstimulating, consisting chiefly of fari- naceous substances and mild diluents; the patient must remain in the house, and avoid all risks of cold. The swelling of the mammre or testes requires the same kind of treatment, 30 angina diffusa (Varieties). or rather non-interference, as that of the parotid, unless there are manifest signs of active inflammation; in which case depletory measures will be needed. Should metastasis to the brain unfortunately occur, the secondary disease must be attacked with the same energy as if it had been idiopathic. 2. Common Parotitis. This form may result from exposure to cold; but when this happens we shall generally find that the first impression was made upon a decayed tooth, and that the parotid has been subsequently engaged. The swelling is very consi- derable, and attended with severe pain: the symptomatic fever sometimes runs very high. If the inflammation be not speedily got under, it will advance to suppuration, a process which in this part is extremely tedious. The abscess may break externally, or discharge itself into the meatus externus of the ear. In a vigorous constitution the disease must be combated both by local and general depletion, and in all cases by leeching, conjoined with purgatives, diaphoretics, and low diet. Should the swelling not diminish under this treat- ment, we must endeavour by fomentations and poultices to hasten the suppu- rative process. When this is fully established, and fluctuation can be felt, the abscess must be opened. If the discharge continues, it will to necessary to sustain the patient's strength by tonics and a generous diet. A less active but not less troublesome form of parotitis is often met with as one of the sequelae of scarlatina, and occasionally of other febrile disorders. The swelling is hard and indolent, and generally extends to the glands of the neck. It requires leeching, fomentations, and poultices, and a degree of the antiphlogistic regimen, proportionate to the previous amount of disease and to the impairment of the patient's strength. A somewhat analogous form of subacute parotitis may be induced by cold in strumous subjects, and is very apt to degenerate into chronic disease. ANGINA, OR INFLAMMATION OF THE THROAT. The term Angina implies inflammation of the parts bounded anteriorly by the velum pendulum palati and its columns, and posteriorly by the upper part of the pharynx. We shall consider it under three forms : Angina Diffusa, Angina Membranacea, and Angina Tonsillaris : the two first bein^ distin- guished by the character of the inflammation, the third by the part principally £uI6Ct6u* ANGINA DIFFUSA. Varieties.—Symptoms.—Causes.—Prognosis.—Treatment. In this, which is the most common form of sore throat, the inflammation is seated in the mucous membrane covering the posterior fauces tonsils and pharynx. It is for the most part superficial; but in severe cases it may extend to the submucous cellular tissue. It is characterized by increased redness of the membrane and a greater fulness than natural. But the former mav varv from the slightest possible exaggeration of the normal hue to the deertft crimson or the most vivid scarlet. When the tint is paler than usual which sometimes happens, the appearance is owing to oedema. The tumefaction will angina diffusa (Causes and Treatment). 31 depend partly on the degree of congestion, and partly on the amount of serous infiltration. In comparing angina with cutaneous inflammation, we should say that it oftener bears an analogy to erythema than to erysipelas. There are three forms of angina diffusa. In one there is a bright red efflo- rescence of the throat, with tumefaction, and a copious secretion of mucus. In a second variety the membrane has a duller and deeper red, and is tense and dry. The third form is marked by relaxation and puffiness of the membrane, in consequence of serous secretion under the epithelium, or in the substance of the mucous tissue itself, or in the subjacent cellular membrane. The symptoms, common to these varieties, are painful and difficult degluti- tion, a sense of soreness in the throat, irritation, or tickling, with frequent dispo- sition to hawking and exspuition, a feeling of choking, and some impediment in articulation. The hearing is occasionally obscured by extension of the inflam- mation to the Eustachian tube. The second variety is often attended with more local irritation and distress than either of the others. The general symp- toms of fever vary with the severity of the attack. Sometimes there is considerable delirium when the fever runs high. The character of the fever is more frequently sthenic than typhoid, but it varies with the previous condition of the individual, or the epidemic constitution of the atmosphere. The third form is frequently exempt from fever, the others very rarely. This form is also more frequently met with as a chronic affection. Causes. The most frequent causes of this form of angina are rapid variations in the temperature of the atmosphere, and the prevalence of humidity with cold winds, as in the spring season. Exposure of the feet or even of the hands to cold and moisture, when the body has been previously heated, will readily induce the affection in persons predisposed. Some individuals are attacked almost instantaneously on passing from a heated room or crowded assembly into the outer air. Angina may often be traced to endemic causes, such as a humid soil, the vicinity of stagnant water, a river-fog, &c. Some of the worst causes met with in practice are those in which the angina is an accompaniment of scarlatina. In many instances the disorder is secondary to gastric or gastro- enteric irritation. The prognosis in uncomplicated angina is generally favourable. The cases which create most apprehension are individuals previously enfeebled, for in such subjects the accompanying fever often assumes a typhoid aspect. The local affection can seldom excite alarm, unless there are symptoms of an extension of* the inflammation to the larynx. This is more likely to occur in the second of the varieties above alluded to. Treatment. In slight cases the exhibition of an emetic followed by a brisk purgative will often cut short the attack;—to which result the use of a pedilu- vium, and the application of a sinapism to the throat will effectually contribute. When notwithstanding such measures the inflammation increases, or if it has assumed an aspect of severity from the commencement, leeches must be freely applied to the exterior of the throat. If there is sharp symptomatic fever, general bleeding must be also practised. Antimonials and salines are useful auxiliaries. The best applications to the diseased part are warm water gargles, or the vapour of hot water impregnated with hops, henbane, or some other sedative. Stimu- lant of discutient gargles may do more harm than good in the first stage of the inflammation. But when antiphlogistic measures have been duly executed, and a state of relaxation or passive congestion only is left, or when the case has presented this character from the beginning, such remedies are applied with good effect. A solution of nitrate of potass in camphor mixture, to which laudanum should be added, may be used pretty early. Gargles of alum, muriatic or sulphuric acid, and tincture of myrrh are better adapted to a later period. Capsicum is deservedly much esteemed in the relaxed sore throat; but of all the local remedies there is none that can equal the nitrate of silver in applicability to all varieties and periods of the disease. Having already adverted to the 3* angina membranacea (Description). excellence of this remedy in stomatitis, we need only remark that mere analog] would suggest its employment in angina. It has been mentioned that thi inflammation sometimes terminates in suppuration. When this takes place j frequent seat of the collection is the loose tissue of the velum. But wherever formed it may require the use of the lancet, to give egress to the pus. Thi.< should be effected as soon as" we can discern a pointing of the abscess, or per ceive fluctuation by the finger. The neglect of a timely incision will cause a much greater extension of the suppuration. Blisters are of service after leeching, or even before the latter, in cases which will not admit of even local depletion. They are especially indicated in the oedematous variety. When the disease is chronic, the elongation of the uvula is often so considerable as to produce tickling and cough, with mucous expec- toration, whenever the patient lies down. The source of the irritation in these cases has often been overlooked, and the patient has in consequence suffered long courses of medicine and other remedies aimed at the fancied pectoral diseases. The negative evidence of auscultation will often lead to an inspection of the throat, and the real evil be thus discovered. The enlargement of the uvula is sometimes caused by actual hypertrophy rather than by mere cedema. In such instances the best remedy is excision. ANGINA MEMBRANACEA. Description.—Two forms, the sthenic and the malignant.—Causes.—Nature,__Diagnosis.— Treatment. This species of angina is characterzied by the formation of albuminous pel- licles on the surface of the inflamed membrane, whence it was named by M. Bretonneau of Tours «Diphtheritis" (Si^spa, pellis). The patches are of various extent, in mild cases white or ashy, separate, and presenting the appear- ance of superficial sloughs, for which they have often been mistaken ; in others dark-coloured, coalescent, and forming one uniform crust. The exudations may extend far down the oesophagus, or into the larynx, trachea, and bronchi % and upwards into the nasal fossae. The membrane beneath and between the' pellicles is in some cases of a bright red, in others purplish or livid. The exu dations vary in density from that of coagulable lymph to that of a soft pultaceous matter. r The local sensations are similar to those of angina diffusa, with the addition of those produced by irritation and obstruction of the air-passages when the disease has extended in that direction. It is common also for the submaxillary and cervical glands to become inflamed and tumefield. The general symptoms are those of fever, and vary with the type of the latter, and the degri of the inflammation. When the patches are but few and circumscribed, the d!sease is often called ulcerated sore-throat, such as mav be spph in e^,i ♦• u,sease 1S but there are no ulcers in these cases, for oTremovfnl Z ~S? "TT as they are called, we find the membrane h^S^terX^^W*" ganization than the loss of its epithelium. In the wo sTcii !.}• ! T" coloured by the admixture of bloody exudation and v^f P 1C GS ^^ throat, so as to create an impression that the paJts are in a staf "r'0"! °f .^ These cases correspond to the angina maligna of many author? „ a ,SphkaCelus> grenous angina of others; but we have The united Smonv R°l^ *™' Guersent, and Deslandes, formed on extensive necrosconi? k Bretonnea"> there are no true eschars in these cases. The idea of a observa!'°ns, that been further kept up by the discharge of serous foetid matte^from f.X,stm8 has and by the putrid character of the fever. Instances of this iw?E.- n°Stn,S' rarely met with, excepting when the disease prevails as an epS c™ *" ^ angina membranacea (Diagnosis). 33 From the above remarks it may be gathered that angina membranacea appears in two forms. In one, the local affection bears the marks of active inflammation in the bright hue of the mucous membrane, and in the white circumscribed exudations, unmixed with blood or sanies. The constitutional symptoms in this form are likewise sthenic, the pulse being full and firm, the skin warm, and the nervous system, though disturbed, not exhibiting the signs of prostration so common in typhoid fever. The other variety may well be called angina maligna. Its approach is often insidious, being attended with but little pain or distress in the throat till the false membrane is already extensively formed. Then the dysphagia becomes extreme, liquids are forced back through the nostrils, and symptoms soon occur denoting that the air-passages are obstructed; such are a croupy cough, hoarseness, and stridulous breathing. The feeling of suf- focation accompanying these symptoms is in part owing to the swelling of the lymphatic glands. On inspection of the throat we see a thick pellicle, sometimes dense, not unfrequently pultaceous, variously coloured according to the degree of its decomposition or to the accompanying secretions, and either continuous, or interrupted by fissures which exhibit the livid hue of the membrane beneath* The pulse is extremely rapid and feeble, delirium sets in early, and is-soon fol- lowed by coma; and the collapsed face and sunken eyes indicate extreme exhaustion. Death often takes place suddenly from the laryngeal complication'. Bretonneau was led by the results of his dissections to attribute the death in all the fatal cases to the changes in the air-passages. As might be expected apriori, the victims of the malignant angina are per- sons living in humid districts, where the disease is occasionally epidemic, the inhabitants of crowded buildings, and the poor ill-fed classes of the community. Persons, however, not under these depressing agencies, may be attacked by a severe form of the disease. Children are more liable to it than adults. In Picardy and Touraine the disease is all but endemial. In this country angina membranacea is far less frequent than on the continent. Whether it is propa- gated by contagion is not absolutely determined, but there are strong presump- tions in favour of this view. When the affection is epidemic, the difficulty of distinguishing the operation of some generally diffused cause from that of con- tagion, meets us in this disease with the same force as in other epidemic mala- dn•>. The most unexceptionable instances of contagion are those in which the sporadic form has been transmitted from one person to another. Guersent relates the case of a nun who caught the disease from'a little girl whom she had nursed in the Hopital des Enfans, and he remarks that practitioners are fre- quently attacked after inspecting the throats of their patients. Nature. That inflammation of the mucous membrane takes place in angina membranacea cannot be for a moment doubted, but why it should cause the secre- tion of coagulable lymph rather than of serum and mucus, which are the ordi- nary products of mucous inflammation, cannot easily be explained. It is probable, however, that the peculiarity does not depend upon the local action merely, but upon the state of the constitution previously modified by epidemic influences or by the unfavourable mode of life. Diagnosis. 1. The fibrinous exudations in this disease, with the obstruction of the air-passages, has caused it to be confounded with croup, yet the diseases are very different. In the latter the inflammation is confined to the tracheal and bronchial membrane, while in diphtheritis the inflammation is seated in the fauces and pharynx, and only in severe cases extends to the larynx and trachea. True croup is rarely if ever attended with the low typhoid fever so common in angina membranacea, the symptoms of exhaustion in the advanced stage being clearly referrible to the impeded respiration. 2. Angina membranacea is with difficulty discriminated from angina gangrae- nosa, the affection described by Fothergill as putrid sore throat, the cynanche maligna of Cullen. The general and local symptoms are very similar, but in the latter disease the difficulty of breathing is attributable rather to the general vol. in. 5 34 angina membranacea (Treatment). tumefaction than to any laryngeal complication, and there are true gangrenous sloughs, which, on separating, leave corresponding concavities in the tissue. y)n this point Fothergill speaks very distinctly, and where the disease is of the mildest kind a superficial ulceration only is observable, which may easily escape the notice of a person unacquainted with it. A thin, pale, white slough seems to accompany the next degree; a thick opaque or ash-coloured one is a lurther advance; and if the parts have a livid or black aspect, the case is still worse. These sloughs are not formed of anv foreign matter spread upon the parts affected, as a crust or coat, but are real mortifications of the substance; since, whenever they come off, or are separated from the parts they cover, they leave an ulcer of a greater or less depth, as the sloughs were superficial or penetrating. In this disease, moreover, there is frequently observed an erythematous or papular eruption on different parts of the body; and there can be little diffi- culty in arriving at the conclusion that it is a variety of scarlatina maligna. (See Scarlatina.) We quite coincide with the opinion given by Dr. Tweedie, in the Cyclopedia of Practical Medicine, art. Scarlatina. "We are inclined," he observes, " to affirm that the scarlatina simplex, scarlatina anginosa, and the scarlatina or angina maligna, and the sore throat without efflorescence on the skin, are merely varieties of one and the same disease." It is scarcely necessary to add that the sore throat here alluded to, is that which presents the same characters as are observed in cases where there is also the cutaneous affection. Treatment. Abstraction of blood both from the arm and from the vicinity of the diseased part, may to requisite in cases which set in with active inflam- matory fever, and which are to be treated, therefore, on general antiphlogistic principles. But the worst description of cases will not tolerate measures of this nature, and are exceedingly intractable under any plan. If the system can be speedily brought under the influence of mercury, the issue will generally be successful. This treatment, which was first practised at Tours by Dr. William Conolly, now at Cheltenham, is much commended by Bretonneau. Calomel may be given in two grain doses every second hour, or in smaller doses still more frequently. If the mucous membrane be irritable, we may administer the Hydr. c. Creta, and direct free mercurial inunction. If the pellicles have formed in the air-passages, very little expectation of recovery can be enter- tained. In cases attended with great prostration from the commencement, or when this state supervenes on the more active symptoms, we must have recourse to wine, ammonia, bark, and animal broths. In some cases we have thought that the combination of muriatic acid with dec. cinchonae conduced materially to a favourable termination. The local treatment is, to say the least, of equal importance with the general. Caustic applications are the most successful; Bretonneau strongly recommends the undiluted muriatic acid, applied by means of a sponge; but we have a far more manageable, if not more efficacious, remedy in the nitrate of silver, which may be applied in substance, or in a strong solution. It should be resorted to as soon as the false membrane is detected, or even before this is actually formed if, from the prevalence of the affection, we have reason to think that the inflam' mation will become diphtheritic. Dr. Evanson has observed satisfactory results from a saturated solution of sulphate of copper. (Op. cit.) Blisters placed on the exterior of the throat, or on the nape of the neck, may be used as subsidiary measures, but must on no account supersede the internal applications When the exudation of lymph has extended to the windpipe, we may attemnt its detachment and expulsion by emetics, as in cases of croup. V angina tonsillaris (Causes). 35 ANGINA TONSILLARIS. Superficial and deep-seated.—Symptoms.—Causes.—Treatment. The popular name of this disease, quinsy, is derived originally from cynanche, having passed through the several transformations of esquinanche (Fr.), squi- nancy, squincy, quincy, quinsy. Inflammation of the tonsils assumes two forms, the superficial and the deep- seated. The former may be only a part of the angina diffusa, or it may be limited to the surface of the tonsil, in which case the inflammation usually dips down into the interior of the follicles of which the organ is composed; but in the common tonsillitis, the vessels in the body of the organ, most probably in the interfollicular cellular membrane, are the seat of the disease. The inflam- mation is phlegmonous, and disposed to suppuration. The symptoms of angina tonsillaris are a sense of fulness in the throat, pain, and difficulty of swallowing, heat and dryness of the fauces, and shooting pains in the ear. The voice has a croaking sound, which will often be quite sufficient to indicate the disease. On inspection of the throat, we see the isthmus faucium considerably narrowed by the projection of one or both amygdalae, and the surrounding parts more or less swollen, and covered with viscid mucus. The gieat vascularity of the tonsil will account for the rapid increase of bulk under the inflammatory turgor. In severe cases, the swelling is so considerable as to press upon the epiglottis and impede the breathing. The state of engorgement may continue several days, and at last terminate by resolution, or it may pass into passive congestion. When the inflammation continues active from the commencement, we may look for suppuration. This termination is often announced by throbbing in the part, and slight rigors. The distress produced by a large abscess in the tonsils can scarcely be surpassed in any disease. The fever accompanying this form of angina is often more active than might be expected from inflammation of an organ of comparatively little importance. The carotids and other arteries in the neighbourhood of the diseased part, pulsate with great force. Causes. No peculiar predisposition seems to be required for the production of tonsillitis. It occurs among the most robust and healthy. The most obvious exciting causes are sudden changes in the temperature, and humidity of the atmosphere, exposure to cold when the body has been heated, currents of cold air, wet feet, &c. Persons who have once suffered an attack of the disease, especially in its suppurative form, are more liable to a recurrence of it. There is no difficulty in the diagnosis, and we may generally prognosticate a favourable issue of the case. Death may result in enfeebled habits from the difficulty of conveying nutriment into the system; and when there is a large collection of pus, from pressure on the larynx. But such a termination in the latter instance may be almost always averted by art. Treatment. If the case be seen at the very commencement, it will not un- frequently give way to the operation of an emetic. But we seldom have it pre- sented to our observation before the inflammation has acquired sufficient activity to demand the free application of leeches. In vigorous subjects, a general bleeding will accelerate the cure. Brisk purgation by calomel and jalap or senna should follow the abstraction of blood. Saline cathartics are indicated from their antiphlogistic property, but the patient has great difficulty in swal- lowing them. Antimonial diaphoretics may be given at bedtime, but the com- 36 diseases of the assoPHAGus (Structural). fort of the patient requires us to be as sparing of medicines by the mouth as the necessity of the case will admit of. Incisions or scarification of the tonsils, though much extolled by some practi- tioners, have appeared to us to produce only a temporary relief to the state of engorgement. When pus has formed, the sooner it can be evacuated the belter. Fluctuation should be felt distinctly before using the lancet, as premature at- tempts at letting out the pus occasion disappointment to the patient, and indis- pose him to the operation when it is more likely to be successful. The progress of the suppuration may be encouraged by external fomentations and poultices, the inhalation of steam, and a gargle of warm water: the latter applications are very grateful even in the earlier stage. Although it is expe- dient to hasten suppuration when it has once commenced, we should do all in our power to prevent such a termination, and the best means for attaining this object are leeches and evacuants. Rubefacient embrocations and blisters may be used after leeching has been carried as far as appears desirable. We can- not say that discutient gargles are of service, except in chronic cases, or in those in which the inflammation partakes of a passive character. HYPERTROPHY OF THE TONSILS. An indolent enlargement of these organs, without pain, heat, or increased redness, may be referred to hypertrophy. It is not an uncommon result of repeated attacks of acute inflammation, or of inflammation chronic from the commencement. In strumous habits it appears to be all but congenital. The augmentation of size is sometimes so great as to produce constant inconvenience in swallowing and speaking. Various methods have been resorted to for reduc- ing the swelling; such as repeated leeching, scarifications, blisters, astringent gargles, mercurial and iodine unguents; but with such partial success that the extirpation of one or both tonsils has been after all required. We have seen most benefit from the daily application of nitrate of silver, either in- lotion, or in substance. We learn from Dr. Graves (Dublin Journal, Jan. 1839), that Mr. Cusack has been very successful in reducing these tumours, by applying the solid lunar caustic to successive portions of the surface, so as to produce an eschar at each application. This is done by pressing the caustic firmly upon the part, instead of lightly touching it, as in the ordinary mode of application. A cure by this method cannot be expected in a shorter time than six months. DISEASES OF THE (ESOPHAGUS. Structural disease of the oesophagus.—Spasmodic stricture.—Symptoms.—Diagnosis.— Treatment. This portion of the alimentary canal is remarkably exempt from acute dis- eases,—an indemnity which may be owing in part, to its organization, which, besides being less vascular than in many other portions of the tube is defended by a thick epithelium, and partly to the rapid passage of the alimentary sub- stances, whereby those which have any irritating property are but a short time in contact with its surface. Inflammation may be excited in the oesophagus bv acrid poisons ; such as the concentrated acids and alkalies, corrosive subfimate oxalic acid, &c.; or it may occur independently of direct irritation as ' tinuation of disease from the fauces and pharynx. Thus it has been ah-eTrW remarked, that diphtheritic angina frequently extends to the oesophagus EIt idiopathic inflammation commencing in this part, is we imagine extremely rare diseases of the cesophagus (Treatment). 37 inasmuch as authors are silent upon the subject, and we have never met with an instance of such disease. The most important chronic diseases of the oesophagus are alterations of structure, producing an impediment to the passage of food. These causes of stricture may be arranged in three groups. 1. Hypertrophy of the submucous cellular tissue consequent upon chronic inflammation. 2. Carcinomatous dis- ease in the form of dense scirrhus, or of encephaloid tumour. 3. Compression from tumours in adjoining parts, such as enlarged cervical glands, and aneurism of the carotid artery, or of the aorta. For further information respecting organic stricture of the oesophagus, we must refer the reader to works on surgery. Spasmodic stricture of the asophagus is characterized by difficulty of swal- lowing, the impediment being generally felt in the pharynx, or upper part of the oesophagus, and accompanied by a distressing sense of fulness and choking. The food may descend after some struggle in the part, or it may be instantly ejected. In many cases it matters very little whether the substance is solid, or liquid, in large quantity or small, the mere contact of it with the surface of the passage being sufficient to provoke the spasmodic constriction. In some in- stances, fluids have been transmitted with more difficulty than solids. The affection is sometimes paroxysmal, and may to accounted for by violent emo- tions, or by temporary disorder of the stomach. In other cases it continues for months, and even years. In one person the dysphagia is attended by increased sensibility, and even pain in the part affected, in another this is not the case. The complaint often disappears as suddenly as it came, and does not return. In other instances it gradually wears out like many other affections of a similar nature. The most frequent subjects of this disorder are persons of the aneurotic dia- thesis; especially hysterical and chlorotic females, and those who have suffered from exhausting maladies. We have known it occur in women who have become ansemial from uterine haemorrhage, or from large bleeding. It is not confined, however, to females. It has been met with in persons suffering from dyspepsia and torpor of the colon. Contiguous irritation, as from ulceration of the larynx, may give rise to the affection. A case of this kind is related by Mr. Mayo (Outlines of Pathology, p. 280). It is not improbable that excrescences from the mucous membrane might produce irregular contraction, in a manner analogous to what occasionally takes place in the rectum. The diagnosis of this complaint from organic stricture, is of vast importance with reference both to the prognosis and to the treatment. When it occurs in paroxysms there can be no difficulty in deciding that there is no structural im- pediment, but the permanent cases are more open to doubt. The introduction of a bougie will often suffice to remove any apprehension of mechanical obstruc- tion ; but its passage may be arrested merely by the spasm which its presence has excited. In some cases we shall find upon close inquiry that the part has been occasionally taken by surprise, as it were, and portions of food swallowed unawares, which could not have happened had there been a real obstacle. The sudden supervention of the disorder, its being accompanied by hysterical ail- ments, or alternating with them, the ansemial state of the patient, an age at which carcinoma does not usually occur, and the absence of the general signs of the cancerous diathesis, or of previous inflammation in the part, are considerations which may severally, or together come in aid of our judgment. Treatment. The indications are, 1st, to lessen the morbid irritability in the oesophagus, and 2d, to correct the general predisposition, or that morbid condition in other organs with which this disorder is sympathetic. In fulfilment of the first intention, we may direct cold sponging and friction of the neck; the appli- cation of a blister, or a rubefacient liniment to the nucha, and antispasmodic medicines; particularly the fetid gums, camphor, castor, and valerian. The endemic use of morphia, or belladonna, may be tried in obstinate cases. The bougie should be frequently introduced for the purpose of habituating the part 38 gastritis (Definition). to stimulation, and thus diminishing its morbid susceptibility. It must be allowed, however, that in some patients this operation is productive of too much excitement to encourage its continuance, and we must then rely upon sedatives, antispasmodics, and the measures appropriate to the accomplishment of the second indication. 2. In cases of debility, from previous illness or other causes, our object will be to restore the strength of the system by a nutritious or even generous diet, a change of air, and the use of tonic medicines. The peculiar irritability of the nervous system in hysterical subjects must be lessened by the use of the shower bath, frequent exercise in the open air, a course of chalybeate medicines, regu- lation of the catamenial function, a firm but unstimulating diet, abstinence from tea and coffee, and the avoidance of modes of life calculated to excite or relax the nervous system, such as late hours, dissipation, excessive mental exertion on the one hand, or addiction to mere imaginative reading on the other. (See Hysteria.) When the disorder can be traced to irritation in the digestive sys- tem, the treatment of the former must obviously to secondary to that of the latter. GASTRITIS. Anatomical characters of congestion and Inflammation of the gastro-enteric membrane.— Redness—Formsof.—Cadaveric.—Physiological.—Morbid.—Congestive.—Inflammatory.— Brown colour.—Slate-gray, black.—Inference from the absence of morbid colourings.— Softening.—Induration.—Hypertrophy.—Ulceration.—Effusion.—Symptoms of acute, sub- acute, and chronic gastritis.—Anatomical characters.—Causes.—Treatment Though the term Gastritis in its strict acceptation implies inflammation of all the tunics of the stomach, it has been generally restricted to inflammation of the internal or mucous lining of the organ, the other tunics becoming in some in- stances involved, according to the nature and intensity of the exciting causes or the duration of the primary disease. Before detailing the symptoms^f gastric inflammation, we shall give a brief account of the anatomical characters of con. gestion and inflammation of the gastro-enteric membrane generally, reserving for description in their proper places the appearances which belong to its several divisions. Redness is a character appertaining equally to congestion and to inflamma- tion. It cannot, therefore, enable us to discriminate these conditions; but in distinguishing cadaveric congestion alike from morbid congestion, and from inflammation, we shall derive much assistance from observing the forms and shades of the colouring. First as to the forms which it assumes : if the accu- mulation of blood is confined to the capillary network, the redness is diffused, and is called the uniform redness; when caused by vital congestion, it is for the most part of a v.v.d hue; when the smallest veins and arteries are likewise injected, the appearance is called capilhform or arborescent; the term ramiform injection is applied to cases in which the larger trunks are distended When the redness is punctiform, separate villi are usually the seats of it though the same dotted appearance is sometimes caused by minute circles of redness corre sponding to inflamed follicles; when from the dots the colour radiates in fine lines, it is said to be stellated. This last is obviously a compound of th tiform and capilliform varieties. The above appearances result from the h?"^ contained within the vessels. The redness which occurs in stripes or I with no intervals of a paler hue, though it may be a circumscribed instance^!" the uniform species, is often caused by ecchymosis; whether it shall be ace gastritis (Anatomical Characters). 39 panied by elevation of the surface, depends on the circumstance of the hemor- rhage occurring in the villi, or in the submucous cellular tissue. Any one of these forms of redness may result from post mortem agency, or from causes in operation at the very time of death, viz., a mechanical obstacle to the return of the blood, or gravitation. But the uniform and punctiform redness, if so produced, will be attended by the capilliform or ramiform, because in these instances the cause acts not on the blood of the capillaries, as during life, but on that of the trunks. In estimating, therefore, the value of redness, as a sign of disease in the mucous membrane of the alimentary canal, we must particularly attend to the state of the venous system, and to the situation of the redness with reference to the position of the body. The condition of the vena porta? is of the greatest importance, and therefore it is a good rule to make a point of ascertaining the state of this vessel, as to fulness, before proceeding to lay open the canal; if it be not more distended than usual, we may feel satisfied that venous obstruction was not the cause of the redness. In like manner, if the redness is found in parts which are not dependent, we may dismiss the idea of gravitation. Cadaveric redness generally occupies a very considerable surface, and if unmixed with morbid redness is not concentrated in particular spots; it is diffused over the part which it affects, and which will be found to be in the most dependent situation. Having determined that the congestion was not cadaveric, we must inquire whether it was morbid or physiological. It is well known that during the process of digestion, more blood is determined to the mucous membrane than at other times; therefore the stomach of a person who had died shortly after a meal may be expected to exhibit redness. The same rule applies to a certain extent to other parts of the tube, the emptiest being ceteris paribus the least vascular. The kind of food must be taken into consideration, as to its stimu- lating quality, and we must inquire whether cordials had been administered recently before death. In numberless instances we have satisfied ourselves that the vascularity was caused by brandy or ether taken in the last hours of life. The age of the individual produces important differences in the natural colour. Thus, as Billard has observed, in the foetus and infant it is rose-coloured; in children, of a milky or satin-like appearance; in adults, of a slight ashy colour, especially in the duodenum and beginning of the ileum ; and in elderly persons, still more decidedly ashy. From what has been stated, it is clear that redness is least equivocal as a morbid sign when it is confined to circumscribed portions of the capillary net- work ; when it occurs in situations where gravitation would produce a contrary state; when there is no remarkable fulness of the portal veins; and when there is no evidence that the digestive function had been active just before death, or that stimulant potions had been recently taken. But it must be well known to all who have had much experience in post mortem examinations, that such a concurrence of circumstances is very rare; that the combined influence of gravitation and of mechanical obstruction occurs in a vast number of cases, and that their effects are complicated with those of disease, which they may heighten for obvious reasons. But if morbid redness accompanies the cada- veric, it will be found in some situations where it cannot be accounted for by such causes; for instance, although we might be in doubt respecting a patch of dull redness in the posterior region of the stomach, we have no difficulty in referring a punctated or arborescent redness in the anterior surface to a vital process. In determining whether though vital, it was normal or morbid, we must consider the circumstances which have been mentioned respecting age and the contents of the stomach; thus, before pronouncing the redness to be morbid in a very young subject, we must be sure that the hue is more intense than natural, and further that it is not an equable suffusion of the membrane, but belonging to the punctiform and capilliform varieties. The form of vital 40 gastritis (Anatomical Characters). congestion most difficult to distinguish from the cadaveric, is obviously that which depends on the same causes as the latter; viz., the passive congestion, which occurs in states of great debility, or in cases of preternatural fluidity of the blood. But, as Andral observes, the passive hypersemia, which is left after long continued irritation, and which is confined to the larger branches of vessels which had not recovered their natural contractility before death, is not so readily confounded with the pseudo-morbid species. Having ascertained that the redness is the effect of disease, we might next inquire whether this was congestion or inflammation; but the question is not to be resolved by the character of redness, which depends merely on a condi- tion common both to congestion and inflammation, viz., a preternatural quantity of blood in the capillaries. It might be presumed that as inflammation differs from congestion in the fact that the blood is stagnant in the former, its redness would be sufficiently distinguished by its permanency; but although in conges- tion the blood may not have been stagnant during life, its coagulation after death may imitate the characteristics alluded to. Redness is said to be perma- nent when it is not removed from a tissue by pressure, or by ablution, or by suspension in a vertical position; but there are other means of ascertaining inflammation. The other colours indicative of congestion and inflammation are the brown, the slate-gray, and the black. They are characteristic of chronic disease, and are, on the whole, much less easily imitated by cadaveric changes than redness; for the plain reason, that they require a longer time for their production. These shades are all owing to stagnation of blood in the capillaries, and to the changes which it undergoes, either by the loss of its serum, and consequently of its saline particles, or by the chemical action of the substances in contact with the membrane. The effect of acids, including sulphuretted hydrogen, in darkening the hue of the blood when extravasated is well known, and is exem- plified in the evacuations peculiar to malsena. A similar action may occur in the textures, but most frequently in the stomach and caecum, because a liquid acid is continually secreted in these parts; and, accordingly, these are the portions of the canal which oftenest present the brown and slate-gray tints. The dark crimson and black, depending often on mere stagnation of the blood, may be observed in every part of the canal, the former very commonly in the lower extremity of the ileum. We may remark, that some varieties in the forms which these colours present, such as the dotted and striated black, are caused by partial haemorrhage in the mucous membrane. Before dismissing the morbid colourings of the gastro-enteric membrane, we must consider the following question :—Does the absence of any of these ap- pearances prove that no vascular disease of the part existed during life? As it regards inflammation the answer must be affirmative, because, if the blood had stagnated and coagulated in the capillaries, it cannot be removed by any forces which operate after death, short of actual decomposition. But the same cannot be said of mere congestion ; and we believe it to be by no means uncommon for an intense congestion to disappear shortly before or after death in conse- quence of revulsion, or of haemorrhage, or of serous effusion. Thus, a severe determination to the bronchial membrane in the last hours may remove the disease from the intestines; or a large quantity of blood or serum may have been voided by stool, leaving the membrane which furnished the fluid nearly pale. J Softening. Before pronouncing upon the value of this change as a si^n of disease, we must be aware of the different tenacity of the healthy membrane in different parts. Thus, although it may be raised by the forceps in considerable flakes from the pyloric end of the stomach, and from the rectum it r HI breaks and tears in the other parts of the canal. In the duodenum and " ' & the disposition of the membrane in the valvules conniventes prevents it"f""1 being separated in large pieces. For the most part, the firmness is in a dire™ gastritis (Symptoms of Acute). \\ ratio with the thickness. The relative thickness of the membrane in its different parts, according to Billard, observes the following order; 1, duodenum: 2, pylorus: 3, cardia: 4, rectum: 5, jejunum: 6, ileum : 7, colon. Preternatural softness may be cadaveric, as in the stomach from the action of the gastric juice; and in other parts, from imbibition of the blood in pseudo- morbid congestion, or from putrefaction. Morbid softness may also be caused by a similar infiltration during life, or by extravasation of blood into the sub- stance of the membrane, as in what is sometimes called hccmorrhagic softening, and may have been preceded by mere congestion. Such kinds of ramollissement will be distinguished by the hue of the membrane. When softening has been preceded by chronic inflammation, it may be of a brown or even of a white colour. The latter is not uncommon in chronic diarrhoea, the villous coat of the large intestine being found white and pulpy, and easily denuded by the nail, or the handle of the scalpel. Induration. This alteration is more common in the subjacent cellular mem- brane than in the mucous coat, and indicates inflammatory disease of some standing, as in chronic dysentery. But the mucous membrane itself may be firmer than natural, though it is nearly always at the same time hypertrophied. As the firmness is judged of by the ease with which portions of the mucous may be separated from the other coats, it must be borne in mind that a fallacy in this respect may result from the unnatural softness of the submucous cellular tissue, which must obviously facilitate the stripping operation. Hypertrophy. This is one of the most striking characters of chronic mucous inflammation. It may be confined to the villi, producing velvety, or fungoid elevations; or to the follicles and glandulse agminatEe, assuming the appearance of warts, or patchy excrescences. Ulceration. This lesion, in a vast majority of instances, is a sign of pre- vious inflammatory action (most frequently of the chronic kind), and occurs in a great variety of forms. It may be confined to the villi or to the follicles simple or agminated; or it may reach the muscular coat, and even penetrate the peritoneum. The characters of ulceration in different parts of the tube will be described hereafter ; we now content ourselves with remarking that, in the stomach, it is very rarely the result of acute inflammation, but, in the intestines, such a consequence is by no means infrequent. Effusion. An increase of mucous secretion confirms the evidence of inflam- mation afforded by vascularity. The opposite state of dryness is a scarcely less valuable sign, indicating an earlier period of inflammation. Blood mingled with the mucus affords, if possible, still stronger proof. But haemorrhage alone, whether on the surface or into the tissue (such as produces maculated and stri- ated ecchymosis) may betoken inflammation or simple local plethora; though it may likewise result from mere mechanical congestion, or from a morbid fluidity of the blood. Fibrinous matter is not often detected upon the free mucous surface; it is, perhaps, not unfrequently overlooked from being confounded with shreds of mucus. When secreted in the mucous or submucous tissue, it causes thickening and induration. It is almost superfluous to add, that the evidence afforded by pus is unequivocal. This secretion is generally found on the sur- face of ulcers, but it may also occur where there is no marked abrasion of the villous coat. The symptoms of gastritis vary according as the disease is acute, subacute, or chronic. 1. Symptoms of acute gastritis. This disease being almost exclusively the result of irritation from substances taken into the stomach, has no precursory symptoms of which we could speak with any degree of precision. One of the earliest symptoms is intense pain in the epigastrium, with a peculiar feeling of distress, extending under the sternum, and often to both hypochondria. It is frequently accompanied by a sense of burning, which may also be felt along the oesophagus. The slightest pressure aggravates the suffering; and the same VOL. III. 6 42 gastritis (Symptoms of Subacute). effect is produced by inspiration, swallowing or vomiting. The latter affection is to the last degree distressing, and alternates with the most deadly nausea ana retching. The matters vomited, at first chymous or bilious, afterwards consist of little more than mucus stained with sanguinolent or sanious matter, ^n un- quenchable thirst, with longing for cool drinks, which the stomach is seldom willing to retain for a minute, adds to the tortures of the patient, ine local signs are a fulness of the epigastrium, and a great increase of heat perceptible to the hand. , . . , . , , ., The extreme prostration of which the patient complains is denoted by the sunken altered countenance, the paleness, and the cold clammy extremities in the advanced stage, and in some very rapid cases almost from the beginning. In others the face, though expressing great anguish, is, in the earlier hours, flushed, and the skin hot, dry, and harsh. The pulse is frequent, and small, for a short time resistent, but soon becoming weak and thready. It the irrita- tion is confined to the stomach, the bowels are constipated. The urine is scanty and high coloured. The tongue is for the most part redder than natural, and covered in the middle with a thick flaky fur. These and other symptoms vary with the nature of the exciting cause ; and for an account of such varieties, we must refer to the treatises on poisoning. The disease most likely to be confounded with acute gastritis is peritonitis, which resembles the other in the intense pain, the vomiting, and the symptoms of prostration ; but the diagnosis may be indicated by the situation of the pain, which, in peritonitis, is diffused over the lower parts of the abdomen, instead of taking a direction towards the thorax, by the peculiar thirst, the sense of burning in the epigastrium, the aspect of the tongue, and the mucous nature of the mat- ters vomited. The disease, if it does not terminate in death in a few hours, or by the second or third day, may extend to two or three weeks, and still prove mortal; or it may pass into chronic gastritis of indefinite duration. Death in the rapid cases is produced by depression of the vital functions, particularly the circulation, ap- parently from the close sympathy between the heart and the diseased viscus. 2. Symptoms of subacute gastritis. This is far more common than the acute variety, being a frequent accompaniment of disease in other organs, and not less often supervening upon the chronic form. The symptoms are pain or un- easiness in the epigastrium, with tenderness on pressure, anorexia, nausea, sometimes vomiting, a sense of distention, flatulence, eructations, thirst, and dryness of the mouth. The tongue is generally red at the tip and margin, and sometimes over the whole surface, with elevated papillce. The pain in the stomach is excited or aggravated by solid food, and stimulating or warm liquids. Many anomalies, however, occur in this respect. We have known persons able to take portions of brandy and water without uneasiness, while warm tea or coffee would immediately bring on the pain. The bowels are sluggish, the skin is dry, and the urine high coloured. The sympathetic disorders are feverish- ness, headache, particularly over the forehead, cough of a hard paroxysmal character, and pains in the limbs. Sometimes these morbid sympathies are so intense, as to supersede or to withdraw attention from the local symptoms. When the gastritis supervenes on disease in other organs, instead of acting re- vulsively, it more frequently aggravates them ; it is one of the most serious ad- ditions to the sufferings of a phthisical patient. The countenance has nearly always a distressed irritated expression, the cheeks are suffused with a cir- cumscribed redness, the lips look dry and parched, the eyes suffused the lids turgid, and the tarsi sore. Nothing can be more variable than the duration of this form of gastritis. If ascertained at an early period, it may soon give way to the appropriate remedies. But very commonly it escapes attention until it has become chronic, and then it is far less easily coped with. As the disease is so commonly masked by the gastritis (Symptoms of Chronic). 43 remote affections which it calls into existence, it is not surprising that the diag- nosis is often difficult. 3. Symptoms of chronic gastritis. The local symptoms differ little in degree from the form just treated of; but they are more variable, and are complicated with a greater variety of sympathetic affections. Sometimes they are very marked ; thus the pain may be severe and uniformly brought on by ingesta, and the tenderness constant. The vomiting is often accompanied by the dis- charge of a colourless glairy fluid, or of mucus in large quantity. Sometimes instead of pain, there is a gnawing or raking sensation in the stomach, a feeling of fuluess, or something hard or heavy pressing upon the epigastrium. The gnawing sensation in some persons, suggests the idea of a living animal enclosed in the stomach. A feeling of vacuity or sinking, is often a source of great distress to the patient, and though it prompts him to take food or a cordial, he is little relieved by it. The appetite is irregular; now there is an utter disgust for food, and now a morbid craving; the articles selected being of the most inappropriate description. The taste is often vitiated, so that every thing has lost its proper, or acquired a new flavour. After food has been swallowed, a feeling of bitterness is sometimes left, with watering of the mouth; sometimes acidity. Bread, biscuit, tea, even water will leave this impression on the palate. Instead of acidity, the patient sometimes complains of a sensation in the stomach cognate to it, which is called heart-burn. Flatulence, and eructations of foetid gas, or acrid secretions, sometimes take the place of, or are added to the other symptoms. Palpitation, pulsation of the epigastrium, pain between the scapulae or in the hypochondria, are among the most common sympathies of contiguity. The action of the intestines is generally torpid, and the appearance of the stools often indicates that the liver is disordered, but by no means constantly. The urine is either of a dark brandy colour and clear, or of a lighter hue, but turbid, —often it is covered with an iridescent film,—occasionally it is passed with difficulty. The skin is for the most part harsh and branny, and frequently affected with papular and squamous diseases. The tongue may appear healthy, but more commonly its hue is one of a deep red. The fur is often in patches, giving it a variegated aspect: even when the two anterior thirds of the organ are clean, the posterior may be thickly coated. Sometimes instead of a decided crust, there is a viscid glutinous mucus clinging to it. Its surface is commonly either preternaturally smooth and shining, or presents fissures of the epithelium. The gums look spongy and unhealthy. The follicles at the base of the tongue are swollen, and the whole surface of the posterior fauces is more injected than natural. The lips are sometimes chapped, and a similar condition may be noticed at the margin of the nares. Feverishness alternating with chilliness, is often complained of, especially at night. The pulse has nothing characteristic; in some persons it is steadily slow, in others, frequent and irritable; in this patient intermittent, in that, irre- gular. The morbid sympathies are endless. Those of the duodenum, and the biliary apparatus might be well expected, but they are often less marked than in organs more remote. Perhaps no system is more frequently and deeply involved than the nervous. Headache, confusion of thought, inaptitude for mental exertion, sleeplessness or distressing dreams, dimness of sight, muscae volitantes, pain in the eyeballs, preternatural acuteness or dulness of hearing, noises in the head", pains in the back, the sides, the limbs, sometimes amounting to neuralgia, numbness, impairment of muscular power, locally or generally, unwonted sensations in parts of which we are generally unconscious, altera- tions of the natural feelings, tremors, spasms: irritability of temper, morbid gloom, entire occupation of the mind with bodily feelings, hallucinations: these are but a scantling of the myriad disorders of thought, sensation, and motion to which the patients alluded to become a prey. The thoracic organs are likewise affected; presenting bronchial irritation, dyspnoea, asthma, and a cough well known as gastric, and distinguished by its hard sounding spasmodic character, 44 gastritis (Symptoms). with the absence of sufficient disease in the chest to account for_it. e ave already spoken of palpitation and irregularity of the pulse; the lormer is^o. e- times accompanied with pain under the sternum, and in the inside 01_ inc arm, imitating angina pectoris. In the genito-urinary system we meet wun a>s"™*« spasm of the urethra, nephralgia; in the male, shooting pains in lhe tesucies, psoriasis of the glans penis; in the female, menstrual irregularities, leucorrhoea, prurigo pudendalis, &c. , ,. . . , , t,^.___. We have seen that the secretions are altered and diminished. Textural nutrition for a time may appear little affected, but when the disease has existed long, this effect becomes manifest enough in the general emaciation, and in the unhealthy complexion. There is evidence, moreover, that it is changed in kind as well as in degree, from the organic diseases which are apt to supervene. A sufficient cause for this might at first appear to be found in the faulty elabora- tion of chyle and consequently of blood ; but there are probably direct morbid sympathies between the diseased stomach and the nutrient actions. Ihis would seem indicated by the unhealthy aspect which ulcers and wounds are apt to assume, and, upon analogy, by the depraved secretions. The symptoms which we have enumerated constitute a form of dyspepsia, or inflammatory indigestion. Some authors consider dyspepsia as always depend- ing upon an inflammatory or a congested state of the mucous membrane of the stomach. This, however, we consider to be a narrow view of the subject, and long observation has led us to believe in the existence of a purely functional disorder of the stomach, that is, uncomplicated with any structural alteration, or with appreciable permanent disease of the capillary circulation. Of almost every other organ, the same remark obtains, certainly of the brain, the lungs, the liver, and the kidneys. But while we maintain that the collective symptoms resulting from chronic gastritis constitute only one form of dyspepsia, we con- cede the difficulty in a great many instances of pronouncing a similar set of symptoms to be independent on such a state of the mucous membrane, and also that great errors in practice are committed every day by overlooking this fre- quent cause of a disorder, which by many is treated as if it were always func- tional. Let us endeavour to point out one or two features more especially characteristic of the cases in which an inflammatory condition prevails. Pain, spontaneous, or occurring after food, may depend on mere increase of sensi- bility. It is often concluded that the pain is not inflammatory if relieved by stimulants and carminatives; but this is not decisive, for reasons which will appear when we discuss the treatment, though in the majority of cases of gastritis, the pain would be aggravated by such means. We have found a better test in the effect produced by hot liquids, such as tea, or plain water, which seldom fail to aggravate or induce pain in these cases. The existence of tenderness at the epigastrium, will confirm this evidence, but cannot be alone relied upon. The state of the tongue used to be thought one of the strongest diagnostic signs, but it is liable to great fallacies, Andral (Clin. Med. tlv.) and Louis (Gastro. Ent., t. ii. p. 64,) have proved that gastritis may co-exist with a moist clean tongue of natural colour; and, on the other hand, that this organ may be red, papillated, or even aphthous, with a healthy state of the stomach. Still in a large proportion of cases, such alterations of the natural appearance of the tongue as we have enumerated among the symptoms, are observable, and should at all events lead us to suspect the°disease. The state of the skin is an important help to us ; thus squamous and papular disease co- existing with stomach disorder, intimates very strongly that the mucous mem- brane is inflamed. The relief afforded by antiphlogistic means, affords some useful hints; but it must be valued only in connexion with other signs. We may remark, however, that relief ensuing upon iced drinks, is more decisive than when produced by local depletion, for the latter will sometimes mitigate a purely nervous gastralgia. The nature of the matters vomited is a valuable indication. For example, it is improbable that a large quantity of mucus gastritis (Causes of Acute). 45 should be secreted, unless the membrane had been previously in a state of plethora. Death from chronic gastritis may be caused by the general exhaustion, con- sequent both upon the long-continued irritation of so important an organ, and upon the impairment of the nutritive function. In most cases, however, the fatal event is brought about by some of the complications of the disease; more particularly those occurring in the liver, the kidneys, and the lungs. Anatomical characters of gastritis. We have now only to point out those modifications of the appearances already described, which are peculiar to the stomach. When this organ has been violently inflamed, it is generally found contracted, and the mucous membrane so wrinkled as to present the honeycomb appearance. In different parts, the form of the red injection varies. In the fundus the redness is more uniform, the villous coat has a swollen appearance, and the larger trunks of the vessels are more loaded ; while on the anterior and superior surface, we meet with the finer distributions of redness, the capilliform, the punctiform, and the stellated ; the intervening membrane, however, being of a more rosy hue than natural. The colour also in the latter situations is more vivid. On the borders of the elevated rugae it is not uncommon to perceive spots and stripes of ecchymosis; these we have noticed in animals poisoned by arse- nic, and in parts of the stomach where gravitation could not have favoured the congestion. In some cases the blood is extravasated in the submucous tissue, presenting the appearance of black watery excrescences, particularly insisted upon by Dr. Christison as indications of poisoning by certain irritants. In less intense degrees of inflammation the redness and vascularity are more circum- scribed, and the surface of the stomach is less puckered. Chronic gastritis may be easily recognised by the hypertrophy of the mucous tissue, and by the brown, slate-gray, and chocolate tints. The last-mentioned, however, must not be confounded with the violet colour of congestion from venous obstruction,—an appearance very common in persons who die of disease of the heart. We must also take care to distinguish the effects of the gastric juice on the blood in the veins, from true pathological appearances. In the former case we find in the fundus of the stomach, just where the gastric fluid gravitates, dark sooty lines, which are easily recognised to be veins, while the interjacent membrane has a dull pearly aspect, sprinkled with points of the same sooty hue, and often a pulpy consistence. Dr. Carswell's researches have esta- blished beyond all doubt that these appearances are caused by the chemical action of the gastric acid, and that they may be produced after death. It is true that the brown tint of chronic inflammation may depend on an alteration of the colouring matter of the blood from the same cause; but in this case the matter is incorporated with the tissue from an action evidently of long standing: the appearance is not confined to the fundus of the stomach, nor is the part traversed by the large trunks of veins above described ; and the membrane instead of being softened may be firmer than natural. Lastly, it must be remembered that the appearances of a post mortem action of the digestive acid, and those of chronic inflammations, are frequently combined. And indeed the quantity of blood accumulated in the membrane by the inflammatory process will favour the former appearance by supplying materials for its production. Such a combination will be detected by observing the state of the membrane adjoining the fundus. Both in acute and chronic gastritis the follicles are generally more developed than usual. In the former, as we have observed, they not unfrequently present the appearance of red spots, or of small red circles. In the latter they are sometimes so much enlarged and elevated, as to produce what has been called the mammellated appearance. In other cases this would seem to depend on hypertrophy of the villi. Ulceration is nearly always the effect of chronic gas- tritis, excepting in cases of irritant poisons. Causes of acute gastritis. A person in health is perhaps more secure from an invasion of this disorder than of any other acute malady ; that is, the more 46 gastritis (Treatment). common causes of disease, such as cold, damp, fatigue, &c, rarely' 1 ever induce it. When the disease can be at all referred to such agency, we snail find that the patient had been previously labouring under the chronic lorm. us causes, then, may be said to be such as act, not through the general system but by a direct operation on the stomach itself. The most prominent of these are the poisons called irritants; comprehending substances which act cue. mically upon the tissue, as the concentrated mineral acids and alkalies, oxalic acid, and corrosive sublimate; those which excite inflammation without pro- ducing any chemical action, as arsenic, salts of copper, and acrid vegetables: mechtnical irritants swallowed, such as pieces of glass and metal; mechanical injuries, such as blows, wounds, &c Some articles of food, or substances not at all capable of irritating a healthy stomach, or under ordinary circumstances, may be decided irritants; a draught of cold water, for instance, during exhaustion from violent exercise. We have known very severe gastritis induced by cider, or subacid beer, in persons previously liable to disorder of the stomach. Fruits and crude vegetables may have a similar effect. Causes of subacute gastritis. This common accompaniment of other diseases may be generally traced to errors of diet, to exposure to cold and damp, to fatigue, mental excitement; these causes being rendered operative by previous or concurrent indisposition; as in convalescence from fevers, in phthisis, rheumatism, and gout. In the two last mentioned diseases it is apt to alternate with inflammation in other organs. The most common predisposition, then, is produced by other diseases. Of the different ages, we have no doubt that infancy is the most liable, for the obvious reason that the mucous membrane is not fitted for the variety of aliments which are often applied to it, and of which it becomes tolerant, only when the teeth have emerged. Causes of chronic gastritis. This disease, as we have already observed, is often the consequence of the subacute variety, and depends on the same kind of causes. Alcoholic drinks, indigestible articles of food, excess as to the quantity, and too great frequency in the times of eating, are the most common exciting agents. A dry sea air has been often known to induce the disease, most probably through its action upon the skin. Persons engaged in occupa- tions which oblige them to maintain a stooping posture for several hours in the day, such as shoemakers, tailors, clerks, &c, are very liable to disorders of the stomach, dependent on chronic congestion or inflammation. The mere sedentariness of the employment would in some measure account for the pre- disposition which it occasions ; but we must not lose sight of the impediment to the venous circulation produced by want of free action of the diaphragm. The venous obstruction, caused by valvular lesions of the heart, and chronic diseases of the lungs, induces a similar tendency. Treatment of acute gastritis. If poison has been taken, the first object is to remove or to neutralize it; but we refer to works on toxicology for the specific treatment required by different kinds of irritants. The severity and rapid progress of this disease would appear to call for the boldest application of antiphlogistic measures : but before resorting to them we must bear in mind two important circumstances : 1st, that many of the causes of the malady have a specific depressing influence on the heart and the nervous system ; and 2dly, that when acute has supervened upon chronic gastritis, the system is too much debilitated by the previous malady to bear the same activity of treatment as would be appropriate to a purely recent disease. The causes then are rare in which we shall find it needful to push general bleeding far. One venesection however is generally practicable, provided the skin is not cold and moist the pulse thready, or the countenance collapsed. If there is general heat w'ith a flushed face and a tolerably firm pulse, we may abstract blood from the 'arm not only with safety but with advantage. But our main reliance must be placed on leeches, applied in numbers proportioned to the age of the patient. We are of opinion that more good is derived from frequent relays than from a lar «*.„ J .• of anodynes for relief of the pain and AcVu^T^^^T" appeared to us more efficient in combination than when administered^^ and it is a good plan to vary them frequently, in order that the wot ' not become insensible to them by long continued use; for it ha I "t?^ observed, that after employing a strong sedative for some time a oh ° to a weaker one will produce more effect. Morphia and prussic acidTt ^U SOFTENING OF THE STOMACH (GaStHc Juice). 53 together; opium, hyoscyamus, and conium; belladonna, stramonium, and extract of poppy. As to morphia, it is a fact not easily explained, that in some persons sickness more frequently results from its use than from opium itself. Perhaps some of the other principles in the opium counteract this effect. Anodyne applications to the epigastrium are valuable auxiliaries; such are belladonna ointment, linen steeped in a watery solution of belladonna or in a hot lauda- num, cataplasms of opium or bread impregnated with laudanum, or made with the leaves of hemlock or belladonna, morphia sprinkled on a small blister, &c. Particular symptoms may require special treatment; such as acidity, bitterness, and flatulence. The action of the bowels must be secured by means similar to those recommended under chronic gastritis. The diagnosis of cancer of the stomach is always doubtful, unless there should be positive proof of the presence of a tumour: if this be connected with difficulty of digestion, frequent vomiting of food, or still more of blood, the existence of cancerous disease may be assumed as nearly certain. There is rarely if ever much pain. G. SOFTENING OF THE STOMACH. It has been already stated that softening of the villous coat, and of the sub- mucous tissue may result from inflammation. We only advert to it again for the purpose of warning the practitioner against mistaking for inflammatory what may be only chemical softening, of a kind to be described presently. Some of the most able modern pathologists have erred upon this point. M. Louis, for instance, attributed, at one time, some instances of pale softening and thinning of the mucous membrane at the cardiac extremity of the stomach, to a slow inflammatory action, but which have been satisfactorily shown to be cadaveric. That this is the more correct explanation is (much to his honour) admitted by M. Louis himself in one of his most recent publications. (Examen de VExamen de M. Broussais, p. 16.) That the gastric juice has the power of softening and dissolving the coats of the stomach after death, so as to produce perforation, was first shown by John Hunter. His observations were confirmed by Spallanzani, Adams, Burns, and Jaeger; and still more recently by Dr. Carswell, whose experiments, conducted under a great variety of modifications, have placed the matter beyond all doubt. The fundus of the stomach is the part most frequently acted upon, because it is most depending. The following extract will convey an excellent idea of the lesion : "The form of chemical softening of the coats of the stomach by the gastric acid presents several important varieties. If the softening be confined to the mucous membrane of the fundus, the form which it assumes is that of small or large patches. These are generally irregular,—their bodies being formed by the mucous membrane, and the bottoms of each by the submucous coat; their edges, besides being irregular, are thin, soft, and somewhat transpa- rent. If the softening has extended to the other coats of the stomach, the edges of these are bevilled outwards, present a fringed appearance, or terminate in thin irregular prolongations which, when water is poured upon them, are seen to float like shreds of transparent coagulable lymph. Such are the forms of softening of the mucous membrane, so long as this membrane is smooth or stretched out by the contents of the stomach. But when this membrane is thrown into two folds, or forms plicae, the softening occurs no longer in patches, but presents those remarkable appearances described by M. Louis, as indicating the existence of pathological alterations. The forms of the softening, in this case, are those of stripes and bands of various dimensions, occupying the situa- tion of the plicae. Wherever these stripes or bands exist, we find that the mucous membrane has been completely dissolved, and the submucous coat laid bare. They have thus a bluish or silvery-gray aspect, while the mucous mem- 54 softening of the stomach (Gelatiniform). brnne which they inclose may be of its natural colour, red, hr^°\l^^f and appears in isolated patches of various forms and extent. ( ^TfmucVblood existed in the organ at the time of death, the softe"eda^r^. °f a blackish or sooty colour. In most cases we have seen it oi a auiI wnue, traversed by sooty lines, evidently the remains of bloodvessels the -content, of which had been discoloured by the gastric acid. Both in man and animals to Li tut; ui ucaiu. aiiu uau i^lwhit *,^i.«~—---- t ._ m „ , of the mucous membrane only, we have often noticed in cases of protracted disease, and we are of opinion, that it is often overlooked. Cruveilhier has described this cadaveric lesion as Ramollissement pultaee, to distinguish it from another which he considers morbid, and which he calls Ramolhsseraent gclutini. forme. In both of them, the softening may go on to erosion and perloration. The gelatiniform softening is according to Cruveilhier an organic process, ski generis, a perversion of nutrition, without any trace of inflammation, suppuration, or gangrene; a kind of " retrogradation vers l'etat gelatineux, muqueux." Andral "points out the analogy between it and the softening of the cornea in animals insufficiently nourished. The existence of'this species, which is sometimes called spontaneous gela- tinization, Dr. Carswell and others are not disposed to admit. There is, how- ever, a class of facts which we shall find great difficulty in explaining, if we believe that the gelatinous softening is always a post mortem occurrence. We allude to certain cases of children prematurely weaned, in which, after an ill- ness characterized by peculiar symptoms, no other morbid appearance was dis- covered capable of accounting for them ; and also to other cases which have occurred in adults, whose death took place after a few hours' illness, and the only serious lesion was that under consideration. The symptoms in the infan- tile cases are. thus described by Cruveilhier—" Une diarrhee verte, tres-fre- quente, semblable a de l'herbe hachee, si la maladie est intestinale; des vomis- semens muqueux ou bilieux, si la maladie attaque l'estomac; une soif ardente, insatiable, tout-a-fait caracterisque ; un amaigrissement tres-rapide (quelquefois en douze heures); une prostration de forces excessive; une face decomposee, et decoloree; un assoupissement leger, interrompu par des cris plaintifs, et des contorsions; une mauvaise humeur que rien n'egale; un pouls lent et irregu- Her, le froid des extremites; voila la reunion des signes le-plus propres a dif- ferencier le ramollissement gelatiniforme de toutes les autres maladies de l'enfance." (Anat. Path. liv. x.) These coincide remarkably with the phenomena observed by Dr. John Gaird- ner, who published (Ed. Med. Ch. Trans., vol. i.) a very valuable collection of cases of the same disease. Of the adult cases the following is a specimen:—" A young lady, previously in good health, was awakened at three one morning, with excruciating pain in the stomach, which nothing could alleviate. She expired seven hours after; and, on dissection, two holes were found in the back part of the stomach, surrounded with much softening of the villous coat." (Christison, p. 119.) The symptoms in this, as in other cases, were referred to the stomach; the person died after a short illness, and the only pathological alteration was this appearance in the stomach. Supposing we consider°the softening and erosion to have been merely chemical, how are we to account for the symptoms and the fatal termination 1 Disease must have existed and disease of the stomach; but this organ presents no sign of inflammation, injury or poisonous action ; nothing but the peculiar softening has been found on the anterior part of the stomach, upon which it is difficult to imagine that the o-as- tric juice could have acted. This happened in the case represented in Cruveil- hier's plate; and in the celebrated case of Miss Burns, who was erroneously supposed to have died of poisoning. (See Christison on Poisons, p. 33.) jj^ ulceration of the stomach (Varieties). 55 Christison mentions that the late Dr. W. Cullen showed him a stomach in which the softening had commenced upon the peritoneal coat, and exposed the muscu- lar fibres. Were it not for this fact, and the locality of the lesion in the fore part of the stomach, we might conclude with Dr. Gairdner, that even in morbid cases the gastric juice was the solvent agent, and that disease had rendered the tissue more soluble. This opinion has also been arrived at by Andral. (Anat. Path., t. ii. p. 88.) The subject requires still further investigation. But thus much appears cer- tain, that whether the change in question is in all cases cadaveric, or in some of a morbid nature, it is not easily confounded with the action of any irritant poison, excepting oxalic acid. And even in the latter case, there are usually signs of vital reaction around the margin of the corroded part. ULCERATION OF THE STOMACH. Ulcers of the stomach, not produced by carcinoma, may be arranged under the following heads:—1. Slight erosions of the mucous membrane, distributed over a surface exhibiting the effects of chronic gastritis; 2. Minute ulcers with red margins, often scattered over a pale surface; these result from inflamma- tion of isolated follicles; 3. Ulcers penetrating the muscular, and even the peritoneal coat, the base being formed by an adjoining organ. These are cir- cular or oval, and are bounded by hard margins, either elevated, or so much on a level with the surrounding membrane, as to appear to have been stamped out with a punch. They generally exist alone, and are situated either in the small curvature, or near the pylorus on the posterior surface. In the latter situation they have assumed an annular form. The edges are of a dead-white, or gray hue, and their density is owing to hypertrophied cellular tissue. They are distinguished from cancerous ulcers by the absence of malignant deposit at the bottom of the ulcers. (See Cruveilhier, Anat. Path. 1. x.) 4. Ulcers of an irregular shape, with ragged margins, produced by gangrene. These are rarely, if ever, seen, except as the result of irritant poisoning. It has been already stated that ulceration of the stomach, as a spontaneous disease, is a chronic action. The two first of the above species are the most common ; and their symptoms and pathology are those of chronic gastritis. The third species are remarkable for being in some cases quite latent, until perfora- tion of the organ has suddenly taken place. This lesion has frequently occurred in chlorotic females. The general condition of these subjects is obviously very favourable to the ulcerative process. In other instances, however, they are attended by the most distressing symptoms, closely imitating those of cancer; and we are not acquainted with any certain means of distinguishing them from the latter. We remember a case which exhibited every characteristic of cancer, both in the local symptoms, and in the general emaciation and cachexia; but which, after death, presented only a large clean-edged ulcer, in the pyloric extremity, close upon the orifice, with enormous dilatation of the stomach. The latter effect, as well as the great sufferings of the patient, were doubtless caused by the irregular action of the fibres about the pylorus, some of them having been destroyed by the ulceration. But although in some cases the diagnosis may be very obscure, in others we shall be assisted by the absence of the general signs of carcinoma on the one hand, or on the other by the presence of a circumscribed hardness in the epigastrium. The tumour, however, may be caused, as we have before remarked, by enlargement of the left lobe of the liver: nor will it suffice to say that such a disease would be wanting in the purely gastric symptoms, such as mucous, or coffee-ground vomiting, pain after food, &c, for the stomach, as we have known, may be unnaturally adherent to the liver, and therefore so embarrassed in its movements as to produce every kind of gastric distress. If hsematemesis should occur in a person who has for 56 dyspepsia (Preliminary Observations). some time suffered from chronic gastritis, or if the patient's stools should pre- sent a dark pitchy appearance, indicating the presence of decomposed blood, we may strongly suspect ulceration of the stomach. It is very desirable to arrive at a correct diagnosis, not so much for the treatment as for the prognosis, which, in the simple ulcer, would be far less discouraging than in carcinoma; the former being capable of cicatrization. The celebrated Beclard cured himself of this disease. The treatment is chiefly dietetical and palliative; consisting in a careful selection of such aliments as are found by the individual to be most easy of digestion, and in the administration of sedatives. If ulcerations of the stomach are not extremely large they give rise to very obscure symp- toms, especially in children. Ulcerations are more frequent with them than with adults, and I have seen numerous rounded and follicular ulcerations, while the appetite of the child was perfectly preserved. It is the extent rather than the depth of the disease which is a matter of much moment. "• PERFORATION OF THE STOMACH. Morbid perforation has often been called spontaneous ; a term which might lead to the supposition that the lesion was a peculiar action, independent of other disease. The term, however, was first used to distinguish morbid per- foration from that occasioned by corrosive poisons; for it was at one time sup- posed that the disorganization was always the effect of such agents. Perforation, from disease, has the following causes:—1. Simple ulceration, beginning either in the mucous coat, and gradually advancing to the serous ; or much more rarely beginning in the peritoneum; sometimes, when the ulcer has reached the serous membrane, the continuity is suddenly destroyed by lacera- tion; 2. Carcinomatous ulceration; 3. Gelatiniform softening. Cadaveric perforation is produced, as we have seen, by the gastric juice. The spleen, liver, diaphragm, and oesophagus, often share the action of the sol- vent liquid which has escaped from the stomach, or transuded through its tissue. Although the stomach may be perforated by ulceration, it does not follow that its contents must escape, for the opening may be closed by adhesions of the neighbouring viscera, caused by extension of inflammation from the outer sur- face. But when the accident does occur the symptoms are those of sudden and violent peritonitis. (See Peritonitis from Perforation.) DYSPEPSIA. Preliminary observations.—Acute dyspepsia.—Two forms.—Symptoms of the first.—Causes and treatment.—Symptoms of the second.—Causes and treatment—Chronic dyspepsia.— Symptoms.—Local.—General.—Causes.—Nature.—General treatment— Diet.—Regimen- Treatment of particular symptoms.—Influence of gastric disorders upon other organs. The term Dyspepsia (derived from - and a report of Cholera in the Seamen's hospital, Dreadnought, by Dr. Budd and Mr'r„.i, ~Lv i a in the Mcdico-Chirurgical Trans, for 183d. * * * Mr" Busk' Pushed cholera (Symptoms of Malignant). 99 matters discharged contain, at first, the ordinary contents of the stomach and intestines, but subsequently consist of a whitish, turbid fluid, which has been likened to whey, water-gruel, or rice-water. These evacuations, which are, either void of smell, or of a faint, sickly odour, are ejected forcibly, without straining or apparent effort, and are often enormous in quantity. The cramps, which begin in the muscles of the extremities, subsequently affect those of the abdomen and chest. The belly of a muscle is contracted into a hard knot with excruciating pain: in a minute or two relaxation takes place, but only for a moment; the same muscle becomes again violently cramped, or the cramp passes to another, leaving the patient scarcely an interval of ease. There is often, from the beginning, headache, noise in the ears, vertigo, or deafness. As the disease advances, the patient falls rapidly into a state of extreme prostration : at the end of an hour or two the pulse is often scarcely perceptible, the surface sensibly cold; and, if an attempt is made to bleed the patient, either no blood flows, or a few ounces only of dark tarry blood, which does not separate, but forms a loose coagulum, is with difficulty squeezed from the arm. The discharges continue, frequently attended with pain at the epigas- trium and with slight degree of colic: the temperature of the surface sinks still lower ; the conjunctivae become dry and glared, the eyes sunk in their orbits: the countenance, especially the nose and lips, assumes a leaden or blue tint, and the same hue is perceivable in the extremities, which are often of icy coldness. The tongue is pallid, or slightly blue, cold, and commonly covered with a thin coating of slimy mucus : the palms of the hands and the soles of the feet are shrunk and sodden, as if long soaked in water ; and the general volume of the body is much diminished. The pulse is feeble and fluttering, or imperceptible ; there is a sense of burning heat at the praecordia, with urgent thirst, and an insatiable desire for cold drinks ; the voice becomes extinct, or feeble and hoarse; the urine is suppressed, the salivary and all other glandular secretions are arrested. There is dyspnoea, attended with high and rapid breathing, and with an intole- rable sense of oppression ; extreme jactitation, so that the patient can with diffi- culty be kept under the bed-clothes, or in bed. In the midst of this general disturbance the intellect, although incapable of exertion, remains clear; the memory perfect. At the end of some hours, the violent symptoms subside, the discharges and cramps cease; but the heat of the surface and the pulse do not return, or they return only slightly and transiently, the patient relapses into his former state, the face becomes bedewed with a cold clammy sweat, and the scene closes in death, sometimes within four or five hours, not unfrequently within seven or eight, but more commonly at the end of twelve, twenty-four, or thirty-six hours from the attack; the patient retaining his mental faculties to the last. Such is the general progress of those cases that prove fatal during the cold stage. When this does not happen, after the violent symptoms have continued some hours, and the patient has fallen into a greater or less degree of collapse, the discharges cease or become less frequent, the heat of the surface returns, the skin loses its leaden tint, the pulse regains its power, the anxiety and oppression diminish, bile again flows into the intestines, the secretion of urine is restored : in fact, reaction becomes fairly established, and the disease in its future course assumes one of the following forms :—1. The patient remains feeble for some days, but the convalescence is immediate, and not interrupted by the occurrence of any internal inflammation. This termination is most common in those cases in which the symptoms of the preceding stage have been mild. 2. The recovery is retarded for a period, varying from a few days to several months, by the continuance of gastric and intestinal irritation, indi- cated by the symptoms we have already described as occasionally occurring in sporadic cholera after the subsidence of the violent symptoms. 3. The collapse is succeeded by a state which has been denominated the secondary fever of cholera, in which the patient presents a typhoid aspect: the cheeks are 100 cholkra (Symptoms of Malignant). flushed, the conjunctivae suffused, the tongue dry and red ; there is stupor with extreme drowsiness, and occasionally subsultus tendinum, and low muttering delirium. A minute papular eruption often appears on the face and body: but there is no great heat of skin or quickness of pulse. After having presented these symptoms the patient sometimes recovers, but more commonly falls into a state of complete coma, and, without offering any more obvious signs of local disease, sinks, in some cases after a few hours, in others at the end of a week or more. This secondary fever is more frequent in cases in which the early symptoms are unusually severe, and the cold stage protracted. We have noticed as characteristic of the cold stage:—1. The leaden or blue colour of the skin,—an appearance which has attracted much attention. It results from distension of the capillaries by dark-coloured blood, and varies much in degree, but is most striking when the disease advances rapidly in persons of a full and sanguineous habit. 2. TJie diminution of animal heat. This is greater than in any other disease: the surface of the body, the inside of the mouth, and even the breath of the patient give to the hand a sensation of cold- ness; and a thermometer placed under the tongue, which, in ordinary circum- stances, indicates a temperature of about 98° F., rises only to 77° or 79° F. Dr. Davy has shown that in the cold stage, even when the inspirations are ample and frequent, the air expired is not only colder than usual, but contains less than the ordinary proportion of carbonic acid. The low temperature of the body in cholera probably depends chiefly on deficient arterialization of the blood, in consequence of imperfect circulation. In morbus coeruleus, in which arterialization is deficient from malformation of the heart, the temperature of the body is likewise many degrees lower than natural. * (Midler's Physiolotn/, Transl., p. 75.) 3. The character of the blood and of the evacuations. We have already alluded to the defective circulation, dark colour, and tarry con- sistence of the blood during the cold stage of cholera. Chemical analysis has discovered in it a great deficiency of water, which, according to M. Le Canu, exists in some cases in less than one-half of its usual proportion; a diminution in the proportion of fibrin ; and the total absence of a very small proportion of carbonate of soda. The peculiar aspect and consistence of the blood, and its imperfect separation into serum and clot, are the natural consequences of these deviations from its normal state. In the blood of some cholera patients, who had secreted very little urine for several days, the presence of urea has been detected.f The gruelly or rice-water evacuations, which form such a striking svmptom of malignant cholera, are distinctly alkaline, and consist of a serous^r watery fluid containing whitish shreds or flocculi, of the colour and consistence of paste or boiled rice, and of a specific gravity greater than that of the liquid, so that they invariably, after a short time, fall to the bottom of the vessel. The liquid portion, according to the analysis by Dr. O'Shaughnessey, is composed of water, carbonate of soda, and the other saline ingredients deficient in the blood, but contains neither albumen, casein, nor the principles of the bile : the solid portion seems to be a mixture of albumen and casein.* Thus, the evacuations contain • We have observed similar diminution of animal heat in cases in which there was ffreat difficulty of breathing from extensive emphysema of the lungs. S t The discovery of urea in the blood, in cholera, was made bv Dr 0'c, p. 110.) We conclude our account of the morbid appearances in ileus, by remarking that in many cases portions of the intestine present a cordlike contraction iust below the inflamed and distended part. ' Nature. In all cases of ileus the propulsion of the intestinal matter is ob- structed. In some, as we have seen, the obstacle is of a mechanical nature and about these there can be no difference of opinion. But, as in others the passage of the canal is observed after death to be quite free, it is obvious that the obstruction must have been caused by some derangement or deficiency in the action of the muscular coat of the intestine. Upon the nature of this dis order two opinions are maintained. According to one, the intestine contracts spasmodically in some part so as to resist the passage of the contents while the other supposes simply a loss of muscular power in some part of the canal which prevents it from taking a share in the propulsive action. The former' is the more prevalent belief, and is grounded upon the character of the symptoms and the exciting causes, as well as upon the nature of the remedies. Dr Aber crombie was the first to broach, and is the principal advocate of the other colic (Varieties—prognosis). 123 opinion, which appears to have been inferred from a consideration of certain peculiar cases already alluded to. He regards the notion of spasm as alto- gether gratuitous, and sees no necessity for looking further than that condition of the diseased part which is found after death. He admits, however, •' that there may be irregular contractions of portions of the intestine, analogous to that to which the term spasm is usually applied, and that these may form the first step in that chain of derangement of the harmonious action of the canal which leads to an attack of ileus." He then adds, " the observations now made strictly apply to the condition of the parts in the fully formed or advanced state of the disease." Upon two points we concur with this distinguished author:—1. That the diseased part of the canal is paralysed, and that upon this depended the obstruc- tion in the latter stage of the illness. 2. That the contraction of the gut does not necessarily indicate disease; for we believe it to be owing to the smaller quantity of gas contained in the part, the principal accumulation of air being in the part where least resistance was offered, viz., that which had lost its con- tractility. But we submit that the error in Dr. Abercrombie's theory is laying an undue stress upon what appears to be only the termination of the disease. The true pathology of fatal ileus must in our judgment, embrace both spasm and paralysis. The reasons for inferring the former have been already alluded to, to which we may add the signs of inflammation in many of the cases, for it would be contrary to all analogy to suppose that inflammation attacks the mus- cular fibres, or even their contiguous tissues, without producing spasm. We see this accompaniment in rheumatism generally, in the intercostal muscles, in pleuritis, and in the diaphragm in pericarditis. But muscles which have been thrown into spasm by inflammation, in the progress of the disease become pa- ralysed, of which we have also proofs in the instances just adduced. As to the cases which present no appearance of inflammation, we cannot doubt that spasm existed at the commencement of the attack, though in its progress the contracti- bility was destroyed. Varieties. Several forms have been distinguished by nosologists, but we do not think it worth while to notice more than the following:—1. Spasmodic colic, which is common in hysterical, dyspeptic, and gouty subjects. This is often accompanied by flatulence, and tympanites, and may be brought on by mental agitation, or by cold applied to the extremities. 2. Colic from crudities or from scybala, including the C. accidentalis and C. stercorea of Cullen, and the Colique vegetale of French authors. 3. Lead colic, which will receive a separate consideration. 4. Inflammatory colic, or muscular enteritis. 5. Colic from mechanical obstruction. The prognosis will depend mainly upon the opinion formed of the cause of the attack. If it can be traced to acrid ingesta, neglect of the bowels, mental agitation, &c, and if it is soon followed up by appropriate remedies a favour- able issue may be expected. But if no such causes can be ascertained, if the constipation continues notwithstanding the rise of active medicines, and especially if the vomiting becomes stercoraceous, the case is one of extreme danger. Hic- cough, tympanites, coldness of the surface, and a small rapid pulse, are among the most alarming symptoms. But patients sometimes recover from the most apparently hopeless forms of ileus. Dr. Kidd once informed us of a case, in which stercoraceous vomiting continued fourteen days, and yet the patient was restored. Sometimes a fortunate termination is owing to sloughing of the inva- ginated intestine, which is discharged by stool. Dr. W. Thompson of Edin- burgh has collected and analyzed a great number of these cases. (Ed. Med. Jour, for 1835 and 1837.) Dr. Howell of Cliften has in his possession a por- tion of the ileum, eighteen inches in length, with the mesentery attached to it, which had been evacuated in this manner. The patient died a year afterwards of another disease. The greatest length of discharged gut on record is forty inches. 124 . colic (Treatment). Treatment. In the milder forms of colic, the best remedies are aperients combined with carminatives, antispasmodics, and sedatives. A dose of calomel, camphor, and extract of henbane, followed speedily by a draught composed of Dec. Aloes C, Inf. Senn. and Tinct. Jalap, or of other stimulating laxatives, will often put an end to the attack. The effect of such medicines may be aided by warm fomentations and large enemata. If the subject is strong or plethoric a bleeding from the arm will be a safe precaution against inflammation, and an excellent auxiliary to the antispasmodic and aperient measures. In cases com- plicated with hysteria, an assafcetida or turpentine injection should be resorted to. In all forms of the disease, when the pulse becomes quickened, or when tenderness is felt upon pressure, the constipation having lasted several hours, it will be expedient to abstract blood. Local depletion by leeches is often prefer- able to venesection. In cases presenting at first the characters of simple colic, but passing into ileus, or assuming the severe form from the commencement, particularly in the violence of the tormina and the vomiting, we must first ascertain that the ex- ternal hernia is not present. The management of this form of the disease is often very difficult, and will put in requisition all the resources and ingenuity of the practitioner. It is often manifest from the tormina, that the alimentary tube is making violent propulsive efforts, but that the impediment is too great to be thus overcome. In such cases it is questionable whether much good is to be attained by the use of purgatives ; and they certainly aggravate the suffer- ings of the patient. The indication is to remove the impediment, for which purpose antispasmodics are sometimes the most efficient means. The cases in which purgatives are most indicated are those produced by acrid ingesta, or feculent accumulations. Now as it cannot always be determined absolutely that such causes have not been in operation, we usually administer at the onset one active cathartic, and if it fails to remove the constipation we no longer attempt at this stage to force the passage, but take measures for reducing the spasmodic contraction, whether this be the principal cause or only an accompaniment of the obstruction. Calomel, in the dose of ten grains or a scruple, is an eligible medicine, because it often allays the vomiting. If the sickness is not very urgent we may administer a full dose of croton oil, two drops for instance in a pill. Soon after such a dose a large emollient clyster should be employed. If no satisfactory evacuation ensues, blood must be taken from the arm, with the view not only of combating what inflammation may exist, but also to induce that general relaxation which favours the operation of medicine. A full dose of opium given after the bleeding will, in many cases, promote the natural ac- tion of the bowels by allaying the tormina. A warm bath may be used at this juncture with very good effect. If the case continues obstinate, our next resource must be an injection of tobacco. This powerful medicine requires great caution in the administration. The plan recommended by Dr. Abercrombie is the safest and most efficient; it con- sists in infusing fifteen grains for ten minutes, in six ounces of boiling water, and injecting this infusion every hour till the characteristic effects of slight giddiness, faintness, and muscular relaxation are induced. The dose may sometimes be increased to twenty grains. The same physician has seen very good results from a small enema, containing two grains of tartar-emetic, given with the same view as the tobacco. Some practitioners are partial to the use of tobacco in the form of vapour. Others place their main reliance upon enemata, containing large quantities of 01. Tereb. When copious enemata are used, it is better to pass a long tube into the sigmoid flexure of the colon, as there will be a much better chance of having the fluid retained a sufficient space of time for its proper action. Considerable quantities of warm water mav be thrown up in this manner with very decided effect. There can be little doubt that the distension thus produced is the chief agent in the beneficial operation. One can imagine that even an intus-susception might be unfolded by powerful colic (Treatment). 125 distension of the lower part of the canal. On this principle may be explained the good effects which have been obtained from inflation of the colon by means of a tube affixed to a bellows. Although we have not recommended the use of strong purgatives after the failure of an efficient dose at the commencement, we can add our testimony to that of Dr. Abercrombie in favour of gentle laxatives frequently repeated, espe- cially of aloes and hyoscyamus. Small doses of Magn. Sulph. in Inf. Ros. may be given in the same manner. Linseed oil has been recommended in doses of half an ounce every hour or two, combined with a few drops of 01. Anisi. In few cases we apprehend is the stomach likely to retain such a potion. Affusions of cold water upon the abdomen have sometimes produced an immediate good effect. Crude mercury, or small shot, swallowed to the amount of two or three pounds, has in many cases been followed by a solu- tion of the disease, but we have ourselves no experience of these remedies. Dr. Abercrombie speaks highly of large blisters applied to the abdomen ; while Dr. Copland prefers hot turpentine fomentation. The best method of employ- ing the latter is that of wringing a flannel out in hot water and then sprinkling it with oil of turpentine. In the advanced stage of the disease, when there is great prostration, wine and other stimulants should be freely exhibited. Vinum aloes may be chosen for its twofold operation. We think highly of the administration, under the same circumstances, of injections of quinine, to which a small opiate should be added. The principal use of such means is to gain time while a spontaneous process of cure is going on. In no case is treatment to be abandoned in despair; but when the constipa- tion continues in spite of the measures which have been enumerated, more good is to be expected from the use of small doses of mercury than from any other remedy with which we are acquainted; very protracted cases have begun to amend after this medicine had produced its characteristic effects upon the system. It is probable that in such instances the impediment was caused by thickening from inflammatory deposit. In intussusception the abdomen has been incised, and the strangulation reduced by the finger, with a successful result. Before deciding upon so formidable an operation, there must be more certainty in the diagnosis than can usually be obtained. Dr. Copland gives the following summary of the diagnostic marks of this condition :—" The sudden invasion of the symptoms of severe colic or ileus after a violent straining at stool, and subsequently the constant desire to go to stool, attempts at evacuation being accompanied with violent tormina and tenesmus, and either unattended by evacuation, or followed by the discharge of a little bloody mucus, and these by symptoms of enteritis, are among the most constant concomitants of invagination. In some instances, also, the sudden occurrence of an elongated tumour, in addition to these symptoms, and before abdominal distension comes on, will further guide the opinion, particularly if the invagination be extensive, and situated in the caecum or course of the colon." We remember a case in which all these signs were present, but which after lasting several days gave way to the operation of a strong dose of croton oil, administered as a dernier resort. 126 lead coltc (Symptoms). LEAD COLIC. Symptoms.—Nature.—Treatment. This form of colic is otherwise designated as Colica Pictorum or Painters1 Colic, and Devonshire Colic, because workmen of this class are particularly liable to ir. The disease having once prevailed extensively in Poitou, it has been called Colica Pictonum, just as in this country it has been known as Devonshire colic In both these localities the disease was owing to the impreg- nation of wine and cider with lead, either purposely to correct their acidity, or accidentally by the use of leaden vessels. The lead colic is well known among plumbers, lead-miners, glaziers, potters, and manufacturers of white lead, &c. It is probable that the lead enters the system chiefly by pulmonary absorption, but /lot entirely, since it has been observed that workmen who are careful to change their clothes, and practice frequent ablutions, are much more free than others from the deleterious effects of their occupation. The disease may be caused by water which has been kept in leaden cisterns, or which has passed through pipes of this metal; but for the water to be impregnated by the metal it must be deficient in certain salts, particularly the sulphates and phosphates, which exert a protective action, by forming insoluble compounds between their acids and the oxide of lead. (See Christison on Poisons, and Taylor in Guy's Hosp. Rep., No. vi.) Symptoms. Many of the symptoms are common to this with other forms of colic; but it has certain distinguishing characters. Thus the pain begins less abruptly, being at first dull, and afterwards increasing in intensity, and it generally extends to the back and the hypochondria. We may often at once form a suspicion of the nature of the disease, by observing the tremulousness of the hands, and the weakness of the carpal joint, called by workmen the wrist drop. The patient generally suffers pains in the limbs as well as in the abdo- men, and not unfrequently spasms of the respiratory muscles. The tongue is usually flat, tremulous, and flabby, and face of a dingy hue, with a dejected or anxious expression ; some have observed even a yellowish tint. Dr. Burton has lately drawn attention to the appearance of the gums, which are of a pale bluish- gray colour, especially along their margin. The abdominal parietes are in some cases tender, while in others the patient finds considerable relief in the pressure of heavy weights. There is great variability, also, as to the abdominal muscles; for the most part they are retracted about the umbilicus, but we have often seen them distended. The stools when produced are at first hard, dry, and knotty. Instead of constipation, diarrhoea has been observed ; but this is extremely rare. The sphincter ani is sometimes so obstinately closed as to pre- vent the introduction of a clyster pipe. Fever is not a prominent symptom, and is sometimes entirely absent, but we have very often found the pulse quick and hard, and the skin hot. The attack is sometimes accompanied by palpitation, and sensations like those of angina pectoris, sometimes by severe headache, and frequently by pain shoot- ing along the course of the genito-crural nerve. The disease is seldom fatal of itself. Thus Andral states that out of 500 cases observed at the hospital " La Charite," only five were fatal. (Pathol. Interne, t. i., p. 158.) But the patient, if the same pernicious cause is in operation, may die eventually of apoplexy or epilepsy. Partial palsy, impair- ment of digestion, atrophy of the muscles, and a debilitated condition of the whole system, are some of the most common consequences. torpor of the colon (Nature—Treatment). 127 Nature. Anatomy has as yet given little more than negative information as to the pathology or nature of lead colic. Andral relates five cases (Clin. Med., t. iv., p. 486), in which no lesions could be detected in the intestines capable of explaining the symptoms. Louis observed a similar absence of morbid appear- ances, in one of the cases narrated in his memoir on sudden and unexpected deaths. (Rechercluis, Anat. Path., p. 483.) The mucous membrane has been found unusually dry, corresponding to the character of the stools, but excepting this, there is no appearance that bears any relation to the symptoms. The pre- valent opinion in the present day is that the disease is of a neuralgic nature. The wandering pains, and impaired action of the voluntary muscles, the occa- sional spasm of the organs of respiration, and the termination of the disease in convulsions, apoplexy, and palsy, intimate that the poison acts directly upon the nervous system, and more especially on the spinal marrow. There is an evident analogy between the state of the intestine and that of the muscles, for in both we observe pain, together with spasmodic or deficient contraction. The treatment is in most respects similar to that of the other species of colic. The chief indications are to relieve the pain and to procure a free action of the bowels. An opiate may be administered at the commencement, combined with calomel in a full dose; after which we must put in force many of the measures recommended in the last section, particularly the warm bath, turpentine or tobacco enemata, and the administration of croton and castor oil. There is not the same objection to beginning at once with strong cathartics as in some forms of ileus. The treatment pursued at La Charite is emetico-purgative; but though it appears to have been very successful, the plan usually adopted in this country of combining anodynes with the aperient remedies is preferable, because, while it is, to say the least, equal in efficiency to the other, it is attended with much less suffering. Bleeding from the arm is very seldom requisite, but we often direct leeches to be applied, with great relief to the feeling, if not with any curative effect. We have observed the symptoms, though previously obstinate, give way under the specific action of mercury, but it will not be often needful to resort to this mea- sure if other remedies are applied with sufficient promptitude. Sulphate of alu- mina in scruple doses is highly spoken of by some authors, but we have no ex- perience of its virtues in this disease. The treatment of lead colic at La Charit6, by purgatives, baths, and opiates, scarcely ever fails, but it is most complex and troublesome to patient and physician. In this country the disease is generally treated by a dose of calomel and opium, say eight or ten grains of the former and two of the latter, which should be followed up by laxatives and opiates. The best laxatives are the infusions of senna, and castor oil: Dover's powders and opiate enemata are the best mode of administering anodynes. Dr. Harlan of this city, who has had great experience in the treatment of the disorder, was extremely successful with the mercurial practice : he generally produced ptyalism, and the mercurial action seemed to be a counter agent to the pernicious effects of the lead: there is however, some inconvenience in this treatment, especially if the ptyalism should be severe. G. TORPOR OF THE COLON. Nature. — Symptoms. — Causes. — Treatment. The state of the colon to which this term is applied, is one of deficient con- tractile power, by reason of which the faecal matters are detained and accumu- 128 torpor of the colojn (Symptoms). Iated in the bowels. It is one of the most common forms of habitual constipa- tion; but the mode of its production varies considerably. In some persons this weakness of the colon is only a part of the asthenic condition of the whole system, such for instance as we meet with in persons exhausted by haemorrhage, in aged subjects, and in chlorotic or leucorrhneal females. In others the deficient contraction depends upon causes more local in their operation. Thus it occurs very frequently in persons who, notwithstand- ing their indolent or luxurious habits, continue to consume the ordinary amount of food, and it may in such cases be traced to the accumulation which takes place in the bowel, from the want of that degree of support and compression which it is intended to receive from the abdominal muscles during bodily exer- cise. The colon like other hollow viscera becomes weakened by the long con- tinuance of a distension disproportionate to its natural power. The indigestible nature of the food is another cause; for not having been reduced to a condition adapted to the natural irritability of the great intestine, it may either stimulate this part to unnatural hasty contractions, as in one of the forms of diarrhoea already described, or, what more commonly happens, it may produce no con- traction at all. In the latter case the accumulation occurs principally in the caput caecum. This form of constipation is often met with, as the consequence of eating large quantities of fruit and vegetables. But in another class of cases the fault is not so much in the food itself as in the processes to which it has been subjected in the upper parts of the tube. The insufficient chymifaction in gastritis and dyspepsia, the imperfect action of the duodenum, the deficiency or bad quality of the bile, will readily explain why the contents of the small in- testine do not stimulate the colon to healthy action. But whether the fault lies in the quality of the food or in the digestive processes, the result is much the same. The feculent matter accumulates in the colon, because the latter is not duly excited to contraction; while the fibres lose their power, both from in- action, and from the distension to which they are subjected. Torpor of the colon is sometimes connected with spinal irritation, but the influence of the latter is probably indirect through the intervention of the rectum, the spasmodic contraction of which occasions the retention of the contents of the colon. In many cases we believe the spinal disorder to be consequent rather than antecedent. When the medulla spinalis is paralysed, the colon is very often involved in the paralysis. Symptoms. Constipation is the most prominent of the local signs, but to this we may add tympanites, borborygmi, and stridulous sounds. The appe- tite is defective or perverted, and the digestion in most cases tardy and accom- panied with uneasy sensations. The tongue is generally pale, sodden, puffed, and indented along its margin, the breath fetid, the skin damp and chilly, the urine turbid and dull, the complexion pasty or of a dingy hue, the areolae round, the eyelids dark, and the expression of the countenance oppressed or anxious. There are sympathetic pains in the head and loins, but especially in the latter, and to such a degree as to simulate lumbago or nephralgia, aching sensations in the limbs, shooting pains in the region of the bladder and genital organs, pal- pitation and dyspnoea. The evil consequences in other parts of the system are manifold. If the torpor of the colon is primary, it can scarcely fail for very obvious reasons to involve disturbance of the stomach and duodenum. The accumulations may be mechanically injurious; thus by making pressure on the biliary duct, they may occasion jaundice ; and in like manner by compressing the mesenteric veins they produce haemorrhoids. It has been thought by some that apoplexy may result from their pressure upon the abdominal aorta; and there can be little doubt that the cedema of the feet in young women suffering from this affec- tion, may be sometimes accounted for by the impeded circulation in the inferior vena cava. The disease is often connected with amenorrhoea, but whether in tympanites (Nature). 129 the relation of cause, or as an associated effect of an antecedent common to both, is not quite evident/ The prognosis is by no means unfavourable when the disease is fully ascer- tained, but this is often more easy to cure than to recognise. Treatment. The first indication is to disburthen the colon of accumulations already formed. For this purpose we may use conjointly cathartics by the mouth, and enemata. The latter may consist of thin gruel, with castor oil and oil of turpentine; or of Epsom salts dissolved in infusion of senna, in the pro- portion of one or two ounces of the former to half a pint of the latter, to which a pint of warm water should be added. In obstinate cases, the enema colocynthidis is a good resource. When the injections return without bringing scybala with them, we have directed the injection of a large quantity of warm water through a long tube passed into the sigmoid flexure of the colon, in the manner recom- mended by Dr. O'Beirne. (New Views of Defecation, Sfc.) The purgative medicines which we have found most efficient in these cases, are Dec. Aloes Comp., with Inf. Senn. and Tr. Jalap.: the Pil. Cambog. Co.; or equal parts of this pill and Ext. Col. Co.; or of the latter and Pil. Rh. Co.; taken twice daily. We may remark that when these combinations fail to pro- duce any effect, which is not a very unfrequent occurrence, there is reason to suspect that the drugs are of bad quality. The purgatives should be continued till the motions are of a natural appearance and devoid of scybala. 2. We must next endeavour to remove or counteract those causes which have rendered the contents of the intestine less stimulating than they ought to be, whether in the food or in the imperfect functions of the stomach and duodenum. (See the treatment of Dyspepsia and Disorders of the Duodenum.) 3. The third indication is to restore the tone of the colon. With this view we may exhibit laxative and tonic medicines in conjunction; for examples, a grain of quinine or of sulphate of iron with four of Pil. Alo. c. Myrrh twice or thrice daily; or the quinine may be given in solution with Magn. Sulph. in cin- namon water. We have found electuaries containing tartrate of iron very ser- viceable. Friction of the abdomen with liniments composed of camphor and turpentine, or with a flesh brush, or a flannel glove, after sponging with salt water, is an excellent auxiliary. Tepid or cold affusion of the loins, followed by brisk friction, is also useful. • If there is spinal irritation, leeches or blisters must be applied over the lumbar vertebrae. 4. The diet must be such as will leave the smallest possible quantity of excre- mentitious product. Animal food may be used twice daily in most cases; but fruits, vegetables, preserves, et id genus omne, must be rigidly abstained from. Wine maybe allowed as apart of the tonic regimen which this affection usually requires. Exercise either on foot or on horseback is indispensable. In addition to the local application of cold, already recommended, the use of the shower-bath will be expedient. A very simple change of diet will often be more effectual than any medicinal substances. We have seen a number of cases which resisted medicines, cured by taking oatmeal porridge at breakfast: whenever dietetic treatment will succeed, it is much to be preferred to any other. G. TYMPANITES. Nature.—Complications.—Diagnosis.—Symptomatic tympanites.—Duration.—Treatment. Distension of the abdominal parietes by a large collection of air in the interior is called tympanites, or meteorismus. The latter term is restricted by some vol. hi. 17 130 tympanites ( Treatment). writers to the symptomatic form of the disease, particularly that which occurs in fevers. Cullen and other nosologists distinguish tympanites as caused by accu- mulation of air in the intestine (T. intestinalis) from that form in which the air is contained in the peritoneal sac (T. abdominalis). But the latter is allowed by all observers to be extremely rare, excepting as the consequence of perfora- tion of the intestine, or of disorganization of the peritoneum. Intestinal tympanites is very common, both as an acute and as a chronic affection. The acute form is generally an accompaniment of other diseases, the chief of which are peritonitis, colic, and typhoid fever. We have known it take the place of an autumnal diarrhoea. Chronic tympanites, though frequently an attendant on other diseases, especially peritonitis, may be the only complaint of its subject, and in this form it has been mistaken for many other species of abdominal intumescence, including the gravid uterus. Diagnosis. Tympanites may be distinguished from solid or liquid distension by the clear resonance which percussion elicits. It may be further distinguished from ascites, by the absence of fluctuation, and by the equable distension of the parietes, which is not altered by position. There can be little doubt that the colon is the most frequent seat of the accumulation in chronic tympanites. When the distension of this bowel is moderate or confined to one part, it is apt to be mistaken for solid tumours. We have observed the abdomen assume a pyriform shape not unlike the protuberance of pregnancy; in such cases the clearness on percussion will be more perceptible in the circumference than in the centre of the abdomen. Distension of the caecum and ascending colon has often been mistaken for hepatic or other visceral enlargements. Constipation is com- monly an attendant of tympanites, but in fever and mucous enteritis it may co- exist with diarrhoea. The pathology of symptomatic tympanites varies according to the nature of the disease which it accompanies. In some forms of colic, the accumulation of gas takes place together with that of the faecal matters, and from the same cause, viz., the want of propulsion. In the flatulent and hysterical varieties of colic more gas is formed than in the natural condition. The tympanites of fever and of peritonitis may be traced to the loss of contractility in the muscular fibres, consequent on inflammation of the mucous or serous coat. The cause of chronic idiopathic tympanites is generally a want of tone in the muscular fibres. That accumulation of gas, which depends on its inordinate quantity, may be sometimes accounted for by the imperfect digestion of vegetable matter, and its consequent fermentation. The enormous amount of gas evolved by this pro- cess is well known; but in other cases we cannot explain its production in this manner. Thus the suddenness of the affection, its excitement by mental emo- tion, and its substitution for diarrhoea, show that it must be referred to direct secretion.* The duration of the chronic disease is indefinite. We have known it last for several years in hysterical women; subject, however, to changes in degree, and sometimes alternating with other manifestations of their Proteiform malady. Treatment. The tympanites accompanying inflammatory affections scarcely calls for special remedies. In fever, however, it sometimes becomes so promi- nent a symptom as to need separate attention. If it is not removed by leeching and blistering, we may administer the oil of turpentine in drachm doses, either with castor oil, or in an emulsion with magnesia, mucilage, and aromatic water. The tympanites of flatulent colic must be combated by carminatives, aperients, and stimulating embrocations. The chronic form of the complaint is a great trial of the resources and patience of the practitioner. His chief object must be not only to stimulate the bowel to contractions sufficient for the expulsion of the wind, but also to restore its tone. In pursuance of the first indication we may resort to turpentine, camphor, the fetid gums, carminatives, frequent frictions * On this subject we beg to refer to the Pathological Introduction. peritonitis (General Observations). 131 of the abdomen, and the use of galvanism. For the more permanent effect, aperients combined with tonic medicines are mostly to be depended upon. Sydenham employed with great success an electuary of iron filings and bitter extracts. We can recommend a combination of sulphate of iron, sulphate of quinine, compound galbanum pill, and powder of capsicum. In an obstinate case we obtained some benefit from strychnia, in the dose of one-twelfth gra- dually increased to one-eighth of a grain. Injections of quinine and sulphate of zinc may be employed, when a change of remedies seems desirable. Some- times we have depended upon the application of cold water in the form of effusion, or of enemata. The support of an elastic belt or of a flannel roller will assist the cure. The artificial removal of the air by means of the tube of a stomach pump passed into the colon has been judiciously practised by Dr. Osborne of Dublin, on the same principle as that of frequently evacuating an atonic urinary bladder by the catheter; for in the latter case, it is well known that the fibres seldom recover their contractility so long as they are subject to distension from a large quantity of fluid. PERITONITIS. General observations.—Anatomical characters.— Symptoms.—Diagnosis.—Causes.—Prog- nosis.—Treatment.—Erythematic Peritonitis.—Puerperal Peritonitis.—Peritonitis from intestinal perforation.—Symptoms and treatment.—Chronic Peritonitis.—Anatomical cha- racters. — Tuberculous complications. — Symptoms. — Latency. — Causes. — Prognosis.— Treatment.—Peritonitis of the Caecum.—Symptoms.—Termination.—Treatment. As the peritoneum invests other organs than those which are the particular objects of present consideration, it may seem to be out of our province to treat of inflammation of this membrane generally. It cannot be questioned that dis- ease may affect separately a portion of the peritoneum, which has no other con- nexion with the alimentary canal than that of the continuity of a serous tissue; for example, the convex surface of the liver; but with the exception of this, and perhaps some parts of the coverings of the uterus, its appendages, and the bladder (which are not necessarily though very often accidentally in contact with the intestinal tube), there are no other inflexions of the peritoneum liable to be attacked by inflammation, without extension of the disease to the serous coat of some part of the alimentary tube; a fact easily explained, when we con- sider that the serous covering of every organ, but those which have been just adverted to, is in contact with some portion of the gastro-enteric surface. The effect of contact in propagating serous inflammation is more obvious than even that of continuity. Hence it is rare to find marks of inflammation on a part of the peritoneum without a corresponding appearance on the opposite surface; and, conversely, we often observe a limitation of the disease to the two surfaces which were in contact when the inflammation began in one of them; as for instance, between two convolutions of intestine ; between these and the omen- tum ; between the uterus and rectum; and still more strikingly between the upper surface of the liver and parietal membrane, without extension to the under surface; and again, between the ascending colon and the concave surface of the liver, without extension to the convex. At first sight we may consider it difficult to explain this communication of morbid action to an opposite surface, and may even fancy it needful to call in the aid of some such agent as elec- tricity. But there is no necessity for such a notion, if we consider the actual condition of the inflamed membrane, which is hotter than natural, at first dry, and afterwards bedewed with inflammatory serum, or roughened by fibrinous 132 peritonitis (Symptoms). deposit. The application of such a surface to the opposite serous membrane cannot fail to irritate the latter, and to produce a morbid action, which will be of the same kind, because the organization of the two parts is identical. Anatomical cluzracters. Redness is far less subject to exception, as a sign of serous than of mucous inflammation, which might have been inferred a. priori from the opinion of the organization of the tissues, and in the agencies to which they are subjected. There is no danger of confounding the dull cada- veric redness on the outer surface of those folds of intestines, which lie in the most dependent situations, with the vivid inflammatory injection in parts least liable to hypostatic congestion. But if the colour could mislead us, we have the means of correcting our judgment in the absence of inflammatory products. On a mucous surface an additional quantity of the proper secretion, or a serous or fibrinous effusion, may easily escape our notice, but this cannot occur in the shut sac of a serous membrane. One of the most common appearances on turning aside the parietes, is an adhesion of the great omentum to the inferior folds of intestine, or even to the pelvic organs; the raising of this membrane discovers the convolutions beneath inflated, agglutinated by soft albuminous exudations, and suffused, on their anterior surface, with a bright vermilion tint. On separating the folds we find, according to the period and character of the inflammation, serum clear or milky, sero-purulent fluid, and actual pus, in the interspaces. These liquids are found in still greater quantity in the iliac and pelvic fossae. The collec- tions of pus among the adherent folds appear like small abscesses. The organization of the false membranes depends partly on the time which has elapsed since the commencement of the inflammation, and partly on the type of the inflammation and the constitution of the individual. In some cases there is very little tendency to organization, though the inflammation has lasted several days; in others the matter is so plastic that blood-vessels have been detected in it after a few hours. The colour of the fibrinous deposit is sometimes a yellowish-green; more commonly a dull white. Peritonitis may be universal or partial. The inflammation is oftener limited in situations where there is but little motion between the opposite surfaces, and consequently little change of contact, and vice versa. Hence it is more diffused over the small intestine, but circumscribed in the neighbourhood of the caecum, the liver, the spleen, and the uterus. Gangrene and ulceration from acute peritonitis are very rare. Symptoms. An attack of this disease is sometimes preceded by chilliness, rigors, and a feeling of indisposition, but frequently it comes on abruptly, with acute pain in some part of the abdomen, generally in the hypogastric or one of the iliac regions. The pain is aggravated by any movement of the body, which puts the abdominal muscles into play, particularly by coughing, sneezing sigh- ing, evacuation of the bladder, &c. Pressure is extremely distressing, and even the bed-clothes may be felt an incumbrance. The patient lies supine, and often with his knees drawn up, probably from an instinctive desire to relax the abdo- minal muscles, and to avoid the contact of the bed covering; but not unfre- quently the great degree of weakness well accounts for this position. The belly is hot, tense, and for the most part, as the disease advances, tympanitic. The bowels, if not constipated at first, become so in the progress of the disease; and nausea and vomiting are frequent from the very commencement. The skin is generally dry and hot, and the pulse rapid, small, and hard. The tongue has a white fur, the lips are dry, the cheeks pale and collapsed, and the eyes sunk, while the countenance indicates great physical distress and depression. To a practised eye the disease is distinguishable by the counte- nance only, even when the other characteristics are wanting. Such is the ordinary display of symptoms in well-marked cases of perito- nitis ; but the disease is very apt to steal on insidiously, rather by the absence peritonitis (Symptoms—Diagnosis). 133 of the usual phenomena, than by the assumption of characters significant of other maladies. We must allude to one or two variations of the symptoms. The bowels may continue to act without impediment during the whole course of the disease: when this is the case, it must be inferred that the irritation has not extended as usual to the muscular coat, sufficiently to produce either spas- modic or paralytic obstruction. (See Colic.) Vomiting under similar circum- stances may not occur. The pulse, instead of rising to 120° or 130°, may keep as low as 80° or 90°, or even at its natural rate; and the temperature of the skin may be scarcely at all elevated. After the consideration of these and other anomalies, Dr. Abercrombie is of opinion that our chief reliance for the diagnosis must be placed on the tenderness of the abdomen. This symptom, however, appears to us to be rather calculated to awaken suspicion of peritonitis in the absence of other signs, than sufficient for distinguishing it from other diseases; since tenderness may exist in many cases where the peritoneum is not at all involved. The effusion of coagulable lymph may be sometimes detected by an impres- sion conveyed to the ear, and to the hand. Dr. Beatty of Dublin was the first who described the sign alluded to. (Dub. Journ., vol. vi.) In a case of peri- tonitis supervening on ovarian dropsy, " a remarkable sensation was communi- cated to the hand, when applied over the umbilicus and its neighbourhood. The sensation was, that of a grating or rubbing together of two uneven or rather dry surfaces, and was rendered most evident by ordering the patient to take a full inspiration, thereby causing the abdominal parietes to move more freely over the surface of the tumour. By the application of the stethoscope a loud and distinct frottement was audible, extending over a space of about five inches in diameter, with the umbilicus for a centre." Dr. Bright subsequently pub- lished some similar observations in the Med. Chir. Trans., vol. xix. He describes the feeling given to the hand as " varying between the crepitation produced by emphysema, and the sensation derived from bending new leather." Afterwards Dr. Corrigan investigated this subject (Dub. Journ., vol. ix.), and adduced reasons for concluding that it is necessary to the production of the sign, that the effused lymph should be in an unorganized condition. Dr. Beatty was of opinion that the sign is observable only in cases " where one at least of the opposed surfaces is adherent to a solid resisting body." Although it does not appear that this condition is indispensable, the general correctness of Dr. Beatty's views is proved by the fact, that out of twelve cases collected into a tabular form by Dr. Stokes (Dis. of the Chest, p. 478), nine presented an organic tumour. Diagnosis. 1, From Enteritis. We have confined this term to inflamma- tion of the mucous coat of the intestines, which may generally be distinguished from that of the peritoneum by the tendency to diarrhoea, the slighter degree of pain and tenderness, the softer pulse, the absence of vomiting, and the redness at the tip and margin of the tongue. 2, From Ileus. In many cases of this affection, especially of that form accompanied by inflammation of the muscular coat, the enteritis of some authors, the diagnosis from peritonitis is impossible at a certain stage. The pain, tenderness, vomiting, constipation, distension, and fever are the same in both diseases, when fully formed; but the mode of accession and the order of the symptoms are different. In Ileus the inflamma- tory symptoms are secondary to the obstruction, while in peritonitis they begin the attack, and take the lead throughout. 3, From Hysteria. This is by far the most important department of the diagnosis, in a practical point of view, because the treatment of the two affections is widely different. The hysterical imitation of peritonitis may often be" detected by the superficial tenderness, which, although greatly excited by slight pressure, and even to a more intense degree than in peritonitis, is something alleviated by deeper pressure. Often a similar tenderness may be discovered on the chest and limbs, though not com- plained of by the patient. Pressure upon the lumbar vertebrae also elicits pain* 134 peritonitis (Causes—Treatment). in many cases of this description; but we cannot agree with Dr. Griffin in I assigning as much importance as he appears to have done to this sign, as dis- - tinctive of neuralgic affections of the abdomen generally from peritonitis, though it is certainly a useful help when taken in connexion with other signs. We have known it present in cases of acute inflammation of the mucous follicles. In many instances we must depend principally upon the history of the case, the expression of the countenance, the mental phenomena, the connexion with menstrual irregularities, the fugitive character of the symptoms, and the thou- sand anomalies appertaining to hysterical cases. Causes. An attack of peritonitis may be brought on by exposure to cold, more especially when the skin has been previously relaxed by a warm atmo- sphere, or by fatigue. The disease is also known in connexion with such causes as mechanical injury of the abdomen, the state of the uterine system left by parturition, and the introduction of foreign matters into the serous cavity, as by perforation of the alimentary tube, bursting of hepatic abscess, rupture or ulceration of the biliary ducts, &c It has likewise been produced from meta- stasis of rheumatism. (Andral, Clin. Med., t. iv. p. 535.) Prognosis. If the case is seen early enough for the application of remedies to the first stage, we may entertain fair hopes of recovery; but if the disease has been allowed to run on unchecked, if the abdomen has become tympanitic, if the vomiting and constipation are established, if the pulse is frequent and thready, and the strength prostrate, and especially if there is hiccough with cold perspiration, the danger is extreme. It must not be hastily inferred from the mere returning action of the bowels that the malady is resolved; for we have known a state of general collapse ensue, in which the rectum and sphincter ani become relaxed and permit the escape of the fluid contents of the bowels, with any thing but an amendment in the condition of the patient. This is a great disappointment to the friends of the sufferer, who fancy that the malady must cease with the obstruction. A due attention to the accompanying symptoms will save the practitioner from the prognostic error alluded to. The duration in fatal cases is various. It may run its course in less than thirty-six hours; while in other cases the termination has been protracted to a fortnight or three weeks; but these are extreme periods, the average duration being from six to eight days. Treatment. From the moment that peritonitis is recognised, there is but one plain straightforward course to pursue, viz., to overcome the inflammation. For this purpose our great dependence must be placed on general blood-letting. Dr. Abercrombie has some admirable observations on the employment of this measure which we cannot forbear quoting:— " In all cases of active inflammation, blood-letting can be of comparatively little avail, unless it be used at an early period, and pushed to such an extent as to make a decided impression upon the system, as indicated by weakness of the pulse, paleness, and some degree of faintness: and a practice to which I am very partial in all urgent inflammatory cases, is to follow up this first full bleeding by small bleedings, at short intervals, when the effect of the first begins to subside. In this manner we prolong, as it were, the impression which is made by the first bleeding, and a twofold advantage arises from the practice, namely, that the disease is checked at an early period, and that the quantity of j blood lost is in the end much smaller than probably would be required under ^ other circumstances. If we allow the patient to lie after the first bleeding ten or twelve hours, or even a shorter period, the effect of it is entirely lost; and a repetition of it to the extent of twenty ounces may be required for producing that effect upon the disease, which, by the former method, might be produced by five; and besides, the disease has in the interval been gaining ground, its duration is protracted, and the result consequently rendered more uncertain. The inflammation of a vital organ should not be lost sight of above an hour or two at a time, until the force of it be decidedly broken, and unless this take per itonitis (Treatment). 135 place within twenty-four hours, the termination must be considered as doubtful." (Op. cit. p. 173.) Leeches should be applied to the most tender part of the abdomen, immedi- ately after the first bleeding, and repeated frequently according to the obstinacy of the inflammation and the strength of the patient. Blisters should never be employed in the early period of the disease; they prevent our ascertaining the state of the parts by pressure, and are by no means desirable remedies until blood has been freely abstracted both locally and generally. In the advanced stage, when the abdomen has become tumid, and tympanitic with obtunded sen- sibility, when in fact there is reason to believe that lymph and serum have been freely secreted, a very large blister may effect a salutary revolution. The best external applications when the inflammation is active are warm poultices made of bran, but we must take care that they are not ponderous. In some cases hot turpentine fomentations have a good effect; while in others cold evaporating lotions have seemed preferable. The evaporation may be accelerated by blow- ing the surface with a common bellows. We have placed a patient in a warm bath, sufficiently long and shallow for him to lie extended, and for the tumid abdomen to rise above the level, so that we could pour a jet of cold water upon the latter. The relief to the feelings has been most striking, even when the disease was too far advanced for a cure. Many practitioners are in the habit of administering strong purgatives in this disease. If such medicines are given, as we fear they too often are, for the pur- pose of removing the constipation, we think the practice, to say the least of it, very unphilosophical. The obstruction is but the effect not the cause of the inflammation, and will be-removed with the latter. It is not wonderful that the patient and his friends should be importunate for medicines which they imagine would get rid of what they suppose to be the predominant mischief; but the practitioner ought never to give way to this prejudice, but on the contrary, to ex- plain to them that the great object is to subdue the inflammation, and that the bowels will afterwards take care of themselves. This treatment, however, is not superfluous merely; it may be positively injurious, since by increasing the peristaltic action we put in motion the inflamed part, which on the contrary ought to have as much repose as possible. There is moreover the danger of tearing asunder recent adhesions, and thus producing additional irritation. We are of opinion, that there is only one principle upon which these .medicines might be useful, viz., that of producing a strong revulsion to the mucous mem* brane. Could we be sure that the inflammation was in its first stage, such a plan of treatment might be adopted with comparative safety; and in cases which forbid the abstraction of blood, we might be tempted to use it, taking care to select those articles which have most of the hydragogue property. Although we have thought it right to condemn the use of powerful cathartics, we see no objection to such mild laxatives as may keep up the usual secretions of the mucous membrane; for example, small doses of rhubarb, with hyoscya- mus, or aloes and hyoscyamus; or perhaps still better, the tartrate of potash and soda, given at intervals in an effervescing form. From the time the case first comes under treatment, mercury should be ex- hibited in such quantities as will bring the system under the full influence of this agent, should it become necessary to do so. We have often found reason to regret that the decisive administration of this remedy had been deferred until the treatment of blood-letting and other means had proved unsuccessful, and that in this way much valuable time had been lost; whereas if the mercury had been given at regular intervals from the commencement, a comparatively slight increase of the doses, or their more frequent repetition, would have effected our purpose; and on the other hand, if the disease had yielded to other means, we might have discontinued the use of it before the specific effects were developed. Experience has therefore long taught us to begin at once the employment of mercury in every case of acute inflammation, which may in its course require the 136 peritonitis (Erythematic). operation of this remedy, and not to wait till the necessity for it becomes mani- fest. Acting on this principle, we may in the treatment of peritonitis prescribe calomel in doses of three grains every four hours, with half a grain or more of opium, which will prevent irritation, and at the same time mitigate the pain. If the necessity for the medicine becomes more striking, we can administer the calomel and opium at shorter intervals, or even in very urgent cases at the same time introduce mercury by inunction. When the gums become sore, we may entertain a favourable opinion of the issue of the case. The vomiting in this disease is often an embarrassing circumstance; but it may be sometimes overcome by hydrocyanic acid or by creosote, and sinapisms or hot laudanum fomentations applied to the epigastrium. It is a great object to quell this symptom, not only because of the distress and the augmentation of pain which it occasions, but also because it interferes with the regular use of remedies. In the advanced stage of the disease, when all hope of succeeding by anti- phlogistic measures is given up, we must endeavour to give nature a chance of spontaneous cure, by supporting the strength. For this purpose wine may be taken freely, and quinine dissolved in beef tea may be injected into the colon. It is generally a most unfavourable sign, when, notwithstanding the cessa- tion of pain and tenderness, the bowels refuse to act, and the abdomen continues distended. Sometimes however these latter symptoms depend simply on the loss of muscular tone, caused by the inflammation, though the latter has sub- sided. When this is the case, the state of the pulse and the temperature of the body may give a more encouraging view ; mild laxatives and assafcetida injec- tions are useful under such circumstances. The pulse, as Dr. Gooch observes, is often the last thing to mend, continuing frequent long after the pain has ceased, and the bowels have resumed their function. For this symptom, which in many cases may be attributed to the irritability induced by the loss of blood, digitalis is the best remedy. Erythematic or Non-plastic Peritonitis. The peritoneum is liable to a form of inflammation which is accompanied by fever of an adynamic character, and which terminates rapidly in the secretion of serous fluid, generally white and milky, sometimes bloody, with scarcely any intermixture of coagulable lymph. When the latter substance is found, it is in flakes, scarcely or not at all adhering to the membrane. We have ob- served this form of peritonitis in puerperal women, and Dr. Abercrombie relates some interesting cases in which it attacked persons suffering from epidemic ery- sipelas. The progress of this disease is rapid, and the termination generally fatal. The local symptoms are not so acute as in the common peritonitis, the abdomen being less painful and tender, and the bowels often freely open, but the powers of the system are very soon depressed, and the pulse from the beginning is fre- quent and feeble. It is most probable that peritonitis of this nature is secondary to a febrile affection of the whole system (perhaps a disorder of the blood), which may re- sult from a peculiar condition of the atmosphere, or from the previous habits of the individual, or from that state of the system which ensues upon parturition. If tho fever were only secondary to the inflammation it would be impossible to account for the rapid termination of the disease, seeing that the local disorga- nization is much less severe than in the usual form of peritonitis, and for the com- parative uselessness of antiphlogistic remedies. Scarcely any thing satisfactory can be said of the treatment; local deple- tion affords some relief, without making any impression on the General condition, for doing which indeed there is little time, whatever be the means adopted. The peritonitis (Intestinal Perforation). 137 rapid introduction of mercury into the system, and maintaining the strength by wine and bark, appear to us to hold out the best prospect of success. After a single application of leeches the abdomen should be covered by a large blister. Puerperal Peritonitis. Women are liable to inflammation of the peritoneum when recovering from child-bearing. The usual time for its accession is about the third day, but it may occur much later. In many cases, especially when the disease is sporadic, it does not differ in its nature and characters from common acute perito- nitis, excepting as to the symptoms depending on the peculiar circumstances of the patient; such as the suppression of the lochia, and of the milk, and the almost universal commencement of the pain and tenderness in the uterine region. This form of the malady may require the same activity of treatment as when it occurs in other subjects. Puerperal females arc also subject, as we have already stated, to the erythe- matic form of peritonitis. Both these forms may occur epidemically, but especially the latter. The former must be viewed in connexion with the fever which accompanies it, if we wish to adopt an appropriate treatment. In sporadic cases the fever is gene- rally active and inflammatory ; but in the epidemic variety it assumes more or less of the typhoid type, and therefore the treatment must have reference to this. In some cases the peritonitis must be viewed merely as a complication of puer- peral fever, holding the same relation to it as pneumonia, bronchitis, and en- teritis to continued fever. But in other cases the inflammation may be pri- mary, depending on the state of the uterus after delivery, such as uterine phle- bitis, or inflammatory softening of the substance of the womb ; and yet we may find the fever of a decidedly typhoid character, just as we may have a typhoid pleuritis or pneumonia. In both cases there pre-exists a certain state of the constitution, induced by the habits of the individual, or by an atmospheric miasma, which causes the fever to assume a typhoid form. (For an account of the peculiar characters and treatment of puerperal peritonitis, see Puerperal Fevers.) Peritonitis from Intestinal Perforation. We think it better to offer in this place a few separate remarks to this subject, not only because the accession of the phenomena is peculiar, but also because a particular kind of treatment is requisite. Perforation of the alimentary canal is commonly the result of ulceration, which may gradually erode all the coats, proceeding from the mucous to the serous ; or when it has arrived at the latter, the solution of continuity may be finally caused by mechanical rupture. This rupture may be determined by the internal pressure of flatus, or of a large quantity of alimentary or faecal matter; or by the sudden external pressure of the abdominal muscles in strain- ing at stool, coughing, sneezing, &c For the latter effect it is necessary that the tube should contain at the time a certain quantity of air, the compres- sion of which by the abdominal muscles causes the accident in question. There is another mode in which this lesion may occur. The serous membrane at the base of the ulcer may be adherent to an adjoining fold of intestine, and during increased peristaltic contraction such force may be exerted upon the false membrane, as to tear away the thin partition between the ulcerated intestine and the peritoneal sac. The ulcerations most frequently productive of this accident, are those which destroy the follicles in typhoid fever and in phthisis. Ulcers of the stomach vol. m. 18 138 peritonitis (Anatomical Characters of Chronic). and duodenum also give rise to it; but they are more frequently guarded by adhesions to the adjoining viscera. (See Ulceration of the Stomach.) The opening is sometimes very minute. The symptoms of intestinal perforation are very characteristic. Excruciating abdominal pain comes on suddenly, and generally in the ileo-caecal region, accompanied with considerable tenderness on pressure, and painful micturition; this is soon followed by great frequency and feebleness of the pulse, collapse of the features, and other indications of sinking. The abrupt supervention of such symptoms in a case of ileo-colitis, typhoid fever, or phthisis, can scarcely fail to conduct the mind to the true pathology of the case. It is to be regretted that we are not also led to the means of cure. Peritonitis thus induced is nearly always fatal, partly because the exciting cause is not to be removed, and partly because the patient's condition, resulting from previous disease, is little fitted for struggling with so severe a lesion. The cure however must be attempted, and we have the encouragement of knowing that it has been occasionally though very rarely successful. Dr. Stokes records one case in which life was saved, and another in which the treatment adopted was mani- festly useful. The plan adopted was one that had been previously employed with success by Dr. Graves, in peritonitis occurring after ascites, and after the discharge of an hepatic abscess. It consisted in simply administering large doses of opium and supporting the strength. Bleeding cannot be practised on account of the depression of the vital powers, and for mercury there is no time; besides that, as Dr. Stokes remarks, it might do harm by increasing the peristaltic action. The object in using the opium is to keep the bowels in complete repose, in order that the organization of coagu- lable lymph may go on undisturbed, and also to prevent any more of the con- tents of the canal from escaping. We subjoin the account of the successful case related by Dr. Stokes :—" In the next case the disease was of three days' standing, and it supervened suddenly from a hypercatharsis produced by an overdose of Glauber's salts. The patient was apparently in the last stage when the opium treatment was commenced. He was ordered a grain of opium every hour. Next day the symptoms were decidedly improved, and though he had taken twenty-four grains, he had not experienced the slightest coma, headache, or delirium. The same plan of treatment was persevered in, the daily doses of opium being gradually diminished until the tenth day, when the convalescence oeing established the remedy was omitted. During this time diarrhoea set in for three or four days severely: this was treated^by the application of a few leeches to the anus, and the use of anodyne enemata. The patient took in all 150 grains of opium, exclusive of that in the injections, without experiencing any of the usual effects of this remedy in large doses." (Cyc. Pract. Med. art. Peritonitis.)* v Chronic Peritonitis. Acute inflammation of the peritoneum may pass gradually into the chronic form, or the inflammation may be chronic from the commencement Anatoniicalcliaracters The omentum, the parietal peritoneum, the intestinal folds, and the surfaces of all the abdominal viscera, are not unfrequently found agglutinated to each other, so as to form one mass of disease. Oftener, how- ever, the formation of liquid as well as solid deposits causes a separation of some of tho surfaces into sacs of various dimensions. The liquids are serum * An ample collection of facts, illustrative of peritonius by perforation will b«» r«,,nH ;« th* Rich. Anat. Path., by M. Louis, in the article by Dr. Stokes atove^SdnnH! •* by M. Cazenave, in Gaz. Med. de Paris for December 3M837 and^anuar^G ?(A S ^hoTdt" SUr kB Perf0rati°nS inteStinaICS qUl M'Ti«^t J^^r.^"^ peritonitis (Symptoms). 139 of a sanious character, sero-purulent fluid, and true pus. Pus is sometimes collected to the amount of several pounds. The solid matter may be coagulable lymph, only in various degrees of organization, but far more frequently it is largely mixed with tuberculous secretion, which is either in the form of miliary semitransparent tubercles, or of opaque yellow nodules, flakes, and masses. Tubercles may be found on the attached as well as the free surface, embedded in the cellular membrane. The thickening of the peritoneum, whether from fibrin or tuberculous matter, or more frequently the mixture of these substances, varies from two or three lines to three-quarters of an inch. Sometimes the hardness of these formations equals that of cartilage. The surface of the parietal membrane is not unfre- quently rough, or presents an areolar appearance, owing partly to the motion of the opposite surfaces while the deposit was going on, and partly perhaps to the simultaneous formation of non-organizable matter, which afterwards sepa- rating from the lymph leaves little cavities behind it. The latter explanation is applied by Dr. Hodgkin to the worm-eaten appearance met with on the surface of the liver and the spleen. M. Louis is of opinion that chronic peritonitis, which has been such from its commencement, is always complicated with tubercles. Dr. Hodgkin observes on this point, " My own inspections would lead me also to the conclusion, that chronic peritonitis is very frequently conjoined with tubercles: yet this concur- rence has not been so uniformly supported by cases observed in this country, as it has been by Louis's cases. That form of peritonitis which is accompanied by copious effusion, and which might easily be regarded as ascites, occurs without any appearance of tubercles. The same may be said of other cases in which the concrete product of inflammation had been more considerable." (Led. on Morb. Anat. of Serous and Mucous Membranes, vol. i., p. 149.) We have in our own experience known some exceptions to this law, though it must be stated that in these cases the peritoneal inflammation was secondary to disease in some of the viscera, such as the liver and the ovaries, and we are inclined to the belief that chronic inflammation, not consequent upon an acute attack, or upon mechanical injury, or upon disease of any other abdominal organ, is confined to scrofulous subjects, and is in fact tubercular. The colour of the deposits in chronic peritonitis is often dark brown or blackish, owing to the stagnation or effusion of blood, and the chemical action of gaseous acids which have penetrated the intestinal coats, or of decomposed pus. The gray granulations are often surrounded by blackish circles, caused by stagnant blood, which have been mistaken for punctiform melanosis. The mesenteric glands in this disease are often enormously hypertrophied, and stuffed with tuberculous matter, constituting a form of Tabes Mesenterica. Ul- ceration may affect communications between the intestinal canal and circum- scribed sacs in the peritoneum, or the convolutions may be so matted together that the latter result cannot occur, in which case several similar openings by ulceration may perforate the adherent folds, so as to make false passages or short cuts across the convoluted intestine, while the natural winding passage becomes obliterated by the pressure of deposit from without, and the want of distension from within. The profession is greatly indebted to Dr. Baron for having been the first to give an accurate account of tuberculous disease of the peritoneum.* Symptoms. The accession and progress of this disease are extremely insi- dious. In many cases there is but very little pain, in others none at all. In some instances, attacks of pain of a griping character come on for a day or two, and then subside, and do not return for weeks or months. A very common symptom is what Dr. Baron describes as a "broiling heat," in the region of the stomach. * See un Inquiry into the Nature of Tubcrculated Accretions of Serous Membranes, &c, by John Baron, M.D., <&c. 1819. 140 peritonitis (Causes). We met with a case not long since in which this feeling continued up to the time of decease. The bowels are generally irregular; sometimes constipated, but far more frequently relaxed; the motions being of a light yellow or stone colour, and of spongy consistence, with a good deal of fetor. The patient often com- plains of nausea, and the tongue has a bright red colour, and is glazed or chapped, or it is of a duller hue, but turgid and uneven on its surface. These states of the tongue, taken in connexion with the nausea and the diarrhoea, often give the impression of disease in the mucous rather than in the serous coat. When vomiting occurs, the matter is generally of a leek-green appearance, consisting of bile, which has acquired this colour from the action of the acids in the stomach. The urine is scanty, and deposits a reddish sediment. The skin very prone to perspiration, especially at night, and is often muddy and otherwise unhealthy in appearance. Emaciation is one of the most constant and marked symptoms. The extremi- ties are cold, pinched, and bluish; the eyes are sunken, and surrounded by a dark halo; and there is a faded look of the whole form and countenance. The pulse, in every case of tuberculous peritonitis that we have met with, has been more or less frequent and feeble. But in the chronic peritonitis, left by acute disease, we have known it very little above the average rate. An examination of the abdomen must be made, and, if conducted with care, it will nearly always enable the practitioner to recognise the disease, if he connects the local signs with the general condition of the patient. There is generally more protuberance than natural; and if there is fluid secretion, we find fluctua- tion and dulness on percussion; more commonly there is a feeling given to the hand, removed alike from the elastic resistance of fluid or gaseous accumulation, and from the suppleness of the healthy abdomen; a feeling which has been well represented by the term doughy. In kneading the abdomen, we seem to move the parietes and viscera together en masse. The tenderness is variable, seldom very acute, and in many instances absolutely wanting. In doubtful cases we have been enabled to form an opinion with greater certainty by exploring the chest, and discovering tuberculous disease of the lungs. Frequently we may detect inequalities of the abdomen, caused by masses of tubercular accretion, which, however, must not be confounded with scybala or enlargements of the colon. In many instances we have detected them after fluid effusions had been absorbed ; and we have at present under our eye, a young lady in whom a large accretion still exists, left by the ascites of chronic peritonitis, though she has completely regained her health, being subject only to attacks of constipation, apparently caused by the pressure of this formation. Tuberculous peritonitis is sometimes completely latent till a short time before death, which takes place suddenly and unexpectedly. In many cases of this sort the individual has been observed to fall off in general health and strength, and to be somewhat emaciated, but still not in such a degree or in so palpable a form as to awaken alarm or to cause application for professional assistance. Perhaps there have been slight attacks of pain and alvine relaxation, which have passed for common bowel complaints. But suddenly the patient is seized with greater pain than usual, and rapid sinking of the vital powers, and dies within thirty hours. On examination of the body it is found that besides numerous deposits of lymph and tuberculous matter, a circumscribed collection of pus had burst its sac, diffused itself over the whole cavity, and thus caused the fatal termination of the case. Causes. It has been already admitted that acute peritonitis may terminate in the present form. The tuberculous variety originating primarily in the stru- r mous cachexia may be developed by any of the common causes of disease, both internal and external. A neglected state of the bowels and of the skin, and an attack of fever, may be numbered among the former; and colds, fati»ue, and imprudences in diet, among the latter. The most frequent subjects are females between the ages of fourteen and twenty-one. peritonitis (Causes—Treatment). 141 The Prognosis can be scarcely favourable unless the habit of the patient is healthy, and the disease can be viewed as the remains of an acute attack. Cases, however, even of the tuberculous form sometimes improve beyond our hopes. We have already alluded to one of this description, which was the more unfavourable, because the father of the patient had died not long before of phthisis ; and Dr. Abercrombie remarks, " I have seen cases terminate favoura- bly in families which had formerly suffered from this affection; and their symp- toms corresponded with those which had been observed in the earlier stages of the cases which had been fatal." (Op. cit., p. 191.) We have been disappointed to find, that after the abdominal disease had ap- peared to abate, the pleura became similarly affected; and in one case, after this secondary disorder had likewise given way, the patient sank under tubercular meningitis. Treatment. It rarely happens that general bleeding can be thought of; even topical bleeding by leeches is often as much as the patient's strength can bear. This may be succeeded by or may alternate with blisters. When the disease is in an indolent state, and especially when it is conjoined with liquid effusion, friction with liniments, or unguents containing iodide of potassium, may be used, and we have often been surprised at the rapidity with which ascites of this description disappears under such treatment. It may also be adopted with the view of discussing by absorption the more solid deposits. Iodine may also be exhibited internally, but with caution, and only in combination either with potassium or with iron. Opiates will be required for the relief of pain and diar- rhoea. The vegetable alteratives are sometimes useful; such are sarsaparilla and taraxacum. They may be succeeded by or conjoined with light bitters, viz., Dec. Lichen., Inf. Cascar., and Inf. Cinch., to which Tr. Myrrhae may be added. The diet should be nutritious and compendious. Peritonitis of the Cacum. This form of peritonitis is nearly always connected with disease of the other coats of the caecum, or of the appendix vermiformis; and its limitation may be attributed to the fixed position of the bowel. When the inflammation has extended from the muscular and mucous coats, the cause of the disease is an accumulation of faecal or indigestible matters; such as crude fruits, cherry stones, kernels of nuts, &c. The symptoms begin with dull pain and feeling of distension in the right iliac fossa, becoming acute after a few hours, constipation, and nausea. A tumour may be detected in the above situation, which is often acutely tender; and if the patient allows us to handle it, we perceive a dulness on percussion, and a non-elastic boggy sensation. When the inflammation begins in the appendix, which is generally owing to the impaction of some hard substance (such as a kernel, a piece of hard excrement, a biliary concretion, a nail, a tooth, &c), though an external contusion might also give rise to the disease, the symptoms are from the beginning more acute, and the signs of caecal accumulation less obvious. This form of the disease is also more fatal, from the impossibility of extricating the irritating substance. The disease, if not speedily relieved, leads to the formation of abscesses, either in the anterior or posterior parietes; most frequently in the lumbar region, partly because it is the most depending in the recumbent posture, and partly because the caecum not being covered in that situation by peritoneum, the inflammation extends more readily to the cellular tissue between the gut and the muscles. The abscess may open itself outwardly, or burst into the peritoneum. From the situation of the appendix, Dr. Burne infers that its perforation is more likely to bo followed by serious results than that of the caecum itself. (Med. Chir. Tra?is., vol. xx.) 142 diseases of the mesenteric olands (Inflammation). This disease is sometimes chronic, and causes gradual disorganization and ulceration of the coats of the caecum. The treatment consists in depletion, not however to the extent pursued in idiopathic peritonitis, but chiefly by leeches applied from day to day, fomenta- tions, poultices, and laxatives combined with opiates. When the integuments are oedematous, or when from the emphysematous feel there is reason to appre- hend gangrene, no time should be lost in making an artificial opening. ENTERALGIA. The intestines are subject to a painful affection, which can be referred only to neuralgia. It is observed in neurotic subjects of all kinds, but especially in persons affected with dyspepsia, hypochondriasis, hysteria, gout, and suppressed or difficult menstruation. Sometimes it is complicated with irregularities of action in the bowels, and disorder of the secretions, the altered qualities of which produce more irritation than in persons who have not the same predispo- sition as the subjects of this complaint. Frequently it exists alone, and can be traced to some mental disturbance, or to changes in the atmosphere. The pain is sometimes relieved by pressure, at other times aggravated. When the latter is the case, it may be confounded with rheumatic or gouty pains in the abdominal muscles and aponeurosis. Enteralgia is in female subjects very often associated with spinal irritation. This affection is distinguished from inflammatory diseases in the abdomen, by the absence of the characteristics of these, and still more decidedly by the precursory and concurrent phenomena. We have already touched upon this subject in our remarks on the diagnosis of peritonitis. The treatment of enteralgia may be commenced by insuring the removal of any cause of irritation within the canal, by a mild laxative, such as castor oil, with a few drops of laudanum; after which we may employ sedatives with greater freedom. Camphor, henbane, and compound galbanum pill, may be administered when there are reasons for withholding opium and morphia. Anodyne fomentations, and poultices, sedative enemata, and the warm baths, are valuable auxiliaries. If there is spinal tenderness, a few leeches or a blister, or rubefacient embrocations, applied over the lumbar vertebrae, will often do more good than anodynes on the abdominal surface. It is almost needless to add, that the treatment will be very incomplete, if we confine our efforts to the relief of the pain, instead of endeavouring to correct the morbid susceptibility of the nervous system, and to remove the accompanying disorder in other organs. (See the treatment of Gastralgia.) DISEASES OF THE MESENTERIC GLANDS. Simplo acute inflammation.—Tuberculous degeneration.—Calcareous deposition.—Osseous transformation.— Induration.—Causes.—Complications.—Symptoms.— Diagnosis.__Treat- ment. 1. Simple acute inflammation of the mesenteric glands seems to have been noticed by pathologists principally as taking place in the progress of certain forms of fever. Baglivi appears to have had some knowledge of the liability of these glands to be affected in fever, and to have paid particular attention to this diseases of the mesenteric glands (Alterations). 143 complication of disease as occurring in Rome; but it was in the account given by MM. Petit and Serres of a fever which prevailed at the Hotel Dieu of Paris in 1811-1813, that the actual state of the mesenteric glands, when they become diseased in the progress of fever, was first very distinctly pointed out. These authors showed that the state of the glands of the mesentery, in those dying of this epidemic, most usually corresponded to that of the mucous membrane of the intestinal canal; that is to say, according as this membrane was less or more ulcerated, the mesenteric glands were less or more advanced in inflam- matory degeneration. Hence the name of entero-mesenteritis, which they con- ferred upon this form of fever. In the writings of the more recent French pathologists, as Cruveilhier, Chomel, and Louis, the frequent co-existence in fever, of disease on the inner surface of the intestinal canal, originating as it is now supposed in the glandular follicles there situated, with disease in the mesen- teric glands, seems to be very fully established. 2. The most important structural alteration to which the mesenteric glands are subject, is unquestionably that which has usually been called their scrofu- lous, or, in the language of modern pathology, their tubercular degeneration. As being supposed frequently to occur independently of any other form of morbid affection, and to give rise to a peculiar and recognisable train of symptoms, tubercular degeneration of the mesenteric glands has been regarded as consti- tuting a peculiar or special disease, to which many nosologists have applied the name of Tabes Mesenterica. It is to be regretted that classical nosology does not possess some shorter term, such as the French name of Carreau, for de- signating this disease. ' The alterations found in the mesenteric glands of persons dying of tabes mesenterica present very great diversities, according to the period at which death has occurred. In a patient dying before the tuberculous affection has made much progress, and consequently before the glands have become entirely converted iftto tubercles, these organs may be found either inflamed, or not pre- senting any trace of inflammation. In their inflamed state the texture of the glands is red, swelled, more or less gorged with blood, and more resistant under the scalpel than in their sound state. " At the earliest period at which we have an opportunity of examining the diseased glands," says Dr. Abercrombie, " they present, when cut into, a pale flesh colour, and a soft fleshy texture, and we sometimes find them of very considerable size, though merely presenting this texture." The tuberculous matter is developed in the substance of the inflamed mesenteric glands, under the form of small round irregular grains; in some rare cases it is deposited under the form of small patches, or irregular plates or stripes, which insensibly merge in the texture of the glands, and are closely adherent to it. When, again, the tuberculous glands are not in a state of in- flammation, they are neither red, nor swelled nor indurated, sometimes even they are paler than in their healthy state. The tubercular matter is, in such cases, in the form of grains or of small round or irregular masses, and adheres less closely to the glandular texture than when inflammation has existed. It seems to be merely interposed between the gland and the peritoneal coat. The shape of the glands is variously altered, according to the part in which the tuberculous deposition has taken place ; and their proper texture, from the compression to which it is subjected, is gradually reduced to a very small volume. When the affection has existed for a great length of time, and is very far advanced, the glands are often completely destroyed, or transformed into masses of isolated or agglomerated tubercles of different sizes, from that of a pea to that of an egg: there can then no longer be recognised any trace of the glandular texture. * The best monograph on this disease which has yet been published is, in our estimation, that by M. Guersent, in the Dictionnaire de Medecine, art. Carheau, from which we shall freely borrow in the following notices, in the persuasion that we shall thereby render a service to English medical literature. 144 diseases of the mesenteric glands (Causes). Mesenteric tubercles pass through all the states of degeneration to which that species of morbid texture is liable in other situations. As the disease advances, according to Dr. Abercrombie, the glands seem to become firmer, and to lose the flesh colour, assuming first a kind of semi-transparency, and afterwards a firm opaque white structure, resembling the white tubercle of the lungs. In a mass of considerable size we often observe these various structures in alternate layers, but in the advanced stages the opaque white tubercular matter is the most abundant, and this appears to become afterwards gradually softened, degenerating into a soft cheesy matter, or ill-conditioned suppuration. It is rare, however, as Guersent remarks, to find very fluid pus in mesenteric tuber- cles, either because, after pus is formed, it is in part reabsorbed, or because patients frequently sink before the tubercular affection arrives at the stage of suppuration. 3. There is sometimes found in mesenteric tubercles a dry and loamy or calcareous matter, analogous to that which is more frequently met with in the bronchial glands when in a state of tubercular degeneration. 4. The mesenteric glands not unfrequently assume the osseous transformation, a considerable number of them being sometimes converted into bone: this has often been seen in cases of mesenteric tabes. In general the glands so affected prove, on examination, to be formed of an osseous shell, containing a substance that bears a resemblance to loam or plaster. 5. M. Guersent mentions another species of degeneration sometimes observed in the mesenteric glands, that of induration, which, though it has often been confounded with scirrhus, is in reality very distinct from it. The glands, when thus degenerated, are much larger than in health, their texture is of a pale gray, almost entirely colourless, dense, smooth, and resisting under the scalpel, but it is neither so dense nor so shining and transparent as scirrhus. This species of induration is analogous, according to M. Guersent, to that which is observed in entero-mesenteritis, and appears to be the result of an inflammatory degenera- tion of the glands ; for the same appearance is met with in the glands of the neck, of the bronchia, and of other parts of the body. Causes. Tabes mesenterica is not, as has been often imagined, a disease peculiar to infancy. Tubercles are found in the mesenteric glands at all ages, in foetuses from six to seven months, in children dying of birth or soon after it, in infants, in adults, and in persons of fifty or sixty years and upwards. The disease is, in truth, more common between the first dentition and the ao-e of twelve and fifteen years, merely because tubercular affections in general are more common at that period of life. But M. Guersent is convinced that, even in children, mesenteric tabes is not so common a disease as some writers affirm. Bayle states, that out of a hundred dead bodies there are scarcely found four which exhibit mesenteric tubercles. He speaks, indeed, of persons of all ages. But at the Hopital des Enfans Malades of Paris, where the patients admitted are never below twelve months nor above sixteen years of age, the proportion of cases in which mesenteric tubercles aro found, amounts, according to Guer- sent's calculation, to from seven to eight per cent., at least in o-jrls, who appear to him to be generally more subject to pulmonary and mesenteric tubercular affection than boys, in whom the proportion may be from five to six per cent. These results, however, M. Guersent regards as merely approximations to the truth. As constituting one of the forms of tubercular affection, tabes mesenterica is liable to be produced by all those causes which give rise to scrofula in oeneral such as a cold and damp residence, and insufficient or bad nourishment (to which last head, according to the opinion of many, must be referred the nursing of infants by a scrofulous, and particularly by a phthisical person), more particularly when these causes operate, singly or conjointly, on persons inheriting a scrofulous diathesis. It seems probable that those causes which diseases of the mesenteric glands (Complications). 145 determine the induction of tubercles in the mesentery, rather than in other textures of the body, operate through the intervention of the intestinal canal. Tubercles maydcvelope themselves in the mesentery in the progress of other diseases. We have already noticed in respect to fever, the frequent coincidence of inflammatory disease of the inner surface of the intestinal canal with similar disease of the mesenteric glands. In mesenteric tubercular tabes, also, the mucous membrane of the intestinal canal, particularly towards the termination of the small intestine, is pretty frequently found red and evidently inflamed on the patches where the mucous crypts are most developed. There arc sometimes remarked in these situations, likewise, small, superficial, round ulcers, as well as traces of the cicatrices of such ulcers, which are easily recognisable by the manner in which the mucous membrane is wrinkled and radiated in the form of a star, towards a point that is thinner and darker than the others. Besides these small ulcers, deep ones are sometimes observable, attacking the whole thickness of the mucous, cellular, and muscular coats of the intestine, down to the peritoneum, which is itself sometimes ulcerated and perforated. These large ulcers are arranged in a circular form, and parallel to the transverse valves of the ileum. They are usually studded with fleshy, violet-coloured, bleeding granulations, in the midst of which there are occasionally found small round tubercles, not advanced to suppuration, and adhering immediately to the internal surface of the peritoneal coat. But though these intestinal ulcers are of very frequent occurrence in mesenteric tabes, being observed in more than half of the persons affected with that disease, M. Guersent does not consider them to be essentially connected with the tubercular affection of the mesentery, or dependent upon it. Their independence seems to him to be established by the facts, that the mucous membrane of the intestinal canal is often found perfectly healthy in cases in which mesenteric tubercles have attained a great size, or are even partially softened; and that, on the other hand, intestinal ulcers are very frequently met with in phthisical subjects, without the mesen- teric glands being diseased. M. Louis informs us that of 202 persons dying of tubercular phthisis in whom he examined the state of the mesenteric glands, in twenty-three they were tuber- cular and enlarged. In all these cases ulcerations were found to exist in the small intestine. But though this author is disposed to believe that inflammation and ulceration of the mucous membrane of the small intestines should be regarded as an occasional cause of mesenteric tubercles in some cases, he is satisfied that there are others in which these tubercles occur independently of any such intes- tinal affection. Dr. Home mentions that of eight cases of pulmonary consumption in which the mesenteric glands were found enlarged, three occurred in children, in whom the symptoms of the tabes mesenterica masked in a great measure the pulmonary affection ; but when this complication occurred in adults, the tubercular mesen- teric glands produced no symptoms. Complications. The danger and incurability of tubercular diseases of the mesenteric glands depend on the diseases by which it is accompanied. M. Guersent professes himself not to be acquainted with a single case in which a child has died from this affection alone: in all the cases of the disease which he has seen prove fatal, it was combined with other diseases capable in themselves of producing this result. These diseases were sometimes chronic, sometimes acute. Among the former, the more common were chronic peritonitis, with or without sub-peritoneal tubercles, intestinal ulcers, and, in particular, tubercular pulmonary phthisis. This latter disease, more especially, is so often combined with mesenteric tabes, that the mesenteric affection seems to be merely a sort of dependence of it. Out of four cases of mesenteric tabes, related by Baumes, in which examination was made after death, in three at least there were found to be tubercles, or abscesses in the lungs. M. Guersent's observations at the Hopital des Enfans Malades have furnished him with a still larger proportion of vol. hi. 19 146 diseases of the mesenteric glands (Symptoms—Diagnosis). such cases. He has found bronchial or pulmonary tubercles in five-sixths of the children affected with mesenteric tabes; so that, with a few exceptions in which the abdomen alone is diseased, most of those who die of tabes are at the same time affected with tubercular disease of the lungs; the rest die of some acute disease, or of chronic peritonitis, or intestinal ulcers. Symptoms. The more indolent forms of mesenteric tabes are not indicated by well-marked symptoms. The functions of individuals so affected do not experience any kind of alteration, unless in consequence of the supervention of other diseases. M. Guersent, after quoting some striking illustrations of this fact from former authors, mentions that he has himself repeatedly found indolent mesenteric tubercles in children who had died of acute diseases, and in whom nothing had occurred during life to lead to the suspicion of their existence. Examples of indolent tubercles are certainly, he says, much more common in the lungs; but it is not the less certain that mesenteric tubercles may reach the last stage of softening, without sensibly affecting the health and without mani- festing themselves by any pain, or other remarkable symptom. Persons in whom they exist may retain their appetite and plumpness, proving that the mesenteric glands are not the only channel by which the chyle may pass into the blood. It is to the inflammatory form of mesenteric tabes, therefore, that almost all that has been written relative to the symptoms of this disease must be considered as applying, since the existence of the indolent form can be ascertained only by the examination of the dead body. But the diagnosis of inflammatory mesenteric tabes, at its commencement, is almost as difficult and as obscure as that of the indolent form. M. Guersent does not scruple to affirm, that notwithstanding all that has been said by writers upon this disease, the symptoms by which they pretend to recognise it are for the most part either uncertain or fallacious. At all events, so far as the diagnosis of inflammatory mesenteric tabes is concerned, we may recognise two different stages. In the first, the tuberculated glands are not large enough to be detected by manual examination. In the second period, whatever degree of uncertainty may attach to the other symptoms, the size of the tubercular glands often permits of their being felt through the abdominal parietes, so that there can be no longer any doubt as to the existence of the dis- ease. M. Guersent mentions the following as the characters which have been assigned by authors to the first stage of mesenteric tabes:—1. Swelling of the belly; 2. Vomiting of a glairy fluid; 3. Diarrhoea, alternating with constipa- tion ; 4. Dyspepsia and irregularities in the digestive functions ; 5. Milky urine; 6. Acid smell of the transpiration; 7. Paleness of the face, with a livid colour beneath the lower eyelid, &c With this enumeration of symptoms we may compare that given by Dr. Joy:—1. Pain; 2. Constipation and diarrhoea, including the appearance of the alvine evacuations; 3. Enlargement of the abdomen; 4. Emaciation; 5. The character of the features; 6° The state of the tongue; 7. that of the appetite; 8. that of the pulse; 9. that of the skin and its secretions; and, 10. that of the mind. (Cyc. Prat. Med. art. Tabes Mesenterica.) M. Guersent, after passing in review the several symptoms that have been enumerated as constituting the physiological characters of mesenteric tabes expresses his conviction that almost all the symptoms which have hitherto been assigned to this disease do not really appertain to it, but depend on several other affections of the abdomen, with which it is often confounded or on other diseases which usually accompany in its course. The only pathognomonic symptom, the only positive character by which we can recognise this disease, and that only in its most advanced stage, is feeling the tubercles; all the other symptoms are more or less doubtful, and masked by those of the diseases with which mesenteric tabes is usually complicated. Diagnosis. The diseases with which mesenteric tabes in its first sta«e is most liable to be confounded are chronic peritonitis, chronic inflammation of diseases of the mesenteric glands (Treatment). 147 the small intestine, and intestinal ulcers. The following are some of the cir- cumstances by which the diagnosis may be assisted :—1. The patient affected with tabes in the first stage, if old enough to express his feelings, complains almost continually of pain, the seat of which he refers to the middle of the belly, but which is never acute nor analogous to colicky pains, unless the tabes is accompanied with inflammation or ulceration of the intestinal canal. 2. The pain increases when pressure is made with a little force, about the lumbar ver- tebrae, and in a direction from behind forwards. 3. The pain is not superficial, and is not accompanied, like that of chronic peritonitis, with considerable ten- sion of the belly, vomiting, and dulness ; nor is it attended, like that of intestinal ulcers, with diarrhoea of gray and yellowish matters, and a peculiar alteration of the features. 4. The pain in tabes often continues for a very long time, and sometimes even for several years, without any other remarkable characters presenting themselves. 5. It recurs more especially in spring and autumn, at which seasons tubercular affections in general are liable to experience aggra- vation and inflammation, and it almost uniformly disappears during the heat of summer. 6. The alvine evacuations in tabes are more or less fluid and variously coloured, but they are never glairy and bloody, as in caeco-colitis and dysentery. These characters belong almost equally to chronic inflammation of the small intestine and to tubercular mesenteritis; and as these two morbid states are most frequently found combined, and present common and analogous charac- ters, it is almost impossible to distinguish between them. The circumstances on which such a distinction may be attempted to be founded, in cases in which these affections occur separately, seem to be that in chronic enteritis the small- est deviations from strict regimen almost always induce diarrhoea, and a slight increase of abdominal pain on pressure; whilst running, leaping, and hiccough, do not produce this last effect. But in inflammatory mesenteric tubercles, on the contrary, violent abdominal successions increase the pain, whilst distension of the intestines, produced by errors in diet, does not aggravate the pain in any remarkable degree. Perhaps, even, the mesentery is less painful on pressure when the intestinal canal is full. The general symptoms that present themselves in the course of tabes mesen- terica, seem to be principally referrible to the other morbid affections with which it is usually accompanied; thus cough, fever, and emaciation, for example, when they occur in the progress of a case of this disease, often depend on pul- monary phthisis. Provided the other organs of the body retain their sound condition, the mesenteric glands may be crowded with tubercles, without the general health being thereby disturbed. In the advanced stage of the disease there can almost always be felt, on a careful manual examination, hard, round, knobbed bodies, deep-seated, about the middle of the belly. The co-existence of chronic peritonitis, or of effusion, may prove impediments to the recognition of these glandular enlargements. Scybala in the intestinal canal have been sometimes mistaken for enlarged mesenteric glands, particularly in very thin persons ; but even the most indolent tubercles, when they have attained a certain size, are always painful on pres- sure, whilst scybala on the contrary never cause pain. The difference in their position also should assist the diagnosis: tubercles usually occupy the ileo- caecal and umbilical regions : scybala the left iliac fossa or hypogastric region. Such an error, too, is the less likely to happen, inasmuch as the latter stage of tabes is almost always accompanied with diarrhoea. The general symptoms that have been assigned, by authors, to the latter stage of tabes mesenterica, viz., hectic fever, emaciation, swelling of the extre- mities, and effusion into the belly and other cavities, are none of them peculiar to this disease, being met with in a number of other affections, pulmonary and intestinal, which are the usual concomitants of the mesenteric affection. Treatment. To practitioners who regard as mesenteric tabes, in its first 148 diseases of the mesenteric clands (Treatment). stage, every case of swelling of the belly attended with dyspepsia, flatulence, alternate diarrhcea and constipation, and emaciation of the extremities, it ap- pears a matter of no great difficulty to cure that disease. These symptoms, which depend in some cases on simple intestinal derangement, in others on incipient chronic enteritis or peritonitis, &c, may disappear more or less speedily under the influence of the curative methods employed, evacuants, anti- phlogistics, tonics, &c, according to the nature of the several cases. But to the practitioner who gives the name of mesenteric tabes only to those cases in which its actual existence is certain, it is by no means so easy to obtain a cure of this disease. M. Guersent is satisfied that in all cases in which the existence of mesenteric tabes is well ascertained, which it can only be by the touch, it usually proves fatal, not, as has generally been supposed, in consequence of the effects which result from the morbid degeneration of the glands themselves, but of those effects which necessarily arise from the diseases by which it is complicated. M. Guersent conceives that in a case of indolent mesenteric tabes, sufficiently advanced to be recognised by the touch, but still uncomplicated with any other disease, benefit might possibly be derived from the resolvent means which are employed in strumous tumours in general, and in particular from those, the efficacy of which in the strumous affection of the mesentery has been so much boasted of by authors, such as the extract of cicuta, the acetate of potass, the protochloruret of mercury (calomel), the oxides of iron and fer- ruginous preparations, mineral baths and particulaly sea baths; these means being seconded by enforcement of the regimen which is suited to other tubercu- lar affections. But this author acknowledges that a case of this simple kind has never fallen under his own observation ; and that it is from the success with which tumours evidently tubercular, seated in the neck, axilla, and else- where, are occasionally resolved, that he is disposed to admit the possibility of reabsorption or resolution of tubercles of the mesenteric glands, organs that are possessed of little sensibility, and the functions of which do not appear not- withstanding all that has been said, to be very necessary to the preservation of life. By the time it becomes possible to recognise the inflammatory form of tuber- cular degeneration of the mesenteric glands, and to distinguish it from other diseases of the abdomen, no remedy in general can be of any avail. The lungs, in almost every such case, have been for a length of time in a state of disease. The liver, the spleen, and the whole of the sub-peritoneal cellular texture have, in many instances, become affected with tubercles. The patient is tormented by hectic fever, and the mesenteric disease is then said to be in its third stao-e. The use of any of the pretended resolvent medicines under such circumstances would be injurious and dangerous,—it could only accelerate the fatal termina- tion. The physician is reduced to the melancholy part of employing the same palliative mode of treatment as is suited to the advanced sta^e of pulmonary consumption, of tubercular peritonitis, or of intestinal ulcers. An example of inflammatory mesenteric tabes, uncomplicated with any other affection, might by chance be met with. In such an event, the physician, after having combated the inflammatory symptoms by antiphlogistics, tepid baths, and strict diet, as in a simple inflammation of the mesentery, when the pain, diarrhcea, fever, and all signs of irritation have ceased, should treat the case as one of indolent tabes. " But here," say M. Guersent, " I strive to suppose curable cases; and I repeat, I have never met with any such, when no doubt could be any longer entertained as to the actual existence of the disease." Participating, as we are constrained to do, in these unfavourable opinions rela- tive to the curability of mesenteric tabes, we shall terminate the consideration of the treatment of this disease with a simple enumeration of the various reme- dies, in.the way of external applications and of internal medicines, which have at one time or other been employed in this disease, and of many of which the practitioner may be glad to avail himself in the various modifications and com- diseases of the biliary organs (Atmospheric Heat). 149 plications which it is liable to exhibit. We shall take this enumeration from the monograph by Dr. Joy already referred to:—External applications,— leeches ; tepid, sulphureous, and cold baths ; electricity ; stimulant and anodyne frictions or plasters; counter-irritation by tartar-emetic ointment, by croton oil, &c. Internal medicines,—purgatives and aperients; alteratives, including mercurials, antimony, guaiacum, sarsaparilla, &c; antacids, as the liquor potassac, carbonate of soda, &c ; tonics, as iron, bark, bitters; and the so- named deobstruents, such as muriate of barytes, burnt sponge, iodine, cicuta, &c. DISEASES OF THE BILIARY ORGANS. GENERAL VIEW OF THEIR CAUSES. Atmospheric heat.—Diet.—Bodily inactivity.—External injuries.—Alcoholic liquors.—Mer- cury.—Foreign matters circulating with the blood.—Mental emotions.—Diseases of other organs. Before proceeding to the consideration of the special diseases of the biliary organs, we shall take a general view of the various causes in which they are known to originate. 1. The agent which seems to have most influence in producing diseases of the biliary organs is atmospheric heat, as is proved by their greater prevalence in hot than in cold or temperate climates, and in hot than in cool seasons in the same climate. Those who are exposed to the direct rays of the sun seem to be more particularly subject to hepatic affections, especially if this be followed by exposure to the night dews and malaria. Mr. Annesley calculates the average annual per centage of hepatitis in the East Indies to be at least treble what it is in the Western hemisphere, and he supposes the greater prevalency of this disease in the southern than in the northern provinces of India, to be in a great degree dependent upon the nature of the soil and climate, and the higher mean annual temperature. It appears from the statistical report on the troops in the West Indies, prepared from the records of the Army Medical Department and the War-office returns, that though diseases of the liver are by no means so common among the troops on that service as among those employed in the tropi- cal regions of the Eastern hemisphere, they are nearly thrice as prevalent as among troops in the United Kingdom, and occasion about five times as high a ratio of mortality. They vary materially, both in prevalence and severity, at different stations in the West Indies, occasioning at Grenada, for instance, three times as much mortality as at most of the other islands, and that without any very apparent cause. In Jamaica, considering the high degree of temperature in that island, diseases of the liver are by no means very prevalent or fatal; and many parts of the island enjoy a remarkable immunity from them. It appears also from the statistical report, that the mortality in the West Indies from these diseases, is much less among the black than among the white troops. Though cases of diseased liver are more numerous in hot than in temperate regions, they seem to be less varied in their nature. In India, the diseased appearances in that organ are generally confined to inflammation and its effects, suppuration or induration, while the different species of tubera, or hydatids, are by no means common. Some authors allege, that biliary concretions are seldom observed in the hepatic passages in India; but this is not conformable with the experience of Mr. Annesley, who states that they frequently form in warm climates in the gall-bladder, and often produce inflammatory action in that receptacle, and in the cystic or common duct, not unfrequently attended 150 diseases of the biliary organs (Mercury). with spasm. Mr. Twining also makes mention, in his work on the diseases of Bengal, of concretions in colour and consistence like yellow soap, extending along the biliary canals, through a considerable space. It occasionally happens that some of the diseases of the liver assume an epidemic character. Dr. Chisholm mentions an affection of this description, under the name of anomalous hepatitis, which he witnessed in Grenada, and which he believed to be propagated in some degree by infection. A considera- ble number of instances have been recorded of the epidemical occurrence of jaundice. Thus Dr. Cleghorn mentions a slight jaundice without fever, which soon yielded to purgatives and saponaceous medicines, as having been a " common distemper in Minorca in July and August, 1745" (Obs. on the Epid. Dis. of Minorca); and Dr. W. Batt has described a similar affection (Edin. Med. and Surg. Journ., vol. i., p. 107), as occurring in Italy in 1792-3. 2. The quantity and quality of the food that is used are by no means unim- portant, as regards the action and condition of the liver. An over proportion of animal food seems to favour an excessive secretion of bile, and there can be no doubt that variety and high-seasoned dishes exert a very prejudicial effect upon the liver, whether immediately or as temptations to excess in the use of animal food. 3. That persons leading a life of bodily inactivity, and those engaged in literary pursuits or other sedentary employments, are peculiarly liable to hepa- tic disease, seems to be very generally admitted. By some this has been attri- buted to the habit of leaning forward, to which such persons generally yield, and the consequent pressure to which the biliary organs are subjected. But the more commonly received opinion is, that the want of exercise causes inac- tivity of the hepatic system, and thereby lays a foundation for derangement of the biliary organs. It is probable that the venous circulation of the liver is promoted by bodily exercise, and that by its neglect this circulation becomes proportionally languid. 4. External injury inflicted upon the region of the liver, independently of the mechanical effects of contusion and rupture, may give rise to different forms of diseased action in that organ. Its most frequent consequence, unquestiona- bly, is inflammation; and traumatic hepatitis may pass through all the same stages as when it depends on internal causes. But a blow on the region of the liver is sometimes followed, at a longer or shorter interval, by the developement of a simple serous or of an hydatid cyst, or perhaps some other form of non- inflammatory structural alteration. 5. The influenpe of alcoholic liquors in inducing diseases of the liver has been insisted on, both as respects tropical and temperate climates, with this difference, that in the former it is inflammation of a more or less acute charac- ter which is produced by this noxious agent, while in temperate climates fatal cases arising from this cause generally exhibit the granular degeneration. The belief that wine and spirituous liquors operate specifically in the production of liver complaints was opposed by Dr. Mills of Dublin, who affirms that persons who indulge freely in the use of these liquors are not the most subject to those ailments; that they occur in those who are temperate, and are found even in children and infants. It has been remarked also, that the troops stationed in Nova Scotia and New Brunswick suffer less from diseases of the liver than those at home, although, from the low price of spirits, there are few stations where the intemperance is greater. It may be observed too, that Sir G. Ballingall, while he conceives that, in India, affections of the liver are obviously, in a great majority of instances, the joint effects of climate and intemperance, acknowledges that in others we find them to be the result of climate alone. When originating solely from the latter cause, he adds, they are often very obscurely marked. 6. It is a well-established fact, that mercury, administered as a remedy, occasionally causes hepatic disease, which presents itself sometimes under the diseases of the biliary organs (Mental Emotions). 151 distinct characters of hepatitis, and sometimes under the more obscure garb of jaundice. The first notice of this operation of mercury with which we have met, is contained in a letter by Dr. Sherwen, dated from the Ganges, in September, 1770. Dr. S.'s experience of this action of mercury was confined to a single case. Dr. Dick, who practised long in Calcutta, states in a letter to Dr. Saun- ders, that he has often observed chronic liver attacks succeed to long courses of mercury, undergone for the cure of venereal complaints. Dr. Cheyne, in the space of two years, met with three cases of jaundice produced by mercurials; and he had been creditably informed of its appearing in large venereal esta- blishments during the exhibition of mercury. (Dub. Hosp. Rep.) Dr. Nicholl, when serving in India with the 80th regiment, occasionally observed hepatitis come on a few days, but often weeks, after a mercurial course for a venereal complaint; a great proportion of the soldiers who had been treated in this man- ner for syphilis suffered from inflammation of the liver; and in eight instances the same effect was produced by the exhibition of mercury, administered for the cure of chronic ophthalmia. Dr. Chapman, of Philadelphia, relates cases of a similar description, and ascribes the prevalence of hepatic complaints in his neighbourhood to the employment of mercury in the cure of autumnal fevers; he also states, on the authority of some old practitioners, that previously to the introduction of the mercurial practice into that district, hepatitis was scarcely known in it. 7. The occasional occurrence of abscesses in the liver, in cases of injury of the head, has long been noticed, and was at one time supposed to indicate the existence of a peculiar sympathy between the head and the liver, a doctrine to which we shall have occasion afterwards to advert. But, besides secondary abscesses, the liver is, as we shall presently see, very liable also to become the seat of secondary malignant growths, in whatever part of the body the primary disease may have developed itself. These facts would seem to imply that foreign matters, circulating with the blood, are peculiarly liable to be detained in this depuratory viscus, and suggests the inquiry whether any thing analogous can happen in respect of alcohol and mercury, when these exert a noxious in- fluence upon this organ. In some interesting experiments of M. Cruveilhier, it was found that when mercury was introduced into the abdominal venous circu- lation, it was for the most part arrested and deposited in the liver, causing in- flammatory action in that viscus; and that, on the other hand, when introduced into the general venous circulation, it was usually arrested in the lungs. These results, however, M. Cruveilhier acknowledges not to have been uniform, the mercury being sometimes deposited in other organs. Dr. Percy detected alcohol in the blood, the urine, the bile, and the liver, and it was separated from the latter with great facility, a circumstance which he thinks may account for the frequency of hepatic disease in drunkards. Andral had previously suggested that the alcoholic particles introduced into the alimentary canal, being carried directly to the liver by the meseraic veins, may in this way act as a direct irri- tant upon that organ. Whatever may be thought of M. Cruveilhier's views relative to the production of liver disease by substances introduced into the ali- mentary canal, it seems probable that in many cases it is on the mucous mem- brane of this canal that alcoholic liquors exert their first morbific effect, and that this is afterwards communicated, by extension, to the mucous membrane of the gall-ducts, and the parenchyma of the liver. Dr. Saunders says, that in dram-drinkers the diseased structure may be traced from the stomach along the course of the ductus communis, and that he has frequently seen the gall- ducts so contracted and thickened in such persons, that they could not transmit bile. 8. The influence of mental emotions over the biliary organs is illustrated by the occurrence of jaundice from a fit of passion, and by the sallowness and other symptoms of biliary disturbance that frequently attended hypochondriasis. Mr. Annesley remarks, that the depressing passions are not always to be re- 152 diseases of the biliary organs (Fatty Liver). garded as symptoms, but in some cases as the cause of hepatic disease; and Dr. Wilson Philip alleges, that not only does mental depression often instantly derange the functions of the liver, but that it seldom fails, if long continued, to affect its structure. 9. Affections of the biliary organs are liable to succeed to diseases of other organs, which may in such circumstances be regarded as standing to them in the relation of exciting causes. We shall, therefore, introduce here a few observations on these successions. That the liver is liable to undergo morbid changes in the progress of fevers, especially those of a remittent and intermittent type, is attested by general experience. In nearly half the fatal cases of the typhoid fever of Paris, M. Louis found the liver in a state of softening. Dr. Davis found in the bodies of those who died subsequently to their suffering from the intermittent fever during the Walcheren expedition, that the liver was generally congested, and sometimes of a gelatinous consistence, and the portal system obstructed. But the affection of the liver accompanying fevers in hot climates, is often of a decidedly inflam- matory character. Dr. Nicholl says, that in India acute hepatitis is frequently complicated with fever, as well as with dysentery or diarrhcea, but whether as the effect or as the cause he cannot determine. That diseases of the biliary organs, dynamical perhaps at their commence- ment, and becoming structural in their progress, may take their origin from affections of the alimentary canal, and particularly of the duodenum, seems, both from anatomical and physiological considerations, to be extremely pro- bable. M. Andral is disposed to concur in the opinion of Broussais, that in most cases of inflammation of the liver, there has been previous duodenitis. The observation of symptoms seems to him to favour this conclusion; and in some cases, the examination of the dead bodies of jaundiced persons has dis- closed acute duodenitis as the only lesion. We have already referred to the general belief, that the primary morbific action of spirituous liquors is on the alimentary canal, and that continuous traces of disease may be observed extend- ing from this canal to the substance of the liver, in persons addicted to intoxica- tion. Ribes suggested (and Andral seems to have agreed in the opinion), that inflammation commencing in the intestinal canal may propagate itself to the liver, not only along the mucous membrane, but also along the veins. It seems not impossible that inflammation of the duodenum, without extending bevond the orifice of the ductus communis, may obstruct the flow of the bile, so as to occasion in the first place jaundice, and eventually organic disease of the liver. Dr. Stokes thinks that the dependence of hepatic affection on duodenitis is to be explained on a different principle; he supposes that the gastro-duodenitis acts sympathetically on the liver, but without exciting hepatic inflammation; and that the jaundice by which this affection is attended, is the result of a mere lesion of the innervation of the liver. Dr. Marsh has adduced several cases to prove, that a long continued obstruc- tion of the large intestines from an accumulation of scybala, occasionally causes jaundice; but he offers no explanation as to the modus operandi of this cause. It was long ago, however, suggested by Dr. Coe, that jaundice may depend upon the " duodenum being loaded with such contents as to stop the orifice of the duct, or the colon being stuffed with hard faeces pressing upon the duodenum and ducts." Dysentery is one of the diseases with which hepatitis is very liable to be complicated, particularly in tropical climates. Much doubt has existed as to the relations of these two diseases—which of them ought to be regarded as the primary, and which as the secondary affection, or whether they should be con- sidered as parts of the same disease. Dr. Nicholl says, that in India he has sometimes seen hepatitis come on immediately after the subsidence of dysenteric symptoms; while, in other cases, weeks and months have elapsed before the appearance of hepatic symptoms. diseases of the biliary organs (Fatty Liver). 153 We shall again have occasion to allude to the influence of diseases of the heart, and particularly of such as impede the emptying of the inferior vena cava into the right auricle, in producing sanguineous congestion of the liver; a sub- ject which has been especially considered by Corvisart. (See art. Inflamma- tion of the Liver, post.) We can easily understand that diseases of the lungs, by occasioning an im- pediment in the circulation of the blood, may act back upon the liver. Mr. Paisley, formerly head surgeon in Madras, particularly noticed this connexion between diseases of the lungs and morbid conditions of the liver; and Dr. Powell has frequently observed the liver gorged and enlarged, of a looser texture, and softened, in examining phthisical patients, or such as from any cause had the lungs rendered less pervious than natural. That fatty degeneration of the liver is a very frequent attendant on pulmonary consumption, seems to be well established, though of the nature of their con- nexion it is impossible to suggest any explanation. Laennec remarks, that fatty infiltration of the liver is found in other chronic diseases, and even with- out any serious concomitant organic lesion ; and he does not agree with Brous- sais, who believes it to be the consequence of inflammation of the duodenum. Of 49 cases of fatty liver which presented themselves to M. Louis's observation, 47 occurred in phthisical persons ; so that, as he observes, it may certainly be considered as a dependency on that affection. He concurs with Laennec in re- fusing to recognise diseases of the duodenum as one of the causes of this morbid production, seeing that duodenal affections are very rare, and quite as unfre- quent among persons with fatty as among those with healthy livers. Dr. Home mentions, that of 65 cases of phthisis in which the liver was examined, in the Edinburgh Infirmary, in 10 it was in a fatty and in 5 others in a waxy state. All these cases of diseased liver, except one, occurred in women. In 23 of Dr. Home's 65 cases, the liver exhibited different forms of the early stages of cirrhosis, —a morbid condition which is not noticed either by Louis or Andral as occur- ring in the liver of phthisical patients. The fatty liver is almost exclusively confined to two different classes of individuals: to phthisical young women, and to drunkards. The most probable cause of the alteration is the condition of the blood, which must he gradually altered under the influence of causes which are totally distinct; as the hydrogen and carbon predominate, fatty matter is thrown out into the tissue of the liver, alone, or in the liver and cellular tissue of the body : the former is true of phthisical patients—the latter of drunkards. G. The frequent coexistence of diseases of the liver and of the brain was par- ticularly noticed by Dr. Cheyne, who pointed out various cerebral affections, in which there is frequently coincidence of dynamical derangement, or of struc- tural alteration of the liver. On the question of priority and succession in these two classes of diseases, Dr. Cheyne remarks, " that the brain should be sud- denly affected in consequence of its connexion with the liver, is not more re- markable than that the liver should be suddenly disordered from affections of the brain. Yet this last is an established observation. I am informed by a gentleman who has occasion to dissect a great many bodies, that, in diseases of the brain, he never fails to find the liver diseased, either as a cause or a con- sequence. The same gentleman assures me, that the liver generally discovers the marks of recent inflammation after fatal injuries of the head. Every sur- geon knows that abscess of the liver is a common effect of injury of the brain." Dr. Prichard, in referring to a statement of the late Mr. Todd, as quoted by Dr. Cheyne, that in every dissection he had made of cases of idiotism and mental derangement (amounting to upwards of 400), he had found the liver more or less diseased, acknowledges that, in his own practice, the instances have not been numerous in which organic disease of the liver, or other large viscera, has been discovered in conjunction with maniacal disorders. But of the con- vol. hi. 20 154 DISEASES OF THE BILIARY ORGANS (Liver). junction of such diseases with epilepsy, he has seen a sufficient number of cases to conclude that there must be some sympathy or connexion, depending on some unexplained principle of pathology, between that morbid state of the brain which gives rise to epilepsy, and a diseased state of the liver, and other large viscera of the abdomen. The liability of the liver to become the seat of abscesses, subsequently to the reception of injuries on remote parts, was first taken notice of in regard to injuries of the head. Pare mentions examples of this occurrence, and endea- vours to account for it. Subsequently to his time, many similar cases were re- corded by surgeons, and various explanations of this occurrence proposed. Some supposed that the matter of the abscess was originally formed within the head, and in some way or other conveyed to the liver. In progress of time it was ascertained, 1st, that the liver is not the only organ in which abscesses are found subsequently to injury of the head; and, 2dly, that injury of the head is not the only form of remote lesion, which is followed by abscess of the liver or other organs; and hence it becomes necessary to look beyond any relation between the head and the liver, or between any other two portions of the body, in at- tempting an explanation of this phenomenon. Recent discoveries suggest the probability of the veins being the medium of communication between the seat of injury and the seat of the consecutive abscess, and that inflammation of the lining membrane of these vessels in the part injured, the consequent formation of pus, and its introduction into the circulation, are some of the steps of the process. But whether the pus thus formed in the seat of the primary lesion is, in some instances at least, simply conveyed to and deposited in the seat of the consecutive abscess, or whether it gives rise there, in all cases, to a new inflam- mation, in the course of which the abscess is formed, is a point which remains open for further investigation,—some pathologists at present inclining to the one, and some to the other of these opinions. (See Edin. Med. and Surg. Journ., vol. iii.) FUNCTIONAL DERANGEMENTS OF THE BILIARY ORGANS. General description.—Diminished biliary secretion.—Excessive biliary secretion.—Vitiated biliary secretion.—Impeded excretion of bile.—General view of the symptoms.—Treatment of functional derangements of the biliary organs.—Biliary concretions or gallstones.—Their symptoms and treatment. As the peculiar functions of the liver and its appendages consist in the secre- tion and excretion of the bile, the functional derangements of these organs must obviously be referrible to an increased, a diminished, or a vitiated secretion of that fluid ; or to its impeded, altered, or deranged excretion. These various disturbances of the functions of the biliary organs may, there is reason to be- lieve, occur independently of perceptible alterations in their structure- or thev may occur as consequences of, or at least in combination with, obvious struc- tural alterations. But whilst the bile may undergo various morbid changes without apparent disease of its secreting organ, on the other hand, it may pre- sent, to all appearance at least, its natural characters, and be found in its usual quantity and situations, in cases in which there exists extensive structural altera- tion of the liver. On what pathological conditions of the solids or fluids can morbid secretion of bile, in respect of quantity or quality, be supposed to depend ? The following appear to be the principal morbid states to which such an effect can be referred • 1, those of the blood, out of which the secretion is formed; 2, those of the the biliary organs (Functional Derangement). 155 secretory apparatus of the liver, by which its formation is effected; 3, those of the nervous system, as influencing the biliary secretion, both organically and mentally; and, 4, those of other organs, more or less remote, which exert an influence over the secretory apparatus of the liver. We can easily conceive that the blood may at one time contain more, and at another time less, than a due share of the principles which enter into the com- position of bile, and that such variations in the composition of the blood may affect the quantity of bile produced. The amount of this secretion may also be supposed to be influenced by the quantity of the blood which reaches the liver, and the length of time that it remains there. Any notion we can form as to changes in the condition of the secretory apparatus of the liver, capable of modifying the biliary secretion, must rest on the idea of secretion being, more or less, a process of filtration. Sometimes the blood passes through the biliary apparatus, little if at all changed; and this cir- cumstance favours the idea that modifications may occur in the state of this apparatus, capable of occasioning some variety in the physical and chemical qualities of the bile. Without insisting on the general physiological doctrine of the dependency of glandular action upon the nervous system, we may remark that various patho- logical phenomena lead to the recognition of an organic influence exerted by the brain over the biliary function in particular; but we shall find that it is not always very clear, whether it is the secretion or excretion of bile that is primarily affected in this manner. Physiology seems to show that the duodenum is the organ, the varying con- ditions of which have the most immediate influence on the biliary function. The flow of bile into the duodenum is not constant, but occasional only, depend- ing upon the presence of foreign matters in that portion of the intestinal canal: it is probable that where excretion is interrupted by any cause, secretion will be more or less arrested; and, on the other hand, that where excretion goes on with more than usual activity, a corresponding impulse will be given to secre- tion. Hence we can suppose, that under various morbid conditions of the duo- denum, the biliary secretion may be affected at least in respect of quantity. Before noticing more particularly the several modifications to which the biliary secretion is subject, we may remark, that a general belief in their fre- quent occurrence, and in their powerful influence in impairing the function of digestion, has led to the recognition of a class of maladies, termed Bilious, without the precise signification of this term having been very clearly defined. Some physicians seem to comprehend under it those diseases of the digestive organs that are attended with excess or redudancy of bile; others, those in which the bile is deficient or vitiated: while others extend it to all derange- ments of the digestive functions, attended with any form of biliary disorder. Nor has much discrimination been shown in distinguishing between cases of impaired digestion, actually depending upon deranged biliary secretion, and those referrible to other morbid states of the organs concerned in digestion; the terms " impaired digestion" and " deranged biliary secretion" being not unfrequently used as synonymous, as if the secretion of bile was the only con- dition upon which digestion depends. But when we consider how very compli- cated a phenomenon digestion is, it must be apparent that its disturbance is not likely always to depend upon the same cause, and that consequently the mere occurrence of indigestion is no positive proof of a morbid condition of the biliary secretion. Diminished Biliary Secretion. The only positive means of ascertaining that there exists a deficiency of the biliary secretion, or (as some term this condition) the state of torpor of the liver, is by finding the faeces more or less pale, or of a dull white or ash-colour, in cases in which there is no evidence of mechanical obstruction to the flow of the bile. There is a class of cases of great interest, in which some pathologists imagine 156 the biliary organs (Functional Derangement). that there occurs not only a diminution, but a suspension or suppression, of the biliary secretion. In these, jaundice occurs, although on post mortem examina- tion no disease of the liver, nor any obstruction to the flow of the bile, is per- ceptible, while the bile-ducts are absolutely empty. It is argued that the jaundice must in such cases be owing to the non-separation, from the blood, of the ele- ments of which the biliary secretion is composed. The advocates of this expla- nation suppose that there is an analogy between this affection and that of the suppressed secretion of urine. In both, the supervention of coma implies the action of a poison on the nervous system. In ischuria renalis, urea is discovered in the blood, as it is in animals whose kidneys have been extirpated. In jaun-' dice, the presence of bile in the blood cannot be doubted. To account for the rapid fatality of this species of jaundice, Dr. Alison has very ingeniously sug- gested that the economy sustains more injury from the excrementitious principles not being separated from the blood at all, than from their reabsorption subse- quently to their separation; and in this circumstance, again, he finds an addi- tional point of analogy between this form of jaundice and renal ischuria, which is a much more severe affection than where the urine is reabsorbed into the system after having been secreted. When either diminished secretion or suppression of bile occurs as a dynamical affection, on which of the several pathological conditions recently noticed can it be supposed to depend? This is a question to which we are probably far from being able to give a satisfactory reply. A deficiency of bile might be expected most usually to accompany structural alterations of the liver, when portions of that organ are more or less completely destroyed, or altogether removed. But experience shows that, in many cases at least, the secretion is carried on at its usual or even at an increased amount, when there exists very extensive disorganization of the liver. It is alleged, that when gall-ducts become impervious, the secretion of bile may cease, being no longer subservient to any purpose. Such a cessation may be supposed to depend immediately, either on the cutting off of the necessary stimulus to secretion derived from the duodenum, or on the pressure of the retained bile upon the secretory apparatus. Excessive Biliary Secretion. Of the occurrence of an excess, as of a defi- ciency, of the biliary secretion, our principal means of judging must be derived from the appearances, and particularly the colour, of the alvine evacuations. This mode of judging is, however, sometimes fallacious; a small quantity of bile may be diluted with fluids in the intestinal canal, so as to give the appearance of copious bilious alvine evacuations; or matters existing in the alvine evacua- tions may be mistaken for bile, when in reality they are of a very different nature, as when they consist of blood more or less altered. " It is possible," observes Dr. Abercrombie, " that the bile may be increased in quantity, but it must at the same time be admitted that our prevailing notions on the subject are rather hypothetical, than founded on facts." " I am not aware of any tests, by which we can judge with precision of its redundancy in the alvine evacuations." Demonstrative proof of an increased biliary secretion is, however, frequently obtained in post mortem examinations. Andral has found the liver gorged, and the intestinal canal filled, with bile, in several cases of copious diarrhcea, m which this could not be attributed to suppressed excretion. The liver, with the excep- tion of the engorgement, exhibited in these cases nothing unusual, but the mucous membrane of the intestines was inflamed and ulcerated ; sometimes there was merely injection of its vessels. It is very generally alleged, that an increased biliary secretion is a common consequence of an elevated temperature. Considerable ingenuity has been dis- played in accounting for this fact, especially in respect of natives of a temperate exposed to the influence of a hot climate; to which exposure the increased secre- tion and all the derangements consequent upon this change of climate have been referred. According to one hypothesis, the increased biliary secretion in hot the biliary organs (Functional Derangement). 157 climates depends on a sympathy between the extreme vessels on the surface of the body, and those of the vena portarum; while others suppose it to depend upon a vicarious connexion between the liver and lungs, which enables one of these organs to perform in part the functions of the other. It has been found, that the quantity of carbonic acid gas formed in respiration, in a given time, is much diminished by a high temperature, and by other circumstances which, as it is said, lower the powers of life. Hence, the excess of carbon must be carried off by some other channel than the lungs ; and as bile is chiefly formed of carbon and hydrogen, an increased secretion of that fluid will guard the system against the superabundance of the former of these substances. To this cause, therefore, has been assigned the increased flow of bile in warm climates; and a similar explanation is offered of its occurrence from other causes, such as sleep, depres- sing passions, fatigue, stimulating drinks, &c, viz., that their primary effect is to diminish the quantity of carbonic acid gas formed in respiration. As to the pathological conditions, out of which excessive biliary secretion may be supposed to arise, the explanation just given of its connexion with an elevated temperature obviously implies, that it may have its immediate origin in the condition of the blood, as containing a larger proportion than usual of the constituent elements of the bile, the presence of which may urge the liver to excessive action. Whether there be any other circumstances besides those already enumerated, in which such a state of the blood is engendered, seems to be a matter well worthy of investigation, particularly with reference to diet, and more especially the plentiful use of animal food. When jaundice occurs without deficiency of bile in the stools, we may conclude that there exists a redundancy of the biliary principles in the system. Increased biliary secretion may also proceed from altered states of the hepatic circulation ; thus it may be excessive in hepatic congestion, and in the first stage of hepatitis. 2. It does not seem to be produced by any dynamical condition of the hepatic secretory apparatus. 3. It may be occasioned by any particular states of the nervous system, or by mental emotions? That a fit of passion has been succeeded by jaundice is well known, but the connexion between these phenomena is very obscure. 4. Increased biliary secretion has usually been supposed rather to give rise to, than to depend upon, deranged action of the intestinal canal, as in the production of bilious diarrhcea and cholera. Vitiated Biliary Secretion. That the bile is liable to undergo various modi- fications in the constituent elements, is shown by the diversities which it pre- sents in its physical characters, as it is found in the gall-bladder and ducts in fatal cases; and is further confirmed by chemical analysis, the only satisfactory mode of ascertaining the nature of these modifications. The noxious influence which, in particular cases, the bile has been found to exert, when introduced into the system of a healthy animal, seem to afford additional proof of its occasional vitiated constitution. Impeded Excretion of Bile. The bile, subsequently to its secretion, may be prevented from entering the intestinal canal by a variety of mechanical impe- diments ; but the gall-bladder and tubuli biliferi may also become distended with that fluid, without there existing any apparent obstruction to its flow. Some pathological facts seem to countenance the opinion that these latter cases de- pend on spasms of the ducts, such as that the attacks are frequently temporary, suddenly commencing and suddenly ceasing, and that they occur in nervous and hysterical habits. By some pathologists, however, the occurrence of spasms in the biliary ducts is regarded as a pure supposition (Andral, Clin. Med., iv. 343), and some imagine that if retention of the bile ever depends on spasm, it is the duodenum, and not the gall-ducts, that is the seat of the spasm. Some attribute the retention of the bile in cases in which the ducts exhibit no mechanical obstruction, to preternatural viscidity of that fluid itself; others think that this viscidity, when it exists, is more probably the consequence of the bile's detention. 158 TnE biliary organs (Functional Derangement). When from any cause the bile has been obstructed, it is very commonly reabsorbed into the system, and being deposited in the different textures of the body produces the state denominated jaundice. But cases are recorded, in which a great accumulation of bile has occurred in the gall-bladder, proving its regular secretion, while the evacuations have been destitute of colour, and yet no jaundice has manifested itself. In some instances of this nature, the accu- mulated bile has even formed a tumour externally, with an evident fluctuation, and such a tumour has been punctured under the idea that it contained purulent matter. Symptoms of functional derangements of llie biliary organs. It is obvious that, in judging of the existence or non-existence of functional derangements of the biliary organs, we must be guided in a great measure by the appearances of the alvine evacuations. It being understood that their qualities, and par- ticularly their colour, are regulated by a due admixture of healthy bile, any changes of this fluid in respect of quantity or quality, may be expected to influence their appearances. From the characters of the alvine evacuations in cholera and in bilious diar- rhcea, these affections have usually been regarded as indicative of an excessive biliary secretion; but of late years, pathologists have been led to suspect that this doctrine rests on insufficient grounds. " I must confess my suspicions," says Dr. Abercrombie, " that the term bilious stools is often applied, in a very vague manner, to evacuations which merely consist of their feculent matter mixed with mucus from the intestinal membrane." Mr. Tytler, Dr. Holland, and others, seem to entertain similar views. The dark or black appearance of the alvine evacuations, usually termed melcena, was formerly regarded as depending on vitiated bile. It is now, how- ever, understood that this condition of the stools is generally caused by a mor- bid exudation from the intestinal mucous membrane. The liability of such discharges to be mistaken for vitiated bile, is increased by their frequent occur- rence in structural diseases of the liver, which Mr. Langstaff attributes to a morbid sympathy between the liver and intestines, but which is probably refer- able to congestion of the portal venous system. From the appearance, how- ever, which the bile occasionally exhibits in the gall-bladder, it seems reasonable to suppose that, in some instances at least, inky or pitchy stools may derive their characters from that fluid. Another appearance of the alvine evacuations not unfrequently observed, and supposed to indicate deranged biilary secretion, is that usually designated as green or greenish stools. Some writers on bilious affections attribute this colour to the action of some acid matter on the bile, subsequently to its entrance into the intestinal canal. Several practical writers, however, believe that this apppearance of the evacuations is attributable entirely to a peculiar morbid secretion from the intestinal canal, and that the bile is not concerned in its pro- duction. This is a subject which seems to deserve fuller investigation than it has yet received. When the alvine evacuations exhibit a white colour, this is generallv in con- nexion with the state of jaundice; and may be regarded as indicating the exist- ence of some obstruction to the passage of the bile into the alimentary canal, and its consequent reabsorption. But white stools have also been observed in some cases in which jaundice did not exist. The most probable explanation of the occurrence of white stools in cases of this last description, seems to be, that the blood is deficient in the biliary principles; for if they depended upon functional derangement of the liver itself, the biliary principles would remain in the blood, and give rise to jaundice. Dr. Coe supposes that, in some cases, the white stools depend upon a morbid condition of the bile, by which its yellowness is destroyed, and he alleges that the same effect (viz., white stools) may be pro- duced by the detention of the bile in the gall-bladder, when, from some peculiar the biliary organs (Functional Derangement). 159 state of the coats of that receptacle and the ducts, or from viscidity of the bile itself, it cannot make its way into the blood. Treatment of functional derangements of the biliary organs. The foregoing view of the simple functional or dynamical derangements of the biliary organs suggests the following indications of treatment, as applicable to the several forms: 1, to diminish biliary secretion when excessive; 2, to increase this secretion when deficient; 3, to correct it when vitiated ; and, 4, to promote the excretion of bile, and the removal of spasm of the biliary passages. The first indication then to be considered, is that of diminishing the hepatic secretion when it is in excess. Independently of any specific power which is attributed to mercury in this respect,—a matter hereafter to be considered,—it is only by avoiding the occasional causes of increased biliary secretion that this indication can be fulfilled, viz., by avoiding exposure to high temperatures, and by diminishing the quantity of animal food. The efficacy of these measures may depend either upon their modifying the qualities of the blood, or on their removing vascular congestion. If the excessive biliary secretion seems to depend upon a morbid condition of the alimentary canal, it is obvious that the attention of the practitioner should be in the first place directed to its correction. The second indication, that of increasing the biliary secretion when it is deficient, is supposed to be effected by a class of medicines that have been deno- minated Cholagogues, respecting the exact mode of operation of which a great diversity of opinion exists. The remedy of this kind on which most reliance is placed by British practitioners, is undoubtedly mercury, and we shall afterwards find that its efficacy is supposed to depend, by some, on its possessing a specific power of directly stimulating the biliary apparatus, while others attribute its effects on the liver to its action on the intestinal canal as a purgative. In connexion with this indication, we may consider the question whether medicine affords any means of counteracting the injurious effects arising from a deficient secretion of bile, so long as this continues. There are obviously two ways in which such a deficiency may act injuriously on the economy. The one, depending upon the absence of bile in situations where it is usually met with, is limited to the function of digestion; the other, depending on its presence in unusual situations, extends to the general economy, and particu- larly affects the functions of the nervous system. If we were acquainted with the precise purpose which the bile fulfils in the function of digestion, we should be assisted in judging what aid medicine can afford for remedying its deficiency. Those who suppose that its action consists in correcting acescency, may imagine that its place may, in part at least, be supplied by alkaline remedies. Those who conceive that the bile promotes digestion, by stimulating the peristaltic motions of the intestines, must consider purgative medicines as the proper substitute for its deficiency. Leaving out of view such speculative judgments, and looking only to the results of experience, we find that the most beneficial treatment in cases of deficient biliary secretion consists in, 1, the careful regulation of the diet, so as to render it as easy of digestion as possible; 2, the administration of bitter tonics; and, 3, of laxative or purgative medicines, so as to keep the bowels gently open. " The tempo- rary defect of bile," says Dr. Saunders, " may be supplied by various bitters, occasionally united with rhubarb, aloes, and the like." Whatever may be the purpose of the bile as a secretion, it cannot be doubted, that the formation of this substance is not of less consequence as an excretion that secures the elimination of some principles noxious to the system. When, therefore, the bile either is not secreted, or is re-absorbed after being secreted, have we any means of correcting its injurious effects? Little, we believe, in the way of palliation, is in our power in this respect. In the very small num- ber of cases in which an attack of coma, supervening on jaundice, has been successfully combated, the benefit seems to have been derived from purgatives, 160 biliary concretions (Calculi). nnd such applications to the head as are suggested by the apprehension of inflammation of the brain. The third indication is to correct the biliary secretion when vitiated. The degree of control over, the acid or alkaline character of the urine, which has been derived from a more accurate knowledge of the morbid states of that fluid, has excited hopes of similar success, with regard to the vitiations to which the various glandular secretions are subject. It must be admitted, however, that the knowledge we at present possess of the biliary secretion in health and disease, does not enable us to lay down any rational indications for the correc- tion of its morbid conditions, with the exception, perhaps, of the treatment required in cases of biliary concretions, which will be presently noticed. The fourth indication of treatment which we have specified, is that of pro- moting the excretion of the bile, and the removal of spasm of these canals, sup- posing them to be muscular. When the bile is accumulated in its passages, in consequence of the torpor of the powers by which it is naturally propelled, or of some slight mechanical obstruction, the administration of emetics, by calling into action the diaphragm and abdominal muscles, and thus compressing the liver, may effect this indication. When by such means the bile is thrown into the alimentary canal, its easy passage is promoted by the copious use of di- luents, with or without laxative medicines. " In general," says Dr. Saunders, " bile is a purgative sufficiently stimulating for its own evacuation, only re- quiring the assistance of warm water for facilitating its discharge. If, however, in some cases, it irritates without purging, I would recommend the use of small doses of the neutral salts, such as-soluble tartar, sal catharticus amarus, and the like, and in all cases they do most, good under dilution." Biliary Concretions, or Gall-stones. As connected with the variations to which the physical and chemical constitution of the bile is subject, we next proceed to the consideration of gall-stones. According to Andral, these concre- tions may, in respect of their chemical composition, be referred to four heads:— 1. Those composed of the yellow matter of the bile; 2. Those consisting of the resinous matter; 3. Those consisting of picromel; and 4. Those of cholesterine. Chevreul and the late Dr. Turner agree in stating that the most common con- stituents of gall-stones are the yellow colouring matter of the bile, and choles- terine ; the latter generally predominating, and being sometimes in a state of purity, but sometimes wholly wanting. Sometimes gall-stones contain a por- tion of inspissated bile; and most cholesterine gall-stones have inspissated bile for their nuclei. The formation of calculi consisting of inspissated bile may be dependent either on original spissitude of the secretion, or on its accidental detention in the gall-passages, favouring the absorption of its watery particles. But when cho- lesterine concretions are formed, we must either suppose that the bile contains this principle in excess, or (as Muratori suggests) that there is a deficiency in the bile of the element on which the solution of its cholesterine depends, viz., soda. Dr. Bright has observed, that concretions of adipocire are frequently de- posited in the gall-bladder, in patients labouring under scirrhus. But besides true gall-stones, concretions composed of phosphate of lime are occasionally found in the gall-bladder. In two instances of this kind observed by Andral, the cystic duct was obliterated. Gall-stones may form in all parts of the biliary passages. Most frequently, however, their first formation takes place either in the tubuli or in the gall- bladder, and they are subsequently conveyed from these into the larger ducts, where they increase in size. In whatever portions of the biliary passages they are formed, they may be driven onwards, by the flow of the bile, to the gall- bladder or to the duodenum. The number and size of biliary concretions vary considerably. Some- times a single calculus fills the whole gall-bladder; while, in other instances, that sac contains several thousands, of minute dimensions. biliary concretions (Sym])toms). 161 It is obvious, that the effects of a biliary calculus as regards the excretion of the bile, must be greatly modified by its situation. If it is lodged in the cystic duct or in the gall-bladder, the bile will continue to enter the duodenum ; but if in the hepatic or common duct, the passage into the duodenum will be closed. A small calculus lodged in the ampulla formed by the union of the biliary and pancreatic ducts, may occasion complete retention of the bile, while a much larger calculus lodged in a more dilatable portion of the passages, may allow the bile to pass between it and the parietes of the duct. Biliary calculi of large dimensions are sometimes voided by stool, or found afler death in the intestinal canal. With regard to these, it may be questioned whether the gall-ducts are capable of such distension as to have allowed them to pass ; or whether they have acquired their large size subsequently to their reaching the intestines ; or whether they have been formed exclusively in the biliary passages, and entered the intestine by some preternatural route. It is not probable that a biliary calculus can receive any addition from the bile after reaching the alimentary canal, though it is conceivable enough that such a cal- culus may form the nucleus of an intestinal concretion. That biliary concre- tions sometimes reach the intestinal canal by a perforated aperture of communi- cation, does not admit of doubt; many cases being recorded in which adhesion and ulceration have taken place between the gall-bladder and the duotlenum, by which an opening has been effected sufficient for the passage of a large cal- culus ; in other cases, the gall-bladder has in the same manner formed a com- munication with the ascending colon. In some cases, biliary concretions are discharged externally, by producing abscess and ulceration of the coats of the biliary passages, particularly of the gall-bladder, and of the parietes of the abdomen. (Soemmering, De Concre- ment. Bil. Corp. Hum. 1795.) Symptoms. When biliary calculi block up the ducts, they give rise to the train of symptoms comprehended by nosologists under the term jaundice, con- sisting particularly in yellowness of the skin, whiteness of the stools, and muddy redness of the urine. The state of jaundice, however, may arise from various other conditions of the biliary organs, some dynamical and others structural, as will be afterwards shown, and cannot therefore be held as conclusive evidence of the existence of calculi. The existence of gall-stones is frequently attended with fits of pain of greater or less intensity, and of longer or shorter continuance; but this is by no means invariably the case. On the contrary, in a large proportion of cases, the exist- ence of biliary concretions remains unknown till revealed by post mortem exami- nation. In considering the presence or absence of pain in the hepatic region as a diagnostic character for determining the existence of biliary concretions, it is necessary to keep in mind the three different situations in which these bodies may exist, viz., 1, the gall-bladder; 2, the gall-ducts; and, 3, a passage formed by ulceration between the gall-bladder or ducts, and the intestinal canal. Biliary calculi may remain in the gall-bladder, without occasioning pain, or any other symptom, and have frequently been found, in that situation, in dead bodies when their existence was unsuspected during life. Sometimes, however, they occasion a dull pain, which may increase on motion or after food, and in some instances the pain is very severe. The pain which usually attends the passing of a biliary concretion along the gall-ducts, is often intense. It is generally seated in the pit of the stomach, extending to the right hypochondrium and back, and recurring in frequent pa- roxysms like labour pains. The sufferings of the patient are of the most acute and agonizing description. Intervals of comparative ease succeed these pa- roxysms, but there generally remains a dull, obtuse pain in the epigastric region, from which those of a more acute character appear to proceed. Of the circum- stances influencing the degree of pain which accompanies the passage of a gall- stone along the ducts, the most obvious is the size of the calculus, occasioning vol. m. 21 162 biliary concretions (Treatment). a proportional degree of distension in the biliary ducts; but besides this, it has been supposed that the ducts are capable of spasmodic contractions, in conse- quence of which intense pain may proceed from the passage of a calculus by no means considerable. When an intense degree of pain occurs in the hepatic region as a consequence of inflammatory action, we may expect it to be accom- panied by febrile excitement, a symptom which is not present in spasm of the gall-ducts. Hence, as Dr. Pemberton remarks, the more exquisite the pain is, provided the pulse is below 100 in a minute, with the more confidence may we rely on this diagnostic symptom. The simultaneous occurrence of perspiration affords another presumption that the pain is not the consequence of inflammation. " The severity of the pain is so extreme," says Dr. Bright, in speaking of the passage of gall-stones, " as to bring on a state of the greatest exhaustion, and reduce the pulse below the natural standard, both as to strength and frequency, or still more often to render it rapid and weak, while the hands and the whole surface are bedewed with a cold perspiration." Where calculi have passed from the biliary passages into the intestinal canal, by perforating their respective coats, there seems reason to believe that the whole of this process has been effected without the production of any considerable degree of pain. When biliary concretions have found their way into the intestinal canal, they are, in a large proportion of cases, discharged with the evacuations. Cases occur in which all the symptoms of ileus manifest themselves, but abate or cease simultaneously with the discharge of a gall-stone from the intestinal canal. In some fatal cases of ileus from gall-stone, the calculus has been found in the gall- ducts (Abercrombie, p. 363); in others, in the intestinal canal (p. 125). Cru- veilhier mentions a case, in which one calculus was found in the jejunum (above which, the alimentary canal was distended with a brownish-yellow fluid); and another was fixed in an ulcerated communication between the gall-bladder and duodenum. Sometimes the ileus appears to depend upon an agglomeration of several calculi causing obstruction of the intestinal canal. Treatment. The indications referrible to this head seem to be the prevention and solution of biliary concretions, so far as these are objects which it is in the power of medicine to promote, and the facilitating their passage along the ducts. The prevention of the formation of biliary calculi must obviously depend mainly on avoiding the causes of their production. It has been alleged, how- ever, that the long-continued use of alkalies renders the bile less disposed to concrete, and even affects the softening and the solution of concretions already formed. Those agents which have been found capable of dissolving biliary calculi out of the body, have, at different times, been recommended as proper for internal administration in cases in which gall-stones are supposed to exist. Of these, the medicine which, in its day, acquired the widest reputation, was a combination of sulphuric aether with spirit of turpentine (two parts of the former with three of the latter), administered at first in a very small dose (two scruples). This remedy, originally recommended by Durande, a physician of Dijon, has also been much commended by Soemmering, Richter, and others, who unhesitatingly attribute to it the property of dissolving biliary calculi; while those who do not acknow- ledge its possessing such a power, admit that the remedy of Durande occasions,, or at least facilitates, in certain cases, the expulsion of those concretions; which beneficial operation they suppose it to effect by calming the spasm of the parts containing them. (Brichcteau.) We arc next to inquire how the passage of the biliary concretions through the gall-ducts may be facilitated. Our views on this subject must, of course, be influenced by our opinions as to the causes which retard or propel a biliary con- cretion in its course ; whether we suppose the resistance to arise from the physical coherence of the coats of the ducts, or from their spasm ; and whether we sup- pose the power by which the resistsnce is to be overcome, to be the muscular biliary concretions (Treatment). 163 contraction of the ducts themselves, as some imagine; or, as is conceived by others, the compression of surrounding parts ; or, as has also been suggested, the pressure of a fluid accumulating, by continued secretion, behind the obstacle. The measures which in practice have been found most efficacious in fits of gall-stone, are the administration of opium, the warm bath, the warm fomenta- tions, emetics, and sometimes blood-letting. The beneficial effects derived in this class of cases from the administration of opium and other narcotics, has been considered a strong argument for attri- buting the detention of the gall-stones to spasmodic contraction of the ducts. It has been suggested, however, that narcotics, if they allay spasm, must at the same time put a stop to any muscular power by which gall-stones can be sup- posed to be propelled. But whatever antispasmodic influence may be exerted by opium upon the gall-ducts, its power in relieving pain is undoubted, and with this intention it must be administered during the fit of gall-stone, and that in very considerable quantity. Dr. Pemberton says that it should be given until the pain abates; and that, till that object is obtained, the patient should take a grain of solid opium, or 25 drops of laudanum, every hour. A starch and laudanum glyster (40 minims of Tinct. Opii in 4 oz. of starch gruel), repeated every six or eight hours, will frequently produce immediate relief. When the stone is arrested in the biliary ducts, blood-letting may be requisite for the removal or the prevention of inflammation. But the intention with which it is employed in these cases is generally similar to that with which the use of opium and of the warm bath is recommended, viz., to produce relaxation. The quantity of blood to be taken must depend upon the peculiar circumstances of the case. The administration of emetics during a fit of gall-stone has been recom- mended, partly on the idea of their contributing to produce muscular relaxation, and partly from their exciting the action of the abdominal muscles, in the manner already alluded to. Among the advocates for their use may be men- tioned Dr. Coe, Dr. Heberden, and Dr. Saunders. The latter recommends their employment in small doses, so as to create nausea for some time before their emetic effect is produced. " For the same reason," he observes, " tobacco de- serves a trial, as the sickness which it occasions resembles sea-sickness more than any other, and it is probably on this principle that sea-sickness has been so very efficacious in those cases." Dr. Powell's experience is unfavourable to the use of emetics. Dr. Pemberton suggests that " the effect of an emetic is not only to produce relaxation of the whole body, but also to increase the secretion of bile. This increased quantity of bile, if its exit be prevented, will mechanically increase the distension of the duct, and thus will a passage be opened for the calculus. But if the stone, in consequence of its angles, does not completely close the ducts, the bile will pass off, and no distension lake place." When gall-stones give rise to symptoms of ileus, the means to be employed for overcoming the obstructed state of the alimentary canal must be the same as when this state arises from other causes. Indeed, it often happens in cases of this kind, that we are ignorant of the immediate cause of the symptoms, till the case terminates, favourably by the discharge of the concretion, or fatally in death. 164 OF THE BILIARY PASSAGES. DISEASES OF THE BILIARY PASSAGES. Glands of gall-ducts.—Their enlargement.—Inflammation of the mucous membrane of the gall-bladder, ducts, and biliary tubuli.—Collections of pus.—Ulceration and perforation of the gall-bladder and ducts.—Contraction.—Distension of the gall-bladder, various causes of.—Symptoms and treatment of diseases of the biliary passages. In this section we shall consider the structural alterations to which the biliary passages, viz., the tubuli biliferi, the gall-ducts and the gall-bladder are liable. 1. The most common of these is the presence of gall-stones, the composition and mode of formation of which we have already noticed. We allude to them at present simply as foreign bodies, occasioning, in the first place, more or less impediment to the flow of the bile; and, secondly, tending to give rise to more or less acute inflammation of the biliary passages, in all parts of which these concretions form. 2. The attention of pathologists has lately been directed by Mr. Twining to an organic affection which seems to prove not unfrequently the cause of ob- struction to the bile in its passage to the duodenum, viz., the developement of tumours, varying in size from that of a grain of barley to that of a bean, in the capsule of Glisson. " Two small bodies," this writer states, " are always to be found by careful dissection, which, from their structure, appearance, and uni- formity of situation, I am inclined to believe are absorbent glands. One of them is situated near the termination of the gall-bladder in the cystic duct; the other at the upper part of the ductus communis choledochus. Enlargement of these bodies, with inflammatory excitement about the capsulae of Glisson, may cause closure of the biliary ducts. I have found the ducts obliterated exactly at the point where these enlarged glands were causing pressure, if my view of the influence of these parts be correct, we shall have a satisfactory explana- tion of one mode in which transient obstructions to the flow of bile into the intestine are produced from temporary irritation of these glands on the occasion of disorders in the vicinity; and we see a distinct reason for obliteration of the cystic or of the common duct, in the chronic disease of old drunkards, which is just the description of subjects in whom the closure of the ducts most frequently take place." 3. The mucous membrane of the gall-bladder and of the large biliary ducts is liable to attacks of inflammation, either acute or chronic, occasioning its vascular turgescence and general swelling from serous or other effusions, and, when the inflammation is chronic, its more permanent thickening and indu- ration. The inflammation may either be circumscribed, or it may spread over the whole inner surface of the ducts and gall-bladder. It has been alleged that, in these cases, the inflammation spreads from the duodenum into the biliary passages. May it in any case be derived from, or be extended to, the substance of the liver? In acute inflammation of the gall-bladder (cho- lecystitis), the substance of the liver is said to be almost always red; and in the chronic form of this affection, it is not uncommon to find abscesses or tubercles and other degenerations in the liver. The mechanical obstruction produced by inflammation and swelling of the mucous membrane of the biliary ducts will, it is obvious, affect the flow of the bile, in precisely the same manner as a calculus occupying the same position. Inflammation may also occur in the mucous membrane of the smaller biliary tubuli, and it seems probable that to them, at least, inflammatory action in the substance of the liver will be readily communicated. Cruveilhier has repeatedly of the biliary passages (Contraction). 165 found cysts containing concrete bile, in the liver of new-born children. He regards these cysts, which he suspects to have been often taken for tubercles, and which may acquire a considerable size, as the consequence of adhesive inflammation of the biliary tubuli. It very seldom happens that inflammation of the mucous membrane of the gall-bladder terminates in purulent effusion : but in a few cases this has occurred, generally from the irritation of biliary calculi. Ulceration of this membrane may take place as a consequence of the same cause. Sometimes the ulceration consists of simple erosion only. Sometimes it goes on to complete perforation. It may be either confined or extended, or there may be a number of distinct ulcers in different portions of the sac If perforation occur, without previous adhesion of the gall-bladder to the adjacent parts, the bile is effused into the cavity of the abdomen, giving rise to fatal peritonitis; but in many cases, such adhesion has taken place before the whole thickness of the coats is destroyed. The parietes of the gall-ducts, in like manner, may be softened, ulcerated, and ultimately perforated; and this last event will of course be followed by effusion of bile into the cavity of the peritoneum. The perforation of a gall- duct, as Andral observes, sometimes happens behind a point where the duct is obliterated, either in consequence of disease of its coats or of the lodgement of a gall-stone. It is probable that many of the morbid alterations to which the coats of the gall-bladder are subject, as, for example, the formation of cartilaginous or bony plates, or of earthy or stony concretions, originate in the sub-mucous or sub- peritoneal cellular coats. Appearances have sometimes been met with, which would lead to the belief that inflammation had had its primary seat in the sub- mucous cellular coat, and either remained confined to that coat, extending over a smaller or larger portion of it, or spread to the membranes on each side. Serous effusions into the cellular inter-coats have been observed to such an extent, as to add considerably to the thickness of the parietes. Louis mentions, that of seventeen cases of diseased gall-bladder which had fallen under his ob- servation, in two the sub-mucous membrane was hard, thick, and scirrhous, in another case it was merely thickened. Whatever be the nature of the coat which is interposed between the sub-mucous and sub-peritoneal cellular mem- branes in the state of health, it is certain that, in some cases of disease, the existence of muscular fibres in that situation does not admit of doubt: Louis states, that in one of his cases, in which the mucous membrane was destroyed throughout a great extent, there were found beneath the sub-mucous cellular coat, fibres of a muscular appearance, resembling those of the fleshy coat of the stomach; and Andral notices the appearance of muscular fibres in the coats of the gall-bladder, as one of the changes which it is liable to undergo in hyper- trophy. 4. In the healing of ulcerations of the mucous lining of the gall-bladder and ducts, the greater or less contraction of their parietes is liable to occur, pro- ducing shrinking in the bladder, and in the ducts stricture or closure, or occlu- sion, as it has been lately termed. M. Louis mentions eight cases of obliteration of the gall-bladder near its neck. In five, there was more or less affection of the mucous membrane, and in these the gall-bladder was very diminutive, con- taining a very small quantity of mucus or pus. In the other three cases, the gall-bladder, not having experienced ulceration, was of considerable size, and distended with a fluid resembling the white of an egg. In nine other cases of diseased gall-bladder, there was more or less alteration of the mucous mem- brane; and in two of these, its size was diminished. From M. Louis's results, it would appear that the number of cases in which obliteration at the neck of the gall-bladder is accompanied with, and independent of, calculi, is nearly equal. But diminution of the gall-bladder, besides proceeding from ulceration of its 166 of TnE biliary Passages (Distension). lining membrane, may, Mr. Twining conceives, arise from inflammation of its external surface. This author states, that in India, the gall-bladder is commonly distended with bile in persons recently arrived, so as to produce enlargement and deepening of the sulcus in which it is lodged. As a consequence of this dis- tension, inflammation of its serous surface is induced; this is followed by effusion of coagulable lymph, which contracting as it becomes organized, ultimately compresses the gall-bladder to less than its natural dimensions. In many cases, in which inflammation of its serous covering has occurred, the gall-bladder is agglutinated by false membranes to the adjacent part, and membranous bands are sometimes formed between it and the duodenum, that produce considerable constriction of that intestine, and give rise to symptoms which simulate those of organic diseases of the pylorus. Diminution in the size of the gall-bladder may also rise from other circumstances. Thus, when from any cause the bile does not reach the gall-bladder for a considerable period of time a diminution of its capacity takes place. The state of its coats in these cases is very various, sometimes being so soft and thin that they tear on being touched, and at other times thickened, and harder than natural. It seems to be under circumstances such as have been just alluded to, that the gall-bladder occasionally undergoes what is called a cellular transformation. Richter found, in the body of a woman who died in a most intense degree of jaundice, that the gall-bladder was wanting, and in its place there was merely a membranous substance, without a cavity, and of the circumference of a sixpenny piece. And Andral mentions a case in which, a man having died some months after biliary calculi had been discharged externally by an abscess opening in the side, no trace of the gall-bladder could be found; there being nothing in its sulcus, except a mass of cellular tissue of considerable density. From the choledoch canal there arose a duct which resembled the cystic, but could not be traced beyond a few lines, terminating interiorly in a cul-de-sac, and losing itself in the cellular tissue. 5. Distension of the gall-bladder may be produced by an accumulation either of bile, or of fluid secreted from its internal surface. In some instances the bile is accumulated in this cavity, in consequence of some obstruction to its pas- sage into the duodenum ; but in other instances the accumulation occurs inde- pendently of such obstruction. The gall-bladder has sometimes been found to contain twelve pounds and upwards of bile, its dimensions being, of course, proportionally increased. In such cases the distended gall-bladder extends beneath the margin of the liver, and produces a fluctuating tumour, which can be felt through the integuments. Such a tumour is apt to be mistaken for hepatic abscess. When, from impaction of the concretion, or any other cause, the passage of bile from the liver into the gall-bladder is prevented, this receptacle as Dr. Powell observes, is not in general found empty, but distended to about its usual size, or somewhat more, by a thick colourless mucous fluid, which is commonly coagulable by heat, by acids, and by alcohol, and which, except that the coa sometimes again with lumbar pains, much emaciation, strong appetite, and much thirst, so as to bear a close resemblance in its general characters to saccharine diabetes. The urine is for the most part abundant in quantity ; sometimes, however, natural in that respect, of a milky appearance, and varying in density from 1010 to 1020 in the generality of cases. After it has been discharged for a short time it sometimes coagulates into a gelatinous body like blanc-mange, and afterwards gradually separates into a clear yellowish fluid and a white clot; at other times a white flaky matter is deposited without general coagulation of the mass ; and in other cases again, a white homogeneous substance is thrown up to the surface like cream. The matter which separates in all these shapes appears to differ somewhat from al- bumen, to approach to fibrin or casein in its characters, and to contain some oleaginous or fatty matter which may be easily removed by sulphuric ether. In all of these properties it bears a resemblance to the white coagulum of chyle; which it has accordingly been supposed to be. The entire fluid is sometimes coagulable by heat, sometimes not, always coagulable by acids, and easily de- composed by keeping. The clear fluid, after separation of the coagulum, some- 254 suppression of urine (Symptoms). times coagulates by heat, and yields a precipitate with solution of ferrocyanide of potassium, acidulated with acetic acid ; by which property it is distinguished from true albuminous urine. Occasionally the white coagulum contains in its substance some of the colouring particles of the blood. The urea is always very defective, but never altogether wanting. The peculiarities of this kind of urine are usually best marked a few hours after a meal. They are apt to be removed for the time by inflammatory action, or by pytalism from mercurials. This singular condition of the urine has been observed sometimes to occur only at intervals, and is then attended with the general symptoms mentioned above. In other cases it has seemed permanent, at least has been traced for five or even for twelve continuous years ; and it is then generally so little apt to give rise to constitutional derangement, that the individual, as in a case men- tioned by Mr. Abcrnethy, may even become corpulent, or may bear children without apparent injury, as in one of the instances described by Dr. Prout. It has been met with in both sexes, and before puberty, as well as in early man- hood, middle life, and old age. A considerable proportion of cases have oc- curred in the instance of individuals who had been a good deal in hot climates. Its causes are exceedingly obscure. Luxurious living, exposure to cold, extreme fatigue, and the constitutional action of mercury, have been the chief apparent causes mentioned by the reporters of cases. It appears to be common in Brazil. The nature of the disease is not well determined. The majority of authors have referred it to the passage of chyle into the urine, and therefore suppose that a portion of the chyle does not undergo the final stage of the process of sanguification on being thrown into the bloodvessels ; that the blood becomes chylous ; and that the morbid ingredients are thrown off by the kidneys, like many other foreign matters. Plausible as this view may seem, it has not yet received that support from observation which will alone establish it: no one has yet proved that the blood is chylous. The condition of the urine is certainly very like that of the blood in cases of milky serum, where a modified albumen and a great abundance of fatty matter are present; but, strange to say, although blood has been several times drawn in the disease, no one has hitherto taken any notice of its appearance or properties. In the account of a case described by Dr. Graves, the coagulable matter is said to have been casein; which, if correct and of general occurrence, would lead to a different view of the nature of the affection. But the secretion of cheesy matter with the urine in any cir- cumstance is a very doubtful fact. In the only cases where a fatal termination has been observed, death arose incidentally from acute internal inflammation ; and no morbid appearance was discovered in the kidneys. Chylous diabetes seldom calls for any particular treatment. When there is constitutional disturbance, it has been found useful to withdraw blood from the arm, to enjoin sparing living, to promote the functions of the skin, and to ad- minister anodynes and regular laxatives, among which the resinous kind pro- bably are the most appropriate. Tonics do not answer well. Where the disease is habitual and without constitutional disturbance, it ought not to be interfered with. At all events no means of removing it are known. SUPPRESSION OF URINE. Symptomatic of various diseases—Symptoms.—Causes.—Treatment By suppression of urine, the Ischuria renales of most nosographists, and more aptly designated by Dr. Willis, Anuria, is understood the diminution or com- plete arrestment of the secretion of urine. Although usually considered by suppression of urine (Symptoms). 255 practitioners and described in systematic works as a disease, it is probably in correct language a mere symptom of various diseases. It occurs as a symptom in some cases of acute as well as chronic nephritis, in the acute and chronic forms of granular deposition into the substance of the kidneys, as well as in atrophy and other chronic renal diseases. It also occurs as a symptom of certain forms of poisoning, probably in connexion with inflammation. Doubts exist whether it is also presented as a mere functional disorder. In compliance with custom, suppression will be here shortly described as an express disease. The urine may, for a time or permanently, be much reduced below the daily average of thirty-five or forty ounces, formerly assigned as the average of health, without any ill consequence resulting. A temporary diminution to only six or eight ounces daily is common enough in febrile diseases, without any peculiar symptoms being observed to follow. Even in a state of health an un- usually dry diet, especially conjoined with much exercise, and likewise, certain obscure constitutional peculiarities, may occasion a very material reduction, but still, as in the former case, without any evident inconvenience. We even some- times see a permanent decrease far below the natural standard occasioned by constitutional circumstances alone without any injurious effects. The writer lately met with the case of a youth of seventeen years of age, who for two years before had passed never more than six ounces, and for the most part only four ounces daily; yet, except several attacks of loss of appetite and consequent languor and weakness, of short standing, he suffered no inconvenience. In some diseased states of the system the same immunity from any peculiar symp- toms has been remarked, where the urine was almost entirely suppressed for many days together. As to the alleged cases, where the secretion of urine appeared to have been suspended for weeks, months, or even years, in persons enjoying tolerable health, or at all events not subject to any affections refer- rible to inaction of the kidneys, they may be all safely put down to the account of imposition. Admitting that exceptions occasionally occur, there can be no doubt of the general fact, that extreme diminution or complete suspension of the flow of urine is usually followed by very serious symptoms, and generally by death at no great distance of time. The symptoms vary with the circumstances under which the suppression takes place, and probably with its causes ; which how- ever are not yet all thotoughly understood. When suppression takes place suddenly from any cause during a state of health, or in any Other circumstance except a pre-existing state of protracted chronic disease, the usual results are the following:—At first little or no uneasiness of any kind is occasioned ; but ere long there is languor, .restlessness, vague general discomfort, a sense of weight, weariness, and sometimes pain in the loins and lower extremities, upon which the attention is probably for the first time called to an excessive diminu- tion or total suspension of the urine. The pulse then commonly becomes ex- cited, and sometimes regular fever is formed, with heat of skin, flushed features, headache, nausea, and vomiting; but these symptoms are not constant. So far the case presents a resemblance to the early stage of continued fever; for which the disease is at first-not unfrequently mistaken. At length drowsiness comes on, generally in the course of the third day; and about the same period, or sooner, puffiness of the features is observed, or at times distinct oedema of the limbs or body generally, sometimes pitting on pressure, more frequently elastic. The drowsiness gradually passes on to coma, which is usually formed on the fourth day; and death ensues, either within three days more, and with- out any additional symptom, or at an early period of the coma with a precur- sory stage of convulsions. When the bladder is examined with the catheter, which is commonly done from curiosity, or to guard against the possibility of mere retention of urine existing, the instrument brings away at the commence- ment only a few drachms of muddy urine, loaded with mucus, commonly pale, 256 SUPPRESSION OF URINE (Causes). low in density, and often strongly coagulable by heat as well as nitric acid. At a later period the bladder is generally found quite empty. When suppression of urine takes place suddenly during the prevalence of chronic diseases, the symptoms are for thejnost part identical with those just described. But if the flow of urine fall gradually, it is sometimes observed that that the quantity may be reduced to one or two ounces daily of a fluid contain- ing not above a third of the ordinary proportion of solids, and nevertheless without the patient presenting for many days any of the consequences usually expected from so great a suppression. Such is not unfrequently found to be the case in the advanced stage of granular degeneration of the kidneys. The symptoms which at length appear are those of unmixed coma, without fever or any excitement of the circulation at all, and likewise without distinct convul- sions ; and death creeps on by degrees from increasing stupor, very much as in poisoning with opium, but more slowly; or the fatal event is occasioned by some accessary affection prevailing at the time the suppression was induced. Another remarkable circumstance in which suppression of urine may take place with very different phenomena, is in connexion with the effects of certain poisons. Complete suppression has been observed in cases of acute poisoning with large doses of foxglove, corrosive sublimate, and cantharides. But here the kidneys are evidently in a state of violent irritation, as appears both from the lumbar pain, strangury, and often bloody urine at the commencement, and from the redness, softening, gorging, and occasionally even suppuration, which are found in their substance after death. All cases of this kind, hitherto re- corded, seem to have proved fatal from the accessary effects of the poison on the alimentary canal or nervous system, at a period too soon for the develope- ment of the constitutional symptoms proper to suppression. In such cases the suppression of urine is probably not a functional disorder, but merely one of the secondary effects of inflammation. It is well known at least, on the one hand, that these poisons produce nephritis, and on the other that nephritis, if acute, whatsoever its cause, whether exposure to cold, a blow upon the loins, or irritation of the kidneys arising from diseases of the prostate, bladder, and uterus, or from calculi in the kidneys, or from calculi or other ob- structions in the ureters, is often attended with complete arrestment of the urinary secretion. There is still another variety of suppression worthy of distinct mention, on account of the peculiar circumstances in which it has been witnessed, namely, a form lately described by a German author, Schbnlein, and likewise shortly noticed by Dr. Willis as a disorder that has occasionally come under his ob- servation. Sometimes in young children the flow of urine is diminished to a very great degree, or almost entirely suspended, so that only a few drops are passed from time to time and with difficulty; and this state is accompanied with a febrile state of the general system, pain in the region of the bladder, scalding of the urethra and external parts over which the urine dribbles, constipation and scybalous fieces, an acetous odour of the breath, and a tendency to pustular eruptions and intertrigo of the cuticular folds. If not arrested, the disease ends in exhaustion and coma. A similar disorder has been observed in elderly persons, especially in connexion with lithic gravel. Dr. JVillis infers from his experience, that this variety of suppression occurs chiefly as the sequela of con- firmed diseases of the digestive organs or nervous system; and it may be safely added, that many cases of the kind are in all probability nothing else than the concluding stage of chronic derangements of the structure of the kidneys, espe- cially granular degeneration and atrophy, to which the most manifest affections, those of digestion and of the nervous system, are merely secondary. The causes of suppression of urine are various and not yet well understood; but the researches of Dr. Bright and his followers have done a great deal towards elucidating the subject, by pointing out that suppression is very often closely connected with pre-existing organic disease in the kidneys. The imme- suppression of urine (Treatment). 257 diate exciting cause has sometimes been a blow, producing concussion of the parts adjacent to the kidneys, at other times general exposure of the body, or exposure of the lower part of the trunk to cold and wet, and in some instances the action of poison taken inwardly. In such cases suppression appears to he commonly induced secondarily through the intervention of acute nephritis. But more generally it is difficult to fix upon any probable extraneous cause; and it is only after an examination of the dead body, or under an exact ac- quaintance with the varying characters assumed during life by chronic renal diseases, that the true relations of the most prominent disorder, the suppression of urine, become intelligible. If the writer may judge from his own observation, suppression occurs very seldom except in the course of acute and chronic organic diseases of the kidneys. The morbid appearances in acute anuria, or sudden suppression without ob- vious pre-existing disease, are darkness, flabbiness, brittleness, and congestion of the kidneys, sometimes with enlargement, especially of their cortical portion, contraction and emptiness of the bladder, and impregnation of the blood with urea, which may also be detected in the blood drawn during life. In suppres- sion connected with the action of poisons, unequivocal marks of inflammation are sometimes found, namely, redness of the lining membrane of the pelvis, and calyces of the kidneys, purulent matter in the tubuli, which may be squeezed out of the papilla-, and occasionally even a collection of pus in the pelvis. In the chronic form of anuria, which occurs suddenly or gradually in the progress of chronic diseases, it is usual to find the kidneys very much altered in their structure, and their healthy organization in a great measure destroyed. Pro- bably various organic diseases of the kidney may terminate in suppression of urine; but those most frequently found in connexion with it are the several forms of disease which have been classed under the general head of granular degeneration. There is strong reason for suspecting that some cases of acute anuria are likewise connected with the same disorder, the suppression arising in the early stage of that functional derangement which gives occasion to albu- minous urine and granular deposition. Other cases of acute anuria are rather referrible to the acute form of simple nephritis. In some instances the apparent renal affection causing suppression has been the presence of one or more calculi in the kidneys, or one of the ureters. But judging from the descriptions of published cases of this nature, it is not improbable that other chronic disor- ders of structure concurred. This was clearly the case in one of the cases quoted by Dr. Willis. The treatment of suppression of urine differs with the circumstances in which the disease arises. In most cases it is fatal, and not even to be interrupted in its progress by any method of cure, especially when the suppression is com- plete, or nearly so. When the urine is merely much diminished, as in many instances of chronic organic diseases of the kidneys, diuretics, among which digitalis and bitartrate of potash are the most active, will sometimes restore the natural quantity of urine, and avert danger for a time. But when the urine is reduced to a few drachms in the twenty-four hours, or is altogether suspended, recovery is exceedingly rare. In cases occurring without previous organic disease, the most efficacious remedies are free bloodletting, anodynes combined with diaphoretics, such as Dover's powder, the warm-bath purgatives, together with frequent brisk purgative injections ; to which some add, though with ques- tionable propriety, blisters to the loins and diuretics. In cases where the kid- neys have been long diseased, blood should be withdrawn sparingly, because it is always very thin, watery, and unusually defective in colouring globules, so that the constitution cannot safely bear further loss. Purgatives and diuretics are here the most advisable remedies, and blisters too are sometimes of service. For the most part, however, when the urine has become nearly suppressed in long-continued organic diseases of the kidneys, no remedial measures will restore its quantity; and if once drowsiness has fairly set in, the case is all but vol. in. 33 258 ORGANIC DISEASES OF THE KIDNEYS. hopeless. In the coma, which constitutes the final stage of suppression, no remedies are of much avail; bloodletting, which may seem indicated by the state of the circulation, does no good, and sometimes evidently accelerates death. ORGANIC DISEASES OF THE KIDNEYS. Few organs in the body are subject to so great a variety of morbid alterations of structure as the kidney. Most of them, however, are of rare occurrence; and those which are frequent have been discovered to be so only within a few years. Hence the knowledge at present possessed of their anatomical charac- ters, and still more of their external signs during life is in many particulars imperfect. To Dr. Bright particularly belongs the honour of pointing out a few years ago the frequency with which the kidneys undergo changes in their organic structure, as well as the important part performed by these structural changes in the developement of several common and fatal disorders. More recently the entire subject of renal diseases has been taken up by M. Rayer ,-* whose investigations, not yet concluded, promise to throw much additional light upon the rarer organic affections. The general result of these and other inquiries is, that the kidneys are more or less liable to all the alterations of structure which are observed in the great viscera generally, and to certain peculiar affections which bear reference to their peculiar functions. They are subject to inflammation, chronic and acute, parenchymatous and membranous; and they also present hypertrophy and atrophy of their proper structure,—congestion and anaemia,—tubercular, granu- lar, cartilaginous, and carcinomatous deposition and degeneration,—serous cysts, osseous cysts, urinary cysts, and general distension from obstruction to the escape of urine,—together with displacement, anomalous conformation, and deficiency of a kidney. Of the pathological conditions now enumerated, two only are so frequent as to require full investigation here,—namely, inflammation and granular deposition. As for the rest, besides being rare, they are rather objects of anatomical interest than of practical importance; for the signs by which they may be detected during life are equivocal, and in their very nature they are little amenable to treatment. The whole subject of organic diseases of the kidney may be conveniently treated in a practical work like the present under the following heads :—1. Er- rors of position or conformation ; 2. Hypertrophy ; 3. Inflammation; 4. Granu- lar deposition; 5. Hyperemia; 6. An&mia ; 7. Atrophy; 8. Tubercles; 9. Carcinoma; 10. Hydronephrosis; 11. Serous cysts. ERRORS IN POSITION AND CONFORMATION. Instead of being situated in the lumbar region, one of the kidneys is sometimes placed in the iliac fossa or pelvis. Rayer says he has detected this malformation during life, both by remarking the tumour in the iliac fossa, and likewise by feeling that the kidney was absent from its usual place, on making the patient lean forward on his knees and shoulders in bed, and then grasping the loins. Sometimes the two kidneys are connected together by renal structure across the spine, constituting what is aptly called the horse-shoe kidney. More fre- quently one kidney is altogether wanting. This malformation is probably not * Traite" des Maladies des Reins. inflammation of the kidneys (Frequency). 259 so common as has been sometimes generally thought, because excessive atrophy of the kidney has been sometimes mistaken for the total absence of the organ. When absent, the ureter is commonly wanting also; but sometimes, as in a case lately examined by the writer, the ureter is present and terminates in the usual region by simple occlusion of its tube. Deficiency of a kidney may be some- times ascertained presumptively by the method of examination just described as proposed by M. Rayer. Malposition, malformation, or deficiency of the kidney, does not give rise to any disturbance of the renal functions or to any incon- venience. These deviations from the ordinary rule are therefore mere anatomi- cal curiosities. When one kidney is wanting, its place is always supplied by unusual size or hypertrophy of the other. HYPERTROPHY OF THE KIDNEYS. The case just mentioned is the clearest example of simple hypertrophy of the kidney ; the organ is simply enlarged in all its parts. In other circumstances, however, both kidneys are affected with hypertrophy in conjunction with other morbid states. Thus, in cases of saccharine diabetes, it is not uncommon to find the kidneys considerably enlarged, and their proper structure unusually developed. But there is always in that case congestion also, which in part accounts for the apparent developement. Again, in that state of the kidneys which many pa- thologists regard as the first stage of the acute form of granular deposition, it is usual to find the kidneys enlarged, and the tubular as well as cortical structures unnaturally developed. But here, too, congestion is constantly present, and likewise frequently some degree of granular deposit, by which the developement of the cortical structure in particular is to appearance much increased, though the augmentation may really be inconsiderable. Little is known of the relations of renal hypertrophy to symptoms. Most probably it either gives rise to no peculiar symptoms, or, as in diabetes, it is consecutive not primary, and nothing else than the result of an increased demand upon the renal functions. That it has nothing to do with the developement of diabetes is plain from the fact, that it is far from being invariably met with in that disease, even where of long standing. INFLAMMATION OF THE KIDNEYS. Frequency of the disease.—Various forms according to Rayer.—Symptoms of acute nephritis. —Of simple chronic nephritis.—Complications.—Symptoms and terminations of Pyelitis.— Causes of the several forms of inflammation of the kidneys.—Anatomical characters.— Prognosis.—Treatment. Inflammation of the kidneys has heen commonly thought to be a rather rare disease ; but if the late investigations of M. Rayer be correct, and all the affec- tions he has included under the head of inflammation belong to that category, it would appear to be one of the most frequent of all organic disorders- Doubts may be justly entertained, whether the use he has made of the term inflamma- tion be not too comprehensive; but, at the same time, there can he little question that inflammation of the kidneys has been proved by him to be much more common than has hitherto been almost universally thought. In particular, it appears often to concur with other diseases either of the urinary organs or else- where, by whose symptoms it is obscured during life, and by whose appearances after death the attention of the pathologist is apt to be led away from it. Inflammation may attack each of the principal textures of the kidney either 260 suppression of urine (Symptoms). separately or conjunctly; and in each case it may put on a variety of forms as regards both its anatomical characters and its external signs. M. Rayer has distinguished no fewer than four diseases according to the texture involved, namely Nephritis, or inflammation of the gland itself; Pyelitis, inflammation of the pelvis and calyces ; Perinephritis, inflammation of its investing fibrous membrane ; and Pyelonephritis, where both the pelvis and glandular structure are affected. Of nephritis he admits no fewer than four different species :— Simple, of which there is both an acute and chronic form; Arthritic, com- prising the peculiarities which occur in connexion with gout and rheumatism; Albuminous, under which designation is comprehended the granular alteration of the kidneys of Dr. Bright; and Nephritis from morbid poisons such as attends typhoid fever, small-pox, and other infectious or malignant febrile dis- eases. Of pyelitis M. Rayer also makes four species, simple, gonorrhoea!, calculous, and verminous ; which differ from one another chiefly in their causes. All these species and modifications of disease, he maintains, are to be distin- guished as well by anatomical characters as by their history, and their special symptoms during life. In the following statements it is impracticable to do full justice to his views, or to follow his arrangement, because the text intended to illustrate his pathological delineations is hitherto only in part published. An attempt, however, will be made to introduce the most material part of what has already appeared under one general head of Inflammation of the Kidneys. All that relates to granular deposition will come better under a separate head; for the connexion of that disease with inflammation has not been established. Symptoms. The symptoms of inflammation of the kidneys differ considera- bly according to the acuteness of the disease, the texture attacked, and the cause which produces it. 1. Simple acute Nephritis. This form of the disease commonly sets in, like other acute inflammations, with an attack of rigors, often very severe, followed soon by sickness, heat of skin, frequency of the pulse, and other symptoms of fever. At the same time there is pain in one or both loins, deep-seated, at times circumscribed, more generally affecting the whole lumbar region and flank, not pulsating, occasionally acute, more frequently dull, sometimes felt only upon pressure in the region of the kidney, always aggravated by firm pressure, and likewise by the sitting posture, bending forward, coughing, sneezing, or other strong efforts of respiration, and even sometimes by the descent of the dia- phragm in ordinary breathing. The lumbar pain is particularly acute in the arthritic variety of the disease. The pain is not always confined to the lumbar region; but more commonly it shoots down the course of the ureters to the neck of the bladder, the groins, or the scrotum, and it is frequently attended with retraction of the testicles. When the patient is made to lie in bed upon his face, with the knees drawn up under the abdomen, the kidney may some- times be felt by grasping the flank with one hand or between both hands ; in which case it is found to be tender, and occasionally too enlarged. The urine is either suppressed altogether, or more commonly it is very scanty, and passed either seldom, or on the contrary, very often, and with straining and severe pain. The fluid discharged is usually bloody, that is, either attended with con- siderable hematuria, or more often tinted merely of a cherry-red or brown colour, and coagulable with heal and acids. Afterwards the blood disappears, and the urine is pale, almost aqueous, without albumen, and hence not coa°ula- ble by heat, no longer acid, but either neutral or even alkaline, especially where the bladder or prostate is also affected, or where the inflammatory action in the kidney tends to. the chronic form. Albumen is sometimes present, although there is no impregnation of blood, so that the urine coagulates with heat as In cases of granular degeneration. This is particularly observed, according to Rayer, in the rheumatic form of nephritis. But where the albuminous impreg- nation is considerable, granular deposition probably always concurs. Lithic acid and the lithates are usually defective in their proportion ; in the arthritic inflammation of the kidneys (Symptoms). 261 variety alone of nephritis are they, on the contrary, superabundant, so as to come away in the form of sandy or earthy gravel, or to be deposited in these forms as the urine cools ; and in correspondence with this state, the urine, instead of being pale and neutral or alkaline, is acid, and often high-coloured. In pure nephritis it does not contain either mucus or pus. But as the disease seldom continues long, without being attended with inflammation of the pelvis, ureters, or bladder, it is in fact usual to observe first mucus, and then purulent matter passing with the urine. The ordinary constitutional symptoms, besides the simple phenomena of general reaction, are a foul, greatly loaded, white tongue; distressing nausea, and frequent vomiting, generally of a muco-bilious matter, which at times possesses a somewhat urinous odour; constipation, tympanitic distension of the abdomen, and wandering pains in the intestines; together with an anxious countenance and much depression. Ere long further symptoms arise, which are connected with the several modes of termination of the disease. Sometimes indeed the inflammation termi- nates in resolution, without any new symptoms. At other times it would appear to terminate in partial induration of the inflamed kidney. In that case there are either no symptoms afterwards, but simply the phenomena of resolu- tion ; or, where the extent of injury produced is great, obscure indications of chronic organic disease may ensue, leading generally to chronic nephritis. The most remarkable termination of the disease is in apoplectic coma. This is very apt to occur where the urine is long greatly diminished or altogether suppressed. Drowsiness then comes on, which gradually ends in deep coma, occasionally intermingled with convulsions; and death usually ensues within three or four days after the first appearance of cerebral symptoms. Allied to this mode of termination are another set of cases where typhoid symptoms appear at an early period,—namely, prostration of strength, torpor of the senses and mental faculties, frequent rigors, a black incrustation of the tongue and teeth, together with an absence of pain except on pressure in the loins, and the involuntary discharge of a little urine at distant intervals. Such cases too end in coma. Another mode of termination is in suppuration. This is indicated, though obscurely, by rigors followed by hectic fever, but not neces- sarily, as some imagine, by the appearance of purulent matter in the urine,— which is rare indeed, except where the pelvis, or membranes of other urinary organs, are also inflamed. Suppuration sometimes leads eventually to renal fistula?, which may communicate either with the cellular tissue of the lumbar muscles, causing abscess there and even an external opening on the integu- ments ; or with the liver, exciting hepatic abscess; or with the peritoneal cavity, giving rise to fatal acute peritonitis; or with the colon or duodenum, through means of which the contents of the renal abscess are discharged by the rectum. Renal fistula; however, with these their several results, are extremely rare, except where pyelitis, or inflammation of the pelvis, is united with inflam- mation of the proper renal structure. Gangrene is a still more rare termination of nephritis. It is rare in any circumstances, and chiefly occurs where the pelvis is inflamed as well as the secreting structure. It is most frequently observed in the pyelo-nephritis, which terminates calculus of the kidney or bladder, or which follows the operation of lithotomy. Its occurrence is indi- cated by sudden remission of pain, a feeble fluttering pulse, constant vomiting and hiccup, anxiety, delirium, complete suppression or a scanty discharge of brown fetid urine; sometimes by pctechiee on the skin, and the other symptoms of malignant typhus. Among the terminations of acute nephritis must also be mentioned chronic inflammation, the symptoms of which may be next considered. 2. Simple chronic Nephritis, like most chronic inflammations of internal viscera, in general begins obscurely. At the commencement, indeed, it scarcely presents any appreciable signs. Even throughout its whole course it may 262 inflammation of the kidneys (Complications). escape the practitioner's notice, unless it be combined, as commonly happens sooner or later, with inflammation of the pelvis of the kidney, or unless the attention be turned to the state of the urine. Pain in the region of the kidney is seldom complained of, but nevertheless is generally admitted by the patient to be present if he is questioned respecting it. The pain is confined to one or both lumbar regions, and does not shoot down- wards to the thigh or testicle, as in acute nephritis. It is aggravated, or, if otherwise wanting, it may be excited, by firm pressure over the kidneys. Often the only proof of increased sensibility of the kidney is, that pressure causes more uneasiness at one side of the spine than at the other. The urine is dimi- nished in quantity, yet is passed more frequently than natural. In the early stage it is feebly acid or neutral; and when the disease is fully formed, it becomes alkaline, and at the same time more or less turbid. The turbidity is owing to the separation of amorphous sediments, which consist at times of phosphate of lime only, more rarely of nothing else but the ammoniaco- magnesian phosphate, but most generally of a mixture of both salts, or of these together with some lithate of ammonia. There is seldom any well-marked fever, but great and progressive exhaustion and emaciation. The most important of the symptoms of chronic nephritis is the alkaline and turbid state of the urine. This is considered by M. Rayer so characteristic in certain circumstances that in all cases of wasting from obscure and apparently constitutional causes, he recommends that the kidneys should be made the object of careful attention wherever the urine is alkaline. Alkaline urine may be connected with diseased spine, diseased bladder or prostate, and even, perhaps, with constitutional cachexies. But from his experience, he is inclined to believe that chronic nephritis, either singly, or concurring with these diseases, is one of its most frequent sources. Where a doubt arises, whether chronic inflammation of the kidney be present or not, some light is occasionally thrown upon the question by observing the effect of local depletion or counter- stimulants in diminishing the alkalinity of the urine, or even removing it for a time altogether. The urine in chronic nephritis very seldom contains any blood or albumen, unless other renal diseases concur. It often presents mucus in considerable quantity, but never purulent matter, unless where inflammation of the pelvis, of the kidney, or of the mucous coat of the bladder be present as a complication. The terminations of chronic nephritis are not yet thoroughly understood. Sometimes it passes into the acute form of the disease; sometimes it is followed by inflammation of the pelvis of the kidney and suppuration, as indicated by the appearance first of mucus, and then of purulent matter in the urine; probably it ends sometimes in resolution, or in partial induration, which does not interfere with the right discharge of the renal functions afterwards ; and in other cases it terminates in extensive induration, cartilaginous degeneration, or atrophy, and may then, in M. Rayer's opinion, give rise to coma, chronic vomiting, simple exhaustion, diarrhcea, and other fatal affections, which have been hitherto con- sidered to be connected only with granular deposition. It is not improbable that some of the causes, where these affections have been described by British authors as terminating granular disease with contraction and atrophy of the kidney, have been really the terminations of what M. Rayer has considered to be nothing else than simple chronic inflammation. The complications of acute and chronic nephritis constitute a very essential part of their history. On the one hand, neither affection often exists lono- without leading to other important diseases, both of the urinary organs and elsewhere; and on the other hand, diseases of various organs in the body are more or less apt to induce renal inflammation. In consequence of the complications thus arising, nephritis frequently remains concealed from observation, and is accord- ingly thought a more rare disease than it is in reality. The following sketch of these complications is taken chiefly from the elaborate treatise of M. Rayer. It will anticipate in part what might be stated under the inflammation of the kidneys (Complications). 263 subsequent head of the causes of nephritis. The most common complications are diseases of the genito-urinary organs. As already mentioned, chronic inflam- mation of the substance of the kidney frequently becomes complicated in its course with acute inflammation. Each of these is very apt to follow and com- plicate acute or chronic inflammation of the pelvis of the kidney, in which case the urine is first mucous or purulent, and then becomes pale and scanty, or altogether suppressed, while the muco-purulent impregnation continues. They may also become complicated with inflammation of the investing renal mem- brane in the course of formation of renal fistulee; but the symptoms of this incident are obscure. Nephritis may further follow and complicate almost any chronic organic disease of the kidney, such as dilatation from retention of urine or hydronephrosis of some pathologists, tubercles, serous cysts, and cancer, the last of which in particular is often terminated by the symptoms of acute inflam- mation. A more rare conjunction is inflammation of the ureter, arising com- monly from obstruction of the flow of urine by an impacted calculus, or a tumour, or spontateous contraction of its canal. The affection of the ureter is here always the prior in point of time; so that the symptoms of nephritis are preceded by pain along the course of the ureter, instead of the pain affecting the lumbar region in the first instance. One of the most frequent of all complica- tions is inflammation of the bladder, in consequence of stone, or of the operation of lithotomy or lithotrity. M. Rayer insists strongly on the frequency of this conjunction in such circumstances, and on the tendency of surgeons to overlook the existence of nephritis both in preparing their patients before operating for stone, and in treating the sequelae of the operation. Their attention is naturally turned to the more prominent symptoms of irritation and inflammation of the bladder; so that they lose sight of a concurring disease, the arrestment of which is not less essential for the patient's safety. He adds that the presence of nephritis may be known by the urine becoming alkaline, which he maintains never to take place so long as the inflammatory action is confined to the blad- der. This would be a highly valuable means of diagnosis, did the general fact stand exactly as he alleges. But further observation is required to establish a statement so much opposed to the present opinions of the surgical part of the profession; for inflammation of the bladder is generally considered to render of itself the urine alkaline, where it follows calculus. Another disease of the bladder, occasionally complicated with nephritis, is cancer. Cancer of the bladder, if it do not prove fatal by constitutional exhaustion, through frequent haemorrhage or constant irritation, generally terminates by inducing inflammation of the kidney; and this appears for the most part to be excited by the malignant tumour obstructing the aperture of the ureter, and so causing retention of urine. Nephritis may likewise be conjoined with diseased prostate, in consequence of the latter occasioning retention of urine, one of the most common immediate causes of the developement of inflammatory action in the kidney. It may like- wise concur with gonorrhoea, to which indeed it is related in various ways. Its conjunction with acute gonorrhoea, which, however, is very rare, is presented, when the discharge of an unusually violent gonorrhoea is arrested by the injudi- cious use of powerful internal stimulants or strong astringent injections. It is more frequently produced in the chronic stage of gonorrhoea, and is then com- monly observed to arise from exposure to cold and wet as its direct cause. The symptoms of its production are, first a sense of great irritation in the blad- der, then pain in the region of the kidneys, frequent discharge of pale urine, speedily becoming mucous and scanty, and attended with straining and distress- ing spasms, sometimes involuntary discharge of seminal fluid, and commonly a sense of heat and weight in the perineum. Gonorrhoea may farther produce nephritis, through the medium of stricture of the urethra. But besides, any cause may produce it which occasions obstruction of that canal, such as a cal- culus impacted in it, or an external tumour or foreign body pressing upon it; and in almost all cases of the kind the inflammation of the kidney is preceded 264 inflammation of the kidneys (Complications). by inflammation of the bladder. Diseases of the uterus are apt, sooner or later* to become complicated with nephritis. It is observed often enough in cancer, or in cartilaginous tumours of the uterus, even sometimes in prolapsus, nay, occasionally in pregnancy, especially where many children have been previously borne. It is right that obstetrical practitioners should be aware of this fact, and that the lumbar pains so frequently observed from compression of the abdominal viscera by the uterus, or dragging of the parts adjacent, may really at times depend on so different and so serious a cause. When nephritis complicates pregnancy, it may occasion miscarriage, or difficult and painful labour, or death in childbed, by favouring various important sequelae. Inflammation of the kidney sometimes is attended with inflammation of the testicles, and at other times with atrophy of these organs. Nephritis may also be complicated with diseases in other organs besides those belonging to the genito-urinary apparatus. The inflammation occasionally spreads to the liver and duodenum from the right kidney, or to the spleen and colon and from that of the left side; and in such circumstances renal fistulae are sometimes formed, particularly fistulas opening into the intestinal canal. On the other hand hepatitis has sometimes seemed to lead to nephritis, instead of the latter preceding the former; and the same complication and order of occurrences has been remarked in respect of carcinoma of the liver. Chronic peritonitis is another disease of the adjacent parts, which sometimes leads to inflammation of the kidney; the symptoms of which however are always ob- scure, so that it is seldom discovered till on dissection after death. Some other visceral inflammations at a greater distance occasionally present a similar con- nexion. For example, pleurisy and pneumonia sometimes occur during nephritis, and inversely nephritis may be developed during the prevalence of one or another of the pulmonary inflammations. The latter case is marked by the urine, from acid, becoming alkaline; the former by the converse. Peritonitis, pleurisy, and pneumonia are much more frequent as incidental diseases in what M. Rayer calls albuminous nephritis, that is, granular disease of the kidneys, than in any of the forms of simple nephritis. Affections of the spinal cord are not un- frequently followed by renal inflammation. It has been long observed, that inju- ries of the spinal cord, producing paralysis and retention, are commonly attended with an alkaline and turbid state of the urine. This has been usually ascribed either to the urine undergoing decay during prolonged exposure to heat in the bladder, or to some modification of the renal function produced directly by the morbid condition of the spinal cord. M. Rayer has satisfied himself that the former explanation is inadequate to account for the pheno- menon, because the urine does not decay when retained in the bladder in other circumstances ; and he is inclined to think, that an alkaline state of the urine depends on renal irritation, tending to inflammatory action, and that, when it occurs after injuries of the spine, it should always direct the attention of the surgeon to the state of the kidneys. Inflammation of the spinal cord in like manner sometimes leads to nephritis ; and so does paraplegia, by inducing re- tention ; in which circumstances therefore alkalescence of the urine ought always to put the physician on his guard. Diseases of the brain may be the indirect cause of nephritis, by inducing paraplegia and retention of urine. A much more important source of such complication, is the tendency of nephritis to terminate in coma and apoplexy, probably through poisoning of the blood by urea and the other ingredients of the urine which are not excreted as usual. The termination of simple nephritis in coma has already been alluded to as an occasional occurrence; but it will be seen afterwards under the head of Gra- nular Disease of the Kidney, that, if this affection is to be considered with M. Rayer as a species of inflammation, coma, convulsions, and apoplexy are among the most common of the complications of nephritis, and may indeed be correctly said to be the natural course of the disease as one of its modes of ter- mination. Among the diseases during which nephritis may arise as an inter- inflammation of the kidneys (Complications). 265 current affection typhoid fever must be enumerated, together with all febrile diseases which are apt to be attended with typhus, such as variola, yellow fever, purulent absorptions, the pustule maligne produced by inoculation from the flesh of diseased cattle, and the like. In all such circumstances latent nephritis would appear to be far from so uncommon as was thought before the late in- quiries of M. Rayer. The disease is latent because the functions of external relation are oppressed, and likewise because alkalinity of the urine, one of the best signs in general for leading to its detection, is here fallacious, since this state probably occurs merely from functional causes connected with the typhoid state. Nephritis, arising in typhoid diseases, is sometimes nothing else than the consequence of neglected retention of urine ; but in other cases the exact relation between the local and general disorder is not apparent. Certain cuta- neous diseases seem in some measure connected with chronic nephritis. It was formerly observed that gravel and calculus lead to the developement of scaly and papular diseases of the skin; so that, as nephritis may originate in calculus, the apparent connexion between it and cutaneous disorders is in some measure accounted for. But besides, there is little doubt that nephritis generally may lead to certain cutaneous eruptions, such as eczema, either general, or confined to the genital organs, and also pemphigus. Dropsical effusion, especially ana- sarca, has been considered one of the diseases incidental to nephritis; but M, Rayer distinctly denies that it is ever produced during the simple form of the disease, or in any other variety except the granular disorder of the kidneys, which he denominates albuminous nephritis. The symptoms of inflammation of the pelvis of the kidney, the Pyelitis of M. Rayer, will, it is hoped, be much elucidated by the forthcoming volume of the pathologist's researches. Meanwhile it may be sufficient to mention that there is both a chronic and an acute form of the disease ; that it presents other varieties, which have led M. Rayer to distinguish a simple, a calculous, a gonorrheal, and a gangrenous pyelitis ; that its tendency is to end in suppura- tion and commonly also distension of the pelvis and calyces of the kidney ; and that most of its symptoms resemble considerably those of nephritis, with the single exception of the properties of the urine. The pain more frequently extends to the testicles and is attended with retraction of them, than where the structure of the kidney itself is alone inflamed. WThen in the progress of the disease, sup- puration and distension of the pelvis or entire kidney have taken place, the en- largement of the organ may be more frequently ascertained by manual examina- tion ; and when the tumour is very large, fluctuation may even be detected. Hectic fever, too, is for the most part better marked than in suppuration of the sub- stance of the kidney. The urine is not so greatly reduced in quantity, and never suppressed; but there are frequent and urgent call's to pass it; and from an early period it presents an admixture of ropy mucus, which ere long gives place in some measure to pus. The presence of mucus and pus, together with the negative evidence of the absence of disease in other urinary organs, is the best character of pyelitis for distinguishing it from nephritis. It may terminate in resolution, suppuration, gangrene, and inflammation of the kidney itself. The second and the last are the most frequent modes of termination. Matter may accumulate without necessarily occasioning disten- sion ; but more generally the pelvis first expands, and then dilatation of the calyces follows; at length the substance of the kidney likewise stretches out, as it were, and at the same time loses its healthy structure by atrophy; and thus occasionally an enormous pouch is formed which is full of pus. Sometimes, when .the inflammation is propagated outwards, it passes to adjacent organs, to which the purulent sac adheres; and renal fistula is gradually formed. The fistula may communicate with the various organs in the neighbourhood, such as the liver, spleen, duodenum, colon, diaphragm and lungs, and the adjoining external integuments, thus producing a variety of superadded symptoms, which it is unnecessary to enumerate. Pyelitis seldom exists long without being com- vol. in. 34 266 inflammation of the kidneys (Causes). plicated with nephritis. Where the two affections concur, the former is gene- rally prior in point of time. It is also often complicated with inflammation of the bladder, and it may occur with any of the other disorders of the urinary organs, which were formerly mentioned as being apt to complicate inflammation of the parenchyma of the kidney. Causes. The causes of the several species and forms of inflammation of the kidneys and their membranes are various. They may be produced by external injuries, such as blows on the loins, concussion of the body affecting that quarter in particular, and penetrating wounds of the kidney. Exposure to cold and wet has the same influence in exciting inflammation there as in other in- ternal organs. Drinking freely of cold water, especially when the body is overheated, has several times been observed to have the same effect. One of its most unequivocal causes is the specific influence of certain irritating poisons on the kidneys. Cantharides has long been considered one of the most power- ful poisons of this kind. According to Rayer, it would appear to act fully more upon the bladder and urethra when it is taken internally ; but nevertheless little doubt can exist that the kidneys may likewise be affected by it, both when swallowed in poisonous doses, and in particular constitutions when applied out- wardly in the form of blister. Oil of turpentine has also been known to excite symptoms like those of nephritis, but more rarely; and a still more rare agent of the same nature is nitre. Corrosive sublimate and other corrosive salts of mercury, when administered in poisonous doses, act in the same manner with considerable certainty, producing bloody urine, strangury, or at times suppres- sion, and leaving in the dead body signs of increased action in the kidneys. Digitalis seems another poison possessing similar properties, with whose effects however we are less acquainted. The abuse of alcoholic fluids, especially strong spirits, has been held to be another cause; but it rather acts by exciting a pre- disposition than as a direct agent; and in this country at least, it more fre- quently occasions granular disease than true inflammatory action. By much the most frequent cause is the pre-existence of other diseases of the urinary organs. This subject has been already anticipated, in what was stated above as to the complications of simple nephritis ; but a brief recapitulation may be here advisable. The coexistence of other diseases of the urinary organs may induce renal inflammation in three ways : They may act in the first place as direct sources of irritation ; as for example, where the kidneys contain calculi in their substance or their pelvis, or where they are affected with tubercles, cysts, cancerous degeneration, and the like, or where they have been injured by external violence. Since, however, calculi, cysts, tubercles, and cancer may exist for a long time in many without leading to inflammation, it would appear that some more direct exciting cause must co-operate; and probably exposure to cold, internal stimulants, or, in the case of calculi, sudden successions of the body, are the chief co-operating agents. In the second place, other diseases of the urinary organs may act by transmission of the inflammatory action along a continuous membranous surface, if not by sympathy of the different parts of the same continuous membrane. This seems the usual way in which violent gonorrhoea in a few rare cases, and inflammation of the bladder much more frequently, excite nephritis or pyelitis. Lastly, various diseases of the urinary organs lead indirectly to renal inflammation, by obstructing the discharge of urine, and in consequence occasioning distension and irritation of the kidney. These diseases are a calculus obstructing one of the infundibula ; obstruction of the ureter by a calculus or tumour, or tubercles, or spontaneous contraction of its canal; obstruction of its orifice by morbid growths in the bladder, or para- lysis and distension of the bladder ; obstruction of the urethra by a calculus, by stricture, by diseased prostate, by a foreign body introduced from without, or by foreign bodies or tumours pressing upon it externally. In all these cases accumulation of urine takes place, distension of the pelvis and calyces of the kidney ensues, and renal inflammation almost certainly follows, if the patient inflammation of the kidneys (Anatomical Characters). 267 do not previously die of some more immediate disorder. Other diseases besides those of the urinary organs may more or less directly excite nephritis. These it is unnecessary to enumerate, as they were mentioned already among its com- plications. The most important of them are diseases of the spine, which appear to act both indirectly by inducing paralysis of the bladder with its consequences, and directly in some obscure way on the renal functions. The relations of age to inflammation of the kidney are important. It occurs occasionally in infants, very rarely between infancy and puberty, seldom also between puberty and middle age, and most frequently after that period. All these facts are easily referrible to the comparative frequency at different ages of the other urinary affections, which either directly excite the nephritis and pyelitis, or predispose to them. Peculiarities of constitution predispose to nephritis in a remarkable manner. It is peculiarly frequent, comparatively speaking, in gouty habits, and in those subject to gravel and calculus. Anatomical characters. A very complete view of the pathological appear- ances in inflammation of the kidney has been given in the delineations and treatise of M. Rayer; whose description may be adopted in the following abstract. In simple acute nephritis, and in the early stage, there are found gorging, and redness or brownness, sometimes partial, often general, affecting chiefly the cortical structure both externally, and where it dips between the tubuli,—en- largement of the blood-vessels of the cortical texture, red points from injection, and sometimes true ecchymosed patches; occasionally some induration of both textures, especially the tubular part, in which case the general redness is mot- tled with pale, bloodless patches, and the external surface of the organ is rugous or botryoidal. There is generally more or less swelling of the kidney, and at times to so great an amount that it weighs four times the healthy standard, or about seventeen ounces. Where the tubular structure is much affected, the infundibula are sometimes much enlarged, so that the papillae equal in size that of the nipple. Purulent deposits are frequently seen, oftener in the cortical than in the tubular structure, sometimes very minute, like grains of sand, and situated near the surface, sometimes in very appreciable masses, as big even as peas, very rarely in larger abscesses. What have been described by authors as large abscesses of the kidney have been cases of pyelitis leading to suppuration and distension, either of the pelvis or of one or more calyces. The purulent deposits are surrounded always by a dark-red circle. Sometimes instead of purulent deposits there is general softening of the cortical texture with purulent infiltration, where the pus is discoverable only by scraping the cut surface with the scalpel. Ulceration of the papillae is occasionally met with. A rare ap- pearance is gangrenous softening, indicated by lividity of the kidney, fever, and such a degree of disintegration that the texture is here and there broken up into tomentous masses by merely washing it. Imbedded calculi are not uncommon. In simple chronic nephritis the kidney is commonly found diminished, seldom enlarged, usually somewhat hardened, occasionally almost cartilaginous, on its surface granular, rugous, or botryoidal, generally pale and ansemious, both externally and internally, but sometimes with red mottling, probably from super- induced acute inflammation. The cortical portion is for the most part chiefly affected. Sometimes this part of the renal structure is atrophied, so that the tubuli approach one another, as well as the external surface of the kidney ; and, in consequence, the surface of the organ is botryoidal or lobulated, the investing membrane firmly adherent, and sometimes the papillae much elongated. Both chronic and acute nephritis are occasionally found to affect both kidneys. In acute pyelitis in its early stage, the mucous membrane of the pelvis and calyces is found vascular, with red spots of ecchymosis, occasionally blood extravasated upon its inner surface, and sometimes lymph thrown out in patches so as to obstruct the ureter. At a more advanced stage there is frequently more or less dilatation of the pelvis and calyces, where retention of the urine was the 268 inflammation of the kidneys (Anatomical Characters). exciting cause ; and occasionally the membrane is softened, ulcerated, or even perforated, where the cause was the presence of a calculus, or where the inflam- mation, whatsoever its cause, had passed on to gangrene. The urine contained in the pelvis and calyces commonly contains blood and pus, not always dis- coverable by the naked eye, but visible enough with the help of the microscope. It also sometimes contains amorphous sediments of lithate of ammonia, crys- tallized lithic acid, crystalline phosphate of magnesia and ammonia, and like- wise albumen. In chronic pyelitis the membrane is dull white, its vessels large and varicose, but without a minute vascular network; the external veins on the kidney are large; the pelvis and calyces are distended in many cases, and then the mem- brane is thickened, without visible vessels, and the ureter much contracted, sometimes reduced to a mere fibrous cord. The inner surface of the membrane sometimes presents a reddish-brown tint, or this mottled with slate-coloured patches; at other times transparent vesicles, like sudamina, are seen on its sur- face ; and occasionally there are ulcerations corresponding with the pressure produced by the edges and points of calculi. In some cases the ulceration penetrates the membrane, forming urinary fistula?, which communicate with the subperitoneal cellular tissue, the peritoneal cavity, the liver, the spleen, the colon, the duodenum, or the lungs through the diaphragm. All the phenomena of pyelitis now mentioned may be presented without dilatation of the pelvis. More commonly the pelvis and calyces are much dilated, especially in cases depend- ing on obstruction of urine; and at times the kidney itself becomes dilated and at the same time atrophied, so that a great multilocular membranous pouch is formed, filled with purulent urine, or nearly pure pus, or a mixture of pus, urine, and blood, and frequently containing one or more calculi, or in rare instances acephalocysts, or several strongyli. Perinephritis, or inflammation of the investing membrane of the kidney, is seldom observed alone, but occasionally in conjunction with inflammation of the kidney itself. It appears in the form of redness and purulent infiltration of the cellular tissue, connecting the membrane and kidney, sometimes with effu- sion of blood, sometimes with deposition of coagulable lymph in layers. In a few instances the membrane adheres to the peritoneum in the loins; and then it may be found ulcerated, and producing purulent infiltration of the lumbar cellular tissue; or an abscess is formed there, pointing outwards. Prognosis. The prognosis in inflammation of the kidney depends mainly on the causes and circumstances which give rise to it. That which arises in the course of other urinary diseases is always unfavourable ; and when it com- mences suddenly during some severe chronic disease, such as enlarged prostate, cancer of the bladder, or after the operation of lithotomy or lithotrity, it is gene- rally fatal. Not less unfavourable, for the most part, are those cases which occur in the course of diseases in other organs, such as the liver, lungs, spinal cord or brain. Those which depend upon calculus in the kidney are more frequently arrested, yet are still formidable; and they are commonly fatal if the calculus is lodged in the ureter or bladder in such a way as to cause stoppage of the flow of urine. Nephritis and pyelitis, produced by exposure to cold,°or by in- juries of the kidneys, are the least unfavourable of all the varieties. Cases attended with suppression of urine, with coma, or with excessive prostration and other typhoid symptoms, are seldom cured. The occasional recurrence of rigors, followed by increase of fever, is an unfavourable sign, inasmuch as it shows continuance and renewal of inflammatory action. Alkalinity of the urine, for the like reason, is upon the whole unpropitious. The termination of the disease in suppuration is indicated, as in other inflammations, by rigors, succeeded by hectic fever, and is likewise an unfavourable, though by no means a fatal circumstance. The favourable signs are the converse of what have just been enumerated; and the most promising circumstances are where no irreme- inflammation of the kidneys (Treatment). 269 diable organic disease pre-exists, and where the urine is neutral or slightly acid, and not tending towards suppression. Treatment. The treatment does not differ essentially from that of other in- flammations. When the disease is acute, blood must immediately be taken from the arm in proportion to the patient's age, constitution, and freedom from exhaustion by prior disease. Little good is done unless faintness be induced. It may be necessary to repeat the venesection again and again, just as in pneu- monia or peritonitis ; and the repetition of it may either be delayed till its neces- sity is pointed out by the renewal of the symptoms, in which case free evacuation will again be required; or, which is better practice, a few ounces of blood may be drawn at intervals of five or six hours, without waiting for aggravation of the symptoms. The disease, however, may sometimes be arrested at once, and with much less loss of blood, by following up the first evacuation with a full opiate. For the efficacy of this practice it is essential that venesection be pushed so far as to induce faintness and subdue pain, and that the opiate be given in a full dose of two or three grains of opium, or thirty or forty minims of the tinc- ture, immediately after the faintness passes off. The writer has seen the disease abruptly arrested in this way. Leeches, or cupping to the loins, may be of service after the severity of the inflammation has been subdued by general blood- letting, or in cases where that remedy cannot be resorted to; and they are of frequent service where the inflammation is chronic, more especially in its early stage. The warm bath, the warm hip-bath, and warm fomentations of the loins, have been generally recommended by authors on this subject; but they sometimes do harm, unless the violence of the inflammation be subdued in the first place by more active means. In chronic inflammation, aud after the partial subsidence of acute inflammation, the most effectual treatment consists in the use of counter-stimulants applied to the lumbar region, among which the most approved are setons, caustic issues, and the actual cautery. Blisters are gene- rally avoided, on account of the risk of their exerting their peculiar action upon the kidneys and bladder in special constitutions; but there seems no good reason for shunning them, where previous experience may show that the con- stitution is not of the kind in which they act injuriously. Anodynes should generally be employed from an early period. The force of the circulation, however, should first be subdued ; but after that, pain must be relieved, either as already mentioned by a full opiate administered imme- diately, or by less doses given according to circumstances. Some prefer hyos- cyamus to opium, perhaps without sufficient reason. Where opium must be given frequently, or where it fails to give relief when administered by the mouth, it is often signally useful in the form of clyster or suppository. Some, not without reason, prefer this mode of using opium in all circumstances. Chronic inflammation may be relieved by opiate plasters, friction, or fomenta- tion ; but these modes of using anodynes are inapplicable to the acute form of the disease, at least in its early stage. The combination of calomel and opium, so familiarly employed in other acute inflammations, has not been much re- sorted to in this species, but may be presumed nevertheless to be admissible. The same remark might be applicable to tartar-emetic in nauseating antiphlo- gistic doses, were it not that there is generally a great tendency to vomiting in the several forms of renal inflammation. It is needless to observe that in the acute form the diet and regimen must be strictly antiphlogistic. When the acute stage is passed, small quantities of nutritive but easily digestible food may be allowed. In chronic inflammation M. Rayer has satisfied himself that a diet moderately animal is better than one purely vegetable; and in all circumstances, except those of acute inflammation, milk is an important article. Complete repose is indispensable in the acute stage and form; and even in the chronic form, or in recovery from the acute, exercise should be long avoided, and practised with caution and in moderation, because it is apt to renew or increase the morbid action. The urine for instance, 270 inflammation of the kidneys ( Treatment). when rendered neutral or acid in chronic nephritis, has become speedily alka- line after indiscreet exercise, showing that irritation was renewed. Certain special symptoms have to be combated. Great importance has been attached to the restoration or increase of the secretion of urine. This is undoubtedly an object of great consequence; but it is to be attained only by subduing inflammation with its own proper remedies, not by the use of diuretic medicines. It is advisable to administer mucilaginous diluents in the acute stage; but diuretics are of no use, and may increase the irritation. In the chronic stage there is not the same objection to them, provided the stimulant species be avoided. Free dilution is sometimes sufficient; but if not, digitalis among vegetable diuretics, and bitartrate of potass among those of the saline class, are the most appropriate. Strangury and frequent micturition are best subdued in general by the treatment already laid down for more general and fun- damental purposes, especially by opiates after bloodletting. Opiate clysters, opiate frictions over the perineum, emollient injections into the urethra, and the warm hip-bath may also be resorted to as occasionally serviceable. Few symp- toms occasion so great distress as the incessant sickness and frequent vomiting which attend most cases of acute inflammation, and even many instances of the chronic form of the disease. They may sometimes be subdued by small doses of solid opium, by hydrocyanic acid, creosote, or small quantities of ice-cold water, but in general these remedies are merely palliative, frequently they fail altogether, and the practitioner must trust for the removal of vomiting to the fundamental treatment. In chronic nephritis it is probable that creosote may prove a more efficient remedy than in acute inflammation of the kidney ; at least its good effects are often shown in vomiting connected with other organic diseases, and among the rest with granular degeneration. The treatment must of course be directed, not merely to the inflammation of the kidney, but likewise to the disease, if any, which seems to have excited it. Where calculus is present, or the urine presents gravelly deposits, such treat- ment must be added as the particular variety of calculus or gravel demands. If lithic acid, or the lithates, abound in the urine, the alkaline carbonates should be given, and turpentine and the balsams are sometimes serviceable; if the earthy phosphates constitute the deposit, either acidulous drinks may be adminis- tered, or alkalis may be allowed in the form of soda-water or kali-water. It should be remembered that the urine may contain earthy phosphates, although there be no calculus any where, and even no previous tendency to phosphatic gravel; for in the advanced stage of acute, and throughout the whole course of chronic nephritis, the urine is alkaline and loaded more or less with amorphous phosphatic deposits. It is desirable to correct this condition of the urine, if possible. It cannot be accomplished, however, by acids. The aerated alkaline bicarbonates are more likely to be serviceable. But the surest remedy is the treatment of the funda- mental disease, which occasions alkalinity, that is the antiphlogistic treatment of the renal irritation. It is unnecessary to take notice here of the treatment applicable to the other urinary diseases, which may cause or complicate ne- phritis. One subject only may be alluded to. Wherever retention of urine has been the immediate exciting cause, or is in any way complicated with inflamma- tion of the kidney, the urine must be withdrawn by the catheter; and it is better to use the instrument at stated periods, than to leave it constantly in the bladder, as at one time was the common practice. Where retention is occasioned by a calculus impacted in the ureter, its discharge must be promoted by the moderate use of diluents, the administration of opium in the form of clyster, and the warm bath. Art, however, can accomplish little in this case. granular diseases of the kidney (Symptoms). 271 GRANULAR DISEASE OF THE KIDNEY. Recent discovery of this form of renal disease.—Definition.—Primary symptoms of the acute and chronic form.—Characters of the urine.—State of the blood.—Secondary diseases.— Causes.—Prognosis.—Anatomical characters and pathology.—Treatment of the primary disease.—Of the secondary affections. Dr. Bright* was the first who clearly pointed out, in 1827, the frequent con- nexion of anasarca and other dropsical affections, with a peculiar disease of the kidneys, the leading character of which is the deposition of a yellowish granular matter in its substance, together with the gradual atrophy of its cortical and tubular structure. There never, perhaps, was an important pathological dis- covery, which in so short a period has been confirmed by so great a number of extensive inquiries. Nevertheless, many unaccountably entertain grave doubts of the truth even of the fundamental discovery, and still more some of the most material pathological details. The general result, however, of the researches of Dr. Bright, and of those which have been since made successively by the writer, by Dr. Gregory, Dr. Osborne, M. Solon, M. Rayer, and many other contributors on a less extensive scale, is that granular degeneration of the kid- neys is one of the most common of organic disorders; that it is intimately con- nected with a great variety of both chronic and acute diseases, which it either exasperates as a complication, or favours by establishing a predisposition ; and that, although often obscure in its characters, it may almost always be success- fully recognised if skilfully sought for. It is possible, indeed, that those who have specially attached themselves to the investigation of the subject, may have allowed themselves occasionally too extensive a range, and included under the general head of granular disease other organic renal disorders, which may be distinguished from it on further inquiry. But this proposition, though admitted, will not affect, at least in any material degree, the validity of the important general conclusions here laid down. This disease may be defined as a morbid deposit in the substance of the kid- ney, generally in a granular form, occasioning atrophy of the proper renal structure, and indicated by more or less tendency to diminution of the solids of the urine, generally also by the presence of albumen, and frequently by the supervention of dropsical effusions.f Symptoms. The symptoms of granular disease of the kidney are partly those which properly belong to the primary disorder, and are more or less essen- tial to it, and partly those which denote the presence of secondary affections. To the former class may be assigned the symptoms of local uneasiness, those of disordered digestion, a morbid state of the urine, a diseased condition of the blood, and leucophlegmatia. To the latter belong the symptoms of oedematous effusion into the cellular tissue, serous effusion into the sacs of the pleura, peri- cardium, and peritoneum, inflammation of the serous membranes, bronchitis, diarrhoea, rheumatism, and apoplectic or epileptic coma. The primary symptoms, which will first be considered, vary materially at the commencement, according as the disease breaks forth suddenly, or developes itself slowly and insidiously ; but after a time they become more uniform. * Reports of Medical Cases, 1827. t The following summary is chiefly an abstract of what has been already made public by the writer. See On Granular Degeneration of the Kidneys, &c. 1839. 272 GRANULAR DISEASE OF THE KIDNEY (Symptoms). When it commences in the acute form, the usual symptoms are rigor, ushering in an attack of inflammatory fever, of more or less severity; scantiness of the urine, which is indeed sometimes almost suppressed, always highly albuminous, occasionally bloody, and often passed frequently and with difficulty; lumbar pain, rarely acute, more generally dull, and occasionally, though seldom shooting to the groins or testicles; pain across the pit of the stomach, felt only on pres- sure, or increased by it, and attended with nausea, and often with vomiting. These symptoms seldom exist long without anasarca being formed; frequently this affection appears in the course of the first or second day; and it commonly puts on the characters of inflammatory dropsy. The subsequent course of the disease is exceedingly various. Sometimes it is checked by active treatment. Sometimes it proves quickly fatal by the developement of some acute visceral inflammation, such as pleurisy, pericarditis, peritonitis, or pneumonia. Fre- quently it ends in coma, which occurs chiefly in the cases where the urine is greatly reduced in quantity, and which almost always terminates fatally. Most generally the acute symptoms give place to those of the chronic form of the disease, which then runs its own proper course. Several of the symptoms now enumerated, as those of its acute form, are sometimes wanting. The only invariable character is scanty, highly coagulable urine, with more or less fever. These symptoms may prevail alone for a few days, till coma and convulsions suddenly occur and prove quickly fatal. Hence the disease is not unfrequently misunderstood at first, where it presents itself in such a shape; and it may even continue to escape notice till the examination of the dead body explains its nature. It is altogether a mistake to suppose with M. Rayer and some others, that dropsy is an invariable attendant of this or any other form of granular disease of the kidneys. The chronic form may commence with acute symptoms, which after a time pass off. More generally it commences obscurely and most insidiously, often indeed without any appreciable symptom at all that attracts the patient's attention for months, except perhaps frequency of micturition and slowly increasing debility. If an examination happen to be made at this time, however, it will be found that there are occasionally obscure pains in the loins, increased by pres- sure, and either a scanty, or on the contrary a superabundant, discharge of pale, sometimes cherry-red or brown, and often muddy urine, low in density, and coagulating more or less by the action of heat and nitric acid. When matters have remained for some time in this state,—which may be for months, or perhaps even for a year or two,—the disease is at length developed either by the supervention of the acuter symptoms somewhat modified, or more generally by the accession of one of the secondary disorders. The fundamental disease is then commonly thus indicated. The strength is much reduced, the body more or less emaciated, the complexion either of a uniform waxy paleness, or dingy, and the skin dry, and little disposed to perspire. There is often drowsiness, often too sickness or retching in the morning, and enfeebled digestion, with much thirst. The urine presents the characters already mentioned, and the blood is thin, watery, and unusually defective in colouring matter. Secondary affections are common ; the most frequent of them being dropsy, acute and chronic visceral inflammations, diarrhcea, rheumatism, both acute and chronic, catarrh, diseased heart, and coma. Life may be prolonged for many years under this chronic form of the disease, provided the secondary affections be avoided or easily sub- dued. But sooner or later the fatal event is occasioned by slowly developed coma, unless some other secondary disorder intervene, and terminate fatally in its own way. The only essential characters of the chronic form of granular disease of the kidneys, are a reduction of the density of urine, with diminution of its solids, excessive reduction of the colouring matter of the blood, and leucophlegmatia. The presence of albumen in the urine, contrary to the opinion of some authors, is not invariable, though a very general fact. GRANULAR DISEASE OF THE KIDNEY (Symptoms). 273 Such is a sketch of the symptoms which belong more or less essentially to the two forms of this disease. As the condition of the urine and that of the blood are highly important in relation both to its diagnosis and to its pathology, some details on these two heads are called for. The urine presents a considerable variety of characters, depending more especially on the stage or form of the disease. In the early stage and acute form its essential characters are a moderate reduction of density, a material diminution of the daily discharge of solids, and a strong impregnation of albu- men. In the advanced stages and chronic form its sole essential character is reduction of density ; but very generally too there is albumen present, though in small quantity, and for the most part the daily discharge of solid matter is much reduced. There are also, however, other qualities of the urine which well deserve attention, although far from being invariable. When the symptoms put on the acute form in the early stage, the quantity of urine is most generally a good deal diminished, often to a few ounces daily, sometimes to a few drops only. Its colour is commonly natural, sometimes blood- red. It is often turbid and continues so even after many hours of rest, in con- sequence of abounding in minute particles which are insoluble by heat, and are occasionally oleaginous in their nature, but far more generally consist of modi- fied mucus or the scales of the epithelion of the urinary mucous membrane. It sometimes deposits lithic acid on cooling, and more rarely lithate or phosphatic sediment on standing a few hours; occasionally it decays very soon, and becomes powerfully ammoniacal; but the reverse is the general rule. The density is for the most part under the healthy standard of urine not abounding in quantity; but the difference is not material, the common range being from 1018 to 1021. Albumen is usually present in large quantity, as shown by heat or nitric acid, severally or conjunctly, occasioning a bulky coagulum. It is sometimes so abundant that the urine forms a uniform tremulous jelly when heated, or else a uniform thick pulp without the separation of fluid. It is seldom so small in amount as to occupy less than a third of the volume of the fluid after the coagulated urine has been allowed to rest for twenty-four hours ; and if the coagulum be separated, washed, and dried, it will be found to weigh seldom less than ten, sometimes so much as twenty-seven grains in every thou- sand of urine. The best method of searching for albumen in the urine is to treat it, first with heat alone, and then with nitric acid. Heat singly is in general a sufficient test where the proportion of albumen is so large as it invaria- bly is in the acute form; but where the proportion is moderate, the acid is neces- sary, on the one hand to secure the separation of the albumen, which may be kept dissolved even under heat, if ammonia has been evolved by decay,—and, on the other hand, to distinguish albumen from the earthy phosphates, which, if in excess, may be detached in the form of a flaky precipitate by heat, but are redissolved by a drop or two of nitric acid. The examination should be made repeatedly, because occasionally the albumen suddenly disappears for a time. It is necessary to attend to the proportion of the albumen, both with a view to the prognosis and the treatment. For this end it should be coagulated in a tube, and left at rest for twenty-four hours : upon which the following degrees of coagulability may be noted :—gelatinous by heat; very strongly coagulable, where a distinct precipitate separates, occupying, however, the whole fluid ; strongly coagulable, where it occupies half the volume of the fluid ; moderately coagulable, where it occupies a fourth of the fluid ; slightly coagulable, where it occupies an eighth ; feebly coagulable, where it occupies less than an eighth ; and hazy by heat, where a turbidity is occasioned without visible flakes.* * It seems unnecessary to overload the text with any investigation of the fallacies, either the tests for albumen, or of albumen as a test of the presence of granular disease ; but a few observations may be hero appended. As to the tests for albumen, heat alone is sufficient where the quantity is so great as it usually is in the acute form: and, in all circumstances, nitric acid renders the test of heat unimpeachable. But nitric acid alone is inadequate; vol. in. 35 274 GRANULAR DISEASE OF THE KIDNEY (Symptoms). Besides being diminished in quantity and density, as well as impregnated with albumen, the urine is always defective in the proportion of solids discharged in a given time. The amount of solids discharged in twenty-four hours seldom exceeds half an ounce, which is scarcely the fourth of the healthy average in a stout adult; and it is often only half that quantity or even less. It was observed above, that the urine is occasionally blood-red. In a few rare cases a large proportion of pure blood is discharged with it, and the urine has even been almost entirely displaced by blood. When the symptoms put on the chronic form the quantity of urine is often natural, not unfrequently much above the healthy standard, so as to constitute a true diabetes insipidus, but sometimes on the contrary, very defective. The last condition occurs chiefly when incidental inflammatory action is excited, or when the case is drawing towards a fatal termination; and in such circum- stances the diminution is often so great, that only one or two ounces may be passed for many days consecutively. The colour of the urine is occasionally natural or brighter yellow than usual, but far more generally it is pale, often excessively so, frequently too blood-red, sometimes smoke-brown, both of which tints disappear when the urine is coagulated by heat. For the most part there is a peculiar opaline turbidity, not removable by repose, and arising from modified mucus, or the microscopic scales of the epithelion of the urinary mucous membrane; in rare cases strings of viscid mucus are seen. Urinary depositions are not common, yet both lithic and phosphatic amorphous sediments may be occasionally observed. The density is invariably low, very seldom above 1014, usually between 1007 and 1011, not unfrequently 1006, and in a few cases so low as 1004, or perhaps even lower, notwithstanding that the quantity of urine may be also at the same time defective. Albumen is com- monly present, and in such quantity as to occupy, when coagulated and allowed to rest, between a fourth and an eighth of the volume of the liquid. It is some- times, however, absent altogether for a time, especially where the urine is dis- charged more freely than natural, or towards the close of very slow cases where the density is excessively reduced, though the quantity be likewise greatly diminished. Its proportion generally increases when incidental inflammatory action is excited; and in that case the urine puts on the characters of the acute form of the disease, except that its density continues very low. It is a com- plete mistake to hold with some late authors that the albumen increases in pro- portion as the disease advances. The converse proposition is more generally true; but deviations from that rule may occur, partly caused by incidental attacks of inflammation, partly depending in all probability on peculiar modifi- cations of the fundamental disorder. The daily solids of the urine are reduced in quantity. This reduction may be inconsiderable where a spontaneous or arti- ficial diuresis makes compensation by diminished density ; but if diuresis do not exist, the solids may be reduced from 67 to 24, or even 15 parts in 1000, and from two ounces to a third of an ounce or even only one drachm in twenty- four hours. The diminution of solids seems to affect all the principles of the because, where lithate of ammonia abounds, lithic acid is separated; and heat alone is insuffi- cient if the precipitate be small, because this may arise from separation of the earthy phos- phates. All other tests are inferior in certainty and convenience. As to the indications derived from the presence of albumen, it appears unquestionable that certain kinds of food may occasion its appearance m the urine of some people : that it may also be produced there by certain poisons that act on the kidneys; occasionally by true nephritis, always more or less by pyelitis; rarely by tubercles; often by carcinoma; often by scurvy and bv purpura; seldom during the crises of acute inflammatory diseases or continued fever Simply and abstractedly, therefore, it is not a proof of granular disease being present in the kidney; but it is far more frequently produced by granular disease than by all other causes put together; and no other cause yet known ever occasions so large a proportion in the urine as is generally seen in the early stage, and sometimes, too, in the chronic form of the disorder; so that urine, at least moderately coagulable, according to the definition given above, probably always indi- cates granular derangement. GRANULAR DISEASE OF THE KIDNEY (Symptoms). 275 urine indiscriminately; but more accurate inquiries on this head are still wanted. The state of the blood is scarcely less remarkable than that of the urine; and like the latter, the former differs in the acute and chronic forms of granular disease. In the acute form and early stage of the disorder the blood commonly presents a very strong buffy coat, and frequently a lactescent serum, which yields fatty matter to sulphuric ether. Its serum is much reduced in density, namely, from 1029, the healthy average, to 1024, 1022, 1020, or even 1018. As this reduction is chiefly owing to the loss of albumen, the scrum coagulates loosely when heated, and instead often, contains often only six per cent, of solid matter. The reduction in density is always proportional to the amount of albu- men discharged with the urine, and the length of time this discharge has existed. The serum very generally contains urea, and always when the urine has been for some time much reduced in quantity. It is discovered most certainly by evaporating the serum to dryness over the vapour bath, boiling the pulverised residuum in absolute alcohol, dissolving the alcoholic extract in water, filtering the solution, and adding to it in a watch-glass half its volume of nitric acid ; upon which scaly crystals of nitrate of urea are gradually formed. The fibrin is commonly increased in proportion as in inflammatory blood. The haematosin, or colouring matter, is unaltered, provided the disease be really in the incipient stage; but as the disease advances, it is rapidly and greatly diminished. In the chronic form and more advanced stage, the properties of the blood undergo further alteration. The crassamentum does not present a well-marked buffy coat, nor the serum much lactescence, unless inflammation or general reaction concur. The clot is small, or if large loose; and the serum is unusually abundant. The density and solids of the serum are for the most part little or not at all reduced, sometimes even above the average of health. This depends upon the state of the urine as to albumen. If local inflammation, general reac- tion, or any other cause, should occasion an abundant discharge of albumen with the urine, the serum is reduced in density and solid contents, exactly as in the acute form of the disease. But in most cases of the chronic or passive form, where little albumen is found in the urine, the serum possesses its natural density, or is even seen so high as 1031, and containing 97 instead of 80 parts of solid matter in one thousand. The serum frequently contains urea, but only when the daily discharge of solids with the urine is much reduced. Hence in the middle stage of the disease it is commonly absent, unless where incidental causes occasion a diminution of the urine; but in the most advanced stage it is commonly present; and towards the close of protracted cases it is seldom alto- gether wanting. The salts of the serum are in their usual proportion. The fibrin too is commonly natural in its proportion. Very different is the case in respect to the haematosin of the blood. When the disease has made some pro- gress, whether in the acute or chronic form, the haematosin is invariaby reduced, and the reduction increases quickly as the degeneration of the kidney advances. Probably no other disease except haemorrhage occasions so great an impoverish- ment of the colouring matter of the blood. The healthy proportion in a stout male, being about 1340 grains in 10,000, it has been found reduced in granular disease of the kidney, according to its stage, to 1110, 955, 720, 564, and even 427. The degree of leucophlegmatia corresponds of course with this reduction. The inferences to be founded on these interesting facts are liable to uncertainty, where the patient has been frequently and largely bled, or where he has suffered severely from some of the exhausting incidental diseases, or where the appetite is small and digestion indifferent. But the tendency of granular disease of the kidney, to induce extreme reduction of the haematosin of the blood, is undoubted, having been observed where the appetite and digestion had been always tolerable, the blood never impoverished by venesection, and the patient little troubled with secondary disorders. Of the symptoms now laid down as proper to the fundamental disease, those 276 cranular disease of the kidney (Secondary Diseases). most pathognomonic are the several morbid conditions of the urine. It would be wron»", however, to trust these characters alone, as some have proposed. For determining the stage of the disease, the state of the urine is a valuable criterion; but the most unequivocal and most precise is the proportion of haematosin in the blood, checked of course by reference to incidental circum- stances, and especially frequent, free, and recent bloodletting. Secondary diseases. Granular disease of the kidneys may follow its course from first to last, without any other symptoms than those hitherto described as proper to the fundamental disorder. Such cases however are rare. In the state of the constitution induced by it, there is an excessive liability to various secondary or incidental maladies. One of these indeed is so common, namely, anasarca, that several esteemed pathologists have held it to be universal and primary, not secondary and occasional. But, from repeated observation, the writer is fully persuaded that this doctrine is founded on error. The secondary diseases are of great practical consequence; for they are often the first signal of alarm by which the primary disease is indicated. They arc rendered much more obstinate than usual by the concurrence of the renal disorder; they constitute the chief sources of immediate danger in its course, at least for a long lime; and if they are warded off, life may be protracted for a number of years in a state of very material comfort. The most important secondary affections are dropsy, diarrhcea, pleurisy, peritonitis, pericarditis, pneumonia, catarrh, dyspepsia, chronic vomiting, coma, chronic rheumatism, and chronic organic diseases of the heart and the liver. Dropsy is the most frequent of all the secondary diseases; it was the one which first drew the attention of Dr. Bright to the disorder of the kidneys; and it is still the affection which most generally excites for the first time a sus- picion of the existence of disease in these organs. Yet it is not essential. In- stances occur where the disease of the kidney runs a long course without any dropsical effusion. It is, however, the most frequent of all the causes of dropsy. The form it most generally occasions is general dropsy or anasarca, attended with more or less effusion into the great serous sacs, and into the pulmonary cellular tissue. The anasarca affects chiefly the limbs and the face, sometimes the latter only. Effusion into the serous sacs is seldom considerable, unless either the general anasarca is very great, or there is an organic disease of some other organ in the cavity besides the kidneys. Most cases of what are usually called inflammatory dropsies depend on disease in the kidney. Many dropsies consequent upon scarlatina are of the same nature. So also are probably all those where the cedematous parts are elastic, and do not pit upon pressure. So too are most, if not all, cases attended with diuresis, provided the urine be not saccharine ; and such cases, strange as the fact may appear, are far from being uncommon. Lastly, it is probable that all dropsies owe their origin to the same cause, which are associated with urine of very low density, and not above the natural standard of quantity, whether it be albuminous or not. In dropsy from granular disease of the kidneys the urine is not necessarily albuminous. For the most part, however, it is more or less so; in the early stage of the primary disease this impregnation is always abundant; and the same is the case at all stages when the dropsy appears with the inflammatory character. This secon- dary disease is probably owing to an increased tendency to transudation, in consequence of the blood being rendered unusually thin and watery in the early stage by diminution of its albumen, and in the advanced stage by reduction of its colouring matter. It is always a most important object in the treatment, because so long as it prevails every other disorder, and almost every other symptom indeed, is apt to be exasperated. A variety of affections of the stomach may attend granular disease in the kidney. Among those the most familiar is simple dyspepsia or defective diges- tion, with its customary train of symptoms. The most serious is chronic vomit- ing, which consists sometimes only of constant sickness and vomiting, occurring granular disease of the kidney (Secondary Diseases). 277 as soon as the patient awakes in the morning, but at other times of frequent vomiting throughout the day, and the rejection of all articles whatever which are swallowed.- This affection is particularly apt to be troublesome towards the close of the disease; and it is sometimes the immediate cause of death, in consequence of deficient nutrition, and exhaustion. It does not appear to be generally connected with reaction, inflammation, or any organic disturbance of the stomach. It is always an obstinate complaint, difficult even to palliate, and apt to be renewed. Diarrhcea has been a very common secondary disorder, as the disease shows itself in Edinburgh. It appears sometimes obviously connected with errors in diet, but more frequently arises without an obvious cause. It sometimes depends merely on inordinate irritability and increased discharge from the mucous mem- brane of the bowels, and may thus continue long and until death without any particular morbid appearance being discoverable afterwards ; but more generally it is nothing else than a chronic dysentery, depending on intestinal ulceration. There is often little pain. The evacuations consist for the most part of watery faeces. It appears sometimes a benignant affection, which carries off dropsy ; but far more generally it is a troublesome exhausting complaint, difficult to subdue, and not unfrequently the immediate cause of death. It has not been observed any where so often as at Edinburgh; yet bowel complaints in other circumstances are certainly not more common there than usual. Inflammation of the serous membrane has been observed as an incidental dis- order in every quarter where granular disease of the kidney has been studied ; but it appears to be more frequent in London than any where else. Pleurisy is the common variety, next peritonitis, and next pericarditis, which is seldom met with. These disorders are apt to be induced by incidental exposure to cold, and to occur on occasions when the primary disease commences in the acute form in its subsequent course. They are sometimes latent, commonly severe; but, unlike the other secondary disorders, are easily subdued. Catarrh is one of the most important of the secondary affections. It is often associated with emphysema; and in one shape or another is seldom long absent in any case, at least in northern latitudes. It is occasionally acute, much more frequently chronic. It is often enough cured, yet it is frequently obstinate, and in many instances it is the immediate occasion of death. Few survive long if it be obstinate, more especially where extensive anasarca concurs and the primary disease has made some progress. Coma and apoplexy are among the most frequent of secondary diseases, and none else is so unfavourable. Sometimes an apoplectic attack supervenes sud- denly, and proves quickly fatal; but this is far from being a frequent occur- rence. In general the head affection comes on in the insidious form of in- creased drowsiness, and perhaps some bluntness of the senses and obtuseness of mind. Gradually the drowsiness passes into constant stupor, and this into complete coma, which is occasionally interrupted by convulsions, but much more frequently not. A week at least commonly elapses between the first ap- proach of drowsiness and the fatal event, where the primary disease is of long standing; but where the renal affection is in the incipient stage, and reaction present, the course of the head affection is much more rapid. It is at times connected with congestion or extravasation of blood within the head, or with serous effusion; but generally with no particular morbid appearance, except unusual paleness of the brain, and want of blood in the cerebral vessels. It is commonly connected with suppression or extreme diminution of urine, yet this connexion is not invariable. Extreme diminution, however, seldom prevails long without coma beginning to form. There is no necessary connexion between the extent of the dropsical effusion and the risk of coma. Arachnitis has been observed as a secondary affection of the head by Dr. Osborne, and repeated attacks of epilepsy by Dr. Bright; but these disorders are compara- tively rare. Coma is always a most formidable affection, and is indeed very 278 granular disease of the kidney (Causes). seldom amenable to treatment. Perhaps it ought not to be considered as merely a secondary affection; for it would rather appear to be the natural termination of the primary disease, where it is not abruptly put an end to by some other undoubted incidental disorder. It seems to be occasioned by poisoning of the blood with the undischarged principles of the urine. At all events urea is always found abundantly in the serum of the blood, unless where congestive or sanguineous apoplexy is the particular form of the affection. According to the experience of all observers of the renal disease as it occurs in Edinburgh, this is at the bottom of almost all the obscure cases which every now and then occur of coma in connexion with suppression of urine. Chronic rheumatism has appeared so common an accompaniment of the ad- vanced stage of granular disease of the kidney, that in all cases of obstinate rheumatic affections, the condition of the urine should be inquired into. It generally puts on the form of mere neuralgia; occasionally, however, the joints present swelling and redness. It is always troublesome to remove. Where dropsy concurs with the primary disease rheumatism is rare. Pneumonia is not common, pulmonary inflammation putting on more gene- rally the form of bronchitis. It nevertheless sometimes attends the acute form of granular disease of the kidney, both in the early and in the more advanced stages. Like other acute inflammations, occurring incidentally in the same circumstances, it is sometimes severe, but for the most part easily checked by proper treatment. Lastly, organic diseases of the liver and heart concur very frequently with granular degeneration of the kidneys. Sometimes the one, sometimes the other disease is obviously prior in origin; at other times it is impossible to say which commenced first; and occasionally the three organs are affected together, and nearly in the same degree. The most common affection of the heart is hyper- trophy, with or without valvular obstruction ; and this is for the most' part betrayed by characteristic symptoms. It always adds greatly to the patient's sufferings as well as danger, and is a frequent cause of death by aggravating anasarca or catarrh. Organic disease of the liver is often much more ob- scurely marked. Most of the local signs, usually trusted to, may be produced equally by the renal disease alone; its best local signs, fulness, hardness, and dulness on percussion in the right hypochondrium and epigastrium, may be rendered fallacious by serous effusion into the peritoneal sac; and the most common variety of diseased liver in cases of granular liver, namely, the tubercular condition proper to intemperate habits, is far from being always attended with enlargement. Where other diagnostics are insufficient to decide the question of its presence, it may commonly be inferred to exist where ascites is a predominating part of the dropsical effusion. Such are the principal diseases which may occur secondarily to oranular degeneration of the kidney. It remains to be observed, that on the contrary this disease of the kidney may occur secondarily to other disorders ; among which those hitherto well ascertained are organic diseases of the liver, hyper- trophy, and valvular disease of the heart, and phthisis pulmonalis. Further it may be added, that in diseases generally the accidental presence of granular kidney is almost always the source of additional danger, by ao-gravatino- the other disease ; which has been well exemplified in the late epidemics of°con- tinued fever and malignant cholera of Edinburgh. Causes. When granular disease of the kidneys appears in the chronic form its cause is generally very obscure. Even the acute form sometimes cannot be referred to a specific exciting cause; but generally some unequivocal exposure to cold, or to wet and cold together, precedes it; and many ascribe it to sitting down on a cold stone, or taking a hearty draught of cold water while over- heated, or getting wet during night-watching. In a few instances the disease has apparently followed a blow upon the loins. Constitutional circumstances clearly predispose to it. These are the constitution of intemperance, the scro- GRANULAR DISEASE OF THE KIDNEY (Causes). 279 fulous habit, and that state of the system which succeeds scarlatina. A very large proportion of the cases observed in Edinburgh have been clearly con- nected with long-continued habits of intemperance in the use of spirituous liquors. In not a few cases this agent has seemed adequate to produce the disease in its chronic form, without the co-operation of any other more direct cause. In other instances it acts evidently by engendering a predisposition merely; and some other cause developes the renal affection. The strumous constitution is another predisposing circumstance by no means unfrequent; and a very common conjunction of circumstances is habitual intemperance in scro- fulous constitutions. Doubts have been raised by some whether scarlatina pre- disposes to granular disease. But the writer would venture to suggest, that the negative evidence advanced by some can never outweigh the clear and positive evidence brought forward by others, and to observe, that the frequent de- pendence of granular disease of the kidney upon scarlet fever, at all events as a predisposing, and very probably as a direct exciting cause, is in his opinion firmly established. It is not improbable that certain agents, which excite irritation of the kidneys, may be arranged among the list of causes. The urine becomes occasionally albuminous under the use of mercury, or in consequence of the action of can- tharides upon the urinary organs, or after certain kinds of diet in which cheese, " pastry, and heavy puddings predominate. It is not impossible that the frequent or continuous action of such agents may, in the end, induce granular disease of the kidneys in persons predisposed to it; and at all events, there is strong reason for thinking that cases of the kind have been observed after the consti- tutional action of mercury. Age, sex, and profession, have only an indirect influence. No age is exempt. Childhood presents a few cases; the period between puberty and adult age a greater proportion; manhood, especially towards the close of it, by far the greatest number; and extreme old age an occasional example. Cases have been met with at the age of five, and younger; and one instance has been re- corded by the writer where the patient was an old man of seventy-nine. Of 74 fatal cases Dr. Bright found 19 under thirty years of age, 50 under the fiftieth year, 13 above fifty, and 4 above sixty. After infancy the effect of age is referrible to the relative predominance of intemperate habits, and the liability to exposure to atmospheric inclemencies. Profession acts in the like manner. A large proportion of cases in the lower ranks occur among those trades which subject workmen to vicissitudes of heat and cold, or to contract intemperate habits. An erroneous idea has been prevalent that the middle ranks may claim exemption. On the contrary, further experience more and more convinces the writer that the disease is by no means confined to the lower rank, though, without a doubt, proportionally more frequent there; that cases are often met with among persons of easy circumstances by those practitioners, at all events in Edinburgh, who have made themselves conversant with the subject; and that, by others, the disease is not unfrequently lost sight of where it affords the only explanation of apparent anomalies. Prognosis. An opinion has gained currency, that granular disease of the kidney is an incurable affection ; but fortunately its validity admits of question. When the disease is in its early stage, as determined by the urine being not much under the natural standard of density, and by the blood containing nearly its due proportion of colouring matter, there seems no reason to doubt that thorough recovery may be accomplished. If most cases of inflammatory dropsy with coagulable urine after scarlatina are connected with the early stage of granular kidney, which seems probable, radical cures are not fjn- common. In other circumstances the practitioner is much more frequently disappointed, because he is apt to mistake for the first commencement of the disease an acute attack, occurring incidentally in the middle of its chronic and latent form. Even in cases unconnected with scarlatina, however, it seems 280 GRANULAR DISEASE OF THE KIDNEY (Causes). probable that complete recovery may be brought about when they are subjected to early and judicious treatment. It is certain at any rate, that in such instances all secondary affections have been removed, all local uneasiness subdued, some- times even the urine restored to its natural state, and the patient ascertained to enjoy good health for two years and more afterwards. More generally, though we may succeed in apparently restoring health, the urine continues essentially morbid and more or less albuminous; and in that situation it is not unlikely that the organic derangement may make insidious pro- gress, while it is certain that trifling causes may renew the previous symptoms essential as well as incidental. When the disease is somewhat advanced, it cannot be removed; because, besides consisting of a morbid deposition in the kidney, it occasions atrophy of the proper renal structure, the loss of which cannot be repaired. But although the disease, or rather its effects, cannot be removed in this stage, it is probable that they may be arrested so as to proceed no further, and to admit of life being long preserved in a state of comfort and tolerable health. Such at least seems the rational explanation of the cases, now ascertained to be not uncommon, where the urine continues permanently pale, low in density, and feebly albumi- nous, although all symptoms of suffering have been removed, all secondary affections arrested, and the general health maintained substantially good for three, four, five years and upwards. The probability of recovery depends, in the first place then, on the stage of the disease; but it also depends greatly on the nature, number, and severity of the secondary diseases. Most of the secondary disorders are obstinate when they concur with diseased kidneys. Dyspepsia may be much mitigated, but is apt to recur. Chronic vomiting, once fairly established, is seldom effectually checked, and may be considered an unfavourable sign. Diarrhcea is difficult to stop, and apt to return, and therefore must also be viewed as unfavourable. Catarrh is often removable; but where it resists treatment, the complication is of evil import. Coma is very rarely arrested, and is one of the most unpropitious prognostics among secondary affections. Diseased liver and diseased heart are also unpropitious, being themselves incurable, besides aggravating the effects of the renal disorder. The acute inflammations are generally severe, but com- monly yield to remedies. If they recur often, however, they will generally prove at last the cause of death. Dropsy, unless excessive, is by no means always an unfavourable sign. The effusion is sometimes difficult to remove; but for the most part it yields at last; and its removal is usually attended with marked improvement in all the other symptoms. The danger is not proportional to the amount of albumen in the urine. On the contrary, where it abounds, the disease is commonly in its incipient stage; and where it is scanty, the disease may be far advanced. Its gradual disap- pearance is favourable, especially if combined with a gradual increase of density in the urine. The danger is not proportional to the inflammatory state of the blood ; yet this state requires watching and sometimes treatment. The danger is greatest where the colouring matter is most reduced in proportion to the other ingredients of the blood. The danger is not always urgent when the dropsical accumulation is great. Incidental risks, indeed, arise of speedy death from dyspnoea, or from distension occasioning erythema and gangrene; and besides, so long as the dropsy is considerable, the other symptoms are all more troublesome. But the dropsy is commonly to be removed with perseverance. The greatest amount of dropsy usually occurs in the early stage of the primary disease. The danger is on the whole proportional to the lowness of the density of the urine, especially where the quantity is also defective. But a better way of expressing this rule is to say, that the danger corresponds with the diminution in the daily discharge of solids in the urine. A patient may live long and in comfortable health, where the diminution has reduced this discharge to one- GRANULAR DISEASE OF THE KIDNEY (Pathology). 281 third of the natural average; when it descends to a fourth, troublesome secon- dary symptoms are apt to show themselves; and any materially greater reduc- tion is soon followed by urgent symptoms, and most generally by drowsiness, leading on to coma. Suppression of urine is invariably a fatal prognostic. Gradual increase of the density of the urine, its quantity remaining the same, or increasing, is a very favourable circumstance. In the advanced stages, a spontaneous diuresis seems a favourable incident; and so long as it continues, the patient enjoys tolerable health. The reason is apparently that the quantity makes up for the lowness of density, so that a full amount of solids is discharged daily. The writer has known the health maintained tolerably entire for four years in such circumstances, the patient passing towards eighty ounces daily of pale urine, about 1010 in density. Anatomical characters and pathology. A considerable variety of alterations of structure are found in the body after death from this disease. Several peculiar derangements of structure are seen in the kidneys; and other organs too are extensively affected, in correspondence with the symptoms during life. It is probable that the term Granular Disease, so far as concerns the precise appearances found in the kidneys, has been applied too generically. Several forms of disease have been comprehended under it, to whose anatomical cha- racters the name does not well apply, although the phenomena during life, as hitherto known, are much the same in all. At least seven distinct appearances have been described as occurring in connexion with albuminous urine and the various symptoms described above; namely, 1, congestion of the kidney with enlargement, and with or without deposition in its internal structure; 2, a gra- nular deposition into its cortical and tubular textures, sometimes finely granular, sometimes roe-like, and attended with atrophy, or absorption of the proper renal tissue; 3, deposition of a homogeneous yellowish-gray matter, with similar atrophy; 4, disseminated tubercles; 5, induration of semicartilaginous hard- ness ; 6, atrophy, from disappearance of the proper renal structure, with little or no deposition; and, 7, mere anaemia, or paleness, an appearance, however, which is of very doubtful existence as connected simply with albuminous urine and the collateral symptoms. The relation which these several appearances bear to one another is not yet thoroughly understood. In all probability some of them are related together as different stages of one disease. M. Rayer is of opinion that the fourth, fifth, and sixth appearances bear no precise relation to true granular disorganization, and that the last two of these are the result of simple chronic nephritis. It is probable, however, that this is a too limited and erroneous view of the subject. All the forms mentioned above agree in occa- sioning atrophy or absorption of the proper renal structure; and there can be little doubt that this result is the cause of many of the symptoms observed during life, and the immediate source of danger and death. It may be well therefore to arrange the succeeding observations on the morbid appearances, according to the degree of this particular effect. In the early stage the organic changes in the kidney may escape notice unless carefully looked for. When the disease has put on during life the acute form, the kidneys are found flabby, friable, larger than natural, and commonly twice, sometimes four times the natural weight of four ounces ; externally dark with ecchymosed spots, internally also dark and full of blood and speckled often with darker ecchymosed spots, especially in their cortical structure. The cor- tical texture, which is sometimes alone diseased, and always most affected, is broader than natural, sometimes twice or thrice its usual breadth, and often pre- sents a deposition of granular matter, similar in colour to the surrounding healthy texture, and therefore seen with difficulty unless the kidney be injected with fine injection, in which case the matter does not flow into the morbid de- position, but every where surrounds and defines it. Unless this precaution be taken, the appearances resemble closely those observed in the early stage of vol. in. 36 282 GRANULAR DISEASE OF THE KIDNEY (Pathology). simple nephritis, for which they have accordingly been sometimes mistaken.* Where the case has lasted some weeks the amount of the granular effusion may be so great as materially to obscure the proper coarsely striated appearance of the cortical portion of the kidney. The bladder is in such cases contracted, and contains only a few drops of pale urine, highly albuminous, and of rather low density. Other organs pre- sent various morbid appearances, which will be mentioned presently under an- other head. They are chiefly the traces of inflammation and hydropic effusion in the serous sacs. In the head, if death take place by coma, which is the usual course, there is occasionally found congestion of vessels, extravasation of blood, or serous effusion ; but much more generally no unusual appearance is seen to explain the manner of death; the state of the brain is that of the simple apoplexy of Dr. Abercrombie. The blood commonly contains urea, and always if the urine was much diminished for some days before death, which is com- monly the case. We are not well acquainted with the appearances presented in the body in the early stage, when the disease assumes the chronic form at that period; obvi- ously because, on the occasions when death takes place in such circumstances from an independent disorder, the attention of the practitioner is rarely called to the state of the kidneys either before or after death. But in all probability the appearances are simply a minor degree of the deposition observed in the more advanced stages. In the middle stage, when the morbid deposit has made some progress, the following are the states observed :—The cortical texture is chiefly, or almost solely affected; but often the disease may be traced also in the internal tubular structure. The kidney is sometimes of the natural size, occasionally rather' diminished, often considerably enlarged. If large, it is commonly softer than usual, and rather flabby ; if diminished, it is occasionally somewhat hardened. The investing membrane may in general be easily stripped off. The external surface is pale, grayish-yellow, or grayish-brown, either uniformly so, or more commonly mottled, and also speckled with star-like and linear spots of vascu- larity ; and it is also rough, often granular, rarely in this stage, botryoidal or roselike as at a later period. Internally the cortical texture has almost or entirely lost its striated appearance and natural reddish-brown hue. It is gray- ish, yellowish-gray, or reddish-yellow, finely granular, or homogeneous, and admits very little or none even of the finest injection. The same characters are seen in that part of the cortical matter which dips between the tubuli. The tubuli themselves are not much affected ; but generally some specks of deposit may be seen among their striae, expanding somewhat their bases, and rendering the fibres finer and more obscure than in the healthy state ; and sometimes their papillae present red indurations. The bladder, the urine, and the blood are much in the same state as in the early stage. Other organs present a variety of morbid alterations, varying with the secondary affections during life. The supra-renal glands are often tuberculated and granular. In the head the brain is usually found pale, and with its membranes less vascular than in ordinary circumstances ; but some- times there is distinct congestion, and more rarely extravasation. Dropsical effusions are often seen in the cellular tissue, lungs, peritoneum, pleura, and more rarely in the pericardium. Emphysema is common, together with the traces of catarrh, namely redness and mucous gorging of the bronchial tubes. In the lungs, besides oedema, there may be seen redness, sanguinolent infiltra- tion, and hepatization, being the traces of pneumonia. Turbid serum, with soft curdy fibrin, is found on the peritoneum or pleura in some cases,'indicating recent inflammation of those membranes. The mucous coat of the intestines * M. Rayer, in criticising observations made in Britain by the writer and others on the early stage of the disease, seems to have fallen into this error GRANULAR DISEASE OF THE KIDNEY (Pathology). 283 often presents redness, effusion of lymph, enlarged muciparous glands, and ulceration. The liver is often tuberculated and enlarged, the spleen softened, the heart hypertrophied, dilated, and enlarged on one or both sides, and sometimes with its valves contracted in the usual way. Among the rarer appearances are oedema of the glottis, ulceration of the larynx, redness of the mucous membrane of the stomach or bladder, induration of the spleen. Traces of old inflamma- tions are not uncommon. All these appearances are of course secondary merely to the fundamental disease in the kidney. They are more frequently seen in this than in the early stage of the primary affection. Although they correspond on the whole with the symptoms during life, they are also often found in the dead body, when they were not betrayed previously by any symptom. In the advanced stage of the renal disorder the tubuli become involved to a greater extent. The external appearances of the kidney may be the same as before; but frequently too it is lobulated, botryoidal, roselike, or finely granular. The kidneys are sometimes larger than natural; but more frequently now than in the early stage they are found contracted, often greatly so, sometimes to one- eighth of their natural weight. They are generally firmer, especially when contracted, and sometimes they approach to cartilage in hardness. Internally, if the kidney is not diminished, the granular or homogeneous matter occupies a large proportion of the organ ; the cortical structure presents scarcely a trace of its proper striated apearance; and the tubili are some of them entirely gone, others broken up into detached fragments, others flattened, or, on the contrary, with their bases expanded, and their fibres fine and delicate; and the matter of a fine injection passes only between the fibres of the tubuli, together with the great vessels passing through the degenerated cortical portion. If, as more generally huppens, the kidney be contracted, its internal appearance is different, the cortical texture is narrow, the tubular bases drawn as it were almost to the surface, the morbid deposit trifling or almost wanting, and the tubuli contracted, twisted and huddled irregularly together. In the most advanced cases the kidney may be seen large and composed of one uniform mass of granular or homogeneous deposit, with only one tubulus remaining of its whole original structure; or it is found shrivelled to the size of a crown, thin, flabby, almost membranous, and without a trace of healthy structure. In such cases the ureter is sometimes impervious. The renal veins occasionally present firm fibrinous clots. The supra-renal glands are indurated. The blood-vessels and heart are unusually, sometimes excessively, destitute of blood ; the membranous organs blanched; the brain singularly white and free of vascularity; the blood commonly loaded with urea; and a great com- plication of secondary morbid appearances is usually seen, like those described above as occurring also in the middle stage. Instances do occur, however, of the primary disease in the most advanced stage, without any secondary morbid derangement of consequence. It was observed at the outset of this enumeration of the morbid appearances, that the exact relation in which they all stand to one another is not yet thoroughly understood. But on the whole the probability is, that the disease consists substantially of a peculiar morbid deposit, preceded in the acute form by congestion or even reaction in the kidney, but in the chronic form without any such precursor; that, as the deposit increases, the healthy texture of the kidney begins to be absorbed ; that after a time, although the absorption of the healthy structure goes on, the deposition of the morbid deposit often ceases ; and that possibly this deposit is sometimes absorbed in its turn. These views derive support, first, from observations showing in the two kidneys of the same individual the appearances of what are here considered two distinct stages of the same fundamental disease ; and, secondly, from the consideration, that the different states of the kidneys in different cases correspond with symptoms during life, varying indeed in degree, but nevertheless essentially the same in 284 GRANULAR DISEASE OF THE KIDNEY ( Treatment). kind. In the early stage the urine is found strongly albuminous and deficient in the daily discharge of solids, but low in density. In the middle stage, whether the kidneys be Ibund contracted or enlarged, and whether the morbid deposit in them be great or small, provided the natural structure be materially invaded, the urine is moderately albuminous, considerably reduced in density, and still defective in daily solids discharged. In the most advanced stage, where the healthy structure is extensively disorganized, either with much or with little morbid deposit, the urine is extremely pale, very low in density, feebly albuminous, unless incidental reaction arise, and exceedmglyidefective in the daily discharge of solid matter. Some apparent exceptions may be found to these general statements. But they are probably not real, and arise from cases having been included under the head of granular disease, which belong to other affections of the kidney, such as chronic inflammation, acute inflammation, atrophy, and tubercles. This would be the proper place for considering what is the nature of the morbid action which gives rise to granular deposit and its accompaniment, al- buminous urine. Nothing, however, can be brought forward on that subject at present, which is not purely theoretical, and unfit for full discussion in a work like the present. The chief question which naturally arises is, whether the morbid action in the kidneys is of the nature of inflammation or not. The question has derived importance of late, in consequence of M. Rayer having adopted the affirmative side, and, in accordance with that view, denominated the disease Albuminous Nephritis. Facts are still wanting to test the validity of that opinion. Meanwhile it may be briefly stated that the chronic form of granular disease, its most frequent variety, would appear as difficult to bring under the category of inflammation as any other chronic organic disease which could be mentioned; and that in most, if not in all, cases of the acute form, the symptoms of local and general reaction may be correctly viewed as secondary or incidental, and not as essential to the fundamental affection. Granular deposi- tion in the kidney in short, like tubercular deposition in the lungs, may be either wholly unconnected with reaction, or it may follow general or local reaction; and the latter circumstance does not necessarily constitute it an inflammatory disease. Treatment. The treatment must be directed first to the primary disease, and then to its complications or secondary affections. In the acute form of the primary disease vigorous antiphlogistics are indis- pensable, and the treatment generally is very much the same with that of the acute inflammation. Free bloodletting, carried to faintness, or till the pulse is affected, and repeated after a short interval if the symptoms be not subdued, constitutes the main remedy. When the force of reaction has been somewhat mitigated, local bloodletting, in the shape of cupping and leeches to the loins, is more serviceable. Depletion is often equally required by the secondary com- plaints, as by the primary disorder. In the latter its good effects are shown by the removal of local uneasiness, the diminution of the albuminous state of the urine, the increase of its quantity and density, and the improved feelings of comfort. The same active treatment is required where the acute form is super- induced by incidental causes upon the chronic form of the disease. But evacua- tions need not be pushed so far; and some reserve must be shown in repeating them, on account of the impoverished condition of the blood. Hence it is advisable, whenever any doubt exists as to the real stage of the degeneration of the kidney, to examine the blood analytically, and ascertain the proportion of its colouring globules. The general antiphlogistic regimen must of course be observed in this form, whether in the early or advanced stage. After a time counter-irritants to the loins, such as blisters, issues, and setons, are preferable to depletion. These remedies become the most appropriate means so soon as the disease granular disease of the kidney (Treatment). 285 puts on the passive form, and, along with occasional leeches, may be used from the first in the cases which do not present an acute stage. The maintenance of the cutaneous discharge is of the first importance, in order to produce derivation from the kidneys. This is to be accomplished by warm clothing as soon as the febrile heat has passed away, by Dover's powder, in the dose of five to eight grains thrice a day, and by the regular use of the vapour-bath, or warm bath, every other evening or oftener. The last remedy is particularly useful for removing restlessness, anxiety, and want of sleep. James's powder may be substituted for Dover's powder, and some prefer the acetate of ammonia. But Dover's powder is the most useful, both as a dia- phoretic, and likewise as a calmative for allaying pain and irritability. For the latter purpose, hyoscyamus may be combined with the other diaphoretics. The bowels must be regulated by laxatives. But in general brisk cathartics should be avoided, because in some people they are apt to bring on the diarrhcea, which was described above as often a troublesome secondary affection. Diu- retics are unnecessary unless where dropsy prevails, or coma is threatened, in connexion with great decrease of the urine. By some they are considered as positively contra-indicated in all circumstances, on the ground that they add to irritation in the kidneys. But this is not necessarily a just cause of contra- indication ; because in therapeutics there is no want of instances, where a stimulus of one kind is employed without injury, in respect of the existence of a stimulus or irritation of another kind in the same organ. Besides, diuretics do not increase the albuminous contents of the urine, the amount of which is probably a test of the degree of local irritation; and there are instances where a continual spontaneous diuresis seems to be associated with the enjoyment of health for a period of years in the chronic state of the renal disease. Mercury is contra-indicated in all circumstances, except to aid the action of cathartics and diuretics. In granular disease it generally affects the constitution with great facility, the constitutional action is apt to be severe; and not improbably the peculiar morbid affection of the kidneys is increased rather than diminished. VVhen the disease has been brought by the preceding treatment into a state of quiescence or arrestment, a rigorous prophylaxis must be observed. Warm clothing, careful avoidance of cold and damp, abstinence from spirituous liquors or the abuse of wine or malt liquors, the use of nutritive digestible food in moderation, the observance of regular and brisk exercise, comprise the leading particulars of the prophylactic plan ; and the warm bath at stated intervals is an excellent addition. By these means there is some hope of arresting the further progress of organic derangement of the kidneys, even where considera- ble advance has been made; and they are absolutely indispensable for avoiding the immediate sources of danger to life—the incidental developement of secon- dary diseases. As the secondary disorders are the chief sources both of danger and of dis- comfort, their treatment is a most material part of the method of cure upon all occasions. They may on the whole be treated as in ordinary circumstances. It must be always remembered, however, that the greater part of them are apt to be peculiarly obstinate ; and a further consideration is, that the primary dis- ease should always be kept in view, even when in the chronic form, and there- fore that, as Dr. Osborne has pointed out, diaphoretics ought to be used, what- ever additional treatment may be necessary. Anasarca in the acute form requires, like the primary disease, free blood- letting. Without this preliminary no other treatment is available, and it is sometimes sufficient of itself, if vigorously employed at the first. General excitement or local reaction having been removed, the anasarcous accumulations may be treated by purgatives, diuretics, and diaphoretics. Diaphoretics some- times succeed alone, and where they answer they are preferable, as being de- rivatives, besides avoiding any possibility of risk from additional stimulation of the kidneys. Purgatives are not to be recommended unless other means fail, on 296 granular disease of the kidney ( Treatment). account of the risk of troublesome or dangerous diarrhoea arising; yet they may often be used with safety where the primary disease is not far advanced, the constitution not much reduced, and the bowels free of irritability. The most useful purgatives are gamboge, finely pulverized with cream of tartar, elaterium, and croton-oil with the compound colocynth mass. Diuretics have been condemned, first by Dr. Osborne, and latterly also by Dr. Bright, for the reason formerly assigned. The relief obtained from all other symptoms by the removal of extensive dropsical effusions is so great, that the usual means of accomplishing that object must not be lightly discarded. Were it generally possible to remove dropsy by diaphoretics, as is stated by these authors, diu- retics might be advantageously avoided. But the diaphoretic plan certainly has not succeeded so often as is desirable in the trials of it which have been made in the Edinburgh Infirmary. Besides, it was observed previously, that doubts may exist whether diuretics are apt to produce the injurious effects as stimulants of the kidneys, which have been imagined. On the whole, the writer would infer from his own frequent experience, that they may be used in dropsy without risk of aggravating the primary disease; and that hydropic effusions cannot in general be so efficiently removed in any other way. The best diuretics are digitalis and bitartrate of potash, and it is useful to employ both at once; the former in the dose of one or two grains of the powder, or ten or fifteen minims of the tincture, thrice a day, and the latter to the amount of a drachm or two drachms as frequently. The decoction of broom-tops also often answers well, and squill sometimes; the spiritus aetheris nitrici more seldom succeeds; nor is nitre, carbonate of potash, or hollands, often serviceable. Where diuretics fail to act, their action is sometimes brought on by an emetic or a single brisk purgative. The effect of diuretics on the dropsical effusion is often very gradual, though steady; and they act for the most part more quickly in the advanced than in the early stage. When other means fail it may be necessary to puncture the limbs. This should be done with accurate puncture needles, not by means of incisions with the lancet, because the former method is less apt to be followed by inflammation and sloughing. This risk is lessened by re- sorting to punctures before the distension becomes very great. Diaphoretics should be united with the diuretic plan, and steadily persevered with so soon as diuretics cease to be necessary. Dyspepsia is to be treated with bitters and antacids, and is often removed by removing concomitant anasarca. For chronic vomiting, when dyspepsia puts on that form, there is not any very efficient remedy. iEther, brandy, and ammonia, sometimes palliate it. Antacids also have occasionally the same effect. Blisters over the stomach are not unfrequently serviceable. Opium and hydrocyanic acid are often effectual for a time ; and the most efficient perhaps of all palliatives is creosote in the dose of one or two minims. Diarrhoea at its first appearance may often be arrested, as in ordinary attacks of this disease, by alternate doses of opium and mild laxatives, followed by small opiates regularly for some days. Where it puts on a more obstinate form, the best remedy is a combination of opium and acetate of lead, in the dose of one grain of the former and three of the latter, given in the form of a pill thrice a day; which dose may be doubled if necessary. An opium suppository of three grains is often the most effectual of all remedies. The diet at the same time should be as much of an animal nature as possible, the drink should be restricted, and malt liquors and acids avoided. To quench thirst, which is often urgent, the best of all drinks is soda-water or potash-water, with or with- out wine. The treatment of acute serous inflammations, pneumonia, and catarrh, scarcely requires any particular directions. It does not differ from the ordinary treat- ment of these diseases in other circumstances, and is commonly successful, except in catarrh, which is often obstinate. The best remedy is the removal of the dropsy, with which the catarrh is commonly accompanied. Squill, OTHER ORGANIC DISEASES OF THE KIDNEYS (Treatment). 287 with opium, constitutes a useful expectorant and calmative. Dr. Osborne is partial to copaiva where expectoration is difficult, and to acetate of lead where it is profuse. Chronic rheumatism, an untractable malady in all circumstances, is peculiarly so when coincident with granular kidneys. No method of treatment is even generally successful; but among various familiar plans the most beneficial appears to be the internal use of tincture of colchicum and muriate of morphia, together with the warm bath. Diseased liver is seldom improved by any treat- ment ; but iodine is probably more often of service than any thing else. Dis- eases of the heart are always much improved, so far as their symptoms are concerned, by removal of the dropsy ; and anodyne anti-spasmodics always relieve the spasmodic dyspnoea which attends them. Coma, the most formidable of all secondary disorders, may be averted occa- sionally in the early stage of granular kidney, if the practitioner takes alarm in time, by free bloodletting, brisk purgatives and active diuretics. Drowsiness, in connexion with great decrease of urine, may thus be prevented from passing into stupor. But where coma in such circumstances is once fully formed, treat- ment of every kind for the most part fails. Where the same affection occurs in the advanced stage of the disease, it generally approaches slowly and insidiously, and is with great difficulty averted. Where signs of cerebral congestion are present, which, however, rarely happens, local depletion is sometimes of service; and brisk purgatives are also proper where the patient's strength will permit of their use. But the chief remedies are diuretics; and where these fail to act, the case may be considered as almost desperate. The most effectual diuretic treat- ment consists in the combination of digitalis and bitartrate of potash. Dr. Osborne puts faith in calomel for averting coma. OTHER CHRONIC ORGANIC DISEASES OF THE KIDNEYS. Hyperemia.—Anaemia.—Atrophy.—Tubercles.—Carcinoma.—Melanosis.—Developement of the erectile tissue.—Phlebitis.—Serous cysts.—Hydro-nephrosis. The remaining organic diseases of the kidneys will require but a few observa- tions. They are interesting chiefly in relation to pathological anatomy, because the practitioner can detect few of them by characteristic symptoms, and cannot arrest any of them by treatment. The sketch here given of them is derived chiefly from the late investigations of M. Rayer. Hyperemia, though admitted as a disease, is probably a mere accompaniment of other diseases. In the dead body it is characterized by unusual darkness of the kidneys, gorging of their structure with blood, and increased vascularity. It attends the early stage of acute nephritis, the early stage of granular degene- ration in its acute form, and frequently also diabetes. It is also sometimes seen, together with hyperaemia of other viscera, in severe cases of typhus. The symptoms of mere hyperaemia, detached from those of the diseases it accompa- nies, are unknown. Ancemia, or excessive paleness and deficiency of blood in the kidneys, is of doubtful existence as a local disease. It occurs in conjunction with a bloodless condition of the body generally; as in death from haemorrhage after frequent copious depletion, or in consequence of protracted acute or chronic visceral diseases. But it is probable that cases of apparent anaemia of the kidneys have been rather cases of granular degeneration. Atrophy of one or both kidneys can scarcely be regarded as a special disease, but is rather the consequence of various diseases. Almost all chronic organic 288 other organic diseases of the kidneys (Carcinoma). diseases of the kidneys may be said to end in atrophy. Sometimes the atrophy of their proper structure is unattended with diminution of their size, or they may even actually increase in size, because a morbid deposit is at the same time thrown out. In other instances, the wasting of the proper renal structure is attended with gradual shrinking of the kidneys, till at length occasionally little else remains but a membranous substance. The symptoms essential to atrophy are, diminution of the colour, density, and daily discharge of solids of the urine ; but a variety of other symptoms are superadded, according to the nature of the fundamental disease by which the atrophy is occasioned. The most fre- quent cause of atrophy with diminution of size is granular deposition, and next to this may be placed chronic nephritis. The appearances usually seen have been described under the former head. Tubercles may affect either the membranes of the kidneys or their substance. They vary in size from that of small grains to that of an olive ; and they are commonly granular and grouped among the tubuli, but large and detached in the cortical texture. Tubercular kidneys are seldom contracted in size, and seldom much enlarged, unless the tubercles obstruct the papilla? or ureters, and cause distension. The proper renal structure is sometimes injected, more gene- rally atrophied. Tubercles seldom invade the capsule of the kidney; but the mucous membrane of the calyces, pelvis, and ureter is not unfrequently affected, and sometimes the bladder too is involved in the disease; while the substance of the kidneys seems about as liable to it as the inner membrane. Sometimes the whole mass of one kidney, and great part of the other, are con- verted into a uniform tubercular substance. Tubercles of the kidneys sometimes undergo softening; and occasionally they ulcerate and establish a communica- tion with the colon, or with the subperitoneal cellular tissue. They are most frequent in adults, rare in infancy or old age; and they are seldom found in the kidneys without being seen also in other parts of the genito-urinary apparatus, and likewise in the lungs. The symptoms are very obscure and dubious. Tubercles often concur with glandular degeneration. Carcinoma not unfrequently affects the kidneys when it also exists elsewhere; but it seldom affects the kidneys alone. Sometimes it commences in adjoining organs, and is communicated to the kidney through juxta-position. At other times, on the contrary, it obviously commences in the kidney, and successively affects the parts in its vicinity, more especially the vena cava, which becomes gradually filled with carcinomatous deposition, and at length completely obstructed. The cerebriform or cephalomatous form of carcinoma is the most frequent variety. As the disease advances softening takes place, and the morbid deposit at last acquires a pulpy consistence like pudding. Its progress is some- times attended with purulent deposits. The kidneys are sometimes not enlarged; but more generally they exceed considerably the natural size. As the cepha- lomatous matter increases, the proper renal structure diminishes, and at length entirely disappears. Fungus haematodes is a rarer form of carcinoma of the kidney. The morbid formation then consists partly of cerebriform matter, partly of clots of blood; and not unfrequently schirrous masses are scattered throughout the general fungoid mass. As in the case of cephaloma, so here the renal veins and vena cava are often obstructed; but the obstruction is com- monly occasioned by clots of blood. The substance of the kidneys is more frequently affected than the membrane of the pelvis. The symptoms are obscure, unless where the variety present is fungus haematodes ; in which case there is frequent haemorrhage from the bladder, conjoined with the constitutional cha- racters of malignant disease. In one case under the writer's care where both kidneys were extensively affected with cephaloma, the urine was pale, low in density, and albuminous; the patient was subject to dropsy, and the immediate cause of death was coma; so that in all its circumstances, this case resembled during life granular degeneration. In another instance, where the cerebriform other organic diseases of the kidneys (Hydro-nephrosis). 289 deposit had invaded the vena cava from the kidney, and caused total oblitera- tion, the superficial veins on the abdomen, from the groins up to the mammary region, were greatly enlarged, to carry on the circulation of the limbs. Melanosis has been met with in the kidney, seldom to a great extent, and never except when it also existed elsewhere. The erectile tissue has also occa- sionally been developed in small portions of the kidney. The renal veins have been found affected with phlebitis in persons who had died of uterine phlebitis, but very rarely without inflammation of the veins elsewhere. None of these disorders is indicated by characteristic symptoms. Serous cysts are often found in the kidneys, small in size, and few in number, without any symptoms having been observed during life. When more numerous, they are formed at the ex- pense of the proper renal texture, and may lead to the usual consequences of diminished secretion of urinary solids. They frequently coincide with granu- lar degeneration. The last renal disease requiring notice is partial or general distension of the kidneys by urine, which has been conveniently termed by M. Rayer, Hydro- nephrosis. When the tube of one of the papilla? of a calyx is obstructed by a calculus or other cause, it becomes gradually dilated till a cyst of considerable size is formed in the kidney, which is filled with urine. In like manner when the ureter is obstructed by spontaneous contraction, the dropping of a calculus or hydatid into its cavity, the pressure of a tumour or calculus in the bladder on its orifice, or the pressure of a tumour of the uterus or vagina from without, the upper portion of the ureter, the pelvis of the kidney, and eventually the substance of the kidney itself, become distended by the secreted fluid. The same changes may occur from habitual retention of urine in the bladder, where the obstruction to the urine is in the urethra. In all these circumstances in- flammation of the pelvis, or of the substance of the kidney, may ensue; as was stated under the head of the causes and complications of nephritis. But if the distension be gradual, no great irritation is excited, and either the pelvis and calyces only are dilated, or more generally the renal substance also, the cortical and tubular parts of which are gradually evolved, atrophied, and absorbed, till at last nothing is left but a membranous bag. These changes in the structure of the kidney take place in some rare cases without enlargement; more gene- rally there is considerable dilatation, and at times the enlargement is enormous, so that the cavity contains eight pounds. Where the bladder has been long affected with retention, and its state neglected, there may be found, as in a case lately examined by the writer, great dilatation of the kidney, enlargement of the ureter to the size of the small intestine, and also enormous expansion of the bladder. The fluid contained in the sac is urine, commonly somewhat altered, and impregnated with albumen. This disease is seldom marked by charac- teristic symptoms. If it depend on obstruction to the flow of urine from the bladder, the renal disorder is obscured by the symptoms proper to distension of the bladder. Where the obstruction lies in the ureter, the disease may be alto- gether latent; but sometimes constant lumbar pain in one side may lead to a suspicion of mischief; upon which, if the dilatation be considerable, a tumour may be detected by manual examination, on placing the patient with his face on the pillow, and with his knees bent up under him. Most frequently the disease continues undiscovered till after death. At times, simultaneous or successive obstruction of both ureters leads to total retention of urine, which imitates suppression. The excellent memoirs of Dr. Christison on the affections of the urinary organs, leave little to be desired. The study of these diseases has been, of late years, carried so much further than formerly, that a new set of disorders seem to have been brought before the medical world, not that they were before positively unknown, but were masked or concealed under dif- ferent names, derived rather from the symptoms than the lesions which are now regarded as » the leading pathological character. It is not, however, yet demonstrated, whether the mere vol. in. 37 290 diseases of tiie Bladder and urethra (Inflammation). organic lesion of the kidneys is the cause of some of the constitutional symptoms or the effect; the probability is, that cither mode of stating the proposition may be regarded as correct, and that in many diseases of the kidneys the cause and effect are naturally convcrti- ble one into the other. It is very clear, from a reference to the text, that although the pathognomonic symptoms of disease of the kidneys consist in the alterations of the urinary secretion, with occasional uneasiness in the lumbar region, yet the attention of physicians is not always first directed towards them, nor are they in most cases the immediate cause of death. When the disease extends to the neck of the bladder, the irritation felt in passing water will naturally indicate the urinary organs as the seat of the mischief; but if the bladder be not involved, the signs of local irritation are often too slight to attract much notice. The physician is usually called to the case as one of dropsy, or of ill-defined languor and feebleness, if it be chronic; or to a disease presenting either the symptoms of subacute arachnitis, or of the typhoid state, if it be of the acute form. Practically, therefore, it is necessary to be alive to the possibility of error in the diagnosis of these disorders, and if we cannot satisfy ourselves that they are really pri- mitive affections, the condition of the kidneys must be carefully examined, and the symptoms will often be traced to some one of the lesions of these organs. Most of the secondary symp. toms of kidney disease may arise from leeions very different in their anatomical character; but all agreeing so far that they produce an altered condition of the blood, which is in all probability the immediate cause of the cerebral disturbance. In this respect we find a very close connexion between the alterations of the liver and of the kidneys,—both organs produc- ing, in many cases, intense stupor, and other cerebral symptoms: but the lesions of the liver rarely disturb the brain, unless they are accompanied by jaundice, which affords con- elusive proof in itself, that a foreign ingredient is found in the blood. The diseases of the kidneys do not of course produce as decided an alteration of the com- plexion as those of the liver; but if the patients who labour under them be attentively exa- mined, there will be found a preternatural tint very difficult to describe, but easily recognised by one conversant with the aspect of patients labouring under renal dropsy. G. DISEASES OF THE BLADDER AND URETHRA. Inflammation.—Vesical catarrh.—Irritable bladder.—Diseases of the prostate gland.—Stric- ture of the urethra. Diseases of the bladder and urethra are generally held to belong to the province rather of the surgeon than of the physician. On that account, ft is unnecessary to consider them in detail in a work on the Practice of Physic. At the same time, some of them may fall quite as well under the cognisance of the physician as under that of the surgeon; and it is indispensable that the former be acquainted with them, because the symptoms are often such as may otherwise lead him to mistake them for those diseases of the kidney, which fall properly under his care, and which have been fully treated in the preceding pages. Hence it would be wrong to dismiss the subject of urinary diseases as a branch of the practice of physic, without some notice being taken of those which affect the bladder and urethra. But a short sketch of their diagnosis will be sufficient. These are chiefly inflammation of the bladder, catarrh of the bladder, spasm of the bladder, irritable bladder, diseased prostate gland, and stricture of the urethra. Inflammation of the bladder may be occasioned by blows or other injuries in the neighbourhood of that organ, by acrid diuretics, by surgical operations , involving the bladder, by the injudicious use of instruments for examining or treating diseases of the urethra or bladder, and by repelled gout and other more DISEASES OF THE BLADDER AND UKETHRA (Catarrh). 291 obscure causes. Its symptoms are acute burning or throbbing pain in the lower part of the pelvis, tension and tenderness in the hypogastrium, constant desire and inability to pass urine, with the usual constitutional signs of general reaction. The urine is at first scanty, dense, high-coloured, and turbid on standing; but in a short time it becomes somewhat turbid even when just passed, probably from modified mucus, and not unfrequently blood is mixed with it. When the disease goes on unchecked, the pain extends upwards throughout the abdomen generally, which becomes tense and tender; nausea and vomiting, with great prostration, anxiety, and restlessness ensue: and involuntary dis- charge of urine, subsultus of the tendons, delirium, and commonly also convul- sions, usher in the fatal termination. Certain varieties in the symptoms have been supposed to depend on the particular seat of the inflammation at the com- mencement ; namely, retention of urine and excessive pain on introducing the catheter into the bladder, upon inflammation of the cervix ; suppression and hypogastric tenderness, on inflammation around the vesical orifices of the ureters; tenesmus, on inflammation of the posterior surface. Dr. Prout has described a form of cystitis, where the inflammation assumes the latent character in gouty individuals, consequent upon an attack of irregular gout. It is preceded by rigors ; febrile exacerbations follow ; and they gradually increase in severity. At length, irritative fever of the most formidable kind is established, attended with extreme prostration, oppressive nausea and vomiting, but for a considerable time without any urinary complaints. In the end reten- tion of urine occurs more or less, and the external organs become tumid; after which the patient rapidly sinks. The urine does not deviate from the healthy condition. It is plain that in the commencement of inflammation of the bladder, at which time alone any difficulty can occur in distinguishing it from inflammation and other acute diseases of the kidneys, the diagnosis may be founded on the rela- tive condition of the urine. Catarrh of tfie bladder. The cystirrlKea of nosographists is usually distin- guished from inflammation, though probably in its nature inflammatory, at least at the commencement. It is sometimes an acute, far more generally a chronic disorder, which attacks elderly persons chiefly, occurs in connexion with the gouty habit or strumous constitution, and seems to arise from exposure to cold, excesses of various kinds, acrid ingesta, stone in the bladder, or other urinary diseases. It sometimes commences suddenly, but for the most part gradually. The principal symptoms are shooting pains, with spasm and burning, in the region of the bladder, and a feeling of weight in the perineum ; afterwards also frequent micturition and dysuria, and at length irritative fever, with much de- bility, weakness in the loins, emaciation, restlessness, and gradual exhaustion. The urine at first is acid, muddy with floating flakes, which only in part sub- side under repose, leaving an opaline appearance, which probably depends on suspended microscopic scales of the mucous epithelion. Afterwards it presents more distinctly an admixture of stringy mucus, which sinks to the bottom, and collects in a gelatinous mass, incapable of being again diffused by agitation ; and in the severer forms of the disease mucus is often passed in gelatinous threads, which occasion great difficulty and distress in discharging urine. At the same time, the urine commonly becomes alkaline, often also somewhat albuminous, occasionally bloody ; and not unfrequently it acquires a fetid putrescent odour. Alkalinity of the urine has been thought by M. Rayer not to show itself, unless nephritis concurs; but this is a doubtful statement. In the most advanced stages of very chronic cases where ulceration of the inner membrane of the bladder may concur, pus is discharged with the urine as well as mucus, and at times there is considerable hemorrhage. In all circumstances mucus, the characteristic ingredient of the urine in vesical catarrh, may be easily known from pus and other deposits by the jelly-like appearance which it assumes in the 292 DISEASES OF THE ULAUIIEK AND URETHRA (Irritable). bottom of the vessel when the urine is allowed to stand for some time, and the supernatant fluid is poured off. Other urinary diseases may in general be distinguished readily from vesical catarrh by the general symptoms and condition of the urine in their early stage. As they advance, however, the diagnosis becomes often very difficult: because in the course of time they are apt to be complicated with irritation of the bladder, and excessive secretion from its mucous membrane, so that it is not easy to de- termine which is the primary disorder. Spasm of the bladder, a rare affection, which may occur at any age, but is chiefly observed in old people, is characterized by an acute sense of pain and constriction in the region of the bladder, sometimes stretching forward to the urethra; globular contraction of the bladder; retention of urine; frequent pressing calls to stool, often attended with protrusion of the rectum ; excessive anxiety, restlessness, and clammy perspiration, but without any fever or ten- derness on pressure in the hypogastrium. If not put an end to by proper measures, it may terminate fatally with the usual symptoms of suppression of urine. The term Irritable bladder has been used in surgery with various meanings, being sometimes applied generally to the mere symptom of irritability of the bladder causing frequent micturition preceded by pain or other uneasiness, and sometimes restricted to that species of irritability which is connected with nervous causes or functional circumstances, and is independent alike of organic disease in the urinary organs and of any diseased condition of the urine. Irri- table bladder, in its more comprehensive sense, may be occasioned by almost any organic disease of the kidneys, the bladder itself, or their adjuncts ; and it is likewise often produced by functional disturbances, leading to a change in the qualities of the urine. The more specific disease, now conveniently indi- cated by the same term, is not uncommon among individuals of a nervous tem- perament, especially exhibiting itself in the female sex by a tendency to hysteria. It is often mistaken for more serious diseases of the urinary organs, but may be known by the frequent and urgent calls to pass urine occurring only in the daytime, or being at least much more troublesome then, than during the night, by this symptom being aggravated by all causes'of nervous excitement and diminished by tranquillity and repose, by the urine being perfectly natural both in quantity and quality, and by the absence of the other signs of organic urinary diseases. Among the organic diseases with which it is apt to be confounded, none perhaps is a more frequent source of error than granular degeneration of the kidneys; but the state of the urine supplies a ready mode of distinguishing them. Diseases of the prostate gland have sometimes been confounded with other diseases of the urinary organs ; but are easily recognised with ordinary care. Chronic enlargement of the gland, a very common disorder in old age, gene- rally commences obscurely, and attains some size before attracting attention. Its symptoms are a sense of weight at the outlet of the pelvis, difficulty and effort in passing urine, sometimes complete obstruction, and enlargement of the part as felt through the rectum. When the gland is examined by the rectum, a ca- theter should be first introduced into the urethra, otherwise the healthy condi- tion of the part may be mistaken by the unpractised for enlargement. Flatten- ing of the faeces, a symptom mentioned by some authors, is not at all to be trusted to, and is indeed seldom observed, even in unequivocal cases of enlarged prostate. The urine at first is natural in its qualities ; but as the disease ad- vances, it is apt to become alkaline, and to deposit phosphatic gravel. Occa- sionally inflammation of the gland is superadded, the symptoms of which are, unusual sense of weight and heat at the neck of the bladder; sometimes pulsa- ting pain, increased on pressure; tenderness of the gland, when examined bv the rectum ; pain on going to stool, with a sense of imperfect evacuation of the gut afterwards; frequent and urgent desire to pass urine, with difficulty in DISEASES OF THE BLADDER AND URETHRA (Prostate Gland). 293 passing it, or complete retention. Inflammation is seldom confined long to the prostate gland ; the bladder sooner or later becomes involved. Sometimes the inflammation leads to ulceration, which may be known by the progress of the disease, and the presence of purulent matter in the urine. It may appear unnecessary to mention Stricture of the urethra among the dis- orders which may be confounded with diseases of the kidney. But as there are cases of purely renal affections, the prominent symptoms of which are referrible to the urethra alone, it often becomes necessary to inquire into the possibility of the existence of stricture. The diagnosis is to be founded partly on the mode in which the urine is discharged ; but chiefly on an examination of the passage with a sound, catheter, or bougie. DISEASES OP THE UTERUS AND OVARIA. DISORDERED MENSTRUATION. General observations on the phenomena of menstruation.—Imperfect puberty—precocious— tardy.—Faulty developement.—Suspended menstruation, or Amenorrhoea—coexistent with healthy state of the constitution—with organic disease—with constitutional debility—with plethora.—Complications.—Treatment.—Vicarious menstruation.—Painful menstruation, or dysinenorrhoea.—Symptoms.—Inflammatory and neuralgic forms.—Causes.—Prognosis.— Treatment.—Excessive menstruation, or menorrhagia.—Pathology.—Causes.—Symptoms. —Prognosis.—Forms.—Treatment.—Chronic menorrhagia and its treatment. For a period of about thirty-five years, the uterus pours out during a few days of each month a blood-like fluid, which does not seem to be so much a mere passive exudation, dependent on local causes, as the result of a general state of the female constitution ; since this peculiar secretion shows itself as the external sign of a function, the developement of which, we are certain, influences the whole organism. Up to the ordinary age of puberty, the uterus had merely exhibited the lowest phenomena of animal life, those of simple vegetation or growth. At this period, however, it begins to put on the signs of a higher vitality in the acquirement of the additional properties of secretion and irritability. While these are localizing, great changes are observable in the whole frame. The nervous system is altered in its capacity of emotion and passion, and the imagi- nation is in an especial manner developed. According to Soemmerring, the cerebellum becomes much enlarged >• the blood is attracted to the upper and the lower portions of the trunk, subserving to the rapid developement of the mammse and the pelvic viscera ; the hips enlarge; the ovaria become red and swollen; the Fallopian tubes, with their fimbriae, are elongated, erectile, and irritable; the uterus has acquired bulk, and a more sanguine hue ; the organs of the thorax participate in the effects of that action, which is increasing the mammae, so that the lungs, the larynx, and even the arms acquire the forms and contours of a maturer developement; the intensity of vitality is such, and so complete is the resistance of the frame, at puberty, in the conflict against external elements, that the mortality of our species is least in this portion of our life. On the other hand, the whole body suffers when the internal organs of genera- disordered menstruation (Imperfect Puberty). 295 tion are undeveloped : the mind is dull, and the emotions and passions depressed or absent; the vegetative function is less vigorous, and fat and cellular membrane is secreted instead of muscular tissue; the mammae are withered, the lungs are scantily developed, and not only is life less intense but less long, and early phthisis soon puts a period to the workings of so faulty an organism. We may therefore conclude that the menstrual flux, being a sign of puberty, should not be regarded as a mere passive exudation, but the index of a general state affecting the frame largely. This view is the more important, as it alone explains the phenomena of the disorders of menstruation, and points to that rational treatment, which is based not solely or mainly in the use of local stimuli for the mechanical attraction of blood to the uterus, but on remedies which, operating on the constitution, rouse and regulate those actions which constitute a function. The developing and the sustaining this function depend it would appear on two circumstances;—1, they require a series of constitutional actions in all their plenitude of vigour ; 2, there must be a healthy organ to which all these actions tend. If either the one or the other be in fault, we shall have disorders of menstruation, springing either from constitutional or from local sources. Most frequently both are conjoined, or very quickly become so. IMPERFECT PUBERTY. 1. Precocious Puberty. The works of Haller, Meckel, and Meissner, contain examples of this state sufficiently numerous to establish the following general conclusions :—1, the signs of puberty may become visible at any period com- mencing shortly after birth, and extending up to the ordinary time of the regular developement of that function : 2, the majority of cases exhibit these signs in the third year: 3, the frame in general participates but partially in the impulse given to the sexual developement: the growth of the rest of the body never being on a par with that of the sexual organs: 4, the internal organs retain the type and textures of an early age, and soon exhibit the signs of premature decay : the ovaria are frequently diseased ; the external organs are rarely harmoniously developed ; the limbs are very short as compared with the trunk : 5, the mental faculties are in most instances obtuse, nay even deficient: 6, the individuals are short-lived. In Haller's cases, amounting to upwards of thirty, and in those of Meckel and Meissner, there can be no doubt that the vaginal discharge was catamenia!, as it was accompanied by all the marks of puberty. In other instances, however, there is reason to believe that simple exudation of blood, per vaginam, has been quoted as menstruation. Climate, heat, sedentary habits and a luxurious life, much and early excitement of the brain and emotions, irritation of the sexual organs, develope imperfect puberty. Where the precocity is dependent on a misdirection of the vital force, it admits of as little medication as any other monstrosity of function and form. If there be that consent between the rest of the body and the function that there is the vigour and developement to meet the waste by the reproductive organs, early menstruation is not precocity. Generally speaking however, this is not the case ; and the woman-infant pines and wastes under irritative fever marked by a rapid pulse, much nervous- ness, disturbed sleep, copious perspirations, languor of body and hebetude of mind, symptoms which are most intense, just before and just after menstruation. The indications are, 1, to remove local excitement; and, 2, to sustain the powers of the constitution. The body during the period should be kept in the horizontal posture in abso- lute repose. After this is over, all those remedies should be resorted to which are useful in certain forms of menorrhagia which are elsewhere detailed; those 296 diseases of menstruation (Amenorrhea). which repress the local action; those which bring up the debile and flagging frame to that degree of vigour which permits it to sustain the premature waste; and, in the majority of instances, this will readily ensue if the faulty educa- tion of mind and body, or the local ailments and irritations be remedied and removed. 2. Tardy Puberty. Puberty may be tardy as well as precocious, but the mere absence of menstrual flux is not a positive sign of the absence of the capacity of conception. Sir Everard Home relates the case of a young woman who was married before the age of 17, and who although she had never men- struated became pregnant. Four months after the birth of her child she became pregnant for the second time, and four months after the second delivery she was pregnant for the third time; after this she menstruated for the first time, and continued to do so for several periods, when she conceived for the fourth time. Kleeman mentions the instance of a woman who being married in her twenty- seventh year bore eight children before she menstruated; the periodical flux then took place and continued regularly till her fifty-fourth year. (Rust. Mag., b. 18.) These and similar facts are to be regarded however as rare, and as warnings against unnecessary medication, for it is not the absence of the men- strual flux, but its absence when the general health is suffering that constitutes the case for medical aid. When tardy menstruation is the result of feeble constitutional power, the treatment is the same as for amenorrhoea, which is elsewhere detailed. 3. Faulty Developement. A class of cases answering to this head, may be collected from most of the better works on physiology and pathological anatomy. The individuals constituting it, termed androgynes, have the traces of feminine character, overpowered in the frame by those of a masculine kind, without any deviation, however, in the form of the sexual organs: the voice is rough, the mammae undeveloped, and the thorax hirsute : there are the broad shoulders, the flat breasts, the narrow hips, and the beard of the male, with a portion both of his vigour and the harshness of his character; the internal organs of generation in these persons are small; they are sterile usually, and prone to phthisis. Suspended Menstruation or Amenorrhea. 1. The menstrual flux may be suspended in certain states of the constitution compatible with the healthiest condition of frame, as in pregnancy and during lactation ; and here it is but an example of a very general law, that increase of the intensity of one function is accompanied by diminution of that of some other. It is not because the os uteri is closed during gestation that there is no flux, for it is in those who have borne many children, in many instances, quite open ; and even if closed, the menstrual discharge might, like common hemor- rhage, be contained to some extent between the membranes and the uterine walls; but it ceases to flow because the function of gestation suspends that of menstruation, suspends it, however, only in part, in the majority of instances. For it will be found that the periods at which the patient would have menstruated had she not been pregnant, are marked by a nisus, as it has been termed, which very sensibly affects her frame. All the sensations which precede the erruption of the discharge in the unimpregnated state, are felt in the impregnated, and, in some instances, even the discharge takes place periodically during the whole of utero-gestation. All abortions not caused by sudden injuries occur, for the most part, during what would have been a menstrual period, and all labours commence at one; both these conditions being determined by the molimen ad menstruationem. Hence the prevention of abortion depends very much on a knowledge of this fact, and on having recourse to that kind of treatment which shall allay at this period the periodical excitement, and regulate the actions diseases of menstruation (Amenorrhea). 297 which tend to disturb the uterus. In those prone to abortion, who are of a plethoric habit, a few leeches applied at this critical moment, with the exhibi- tion of a saline aperient, followed by a sedative, together with the horizontal posture and a spare diet, will ward off the evil of premature decay of the ovum. In the nervous and debilitated a different procedure is demanded; but these being subjects pertaining to the diseases of pregnancy, it is sufficient, in this place, simply to point out the fact of the influence of the function of menstrua- tion, even on the impregnated state. The suspension of the catamenia during lactation is scarcely remarked by any disorder of the frame. The incessant secretion of milk seems to have the same power of allaying, though more efficiently, the periodical constitutional excite- ment caused by the menstrual nisus, as when it is quelled artifically by bleeding or by purging. When, however, the flux appears during lactation, it may, in many cases, be augured, even though the nurse attempts concealment, by the effects on the infant, who is generally affected by vomiting, diarrhoea, or colic, and not unfrequently by convulsive fits. When a healthy nursling is suddenly and unexpectedly indisposed, the nurse should be questioned as to the catamenia, that the milk may be changed if requisite. The suspension of the catamenia by organic disease takes place chiefly after such disorders as strike deeply at the nutritive process, such as chronic disease of the intestines or liver, phthisis, and in hydropic affections. In most disorders of the heart, and in ovarian dropsy, there is menorrhagia. In both these cases, the curative indications pertain to the original malady, and not to the disturb- ance of the menstrual function. 2. In practice we meet with two forms of Amenorrhea, or obstructed men- struation, dependent on disorder of the reproductive function : the one attended with constitutional debility, the other with the appearance of superabundant cir- culation. In the former kind the symptoms show, 1, a languid circulation ; for the face is pale, the hands and feet habitually cold, the pulse small, weak, and if not quick, easily quickened. They show 2, muscular debility ; for quick walking is followed by breathlessness, and exercise of all kinds soon fatigues. They show 3, torpor, or inequalities of the nervous function; the mind is lazy, and the spirits low and uncertain. They show 4, defective nutrition ; for the body is lean, and the appetite bad. This state steals on the patient so insidiously that months elapse before medical aid is resorted to. The cessation of the men- strual discharge is very gradual. It usually is scanty or pale, and nearly serous, or defective both in quantity and in colour; then it becomes irregular, prior to its cessation: when allowed to proceed uninterruptedly, Amenorrhoea terminates in Chlorosis ; a state of constitution characterized by the following group of symptoms :—The complexion looks waxen or cadaverous; the upper eyelids are brown, while the lower are lead-coloured; the general surface of the skin is harsh and dry, and slightly suffused with a sallow bilious tinge; the stomach is the seat of unwonted sensations and diseased cravings; the bowels are at one time constipated, at another tormented with painful diarrhoea, the head aches under light and sound, and the mental faculties are altered; the breath is foetid, the tongue rough and sulcated; the fauces pale, or striated with pencils of capillaries. There is oedema of the lower extremities in the evening, and of the face in the morning; together with such shortness of breathing, and so scanty a secretion of urine, as to lead to the suspicion that the lungs partici- pate in the oedematous condition of the rest of the body. The very aspect of the patient is sufficient to prove the great alteration which the fluids have under- gone, without our seeking support for the opinion from the authority of Dr. Marshall Hall, who has seen the epistaxic flow scarcely tinge the linen ; or from the theory of MM. Roche, Sanson, and Blaud, who fix the essence of the malady either in the deficient stimulant properties of the blood, together with an asthenic state of the vessels, or in the preponderance of serum. Whatever vol. hi. 38 298 disordered menstruation (Amenorrhea). theory we may adopt, whether that of Cullen, which makes the disease depen- dent on some peculiar state of the ovaries, or that latter developement of it by M. Gendrin, which connects menstruation with the formation and escape of an ovule from the Graafian vesicle, or that of Dr. M. Hall, who traces it to " Dis- order of the General Health," or to the opinions above quoted ; the practical fact is this, that there is scarcely a single solid texture or a single fluid which is not altered from its healthful condition. The nervous and the vascular systems, though not equally, are simultaneously disordered, and no organ escapes from the pressure of much functional derangement. In the second form of amenorrhoea girls attain to the age of puberty without menstruating, or having menstruated cease to do so, and yet retain all the appearance corporeally and mentally, of vigorous health. The complexion is florid, the frame well nourished and plump, indicating the probability of a local cause for the deficiency of function. The girls are subject to giddiness and headache, a sense of fulness about the loins, and the general sign of plethora. Many explanations have been given of this state, but though specious they are scarcely satisfactory. It is one of those many facts which are better known than understood. Some, in accounting for it, have asserted that the amenorrhoea originated in the want of consent between the organ which secretes, and the constitutional powers which prepare the fluid; an explanation which is but another mode of stating the same thing. Others have accounted for the defi- cient flux, by assuming some local inefficiency under the vague term of rigid uterine fibre, which simply amounts to the expression of a belief that there is some local obstruction neither definite nor intelligible. Cams in his Gynce- kology has the following speculation: He says that a certain state of relaxation is requisite for the performance of any secerning function, as evidenced in the relaxation induced by syncope as being favourable to perspiration; that caused by fear in promoting the secretion of the kidneys and bowels; while on the other hand, where there is over-active vascular effort there secretion ceases, as in the example of the vascular impetus of fever inducing the dry hot skin. Now in the amenorrhoea, accompanied by plethora, the deficiency in the secerning pro- cess is dependent, or may be so, on the over-energetic action of the vascular system. This analogy may probably account for some of the forms of amenorrhoea, but is insufficient for explaining the instances where sudden emotion in a healthy person, not only suspends but suppresses for months the catamenia. Complicatio?is. To one or other of these two states very many local ailments or special disorders are attached. Their variety and intensity show how deeply the function of menstruation influences the whole frame. 1. Disorders of the vascular system. In the amenorrhoea of debility it has been asserted by Dr. Marshall Hall, Blaud, and indeed by the majority of authors, that the brunt of the malady falls on the blood, which becomes so altered as to present but few of its healthy characteristics. Chlorosis, therefore, may be looked on as a deficient haematosis. Whatever be its origin, this is one of its most important results. The want of the due stimulus in°each organ is followed by all those reactions which succeed great losses of blood, and which are admirably described by Dr. Marshall Hall. There is intolerance of light and sound, and an aching brain, confusion and even delirium when the head is affected. There are sudden attacks of what appears to be pleuritis or pneumonia, as far as dyspnoea and pain are concerned: often the chest suffers, or there is exquisite tenderness of the peritoneum if this organ be affected. In all these the suddenness of the attack, its liability to shift or to cease, the previous history, the relief afforded by opiates and nervines, with depletion merely as accessary, point to the real nature of these attacks. Besides these diffusive affections, defective haematosis, accompanied as it always is, by all the signs of deficient nutrition in the solid structures, is fol- lowed by a weakened state of the heart and blood-vessels, deserving of great disordered menstruation (Amenorrhea). 299 attention. Most unexpectedly these patients will fill down apoplectic, and effu- sion of blood or serum will be found in the brain, and the heart thin and pale. The defective state of the organ, and its inefficient propelling power, give rise to congestions, inasmuch as the blood is not forced back into the heart. The blood- vessels lose their elasticity, and become passivly distended. Hence the liver is gorged, and the motions tinged with exuded blood; hence the anasarca of the extremities. There are in these cases very remarkable modifications of sound, heard on auscultation. The valvular sounds of the heart are those of deposit upon, and contraction of these parts, while the peculiar droning noise, known as bruit du diable, may be heard in the course of the large veins. It is wonderful how readily this state of the vascular system is remedied by steel, and how speedily the heart regains its force under the treatment rigidly enforced for ancemia, namely, light and digestible animal diet, much fresh air, regular foot exercise, wine and steel. M. Blaud has stated that similar condi- tions of frame are remedied on an average in three weeks. There is a different form of modification of vascular disease which we will venture to term congestive amenorrhea, in which the capillaries are chiefly in fault; and that, not from any defect in the heart, or great vessels inducing mechanical distension, as in the last case. The patient's fingers are patched with purple as affected by chilblains, or, what is as common, the leg is covered with fine vessels. The surface »so affected is hot and dry and painful, and hence the patient is more or less lame; sometimes there is exudation of black blood under the skin, which soon peels off, leaving a thin pellicle of dried cruor which falls away, and exposes a red and painful surface. This state of the leg, for it rarely affects the upper extremities, may last for several months. It is always worse when the periods should appear, and becomes an index of the constitu- tional effort. We have in many instances found the patients, so affected, perish of phthisis. 2. Disorders of the digestive organs. Besides the general disorders above mentioned, the stomach is very often the seat of peculiar uneasiness, noted by the patients as indescribable; sometimes they attempt to liken it to pruritus, sometimes a sensation of sinking and exhaustion. With these states, the appetite is variable, or there is a disordered longing for inedible substances, such as sealing-wax, brown paper, coal, chalk, slate pencil, and even dirt. Another state of the intestinal canal accompanying amenorrhea, is its partial distension in the neighbourhood of the uterus, so that the abdomen has the exact shape of pregnancy, while the morning sickness, capricious appetite, together with the cessation of the menstrual discharge has not unfrequently led the prac- titioner into a belief that such might be the fact. This class of cases may be detected by an accurate knowledge of the signs of pregnancy. 3. Spasmodic affections of the involuntary muscles. The whole of the intes- tinal tube, from oesophagus to rectum, may be the seat of spasm. In its severest form we have the very acute disease known as hysteric colic, in which, with intense abdominal agony, we observe great, though temporary disorder of the mental functions. A milder form, and a very common one, is marked by great irrita- bility of the canal, with much rumbling of wind, and sometimes with incessant noise, as if of the splashing of water. The oesophagus may be spasmodically affected, forming hysteric dysphagia. These spasmodic affections may occasionally attack the heart; when in a mild form there are various grades of distress, from si#nple palpitation to severe angina. In a severe form the patient will be suddenly killed, as the following case, detailed to the writer by Mr. Green, of St. Thomas's Hospital, proves:— .A young lady who had for some time been hysterical was attacked by peritonitis, from which she was not relieved by depletants ; the pain subsided spontaneously, but soon after cerebral disorder arose; one day she exclaimed suddenly that flames were rushing to her brain, and fell down dead. On inspection, it was found that the cerebellum was pale; the cerebrum and its membranes slightly 300 disordered menstruation (Amenorrhea). injected; the right side of the heart was completely gorged with blood. On the left side, however, not only was the ventricle quite empty but spasmodically contracted, and this was looked on as the active cause of death. A rope of mucus hung from the os uteri. The Fallopian tubes were dark with black blood; several Graafian vesicles were ready to burst; the hymen was entire. A case of a similar kind is mentioned by Dr. Bright; the source of irritation, however, was a calcareous deposit on the fimbriae. 4. Spasmodic affections of the voluntary muscles. These are not uncommon accompaniments of functional disorder of the uterus. They are enumerated here, not because they invariably accompany amenorrhoea, for sometimes the mere discharge is wanting, but because they are obviously connected with the constitutional nisus at the period, for these are the times when they are either aggravated or called into existence. The muscles of a limb become and remain contracted in so great a degree as to be forced into the most constrained and unnatural positions. In others, a larger section of the muscular system is sub- jected to spasmodic action. In one instance that came under our care, the shoulders were for months spasmodically drawn up to the level of the ears, and such was the whimsical sensibility of the nervous system, that the limbs were involuntarily jerked out at the sound of street-music. In the majority of these cases, together with excessive irritability of the muscle, there is positive lesion of the faculty of volition, which prevents them jrom vigorously willing an act. Some require the shock of terror to force them into necessary exertion. There often is difficulty in evacuating the bladder, and the rectum. Chorea, or St. Vitus's dance, the most general disturbance of the muscular system is rather a precursor of puberty than a common complication of amenor- rhoea. It is, however, very often connected with functional disturbance of the uterus; for, of its subjects, three-fourths, according to Heberden, are girls be- tween the age of ten and fifteen, the disease yielding with the establishment of the menstrual function. The nervous excitement and vascular erythism which arise during the developement of puberty, are the conditions most favourable for inducing chorea: hence, in those rare cases which are fatal, the heart is either inflamed, or there is apoplexy or fatuity, or softening of the spine. (Med. Gaz. 1831.) 5. Affections of the nervous system. Besides those affections of the great cavities of the body which simulate pleuritis, peritonitis, and frenzy, the limbs and joints are subject to acute and chronic forms of pain, which seem to por- tend disorganization. In some the bone is the seat of pain, likened to that caused by the gnawing of dogs ; in others the joint exhibits the signs of ulcera- tion ; in a third class the painful affection resembles, in its agonizing effects, tic douloureux, and the knife has been resorted to, where steel, in a less formidable shape, would have been the more beneficial remedy. The mind may be, and generally is, disordered in its faculties or emotions, in most cases very slightly, in others in a more marked form. Of the slighter grades, mere irritability may be carried to such an extent, that a hitherto happy home is broken up from intolerable captious caprices. Of the graver kinds of lesion, the most common forms of functional aberration are met with : 1, as dis- ordered instincts or appetites; 2, diseases of some of the intellectual faculties. Of the first kind, we have already noticed disordered appetite, impelling the patient to swallow greedily the most nauseous substances. Of emotions, the commoner forms of aber«ition are exhibited in causeless dislike, or vehement and sudden affection towards individuals, who have neither provoked the one nor invited the other. In some instances it is impossible to account for the insane ^ratification arising from disorder of emotion. One of our most reputed physicians was called to see a young lady who vomited large quantities of urine. He was informed by the patient, and by her attendants, that the only remedy for this strange misplacement of function was disordered menstruation (Amenorrliea). 301 bleeding, but that this had been so often done that it could not without danger be continued, an inference readily made from the blanched cheek and feeble pulse of the patient. The consulting physician at once declined acceding to the urgent entreaties of the girl, who accordingly soon vomited large quantities of a fluid which was proved to be urine by a celebrated chemist. The patient was ordered to be watched night and day, no bleeding being allowed; when it was soon ascer- tained that the kidneys performed their functions regularly, and that the bladder became so painfully distended in the usual time, as to cause the patient to request the ordinary relief. She confessed that she had deceived her medical attendants, solely to induce them to bleed her, adding that the operation was attended with indescribable pleasure, and to insure this, she swallowed her urine, so as to impose on them more readily with her incredible tale. A not uncommon form of aberration of emotion is a diseased desire for sympathy or wonder, and rather than not be the sole objects of attention, these monomaniacs carry on with great ingenuity a long series of frauds. In one instance the patient nearly fell a victim to this diseased passion, pretending total inability to eat. When reduced to a skeleton, when neither any sustenance was ever known to have passed her lips for weeks, nor any evacuation of the bowels discovered, it was determined to try the efficacy of a stream of cold water on the head, in arousing hunger, while a basin of hot soup was at hand to gratify it, should it arise. The patient resisted the shock the first day. On the next, when the bucket was larger and the dash threatened from a greater height, a very little soup was asked for on trial, which was not found intolerable, and from that hour the rebellious stomach soon regained its powers. 6. Affections of tlw intellectual faculties. We have seen two forms of mania accompanying menstrual disorder;' the one constant, the other intermittent. The constant form differs in no essential from mental aberration, arising from common causes: it has all its varieties of delusion, whether of exaltation or depression. In the intermittent form, the patient is maniacal only during the time of the discharge, the mental disorder beginning with the eruption of the menstrual flux, and ceasing as this subsides. In a few instances, the return to sanity was incomplete, so as to be rather remitting than intermitting mania. Both the constant and the intermittent forms differ, however, in one important feature, from mania arising from other sources, viz., on the essential point of curability. There are but few examples in which mental disorder, dependent on menstruation, has not been cured in our experience. The intermittent form, however, may last several years, and is less tractable than the constant. There are other and rarer affections of the nervous system called forth by menstrual disorder, which we shall simply enumerate. 1. Ecstasy, or motionless- ness depending on intense mental exaltation. 2. Catalepsy, or loss of volition, in which action is solely dependent on mechanical causes, externally applied. 3. Trance, or lesion of the functions of animal life. 4. Somnambulism, or intense sleep of some of the senses and faculties, and intense wakefulness of others, the phantasy being possessed by a vivid dream. 5. Anomalous action of the senses, as hallucinations, visions, affections determined by particular odours or certain sounds. Treatment. In amenorrhsea attended by debility, the best way to excite the uterus is to strengthen the constitution, and the best remedies are such as im- prove the general health. As there is almost always in these cases disorder of the digestive organs, the treatment should commence with a brisk mercurial purgative, followed up by a course of warm aperients of a milder kind: two grains of calomel, and four to eight of scammony, may be given once a week and the aloetic pill on the other days. But the chief remedy for a radical cure is steel in some of its various forms. 302 disordered menstruation (Treatment of Amenorrhea). The difficulty experienced by most patients in tolerating this medicine arises from the extreme susceptibility of the nervous system, which causes the exhibi- tion of steel to be followed by headache, a sense of fulness, bleeding from the nose or even from the lungs, and a wearing fever. There are, however, two modes of exhibiting this remedy, by which these inconveniences may be obviated : the one is to combine the steel with an aperient, the other to begin with the minutest doses. M. Blaud says that the carbonate of iron is the most efficacious form, and that on an average amenor- rhoea is cured by it in 21 days. The muriated tincture is the strongest, and the vinum ferri the weakest, of the preparations of iron. The course of steel should be carried on for eight weeks, omitting the period in which the patient should have been unwell, and during which the attentive practitioner will remark the constitutional disturbance created by the nisus. During the whole period of using chalybeates, an aperient of Dec. Aloes Comp. variously modified should be used; and if the biliary system be in fault, mercurial alteratives conjoined with iron (Plummer's pill and compound iron pill) will be found of singular use. The invigoration of the constitution may be furthered, 1, by diet; the food should be the lighter kinds of meat proportioned in quantity to the powers of digestion: 2, a moderate use of wine: 3, exercise, so as to keep the patient as much as possible in pure air, yet not so as to fatigue and waste her strength : foot and horso exercise are preferable to carriage: 4, a residence in the country away from the wearing excitements of a town life : 5, bathing, shower bathing, at first with warm, then tepid, and at length with cold water; in cases of great debility simple sponging is sufficient: a cautious use of sea bathing. In the plethoric form of amenorrhcea, marked by signs of a disturbed circula- tion in an otherwise healthy frame the treatment required is precisely the reverse to that which has been just noticed. The uterus must not, as in the former case, be stimulated, by filling and stimulating the system. The indications are, 1, to use such agents as act on the uterus without stimulating the constitution : 2, to relieve the general or local plethora, until menstruation takes place. Under the latter indication, blood should be abstracted in small quantities from the arm, especially at the expected period. Should this be objected to, blood may be abstracted from the loins by cupping, or the application of leeches, and the aperients should all be of a saline nature producing watery evacuations. In those who are subject to periodical haemorrhages, we have found that these may be commanded by a draught of two ounces of the infusion of roses, two drachms of salts, and twenty minims of the tincture of hyoscyamus, to be taken every night, for a few days just anterior to the expected attack, which as before remarked, will be when the menstrual flux should have occurred. The diet should be spare, and wine and fermented liquors proscribed. In some obstinate cases of plethoric amenorrhcea, a milk diet will be found very beneficial. For exciting the action of the uterus, the chief means are the following: they apply to both forms of amenorrhcea ;—1, warm hip baths, and especially at the expected period; they should be used for half an hour at least: 2, aloes, and such medicines as stimulate the rectum, and excite sympathetically the uterus: 3, supposed emmenagogues, such as hellebore, savine, and electricity; the last is the best of direct applications. There are numberless nostrums of greater or less value, which, from their very number, prove how capricious a disease is amenorrhcea, and how curable. Dale excites the mammae, by repeated application of one or two leeches ; the organ enlarges greatly, and the uterine sympathizes on being thus aroused. Very many authors give five to eight grains of ergot. Carron des Villard re- commend scyanuret of gold in minute doses : Bradley gives strychnine : Brera, iodine: Amussat applies an exhausted glass to the uterus : and Rostan leeches. It is impossible to give a sketch of the treatment of the various complications disordered menstruation (Amenorrhea). 303 of amenorrhcea which, though rooted on the general malady, form specific dis- eases requiring the specific treatment which is detailed in other places. Obstructed menstruation may depend on local conditions of the uterus. After menstruation has been thoroughly established, it may be and often is suddenly suppressed in a healthy woman, not pregnant, by various causes, of which the most distinct in their effects are cold and mental emotion. When menstruation is interrupted by cold or fright, it may be either near and is prevented, or has commenced and suddenly stops; in both cases there ensue symptoms indicating more or less distinctly an inflammatory state of the uterus, and the usual sym- pathetic disturbance in the constitution : there is fever, nausea, or vomiting, tenderness of the abdomen extending down the thighs, a quick pulse, hot skin, and throbbing headache. In the severest forms, we have known death produced in a few days, and inspection has proved it to have been brought about by phle- bitis. In a milder form it may terminate in chronic enlargement of the uterus, or in a condition of the uterus unaccompanied by any sensible disease save of want of discharge. The treatment for acute suppression is the same as for phlebitis, viz., general or local bleeding, warm applications, mercurial aperients followed by sudorifics. For chronic enlargement, the remedies which apply to chronic metritis are beneficial here, as mercurial alteratives, repeated leeching, frictions of tartarized antimony, &c. When there is amenorrhcea, which in these instances is termed chronic suppression, it is accompanied by one or other of the two states of constitution already noticed, and demands for its cure the remedial measures already discussed. Menstruation may be mechanically obstructed by any malformation impeding its egress. The impediment may exist in any part of the vaginal canal, from the external orifice to the occlusion of the os uteri. There is a swelling of the abdomen or of the perineum, or of both parts, according to the site of the oc- cluding membrane. There are at first symptoms of periodical colics with much pain, very similar in character to those of labour; to these succeed increased size of the abdomen ; after which the signs of absorption of morbific matter into the system, viz., hectic or irritative fever, wasting, delirium, dusky hue over the surface, great debility, and death. The uterus and vagina are found distended, sometimes enormously, with the menstruous fluid in various grades of alteration. In Mr. Friar's case thirty ounces gushed out on the first incision. (Med. Facts and Observ., vol. viii.) In Dr. Sherween's, twelve pounds were evacuated. (Duncan's Med. Com., vol. ii.) In the former instance the discharge was quite liquid ; in the latter, ropy and of the consistence of treacle; in others the watery particles have been still more absorbed, leaving a gritty deposit in utero. In a few cases the matter was putrid, although secluded from atmospheric air. In Dr. Sherween's case the patient must have been menstruating internally at least fourteen years, in Dr. M'Kormich's about seven. (Duncan, 1. c.) There are cases in which the vaginal canal is imperforate without being ac- companied by any of the disorders just described. The obvious and indeed the only remedy is the knife, and the sole practical question is, What are the cases fit lor it 1 A patient in the prime of life consulted Morgagni for an imperforate vagina. She said she had never menstruated, had never been subject to lumbar or dorsal pains, and it was obvious that her general health was good. Morgagni found a septum about one-third up the vagina, closing the canal. His reasonings on the propriety of an operation may be taken as presenting the particulars for judgment in all similar cases ; it is eminently sagacious and practical:— " Having considered all these things, and hearing, not only that this woman had never had menstrual discharges, but not even any uneasiness nor pain tend- ing thereto, nor even the slightest beginning of them ; and, on the other hand, seeing that she was endowed with very good health, colour, and strength, as every healthy woman is at that time of life, which may be considered as the prime, I began to suspect that, as she was without a continued and open canal, 304 DISORDERED MENSTRUATION (Vicarious). or orifice of the vagina, she might be perhaps, without a uterus from the ori- ginal formation ; so that if the obstacle could even be removed with the scalpel, there would nevertheless be danger, lest the bladder or some one of the intes- tines, lying in contact with it, in consequence of the uterus being absent, should be pierced through at the same time. I therefore persuaded this woman pla- cidly to suffer her marriage to be dissolved, which had been improperly con- tracted, rather than imprudently submit to the operation." (Let. xlvi. art. 2.) Of this species of malformation the examples are sufficiently numerous. Where the uterus is wanting, the ovaria and Fallopian tubes are also absent, the place of these organs being supplied by a cylindrical mass, from one to three inches long, and one inch thick, or by a closed sac. (Meckel, Path. Anat., b. i. p. 59, &c.) There are examples of operations attempted and discontinued. Thus Nabothus mentions, that " a physician attempting to remove with a knife a coalition of the vagina which had been from birth, was obliged to desist when he saw the coalition extending very high and the large vessels appearing, and his opinion is, that when there is a fleshy interstice, it is better to abstain from the incision of it, partly on account of the very great haemorrhage, and partly on account of the subsequent inflammation." Denman was consulted in a case of imperforate hymen. He advised the friends of the patient to allow the menstrual flux to collect, and thus let nature herself demand the operation, and at the same time show the best point, at which to make the incision. From these, and similar facts, we may conclude that not every case of imperforate vagina is fitted for operation ; that especially we should hesitate if there never has been any sign of menstrual excitement in the system; and if in the frame there be the signs of absence of the ovaria and uterus, as flatness of the mamma?, &c, and the other characteristics of sexual deficiency which have been enumerated. On the other hand, if there has been a succession of attacks occurring at the end of the ordinary menstrual intervals, if there be a tumour above the pubes or at the perineum, we are called on to advise an incision. If the imperforation be near the orifice of the vagina we may always operate; if higher, care is demanded; and if very high, we should be quite certain that there is a uterus, and that the incision or puncture be in the direction of that viscus. If the operation be postponed until the general health shall have suffered, the chances of recovery are much diminished. Whenever the contained fluid is much altered, the uterus is not speedily evacuated; and then the secretion is apt to become putrid on the access of air. Much of the success of the operation depends on relieving, by repeated injec- tions of warm water, the uterus from the contact of the matter. In some in- stances the uterus has suffered irreparable mischief from ulcerative disease of its inner tunic. VICARIOUS MENSTRUATION. For instances of this curious subject the reader may consult Sauvages, Cullen, and Mason Good, in their several works on Nosology. Numerous examples are scattered, also, among our periodicals. We have known the vicarious discharge to occur from the lungs, the stomach, the rectum, and from sore surfaces of the skin. The fluid differs from the true menstrual discharge in being common blood, but authors have noticed differences of aspect and odour which have as- similated the secretion from the vicarious surface with that of the uterus in a greater or less degree of affinity ; nothing positive on this point, however, is made out. Authors have enumerated examples of vicarious menstruation from the eye, ear, nostrils, stomach, intestine, sockets of the teeth, lungs, mamma:, bladder, and skin. It is probably that it is always or nearly always determined to a mucous surface as giving an outlet. The treatment is regulated by two indications: 1, to excite the uterus to disordered menstruation (Dysmenorrhea). 305 resume its natural function; 2, to guard the organ which is burdened with this unnatural effort. Bleeding just before the expected attack, to the amount of about four to eight ounces, and purging with saline aperients a week prior to if, will convert the case into one of amenorrhoea, or greatly moderate the vicarious afflux to the organ unwontedly labouring, while the known means of exciting the functions of the womb may be resorted to in the intervals. In the cases of vicarious Hiematemesis or Haemoptoe which have fallen under our observations, the lungs and stomach were either diseased or ran the hazard of being left so. The specific treatment will vary according to the organ at- tacked, as that determines the kind of reaction caused by the irritation. The greatest risk to life is undoubtedly from vicarious Haemoptoe, and yet by the plan of moderate purging just anterior to the monthly period, the patient sur- vived three years with comparatively slight expectoration of blood ; at the end of which time, having died, we found one lung contracted into small dimen- sions from an old pleuritic attack, but without any signs of tubercle on either side. The state of the organ had probably assisted in determining the discharge to it, just as when the skin is ulcerated the vicarious flux will be seen to exude monthly from the diseased rather than from the sounder surface. PAINFUL MENSTRUATION, OR DYSMENORRHGEA. Symptoms. Pain in the loins, commencing a few days before, or just pre- vious to, the menstrual eruption. The umbilicus and the pubic region are tender on pressure, and most ease is obtained by the recumbent posture. These pains vary in their character and intensity, from constant soreness to agonizing dartings or colics: they are mostly remittent. The stomach and bowels are rendered irritable, there is vomiting, or diarrhcea with tenesmus, and the urine is generally passed with scalding pain. In the more severe forms the nervous system gets much disordered, and either syncope or hysteric convulsion, or even catalepsy may occur. These symptoms increase in intensity until the eruption of the menstrual flux, and then suddenly or gradually cease, or simply decrease. The flow of blood is often scanty, but by no means always so. Causes. No defect nor organic lesion is discoverable even in the most severe forms of Dysmenorrhcea. That the malady is connected most intimately with the menstrual function, is apparent from the fact of its never affecting the female, either before puberty or after the cessation of the menstrual function, and from the consideration that it is always during the period that it subsists. Dysmenorrhcea has been divided by many authors into inflammatory and neu- ralgic ; and to these two varieties, Dr. Churchill in his Work on the Diseases of Women has added a third, viz., that dependent on mechanical impediment to the menstrual fluid. While we acknowledge that in a certain number of in- stances the vascular system is chiefly in fault, as in others the nervous functions are disordered; while we would lessen the impetus of circulation in the former, and adopt, very often, contrary measures for the latter, we are by no means satisfied that true inflammatory action constitutes any part of Plethoric Dys- menorrhcea. What would be the state of an organ which for years laboured four or five days, in every twenty-eight, under the violent symptoms supposed to be inflammatory dysmenorrhcea? we have no instance of any other viscus of the body so suffering without accession, sooner or later, of disorganization of its texture, and yet such a termination rarely or never is the result of dysme- norrhcea. Again then, this supposed inflammation, not only after repeated attacks does not disorganize texture, but is remittent in its action. If it is not an inflammation sui generis, it must be compared with other diseases, such as gout and rheumatism, which attack organs from time to time at distant inter- vals, but with these maladies the analogy also fails in the main point, namely, vol. in. 39 306 disordered menstruation (Dysmenorrhea). that they, unlike dysmenorrhcea, disorganize texture. We prefer therefore the not involving ourselves in the theory which the term Inflammatory Dysme- norrhcea implies, and the rigid practice it should induce. It is true that a not uncommon effect of dysmenorrhcea is the forma- tion of coagulable lymph, modelled to the shape of the inner surface of the uterus : this has been supposed to be the effect of inflammatory action. Prac- tically, perhaps, it is safer to consider it as the result of irritation, for and- phlogistic remedies are not in every case the best for preventing its formation. It should also be remembered, that the uterus is especially organized to pour forth lymph under certain irritations of the internal organs of generation, as when conception takes place, whether that be uterine or extra-uturine, the inner surface of the womb is lined by the plastic fluid. Whatever be the analogy between this action and that of inflammation, the diversity is still greater; and, unless we are prepared to say, that metritis and pregnancy are convertible terms, we are warranted in placing the single phenomenon of the effusion of lymph, common to both states, under different causes. We are inclined to believe therefore that the membrane formed in utero, in some instances of dysmenorrhcea, results from a local condition, which may practically be more safely designated irritation than inflammation ; and that, as in the ovary serous cysts are more readily formed than in any other part of the body, from a devia- tion of the natural functions of that organ, so spurious decidua is more readily deposited in utero under certain irritations from a deviation of its functions. The readiness with which either the uterine membrane, or the ovarian cyst is formed, being deducible in both cases from the natural tendencies of either organ. The exciting causes of dysmenorrhcea are many, but in general all such as excite the nervous system, more especially such as exalt the sensibilities of the uterus. Thus the emotions of terror or joy, coincident with the menstrual period, have been known to produce dysmenorrhcea. Thus too the venereal congress, immediately previous to the expected flux, has excited the severest forms of this malady. In other instances, causes which have lessened the dis- charge suddenly have produced a state of uterine sensibility, which has termi- nated in dysmenorrhcea. The prognosis is favourable, as to danger to life: as to sterility, it is not unfavourable; though they who are severely affected do not readily conceive, and when they do so are prone to abortion. As to curability, the majority are cured. There are a few, however, who resist all the known means of alle- viating the intense suffering incident to the malady, and are relieved only when the function of menstruation ceases. Treatment. As in most of the maladies of menstruation, the treatment requisite is applicable, 1, to the period, 2, to the interval between two. During the periodical attacks the pain may be relieved in various ways. Just before the eruption of the menstrual flux, when symptoms of plethora are present, one of the most efficacious means of lessening pain is local depletion, which may be resorted to by means of leeches or the cupping-glass. The case however should be recognised as decidedly one admitting depletion; with or without this, the appearance of the menses should be solicited by tepid, or hot, or vapour baths, for generally speaking, a marked amelioration takes place, when the flow from the uterus is established. The great remedy, however, in lulling excessive pain, is opium, and in cases of real anguish a full dose should be given and repeated. We have found a mixture of laudanum, and tartarized antimony in minute doses, frequently repeated, of singular benefit. We have also used stramonium with the most marked good effects in the more severe forms of dysmenorrhcea. Colchicum, in our experience, is not equal either to opiates or to stramonium. In general, then, we may say, that 1, anodynes, 2, depletion, and 3, warm local applications, are indicated in the paroxysms of dysmenorrhcea; and that these maybe combined, or separately used,according disordered menstruation (Menorrhagia.) 307 to the nature of the individual case. The acetate of ammonia has been much lauded by M. Patin ; ergot of rye has been found beneficial; and there are but few practitioners who have not some remedy, or combination of remedies, sup- posed to be efficacious in removing the distress of this malady ; a proof that the paroxysm subsides spontaneously, or that it is in the majority of cases easily remediable. During the intermenstrual period, the chief remedy to be relied on is a course of steel. Here, as in all the functional disorders of menstruation, it is a most valuable medicine for producing the radical cure. Where the patient exhibits the neuralgic form, it may be at once proceeded with. Where there are signs of a disordered circulation, this should be regulated by bleeding or cupping, and a bland unexciting diet, and then the steel will usually effect a cure in two inter- menstrual periods. With respect to the treatment of the variety of the dysme- norrhcea, dependent on mechanical impediment, Dr. Churchill recommends dilatation of the narrow orifice of the uterus by a bougie, and cites an instance supporting the efficacy of the treatment. We are not prepared to admit the exist- ence of the form of the malady mentioned by him. It is difficult to trace the connexion between the effect alleged and the cause assigned. Obstructed men- struation acts by distending the uterus, and so exciting labour pains. The mere narrowing of the os uteri would not interfere with the exit of the fluid, slowly as that fluid is formed during the menstrual period, and therefore would not, we believe, cause accumulation in utero. If it did, the symptoms should be referred to obstructed menstruation, a totally different malady from dysme- norrhcea, having nothing in common with it but the fact of painfulness. The remedy recommended by Dr. Churchill in his elaborate and useful volume, namely, the introduction of a bougie, would be in our opinion beneficial in many cases of dysmenorrhcea, not however as removing obstruction, but as altering the action of parts, just as many states of irritable urethra in the male are cured by catheterism. However, the objection to the use of a similar means in the female, considering the age in which the malady is most rife, is all but insuperable. EXCESSIVE MENSTRUATION, OR MENORRHAGIA. We include under this term only those uterine haemorrhages which are directly or indirectly connected with the periodical flux, omitting such as arise as a symptom of uterine structural disease. The quantity of blood discharged at each menstrual evacuation varying in different women, menorrhagia exists only when there is disproportion between the loss and the power of replacing it. If with the usual daily flux the periodical returns be shortened, or the time of the flux be lengthened, or if there is a larger quantity evacuated, although neither the interval between the periods nor the duration be altered: we have menorrhagia. It is the relative quantity lost, and not the absolute, which con- stitutes the disease. An abundant menstruation must not be confounded with a disordered one. The former retains its periodicy, its quantity, and quality, and does not deteriorate the general health. The latter is irregular, and leads to disease. Causes. Heated rooms, too warm clothing, warm bathing in excess, are all known to determine to the uterus. In the tropics menstruation is not only early but copious, while in the frozen zones the discharge is both late and scanty. Mechanical irritations, excessive venery, some of the pathemata, as fear or anger, are predisponents to uterine discharge. Various diseases, especially those which interfere with the free circulation of the blood, as diseases of the heart, asthma, and such as affect the circulation in the vena porta?, also diseases of the ovaria, uterine polypi, are mostly followed by menorrhagia. In some affections of the fluids, purpura for example, the drain from the uterus we have known occasion 308 disordered menstruation (Mcnorriiagia). death. In some anomalous irritations of the ovaria and Fallopian tubes a similar event has occurred. The late Mr. John Shaw examined a young lady who, while in full health, was suddenly seized with menorrhagia accompanied by a succession of fainting fits, under which she succumbed. A large mass of coagula was found in the abdomen, but the source of the hemorrhage was a mystery until the Fallopian tubes were laid open, and then it was discovered that, for the space of about an inch and a half of one of them, its lining mem- brane was pointed with bloody spots from which the fluid found in the perito- neum had rapidly been poured out. These kind of hemorrhages are essentially similar to those from the membranes of the brain or nostril, or lung, in which mechanical lesion of the blood-vessels is rarely found. Certain kinds of exer- cises, as equitation, mechanical impediment to the free circulation of the blood, such as that which is caused by tight lacing, will give rise to menorrhagia or increase the tendency to it. In nervous women emotion will very speedily determine a menorrhagia of a very terrific character. Latterly, M. Trousseau (Journ. des Connaiss. Med. Chir., Dec. 1838) has assigned chlorosis as one of the causes of menorrhagia. The blood he says is altered and attenuated by menorrhagia in the first place, and this attenuation, in its turn, becomes a source for furthering the flux. He remarks that this cause is a common one in married women, and uncommon in virgins. In twelve cases nine of the former class were affected to three of the latter. With regard to the symptoms, there is the prominent one of excessive dis- charge followed by the consecutive effects of loss of blood on the constitution. The natural menstrous secretion becomes mixed with large clots ; there is in many signs of increased activity in the uterine circulation, a sense of heat and weight, and throbbing. These signs usher in the discharge, and are its precursors. There is a sense of pressure in the pelvis, feverish ness, irrita- bility, and an uncertain state of the digestive organs, vomiting, and constipa- tion, or diarrhcea. If during this state of the disorder the uterus be examined, it will be found turgid and considerably enlarged, and in chronic cases the finger is smeared with blood which stagnates in the texture of the womb. The prognosis varies according to the cause: where there is a healthy uterus and no peculiarity in the constitution, the vast majority of persons affected with menorrhagia recover. Where, however, there is uterine irritation or disease, or where the flux is dependant on the state of the heart or lung, the probable result must be determined by the aspect of the primary maladv° In chronic cases the constant loss of blood brings the constitution into a state very favourable to the developement of any acute general disease, or for disor- ganizing the uterine texture. Forms of Menorrluxgia. There are two forms, the acute and the clironic; the former occurs with all the symptoms we have noted, and with complete intermissions. The latter is marked by constant oozing rather than gushing of blood, by the signs of general debility rather than of fever and hurry of circu- lation, and by a deeper disorder of the general health as well as of the uterine tissue. The occasions in which menorrhagia is most common are, 1. It is very generally coincident with the menstrual period; when it is not, either it is dependent on some uterine malady, or on some impediment to the general circu- lation ; or it is the result of the nervous temperament put into violent emotion. 2. It occurs as a sequela of parturition. The natural congestion after child- birth is a strong predisponent to excessive uterine flux, and repeated abortions and pregnancies determine very decidedly to the vascular system of an or°an whose anatomical structure is already favourable to haemorrhage. 3. It occurs as a symptom of the perturbations of what has been termed^he critical a^e. The suspension of uterine function is preceded by irregularity of menstruation, both as to time, and as to quantity of discharge. 4. It occurs after undue lactation. 5. It occurs anterior to puberty. 6. It is symptomatic of many disordered menstruation (Treatment of Menorrhagia.) 309 diseases. When the flux cannot be traced to obstruction of the circulation, or to any visceral or general malady predisposing to haemorrhage, we must look on it as dependant on a cause which, under the vague term of irritation, appears to have its seat in the nervous system. The most obvious example of which, and the most familiar, is the suffusion of the cheek by the emotion of shame or its blanching by the passion of fear. Here we see how the nervous power directs the flow of blood unequally to certain tissues, while the more mechanical impulse of the heart, however strong, could only pump it, in the largest quantities, where the recipients for the fluid were of the amplest calibre. In certain exanthemata, perhaps in the erythema of gout, in many shifting erubescences of the surface, this effusion becomes more permanent, but still retains its connexion with the afflux of irritation rather than that of inflamma- tion, by its not changing the structure of the part injected. By thus looking through vascular movement, we are enabled to trace a gradation of disease from simple and transient distension of the capillaries, to alterations of structure accompanied by effusions of fluid in the form of blood, or its constituents, or of new combinations arising out of those endowed with specific powers. In this view, however, medicine has rather seen the chain than proved its linking, for great gaps in the continuity of our knowledge are felt. Menorrhagia unconnected with structural disorder, whether uterine or not, is chiefly found in two kinds of constitution : the nervous, and what may be termed the lymphatic. Although stated as existing in those in full vigour, our own experience affords us few examples of the robust being menorrhagic. In the nervous temperament, marked by extreme mobility in all the sensations and emotions, characterized generally by rapid muscular movement, and a thin frame and pallid surface, the gushes of uterine haemorrhage follow agitation of all kinds, and are incredibly great. The wonder has been, how they were con- sistent with any health. In the second kind of temperament, which we have termed the lymphatic, the persons are disposed to be bulky, and even florid, but they have no muscular strength : they are readily tired, and the capillary cir- culation almost stagnates in bright red patches in the cheek, or pencils the skin of the limbs with a slender vascular fringe. These persons faint on small abstractions of blood, and are much exhausted by the periodical flux. Treatment. There are three circumstances which modify our views in treating menorrhagia : 1, whether it be simple: 2, whether it be dependent on some visceral or some constitutional malady : 3, whether it be connected with uterine structural disease. If simplicity of arrangement were always most useful, we might reduce these to two, by ascertaining whether the flux was idio- pathic or symptomatic. The three questions, as above stated, lead more directly, however, to a definite conclusion, and therefore to more precise reme- dial action. It is to simple or idiopathic menorrhagia that the following rules of treatment are especially directed, although they are not inapplicable to the symptomatic with some modifications. The first thing to be attended to in menorrhagia, whether acute or chronic, is absolute repose in a horizontal posture. From a known law of hydrostatics, namely, that the pressure of fluids is as the height of the column and not merely as the quantity of liquid matter composing it, it is certain that the pressure of a column of blood, extending from the heart to the uterus, must be greatly lessened by placing the body horizontally. The pressure is in fact reduced to that of a column of blood whose height is that of the diameter instead of the length of the containing vessel. Accordingly we find that in the majority of cases of incipient acute menor- rhagia, the assumption of the horizontal posture is alone sufficient to-check the flux, and even to cause its cessation. The laws of dead matter, however, are modified in the living frame, and in other instances this is but a palliative, though it is true it is one of the first class. The afflux of blood to the uterus is 310 disordered menstruation (Treatment of Menorrhagia.) to be checked by agents acting on the causes which have either produced it or keep it up. The vascular and nervous systems are to be constrained in their inordinate movements. For this purpose, we possess, as to this malady espe- cially, three great remedies; aperients, depletion, and cold. We have found a purgative composed of sulphate of magnesia and infusion of roses, with twenty- five minims of tincture of henbane, of very great service in both chronic and acute menorrhagia; it acts both as a revulsive and as depleting the bloodves- sels. To be efficacious, it should be given over night so as to insure four to six watery evacuations in the morning. This draught may be used every night, but it should most especially be resorted to the week before the expected menor- rhagic period. Depleting is of the same nature in its action as the purgative plan, but not so universally applicable. A few ounces of blood, drawn from the arm shortly before the eruption of the flux, will almost invariably stop its inordinate flow ; but in one instance we witnessed a violent hacmatemesis succeed the diminished uterine discharge, and in most women the remedy creates much nervous pertur- bation. In those of full and injected habit of body, in those where the uterine congestion is accompanied with much lumbar or inguinal pain, with throbbing and heat in the vagina, and a tender state of the uterus on contact, it is not only indicated but should be insisted on. Where these symptoms occur in a debile and flaccid frame, cupping on the loins, or, what is best of all for every case, a few leeches (one to four) applied to the cervix uteri by means of the leech tube should be resorted to instead of general bleeding. During the period of active discharge the medication should be cooling, and the diet unexciting, and the loins and hips should be sponged with cold vinegar water. Cold in a more determined form is rarely required during the active flow of blood, except where the menorrhagia amounts to flooding, and then the treatment is in every respect the same as for that formidable accident in an indistensible uterus, viz., the plug, and cold so as to diminish the temperature of the bleeding part. Where the excessive discharge takes place in the nervous temperament, the aperient plan is better than the bleeding. A few leeches may be required, however, but the modification, chiefly necessary in this class of cases, is in the use of such remedies as quell inordinate nervous action, and such a regimen as shall insure repose to the nervous system. A bella- donna plaster should be applied to the loins, and opiates may be administered with the greatest benefit, either as enemata or in the usual mode. All emotion, all excitement, should be most carefully avoided, and the body should be kept as free from stimulus as the mind from perturbation. To these general means we may add two classes of remedies which are sup- posed to check the flow of blood: these are astringent injections into the uterus, and the use of certain medicines, which act, or are said to act, as styptics. No astringent should be used for the first, few days of the period. We should wait until the constitutional effort is established, until the secretion is converted into an haemorrhage, known by gushings of blood instead of oozings, by a clotted instead of a fluid discharge, and by the absence of constitutional excitement. It is when this has ceased we may resort to alum or sulphate of zinc, or to the vegetable astringents. As to such as stop the blood as styptics, we have found alum in eight or ten grain doses taken in syrup of ginger among the best. We have resorted to the secale cornutum in doses of eight to eighteen grains thrice a day with decided advantage. Its effects differing from styptics are unequi- vocal, and may be injurious if continued when a sense of tenderness over the pubic region is excited by it. The various kinds of acids are most efficacious when the menorrhagia is connected with that kind of disorder of the fluids attending scorbutus or purpura. Trousseau, in the paper on the Menorrhagia of Chlorosus, recommends pure lemon juice during the day in the milder cases, and ergot of rye in the more severe. The latter remedy will be found most efficacious at night, when, as disordered menstruation (Treatment). 311 he very justly remarks, the gushes of blood are much more copious than during the day. One dose should be taken on going to bed, and a second, if possible, in the early morning. Medicines containing tannin, as catechu, rhattany, are said by most authors to be of much avail. Such are the means for quelling the excess of discharge in impetu ; but what are the modes of preventing its recurrence? Where in simple menor- rhagia, the previous discharge has weakened the frame but not removed the congestion of the uterus; where the functions are languidly performed; where there is a feeble rapid pulse, and a fretful fever uncertain in its attack ; where there is a slow and laborious digestion; where the external surface is pale and the lips bloodless, the constitution will require corroborants during the inter- menstrual periods, while the congested uterus may with advantage be depleted by one or two leeches ; and this twofold medication is not contradictory. The loins and hips should be well sponged, and the patient directed to sit for a few seconds night and morning in cold water placed in a shallow vessel. When there is the state of body just described, the best corroborants are steel and quinine. Those persons who exhibit what has been noted as the lymphatic temperament, bear these medicines better than those who are nervous; but even in these this treatment is beneficial, provided it is resorted 'to in dimi- nished force. To this last class, pure country air, shower bathing, and those adjuvants well known as diminishing nervous action, must be resorted to. When the disease is chronic, that is, when there is oozing of blood almost always present, in small quantities, with occasional gushing; when exercise even of a gentle and ordinary kind will produce the discharge, it has a great tendency to disorganize the uterine texture. The womb will be found large and heavy in the early stages of the chronic malady; still however it retains its shape, and the relative proportion of its parts. In the latter stages the cervix uteri becomes most congested and bulges, so that the whole organ is more in shape like an hourglass of unequal bulbs, rather than that of a pear. This is a pure effect of gravitation of blood to the most dependent part. If examined by a speculum the cervix is of a deep sanguine hue, smooth but not tense, and shining and dry and painful as in inflammation of this part. In extreme cases the texture is infiltrated with blood,.and small clots and scales of cruor adhere to the outer surface of the neck of the womb. Chronic menor- rhagia may have these consequences: 1, sterility; 2, prolapsus uteri; 3, it readily leads to a succession of slight inflammations of the womb, known by heat and pain in the part, and by sympathetic nausea or vomiting; 4, it has a tendency to lay the foundation of organic alteration, especially if it occur at the period termed critical. The treatment for chronic menorrhagia is based on two indications: 1, the state of the organ ; 2, the state of the general health. The organ must be unloaded, and at the same time its congested vessels strengthened. All those remedies which prevent the afflux of fluid to the part, or remove its super- abundance, and all such as give firmness and vigour to its fibre, must be re- sorted to : 1, slight local depletion ; 2, counter-irritants to abstract the diseased action ; 3, the use of such agents as are known to diminish the bulk of parts, viz., tartarized antimony, rubbed in as an unguent, but so as not to create pus- tules: or iodine; 4, astringent injections cautiously used ; 6, sedulous attention during the natural menstruous periods, so as to diminish in every mode the uterine flux, which, however natural, only increases the local malady. With regard to the general health this soon becomes deeply injured by chronic menorrhagia. There are all the effects of loss of blood added to all those which result from want of exercise and the habits of confirmed invalids. These cases are most difficult to treat, requiring patient attention for a length of time and incessant watchfulness: the majority however recover. When death takes place it is induced either by direct hemorrhage, of which we have seen but few examples; or by diseases awakened in a frame rendered apt for their reception, or by uterine disorganization. 312 irritable uterus (Diagnosis- >—Prognosis). IRRITABLE UTERUS, OR HYSTERALGIA. Symptoms.—Diagnosis.—Prognosis.—Treatment. Under the term Hysteralgia, Dr. Gooch first described a painful disorder of the uterus, which, in its symptoms, and the sufferings consequent on them, simulated some of the fatal diseases of this organ. As little or nothing has been added to his masterly essay on a malady, which is as difficult for the patient to bear as for the practitioner to cure, the reader is referred to the original paper, of which the following observations may be looked on as a brief abstract. Many of the persons who were the subjects of this malady came, after Dr. Gooch's death, under our care : we can therefore corroborate, in every particular, the accuracy, while we admire the force of his descriptions. Symptoms. There is pain in the loins and round the brim of the pelvis, which, while it is incessant, yet is subject to aggravations, especialy after mental excitement or bodily exertion. A few days before, or a few days after men- struation, these paroxyms of anguish come on. In one instance, the middle of the intermenstrual period was always the time in which the patient was most urgently affected. The constant uneasiness, with occasional exacerbation, soon induces the patient to give way to the relief afforded by repose, and to stir rarely from the sofa. The result is that the general health is broken by the worrying pain, the want of fresh air and of due exercise; and a languid cir- culation, censtipation, and some of the complications of dyspepsia, are super- induced. In very few cases is the pulse permanently excited. The catamenia at first are unaffected, but subsequently cease as the constitution becomes more debile. If the uterus be examined, slight pressure will give rise to exquisite pain, which will continue for some time after the removal of the cause. We have found the cervix uteri in most instances puffy and swollen, though without any of the characteristics of scirrhus or other malignant disease, while the vagina is invariably in a healthy state. The persons most liable to the malady are the young or the middle-aged ; rarely, or never, old women. A large proportion of Dr. Gooch's patients had been subject to dysmenorrhcea, and most of those affected were of a nervous and very susceptible temperament. The exciting causes are generally some undue exertion at a period when the uterus is sus- ceptible. Violent jolting, long standing when the catamenia are present, will give rise to the malady. In one instance an astringent lotion, used to check profuse lochia, produced this affection. Diagnosis. Hysteralgia may be confounded with acute or with chronic in- flammation of the uterus, but the absence of enlargement, heat, and throbbing in the organ, the slight alteration of texture contrasted with the intensity of suffering, the stationariness of the symptoms, and the length and course of the malady, are sufficient guides by which hysteralgia may be distinguished from affections which have a tendency to produce disorganization. It might be mis- taken for prolapsus, did we not find that this is completely relieved in all its symptoms by the recumbent posture, when the irritable uterus is only rendered less painful. From the periodical pain of dysmenorrhcea, it differs as to the fact of the suffering being constant. The nature of the malady, therefore, must be inferred to be nervous, from a comparison with painful affections of other parts of the frame, which are characterized by much and long suffering, unac- companied by organic change. Sir Benjamin Brodie has described these under the term of Local Hysteria, and Sir Astley Cooper has given instances of pain- ful mammas, which might readily have been mistaken for incipient cancers. irritable uterus (Treatment). 313 The various joints, the spine, the breasts, may be the seat of acute pain more or less constant, enduring for many years and yet never interfering with health of structure. The prognosis, therefore, is always favourable as to life, not quite so as to ultimate recovery, and never so as to a speedy return to health. The majority, however, do recover completely, and all are much relieved. The treatment is based on two indications, 1, to subdue pain, 2, to sustain the general health. When the paroxysms of uterine pain are brought on by even moderate exertion of body, we are compelled to enforce the horizontal posture and absolute repose; but this treatment should not be rigidly adhered to for any length of time, as the nervous irritability, the dyspepsia, and the general health are all unfavourably influenced by it. Even when repose is most strictly enjoined, the patient should be carried into the open air when feasible. The local pain is often mitigated by narcotics, which may be applied to the lumbar surface in the shape of a belladonna plaster, or by friction of the linimentum saponis medicated with opium; or a pill composed of one-third camphor and two-thirds of extract of hyoscyamus, may be taken thrice daily, or injections of acetate of morphia (two to four grains in the ounce of distilled water) may be thrown into the vagina night and morning; or all these various means of influencing the nervous system may, with advantage, be simultaneously resorted to in the more severe forms of hysteralgia. The vapour of steam, or a warm hip bath not of so high a temperature as to stimulate the uterus, will often pro- cure ease. Local bleeding has sometimes been resorted to by Dr. Gooch, and repeated according to the circumstances of the case; but, for the use of this and similar remedies, that sagacious practitioner had the aphorism, That we should cease to employ them if the constitution, rather than the disease, seemed giving way. All active purgation is invariably injurious in hysteralgia, as never failing to induce a paroxysm of pain. Counter-irritants are of very doubtful use. A generous diet, but so as not to burthen the stomach, fresh air, a gradual and sustained course of steel, and narcotics locally applied, are the best means of attacking this capricious and obstinate disorder. The worst are low diet, the constant supine posture, close confinement and depletions, whether by purga- tives or by bleeding. With the former, the malady will be subdued or will sub- side; with the latter, the health, and even the life of the patient are endangered. There is a painful state of the vagina which we have frequently met with, which appears to be allied to the affection of the uterus just described. There is neither discharge, nor inflammation, to account for the anguish produced by contact, even of the finger ; the inner membrane is not discoloured, nor tense; nor unlubricated, nor in short, in any way deviating from its natural slate, save in the fact of a painfulness so excessive, that walking is intolerable, and coitus is not unfrequently followed by a fit of hysterics. All the patients whom we have seen were married, and of extreme nervous susceptibility; in some the painful condition of the vagina came on subsequent to the birth of a first child, and they never conceived again ; in others this state was developed by marriage, and was not removed by repeated childbirths. This malady is to be distinguished from irritable granulations which some- times succeed ruptures of the perineum, and from chronic inflammation of the vaginal walls. The absence of ruptures in the one case, and of hardness and paleness of the lining membrane of the vagina in the others, are sufficient guides for diagnosis. The treatment is, in the main, that for Hysteralgia. vol. in. 40 314 leucorrhqua (Divisio?is). LEUCORRHOEA. Acute and chronic forms.—Symptoms.—Causes.—Treatment A white discharge, issuing from the vagina, and unconnected with structural disorganization of the genitals, has usually been defined as constituting leucor- rhoea. The fluid discharged varies in colour, consistency, and quantity. In colour, from that of a thin solution of gum-arabic to that of pus, which itself may be tinged greenish, or brown, or slightly red; in consistence, from that of limpid water merely, to that of a tenacious, ropy substance, mixed with a thin- ner liquid; in quantity, from a slight increase of the natural moisture, lubrica- ting the mucous membrane, to several ounces in the twenty-four hours. Various divisions have been made by way of classification, which throw some light on the nature of the malady. Dewees refers leucorrhcea always to some local disease, generally inflammatory. Pinal has a vicarious, a constitutional, and an accidental variety. Then to these, other authors add a syphilitic, a critical, and a dyspeptic leucorrhcea. The source of the discharge, whether uterine or vaginal, has given rise to another mode of classification. For practical purposes the division of leucorrhoea, into acute and chronic, appears not to exclude the more elaborate ones, founded on the supposed causes of the malady or its situation, or nature, while it at once points to a variety in the main object, namely, its cure. We shall not enter on the subject of contagious discharges from the vagina. With regard to the vicarious variety of leucorrhcea it may be stated, we have known a colourless discharge supersede the menstrual flux, and be accompanied by all the symptoms of the periodical secretion ; that the suppression of evacua- tions, to which the constitution has been inured, has been described as being followed by leucorrhcea; on the other hand, a sudden cessation of vaginal dis- charge has been succeeded by a large flow of pus from the bronchial membrane and by death. (Locock.) Leucorrhcea may occur at any period of life; it is most common, however, during that comprised between the ages of fifteen and forty-five. Young infants and children are subject to acute attacks of vaginal discharge, accompanied by more or less of local inflammation; and here the mucous membrane of the vagina appears to share in the susceptibilities of this class of organs, common to this period of life, in which the intestinal surface is easily deranged, and always is more active than at any other stage of existence; when the lungs secrete copiously; and when the commonest form of acute pulmonary attack is that formidable bronchitis known under the name of bronchial fever, or the epidemic peripneumony of children ; when the membrane of the nostril is also the seat of maladies unfrequent or unknown at a later age. The leucorrhcea of infants is very often a mere catarrh of the vagina, but most generally sympa- thetic of intestinal irritation. In old age discharges from the vagina are comparatively rare, and should always be viewed as less innocuous than those of early life. In certain consti- tutions leucorrhcea is more common than in others. The luxurious excitements of the higher orders of society, where the nervous system is so much, and the muscular so little exerted, is very favourable to the developement of this malady. Any thing which debilitates or over-excites the uterine system, will tend to pro- duce it; and there are few disorders of the general health unaccompanied by some irregularity of the vaginal secretion. With regard to the seat of this disorder, pregnant women, in whom the orifice of the uterus is closed, are sub- LEUC0RRH03A (Causes). 315 ject to leucorrhcea: hence we have direct evidence of its seat being, in these instances, exclusively vaginal. On the other hand, we are equally certain that the inner membrane of the uterus, when irritated by structural disorder of the womb, is capable of secreting matter not to be distinguished from that of com- mon leucorrhoea. There is no reason, therefore, for doubting that other causes of irritation than those dependent on uterine disorganization may likewise rouse the inner membrane of the viscus to unhealthy secretion. In severe forms of leucorrhcea, whether chronic or acute, the cervix uteri is rarely unaf- fected, being generally softer, larger, and moister, and not unfrequently more sensitive than natural. This portion, too, of the lining membrane extending through the cervix into the orificium internum uteri, is especially formed for active secretion; the palmae plicatae which radiate on it, and which in the pro- gress of utero-gestation become so curiously developed, and in the progress of labour pour forth such a load of mucous secretion, prove by the inferences derivable from the structure itself, as well as the direct fact, that it can be the seat of active secretion, and therefore of deviation in its natural function. ^ In the majority of cases, however, we are inclined to believe that the seat of discharge is vaginal. The forms of leucorrhcea are either acute or chronic. In the acute, the symptoms are those of inflamed mucous membrane; pain, swelling, heat; at first a thin exudation, like that in common catarrhal inflammation of the Schnei- derian membrane; then thicker, and, lastly, purulent: with the establishment of pus the pain and swelling abate. The other symptoms depend mostly on the effect produced on the bladder and rectum, both of which are irritated. Diffi- culty of walking, excoriations, &c, are readily traceable to the situation of the inflamed organ, and to the character of the discharge. In some cases the con- stitution is affected with febrile excitement. In the chronic form there is a variation in the symptoms, corresponding with the quantity and quality of the discharge. When the evacuation is large, the signs of debility, of dyspepsia, of a deficient haematosis, and of nervous excita- bility, supervene; to which there are added pelvic uneasiness, weight, or even obtuse pain. The flow of matter exhibits these peculiarities; it is generally imperceptible and continuous ; sometimes, however, it is intermittent, that is, discharged in gushes, as in haemorrhage; or it comes away mixed with masses of ropy mucus, as thick as that passed in chronic dysentery, or in the last stages of common catarrh of the nostril. . , It is probable, that the intermission of discharge is a mere result of retention of fluid in the hollow and dependent parts of the pelvis, until the quantity over- flows ; in some instances, however, there is painful contraction, which the patient refers to the internal portions of the vagina, and which, whether uterine or not, we cannot determine. The mucous masses are, probably, secretions from the superior part of the vagina and cervix uteri itself, as it is in these structures that the mucous crypts and follicles are most developed ; the purulent secretion with which it is passed obviously having a different source, since the same part never casts off at the same time both pus and mucus. Causes. This discharge is, in many instances, but an indication of the general vigour and activity of the organs of generation. It is compatible with excellent health, a full habit of body, and amounts only to a local inconvenience. The persons so constituted are, however, liable to pains in the situation of the ovaria, which endure many days with little fever, but great discomfort, amount- ing at times to agony. The paroxysms unite the characteristic of two maladies, colic, and circumscribed peritonitis ; and, did the symptoms not remit, and thus for days remain stationary, instead of running the onward course of a pure inflammatory disease, we might be much puzzled. It is best relieved by local instead of general bleeding, by saline and not by aloetic aperients, and by anodynes. The above form of leucorrhcea must be considered as dependent on constitutional causes and on local irritability. There is a reverse state exhibited 316 LEUcoRRiiffiA (Causes). in the leucorrhcea of debility. In these the frame is weak, the vaginal folds ample, and much relaxed. A third class of causes depends on sympathetic irritation, arising from functional or structural disorders of the digestive organs. Obstruction to the return of blood, to the right side of the heart, will cause and keep up leucorrhcea. Diseases in the system of the vena portae, or in the haemorrhoidal veins, will especially do so. A fourth class of causes must be looked for in such as act purely locally, giving rise to irritations or inflamma- tions of the uterine system. Dewees, who seems to consider all forms of leu- corrhcea reducible to this last class, is certainly exclusive in so doing. The treatment must, of course, have reference to the cause which produces the malady, to the state of the constitution, and to that of the organ. In the acute form of leucorrhcea the organ generally requires local depletion : a few leeches, tepid lotions, aperients, and a restricted diet soon allay the congestion of the mucous membrane, and then the treatment merges in that for the chronic form of discharge. In chronic leucorrhcea the first thing to be assured of is the absence of local disease; of prolapsus, polypi, ulcerations, excrescences in the vagina or uterus. The next is to ascertain that the flux is not a symptom of oppressed circulation, or of disease in the abdomen, and especially of the rectum. When these causes have been eliminated, and it is made out that the malady is dependent on a local state, combined with disorder of the general health, we have the disease for which such a variety of empirical remedies are said to be successful. Nothing can be more variable than the shadings of disordered health ; for in ninety cases in the hundred, hysteria, in its Protean forms, mingles with leucorrhoea. In some there is inordinate nervous sensibility, in others torpor and inactivity; in a third, with general debility, there is extreme nervous irritation in the uterine system, unceasing pruritus referrible to the uterus itself, or aching scarcely amounting to, but more intolerable to the patient than pain. In any grade or kind of chronic leucorrhcea, however, the uterus does not fail to draw into its sympathies the digestive organs. Strict attention, therefore, must be given to diet, exercise, and mode of life. A diet which is devoid of all excitement, and is confined to simple nourishment, without stimulating the stomach; pure air, and absence from those habits of late hours entailed by a life in the metropolis; are essentials to a speedy cure of the severer forms of chronic leucorrhcea: and with these prophylactics, all that regimen so well known as the dyspeptic should be resorted to. The treatment for disordered general health is not alone suffi- cient. In leucorrhoea, as in the other functional disorders of the uterus, steel is among the best remedies; hence the inveterate forms are most speedily cured at chalybeate springs, either at home or abroad. With this general atten- tion to the constitutional treatment, the local affection must be locally attacked, first by extreme cleanliness, and then by anodyne, astringent, or alterative applications, together with such medicines as, when taken internally, are known to act on mucous surfaces. Of the local applications zinc, alum, the vegetable astringents, as catechu, cinchona, oak bark, the rind of the pomegranate, may be used so long as no tenderness, nor sense of weight in the pelvi°be produced by them. If this be brought on it is a sign of uterine congestion in a slight degree; if it be further accompanied by evening or morning sickness, the con- gestion is of a more serious form. Anodyne injections of laudanum, poppy decoction, &c, are indicated when the leucorrhoea is accompanied by hyper- sensibility of the vagina and uterus. The class of applications, termed altera- tive, are such as disturb the secreting surface of any organ, such as mercury, a remedy proposed by John Hunter to be applied to the vagina on a cylindrical pessary; the Lunar Caustic (Jewel): or the Lapis Infernalis (gr 10 to 3j water) (Ricord): weak solutions of ammonia; and, in short, such agents as are known to disturb the secerning process of diseased surfaces. Every thing depends on the mode of application. In the virgin state the leucorrhoea is rarely so intense as in married women, INFLAMMATION OF THE UTERUS (Congestion). 317 though, perhaps, more frequent; and to these local applications are rarely admissible, save as lotions. In the married patient, a cylindrical pessary, made of sponge dipped in the proposed solution, whether astringent, anodyne, or alterative, may be applied, and retained, or speedily withdrawn according to circumstances. With regard to the medicines which act on the utero-vaginal membrane through the general system, the best are cubebs, copaiba, cantharides (Dcwees), the various turpentines, alum, uva ursi. Besides these there is a long list of specifics, which are partly single medi- cines, partly compounds, resting on individual experience, unsanctioned by general use. INFLAMMATION OF THE UTERUS, OR METRITIS. Congestion of the uterus, and its treatment.—Acute metritis.—Anatomical Characters.— Causes.—Symptoms.—Treatment.—Chronic metritis.—Various forms.—Ulcerative inflam- mation.—Suppurative inflammation.—Membranous inflammation.—Inflammatory enlarge- ment and induration of the substance and mucous follicles of the uterus.—Symptoms of chronic metritis.—Causes.—Treatment. Congestion of the Uterus. At the return of each menstrual period the uterus becomes the seat of a temporary congestion. Under the healthy action of the system this degree of congestion can scarcely be regarded as morbid, but it certainly borders upon that state; and on every slight derangement, either in the function or organization of the uterus, it readily passes into a concretion which must be looked upon as a diseased state, which is per se of little moment; but it becomes a morbid condition of primary importance when considered in relation to its effects and in reference to the rank which it holds in the produc- tion, pathology, and proper therapeutic treatment of the diseases, functional and organic, of the internal female organs of generation. By its monthly repetition it acquires, in the eye of the practitioner, a power which it would not otherwise possess, and exerts a great influence over the course and treatment of all uterine affections. It is on this principle that we would explain much of the inveteracy of uterine diseases, and the inefficacy of the curative means employed in their treatment. Diseased uterine actions, originally slight, are liable in their nature to be aggravated by the supervention of this monthly congestion, and more serious forms of disease are often prevented by it from proceeding to a healthy termina- tion. Acute diseases, which were probably nearly subdued, are readily re- kindled by its recurrence, and under the repetition of periodic excitement, such diseases are apt to become chronic. Chronic affections, on the other hand, are liable to undergo from the same cause, at each monthly term, a degree of tem- porary activity, and in each case the advantages that may have been gained by perseverance in the proper remedial measures during the time intermediate between the two menstrual periods, may be more or less lost during the next accession of the catamenial congestion. It is on these grounds that even the natural state of menstrual congestion becomes an object of interest, and its importance is always increased when the congestion itself is rendered greater or more marked, as it so often is, by the existence of any functional or organic disease of the viscus. It is unnecessary to dwell upon the pathological characters and terminations of congestion of the uterus. The congested organ is injected, swollen, has often an oedematous feel, and possesses all those other characters pointed out in the section on Inflammation, under the general head of Morbid Congestion ; with 318 inflammation of the uterus (Congestion). this exception, that more frequently perhaps effusion of blood occurs from the congested vessels of the uterus than from those of most other organs under the same condition. This tendency to haemorrhage is always greatly increased by the presence of organic disease in the uterine parietes. The effused blood generally escapes from the free mucous surface of the organ, but it is sometimes retained and accu- mulated in great quantity in the uterine cavity, when the os uteri happens to be so obstructed as to prevent its exit. In other cases it is accumulated within the cavity in the form of a solid lami- nated coagulum. It is rarely effused amidst the proper tissue of the uterus, except in the puerperal state, and in the last stages of malignant disease. Some- times, however, in females dying at an advanced age, the more internal layers of the uterine parietes are found injected, ecchymosed, and softened. In these cases the body of the uterus is generally alone the seat of the effusion and the cervix remains unaffected. The most frequent exciting causes of morbid uterine congestion certainly con- sists in the periodical determination of blood to the organ at each return of men- struation. It is at these times principally, and in some cases only, that the con- gestion accompanying an uterine polypus, or other organic diseases of the viscus, gives rise to actual effusion of blood from the vessels. Any cause tending to produce an unusual determination of blood to the part, may lead to the same effect, such as venereal excitement, strong mental emotions, exercise and fatigue in the erect posture, &c. A powerful predisposition to the disease is sometimes given by the frequent repetition of abortion. The principal local symptoms, in cases of uterine congestion, are a feeling of fulness and weight in the uterine region ; pains not increased on pressure, and generally of an intermittent character resembling colic and tenesmus ; and, oc- casionally, discharges of true blood in greater or less quantity. Where the con- gestion has been of long duration, the uterus itself, when examined per vagi- nam, will generally be found enlarged, and low in the cavity of the pelvis, the os uteri patulous, and its lips swollen and spongy, but little if at all tender upon pressure; there is not, however, the increased heat of those parts as we find in cases of inflammation. The use of the speculum shows the discoloured and purplish state of the surface of the cervix and os uteri, and particularly of the lining membrane of the latter; occasionally an exudation of blood is to be seen upon it. The constitutional symptoms of uterine congestion vary exceedingly in differ- ent cases. Slight febrile symptoms and alternate shivering and flushing are often present, with lassitude, headache and sickness. Sympathetic pains are sometimes excited in distant parts of the body, particularly in the left hvpo- chondriac region ; and the mammae occasionally enlarge and become irritable. In other cases variously marked, hysterical symptoms occur in connexion with uterine congestion, and become aggravated at every return of it. In itself morbid congestion is seldom a diseased state demanding direct medical interference. It is, however, as we have already stated, of the greatest impor- tance, as an almost constant complication of the other functional and organic diseases of the uterus. We need not discuss the general treatment of conges- tion, but shall mention only these peculiarities which congestion of the uterus requires in this respect; we allude particularly to that form of congestion which is so apt, in the uterine diseases, to accompany and aggravate these affections at the return of the monthly periods. Rest, in the supine posture, is one of the most important of the measures which we should adopt. It is not, however, to be regarded alone as a direct and effectual means of treatment, but, without it, all our other resources will in general fail. Its importance we can easily understand when we reflect how readily blood gravitates to the more dependent parts of the body, more espe- cially if the general system happens at the time to be debilitated, or if the inflammation of the uterus (Causes). 319 vascular system of any dependent organ is in so weak a state as to admit of congestion occurring in its vessels with more than usual facility. We assume, in fact, the supine posture here as one element in the treatment, for the same important reason as the surgeon" insists upon it in the treatment of an injured, inflamed, or ulcerated limb; and we look upon it as an indispensable measure, during the period of menstrual congestion, as well as in the course of the active treatment of all uterine affections. It is sufficient, in many cases, to cancel the bad effects of the uterine congestion, but where it is not, the detraction of blood either generally or locally becomes indispensable. The selection of local or general bloodletting must necessarily depend upon individual peculiarities, such as the state of general plethora and the strength of the patient's constitution. We have seen excellent effects from small venesections from the arm (to the extent of six or eight ounces) immediately before or at the commencement of the menstrual period, in cases where it was our object to avert the dangers of the accompanying congestion ; and we have known similar good effects result from the application of a few leeches to the cervix uteri at the same period. In constitutions so reduced or anaemic as not to justify the detraction of blood, dry cupping, or slight counter-irritants to the lumbar and dorsal regions may be employed with a similar indication, with such other means as keep the general circulation as much as possible equalized. The treatment of haemorrhage from the uterus, where it occurs as a result of uterine congestion, has been already detailed. Acute Metritis. Metritis, or acute inflammation of the uterus, is a rare disease in the unimpregnated state : the more chronic varieties are however very frequently met with. The morbid action may be seated in the serous or mucous coats alone, or simultaneously in these and in the proper structure of the uterus. Its effects upon the mucous and serous coats of this organ are similar to those upon the same membrane in other parts of the body. When it attacks the proper tissue of the uterus, the organ becomes enlarged, oedematous, and diminished in con- sistence. Sometimes, when the morbid action has been very acute, the inflamed part is soft and friable, with pus infiltrated through its tissue. Occasionally, instead of being diffused, the pus is collected in a cavity or abscess in the sub- stance of the uterine parietes. This, however, is a very rare pathological appearance, and we have not seen more than one well marked preparation of it. The purulent matter may occupy other tissues. Thus it has often been found in the veins, as well as in the dilated lymphatic vessels of the uterus. These appearances, however, have hitherto been only remarked in the puerperal forms of metritis ; and in the epidemics of that disease which we have seen, the lym- phatics were certainly more frequently the seat of the purulent deposit than the veins. Sometimes the pus, when effused on the mucous surface, is collected in the uterine cavity in consequence of coexisting obstruction of the os uteri; and again the purulent matter occasionally collects in abscesses limited by pseudo- membranes, the external surface of the organ, or in the cellular tissue between it and the rectum. The more frequent lesion on the peritoneal surface of the inflamed organ, however, consists of the effusion of coagulable lymph and false membranes binding the surface to the neighbouring parts, and leading often to sterility by obstructing the necessary change of position of the Fallopian tube and ovaries, or to abortion by preventing the developement of the uterus beyond a limited extent. Gangrene also occasionally occurs in the uterus as an effect of acute inflam- mation, but this is principally observed in the puerperal state, and when the uterus becomes the seat of inflamed and disorganizing morbid deposits. Causes. Suppression, partial or complete, of the menstrual discharge from exposure to cold, or the use of astringent injections, and mental emotions con- stitute perhaps the most common causes of acute metritis in the unimpregnated state. Abuse of sexual intercourse, physical injuries and succussions of the 320 inflammation of the uterus ( Treatment). lower part of the body, particularly if they have occurred at the catamenial period, are sometimes also observed to give rise to it. Symptoms and Diagnosis. Sudden stoppage of the catamenia, a feeling of heat with tenderness on pressure in the uterine region, pain, and sometimes swelling of the cervix of the organ on vaginal examination, pains stretching to the loins and thighs, difficult micturition, a sense of weight and bearing down, and occasionally, after a time, abdominal swelling and tympanites constitute the more important local symptoms which severally or conjointly accompany acute metritis in the unimpregnated state. The constitutional symptoms vary greatly in character and intensity. They are regulated by the severity of the attack, but still more by the susceptibility and irritability of the system of the patient. In some cases there is well marked fever. Frequently the disease gives rise to irregular hysterical symptoms, particularly in those who are subject to this affection, and nausea and vomiting are often present. Occasionally in the more aggravated cases, headache and the more formidable symptoms of cerebral derangement, such as slight delirium, deafness, impaired vision, and even a tendency to coma, with great prostration and subsultus tendi- num, supervene. These last symptoms are frequently observed in cases arising from sudden suppression of the catamenia, and we are inclined to think that they ought not so much to be attributed to any constitutional sympathy as to the retention in the circulation of the principles intended to be eliminated by the menstrual evacuation. We see, at least, similar symptoms produced when other excreted fluids (such as the bile or urine) are retained in consequence of inflam- mation, or other disease of their appropriate organs. Treatment. This differs little, if at all, in its general principle from that which has been laid down so frequently in different parts of this work with regard to acute inflammation in other internal organs. We may state that, in general, we find venesection and the local detraction of blood well borne in these cases. Local depletion in this case is best effected by cupping the loins, or by applying leeches to the groin or vulva. We have at the same time frequently employed a combination of opium and tartrate of antimony (1 gr. of opium and | gr. of the tartrate in the form of a pill) repeated every hour or two, till either the pain was abated, or sleep was procured. In some aggravated forms of puerperal metritis this practice has been followed by the best effects. In cases of the disease originating in suppression of the menses, antimony, acetate of ammonia, and other diaphoretics are often of much use: local fomentations frequently repeated, the hip-bath, and other measures calculated to restore the uterine discharge being at the same time employed. Counter-irritation by turpentine, mustard poultices, and croton oil, is preferable to that effected by cantharides, which sometimes aggravates such cases by its effect on the urinary bladder. The dysuria which not unfrequently accompa- nies acute inflammation of the uterus may be relieved by mucilao-inous drinks, but can only be fully removed by the measures calculated to relieve the metritis itself. The bowels must be kept open by some of the milder cathartics only, in order to avoid undue intestinal irritation; and these, if necessary, may be assisted in their operation by injections of warm water, or any simple form of emollient enema. Lastly, we would state as being a point of great consideration, that if once the disease is detected, our measures should be employed and pursued vigorously, in order to arrest the disease as early as possible, and to prevent its running on, as it is so very liable to do, into any of the different and distressing chronic forms of metritis that we have now to describe. Chronic Metritis. Chronic inflammation of the uterus, from the frequency with which it occurs, is probably, in a practical point of view, the most important structural disease of this organ. The idiopathic form is exceedingly common, but it is also often found complicating various other organic diseases of the uterus, adding greatly to the distress created by them, and in many inflammation of the uterus (Chronic). 321 instances accelerating their progress. It is an affection to which too little atten- tion has hitherto in general been paid; its effects and consequences, however, have received more patient investigation than the disease itself. Chronic metritis may appear under different pathological forms: we shall in the present instance consider it in relation to the four principal varieties under which it is met with in practice, namely, as consisting of and terminating in 1, ulcerative, 2, suppurative, 3, membranous inflammation, and, 4, as leading to inflammatory enlargement and induration of the substance and mucous follicles of the uterus. 1. Ulcerative inflammation. WTe have seen ulceration of the inner sur- face of the body of the uterus result from acute metritis in the puerperal state; but when ulceration takes place as an effect of chronic inflammation of the organ, it is almost always confined to the region of the cervix. In this locality, chronic ulceration becomes important, from its occasionally giving rise to very distressing symptoms, and from its being frequently mistaken for disease of a more malignant character. Chronic ulcerations, the result of inflammatory action, are generally situated on the vaginal surface of the posterior lip of the cervix, mere rarely on the anterior, and we have found it occasionally appearing at, and as it were encircling, the very orifice of the os uteri. At present we know little of the history of the first appearance of this disease, whether it originates in local inflammation and distension of the Nabothian follicles, or, as in the mucous membrane of the eye, in pustular or other forms of inflammation of the proper mucous membrane of the part. In some cases the ulcer is single, small, and circumscribed, with smooth edges; in other instances we see several ulcers present, or one large one of an irregular shape and of a diffused form. The ulcerated surface may be found either of a bright red colour like a healthy granulating sore, or the redness may be less marked, or again, it may present a straw or yellowish colour. The ulcer is generally very superficial, and hence it cannot, in some cases, be detected by touch alone; it may, however, extend, so as to eat more or less deeply into the substance of the cervix. The neighbouring parts are indurated, in proportion to the degree of chronic inflammation which accompanies the ulcerative process. 2. Suppurative inflammation. To this form of chronic metritis we refer almost all those cases of leucorrhcea in which the discharge proceeds from the mucous membrane of the uterus itself. The source of the discharge in these cases is in general well shown by its aggravation immediately before or after a monthly term, and by its assuming at these periods a more purulent appear- ance, facts which do not hold good with regard to vaginal leucorrhcea. We refer for the more full discussion of this subject to the article Leucorrhoea, and shall only further remark here, that chronic suppurative inflammation of the uterus may be either an idiopathic affection, or may be excited and kept up by the presence of tumours, polypi, &c, in the walls or cavity of the uterus itself. When the os uteri happens to be obliterated by inflammation or other causes, the pus may accumulate within and distend the uterine cavity, a pathological appearance of which we have several cases on record. 3. Membranous inflammation. One form of chronic metritis is well marked by its tendency to the effusion of coagulable lymph upon the mucous surface of the uterus. This lymph or fibrin may be thrown off in the form of shreds and laminated patches, but in general it is accumulated within the uterus to such an extent as to form, before its expulsion, a complete mould of its cavity. In some cases these fibrinous moulds are passed only once or twice during life, but in other instances they almost constantly collect during the interval between the menstrual periods, and are expellled regularly at every monthly term, or at more distant periods. When this occurs they give rise to one very painful form of dysmenorrhcea. vol. m. 11 322 inflammation of the uterus (Symptoms). These false membranes often acquire considerable size, and by their accumu- lation distend the cavity of the uterus. They have often been mistaken for abortions: this error is the more likely to occur, in consequence of uterine con- tractions and pains, and sometimes a degree of haemorrhage accompanying their expulsion. They want, however, many of the characters which distinguish the fcetal bag and membranes. They have no embryo in their cavity ; and, what is still more important as a means of distinction, they show none of the villi of chorion, nor any of those small but numerous foramina peculiar to the decidua to be traced on their surface. We have been led by various circumstances to consider the form of chronic metritis as much more frequent than it is generally supposed; and we have often found more or less distinct traces of it in uterine complaints, where the shreds and discharges were not remarked until the patient's attention was par- ticularly directed to the subject. This form of chronic metritis is analogous in its pathological characters to that sub-inflammatory action which occasionally gives rise to similar chronic fibrinous effusions upon the mucous membrane of the bronchial tubes, intestines, Schneiderian membrane, &c. In one case that was some time ago under our charge, these fibrinous membranes were alternately discharged from the uterus and intestines. We have seen one specimen of a false membrane forming one complete fibrinous coat of the puerperal uterus, resulting from acute inflamma- tion during that period; but such cases are exceedingly rare, and metritis with membranous effusion upon its mucous surface is almost peculiar to the chronic form of the disease alone. 4. Inflammatory enlargement and induration of the substance and mucous follicles of the Uterus. The effusions of serum and coagulable lymph resulting from chronic metritis may in this, as in other organs, be thrown out among the component tissues and structures of the viscus, and thus lead to their enlarge- ment and hypertrophy. Granular inflammation of the cervix, as it is termed, is one form of such disease. In this case, the mucous follicles, scattered over the cervix and at the os uteri, are distended with serous or fibrinous effusion, and project beyond the surface of the part. The disease has been described as a form of chronic metritis, consisting essentially of inflammation and hypertrophy of these follicles themselves; but the whole component tissues of the cervix are generally in an inflammatory state at the same time, and thus enlargement of the mucous folli- cles can only be properly regarded as one effect and form, and that not constant, of this diseased state. There is another variety of chronic metritis to which the term granular in- flammation has been applied. In this second form the effused lymph, instead of being infiltrated into the follicles or substance of the cervix, is thrown out on its mucous surface in the form of red granulations, like those seen in granular inflammation of the conjunctiva of the eyelids. Sometimes the whole uterus is enlarged and hypertrophied from chronic inflammation, but more frequently this effect is more limited, and certainly the cervix is, of all parts, that which in the majority of cases is principally or alone affected. Symptoms. When chronic inflammation or other forms of organic disease and irritation exist in the uterus, we may have symptoms referrible to several different sources present:—1, morbid derangements in the functions and state of the uterus itself; 2, derangements and sympathetic pains in the pelvic and other adjoining parts and viscera ; and, 3, we may have a series of morbid phe- nomena, having reference to the effects of the disease upon the constitution. In addition to these, there is in the class of diseases in question a further most important set of diagnostic signs to be derived from abdominal, rectal, and vaginal examinations, and by the use of the speculum. In the different forms of chronic metritis the functions of the uterus itself are INFLAMMATION OF THE UTERUS (Symptoms). 323 very rarely altered. Very generally, however, the peculiar mucous secretion of the lining membrane and cervix of the organ is increased, and it often alters more or less to a purulent character. At the monthly periods, the catamenial discharge is liable to be either partially suppressed, or in greater quantity than usual, and sometimes it is mixed up with clots of blood. When the membra- nous form of chronic metritis is present, there may be greater suffering from dysmenorrhcea at the time these membranes are discharged. In chronic me- tritis and most varieties of uterine organic diseases, the uterus itself seems always prone to a degree of prolapsus. Conception is in most cases impossible under the varieties of chronic metritis affecting the substance and lining mem- brane of the organ, and hence sterility is a very common consequence of the more inveterate varieties of this affection. Nothing can be more various than the degree of local suffering produced in different cases by chronic metritis in the uterine region and neighbouring organs. In some instances, the several symptoms referrible to this head are almost en- tirely wanting, whilst in others, there are in a more or less marked degree a feeling of heat and weight, increased sensibility in the uterine or pelvic regions, sensations of tension and bearing down, dragging pains in the hypogastrium, loins, and thighs, and sometimes sharp or lancinating pain in the locality of the uterus itself. These symptoms are relieved by the supine posture, and on the other hand are liable to be increased by long standing and fatigue. They are generally aggravated during the menstrual period. We often find also the urinary bladder and rectum much irritated and deranged in their functions, and occasionally we have deceitful sympathetic pains in these organs, as well as at the anus and vulva, or in the course of the lower extremities. In the more aggravated in- stances of chronic metritis, much constitutional irritation is sometimes produced. There are often present various dyspeptic symptoms, with headache and sym- pathetic pains in the mammae, loins, and particularly in the left hypochondriac region. This last symptom (pain under the left mammae) we have observed to be a very constant phenomenon in almost all varieties of chronic uterine disease. Frequently these constitutional symptoms are complicated with those of hys- teria, and occasionally, in the more inveterate cases, an impaired condition of the general constitution approaching to the state of cachexia is superinduced. This last is particularly apt to take place in the cases of the disease that are accompanied with much leucorrhoeal discharge, or kept up by the constant re- currence of severe dysmenorrhoeal symptoms. Most of the symptoms which we have now enumerated are common both to chronic metritis and to other varieties of chronic uterine disease. By their pre- sence, in greater or less number, we may probably be enabled to determine, in any individual case, that morbid action does exist in the uterus; but, in most instances, it will be impossible by them alone to ascertain the specific patholo- gical nature of that action. No organ of the body shows less correspondence between the gravity of its morbid lesions, and the severity of the local and con- stitutional symptoms which these lesions excite. Thus there are sometimes much local and general irritation when only a small and simple ulcer exists on the cervix uteri; whilst, on the other hand, it occasionally happens that the uterus has undergone an extensive and advanced degree of carcinomatous degeneration, without giving rise to any phenomena that would lead us to sus- pect its existence. Hence arises the great advantage, in uterine pathology, of employing, as measures of differential diagnosis, such means as will make us acquainted with the physical conditions of the organ, namely, 1, manual or tactile examinations, and, 2, visual examination by the speculum. In chronic metritis it is by vaginal examination alone, and through the medium of the sense of touch, that we can hope to detect the changes that usually take place, to a greater or less extent, in the physical conditions of different parts of the uterus, such as the tumefaction, and probably the induration of one or both 324 inflammation of the uterus (Treatment). of the lips of the os uteri, the patulous or funnel-shaped condition of that opening, the existence of ulcerative breaches of continuity in its neighbourhood, the in- creased sensibility and heat of the parts, and the frequent partial prolapsus of the whole uterus. Again, in the same disease, we have in the speculum uteri, not only a most valuable auxiliary measure for confirming several of the more important points ascertained by the sense of touch, but, further, it is through its employment alone that we can recognise the existence of the morbid inflamma- tory changes of colour at the os uteri and in its neighbourhood. Besides, by its use we may often recognise superficial ulcerations and granular elevations that are too siight to be detected by the most practised touch, and in all cases in which the disease is conjoined with a discharge, we may satisfy ourselves both as to its exact source and its prominent physical characters. Great difficulties have been placed against the general introduction of the speculum into practice, in consequence of the revolting exposure of the person of the patient which is usually considered necessary for its employment. We have latterly in our own practice endeavoured to avoid this very natural objec- tion, by teaching ourselves to introduce and use the instrument when the patient was placed on her left side in the position usually assumed in making a tactile examination. In this way we have found that the instrument can be employed with little, or indeed without, exposure of the body of the patient. We have made trials of many different forms of specula, and find, for almost all purposes, that of Ricord by far the most useful and manageable. Causes. The causes of chronic metritis are such as induce the acute forms of the disease, more especially sudden suppression of the menses and other irregularities in the catamenia, injuries received in abortion or parturition, ex- cessive sexual excitement, exposure to cold particularly during menstruation, physical violence, displacement of the uterus, &c. Treatment. Till of late years no class of complaints were more generally mistreated than those arising from chronic metritis. Within a very recent period, the several consequences and principal symptoms of the disease were each looked upon as independent functional affections, and treated accordingly. In other words, remedies were applied, almost at hazard, to the effects of the metritis; and the leading phenomena of the disease were subjected to medici- nal measures, whilst the metritis itself was neglected or misunderstood. In no department of practice has the importance of the more accurate patho- logical views which have been acquired of late years been more forcibly illus- trated than in reference to the present affection; and the great improvement which has at the same time taken place in our means of forming an accurate diagnosis in uterine complaints has also, no doubt, greatly promoted this result. Thus as we have just hinted, the particular forms of leucorrhcea, dysmenorrhcea, &c, which occasionally accompany chronic metritis, were formerly empirically treated, along with all the other varieties of the same nosological affections, upon some general and common rules, and without any regard whatever to the patholo- gical state of the uterus on which they might be dependent. In other instances, again, the local diseased state of the uterus present in metritis, when it was really ascertained, was too often looked upon as of a malignant nature, and palliative measures were alone employed, when more active means might have restored the patient and arrested the progress of the diseased action. It is unnecessary to add how much our increased knowledge of the pathology and diagnosis is cal- culated both to improve, and at the same time to simplify, our prognosis and our principles of treatment. In fact, with the modern views of uterine pathology, a case of chronic metritis, instead of appearing under a variety of forms with a variety of diversified treatment adapted to each, simply resolves itself into a case requiring the application of those general principles of treatment that guide the practitioner in the management of other local chronic inflammations, with such modifications only as we have already pointed out funder Conges- inflammation of the uterus (Treatment). 325 tion of the Uterus) as required by its dependent position and peculiar func- tions. We consider it unnecessary to state at length the detailed treatment of a local chronic inflammation, such as chronic metritis, inasmuch as the general prin- ciples applicable to this state have been already sufficiently laid down and dis- cussed under different heads, and in reference to other internal organs. We shall therefore confine ourselves to a few remarks on this subject. When the constitution of a patient affected with any of the forms of chronic metritis is in any degree plethoric, or can bear loss of blood without material constitutional harm, small derivative bleedings from the arm to the extent of six or ten ounces, will often prove of great advantage, particularly towards the recurrence of the menstrual period. We have pursued the plan of small general bleedings at the interval of a few days between each, in cases where local abstraction of blood was objected to, and have seen excellent results from it; but certainly we prefer, as a more effectual measure, the repetition of the local bloodletting, when that can be accomplished. In uterine diseases it was formerly the practice to abstract blood locally when required, by cupping glasses to the lumbar region or sacrum, or by leeches to the groins or vulva. Certainly, one of the greatest improvements that has been introduced of late years into the treatment of these affections, and particularly of chronic metritis, is the adoption of a more efficacious plan of local bloodletting by the direct abstraction of blood from the uterine vessels themselves. This may be very readily effected by one of two plans, 1, by the application of leeches to the vaginal surface of the cervix uteri; or, 2, by making scarifications in that part. We have employed the latter mode (scarifications of the os uteri) in several cases with such ease and effect, that we would be inclined to prefer it to the employment of leeches, if its adoption could be made less formidable in the idea of the patient. The blood is drawn more rapidly, and at the same time with much greater precision, from the engorged vessels themselves. The scarifica- tions must be very numerous in order to be effectual, but they give surprisingly little pain to the patient, and indeed, in some cases, she can scarcely be said to be aware of their performance. We have generally used a sharp-pointed bis- toury in this little operation, after having exposed the os uteri with a double- bladed speculum ; and by keeping the vagina extended by the latter, three or four ounces of blood will escape in the course of ten or fifteen minutes. We have endeavoured to promote its flow by using the tubular speculum, and apply- ing an exhausting cupping-glass to the outer extremity of it. Hitherto, how- ever, we have not been able to make this addition of much avail. In applying leeches to the os uteri, some practitioners are in the habit of employing the speculum for the purpose of introducing them up to the cervix. We have found a tube of ivory or pewter, of ten or twelve lines in caliber, to be equally effectual, and it can be used without the necessity of exposing the patient. The tube is six or seven inches in length, and open at both extremities, and when fully introduced to the upper part of the vagina, the leeches are pressed along with a wooden rod. They generally fix readily and may draw a considerable quantity of blood. The haemorrhage may be kept up after they are removed from the vagina by the use of the warm bidet or hip bath. The number of leeches to be applied, and the quantity of blood drawn, as well as the frequency of the repetition of the local bloodletting, must be regulated by the circumstances and necessities of each individual case. We may remark, how- ever, that the more actively and frequently the measure is pursued in those cases that are at all appropriate for it, the more marked will the effects of the treat- ment be. During the active stage of the treatment we have been in the habit of employing from three to six leeches every alternate or every third day, until the symptoms more or less completely yielded ; and we have been repeatedly 326 fibrous tumours of the uterus (Anatomical Characters). surprised at the good effects resulting from this practice, in patients whoso apparently debilitated and impaired general state of body might d priori have seemed entirely to forbid it. In some of these instances the great relief derived from each repetition of the local bleeding, and expressed by the patients them- selves, has encouraged us to proceed in it when otherwise we might have hesi- tated to do so. The small general and local bleedings that we have spoken of, should after a time be followed by blisters or other counter-irritants to the neighbourhood of the diseased organ. We have generally been in the habit of applying them to the region of the sacrum, and it is a point of much impor- tance that this counter-irritation should be either frequently repeated, or kept up in the form of a continuous discharge. For this purpose, strong stimulant liniments may be applied to the lumbar and sacral regions, croton oil or nitrate of silver may be rubbed in upon'these parts, a tartar-emetic eruption brought out, or any form of issue opened. If cantharides be used, they must be employed in such a way as to avoid irritating the urinary bladder. Along with these active means other antiphlogistic measures require to be adopted. The extent and nature of these must be regulated in a great degree by the circumstances of each individual case. In all, it is a matter of the highest importance to restore and keep up a healthy degree of action in the skin and intestinal mucous surface, and to avail ourselves as much as possible of the advantage to be derived from keeping the patient in a recumbent posture. There is a period in this as in all other forms of chronic inflammation, when tonic and slightly stimulant measures may be advantageously substituted for those of a strictly antiphlogistic character. Hence we find authors describing the benefit they had experienced in the treatment of the cases (which are now known to have been chronic metritis) from preparations of mineral and vege- table tonics. In the latter part of the treatment, the cold hip bath or cold affu- sion upon the loins will be found to be an excellent local tonic. It is always of importance that the lower extremities of the patient should be kept warm and equally clothed. In the ulcerative and granular forms of chronic metritis, the use of astringent, stimulant, or sedative washes of different kinds, or the employment of the solid nitrate of silver or sulphate of copper, as direct local applications to the affected part, are of the greatest advantage. In one case of large irregular ulceration of the cervix, we saw the repeated application of a solution of the corrosive sub- limate in the nitro-muriatic acid eminently successful in changing the condition of the sore, and in causing it to assume a healthier state of action. For the treatment of those derangements in the functions of the pelvic and other viscera, that are liable to be excited by or to accompany chronic metritis, we refer to the articles in the present work particularly devoted to the consideration of the diseases of these viscera. FIBROUS TUMOURS OF THE UTERUS. Anatomical characters.—Nature—Progress.—Symptoms.—Prognosis.—Treatment The uterus may be the seat of various heterologous deposits and morbid growths. Of these by far the most frequent in their occurrence are fleshy or fibrous tumours. This appellation is applied to a species of tumour, and which, as its name implies, is characterized by its highly marked fibrous texture. On dividing such tumours they are found to consist of a mass of irregularly con- voluted and contorted fibres. These fibres are generally also collected into a FIKROUS TUMOURS OF THE UTERUS (Nature). 327 number of separate nodules or lobules, which are connected together by loose cellular tissue; so that in each tumour we can generally trace an aggregate, as it were, of smaller tumours which may be either nearly equal to one ano- ther in point of size, or have one or more among the number disproportionally large. Fibrous tumours are attached to the uterine structure in which they are imbedded by a capsule of cellular tissue, which is sometimes so lax as to allow them to be easily enucleated. They vary much in size. They may not be larger than a pea, and in some rare instances, on the other hand, they have been found to weigh as much as thirty or forty pounds. Generally we find several of them coexisting in different parts of the same uterus, and very unequal in regard to size. Their form is usually more or less globular, but they may be very irregular in shape, and either equal or modulated on their surface. Though fibrous tumours are found in the body, or fundus of the uterus in probably the majority of females advanced beyond the age of forty or fifty, yet they are rare in the region of the cervix. They may occupy different situations in relation to the component parts of the walls of the uterus. Thus they may be developed: 1, immediately under the peritoneal coat; 2, in the substance of the walls ; or, 3, they may be situated between the proper tissue of the uterus and the mucous coat. In the first and last situation, they generally become more or less peduncu- lated. When imbedded in the substance of the walls, they are usually more chronic in their growth and denser in their tissue, than when placed beneath either the peritoneal or mucous membranes. Indeed, the rapidity of their deve- lopement and the degree of their density seem to be always regulated in a great measure by the amount of resistance which is offered to their increase by the neighbouring tissues. Hence it happens, that if they are placed near one of the surfaces of the uterus, they enlarge principally in the direction of that sur- face or towards the side from which they meet with the least resistance; and they may thus come to carry before them in the direction of their greatest increase a thin layer of the proper uterine substance. Further we find, that in proportion as the resistance of the neighbouring parts is overcome either by the natural position or by the growth of the tumour, that its developement is corre- spondingly rapid, and its component tissues become less and less compact, so much so that when the tumour is only restrained by the mucous lining of the uterus, it may partially assume a loose cellular, vesicular, or cystic structure (the vesicular or cystic polypi of some pathologists). In other cases where this diminution in their density does not take place, when the tumours are situated in the circumstances alluded to, it will be found that the resistance to their greater developement has been sufficiently maintained through the restraint exercised by the strong capsular layers of the tumour itself. Many pathologists look upon fibrous tumours of the uterus to be of a schir- rous or carcinomatous nature. We are ready to admit that, like all other tis- sues either healthy or morbid, they may become the seat of the deposit of carci- noma, when the diathesis of that disease happens to coexist, and that then the tumour of which we speak may present all the characters and changes peculiar to a part attacked with that affection. We admit further, that the low vitality of fibrous tumours may predispose them to be the first, or one of the first, seats in which the carcinomatous deposition, when it does occur, may localize itself. But it is certainly no part of the pathological history of fibrous tumours that they are primarily of a schirrous nature, and have a natural tendency to undergo the alterations characteristic of a schirrous part. On the other hand, the series of changes which usually occur in them is of a very differet kind. Like all morbid fibrous tissues, their principal tendency is to degenerate first into cartilaginous matter, and subsequently to become the seat of an osseous or calcareous transfor- mation. This calcareous degeneration sometimes commences towards the circum- ference, and hi other instances towards the centre of the tumour, and occasionally 328 fibrous tumours of the uterus (Symptoms). it goes on to a degree of stony induration. In fact, the bodies described by the older pathologists under the name of womb-stones are merely degenerated fibrous tumours that have produced ulceration through the intervening mucous and other tissues, and thus reached the proper cavity of the uterus, from which they are occasionally afterwards expelled by the uterine contractions. We have had repeated opportunities of remarking this calcareous degeneration equally in the very smallest fibrous tumour, and in those of a larger size. We believe that fibrous uterine tumours may, in some rare cases, undergo an- other or cellular form of transformation, and in this way become diminished both in density and volume. It is only by this kind of cellular atrophy that we can explain to ourselves the circumstance of the disappearance to a greater or less degree of uterine tumours that appeared to have all the characters of the fibrous tumour. We have lately had an opportunity of watching one such case, and there are a few others on record. The appearances after death, observed in some instances of this kind, would prove a great addition to our present knowledge. Fibrous tumours are not very vascular, but we have seen two or three speci- mens in which their bloodvessels were beautifully and minutely injected. They are very liable to attacks of inflammation, and are more particularly prone to this morbid action when pregnancy supervenes. Under the last condition they entail great danger upon the patient; for very frequently, owing to the increased supply of blood which is afforded to them by the enlarged vessels of the preg- nant uterus towards the latter months, or in consequence of the injuries they sustain at the period of parturition, they take on a destructive degree of inflam- matory action, which speedily ends in effusions of serum and unhealthy puru- lent matter into the tissues of the tumour. Softening and disorganization of some parts of their internal structure are thus rapidly produced. We here speak principally of loose fibrous tumours connected with the pregnant uterus, for we have known more than one instance, where these tumours, when dense and of small size, showed no tendency to assume inflammatory action. We may only add further, with regard to the pathological history of fibrous tumours, that they not unfrequently excite at different periods of their course, considerable irritation and inflammation in the surrounding tissues of the uterus. Symptoms. Occasionally we meet with large fibrous tumours in the uterus of the dead body, that have not given rise to any appreciable symptoms during life. When imbedded in the proper structure of the uterus, or situated below its peritoneal coat, they rarely produce any phenomena, except those attribu- table to their mechanical pressure and irritation upon the adjacent organs. In this way we may find them disturbing, to a greater or less extent, the function of the bladder or rectum, producing various complaints, by their pressure upon the pelvic vessels and nerves, or leading to that feeling of bearing down, which all enlargements and irritations in the uterus are so apt to occasion. In these instances, the functions of menstruation may be either irregular or scarcely interfered with ; but when the tumour is situated towards the°mucous surface of the organ, we generally find the catamenia increased in quantity, and accompanied with coagula and discharges of blood. The great practical distinc- tion between the effects of fibrous tumours, as imbedded in the substance of the organ or beneath the peritoneum, and as located behind the mucous membrane, consists in the marked tendency of the disease in the latter situation to produce considerable and even fatal attacks of haemorrhage. A leucorrhceal discharge is also frequently present, when the tumour is thus so placed, as to keep up a degree of chronic irritation and inflammation in the mucous lining of the uterus Examination through the abdominal parietes, or by the vagina or rectum may enable us to recognise the presence of the tumours, when they have at- tained a considerable size, and to determine their position, magnitude &c When the uterus is the seat of an aggregation of such tumours, it presents a roiA'Pi of the uterus (Descripition). 329 dense resistance, and a nodulated and irregular form, that are quite peculiar to the disease. Prognosis. In simple fibrous tumours, the prognosis may in general be very favourable. They rarely grow to such a size as to prove very hurtful to the patient from their mere magnitude, and, as we have seen, they are not intrin- sically liable to take on any destructive morbid action. When imbedded in the uterine walls, or below the peritoneum, they may remain perfectly dormant, for a long series of years ; but they are always liable, as we have already stated, to occasional attacks of inflammation, when sufficient exciting causes are ap- plied. When they project into the uterine cavity, they require removal, in con- sequence of the discharge and haemorrhage which they excite. One of the greatest steps made in modern times, in the pathology of the uterus, is the perfect distinction of these fibrous tumours from cancer of the organ, and the consequent difference which we are now enabled to form in in- dividual'cases, with regard to their prognosis. Treatment. From the pathological remarks that we have made, it will be readily inferred that the treatment of fibrous tumours is in general more of a negative and palliative, than of a positive character. It has been supposed that iodine, mercury, and other deobstruent medicines have had the effect both of ar- resting and reducing fibrous tumours. It would require, however, more evidence than we as yet possess, before we could with certainty assign such powerful effects, to the remedies in question. In general, all that requires to be done is simply to use means to avoid as much as possible morbid determinations of blood to the vessels of the uterus, to subdue inflammation when it does supervene by the means already pointed out under metritis, and to restrain excessive haemorrhage by the measures described in the article Menorrhagia. In the submucous variety of fibrous tumours, it sometimes occurs, that no means less than the. use of the vaginal plug or tampon will be sufficient to arrest the dangerous haemor- rhage that occasionally accompauies this variety of the disease. Fibrous tumours have occasionally been separated from their connexions by ulceration of the intervening uterine tissues, and have in this way come to be discharged from the female passages. In other instances in which they were pediculated, the pedicle has become more and more slender, till at last the tumour was actually separated. We have known such a separation take place even in subperitoneal fibrous tumours; but we speak of it here, as it is more frequently seen, in the submucous variety. Both these operations of nature have been imitated successfully by the surgeon; and the latter in particular is constantly had recourse to when the disease assumes that form which we have next to consider, namely, Polypus of the Uterus. POLYPUS OF THE UTERUS. General description.—Forms.—Symptoms, local and constitutional.—Diagnosis.—Prognosis. —Treatment. The term polypus of the uterus is employed to designate a class of tumours that grow from the inner surface of this organ, or of its os and cervix, and are at- tached to these parts by means of a neck or pedicle, less in diameter than the body of the tumour itself. Uterine polypi vary greatly in regard to shape, size, and other physical cha- racters. Generally, they are of a pyriform figure, but we find them nearly or even round in some instances, and of a tapering elongated shape in others. They vary in size, from the volume of a pea to above that of a child's head. vol. in. 42 330 POLYPI OF THE uterus (Forms). Their surface is generally smooth, but it may present considerable difference of colour, being sometimes pale and straw-coloured, and in other cases more or less bluish or purple, and vascular. These polypi may grow from the fundus of the uterus, from its body, from the inner surface of the cervix, or from one of the lips of the os uteri. They are generally attached by their single original pedicle, but we have seen a preparation of polypus that was provided with two, and of another attached by three points or pedicles to the inner surface of the uterus, probably inconsequence of adhesive inflammation having taken place between their surface and that of the contiguous mucous membrane, in the locality of these second attachments. Their investing membrane is not unfre- quently the seat of inflammation, and it is sometimes under the aggravation of symptoms arising from this cause, that the patient applies for medical aid. We lately were consulted in a case of an enormous polypus which distended the whole cavity of the vagina. On making an examination, the finger brought away a quantity of recent coagulable lymph that had been effused upon the surface of the polypus ; and we once witnessed the dissection of a case in which the surface of the tumour was universally adherent, through the medium of a recent false membrane, to the internal surface of the dilated uterus. A polypus of the fundus or body of the uterus is in its first commencement, and when still small, entirely enclosed within the cavity of the organ; but, in general, it gradually dilates the cervix and os uteri and passes through it, either slowly or insensibly, or it stimulates the containing organ to contract forcibly upon it, and protrudes it, more or less completely, into the vagina. But excep- tions to this may be met with ; for occasionally we find (as in the case above adverted to) a polypus of a large size still altogether included within the uterine cavity. Uterine polypi differ considerably from one another in their pathological struc- ture. The principal varieties that we meet with in practice may be reduced to the following forms: 1. Polypi composed of a structure the same as that of the fibrous tumour of the uterus, which we have already described. In fact this kind of polypus, which is the most common type of large uterine polypi, consists merely of a fibrous tumour that had been originally placed immediately beneath or near the mucous surface of the organ, but by afterwards enlarging in the direction of the uterine cavity, it ultimately forms a pediculated or true uterine polypus. This fibrous polypus may, like the fibrous tumour of the uterine walls, present a cartilaginous or osseous transformation of its tissue. 2. Polypi of a cellular tissue, resembling in structure and origin the common benign polypus of the Schneiderian membrane; and, like it, consisting of a morbid hypertrophy of the submucous and mucous membranes of the affected part. 3. A vesicular or cystic variety of uterine polypus is sometimes met with. The cystic structure may be seen through the semi-transparent coats of the tumour in some cases, while in others, it is not apparent until section is made; and it may be confined to the centre or some other individual part of the o-r0wth. We have seen this kind of polypus existing in the same uterus with other small polypi of a strictly fibrous tissue, and we believe the former to be merely a tvpe of structure assumed by the fibrous, and probably, also, by the cellular polypus, when their growth or increase towards the uterine cavity is less restrained than usual from the relaxed state of their investing mucous membrane, or in conse- quence of the morbid dilatation or dilatability of the uterine cavity itself. 4. A small variety of polypus is freqently met with growing from the mucous surface of the cervix, and resembling in its structure in most points the second species. This common species of uterine polypus appears to beo-in orio-inally in a morbid dilatation of one or more Nabothian glands. Thes&e glands are very often seen greatly distended, and give an appearance of numerous small serous cysts existing below the mucous membrane of tho cervix. polypi of the uterus (Diagnosis). 331 5. Another variety of polypus, with a broad base and composed of erectile tissue, has been found in a few rare cases attached to the fundus of the uterus. The trunks of the vessels supplying these several varieties that we have de- scribed, are in general not very large; though ramifications upon the surface of it are usually morbidly dilated. Occasionally, however, the vascular trunks passing through the pedicle are large enough to cause considerable and even dangerous haemorrhage by their division. In a case in which we removed a very small fibrous polypus by excision, haemorrhage took place within a few hours after the operation, to such a degree as to cause repeated syncope. Symptoms. The local symptoms accompanying polypus of the uterus con- sist of those to which a foreign body may readily b3 conceived as giving rise, when occupying the cavity of the uterus or vagina. Thus the mucous secre- tion of the female passages is increased, and usually becomes more or less purulent in consequence of the irritation and inflammatory state of the mucous membrane, which is kept up by the presence of the polypus. In other words, there is almost always a state of leucorrhcea present, commencing from an early stage of the disease, which varies much in quantity in different cases. The discharge itself is in general comparatively inodorous, but it occasionally has a foetid character, in consequence of being retained for some time in the pas- sages by the polypus offering a mechanical obstruction to its free escape. The mucous or muco-purulent discharge is in most instances followed, sooner or later, by an occasional intermixture of blood from the surface of the polypus. This haemorrhagic discharge is apt to occur under the action of any causes producing a temporary determination of blood to the parts, and if the patient still menstruates, it is generally first observed at the menstrual periods. When the haemorrhage is at any time profuse, the blood may escape in a fluid state, but it is generally voided in the form of coagula: these coagula occasionally show a laminated appearance, as if they had been moulded upon the surface of the polypus. These several symptoms of polypus are often mistaken for those of simple leucorrhcea or simple menorrhagia, and the fears of the patient and practitioner are not excited, in consequence of the discharges being unaccompanied by pain. In addition to these uterine symptoms, there may be present the usual pheno- mena produced by the irritation and mechanical obstruction of a foreign body, situated within the cavity of the pelvis. There is often, particularly after the polypus has acquired any considerable size, a feeling of weight, with dragging sensations in the loins and back. Bearing down pains sometimes occur, more especially when the tumour is making its way from the uterus into the vagina. Tenesmus and dysuria may result at a later stage from the obstruction and irritation produced by the tumour upon the urinary and intestinal passages. Severe constitutional symptoms are often induced by polypus in the uterus. If the leucorrhoeal or haemorrhagic discharges are profuse, the stomach generally suffers much. Severe dyspepsia supervenes with vomiting, palpitation, excite- ment of the pulse, oedema of the limbs, and other symptoms of constitutional debility and cachexia, and if the disease be neglected "tAe patient may sink under the continued discharges. The quantity of haemorrhagic discharge and consti- tutional debility, accompanying polypus of the uterus, is not, by any means, always proportioned to the size of the tumour; thus a small polypus at the cer- vix sometimes gives rise to effects as severe and fatal as those produced by one of the largest volume. Diagnosis. The preceding local and constitutional symptoms are so common in most chronic organic diseases of the uterus, that our diagnosis of polypus can never approach to certainty, unless we make a vaginal examination. In every case of obstinate leucorrhcea or menorrhagia, it is the imperative duty of the practitioner to do so, in order that he may ascertain the pathological state of the uterus, which he has in reality to treat. On making an examination per vaginam in a case of polypus, a tumour in 332 CAULIFLOWER EXCRESCENCE OF THE UTERUS. some respects moveable, and with its stalk passing either entirely through the os uteri, or attached to one of its lips, is generally at once detected. The tumour may, however, on our first examination, be still entirely included within the cavity of the uterus, and hence may not be reached by the finger. The tumour itself is, in the great majority of instances, perfectly insensible, so that it may be pinched or punctured without producing pain; but rare exceptional instances to this general rule occasionally occur in the case of fibrous polypi, that had descended into the cavity of the vagina invested by a considerable layer of the proper tissue of the uterus. Prognosis. When once polypus of the uterus is detected, the prognosis may in general be highly favourable. The difficulty of the case consists as much in making the diagnosis as in following out the treatment. The diseased struc- tures of which common uterine polypi are composed have no tendency to repro- duction after they are once removed. The operation for their removal is in the great majority of cases attended with little danger; and the rapid improvement which the patient experiences after its performance renders it one of the most satisfactory which the practitioner is called upon to perform. The polypus is certainly not in itself a tumour inevitably fatal, nor in any degree malignant in its character, but it is liable (as we have already observed), if it goes on pro- gressing, to produce death by the excessive discharges and constitutional effects which we have described. In some instances the tissues of the tumour have become inflamed and broken up, and the inflammatory action has stretched to the uterus and peritoneum and thus proved fatal. In a few rare instances, the tumour has been successfully separated at its pedicle by the efforts of nature; and it is this operation which we endeavour to imitate with such advantage in its treatment. Treatment. The usual treatment of menorrhagia and leucorrhcea may be temporarily useful in cases of polypus; but it is an established rule in practice, that as soon as the tumour is sufficiently within reach, it should be removed by operative interference. The tumour may be separated by one of three methods: 1. If it is very small, or of a cellular character, it may be reversed by tortion; 2. The tumour may be drawn downward and the pedicle divided by the knife or scissors; and 3. A ligature may be applied to the pedicle of the polypus, and thus a process of disjunctive ulceration may be set up in the constricted part to such an extent, as completely to divide the stalk in the course of a few days. We must refer to works on midwifery, and surgery for the details of these different operations, and the particular cases to which they are each respectively applicable. CAULIFLOWER EXCRESCENCE OF THE UTERUS. Pathowical nature —Symptoms.—Treatment. A morbid fungus-like excrescence sometimes grows from one lip, or from the whole circumference of the os uteri, insensible like the ordinary polypus, but differing from it in having a broad base and rather irregular surface, and with a greater disposition to bleed, and a much more marked tendency to become re- produced, after it has once been removed. This species of growth has received the name of cauliflower excrescence, in consequence of its generally granulated surface; both in colour and other physical characters it might be more properly compared to the strawberry. The granular surface is not by any means always distinct during life, and the fungus mass often imparts the feeling to the finger of a solid and irreo-ular cauliflower excrescence of the uterus (Treatment). 333 coagulum of blood, or, as it has been described by some authors, it communi- cates to the touch a sensation like that of the uterine surface of the placenta. Pathological nature. Considerable difference of opinion has been expressed by pathologists with respect to the morbid anatomy of cauliflower excrescence. Several facts would almost seem to show that, in its first stage, the disease par- takes much of the nature of an erectile tumour, or of simple vascular sarcoma. Thus its occurrence in some cases as early as the twentieth year of life, its occasional shrinking and almost total disappearance upon the application of a ligature, or after the death of the patient, its alleged total removal in one or two instances under the use of astringent applications and other simple means, the slowness of its general progress during life, and the healthy condition of the neighbouring tissues and parts after death, are all circumstances which lead to the opinion that, in the earlier part of its progress, the tumour is at least not of a carcinomatous nature. At the same time, however, we have seen sufficient evidence to convince us, that the cauliflower excrescence may become the seat of carcinomatous or encephaloid deposit during its progress, whatever may be its nature at its first commencement. We have a preparation in our museum of a cauliflower excrescence which we removed a short time ago by excision of the cervix uteri. The growth has the small granulated character very well marked upon its surface: on rubbing a portion of the recent tumour between the finger and thumb, it readily broke down, and left a kind of vascular or cellular frame- work ; but, after immersing for some time the mass of the tumour in an alcoholic solution of corrosive sublimate, it presented to the touch and sight an appear- ance exactly resembling that of cerebral matter hardened by the same means, with the exception only of showing a number of small cells on the surface of the section. Symptoms. Cauliflower excrescence is accompanied with little or no pain. From the delicate vascular membrane which invests its surface an abundant secretion or exudation of serous fluid is generally poured forth; and this dis- charge constitutes, along with the great tendency to haemorrhage, one of the most marked effects or symptoms of the disease. Haemorrhagic discharges are liable to occur from its vessels, under any causes producing local excitement or determination of blood to the uterus. These occasional haemorrhages and the drainage occasioned by the profuse watery secretion from the surface of the tumour, sooner or later produce general symptoms of anaemia and constitutional exhaustion. The watery exudation is inodorous in most cases: occasionally it is mixed up and accompanied with leucorrhneal discharges. On making a vaginal examination during life, the physical characters of the tumour which we have above described are easily recognised, and its insertion into the os uteri by a broad base ascertained. When examined by the speculum, the surface of the tumour is seen to be very red or of a bright flesh colour. The tumour itself may not be larger than a hazel-nut, but in a few extreme cases, it has been of sufficient size to fill and distend the whole cavity of the vagina, and even to protrude partially at the vulva. In many instances the disease does not attract the particular attention of the practitioner until the tumour has reached the volume of a large strawberry. Treatment. As palliative measures in this disease, our two great indications are, 1, to enforce all those measures general or medical, which are calculated to prevent and subdue determinations of blood to the vessels of the uterus, such as mild and unstimulating diet, the recumbent posture, avoiding mental and sexual excitement, with the application in some cases of cupping-glasses and deriva- tives to the lumbar or sacral regions : and, 2, to use means to arrest the abun- dant and exhausting watery discharge from the surface of the tumour and the haemorrhages which are occasionally taking place from it, by the use of the cold hip-bath or douche to the loins, and by the employment of astringent injections. These means appear to be often further useful in this complaint, by producing such a degree of contractile resistance in the walls of the vagina, as compresses 334 carcinoma of the uterus (Description). the tumour, and so restrains the rapidity of its increase. It is always important to keep the bowels open, as the pelvic congestion arising from constipation is apt to increase both the watery discharge and haemorrhage. It has been proposed to destroy cauliflower excrescences by the use of caustic, and they have often been partially removed by the application of a ligature to their base. The good results following this treatment can scarcely be expected to be more than temporary ; and occasionally the ligature has done much harm by the irritation which it has caused, and the impetus which has thus been given to the regeneration of the disease. For our own part, we believe that if we adopt at all any form of operation for cauliflower excrescences, the amputation of the cervix uteri, and the consequent excision of the very basis of the tumour, is the only measure which promises ultimate success. The disease has recurred in some instances even after this operation, but in other cases on record, the patient was known to remain free from its return for several years afterwards. In the case to which we have above referred, and in which we excised the cervix uteri, together with a cauliflower excrescence of the size of a small orange attached to its posterior lip, the patient had not one bad symptom, local or constitutional, after the operation, and is now beginning to lose her anaemic appearance and regain her former looks and strength. The form of diseased structure of the tumour in this case is certainly such, as renders its future reproduction very probable; but at the same time there is no doubt that the operation has, in the mean time, entirely freed the patient from those discharges, which were making very rapid inroads upon her constitution, and that it will at least prolong her life, if it do not entirely preserve her from any future return of the disease. CARCINOMA OF THE UTERUS. Description.—Symptoms, local and constitutional.—Treatment. No organ in the female body is more liable to carcinoma than the uterus. This disease attacks the uterus under all its different modifications, from simple scirrhus to extensive cancerous ulcerations and encephaloid deposits in the walls of the organ and in the contiguous structures of the pelvic viscera. The car- cinoma generally affects the structures of the cervix in the first instance, and thence spreads upwards into the walls of the uterus and downwards into the upper part of the vagina. We have, on the other hand, seen specimens of it in which the disease followed a different course, attacking the fundus first, and thence spreading downwards in the direction of the cervix. When it commences, as it certainly does in most cases, in the tissues of the cervix, it may appear under the form of a limited deposit or tumour. Most frequently, however, it infiltrates and indurates the whole substance of the cervix, and spreads early, in a greater or less degree, both upwards along the walls of the uterus, and downwards into those of the upper part of the vagina, without there being any very marked limit, at which it would be possible to point out an exact line of demarcation between the healthy and diseased structures. The carcinomatous degeneration after a time affects the more contiguous tissues of the pelvis. The intervening cellular tissues, and latterly the walls of the bladder and rectum, become thickened and changed into the diseased structure. The process of disorganization and ulceration commences at different periods in different cases. Sometimes the deposit has taken place to a great extent in both the cervix and neighbouring parts before ulceration supervenes. In other cases, this process begins at a time when the tissues of the cervix itself are only partially indu- rated and affected. If the patient survive, the ulceration extends latterly into the rectum, and still more frequently into the cavity of the bladder ; or the CARCINOMA OF THE UTERUS (Symptoms). 335 cavity of the peritoneum may be perforated by the ulceration and sloughing of the affected tissues. At the same time that the process of ulceration is pro- ceeding in one part, the deposit of encephaloid matter may be going on in another; and ultimately, at the period of the patient's death, the contiguous structures of the uterus and upper part of the vagina, the posterior wall of the bladder and urethra, and the anterior wall of the rectum, with their connecting cellular tissues, are ultimately amalgamated, and form one nearly homogeneous mass of carcinomatous degeneration and frightful ulceration. The neighbouring lymphatic glands are often diseased, though not to a very great extent; and frequently the branches of the veins of the uterus and of the adjoining affected parts are filled with the carcinomatous deposit. Symptoms. The effects produced upon the functions of the uterus itself and the surrounding pelvic organs, by carcinoma in its first stages, differ in few or no respects from those attending other organic uterine diseases. The sensation of pain in the affected part is in general more acute, hot, and lancinating, than in the other forms of disease to which we allude, but it varies exceedingly in different cases in its character and intensity, and even in its locality. In some instances, it as well as the other usual symptoms of pelvic irritation and uneasi- ness are so very slight, as not to excite the attention or fears of the patient, until the ulcerative stage of the disease is considerably advanced. This certainly is not a very common exception to the general rule, but it is useful in showing us the fallacy of placing implicit confidence upon any particular symptom or set of external symptoms in this and other organic diseases of the uterus. The menstruation is generally irregular and profuse, but in the first stage of the disease, it may remain unaffected; and at that period conception may even take place, and the woman proceed to the full term of pregnancy. We have seen two cases of this kind, both of whom sunk under all the more aggravated symptoms of carcinoma in the course of a few months after delivery. In one of these cases, the structure of the cervix was so indurated and enlarged at the time of parturition, as to have conveyed to the attendant the impression that the head of a second child was presenting. On examining per vaginam in the first stage of carcinoma, the cervix uteri (if it form the seat of a deposit) is found tumefied and indurated. The induration is sometimes diffused; more generally, perhaps, it is circumscribed or notched and irregular. The os uteri is more patulous than usual, and the pressure of the finger upon the rigid lips produces pain and some sanguineous exudation. The uterus is usually partially prolapsed and less moveable in the pelvis. The speculum shows the surface of the cervix tense and shining, and of a reddish, purple, or brownish hue. It is certainly difficult, however, either by sight or touch to distinguish between the state of the cervix peculiar to chronic metritis, and that present in the first stage of carcinoma. When the parts begin to ulce- rate, the disease is more easily distinguished by a vaginal examination. The irregular fungous ulcer is visible by means of the speculum, and its surface is generally tender on pressure. The other external symptoms also become more unequivocal. The leucorrhoeal discharge which has generally been present from an early date, now assumes more and more of a foetid and sanious cha- racter, in consequence of being mixed with the discharges from the ulcerating and disorganising surface of the ulcer. It has a peculiar and highly offensive odour, is more or less discoloured, and often by its acridity causes pruritus and irritation of the passages and vulva. The discharge very soon becomes mixed with blood ; and occasionally a profuse haemorrhage is almost the first symptom which alarms the patient. In advanced life this haemorrhage is often mistaken for a reappearance of the catamenia. As the disease advances in its destructive progress, the constitution deeply sympathises, and all the symptoms of cancerous hectic that supervene, are fear- fully increased and aggravated by the excessive discharges and other distress- ing local symptoms; the sympathetic morbid states excited in distant organs 336 carcinoma of the uterus (Treatment). occasionally bring on symptoms very nearly resembling those of heart disease, and of dyspepsia and nephritis. There is often dysuria with tenesmus ; while the functions of the bladder and rectum are otherwise greatly disturbed. If perforation of their coats takes place, the urine and faeces may be latterly dis- charged by the common cloaca of the vagina, and at last the patient perishes in misery and anguish beneath her accumulated load of local and constitutional sufferings. Treatment. In cancer of the uterus, as in cancer of other organs, medicine offers no hope of effecting a cure ; and in the few observations which it is neces- sary to make in this place upon the treatment of the disease, we shall merely very briefly allude to the general means which appear to have the most influence either in retarding the progress, or in alleviating the symptoms of this hopeless and frightful malady. In the early stage of the disease, the great indication is to prevent or subdue any thing approaching to vascular activity in the affected part. The more completely we can attain this end, the longer, in all probability, we shall be able to keep the disease in a latent state, and we certainly can often date the oc- currence of the ulcerative or second stage to the action of some aggravating causes of local excitement. To fulfil this indication, it will be necessary to feed the patient upon a mild and unstimulating diet, to promote the action of the skin and intestines, to avoid all causes of general or local vascular excitement, whether corporeal or mental, to avert the effects, as far as possible, of the catamenial congestion by the means pointed out under that head, and to subdue any other congestive or inflammatory determination of the blood to the uterus, by the application of cupping-glasses to the loins or sacrum, or by leeches to the vulva or region of the anus. When there is any tendency to haemorrhoids, (as sometimes occurs, when local uterine congestions take place in connexion with this or other organic diseases of the uterus) the application of a few leeches so as to drain blood from the haemorrhoidal vessels, is a practice often attended with direct and excellent benefit. After these remarks it is unnecessary for us to state our opinion of the injurious effect of those stimulant and astringent injections which are too often prescribed in the first stage of this disease, in order to control the leu- corrhoeal discharge and the symptoms of menorrhagia that sometimes attend upon it. In the second stage of the disease, in addition to attending as much as pos- sible to the general health, and to the relief of the different complications that may arise, medicine can do little or nothing except subdue the attendant bodily and mental suffering by powerful sedatives. These sometimes are called for even in the first stage, when the pain is more than usually severe. The seda- tives must be varied from time to time, in order to keep up their action on the system. Opiates may be used in the form of sedative washes, or they may be employed as internal medicines, and alternated or combined with hyoscyamus, belladona, conium, and the like. The preparation of this last medicine (hem- lock) often seems to act with almost specific sedative power over painful affec- tions of the uterus. The fcetor of the discharge may in some decree be cor- rected and modified by the assiduous use of weak injections of chloride of lime ; and the passage of the external organs may be defended against its acrid effects by frequent ablution, and the inunction of their surfaces with oleaginous substances. A surgical cure of cancer of the uterus has been attempted in a number of cases, by removing the whole organ. The almost immediately fatal results of this operation in by far the greatest proportion of instances, and the unsatisfac- tory termination of it in the remaining cases in which it has been performed, are such as will, in all probability, prevent others from recklessly repeating it. The less formidable operation of excision of the cervix uteri has evidently been had recourse to on the continent of Europe in so many cases in which true carcinomatous disease was not present, and the effects of it in true cancer corroding ulcer of the uterus (Diagnosis). 337 have hitherto been so imperfectly followed out and detailed, that we have not as yet any sufficient data upon which to form a true estimate of its value from ex- perience alone. From what we have observed, however, in regard to the pathology of cancer of the neck of the uterus, and from its generally involving at an early date the more immediately contiguous structure, we are inclined to believe that, if found at all useful, it will be only in a very limited number of cases. CORRODING ULCER OF THE UTERUS. * Characters of this ulcer.—Diagnosis.—Treatment. A peculiar and dangerous variety of disease, known among English authors under the name of malignant or corroding ulcer, sometimes attacks the uterus. It commences in the cervix of the organ, and when the attention of the practi- tioner is first attracted to it, by the occurrence of haemorrhages or other symp- toms, the ulceration may not have extended beyond the mucous membrane, but it gradually spreads in an irregular manner over the whole surface of the cervix, and in its further course involves the walls of the uterus and vagina, and may ultimately perforate the parietes of the rectum behind, or of the bladder in front. Sometimes it has been known to reach the cavity of the peritoneum and give rise to fatal peritonitis. Of late years pathologists have described corroding ulcers as a result of inflammation in the affected parts. We believe that this explanation may be so far true, but at the same time we cannot but regard the inflammatory action as at least specific in its nature. Its whole pathological history and characters appear to us to assimilate it with that destructive chronic inflammation and ulcera- tion which constitutes lupus in external parts. If the phenomena of the first commencement of the corroding ulcer were more accurately ascertained, this analogy would probably be found to be more correct than the present state of our knowledge will warrant us to assume. Corroding ulcer of the uterus has often been mistaken for the true cancerous ulcer. The two diseases are doubtless very similar in their symptoms, course, and terminations, but the corroding ulcer specifically differs, in two important respects at least, in its pathological history from carcinomatous ulceration: 1. The corroding ulcer is not preceded by carcinomatous or other morbid deposit in the affected part, similar to that which takes place previously to the commencement of ulceration of a truly cancerous nature. In several prepara- tions of sections of uteri affected with corroding ulcers which we have had an opportunity of examining, we have observed with surprise the uterine and other involved structures apparently perfectly healthy up to the very line of the exist- ing ulceration; and in corroding ulcers, the whole uterus may be seen some- times eaten away to near the fundus, without the remaining part being mate- rially altered in structure. 2. Corroding ulcer, like the ulcer of cancer, generally goes on though at a slower pace to a fatal termination, but certainly in some cases the disease has appeared to be ultimately cured by the efforts of nature, or by the use of local applications; and this is a termination which we assuredly never see in true cancer. Diagnosis. The general and local symptoms of corroding ulcer are those characteristic of cancer. The attendant pain is usually not very acute. The diagnosis between it and cancerous ulcer can be only accurately made by vaginal examination, and by watching the effects of treatment. The great point of dis- tinction consists in the fact, that before carcinoma has gone on to ulceration, it vol. in. 43 338 structural diseases of the uterus (Hypertrophy). has in general been already preceded by such a quantity of morbid deposit in the cervix uteri and neighbouring tissues, that on examination by the vagina and rectum, the uterus itself is found to be much more fixed and immoveable than it is in the healthy state, and the cavity of the pelvis is more filled up. On the other hand, in cases of corroding ulcer we find by the same examination, that so far from being more fixed, the uterus is equally if not more moveable in the pelvis than in the natural state, while the space around the cervix is not occupied by any deposition of new or foreign matter. Treatment. The general indications of treatment in this disease are in their principles and details the same as those laid down in regard to carcinoma of the uterus. In corroding ulcer, however, we have one great additional rational indication in the employment of local applications calculated to arrest the ulcera- tive process, and excite a healthy action in the surface of the sore. Various means have been proposed and employed to attain ihis end. The applications of the solid nitrate of silver, muriate of antimony, solutions of corrosive subli- mate in nitro-muriatic acid, and several other analogous stimulant and caustic substances have each been recommended by different authors. In the treatment of lupus we know well how seldom one kind of application agrees for any great length of time with the disease, and the same seems to hold good with regard to corroding ulcers. The application must, we believe, be repeatedly alternated, and probably practitioners have hitherto erred in the treatment of this affection in two different ways, viz., by applying medicine too powerfully caustic, when they have used local application, and by not persevering with sufficient assiduity in the employment of such mild local measures as we find useful in treating similar ulcers on other parts of the body. In the local treatment of a case of this kind, the speculum is an invaluable instrument in enabling us to make the appli- cations that may be deemed necessary more directly to the affected part, and to it alone. OTHER MORBID DEGENERATIONS OF THE STRUCTURE OF THE UTERUS. Cartilaginous and osseous transformation.—Phlebolites.—Hypertrophy and atrophy.—Sub- stances in the uterine cavity. The uterus is also liable to a number of morbid states and, degenerations of minor importance. Cartilaginous and osseous transformation. The walls of the uterus are occa- sionally the seat of cartilaginous and osseous transformation, independently of the presence of fibrous tumours. Eitherof these morbid conditions may occur through- out a large portion of the parietes of the organ, or they may be found only in parti- cular parts of it. We have observed them most frequently in the higher part of the cervix, where they sometimes produce complete, or nearly complete, obliteration of the os internum. Cartilaginous and osseous degenerations are rarely found in the substance of the uterus itself, except at very advanced periods of life; but we have seen an approach to both of these states, and in the coats of the uterine vessels, at a comparatively early age. Phlebolites are more frequently found" in the uterine and adjoining veins than in those of any other part of the body; and we have found them there, in all stages of their progress, from simple fibrinous coagula to small solid calcareous masses. We believe these phlebolites to be a much more common morbid appearance in the uterine veins, than they are generally reported to be. Hypertrophy and Atrophy of the uterus are states which are occasionally met with, independently of any connexion with other coexisting forms of organic STRUCTURAL DISEASES OF THE UTERUS (Substances). 339 disease. A diminution of the uterus, in regard to volume, may be very gene- rally observed in females, who die at an advanced period of life; but this state can scarcely be said to be one of morbid atrophy. Hypertrophy of the walls of the uterus, around the site of fibrous tumours, is a very common appearance. We have seen the uterine parietes in the neighbour- hood of such tumours nearly as thick as the contracted uterus immediately after delivery, and with its blood-vessels enlarged in a proportionate degree. But again, in other instances of the very same form of tumour, when little irritation had been excited by the presence of the morbid growth, and when the tumours were in near apposition, we have found the portion of the uterine parietes enclosing it evidently diminished in thickness, and in a state of partial but decided atrophy. In some cases we meet with a local atropy confined to one or both lips of the os uteri; and in other cases, the same parts are found in a state of local hypertrophy, and projecting downwards into the cavity of the vagina. The cavity of the unimpregnated uterus is liable to be changed, both in its figure and volume,, in some states of organic disease of the viscus. Indeed it is occasionally found to be partially or entirely obliterated, in cases in which organic and inflammatory disease has taken place in its walls, after the catame- nial period of life has passed over. Both the shape and size of the uterine cavity are often found changed, when fibrous tumours are developed in consi- derable numbers in different parts of its walls. Under these circumstances the parietes of the organ often become enlarged and elongated, in proportion as the tumours themselves are developed, particularly when the tumours are situated towards the mucous surface. The cavity of the uterus is at the same time lengthened, occasionally to the extent of several inches ; and it may also be found irregularly contracted and dilated at different points. The cavity of the unimpregnated uterus may be enlarged by the morbid accu- mulation of different fluid substances within it. Thus, when the catamenial fluid is not allowed to escape, in consequence of obliteration congenital or acquired of the os uteri, vagina, or external parts, the uterine cavity itself may become gradually distended to an enormous degree by the retention of the fluid within it. The same state, as we have already mentioned, occasionally, though rarely, takes place in instances of metritis, in consequence of large accumula- tions of pus within the uterine cavity. In this last case, the canal of the os uteri must necessarily be obliterated before the collection occurs. The mucous surface of the uterus and Fallopian tubes is in rare cases coated with a collec- tion of true tubercular matter. This only happens in instances in which the tuberculous diathesis is otherwise well marked. Substances in the uterine cavity. When the os uteri is accidentally shut up, especially at an advanced period of life, by the formation of tumours in that part of the organ or by chronic inflammation or other such causes, the cavity of the uterus sometimes become filled and distended by an accumulation of the mucous or sero-mucous secretion of its lining membrane. This con- stitutes the disease known under the name of Hydrometra, or Dropsy of the Uterus. The fluid may vary in its qualities by admixture with blood, pus, &c. The quantity which may be accumulated within the cavity of the uterus in this dis- ease is sometimes very great. The organ may be distended to a size equal to that which presents at the fifth or sixth month of pregnancy, and it has even been alleged, to an extent greater than the gravid uterus at the full time. Usually, however, long before any such extreme degree of distension takes place, the walls of the uterus, which in general become more and more attenu- ated as the accumulation increases, give way at some part or other from pro- gressive absorption; or this result may be hastened by the supervention of ulcerative or gangrenous inflammation in a portion of the distended uterine parietes. 340 inflammation of the ovary (General Observations). In hydrometra, as also in the other forms of morbid distension of the cavity of the uterus by fluid accumulations within it, the enlarging organ maintains pretty nearly the form and shape of the gravid uterus at different periods. In such cases, we may meet with a layer of coagulable lymph or false membrane, continuous or interrupted, lining the surface of the dilated cavity. This false membrane, which is merely the result of inflammatory effusion from the internal surface of the cavity, has, in some instances, been mistaken for decidua; and in hydrometra, it has often been erroneously looked upon as the walls of a hydatid. The cavity of the uterus may also contain solid bodies; such as the sepa- rated polypi and womb stones (the nature and origin of which we have already described), accumulated coagula of blood, or of effused lymph and ova that have become diseased and arrested in their developement. Acephalocysts have been found imbedded in the walls of the uterus, and may probably have passed in some cases from thence into the cavity of the organ. But the morbid struc- ture, known under the name of Hydatids of the Uterus, is of a very different nature, and consists merely of a diseased state of the membranes of the ovum, originating in a morbid persistance and developement of the villi of the early chorion. It is unnecessary to dwell, in this work, upon the treatment required for the expulsion and extraction of foreign solid bodies from the uterus; and in regard to hydrometra and other liquid collections within the cavity of the organ, we shall merely observe, that occasionally they each require to be evacuated by an artificial opening into the uterus, in order to avert the danger that would other- wise arise from their accumulating to such an extent, as to escape through the perforated or ruptured walls of the viscus into the cavity of the peritoneum. INFLAMMATION OF THE OVARY, OR OVARITIS. General observations.—Congestion and haemorrhage.—Anatomical characters and termination of inflammation of the ovary.—Symptoms and diagnosis.—Causes and treatment. The morbid states to which the ovaries are subject are very diversified in regard to their pathological nature, but in a practical point of view by far the most important are, 1, inflammation of the organ; and, 2, that complicated form of disease which is generally described under the common term of Ovarian Dropsy. We purpose in the first place to consider these two affections of the ovary in full detail, and afterwards to give a brief enumeration of the other organic diseases of a less frequent and less practical nature that invade this oro-an. The general remark as to the rarity of disease in the internal sexual organs of the female during the earlier years of life, holds particularly true with regard to the ovaries. Morbid lesions are very seldom indeed found" in them previous to the age of puberty. From the time, however, that the menstrual function is established, they are subjected to periodic congestions, to sudden changes in the state of the Graafian vesicles, to lacerations in their tissues, in consequence of the rupture of these vesicles, and to other morbific causes connected with derangements of the functions and consequences of menstruation, conception, and parturition, that, singly and conjointly, render the organs in question very common localities for diseased action in the female economy. Congestion and hemorrhage. The ovaries are the seat of a marked func tional congestion at each menstrual period, for some time after conception, and probably also under the excitement of sexual passion. This congestion fre- quently terminates in small effusions of blood into the structure of the organ, inflammation of the ovary (Symptoms). 341 and still more frequently into the Graafian vesicles. Many of the slighter morbid appearances which we so constantly meet with in the ovaries of the adult female, may be traced to these apoplectic effusions. A great portion of the lesions, known under the name of false corpora lutea, are no doubt attribu- table to this source ; and we have often had occasion to trace the small effused masses of blood through all their series of changes, from a recent red coagu- lum, till they assumed a brown, yellowish, and ultimately a straw-coloured and fibrinous appearance, or were at least more or less completely absorbed. The degree of serous effusion accompanying these apoplectic clots modifies their appearance considerably. We have seen a true corpus luteum very exactly imitated in two or three instances in which the blood was still party-coloured, and coated the internal surface of a morbid Graafian vesicle that happened to have its walls thickened, and at the same time partially contracted and puckered in consequence of absorption of some of the effusion. Inflammation. Inflammation of the ovary occurs both under the acute and chronic form. The acute variety is generally found in connexion with co- existing inflammatory action in the uterus, broad ligaments or peritoneum; more frequently chronic ovaritis is found in an isolated and idiopathic form. In the first stages of acute ovaritis, we find on dissection the organ reddened, injected, swollen, and generally softer than usual; serous effusion takes place early into the structure of the organ, and when mixed with purulent infiltration as sometimes occurs, the mass of the ovary will be found in a friable and almost disorganized state. Coagulable lymph, also, is in general early effused upon the serous surface of the organ in acute ovaritis, and in the more chronic forms of this disease, this effusion often leads to the formation of extensive adhesions to the neighbouring peritoneal surfaces, or to the thickening and induration of the capsule of the ovary itself, or of the lining membrane of one or more of the Graafian vesicles. When purulent effusion takes places, the pus, instead of being infiltrated into the tissue of the organ, is, particularly in some of the more chronic forms of the disease, collected into abscesses. These abscesses are generally small, and occasionally they are found to the number of three or four in the same organ. In other cases, however, one large abscess alone is formed, and distends the fibrous capsule of the organ to an excessive degree. The pus may again be- come absorbed, but much more frequently it leads to the ulceration and perfora- tion or rupture of the containing cyst, and, according to the locality of the perforation, and the occurrence or non-occurrence of previous adhesions, it may be discharged into the cavities of the intestinal canal, urinary bladder, Fallopian tube, uterus or vagina; or it may escape into the cellular tissue of the pelvic and iliac regions, and produce all the phenomena of an ileo-coccal abscess, as it may be evacuated into the cavity of the peritoneum itself. This last circumstance has repeatedly occurred in cases of acute gangrenous abscess of the ovary during the puerperal month, but it is rare under other forms of large abscesses in this region. We have, however, known it repeatedly to take place where the disease was chronic, and the purulent collection very small. The erisypelatous form (as it has been called) of peritonitis, has, within our own knowledge, been traced in repeated instances to the irritation produced by the bursting of such small ovarian abscesses. Symptoms and diagnosis. The presence of acute ovaritis is principally marked by a feeling of heat and deep-seated pain in the corresponding parts of the pelvic cavity. This local pain is generally increased, if the patient suddenly assume the erect posture, and when the rectum is distended in the act of defaeca- tion. It sometimes stretches down the corresponding limb or affects the loins; and it is always liable to become much more acute in its character provided the inflammatory action spreads to the peritoneum. The function of the bladder is very frequently deranged, and the dysuria may be considerable; more rarely we have tenesmus, combined with a sensation of bearing down in the pelvic 342 inflammation of the ovary (Treatment). region when the inflammation spreads over the recto-vaginal reflection of the peritoneum. After a time, when we press upon the lower part of the abdomen, we may detect a painful roundish tumefaction produced by the inflamed and swollen ovary ; but this can only occur when the organ is considerably enlarged. In the earlier stages of the disease the transverse diaphragm, formed across the pelvis, by the septum of the broad ligaments and uterus, prevents us from bein^ >" keep the circulation quiet for some time afterwards. Epistaxis is likewise met with as a passive haemorrhage; in this form it occurs most frequently in delicate children and young persons about the age of puberty, and sometimes to a most alarming extent: it also happens in persons of all ages, labouring under cachexia: it is an occasional symptom in fevers, particularly in those forms accompanied with typhoid phenomena, and in those diseases where it is known that the blood is greatly deteriorated, as in scorbutus and purpura. When epistaxis occurs as a passive haemorrhage, it is not usually preceded by any marked premonitory symptoms; the blood suddenly pours forth from the nostrils, in large quantities, without any assignable exciting cause; and in young children of delicate constitutions, in the upper classes of society, it may induce dangerous and almost fatal syncope before the haemorrhage can be arrested. When it occurs in the cachectic the flow of blood is seldom so rapid, but the oozing often continues for a longer time, sometimes for several days in succession. In either case we may remark an aggravation of constitutional depression, and an increased tendency to a repetition of this unfavourable symptom. The quantity of blood lost by this 380 hemorrhage from tiie nose (Treatment). form of epistaxis is generally considerable, often to the extent of many pounds; and cases are recorded, where the amount lost is hardly credible. Epistaxis sometimes appears as a vicarious haemorrhage, as, for example, upon the suppression of the catamenia or haemorrhoidal flux, and continues as long as either of them is suspended. Indeed, epistaxis is not often met with in the female, after the period of puberty, unless the menstrual discharge is scanty, or accidentally suppressed. Epistaxis, like other haemorrhages, maybe the consequence of a morbid con- dition of the bleeding part; thus, the Schneiderian membrane may be preter- naturally delicate, vascular and sensitive, so that very slight injuries, as the insertion of the finger into the nostril, blowing the nose, or sneezing, may rup- ture that membrane, and induce a considerable flow of blood. Inflammation of this membrane in common catarrh, or in that which accompanies some of the eruptive fevers, may give rise to epistaxis ; or the presence of polypi in the nos- trils, or disease of some of the bones of the nose, may excite undue vascularity of these parts, and give rise to epistaxis. Treatment. When bleeding from the nostrils occurs with those symptoms which indicate it to be a constitutional haemorrhage of either the active or pas- sive form, it must be treated on the principles which have already been pointed out, when constitutional haemorrhages were fully considered. In those cases, where it is thought advisable to restrain the flow of blood, an erect posture, the application of cold about the head, nose, and neck, with pres- sure on the bleeding surface, will be found the most effectual means of control- ling the haemorrhage. Pressure may be accomplished in two ways. Direct compression may be made bypassing a long piece of catgut, or other convenient flexible director, from the anterior aperture of the nostrils, whence the haemor- rhage issues, so far into the pharynx, that, by the aid of a pair of forceps, its extremity may be drawn into the mouth. To this director, a piece of cotton or lint is to be attached, of sufficient thickness to press against the walls of the nostrils, when it is retracted from the pharynx ; this being done, the director is to be separated from the lint or cotton, which is allowed to remain in the nostril, until further means shall have the effect of suppressing the haemorrhagic ten- dency. Such is the method generally recommended by surgical writers: but the irritation excited, when an attempt is made to put it in practice, and, when effected, the aversion expressed by patients to its endurance, are so great, that whatever the danger may be, they will rarely submit to it, or suffer its continu- ance for a sufficient length of time; and it must be acknowledged, that there is some hazard that its removal may prove a fresh cause of excitement. (Cyc. of Prac. Med. art. Epistaxis.) A great surgical authority (Mr. Abernethy) used to tell his pupils with his accustomed humour, that he knew that such a method could be adopted, for he had seen it done: but whenever he had tried to do it, he always failed, finding an obstacle in the excessive irritation produced in the muscles of the pharynx; but the same eminent surgeon has observed, that he had never seen an instance of epistaxis, which could not be suppressed (and he had seen a great many instances) by the introduction of a cylindrical plug of lint through the anterior nares, made sufficiently large to fill the tubular part of the nostril, being first wetted and wound round a probe, so as to give it the form of a bougie, long enough to allow it to be passed along the floor of the nose, from the anterior to the posterior aperture, but not into the throat, the probe being withdrawn when the lint has thus been disposed of. This plug should be allowed to remain in three or four days, while the proper means are taken to remove the causes of the haemorrhage. When this method of compression is very unpleasant to the patient, or when it cannot be effectually accomplished, some cooling and astringent fluid may be injected into the nostrils; either vinegar and water, the diluted solution of the acetate of lead, a weak solution of alum, sulphate of zinc or copper. Some- times a very finely levigated astringent powder blown into the nostrils through HEMORRHAGE FROM THE LUNGS (Definition). 381 a quill, or other small tube, will cause the blood to coagulate, and thus arrest the haemorrhage. Powdered alum, powder of galls, and similar substances have been employed for this purpose; but unfortunately their presence some- times excites sneezing and considerable irritation of the Schneiderian membrane, thus displacing the coagulum, and the haemorrhage is renewed. An instance of the successful use of the powder of gum acacia blown into the nostril in a case of epistaxis, which had continued for two days, and had resisted the other means generally adopted, has been reported in the Medical Repository, vol. xxvii., extracted from Hufelands Journal. As this substance is not only free from the objection we have mentioned to astringent powders, but congenial to the sensibility of the Schneiderian membrane, and probably produces its good effects simply by increasing the tenacity and the adhesive quality of the blood on its issue from the bleeding surface, it may in some cases be an eligible application. The arrest of the haemorrhage may often be accelerated by resorting to the use of those remedies which act by revulsion; thus, hot stimulating pediluvia, mustard cataplasms to the calves of the legs or soles of the feet, or a powerful stimulating purgative, as a large dose of oil of turpentine, will be found useful. Purgatives, indeed, are most efficacious in controlling epistaxis, whether of the active or passive forms. The principles which are to guide the practitioner in his attempts to prevent the return of constitutional haemorrhages from the nostrils, have already been explained. In those cases of passive epistaxis occurring in delicate children and young persons of precocious intellect, great advantage will be derived from shaving the head, or keeping the hair cut close; from a residence at the seaside, and bathing in. the open sea; from cold shower baths, and cold bathing of the head and neck every morning; from gentle exercise in an open carriage, and from those various remedies which conduce to strengthen the constitution. When epistaxis is vicarious of menstruation, or of the haemorrhoidal flux, it is desirable to resort to those methods of restoring the natural or habitual dis- charges, which have already been recommended. When this form of haemorrhage frequently recurs, in consequence of the delicacy of the Schneiderian membrane, it is advisable to protect it by anoint- ing it daily with some simple ointment. If this membrane, or its subjacent bones be inflamed, the application of leeches externally about the nose, or at the entrance of the nostrils, will often prevent a recurrence of epistaxis. If a polypus, or other cause of irritation, exist within either nostril, exciting con- gestion and nasal haemorrhage, it should be removed by surgical operation without delay. HEMORRHAGE FROM THE LUNGS, OR HEMOPTYSIS. Definition.—General description.—Sources from which the blood may issue.—Pulmonary lesions induced by haemoptysis.—Pulmonary apoplexy.—Causes of haemoptysis.—Active constitutional haemoptysis—its symptoms and treatment.—Passive constitutional haemop- tysis and its treatment.—Vicarious haemoptysis and its treatment.—Haemoptysis induced by pulmonary diseases, symptoms and treatment—by cardiac diseases, symptoms and treatment.—Haemoptysis resulting from obstruction in the abdominal circulation. This word, derived from auxa, blood, and ifr\j(fig, spitting, strictly signifies the rejection of blood from the mouth, without reference to the source whence it may be derived, whether it pass upwards through the trachea and larynx, or through the oesophagus and pharynx, or be simply poured forth from the membrane of the mouth itself; but in the present day, pathologists are in the 382 HEMORRHAGE FROM THE LUNGS (Sources). habit of employing it, in a restricted sense, to signify the expectoration of blood from the lungs and air-tubes. It is then necessary to bear in mind, in every case where blood is rejected from the mouth, that its source may be either from the mucous membrane of the mouth itself, from the pharynx, from the stomach, from the larynx, trachea, and bronchial tubes, or from the vesicular structure of the lungs; but under the term Hemoptysis are comprised haemorrhages from the respiratory organs only. The respiratory organs are peculiarly predisposed to haemorrhage, which will not appear surprising, when it is recollected how extensive a surface the mucous membrane of the bronchial tubes offers for exhalation, and how abun- dantly the lungs are supplied with blood ; so that any cause which obstructs the free passage of the blood through the minuter branches of the pulmonary vessels, readily produces extreme congestion of the lungs, exhalation of blood, and untimely haemoptysis. Although the extravasation of blood, in any quantity within the bronchi or vesicles of the lungs, is almost sure to be succeeded by haemoptysis, still this symptom is by no means constantly present, when smaller quantities are extravasated into the minuter structure of the lungs ; as in that form of pulmonary haemorrhage, called pidmonary apoplexy. It would thus appear that haemoptysis is an insufficient term to designate every form of haemorrhage from the respiratory tubes; but as it is consecrated by long usage, it has been thought better here to point out this objection to its uni- versal application to haemorrhages from the air-tubes, rather than introduce any new word of doubtful acceptation. Although no period of life can be regarded as exempt from haemorrhage from the respiratory organs, still it is certain that haemoptysis occurs most frequently in the interval between the ages of fifteen and thirty-five—the period when tubercular phthisis manifests itself, and active congestion of the lungs giving rise to exhalations of blood may be expected. But the aged and the infant are by no means exempt from pulmonary haemorrhage. When it occurs in the former, it is most commonly connected with disease of the heart; and M. Bil- lard has pointed out the existence of pulmonary apoplexy in infants only a few days old. We have also, upon two or three occasions, detected the existence of this form of pulmonary haemorrhage in the bodies of infants at the Hopital des Enfans trouves at Paris. It is also probable that pulmonary haemorrhage may occur much oftener in children than pathologists suppose, as children invariably swallow the expectorated secretions. It has been stated that the blood in haemoptysis may arise from other sources than the respiratory organs. It is not uncommon to meet with individuals who, having observed streaks or spots of blood intermixed with their saliva, imagine that they have been attacked by haemoptysis. It is generally easy to discover whether or not the blood comes from the mouth itself, by an attentive examina- tion of the different parts of that cavity; besides, the blood is generally scanty in quantity, of a scarlet colour, quite fluid, and unmixed with air, which may generally be observed in that which comes from the respiratory tubes. The escape of blood from the posterior opening of the nostrils into the pharynx, and afterwards into the mouth, may be distinguished from that which passes upwards from the lungs. When the haemorrhage is abundant, blood is sure to escape also from the anterior opening of the nostrils, and thus there is little doubt as to its origin ; when the quantity is small, and flows backwards only, after rest- ing some time on the velum palati, it is rejected from the mouth dark, coagulated, and unmixed with air; besides, shortly before or after this kind of spitting of blood, the mucus which comes from the nostrils will be observed to be tinged. The blood, which is rejected by haemoptysis, varies much in quantity in its phy- sical characters, and in the length of time it may continue to flow. The quantity of blood lost by haemoptysis is sometimes so great, amounting in some instances to several pints, that it is surprising a fatal result is not im- HEMORRHAGE FROM THE LUNGS (Sources). 383 mediately produced : nevertheless, cases occur where similar quantities are lost several times, and it fs not until long afterwards that incurable disorganization of the lungs manifest itself; and indeed, in some rare cases, the individual after the cessation of the haemoptysis continues in the enjoyment of good health. (Andral, Clin. Med., vol. ii., p. 179.) At other times the quantity is less con- siderable ; the person expectorates a mouthful every now and then, after which haemorrhage entirely disappears : it is, however, to be regarded with alarm, as an index of deep-seated and incurable mischief in the lungs. Lastly, the ex- pectorated mucus may be merely tinged, or streaks of blood may be seen mixed with it; in either case, serious lesions of the heart or lungs may be suspected. From the foregoing observations it is clear, that the quantity of blood lost by haemoptysis is no index of the extent of thoracic disease, nor of the degree of danger in any particular case. It is desirable that the physical characters of expectorated blood should be known, as this knowledge sometimes assists the practitioner in forming a diagnosis, whence the blood has been poured forth. If the quantity be very large, it is generally of a bright scarlet colour, mostly fluid, although some coagula are generally observed mixed with it, and the upper surface of the ejected blood received into a basin appears frothy. When the blood is brought up in smaller quantities, as a mouthful at a time, it is gene- rally of a bright colour, partly fluid and partly coagulated, but mixed with few or no bubbles of air : when the quantity of pure blood is still less, and is expec- torated by coughing, it is generally coagulated, rather dark, and moulded into the form of the bronchial tubes. When the haemoptysis consists in the expec- toration of mucus more or less intimately imbued with blood, it is generally of a very florid red, minute air bubbles are disseminated through it, and the secre- tion is viscid. In such cases we may predict that the blood is exhaled from the minuter ramifications of the bronchi, or from the air vesicles themselves. The appearances of the expectorated blood will however vary, depending a good deal upon the length of time it has remained in the bronchi before it has been expectorated, and still more upon the time which has elapsed from the actual haemoptysis, and the period when the blood is presented for inspection. It is evident, therefore, that much caution is requisite in judging upon the physical characters of the blood, although in some cases they may render great assist- ance in forming the diagnosis of the source of the haemorrhage. The duration of an attack of haemoptysis is also liable to considerable varia- tion : some individuals are suddenly seized with a profuse discharge of blood, which gradually subsides and entirely disappears in the course of twelve or twenty-four hours. Others expectorate a smaller quantity of blood every morn- ing for several days successively; the haemoptysis subsides and recurs in a similar manner after some weeks or months. Where the quantity expectorated daily is small, or where the haemoptysis consists in the expectoration of blood intimately blended with mucus, the attack may last for one or two weeks, then cease, and again recur in a similar manner. The cessation may be the result of the treatment adopted, and the recurrence may be traced to some imprudence on the part of the patient; but the greater number of individuals who are at- tacked with haemoptysis, have a recurrence of it. It is very rare that in a first attack, however alarming, the haemorrhage proves fatal; when death follows such an accident, it may be, as in the case of any other haemorrhage, from exhaustion by syncope, or the quantity of blood poured forth may so obstruct the bronchial tubes as to produce asphyxia. The sources from which the blood may issue in haemoptysis (according to the definition of the term we have given), appear to be the three following:—1. The larynx and trachea; 2. The bronchial tubes ; 3. The vesicular structure of the lungs. Haemoptysis, arising from laryngeal or tracheal haemorrhage, is of very rare occurrence; when it does happen, the blood may escape by exhalation from the lining membrane as in other parts, or from the mucous membrane, in conse- 384 HEMORRHAGE FROM THE LUNGS (Sources). quence of ulceration exposing some subjacent vessel, or from the rupture of an aneurismal sac into the larynx or trachea. Chomel, one.of the most able writers on haemorrhage, has stated that laryngeal and tracheal haemoptysis have been admitted rather from analogy, than established by any precise obser- vations. " It has been thought," he adds, " that in those cases where patients have rejected a few frothy bloody sputa, preceded by tickling and heat in the larynx or trachea, and without dyspnoea, or other distressing sensations within the chest, it was rational to suppose the haemorrhage took place from these parts of the respiratory organs; and it has been also thought, that if after such an haemoptysis no symptoms of phthisis have supervened, this circumstance tended to confirm the opinion that the blood was not exhaled from the bronchial tubes. We can only admit this variety with doubt and reservation." (Diet. de. Med. art. Hemoptysis.) If a scanty exhalation of blood do sometimes take place from the larynx and trachea, it will be in those persons whose professions require a violent and prolonged exercise of the vocal organs ; such as singers, actors, and public speakers. That haemoptysis may sometimes, however, take place in consequence of ulceration in these parts, there is no doubt; an interest- ing example has been published by Dr. Watson. (Med. Gaz. vol. iii., p. 156.) Haemoptysis may also arise from the rupture of an aneurismal sac into the larynx or trachea ; in such cases, previous to the occurrence of the haemoptysis, unequivocal signs of this lesion, and all the distressing symptoms of continued pressure on the larynx or trachea, are observed. It appears needless to advert further to this source of haemoptysis, because the haemorrhage is so sudden and copious, that death almost immediately follows. The bronchial tubes are by far the most frequent source of haemoptysis, and the mode in which the blood escapes is by exhalation. Formerly, when it was generally believed that haemoptysis only arose from a ruptured blood-vessel in the lungs, cases of recovery from haemoptysis must have excited great surprise; but repeated observations have recently shown, that in many individuals who have died from profuse haemoptysis, there is no physical lesion in the lungs beyond the presence of tubercles in different stages of developement. The mucous membrane in these cases presents no other appearances than are observed in simple bronchitis ; indeed, sometimes the bronchial membrane is found pale or only slightly stained. Andral has recorded a case of fatal hae- moptysis, where the parenchyma of the lungs was perfectly healthy, where no tubercles were present, and where a simple exhalation of blood from the bron- chial mucous membrane appeared to be the sole cause of death. When blood is thus poured out into the bronchial tubes, it gives rise to many distressing symptoms:—Aggravated dyspnoea, a sense of a fluid bubbling or gurgling in the chest, which excites cough, and thus accomplishes the expulsion of the blood from the bronchi. When the blood is poured forth rapidly and abundantly into the bronchial tubes, it necessarily causes great obstruction to respiration. The person suffers great distress and a sense of impending suffo- cation ; all the auxiliary muscles of expiration are called into action; they contract spasmodically; the lungs are forcibly compressed in every direction; and the blood is expelled from the bronchi into the trachea, larynx, pharynx, and mouth, whence, as well as from the nostrils, it escapes in jets. The irrita- tion of the blood in the pharynx excites nausea and vomiting; so that upon examination the rejected blood is found mixed with the contents of the stomach, and thus often arises some difficulty in forming a diagnosis between haemoptysis and haematemesis: this difficulty, however, is considerably lessened by the physical signs of disorganization of the lungs being readily detected by auscul- tation. Other distinguishing signs will be enumerated when the subject of haematemesis is considered. When blood is exhaled into the bronchi in smaller quantity, it often excites but little irritation, and escapes readily through the larynx into the mouth, hardly producing cough. When, however, the extravasated blood is more or less HEMORRHAGE FROM THE LUNGS (Sources). 385 intimately blended with mucus, it generally produces more irritation, and is often expectorated by coughing with considerable effort. When the extravasation of blood takes place from the smaller bronchial tubes, it sometimes happens that the blood stagnates and coagulates in them; and the consequence is, that some of the lobules of the lungs have a dark brown or black colour. Andral states his belief, that this is the most common origin of that peculiar lesion of the lungs, which has been designated pulmonary apoplexy by Laennec. In such cases there are found at various parts of the lungs several hard dark masses, more or less exactly circumscribed. They are found almost exclusively, he thinks, in individuals who have died during haemoptysis; nevertheless, he found similar lesions in the lungs of those who have never had haemoptysis. He is far from regarding the situation of these apoplectic effusions as the only parts whence the haemorrhage has taken place: they are but acci- dental lesions, which depend upon the stagnation and coagulation of the effused blood in some of the smaller bronchial tubes, the haemorrhage which gives rise to the haemoptysis taking its origin from a much more extended surface of the mucous membrane. (Anat. Path., vol. hi., p. 488). This view of the mode in which these collections of blood are formed in some few lobules of the lungs, is very similar to that adopted by Dr. Watson, who thinks it probable that the seat of the effusion is (sometimes at least) in the larger branches of the air-tubes, and that the blood is forced into certain of the pulmonary lobules by the con- vulsive efforts to respire; and that they thus become so completely crammed with blood, as to preclude any subsequent admission of air, and to present the appearances of pulmonary apoplexy. (Med. Gaz., vol. ix., p. 656.) The observations of Andral, and the interesting cases of haemorrhage from an ulcerated lingual artery, recorded by Dr. Watson, prove that, when the blood is effused into the bronchial tubes, it may gravitate and coagulate in the vesicular structure, giving rise to those hard dark masses which are commonly described as pulmonary apoplexy. But the writer has, for many years, directed his atten- tion to this pathological condition of the lungs; and although his field of obser- vation has been extensive, still he has never been able to meet with a case of pulmonary apoplexy, where he could satisfy himself that this particular lesion was produced in the manner described by Dr. Watson. In the numerous cases of pulmonary apoplexy which have fallen under his observation, the blood has appeared to have been extravasated where it is found coagulated; and so far from the majority of such individuals having died from haemoptysis, as remarked by Andral, many have not had that symptom at all, or only in a very slight degree. Another but rare form of bronchial haemorrhage arises from the ulceration, of the mucous membrane and perforation of the coats of some subjacent pulmonary blood-vessel. Dr. Carswell has recorded and delineated a case of this kind, where scrofulous ulceration made its way through a large bronchus, and per- forated a contiguous branch of the pulmonary artery. Through this direct com- munication the blood escaped so abundantly, that the case proved fatal in less than a quarter of an hour. The sac of an aneurism of the thoracic aorta will sometimes compress and cause the absorption of the walls of a bronchial tube; at length the blood bursts into the bronchus, and the profuse haemoptysis proves rapidly fatal. The source of the haemorrhage in haemoptysis may be the vesicular structure of the lungs. A sanguineous exhalation into the pulmonary parenchyma is much more frequent than is generally supposed; and, no doubt, many persons die with this lesion of the lungs without its having been suspected, because it is not always accompanied by haemoptysis. This kind of pulmonary haemorrhage has not been so long known to pathologists as the former: it was first accurately described by Laennec, under the name of Pulmonary Apoplexy. The extrava- sated blood is found coagulated, blocking up the vesicular structure of a certain number of lobules of the lungs: these masses are hard, dark, and generally vol. in. 49 386 HEMORRHAGE FROM THE LUNGS (CaUSCS). circumscribed: their section presents a dark granular surface, almost like a piece of damson cheese: upon scraping the surface the blood is removed, and the parenchyma of the lungs becomes very visible; sometimes the surrounding tissue is unaffected ; at other times fluid blood is found in the adjoining smaller ramifications of the bronchi. Sometimes the extravasated blood is not confined to the smaller bronchi and the air-cells of certain lobules ; but these latter are ruptured ; the blood then escapes into the interlobular cellular tissue; the paren- chyma of the lung is broken down by the extravasated blood, which collects in clots in a cavity hollowed out of the substance of the lung. This, says Andral, is a true pulmonary apoplexy, very different from the former, where the blood is merely extravasated and coagulated in the bronchi and air-cells ; in this latter lesion the pulmonary tissue is actually lacerated by the effused blood, just as the medullary substance is in cerebral apoplexy. (Op. cit., vol. iii., p. 511.) The extravasation is sometimes so considerable, that the structure of one lobe or more of a lung may be almost obliterated and reduced to a sort of pulp, con- sisting of liquid and coagulated blood. The extravasated blood may not only lacerate the substance of the lung, but also the pleura, into the sac of which it escapes in considerable quantities. Andral has recorded an instance of this kind, where a phthisical patient was seized with aggravated dyspnoea, bloody sputa, with the physical signs of pleurisy of the left side. After death the lower lobe of the left lung was found lacerated by the extravasation of blood, which had made its way into the pleura, and excited pleurisy. (Clin. Med., vol. ii., p- 167.) When the pulmonary apoplexy is of small extent, it is not followed by immediate death: the individual may survive days and weeks. M. Bouillaud has recorded a case where a mass of pulmonary apoplexy was surrounded by a well organised cyst, of which the internal surface was probably destined to ac- complish the absorption of the extravasated blood. (Arch, de Med., Nov. 1826.) It would seem that, in this case, the same series of processes was about to be performed around this mass of extravasated blood, as pathologists have so often observed taking place after cerebral apoplexy. Causes. The causes of haemorrhage from the respiratory organs are some- times general and constitutional; in other cases purely local and physical. Constitutional haemoptysis is in some instances of an active, in others of a pas- sive nature; or it may be merely vicarious of other natural or habitual haemor- rhages. Haemoptysis from local causes sometimes arises from physical lesions of the substance of the lungs themselves, or is connected with diseases of other important organs, especially of the heart, and occasionally of the larger ab- dominal viscera. Haemoptysis, appearing as an active constitutional haemorrhage, independent of any discoverable alteration of texture, either in the mucous membrane of the bronchial tubes, or in any other part capable of influencing the capillary cir- culation of that membrane, is certainly of very rare occurrence. Those who have paid most attention to this subject have met with but few instances of it. It would seem that, whenever the constitution is in a state favourable to haemor- rhage, an effort is made to get rid of the superabundant circulating fluid through some other medium, as the nostrils, the stomach, intestines, or uterus. Al- though the presence of effused blood of the bronchial tubes is productive of alarming symptoms, and is so often followed by fatal results, nevertheless in those cases of vicarious menstruation through the lungs, the effused blood is expectorated again and again without permanent injury of their parenchyma. Chomel states, that a good many persons are to be met with who have had one or two attacks of haemoptysis in the course of their lives, but who have notwithstanding reached an advanced age. (Diet, de Med. art. Hemoptysis.) Andral also admits the occasional occurrence of constitutional haemoptysis, and states that, in some individuals, it is not accompanied by more serious symptoms than a simple epistaxis. (Clin. Med., vol. ii. p. 178.) Though the existence of haemoptysis as an active constitutional haemorrhage is established by recorded hemorrhage from THE LUNG.s (Treatment). 3S7 Cases, we are still disposed to think that, in the greater number of supposed instances of spontaneous constitutional haemoptysis, there exists a latent physical lesion, which will sooner or later manifest itself by more certain symptoms. When this form of haemoptysis does occur, the constitution of the individuals corresponds with the description given of those predisposed to active haemor- rhages, while the general symptoms do not materially differ from those ob- served in similar haemorrhages from other parts. Those local symptoms which have been enumerated as preceding active haemorrhages, will be observed in reference to the lungs. A sensation of dyspnoea, constriction across the chest, more or less pain, or sense of heat beneath the sternum, or irritation in the trachea or bronchial tubes, generally precede the expectoration of florid blood. The presence of the extravasated blood in the bronchial tubes produces an aggravation of dyspnoea, exciting frequent cough, a sense of gurgling or ebulli- tion, being, at the same time, felt in the chest, resulting from the passage of the inspired and expired air through the fluid blood in the bronchi. Auscultation generally detects the existence of that peculiar sound, technically called large crepitation, in various parts of the chest. These local symptoms continue until all the extravasated blood is expectorated. When haemoptysis occurs as an active haemorrhage, the further exhalation of blood is arrested, both by the effect of actual loss of blood on the heart's action, and also by the shock to the nervous system, from the alarm of the patient upon viewing the gush of blood from the mouth, the haemoptysis thus relieving the peculiar state of constitution on which it depends. Treatment. As we have endeavoured to show that haemoptysis is to be re- garded as a symptom of different pathological condition of the whole system, or of particular parts, it is evident that it requires great modifications in its treatment. On this account it will be preferable to point out the treatment applicable to each form of haemoptysis after describing its history. Although every active haemorrhage may, to a certain extent, be regarded as a salutary effort of nature, and as tending to promote its own cure, still the extravasation of blood into the bronchial tubes is accompanied with such urgent symptoms, that the practitioner, upon its first appearance, is naturally most anxious to arrest further haemorrhage. The plan of treatment, already recommended for active haemorrhages in general, may be adopted in cases of haemoptysis of an active character. After the haemorrhage is arrested, too much caution cannot be adopted in exercising the organs of respiration ; and it may be necessary to repress the tendency to plethora by repeated bloodlettings. For a considerable period after the cessation of the haemorrhage, the greatest care is necessary on the part of the patient. Passive constitutional haemoptysis is of more rare occurrence than the active form, and is only met with as a symptom in purpura, scorbutus, and perhaps some petechial fevers. The treatment principally consists in that adapted to the disease of which the hemoptysis is an accidental symptom. It is in this kind of passive haemorrhage that bloodletting is sometimes desirable, as the loss of blood by venesection is a much less serious evil than its exhalation into the parenchyma of the lungs; neither is it inconsistent with sound patho- logy to administer tonics and nutritious diet at the same time that we employ moderate depletion; for, while we attempt to improve the supposed deteriorated quality of the blood, we also diminish the quantity of the circulating fluid, and thus repress the tendency to its escape from the vessels. Haemoptysis not unfrequently appears as a vicarious secretion, supplying the place of some suppressed periodical or habitual discharge. Thus in females, particularly among the lower classes, in whom disordered uterine functions are often long neglected, upon the suppression of the catamenia from cold or other cause, an occasional, and sometimes a periodical, haemoptysis is observed. Perhaps, after the physical lesions of the lungs and heart, this is the most 388 hemorrhage from the lungs (Treatment). common cause of haemoptysis. In some cases of vicarious haemoptysis, we find it anticipating the usual menstrual period, and ceasing when the natu- ral flux is established. In other cases the haemoptysis altogether super- sedes the catamenia for a great length of time, and establishing itself into a function almost necessary to the health of the individual. More commonly, however, the periodical haemoptysis is supplemental of deficient or arrested menstruation. In these cases the individual suffers all the usual symptoms of constitutional disturbance preceding natural menstruation, when, after a few days, instead of the catamenia, pulmonary haemorrhage makes its appearance, by which a degree of uneasiness in the chest is relieved. This state of things may continue for several years with much less detriment to the lungs and to the general health than might be anticipated. The treatment of this form of haemoptysis consists in the employment of those means which will strengthen the general health, and solicit the return of the menstrual discharge. They consist principally in the occasional application of a few leeches about the vulva or anus ; the employment of pediluvia; the hip-bath, and the internal administration of emmenagogues. When haemoptysis occurs as supplemental of an habitual haemorrhoidal discharge, its consequences are much more pre- judicial, than haemoptysis vicarious of menstruation. Laennec supposed that the former was more likely to be productive of pulmonary apoplexy, while the latter was generally a simple bronchial haemorrhage. This form of haemo- ptysis is certainly a rare disorder, for out of 20,000 patients which have come under our observation, during the last four years, we have only met with one instance of it. This individual has long suffered from haemorrhoids, and upon their suppression, he was attacked with haemoptysis, which entirely disappeared on the return of the habitual discharge. In such cases the tendency to further haemoptysis should be repressed by those means which have been recommended in the treatment of active constitutional haemorrhages, and then every effort made to encourage a return of the haemorrhoidal discharge. Occasional local depletion about the anus should be adopted, to supply the want of the accustomed discharge. Haemoptysis arising from local and physical causes may be symptomatic, or the result of pathological conditions of the lungs themselves, and which may be comprised under the two following heads:—1. The existence of tubercles in the lungs ; 2. Inflammation of the bronchial tubes, or the parenchyma of the lungs. Unquestionably the physical lesion with which haemoptysis is most frequently associated, is the developement of tubercles in the lungs. This fact is admitted by the best pathologists of the present day ; but they are not all agreed in re- garding the tubercles as the cause of the haemoptysis; on the contrary, some have supposed, that in certain cases the haemorrhage from the lungs has been the cause of the appearance of the tubercles. Andral has been cited as support- ing this view of the question; but it seems to us that this author's opinion has been misunderstood. Although he relates a case, where it appeared to him that the tubercles were altogether dependent on the extravasation of blood, still he informs us, that of persons who die of phthisis, one-half do not expectorate blood until the tubercles have given unequivocal proofs of their existence; and that another sixth never spit blood at all, throughout the whole course of the disease, while in one-third only does the haemoptysis precede and appear to be the start- ing point of the developement of the tubercles. (Clin. Med., vol. ii., p. 181.) Andral thus establishes, by the results of his own clinical observations, the very opposite opinion to that assigned to him by Dr. Law. (Cyc. Pract. Med. art. Hemoptysis.) Laennec is of opinion, that the formation of tubercles precedes the haemoptysis; and though this may be the first symptom of disease which alarms the patient, and induces him to seek medical assistance, yet if the chest be examined before its appearance, the physical signs of the existence of tuber- cles in the lungs will be delected. hemorrhage from the lungs ( Tubercular Ulceration). 389 Andral considers that these affections are so constantly associated together, that of all those persons who at some period of their lives have had haemoptysis, only one-fifth are exempt from the developement of tubercles in the lungs. The opinion of Louis on this point is still more strong. He states, that for the space of three years he inquired of every patient who came before him, whether they had ever suffered from haemoptysis, and he found that none but phthisical pa- tients replied in the affirmative, excepting a few who had suffered from violence to the thoracic organs, or women labouring under amenorrhcea. He therefore thinks, that at whatever period haemoptysis may occur (with the exception of the above mentioned cases), it renders the existence of tubercles in the lungs highly probable. In only one-fifth of the cases of Louis, the haemoptysis pre- ceded the cough and expectoration, so that the exhalation of the blood is rather to be regarded as the result than the cause of the tubercular infiltration. (Sur la Phthisie, p. 193, 204.) We may, perhaps, ascribe the frequency of haemo- ptysis, in the early stage of phthisis, to the obstruction of the pulmonary circula- tion, caused by the extensive developement of tubercles in the parenchyma of the lungs. This obstruction may give rise to the haemorrhage in two ways; it may either compel an increased energy of the right ventricle, whereby the blood is thrown with undue force into the pulmonary vessels, and thus induce haemorrhage, or, the tubercles obliterating a considerable portion of the pulmo- nary parenchyma, there is no longer a just proportion between the quantity of blood circulating through the lungs and the capillaries of those organs, and thus a relative plethora is induced, and escape of blood in the bronchial tubes is the consequence. This accident is much more likely to occur, when the develope- ment of tubercles has been very rapid, and there has not been time for the heart to undergo that atrophy, so common in phthisis, nor for the quantity of the blood to have been reduced to the altered state of the system. The next source of the blood in haemoptysis is tubercular ulceration of the lungs. Those who are familiar with the disorganizing process in the lungs which ensues when tubercles soften, would .reasonably expect that erosion of large vessels, and consequent haemoptysis, would occur. Again, those who, having opened the bodies of persons dying with haemoptysis, have found the tubercular cavities, as well as the bronchi leading to them, full of blood, might anticipate that the blood had escaped from some eroded blood-vessel; but the careful investigations of Laennec, Andral, and others, into the pathology of phthisis, have demonstrated the interesting fact, that the blood-vessels of the lungs generally escape the destructive process : that they become pressed against the walls of the vomica, and are gradually obliterated. Laennec states, that he never found a vessel of any consequence, included within the substance of these bands, traversing a vomica ; and that Bayle had mentioned only one case in which fatal haemoptysis ensued upon the rupture of a vessel that extended across a very large cavity. Andral states, that he never but once found the orifice of a ruptured vessel in fatal haemoptysis, and that this vessel was con- tained in a band stretching across a cavity which had been ruptured. The orifice of the torn vessel was plugged up by a small pale coagulum, which was easily removed, and left the extremity of the vessel quite free and open. In every other instance of fatal haemoptysis, Andral was unable to discover that the haemorrhage was the consequence of a ruptured vessel. In the course of twelve years' nearly constant attendance in the medical wards of St. Bartholo- mew's Hospital, we have only once met with a case of haemoptysis, where the open orifice of an ulcerated blood-vessel in a vomica was discovered in the lungs after death. Instead of pure blood in a vomica, there is often only some puri- form fluid, more or less stained with blood. In both cases the effused blood is evidently in the great majority of cases the result of exhalation from the bronchi and the walls of the vomica, and not from a ruptured vessel. Since haemoptysis is so frequently a symptom of the developement of tubercles in the lungs, it is necessary that the diagnosis between it and that which we have called 390 hemorrhage from the lungs ( Treatment). active constitutional hremoptysis should, if possible, be established. In that form of constitutional haemoptysis, which arises from general plethora, and that which attends upon the early stages of the developement of tubercles, the local and general physiological phenomena are so similar, that the diagnosis between .them cannot be established upon such data. But the physical signs, elicited by auscultation and percussion, will generally distinguish those cases which depend upon the presence of tubercles in the lungs. It has been stated by Louis, that phthisical haemoptysis is seldom preceded by heat, pain in the chest, or other symptoms of fever more striking than those present for some days previously. (Op. cit. p. 204). This assertion, however, is not corroborated by the observa- tions of other inquirers ; and ever since these remarks of Louis have come under our notice, we have inquired of many persons suffering from haemoptysis, for the first, second, or third times, whether they have been sensible of any uneasy sensations previous to its appearance, and they have invariably replied in the affirmative. The only exceptions met with have been in robust men en- gaged in laborious occupations, who, it is well known, do not attend to those minor indications of approaching disease, which alarm persons in tho higher classes of society. When haemoptysis occurs at the more advanced stages of phthisis, the local and general physiological symptoms, as well as the physical signs of tubercles, which have existed for a longer or shorter time, render the diagnosis comparatively easy. The practitioner called to a case of haemoptysis for the first time, might mistake the large crepitation from blood in the bronchi for that arising from softened tubercles. The treatment of haemoptysis, occurring as an early symptom of the deve- lopement of tubercles, will not essentially differ from that recommended when it results from general plethora : we must employ general bleeding until an im- pression is made upon the activity of the circulation, and the pulmonary haemor- rhage is arrested. Laennec has very justly remarked, that bleeding in such cases will not prevent the developement of tubercles, nor remove them when already formed in the lungs ; the abstraction of blood, therefore must be limited to the quantity sufficient to relieve the congestion of the vessels. Any loss of blood beyond this is a serious diminution of the patient's strength, and is more likely to accelerate the progress of phthisis. Abstraction of blood by vene- section in these cases of haemoptysis may generally be followed by local deple- tion near that portion of the lungs, which we suspect to be the seat of tubercles. The local symptoms of distress about the chest will greatly subside after the application of a few leeches or the cupping glasses. The circulation should then be kept as tranquil as possible by perfect rest of body and mind, the reclined posture, a cool temperature, and abstinence from all stimulating food or drink. To avoid the necessity of further abstraction of blood, such remedies as digitalis, tartarized antimony, nitre, and saline purga- tives may be prescribed. When haemoptysis depends upon the presence of tubercles it is very seldom, even with the utmost care, that a recurrence can be prevented. The return may be procrastinated by judicious treatment, but at length some accident causes congestion of the pulmonary circulation, and a second attack of haemoptysis ensues. The case now generally resolves itself into one of phthisis, and the treatment must be conducted with reference to that disease, and not simply to the accidental symptom of haemoptysis. The slighter forms of haemoptysis, which occur at the more advanced stages of phthisis, seldom require bloodletting; we must endeavour to repress it by acetate of lead, mineral acids, opium, digitalis, nitre, and counter-irritation. Haemoptysis may be the result of inflammation of the mucous membrane of the bronchi or the vesicular structure of the lungs. When the haemorrhage takes place at an early stage of the inflammation, it is sometimes considerable; but when it comes on at a more advanced stage, the quantity of blood effused is trifling, and generally mixed with expectoration. The appearance of mucus, streaked or stained with blood, is an index of the severity of the inflammation, hemorrhage from the lungs (Symptoms—Treatment). 391 and this kind of rusty expectoration is almost pathognomonic of pneumonia. The treatment of haemoptysis, resulting from these pathological states of the lungs, merges altogether into that which is necessary to control the inflamma- tion. It is but an accidental symptom arising from the inflammatory conges- tion, and disappears when that is relieved. The next form of haemoptysis is of a most serious description, and is an in- stance of what has been termed sympathetic haemorrhage resulting from phy- sical lesions in other important organs. It may be safely asserted, that next to the existence of tubercles in the lungs, the most frequent cause of pulmonary haemorrhage and haemoptysis is to be found in structural diseases of the heart. Chomel states that in these cases of haemoptysis the disease is commonly situ- ated in the right chambers of the heart. (Diet, de Med. art. Hemoptysie.) This opinion was also maintained by Dr. Law. (Cyc. Pract. Med. art. He- moptysis.) But we entirely coincide with Dr. Watson, who thinks these opinions " are not borne out either by reason or general experience." The alteration in the structure of the right cavities of the heart, which these authors have asserted to be the cause of pulmonary congestion, pulmonary apoplexy, and consequent haemoptysis, is hypertrophy of the right ventricle,—a morbid condition which is comparatively rare on that side of the heart, and which, we believe, would not suffice for the production of haemoptysis, even if it did exist. At least the most striking cases of hypertrophy of the right ventricle we have met with, have been in cases of extensive emphysema, and where there never had been any haemoptysis. The immediate effect of any obstruction to the free flow of blood, through the right side of the heart, would be to gorge the liver and the branches of the vena porta, and to prevent the lungs receiving their due proportion ; whereas any physical alteration of the left side of the heart may impede the return of blood from the lungs, cause accumulation there in the form of congestion of the capillaries, and so dispose to pulmonary haemorrhage. Upon this point of pathology Dr. Watson has made some judicious remarks which are worthy of attentive consideration. (Med. Gaz., vol. ix. p. 156.) Numerous cases corroborating the views of Dr. Watson may be found re- corded in medical journals. Dr. J. A. Wilson was one of the first to point out the connexion between the contraction of the mitral orifice and that pulmonary haemorrhage which produces pulmonary apoplexy and haemoptysis. There is, however, another and Jess common morbid condition of the left side of the heart, which may be the cause of pulmonary haemorrhage, and that peculiar lesion termed apoplexy of the lungs; it is a dilated state of the left auriculo-ventricular opening. We have twice lately met with patients, who were suffering under haemoptysis, with the physical signs of extensive pulmo- nary apoplexy and obstruction of the circulation through the left side of the heart, and in whom during life we had suspected the existence of extreme con- traction of the mitral orifice, but, upon examination of the body after death, there was fouqd extreme dilatation of that orifice; so that it was permanently patulous, and permitted the reflux of blood upon the lungs upon each contrac- tion of an enlarged and hypertrophied left ventricle. We must therefore admit, that any lesion of the left side of the heart, which is capable of obstructing the circulation through it, may be the cause of pulmonary haemorrhage. The symptoms which accompany pulmonary haemorrhage, depending upon disease of the heart, are of course combined of those which indicate disordered functions of both those important organs. There is most distressing dyspnoea, constant hacking cough, with expectoration of a more or less abundant tena- cious mucus, deeply dyed or intimately blended with blood. It is seldom that the quantity of blood is so considerable as in phthisical haemoptysis. Ausculta- tion and percussion reveal the presence of fluid blood in the smaller bronchi of some portions of the lungs ; while other portions seem to be rendered quite im- pervious to the air. At the same time there are unequivocal signs, both phy- sical and physiological, of structural lesions of the left side of the heart, which 392 hemorrhage from the lungs. usually have existed for a considerable length of time. It is obvious, that the treatment of this form of haemoptysis can never be successfully pursued by the internal use of those remedies which are supposed to possess the specific pro- perty of arresting haemorrhage. As long as the obstruction to the circulation through the left side of the heart is sufficiently great to produce remora of the blood in the lungs, so long will the pulmonary haemorrhage continue. The treatment must therefore consist, in the first place, in relieving the oppressive congestion of the capillaries of the lungs, by local depletion, by the application of cupping glasses near to that spot where we suspect the pulmonary apoplexy is forming ; secondly, a return of this condition of the lungs may be obviated, by diminishing the quantity of blood by the occasional application of a few leeches over the region of the heart, and by the administration of saline pur- gatives and diuretics, particularly nitre, digitalis, bitartrate of potash. By such means, if the extravasation of blood into the lungs be not already considerable, the haemoptysis may be arrested, and the individual rescued for a time from the destructive effects of the effused blood on the parenchyma of the lung. The last form of haemoptysis to which we shall direct attention, is another instance of what has been termed sympathetic haemorrhage, viz., that which arises from obstruction of the circulation through the abdominal aorta and its branches, in consequence of distension and pressure caused by enlargement of some of the abdominal viscera. In the advanced stage of pregnancy the great distension is sometimes attended with haemoptysis. The same accident may happen from pressure on the abdominal vessels in ascites or tympanitis. In all such cases, if the disease on which the distension of the abdomen depends can- not be removed, the treatment must consist in diminishing the quantity of the circulating fluid and keeping the action of the heart as tranquil as possible. CONNEXION OF HEMORRHAGE OF THE LUNGS WITH TUBERCLES. The connexion of haemoptysis with tubercles in the lungs appears in three different ways: 1st, haemoptysis takes place in individuals disposed to consumption, in whom no tubercles are yet formed; 2d, in those actually labouring under the disease, but offering tubercles in the crude state only, varying in amount from a few scattered granulations to large masses of tuberculous matter ; 3d, after cavities are formed. In the latter case, haemorrhage may take place from simple ulceration of the bands containing vessels which pass from one side of the cavity to the other; and the haemoptysis is then very profuse, and usually soon fatal. When haemoptysis occurs before tubercles are formed, the attack may depend altogether upon constitutional causes; and although the blood is discharged from the lungs, these organs are not always actually at fault, and there is no other connexion between consumption and haemoptysis except that there is one condition of vessels which disposes to both disorders. But as this condition does not necessarily give rise to consumption, although it predisposes to it, haemoptysis may occur without the developement of tubercles in one individual, while in another, who is placed under similar circumstances, decided phthisis may follow. In some of these cases, the mere raptus of blood towards the lungs is the exciting cause of the tuber- culous developement, as may be demonstrated by pathological observation. In those cases in which phthisis does not follow, the haemorrhage is generally slight, or its mischievous effects are obviated by treatment, or favourable hygienic circumstances. In our examination of the cases in which phthisis does not follow pulmonary haemorrhage, we omit those in which the bleeding is produced by violent efforts, blows upon the chest, or disease of the heart. In some cases, however, of haemoptysis following sudden muscular efforts, phthisis supervenes very quickly; in many of these caBcs the patients are evidently hemorrhage from the stomach (Symptoms). 393 predisposed to the disease; in others the tuberculous deposit appears to depend upon the haemorrhagic congestion. When tubercles are formed in the lungs before the haemoptysis occurs, the spitting of blood arises from the combined influence of the local irritation and congestion caused by the tuber- cles, and of the general cause to which I have already alluded. It generally recurs several times if it has once taken place; although many patients pass through all the stages of the disease without haemorrhage. As the flow of blood relieves to a certain extent the local irri- tation, many symptoms, such as cough and uneasiness in the chest, are greatly diminished, and the patient is much more comfortable, unless the effused blood should prove to be a new cause of irritation. Haemorrhagic cases of consumption are therefore amongst the most favourable varieties of the disease, and frequently last through a long life, or end in perfect recovery. There are two classes of individuals, however, who may suffer from haemoptysis, without the least tendency to consumption; these are women in whom the spitting of blood is merely a vicarious discharge, intended to supply the suppressed menstrual secretion, and patients labouring under decided disease of the heart. In the latter of these cases the blood is dis- charged from the mucous membrane of the bronchi, or from the vesicular structure of the lungs, and relieves the congestion which arises from the difficulty in the return of the blood from the lungs to the heart. Neither of these cases is dependent upon actual disease of the lungs, or on the vascular condition which predisposes to tuberculous deposit. G. HEMORRHAGE FROM THE STOMACH, OR HAEMATEMESIS. Etymology.—Symptoms.—Diagnosis.—Prognosis.—Duration.—Influence of age and sex.— Quantity of blood effused.—Its physical characters.—Condition of the stomach in haemate- mesis.—Causes.—Active constitutional haematemesis.—Symptoms and treatment.—Passive haematemesis and its treatment.—Vicarious haematemesis and its treatment.—Haematemesis induced by organic lesions—of the stomach—of other organs. Hematemesis (derived from aifjta, blood, and sjxsw, I vomit) literally signifies the vomiting of blood, and therefore has been very generally employed to desig- nate haemorrhage from the stomach. Dr. Watson, however, has remarked that vomiting of blood is by no means the invariable accompanying symptom of escape of blood into the stomach, and he therefore objects to the employment of this term haematemesis in its usual acceptation. Other modern writers have objected to the term on similar grounds, and have proposed to substitute for it the Greek compound, gastrorrhagia. But as equally strong arguments may be adduced against the acceptation of this term, especially that it conveys erroneous ideas of the pathology of gastric haemorrhage, and no advantage being gained by the proposed substitution, we shall employ haematemesis to designate gastric haemorrhage. The symptoms which usually accompany gastric haemorrhage may be thus described:—An individual, previously perhaps in apparent robust health, after some powerful mental emotion or bodily exertion, is suddenly seized with a sense of fulness of the stomach and sickness, when he speedily ejects by vomit- ing, much to his own surprise and alarm, a quantity of blood. Previous to the attack of haematemesis, various premonitory symptoms, indicating considerable functional disturbance of the digestive organs, are generally experienced; such as loss of appetite, indigestion, sense of fulness in the epigastrium, pains in the hypochondriac regions, and costive bowels, until at length the uneasiness at the epigastrium amounts to dull pain, accompanied by a sense of weight and dis- tension, with distressing sickness; a general feeling of chilliness and coldness vol. in. 50 394 HEMORRHAGE FROM THE STOMACH (Diagnosis). of the extremities, giddiness, dimness of sight, and faintness are felt, when at last blood in a fluid or partly coagulated state is vomited. These symptoms, which precede and accompany the haematemesis, probably arise from very dif- ferent causes. At first there is a feeling of uneasiness, from congestion of the vessels of the stomach ; then arise the sense of weight, distension, and nausea, occasioned by the presence of the effused blood in the stomach ; and, lastly, the symptoms of syncope from the actual loss of blood supervene. It is not until a quantity of blood is effused, sufficient to excite nausea or produce distension, that an effort to vomit is made. After the actual haematemesis has ceased, many of these symptoms also sub- side, and the person remains greatly exhausted, and much alarmed lest the haemorrhage should return. It is in this state of collapse, with a pallid face and cold skin, that the patient is usually found on the arrival of the practi- tioner. When symptoms such as have been described present themselves, the diag- nosis of Jiematemesis appears to be clear, but in practice it is often difficult and obscure, and only to be arrived at through presumptive evidence. In the first place, haemorrhage may take place from the mucous membrane of the stomach, and no haematemesis ensue. This may happen, either when the quantity of blood extravasated is very small or very large. When blood escapes from the gastric vessels very slowly and in small quantities, it passes the pylorus, and becomes visible only in the alvine evacuations, in which, however, it may not always be recognised, in consequence of the changes it has undergone in its passage through the alimentary canal. But if a small quantity of this altered blood be detected in the stools, there is not only uncertainty from what part of the canal it has been effused, but there is little suspicion of its being effused from the stomach. On the other hand, the quantity of blood poured into the stomach may be very large, and the haemorrhage very sudden ; the individual sinks into fatal syncope, and no blood is vomited. A case of this description is alluded to by Dr. Watson. (Med. Gaz., vol. x., p. 438.) Whenever blood is vomited, some degree of caution in deciding upon the source of the haemorrhage should be exercised. There are cases of bleeding from the nostrils, the fauces, or even lungs, in which the blood, collecting in the pharynx, provokes, from time to time, an involuntary action of deglutition, and gradually accumulating in the stomach, is at length ejected by vomiting. This may occur in epistaxis coming on during sleep, especially in young children. The blood which is vomited is often in considerable quantity and coagulated, so that, from its appearance, it is scarcely possible to conclude that it has pro- ceeded from any other source than the stomach itself. Haematemesis is one of the few complaints which may be successfully feigned by impostors, either for the sake of avoiding military or naval service, or with the intention of exciting the compassion of the charitable. Blood has some- times been swallowed in considerable quantities by such persons, and then vomited in the presence of those whom they wish to deceive. Diagnosis. There is only one disease which is likely to be confounded with haematemesis, and that is a very profuse haemoptysis. In copious haemoptysis, the blood issues from the mouth in gushes, as it does in haematemesis; its re- gurgitation into the pharynx, the tickling sensation it produces there, or the violence of the cough which frequently excites retching—these causes, acting singly or together, produce sometimes a convulsive contraction of the muscles of the thorax, followed not unfrequently by vomiting. On the other hand, in sudden and profuse haematemesis, the irritation of the blood passing over the epiglottis is very likely to provoke a violent fit of coughing. In these cases, which are perplexing when we first approach them, and par- ticularly so if the patient be of the lower class, we may nevertheless arrive at a correct diagnosis by a careful investigation of the symptoms that precede, accompany, and follow the haemorrhage. The premonitory symptoms of haema- hemorrhage from the stomach (Quantity of Blood). 395 temesis, particularly in reference to the digestive organs, have already been described. This affection is also more frequently than haemoptysis preceded by the symptoms of approaching syncope, because the quantity effused in gas- tric haemorrhage is sometimes very considerable before the actual haematemesis, but not so in bronchial haemorrhage. On the other hand, haemoptysis is usually preceded by dyspnoea, cough, tickling in the throat, and a sensation of a bub- bling fluid in the chest. Most commonly too, immediately before or after the haemoptysis, there is expectoration of bloody sputa. Again, those who are conversant with the practice of auscultation and percussion, will find the physi- cal signs of structural changes in the lungs, or of the presence of the effused blood within the bronchial tubes. The expulsion of blood in gastric haemor- rhage ceases shortly after the first full vomiting, and is succeeded by obscure pains in the abdomen ; but in haemoptysis the haemorrhage continues in smaller quantities, and is followed by increased dyspnoea and cough. It has been stated by Chomel (Diet. deMed., vol. x.) and other writers, that haematemesis is a rare form of haemorrhage; some have even asserted that haemorrhage takes place less from the stomach, than from any of the mucous surfaces. There is no doubt, however, that haematuria is much more rarely met with, and that haematemesis is, in this metropolis, at least, by no means a rare disease. Haematemesis, like other forms of haemorrhage, is apt to recur; some- times there is no recurrence, though more commonly it is reproduced by the same or other exciting causes. Though an alarming syncope may take place at the time of the haemorrhage, death is very rarely the immediate con- sequence of haematemesis, even when the quantity of blood vomited is very large. Its frequent recurrence will necessarily weaken and undermine the constitution, more especially when it is dependent upon structural disease of some important organ. Far more danger is to be apprehended from the cause than the extent of the haemorrhage. Individuals who have suffered repeated attacks, are sometimes reduced to a complete state of anaemia; and the obvious characters of that pathological condition are often the symptoms which first excite suspicion that haemorrhage is going on from the alimentary canal. There is nothing definite in the duration of haematemesis; it is extremely diffi- cult to ascertain the precise moment when the gastric haemorrhage commences; and medical aid is rarely sought until the patient and attendants are alarmed by the vomiting of blood. Like other formidable affections of the abdominal organs, gastric haemorrhage occurs most frequently during the middle period of life, from the age of thirty to fifty ; it very rarely occurs in old people, and Chomel thinks that it has never been observed in children. It is commonly stated, that women arc more frequently subject to haema- temesis than men, and this accords with the writer's experience, and it is gene- rally less formidable and more easily cured in females. In women it may generally be traced to suppressed menstruation, or to insufficient discharge in persons of full plethoric habits and of sedentary occupation. In men it is gene- rally the result of structural change in an important organ, induced almost invariably by habits of life unfavourable to health, by too close application to business, by neglect of proper exercise, by indulgence in the pleasures of the table, and, among the lower orders, by excessive use of ardent spirits. In per- sons so predisposed, any causes which are capable of exciting congestion of the vessels of the stomach, may bring on an attack of haematemesis. The quantity of blood effused in haematemesis varies from a few ounces to several pints. When only a small quantity is extravasated, after undergoing more or less completely the process of digestion in the stomach, it may pass onwards through the pylorus; and a portion of the blood, doubtless pursues that course in most cases. But when it is vomited, it comes up in large quantities, usually in great part coagulated. Sometimes the coagula appear to have 396 HEMORRHAGE FROM THE STOMACH (Causes). assumed the form of the stomach; in other cases the clots thrown up are par- tially deprived of their colouring particles, and resemble the fibrinous concre- tions so often found within the cavities of the heart after death. The degree of coagulation of the blood, of its separation into the crassamentum and serum, as well as the changes in colour the coagula undergo, will generally be in propor- tion to the time it has remained in the stomach, this depending materially upon the rapidity of the effusion. The blood ejected by haematemesis is usually dark and partially coagulated, and more like venous than arterial. The colour does not, however, indicate whether the effusion has taken place from arteries or veins, but rather the length of time it has remained in the stomach. Dr. Cars- well in his work on the elementary forms of disease (Hemorrhage and Mela- nosis), has, more completely than any other author, explained the changes which take place in the effused blood, both in gastric and intestinal haemor- rhage. He states, that the blood effused into the stomach and intestines is seldom found to present its natural red colour, either when thrown out from these organs or when contained in them after death. It has often acquired a dark purple hue, and still more frequently a deep brown tint resembling bistre or the peculiar blackness of soot. The dark brown and sooty discolorations of the blood may always be regarded as the result of the action of an acid che- mical agent formed in the digestive organs, on the effused blood; except in those cases in which they are produced by the introduction of an acid poison. Hence he concludes, that the diseases called black vomit and melcena are mere modifications of gastric and intestinal haemorrhage; the black colour being an accidental circumstance of no importance, and derived from the chemical action the acid of product on the blood, previous to its evacuation. The mode of escape of the blood, from the vessels of the stomach in haema- temesis, presents the same peculiarities which have been pointed out in haemor- rhages from other mucous membranes. The effusion of blood is very seldom occasioned by the rupture of a blood-vessel, as was formerly supposed; but far more commonly by exhalation. It is true, that anatomy has not contributed much information on the pathology of haematemesis, because it is very seldom that such cases terminate fatally immediately; but, in many cases, the evidence that the blood is exhaled from the mucous membrane is satisfactory and con- clusive, because we are able to scrutinize minutely the whole extent of surface, which cannot be so thoroughly done in the bronchial tubes after haemoptysis. When death has followed immediately after haematemesis, the mucous membrane of the stomach has, again and again, been found completely entire and of its natural consistence and texture; sometimes partially red, vas- cular, and pulpy, or universally so, the submucous capillary network of vessels being still gorged with blood; in other instances it is quite pale, the congestions of the capillaries having been completely relieved by the haemorrhage. ° Some- times, again, the gastric membrane is studded with minute dark spots, which can be made by slight pressure to start from the surface, as if it were sprinkled with soot or grains of very fine black sand. These latter appearances are cor- roborative of the opinion, that the blood passes through pores or channels, which do not, in the natural state, permit its escape. These sandlike bodies, Dr. Watson thinks, are small portions of blood which have coagulated in the exha- lant orifices of the membrane, and received from them their shape. The sooty points, above alluded to, are no doubt small portions of blood acted on by the free acid in the stomach. J Causes. A point of as great importance as the diagnosis, and upon the solu- tion of which depends the prognosis or treatment of the case, is the cause of the haematemesis. The gastric haemorrhage is sometimes referable to general constitutional dis- turbance ; in other cases it arises from some organic lesion. When haematemesis arises from constitutional disturbance, it is sometimes attended with symptoms indicative of an active form of haemorrhage; at other hemorrhage from the stomach (Treatment of Passive). 397 times, it can only be regarded as a passive effusion, or, in other instances, as a vicarious discharge when some constitutional or habitual flux has been sup- pressed. Haematemesis, independent of any apparent change of structure in the mucous membrane of the stomach, or in any organ capable of influencing the circulation through that membrane, is certainly rare, although the writer believes that he has met with several such cases. Dr. Watson has stated that he had never seen nor heard of any instances of haematemesis, analogous to the epistaxis which is so common in children and young persons, and which, he considers, affords the most familiar examples of idiopathic, or of what we have described as active constitutional, haemorrhage. Andral, in enumerating the various causes under the influence of which haemorrhage may take place from the lining of the alimentary canal, after pointing out the effects of mechanical obstruction to the circulation through the portal vein and those arising from some evident process of iritation of the mem- brane, adverts to simple congestion of the blood-vessels of the membrane:— " The blood accumulates in the vessels of some part of the mucous membrane, and then escapes from them; and this is all that we are able to discover." (Precis. sexual intercourse, he having passed the preceding night in company with a female. The bleeding was permanently arrested by the introduction of a I bougie, which was allowed to remain a short time in the urethra. Vesical Hemorrhage. Haemorrhage from the bladder is of more common occurrence than that from the urethra. There are many causes which may operate either directly or indirectly on that viscus, and excite bleeding from its mucous membrane. Sometimes the blood is poured out in very small quantities, at other times the haemorrhage is very profuse. In the former case the urine is only slightly tinged with blood, while pure blood and mucus follow its expulsion. At the same time there is pain in the situa- tion of the bladder, often extending along the urethra, accompanied with fre- quent and urgent desire of micturition. With these symptoms of disease or irritation of the bladder, there is an absence of symptoms referrible to the kidneys or ureters. When the vesical haemorrhage is profuse, it very soon produces a series of most distressing symptoms. While the serous portion of the blood passes off of a dark brownish colour, the remainder coagulates in the bladder, and becomes a source of inconvenience, suffering, and even danger, to the patient. At first there are the feelings of dull pain in the hypogastric^ region, and weight at the neck of the bladder; afterwards, all the symptoms of J retention of urine appear, and lead very generally to a fatal termination, when^ the bladder is found distended by a large coagulum of blood. The formation * of such a coagulum may be suspected when the patient suddenly passes a quan- \ tity of pure blood, which is followed by the expulsion of dark brown urine, ' depositing a coloured sediment, and the supervention of the symptoms above described. WThen there are symptom's of stone in the bladder, or disease of that viscus \ can be ascertained, and when the passage of pure blood is followed by the dis- \ charge of bloody urine, there can be little doubt that the bladder is the seat of ' the haemorrhage; and this diagnosis will be corroborated by the absence of symptoms referribft to the kidneys and ureters. Renal Hemorrhage. When haemorrhage from the kidney is not very abun- dant nor rapid, the blood is discharged intimately blended with the urine: when blood is passed from the kidney in greater abundance, the fibrinous portion vol. in. 52 410 HEMORRHAGE FROM THE URINARY ORGANS (Renal). coagulates as it passes towards the bladder, and then the urine not only has a reddish or darker hue, but contains coagula, often having the mould of the excretory ducts. This appearance is generally considered characteristic of renal haemorrhage, or of escape of blood towards the commencement of the ureter. , The bleeding may be presumed to come from the kidney, or the commence- ment of the ureter, when there is a sensation of heat or of weight, or some degree of pain in the situation of one kidney; and this presumption is strength- ened if calculi have been previously passed from the kidney, and if there be no symptom of stone or other disease of the bladder. There is a still greater certainty as to the source of the haemorrhage in haematuria, when there are symptoms which denote the passage of concretions from the kidney, through the ureter, to the bladder. There are sharp intermit- ting pains in the loins and abdomen, following the course of the ureter, and radiating to those parts receiving filaments from the lumbar plexus of nerves, particularly to the thigh and testicle. Nausea and vomiting are frequent con- comitants. It appears, then, that in many instances the appearance of the blood, taken in conjunction with the local symptoms, points out, with tolerable precision, from what part of the urinary organs the haemorrhage occurs ; but many cases of haematuria are undoubtedly obscure with reference to the actual source of the haemorrhage. Blood may appear mixed in a greater or less quantity with the urine, without pain or other symptom to lead us to fix upon one part rather than another, as the source of the haemorrhage. It is the opinion of Dr. Watson, " that haematuria bearing this indeterminate character is generally found to be renal, and to depend upon calculous disease." (Med. Gaz. vol. x. p. 472.) This opinion was also evidently entertained by Dr. Heberden in the following passage in his Commentaries:—" Urine made of a deep coffee-colour, or mani- festly mixed with a large quantity of blood, has within my experience been very rarely the effect of any thing but a stone in the urinary passages. I therefore suppose a strong probability of this cause, whenever I see this ap- pearance." In the few cases of severe haematuria which have fallen under our observation, the local symptoms have certainly been ambiguous, but they have rather led to the suspicion of some cause of irritation, as a calculus in the kidneys. The symptoms which accompany haemorrhage from the bladder are generally much more marked than those which attend on renal haemorrhage. Calculus in the bladder, or serious disease of that viscus, cannot long remain without affording manifest symptoms, and certainly could not induce haemorrhage from the mucous membrane without the patient suffering, at the same time, many other most painful symptoms. But calculi form in the pelvis of the kidney, and malignant disorganization may be going on in its substance without symptoms indicative of their existence. It will strengthen the presumption that the kidney is the source of the haematuria, if it has succeeded a fall, strain, or blow upon the back, or perhaps a long ride on horseback. It will be inferred from the preceding remarks that the diagnosis of the source of the blood in haematuria, founded on the local symptoms, is far from being conclusive. Cases of haematuria present examples of the different modes in which haemor- rhage takes place from the respiratory and alimentary canals. Sometimes it may be traced to some peculiar condition of the constitution; in other instances, to the operation of purely local causes. Constitutional or idiopathic haemorrhage from the urinary organs is, undoubt- edly, rare, but there is reason to suppose, that the mucou^membrane of the bladder, ureters, and pelvis of the kidneys may occasionally take on the same morbid action as the lining of the respiratory and alimentary tubes, and give rise to exhalations of blood from their surface. The extreme rarity of idiopathic haematuria cannot be more forcibly ex- pressed than by stating, that that accurate observer of diseases, Dr. Cullen, HEMORRHAGE FROM THE URINARY ORGANS (Symptoms). 411 doubted of the existence of idiopathic haematuria. Frank, also, informs his readers, that out of 4000 patients treated by him in the clinical wards of the Hospital of Pavia, he had only observed six cases of spontaneous haematuria. (De. Cur. Horn. Morbis, vol. i., pt. ii., p. 25G.) Of the annual average of 4000 out-patients treated by the writer at St. Bartholomew's Hospital, not more than one or two cases of idiopathic haematuria have been met with. However rare such cases may be, all the best writers on this subject admit the existence of haematuria independent of structural disease of the urinary organs. Dr. Watson states (Med. Gaz., vol. x., p. 469), that renal haemor- rhage may occur independent of any discernible disease or change of texture in the kidneys themselves. It sometimes appears to be the consequence of a determination of blood to those organs, taking place without any obvious or intelligible cause. Dr. Willis maintains the opinion, that haematuria does appear now and then with all the characters of a peculiar and independent affection, and that he had recently met with a case which he regarded as idiopathic, and viewed as though the discharge of blood constituted the sum of the affection. (On Urinary Dis- eases, p. 176.) Andral, also, admits the existence of haematuria depending wholly on constitutional causes. (Precis dAnat. Path., vol. i., p. 339.) The disease sometimes presents all the characters of an active constitutional haemorrhage : it is also met with as a passive haemorrhage, or it may appear as supplemental or vicarious of other natural or habitual discharges of blood. With respect to the treatment of cases of active exhalation of blood from the urinary organs without discoverable disease, nothing more can be suggested than to pursue the plan which has been already recommended for other active constitutional haemorrhages. A much more alarming form of haematuria is that which bears the character of a passive constitutional haemorrhage, and which occurs in the progress of those diseases which affect the system at large, especially scorbutus and pur- pura haemorrhagica. Such cases generally terminate fatally. Andral states that he was in attendance upon an old woman suffering from a cancerous affec- tion of the stomach, and that, a fortnight before her death, numerous purpurous spots appeared upon the skin, and at the same time a notable quantity of blood escaped daily with her urine. After death purpurous spots were found on the pleura, peritoneum, in the alimentary canal, and on the lining of the heart. A bloody fluid filled the pelvis and ureter of each kidney, and when the tubular portions were pressed, a similar fluid exuded. A liquid dark blood was found in the heart and great blood-vessels, and without any appearance of coagula- tion. Haematuria appears also, though rarely, as a passive haemorrhage in the course of typhus fever, malignant small pox, measles, scarlet fever, and plague. In these diseases it is to be regarded as a fatal symptom. When bloody urine is voided in the course of these several constitutional affections, the mere haemorrhage from the urinary organs is not so much the symptom to be combated, as the general condition on which it depends. The treatment, therefore, of the haematuria is wholly absorbed in that most suitable for the general constitutional disturbance. When haematuria appears as a vicarious haemorrhage supplemental of haemor-| rhoidal or menstrual discharge, the blood is generally effused from the inner! coat of the bladder. In obstinate cases of haematuria, and particularly when it recurs from time to time, inquiry should be made as to previous haemorrhages from the rectum, and in females, as to the state of the catamenial function. Some > modern French writers on this subject state that elderly females sometimes pass bloody urine in considerable quantity at intervals, after the complete disappear- ! ance of the catamenia. One of these writers had under his care an elderly woman whose general health was good, but who passed a considerable quantity of blood with her urine nearly every month. This haemorrhage was preceded 412 HEMORRHAGE FROM THE URINARY ORGANS '(Causes). by heat and uneasiness in the hypogastric region, some general indisposition, with headache; these symptoms vanished as soon as the haematuria com- menced, and she remained perfectly well, in spite of pvery active habits of life, until the expiration of the usual period. (Diet, de Med. et Chir. Prat, art Hematurie.) In such cases the object of treatment is to restore, if possible, the suppressed haemorrhage: this is often a difficult undertaking, because the means to be employed sometimes increase the discharge of blood from the urinary passages. /The oil of turpentine, the tincture of cantharides, or the muriated tincture of / iron, employed cautiously and in very small doses, will be found most effica- 1 cious in controlling the haemorrhage. When there is local pain or irritation, ' sedatives, as, for example, the uva ursi, opium and warm baths are of service. Lastly, haematuria frequently arises from morbid conditions of the urinary organs themselves. There are several diseased conditions of the kidney under the influence of which blood is poured out from that organ and mixed with the urinary secretion. In inflammatory dropsy with albuminous urine, and in that form of dropsy , which supervenes during the convalescence from scarlet fever, it is by no means uncommon to observe a certain quantity of blood, or its colouring and albuminous principles, excreted with the urine. When such cases terminate fatally the kidneys are usually found intensely congested with blood. Again, blood is sometimes mixed with the urine in inflammation of the kidney, and likewise during the progress of carcinomatous or other malignant degene- ration of its substance; but a much more frequent cause of renal haemorrhage is the irritation occasioned by the formation of a calculus in the pelvis of the kidney. The irritation produced by the constant growth of the calculus will excite intense congestion of the surrounding mucous membrane, which relieves itself by the exhalation of blood : at other times, the enlargement of the calculus or its change of position causes laceration or ulceration of the surrounding highly vascular parts. The calculus, in its descent to the bladder, may in a similar manner excite haemorrhage from the lining of the ureter. Haematuria may be the consequence of some morbid state of the urinary bladder. A calculus may have descended from the kidney into this viscus, or it may have had its commencement there: under either circumstance, it may occasion haemorrhage from the mucous surface of the bladder. Inflammation of the mucous membrane of the bladder is another cause of the appearance of blood in the urine. This affection sometimes appears almost as an epidemic, and especially in hot climates. M. Renoult has described a trou- blesome and obstinate haematuria which affected numbers of the French troops in Egypt, and particularly the cavalry. It was attended with much pain in the region of the bladder, extending along the urethra to the extremity of the glans penis, with a frequent and urgent inclination to pass urine. The last drops voided consisted often of pure blood, and their expulsion was accompanied by acute pain. Several of these men died and on dissection the mucous mem- brane of the bladder was found inflamed. The same disease appeared anions the horses. (Diet, de Med., vol. ix. art. Hematurie.) Similar affections occur to couriers and others who perform long and rapid journeys on horseback. The diagnoses of the seat of haemorrhage is easy, and the treatment is involved ( in that which is appropriate for the cystitis. Chronic disease of the mucous * membrane of the bladder, whether simply inflammatory or of a malignant nature, will give rise to occasional haemorrhage from its surface. In some of these cases, only a small quantity of blood, mixed with puriform mucus, passes after the urine is voided; in others the quantity of blood poured out is very con- siderable, and produces serious inconvenience. A case of this latter description occurred to the late Mr. Heaviside. An old East Indian, who had long been subject to nephritic complaints was suddenly seized with symptoms resembling retention of urine. A catheter was passed, but as no urine flowed, it was sup- hemorrhage from the uterus (Active and Passive). 413 posed that the instrument had not entered the bladder, in which region there was a manifest tumour. The patient died the next day, and the bladder was found distended by a very large coagulum of blood, which had come from its diseased mucous membrane. There was no trace of escape of blood within the kidneys or ureters. The treatment of Haematuria has not been detailed at any length, because it has been our object to show that when it occurs as an idiopathic haemorrhage the attention is to be directed to the state of the constitution; and where it is a symptom of a morbid condition of the urinary organs, it will be most success- fully combated by judicious management of the local affection on which it depends. HEMORRHAGE FROM THE UTERUS. Definition.—Active and passive menorrhagia.—Symptoms and treatment.—Occurring during pregnancy and parturition.—Causes and treatment.—Resulting from structural diseases of the uterus. The periodical escape of a bloody fluid from the vessels of the uterus is an indi- cation of a healthy and robust constitution. When it is limited to a certain quantity, varying from two to six ounces in different individuals and climates, and recurring every lunar month, for about thirty years after the age of puberty, in the unmarried female, it cannot be regarded as a pathological phenomenon, but constitutes natural menstruation, the healthy function of the unimpregnated uterus. When, however, the natural menstrual fluid is excessive in quantity, or when blood escapes from the gravid uterus, or where it flows in large quan- tities from that organ immediately after parturition, or when the substance of the organ is diseased, the affection is termed uterine haemorrhage, the various forms of which we shall briefly advert to. That variety of uterine haemorrhage which is termed menorrhagia consists in a morbidly profuse menstruation, and may occur in very opposite states of the system. It may present itself either as an active or passive haemorrhage. In active menorrhagia, for a few days before the expected menstrual period, there is a sensation of unusual fulness about the pelvis, with throbbing sense of heat and weight referred to the situation of the uterus; the external organs of gene- ration are often slightly swollen, and the mammae become hot, tumid, and tender; the pulse is accelerated, the mouth hot, the tongue dry ; the patient is thirsty, and there is a general feeling of oppression, with headache and giddi- ness. The discharge from the commencement comes on with violence, often in gushes of pure blood, as is proved by its coagulation, and the pain experienced from the passage of the coagula. Sometimes, after the first few hours, the woman feels relieved, lighter and cooler; and the rest of the period proceeds' as in healthy menstruation. In more aggravated cases, the flow still proceeds in equal or increased quantity, and lasts for several days, occasionally inter- mitting, but again bursting forth upon the slightest exertion, till at the end of the period she is left weak and languid, with a feeble pulse and pallid counte- nance. Before the recurrence of the next monthly period she has perhaps recovered her wonted health; but the same series of symptoms returns, perhaps with some aggravation, particularly with a longer continuance of the discharge. In this manner one period has scarcely terminated before another commences, and the most strong and plethoric woman is brought down to a state of great weakness, 414 hemorrhage from the uterus (Passive). and the disposition to haemorrhage continuing, active menorrhagia may thus lapse into passive haemorrhage. In passive menorrhagia the female is usually delicate, with feeble constitu- tional powers, or has become so from repeated losses of blood in the more active form of the disease. She has a frequent circulation; the heart is easily excited to overaction: she suffers from violent headaches, with throbbing of the tem- poral arteries, singing in the ears, and giddiness, symptoms arising not from general plethora but from exhaustion and unequal distribution of blood. In passive menorrhagia there are seldom any premonitory symptoms; if the men- strual periods are still regular as to time, they are unnatural as to duration and the quantity of blood lost: they are generally, however, too frequent, and there is scarcely any cessation of the discharge. When the gushes of blood have stopped, they are succeeded by a constant oozing of a thin serous fluid; and when the catamenia have ceased, a profuse leucorrhceal discharge takes place: slight bodily exertion or mental excitement brings on a return of the sanguineous discharge. The usual constitutional effects of repeated loss of blood are at last induced, and the person exhibits the well-known appearance of confirmed anaemia. The danger of passive menorrhagia is not merely confined to the serious constitutional effects just adverted to ; the discharge may be so sudden and profuse as to bring on alarming syncope. Another evil consequence of continued menorrhagia has been remarked in the tendency of such women to profuse losses of blood after abortion or parturition at the full time. Females who are naturally plethoric are disposed to active menorrhagia; in such cases it is often a natural mode of relieving the over-distended vessels: this tendency is aggravated by luxurious habits, a sedentary and indolent life, and inattention to the regular and free action of the bowels. All those causes which tend to lower the constitutional powers dispose to passive menorrhagia ; but there certainly are delicate females in whom from early life there seems to be a superabundant or undue distribution of blood to the uterus, and who, under the influence of certain exciting causes, are almost sure to suffer from passive menorrhagia. The principal exciting causes which peculiarly attend to increase the activity of the circulation through the uterine system, and thus bring on menorrhagia, are violent exertion or fatigue in the erect posture, just prior to the appearance of the catamenia; blows, falls, or any other local violence; frequent abortions; over-indulgence in sexual intercourse, particularly before the period has entirely passed over; irritation in the rectum or bladder, &c. The treatment of menor- rhagia must mainly depend upon the nature of the haemorrhage, and the exciting causes which have brought on the discharge. Where the menorrhagia still bears an active character in a robust and ple- thoric female, we may abstract a moderate quantity of blood by venesection: and in those cases which are accompanied by much pain in the loins and pelvis, great relief will be obtained by the abstraction of six or eight ounces of blood by cupping from the sacrum. The patient should be kept at perfect rest in the horizontal posture, the body covered with light clothing, and cold applied to the lower parts of the body ; cold water may be dashed from time to time over the hypogastrium or loins, and ice-cold applications laid over the pubes and pe- rineum. When the discharge is so excessive that much additional loss of blood might be attended with danger, we may resort to a very effectual method of restraining the haemorrhage, viz., plugging the vagina, according to the directions of Dr. Locock in his paper on menorrhagia :—" A fine cambric handkerchief may be gradually introduced into the vagina up to the os uteri, so as to fill the vagina firmly throughout its whole extent, and be allowed to remain there. Many prefer soaking it previously in some strong astringent liquid, and this is perhaps still more efficacious. If the plug produce pain, it must be withdrawn; and, at all events, it should not be allowed to remain more than twenty-four hours. On withdrawing it, unless it be done very gently and gradually, a fresh discharge of HEMORRHAGE FROM THE UTERUS (Occurrence). 415 blood is apt to be occasioned: but it can easily be restrained by another plug, or some of the other remedies." (Cyc. Pract. Med.) Of the internal remedies for restraining uterine haemorrhage when it is excessive and of the active kind, we have nothing further to suggest than those which have been recommended in all active constitutional haemorrhages. In passive menorrhagia occurring, in feeble constitutions, or in those reduced by a long continuance of the disease in an active form, besides the topical reme- dies for the actual repression of the haemorrhage, we must endeavour, in the intervals between the periods, to restore tone to the vessels of the uterus ; and to strengthen the general health. To accomplish the former object, cold bath- ing, the cold hip bath, and sponging the body with cold vinegar and water, will be found of great use. These should be employed daily, and a cold astringent injection may be thrown up into the vagina every morning. The various mineral tonics and astringents, judiciously administered, will be found eminently serviceable in cases of passive menorrhagia. The salts of iron and zinc are those upon which most reliance may be placed, and the former are particularly efficacious, when taken in the minute quantities in which they are found in many natural mineral springs. Dr. Locock has also found the Liq. Potass. Arsenitis, in doses of five drops, gradually increased to twenty-five, of great service in some cases of menorrhagia of the atonic character. The other rules for the improvement of general health will be the same in this as in other forms of passive haemorrhage. Uterine haemorrhage may occur during pregnancy ; this accident may happen in the early or in the more advanced stage of utero-gestation. When uterine haemorrhage occurs at the early period of pregnancy, it is occasioned by the partial separation of the placenta from the uterus, and the probability of arrest- ing the haemorrhage and preventing abortion will depend upon the extent to which the detachment of the placenta has proceeded. The further practical consideration of this variety of uterine haemorrhage will be more conveniently entered upon, where the causes and treatment of abortion are discussed. When uterine haemorrhage does not make its appearance until the fifth month of preg- nancy, it is usually a much more formidable accident, and commonly arises from malposition of the placenta near the mouth of the uterus. It appears without any obvious cause, and subsides after some precautions have been adopted, but again appears more profusely, continues longer, and does not yield to the former treatment. This variety of uterine haemorrhage generally goes on in- creasing until the foetus dies, or premature delivery is accomplished. The quantities of blood lost are sometimes so considerable as to endanger the life of the mother; or, if she escape with her life, she is reduced to a state of com- plete anaemia, and is harassed with the distressing train of symptoms with which it is accompanied. The various means to be resorted to for controlling this form of uterine haemorrhage, and the indications which should induce the practitioner to bring on premature delivery, are more appropriately considered in treatises on mid- wifery. When such an amount of blood is lost during parturition as to entitle it to be called a haemorrhage, it may occur either at the commencement or at the termi- nation of that process. When the haemorrhage comes on at an early stage of labour, it is usually from the attachment of the placenta near the mouth of the uterus, or from its partial separation from unequal contractions of the uterus. In rarer cases it may proceed from laceration of some part of the substance of the uterus, or from rupture of the umbilical cord. When the haemorrhage comes on towards the termination of labour, after the expulsion of the foetus, it appears to arise either from imperfect separation of the placenta, connected with irregular or spasmodic contraction of the uterus, or from torpidity and imperfect contrac- tion of the womb after the expulsion of the placenta. If uterine haemorrhage occur at the termination of labour from either of the above-mentioned causes, 416 HEMORRHAGE FROM THE UTERUS (Causes). the blood may either escape through the vagina or remain confined within the uterus. The former is readily indicated by the profuse flooding, but the latter may not be detected until the woman is falling into fatal syncope, when the uterus is found distended almost to the size it was before delivery. It is obvious that this internal haemorrhage is of a most formidable nature, from the insidious manner in which it goes on to an almost fatal extent. We shall content ourselves with having pointed out these varieties of uterine haemorrhage, and the causes which apparently give rise to them, referring for more ample details, and the requisite treatment, to treaties on midwifery. The last form of uterine haemorrhage which we propose to consider is that which is independent of menstruation, pregnancy, or parturition, and which may be properly termed symptomatic, arising from some structural disease in the uterus itself. Haemorrhage from the uterus sometimes occurs as a critical evacuation in the course of uterine inflammation, but the most frequent morbid condition of the uterus, which gives rise to repeated attacks of haemorrhage, is the developement of some morbid growth within its cavity. These formations are tumours of various kinds, either in the muscular walls of the organ, or immediately beneath the internal lining; polypous growths, moles, carcinoma, and destruc- tive ulcerations. The presence of any of the above-described morbid formations in the uterus has a tendency to excite undue activity in the circulation of the organ. If they form during that period of life when the woman should menstruate, their exis- tence may perhaps be indicated by no other symptoms than profuse and painful menstruation, followed by occasional leucorrhcea. Many of the most severe and obstinate cases of menorrhagia are dependent upon some fibrous tumour or polypous growth in the uterus, and such cases progress from bad to worse, unless the exciting cause is detected. The only permanent cure for interior haemorrhage of this kind is by surgical operation. Uterine haemorrhage sometimes comes on and continues for a short time after the cessation of the catamenia. When this appears only once or twice, it readily yields to remedies which diminish plethora and equalize the circulation; but when uterine haemorrhage occurs to any extent after the cessation of the catamenia, and recurs from time to time, particularly if the woman is approach- ing her fiftieth year, there is just cause of alarm that this haemorrhage is symp- tomatic of serious structural disease of the uterus. It is the opinion of Louis and some able pathologists, that haemorrhage from the uterus and other organs is one of the most constant symptoms of malio-nant formations. The frequent recurrence of uterine haemorrhage in a woman of middle age should at once excite the suspicion of structural disease in that organ, and induce the practitioner to institute a careful manual examination of its condition. Women themselves are sometimes apt to imagine, that the dis- charge of blood is only a return of the catamenia ; but symptomatic haemor- rhage may be distinguished from the catamenial by the character of the dis- charge, by the irregularity of the periods, by its longer continuance, and by the succession of leucorrhcea to the bloody fluid. Although this form of haemorrhage is only a symptom of structural disease, still it often requires more serious attention for the time than the disease on which it depends. Its frequent recurrence and the consequent anaemia demand immediate relief. For this purpose the various remedies suggested to control the different forms of menorrhagia will be applicable, but the only permanent relief to be anticipated must be through a judicious treatment of the structural disease of the uterus. SCURVY. Historical details.—Causes.—Prevention.—Symptoms.—Anatomical characters.—Diagnosis. —Treatment. The English word scurvy, anciently scorbie, is of Saxon origin, and evidently derived from the same root as the vernacular names of the disease among the other nations of the Saxon race; namely, in the German language scliarbock, which signifies a griping, or tearing of the belly; in the Dutch scheurbuilc ; in the Swedish slcdrbjugg ; and in the Danish skbrbug. The medical term scor- butus appears to be merely a latinized variation of the last of these. This disease was endemic two centuries ago, in all the northern countries of Europe. It became gradually less frequent as agriculture and gardening im- proved ; and we have witnessed the almost complete extinction of scurvy on land, as the influence of these arts has extended to the almost remote parts of Europe and to the humblest classes. It seems to have been very imperfectly, if at all known to the Greek, Roman, and Arabian physicians. Some passages in the writings of Hippocrates have, indeed, led to the supposition that he was acquainted with this disease; but those passages, if they refer to scurvy, are extremely vague, and show, at least, that his acquaintance with it was very slight, and that he had not learned to distinguish it from other diseases of dif- erent nature. The Greek and Roman physicians, subsequent to Hippocrates, either copy his descriptions, or make no mention of any group of symptoms that can be supposed to refer to scurvy. It is probable, indeed, that they seldom met with instances of it, which must have been very rare among them, on account of the abundance of fruits and vegetables in their climate, and the shortness of their coasting voyages ; a circumstance unfavourable to its occurrence at sea. They were also little acquainted with the northern countries, where it must then, as since, have prevailed. The earliest unequivocal description of scurvy is to be found in the narrative of the campaign of the Christian army in Egypt under Louis IX., about the year 1260. The historian of that crusade was not only eye-witness of the disease in others, but was himself affected with it. He speaks of the debility and tendency to swoon, black spots on the legs, bleeding from the nose, and the livid and spongy condition of the gums. With respect to the last-mentioned symptom, he says, " The barbers were forced to cut away very large pieces of flesh from the gums, to enable their patients to eat. It was pitiful to hear the cries and groans of those on whom this operation was performing; they seemed like the cries of women in labour." The disease showed itself in Lent, during which the soldiers, in compliance with the ordinances of their religion, ate no meat, and they had only one sort of fish, the bombette; this circumstance, to- gether with bad air and great scarcity of water, was supposed to have brought vol. in. 53 418 scurvy (History). on the disease. (Histoirc de Louis IX. par le Sieur JoinviUe, Trans., vol. i., p. 162.) Scurvy has, unquestionably, existed in the north of Europe from the most remote antiquity. That we have no mention or it in the early history of the northern nations must be imputed to the extreme'ignorance of the people, espe- cially as regards medicine; but about the commencement of the sixteenth cen- tury, when they began to cultivate letters, we find accurate descriptions of this disease, which is frequently mentioned by their historians and other authors. Olaus Magnus, in his history of the northern nations, published in 1555, when speaking of the diseases peculiar to those nations, gives a particular description of scurvy, which, he tells us, infested chiefly soldiers in camps and persons shut up in prisons or besieged towns. About the same time we find three physicians, Roussens, Ecthius, and Wierus, expressly treating of this disease. Their descriptions of its symptoms are very accurate, and they recommend those remedies which are found, at present, the most efficacious. In 1645 the Faculty of Medicine at Copenhagen, in Denmark, published a consilium for the benefit of the poor in that country. This consilium treats of the causes, prevention, and cure of scurvy. We learn from it that scurvy was at that time prevalent among the Danes and other northern nations. (Con- silium Medice Facultatis Hafniensis de Scorbuto. Lind, p. 353.) It appears by a letter from Linnaeus to Dr. Lind, dated 1755, that scurvy was, at that time, common on the borders of the Baltic among peasants, artificers in iron, and miners. (Lind, p. 283.) It was prevalent also in several parts of Scotland, where it was popularly known by the name of black legs. Dr. Grainger, in answer to some inquiries by Dr. Lind, says that it has often been very epidemic and fatal to the miners at Strontian, in Argylshire. Dr. Huxham, in a letter to Dr. Lind, says that scurvy was at that time endemic in some seaport towns of Devonshire and Cornwall. He remarks that it was most common in fishermen and tradesmen, and seldom met with in agricultural labourers, who drink cider and eat plentifully of vegetables and fruits. AH the writers from whom the preceding accounts are derived, agree in stating that the latter part of winter and the early part of spring was the season in which scurvy prevailed most; and that it uniformly disappeared during sum- mer and autumn. The causes which in the middle of last century had rendered scurvy less frequent on land than previously have continued to operate with increasing effi- ciency ; so that at present, except under peculiar circumstances, the disease is never met with in England, and, we believe, very rarely in any of the northern countries of Europe. That it should, a century or two ag0, have been endemic in many parts of England seems almost incredible, when we consider the cir- cumstances under which it arises, and the present aspect of this country; but we have undeniable evidence of the fact, and it affords proof of the extraordi- nary change which a few centuries have wrought in the cultivation of the soil, and in the habits of the people, especially with reference to the increased con-' sumption of vegetable food. This is confirmed by the historical fact that, until the commencement of the sixteenth century, no salads, carrots, turnips or other edible roots were grown in England. The little of these vegetables that was used before that time was imported from Holland and Flanders; and in the reign of Henry VIII. Queen Catherine, when she wanted a salad, was obliged to despatch a messenger thither on purpose.* D But although, two centuries ago, scurvy was endemic in the northern coun- tries of Europe during the spring of every year, it was in seasons of scarcity, or when its usual causes were strengthened by the desolation of war, and during long sioges, that its ravages were principally felt. • Hume, Hist, of England, vol. iv. p. :>41; see also, art. Gout, in this work. scurvy (History). 419 During the siege of Breda, in North Brabant, by the Spaniards, in 1625, the inhabitants and garrison were dreadfully afflicted with scurvy: on the 16th of March, when an account was taken of the sick, 1608 soldiers were found affected with this disease; and the number afterwards increased daily. The town was surrendered in June, after a siege of eight months. (Frederic Van- der Mye, De Morbis, Bredanis.) J. F. Backstrom, in an essay, published in 1734, which is replete with just observations on the causes, nature, and treatment of scurvy, informs us that in 1703, during the siege of Thorn, in Prussia, by the Swedes, which lasted only five months, and was carried on during the heat of summer, 5000 of the garrison, besides a great number of the inhabitants, died of this distemper. The besiegers were, at the same time, quite free from it. (Holler, Disput. ad Morbos, vi.) In 1720, during the war between the Austrians and Turks, when the im- perial army wintered in Hungary, many thousands of the common soldiers (but not one officer,) were cut off by scurvy. Dr. Kramer, a physician to the army, being unacquainted with a remedy for it, requested a consultation of the college of physicians at Vienna. Their prescriptions and advice were, however, of no avail: the disease, which broke out at the end of the winter, persisted until, at the approach of summer, the earth became covered with greens and vegetables. (Holler, Disput. ad Morbos, vi.) In the early part of the last century scurvy was also very common, and very fatal in the Russian armies. (A Treatise on Scurvy, as it appeared in the Rus- sian Armies: by A. Nitzch, 1747. See Lind, p. 415.) In the spring of 1760, scurvy prevailed to a great extent among the English that formed the garrison at Quebec, which had been taken from the French the preceding year. These troops, at first 6000 men, suffered so much from cold and want of vegetables and fresh provisions, that before the end of April, 1000 of them were dead of scurvy, and twice that number unfit for service. (Smol- lett's Hist, of Eng., vol. v., p. 198.) But instances of armies being much weakened by scurvy, have occurred more recently, and among a people, who, by reason of their climate, which is favour- able to the growth of vegetables and fruits, have enjoyed comparative impunity from that disease. In the spring of 1795, scurvy was very general among the French soldiers in the army of the Alps. Fodere, who was physician to the army, informs us that he treated between seven and eight hundred soldiers affected with it. In 1801, during the siege of Alexandria, it prevailed among the inhabitants and garrison to a most frightful extent. During the siege which was commenced by the English in May, and which lasted only till the end of August, 3500 scorbutic patients were received into the military hospitals, which the French established in that city. (Mem. de Chir. Milit. de D. J. Larrey, Paris, 1812, torn, ii.) In late years, scurvy has shown itself occasionally in our armies in India, as well as in some public establishments in that country ;* and in the autumn of 1836, it prevailed to a great extent among our troops, stationed in the new pro- vince of Queen Adelaide, at the Cape of Good Hope. The disease first ap- peared about the end of July, and continued to prevail from that time to De- cember, a season corresponding to spring in the northern hemisphere. None of the officers were affected with it. The men had no harassing duties, and were abundantly supplied with good fresh meat, without having had an ounce of salt provisions; but they had been a long time without fruit or fresh vege- tables. In all these circumstances, we find perfect agreement with some ac- counts left us of the occurrence of scurvy in the continental armies in the early part of the last century.| * Med. and Phys. Trans, of Calcutta, vols, iii., iv., vii., and viii.; and the Quarterly Journal of the Med. and Phys. Society of Calcutta, vol. i. p. 306. t See Med. Gazette, vol. xx. Extract from the annual report of Dr. Murray, principal medical officer at the Cape of Good Hope. 420 scurw (History). But it is not only in armies and during sieges, that we mc^t with even modern instances of the occurrence of scurvy on land. From the earliest times, it has appeared occasionally in persons long confined in prisons and asylums ; and an instance of its prevailing extensively, under such circumstances, happened in England so recently as in the year 1823. We allude to the disease which pre- vailed in the spring of that year among the inmates of the Milbank Peniten- tiary. The description of this disease, by Dr. Latham, shows that it was scurvy in conjunction with dysentery and other effects of starvation. This complicated malady was occasioned by a diet, of which fresh succulent vegetables formed no part, and the quantity and quality of which were not adequate to the support of health.* The reports of the inspectors of prisons, for the years 1836, 1837,1838, abound with instances of the occurrence of scurvy in our gaols and prisons. In 1836 it assumed a very malignant form in the county gaol at Norwich; not fewer than eighteen persons were severely affected with it. (First Report of Inspectors of Prisons ; Northern Division, p. 39.) In the House of Correc- tion at Swaffham, as appears by the report of the surgeon, the prisoners fre- quently lost their teeth from the effects of scurvy; and when they were exa- mined (1836) in presence of the inspector, sixteen were found presenting its early symptoms.\ (Ibid., p. 49.) In most of the instances mentioned in these reports, it appeared in prisoners who had been some months in confinement; and originated in a circumstance already specified, namely, prolonged use of a diet of which fresh succulent vegetables formed no part. We have said that notices of scurvy, as a disease peculiar to the northern nations of Europe, became frequent as soon as they began to cultivate letters; but two other circumstances, which happened about the same time, tended powerfully to direct men's minds to the consideration of this disease, and, by exhibiting it in an isolated manner, to give them precise ideas respecting it. We allude to the frequent performance of long voyages at sea, and to the esta- blishment of colonies in the northern part of the newly-discovered continent of America. The early northern colonies in America were dreadfully afflicted with scurvy. The French, especially upon first planting Canada, experienced such loss from the mortality it occasioned in winter, that they often had thoughts of abandon- ing their settlement. The same was the case with the English, on their settling in Newfoundland. The adventurers who first wintered in Hudson's Bay, were almost all destroyed by scurvy ; and, after many unsuccessful trials, it was deemed impracticable to pass the winter in those parts. As early as the middle of last century, however, the persons employed in our factories at Hudson's bay, enjoyed extraordinary health, and were entirely ex- empt from scurvy ; a circumstance which has been ascribed to the use of spruce- beer, which they had adopted as a common beverage. But it is during long voyages that the ravages of scurvy have been most felt, and the existence of it, as a prevalent disease maintained. The earliest account of the occurrence of scurvy at sea is to be met with in the narrative of Vasco de Gama, who first discovered a passage to the East Indies by the Cape of Good Hope, in the year 1497 ; about a hundred of his men, out of a hundred and sixty, died of this distemper.^ The narratives of subsequent navigators, especially Cartier, Drake, Caven- dish, and Dampier, abound with descriptions of the frightful ravages of scurvy. * Scurvy showed itself in some of the prisoners soon after Christmas, and became very general in the month of February. The winter was very severe. t For other instances, see First Report, 1836, No. 2, p. 55, 60, 63 85 &c • Second Report, 1837, No. 1, p. 81,217, 232, &c.; Third Report, 1838, No. 2, p. 81, No. 3, p! 79, &c. t V. de Gama sailed on the 8th of July, 1497, and returned to Lisbon in the month of Sep- tember 1499, more than two years after his departure. scurvy (History). 421 In the account of the second voyage of Cartier to Newfoundland, in 1535,* there is a very graphic description of tho disease, which showed itself in his men soon after Christmas, and which he ascribed to their intercourse with the natives who were at that lime affected with it. The following passage will give some idea of the sufferings it occasioned :—" With such infection did the sick- ness spread in our three ships, that about the middle of February, of a hun- dred and ten persons that we were, there were not ten whole; so that one could not help the other ; a most horrible and pitiful case. Eight were already dead, and more than fifty sick, and, as we thought, past all hope of recovery. This malady being unknown to us, the body of one of our men was opened, to see if by any means possible the occasion of it might be discovered, and the rest of us preserved. But in such sort did the sickness continue and increase, that by the middle of March there were not above three sound men left. Twenty-five of our best men had died, and all the rest were so ill that we thought they would never recover again; when it pleased God to cast his pitiful eye upon us, and send us knowledge of a remedy for our health and recovery." (Hakluyfs Collection of Voyages, vol. iii.). The remedy alluded to was a decoction of the bark and leaves of a tree, called by the natives, Ameda, or Hanneda, by the use of which they were all perfectly restored in a short time. In the first voyage for the establishment of the East India Company, the equipment, consisting of four ships with 480 men, under Commodore Lancaster, sailed from England on the 2d of April, 1600. The crews of three of these ships were so weakened by scurvy, by the time they had got only three degrees beyond the line, that the merchants who had embarked on this adventure were obliged to do duty as common sailors. On the 1st of August, when they arrived at Saldanha, near the Cape of Good Hope, the commodore's own ship was in perfect health, from his having given three table-spoonsful of lemon juice every morning to each of his men ; while the other ships were so sickly that the commodore was obliged to send men on board to take in their sails and hoist out their boats; and there died, at sea and on shore at Saldanha, 105 men, nearly one-fourth of their whole number. (Purchases Collection of Voy- ages, vol. i.) The memorable expedition of Lord Anson in 1740, and the four following years,f offers another example of the mortality formerly occasioned by scurvy during long voyages. At the end of two years from their leaving England, tho vessels engaged in the expedition had lost, from this disease, a larger proportion than four in five of the original number of their crews. It is gratifying to turn from the descriptions of sufferings undergone in tho voyages of earlier navigators, to the narrative of Captain Cook, who in 1772, 3, 4, and 5,^. in the Resolidion, with a company of 118 men, performed a voyage of three years and eighteen days, in all climates, from 52° north to 71° south, with the loss of only one of his crew by disease. It is to the sagacity of this extraordinary man that we are indebted for the first impulse towards those improvements in the treatment of sailors by which scurvy is at present so effectually prevented in our navy. In 1780 scurvy was very prevalent in the channel fleet. In the month of August the squadron under Admiral Geary, after a cruise of ten weeks in the Bay of Biscay, returned to Portsmouth with 2400 men affected with it. During the same year and the following, scurvy prevailed also to a great extent in our fleet, under Lord Rodney, in the West Indies; it was, however, much mitigated by improvements which were then introduced, chiefly at the suggestion of Sir * Cartier sailed from St. Malo on the 19th of May, 1535, and arrived at Newfoundland on the 7th of July. He spent the autumn in exploring the coast and the river St. Lawrence, which was discovered by him. t Lord Anson left England in September, 1740, and returned in June, 1744. t Captain Cook sailed from Plymouth on the 13th of July, 1772. 422 scurvy (History). Gilbert Blane, into the victualling of the fleet. From this time scurvy was much less prevalent than before, but in the spring of 1795 it broke out in the Channel fleet under the command of Lord Howe, to such an extent as to endan- ger the safety of the whole fleet. Its uncommon violence was owing to the fol- lowing circumstances. The winter had been extremely severe, and all vegetation was destroyed in the neighbourhood of Portsmouth, so that no vegetables could be procured, or they could be procured only at a price which put them out of reach of the sailor; beef, too, had much risen in price, and the Victualling Board had, in consequence, allowed fresh meat only one day a week. In the beginning of April, scurvy made its appearance, and soon after pervaded every ship. To suppress it, became, of course, an object of great national importance, and every effort was made by the commissioners of the Admiralty for the ac- complishment of this purpose. Fresh meat, together with a plentiful supply of oranges and lemons, was granted. Vegetables at first could be procured only in small quantities; as the season advanced, they became more plentiful, and after the 31st of May, 5000 weight of salad was distributed daily among the ships at Spithead. The good effects of these refreshments were astonishing; on the 12th of June the squadron sailed again in good health. (See an admirable account of the health of the fleet in Trotter''s Medicina Nautica.) It was in the course of this year that an admiralty order was first given for furnishing the navy with a regular supply of lemon juice, which had been long known to be a remedy for scurvy, and which some recent experiments had proved to be equally efficacious in preventing it. From this time we may date the extinction of scurvy in the British navy. It has, indeed, shown itself on several occasions since, especially in some of the expeditions for the discovery of a north-west passage; but it has prevailed only in a slight degree, and has almost always been suppressed by an additional allowance of lemon juice. This happy result is far, however, from being realized in the commercial marine of this country. The means, which experience has proved to be of such certain efficacy, and which are so easy of adoption, are in many instances ne- glected : in proof of this we need only mention, that in the space of a year and a half, during which we have been physician to the Seamen's Hospital, Dread- nought, we have had to treat nearly fifty cases of scurvy; and from information obtained from these patients, are led to estimate the number of sailors who entered the port of London affected with scurvy during this period, at not less than double that number. The wretched condition of some of these men has convinced us that the descriptions of the sufferings occasioned by scurvy in voyages of the early navigators have not been exaggerated. All the cases that have fallen under our observation, with the exception of four, occurred in sailors who had come from the Mauritius, Sidney, Ceylon, China, or some port in India; of these four, two happened in the spring of the present year (1838), in Russian sailors belonging to two different vessels, each of which had been several months in the Thames;* one, in a sailor who came last from the West Indies; and the fourth, in a sailor recently arrived from the coast of Spain. We have no data for forming an accurate estimate of the mortality occasioned by scurvy before preventive measures were generally adopted. It has been * One of these men was admitted on the 2d, the other on the 15th of March. The winter had been uncommonly severe. The diet of one of them consisted of black rye bread and Rus- sian butter, with tea, mornings and evenings; and for dinner, one pound of salt beef with boiled pearl barley, two days; one pound of Russian pork, with peasoup, three days a 'week; dry stock fish, with flour pudding on Saturdays; one pound of fresh meat, with barley soup] on Sundays. A small glass of brandy daily, but no beer or vinegar. The diet of the other had been nearly the same; in fact, this is the general diet of Russian sailors in merchant ships; the only variation being in the relative number of beef and pork days. On referring to the registers of the Dreadnought for former years, I find other instances of Russian sailors, en- gaged in the trade between Russia and this country, admitted for scurvy during the spring months. scurvy (Causes). 423 supposed, however, to have destroyed more sailors than the other various acci- dents incidental to a sea-life, together with the terrific consequences of naval warfare ; and history furnishes us with many examples, which tend to show that in this estimate the destructive effects of it have not been overrated. Sir R. Hawkins, who lived in the latter part of the sixteenth century, and whose description of this disease shows that he was well acquainted with it, informs us that he could give an account of ten thousand mariners, consumed by scurvy alone, in twenty years that he had been at sea.* Admiral Hosier, who set sail in the month of April, 1726, with seven ships of the line for the West Indies, buried his ships' companies twice, and died him- self of a broken heart in consequence. We are told by Dr. Lind that during the war which terminated in 1748 in the peace of Aix-la-Chapelle, scurvy proved more destructive, and cut off a greater number of valuable lives than the united efforts of the French and Spa- nish arms. (Lind, Preface, p. 5.) But the most striking illustration of the dreadful effects of scurvy in former times is the contrast, in point of health, which our present navy offers with the fleets of this country before effectual remedies were resorted to. The mortality in the navy had been gradually decreasing since 1780, when various improve- ments were made in the victualling of the fleet and in the general treatment of the men; but in 1795, when a regular supply of lemon juice was first granted, the mortality fell suddenly, and to a degree scarcely credible. The effect of all these salutary measures may be estimated by the fact mentioned by Sir J. Bar- row, that between the years 1779 and 1813, the diminution of sick and of deaths in the British navy was in the proportion of four to one nearly. (See Supplement to Encyc. Britan. art. Navy.) Causes. In the preceding sketch of the history of scurvy we have found it difficult to avoid allusion to its causes, and to the means by which it may be prevented. The following observations must be considered, therefore, as the complement of what we have already said in reference to these subjects. Salt Provisions. In consequence of the frequent occurrence of scurvy at sea, and on shore, in persons whose diet, like that of sailors, consisted chiefly of salt meat, it was at one time supposed to be occasioned by excessive use of salt. A more extended view of the circumstances under which scurvy arises, is suffi- cient to show that this opinion is erroneous. Kramer, in the letter we have already quoted, informs us that the Germans, among whom scurvy occasioned such great mortality in the spring of 1720, in Hungary, ate no salt beef or pork, but, on the contrary, had plenty of fresh meat at a very low price. The soldiers in the Russian armies, who, in the early part of last century suffered greatly from scurvy, had also no salt provisions. We have already remarked that the same was the case with our regiments at the Cape, in which scurvy prevailed in the autumn of 1836. In the middle of last century, when Sisinghurst Castle in Kent was filled with French prisoners, scurvy broke out among them, although from the time of their arrival in England, they had eaten no salt provisions, but had been served daily with fresh meat and bread, but without greens or other vegetables.! The severity of the winter of 1794-5, which we have already mentioned as the cause of the unusual prevalence of scurvy in the Channel fleet in the fol- lowing spring, was also productive of scurvy on shore. During that spring cases of genuine scurvy were admitted into most of the London Hospitals ; and Dr. Heberden has well described those of some patients that were under his own care in St. George's. Speaking of one of these patients, he says, " His diet * Observations of Sir R. Hawkins, Knt., in his Voyage to the South Sea, a. d. 1593. (Pur- chase Pilgrim, vol. iv.) t Address to tho Royal Society, by Sir J. Pringlc, 1776-7. 424 scurvv (Causes). previously to the occurrence of scurvy, consisted of bread and butter, with tea for breakfast, fresh meat and bread for dinner, and water-gruel for supper. This was his common food at all times, excepting that he had been used to eat vegetables, which, on account of their high price, he had not been able to pro- cure for some months." (Med. Trans., vol. iv.) From a paper published in the Trans, of Med. and Phys. Soc. of Calcutta, vol. iv., it appears that in the lunatic asylum at Moorshedabad, in that presi- dency, one-third of the inmates are annually affected with scurvy, which shows itself during the rainy and cold season, and disappears in the hot season. The diet of the inmates consists of rice, split peas, curdled milk, oil, salt, pepper, water; all good of their kind, and in sufficient quantity. In addition to this, a small quantity of tobacco is allowed them. Cakes, made of the flour of wheat, are occasionally substituted for rice; and fresh fish, and sometimes animal food is given to those who wish for a change of diet. It is remarked that no cases of scurvy have ever occurred in the jail, which is only about three hundred yards distant from the asylum, and in which the diet is in no respect better.* The preceding instances are sufficient to show, that scurvy may arise inde- pendently of the use of salt provisions; there are other facts which lead to the conviction, that salt has no influence whatever in producing it. It was remarked by Dr. Lind, who had the merit of first showing the error of the opinion in question, that few workmen in any business are so healthy as those engaged in the preparation of sea-salt; and that the persons who work night and day in the salt mines in Poland, and even live in them, are not at all subject to scurvy; on the contrary, remarkable for health and the vigour of their constitutions. (Lind, p. 51.) Salt water, even in persons who have continued the use of it a long time, has never been known to bring on scurvy, and when given to scorbutic patients,— an experiment often tried,—it has in no instance been found to aggravate the disease. (Lind, p. 51, Blane, Dis. of Seamen, p. 296.) Another circumstance of great moment in reference to this question, is the readiness with which scurvy may be cured by lemon juice, even while the patients continue to subsist on salt provisions. The history of modern naviga- tion abounds with instances which establish this fact. The circumstances we have adduced, showing that scurvy may prevail to a frightful extent among persons living solely on fresh meat; that persons who, from the nature of their occupations, are continually absorbing saline particles, are exempt from scurvy; that scurvy is not brought on by the use of sea water, which maybe drunk with impunity, even by scorbutic people; and that the disease may be prevented for any length of time, in persons who subsist on salt provisions, and can be readily cured even in those who continue the use of them ;—are sufficient to justify the conclusion, that salt has no share whatever in producing it. The frequency of scurvy during long voyages led also to the supposition, that sea-air, or some unknown marine agency, had an especial influence in causing it. At present, this opinion scarcely needs refutation. Modern expe- rience has amply proved, not only the harmlessness, but the extraordinary salubrity of sea-air. The fact, that it asserts no particular influence in pro- ducing scurvy, was, however, first established by Captain Cook, who, as we have before observed, performed with a company of 110 men, a voyage of more than three years with the loss of only one man by disease. Impure air. It has been supposed, too, that the air of ships, impure from defective ventilation and want of cleanliness, has had some share in bringing on scurvy. But there is reason to believe that this opinion is as unfounded as * Med. and Phys. Trans, of Calcutta, vol. iv. p. 16. Land Scurvy among the Natives, byB. Burt, M. D. scurvy (Causes). 425 those we have already discussed. Scurvy is, at present, never met with in the most crowded and filthy parts of this metropolis, where, from the operation of the causes in question, fever almost always prevails. It was remarked by Dr. Lind that ship carpenters, though more exposed to the foul air of the hold, were not more subject to scurvy than the rest of the crew. Nor does attention to cleanliness and ventilation, when the causes of scurvy continue to operate, seem to have much influence in mitigating its severity. The writer of Lord Anson's voyage informs us, during the latter part of their run, before their arrival at the island of Tinian, all the ports were kept open, and uncommon pains taken in sweetening and cleansing the ship, without producing any abatement in the progress or the virulence of the disease. Dr. Trotter, in his account of the health of the Channel fleet in 1795, says, " To have the thought of foul air as the cause of a scurvy when it appeared in the Royal George and Queen, would have been the last resource of a physician investigating causes, who had witnessed the admirable system of duty practised by Captains Domet and Bedford." (Med. Naut., vol. i., p. 427.) Another circumstance, which powerfully supports the opinion that the causes in question have no share in producing the disease, is the readiness with which scorbutic patients may be cured while they continue to reside on board. We have ample testimony in the writings of Sir Gilbert Blane and other naval physicians, that these patients recovered quite as rapidly on board their ships as in hospitals on shore. (Diseases of Seamen, p. 59; Med. Nautica, vol. i. p. 426.) Cold ; moisture. The fact that scurvy, when it first attracted attention, pre- vailed exclusively in northern countries, early led to the opinion that cold and moisture had considerable share in causing it; and this opinion has been main- tained up to the present time by the highest authorities on this subject. Dr. Lind tells us, that Channel cruisers were often quickly overrun with scurvy, while their consorts, fitted out at the same port, and consequently with provi- sions and water of like quality, who soon after left them for a much longer cruise off the Canaries, or Cadiz, or a voyage to the Indies, kept pretty free from it; and that it always appeared in much shorter time, and raged with greater violence in a squadron cruising in the narrow seas of the Baltic and Channel, or upon the coast of Norway, or Hudson's Bay, than in another con- tinuing the same length of time in the middle of the Atlantic ocean. (Lind, p. 68.) Sir G. Blane expresses the same opinion, which seems, however, to have been refuted by his own experience while physician to the fleet in the West Indies. An attentive consideration of the history of scurvy has convinced us, that the influence of these causes has been much over-rated, and that the comparative immunity from this disease formerly enjoyed by fleets in warm latitudes was mainly owing to the supplies of oranges and other fruits with which Cadiz, Ma- deira, or the islands of the West Indies furnished them. We have already given instances* of the occurrence of scurvy in the highest degree during the months of summer, and in tropical climates; so that no tem- perature is a preservative from this malady ; nor does change from a cold to a warm climate, where scurvy exists, seem in any degree to lessen its severity. The writer of Lord Artson's voyage says, " Some of us were willing to believe that in this warm climate, the violence of the disease, and its fatality might be in some degree mitigated ; but the havoc of the distemper in our present cir- cumstances soon convinced us of the falsity of this speculation." In confirmation of this testimony we may again mention that, at present, the merchant-seamen who enter the port of London, affected with scurvy, come * In the sieges of Thorn and Alexandria; and in the voyages of Commodore Lancaster, Admiral Hosier, Admiral Geary, &c. vol. in. 54 426 scurvy (Causes). almost exclusively, from the Mauritius, India, Ceylon, or China; and have, consequently, been in no higher latitude than that of the Cape. Another circumstance which shows that cold has not much influence in pro- ducing scurvy, is the readiness with which this disease can be prevented* or cured, even in the coldest countries. We have already noticed the entire ex- emption from scurvy enjoyed by the persons employed in our factories at Hud- son's Bay ; the same is the case in Greenland and Iceland. When the disease occurs in those climates it is quickly cured by lemon juice, or by sorrel or scurvy-grass, plants found in great abundance in the polar regions during the summer months. That moisture alone is incapable of producing scurvy is evident from the example of Venice, and many insular positions, where the disease is never met with. Contagion. Scurvy, like all diseases which have prevailed epidemically, was at one time, supposed to be contagious; but the error of this opinion was early shown by the almost constant exemption of officers in armies and in ships. The same opinion has been advanced, however, in modern times, and by an author of considerable merit. In further confutation of it, we cannot do better than repeat the just remark of Dr. Lind, that those authors should have given us attested histories of persons infected in this manner, where the other causes that always produce the disease had no influence. But no such histories are to be found.f We have already seen that scurvy may occur in all climates, either on land, or at sea; in persons who subsist on salt meat or fresh; and in situations in which the utmost attention is paid to cleanliness and ventilation. There is one condition, however, which is necessary for the production of scurvy ; namely, prolonged abstinence from succulent vegetables or fruits, or their preserved juices as an article of food. When this condition is fulfilled, we find scurvy arising in persons whose situations are the most various in every other respect in which we can compare them; while not a single instance can be cited of its occurring in a person well supplied with these vegetables or fruits. This cir- cumstance, together with the fact that scurvy is, in all cases, rapidly cured when a supply of these vegetables or fruits is furnished, leads us to consider the abstinence in question as its essential and sole cause. We have said that this abstinence must be prolonged : it would seem, indeed, that in a person pre- viously well supplied with vegetable juices, abstinence of from two to five months is necessary to produce the disease. On land, scurvy has shown itself always towards the end of winter or in spring; at sea, it has appeared after voyages of very different durations ; in some cases, at the end of a month or six weeks; in others, after the lapse of five or six months. This difference depended on the time of year when the vessel left port, or rather on the previous diet of the men. Attention to this circumstance will serve to explain all the apparent anomalies which have forced writers on scurvy to have recourse to such a variety of causes. Dr. Lind tells us that while he was surgeon of the Salisbury, in 1746 and 1747, scurvy raged with great violence in that ship, during two Channel cruises, one of ten weeks, the other of eleven ; and that, in each of these cruises, it showed itself in less than six weeks, after they put to sea ; yet, at the end of a subsequent cruise of twelve weeks, which was the longest the Salisbury made, there was but one scorbutic person on board. Dr. Lind could assign no cause * In the second polar expedition of Sir E. Parry, scurvy showed itself only after the crews Had spent two successive winters in the polar seas and when they had been for twenty-seven months in entire dependence upon the resources contained within their ships, unassisted by any fresh antiscorbutic plants or other vegetables. In this expedition Sir E. Parry left the Nore, with the Hecla and Fury on the 8th of May, 1821, and reached the Shetland Islands on his return on the 10th of October, 1823. t Lind, p. 45, 146. Diseases of Seamen, p. 476. Fodere", Diet, de Sc. MeU, art. Scorbut. scurvy (Predisposing Causes). 427 for this difference except the state of the weather. The real cause of it is un- doubtedly to be found in the circumstance, that the two former cruises were made in the months of April, May, and June, so that the men left port in spring when scurvy was already imminent; while the last cruise was performed in the months of August, September, and October. (Lind, p. 56-65.) The great mortality from scurvy in the ships under the command of Commodore Lancaster in 1600, was principally owing to his having commenced the voyage in spring. In this instance cold had evidently no share in producing the disease. The same was the case with the squadron sent to the West Indies under Admiral Hosier in 1726. The history of our navy abounds with similar examples. (Diseases of Sea- men, p. 102-148.) We shall content ourselves with mentioning another instance which occurred in the Channel fleet in 1795, and which is illustrative of the same point. We have already stated that scurvy raged with extraordinary vio- lence in the fleet in the spring of that year, and that it was suppressed by the abundant supply of lemons and salad furnished to the ships at Spithead in the latter part of May and the beginning of June. On the 10th of June the fleet again sailed, and scurvy soon made its appearance; but it was found from the list of patients that, during the cruise, which was a long one, not a man who had shared in the allowance at Spithead showed the slightest symptom of the disease. (Med. Naut., vol. i., p. 423.) It has been brought forward by writers on scurvy, as a strong argument in favour of the great influence which they ascribed to cold in the production of this malady, that the sailors most prone to it were those engaged in the northern whale fishery, although the vessels employed in this service were better fitted out than any others, with respect both to variety and quality of provisions; the voyage from this country short; and the men kept constantly in action. The fact has been unnoticed that these vessels always left this country in spring. The great mortality occasioned by scurvy during the siege of Thorn, in 1703, admits of similar explanation. The siege, which lasted only five months, was carried on during the heat of summer. This circumstance, which rendered the mortality unaccountable to Bachstrom, Dr. Lind, and others, who believed that cold has great influence in causing this distemper, affords the true explanation of its unusual fatality. The siege was commenced in spring, when scurvy was already imminent in the inhabitants : had the siege been undertaken at the end of summer, they would have suffered comparatively little from the disease. The history of the siege of Alexandria furnishes us with a precisely parallel instance. The fatal effects of scurvy have, in fact, been generally felt most during sieges commenced in spring, and in voyages entered on in spring from cold countries. The siege and the voyage have in these cases prolonged to the inhabitants and the sailors, not the cold indeed of winter, but abstinence from fresh vegetables, which, in former times, the cold of winter always occasioned. Predisposing causes. When a number of persons are placed in circumstances conducive to scurvy, the first to exhibit its symptoms are those who, from sick- ness or other causes, are in a state of debility.* In the Channel fleet, in the spring of 1795, scurvy appeared chiefly in those men who were convalescent from an epidemic catarrh (Med. Naut., vol. i., p. 407); and, during the siege of Alexandria, in 1801, those soldiers who had received severe injuries, or were reduced by the ophthalmia, which at that time prevailed among them, were the first to suffer from scurvy (Larrey, Chir. Milit. t. ii., p. 284). It has often been observed to affect in especial manner persons recovering from intermittent fevers (Lind. p. 210); and our own experience furnishes us with several instances which tend to confirm that observation. * Lind. p. 77 and 402 ; Curtis's Diseases of India, p. 9. 428 scurvy (Predisposing Causes). Age. Scurvy may occur in persons of all ages. Dr. Mertans, in a paper published in 1778, when he was physician to the Foundling Hospital at Moscow, informs us that scurvy showed itself every spring among the children in that establishment, and that one year as many as sixty of them were affected with it. (Phil. Trans., vol. lxviii.) We have obtained from the registers of the Dreadnought the ages of 200 scorbutic patients received into that hospital; and we have arranged these so as to show how many of them were under 20, between 20 and 30, 30 and 40, and so on. These numbers we have compared, in the subjoined table, with the average numbers of merchant seamen whose ages are comprised within the same limits. The average numbers have been derived by taking from the registers at the Custom House, where the age of every sailor who comes into the port of London is registered, the ages of 5000 sailors, entered in succes- sion, by arranging these so as to show the numbers whose ages are comprised within the limits in question; and by reducing these numbers to the scale of 200.* Patients. Age. Total. No. of scorbutic patients - - Under 20. 20-30. 30-40. 40-50. 50 and up-wards. 20 71 54 36 19 200 Average number of sailors - - 21-32 95-04 45-20 26-88 11-56 200 In this table, those in the first vertical column are almost all between the ages of 15 and 20 ; the second column (20—30) includes all whose ages have 2 for the first figure; the third (30—40) all whose ages have 3 for the first figure; and so on. It appears from this table that persons between the ages of 20 and 30 are, of all persons above the age of fifteen, the least liable to scurvy ; and that above the age of 30, the proportion of scorbutic patients continually increases with age. We are inclined to believe that the predisposing influence of age is even greater than is indicated by the preceding table. The average numbers in this table are derived from the ages of sailors, taken indiscriminately; whereas scorbutic patients all come from distant ports. Sailors engaged in the merchant service may be arranged in two classes ; the one comprising those employed in the home, the other those in the foreign trade. Now, sailors ad- vanced in life frequently leave the latter service for the former; and the mor- tality among seamen is greater in hot climates than in our own ; so that there is reason to believe that the proportion of sailors of an advanced age is less in those engaged in the foreign trade, than in those employed at home. Indolent, lazy habits, and despondency, have often been mentioned as exert- ing a powerful predisposing influence in the production of scurvy ; and instances may be cited which seem to show the reality of such an influence. In ships that have contained marines as well as sailors, the marines have in general been more affected with scurvy than the sailors, f The historian of Lord Anson's voyage tells us, that " whatever discouraged * See. art. Cholera. t See Diseases of Seamen, p. 322 and 465, and Rouppe De Morbis Navigantium, Trans., p. 121. scurvy (Preventives). 429 the people, or at any time damped their hopes, never failed to add new vigour to the distemper; so that it seemed as if alacrity of mind and sanguine thoughts were no contemptible preservatives from its fatal malignity." It is probable, however, that the influence of these causes has been much overrated, and that listlessness and aversion to exercise, from being early and constant symptoms of the disease, have often been mistaken for its cause. Preventives. We come now to speak in detail of the means by which scurvy may be prevented; and shall first mention as the chief of these means, the use of oranges, lemons, or limes; and, we believe, we might add, shaddocks, and all fruits which botanists have included in the order Aurantiacee. The efficacy of oranges in preventing and curing scurvy was discovered before the disease had been described by physicians. Rousseus, one of the earliest writers on scurvy, in a work published in 1564, observes that seamen in long voyages cure themselves of it by the use of oranges. He conjectures that Dutch sailors, afflicted with scurvy on their return from Spain with a cargo of these fruits, had by chance discovered their efficacy. Albertus, in a treatise on Scurvy, published in 1593, recommends the juice of oranges, and of sour and austere plants. He advises that this juice should be put into soups, and that meat, while roasting, should be sprinkled with it. In the same year, the virtues of lemon juice in the cure of scurvy were experienced by Sir R. Hawkins, whose crew, while within the tropics, were affected with it in an extreme degree. We have already given an instance of the extraordinary efficacy of lemon juice as a preventive of scurvy, in the first voyage for the establishment of the East India Company in 1600. After this it seems to have been pretty generally used in the Company's ships; and, in a medical work published in this country in 1636, it is recommendde as the best remedy for scurvy. From this time it is recommended by a series of writers who have treated of this subject; ■ and instances which show its extraordinary efficacy are to be frequently met with in our naval annals. When Admiral Sir C. Wager commanded our fleet in the Baltic, in 1726, his sailors were dreadfully afflicted with scurvy. He had recently come from the Mediterranean, and had on board a great quantity of lemons and oranges, which he had taken in at Leghorn. Having often heard of the efficacy of these fruits, he ordered a chest of each to be brought upon deck, and opened every day. The men, besides eating what they liked, mixed the juice with their beer. It was also their constant diversion to pelt one another with the rinds, so that the deck was always strewed with them, and wet with the fragrant liquor : the happy result was that he brought his sailors home in good health. (Mead on Scurvy.) Most of these proofs of the efficacy of oranges and lemons were collected by Dr. Lind, and published in his justly celebrated work on Scurvy in 1757. His earnest recommendation for the general employment of these fruits in the navy was, however, not acted upon for some time; the disease continued to depopu- late our fleets, offering a striking example of the delay which sometimes attends the practical application of most important truths. To the cause of delay in the present instance, we shall allude particularly hereafter (see chap, on Diagnosis); at present we only mention the fact, as one of the most singular and instructive in the history of the disease. We have already noticed the prevalence of scurvy in our fleet in the West Indies in the years 1780-1-2, and in the Channel fleet in 1795. The history of these fleets afford numerous proofs of the efficacy of the fruits in question; but in 1794 an experiment was made which established it beyond doubt. The Suffolk of 74 guns, sailed from England for Madras on the 2d of April, 1794. She was provided with lemon juice; and two-thirds of * John Drawitz, 1647; Une Voyage aux Indes Orientales, par. M. Dillon, M.D. 16S3; Martin Lister, 1694. 430 scurvy (Preventives.) a liquid ounce of this juice, together with two ounces of sugar, were mixed with each man's daily allowance of grog. The Suffolk was twenty-three weeks and one day on the passage, during which she had no communication with land. Scurvy showed itself in a few men in the course of the voyage, but soon disap- peared on an additional quantity of lemon juice being given them ; and the ship arrived at Madras, without the loss of a single man, and with her crew entirely exempt from scurvy.* * It is to the representations of Dr. Blair and Sir G. Blane, in their capacity of commissioners for the relief of sick and wounded seamen, enforced by the result of this experiment in the Suffolk, that we owe the systematic introduction of lemon juice into nautical diet, in 1795, by order of the Admiralty. We have already spoken of the improvement in the health of the navy consequent on this wise measure; but we may be permitted to mention the following cir- cumstances which show how completely it has realized the expectations of its proposers. In 1780, 1457 cases of scurvy were admitted into Haslar Hospital: in 1810, one of the physicians of that hospital informed Sir G. Blane that he had not seen a case of it for seven years; and, in the four years preceding 1810, only two cases were received into the naval hospital at Plymouth. At present, there are many surgeons in the navy who have never seen a case of scurvy, which has, in fact, been expunged from the list of diseases incident to seamen in the navy. The present allowance of lemon juice in the navy consists of a fluid ounce, which, after ships have been a fortnight at sea, is served daily with an ounce and a half of sugar to each of the men. Dr. Lind recommended a rob, formed by evaporating the juice, by a slow heat, to the consistence of thick syrup. This was found to be very inferior in efficacy to the fresh fruit (Diseases of Seamen, p. 56 ; Med. Nautica, vol. i. p. 425); and Sir G. Blane, in consequence, advised that the juice should be pre- served by the addition of a small quantity of spirit, without the aid of heat; a plan now generally adopted. The juice with which the navy is supplied is brought from Sicily, and kept good by the addition of one part of strong brandy to ten of the juice. When preserved in this manner, its virtues seem unim- paired. These fruits, when employed in the treatment of scurvy, combine all the good qualities we can desire in a remedy. They have a specific influence in curing the disease, but produce no other sensible effect, except a small increase in some of the secretions ; and the eating of them is attended with great pleasure. Dr. Lind tells us that he has often observed, upon seeing scorbutic people landed at our hospitals, that the eating of these fruits was attended with a pleasure more easily imagined than described ; and his testimony is confirmed by that of other naval physicians. Oranges, lemons, and limes, seem to have nearly equal efficacy : and per- haps the same may be said of shaddocks, and all fruits of a like kind. Dr. Lind, however, from some comparative trials, was led to give oranges a pre- ference to lemons. It is probable that the state of the fruit, as to maturity, has considerable influence on its virtues. That such is the case with the guava, appears clearly from an experiment made by Dr. Trotter. Having repeatedly observed scorbutic slaves throw away ripe guavas, while they devoured green ones with much avidity, he resolved to try if any difference could be remarked in their effects. For this purpose he selected nine blacks affected with scurvy in nearly equal degree. To three of these he gave limes, to three green guavas, and to three ripe guavas. They were kept under the half-deck, and served by himself two or three times a day. They lived in this manner for a week ; at the * Sir G. Blanc, Comparative Health of the Navy. scurvy (Preventives). 431 end of which those restricted to ripe guavas, were in much the same state as before the experiment, while the others were almost well. Most sour fruits are in all probability antiscorbutic. The good effects of un- ripe grapes were noticed by Fodere in the French army of the Alps, in 1795; and, in 1824, when scurvy prevailed among our troops at Rangoon, in India, great benefit was derived from giving the men the fruit of the Phyllanthus Em- Mica, or Anola; which, when dry, as sold in bazaars, has a rich and strongly acid taste, with a flavour resembling that of tamarinds. (Quarterly Journal of tlie Med. and Phys. Society of Calcutta, vol. i. p. 306.) The efficacy of apples, as a preventive of scurvy, was alluded to by Sir J. Pringle in an address to the Royal Society, in 1776 ; and the following proof of their curative virtues is given by Dr. Trotter :—When Lord Bridport's fleet arrived at Spithead on the 19th of September, 1795, almost every man in the fleet was more or less affected with scurvy. Large supplies of vegetables were provided, and lemon juice being scarce in consequence of the previous great consumption, fifty baskets of unripe apples were procured at the Isle of Wight for the use of the fleet. The Royal Sovereign, in particular, derived great benefit from them ; and the cure of the disease was every where so speedy, that little remained to show Earl Spencer, when he visited the fleet at the end of the month. (Med. Naut., vol i. p. 420.) As the expense of lemon juice offers great impediment to the employment of it in the commercial marine of this country, to the extent necessary for com- plete extinction of scurvy, it deserves to be ascertained whether the juice of apples, preserved like that of lemons, by the addition of a certain proportion of spirit, would not be an effective substitute. All succulent vegetables that are wholesome, are perhaps, as well as fruits, more or less antiscorbutic ; but this property seems to be possessed in the highest degree, by plants comprised in the order Crucifere, in which most of the vegetables in common use, as the cabbage, turnip, radish, water-cress, &c. are included. In the earliest notices of scurvy, mention is made of the efficacy of herbs of this class in its treatment. Rousseus, writing in 1564, informs us, that the common people cured them- selves by scurvy-grass, brook-lime, and water-cresses. W. Cockburn, in a work published in 1796, entitled Sea Diseases, remarks the extraordinary effi- cacy of vegetables in the treatment of this distemper. As a proof of it he men- tions the following circumstance :—When Lord Berkeley commanded the fleet in Torbay, Mr. Cockburn prevailed on his lordship to erect tents for the sick on shore. Above a hundred of the most afflicted scorbutic patients, perfect moving skeletons, hardly able to get out of their ships, were landed, and fresh provi- sions, including carrots, turnips, and other vegetables were given them. In a week they were able to crawl about; and before the fleet sailed, they returned healthy to their ships. The subsequent history of scurvy abounds with instances equally decisive ; but the strongest proof of the efficacy of vegetables of this class, is derived from the fact that the disease, when it occurred on land, uniformly disappeared during summer and autumn; and that it gradually became less frequent as the consumption of vegetables increased. There seems to be no country naturally destitute of remedies for scurvy. The fruits of tropical and temperate climates are replaced in countries within the polar circle by herbs of almost equal efficacy. We are told that in Green- land, where scurvy was formerly very common, the natives employed sorrel and scurvy-grass together, and that by these herbs, which were put into broths, the most advanced cases were cured in a surprisingly short time.* Sir Edward Parry informs us that the Esquimaux eat sorrel but not scurvy- * Lind, p. 214. Also, for a remarkable instance of the efficacy of scurvy-grass, see a paper by Bachstrom, published by Haller in Disput. ad Morbos, vi. 432 scurvy (Preventives). grass. In the narrative of his first voyage of discovery, he gives an instanco from his own experience of the good effects of sorrel. He sailed from London in the beginning of May, 1819, and in the following spring scurvy showed itself in four of his men. In the early part of April, in consequence of a serious loss of lemon juice, from bursting of the bottles by frost, the daily allowance of it was dininished one-third, and in the middle of June it was entirely discon- tinued. At this period the sorrel began to vegetate, and the men were enjoined to gather daily a prescribed quantity : in the month of August it increased almost to exuberance, and proved a most valuable antiscorbutic. The garden-cresses also have been especially noticed for their antiscorbutic qualities. It was suggested by Bachstrom, that the inhabitants of a besieged town, by sowing the seeds of these herbs on the ramparts, or even in their apartments, might, in a few days, furnish themselves with a fresh antiscorbutic salad. Dr. Lind* recommended the adoption of the same measure in ships during long voyages; and his advice has been recently followed by Sir Edward Parry.f We have quoted the following passage from the narrative of the first polar expedition of this enterprising navigator:—" I began also about this time to raise a small quantity of mustard and cress in my cabin, in small shallow boxes, filled with mould, and placed along the stove-pipe; by this means, even in the severity of the winter, we could generally insure a crop at the end of the sixth or seventh day after sowing the seed; which, by keeping several boxes at work, would give to two or three scorbutic patients nearly an ounce of salad daily ; even though the necessary economy in our coals did not allow of the fire being kept in at night. The mustard and cress thus raised were necessarily colourless from privation of light, but as far as we could judge, they possessed the same pungent aromatic taste, as if grown under ordinary circumstances, and appeared to be equally efficacious." We have already spoken of the pleasure which scorbutic persons derive from eating oranges; in treatises on scurvy frequent mention is also made of their relish for fresh vegetables. Bachstrom tells us, that at the siege of Thorn, when some of the coarsest vegetables were sent into the town by the enemy, for the use of a particular family, they were seized on by the officers at the gates, and greedily devoured as the greatest delicacies. (Hatter, Disp. ad Morbos, vi.) It appears that the antiscorbutic virtue of vegetables is greatest when they are eaten raw. Herbs in the form of salads are more efficacious than when boiled, or any way prepared by heat; and their antiscorbutic properties are entirely destroyed by drying4 Kramer tried a great variety of dried plants to no purpose; and the college of physicians at Vienna, when applied to by him, sent into Hungary a large supply of the most approved antiscorbutic herbs, pre- pared in this manner, but they were productive of no benefit. Pickles. But when vegetables are preserved as pickles, their antiscorbutic properties are retained. It was observed that Dutch ships were formerly much less subject to scurvy than our own; and in some instances, when our fleet has acted in concert with that of the Dutch, our sailors have become affected with scurvy, while the Dutch continued free from it. This immunity on the part of the Dutch was owino1 to the use of sour krout, which was regularly supplied to their ships. The extraordinary health of the Centurion in the memorable voyage of Cap- tain Cook, seems to have been mainly owing to a liberal supply of sour krout. A pound of it was served to each man twice a week, or oftener throughout the voyage. * Lind, p. 141. t In his first polar expedition, Captain Parry sailed from London with the Hecla and Griper, on the 5th May, 1819, and returned on the 26th Sept. 1820. f See Lind, p. 170. Diseases of Seamen, p. 56. Phil. Trans, vol. lxviii. Obs. on Scurvy, by Dr. Mertans. scurvy (Preventives). 433 In a paper published in 1770, in the Transactions of the Royal Society, Dr. Mertans informs us that, during a residence of many years in Moscow, he fre- quently met with cases of scurvy among gentlemen and merchants, but very rarely in persons in the lower classes. The comparative immunity of the latter, he ascribed to their eating plentifully, all the year round, sour cabbage soup and vegetables, which were sparingly used by the rich, whose diet consisted chiefly of fresh animal food and bread. In 1780, sour krout was furnished to our navy as a regular article of ship's provisions; and in the history of the fleet about that time, we find many proofs of its good effects. The allowance was two pounds a week to each man. (Dis. of Seamen, p. 140. 287.) Sour krout is prepared in the following manner:—The soundest and most solid cabbages sliced, as we slice cucumbers, are put into a barrel in layers, hand high ; over each layer is strewed a handful of salt and caraway seeds; the whole is then rammed down, and the process continued till the barrel is full, when a cover is put over it and pressed down by a heavy weight. After stand- ing some time in this state the cabbage begins to ferment, and it is not till the fermentation has entirely ceased, that the barrel is finally shut up. Vinegar is not, as some have imagined, employed in the preparation of sour krout. (Cyc. Prac. Med., art. Scorbutus.) In Austria, and several parts of Germany, people eat sour turnip, which is prepared in the same manner as sour krout;* in fact, most vegetables may be preserved by this method ; and we strongly recommend a trial of it, with scurvy- grass and sorrel, to navigators who may in future be compelled to winter in the polar seas. The fir-tribe deserve to be next mentioned, on account of their antiscorbutic properties. These, like many of our best remedies, were discovered by chance. When the Swedes were at war with the Muscovites, almost all the soldiers in the Swedish army became affected with scurvy. Its progress was arrested by the use of a simple decoction of fir-tops, which was found equally efficacious as a preventive and a remedy. This medicine acquired, in consequence, great reputation, and the common fir, Abies rubra, was afterwards called Pinus anti- scorbutica. The mountain pine, Pinus sylvestris, has likewise been found highly antiscor- butic. In 1736, two squadrons, fitted out by the court of Russia, were obliged to winter in Siberia. One, not far from the mouth of the river Lena, was attacked by scurvy. The sailors, in their distress, by chance found this tree growing in the mountains near them, and discovered that it had a most sur- prising antiscorbutic virtue. At the same time, the crews of the other squadron, who were passing the winter in the river Judoma, were much afflicted with the same disease. They, too, chanced on the pines, which grew plentifully on the mountains, and by the use of them, in decoction, were all perfectly restored in a few days. In some, this medicine proved gently laxative; in others it affected the body so mildly, that its operation was scarcely sensible. (Lind, p. 177.) From the description given by Cartier of the Ameda treef (by a decoction of the leaves and bark of which his crew were so speedily cured), it would seem that it was the large spruce tree of American swamps. All pines and furs, indeed, though differing from each other in form and appearance, seem to have analogous medicinal virtues, and great efficacy in the prevention and cure of scurvy. Onions, garlic, and vegetables of the same class, were at one time much used * See Phil. Trans, vol. lxviii. t Cartier says, " It wrought so well, that if all the physicians of Montpellier and Louvain had been there with all the drugs of Alexandria, they would not have done so much in one year as that tree did in sixe dayes : for it did so prcvaile that as many as used of it, by th» grace of God, recovered their health." (HakluyVs Coll. of Voyages, vol. iii.) VOL. III. 55 434 scurvy (Preventives) for the prevention of scurvy at sea; but they are now very rarely employed for that purpose. Potatoes also, when raw, seem to be antiscorbutic ; and Sir G. Blane informs us that, in 1780, they were used with advantage in the fleet. (Dis. of Seamen, p. 57.) They will keep a considerable time in a warm climate, and in point of economy have an advantage over most articles employed as antiscorbutics. Infusion of malt, which had been before recommended as a remedy for scurvy,* was employed for that purpose by Captain Cook, who speaks in very high terms of it. He took with him in the Centurion, a large supply of malt, for the purpose of making sweet wort, of which from one to three pints were given daily to each man.f The good effects of wort in the treatment of scurvy have also been noticed by others.^: In 1780, our fleet in the West Indies was supplied with essence of malt. We are told by Sir G. Blane, that it proved of service; but its antiscorbutic proper- ties were inconsiderable ; so much so, that some of the surgeons even denied that it hadany. It was only in the early stages of the disease that the effects of it were sensible. (Ibid. p. 55, 141, 464.) We can reconcile this with the testimony of Captain Cook, and others, in favour of the antiscorbutic properties of infusion of malt, only by supposing that those properties were impaired by the process of extracting the essence ; just as those of lemon juice are impaired in the preparation of syrup. Molasses, also, was recommended, about the same time; and, in the Fou- droyant, the ship in which it was first tried, it answered so well, that in a cruise under Admiral Geary, in 1780, she was the only ship in the squadron that was free from scurvy, which prevailed to such an extent in the other ships, that, on their return to Portsmouth, in the month of August, 2400 men were sent to the hospital affected with it. (Ibid. p. 290.) Subsequently, by order of Lord Howe, molasses was served with rice to the men who were scorbutic, or threatened with scurvy, in the squadron which he commanded ; and the benefit derived from it was so great, that, during the last two years of the war, molasses was made a regular article of ships' victualling, and substituted for a certain proportion of oatmeal. (Ibid. p. 287.) The disease was unquestionably much mitigated by this regulation, but was far from being entirely prevented. It prevailed even to a great extent in some ships well supplied with molasses. (Ibid. p. 55.) There is reason to believe that the antiscorbutic properties of sugar-cane are greater than those of molasses, and that they are much impaired by the process employed in the manufacture of sugar. Fermented Liquors. Spruce beer seems to be the most efficacious of fer- mented liquors. We have abundant proof in the experience of the Northern American colonies, and of the countries bordering on the Baltic, that it is not only an effectual preventive, but an excellent remedy. It has this advantage, that materials for it can often be procured, at all seasons, in countries in high latitudes, where the scarcity of fruits and vegetables renders a powerful anti- scorbutic extremely valuable. These materials can also be carried about, and used occasionally; a plan adopted by Captain Cook with great advantage. Malt liquors possess similar virtues. Frequent notices of the benefit derived from the use of small beer at sea, are to be met with in the writings of our naval physicians; and Sir G. Blane has recorded a striking instance of the good effects of porter. (Dis. of Seamen, p. 301.) Instances are also to be found which afford evidence of the antiscorbutic properties of cider. (Lind, p. 150; Sir J. Pringlds Address to the Royal Society, p. 15.) * Method of Treating the Scurvy at Sea, and Use of Wort in it. London, 8vo. 1767. (Anonymous.) + Phil. Trans. 1776. Address by Sir J. Pringle. t Med. Obs. and Inq. vol. v. On the Use of Wort in the Cure of Scurvy: by J. Bade- noch, M.D. scurvy (Preventives). 435 Wine ranks next to spruce beer and malt liquor in efficacy, and it is perhaps to the habitual use of it that must be ascribed the fact, that the French fleets have generally been less subject to scurvy than our own. The superiority of wine over spirits in this respect has, indeed, been fre- quently noticed; and Sir G. Blane was so convinced of it, that in a memorial, presented to the Board of Admiralty in 1781, he recommended the substitution of wine for rum in the victualling of the fleet. He agrees with Dr. Lind in ascribing even a pernicious influence to distilled spirits.* (Lind, p. 81; Dis. of Seamen, p. 334.) The good effects derived from the use of lemons and other sour fruits, were naturally attributed to their most striking quality, acidity, and it was imagined that vinegar would prove of equal service. It was, in consequence, early recommended as a preventive of scurvy. Experience, however, has shown that this opinion is unfounded. Dr. Lind, in the middle of last century, when scurvy proved so destructive in our fleets, remarked that few ships had ever been in want of vinegar. (Lind, p. 158.) Testimony to the same effect has been given by other naval physicians. Vinegar was liberally supplied to our fleet, in which scurvy was so fatal, in the West Indies in 1780, and the two following yeara (Dis. of Seamen, p. 284), and Dr. Trotter, in his account of the health of tho Channel fleet, in 1795, says that vinegar was carefully served to the messes ol seamen, throughout the squadron, to be used with the salt meat; yet in those ships in which the men took it in large quantities, it was not observed to retard the progress of the disease. (Med. Naut. vol. i. p. 418.) Our own experience furnishes us with many instances of the occurrence of scurvy in a high degree, in ships well supplied with vinegar, even in voyages of moderate duration ; but in the cases in which we have witnessed the disease in the most aggravated form, the crews had no regular allowance of this article. From the facts that have fallen under our own notice, we are led to ascribe to vinegar some antiscorbutic virtue, equal perhaps to that of malt liquor or cider, but not sufficient to render it a substitute for lemon or lime juice. There is indeed some degree of contradiction in the testimony of naval physi- cians respecting the antiscorbutic properties of vinegar, which renders it likely that these vary in some degree with the material from, which the vinegar is prepared. All the substances which we have mentioned as preventives of scurvy, are derived from the vegetable kingdom; and it is probable that antiscorbutic pro- perties are possessed exclusively by substances of vegetable origin. All the mineral acids, and, indeed, most medicines derived from the mineral kingdom, have been tried without success. The antiscorbutic virtue is, as we have seen, possessed in very different degrees by different classes of vegetables and fruits, but in the lowest degree, if at all, by those which are farinaceous. Dr. Lind remarked that scurvy was most commonly met with on land, in persons who subsisted chiefly on dried or salt fish or flesh, and the unfermented farines ; or upon bread made of peas, or a composition of peas with oats. (Lind, p. 93.) Kramer informs us that in his time the disease often occurred in Germany among people, who lived altogether on boiled pulses, without eating any green vegetables or summer fruits. We have already mentioned the prevalence of scurvy among Russian soldiers, whose principal food was rye bread, and meal, and among the inmates of the lunatic asylum at Moorshedabad, where rice and split peas formed the chief articles of subsistence. Its occurrence has also been noticed in prisoners kept on a diet of bread and water. (See a Letter on Solitary Confinement, by J. G. Malcolmson, Esq.) Fresh leavened bread has, however, been supposed to be highly antiscorbutic, * The opinion that distilled spirits have a pernicious influence, is warmly opposed by Dr. Nathaniel Hulme in a Latin thesis, in which the reader will find an elegant and very accurat description of the symptoms of scurvy. (Dissertatio Inauguralis, De Scorbuto.) 436 scurvy (Preventives). and has, in consequence, been recommended by many writers on scurvy; but we must bear in mind that the good effects ascribed to it have been witnessed in sailors, on their return from a long voyage, who were supplied not only with fresh bread, but also with vegetables, the efficacy of which was probably not duly appreciated. The antiscorbutic properties ascribed to bread, seem incom- patible with the fact of which we could bring many proofs, that scurvy may occur in persons with whom bread forms the main article of subsistence.* It has been supposed that flour is antiscorbutic in a much higher degree than biscuit, which has been subjected to the influence of a strong heat; and Sir G. Blane in consequence recommended that in the navy a portion of the present allowance of biscuit should be discontinued, and compensation given in flour, which might be made into bread or puddings. This advice was followed by Sir Edward Parry, who, in his first Polar expedition, by taking with him a supply of flour, was euabled to furnish his crew with a daily allowance of well fermented bread. There is, however, a preparation of oatmeal, which seems to have great efficacy in preventing and curing scurvy. This is sooins, or sowens, an article of food well known in Scotland. It is prepared by pouring hot water on some oatmeal in a wooden vessel, and allowing it to stand till the liquid grows acidulous, which, in a place moderately warm, happens in about two days; the liquid is then poured off from the grounds, and boiled down to the consistence of jelly. Sir J. Pringle has given a remarkable instance, not, however, from his own experience, of the efficacy of this preparation ;f and Sir G. Blane considered it of equal virtue with any antiscorbutic, except the juice of oranges and lemons; and informs us that he knows some well attested instances of crews saved from scurvy by this alone. (Dis. of Seamen, p. 291.) It would be interesting to ascertain whether the acetous fermentation, excited as in sooins, would impart similar properties to other farinaceous substances.^ We have already given examples of the occurrence of scurvy, in the highest degree, in persons well supplied with fresh animal food ; and instances are not wanting, which show that food of this kind is without much efficacy as a remedy. Dr. Lind tells us that in the Salisbury, during a Channel cruise in 1746, the scorbutic people, by the liberality of their commander, were daily supplied with fresh provisions, such as mutton broth and fowls, and even meat from his own table; yet, at the expiration of ten weeks, they brought into Plymouth eighty mop,, more or less afflicted with scurvy, out of a complement of 350. (Lind, p. 66 ; see also Lind, p. 137, and Dis. of Seamen, p. 462.) The opinion that scurvy can be prevented, or cured by fresh meat, is how- ever still held by persons, by whom it is of the utmost importance that correct notions on this subject should be entertained. We have known the most fatal effects result from the erroneous opinions of captains of merchant vessels on this point. During the course of the present year, the captain of a vessel trading to the Mauritius furnished his men, while they stayed at the island, with a plentiful supply of fresh beef, which, being imported from Madagascar, is procured at considerable expense; but neglected to provide them with vegetables or limes, which abound in the island, and are sold at a price scarcely worth naming. The consequence was that scurvy broke out soon after they set sail; and before the ship arrived in this country, one half the men before the mast had died of it, and the rest were totally disabled. * See Med. Trans, vol. iv.; and vol. ii. paper by Dr. Milman. t Address to the Royal Society in 1776, p. 18. t The antiscorbutic properties of sooins require to lie substantiated by facts. In the instance mentioned by Sir. J. Pringle, no detailed account of the circumstances is given; it is noticed, however, that the sooins was seasoned with some prize wine which had turned sour, and which may with reason be supposed to have had some share in restoring the men. Sir. G. Blane is content with expressing his opinion of the efficacy of sooins, without stating the facts on which that opinion was founded. scurvy (Preventives). 437 Portable soup was much used by Captain Cook, and has been extensively employed by Sir Edward Parry, and other modern navigators. Its antiscorbutic properties must depend chiefly on the vegetables it contains. The facts we have adduced seem to lead to the following general conclusions. 1. That antiscorbutic properties reside exclusively in substances of vegetable origin. 2. That these properties are possessed in very different degrees by different families of plants ; and that vegetables and fruits, which are farinaceous, pos- sess them in the lowest degree ; while all those, which possess them in a very high degree, are succulent. 3. That the antiscorbutic virtue resides in the juices of the plant; that it is, in general, considerably impaired by the action of strong heat, and by the pro- cess of vinous fermentation ; and that it varies, in some degree, with the state of maturity of the plant from which it is derived. 4. That these properties of vegetables are not destroyed, but in some instances seem even to be developed by the process of acetous fermentation. We are ignorant of the essential element, common to the juices of antiscorbutic plants, on which the properties in question depend ; but shall, probably, not be deemed too sanguine, if we anticipate that the study of organic chemistry, and the experiments of physiologists, will at no distant period throw some light on this subject. We cannot bring this part of our subject to a conclusion, without insisting on the importance of making a certain proportion of succulent vegetables an occa- sional article of food in jails, poorhouses, and especially in lunatic asylums ;*f in fact, in all establishments where persons are kept a long time on a diet regulated by principles of economy, and subject to little variation. In the pro- visioning of troops, also, in districts which have been laid waste, or where the winter is long and severe, we would recommend the adoption of the same measure, particularly during spring; and, in cases in which difficulty of pro- curing fresh vegetables is likely to arise, that lemon juice, as in the navy, should be provided in their stead. Such a regulation would, we believe, contribute much to the health of the men, and would effectually prevent scurvy, which, we have no doubt, occurs much more frequently under the circumstances we have mentioned, than is generally imagined. The approach of the disease is, in fact, so gradual, that it may advance far enough to reduce the strength of the men considerably, be- fore the real nature of it is discovered by a surgeon, not familiar with its symp- toms or not expecting to meet with it. Dr. Murray, in the report from which we have derived the account we have given of the prevalence of scurvy among our troops at the Cape, in the autumn of 1836, informs us that such was the case in that instance: "that it was not recognised for some time after it appeared, nor until the morbid diathesis had widely extended itself in the corps." He adds also, " I candidly confess that, although I had before treated cases of this malady, I did not know it by its proper name, but used incorrectly to return * We have already mentioned, that the inmates of the Lunatic Asylum at Moorshedabad are annually affected with scurvy; while those of the jail, which is very near the asylum, continue free from it. In the Lunatic Asylum at Madras, also, scurvy occasionally shows itself. The greater frequency of scurvy in lunatic asylums, than in other establishments in which the diet is in no respect better, is, we imagine, not owing to greater liability to the dis- ease in lunatics, but to the great length of time they remain in those establishments. In the Milbank Penitentiary, in 1823, scurvy first appeared in those who had been longest confined there. The occurrence of scurvy in persons long insane, has also been noticed in this country. (See Prilchard on Insanity, p. 149.) t Wc have met with a partial epidemic of scurvy associated with malignant dysentery in a lunatic asylum : the chief cause seemed to be want of sufficient exercise in the open air, and a deficiency in fresh vegetable food. It gradually ceased as soon as this was remedied. The bodies of chronic lunatics seem to be always in a condition which depresses the powers of life, and renders them to a great degree incapable of resisting severe diseases. G. 438 scurvy (Symptoms). it under the heads, Purpura, Cachexia, Neuralgia, Rheumatism, CEdema, &c, until its late extraordinary prevalence in the 75th regiment (at the Cape), and the recent admission into the civil hospital there, from whaling vessels, of a number of sailors affected with it; which attracted my particular attention to its diagnosis." Symptoms. A change in the complexion, from its natural healthy tint to a pale, slightly sallow, and dusky hue, is generally one of the earliest indications of scurvy. This change is attended with great languor and despondency, and with aversion to every kind of exercise, and the patient is readily fatigued, and complains of pains in the muscles, especially of the legs and loins, like those produced by over-exertion. The gums soon become sore, and apt to bleed on the slightest touch. On examination, they are found to be swelled and spongy, and of livid redness. Lividity of the gums first appears, and is always deepest at their free edges, diminishing gradually towards the roots of the teeth; while the lining membrane of the lips does not exhibit it in the slightest degree, but, on the contrary, is unusually pale. As the disease advances, all these symptoms become more marked; the complexion acquires a more dingy and somewhat brownish hue; the debility increases, so that the least exertion causes breathlessness and palpitation, and not unfrequently an alarming syncope; the gums become more swelled and more livid, forming, in some cases, a black spongy mass, which completely conceals the teeth, and they frequently slough, especially at their edges, leaving the crowns of the teeth exposed; the teeth themselves become"loose, and often drop out, without having suffered decay; and the breath is remarkably offensive. The patient, from the beginning of the affection, is subject to haemorrhages. These occur most frequently from the gums and nose, and from any ulcers he may happen to have; but often, also, from the intestines; occasionally from the stomach ; and, in some rare instances, from the bladder. Of the last nine cases that have fallen under o"ur observation, in all which the disease was advanced, seven presented epistaxis. In most of these, bleeding from the nose occurred, for the first time, at an early period of the disease, and recurred several times, but in all it ceased spontaneously. In three of these nine cases, blood has been passed by stool: it is probable that haemorrhage from the intes- tines, happened in a greater number of these cases, but was unobserved. In none of them was there any hasmorrhage from the stomach, lungs, or bladder. In taking notes of these cases, great attention was paid to this point. Of twenty-seven cases, the notes of which were taken previously, but not with equal care, three presented haematemesis; and in one of these three the vomit- ing of blood recurred several times. We have never had a patient affected with scurvy in whom haemorrhage from the bladder, or haemoptysis, was stated to have occurred.* Ecchymoses also appear on the skin, in the form of petechial spots, particu- larly on the lower extremities; often, however, in advanced stages of the dis- ease, on the arms and trunk, but rarely on the head or face. These petechia?, which are sometimes very numerous, are generally small and circular; the centre of each spot being the point at which the skin is perforated by a hair. Besides these petechial spots, we often meet, especially when the disease is far advanced, with other spots, as large as the palm of the hand, sometimes much larger, in which the skin is of a variegated violet and green tint, and which resemble in every respect marks produced by a severe bruise. These bruise- like marks occur without the infliction of any blow, or at least of one sufficient to attract the patient's attention, and often surround an old scar, or appear on a part, which, a long time previous, had been the seat of some injury. Like the smaller petechial spots, they are met \vith most frequently on the lower e have stated that hasmorrhag Dr. Lind, and other authors. scurvy (Symptoms). 439 extremities, but are not uncommon on the arms and trunk, and in a few instances we have observed them along the border of the lower jaw. Effusions not, we imagine, of pure blood, but composed chiefly of its fibrinous portion, take place also in deep-seated cellular tissue, and between layers of muscles, particularly in the legs and thighs. The parts which are the seat of these effusions are painful, when pressed or moved, and are much swollen, and of a hardness like that of board, so that they resist the strongest pressure of the finger. The skin covering these parts is thickened, and firmly adherent to the parts beneath,* from which a fold of it cannot be pinched up: it sometimes retains its natural colour, but more commonly presents the appearance of a bruise. These effusions are sometimes very partial, frequently confined to the calf or thigh of one leg; but their most common seat is the ham, where the swelling is often very considerable, and always attended with stiffness and contraction of the knee-joint. This swelling of the ham and contraction of the knee-joint, a symptom which has much attracted the attention of writers on scurvy, some- times occurs very early, and in cases in which the other symptoms are mild. In a patient at present under our care, in whom the other symptoms of scurvy are by no means severe, the calf and ham of the left leg are much swollen, and the knee-joint is stiff and contracted, the leg being at right angles to the thigh. This swelling of the ham, and contraction of the knee-joint, came on at a very early stage of the complaint, and were attended with pain on any attempt to move the leg, and with some degree of tenderness on pressure, symptoms which have ceased, however, after a treatment of two or three days : the parts which are thus swollen are hard and brawny, and no impression is left by the finder, except over the tibia, where there is some pitting. The skin is thickened, and glued to the parts beneath, but presents no discoloration, except on the inner aspect of the calf, where, in a space nearly as large as the palm of the hand, it has the appearance of a bruise, and gives to the hand a sensation of greater heat than elsewhere. There is not at present, nor has there been from the commencement, any swelling or oedema of the foot. There are a few scattered petechia? on this, and on the opposite leg, which is free from swelling, and of which he retains the perfect use. Contraction of the joint (which has been ascribed in such cases to contraction of the tendons), as well as swelling of the ham, result we imagine, from a solid effusion, chiefly of the fibrinous part of the blood, between the tendons and the bone; which, acting as a foreign body, prevents the tendons from coming in opposition to the bone, which is necessary for extension of the leg. Stiffness and contraction, such as we have described, are not peculiar to the knee-joint. Instances are mentioned by authors of similar contraction of the elbow-joint (see Phil. Trans., vol. lx. paper by Dr. Mertans); and in a case which has recently come under our notice, both ankles were affected in like manner. In this patient there was no swelling of the calves or contraction of the hams, but the feet were extended and the heels drawn up, as in that form of club-foot, which has been designated Pes equinus.f When he attempted to stand, his toes only came in contact with the ground; and if, while he was seated, his feet were placed flat on the ground, and kept so, on making an effort to rise he fell backwards. The skin over the tendo-Achilles was in both ankles the seat of an extensive bruise mark. We have stated that the skin of the swelled and indurated calves and hams, sometimes retains its natural colour; this seems to depend on the effusions taking place beneath the fascia, without involving the subcutaneous cellular tissue. But even in such cases the skin is thickened and brawny, as if infil- trated with the fibrin of the blood, and is firmly adherent to the parts beneath.:{: * This does not depend on the skin being stretched. We have found the skin adherent in this way over the calf when the latter has been very slightly swollen, and but little larger in circumference than the calf of the opposite leg, which was unaffected. t Similar cases have been noticed by Baron Larrey, Mem. de. Chir. Militaire, torn. ii. X Occasionally, when a scorbutic person has received a slight blow or contusion, there is an 440 scurvy (Symptoms). The situations we have mentioned are not the only ones in which such effu- sions take place; they occur also very frequently between the periosteum and bones, causing node-like swellings, which are often exquisitely tender. We have met with these on all the long bones of the lower extremities, but most frequently on the tibia?; they often occur also on the rami of the lower jaw, where they are marked by swelling of the lower part of the face, following the outline of the jaw, and by great tenderness on pressure; and in one instance we have seen a swelling of the same kind, on the roof of the mouth, occasioned by an effusion under the periosteum of the palate bone. The effusions, whether of blood or of fibrin, are never followed by suppura- tion, and, when they exist between the periosteum and bone, do not, however great their extent, lead to exfoliation of the bone. Under the influence of appro- priate general treatment they become absorbed : the petechia? and bruise-marks on the skin disappear in the same manner as when occurring in ordinary cir- cumstances : when the effusions are more deeply seated, the absorption of them is marked by diminution of swelling, and of pain when the limb is moved : the node-like swellings of the periosteum become rapidly less tender, diminish in size, continuing, however, for some time to pit on pressure, and gradually disappear. The extent to which these effusions take place is very variable; although oc- curring under the influence of slight, often inappreciable causes, they seem in some degree accidental, and do not afford a correct measure of the severity of the disease. Swelling and contraction of the ham, for instance, is often wit- nessed in one leg only, and sometimes at an early period, while in other cases, even in advanced stages, it does not exist at all. Like variation is observed, in the extent and number of petechial spots, bruise-like marks, and nodes, and in the time of their occurrence. It is to the effusions, especially to those between the periosteum and bones, that we must ascribe the pains scorbutic persons suffer. These pains are con- fined to the parts in which effusions exist, and are consequently most common in the legs and jaws ;* they are not increased by the heat of the bed, and are not more severe at night than by day; the patient, when quite still, is at ease, but the exertion of walking, and, in advanced stages of the disease, even the act of turning in bed, or any attempt to move the affected limbs, is productive of great suffering. If a scorbutic person have any wounds or ulcers, these assume a peculiar aspect. At first, the discharge from them is thin and sanious; later in the dis- ease it coagulates, forming a dark crust which adheres to the surface of the ulcer, and is with difficulty separated from it. If this separation be effected, the ulcer is apt to bleed, and the crust, which consists chiefly of coagulated blood, is formed again in a few hours. Underneath this crust the surface of the ulcer is soft and spongy; and livid, fungoid granulations sprout up at its edges. In a still more advanced stage, the surface of the ulcer is covered with a soft dark coagulum, which, when scurvy was more common than at present, was familiarly termed by sailors bullocks liver, from its resemblance in colour and consistence to that substance boiled. This coagulum often rises in course of a night to a size that would scarcely be credited, and if destroyed by cauteriza- tion, or the knife (in which case copious haemorrhage generally ensues), it is reproduced in a few hours, appearing at the next dressing as large as before. (Lind.) The slightest wounds and scratches, which in ordinary circumstances would be scarcely noticed, are apt in scorbutic persons to degenerate into ulcers of this description. These ulcers continue without much change until the scor- butic habit is corrected. It is worthy of remark, that they rarely become gan- effusion of actual blood under the integument, or between the muscles; but this forms a soft, indolent tumour, and remains liquid until it is absorbed. It is very different from the ordi- nary effusious in scurvy, which are painful and solid from the commencement. * Headache, properly so called, is rarely, if ever, experienced by scorbutic persons. scurvy (Symptoms). 441 grenous, and that they may exist for a long time on the spine of the tibia, and other parts, without affecting the bone. Not only wounds and ulcers, but all eruptions on the skin, particularly when seated on the lower extremities, assume in scorbutic persons a livid or purple colour. It is the modification produced by the scorbutic habit in these cuta- neous affections, that in many instances certainly has given rise to the varieties described by authors as lichen lividus ;* ecthyma cachecticum, &c. The symptoms we have described are all the effects of a common cause, but have no mutual dependence, and the order of their succession is not constant. When the scorbutic habit is established, parts previously debilitated are the first to assume the characters peculiar to scurvy. If, for example, the patient have lately been mercurialized, it is in the condition of the gums that the disease will be first manifested ; if he have recently suffered a sprain of the ankle, that part by becoming swelled, painful, and soon after covered with ecchymoses, will give the first token of scurvy ;j" if he have any ulcers, or eruption on the legs, these will be the first to put on the scorbutic appearance even before a change in the complexion has led to a suspicion of the disease. The pulse in scurvy is generally slower and more feeble than in health, and the patient is frequently chilly; but occasionally, especially when the disease is far advanced, we find the skin hot, and the pulse attaining, or even exceeding the rate of 120 a minute. This variation in the temperature of the skin and in the frequency of the pulse, has given rise to the designations hot, and cold scurvy; and for a long time it was imagined that there was spme essential dif- ference between these forms. In all the cases in which we have witnessed quickness of pulse and heat of skin, there have been effusions between the mus- cles, or between the periosteum and bones: the tumours caused by these effu- sions were exquisitely tender, and the slightest movement of the limbs occasioned great suffering. It is to an inflammatory action, connected with the presence of these effusions, that we are inched to attribute the fever in such cases.J (Lind, p. 390. 2d ed.) The natural secretions are scanty. There is suppression of perspiration, and the skin is dry and rough, and of the aspect, which has obtained the popular designation, " goose-skin." This, however, is not universally the case: the skin of the swelled legs in most frequently smooth and shining, from distension ; and we have met with one instance in which, at an advanced stage of the * Willan remarks, that in this variety of lichen the papulae, which are found chiefly on the extremities, are sometimes intermixed with petechia?, or with larger purple patches and vibices. He notices the affinity which it has to scurvy, and which is shown by its arising under similar circumstances, and yielding to the same mode of treatment. (Cutaneous Dis- eases, p. 15.) Biett says that in this form of lichen, which occurs in persons weakened by distress and privations, the papulae are seated chiefly on the lower extremities, and are often mixed with purple, or hemorrhagic spots. He observes that it is extremely rare. In the time of Willan it was probably much more common in England than in France, for the reasons we have stated when speaking of the causes of scurvy. t We have more than once observed, in sailors admitted into the Dreadnought on account of scurvy, an extensive bruise-mark on the knee or ankle, to which a blister had been applied some time previously under the idea that the pains which the patient suffered in the limb, and which were in reality scorbutic, were owing to inflammation affecting these joints. In such cases the blister rises well, discharges serum as usual, and heals readily ; but in the course of some days the patient finds the part tender to the touch, and by observing that it is the seat of an extensive deep violet-coloured spot, first discovers the real nature of his complaint. t In such cases, when blood is taken from the arm, the clot contracts firmly, and has a buffy coat. The effusions between the muscles, and under the periosteum, which are so com- mon in scurvy, do not result from simple haemorrhage. The fluid poured out is not pure blood, which always remains soft, and in some measure liquid; nor serum, which causes oedema; but a fluid, which glues the parts together, and gives a feeling of hardness. It can be no other, therefore, than the fibrinous portion of the blood; mixed, it may be, with a small proportion of the other constituents. The process is not wholly passive, but gravitation seems to have something to do with it, and the state of the blood still more. With these conditions, the process may properly be called inflammatory. vol.in. 56 442 scurvy (Symptoms). disease, the patient was subject to profuse sweats, a peculiarity for which no- thing in his history enabled us to account. After he came under our notice, he was plentifully supplied with lemon juice, which seemed to increase the perspiration, so that at the end of two days his chest was found covered with sudamina. The urine is transparent, but high-coloured and scanty : it is, however, quickly restored to its normal condition. We have examined the urine in numerous instances after the patients had drunk freely of lemonade for two or three days, and have then almost uniformly found it nearly natural in colour and quantity; transparent; imparting a red tint to litmus paper; and not losing its trans- parency by the action of heat or nitric acid. The bowels are, in some cases, regular throughout the whole course of the disease; but they are more fre- quently, and indeed generally, confined. We have met with instances in which the patients have had no discharge from them for seven or eight days. The evacuations present, in general, no remarkable appearances. But, though usually costive, scorbutic persons are liable to occasional liquid stools, which are uncommonly foetid, and probably consist chiefly of altered blood. The secretion of saliva is generally natural: we have never witnessed a case in which spontaneous salivation occurred. It has been remarked, however, by Dr. Lind and others, that scorbutic persons are very susceptible of the influence of mercury, and that very small quantities of this medicine are sufficient to bring on copious and dangerous salivation. (Lind, p. 126. et alia.) The tongue is almost always clean, moist, and pale. In some instances, in which there was unnatural heat of skin, with quickness of pulse, we have re- marked the tongue to be small; but, when these febrile symptoms are absent, we often find it broad, and its edges indented. The inside of the lips is also clean, smooth, and extremely pale, presenting the aspect which it has in chlo- rosis. The contrast between the pale, bloodless lips, and the livid and spongy gums is very striking. The lividity and sponginess is always limited to the gums, ceasing abruptly at the reflection of the lips, and of the mucous mem- brane connecting the tongue and interior of the lower jaw, and seldom ex- tending over the palate to a distance of more than two or three lines from the teeth. In some rare instances, however, the lividity extends nearly all over the hard palate; but we have never seen either the lips, the inside of the cheeks, the tongue, or the fauces, present any thing but the pallid appearance we have described. The patient frequently acknowledges a slight degree of thirst; but the appetite, in almost all cases unattended with fever, continues, even in advanced stages of scurvy, as good as, or better than in health, and the powers of digestion remain unimpaired. Patients have often spoken to us of the sufferings they endured before their arrival in port, from hunger, which the state of their gums did not allow them to appease by their hardened ship's provisions. In the early stages of scurvy patients generally sleep well; but when the disease is far advanced, one of the most constant symptoms is indisposition to sleep, for which these persons can often assign no cause. The intellect is, in all cases, unaffected ; the memory remains clear; and the patients, though much dejected, talk rationally to the last moment of their lives. Their senses also continue perfect. Sir Gilbert Blane (Dis. of Seamen, p. 461) has, indeed, remarked weakness of the eyesight as an occasional symptom, but it is not mentioned by other authors, and must be of rare occurrence.* Our own experience furnishes us with only one instance in which any defect of vision was complained of: this was in a man highly scorbutic, and at the same time dropsical from organic disease of the kidney. He died while under our care ; and for a week before his death complained that his sight was dim, and * Dr. Hulmc relates tho case of a man affected with scurvy, who could see only in a strong light. He suffered no pain in the eyes, which appeared clear and healthy, except that the pupils were dilated. The pupils were, however, sensible to every variation in the intensity of light. This symptom disappeared with the ordinary scorbutic symptoms. (Hulme, De Scorbuto.) scurvy (Symptoms). 443 that all?objects appeared green. In those cases of scurvy, in which we have remarked the state of the pupils, we have generally found them dilated. We have already spoken of the debility, and the tendency to swoon, in per- sons affected with scurvy. In high degrees of scurvy this tendency is so great, that the slightest motion, the erect posture even, occasions fainting, which some- times proves fatal. The fact that scorbutic persons not unfrequently expire suddenly, on any exertion of strength, has, indeed, been noticed by all writers on scurvy, as constituting one of its most remarkable features. It is well ex- pressed in the following passage, which we have quoted from the narrative of Lord Anson's voyage :—" Many of our people, though confined to their ham- mocks, ate and drank heartily, were cheerful, and talked with much seeming vigour, and in a loud, strong tone of voice; and yet, on their being the least moved, though it was only from one part of the ship to another, and that in their hammocks, they have immediately expired ; and others, who have con- fided in their seeming strength, and have resolved to get out of their hammocks, have died before they could well reach the deck. And it was no uncommon thing for those who could do some kind of duly, and walk the deck, to drop down dead in an instant, on any endeavours to act with their utmost vigour ; many of our people having perished in this manner during the course of this voyage." When the disease is considerably advanced, the breathing is often quicker than natural, the inspirations attaining the rate of twenty-four to twenty-six in a minute, without cough or complaint of pain. We have generally found this symptom of the frquency of the act of breathing associated with increased fre- quency of the pulse. Occasionally, in the latter stages of the disease, the breathing is still more rapid, the inspirations thirty-six a minute,, or more, and the patient has cough, and expectorates frothy mucus, or a transparent fluid of mucilaginous consistence. Towards the close of the malady the dyspnoea some- times becomes extreme. When speaking of the morbid anatomy of scurvy, we shall give the details of a case in which this circumstance occurred., We have recently practised auscultation and percussion on six patients under our care at once, affected with scurvy in a high degree ; and with the same re- sult in all. The chest was every where unusually resonant, and the respiratory murmur louder than natural, and pure.* The sounds of the heart were loud and extensive, but unaccompanied by any morbid bruit. In these cases the condi- tion of the abdomen was observed at the same time ; in all it was soft and flaccid, and without tenderness on the strongest pressure; in none could the liver or spleen be felt below the false ribs.")" We have already mentioned, that parts previously debilitated or injured are especially prone to assume the scorbutic appearance* Our own experience fur- nishes us with two instances which may serve as illustrations of this fact. The first occurred in a man, aged 60, who was admitted into the Dreadnought, on the 18th of April, 1837, in the last stage of scurvy. On the middle of his left shin was a livid spot, larger than the palm of the hand, and in the centre of this spot, a scar, which, he assured us, had been there twenty years, and resulted from a wound caused by the kick of a horse. The second instance was in a man aged 55, who came into the Dreadnought on the 4th of June, 1837. Tho right foot was swollen and painful, and all the outer part of that foot and ankle was the seat of an extensive bruise-mark, which surrounded a scar occasioned by a blow he received in 1813. In high degrees of scurvy it is not unusual for ulcers, long healed, to break * The unusual resonance on percussion of the chest, results probably from an anssmic con- dition of the lungs. (See cases in the chapter on the Morbid Anatomy of Scurvy.) t An account, published by Dr. Mead, of the dissection of a man who died of scurvy, and whose spleen weighed five pounds and a quarter, has, from the dearth of facts, illustrative of the morbid anatomy of scurvy, been quoted by many subsequent writers. This man, who came from Sheppey, was affected with ague as well as with scurvy; and it is, unquestionably, to the former disease, that the very large size of the spleen must be ascribed. 444 scurvy (Anatomical Characters). out afresh. Lord Anson relates the case of a man on board the Centurion who had been wounded fifty years before at the battle of the Boyne. " His wounds soon healed, and had continued well for many years, when, in the progress of scurvy, they broke out afresh, and seemed as if they had never been healed ; nay, what is still more extraordinary, the callus of a broken bone, which had been completely formed for a long time, was found to be hereby dissolved; and the fracture seemed as if it had never been consolidated." A case in which bones consolidated after fracture became disunited in the progress of scurvy, is mentioned by Dr. Mead ; and not long ago an instance of the same kind was witnessed in a patient in the seaman's hospital, Dread- nought. This man, while in China, broke one of his ribs, which united in the usual time ; in the voyage home he became scorbutic; the rib which had been broken, became disunited, and was so on his arrival in this country, when he was admitted into the Dreadnought. On his recovery from scurvy, the rib speedily united again. Another symptom, somewhat allied to the preceding, is mentioned by authors as occurring in children and young persons, in advanced stages of scurvy; namely, separation of the epiphyses, from bones. (See Phil. Trans, for 1669 and 1670.) No instance in which this occurred has ever fallen under our own notice, and the symptom has not been remarked by naval physicians; a circum- stance unquestionably owing to the mature age of the generality of sailors. Although it is not unusual for ulcers that have been long healed to break out afresh in persons affected with scurvy, there is very little disposition to become ulcerated in parts that have not previously been so. We have often had to treat scorbutic patients, who had been confined to their hammocks six or eight weeks, and during that time had been scarce able to change their posture by reason of the pains occasioned by any attempt to move the legs; but we have never met with an instance, in which sores were produced by lying. We have at present under our care a man who has recently come from the Mauritius, in a vessel in which all the crew were in a dreadful condition from scurvy. On his passage outwards, seven months before he was received into the Dreadnought, he be- came hemiplegic ; the paralysis of the arm and leg was complete, and he was quite unable to sit up in bed; his urine and faeces also passed involuntarily. Notwithstanding all this, he had no sores on the sacrum, hips, or any other part of his body. In advanced stages of scurvy we have generally found patients much ema- ciated. This, however, is not always the case; we have even met with an instance, in which, up to the last period of the disease, the patient had expe- rienced no loss of flesh. Loss of flesh is not dwelt on by authors among the symptoms of scurvy. The persons in whom we have observed it were sailors, who had nothing to eat but hard salt beef and ship biscuit, which they could not masticate from the state of their gums. Many of them have assured us that, although hungry, they have often passed the entire day without eating. Anatomical characters. Notwithstanding the great mortality occasioned by scurvy, and the attention it excited up to the present century among the most distinguished physicians, very little is known of its morbid anatomy. The records that we possess of dissections of persons, dead of this disease, are very few ; and in these, the terms in which the state of organs is described are often vague, and leave us in doubt as to the meaning.they convey. At the present day scurvy very seldom proves fatal, except at sea, in ill-equipped vessels ; so that opportunities of supplying this deficiency in former treatises on scurvy, are extremely rare.* We have had an opportunity of examining the state of the organs in three subjects only, who at the time of their death were affected with scurvy. In the * For dissections of subjects who died of scurvy, see Narrative of Lord Anson's Voyage; Phil. Trans, for 1G69; Diet, des Sc. Medicales, art. Scorbut; Rouppe De Morbus Navigan- lium. scurvy (Anatomical Characters). 445 first of these instances, the patient, John Rumney, twenty-five years of age, died soon after his admission into the Dreadnought, simply of scurvy. He had come from the Mauritius in a vessel in which scurvy prevailed to such a degree, that one-half of the men before the mast had died of it in their passage home- ward, and the rest were so disabled that, for some time before they arrived in port, the vessel was worked entirely by the officers. The following were the appearances noticed in an examination made twenty- five hours after death :— The body was much emaciated ; the extremities were rigid ; and on the back there was an extremely faint violet stain. The mucous membrane of the oesophagus was pale and healthy. The sto- mach was large ; its mucous membrane in the splenic extremity was thin and soft, and presented a dark gray stain in lines (apparently folds of the stomach); elsewhere, it was pale, of natural thickness and consistence, not mammellated. The duodenum contained a fluid tinged with a yellow bile ; its mucous coat was pale and healthy. The mucous membrane of the small intestines, in all their extent was pale, and had no appreciable alteration in thickness or consistence. Many patches of Peyer's glands were very conspicuous, from being dotted with black points, and of a darker cast than the surrounding membrane; but they had no unnatural thickness or softness. The coats of the jejunum offered, here and there, some dark (blackish) spots, about the size of split peas ; the mucous and peritoneal coats, when stripped off, were free from this stain, which was con- fined to the intervening muscular coat of cellular tissue, and which probably re- sulted from ecchymoses. There were none of these discolorations in the ileum. The contents of the small intestines were natural. The large intestine was filled with solid faeces of a light yellow colour. Its mucous surface presented a blackish or dark gray stain in variable degrees; this stain was found to involve the mucous coat, which offered a few small, scat- tered, and very superficial ulcerations. Some of these ulcerations occupied the centres of stained spots, while others, as well as the surrounding mucous mem- brane, were perfectly pale. In the lower portion of the large intestine was some viscid mucus (probably resulting from the irritation of scybala), adherent to the mucous coat. The external surface of the large intestine, though in much less extent than the internal, also presented some blackish stains ; these stains were confined to the peritoneal coat, which, on being stripped off, retained this colour. There was no general discoloration of the peritoneum ; no enlargement of the mesenteric glands ; no blood in any portion of the intestinal canal. The liver was of nutmeg appearance (colours contrasted, buff, and red); of normal consistence, and 3 lbs. 9 oz. avoid, in weight. Liquid blood issued from some large vessels divided by incision. The gall-bladder contained some yellmo bile of the consistence of thick syrup. The spleen was soft, of a plum colour, and weighed ten ounces and a half. By squeezing it, the fluid portion was made to exude, and a whitish spongy mass was left. The pancreas was perfectly natural; the parotid also. The larynx and trachea contained a white, frothy fluid ; their mucous mem- brane was pale and healthy. Both lungs were united to the pleura costalis by old adhesions, which were infiltrated with serum ; and both of them were very pale, and remarkably oedematous. When they were cut into, there was an abundant flow of serum, which could be seen streaming from minute bronchial tubes ; "these were readily distinguished from the veins, which gave issue to liquid blood. The lower lobes of both lungs, on account of the oedema, gave no crepitus on pressure, but had a tough, doughy feel; there was no softening of their tissue, and all the serum could be squeezed out. The heart was about the size of the fist, and when emptied of its contents, 8 oz. avoid, in weight; it was flabby, and its muscular tissue remarkably pale; the proportions of the cavities were natural, as well as the thickness of the parietes, the valves per- fectly healthy ; the lining membrane of the heart and of the vessels, pale. In the left auricle was a white, fibrinous clot, which was firm, and of the size of a 446 scurvy (Anatomical Characters). nutmeg, with threads which extended into the vessels. In both cavities on the right side were larger white clots with threads ; in the left ventricle, only a few small portions of fibrin, entangled in the chordae tendineae of the mitral valves. The pericardium, which had its usual polish, contained some ounces of limpid serum. In the large veins the blood was thin and liquid. The kidneys were pale but healthy ; the weight of each, 65 oz. A catheter was introduced into the bladder, and some urine drawn off, which was trans- parent, acid, and free from albumen. The surface of the brain was very pale, and presented considerable effusion of serum under the arachnoid. When the hemispheres were sliced, the surface of the incisions offered some bloody points; there was no softening of the cere- bral substance. The choroid plexuses were very pale, and each lateral ventri- cle contained some colourless serum. The pectoral muscles were of good colour; the temporal, and the muscles of the thigh, paler than natural. There was no oedema of the legs, no swelling and hardness of the calves, an alteration so fre- quent in scorbutic persons. On the left tibia was a node-like swelling, which had attracted our attention during the lifetime of the patient. This leg was injected with size, before it was examined ; the injection was very successful, the fluid employed returning by the veins, and imparting a vermilion colour to the integument. On cutting down over the tibia, there was found under the fascia, a thin layer of coagulated blood, but no sensible extravasation of the size, and no injection of the clot. On cutting deeper, the periosteum was found to be separated from the bone, for the length of six or seven inches, by solid fibrinous effusion or clot, of chocolate colour, and a line or two in thickness. On the periosteal and osteal surfaces of this clot, there was a slight extravasa- tion of the size, but the clot itself was beautifully injected. Small injected ves- sels could be seen in the clot by the naked eye, and by aid of a glass they were very manifest. When the periosteum, which was itself thickened and infil- trated with blood, was gently stripped from the clot, many threads were seen to pass from one to the other ; these were evidently vessels, and some of them filled with size. On stripping the clot from the bone, some vessels were also seen filled with size, coming from the former, and entering the latter; but the vascular connexion of the clot and bone was much less than that of the perios- teum and clot. The clot in question surrounded the tibia, with the exception of the ridge on the anterior and outer surface of the bone ; on this ridge the periosteum adhered to the bone, but could be readily stripped from it. A. few lines beyond the limits of the clot the periosteum was perfectly natural in ap- pearance, and adhered to the bone with its usual firmness. The bone itself did not appear diseased; it was firm, and resisted the saw as much as usual. The membrane lining the medullary canal was well injected, and the bone itself was injected in a slight degree. There were other clots separating the periosteum from the bone, on the fibula of the same leg; one on the femur, some on the tibia of the opposite leg. There was no extravasation of the size that could be detected by the naked eye, on the integument or between the muscles; in fact, none except that already mentioned between the periosteum and bone. The periosteum was separated by a clot from the bone of the lower jaw in its whole extent, except at the attachments of the temporal and pterygoid muscles; at the neck of the bone on each side; and also in a space, about an inch in breadth, inside and out, at the chin. The attachments of the genio-hyo-glossi were preserved ; those of the mylo-hyoid on both sides destroyed.* Where the periosteum was detached from the bone, the intervening clot was black, and a line or two in thickness. A considerable portion of the gum, immediately surrounding the teeth, had * Dr. Cook, in a letter to Dr. Lind, describing the scurvy that prevailed in the garrison at Riga, in the spring of 1751, says, "their rotten gums gangrened, as also their lips, which dropped off; the sphacelus spread to their cheeks and the muscles of their lower jaw; and the jawbone in some, fell down upon the sternum." (Lind, p. 280.) scurvy (Anatomical Characters). 447 sloughed. The bone had a dark stain in a space extending three or four lines from the edges of the alveoli; elsewhere it appeared healthy. There was no caries. On the upper jaw also the periosteum was separated from the bone by a dark clot, which extended as high as the zygoma. In portions of the bones of the leg or face, where there were no clots, the periosteum was healthy, and firmly adherent. There was no effusion between the muscles of the face; no enlargement of the salivary glands. There was a considerable ecchymosis between the muscles covering the abdomen. In this patient scurvy existed almost without complication. Before its acces- sion, indeed, he had taken mercury, which, perhaps, rendered the state of the gums worse than it would otherwise have been, but which did not modify in any other way the progress of the disease. The great emaciation was probably oc- casioned by abstinence from food; for some time before his admission to the Dreadnought, he had nothing to eat but hard salt beef or pork, and ship bis- cuit, which, for many weeks, he must have been unable to masticate. To the same cause we may perhaps ascribe the softness and thinness of the mucous membrane of the stomach. GEdema of the lungs, and the extreme debility to which he was reduced, seem to have been the immediate cause of his death. After death, the chief morbid appearances, observed in the organs of diges- tion, were softness and thinness of the mucous coat in the splenic extremity of the stomach; an alteration which the good appetite and the power of digestion, usually possessed by scorbutic persons, would lead us to suppose occurs seldom in scurvy; small, superficial ulcerations of the mucous membrane of the large intestine; and blackish stains in the muscular coat of the jejunum, and in the mucous and peritoneal coats of the large intestine. The comparison of this case, with the two following, renders it very probable that these stains are referrible to the scorbutic habit, and that they resulted from haemorrhages, the tendency to which is so characteristic of scurvy. It is worthy of remark, that no traces of disease were observable in the mesenteric or salivary glands. The bile, instead of being of its usual olive colour, was yellow ; it is probable that this alteration in the character of that secretion resulted also from the scorbutic condition, and it may perhaps serve to explain the constipation so often remarked in cases of scurvy, as well as the peculiar cast of complexion in persons affected with this disease. In the lungs the only morbid change was the oedema, which must have taken place in the last days of life; and, with the exception of paleness and a flabby state of the heart, no appearances of disease were discovered in the central organs of circulation. Nothing was remarked of the state of the blood, except that it was thin and fluid in the large veins. That it was deficient in quantity, at least of red particles, was shown by the faintness of the violet stain on the back at the end of twenty-five hours after death ; by the paleness of the muscles, and of the mucous membrane of the intestinal canal in its whole extent, of the mucous membrane of the bronchi, of the pulmonary tissue, of the brain and choroid plexuses, and of the kidneys; as well as by the paleness of the tongue, and mucous membrane of the lips, observed during life. The fibrinous clots in the ventricles show, however, that it had not lost the property of coagulating: it is also worthy of remark, that it had imparted no stain to the lining mem- brane of the heart or vessels. But the most singular fact which this dissection discloses is the presence of clots between the periosteum and bones of the jaws and lower extremities. Painful nodes on the tibia;, and swellings along the lower jaw, have been mentioned by many writers as symptoms of common oc- currence in advanced stages of scurvy; but we are not aware that the cause of them has ever before been ascertained. The persistence of the vascular con- nexion of the periosteum with the bone, through the clot, renders it probable that the effusion took place very gradually, and serves also to explain the cir- cumstances, noticed by Dr. Lind, that, although scorbutic nodes continue a long 448 scurvy (Anatomical Characters). time on the tibiae, they never give rise to exfoliation of bone. The fact that, notwithstanding the force used in injecting the leg, there was no extravasation of the size, that could be detected by the naked eye, on the integument, in the subcutaneous cellular tissue, or between the muscles, affords an argument in support of the opinion that the haemorrhages in scurvy result more from a change in the blood than from weakness of minute vessels. In the second fatal case the patient, set. 23, was admitted into the Dread- nought, immediately on his arrival from Calcutta, and was affected with albu- minous dropsy, as well as with scurvy. At the time of his admission his legs were sprinkled with petechial spots, and his gums formed a black, spongy mass, which completely concealed the teeth. He was tapped two days after his admis- sion, and three gallons and a half of serous fluid, slightly tinged with blood, were drawn off- This produced temporary amendment, but at the end of some days inflammation of the pleura supervened, and he died a fortnight after his arrival in this country. The following notes were taken of the morbid appear- ances. The body was very oedematous. In the cellular tissue, under the lower portion of the great pectoral muscle on the left side, and ahove the ribs, there was an infiltration of pus, which had no communication with the pleura. The lower lobe of the left lung was united to the pleura costalis and dia- phragm by very soft adhesions; the false membranes that formed these adhe- sions were imbued with pus, and the pleural cavity contained a considerable quantity of turbid serum. The pleura costalis presented a mottled rosy appear- ance : the lung itself was healthy. The cellular tissue over the pericardium was infiltrated with pus. The pericardium contained a small quantity of serum, and had its usual polish, except on the surface of the heart, where there were a few thin shreds of false membrane. The heart was natural in size ; the parietes of the left ventricle thickened; in other respects it was normal. The valves were quite healthy. The right lung was healthy, but somewhat compressed by a considerable quantity of colourless serum in the pleural cavity. There was no appearance of inflammation about the puncture made by tap- ping. The intestines, which (especially the large) were much inflated, pre- sented on the outside a blackish-green, or dark olive tint. The peritoneal coat, when stripped off, was almost uniformly of this colour. The mucous membrane of the stomach presented in the splenic extremity a similar dark-green colour, in spots about the size of pins' heads. In the pyloric extremity, which did not offer this colour, there was a bright blood-red mottling, which resembled in every thing but colour the mottling in the splenic extremity. The mucous mem- brane of the small intestines appeared as if sprinkled with a fine dark green powder ; the coloured points were in the villi. There was nowhere any change in the consistence of the mucous coat. The liver was large, and its convex surface presented some ecchymoses ; its tissue was pale, and both colours blended. The spleen was natural in size, and readily broke into a pulp under the finger; the pancreas, natural. The kidneys were large, and lobulated externally. The cortical substance, of a dull white, contrasted strongly with the medullary, which was of a pale pink colour. In this case there was a general discoloration of the peritoneum, like that observed in patches on the large intestine in the case of Rumney. The dark green spots on the mucous membrane of the stomach and small intestines were also unquestionably analogous to the stains in the mucous membrane of the large intestine of Rumney. The blood-red mottling in the pyloric extremity of the stomach, which resembled in every thing but colour the mottling in the splenic extremity, goes to prove that the latter was of the same character with the former, but of earlier dale. The presence of pus in the cellular tissue and on the pleura shows that, although acute inflammation seldom occurs in scurvy, scurvy (Anatomical Characters). 449 the scorbutic habit is not incompatible with the existence of inflammation in its highest degree, and does not prevent the formation of its usual products. The dropsy and albuminous urine in this case are undoubtedly referrible to disease of the kidneys. It is worthy of remark that, notwithstanding the great tendency to haemorrhage in scurvy, we have never met with an instance in which blood was observed in the urine ; and in more than twenty cases of scurvy we have tested the urine by heat and nitric acid, without finding it albu- minous in a single instance, except in the case of Williams. There was a circumstance noticed in this case which shows the specialty of the morbid changes which constitute scurvy. We allude to the improvement in the state of the gums in Williams, after he was liberally supplied with oranges. This improvement, notwithstanding his general condition, was as rapid as we have ever witnessed it. In the third fatal case, the patient, aged sixty, had been twenty-one years in India, a soldier in the Company's army. His health had been somewhat im- paired for two or three years before he left India; and soon after he entered on his homeward voyage he became affected with scurvy in a high degree. He had a very severe rigor, and died, apparently from exhaustion, soon after he arrived in this country. Inspection six hours after death. The body was of a dusky olive colour; of robust figure, and not emaciated. The skin of the extremities sprinkled with black spots, some of them as large as a shilling, which were found to depend on coagulated blood. The muscles unusually pale. The lungs were remarkably bloodless, and very much collapsed, presenting no trace of disease. The heart was very large; the right cavities were much dilated, without hypertrophy, and contained soft fibrinous coagula; the left ven- tricle was thickened, its cavity not dilated. The pericardium and valves, as well as the aorta, were quite healthy. The mucous membrane of the stomach was of a rosy tint. The small in- testines, which were much contracted, were very pale, and offered here and there a small ecchymosis under the peritoneal coat. The large intestine was so con- tracted as scarcely to admit the finger; its mucous membrane was much thick- ened, and every where of a strawberry tint, except in the caecum, where it was of a mottled olive colour. There was no ulceration in any part of the intestine. The liver was large, and very friable. The gall-bladder was much distended by a yellow, ochry fluid ; and contained also eight calculi, about the size of small peas, of dark olive colour, and all regular tetrahedrons in figure. The spleen was large, and broke into a pulp under the finger; its capsule was readily stripped off. The kidneys were pale; in other respects normal. The urinary bladder con- tracted. There was a great quantity of transparent serum under the arachnoid, and in the ventricles; the cerebral substance was pale, in other respects normal. Thin fluid blood escaped when the large vessels in the neck were divided. In this case the mucous membrane of the caecum presented the same mottled olive colour that we have noticed in the dissections in the former cases. The origin of this colour is also indicated in this case by the strawberry tint of the mucous membrane in the remaining portion of the large intestine, and by the ecchymoses under the peritoneal coat of the small intestines. The contents of the large intestine were not noticed. The manner of his death, and the state of the large intestine, render it probable that intestinal haemorrhage had taken place. The condition of the liver, and the contraction of the colon with thickness of its coats, serve to explain the impaired state of the patient's health before he left India. The general inferences to be drawn from the preceding facts are, that in the inspection of the bodies of persons who die of scurvy, the chief indications of that disease are met with in the colour of the skin, in the state of the gums, and vol. in. 57 450 scurvy (Anatomical Characters). in the presence of fibrinous effusions, and of ecchymoses or effusions of blood. These effusions occur most frequently in the skin, in the subcutaneous cellular tissue, and between the muscles of the lower extremities ;* between the perios- teum and bones of the lower extremities and of the jaws ; and in the peritoneal coat, and in the muscular and mucous coats of the intestinal canal. The numerous traces of haemorrhage observed in the coats of the intestines are in accordance with the frequency with which scorbutic persons pass blood by stool. The change observed in the complexion is referrible to the state of the blood; and we have already mentioned a fact which supports the opinion that the haemorrhages also mainly depend on the same cause. Our observations, how- ever, furnish us with no direct information respecting that fluid, except that it is deficient in red particles ; that it has not lost the property of coagulating; and that it does not impart a stain to the lining membrane of the heart or vessels.f Beyond a general paleness of tissue, there is no change characteristic of scurvy observable in the brain ; in the organs of respiration; in the heart or large vessels; in the glandular system (except perhaps in some of the secre- tions) ; or in the bones. The cases which have been recorded of the disunion, during the progress of scurvy, of bones which have been consolidated after fracture, and the separa- tion of the epiphyses from the bones, mentioned by authors as sometimes oc- curring in young persons affected with this disease, seem indeed to lead to the opinion that the bones themselves may become affected in scurvy. A case, however, lately published by Dr. Godechen, of a scorbutic patient who died in 1834, in the marine hospital at St. Petersburg, serves to explain the process by which the disunion and the separation in question are effected. During the lifetime of this patient it was observed that some of his ribs were dislocated from their cartilages, and that several others were fractured near their anterior extremities. These fractures occurred without violence, some of them even during his stay in the hospital. Examination of the fractured ribs, after death, proved that the periosteum was stripped from their bodies to the extent of half an inch on each side of the seat of fracture; and that a sort of pouch, which was filled with soft dark-red coagulum, containing small fragments of bone, had been formed around the fractured extremities of each bone. The surfaces of the fracture were rough, but not splintered; and the neigbouring costal pleura presented no appearance of inflammation. At those spots where separation of the cartilages from the ribs had taken place, like changes had occurred • the extremities of the cartilages being further softened, but neither remarkably rough nor thickened.:}: Although it is not so stated in the account given of this case, we have little doubt that the ribs of this patient had been fractured at some former period, and that, as in a case we have already mentioned, and also in the one recorded by Dr. Mead, a disunion of the consolidated fractures took place in the progress of scurvy. The process seems to be, effusion of blood between the periosteum and bone, and consequent destruction of the vessels which serve to nourish the bone. Such are the morbid changes which we discover by dissection in the bodies of those who die of scurvy. They are in themselves interesting, but we arrive at much more important information respecting the nature of this disease, by consideration of the circumstances detailed in former chapters. When'we reflect that the exclusive cause of scurvy, is prolonged abstinence from the juices of succulent plants and fruits; that by the use of these it may always be prevented ; and that, when it exists even in its highest degree, it may be speedily * The greater frequency of effusions of blood in the lower extremities, is probably owing to t This confutes an opinion, expressed by an eminent physiologist, that in scurvy the globules of the blood are dissolved in the serum. (See Midler's Physiol. Trans, p. 257.) t See a notice of this case, (which was originally published in Zeitschrift fiir die gesammtt Medizin, band vi. heft i.), in the British and Foreign Medical Review. scurvy (Anatomical Characters). 451 cured by the same means, the inference is plain, that these juices contain some element essential to the formation of healthy blood ; and the history of scurvy shows that they cannot be replaced by any of the other elementary nutritive substances from the vegetable kingdom ; such as starch, mucilage, oils, albu- men, gluten ; or by any of the elementary nutritive substances of animal origin. The powers of digestion in scurvy are not impaired, but the materials on which they act are deficient in necessary constituents, and the blood formed from them is imperfect. This imperfection of the blood is the source of all the symptoms and the eause of all the morbid anatomical changes which are observed in scurvy. We have already considered at great length the variety and serious nature of the former, and the peculiar character of the latter. The study of scurvy is, therefore, most instructive to the pathologist, showing as it does the variety and importance of the effects which may result from a primary alteration in the quality of the blood, independently of any morbid change in the solids. The history of its treatment further shows how quickly that fluid may be restored to a healthy state, when its "morbid quality does not depend on any vitiation by poison, but simply on a defective supply of some of the elements necessary for its formation. The exact difference between the composition of healthy blood and that of the blood in scurvy is not known to us by direct experiments; but the reality of a change in the blood in scurvy, proved as it is by the foregoing considera- tions, is sufficiently attested also by the pallid dingy hue of the complexion, by the state of ulcers, and by the frequency of spontaneous haemorrhages.* The * Since this paper has been in the hands of the printer, my friend Mr. Busk has made for me an analysis of the blood in three well marked cases of scurvy. The result of this analsyis, which was performed in the manner recommended by Dr. Christison, in his work on granular kidney, is given in the subjoined table. The fourth horizontal line in this table is introduced for the sake of comparison, and gives the analysis, by the same method, of blood taken from a robust sailor, who had slight psoriasis, but was otherwise in good health. This analysis of scurvy blood, although it does not enable us to say what is the peculiar change of the blood in scurvy, is sufficient to disprove the prevalent notion that in this disease the globules are dissolved in the serum. In the blood taken from these scorbutic patients, the separation into serum and clot was as perfect, and took place as rapidly as in healthy blood. The same fact has been noticed by Rouppe in his work, De Morbis Navigantium. Trans^p. 180. Case. Age. Serum. Clot. , Appearance. Specific gravity. 1 2 3 4 27 33 23 45 Pale straw-colour. Ditto. Yellow, hazy. Yellow, straw colour. 1-028 Not ascertained. 1-025 Small, firm, buffed, and cupped. Large. Small, firm, buffed, and cupped. Large, sizy. In 1000 parts. Water. Hematosine. Fibrin. Albumen. Salts. 849-9 835-9 846-2 788-8 47-8 72-3 60-7 133-7 6-5 45 5-9 3-3 84-0 76-6 74-2 67-2 9-5 11-5 10-9 6-8 452 scurvy (Diagnosis). general paleness of the tissues shows that there is great deficiency of red par- ticles, and the tendency to swoon, so constant in scurvy, is undoubtedly owing in some measure to this deficiency, for physiologists have shown that the vivify- ing influence of the blood resides chiefly in these particles. It is evident, how- ever, that diminished proportion of red particles, which is common to many diseases, is not the only nor the most important change of the blood in scurvy. The cause of scurvy suggests considerations scarcely less interesting than those which arise from a study of its pathology. We here learn the great importance of considering food, not only in reference to digestibility and other qualities, but also as the material from which healthy blood is to be formed. We are of opinion that this point of view is too often overlooked, both as regards public health, and in prescribing diet in individual cases, and we hope these pages may call anew the attention of physicians to this interesting subject. We have seen that the approach of scurvy is gradual, and that prolonged abstinence from succulent vegetables is necessary for its full developement; but it is our opinion that something short of this—that a condition which might be correctly designated a scorbutic taint—must often occur in the lower classes in towns, but especially in prisons and asylums, towards and at the close of long winters, when succulent vegetables are scarce and expensive. Such a condition of the system would necessarily modify the character and course of supervening acute diseases; and it is worthy of the most diligent inquiry whether that form of scarlatina, designated by the epithet maligna, and analogous types of other eruptive diseases, may not, in some cases, owe their peculiar aspect and charac- ter to the circumstance of a scorbutic taint already existing, when the system becomes subject to the specific poison of these several diseases.* It appears to us, also, that by the common practice of physicians in many chronic diseases, patients are kept far too long a time on a diet consisting of farinaceous food, or of this with some proportion of animal food. When a moderate use of succulent vegetables is considered prejudicial, it would be advisable to supply the patient with their equivalent, namely, a certain propor- tion of orange or lemon juice.f Physiologists have made experiments on animals to ascertain the effect of a diet composed of substances devoid of nitrogen. The condition of the system which this brings on is different from scurvy, and of far more serious nature. It appears from the experiment of Magendie, that after an animal has been kept a certain time on such a diet, the allowing him his customary food does not save him.J The contrary is notoriously the case in scurvy, which, as far as we can judge, does no permanent injury to the constitution. Diagnosis. The history of scurvy shows, more completely than that of any other disease the great practical importance of accurate diagnosis. It was owing * A fact which renders this probable is, that these types prevail most, during and at the close of long winters. We may here notice the extraordinary prevalence of typhus in the severe winter of 1837, 1838, and the petechial character of that epidemic. Sir G. Blane has remarked, that the low spotted typhus is always most prevalent in long and severe winters. Willan stales also, that the malignant form of scarlatina is usually limited to the winter months. The following paragraph from Huxham's Essay on Small-pox, may also bear on this subject: " I have never observed either the vegetable or mineral acids of any great service in the crude crystalline pox, but I have often found them highly useful in the small, black, con- fluent kind, with petechia" + On the 28th of May, of the present year, a patient was admitted into the Dreadnought, presenting the usual symptoms of scurvy. He entered a hospital in Scotland, on the 15th of the preceding November, on account of an injury on the leg, received the same day, and con- tinued there till the 22d of May. During this period, he lived chiefly on oatmeal porridge with milk ; but latterly he had four ounces of meat, which he ate with bread, and three ounces of whisky daily. Occasionally he had broth without kale. No potatoes or other vegetables; no beer. The scorbutic symptoms disappeared in a few days, under the free use of lemon juice. \ The reader who is desirous of further information on (his point, may compare the account of these experiments of Magendie with the description given by Mr. Malcolmson, of the effect produced by a diet of bread and water on the health of prisoners in India. (Letter on Solitary Confinement, &c.: by J. G. Malcolmson, Esq.) scurvy (Diagnosis). 453 to want of it, that scurvy continued to prevail, to a most fatal extent, for two centuries after effectual preventives and remedies had been discovered in the most abundant productions of nature. We have already mentioned that in the earliest accounts of the disease by Ecthius. Rousseus, and Wierus, who wrote in the first half of the sixteenth century, there is not only an accurate descrip- tion of its symptoms, but an enumeration of many of the vegetables and fruits which at present are the most distinguished for antiscorbutic properties. In the early part of the seventeenth century, however, a work on scurvy was published by Eugalenus, a Dutch physician, who laboured to prove that almost all cuta- neous diseases, hypochondriasis, and various other maladies, were merely dif- ferent manifestations of the scorbutic diathesis, and ought to be considered as one disease. The confusion was made still greater by subsequent writers, until at last physicians had comprehended under the term scurvy, almost every dis- temper incident to man. Sydenham tells us that, in his time, scurvy and malignity were the subterfuges of ignorant physicians; and Willis, writing in 1679, could make use of such expressions as these:—" Si accidens quoddam inusitatum nee prius auditum in corpore humano eveniat, cum ad aliud certum genus referri nequit, sine dubio statim illud scorbuticum pronuntiamus." (Willis, De Scorbuto, cap. i. p. 14.) In the middle of last century Dr. Lind complained much of the same want of accurate diagnosis, and dwelt very impressively on the evils that resulted from it. (Lind, Preliminary Discourse, ch. iii.) It is to this author, who, as physician to the fleet, was well placed for observing the uniformity of the disease, that we are indebted for the final dispersion of most of the errors that prevailed on this subject. His patient investigation of the history of scurvy will insure him the rank of a philosophical physician ; while his perseverance in forcing on the public notice the means by which it might be prevented, and the beneficial influence which the adoption of these means has had on the condition of a numerous and important class of our fellow-subjects, will ever entitle him to a high place among the benefactors of mankind. At present, the subject of diagnosis is comprised within very narrow limits. The only disease with which scurvy can be confounded, is purpura. This term, in the language of modern pathologists, is intended to include every variety of petechial eruption, or of spontaneous ecchymosis (see Bateman and Biett); it consequently comprehends typhus, or petechial fever, scurvy, and probably other distinct diseases, which until we have learned to discriminate between them, we are compelled to group under the generic term, Purpura. Petechial fever, indeed is easily distinguished by the peculiar character of its symptoms from the other diseases, which, by the preceding definition, are included in the same class; but scurvy, and the maladies to which we would restrict the term purpura, are confounded by the best writers on diseases of the skin.' They are, however, essentially different; they arise from different causes; they differ in the circumstances and mode of attack; and they require different treatment. We have already stated that the essential cause of scurvy is prolonged absti- nence from vegetable juices, and that the approach of the scorbutic habit is very gradual: purpura, on the contrary, often appears suddenly, and in many cases it cannot be attributed to any peculiarity in diet. Scurvy, when occur- ring on land, is, from circumstances we have before mentioned, met with almost exclusively at the end of winter, or in the early part of spring; purpura, on the other hand, is most common in summer and autumn. The livid and spongy state of the gums, which is pathognomonic of scurvy, and which, as well as the sallow and dusky hue of the skin, is a constant symptom of that disease, is not observed in purpura. Lastly, in scurvy, bleeding always does harm, and the disease is speedily cured by the use of succulent vegetables and fruits; while, in purpura, the abstraction of blood is often followed by relief, and the antiscor- butics are rarely, if ever, productive of much benefit.* * This circumstance alone is quite sufficient to prove an essential difference between scurvy 454 scurvy ( Treatment). It has been supposed that there are varieties of scurvy, and that scurvy occurring on land is different from that which arises at sea. If, however, we compare the descriptions given by the early writers* on scurvy, who observed it on land, or the cases recorded by Dr. Heberden, with the accounts of naval physicians, we shall perceive an entire agreement in the essential symptoms of the disease. Moreover, it is easy to see that the disease, depending as it does on a single cause, must be identical wherever it occurs. Treatment. After the details into which we have entered respecting the causes and prevention of scurvy, we have little to say on the subject of treat- ment. The essential point is to administer liberally those articles of vegetable food, which have been distinguished for their antiscorbutic qualities. Oranges, lemons, or fruits of that class, if they can be procured, should be preferred. Their salutary effect is extraordinary, and such as would scarcely be imagined by persons who have not witnessed it. In the course of a few days, the com- plexion loses its sallow and dusky hue; the gums become firm and florid; the petechia? and bruise-marks on the skin disappear; the legs, if swollen and rigid, begin to regain their natural size and pliancy ; despondency and muscular weakness are replaced by cheerfulness and a feeling of strength :—in fact, the aspect and condition of the patient soon betoken return of health. If the state of the gums be such as to prevent the patient from masticating, he should be kept for two or three days on milk diet,f or on soups, in addition to antiscorbutics. At the end of this time, or at the commencement, if the case be less severe, his diet should consist of fresh animal food, with vegetables, especially in the form of salads. As long as he continues very feeble, wine should be freely given him; afterwards, this may be replaced by porter or ale. In advanced stages of the disease, when debility is extreme, and the slightest exertion produces fainting, the patient should not be exposed to sudden change of air, or be even allowed to sit up in bed without great caution. Before he is moved or permitted to get up, a glass of generous wine, well acidulated with lemon or orange juice, should be given him. This injunction was first made by Dr. Lind, and we have more than once had to regret not having obeyed it. Sleep should be procured by an opiate by night, which we have often found to produce great comfort. Constipation, when it exists, may be removed by mild purgatives; and for this purpose none are preferable to moderate doses of castor oil. On account of the great debility, and the tendency to swoon, which in high degrees of scurvy is sufficient to cause alarm, all strong cathartics should be avoided. For the gums we may prescribe an astringent gargle; and none answers better than a weak solution of chloride of lime. For scorbutic ulcers, the best dress- ing is lint soaked in lemon or lime juice, diluted with two or three times its quantity of water. (Dis. of Seamen, p. 468.) The lint when placed on the ulcer, should be covered with oiled silk to prevent evaporation. Firm compres- sion should be avoided, from the tendency it has to produce gangrene. If the legs be much swelled, stiff, and painful, considerable relief will be procured by warm fomentations. But all these complaints yield readily to the general method of cure, and can only be palliated until that is undergone. Bleeding should never be had recourse to, although acute pains, heat of skin, quickness of pulse, and other febrile and the diseases to which we would limit the term Purpura. The effect of vegetable juices is so constant and so specific in real scurvy, that we may safely infer that a disease not benefited by them, is of essentially different nature. * Ecthius, Wierus, or in fact, any writer before the time of Eugalenus. See also Med. Gazette, vol. xx. report of Dr. Murray. t We have no evidence showing that milk is antiscorbutic. Dr. Lind mentions, on the authority of Sinopreus, that scurvy is common among the Tartars, who live chiefly on milk and flesh (Lind, p. 246); and we have already noticed its occurrence in the Lunatic Asylum at Moorshedabad, in which milk was regularly supplied to the inmates. scurvy (Treatment). 455 symptoms, or a dangerous haemorrhage may seem to render it advisable. In advanced stages of the disease patients do not survive it. (Lind, p. 216.) Blisters are apt to produce gangrene, and for this reason we should abstain from their employment. (Larrey, Mem. de Chir. Mil. torn. ii. p. 288.) Mercury, in every form, should be religiously avoided: even in very small quantities it has been known to produce dangerous salivation. We have met with instances in which the scorbutic symptoms seemed to have been much aggravated by mercury taken before the scurvy made its appearance. The ill effects of this medicine are indeed noticed by most writers on scurvy ; and Kramer, who was physician to the imperial armies in Hungary, from 1720 to 1730, relates that of 400 men, affected with genuine scurvy, to whom, on the advice of Boerhaave, mercury was given so as to induce salivation, not one survived. In the writings of the physician whose testimony we have just given, is a passage which expresses so pithily and so truly almost all that we can say on the subject of treatment, that we cannot refrain from quoting it. " Scurvy is the most loathsome disease in nature ; for there is no cure for it in your medicine- chest ; no, nor in the best furnished apothecary's shop. Pharmacy gives no relief, surgery as little. Beware of bleeding: shun mercury as poison: you may rub the gums, you may grease the rigid tendons in the ham to as little purpose. But if you can get green vegetables; if you can prepare sufficient quantity of fresh, noble, antiscorbutic juices; if you have oranges, lemons, or citrons ; or their pulp and juice preserved with sugar in casks so that you can make lemonade, or rather give to the quantity of three or four ounces of their juice in whey, you will, without other assistance, cure this dreadful evil." (Krameri, Medicina Castrensis.) \ DROPSY. GENERAL.DOCTRINES OF DROPSY. Conditions of the system under which dropsical effusions arise—General pathology of dropsy. —Chemical composition of dropsical fluids.—Remarks on some of the phenomena of the effusion.—Prognosis of dropsy.—General principles of treatment.—Cardiac dropsy.—Indi- cations that dropsy originates in cardiac disease.—Forms of cardiac disease that induce it, and progress of the dropsical effusion.—Renal dropsy.—Peculiar characteristics of this form.—Appearances in the structure of the kidney in renal dropsy.—Relation of renal dis- ease to dropsy.—Condition of the urine—of the blood.—Incidental complications.—Causes of the renal disorganization.—Acute or Febrile Dropsy.—Nature, symptoms, and causes.— Dropsy following scarlet fever.—Treatment of general dropsy—of acute or febrile dropsy— of chronic general dropsy—of the renal form of chronic general dropsy—of cardiac dropsy —of diet and drinks. Dropsy, strictly defined, consists in the accumulation of a preternatural quantity of watery or serous liquid in some one or more of the natural serous cavities of the body, or in the interstices of the serous cellular tissue; independently of inflammation of the boundaries of those parts. But the term dropsy has likewise been applied to collections of serous or other liquids in cysts: that is, in cavities which are themselves preternatural, which have been formed, or greatly enlarged and altered, by some morbid process. Serous effusions into the circumscribed cavities of the body are often the immediate results of inflammation of the internal surface of the cavity ; and these also have sometimes, though inexactly, been denominated dropsies. They will be no further noticed in the following dissertation than may be necessary for better understanding and discriminating the watery accumulations that are more properly accounted dropsical. Nor is every collection of serous liquid found in the shut cavities of the dead body, and independent of inflammation, to be considered a dropsy. If the liquid does not exceed a certain measure, and especially if the examination of the corpse has been delayed, as is customary in this country, till twenty-four or thirty-six hours affer death, the effusion must not be regarded as a morbid appearance, or as affording any evidence of pre- vious disease. It is a purely physical phenomenon. As vitality ceases the blood accumulates, and ultimately stagnates, in the venous system; the tissues of which the veins are composed become loose and more permeable than during life, in consequence of commencing decomposition; and the serous parts of the blood transudes mechanically through them with greater facility than before. It has been said, and said with much truth, that dropsy is rather a symptom of disease, than a disease in itself; and that it would therefore be more philo- dropsy (General Pathology). 457 sophical to treat of the original malady on which the accumulated water de- pends, and to withdraw dropsy altogether from the number of substantive dis- eases. But the propriety of still regarding dropsies as constituting a genus of disease, and particular dropsies as specific forms of disease, may be defended by the following considerations:— 1. Allowing that dropsy is often, or always, a symptom, it is a symptom which, in many instances, we cannot trace home, while our patient is yet alive, to its antecedent morbid action, nor satisfactorily ascribe to any organic change discoverable after he is dead. Practically speaking, in such cases the dropsy is the disease, and the sole object of our treatment. Moreover, the liquid accumulation is a symptom very obvious and striking in itself, while it results from various physical alterations, differing both in their seat and in their nature; and it will be useful to study dropsies collectively, if it be only with the view of analyzing them, and of re- ferring them, as often and exactly as possible, to the pre-existent disease. Dropsy is, in fact, to a medical eye, in all cases, something more than an effect or symptom of disease. The fluid collection itself is a cause of various other symptoms (<7uu,#ru|xa - - - - 1-85 Carbonate of lime ) and some traces of oxide of iron. Scrofula readily associates itself with, and modifies the progress of, other diseases, more especially common inflammation, syphilis, diseases of the skin, rickets, and certain local and nervous maladies. Indeed, very few local inflam- matory affections occur, in which the symptoms as well as the operations of food and medicines, are not more or less influenced by the scrofulous constitu- tion ; and it is from this complication, that sores and many other similar affec- tions are so obstinate of cure. Gonorrhoea and the diseases of the mucous scrofula (Complications). 533 membranes generally offer striking examples of this fact. Scrofula and syphilis modify each other very remarkably ; generally, both diseases run their course under mutual states of aggravation. Sometimes, however, the tubercular dis- ease is arrested during the progress of this affection ; on the subsiding of which, the scrofulous symptoms are renewed with redoubled aggravation. (Royer, Obs. ex Praxi in Nosoc. Milit.) With some diseases of the skin, the complication is so frequent as to induce many writers to view them as essentially scrofulous. It is very certain, that when they do occur in a constitution of this tendency, they are aggravated in character, and more obstinate in resisting curative means. Rickets, by many writers, has been erroneously esteemed a scrofulous dis- ease : not only is its pathological state opposed to such a view, but it occurs occasionally in children, in whom there is not the slightest tendency to scro- fula. Should it, however, be complicated with tuberculous disease, its treatment becomes troublesome and unsatisfactory, which otherwise is not particularly the case. Scrofula is often combined with uterine affections. It has previously been observed, that, in persons of this diathesis, great tendency to catamenial irregu- larity prevails : generally, the recurrence of the period is too frequent, and the discharge excessive. The constitution soon shows evidence of its labouring under the weakening effects of menorrhagia. On the other hand, it sometimes happens, though much less frequently, that there is a total suppression of the discharge, or its recurrence takes place only at lengthened periods, and attended with more or less pain. The scrofulous constitution is very liable to nervous disorder. In females of this habit, the symptoms are so often mingled with those of hysteria, as to render it difficult to distinguish which are to be referred to organic affection, and which to mere complication. With regard to mental disorders, Dr. Cumin says they claim an alliance with scrofula which has not been sufficiently attended to. He states, on the authority of a physician eminent for his knowledge of these disorders, that more than one-half of those who are subject to mental derangement, are of a scrofulous constitution, the existence of which is manifestly indicated in these persons ; and that scrofulous symptoms often alternate with attacks of mania ; that purulent expectoration has often ceased during the urgent symptoms of insanity, and, on the other hand, reason has been restored before the pulmonary disease proved fatal. With the view of elucidating this, Dr. Cumin examined all the paupers of a lunatic establishment. Of forty-four females, exactly one-half presented indurated or enlarged glands of the neck or throat, and several had extensive scrofulous cicatrices. Of forty-six males, twenty-eight had no decided symp- toms of scrofula, though several had the strumous aspect; sixteen presented the marks already mentioned : in reference to the females, two belonged to families known to be afflicted with scrofula in an aggravated form. All of these ninety lunatics were adults, and not one of them exhibited any active symptoms of scrofulous disease. It appears, however, from the above that mental disease is not promoted by scrofula, though occurring in the same subject, nor scrofula promoted by mental affections ; on the contrary, when one disorder was in a state of activity, the other was at its minimum intensity; in confirmation of this it has been observed, that where insanity has occurred in families eminently scrofulous, the least strumous were its victims. Epilepsy is another occasional complication of scrofula. Dr. Cheyne goes so far as to think it as certain a manifestation of the strumous diathesis, as tubercular consumption itself. We cannot, however, view it in so strong a light. There can be no doubt that many, nay most, so afflicted, present strong characteristics of the strumous constitution : but, on the other hand, it occurs in those who can in no way be said to have this taint. The statistical history of tuberculous disease has, of late years, been occupy. 534 scrofula (Statistics). ing much attention ; but as the results obtained have been rather deduced from those labouring under phthisis pulmonalis, it would be out of place here to go into minute details ; a few general remarks will be sufficient. Tubercles are generally stated to be but very rarely developed until after the second year of life. We are inclined, however, to doubt the correctness of this opinion. Occasionally they are met with in the foetus. Chaussier, fJEhler, Husson, Billard, have each detailed cases ; yet Guisot states, that of 400 newly born children whom he had examined, he had not met with a single case. Bil- lard relates instances of tuberculous deposits in the first months of life. We have examined infants in whom tuberculous disease was not suspected, and yet the deposit was found largely diffused in several organs. This leads to the conclusion that infants succumb to the influence of this affection more fre- quently than is suspected. Billard states some observations which fully bear out this view. He found tubercles in the lungs of four children who died at the respective ages of one, two, three, and five months, in neither of whom were any of the'symptoms of phthisis developed as is usual in adults. The observations of Sir J. Clark tend to the same effect; he met with many cases of extensive tuberculous disease in the first dawn of life. After the second year, however, there is a great increase in the developement of tubercle. Ac- cording to Guersent, of those who died belween one and sixteen at the Hopital des Enfans, two-thirds or five-sixths were tuberculous : and Dr. Alison states, of the lower orders of children in Edinburgh, more than one-third of the deaths are from scrofula. Sir J. Clark has given a table which, as deduced from a large number of observations, is most probably accurate in its results ; it is cal- culated from 695 observations made by Papavoine and his colleagues, from which it appears that the period of life below the fourth year is the most prone to tuberculous disease. To speak, however, in general terms, it appears that scrofula exists in its greatest extent between the period of the first and second dentition. Le Peiletier affirms that the number of strumous females as compared with males is as five to three. (Sur la Maladie Scrofuleuse.) This, however, is very much greater than is found to exist elsewhere. From another table of Sir J. Clark, and constructed from the returns of thirteen different hospitals, the proportion is found to be in seven of them much in favour of females: taking, however, the thirteen returns, and drawing the average from the whole, the prevalence of tuberculous disease bears the relation of 100 males and 106 females. In connexion with this it must be borne in mind, that on the whole population there is an excess of females over males, and this may render it a nearly equal division of the disease. In Dr. Home's report (Edin. Med. and Surg. Journ.) a contrary result, however, is shown to be the case; and this is not owing to the admission of a larger proportion of males into the hospital,—the numbers being, males 4512, and females 4719. Tuberculous disease is not confined to man. Farcy and glanders in the horse are both essentially scrofulous diseases.* Dupuy has shown that, in the latter, the leading feature is the formation of tubercle in the pituitary membrane (Maladie Tuberculeuse); while, in the former, the tumours called farcy buds are really tuberculous deposits. A large proportion of those ani- * This is a mistake. There is no similarity whatever between glanders and scrofula—the former is highly contagious, the latter not at all so. In many cases of glanders which have been communicated from horses to grooms and others in charge of the animals, experiments have been made by inoculating horses with the pus from the glandered men, and the samn disease was developed rapidly in those animals. In scrofula it is well known that the same experiments have failed. The lesions in the two diseases are also totally different; and there is no other point of resemblance other than that both affections are connected with a general disease of the system, and in both scattered purulent collections are formed in the glands which have a slight external resemblance one to another. G. scrofula (Causes). 535 mals which are imported into this country for the purpose of menageries, die from tuberculous disease. This is especially the case amongst the monkey tribe. Regnaud, who has had frequent opportunities of dissecting those dying at the Jardin du Roi in Paris, states that the disease, as occurring amongst them, is in every way analogous to its appearance in the human sub- ject. We have enjoyed some limited opportunities of observing the same fact in monkeys, two lions, and a kangaroo. In each of these the tuberculous disease was fully developed. (Jlrch. de Med. t. xxv.) The cows which are confined in large towns are found soon to show evidence of this complaint; and it is remarkable, on this occuring, the milk becomes more abundant. The flesh also becomes softer, and in Paris is prized in proportion. Mr. Newport has made some very interesting observations on the oc- currence of tuberculous formations in insects, both vegetable feeders and carnivorous. He was enabled to produce its deposition by submitting the insects to changes of temperature, and supplying them with food of a dete- riorated quality. From the results of an experiment upon the larvae of the Sphinx ligustre, he is led to conclude that these depositions in insects may be produced almost at pleasure. About eighteen or twenty larva? of this species, collected just after entering their last skin, were confined in a box closely covered, and kept, uncleansed, in a room the temperature of which ranged from 65° to 80° Fahr., and were supplied with food of a deteriorated quality. By this means their growth and the period of their changing were retarded. In order to produce a sudden impression of cold upon them they were re- peatedly plunged into cold water. The result was, that in the whole of them deposits were formed, and generally in the secreting organs. (Mr. Newport's Letter ; vide Clark, op. cit.) Causes. The frequency of scrofula, the insidiousness of its approach, and, when fairly set in, its inveterate nature, render an examination of its causes of the utmost consequence. We have already shown that scrofula is a disease of a tuberculous nature; and the probability that the immediate origin of the characteristic deposit is due to a chronic, low, inflammatory condition of the interstitial cellular system by which means albuminous deposit takes place from the blood. We shall now turn our attention to those agents which have been considered to excite such a condition. The first in importance is hereditary influence. Different opinions have prevailed upon the relative importance of this; some maintaining that it is essentially and only of hereditary origin ; some, that it is never so ; and others, that it may be both hereditary and capable of being spontaneously excited. Much difficulty has ensued from confusing together hereditary disease and he- reditary predisposition. (Hunter's Works, vol. i., p. 591.) Faur, White, Diel, Henning, and John Hunter, are among those who have most prominently opposed the view that scrofula is hereditary. The latter, however, while maintaining this, allows the existence of an hereditary predisposition. Dr. Thomson, whose writings are as clear as they are accurate and instructive, puts the whole question in its proper point of view. " It had from time im- memorial been observed that the children of those parents who themselves have had scrofula become sooner or later affected with this disease; and from this uniform observation and experience it was inferred, that scrofula was an hereditary disease. "This conclusion however has been denied, upon the grounds that children are never born with the disease actually existing, and that it is improper to give the name hereditary to a disease which is not immediately communicated from the parent to the child. By keeping in view the distinction I have already men- tioned, of scrofula as a disease which has actually manifested itself by attack- ing some part of the general system, and as a predisposition, diathesis, or state, liable to be attacked with, or to pass into, the disease, you cannot fail to per- ceive that the dispute with regard to the hereditary nature of scrofula is merely a strife about words; and that this controversy must cease, as soon as you affix 536 scrofula (Causes). any thing like a precise and determinate meaning to the terms which you em- ploy. If by applying the word hereditary to scrofula you mean to express that the disease is communicated directly by the parent, so as to appear in the child from the first moments of its existence, or, in other words, that the child must actually be born with the disease obviously existing, the question, it is evident, whether scrofula be hereditary or not, can only be resolved by an appeal to experience. I have not heard of any very decided example of a child being born with scrofulous glandular tumours on any part of the body, though the circumstance does not in itself appear to be at all impossible." The acumen of this intelligent physician has been fully borne out by the observations of Langstaff, Husson, Ohler, Andral, &c, who have detected tubercles in the foetus. Though there can now be no doubt that both the predisposition, as well as the disease itself, may be derived from the parent,* there is also every reason to suppose that it is not exclusively so, as is stated by Le Masson, Delalande, and others. In fact, there can be little doubt that tubercular disease is both hereditary and capable of being acquired. Cullen, who has a strong bias in favour of viewing it exclusively as of hereditary origin, allows that it sometimes may be otherwise. Admitting it to be hereditary, some have attributed its origin to impregnation taking place during the menstrual period, in the parents being either too old or too young, or to accidents during gestation. These views, however, are supported by no solid arguments. The Faculty of Medicine in Paris, in 1578, decided that scrofula was conta- gious : this view is scarcely entertained in the present day. Those who con- sider it so, mention as the media—intercourse (Pujol), inoculation with small- pox (Deluc, Rowley, White), and nursing (Bordeu). That it is not communicated by intercourse, every day observation is sufficient evidence. Baudelocque quotes the fact, that in the Hopital des Enfans 150 beds are occupied by children, some of whom are scrofulous, yet no result of the kind has ever taken place. The same negative evidence is afforded at the Hopital St. Louis, where they are indiscriminately mixed. Rowley, White, Dehaen, are those who chiefly maintain that scrofula has been introduced into the system with the matter of small-pox. No sufficient grounds however have been staled, which should induce us to believe that it makes its appearance more frequently after inoculation than after natural small- pox. We may indeed conclude from the following experiments, that it is not inserted with the variolous matter; for, in order to test this view, the endeavour has been frequently made to introduce this disease by artificial means. Hebr&ard and Lepelletier inoculated animals with the virus without success. Kortum and a colleague of Lepelletier experimented (most unjustifiably) upon children, while Lepelletier and Goodlad did the same upon their own persons with the like result. The humoral pathologists have very generally maintained, that scrofula may be communicated to a child by a nurse embued with the disease. Be this as it may, it must be admitted that a nurse of a scrofulous constitution is objec- tionable; for, as Labillardiere has shown, the milk of a cow affected by tuber- culous disease contains at least seven times more earthy matter than a healthy one, and consequently is less nourishing. Many have thought scrofula to be a degeneration from the syphilitic virus. The question is important, not only from the authority of those who support it, but from its involving the whole question of the nature and treatment of scrofula. It was first entertained by Astruc, and in the present day we find amongst its advocates such names as Hufeland, Richerand, and Alibert: the latter states, by far the greater proportion of scrofulous disease to be only disguised cases of syphilis, which is modified by hereditary transmission ; he feels assured that its occurrence in children is almost entirely owing to the debaucheries of their parents. Notwithstanding this array of important names, we find little in their works * Tuberculous matter has been found in the umbilical cord. scrofula (Causes). 537 on the subject, save the mere assertion, and which chiefly rests on the similarity of certain symptoms. Attentive observation, however, discovers sufficient to negative the views of their identity. Besides, we see that the children of syphilitic parents are born with the disease upon them. Bierchen, who maintains that the disorder of such children is scrofula, has evidently erred in his diagnosis; and what he calls scrofula is doubtless no other than syphilis. The experience of Baudelocque is, that children born of mothers infected with syphilis are not more prone to scrofula than when this is not the case. Another reason which has been advanced (insufficient even if the fact were substantiated) is, that the same remedies are applicable to both disorders. We shall have an opportunity of showing, when detailing the treatment, that there is every reason to believe the contrary to be the case; an opinion maintained also by Richerand, one of the chief advocates of the view of syphilitic degeneration. As further negativing such a position we may allude to the circumstance of scrofula being known in Europe long anterior to the introduction of syphilis. The external agents generally regarded as the exciting causes of scrofula are peculiarities in diet, situation, and atmosphere. Bad diet has usually been stated to exert peculiar influence. Though there can be no doubt that the disease greatly prevails amongst the ill-fed poor, yet on examining the ques- tion more fully, it would seem that the effects of diet have been greatly exag- gerated, as the disease exists to a great extent amongst the well-fed also : in fact, were we to take our examples only from those in a parallel walk of life, the contrary conclusion might be stated as the correct one, for the poor of towns, who are much better fed than the poor in the country, are the more prone to it. Baudelocque, who states a vitiated atmosphere to be the sole exciting cause, and has analyzed all the other theories, in order to dispute them, brings forward many strong facts in favour of this position. He con- trasts the scrofulous liability of the children of artisans in Paris with those in Picardy. The former who are well-fed are frequent victims of the disease, while the ill-fed enjoy a comparative immunity ; and he quotes the memoir of Madier on the medical topography of Bourg. St. Andeol, where it appears that food is good, abundant, and cheap, where situation and all other circumstances concur to produce a healthy district, yet the disease is found to be very com- mon amongst the inhabitants ; and Bordeu states the more conclusive fact, of the sons of mountaineers who are sent into towns to qualify themselves as churchmen, and are better fed than their brothers in the mountains, and yet frequently become scrofulous, which is rarely the case with the others. At Palermo it is very notorious that the food is of the most innutritious and worst kind, yet among its inhabitants the disease is almost unknown. Many writers have specified diets of particular kind as sources of its origin. Haller and Hufeland attributed its occurrence to the use of potatoes. The latter also attributes it to mothers not nursing their own children, but bring- ing them up by hand. In Normandy, however, where it is much the custom to rear children after this fashion, scrofula does not particularly prevail. The opinions with regard to diet have varied with the prevailing theories of the disease. If it have been attributed to the presence of acid or calcareous salts, so importance has been given to food containing these ingredients : if its origin have been thought to exist in the secretion of thick viscid lymph, so any thing causing a thick chyle, as soups, potatoes, &c, have been con- demned. Milk by some is regarded as injurious, because it produces acid (Bordeu); while others look upon it as anti-scrofulous. The use of tea, coffee, an undue proportion of fluid to solid food, the inordinate employment of pur- gatives, spirits, &c, have each been severally stated as capable of producing the disease. It is useless, however, to quote at length these opinions, for it appears evident that scrofula attacks indiscriminately the well and ill-fed, and that no particular diet gives an immunity. At the same time it is not to be vol. in. 68 538 scrofula (Causes). denied, that when scrofulous action is excited, diet of an innutritious and un- wholesome nature is exceedingly hurtful, and tends much to its aggravation. The use of particular kinds of water has been so seriously dwelt upon by many as a chief exciting cause, that an examination of its true bearing is neces- sary. Our own most excellent physician Dr. Heberden, states his belief that it is probably owing to the existence in it of some noxious quality, and quotes in confirmation the history of the occurrence of scrofula at Rheims. The cir- cumstances may be thus briefly stated :—This city was so afflicted with scro- fula as to have a hospital, St. Marcon, specially devoted to cases of scrofula, when a citizen from pure benevolence introduced into the town the water of the Vesle, it previously being but ill and scantily supplied by tanks. Imme- diately on this taking place, according to Thouvenel, scrofula almost entirely ceased. This statement was made in 1777. In 1806, Desgennettes reports that the hospital is again filled with scrofula, and that the water-works of the Vesle are so out of repair as to supply but little water, obliging the inhabitants to resort to their previous sources of supply. So far it appears conclusive, but the searching investigation of Baudelocque throws doubt upon the whole. He shows that the decrease of the disease commenced before the waters of the Vesle were brought into the town ; and that there is every reason to be- lieve that the decrease was attributable rather to some general improvements in the place, while its recurrence is due to the establishment of manufactures. Snow and ice water have by many been considered as a cause; by others, water containing lime; this latter view has lately been very ably sustained by Mr. M'Clelland in his sketch of the topography of Kemaon. (Dub. Journ., May, 1837.) Want of cleanliness has been very generally considered as a cause, and Kortum explains this by supposing that it opposes free transpiration ; but we see that scrofula occurs in those who are not uncleanly. The children of Pa- lermo, to whom we have before alluded as enjoying a peculiar immunity, are notoriously living in a state of the most squalid filth ; on the other hand, the children of this country and of Holland, where the disease finds so many vic- tims, are those of all others where cleanliness is most attended to. The nature and variations of the atmosphere are also said to exert a power- ful influence—a view which is by no means improbable, when we reflect that it is the medium by which light and heat, moisture and electricity, all such important agents as regards the animal economy, are applied to the sys- tem. Considering the importance of the question, it has not been so philo- sophically examined as might have been expected. The very excellent work of Dr. Edwards (Influence of Physical Agents on Life) promises, however, to create a new era in these researches. With regard to the effects of light and electricity, but very few observations have been made. Humboldt thinks he has remarked that a diminution of elec- tricity in the atmosphere concurs to the developement and progress of scrofula. The influence of this agent, however, has not been so examined as to induce any reliance to be placed upon this vague opinion. Observation has shown that light produces very serviceable effects upon vegetable existence; and judging from analogy, we are induced to infer that it exerts some influence on the animal economy. Dr. Edwards has proved this by direct experiments, the results of which are, that the presence of solar light favours the developement of form as contra-distinguished from size merely (p. 210); and the principles deduced involve the opinion, that in climates where nudity is not incom- patible with health, the exposure of the whole surface of the body to light is very favourable to the regular conformation of the body ; while, on the other hand, we must also conclude that the want of sufficient light must constitute one of the external causes which produce those deviations of form in children affected with scrofula, which conclusion is supported by the observation, that this disease is most prevalent in poor children living in confined and dark scrofula (Causes). 539 streets (211). Daily observation, doubtless, shows us that those who are placed in situations where light is deficient, such as miners, prisoners, &c, are etiolated, unhealthy, and prone to scrofula; but many other deleterious causes are united in those unhealthy situations, so that their effects cannot be sepa- rately estimated ; nay, it may be adduced as an argument almost conclusive against the agency of light, that many districts which are particularly liable to scrofula are open to the direct rays of the sun. This is especially the case in the district of the Rhone, where the occurrence of cretinism is so frequent. Moreover, the experiments of Dr. Edwards, though showing that an influence of a powerful nature is excited by light, tend to prove that a deprivation of it would not produce scrofula, for whatever changes took place under these cir- cumstances, they in no way proceeded from a decay of the individual. Baudelocque says, that, of itself, temperature exerts no influence in the pro- duction of scrofula: it certainly is not a disease of either warm or cold lati- tudes, occurring chiefly in temperate climates. At the same time he remarked, that in the hospitals of Paris, winter exercises a very unfavourable influence on those suffering from this disease ; that the ulcers suppurate more abundantly, the swellings become more numerous, and obstinate diarrhcea opposes the effects of anti-strumous medicines. He does not admit, however, that this is owing to the change of temperature, but to the imperfect manner in which hospitals are heated and ventilated, thus causing those suffering under the disease to lie long in bed, by which means they inhale a vitiated atmosphere, and are deprived of proper exercise. In confirmation of this view, of its not being owing to the cli- mate of winter, he says that none of these ill effects are found to arise in cases where means are taken to guard against the immediate effects of cold. If we view humidity as distinct from temperature, it cannot be said to be a source of this disease, for there are many districts where moisture greatly pre- vails, but which are not particularly characterized by the occurrence of scro- fula. We might name the departments of Comme, Boves, &c. In this latter place, notwithstanding its being built in the midst of a morass, formed by the junction of two rivers intersected by three streams of water, and surrounded by canals and pools, so that fogs prevail to a great extent, in fact, presenting every condition of a humid climate, there are found but very few who are scrofulous ; while, on the other hand, it has been observed that the inhabitants of many places remarkable for dryness are particularly liable to this disease. There can be no doubt, however, that temperature and moisture combined exert a considerable influence on health. A temperate and moist climate pre- sents that condition which, from its changeableness, is likely to be a source of disease generally, but especially of the disease under discussion. At the same time the department of Picardy, where such a climate exists, is not prolific in cases of scrofula, excepting amongst those whose occupations confine them to their houses. Baudelocque, to whose views we shall immediately refer, at- tributes its origin to the inhaling a vitiated air, and very ingeniously observes, that these climates induce the building of small and ill-ventilated houses— whence the disease; that its absence is accounted for in warm climates by the inhabitants being chiefly in the open air ; and in cold latitudes by the great and effectual changing of the air, caused by the general use of fires in the rooms in- habited, so that the consequences of a vitiated atmosphere are avoided. That a vitiated atmosphere exerts some influence in the production of scro- fula, is an opinion that has been entertained by many. Baudelocque devotes a large portion of his work to show that it is exclusively the exciting cause. " The occurrence of scrolula is always preceded by a residence, more or less prolonged, in an atmosphere which is not sufficiently renewed. This cause is the only one to be met with, whether isolated or united to conditions whose action is only secondary." (Op. cit. p. 264.) Without taking so exclusive a view of the origin of this disease, many cir- cumstances give much ground for supposing this cause very influential. The poorer classes of large cities, who are frequently subjects of its ravages, noto- 540 scrofula (Prevention). riously live in rooms and situations which are not well ventilated; and Riche- rand states that a considerable proportion of scrofulous cases which are ad- mitted to the Hopital St. Louis come from those quarters of Paris where, from the height of the houses, and the crowded character of the district, there can be but a limited supply of fresh air; and that at Troyes in Champagne, where many circumstances combine to make the atmosphere close, scrofula exists to a great extent. Baudelocque attributes the occurrence of the disease in the upper classes to the confined sleeping rooms they often occupy, the length of time passed in bed, and the not infrequent customs which children have, of sleeping with the head beneath the bed coverings, or deeply buried in a soft pillow. At Bourg. St. Andeol it would appear that a vitiated atmosphere is the chief if not the sole, origin of the disease. The air, water, and food, are good ; its situation is healthful; and there appears so little cause to account for its origin, that Madier is induced to attribute its frequent occurrence there to the presence of strangers. It is, however, stated that the streets are narrow, the houses high ; and that, besides these causes of a want of ventilation, the air is vitiated by the effluvia emanating from domestic animals, which they keep in courts attached to their houses, and from silk-worms, which are fed in great numbers within doors. Alibert observed that, at Mende, those work- men employed in the woollen manufactory and confined in close rooms are frequently afflicted; while those in open shops enjoy an immunity. The same is observed by M. Regnault to be the case at Aubigny; but the most conclu- sive fact in favour of this view occurred at a village called Oresmeaux, about nine miles from Amiens. It is situated in a large plain, exposed on all sides, and about one hundred feet above the level of the neighbouring valleys. The houses, built in the earth, lighted by one or two pieces of glass fixed into the walls, with floors some feet below the level of the soil, and low ceilings, were ill-ventilated in the extreme. Nearly all the inhabitants of this little village were afflicted with scrofula. A fire destroyed it; it was rebuilt by houses of a more airy description; since which time the disease lias gradually subsided. It may now be said to have disappeared from that part of the country. Prevention. There are three points to be particularly attended to in the prevention of scrofula:—1. Where a taint of the disease evidently exists in the mother, the state of her health during the period of utero-gestation should be regarded with the most jealous care. 2. That, on the birth of the child, if either parent should have strumous predisposition, prophylactic means must be resorted to during the early years of life. 3. In cases where there is no hereditary predisposition, but locality or other external agents appear the sotu'ce of the disease, these must be obviated. 1. ,Females are not, for the most part, sufficiently impressed with the influ- ence exercised by their own state of health, during pregnancy, on the offspring they are carrying. This applies generally; but when the system is imbued with disease, the foetus is in a condition to receive any morbid impression much more easily. It would be useless here to lay down any series of rules. Particular stress, however, may be laid upon the necessity of sufficient cloth- ing, exercise in the open air, avoiding heated rooms and late hours, and ab- staining from an indulgence in a full stimulating diet. On a child being born of strumous parents, every means should be taken as regards food, air. clothing, &c, to strengthen the general health, and to counteract the hereditary tendency. Should the father only be endued with the strumous habit, and the mother be in every way a proper person to nurse her own offspring, the infant should, by all means derive its nourishment from her in preference to a stranger. If, however, the mother, be scrofulous, a young healthy nurse should be substituted ; and for the first six or seven months the infant should be entirely nourished from the milk so afforded : in the succeeding three or four months, the addition of other light and nutritious food should be resorted to in addition to that of the breast. scrofula (Prevention). 541 It is absolutely necessary that the wet-nurse should not have given suck to her own child above a few weeks or rather days previous to the one she is to nurse : and during the whole period of her supplying milk, she, as well as the infant under her charge, should occupy large and airy rooms, and should take regular exercise in the open air, attending especially to the state of the diges- tive functions. A very common error prevails, that women, during the time they are fulfilling this function, should take in more nourishment than is their usual custom, and that it should be of a more stimulating and heating nature. About the age of ten months, or at the latest twelve, the infant should be weaned. Nothing conduces so much to produce a feeble frame of body as protracting the period of nursing. The milk after twelve months becomes poor and innutritious, causing in the child fed with it flatulence and indiges- tion. The food, at this period, should in great measure consist of cow's milk, toge- ther with light nutritious matters taken from the vegetable kingdom, with some very slight addition of broth. Dr. Paris strongly recommends milk impregnated with the fatty matter of mutton suet. It is prepared by enclosing the suet in a muslin bag, and then simmering it with milk. W7here it is an object to introduce much nutritive matter in a small space, he is not acquainted with a better form of aliment. (On Diet, p. 220.) Dr. Cumin, who has made trial of it, fully bears out this recommendation ; and says that it has a near resem- blance to goat's milk, but that it has the advantage of being more astringent. He found it to be very useful in cases of scrofulous marasmus, when almost every other article of diet caused irritation of the bowels, and passed through them undigested. The clothing of infants is of great importance. Dr. Edwards has shown that they neither have the temperature of adult age, nor enjoy the power of generating heat to the same extent. The practical applications which result from his observations are of the highest importance. He says with great justice, that if the attentions which children require in climates and seasons little favourable to the preservation of their existence were generally under- stood and put in practice, it would considerably reduce one of the most powerful sources of mortality affecting that age in our climate. Cold operates much more generally than is supposed, and often affects the constitution most seriously, even when its effects are not manifested by any immediate sensa- tions. " They do not feel the cold, but they have an uneasiness or an indis- position which arises from it; their constitution becomes deteriorated by passing through the alternations of health and disease; and they sink under the action of an unknown cause. It is the more likely to be unknown, because the injurious effects of cold do not always manifest themselves during or immediately after its application. The changes are at first insensible: they increase by the repetition of the impression, or by its long duration; and the constitution is altered without the effect being suspected." (Edwards, op. cit. p. 265.) In those countries where, from the degree of cold, its effects are more sensible than with us, the necessity of guarding their children against its influence is fully appreciated. The result is, that in these colder climates this agent is a less frequent cause of mortality than amongst us. At the same time that it is necessary to watch the progress of the seasons, and to guard against the injurious effects of their climate, it is also of consequence to promote that state of the system which is favourable to the generation of animal heat, in order to compensate for the abstraction of it by radiation, the temperature of our climate always making ihis a condition of our existence. This is effected by maintaining the organs of respiration and circulation in a state of vigour. The chief means which we have of promoting this are, exercise in the open air, living in apartments where ventilation is good, and the maintaining a healthy condition of the surface of the body. Immersion in cold water is useful to this end. 542 scrofula (Treatment). The importance of fresh air cannot be too strongly inculcated; the rooms occupied by those of a strumous tendency should be large, airy, well-ventilated, and not over inhabited: and of all things the child should not be confined in a cot or bed surrounded by curtains. The child of a country labourer, with every thing against him except that he enjoys fresh air, exhibits a vigour of health and appearance that is in vain looked for in those nurtured in the con- fined atmosphere of the nursery. Fresh air gives tone to the skin, vigour to the respiration, and conduces in great measure to a healthy state of the diges- tive organs. As the infant advances to childhood, the same general rules are to be fol- lowed out. New faculties however come into play, whose progress should be watched with most jealous care. The developement and management of the mind requires a constant surveillance. Parents are too apt to be led into error by the precocity of mind inherent in many of this constitution; and in place of curbing it, they excite its developement at the expense of the bodily health. Nothing can be more injurious in the early years of life than that forced system of education which prevails in the present day : the head is developed at the expense of the body ; and a child thus brought up presents the appearance of a weakly frame with a precocious intellect. Eventually however these hopes are disappointed, for that state of intellect which should only have been the ac- companiment of after and mature years, fades into weakness and irresolution as manhood advances, that very period of life when the independence of intel- lect is required. A child with a scrofulous diathesis should learn its lessons in the fields, and not be bound down to books in the crowded atmosphere of a schoolroom. Amongst boys there is some relief and antidote to the disad- vantages of the school system in the hours of exercise and free enjoyment both of body and mind when out of school. The whole period, however, of female school education is fraught with conditions the most obnoxious to the strumous constitution. Their rooms are generally confined and ill-ventilated, the use of stays, and bands, and strings, prevents the free exercise of the muscles. In school and out of school it is one system of drilling and exhaust- ing attention, either to mental or external qualifications; and the natural posi- tions of the body, which are occasionally assumed to relieve the exhaustion of constraint, are reproved as unseemly and unlady-like. Then again, the course of study is so copious and extensive, that the energies of the mind are weakened by a succession of ever varying impressions. Another point to be attended to particularly is the state of the moral feelings. Should they naturally be excitable, control must be exercised, but of that qhiet and unsuspecting kind as not to irritate and wound. Children at an early age are much more susceptible of moral impressions than is generally supposed. On the other hand, should the tone be of a morose or apathetic nature, means should be taken to excite them to cheerfulness and activity. We have hitherto been speaking of those in whom the scrofulous constitu- tion may be, a priori, supposed to exist from the condition of their parents. We must not however forget that the disease arises as it were spontaneously: the circumstances connected with its spontaneous origin should be diligently sought for, and if possible removed. They will generally be found attributable to locality and errors in construction of houses,—ill-ventilated damp houses and confined localities are much more frequently, than is supposed, fruitful sources of scrofula. Treatment. Perhaps no disease requires greater exercise of that peculiar tact which should characterize the physician, than those which are tuberculous in their nature. The character of the inflammation which is attendant on the developement of tubercles rarely requires bleeding or purging, and the state of the constitution is such as generally to be injuriously acted on by a depletory course of treatment. Occasionally bloodletting may be sparingly employed on the advent of any decided inflammatory accession. scrofula (Treatment.) 543 Strong purgatives are also particularly to be avoided. The observations of Louis on the frequency of tuberculous deposits in the membranes of the ali- mentary canal are sufficient to induce one to pause before their exhibition is resorted to. Independently of any local irritation they may be the means of exciting or setting up, their action upon the system generally is not beneficial: they tend to depress its powers, and derange its functions. Should alvine evacuants be required, which is very frequently the case, the safest and most convenient medicine to be administered is rhubarb with the addition of a little soda. We have also found the preserved walnut of great service to constitu- tions of this nature: it acts effectually, gently, and without leaving depressing results. On the occurrence of any febrile accession, in preference to severe evacuants by blood-letting or purgatives, a saline treatment combined with antimonials should be resorted to. This has generally the effect of lowering the system sufficiently without tending permanently to weaken it. Mercury in all its forms has been administered in cases of scrofula. Wise- man, Pearson, Curry, Carmichael, Lloyd, &c, have been strenuous advocates in favour of its administration. Others, however, if not condemning, do not recommend it. John Hunter, the great advocate of mercury in syphilis, does not mention its employment, and in fact we may infer from his observations, that he was opposed to its use, for he says the remedies must be directed both to the constitution and to the part affected : but, if we had a specific medicine, then attacking the constitution alone would be sufficient, as it is in the venereal disease (Hunter's Works, vol. i. p. 598), and in another place he states, as some of the evil effects of mercury (vol. ii. p. 432), the production of scrofulous enlargement of the glands, rheumatic pains in the limbs, or languid inflamma- tions of the joints, having something of a scrofulous character. Cullen and Farre are decidedly opposed to its use. Cullen never found mercury in any shape of use in this disease, and that it is decidedly hurtful when any degree of feverish- ness had supervened. (Pract. of Phys. vol. ii. p. 272.) Dr. Thomson states that mercury has been used in every form of preparation, and in every variety of manner and dose. From the great apparent similarity of the symptoms, progress, and seats of scrofula to those of syphilis, and from the well-known effects of mercury in curing syphilis, it need not seem strange that medical men should have been a little obstinate in their attempts to obtain benefit from the use of mercury. These expectations are in general abandoned, and mercury is now given in the treatment of scrofula as a purgative only. A long-continued or improperly administered course of this medicine has often been known to aggravate all the symptoms of scrofula, and in many instances to excite them in persons in whom they did not previously exist. We have been particular in quoting these opinions, as they so entirely coincide with our own. We regard mercury in all its forms as a most injurious medicine in scrofula. Administered in small doses as an alterative, it frequently keeps up an irritation and excitement in the system which is eminently hurtful. As a purgative, independent of its specific effects, it is injurious, as belonging to the class of drastic medicines. (On Inflammation, p. 194.) Mr. Phillips, on the autho- rity of Hufeland, Charmeil, &c, tried the black sulphuret; but at the same time he states that he found no sufficient reason to induce him to employ it generally, he yet prefers it to the common mercurials in use, stating its chief excellence to consist in its not producing the usual effects of mercury, nor other- wise manifesting any decided antiscrofulous virtue. (Med. Gaz. 1839, p. 814). A variety of other medicines have been resorted to in the cure of scrofula. The muriates of barytes and lime were some years since particularly recommended. Dr. Wood, the great advocate of the latter preparation, speaks of it as most valuable, safe, and effective. (Edin. Med. and Surg. Journ. vol. i. p. 147.) Other practitioners, however, have not found the same beneficial results, and it has gradually fallen into disuse. Lime-water, taken with milk to the extent of 544 scrofula (Treatment). half an ounce three or four times a day, we have seen in many cases of most eminent service, especially so in those of long standing, where gland after gland becomes the seat of abscess and ulcer. The muriate of bnrytes was proposed in 1784 as a remedy by Dr. Adair Crawford. (Med. Comment, vol. xiv. p. 433, and vol. xvi. p. 225.) Mr. Phillips speaks well of this medicine, and says that, with the exception of iodine, none seems to exert a more decided influence over scrofula. It usually increases the appetite, the secretions, and sometimes, like some of the forms of iodine, produces diarrhcea. The liquor potassae, so much recommended by Brandish, is occasionally of benefit, but by no means produces those uniform results its admirers led one to anticipate. The carbonate of soda conjoined with a very small quantity of rhubarb, taken two or three times a day, is a very serviceable remedy. Ammonia has likewise been recommended, but of its continued use in this disease we have not made sufficient observation to speak decidedly of its merits. Dr. Cumin, on the authority of Dr. Charles Armstrong, says the carbonate has been administered in scrofulous cases with excellent results; but that its stimulant and diaphoretic properties render it suitable only for cases in which there exist torpor, languid circulation, impaired appetite, and a dry husky state of the skin, such as we often meet with among the poor, and in that form of the disease so well charac- terized by Alibert (Nosologie Naturelle) under the designation of scrofule momie. (Cyc. Pract. Med. vol. iii. p. 718.) The whole class of tonic medicines have, in their turn, been recommended. Some of them are exceedingly valuable. We have frequently seen the ema- ciated frames of those worn down by this disease rally most surprisingly under the use of small doses of quinine and conium. The exhibition of quinine, how- ever, requires to be carefully watched, as in some constitutions it sets up an irritation in the alimentary canal, which is not easily subdued. We have found it produce uneasy griping pain, followed by small irritating evacuations. The wine of iron is another tonic, which is often of essential service. The carbonate we have generally observed to be too stimulating, and apt to derange the diges- tive organs. Arsenic has also been recommended, and a recent writer speaks especially of its power in allaying the pains of scrofulously inflamed bones and joints. The probability, however, of its setting up an irritation in the muco- digestive passages should induce us to employ more safe tonics, unless in cases where the skin is affected by some of the eruptions which are proper to this constitution. In these cases, it is very remarkable how effectually it alleviates the morbid condition of the integuments. Of the use of the ammoniacal muriate of copper we have no experience; it was recommended formerly by Helvetius and Stisser, and enjoyed great reputa- tion under the name of the Liquor of Koechlin. It has now, comparatively speaking, fallen into disuse. The employment of acids is, at times, absolutely called for. During the progress of the disease the tendency to perspiration becomes so extreme that, if not controlled by their exhibition, great debility ensues. Their use at other times, as alteratives and provocatives to a healthy state of the system, is at- tended by very marked advantages. At the same time their exhibition should be narrowly watched, as, in many constitutions, they tend to set up alvine irritation, and, in others, produce constriction of the chest. Occasionally local pains render it necessary to resort to sedatives. They should not, however, be used unless absolutely required, as they tend to derange biliary secretions, and otherwise to deteriorate the state of the system. When employed, the least stimulating should be selected : as the belladonna, hyoscya- mus, and the preparations of morphia. We prefer the hyoscyamus, as tending not to derange the bowels to the same degree as the others. Of all the remedies, however, which have acted beneficially in this disease, none are to be compared with iodine and its compounds. This substance was scrofula (Treatment). 545 first discovered in 1812 by Courtois, and was recommended by Coindet of Geneva as a remedy for bronchocele. It is a powerful medicine, but if used in proper quantities is safe, and exceedingly efficacious. It fell somewhat into disuse, however, on account of some obnoxious qualities attributed to it, until, in 1829, M. Lugol brought it again into notice by that judicious employment of it, which has almost identified his name with its administration. The chief objections that have been urged against this remedy are, that it produces absorp- tion of some of the larger glands of the body, causes general emaciation, pro- duces pulmonary tubercles and haemoptysis, induces palpitations, restlessness, fever, and irritation in the mucous membrane of the fauces and stomach, and, if continued for sufficient time, general dropsy. That these effects are not pro- duced when judiciously employed, sufficient trial has been made to enable one to state most decidedly. The error in the administration of iodine, before the memoir of M. Lugol informed the profession upon the question, consisted in form and in too large doses. Given as he has advised it, the results show no ground for the statement of its injuriousness, and so far from emaciation being a conse- quence, the immediate effect of its exhibition is often observed to be, that thin females have acquired a state of embonpoint, together with a feeling of in- creased strength and improved health. In order to insure its efficacy, it should not, previously to its being required for use, be mixed with a large quantity of water. For the sake of convenience it may be kept in a concentrated form, and mingled with its menstruum, guttatim, at the time required to be taken. Lugol has shown that its certainty is much insured by being mixed with the hydriodate of potassa. We have found it convenient to adopt the following formula :*—R. Iodini gr x, Potassa? Hydriodatis gr xx, Aquae 3>j- This makes an available and elegant preparation. From eight to twelve minims dropped into a glass of water, and taken three or four times a day, for an adult, has proved of the most signal service, and but rarely disagrees. There are certain states of the system which contraindicate its use, the chief of which, in females, is a tendency to menorrhagia. It sometimes, in women of a lax weak fibre, produces this morbid state. Neither must it be employed when any erysipela- tous state of the skin exists, nor when pneumonia, gastro-enteric affections, or diarrhcea, are present. Its ostensible and almost immediate effects upon the system are, an improved appetite, a more transparent and healthy colour of the skin, together with a general amelioration of the symptoms, followed by a de- crease in, and eventually an absorption of, the morbid glandular swellings. On the use of this medicine being persevered in a very long time, some patients suddenly become feverish, affected by headache, and loss of appetite, &c. On remitting its employment, these symptoms soon subside. An excess of this state, which has been termed by Coindet and others iodic saturation, is characterized by acceleration of the pulse, palpitations, dry and frequent cough, night watchings, rapid thinning, loss of strength, trembling, &c. This condi- tion of things should never be permitted to supervene. Baudelocque, whose employment of this remedy has been very extensive, affirms that he has never witnessed such a series of symptoms. The statistical report of Baudelocque on the use of iodine is very satisfactory : of 67 cases of scrofula at the time of making his returns, 15 were cured, 14 were on the point of being declared well, 13 were in that state of progress which promised recovery, 5 had manifested some slight change for the better, and 20 were not benefited. Very frequently, when it disagrees with the stomach, the hydriodate of potassa, administered by itself, or in conjunction with the decoction of sarsa- parilla, is very useful. The other preparations of iodine taken internally are * The London Pharmacopoeia directs that one ounce of iodine and two ounces of hydriodate- of potassa should be dissolved in two pints of spirits, to form their tincture. We, however, prefer the aqueous solution. vol. in. 69 546 scrofula (Treatment). the iodurets of zinc and iron: these are both very beneficial. The iodide of iron is a most valuable preparation in cases of dilapidated constitution, espe- cially when worn down by the effects of superficial ulcerations: occasionally, however, patients in this condition are not capable of bearing the iron from its overheating the system, producing constriction of the chest and unpleasant feel- ings of fulness : we have then found the iodide of zinc a convenient substitute: the dose of either may be stated to be from about three to five grains three times a day. The ioduret of lead, in the form of an ointment, applied externally either to simply swollen glands or to scrofulous abscesses or ulcerations, produces effects which are quite amazing when compared with the obstinacy of these conditions under other treatment. We have seen the most marked daily improvement follow its application in these cases, and may almost say have never been dis- appointed : it is bland, mild, and unirritating; for which reason it is to be pre- ferred to the ointments made with iodine or with the protoiodide of mercury, which produce, for some short time after application, sensations of heat, prick- ing, and burning. Baudelocque and Phillips, however, lay much stress upon the alternate use of these preparations, affirming that the tumefactions are only acted on by them for a short time after their first application. Our own obser- vation has led us to conclude that the effect does not so speedily wear out. Lugol is a strenuous advocate for applying iodine and its compounds in the form of baths. In this country we believe that this mode of application has not been much resorted to. We ourselves certainly have no experience of its employment in this form. Mr. Phillips does not approve of them, and states that in two cases where iodurated baths were prescribed by him, an extensive and troublesome eruption of the skin was produced, and in three others vertigo with a suffused countenance, which was not dissipated for some hours, while no sensibly good effects were produced upon the tumours. He does not state the strength of his baths, but the above effects call to mind the symptoms stated by Lugol as evidence in his experimental trials of the baths being too strong: and he particularly dwells upon the evils which result from employing iodurated baths prepared in stronger proportions than he has directed. The following tabular view of the proportions of iodine and hydriodate of potassa and water in baths for children and adults has been reduced from Lugol's formula? to English measure by Dr. O'Shaughnessy:— BATHS FOR CHILDREN. i BATHS FOR ADULTS. Age. Water. T ,. Hydriodate Iodine. , ;D. ] of rotassa. Degree. Water. Iodine. Hydriodate of Potassa. 4 to 7 7—11 11—14 Quarts. 36 75 125 Grs. (Tr). Grs. (Troy). 30 to 36 60 to 72 48—60—72 96—120—144 72—96 \ 144—192 1 2 3 Quarts. 200 240 300 Drms. (Tr.) 2 to 2} 2—24— 3 3—3J Dims. (Tr). 4 to 5 4—5—6 6—7 The patients were generally immersed in these baths for the space of half or three-quarters of an hour. The recommendation in their favour is fully borne out by the observations of Baudelocque, who in mentioning their remarkable effect on ulcerated surfaces, states, that on the individual coming from the bath, they appeared dried up, and as it were healed. In the course of the day, how- ever, the surfaces again became moistened, and the secretion of pus which had been suspended reappeared, though in less quantity. The_author uses the word scrofula as synonymous with tuberculous disease. This is, no doubt, very nearly correct, but it requires some explanation. The term scrofula may be applied to SCROFULA. 547 most disorders of a slow character tending to disorganization of the part, and not classed under different specific designations, as cancer, melanosis, gangrene, &c. These disorders tend sooner or later to the formation of tubercle, which is the anatomical character of the scrofulous disease, and may be secreted in every tissue of the body: but previous to the formation of tubercle a change takes place in the part, which is different from common inflammation, and may be properly termed scrofulous. It is of course extremely difficult to explain the exact nature of scrofula j the definition given of it by the author approaches, perhaps, as nearly as any other to the correct one. In most cases of tuberculous disorder there is evidently a peculiar constitutional state which is called the scrofulous, or consumptive, diathesis or tendency, but this is not always called into action. It is developed either by positive inflammation, or the gradual increase of the general disorder, which at last shows itself in particular organs, by a gradual alteration of the part, in most cases accompanied by the secretion of tuberculous matter. The nature of this alteration is difficult to define, other than that it is either a slow inflammatory action or a secretion of tuberculous matter not preceded by active excitement. In either case the nature of the alter- ation is so far specific that the disease is slow, does not readily tend to maturation, and is apt to recur in different parts of the body. The colour of the tissues is in general less red than in ordinary inflammation; hence it has been said that the disease consists in an inflammation of the white blood-vessels, or lymphatics. It is. very true that the red blood-vessels are not much involved, but the most distinctive character is not the colour of the part, but the secre- tion of the newly-formed matter, which either appears as ordinary tuberculous substance or as a white transparent infiltrated liquid. This in the bones produces caries, in the other organs either tubercles or slow alteration and thickem*hg of the tissue. The treatment, therefore, of scrofula is much more of a general than local character, and consists mainly in the use of such remedies as are capable of correcting the general diathesis, with occasional local treatment. (o A . i«"k •*• >,> * r>Jt?" -» ' . *L.*1 - . ♦r^ ^ U,| j;^ +^]J\- -^ >"•' ^ BRONCHOCELE. History.—Causes.—Cretinism.—Connexion between broncbocele and cretinism.—Diagnosis. —Treatment. The term Bronchocele (from fipoyxog, the windpipe, and x-ffkrj, a tumour) is applied to a morbid enlargement of the thyroid gland. This affection is en- demic in every quarter of the world, particularly in mountainous districts. From its prevalence in some parts of Derbyshire, it is generally known in this country as the Derbyshire Neck. The Swiss call it Goitre, which is probably a corruption of guttur, throat. In most cases, the whole gland is uniformly affected with the disease, and forms a tumour in the front of the neck, often of an enormous size. Sometimes, however, the swelling is confined to the centre of the gland, or to either sidcjv At the commencement, the tumour has, in general, a firm elastic feel; but when it has existed a considerable time, it loses this character, and becomes soft and flabby, with hard knotty lumps distinguishable in its centre. Its growth is at first slow, but it afterwards advances rapidly in size, and extends in all directions, projecting beyond the boundaries of the chin and neck, and fre- quently becoming pendulous over the chest. Its appearance has often been compared to the dew-lap of the turkey-cock, and in many cases the resem- blance is tolerably correct. In some instances the tumour is said to have reached the lower extremity of the sternum, and even to the knees. Dr. Broadbelt saw a case, where it was so large and flaccid, that the woman was in the habit of throwing it over her shoulder, to relieve herself from its dis- ^C^tressing weight. Sometimes three distinct tumours are observed, corre- * sponding to the three divisions of the thyroid gland. At others, one lobe only is affected, and, according to Alibert, the right is more frequently attacked than the left. The skin over the tumour retains its natural appearance, but large varicose veins ramify in all directions beneath. The swelling is unac- companied by pain, and, in general, causes but little inconvenience. Some- times, however, distressing and even dangerous symptoms are induced by the pressure of the gland on the surrounding parts. In this manner, the circula- tion through the cervical vessels may be impeded; or respiration and deglu- tition rendered painful and difficult by the compression of the trachea and oesophagus. These complications do not apparently depend so much on the size of the tumour as on the mode of its growth, being wholly absent in many cases where the gland has obtained an enormous magnitude; whilst in others the patient is harassed by them, even from the commencement of the swelling. The obstruction of the circulation is sometimes so great, as to occasion con- gestion of the brain, and apoplexy. In some instances, also, the pressure on the trachea has been so complete, as to cause death by suffocation. De Haen found this tube nearly obliterated in a case of this kind. In milder cases the respiration becomes habitually wheezing, and the voice shrill or hoarse. Not unfrequently, the patients complain of palpitation on slight exertion. When goitrous tumours are examined internally, the following appearances f are observed. The diseased gland is surrounded by a supernatural quan- * bronchocele (Causes). 549 tity of cellular membrane, thickened and condensed, which in some instances is so abundant, that it forms the chief bulk of the tumour. The gland itself is hypertrophied either uniformly or partially. Most commonly its whole sub- stance is simultaneously affected ; but sometimes one of the lobes is enlarged, while the rest of the gland remains free from disease. When cut into, the dis- eased gland exhibits a cellular appearance. These cells are very various in size in the same gland : they are sometimes no larger than a pea; whilst at others they form considerable cavities, which seem to be produced by the dila- tation of the cells which enter into the natural structure of the gland. They contain morbid matter of various kinds, either fluid or solid. Sometimes it is perfectly aqueous, or more or less viscid and adhesive; sometimes it has a gelatinous consistence ; at others, these depositions have a fatty, fibrous, car- tilaginous, and, in some cases, even a bony character. Causes. Numerous theories respecting the origin of bronchocele have at different times been advanced, which have fallen to the ground under the test of more extended experience. It has frequently happened that some accidental circumstance in its local history has been made the basis of doctrines respect- ing its origin which have been found inapplicable on a more general view of the disease. With regard to its predisposing cause, there can be no question that women are far more liable to it than men : indeed, it rarely occurs in the latter sex in this country; and even in localities where it is more particularly endemic, it is almost exclusively confined to females, except when connected with cretin- ism, to be presently noticed. It generally commences in infancy, between the ages of eight and twelve, and sometimes much earlier. In some instances it is said to be congenital. It frequently begins at the approach of puberty, the thyroid and mammary glands enlarging simultaneously and in some locali- ties almost as certainly. A moderate fulness of the thyroid gland is by no means uncommon at that period in girls of this country, often exciting appre- hension, but generally subsiding after a few months. The developement of the disease is often preceded or accompanied by uterine disturbance. (Cop- land's Diet, of Pract. Med. art. Bronchocele.) Women of the leucophlegmatic temperament seem to be more liable to it than others. It is a popular notion in some countries that the disease pre- dominates in those who have long necks ; and girls of this conformation, have, in consequence of this opinion, a difficulty in forming a matrimonial engage- ment. The scrofulous diathesis has been considered by some to give a predispo- sition to bronchocele, which, however, is deficient in some of the essential cha- racters of struma. The swelling is rarely preceded or accompanied by consti- tutional disturbance. There is little tendency to ulceration, the tumour con- tinuing "for many years in an indolent and inactive state. The lymphatic glands do not in general partake of the disease. There seems more ground for the opinion of an hereditary predisposition to this disease. Certain families are observed, in districts where it is endemic, to be goitrous through successive generations. Dr. Crawford knew " a woman with goitre, whose grandmother, father, paternal aunt, and cousins also had it, although they did not all live in the same place, and no other person in their neighbourhood was affected with the disease." (Cyc. Pract. Med.) Similar facts have been mentioned by Fodere and others. Indeed, in Switzerland, this tendency of the disease is a matter of common observation. Great obscurity attends every step of the inquiry into the nature of the exciting causes of bronchocele, or the influences which occasion its appearance in certain localities as an endemic disease. This investigation may eventually lead to the discovery of important principles respecting the action of moral and physical conditions upon the growth and developement of organized beings. At present, however, our knowledge on this point is too limited and uncertain 550 BRONCHOCELE (CttUSes). to permit any safe or legitimate conclusions. In general terms it may be said that bronchocele fixes its abode in the deep, dark, and humid valleys of moun- tainous regions, which are filled with malarious exhalations, and where the atmosphere is seldom ruffled by a breeze of sufficient power to remove the accumulated poison. In Europe, it is a prevailing affection in the valleys of the Pyrenees, the Tyrol, and the Alps ; and it is also met with among the moun- tain ranges of other parts of the world^: generally speaking, too, the disease predominates in those localities where the agencies alluded to are in the greatest abundance. In Switzerland, it is most common in the Vallais, which of all the Alpine districts is the closest and worst ventilated. " Were this valley (says Dr. J. Johnson) beneath a tropical sun, it would be the seat of pestilence and death. As it is, the air must necessarily be bad; for the high ridges of moun- tains, which rise like walls on the north and south sides, prevent a free ventila- tion ; while, in summer, a powerful sun beats down into the valley, rendering it a fpcus of heat, and extricating from vegetation and humidity a prodigious quantity of malaria." It has been remarked by observers in goitrous districts in different parts of the world, that the disease disappears at a certain height above the level of the sea. Saussure found in his travels through Switzerland, that in a valley watered by the same stream, and where the habits and occupations of the in- habitants were precisely similar, those who lived in the upper portion of the valley were never attacked with the disease, which was endemic in the lower portion. He states, also, that goitrous patients, who removed from the latter to the former of these localities, were gradually disburdened of their complaint; while, on the contrary, it frequently attacked those who left the upper to reside in the lower parts of the valley. The investigations of Fodere, and others, have led them to the same conclusion. But, on the other hand, bronchocele is sometimes endemic in places of con- siderable elevation. Humboldt (Magendie, Journ. de Physiol, t. iii., p. 116) found it in Bogota, in South America, 6000 feet above the level of the sea. Mr. Bramley met with it among the Himalaya mountains at the height of 5000 feet; and upon the summit of a high mountain, forty-eight persons out of fifty-three were goitrous. (Brit, and For. Med. Rev. 1839.) Ramond, quoted by Dr. Crawford (Cyc. of Pract. Med.), observed both goitre and cretinism in the "open, well-watered, and well-ventilated valleys of the Pyrenees." In some places, also, where all the ingredients for the production of malaria are present, bronchocele is unknown. It has often been observed to be less prevalent at the foot of a valley, where the miasmata must be supposed to be most concentrated, than its more open and elevated portions. Bronchocele, moreover, is not generally attended by any of the ordinary symptoms which are supposed to denote the action of malaria ; on the contrary, goitrous.persons are frequently robust and healthy. It may be doubted, therefore, whether this affection can be attributed to malaria in the ordinary acceptation of the term ; that is, to the poison which induces remittent and intermittent diseases. At the same time it seems obviously dependent upon some deleterious quality of the atmosphere in places where it is endemic, not only attacking natives of those districts, but visiters who remain there for even a short time, although the greatest caution is observed in avoiding improper diet and other reputed sources of the disease; while by a removal from these localities goitrous swellings often disappear spontaneously. Dr. Good supposed that bronchocele is the consequence of a diet deficient in nutriment, and attributed its prevalence in Derbyshire to the quantity of oaten cake employed there as an article of food. It is a common opinion in Switzer- land that those who eat large quantities of chestnuts are very liable to the com- plaint. The wretched condition of the poor in the Vallais may, however, pro- bably contribute to its prevalence there. Goitre attacks indifferently the rich and the poor. We know an instance of BRONCHOCELE (CaUSes). 551 an English lady in affluent circumstances, who became affected with it after a residence of a few months in a goitrous district in Switzerland ; and many similar cases might be mentioned to prove, that the utmost care in the selection of diet does not remove the liability to the disease. Indeed, the rareness of its occurrence in the crowded parts of London is sufficient to prove, that misery, filth, and destitution, are not alone sufficient for its production. The frequency of goitre in Alpine regions has given rise to the opinion (no- ticed by all authors on the subject since the time of Pliny) that it is caused by drinking the water from the glaciers or melted snow. Dr. Friend says, " The liquor, in going down, must needs chill the muscles of the throat, i. e., it contracts the vessels, and thickens the humours which circulate through them, at the same time, from whence must flow a stagnation or obstruction, and, after a while, a swelling in those parts." (Hist, of Phys., vol. ii., p. 146.) It is now, however, well ascertained that the disease is endemic in warm latitudes where snow never falls, as China, India, Sumatra ; while in Lapland, Greenland, and some other northern regions, where melted snow is the com- mon drink of the inhabitants, bronchocele is never seen. It is curious that the converse of this opinion respecting the origin of goitre has been maintained by some modern observers. Fodere remarked that it is less prevalent in the neighbourhood of glaciers which supply the villages with water, than in other parts of a goitrous valley. (Traite sur le Goitre et le Cretinisme.) Captain Franklin states that at Edmonstone on the Saskat- chanan river, where goitre is endemic, those persons who drink snow water entirely escape the disease; but those who use the river water are almost universally attacked. (Jour, of Voy. to the Polar Seas.) These facts seem to favour the notion, which is a popular one in goitrous districts, that broncho- cele originates in some deleterious quality of the water; indeed, it is impos- sible to examine the filthy beverage of some of these districts, without being convinced that pernicious consequences must ensue from its habitual use. Bally (Diet, des Scien. Med.), a native of a district in Switzerland, where bronchocele is endemic, states that, in his country, those who drink the waters of'certain fountains are almost always attacked, whilst others of the same village who avoid these waters are not liable to the complaint. Rombateau, also, considers that water impregnated with calcareous salts contributes to its developement. Dr. Coindet observed that almost every individual of a regi- ment who drank the calcareous water of the pumps at Geneva were attacked with goitre, which disappeared rapidly upon their removal to other quarters. Its prevalence in Nottingham is ascribed by Dr. Manson to the same cause. (On the Effects of Iodine.) Mr. M'Clelland has lately made extensive researches into the causes of bronchocele among the Himalaya mountains. His inquiries extended over 1000 square miles, and he invariably found limestone rocks in the immediate neighbourhood of goitrous districts, while in villages where this stratification was not observed, the disease was rarely met with. When it was found in the latter places, Mr. M'Clelland could generally trace it to the use of water having its source in the limestone rocks, and where these waters were avoided, the complaint seldom appeared. Unfortunately, however, there are facts which prevent the universal application of this theory respecting the origin of the disease. 1. Bronchocele is met with abundantly in districts where there are no limestone rocks, as, for instance, in the Vallais. 2. It is absent in many places abounding in limestone formations. 3. It prevails in districts where the water is pure, and free from calcareous impregnations. (Humboldt, op. cit.) 4. A strict adherence to distilled water is not sufficient to ward off the disease in affected places. The only way of reconciling these conflicting statements is, by supposing that the habitual drinking of calcareous waters strongly predisposes to bron- 552 bronchocele (Causes.) chocele, and that there are other causes which have the same tendency, although few, to an equal degree. But the presence of some additional in- fluence hitherto unknown, and probably of a more subtle and hidden nature, seems necessary for the developement of the disease. Cretinism, to which we have before alluded, forms a most remarkable and interesting part of the history of bronchocele. The cretin—the most disgusting and hideous of beings possessing the human form—is found accompanying bronchocele in the Alps, the Pyrenees, the Himalaya mountains, and wherever the disease is abundantly endemic. His stature is diminutive, seldom exceeding from four to five feet; the head is large, and the skull excessively thick; the countenance is vacant and void of intelligence, having in youth the aspect of old age; the eyes project and are widely separated : the eyelids are coarse and prominent; the nose wide and flattened; the tongue large and protruding, causing thick and babbling speech ; the lips are thick, and the mouth large and drivelling; the skin is loose, wrinkled, and of a dirty-brown colour; the muscles are soft and flabby; the abdomen large and pendulous ; the legs short and curved, occasioning the gait to be awkward and waddling ; and a goitrous tumour occupies the neck. This wretched deformity of body, is, in general, accompanied by a corre- sponding infirmity of mind. Idiotism of the very lowest grade is often the lot of the cretin. Sometimes even the external senses are absent; and the cretin is deaf, dumb and blind, with complete insensibility even to the demands of nature ; more frequently, however, he is wholly governed by the animal pro- pensities, being mischievous and lascivious, yet indolent and sluggish to an extreme degree. In some instances, however, he possesses a certain degree of intelligence scarcely inferior to that of the community among whom he dwells. A cretin of this class joined the writer and his party in the ascent of the Great St. Bernard. He was quiet and respectful, and answered questions coherently, so far as his imperfect articulation could be understood. The connexion between bronchocele and cretinism is a subject well deserving attention, but on which our space will not allow more than a brief summary. 1. Cretinism is confined to districts where goitre is endemic. 2. Wherever cretinism prevails bronchocele is invariably found, but the latter is prevalent in districts where the former is never seen. 3. These affections seem to result from the same cause, but cretinism is not produced except in localities where the poison, on which they both depend, exists in the greatest activity. It is never seen, for instance, in the goitrous districts of this country, or in several of the more open goitrous valleys of Switzerland. It is comparatively rare in the better-ventilated parts of the Vallais; whilst in the gloomy valley of the Rhone it is so common as to give a character to the district. In accordance with the same rule, it has been observed that bronchocele and cretinism occur together in the deepest parts of a goitrous valley, but that the traces of the latter are lost beyond a certain altitude, where bronchocele continues endemic. 4. It has been supposed, when a family has been goitrous for two generations, that cretinism will appear in the third. It is also said, that when both parents are goitrous, their offspring will be cretins. But although these assertions may not be lite- rally true, they convey the general impression of the inhabitants of affected districts as to the importance of intermarriage in removing the taint of cre- tinism ; and the researches of M. Rambeteau tend to confirm the correctness of these views. He ascertained that those inhabitants of the Vallais who take their wives from places where neither cretinism nor bronchocele are endemic, have cretinous children far less frequently than those who marry females of their own valley, or other goitrous districts. Diagnosis. Although the tumour of bronchocele is in general sufficiently characteristic, it may sometimes be confounded with other affections. The thyroid gland is liable to inflammation ; but this disease may be distinguished from goitre, by the hard unyielding character of the swelling, by its being ac- bronchocele ( Treatment). 553 companied with redness of surface, increased heat and pain on pressure, by the suddenness of its appearance, by its not attaining the size of a goitrous tumour, and by its tendency to suppurate. The gland is sometimes affected with scirrhus. In this case, however, only a small portion is usually affected, which differs from bronchocele in its extreme hardness, and in being generally the seat of severe lancinating pain. In scirrhus, also, the swelling seldom attains a large size. Encysted tumours sometimes form in the course of the trachea, which may be distinguished from bronchocele by their situation, by their compact form, and by their giving a sense of fluctuation. Aneurism of the thyroid arteries may be known from goitre by the pulsation which accompanies the former affection, by the situation of the swelling, and by its diminishing or disappearing under firm pressure. Treatment. The introduction of iodine as a therapeutic agent has nearly superseded all other remedies for bronchocele. This substance formed the active ingredient of several combinations that had previously obtained a reputa- tion for the cure of this disease. The most remarkable of these was the burnt sponge, which has been successfully administered in many cases. It was prin- cipally used in the form of lozenge, and suffered to dissolve slowly and gra- dually in the mouth, a method supposed necessary to insure its good effects. The ashes of the fucus vesiculosus, called by Russell the vegetable aethiops, an empirical remedy named Le Poudre de Sensy, and some others, formerly favourite remedies for goitre, have also been found to contain a portion of iodine. About six years after the discovery of iodine by Courtois, its presence was detected in burnt sponge by Dr. Straub of Berne. About the same time Dr. Coindet of Geneva, observing the similarity between burnt sponge and the ashes of the fucus vesiculosus, which was known to yield iodine, conceived that this substance might form the active principle of these medicines, and the idea oc- curred to both these gentlemen that iodine would prove an important remedy in the treatment of bronchocele. These views were immediately put into prac- tical operation by Dr. Coindet with the most complete and gratifying success, for of 100 patients to whom the medicine was given two-thirds were cured. Since that period iodine has been extensively employed wherever bronchocele prevails, and its utility in this affection may be considered as fully and satis- factorily established. The formula employed by Coindet consisted of 40 grs. of iodine to an ounce of alcohol, of which from 10 to 20 drops were a dose. He also recommends an ointment composed of half a drachm of the hydriodate of potash to an ounce and a half of lard, of which a drachm is to be rubbed over the tumour night and morning. Dr. Marson of Nottingham cured 79, and greatly relieved 12, out of 120 cases. His preparation consists of 24 grs. of the hy- driodate of potash dissolved in an ounce of distilled water, to be given in doses of 5 drops three times a day. Dr. Elliotson recommends a drachm of the iodide of potash to an ounce of distilled water, the dose at the commencement to be from 10 to 15 minims, and gradualy increased. Dr. Copland has found this remedy most efficacious in small and soluble doses, and has succeeded in curing some cases by this method, upon which large quantities of the remedy had made no impression. As to the question whether this medicine is best employed internally or ex- ternally, it may be remarked that both methods may often be advantageously combined. Some patients, however, cannot bear even the smallest dose of the medicine taken into the stomach, who feel no inconvenience from its topical application. In either case, however, its effects should be carefully watched, and its exhibition suspended for a period, or its dose lowered, upon the mani- festation of poisonous symptoms. Little benefit, however, may be expected from this or any other remedy unless regard be paid to other circumstances con- nected with the treatment. Whenever it is practicable, the patient should be removed from the goitrous district into some open and elevated situation. Nu- merous instances are recorded where the adoption of this change was followed vol. in. 70 554 bronchocele (Treatment). by a rapid subsidence of the disease. Where the patient is plethoric, the exhi- bition of iodine may be properly premised by general bleeding. The application of leeches to the swelling is often useful to diminish any inordinate irritation— an accident which not uncommonly occurs during the exhibition of iodine,— and they may also assist in the reduction of the swelling. If there should be symptoms denoting derangement of the digestive organs, a course of alterative medicine should be commenced and presevered with until their healthy action is restored. When the uterine functions are unduly performed, which is often the case in bronchocele, emmenagogue remedies should be prescribed. Other remedies were formerly used in the treatment of goitre, which are now seldom employed : of these the principal are digitalis, belladonna, conium, muriate of barytes, muriate of lime, calcined egg-shells, sulphuret of potash, mercurial preparations, &c. As external applications, it was the practice to employ repeated blisters, stimulating plasters of ammoniacum and mercury, or cicuta and ammoniacum, stimulating or opiate liniments, caustic applica- tions, &c. When the tumour of bronchocele occasions great inconvenience by its pres- sure on the trachea or oesophagus, and the ordinary means of relief have failed, a cure has been attempted by means of a surgical operation. (See Cooper's Surg. Diet., art. Bronchocele.) Several cases are recorded where the tumour was reduced by the introduction of setons into the diseased gland. This method appears to have been practised in the middle of the last century, but was not generally known until Dr. Quadre of Naples published some cases in which it had been employed with success. It was afterwards adopted with benefit by Mr. Copland, Hutchinson, and others. The objections to its use are, that it is sometimes attended with dangerous haemorrhage, or by extensive suppuration of the gland. There is also danger of the communication of the inflammation to the trachea and larynx. In some instances the operation of tying the thyroid arteries has been prac- tised. It was first attempted by Sir W. Blizard, with the effect of reducing the size of the tumour one-third. The ligatures subsequently sloughed off, con- siderable haemorrhage ensued, and the patient finally sunk from hospital gan- grene. In 1814 this experiment was repeated by Walther of Landshut. He first placed a ligature on the left superior thyroid artery, which in a short time occasioned a diminution of the gland on that side to one-third its original size. He then tied the artery on the opposite side, which was followed by wasting of the tumour on the corresponding side, but not to the same extent as in the pre- vious operation. The patient, who had suffered from dyspnoea in consequence of obstruction of the windpipe, was greatly relieved, and continued well two years after the operation. Mr. Coates of Salisbury also tied the left superior thyroid artery in bronchocele with urgent symptoms. The swelling diminished to nearly one-half its former dimensions, and the patient left the hospital in good health. In the subsequent history of this case, however, communicated by Mr. Coates to Dr. Crawford (Cyc. Pract. Med.), it appears that, after continu- ing well for some time subsequent to her discharge from the hospital, the tumour gradually returned, and at length occasioned death by suffocation. A case very similar to that of Mr. Coates is given by Dr. Crawford from the notes of Mr. Wickham of Winchester. The tumour was diminished by the operation; but after six weeks it began to return, and shortly regained its former size. "It seemed (says Mr. Wickham) that the decrease of the tumour continued so long as the part of the gland, which had been supplied by the vessel, remained with- out nourishment, but as soon as the supply was restored by the anastomosing branches from the opposite superior thyroideal arteries, the swelling returned to its former dimensions." Some surgeons have effected the complete extirpation of the gland. Desault is said to have removed a portion of it successfully, but from the description of bronchocele (Treatment). 555 his case, it appears to have been more allied to scirrhus than to bronchocele. Mr. Gooch (Med. and Chir. Obs.) attempted the excision of the gland in two instances. In the first, the haemorrhage was so alarming that he was obliged to relinquish the operation, and the patient sunk from exhaustion. In the other case, the bleeding was also excessive, and could only be arrested by the pres- sure of the hand on the part, which was kept up by a succession of persons for a whole week. Dupuytren completed this operation, and although the patient only lost a small quantity of blood, death ensued in thirty hours. ° The operation has sometimes, however, been followed by happier results. Dr. Hedenus of Dresden has performed it six times with success, and a few other similar instances might be mentioned. But it is always attended with great hazard, and is hardly justifiable, except where the patient is threatened with immediate destruction from the pressure of the tumour. RHEUMATISM. Forms.—Acute rheumatism.—Complications.—Rheumatic inflammation of the heart.—Rheu- matic pleurisy.—Arachnitis.—Diagnosis.—Pathology.—Causes.—Treatment of acute rheu. matism.—Chronic rheumatism—Description and treatment—Muscular rheumatism.— Lumbago.—Pleurodynia.—Rheumatism of the muscles of the neck—Of the muscles of the limbs—Of the abdominal muscles.—Treatment of muscular rheumatism. The word RJieumatism, like its kindred term gout, is the offspring of the humoral school of pathology. Its literal signification is " fluxion," and it is primitively derived from the Greek word " psw," to flow; " peufia," a fluxion. Rheumatism has always deservedly engaged the attention of English physi- cians, on account of its great frequency in our climate, its painful and protracted course, and the baneful evils which often follow in its train. Of late years, additional interest has been attached to its study, by the discovery that, in the acute form, it often fixes on the fibro-serous textures of the heart, and causes changes in their structure which interfere with the functions of that vital organ. Many have laid claim to the merit of this discovery, and M. Bouillaud, in par- ticular, has been loud in his pretensions ; but it appears that Dr. Pitcairn first noticed this fact, and pointed it out to his pupils at St. Bartholomew's, as early as 1788. In November, 1808, Sir D. Dundas read a paper on the subject before the Medico-Chirurgic'al Society. In that paper rheumatism of the heart was considered in its true character, and described as occurring, not by metastasis, but at various periods in the course of the malady. By reference to morbid anatomy, Sir D. Dundas showed that the internal membrane of the heart was liable to be affected, as well as the pericardium. Subsequently, Dr. Wells and Dr. Odier of Geneva made some important observations on this subject. It is, then, certain, that the true con- nexion between disease of the heart and acute rheumatism was observed long ago by British physicians, and that they did as much for its history as could be expected without the help of auscultation. The extreme frequency of rheuma- tism of the heart was not known to them, because their diagnosis of it was imperfect. Since Laennec's discoveries British physicians have continued to improve their knowledge of this affection: its great frequency has been recog- nised, and its seat and morbid effects well ascertained. Rheumatism affects two forms, the acute and the chronic. Acute Rheumatism. Persons from fifteen to thirty years of age are the most subject to acute rheumatism : in old persons and in children it is°comparatively rare: the latter are not, however, so generally exempt from this disease as they are from gout, for instances of acute rheumatism in children are by no means uncommon. The first symptom of the malady is, in the great majority of cases, severe pain of the insteps and ankles, which is sometimes, but not always at- tended with shivering. When the attack is sudden, as generally happens, the affected parts become, in the course of a few hours, uniformly swollen, tense, RHEUMATISM (Acute). 557 and elastic, and soon afterwards the integument is suffused with a bright rose- coloured blush, mostly in patches, the neighbouring cutaneous veins being at the same time turgid. The tense and elastic condition of the parts soon gives place to a flaccid and puffy state, and while this change takes place the pain abates. The knees are attacked soon after the ankles; the affected limbs are immediately and completely disabled, so that in many cases the patient is obliged to be helped to his bed soon after the accession of the first symptoms : the slightest motion of the rheumatic limbs occasions excruciating pain. The upper extremities become next affected, and the patient is thereby rendered incapable of movement; a circumstance which causes a peculiar and characteristic pos- ture. Fever comes on with or soon after the local symptoms, and increases with them; it is attended with profuse sweating when the pain is severe, and this sweating, far from giving relief, is more profuse as the pain increases. The pain is in most cases aggravated by warmth, and usually much more severe at night than by day: the fever, too, is much greater at night, when the patient's linen is often drenched with perspiration which has a sour and pungent odour. During the day there is also considerable fever; the face is flushed ; the pulse, which is seldom less than 90 and sometimes reaches 120, is hard and full: there is loss of appetite; urgent thirst; and the urine, scanty and high-coloured, deposits, on cooling, an abundant brick-coloured sediment. The patient remains in this state until nearly all the joints of the extremities have become affected in their fibrous textures; tendons and sheaths of muscles likewise suffer, and effu- sion takes place into the cellular tissue and synovial capsules in contiguity with these several structures. The affection of each part does not usually continue during the whole course of the disease; after a certain period it subsides, but generally returns at least once. The number of parjts-affected at the same time is considerable, and, with few exceptions, much greater than in gout. About the end of the first fortnight there is generally some amendment: the pain lessens, especially at night; and there is corresponding abatement of fever, and diminution of perspiration. At the same time the urine becomes more abundant, and less charged with deposit; appetite returns, and thirst diminishes, while the pulse falls to nearly its natural standard; the movements also are more free, and the patient varies his posture. The course of this amendment is however often interrupted by exacerbations, and convalescence is not in general confirmed until the middle or end of the fourth week. In some rare instances, convalescence appears as early as the second week, but is more frequently de- ferred to the sixth week, or a still later period. In an average, drawn from a considerable number of cases, we found the duration nearly one-fourth greater in first than in subsequent attacks. We have stated that, at the height of the malady, effusion takes place from the affected parts. The appearances differ according as the fluid is effused .into cellular tissue or into The definite cavities of synovial capsules : in the former case the part is puffy, and, in some rare instances, oedematous, as on the wrists and insteps; in the latter, fluctuation may be perceived with tense swelling, in form of the capsule, tendinous sheath, or bursa. The characters last mentioned are most obvious in the knees, because effusion into the capsules of those joints is either conspicuous, or at any rate easy of detection. As effusion proceeds the pain abates, unless the quantity of fluid poured out be sufficient to occasion much distension. It has been stated that each part does not continue to he affected in this way through the whole course of the disease, but that the individual affection sub- sides, and generally returns at least once. Each of these attacks of a given part occupies .a period varying from three to fourteen days. The circumstance that effusions into synovial capsules are more general in some cases than in others, has led many to suppose an essential difference between such cases, which have accordingly been distinguished by the epithets fibrous and syno- vial: it has even been alleged that the heart, if not entirely safe, is much less 558 RHEUMATISM (Acute). liable to be affected in synovial rheumatism ; and further, that these two forms require entirely different treatment. We are of opinion that they are identical in nature ; that the fibrous tissue is primarily affected in both, whether the con- secutive effusion take place into cellular tissue or into a synovial capsule : and in almost all those cases, called fibrous rheumatism by authors, we can from observation affirm that effusion does take place into the capsules of the knees at least. We have elsewhere shown that the heart is equally liable to be affected in both cases. On the approach of convalescence, when recovery is to be complete, the fluid effused in different parts is rapidly absorbed, and the joints regain their natural form and usual freedom of motion. They continue weak, however, for some time, and are occasionally painful at night. In less favourable cases the fluid effused in the synovial capsules does not become absorbed, and the ligaments continue in a thickened state; the functions of the joints are thereby much im- paired, and disposed to be still further altered by chronic rheumatism, which is the common sequel. Effusions become permanent in the small joints of the hands and feet, oftener than in any others; the synovial sheaths of the tendons of the fingers are also very liable to the same condition, and their course is then marked out by ridges on the palm and back of the hand. Such are the course and characters of acute rheumatism when affecting external parts; but in a large proportion of cases there comes on at some period of the disease another group of symptoms. These are, chiefly, sudden pain in the praecordial region, and palpitation, attended with difficulty of breathing and sense of oppression. The appearance of these symptoms indicates, pretty surely, that the heart has become affected with rheumatic inflammation; whether the internal membrane or the pericardium be its seat, can be determined only by auscultation and careful examination of the chest, for the general symptoms are alike in both cases. The praecordial pain sometimes extends to the left hypo- chondrium, is generally increased by pressure in the intercostal spaces, by inspi- ration, and by lying on the left side. The difficulty of breathing is often consi- derable, and there is usually a slight increase in the frequency of the pulse, which, with rare exceptions, maintains its regularity. These symptoms usually lose much of their severity in the course of the twenty-four hours which follow their accession ; the dyspnoea and oppression are alleviated; the palpitation and pain remit, and subsequently occur only when the patient coughs, or, if at other times, for very short intervals. After this period there is seldom any thing very alarming in the general symptoms ; often, the patient is tranquil, and unembarrassed in manner, and nowise suspects that he is affected with disease of a vital organ. This freedom from suffering is observed even when there is considerable effusion into the pericardium, and sufficiently explains the fact, that rheumatic inflammation of the heart so long escaped the notice of physicians. The symptoms above described are sometimes so slight, even at their onset, that they are not complained of, and it is only by inquiry that their occurrence is ascertained. In some cases (of pericarditis especially), the only indication that rheumatism has become extended to the heart is a singularity of manner and waywardness, which are characteristic, and easily recognised by those who have once witnessed them. Taciturnity and a look of listlessness are often the most striking characters of this state of mind, which is not one of active delirium. If the patient be narrowly watched it will be generally found, also, that the breathing is much quicker than natural, for difficulty of breathing is one of the most constant of the symptoms of rheumatism of the heart. Indeed, the breathing appears to be more affected than the pulse in these cases, as regards frequency at least. Although acute rheumatism of the heart often lays the foundation of future irreparable mischief, it is not often immediately fatal; the instances of death RHEUMATISM (Acute). 559 occurring in the acute stage being chiefly in persons of weak or broken consti- tution. If the chest be carefully examined some hours after the onset of the affection, various important circumstances are observed. Abnormal sounds attend the heart's action, and these vary in character according as the seat of rheumatic inflammation is in the pericardium, or in the lining membrane of the heart. In the latter case the morbid sound is some modification of " bruit de rape," or of bellows-sound, and attend the heart's systole or diastole, or both. In twenty-three cases of rheumatic endocarditis which were observed with much attention, the different conditions of this sound as regards time and situation were carefully noted, and the following circumstances remarked:—In all but three, this sound was loudest at that point of the praecordia where the heart's impulse was felt, and was also much louder in the left praecordial region than in the right, where often the sounds of the heart were quite natural. The sound attended the diastole in one case only ; in all the others the systolic sound was exclusively altered. At the point of impulse, however, the diastolic sound was quite inaudible, and seemed to be involved in a prolongation of the systolic. From these facts, we must infer that the morbid sound originated principally, and often exclusively in the left cavities of the heart, and was most probably produced by a morbid condition of the aortic valves. The first inference accords well with what we know of the pathology of the valvular apparatus of the left side of the heart, which, from being more tendinous in structure than that of the right side, is more subject than the latter to rheumatic inflammation. It is easy to show why, under common circumstances, a morbid sound, proceeding from the aortic valves, should be louder at the point of impulse than elsewhere; for, since the systole and impulse are exactly synchronous, the point of the left ventricle is thrown into firm contact with the walls of the chest at the very moment the sound is produced; thus establishing, between the origin of the sound and the ear of the observer, a more direct and more uniform medium of communication than can be found at any other point of the praecordia. At that point, also, there is in many cases a palpable vibration (fremissement cataire), which sometimes indicates the character of the sound in a most remarkable manner. We have stated that this morbid sound affected the diastole in one case only of the twenty-three referred to; this fact admits of the following explanation. At the moment of diastole the heart has ceased to be in firm contact with the walls of the chest, so that the condition, which is so favourable to the transmis- sion of systolic sounds, no longer exists ; to this circumstance, and to the greater remoteness of the mitral valve from the surface, must be ascribed the rare occurrence of abnormal diastolic sounds in acute rheumatism. The mitral valve is, without doubt, quite as often affected with rheumatic inflammation as the aortic valves, for it is more tendinous in structure, and in the aggregate of valvular diseases is oftener affected. The plain inference from these facts is, that it is possible for rheumatic inflammation of the lining membrane to exist, without altering the sounds of the heart at all; and it would therefore be pru- dent, when marked general symptoms of the affection appear, to adopt the same remedial measures as if no doubt of its reality existed. We have never known the morbid sound in question entirely cease after it had once come on, but in most cases a change in its character takes place as febrile excitement subsides, and convalescence approaches; at first generally harsh, and sometimes a true "bruit de rape," it gradually loses this quality of harshness, and acquires the pure bellows-tone, while at the same time it diminishes in loudness; thus illustrating Laennec's remark, that these are merely modifications of the same sound. These changes are mainly owing to diminished rapidity of the cir- culation, for when that function becomes temporarily accelerated by exercise, the former character of the sound in great measure returns. It is in those I 560 rheumatism (Acute). cases, in which the quality of the sound is very harsh, that a palpable vibration is remarked. These are the circumstances observed in a careful examination of the chest, in the common course of rheumatic inflammation of the valvular apparatus of the heart. We have dwelt at some length on the subject of the morbid sound, because some writers of authority, and especially M. Chomel, have lately endea- voured to depreciate its value as a sign of the affection under consideration ; but the circumstances, detailed in connexion with this sound, leave no doubt of its real value as a symptom. When the pericardium has become the seat of rheumatic inflammation, the local signs, observed in auscultation and examination of the chest, differ in character from those just described, and denote the effusion of lymph and serum from the inflamed membrane. The principal of these signs are, dulness on percussion in the prascordial region ; prominence of that region, so that the intercostal furrows are effaced; and a rubbing sound attending the heart's action—or, when the effusion is very abundant, diminished clearness of the heart's natural sounds, which seem remote and stifled.* We have never seen an example of rheumatic pericarditis in which the rubbing sound was wanting, but have known many of idiopathic pericarditis in which it was not observed: we have reason, therefore, for believing that it is more frequent in the rheumatic than in the idiopathic form of pericarditis ; a circumstance which indicates some difference in the quality or quantity of the effused fluid in the two varieties. The fluid seems to be, generally speaking, less abundant in rheumatic than in com- mon pericarditis, the increased dulness on percussion being, as far as we have observed, less extensive. These circumstances give additional value to the rubbing sound as a sign of rheumatic pericarditis. The period during which the physical signs continue varies much in different cases, and depends on the rapidity with which the affection proceeds towards a favourable or fatal termi- nation. In one case which fell under our notice the rubbing sound continued during two days only, and was almost the only physical sign of the affection, for the fluid effused was not in sufficient quantity to occasion extensive dulness, or alter the form of the praecordial region. The general symptoms of the affection had already subsided before the sound ceased, so that its cessation undoubtedly marked the completion of cure by adhesion. In most cases, however, this sound lasts from a week to a fortnight, but as the curative pro- cess advances gradually becomes less loud and more limited, and at length ceases altogether; an event which probably denotes adhesion between the surfaces of the pericardium. While this change is taking place the extent of dulness on percussion diminishes, and the natural form of the praecordia is in great measure restored. But the general symptoms of the affection have usually: subsided long before these physical signs disappear, so that patients are often at a loss to know why the physician continues to examine the region of the heart with so much attention. Cases do occur, however, in which rheu- matic pericarditis terminates fatally, and in these the symptoms have exactly the same progress and character as in fatal pericarditis from other causes. The physical signs mentioned as characteristic of pericarditis are never ob- served in simple endocarditis, but in all the cases of rheumatic pericarditis which we have seen, endocarditis was also present, and was distinguished by its usual physical signs. In some cases these existed before pericarditis came on; and in all, they continued after the proper signs of that affection had ceased. In some, the " bruit de rape," which had come on first, and which characterized the deeper affection, could be heard, as it were, through the rub- bing sound of the pericardium : from this it appears that rheumatic inflamma- tion of the pericardium is less frequent than that of the valves of the heart. In twenty-one cases of acute rheumatism affecting the heart, which were taken * For the physical explanation of these signs wc refer to the article Pericarditis. RHEUMATISM (Acute). 561 indiscriminately, and whose history was written with exactness, there were five only of pericarditis, and in all these the lining membrane was also affected. We shall presently show that the remote effects of the deeper affection are also much more serious than pericarditis. Pleurisy very often complicates rheumatic pericarditis : it existed in three of the five cases just referred to ; and since the period at which these five were observed we have seen five other instances of the same complication. In all these, the pleurisy was on the left side (double in one case); and where the order of succession of these affections was observed, pericarditis had the priority. These are the only examples we have seen of pleurisy occurring in the course of acute rheumatism. We infer, from the circumstances mentioned, that in those cases the pleurisy was not of rheumatic origin, but a simple in- flammation, excited by the pericarditis which previously existed. This infe- rence is strengthened by another order of facts : we have lately seen three examples of idiopathic pericarditis, and in all three pleurisy supervened—single, and on the left side, in two cases ; double in a third. In the last,.which proved fatal, the priority of pericarditis was evident from inspection of the alteration, which was much more advanced in the pericardium than in the pleura. We do not however deny the possibility of rheumatic inflammation of the pleura. M. Chomel states (Legons Cliniques sur le Rhtumatisme et la Goutte) that he has seen pleurisy come on at least as often as pericarditis in acute rheumatism. He does not however relate any example of it; and if he speaks of pleurisy unconnected with pericarditis, his experience differs very widely from our own. We have stated that the symptoms which characterize rheumatic inflamma- tion of the heart come on in a large proportion of cases of acute rheumatism : of forty-three cases of which we have preserved accurate notes, these symp- toms were present, and quite unequivocal in twenty-one, five of which were examples of pericarditis. This accords pretty well with the experience of M. Bouillaud, who however raises the frequency of these affections to a still higher standard, and states that they occur in the great majority of cases of aSute rheumatism. The great frequency of these affections is well known to hospital physicians in London, where acute rheumatism is very prevalent. In the publication already referred to, M. Chomel has not only denied that affections of the heart are common in acute rheumatism, but slates that they occur only in rare and exceptional cases : but as he sets out with avowing his belief that gout and rheumatism are identical, his inferences as to the affec- tions in question are all vitiated by the consequences of that belief. His argu- ments, grounded on the alleged insufficiency of the signs, generally considered to characterize these affections, have already been adverted to. The period at which the cardiac disease comes on varies, according to our observation, from the eighth to the twenty-seventh day. In general, it may be said to come on when the disorder is at its height, but we have seen one in- stance in which it was highly probable that pericarditis came on as early as the first day of illness. When the heart becomes affected the rheumatism of the joints does not subside, but continues as before: the fibro-serous textures of that organ do not become affected by metastasis from the joints, nor must their affection be considered as accidental, but as one of a series of local affections which implicate identical tissues in various parts of the body. There is no doubt that affection of the heart is most frequent in severe cases, as may be partly inferred from the following statement:—Of twenty-six patients, in whom rheumatism occurred for the first time, the heart became affected in sixteen, or nearly two-thirds; but in five only of seventeen, in whom it had occurred once before or oftener; so that rheumatism of the heart was more than twice as frequent in the first as in the second series, and we have already seen that acute rheumatism is more severe in the first than in subsequent attacks. This part of our subject would be incomplete if we did not point out in VOL. III. 71 562 rheumatism (Diagnosis of Acute). general terms the more remote sequel of these rheumatic affections of the heart. It is beyond doubt that the remote effects of endocarditis are much more serious than those of pericarditis ; for, when the latter terminates in cure by adhesion, the impediment which results to the functions of the heart is slight, and the consecutive change of structure in that organ is seldom con- siderable. We have seen a great number of cases of adhesion of the peri- cardium (often general) of long standing, in which the heart was in all other respects natural, and its functions during life perfectly performed. The con- sequences of endocarditis are very different. It will be seen in our remarks on the pathology of rheumatism, that the immediate effects of endocarditis are, to narrow the orifices at which the valves are placed, to impair the action of those valves by means of adhesions or by destroying their elasticity, and to substitute, for the naturally smooth surface over which the blood flows, a rough membrane, which, on the valves themselves, is often beset with vegeta- tions. These different alterations have one common effect, which is obstacle to the course of the blood ; and the necessary consequence of that obstacle is, distension of those cavities which are situated behind it in the course of the circulation. The heart labours in the discharge of its functions, and, by the operation of a general physiological law, its nutrition is promoted, and hyper- trophy the consequence. The dilatation and hypertrophy increase, because the original obstacle remains, or perhaps increases, and because dilatation itself is a further cause of obstacle; for the force required to empty a cavity through a given orifice is greater as the capacity of the cavity increases. At length the deviation from the natural structure of the heart becomes very great, and its functions suffer in proportion : all the dis- tressing symptoms of advanced disease of the heart supervene, and sooner or later terminate in fatal dropsy. These deplorable effects follow with greater certainty and in shorter time, in proportion as the obstacle is greater which is offered to the course of the blood by the original morbid alteration of the lining membrane. It would be interesting therefore, as regards prognosis, if we could appreciate at an early period the degree of this obstacle. Laennec has remarked that " fremissement cataire," or purring tremour, is generally a sign of " notable" obstacle at the orifice in which it originates. Our experience confirms his statement. A lad, in whom this tremour was observed in a very marked degree when the valvular affection was only of a fortnight's date, was obliged to seek medical relief, a few months afterwards, for distressing symptoms of disease of the heart. It is not ascertained whether or not the rheumatic affection of the valves may continue in a chronic form like that of the joints, or whether it be affected by the same circumstances. We are convinced, however, that the morbid altera- tion of the valvular apparatus increases in the course of time, although no fresh attack of acute rheumatism should occur. It is rational, therefore, to attribute the temporary praecordial pains, and other passing local symptoms which these patients occasionally experience, to slight returns of rheumatic affection of the valves. This is also a desirable conclusion as regards treatment. In many cases of acute rheumatism symptoms of arachnitis come on, and lead rapidly to a fatal termination. In all the instances of this affection on record the heart likewise was affected. We have seen one case of recovery from this cerebral affection. Diagnosis. Gout is the only disease which can be readily confounded with acute rheumatism. For a statement of the means of diagnosis between them, we refer to Gout. Pathology. In the description of the symptoms of acute rheumatism, it is stated that morbid effusions into the cavities of synovial capsules and serous membranes may be detected during life; we might thence be led to consider the membranes which enclose these cavities as the seat of the affection ; but tissues » of this kind do not enter into the composition of all parts that become affected with acute rheumatism ; whereas there is one element which is never wanting, rheumatism (Pathology of Acute). 563 namely, the fibrous tissue: it is this tissue which is the primary seat of the local affection ; the synovial capsules and bursae, the serous membranes, and the lining membranes of the heart become affected secondarily, and only by reason of their intimate connexion with the fibrous tissues which support them. This point, once established, will materially assist us in our inquiry into the character of the local affection ; a question which has long been, and continues to be, a subject of warm debate with pathologists. In this inquiry we must not limit * our attention to the effects of acute rheumatism on the joints (for that would give only a partial view of the subject), but also study them in those oro-ans in which the fibrous tissue is invested with a serous membrane. There can be no doubt that the rheumatism of the fibrous tissue in these different situations is quite identical, and it therefore follows, that what is true regarding it in one situation holds good in another. The character of the local affection can thus be best determined by studying its effects in those situations in which serous membranes become implicated; for the true import of lesions of those membranes is well known, and pathologists are of one mind respecting them. The lesions which acute rheumatism produces in these membranes prove the inflammatory nature of the affection, for it is impossible, by simple inspection after death, to dis- criminate between the appearance of common and of rheumatic pericarditis ; serous effusion, false membranes, and sometimes pus, are present in both cases. On the lining membrane of the heart the evidence of inflammation are equally decisive. It is superfluous, therefore, to refer to the symptoms during life in cor- roboration of this view. The opportunities of examining, after death, joints which have been recently affected with acute rheumatism, are extremely rare : there is some discrepancy in the few accounts of their condition which have been given by authors. In one instance of well-marked acute rheumatism, the course of which was cut short by fatal cholera, we found shreds of false membrane adhering to the synovial capsules of both knees. M. Chomel has described the joints of a per- son who died two or three days after cessation of the local affection in acute rheumatism : in one knee there was slight excess of synovia, which was viscous and semitransparent, but the interior of all the joints examined was while and smooth. The formation of false membranes in synovial capsules in acute rheumatism is perhaps not a common case, but we should not thence conclude that the affection of the joints is different in its nature from that of the fibro-serous parts, but that synovial are less apt than serous membranes to the formation of these peculiar morbid products. It is, then, our firm conviction, that the local affection in acute rheumatism is identical in all the parts it visits, and that its inflammatory character is as real in the joints as in the fibro-serous membranes. We have seen that during life the affection of the joints is attended with severe pain, local redness, swelling, and effusion of fluid; that much fever accompanies these local symptoms ; and, that when blood is drawn it is always buffed and cupped; all which circumstances bear out what has been stated of the nature of the local affection. We have already shown, also, that the affection is found, on attentive in- quiry, to be much less shifting than is generally supposed, and that its usual duration in individual parts is ten days, and sometimes fourteen or more. We do not, however, argue, that the local affection is common inflammation, but that inflammation is an important element in its pathology, and the agent which injures the structure of the joints, by producing false membranes and permanent effusions in their cavities, and external thickening of their fibrous tissues; alterations which impede their movements, and tend to prolong rheumatism in a chronic form. The character of the local affection is not, therefore, an idle question. The agency of inflammation in acute rheu- matism of the heart is too obvious to require further comment, but even in that organ it is undoubtedly of a specific nature: we have, moreover, shown 564 rheumatism (Pathology of Acute). that in rheumatic pericarditis there occur during life appreciable circumstances which distinguish it from common pericarditis. To make our statement per- fectly accordant with the course of rheumatism, we must add, that the affec- tion of an individual part does not always attain a degree which can be pro- perly qualified as inflammation, since it sometimes subsides within forty-eight hours from its accession, terminating in what pathologists have named de- litescence. We have now to notice more particularly the effects of acute rheu- matism on the internal surface of the heart. The primitive alterations consists in effusion, from the surface of the valvular apparatus, of lymph, which subsequently becomes organized. On the broad surface of the valves this lymph often assumes the form of false membrane; but on the chordae tendinae and the edges of the valves, it is disposed in the form of grains, which vary in size from a pin's head to a millet seed. These granulations are sometimes confluent; at others, discrete or isolated ; and often stud, like a string of beads, the parts we have mentioned. It has been correctly remarked by Dr. Watson, that on the aortic valves they often form a double festoon, following a natural line of division in the structure of those valves. The consistence of these morbid productions varies with their date: at first their substance is soft and friable, and of grayish colour, ad- hering very slightly to the lining membrane: as organization proceeds they become more solid, of a nearly white colour, and adhere so intimately to the subjacent membrane as to make one body with it; the grains now resemble, very exactly, syphilitic vegetations, and ultimately acquire cartilaginous hard- ness. The valves themselves are thickened and opaque, have lost their na- tural pliancy, and are sometimes puckered. In some cases lymph accumulates about the base of the valves in considerable masses, which occupy a large space in the cavity of the heart. This creates immediate and great impedi- ment to the circulation, and dilatation and hypertrophy follow often with great rapidity. All these alterations affect, especially, the valvular apparatus of the left side of the heart; and the mitral and aortic valves seem to be, in an equal degree, subject to them: the valves of the right side of the heart are much less so, and in a large proportion of cases of acute rheumatism are not at all affected; when they do suffer, the alterations are exactly of the same nature as those of the left cavities, and represent them in miniature. This comparative exemption of the valvular apparatus of the right side of the heart is owing to its less tendinous structure ; and, for the same reason, the pulmonary is less subject than the tricuspid valve to these alterations. Sometimes the affection extends to that part of the lining membrane which covers the muscular fibres; the appearances it produces are opacity and thickening of this membrane, and, but more rarely, the same kind of granula- tions as are found on the valves. We have little to add to the remarks already made on the pathology of the joints. It is necessary, however, to state, that though the attacks of acute rheumatism be ever so frequent, concretions of lithate of soda are never formed, even in the small joints, and there is no fact to show that this salt is ever deposited in the course of rheumatism. We agree with M. Chomel, that the cases which have been cited by authors, as rheumatism terminating in suppuration in numerous joints, are cases, not of rheumatism, but phlebitis. In those cases of rheumatism which terminate fatally, with symptoms of arachnitis, the appearances afier death are by no means decisive. In no case on record were there found either false membranes or purulent effusion : in some, there were no morbid appearances; and in the rest, these were simpiy a turgid state of the vessels, and a small quantity of transparent or opaline se- rum beneath the arachnoid. As in all these cases there was also rheumatic in- flammation of the heart, many pathologists have considered that the symptoms rheumatism (Causes of Acute). 565 observed were connected with that affection, and not with an independent morbid condition of the membranes of the brain. Their reasoning is open to many, and, we think, insuperable objections, though it may be said that this question is yet quite undecided. Causes. Remarkable individual examples occur, which leave no doubt that the tendency to acute rheumatism is, in some measure, hereditary, but in what proportion has not been ascertained, and this interesting question is still open. The circumstance of an individual having already suffered an attack of acute rheumatism, constitutes one of the most efficient predisposing causes known. Of forty-five examples of acute rheumatism, taken indiscriminately, seven- teen occurred in persons who had suffered from it at least once before. Now the proportion of seventeen to forty-five is very much larger than that of persons who have had acute rheumatism to those who have not, in any given population, within the ages subject to the disease. Men are more subject than women to this disease. Of the forty-five examples just mentioned fourteen only, or rather less than one-third, were women; and these examples were collected in an hospital in which the admis- sions to the female medical wards were, for the time being, more numerous than those to the male wards. The greater liability of men is, perhaps, owing to their being more exposed to the exciting causes of rheumatism. The great majority of cases of acute rheumatism occur in persons between fifteen and thirty years of age: we have never seen an example of it in a person beyond sixty or below eight; nevertheless, children not more than four years old have been affected with it. Persons between forty and sixty are, however, more liable to it than those below fifteen. Bichat ascribed the immunity of young children to the soft condition of the fibrous tissue which, not having acquired its ultimate mode of vitality, was, he thought, unapt to develope those maladies of which it is the peculiar seat. Thus far there is some analogy between rheumatism and gout, as regards predisposing causes; but here that analogy ceases; free living does not dis- pose to rheumatism, nor does temperance preserve from it. Husbandmen, and the poor generally, suffer from it at least as much as the rich, and pro- bably more; in fact, this disease is incident to persons of the most various constitutions and habits of life. It has been erroneously maintained that a high state of nutrition predisposes to acute rheumatism. In eight of the forty-five cases, more than once quoted, the patients were weakened by previous indisposition when rheumatism came on. This is a proportion of nearly one in five and a half; now it appears from the tables of the friendly societies in England, that one in thirty-six only is constantly on the sick list. These tables are calculated for all ages above twenty, and for persons in nearly the same class of life as the inmates of hospitals. From this comparison it seems probable that debility predis- poses to acute rheumatism: that it increases susceptibility of cold, is admitted on all hands. The only known exciting cause of acute rheumatism is cold. This operates with more effect when it suddenly follows an opposite condition of the air, or when it acts on a person in a heated or perspiring state. This cause is recog- nised by the patient in the majority of cases, and there is no doubt of its reality. Its effect is, in general, felt immediately, or, at furthest, at the end of a few hours. The cases are not rare, however (probably one-third), in which acute rheumatism comes on without any appreciable influence of these circum- stances ; and in many, indeed, it is impossible, in our present state of know- ledge, to assign any probable cause for the attack. It is to be lamented, that the influence of seasons and climate has not been studied sufficiently to bear decisive evidence on this question. Acute rheu- 566 rheumatism (Treatment of Acute). matism is much more frequent in the east than in the west of England. We doubt whether this can be wholly accounted for by the known difference of climate; but this is still an interesting field of inquiry. Treatment. No single remedy is yet known, nor any plan of treatment, which has the power of cutting short the course of acute rheumatism. The objects to be kept in view are,—1, to limit as much as possible the dissemination of the local affection, and thereby, to diminish the chances of rheumatic inflammation of the heart; 2, to moderate that inflammation in those cases in which it may occur, with a view to prevent or diminish the amount of morbid productions, as well as avert immediate danger; 3, to diminish the severity of the affection of the joints, and to prevent it from con- tinuing in a chronic form ; 4, to procure sleep. We have shown that rheumatic inflammation of the heart is most common in severe cases, especially when there is much fever, and the parts affected are numerous. It is our opinion, that it is the fever chiefly which tends to extend the rheumatic inflammation over a great number of parts, and thereby increases the liability of the heart, in common with other parts, to become affected with rheumatic inflammation.* Our principal and leading indication is, therefore, quite clear: we must endeavour to moderate fever by appropriate means. None are so well quali- fied to effect this as general bleeding, which has the additional advantage of mitigating the severity of the local affection in those parts which already suffer. The measure of this remedy must be regulated by the degree of fever present, and by consideration of the resources of the patient. In well-nou- rished men it may be had recourse to twice in the early stage of the malady with signal advantage; but it should always be borne in mind, that there may be occasion for its repetition in a more advanced stage, on account of inflammation of the fibro-serous textures of the heart. This consideration should warn us from being prodigal of the patient's resources in the early stage, though it should not be allowed to produce over-timidity in the first use of the lancet. Much prejudice against bleeding has been kept up by the • erroneous doctrine, that rheumatism of the heart is the effect of metastasis from the joints, which bleeding is supposed to favour. As this objection to bloodletting is speculative only, and necessarily falls with the error in which it originated, it needs no direct refutation. We may add, that in the forty-two cases already alluded to, in one-half of which rheumatism of the heart came on, bloodletting was not practised until the accession of the cardiac affection. Purgatives may be associated with bloodletting, but some evils attend their use; namely, the necessity of frequent movements, and some degree of exposure to cold : these evils may, however, be rendered very slight by good nursing, and then the moderate use of saline purgatives is attended with good effects. A dose of calomel, followed by a draught of senna and salts, may be given to begin with; after that the use of active purgatives should be restricted to the occasional exhibition of the same draught when the bowels are confined, which, if opiates are given, will generally be the case. In the intervals the patient may take about 3vj of citrate, and 3ss of nitrate of potash, in divided portions, daily, in the form of common effervescing draughts ; or, in the same view (that is, of allaying fever), the eighth of a grain of tartarized antimony, and five grains of nitrate of potash, every four or six hours. Much comfort is derived from opiates at night, and for this purpose the solu- tion of muriate of morphia, or Battley's liquor opii sedativus, are to be preferred. A full dose of one of these should be given in pure water; the exact quantity of the drug will, of course, vary with the age of the patient, the severity of the pain, and many other circumstances. Opiates do not, according to our expe- * M. Louis has shown that, in pneumonia, typhoid fever, and many other acute diseases, the extent and number of secondary lesions bear exact proportion to the degree of febrile movement, and there is reason to believe this to be a general law. rheumatism (Treatment of Acute). 567 rience, produce bad effects, and the comfort they afford to the patient is so great that he is always most desirous of continuing their use. Such is the general treatment to be adopted in acute rheumatism. The great number of parts which suffer precludes the possibility of local treatment for all, and it must therefore be reserved for those in which the affection may be very severe, or of unusual tenacity. In general, it is most required for the hands and-feet, the joints of which are more apt than any others to become the seat of permanent effusions and rheumatism in its chronic form. Our practice must, however, be guided by the circumstances mentioned. Leeches, varying in number from six to twelve according to circumstances, should be applied on or near the affected part; when the hands or feet are the subject of treatment the leeches should be applied on the wrists or insteps, and the bleeding promoted in the usual way. in cases in which there is much pain in particular parts, and local bleeding is, for some reason, deemed unadvisable or unnecessary, much relief may some- times be afforded by lukewarm poultices, and their effect may be improved by impregnating them with laudanum or decoction of poppy. If, in spite of these means, the affection of particular joints continues after fever has subsided, nothing gives such signal relief as blisters. These should not be kept open, but repeated at short intervals as the case may require. It is when effusions into the joints give indications of becoming permanent, that the beneficial effects of blisters are most conspicuous. The diet is easily regulated. In the early stage of the disorder fever and loss of appetite interdict all solid or stimulating food; diluent and cooling drinks must be the sole support of the patient, and these may be varied to his taste; gruel, whey, weak broth, beef tea, and the like, are the first articles of nourishment to be allowed. In short, the diet must be the same as in all acute diseases of an inflammatory type; the only deviation from it, which it is proper to make, is an earlier return to substantial food; especially in simple cases, for it will be found that when the strength of the patient is restored early, he will be less susceptible of the impression of cold in convalescence than he otherwise would have been. Such is an outline of the treatment to be followed in those cases in which rheumatism is confined to external parts. When it attacks the heart also, the vital importance of that organ calls for more energetic measures. Bloodletting, either general or local, or both, according to the strength of the patient, must be had recourse to, and indeed must be the basis of the treatment. The practi- tioner should not, however, be led on to repeated and unmeasured abstraction of blood by undue fear of immediate danger, an error into which those not acquainted with the usual course of these affections are very liable to fall. If the symptoms continue urgent after the first bloodletting, the further abstraction of blood should be made, in general, by leeches or cupping; the practice must, however, be regulated by the urgency of the symptoms and the powers of the patient. When the patient is already weak, the blood which it is deemed proper to take should be drawn in the first instance by leeches or cupping, rather than by venesection ; in fact, local bleeding should seldom be dispensed with. But the point of greatest importance is, that these means should be applied early, and, especially so, when the internal membrane of the heart is affected, because our object is to prevent the formation of morbid productions in the cavities of the heart, in which organ a mechanical obstacle becomes a source of irreparable and fatal mischief. This rule of practice cannot be too earnestly enforced. The practitioner should not be induced by the trivial aspect of the symptoms in endo- carditis, to let pass the only moment at which he can hope to act with material advantage; for, however the means employed in a future stage may alleviate present symptoms, they will almost certainly fail to remove those alterations which we have seen to be the usual product of this affection. By a timely adoption of these means great and immediate relief is always afforded, and in most cases this relief is permanent; there can be little doubt, therefore, that if 568 rheumatism ^Treatment of Acute). by this practice morbid alterations cannot be altogether prevented, their amount may be greatly diminished- Bloodletting is alike efficacious in pericarditis and endocarditis, and in our general recommendation of it we have therefore made no distinction between these affections. Pericarditis is attended with more immediate danger, and, on that account, it is sometimes necessary to carry bloodletting further than in endocarditis. The advantages of local bleeding, as also of blisters, are more immediate in the former than in the latter affection: blisters should not be applied until bloodletting has been carried as far as expedient, and until the heat of the surface has fallen to its natural standard; when applied to the prae- cordia under these conditions, they often seem to produce much relief. The blistered surface should be allowed to heal immediately. In the slight returns of pain and palpitation which occasionally occur in the convalescence, blisters always afford prompt relief. The internal treatment already recommended need not be deviated from. In our opinion, experience has not proved the efficacy of mercury in these cases. We have seen the common practice of giving calomel and opium very exten- sively tried, and have never observed any marked improvement take place even in pericarditis, on the appearance of the constitutional effects of mercury, whereas these effects are invariably attended with marked improvement of symptoms in all diseases over which mercury exercises curative influence. In the numerous cases that have fallen under our notice, in which rheumatism of the heart came on while the system was already under the influence of mer- cury, the course of that affection did not seem to be more favourable in conse- quence. We can also affirm from experience, that cases treated without mer- cury turn out equally well. We are aware that, in making these statements, we are much at variance with a large body of the profession in this country, and that, in raising a doubt, even, as to the efficacy of mercury in these affec- tions, we render ourselves liable to be assailed from many quarters; but it appears to us that the use of this medicine in this and many other affections has been suggested, at first by imperfect analogy, and afterwards persisted in with- out further inquiry as to its effects. Such analogy, however perfect it may seem, must be considered merely as a motive for the trial of a medicine, but never as evidence of its efficacy, which experience alone can determine. We have now to examine the merits of various remedies and plans of treat- ment for acute rheumatism, which have at different times been much praised, and which have more or less engaged the favour of the medical public. Col- chicum has long held, and continues to hold, an ill-deserved reputation as a remedy for acute rheumatism. Having in eleven cases taken careful note of its effects, we did not remark in any one a favourable influence on the course of the disease; in six of the eleven the constitutional effects of the drug were produced in a very marked degree. From observation of numerous other cases we have been convinced of its entire inefficacy, and this conviction is also held by many physicians of great experience. It is easy to account for the main- tenance of its reputation : acute gout, when much disseminated, is often mis- taken for rheumatism ; and the remarkable success of colchicum in these cases confirms medical men in their erroneous estimate of its virtues. Hence, also, the assertion that the efficacy of colchicum is more marked in the synovial than in the fibrous form of rheumatism, for, in gout, effusions are, generally speak- ing, more conspicuous than in rheumatism. We have already spoken of calomel in combination with opium in the treat- ment of rheumatism of the heart. The dangerous nature of that affection may sanction, and, according to some, peremptorily calls for the employment of this remedy ; but it is also much used in the treatment of acute rheumatism in the first instance, when the extension to the heart has not taken place. In our opinion, however, it is wholly without virtue; and when its use has not been preceded by bloodletting it has the effect of increasing the fever. We have rheumatism (Treatment of Acute). 569 kept accurate notes of eleven cases in which it was used, in eight of which the constitutional effects of mercury were well marked. In not one of these did any decided amendment occur when these effects appeared ; in four, on the contrary, an unfavourable change took place at that time, and in three of these four, extension of rheumatism to the heart occurred while the mercurial symp- toms were present. These four cases were very protracted.* Sudorifics have been very popular in the treatment of acute rheumatism, and still enjoy a high reputation with some. They are much used in the Infirmary of Edinburgh, where it is taught that, strong sudorifics employed after blood- letting in the early stage of the malady, often shorten its course in a remarkable manner. We confess that our objections to sudorifics are speculative merely, and founded on the consideration that sweating is naturally very profuse in acute rheumatism, and that, far from relieving pain, is more profuse as the pain is more severe. The warmest advocates of sudorifics state, however, that their efficacy is much less marked, or even questionable, after the very early period of the malady.. Their use should always be guarded by previous bloodletting, and be promoted by warm diluents ; for, otherwise they are apt to fail in their sudorific effects, and in that case they invariably increase the fever. There is another objection to their use ; the relaxation of the skin, which they produce, renders the patient remarkably susceptible of cold in convalescence, and thereby predisposes to relapses. The employment of Peruvian bark was first suggested by the remittent cha- racter of acute rheumatism, and, like all other reputed remedies, it soon enlisted warm partisans. Dr. Haygarth, especially, was unqualified in his praises, but experience has shown that they were not deserved. Peruvian bark is now justly abandoned as a remedy for acute rheumatism, and its use, or rather that of sulphate of quinine, is restricted to those cases in which some tonic is required in the course of convalescence. The inefficacy of tartarized antimony, in large doses, has been well shown by M. Dance, in a memoir on the subject. We have ourselves made extensive trial of this plan of treatment, and our experi- ence accords entirely with his. Before we conclude we must warn our readers against the danger of the repeated and unmeasured abstraction of blood, lately recommended by M. Bouillaud. The alleged efficacy of this treatment is entirely without proof, for the statements he gives in support of it are wholly inconclusive. On the other hand, he says nothing of the serious evils which must follow this sudden and excessive loss of blood, which, in females espe- cially, must frequently occasion, for many years, total subversion of health, and if not entire ruin of the constitution, a most deplorable train of nervous symptoms, and permanent languor of all the functions. 2. Chronic rheumatism. Chronic is often the sequel of acute rheumatism, but also comes on in some cases quite independently of any previous acute attack. In either case the affection is of much the same character as acute rheumatism, the chief difference being less activity, with indefinite duration of all the symptoms. Fever and sweating are seldom present, and occur only when the local affection partakes of an acute character; in severe cases (the active chronic rheumatism of authors) these circumstances may continue with few intermissions, for many months, and the circumstances are then extremely harassing. In active chronic rheumatism the effects on joints are much the same as in the acute form; effu- sions take place into all the varieties of synovial capsules, and ligaments become permanently thickened by the long continuance of the affection. Thus the form of joints is much altered, their motions painful and impeded ; and, when the disease does not yield to the remedial means employed, their structure becomes ultimately so materially injured as to cause premature and lasting decrepitude, while the continuance of harassing pain and fever waste the body * This furnishes us with an analogy which may be applied to estimate the probable effects of mercury on rheumatism of the heart with much greater strictness than any analogy drawn from the effects of this medicine in other diseases. VOL. III. 72 570 rheumatism (Treatment of Chronic). and destroy the health. One remarkable feature of the disease is, that similar parts become affected so exactly alike, that the distortion of one joint is usually a perfect model of that of its fellow ; and the same is true even of bursa? and tendons. As happens in acute rheumatism the pain is more severe at night than by day; it is relieved or aggravated by warmth, according to the greater or less activity of the disease, and perspiration generally affords temporary relief. The patient is very sensible to the state of the weather, and usually worse in a moist and cold, and better in a warm and dry air: hence recovery commonly takes place on the approach of summer; it is seldom, however, com- plete, for the joints do not regain their natural state, and the invalid is much disposed to relapses on the return of the cold season. In its less active form chronic rheumatism is distinguished by pain of the joints, which is increased by their movements, but is unattended with swelling or local heat; the patient often complaining of an unpleasant feeling of coldness in the part affected. This form is much less serious than that just described: it seldom disables the patient; does not impair the general health; does not be- come disseminated ; nor does it effect appreciable changes of structure. Cold is its immediate cause, and the part which suffers is that which has been most directly exposed to it. There is one remarkable point of difference between acute and chronic rheumatism; in primitively chronic rheumatism the heart never becomes affected. Many diseases, of which the exact nature is not known, but which seems to have some affinity with chronic rheumatism, have been included under that term, to the great confusion of the subject. One of the most remarkable of these is spoken of by Sir B. Brodie, in his chapter on Inflammation of the Synovial Membranes of Joints, in the following terms: " There is a remarkable yet not uncommon form of the disease, which may be considered as bearing a relation to both gout and rheumatism, yet differing from them both in some essential circumstances. The synovial membrane be- comes thickened so as to occasion considerable enlargement of the joints, and stiffness, there being at the same time but little disposition to the effusion of fluid. In the first instance the disease is often confined to the finders; after- wards it extends to the knees and wrists; perhaps to nearly all the joints of the body. Throughout its whole course the patient complains of but little pain, but he suffers, nevertheless, great inconvenience, in consequence of the gradually increasing rigidity of the joints, and at the number which are affected in succes- sion. The progress of the disease is usually very slow, and many years may elapse before it reaches what may be regarded as its most advanced stage. Sometimes, after having reached a certain point, it remains stationary, or even some degree of amendment may take place; I do not, however, remember any case in which it could be said that an actual cure had been effected. The indi- viduals, who suffer in the way which has been described, are, for the most part, those belonging to the higher classes of society, taking but little exercise, and leading luxurious lives; but there are exceptions to this rule, and the disease occasionally occurs in hospital practice, in men and even females of active and temperate habits." We have seen one example of this affection, in which the disposition to effusions was very remarkable, and especially the rapidity with which considerable effusions into the knees from time to time took place, and were again absorbed. We believe that this affection is essentially different both from gout and rheumatism; the most remarkable point of difference being the signal freedom from pain enjoyed throughout its course. It is probable" that synovial membrane, and not fibrous tissue, is the primitive seat of the affec- tion. Treatment of chronic rheumatism. This disease often baffles the seemingly best directed treatment, and has become a reproach to the medical art. When, however, the structure of joints is not permanently altered, we may hope to procure much benefit, especially by local treatment. This must vary according to the activity of the local affection: when there are indications of an active inflammatory process, local bleeding must be first had recourse to. When the rheumatism (Muscular). 571 affection is of a less inflammatory character, or has been moderated by local bleeding, our chief reliance must be placed on a succession of blisters, applied upon, or in the immediate neighbourhood of, the parts affected. When there is much pain great relief will be obtained by dressing the blistered surface at night with one-fourth or one-third of a grain of muriate of morphia, which will also procure sleep as effectually as if given by the mouth. But it often unfortunately happens that local bleeding and blisters cannot be employed to a sufficient extent, in consequence of the multiplicity of local affections, or of constitutional debility; and, as there are no general remedies, at present known, which exer- cise a directly beneficial influence on these affections, the two circumstances mentioned deprive us of our best resources, and render the treatment in a great measure nugatory. The general remedies usually employed in these cases are diaphoretics: Dover's powder, guaiacum, and sarsaparilla, are those which enjoy the greatest reputation, but their effects are after all very uncertain, and in most cases questionable. When there is much fever their use is imjyKfper; while the feverish state lasts the internal treatment must consist in tne use of mild purgatives and salines. The eighth of a grain of tartarized antimony and five grains of nitre, given three times a day as recommended in acute rheuma- tism, will be found a very cooling medicine: we disapprove of general bleeding, because the good obtained from it is not sufficient to counterbalance the debility it produces. Warm baths judiciously employed are often of great benefit, and salt baths are to be preferred. There is a medicine which, from its great suc- cess as a remedy in affections of the periosteum, has lately come much into fashion in all forms of chronic rheumatism: we allude to the hydriodate of potash. Our own experience does not bear out the high encomiums which many have bestowed upon its efficacy in this disease; in many cases it has seemed to produce marked benefit, while in others it has totally failed. The results at present known certainly encourage further trial. The dose should not exceed five grains three times a day. Diligent friction, especially when practised in the method called shampoo- ing ; warm affusion, conducted so as to impart a mechanical shock, and long perseverance in attempts to exercise the parts, often produce remarkable effects. In inveterate chronic rheumatism in our own country, all these means applied in the most judicious manner often fail to produce any permanent or solid advantage. We have yet to mention the most valuable resources known in the treatment of this disease; namely, a warm climate, and the internal and external use of thermal mineral waters. A long residence in a warm climate has often effected remarkable cures: Rome and Nice are the most eligible situations in Europe, but the climate of the West Indies seems to exercise a still more beneficial influence over this disease. The beneficial effects of thermal mineral waters are now well established, and examples are not wanting of persons who have visited them quite in a crippled state, and have returned with their limbs restored to pliancy and use. The waters most celebrated in France are those of Neris, Mont-Dore, and Vichy; Aix-Ia-Chapelle in Savoy is much resorted to; and in Germany, Karls- bad and Wiesbaden. W7hen the circumstances of the patient allow it, the beneficial effects of these waters might be confirmed by a winter's residence at Rome. It is almost superfluous to add, that in all cases patients should be carefully protected from the influence of changes of weather; a complete dress of flannel next the skin is of great importance; the diet should be mild and simple, not too low, but regulated with the view to promote the general health. Muscular rheumatism. We have already stated, in the description of acute rheumatism, that the muscles, or rather their fibrous coverings, become affected along with the joints : the muscular affection of which we now treat is quite independent of rheumatism of the joints, although it often occurs in persons subject to acute articular rheumatism. It is more common in muscles of the trunk than in those of the limbs, and, usually, not more than one muscle is affected at a time. Its essential character is pain of the muscle affected, the 572 rheumatism (Muscular). pain being very much aggravated by any attempt to use the muscle. The pain is not attended with swelling, local redness, or heat; and the patient commonly has a sense of coldness in the affected part. Febrile excitement is very rare, even in the severest forms of this affection. Cold is almost its only exciting cause, and the influence of this agent is generally so obvious as to attract the attention of the patient. It very commonly happens that the muscle which suffers is that one which has been most directly exposed. The most important varieties of this affection are lumbago and pleurodynia, and to these we shall specially direct our attention. In the detail of their symp- toms we shall have little to add to what has been already said of the affection generaljy. Lumbago. The pain of lumbago occupies the fleshy mass of the loins on one or both sides, and is very much increased by every movement of the back. When the affection is severe the patient is not only confined to bed, but quite incapable of moving his body without the help of others; and every change of posture causes excruciating pain. In milder cases the invalid can still walk, but with his body quite upright and stiff: he also chooses the most even ground, is unable to stoop, and when he turns, it is by a movement of the entire body. Lumbago cannot well be confounded with those lumbar pains which are often the preliminary of febrile diseases, for these pains are scarcely or not at all aggravated by motion, and are attended by other symptoms which point out their character ; nor with affections of the kidney or uterus, for these may be readily detected by their peculiar symptoms. It has been said, that caries of the spine, and some affections of the spinal cord, present greater difficulties; but in the former, the pain is not aggravated by motion in the very remark- able way in which it is in lumbago; and when motion is attended with much pain in caries of the spine, other and characteristic symptoms are usually pre- sent. The lesion of sensibility and motility in the lower extremities, in all affections of the cord itself, is sufficient to distinguish them from lumbago. Lumbago sometimes proves of long duration, and does not readily give way to treatment; it is also very apt to return. Lying on the grass in summer is one of its most common causes, and it is sometimes brought on by a sudden and violent effort of the lumbar muscles. Pleurodynia. Pleurodynia is characterized by an acute pain, which has usually the seat and character of the pain of pleurisy, and by the absence of the physical signs and general symptoms of the latter affection. The pain is gene- rally felt a little below the breast, and is increased by pressure, by movement of the body, and still more by the act of breathing, and by cough, if present. One effect of this painful state of the intercostal muscles, is, that the inspiration on the affected side is less ample than on the other, and, consequently, the re- spiratory murmur is not quite so loud, nor the sound of percussion so clear, as on the healthy side; this is, however, very different from the dulnesss on per- cussion, and the altered character of respiratory murmur in pleurisy. In pleu- rodynia there is seldom fever; in pleurisy fever is rarely absent: as a general rule, the pain is more acute and more diffused in the former than in the latter affection. When the general symptoms and the physical signs are carefully inquired into, there can be seldom any difficulty in the diagnosis. Pleurodynia is occasionally brought on by exposure to cold, at other times by cough or sneezing: in some cases its cause escapes observation. It remains for us to speak of a slight but painful affection popularly designated crick of the neck. It consists in a very painful condition of the muscles of one side of the neck, which causes an inclination of the head to the side affected. Any deviation from that posture is attended with such severe pain that the patient cautiously avoids all independent movements of the neck, keeping the head in a fixed and characteristic attitude. In the slate of rest the sensation in the part is more that of numbness than of pain. It is sufficient to know, that inflamed glands or a phlegmon may produce similar appearances, to prevent our being misled by them. rheumatism (Treatment of Muscular.) 573 This painful malady is generally of short duration. It is often brought on by exposure of the neck to a draught of cold air ; sometimes by a sudden and abrupt turn of the head. Rheumatism of the muscles of the limbs is not so severe and acute an affec- tion as those varieties just described: it is also more wandering; and it is in rheumatism of these muscles that the sense of coldness in the affected part is most frequently complained of. The muscles nearest the trunk are the most subject to it, those of the arm and thigh being much oftener affected than those of the fore arm and leg; a circumstance first noticed, we believe, by M. Chomel. Rheumatism of these muscles does not disturb the general health, but often proves very tedious. It may be confounded with syphilitic pains by an inatten- tive observer. Syphilis is to be distinguished by the previous history of the patient, by the altered form of the bones, and by other characteristic symptoms. M. Chomel has described rheumatism of the abdominal muscles, but the case which he gives as a type of that affection, at page 73, of his Lecons Cliniques sur le Rheumatisme et la Goutte, seems to us to be a case, not of rheumatism, but of neglected constipation. We have never seen these muscles affected with rheumatism. This naturally leads us to remark, that pains sympathetic of visceral derange- ment are very apt to be confounded with rheumatism of the muscles. An affec- tion simulating rheumatic lumbago or pleurodynia, is a very common effect of accumulations or obstruction in the large intestine; a fact which should always be borne in mind by the practitioner. Pain in the limbs, also, is often merely indicative of derangement of the abdominal viscera. The chief distinctive character between these pains and those of rheumatism is, that the former are scarcely aggravated by motion, whereas the latter are so to a great degree. The treatment of muscular rheumatism must vary with the seat and degree of the affection. In severe lumbago, abstraction of blood from the loins by cupping is the most certain remedy, and often effects an immediate and perfect cure; it may be repeated with advantage if the symptoms are not completely relieved by its first employment. Narcotic liniments should also be freely used ; the patient should be kept in bed, be moderately purged, and live low. If the affection continues after a fair trial of these means, blisters must be applied to the loins, and the blistered surface may be dressed with muriate of morphia in the way described in the treatment of chronic rheumatism. Turpentine and balsam of copaiba have been extolled as remedies for lumbago; in our experi- ence, the latter has in some cases seemed to succeed after the means described above had been tried without material benefit. It should be given in doses varying from twenty minims to 3ss three times a day. In all cases of lum- bago, one of the most important points of treatment is to confine the patient to bed. Pleurodynia is less obstinate. We have often known it completely removed by a mustard poultice applied over the seat of the pain. Opiate liniments are also frequently successful; but if the affection be unusually severe, blood should be taken by leeches or cupping; it seldom fails of being relieved by this measure. A blister and the local application of muriate of morphia will com- plete the cure. In crick of the neck the local treatment may generally be limited to diligent friction with laudanum, warm fomentations with poppy-head decoction, and warm clothing of the part. More powerful measures are seldom needed : leeches afford immediate relief; but in females, especially of the better classes, they are inadmissible, on account of the permanent marks they leave; blisters are open to an objection of the same kind. Warm baths to the chin are often serviceable. Rheumatism of the muscles of the limbs must be more generally treated by- stimulating and opiate liniments ; local bleeding is not advisable; but if the affection J3 obstinate blisters may be had recourse to with great advantage. 574 RHEUMATISM. It is well remarked in the text, that the most important practical point connected with the study of acute rheumatism is the connexion of inflammation of the heart with the rheumatic fever. There is no doubt whatever that the British physicians were the first to point out the connexion; and it was also well known in this country, but in a loose indefinite way, so that the exact nature and extent of this relation certainly was not known until the researches of Dr. Bouillaud ; and although his claim to priority is unfounded in many respects, yet he was the first to establish the true rules which govern the developement of heart disease during the course of rheumatism, and to show that it arose directly during the inflammatory period, and rarely from metastasis. These researches could not have been made without the assistance of auscultation, because the cardiac disease is either quite latent in the majority of cases, or so nearly so that the patient complains only of a dull feeling of uneasiness, which he soon forgets- Rheumatism attacks the heart in the acute disease in three different ways : the inflammation of the internal membrane is the most frequent, and if severe, is attended with the most dis- tressing symptoms, which depend chiefly upon the thickening of the valves. As to the description both of endocarditis and pericarditis we have little to add to the text. The latter is known by the signs indicative of effusion into the pericardium, and by the creaking in cases where the quantity of liquid is extremely small. The endocarditis is at first recognised almost exclusively by the bellows or rasping sound which occurs during the systole of the heart, and the gradual diminution of the second sound as the inflammation and the congestion of the heart advances. When the blood remains comparatively stagnant a coagulum forms in the heart, and the second sound is gradually lost, while the augmented size of the organ ren- ders the percussion dull. The signs of some of these lesions often remain for a long time after the active period of the inflammation is passed. There is a second modification of the action of the heart which is not positively connected with inflammation of its membranes. It occurs chiefly during the active period of the in- flammation, but it also follows the rheumatism, or several successive attacks of it; or it occurs after simple muscular rheumatism, when the patient has not kept his bed at any period of the disease, and is then slowly developed. It is in fact a mere muscular disease of the heart, and, in the acute form, produces a disturbance in the functions of the organ, which resemble in some respects the membranous inflammation; and in chronic varieties terminates gene- rally in hypertrophy. The latter lesion arises perhaps more frequently from the muscular disease than from inflammation, and is a more common result of chronic than of acute rheumatism. The muscular disease differs from ordinary inflammation, or at least it is modi- fied by the peculiarities of the structure affected, and has very nearly the same relation to the membranous inflammation that muscular bears to articular rheumatism. In the acute form the first sound of the heart is slightly modified, and its action becomes quick and spasmodic; this modification does not generally amount to a bellows sound, although it sometimes does: in the chronic form the muscular rheumatism is almost always connected with hypertrophy, and the signs of the two diseases are generally more or less confounded together. The disease is not always attended with pain; that is, the most essential element of ordinary rheumatism is not always present, and when this is the case the affection sometimes escapes notice; in other casrs it is perfectly understood and readily recognised. The third variety is that in which the inflammation of the joints diminishes when the cardiac irritation begins; that is, a real metastasis occurs. The disease of the heart is then generally inflammation of the pericardium or endocardium, although it is sometimes a pure rheumatism of the heart. The treatment of acute rheumatism is still attended with difficulty ; that is, the treatment which is strictly curative and will entirely arrest the disease. The remedies that relieve are very numerous, and some of these will so far moderate the symptoms that the cure will speedily follow ; but none is actually certain in its action, and often all fail. The opinion of physicians is on the whole decidedly in favour of bloodletting in the more violent cases, but carried only to a moderate degree, and not, as advised by Dr. Bouillaud, in inordinate " doses." The utility of local depletion is equally incontestable, especially of cupping to the spine when the pain extends from the spine to the joints; we do not believe it equally beneficial when the spine is not directly affected, although Dr. Mitchell advises it even under such circumstances. Depletion to the joints themselves is less convenient. RHEUMATISM. 575 The usual practice at Philadelphia is to resort to depleting measures at first in severe cases, and afterwards to prescribe an opiate, either alone or in combination with a nauseant dia- phoretic : such as the Dover's powder and small doses of tartarized antimony. These may be given if the perspiration, which forms a necessary part of the disease when it passes through its regular stages, should be arrested. Sweating will not cure, if excessive, it may weaken the patient most injuriously, but to some extent it certainly forms a natural outlet in acute rheumatism, and cannot be suppressed without proportionate mischief. Opium alone, in large doses, given so as to produce a tranquillizing, and almost a narcotic effect, is recom- mended in New England as one of the most successful and least painful modes of treatment. This remedy is certainly almost indispensable; but we cannot approve of the very large doses in which it has been given; there is always danger in producing a near approach to narcotism, and the treatment will not in most cases arrest the disease. Colchicum is a favourite remedy with many physicians, either in a simple form or combined in that of Scudamore's mixture. It is an excellent revulsive ; but is of course much too irri- tating whenever the digestive canal is at all disordered. Many other remedies of the acrid narcotic kind, and more or less similar to colchicum, such as veratrum album, &c, are used occasionally in the treatment of rheumatism, and produce more or less service as palliatives in nearly every case, but as irritants of much strength they are not free from inconvenience. Diaphoretic drinks, especially if they possess some other medicinal property than that of determining to the skin, are useful remedies ; with this view the decoction or tincture of cimi- cifuga is occasionally very useful: still its good effects are extremely uncertain, and we cannot rely upon it with sufficient certainty to induce us to depend upon it to the exclusion of other remedies. Chronic rheumatism is one of the most difficult diseases to treat. Whether it succeeds to the acute variety, or is from the first chronic, matters but little: if once firmly settled in the system it resists most remedies. Those which promise the best success, are the alterative diaphoretics, local anodyne or stimulant applications when the temperature of the part is reduced, and general alteratives. The compound decoction of sarsaparilla is often of great benefit, or the powder of guaiacum combined with sulphur, or with camphor and Dover's powder, given in quantities not sufficient to derange the bowels, and combined with some aro- matic. The decoction of cimicifuga, and various other remedies, which combine, with altera- tive properties, a slight narcotic effect, are sometimes of benefit. If the pain radiate from the spine, cups near the vertebrae sometimes quickly dissipate it. The benefit of cups or leeches to the affected parts is, however, quite problematical, unless there should be pain or swelling at the joints. A much better application consists of those remedies which keep up warmth in the part and excite the cutaneous perspiration, such as the oiled silk, thin sheets of caout- chouc when not too irritating, and soap plasters, or simple flannel bandages. Stimulants of a different kind, as the oil of cajeput and of turpentine, are occasionally used both internally and externally in chronic rheumatism, to excite the capillaries of the skin, and oftentimes relieve the pains in affected joints. I f the remedies recommended by authors fail, as is often the case, the different mineral waters which have acquired a celebrity in the treatment may be resorted to, as the Carlsbad and Bareges Springs recommended in the text, and the Hot Springs of Virginia. The latter are the only hot springs much resorted to in this country, those of Arkansas being compara- tively little known, although of much higher temperature. The Bath County Springs of Vir- ginia do not exceed 106 degrees, they are not drunk internally, but used exclusively for bath- ing, and in the form of spout-bath or douche. In many cases they succeed admirably well, but in others fail entirely, like all other remedies in this disease. A warm climate is the last and sometimes the most successful means of preventing a return of the disease, if not of curing it. There is no disease which affords a larger field for empirics than chronic rheumatism. Their remedies almost always consist of different embrocations or liniments, of terebinthinate or other stimulating substances often combined with anodynes. They give relief for a time, but, in the majority of cases, the pain afterwards returns. Still we must not omit these external palliative means ; they often soothe the patient, and are so readily prepared by every practitioner that there can be no good reason for neglecting them. G. GOUT. Synonymes.—Symptoms of acute gout—of chronic gout.—Gouty concretions.—State of the urine in gout.—Gouty affections of external structures—of internal organs.—Diagnosis.— Pathology.—Causes.—Treatment.—Prevention. The term Gout, derived from the Latin word gutta, a drop, was first employed to designate the disease we treat of, by physicians of the old school of humoral pathology, and was adopted in accordance with their theory, that the local affec- tion in gout is caused by the distillation, " drop by drop," of a peccant humour in the structure of the joints. As this theory was very general, we accordingly find synonymes of the word gout in most European languages :—Gicht (Germ.), goutte (Fr.), gotta (Ital.), gozza (Span.) Some modern physicians have endeavoured to substitute for this word the term Arthritis, intended to express a different theory of the disease ; but as this theory is at least as imperfect as the old one, the word gout should be retained, were it only on a title of priority. Gout was well known to the Greek, Roman, and Arabian physicians. The Greeks gave the local affection special names, derived from those of the parts which happened to be affected. Gout of the foot was called ifoSaypa; gout of the hand, ^sipaypa ; and so on. It appears from their writings that the ancients confounded gout with rheumatism, and con- sidered them one disease; although most moderns distinguish them in theory, yet the serious error of mistaking gout for rheumatism is often committed in practice. Gout has in all times been observed to affect chiefly the rich and well-fed members of society ; and it may be gathered from the pleasantries of many Greek and Latin authors, that the victims of this disease were not favoured with a greater measure of sympathy in ancient times than they enjoy in our own. It very seldom comes on before the age of thirty or thirty-five, never before puberty, and it is very much rarer in women than in men. Spring and autumn are the most common seasons of its attack, but summer does not wholly pre- serve from it. Symptoms. The first fit of what may be termed acide gout, is sometimes preceded, for a few days, by slight derangements of health, but more frequently comes on suddenly, and often \vithout obvious cause. The suddenness of the attack, in some cases is very remarkable. It is generally at night that the first symptoms are felt. The patient is awakened soon after midnight by acute pain in the first joint of the great toe of one foot. This pain is often preceded by, or attended with, slight rigour, which is soon followed by fever with great rest- lessness. These symptoms continue ; and the next morning the affected part is of a bright red, much swelled, and exquisitely tender. The joint is quite disa- bled, and the neighbouring veins are very turgid. In slight cases the symptoms abate towards morning; but, in severe ones, the pain continues to increase for about twenty-four hours from its first accession ; it then suddenly remits, and the affected part, when examined, is found to be more swelled than before, and also osdematous ; in some cases the skin of that part has a shining appearance, as if varnished. At this crisis, gentle perspiration comes on; and the patient, relieved from pain, falls asleep. The relief from pain is often so sudden, that, gout (Symptoms). 577 as Sydenham remarks, the patient is inclined to attribute it to the last position given to the gouty limb. As the pain abates, the fever subsides, and this im- provement continues until the following evening. The symptoms then return, and the patient is harassed throughout the night with acute pain and fever; the next morning these abate as before. The disease continues to hold this course, but the symptoms gradually diminish in severity ; and at the end of a period, varying from five to ten days, the patient is generally restored to his usual health. The oedema, which at the height of the paroxysm is very considerable, continues for a short time after the cessation of the other symptoms. In conva- lescence, the cuticle of the affected part peels off—a process usually attended with much itching. In the first fit of gout there is seldom more than one joint affected, and the attendant fever seems proportional to the severity of the local affection. There is much loss of appetite, and increase of thirst; the urine is scanty, and deposits, on cooling, an abundant brick-coloured sediment. The bowels are generally confined. Such is the usual course of a first fit of gout; but it often happens that, before experiencing so well-marked an attack as that described, the patient has, at times, suffered some degree of lameness and soreness of one foot, of which the true cause was not suspected. Some of the circumstances we have noticed, must now engage more par- ticular attention. We have stated that, in most cases, the attack cannot be ascribed to any Obvious cause; in some, however, it seems the effect of local injury, as a bruise or sprain ; and when the gouty inflammation which follows is not attended with much constitutional disturbance, the error into which the patient has fallen, regarding the nature of his malady, remains uncorrected. We have known instances of first gout being mistaken for a sprain, both by the medical attendant and patient, and treated accordingly ; but, in general, the sprain is a pretext adopted by the patient in order to escape the imputation of being gouty, to which most persons have a great aversion. Convivial excesses are sometimes the immediate cause of the paroxysm. The oedematous nature of tf^e swelling in gout is of some value as regards diagnosis ; it is not always present, but is seldom wanting when the affected part is not deep-seated ; it is more frequent and more extensive, when it does occur, than in acute rheumatism. Desquamation of the cuticle is the sequel of erythema of the skin, which, like oedema is most common in gout of superficial parts. This erythema is some- times wide-spreading, and in appearance much like erysipelas. After it has been some time present, its original bright red tint generally changes to some shade of purple. GCdema and desquamation are most common in gout of the hands and feet, and are therefore seldom wanting in the first fit. One of the most remarkable circumstances in the history of the first fit is the great propor- tion of cases in which the great toe is alone affected. Sir C. Scudamore found this the case in 130 of 193 instances ; in other 10, the gout was limited to the two great toes, and in all, except 8, the joints affected were exclusively those of the foot and ankle of one or both legs. In those raTe cases in which many joints become affected in the first attack, its duration is prolonged, sometimes to a period of several months. After recovery, the functions of the joints which have suffered are not sensibly im- paired. • When those causes which foster the gouty diathesis continue to operate, the attacks do not fail to return, their frequency depending, in great measure, on the degree of influence which these causes are allowed to exercise, and on the hereditary predisposition of the individual. In general, however, there is an interval of a year, at least, between the first three or four attacks, and we have even known a period of seventeen years elapse between the first and second. In these subsequent attacks, the local affection is limited to the part affected in the first gout, or to that part and the great toe of the other foot; seldom more than one or two joints are affected at once. It is worthy of remark, that fits of vol. in. 73 578 gout (Symptoms). gout often observe an exact periodicity in their return; occurring with great regularity in a given month for many successive years. When the gouty diathesis is confirmed, the paroxysm is generally preceded, for a period which varies greatly in different cases, by transient gouty twinges in the part about to be affected, or by various derangements of important func- tions. These derangements, either on account of their peculiar character, or because they suddenly cease when gout is developed in the extremities, are fairly presumed to be essentially connected with, or rather part of, the disease; and it is, therefore, important to give an account of them in this place. Indigestion, with unusual tendency to heartburn and sour eructations, so fre- quently precedes the gouty paroxysm, that theories of the intimate nature of gout have been founded on the consideration of this single circumstance. This form of indigestion may continue for months before gout appears in the extremities, and indeed gouty persons are at all times singularly liable to it. The secretion of urine is deranged not less frequently than digestion. In some cases the urine, for a few days immediately preceding the paroxysm, is scanty, high-coloured, and much charged with red deposit; in others, on the contrary, it is usually abundant, pale, and limpid—a condition observed, for the most part, in the urine of persons of nervous temperament or exhausted constitution.* Severe headaches, with disturbed sleep and great languor, are perhaps the next in order of frequency as precursory symptoms ; and low spirits and despondency are very remarkable and very common indications of an impending paroxysm. Palpitation of the heart, recurring at uncertain intervals for many weeks, and in other cases attacks of difficult breathing resembling asthma, have been known to precede the gouty paroxysm, and to give way suddenly and permanently to developement of gout in the extremities. But when regular paroxysms of gcut have already occurred, there are generally other and more characteristic symp- toms to announce their approach. Such are transient gouty twinges, as before stated; also soreness and stiffness of the feet, especially after exercise; sup- pression of their habitual perspiration, and, occasionally, cramps in the gouty limbs: these symptoms sometimes occur alone, but are more often associated with some of the functional derangements noticed above. It is important however to add, that even in cases of confirmed gouty diathesis, a severe paroxysm sometimes comes on without any precursory symptom, or at least, without any of sufficient moment to attract the attention of the patient. In some persons, gout, however numerous its attacks, never affects any joints but those of the feet; in all, the feet and hands suffer more than other parts. In most cases, however, it becomes more disseminated ; and when the diathesis is very confirmed, many external parts are affected in a single fit. In a case of chronic gout, (the sequel of an acute attack), which lately fell under our observation, the left knee was much distended with fluid for nearly two months ; there was also pain of the chest, with difficulty of breathino-; and these symptoms were found to depend on gout of the sternum and cartilaces of the ribs, marked by great local tenderness and considerable oedema. In severe attacks of acute gout, the insteps, ankles, knees, elbows, and wrists, may suffer in turn, or several of these parts may be affected at once. In addition to the appearances described as present in the first fit of gout, we now observe abun- dant effusions into capsules of joints, into bursa? and sheaths of tendons. Wc have seen the capsules of both knees, and the bursae on the olecranon of each elbow, greatly distended with fluid, while there was also considerable effusion into the tendinous sheaths of the wrists and ankles.f In such cases the pain is excruciating, and is described by the patient in superlative terms. Thus it is * In appreciating the quality of urine, it is essential to ascertain the proportion of diluents used by the patient; and the morning urine is, for obvious reasons, to be selected for exami- nation. t Cases of this description are often mistaken for acute rheumatism by inattentive practi- tioners. gout (Chronic). 579 hyperbolically compared to crushing the joint—to forcibly tearing it asunder— to pouring boiling lead on the part—to the gnawing of a dog; and the like. There is much throbbing in the affected parts, with a sense of great tightness and of cumbrous weight. As effusion proceeds, the acuteness of the pain dimi- nishes, while the throbbing and sense of weight continues.* The sufferings are often aggravated by cramps; the weight of the bed-clothes is insupportable, and the tread of another person across the chamber is painfully felt by the patient. If the affected parts be enveloped in flannel, a copious exudation from their surface takes place, emitting a peculiar and characteristic odour, which often pervades the whole apartment. While the joints are in the condition just described, there is also much fever. The face is deeply flushed ; there is total loss of appetite; urgent thirst, with furred tongue and confined bowels. The urine is scanty; its specific gravity increased, and on cooling it deposits an abundant brick-coloured sediment, together with much mucus. When the urine is inordinately charged with this deposit, there is often pain in the bladder, and scalding in the urethra when the urine is voided. In a very severe fit of the gout, the pain and fever may con- tinue without remission for the first three or four days. After this, the symp- toms abate towards morning, to become worse again as night approaches. If no curative means be had recourse to, several weeks, or even months, may elapse before permanent convalescence is established; but during this period a transient respite from pain and fever, for a few days, may happen more than once. True convalescence is indicated by gradual diminution in the severity of the exacerbations ; cessation of fever ; restoration of the healthy characters of the excretions (especially of the urine); and return of appetite. At this period, the patient is thin and feeble ; the gouty joints are weak, puffy, and oede- matous, or their capsules still distended with fluid. The weakness of the gouty limb is, in some cases, very remarkable, almost amounting to paralysis. When, however, the structure of the joints has not been materially and permanently injured, nor the constitution broken down by a long series of attacks, recovery is pretty complete ; the oedema about the gouty joints gradually subsides ; effu- sions become absorbed ; and, with returning strength, the patient regains a tolerably free use of his limbs. The ailments we have described as preceding the fit are for a time removed, and the general health thereby much improved. Chronic Gout. When the favourable conditions just stated are reversed, it more commonly happens that the fever subsides, the local affection becomes less inflammatory in character, and gout continues in a chronic form. In this form the parts affected are either of natural colour, or muchless red than in acute gout; the pain of the joints is less severe and more wandering, in many cases alternating with pain and cramp in the stomach ; but copious effusions still take place into capsules of joints and into bursae, and continue many months. In chronic as in acute gout the pain of the joints increases at nightfall, and is then generally attended with slight fever, rendering the patient watchful and restless. The limbs are disabled for exercise, and the patient always evinces much cau- tion in changing their posture. The general health is much impaired, the com- plexion sallow, the countenance haggard; there is great languor, debility, and depression of spirits; appetite is uncertain, and digestion difficult, with much disposition to heartburn. We have here described the chronic gout as the sequel of acute attacks; but it may also be primitive, and follow the course described without having been preceded by acute gout. In inveterate chronic gout the patient has scarcely any respite, except during two or three of the summer months. It is in cases of this kind, chiefly, that concretions are observed, which, when of considerable size, or occupying cavities of joints or the texture of tendons, tend more than any other circumstance to render gout * This diminution of pain on the supervention of effusion is analogous to what occurs in pleurisy, pericarditis, and many inflammations that terminate in effusion. 580 gout (State of the Urine). permanent. These concretions, however, are formed much earlier in some cases than in others. The matter of which they consist is at first semi-fluid hydrated lithate of soda ; and (as we shall hereafter more particularly notice) a layer of it, of the consistence of thin plaster, is often found coating that part of the synovial membranes which covers the heads of bones. The more fluid parts of this matter become gradually absorbed, leaving the salt alluded to in the form of a solid friable concretion. Such concretions receive additions to their substance not only from the effusions of successive paroxysms, but also, in the intervals of these, from the gradual deposition of lithate of soda; and in this way they often attain a large size. They are most frequent, and larger than elsewhere, in the joints of the hands and feet, which they distort into most unsightly shapes ; but there are few parts subject to gouty inflammation alto- gether exempt from such concretions. Their presence modifies a fit of gout both with regard to its course and local appearances. Their condition in a paroxysm is admirably described in the following passages, which we quote from a paper by Mr. James Moore :-i— " When a violent fit of the gout attacks a chalky tumour, the appearance is frequently very alarming, the new paroxysm being accompanied with a fresh serous and chalky effusion, which, added to the old deposit of chalk, occasions a prodigious swelling; the cutis, when distended to the utmost, opens, yet sometimes the cuticle remains entire. The chalky or serous fluid may then be seen through the semitransparent epidermis. The surrounding integuments appear of a deep red or purple hue, threatening mortification, while the pain is excruciating. At lengh the cuticle gives way, a discharge of serum and chalk takes place, and a remission of all the symptoms usually follows. During the whole of this alarming process, suppuration never oc- curs ; but soon after the opening has taken place suppuration commences, and chalk and pus are then discharged from the ulcer. When an opening is formed, the whole of the chalk never escapes, and its complete evacuation is usually a very tedious process. This is owing to its being diffused through the cellular membrane, as in the cells of a sponge. One cell must sometimes give way after another, and small portions of chalk are successively thrown out; so that.months and even years pass away before the whole is discharged. It also frequently happens that the orifice contracts and closes over, leaving portions of chalk underneath. This kind of cicatrix sometimes stands its ground, but more commonly breaks out again and again to discharge chalk. Even openings into joints, which are so dangerous when occasioned by other extraneous bodies, are often attended with no serious symptoms when the joint is filled with chalk." (Med. Chir. Trans, vol. i.) Mr. Moore remarks justly, that the suffering occasioned by these concre- tions is not owing to any irritating quality they possess, but to the pressure and distension occasioned by their bulk, and to the obstruction they offer to the motion of tendons and joints. It has been stated already, that during the paroxysm of gout the urine deposits a copious brick-coloured sediment composed chiefly of lithates. Sir C. Scu- damore has ascertained that, at the same time, the urine contains an excess of urea, as indeed of all solid ingredients. Dr. Prout has made some inte- resting observations on these points. Speaking of urinary deposits in febrile diseases generally, he says, •• The deeper the colour of the sediment, and the more approaching to red, the more severe, in general, the symptoms ; and it may be mentioned, that the most decided and most strongly marked specimens of the kind which I have seen, have been deposited by the urine of gouty in- dividuals, in which case, as before observed, the sediment consisted chiefly of lithate of soda, and the tinging substance appeared from the tint to be the pur- purate of soda." (Treatise on the Diseases of the Urine, p. 123, 2d ed.) It is proper to add that the urine, however much charged with the material of these deposits, is transparent when first voided, and that red deposits are gout (Affecting Internal Organs). 581 not uncommon in other febrile diseases; in rheumatism especially they are very copious ; scarcely less so than in gout.* But it is also common for gouty persons to pass an excess of lithates in their urine in the intervals of gouty paroxysms, and these persons are more liable than others to gravel and calculus of lithic acid origin. Dr. Prout says, " Besides these amorphous sediments, consisting chiefly of lithic acid, I have seen two or three instances in which large quantities of perfectly white lithate of soda were deposited from the urine. In one case, in particular, the quantity was immense, and voided, not only mixed with the urine, but in a state of consistency like mortar, especially during the night, so as to produce great difficulty in passing the urine. I suspected the existence of gouty irritation or abscess in the kidneys in these cases." (Ibid., p. 127.) The deposition of lithate of soda in joints and other parts affected with gout, proves that the formation of this salt is not a functional act of the kidneys, and the separation of it from the blood by tissues so remote from one another, and so various in structure, further proves that it exists already formed in that fluid.t Hitherto we have described gout as affecting chiefly the structure of joints : they are indeed its most common seat: but many other parts, including some of the viscera, are subject to its morbid action. Of external parts, almost all that are composed of fibrous tissue are liable to gouty inflammation : we may particularize aponeurosis of muscles ; the sclerotica; cartilages of the nose, eyelids, and ears ; ligaments, other than those of joints ; the periosteum, and probably the tunica albuginea of the testicle. Morgagni relates an instance of acute gouty ophthalmia in his own person, and we have seen a case of the same kind. In both the ophthalmia came on at the beginning of the attack, and its nature was inferred from its not running the usual course of common inflammation, and from its immediate subsidence on the developement of gout in the extremities. It has been remarked by a surgeon of eminence, that in persons afflicted with gout, operated on for cataract, gouty inflammation often attacks the eye and causes blindness, either by acute inflammation, with rapid effusion of lymph into the vitreous humour, or by the slower but. equally de- structive process of repeated inflammation of the sclerotica.^ Gout affecting the whole surface of the forehead, temples, and eyelids, is not uncommon ; the aponeurosis of the abdominal muscles is also sometimes its seat; and in some other cases the symptoms seem to refer to the tendinous centre of the dia- phragm. But it is when gout attacks internal organs that it puts on a most alarming aspect, and becomes immediately dangerous to life. As in this case the gout of the extremities generally subsides rapidly when the internal affec- tion begins, the term " retrocedent gout" has been adopted to express it. The stomach, or the stomach and intestines, are almost invariably the organs to which retrocession takes place: there are no well authenticated examples of transference of gout to the lungs ; and instances of gout affecting the heart are few, and not described well enough to be conclusive. The most marked case we are acquainted with of gout affecting the heart is described by Dr. Haygarth in the Medical Transactions, vol. iv. Apoplexy, or other symptoms of cerebral congestion, sometimes come on when gout is repelled by cold applications. Such cases, are, however, rare; and we shall confine our further remarks to gout of the stomach and bowels. It has been already stated that in chronic gout a painful affection of the stomach sometimes alternates with that of the extremities. This affection is * Sir C. Scudamore has endeavoured to connect these deposits in gout with derangement of the liver : in acute rheumatism it seems impossible to do so without indulging in unwarrant- able hypothesis. t Since this salt is an ingredient of healthy urine, there can be no doubt, from the reason- ing in the text, that it exists also in healthy blood. ; We are indebted for this valuable remark to our friend Mr. Barnes of Exeter. 582 gout (Diagnosis). not inflammatory in character, nor, generally, dangerous to life; the pain at- tending it is like cramp or gastrodynia, and is usually relieved by pressure ; the heat of the surface is rather below than above the natural standard, and there is seldom vomiting. But when affection of the stomach succeeds to well- marked acute gout of the extremities, in the height of a febrile paroxysm, the symptoms are much more alarming, and often tend rapidly to a fatal issue. In such cases the pain is very severe; is usually attended with incessant vomiting, or hiccough, and, when the bowels are affected, with profuse diarrhoea also. At first there is considerable fever ; but if the symptoms are not relieved, collapse ensues early, and soon terminates in death. The early symptoms are therefore of an inflammatory kind, like those of the affection of which they have taken the place. It is of the highest importance to discriminate well be- tween these two forms of gout in the stomach, because they require opposite plans of treatment. There can be no doubt that these internal affections are as specific in nature as the gout of external parts. We consider the following facts to be sufficient proofs of the truth of the proposition. The affections in question do not run the course of common inflammation, or of any other simple form of disease: they alternate in a complete and remarkably sudden manner with gout of the extremities, and if we can succeed in fixing the latter, the internal affection is at once and permanently relieved. Diagnosis. Rheumatism is the only disease which can be readily con- founded with gout. Identity in the seat of the local affection is not the only point in which they resemble, and it often requires patient inquiry into the history of the disease, and accurate scrutiny of present symptoms, to enable us to distinguish between them. For lack of these precautions, gout is often mistaken for rheumatism by men of large experience, and we believe that it is by mistakes of this kind that colchicum maintains its undeserved reputation as a remedy for rheumatism. In a first fit of gout, the seat, and limited nature of the local affection, the appearance of the part, and the other circumstances detailed in the description, are characteristics of sufficient peculiarity to pre- clude doubt about the nature of the malady : it is not here that the difficulty lies, but in more advanced cases, when numerous joints are simultaneously affected. In such cases the history of former attacks is of much assistance, as may be seen from the statement ahead}' quoted from Sir C. Scudamore, that in 190 of 198 cases gout was limited, in the first fit, to the joints of the feet and ankles : such a limitation never occurs in rheumatism. The age of the individual is a circumstance of less extensive bearing, for although gout never occurs in childhood, and rheumatism often does, yet, as we have else- where shown, adult and mature age are, much more than infancy, exposed to the latter disease. Much stress has been laid on the statement, that gout comes on without obvious cause, and that rheumatism may always be as- signed to an evident one; namely, exposure to cold. But the paroxysm of gout may often be attributed to the same cause, while in many cases of acute rheumatism the operation of any obvious cause altogether escapes the notice of the patient. But the symptoms of gout, narrowly observed, will be found to differ considerably from those of rheumatism. OZdema of the affected parts, and de- squamation of the cuticle, we have already adverted to in the description of gout; they do not always exist, but, when both are present, they may almost be con- sidered pathognomonic of gout. Sir C. Scudamore makes the following state- ment in regard to desquamation :—" In 98 cases in whom 1 have examined this point, I find that 25 have never experienced this symptom : not more than 6 of the 73 invariably, and many of them in some fits and not in others ; and in no instance, I believe, except from the hands and feet." OZdema is much more general, and is, we believe, present at some period in the course of every fit. In acute rheumatism, oedema is rare ; and, when it does exist, is not nearly so marked as in gout. This is therefore a character of cout (Patliology). 583 considerable value. In gout the variation from day to day, in the degree of fever, is much greater than in acute rheumatism ; passing, in the course of a few hours, from the highest degree of febrile excitement to complete apyrexia, and this to be followed as suddenly by return of fever. We know of no other single circumstance which marks so well the distinction between these two diseases. In rheumatism, when pain is severe and fever considerable, there is always profuse sweating; in gout, sweating is often absent, and when present, is very much less abundant than in rheumatism. Something also may be gathered from the nature of the pain, which is more agonizing and more deep-seated in gout. In cases of gout, where only one or two joints are affected at a time, this limitation of itself excludes difficulty. Chronic gout being generally a sequel of acute gout, and occurring when fits of the latter have been both fre- quent and protracted, the history of the disease elucidates its nature. Occa- sionally, however, and especially in persons of a weak constitution, and in women, chronic gout is primitive. A careful scrutiny of the history of the malady generally suffices to establish a diagnosis; but local signs are not want- ing. In chronic gout there is often not more than one joint affected, never many at a time; and the affected parts generally exhibit oedema in a remark- able degree. The reverse of these circumstances are observed in rheumatism. The hands and feet are also more exclusively subject to chronic gout than to rheu- matism : bursae, synovial capsules, and sheaths of tendons, may be distended with fluid in either. We have not referred to syphilitic affections of the bones : to confound these with gout can happen to those only whose ignorance is exceeded by their negli- gence. Pathology. In the foregoing description we have made known various im- portant lesions which affect ligamentous and tendinous structures and contiguous synovial capsules. We have seen that the principal morbid change appreciable in the living subject is effusion of fluid into these capsules, and into the cellular tissue adjacent to tendons and ligaments; and that this effusion of fluid is generally attended with acute pain, swelling, local redness, and much febrile excitement; circumstances which point out the inflammatory nature of the affection. On the other hand, the hereditary succession of gout, its spontaneous accession and repetition, prove it a constitutional disease; while the course and products of the local inflammation further prove that inflammation to be specific in kind. The formation of gouty concretions has already been described at some length. On dissection they are found to occupy the cavities of joints and bursa?, the substance of tendons, and the cellular tissue adjacent to liga- ments; in the latter situation the lithate of soda is deposited in separate cells, and not in a cyst. The manner in which the concretions are, as it were, im- pacted in the tissue of tendons, suggested to Musgrave the expression,—" Tophi in tendinibus tanquam clavi trabibus impacti, non raro observantur." We have remarked that the material of these concretions is fluid when first effused, and that it becomes solid by absorption of the liquid parts. The cartilages cover- ing the condyles of the femur and heads of various bones are often coated with a thin layer of lithate of soda of the purest white, and of the consistence of very soft plaster, there being at the same time no similar deposit on any other surface within the joint. When this substance has acquired a considerable degree of hard- ness, the cartilages become absorbed, and the new surface sometimes exhibits grooves which seem the effect of friction. In such cases the functions of the joint are permanently injured ; sometimes anchylosis follows ; but if the deposit be very considerable (as in joints of the fingers), dislocation is the more common result. These effects are most frequent in joints of the hands and feet, for the plain reason that these are more subject to gout than others; but concretions have been found on the pericranium, cartilages of the ear, and in many other situations. When the irritation of a concretion has caused ulceration, very large quantities of lithate of soda continue to be secreted from the surface of the 584 gout (Pathology). cavity after entire separation of the concretion. It has been stated that these concretions are formed of lithate of soda; a small proportion of phosphate of lime is always present; and M. Cruveilhier has published the analysis of a con- cretion, in which the proportion of phosphate of lime was greater than that of lithate of soda. (Anat. Path. liv. iv.) Effusion of lithate of soda, in quantity to form obvious or palpable masses, is of rare occurrence in gout, and happens only after numerous and protracted fits. Sir C. Scudamore states, that in 206 cases of gout he did not discover any trace of concretions in more than 21,— a proportion rather above one in ten ; but as he does not mention in what degree the subjects of these cases had suffered from gout, no valuable inference can be drawn from the statement. We certainly should not infer, from the rareness of the concretions, that effusion of the lithate of soda is of rare occur- rence in gout. That this substance is often poured out in quantity so small as to elude detection in the living subject, dissection has amply proved; and, on the other hand, while it remains in a fluid state, there is no physiological obstacle to its absorption,—an event which would render concretions of pal- pable size comparatively rare. The effusion of lithate of soda in various parts is a circumstance so peculiar to gout, and is in many cases so obviously an essential part of the disease, that there can be no doubt of its being an important element in all. But we have seen that it is also common for gouty persons to pass an excess of lithates in their urine, in the intervals of gouty paroxysms; and that these persons are more liable than others to gravel and calculus of lithic acid origin. However we may abstain from raising a theory of the proximate cause of gout on the foundation of these facts, yet we must consider the discharge from the blood, at various outlets, of so large a quantity of such a highly animalized principle, as a fact of paramount interest in the pathology of gout, especially when viewed in connexion with those habits of life which we shall hereafter show to be a main cause of gouty diathesis. Having already shown that the lithates are not formed by the act of secretion, but merely separated from the blood, the discharge of them in such large quan- tity in gout, (especially during the paroxysm) proves that in this disease the blood must be charged with great excess of them, and further shows that the paroxysm is, in one sense, a depurating process. Such vitiation of the blood with excess of lithates must tend to injure the functions of many organs; and when we reflect on the removal of ailments, which usually follows the elimina- tion of these principles in the paroxysm, we do not outstep the bounds of cau- tious inference in considering accumulation of them in the blood as the probable cause of those various and anomalous ailments which often precede the pa- roxysm, and as intimately connected with the cause of regular gout itself. As in some other febrile diseases there must also be excess of lithates in the blood, (as proved by elimination of them in unusual quantity), it is probable that the cause of gout is the presence, in that fluid, of some kindred but more specific principle. It may be objected to these views, that a full paroxysm sometimes comes on without precursory symptoms; but to this it may be answered, that in diseases of which contamination of the blood is the sole cause, precursory symptoms occur in some cases, and not in others, although such contamination exist a considerable time before the developement of the disease. That gout sometimes follows local injury is no objection, for the fact that this is not con- stant, implies a predisposition. We now proceed with the anatomical characters. The muscular tissue is never primitively affected with gout. When a joint has been a long time anchylosed, the muscles which formerly moved it dwindle for want of use; and the texture of muscles may suffer much damage in consequence of repeated gouty inflammation of their aponeuroses. Ligaments and tendons lose much of their elasticity through frequent attacks of gout, and often remain habitually sore. Gout very seldom causes suppuration; we have never seen an example of it. Sir C. Scudamore states that he has seen it in four cases, and, in all, the gout (Causes). 585 result was curiously modified by attendant secretion of lithate of soda. Patho- logical anatomy has done nothing for gout of the viscera; no effects of gout on the pericardium, or on the internal membrane of the heart, are recorded. Gouty inflammation of the stomach is not questionable, and is often fatal; yet we pos- sess no good description of its morbid anatomy. We have examined after death but one case of this affection. The appearances were peculiar and difficult to describe, and our notes of it are very imperfect. It would be interesting to ascertain whether there be, in these cases, effusion of lithate of soda into the cellular coat of the organ. Almost every organ has been named by authors as the occasional seat of gout, and every ailment of gouty persons has been attributed to this Proteus. It is almost needless to add, that much which has been written on this subject is extremely fanciful, and has not been submitted to the test of a sound pathology. What are the viscera that are liable to gouty inflammation, is not yet deter- mined ; although it is obvious that the functions of all may suffer from that contamination of the blood which is probably the most important element of the gouty diathesis. Gouty inflammation of the kidney has been described with some appearance of truth; it is yet, however, matter of doubt, whether the symptoms of this affection should be referred to gouty inflammation, or to such modification of the urinary secretion as is most likely to result from the gouty diathesis. For a very full account of the inflictions, real and supposed, of anomalous gout, the reader is referred to Stole (Dissertatio de Arthritide), Musgrave (De Arthritide Anomald), and to the Dictionnaire des Sc. Medicales, art. Goutte. Causes. The circumstance of being the offspring of gouty parents is of great influence in predisposing to gout. Sir C. Scudamore (from whose elaborate treatise we must here borrow largely) found, that of 189 patients taken indis- criminately, there were 105 whose father or mother, or both, were subject to gout; the remaining 84 were born of parents free from gout, and not allied to it by family. Now, if the children of gouty persons were not more subject to gout than those of persons not gouty, 105 to 84 would express the proportion which the former class bear to the latter; but it must be evident to every one, that even in that class of life in which gout is most frequent, gouty persons are a small minority,—a fact which, contrasted with the numbers 105 to 84, show- ing the proportion of cases of hereditary to those of acquired gout, demopstrates the vast influence of hereditary predisposition. This is also further shown by particular examples, of which many striking ones might be adduced. Sir C. Scudamore has related some curious instances, in which nearly all the members of a family have suffered from gout, although the parents and other relatives were entirely free from it. He states, that in one family, three brothers and a sister, out of six children, have been severely affected; and that in another, also consisting of six, four brothers have suffered from very aggravated gout, and the two sisters only have escaped. In these examples the disorder was not known in the two preceding generations. These facts are deserving of notice. The immunity from gout enjoyed by women is very notorious. We shall see that this is probably merely the expression of a more general fact, namely, that persons of temperate habits are, with few exceptions, exempt from this dis- ease. Menstruation, and the natural temperament of women—much less san- guineous than that of men—may also have some share in procuring this happy immunity. Examples of gout occurring before puberty are exceedingly rare, and the few which have been cited do not appear to be well authenticated. Gout is, indeed, rare before the age of thirty. Sir C. Scudamore has noted the period of first attack in 209 cases. vol. in. 74 586 gout (Causes). It occurred before the age of 20 in 4 persons only. — between the ages of 20 and 30—63 persons _ _ 30 _ 40—78 — — 40 — 50—43 _ _ 50 — 60—16 — _ 60 — 70— 5 209 Bearing in mind that the number of persons in existence decreases rapidly as age increases, the very great liability to gout in persons between the ages of 30 and 40 becomes obvious. Persons between 40 and 50 are, probably, quite as liable to the accession of gout as those between 20 and 30. After 50, the liability decreases rapidly, but even persons between 60 and 70 are very much more liable to have gout come on, than those under 20. Sir C. Scudamore has not met with gout coming on, for the first time, after the age of 66. Thus it appears that gout usually comes on soon after the growth of the body is com- pleted, and while the function of nutrition is yet in full vigour. Authors seem to have no doubt that a particular form of body predisposes to gout, and some have described the "gouty form" with great minuteness. No one however has determined the proportion of persons of such form to those of different shape, and therefore speculations upon it are without value. The opinion that sexual indulgence is a cause of gout is probably still more fanciful. Habits of life furnish the most important considerations connected with our subject, for we shall see that, without the co-operation of causes arising in certain habits of life, all the circumstances hitherto enumerated remain without power to produce gout. Several influential circumstances prevail in the mode of life of gouty persons; namely, high feeding, especially great consumption of animal food, habitual abuse of spirituous liquors, and sedentary habits. The first two are more constant and undoubtedly more influential than the last, which may be considered of a more negative character. These several circumstances appear in a stronger light when contrasted with the habits of a class who may be said to be entirely exempt from gout; we allude to agricultural labourers: these men are, from necessity ^ sparing in the use of animal food, habitually temperate, and all day long work hard in the fields. During a long and extensive profesional con- nexion with a large rural district, we never knew an instance of gout among agri- cultural labourers, who of course form the great mass of the population ; gout was not uncommon among tradesmen, but still more frequent in the class of gentle- men and opulent farmers. That the quantity of animal food consumed by agricultural labourers is com- paratively very small, must be well known to persons who have lived in the country; and we believe this circumstance has considerable share in procuring for that class their signal exemption from gout. It is nearly established that large consumption of animal food tends to produce the lithic acid diathesis: a condition so often associated with gout that more than one author has been led to consider these forms of disease as essentially connected. In advancing the opinion that large consumption of animal food is a cause of gout, we are glad to avail ourselves of the support of one of the most distinguished physiologists of our day. Muller, in commenting on Magendie's experiments on food, says, " These experiments have thrown some light on the causes and mode of treat- ment of gout and calculous disorders. The subjects of these diseases are gene- rally persons who live well, and eat largely of animal food: most urinary cal- culi, gravelly deposits, the gouty concretions, and the perspiration of gouty persons, contain abundance of uric acid ; a substance into which nitrogen enters in large proportion. By diminishing the proportion of azotized substances in the food, the gout and gravelly deposits may be prevented." An elderly country practitioner has assured us, that, forty years ago, gout was much more gout (Causes). 587 frequent among farmers and tradesmen than at present: he is of opinion that men in these classes drank more freely then than now, and to this difference he ascribes the greater prevalence of gout at the period referred to. This greater prevalence of gout formerly has been averred to us by so many of credit and observation, that we have no doubt of its reality. Allowing that free drinking was more common in those times, we must also remark the important fact, that vegetables were scarce and. dear, and that meat formed a much larger propor- tion of food than at present.* Abuse of malt liquors and wine is so commonly associated with the love of good cheer generally, that it is difficult to form a separate estimate of its influ- ence as a cause of gout. This influence is real and probably considerable, and we are disposed to think that malt liquors tend, even more than wine, to pro- duce a gouty diathesis. Their effects are especially manifest in those examples of gout which occur in the lower classes. There is a body of men employed on the Thames whose occupation it is to raise ballast from the bottom of the river. As this can be done only when tide is ebbing, their hours of labour are regulated by that circumstance, and vary through every period of night and day. They work under great exposure to inclemencies of weather; their occu- pation requires great bodily exertion, occasioning profuse sweating and much exhaustion- In consideration of this, their allowance of liquor is very large; each man drinks from two to three gallons of porter daily, and generally a con- siderable quantity of spirit besides,. This immoderate consumption of liquors forms the only exception, as far as relates to food, which these men offer to the general habits of the lower classes in London. Gout is remarkably frequent among them, and although not a numerous body, many of them are every year admitted to the Seamen's Hospital Ship affected with that disease. This is a very interesting fact, and seems to show that no amount of bodily exertion is adequate to counteract the influence of such large doses of porter; the exposure of ballasters to wet and changes of temperature probably favours its operation. These men are almost all derived from the peasantry of Ireland; they can rarely, therefore, inherit a disposition to gout. All the tradesmen we have met with affected with gout, have been known to us for their intemperate habits, and especially their abuse of malt liquors; a very large proportion were innkeepers. The abuse of wine has been considered in all times one of the most efficient causes of gouty diatheies, and there is ample reason to confide in the truth of this opinion. Wine probably acts in the same way as malt liquors: the strongest wines, such as port and madeira, are considered to be the most powerful in producing a disposition to gout; while, on the other hand, it is sup- posed that in persons who have had gout, sour and light wines, especially champagne and claret, more readily bring on the gouty paroxysm. VVe shall see that in the quality of an exciting cause, the abuse of wine holds the fore- most rank, and this probably first led to its recognition as a general cause of gout. The effects of spirits cannot well be separately treated of: it seems probable, * We have before us an account-book bearing date from the middle to the latter end of the last century, and in it we find some interesting entries of the comparative prices of meat and vegetables. The prices for a long period run as follows:—Quarter of a sheep, two shillings; peck of potatoes, sixpence. In the same districts, at present, potatoes are often only three- pence a peck, whereas mutton is sixpence a pound, and sometimes more. The gentleman who gave us this account-book, and who is now more than seventy years old, informs us that when he was young, no potatoes were kept for winter use, and that the only other sort of gar- den stuff used was a coarse kind of kale, the leaves of which were stripped off the stalk, and prepared for the table by plain boiling. This vegetable was tough and unpalatable; and during four or five winter months the food consisted, almost exclusively, of meat, bread, and flour puddings. The change which extensive cultivation of the potato and diffusion of garden- ing has wrought in the nature of the food of the population generally, is renarkably great, and well deserves the attention of physicians. (See Scurvy.) 588 gout (Causes). that when drunk exclusively they do not powerfully predispose to gout: gouty patients assure us they are much more safe from their enemy in the habitual use of gin and water, than when taking an equivalent of wine or malt liquors. We have endeavoured to estimate the influence exercised by abuse of liquors separately from that of other indulgences of the palate. In reality, however, they are generally found together; and in habitual indulgence in the pleasures of the table considered in the aggregate as constituting good cheer, we see a cause more prevalent than any other,—a cause recognised by physicians in very early times, and undisputed in our own. No truth is established on a surer foundation than this; that habitual indulgence in pleasures of the table brings on gout, and abstemiousness, temperance, and active habits preserve from it. The fact is striking, and is well exemplified by the almost complete immunity of females, and, as we have said before, by the total exemption of agricultural labourers and young persons. We do not, however, mean to stigmatize all gouty persons as intemperate. We have already amply shown the influence of hereditary predisposition, and this may be so strong that gout may come on without the co-operation of indulgences which can be accounted culpable. Of this, our own experience furnishes many instances. Great bodily exercise, by producing expenditure of power, by rendering assi- milation more perfect and excretion more complete, sanctions the use of a large quantity of food, and may even counteract the ill effects of occasional excesses at table:—sedentary habits, on the contrary, do not furnish any one of these motives for a large supply of food, and, by inducing repletion, pro- bably favour the operation of those causes which we have just been considering. The discovery that many excrementitious principles are not formed in the organs through which they are discharged, but exist already in the blood (pro- bably as a residue of assimilation), has given additional interest to the functions of excretion, and has shown the importance, in regard to the purity of that fluid, of promoting these by appropriate habits. The skin has important func- tions of this kind, and in transpiration and sweating offers an outlet to highly animalized excrementitious principles;—a still larger portion passes off by the kidney. The efficacy of bodily exercise in promoting the proper discharge of these functions is well known; and it seems probable that to this quality more than to the prevention of plethora, may be ascribed its success as a means of protection from gout. We now come to treat of exciting causes. The most common of these are indulgence in pleasures of the table, and especially abuse of wine or spirituous liquors ; the use of stimulant mineral waters; local violence, such as a bruise or sprain, or violent exercise of a part; exposure to cold and moisture ; and when the gouty diathesis is rife, any circumstance which excites fever or in any way disturbs the health of the patient: in this way excess in venery may possibly be an exciting cause of a paroxysm, but it is in nowise a cause of the gouty diathesis. As striking examples of the immediate effects of abuse of wine, Sir C. Scudamore gives the case of a person, neither descended from gouty parents, nor having reason to expect such a disease, who, after three or four days of excessive conviviality, in which he drank champagne very freely, was seized severely with the gout. In another individual, of a temperament bordering on the pure sanguineous, with a circular chest and large veins, not born of gouty parents, after committing the extraordinary excess of drinking four bottles of port wine at a sitting, was seized the same night, and for the first time, with the gout. Three persons sat down to a convivial dinner with scarcely the sensation of gout, but on rising to depart, the feet were com- pletely disabled by the inflammation and swelling, which had made rapid pro- gress. (Treatise on Gout, pp. 101, 102.) In the last century, when a fit of gout was considered a cure for every ail- ment, and the doctrine had become popular, because it countenanced the most cherished habits of good livers, physicians had very extensive experience of gout (Treatment). 589 the effects of mineral waters as an exciting cause of gout: they all agree in ascribing considerable power to their use, and the waters of Bath, in particu- lar, acquired great celebrity. A gouty paroxysm is frequently the consequence of severe local injury ; but, in advanced cases, unusual exertion in walking is often sufficient to excite a paroxysm. One of our patients has been visited with a severe fit of gout in several successive years, manifestly excited by considerable exertion in the pursuit of his favourite diversion, partridge shooting. The influence which local violence, long previously sustained, has in deter- mining the seat of gout, is interesting. We are acquainted with a gentleman, who, when young, sprained his ankle severely; many years afterwards he experienced his first attack of gout; that part only was affected then, as well as in the two or three following fits. Sir C. Scudamore relates a similar instance, and another still more interest- ing, of a gentleman, who, when a youth, accidentally received some small shots from a gun in one knee. They were removed, but the knee was ren- dered permanently weak in a slight degree ; and to this part the gout in after life first attached itself, and always afterwards with more severity than in any other situati6n. In scurvy, also, facts exactly analogous to these are observed ; a circumstance which imparts to them additional interest for the pathologist. Gouty persons are remarkably sensible to the influence of cold and damp: we know many who invariably suffer twinges of gout after the slightest damp- ness of the feet, and even a full gouty paroxysm is often excited by this cause. We shall not pursue further the enumeration of exciting causes ; when the gouty diathesis is confirmed, any, even trifling, disturbances of the system, from whatever cause it arise, may occasion the developement of a paroxysm. Treatment. The treatment of gout has been, and continues to be, subject to much caprice and prejudice. Many persons, having once found their health improved by a severe attack of gout, are led to consider the paroxysm exclu- sively in the light of a salutary process, which it would be unwise or even unsafe to interfere with; others go still further, and, believing the relief to the system to be proportionate to the violence of the paroxysm, endeavour to promote the developement of gout by local warmth and an exciting regimen. But improved health is by no means a constant result of the gouty paroxysm: while on the other hand, the lamentable disorganization of joints which ensues when severe fits of gout are repeatedly allowed to take their own course, is a peremptory motive for the interference of our art. The great advantage of judicious medical treatment in severe attacks of gout is now fully recognised by the Profession, and persons who suffer from gout are daily becoming more sensible of it. The first fit of gout is usually so slight an illness, and tends so early to a favourable termination, that little interference is necessary, and in- deed medical aid is seldom sought for; when, however, the first fit is unu- sually severe, or gives indication of becoming protracted, those means should be employed which we shall now describe as applicable to a severe paroxysm in a more advanced stage of the disease. When the acute gout comes on in a person of full habit, and is attended with much fever and urgent local symp- toms, direct depletion affords great relief, and .cannot safely be dispensed with. In such circumstances, general bleeding should be had recourse to; but it should be borne in mind that the object of bleeding is not to cut short the paroxysm, an effect to which it is inadequate, but to moderate fever, lessen the severity of local symptoms, and diminish repletion. These important effects may be attained by a prudent use of the lancet, and if nothing further be attempted, no bad consequences need be apprehended; but profuse bloodlet- ting, repeated without due regard to the resources of the patient, is a practice fraught with danger and bad consequences.* Purgatives are of great service * There is some reason to believe that the old doctrine, that profuse bleeding favours metas- tasis to vital organs, is true as regards gout; and that this effect is one, though not the only, source of danger arising from such practice. 590 gout ( Treatment). in the treatment, and no form of these is so eligible as blue pill, followed at the end of some hours by a common black draught. When the complexion and other appearances bespeak a bilious condition of the system, these medicines should be repeated several times at proper intervals : this treatment, in alli- ance with low diet and the use of diluents, materially alleviates the symptoms of gout, but is insufficient to accomplish a speedy cure:—fortunately, how- ever, this may be safely completed by preparations of colchicum. The efficacy of this medicine in the cure of gout was known to the Greeks and Arabians; and the Hermodactyl mentioned by Greek authors, and extolled as a remedy for gout by Alexander of Tralles, a city of Lydia, in the sixth century, has been ascertained to be the colchicum. In our own times there has been much difference of opinion as to the efficacy of this medicine; for, while all have acknowledged its power, when first employed, to remove speedily the local symptoms, many have argued that the cure thus obtained is not permanent, but is followed by early and frequent relapses, and that in a short time the drug seems to lose all control over the course of the disease. Notwithstand- ing this impeachment of its virtues, colchicum has continued to advance in favour as a remedy for gout, and counts among its advocates the best and latest writers on the subject, among whom we may mention Scudamore, Hal- ford, and Barlow. Sir H. Halford states that he has never known a single instance of untoward effect from its use, and affirms that gout does not return more quickly after its use, than when treated by other means or left to its own course. As far as we have observed, it is only when colchicum is used to the exclusion of other means, without observance of proper diet, and left off on the first subsidence of local symptoms, that gout returns more quickly after its use. In persons of very full habit, in the height of a febrile paroxysm, direct depletion accomplishes what cannot be effected by other means, and it ought not, therefore, to be superseded. It is certainly not by depletion that colchicum cures gout. When the fever and local .symptoms are not urgent, and especially when direct depletion is for some reason inadmissible, we may have recourse to col- chicum in the first instance. The cure obtained by it will be speedy in most cases, and if the remedy be long enough continued, as permanent as if effected by any other means. We shall now make a few remarks on the usual physio- logical effects of colchicum, as these effects will be found to suggest some important rules for its use. When the wine of the root is given in large doses, it occasions violent vomiting and purging; the stools are copious, watery, and attended with much griping; the vomiting occurs at short inter- vals, and there is much nausea and sense of load at the stomach, with dis- tressing faintness and sinking. In some cases there is a marked diminution in the frequency of the pulse, which is also faltering and occasionally inter- mittent. We have frequently observed these distressing symptoms in persons ill of acute rheumatism, and taking 3ss of the wine three times a day. In smaller doses, colchicum acts as diuretic, and promotes perspiration; it some- times purges moderately, but rarely produces diminution in the frequency of the pulse. In a long series of careful observation on the subject, we never remarked material diminution in the frequency of the pulse, except in con- nexion with the more violent effects already described; and we believe the effects of colchicum on the pulse have been much overrated. From these observations it appears, that the caution to be observed in the employment of this medicine regards chiefly its effects on the stomach and bowels, as it seems probable that, if allowed to produce violent irritation there, gouty in- flammation might thereby be determined to these organs. WTe have know- ledge of one instance in which this seemed the result, and the issue was fatal. The most striking symptoms in that case were, uncontrollable vomiting and purging, followed by early and profound collapse. When, therefore, distress- ing nausea or violent purging supervenes, colchicum should be left off until gout (Treatment). 591 these effects have ceased. On returning to its use, it will be prudent to em- ploy a smaller dose than before. We also approve of Sir H. Halford's precept, —that in the common circumstances of gout in the extremities, colchicum should not be used at first, but that we should wait a day or two until the malady shall have fixed itself. We need scarcely add, that the presence of symptoms of gout in the stomach entirely contravenes the use of colchicum by the mouth, and that profuse diarrhcea is also a counter-indication.* It has been argued by many, and very forcibly by the late Dr. Sutton, that colchi- cum cures gout by its purgative effects; but this statement is disproved by the experience of all who have much employed this medicine, for it often cures without producing sensible increase in any of the excretions, and, according to our own experience, its beneficial effects are quite as soon shown under these as under any other circumstances. On these grounds, we do not see why Dr. Barlow and Sir C. Scudamore should have denied to colchicum a specific action. The wine of the root of colchicum is as good a preparation as any; twenty-five drops, twice a day, in cinnamon water, may be given at first, and if this agree with the patient, may be increased to thirty. We have never found it necessary to carry the dose beyond this. When there is acidity in the stomach, fifteen grains of carbonate of magnesia may be given with each dose, and is indeed always a safe and perhaps good addition. These doses of colchicum generally produce moderate purging and increased secre- tion of urine ; effects which must undoubtedly be considered salutary. Under this treatment the local symptoms soon abate, fever subsides, and the general condition of the patient rapidly improves ; often, in a few days, convalescence is fully established. But it is necessary to continue the medicine for many days after entire cessation of symptoms; the doses may, however, be dimi- nished, and the intervals between them lengthened. We have learned from experience the great importance of this rule, and it is explained by those views on the pathology of gout, which show that removal of the local symptoms and attendant fever is far from equivalent to complete cure. This continuance in the use of colchicum is, moreover, never attended with ill effects. In cases in which the stomach is irritable, colchicum should be given at first in small doses, and its best vehicle is a common effervescing draught; when it has a tendency to purge too freely, this may be counteracted by the addition of a small quantity of tincture of opium to the evening dose. Sir C. Scudamore prefers the Acetum Colchici to all other preparations. The following is the formula he recommends:—R. Arcetici Colchici, 3j ad 3ij; Magnesiae, gr. xv and xx; Magnesia? Sulphatis, 3i ad 3ij; Aquae puree, 3iss. Fiat haustus. This draught to be given every four, six, or eight hours, according to the freedom of its operation and the urgency of the symptoms. Sir H. Halford recommends the wine of the root. He states that, so far from finding it prona to purge the body, as the eau medicinale often did, he generally finds it necessary to add a small portion of sulphate of magnesia. The diet in acute gout must be much the same as in other febrile diseases. While there is much fever, the patient must be restricted to the use of diluents: rennet whey, toast and water, and weak tea, are generally relished. There is no objection to the moderate use of oranges, grapes, or roasted apples, pro- vided there be no acidity of stomach, and they do not increase too much the purgative effects of colchicum. * It seems to us, however, that it is eminently desirable, even in these cases, to introduce colchicum into the system by some means or other. In case the stomach were affected, and diarrhcea not present, we should be much disposed to try the effect of colchicum in enemata. In cases attended with vomiting and purging, administration of veratria by the endermic method is well worth trying, for in such cases the means in present use so commonly fail, that it is incumbent upon us to try any that give fair promise of success. 592 gout (Treatment). The return to a more nourishing diet, should be commenced with farina- ceous food. An attack of gout is, generally, so soon relieved by the means described, that there is no need of local treatment. Gout is also so shifting in character, that local treatment promises much less advantage than in simple inflamma- tion. We object therefore to the practice of applying leeches to the gouty limb, partly on the ground of its being needless. Those who have had the most experience of this practice in our own country state, that it often promptly relieves the affected part, but that it produces great and lasting weakness of the joint, and that the relief of the extremity not unfrequently seems the occa- sion of gouty inflammation of the stomach, or some other important organ. The application of leeches may, however, be sanctioned by unusual conti- nuance of violent inflammation, in spite of judicious general treatment. We have employed them in a few instances, and in these they soon relieved the local affection without producing untoward consequences. It is proper to state that local bleeding is much extolled by many French authors of good repute. It is, we believe, sufficient in all cases merely to cover lightly the gouty part, and relieve it from the weight of bed-clothes. The prevalent custom of wrap- ping it in flannel is very pernicious; the unnatural heat of the part is thereby increased, and much relaxation and weakness result from the copious local transpiration it occasions. We have had no experience of the method of local evaporation, so strongly recommended by Sir C. Scudamore; but as he states that it has given signal relief in 130 cases in which he has tried it, and not once produced any unpleasant effects, we give an account of his method for the use of those who may be disposed to try it. It consists in applying to the gouty part linen rags wet with a lotion (lukewarm,) composed of one part of alcohol and three parts camphor mixture. The linen compresses, constantly kept wet with the lotion, should consist of six or eight distinct folds, one laid upon another; and the lightest and coolest covering only used in addition. When the lotion is discontinued, the part should be wrapped in a single layer of flannel. The best method of applying the lotion to the knee and elbow is in a bread poultice saturated with it, and laid on thick and lukewarm. We cannot warn our readers too strongly against the irrational and dan- gerous practice of repelling gout by immersing the affected parts in cold water. In the convalescence of gout, the diet should be light and simple, and the bowels kept regular by the use of a mild warm purgative. Exercise of the parts which have been affected should be attempted gradually: its measure will, in general, be best indicated by the feelings of the patient, who should however be warned against the danger of excess, which almost certainly brings on a relapse. Moderate exercise should not be too long deferred, as, by promoting the absorption of effusions, it tends more quickly than any other means to remove stiffness and weakness. When capsular effusions persist, moderate friction with the hand is very beneficial: a well-applied bandage is also of great use, especially when there is oedema. The patient should be very cautious of early exposure to cold. In chronic gout, the treatment must of course be much less active. Direct depletion is very injurious, as in this form of the disease,—generally the sequel of acute gout,—there is usually much constitutional debility. This may have proceeded so far as to furnish the leading indication of treatment: the counte- nance may be blanched, the tongue pale and indented, the pulse weak, the breathing short on the slightest exercise, and the heart palpitating. In such cases the affection of the joints has a much less inflammatory character than in acute gout, is more wandering, and often alternates with pains of the stomach like gastrodynia, and anomalous pains of the head and other parts. In these circumstances, tonic medicines and generous diet are of the greatest gout (Treatment). 593 service. Preparations of iron are generally to be preferred to other tonics, and tincture of muriate of iron is an eligible form : its object may be promoted by the daily use of two or three glasses of good sherry. The good effects of Bath waters in this form of gout (the atonic or anomalous gout of authors) in some measure justify the high reputation in which they were once held. In acute gout these waters are invariably injurious. Under the treatment just described, it generally happens that the body is invigorated, the internal parts are relieved, and gout settles in the extremities, assuming a more frankly in- flammatory character. When this desirable object is attained, the remedies may be more specially directed to its cure, and preparations of colchicum, given with the precautions already enjoined, produce admirable effects : in cases of this kind we have found camphor mixture an excellent vehicle. In chronic gout, unattended with much debility, our chief reliance is to be placed on colchicum, which should be continued for some time after apparent cure is ac- complished. If the secretion of bile be defective, or the complexion sallow, blue pill fol- lowed by a mild purgative draught should be occasionally given. The diet too must consist chiefly of farinaceous food: a small portion of wine may be advi- sable when the patient has been accustomed to take it freely. In protracted chronic gout, where the joints are very stiff and weak, the gouty diathesis confirmed, and the health much broken, the use of mineral waters is sometimes remarkably successful: the relief from local stiffness and weakness is, in particular, very striking when thermal waters are used locally by affusion and in the form of warm baths. The waters of Aix-la-Chapelle, of Wiesbaden, and of Carlsbad, enjoy great reputation. The presence of gouty concretions may require some modification of the usual local treatment: on this point we shall again quote the excellent paper of Mr. James Moore:—" The shocking appearance of a severe fit of gout when it attacks a part in which there is an accumulation of chalk, has already been noticed. In this situation a warm poultice is a far better application than dry wool or flannel. If there is any tendency to gangrene, the poultices ought to be of the cordial kind, into the composition of which porter, wine, or opium, should enter. If the cutis opens, yet leaves the chalky effusion confined by the cuticle only, a puncture should be made. It is imprudent to touch;with a lancet the organized cutis, or even to make a large opening into the cuticle to expose parts in so precarious a state. Even a small puncture will permit some portion of the fluids to escape, and more will run out into the poultice. The tension is then removed, and the symptoms commonly improve. After the violence of the fit has subsided, an ulcer frequently remains with chalk in the bottom, which renders it extremely difficult to be healed. It is bad practice to attempt to remove the chalk by the knife, for a wound might occasion a renewal of gout, or at least a great deal of inflammation; and as the chalk is a solid substance, and dispersed in separate cells, very little could be removed by the incision. Caustics employed with caution answer better. We may add, that when gangrene does take place, the yeast poultice is the best application that can be used." In retrocedent gout, the relief of the suffering organ must be attempted by remedies which affect it primarily, and by others which tend to recall the gouty inflammation to the extremities. The means best calculated to attain the latter object are hot stimulating pediluvia or sinapisms, or both. Those which may be employed to fulfil the former, must vary in some measure with Ihe organ which suffers, and with the degree and character of the symptoms. When these are of an inflammatory kind, as happens when they have succeeded to acute and well-marked inflammatory gout of the extremities, those measures must be adopted which are known to be most efficacious in quelling common inflamma- tion of the suffering organ. When the stomach is affected, and the symptoms are of the kind referred to, local bleeding must be freely employed ; and if there vol. in. 75 594 gout (Prevention). be much pain, and incessant vomiting, as generally happens, opium must be given in full doses, and an effervescing draught is its best vehicle. In such cases we object to the use of more direct stimulants, unless there be alarming collapse. In the gouty affection of the stomach, which often alternates with that of the joints in chronic gout, and which is remarkably painful, and of the character of gastrodynia, stimulants are invariably successful. We have given, with uniform advantage in these cases, an ounce of tincture of rhubarb in one dose, allowing at the same time a pretty free use of brandy and water. But in all cases of retrocedent gout, in which the symptoms are urgent, it is right to attempt to recall the gout to the extremities by suitable means, before adopting more vigorous measures, since if we succeed, in the first instance, the relief to the internal parts will be complete, and the patient will be spared much painful and hazardous discipline. Prevention. We have seen that the chief causes of gout, setting aside heredi- tary disposition, are free living and sedentary habits; it follows, therefore, that the surest means of prevention are temperance and active exercise. When hereditary tendency is present, temperance especially should be strictly ob- served, and a preponderance of vegetables in the habitual food is also advisable. In short, those threatened with gout should imitate, as far as practicable and consistent with comfort, the habits of agricultural labourers. The application of these principles must be rigidly enforced when the occurrence of an attack of gout has ,already declared the existence of gouty diathesis. Field sports furnish admirable exercises for the higher classes, and are advisable in all cases in which gout has not injured the structure, or impaired the functions of joints. Perseverance in temperate and active habits will often wholly preserve from further attacks; but if it fail in this, still their frequency will be lessened, and severity much diminished. Much less can be done by the use of medicines. When, however, premonitory symptoms appear in persons who have had gout, the impending paroxysm often seems averted by a dose of blue pill followed by a mild draught of sulphate of magnesia and senna, and the observance of a low diet for a few days. We have seen this a great number of times in one of our patients, when the symptoms of impending gout have been of the most charac- teristic kind. Sir H. Halford states, that in regard to medicine he has had " incomparably the most satisfaction in giving a few grains of rhubarb and double the quantity of carbonate of magnesia every day, either at bedtime or early in the morning; or, under evident weakness of the powers of digestion, half an ounce of compound tincture of rhubarb with fifteen grains of the carbo- nate of potash in some light bitter infusion daily, before the principal meal." When the joints have been crippled by repeated and prolonged attacks, little can be done in the way of prevention, especially as exercise is impracti- cable, and the gouty diathesis deeply rooted. Here a warm climate seems to promise more advantage than any thing else. Haller and Van Swieten relate striking examples of success obtained by a few years' residence in the West Indies. Rome is a good European residence for gouty persons ; and Sir J. Clarke states, that Genoa is remarkable for the rare occurrence of the disease among its inhabitants. In the cases referred to, we strongly object to the prac- tice of entirely withholding wine or other stimulants from persons who have been long accustomed to their use. The prospect of benefit to the gout from this practice is very uncertain ; and it will be found that the patient is after- wards constantly ailing, and deprived of all comfort, if, indeed, no worse con- sequences ensue. Where indulgence in wine has been excessive, the supply of it may be restricted with advantage.* * Since this article was written, Dr. Holland's admirable volume of Medical Notes and Re- flections has fallen into our hands. In the chapter on gout and colchicum, we were much pleased to see developed, with great ability, views similar to many advanced in this article, especially as regards the nature of gout, and the use of colchicum. The reader will find, in Dr. Holland's chapter, some ingenious and valuable speculations on the hereditary succession of gout; on wine, as a cause of the disease ; and on the operation of colchicum as a remedy. WORMS FOUND IN THE HUMAN BODY. Parasites.—Origin of Worms.—Causes.—Seat.—Symptoms, local and constitutional.—Morbid appearances caused by worms.—General treatment.—Classification of worms.—Particular species.—Acephalocystis endogena.—Acephalocystis multifida.—Echinococcus hominis.— Cysticercus celluloses.—Animalculi echinococci.—Diplosoma crenata.—Taenia solium.— Bothriocephalus latus.—Distoma hepaticum.—Polystoma pinguicola.—Trichini spiralis.- Filaria Medinensis.—Filaria oculi.—Filaria bronchialis.—Triocephalus dispar.—Spiroptera hominis.—Dactylius aculeatus.—Strongylus gigas.—Ascaris lumbricoides.—Ascaris vermi- cular is. It would appear to be a principle in the economy of Nature, to which per- haps few exceptions will be found, that every species of animal, either during life or after death, shall be subject to the depredations of some other species. The final purpose to be served by such a law, in providing for the removal of dead animal bodies by the reconversion of their decomposable materials into living structures, appears to be of a twofold nature; first, to prevent the injurious consequences which would result to living species from the extrication of noxious gases accompanying chemical decomposition ; and secondly, which is of far higher importance, to provide a supply of matter already organized, and therefore capable of being more readily assimilated to the textures of those animals which are destined to feed upon it; for by this means the organic particles of decomposing animal bodies are rescued, as it were, in their tran- sitorial stage, and brought back again to life, before opportunity is afforded for them, in the ordinary course of chemical decomposition, to pass over to the mineral kingdom. But the occupancy of living bodies by parasites presents us with a more remarkable and Jess understood feature in the law of predation, one indeed for which it is difficult to find a satisfactory explanation, unless we regard it as a provision, by which the stronger and generally more highly organized species are destined to afford protection and nutriment to the weaker; a provision which, while it in some measure tends to counterbalance the more ordinary rule of the weaker yielding to the stronger, at the same time contributes to fulfil another recognised principle of Nature, that " every situation which is capable of supporting living beings shall be peopled with them.'' But whatever may be the final cause, it is an admitted fact, that almost every species of animal is liable to be infested by its peculiar parasite or para- sites, which are developed in and protected by its various textures, and draw their sustenance from its juices, while man is so far from constituting an ex- ception to the general rule, as to be subject to a greater number of parasites than any other living being. Some of these are limited to the surface of the body, and cause but slight inconvenience; others penetrate the skin, and produce more or less irritation; while the greater number occupy the internal parts, and give rise to symptoms varying in character and intensity, according to the nature and position of the parasite. The frequency with which these parasites occur, and the variety of disorders which accompany their presence in the human body, demand for this subject 596 worms (Origin). the attention of every medical practitioner. It is not, however, our intention to describe every species of parasite which has been discovered in or upon the human body. The external parasites require little or no attention from the practitioner; while of the internal, many, such as the larvae of numerous insects, are of only occasional occurrence, and their presence must be considered acci- dental. But it is to those genera and species whose fixed and frequent occur- rence in the human body entitles them to be considered as the peculia r parasites of man, that our observations will be mainly directed, still, however, not ex- eluding others, which, though of rare occurrence, nevertheless are clearly entitled to be associated with them. These internal parasites, to which the term Entozoa, or the more familiar one of Worms, has been generally applied, we propose to treat of under the follow- ing subdivisional heads: 1, the origin, causes, and seat of worms; 2, the symptoms and morbid changes which accompany their presence; 3, their treat- ment ; 4, their classification ; and lastly, under the head of each separate genus or species, will be given such particulars in relation to their characters, struc- ture, symptoms, and treatment, as may appear most conducive to a practical knowledge of the subject. Origin of worms. This is a point upon which much difference of opinion is found to exist among helminthologists, for while some adduce the entozoa as presenting examples of spontaneous or equivocal generation, others contend for their external origin in all cases, while others maintain a somewhat intermediate position, and, allowing the origin of the entozoa in distinct ova, contend that these are transmitted from the parent to the foetus in utero, through the medium of the circulation. It would not accord with the objects of a practical work to enter at any length upon a question involving so much speculation; but a few of the more important points, which have been advanced, may be noticed. Those who contend for an internal origin, whether by spontaneous production, or by the developement of transmitted ova, consider that this view is supported by the fact, that while the number of known entozoa is very great, yet that each species is for the most part limited to particular animals, and appears in no others, thus presenting an uniformity in this respect, which it would be difficult to reconcile with the notion of a promiscuous external origin. That the struc- ture of the entozoa is such as renders them fit to inhabit only such situations as the bodies of the animals in which they are found ; that their frequent existence in various structures of the body, having no external communication whatever, negatives the idea of an outward source; and that their occasional occurrence in the unborn foetus must remain equally unexplained, unless either their inter- nal or spontaneous origin be admitted. On the other hand is to be noticed the singular fact, that many of the entozoa are remarkable for the great developement of the reproductive organs, many possessing distinct sexes, and most of them true ova, which it is not difficult to imagine would become developed in those situations and those only which would afford them an appropriate nidus, while no purpose would appear to be answered by the possession of an extensive generative system in an animal capable of spontaneous developement. The singular fact also that individuals visiting articular countries may become infested by the species of entozoa peculiar to that country, has been repeatedly ascertained, and must be regarded as milita- ting greatly against the idea of any other origin than an external one, at least in those particular instances. Some of these contending views might perhaps be reconciled by a more strict limitation, or particularization, of the objects to which the general argument has been applied; for the class entozoa contains animals, which in many instances may be said to possess little or no character in common beyond the mere cir- cumstance of their inhabiting the bodies of others. Some have well developed and distinct organs for nutrition and reproduction; others consist of a more solid parenchyma, in which these parts are as it were but sketched out in a rudimental form; while others again, still more simple in structure, consist only worms (Causes). 597 of a granular membrane, in which it is impossible to trace any of the structures possessed by the hig*her classes. With so great a variety of form and organi- zation, it may well be supposed that there exists a corresponding difference in the mode of reproduction of the entozoa, sufficient to account for their presence in the various parts of animal bodies in which they are found, without having recourse to the idea of a spontaneous origin. All those for example which are found in the alimentary canal may be sup- posed to have been introduced in the form of ova, which required only a suitable nidus for their developement; and their subsequent multiplication there is easily effected, whether their ova be the product of separate sexes on the same indi- vidual as in tenia, or in different ones as in ascaris. Nor can the possibility of an external origin be altogether denied to worms inhabiting any organ having an external outlet, though remote, such as the urinary or even gall-bladder. The subject becomes more obscure when we regard the occupancy of parts having no external communication, such as the cavity of the eye or the muscu- lar or cellular texture, and that also by worms of considerable size. It seems to us, however, that all these cases may be reduced to two condi- tions. We may suppose that there has been either a penetration of these parts from without by the parasites, or that their ova or germs, under whatever form, have circulated with the blood, and afterwards escaping from the general course of that fluid, have been deposited in the remote situations in which they are found. In a subsequent part of this essay will be given evidences in favour of this power of certain species to penetrate textures. In the case indeed of the Guinea-worm, the evidence in favour of this power of penetrating to the cellular texture from without is so strong, as to have led many observers to adopt a thorough conviction of its external origin, and some even to believe in the pos- sibility of its being communicated by contagion ; and until these evidences can be set aside, there appears to be no difficulty in allowing an external origin to worms inhabiting even the globe of the eye, or similar positions. On the other hand, in the case of those parasites which occupy positions that are clearly unattainable in this mode, they will be found to consist chiefly of those slowly organized genera, of whose mode of propagation, and of the nature of whose germs we know but little, and which are therefore not calculated to throw much light upon this question either way; or, as in the case of the minute trichina spiralis, the ova may fairly be supposed to be so small as to present no difficulty in reference to the notion of their circulating with the blood. It is not, however, so much our object to enter into the merits of an unsettled question in physiology, as it is to draw attention to those points, by a more extended examination of which it may be expected that the question will be ultimately set at rest. Causes. The circumstances which favour the production of worms, no less than their direct origin, are involved in much obscurity. It would appear from the perfect adaptation of the entozoa to the peculiar situations in the bodies of the animals which they inhabit, that they are as much indigenous, so to speak, to those situations, as particular plants are to the particular districts or coun- tries in which they are found; and that their germs, be they of whatever nature, are equally dependent for their developement upon certain external conditions, as are the seeds of a plant upon the nature of the climate, or the quality of the soil from which they spring. This analogy, indeed, would not inaptly furnish us with a guide to the investigation of the circumstances which favour the pro- duction of the entozoa, in so much as relates to locality, climate, season, and the like influences, as well as in considering the nature of the nidus and pabulum which are most favourable to their developement and growth. With regard to the influence of locality and district, it has been distinctly ascertained that certain species are found in certain districts only, and in no others, but that individuals visiting those districts are as liable to be infested by 598 worms (Causes). these particular worms as the native inhabitants, and may carry them away to other parts. This is the case, for example, with the Guinea-worm, which is not uncommonly found in certain parts of Africa and Asia within the tropics, and where the European resident becomes equally liable to it with the native inhabitants. It would even seem to prevail occasionally in an epidemic form, as appears from the account given by Sir James M'Grigor of the 86th and 88th regiments while resident at Bombay. The first of these regiments had con- tinued quite free from the disease until the monsoon set in, when no less than 300 of the men were attacked by it; and, still more remarkably, the second, that replaced the first, and which after remaining two months at Bombay embarked, and were attacked while at sea to such an extent, that nearly half the men became affected. The tenia and bothriocephalus also afford another striking example of the effect of climate, or district, in the localization of species. These two forms of tape-worm nearly resemble each other in general conformation, but differ in certain particulars, which will be subsequently noticed. The bothriocephalus latus, however, is met with only in Switzerland, Poland, and Russia; while in England, France, Holland, and Germany, the tenia solium alone prevails; and in those parts of France which border upon Switzerland the inhabitants are infested by both forms. With regard to season and climate, as influencing the production of worms, there appears to be a pretty general belief, that a moist or damp atmosphere is favourable to the production of worms. If this be true, their greater frequency in Holland and Switzerland might be explained by reference to the humid atmo- sphere of those parts; and this accords with the observations that, in many of the fenny parts of England, the residents are much troubled with the ascaris vermicularis. Certain it is that, in many animals, the developement of worms can be distinctly traced to the influence of these causes, as in the case of sheep, which invariably become the prey of parasites if placed in too damp a pasturage; and the ancient observation of Hippocrates, that worms are more prevalent in autumn than at other seasons, might meet with a similar explana- tion. So far then the production of worms in the human body appears to be influ- enced to a certain extent by the remote operation of climate, season, and locality. But the inquiry becomes the more interesting when we attempt to trace their origin to less remote causes. When we come to inquire how far their presence may be accounted for by reference to the nature of the food taken into the bodies of those animals upon which they are parasitic; and how far their well being in those situations most favourable to their developement and growth is to be accounted for by reference, on the one hand, to a pre-existing favouring con- dition of the parent body, or, on the other, to a state of constitution which, while it is that which is the most appropriate to the parasites, may have been in a great measure, if not solely, induced by its presence. In reference to the first point, that is, the dependence of parasites upon the nature of the ingesta, it is clear that if we regard the origin of worms as in all cases external to the body, we should herein find the clue to their introduction in most cases at least; while it will be observed, that the subject loses all its practical interest in that view of it which attributes the origin of worms to a spontaneous production of them within the bodies of the animals which they inhabit; for so long as we believe in their external origin, we shall be naturally led to investigate the sources from which they may be supposed to be derived, and to seek the means of preventing their introduction. But it is to be regretted that none but very general observations have been made upon this point. Where the food taken is of such a nature as to be readily digested, and no more chyle is produced than is readily absorbed, there appears to be but little chance of the developement of worms; but the food being of an improper nature, and the powers of digestion inadequate to its due concoction, that state of the ali- worms (Seat). 599 mentary canal is induced which, from the imperfect absorption of the chyle and the too abundant secretion of mucus, is the most favourable to the nutrition of the parasites. Hence the observation of Rudolphi, that children who eat vora- ciously of coarse bread and potatoes, and similar articles of food, are more liable to worms than those whose digestive organs are less oppressed. Hence Mr. Annesley observed that the Hindoos, who live almost entirely upon rice, are so infested with worms, that not more than one in ten is free from them; whilst, in some parts, the combination of certain condiments with the daily food appears to be so essential to the prevention of worms, as to have given rise to that ancient law in Holland, which enacted as a punishment, that criminals should be obliged to eat bread without salt, in order that their bodies might become infested with worms. The second point of inquiry proposed with reference to the immediate cause of worms, namely, how far their developement in the body may depend upon a pre-existent favouring condition of constitution, affords one of the most difficult questions in helminthology. It appears, indeed, almost impossible to say, in any given case where worms are known to exist, and where their presence is ac- companied by constitutional derangement, how far that state of constitution might have preceded the existence of parasites; or, on the other hand, to what extent it may have been caused by them. Common observation shows that the presence of worms is, in most cases, associated with a debilitated state of con- stitution, though they occasionally exist in the robust and healthy : but the amount of their dependency upon such a state of constitution, or, on the other hand, the share which they may have had in inducing it, is not easily determined. The general law which has been attempted to be laid down, that parasites do not appear until the powers of the constitution are reduced to a certain standard, which is supposed to be favourable to their developement, is liable to so many obvious exceptions, as not, perhaps, to be of great value in physiology, at the same time it is that which every practitioner will bear in mind with advantage, since it is the one which will lead him to the most successful practice. For though, in many cases, no more may be required than the simple administra- tion of medicines calculated to remove the parasites, yet the co-existence, fre- quently, of a state of debility or cachexia, appears so obviously favourable to their recurrence, as to leave no doubt of the necessity of combining constitu- tional with local treatment. Nor can the obvious connexion of worms with a certain state of constitution be overlooked in reference to the fact, that age ap- pears to have a great influence over their developement, since in infants at the breast, and in adults, they are much more rare than in children in whom the tendency to their formation appears to be strong up to a certain age, generally the period of puberty, after which the habit of producing them appears sponta- neously to cease. Seat of worms. In reviewing the parasites of the human body and the various textures which they inhabit, it becomes difficult to fix upon any organ that may not afford a nidus for some one or more of them; for with the excep- tion of the more solid parts, few appear exempt from their influence. Each organ or texture, however, seems to have its peculiar parasite, which is also in most instances limited to that organ. The following table will show the textures usually infested, and the species by which they are inhabited. ( Ascaris lumbricoides. Small intestines - < Tenia solium. { Bothriocephalus latus, Large intestines - Trichocephalus dispar. Rectum - - - Ascaris vermicularis. C Diplosoma crenata. Urinary bladder < Spiroptera hominis. ( Dactylius aculeatus. 600 worms (Symptoms). Gall bladder - - Distoma hepaticum. Kidney - - - Strongylus gigas. Eye - - - Filaria oculi. j . ( Acephalocystis endogena. I Echinococcus hominis. Spleen and omentum - Echinococcus hominis. Ovary - - - Polystoma pinguicola. Bronchial glands - Filaria bronchialis. M . C Trichina spiralis. MuscIe I Cysticercus cellulose. Brain - - - Acephalocystis multifida. Cellular texture - Filaria Medinensis. Symptoms. Under this head it is intended to mention only those symptoms which are caused by worms in general, as contra-distinguished from those which are peculiar to each species, and which will be subsequently noticed in conjunc- tion with the description of those species. For convenience of description, the symptoms caused by worms may be divided into the local and the constitutional, though it may be difficult to draw an exact line between these two. The local symptoms vary according to the particular seat of the worms, the nature of the organ they inhabit, and the degree of impairment to its functions caused by the presence of the worms. The body may be infested by thousands of worms, and yet no symptoms whatever, either local or general, manifest themselves, so as to lead to any suspicion of their existence. This is the case with the trichina spiralis, whose seat in the muscular system. The trichina is generally found in such numbers as to defy all attempts at computation: yet their presence does not appear in the least degree to impair the functions of the texture through which they are scattered, nor was the presence of this worm in any of the cases on record even suspected during life. This circumstance may probably be explained by reference to the minute size of the entozoon, and also to the comparatively less importance of the muscular system in the animal economy. Where the worms are larger, and the parts which they inhabit more imme- diately concerned in the vital functions, the local disturbance is proportionally greater. Thus the brain and the liver each exhibit symptoms of the dis- turbance to their function, when they become the seat of parasites. But it is more particularly in the case of worms inhabiting the intestinal canal that we may expect to find the evidences of their existence from symptoms especially referable to those parts. Pain in the abdomen like that of colic, and situated chiefly near the navel, is often complained of, though pain is by no means an in- variable symptom of worms. Some indeed appear seldom to cause pain, as the tapeworm, which on account of the softness of its texture could hardly be expected to give rise to any very definite sensations, except such as might arise from its great length and bulk, interfering with the movements of the intestines. The ascaris lumbricoides more frequently causes pain, probably on account of its greater power of motion and firmer texture, and from the circumstance also of the body terminating in somewhat sharp extremities. The sensations, how- ever of gnawing, piercing, or creeping, thus produced, are by no means con- stant, and not peculiar to worms, as they have frequently led to a suspicion of their existence where none certainly were present. The symptoms become more marked when the worms find their way to either extremities of the canal, as when the ascaris lumbricoides gets into the stomach and excites vomiting, or the ascaris vermieularis accumulates in or near the rectum, and gives rise to the intolerable itching which characterizes in a great measure the presence of that species. The irritation thus caused, however, is frequently propagated to a distance along the alimentary canal, so that not only is the rectum or anus worms (Symptoms). 601 the seat of these distressing sensations, but the opposite extremity appears equally to sympathize ; hence the frequent picking of the nose and lips, causing these parts to swell and often to bleed violently ; the grinding of the teeth, especially in sleep, and similar marks of irritation. The functions of the bowels are seldom properly performed. The evacua- tions are unnatural in quality and quantity, and there is generally either a costive or relaxed condition of body : these states frequently alternate with each other. The evacuations themselves sometimes consist almost entirely of mucus, which by some is considered to be produced by the irritation of the worms in the intestinal tract, and by others to be the very cause of their existence there. This mucus is generally more abundant at the times when the worms are passed, and the evacuations are then occasionally tinged with blood. More frequently, however, it may be said, that the stools present no unusual or characteristic appearance. Much, however, will depend upon the extent to which the diges- tive powers may have been impaired, for where the stomach is weak, the food is often passed in half-digested masses, or appears but little altered, and the evacuations become extremely offensive from the decomposition of the alimentary matters and the accumulation of unhealthy secretions. When this is the case, there is generally also considerable swelling of the belly, chiefly caused by accumulation of flatus in the bowels. The appetite is impaired, or more often voracious, so that a much larger quantity of food is taken than can be digested. The tongue is often white and loaded, the breath heavy or fetid, and there is often an increased flow of saliva, with a disposition to sickness, or actual vomiting. The symptoms which indicate a disturbed state of the constitution, more remotely connected with the presence of worms in the alimentary canal, are so varied, that it is difficult to class them. The primary disorder of the digestive organs is often accompanied by a corresponding disturbance in other functions; and these remote influences are perhaps most frequently manifested in a dis- ordered condition of the cerebral system, as manifested in the frequent occur- rence of headache and giddiness, with ringing in the ears, disturbed sleep, with grinding of the teeth and sudden waking alarm ; and the prevalence of somno- lency, indolence, or ill-temper. The symptoms have, in some instances, run so high as to cause the case to be mistaken for one of hydrocephalus ; but the pain in the head, dilated pupil, convulsions, and other signs imitating the true disease, have suddenly subsided on the removal of the exciting cause. These cases however must not be confounded with those in which hydrocephalus and worms are co-existent, constituting a combination of not unfrequent occurrence, espe- cially in scrofulous children. Chorea appears to be a not infrequent concomitant of worms in the intestines, though the degree of dependency of the disease upon theirfpresence is not always easily ascertained : for it may be argued, that the subsidence of the disease on the removal of the worms might be more fairly attributed to the evacuation of the faulty secretions and the restoration of the parts to a more healthy condition. The spasmodic affection has sometimes assumed the more severe form of epilepsy, of which Bremser and others have related examples, though doubtless some of the cases related may have been more dependent upon the circum- stances just noticed than upon the mere presence of worms. The cases in which, however, these morbid conditions are the most unequivocally connected with the existence of worms are those in which the symptoms have suddenly disappeared after their expulsion, and when various plans of treatment, short of effecting this, have failed, as in a striking case related by Dr. Suck, in which a young girl had been suffering from a violent spasmodic affection of the eyes, to which furious delirium and convulsions succeeded, and who was cured on the expulsion of a large number of worms, but not until after various purgative and vermifuge medicines had been used without effect. More rarely, trismus, tetanus, and hysteria, and various affections of the senses, as temporary deaf- vol. in. 76 602 worms (Symptoms). ness and amaurosis, have appeared capable of being traced to the existence of intestinal worms ; and we have the authority of Hoffman for stating that aphonia may be produced by a like cause, the voice being suddenly recovered upon the expulsion of worms. The same author considers worms as capable of inducing temporary mental alienation. A disordered condition of the circulation is also an occasional attendant on the presence of worms in the intestines. The pulse is often feeble, and the general circulation languid, giving rise to coldness of the surface, especially of the extremities, accompanied by palpitation of the heart. In these cases the countenance is pallid and sallow, the eyes sunken, and surrounded by a livid circle. Occasionally there appears a temporary excitement of the circulation, constituting what has been denominated worm fever, which however is gene- rally observed in scrofulous habits, and assumes the form of hectic, and hence may be considered rather as a concomitant of that particular state of constitu- tion, than as having any immediate connexion with the existence of worms. When the digestive functions have been long impaired, the loss of balance between lymphatic and lacteal absorption becomes strongly manifested in the general atrophy which ensues. The adipose and muscular tissues are gradually wasted, and the dwindled limbs strongly contrast with the tumid and hard belly so frequently met with in scrofulous children. The intimate connexion of pulmonary affections with a disordered condition of the alimentary canal, which so frequently comes under the notice of the prac- titioner, receives a striking illustration in the case of worms. Numerous cases might be cited in which not only has the sympathetic connexion between gas- tric or intestinal irritation and pulmonic disorder been manifested in the com- paratively slighter forms of dry cough and dyspnoea as attendant upon worms, but some more severe affections have been noticed, such as pulmonary haemor- rhage, of which examples have been given by Mr. Rumsey in his observations on the coincidence of haemoptysis with worms in the intestines. (Med. Chir. Trans, vol. ix.) Morbid appearances caused by worms. The worms which inhabit the intes- tinal tract appear to be capable of inducing but very slight organic changes in the textures with which they come immediately in contact. For the most part their presence there is accompanied only by a greater or less accumulation of mucus, with some increased vascularity of adjacent textures; but even these appearances are often wanting. The soft texture indeed of these parasites is such as is not likely to produce any very marked changes in the adjacent tex- tures by causing serious injury to these parts; and even those worms which may be found adherent by their suctorious mouths to the mucous membrane, as the tenia and bothriocephalus, do not appear to excite much vascular action, except perhaps in the immediate spot to which they are attached. Both Brem- ser and Rudolphi doubt whether the ascaris lumbricoides ever cause any amount of irritation in the intestines. They never observed them adherent to the mucous membrane, but always loose, and generally enveloped in mucus, by which they are as it were insulated from the surface of the bowels and thus pre- vented from exciting inflammation. One species, however, the trichocephalus dispar, appears occasionally to do injury to the intestines, as in a case met with by Mr. Joshua Brooks (noticed in the fourth volume of the museum cata- logue of the Royal College of Surgeons), in which the worms were found in a living state upon and in the caecum, which was perforated, as it were, by a number of pin holes. A considerable portion of the internal coat was eroded. (Hunt., Mus. Gall. prep. 173. A.) The power of worms to penetrate into the abdominal cavity by perforating the healthy coats of the intestine in the human subject has been asserted, but is denied by Wickmann, Bianchi, Rudolphi, Bremser, and others, who consider that all the cases on record of worms found in the peritoneal cavity after death may be explained on the supposition that they had escaped by ulcerated worms (General Treatment). 603 openings in the gut, or had been allowed to pass in by apertures caused by the sloughing of strangulated intestine. That worms do occasionally perforate the intestinal walls, so as to escape into the peritoneal cavity in certain animals, as fishes, birds, and some mammals, is beyond dispute. This is the case with the ecchinorhynchus, for instance, whose armed proboscis seems to render it fully capable of such performance ; but it is difficult to understand how the ascaris lumbricoides with its simple suctorious mouth could penetrate the healthy intes- tines of man; nevertheless, the two following cases by M. Gaultier de Claubry may be quoted, as having been advanced in favour of such an idea. In a girl seven years old, who died of convulsions in six days, he found eleven of these worms in the general cavity of the belly, and the coats of the stomach perfo- rated with holes, in some of which other worms were sticking. In another child of the same age, who died in seven days of convulsions, he found thirty- six worms in the peritoneal sac, a great mass of them in the stomach, and twenty-seven of them making their way through holes in its coats. (Nouv. Journ. de Med. ii. 266.) In these cases it is quite possible that the worms had escaped after death, in consequence of post mortem softening of the coats of the stomach. In the following instance, however, it is probable that the worm escaped during life, though there is nothing to show that there had not pre-existed an ulcerated opening in the intestine by which the worm had escaped, the case therefore not differing from one of ordinary perforation of the gut and escape of its contents. A soldier in the Mauritius was seized with slight fever and severe pain, beginning at the pit of the stomach and gradually extending over the whole belly, which by the third day began to enlarge; bilious vomiting with costiveness and suppression of urine followed ; the belly continued to increase, and the man died on the fourth day. On dissection several quarts of muddy fluid were found in the sac of the peritoneum, the viscera were ag- glutinated by lymph, a round worm was discovered among the intestines between the umbilicus and pubes, and the ileum exhibited a perforation six inches from the colon, corresponding in size with the worm. (Med. Gaz. vol. ii. p. 649.) In Rust's Journal the case of a woman also is mentioned, who after a tedious illness vomited several of these worms and was then seized with a painful swelling in the left side, which in course of time suppurated, and discharged along with purulent matter three other worms of the same kind. Here therefore it would appear that the worms had gradually made their way from the bowel to the surface of the body, by slowly exciting in- flammation and suppuration with surrounding adhesion of parts, and so causing a cyst to be formed around the worms which subsequently opened externally. This property of inducing so much irritation in the parts in contact with the entozoa as to cause the formation of a cyst around it, has been hardly ever observed in the case of worms inhabiting cavities which have external openings ; but where the solid parenchyma of organs becomes the habitation of entozoa, then a cyst is generally formed, by which the worm is isolated from surrounding parts. This is the case when the liver, for example, be- comes occupied by hydatids; a more or less dense albuminous or cartilagi- nous cyst is developed, in which the hydatids are contained, either singly or in great numbers. Even the minute trichina spiralis has been invariably found to be enveloped in a small cyst, in which the worm lies coiled up, and the walls of which are generally strengthened by a greater or less deposit of earthy materials in its interstitial texture. General treatment. Under this head it will be convenient to point out the general principles which should constitute a guide in the management of cases of worms, and also to mention the principal medicines which have obtained reputation for their vermifuge properties, referring, however, to the description of the different species for particular plans of treatment appropriate to each. Some of the entozoa are necessarily not answerable to medical treatment, on 604 worms (General Treatment). account of their position, even could their existence be certainly ascertained ; others occasionally require manual interference for their removal; while those only which occupy the alimentary canal may be considered as within the in- fluence of remedial agents. The indications to be fulfilled in the treatment of worms are of two distinct kinds, the one having reference simply to the expulsion of the parasites, and the other to the correcting of that state of constitution which appears most favourable to their developement. Hence vermifuge medicines have been divided into the evacuant and the corroborant, according as they have been supposed capable of effecting one or other of these ends, and both these are included under the general head of Anthelmintics. The evacuant anthelmintics, or those which accomplish the expulsion of the worms, may be again subdivided into such as are simply purgative, and such as dislodge or destroy the worms by their mechanical action upon them. Of these, the purgative evacuants are those in most frequent use. The object of their exhibition is to remove, not only the worms themselves, but also the superabundant mucus in which they are often lodged, at the same time that they assist in restoring the healthy secretion. The purgatives may be either of the saline, oily, or drastic class, but in the employment of these some discrimination and caution must be used. Drastic purgatives are perhaps too commonly employed in the treatment of worms without due regard being had to the powers of constitution, and particular condition of the patient. Their frequent exhibition, if too long continued, is often attended by a degree of debility, which in itself will constitute one of the conditions apparently most favourable to the production of worms; and in all cases where there is much gastric or intestinal irritation, the drastic class of purgatives should be carefully avoided. Those in most frequent use are scammony, gamboge, aloes, colocynth, and calomel, which may be given singly or in combination. Their exhibition, also, in a large dose and at intervals, is more likely to accomplish the object intended, than when smaller quantities are more frequently exhibited ; and in some children, especially those of strong constitution, it is necessary to follow up this plan with great perseverance. The combinations with calomel are exceed- ingly useful by preventing the secretion of bile, and thus assisting in clearing away the superabundant mucus which lodges in the intestines. The saline purgatives are not usually much employed, but of these the sulphate of potash and common salt or sea water are considered the most efficacious. The oily purgatives, on the other hand, are deservedly in great repute—castor oil, cro- ton oil, and even the olive and other bland oils in large quantity, but especially oil of turpentine, which, for the expulsion of teniae, constitutes one of our best anthelmintics, acting both as a poison to the worm, and also as an evacuant. The mechanical evacuants have by some authors been much lauded, but their powers appear to have been overrated, and some have been proposed which certainly could not be exhibited with safety. Of mechanical evacuants, the two which have acquired the greatest reputation are cowhage and pulverized tin, zinc, or iron. Cowhage, or the hairs of the pod of mucuna pruriens, has long been reputed as a vermifuge, and though not much used in this country, appears to be still often administered in the West Indies. The pods are dipped in syrup to entangle the hairs upon their surface, which are then scraped off, and formed into an electuary, of which a tea-spoonful or more is given daily for three successive days, followed by a brisk purgative. This remedy-appears most useful in expelling the thread-worms, upon which it is considered to act mechanically, the sharp spines entering their delicate skins, and causing them to quit their position, their expulsion being afterwards effected by cathartics. As a mechanical means, the powder of tin appears to act in a similar way. This is a more ancient remedy ; at least it is mentioned by Paracelsus, though it does not appear to have been much used until it came to be generally intro- worms (General Treatment). 605 duced about a century ago by Dr. Alston, who prescribed it in doses of from half an ounce to an ounce mixed with treacle, followed by a purgative, which generally brought away the worms. These large doses, however, appear to have been abandoned, not more than from a scruple to a drachm being given for a dose three or four times a day, and followed by a purgative ; neither this, however, nor the former remedy, are now much employed in this country Several other substances, which have obtained more or less repute, appear to act by irritating or destroying the worms. Turpentine has been already men- tioned, which acts both as a purgative and also by poisoning the worms, as appears from their being expelled dead in almost every instance when this has been given. Dippel's animal oil and Chabert's oil appear to act in the same way, as probably do also the following—oil of juniper, essence of bergamot, camphor, tobacco, sulphuretted hydrogen and sulphuret of tin, valerian, assa- fcetida, garlic, bark of Geoffroya inermis, bark of pomegranate root, and root of male shield fern, together with certain bitters, as wormwood, tansy, chamo- mile, &c. It would not be difficult to extend the list of specifics, which have been pro- posed for worms, almost ad infinitum; and it may be doubted how far some of those just enumerated act as a direct poison to them, while it may be contended that the bitters act also as tonics by restoring the tone of the digestive organs, and thus might, with more propriety, be arranged under the second class of remedies, namely, Corroborant anthelmintics. It has been staled, that while^the first object in the treatment of worms is to effect their expulsion by the exhibition of such remedies as either act destructively upon thern, or expel them living, the second and almost equally important end is to prevent their recurrence by restoring the powers of the constitution when they may have been, as they often are, im- paired. For this purpose chalybeates have been preferred to any other form of tonics ; and their exhibition must be guided, not so much by reference to any precise mode of practice, as upon the general rules which would direct the prac- titioner in the exhibition of tonic medicines. When the stomach will bear it, we have found the carbonate of iron given in drachm doses mixed with treacle, twice or thrice daily, one of the most useful forms. In other cases, especially in females and delicate children, the milder preparations often prove more ad- vantageous, as the potassio-tartrate of iron in half drachm doses in solution, or the wine of iron. The Mistura Ferri and the sulphate of iron are preferred by many practitioners; the former especially appears to restore red blood rapidly, and is a very efficient remedy. But when all these have failed, and it is often necessary to try each in succession, we have found great advantage from the exhibition of the Liq. Ferri Superacetat. (prepared by Messrs. Drew and Hey- ward) in doses of five to ten minims, three times a day. The Tinct. Ferri Sesquichloridi will be occasionally found a useful form, particularly in females; or the natural chalybeate waters may be used, according to circumstances. In those constitutions which will not bear the exhibition of steel, and espe- cially in scrofulous children, the combination of powdered bark with carbonate of soda, in doses of five grains each, given twice or thrice daily, will often prove extremely serviceable. The necessity of a strict attention to diet, and the exclusion of all unwhole- some and indigestible articles of food, where this is possible, need hardly be insisted on ; but among the children of the poor, in whom it will perhaps be generally admitted that worms are the most frequently found, the practitioner will of necessity encounter great difficulties upon this point. 606 worms (Classification). CLASSIFICATION OF WORMS. No natural arrangement of the animal kingdom could ever comprehend such a class as the entozoa (evrog, intus ; £wov, animal); for the animals which have been thus indiscriminately grouped together, possess but one character in com- mon, which is derived from the circumstance of their inhabiting the bodies of other animals. Beyond this single part of similarity in habits and localization, they have no claim to be considered as a natural group ; for they differ widely from each other both in organization and in form : while on the other hand, many of the species so closely resemble others that are not of parasitic habits, but are found in totally different situations, as clearly to show, that the setting apart of a group of animals merely from the circumstance of similarity in their pre- dacious habits, while it constitutes an unnatural union of widely differing forms, must, at the same time, necessarily dissociate others which have the closest congeneric affinities. This view of the subject is the necessary consequence of a more perfect knowledge of the organization of the entozoa; and while for the sake of con- venience we still class them together as a peculiar group of animals, we may at the same time with advantage subdivide them, in reference to their more natural affinities. The following tabular arrangement presents such a subdivision. The ento- zoa of man are there arranged, according to their structural affinities, in three classes, which would again admit of further separation into orders. But since we have only to speak of the few entozoa which inhabit the body of man, no further division seems necessary. The locus, or peculiar habitat of each species, is subjoined to the generic and specific names. I. ENTOZOA HOMINIS.* Classis Psychodiaria (Bory St. Vincent). Genus 1. Acephalocystis endogena - - Liver, abdominal cavity. 2. Acephalocystis multifida - - Brain. 3. Echinococcus hominis - - Liver, spleen, omentum. Classis Stekelmintha (Owen). 4. Cysticercus cellulosae - - Muscle, brain, eye. 5. Animalcula echinococci - - Liver, in the echinococcus. 6. Diplosoma crenata - - Urinary bladder, 7. Taenia solium - - Small intestines. 8. Bothriocephalus latus - - Small intestines. 9. Distoma hepaticum - - Gall-bladder. 10. Polystoma pinguicola - - Ovary. Classis Cozlelmintha (Owen). 11. Trichina spiralis - - Muscle. 12. Filaria Medinensis - - Cellular tissue. 13. Filaria oculi - - Eye. 14. Filaria bronchialis - - Bronchial gland. 15. Trichocephalus dispar - - Caecum, large intestine. * This classification is a slight modification of that of Mr. Owen, in the Cyclopaedia of Anatomy and Physiology, vol. ii. p. 126, art. Entozoa. worms (Acephalocystis endogena). 607 Genus 16. Spiroptera hominis - - Urinary bladder. 17. Dactylius aculeatus - - Urinary bladder. 18. Strongylus gigas - - Kidney. 19. Ascaris lumbricoides - - Small intestines. 20. Ascaris vermicularis - - Rectum. ClaSS PSYCHODIARIA. This class includes the simplest forms of parasites with which we are ac- quainted ; so little indeed do they possess of the character of true animals, that some physiologists have been led to question the propriety of placing them at all in the animal kingdom. Those which here require notice are well known under the familiar name of hydatids, of which they constitute the simplest kind. They consist of a globular bag in which is contained a trans- parent fluid; the parietes being formed by successive layers of opaque con- densed albuminous matter. A power of growth by imbibition, and of repro- duction, by the developement of buds from either the outer or inner surface of this animal bag, constitutes the only features which appear to give these pro- ducts any title to be ranked in the same kingdom with the parasites of a higher grade, circumstances however in which they very nearly approximate to some of the lowest classes of vegetables. 1. Acephalocystis (a, xeipaX*], caput; xuCnj, vesica) endogena. This was denominated by Hunter the pill-box hydatid, from the circumstance that the young are developed between the layers of the parent cyst, and gradually protrude like buds from the inner surface, until they become detached and float about in its cavity, where they grow by the simple process of imbibition, and in turn produce other cysts from their interior. The term endogena, as expressive of this fact, is used to distinguish this species from the acephalo- cystis exogena of ruminant animals, which develope the young vesicles from its exterior surface. This form of hydatid presents no other kind of organiza- tion or structure than that just described. It appears to be nourished by the imbibition of fluids, and the fluids, and the transmission of them into the inte- rior through the membraneous parietes. This species of acephalocyst is by no means unfrequently met with in the human liver, where it will sometimes accumulate in immense quantities. It does not appear to injure the structure of that organ, for it is invariably found enveloped in an adventitious cyst, which forms no part of the animal itself, but appears to be thrown around by the action of the vessels of the liver, with the object of isolating the parasite, and so preventing its interference with the functions of the organ, which, however, generally become deranged when the hydatids are very numerous. From the particular mode in which these ani- mals multiply, it will be easily understood how a single cyst in the liver may contain a very large number of them; for as the parent cyst grows, successive cysts are perpetually forming in its interior, and these again giving rise to successive generations, until the primary cyst at length comes to contain many thousands of them. When the cyst in the liver becomes thus enlarged, it generally forms a prominent tumour, which points in the hypochondrium. And these cases have been occasionally tapped, where, on account of the great accumulation of fluid, the sensation of fluctuation was very distinct in the part; and by this means the cyst has been emptied of its contents, the smaller hydatids flowing through the canula, and the larger ones coming away in shreds. The diagnosis of these cases cannot be made with any certainty, and the treatment of them does not differ from that usually adopted when the functions of the liver are otherwise deranged. When the fluctuation is very distinct, and other circumstances are favourable, tapping affords a fair prospect of relief. For this purpose a large canula should be used, that it may not be 608 worms (Acephalocystis multifida—Echinococcus). blocked up by the hydatids sticking in the tube, and thus retarding the evacua- tion of the cyst. It is surprising how large a cyst may be permanently emptied in this way. A woman between forty and fifty years of age was for more than two years a patient in St. Bartholomew's Hospital. During the earlier part of this time she was tapped repeatedly, and as much as from two to three gallons of fluid mixed with hydatids were drawn off at a time. This woman died of another disease, and on post mortem examination the structure of the liver was found perfectly natural, and the remains of the empty cyst which had contained the hydatids reduced to the size of a walnut: no other cyst could be found in the liver. 2. Acephalocystis multifida. This we have ventured to name as a new species, conceiving it to differ from the foregoing in some important particulars. We are not aware that it has ever been met with or described previously. The preparation from which this description is taken is in the pathological col- lection of Dr. Farre, and was brought over to this country from Barbadoes, by the late Dr. Jones, who, it is to be regretted, has left no record of the case. The subject of it however is known to have been a coloured man named Bel- grave, who by his own exertions had amassed considerable property in Bar- badoes, and who had been subject to fits. The preparation consists of that portion of the brain in which the hydatids were found. They are seen occu- pying an irregular cavity about an inch and a half in breadth and nearly three in length, which is situated in one hemisphere of the brain, and extends into the lateral ventricle of the same side. Each hydatid occupies a separate cyst, the walls of which are formed of a thin and delicate membrane; but as all the cysts are in close apposition, a coarse kind of cellular tissue is the result, within which the hydatids are contained. Several of the hydatids are perfectly globular and vary in diameter from a quarter to half an inch. Others present an appearance of small buds or projections from the outer surface, which are contained in corresponding pits or depressions in the enveloping cyst, while others again have a true multifid character, consisting of several hydatids of an irregular pyriform shape, connected together by their elongated necks. Each of these however occupies a separate cell, the necks piercing the walls of the individual cells, and communicating with a common cyst, which may be supposed to have been the parent one. One of these groups of hydatids con- sisted of six united together. No structure whatever beyond that of a mere membrane could be discovered. There was no distinct head nor armature of any kind, but where the necks were joined the membranous parietes were con- tinuous, thus constituting as it were a compound or ramified bag. It would appear as if all the hydatids had been at first simply globular, but by a process of generation from the outer surface the little buds already metioned arose, and forming corresponding pits or depressions in the walls of the containing cell, thus assumed a compound form; the little buds growing into larger vesicles, and the pits enlarging into separate cells to contain them. 3. Echinococcus (sxmg echinus ; xoxxos bacca) hominis. This parasite, which closely resembles the preceding genus, is found in cysts in the liver, spleen, omentum, and mesentery. It consists like the former of a simple bag, which appears to be formed of two layers—an outer coriaceous one, and an inner transparent gelatinous tunic. To this inner coat are appended the singular bodies, termed the animalcules of the echinococcus, presently to be noticed, for which this genus is remarkable; and except in this particular it does not appear to differ from the simple acephalocyst. Class Sterelmintha. The class of solid or parenchymatous entozoa, Sterelmintha (sX.wivs, lumbri- cus; (frspsog, solidus), though more perfectly organized than the preceding, present worms (Animalcula echinococci). 609 nevertheless great simplicity of structure. They consist for the most part of a solid parenchymatous texture, in which are excavated, as it were, the canals or cavities which serve the purpose of digestion. They have no separate tegu- mentary system. They have but one opening to the alimentary canal, and the sexes are placed upon the same individual. 4. Cysticercus (xutfng, vesica; xfpxoj, cauda) cellulosa. This parasite is not common in man, though very frequently met with in animals, especially in the hog, when it produces the state of muscles called measly pork. It occurs in the muscular system, but has also been found in the eye. The animal is always enveloped in an adventitious cyst formed apparently out of the interfas- cicular cellular tissue of the muscles condensed by adhesive inflammation. It differs in structure from the acephalocyst in the circumstance of its possessing an elongated neck terminating fn a distinct and somewhat globular head. This head is armed by a small crown or double row of recurved spines, for the pur- pose of enabling the entozoon to pierce and fix itself to the soft parts in which it is found ; while around this are placed four suctorious discs or true mouths, through which the nutriment is imbibed and carried into the dilated bag which constitutes the body of the animal. It is in the circumstance of these distinct traces of organization about the head, that the cysticercus differs mainly from the acephalocyst, though both are confounded together under the common term of hydatid. But few of our museums contain speicmens of this entozoon; hence it must be considered as rare, though it appears to be more frequently met with on the continent. Rudolphi states that four or five examples occurred annually at the anatomical school at Berlin for several years. They have been most frequently met with in the glutsei, psoas, and iliacus internus muscle, and in the extensors of the thigh. Soemmering met with one instance in which it appeared in the anterior chamber of the eye, and a similar case is related by Mr. Logan, as having oc- curred at the Glasgow Ophthalmic Infirmary. In the latter case, the child who was the subject of it had suffered for a considerable period with ophthalmia, after recovery from which the hydatid was observed. Its movements could be easily seen through the cornea, and as it continued to grow, inflammation was again set up. It was thought desirable to attempt the removal of the hydatid by incision through the cornea: in the attempt the hydatid was ruptured, and the remains of it extracted by the forceps. It was so delicate as scarcely to bear the slightest touch. 5. Animalculi echinococci. These animalcules are chiefly remarkable for the position in which they are found, being apparently the parasites of a parasite. They are found floating loosely in the cavity of the echinococcus ; at least when the cyst is broken they float freely out, though from the nature of the armature about the head, it may be inferred that they have the power of attaching them- selves to the walls of the cyst in which they are enveloped. In a case related by Muller in which a cyst of this kind was passed with the urine, the animalcules which floated in the contained fluid of the cyst were found to present a circlet of hooks and four processes around the head. The posterior end of the body was obtuse. Some of the animalcules were enclosed in secon- dary cysts floating in the primary one; while others presented a sort of pedicle at their obtuse extremity, which had probably been a medium of attachment, and appeared to have been broken. Upon examining the body of a patient who died lately in the London Hospital, a large cavity was found in the liver, in which were contained from thirty to forty of these echinococci. Some of these were as small as a mustard-seed; the largest about the size of a musket-ball. All however contained the animalcules, some with and some without cysts. The animalcules measured about the ^th of an inch in length, and had the usual armature of spines about the head. It would appear therefore that the presence or absence of theso animalcules constitues the distinguishing feature between vol. in. 77 610 worms (Diplosoma crenata). echinococcus and acephalocystis, a distinction, which for the purpose of classifi- cation it may be well, in the absence of more extended observation upon the relative connexions of the enveloping cyst and its singular contents, toretain: for pathological purposes however the distinction is an unnecessary one. 6. Diplosoma (oWXoos, duplus; tfw^a, corpus) crenata. This parasite has been confounded with spiroptera hominis, to which however it does not bear the slightest resemblance; but the confusion has arisen from the circumstance of both having been passed from the urinary bladder of the same individual, whose case also constitutes the only example on record of either of these parasites oc- curring in man. The particulars of this case are recorded by Mr. Lawrence, in the Medico-Chirurgical Transactions, vol. ii. The female who is still living in St. Sepulchre's workhouse, has been subject for a period of thirty-five years to retention of urine, accompanied by various distressing sensations referred to the bladder and kidneys, and requiring daily use of the catheter. The passing of these worms dates from an early period in the history of the case, and appears to have commenced shortly after the introduction of a sound into the bladder, with a view to ascertain whether the symptoms were due to stone. It appears probable that the worms had been contained in a cyst in the bladder, which was ruptured by the instrument; as shortly after this event, they began to pass by the catheter, and the operation itself was attended by sensations on the part of the woman, which appeared to arise from the rupture of a cyst, and the libera- tion of worms into the bladder. The worms thus passed were of two kinds; one of which will be here described, and which though long known, yet from the uncertainty which ap- pears to attach to the precise nature of its organization, and the doubts which some physiologists have cast upon its title to be ranked at all as an organized being, has not yet been described under any definite name. This deficiency therefore has now been supplied, from a firm conviction derived from the exa- mination of numerous specimens, that the worm is a true entozoon, and there- fore deserving to be so entitled. This worm varies in length from four to six or eight inches, and is thinnest at the middle part, where it is bent at an acute angle upon itself, so that the two halves hang nearly parallel, and give to the entozoon an appearance as if two worms had been tied together by their heads. At the point opposite the angle there is always found a rough surface, as if at this part there was a point of attachment which had been broken. From this central point the body gradually swells out towards the extremities, but contracts again within half an inch of the end, and terminates at one extremity in a tole- rably sharp point, and at the other in a ragged end. The worm is solid throughout, consisting of a firm homogeneous texture of a white or yellow-white colour. The upper surface is convex ; the under is formed usually of two planes meeting at an obtuse angle, and leaving a longitudinal groove between them, in which is often found lodged a dark corneous concretion. Along the line of junction of the upper and under surfaces, there runs on the outer side a delicate membranous border, the edge of which is beautifully crenate, and upon examination with the microscope the crenatures themselves are seen to be also crenate. The worm is solid throughout, and has no trace of any internal organization, except that of a delicate white line like a nerve running through the centre of the body, and giving off a few small branches. There are no signs of a mouth, but from the circumstances of the central bent portion of the body having a rough surface, it may be presumed that the worms are not voided entire, and indeed it is probable that nothing but the opportunity of instituting a post mortem examination of the case will serve to clear up the nature of this singular product. The notion of Rudolphi, to whom specimens were transmitted for examination, that they are simply portions of lymph cast in this peculiar form in the internal parts, is not reconcilable with the circumstance of their being very unequal in size, and not by any means uniform in shape, and having worms (Symptoms of Tenia). 611 also the beautifully perfect crenate margin already described. We have been repeatedly also assured by the woman herself, that when first voided the worms may be seen to move, and that they are found to make their way to a distance in the bed. But very few specimens have been passed lately, and these only when the bladder has been previously injected, for which purpose warm water is occasionally used. The other form of worm passed will be described under the title of Spiroptera. 7. Tenia solium. The common tape-worm of this country is generally from five to ten feet in length, and in breadth from the fourth part of a line at its anterior part to three or four lines towards the posterior part, where it again diminishes. It is composed of numerous segments, which towards the head appear to be very slightly indicated, but are more marked lower down, where they become subquadrate, and at length elongated, so that the length of each segment exceeds the breadth. The head is small and somewhat flattened. In the centre of it is a projecting papilla armed with a double circle of hooks, and around this are four apertures of suckers, placed at equal distances, which constitute the true mouths by which nourishment appears to be imbibed. Each of the joints is also furnished with a pore situated in the centre of a small prominent papilla ; the pores occurring on either side alternately. These were formerly supposd to furnish each joint of the animal with a means of obtaining nutriment independently of the head, but are now generally believed to be connected solely with the generative system. From the mouth proceeds a canal or vessel on either side : these run parallel and near the margin of each segment, from one extremity of the ani- mal to the other, being connected by numerous transverse vessels, of which there is one at the top and bottom of each segment. These canals may be easily injected by a pipe placed in one joint, the injection running readily into several contiguous joints. It is supposed that some amount of nourishment may also be effected by cutaneous absorption. The generative apparatus in the taenia consists of a ramified canal or ovarium occupying the greater part of the centre of each joint, and containing the ova. From this a duct is extended to each lateral pore, to allow of the escape of the ova, and these latter are supposed to be impregnated, in their passage outward, by the secretions from a small vesicle furnished with a duct, which terminates at the same point as the oviduct. These worms are very rarely passed entire: single joints often come away, especially in children; or portions of two or three feet in length are voided, but it is very rarely that the portion on which the head is situated is thus passed. There appears to be no limit to the length to which the worm may grow. If we are to credit the older writers, many hundred feet have been attained, but there appears to be no reason to doubt that worms measuring sixty feet are of occasional occurrence. As many as eighteen or twenty worms have been passed in the course of a few days, but frequently they occur singly. The symptoms caused by taenia are in many instances not exhibited in a striking degree ; indeed, it not unfrequently happens that the passing of a por- tion of a tape-worm is, to the patient, the first indication of its presence. More frequently, however, the functions of the stomach and bowels are impaired. There is either a loss of appetite or a continual craving for food ; pains in the stomach and bowels are often complained of, and certain uncomfortable sensa- tions are referred to the supposed movements of the worm ; but, probably with the exception of those cases when the worm accumulates in tangled masses and so causes obstruction of the bowels, their presence cannot give rise to any dis- tinct sensations on the part of the patient. They cause, however, itching about the nose and anus ; and the bowels are either relaxed, or more often in a state of constipation. The constitution, is generally more or less affected. Giddi- ness, headache, stupor, dulness of vision, weariness and pains in the limbs, accompanied by pallor of countenance and emaciation, and indeed a general 612 worms (Treatment of Tenia). torpor of the system not unfrequently accompany the presence of this parasite; especially in the ill-fed, who appear to be more than others liable to become in- fested with this worm. The habit of passing portions of tape-worm will con- tinue with some individuals for a period of several years. In others all the symptoms subside rapidly, and the body is restored to a perfect state of health shortly after the complete expulsion of the parasite. It is by no means uncom- mon to observe a number of separate joints expelled at a time, especially in children ; a circumstance which has led to the mistake of supposing that each joint was a separate worm of some very different genus. Treatment. The remedies which have been found most efficacious in the treatment of tape-worm, are oil of turpentine and some empyreumatic oils ; the root of the pomegranate and of the male shield fern; zinc filings, and drastic purgatives. Many other anthelmintics have been proposed for the expulsion of this worm, but are either very inferior to these, or totally inefficacious. And of those just enumerated, the oil of turpentine appears to have obtained so decided a superiority in the practice of the present day, as to have almost en- tirely superseded the use of other remedies. The use of the oil of turpentine appears to have been first noticed by Mr. Maiden in the Memoirs of the London Medical Society for 1792; and though, since that time, it had been used by Dr. Sims, and also recommended in the work of Rudolphi, it does not appear to have been generally known to the pro- fession until the publication of a letter to Dr. Baillie by Dr. Fenwick in the Medico-Chirurgical Transactions, vol. ii., in which the author speaks of oil of turpentine as a new remedy, and relates several cases in which it had been exhibited with success. The quantity given in these cases was two ounces, which, if no evacuations were procured, was followed by another dose of one ounce, and this succeeded generally in bringing away the worm dead, in from half an hour to an hour afterwards. " From the general failure," he observes, " of purgative medicines in this disease, and from the worms being dead when they are passed, we may conclude that, besides its purgative quality, the oleum terebinthini is really poisonous to the taenia; but although destructive to the worms present, it does not appear to remove the tendency to generate others. And in reference to the largeness of the dose recommended, he remarks, that "its quick action on the bowels prevents its absorption, and, accordingly, we find in these cases no complaint of those affections of the urinary passages which have arisen from much smaller doses." With regard to the mode of exhibition, he recommends " to take either no supper, or a very light one the night before; to abstain from all food or liquid till the medicine has operated twice or thrice, or a worm has passed, and then to dilute freely through the day." The oil of turpentine is not now usually given in such large doses as here recommended. The dose for an infant, says Dr. Mason Good, is from half a drachm to a tea-spoonful given in milk; a child often or eleven years old may take an ounce without any evil effects in ordinary cases: but in delicate habits a full dose sits uneasy on the stomach, and disquiets the system generally, though in different ways: for it sometimes produces a general chill and pale- ness, sometimes a tendency to sleep, and sometimes an alarming intoxication. It is in small doses alone, as half a drachm or a drachm to an adult, that it enters into the circulation, and proves an acrid irritant to the bladder, often exciting bloody urine. The remote effects upon the urinary organs may in most cases be avoided, by taking care to give the turpentine in sufficiently large doses to insure its purgative action, and thus to prevent its retention in the bowels for so long a time as to favour its absorption; or, if it do not thus act, to combine it or follow it up with a dose of castor oil, the combination of half an ounce of oil of tur- pentine with an equal quantity of castor oil, or double the quantity of olive oil, will be generally found to accomplish the intended object with little, if any of worms (Treatment of Tenia). 613 the unpleasant effects attaching to the use of this remedy. The sense of giddi- ness and intoxication, however, appear in most cases to be the unavoidable accompaniments of this medicine: they are generally only of short duration, but will sometimes continue for several days afterwards, accompanied by head- ache, and must in that case be combated by gentle purgatives as long as the unpleasant sensation continues, and any smell of turpentine remains in the urine. To avoid the occurrence of gastric or intestinal, or urinary irritation during the use of the remedy, it is desirable to take freely of broths and muci- laginous decoctions ; and, to avoid sickness, the patient should remain at rest; and take the medicine two or three hours after a full meal rather than upon an empty stomach. It is frequently necessary to repeat the medicine two or three times, with intervals of a day or two, and, when half an ounce is not sufficient, to increase the quantity to an ounce or even two ounces where the constitution is strong; but this larger dose is not often required, and should not be exceeded. The turpentine, when given alone or combined with castor oil, is most conve- niently exhibited in milk, or in some of the aromatic waters. The various forms which have been proposed for making it into an emulsion are objectionable, both on account of their proving more offensive to the stomach than the plain oil, and, also, from the minute subdivision favouring absorption into the circula- tion, and diminishing the purgative power of the medicine. Chabert's empyreumatic oil, though not much known in this country, appears to have attained a high reputation on the Continent as a vermifuge in the treat- ment of taenia. Rudolphi considers it as the very best of all vermifuges, and Bremser attaches a very high value to it. The observations of Chabert on its efficacy in expelling worms from oxen, sheep, and dogs, appears to have led to its exhibition in man. The oil is prepared by mixing together one part of empyreumatic oil of hartshorn with three of oil of turpentine, and, after allow- ing them to stand three days, distilling off three-fourths of the mixture by the aid of a sand bath. It appears to be very similar in its effects to the oil of tur- pentine, but is even more unpleasant to the taste, especially after being exposed to the air, when it becomes blackened, and is rendered thicker and more nau- seous. According to the experience of Bremser, who has used Chabert's oil in many hundred cases, it not only has the advantage of destroying the worms, but also appears to exterminate their ova, and thus effects a permanent cure; as the proportion of cases in which the parasite was found to return was not more than one per cent, of the number treated. He has given it to children of a year and a half old with impunity. He begins his plan of treatment by the exhibition of a purgative electuary, and then gives two tea-spoonsful of the oil in a little water, night and morning, and when, in the course of a few days, about three ounces have been taken, a purgave is interposed, and the oil resumed until from four to six ounces altogether have been consumed, lie recommends during the time a moderate diet, and cautious use of farinaceous food and fatty substances. The worm is not generally expelled, immediately and entire, as after the use of turpentine, but appears to remain and become partially digested and disorganized, and hence the efficacy of the treatment is to be gathered, rather from the cessation of the symptoms, than from the obvious expulsion of the worm, which, in many cases, could not be detected. This remedy is liable to the same objections as the oil of turpentine, and is apt to produce the same symptoms of irritation both in the digestive and urinary organs, and also in the cerebral system. These it is recommended to obviate by the same means and precautions as are to be followed in the use of turpentine; and some authors considers it safer to begin with a smaller dose than that recommended by Chabert; as half a tea-spoonful, gradually increased. The nauseous flavour may be in some measure covered by the addition of syrup of lemon, or by for- cibly rinsing the mouth afterwards with water, and then chewing a clove or piece of cinnamon ; or the oil may be made into small boluses, and swallowed enveloped in thin wafer paper. 614 worms (Treatment of Tenia). Dippel's animal oil, given in doses of a few drops in water or emulsion, and repeated two or three times daily, has proved efficacious in the treatment of some obstinate cases, but appears now to have fallen into disuse. The bark of the pomegranate root (punica granatum) has somewhat recently obtained reputation as a means of expelling taenia, though it is spoken of as a vermifuge by Celsus. The attention of the profession appears to have been called to it by a paper by Mr. Breton published in the Medico-Chirurgical Transactions, vol. xi. p. 301, and entitled, "On the efficacy of the Bark of the Pomegranate Tree in cases of Taenia." The author states that, "having observed in Dr. Fleming's catalogue of Indian medical plants and drugs, that the decoction of the bark of the pomegranate root is ranked as an efficacious remedy for the removal of tape-worm, he had afterwards an opportunity of putting its effects to the fairest test of experiment, and relates eight cases in which the remedy had been effectual in getting rid of the worms. The bark was used by him both in the form of decoction and powder. The decoction was, in the first instance, made by boiling two ounces of the recent bark of the root in a pint and a half of water, and reducing this to three-quarters of a pint. About two ounces of the cold decoction were given, and repeated four times at intervals of half an hour. About an hour after the last dose, an entire taenia was voided alive, measuring eight feet in length. A decoction, made with a similar quantity of the dried bark, was found to be rather too strong, producing giddiness, sickness, and uneasy sensations in the bowels, but equally expelling the worms. The dried bark in the form of powder, in doses of one or two scruples, mixed with an ounce of cold water, was given in other cases with similar results, and this form of exhibition appeared preferable on account of the greater mildness of its action. With a view to ascertain the nature of the action of this substance upon the taenia, some living specimens were placed both in the decoction, and also in the water with which the powder was mixed. The instant they were plunged in these preparations, they writhed and otherwise manifested great pain, and died in the space of five minutes. In plain water these worms will live several hours after expulsion. The use of the pomegranate root, both in this country and in France, appears to have borne out the favourable character which it had previously acquired in India, and both Cloquet and Martinet speak of it as being the remedy which in France is chiefiv trusted to for the expulsion of taenia. It is recommended that the medicine should be exhibited to the patient fasting, and should be followed by a purgative, as a full dose of castor oil. The root of the male shield fern (aspidium filix mas) spoken of as a vermi- fuge by Pliny and Galen, has acquired some notoriety in modern times. It constituted the basis of Madame Nouffer's treatment, whose secret was purchased in the last century by the French government at a large sum. In preparing the root, or underground stem, the outer part is to be removed, and also both extremities, that is, the upper greener part, and the lowest or oldest portion. The root is then to be pounded, and from two to four drachms of this taken in water. It is, however, a nauseous medicine, and requires to be long persevered in, and given sufficiently often to keep the bowels constantly full of it. Hence it is very apt to disorder the stomach. M. Peschier has recommended as a sub- stitute the oil of fern root, prepared by treating the root with aether. Thirty drops of this oil are equal to three drachms, or a full dose of the powder, and this quantity is recommended to be given in two portions, either in pills, or in the form of an emulsion. In those cases where it succeeded, the worm was expelled lifeless. The success of this remedy appears to be chiefly exhibited against the bothriocephalus latus, but in the treatment of the taenia of this country, its efficacy appears very doubtful. The efficacy of the oil shows that the action of the fern root upon the worm is not, as has been supposed, merely mechanical. Drastic purgatives appear to be of less value in the treatment of tamia than worms (Distoma Hepaticum). 615 in that of other worms. The exhibition, of purgatives has been shown to be in most instances a necessary accompaniment to other remedies ; but, given alone, they will very seldom succeed in effecting the expulsion of tape-worms, and should not therefore be given until other remedies have failed. Lastly may be mentioned zinc, either granulated or in filings. The action of this remedy appears to be purely mechanical. Hence, as might be supposed, the filings, from being sharper, have been found more efficacious in expelling the worms than the grains. Alston recommends an ounce of the filings to be taken in four ounces of treacle, a purge being first exhibited ; half the quantity to be repeated on the two following days, and lastly a purge to remove all. The granulated zinc is less apt to irritate the bowels than the filings. Tin has been used for the same purpose as zinc. 8. Bothriocephalus (/3o()piov, scrobs ; xsqjaXrj, capid) latus. This was formerly called tenia lata, but is now placed in a separate genus on account of the fol- lowing distinctive character. The segments of the body are broader than they are long, a circumstance which has given to the worm its trivial or specific name latus. The head is of a different form from that of taenia. It is small and elongated, and instead of the four round oscula characteristic of taenia, it has a longitudinal fossa or bothria on each side, which divides the head into two lobes; a minute pore, situated in the centre between these, is considered to be the mouth. In some species, however, there are certainly two pores or mouths, situated one at the extremity of each lobe of the head. The head is not armed with spines like that of taenia. The generative pores, instead of occurring alter- nately at the margins of the segment, are placed in a single row, one occupying the centre of each segment, a circumstance which gave rise to the two species being characterized as " taenia osculis marginalibus," and " taenia osculis super- ficialibus." In other respects, bothriocephalus does not differ from taenia, except perhaps that the former is less opaque than the latter, and when placed in alcohol has a semi-opaline or grayish tint. The bothriocephalus latus is peculiar to the inhabitants of Switzerland, Russia, and Poland, and of those parts of France which border on Switzerland. Hence it does not come under the notice of British practitioners, except as it occa- sionally occurs in the natives of those parts visiting this country, or in the case of our own countrymen who may have resided for a time abroad. This circumstance has been already alluded to as favouring the idea of the external origin of worms ; and although the truth of it has been questioned, yet several examples might be quoted in proof of the possibility of peculiar species being thus transported from one country to another. A case of this kind lately oc- curred in the practice of Dr. Latham. A young lady, a native of England, had resided for some time in Switzerland, where she became subject to tape- worms, some of which were passed by stool. After her return to this country she still manifested symptoms of worms, and this circumstance, with the knowledge of her former history, led to the administration of oil of turpentine, which brought away a portion of a bothriocephalus latus several feet in length. The symptoms and treatment of this species do not require to be noticed apart from what has been said of taenia solium. 9. Distoma (dig, bis ; Cro/xa, os) hepaticum. This is commonly termed the . fluke or liver fluke. Its seat is the gall-bladder and biliary duct, where it has been occasionally observed in man, and is very common in the same situation in many quadrupeds, especially in sheep, and is connected with the state called " the rot" in those animals. In form it is flattened, ovate, and elon- gated, somewhat pointed toward either extremity. Its under surface presents three cavities or apparent pores: the posterior one is larger than the rest, transversely oval and imperforate, being destined only for the purpose of ad- hesion or locomotion. The anterior pore, which is round and small, is the true mouth, and is connected to the body by a short neck. The middle pore 616 worms (Trinchina spiralis). is for the purpose of generation, and is, therefore analogous to the lateral pores of taenia, and the central pore of bothriocephalus. The animal is of a yellow or light brown colour. The centre of the body is mainly occupied by diges- tive canals. From the anterior pore or mouth the oesophagus is continued, forming, a short, wide and somewhat funnel-shaped tube, leading to a double intestinal canal. From the outer side of these canals short and wide caecal processes are sent off, which ramify to Ihe end of the body, but have no anal outlet. According to the observations of Rudolphi, when these digestive canals are successfully injected, more minute vessels may be seen to be con- tinued from their apices, ramifying and forming a network over the surface of the body, and thus presenting the rudiments of a vascular system. This parasite is supposed to feed upon the bile, or perhaps upon the mucus of the gall-bladder and ducts. Besides the digestive canal, there are separate seminal and ovigerous tubes which terminate at the pore already described; and from which there may be generally seen protruding, in the full-grown specimens, a small cylindrical process or lemniscus. Reciprocal fecundation takes place in these animals, and the ova escape by an aperture situated near the base of the projecting spiculum or penis. The flukes have been found in considerable numbers, but do not appear to give rise to any characteristic symptoms. They have been passed during life, as in the case of a girl twelve years old treated by Chabert, with his em- pyreumatic oil, which caused the expulsion of a great number of them. A second species of distoma was described by Rudolphi under the term lanceolatum, but is no more than the young of the distoma hepaticum. 10. Polystoma (xokvg, mullus; flVojxa, os) pinguicola. This has been met with but once in the human subject. It was discovered by Treutler in the cavity of an adipose tumour, connected with the left ovarium of a female aged 20, who died in childbed. The cavity was nearly filled by the worm. It is about three-quarters of an inch in length, flattened, and rather convex above, and concave below: truncated towards the head, and pointed towards the opposite extremity. On the under part of the head are six pores arranged in a crescentic form. A suctorious cavity is situated on the ventral surface near the tail, at the extremity of which is also another pore. Treutler has also described another species under the name of polystoma venarvm, which he states to have been found in the anterior tibial vein of a man which ruptured while bathing. But this was probably a planaria which had been accidentally introduced there. Class Coslelmintha (xoiXo?, cavus ; sX/xivg, lumbricus). This class comprehends the " cavitary" or hollow cylindrical worms, as dis- tinguished from the foregoing, which are the solid worms. They constitute a more highly organised group of animals, possessing a distinct alimentary canal, having its proper parieties separate from the walls of the body, and contained in a visceral cavity which is bounded by muscular parietes. The mouth and anus are always separate, and generally at opposite extremities of the body. The organs of generation are extensively developed, and are placed on separate individuals. Most of these species have also a distinct nervous system. 11. Trichina spiralis. This remarkable entozoon exceeds, in minuteness of form and in numbers, every other parasite of the human body. Its seat is the muscular system. It appears to have been first publicly noticed in 1833, by Mr. John Hilton, in a subject dissected at Guy's Hospital, the muscular system of which he observed to be studded with the minute cysts of the trichina, which he imagined to be cysticerci, but in which "no organization could be dis- covered with the aid of the microscope; probably on account of the opacity of the cysts preventing a view of the contained worm." (Lond. Med. Gaz., vol. worms ( Trichina spiralis). 617 xi., p. 605.) The entozoon itself, therefore, remained unknown until two years afterwards, when its nature was investigated by Mr. James Paget and Mr. Owen, on the occasion of the body of an Italian, which was infested with these para- sites, being brought into the dissecting room of St. Bartholomew's Hospital. The singular appearance produced in the muscular system had been previously noticed on several occasions, but no idea had been entertained of its animal nature, until the existence of the worm was satisfactorily demonstrated by the independent observations of Mr. Paget and Mr. Owen, the latter of whom published a minute description of the parasite in the Transactions of the Zoolo- gical Society of London, vol. i., p. 315, and named it accordingly. Our own observations on the minute structure of this entozoon will be found in the Lon- don Medical Gazette, vol. xvii., p. 382. Since the period of its discovery, the trichina has been observed in many of the subjects examined in the various dissecting rooms in London : but even still, on account of its extreme minute- ness, it is probably often overlooked. The cysts are generally so numerous as to give to the muscles in which they are found a peculiar gray speckled appearance, as if the part had been thickly sprinkled with the eggs of some small insect. They are seen to consist of minute white ovate grains, which require the aid of the microscope for their examination. If a small portion of the infected muscle be laid upon a strip of glass, or compressed between two glasses, and examined by transmitted light with a single lens of a half or quarter inch focus, or a compound power of an inch focus, the cysts are observed to be arranged with their long axes parallel to the course of the muscular fibre, and closely adherent to the interfascicular cellular tissue ; this adhesion being closest at either extremity of the cyst, so that they are not easily detached. The cysts are generally about one-thirtieth or one-fortieth of an inch in their larger diameter, and from one-third to one- half in their length in their shorter diameter. They are in form elliptical, attenuated towards the extremities, which are opaque and bulging in the centre, which is usually transparent. The opacity is due to the presence of earthy matter, which is often so abundant as to produce a gritty feel in pressing the cysts under the dissecting needle. When the cysts are sufficiently transparent, the outer cyst is seen to be occupied by an inner one of a more regular ellip- tical form, which by practice in the manipulation can sometimes be detached from the outer one: but, without this process, the inner cyst may generally be seen to be occupied by a minute worm coiled up in its interior, and disposed in from two to three spiral turns ; the two extremities of the worm pointing gene- rally to the centre of the short diameter. The cysts present many varieties in form; sometimes they have only one opaque extremity, and sometimes both are absent. In general, each cyst contains only a single worm ; but in one subject which we have dissected most of the cysts contained two worms; and one contained three. The cysts are often so opaque as to prevent the worm from being seen through its walls, and sometimes the cysts are found when cut open to contain only a granular fluid. The worm itself when extracted from the cyst, which it occupies in common with some granular fluid, and extended on a piece of glass, is found to measure generally one-thirtieth of an inch in length, and about one seven-hundredth of an inch in diameter. It is cylindrical and filiform, terminating obtusely at one extremity, but tapering toward the opposite end for about one-third of its length, and ending in a point. Accord- ing to our own observations, the worm possesses a distinct alimentary canal. Commencing from the large end of the worm, the canal is seen bounded by two slightly irregular lines, running parallel to each other for a distance of about one-third or one-fourth of the length of the body, where they terminate in a transverse line, presenting a slight concavity toward the larger end, and indi- cating the termination of the first portion of the canal. From this point the canal assumes a sacculated form, and these sacculi appear as if bound down by a line extending along the surface of the canal in the direction of its axis. This vol. in. 78 618 worms (Trichina spiralis). line is not dissimilar to the longitudinal bands of the human colon, but may possibly be a nervous filament. The sacculated character of the intestine be- comes gradually lost towards the smaller end, where the part assumes a zig- zag or spiral course, and at length terminates in the smaller end. In some instances where the worms were alive when examined, the intestine was seen to be drawn backwards and forwards several times within the body of the worm ; and if the worm be cut across, this part may be observed to pro- trude to a considerable extent from the divided extremity. An aperture was repeatedly observed at the larger extremity, which, when viewed laterally, had a notched appearance; and, occasionally, appearances were observed indicating a smaller aperture at the opposite end of the worm. At about one-fifth of the entire length from the blunt end, a small group of granules was, in most in- stances, observed occupying about half the diameter of the worm, and probably constituting an ovarium. The worms, if examined recently, are generally found to be alive, and will continue to live, sometimes, for several days after the death of the individual in whom they are found ; and, in one instance, they were observed to move after the portion of muscle from which they were ex- tracted had been immersed for a day in spirit. The singular locality of the entozoon, and the immense numbers in which it is found thus occupying the muscular system, suggests, more directly perhaps than any other species, the question as to its origin; but, unless we admit its spontaneous production, there is no other way for accounting for'its presence than by supposing that its ova or germs must have circulated with the blood, and have been thus distributed through the muscles ; and if we admit the little granular bodies already described to constitute the germs, then there is nothing unreasonable in such a supposition, since the size of these bodies is such ns to allow of their readily passing along the minute blood-vessels. It is considered by Mr. Owen that the trichina is not a distinct and perfectly grown species, but is probably the young of some other genus, perhaps a strongylus. All parts of the muscular system do not appear to afford an equally favoura- ble nidus for the developement of this parasite. The superficial muscles are found to contain them in far greater numbers than the deep-seated ones, and especially the broad flat muscles, as the pectoralis major and latissimus dorsi. They are generally present, however, in a greater or less degree, in all the muscles of the trunk and extremities, and have been found in those of the eye, and external and internal ear, in the tongue and soft palati, the constrictors of the pharynx and the oesophagus, the crura and the radiated portion of the dia- phragm, in the levator and external sphincter ani, and the muscles of the urethra. Indeed, the only muscular structures that seemed free from them were the heart and muscular envelope of the stomach, intestines, and urinary bladder, together with one or two other exceptions. The outer cyst, in. all probability, does not properly belong to the worm, but may be supposed to be formed around it by the adjacent parts after the usual manner of entozootic cysts ; but it may be questioned how far the inner cyst is formed in the same way, or whether it may not rather be looked upon as constituting a proper envelope to the embryotic worm. The history of the cases in which the trichina has been found does not afford any clue which might serve to explain the cause of their presence. They have been found equally in the diseased and in the healthy ; in those who have died from chronic disease attended by atrophy, and in those who have been cut off in robust health by some violent accident, as fracture of the skull. They have been also equally observed in the dead-house of the hospital when the examina- tion has been made a few hours after death, and in the dissecting room where it has been delayed for some days. No symptoms have been° in any case manifested during life which could lead to the supposition of their existence, and in all cases the individuals themselves appear to have been unaware of their presence. worms (Filaria medinensis). 619 To those who may have the opportunity of examining this remarkable ento- zoon, which appears to have been so long overlooked, probably on account of its minute size, the following observations, as to the best method of pursuing the investigation, may not be without use. To examine the worm, a very thin slice of the muscle, containing about half a dozen cysts, should be placed upon a slip of glass, with a drop of water. This being placed on the stage of the microscope, under a lens of a half or a quarter of an inch focus, one of the cysts is to be separated from its attachment to the surrounding cellular tissue, by means of a couple of needles fixed in handles, leaving it however adherent at one extremity, which serves to fix it, while the other is cut off by a cataract needle, or other fine and sharp instrument, so as to open the inner cyst, but without injuring the worm. This is the most delicate part of the operation, and requires some practice to effect it dexterously. As soon as the cyst is opened, the worm, which is free within it, generally starts out, from the pressure used during the operation ; or its expulsion may be effected by a very gentle pressure upon the opposite extremity of the cyst. Every thing being then removed from the glass except the worm, this is to be covered by a very thin piece of talc, taking care that there is sufficient water between the talc and glass to prevent the worm being injured by pressure. The object may then be examined by a power ranging from 200 to 500 linear measurement, always using daylight in preference to any other. These examinations should be made, if possible, upon the living worms, at least as far as the internal parts are concerned, since the natural appearances are often entirely lost when the worms are dead, or they are replaced by others, which are likely to convey erroneous impressions. The living worms, moreover, will uncoil themselves, so as to admit of their structure being more clearly seen than when two or three coils are lying over one another, as in the usual position of the animal. The uncoiling, however, may generally be effected by means of a couple of hooked needles. The cysts are best examined by placing the thinnest possible slice of muscle between two slips of glass, or one of talc and one of glass, and slightly pressing them, so as to distribute the muscle in a thin layer. If the edges of these are surrounded by white paint, so as to prevent evaporation, the specimens may be preserved for several months, but become at length decomposed. This method is far preferable to that of drying and placing them in Canada balsam, which renders the cysts too transparent. 12. Filaria medinensis. The Guinea, or hair-worm. This worm is de- veloped in the subcutaneous cellular texture, chiefly of the lower extremities, especially the feet, and in the scrotum, but has also been occasionally found in the abdominal and thoracic parietes, about the head, neck, arms, hands, and even beneath the conjunctiva of the eye. In length the worm varies from about six inches to twelve feet: its diameter, which is nearly equal throughout, is half a line or rather more, being a little attenuated towards the anterior ex- tremity, where the mouth is situated, surrounded by a slightly raised lip. The opposite extremity is obtuse in the male, and furnished with a spiculum ; but in the female it is acute, and more suddenly inflected. The body is round, sometimes of a whitish colour, but more often dark brown. The external tunic is of a fine elastic texture, and marked by minute circular striae, which are probably muscular fibres. Within this are readily seen the longitudinal mus- cular fibres arranged in two bands, and separated from each other by two longitudinal depressions, one on each side of the body, which are conspicuous externally. Dissection has, in many instances, failed in detecting either diges- tive or generative tubes in the interior of this species, though they have been frequently found completely filled with young, their generation being vivi- parous. These young filarix appear to be contained in the free cavity, or muscular envelope of the body, along with some granular matter, but without any specific covering, or enveloping tube; and Rudolphi states, that he has met with filarix thus stuffed with countless thousands of young progeny. 620 worms (Filaria medinensis). The worm appears to be capable of slowly changing the positions which it occupies in the cellular tissue, and probably its extrusion is effected by a process of inflammation and suppuration, as in the case of other foreign bodies. It usually occurs singly, or in small numbers. From ten to twelve, however, is in some localities not an uncommon number; and even as many as fifty have been met with in a single individual. It appears to be a parasite peculiar to warm climates, and is most abundant in Arabia, Upper Egypt, Abyssinia, and Guinea. It usually attacks the natives, but Europeans and others visiting these parts have occasionally become infected with it; and in some districts it has prevailed to such an extent as to affect one-fourth part of the population. The idea that it is capable of being communicated by contagion has been enter- tained by many who have had competent opportunities of making observations on that point; but as to the source from which it is derived, but little satisfactory knowledge has been obtained. It. has been supposed by some to be introduced in the form of ova in the drinking of stagnant water; and many writers have thus attributed its presence to the use of water of bad quality ; and it appears pretty certain that dogs kept in hospitals, and fed on the poultices with which the sores produced by filarise have been dressed, have become affected with this species. On the other hand, the native inhabitants, still attributing it to the water, and noticing its abundance in the rainy season, have generally supposed that it is introduced through the skin, especially while bathing : and it has also been observed that the water-carriers in India frequently suffer from this para- site, which more particularly infests the skin of the back at the part which is kept continually wetted by the leathern water-bottle being frequently in contact with it. The Guinea-worm does not appear generally to excite any very prominent disorder of the part immediately on its introduction, but may lie dormant, or perhaps undeveloped, at least without manifesting any signs of its presence, for a period of several weeks or months. The first symptoms are generally those of uneasiness, or itching in the part occupied by the worm ; which is sometimes attended by a slight cord-like elevation indicating its seat; to this succeeds the formation of a vesicle or pustule, which breaking and discharging more or less fluid, at length gives exit to the head of the worm, at the same time that a cer- tain amount of constitutional disturbance is often experienced by the patient. The suppurative process is often attended by considerable swelling of adjacent parts, and the pain experienced is at times very severe. The treatment consists in aiding the expulsion of the worm by careful manipu- lation. If the worm is short, and the texture of the part which it occupies loose, as the scrotum, it may sometimes be extracted at the first attempt; but more often its removal is a tedious process, extending over a period of many weeks. It has been usually recommended to allow the worm to make its way spontaneously to the surface, and then, as soon as any hold can be obtained upon it, to gently draw it forwards until some resistance is felt, and then to prevent its retraction by winding the protruded portion round a piece of adhesive plaster on a bit of stick or bougie, which is to be kept in contact with the aper- ture and covered by some light dressing, the attempts being renewed once or twice daily until the whole has been extracted. When the worm is seated near the surface, the process of extraction may be much accelerated by cutting down, as nearly as can be guessed, upon the middle of the worm, and so commencing the traction from its centre. The object of this caution in extracting the worm is to prevent its being broken ; an accident which appears to be generally followed by violent inflam- mation and the formation of abscesses and sinuses in its course, accompanied by much constitutional disturbance. These serious consequences were supposed by Hunter to be caused by the contact of the dead animal with a considerable extent of living surface: but from what has been said of the structure of the worm, it will be readily seen that its rupture, or breaking across, must be fol- worms (Tricocephalus dispar). 621 lowed in many cases by the escape of thousands of young filarie into the wound; a circumstance quite sufficient to account for the degree of mischief thus produced. The fistulous ulcer generally heals rapidly after the extraction of the worm. 13. Filaria oculi. This species was observed by Nordman in the human subject. A patient of Baron von Graafe had undergone the operation of extrac- tion, and the crystalline lens had been brought away with its capsule entire. On opening this half an hour afterwards, there were found in the liquor Mor- gagni two minute and deWcaie filarie coiled up in the form of rings. The more perfect one of these measured only three-fourths of a line in length, having a simple mouth, without projecting papilla, and the body so transparent as to allow of the straight alimentary canal being seen through the parietes, surrounded by the tortuous ovigerous tubes, and terminating in a curved anal extremity. A larger species of filaria is not unfrequently met with in the eye of the horse. 14. Filaria bronchialis. This, like the former species, has been met with only once in man, when it was observed by Treutler in an enlarged bronchial gland of a phthisical patient. The worm was about an inch in length, and curved somewhat in the form of the letter S; its colour dark brown with white spots. The body was somewhat flattened, attenuated towards the head, but obtuse at the anal extremity, which emitted a male spiculum. It is described by Treutler under the name of Hamularia lymphatica. (Opusc. Patlvol. Anat. p. 10, tab. 2. f. 3—7.) 15. Tricocephalus (Spif, capiUus; xecpaX>], caput) dispar. This worm is commonly found in the caecum and large intestine, but has been detected in every part of the alimentary canal as high as the pylorus. It is someiirnes called the long thread-worm. The body of the male, which is smaller than the female, is generally found spirally convoluted in the same plane. It measures, when uncoiled, from one to two inches in length. The anterior capillary portion of the body is exceedingly slender, and forms about two-thirds of the length of the worm : it is occupied along the centre by the simple straight alimentary canal, terminating in a small orbicular mouth. The capillary portion bulges some- what suddenly into the main part of the body, which contains a sacculated or moniliform intestine. The body terminates in an obtuse anal extremity, which in the male bears a projecting intromittent spiculum, furnished with a sheath ; but in the female exhibits only a simple foramen, serving for both anus and vulva. In the former, the tortuous spermatic vessels, and in the latter, the oviducts containing elliptical ova, are seen terminating at these points. Dr. Baillie speaks of this worm as of rare occurrence, not only in this but in every other country; and previously to the year 1760, when it was discovered in Germany, it appears to have been totally unknown. Yet there is probably no other human entozoon of so frequent occurrence as this ; and we must there- fore suppose, that on account of its comparatively delicate form it has been gone- rally overlooked. Of twenty-nine bodies examined by Dr. Bellingham of Dublin, at St. Vincent's Hospital, the worms were found in greater or less number in twenty-six. During the mortality of the cholera at Naples, M. Thi- bault took the opportunity of examining them, and in eighty cases examined, many of the individuals having died of other affections than the cholera, the worms were found in the alimentary canal in all without exception. And, according to Mr. Curling, during- the winter before last, they were delected at the London Hospital " in nearly all the cases in which much pains were taken in looking for them, in the intestinal canal of healthy persons destroyed by severe injuries, as well as those cut off by acute and chronic diseases." (Med. Chir. Trans, vol. xxii. p. 285.) They are often found in considerable numbers, and either loose, or having the long filiform anterior extremity of the body imbedded in the substance of the mucous membrane, while the posterior portion floats freely in the cavity of the intestine. It is remarkable that they do not appear, in most cases at least, to give rise to any symptoms indicative of their 622 worms (Spiroptera Iwminis—Dactylius aculeatus). presence : and that they are found as well in those who have died from violence or acute disease, as of more lingering affections. 16. Spiroptera Jurminis. This worm has been already alluded to as having been expelled from the urinary bladder of the woman whose case is mentioned under the head of Diplosoma crenata (p. 610). The spiroptera was met with only during the earlier progress of the case, and has long ceased to be passed, though the other form of worms by which it was accompanied is still occa- sionally evacuated. This worm is known chiefly by the description given of it by Rudolphi, to whom some specimens were transmitted in a phial for the purpose of examination. They were found to be of different sexes ; the males eight and the females ten lines in length, of a white colour, slender, and very elastic. The head, rather truncated, is furnished with an orbicular mouth, and one or two papillae. The body is attenuated towards each extremity, but espe- cially towards the head. In the female, the posterior extremity has a short obtuse apex, and is thicker than that of the male : in the latter, there is at this point a short tubulus, which is probably the sheath of the penis. Near the tail there is the dermal aliform structure characteristic of this genus. From the same patient from time to time have been expelled with the urine a number of granular bodies of tolerably uniform size, which are considered by Rudolphi to be merely " lymphatic concretions." From our own observations however of these substances we have no doubt that they are distinct ova, but whether belonging to either of the worms voided from the bladder, the circum- stances of the case do not warrant us in determining. They appear far too large to have belonged to the spiroptera, while with regard to diplosoma, no trace of ovarium, or indeed of any cavity or tube for the purpose of containing ova, could be discovered in this remarkable entozoon. The ova continued to be passed long after the spiroptera ceased to appear, and have now in their turn also ceased to be produced. The ova are about one-third or one half of a line in diameter. Those which have been long in spirit are of a brown colour, and have many flattened sides; but the more recent ones are white, and perfectly spherical. They consist of an external smooth covering of firm texture, enclosing a mass of granular matter. This investing tunic is found, upon examination with the microscope, to consist of an arrangement of cells of a most beautifully regular hexagonal form, which are more readily seen upon the inner surface, and in those parts which are the thinnest and most transparent; and as this structure may be observed in almost all the more recent specimens, which possess moreover the usual characters and form of ova, we cannot with Rudolphi regard them as accidental formations. 17. Dactylius (oaxj. pro fomentatione. Solve ft Tinct. Opii 3j. Aqua? ft>j. M. Fiat Lotio. (Anodyne and refrigerant.) ft Soda? Carb. 3ij. Extr. Opii gr. x. Calcis 3j. Adipis |ij. M. Fiat Un- guentum. (Prurigo.) R Lin. Camphora? Comp. gij. Tinct. Opii 3ij. M. An embrocation for the spine. (In Hooping-cough, also in Rheumatic and Neuralgic pains.) R Opii et Camphora?, aa 3ss. Empl. Plumbi q. s. M. A plaster to be applied to the breast. (Angina Pec- toris.) R Conii Fol. Exsic. gj. Aquae fbijss. Boil to Ifcij. and strain. For a fo- mentation. (In Scrofulous Ulcera- tions, Cancer, &c.) R Conii Fol. Exsic. Jij. Med. Panis gvj. Aqua? Fervent. ft>j. Boil to- gether to make a cataplasm. (Can- cer, &c.) R Extr. Belladonna? 3ij. Cerat. Cetac. 3j. M. Fiat Ung. (In Spasmodic Stricture of the Rectum, or Sphincter Ani, or Neck of the Bladder to be, rubbed on the perineum ; also in in-j flamed Piles, Scrofulous Swelling of the Joints, &c. and Dysentery.) R Extr. Belladonna? gj. Lin. Saponis gviij. M. Fiat Liniment. (Tic Douloureux, &c.) R Fol. Belladonna? gr. xij. Aqua? Fer- vent. 3vj. Macera. Fiat Enema. (In Spasmodic Contraction of the Urethra, preventing the introduction of catheter. The employment of this and all other forms of Belladonna re- quire much caution; their effects should be closely watched.) R Extr. Belladonna? 3ij- Aqua? Cal. 3viij. Olei Amyg. %iv. M. Fiat Lin. (In Acute Eczema and Impe- tigo : to be applied with a feather.) R Extra. Belladonnas 3j. Emp. Saponis 3ij. M. A plaster to be applied to the praecordial region. (Angina Pectoris. It should be renewed weekly.) R Tabaci. Fol. 3ij. Aquae Ferv. foiv. M. Strain for half an hour. A fo- mentation for the abdomen. (In Acute Dysentery, Lead Colic, &c. The fomentation to be continued till dizziness or nausea supervene.) R Acidi Hydrocyanici Dil. 3j.—iv. Decocti Malvae tbj. M. Fiat Lotio. (In Irritable Cutaneous Affections, to correct itching (Acne and Impetigo); in Ulcerated Cancer, to diminish pain. The bottle should be well shaken be- fore each application.) R Veratria? gr. iv. in alcohol, rn^vj. solutae; Adipis 3ss. M. optime. Fiat Unguentum. (In very painful Chronic Rheumatism, Neuralgia, Angina Pectoris, Gouty and Rheu- matic Paralysis, &c. about the size of a small nut, to be rubbed in night and morning. Its strength may be gradually increased to double the above. It causes heat and tingling in the part, sensations which some- times extend after a few days over the whole body, accompanied occa- sionally by muscular twitchings of the mouth and eyelids. Though it modifies so remarkably the sensi- bility of the parts on which it is 662 extemporaneous formula (Antispasmodics.) rubbed, it produces no external marks of irritation. It has sometimes caused Diuresis and Constipation; yet its internal use in the form of tincture and pill, in doses of from the six- teenth to the half of a grain has been resorted to by Magendie with success in cases of obstinate Constipation in old persons, and as a substitute for the eau medicinale, a practice which, however, from the virulent nature of the poison, we by no means recom- mend for imitation. The author just named has used it also endermically to the amount of a grain, applied to a small blistered surface over the course of the nerve, in violent tic of the face, the application being re- newed at a fresh point every fifth day. The experience of Dr. Cop- land and most others who have em- ployed it recently in painful affec- tions, by no means confirms the high eulogium passed on the ointment of Veratria some years ago; for, like other remedies, it very often disap- points us in these cases. Its ex- ceeding high price also limits its use. See Gully's Translation of Magendie's Formule.) R Aconitina? gr. ij.—iv. Alcohol. rt\,vj. Adipis 3ss. M. optime. Fiat Ung. (In similar cases to the above, and like it, its effects must be carefully watched.) R Liq. Potass. 3ij. Acid. Hydrocyan. Dil. 3j. Mist. Amyg. 3viij. M. Fiat Lotio. (In Prurigo; and also, omit- ting the Liq. Potass., in Eczema.) R Mist. Amyg. 3yj. Hydr. Bichloridi gr. j. Fiat Lotio. (To check the itching of Lichen, a drachm of dilute Hydrocyanic Acid may occasionally be added with advantage.) R Acid. Hydrocyan. 3ij.—iv. Aquae Distil. 3viij. Alcohol. 3iv. Acet. Plumbi gr. xvj. M. Fiat Lotio. (In Impetigo with excessive itching.) R Potassa? Cyanidi gr. xij. Mist. Amyg. 3vj« M. Fiat Lotio. (In Lichen aud other Chronic Eruptions attended with much pruritus.) R Potassae Cyanidi gr. xij. Olei Amyg. 3ij. Ung. Cera? Alba? 3ij. M. Fiat Ung. (In Lichen and Prurigo, when the skin is very dry and the pruritus severe.) R Cocculi Suberosi (Indici) 3j.—ij. Adipis 3j- M. Fiat Unguentum. (Porrigo Scutulata (Ringworm). Narcotic and stimulant. An Indian remedy of some celebrity in the same affection, consists of an ounce of Galls along with the same quantity of Lard, and one scruple of Sulphate of Copper.) III. ANTISPASMODICS. Of the substances which tend to put an end to irregular muscular contractions, some owe this power to their narcotic, and others to their tonic qualities ; the former apparently obviating, by their sedative influence, the irrritation on which spasmodic actions is so often dependent; the latter counteracting debility j a con- dition in which this morbid phenomenon is likewise peculiarly apt to manifest itself. Another set appear to act mainly by their stimulant nature, enabling them to make so strong an impression on the nerves of the suffering organ, as is sufficient to counterbalance the diseased excitement in which the spasm origi- nates. There are yet others, such as musk, castor, valerian, and assafcetida, which without being strikingly endued with any of the qualities just named, seem to exert a specific power of alleviating spasm. The change of action which they induce is not succeeded by any marked degree of collapse, as is the extemporaneous formula (Antispasmodics). 663 case with some of the other agents just now mentioned. Their influence, how- ever, being like that of narcotics, of a fleeting nature, they ought to be ad- ministered either immediately before an expected attack, or frequently repeated during its continuance. Narcotics themselves too, when given with the intention of counteracting spasmodic action, should be employed in full and reiterated doses. It is quite remarkable how freely opiates may be exhibited with impunity, and with the most beneficial results, in painful affections of this kind. When tonics, on the contrary, are resorted to with a view of obviating a spasmodic tendency, their use must long be persevered in, during the intervals of the attacks. In spasms of the stomach, especially when complicated with biliary derange- ment, a protracted course of calomel often succeeds in removing the morbid disposition after the failure of all the more ordinary remedies. Amongst the diseases to which antispasmodics are chiefly applicable, may be enumerated nervous palpitations, asthma, and angina pectoris, hysteria, chorea, epilepsy, tetanus, and hydrophobia, spasm in the stomach, diaphragm, and bladder, cholera, and colic, &c. R Mist. Assafcet. 3vss.; Tinct. Valer. Ammon. 3iv. M. Fiat Mistura. Take one-fourth of it every four hours. (In Nervous and Spasmodic Affections, Hysteria, Asthma, &c.) R Mist. Camphora? |v. Spirit. Ammon. Fcetid. 3v. Syr. Croci 3iij. M. Fiat Mist. Two tablespoonsful for a dose. ft Mist. Camphorae 3x. Tinct. Opii. nixl. Spirit. ^Ether. Sulph. 3j. Syr. Rhoeados 3j. Misce. Fiat Haustus. (In very painful Spasmodic Affec- tions, in Cramp of Stomach, &c.) ft Camphora?, Conf. Rosa? aa Bij- Di- vide in Bolus viij. Take one every four hours. (In Typhus, with mut- tering delirium and subsultus tendi- num.) R Camphors?, Potassa? Nit. aa Bj. Vi- telli Ovi q. s. Tere simul; adde Aqua? Flor. Aurant. 3iv. Tinct. Hyosc. et Tinct. Conii aa 3j. Fiat Mistura. Take a tablespoonful every three hours. (Chordee.) R Pulv. Valer. Rad. Bj. Pulv. Cinnam. Comp. gr. x. M. A powder to be taken every four hours. (In Hyste- ria, Nervous Headache, &c.) R Pulv. Ipecac. Rad. gr. iv. Soda? Carb. Exsic. Bij- Pulv. Opii. gr. ij. M Divide in Pulv. iv. One every six hours. (Spasmodic Asthma—Pertus sis of adults.) R Opii gr. j. Castorei gr. ix. Pulv. Digit, gr. ij. Pil. Scilla? Comp. gr. viij. Divide in Pil. iv. One three times a day. (Asthma.) Tinct. Assafcet. 3ij. Tinct. Castor., Tinct. Moschi aa 3j. Tinct. Opii TTlxxx. Fiat. Mist. TTlxxx in an ounce of mint-water every two hours. (Hysteria.) R Tinct. Castor. 3J- ^Ether. Sulph. fn_xx. Tinct. Opii TTlviij. Aqua? Cinnam. 3jss. Fiat Haustus. To bo taken three times a day. R Assafcet. 3j. Aq. Menth. Pip. 3vss. Tere optime simul. et. adde Tinct. Valer. Ammon. 3ij. Tinct. Castor. 3iij. Mlher. Sulph. 3j. M. Fiat Mistura. A tablespoonful every two hours. (In Hysterical Paroxysms.) R Valer. Rad. Pulv Bj. Tinct. Valer. Ammon. Tinct. Castor, aa 3j. Mist. Camph. 3jss. M. Fiat Haustus. To be taken three times a day. R Tinct. Opii TH.iij. Vini Ipecac. 3v. Syr. Tolut. 3iij. Sodae Carb. Bj. Aqua? Rosa? 3j« M. Fiat Mistura. A teaspoonful every four hours. (To infants in Hooping-cough, &c) R Moschi 3j. Oxid. Zinci 3ss. Extr. Valer. q. s. ut fiat Pil. xxx. Take three pills three times a day. (Epi- lepsy, &c.) R Moschi Bi- Pulv. Acac. 3ss. Tere 664 extemporaneous formula ( Tonics). simul, et adde gradatim Aqua? Cin nam. 3x. iEther Sulph. 3ss. M Fiat Haustus. To be taken as there may be occasion for it. R Mist. Moschi fj. Spir. Amm. Arom. 3ij. Tine. Castor. 3iv. Syr. Papav. 3ij. Fiat. Mist. Take three table- spoonsful every four hours. (In Hys- teria and Convulsive Affections, after purgatives.) R Moschi gr. x. Camphora? gr. v. Pulv. Opii gr. ss. Cons. Rosa? q. s. ut fiat Bolus. R Castorei Syr. q Bj. Ammon. Carb. gr. v s. ut fiat Bolus. (Hysteria. R Bismuthi Tris-Nitrat. gr. iv. Mag- nes., Sacch. Purif. aa Bij. Divide in Chart, iv. Take one every three hours. (Dyspepsia.) R Bismuthi Tris-Nitrat. 3ij Muc. Acac. q. s. ut fiat Pil. xxxvi. Take one every two hours. (Gastrodynia.) R Bismuthi Tris-Nitrat. 3J. Castorei 3ss. Pulv. Trag. Comp. 3ij. M. Divide in Pulv. xij. Take one three times a day. (In Neuralgic Pain of Stomach and Intestines, Pyrosis, Chronic Gastritis, Cramps, Diarrhcea and Vomiting of Spasmodic Cholera. For formula? for the Nitrate of Silver, the Sulphate and Ammoniuret of Cop- per, and the Salts of Iron, see Tonics and Astringents.) R Tinct. Digit. ttU. Tinct. Calumba? 3j. Mist". Camph. 1). M. Fiat Haustus. To be taken twice or three limes a day. (In Palpitations, with great nervous irritability.) R Assafcet. 3ij. Decoct. Avena? 3x. M. Fiat Enema. (In Flatulent Colic. This and the following ones to be administered tepid. One or two drachms of the aromatic Spirit of Ammonia and half a drachm of Tinc- ture of Opium may occasionally be added.) R Castorei Moschi aa 3ss. Pulv. Acac. 3ij. Tere simul, et adde gradatim Decoct. Hordei 3viij. Tinct. Opii nix. M. Fiat Enema. (In Hys- teria, Epilepsy, Typhus with sub- sultus.) R Camph. 3J. cum guttis quibusdam Spirit. Reclif. in Pulv. redactae; Vi- tel. Ovi unius ; Decoct. Hordei 3xiv. M. Fiat Enema. (In the adynamic stage of Fever.) R Olei Tereb. 3j. Camph. Rosa? Bj. 01. Oliv. 3jss- Vitelli. Ovi j. Spirit. Ammon. Foetid. 3ij. Decoct. Avenae Six. M. Fiat Enema. (Purgative and antispasmodic, in Flatulent Colic, Tympanites, &c.) R Tabaci Fol. Bj. Aqua? Ferv. 3viij. Macera per horam et cola. Fiat Enema. (In Ileus, Strangulated Her- nia, Tetanus, &c.) R Fol. Belladonna? Exsic. gr. xij. Aquae Calida? 3yj. M. Macera et cola. Sit pro enemate. (In Spasm of the Rectum or Neck of the Bladder.) R Lin. Camph. 3ij. Extr. Opii. Aquos. 3ss. Tere simul. Fiat Embrocatio. (To be rubbed along the spine in Hooping-cough.) R Lin. Camph. Comp. 3jss. Tinct. Canthar. Biv. Tinct. Opii oiij. M. Fiat Embrocatio. (To be rubbed over the abdomen in Colic, Cramp of Stomach, ice.) IV. TONICS. Tonics arc medicines, which, when judiciously employed, have the power of invigorating the functions of the body generally. They may be considered somewhat in the light of stimulants, of a slow but comparitively very perma- extemporaneous formulae (Tonics). 665 nent operation. Their beneficial results are to be sought for rather in their action on the vital principle than in any immediate chemical or mechanical change effected in the solids or fluids. Their influence, in the usual mode of their exhibition, is exerted, in the first instance, on the stomach and subse- quently by sympathy, aided in some cases by absorption, on more distant organs. When given in states of debility unaccompanied by any marked inflammatory tendency which should counter-indicate their use, they often dis- play, in a very remarkable degree, their power of strengthening the digestion and circulation, and adding tone to the enfeebled muscular system. When taken imprudently by the strong and healthy, or by those labouring under plethora, with alarming tendency to congestion of the brain and other internal organs, and even in cases where their use is injudiciously prolonged, how- ever suitable it may at first have been, they are capable of inducing event- ually debility of the digestive organs and other very disastrous consequences, of which numerous instances presented themselves at the time when the employ- ment of the celebrated Portland powder in the treatment of gouty patients was in vogue. Tonics are divisible, according to their source, into the vegetable and the mineral. Many of the most influential of the former are possessed of bitter and aromatic principles in various degrees: and it is such which exert the most beneficial effects on the stomach and digestive organs. It is in convalescence from fever and other acute disorders, and in intermit- tents, that the most beneficial effects of tonics are witnessed, provided the stomach and bowels be first ascertained to be free from inflammatory action. In nervous affections, as chorea, neuralgia, and a general morbid increase of nervous susceptibility, &c, they are often employed with great advantage, and especially quinine and those of the mineral kind. In inflammation of the chest, of an acute or subacute character, they are on the contrary, decidedly injurious ; and it is only in the more chronic stages of bronchitis, where the mucous secre- tion is in excess, that we can hope for any good from their use. In hectic they are occasionally resorted to as palliatives. In the advanced stages of rheuma- tism they are often a valuable resource. In the treatment of typhus fever, in its latter periods, they are important auxiliaries to stimulants; and those of a more exciting character, such as quinine, or some other preparation of bark with sulphuric acid, cascarilla, cusparia, or serpentaria, are here usually selected. In all cases where the effects likely to arise from the use of tonics are dubious, and especially where they are about to be administered for the relief of indiges- tion accompanied by marked irritability of the stomach, or in the course of con- valescences where there exists even the slightest suspicion of lingering inflamma- tion, or ulceration in the intestines, their use should be entered on, if at all, with the greatest caution, the mildest kinds, the aromatic and bitter, being first experimentally prescribed, and that in the most moderate doses, and an ascend- ing gradation of strength being subsequently resorted to, if the health is found to improve under their employment. Where it is desirable that they should be absorbed, it is particularly requisite that they should not be given in such a manner as to produce either general or local excitement. The most useful adjuncts during their exhibition will be found in a somewhat generous diet proportioned to the strength of the digestive organs, together with the cold bath, the enjoyment of pure cool air, regular exercise, assiduous fric- tion of the surface of the body, change of scene, rational amusement, and the indulgence of hopeful feelings. R Infus. Gentian. Comp. 3iij. Aquae Cinnam. 3j» Carb. Soda? Bij. Rhei. Pulv. gr. viij. Spirit. Lavand. Comp. 3ij. M. Fiat Mistura. A fourth vol. in. 8 part to be taken in the morning and at noon. (In Dyspepsia with acidity.) R Infus. Cascar., Infus. Rhei. aa 3iij. 666 . EXTEMPORANEOUS FORMULA ( Tonics). Aqua? Cinnam. 3iv. M. Fiat Haus- tus. To be taken twice a day. R Pul. Rhei Bj. Pulv. Capsici. Extr. Anthem, aa gr. x. M. Divide in Pil. x. One to be taken every day before dinner. R Pul. Myrrhae, Pulv. Rhei aa Bij. Aloes Spicat., Extr. Tarax. aa 3ss. Olei Anthem. fr\x. M. Divide in Pil. xxx. Two to be taken every night. R Pulv. Rhei, Potass. Sesquicarb. aa 3j. Pulv. Calumba? 3ij. Pulv. Arom. 3ss. M. Fifteen grains twice a day. R Pulv. Rhei, Soda? Carb. Exsic, Extr. Gentian, aa 3j. Pulv. Zing. Bj. M. Divide in Pil xl. Take two three times a day. R Infus. Gentian. Comp. Aq. Cinn. aa 3ij. Soda? Carb. 3j.; Soda? Potassio- Tart. 3j. M. Fiat Mistura. Take two tablespoonsful morning and noon. (Tonic and aperient.) R Infus. Gentian. Comp. 3'j- Liq. Cal- cis 3iijss. Liq. Potass. 3j. Tinct. Aurant. 3iij. M. Fiat Mistura. Take three tablespoonsful twice or three times a day. (In Acidity of Sto- mach.) R Infus. Cascar. 3vij. Tinct. Cascar., Tinct. Zing, aa 3iv. M. A stoma- chic mixture, of which three table- spoonsful are to be taken three times a day. (Dyspepsia with loss of appe- tite.) R Extr. Tarax. 3ss. Aqua? Menth. Sativ. 3jss. M. A draught to be taken at noon and in the evening. R Infus. Cuspar. 3j. Ammon. Carb. gr. v. Conf. Aromat. gr. x. Spirit. Armor. Com. 3j. M. Fiat Haustus. To be taken three times a day. R Ext. Tarax. gr. x. Infus. Calumba? 3j. Soda? Carb. gr. iv. Tinct. Cardam. Comp. 3j. Aqua? Pimenta? 3iij. M. Fiat Haust. To be taken three times a day. (Dyspepsia, Chro- nic Hepatic Affections.) R Extract. Gentiana? 3ij. Fellis Bo- vina? 3iij. Pulv. Rhei 3ij. Assa- fcetida? 3j. M. Divide in Pil. cxx. Take two or three, three times a day. R Infus. Cinch., Infus. Rosa? Comp. aa 3iv. M. Fiat Mistura. Take three tablespoonsful three times a day (In convalescences.) R Pulv. Cinch. 3ij Pulv. Valer. 3j. M. Divide in Chart, xij. Take one twice a day. (Neuralgia, Hysteria, Hemicrania.) R Decoct. Cinch. 3vjss. Acid. Sulph. Dil. 3j. Tinct. Cardam Comp., Syr. Aurant. aa 3vj. M. Fiat Mistura. Take two tablespoonsful three times daily. R Decoct. Cinch. 3jss. Extr. Cinch. gr. xv. Tinct. Cinch. 3j. Spir. Ammon. Arom. rt\,xxx. M. Fiat Haustus. To be taken every four hours. R Cinch. Lancifol. Cont. 3ss. Decoque ex aqua? purae 3xvj. ad consumpt. dimid., adjectis sub finem Coctionis Serpent. Rad. Cont. 3ij. Cola frigid. et Colatura? adde Spir. Cinnam. Comp. 3jss. Acid. Sulph. Dil. 3jss. M. Fiat Mist. Take four tablespoons- ful every four hours. (Pringle.) R Pulv. Cinch. 3ss.—3j. Pulv. Arom. gr. viij. M. Fiat Pulvis. To be repeated every four hours until four R Calumba? Rad. Incis., Cascar. Cort. Cont. aa 3}. Aqua? Ferv. 3yj. Ma- ce ra per horas duas et cola. Cola- tura? adde Tinct. Calumba? 3iij. Spir. Ammon. Arom. rq,xxx. Spir. Aurant. 3ij. M. Take a tablespoon- ful three times a day. (A light tonic in convalescences, after Fever, Dy- sentery, &c.) R Decocti Cinch. 3vij. Confect. Arom. 3jss. Tinct. Cinch. Comp. 3j- M. Fiat Mist. Take three tablespoons- ful every four hours. EXTEMPORANEOUS FORMULAE ( Tonics). 667 have been taken. (In Ague, in the intervals.) R Cinch. Cordifol. 3j- Antim. Potassio- Tart. gr. j. Opii Pulv. gr. j. M. Di- vide in partes iv. Give one every two hours. (Malignant Intermit- tents of Italy.) R Gtuinae Disulph. gr. iij. Sacch. Albi gr. vij. M. Fiat Pulvis. To be taken every three hours during the intermission. (Ague.) R Quina? Disulph. Bj. Extr. Cinch, gr. xv. M. Divide in Pil. x. Take one every three hours. R Quina? Disulph. gr. ij. Infus. Rosae Comp. 3x. Syr. Aurant. 3ij. M. Fiat Haustus. To be taken every four hours. R Q,uina? Disulph. gr. ij. Acid. Sulph. Arom. rrtxvj. Aqua? Distil. 3jss. Syr. Caryophyll. 3ss. M. Take 3j. —3ij. three times a day. (Tonic for very young infants.) R Q,uina? Disulph. gr. xviij. Acid. Sulph, Arom. mjx. Infus. Aurant. Comp. 3vj- Tinct. Cinch. Comp., Syr. Zing, aa 3j. M. Fiat Mistura. Take one or two tablespoonsful every three hours. R Decoct. Cinch. 3vjss. Acidi Hy- drochlor. 3jss. Mellis 3jss. M. Fiat Gargarisma. (In Cynanche Maligna.) R Cinch. Pulv. 3j. Anthemid. Flor. 3ij. Aquae Oj. decoque ad 3x. Cola et adde Vini Rubri 3ij. M. Fiat Enema. R Quinae Disulph. gr. xij. Acid. Sulph. Dil. n\,vj. Tinct. Opii fftvj. Aqua? Tepidae 3vj. M. Fiat Enema. (Where the state of the stomach does not admit of the exhibition of Qnina? Sulph. in the ordinary way. It may also be employed in the endermic method; two or three grains, mixed with a little starch being applied fresh every fourth or fifth hour to a blistered surface in the epigastric region,—or five or six grains with lard in the form of an ointment. When the Sulphate of Quinine has been applied alone and unmixed; it has been known to produce troublesome ulce- rations.) R Ferri Sulph. 3ss. Sacchari Albi 3jss. M. Divide in chart, xij. Signetur No. 1. R Soda? Carb. 3ss. Sacchari Albi 3jss. M. Divide in chartulas xij. Signetur No. 2. (One of each of these powders is to be separately dissolved in half a glass of water, the solution to be then mixed and drank off immediately. A substitute for natural chalybeate waters.) R Ferri Sesquioxid., Pulv. Calumba? aa gr. v. M. Fiat. Pulv. To be taken twice a day. R Ferri Sesquioxid, Pulv. Rhei aa 3j. Pulv. Calumba? Biv. Zing. Pulv. Bij. M. Divide in Pulv. xij. Take one three times a day. (In Tic-dou- loureux, Chlorosis, &c.) R Ferri Sesquioxid. 3iij. Pulv. Cin- nam. Comp. 3j. Syr. Aurant. 3j. M. Fiat Elect. Take a tablespoon- ful three times a day. R Ferri Sesquioxid. gr. x. Pulv. Valer. 3ss. Syr. Zing. q. s. ut fiat Bolus. To be taken three times a day. R Ferri Sesquioxid. 3jss. Pulv. Rhei gr. xv. Olei Anthem, rr^v. Extr. Gent. q. s. ut riant Pilul. xx. Take three morning and noon, drinking immediately after mjxv. Acid. Sulph. Arom. in a cup of water. R Ferri Sesquioxid. gr. xij. Extr. Cinch. Bj. Syr. Zing. q. s. ut riant Pil. xij. Take two three or four times a day. (Dyspepsia.) R Pulv. Cort. Cinch. 3j. Ferri Ses- quioxid. 3j. Syr. Zing. q. s. ut fiat Electuarium. A tablespoonful three times a day. R Ferri Potassio-Tart. Bij. Syr. Tolut. q. s. Divide in Bolus vj. One three times a day. In Scrofulous Affec- tions, Rickets, debility of the diges- 668 EXTEMPORANEOUS FORMULA (Tonics). tive organs, &c. From its taste not being disagreeable children take it readily. A nutritive diet should be conjoined, and the secretions of the intestinal mucous membrane pro- moted and corrected, if necessary, by Rhubarb, Ipecacuanha, Hydrarg. cum Creta, &c.) ft Ferri Potassio-Tart. gr. x. Pulv. Calumb. gr. xij. Pulv. Arom. gr. iv. M. Fiat Pulv. To be taken three times a day. ft Ferri Ammon. Chlor. 3j. Extr. Aloes, Extr. Gent, aa 3ss. Con- tunde simul. Divide in Pil. xxx. Take two three times a day. (Tonic and aperient. In Anaemia, Chlorosis, Scrofula, &c.) R Ferri Sulph. 3j. Potass. Carb. gr. vj. Myrrha? 3j. Pulv. Aloes Comp. 3ss. Contunde simul et divide in Pil. xxx. Take three twice a day. (Tonic and aperient. In Chlorotic Amenorrhcea.) R Infus. Quassia? 3jss. Tinct. Calumb. 3j. Tinct. Ferri Muriat. n*x. M. Fiat Haustus. To be taken three times a day. R Solutionis Magnesia? (ope Acidi Car- bonici) 3jss. Tinct. Ferri Mur. rjtx. —xxx. Fiat Haust. To be taken three times a day followed by a cup of cold or tepid water. (A very efficient preparation. In Ana?mia, Chlorosis, Nervous palpitations, &c.) ft Ferri Sulph. Pulv. Subtiliss, 3ss. Magnesia? Calcin. Bij. Aqua? 3yj. Tinct. Quassia?, 3ij. Rub the mag- nesia with a very little of the water, and when they are mixed, add the remainder; afterwards add the sul- phate and tincture. Rub up again for a little while, and as soon as possible divide into six phials, which are to be immediately corked and sealed. Take one night and morn- ing. (In this formula of Mr. Dono- van, the Protoxide is presented in its most soluble and energetic state. Each draught contains about 10 grains of Protoxide, and nearly 29 grains of Sulphate of Magnesia. Forj delicate stomachs half the above dose will be preferable. It should be pre- pared fresh every second or third day. The pilules ferrugineuses of Vallet are considered by the able chemist to whom we are indebted for the above preparation, to be the next best formula, and superior to the ferruginous sugar of Becker and Klauer, in which the Protoxide forms a compound of little solubility. Grif- fith's Mixture and the Pil. Ferri Comp. (Ph. Dub.), though admitted to be very scientific preparations, are thought by Mr. Donovan to con- tain too little iron to be effectual. The tonic effects of chalybeates ap- pear, however, in a great proportion of cases to be most satisfactory and permanent where administered in moderate quantities, as well as in a very soluble an€ dilute form, and where their use is long persevered in, as in the case of ferruginous mineral waters.) R Ferri Cyanidi (Ferri Prussiat.) gr. iij. Syr. Simpl. 3j« M. Fiat Haust. To be taken three times a day. (In Chorea and Epilepsy; also in Intermittents and Scrofula. The dose may be gradually increased to six grains. Used in the hospitals of America.) R Argenti. Nit. gr. ij. (in Aqua? fit ij. solut.) Mica? Panis 3j. M. optime. Divide in Pil. xvj. One to be taken three times a day. (The bread should be well washed to remove all its free Muriate of Soda, and the Nitrate of Silver rubbed down quickly with a drop or two of distilled water in a glass mortar. The dose may be gradually increased to three or four pills or even a greater number, but its use should be frequently inter- mitted to avoid gastric irritation and permanent discoloration of the skin. Its use requires great caution in Epilepsy, Angina Pectoris, palpita- tions connected with Dyspepsia, Gastrodynia, and other Neuralgia.) R Argenti Nit. gr. ij. Ex. Humuli Bj- Extr. Hyosc. gr. xij. Tere optime simul. Divide in Pil. octo. extemporaneous formula (Astringents). 669 One three times a day. (In dys- peptic palpitation, Pyrosis, obstinate Leucorrhcea. The dose may be cautiously increased to two or even three pills, but only continued for a few days at a time. In the case of Pyrosis its influence is augmented by the addition of one-eighth of a grain of Opium to each pill. Nitrate of Silver has also been used with good effect in the form of injection in Dysentery, four grains to six ounces of water. R Cupri Ammon. Sulph. gr. xij. Extr. Gent., Pulv. Calumb. aa 3ss. M. optime. Divide in Pil. xxxvj. Take one twice a day. (Epilepsy, Chorea, &c. after a course of purgatives. The dose may be very cautiously increased to five or six pills at a time and upwards.) R Cupri Sulph. gr. j. Syr. Papav. 3j- Aquae Anisi 3iij- M. Fiat Mistura. A teaspoonful every four hours. (In Hooping-cough. The dose for chil- dren above seven years old may be double the above.) R Cupri Sulph. gr. v. Pulv. Rhei 3ss. Extr. Gent. 3j. Syr. q. s. M. optime. Divide in Pil. xx. Take one or two twice a day. (Leucor- rhoea, Chorea, &c.) R Liq. Arsenic, mjv. Decoct. Cinch. 3x. Syr. Aurant. 3ij. Tinct. Opii r^v. M. Fiat Haustus. To be taken twice a day after eating. (In obstinate Agues, inveterate Neural- gic Affections, periodic Headaches, Chronic Rheumatism, and some in- tractable cutaneous diseases. Its employment requires extreme cir- cumspection, and should never be had recourse to till all milder remedies have failed. The Liquor Arsenicalis has, in some instances, been administered in gradually in- creased doses to the extent of fifteen or even twenty drops, but it is rarely requisite or even safe to go beyond half the latter quantity. Its use should be immediately suspended as soon as there is the slightest sign of irritation of the stomach, as in- creased thirst, nausea, anorexia, &c. or acceleration of the pulse, or a prickling sensation and stiffness in the eyelids. It should always be given after a light meal, so as in some degree to protect the mucous membrane.) R Arsen. Protox. gr. j. Piper. Nigri gr. xij. Pulv. Acacia? gr. ij. Aqua? Distil, q. s. Mix them well, and divide the mass into sixteen pills. (The celebrated Asiatic pill. The Arsenic ought to be very finely powdered and beaten for several hours in an iron mortar along with the Pepper, the gum and water after- wards added. One pill to be taken daily in Lepra Vulgaris, Lepra, Tuberculosa, Lupus, Psoriasis, &c. The dose may sometimes be increased to two pills daily. For the mineral acids, see Stimulants.) V. ASTRINGENTS. Astringents are defined, by Cullen, to be " such substances as, when applied to the human body, produce contraction and condensation of the soft solids, and thereby increase their density and cohesion;" their effects being supposed to take place either immediately by contact, as in the case of their direct application to a part, or of their being subsequently carried to it through the medium of absorption and the circulation; or else, secondarily, through the intervention of sympathy. But there is every reason to believe that this view 670 extemporaneous formulae (Astringents.) of their operation is too limited, and that they exert a powerful influence imme- diately over the vitality as well as over the chemical and mechanical condition of parts. The astringent and the tonic principles frequently co-exist in the same sub- stance, in various degrees of respective predominance : the presence of the former often limiting the applications of the latter, and rendering the drug which contains both unsuitable to cases of great irritability of fibre. Astringents of the vegetable class owe their corrugating influence, for the most part, to the presence of tannin, an element which seems sometimes to dis- play a considerable power in controlling intermittent fever, and often enhances the febrifuge virtue of such tonics as it is naturally combined with. Of the astringents drawn from the mineral kingdom the most frequently used are the sulphuric acid in a dilute state, alum and lime-water, the salts of iron, zinc, copper, silver, and lead. This class of medicines manifest a remarkable power of restraining excessive evacuations and haemorrhages of a passive character. Thus they are often very useful in leucorrhcea, in the latter stages of gonorrhcea and ophthalmia, of pulmonary and vesical catarrh, diarrhcea, and dysentery, after the inflamma- tory symptoms have been reduced by time or suitable treatment, and also in some cases of haemoptysis, haematemesis, melaena, and haematuria, as well as of hemorrhoids when in an indolent state. They are often useful in diabetes, and in cases of inordinate sweating, accompanied by great debility, and in the latter case especially so, if their effects be aided by a moderately cool atmosphere, and by the direction of the fluids internally by the judicious exhibition of aperients and other gentle evacuants tending to substitute a vicarious discharge. In chronic hoarseness and relaxed sore throat, astringent applications are of decided utility, so likewise in calculous affections and chronic irritation of the urinary organs, in which a great portion of the benefit is probably ascribable to their action on the digestive system. Their use in flabby ulcers and various other morbid conditions of the surface of the body falling under the care of the surgeon, is well established. In the earlier or more acute stages of inflammation, when the morbid action is already fully established, a recourse to astringent medicines commonly proves decidedly injurious; though there are certainly some exceptional cases, as for instance the ophthalmia neonatorum, connected with the irritation of gonorrhceal matter, in which applications of a very powerful astringent and stimulant nature (as the solution of the nitrate of silver containing from ten to twenty grains to the ounce of the distilled water), when resorted to in the very com- mencement of the disorder, prove most beneficial; so also the use of a similar injection in the earliest period of specific urethral inflammation, care being taken by pressing upon the passage, that it shall not pass backwards above a couole of inches. v The dangerous consequences of the employment of astringents in the case of critical discharges, or of such as are connected with a gorged state of the blood- vessels, or with some unremoved cause of local irritation, as, for example irri- tating matters in the bowels, are indubitable. The well-known power of opium in controlling the secretions and excretions by d.min.sh.ng the activity of nearly all the functions of the body, renders it a valuable auxiliary to astringents in many cases of profuse discharaes a< like- wise in many spec.es of haemorrhage, especially when preceded or accompanied by such remedies as tend to depress the circulation, as venesection, aperients, nauseants, digitalis, and the judicious employment of cold, both externally and internally. J Of the metallic astringents two of the most energetic, and which have of late years been considerably employed, are the diacetate of lead and the sulphate of copper. The former is one of the most powerful agents we possess for con- extemporaneous formula (Astringents). 671 trolling internal haemorrhages; and any injurious consequences which might otherwise arise from its use may generally be obviated by its combination with opium: and the free use of drinks acidulated with vinegar, to prevent the risk of the formation of the poisonous carbonate, is said to promote still further the safety of its exhibition. In the treatment of Asiatic cholera it has been strongly recommended upon high authority. In cases of obstinate diarrhcea and dysentery the sulphate of copper, united with opium, has been found in judicious hands a safe and very effectual remedy. R Pulv. Alum. gr. x. Pulv. Kino gr. v. Confect. Rosa? 3j. M. For a Bolus—to be taken every six hours. (In internal passive Hemorrhages, Diabetes, Leucorrhcea, and Chronic Diarrhcea.) R Lactis Vaccinae Bullientis fbj. Alum. Contr. 3ij. Boil them together until they coagulate. Strain off the liquid, of which a cupful may be taken from time to time. R Infus. Rosa? Comp. 3jss. Acid- Sulph. Dil. filxv. Syr. 3j. M. For a draught, to be repeated every foui hours. (Internal Haemorrhages.) R Infus. Cascar 3vj. Pulv. Kino Comp. 3j. Syr. Papav. 3iv. For a mix- ture, of which take two tablespoons- ful every six hours. (Chronic Diar- rhoea.) R Infus. Caspar. 3j. Tinct. Catechu 3j. Pulv. Ipecac, gr. x. M. For a draught. (In internal Haemor rhages. Ipecacuanha, in scruple doses at distant intervals, or three or four grains every second hour, has been found very effectual in checking Haemorrhage from the sto- mach or bowels as well as from the uterus and lungs.) R Pulv. Ipecac. 3j. Aquae 3xij. De- coque ad 3vj. Take four table- spoosful every six hours. (Chronic Dysentery.) R Pulv. Ipecac, gr. jss. Alum. gr. vj. Syr. Papav. q. s. For a Bolus, to be repeated every four or six hours. (Chronic Dysentery.) R Pulv. Rhei 3ss. Pulv. Opii gr. ij. Pulv. Aromatic gr. xij. M. Di vide in Pulv. vj. Take one every four hours. (In Mercurial Dysen- tery, &c.) R Mist. Cretae 3jss. Tinct. Opii n^x. Tinct. Catechu 3j. M. For a draught, to be taken every three hours, or after every liquid stool. (Diarrhcea. See also Narcotics.) R Pulv. Ipecac. Com. gr. xij. Pulv. Arom. gr. viij. M. Divide in Pulv. iv. Take one every third hour. (Diarrhcea and Dysentery.) R Catechu Extr. Pulv. gr. xv. Pulv. Cretae Comp. cum Opio Bj. M. For a powder, to be taken every four hours. (In Diarrhcea unaccompa- nied by inflammatory symptoms.) R Extr. Haematox. gr. xv. Tinct. Krameria? Rhatania? 3j. Aqua? Cin- nam. 3xv. M. For a draught, to be taken every fourth hour. (In the latter stages of Diarrhcea and Dys- entery.) R Krameria? Rhatania? Rad. 3ss. Aqua? Ibij. Decoque ad Ihjss. Cola. Take three tablespoonsful every third hour. R Extr. Krameria? 3j. Aqua? Rosae 3iv. Syr. Papav. 3j- For a mix- ture. Take one tablespoonful every second hour. ft Granati Bacca? Court. 3ss. Lactis Vaccini Recentissimi tbiv. M. De- coque ad fcij. Take three table spoonsful every three hours. (Chro- nic Diarrhcea. A Spanish remedy of great efficacy, especially in cases when ordinary astringents are too irritating. When milk disagrees, it may be made with water and sweet- 672 EXTEMPORANEOUS FORMULJ3 (Astringents.) ened with Liquorice-root. It may also be used as an enema.) ft Pulv. Nucis Vomica? 3j. Aquae 3viij. M. Decoque ad 3vj. Adde Tinct. Opii fnjx. For a mixture; of which take a heaping tablespoonful every two hours. (In Dysentery. The influence of Nux Vomica in Dysen- tery is attested by Hagestrom, Hufeland, Richter, Geddings, &c. It may also be given in the form of pills, three to six grains thrice a day.) ft Extract. Nucis Vomicae gr. viij.— xvj. Mucilag. Acacia? 3j. Aquae Distil. 3vj. Syrupi Altheae 3j- M. For a mixture. Take half an ounce every two hours. (Dysentery. Its use should not be long persevered in, if it fails to give early relief.) ft 01. Tereb. fllxv. Aquae Menth. Pip. 3j. M. For a draught: to be re- peated every four hours. (In inter- nal passive Haemorrhages.) * ft Tinct. Ferri Mur. (Sesquichlorid.) n\,x. Aqua? 3j. M. For a draught: to be taken every third hour. (In uterine and vesical Haemorrhages.) ft Zinci Sulph. gr. xij. Myrrha? Pulv. Bij. Conf. Rosae v. s. ut fiant Pil. xij. Take one three times a day. (In Phthisis or Chronic Bronchitis with excessive expectoration, in Leu- corrhcea and Nervous Affections.) R Plumb. Acet., Opii aa gr. vj. Pulv. Sacch. Bij. M. Divide in Pulveres. xij. Take one night and morning. (In Colliquative Diarrhcea, and sweat- ing of Phthisis. A glass of barley- water slightly acidified with simple Oxymel may be taken after it, to prevent the formation of the carbo- nate.) R Plumb. Acet. gr. iv.—xij. Aqua? Distil. 3iij. Acid. Acet. Dil. 3ij. Aceti Opii n^xi. Syr. Papav. 3v. For a mixture. Take one table- spoonful every third hour. (In Hae- morrhages from the stomach -and in- testines, uterus and urinary organs, and lungs.) ft Acet. Plumb. Bj. Opii gr. j.—ij. Pulv. Glycyr. gr. xij. Muc. Acac. q. s. ut fiant Pil. xij. Take one every hour. (In the premonitory Diarrhcea of Asiatic Cholera. If the characteristic vomiting, purging, and spasms already exist, give them every quarter of an hour till relief is obtained, and then gradually increase the intervals at which the dose is given to every third or sixth hour.) ft Cupri Sulph. gr. ss. Opii gr. ss. Conf. Rosa? q. s. For a pill: to be taken three times a day. (In Chro- nic Diarrhcea or Dysentery. The dose of the Sulphate may be gra- dually raised to two grains at a time, to be taken immediately after food, so as to diminish the risk of irrita- tion of the mucous membrane.) ft Alum. Sulph. 3j. Decoct. Cinch. 3xij. Mellis Rosae 3jss. M. For a gargle. (In relaxation of the uvula and fauces.) ft Infus. Krameria? Rad. 3vij- Acid. Sulph. Dil. 3ij. Syr. Rosa? Gall. 3j. For a gargle, to be used with the assistance of a glass tube. (In relaxation of the uvula. For other gargles, see Stimulants and To- nics.) ft Alum. Sulph. gr. viij.—xvj. Aqua? Rosa? 3iv. M. For a Collyrium. (In chronic stage of Ophthalmia.) ft Aqua? Rosae 3yj. Zinci Sulph. xij. M. For a Collyrium. gr- R Liq. Plumb. Diacetat. rnjv.—viij. Aqua? Distil. 3iv. M. For a Col- lyrium. R Liq. Plumb. Diacetat. 3ss. Ung. Cetac. 3j- M. For an ointment. (In Ophthalmia Tarsi.) R Liquor. Plumb. Diacetat. Bj.—ij. Aqua? Rosae 3viij. Vini Opii 3j. M. For a Collyrium. (In scrofulous in- flammation of the eyelids.) R Plumb. Acetat. gr. xij. Suberis Usti gr. iv. Butyri Recentis 3j. M. For an ointment. (Haemorrhoids.) extemporaneous formula (Diaphoretics.) 673 R Pulv. Gallarum 3j. Opii Pulv. gr, xv. Adipis SuilJa? 3j- M. For an ointment. (Haemorrhoids.) R Aluminis Sulphat. 3j. Aqua? 3viij M. For a lotion. (Haemorrhoids when free from inflammation ) R Aquae Calcis 3j- Olei Oliva? 3U- Cam- phora? 3ij. M. For a Liniment. (In superficial inflammations, burns,&c.) R Cort. Gallarum 3ss. Aqua? 3xviij. M. Decoque ad 3xvj. For an in- jection into the vagina. VI. DIAPHORETICS. Diaphoretics are medicines by which the cutaneous exhalation is increased ; those by which copious sweating is produced are called Sudorifics. Medicines of this kind act either by stimulating the exhalants of the skin, or else by aug- menting the force of the circulation generally, or by both these ways at once. Of the first we have examples in the influence of saline diaphoretics, and in that of the large ingestion of aqueous fluids : of the second, in the effects of stimu- lant diaphoretics, alcoholic liquors, and violent exercise. Tepid diluents and external warmth seem at once to augment the vigour of the circulation, and lo relax the mouths of the exhalant vessels. Emetics and nauseants have also a great tendency to relax the cutaneous surface. Diaphoretics prove beneficial in most acute and chronic disorders by deter- mining to the skin, and perhaps also, (though in a very inferior degree, in conse- quence of the quantity of drinks, which are generally simultaneously swallowed,) by diminishing the quantity of circulating fluids, and thus in both these ways relieving such internal organs as may be the seat of inflammation or of conges- tion. Their good effects are particularly well seen in cases where the urinary or alvine excretions are in excess; as also where the mucous membrane or the parenchyma of the lungs is in a congested state, and where the pulmonary secretion is superabundant. Their sanative influence, and especially that of the well-known Dover's powder, in diarrhoea and dysentery, is one of the best established facts in therapeutics. When the powder just named tends to pro- duce vomiting, this may generally be obviated by administering it in the form of a pill along with some bitter extract, as that of gentian, for example. Dia- phoretics afford a very effectual means of lowering the pulse, and bringing back a healthy condition of the surface, in febrile disorders when unaccompanied by symptoms of a low or typhoid type. To catarrhal and rheumatic fevers they are peculiarly applicable. It is only, however, in the very commencement of fevers that diaphoretics, like emetics, can have any chance of cutting short their progress; and even here, those of a heating kind should generally be avoided. Besides their other modes of action already alluded to, the evaporation from the skin, which follows the operation of a diaphoretic, has a great effect in lower- ing the temperature. In the scaly and some other forms of cutaneous eruptions their employment is often followed by very satisfactory results, especially when accompanied by the use of the warm bath or vapour bath in their simple or medicated form; so likewise in diabetis, the body being kept at the same time habitually warmly clothed, and flannel worn next the skin. In dropsy, gout, and secondary syphilis they are often had recourse to with advantage. In the phlegmasia? and fevers, and especially when the symptoms of inflam- mation run high, not only should those of an exciting nature be avoided, but venesection and aperients should be premised in order, in some degree, to cool the surface and relieve the over-distended and imperfectly acting capillaries. The body should be sufficiently, but yet moderately covered, so as to guard against the influence of cool air, without, at the same time, over-exciting the vol. in. 85 674 extemporaneous formula (Diaphoretics). superficial vessels, and so producing a state incompatible with the free exercise of the secerning function. The exhibition of stimulant diaphoretics, whilst the body is perhaps at the same time kept heated with a profusion of bedclothes, tends to the production of typhoid symptoms and miliary eruptions. When it is desirable that sweating should be long sustained, wearing a flannel dress next the skin to absorb the moisture and prevent the risk of sudden cool- ing, is a useful precaution. Bathing the feet in hot water, or assiduously fomenting them with cloths wrung out of the same, form, together with a copious supply of tepid diluents, the best auxiliaries to diaphoretic medicines. Opium and calomel constitute, in many cases, very valuable adjuncts to several medicines of this class, and especially to ipecacuanha and to antimony. Acidu- lated drinks should be avoided for some time after a dose of an antimonial dia- phoretic has been swallowed, lest vomiting should unnecessarily be induced. Aperients should, of course, scarcely ever be exhibited simultaneously with sweating medicines, both because their effect is in some degree of a contrary nature, tending to impede the action of the latter, as well as because if diapho- resis were to take place, the exposure of the body in the act of getting up to stool might give rise to dangerous consequences. The use of cold drinks should be avoided, after once the perspiration has begun to flow. The action of the skin being most easily excited during the night and towards morning, these are the periods usually selected for the promotion of artificial perspiration. When sweating has already continued as long as it is desirable, it may generally be checked with safety by wiping the body hastily with flannel cloths, and substi- tuting a fresh supply of well-aired garments and bed-coverings, and gradually exposing the hands and arms to the air. As in health, so likewise in some chronic diseases, as habitual dyspepsia, for example, active exercise and friction are the best modes of increasing the action of the cutaneous vessels, and so relieving the internal organs. Copious draughts of water, either cold or hot, are often sufficient to excite very profuse sweating without the aid of any more strictly medical agent. Cold affusion is a safe and useful appliance in cases of high fever .attended by a firm and frequent pulse, and a hot and dry skin, tending, in a very striking manner, to reduce the vio- lence of the circulation, and to promote perspiration, if the patient be quickly dried and covered up after its use, and adequately supplied with diluent drinks. In the more advanced stages of fever, or where the pulse is somewhat feeble, tepid affusion, or rather sponging, should alone be resorted to, and even these are inadmissible where the skin is moist and relaxed, and the heat not well developed. Cold affusion is inadmissible, even in febrile states, if internal inflammation exist, as well as in advanced pregnancy and during menstruation. By violent exercise, as well as by the exhibition of diaphoretics, the expected access of an ague fit has been prevented in some instances, and its stages have been moderated in others. Partial perspirations in fever, the pulse at the same time keeping up, are by no means indicative of an improvement in the case, but rather the reverse. R Potass. Nit. gr. xv. Pulv. Acac. gr. x. Mist. Amyg. 3ij. M. For a draught, to be repeated every four hours. (Acute Rheumatism. Tepid diluents to be at the same time freely administered.) R Potass. Nit. gr. v. Liq. Ammon. Acet. 3ij. Aqua? Mentha? Pulegii 3v. Vini Antim. Potassio-Tart. trixx. Muc. Acac, Syr. aa 3j. M. For a draught, to be repeated every fourth hour. (In inflammatory diseases to relax the skin and reduce the pulse. A few drops of Tinct. Digitalis (rnjij. —vj.) may occasionally be added with advantage.) R Potass. Nit. gr. xij. Pulv. Ipecac, gr. jss. M. Divide in Pulv. vj. Take one every third hour. (A diaphoretic in early infancy.) R Potass. Carb. gr. xviij. Sue. Lim. extemporaneous formulae (Diaphoretics.) 675 3iv. Aqua? Distil. 3j- Sacch. Albi Bj. M. For a draught, to be repeated every three hours. (When inflam- mation runs high xx—xxx. drops of Antimonial Wine may be added to each dose.) R Ammon. Sesquicarb. Bj. Aqua? 3jss. Syr. 3j. M. For a draught, with a table-spoonful of lemon juice: to be repeated every four hours. R Spir. iEtheris Nit. 3iij. Vini Ipecac. 3j. Mist. Camphorae 3v. Syr. Simp. 3iv. M. For a mixture. Take two tablespoonsful every three or four hours. R Liq. Ammon. Acet. 3iij. Mist. Camph. 3j. Syrup. Aurant. 3j. M. For a draught, to be repeated every four hours. (One of the mildest and most effectual diaphoretics. A few drops of Antimonial Wine, or Wine of Ipecacuanha may occasionally be added, where inflammatory symp- toms prevail; or the Aromatic Spirit of Ammonia, if there be much de- pression.) R Pulv. Antim. gr. xij. Pulv. Trag. Comp. Bij. M. optime. Divide in Pulv. iv. Take one every fourth hour. (In Inflammatory Affections after ape- rients.) R Pulv. Ipecac. Comp. gr. vj. Liq. Am- mon. Acet. 3iij. Pulv. Acac. gr. x. Aquae Cinnam, 3ix. M. For a draught, to be repeated every six hours. (Rheu- matism, &c.) R Pulv. Ipecac. Comp. gr. xij. Conf. Arom. q. s. A piece to be taken at bed-time. (Dysentery, Diarrhoea, Rheumatism, &c. Some time after the bolus is taken, tepid diluents should be used freely.) R Pulv. Jacobi Veri gr. viij. Pulv. Ipe- cac. Comp. gr. xvj. Conf. Arom. q. s. ut fiant Pil. viij. Take two every three hours. R Antimon. Potassio-Tart. gr. ss. Hydr. Proto-Chlor. gr. iv. Opii gr. ij. Conf. Rosa? q. s. Misce optime. Divide in Pil. ij. Take one at bed-time. (Acute Rheumatism.) R Tinct. Guiaci Ammon. 3j. Pulv. Trag. gr. xv. Aqua? Cinnam. 3jss. M. A draught, to be taken three times a day. (Chronic Rheuma- tism.) R Guiaci Gummi Res. gr. x. Pulv. Ipecac. Comp. gr. v. Potass. Nit. gr. x. Conf. Rosa? q. s. A bolus, to be taken at bed-time. R Mist. Camphorae 3vss. Tinct. Guiac. Ammon. 3vj. Liq. Ammon. Acet. 3j. Acet. Opii 3j. Syr. Aurant. 3v. A mixture, of which one table- spoonful is to be taken three or four times a day. (Dysmenorrhcea.) ft Extr. Aconiti gr. j. Extr. Anthem. gr. xj. Antimon. Sulphureti Praecip. (Oxysulphureti) gr. iv. M. optime. Divide in Pil. iv. Take one every night and morning. (In obstinate Chronic Rheumatism, &c. Requires caution.) ft Mist. Camphora? 3j- Vini Colchici 3ss. Liq. Ammon. Acet. 3ij. M. A draught, to be repeated every six hours. (Gout and Rheumatism.) R Rad. Sarsapar. Concis. 3iv. Glycyr. 3ss. Liq. Calcis Oij. M. Macera per horas xxiv. in vase vitreo optime opere lato, et in loco frigido et ob- scuro, dein cola. Take 3iv. three or four times a day. (In secondary Syphilis, mercurial affections, de- bility and impairment of the general health, Scrofula, and Chronic In- flammation of the Bladder. Its use should be continued for several weeks.) ft Rad. Sarsap. Conci. 3ij. Aquae Bull. 3viij. Stet per horas 24. Cola et adde Liq. Potass. 3j.—ij. Extr. Glycyr. 3j. M. Take four table- spoonsful three times a day. (Scro- fula, &c.) 676 extemporaneous formuljs (Expectorants). VII. EXPECTORANTS. Expectorants are medicines by which the excretion from the respiratory organs is promoted. Emetics, nauseants, many stimulants, and some antispas- modics have this tendency. The operation of expectorating medicines is gene- rally somewhat complex, but may, in great part, be resolved into the altering of the quantity of the secreted matter, and the facilitation of its expulsion. The latter object may be effected either by inducing some change in the quality of the pulmonary and tracheal secretions (diminishing the viscid nature of the sputa when excessively glutinous and adhesive, or, on the other hand, aug- menting their consistency when unnaturally thin, serous, and frothy), or by stimulating the action of the muscles which co-operate in the act of expec- toration, or by both these ways simultaneously. In some states of the respi- ratory organs, antiphlogistics, diaphoretics, counter-irritants, and other reme- dies by which the excessive action of the pulmonary capillaries is reduced to the secreting point, are the true expectorants. In others where there is an excessive flow of mucus, impaired aeration of the blood, and a consequent deficiency of nervous and muscular energy, emetics are often very useful in getting rid of the superabundant quantity of fluid already poured out, by means of exciting the vehement action of the expiratory muscles, and thus compressing and emptying all the bronchial ramifications. In these cases too, the stimulating expectorants, such as squill and seneka combined with ammonia, the balsams, myrrh, and the other gum resins, often prove most effectual, along with such measures as tend to sustain the strength, and to alter the mode of action of the vessels by which the mucus is secreted. Of the beneficial effects of both these modes of treatment, when well timed, we may have ample evidence in the management of the suffocative catarrh of the aged, the peripneumonia notha of the older writers. In pneumonia itself, in its advanced stage, where accompanied by predomi- nant typhoid symptoms, and where it is considered advisable to endeavour to effect a crisis through the medium of expectoration, the stimulant expectorants, such as seneka, are most commonly preferred. In acute and chronic bron- chitis and humid asthma, the nauseating expectorants, such as fractional doses of ipecacuanha or of the tartrate of antimony, are amongst our most valued resources, and may be combined, in many instances, with augmented efficacy, with opiates, antispasmodics, and mercurials. Such combinations tend much to allay irritation, and to relax spasmodic constriction in the air-tubes, as well as in the minute vessels by which their coats are lined. In asthma of a ner- vous character, and in that of cardiac origin in its advanced stage, expecto- rants of a depressing kind are often altogether unsuitable, inasmuch as they tend still further to lower the vital energy which is already at too low an ebb. In infancy, emetics answer particularly well as a means of relieving bron- chial inflammation, and their use is attended with much less distress than in after life. In phthisis, likewise, they often prove useful palliatives, discharging rapidly a large quantity of secreted mucus, and for a time diminishing the irri- tation within the lung. The list of stimulants affords, as we have seen, numerous agents of much topical efficacy in modifying the action of the pulmonary exhalants, such as turpentine and tar vapour, chlorine and iodine; but of all these it may be stated generally, that their influence cannot fail to be highly injurious when- ever they produce much excitement. Here watery vapour, either simple or very slightly medicated, as by aromatics, vinegar, tincture of opium, &c, will commonly be much more appropriate. extemporaneous formulae (Expectorants), 677 During the administration of expectorants, a moderate action of the skin should be maintained by means of adequate clothing, lest an oppressive deter- mination of blood to the lungs should defeat their object; whilst, at the same time, all strong diuretics and purgatives should be abstained from, as calcu- lated to impress a false direction on the circulating fluid, or, to speak more correctly, to produce an inconsistent irritation or excitement in an antagonist organ. R Mist. Amyg. 3vj. Vini Ipecac, Potass. Carb. aa 3jss. M. Take two tablespoonsful, with one of Lemon juice (during the efferve- scence) every third hour. R Vini Ipecac. $\. Syr. Simp. 3jss. M. A mixture : of which give the child a teaspoonful, whenever the cough is severe. (The syrup of Squills may occasionally be substi- tuted for, or added to the Wine of Ipecacuanha.) R Mist. Amyg. Amar. 3vij. Vini Ipecac, Aceti Scilla? aa 3jss. Syr. Tolut. 3v. A mixture. A table- spoonful to be taken if the cough be violent. R Potass. Nit. Bj. vj. Myrrha? gr. Pulv. iv. Take hour. Pulv. Ipecac, gr. xij. M. Divide in one every fourth R Pulv. Ipecac, gr. xij. Calomelanos gr. iv. Conf. Rosa? q. s. Divide in Pil. viij. Take one every fourth or sixth hour. (In acute and extensive Bronchitis accompanied by consider- able fever.) R Pulv. Ipecac, Calomelanos aa gr. v. Sacch. Albi gr. x. M. Divide in Pulv. xx. Take one every third hour. (In extensive Bronchitis and Pneumonia of very young infants.) R Aqua? Mentha? 3j. Muc. Acac. 3ss. Liq. Antim. Potassio-Tart. 3i.—ij. Syr. Limon. 3ij. Tinct. Opii rnjij. M. A mixture. Take from one to two teaspoonsful every two hours. (In the Pneumonia of very young subjects.) R Extr. Conii 3ss. Pulv. Scilla? gr. x. Pulv. Ipecac, gr. v. M. Divide in Pil. x. aequales. Take one two or three times a day. R Pulv. Ipecac, gr. xij. Aceti Distil. 3xij. Aqua? Mentha? Pulegii 3ijss. A mixture. Take two tablespoonsful every four hours. (Asthma.) R Amygdal. Amar. Contrit. 3j. Potass. Nit. 3ss. Pulv. Ipec. Bj. Extr. Glycyr. et Muc. Acac. aa q. s. ut fiant Trochisci xxx. Take one every two or three hours. (Bronchitis.) R Extr. Opii Aquos, gr. x. Pulv. Ipec. gr. x. Extr. Glycyr. 3iv. Sacchari Albi 3*iv. Muc. Trag. q. s. Divide \*Ad in Trochiscos octoginta. Take one more or less frequently during the day, according to the violence of the cough. (In the latter stages of Bron- chitis. Very useful.) R Soda? Carb. 3ss. Vini Ipecac. 3J- Tinct. Opii n*x. Syr. Tolut. 3iij. Aqua? 3jss. A mixture; of which a tablespoonful may be taken every four hours. R Tinct. Scilla? rprxv. Acid. Nit. Dil. mjxv. Extr. Hyosc. gr. iij. Aqua? 3jss. M. Fiat Haust. A draught to be taken every third or fourth hour, until the fourth repetition. (Asthma.) R Lobelia? Inflata? 3x. Spir. Ten. 3viij. M. Digere per dies decern et cola. Of this Tincture take from r#x. to xl. in gradually increasing doses. (Expectorant, diuretic, and antispas- modic. In Asthma, Hooping-cough, and Croup. In larger doses (3J-— 3U0 it is emetic; and dangerously narcotic in excessive doses.) R Oxymel. Scilla? 3v. Tinct. Camph. Co. 3iij. Spir. iEther. Nit. 3iv. Infus. Lini Comp. 3vjss. A mixture. Take two tablespoonsful every third hour. R Mist. Ammoniaci 3yj. Acet. Scilla? 678 extemporaneous formulae (Expectorants). 3\v. Vini Ipecac. 3ij. Tinct. Opii rftxl. Aquae Fcenic 3x. A mixture. Take two teaspoonsful every third hour. (Chronic Catarrh. If there be great depression of strength, a drachm of the Carbonate of Ammonia may be added to the mixture, and the Tincture of Squill 39- substituted for the Vinegar of Squill.) R Mist. Camphora? 3iv. Tinct. Digit. rpjx. Oxymel. Scilla? 3ss. M. A draught to be taken every four hours. (Chronic Bronchitis grafted on Mor- bus Cordis.) R Mist. Assaf. 3uj- Aq. Mentha? Pip. 3ij. Tinct. Scilla? 3ij. Tinct. Cam- phora? Comp. 3ij. Syr. Tolut. 3iv. M. A mixture. Take one table- spoonful every three hours. R Myrrha? Gum. Res. 3j- Scilla? Pulv. Bj. Gum. Res. Ammoniaci 3ss. Ammon. 3ss. Extr. Hyosc Bij. Muc. Acac. q. s. M. Divide in Pil. xl. Take two three times a day. (Phthisis and Chronic Catarrh.) R Assafcet. Bj. Scilla? Pulv. gr Tolut. aa q. s. ut fiant Pil Pulv. Ipecac. 3SS- viij. Sap Duri. Syr. xvj. Take one every four hours. (Chronic Catarrh of the aged, Asthma.) R Pulv. Scilla?, Extr. Conii aa 3s3. Ammoniaci Gum. Res. 3jss. M. optime. Divide in Pil. xxx. Take one every fourth hour. R Mist. Ammoniaci 3iv. Vini Antim. Potassio-tart. 3iij. Tinct. Camph. Comp. 3v. Syr. Tolut. 3j- M. A mixture. Take a dessert-spoonful when the cough is violent. R Decoct. Senega? 3vj. Ammoniaci 3ij. Syr. Tolut. 3vj. M. A mix- ture. Take two tablespoonsful four times a day. (In Pectoral Affections with debility and excessive secretion of mucus.) ft Decoct. Senega? 3j- Liq. Am. Acet. 3ss. Syr. Scillae 3ij. Syr. Papav. 3ij. M. Take 3i.—ii. every three hours. (For very young infants in the advanced stages of Pertussis and Chronic Bronchitis.) R Mellis, Olei Amyg. aa 3j- Sue. Limon. 3iv. Syr. Tolut., Syr. Scillae aa 3ij. M. For a linctus. (In common Catarrh.) VIII. EMETICS. Emetics are medicines which have a peculiar tendency to excite vomiting in almost all cases, even when given in very moderate doses. There are many other medicines which being of a disagreeable flavour are occasionally rejected by irritable stomachs, or if they are swallowed in considerable quantity ; but these are intentionally excluded by the above definition. There is, in fact, scarcely any substance, however simple, which if taken to excess will not cause an inverted action of the stomach. Bitters, when taken largely, approach most nearly in their effects to special emetics. A strong tepid infusion of chamomile rarely fails to turn the stomach, and a weak one swallowed liberally is one of the most usual means resorted to for promoting the action of the class of medi- cines now under consideration. Tepid water and most other tepid fluids taken rapidly, and in unusually large quantities, are by their sickly flavour and the distension they cause commonly alone sufficient to induce vomiting. A few minutes after an emetic has been administered, nausea and a peculiar sinking sensation come on, accompanied by paleness, quickness and weakness of pulse, and chilliness, and all this is speedily succeeded by the free evacuation of the stomach, and the establishment of a certain degree of reaction in the system. During the efforts of vomiting, the face is^ flushed and turgid from the mechanical obstruction to the return of blood from the head. Considerable EXTEMPORANEOUS FORMULAE (Emetics). 679 languor and drowsiness usually succeed to the operation of such medicines ; and hence the evening is generally to be preferred for their exhibition : the skin is left in a relaxed and perspiring state, and the pulse for the most part continues, for some time after, feebler than it was before, and any inflammatory symptoms which may have existed, are somewhat diminished in intensity. Where the vomiting induced is severe, the irritation often extends to the hepatic ducts and liver, and a profuse flow of bile makes its way into the stomach, and comes up along with its other contents, of which an abundant secretion of ropy mucus is commonly a conspicuous one. By this sudden secretion of bile, and the consequent distension of the biliary ducts, as well as by the vehement compression of the abdominal organs, and the general tendency to relaxation, large impacted biliary calculi have sometimes been liberated. The degree of nausea induced by a medicine is not always proportionate to its emetic influence. Thus the sensation of sickness which ensues upon the use of the sulphate of zinc is very much less oppressive than that caused by the tartrate of antimony, or by tobacco. In quickness of operation also emetics differ very remarkably : thus the sulphates of zinc or of copper act almost im- mediately ; the tartrate of antimony requires a somewhat longer time: and ipecacuanha longer still, though even this, when the medicine is given in an adequate dose, rarely much exceeds a quarter of an hour; but in certain cases, as for instance after poisons have been swallowed, even the difference of a few minutes is of great practical importance. There is a great difference in individuals in regard to the facility with which vomiting is excited, and this exists in a still greater degree in respect to different classes of animals, in some of which, from the structure of their stomachs, this action can scarcely, if at all, be induced, as in the horse for example. In per- sons labouring under mental derangement, much stronger doses than ordinary are commonly required. Many stimulant substances, when freely swallowed, have an emetic tendency, of which we have a conspicuous instance in the infusion of mustard-seed, which is capable of exciting the stomach to action, even when great general and local torpidity exists. Most irritant poisons give rise to severe vomiting. Narcotics on the other hand, if not rejected almost immediately after they have been taken, diminish in a remarkable degree the sensibility of the stomach. Several emetics, as ipecacuanha, tartrate of antimony, &c, have also a pur- gative tendency, so that even if they fail of fulfilling the original intention of their exhibition, they often prove useful by acting on the bowels. To their utility in promoting diaphoresis and expectoration we have already called the reader's attention in the preceding class; they have also a marked influence over the process of absorption, their use having in some instances been almost immediately followed by the disappearance of dropsical effusions, of indolent buboes, and various morbid deposits. Nauseant medicines, and especially ipecacuanha, are often given, and with great success, for checking internal haemorrhages, such for example as those from the stomach and intestines, kidneys, bladder, uterus, &c. On the well established antiphlogistic efficacy of the tartrate of antimony in pneumonia and acute rheumatism, ophthalmia, and various other inflammatory affections, when given in large doses (as one or two grains in small quantity of a weak aromatic infusion, repeated every two or three hours, drinks being with- held in the mean time, in order to diminish the chance of its expending its ope- ration on the stomach or bowels), we shall not here "dwell, as its beneficial influence does not seem to be by any means necessarily connected with its occa- sional emetic effect. Amongst the most common cases in which the action of emetics is called for, are those where the stomach is oppressed by food of indigestible quality, or taken in excessive quantity—intoxication, when there is reason to apprehend that the alcoholic liquors which have caused it have not been fully expelled by 680 EXTEMPORANEOUS FORMULiE (Emetics). the spontaneous vomiting which so commonly ensues—poisoning by acrid or narcotic substances—periodic and bilious headaches—fever in its commence- ment, to cut short its progress—and ague just before or during the cold stage, to break through the concatenation of morbid actions, and to restore the balance of the circulation—cynanche tonsillaris in its inflammatory stage as well as when abscess has taken place, in which it often affords immediate relief— obstinate diarrhoea—incipient cholera, to act as a general stimulant to the sys- tem and to drive the blood more equally through all the vessels, and so equa- lize the circulation and overcome local congestion—bronchitis, especially if accompanied with excessive mucous secretion, as well as phthisis and asthma. In several of these cases, a great part of the good effect seems attri- butable to a species of counter-irritant action on a sound portion of the gastro- intestinal mucous membrane. In infancy emetics are particularly well borne, and prove very effectual in relieving the chest in bronchitic inflammation, hooping-cough, croup, &e. Their use should generally be avoided in diseases of the heart and great vessels, especially in their advanced stage; in cases where a tendency to congestion of the head exists ; in hernia; prolapsus of the rectum and uterus; and in the latter months of pregnancy. When there is a very irritable state of the sto- mach their employment is obviously counter-indicated, as well as in chronic disorders as in fevers; their imprudent administration in such cases often lays the foundation of formidable gastro-enteritic inflammation. The habit of taking them very frequently under almost any circumstances, has a tendency to render the stomach very susceptible, and impatient even of many of the ordinary forms of aliment, and to debilitate both it and the system at large. When vomiting takes place to excess, it may often be effectually checked by the exhibition of an effervescing draught, an opiate, a couple of drops of the dilute hydrocyanic acid or of creosote in a potion, or by a dose of magnesia combined with aromatics and stimulants. R Pulv. Ipecac. Bj. Aqua? Mentha? Pulegii 3jss. M. For a draught, which must be immediately followed by a cupful of tepid water, or of a tepid infusion of Chamomile. R Antim. Potassio-tart. gr. ij. Aquae Distil. 3>v. A mixture, of which two tablespoonsful must be taken every fifteen minutes until vomiting oc- curs. ft Pulv. Ipecac, gr. xv. Vi ni Antim. Potassio-tart. 3ij. Aqua? Menth. Sativ. 3jss. M. A draught to be taken immediately. R Vini Ipecac. 3ss. Syr. Simp. 3ss. Aqua? 3j- M. Take one teaspoon- ful every fifteen minutes, until an emesis is produced. (A mild emetic for very young infants. When a more depressing emetic is advisable, the Tartrate of Antimony, in doses of from y^ to | of a grain, may be added to each dose.) R Aqua? Distil. 3j- Vini Ipecac. 3ss. Liq. Antim. Potassio-tart. 3ij. Syr. Scillae 3ij. M. A mixture. One teaspoonful may be taken frequently until vomiting comes on. (Emetic for very young infans in Croup, &c.) R Pulv. Ipecac, g. xij. Aceti Scilla? 3ij. Aqua? Menth. Pulegii 3x. M. A draught. R Sinapis Pulv. 3ss. Aqua? Tepid. 3xij. M. One half to be taken im- mediately, and the remainder after the lapse of fifteen minutes, if it seems necessary. (In cases of dimi- nished sensibility of the stomach, or of general debility, where the de- pressing effects of ordinary emetics are likely to prove injurious, as in Paralysis, Cholera, cases of poison- ing by narcotics, &c.) R Zinc. Sulph. Bj. Conf. Rosa? Can. q. s. A Bolus: to be taken immedi- EXTEMPORANEOUS FORMULA (CatliarticS.) 681 ately. (Applicable to cases where rapid operation of the emetic is desirable, without extreme or long continued nausea, as in Ague, poi- soning, &c.) R Cupri Sulph. gr. viij. Aqua? Distil. 3ij- M. An emetic draught. (In cases of poisoning by Opium and other narcotics, when the common emetics have failed to excite the stomach to action, and when the stomach-pump is not at hand.) R Ammon. Carb. Bj. Pulv. Ipecac. 3ss. Tinct. Capsici 3ij. Aqua? Mentha? Pip. ^iij. M. A draught to be taken immediately. (In cases similar to those last mentioned, of greatly impaired sensibility of sto- mach and nervous system.—N. B. The stomach-pump in the great ma- jority of such cases, as well as in dangerous intoxication by ardent spirits, when vomiting has not taken place spontaneously, is a most valu- able resource, superseding the ne- cessity of recurring to the employ- ment of these violently irritating emetics.) R Tabaci Fol. 3j. Aqua? Tepida? q. s. Contunde simul. A poultice, to be applied to the Epigastrium. (Re- quires caution; must be removed instantly on the supervention of sickness.) IX. CATHARTICS. Cathartics, or purgatives, are medicines which promote the alvine evacuations; those which are very violent in their operation being called drastics, or, from their producing large watery stools, hydragogue cathartics; whilst those of a peculiarly mild action are termed aperients or laxatives. The effects of purgatives are ascribable partly to their augmenting the secre- tions from the mucous follicles and exhalants opening upon the inner surface of the intestines, as well as those from the liver and pancreas, and partly to their stimulating the muscular fibres of the bowels to increased peristaltic action. Different kinds of purgatives produce these effects in very different relative proportions, some increasing greatly the liquid secretions, whilst others seem to do little more than propel the faecal matter already existing in the in- testinal tube, only very slightly augmenting, at the same time, the quantity of bile and mucus. Calomel and blue pill again promote the action of the liver in a very marked manner, as do likewise, though in an inferior degree, rhubarb and colchicum. Some purgatives, as has been already stated in our preliminary remarks on the art of prescribing, exert their influence chiefly on the upper por- tion of the bowels, and others on the lower; whilst a third set, such as the saline aperients, senna, and castor oil, seem to act on the whole length of the intestinal canal pretty equably. There are still some other important points of difference amongst purga- tives, as, for instance, in regard to the time required for their operation, and the degree of sickness, uneasiness, or pain, which they cause, as well as in respect to the amount of general excitement or irritation in the system which follows their use. Of the several untoward results to which their injudicious employment occasionally gives rise, the most conspicuous are those connected with the incautious exhibition of the strongest kinds, such as calomel, scam- mony, and colocynth, gamboge, colchicum, croton oil, and elaterium. The cases in which purgatives are most frequently resorted to are those in which irritating matters are retained in the intestines, or where the habitual alvine discharges are tardy or insufficient, or unnaturally altered in quality. In inflammatory and congestive disorders, in active sanguineous and serous effusions, and in general plethora, they constitute most valuable auxiliaries to vol. in- 86 682 EXTEMPORANEOUS FORMULJ3 (Catliartics). other antiphlogistic or depletory and counter-irritant remedies. In fevers, where the secretions are deficient or depraved, they are commonly very freely exhibited in the earlier stages before debility has set in; but, like all other useful remedies, they are very liable to abuse, and since the publication of Dr. Hamilton's valuable work they have, in fact, too often been pushed to extrava- gant lengths by his less judicious disciples in the treatment of such low fevers as are characterized by predominant alvine irritation or inflammation, and especially as regards their too liberal exhibition towards the close of such dis- orders. During the course and after the subsidence of some of the exanthemata, a pretty free recourse to cathartic medicines is generally advisable: so likewise in chorea and hysteria and several other nervous and spasmodic affections, where the alvine evacuations are in a morbid state, as is so often the case. In the treat- ment of mania, purgatives were long trusted to as the sheet anchor, and though it is now well known that their importance was overrated, they are still acknowledged to be very valuable auxiliaries. The disorders, in short, in which this class of remedies has been at one time or other confidently recom- mended and largely employed, are almost commensurate with the entire list of the nosologist. They have been loudly praised in jaundice, gout, rheumatism, neuralgic affections, and habitual headache, in purpura and cutaneous diseases, in chlorosis and amenorrhcea, in verminous affections, colic from lead and other causes, obstructions of the bowels, liver, &c, and even in dysentery: in these and a vast number of other diseases which we have not space to enume- rate, they have been very commonly resorted to in these countries with great boldness and frequent success. There is, however, every reason to believe, that those practitioners who hold a middle course between the excessive and indiscriminate employment of purgatives, towards which the popular preju- dice in Great Britain tends, and the timid and too restricted use of them for which our continental neighbours have latterly been notorious, effect at once the greatest amount of good and the least mischief, and are, consequently, the most worthy of imitation. In indigestion, in particular, the abuse of cathar- tics amongst us has been carried to a fearful length, the sensibility of the mucous membrane being thus frequently almost exhausted, and the nervous system kept in a miserable state of alternate excitement and depression by their diurnal and exaggerated employment. Many a case of dyspepsia and sluggishness of bowels, which diet, exercise, and time, would have gradually subdued, is thus deeply aggravated, and rendered permanent for life, by an impatient and irrational recourse to the daily and unwarrantable irritation of the stomach and bowels by violent drastics ; and doubtless, in not a few in- stances, an inflammatory and even an ulcerated condition of the mucous mem- brane have been the result, together with exasperated haemorrhoids, and pain- ful prolapsus of the bowel. The vulgar notion that the enjoyment of health is impossible where there are not one or more alvine evacuations daily, has given rise to a greater amount of suffering in England than perhaps any other erroneous medical idea of our day. The naturaf habit of different individuals differs ab origine in respect to the frequency with which their bowels ought to be moved, and any attempt to compel all under the same standard, cannot fail to be productive of disagreeable consequences. The temporary stimulus which a purgative imparts to the system, is often mistaken for the feelings of health, and contributes not a little to the perpetuation of the erroneous prac- tice. Thus Lord Byron was tempted to have very frequent recourse to saline aperients, from finding that their operation was followed by an immediate though evanescent rise of spirits, superior to that caused by any vinous stimu- lant. As long as a person feels well, the mere interruption of the alvine evacua- tions for a day or two should by no means be considered as invariably afford- ing grounds for the exhibition of opening medicine. By waiting, and trusting to the efforts of nature, and the effects of food of a more laxative quality, the bowels will generally return to their duty very speedily, provided a habit of undue purgation has not already been formed ; and even then, recourse for a I extemporaneous formula (Cathartics). 683 few weeks to some natural saline mineral water of happy composition, though perhaps of feeble ingredients when taken separately, will often re-establish the muscular tone and secretory power of these parts. In weakly patients, and pregnant and menstruating females, violent purga- tion is peculiarly inappropriate; in passive dropsies likewise the employment of energetic cathartics requires great circumspection: in hydrothorax in par- ticular, occurring in the aged or debilitated, they are rarely if ever admissible, and have appeared in some instances decidedly to accelerate the fatal termina- tion ; and even in those cases of dropsy of the cellular membrane or abdomen, where drastics or hydragogues are called for, they should not be uninterruptedly administered, and the strength will often require to be supported under their use by tonics and stimulants and a light but nutritious diet. When a tendency to haemorrhoids exists, aloetic purgatives, from their proneness to cause irrita- tion of the lower bowels, are generally improper, and should give way to aperients of the mildest description, such as castor oil in gradually decreasing doses, or olive oil, sulphur, and cream of tartar, or some of the saline mineral waters. In dysentery too, where aperients are required, none but those of the gentlest kind should be ventured on. As to the purgative effects of oil of turpentine, the error of supposing them very violent was till of late years common, and it is now well known to be a medicine of great value and mild operation, especially when given in pretty full doses along with castor oil, or even with sweet oil, by the mouth or in injections, and to be peculiarly servicea- ble in those cases of low fever where the evacuations are very fetid and un- natural, and meteorism exists, as well as in spasmodic affections, colic, melaena, and worms. From its stimulant nature it is often admissible in cases of fever, where great sinking precludes the use of more debilitating aperients. Of the methods best suited for correcting the irritating and sickening ten- dency of some purgatives, we have already spoken in our preliminary remarks. Those of a very potent nature should rarely be given, save in divided doses repeated at moderate intervals, and for the most part are much the better for being united with others of a milder and somewhat dissimilar operation. Calomel or blue pill forms a useful adjunct to many, when only occasionally had recourse to, as they both possess a great power of correcting unhealthy secretions, and are peculiarly applicable where the tongue is white and slimy, the conjunctiva of a yellowish tinge, and the skin arid and disco- loured : at the same time, against the habitual use of mercury as an aperient, whether in the diseases of infancy or of adult age, we can scarcely warn the young practitioner too strongly. When our object is to lower excitement and to diminish the quantity of blood circulating in the system, the regular employ- ment of the saline aperients is the most appropriate and least permanently debilitating. The state perhaps of all others in which the use of purgatives is the most unexceptionable and productive of the most certain relief, is that where, along with an unusual feeling of anorexia, the tongue, broad, flabby, and without redness of its point or borders, is loaded with a white or brownish fur, the abdomen distended but free from acute pain even on pressure, and the urine of a muddy or bilious appearance. It is not always possible to fix on the precise dose most suitable to a given case, even in respect to the mildest and most used aperients; and, generally speaking, their operation can be most satisfactorily adapted to the object we have in view by administering them in divided doses, at intervals of from two to six hours. When purgation is necessary, and yet the patient is incapable of swallowing, as in apoplexy and the comatose state induced by narcotic poisons, &c, a drop of croton oil placed on the tongue will often suffice to open the bowels most effectually, or the stomach-pump or enemata may be had recourse to. In very obstinate obstruction of the bowels, purgatives may sometimes be rendered effectual by combination with narcotics, by premising venesection, 684 extemporaneous formulae (Cathartics.) I dashing cold water on the extremities, by giving mercury to salivation, or by the cautious use of tobacco in the form of enemata, or of fomentation, or finally by the employment of the exhausting syringe introduced into the rectum. Where enemata are had recourse to, in such cases, they ought to be of large size and very active ingredients. An emulsion containing turpentine, castor oil, and assafcetida, is often very effectual. We are frequently obliged to employ injections in cases of habitual constipation, where the stomach will not bear, or appears to be weakened by the use of aperients ; but the diurnal use of the former is scarcely less to be deprecated than that of the latter, and will at length almost invariably disappoint us. In cases of permanent or mechanical obstruction in the rectum, however, they constitute a valuable resource. An attempt is here made to group them according to their respective energy. The same purgative, however, it must be remembered, acts with a very diffe- rent degree of force on different individuals, and even on the same individual under different circumstances. 1. The stronger Purgatives. R Pulv. Jalap, gr. x. Calomelanos gr v. Pulv. Arom. gr. ij. M. A powder to be taken immediately. R Hydr. Chloridi Mit. gr. ij. Pulv. Scam. gr. iij. Sacch. gr. ij. Pulv. Zing. gr. ij. M. A powder. R Pulv. Rhei gr. xv. Calomelanos gr. iij. Pulv. Zing. gr. ij. M. A powder. R Pulv. Jalap, gr. xij. 3ss. Pulv. Arom. powder. Potassa? Bitart. gr. ij. M. A R Calomelanos gr. iij. Pulv. Scam. Comp. gr. x. M. A powder, to be taken twice a week. (In Worms and morbid state of the intestinal secre- tions ; incipient Hydrocephalus, &c.) R Infus. Senna? Comp. 3v. Potass. Tart. 3j. Tinct. Senna?, Tinct. Jalap, aa 3iv. Syr. Rhamni 3iij. M. Take one-fourth part immedi- ately! and repeat the dose every fifteen minutes, until a free alvine evacuation is obtained. R Hydrarg. Submur. gr. v. Pulv. Antim. aa gr. iv. Extr. Papav. gr. iij. M. Divide in Pil. ij. To be taken at bed-time. (In this and the preceding formula? we have used the three synonymes of Calomel pro- miscuously, as the prescriber ought to be familiar with each.*) R Hydr. Chlor. Mit. gr. iij. Pulv. Jacobi Veri. gr. iij. Extr. Col. Comp. gr. iv. Extr. Hyosc. gr. ij. M. Divide in Pil. ij. To be taken at one dose. R Pulv. Jalap, gr. x. Pulv. Rhei gr. v. Calomelanos gr. iij. Pulv. Cin- nam. Comp. gr. ij. M. A powder. R Pulv. Jalap., Potass. Tart, aa gr. xv. Sacch. 3j. Olei Caryoph. rnjj. M. A powder to be taken in a cup of orange-flower water. R Soda? Sulph. 3ss. Antim. Potassio- tart. gr. j. Aqua? 3«v. M. An Emetico-cathartic draught. R Senna? Fol. 3ss. Aquae Ferventis Ibj. Macera et cola. Adde Soda? Sulph. 3ss. Vini Antim., Potassio- tart. 3j. M. An Enema. (In Painter's Colic.) R Vini Colchici Sem. 3ij. Magn. Carb. 3j. Aqua? Cinnam. 3iij- A mixture, of which take a tablespoonful every three hours. (In Gout, an aperient pill having been previously admi- nistered.) R Acet. Colch. 3ss. Magn. Calcin. Biv. Magn. Sulph. 3vj. Syr. Croci 3ss. Aqua? Mentha? Vir. 3v. M. A mix- ture, of which take a fourth part every six hours. (Use as in the preceding.) * We protest against all synonymes for Calomel: if this word be used, no mistakes can occur. EXTEMPORANEOUS FO R Vin. Colch. Cormi r#xxx. Potassa? Sulph. 3jss. Soda? Carb. Bij. Aqua? Anethi 3jss. Tinct. Calumba? 3jss. M. To be taken while effervescing in a tablespoonful of Lemon juice. R 01. Croton. Tiglii mjj. Muc. Acac, Syr. aa 3j. M. A mixture. Take a fourth part, every four hours until the effect is obtained. R 01. Crot. Tig. rnjj. Mica? Panis gr. viij. Misce optime. Divide in Pil. ij. Take one immediately, and re- peat it after six hours, if necessary. R Hydr. Chloridi gr. xij. Pil. Cambog. Comp., Extr. Coloc. Comp. aa gr. xv. Syr. Zing. q. s. M. Fiat Pil. xij. Take two at bed-time pro re nata. (In obstinate Costiveness.) R Cambog. Contr. gr. ij.—iij. Sacch. Purif. Bj. Tere optime simul. A powder to be taken every third hour, until a full alvine evacuation is ob- tained. (In Dropsy. Requires cau- tion.) R Pil. Cambog. Comp. Pil. Rhei Co. aa Bj. Pulv. Scam. gr. xvj. Extr. Jalapae, Extr. Coloc. Comp. aa gr. xij. 01. Carui q. s. M. Divide in Pil. xxij. Take two or three at bed- time, and the next morning take two or three tablespoonsful of the follow- ing mixture:— R Decoct. Aloes Comp. 3jss. Infus. Senna? Comp. 3U- Tinct. Senna? Comp., Tinct. Jalapae aa 3iv. M. A mixture. (In obstinate torpor of the bowels after milder purgatives have lost their influence.) R Pulv. Rhei Bj. Conf. Arom. gr. x. Aqua? Mentha? Pip. 3jss. M. A draught. R Magn. Sulph. 3vj. Infus. Rosa? Comp. 3iv. Syr. Zingiberis 3iij. M. Take half immediately, and the remainder after the lapse of two hours. rmuljs: (Cathartics.) ' 685 R Elaterii gr. vj. Cambogia? gr. x. Extr. Aloes Spic, Sagapeni aa gr. xij. 01. Carui q. s. Fiat Massa in Pil. xij. dividend. Take two every six hours. (In similar cases to the preceding. Such violent drastics can rarely, if ever, be habitually requisite in respect to constipation alone, if there be a due management of diet, air, and exercise. Where the sensi- bility of the mucous membrane of the intestines has been temporarily exhausted by imprudent purgation, the constipation which ensues is a natural consequence, calling not for renewed excitement, but for tempo- rary repose, to allow time for the parts to recover their susceptibility to the ordinary stimulus of food and drink.) R Elaterii Extracti gr. ij. Mastiches, Extr. Glycyr. aa gr. vj. Misce op- time, et divide in Pil. iv. equales. Take one every night. (In dropsical affections, to bring away large watery evacuations. The use of Elaterium requires extreme circum- spection.) R Elaterii Extr. gr. j. Pulv. Zing. Bss. 01. Junip. mjij. Syr. Rhamni q. s. A bolus. (In Anasarca, &c. after other remedies have failed.) R Extr. Elaterii gr. j. Calomelanos gr. xij. Pulv. Zing. 3ss. Sacch. Bij. Tere optime simul et divide in Chartulas xij. Take one three times a day. (To children of six years old and upwards affected with Dropsy after Scarlatina, milder reme- dies having failed.) ft Pulv. Rhei gr. xv. Potass. Sulph. Bj. Aquae Mentha? Pip. 3jss. M. A draught. R Pil. Hydrarg. Bj. Extr. Coloc. Comp. 3ss. M. Divide in Pil. x. Take one every other night, or pro re nata. 2. Milder Purgatives. 686 EXTEMPORANEOUS FORMULAE (Cathartics). R Hydr. Chloridi gr. ij. Extr. Coloc. Comp. gr. vi. M. Divide in Pil. ij. To be taken immediately. R Pulv. Rhei, Pulv. Jalapae aa gr. v. Calomelanos gr. ij. M. A powder: to be taken at bed-time: and the next morning take three tablespoons- ful of the following mixture, to be repeated every three hours until the bowels are freely evacuated. R Infus. Senna? Comp. 3v. Magnesia? Sulphat. 3j. Tinct. Senna?, Tinct. Jalapae, Syrupi Zingib. aa 3iij. M. A mixture. (The Black Draught of most hospitals, given in divided doses, some hours after an aperient pill, powder, or bolus, to accelerate their operation, in the commence- ment of many inflammatory affec- tions, &c.) ft Extr. Coloc. Comp. 3ss. Pil. Aloes cum Myrrha Bij. M. Divide in Pil. xvj. Take two pro re nata. (This and the two following for- mula? are suitable to cases of habi- tual constipation; a state which is however, in the great majority of in- stances, artificially induced by the abuse of purgatives, injudicious diet, or deficient exercise; and which will often cease spontaneously, on reso- lutely abstaining for some days from the accustomed aperient.) R Pil. Rhei Comp. 3j. Pulv. Scam. 3ss. Pulv. Zing. gr. x. 01. Ca- ryoph. nfiv. Theriacae q. s. M. Divide in Pil. xxiv. Take one or two pro re nata. R Extr. Coloc. Comp., Castorei aa 3j. Carb. Sodae Sic Bj. 01. Carui rftvij. Saponis q. s. ut fiant Pil. xxx. Take two or three twice a week. R Extr. Coloc. Co., Pil. Rhei Co. aa 3ss. Calomelanos gr. xij. 01. Carui rnjv. Syr. q. s. Fiat Massa. Di- vide in Pil. xv. Take one to three at bed-time. (In commencement of febrile affections, or in habitual cos- tiveness, the Calomel being in the latter case for the most part ex- cluded.) ft Pil. Rhei Comp. 3j. Pil. Hydr. gr. vij. 01. Cinnam. n*iv. Divide in Pil. xiv. Take two at bed-time. R Aloes Extr. Spic Bij. Myrrha? 3j. Extr. Gent., Ferri Sulph. aa 3ss. M. Divide in Pil. xxxvi. Take two night and morning. (A tonic aperi- ent in Chlorosis, Anaemia, Dyspep- sia, &c.) R Pulv. Rhei gr. vj. Potass. Bitart. gr. xij. Pulv. Cinnam. Comp. gr. iij. Sacch. Bj. M. A powder. (A gentle purgative for children.) R Extr. Coloc. Comp. 3ss. Opii gr. j. M. Divide in Pil. vj. Take one every other hour until the effect is obtained. (In Ileus.) ft Olei Ricini 3vj. Tinct. Senna? Co. 3iij. M. A draught. (In Colic and Dysentery. A few drops of Tincture of Opium may be added with advan- tage in many cases.) R Olei Tereb., Olei Ricini aa 3iij. Olei Cajeputi fftvj. Magn. Calcin Bj. Aquae Menth. Pip. 3jss. A draught. (In Typhoid Fevers, to correct the morbid state of the alvine secretions and combat Tympanites.) R Extr. Coloc. Comp. gr. xvj. Pil. Hydr. gr. vj. Extr. Hyosc gr. viij. Pulv. Capsici gr. ij. M. Divide in Pil. vj. Take one or two at bed- time pro re nata. R Elect. Sennae 3ss. Pulv. Jalapae Comp., Pulv. Rhei aa 3j- Syr. Simp. q. s. An electuary, of which take a teaspoonful at bed-time pro re nata. R Extr. Aloes Spic. gr. xx. Pulv. Ipec gr. viij. Pulv. Zing. 3ss. Syr. Simp. q. s. ut fiant Pil. xvj. Take one at noon. R Magn. Sulph. 3ss. Mannae 3ij. In- R Infus. Sennae Comp., Aquae Pimenta? aa 3vj. Potass. Tart. Biv. Tinct. Jalapae, Syr. Aurant. aa 3j. M. An aperient draught. EXTEMPORANEOUS FO fus. Senna? 3vj. Tinct. Senna? 3ij. Aquae Mentha? Vir. 3j. Aqua? Distil. 3U- M. A mixture. Take three tablespoonsful every morning, and repeat the dose, if necessary, after four hours. (Abernethy.) ft Magn. Sulph., Soda? Sulph. aa 3ss. Aquae Mentha? Vir. 3vijss. Vini Antim. Potassio-tart. 3j. M. A mixture; take three tablespoonsful three times a day. ft Magnes. Sulph. 3j. Antim. Potas- sio-tart. gr. ss. Aquae Oij. M. Take a cupful (3iv.) every hour until an evacuation is obtained. R Potass. Bitart. 3ij. Antim. Potas- sio-tart. gr. j. Aqua? Oij. M. Take a cupful every two hours. (Ery- sipelas.) R Infus. Senna? Comp. 3uj- Infus. Gent. Comp. 3ijss. Liq. Potass. 3jss. Tinct. Card. Comp. 3ijss. M. A mixture. Take two tablespoons- ful three times a day. (Aperient and stomachic.) R Olei Tereb., Olei Ricini aa 3v. A draught. (In Puerperal Fever, Tym- panites, Worms, Hysteria, &c) R Infus. Sennae Co. 3iv- Aqua? Carui 3ij. Tart. Potass. 3ij. Mannae 3j. M. A mixture, of which take a tablespoonful every three hours until the effect is obtained. (Aperient for ft Pulv. Rhei 3j. Magnes. Calcin. 3iv. Pulv. Zing. 3ij. M. Take one tea- spoonful pro re nata in one ounce of Peppermint water. R Pruni Domestica? ft>ss. Sennae Fol. 3j. Caryophyl. Contus. 3ss. Sacch. brunei 3j- Aqua? Ferv. Oij. M. Macera per horas ij. Cola. Take 3iv. every three hours until an effect is produced. rmulje (Cathartics). 687 young infants. Maunsell and Evan- son.) R Mannae 3ss. Muc. Acaciae 3ss. Syr. Viola? 3ij. Aquae Menth. 3j. M. A mixture. Take one or two tea- spoonsful every third hour. (For in- fants in the early months.) R Pulv. Rhei gr. xij. Magnes. Bij. Pulv. Cinnam. gr. vj. M. Divide in Pulv. xij. Take one every three hours. (Aperient for an infant under the half year.) R Pulv. Rhei. gr. xij. Hydr. cum Creta gr. vj. Pulv. Arom. gr. ij. M. Divide in Pulv. vj. Take one every third hour. (In Diarrhcea of young infants, with stools of an unnatural appearance.) R Pulv. Scam., Pulv. Rhei, Potass. Sulph. aa gr. x. Pulv. Arom. gr. vj. Tere optime simul. Divide in Pulv. vj. Take one every fourth hour until the bowels be fully opened. (For young children. Operates mildly.) R Fol. Senna? 3ss. Soda? Sulph. 3j. Aqua? Ferv. Oj. Infunde per semi- horam et cola. An enema. R Olei Tereb. 3vj. Vitelli Ovi q. s. Infus. Lini 3x. M. An enema. R Colocynth. Pulp. 3j. Adipis Praep. |j. M. An ointment to be rubbed upon the abdomen. Syr. Tolut. q. s. ut fiat Elect. Take two or threeteaspoonsful every'morn- ing and repeat the dose every three hours until an evacuation occurs. (Haemorrhoids.) R Potass. Bitart. 3j. Magn. Carb., Flor. Sulph. aa 3iv. Potass. Nit. 3j. M. Divide in Pulv. viij. Take one in a little honey every night and morning. 3. Gentle Aperients or Laxatives. R Conf. Senna? 3j. Sulph. Loti 3iv. R Potass. Bitart. 3ss. Sulph. 3j. Con- 688 EXTEMPORANEOUS FORMUL.F. (Diuretics). feet. Piper. Nigri 3ij. Olei Carui fRvj. Theriacae 3uj. M. Fiat Elec- tuarium. Take one teaspoonfui twice a day. (In Haemorrhoids.) R Soda? Potassio-tart. gr. xiv. Rhei Pulv. gr. vj. M. Divide in Pulv. duos. Take one every morning. (An aperient for infants. The Sul- phate of Potass, a favourite remedy of Fordyce, Butter, Pemberton, &c in Infantile Remittent, may occa- sionally be substituted advantage- ously for the Rochelle Salt in the above.) R Cassia? Fistula? Pulpae, Mannae, Olei Amyg. aa 3ij. Aqua? Flor. Aurant 3ij. M. An Electuary. Take a tablespoonful every hour until the bowels are opened. R Manna? 3j. Potass. Bitart. 3ss. Seri Lactis 3vj. M. Take one half im- mediately, and the remainder after two hours have elapsed. R Olei Amyg. 3j. Syr. Simp. 3ij. Vitelli Ovi q. s. M. An Emulsion. To be taken immediately. R Cassia? Fistula? 3j- Caryophyl. Con- tus. Bj. Aquae Ferv. 3xij. M. Take a fourth part every two hours until a mild operation is induced. R Tamarind. Pulp. 3ij- Aquae Ferv. Ibij. Macerate for fifteen hours, and use as a common drink. (In in- flammatory affections, where a gentle aperient effect is required, Manna, or Cassia B'istula, or Senna, may be added to it if necessary.) R Tamarind. Pulpa? 3jss. Pulv. Rhei 3j. Potass. Supertart. 3ij. 01. Carui rpjvj. Syr. Rosa? q. s. An Electuary. Take one teaspoonful pro re nata. R Pulv. Rhei 3ss. Pulv. Ipecac, gr. vj. Pulv. Zing. gr. xij. Extr. Gent. q. s. M. Divide in Pil. xij. Take two one hour before dinner, or at bed-time. R Pulv. Rhei. Hydr. cum Creta aa gr. xij. Pulv. Ipecac, gr. ij. M. Divide in Pulv. iv. Take one every other night. (Alterative aperient for young infants.) R Olei Ricini 3iv. Muc Acac. 3iij. Aquae Pimenta? 3iv. Syr. Tolut. 3j. Tinct. Opii rpjyj. M. A draught to be taken every four hours, until the bowels are opened. (Lead Colic, Dysentery, &c.) R Soda? Potassio-Tart. 3ij. Soda? Ses- quicarb. Bj. Aquae 3ij. M. A draught, to be taken with a tablespoonful of Lemon juice during effervescence. R Sol. Magn. (in aqua ope Acidi Car- bonic) 3vj.; Syr. Rosa? 5vj. M. A mixture. Take four tablespoonsful with one of Lemon juice during the effervescence, and repeat the dose every four hours, until an evacua- tion is induced. R Conf. Senna? 3jss. Ferri Tart. Bij. Syr. Zing. 3iij. M. An Electuary. Take one or two teaspoonsful at bed- time. (Mild aperient and tonic com- bined.) ft Sodii Chloridi (salis communis) 3ss. Decoct Avena? 3x. Olei Oliva? 3ij. M. A domestic injection. X. DIURETICS. Including not only such medicines as increase the flow of urine, but also those which tend to subdue irritation or clironic inflammation in the kidneys and bladder. Diuretics are medicines by which the flow of the urine is augmented. This effect may originate in several different ways, viz., either by the direct action of these substances on the organs by which this fluid is secreted ; by their EXTEMPORANEOUS FORMULA (Diuretics). 689 influence on the stomach and bowels and its sympathetic transference to the kidneys ; and finally by an impression made on the brain and nervous system, of the possibility of which mode of acting artificially on the urinary organs we have collateral proof in the effects of fear and other depressing passions, as well as in that of hysteria and some other nervous disorders, on the kind and quantity of the renal secretion. That several substances, and especially those of a saline kind, as nitre for example, and some of an organic nature, as the odorous principle in asparagus and mint, the colouring matter in rhubarb, as also turpentine and cantharides, actually reach the kidneys, we have satisfactory proof; and in respect to such it is probable that when they increase the urinary secretion, this may be in great part ascribed to their direct stimulant action on the nerves and capilla- ries of the secreting organ. The effect of others again is so rapid, that coupling this with the circumstance of their never yet having been detected in the urine, we are led to suppose that they produce their diuretic effect by either the second or third of the ways above alluded to. Aqueous fluids, taken largely whilst the surface of the body is kept cool, generally act as diuretics : hence it appears how erroneous was the practice of certain of the older physicians, who prohibited the free use of drinks in dropsies. The saline diuretics in particular, if diluents be withheld, would generally irritate the kidneys to a pitch quite incompatible with secretion. If the dose of a diuretic be so large as to produce intestinal irritation, its spe- cific effect on the kidneys is commonly quite lost, of which we have examples in cases where the nitrate of potass, cream of tartar, or turpentine, are given in considerable quantity. The action of diuretics is often greatly promoted by the previous employ- ment of antiphlogistics to reduce any inflammatory tendency existing in the organs to which they are particularly directed, or in the system generally. Of the influence of general excitement over the urinary secretion, we have a remarkable evidence in the succession of changes which it displays in the course of common fevers. There is however an opposite state of the system, in which it is to the removal of depression and debility by means of bitters, mineral acids, steel, and other tonics, that we must look for the restoration of the due action of the kidneys, no less than that of the other secreting organs. Where serous effusions exist in large quantity, any medicines which favour their absorption, and thus bring a sudden accession to the watery portion of the blood, are apt to act as diuretics : hence, probably, in part arises the con- spicuous influence of calomel and of blue pill in augmenting the effects of squills and some other agents of a similar nature, though it may also be in a considerable measure ascribed to the stimulation of the minute capillaries and nerves of the kidney, whilst in some cases the cessation of the dropsical symp- toms must be attributed to the beneficial changes wrought in inflammatory and organic affections of the heart, liver, and other internal organs. Of the saline diuretics, though some, as we have seen, reach the kidneys unaltered, others, particularly some of those containing vegetable acid, undergo decomposition in the prima? viae, and appear to act chiefly by means of their alkaline bases. The principal employment of diuretics is in the treatment of the different varieties of dropsy, with the exclusion of the encysted kind, in which they are almost invariably useless and even prejudicial. They are often admissible in cases where the strength is already too far reduced to justify us in venturing on the use of drastic purgatives. The best period for their exhibition is in the daytime, as the rest is thus not interfered with, and the patient should be encouraged, strength permitting, to sit up and keep himself rather lightly clothed, in order to prevent them from expending their influence on the skin; and purgatives should, for the time, be withheld. If diuretics be exhibited in the course of fever, a disease in which the urine is often retained or suppressed, the state of the bladder ought daily to be ascertained, as, from the loss of power vol. in. 87 690 EXTEMPORANEOUS FORMULA (DiuieticS.) of emptying itself, and inconsciousness of its condition on the part of the patient, great and very injurious accumulation of this fluid occasionally takes place. In the inflammatory dropsical effusions which sometimes ensue upon scar- latina, active antiphlogistic measures, as free venesection and purging, are generally much more decisive in their effects than diuretics. It is probable that diuretics are capable of more extensive application in practice than is commonly apprehended. In veterinary practice they are made much use of, and with excellent results, in combating pulmonary and other internal inflam- mations, as well as for the purpose of getting the animal speedily into good condition and improving the state of his hide. The action of diuretics is proverbially uncertain ; hence the necessity of having a large number from which to select, and to enable us to try a variety of them in succession. In many of the cases in which they are had recourse to, their effects, even under the most favourable circumstances, are at best but temporary, the watery accumulations speedily recurring, inasmuch as they depend on incurable organic diseases for their source. Where the dropsy is of a passive kind, or dependent on great general de- bility of the system, the simultaneous or subsequent exhibition of tonics and stimulants is, as we have already seen, very useful in aiding or confirming the cure. In cases of gravel and stone, diuretics and abundant diluents are often had recourse to in order to render the urine less concentrated, and consequently less irritating, as well as liable to form deposits. Under the head of diuretics we have also arranged, for convenience of reference, such medicines as seem to modify the sensibility of the kidneys, bladder, and urethra, either by their direct action on those parts to which they are occasionally carried by the circulation, or by their stimulant or tonic influence on the digestive organs, which being thus enabled more perfectly to fulfil their functions, assimilation of the food is more complete, and consequently less labour remains for the urinary organs, and their secretion is of a less irritating quality. Of the influence of temperature, and of the condition of the skin over the urinary secretion, we have evidence in its loaded state and diminished quantity during summer and after being long in heated apartments, as also in its aug- mented bulk and less proportion of saline ingredients in frosty weather. In diseases of the urinary apparatus the importance of suitable clothing, moderate exercise and friction, the occasional use of the warm bath, a mild climate, and such other means as are known to sustain the subsidary action of the cuta- neous vessels, should never be forgotten. ft Mist.'Amyg. ftij. Potass. Nit 3j. Solve. Fiat Emulsio. Take three tablespoonsful every hour. ft Potass. Bitart. 3ij. Aqua? Ferv. ft>ij. Cortic. Limon. et Sacch. q. s. ad conci- liand gustum. Use as common drink. R Nit. Potass, gr. x. Bitart. Potass. gr. xv. Pulv. Acac. gr. x. Sacch. 3ss. M. A powder to be taken every fourth hour in a cupful of the warm decoction of Barley. (Dropsy.) ft Spartii Cacumin. Concis. £j. Aquae tbj. M. Boil it down to one half and strain. R Colatura? 3vij. 3ij. Syr. Zingib Spirit. ^Ether. Nit. ovj. M. A mix- ture. Take two tablespoonsful every other hour. R Junip. Bacc. Contr. 3ij- Sem. Contus. 3ij. Aqua? Ferv. Jbj Macera per horas iij. et cola. a cupful. Anisi . M. Take R Infus. Cascar. 3vj. Spirit. Junip. Comp., Spirit. .Ether. Nit. aa 3j- Confect. Arom. 3jss. M. A mix- ture. Take two tablespoonsful three times a day. R Potass. Subcarb. 3j. Infus. Gentian. EXTEMPORANEOUS FORMULA (Diuretics). 691 Co. 3vij. Spirit. Junip. Comp., Tinct. Cardam. Comp. aa 3iv. A mix- ture. Take three spoonsful every fourth hour. R Pulv. Jalap, gr. xv. Potass. Bitart. 3ij. Pulv. Zingib. gr. v. Oxymel. Scillae q. s. A Bolus. R Potass. Bitart. 3jss. Junip. Bac. et Cacum. Contr gss. Pulv. Jalap. 3ij. Oxymel. Scillae 3j. Syr. Zing. 3ss. Tere bene simul. An Electuary. Take one or two spoonsful three times a day. ft Soda? Carb. Exsic. 3j. Sap. Duri Biv. Olei Junip. tri vj. Syr. Zing. q. s. Fiat Massa, in Pil. xxx. divi- denda. Take three a day. (Renal Calculus, &c) ft Potass. Bitart. 3j. Pulv. Scillae gr. ij. Pulv. Cinnam. Comp. gr. iv. Sacch. 3ss. M. A powder. To be taken three times a day. ft Scillae Rad. Exsic gr. xij. Potass Nit. 3j. Sacch. 3j. Pulv. Cinnam. Comp. 3ss. M. Divide in Pulv. vj. Take one twice a day. R Pil. Scilla? Comp. Biy. Hydr. Chlo- ridi gr. v. Divide in Pil. xx. Take two night and morning. ft Pil. Hydr. 3j. Pulv. Scilla? Bj. Opii gr. v. Conf Rosa? q. s. ut fiat Massa, in Pil. xx. dividend. Take one three times a day. (Ascites and Anasarca.) ft Pulv. Digit., Pulv. Scilla? aa gr.j. Pil. Hydr. gr. iij. M. A pill. To be taken every morning and evening. R Pulv. Digit, gr. x. Pulv. Scillae gr. xv. Hydr. Chloridi gr. v. Extr. Gentian, q. s. Divide in Pil. x. Take one night and morning. R Infus. Digit. 3iv. Potass. Acet. Bj. Spirit. .Ether. Nit. 3j. Aquae Cin- nam. 3v. M. A draught. To be repeated every sixth hour. (In Hy- drothorax. To be continued till the urine is increased, unless the pulse, head, or digestive organs, be affected by it, when it should be instantly dis- continued.) R Mist. Camph. 3jss. Am. Carb. gr. viij. Spirit. .Ether. Nit. 3j. Tinct. Digit. n*xx. M. A draught. To be taken twice a day. ft Tinct. Scillae 3ij. Spirit. Armor. Comp. 3ij. Spirit. .Ether. Nit. 3iv. Infus. Calumba? 3vij. M. A mixture. Take two tablespoonsful three or four times a day. R Acet. Colch. 3 v. Potass. Acet 3ij. Aqua? Foenic 3vij. Spirit. Junip. Comp. 3ss. M. A mixture. Take two tablespoonsful three times a day. R Decoct. Senega? 3v. Tinct. Scilla? 3j. Spir. Junip. Comp. 3iij. Syr. Simp. 3iv. Spirit. iEther. Nit. 3ij. M. A mixture. Take two table- spoonsful every four hours. (In Dropsy, with great debility and op- pression of chest.) ft Infus. Diosma? Crenata? (Buchu) 3vij. Tinct. Diosma?, Tinct. Cubeba? aa 3iv. M. A mixture. Take two table spoonsful three times a day. (In Chronic Diseases of the Prostate, Bladder and Kidneys, Gravel, &c.) R Uvae Ursi 3jss. Carb. Soda? Exsic. 3ss. Pulv. Cinnam. Comp. 3ss. Conf. Rosa? q. s. Divide in Bolus vj. Take one three times a day. (In Chronic Inflammation of the Kidneys and Bladder, Calculous Affections, &c Three grains of Extract. Conii may occasionally be added with advan- tage to each dose.) R Uva? Ursi Fol. 3ij. Aqua? Ferv. ft>ss. Macerate for three hours and strain. R Colaturae 3vijss. Acid. Sulph: Dil. 3j. Tinct. Digit. m_lx. Syr. Papav. 3iij. M. A mixture. Take three tablespoonsful three times a day. (In Chronic Larnygitis and Bron- chitis.) R Decoct. Uva? Ursi, Liq. Calcis aa 3iv. M. Take a wine-glassful (3ii.) four times a day. 692 extemporaneous formulje (Emmenagogucs.) R Infus. Pareira? 3viij. Extr. Ejusdem 3ij. Tinct. Hyosc. 3ij. M. A mix- ture. Take three tablespoonsful three times a day. (Chronic inflam- mation of the Bladder, Calculous Affections, Rheumatism, &c) ft Infus. Pareira? 3viij. Acid. Nitr. Dil. ruxl. M. A mixture. Of which take three tablespoonsful three or four times a day. (In Cal- culous Deposit consisting of the triple phosphate, announced by the iridescent pellicle on the surface of the urine.) R Chimaphila? Umbellatae .(Pyrola?) 3j. Aqua? Ifeij. Decoque ad tbj. Cola. Colaturae adde Liquor. Carb. Potassae 3ij. Take four tablespoonsful three times a day. (In Dropsy and Chronic Affections of the urinary Organs.) R Tinct. Ferri Mur. ff*xij.; Aqua? Tepid. 3j- M. A draught, to be repeated every fifteen minutes, until nausea, or a flow of the urine is in- duced. (In retention of urine, Dy- sury, and Haemorrhage from the Urinary Organs.) ft Tinct. Lytta? 3ij. Tinct. Camph. Co. 3ij. Tinct. Cinch. Comp. 3ijss. M. A mixture. Give the child rr^xxx. three times a day. (In Hooping-cough. The dose may be cautiously increased.) XI. EMMENAGOGUES. The measures proper to be employed with a view to the establishment or re- storation of the menstrual discharge are as numerous and dissimilar as the varieties of amenorrhcea. For their full consideration we must refer to a former portion of this work, where all the forms of this affection are treated of. In most cases it is much more to the management of the general health, the establishment of a sound condition of the assimilative functions and of the ner- vous system, and bringing the vascular system into a natural state, or one equally remote from plethora and from anaemia, than to any medicine supposed to act specially on the uterine organs, that we should look for the removal of this disorder, or, to speak more correctly, of this symptom of disorder. The means usually resorted to in the asthenic variety of amenorrhcea, to which we must here chiefly confine our attention, are reducible for the most part to general stimulants and tonics, antispasmodics and purgatives. The latter in particular, when combined with bark, or iron, are very effectual in some of the more common forms, in which a general torpor of the system is complicated with a remarkably defective action of the stomach and bowels. The use of the pediluvium and warm hip bath, the passing of feeble electrical shocks through the pelvis, and the application of a few leeches to the groin or adjacent parts, so as to favour a determination of blood towards the uterus, are often useful auxiliaries. R PjJ. Galb: Comp., Pil. Aloes cum Myrrha aa Bij. M. Divide in Pil. xx. Take two twice a day. (At the same time either of the following preparations of iron may be taken; and at the approach to the menstrual period, two or three leeches applied to the upper part of the thighs, or the tepid hip bath employed, and sinapisms applied to the breasts.) R Quin. Disulph. gr. xij. Pil. Aloes cum Myrrha Bijss. M. Divide in Pil. xij. Take two twice a day. R Pulv. Jacob. Veri 3ss. Guiaci Resin., Pil. Aloes cum Myrrha aa Bij. Syr. Simple, q. s. Divide in Pil. xxiv. Take two three times a day. EXTEMPORANEOUS FORMULAE (Antacids). 693 R Mist. Ferri Comp. 3jss. Aquae Cinnam. 3ss. M. A draught. To be taken three times a day. R Vini Ferri 3j. Tinct. Aloes Comp. 3vi. Tinct. Castor. 3ij. M. A mixture. Of which a teaspoonful may be taken three times a day, in a cupful of the infusion of Chamo- mile. R Pil. Aloes cum Myrrha, Pil. Ferri Comp. aa 3j. M. Divide in Pil. xxiv. Take two or three twice a day. R Myrrha? Pulv. Bj. Ferri Sulph. gr. jss. Soda? Carb. gr. iv. Tinct. Croci 3j. Aqua? Mentha? Puleg. 3jss. M. A draught. To be taken three times a day. R Sabinae Fol. Exsic, Pulv. Zing, aa gr. vj. Potass. Sulph. 3ss. M. A powder. To be taken twice a day. (A stimulant emmenagogue. Its em- ployment demands much caution, and may generally be dispensed with.) For formulae containing Hy- driodate of Potass, see Alteratives. R Liq. Ammon. mjxij. 3jss. M. (For a tion.) Lactis Tepidi vaginal injec- XII. ANTACIDS. Including Absorbents and Antilitliics. These are. as their name imports, medicines for neutralizing acidity. The sub- stances which exercise this power in the most direct manner are the fixed and volatile alkalies, either in their simple or in their carbonated state, together with lime and magnesia. These all act, however, for the most part only as palliatives, neutralizing the acidity already existing in the stomach or bowels, without in any degree preventing its almost immediate regeneration, whether by secretion or fermentation. To obviate permanently the tendency to the excessive formation of acid, we must have recourse to such measures dietetic and medicinal as may gradually improve the tone of the digestive organs. With this view regular exercise, and the enjoyment of a pure bracing air, are very important, together with temperance in regard to vinous stimulants, abstinence from mall liquors, pastry, made dishes, and crude vegetables. The food, of which a fair proportion should consist of animal substances, should be taken at regular and moderate intervals, as from five to seven hours, inasmuch as both eating too frequently and fasting too long tend in a remark- able degree to weaken the stomach, and cause an extrication of superfluous acid. Over-anxiety of mind, intense and prolonged intellectual exertion, late hours, and all species of dissipations are likewise injurious. Bitters and other tonics, and especially the mineral acids (and above all the sulphuric), in a dilute form, frequently prove very useful in counteracting the morbid tendency in question. We have likewise known great benefit from taking frequently in the course of the day, for a length of time, a teaspoonful of the white of egg beaten up raw. In the mean time, or till the debilitated state of the stomach has been perma- nently corrected, the alkalies and earths above alluded to form useful resources. In respect to neutralizing power, ammonia stands at the head of them all; magnesia comes next, then lime, and last on the list stand soda and potash. Magnesia is, however, in the great majority of instances, deserving of a pre- ference, both on account of its comparatively inert nature rendering the pre- cise adaptation of the dose less important, as well as from its insolubility, caus- ing it to remain longer in the stomach, or till the time for its operation arrives, and finally, from its forming with the acid a compound of gently aperient 694 EXTEMPORANEOUS FORMULAE (Antacids.) qualities. This last circumstance renders it very valuable in the most frequent cases of chronic dyspepsia in which constipation coexists; as well as for gouty subjects, in whom an open state of the bowels is very important. When there is much flatulence, or it is desirable that the dose should be comprised in as small bulk as possible, the calcined magnesia, and especially Dr. Henry's pre- paration, is to be preferred. Its solution in carbonated water is a very con- venient form of exhibition, and much the least disagreeable to most persons, as well as less apt to give rise to the formation of the concretions in the intes- tines to which we have already alluded. When acidity gives occasion to troublesome diarrhcea, as is so often the case in early infancy more especially, lime is to be preferred either in the form of chalk (its carbonate), or in that of lime water. When the alkalies are resorted to with a view to correcting acidity, the carbonates, or rather the bicarbonates, ought commonly to be selected, provided flatulence is not complained of, inasmuch as they are less likely to irritate the mucous membrane. The liquor potassae is, however, in some cases, much more effectual. Its use requires caution; but with this it has been carried safely, and with conspicuous advantage, by gradual increase, so high as the fluid drachm, and upwards, at a dose (repeated thrice in the day) in some obstinate cases of scaly diseases of the skin, connected apparently with derangement of the digestive organs. It seems not only to obviate asce- scency, but also, when properly diluted, to exercise a considerable power of soothing the irritable mucous membrane. R Liq. Potass. 3ij. Liq. Calcis 3vj. M. A mixture. Take one or two tablespoonsful, if the acidity be trou- blesome, in a cupful of weak broth. (To correct acidity and tendency to the formation of lithic acid deposit in the urine. To be taken in a small cupful of chicken broth, beef tea, flax- seed tea, or infusion of chamomile.) R Liq. Calcis, Lactis Vac. aa 3vj. M. To be used as a drink. R Potass. Carb. gr. x. Infusionis Gen- tianae Comp. 3jss. Tinct. Cascar. 3j. M. A draught. To be taken three times a day. (In Acidity of Stomach, and lithic acid diathe- sis. Potass and its carbonates are preferable in the latter case to Soda, as the compound they form with Uric Acid is more soluble.) R Liq. Potass, n^xx. Mist. Creta? 3ij. Tinct. Calumb. 3j. M. A draught. To be taken three times a day. R Liq. Ammon. fltxv. Mist. Amyg. 3ij. Tinct. Opii mjvj. M. A draught. To be taken three times a day. (Acidity of the Prima? Via?.) R Soda? Carb. Exsic 3jss. Pulv. Cin- nam. Comp. 3ss. Sapon. 3ss. Bal- sami Peruv. q. s. ut fiant Pil. xxx. Take three three times a day. (In lithic diathesis, and Chronic Irritation of the Urinary Organs.) R Ammon. Carb. gr. viij. Extr. Rhei gr. viij. Syr. Zing. q. s. Divide in Pil. iv. Take one or two pro re nata if acid be abundant in the sto- mach. R Magnes. 3j. Aqua? Menth. Pip. 3xv. Tinct. Aurant. 3j. M. A draught. To be taken pro re nata. (Heart- burn.) R Magnes. Carb. gr. x. Soda? Carb. gr. v. Pulv. Zing. gr. iij. Pulv. Glycyr. gr. xij. M. A powder. R Magnes. 3ij. Pulu. Rhei Bij. Aqua? Cinnam., Aqua? Font, aa 3iijss. Spir. Ammon. Arom., Syr. Zing, aa 3iv. M. A mixture. Take two tablespoonsful three times a day, having previously shaken the vial. (Cardialgia, Pyrosis, &c) R Solut. Magnes. (ope Acidi Carbon.) 3xij. Syr. Aurant. 3jss. Tinct. Cardam. Co. 3jss. M. A draught. To be taken pro re nata. (Acidity of Stomach. Magnesia in solution extemporaneous FOEMULJG (Lithontriptics—Refrigerants.) 695 is much less disagreeable to the taste, and less prone to form alvine con- cretions, than in its pulverulent state.) N.B.—Acidity of Stomach is often much more effectually combated by the mineral acids, and especially sulphuric acid, in a very dilute form, than by its more direct chemical antagonists, the alkalies and absorbent earths. (For Formula?, see Stimulants and Tonics.) Opiates have also, as remarked by Cul- len and others, a very remarkable power of restraining the secretion of acid, and especially when combined with bitter tonics, as in the following formula of Dr. Osborne: R Tinct. Opii 3j. Tinct. Rhei, Tinct. Humuli aa 3jss. M. Takefftxxiv. three times a day, in a dessert-spoon- ful of water. (It should be taken on an empty stomach.) For the medicines proper in those cases of Calculus resulting from the predominance of the alkaline diathesis, see the acid mixtures, &c, under the heads of Stimulants and Diuretics. XIII. LITHONTRIPTICS, OR ANTILITHICS. Medicines exhibited with a view to the removal or palliation of calculous affec- tions scarcely appear to demand a separate place in our classification. It is doubtful, indeed, whether there exist any remedies deserving strictly the title lithontriptics, if we are to understand by it substances capable, with safety, of dissolving stone or gravel within the body. For formula? by which the symp- toms connected with them may be in some degree assuaged, and an attempt made to prevent the continuance of deposit, the reader is referred to antacids and tonics, including the mineral acids, to diuretics, demulcents, and narcotics, or sedatives. For the mode of their application, and especially of that of alka- lies and acids, which requires the utmost discrimination in order even to avoid doing harm, the article on calculous disorders in a previous part of this work is particularly worthy of perusal. The uric acid concretions are the most frequent; and here it is to the alka- lies, to lime, and, above all, to magnesia, that we look for aid. The phosphates of lime and of this earth along with ammonia and magnesia require, on the other hand, the cautious exhibition of an acid. Whatever may have been the original nucleus, the phosphatics diathesis is apt sooner or later to occur. A very great difficulty often arises in practice from the circumstance of the suc- cessive layers of the calculus being of different, and even opposit natures. The actual condition of the urine should be almost daily tested, and the treat- ment modified accordingly. XIV. REFRIGERANTS. These are medicines which are supposed to be capable of diminishing the tem- perature of the body without inducing debility. The acids, especially those fur- nished by the vegetable kingdom, and nitre, have very commonly received credit for such powers. Acidulous drinks certainly tend, in a remarkable de- gree, to relieve thirst, and so to diminish irritation and feverishness in many acute disorders, but require caution where the mucous membranes of the chest, or of the digestive or urinary organs are inflamed. Cold water and ice are the refrigerants of the most extensive applicability and most certain efficacy. Cold 696 extemporaneous formula (Refrigerants.) drinks are highly beneficial in many febrile diseases, and cool fresh air is in- valuable. The cold affusion produces the most happy results, in simple fevers unattended with internal inflammation, as well as in small-pox and scarlatina, provided the skin be hot and dry, and the pulse quick and strong, and the disease in its early stage. Where, however, internal inflammation coexists, or the pulse is feeble, and the skin cool, or a sensation of chillness is complained of by the patient, cold affusion is highly improper. In doubtful or intermediate cases, tepid sponging is preferable. In uterine haemorrhages, the cold dash directed on the hypogastric region is a very powerful remedy; in delirium ferox and raging madness, the dropping of cold water on the top of the head is a most potent sedative, and one requiring great caution in its application, inasmuch as, if pushed too far, it might cause dangerous and even fatal collapse. In inflam- mation of the brain and its membranes, the application of a bladder filled with pounded ice, or of cloths dipped in cold water, or evaporating lotions, are often productive of much benefit, the body and extremities being kept warm. In a great variety of haemorrhages, and in inflammations of the skin and of the sto- mach, and in the case of wounds, the external and internal employment of cold is a precious resource. In hectic, sponging the chest and neck with cold vine- gar and water has often seemed to exercise a marked control over the progress of the symptoms in cases of pulmonary disease. Cold applications generally require to be suspended during the menstrual period, and cold affusion or shower-bath is rarely admissible in advanced pregnancy, except perhaps in those long habituated to its use. ft Spir. Vini. Rectif. 3j. Aquas Font. 3v. M. An evaporating lotion. (To reduce the heat of inflamed parts.) ft Ammoniae Hydrochlor. 3j. Aquae Font. 3v. Spir. Rect. 3j. M. A discutient lotion. (In swelled testicle or other inflammatory tumours.) R Liq. Ammon. Acet., Aqua? Distil., Spir. Rect. aa 3'j. M. A Lotion. (In Phlegmonous Inflammation.) ft Ammon. Hydrochlor. 3ij. Acid. Acet. Dil. |vj. Spir. Camphora?, 3ij. M. A Lotion. (In Sprains and Con- fusions, and to promote the absorp- tion of ecchymosed blood.) ft Liquoris Plumbi Diacet. 3j. Acid. Acet. Dil. 3ij. Spirit. Rectif. 3j. Aqua? Rosae 3vij. M. A Lotion. ft Liq. Ammon. Acet. 3yj. Spir. Rosmar. 3'j. Aquae 3xvj. M. A Lotion. (To be applied to the head in the headache of the earlier stages of Fever, &c) R Potass. Nit. Ammon. Hydrochlor. aa 3ss. Aqua? Perfrig. ftj. M. A Lotion. (To be applied as above, immediately after its solution, by means of lint or old linen saturated with it, and frequently replaced. If used as a substitute for ice, the pro- portion of the salts used should be much greater than this, or about as one of each to three of water. The mixture may be made in a bladder and thus be conveniently applied to the head in Fever, or to the tumour in Strangulated Hernia, &c. It should be renewed at short intervals. A very intense degree of cold may also be produced by the sedulous evaporation of ether.) XV. DEMULCENTS AND EMOLLIENTS. Demulcents are substances of a mucilaginous, gelatinous, or oleaginous nature, which tend to defend the parts to which they are applied from irritating extemporaneous formulae (Demulcents, etc.) 697 matters; and at the same time to relax and to soothe inflamed membranes, either by direct contact, or by continuous, contiguous, or remote sympathy. It is almost exclusively in diseases of the mucous membranes of the respiratory, digestive and urinary organs that they are employed. The jellies and decoctions formed of arrow-root and other similar farinaceous substances constitute amongst the best and least irritating species of nutriment in diarrhcea and dysentery, subacute inflammation of the stomach, and con- valescence from various debilitating diseases whilst the digestive powers are still weak. Enemata of starch with or without the addition of an opiate are found often of great service in allaying irritation within the rectum, and in the neighbouring portions of the urinary and genital organs. The decoction of sarsaparilla, which is commonly arranged under the head of diaphoretics, might perhaps with equal propriety, so feeble are its cbvious medicinal qualities, be placed here. Liquorice, one of the most useful of the class of demulcents, is sometimes employed with good effect to relieve the heartburn connected with acidity. Emollients are in their action very similar to demulcents. The term has generally been restricted to relaxants adapted for external application. Heat and moisture conjoined constitute the most effectual emollients, of which we have daily evidence in the happy results of the applications of poultices and fomentations in painful and inflammatory affections, contused wounds, &c.; and oily and mucilaginous additions are sometimes thought to augment their efficacy. Some of the milder liniments and ointments also belong to this class. R Mucilag. Acacia? ^ij. Aqua? 3iv. Syrup. Tolut., Aqua? Flor. Aurantii aa 3j> A mixture. Take one table- spoonful every second hour. (In irritation of the mucous membranes, either simply, or as a vehicle for narcotics, or to sheath irritating medi- cines. It may be rendered more agreeable in some cases by acidula- ting it slightly with lemon juice or sulphuric acid.) Pulv. Acac. 3ij. R Olei Amyg. 3j Tere bene simul W adde gradatim Aqua? Distil. 3v. Aqua? Cinnam. 3j. Syr. Papav. 3iv. A mixture. Take one tablespoonful frequently. (Bronchitis, &c. A couple of drachms of Wine of Ipecacuanha may often be added with advantage.) R Cetacei 3ij. Vitel Ovi j. Syr. Altha?a? 3iv. Aquae Cinnam. 3ss.; Aqua? Rosa? 3'tvss. A mixture. Take one tablespoonful from time to time. (Bronchitis, &c.) R Infus. Lini Comp. Oij. Potass. Nitr. 3j. Mannae 3j« M. A mixture. Of which a wine-glassful may be taken occasionally. (In Gonorrhcea. Slight- ly aperient and diuretic.) VOL. III. R Camphorae, Potass. Nitr. aa Bj. Pulv. Acacia? 3j. Mist. Amyg. 3vj« A mixture. Take two tablespoonsful every three hours. (In Chordee, Strangury, with plentiful dilution.) R Acacia? Gummi% 3ss. Aquae ftij. Solve. To be used as a common drink. (In Strangury from blisters, and Dysury from inflammation of the urethra, from whatever cause. It is one of the most common ptisans in the hospitals d$ France in all inflam- matory diseases, especially of the mucous membranes of the stomach and intestines. It may be flavoured with syrup, with bitter almonds, and in some instances also with lemon juice, but not if the urinary organs are in an irritable state.) R R 88 Oryza? 3ss. Aqua? ftiij. Decoque ad ibij. To be used as a drink. (In Diarrhoea, Dysentery. It may be flavoured with Syrup of Red Rose, or with Aromatic Sulphuric Acid, or combined with the Infusion of Cate- chu and other astringents.) Cornu Cervi Rament. ^iv. Mica? Panis |j. Aqua? tbiij. Decoque ad 698 extemporaneous formula (Anthelmintics). libras ij. Cola. Adde syr. Simpl. §ij. Aqua? Cinnam. 3iv. M. Take from time to time two or three table- spoonsful. (In Chronic Diarrhcea and the advanced stages of Inflam- matory Affections, where a light nu- triment is requisite. This is " the white decoction" of the French hos- pitals, and of Sydenham nearly.) R Carnis Vitulina? 3iv. Aquae ft>ij. Decoque ad Ibjss. To be used as a drink. (Demulcent and slightly aperient. In the irritation of the mucous membrane of the intestines from mercury, &c. Its laxative quality may be increased, if requisite, by the addition of an ounce of Ta- marinds, or a grain of Tartrate of Antimony.) R Althaeae Offic 3j« Aquae Bullient. ft>ij. Syr. Simp. q. s. To be drank freely. (In inflammations of the Chest, Abdomen, and especially of the Kidneys and Bladder. " Eau de Guimauve," of the French hospitals.) R Ichthyocolla? 3'j. Aqua? feij. De- coque ad fcj. Cola, et adde Lactis Vaccini Iij. Sacchari 3j. M. Take three or four tablespoonsful occa- sionally. (Demulcent and Nutritive.) R Decocti Althaeae Rad. ft>j. Liq. Plumb. Diacet. 3j___3ij. M. A lo- tion. (In Lichen, Eczema, and Im- petigo.) R Furfuris Tritici ft>iv. Aqua? Frigidi ftxij. M. Boil, strain, and add it to a warm bath. (To form an emol- lient bath in acute cutaneous dis- eases, as Eczema, Impetigo, Lichen, Herpes, &c The water should not be much above 90°. The patient may continue in it from half an hour to two hours ; one or two pounds of isinglass dissolved in water may be substituted if expense be unimpor- tant.) R Fecula? Tuber. Solani, Decoct. Rad. Althaeae aa q. s. Mix the Fecula with the cool Decoction, then add the remainder of the Decoction, and boil it down to the proper consistence for a cataplasm. (An excellent poultice in irritable disease of the skin, ap- plied lukewarm. It does not become sour or rancid.) XVI. ANTHELMINTICS. Some of the most im§prtant and generally applicable remedies in the treatment of worms (especially the ascarides vermiculares, and lumoricoides) will be found under the head of tonics and purgatives. Of the latter class, the most commonly useful are calomel and jalap in large doses, castor oil, croton oil, rhubarb, aloes, senna, scammony, and gamboge. Of medicines which seem to exert a special influence over the worms themselves, a few are here subjoined. R Semin. Santonici, et Semin. Tana- ceti rude Contus. aa 3ss. Pulv. Valer. 3ij. Pulv. Jalap. 3jss. Sulph. Potass. 3ij. Oxymel. Scill. q. s. et fiat Elect. Take one teaspoonful every night and morning. (Lumbrici and Asca- rides. Its use should be continued for five or six days.) (Bremser.) R Artemisia? Santonica? Bj. Hydrarg. Chloridi gr. vj. Pulv. Rhei 3ss. Camphorae gr. xij. Syr. Simp. q. s. M. Divide in Bolos ij. Take one in the morning, and the other after six hours have elapsed, unless a full evacuation have occurred before that time. R Stanni Pulv. 3j-; Extr. Artem. Ab- sinth., Pulv. Jalap, aa 3ij. Syr. Aurant. q. s. M. Divide in Bolos xij. Take one every half hour, until a free evacuation occur. (In Asca- rides, Lumbrici, and Taenia.) extemporaneous formula (Anthelmintics.) 699 R Dolichi Pruriens Mucuna? 3j. The- riaca? 3j. M. Fiat Elect. Take one teaspoonful every morning. (In Lumbrici and Ascaridas. A purga- tive should be given every second or third day.) R Absinthii, Tanaceti aa 3iij. Valer. Radicis Trita? 3ij. Cort. Aurant. 3j. Aquae Fervent. 3viij- Macera per horam. Cola. An enema, to be in- jected every night and morning. (In Ascarides. Its efficacy is remark- ably increased by the addition of half a drachm of the " 01. Empyreumat Cornu Cervi," or of a drachm of Chabert's Oil.) R Tinct. Ferri Muriat. 3iv. Aquae 3viij M. An enema. (Ascarides ; a pur- gative of Calomel and Jalap being administered simultaneously (Dar- wall),and Chamomile Infusion drank thrice a day for a fortnight after- wards.) ft Mist. Assafcet., Lactis Vac aa 3iv. M. An enema, to be given at bed- time. (Ascarides. Assafcetida in five- grain doses four times a day for two days, followed by a purgative (Rhu- barb) on the third day, has also been found useful; as has likewise a starch injection containing half an ounce of Turpentine. Half-drachm doses of Turpentine administered in half an ounce of Mucilage thrice a day for a week has proved very effectual in ex- pelling the Lumbrici of children.) R 01. Tereb. 3j___ij. Decoct. Hordei Frig. fj. M. A draught. (Taenia The dose may be repeated every morning for three days running, or in persons of delicate frame every second morning. If it do not purge within two hours, a dose of Castor Oil should be administered. A very effectual remedy. It occasionally causes a temporary headache and giddiness, like intoxication.) R Filicis Maris. Rad. Contrit. 3ij. To be taken early in the morning in a cupful of Mint-water, and after two hours, a purgative Bolus is to be ad- ministered, viz.:— R Hydr. Chloridi gr. v. Jalap. 3j. M. A Bolus. (In Taenia. The medicine to be worked off by drinking plenti- fully of green tea. This was Madame Nouffler's celebrated remedy, save that six grains of Gamboge and twelve of Scammony were given in the Bolus in place of Jalap, and the quantity of Calomel was double that here specified.) R Decoct. Filicis Maris 3iv« (3jss. ad Ibij.) iEther. Sulph. 3j. M. A draught, to be taken in the morning, and afterwards, without delay, ad- minister an injection of Decoct. Fili- cis 3x. .Ether. Sulph. 3ii. One hour after, give the following purgative mixture:— R 01. Ricini 3ij.; Syrup. Flor. Persic 3j. M. A mixture. (Bourdier's treatment of Tape Worm. An a?the- rial solution of the oleo-resinous principle in the male fern root, has been found very effectual by Peschier in destroying these parasites. The dose is 30 drops in bread pills, one- half of which is taken at night, and the remainder the following morning; a dose of Castor Oil being given an hour after the latter. Chabert's Oil is one of the most generally successful remedies in this affection. The fol- lowing is the formula for its prepara- tion and use) :— ft Olei Empyreumatici Cornu Cervi 3'j. Olei Terebinth. 3vj. M. Let the mixture stand three days, then distil 3vj. from a glass retort. Pour it out into six small vials well stopped, and kept in a cold and dark room. Take rnjxv. (gradually increasing the dose to 3j.) in a little Cinnamon water, every night and morning, for five or six weeks. (The bowels should be well cleared out with the aperient ver- mifuge electuary of Bremser, given above, before the use of this oil is commenced, and occasionally during its employment. It seems not only to destroy the Tape Worm, but also to prevent its reproduction in the great majority of cases. Its admi- nistration requires caution, though it is much less energetic and dangerous 700 extemporaneous formulje (Antiphlogistics, etc.) than the " animal oil of Dippel" (the empyreumatic oil obtained from the Hartshorn rectified, &c), the latter being three or four times as strong as Chabert's Oil. These oils become dark-coloured and unfit for use by long keeping and exposure to light, and then require to be redistilled.) R Pulv. Rad. Granati Cort. 3ss. Di- vide in Pulveres vj. Take one every half hour, until the sixth repetition. (The employment of the bark of the root of the pomegranate has been re- cently revived with much success in the treatment of Tape Worm. The last dose should be followed by an active aperient, as Senna and Salts ;l R Hydr. cum Creta. 3ss. Pulv. Ipecac. gr. x. Pulv. Rhei Bij. Pulv. Cin. Comp. gr. x. Pulv. Sacch. Albi 3j. M. Divide in Pulv. x. Take one two or three times a day. (Mesen- teric disease, &c. A deobstruent for infants.) R Hydrarg. Chlor. Bj. Antimon. Po- tassio-tart. gr. iv. Guiaci Gum. Res. 3j. Tere optime, et adde Confect. Rosae q. s., et fiant Pil. xx. Take one night and morning. (In chronic inflammations of the joints, and of internal organs, and of the skin, eyes, &c. In many cases a pill every pight or second night is sufficient.) 3 and the whole treatment may be re- 3 peated at the interval of a week, to r the third time. It occasionally causes y a transient stupor or giddiness, or ? vomiting.) (Elliotson.) J R Cort. Rad. Punica? Granati 3ij. Aqua? ibij. Macera per horas viginti-qua- tuor. Decoque ad tbj. Adde Syrupi r Zingiberis 3j« M. Divide in partes tres. Take one every half hour, ; until the third repetition, beginning in the morning. (It may also be i simultaneously exhibited in the form ; of enema. A large dose of Castor Oil, with Syrup of Lemon, is gene- ;l rally administered the night before.) R Massa? Pil. Hydr. 3j. Divide in Pil. xij. Take one three times a day. (In Syphilis, Acute and Chronic In- flammation of the Liver, ccc.) R Pil. Hydr. Chlor. Comp. 3ss. Extr. Sarsa?, et Extr. Tarax. aa 3j. Di- vide in Pil. xxx. Take two three times a day. (Alterative.) R Hydrarg. Chloridi 3ss. Opii gr. v. Conf. Rosa? q. s. Divide in Pil. xx. Take one twice a day. (In Syphilis, Chronic Hepatitis, and subacute in- flammation of various organs.) R Hydr. Chloridi 3ss. Opii gr. v. Pulv. XVII. ANTIPHLOGISTIC, ANTISYPHILITIC, ALTERATIVE, AND DEOBSTRUENT REMEDIES. Unoer these heads we have collected together, rather with a view to practical utility than in accordance with strict accuracy of scientific arrangement, for- mula? for such medicines as exert a peculiar control over the capillaries through- out the system at large, as manifested in the power of restraining inflammation in its acute or in its chronic form, or else in that of promoting the absorption of inflammatory or other abnormal deposits (mercury, antimony, iodine). To have arranged these under the head of stimulants, or of tonics, as some systematic writers have done, or to separate from the rest the most valuable amongst them (mercury), and place it under the head of sialagogues in a distinct class, thus fixing on one of the least important effects of a medicine as the grounds for its classification, could scarcely be considered as an improvement even in respect to theoretic principles of arrangement, and would assuredly be of much less advantage as to the great object of all medical classification,— aiding the memory by judicious associations of a practical tendency. extemporaneous formula (Alteratives). 701 Antimon. Bj. Conf. Rosae q. s. ut fiant Pil. xv. Take one every fourth hour. (In acute inflammation of the viscera, Acute Rheumatism, Syno- vitis (after bloodletting and aperients.) Invaluable in inflammation of the serous membranes more especially. . The Antimonial Powder may be | omitted, when it deranges the sto- mach or bowels. A much smaller quantity of Mercury, given at very short intervals, will often salivate very rapidly, and may be trusted to in cases which are not of extreme urgency, and especially where the after-effects of the remedy are sub- ject of apprehension : thus, a single grain of Calomel will frequently be sufficient for every purpose, as in the following formula of Dr. Law):— R Hydrarg. Chlor. gr. j. Extract. Gentianae q. s. M. Divide in Pil. xij. Take one every hour. R Hydrarg. Bichlor. (Oxymur.) gr. ij. Spir. Rect. 3iv. Aqua? Distil, giijss. M. Fiat Mist. Take a teaspoonful daily in a cupful of the decoction of barley, or of sweetened water. (In Syphilitic Affections, Lepra, &c, the dose may be cautiously increased to two, three, or even four teaspoonsful. It should not be taken on an empty stomach.) R Hydr. Bichlor. gr. iv. Ammon. Bichlor gr. v. Solve in Aqua? Fer- vent, pauxill. Adde Mica? Panis q. s. ut fiant Pil. xx. Take one daily. (Syphilis. It may be guarded, if requisite, with Opium.) R Hydr. Bichlor. gr. j. Tinct. Cinch. 3ij. Solve. Take a teaspoonful twice a day in a cupful of the infu- sion of chamomile. (In Scrofula.) R Hydr. Acetatis 3ss. Camphora? Rasa? 3ss. Opii gr. x. Syr. Papav. q. s. ut fiant Pilula? xxx. Take one every night and morning. (Syphilis. May be gradually increased to four or five pills at a dose.) R Hydr. Chlor. 3ij- Liq. Calcis ibj. M. A Lotion. (Common Black Wash. Applicable to syphilitic ul- cerations and irritable sores.) R Hydr. Bichlor. gr. xxv. Liq. Calcis Ibj. M. A Lotion4 (In syphilitic sores requiring to be stimulated.) R Hydr. Binoxidi (Oxidi Rubri) 3ss. Adipis Praep. 3j. Cera? Alba? Biv. M. An ointment. (In Chronic In- flammation of the Tarsi and Conjunc- tiva, a minute portion being smeared along the edges of the palpebrae, so as to produce an abundant secretion from the Meibomian glands.) R Hydr. Binoxidi gr. v. Zinci Sulph. gr. x. Adipis 3j. M. An ointment. (In Tarsal Ophthalmia, in scrofulous habits.) R Antim. Potassio-tart. gr. vj. Aqua? Cinnam., Aqua? Distil, aa ^viij. Syr. Altha?a? 3'j- M. A mixture, of which take a sixth part every two hours. (Pneumonia, Acute Rheu- matism, &c. After the sixth dose, the medicine is intermitted, except in very severe cases, for seven or eight hours. Where it continues to produce much sickness and purging, three or four drachms of the Com- pound Tinct. of Camphor may be added to the mixture, or an ounce of the Syrup of Poppies substituted for that of Marsh Mallows. In some in- stances, it controls the inflammation, without affecting either the stomach or bowels.) (Laennec.) R Antimonii Oxysulphureti (Sulph. Antim. Aurat.) gr. x. Flor. Sul- phuris 3jss. Guiaci Resin., Extr. Conii aa 3j. Sacchari Faecis q. s. Divide in Pil. Ix. Take three, three times a day. (In Chronic Cutaneous Affections.) R Tinct. lodinii Comp. r\x. Aquae Distil. 3j. M. A draught, to be taken three times a day in a cupful of sweetened water, or of the decoc- tion of Sarsaparilla. (In- Scrofula, Goitre, Amenorrhcea, Hypertrophy of various organs, Secondary Sy- philis, &c. The dose may be cau- 702 extemporaneous formula (Alteratives). tiously increased to 20 or 30 drops thrice a day, and the Unguent. Iodinii Composit. at the same time applied to the tumours externally, in the case of Bronchocele, Glandular Diseases, &q. Where it causes emaciation, its use must be sus- pended for a time; so likewise where rapidity of the pulse and pal pitations are induced, or cough, loss of sleep, and tendency to cerebral congestion, giddiness and headache, extreme irritability and trembling, or pain in the stomach. Its tendency to produce wasting of the mamma? and testes, when pushed too far, should not be forgotten.) R Potass. lodidi (Hydriod. Potassa?) gr. iij. Aqua? Distil. 3j. M. A draught, to be taken three times a day. (Syphilitic affections of the bones, and Chronic Rheumatism, &c. in a glass of Decoction of Sar- saparilla, or of sugar and water. The dose may be gradually increased to five or six grains and upwards; but the very large doses in which it is sometimes administered (even drachm doses) seem to be neither safe nor necessary when long con- tinued. Its frequent impurity may account for such large quantities having done less mischief than might have been anticipated. In Peritos- titis, where it is an object to cut the disease short, scruple doses, guarded if necessary with Tinct. Opii, may be administered thrice a day for a short period.) R Potassii lodidi 3j- Tinct. Digit. TTixl. Lactucarii 3j. Aquae Distil. 3iij. Aqua? Flor. Aur. 3ij. Syr. Althaea? 3yj. M. A mixture. A tablespoonful of which may be taken night and morning. (Hypertrophy of the Heart.) R Potassii lodidi gr. ij. Iodinii gr. j. Aquae Distil. 3viij. M. A mix- ture. Take one third three times a day. (In Scrofula. For children under seven years, the third of the above dose will generally be suffi- cient, and each draught of it may be sweetened wilh sugar, just before taking it, but not sooner, as decom- position would ensue. It may be made still more dilute, and used for common drink, where it is to be long continued.) R Ferri lodidi (Hydriodat.) gr. ij. Aqua? Distil. 3j« M. A draught, to be taken three times a day in a cupful of sweetened water. (In Scrofula, Chlorosis, Amenorrhcea, Leucorrhoea, Phthisis, Secondary Syphilis, Lepra, &c. the dose may be increased to four grains and up- wards. Iodine administered in this form is said to be less liable to ac- cumulate in the system, as it passes off readily by the kidneys; but the facility of the decomposition of Iodide of Iron renders the rapid evolution of an injurious quantity of Iodine possible.) R Ferri lodidi gr. xxx. Croci Stig. Pulv. 3j. Sacch. Albi 3iij. Muc Trag. q. s. M. Contunde simul, et divide in Pil. xc. Take two or three three times a day. (Stimulant and tonic properties of Iron and Iodine combined as in the preceding for- mula ; but the solution is a much more permanent and therefore preferable form.) R Hydr. lodidi gr. j. Extr. Glycyr. gr. xij. Pulv. Ejusdem q. s. ut fiant Pil. viij. Take one night and morning. (In Syphilitic Affections, especially when occurring in scrofu- lous constitutions. Its use requires great caution. The dose may be gradually increased to seven or eight of the above pills in the day.) R Hydr. Biniodidi gr. j. Extract. Glycyr. gr. xxxij. M. Optime. Divide in Pil. xvj. Take one night and morning. (In Syphilis. The dose may be cautiously increased to five or six of these pills at a time. Its employment, like that of Corro- sive Sublimate, demands extreme cir- cumspection.) R Hydr. Biniodidi gr. xx. Alcohol. 3jss. M. A mixture, of which TTlvj; (carefully increasing the dose extemporaneous formula (Alteratives). 703 to nixx.) may be taken twice a day in a cupful of distilled water. (In obstinate Syphilitic Affections. The ointments of the Iodide and Bin- iodide of the new pharmacopoeia are very energetic stimulants applicable to the above cases and to scrofulous and flabby sores. They should be applied only in very small quantity, and to a very limited surface at a time. R Plumbi lodidi gr. iv. Conf. Rosa? gr. xx. Misce optime. Divide in Pil. xij. Take one night and morn- ing. (In scrofulous affections of the glands, joints, &c The dose may be gradually increased to three or four pills at a time and upwards. The ointment of Iodide of Lead should be simultaneously applied to the tumours externally. It is a very active and valuable preparation, and less apt to inflame the skin than the ointment of the Hydriodate of Potass.) R Potas. Bromidi gr. xij. Aqua? Distil. 3iij. Syr. Althaeae 3j. M. A mix- ture. Take a tablespoonful three times a day. (Deobstruent and stimulant in glandular affections, enlargement of the spleen and heart, Amenorrhoea, &c) R Potassii lodidi gr. vj. Iodinii gr. iij. Aqua? Distil. Ibj. Solve. A collyrium, to be applied four times a day. (Scrofulous Ulceration of the Cornea, Inflammation of Conjunc- tiva, &c. When there is great ir- ritability, a minute quantity of Mor- phia may be added. The ointments containing Iodine are likewise often rendered much more effectual, by the addition of an opiate. The above solution is also used as a fomentation to scrofulous ulcers, and an injection into fistulous sores.) R Iodinii 3ij. Potassii lodidi 3ss. Aquae Distil. 3viij. Solve. An embrocation. (To excite very in- dolent strumous diseases. It may be used also through the medium of a cataplasm, being mixed in a flax- seed poultice, and applied very warm. It acts as a powerful rube- facient, or even as a caustic, if the skin be very susceptible. Lugol applies it to scrofulous diseases of the skin and cellular membrane, tubercles, ill-conditioned esthio- menous ulcers, Ozaena, excessive growths, caries, &c. In Lupus it is one of the very best applications that can be made. To form a bath the whole of the above solution may be added to about forty gallons of water, in a wooden vessel. These baths should produce a slight rubefacient effect on the skin ; and their strength may be somewhat increased or diminished, according to their in- fluence. The patient should remain in the bath about half an hour, every second day; and the temperature should be from 96° to 98°. The Iodine is the active ingredient in these baths, the Hydriodate serving chiefly for keeping it in solution. One-third of the above quantity is sufficient for a bath for a child, the strength remaining the same. The solution serves also, when largely diluted, for fomenting scrofulous parts, in which we do not wish to produce a very rapid or great increase of ac- tion. N. B. For formula? for the exhibition of the Nitric and Nitro-Muriatic Acids and Sarsaparilla in Syphilis, as well as that of Turpentine in Iritis and Rheu- matic Inflammation, and that of Tinc- ture of Cantharides and of Arsenic in certain obstinate Chronic Cutaneous Affections, over which they exert a re- markable alterative influence, see pre- vious classes, Stimulants, Tonics, and Diaphoretics, &c. 704 EXTEMPORANEOUS FORMULAE (Alkaloids). XVIII. ALKALOIDS. Formula? for certain of the Alkaloids and other active medicinal agents not in the British Pharmacopeias. Brucina—obtained from the false An- gustura Bark; action similar to Strychnine, but about six times weaker. Dose gr. A to gr. j. R Brucina? gr. xviij. Alcohol (36°) 3j. M. A Tincture:—Take iTlvi. cautiously increasing it to TTlxxx. (Paralysis.) R Brucina? Pulv. gr. xii.; Conf. Rosae 3ss. M. Divide in Pil. xxiv. Take one every night and morn- ing; if necessary, the dose may be gradually increased to two or three pills. Emetina—obtained from Ipecacuanha, used as an emetic and expectorant; in large doses causes, in consequence of its narcotic properties, stupor and death ; has little, if any, advantage over the ordinary preparations of Ipe- cacuanha. There are two forms of it, the coloured, and the pure or white; the latter being many times (at least four times) as strong as the former. The dose of pure Emetine for an emetic is from gr. \ to gr. ij. R Emelinae Pura? gr. j. Solve in Acido Acetico v\x.; adde Aqua? Flor. Aurant. 3iij« Syr. 3j« M. A mixture: one tablespoonful of which may be taken every fifteen minutes, until vomiting ensues. R Emetina? Pura? gr. viij. Sacch. Albi 3iv. Muc. Trag. q. s. Fiat Massa in Trochiscos cc dividenda. (Each contains l-25th of a grain of Emetine, a convenient form for children; one every quarter of an hour to the fourth time, or till vomit- ing supervenes.) R Emetinae Colorate gr. iv. Aquae Flor. Aurant. 3j« Syr. 3ss. M. A mixture, of which a tablespoonful may be taken every half hour until vomiting occurs. R Emetina? Cohrate gr. xvj. Syrup. Simp. ft>j. M. Take one or two tablespoonsful at a dose. (A sub- stitute for Syrup of Ipecacuanha.) Gentianina—obtained from the root of Gentiana lutea ; intense bitter. Dose gr. ij.—iv. R Gentianina? gr. v. Alcohol. 3j> Solve. A tincture, of which, from a half drachm to a drachm may be taken three times a day, in half a cupful of water. (A tonic bitter.) R Gentianina? gr. xvj. Syr. Simpl. ft>j. Misce. A Syrup, of which take one to three teaspoonsful at a dose. • Lupulina—obtained from Humulus lu- pulus; a bitter tonic; slightly nar- cotic. Dose gr. ij.—vj. or, in the form of tincture (3j. Lupuline to 3iij. Alcohol), ttix.—xxx. Salicina.—Antiperiodic; much inferior in efficacy to Quina generally, though it has been known in some instances to succeed after the failure of the latter. Dose gr. ij.—viij. R Salicina? gr. xij. Extr. Gentian., Pulv. Glycyr. aa q. s. ut fiant Pil. vj. Take two every two hours. (In Ague and Neuralgia; and in Dyspepsia, in smaller doses.) huiigo. R Indigoferae Disperm. 3j. Syr. EXTEMPORANEOUS FORMULAE (Alkaloids). 705 Simp. ^ij. M. An Electuary :— Take half a teaspoonful every night and morning. (In Idiopathic Epi- lepsy. The dose may be gradually increased to three or four drachms of Indigo, in a day, and its use con- tinued for several weeks. In over- doses, it produces irritation of the stomach and bowels, and spasmo- dic twitchings, like strychnia; the former of which may be guarded against by combination with Dover's Powder. Though it is only in very large doses that it has proved useful, as a matter of precaution we should commence with small ones. It tinges both the stools and urine of a bluish colour, and appears to ag- gravate the disease at the first.) Iodidum Strychnie gr. £ bis quotidie (ad gr. i caute auct.) In similar cases with Strychnia (see before) its use requiring great caution. So also the Sulphate of Strychnia which has been employed in France in doses of jVh to Tl5th of a grain ; the energy of its action even exceeding that of Strychnia, partly in conse- quence of its greater solubility. Iodidum, Sulphuris. R lodidi Sulphuris gr. xij. Adipis 3ss. M. An ointment. (In tuber cular affections of the skin (Lupus and Acne), and in Lepra and Tinea.) Iodidum Barii. R lodidi Barii gr. iv. Adipis Praep. 3j. M. An ointment. (Scrofulous tumours. Its employment requires caution.) Iodidum Zinci. R lodidi Zinci 3j. Adipis 3j. M. An ointment. Rub_ in one drachm daily. Iodidum Arsenici. R lodidi Arsenici gr. iij. Adipis 3j- M. An ointment. (In Cancerous Diseases, Lupus, &c. Its use re- vol. in. 89 quires extreme caution, and should not be had recourse to till after the failure of all other means. It should be applied only in very minute quan- tity, and never to a large surface at a time.) R Chloridi Zinci 3j. Farina? 3iv. M. (This powder, moistened with a few drops of water, forms a caustic paste of great efficacy in Lupus. It is sometimes used of double this strength. When it is intended to act deeply, the cuticle should first be removed by a small blister. It is much less dangerous than the arseni- cal paste of Fra. Come.) Cyanidum Potassi—has been used in France, America, &c, as a substitute for Prussic Acid, in doses of gr. ^ to gr. j. in an ounce of a simple syrup, or in a potion twice or thrice a day. Cyanidum Zinci—gr. l to gr. j. admi- nistered in an ounce of simple syrup, as a vermifuge. (Magendie.) Also as a substitute for Prussic Acid, in Hooping-cough, Spasm of the Sto- mach, &c. & Cyanidi Zinci gr. j. Magnes. gr. v. Pulv. Cinnam. Comp. gr. iij. M. A powder, to be taken every three hours, if the spasm be vio- lent. Cyanidum Hydrargyri. R Hydrarg. Cyanidi gr. xvj. Adipis 3j. 01. Ess. Limon. r#xv. M. An ointment. (In some obstinate forms of Impetigo, accompanied with distressing itching.) Bromidum Ferri. R Ferri Bromidi, Gum. Arab. Pulv. aa gr. xij. Conf. Rosae Gall. gr. xviij. M. Divide in Pil xxiv. Take two night and morning. (Stimulant and tonic Bromine is an irritating poison: its action resembles that of Iodine. Both it and its compounds have been used in Scrofula and Amenor- 706 EXTEMPORANEOUS FORMULAE (Alkaloids). rhcea, Hypertrophy of the Heart, &c.) Aurum.—Gold in a state of extreme subdivision, its oxide and its salts, have all, like similar preparations of Mercury, a very powerful influence on the system. Chloridum Auri.—The Chloride of Gold is an energetic poison. In very small doses it has been found to act as a general stimulant and alterative, like Corrosive Sublimate, but with less tendency to affect the salivary glands. It has been em- ployed in Germany and France in Secondary Syphilis, Scrofula, and Herpetic Affections, in doses from J^th to -^th of a grain. Its effects must be carefully watched. It should only be had recourse to in very obstinate cases. R Auri Chloridi gr. v. Pulv. Glycyr. 3ij. Syr. Simp. q. s. Misce op- time. Divide in Pil. c. Take one or two three times a day. R Auri Chloridi gr. j. Amyli Pulv. Bv. Misce optime. Divide in Pul- veres xv. (One of these powders to be rubbed into the gums night and morning.) Chloridum Auri et Sodii.—This has been more frequently employed in France than the preceding; the dose being from Jsth to TVth of a grain, internally. Also in the form of an ointment (gr. x. to 3ss. Adipis,) of which about the size of a pea is ap- plied to a small blistered surface, so as to be readily absorbed. Pilulae Arseniatis Ferri. (Biett.) R Proto-Arseniatis Ferri gr. iij. Extr. Humuli 3ij. Pulv. Altha?ae (vel Glycyr.) 3ss. Syr. Aurant. q. s. M. Mix it carefully. Divide the mass into eighty-eight pills, of which one may be taken daily. [See the previous cautions as to the mode of exhibition of Arsenic, under the head of Tonics.] N.B. For formula? for external use, as gargles, collyria, lotions, liniments, ointments, baths, &c, see particularly the classes of Stimulants, Narcotics, Astringents, and Emollients, &c. For enemata, see Purgatives, Narcotics, Astringents, &c. GENERAL INDEX TO THE THREE VOLUMES. Abdomen, worms found in the, iii. 607. See Worms. Inflammation of the, iii, 74. See Ileo-co- litis. Dropsy of the, iii. 512. Percussion of the, to ascertain the exist- ence of dropsical effusion, iii. 512. Affections of, in fever, i. 148. Abdominal Aorta, nervous pulsation of the, ii. 593. Aneurism of the, ii. 613. Abdominal Dropsy, iii. 512. See Dropsy. Worms, iii. 607. See Worms. Abscess of the brain, i. 504. Of the pancreas, iii. 192. Of the spleen, iii. 198. Of the liver, iii. 170. Scrofulous, iii. 523. See Scrofula. Acardia, ii. 588. See Heart, malformations of the. Acarus Scabiei, i. 404 ; iii. 629. See Scabies and Worms. Acephalocystis endogena, iii. 607. Multifida, iii. 608. See Worms. Achor, i. 386. Acne, general characters of, i. 416. Varieties of, i. 416. Diagnosis of, i. 417. Treatment of, i. 418. Acupuncture, in neuralgia, ii. 108. In dropsy, iii. 4!)9. Adipose Degeneration of the heart, ii. 573. Of the liver, ii. 153. Adynamic Fever, i. 140. See Fever, Typhus. Aerophobia, ii. 83. See Hydrophobia. ./Egophony, how produced, ii. 212. Occurring in the progress of pleurisy, ii. 304. See Diseases of the Lungs ; Pleu- risy. Affusion, cold, in the treatment of fever, i. 182. See Fever. Ageustia, ii. 118. Sec Paralysis. Agria, i. 413. See Ecthyma. Ague, i. 231. See Fever, Intermittent. Leaping, ii. 41. See Chorea. Air-cells, dilatation of the, ii. 356. See Em- physema. Air-tubes, structural lesions of the, ii. 297. See Bronchi. Aix-la-Chapelle, efficacy of the waters of, in rheumatism, iii. 571. Albuminous Urine, tests of, iii. 273 ; iii. 481. Aleppo Evil, i. 450. Alimentary Canal, diseases of, iii. 17. Alkaloids, formulae for, iii. 704. Alterative Remedies, observations on, iii. 700. Formulae for, iii. 700. Alvine Concretions, iii. 112. Amaurosis, ii. 170. Symptoms of, ii. 171. Causes of, ii. 173. Diagnosis of, ii. 174. Prognosis and treatment of, ii. 175. Amaurotic Cat's-eye, ii. 173. See Amaurosis. Amenorrhcea, iii. 296. During pregnancy and lactation, iii. 296. Attended with constitutional debility, iii. 297. J Attended with plethoric symptoms, iii. 298. J * Complications, iii. 298. Congestive, iii. 299. Disorders of the digestive organs, iii. 299. Spasmodic affections, iii. 299. Affections of the nervous system, iii. 300. Of the intellectual faculties, iii. 301. Treatment, iii. 301. From mechanical obstruction, iii. 303. Amphimerina Anginosa, ii. 401. See Influenza. AntEmia, local, i. 30. Causes of, i. 30. Signs of, i. 31. General, i. 57. Anaesthesia, i. 60 ; ii. 118. See Paralysis. Anasarca, iii. 458. See Dropsy. Analcpsia, i. 633. See Epilepsy. Aneurism of the heart, ii. 560. Of the aorta, ii. 602. Of the other large vessels, ii. 604. Of the coronary arteries, ii. 605. Angina Pectoris, ii. 503. Symptoms of, ii. 503. Seat and nature of, ii. 504. Complications of, ii. 506. Diagnosis of, ii. 507. Prognosis of, ii. 507. Treatment of, ii. 507. See Neuralgia. Polyposa, ii. 247. Membranacea vel exudaria. See Croup. Diffusa, iii. 30. Maligna, iii. 33. Membranacea, iii. 32. See Scarlatfha Maligna. Tonsillaris, iii. 35. Animalcula Echinococci, iii. 609. See Worms. Anosmia, ii. 118. See Paralysis. 708 INDEX. Antacids, formulae for, iii. 694. Anthelmintics, iii. 604. Evacuant, iii. 604. Mechanical, iii. 604. Corroborant, iii. 605. See Worms. Observations on, iii. 698. Formulae for, iii. 698. Antilithics, observations on, iii. 695. Antiphlogistic Remedies, observations on, iii. 700. Formulae for, iii. 700. Antispasmodics, observations on, iii. 662. Formulae for, iii. 663. Antisyphilitic Remedies, observations on, iii. 700. Formulae for, iii. 700. Anuria, iii. 254. See Urine, suppression of. Aorta, nervous pulsations of the abdominal, ii. 593. Curvation of the, ii. 460. Aneurism of the, ii. 602. True aneurism of, ii. 602. False, ii. 602. Mixed, ii. 603. Hernial, ii. 603. Causes of, ii. 603. Symptoms of, ii. 603. Effects of, on neighbouring organs, ii. 604. Process by which a spontaneous cure may be effected, ii. 605. Dissecting aneurism of the, ii. 606. General symptoms of aneurism of the tho- racic, ii. 606. Physical signs of, ii. 608. Diagnosis of aneurism of the thoracic, ii. 609. ' General symptoms and physical signs of aneurism of the abdominal, ii. 613. Diagnosis, ii. 614. General treatment of aneurism of the, ii. C15. Aperients, formulae for, iii. 687. Observations on, iii. 683. Aphonia, ii. 115. See Paralysis. Nervous, ii. 261. Hysteric, ii. 53. Aphthce, iii. 17. See Stomatitis. Apoplexia Hydrocephalica, ii. 524. See Hy- drocephalus. Apoplexy, cerebral, i. 545. Symptoms of, i. 546. Transient or fugitive, i. 546. Sudden or primary, i. 547. Ingravescent, i. 547. Paraplexia, i. 548. Anatomical characters of, i. 549. Connexion of symptoms with morbid ap- pearances in, i. 553. Pathology or theory of, i. 554. Causes of, i. 556. Diagnosis of, i. 557. From inflammation of the brain, i. 513. Prognosis of, i. 559. Treatment of, i. 559, 563. , Spinal, ii. 37. Connexion between hypertrophy of the heart and cerebral, ii. 556. Pulmonary, iii. 385. Dependent upon structural disease of the heart, iii. 391. See Hemorrhage. Arterial Pulsations, inordinate, ii. 593. Causes of, ii. 594. Treatment of, ii. 595. Arteries, diseases of, ii. 593. Neuralgia of the, ii. 593. Inordinate pulsation of the, ii. 593. Inflammation of, ii. 596. See Arteritis. Morbid deposits in the, ii. 599. Softening of the lining membrane of, ii. 599. Arteritis, ii. 596. Anatomical characters of, ii. 596. Causes of, ii. 600. Symptoms of, ii. 600. Treatment of, ii. 601. Sequelae of, ii. 601. Arthritic Iritis, ii. 164. See Ophthalmia. Arthritis, iii. 576. See Gout. Ascaris lumbricoides, iii. 624. Vermicularis, iii. 626. See W oms. Ascites, iii. 512. Causes of, iii. 515. Cirrhose, iii. 515. Diseased spleen, iii. 516. Treatment of, iii. 516. Paracentesis abdominis, iii. 517. Acupuncture, iii. 518 Asphyxia, ii. 414. Connexion of respiration with the other vital functions, ii. 414. Dependence of the movements of the respiratory muscles on nervous influ- ence, ii. 416. Causes of, ii. 417. Injury of the respiratory nerves, ii. 417. Compression of the thorax, ii. 418. Accumulation of fluid within the pleurae, ii. 418. Obstruction of the air-passages, ii. 419. Structural diseases of the lungs, ii. 420. Deleterious gases, ii. 421. Phenomena of, ii. 421. Anatomical characters of, ii. 423. Theory of, ii. 423. Effects of imperfect respiration, ii. 430. Treatment of, ii. 431. Method of employing artificial respiration, ii. 431. Other modes of resuscitation in, ii. 433. Produced by strangulation, ii. 434. Submersion, ii. 442. Aspretudo, i. 395. See Urticaria. Asthma Arthriticum vel Diaphragmaticum, ii. 503. See Angina Pectoris. Asthma Infantum, ii. ~'56. See Laryngismus Stridulus. Asthma, humoral, ii. 279. See Bronchorrhoea. Hay, ii. 280. See Bronchorrhoea. Congestive, ii. 282. See Bronchial Con- gestion. Spasmodic, ii. 284. Causes of, ii. 286. Diagnosis of, ii. 286. Prognosis of, ii. 287. Treatment of, ii. 287. Astringents, observations on, iii. 669. Formulas for, iii. 671. Atonic Affections of the Larynx, ii. 260. Atrophy, in what it consists, i. 51. Of the heart, ii. 569. Of the pancreas, iii. 493. INDEX. 709 Atrophy of the spleen, iii. 201. Of the kidneys, iii. 287. Auscultation, of the respiration, ii. 205. Natural respiratory sounds, ii. 206. Tracheal, ii. 206. Bronchial respiration, ii. 206. Vesicular respiration, ii. 206. Puerile respiration, ii. 207. Cavernous, ii. 208. Amphoric, ii. 208. Rhonci, different kinds of, ii. 208. Sibilant, ii. 208. Sonorous, ii, 209. Dry mucous, ii. 209. Subcrepitant, ii. 210. Crepitant, ii. 210. Of the voice, ii. 211. Bronchophony, natural and morbid, ii. 211. iEgophony, ii. 212, 175. Pectoriloquy, ii. 212. Amphoric resonance, ii. 213. Metallic tinkling, ii. 213, 328. Tabular view of the sounds connected with the organs of respiration, ii. 213. Immediate and mediate, ii. 214. Of the heart, ii. 483. Natural sounds, ii. 483. Morbid sounds, ii. 466. Bruit de Soufflet, ii. 467. Fremissement cataire, ii. 472. To-and-fro sound, ii. 472. See Diseases of the Lungs and Heart. Aussatz, i. 438. See Lepra Tuberculosa. Balam Fever, i. 273. See fever, Yellow. Barbadoes Leg, i. 449. See Elephantiasis Arabica. Barbiers, ii. 131. Symptoms of, ii. 131. Causes of, ii. 131. Diagnosis of, ii. 132. Treatment of, ii. 132. Baths, warm sulphur, use of, ii. 50. Bicardia, ii. 588. See Heart, malformations of the. Bile, causes which occasion a deranged secre- tion of the, iii. 155. Diminished secretion of, iii. 155. Excessive secretion of, iii. 156. Vitiated secretion of, iii. 157. Bile, impeded excretion of, iii. 157. Its influence on the alvine evacuations, iii. 158. Biliary Calculi, varieties of, in. 160. Mode of their formation, iii. 160. Seat of, iii. 161. Symptoms of, iii. 161. Prophylactic treatment of, iii. 162. Treatment of the paroxysm, iii. 163. Biliary Organs, diseases of the, iii. 149. Causes of, iii. 149. Prevalence of, in warm latitudes, m. 14». Functional derangements of the, iii. 154. Symptoms of, iii. 158. Treatment of, iii. 159. Diagnosis of, iii. 159. Biliary Passages, structural diseases of, in. 164. Symptoms of, iii. 167. Biliary, treatment of, iii. 167. Bilious Diarrhcea, iii. 87. Bilious Remitting Fever, i. 273. See Fever, Yellow. Black Disease, i. 451. See Lepra Astracha- nica. Black Vomit of Yellow Fever, i. 278, iii. 396. Bladder, diseases of the, iii. 290. Inflammation of the, iii. 290. See Cys- titis. Catarrh of the, iii. 291. Spasm of the, iii. 292. Irritable, iii. 292. Bleb, i. 409. See Pemphigus. Blood, buffy coat, causes of the, i. 58, 65. Congestion of, i. 28. Elimination of, i. 32. Excess or deficiency in the constituents of the, i. 57. Changes effected by respiration on the, ii. 415. Haemorrhage, dependent upon disease of the mass of, iii. 397. Alteration in the composition of, in renal dropsy, iii. 485. See Dropsy. Bloodlessness. See Anaemia, L 30. Bloodletting, its effects in inflammation,!. 108. Symptoms indicating its employment, i. 111. Extent to which it may be carried, i. 112. Cautions to be observed in its employ- ment, i. 114. Bloody Flux, iii. 79. See Dysentery. Blue Disease, ii. 590. See Cyanosis. Bones, scrofulous affection of the, iii. 527. Bothriocephalus Latus, iii. 615. See Worms. Brain, inflammation of the, iii. 470. Precursory symptoms of, i. 471. Predisposing causes of, i. 506. Exciting causes of, i. 507. Diagnosis of, i. 509. Prognosis of, i. 514. Treatment of, i. 515. See Cerebral Con- gestion, Meningitis, Cerebritis. Intermittent inflammation of the, i. 503. Softening of the, i. 504. Suppuration and abscess of the, i. 504. Ulceration of the, i. 505. Induration of the, i. 505. Inflammation of the membranes of the, i. 497. See Meningitis. Effects of profuse haemorrhage on the functions of the, i. 523. Dropsy of the, iii. 501. See Dropsy, cere- bral. Hypertrophy of the, iii. 505. Tubercles in the, iii. 530. Perforation of the membranes of the, in chronic hydrocephalus, iii. 508. Worms found in the, iii. 607. Affections of the, in fever, i. 145. See Fever. Brain Fever, i. 605. See Delirium Tremens. Breathing, difficult, ii. 217. See Dyspnoea. Bronchi, hypertrophy of the, ii. 297. Dilatation of the, ii. 298. Contraction of the, ii. 298. Obliteration of the, ii. 298. Physical sign of dilated, ii. 300. Diagnosis of, ii. 301. 710 INDEX. Bronchi, treatment of dilated, ii. 301. Ulceration of the, ii. 302. Tumours of the, ii. 302. Aneurisms pressing on the, ii. 302. Bronchial Congestion, ii. 282. Symptoms of, ii. 282. Causes of, ii. 282. . Anatomical characters of, ii. 282. Prognosis of, ii. 283. Treatment of, ii. 283. Bronchial Flux, ii. 279. See Bronchorrhoea. Gland, worms found in the, iii. 606. See Worms. Bronchial Glands, diseases of the, ii. 400. Bronchitis, ii. 267. Acute, ii. 267. Sthenic, ii. 267. Asthenic, ii. 268. Infantile, ii. 269. Causes of, ii. 269. Symptomatic, ii. 269. Anatomical characters of, ii. 269. Diagnosis of, ii. 270. Prognosis of, ii. 270. Treatment of the sthenic form, ii. 271. Treatment of the asthenic form, ii. 272. Treatment of infantile, ii. 273. Chronic, ii. 273. Character of the expectoration in, ii. 273. Symptoms of, ii. 274. Causes of, ii. 275. Anatomical characters of, ii. 275. Prognosis of, ii. 275. Treatment of, ii. 276. Mild, ii. 262. Bronchocele, iii. 548. Character of the tumour, iii. 548. Symptoms, iii. 548. Anatomical characters, iii. 548. Causes, iii. 549. Connexion of cretinism with, iii. 561. Diagnosis, iii. 552. Treatment, iii. 553. Bronchorrhoea, ii. 279. Symptoms of, ii. 279. Causes of, ii, 279. Anatomical characters of, ii. 279. Prognosis of, ii. 280. Treatment of, ii. 280. Bronchotomy, operation of, ii. 239. See Laryngitis. Brow Ague, i. 627. See Cephalalgia, Bruit de Diable, its occurrence in anaemia, iii. 299. Bruit de Soufflet, theory of its production, ii. 469. See Heart, diseases of the. Brunner's Glands, enlargement of, in continued fever, i. 149. Btch of a year, i. 450. See Aleppo Evil. Buffy coat, cause of the, i. 58,65. See Blood Bulla, i. 388. Bulimia, iii. 59. See Dyspepsia. Cachsemia, varieties of, i. 57. Cachexy, tubercular, ii. 384. See Consumption, pulmonary. Cactus Opuntia, its effects on the urine, iii. 408. Caecum, inflammation of the, iii. 86. Peritonitis of the, iii. 141. Caecum, Worms found in the, iii. 606. See Worms. Calcareous tumours of the uterus, iii. 328. Deposits in the arteries, ii. 598. Calculus, biliary, iii. 160. See Biliary Calculi. Pancreatic, iii. 194. Urinary, iii. 228. Symptoms of, iii. 228. Chemical composition of, iii. 230. Treatment of, iii. 230. Renal, iii. 231. Vesical, iii. 231. Cancer. See Scirrhus, Carcinoma. Gelatiniform, or areolar, i. 43. Cancroide, i. 443. See Cheloidea. Cancrum Oris, iii. 21. See Gangrsena Oris. Capillary circulation, dropsy from the obstruc- tion of, iii. 466. Carcinoma, varieties of, i- 44. Anatomical structure of, i. 45. Of the stomach, iii. 50. Symptoms of, iii. 51. Causes of, iii. 52. Treatment of, iii. 52. Of the intestines, iii. 111. Of the kidney, iii. 288. Of the uterus, iii. 334. Symptoms of, iii. 335. Treatment of, iii. 336. See Scirrhus. Of the stomach, haematemesis from, iii. 399. Cardia, carcinoma of the, iii. 50. See Carcinoma of the Stomach. Cardiac Dropsy, iii. 471. See Dropsy. Cardialgia, iii. 67. See Gastralgia. Carditis, ii. 544. Examples of, ii. 544. Anatomical characters of, ii. 544. Symptoms of, ii. 547. Cartilaginous transformation of the uterus, iii. 338. Catalepsy, i. 652. Symptoms of, i. 652. Causes of, i. 653. Nature of, i. 654. Diagnosis of, i. 654. Prognosis of, i. 654. Treatment of, i. 654. Catamenia. See Disordered Menstruation iii 294. Cataphora, i. 653. See Catalepsy. Catarrh, nasal, ii. 261. See Coryza. Pulmonary, ii. 261. Symptoms of, ii. 262. Physical signs of, ii. 263. Catarrh, character of the expectoration, ii. 263. Causes of, ii. 264. Treatment of, ii. 2(54. The dry method of treating, ii. 266. Pituitous, ii. 279. See Bronchorrhoea. Dry, ii. 282. See Bronchial Congestion, Epidemic, ii. 401. Contagious, ii. 401. See Influenza. Of the bladder, iii. 291. Catarrhal sore-throat, ii. 261. Ophthalmia, ii. 261. See Catarrh. Cathartics, observations on, iii. 681. Formulae for, iii. 684. Catochus, iii. 652. See Catalepsy. Cauliflower excrescence of the uterus, iii. 332. INDEX. 711 Cauliflower excrescence of the uterus, nature of, iii. 333. Symptoms of, iii. 333. Treatment of, iii. 333. Causus, endemial, i. 273. See Yellow Fever. Cavities of Veins, obliteration of the, ii. 625. Cellular Substance, inflammation of, i. 83. Dropsy of the, iii. 458. See Dropsy. Worms found in the, iii. 606. See Worms. Cephalcea, i. 623. Sec Cephalalgia. Cephalalgia, i. 623. Symptoms of, i. 623. Causes of, i. 624. Pathology of, i. 624. Varieties of, i. 626. Diagnosis of, i. 627. Prognosis of, i. 630. Treatment of, i. 630. Cephaloma, in what it consists, i. 44. Varieties of, i. 44. See Carcinoma. Cerebral determination and congestion, i. 471. Anatomical characters of, i. 474. Causes of, i. 475. Treatment of, i. 475. Arising from debility, or inanition, i. 477. Cerebral determination and congestion, occur- ring in infants and children, i. 480. Apoplexy, i. 545. See Apoplexy. Dropsy, iii. 501. See Dropsy. Inflammation, comparative frequency of the different forms of, i. 506. Symptoms from exhaustion, i. 521. See Hydrocephaloid Disease. Cerebralgia, ii. 99. See Neuralgia. Cerebritis, i. 498. Acute, i. 499. Chronic, i. 502. Anatomical characters of, i. 503. Diagnosis of, i. 509. Treatment of, i. 515. Cheiragra, iii. 576. See Gout. Cheloidea, i. 443. Symptoms of i. 443. Diagnosis of, i. 444. Treatment of, i. 444. Chemical composition of urinary calculi, iii. 230. Composition of dropsical effusions, iii. 467. Chest, affections of, in fever, i. 146. See Fever. Physical examination of the, ii. 196. Inspection, ii. 197. Mensuration, ii. 198. Percussion, ii. 199. Contraction of from the absorption of effused fluid, ii. 313. See Pleurisy. Chicken-pox, i. 407. See Varicella. Children of strumous parents, management of, iii. 540. Childbed Fever, i. 368. See Fever, Puerperal Chin Cough, ii. 289. See Pertussis. Chin Wclk, i. 416, 418. See Acne; Mentagra Chloasma, i. 436. See Pityriasis. Chlorine, inhalation of, in phthisis, ii. 396. See Consumption, pulmonary. Chlorosis, symptoms of, iii. 297. Nature of, iii. 297. See Amenorrhcea. Cholera, iii. 90. Common, or sporadic, iii. 90. Malignant, or Asiatic, iii. 92. History of, iii. 92. Course of, iii. 92. Cholera, Causes of, iii. 95. Arguments for and against its contagious nature, iii. 95. Symptoms of, iii. 98. Prognosis of, iii. 101. Anatomical characters of, iii. 103. Nature of, iii. 105. Treatment of, iii. 107. Cholesterine, existence of, in gall stones, iii. 160. See Liver, diseases of the. Chorea, ii. 39. Analogous affections, ii. 40. Anatomical characters of, ii. 43. Nature of, ii. 44. Chorea, causes of, ii. 45. Diagnosis of, ii. 45. Prognosis of, ii. 46. Treatment of, ii. 46. Connected with uterine disturbance, iii. 300. From the irritation of intestinal worms, iii. 601. Choroid, inflammation of the, ii. 168. See Ophthalmia. Choroiditis, ii. 155, 168. See Ophthalmia. Chronic arteritis, ii. 600. # Bronchitis, ii. 273. Cerebritis, i. 502. Colitis, i. 80. Cystitis, iii. 290. Duodenitis, iii. 72. Eczema, i. 398. Gastritis, iii. 43. Hepatitis, iii. 173. Chronic inflammation, terminations of, i. 92. Ileo-colitis, iii. 75. Laryngitis, ii. 241. Meningitis, i. 497. Choroiditis, ii. 155. Metritis, ii. 320. Nephritis, iii. 261. Otitis, ii. 181. Ovaritis, iii. 342. Pericarditis, ii. 520. Peritonitis, iii. 138. Phthisis, ii. 382. Pneumonia, ii. 351. Pleurisy, ii. 310. Rheumatism, iii. 569. Circulation, diseases of the organs of, ii. 451. Cirrhosis, nature of, iii. 181; iii. 515. A fre- quent cause of ascites, iii, 515. See Disease of the Liver ; and Dropsy. Cloasma, i. 444. See Ephelis. Ccelelminthae, iii. 616. See Worms. Colchicum, use of in chronic rheumatism, iii. 575. Cold in the head, ii. 262. See Coryza. In the eyes, ii. 262. See Catarrh. Colic, iii. 121. Symptoms of, iii. 121. Anatomical characters of, iii. 121. Nature of, iii. 122. Varieties of, iii. 123. Prognosis of, iii. 123. Treatment of, iii. 124. Hysteric, iii. 299. Colica Pictonum, iii. 126. Causes of, iii. 126. Symptoms of, iii. 126. 712 INDEX. Colica Pictonum, nature of, iii. 127. Treatment of, iii. 127. Colitis, iii. 79. Acute, iii. 79. Chronic, iii. 80. Diagnosis of, iii. 80. Prognosis of, iii. 81. Causes of, iii. 81. Treatment of, iii. 82, 86. In the United States, iii. 85, 86. Colon, non-malignant stricture of the, iii. 112. Torpor of the, iii. 127. Communication, preternatural, between the two sides of the heart, ii. 588. Concretions, alvine, iii. 112. Gouty, composition of, iii. 579, 583. Confluent Small-pox, i. 314. See Small-pox. Congenital malformations of the heart, ii. 588. Congestion of blood, i. 25. Causes of, i. 26. Signs of, i. 23. In continued fever, i. 145. Cerebral, i. 471. Bronchial, ii. 282. Hepatic, iiL 167. Pancreatic, iii. 192. Of the spleen, iii. 198. Of the uterus, iii. 317. Of the ovary, iii. 340. Conjunctiva, inflammation of the, ii. 134. See Ophthalmia. Constipation, iii. 127. See Torpor of the Colon. Consumption, pulmonary, ii. 361. General characters of, ii. 361. Anatomical characters of, ii. 361. Miliary tubercle, ii. 362. Yellow induration, ii. 362. Infiltrated tubercle, ii. 363. Number, size, and structure of tubercular excavations, ii. 363. Symptoms of first stage, ii. 371. Haemoptysis, ii. 372. Symptoms of the second stage, ii. 372. Symptoms of the third stage, ii. 372. Character of the expectoration, ii. 372. Accidental lesions occurring in the pro gress of, ii. 374. Physical signs of the first stage, ii. 375. Of the second stage, ii. 376. Of the third stage, ii. 377. Cavernous rhoncus, ii. 377. Cavernous respiration, ii. 377. Pectoriloquy, ii. 378. Complications of, ii. 380. Varieties of, ii. 381. Acute, ii. 381. Chronic, ii. 382. Latent, ii. 383. Origin and causes of, ii. 383. Tubercular cachexy, ii. 384. Hereditary predisposition, ii. 386. Diagnosis of, ii. 386. Prognosis of, ii. 389. Treatment of, ii. 390. Of the first stage, ii. 390. Advantages of change of air, ii. 394. Treatment of the second and third stapes ii. 395. s Prevention of tubercular disease, ii. 397. i Continued Fever, i. 136. See Fever. Contraction of the joints in scurvy, iii. 439. See Scurvy. Convalescence from fever, management of, i. 196. Convulsive cough of children, ii. 289. See Pertussis. Cophosis, ii. 118. See Paralysis. Copper Nose, i. 416. See Acne. Cornea, inflammation of the, ii. 155. See Ophthalmia. Coryza, symptoms of, ii. 262. Cough, ii. 261. See Catarrh. Causes which excite, ii. 220. Coup de Sang, i. 545. See Apoplexy. Couperose, i. 416. See Acne. Cow-pox, i. 341. See Vaccination. Cowrap, i. 414. See Impetigo. Creeping Palsy, ii. 114. See Paralysis. Cresmos, i. 429. See Prurigo. Cretinism, iii. 551. See Bronchocele. Crick of the Neck, iii. 572.* See Rheumatism. Critical days in fever, i, 143. Of continued fever, table of, i. 144. Croup, ii. 247. Symptoms of, ii. 247. Different forms of, ii. 247. Anatomical characters of, ii. 249. Nature of, ii. 250. Formation of false membrane, ii. 251. Diagnosis of, ii. 251. Causes of, ii. 252. Prognosis of, ii. 252. Treatment of, ii. 253. Operation of tracheotomy in, ii. 256. Spasmodic. See Laringismus Stridulus. Crowing Disease, ii. 256. See Laryngismus Stridulus. Crusta Lactea, i. 396. See Eczema. Crusted Tetter, i. 414. See Impetigo. Cutaneous transpiration deficient, dropsy from, iii. 466. Cyanosis, ii. 590. Cynanche Maligna, i. 358. See Scarlatina Maligna. Parotidcea, iii. 29. See Parotitis. Trachealis—Stridula infantum, ii. 247. See Croup. Tonsillaris, iii. 35. See Angina Ton- sillaris. Cystitis, iii. 290. Causes of, iii. 290. Symptoms of, iii. 291. Varieties of, iii. 291. Cysts in the liver, iii. 179. Ovarium, iii. 344. Dactylius Aculeatus, iii. 622. See worms. Dal Fil, i. 449. See Elephantiasis Arabica. Dandriff, i. 436. See Pityriasis. Dartre Crustacea, i. 414. See Impetigo. Crustacea flavescente, i. 414. See Im- petigo Figurata. E'cailleuse, i. 431. See Psoriasis. E'rythemoide, i. 3.^9. See Erythema. Furfuracee volante, i. 427. See Lichen. Pustuleuse, i. 418. See Mentagra. Pustuleuse Couperose, i. 416. Disseminee, i. 416. Miliare, i. 416. See Acne. INDEX. 713 Dartre Crustacee, phlyctenoide confluente, i. 409. See Pemphigus. Rougeante, i. 440. See Lupus. Seche, i. 431. See Psoriasis. Squammeuse humide, i. 396. See Eczema. Squammeuse lichenoide, i. 431. Squammeuse vive, i. 396. See Eczema. Decline. See Consumption, pulmonary. Degeneration, fatty, of the heart, ii. 573. Of the liver, iii. 153. Granular, of the kidney, iii. 271. Malignant, of the ovary, iii. 355. Delirium of fever, i. 145. From excessive haemorrhage, iii. 366. From hunger, i. 523. Ebriositatis, i. 605. See Delirium Tre- mens. Tremifaciens, i. 605. See Delirium Tre- mens. Ebrietatis potatorum, i. 605. See Delirium Tremens. Delirium Tremens, i. 605. Causes of, i. 605. Symptoms of, i. 607. Anatomical characters of, i. 609. Nature of, i. 609. Diagnosis of, i. 610. From inflammation of brain, i. 513. From mania, i. 605. Prognosis of, i. 610. Treatment of, i. 610. In the United States, i. 613. Common, i. 614. First stage, i. 614. Second stage, i. 614. Third Stage, i. 615. Second variety of, i. 616. Complications of, i. 616. Diagnosis of, i. 617. Prognosis of, i. 617. Anatomical characters of, i. 617. Treatment of, i. 617. In Philadelphia Hospital, i. 617. Dementia, i. 569. See Insanity. Demulcents, observations on, iii. 696. Formulae for, iii. 697. Dentition, diseases incident to the process of, iii. 24. Local symptoms of, iii. 24. Remote affections, iii. 25. Treatment of, iii. 27. Order in which the teeth appear in the first dentition, iii. 27. Deobstruent remedies, observations on, iii. 700. Formulae for, iii. 700. Derbyshire Neck, iii. 548. See Bronchocele. Drematagria, i. 447. See Pellagra. Devonshire Colic, iii. 127. See Colica Pic- tonum. Developement, imperfect of the female, sexual organs, iii. 296. Diabetes, iii. 233. Insipidus, iii. 234. Varieties, iii. 234. Mellitus, iii. 237. History of, iii. 237. Symptoms of, iii. 238. Characters of the urine in, iii. 239. Excessive secretion and increased density of the urine, iii. 239. VOL. HI. 00 Diabetes, tests of presence of sugar, iii. 240. State of the functions of the alimentary canal, iii. 243. Of the blood and circulation, iii. 244. Of the cutaneous functions, iii. 244. Secondary disorders, iii. 245. Anatomical characters of, iii. 246. Pathology of, iii. 246. Causes of, iii. 248. Prognosis of, iii. 248. Treatment of, iii. 250. Chylosus, iii. 253. Diaphoretics, observations on, iii. 673. Formulae for, iii. 674. Diarrhoea, iii. 87. From increased peristaltic action, iii. 87. Feculent, iii. 87. Bilious, iii. 87. Mucous, iii. 88. Serous, iii. 88. Fibrinous, iii. 88. Treatment of, iii. 89. From excessive pancreatic secretion, iii. 190. Diathesis, characters of the scrofulous, iii. 519. Signs of the cancerous, i. 47. Of the neurotic, i. 61. Diet, proper, for dyspeptic patients, iii. 62. Digestive organs, diseases of the, iii. 17. Dilatation of the bronchi, ii. 298. Of the heart, ii. 561. Causes of, ii. 562. Anatomical characters of, ii. 562. Physical signs of, ii. 563. General symptoms of, ii. 564. Prognosis of, ii. 565. Treatment of, ii. 565. Partial, of the heart, ii. 566. Of the aorta, ii. 602. Of the pulmonary artery, ii. 612. Of the right side of the heart, dropsy from, iii. 471. Diphtheritis, iii. 32. See Angina Membra- nacea. Diplosoma Crenata, iii. 610. See Worms. Disease, definition of, i. 17. Forms of, i. 18. Symptoms of, i. 18. Revulsion of, i. 21. Metastasis of, i. 22. Causes of, i. 23. The black, i. 451. See Lepra Astracha- nica. Diseases of the capillary system, i. 25. Of the blood, i. 56. Of the nerves, i. 59. Of the skin, i. 388. Of the nervous system, i. 461. Of the organs of respiration, ii. 195. Of the organs of circulation, ii. 451. Of the heart, ii. 451. Of the arteries, ii. 593. Of the veins, ii. 617. Of the organs of digestion, iii. 17. Of the biliary organs, iii. 149. Of the pancreas, iii. 190. Of the spleen, iii. 198. Of the urinary organs, iii. 206. 714 INDEX. Diseases of the kidneys, iii. 210. Of the bladder, iii. 290. Of the prostate gland, iii. 292. Of the uterus, iii. 294. Of the ovaria, iii. 340. Displacement of the heart, ii. 586. From pleuritic effusion, ii. 586. From other diseases, ii. 586. Diagnosis of, ii. 586. Distoma Hepaticum, iii. 515. See Worms. Diuretics, observations on, iii. 688. Formulae for, iii. 690. Dolor Faciei, ii. 10U. Typico charactere, ii. 100. See Neu- ralgia. Dothinentcritis, i. 130, 149. Specific nature of, iii. 74. See Fever Ileo- colitis. Dropsy, iii. 456. General doctrines of, iii. 456. Forms of, iii. 457. General pathology of, iii. 459. Balance between exhalation and absorp- tion, iii. 458. Conditions favourable to the production of, iii. 459. Active, iii. 461. Passive, iii. 462. From venous obstruction, iii. 462. From deficient cutaneous transpiration, iii. 466. From capillary obstruction, iii. 466. Comparison of the active and passive forms of, iii. 467. Gravitation of effused fluid, iii. 467. Chemical composition of the effusions in, iii. 467. Inflammatory, iii. 469. Prognosis of, iii. 469. Treatment of, iii. 469. Cardiac, from dilatation of the right side of the heart, iii. 471. From endocarditis, iii. 474. From pericarditis, iii. 474. From disease of the lungs, iii. 475. Renal, iii. 477. Morbid appearances of the kidney in, iii. 477. Symptoms of, iii. 479. Characters of the urine in, iii. 480. Albuminous urine in, iii. 481. Specific gravity of the urine in, iii. 484. Alterations of the blood in, iii. 485. Complications, iii. 487. Causes of, iii. 490, 503. Acute or febrile, iii. 492. Following scarlet fever, i. 359; iii. 493. State of the urine in, iii. 494. Treatment of general, iii. 495. Cerebral, iii. 501. Symptoms of, iii. 501. Effects of, on the conformation of the cranium, iii. 502. Treatment of, iii. 506. Perforation of the cerebral mem- branes in, iii. 508. Thoracic symptoms of, iii. 510. Physical signs of, iii. 510. Hydro-pericardium, iii. 511. Dropsy, abdominal, iii. 512. Ascites, iii. 512. See Ascites. Ovarian, iii. 512. Diagnosis of, iii. 343, 512. Omental, iii. 515. A sequela of scarlet fever, i. 359. Of the pericardium, ii. 582. In affections of the liver, iii. 188. In granular disease of the kidney, iii. 276. Of* the uterus, iii. 339. Of the Fallopian tubes, iii. 344. Of the ovary, iii. 343. Encysted, iii. 344. Paracentesis in, iii. 351. Obliteration of the cysts by adhesive inflammation, iii. 351. Incisions in the diseased ovary, iii. 352. Extirpation of the ovary, iii. 352. Drowning, asphyxia from, ii. 442. See Sub- mersion. Dry Catarrh, ii. 282. Scall, i. 431. See Psoriasis. Duodenal Dyspepsia, iii. 72. Duodenitis, iii. 71. Acute, iii. 71. Chronic, iii. 72. Duodenum, inflammation of the, iii. 71. Structural diseases of, iii. 73. Influence of affections of the, in occasion- ing jaundice, iii. 155. Dura Mater, inflammation of, i. 486. See Meningitis. Dysesthesia, in what it consists, i. 60. Dysentery, iii. 69. Dysmenorrhcea, iii. 305. Symptoms of, iii. 305. Causes of, iii. 306. Membrane expelled from the uterus in, iii. 306. Prognosis of, iii. 30o. Treatment of, iii. 306. Dyspepsia, causes of its prevalence in modern times, iii. 56. Acute, iii. 58. Symptoms of, iii. 58. Causes of, iii. 58. Treatment of, iii. 59. Bilious seizure, iii. 58. Symptoms of, iii. 58. Causes of, iii. 59. Treatment of, iii. 59. Chronic, iii. 59. Symptoms of, iii. 59. Causes of, iii. 60. Nature of, iii. 61. Treatment of, iii. 61. Diet, iii. 62. Secondary affections arising from, iii. 65. Duodenal, iii. 72. Gastric, ii,. 67. See Gastralgia. Dyspeptic Phthisis, iii. 66. Dysphagia, hysteric, iii. 299. See Stomatitis, iii. 17. Dyspnoea, tabular view of the causes of, ii. 219. Atonic, or paralytic, ii. 283. Earache, ii. 178. See Otitis. Ear, inflammation of tho, i. 178. INDEX. 715 Ear, perforation of the, ii. 182. Sec Otitis. Ecchymosis, value of, as a sign of violent death, 1. 653. See Asphyxia. Ecstasy, i. 653. See Catalepsy. Ecthyma, i. 413. General characters of, i. 413 Infantile, i. 413. Cachecticum, i. 413. Syphiliticum, i. 413. Diagnosis of, i. 413. Treatment of, i. 413. Ectopia Cordis, ii. 587. See Hernia of the Heart. Eczema, general characters of, i. 396. Acute, i. 397. Simplex, i. 397. Rubrum,i. 397. Impetiginodes, i. 398. Chronic, i. 393. Seat of, i. 399. Causes of, i. 399. Diagnosis of, i. 400. Prognosis of, i. 400. Treatment of, i. 401. Efflorescentia Erysipelatosa, i. 394. See Roseola. Effusion, a termination of inflammation, i. 63. Elephant Leg, i. 449. Sec Elephantiasis Arabica. Elephantiasis Arabica, i. 449. Treatment of, i. 450. Graecorum, i. 438. See Lepra Tuber- culosa. Tubereux d'Alibert, i. 449. See Elephan- tiasis Arabica. Emetics, observations on, iii. 678. Formulae for, v. iii. 680. Emmenagogues, observations on, iii. 692. Formulae for, iii. 692. Emollients, observations on, iii. 690. Formulae for, iii. 697. Emphysema, pulmonary, ii. 356. Anatomical characters of, ii. 356. Causes and nature of, ii. 356. Symptoms of, ii. 358. Physical, signs of, ii. 358; Prognosis, of, ii. 359. Treatment of, ii. 359. Interlobular, ii. 366. Emprosthotonos, ii. 67. Sec Tetanus. Empyema, ii. 315. Symptoms of, ii. 315. Discharge of the contained matter by ulceration, ii. 316. Paracentesis thoracis, ii. 320. Encephaloid Matter, i. 44. See Sarcoma, medullary. Endemial Causes, i. 273. Endocarditis, ii. 530. Anatomical characters, ii. 530. Vegetations and granulations, ii. 532. Adhesion of a valve, ii. 532. Organized false membranes, ii. 532. Symptoms of, ii. 534. Physical signs of, ii. 535. Signs referred to the different cardiac ori- fices and valves, ii. 536. Causes of, ii. 541. Complications of, ii. 541. Prognosis of, ii. 542. Endocarditis, duration of, ii. 542. Infantile, ii. 542. Treatment of, ii. 542. Rheumatic, iii. 474, 561. Complicated with pleurisy, iii. 561. Anatomical characters, iii. 563. Dropsy from, iii. 474. Endogena, iii. 607. See Acephalocysts. Engorgement of the lung, ii. 334. Sec Pneu- monia. Of the liver, iii. 167. See Liver, inflam- mation of the. Of the spleen, iii. 190. See Spleen, congestion of the. Enlargement. See Hypertrophy. Enteralgia, iii. 142. Treatment of, iii. 141. Enteritis, iii. 74. See Ileo-Colitis. Entozoa, iii. 596. See Worms. Envies, i. 445. See Naevi. Eolica Japanica, i. 449. See Elephantiasis Arabica. Ephelis, i. 444. Treatment of, i. 445. Lentiformis, i. 444. See Lentigo. Ephemera, i. 123. See Fever. Epidemic Cholera, iii. 91. See Cholera. Catarrh, ii. 401. Circumstances observed to precede the appearance of, ii. 404. See Influenza. Epidemiede Paris, ii. 102. See Neuralgia. Epiglottis, effusion into the submucous tissue of, ii. 238. See Laryngitis. Epilepsia Saltator, i. 634. See Epilepsy. Epilepsy, i. 633. Premonitory symptoms, i. 633. Symptoms of the seizure, i. 634. Symptoms which follow the attack, i. 636. Duration of, i. 636. Causes of, i. 636. Varieties of, i. 638. Idiopathic, i. 639. Sympathetic, i. 639. Anatomical characters of, i. 640. Nature of, i. 642. Diagnosis of, i. 643. Prognosis of, i. 644. Treatment of, i. 644. Epinyctis Pruriginosa, i. 395. See Urticaria. Epistaxis, iii. 378. Causes of, iii. 379. Varieties of, iii. 379. Treatment of, iii. 380. Equinia, i. 422. Origin of, i. 423. Mitis, i. 423. Glandulosa, i. 424. Duration of, i. 426. Treatment of, i. 426. Eruptions, syphilitic, i. 453. Erysipelas; its occurrence in continued fever, i. 153. In lying-in hospitals, i. 386. Verum, i. 391. Phlegmonodes, i. 392. Gangrenosum, i. 392. Of the face, i. 392. Of the extremities, i. 392. Causes of, i. 392. Treatment of, i. 393. 716 INDEX. Erysipelatous Laryngitis, ii. 237. Erythema, i. 389. Fugax, i. 389. Papulatum, i. 389. Nodosum, i. 390. Laeve, i. 390. Centrifugum, i. 390. Acrodynum, i. 390. Diagnosis of, i. 390. Treatment of, i. 391. Erythematic Peritonitis, iii. 136. Essera, i. 395. See Urticaria. Estiomene, i. 440. See Lupus. Exanthema Urticatum, i. 395. See Urticaria. Exanthemata, general characters of the, i. 133, 388. Exanlheme Tnterne, iii. 74. See Ileo-colitis. Exhalation, haemorrhage by, iii. 359. Exhaustion, cerebral symptoms from, i. 521. See Hydrencephaloid Disease. Expectorants, observations on, iii. 676. Formulae for, iii. 677. Expectoration, physiological explanation of the act of, ii. 224. Important information to be derived from the character of the, ii. 225. Mucous, ii. 226. Albuminous, ii. 226. Watery, ii. 227. Compound, ii. 227. In acute catarrh, ii. 263. In acute bronchitis, iii. 267. In chronic bronchitis, ii. 273. In bronchorrhoea, ii. 279. In pneumonia, ii. 333. In pulmonary consumption, ii. 372. Eye, inflammation of the, ii. 133. See Oph- thalmia. Worms found in the, iii. 621. See Worms. Face, paralysis of the, ii. 116. Fainting, ii. 495. See Syncope. Falling sickness, i. 633. See Epilepsy. Fallopian Tubes, dropsy of the, iii. 344. Fatty degeneration of the heart, ii. 573. Of the liver, iii. 153,180. Of the pancreas, iii. 194. Discharges from the intestines, iii. 113. Fatuity. See Dementia. Favus, i. 420. See Porrigo Favosa. Febris Ampullosa, i. 409. Bullosa, i. 409. See Pemphigus. Miliaris, i. 405. See Miliaria. Pemphygodes, i. 409. Pompholix, i. 409. See Pemphigus. Remittens catarrhalis, ii. 401. See Influ- enza. Urticata, i. 395. See Urticaria. Topica, ii. 100. See Neuralgia. Feculent Diarrhcea, iii. 87. Fever, occurrence of inflammation in, i. 100. General doctrines of, i. 123. Definition of, i. 123. Forms of, i. 123. Local diseases in, i. 125. Nature of, i. 126. Classification of, i. 134. Continued, i. 136. Symptoms of, i. 136. Fever, synocha, i. 137. Synochus, i. 139. Typhus, i. 140. Critical days in, i. 143. Secondary affections in continued, i. 144. Of the head, i. 145. Of the throat, i. 146. Of the chest, i. 146. Of the abdomen, i. 148. Of the hepatic system, i. 150. Of the skin, i. 151. Petechiae, i. 151. Vibices, i. 152. Erythema, i. 152. Gangrene, i. 152. Erysipelas, i. 153. Miliaria, i. 153. Sequelae, i. 153. Relapses, i. 154. Rheumatism and neuralgia in, i. 155. Partial palsy, i. 155. OZdema, i. 155. Phlegmasia dolens, i. 155. Acute febrile inflammations, i. 155. Phthisis pulmonalis, i. 156. Mania, i. 156. Prevalence of, i. 156. Typhus and Typhoid, i. 199. Mortality of, i. 158. Duration of, i. 159. Anatomical characters of continued, i. 160. Brain and its membranes, i. 161. Alimentary canal, i. 162. Serous membranes, i. 162. Glandular system, i. 162. Great viscera, i. 163. Causes of continued, i. 164. Infection, i. 164. Prognosis of continued, i. 174. Treatment of continued, i. 180. Prophylaxis, i. 198. Remittent of United States, i. 271. Intermittent, i. 231. Symptoms of, i. 232. Varieties of, i. 235. Quotidian, i. 235. Tertian, i. 236. Quartan, i. 238. Complicated, i. 239. Diagnosis of intermittent, i. 243. Prognosis of intermittent, i. 243. Terminations of intermittent, i. 244. Anatomical characters of intermittent, i. 245. Statistics of intermittent, i. 247. Nature of intermittent, i. 249. Exciting causes of intermittent, i. 249. Treatment of intermittent, i. 250. Remittent, i. 256. Symptoms of, i. 256. Bilio-inflammatory form of, i. 258. Malignant form of, i. 261. Complications of, i. 263. Terminations of, i. 264. Anatomical characters of, i. 264. Duration of, i. 265. Prognosis of, i. 265. Nature of, i. 266. Diagnosis of, i. 267. Treatment of, i. 267. INDEX. 717 Fever, yellow, i. 273. Symptoms of, i. 274. Varieties of, i. 278. Black vomit in, i. 278. Anatomical characters of, i. 264, 282. Statistics of, i. 284. Prognosis of, i. 285. Diagnosis of, i. 285. Nature of, i. 286. Causes of, i. 287. Treatment of, i. 292. Infantile gastric remittent, i. 296. Symptoms of the acute form, i. 296. Causes of, i. 299. Diagnosis of, i. 299. Treatment of, i. 301. Chronic form of, i. 302. Treatment of, i. 303. Diagnosis of, from hydrocephalus, i. 533. Hectic, i. 305. Symptoms of, i. 306. Diagnosis of, i. 307. Causes of, i. 308. Treatment of, i. 309. See Consump- tion, pulmonary. Scarlet, i. 354. See Scarlatina. Puerperal, i. 368. Opinions on the nature of, i. 368. Character of different epidemics, i. 369. Causes of, i. 369. Acute puerperal peritonitis, i. 373. Adynamic or malignant puerperal, i. 376. Puerperal intestinal irritation, i. 382. False peritonitis, i. 384. Milk, i. 386. Occurrence of bronchitis in the progress of continued, ii. 269. Inflammatory swelling of the lower ex- tremities in, ii. 622. Marsh, i. 231. See Intermittent Fever. Fibrous Membranes, effects of inflammation on, i. 86. Tumours of the uterus, iii. 326. Filaria Medinensis, iii. 619. Oculi, iii. 621. Bronchialis, iii. 621. See Worms. First Dentition, disorders of, iii. 24. Fish-skin Disease, i. 437. See Ichthyosis. Flatulence, iii. 56. See Dyspepsia. C U Treatment of, iii. 64. Fluids, pathology of, in fever, i. 126. Fluke. See Distoma Hepaticum. Flux, bronchial, ii. 279. See Bronchorrhoea. Folie des Ivrogens, i. 605. See Delirium Tre- mens. Formulary, iii. 630. Frambcesia, i. 441. Treatment of, i. 442. Freckle, i. 444. See Lentigo. Fullness. See Plethora. Fumigations in continued fever, i. 197. Fungus Haematodes. Sec Sarcoma, medul- lary. Furunculi Atonici, i. 413. See Ecthyma. Gale ^pidemique, i. 396. See Eczema. Gall-bladder, worms found in the, iii. 607. See Worms. Gallstones, iii. 160. See Biliary Calculi. Galvanism, as a solvent of vesical calculi, iii. 233. Gangraena Oris, iii. 21, 24. Symptoms of, iii. 22. Causes of, iii. 22. Prognosis of, iii. 23. Treatment of, iii. 23. Gangrene, a termination of inflammation, i. 76. See Inflammation, Of the lungs, ii. 353. See Pneumonia. Of the liver, iii. 172. Gastralgia, iii. 67. Symptoms of, iii. 67. Nature and causes of, iii. 67. Treatment of, iii. 68. Gastric Dyspepsia, irritable, iii. 67. Gastric Juice, softening of the coats of the stomach by the, iii. 53. Cadaveric perforation of the stomach by the, iii. 53. Infantile remittent fever, i. 296. Gastritis, iii. 38. Symptoms of acute, iii. 41. Of sub-acute, iii. 42. Of chronic, iii. 43. Anatomical characters of, iii. 45. Causes of, iii. 45, 46. Treatment of acute, iii. 46. Of sub-acute and chronic, iii. 47. Gastrodynia, iii. 67. See Gastralgia. Gastro-enteritis, occurrence of, in continued fever, i. 149. Gastrorrhagia, iii. 3D3. See Haematemesis. Gastrorrhoea, iii. 70. From disease of the pancreas, iii. 192. Glanders, i. 422. See Equinia. Glands of Peyer and Brunner, enlargement of, in continued fever, i. 149. Bronchial, diseases of the, ii. 400. Parotid, inflammation of the, iii. 29. Mesenteric, diseases of the, iii. 142. Lymphatic, scrofulous enlargement of, iii. 522. Glasgow. Table showing the comparative prevalence of fever in, during a series of years, i. 157. Table showing the proportion of cases of fever to the population in, i. 170. Globus Hystericus, ii. 52. See Hysteria. Glossitis, iii. 28. Glottis, oedema of the, ii. 236. See Laryngitis. Spasm of the, ii. 256. See Laryngismus Stridulus. Goitre, iii. 548. See Bronchocele. Gonorrhceal Ophthalmia, ii. 142. See Oph- thalmia. Gout, iii. 576. Symptoms of, iii. 576. Acute, iii. 576. Causes of, iii. 577, 585. Chronic, iii. 579. Symptoms of, iii. 579. Concretions in, iii. 579, 583. Characters of the urine in, iii. 580. Seat of, iii. 581. Retrocedent, iii. 581. Of the stomach, iii. 581. Symptoms of, iii. 582. 713 INDEX. Gout, diagnosis of, iii. 582. Pathology of, iii. 582. Anatomical characters of, iii. 584. • Treatment of, iii. 589. Prevention of, iii. 594. Graecorum Elephantiasis, i. 438. See Lepra Tuberculosa. Granular Disease of the Kidney, iii. 271. Symptoms of, iii. 271. Characters of the urine, iii. 273. State of the blood, iii. 275. Secondary diseases, iii. 276. Causes of, iii. 278. Prognosis of, iii. 279. Anatomical characters of, iii. 281. Pathology of, iii. 281. Treatment of the primary disease, iii. 284. Of the secondary disorder, iii. 285. Granulations in the cardiac valves, iii. 564. Gravel, iii. 216. Symptoms of, iii. 216. Varieties of, iii. 217. Causes of, iii. 219. Pathology of, iii. 219. Prognosis of, iii. 223. Treatment of, iii. 223. Of the lithic, iii. 224. Of the phosphatic, iii. 227. Grease in horses, connexion of, with cowpox, i 342. Grippe La, ii. 402. See Influenza. Guinea Worm, iii. 619. See Filaria Medi- nensis. Gums, sponginess of the, in scurvy, iii. 442. See Scurvy. Haematemesis, iii. 393. Symptoms of, iii. 393. Diagnosis of, iii. 394. Liability to recur, iii. 395. Quantity of blood lost, iii. 395. Changes which take place in the effused blood, iii. 396. Mode in which the blood escapes, iii. 396. Causes of, iii. 396. Passive, iii. 397. Vicarious, iii. 398. Depending upon the diseases of the mass of blood, iii. 398. Depending upon structural disease, iii. 399. From corrosive poisons, iii. 399. From ulceration of the stomach, iii. 399. From perforation of a vessel, iii. 399. From carcinoma of the stomach, iii. 400. Sympathetic, iii. 400. Of diseases of the liver and spleen, iii. 401. * Hamiaturia, iii. 406. Characters of the effused blood, iii. 407. Tests of the presence of blood, iii. 407. Scat of the haemorrhage, iii. 409. Urethral, iii. 409. Vesic.il, iii. 409. Renal, iii. 409. Idiopathic, iii. 410. Passive, iii. 411. Vicarious, iii. 411. Sympathetic, iii. 412. Epidemic, iii. 412. Haemoptysis, iii. 381. Quantity of blood lost in, iii. 382. Duration of the attack, iii. 383. Sources of the haemorrhage, iii. 383. From the larynx and trachea, iii. 383. From the bronchi, iii. 384. From the vesicular structure of the lung, iii. 385. See Apoplexy, pulmonary. Causes of, iii. 386. Treatment of, iii. 387. Symptomatic of the deposition of pulmo- nary tubercle, iii. 390. Of tubercular ulceration iii. 391. Connexion of, with tubercles in the lungs, iii. 392. In phthisis, ii. 372. Haemorrhage, active, iii. 362. Congestive, i. 32. Constitutional, iii. 361,369. Cutaneous, iii. 370. Diagnosis of, iii. 360. Doctrines of, general view of the, i. 32, iii. 367. Effects of local, iii. 365. Constitutional effects of, iii. 365. Exhalation by, iii. 359. Epistaxis, iii. 378. Hepatic, iii. 167. Disease, occurring in the progress of iii. 168. Hereditary tendency to, iii. 362. Inflammatory, i. 33. Into the iliac cavity, iii. 474. Pericardium, iii. 375. Peritoneal cavity, iii. 377. From the lungs, iii. 375. See Haemo- ptysis. From the ovaries, iii. 340. From the pancreas, iii. 192. Passive, iii. 363. Predisposition to particular forms of, with reference to age, i. 33. From serous membranes, iii. 373. Spontaneous, different forms of, iii. 360. Subcutaneous, iii. 372. Sympathetic, iii. 369. Symptomatic, iii. 391. Symptoms preceding an attack of, iii. 363. Of profuse, referred to the brain, i. 503. Vicarious, iii. 361. Connexion of, with inflammation, iii. 377. Connexion of, with tubercles, iii. 392. From the nose, iii. 378. Stomach, iii. 393. Intestines, iii. 402. Urethra, iii. 409. Bladder, iii. 409. Kidney, iii. 409. Uterus, iii. 414. In scurvy, iii. 438. Haemorrhoea Pttechialis, i. 446. Haemorrhoids, iii. 114. Causes of, iii. 114. Haemorrhoidal tumours, iii. 115. Symptoms of, iii. 116. Causes of, iii. 117. Treatment of, iii. 117. Hair-worm, iii. 619. See Filaria Medinensis. Hanging, cause of death from, ii. 434. See Asphyxia; Strangulation. INDEX. 719 Haut Mai, i. 633. See Epilepsy. Hay Fever, ii. 279. See Bronchorrhoea. Head affections, of the, in fever, i. 145. See Fever. Headache, i. 623. See Cephalalgia. Heart, aneurism of the, ii. 548. See Hyper- trophy. Real aneurism of the, ii. 566. Auscultation of the, ii. 463. Natural sounds of fhe, ii. 463. Physical causes of, ii. 464. Morbid sounds of the, ii. 466. Bruit de soufflet, ii. 467. Fremissement cataire, ii. 472. To-and-fro sound, ii. 472. Atrophy of the, ii. 569. Cartilaginous and bony deposits, ii. 574. Dilatation of the, ii. 561. Diseases of the, general observations on, ii. 481. Disordered motions of the, ii. 472. Displacement of the, ii. 585. From pleuritic effusions, ii. 309. Causes of diseases of the ii. 485. Prognosis of diseases of the, ii. 486- General principles of treatment, ii. 487. Fatty degeneration of the, ii. 573. Fungus haematodes, ii. 574. Haemorrhagic effusion, ii. 572. Hernia of the, ii. 587. Hydatids of the, ii. 574. Hypertrophy of the, ii. 548. Impulse of the, ii. 462. Induration of the, ii. 570. Inflammation of the, ii. 544. Irregularity of the rhythm, ii. 473. Malformations of the, ii. 588. Measurement of the, ii. 456. Divisions of the, ii. 459. Motions of the, ii. 461. Nervous affections of the, ii. 488. Neuralgia of the, ii. 510. CEdema of the, ii. 572. Ossification of the, ii. 574. Palpitation of the, ii. 489. Polypous concretions of the, ii. 579. Rheumatic inflammation of the, ii. 523. Relation of the, to the lungs, ii. 454. Rupture of the, ii. 576. Scirrhus of the, ii. 574. Site of the, ii. 452. Softening of the, ii. 571. Structure of the, ii. 455. Tubercle of the, ii. 574. Tumours of the, ii. 574. Valves, diseases of the, ii. 537. Weight of the, ii. 456. Wounds of the, ii. 578. Haemoptysis from structural affections of the, iii. 391. Dropsy from disease of the, iii. 471. Rheumatism of the, iii. 558. Granulations on the valves of the, iii. 564. Preternatural communication between the two sides of the, ii. 588. Heartburn, iii. 67. See Gastralgia. Hectic Fever, i. 305. See Fever, hectic; and Phthisis. Hectic Fever, infantile, i. 296. See Fever, in- fantile gastric remittent. Hemacelinose, i. 446. See Purpura. Hemicrania Idiopathica, ii. 100. See Neural- gia. Hemiplegia, ii. 114. See Paralysis. Hepatic cough, iii. 169. See Purpura. Abscess, iii. 170. Different organs through which its con- tents may be discharged, iii. 171. See Hepatitis. Congestion, iii. 167. Haemorrhage, iii. 167. Hepatization of the lung, ii. 334. See Pneu- monia. Hepatitis, iii. 167. Acute, iii. 168. Sympathetic pains, iii. 169. Hepatic cough, iii. 169. Terminations of, iii. 170. Suppuration of, iii. 170. Chronic, iii. 173. Treatment of, iii. 173. Mercury as a remedy for, iii. 174. Other specific remedies, iii. 177. Hereditary predisposition to disease, i. 82. To phthisis, ii. 386. Haemorrhagic affections, iii. 362. Hernia of the heart, ii. 587. Herpes, i. 401. General characters of, i. 401. Phlytenodes, i. 401. Labialis, i. 402. Preputialis, i. 402. Zoster, i. 402. Circinnatus, i. 403. Iris, i. 403. Treatment of, i. 404. Exedens, i. 440. ^sthiomenes, i. 440. See Lupus. Heterologous Formations, pathology of, i. 39. Anatomical structure of, i. 45. Hiccup. See Singultus. Hob-nail Liver. See Cirrhosis. Homicidal Impulse, i. 580. See Insanity. Hooping-cough, ii. 289. See Pertussis. Hunger, delirium from, i. 523. Hydatids of the heart, ii. 574. Liver, iii. 179. Pancreas, iii. 194. Spleen, iii. 201. Uterus, iii. 340. Ovaries, iii. 344. Hydatids, i. 409. See Pemphigus. Hydrencephaloid disease, i. 521. Symptoms of, i. 521. Treatment of, i. 522. Diagnosis from inflammation of the brain, i. 521. Hydroa, i. 409. See Pemphigus. Hydroa-suetta et miliaire, i. 405. See Miliaria. Hydrocephalus, i. 524. Symptoms of acute, i. 524. First stage, i. 525. Second stage, i. 526. Third stage, i. 526. Forms of acute, i. 527. Anatomical characters of, i. 529. Causes of, i. 531. Diagnosis of, i. 533. From infantile gastric remittent fever, i. 301. 720 INDEX. Hydrocephalus, prognosis of, i. 534. Treatment of, i. 535. Pathology of, i. 542. Spurious, i. 521. See Hydrencephaloid Disease. Connexion of, with tuberculous diseases, i. 542. Hydrometra, iii. 339. Hydro-nephrosis, iii. 289. See Kidney, diseases of the. Hydro-pericardium, ii. 582 ; iii. 511. Hydro-pneumo-pericardium, ii. 585. Hydrophobia, ii. 83. Premonitory symptoms of, ii. 83. Symptoms of the attack, ii. 84. Causes of, ii. 87. Period of incubation, ii. 89. Anatomical characters of, ii. 90. Nature of, ii. 91. Diagnosis of, ii. 92. Prognosis of, ii. 93. Treatment of, ii. 93. Hydro-rachis, ii. 31. Congenital, ii. 31. Developed after birth, ii. 32. Causes of, ii. 33. Anatomical characters of, ii. 33. Nature of, ii. 34. Diagnosis of, ii. 34. Prognosis of, ii. 34. Treatment of, ii. 35, 36. Hydrothorax, iii. 510. See Dropsy, Thoracic. Hygrophobia, ii. 83. See Hydrophobia. Hymen, imperforate, iii. 304. Hyperaemia, in what it consists, i. 56. Hyperesthesia, in what it consists, i. 60. Hypertrophy, in what it consists, i. 50. Causes of, i. 50. Of the heart, ii. 548. Forms of, ii. 549. Weight of the heart in, ii. 550. Anatomical characters of, ii. 551. Physical signs of, ii. 551. General symptoms of, ii. 553. Complications of, ii. 556. Causes of, ii. 557. Duration of, ii. 558. Prognosis of, ii. 558. Treatment of, ii. 558. Of the tonsils, iii. 36. Of the mucous membrane of the stomach, iii. 41. Of the pancreas, iii. 193. Of the spleen, iii. 198. Of the kidneys, iii. 259. Of the uterus, iii. 338. Of the ovary, iii. 354. Of the brain, iii. 505. Hypochondriasis, i. 600. Symptoms of, i. 600. Causes of, i. 601. Nature of, i. 602. Treatment of, i. 602. See Insanity. Hysteralgia, iii. 312. Symptoms of, iii. 312. Diagnosis of, iii. 312. Prognosis of, iii. 313. Treatment of, iii. 313. See Neuralgia. Hysteria, ii. 51. Regular, ii. 52. Hysteria, irregular, ii. 52. Complicated, ii. 55. Nature of, ii. 56. Occurrence of, in males, ii. 58. Treatment of the paroxysm, ii. 59. Of affections with which it is associated, ii. 59. Hysterical Colic, iii. 299. Dysphagia, iii. 299. Cough, ii. 53. * Aphonia, ii. 53. Vomiting, ii. 54. Ischuria, ii. 54. Affections of the joints, ii. 54. Treatment of, ii. 59. Ichthyosis, i. 437. Diagnosis of, i. 438. Treatment of, i. 438. Icterus. See Jaundice. Ignis Sacer, i. 391. See Erysipelas. Ileo-colitis, iii. 7 i. Acute, iii. 74. Chronic, iii. 75. Symptoms of, iii. 76. Causes of, iii. 78. Treatment of, iii. 78. Ileum, inflammation of. See Ileo-colitis. Ileus, iii. 121. See Colic. Iliac Passion, iii. 121. See Colic. Impetigo, i. 414. General characters of, i. 414. Figurata, i. 414. Sparsa, i. 415. Diagnosis of, i. 415. Treatment of, i. 415. Indian Cholera. See Cholera. Indigestion, iii. 56. See Dyspepsia. Induration, general causes of, i. 53. A termination of inflammation, i. 86. Of the brain, i. 505. Of the heart, ii. 570. Of the stomach, iii. 41. Of the pancreas, iii. 194. Of the spleen, iii. 200. Infantile Gastric Remittent Fever, i. 296. Infection of Fever, i. 164. Inflammation and Haemorrhage, connexion of, iii. 377. Phenomena of, i. 31. Nature of, i. 62. Natural effects of, i. 75. Causes of, i. 79. Anatomical characters of, i. 83. In cellular substance, i. 83. In membranous parts, i. 83. In serous membranes, i. 84. In mucous membranes, i. 84. In parenchymatous viscera, i. 85. Fibrous membranes, i. 86. Muscular fibres, i, 87. Symptoms of, i. 87. Varieties of, i. 92. Latent, i. 92. Subacute, i. 92. Chronic, i. 92. Scrofulous, i. 93. Erythematic, i. 95. Exanthematous, i. 97. Rheumatic, i. 98. INDEX. 721 Inflammation, gouty, i. 99. Syphilitic, i. 99. Gonorrhoeal, i. 99. Symptomatic, i. 100. Modified, i. 100. Modes of fatal terminations, i. 101. Treatment of, i. 107. Of the brain, i. 470. Of the dura mater, i. 486. Of the membranes of the brain, i. 487. Of the eye, ii. 133. Of the ear, ii. 178. Of the lungs, ii. 232. Of the heart, ii. 544. Of the arteries, ii. 596. Of the veins, ii. 618. Of the mouth, iii. 17. Of the tongue, iii. 28. Of the parotid gland, iii. 29. Of the throat, iii. 30. Of the tonsils, iii. 35. Of the stomach, iii. 38. Of the bowels, iii. 71. Of the peritoneum, iii. 131. Of the liver, iii. 167. Of the pancreas, iii. 192. Of the spleen, iii. 198. Of the kidneys, iii. 259. Of the bladder, iii. 290. Of the uterus, iii. 317. Of the ovary, iii. 340. Of the synovial membranes, iii. 570. Intermittent, of the brain, i. 503. Inflammatory Fever, i. 136. See Fever. Blush, i. 389. See Erythema. Dropsy, iii. 469. Influenza, ii. 401. Symptoms of, ii. 401. Complications of, ii. 402. History of, ii. 402. Diagnosis of, ii. 408. Nature of, ii. 408. Causes of, ii. 409. Treatment of, ii. 412. Sequelae of, ii. 414. Inhalation, in bronchitis, ii. 276, 393. Inoculation of small-pox, i. 336. See Small- pox. Cow-pox, i. 341. See Vaccination. Measles, i. 352. Scarlet fever, i. 362. Insanity, i. 564. Mania, i. 566. Dementia, i. 569. Phenomena of moral insanity, i. 573. Monomania, i. 577. Melancholia, i. 578. Insane impulse, i. 580. Progress and terminations of, i. 586. Anatomical characters of, i. 587. Diagnosis of, i. 591. Causes of, i. 592. Treatment of, i. 534. Hypochondriasis, i. 600. Puerperal, i. 602. From menstrual disorder, iii. 301. Its connexion with scrofula, iii. 533. See Scrofula. Interlobular Emphysema, ii. 360. Intermittent Fever, i. 231. See Fever. vol. in- 91 Intermittent, hemiplegia, ii. 114. See Pa- Intertrigo, i. 389. See Erythema. Intestinal Concretions, iii. 112. Intestines, inflammation of, iii. 74. Organic diseases of, iii. 111. Carcinoma of, iii. 111. Fatty discharges from the, iii. 113. Perforation of, by worms, iii. 602. Worms found in the, iii. 607. See Worms. Irritable bladder, iii. 292. Uterus, iii. 312. Irritation, puerperal intestinal, i. 382. Spinal, ii. 17. See Spinal Irritation. Iritis, ii. 158. See Ophthalmia. Ischuria Renalis, iii. 254. See Urine, suppres- sion of. Itch, the, i. 404. See Scabies. Jaundice, from affections of the duodenum, iii. 155. Without evident disease of the liver or gall- ducts, iii. 156. From excessive bilious secretion, iii. 156. From impeded secretion of bile, iii. 157. Symptoms of, iii. 158. Conjectures, regarding the condition of Ihe liver from the character of the, iii. 185. Affections of the brain, succeeding to, iii. 186. State of the alvine evacuations, iii. 187. State of the urine, iii. 187. Joints, hysterical affection of the, ii. 65. Contraction of the, in scurvy, iii. 439. See Scurvy. Karlsbad, efficacy of its mineral waters in chronic rheumatism, iii. 571. Kidney, haemorrhage from the, iii. 409. Morbid appearances of, in dropsy, iii. 477. Albuminous urine, as a sign of disease of the, iii. 481. Worms found in the, iii. 607. See Worms. Keloide, i. 443. See Cheloidea. Kidneys, diseases of the, iii. 210. Functional, iii. 210. Morbid states of the urine, iii. 210. Calculous diseases, iii. 215. Organic diseases of, iii. 258. Errors in position and conformation, iii. 258. Hypertrophy of the, iii. 259. Inflammation of the, iii. 259. Granular disease of the, iii. 271. Hyperaemia of the, iii. 287. Anaemia of the, iii. 287. Atrophy of the, iii. 287. Tubercles of the, iii. 288. Carcinoma of the, iii. 288. Melanosis of the, iii. 289. Hydronephrosis of the, iii. 289. Ladrierie, i. 438. See Lepra Tuberculosa. Land Scurvy, i. 446. See Purpura. Laryngismus Stridulus, ii. 256. History of, ii. 256. Causes of, ii. 256. Diagnosis of, ii. 258. Prognosis of, ii. 258. 722 INDEX. Laryngismus Stridulus, treatment of, ii. 258. Laryngitis, ii. 325. Acute, ii. 236. Symptoms of, ii. 236. Causes of, ii. 237. Anatomical characters of, ii. 237. Diagnosis of, ii. 238. Prognosis of, ii. 238. Treatment of, ii. 238. Operation of bronchotomy, ii. 239. Chronic, ii. 241. Symptoms of, ii. 241. Causes of, ii. 242. Anatomical characters of, ii. 243. Diagnosis of, ii. 244. Prognosis of, ii. 244. Treatment of, ii. 244. Larynx, nervous affections of the, ii. 259. Atonic or paralytic affections of the, ii. 260. Nervous aphonia, ii. 261. Laxatives, formulae, for, iii. 687. Leaping Ague, ii. 41. See Chorea. Leipothymy, ii. 498. See Syncope. Lentigo, i. 444. General characters of, i. 444. Leontiasis, i. 438. See Lepra Tuberculosa. Lepra Tuberculosa, i. 438. General characters of, i. 438. Diagnosis of, i. 439. Treatment of, i. 439. ^Sgyplica, i. 438. See Lepra Tuber- culosa. Astrachanica, i. 451. General characters of, i. 451. Elephantiasis, i. 449. See Elephantiasis Arabica. Hebraeorum, i. 438. See Lepra Tuber- culosa. Lcontina, i. 438. See Lepra Tuberculosa. Norvegiana, i. 448. See Radesyge. Syphilitica, i. 448. Vulgaris, i. 431. See Psoriasis Circinnata. Leprosy, Scaly, i. 431. Sec Psoriasis. Lethargy, i. 654. See Catalepsy. Leucorrhoea, iii. 314. Acute and Chronic, iii. 315. Causes and Treatment of, iii. 315. Lichen, i. 427. General characters of, i. 427. Varieties of, i. 427. Simplex, i. 427. Pilaris i. 427. Lividus, i. 427. Circumscripta, i. 427. Gyratus, i. 427. Urticatus, i. 427. Strophulus, i. 427. Agrius, i. 428. Syphiliticus, i. 454. Diagnosis of, 428. Treatment, i. 429. Lithic Gravel, characters of, iii. 217. Lithontriptics, observations on, iii. 695. Liver, diseases of the, iii. 149. Abscess of the, iii. 170. From injury of remote parts, iii. 154. Different modes, in which its contents are discharged, iii. 171. Treatment of, iii. 177. Liver, disease of the, diagnosis from distension of the gall-bladder, iii. 183. Biliary concretions, iii. 160. Biliary passages, diseases of the, iii. 164. Causes, general, of diseases of the, iii. 149. Congestion of the, iii. 167. Displacement of the, from pleuritic effu- sions, ii. 308. Dropsy, in affections of the, iii. 188. Functional derangements of the, iii. 154. Gangrene of the iii. 172. Haemorrhagic effusions in diseases of the, iii. 188. Inflammation of the, iii. 167. Acute, iii. 168. Chronic, iii. 173. ffidema of the, iii. 170. Specific remedies in the cure of affections of the, iii. 174. Structural affections of the iii. 179. Adipose degeneration of the, iii. 153, 180. Malignant formations of the, iii. 181. Serous cysts and hydatids of the, iii. 179. Tubercles of the, iii. 180. Treatment of structural affections of the, iii. 189. Hob-nail, iii. 515. See Cirrhosis. Worms found in the, iii. 607. See Worms. Liver-fluke, iii. 615. See Distoma Hepaticum. Locked-jaw, ii. 67. See Tetanus. Looseness of the bowels, iii. 87. See Diarrhoea. Loss of blood, symptoms induced by excessive, iii. 308. Lumbago, iii. 572. See Rheumatism. Lumbricus, iii. 624. Lungs, diagnosis of diseases of the, ii. 195. Inflammation of the, ii. 332. See Pneu- monia. Suppuration of the, ii. 335. Gangrene of the, ii. 353. OZdema of the, ii. 355. Emphysema of the, ii. 356. Atrophy of the, ii. 360. Hypertrophy of the, ii. 360. Tubercles of the ii. 361. See Consump- tion, pulmonary. Malignant growths in the, ii. 39?. Relation of the heart to the, ii. 454. Dropsy from disease of the, iii. 475. Lupu«, i. 440. General characters of, i. 440. Varieties of, i. 440. Causes of, i. 441. Diagnosis of, i. 441. Treatment of, i. 441. Scrofulous character of, iii. 524. See Scrofula. Lymphatic Glands, scrofulous enlargement of, iii. 522. Lyssa, ii. 83. See Hydrophobia. Macula, characters of, i. 389. Materna, i. 445. See Naevi. Volatica, i. 389. See Erythema. Maculae Syphilitica;, i. 453. Madeira, climate of, beneficial to consumptive invalids, ii. 394. Madness, i. 564. See Insanity. Mai de Siam, i. 273. See Fever, Yellow. INDEX. 723 Mai de Siam, rouge de Cayenne, i. 438. See Lepra Tuberculosa. De Terre, i. 633. Saint Jean, i. 633. See Epilepsy. Malaria. See Miasma. Malattia di Miseria, i. 273. See Fever, Yellow. Malformations of the Heart, ii. 588. Malignant or Asiatic cholera, iii. 92. Fever, i. 141. Remittent fever, i. 261. Sore throat, i. 358. See Scarlatina Ma- ligna. Growths in the lung, ii. 398. Formations of the liver, iii. 181. Degeneration of the ovary, iii. 355. Diseases of the uterus, iii. 332. Malleatio, ii. 41. See Chorea. Malum Alepporum, i. 450. General characters of, i. 450, Treatment of, i. 451. Mania, i. 566. Precursory symptoms of, i. 566. Symptoms of the paroxysm, i. 567. See Insanity. Puerperal, i. 602. Diagnosis from meningitis, i. 512. A potu, i. 605. See Delirium Tremens. Marasmus, iii. 142. See Mesenteric. glands, diseases of the. Marsh Fever, i. 231. See Intermittent Fever. Matiere Colloide, in what it consists, i. 44. Maw-worm, iii. 626. See Ascaris Vermicularis. Measles, i. 347. See Rubeola. Mediterranean, voyage to the, beneficial in phthisis, ii. 394. Medullary Sarcoma, i. 44. See Sarcoma. Megrim, i. 623. See Cephalalgia. . Melaena, iii. 402. See Haemorrhage from the Intestines. Symptoms of, iii. 402. Diagnosis of, from the haemorrhoidal flux, iii. 403. Quantity of blood passed in, iii. 403. Character of the alvine evacuations, iii. 403. Sources of the effused blood, iii. 404. Causes of, iii. 404. In the progress of continued fever, iii. 404. From disease of the blood, iii. 404. Vicarious, iii. 405. From structural disease, iii. 406. Sympathetic, iii. 405. Treatment of, iii. 405. Melancholia, i. 578. See Insanity. Melanosis of the lung, ii. 399. Of the liver, iii. 181. Of the pancreas, iii. 194. Of the kidney, iii. 289. Melanotic Secretion, general characters of, i. 48. Chemical analysis of, i. 48. Membranes of the Brain, inflammation of the, i. 487. See Meningitis. Mucous, distinction between inflammatory and cadaveric redness of the, iii. 38. Softening of, iii. 40. Induration of, iii. 41. Hypertrophy of, iii. 41. Ulceration of, iii. 41. Membranes, effects of inflammation on, j. 83. Haemorrhage from serous, iii. 373. Meningitis, i. 4b7. Acute, i. 490. Symptoms of, i. 490. Varieties of, i. 493. Duration of, i. 495. Anatomical characters of, i. 495. Chronic, i. 497. Duration of, i. 497. Anatomical characters of, i. 498. Tuberculous, i. 544. Spinal, ii. 22. Symptoms of, ii. 22. Causes of, ii. 23. Anatomical characters of, ii. 23. Nature and Diagnosis of, ii. 24. Prognosis and Treatment of, ii. 24. Menorrhagia, iii. 307. Causes of, iii. 307. Symptoms of, iii. 308. Prognosis of, iii. 308. Forms of, iii. 308. Treatment of, iii. 309, 415. Active, iii. 413. Passive, iii. 414. Occurring during pregnancy, iii. 415. Menses, retention of the, iii. 303. Suspension of the, iii. 296. Menstruation, disorders of, iii. 294. Phenomena of, iii. 294. Suspended, iii. 296. See Amenorrhcea. Vicarious, iii. 304; iii. 363. See Hae- morrhage. Painful, iii. 305. Excessive, iii. 307. See Menorrhagia. Mensuration of Chest, ii. 198. Mentagra, i. 418. General characters of, i. 418. Diagnosis of, i. 419. Treatment of, i. 419. Infantum, i. 414. See Impetigo Figurata. Mercury, effect of, in inflammation, i. 120. Mesenteric Glands, inflammation of, iii. 142. See Tabes Mesenterica. Fever, i. 296. See Fever, gastric infantile remittent. Scrofulous disease of the, iii. 528. See Scrofula. Metallic Tinkling, ii. 213, 328. See Auscul- tation and Pneumothorax. Metastasis, in what it consists, i. 22. Metritis, iii. 317. Acute, iii. 319. Seat of, iii. 319. Causes of, iii. 319. Symptoms of, iii. 320. Diagnosis of, iii. 320. Treatment of, iii. 320. Chronic, iii. 320. Ulcerative inflammation of the uterine, iii. 321. Suppurative, iii. 321. Membranous, iii. 321. Enlargement and induration of the sub- stance and mucous follicles of the uterus, iii. 322. Symptoms of chronic, iii. 322. Causes of, iii. 324. Treatment of, iii. 324. 724 INDEX. Miasma, examination of its physical qualities, i. 300. Mielitide Sthenica. See Myelitis. Micosis, i. 441. See Framaesia. Miliaria, i. 405. General characters of, i. 405. Symptoms of, i. 406. Rubra, i. 406. Alba, 406. Diagnosis of, i. 407. Treatment of, i. 407. Its occurrence in continued fever, i. 153. Miliary Tubercle, characters of, iii. 521. See Tubercle and Scrofula. Millet-seed Rash, i. 405. See Miliaria. Milk Fever, i. 386. Mineral Waters, use of, in chronic rheumatism, iii. 571. Mitral Valve, disease of the, ii. 537. Normal situation of the, ii. 460. Modified Small-pox, i. 341. Mole, i. 445. See Naevi. Molluscum, i. 442. Treatment of, i. 443. Monomania, i. 577. See Insanity. Mont Dore, efficacy of its mineral waters in rheumatism, iii. 571. Morbilli, i. 347. See Rubeola. Morbus Coeruleus, ii. 590. See Malformations of the Heart. Carducus, i. 633. See Epilepsy. Comitialis, i. 633. Convivialis, i. 633. Sacer, i. 633. Scelestus, i. 633. Herculeus, i. 633. Demoniacus, i. 633. Deificus, i. 633. Divinus, i. 633. Lunaticus, i. 633. Major, i. 633. Sonticus, i. 633. Maculosus haemorrhagicus, i. 446. See Purpura. Taurus, i. 451. See Lepra Astrachanica. Mortification, in what it consists, i. 55. A termination of inflammation, i. 76. Mother mark, i. 445. See Naevi. Motion, paralysis of, ii. 119. Mouth, inflammation of the, iii. 17. Gangrene of, iii. 21. Moxas, employment of, in neuralgia, ii. 107. Mucous Diarrhoea, iii. 88. Membranes, affections of. See Mem- branes, mucous. Mucous Membranes, scrofulous affections of the, iii. 526. Muscle, worms found in the, iii. 607. See Worms. Muscular fibres, effects of inflammation on, i. 87. Mumps, iii. 29. See Parotitis. Myelitis, ii. 26. Symptoms of, ii. 26. Duration of, ii. 27. Causes of, ii. 28. Anatomical characters of, ii. 29. Nature of, ii. 29. Diagnosis of, ii. 29. Prognosis of, ii. 29. Myelitis, Treatment of, ii. 29. Naevi, i. 445. Narcotics, including anodynes and sedatives, observations on, iii. 657. Formulae for, iii. 658. Natural Small-pox, i. 310. Nausea and Vomiting, treatment of, iii. 64. Necrosis Infantilis, iii. 21. See Gangraena Oris. Nephralgia, ii. 102. Nephritis, iii. 260. Acute, iii. 260. Symptoms of, iii. 261. Terminations of, iii. 261. Chronic, iii. 261. Symptoms of, iii. 262. Terminations of, iii. 262. Complications of, iii. 262. Latent, iii. 265. Pyelitis, iii. 265. Causes of, iii. 266. Anatomical characters of, iii. 267. Prognosis of, iii. 268. Treatment of, iii. 269. Neris, efficacy of its mineral waters in chronic rheumatism, iii. 571. Nervous System, diseases of the, i. 461. General view of the anatomy, physiology, and pathology of the, i. 461. Aphonia, ii. 261. Asthma, ii. 284. Fever, i. 140. Larynx, affections of the, ii. 259. Palpitation, ii. 489. Pulsation, ii. 593. Nettle-rash, i. 395. See Urticaria. Neuralgia, ii. 99. Varieties of, ii. 100. Facial, ii. 100. Cerebralgia, ii. 100. Intercostal, ii. 101. Femoro-popliteal, ii. 101. Plantar, ii. 101. Affecting parenchymatous structures, ii. 101. Muscular, ii. 101. Membranous, ii. ] 01. Glandular organs, ii. 102. From the pressure of a subcutaneous tumour, ii. 102. Angina pectoris, ii. 102. Gastralgia, ii. 102. Enteralgia, ii. 102. Diagnosis of, ii. 102. Causes of, ii. 103. Nature of, ii. 103. Treatment of, ii. 105. Of the air-tubes, ii. 296. Of the heart, ii. 510. Of the arteries, ii. 593. Neuralgia, Spasmodica, ii. 100. See Neu- ralgia. Nomra, iii. 21. See Gangraena Oris. Nose, bleeding from the, iii. 378. See Epis- taxis. Notamyelitis, ii. 26. See Myelitis. Nutrition, diseased, i. 50. Hypertrophy, i. 51. INDEX. 725 Nutrition, diseased, Atrophy, i. 51. Softening, i. 52. Induration, i. 53. Transformation, i. 53. Ulceration, i. 55. Mortification, i. 55. Obliteration of the veins, ii. 625. CEdema of the glottis, ii. 236. Of the heart, ii. 572. Of the lungs, ii. 355. Of the liver, iii. 170. (Edematous Erysipelas, i. 392. (Esophagus, diseases of the, iii. 36. Spasmodic stricture, iii. 37. Treatment, iii. 37. Olophlyctide, i. 401. See Herpes. Omental Dropsy, iii. 515. See Dropsy. Omentum, dropsy of the, iii. 515. Worms found in the, iii. 607. See Worms. Ophthalmia, ii. 133. Inflammation of the conjunctiva, ii. 134. Catarrhal, ii. 134. Symptoms of, ii. 134. Diagnosis of, ii. 135. Treatment of, ii. 136. Purulent, in infants, ii. 137. Prognosis of, ii. 137. Causes of, ii. 138. Treatment of, ii. 138. In adults, ii. 139. ^Egyptian, ii. 139. Symptoms of, ii. 139. Causes of, ii. 140. Treatment of, ii. 140. Gonorrhoeal, ii- 142. Symptoms of, ii. 142. Causes of, ii. 143. Treatment of, ii. 143. Strumous, ii. 144. Symptoms of, ii. 144. Causes of, ii. 146. Treatment of, ii. 147. Variolous, i. 317 ; ii. 149. Morbillous, ii. 150. Scarlatinous, 150. Erysipelatous, ii. 151. Inflammation of the sclerotica, ii. 151. Rheumatic, ii. 151. Symptoms of, ii. 151. Causes of, ii. 152. Diagnosis of, ii. 152. Treatment of, ii. 152. Catarrho-rheumatic, ii. 153. Inflammation of the cornea, ii. 155. Inflammation of the iris, ii. 158. Acute idiopathic, ii. 158. Symptoms of, ii. 158. Causes of, ii. 160. Diagnosis of, ii. 160. Treatment of, ii. 161. Syphilitic iritis, ii. 163. Rheumatic iritis, ii. 164. Arthritic iritis, ii. 164. Strumous iritis, ii. 166. Inflammation of the retina, ii. 166. Inflammation of the choroid, ii. 168. Ophthalmodynia periodica, ii. 109. See Neu ralgia. Opisthotonos, ii. 67. See Tetanus. Opium, use of, in chronic rheumatism, iii. 573. Organic Headache, i. 629. See Cephalalgia. Osseous transformation of the uterus, iii. 338. Ossification of the heart, ii. 574. Of the arteries, ii. 598. Otalgia, ii. 99. See Otitis—Neuralgia. Otitis, ii. 178. Acute external, ii. 178. Acute internal, ii. 179. Chronic, ii. 181. Causes of, ii. 184. Anatomical characters of, ii. 185. Diagnosis of, ii. 186. Prognosis of, ii. 189. Treatment of, ii. 189. Otorrhcea, ii. 181. See Otitis. Ovarian Dropsy, iii. 343, 512. Ovaritis, iii. 340. See Ovary, Inflammation of the. Ovary, inflammation of the, iii. 340. Anatomical characters, iii. 341. Acute, iii. 341. Symptoms of, iii. 341, Diagnosis of, iii. 341. Chronic, iii. 342. Symptoms of, iii. 342. Causes of, iii. 342. Treatment of, iii. 342. Dropsy of the, iii. 343, 512. Hydatids of the, iii. 344. Extirpation of the, iii. 352. Structural diseases of the, iii. 354. Hypertrophy of the, iii. 354. Atrophy of the, iii. 354. Morbid transformations of the, iii. 354. Cysts containing hairs, &c, iii. 354. Malignant degeneration of the, iii. 355. Symptoms of, iii. 355. Treatment of, iii. 356. Worms found in the, iii. 607. See Worms. Ozaena, iii. 273. See Bronchitis. Pain, a symptom of inflammation, i. 65. Painters' Colic, iii. 127. See Colica Pic- tonum. Palpitation, nervous, ii. 489. Symptoms of, ii. 489. Causes of, ii. 490. Diagnosis of, ii. 491. Treatment of, ii. 493. Inordinate abdominal or epigastric, ii. 593. Dyspeptic, iii. 65. Pancreas, diseases of the, iii. 190. Alterations in the secretions of the, iii. 190. Congestions of the, iii. 192. Haemorrhage of the, iii. 192. Inflammation of the, iii. 192. Abscess of the, iii. 192. Hypertrophy of the, iii. 193. Atrophy of the, iii. 193. Transformations of the, iii. 194. Steatomatous concretions of the, iii. 194. Serous cysts and hydatids of the, iii. 194. Scirrho-cancerous degeneration of the, iii. 194. 726 INDEX. Pancreas, melanosis of the, iii. 194. Calculi of the, iii. 194. Diagnosis of the, iii. 194. Symptoms of, iii. 194. Causes of, iii. 197. Treatment of, iii. 197. Palsy, shaking, ii. 121. Pannus hepaticus, i. 444. See Ephelis. Lenticularis, i. 444. See Lentigo. Pantaphobia, ii. 83. See Hydrophobia. Papula, general characters of, i. 388. Papula Sudoris, i. 405. See Miliaria. Papulae Cuticulares, i. 395. See Urticaria. Siccae, i. 427. See Lichen. Paracentesis thoracis, ii. 320. Of the ovary, iii. 351. Paralysis, ii. 111. Varieties of, ii. 111. Appearance of parts affected with, ii. 112. Sensibility of paralysed parts, ii. 112. State of the circulation in paralysed limbs, ii. 112. General, ii. 114. Hemiplegia, ii. 114. Paraplegia, ii. 115. Local, ii. 115. Of sensibility, ii. 118. Of motion, ii. 119. Accompanying insanity, ii. 119. From metallic poisons, ii. 120. Agitans, ii. 121. Causes of, ii. 121. Anatomical characters of, ii. 122. Nature of, ii. 123. Diagnosis of, ii. 125. Prognosis of, ii. 127. Treatment of, ii. 127. Paralytic affections of the larynx, ii. 260. Paraplegia, ii. 115. Paraplcxy, i. 548. See Apoplexy. Parasites, iii. 595. See Worms. Parenchymatous Viscera, effects of inflamma- tion on, i. 85. Parotid Gland, inflammation of the, iii. 29. See Parotitis. Parotitis, iii. 29. Specific, iii. 29. Common, iii. 30. Pectoriloquy, how produced, ii. 212, 378. Pedarthrocace, i. 449. See Elephantiasis Arabica. Pediculis, iii. 629. See Worms. Peliose, i. 446. See Purpura. Pellagra, i. 447. General characters of, i. 447. Pemphigus, i. 409. General characters of, i. 409. Acute, i. 410. Solitarius, i. 410. Chronic, i. 410. Diutinus, i. 410. Diagnosis of, i. 411. Treatment of, i. 411. Variolides, i. 407. See Varicella. Percussion, application of, iii pectoral diseases, ii. 200. Mediate, ii. 201. Sounds elicited by, ii. 202. Mode of performing, ii. 204. Percussion, value of, in detecting enlargement of the liver, iii. 184. Sounds elicited by in abdominal dropsy, iii. 512. See Dropsy. Perforation of the aorta, ii. 605. Of the gall-bladder or ducts, iii. 165. Of the intestines, iii. 137. Of organs from the pressure of an aneu- rismal tumour, ii. 604. Of the pleura, ii. 326. Of the stomach, iii. 56. Of the cerebral membranes in chronic hydrocephalus, iii. 508. Of the coats of the intestines by worms, iii. 602. Pericarditis, ii. 511. Anatomical characters of, ii. 511. Symptoms of, ii. 514. Physical signs of, ii. 517. Chronic, ii. 520. Duration of, ii. 520. Complications, ii. 520. Diagnosis of, ii. 521. Causes of, ii. 523. Relation of, to rheumatism, ii. 524. Treatment of, ii. 525, 529. Rheumatic, iii. 560. Physical signs of, iii. 474, 561. Dropsy from, iii. 474. Pericardium, dropsy of the, ii. 582. Secondary effusions into the, ii. 584. Air within the, ii. 585. Haemorrhage into the, iii. 375. Perinephritis, iii. 260. See Nephritis. Periodic Headache, i. 627. See Cephalalgia. Periosteum, scrofulous disease of the, iii. 527. Peripneumonia, ii. 332. See Pneumonia. Notha, ii. 268. See Acute Bronchitis. Peritoneal Fever, i. 368. See Fever, Puerperal. Peritoneum, dropsy of the, iii. 512. See Dropsy. Peritonitis, iii. 131. Anatomical characters of, iii. 132. Symptoms of, iii. 132. Diagnosis of, iii. 133. Causes of, iii. 134. Prognosis of, iii. 134. Treatment of, iii. 131. Erythematic, iii. 136. Puerperal, iii. 137. Acute puerperal, i. 373. Of the caecum, iii. 141. From intestinal perforation, iii. 137. Chronic, iii. 138. Pertussis, ii. 289. Symptoms of, ii. 289. Varieties of, ii. 291. Complications, ii. 291. Causes of, ii. 292. Anatomical characters of, ii. 292. Pathology of, ii. 293. Diagnosis of, ii. 294. Prognosis of, ii. 294. Treatment of, ii. 294. Diet and Regimen in, ii. 295. Treatment of the complications, ii. 296. Pestis. See Plague. Petechiae, i. 446. See Purpura. In continued fever, i. 151.' See Fever. Peyer's Glands, enlargement of, in fever, i. 149. INDEX. 727 See Throat, inflamma- Pleurisy, acute, ii. 304. Symptoms of, ii. 304. gall-stones, iii. Pharyngitis, iii. 30. tion of the. Phlebitis, ii. 618. Anatomical characters of, ii. 618. Symptoms of, ii. 619. Causes of, ii. 620. Treatment of, ii. 621. See Phlegmasia Dolens. Phlebolitis, ii. 626. Origin of, ii. 626. In the uterine veins, iii. 338. Phlegmasia Dolens, ii. 621. Occurring after delivery, ii. 621. After abortion, ii. 621. In fever, i. 155 ; ii. 622. Phlegmonous Erysipelas, i. 392. Phlygacia, i. 413. See Ecthyma. Phlyzacium, i. 388. Phobadipsia, ii. 83. See Hydrophobia. Phosphatic Urine, ii. 211. Phrenitis, i. 493. See Brain, inflammation of the. Phthisis Pulmonalis, ii. 361; iii. 19. See Con sumption, pulmonary. Pian, i. 441. See Framboesia. Pica, iii. 59. See Dyspepsia Picromel, existence of, in 160. Piles, iii. 114. See Haemorrhoids. Pimple, i. 388. See Papula. Pituitous Catarrh, ii. 279. See Bronchorrhoea Pityriasis, i. 436. General characters of, i. 436. Varieties of, i. 436. Capitis, i. 436. Rubra, i. 436. Versicolor, i. 436. Nigra, i. 437. Diagnosis of, i. 437. Treatment of, i. 437. Plague, i. 209. Symptoms of, i. 209. Analysis of the blood in, i. 210. Varieties of, i. 210. Simple or glandular, i. 210. Eruptive, i. 21 J. Malignant, i. 213. Sequelae, i. 214. Anatomical characters of, i. 215. Diagnosis of, i. 218'. Prognosis of, i. 219. Statistics of, i. 220. Mortality of, i. 221. Nature of, i. 223. Causes of, i. 225. Arguments of the contagionists examined, i. 225. Predisposing causes of, i. 228. Prophylactic measures, i. 228. Treatment of, i. 229. Plethora, symptoms of, i. 56. Pleura, inflammation of the, ii. Pleurisy. Perforation of the, ii. 326. Pus in the cavity of the, ii Empyema. Air in the cavity of the, ii. 326. See Pneumothorax. Pleurisy, ii. 303. Pathology of, ii. 303. 303. See 315. See Physical signs of ii. 304. Adhesions, ii. 309. Symptoms of the decline of acute, ii. 309. Chronic, ii. 310. Pathology of, ii. 311. Absorption of the pleuritic effusion, ii. 313. Physical signs of the absorption, ii. 314. Causes of, ii. 316. Diagnosis of, ii. 317. Prognosis of, ii. 317. Treatment of, ii. 318. Paracentesis thoracis, ii. 320. Connexion of, with Tuberculous disease ii. 325. Haemorrhagic, iii. 375. Complicating endocarditis, iii. 561. Pleuritis, ii. 363. See Pleurisy. Pleurodynia, ii. 330; iii. 572. See Rheuma- tism. Pleuro-pneumonia, ii. 341. See Pneumonia. Pleurosthotonos, ii. 67. See Tetanus. Pleximeter, ii. 201. Pneumonia, ii. 332. Symptoms of, ii. 332. Anatomical characters of, ii. 334. Hepatisation of the lung, ii. 334. Gangrene of the lunjr, ii. 335. Physical signs, ii. 336. Typhoid, ii. 340. Complication of, with bronchitis, ii. 340. Pleuro-pneumonia, ii. 341. Other complications, ii. 342. Diagnosis of, ii. 342. Prognosis of, ii. 343. Causes of, ii. 344. Treatment of, ii. 345. Chronic, ii. 351. Of children, ii. 352. Lobular, ii. 352. Pneumopericardium, ii. 585. Pneumothorax, ii. 326. Varieties of, ii. 326. Physical signs of, ii. 327. Prognosis of, ii. 329. Treatment of, ii. 330. Pock, anatomical characters of the variolous, i. 313. Podagra, iii. 575. See Gout. Poisons, corrosive, haematemesis from swallow- ing, iii. 399. Polypus of the heart, ii. 579. Of the uterus, iii. 329. Mode of growth of, iii. 329. Varieties of, iii. 330. Symptoms of, iii. 331. Diagnosis of, iii. 331. Prognosis of, iii. 332. Treatment of, iii. 332. Polystoma pinguicola, iii. 616. See Worms. Pompholyx, i. 410. See Pemphigus. Porridge, oatmeal, iii. 129. Porrigo, i. 419. Chloasma, i. 436. See Pityriasis. Favosa, i. 420. Larvalis, i. 414. See Impetigo Figurata. Lupinosa, i. 420. 728 INDEX. Porrigo Scutulata, i. 422. Treatment of, i. 422. Portio dura, paralysis of the, ii. 116. See Paralysis. Pouss6e, i. 427. See Lichen. Prepuce, herpes of the, i. 402. Prescribing, art of, iii. 630. Prosopalgia, ii. 100. See Neuralgia. Prostate Gland, diseases of the, iii. 292. Prurigo, i. 429. General characters of, i. 429, Varieties of, i. 429. Mitis, i. 429. Formicans, i. 430. Senilis, i. 430. Podicis, i. 430. Genitalium, i. 430. Diagnosis of, i. 430. Treatment of, i. 430. Pruritus, i. 429. See Prurigo. Psora, i. 404. See Scabies. Leprosa, i. 431. See Psoriasis. Psoriasis, i. 431,436. See Pityriosis. General characters of, i. 431. Varieties of, i. 431. Guttata, i. 431. Circinnata, i. 431. Diffusa, i. 432. Gyrata, i. 432. Ophthalmica, i. 433. Labialis, i. 433. Preputialis, i. 433. Scrotalis, i. 433. Palmaria, i. 433. Dorsalis, i. 433. Unguinum, i. 433. Causes and diagnosis of, i. 433. Treatment of, i. 434. Psychodiaria, iii. 607. See Worms. Psydracium, i. 388. See Pustule. Puberty, precocious, iii. 295. Tardy, iii. 296. Puerperal Fever, i. 368. See Fever. Insanity, i. 602. Period of the attack, i. 603. Symptoms of, i. 603. Mortality of, i. 6I>3. Treatment of, i. 604. Peritonitis i. 373; iii. 137. Acute, i. 373. Symptoms of, i. 373. Anatomical characters of, i. 374. Treatment of, i. 374. False, i. 384. Fever, symptoms of, ii. 385. Causes of, i. 385. Pulex penetrans, iii. 629. See Worms. Pulmonary Apoplexy, iii. 385. Catarrh, ii. 261. Consumption, ii. 361. Emphysema, ii. 356. OZdema, ii. 355. Pulmonary Artery, ii. 460. Pulmonitis, ii. 332. See Pneumonia. Pulsation, inordinate, abdominal or epigastric, ii . 593. Pulse, variations of the, ii. 230. Arterial, ii. 475. - Value of, as an indication of disease, ii. 475. Pulse, circumstances modifying the character of the, ii. 476. Venous, ii. 480. Explanation of its occurrence, ii. 480. Resilience of the, ii. 607. Fallacious fulness of the, i. 114. Purgative, strong, formulae for, iii. 684. Mild formulae for, iii. 685. Purpura, i. 446. General characters of, i. 446. Varieties of, i. 446. Alba, i. 405. See Miliaria. Simplex, i. 446. Hemorrhagica, i. 446. Causes of, i. 447. Diagnosis of, i. 447. Treatment of, i. 447. Purpuric Urine, iii. 214. Purulent infiltration of the lung, ii. 334. See Pneumonia. Ophthalmia, ii. 137. See Ophthalmia. Pustula, i. 388. Putrid Sore Throat, i. 358. See Scarlatina Maligna. Pyelitis, iii. 265. See Nephritis. Pylorus, scirrhus of the, iii. 50. See Carci- noma of the Stomach. Pyrosis, iii. 70. See Gastrorrhoea. Quartan Fever, i. 238. See Intermittent Fever. Quinsy, iii. 35. See Angina. Quotidian Fever, i. 235. See Intermittent Fever. Rabies Canina, ii. 83. See Hydrophobia. Rachialgitis, ii. 26. See Myelitis. Radesyge, i. 448. Symptoms of, i. 448. Treatment of, i. 449. Rage, ii. 83. See Hydrophobia. Rale. See Auscultation. Ramollissement. See Softening. Rash, i. 388. See Exanthema. Rectum, spasmodic stricture of the, iii. 119. Treatment of, iii. 120. Worms found in the, iii. 607. See Worms. Recurrent Small-pox, i. 331. See Small-Pox. Red Gum, i. 427. See Lichen Strophulus. Redness, a symptom of inflammation, i. 62. Refrigerants, observations on, iii. 695. Formulae for, iii. 696. Relation of diseases, i. 19. Remittent Fever, i. 256. Infantile gastric, i. 29€. See Fever. Respiration, diseases of the organs of, ii. 195. Sounds produced by, ii. 205. Explanation of, ii. 206. See Auscultation. Retinitis, ii. 166. Symptoms of, 166. Chronic, ii. 166. Causes of, ii. 166. Diagnosis of, ii. 167. Treatment of, ii. 167. Retrocedent Gout, iii. 581. See Gout. Revaccination, necessity of, considered, i. 343. Renal haemorrhage, iii. 409. See Haemorrhage. Dropsy, iii. 477. See Dropsy. Revulsion, in what it consists, i. 21. Rheuma Epidemicum, ii. 401. See Influenza. Rheumatic Endocarditis, iii. 474, 561. INDEX. 729 Rheumatic Pericarditis, iii. 474, 560. Ophthalmia, ii. 151. See Sclerotitis. Iritis, ii. 164. Pericarditis, iii. 560. See Pericarditis. Rheumatism, iii. 556. Acute, iii. 556. Symptoms of, iii. 556. Fibrous effusion, iii. 557. Synovial effusion, iii. 557. Of the heart, iii. 558, 574. Symptoms of, iii. 559. Physical signs of, iii. 559. Of the pericardium, iii. 560. Physical signs of, iii. 560. Endocarditis, iii. 561. Frequency of cardiac disease in, iii. 561. Period at which cardiac affections appear, iii. 561. Remote effects of the cardiac affections, iii. 562. Diagnosis. See Gout. Pathology of, iii. 562. Causes of, iii. 565. Treatment of, iii 566. Cardiac, treatment of, iii. 567, 574. Chronic, iii. 569. Treatment of, iii. 570, 575. Efficacy of mineral springs in, iii. 575. Muscular, iii, 571. Lumbago, iii. 572. Pleurodynia, iii. 572. Crick of the neck, iii. 572. Of the limbs, iii. 573. Of the abdominal muscles, iii. 573. Diagnosis of, iii. 573. Treatment of, iii. 573. Rheumatismus Canerosus, ii. 100. See ralgia. Rhonchus. See Auscultation. Ring Worm, i. 402. See Porrigo Scutula Rogne, i. 404. See Scabies. Rosa Volatica, i. 391. See Erysipelas. Rosacea, i. 394. See Roseola. Rosea vel Rosacea, i. 416. See Acne. Rose, the, i. 391. See Erysipelas. Rose Rash, i. 394. See Roseola. Roseola, i. 394. Infantilis, i. 394; ^Estiva, i. 394. Auturnnalis, i. 394. Annulata, i. 394. Febrilis, i. 394. Rheumatica, i. 394 Variolosa, i. 394. Vaccinia, i. 394. Diagnosis of, i. 394. Treatment of, i. 394. Rossalia, i. 394. See Roseola. Rossaria, i. 394. See Roseola. Rubeola, i. 347. History of, i. 347. Vulgaris, i. 347. Nigra, i. 348. Sine catarrho, i. 349. Maligna, i. 349. Sequelae, i. 350. Anatomical characters of, i. 350. Prognosis, i. 351. Causes of, i. 351. VOL. III. Rubeola, contagious nature of, i. 352. Inoculation of, i. 352. Period of inoculation, i. 352. Diagnosis of, i. 351, 363. Spuria, i. 394. See Roseola. Rubores cum vesiculis et prurita, i. 396. See Eczema. Running Scall, i. 396. See Eczema. Tetter, i. 414. See Impetigo. Rupia, i. 411. General characters of, i. 411. Simplex, i. 411. Prominens, i. 412. Escharotica, i. 412. Diagnosis of, i. 412. Treatment of, i. 412. Rupture of the heart, ii. 576. Of the spleen, iii. 199. Of bloodvessels, ii. 604. 571, Neu- ,ta. Q2 Saccharine Urine, in. 240. Saint Anthony's Fire, i. 391. See Erysipelas. Saint Vitus's Dance, ii. 39. See Chorea. Saline treatment of fever, i. 192. Of malignant cholera, iii. 108. Salze Fluss, i. 448. See Radesyge. Sarcocele d'Egypt, i. 449. See Elephantiasis Arabica. Sarcoma, mammary, i. 44. Pancreatic, i. 44. Vascular, i. 44. Medullary, i. 44. Of the lungs, ii. 398. Of the heart, ii. 574. Satyriasis, i. 438. See Lepra Tuberculosa. Scabies, i. 404. Acarus scabiei, i. 404. General characters of, i. 404. Diagnosis of, i. 405. Treatment of, i. 405. Agria, i. 427. See Lichen. Farina. See Prurigo. Fera, i. 413. See Ecthyma. Papuliformis, i. 429. See Prurigo. Sicca, i. 427. See Lichen. Scabrities, i. 427. See Lichen. Scale, i. 389. See Squama. Scaly Tetter, i. 431. See Psoriasis. Leprosy, i. 431. See Psoriasis. Scarlatina, i. 354. General symptoms of, i. 354. Varieties of, i. 355. Simplex, i. 355. Anginosa, i. 357. Maligna, i. 358. Sine exanthemate, i. 359. Sequelae, i. 359. Anatomical characters of, i. 361. Inoculation of, i. 362. Causes of, i. 362. Diagnosis of, i. 363. Prognosis of, i. 363. Mortality of, i. 363 Treatment of, i. 364. Scarlet Fever, i. 354. See Scarlatina. Sciatica, ii. 101. See Neuralgia. Scirrhoma, varieties of, i. 44. Scirrhus of the lungs, ii. 399. Of the heart, ii. 574. 730 INDEX. Scirrhus of the stomach, iii. 50. Of the liver, iii. 181. Of the pancreas, iii. 194. Scorbutus, iii. 417. See Scurvy. Scorbutus Alpium, i. 441. See Pellagra. Sclerotitis Atmospherica, ii. 151. Symptoms of, ii. 151. Causes of, ii. 152. Diagnosis and treatment of, ii. 152. Scrofula, iii. 519. Definition of, iii. 519. Scrofulous diathesis, iii. 519. Incipient stage of, iii. 521. Second stage of, iii. 522. Glandular swellings in, iii. 522. Third stage of, iii. 523. Abscess, iii. 523. Ulcer, iii. 524. Deposition of tuberculous matter in the subcutaneous tissue, iii. 524. In mucous membranes, iii. 526. In the serous membranes, iii. 527. In the osseous system, iii. 527. In the periosteum, iii. 527. In the lymphatic glands, iii. 528. In the mesenteric glands, iii. 528. Other glandular swellings, iii. 529. Effect of, in modifying other diseases, iii. 532. Causes of, iii. 535. Hereditary influence of, iii. 535. Question as to its contagious nature, iii. 536. Its identity with syphilis considered, iii. 536. Circumstances favourable to the produc- tion of, iii. 537. Prevention of, iii. 540. Management of children of scrofulous parents, iii. 540. Treatment of, iii. 542. Scurvy, iii. 417. Origin of the term, iii. 417. History of, iii. 417. Causes of, iii. 423. Causes of, salt provisions, iii. 423. Impure air, iii. 424. Cold and moisture, iii. 425. Contagion, iii. 426. Abstinence from succulent vegetables and fruits, iii. 426. Predisposing causes of, iii. 427. Debility from previous disease, iii. 427. Age, iii. 428. Inactivity, despondency, &c. iii. 428. Preventives, iii. 429. Juice of the aurantiaceae, iii. 429. Other acidulous fruits, iii. 429. Plants of the order crucifer®, iii. 431. Pickles, iii. 432. Sour kroute, iii. 433. Fir tribe, iii. 433. Onions, garlic, &c, iii. 433. Potatoes, iii. 434. Molasses, iii. 434. Infusion of malt, iii. 434. Fermented liquors, iii. 434. Vinegar, iii. 435. Sowens (a preparation of oatmeal), iii. 436. Scurvy, Preventives, erroneous impression as to the efficacy of fresh meat, iii. 436. General conclusion concerning, iii. 436. Symptoms of, iii. 438. Haemorrhagic effusions, iii. 438. Contraction of the joints, iii. 439. Peculiar aspect of wounds in, iii. 440. Spongincss of the gums in, iii. 442. Tendency to syncope in, iii. 443. Breaking out of old sores in, iii. 443. Anatomical characters of, iii. 444. Morbid condition of the blood in, iii. 451. Diagnosis of, iii. 452. Treatment of, iii. 454. Secretion, diseased, i. 34. Fibrinous, i. 34. Serous, i. 36. Purulent, i. 37. Use of, i. 76. Tuberculous, i. 41. Carcinomatous, i. 42. Melanotic, i. 48. Gaseous, i. 49. Sensation, paralysis of. See Paralysis, ii. 118. Septum, ii. 460. See Heart, divisions of tho. Serous Membranes, inflammation of, i. 84. [ Diarrhcea, iii. 88. Serpedo Serpigo, i. 431. See Prurigo. [Shaking Palsy, ii. 121. See Paralysis Agitans. Shingles, i. 403. See Herpes Zoster. Sick Headache, i. 627. Skin, disease of the, i. 388. Classification of. i. 389. Sloughing, phagadenic, of the mouth, iii. 21. See Gangraena Oris. Small-pox, i. 310. Varieties of, i. 310. Variola benigna discreta, i. 311. Stage of incubation of, i. 311. Initiatory stage of, i. 311. Period of maturation of, i. 312. Anatomical characters of the variolous vesicle of, i. 313. Variola confluens, i. 314. Eruptive fever, i. 314. Complications, i. 315. Secondary fever, i. 316. Variolous ophthalmia, i. 317. Variola semiconfluens, i. 319. corymbosa, i. 319. maligna, i. 325. anomala, i. 320. confluens mitigata, i. 321. varicelloides, i. 321. Febris variolosa sine cruptione, i. 322. Diagnosis of, i. 322. Prognosis of, i. 323. Mortality of, i. 324. Anatomical characters of, i. 326. Causes of, i. 328. Contagious origin of, i. 328. Epidemic origin of, i. 329. Susceptibility of, i. 330. Recurrent, i. 331. Treatment of, i. 332. Inoculated, i. 335. History of inoculation, i. 336. Practice of inoculation, i. 338. Treatment of inoculation, i. 339. Value of inoculation, i. 339. INDEX. 731 Small-pox, modified, i. 341. Diagnosis from varicella, i. 409. Smell, loss of, ii. 118. Smyrna, table of mortality from the plague in, Softening, in what it consisis, i. 52. Of the brain, i. 504. Of the spinal marrow, ii. 29. Of the heart, ii. 571. Of the inner membranes of the arteries, ii. 599. Of the stomach, iii. 40. Inflammatory, iii. 40. Cadaveric, iii. 41, 53. From the action of the gastric juice during life, iii. 54. Of the spleen, iii. 199. Sore Throat, ulcerated, iii. 32. See Angina Membranacea. Sore Throat, iii. 30. See Angina. Soussee, i. 396. See Eczema. Spasmodic Croup, ii. 256. See Laryngismus Stridulus. Spasms of the glottis, ii. 256. Of the oesophagus, iii. 37. Of the bladder, iii. 292. Of the involuntary muscles in amenor- rhoea, iii. 299. Of the involuntary muscles, iii. 300. Spedal Sked, i. 448. See Radesyge. Sphacelus, in what it consists, i. 55. Sphinx Ligustrc, deposition of tuberculous matter in the larva of, iii. 535. Spilus, i. 445. See Naevi. Spina bifida, hydrorachis complicated with, ii 31. See Hydrorachis. Spinal Apoplexy, ii. 37. See Apoplexy. Spinal Cord, inflammation of, ii. 26. See Myelitis. Dropsy of the, ii. 31. See Hydrorachis Haemorrhage from the serous membrane of the, iii. 373. Spinal irritation, ii. 17. Symptoms of, ii. 17. Causes of, ii. 19. Nature of, ii. 19. Diagnosis of, ii. 20. Prognosis of, ii. 20. Duration of, ii. 20. Treatment of, ii. 21. Hysterical symptoms connected with, ii 60. See Hysteria and Neuralgia. Spinal Meningitis, ii. 22. See Meningitis. Spinal Marrow, softening of, ii. 29. Spinitis, ii. 26. See Myelitis. Spleen, diseases of the, iii. 198. Congestion of the, iii. 198. Inflammation of the, iii. 198. Hypertrophy of the, iii. 198. Softening of the, iii. 199. Rupture of the, iii. 199. Induration of the, iii. 200. Purulent formations in the, iii. 200. Gangrene of the, iii. 200. Tubercle of the, iii. 200. Serous cysts and hydatids of the, iii. 201. Symptoms of, iii. 201. Causes of, iii. 202. Treatment of, iii. 203. Spieen, haematemesis from congestion of the, iii. 401. Worms found in the, iii. 607. See Worms. Squama, i. 389. Starvation, delirium from, i. 523. Symptoms of, i. 523. Treatment of, i. 523. Slernalgia, ii. 503. See Angina Pectoris. Stethoscope, description of the, ii. 214. Method of using the, ii. 216. Use of in valvular murmurs, ii. 537. Stimulants, observations on, iii. 650. Formulae for, iii. 651. Acting on the spinal marrow and motor nerves, iii. 656. Stomach Fever, i. 296. See Infantile gastric remittent fever. Stomach, inflammation of the, iii. 38. See Gastritis. Carcinoma of the, iii. 50. Softening of the, iii. 53. Ulceration of the, iii. 55. Perforation of the, iii. 56. Gout of the, iii. 581. See Gout. Stomatitis, iii. 17. Aphthosa, iii. 17. Mercurialis, iii. 19. Ulcerosa, iii. 20. Strabismus, ii. 115. See Paralysis. Strangulation, ii. 434. Cause of death in, ii. 434. Signs of, ii. 436. Treatment of, ii. 442. See Asphyxia. Stricture, non-malignant, of the colon, iii. 112. Spasmodic, of the rectum, iii. 119. Strongylus Gigas, iii. 623. Sec Worms. Strophulus albidus, i. 427. Candidus, i. 427. Confortus, i. 427. Intertinctus, i. 427. Volaticus, i. 427. See Lichen. Strumous Ophthalmia, ii. 144. Iritis, ii. 166. Submersion, ii. 442. Cause of death in, ii. 442. Indications of death by, ii. 445. Treatment of, ii. 450. See Asphyxia. Succussion, ii. 329. Sudamina, i. 405. See Miliaria.,. Suffocative Breast-pang, ii. 503. See Angina Pectoris. Suicide, propensity to, i. 582. See Insanity. Suppuration, a termination of inflammation, i. 37. Of the brain, i. 504. Of the liver, iii. 170. Of the pancreas, iii. 192, Of the spleen, iii. 200. Suspended Animation, ii, 414. See Asphyxia. Swallowing, difficulty of, iii, 301. Swelling, a symptom of inflammation, i. 62. Swine-pox, i. 407. See Varicella. Sycosis, i. 418. See Mentagra. Syncope, ii. 495. Symptoms of, ii. 495. Causes of, ii. 496. Diagnosis of, ii. 498. Treatment of, ii. 499. 732 INDEX. Syncope, beneficial effects of, in the cure of certain affections, ii. 500. Anginosa, ii. 503. See Angina Pectoris, Tendency to, in scurvy, ii. 443. See Scurvy. Synocha. See Fever. Synochus. See Fever. Synovial membrane, inflammation of, iii. 570 See Rheumatism. Syphilida, i. 452. See Syphilitic Eruptions. Syphilitic blotches, i. 453. See Syphilitic Eruptions. Eruptions, i. 453. Classification, i. 452. Exanthematous, i. 453. Vesicular, i. 453. Pustular, i. 453. Papular, i. 454. Squamous, i. 455. Tubercular, i. 456. Lesions accompanying, i. 457. Causes of, i. 457. Diagnosis of, i. 458. Treatment of, i. 459. Iritis, ii. 163. Tabes Mesenterica, iii. 143. Anatomical characters of, iii. 143. Causes of, iii. 144. Complications of, iii. 145. Symptoms of, iii. 146. Diagnosis of, iii. 146. From gastric remittent fever, i. 299. Treatment of, iii. 147. Table of the occurrence of critical days in continued fever, i. 143. Of the progress of epidemic fever, i. 157. Of the comparative prevalence of fever in different years at Glasgow, i. 157. Of the proportion of fever cases in Glas- gow to the population, i. 170. Of the mortality from plague in Smyrna, i. 221. Of the period of the eruption of small-pox when death occurred, i. 324. Exhibiting the comparative prevalence of scurvy at different periods of life, iii. 428. Of the analysis of the blood in scurvy, iii. 451. Of the chemical composition of the effused fluid in different forms of dropsy, iii. 467. * Of the quantities of iodine and hydriodate of potass in baths, according to the age of the patient, iii. 546. Of the comparative liability to gout at different periods of life, iii. 586. Of the various species of worms found in different organs and textures, iii. 599. Of the mortality of small-pox, i. 324. Of the respiratory sounds, ii. 213. Of the causes of dyspnoea, ii. 219. Of the order in which the teeth appear in the first dentition, iii. 27. Of the diagnosis between enteritis and typhus fever with enteritic complica- tion, iii. 76. Taenia solium, iii. 611. Latum, iii. 615. See Worms. Tape Worm, See Taenia Solium. Tapping. See Paracentesis. Tarantism, ii. 39. See Chorea. Tarantulismus, ii. 39. See Chorea. Taste, loss of, ii. 118. See Paralysis. Teeth, order of their api>earance in the first dentition, iii. 27. See Dentition. Teigne, i. 414. See Impetigo Figurata. Temperament, characters of the scrofulous, iii. 519. Tenesmus, iii. 79. See Colitis. Tertian Fever, i. 236. See Fever, Intermittent. Tetanus, ii. 67. Symptoms of, ii. 67. Causes of, ii. 71. Anatomical characters of, ii. 73. Nature of, ii. 74. Diagnosis of, ii. 76. Prognosis of, ii. 76. Treatment of, ii. 77. Tetter, i. 402. See Herpes. Crusted, i. 414. Running, i. 414. See Impetigo. Scaly, i. 431. See Psoriasis. Thoracic Dropsy, iii. 510. See Dropsy. Thread Worm, iii. 626. See Ascaris Vermi- cularis. Throat, diseases of the, iii. 30. See Angina. Affections of the, in fever, i. 146. Thrush, iii. 17. See Stomatitis Aphthosa. Tic douloureux, ii. 100. See Neuralgia. Tinea annularis, i. 422. See Porrigo Scutu- lata. Favosa, i. 420. See Porrigo Favosa. Granulata, i. 414. See Impetigo Figu- rata. Mucosa, i. 414. See Impetigo Figurata. Rugosa, i. 420. See Porrigo Scutulata. Muciflua, i. 414. See Impetigo Figurata. Tongue, inflammation of the, iii. 28. Symptoms of, iii. 28. Treatment of, iii. 28. Scrofulous affection of the, iii. 529. Tonics, observations on, iii. 664. Formulae for, iii. 665. Tonsils, inflammation of the, iii. 35. Hypertrophy, iii. 36. Tooth-rash, i. 389. See Erythema. Torpor of the colon, iii. 127. Touch, loss of, ii. 118. Tracheitis, ii. 247. See Croup. Transformation, in what it consists, i. 53. Cellular, i. 53. Cartilaginous and osseous, of the uterus, iii. 338. Of the ovary, iii. 354. Transposition of the Heart, ii. 585. Trichina Spiralis, iii. 616. See Worms. Tricocephalus Dispar, iii. 621. See Worms. Tricuspid valve, normal situation of the, ii. 460. Trismus, ii. 67. See Tetanus. Clonicus, ii. 100. Dolorificus, ii. 100. See Neuralgia. Tsarath of Moses, i. 438. See Lepra Tuber- culosa. Tubercles, comparative frequency with respect to age and sex, iii. 534. Occurring in the lower animals and in- sects, iii. 534. Nature of; i. 41. Varieties of, i. 41. INDEX. 733 Tubercles, analysis of, i. 41. Mode of formation of, i. 42, 94; iii. 531. Consistence of, ii. 351. Colour of, ii. 361. Size of, ii. 361. Form of, ii. 361. Infiltration of, ii. 362. Cavities and excavations resulting from, ii. 363. S Relative frequency of, in different organs, ii. 363. Pathology of pulmonary, ii. 364. Origin and progress of, ii. 365; iii. 531. Symptoms of, ii. 371. Physical signs of, ii. 375. Of the heart, ii. 574. Of the intestines, iii. 111. Of the mesenteric glands, iii. 143. Of the liver, iii. 180. Of the pancreas, iii. 194. Of the spleen, iii. 200. Of the kidney, iii. 288. Connexion of, with haemorrhage of the lungs, iii. 392. Tubercula, characters of, i. 389. See Tuber- culous Disease of the Lungs and Scro- fula. Tuberculous disease, prevention of, ii. 397. Of the lung, ii. 361. See Consumption, pulmonary. Of the liver, iii. 180. Tumours, Fibrous, of the uterus, iii. 326. See Uterus, diseases of. Of the ovary, iii. 354. Tympanites, iii. 129. Treatment of, iii. 130. Hysteric, ii. 60. Typhoid Pneumonia, ii. 340. Typhus Fever, i. 199. See Fever. Icterodes, i. 273. See Fever, Yellow. Ulcer, corroding, of the uterus, iii. 337. Nature of, iii. 337. Diagnosis of, iii. 337. Treatment of, iii. 338. Scrofulous characters of the, iii. 524. Ulcerated Sore Throat, iii. 32. See Angina Membranacea. Ulceration, process of, i. 55. A termination of inflammation, i. 65. Of the bronchial tubes in phthisis, ii. 363. Of the trachea and larynx in, ii. 363. Of the mucous membrane of the stomach, iii. 55.' Of the intestines, iii. 76. Of Peyer's glands, i. 149 ; iii. 76. Of the stomach, haematemesis arising from, iii. 399. Ulcus Atonicum, i. 411. See Rupia. Uredo Porcelana, i. 395. See Urticaria. Urinary organs, diseases of the, iii. 206. Haemorrhage from the, iii. 406. See Hae- maturia. Calculi, iii. 228. See Calculi. Bladder, worms found in the, iii. 607. See Worms. Urine, properties of healthy, iii. 206. Density of the, iii. 207. Quantity of the, iii. 208. Morbid alterations of the, iii. 210. Urine, morbid impregnation, iii. 212. Gravel, iii. 215. See Gravel. Suppression of the, iii. 254. Symptoms of, iii. 255. Causes of, iii. 256. Treatment of, iii. 257. Substances which impart a red colour to the, iii. 408. Characters of, in gout, iii. 580. Urticaria, i. 395. General characters of, i. 395. Varieties of, i. 395. Febrilis, i, 395. Evanida, i. 395. Subcutanea, i. 396. Tuberosa, i. 396. Diagnosis and treatment of, i. 396. Uterine Haemorrhage, iii. 413. Uterus, diseases of the, iii. 294. Irritable, iii. 312. See Hysteralgia. Inflammation of the, iii. 317. See Metritis. Congestion of the, iii. 317. Fibrous tumours of the, iii. 326. Mode of attachment of, iii. 327. Nature of, iii. 327. Symptoms of, iii. 328. Prognosis of, iii. 329. Treatment of, iii. 329. Polypus of the, iii. 329. Cauliflower excrescence of the, iii. 332. Carcinoma of, iii. 334. Corroding ulcer of, iii. 337. Cartilaginous and osseous transformation of, iii. 338. Phlebolites, iii. 338. Hypertrophy of the, iii. 338. Atrophy of the, iii. 338. Dropsy of the, iii. 339. Hydatids of the, iii. 340. Haemorrhage from the, iii. 413. Vaccination, i. 341. History of, i. 341. Phenomena of, i. 343. Period at which the lymph should be taken from the vaccine vesicle, i. 344. Mode of making the incision in, i. 345. Theory of, i. 345. Duration of the protecting power of, i. 345. Recurrence to the cow for the matter of, i. 346. Revaccination, i. 346. Vagina, Imperforate, iii. 304. Valves of the heart, diseases of the, ii. 532. Tricuspid and mitral, ii. 460. Vegetations, or granulations, ii. 532. Induration of the, ii. 533. Perforation of the, ii. 533. Adhesion of, to the sides of the heart, ii. 532. Physical signs of, ii. 535. General symptoms of, ii. 536. Granulations on, iii. 564. Varicella, i. 407. General characters of, i. 407. Identity of with small-pox, considered, i. 407. Varieties of, i. 408. Lenticularis, i. 4Q8. Globata, i. 409. * 734 INDEX. Varicella, diagnosis of, i. 409. Treatment of, i. 409. Varicose Veins, causes of, ii. 624. Treatment of, ii. 625. Variola, i. 310. See Small-pox. Spuria, i. 407. See Varicella. Variolous Vesicle, anatomical characters of the, i. 313. Varus, i. 416. See Acne. Mentagra, i. 418. See Mentagra. Veins, injection of air into the, ii. 497. Pulsation of, ii. 480. Inflammation of, ii. 618. See Phlebitis. Varicose, ii. 624. Perforation of, ii. 626. Obliteration of, ii. 625. Calcareous depositions in, ii. 626. Fatty tumours in, ii. 626. Venous pulsation, ii. 480. Obstruction, dropsy from, iii. 466. Verolette, i. 407. See Varicella. Vesical Calculi, iii. 231. Treatment of, iii. 231. Injection of solvents into the bladder, iii 232. Galvanism, in treatment of, iii. 233. Vesicula, characters of, i. 388. Vicarious haematemesis, iii. 398. Melaena, iii. 405. Haematuria, iii. 411. Menstruation, iii. 304, 363. Vichy, efficacy of its mineral waters in chronic rheumatism, iii. 571. Vitiligo, i. 445. Voice, loss of. See Aphonia. Vomit, Black, i. 278. See Fever, Yellow. Vomiting, treatment of, in dyspepsia, iii. 64. Vomito Negro, i. 278. Prieto, i. 278. See Fever, Yellow. Walcheren Fever. See Intermittent Fever. Water Stroke, i. 524. See Hydrocephalus. Canker, iii. 21. See Gangraena Oris. Brash, iii. 71. See Gastrorrhoea. Wiesbaden, mineral waters, efficacy in chronic rheumatism, iii. 571. White Gum, i. 427. See Lichen Strophulus. West Indies, climate of, beneficial in chronic rheumatism, iii. 571. Worm Fever, i. 296. See Infantile gastric remittent Fever. Worms, found in the human body, iii. 595. Origin of, iii. 596. Causes of, iii. 597. Influence of locality, iii. 597. Of season and climate, iii. 598. Food, iii. 598. Worms, seat of, 599. Table of the various species of, found in different organs and textures, iii. 599, 606. Symptoms of, iii. 600. Local, iii. 600. Constitutional, iii. 601. Morbid appearances of, iii. 602. Perforation of the coats of the intestines by, iii. 602. General treatment of, iii. 603. Evacuant anthelmintics, iii. 604. Mechanical evacuants, iii. 604. Corroborant anthelmintics, iii. 605. Classification of, iii. 606. Classis psychodiaria, iii. 607. Acephalocystis endogena, iii. 607. multifida, iii. 608. Echinococcus homines, iii. 508. Classis sterelmintha, iii. 608. Cysticercus cellulosa, iii. 609. Animalcula echinococci, iii. 609. Diplosoma crenata, iii. 610. Taenia solium, iii. 611. Symptoms of, iii. 611. Treatment of, iii. 612. Bothriocephalus latus, iii. 615. Distoma hepaticum, iii. 615. Polystoma pinguicola, iii. 616. Class coelelmintha, iii. 616. Trichina spiralis, iii. 616. Its seat in the muscular system, iii. 616. Method of examining it, iii. 619. Filaria Medinensis, iii. 619. Oculi, iii. 621. Bronchialis, iii. 621. Trichocephalus dispar, iii. 621. Spiroptera hominis, iii. 622. Dactylius aculeatus, iii. 622. Strongylus gigas, iii. 623. Ascaris lumbricoides, iii. 624. Symptoms, iii. 625. Treatment, iii. 625. Ascaris vermicularis, iii. 626. Symptoms, iii. 626. Treatment, iii. 627. External parasites, iii. 629. Pediculus, iii. 629. Acarus scabiei, iii. 629. Pulex penetrans, iii. 629. Wounds, peculiar aspect of, in scurvy, iii. 440. See Scurvy. Yaws, i. 441. See Framboesia. Yellow Fever, i. 273. See Fever. THE END. LEA AND BLANCHARD HAVE JUST PUBLISHED A NEW AND CHEAPER EDITION OP THE LIBRARY OP PRACTICAL MEDICINE: CONDUCTED BY ALEXANDER TWEEDIE, M.D., F.R.S. PHYSICIAN TO THE LONDON FEVER HOSPITAL, AND TO THE FOUNDLING HOSPITAL ; EDITOR OF THE CYCLOPEDIA OF PRACTICAL MEDICINE, ETC. WITH THE ASSISTANCE OF NUMEROUS CONTRIBUTORS. THE WHOLE REVISED, WITH NOTES AND ADDITIONS, BY W. W. GERHARD, M.D., LECTURER ON CLINICAL MEDICINE TO THE UNIVERSITY OF PENNSYLVANIA, PHYSICIAN TO THE PHILADELPHIA HOSPITAL, BLOCKLEY, ETC. The whole Five Volumes of the former edition, now complete in Three large Volumes, AND FOR SALE BY ALL BOOKSELLERS. The design of this work is to supply the want, generally admitted to exist in the medical literature of Great Britain, of a comprehensive System of Medicine, embodying a condensed, yet ample, view of the present state of the science. The desideratum is more especially felt by the Medical Student, and by many Members of the Profession, who, from their avocations and other circumstances, have not the opportunity of keeping pace with the more recent improve- ments in the most interesting and useful branch of human knowledge. To supply this defi- ciency, is the object of The Library of Medicine ; and the Editor expresses the hope, that with the assistance with which he has been favoured by Contributors, (many of great eminence, and all favourably known to the Public,) he has been able to produce a work, which will form a Library of General Reference on Theoretical and Practical Medicine, as well as a Series of Text Books for the Medical Student. It is intended to treat of each Department, or Division of Medicine, each Series forming a complete Work on the subject treated of, which may be purchased separately at a very mode- rate price or it will constitute a part of The Library of Medicine. This arrangement is made with the view of giving those persons who may wish to possess one or more of the Series the opportunity of purchasing such Volumes only, and thus avoid the inconvenience f kinff a larger addition to their stock of Books than their wants or circumstances may FGOUirC* F h treatise is authenticated by the Name of the Author ; and from the care bestowed in th rranffements, it is confidently hoped that the want of uniformity noticed in works of a • '1 kind has been obviated, at least, as far as is compatible with the execution of the work by a numerous body of united Authors. ADVERTISEMENT THE AMERICAN PUBLISHERS TO THEIR NEW EDITION IN THREE VOLUMES. The matter embraced in the Three Volumes now presented, was published in. London in five separate volumes, and at intervals republished in this country. The rapid sale of these volumes, embracing as they do a History of Practical Medicine, is the best evidence of the favour with which it lias been received by the physicians of the United States. Embodying as it does the most recent information on nearly every disease, and written by men who have specially devoted themselves to the study of the disorders which form the subject of their articles, the work is the most valuable for reference within the reach of a practitioner. The arrangement of the Library into classes of diseases, grouped according to the cavities of the body, is much more agreeable to the reader than the alphabetical order, and nearly as convenient for reference. The reader will not fail to perceive some inequality in the articles, even of the same authors; the subjects with which an author is most familiar, and upon which he had pre- viously written, are usually the best treated and most elaborate. Among the most finished treatises are those of Dr. Christison on the urinary organs, and of Williams and Joy on the thoracic viscera; several other essays are excellent monographs, and very few fall much below the average standard of the series. The object of the publishers in compressing the five volumes of the former edition into three is to place the work at such a price as to be within the reach of every reader. There is no abridgement or alteration whatever of the text of the former edition, and the general ap- pearance of the volumes is scarcely inferior. The notes added to the last four volumes have been revised, and some additions made to them. New notes have also been added to the first volume, which was not revised in the former edition. For the note on Remittent Fever, the American Editor is indebted to Dr. Stewardson, for those on Ophthalmia to Dr. W. P. Johnston. The principal notes are one on Typhoid Fever, another on Remittent, one on Tuberculous Meningitis, and a fourth on Delirium Tremens. It was neither intended nor wished to over- load the work with annotations; the notes refer either to some trivial errors which have crept into the text, or to subjects which were treated less completely than they deserved to be; they are, therefore, comparatively few in number. Several diseases are, from the difference of cli- mate, more frequent and severe in the United States than in Great Britain, and the articles which relate to them required some additional matter. The notes which appeared in the London edition are designated by the word Author. Those of the American Editor are indicated by the letter G. The Editor of this edition did not feel himself at liberty to make any change in the for- mulae of the prescriptions, which are published towards the end of the last volume, believing- as he does, that very strong reasons alone can justify such use of a scientific work. One alteration, which adapts them to the custom of this country, was, however, made;__that i<* the translation of the directions for the doses and administration of the prescriptions from Latin into English: there is an obvious convenience in this change. The Three Volumes now presented contain the first series, that on Practical Medicine of Library of Medicine, edited by Dr. Tweedie, and now in course of publication, and are com plete in themselves. The series will be continued in London, embracing works on Midwiferv * Surgery, Anatomy, and the other Departments of Medical Science. Such of them as mav l' deemed worthy of republication will be issued here with notes and additions each work unde its particular title, but in a style and manner to match this work. * The work on Midwifery, by Edward Rigby, with numerous wood cuts, has lately been issued by the pUh lishers of these volumes. f\ tx. y \ iKKU NATIONAL LIBRARY OF MEDICINE NLM D3B7fiDfll M ^H &fe ^M m sft ;«» «S» M. ' 't^jt**** I *l I I Xrfa ?tfffi« ^1 -v.s$ ■ I NLM032780814