.wv-r Mmmrn. ffi$£$M£^ v-' ■ ','.:^. y^a: ^pX*H**t>uCt NATIONAL LIBRARY MEDICINE Washington,D.C. A TREATISE ON THE PRACTICE OF MEDICINE, BY GEOEGE B. ]£OOD, M.D., >>t PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA; PRESIDENT OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA ; ONE OF THE PHYSICIANS OF THE PENNSYLVANIA HOSPITAL; ONE OF THE AUTHORS OF THE DISPENSATORY OF THE UNITED STATES OF AMERICA ; ETC. ETC. FIFTH EDITION. IN TWO VOLUMES. VOL. II. PHILADELPHIA: J. B. LIPPINCOTT AND CO., Nos. 22 and 24 NORTH FOURTH STREET. 18 58. WB \S58 a. \ Entered, according to the Act of Congress, in the year 1858, By George B. Wood, M.D., in the Clerk's Office of the District Court of the United States in and for the Eastern District of Pennsylvania. PRACTICE OF MEDICINE. PART II., or SPECIAL PATHOLOGY, CONTINUED. CLASS III., or LOCAL DISEASES, CONTINUED. SECTION III., or DISEASES OF THE EESPIEATORY ORGANS, CONTINUED. SUBSECTION III. ORGANIC DISEASES OF THE PULMONARY TISSUE AND PLEURA. •Article I. INFLAMMATION OF THE LUNGS, or PNEUMONIA. Syn.—Peripneumonia.—Pneumonitis.—Pulmonitis. The name of pneumonia is now universally applied to inflammation of the spongy tissue or parenchyma of the lungs. There are numerous varieties of this disease, which it will be most convenient to notice in the present place, because reference will be frequently made to them throughout the subsequent remarks. These varieties are founded upon the different portions of the lungs, or the different constituents of any one portion, which may be in- flamed, upon the relation of the disease to other diseases with which it may be associated, and upon the character of the accompanying fever or general state of system. The inflammation may occupy a considerable extent of the lungs continuously, embracing a whole lobe more or less, or even one whole lung. This is the common form of the disease, and the one usually meant, when the simple term pneumonia is employed. For the sake of distinction it is sometimes called lobar pneumonia. Sometimes small isolated portions of the lungs are inflamed, as, for example, distinct lobules or parts of lobules, with sound lung intervening. In this case, the complaint is denominated lobular pneumonia. Though the inflammation is usually confined to one lung, it occasionally involves both, and, in the latter case, is distinguished by the name of double pneumonia. In some rare instances, it appears to affect chiefly or exclusively the air-cells, and may then be called vesicular pneu- monia, though Rilliet and Barthez name it vesicular bronchitis. Again, the inflammation is sometimes seated more especially in the cellular tissue inter- vening between the different air-vesicles, or between the lobules, in which case it has been proposed to name it intervesicular, or interlobular pneu- monia. Most generally, however, it occupies the whole of the constituents which form the pulmonary parenchyma, including the air-cells, the smaller bronchial tubes, the intervening cellular tissue, and the vascular ramifications. 4 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. The pleura is very frequently involved with the substance of the lungs ; but, when the inflammation is confined to that portion of the investing membrane which is in contact with the diseased pulmonary tissue, it is not generally deemed worth while to give the affection a distinct title. When large por- tions of the pleura are affected, the disease receives the name of pleuro-pneu- monia. The complaint is frequently primary; but it is also frequently a mere accompaniment of other diseases, in which case it is called secondary. When associated with a low or typhous condition of the system, it is named typhoid pneumonia; and when with bilious disorder, whether dependent on simple derangement of the liver, or upon a concurrent bilious fever, bilious pneumonia. Finally, the disease may be of short, or of protracted duration, or in other words may be acute or chronic. In the following remarks, the ordinary arrangement pursued in this work will be deviated from by treating first of the anatomical characters of the complaint; because, without a know- ledge of these, we can have no just idea of the value of many of the symptoms. Anatomical Characters. 1. Common or Lobar Pneumonia.—There are three well-marked stages in acute pneumonia; viz., 1. that of congestion, 2. that of fully-developed inflammation, and, 3. that of suppuration. In the first stage, or that of congestion, the affected portion of the lung is of a deep-red colour, crepitates under pressure, though less than in health, retains the impression of the finger, and, when cut, exudes copiously a bloody, turbid, and somewhat frothy serum. It is more compact and heavy, but less tenacious than in health, and, notwithstanding its increased density, still floats in water. The cells are not yet obliterated, and, though somewhat obstructed by extravasation, still contain air. The condition altogether very much re- sembles the mechanical congestion, occasioned by the gravitation of the blood after death, or at the very close of life ; but the colour is usually of a brighter red, and the softening greater. The position of the congestion may also sometimes aid in the formation of a correct judgment, as, if mechanical, it must occupy the most dependent part of the lung, which is not necessarily the case when it is vital. If the disease be arrested in this stage, the lung reassumes the healthy appearance; if not, it passes into the condition de- scribed in the following paragraph. Dr. Stokes maintains that the congestive stage, with the characters above mentioned, is preceded by another, marked by intense arterial injection with dryness; in other words, a condition of irri- tation, which, as taught in this work, always precedes inflammation. The second stage, named by Laennec that of red hepatization, by Andral that of red softening, is characterized by a deep-red, reddish-brown, or gray- ish-red colour, the absence of crepitation under pressure, a density so much increased that the diseased lung will sink in water, and a diminution of cohe- sion still greater than in the first stage. The grayish colour sometimes ob- served is owing to an intermixture of particles of the black pulmonary mat- ter, and to the lighter hue of the interlobular tissue, which is occasionally less congested than the other parts. The softening is so great that the lung may be readily torn, and the finger may be passed through the parenchyma with little resistance. It is greater in proportion as the inflammation has been more acute and recent. When cut into, the lung bears a striking re- semblance to liver; and on this account is said to be hepatized. When pressed between the fingers, it exudes a reddish fluid, which is thicker, less frothy and in less amount, than that observed under similar circumstances in the congestive stage. The cut or torn surface of the lung generally exhibits numberless minute granules, which are probably the air-cells filled and dis- CLASS III.] PNEUMONIA. 5 tended with concrete fibrinous exudation, though Dr. Williams ascribes them to interstitial deposit of lymph in the parietes of portions of the bronchial tubes and vesicles. The granular appearance, however, is not always ob- served. The surface is sometimes quite smooth and uniform, especially in the pneumonia of advanced life and that of infancy, probably in consequence of the obliteration of the cells by the pressure of effused matter without them. The same appearance is presented, when a portion of lung compressed by pleuritic effusion has become inflamed. Dr. Williams supposes the absence of the granular character to occur in those cases in which the inflammation is situated without the air-vesicles, in the cellular tissue between them, and which he distinguishes by the name of intervesicular pneumonia. This affec- tion has also been called interlobular pneumonia, though with less propriety. In the red hepatization, the bronchial tubes, the blood-vessels, and the in- terlobular cellular tissue are still obvious to examination. The lung does not collapse upon exposure to the atmosphere, as in a healthy state. In the third or suppurative stage, there are two conditions, one of which, and infinitely the most common, is that denominated byLaennec gray hepa- tization, and by Andral gray softening, and the other is abscess. In the former, the lung is compact and dense as in the red hepatization, but, instead of the dark-red colour, presents externally and within a yellowish or grayish appearance, and, when cut, exudes a yellowish, opaque, purulent fluid some- times tinged with blood. It is much softer too than in the second stage, so much so that, if pressed between the fingers, it is almost wholly resolved into a purulent fluid, with only shreds of the solid tissue remaining. A very moderate degree of force, even a slight violence in handling, or otherwise ex- amining it, occasionally produces a cavity in its substance, which gradually fills with pus, and may easily be mistaken for an abscess. It generally still preserves, when cut or torn, the granular aspect, but sometimes exhibits a uniform surface, as in the red hepatization. The second condition above alluded to, or that of abscess, is exceedingly rare in adults. Not unfrequently the pathological anatomist meets with collections of pus in the lungs. Some- times metastatic abscesses are found after death from violent injuries, or severe surgical operations. Abscesses of the neighbouring parts, as in the pleural cavity, between the adhering lobes of the lung, in the mediastinum, liver, &c, occasionally open into the lungs, and form cavities in its substance. Tuber- culous vomicse, and enlarged bronchial tubes filled with pus, seem to have sometimes been mistaken for abscesses. But it is very uncommon to meet with collections of pus, as the result of the variety of pneumonia at present under consideration. Chomel states that, during an experience of twenty-five years, he had seen only three; and of several hundred cases examined by Laennec, only five were of this kind. (Diet, de Med., xxv. 151.) These ab- scesses sometimes appear to be mere excavations in the hepatized mass, being everywhere surrrounded by the diseased parenchyma of the lungs, which is in some instances gangrenous. In other cases, the walls of the cavity are lined by a smooth, grayish false membrane. Sometimes there is only one cavity, sometimes several, which may remain separate, or run together. The abscess may either be closed, or may communicate with the bronchia, pleura, pericar- dium, mediastinum, or even the peritoneum, or may open externally between the ribs. Such purulent collections are occasionally observed around tuber- culous deposits, or foreign bodies in the lungs. But, though true pneumonic abscess is rarely observed after death, there is reason to believe that it is more common in cases which recover. When large portions of the lungs are hepa- tized, the patient dies before the tissue so far breaks down as to form an ab- scess ; but when a small portion only is affected, insufficient to destroy life, there is time for this result. Hence abscesses are more apt to occur when the 6 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. hepatization is moderate than when it is extensive; and hence too recoveries not unfrequently take place. Gangrene is a very rare result of ordinary pneumonia, though it does occa- sionally occur. (See Gangrene of the Lungs.) The three different conditions above described are sometimes, but not always, distinct. They are in fact often more or less intermingled. Thus, in the midst of a congested portion of the lungs, some spots of red hepatiza- tion may appear, and, in the midst of the latter, some spots of gray hepatiza- tion, which give a mottled appearance to a section of the diseased lung. Sometimes the three conditions exist at the same time, the gray hepatization being in the centre, the red around it, and the congestion on the borders of the latter, though the boundary between them is not accurately defined. In relation to the pathology of these different conditions, it may be sufficient to state that, in the first, the vessels are merely engorged with blood, and the air-cells partly filled with a sero-mucous, somewhat bloody effusion; in the second, a plastic extravasation has taken place, and the cells, as well as the intercellular tissue, are filled with a more or less concrete and bloody lymph; in the third, the place of the plastic secretion has been supplied by a purulent fluid. The pleura is very frequently, but not always, inflamed over the he- patized portion of the lung. Coagulable lymph is often thrown out, forming a false membrane upon its surface; and sometimes the two opposite surfaces adhere; while a little turbid serum is found in the pleural cavity. In some instances, the inflammation of the pleura is much more extensive; and then the disease comes under the designation of pleuro-pneumonia. (See Pleuro- pneumonia.) The bronchia, both large and small, are almost always inflamed, containing mucus, and exhibiting a reddened surface ; and, if one lobe is in- flamed, the bronchial tubes going to that lobe are also affected. The bronchial glands are often enlarged, reddened, and softened. The right cavity of the heart frequently contains red and soft, or yellowish and firm coagula. In a great majority of cases, the morbid phenomena are confined to one lung; and the right lung is much more frequently affected than the left. From a comparison of 1430 cases, collected by M. Grisolle from various authors, it appears that the cases of double pneumonia were about 18 per cent, of the whole number, those of the left side about 30 per cent, and those of the right side about 52 per cent. In secondary pneumonia, the opposite sides appear to be about equally affected. In relation to the part of each lung attacked, Laennec stated that the lower portion was most frequently the seat of the in- flammation, and that when this occupied the whole lung, it almost always began in that portion. Some have considered the lower and middle parts as almost the exclusive seats of the incipient inflammation. It is probably true that these are most frequently affected; but observation has shown that the disease not unfrequently also begins in the upper lobe; and in certain seasons this appears to be more frequently the case than in others, without any known cause for the difference. Of 264 cases investigated by M. Grisolle, the in- flammation began in the lower lobes in 133, at the summit in 101 and at the middle in 30. 2. Lobular Pneumonia.—In this variety, which is most common in chil- dren below six years of age, and is comparatively rare in adults the inflam- mation occupies distinct spots, surrounded by healthy tissue. These little islands of inflammation may be distinctly defined, occupying one or several lobules, and abruptly bounded by the interlobular areolar tissue; or they may gradually run into the surrounding parenchyma, so that their 'limits cannot be precisely fixed; or, finally, they may run together, and thus form one con- tinuous mass of inflammation, as in the common form of the disease. Of these three forms, the first is less frequent than the other two • and some- CLASS III.] PNEUMONIA. 7 times all are found in the same patient. (Rilliet and Barthez.) The patches of inflammation are exceedingly diversified in size, form, number, and position. Those with definite boundary may vary in magnitude from the size of a millet- seed to that of an egg; may be spherical, elongated, or quite irregular; may number from one to thirty or more in the same lung; and may occupy both lungs, or, what is comparatively rare, may be confined to one, and, in either case, are most frequently met with in the posterior part of the lung. In con- sequence of the red colour of the inflamed spots, they often contrast strikingly with the healthy structure, and give the lung, both on its external and cut surface, a marbled appearance. They are also more prominent than the neigh- bouring tissue, from not collapsing when exposed to atmospheric pressure, and have a firmer feel under the finger. In fatal cases, they are sometimes found almost filling up both lungs, and leaving but a small portion permeable by the air. (Gerhard.) They present the same stages of congestion, red hepatization, and suppuration, as occur in ordinary lobar pneumonia. In the third or sup- purative stage, when the pus is disseminated equably through the diseased structure, they do not differ materially in colour from the healthy parenchyma; but may be distinguished by their greater prominence and density, and by exuding a purulent liquid when pressed. Abscesses are not unfrequent in this variety of pneumonia, probably in consequence of the small extent of the in- flamed patches. These are sometimes single and isolated, sometimes run together, and generally have a tendency to approach the surface. They may communicate with the bronchia, or one of the neighbouring cavities, or may have no outlet. In the latter case, there is reason to believe that the pus is sometimes absorbed. They may occupy both lungs, but are more frequently found in one only. (Rilliet and Barthez.) It has been demonstrated by MM. Bailly and Legendre that, in many in- stances, what has been taken for lobular pneumonia in infants is not true hepatization, but a consolidation of the lobule such as exists in the fetal state. This consolidation they believe may be wholly independent of inflammation, and the consequence merely of the contractility of the pulmonary tissue, or may be the result of compression of the vesicles by vascular congestion ex- terior to them. Dr. Gairdner has rendered it probable that the condition is generally, if not always, the result of bronchitis, in which the viscid mucus so clogs certain bronchial tubes as to allow the exit, but to prevent the access of air, in consequence of which the air-cells, supplied by the tubes thus closed, collapse; and he has shown that the same result not unfrequently takes place, from the same cause, in adults. That the consolidation is produced by col- lapse, and not by inflammation of the pulmonary tissue, is proved by the fact that the solidified parts, unlike hepatized lung, may often be expanded by insufflation. As the affection, however, is connected with an inflammatory condition of the tubes, it is easily conceivable that this may have extended into the solidified portion before collapse, which may thus sometimes put on the appearance of parenchymatous inflammation. (See Vol. i. page 832.) But we may attach full credence to the observations of MM. Bailly and Legendre, and of Dr. Gairdner, without surrendering our previous convictions in relation to the existence of the lobular pneumonia of children. It is suffi- cient to admit that many cases have been mistaken for that affection, which were of a different nature. It is scarcely possible that the most accurate observers, who have investigated what they deemed lobular pneumonia, could have been altogether mistaken; and the progress of the isolated and defined patches of inflammation has been too often traced through its different stages, to admit of a denial of their occasional and even frequent existence. The pneumonia of children, however, is much more apt than that of adults to result from a propagation of inflammation from the bronchial tubes to the 8 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. vesicular structure; and it is probable that the lobular pneumonia generally originates in this way. 3. Vesicular Pneumonia.—Under the name of vesicular bronchitis, Ril- liet and Barthez describe a variety of pneumonia in which the inflammation appears to be confined to the air-cells, and perhaps small portions of the com- municating bronchial tubes, without extending to the intervening cellular tissue. When the lung is cut, it exhibits a vast number of gray or yellowish granules, of the size of millet-seed, and bearing no inconsiderable resemblance to miliary tubercles, being about equal in size, and like them disseminated; but distinguishable by their want of hardness, and by exuding a drop of pus and collapsing when cut. (Maladies des Enfants, i. 21.) 4. Typhoid Pneumonia.—When pneumonia is associated with a low or asthenic state of system, the disease appears sometimes scarcely to pass the stage of congestion; or, if it does so, the blood remains liquid, and yields none of the plastic secretion which gives solidity to ordinary hepatization; and the inflammation, if it continue, is apt to run into gangrene or imperfect sup- puration. Of this nature appears to be the condition of the lung called sple- nization, in which the diseased portion, though gorged with blood, and so dense as to sink in water, is quite soft like the spleen. The pneumonia in such cases is usually secondary, or associated with other diseases of a low and feeble character. Under this head may also be arranged the hypostatic pneu- monia of some writers, which results from the pulmonic congestion produced by lying long and constantly on the back, in debilitated states of the system. 5. Chronic Pneumonia.—Under this head might be placed the abscesses which occasionally follow acute pneumonia, and continue sometimes for many months before coming to their termination in health or death. But there is another form of chronic pneumonia, in which the hepatization consequent upon acute inflammation, instead of undergoing resolution or passing into the suppurative stage, assumes a permanent character. In such cases, the lung is found compact and heavy, pitting little or none upon pressure, not crepi- tant, tearing with difficulty, sometimes almost cartilaginous, and, when cut, exuding only a little serous fluid. The cut surface is sometimes smooth and uniform, sometimes finely granular, and occasionally striated or veined. The colour is dull-red, reddish or yellowish-brown, or grayish. When distinct lobules are affected, the lung has an irregular surface, and a knotty feel. The volume of the lung is somewhat diminished, and the chest consequently contracted. The pleura is often adherent. Sometimes abscesses exist within the hardened structure, and in one instance gangrene was observed by Andral. Rilliet and Barthez describe a condition of the lungs in the pneumonia of infants, which they call camification, and consider as the result of chronic inflammation. The diseased portion of the lung is depressed on the surface, soft, and flaccid, not crepitant, and of a violaceous or pale-red colour, marbled with white lines which define the lobules. Its cut surface is red, glossy, and penetrable with difficulty, and when pressed exudes a bloody serum. Its ap- pearance is like that of a muscle with close and indistinct fibres. (Maladies des Enfants, i. 13.) This, however, is undoubtedly the state of collapse described by MM. Bailly and Legendre, and which Dr. Gairdner has shown to exist occasionally in adults as a consequence of bronchitis. Symptoms, Course, Termination, &c. 1. Common or Lobar Pneumonia.—This is usually ushered in with a chill often very decided, followed by febrile reaction, difficult breathing, cough' and severe pain in the side or back part of the chest. Sometimes the fever and local symptoms occur without an antecedent chill, especially in infants • and sometimes the local symptoms precede for a short time the general. Occa- CLASS III.] PNEUMONIA. 9 sionally the characteristic symptoms of the disease are preceded for some days by general uneasiness, lassitude, loss of appetite, and more or less fever. Not unfrequently the disease commences with catarrhal symptoms, which continue for several days before signs of pneumonia become manifest. In secondary pneumonia, the disease often begins obscurely, without pain, cough, or fever, unless this has previously existed, and is recognizable only by the hurried respiration, depression of strength, and the physical signs. Pneumonia is apt to assume this obscure form, when complicated with cerebral disease. When fully developed, the complaint is characterized, in most cases, by fever, quickened breathing, pain in the chest, cough, and a scanty viscid expectoration often intimately mixed with blood. On each of these symptoms it is necessary to dilate; as they are liable to great diversity. The pain may either precede, accompany, or follow the commencement of the fever. It is often in the beginning very acute and severe, is much in- creased by a full breath, coughing, or pressure between the ribs, and is situ- ated either in the side or back part of the chest, or in the mammary region. When both lungs are inflamed, it is sometimes felt on both sides, and some- times referred to the vicinity of the sternum. The sharp pain is probably owing to the participation of the pleura, covering the affected portion of the lung, in the inflammation. It is in general quickly subdued by depletion, or by the other remedies employed, and only an obtuse pain remains. But, in many instances, there is no acute pain either in the beginning, or in the course of the disease. Instead of it, the patient complains of a dull, aching sensation, or of soreness, oppression, stricture, weight, or heat, sometimes re- ferred to the side, sometimes to the anterior part of the chest, and often to the epigastrium. Occasionally the pain is rendered sensible only by a deep inspiration, or is evolved by percussion when otherwise latent. It sometimes happens that no uneasiness whatever is felt, calculated to excite suspicion. The breathing is always quickened. The number of respirations may be increased from between sixteen and twenty in a minute, the average standard of health, to thirty, forty, fifty, or even sixty. At the same time there is almost always a feeling of oppression which is increased by speaking, or other vocal effort. The dyspnoea is sometimes very urgent, necessitating an erect position, and rendering it difficult for the patient to speak. It is increased usually with the extent of inflammation, and of the consequent consolidation of the lung. But it differs very much in different individuals, even with the same amount of local disease. Inflammation in the upper lobe is said to be attended with more of it than in the lower. (Watson.) Yiolent dyspnoea, with short and quick respiration, and a purple or livid colour of the face, is indicative of very great danger. Cough, in a greater or less degree, is almost always present in the course of the disease. I have known it, however, entirely wanting for several days after the commencement of a very severe attack, involving the greater part of the left lung. It is in some instances violent and painful, in others mode- rate and with little or no pain. At first it is usually dry, or attended with only a little mucous expectoration, if the disease is uncomplicated. But very soon, often in a day or two, a viscid semi-transparent matter is thrown up, which either is in the beginning or very soon becomes stained more or less with blood, so as to have a reddish or rusty colour, sometimes inclining to yellow or green, according to the quantity of blood present. As the disease advances, these properties of the sputa become more striking. The tenacity is so great that the matter adheres to the vessel containing it, when this is turned bottom upward. Sometimes, when more copious, it runs together, so as to form a kind of tremulous jelly. This viscid and rusty-coloured expecto- ration is probably the most characteristic general sign of pneumonia, and VOL. II. 2 10 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. sometimes indicates its existence even when the physical signs fail. In some instances, nearly pure blood is expectorated; but this is comparatively rare, and very generally the blood is intimately incorporated with the viscid semi- transparent matter. The sputum is thus distinguished from that of bron- chitis, which is often streaked with blood. The expectorated matter comes from the minute tubes, and is the result of a slow exudation from the in- flamed vessels, during which the intimate admixture of its constituents takes place. It contains a large proportion of coagulated fibrin. Dr. R. Remak has observed that the expectoration of pneumonia, if carefully examined in a dark-coloured flat vessel filled with water, or upon a dark glass plate, will always be found to contain ramifying tubular coagula, corresponding with the minute bronchia in which they have been formed. (Brit, and For. Med. Rev., April, 1847, p. 505.) Dr. J. Da Costa, however, states that he has frequently sought for them in vain both in the sputa and the air-cells. (Am. Journ. of Med. Sci., Oct. 1855, p. 302.) When the catarrhal symptoms are mingled with those of pneumonia, there is often a more copious expectoration of transparent and sometimes frothy mucus; and, in such cases, portions of the true pneumonic expectoration may be seen mixed with the catarrhal in the cup, one being thrown up at one time and the other at another. As the complaint advances, the secretion increases, but seldom becomes very copious in pure pneumonia. In the latter stages, the expectoration sometimes again becomes more scanty. Occasionally it is purulent, in consequence either of a changed secretion of the bronchial tubes, or of the discharge of the pus of the vesicles. In some rare cases, it becomes all at once purulent and copious, from having been previously scanty and fibrinous. The quantity of matter is sometimes so large as to overwhelm the debilitated lungs, and thus to prove suddenly fatal. This result occurs more especially in young children. It indicates the opening of an abscess into the bronchial tubes. This was form- erly thought to be common; but has been proved by dissection to be a rare event in pneumonia. Sometimes, instead of the characteristic viscid sputa, we see a copious expectoration of a uniform liquid, like mucilage, which is more or less tinged with blood. Towards the close of bad cases, this assumes occa- sionally a dark appearance, like that of liquorice dissolved in water, to which it is compared by Andral. This is usually a fatal symptom. A fetid odour of the expectoration indicates gangrene, but is very rare.* In relation to the decubitus, the patient most frequently lies on the back, with his head and shoulders somewhat raised. Sometimes, however, he pre- fers lying on the side, and, in the case of inflamed pleura, on the one oppo- site to that affected. Fever is an almost uniform accompaniment of severe cases ; and, in some instances, constitutes, with increased frequency of respiration, the only ob- vious affection. It varies extremely in degree, being sometimes so mild as almost to escape notice, and sometimes in the highest degree intense. It is very often attended with flushed cheeks and pain in the head, especially about the brows or forehead, from which the patient may even suffer more than from the pain in the chest. Occasionally, the headache is the only symptom of which the patient complains for the first few days. Delirium now and then occurs, and is usually an unfavourable sign. The fever often * Dr. Boling, of Montgomery, Alabama, has noticed, in many cases of pneumonia an appearance in the mouth which he considers characteristic. "It consists of a deposi- tion on the teeth, just along the margin of the gums, of a matter of different shades of colour, from a light orange to a dull vermilion, forming a line about the sixteenth of an inch wide, of a deeper tint at the gums, and paler as it recedes." He suggests that the miasmatic poisoning of the system, in the pneumonia of the south, may lead to its production. (Am. Journ. of Med. Sci., N. S., xxiv. p. 278.) CLASS III.] PNEUMONIA. 11 has a remittent character; the exacerbations occurring daily, for the most part towards evening, and accompanied with increase of pain, cough, dys- pnoea, and bloody expectoration. The pulse is usually full, strong, and only moderately accelerated; but it is sometimes very frequent even from the com- mencement, and in the latter case is apt to be smaller and less vigorous. It sometimes reaches one hundred and forty in the adult. Blood drawn from the arm is almost always buffed, and not unfrequently strongly cupped; or, if it has not this character at the commencement, very soon acquires it. The skin is usually hot and dry, though occasionally moist. The urine is generally scanty and high-coloured. Thirst and loss of appetite are almost universal. The tongue is generally moist and coated with a white or yellowish-white fur; but is sometimes clammy, or dry and red. Yomiting and diarrhoea are occa- sional symptoms, the latter more especially in the advanced stage ; but both are accidental. Frequently the patient is prostrated from the commencement of the attack; but, in mild cases, he sometimes keeps upon his feet for several days before taking to his bed. An observation originally made by Dr. Redtenbacher, in relation to the absence of chloride of sodium from the urine in pneumonia, has been con- firmed by Mr. L. S. Beale, of London. The salt disappears from the urine when hepatization begins. Mr. Beale ascertained, as the result of numerous trials, that the chloride returns soon after resolution has taken place, that dur- ing its absence there is more than the normal proportion of the salt in the serum of the blood, and that the sputa contain a larger proportion than healthy mucus; and infers that its absence from the urine depends on its determination to the inflamed portion of the lung. (Lond. Medico-Chirurg. Trans., xxxv. 374.) The physical signs are of the highest importance in the diagnosis of pneu- monia. The disease is often very obscure ; and, before the discovery of the processes of percussion and auscultation, many cases ran their whole course quite unsuspected. Cough and pain in the chest are sometimes wanting; and fever with headache and hurried respiration, which are common to this with numerous other diseases, are the only observable phenomena. Even the symptom of viscid and rusty sputa often fails us. Either the patient swal- lows the expectorated matter, as generally happens in infants ; or no expec- toration whatever may take place ; or the discharge, from a predominance of catarrhal or hemorrhagic affection, may want the characteristic properties. In many of these cases, percussion and auscultation combined afford sure evi- dence of the nature of the disease. Yet even these do not always succeed; as, for example, when the inflammation occupies an interior portion of the lung, and is everywhere surrounded by healthy structure. In the first stage, or that of congestion, percussion affords little evidence of the condition of the lung. There is usually a slight diminution of the healthy resonance, but not so decided as to serve for a ground of diagnosis.* A sense of diminished elasticity is imparted to the finger, when this is used as the pleximeter. But auscultation is much more decisive. By this it may * According to Skoda, alteration of the sound does not take place from mere con- gestion, but is first perceived when exudation has begun, and is then somewhat tym- panitic, so long as the portion of lung affected still contains air; and this tympanitic character of the percussion sound sometimes continues, even after it has become quite dull. No change will be perceived in the percussion sound, or in the sense of resist- ance, unless the infiltrated tissue is in contact with the thoracic wall, and at least an inch thick. The probability is that the tympanitic resonance, which sometimes replaces the normal percussion sound in pneumonia, is owing, in some instances, to the convey- ance through the consolidated lung, of sonorous vibrations from the stomach or colon, in others to a similar conveyance from the larger bronchial tubes, which, remaining open while the vesicular tissue is filled up with exudation, cannot but impart something of the tubal or tympanitic character to the percussion sound, though it may be feeble. [Note to the fourth and fifth editions.) 12 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART be discovered that the healthy vesicular murmur has given place to the cre- pitant rale, though the former may be sometimes heard mingling feebly \yitn the latter, before it is quite lost. The crepitation is more distinctly audible the nearer the disease happens to be to the surface of the lung. It is gene- rally stated to be heard only during inspiration. Though it may at nrstbe confined to the beginning of the inspiration, it soon extends throughout that movement. It is certainly extremely rare in expiration; and the analogous sound of capillary bronchitis and resolving hepatization, which belongs to the subcrepitant rale, has probably been mistaken for the true primary crepitant rale by those who suppose they have observed it in expiration. It should be recollected, as mentioned in the preliminary observations, that a full inspira- tion will often develope the crepitus, when not perceptible in ordinary breath- ing. This is the characteristic sound of pneumonia. Whenever it is heard, the existence of pulmonary inflammation is indicated; and the progress of this affection can be traced, with considerable accuracy, by marking the pro- gress of its attendant sound. In some cases, however, of ordinary genuine pneumonia, it cannot be discovered, even though the disease may be observed from the commencement; probably, as suggested by Dr. Walshe, in conse- quence of the rapidity with which the vesicles are filled with the exudation. About the inflamed part, when crepitation has not yet become manifest, a weakness of the respiratory murmur sometimes indicates the commencement of congestion. In other parts of the chest, the respiration is often puerile; and Dr. Stokes observed that this greater loudness of the natural murmur precedes the occurrence of the crepitant rale, an effect probably ascribable to the narrowing of the minute tubes, while the vesicles yet remain empty, so that the air has a more than usually rapid movement. There is often also increased resonance on percussion over the unaffected part of the lung. Ac- cording to Dr. Boling, of Montgomery, Alabama, a fine mucous or crepitant rale, heard in the larynx, even at some distance from the patient, persisting notwithstanding efforts at expectoration, and without evidence of disease or of the presence of mucus itself in the larynx, is a sign of pneumonia affect- ing the apex of the lung. One of the characters by which this sound may be distinguished from that produced by the presence of mucus in the larynx, is the perfect indifference of the patient, who makes no effort to clear his throat, unless prompted to do so. (Am. Journ. of Med. Sci., N. S., xiv. 125.) As the disease advances into the second stage, the crepitation ceases; and, the respiratory murmur having been previously abolished, either no sound is heard, or only that of bronchial respiration, which is one of the characteristic signs of hepatization. Dr. James Jackson, of Boston, observed that the expi- ratory murmur became prolonged and somewhat blowing, before the true bronchial respiration was established; and Grisolle states that, of twenty-four cases which he carefully examined, twenty-one presented the expiratory sound exclusively, before the respiratory murmur became in any degree bronchial. It is only in a comparatively few instances, that the ear is sensible of no other impression than the one produced by the rise and fall of the walls of the chest. This happens sometimes when the inflammation occupies the lowest portion of the lung, where there are no large tubes, or the whole lung, so that respi- ration ceases on the side affected. Usually the bronchial respiration is heard distinctly. It is loudest when the parts surrounding the larger tubes are in- flamed, as near the root of the lung. The sound is owing to the consolidation of the inflamed structure, enabling it to convey to the ear the tubal vibrations which, in the ordinary condition of the parenchyma, are arrested in its spongy texture. In some instances, during the passage of the congestion into hepati- zation, before the latter condition is fully established, the crepitant rale and bronchial respiration are mingled together, and give rise to a sound which has CLASS III.] PNEUMONIA. 13 been compared to that produced by the tearing of taffeta. Not uncommonly, while the bronchial sound is heard in one part, generally near the centre of inflammation, crepitation is audible in another, which is usually on the boun- daries. Besides the bronchial respiration, there is also a stronger vocal resonance in the stage of hepatization ; the vibration produced in speaking being conveyed more readily through the condensed structure. Bronchophony is therefore another characteristic of the second stage. Should the patient be unable to speak, it is asserted that the resonance occasioned by the operator's own voice is conveyed more distinctly to the ear applied to the chest, than in a healthy state of the lungs. Still another important character of this stage is the greater vibration of the walls of the chest when the patient speaks or coughs, rendered sensible by placing the hand upon the chest over the part affected. Should the hepatization, however, be very extensive, I have noticed that this impression is scarcely felt in the more distant parts. But quite as important as either of the above signs is that yielded by percussion in this stage. In- stead of the slight diminution of clearness observed in the state of congestion, we have now decided dulness, and sometimes even perfect flatness in the parts most consolidated. The dividing line between clearness and dulness is often well marked, and may be considered as representing the boundary of the con- solidated lung; and, as the consolidation is frequently confined to a single lobe, it is obvious that an obliquity in this boundary line, corresponding with the division between the lobes, may serve as a means of diagnosis be- tween the solidification of pneumonia, and the compression from fluid effused into the pleural cavity, as in pleurisy, in which the line of dulness is usually horizontal in the erect position. Dr. Austin Flint was, I believe, the first to call attention to this means of diagnosis. In some instances, the bronchial respiration and bronchophony are wanting, perhaps in consequence of the filling up or obstruction, at some particular point, of the bronchial tubes entering the hepatized portion of the lung, so that the condition on which those sounds depend does not exist. Occasionally the sounds referred to may be heard at one time and not at another, in the same condition of the hepatization. This may be owing to an alternate obstruc- tion and opening of the tube, through the alternate presence and removal of concrete mucus, or from other cause. Dr. Walshe states that he has traced it, in one case, to a pressure on the main tube, acting at different times with different degrees of force. Should the disease be arrested in the stage of congestion, the crepitant rale gradually ceases, and the respiratory murmur of health is restored. After the establishment of hepatization, should resolution of the disease take place, the bronchial respiration and bronchophony vanish by degrees, and the crepita- tion returns, in general, however, somewhat modified, and assuming the char- acter of the subcrepitant rale, in consequence of the more fluid nature of the secretion. This sound in its turn gives way to the respiratory murmur, the return of which, together with the healthy resonance upon percussion, is evi- dence of a restoration of the lung to its healthy state. In some instances, there is a direct passage from the bronchial respiration to the healthy murmur, without the intervention of crepitation. The third stage cannot be distinguished by the physical signs, so long as the pus remains diffused in the parenchyma, constituting the gray hepatiza- tion of Laennec. It presents the same flatness on percussion, and the same respiratory sounds. The supervention, however, of a mucous rale upon the bronchial respiration, might sometimes lead to the suspicion that the concrete exudation with which the cells are filled in the second stage, has been replaced 14 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. by the pus of the third stage. Should an abscess have formed, and opened into the bronchia, a gurgling rale, if the cavity contain a liquid, and pecto- riloquy with cavernous respiration, if it be empty, will be the diagnostic signs. To revert to the ordinary symptoms, should the disease yield to treatment in the congestive stage, as it sometimes begins to do on the second, third, or fourth day, the pain disappears, the expectoration becomes more copious and more of the character of ordinary mucus, the frequency of the pulse and other febrile symptoms diminish, the tongue begins to clean, and convalescence may be established in less than a week; though the disease may run on for two or three weeks, before all the symptoms disappear. A fatal result very seldom happens in this stage, and only when a large portion of the lungs is involved at once. In the great majority of cases, the first stage advances to that of consolidation. This comes on at various periods from the commencement of the attack, but generally in from one to four days, and seldom so late as a week. The change is not marked by any very obvious general symptoms. There may be some increase of dyspnoea, frequency of respiration, fever, and debility, and the countenance may assume a duller expression, and a darker- red or more dusky hue. The pain, instead of increasing, is not unfrequently diminished. If the disease now advances, it passes into the stage of suppu- ration. This happens at a variable period, usually some time in the course of the second week, though occasionally in old persons so early as on the fourth or fifth day, and in other cases not before the end of the third week. There is no certain sign by which the accession of the third stage can be distinctly marked. But, generally speaking, the difficulty and frequency of respiration increase, so that the patient is compelled to lie with his shoulders elevated, or to maintain a half sitting position; the pain often quite vanishes; the expec- toration diminishes in quantity, or becomes purulent, or assumes the appear- ance of a dark turbid liquid, or ceases altogether in consequence of the debility of the patient, which disables him from coughing up the matter formed; the countenance becomes pale and haggard, and the pulse extremely feeble and rapid; the skin is bathed with a cold sweat; and death occurs, preceded by the rattling of accumulated mucus in the chest, while the mind usually re- mains clear to the last. Such is often the course of fatal cases; but much more frequently the disease takes a favourable turn in the second stage, per- haps at the end of a week from the commencement; and, in four or five days more, convalescence is established, though not unfrequently the case is pro- tracted to two or three weeks, and occasionally the patient retains one or more of the symptoms for a considerable time, such as cough, dyspnoea, pain upon full inspiration, or a frequent pulse. It has been doubted whether recovery ever takes place from the state of diffused suppuration, usually constituting the third stage: but, when not yet advanced to complete disintegration of the tissue, I can see no impossibility in this result; and the course of the symp- toms, such as we occasionally observe them, including night sweats and puru- lent expectoration, in severe and protracted cases which nevertheless recover has convinced me of the fact. That when the inflammation terminates in abscess, recovery frequently takes place, cannot be doubted • and the reason obviously is, that abscess is only apt to occur when the extent of inflamma- tion is moderate. Such instances are more frequent than the rarity of ab- scesses in post-mortem examination might lead us to imagine. Laennec states that he met with more than twenty cases of abscess in one year all of which recovered except two. The return to health in pneumonia is frequently marked by the occurrence of certain discharges, or of other phenomena considered critical Among1 these is a disposition in the urine to let fall a deposit upon coolino- and as has been asserted, to coagulate with heat and nitric acid, showing&the me" CLASS III.] PNEUMONIA. 15 sence of albumen, which is sometimes very abundant. But Dr. Walshe states that, though albumen may exist in the urine in small quantities at different periods of the disease, his own observations prove that there is no connection between its appearance and the occurrence of convalescence. A return of chloride of sodium to the urine, after its absence during the progress of the inflammation, may be considered a favourable sign. Copious perspiration, diarrhoea, epistaxis and other hemorrhages, cutaneous eruptions, especially herpes about the lips, boils, and large abscesses, are also mentioned among the critical symptoms. Relapses are not uncommon in this disease. Various modifications of the symptoms above enumerated occur, some of which will be noticed under the heads which immediately follow, but others may be more conveniently considered here. In double pneumonia, the dys- pnoea is usually much greater than when only one lung is affected, the general strength is more depressed, and the countenance more expressive of anxiety. As the pain is often felt only upon one side, the case is liable to be mistaken for single pneumonia; but the physical signs will always enable the practi- tioner to come to a just conclusion. It should be recollected that, as the dul- ness may be about equal over both lungs, we are deprived of the advantage ordinarily derived from a comparison of the two sides. In some cases, the inflammation is situated in the centre of the lung, or at the mediastinum, so that it comes into contact at no point with the exterior surface. The symptoms are, in these cases, the same as in the ordinary form of the complaint, except that the acute pleuritic pain is wanting. The phy- sical signs here sometimes fail, in consequence of the intervention of the healthy tissue of the lung between the diseased portion and the ear. Perhaps a very expert hand may elicit by percussion the flat sound from its depths; perhaps a very acute and exercised ear may distinguish the far off crepitant rale through the superficial vesicular murmur; but most operators will be unable to detect the hidden disease by these means. When, therefore, all the ordinary symptoms of pneumonia, including the viscid and rusty sputa, and excepting only the acute pain, are observed in any case in which percus- sion and auscultation fail to yield any signs, we may conclude that the dis- ease occupies the interior of the lung. Such instances are rarely observed in dissection ; for, when the inflammation is sufficiently extensive to prove fatal, it almost always reaches the surface before death. Walshe considers exag- gerated normal respiration, in these cases, proceeding from the intervening healthy lung, as a sign of some value. Pneumonia is somewhat modified in its symptoms when it occurs in persons greatly debilitated by old age or other cause. It often happens, under these circumstances, that there is no acute pain, and little or no expectoration, and that any matter that may be coughed up wants the appearance which characterizes that of ordinary pneumonia. The only local symptoms are a little cough, dyspnoea, and hurried breathing, with some fever; and even these are sometimes wanting. Great prostration, a small and irregular pulse, sunken features, a pale or livid complexion, and a certain degree of mental aberration, may generally be observed, but afford an insufficient basis for a certain diagnosis. The crepitant rale, moreover, is apt to be obscured by mucous sounds, and bronchial respiration is from the same cause less observ- able; but the dulness on percussion, taken in connection with the other phe- nomena, will be sufficiently distinctive. This form of the disease is very fatal. The patient sometimes sinks with great rapidity ; and cases now and then occur, in which the system never efficiently reacts after the depression of the chill. The cases denominated hypostatic have something of the same char- acter. They arise from a mechanical congestion, consequent upon a long- continued position upon the back, in states of great debility. A low inflamma- 16 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART tion is produced, with few of the general signs ; and the physician has to rely chiefly on the absence of the respiratory murmur, the occasional presence of bronchophony, and the flatness on percussion. The same remarks are ap- plicable to the pneumonia which sometimes comes on near the termination of other diseases, and occasionally at the very close of life. Inflammation of the lungs is very often complicated with other pectoral diseases, and especially with bronchitis, pleurisy, and pericarditis. ^ 2. Lobular Pneumonia.—Infantile Pneumonia.—The diagnosis of this variety of pneumonia is much more obscure than that of the preceding. It occurs, as shown conclusively by Dr. Gerhard, most commonly in children under the age of six; and, though it may in some rare instances be observed in adults, it may be emphatically entitled the pneumonia of infancy. After the age mentioned, the disease almost always assumes the common or lobar form. (Am. Journ. of Med. Sci., xiv. 330.) The age of the subjects has a great effect in embarrassing the diagnosis in lobular pneumonia. Children seldom expectorate, or at least they are apt to swallow what they raise from the lungs, so that the pulmonary secretions are not brought to light. It is difficult to ascertain whether they have pain, and what is the seat of it; and their constant movement and frequent cries often render the results of per- cussion and auscultation uncertain. Besides, the symptoms of the disease itself are often obscure. The matter of expectoration, when visible, instead of having the peculiar properties of that of ordinary pneumonia, rather resem- bles the mucus of catarrh. Pain is often wanting. The disease too is very often a mere consequence of other diseases, and is apt to escape especial no- tice, because the attention of the physician has received another direction. It has not unfrequently been unknown and even unsuspected, until revealed by dissection after death. It is probable, however, that many of those cases which have been considered as pneumonia only upon post-mortem examina- tion, were, in fact, merely instances of that fetal consolidation of the pulmon- ary tissue, described by Bailly and Legendre, and referred to under the head of the anatomical characters of the disease. (See page 7.) Sometimes the disease begins frankly with fever, hard cough, hurried breathing, and pain indicated by the crying of the child when he coughs. But much more frequently the disseminated points of inflammation are at first in- sufficient to bring the constitution into decided sympathy, or the slight symp- toms produced are confounded with those of some previously existing disease, such as catarrh, measles, hooping-cough, &c. But, when the complaint is some- what advanced, fever sets in, with a very rapid pulse, frequent respiration, flushed face, contraction and expansion of the alse nasi, often great restless- ness, a frequent and sometimes painful cough, in some instances hard and dry, in others loose, but generally without expectoration. The pulse is scarcely ever under 120, sometimes as high as 140, 160, or even 180 in the minute, but usually regular. The number of respirations varies ordinarily from 40 to 60, or 70, but is sometimes considerably greater, and has been known to exceed 100. If the complaint now advances, the powers of the system begin to fail, the cough becomes feeble or quite suppressed, the voice can scarcely be heard, the cries grow faint or cease altogether, the pulse becomes exceedingly small and weak, the respiration irregular and sometimes inter- rupted with deep sighing, the extremities cold, the face pale or livid and death soon takes place, usually preceded by a period of drowsiness or stupor. Should the disease, on the contrary, take a favourable turn, all the symptoms begin to improve in about a week, more or less, and the child gradually re- turns to health. The duration of the disease is almost always longer than that of the ordinary form of pneumonia, often extending to two or three weeks before death or recovery. Sometimes it is much more protracted. Occasion- CLASS III.] PNEUMONIA. 17 ally abscesses are formed, and, discharging suddenly, either overwhelm the lungs and produce sudden death, or are followed by purulent expectoration, severe cough, night sweats, hectic fever, and emaciation, until at length the child sinks exhausted, or, as sometimes happens under judicious treatment, returns gradually to health, after a struggle of several months' duration. In the earliest stage of the disease, the physical signs often fail entirely to detect it; but, at a more advanced period, they become important and even indispensable aids to a just diagnosis. The crepitant rale is rarely heard, being covered by the mucous sounds, which are always audible in a greater or less degree. The most characteristic auscultatory sign is the subcrepitant rale, which is usually heard throughout the complaint, here and there all over the lungs, and is sometimes so fine as to approach closely to the crepitant. Should the proper crepitation of pneumonia be detected in distinct spots of the chest, with healthy respiration around them, it would be a clear indication of the nature of the complaint. In the advanced stages, bronchial respiration may be heard in the upper part of the lung, and there is an unhealthy resonance of the cry over the chest, which is one of the characteristic phenomena. Dr. Gerhard describes, as a peculiarity of this form of pneumonia, a modification of the respiration, consisting in " a short, obscure blowing" inspiration, "al- most without the vesicular murmur," with an indistinct expiration. (Am.. Journ. of Med. Sci., xv. 100.) Percussion, which is wholly useless in the early stage, now becomes a valuable sign. There is dulness, and often per- fect flatness, on the posterior part of the chest, usually equal on both sides. Should the operator be doubtful, in consequence of the equality of the sound on the two sides, and the want of a point of comparison, he may compare the sounds elicited with those of a healthy chest. Both in auscultation and percussion, he should direct his examination especially to the posterior part of the chest. In some cases of the disease, especially those occurring in the course of chronic complaints of debility, the general symptoms are so very slight and uncertain, that the physical signs afford the only positive evidence of the existence of the affection. 3. Bilious Pneumonia.—Bilious Pleurisy.—Miasmatic Pneumonia.— Pneumonia is not unfrequently associated with symptoms of bilious derange- ment. These may arise from different causes. When the inflammation occu- pies the lower portion of the right lung, an irritant if not inflammatory action is sometimes extended to the upper portion of the liver, and the symptoms of pneumonia become complicated with those of hepatitis, or at least of de- ranged hepatic function, such as pain and tenderness upon pressure in the right hypochondrium, pain in the right shoulder, nausea and vomiting, yellow- ness of the eyes and skin sometimes amounting to jaundice, and deep-coloured, yellowish-brown urine. In other instances, a similar complication occurs in consequence of pneumonia supervening upon hepatic disease, as not unfre- quently happens during the colder seasons in malarious countries. But by far the most frequent form of bilious pneumonia is that which oc- curs as an associate of remittent or intermittent miasmatic fevers, and which may, with great propriety, be distinguished as miasmatic pneumonia. This is a very common disease in the miasmatic regions of the United States; and is especially prevalent in the cold seasons, in the low-lying parts of the west- ern and southern sections of our country. The pneumonia may either be secondary, making its appearance after the fever has set in, or it may be pri- mary, and, by the disturbance which it excites in the system, call the pre- existing tendencies to the miasmatic fever into action. It occurs usually in the latter part of the autumn, in the winter, or in the early spring months, and appears to be caused by vicissitudes of the weather, acting on a predis- 18 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART position acquired by exposure to malarious influences during the summer and early fall. It is most frequent and fatal in seasons which follow an unusual prevalence of bilious fever. It is very common among the black and coloured population of the South. The name by which this complicated disease has perhaps been most generally known in our country is bilious pleurisy. From the frequency of acute pain at the commencement, there can be no doubt that, as in ordinary pneumonia, the disease of the lung is often attended with inflammation of the pleura ; and it is possible that, in some instances, the in- flammation may be confined chiefly to that membrane ; but generally the lungs are most deeply involved, as shown by the bloody expectoration, the physical signs during life, and the results of post-mortem examination. The pectoral symptoms and physical signs do not materially differ, in this form of pneumonia, from those already described as characteristic of the un- complicated disease. It is not necessary, therefore, to repeat them. The peculiarities are those derived from the miasmatic complication. In those cases in which the fever is the primary affection, the chill and febrile symp- toms generally precede those proper to the pneumonia for one, two, or three days, and sometimes a longer period. In other instances, the pneumonia and bilious symptoms pursue an even march. When the complicated disease is established, we have usually, besides the signs of pulmonary inflammation, more or less of the following symptoms: viz., headache, a yellowish, or yel- lowish-white fur on the tongue, nausea and vomiting sometimes of bile and sometimes of the ordinary gastric fluids, a more or less yellowish tinge of the skin and conjunctiva, often a brownish colour of the face arising from the mixture of the pneumonic redness with the icterode hue, and a deep-coloured, yellowish-brown urine. The fever is always remittent, generally with daily paroxysms, which, however, are often more severe on the alternate days; and occasionally the remission is so considerable, that the disease appears almost in the form of a quotidian or tertian intermittent. In the latter cases, we may consider any existing fever in the intervals as sustained by the pulmo- nary inflammation. The grade of inflammatory action is in general less ele- vated than in ordinary pneumonia, and sometimes the fever assumes a typhoid character; the pulse becoming feeble, the tongue brown and dry, and the mind often somewhat wandering. The cases of intermittent pneumonia, spoken of by writers, probably belonged to this variety of the disease. Under proper treatment, bilious pneumonia generally terminates favourably; though it may prove exceedingly fatal, when associated, as it sometimes is, with the more malignant forms of miasmatic fever. 5. Typhoid Pneumonia.—Occasionally pneumonia, occurring in persons with enfeebled constitutions, or who have been exposed to certain depressing influences calculated to impair the condition of the blood, puts on that char- acter of feebleness and depravity, which, for want of a better term, is usually denominated typhoid. More frequently, perhaps, it is developed in the course of an attack of typhus fever, or other malignant disease which neces- sarily influences the nature of the local affection. In either of these cases the pulmonary inflammation is distinguished by the name of typhoid pneu- monia. It was a mistake to attach the title of pneumonia typhoides as was done by some of our medical writers, to the malignant epidemic which prevailed in many parts of the United States, between the years 1807 and 1820. It is true that the disease was in many instances attended with pneu- monia; but so also was it attended with other inflammations, and very fre- quently ran its whole course without any inflammation whatever. It was properly typhus fever, and the pulmonary affection was merely an incidental accompaniment. In all such cases, we may speak of the pneumonia as ty- CLASS III.] PNEUMONIA. 19 phoid, but we must guard ourselves against considering it as the main dis- ease, and especially against the practical error of treating it as such. In typhoid pneumonia, most of the local symptoms do not materially differ from those of the disease in its ordinary form. There are pain, dyspnoea, and cough; and the pain may be either acute or obtuse; but there is occa- sionally this peculiarity, that severe neuralgic pains are superadded, which are not necessarily confined to the exact seat of inflammation, but may be felt even on the opposite side, and sometimes extend beyond the chest, down the back or sides, and even to the extremities. In many instances, however, painful sensations are quite wanting; and the local symptoms are in general masked, to a considerable degree, by the obtuseness of sensibility consequent upon the state of the brain. Another very striking peculiarity is the char- acter of the matter expectorated. Even in the early stage, it is generally bloody, and sometimes almost pure blood. In all stages, it is less viscid, and usually more copious than in ordinary pneumonia. Not unfrequently it is brown or even blackish, and sometimes fetid. Either from want of energy in the vessels, or from the character of the circulating blood, there appears to be an oozing of this fluid, little changed, through the capillaries, instead of the somewhat plastic lymph that is exuded in vigorous inflammation. The general symptoms are those of depression. The pulse, though sometimes sufficiently full in the beginning, is weak and readily compressible, and sinks rapidly under the loss of blood. Further on in the disease, it is frequent, small, and very feeble. The skin is hot and dry, or cold and clammy, and not unfrequently covered with petechia?. The pneumonic flush of the face, if it exist, is dark and dusky. The tongue is covered with a brownish fur, and in the advanced stages is dry; while the teeth, gums, and even lips are often incrusted with a dark sordes. The evacuations are generally dark and offensive. There is throughout an obtuse condition of intellect, often ex- pressed in the countenance, and degenerating towards the close into stupor or low delirium. The physical signs are dulness on percussion, and the loss of the respiratory murmur, with little or none of the crepitant rale, the place of which is supplied by the mucous sounds, or those arising from diminished caliber of the tubes. The consolidation of the lung is most commonly found in the posterior portion of the chest. Drs. Graves and Stokes have ob- served, in certain cases of pneumonia, especially of the typhoid form, a tym- panitic sound of the chest succeeding dulness, and accompanied with an absence of respiratory murmur, which they ascribed to air in the cavity of the pleura (Stokes, Diseases of the Chest, p. 333); and a similar case oc- „ curred to myself in the Pennsylvania Hospital, not precisely typhoid, though with a feeble state of system, in which the tympanitic sound extended above the nipple. This patient recovered. Recovery, though not unfrequent, is generally slower than in the sthenic forms of the disease; and the solidified portion of the lung is longer in undergoing resolution. This affection occurs most frequently in the course of malignant epidemics; but sporadic cases of it are now and then observed, as, for example, under those influences which produce a scorbutic state of system, or from the action of the sedative and poisonous gases, among which sulphuretted hydrogen is perhaps the most deleterious.* * Dr. Samuel Gordon, of Dublin, describes a variety of typhoid pneumonia having peculiar characters which render it worthy of notice. From his account, it would appear not to be uncommon in Ireland, often occurring epidemically, and sometimes superven- ing on other diseases. In some cases, the attack is extremely violent, with great pros- tration at the commencement. The symptoms are hurried diaphragmatic respiration, with little cough; often pain in the side, not always referred to the real seat of disease; a small, feeble, and very frequent pulse ; coldness of the surface, with purple lips, and a 20 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART 6. Chronic Pneumonia.—-This is comparatively rare, and some doubts even of its existence have been expressed. But cases of protracted disease of the lungs following acute pneumonia, and running on for months or even years, do occasionally occur; and physical exploration shows that, in these cases, the lung still remains consolidated in the situation of the original hepatization. In a case of this kind occurring in a young woman under my care, the disease was confined exclusively to the upper lobe of the right lung, which was in no degree tuberculated. There is occasionally pain in the part affected; but it is seldom steady, and is often quite wanting. There is always, however, when the disease is at all extensive, more or less dyspnoea, which is occasionally considerable, and is greatly increased by exertion. ^ In the case of a female which occurred to me in the Pennsylvania Hospital, in whom the whole of one lung appeared to be consolidated, it was the only prominent symptom. The cough is usually moderate, either with or without expecto- ration, and the matter thrown up is mucus or pus, but not viscid or rusty. There is generally some frequency of pulse, with a little febrile heat towards evening. The appetite is impaired but not lost. The patient has usually sufficient strength to enable him to walk in the apartment, and sometimes to keep about. Occasionally hectic symptoms set in, and pus is expectorated in considerable quantities. When tubercles are not generated, there may always be hope for the patient. The physical signs are dulness or entire flatness on percussion, the absence of the respiratory murmur, and, when the consolidation is extensive, the want of all respiratory sounds, and even of vocal resonance in the distant parts of the lung. But, near the borders, bronchial respiration and bronchophony may be heard, and the hand upon the chest perceives a decidedly stronger vibration from the voice than upon dark suffusion of the face; and great general prostration, ending often in fatal col- lapse. This condition, however, occurs only in persons previously enfeebled. In ordinary cases, there is little heat of the skin, which has a yellowish hue; the cough is short, frequent, without effort, and wholly different from that of ordinary pneumonia; there is seldom expectoration, and when it does occur, the sputum is not tenacious; the pain is not severe, never sharp as in pleurisy, and often referred, as in the cases of col- lapse, to a part of the chest where there is no other evidence of disease; the pulse is seldom very frequent, always feeble, and soon acquires a jerking character; constant vomiting is a frequent symptom; and, in addition, there are complete anorexia, great thirst, restlessness, want of sleep, and often considerable modification of the voice, amount- ing sometimes to aphonia. The physical signs are dulness on percussion, feebleness of the vesicular murmur, ending in bronchial respiration, and bronchophony, without the crepitant rale at any stage. If the patient recovers, the bronchial sounds rapidly, some- times within twenty-four hours, give way to the vesicular; showing that the air-cells were obliterated by pressure, not effusion. The progress of the affection is rapid, and if it does not end favourably, the lungs seem to pass into a state analogous to gangrene, effusion takes place into the bronchia, and the patient dies of asphyxia. The lung, after death in the early stages, has at first a dark-blue colour, which dis- appears in three or four hours, is firm like muscle, heavy, and sinks in water, but pre- sents no appearance like that of hepatization, and never crepitates. If death takes place at a somewhat later period, the lungs are tough, heavy, and, when cut, of a light-gray colour. In the advanced stage, they are of a dirty-gray, softened, and apparently in the commencement of decomposition, but with no well-marked suppuration. A marked feature of the disease is that it is " not amenable to any of the usual modes of treatment." Bleeding, tartar emetic, and mercury, are useless, or worse than useless. Wine and other diffusible stimulants are useful by supporting strength, but have no con- trol over the disease. Sulphate of quinia is the great remedy. Under its use if resorted to before effusion, the patients always recover, and, even after the commencement of collapse, are sometimes saved. The average dose is five grains every three hours Dr. Gordon considers these cases to be characterized by the seat of the inflammation being essentially in the pulmonary capillaries, which become engorged with imperfect fibrin, and are thus disabled from carrying on the pulmonary circulation (Dnhiin Quarterly Journ., Aug. 1856, p. 96.)— Note to the fifth edition. vuoun CLASS III.] PNEUMONIA. 21 the healthy side. In favourable cases, the return of respiration is generally first perceived in the upper portion of the chest, and gradually extends down- ward with the resolution of the solidified lung. A variety of chronic pneumonia has been described, which is characterized by an infiltration of the interlobular cellular tissue with fibrinous matter, which becomes indurated, causing contraction of the lung, obliteration of the air-vesicles, and sinking in of the side. It is the "cirrhosis" of Dr. Corrigan, and is probably rather fibroid degeneration than the result of inflammation. It will be more particularly described among the non-inflammatory organic affections of the lungs. Diagnosis. The diseases with which pneumonia is most liable to be confounded are bronchitis, pulmonary oedema, pleurisy, and certain states of phthisis. It will be sufficient here to mention the characters by which the disease may be distinguished from bronchitis. In reference to the other affections, the reader is referred to the articles respectively in which they are treated of. It is in cases of bronchitis extending to the minute ramifications of the bronchia, that the greatest resemblance is presented to pneumonia. But, in the former affection, the sensations are more those of soreness than acute pain, and are usually seated in the anterior and upper part of the chest, be- hind and in the vicinity of the sternum; the expectoration, though some- times streaked with blood, never has the extremely viscid and rusty character of the sputa of pneumonia, and when it once begins is much more copious; no true crepitant rale is heard, but instead of this the dry and mucous rales; there is no bronchial respiration or resonance, and very seldom a permanent want of the respiratory murmur in any part of the chest; and finally there is no considerable dulness on percussion. But not unfrequently the two diseases are combined; and, when the pneumonia is in the centre of the lung, or disseminated, it is sometimes difficult if not impossible to distinguish between them. Prognosis. In cases of primary pneumonia, of the common or lobar kind, occupying only a portion of a single lung, occurring in persons of a good constitution, and without complication of any kind, there is every reason to hope for a favourable issue. Cases of this kind almost always end in recovery under proper treatment, and not unfrequently even without remedies, or with such as are improper. The disease appears to be remarkably mild between the ages of six and twenty-one. Of forty cases observed by Dr. Gerhard and M. Rufz, in the Children's Hospital at Paris, occurring in children from six years old to the age of puberty, only one terminated in death. (Am. Journ. of Med. Sci., xiv. 330.) In debilitated persons, and in those above fifty years, the disease is much more fatal. In very advanced age, it is extremely dan- gerous. It is said to be more unfavourable in its termination in the upper than in the lower lobes. The danger is much increased when the whole of one lung is affected; and in double pneumonia it is always very great. It is more apt to terminate fatally in hospitals than in private practice, chiefly, in all probability, in consequence of the previously shattered constitution of the patient, and of the advanced stage at which it is brought into the wards, after previous neglect or ill-treatment. In tuberculous subjects, or those having the scrofulous diathesis, pneumonia is sometimes attended with copious tuberculous deposition, which, under these circumstances, may be considered 22 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. as inevitably fatal, and often runs a very rapid course. Secondary pneumonia is much more fatal than the primary, and the lobular than the lobar variety; but the greater danger of the lobular, independently of the fact that it is more liable to escape notice, and therefore not to be treated properly, is owing to the fact, that it is generally secondary, and is apt to occur in debilitated constitutions. In bilious pneumonia, the fatality probably depends more upon the febrile disease, of which it is a mere accompaniment, than upon the pulmonary inflammation. Though it generally yields very happily to reme- dies, yet, if improperly treated, it is sometimes extremely dangerous, espe- cially in cases in which a malignant or pernicious tendency complicates the disease. The same remark may be made of typhoid pneumonia. When associated with a malignant epidemic it is often very fatal. But, when ori- ginating in local or accidental causes, it may be comparatively mild. It has occurred to me to attend between twenty and thirty persons of various ages, from childhood to middle life, in an institution in Philadelphia, all affected in one season with typhoid pneumonia of various grades, and all of whom recovered. The cause of the disease, so far as could be ascertained, was an excessively offensive exhalation which filled the whole house, and proceeded from a cellar into which the contents of a privy had been discharged by the giving way of a separating wall. But the mortality of typhoid pneumonia depends much on its management. If treated with the same energetic de- pletion which is adapted to the ordinary form of pneumonia, it may be enor- mously fatal. In any case of pneumonia, an exceedingly hurried respiration, inability to lie down, very dark and consistent or thin brownish or blackish or fetid expec- toration, copious diarrhoea or colliquative sweats, and an extremely frequent, feeble, or irregular pulse, amounting in the adult to 140 in the minute, are all very dangerous symptoms. Causes. Vicissitudes of the weather are among the most frequent causes of pneu- monia. Sudden exposure to cold, when the body is warm and perspiring, is very apt to induce it. This is especially the case, when the individual ex- posed is at the time labouring under a catarrhal attack. Direct violence, acrid or poisonous inhalations, the excessive use of the voice, violent exertion of any kind which accumulates the blood in the lungs, powerful emotions, ex- cesses in drinking, the suppression of habitual discharges, the retrocession of gout or rheumatism, and the sudden disappearance of cutaneous eruptions, are ranked among the occasional causes. A long-continued position upon the back is said to give rise to the disease in debilitated persons. It sometimes follows accidental injuries, or surgical operations of a severe character- at least, abscesses in the lungs have been observed under these circumstances though it may be doubted whether they are not rather the result of purulent infection of the blood, than of proper pulmonary inflammation. Various diseases are apt to be accompanied with pneumonia, and are thought to favour its production. The one in which it most frequently occurs is pro- bably bronchitis; but it is also frequent in measles and hooping-cough. It is an occasional attendant upon smallpox, scarlatina, and erysipelas. Phthisis can scarcely run its course without more or less of it. Affections of the heart not unfrequently occasion it, by the pulmonary congestion to which they so often give rise. It is not uncommonly associated with organic disease of the kidneys, and, under these circumstances, has been observed by Dr B G McDowel, of Dublin, to have a tendency to the suppurative or gangrenous condition. (Dublin Quart. Journ., May, 1856, p. 322.) It is not unfrequent in enteric or typhoid fever, and is occasionally associated also with the mias- CLASS III.] PNEUMONIA. 23 matic and typhus fevers.* Chronic diarrhoea appears to predispose to it in young children. (Gerhard.) It is one of the most common inflammations which attend reaction after the collapse of malignant cholera. It is occa- sionally epidemic, but probably only as an associate of other diseases. Of the predisposing causes, cold may be ranked among the most efficient. Hence, the disease prevails most in cold countries, and in the colder seasons. It is probably as common in cold and dry as in moist climates. It is not un- common in the mountainous regions of this country. It is especially apt to occur towards the end of winter, and in spring. Those occupations are be- lieved to predispose to it which expose the lungs to injury from over-exertion, or the inhalation of irritant substances, and which render necessary an ex- posure to the vicissitudes of the weather, without due protection. Some per- sons have a peculiar tendency to the disease, without any known cause, and suffer from repeated attacks. Age and sex do not appear to have any very considerable influence over the frequency of its occurrence. In the first five or six years of life, it is not uncommon; but it is then apt to be connected with other diseases, which are probably its real causes. It is most commonly the lobular variety which occurs at this age. Perhaps the period of life at which it is most frequent is from 20 to 30 or 35, when the body has attained its full height, but is still spreading laterally. The disease is more frequent in men than women; but the reason of this probably is, that the former are more exposed to the vicissitudes of the weather and to other exciting causes. Treatment. In no disease is it more important to make a proper discrimination in the treatment. The measures which are salutary and even essential under cer- tain circumstances, are injurious and may be fatal under others. In order to make the importance of this distinction in the mode of practice more obvious, it will be best to treat, under distinct heads, of the varieties of the disease which most differ in the measures they require. 1. Common Pneumonia.—In persons with vigorous constitutions, bleed- ing is the most efficient remedy. No disease bears the loss of blood better than open, well-developed pneumonia. This evacuation is called for, not only in reference to its direct effect in relieving inflammation, but also with the view of diminishing the labour of the lungs, and thus procuring rest for the diseased organ, so far as this is possible. As all the blood in the body must pass through the lungs after reaching the heart, before it can be again dis-g^ tributed, and as in pneumonia a considerable portion of the lungs performs^© the duty but imperfectly, a greater burden necessarily falls upon the remain- der ; and thus, not only is the sound part of the lung unduly loaded with blood, but the movements of respiration must be accelerated in proportion. By diminishing the amount of blood, we relieve the lung of a portion of this duty. In deciding upon the quantity to be taken, we must be guided by the stage of the disease, the state of the pulse, and the constitution of the patient. In a vigorous patient, in the earlier stage of the disease, with a strong pulse, and before hepatization has been fully established, from sixteen to thirty ounces may be taken at the first operation. There is some reason * From the observations of Dr. Woillez, it appears that in most acute febrile dis- eases there is an attendant pulmonary congestion, evinced by expansion of the chest with diminished elasticity, feebleness of the respiratory murmur with or without sono- rous rales, and some degree of dulness on percussion, especially behind. The sonorous rales he conceives to be much more frequently a sign of congestion than of bronchitis. This condition of the lungs may readily pass into inflammation, and hence the not un- frequent occurrence of this affection in acute febrile diseases. (Archives Gen., Mai, 1854, p. 678.)—Note to the fourth edition. 24 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. to hope, in this stage, that we may arrest the progress of the disease by de- cided measures. I am quite convinced that I have witnessed this result in my own practice. Should the symptoms have in no degree abated, we may bleed again at an interval of from twelve to twenty-four hours, and the opera- tion may even be again repeated, should the pulse not have been reduced, nor the inflammatory symptoms decidedly checked. In the subsequent bleed- ings, it will seldom be proper to take as much as at the first; but the pulse and general condition of the patient must be the guides. The occurrence of nausea or faintness, while the patient is bled in the sitting posture, should be a signal to stop the discharge. Cases sometimes occur in which the loss of blood is necessary, though the pulse may not seem to indicate it. The lungs are overwhelmed with the sudden and extensive congestion, and the function of respiration consequently so much impeded as to occasion a partial asphyxia, in which the surface becomes pallid or purplish, and the pulse very small, frequent, and feeble, suggesting the idea of great prostration of the vital forces. In these cases, however, the fault is not in debility, but in excessive action in a vital organ; and the remedy is not stimulation, but abstraction of blood. It is proper to excite the surface by irritants; but the important object is to unload the lungs. It generally happens that the pulse rises under the lancet, and this affords an indication that the remedy has been rightly employed. There may be some difficulty in discriminating between such cases and those of true debility. Should the apparent prostration come on suddenly, when no typhous epidemic is prevalent, in persons previously in tolerable health, and the respiratory movements exhibit evidences of great oppression of the lungs, it is much the safer plan to treat the case as one of active pulmonary congestion, and to try the lancet. Should the pulse become still weaker, the bleeding must be stopped; but should it rise, the operation ought to be con- tinued until the symptoms are relieved, or the patient can bear no further loss. Laennec proposes, as a test of the propriety of bleeding under such circumstances, the application of the stethoscope to the heart. Should the pulsation of the heart be found proportionably much stronger than that of the arteries, he considers it an indication that bleeding is proper. After the first bleeding, the bowels should be thoroughly evacuated by an active cathartic, as calomel and jalap, the compound cathartic pill, infusion of senna with Epsom salt, &c.; but subsequently, throughout the case, it will be sufficient merely to keep them open once or twice a day, which may be effected, if necessary, by small doses of a saline cathartic, castor oil, or mag- nesia, or, what may sometimes be preferable, by enemata. But it very often happens that the remedies employed to meet other indications have the effect of sufficiently loosening the bowels, so that measures are not required for that purpose especially. The bowels having been evacuated, recourse should be had to small doses of tartar emetic, repeated at short intervals; from the twelfth to the quarter of a grain, for example, every hour or two hours during the day. When the skin is hot and dry, this may be accompanied with the neutral mixture or nitre, if borne well by the stomach. In cases attended with vomiting the effervescing draught should be substituted for the antimonial. After two or three days, when the force of the circulation has been suffi- ciently subdued by the lancet, a mixture consisting of a grain of opium a grain of ipecacuanha, and two or three grains of calomel, may be given'at night, in the form of pill; the treatment above pointed out being continued through the day. Sometimes it may be deemed proper to increase the dose of the anodyne, when the system is not very susceptible to its influence In such cases, twice the quantity of materials just mentioned may be made into four pills, two to be taken at bedtime, and one at intervals of an hour or two CLASS III.] PNEUMONIA. 25 afterwards, until the soporific effect is produced. The advantages of this combination are, that it procures rest for the patient, obviates the injurious effects of the cough, directs action to the skin, and lays the foundation for a mercurial impression, if this should subsequently be deemed advisable. If the pain should continue after general bleeding has been carried as far as may appear admissible, and especially if the physical signs indicate the unchecked progress of inflammation, blood should be taken by cups or leeches from the chest to an extent corresponding with the strength of the patient. From four to ten ounces may be abstracted in this way, and sometimes with great advantage. Large emollient cataplasms are also sometimes useful; but their use requires great caution, lest they may render the patient liable to cold by improper exposure of the wet surface. Very frequently, under this treatment, the symptoms of inflammation will gradually subside, and the patient recover without further remedies. But, should the disease prove obstinate, it will be proper to resort to the mercurial impression. The combination of calomel, opium, and ipecacuanha, before given only at night, may now be continued through the day, in smaller doses, repeated at short intervals. The relative quantity of the ingredients must vary according to circumstances; the ipecacuanha being increased or dimin- ished according as it is well borne by the stomach or nauseates it, and the opium and calomel proportioned to the susceptibility of the patient. Gene- rally speaking, half a grain or a grain of calomel, one quarter of a grain of ipecacuanha, and the same quantity of opium, may be given at intervals of one, two, three, or four hours, so that not more than from two to four grains of opium shall be administered in twenty-four hours. When the symptoms are threatening, and a speedy mercurial impression is requisite, three or four grains of calomel with half a grain or a grain of opium may be given every four hours. Sometimes even thus combined, calomel produces purging, and worries the bowels. In such cases, the mercurial pill should be substituted, in proportional doses, with the same additions. It is important to push the mercurial plan until the gums become somewhat affected, when the symptoms will generally begin to improve. A profuse ptyalism is never requisite; and, as soon as evidence is given, by the state of the gums, that the system is affected with mercury, it should be suspended, or continued in diminished quantities, so as merely to sustain the effect produced, until all symptoms ot pectoral inflammation shall cease. It will often be proper to begin the mer- curial plan upon the fifth day, if the symptoms have not begun to decline before that period; but the precise time may be earlier or later in any particular case, and must be left to the judgment of the practitioner. At the same time that this plan is in operation, a blister may with great propriety be applied to the chest. It should be large, not less, as a general rule, than six inches by eight, and often as much as eight by ten. Before this period it would be improper; as, without unseating the inflammation, it might injuriously aggravate the fever. Should the case linger, the blister may sometimes be repeated with advantage. In the declining stage of the disease, expectorant medicines are often useful. The syrups of squill and seneka may be combined with a little tartar emetic and one of the salts of morphia, and given in such doses as the stomach will bear without being nauseated. If the pulse, as sometimes happens, remain frequent, the tincture of digitalis may be added to the other ingredients. Not unfrequently it will be found best to omit the antimonial, in consequence of its depressing properties; and in such cases wine of ipecacuanha may be substituted. Should the strength fail in the advanced stages, it will often be found very useful to employ carbonate of ammonia, in two and a half, five, or ten-grain VOL. II. 3 26 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART doses, at intervals of two hours. Wine-whey may also be added, and, if hectic symptoms should set in, or copious night sweats occur, recourse snould be had to sulphate of quinia. Oil of turpentine has also sometimes proved highly useful, given in pretty large doses. The timely employment ot mode- rate stimulants, with a nutritious diet, under such circumstances, has, 1 be- lieve, often saved life. Gangrenous symptoms may be met with chloride ot lime, opium, quinia, and the mineral acids, especially the nitromunatic. It is highly important, in the cases of intemperate individuals, not entirely and at once to abstract their accustomed stimulus. It should be diminished, but not quite cut off. Otherwise, delirium tremens would be likely to set in, and the patient might sink under the requisite depletion. In such persons, alcoholic drinks in moderated amount cease to be stimulant. They are only one of the agents requisite to the support of their nervous system at the requisite point of elevation. The right plan is to allow the stimulus, and at the same time to bleed. The nervous system is thus supported, while the inflammation is combated. If pneumonia is not seen until it has reached the stage of hepatization, bleeding must be employed with more caution. Still, moderate quantities of blood may often be taken with advantage both generally and locally; and, if there be any doubt about the propriety of the lancet, cups or leeches will at least generally be proper. The further spreading of the inflammation, as indicated by the extension of the crepitant rale around the borders of the hepatized part, especially demands this treatment. After four or five days, there is little hope of cutting short the disease by direct depletion. It will run its course, and the strength must be husbanded for the future struggle. Fatal consequences have, I am convinced, often resulted from profuse bleed- ing under these circumstances. Still, as stated, it should be employed in moderation, if called for by the state of the pulse, and of the local symptoms. Nor can copious bleeding always be employed with propriety, even at the commencement. When the disease occurs in persons enfeebled by previous ill-health, or by extreme old age, or when it is associated with diseases of a low grade of vital force, as scarlet fever, malignant erysipelas, Arc, the loss of blood is badly borne, and one moderate bleeding is at most all that is admissible. Indeed, it will often be prudent to omit even this, and employ leeching or cupping in the place of it. In very young children, too, local bleeding by leeches is generally preferable. Such as above described is the course of treatment which I have generally employed, and continue to employ, in ordinary pneumonia. But other means have been recommended, which it would be improper to pass over without notice. Among these is the use of tartar emetic in large doses. This plan was in modem times introduced by Rasori, of Italy, was subsequently em- ployed and highly recommended by Laennec, and has been much in vogue both in America and Europe. It has undoubtedly great influence over the dis- ease, and, even unaided by the lancet, has probably often effected cures. Some indeed have relied upon it to the exclusion of blood-letting. Others bleed moderately once or even oftener in the early stage, and then give the antimo- nial. Others, again, treat ordinary cases with blood-letting, and have recourse to the antimonial in cases deemed unsuitable for the lancet, and yet demand- ing a sedative treatment. The antimonial does good probably in various ways. It depletes by its frequent emetic and cathartic effect, acts as a derivative to the alimentary canal from the lungs, and immediately reduces arterial excite- ment by its powerful sedative agency. Though it generally vomits at first and often purges, the stomach and bowels not unfrequently become subse- quently reconciled to it, so that in some instances it scarcely produces nausea in doses in which it originally vomited. Rasori gave it in enormous quanti- CLASS III.] PNEUMONIA. 27 ties; for example, from one to three drachms in twenty-four hours, in divided doses. Laennec gave a grain of tartar emetic in three ounces of liquid vehicle every two hours, suspending it in mild cases, after the sixth dose, for seven or eight hours } but, in those of a threatening character, continuing steadily on until amendment was evident; and, in the worst cases, increasing the dose to a grain and a half, two grains, or even two grains and a half. Other prac- titioners use the medicine in smaller quantities. The safest plan is probably to begin with small doses, and gradually increase to the larger if necessary. From one-quarter of a grain to two grains maybe given every two, three, or four hours, in from a fluidounce to two fluidounces of water. The vehicle may be pure water, or water rendered demulcent by gum arabic and loaf sugar, or some mild aromatic infusion. A little laudanum should be added if the antimonial shows a disposition to produce exhausting purgation. Dr. Williams recommends the addition of a few drops of hydrocyanic acid, if it continue to vomit. Its effect, even when it does not vomit, which occasionally happens even from the beginning, and frequently after the administration of two or three doses, is to produce great depression of the pulse and coolness of the skin, which are often attended with a striking amelioration of the disease. As, if the remedy is now omitted, the inflammation is apt to increase, it is necessary to continue it, though in somewhat moderate quantities, for some days after the beginning of amendment. M. Trousseau prefers kermes min- eral to tartar emetic, as less apt to disturb the stomach, and otherwise to produce unpleasant effects. But the antimonial plan is not without its dangers. The depression may be too great, or gastro-intestinal inflam- mation may be induced, or the patient may be exhausted by the excessive vomiting and purgation. A patient who is put upon its use should seldom be long from under the oversight of the practitioner, as serious evils may happen in the intervals of his visits, if long protracted. The plan is alto- gether unsuited to cases in which there is already gastro-intestinal irrita- tion. It is, I believe, upon the whole, less manageable than the lancet, and less safe than the mercurial plan, when the lancet is not admissible. Having witnessed fatal effects from the abuse of tartar emetic, I have been from the first averse to the plan; and the result of the few cases in which I have seen it employed has not tended to reconcile me to it. In one instance, it appeared to me to have hastened, if not occasioned the fatal issue. The late Dr. J. F. Peebles, of Petersburg, Virginia, recorded several cases, in which a hemor- rhagic tendency seemed to have been generated by the antimonial treatment, which resulted fatally after all signs of the pulmonary inflammation had dis- 4| appeared. (Am. Journ. of Med. Sci, N. S., xv. 338.) Dr. Boling, of Mont- gomery, Alabama, has repeatedly witnessed death occurring rather suddenly in pneumonia, after a rapid subsidence of the pectoral symptoms, which he ascribes to a translation of inflammation from the lungs to the alimentary mucous membrane, consequent on the irritant revulsive influence of tartar emetic. (Ibid. xxii. 331.) In small doses, it is a safe and useful adjuvant to the lancet; and I habitually use it in the early stages, when not contraindi- cated by the existence of nausea or vomiting. Veratrum viride, or American hellebore, has recently been much used in this country in the treatment of pneumonia, especially in the miasmatic regions, and, according to the reports published in the journals, with extra- ordinary success. So given as to reduce the pulse to the normal standard, and to maintain it there, without vomiting, it appears to moderate the in- flammation, and to a considerable extent to supply the place of the lancet, in those cases in which, from the state of the system, this remedy may be con- sidered of doubtful applicability. For the dose and mode of administration, the reader is referred to the U. S. Dispensatory, or the work of the author on TJierapeutics and Pharmacology. 28 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. Other remedies, which have been used with asserted benefit in pneumonia, are acetate of lead, hydrocyanic acid, digitalis, muriate of ammonia, the alkalies and their carbonates in the earlier stage, and iodide of potassium in the advanced stage, when the lung remains consolidated, and fever has disappeared. When opium disagrees with the patient, hyoscyamus or coniuni may be substituted; and small doses of camphor in addition to opium and ipecacuanha, after due depletion, have been highly recommended. Dr. Madi- son, of Petersburg, Va., has found pneumonia to be cut short by the exhibi- tion of emetics at the commencement. (Stethoscope, iv. 63.) Varentrapp, of Frankfort, Germany, has employed chloroform by inhala- tion as the main or exclusive remedy, with remarkable success, having lost only four and one-third per cent, while of cases previously treated by him in theordinary mode he had lost fifteen per cent. About sixty drops were placed on compressed cotton, and the vapour allowed to enter the lungs, for ten or fifteen minutes; and the dose was repeated every two, three, or four hours. It was not permitted to produce unconsciousness. There was a gradual amendment of the symptoms, which ended in recovery on the twelfth or thir- teenth day of the disease. (See Am. Journ. of Med. Sci., N. S., xxiii. 517.) But the course of treatment would be very imperfect, without attention to various points of management not yet particularized. It is important not to disturb any of those actions which may be considered as critical, but, as a general rule, rather to follow the lead of nature, and encourage them. Should the disease have arisen from repelled eruptions, or translated irritations of any kind, efforts should be made to restore them to the surface, or exterior parts, by the warm bath, hot pediluvia, and blisters or rubefacients. The patient should lie with his shoulders somewhat elevated, and, in protracted or debilitated cases especially, should have his position changed occasionally, in order to prevent the settling of blood into any one portion of the lungs, under the influence of gravitation. This remark is peculiarly applicable to infants. In the physical examination of the chest, care should be taken to expose the surface as little as possible. Percussion should not be made so strongly as to occasion pain. The air of the apartment should be of a uni- form temperature and warm, but purified by sufficient ventilation. In the early stage, the diet should be of mucilaginous or farinaceous drinks, such as gum-water, barley-water, thin gruel, &c, to which may be added the decoc- tion or infusion of the dried fruits, and the juice of oranges or fresh grapes, the indigestible portions of these fruits being rejected. At a more advanced period, when the fever has been somewhat subdued, tea and toasted bread or crackers, with a little rice or Indian mush maybe allowed- after these milk- and finally, in convalescence, broths, and the lighter meats', eggs, oysters, &c! In cases of debility, it is highly important to resort to these nutritious'sub- stances before convalescence. There is reason to believe that patients in pneumonia have sometimes been starved to death. Lobular or Infantile Pneumonia.—There is nothing so peculiar in this form of pneumonia as to call for a different set of remedies. The treatment is to be conducted upon the same general plan as in the ordinary variety But reference must be had especially to the origin of the disease and the strength of the patient. Arising frequently in debilitated subjects and in the course of other diseases, it will not, in many instances, bear the depletorv measures so strongly called for in the more frank and uncomplicated cases The age of the subject also requires attention. In very youna- infants leeches may be advantageously substituted for the lancet Ernests is often* beneficial; and tartar emetic may be employed for this purpose It miv also be continued afterwards in small doses; but the gigantic plan of id istering this remedy, recommended in cases of adults, is too hazardoi min- ous in CLASS III.] PNEUMONIA. 29 children. Calomel is a most invaluable remedy, and may be given in the same combinations as already mentioned. But there is, perhaps, no point in the pneumonia of children, to which it is more important to direct attention, than to the treatment of the advanced stages. Debility is here a prominent character, and often demands the use of stimulants. Carbonate of ammonia, wine-whey, and assafetida, with a nutritious diet, and the addition of sulphate of quinia when hectic symptoms appear, are the chief remedies. A mistake at this stage of the disease, and the substitution of depletory for supporting measures, would prove almost certainly fatal. In cases of the fetal state of lung, simulating pneumonia, depletory treatment is inadmissible, and stimu- lating and supporting measures are often required. Bilious Pneumonia.—If this owe its peculiarities merely to an association of hepatic with pulmonary inflammation, no modification of the treatment before recommended will be necessary, except that the mercurials should be employed at the beginning, and continued until they affect the mouth. But if the disease be associated, as it generally is in this country, with miasmatic fever, or a miasmatic state of system, it will require other measures. Bilious pneumonia does not bear bleeding so well as the uncomplicated disease; but, frequently, the loss of twelve or fifteen ounces at the commencement is ad- vantageous, and sometimes the operation may be repeated. Much depends upon the grade of constitutional forcS in the febrile affection. A good plan is to place the patient erect in bed during the operation, and, with the finger on the pulse, to stop the discharge when this begins to falter. When bleed- ing can no longer be supported, and in cases which do not admit of it, cups or leeches are generally safe and useful. It is best, in cases in which the propriety of the lancet is doubtful, to commence with an emetic, or an emeto- cathartic. For this purpose, a dose of tartar emetic may be prescribed, followed by a purgative dose of calomel; or a mixture of ipecacuanha or precipitated sulphuret of antimony with calomel may be given at first, and the mercurial afterwards carried off by sulphate of magnesia, or a combina- tion of this with infusion of senna. In this affection, when the bowels are not irritable, cathartics into which calomel enters may in general be occasion- ally employed throughout the complaint, or at least until evidences of de- bility are presented. Blisters may be resorted to at an early period, and may often be repeated with advantage. In other respects, with a single ex- ception, the treatment may be conducted as in ordinary pneumonia. That exception consists in the early use of sulphate of quinia. Whenever the re- mission is decided, after the thorough evacuation of the bowels, and the ab- straction of whatever amount of blood may be deemed advisable, no matter at what stage the remission may occur, recourse should be had to this medi- cine, as in remittents without the same complication. By arresting the paroxysm we do infinitely more good, in relation to the inflammation, than the stimulant action of the quinia can do harm. • There is no stimulant so powerful as the paroxysm itself, and each recurring one has a strong ten- dency to sustain the inflammation. Indeed, the pneumonic symptoms are almost always worse in the exacerbation of the fever, and decline as that re- mits. From twelve to eighteen grains of the sulphate of quinia should be given between the paroxysms, usually in divided doses of one, two, or three grains, according to the length of the interval. Some prefer larger doses, as of five grains; and these should be preferred where it is necessary to pro- duce a speedy impression. Should the disease put on, as it not unfrequently does, a typhoid character, this medicine becomes still more proper, and in malignant or pernicious cases it is absolutely indispensable. In these latter cases, it must be administered unsparingly; for it is of the utmost import- ance to prevent the recurrence of the paroxysm. The quinia may often 30 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. be advantageously combined with calomel, opium, and ipecacuanha. A ery commonly, the pneumonia subsides along with the fever, and ™qmTe* .llttle further treatment when the paroxysms have been superseded, bbouia it re- main, however, it may then be managed as if an original affection, fenould the disease be intermittent, the propriety of employing this remedy is still more obvious. In low cases of * bilious pneumonia, it sometimes becomes necessarv to stimulate, as in the following variety. Typhoid Pneumonia.— Bleeding is not usually well borne in this variety of the disease, and, if pushed far is not unfrequently fatal. Occurring gene- rally as an attendant upon malignant epidemics, and assuming in its onset features which to the inexperienced eye are not strikingly different from those of ordinary pneumonia, it is apt to be treated at first in a similar man- ner, by blood-letting and other evacuants, until the practitioner becomes alarmed by its terrible fatality, and finds it necessary to change his measures. When there is doubt as to the nature of the disease, in any particular case, attention should be paid to the character of any epidemic that may be prev- alent in the same or some neighbouring region, and, if this be typhous, great caution should be exercised in the use of the lancet. In some cases, a moder- ate loss of blood may not be unsafe, and may even be advantageous; but these are to be considered as rather the exceptions than the rule; and, in general, leeching or cupping is the most that should be done in the way of direct de- pletion. The best plan is usually, if the disease is seen in its earliest stages, to commence with an emetic of ipecacuanha or sanguinaria, and to follow this with a purgative dose of calomel, or of calomel and rhubarb conjointly. Afterwards, the patient should be put immediately upon the use of opium and ipecacuanha with calomel, a dose of which, containing half a grain of each of the first two ingredients and one or two grains of the third, should be given every three or four hours; and persevered in until the gums become affected ; the mercurial pill being substituted for the calomel, should the lat- ter purge. So soon as decided signs of debility or prostration appear, stimu- lants should be resorted to, the milder being first employed, and the more energetic afterwards, if these should not answer the purpose. Infusion of serpentaria, small doses of carbonate of ammonia, and wine-whey may be first used; then, if necessary, compound infusion of Peruvian bark or quinia with wine; and, lastly, brandy in the form of milk-punch, or beat up with the yolk of eggs and sugar. When the debility is considerable, wine and sulphate of quinia are the standard remedies, and should be used freely, without inter- mission, until the danger is passed. Ardent spirit must be resorted to in the cases of those in any degree accustomed to it. Oil of turpentine very freely given is also serviceable, and may be considered as especially applicable when there is considerable bloody discharge from the lungs. Musk has been highly recommended in the dose of twenty or thirty grains. Dry cupping and blist- ering are important adjuvants. If the bowels are confined, they should be kept daily open by means of rhubarb, in the form of aromatic infusion or tincture. The diet should be nutritious, and sometimes even stimulating. In the earlier stages, tapioca, sago, arrow-root, &c, prepared with nutmeg, sugar, and a little wine ; in the advanced stages, milk, egg and wine rich broths and jellies, and even essence of beef, should be employed. In asthenic cases of pneumonia, known to be such from the commencement the free employment of sulphate of quinia, given so as to suppress the febrile movement, will probably be found one of the safest and most efficacious meth- ods of treating the disease. It has the advantage, that its depressing effects are produced through an excitation of the cerebral centres so great as to re- press their functions, and those of dependent organs, without producing fatal prostration on the one hand, or, in this state of system, a dangerous cerebral congestion on the other. CLASS III.] GANGRENE OF THE LUNGS. 31 Chronic Pneumonia.—In this affection, the treatment must be directed by circumstances. If the consolidation of the lung continue, without evidence of suppuration or abscess, it may sometimes be proper to take a little blood from the arm or chest, especially when there is pain or exacerbation of fever. But the remedy should be used with caution. The most efficacious measure is probably a steady course of the mercurial pill, in small doses, so repeated and continued as to produce and sustain the slightest visible impression on the gums for a considerable time. Should mercury fail, iodide of potassium may be tried. Squill and seneka, with or without ipecacuanha, tartar emetic, or sanguinaria, will be found valuable adjuvants. These medicines may in general be most conveniently combined together, in the form of their officinal liquid preparations; and advantage will accrue from adding to them some preparation of opium, especially one of the salts of morphia, or, as a substi- tute for this, hyoscyamus, lactucarium, or conium. Blisters should be applied in rapid succession to the chest; or a steady external irritation should be kept up by means of tartar emetic, croton oil, an issue, or a seton. When suppuration has taken place, and hectic symptoms appear, infusion of wild- cherry bark with one of the mineral acids, morphia or one of the other nar- cotics with expectorants to allay cough, and the inhalation of tar vapour, are the chief remedies. In this condition no mercurial should be given. In infantile cases especially, I have apparently found the greatest advantage from causing the child to inhale constantly, for weeks or months together, the air of an apartment more or less impregnated with the vapours of tar. This may be effected by exposing tar in a water-bath to a moderate heat by means of a nurse lamp. The diet must be regulated by circumstances, being exclusively of vegetable aliment, when there is increase of inflammatory symptoms, of this with milk in moderate cases, and, when there is debility, of the more nutritious and digestible forms of animal food. Article II GANGRENE OF THE LUNGS. This occurs sometimes, though rarely, as a consequence of ordinary pneu- monia, When this disease is sufficiently extensive and violent to prove fatal, death results before the parenchyma, even if it has lost vitality, has had time to undergo that putrefactive decomposition which characterizes gangrene. Hence, this affection is most frequently connected with cases of circumscribed pneumonia, which sometimes ends in abscesses, and in which, on account of the smaller extent of the disease, life is in less immediate danger than when the inflammation is more extensive. It is probable, too, that gangrene is less frequently dependent on the mere violence of the inflammation, than on a peculiar predisposition, derived from a vitiated state of the blood, or a de- praved and debilitated condition of the system. But, in most cases of gangrene of the lungs, the antecedent or attendant inflammation is so slight as to have led to the suspicion, that it is not the cause, nay, that it is sometimes even the effect of the mortification, and quite analogous in its origin to that which surrounds an eschar resulting from the external use of caustic. This may be true, in some cases in which the gan- grene results from mechanical causes interfering with the circulation in por- tions of the lung. But the probabilities are, that, as some degree of inflam- « mation is always present, and, where examinations have been made, has usu- ally been found to precede the evidences of gangrene, it is in fact generally 32 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART the cause of this state. The inflammation, however, is so modified by its cause, or by the condition of system, as to be peculiarly disposed to run into gangrene ; and thus modified it deserves to be considered as a distinct va- riety, which might very properly be designated as gangrenous inflammation of the lungs, as we speak of gangrenous erysipelas, sore-mouth, &c. Two varieties of gangrene of the lungs are admitted by Laennec and most subsequent writers, in one of which the disease occupies a large portion of the lung, and is without definite boundary, in the other is of comparatively small extent, and has a precise outline. The former may be called diffused, and the latter circumscribed gangrene. The diffused is comparatively rare; only six out of sixty-eight cases, collected from various sources by M. Lau- rence, belonging to that variety. (Diet, de Med., xxvi. 48.) Anatomical Characters.—In the diffused gangrene, the greater portion of one lobe or of a whole lung is usually involved; the mortified and healthy portions being insensibly blended, or separated by inflamed parenchyma in the stage of congestion, or more rarely of hepatization. The lung is more moist and less cohesive than in health, has the density of the congestive stage of pneumonia, and presents dirty-whitish, greenish, brownish, and blackish hues, variously intermixed, and sometimes still further diversified by portions of a livid redness. Here and there parts of the lung are softened and completely disorganized, and exude when cut a greenish-gray and excessively putrid sanies. Among the lesions present are sometimes also diffused infiltration of blood, and small spots of sanguineous extravasation. The circumscribed gangrene generally occupies only a small portion of the lung, but is sometimes very extensive. In either case, it is characterized by having a definite boundary. Three stages are distinguished by Laennec ; the first, that of recent mortification, the second, that of deliquescence or break- ing down of the tissue, the third, that of a cavity or abscess. These stages present the following characters. In the first, the mortified portion is of a black or greenish-black colour, of a firmer and denser consistence but moister than in health, and of an offensive odour. In the second, the slough has either been softened, and converted into a greenish-gray, sometimes bloody, and ex- cessively fetid pasty matter, or much more rarely has been separated from the pulmonary tissue, and lies unconnected. In the third, the putrid col- luvies has been discharged through the bronchial tubes, and a cavity exists, sometimes traversed by blood-vessels which have escaped destruction, and generally containing a purulent, or blackish, sanious, and extremely offensive matter, secreted by the walls of the cavity, and sometimes blood proceeding from the open mouths of divided vessels. Around the cavity is a portion of inflamed lung, seldom more than an inch in thickness, and in the stage usually of hepatization. A newly organized secreting membrane generally lines the cavity, but sometimes no such membrane exists, and the walls consist of the inflamed pulmonary tissue. They are in some instances firm, dense, and dry, in others soft and fungous. Instead of opening into the bronchia, the cavity sometimes forms a com- munication with the pleura, into which its contents are discharged. In other instances, it communicates with the bronchia and pleura at the same time. In both cases, pleurisy and pneumothorax are produced • the air in the former being derived from the decomposition of the disorganized tissue of the lung. Occasionally the layers of the pleura are consolidated by adhe- sion, and the matter makes its way into the cellular structure beneath the skin. A case is recorded in which a large portion of mortified lun«- escaped through an abscess formed in the walls of the chest beneath the mamma and the patient ultimately recovered. (Lond. Med. Times and Gaz iv 578 ^ Besides the form of gangrene above described, this condition is sometimes found in the walls of abscesses, or of tuberculous cavities. CLASS III.] GANGRENE OF THE LUNGS. 33 Symptoms.—In the diffused gangrene, great prostration takes place at the commencement, with much oppression, a small, frequent, and feeble pulse, and a copious fetid greenish or dark bloody expectoration. But the patient soon loses the power of throwing off the matter, which accumulates in the lungs, and produces suffocation. In the circumscribed variety, a great diver- sity of symptoms precedes those which indicate the existence of gangrene. Usually there are some signs of inflammation; but a degree of prostration and anxiety is exhibited, altogether disproportionate to the extent of local disease, as indicated by the symptoms, or by physical exploration. The patient ex- pectorates a rather opaque mucus, and sometimes blood. But nothing char- acteristic of the affection is perceived, until the matter coughed up begins to have a putrid smell. The cavity has now opened into the bronchia; and, if the ear be applied, a gurgling sound, or cavernous respiration and pectoriloquy will be heard, according as the cavity contains liquid matter or is empty. These physical signs, connected with the excessive fetor of the breath, and the character of the expectoration which now takes place, are sufficiently dis- tinctive of the affection. The matter discharged is purulent or sanious, of a greenish, yellowish-brown, or ash-gray colour, and intolerably fetid. Accord- ing to Dr. Stokes, the breath may not be offensive, while the sputa are very much so; and Rilliet and Barthez state that, out of sixteen cases in children, five only were accompanied with a gangrenous odour of the breath, and three others with a simply fetid odour. Blood is frequently expectorated, and sometimes disorganized portions of the pulmonary tissue. Pain of the most violent character occasionally attends the progress of the complaint. The patient often sinks rapidly, and dies in the second or beginning of the third stage. Sometimes he is cut off suddenly, by an attack of haemoptysis. But occasionally the first shock is survived, and the disease runs on for weeks or months. In this case, the expectoration becomes quite purulent, though still extremely offensive, and hectic fever sets in, with night sweats, great debility and emaciation, and all the obvious symptoms of pulmonary consumption, under which the patient at length sinks exhausted. The termination, how- ever, is not always unfavourable. After a severe struggle, the system some- times rallies, the matter discharged gradually diminishes in quantity, becomes mucous instead of purulent, and ceases to be offensive ; the hectic symptoms disappear, and the patient is restored to perfect health. From the researches of Laurence, it appears that, out of sixty-eight cases recorded by various authors, eight terminated favourably. Valleix, however, upon analyzing the reported cases of cure, finds that they are very defective in precise details. The offensive odour and purulent expectoration are not alone sufficient evi- dences of gangrene, without the signs of a cavity. Cases have occurred pre- senting the two former symptoms, which, after death, have exhibited no appearance of mortification; though Laennec observes that, in two instances of the kind which he had seen, there was an unusually strong tendency to putre- faction in the body generally. It is very possible also, as already stated, that gangrene in the lungs may exist without evincing itself by fetor of the breath. An example of this we have in cases which terminate in death, before the gangrenous cavity has communicated with the bronchia. But we have no means of certainly ascertaining the existence of this condition during life. It may be suspected when great prostration comes on, along with evidences of a moderate extent of pulmonary inflammation, and without any general typhoid tendency. Gangrene, supervening upon tuberculous vomica?, may be known by the antecedent symptoms. Should the signs of a cavity have been presented before the gangrenous odour of the breath, and without the marks of pneumothorax, it may be taken for granted that either an inflammatory or tuberculous abscess preceded the occurrence of gangrene. Rilliet and Barthez 34 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART look upon expectoration of blood as one of the most conclusive signs of gan- grene in children, having observed this phenomenon in six out ot sixteen cases; a very large proportion, when the rarity of pulmonary hemorrhage in children is considered. , . . Causes.—These have not been well ascertained. The diffused variety is said sometimes to be produced by exposure to deleterious vapours, as when persons die from descending into old privies. Whatever greatly debilitates the system, and depraves the blood, may act as a predisposing cause. Hence, the affection is apt to occur in the intemperate, and those exhausted by de- pressing diseases. Dr. Fischel, of Prague, found it peculiarly prevalent among the insane, having noticed it in more than seven per cent of his autopsies among that class of patients. (See Med. Exam., N. S.,vi. 334.) There is reason to think that it occasionally depends upon the obstruction of one of the branches of the pulmonary artery by a fibrinous clot, either formed in the vessel, or carried thither from the heart. It is said sometimes to have followed pulmonary apoplexy. According to Dr. Stokes it may be induced by tumours pressing on the nutrient vessels and nerves of the lungs. (Dub. Quart. Journ. of Med. Sci., ix. 1.) It attacks preferably persons in middle life. The very young and very old are rarely affected. Treatment.—This must be directed chiefly to the support of the general strength, until the diseased lung shall have gone through the requisite pro- cess for throwing off the slough, and repairing the consequent loss of sub- stance. At the same time, it is important to counteract the morbid tendency of system by improving the quality of the blood. Both of these indications are met by the use of tonics and stimulants, and a generous diet. It is ob- vious that the degree of stimulation must be proportioned to the apparent exigencies of the case. It is not altogether incompatible with this plan, that a little blood should be taken by cups from the neighbourhood of the affected part, when the pain and other evidences of inflammation are considerable. A depraved blood may be quite capable of supporting the inflammatory pro- cess, even more so than the same fluid properly constituted. We may, there- fore, very properly attempt to produce good blood by nutritious food, and a degree of stimulus necessary at once to a proper assimilation of that food, and the support of the nervous power, while we abstract a certain quantity of the diseased fluid. But experience has shown that depletion must be used very cautiously in such cases. Carbonate of ammonia, wine, and even ardent spirit may be necessary when the debility is great; and these should be con- joined with opium or camphor, or both. Bark or quinia is also an excellent adjuvant, in order to give a more permanent support. When the case runs on to suppuration and hectic, the mineral acids, and especially the nitro- muriatic, are appropriate remedies. In this stage, sulphate of quinia, or in- fusion of wild cherry bark should also be given freely; and malt liquors are perhaps preferable to the more concentrated forms of alcohol. Chloride of soda, or creasote may be used internally, and chlorine gas, as it issues from moistened chloride of lime, may be inhaled with the air of the apartment. The gas is useful also by sweetening the air. Dr. Probart, of England, has met with great success from the use of chlorate of soda and common salt, which he was induced to give originally from discovering that a patient', affected, with the disease, had abstained from the use of salt for five years! (Trans, of the Prov. Med. and Surg. Assoc, xvii. 351.) Professor Skoda has found inhalation of the vapour of oil of turpentine successful. He pours the oil on boiling water, and causes the patient to inhale the vapour for fifteen minutes every two hours, using sulphate of quinia at the same time (See Lond. Med. Times and Gaz., April, 1854, p. 382.) The cough and nervous irritation should, throughout the disease, be allayed by opium, hyoscyamus CLASS III.] PLEURISY. 35 lactucarium, or one of the other narcotics. The diet should be at once easy of digestion and highly nutritious. The farinaceous substances, fresh fruits, milk, oysters, soft boiled eggs, soup, and the lighter meats, should be employed. Article III INFLAMMATION OF THE PLEURA, or PLEURISY. Syn.—Pleuritis. This is one of the most frequent of the inflammatory diseases. There is reason to believe that it often occurs without being recognized, or perhaps even attracting serious attention; as, in most cases of post-mortem examina- tion, no matter what may have been the cause of death, adhesions of the pleura are found, which must have resulted from inflammation of that mem- brane at some period more or less remote. In treating of this disease, as in the case of pneumonia, it will be most convenient to notice first its anatomi- cal characters ; because a knowledge of these is necessary to a proper appre- ciation of its signs. The pleura, being less complex in structure than the pulmonary parenchyma, offers less diversity in its inflammatory affections. It will be sufficient, for practical purposes, to treat of these under the two varieties of acute and chronic pleurisy. The disease may be associated with bilious fever or other form of bilious disorder, or with a typhoid state of sys- tem, and, in such cases, may be denominated bilious and typhoid pleurisy; but these are very frequently complicated with pneumonia, and all that is peculiar in them, as regards either character or treatment, may be sufficiently learned by referring to the account of the latter disease similarly modified. (See vol. ii., pages 18 and 29.) The inflammation may occupy both pleurae, or may be confined to one; but the former event is comparatively very rare, unless where the disease is associated with phthisis. The right side is more frequently affected than the left. Sometimes the whole membrane, and some- times only a part of it is involved. Anatomical Characters. Acute Pleurisy.—The first observable deviation from the healthy state is redness of the membrane, which, however, is dependent on the injection of the subserous blood-vessels rather than inherent in the proper serous tissue. This is in most cases speedily followed by increased secretion. The product is either concrete, or liquid, or both. Sometimes a serous fluid is poured out by the inflamed vessels, which are relieved by this depletion, and the surface of the membrane remains smooth. On the other hand, an exudation occa- sionally takes place, which, becoming concrete immediately after elimination, adheres in the form of false membrane to the surface of the pleura, and is attended with no liquid, or with a quantity too small to be appreciated. But more frequently the two forms of extravasation are associated, if not at the beginning of the disease, yet very soon afterwards. At first the coating of concrete matter is very thin and soft, and over a great portion of the lung is scarcely visible, being rendered sensible only by scraping it from the surface. It afterwards becomes thicker, and has a gray- ish, grayish-white, or slightly reddish hue; but is still soft, paste-like, and easily detached. I have, however, seen it almost black, probably in conse- quence of the simultaneous deposition of melanotic matter. Somewhat later, it has acquired a firmer consistence, and become more adherent. Its surface is usually somewhat rough, from the inequality of its deposition, as well as 36 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART from the friction of the opposite portions of membrane, though in some in- stances it is nearly smooth. Its extent corresponds with that of the lnnam- mation, and it sometimes covers the whole of one pleura, though not always equably. It is of a fibrinous nature, and is susceptible of organization ex- hibiting first red points, then red lines ramifying here and there, and at length forming a close vascular connection with the pleura. At first there is little liquid along with this concrete substance; but the quantity gradually increases, and sometimes becomes very great, varying from a few ounces to several pints Occasionally it is traversed by filaments or bands of the plas- tic matter, running between the costal pleura and that of the lung. W hen copious, it fills up'the cavity of the pleura, and, in some rare cases, has been known, in the course of a few days, largely to distend the chest, and by its pressure to displace very considerably the neighbouring viscera, whether of the thorax or abdomen. But it is more frequently in the protracted or chronic cases, that these results take place; and they will be more particularly noticed hereafter. In acute pleurisy, the distension is not often very striking. In relation to the character of the liquid, it is usually a yellowish, limpid, or slightly clouded serum, with flocculi of concrete matter floating in it Often, however, it is more turbid, like whey; sometimes is sero-purulent, sometimes purely pus, and occasionally bloody, with or without coagula. In ordinary cases it has little or no odour. It is usually free in the pleural cavity, changing its position with the movements of the patient; but it is sometimes limited and confined by old or recent adhesions of the pleura. The lung is compressed by the fluid, and forced from its ordinary position, generally towards the mediastinum or spinal fossa. The degree to which it is compressed and displaced depends upon the quantity of the liquid; and, when this is very great, it is sometimes reduced to a sort of flattened cake, scarcely larger than the hand, which is confined to the upper and back part of the chest. This, however, is more common in chronic than acute pleurisy. The air-cells, though compressed, do not in recent cases contract adhesions, and may be readily expanded by the insufflation of the lungs. During these changes, the proper serous membrane is not thickened or materially softened; and, if it sometimes appears swollen, this is owing to the injection or infiltration of the cellular tissue beneath it, or to the superposi- tion of false membrane. It may sometimes be peeled off from the lung or chest more easily than in health. It almost always happens that, when a portion of the pleura is coated with concrete exudation, that opposite to and in contact with it is similarly affected. Sometimes a small portion of the sur- face of the lung is gangrenous, in which case, the fluid of the cavity, as well as the false membrane, has an extremely offensive odour. Occasionally the pleurisy has been caused by the opening of a tuberculous or gangrenous cavity of the lung, communicating with the bronchia, into the pleural cavity, which thus contains air along with purulent fluid. (See Pneumothorax.) In cases which terminate favourably, the effused liquid is gradually ab- sorbed, and, if no false membrane has been formed, the parts are restored without change to their original condition. But this is probably a compara- tively rare result. More commonly the opposite surfaces unite, in conse- quence of the adhesion and organization of the coagulable lymph with which they were coated. When no liquid exists in the cavity to prevent the con- tact of these surfaces, the union often takes place in a very short time But when liquid is present, it must be removed by absorption before such a union can be effected, and more time is of course necessary for the cure. The whole of the inflamed surfaces do not unite at the same time; but those parts first which first come in contact, and afterwards other parts successively as the fluid undergoes absorption. Occasionally, portions of the fluid are retained CLASS III.] PLEURISY. 37 here and there in the meshes of the false membrane. The changes do not end with the mere junction of the pleural surfaces. The organized lymph undergoes a vital process by which its superfluous parts are removed, and at length the connecting medium is reduced to a delicate tissue of cellular mem- brane. Sometimes the whole cavity of the pleura is thus abolished; in which case, the patient cannot be again attacked with pleurisy of the same side. In other instances, the adhesion is only partial; and sometimes filaments of cellu- lar membrane run from the pleura of the ribs to that of the lungs, having been formed, probably, during the plastic state of the exuded lymph, by the movement of the lung upon the wall of the chest during respiration, drawing it out into slender connecting bands. With the absorption of the liquid, the lung again expands; but, if the compression has continued long, the air-cells do not at first yield completely to the expanding force, and the lung conse- quently does not immediately recover its origiual dimensions. The walls of the chest are, under these circumstances, forced inward, and the contents of the abdomen upward, to supply the deficiency. But this rarely happens to any considerable extent in acute pleurisy; and, even when the chest is at first somewhat contracted, it in time usually resumes its former shape, in con- sequence of the recovered expansibility of the lung. In chronic pleurisy, the case is sometimes much otherwise. Occasionally, the lesions resulting from inflammation are confined to the interlobar, and diaphragmatic pleura. Chronic Pleurisy.—As this form of pleurisy is in general nothing more than a continuation of the acute, the same anatomical appearances are pre- sented, though somewhat modified by the influence of time. The false mem- branes are usually thicker, and often exhibit several layers of different con- sistence, those first deposited being firmest and adherent to the pleura, and the recent, softer and nearer the surface. The liquid, though sometimes limpid, is less frequently so than in the acute disease. It is generally turbid with abundance of fibrinous flocculi, or is quite purulent, and not unfre- quently has a disagreeable odour. Sometimes it is of a consistence like that of thin jelly. The quantity of the fluid is usually much greater than in the acute form. It is sometimes enormous, producing great dilatation of the thorax, and compressing the lung into a very small space along the spine and mediastinum, in the upper portion of the chest. In consequence of the length of time during which it is thus compressed, the lung changes its tex- ture, ceases to be crepitant, and assumes an appearance somewhat similar to that of the same organ in the foetus. It is scarcely penetrated by air or blood; and is sometimes bound down in its confined position by organized false membrane, so that it could not expand, even were its cells not oblite- rated. The mediastinum, heart, and upper abdominal viscera are displaced much more than in acute pleurisy. In some instances, instead of this great distension, the lung is here and there adherent to the wall of the chest, forming one or more sacs in which fluid is contained; and bands of false membrane frequently pass from one part of the pleura to another. When the effusion is not purulent, and the disease is not complicated, absorption of the liquid, under proper treatment, generally takes place in the end, and the case advances towards a cure. But, as the lung cannot now readily expand by the admission of air, the walls of the chest, the mediasti- num, and the diaphragm are forced by the atmospheric pressure into the space before occupied by the liquid. A portion of the space is also filled up with false membrane, which is sometimes very thick, so much so that it cannot be converted wholly into cellular tissue, as in acute pleurisy, and therefore assumes a fibrous consistence, and occasionally becomes the seat of various morbid processes, resulting in the production of cartilaginous or bony plates, tubercles, abscesses, hemorrhagic effusions, and even gangrene. In certain 38 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART rare cases, the ribs themselves undergo a peculiar change, their internal sur- face being replaced by a new bony formation, which gives them a prismatic or triangular form. (Parise, Arch. Gen., \eser., xxi. 320 and 478.) Some- times the walls of the chest are forced inward contrary to their elasticity so that, when a puncture is made from without, the air rushes m to supply the vacuity produced by their resilience. In some instances, effusion goes on as rapidly as absorption, and the liquid accumulation remains for a great length of time. This is especially the case in empyema, or collections of pus in the cavity of the pleura. Sometimes the pus makes its way into the substance of the lung, and a fistulous communi- cation is formed between the bronchia and the pleural cavity, through which pus is discharged and air admitted. In other instances the liquid takes an external direction, and by means of ulceration escapes into the cellular tissue without the chest, and, travelling occasionally for considerable distances, pro- duces subcutaneous abscesses in various parts of the chest, which ultimately open, unless life is previously worn out. In thus travelling, the pus has been known to occasion caries of the ribs and vertebra?. Sometimes the purulent collection is found to be connected with a tuberculous vomica. Pleuro-pneumonia.—It has been stated, under pneumonia, that this dis- ease is very frequently attended with inflammation of that portion of the pleura which immediately covers the inflamed part of the lung. Strictly speaking, the name of pleuro-pneumonia might be conferred upon it under such circumstances; but, as it is seldom attended with liquid effusion, and the pleurisy does not extend beyond the hepatized tissue, the cases are not usually considered otherwise than as simple pneumonia. To constitute a case of pleuro-pneumonia, in the sense in which it is here considered, there must be an extension of the pleuritic inflammation beyond the hepatized structure; or at least such an amount of it as to produce observable effusion. Such cases are not very uncommon. Out of 247 patients with pneumonia who came under the notice of M. Grisolle, 31 exhibited signs during life of more or less pleuritic effusion, or about one in eight. The liquid, unless confined by old adhesions, is found in the most dependent part of the cavity, no matter what part of the lung may be inflamed. The appearances are those already described as characterizing the two diseases, with this dif- ference, that, in consequence of the consolidation of the lung by inflamma- tion, it is less compressed, and for the same reason the quantity of effusion is less than in simple pleurisy. A peculiar condition of the lung was ob- served by Laennec in cases in which pneumonia had supervened upon copious pleuritic effusion, and was named by him caxnification, from its close resem- blance in appearance to muscle that has been beaten to render it tender. The affected portion of the lung is more compressed than in ordinary pneu- monia; the air-cells are obliterated; the granular appearance is wholly wanting; the colour is redder; and the texture is more flabby and less solid. Resolution is effected more slowly than in hepatization, but the part seldom advances to suppuration, probably because the inflammation is moderated by the pressure. Dr. Williams says that this form of pneumonia sometimes proves a cause of dilatation of the bronchia, at the period of convalescence. The compressed air-cells do not yield readily to the expanding force of the air, when the liquid effusion has been absorbed, and the bronchia are dilated to supply the deficiency. Symptoms, Course, &c. Acute Pleurisy.—This disease commences usually with a febrile chill and sharp pain in the side; and the characteristic symptoms subsequently are pain in the side, cough, short and quick breathing, and fever. Each of these requires a more particular notice. CLASS III.] PLEURISY. 39 The pain may come on before the chill, or along with it, or a short time after it. In character, it is severe and sharp, as if from the thrust of a sharp instrument, and hence it is frequently designated by the term stitch in the side. It is usually confined to one spot, most commonly somewhere in the mammary region; though it is occasionally felt elsewhere, as, for example, near the lower margin of the chest, when the pleura of the diaphragm is in- flamed. The reason of this concentration of the pain is probably that, when nervous trunks are inflamed, the suffering is referred to the part in which the nerves are distributed rather than to the real seat of disease ; and, as the nerves coming off from the spinal marrow are distributed over the anterior part of the chest, the inflammation affecting them in their course makes itself felt in the latter position. Sometimes, however, it is diffused over the side, and is then less severe. It is increased by inspiration, cough, pressure in the intercostal spaces, and generally by lying upon the affected side, proba- bly in consequence of the weight of the lung bearing upon the inflamed membrane. It may often be suspended by holding the breath. Sometimes it is observed to increase and diminish along with the exacerbations and re- missions of the fever. Occasionally it is attended with a burning sensation. It generally moderates considerably in the course of one, two, or three days, as the effusion increases; and the difficulty of lying on the affected side is now greatly diminished or ceases. In some cases, it is scarcely felt from the begin- ning, unless in consequence of full inspiration or coughing, and, in others, is quite wanting, or felt only as soreness when pressure is made between the ribs. The cough is at first short and dry, or attended with a slight mucous or frothy expectoration, and may remain so throughout the complaint. Fre- quently, however, in consequence of the existence of some bronchial inflam- mation, the discharge is more copious; and occasionally it is streaked with blood. In some cases, it is exceedingly painful; and the patient often en- deavours to restrain it, though not always successfully. It is, however, much influenced by these efforts, sounding as if interrupted and unfinished, in con- sequence of the partial contraction of the muscles concerned in it. Cases now and then occur in which it is wholly wanting; and, as pain is also sometimes wanting at the same time, the disease has, under these circumstances, been designated by some writers as latent pleurisy. The breathing is almost always more or less difficult or embarrassed. In consequence of the pain produced by a full expansion of the lungs, the inspi- ration stops short before it is completed. The patient is said to have a catch in his breath. As less air is thus taken in at one inspiration, the deficiency must be supplied by a more frequent repetition; and hence the breathing is not only short but rapid, though the patient is often scarcely aware of the change. The dyspnoea, instead of diminishing with the pain, often increases as the disease advances; but it now arises from the compression of the lung by the effused fluid. The function of one lung is always cramped, sometimes entirely suspended ; and the other lung is scarcely adequate to the increased duty. The patient, therefore, feels a want of breath, which is sometimes dis- tressing. This is especially the case when the effusion is at once sudden and copious. When it is gradual, the system accustoms itself to the new condi- tion of the respiratory organs, and the want is less felt. The dyspnoea also differs greatly in different individuals, according to their constitutional pecu- liarities. It is often the most prominent symptom in the latter stages. The decubitus is generally at first on the sound side; but, when the acute pain has subsided, and considerable effusion has taken place, this becomes difficult in consequence of the dyspnoea excited, partly by the interference of the weight of the body with the movements of the ribs, but chiefly by the pressure of the contents of the chest upon the sound lung, the only one now 40 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART capable of performing the office of respiration. Hence the patient, in this stage, generally lies on the back, or on the diseased side, or in a position intermediate between the two. The fever is usually considerable, and attended with all the characteristic phenomena of this form of disease, such as a chill, followed by heat ot skin, frequent pulse, loss of appetite, furred tongue, scanty urine, &c. _ The pulse is generally frequent, full, and tense ; but sometimes, when the pain is exceed- ingly violent, it is contracted. Occasionally, though very rarely, there is de- lirium. The fever often undergoes a daily remission and exacerbation, the former occurring in the morning, the latter towards evening. It usually moderates considerably in four or five days. The physical signs are often of the highest importance in forming a correct diagnosis. The motion of the affected side is observably less than that of the sound side. At the commencement of the attack, before effusion has taken place, percussion is quite clear, and no other auscultatory sign is given than some diminution of the respiratory murmur, consequent upon the deficient expansion of the lung, which is rendered more evident by a comparison of the two sides. But, as this depends merely upon the pain of inspiration, it is obvious that the same result must take place in all other cases in which the pain is equally acute, and especially in pleurodynia, so that the sign is of no great value. But, very soon after the onset of the disease, when the concrete exudation has had time to cover in some degree the surface of the membrane, a peculiar and characteristic sound may generally be heard, especially in the middle portions of the chest. This is the friction sound, produced by the rubbing of the opposite roughened surfaces against each other. It has been thought by some that the sound may be developed even before the commence- ment of exudation, by the rubbing together of the pleuritic surfaces, rendered dry by the commencing inflammation, or unequal by the enlarged vessels. The grating movement which gives rise to the sound, may be felt by the hand applied flatly to the side. But, as the conditions upon which the sound de- pends are usually of short continuance, the sign must also be evanescent. It must vanish whenever union of the opposite surfaces takes place, or as soon as they are separated by the liquid effusion. Though, from its uncertain occurrence and fugitive character, it cannot be always depended on, yet, when perceived, it is a valuable sign, especially in cases unattended with liquid effusion, such as have sometimes been called dry pleurisy. But the most decisive signs are those afforded after liquid effusion has com- menced. A diminution of the healthy resonance upon percussion may very soon be perceived by a comparison of the opposite sides; and the dulness goes on increasing with the increase of the effusion, until at length it often amounts to perfect flatness. At first, it is observed in the most°dependent parts of the chest, and rises higher and higher with the advance of the dis- ease. It usually varies with the position of the patient, following, of course, the position of the liquid, which necessarily gravitates to the most dependent part, while the lung, which is lighter has a tendency to float above it The only exceptions to this rule are the cases in which the lung, and consequently the liquid, are confined by adhesions, and those in which the whole cavity is filled. In the latter, flatness is universal over the affected side of the chest The last part to lose its resonance is generally the subclavicular region In percussing the left side in pleuritic effusion, allowance must be made for the resonance of the stomach, which, when that organ is full of air often modifies the sound for a considerable distance up the chest. Sometimes, when a small portion of the lung is in contact with the walls of the chest, while all the rest is separated from them by the effusion, a tympanitic sound is yielded on cussion, which might be mistaken as the sign of pneumothorax or a l" CLASS III.] PLEURISY. 41 monary cavity. (Notta, Arch. Gen. 4e ser., xxii. 437.) Skoda states that, " when the lower portion of the lung is entirely compressed by pleuritic effu- sion and the upper portion reduced in volume, the percussion sound at the up- per part of the thorax is distinctly tympanitic." This phenomenon, which has long been noticed as an occasional event, is ascribed by Dr. Williams to the increased conducting power of the lung, which causes the vibratory move- ments excited in the trachea and bronchial tubes to reach the ear. The respiratory murmur, somewhat enfeebled by the defective movement of the lung from pain, is still more so when liquid effusion takes place, and goes on diminishing with the increase of effusion, and of the consequent com- pression of the lung, until it entirely ceases in those cases in which the liquid is abundant. In parts in which the lung is still in contact with the chest, the healthy murmur is often superseded by bronchial respiration, dependent upon the compression of the air-cells, which thus more readily convey the vibra- tions of the bronchia to the surface. This sound is usually greatest near the root of the lung, and diminishes as we recede from that part, though it often extends more or less over the whole side of the chest. According to Behier, cavernous and even amphoric respiration, and amphoric resonance of the voice are sometimes heard under similar circumstances. (Arch. Gen. Aout, 1854, p. 129.) But, when the effusion is very abundant, these sounds are also quite lost, except in the regions between the scapulas, and sometimes even there. On the opposite side of the chest, the respiration is louder than is usual in health, and often becomes puerile. The vocal resonance, increased at first while the exudation is plastic, be- comes at a somewhat more advanced stage of the disease quite peculiar. When a moderate effusion has taken place, and a thin stratum of liquid inter- venes between the lung and side of the chest, the tremulous, quivering, or bleating sound of the voice denominated asgophony is heard. The bronchial sound, conveyed outward by the compressed parenchyma, is modified as it passes through the trembling liquid, and acquires the striking character alluded to before it reaches the ear. The modified sound is heard especially between the third and sixth ribs, in the interscapular regions, and between the scapula and the mamma. It is most obvious in women and children, in consequence of the higher tone of their voice. Over the larger bronchia, near the spine, for example, it is often mingled with the bronchial resonance, and the sound acquires a peculiar complex character. As the effusion increases aegophony diminishes, and at length ceases altogether. Dr. Williams is of opinion that little sound of the voice is transmitted, when the stratum of intervening liquid exceeds an inch in thickness, except over the larger tubes. When the quan- tity of liquid is very great, no vocal resonance is heard, unless in a narrow space upon the side of the spine. These results are of course modified, when the lung adheres more or less extensively to the sides of the chest. In such cases, the bronchial resonance is usually loud and distinct at the adhering parts, in consequence of the compression of the air-cells. When the extent of adhesion is small, the compressed lung forms a column, or kind of internal stethoscope, for conveying the sound to the ear. The vibration of the walls of the chest is affected similarly with the sound of the voice, being somewhat increased while the effusion is plastic, gradually diminished with the increase of liquid, and suppressed when the intervening effusion is copious, but still distinctly observable where the lung adheres. Hence, when one hand is placed upon the sound side, and the other upon the diseased one, and the patient is told to speak, little or no movement is felt in the latter, with the exception just mentioned ; while in the former the thrill is distinct. Besides the above signs, there are others derived from the movements and shape of the chest; and the relative position of neighbouring organs. Thus, vol. n. 4 42 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART the affected side may sometimes be observed to be quiescent, while the other moves in respiration. When the effusion is great, the chest may be vjslbly distended, and, if measured by a tape, in the direction of a line around the body at the scrobiculus cordis, will be found to be larger on the diseased than the sound side. This, however, is not common, to any great extent, in acute pleurisy. Any difference that may exist will be most readily detected by making the measurement at the moment of full expiration, as it is then greatest, in consequence of the non-contraction of the distended side. But the fact must always be taken into account, that the right side in health ordinarily measures from a quarter to half an inch more than the left. The displacement of the heart, liver, &c, is much more frequently to be observed in the chronic than the acute form of the disease. The course of acute pleurisy is variable and uncertain. There is reason to believe that, if the disease is vigorously treated by depletion at the begin- ning, it may often be arrested almost at the threshold, before it has exhibited any other signs of its existence than pain, decubitus on the sound side, a little cough, and a chill followed by fever. Exudation not having yet taken place, the physical signs are wanting. Should a catarrhal cough have preceded the attack, or should no cough exist, as sometimes happens, there are no means by which the disease could be certainly distinguished from febrile pleuro- dynia, which has the general symptoms above mentioned, and the same dimi- nution of the respiratory murmur, arising from the restrained movements of the chest. Hence the doubt, in these cases, whether it was pleurisy or rheumatism of the intercostals that was cured. In other cases, along with the general symptoms mentioned, there is the friction sound upon auscultation, which is sufficiently decisive as to the nature of the complaint. The effusion of coagulable lymph has probably taken place, and a longer period is necessary for the cure. Sometimes, however, the morbid phenomena wholly disappear in from three to five days, leaving no unhealthy sound in the chest. In such cases, the opposite surfaces of the pleura have united, and the friction sound ceases because the surfaces do not move on each other. In a third set of cases, the signs of liquid effusion are perceived sometimes on the first day, sometimes not until the second, third, or even fourth day, when the severe pain abates. In these cases, the friction sound, if observed at all, is soon followed by feebleness and gradual cessation of the respiratory murmur, by bronchial respiration, aegophony, and dulness on percussion. Should the progress of the disease be now arrested, the general symptoms abate, and the morbid sounds gradually give way to the healthy, as the fluid is absorbed. The friction sound is sometimes heard for a brief period after absorption has taken place, and before union between the opposite surfaces has been effected. The disease is usually cured in five or seven days. But, instead of the favourable turn at the period above alluded to, there is often a continued advance of the disease; the effusion g"oes on increasing • aegophony ceases ; the bronchial respiration becomes more and more distant, until this also ceases, or is but faintly heard; flatness upon percussion prevails to a greater or less extent over the chest, generally varying with the position of the patient; the dimensions of the affected side of the chest are sometimes even visibly enlarged; and the healthy vibratory movement of its walls in speaking is much lessened or quite wanting, as may be ascertained by apply- ing the hand to the surface. The pain has nearly ceased, and the fever moderated; but the dyspnoea is often great, and the patient is unable to lie upon the sound side. The disease, in this form, continues for a very variable period. Sometimes recovery takes place in two or three weeks, sometimes not for months; and the complaint not unfrequently assumes the chronic CLASS III.] PLEURISY. 43 form. Should it terminate favourably, the fever, cough, and dyspnoea gra- dually disappear, the dulness on percussion diminishes, aegophony occasion- ally returns in the progress of the absorption, the respiratory murmur is again heard, the friction sound maybe noticed for two or three days or more and health is at length re-established. The clearness on percussion, and the healthy respiratory sound, return usually first in the upper part of the chest and afterwards in the lower. As the lung has not been sufficiently long com- pressed to have lost its expansibility, it is generally dilated as the fluid is absorbed; but sometimes, either from its own altered state, or because bound down by false membrane, it does not completely resume its original dimen- sions, and a degree of contraction in the diseased side of the chest ensues which, however, generally diminishes, or disappears with time. The favour- able termination is often attended or preceded by certain critical affections as urinary sediment, copious perspiration, diarrhoea, eruptive affections of the lips and skin, phlegmonous tumours, and rheumatic pains. After convales- cence, the patient not unfrequently complains of a stitch in the side upon taking a long breath ; and sometimes a degree of cough, dyspnoea, and fre- quency of pulse remains for a considerable time. I have known the friction sound, after being first noticed at the commence- ment of the disease, to continue uninterruptedly for a long time, gradually becoming coarser with the continuance of the disease. In one case of chronic pleurisy, it continued for several weeks. This may be ascribed to the exuda- tion of a fibrinous matter imperfectly coagulable, with too little adhesiveness to serve as a bond of union between the opposite pleural surfaces, and in- sufficient vital force to undergo organization. Other diversities in the disease require notice. When the inflammation occupies both pleurae, the pain may be felt in both sides, or one only, or may be absent; the dyspnoea is much greater than in the ordinary variety; and the fever and other attendant symptoms are more severe. There is no longer the advantage of a comparison of the two sides in auscultation or per- cussion. Nevertheless, the signs are generally sufficiently evident. Double pleurisy is much more dangerous than that which is confined to one pleura. The inflammation in pleurisy is often partial; being limited by previous adhesions, or prevented from spreading over the whole membrane by some unknown cause. Thus, it may occupy only the costal and the opposite pul- monary pleura, in which case the symptoms are all those above enumerated. It seldom if ever happens that one of these surfaces is inflamed, for any length of time, without involving the opposite surface, when in contact with it. The pleura of the diaphragm is sometimes the exclusive seat of the dis- ease. In such cases, the pain is usually along the lower border of the chest, or in the hypochondriac region, and is much increased by vomiting, eructa- tion, inspiration, and sometimes by pressure on the abdomen. M. Gueneau de Mussy has pointed out, as extremely sensitive to pressure, a spot situated one or two fingers' breadth from the linea alba, on the level of the bony part of the tenth rib. Not only is extreme pain felt when this point is slightly pressed, but there is at the same time experienced a sudden increase of the dyspnoea, so great as apparently to threaten suffocation (Arch. Gen., Sept., 1853, p. 274.) The patient breathes with the ribs rather than the diaphragm. The difficulty of respiration is sometimes so great as to render the erect pos- ture necessary. Occasionally the pleurisy is associated, in these cases, with nausea and vomiting, and symptoms of jaundice, probably in consequence of the extension of irritation from the pleura to the subjacent organs. In fatal cases, delirium often precedes death for some days. Again, the inflammation may be seated in the mediastinum, or in the fissures between the lobes of the lungs; but there is scarcely a sign by which it could be certainly distin- 44 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART guished in these situations. The position of the pain, and the absence peculiar signs of other diseases, might lead to probable inferences, ycoa- sionally, abscesses have been found in these situations after death; ana *»uuueu discharges of pus by expectoration sometimes occur, which may oe conjec- turally ascribed to the opening of such abscesses into the broncnia.^ Pleurisy sometimes occurs, and runs its whole course, without pain, cougn, or observable dyspnoea, and without having attracted attention during lite These latent attacks usually take place in the progress or at the close ot other diseases, or in individuals previously much weakened, or cachectic. When acute pleurisy is about to terminate fatally, which very seldom hap- pens in the uncomplicated disease, if well treated, the effusion increases, the breathing becomes very greatly oppressed, the countenance assumes a pale hue and anxious expression, the pulse increases in frequency and at length becomes small and feeble, and the heart ceases to beat hi consequence of the imperfect performance of the respiratory function. In the advanced stages, death sometimes results from a gradual failure of the powers of the system, under the combined exhaustion from the discharge, and irritation from the diseased structure. In double pleurisy, according to Andral, a fatal issue may take place from the mere influence of the inflamed membrane, without any discoverable amount of fluid effusion. (Clinique Med., iv. 513.) Chronic Pleurisy.—This is, in most instances, a mere continuation of the acute, though sometimes apparently of the same lower grade of action from the beginning. When pleurisy is connected with other complaints of a chronic character, such, for example, as phthisis, it is apt to assume itself the chronic form; and, in very obstinate cases of the disease, which long resist the plans of treatment ordinarily most effective, there is ground for suspicion, that the obstinacy may be owing to some other existing, though possibly concealed organic affection. In this form of pleurisy there are occasionally sensations of acute pain, but more frequently of mere soreness, oppression, weight, or vague uneasi- ness. There is also in general more or less cough, which is sometimes short and dry, but sometimes also attended with even copious expectoration, which may be either mucous or purulent. In the latter case, the disease is usually complicated with chronic bronchitis. In some instances cough is wanting. The most prominent general symptom is dyspnoea, which is in some cases very distressing, in others scarcely observable unless in consequence of bodily exertion. It is usually less troublesome in chronic than in acute pleurisy from an equal amount of effusion, because in the former the accumulation is more gradual, and the respiratory organs adapt themselves in some measure to the new circumstances. The patient is often able to walk about, though in general pale, feeble, and more or less emaciated. Sometimes the face ap- pears slightly bloated, and the extremities somewhat edematous; and the oedema is said to be apt to appear on the chest and arm of the side affected. The circulation is in some instances little disturbed; but generally there is frequency of pulse, sometimes great frequency, with paroxysms of hectic fever, night sweats, and great emaciation. In such cases, there is reason to suspect the existence of pus in the pleural cavity, constituting empyema. The physical signs are usually conspicuous. The chest is considerably and sometimes enormously distended, bulging outwards usually in the lower por- tion upon the side affected, which measures more than the other side The intercostal spaces are widened, and, instead of being somewhat concave as in the healthy state, are either flat or convex. Sometimes fluctuation can be felt between the ribs, by placing the flat of the hand upon the side and striking quickly but gently with the finger one of the intercostal spaces ' The ribs do not move in respiration. The heart is sometimes displaced by the CLASS III.] PLEURISY. 45 pressure. If the effusion is on the right side, it may be found to pulsate on the left of the left nipple, or even in the axilla; if on the left, it may beat under or beyond the right side of the sternum, or in the epigastrium. The mediastinum is also displaced, and affords a dull, instead of the clear healthy sound, to percussion upon the sternum. The liver is sometimes depressed several inches below the margin of the false ribs, and the affection has in consequence been mistaken for chronic hepatitis. The spleen and neigh- bouring colon are also below their ordinary level in the abdomen. Percussion yields a perfectly flat sound over the distended part of the chest, and sometimes over the whole side affected, though this is compara- tively rare. Very frequently the limits of the flatness vary with the position of the patient, always, indeed, if liquid is present in any considerable quan- tity, and not confined by adhesions, or by fulness and distension of the whole pleural cavity. The respiratory murmur is wanting, there is no vocal reso- nance, and even bronchial respiration is but faintly if at all heard, in the dis- tended portion of the chest. But the above signs are sometimes modified by adhesions. In some places, the lung may adhere to the costal surface, in others, may be separated from it by effused liquid. In such cases, bronchial respiration and bronchophony may be heard distinctly in certain parts, and not in others. Sometimes the adhesions are in the lower portion of the chest, which may yield a clear sound on percussion, with the sounds also of respiration and the voice, while the upper parts present the ordinary signs of effusion. Again, the relative posi- tions of the adhesion and the effusion, and consequently of their characteristic signs, may be reversed. Occasionally the diaphragm or mediastinum may adhere to the lung, so that displacement of these parts may not be produced, or at least to the same extent as when no such adhesions exist. In the progress of chronic pleurisy, either absorption after a time predom- inates over effusion, and the liquid is partially or wholly removed; or the pleural cavity remains distended until the patient is worn out, or until the fluid is discharged by a natural or artificial outlet, independently of absorp- tion. In the former case, as the liquid is removed, and the sides of the chest and the lung are brought together, adhesion takes place, accompanied with contraction of the chest, resulting from the want of expansibility in the long compressed lung, or its restraint by false membrane, and its consequent in- ability to fill up the vacuity. The shrinking of the chest is not at first general. The upper part of the pleural cavity, being for the most part first freed from the liquid, the contraction will be first observed in the corresponding part of the chest, and it will gradually extend downward with the progress of ab- sorption. The contraction may be slight, so as to occasion no obvious de- formity, and not materially to interfere with the restored health. Sometimes, however, it is very great; so that the chest, after the completion of the pro- cess, scarcely exceeds one-half of its former capacity. The contraction of the false membranes, in the progress of their organization, may contribute to increase the effect, after all the liquid has been removed. The deformity in these cases is considerable. The shoulder is drawn down, the scapula is rela- tively more prominent and nearer the spine, the ribs are lower and lie more closely together, the liver encroaches upon the chest, and, if the right side be the one affected, the heart may sometimes be heard on the right of the sternum; reversing exactly the derangement previously occasioned by the effusion. More or less disorder of the general health attends this condition of the chest. The patient is affected with shortness of breath and palpita- tions, especially upon exertion, and continues liable to them for a long time, if not during life. But, if young, he may in a considerable degree surmount these disadvantages, in consequence of the gradual expansion of the lung, and 46 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. the conversion of the pseudomembranous products into distensible cellular tis- sue. During the continuance of the contraction, the sounds of respiration ana of percussion are usually somewhat imperfect, even though the liquid may have been wholly removed. When the effusion has been partial, and limited by firm adhesions, the chest cannot contract sufficiently to fall the emptied space, which is therefore occupied by air, by the neighbouring viscera thrust into it, or by the semi-solid residue of the absorbed fluid. (Williams.) In the instances in which absorption is not effected, the fluid may be of a serous character, or may be pus. In the latter case, the danger ot a latal result is the greatest, Large collections of pus in the pleural cavity are sel- dom if ever absorbed. The symptoms do not always enable us to discrimi- nate between these two conditions. When, however, the affection is very obstinate, and attended with hectic symptoms, the existence of proper empy- ema may be suspected. Nature occasionally attempts, and even accomplishes a cure of this affection. A communication is formed between the pleural cavity and the bronchia, and the pus escapes by expectoration. If not so abundant as to overwhelm the lungs, and produce suffocation, it may thus be discharged, and the patient may possibly reach health through a long and doubtful struggle. Sometimes, moreover, the pus makes its way externally, forming a soft, rounded, subcutaneous abscess upon the chest, which may ultimately open, and thus form a direct communication between the cavity of the pleura and the external air. Such an abscess may be recognized by the changes it undergoes in the act of breathing, being firm during expiration and soft during inspiration. In some instances, the tumour disappears under pressure, and by change of position, and reappears when these causes cease to act. By whichever outlet the pus escapes, air is apt to enter the cavity, and, by exciting putrefaction in the purulent matter, to occasion fresh inflam- mation, and thus increase the immediate danger. In all these cases, the result is very doubtful, and the patient not unfrequently perishes in the end. Sometimes death comes suddenly and unexpectedly; sometimes the patient is worn out by hectic, with diarrhoea, dropsical effusion, &c. Chronic pleurisy may terminate in a few months, or may run on for years. Its danger is much increased by complication with tuberculous, or other organic disease.* Pleuro-pneumonia.—In this there is a combination of the peculiar general symptoms of pneumonia and pleurisy, of which the viscid and rusty expec- toration is most characteristic of the former, and the sharp stitch in the side of the latter. The physical signs of the two affections are also to a greater or less degree combined in the case. The crepitation of pneumonia is gene- rally heard early in the disease, and, after being quite lost in consequence of * Prof. Landouzy, of Reims, has arrived at certain conclusions in relation to chronic pleurisy, which have considerable diagnostic and therapeutic value. 1. Bronchial and amphoric sounds, both of respiration and the voice are observable in a considerable proportion of cases of chronic pleurisy. They occur in cases attended with serous or purulent effusion, or with false membrane with or without effusion and may persist even after the liquid has been absorbed. They are owing not immediately either to the liquid or plastic matters in the pleural cavity, but to the pulmonary con- densation produced by them, and are formed in the large tubes. If, when the sounds cease, there is a return of the respiratory murmur, or of one of the bronchial rales a diminution of this condensation of the lungs is indicated. If, on the contrary there is under the same circumstances, an absence of the respiratory murmur and rales an in- crease of the condensation either by liquid or false membrane is shown to exist • the bronchial tubes themselves being now compressed so as to exclude the air If the ces- sation of the bronchial and amphoric sounds coincides with enlargement of the inter costal spaces and displacement of the viscera, the compression is known to be produced by liquid; if with shrinking of the thorax, false membrane without liquid is the com- pressing agent. H ia lIie Lom When these sounds are heard after the tapping of the chest, if unmixed with normal CLASS III.] PLEURISY. 47 the accumulation of liquid, sometimes returns when this is absorbed. The friction sound, aegophony, and flatness on percussion indicate the existence of pleurisy. Sometimes the two inflammations occupy different portions of the lungs, the pleurisy for example the lower, and the pneumonia the upper. In such cases, the peculiar signs of each affection are perceived in the part which it occupies. But more frequently both affections exist at the same time in the lower portion of the lung. Here we have a mixture of the peculiar signs of both. The crepitant rale may be heard at an early period, but is gradually lost as the liquid in the pleura accumulates, when flatness on per- cussion supervenes, with bronchial respiration, and, instead of pure aegophony, a mixture of this with bronchophony, constituting a sort of double voice, which has been compared to that heard in the performance of Punch. Chomel states that this complication was first noticed by himself. Sometimes no re- spiratory sound can be heard unless the patient draw a quick and full breath, as after coughing; and then the peculiar signs of pneumonia may be per- ceived. Occasionally, by changing the position of the patient, pneumonic sounds become evident, which were before covered by the liquid. Vocal re- sonance is said by Williams to be greater in pleuro-pneumonia than in either of its component affections separately; and, indeed, all the auscultatory sounds of pneumonia may be increased by pleuritic effusion, when not too copious. According to Laennec, pleuro-pneumonia is less dangerous, cseteris pari- bus, than either pleurisy or pneumonia. The compression of the lung by the pleuritic effusion he supposed to diminish the intensity of inflammation in its parenchyma; while, in consequence of the less yielding nature of the inflamed lung, it diminishes the space for effusion, and renders it more easy of ab- sorption by limiting its quantity. Cause. The most frequent cause of pleurisy, as of so many other inflammations, is exposure of the body to cold, especially when previously heated or perspiring. It is said that cold drinks, under similar circumstances, sometimes produce the disease. Other causes are mechanical injuries, the transfer of irritations from without, the sudden checking of habitual discharges, and the influence of various diseases. Among the most frequent of these are tubercles. They may occasion pleurisy either by a direct irritation from their contiguity to the membrane, or by the discharge of the matter of a vomica, through an ulcer- ated passage, into the pleural cavity. The latter result is not unfrequently prevented by the adhesions consequent upon the former. Tubercles in the or abnormal respiratory murmur, they indicate that the large bronchia alone are open; if mixed with the pure respiratory murmur, or with rales, they show that the lung is partially permeable. 2. JEgophony, like the amphoric voice, is a modification of bronchophony, and de- pends not on the effusion, but on a change of the lung produced by it; as it can be heard immediately after the evacuation of the liquid. 3. The tympanitic resonance on percussion of the summit of the lung, noticed by Skoda as occurring in some cases of pleuritic effusion, is heard in chronic pleurisy after the absorption of the liquid, showing that this sound also depends on a modifica- tion of the lung itself, and not on the presence of the liquid. 4. Recent false membranes may, at the end of two weeks from their production, have attained sufficient consistence to cause amphoric respiration. But, even when thus at- tended, they are not necessarily refractory, but, after paracentesis may quite disappear, bo as to leave no sign to auscultation. If they continue, however, they may form a fibrous, fibro-cartilaginous, or osteo-fibrous shell or case for the condensed lung, which will preclude it, ever after, from the performance of its functions. 5. If one lung cease to perform its functions, the duty is thrown upon the other, which therefore acts with an energy that endangers serious or fatal inflammation. The practical deduction from these conclusions will be stated in a future note. (Arch. Gen., Nov. 1856, p. 690, and Dec. 1856, p. 513.)—Note to the fifth edition. 48 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. membrane itself may also be the cause of the disease. Inflammation of the lungs is not unfrequently propagated to the pleura; and gangrenous abscesses in the parenchyma, or mortification upon the surface of the lung, sometimes give rise to pleurisy, the former by opening into its cavity, the latter by the contact of its putrescent products. Apoplexy of the lungs is said occasionally to produce it. Inflammation, ulceration, and abscesses of the walls of the chest, as well as cancerous or other malignant disease of the same parts, or of the lung itself, are not unfrequent causes of pleurisy. This affection has repeatedly been observed to follow operations for the removal of tumours from the breast and axilla. (Broca, Arch. Gen., ie ser., xxii. 395.) The disease is more frequent in men than in women, chiefly, in all proba- bility, because they are more exposed to its ordinary causes. It is common to all ages. The robust and vigorous, and persons of sanguine temperament, are said to be most liable to it; and the seasons in which it specially prevails are the winter and spring. Diagnosis. The only diseases with which pleurisy is peculiarly liable to be confounded are rheumatism of the intercostal muscles or pleurodynia, pericarditis, and pneumonia. In pleurodynia, the physical signs which have been mentioned as characteristic of pleurisy are wanting, with the exception of the dimin- ished respiratory murmur, and other results of the want of free expansion of the chest in breathing. There is usually also an absence of fever and cough. Besides, in pleurodynia, the pain is often more shifting than in pleurisy, is frequently felt in neighbouring parts, and is more apt to be increased by a twisting motion of the chest. For the means of distinguishing pericarditis, the reader is referred to that disease. It will be proper to give in this place the diagnosis between pleurisy and pneumonia. In the former, the pain is sharp and severe, and usually concen- trated in one spot; in the latter, it is moderate and dull when the pneumonia is wholly uncomplicated; but, as this is generally associated with inflammation of the pleura which invests the inflamed portion of the lung, the symptom is little to be relied on. The character of the expectoration is more important, being viscid and rusty in pneumonia; mucous and transparent, or whitish, or simply streaked with blood, in pleurisy. In the latter, the crepitant rale of pulmonary inflammation is wanting; in the former, the friction sound and aegophony of pleurisy. In both, bronchial respiration may exist; but it is more extensive, and heard over remoter parts of the chest, in pneumonia, than in pleurisy with much effusion. In the latter affection, over the part where compression is greatest, respiration is often scarcely if at all heard, and vocal resonance is wanting; while in pneumonia, with the hio-hest deo-ree of dulness on percussion, bronchial respiration is usually distinct^ and the vocal resonance much greater than in health, amounting often to bronchophony. Percussion yields no distinctive sound in the earliest stage; but the dulness is perceived earlier in pleurisy, and the flatness of the advanced stage is more complete. ^ In pleurisy, the flatness often changes with the position of the patient, which is not the case in pneumonia. The whole sternum may be flat in pleuritic effusion, only one half of it in hepatization. The hand placed over the seat of copious pleuritic effusion feels no vocal vibration, while in pneumonia it is more striking than in health. In pneumonia, the distension of the chest, flatness or bulging of the intercostal spaces, and the displace- ment of the heart, liver, stomach, &c, which occur in pleurisy with We effusion, are wholly wanting. b In some cases of partial pleurisy, especially the interlobar and mediastinal the diagnosis is very uncertain, and at best but conjectural. When more- CLASS III.] PLEURISY. 49 over, the disease is unattended with pain and cough, it is very apt to be over- looked. This happens most frequently when the pleurisy comes on in the course, or towards the termination of other diseases. It is, therefore, a good rule, whenever in any complaint a sudden increase of fever, or other material change for the worse occurs, not readily traceable to its cause, to examine the chest minutely, and ascertain whether pleurisy may not exist. In chronic pleurisy, when the effusion is not confined by adhesions, there can generally be little difficulty in making a correct diagnosis. But, when partial and limited by old adhesions, it is not always so easily distinguished. Not to speak of the interlobar and mediastinal forms, which are generally first recognized after death, unless in certain rare cases in which the pus escapes through the lungs, and thus leads to plausible conjecture as to the seat of dis- ease, even the costal cases are occasionally somewhat embarrassing. The flat- ness on percussion, and the shortness of breath, cough, and other general symptoms, are not always sufficient proofs of pleurisy; for they are met with also in pneumonia and phthisis, and may result from tumours within the chest, and even from the enlarged liver pushing up the diaphragm considerably above the ordinary level. Chronic pneumonia, however, is rare; and, besides, some bronchophony and bronchial respiration may be heard, which is not usually the case in pleurisy, unless in those points at which the lung adheres to the chest, and which may be distinguished by their strong contrast with the part in which the flatness is perceived. In phthisis the dulness is usually con- fined to the upper part of the chest, and various sounds are perceived by aus- cultation, which are wholly wanting in pleurisy. (See Phthisis.) Neither in pneumonia, nor in tuberculous cases, does the dulness on percussion equal that produced by liquid effusion. In relation to tumours, in which there is the same flatness, and the same absence of auscultatory sounds as in pleurisy, the discrimination must be founded on a survey of the origin and course of the complaint, and its general symptoms, and on the fixed character of the physi- cal signs. The same is the case with enlarged liver, in which the symptoms of chronic hepatitis, or the existence of some cause in the abdomen calculated to push that viscus upward, would be apt to lead to a correct conclusion. Prognosis. Simple pleurisy of one lung almost always terminates favourably, if treated properly in the earlier stages. When copious effusion has taken place, the cure is more uncertain, but may generally be effected in uncomplicated cases. It is usually by association with other diseases that pleurisy acquires great obstinacy, and becomes very dangerous. Thus, when it occurs in the course of febrile affections, or in persons debilitated by some wearing complaint, it increases the danger, and not unfrequently hastens the fatal issue. Perhaps the most frequent cause of its obstinacy is the existence of tubercles in the lungs. Heuce, an intractable character, or disposition to very frequent recur- rence in pleurisy, is a reasonable ground for apprehending the existence of latent phthisis. Coexisting organic disease of the heart, liver, or kidneys, adds to the danger of the complaint. It is more serious in the old than in the young and vigorous; because in the latter, independently of their greater ability to withstand disease in general, there is a tendency to the exudation of fibrin, and to consequent adhesion of the pleura, while in the former the dis- position is to the effusion of serum or formation of pus, both of which inter- fere with the curative process. Indeed, pus in the pleural cavity is always very hazardous. Purulent expectoration, hectic fever, and emaciation are very unfavorable signs in this complaint; as is also the escape of pus through the walls of the chest; though in both cases recovery sometimes takes place. Double pleurisy may always be regarded as a very serious affection. 50 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. Treatment. Acute Pleurisy.—At an early period of the disease, the lancet should be freelv employed. Few diseases bear bleeding better, or call for it more strongly than acute pleurisy. The patient should be placed in a sitting posture in bed, and the blood allowed to flow until a decided impression is made upon the pulse, or some degree of sickness of the stomach or faintness is produced. From twelve to twenty-four ounces may usually be taken at the first opera- tion. The disease is thus not unfrequently arrested at the outset, or rendered so mild as no longer to be an occasion of solicitude. Should the sharp pain not have ceased, or should it return, after having been mitigated, the bleed- ing may be repeated in the same or the subsequent period of twenty-four hours; and, indeed, again, if the pain call for it, and the pulse permit. Even after the pain has ceased, should the pulse remain strong, without cardiac hypertrophy, and the physical signs afford evidence of a progress of the inflammation, the lancet may still be resorted to. Nor is this remedy to be limited by time. No matter what may be the period of the complaint, the coexistence of pain and a strong pulse indicates the propriety of the remedy; but less blood must be taken at once in the advanced than in the early stages. After the first bleeding, the bowels should be thoroughly evacuated by sulphate of magnesia, the infusion of senna with salts, or calomel combined with or followed by an active cathartic. Subsequently, throughout the complaint, it will generally be sufficient to keep them opened once daily; for which purpose the saline laxatives, castor oil, or enemata may be used if necessary. The bowels having been unloaded, and the febrile symptoms reduced by the lancet, opium and ipecacuanha in the dose of a grain each, combined with two or three grains of calomel, may be given at bedtime, if the pain should be sufficient to prevent sleep. During the day, small doses of tartar emetic may be given every two or three hours, with the effervescing draught or neutral mixture, when the skin is hot and dry. Should the inflammation continue after the pulse has been subdued by general bleeding, leeches or cups may be freely applied to the chest, and followed by an emollient poultice ; great care being taken not to allow the moistened skin to be exposed to the cool air. At the end of the third, fourth, or fifth day, after depletion has been sufficiently employed, great advantage will often accrue from a blister over the affected part. This should be large, eight by ten inches for example, and kept on in the adult ten or twelve hours' or even longer, should it not have drawn previously. At the same period, if the effusion be considerable, and the general symp- toms do not indicate a speedy and favourable issue, it will be proper to employ mercury, which should be given in moderate doses, and at short inter- vals, until the gums are touched, when it should be suspended. Calomel is in general preferable to any other preparation, though the blue mass may be substituted, if the former prove too irritating to the stomach or bowels. Sometimes it may be advisable to associate the mercurial with opium • but it will generally be sufficient to give this narcotic at night, as before recom- mended. After the decline of the fever, should effusion remain, attempts may be made to promote the absorption of the liquid by squill in connection with calomel, if this be still administered, and with digitalis if there should be a frequent pulse, and no great debility. Seneka is also useful, when catarrhal symptoms coexist with those of pleurisy. If these measures fail in producing: absorption of the liquid, nitre freely given in a large proportion of water or cream of tartar may be substituted ; and colchicum, muriate of ammonia and iodide of potassium are recommended by some writers. Nitre is peculiarly CLASS III.] PLEURISY. 51 appropriate when some febrile action continues, and may, under these circum- stances, be given in conjunction with the mercurial and digitalis, instead of squill. Repeated blistering is also here a most valuable remedy. In the treatment of pleurisy, reference must always be had to the state of the system; and, when this is asthenic, depletion must be employed with caution, and the mercurial practice commenced earlier. In such cases, it will often be sufficient to leech or cup instead of bleeding. Blisters may often also be very promptly applied. In bilious pleurisy, purging with calomel, and an early recourse to the mercurial impression are usually indicated; and, as in the case of the same variety of pneumonia, quinia should be used freely when the disease assumes an intermittent form, or even when it is dis- tinctly remittent, provided there be at the same time a typhoid tendency. The observations made under typhoid pneumonia are applicable to pleurisy when similarly complicated. When pleurisy is associated with tubercles, should the loss of blood be deemed necessary, cupping should be substituted for the lancet, and, if mercury be employed, care should be taken, that it be not allowed to produce a deep effect, or to act long upon the system, lest it might favour their further deposition. Blisters are here peculiarly indicated. The diet in acute pleurisy should be very low, consisting in the early stages, chiefly of the mucilaginous or farinaceous liquids, and, at a somewhat more advanced period, of toasted bread and tea, fresh fruits, as oranges or grapes, and stewed dried fruits or preserves. Refreshing acidulated drinks may be allowed freely. The patient should be kept at rest, and should avoid speaking or coughing as much as he conveniently can. He should lie with his shoulders and chest somewhat elevated with pillows. It is important that the temperature of the chamber should be uniform, and comfortably warm, day and night. Caution must also be employed not to expose the naked chest unnecessarily, in any physical exploration which may be deemed requisite. Chronic Pleurisy.—Occasionally, in this form of pleurisy, moderate bleed- ing is admissible ; but in general, when the loss of blood is indicated, local measures are preferable. The existence of pain with sufficient strength of pulse offers the requisite indication. Blisters are here invaluable. They should follow each other rapidly, or be kept constantly open by stimulating dressings. I prefer the former plan, as a more copious discharge may thus be obtained. Free pustulation with tartar emetic, and, in very chronic cases, issues or setons, may be substituted for blistering. Of internal remedies the most effective are probably combinations of calomel, squill, and digitalis. Seneka may sometimes be advantageously added, or substituted for one of the two latter ingredients. With the view of promoting absorption, iodide of potassium, or of mercury, or the compound solution of iodine, may be used internally, and the ointment of iodine applied to the surface by means of friction. Mercurial frictions will sometimes also be found useful. Opium, hyoscyamus, or some other narcotic should be employed to allay cough. When hectic symptoms appear, they must be combated by mild tonics, such as infusion of wild-cherry bark, the mineral acids, and the chalybeates, in- cluding iodide of iron, and by sulphate of quinia, if the debility is consider- able. Opium should also be given, and the diet should be nutritious without being stimulant. In doubtful cases, milk with the farinaceous substances, fresh vegetables, and fruits should be used; and, in greater debility, the lighter kinds of animal food, as eggs, oysters, broths, and boiled meats. Empyema.—Whether in the acute or chronic form of pleurisy, when the liquid in the chest is so copious as to threaten immediate suffocation, recourse should be had to the operation of paracentesis. This operation is also called for in chronic cases, when all other measures have failed to remove the fluid, and life is endangered by its continuance in the chest. A consideration, in 52 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. these cases, strongly in favour of a somewhat early recourse to the operation, is that the plastic exudation becomes firmer and more unyielding the longer it continues, and that consequently, the longer the liquid is allowed to re- main in the chest, compressing the lungs, the more apt will these be to De- come irrecoverably fixed by the inexpansible new tissue that binds tnem down. Whenever, therefore, progress ceases to be made in producing absorption of the effused liquid, after a fair trial of the remedies adapted to this purpose, the practitioner would be justified, in cases in wMcn the future capacity of the lung to perform its office might be endan- gered,in resorting to this method of relief.* Though it often fails to effect cures, and though it sometimes aggravates the inflammation of the pleura, probably by the admission of air into the cavity, and the consequent chemical changes produced in the contained liquids, yet it generally affords temporary relief, often protracts life, and sometimes saves it. Out of six- teen cases recorded by Dr. Davies, in which the operation was performed, twelve recovered; but this is an unusually large proportion, in chronic pleurisy; and it is highly probable that many of them might have been re- lieved without it. The operation is more successful in serous than puru- lent accumulation, but the necessity for it is greater in the latter. The nature of the liquid may be ascertained by introducing a grooved needle, which may be done with little pain, and almost no risk. The quantity of fluid which has sometimes been discharged is enormous. A case is mentioned by Dr. Townsend, in which fourteen imperial pints were drawn off by Mr. Crampton, of Dublin. (Watson's Lectures.) Writers differ upon the questions, whether the liquid should be drawn off wholly at once, or by successive operations, and whether the orifice should be closed or left open. When the quantity of the liquid is large, and the whole is taken away at once, it is thought that the consequent entrance of air into the cavity must prove injurious by giving rise to inflammation of its walls ; and the fact is, that, after the operation, the fluid if before serous is apt to become purulent, and if purulent, to undergo putrefaction; and the danger of the case may thus be aggravated. When the liquid is serous, and not in itself irritant, and when there is reason to think, from the period of the disease at which the operation is performed, that the lung may retain a considerable degree of expansibility, it appears to me best that such a por- tion only should be drawn off at once as will flow out readily, under the * The reader will please refer to the note at the foot of page 46, for certain facts stated by M. Landouzy, which have a strong bearing upon the subject of the early per- formance of paracentesis. The practical inferences which M. Landouzy draws from them are the following, coinciding mainly with the recommendations in the text. 1. In all cases of pleuritic effusion, efforts should be made to promote absorption both of the liquid and plastic matters, in order to prevent their conversion into inextensible tissue, which might permanently bind down the lung. A case of pleurisy should not, therefore, \q left to nature. 2. As soon as the efforts of nature and the influence of remedies are found to fail in lessening the effusion, provided it be not dependent on disease of the heart, blood, lungs, or kidneys, or associated with an incurable cachexy, recourse should be had to paracentesis. 3. If there is amphoric respiration, indepen- dent of tubercles or pulmonary fistulae, the operation should be immediately performed. 4. The same occasion for immediate action exists, whatever may be the cause of the effusion, if it threaten speedy death. 5. If the void resulting from the atrophy or com- pression of the lungs be promptly filled after the operation, by the expansion of the lungs or the shrinking of the thorax, the prognosis is favourable; but if a large pus- producing cavity remain, there is reason to apprehend a fatal issue. 6. If the liquid is serous, injections after the operation are useless; if purulent, the cavity should first be washed out by a slightly chlorinated liquid, and afterwards iodine injections used • if fetid, or very rapidly reproduced, instead of leaving any kind of instrument in the puncture to keep it open, which must have the effect of irritating the pleura the junc- ture should be converted into an incision. (Arch. Gen., Dec, 1856, p. 704.)' CLASS III.] PLEURISY. 53 force of the contracting chest and the dilating lung. The plenum is thus preserved, and no air admitted; and, before a second operation is performed, the lung will probably acquire a still greater expansibility, and the chest a still greater contractile power, so that more may flow out without solicitation. In this way, it is possible that an equilibrium may be preserved between the diminution of the fluid, on the one hand, and the supplying expansion of the lung and contraction of the thorax on the other, until the parts are restored to their healthy state. Sometimes only one operation is necessary; as nature, assisted by remedies, is competent to the removal of the remaining liquid. But, if the liquid be pus, as much should be withdrawn as possible; and it is even recommended by some to withdraw it by means of a syphon or suction instrument. It is also recommended to wash out the pus by the injection of warm water. In relation to the question whether the wound should be closed or left open, the answer must depend upon the nature of the fluid. Should it be serum, it will be obviously proper to close the wound, so as to obviate the danger of inflammation from the admission of air, or the imperfection of the cavity. If it be pus, and this have a tendency to accumulate rapidly, the wound should be allowed to remain open, so that the liquid may escape as rapidly as it forms. If, therefore, the wound be closed after the first opera- tion, and the cavity become again speedily distended, there can be little doubt that subsequently the external communication should be kept free, and nature imitated in the process, by which she sometimes effects a spontaneous cure through an external opening. It may, however, possibly happen that the cause producing the pus may have ceased in great measure to operate, and that the quantity drawn off may be replaced slowly if at all. In such a case, it would be fortunate that the danger of inflammation from a permanent im- perfection of the cavity should have been avoided by a closure of the orifice. When the pus discharged is offensive, and the parts exhibit no tendency to a recovery of their healthy state, it has been recommended to inject antiseptic and moderately stimulant liquids, such as a weak solution of creasote, or of one of the chlorinated compounds. Several successful cases have been re- corded from the use of iodine injections. The pus having been washed out by a mucilaginous injection, as of decoction of marsh-mallow, a solution com- posed of one part of iodide of potassium, ten parts of tincture of iodine, and a hundred parts of water, making altogether about four fluidounces, may be thrown into the cavity every two or three days; and the strength of the in- jection may be increased as the parts become accustomed to the impression. (Boinet, Archives Generates, be ser., i, 523.) The strength of the injection has been increased, in some instances, to equal parts of tincture of iodine and water, with enough iodide of potassium simply to prevent the precipita- tion of the iodine on dilution. Sometimes the iodine, used in this way, has produced its effects on the system, causing irritation in the nostril%and air- passages, profuse salivation, &c. (Ibid., Aoiit, 1S56, p. 132.) The method of performing the operation of paracentesis belongs to sur- gery. It will be sufficient here to state, that the operator should be per- fectly satisfied of the existence of liquid at the spot where he makes the opening, lest he should wound the lung, or the liver, if this should hap- pen to have encroached upon the thorax. As a general rule, the space be- tween the fifth and sixth ribs should be preferred. In the upper part of the chest, adhesion is apt to exist; in the lower, the liver might be in the way. In relation to the treatment of pleuro-pneumonia, no special instructions are necessary. The practitioner who understands how to treat each disease separately, will have no difficulty in deciding upon his measures when the two are conjoined. 54 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. Article IV. PNEUMOTHORAX. This name, first applied by M. Itard to the affection in which air is con- tained in the cavity of the pleura, has been generally adopted. To Laennec belongs the merit of having first fully investigated the subject; and little has been added to what was taught by him. The affection scarcely deserves to rank as a disease; being a mere incident in the course of several very dif- ferent complaints, and injuries of the respiratory organs. Pneumothorax may exist in three distinct forms; 1. that in which the cavity of the pleura has no communication with the external air, 2. that in which it communicates with the air through the bronchial tubes, and 3. that in which the communication is directly through the walls of the chest. The second is by far the most common, and sometimes coexists with the third. Another distinction might be founded on the presence or absence of organic lesion; but the latter condition is comparatively so rare, that it might almost be considered as an anomaly scarcely worthy of notice. Still another dis- tinction has been made, dependent on the presence or absence of liquid in the cavity; and the name of hydro-pneumothorax has been proposed for the variety which is characterized by the former condition, while pneumothorax simply is retained for that in which there is only air. This nomenclature, however, has not been generally adopted, and the simpler title is usually em- ployed to express the two varieties indiscriminately. It is a rare event, however, to find air quite alone in the pleural cavity. Symptoms.—The general symptoms are very equivocal, and altogether in- sufficient to serve as the basis of a confident diagnosis. Dyspnoea, dependent upon the compression of the lung, is an almost constant symptom. It varies greatly in degree, according to the amount of air and liquid within the cavity of the pleura, to the rapidity and permanence of the accumulation, and to the state of the opposite lung. Sometimes the quantity of air and liquid com- bined is so small as to occasion but slight compression of the lung, in which case there may be little inconvenience of breathing from this cause. When the accumulation is gradual, the organs of respiration and circulation accom- modate themselves, in some measure, to the new condition of things, and the suffering is less than under opposite circumstances. It happens, however, most frequently, that the entrance of air into the cavity is sudden. In that case, severe dyspnoea usually comes on immediately, attended frequently with sharp pain in the side, and sometimes with a sensation as if something had given way in the chest. Occasionally these sudden attacks are marked by the occurrence of a copious expectoration of pus, consequent upon the opening of the pleural cavity, in a state of empyema, into the bronchia. It may happen that the opening, which admits air into the cavity during inspiration, shall be large or free enough to admit its ready expulsion during expiration.' In such a case, excessive pressure upon the lung may not occur, and the dys- pnoea may not be exceedingly violent. In other instances, on account of the orifice being under the surface of the liquid in the cavity, or of its having a kind of valvular arrangement, the air admitted during inspiration is either not expelled at all, or only partially so during expiration, and consequently goes on accumulating, and thus compressing the lung, until suffocation en- sues, unless through change of position, violent effort, or other cause, the air can find an exit. The fatal issue, under such circumstances, may take place very speedily, and is preceded by the most painful and laboured breath- CLASS III.] PNEUMOTHORAX. 55 ing, intense anxiety, and universal prostration. When one lung is from pre- vious disease unfit for duty, and pneumothorax occurs upon the opposite side, speedy death is almost inevitable. When the communication first takes place between the lung and the pleural cavity, there is not only dyspnoea, but often also a sharp pain in the side, and severe cough, in consequence of irritation of the membrane. The irritation is sometimes so intense as to be attended with a temporary depression of the vital functions; but inflammation and febrile reaction soon follow. These effects are usually ascribed to the direct influence of the air upon the pleura; but, when it is considered how innoxious is air in the cellular tissue, as in emphysema, this explanation must be received with hesitation ; and the pro- bability appears much greater, that the real source of irritation is the liquid, often highly acrid, which is at the same time admitted into the cavity from tuberculous vomica?, gangrenous abscesses, &c. Should liquid have pre- existed in the cavity; then the admission of air may prove the source of irritation indirectly, by causing putrefaction in the liquid. The patient gene- rally prefers the sitting posture, or, if he lie down, does so of choice upon the side affected, at least after the first violence of the pleuritic pain has subsided. The physical signs afford the only certain evidence of this affection; and these are quite distinctive. Sometimes there is distension of the chest, with enlargement and bulging of the intercostal spaces, and displacement of the neighbouring viscera, as in copious liquid effusion; but these effects are not constant. When the air is between the ribs and lung, percussion yields a clear, drum-like sound, much clearer than upon the corresponding part of the healthy side, and of a different character, being analogous to that produced by per- cussion over the stomach. If liquid exist in the cavity at the same time, per- cussion produces over it a flat sound, strongly contrasting with the tympa- nitic sound occasioned by the air; and the limits of the resonance and dulness are often well defined, and vary with the position of the patient, the former occupying a place in the chest above that of the latter. Thus, if the patient sit, the clearness will be in the upper and the flatness in the lower portion; if he lie upon his back, the former will be anterior and the latter posterior, and vice versa. But this sign is of itself not sufficient; for the difference between the sound of the lung in health, and the sonorousness of pneumothorax is not always to be depended upon. Auscultation here lends its aid and supplies the deficiency. The ear, applied to the chest, perceives no respiratory mur- mur in the part where the sound upon percussion is clearest; while, at the corresponding spot on the opposite side, the percussion is less clear, and the respiration heard distinctly. The vocal resonance, and vibratory thrill of the walls of the chest, are also less over the tympanitic than over the healthy part. These signs taken in connection with the movable limits of the dulness and sonorousness, are peculiar and distinctive. Sometimes, owing to adhe- sions of the lung to the side, respiration is heard; but other sonorous parts exist where the sound is wanting. If the quantity of air is very great, and no ad- hesions exist, the respiratory murmur is nowhere audible except near the root of the lung. Besides this sign, there are others which belong equally to this affection, and to large cavities in the lung. Such are the amphoric respira- tion, amphoric resonance of the voice and cough, and metallic tinkling. For the value of these signs, the reader is referred to the remarks preliminary to the subject of diseases of the respiratory organs. (See vol. I, pages 791, 793, and 796.) Of course, the first two are heard only when the cavity com- municates with the bronchia, and the last most frequently under the same cir- cumstances, though the metallic tinkling may be occasionally produced in the closed cavity, as for example by change of position, when drops of the liquid 56 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART which has adhered to the surface now uncovered fall into the mass of liquid beneath, and by rales in the bronchial tubes, &c. Still another sign is the sound of fluctuation or splashing, which is sometimes heard, especially it tne ear be applied to the chest during succussion, that is, a quick and sudden movement of the body, as when shaken by a person having hold of the shoul- ders. This sound is produced only when there is a considerable quantity of liquid along with the air. It is often audible to the patient in moving. M. Aran has called attention to another sign, sometimes offered in this disease; a shock, namely, occurring during the cough, giving to the patient a sensa- tion as though something were striking against the costal pleura, and resem- bling to the ear, or to the hand of an observer, the blow of a hammer. This was observed a little below the lower angle of the scapula, and was ascribed by M. Aran to the lung, floating upon the liquid in the pleural cavity, and when distended in inspiration, striking against the wall of the chest. (Arch. Gen., Aout, 1856, p. 156.) The course of this affection is various, being dependent on the nature of the disease of which it is an attendant. Sometimes it is very speedily fatal, within an hour, or a few hours, or a few days, and, when produced by the rupture of the pleura in tuberculous and gangrenous affections of the lungs, generally in the course of a week or two. Sometimes, however, it runs on for months and years, and cases are on record in which it continued for three and even six years. The termination is usually sooner or later in death, though recoveries do occasionally take place, especially when the affection has originated in pleuritic effusion. Sometimes the symptoms of phthisis are ameliorated after perforation of the pleura. Causes.—By far the most frequent cause of pneumothorax is the opening of a tuberculous vomica, already communicating with the bronchia, into the cavity of the pleura. Hence, the affection is not a very uncommon accom- paniment of phthisis. The opening is made either by ulceration, or by the rupture of the membrane over a superficial vomica, in consequence of some violent action of the chest, as in a paroxysm of coughing. As a communi- cation is thus established between the cavity and the external air, this of course enters the pleura at every expansion of the chest, and, if the commu- nication be perfectly free, passes out again in great measure during expira- tion, only so much remaining as may be necessary to occupy the space left by the elastic contraction of the lung. Should the exit, however, be less free than the entrance, the air goes on accumulating in the cavity, and the lung becomes very much compressed. In general there is only one opening, but sometimes there are several. As the tubercles producing them are seated usually in the upper part of the chest, the opening is most commonly found in the same part. In this variety of pneumothorax, the attack is often very sudden; for, though the ulceration may make its way gradually to the surface of the lung, yet, when the pleura only remains, this is apt to give way under some more than usual violence, and the phenomena at once occur. Upon the same principles, pneumothorax occasionally arises from gangren- ous or phlegmonous abscesses of the lungs, and hemorrhagic effusions in their tissue, making a passage into the pleural cavity ; and the progress of cancer- ous ulceration, and the rupture of a hydatid, have led to the same result But all these cases are very rare. In some instances, the opening is made from the pleura into the lunjrs This happens in cases of empyema, in which the pus excites inflammation and ulceration in the pleura, and by the same processes opens a passage through the pulmonary parenchyma into the bronchial tubes, and is discharged Some- times it makes its way externally through the walls of the chest instead of into the lungs, and thus establishes a direct communication between the cavity CLASS III.] PNEUMOTHORAX. 57 and the outer air. In either of these modes, pleurisy may be the cause of pneumothorax. The operation for empyema, and other penetrating wounds of the chest, occasionally give admission to the air through its walls; and, when the lung is penetrated at the same time, from the bronchial tubes also. A fractured rib sometimes causes pneumothorax by wounding the lung; and the same result is said to have been produced by violent compression from without, rupturing the pulmonary air-cells and pleura. In an emphysematous state of the air-cells, it sometimes happens that the superficial cells are ruptured in violent paroxysms of dyspnoea, and the air, escaping beneath the pleura, rup- tures that also, and enters the cavity. In all the cases hitherto alluded to, there is an external communication. But the affection sometimes occurs without such communication. Occasion- ally a portion of the surface of the lung becomes gangrenous, and the gases arising from its decomposition are confined in the pleural cavity. Ulcerous communications have also been formed between the hollow abdominal viscera and this cavity, which has thus been filled with air. In some rare cases of partial pleurisy, in which the liquid effusion is limited by adhesions, it is said that the place of the liquid absorbed is sometimes supplied by air; the lungs not being sufficiently expansible, nor the ribs sufficiently flexible, to fill up the vacuity. It is probable that the air, in such cases, proceeds from the liquid, which always contains more or less of it under the ordinary atmospheric pressure, and yields it when that pressure is removed. Sometimes the liquids contained in the cavity of the pleura, especially when mixed with blood, un- dergo decomposition, and give out gaseous matter. Again, it is thought that, in some rare instances, air is extravasated from the pleura, without any observ- able organic lesion. Such an event may happen in certain low states of the system, analogous to those in which a similar extravasation of air takes place into the cells of the exterior cellular tissue. It is possible that the air occasion- ally found in the pleural cavity after death, without any discoverable organic affection, may be the result of the debility immediately preceding death, or even a pure cadaveric phenomenon. In relation to the comparative frequency of the foregoing causes of pneu- mothorax, it is stated by M. Saussier that, out of 147 cases of the affection, it was in 81 the result of phthisis, in 29 of pleurisy, in 8 of gangrene of the lungs, in 5 of emphysema, in 3 of hydatids, in 3 of wounds; while none of the other causes enumerated had produced more than a single case. (Diet, de Med., xxv. 236.) The nature of the gas in pneumothorax depends on the cause of the affec- tion. Sometimes it is inodorous, as when derived immediately from the atmosphere; sometimes highly offensive, as when the product of gangrene, or of putrefactive decomposition of the pleural liquid. The lung is sometimes pressed against the spine, sometimes into the upper part of the chest, and very rarely into the anterior part. The degree of com- pression varies greatly. In some instances, it is so slight as scarcely to be sensible; in others, the lung is reduced to the size of the fist or even less; Sometimes it is much limited by the adhesion of the lungs to the parietes of the chest. There is occasionally much difficulty in finding the fistulous open- ing after death. Though generally fatal, pneumothorax is not necessarily so, even when dependent on phthisis. Dr. Woillez has shown that perforations of the lungs by tubercles are sometimes closed spontaneously by false membrane, connect- ing the parts around the orifice with the opposite costal pleura; and that, alter this has taken place, the signs of pneumothorax may gradually disap- pear. (Archives Gen., Dec. 1853, p. 695.) VOL. II. 5 58 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. Treatment.—This is usually directed less to the removal of the air con- tained in the pleura, than to the relief of the attendant symptoms. Imme- diately upon the occurrence of a sudden attack, it is often proper to allay irritation and obviate depression by opiates and sinapisms. The subsequent pleuritic inflammation must be combated by such an amount of depletion, either by the lancet or preferably by leeches, as the patient can bear, by emollient poultices, blisters, or antimonial pustulation, by refrigerant laxa- tives and diaphoretics, and, if the case be not tuberculous, by a moderate mercurial impression. At the same time, the various remedies mentioned under pleurisy, as fitted to produce absorption of the effused fluid, should be employed. Opiates or other narcotics should be given to allay cough; and, when symptoms of hectic appear, with night-sweats and emaciation, the strength of the patient must be supported by tonics and nutritious food. The only measure directed especially to the air in the pleura, is the making of an opening through the walls of the chest in order to let it out. This is warrantable only where the accumulation is so great as to threaten speedy suffocation. The operation should be performed as in empyema. Sometimes it affords instantaneous relief; and, if the pneumothorax depend upon reme- diable causes, may be the means of saving the life of the patient. But gene- rally it is only palliative; and, in the advanced period of phthisis, when death must ensue ere long in the ordinary progress of the disease, the performance of the operation, for the sake of a few days' respite, is, to say the best of it, of equivocal propriety. M. Aran has punctured the chest and injected tinc- ture of iodine, as in ordinary cases of chronic pleurisy, with relief to the patient (Arch. Gen., Aout, 1856, p. 153); and M. Trousseau has succeeded in curing, by the same remedy, three cases diagnosticated as pneumothorax, in which the affection was the result of simple pleurisy. (B. and F. Med.-Chir. Rev., Jan. 1858, Am. ed., p. 197.) Article V. EMPHYSEMA OP THE LUNGS. This name has been applied to that affection of the lungs in which their tissue is morbidly distended with air. There are two varieties of the affection; one in which the dilatation is confined to the air-cells, the other in which the air has escaped from the vesicles into the extravesicular or interlobular cel- lular tissue, or upon the surface of the lung beneath the pleura. The former was called by Laennec vesicular emphysema, the latter may very properly be designated as extravesicular. The complaint is not uncommon, but has not been well understood until recently. Laennec gave the first satisfactory and consistent account of it, though many isolated facts had been recorded by previous pathological anatomists. Anatomical Characters.—In vesicular emphysema, the lung does not col- lapse on the opening of the chest, but sometimes on the contrary expands as if previously compressed by the ribs and diaphragm. This is ascribed to'an inelastic or rigid condition of the membrane which forms the cells consequent probably upon a sort of hypertrophy which not unfrequently thickens the walls of distended cavities. In consequence of this rigidity, they do not con- tract upon the air which they contain, and therefore remain distended The lung is very light, and does not sink so much in water as in the sound state It crepitates less upon pressure, has a firmer feel, and pits under the finder The surface is sometimes irregular in consequence of unequal proiecfine vesicles, and occasionally single vesicles are observed, sometimes as lar«-e as CLASS III.] EMPHYSEMA OF THE LUNGS. 59 a pea or larger, of a globular form, and apparently attached, by a pedicle. This, however, is only a contracted portion of the vesicle, which continues beneath into the substance of the lung. That these are distended air-cells and not extravasated air, is proved by the circumstance, that they cannot be moved from place to place under the pleura by pressure. If the lung is dis- tended by blowing into it, these vesicles appear to flatten and sink away; but the fact is, that they remain unaltered, while the sound structure around them swells to their level. When the diseased lung is cut into, the air-cells are found to be in various degrees enlarged, generally to about the size of a millet-seed, sometimes to that of a hazel-nut; and occasionally one is observed of much greater magni- tude. The smaller cavities are probably mere dilated vesicles, the larger are sometimes produced by the rupture of the intervening coats, and the gradual absorption of the torn membrane. In order that the structure may be well exhibited, the lung should be fully inflated and dried before being sliced; and, in order to compensate for any air that may escape through the mem- brane, the inflation should be repeated now and then during the drying process. In consequence of the distension of the cells, the whole amount of surface over which the blood-vessels can ramify is lessened, and these, therefore, undergo absorption. There is consequently a diminished supply of blood, and the portions of lung affected have a whitish appearance, which sometimes contrasts, in a marked degree, with the colour of the healthy parts. The lung is also less moist than in health. The dilatation may affect only one or a few cells, or may occupy isolated spots, as single lobules, for example, while others remain unchanged, or may extend to large and continuous portions of the parenchyma. It may be con- fined to one lung, or may affect both. The latter is most frequently the case. When one lung only is the seat of the complaint, it is much larger than the other, so as sometimes observably to displace the mediastinum and heart. The dilatation is more frequent in the upper portion of the lung, and at its borders, than elsewhere. The edge of the lobes is sometimes irregularly fringed with the projecting dilated vesicles, of different sizes. The small bronchial tubes are usually also dilated in the emphysematous part. Extravesicular Emphysema.—In this variety, the air is sometimes effused upon the surface of the lung, underneath the pleura, producing little bladders of various size and form, in some instances not larger than a shot, in others as large as an egg, and even larger. An instance is mentioned by Bouillaud, in which the bag of air was equal to a common stomach in size. The affec- tion differs from that in which the vesicles are dilated in the circumstance, that, in the former, the air can be pressed from point to point beneath the pleura, while in the latter the vesicles are not movable. The effusion results from rupture of one or more air-cells. Sometimes the pleura gives way, and the air escapes into its cavity, constituting pneumothorax. In some cases, the air is effused into the interlobular cellular tissue; and the affection, under these circumstances, is named by Laennec, interlobular em- physema. The partitions of cellular matter between the lobules, which in health can but just be distinguished by the eye, are now much expanded, being from a line to half an inch, and sometimes nearly an inch in thickness. On the surface of the lung they appear as translucent bands, sometimes run- ning in parallel directions, but frequently intersecting each other, so as to form lozenge-shaped spaces of sound lung. If the effusion of air takes place near the root of the lung, it escapes into the mediastinum, and thence into the cellular tissue of the neighbouring parts of the neck, which thus becomes emphysematous ; and the affection may extend to the cellular tissue under- neath the skin, and among the muscles, over the whole body. Though the 60 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART emphysema in this case, is dependent on some solution of continuity m the air-cells or bronchial tubes, this cannot be detected. The proper cells ot the lungs are generally not themselves dilated; though sometimes this kind ot emphysema is associated with and dependent upon the vesicular variety. Rilliet and Barthez state that, in children, they have almost always found inflammation of the bronchial tubes, or of the parenchyma; though these lesions have not generally occupied the same portion of the lung as the em- physema. (Maladies des Enfants, i. 137.) Symptoms.—Yery slight emphysema cannot be certainly detected either by the general symptoms or physical signs, and is first known to have ex- isted after death. When so considerable as to produce observable effects, it is always attended with dyspnoea, which, in very mild cases, may be occa- sional, appearing only under the influence of exciting causes, but, in those of a higher grade, is in a greater or less degree continuous and unceasing. In the latter cases, however, it varies exceedingly, being sometimes quite toler- able, at others exacerbated into the most distressing paroxysms, similar to those of spasmodic asthma, with which this affection was formerly con- founded. These paroxysms occur quite irregularly, whenever, indeed, the patient may happen to be exposed to causes which call for more than ordinary exertion of the lungs, or in any degree tend to cramp their action, such as violent muscular effort, elevated situations where the atmosphere is rarefied, the horizontal position which throws the weight of the bowels partly upon the diaphragm, flatulence and overloading of the stomach, which act in the same manner by confining the lungs, and, above all, acute catarrhal attacks. As one of the consequences of the dyspnoea, the patient usually prefers the erect position, and in some instances finds it difficult to lie with his head low. Cough is a very frequent attendant; but is rather a result of some concomi- tant disease than of the emphysema itself. It is not, as Laennec appears to have believed, invariably present in the complaint. Sometimes there is either no expectoration, or only of a small quantity of clear and viscid or frothy mucus; but, in other cases, and especially when the patient labours under a catarrhal attack, there is a copious discharge from the bronchia, which affords considerable relief to the dyspnoea. When not complicated with acute in- flammatory affections, the complaint is entirely free from fever, and the pulse is usually slow and regular. During the paroxysms, the face often exhibits the usual marks of imperfect aeration of the blood, being pale or livid with purple lips; and in bad cases there is sometimes an habitual dusky hue of the countenance. According to Stokes, these phenomena are most common when the lower lobes are chiefly affected. The physical signs, however, are much more accurately diagnostic than the general symptoms. When the affection is severe, there is usually some dilatation of the chest, which is general or partial according to the extent of the emphysema. The thorax is more cylindrical than in health being rounded somewhat both before and behind. The intercostal spaces are widened, though not bulging, the ribs have a more horizontal direction and the hollow above and below the clavicle is apt to be filled up. Sometimes only one side is enlarged, and sometimes the bulging is quite partial The heart, spleen, and liver are occasionally displaced as in empyema If the movements of respiration are closely watched, it will be found that the chest falls little if any during expiration. Mr. Corfe gives as a diagnostic sign of emphysema of the upper lobes, the appearance of a tumour in the tri- angular space between the clavicle, sterno-cleido-mastoid, and omohvoid muscles at each spell of hard coughing; a phenomenon resulting from a sort of "hernia of the lung" in consequence of a want of support to the nleura at this place. (Med. Times, March 18, 1848.) pleur CLASS III.] EMPHYSEMA OF THE LUNGS. 61 But these deviations from the normal shape of the chest are not always present. The most sure signs are those afforded by percussion and ausculta- tion combined. Under the former, the chest over the affected portion of lung emits an unusually clear and hollow sound, which is not, as in health, in- » creased by a full inspiration; while, by the latter, the respiratory murmur can be heard but very feebly if at all. The expiratory sound is often much pro- longed, probably owing to narrowing of the bronchia. The vocal parietal vibrations of the chest are generally diminished in emphysema; though the resonance is said to be sometimes natural, and sometimes augmented, even to bronchophony. Pneumothorax is the only affection which yields the same combination of signs; and, as this is generally attended with liquid effusion, the marks of such effusion are sufficiently diagnostic, especially when taken in connection with the very different origin of the two affections, and their very different course. In pneumothorax, moreover, there is a total want of the respiratory murmur, which can usually be heard, though feebly, in emphy- sema; while in the latter the metallic sounds are quite wanting. The dry and moist rales of catarrh are often heard, and occasionally, accord- ing to Laennec, a dry subcrepitant rale, which, Dr. Gerhard says, is "nothing but the slight rustling sound produced by the bubbles of air, either forcing themselves into the cellular tissue, and forming little bags which rub against the pleura, or the dilated vesicles themselves, which are occasionally suffi- ciently rigid to give rise to some friction." (Med. Examiner, iii. 583.) Of course, in the purely vesicular emphysema, the sound can proceed only from the latter of these two causes. Yesicular emphysema is almost always a chronic and very protracted affec- tion. Beginning not unfrequently in childhood, it may run on to an advanced old age, and seldom proves fatal, unless through some concomitant affection. At first, the dyspnoea is usually slight, and the paroxysms at distant inter- vals. But, as life advances, the general difficulty of breathing increases, and the paroxysms become more frequent and distressing. In consequence of the interruption afforded to the passage of blood through the lungs by the great diminution of the vesicular surface, the right side of the heart is apt to be affected with hypertrophy and dilatation, and hence a cachectic state of system, and dropsical effusion. When certain parts of the lungs are affected and others sound, it is evident that a greater than the due portion of the circulating office must fall upon the latter, so that they become especially liable to congestion and consequent pneumonia. It is probably by this affec- tion that life most frequently terminates, in pulmonary emphysema. According to Rilliet and Barthez, the physical signs of emphysema in children are different from those above given. The respiratory murmur, instead of being diminished, is remarkably exaggerated, the sound upon per- cussion remains about as in health, and the walls of the chest are not changed in form; so that it is not always easy to recognize the disease. They ascribe the louder murmur to the great efforts made by infants in breathing, the state of percussion to the naturally resonant character of the chest, and the want of alteration in the walls of the chest, to the rapid march of the affection. But emphysema may always be suspected, in children affected with rachitis, or with an acute disease of the chest, which has continued for some days, and occasioned violent respiratory efforts. (Maladies des Enfants, i. 138.) The extravesicular variety differs somewhat in its course from the vesicular. Instead of being very chronic, it is generally induced suddenly by causes cal- culated to rupture the air-cells. When dyspnoea comes on all at once, after violent efforts at inspiration, it may be inferred to belong to this affection. The patient is sometimes sensible, under these circumstances, of a feeling of crackling. Laennec says that a characteristic sign always present is a dry 62 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. subcrepitant rale, or, as he expresses it, a dry crepitant rale icilh large bub- bles. It is much more constant and more marked in this than in the vesicular variety. He distinguishes this from the fnotion sound, which is also neard and which is produced by the irregular surface of the lungs rubbing against the ribs, diaphragm, or mediastinum. It appears to me that Dr. Bernard has given the true explanation of this phenomenon in the sentence already quoted. The vibration which produces the sound may sometimes be telt by the hand upon the chest. If, along with the above signs, there is an appear- ance of emphysema about the anterior parts of the neck, there can be no doubt of the nature of the case. This form of pulmonary emphysema is in general a comparatively trifling affection. It may, in some very rare instances, be so extensive as to occasion suffocation ; but usually absorption of the effused air takes place, the ruptured orifices heal, and the patient recovers in a short time. Causes.—Whatever produces and sustains severe dyspnoea, while from any cause portions of the tissue of the lungs have been rendered incapable of ordi- nary expansion, may prove the cause of pulmonary emphysema. The expand- ing power of the muscles of inspiration, thus abnormally and excessively exerted, is brought to bear not on the whole of the pulmonary tissue, as in health, but on the portion remaining expansible, which is, therefore, forcibly dilated beyond the normal extent, and, by a continued application of the cause, becomes permanently dilated, the vesicles being not unfrequently ruptured at the same time. In asthma, the deficiency to be supplied by the expansion of the air-vesicles results from the spasmodic contraction of all the bronchial tubes. Hence, the emphysema is apt to be general in that affection. So constant an attendant, indeed, is it upon spasmodic asthma, when of consider- able duration, that some pathologists have been induced to consider the latter complaint as nothing more than emphysema. But the mere mechanical dila- tation of the air-cells is wholly insufficient to account for the nervous pheno- mena of asthma, which is undoubtedly the original affection. Besides the disease just mentioned, bronchitis is a frequent cause of emphysema, par- ticularly when it affects the smaller tubes, and is attended with a very viscid obstructive secretion. It then affords the two conditions mentioned, in a high degree, causing much dyspnoea, while, by obstructing the tubes in certain parts of the lungs, and thereby disabling the tissue supplied by them from expanding duly, or, as shown by Dr. Gairdner, even producing collapse, it throws the whole office of expansion upon the remainder. Dr. Williams has ingeniously suggested, as an immediate cause, a want of longitudinal exten- sibility in the bronchia, consequent upon chronic bronchitis, the result of which is, that the vesicles necessarily dilate towards the surface of the lung, so that this may remain in contact with the expanding walls of the chest. Cardiac affections, pulmonary abscesses, partial induration, atrophy con- cretions, and tumours of all kinds pressing upon the bronchia, and partially filling the cavity of the chest, may be ranked among the causes of the com- plaint. In a slight degree, therefore, it should attend tubercles in the lungs- and though, according to Louis, the disease is seldom complicated with phthisis' yet, from the more recent observations of M. Gallard, it would appear that more or less of an emphysematous condition of the pulmonary tissue is a con- stant and almost necessary result of tuberculous deposition. (Archivp* a™ Aug. 1854, p. 200.) It follows, from what has been said, that pulmonarv em- physema is usually a secondary affection, originating in dyspnoea and aLra- vatmg the cause which produced it. bh Yiolent efforts at expanding the chest, or which require that the oh^t should be kept long in the expanded state, are also capable, unaided of Mrn ducing emphysema, though it is more frequently the extravesicular than the CLASS III.] EMPHYSEMA OF THE LUNGS. 63 vesicular variety which results. Playing upon wind instruments, lifting very heavy burdens or other violent straining, and the practice of diving and re- maining long under water, may be mentioned as examples of this kind of cause. The extravesicular emphysema is very apt to occur in the course of the other variety, upon the superadded operation of such causes; and the two forms, therefore, not unfrequently coexist. Treatment.—During the exacerbations of dyspnoea, the patient must be kept at rest, and all existing occasional causes of the dyspnoea removed as far as possible. Should evidence be presented of the existence of acute bron- chial inflammation, or active pulmonary congestion, blood should be taken by the lancet, or from between the shoulders by cups, or both generally and locally, according to the state of the circulation, and the urgency of the symptoms; and small doses of tartar emetic may be given, at short intervals, during the continuance of the acute inflammatory symptoms. After these, if existing, have been reduced, and originally in cases in which they do not exist, narcotics, antispasmodics, and local irritants are highly useful. Such are laudanum and Hoffmann's anodyne, with sinapisms to the breast or back. The smoke of stramonium may also be tried, if not contraindicated by cere- bral symptoms; and the various remedies enumerated under spasmodic asthma may be resorted to if necessary. To promote expectoration, and re- lieve the bronchial spasm, few remedies will probably be found more effica- cious than mixtures of equal parts of syrup of squill and seneka, with twice the quantity of tincture of lobelia. One or two teaspoonfuls of such a mix- ture may be given every hour or two, or even more frequently unless it nauseate, until the symptoms are relieved. For a more permanent effect than can be obtained from sinapisms, blisters or pustulation by tartar emetic may be had recourse to, when the dyspnoea is protracted. But the most important part of the treatment is that which is directed to the prevention of the paroxysms of dyspnoea. Towards directly relieving the habitual amount of it, little can be done; but there is reasonable ground to hope that, if the exacerbations can be prevented, the progress of the disease may be delayed or arrested, and that, especially in the young subject, the air-cells may in the end gradually contract, and a positive amelioration of the disease take place. The patient, therefore, should carefully avoid all the causes calculated to bring on dyspnoea. He should never use any great mus- cular exertion likely to put him out of breath; should never, for example, attempt to run, or rapidly ascend heights, or lift heavy burdens. He should guard with peculiar caution agaiust taking cold; and should therefore clothe himself warmly with flannel next the skin, always keep his feet dry, and take care not to expose himself, when heated, to currents of cold air. Laennec recommends frictions with oil as a preventive of catarrh. Measures should be promptly taken to relieve attacks of inflammation in any part of the air-passages. Residence in a warm and equable climate is highly desira- ble ; and sea voyages in the warmer latitudes may prove beneficial. When the original cause of the dyspnoea continues to exist, and can be reached, the efforts of the physician should be especially directed towards it. Thus, in anemic cases, the chalybeates and other means calculated to restore the pro- per condition of the blood should be used. In the extravesicular form, little treatment is requisite. In cases of ex- treme and threatening dyspnoea, bleeding should be resorted to in order to lessen the duty of the lungs; and, if emphysema should appear about the neck, the air may be let out by punctures. 64 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. Article VI BRONCHIAL DILATATION. This is not so much a disease in itself as an effect of disease. It is worthy of notice chiefly from the close resemblance of its signs, in some.instances, to those of phthisis, and the consequent occasional difficulty of diagnosis. The smaller tubes are more commonly affected than the larger, probably because they have less of the cartilaginous structure. The dilatation is m different forms. Sometimes the tube is equally enlarged, and of a nearly cylindrical form for a considerable distance; sometimes the dilatation is confined to one spot, and is somewhat spherical in shape; and again, there is a succession of dilatations and contractions in the same tube. Iu the first case, the bronchial passage may be dilated from the size of a fine straw to that of a crowquill, or the finger of a glove. A number of the branches of one of the large bronchia are often affected, and sometimes the whole of those going to a particular part of the lung. The globular dilatations vary, to use the language of Laennec, from the size of a hempseed to that of a cherry-stone, almond, or even walnut. These cavities often contain pus. Their coats are sometimes much and irregularly thickened, and exhibit little or nothing of the healthy structure. In other instances, they are so thinned by distension as to have the appear- ance of fine membrane. Frequently the pulmonary tissue without them is considerably compressed by their dilatation; and a compact layer of this compressed tissue forms a sort of exterior coating to the tube. Symptoms.—There are no general symptoms by which this affection can be recognized with tolerable certainty. It is almost always accompanied with cough and expectoration, which, however, are the signs of an attendant chronic bronchitis, and not of the dilatation. The expectoration is often purulent, and sometimes fetid, possibly in consequence of being detained in the enlarged tubes, and undergoing decomposition there. When the dilata- tion is considerable, it produces more or less dyspnoea, consequent upon the compression of the lungs, and is sometimes attended by a pale or livid com- plexion, a general cachectic appearance, and dropsical effusion, arising from deficient aeration of the blood. The physical signs are much more decisive. The hand applied to the chest is sensible of a more than healthy vibration from the voice and cough. Dul- ness on percussion often results in some degree from'the compression of the tissue of the lungs. Sometimes percussion elicits a tubular sound, such as is produced by the same means over the trachea. The mucous and subcrepitant rales of bronchitis may usually be heard by auscultation. When the affection consists in a general enlargement of the tubes of a particular part of the lung, a diffused sound of bronchial respiration, and a bronchial resonance of the voice, are audible. When the dilatation is a rounded cavity, the respiration is cavernous; and, if liquid is present, there is a cavernous gurgling, and the voice issues from the wall of the chest in the form of bronchophony or pecto- riloquy. These are the signs also of a tuberculous cavity ; and there are no certain means of distinguishing the two affections, except by their general symptoms and course. (See Phthisis.) Some aid may be derived from the situation of the physical signs. Tuberculous vomica? generally exist near the apex of the lungs; while dilatation is certainly not less frequent in the middle and lower than in the upper lobe. According to Skoda, the bron- CLASS III.] BRONCHIAL DILATATION. 65 chial walls must be thickened, or surrounded by consolidated lung tissue, to yield the sounds above referred to. Causes.—Two causes may produce bronchial dilatation. One of these is the loss of the equable distribution of atmospheric pressure, and its concen- tration in an especial manner upon some one portion of the bronchial surface; the other is a morbid alteration in the coats of the tubes, which, by impair- ing their elasticity and muscular contractility, disposes them to dilate under any pressure that might be applied to them. Both of these causes operate in chronic bronchitis. By the abundant mucus secreted, or by the thickening of the tubes, the access of air to some part of the lungs is'diminished or pre- vented, and, as this part cannot expand fully with the dilatation of the chest, the deficiency must be supplied by the more than ordinary expansion of the neighbouring structure. Bronchitis too, produces the altered state of the tubes themselves, which has been alluded to as favouring their dilatation. The violent cough which often attends the complaint increases the result, by augmenting the force of the expanding agency. Hence, chronic bronchitis and hooping-cough are the complaints in which bronchial dilatation is most frequent. Whatever is capable of producing similar obstruction may occa- sion the same result. Hence, pulmonary tumours pressing upon the bronchia, such as aneurisms, scirrhus, or enlarged bronchial glands, are among the causes of dilatation. It will be seen, hereafter, under cirrhosis of the lungs, that compression of the air-cells, by the formation of an abnormal fibroid tissue, occasionally gives rise to the affection. Dr. Williams has noticed another condition in which it sometimes originates. In pleuro-pneumonia, the air-cells of the lung, compressed by the pleural liquid, are sometimes un- able to expand sufficiently to fill the vacuity caused by the absorption of the liquid, and the deficiency is supplied by the dilatation of the bronchia. Those of the middle size are usually most affected. Treatment.—The mere dilatation of the bronchia requires no treatment. It cannot be relieved by medicines. Attention must be directed to the dis- eases in which the dilatation originated, and by which it continues to be ac- companied. Of these the most frequent is chronic catarrh or bronchitis, to the remarks upon which the reader is referred for an account of the proper treatment. The chief practical point of interest, in connection with this subject, is the importance of not abandoning, as incurable, cases of pectoral disease presenting most of the general characters, as well as physical signs of phthisis, unless it should have been well ascertained that they are not chronic bronchitis, with dilated tubes. Article VII PHTHISIS. Syn.—Pulmonary Consumption.—Tuberculous Consumption.—Phthisis Pulmonalis. As employed in this work, the term phthisis is restricted to that form of tuberculous disease, in which the lungs are the part prominently affected. Formerly, various other pulmonary diseases, bearing a close resemblance to that under consideration, were confounded with it under the same general name; but, anatomical investigations having shown an essential difference between them, and the comparatively recent improvements in the means of diagnosis, by the discovery of percussion and auscultation, having offered the means of detecting this difference during life, there is an obvious propriety in 66 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART distinguishing them also by name; and most writers now recognize phthisis as the distinctive title of the tuberculous complaint. This disease is probably the greatest existing scourge of the human race, at least in the northern and middle latitudes. It will not be deviating far from the truth to state, that it causes about one-sixth or one-seventh of all the deaths north of the tropics.* In treating of phthisis, it will be proper to give first its anatomical characters; as a knowledge of these is requisite to a thorough understanding of all other parts of its history. In detailing these characters, I shall not confine myself to the appearances usually presented after death, but shall endeavour to trace the progress of organic change from the commencement to the close, as ascertained by the minute and indefatigable researches of pathological anato- mists, in every stage and variety of the disease. Anatomical Characters. Though there is reason to believe that the pulmonary affection is a conse- quence of a previously existing vice of the system, yet the first discoverable process, the first overt act of the disease, is the deposition of tuberculous mat- ter in the lungs. This appears in different forms, and with different charac- ters, being sometimes deposited in small roundish well-defined bodies denomi- nated tubercles, sometimes irregularly infiltrated into the pulmonary tissue, and, in relation to its sensible properties, varying from a firm consistence, and grayish translucent appearance, to a yellowish opacity with or without hardness. Each of these modifications requires a more particular notice.f 1. Pulmonary Granulations. — Gray Granulations. — Miliary Tuber- cles.—Under these various names have been described, by different authors, minute, roundish, shining, translucent, hard, homogeneous bodies, often not larger than a millet-seed, but varying from this size to that of a pea, which appear often in great numbers as the first step of phthisis. They are usually grayish, but sometimes have a light-reddish, and sometimes a dull dark-red or brownish colour; and occasionally are nearly colourless. They are either isolated, or clustered in small bunches, or in aggregate masses in which por- tions of the pulmonary tissue are inclosed and consolidated. In the last- mentioned state, they are almost always confined to the upper portion of the lungs; but, in the distinct or isolated condition, they are occasionally dispersed * From a table contained in the report of Dr. J. Curtis, published in the Transactions of the American Medical Association (ii. 540), it appears that the deaths from phthisis in Boston, during the twenty-eight years from 1821 to 1848 inclusive, were one in 5-76, or 17-36 per cent. Dr. Hayward, from an examination of the statistics of New York'for thirty years, gives the proportion in that city at 1 in 5 547, or about 18-02 per cent, (Am. Journ. of Med. Sci., N. S., xx. 312.) In Philadelphia, in the ten years from 1831 to 1840 inclusive, according to the tables of Dr. Emerson, the deaths were 1 in 7-03 or 14-10 per cent. (Ibid., xvi. 28.) In the ten years preceding 1820, on the same authority the proportion in Philadelphia was 1 in 6-38, or 15-67 per cent. (Mnrton's Illustrations p. 1G7.) The mean of these will give for Philadelphia, during the period of twenty years 1 in 6-705, or 14-91 per cent. To give the results in one view, the average mortality by consumption in Boston has been 1 in 5-76 of the whole number of deaths or 17-36 percent., in New York 1 in 5-547, or 18-02 per cent,, in Philadelphia 1 in 6-705 or 14-91 per cent. From a subsequent statement, it will appear that the mortality from this cause was greatly diminished in Philadelphia after the year 1840, which is the latest date to which the above estimate extends. (Note to the third edition.) f For an interesting and valuable paper on the microscopic characters oriein devel- opment, and progress of tubercles in the lungs, by Dr. C. Radclyffe Hall contain'ine the results of an extensive series of original investigations, the reader is'referred to the British and Foreign Medico-Chiruryical Review for April and October 1855 and Anril 1856. There is in this paper a great amount of information on minute points for which room can scarcely be found in a general treatise like the present, but which will amnlv repay the trouble of a careful perusal. (Note to the fifth edition.) nuipiv CLASS III.] PHTHISIS. 67 throughout the whole or a greater portion of these organs, giving rise to great pulmonary irritation. In children they are often situated immediately beneath the pleura, producing an irregularity perceptible to the fingers; and the same is sometimes the case in adults. 2. Gray Tuberculous Infiltration.—The same kind of matter which forms the granules above described, is often also deposited in the cellular tissue of the lungs, in irregular masses, sometimes one, two, or even three inches in cubic dimensions, without definite boundaries, or limited only by the extent of the lobules. This is the gray tuberculous infiltration of Laennec. It is homogeneous, hard, translucent, and of a grayish colour, sometimes darkened by the black matter of the lungs, portions of which become enveloped in the masses as they are formed. In some instances, no traces of pulmonary tissue can be detected by the unassisted eye in the masses; in others, they present remains of blood-vessels, bronchial tubes, and cellular membrane ; and occa- sionally they are partially penetrated by the air in respiration. 3. Gelatinous Infiltration.—Under this name, Laennec described a col- ourless or rose-coloured substance, more transparent than the gray matter noticed in the last paragraph, and of a jelly-like consistence, which is some- times deposited in small quantities in the tissue of the lungs, in the intervals of the tuberculous granules, and which he believed to be gradually converted into proper tuberculous matter. Louis states that he has met with this spe- cies of infiltration, but has not noticed in it the yellow tuberculous points spoken of as not uncommon by Laennec. Dr. Morton, in his Illustrations of Pulmonary Consumption, gives two cases in which the tuberculous trans- formation appeared to have commenced in this gelatinous matter. Dr. Hall states that its microscopic elements are the same as in the gray tubercle, but contained in a more abundant and softer matter. 4. Crude Tubercle, and Yellow Tuberculous Infiltration.—The gray translucent matter constituting the first two deposits above noticed, appears to undergo a gradual conversion into what has usually been considered the proper tuberculous substance. In the miliary granulations, the transforma- tion commences by a small yellowish-white spot, which most commonly ap- pears at or near the centre, and gradually enlarges until the whole granule assumes that character. In this altered state, the little bodies are denomi- nated crude tubercles. In the aggregated granules, the change commences at several points, each probably answering to a distinct granule ; and con- siderable masses of yellow opaque matter result from the extension and ulti- mate coalescence of these central spots. The same transformation takes place in the infiltrated translucent matter, beginning in like manner with isolated opaque spots, and spreading until it involves the whole deposit, which, when thus altered, receives the name appropriated to it by Laennec of yelloio tuberculous infiltration. This may be distinguished from the crude tubercle by an irregular and angular, instead of roundish form, and by a less definite line of division between it and the pulmonary tissue. There is no doubt that both the crude tubercle and yellow infiltration are often originally deposited in their characteristic state, without the prelimi- nary formation of the translucent matter. The minute bodies originally deposited in the state of crude tubercle, that is, yellow and opaque, are also frequently called miliary tubercles, especially when found in other tissues than the lungs ; and, in the general observations on tuberculosis in the first volume of this work, the name of miliary tubercle is applied as well to the opaque as to the translucent granules. Progress of Tubercles.—The yellow tubercle, whether original, or the re- sult of a transformation of the gray, gradually increases by new accretions. As observed upon dissection, it is frequently found, when quite mature, 68 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. about as large as a pea; but it varies from the size of a large pin's head to that of a hen's egg, is irregularly roundish, and consists of a yellowish-white, opaque, friable substance, which easily breaks up between the fingers In re- lation to its chemical composition, microscopic characters, and peculiar con- stitution, the reader is referred to the general remarks on tuberculosis, in the first part of this work. (See vol. i. p. 114.) The next change in the tubercle is that of softening. This usually begins in or near the centre, and gradually advances towards the circumference, until the whole tubercle is converted into a soft, pultaceous, yellowish mass, not unlike pus in appearance. According to Dr. Hall, softening sometimes begins at the circumference when this is in contact with inflamed tissue. The same alteration takes place in the infiltrated masses. In some instances, instead of this gradual change, the whole tuberculous deposit, whether circumscribed or not, appears to be simultaneously softened; and large por- tions of the lungs may be thus rapidly converted into pultaceous matter. According to Rilliet and Barthez, the softening of tubercles is comparatively rare in infants ; and gradually becomes more frequent, as the child becomes older. (Maladies des Enfants, iii. 231.) At this stage, the irritating properties of the confined matter produce in- flammation of the adjacent parts, which at length ends in ulceration, and thus opens a communication between the tubercle and the bronchial tubes. The matter now escapes, and is expectorated, leaving a cavity which is technically called a vomica. The cavities thus formed are sometimes lined, more or less completely, by a secreting membrane formed out of fibrinous exudation, and are sometimes as it were hollowed out of the substance of the lung, without any intervening tissue. When recent, this membrane is delicate and easily sepa- rable ; when old, it is firm, translucent, grayish, and sometimes of an almost cartilaginous consistence. The surrounding parenchyma is sometimes healthy; but much more frequently is altered, and often greatly so, being crowded with tubercles, or with tuberculous infiltration, or both, in various stages of advancement. The cavities are sometimes isolated and remain so ; but not unfrequently they gradually spread by the breaking down of the surrounding tissue, and thus run together, forming caverns of various dimensions, and of very irregular shape, occasionally winding, and now and then crossed by bands of solid tissue, composed generally of the tuberculated substance of the lungs, but sometimes of altered blood-vessels which remain in a certain degree per- vious. Dr. Morton traced, in some instances, by means of a delicate probe, a communication between these vessels, and branches of the pulmonary artery or veins, (lllust, p. 30.) The tuberculous cavity may not be larger than a pea, or it may occupy a whole lobe of the lungs; and there is every grade between these extremes. The bronchial tubes, ulcerated in the progress of the tuberculous deposit, open directly into the cavities, with the lining of which their own mucous membrane is often continuous. The tubes show signs of inflammation in their increased thickness, and the redness and occa- sional ulceration of the mucous coat. The contents of the cavities, after the evacuation of the altered tuberculous matter, consist of pus secreted by the lining membrane or the surrounding tissue, with which are occasionally mixed small quantities of blood tubercu- lous matter from the falling in of the walls, and portions of disorganized pul- monary tissue. They are usually inodorous, but sometimes fetid. The pro- per blood-vessels of the lungs are generally obliterated in the immediate vicinity of the cavity; and the new tissue formed around it is nourished by new vessels, derived either from the bronchial arteries, or, when the lung ad- heres to the side of the chest, from the intercostals. Cavities are much less commonly produced in children than in adults. CLASS III.] PHTHISIS. 69 By the progress of the changes above described, the lung is at length so far destroyed as to be no longer adequate to the performance of its office, and the patient perishes. But the march towards this result is by no means steady or constant. In many instances, clear evidence is afforded by dissection of attempts, not always fruitless, to repair the mischief which has been done. When the tissue around the cavity is healthy, its lining membrane sometimes ceases to secrete; the walls contract, and the opposite surfaces, coming in contact, unite together, and are consolidated into a fibro-cartilaginous body, which is quite harmless in the lungs. Such cicatrices have been repeatedly observed in parts of the lungs where tuberculous vomicae are most apt to form. They are rare, it is true, but there can be no doubt of their occasional existence, and little-of their tuberculous origin. In such cases, a cure must result, if the morbid deposition has been confined to this one spot. Another mode in which the tubercle may terminate favourably is by conversion into calcareous matter. This may happen by the absorption of the organic por- tion of the tubercle, the earthy or saline constituents being left; and re- peated depositions, followed by similar absorption, may finally result in the filling of the cavity with the earthy substance. Xow such concretions, of size varying from that of a hempseed to that of a chestnut, are not unfre- quently found in the lungs, especially of old persons, though not of these ex- clusively. They are sometimes soft like chalk, sometimes much harder; but in both cases consist of the same ingredients, which are chiefly carbonate and phosphate of lime ; the same essentially as the inorganic constituents of tuberculous matter. The difference in consistence appears to be owing to the effect of age, in producing a firmer aggregation. The inference from these facts is fair, that the calcareous concretions are altered tubercles ; and that some of them are so, can scarcely be doubted; for tubercles have been found with portions of calcareous matter in the midst of their ordinary con- tents, showing a commencement of the process. According to M. Yalleix, tubercles are sometimes seen consisting of hard calcareous matter in the cen- tre, next of a softer layer of the same substance, and lastly of unchanged yellow matter at the circumference. (Diet, de Med., xxiv. 327.) This would seem to show that a change had begun in the centre, and was gradually pro- ceeding outward. Nevertheless, it is possible to commit an error in referring these concretions always to a change of tubercles; for they may sometimes be nothing more than calcareous deposits in cavities, resulting from disten- sion of bronchial tubes. The views here given of the origin and progress of tubercles are not uni- versally admitted. They are, however, such as, upon a careful examination of the subject, have appeared to the author to approach nearest the truth. They correspond essentially with the opinions of Laennec and Louis, and with those of M. Yalleix, as contained in an excellent essay upon the anatomical lesions of phthisis, in the Archives Generates (3e ser., x. 133 et 279). There are yet several interesting questions in relation to the anatomical history of tubercles. In the first place, in what precise portion of the pulmo- nary tissue are they deposited? Yarious opinions have been put forth upon this point. Thus, they have been supposed to be enlarged absorbent glands; but this opinion is supported by no fact, while it is contradicted by the absence of all signs of organization, and by the utter want of any proof of the exist- ence of such glands in many situations where the tubercles are found. Another opinion considers them as the result of exudation into the air-cells, to which they are thought to owe their shape. But they are fouud of the same shape in other organs, where no such cells exist. Finally, they have been placed in the radicles of the veins, in the mucous membrane or cavity of the bronchial tubes, and in the intervesicular tissue. The fact, however, appears to be, that 70 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART they are confined to no particular position; but are found wherever there are blood-vessels to throw out the materials of which they are composed, whether in the vesicles, the minute bronchia, the cellular tissue between the air-cells, or that between the lobules. A second point of inquiry is in relation to their origin. Many persons, and of these some whose names stand among the highest in pathology, have main- tained that they are the result of an inflammatory process. But, though it is readily admitted that inflammation sometimes precedes the tuberculous depo- sition, and may even favour or give rise to it when a predisposition exists, yet there are many other cases in which not a trace of it can be detected, either at the origin or in the early stage of the tubercle; and, when it afterwards occurs, there is good reason to consider it as the consequence, and not the cause of that morbid product. A strong argument against the inflammatory origin of tubercle is deduced from the fact, that it is least frequently found in those parts of the lungs where inflammation is most frequent; the former almost always preferably occupying the upper, while the latter is most com- mon in the lower portion. Laennec and Louis have been among the most strenuous opponents of the inflammatory hypothesis; and the general opinion of the profession is at present against it. The mode of softening in tubercles has been another subject of controversy. Many have maintained that this is effected by the infiltration of purulent or serous fluid secreted by the tissue which invests the tubercle, and which is stimulated by its presence into an inflammatory condition. Broussais, An- dral, and Carswell have been, among others, the supporters of this hypothesis. But there is one difficulty in the way of its reception, which cannot well be surmounted. The softening commences at or near the centre of the tubercle, or at least at some point within its substance. Though there may be some exceptions, the fact is, beyond all reasonable doubt, generally as stated. To this effect we have the concurrent testimony of the closest observers, among whom may be cited Starck, Baillie, Laennec, and Louis. The last-mentioned writer, who is perhaps the highest authority upon the subject, speaks un- equivocally upon this point. Now, as the tubercle has no blood-vessels pene- trating through its substance to the point of softening, it appears impossible that this should result from the influence of any secreted liquid. The change is probably altogether spontaneous. The tuberculous matter appears to be exuded with the character of change impressed upon it. When deposited originally in the form of gray translucent granules or masses, it first becomes yellow and opaque, and then softens into a pus-like substance. Each altera- tion commences in the centre, because that was the seat of the first deposition, and the time of change for any portion of the matter must obviously be in the order of its production. We may go even beyond the softening, and suppose that, in relation to each tubercle, when the softened matter fails to make its way out of the cavity containing it, nature may have provided another remedv by rendering it liable to a last change, which may end in the separation of its earthy and saline ingredients, and such a modification of the animal matter as to enable it to be absorbed. Thus the chalky concretions may be accounted for. From the latest researches into the nature of tubercle, it is most proba- ble that, as thrown out from the blood-vessels, it is a formless matter pos- sessing a feeble vitality, which enables it to take on a partial organization characterized by peculiar imperfect cells, and ending, after various changes in complete disintegration. (See Tuberculosis, vol. I, page 118.) ' The first seat of the tuberculous deposition is, in the great maioritv of cases, in the upper part or near the summit of the lung; and when as not unfrequently happens, it occurs in other parts, the tubercles are almost alwivs more abundant, larger, and more advanced, in the situation alluded to than CLASS III.] PHTHISIS. 71 elsewhere; and it is here also that vomicae form. Large cavities are generally nearer the posterior than the anterior surface. The tubercles seem to evince a preference of the upper over the lower lobe, even at the same level. Thus, the former may be completely occupied with the morbid deposit, while the latter is nearly or quite free from it. When the tubercles are widely diffused, they usually begin to appear above, and extend gradually downward; and of course the upper are more advanced than the lower. Gray miliary tubercles are sometimes scattered through the whole of the lungs; but, in such cases, the patient is apt to perish before they have advanced to the crude state. In those rare instances in which the middle and lower portions of the lung are first affected, the deposition is apt to be in the form of yellow and opaque tubercle at the commencement.* In almost all cases, there is more or less of the tuberculous deposition in both lungs, sometimes in about an equal degree, but much more frequently in one to a greater extent than in the other. Sometimes the tubercles are confined exclusively to one lung. According to the observations of Louis, the left lung is more frequently affected than the right; and this appears to be the general experience, though Laennec has made a contrary statement. Sometimes the tubercles are few and isolated; and the surrounding pul- monary structure may be quite healthy. But much more frequently they are numerous; and, if the disease is of long standing, they are found in different stages, showing a deposition at successive periods; those in the upper portion of the lung being most advanced, and the others appearing less and less so as they descend. Occasionally something like a boundary line, though never quite precise, may be observed between the successive crops. Thus, in the same lung, tubercles may often be found in all their different stages. It not unfrequently happens that large portions of the lungs are consolidated by a mixture of tubercles and tuberculous infiltration, and, when cut into, present a mottled appearance, arising from the different colours of the deposit in its different stages, and of the portions of pulmonary tissue which remain. Some- times the whole of one lung is thus solidified. In the midst of this consoli- dation are frequently isolated or communicating cavities, which gradually increase by the falling in of the disorganized structure, until at length vast caverns are sometimes formed; and almost the whole lung may thus become excavated, or otherwise rendered unfit for duty. Very often, and, when the disease is extensive, almost always, the pleura of the lung is found adhering to that of the side. Of 112 cases examined by Louis, there was only one in which no adhesion could be found in either lung. Generally it is limited to that portion of the surface which corresponds with the tuberculous affection; but in some instances it is very extensive, and may be even universal. The adhesion is the result of inflammation of the pleura, and the consequent effusion of organizable lymph, and is found in different stages, from the mere cohesion of the recently deposited fibrin, to the perfect union by intervening cellular tissue. It often answers an admirable purpose, by preventing the effusion of the contents of the tuberculous cavities into the pleural cavity. Sometimes, however, such effusion does take place, and gene- * In the examination of a negro who died of phthisis in the winter of 1856-7, I was struck with the fact that the upper part of the lungs was entirely free from tubercle, which had been deposited copiously at the base, and here and there through the lower and middle portions. Dr. J. J. Levick, one of my colleagues in the Pennsylvania Hos- pital, informs me that he has met with a similar case, also in a negro; and I have learned that others have made the same observation. These facts are yet too limited to justify the conclusion, that negroes are peculiarly apt to offer exceptions to the gene- ral rule that tubercles are deposited primarily and especially near the apex of the lungs; but they are interesting, and, if confirmed, may form an important ground of diagnosis in the pectoral complaints of this class of patients. (Note to the fifth edition.) 72 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART ral inflammation of the pleura results, which adds greatly to the danger. Should a communication, in such cases, exist also between the vomicae and the bronchia, air enters the pleural cavity, and pneumothorax results. The bronchia are always more or less inflamed in the advanced stages of phthisis, especially those which communicate with the tuberculous cavities. Occasionally, numerous minute ulcers may be seen in their mucous surface. These, however, are more frequent in the trachea, especially in its posterior part. They are found also not unfrequently in the larynx, and upon the pos- terior surface of the epiglottis. Occasionally the bronchial tubes are dilated, and partial emphysema of the lungs is very common. The bronchial glands are frequently enlarged, indurated, and loaded with yellow tuberculous depo- sition. In very many cases, the pulmonary tissue is more or less inflamed, but generally in isolated patches. Hepatization of large and continuous por- tions of the lungs is not common, and, when it occurs, arises generally from incidental causes, unconnected, at least directly, with the tubercles. Appearances in other parts of the body.—As tubercles in the lungs are the result of a general predisposition, it might be expected that they would be found in other organs; and this is very frequently the case. It is a singular fact, that, without the lungs, the deposition seldom takes place in the form of translucent granules, but almost always in that of the yellow and opaque tubercle. Nevertheless, the translucent granulations, the opinion of Andral to the contrary notwithstanding, have been seen by many observers in differ- ent parts of the body. (Archives Gen., 3eser., x. 136.) I have myself seen them in countless multitudes in the liver of a patient who died of phthisis. The extrapulmonary tubercles are generally consecutive to those in the lungs, but by no means universally so; and the exceptions are not unfrequent in children. They have been observed in the pleura and its false membranes, the pericardium, the peritoneum, the stomach and intestines, the mesenteric glands, the liver, spleen, and kidneys, the prostate gland and testicles, the membranes and substance of the brain, the external lymphatic glands, and even in the bones. Indeed, there seems to be scarcely a living part of the body which is not liable, in a greater or less degree, to this deposition. In relation to their relative frequency in different organs, Louis found that, of all the cases of pulmonary tubercles occurring in persons over the age of fif- teen, one-third presented tubercles in the small intestines, one-fourth in the mesenteric glands, one-ninth in the large intestines, one-tenth in the cervical glands, one-twelfth in the lumbar glands, one-fourteenth in the spleen, and a smaller proportion in other organs. In the great majority of cases, the stomach exhibits after death signs of organic disease. It is usually larger and thinner than in health, and the mucous membrane has all the marks of chronic inflammation, including some- times ulceration. It is probable, however, that the loss of tissue, consequent on the solution, after death, of the mucous membrane, in the gastric juice has sometimes been mistaken for the result of ulceration. Similar marks of inflammation also exist in the small intestines; but the lesions here are more frequently of a peculiar character. Small tuberculous granules are developed in the substance of the intestinal coats, in the glands of 1'eyer as well as else- where, which undergo the regular process of softening and discharge and terminate in ulcers. These are small when isolated, but, by running together, frequently acquire considerable dimensions, sometimes occupying the whole inner circumference of the intestine. I have noticed that the greater length of these patches of ulceration is rather in the direction of the circumference of the bowel, than longitudinal, as in enteric or typhoid fever They are most numerous in the vicinity of the caecum. Other little tumours not of the tuberculous character, are also often visible in the mucous membrane of the CLASS III.] PHTHISIS. 73 small intestines. They are of a semi-cartilaginous consistence, and are thought by Louis to be inflamed mucous glands. Like the tubercles they end in ulceration. Occasionally, the tuberculous ulcers penetrate the coats of the intestines, and allow their contents to escape into the peritoneal cavity. Ulcers are also not unfrequently found in the large intestines, and sometimes of enormous extent. The mesenteric glands are often enlarged and inflamed, in consequence of the deposition of tuberculous matter within them. The liver is subject to a singular fatty degeneration, with great enlargement. In children, the membranes of the brain are frequently tuberculated, with all the phenomena of hydrocephalus. (See Tuberculous Meningitis.) From observations made by Dr. Theophilus Thompson, it appears that the average weight of the heart is above that of health, a result which might have been anticipated from the excessive action of this organ. (Clin. Led. on Pul. Consump., Am. ed., p. 89.) Yarious other lesions are frequently observed in the dissection of consumptive cases; but they are generally such as equally attend other affections, and have no peculiar dependence either on the tuber- cles or the tuberculous diathesis. Symptoms, Course, &c. Two stages may be observed in the course of phthisis, corresponding with the two stages in the progress of the tubercles, one preceding and the other following the period of their maturation and discharge. These are not always separated by a precise line of division; and it is often difficult to decide, in particular cases, where exactly the first ends and the second begins. But each stage is sufficiently characterized in its prominent symptoms, at periods when the pathological condition peculiar to it is quite unmixed. First Stage.—Phthisis begins in different modes. Most frequently, per- haps, the first symptom is a short, dry, hacking cough, very slight at the commencement, so as often scarcely to attract any notice, but gradually in- creasing, and, after a longer or shorter time, attended with expectoration first of transparent mucus, and afterwards of a white or yellowish opaque matter, as in common catarrh. For some time there is little other observable de- rangement of system. The appetite is good, most of the functions are regu- larly performed, and the patient is scarcely sensible of any diminution of strength. Perhaps, upon the occasion of any unusual exertion, there may be some shortness of breath, and a more than ordinary feeling of fatigue. The pulse, too, is often accelerated, especially during exercise; and, as the com- plaint advances, the patient begins to experience febrile sensations towards evening, with some flushing of the cheeks, and heat in the palms of the hands and soles of the feet. Occasionally fugitive pains are felt between the shoul- ders, in the sides, or about the sternum. But probably the most characteris- tic symptom is a slight but progressive emaciation, which cannot be ascribed to any discoverable failure of the appetite or digestive powers, and seems out of proportion to any existing evidences of disease. This, however, is not a uniform attendant upon the incubative stage. Indeed, the symptoms alto- gether are frequently such as occur in other complaints, especially dyspepsia; and it is not uncommon for patients with the latter affection to entertain serious apprehensions of phthisis, while those really consumptive have no such fears. In the condition above described, the patient may continue for weeks, or months, and sometimes even for years. His cough he ascribes to an ob- stinate cold, or to frequently taking cold ; his pains, if he has any, to rheu- matism ; and he either shuts his eyes against the other symptoms, or explains them in some satisfactory manner. At length, however, the increase of cough and fever, the occurrence of severe pain, or perhaps, still more frequently, an attack of hemorrhage from the lungs, excites alarm. Sometimes the hem- VOL. II. 6 74 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. orrhage, which usually subsides spontaneously, or readily yields to remedies is followed by an amelioration of the cough, fever, and pains, and the patient feels himself much better, and even believes himself recovering. In other instances, it appears to mark an aggravation of the disease, the progress of which is afterwards much more rapid. Not unfrequently the haemoptysis returns again and again; and, in some cases, the patient is seldom long with- out the discharge of blood from the lungs. But, whether hemorrhage occurs or not, the symptoms continue to advance, sometimes regularly, but more frequently with remissions, which are occasionally of considerable duration, and always a source of hope and comfort to the patient. The cough at length becomes very troublesome, often disturbing sleep, and sometimes occurring in violent paroxysms. The expectoration takes on a more decidedly purulent character. The dyspnoea and thoracic pains often increase, and the febrile symptoms are more decided, the pulse being almost always frequent, the face often flushed, the tongue somewhat furred, and the appetite impaired. In some instances, the fever exhibits a tendency to the paroxysmal form, and the patient not unfrequently perspires during sleep. The first stage is now at its height, and, having continued in this state a variable length of time, passes sometimes abruptly, sometimes by imperceptible degrees into the second. Occasionally, instead of beginning and gradually increasing as above de- scribed, the disease, with no observable premonitory symptoms, or at least with none that attract notice, comes on suddenly with an attack of haemop- tysis, after the subsidence of which the characteristic phenomena are devel- oped, slowly or rapidly, according to the susceptibilities of the patient. Again, the disease has its origin apparently in some inflammatory affection of the respiratory organs, as bronchitis, pneumonia, or pleurisy, or follows closely in the footsteps of some febrile disease, such as smallpox, scarlatina, typhoid fever, or bilious fever. In these cases, after the subsidence of the peculiar symptoms of the disease, the pulse remains obstinately frequent; cough, if previously wanting, sets in, or, if already existing, perseveres beyond the usual period ; and the other characteristic phenomena of early phthisis show themselves, for the most part, with unwonted severity. Sometimes a catarrhal affection glides so imperceptibly into phthisis, that it is impossible to decide which was the original disease, unless the catarrh may have com- menced suddenly in sound health, and with unequivocal symptoms, as in influenza and measles. Another mode in which phthisis occasionally commences is with the symp- toms of chronic laryngitis, which prevail for some time before those of the pectoral affection are developed, and often serve to mask the latter until the complaint is far advanced. Lastly, cases occasionally though rarely occur, in which the disease comes on so insidiously as altogether to escape notice, until it breaks forth fully formed, and with the most fatal symptoms. In such cases, there is little or no cough, no pain, and no observable febrile excitement. Perhaps the patient may experience some dyspnoea upon any unusual exertion, may feel rather weaker than in his ordinary health, and may gradually become thinner; but these effects, if they happen at all, are so slight as scarcely to attract notice, and, if perceived, are referred to some other cause. At length, some symp- tom calculated to excite suspicion occurs, which leads to a physical explora- tion, and unequivocal signs of extensive disease are found in the upper part of the chest; or the vomica which has been imperceptibly forming, opens into the bronchia, and the symptoms of the second stage are at once developed. Second Stage.—This4)ften comes on so gradually that the precise time of its commencement cannot be fixed. There is not unfrequently an increase of fever preceding the opening of the vomica, consequent probably upon the in- CLASS III.] PHTHISIS. 75 flammation excited by the matter of the tubercle, seeking an outlet through this means. The patient, previously walking about, now takes to his bed, and suffers with pains in the chest, heat, thirst, loss of appetite, furred tongue, &c.; till at length the character of the expectoration proves that an outlet has been made; after which there may for a time be a subsidence of the febrile symptoms. But, in many instances, the second stage sets in gradually with- out any such premonition; and occasionally, as already stated, bursts at once upon the patient almost without previous warning of any kind. The most characteristic symptom of this stage is the peculiar appearance of the expec- toration, which is now decidedly purulent, and generally in distinct well de- fined masses, with an occasional accompaniment of softened tubercle, in the shape of small lumps of yellowish cheesy or curdy matter. These, however, often escape notice. The cough is now generally increased, and is especially troublesome in the morning, when the accumulations of the night are to be discharged from the lungs. The fever assumes a decidedly hectic character. The pulse, almost always frequent, becomes considerably more so at some period of the twenty-four hours, generally towards evening; and this exacer- bation is accompanied with increased heat of skin, flush of the face often circumscribed upon the cheek, and a remarkable clearness of the conjunctiva and general brilliancy of the eye. The febrile paroxysm often subsides with a gentle perspiration. Not unfrequently, chills occur at somewhat regular periods every day, followed by fever and perspiration, like the paroxysms of intermittent, but less regular, usually less violent, and with much less pain in the head. These chills do not occur in all cases, and are frequently inter- rupted, to return again, often without any appreciable cause for either change. The patient very frequently perspires during sleep, and, in the progress of the complaint, the night-sweats become profuse and exhausting. They are not necessarily connected with the febrile paroxysms; but continue when these are suspended, and are sometimes very abundant, even in those rare cases in which the pulse is little excited. Sharp pains in the sides and posterior parts of the chest are frequently experienced, which are sometimes neuralgic, but oftener probably the result of pleurisy, which is a very common accompani- ment of phthisis. In the latter case, the pains are generally attended with some increase of fever, which subsides again upon their removal. Hemor- rhage from the lungs now and then takes place, but not in all cases, and less frequently and copiously than in the first stage. The purulent expectoration is generally very copious; and this, together with the exhausting night-sweats, and the constant irritation of system, hastens the progress of debility and emaciation. The ends of the finger nails often curve forward, giving a pecu- liar appearance to the fingers which has been thought to be characteristic of phthisis, but is found, though less frequently, in other chronic and exhausting diseases. The menses are almost always suppressed in the course of the com- plaint, though at uncertain periods. The appetite is often greatly impaired, if not lost. All these symptoms, however, are occasionally relieved, or quite disappear for a time. The discharge of pus diminishes and at length ceases; the cough and fever subside; the appetite returns; and the patient even begins to recover flesh. The vomica has been emptied, and has probably begun to take on the healing process; but a new crop of tubercles is deposited, and the delusive calm is generally succeeded by a return of the original symptoms, often more violent than at first. At an advanced period of this stage, the stomach and bowels often become involved in the disease. The patient suf- fers from frequent attacks of diarrhoea, which are sometimes very exhausting. They occasionally alternate with the night-sweats; but not unfrequently the two discharges are simultaneous. Nausea and vomiting are occasionally added to the other sufferings of the patient; and, in some instances, food of all kind 76 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. is rejected by the stomach. Hoarseness and total loss of voice are not un- common, and the dyspnoea sometimes becomes very distressing. In some instances, the patient is suddenly carried off by the supervention of some secondary affection, such as active congestion of the only portion of lung remaining fit for duty, copious pleuritic effusion on the same side, pneu- mothorax, profuse hemorrhage from the lungs, severe peritoneal inflamma- tion consequent upon perforation of the bowels, the bursting of a large vomica overwhelming the lungs, and disease of the brain produced by tuberculous deposition in that organ or its membranes. This last cause of death, how- ever, is almost peculiar to children. Generally, the fatal termination approaches more gradually. Among the symptoms now presented, in one or another case, are oedema of the extremi- ties, especially of the feet and legs; redness of the tongue, with the loss of its papillary appearance, and a thrush-like exudation upon its surface; a total loss of appetite, with vomiting and diarrhoea, the latter sometimes approaching to dysentery; severe dyspnoea ; extreme emaciation; and complete prostration of strength. The adipose matter is almost wholly absorbed, the muscles are wasted, the cheeks are hollow, the eyes sunken, and the bones everywhere prominent, unless concealed by oedema. Not unfrequently the back sloughs, in consequence of pressure upon the bony prominences. Until near the close, the debility is sometimes less than might be anticipated; the patient being frequently able to sit up much of the time until a few days before death. But at last the weakness becomes so great that expectoration is no longer possible; the cough ceases; the pus accumulates in the lungs, and life ends, because respiration cannot be carried on. The intellect generally remains clear to the last. Dr. Theophilus Thompson has called attention to the frequent existence, in consumptive patients, of a reddish streak or margin at the reflected edge of the gums, having in decided cases a vermilion tint, inclining to lake, and sometimes more than a line in breadth. It is present in the earliest as well as in the advanced stages, and when seen in women, may, according to Dr. Thompson, be considered as almost conclusive evidence of the existence of a tuberculous state of system. Its absence is a favourable sign. (Clin. Led. on Pul. Consumpt., Am. ed., pp. 171 and 184.) This symptom, however, is found in other diseases, particularly in those in which the blood is disordered, and frequently occurs in pregnant and puerperal women, in whom no pa- thological lesion can be discovered. (Drs. Saunders and Draper, N. York Journ. of Med., Jan. 1857, p. 64.) But the disease is liable to great diversities, and there is scarcely a symp- tom which does not vary in different cases. Complications also exist which require notice. It is, therefore, necessary to add to the above general picture some account of individual symptoms, and of different attendant or intercur- rent diseases. I shall endeavour to avoid the repetition of facts already stated, so far as may be consistent with clearness. 1. Cough and Expectoration.—Cough is generally the most prominent and distressing symptom, though sometimes wanting until near the close In the early stage, it is probably the result of bronchial irritation, produced by the increasing tubercles, which act like so many foreign bodies in the lungs It has been described as generally trifling at the commencement- but in some instances, it is from the first severe, occurring in irregular and distressing paroxysms, owing probably to some ill defined nervous irritation It jrene rally increases with the advance of the disease, and in the second stao-e be- comes very harassing, so as sometimes almost to prevent sleep and thus greatly to aggravate the complaint. The cause of this increase is partlv the necessity for discharging the contents of the vomicae, but probably still more CLASS III.] PHTHISIS. 77 the bronchial inflammation, induced by the contact of the irritating tuber- culous matter with the mucous membrane in its passage. The expectoration, which, until this time, had been purely bronchial, now assumes a peculiar character. It is in distinct, somewhat globular sputa, of a thick semi-fluid consistence, homogeneous, destitute of air, of a yellowish or greenish-yellow colour, often streaked with deeper yellow lines, and generally somewhat ragged or flocculent at the borders. When discharged into water, they flatten out without quickly losing their distinct character, and either sink or float as they happen to be more or less connected with mucus. Along with these sputa are occasionally minute portions of curdy matter.* Besides this kind of ex- pectoration, the patient often also discharges a large quantity of more liquid purulent or muco-purulent matter, which no doubt proceeds chiefly from the inflamed bronchia. The peculiar distinct sputa come from the cavities, and are among the most certain general symptoms of phthisis. Sometimes, though very rarely, they are met with in other complaints of the chest. They consist of pus, and the liquefied tuberculous matter, which, according to Louis, is indicated by the yellow streaks. The quantity of matter expectorated varies exceedingly in different cases. In some, very copious and even exhausting, in others it is scanty, and in others again scarcely observable. In the last- mentioned cases, there is reason to suppose that the bronchia are little involved. I have known a case, in which the whole amount during the progress of the disease, so far as could be ascertained, scarcely exceeded the dimensions of the vast cavity which was found in the lungs after death. Sometimes the distinct sputa are quite wanting; the expectoration being exactly like that of chronic bronchitis in the purulent stage. This is apt to happen when there are large caverns in the lungs. Occasionally the pus in this stage of phthisis is streaked with blood. In some instances, after having been copiously discharged, it gradually diminishes, and at length ceases, at least for a time. There is then reason to suppose that the cavity has taken on a healthy action, and to hope that it may in time become obliterated. Very commonly, however, other tubercles maturate, and the discharge is renewed. In the last period of the disease, the pus is sometimes of a reddish or brownish appearance; and por- tions of the pulmonary structure and of unchanged tubercle have been ob- served in it, derived from the falling in of the walls of the caverns during their enlargement. The cough in advanced phthisis often has a deep hollow sound, which has long attracted notice as one of the fatal signs of the disease. Both the expectoration and cough are apt to cease a few days before death, in * According to Schroeder Van der Kolk, of Utrecht, the existence of a cavity in the lungs may be infallibly detected by the aid of the microscope, which reveals in the ex- pectorated matter the presence of the elastic fibres which surround the air-vesicles. These fibres are curved, very thin, sharp at the borders, and sometimes covered with fatty matter, which is dissolved by ether. They are distinguishable from a species of conferva which soon appears in the sputa, by the ramifications of the latter terminating in cells. (Rev. Med.-Chirurg., viii. 222.)—Note to the third edition. Dr. C. Radclyffe Hall gives, as characteristic microscopic ingredients of the expecto- ration in impending tuberculization of the lung, "single plates, or small flakes of flat epi- thelium from the air-vesicles, fattily degenerating, and bronchial columnar epithelium, also presenting various degrees of fatty degeneration;" considering this change of the cpithelia of the vesicles and small tubes as the first step in the process of forming tuber- cle. In incipient tuberculization, besides these ingredients of the sputum, there are also "red globules more or less shrivelled and faded, enveloped in a filmy cell, a few large many-nucleated cells, granules, and frequently small casts of the air-vesicles and ulti- mate bronchi, in which are plainly visible epithelial cells of various sizes, and in various stages of fatty degeneration." In established phthisis, there are largely mixed with the last-mentioned bodies, "corpuscles of mucus and pus, and free tubercle-nuclei (the proper tubercle cell) occasionally in small quantity." (B. andF. Med.-Chir. Rev., Am. ed., April, 1855, p. 379.)—Note to the fifth edition. 78 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. consequence partly of the muscular debility of the patient, which renders him unable to use the necessary efforts, partly/in all probability, of that insensi- bility which creeps over the system, and prevents any impression upon the sensorium by the matter which may exist, or be accumulating in the lungs. Dyspnoea.—This is a much less prominent symptom in phthisis than might be supposed. Very often in the early stage, and not unfrequently m the second, till within a short period before death, the patient is scarcely sensible of any difficulty of breathing; and it is not uncommon for persons in this complaint to expand their chest to its full limits, in order to show how free they are from disease of the lungs. This frequent exemption from dyspnoea is probably owing, in the first stage, to the very gradual progress of the tuber- culous encroachment, which enables the system to accommodate the quantity of blood produced to the capacity of the lungs; and, in the second, when the encroachment is more rapid, to the colliquative sweats and diarrhoea, which, while they exhaust the strength, have the compensatory effect of duly propor- tioning the circulating fluid to the diminished extent of the respiratory func- tion. The feeling of dyspnoea, being generally owing to an insufficient change of the blood in the lungs from venous to arterial, is not experienced when all the blood which the system requires passes through these organs, and under- goes the requisite alteration in its passage. But when the patient uses un- wonted exertion, he becomes more or less short of breath, because the lungs are inadequate to the due aeration and transmission of the increased quantity of blood sent to them in a given time, in consequence of the heart's increased action. Sometimes, however, severe dyspnoea is experienced in phthisis, especially towards the close. This is peculiarly liable to happen when the disease is complicated with pleuritic effusion, or pneumothorax. I have known a patient to maintain steadily, for one week before death, a sitting posture, leaning forward with his head resting upon the hands of his nurses, because extreme dyspnoea rendered any other position insupportable. In the cases of diffused miliary tubercles, which sometimes rapidly deteriorate the powers of respiration, and produce speedy death, dyspnoea may be through- out the disease a somewhat prominent symptom. Pains.—Pains in the chest are not usually among the most striking phenomena in consumption. In many cases they are slight, and in some are almost wholly wanting throughout the complaint. There are, however, in- stances in which they are frequent and severe ; and, in the majority of cases, the patient is subject to sharp fugitive pains, attacking various parts of his chest, sometimes ascribable to inflammation of the pleura, sometimes merely neuralgic. Occasionally, neuralgic pains are felt in other parts of the body. Hemorrhage.—This is one of the most prominent features of phthisis. Sometimes, as before stated, it appears to usher in the disease ; but more fre- quently occurs in the course of it. Even in the latter case, however, it is apt to be regarded by the patient as the initial symptom, because the cough which may have preceded it has scarcely been noticed. In some instances, the hemor- rhage is copious ; but, in a greater number, is slight, and in itself insignificant. It almost always yields speedily to remedies, or subsides spontaneously. In some cases there is only one attack, in others the attacks are frequent ■' and they are more apt to occur in the first than in the second stage of the disease. The obstruction of a portion of the lungs necessarily produces congestion in other parts of the organ, which is probably the immediate cause of the hemor- rhage in most instances. In the latter period of the disease, this congestion is relieved by the copious purulent secretion, not to mention the night-sweats and diarrhoea ; and the hemorrhagic predisposition is thus diminished Those rare instances in which a sudden and copious hemorrhage overwhelms the CLASS III.] PHTHISIS. 79 lungs, in advanced phthisis, are usually ascribed, and probably with justice, to the opening of a large vessel in the course of the pulmonary disorganization. Though a frequent symptom, there are many cases in which haemoptysis does not occur from the commencement to the end, unless so far as merely to stain the sputa. Out of 87 cases noticed by Louis, it was observed in 57. It is among the most certain diagnostic symptoms of phthisis. When a patient, with a chronic cough and emaciation, spits blood copiously, he may be re- garded as almost certainly tuberculous. Louis goes much further than this, and states that, since his attention had been directed to the subject, he had seen haemoptysis in no other affection than phthisis, except in females at- tacked suddenly with amenorrhcea, and in cases of external violence. (Diet. de Med., xxiv., 344.) The same author, in his great work on phthisis, ex- presses the opinion, that, with the exception just named, haemoptysis indi- cates, "in a manner infinitely probable, whatever may be the period'of its appearance, the presence of tubercles in the lungs." (Recherches, p. 194.) But I am convinced that this most accurate observer has, in this instance, permitted himself to draw an incorrect general inference from his personal observations. I presume that every practitioner of large experience, in this country, has known many instances of spontaneous hemorrhage from the lungs, in male subjects, from which the patients have perfectly recovered, without, through the subsequent course of their lives, evincing any signs of phthisis. Such cases have repeatedly fallen under my own observation; and there are men to be seen daily in our streets, in good apparent health, whom I know to have suffered with haemoptysis at various periods from ten to thirty years since. It is hardly probable that all these cases are examples of the cure of phthisis. Besides, what is there in the structure or position of the bronchial mucous membrane, which should exempt it from an affection so common in other mucous membranes ? I have insisted more than I other- wise should have done on this point, because I believe that the impression of the almost certainly fatal significancy of hemorrhage from the lungs, is calcu- lated to do much harm, by alarming patients, and discouraging their medical advisers. The affection is more frequent in women than in men, and is very rare in children. Frequent Pulse.—Fever.—Night-sweats.—Next to the cough, there is probably no symptom more constant than a frequent pulse. An obstinate continuance of these two symptoms alone should always be regarded with great solicitude, unless they have some other obvious cause than tubercles. The frequency of pulse often begins early, and continues steadily until the close of the disease. It is usually increased in the second stage, when it not uncommonly amounts to 120, and sometimes to 130, or even more, in a minute. In some cases, however, the pulse is unaffected as to its frequency through the whole course of the disease. It is in general very much accele- rated by exertion. In the early stage, there is often, as before stated, a slight irritative fever, with flushed face and heat of hands and feet, coming on especially towards evening. The source of this affection is not by any means always obvious. It occurs sometimes when no inflammatory action can be shown to exist in the lungs, and cannot, therefore, be certainly ascribed to the direct irritation of the tubercles upon the neighbouring pulmonary tissue. It is not improbable that a strong tuberculous diathesis may be capa- ble of generating a moderate febrile movement, in which case, this affection may be a mere accompaniment, and not a result of the tubercles. Neverthe- less, whatever may be its origin, it is certainly often much aggravated by the inflammation produced by the tuberculous deposit, acting as foreign matter in the lungs. As the disease advances, the fever gradually assumes a hectic character, with a tendency to the paroxysmal form, and to perspiration at 80 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. night. This often occurs before the commencement of the second stage perhaps under the influence of the pus secreted by the bronchia or that which may be contained in the tuberculous cavities yet unopened. But it is not until the cavities communicate externally, that the hectic fever as a general rule, becomes decided. The night-sweats are often extremely dis- tressing, giving rise to so much discomfort and exhaustion upon the awaken- ing of the patient, that he often dreads going to sleep. They appear to depend on a debility of the capillaries, which allows the watery portions of the blood to pass without resistance; and they occur during sleep, because then the vital forces, and among them contractility, are at their lowest ebb. Emaciation.—Debility.— Emaciation without apparent cause, in a patient having any other evidences of consumption, is an alarming symptom. Should the appetite fail, or anv obvious disorder of digestion or source of exhaustion exist,- sufficient to account for the loss of flesh, this in itself need occasion little solicitude. It is when apparently independent, that it becomes import- ant as a sign. We know that some vice of system must be sapping its foundation ; and experience has taught us that the existence of tubercles, or perhaps even a strong tuberculous diathesis, is one of the most common of these depravities. Occasionally, in the course of phthisis, the patient gains flesh during the remissions of the disease. This is a most favourable sign; and, if it persevere, even under other circumstances much less favourable, we have good grounds for the cheering impression, either that the disease is not really tuberculous, or that it is undergoing a process of amelioration. The debility is in general scarcely proportionate to the loss of flesh. It not unfrequently happens that the patient is not confined to his bed one day, until very near the close of the disease; and he is often able to walk out almost to the last. It is generally when associated with disease of the stom- ach and bowels, that the debility is greatest. Laryngeal Symptoms.—These may precede the signs of tubercles in the lungs, but much more frequently they come on in the course of the disease, and often not until it has advanced considerably into the second stage. At first, there is some hoarseness, with perhaps a feeling of dryness or huskiness of throat, or some pain in the larynx; and the affection may stop at this point. But not unfrequently, what was at first only inflammation becomes at length ulceration of the larynx, and this in its progress gives rise to loss of voice, difficulty of deglutition, the return of drinks by the nostrils upon attempts to swallow, and a most harassing and sometimes convulsive cough. The affection hastens the fatal issue, and sometimes proves an immediate cause of death through suffocation. (See Chronic Laryngitis.) Stomachic and Intestinal Symptoms.—Little upon this point is required in addition to what has been already stated. In the first stage, the appetite is generally little impaired, though cases now and then occur in which the symptoms of dyspepsia or chronic gastritis appear to precede those of the tuberculous affection, and have given origin to the name of dyspeptic con- sumption, which has sometimes been applied to the disease in this form. The complication is probably merely accidental, at least in most instances. It is not, however, impossible, that the debility arising from deranged digestion may aggravate a previously existing tuberculous diathesis into a more speedy explosion in the lungs. It has been observed that, when chronic gastritis with occasional diarrhoea attends the early progress of phthisis its march is more rapid than under ordinary circumstances. Except as attendants upon the symptomatic fevers that occasionally occur in the course of phthisis it is not usually until the second stage, and even a somewhat advanced period of that stage, that severe gastric symptoms appear. Loss of appetite heat pain, or oppression at the epigastrium, with nausea and vomiting are now CLASS III.] PHTHISIS. 81 experienced. The vomiting is occasionally very obstinate, so that every article of food or medicine is rejected. These symptoms are usually the re- sult of chronic gastritis, the signs of which are very often found after death. The gastritis appears to be a consequence of the unceasing fever, rather than the direct result of a deposition of tubercles in the mucous membrane. Some- times obstinate vomiting occurs, without leaving behind it in the dead sub- ject any marks of inflammation whatever. Diarrhoea also is in general a symptom of the advanced stages. It shows itself in every form, mild and severe, scanty and copious, with and without abdominal pains, sometimes ap- proaching to dysentery, sometimes accompanied with hemorrhage from the bowels, and not unfrequently indicating, by the character of the stools, a per- verted or deficient action of the liver. Unlike the stomachic symptoms, it seems to be most commonly dependent upon tubercles in the bowels, which, by their softening and discharge, give rise to ulcers and inflammation. That the inflammation is the result, and not the cause of the tubercles, is proved by the fact, that the latter are frequently found unattended with the former, in their early stage. The diarrhoea, after having been fully established, is, for an obvious reason, seldom permanently cured. It may often be arrested by medicines for a time, but generally returns, and often hastens the fatal result. Nervous Symptoms.—There is generally a remarkable exemption from nervous disorder, when the duration and severity of the disease are considered. The cerebral functions are very little disturbed, and the intellect usually re- mains unclouded until the close, or near it, unless the membranes of the brain become involved in the tuberculous disease. When there is no disease of the stomach or liver, the patient almost always evinces a cheerful and hopeful frame of mind. He either believes that he will recover, or is calmly resigned to the fatal issue. The powers of self-deception, in this complaint, when the patient is unwilling to admit the idea of death, are truly wonderful. In the last stage of the disease, lying upon his bed, exhausted, breathless, and scarcely able to speak, he assures his medical attendant that he is better, and will soon be about again. Even physicians, perfectly acquainted as they are with the nature of the disease, and the value of the symptoms, are scarcely less apt than others to deceive themselves as to the probable issue. Sexual Symptoms.—In male patients, nothing remarkable occurs in con- nection with the sexual functions. It is otherwise with women. Suppression of the menses is very common, and may generally be considered as increasing the danger. The occurrence of pregnancy undoubtedly, in many instances, arrests for a time, the progress of the disease ; and lactation appears to ex- ercise a favourable influence over it. Alarming symptoms often disappear during gestation ; and it sometimes happens, in young married women, that the disease is kept at bay many years by child-bearing and nursing ; occa- sionally, indeed, so long, that the predisposition appears to be overcome. In most instances, however, it returns after delivery, and sometimes appears to compensate for the lost time by a more rapid march.* * Some observations have been made which tend to throw doubt over this long ad- mitted fact of the influence of gestation in retarding phthisis. But, independently of the general belief, my own personal observation has been such as to render it impos- sible for me to have any doubt upon the subject. I have repeatedly seen the disease, even in its somewhat advanced stages, apparently quite arrested on the occurrence of pregnancy. Two cases are prominent in my recollection. The patients were admitted into the Pennsylvania Hospital, with cavities in their lungs, and all the symptoms of decided phthisis. After a time, they began to improve wonderfully and unaccountably. The general symptoms vanished almost entirely, and they became fat and quite healthy in appearance. This change was found to be coincident with the occurrence of preg- nancy. They left the institution before delivery, and I have never learned what became of them afterwards. (Note to the third edition.) 82 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. Complications.—The laryngeal and gastro-enteric affections already de- scribed, being either the direct result of the same diathesis which produces the pulmonary tubercles, or a secondary effect arising from the tubercles themselves, must be considered rather as parts of the disease than as compli- cations. The same may be said of the bronchial inflammation, which arises from the irritation of the tubercles, or that of the tuberculous matter in its passage, and which is the source of most of the matter expectorated in phthisis, and is scarcely ever quite wanting in the course of the disease. The partial inflammation of the pulmonary tissue, in the vicinity of the tubercu- lous deposit, may be placed in the same category; as may also the pleurisy which results directly from the irritation of the tubercles near the surface of the lungs, or from the escape of the contents of a tuberculous vomica into the pleural cavity. (See Pneumothorax.) Tuberculous meningitis, which occasionally accompanies phthisis, though very rarely in adults, belongs to the same category. For the symptoms of this affection the reader is referred to the article specially devoted to it. There is always reason to suspect it, when vomiting, headache, and a quiet delirium occur. But accidental attacks of all these affections now and then supervene upon phthisis, arising from cold, epidemic influence, or other ordinary cause. In such cases, they are properly complications, and often add greatly to the im- mediate danger, and hasten the fatal result. They differ in various respects from the analogous inflammations constituting a part of phthisis. Thus, they may occur at any period of the complaint; and, if they do' not prove fatal, very generally disappear spontaneously, or yield to remedies, though frequently more obstinate than the same diseases under other circumstances. Their precise seat, also, is not always exactly the same. Thus, accidental bronchitis may attack any portion of the lungs, while that essentially belong- ing to phthisis is confined to the bronchia connected with the tuberculated structure. Accidental pneumonia occupies usually the lower lobes, instead of being limited to the neighbourhood of the morbid deposit. Accidental pleurisy may affect any portion, or the whole of either membrane, even that of the healthy side, and is much more apt to be attended with liquid extra- vasation than the proper phthisical affection. An increase of fever generally attends these phlegmasia?, and the existence of some one of them may be sus- pected, when a consumptive patient is suddenly seized with chill, followed by fever, not presenting the proper hectic characters. There are diseases between which and phthisis a certain degree of incom- patibility is thought to exist. Thus, consumptive patients are little disposed to attacks of acute rheumatism ; and to this circumstance it is ascribed by Dr. T. K. Chambers that, of a large number of cases of pericarditis examined in St. George's Hospital, London, a very small portion relatively was asso- ciated with tubercles of the lungs. (Med. Times and Gaz., v. 455.) Roki- tansky teaches that cyanosis affords a complete protection against tuberculo- sis, and that whatever produces a similar venous condition of the blood, has more or less of the same protective effect. Though this is, perhaps, gene- rally true, it is not so universally; for a case is on record in which the two affections existed conjointly. (Assoc. Med. Journ., March 10,1854, p. 222.) Few habitual drunkards are attacked with phthisis ; and the exemption may possibly be owing to a somewhat similar carbonaceous condition of the blood. It has been supposed that miasmatic fevers afford some protection against tuberculous disease ; but proof is yet wanted of the truth of this conjecture. There can be little doubt, however, that, as a certain condition of the blood favours the development of tubercles, so there may be diseases which may have a contrary effect, by their influence upon that fluid. Physical Signs.—In the earliest stages these are very equivocal. When CLASS III.] PHTHISIS. 83 the deposition is considerable, some dulness may be perceived in percussion under the clavicle, and upon that bone. This sign is more significant, if the dulness upon one side is decidedly greater than on the other, and especially if greatest upon the left side. A similar inequality of sound upon the two sides exists in emphysema and pneumothorax, the diseased side being, in these cases, more sonorous than the other; and there may be some danger that the diseased side may be considered healthy, and the sound side tuberculous. But the mistake may be avoided by recollecting that, in both of these affec- tions, the respiration is feebler where percussion is most sonorous, than where it is least so. If the dulness be very slight, some advantage may be derived from the fact, that the increase of clearness on percussion, during a full inspi- ration, is greater on the sound than on the affected side. An emphysematous condition of the lung, in the vicinity of the tubercles, may render this sign nugatory by compensating for the partial solidification, so that the percussion may not materially vary from that of health. Among the first deviations from health discovered by auscultation, is feeble- ness of the respiratory murmur below the clavicle. While this is observed in one part, another may yield a more than usually loud sound, in consequence of being compelled to perform a greater amount of duty. As the consolida- tion advances, the respiration becomes somewhat rough, or even bronchial, with a considerable prolongation of the expiratory sound, which is one of the most striking characteristics of this stage of tuberculous deposition. At the same time, the inspiration is sometimes interrupted, wavy, or jerking. The sounds of the heart are more distinctly audible in the part. The vocal reso- nance, and that of the cough, are also increased ; but it must be remembered that, near the sternum, both bronchophony and bronchial respiration are heard in health ; so that, in order to be of any weight as signs of tubercle, they must be found towards the humeral extremity of the clavicle. Allowance must also be made for the natural difference of the two sides, in respect to these sounds. (See vol. i., p. 789.) It is said that the greater extension of healthy bron- chial respiration, more or less pure, on the right side than the left, is most observable in females. Hence, in relation to these, special care must be ob- served not to mistake the normal for an abnormal state. Another physical sign is the increased vibratory motion from the voice, felt by the hand applied to the sub-clavicular space. All these signs may also, in general, be per- ceived, though in a less degree, over the upper portion of the scapula, behind. They indicate solidification, more or less complete, of the pulmonary tissue; and, when this takes place under the clavicle without the ordinary evidences of acute pneumonia, the probability is very strong that it is owing to tubercles. In a more advanced state of the deposition, the mucous and subcrepitant rales, and occasionally also the sonorous and sibilant rales, make themselves heard in the same position. These are the sounds of catarrh; but this, occur- ring as an original disease, commonly affects other regions of the lungs. Percussion is still more dull than before, and the vibrations produced by the cough and voice still more perceptible by the hand. Very frequently too the upper part of the chest is obviously contracted or sunken, and there is less movement of the ribs in respiration. This sinking is probably owing in part to atrophy and shrinking of the pulmonary tissue, partly to the formation of false membrane between the pleural surfaces, and the contraction which it undergoes in the process of organization. Another sign consequent upon the formation of false membrane is the friction sound, which may sometimes be heard for a short time; but it is so fugitive as usually to escape notice. I have repeatedly observed also a creaking sound, which I have ascribed to the flexion of organized false membrane consolidating the opposite pleural surfaces. In general, the progress of the formation of a cavity can be followed 84 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. with considerable accuracy. At first, a loose crackling sound will be heard during inspiration, at a point where induration exists; the bubbles become more numerous, larger, and somewhat more diffused, and are audible both in inspi- ration and expiration ; and finally all the signs of a cavity are perceptible. After the vomica? have opened, and begun to discharge their contents, per- cussion usually remains dull, the increased vibratory movement of the wall of the chest with speaking and coughing continues, and the contraction of the sub-clavicular space and its comparative want of motion, are still observable. But the characteristic sounds of cavities are now perceived; as the cavernous rale or gurgling when the cavity is partly filled with liquid, cavernous respi- ration and resonance of the voice and cough, and at length pectoriloquy. Skoda denies that these signs can be certainly relied on, as all of them, even pectoriloquy, may arise from a condensed lung without a cavity. Yet, when they are all perceived, there can be little doubt upon the point, especially when their indications are in accordance with those of the general symptoms. When the cavity is very large, the vibrations produced by the voice imme- diately over it, are diminished, but they are increased at the margin, where the lung is solidified. Frequently, in large cavities, the respiration becomes amphoric, the voice acquires an amphoric resonance, and the sound denomi- nated metallic tinkling may be heard. This is particularly the case when the walls of the cavity are very firm, approaching the consistence of cartilage. These are unfailing signs. When other means fail, the existence of a cavity may sometimes be detected by a sound of fluctuation produced by coughing, or a slighter sound of the same nature occasioned by the impulse of the heart on the contained liquid. It has been stated that percussion usually continues dull in this stage. It is so occasionally for a very considerable extent. But, in some cases where the cavity is very large, and near the surface, it yields a hollow tubular or somewhat tympanitic sound, such as is produced by per- forming percussion over the trachea, or an amphoric sound like that which results from striking the distended cheek, or finally, the bruit de pot fele of Laennec, or cracked-metal sound, which is compared by Dr. Walshe to that occasioned when the hands, loosely folded, are struck against the knee so as to allow air to be forced out from between them.* In relation to the indi- cations afforded by percussion, it must be remembered also that the tissue, not occupied by the tubercles, but in their immediate vicinity, not unfre- quently becomes more or less emphysematous, and consequently increases the resonance upon percussion. This is sometimes so great as to overbalance the pulmonary solidification. Even the increased respiratory duty performed by these unaffected parts, in consequence of the want of action in the consoli- dated portion, may occasion greater resonance on percussion, through the larger amount of air admitted, independently of emphysema. It is obvious that all these circumstances must be considered, in forming an estimate of the value of percussion signs in the diagnosis of tubercles. Hutchinson's spirometer may sometimes be advantageously resorted to, in order to ascertain the rate of progress of the disease. (See vol. i., page 805.) * This sound, which was supposed by Laennec to indicate the presence of air and fluid in a pulmonary excavation, may, according to Walshe, be produced without the presence of fluid, all that is necessary being a large anfractuous cavity communicating freely by several openings with the bronchia. The cause of the sound' is probably the vibrations produced in the sides of the bronchia, as the air is driven into them from the cavity by percussion over it. A proof of this is that if, during percussion the mouth and nostrils be firmly closed, the sound is not emitted, because resistance is afforded to the entrance of air into the passages. Dr. R. C. Golding observed this peculiar sound to be produced by percussion over a circumscribed sub-pleural emphysema in the unner part of the lung, the air from which was driven by the blow into the surrounding cellular tissue, and returned on the cessation of the impulse. (Lond. Med. Gaz. July 1848 p. 83.)—Note to the second edition. *' ^' ' CLASS III.] PHTHISIS. 85 Course, Duration, &c.—Upon these points it is necessary to add some- thing to the general description already given, in order to present a com- plete view of the disease. The duration of phthisis is exceedingly variable. While some cases run their course to a fatal termination in less than a month, others have been known to continue thirty or forty years. The greater number of cases probably terminate in from one to two years. When the disease is very rapid, it is sometimes denominated acute phthisis, or vul- garly galloping consumption. Its whole duration is only one, two, or three months; and sometimes death occurs in the third week. It is associated with different pathological conditions of the lungs. In one variety, miliary tuber- cles are diffused, in countless numbers, through the pulmonary tissue; and the diffusion is pretty uniform, except that there may be a somewhat greater accumulation towards the summit of the lung. These tubercles in general do not advance even to the yellow or crude state before death. Sometimes they may be attended with infiltration of gray matter, which also remains, throughout, in its first stage. There may occasionally be some softening of the tubercles in the upper part of the chest, and possibly a few small cavities in the more protracted cases. The attack in these cases is usually sudden, and the disease quickly acquires great violence. The symptoms, almost from the outset, are dyspnoea, severe cough, occasional pains in the chest, great frequency of pulse and respiration, a hot skin, headache, loss of appetite, and other marks of considerable fever. The expectoration is not generally co- pious, and is exclusively bronchial; never exhibiting the peculiar purulent sputa of ordinary phthisis in its second stage. Occasionally there is hemor- rhage. As the disease advances, the symptoms acquire greater intensity, though sometimes a remission is observable, even in their short course. Towards the last, the pulse and respiration become exceedingly frequent, night-sweats occur, and the patient rapidly emaciates, though not to the same degree as in the more chronic forms. The ordinary physical signs of phthisis are often wanting. There may be no peculiar dulness under the clavicle, no signs of extensive consolidation anywhere, and none of the marks of a cavity. The clearness upon percussion may be somewhat diminished here and there; and the respiration may be feeble in some points, and puerile, rude, or some- what bronchial in others. The sibilant, sonorous, mucous, and subcrepitant rales of bronchial inflammation are heard in various parts of the chest. The steady perseverance of mucous or submucous rales, in the same parts of the chest, and over large portions of it, quite unaltered by treatment, indicating the permanent presence of some irritating agent, has been among the signs upon which I have most relied in the diagnosis of this form of phthisis. That the disease is not pleurisy or pneumonia will be inferred from the want of the characteristic signs of these affections. Bronchitis exists, but the onward course of the disease, the greater frequency of pulse and respiration, the oc- casional presence of haemoptysis, and the occurrence of night-sweats without purulent expectoration, evince that there is something more, and this can be phthisis only. Death, in these cases, appears to arise from the interference of the tubercles with the functions of the lungs, and the exhaustion of system from the wearing effect of the local irritation. Another variety of acute phthisis, presenting almost the same symptoms, and equally wanting the peculiar purulent expectoration of the ordinary dis- ease, is connected with a rapid and copious deposition of tuberculous matter, so as to produce almost complete consolidation of a large portion of the lungs, or perhaps of one whole lung, and thus destroy life before the tubercles have had time to reach the second stage. Portions of the tuberculous depo- sition may in these cases be yellow and opaque, and even softened; but they have formed little communication with the bronchia. In such cases, the 86 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. peculiar physical signs of the first stage of phthisis are observable in a marked degree. , ,, +, A third variety of the acute disease is that which runs through all the stages with great rapidity. In these, the whole train of symptoms character- izing the last stage of ordinary phthisis, including the peculiar sputa comes on in the course of a few weeks; and physical examination evinces beyond doubt the existence of vomica?, sometimes of considerable size. Such cases sometimes follow an attack of copious haemoptysis, or supervene upon inflam- matory affections of the lungs, and febrile diseases of various kinds. Ordinary phthisis, even when of considerable duration, is sometimes regu- lar in its march, beginning in the usual insidious manner, and steadily ad- vancing, with little or no remission, to its fatal close. But much more frequently it undergoes temporary interruptions; and, in many instances, the occasional signs of amendment are so considerable that both the patient and his friends indulge strong hopes of a favourable issue. The general and local symptoms abate, the appetite and digestion improve, and the patient gains strength and flesh. These changes occur both in the first and second stages, and, in some cases, several times in the course of the disease. Occasionally they may be traced to some known cause. Thus, the occurrence of preg- nancy, as before stated, may partially or entirely supersede the symptoms of phthisis, even though advanced into the second stage ; and the same favour- able influence is in some degree exerted by lactation. An external direction, also, of the scrofulous disease appears to divert the tendency to tuberculous deposition from the lungs. This was strongly insisted on by the late Dr. Jos. Parrish, of Philadelphia, as one of the results of his extensive observation. I recollect well two instances of the disease in women of middle age, in which the symptoms of phthisis rapidly followed the disappearance of a long-con- tinued scrofulous swelling of the neck, and appeared to have been kept back by the external affection. The influence of fistula in ano, and of old ulcers in the leg, in restraining the progress of phthisis, must be familiar to the ex- perience of most practitioners who have seen much of the disease. Not un- frequently, also, the amendment occurs simultaneously with the return of mild weather, which not only appears to exercise a directly favourable influ- ence over the tuberculous diathesis, but is indirectly useful by favouring exercise in the open air. Some consumptive patients appear to regain in the summer what they lose in winter, and run on for many years, sometimes even to the end of a long life, never entirely free from tuberculous disease in the lungs, and yet enjoying much comfort in existence. I was for many years in the habit of attending a gentleman with this disease, who died at the age of seventy, and had suffered with coagh, some dyspnoea, and occa- sional attacks of hemorrhage from the lungs, from an early period of life. These alternations in the symptoms of phthisis are explained by the fact, that the tubercles are often deposited, not continuously, but in successive crops. Those first deposited advance to maturity, are discharged through the bronchia, and leave cavities which have a tendency towards health. Should the predisposition not be strong, and nothing occur to call it speedily into action, no new deposition may take place until the first crop has ceased to exert any unfavourable influence on the system, and the patient apparently recovers his health. Indeed, there is every reason to believe that permanent recoveries occasionally take place in this way. But much more frequently a fresh deposition occurs before the disappearance of the symptoms or soon afterwards; and thus the disease only remits, or returns after having seemed to cease. Still more frequently, the process of amendment has had time to make but little headway, before the new crop is sown, and then the remission is but slight. In other cases, again, either the original deposit is sufficient CLASS III.] PHTHISIS. 87 to destroy life in its course towards maturation, or the progress of deposition is so constant as to sustain a nearly regular advance in the symptoms, until the lung becomes unfit for duty. Cases sometimes occur, in which the most cheering signs of amendment appear, so far as regards the general symptoms; while to physical exploration the lungs yield evidence, not only of undimin- ished disease, but of a continual progress of disorganization. In these cases, of course, the favourable symptoms are altogether deceptive. No case can be considered as having undergone a real amendment or cure, unless the physical signs coincide with the general symptoms. Sometimes phthisis is latent so far as regards the ordinary signs of its ex- istence, and continues so until a short period before the end. The tuber- culous deposition takes place slowly, so as not to excite sensible irritation in the surrounding tissue, which, therefore, undergoes the necessary absorption or condensation, without any of those external expressions which constitute the early symptoms of the disease. Accumulation may thus gradually go on, and the tuberculous matter pass through all the regular changes, until one or more large collections are formed. These now make themselves felt by the inflammation necessary to effect their discharge; and, wrhen the com- munication with the bronchia is opened, the irritating influence of the pus superadds bronchitis; and all the symptoms of the last stage are speedily developed. But another cause of the occasional latency of phthisis is, that tubercles after deposition, and a certain degree of advance, cease to make further progress, becoming, as it were, indolent, and sometimes remaining so for years. There is, indeed, reason to believe that in such cases they some- times undergo absorption, and leave only calcareous matter in the place of the tuberculous. Nature and Causes. Phthisis does not consist merely in the deposition of tubercles in the lungs, and its consequences. There is, besides, a morbid state of system which pre- cedes and attends the deposition, and upon which it probably depends. This state of system is commonly denominated the tuberculous diathesis or predis- position. It is either identical with the scrofulous diathesis, or closely analo- gous to it, and has been sufficiently treated of, in a general way, in the section upon general pathology. In the present place, it is considered only in its relation to pulmonary tubercles. What is the exact nature of this diathesis is unknown. It may consist essentially in a certain laxity of the tissues, which leads to weakness or perversion of function, so that, instead of well elaborated material for the purposes of nutrition, there is separated from the blood a peculiar product, of the lowest grade of vital force, with the tendency to degeneration fixed upon it, which exists as foreign matter in the midst of the living structure. It is possible that the blood also may be in fault. The only defect, however, which has been shown to exist in it, is a want of the due proportion of red corpuscles, and this defect has not been proved to be essential. It goes on increasing with the advance of the disease (Andral and Gavarret), and may, in this state of things, be as much the result as the cause of tubercles in the lungs. The fibrin of the blood is sometimes redundant in the course of the complaint; but this appears to be owing to the inflammatory affections which so often attend it. But, whether the blood is in any degree essentially perverted or not, this much may be con- sidered as certain, in relation to the tuberculous diathesis, that it is accom- panied with a reduction of the vital forces below the healthy standard, or, in other words, is a condition of debility. What else there may be cannot be told in the present state of our knowledge; though, that there is something besides mere debility, is sufficiently obvious from the consideration, that an 88 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. equal degree of this condition often exists without any production of tubercle, or any apparent tendencv towards it. The causes of phthisis are either those which create this morbid state of system, or those which call it into action, when it might otherwise remain quiescent. These will be separately considered under the heads of predis- posing and exciting causes. 1. Predisposing Causes.— Decidedly the most influential of these, so far as known, is inheritance. Phthisis is pre-eminently a hereditary disease. One parent very often entails it upon the offspring, and both still more frequently. Whole families thus descended are not unfrequently swept away by this fear- ful malady. Even where the immediate descendants of consumptive parents escape its developed form, they nevertheless often retain the predisposition, and hand it down to their children. So strong is the influence of this cause, that a mere suspicion of the existence of pulmonary consumption, arising from an observation of the symptoms, is strengthened into conviction by the known possibility of an inherited taint. Next, perhaps, in the degree of influence, is cold. Allusion is not here made to the vicissitudes of weather, which so frequently occasion attacks of inflammation. Cold may act in this way as an exciting cause ; but its most pernicious agency is probably connected with its long-continued and steady application. Moderate and temporary reductions of temperature are often indirectly tonic, by the reaction they occasion. But, under a steady continu- ance of cold, the power of reaction at length becomes exhausted, so that a condition of debility ensues; and experience has shown that the debility thus induced often assumes the character of the tuberculous diathesis. Hence, chiefly, the greater prevalence of the disease in cold than in warm climates. It is true that phthisis is said to be less prevalent in the coldest regions of the north, as, for example, in Russia, and the regions about Lake Superior, upon this continent, than it is in the more temperate latitudes. But this apparent anomaly is easily explained. The inhabitants of the north suffer in fact less from cold than those further south. The intensity and steadiness of the cold in the former regions lead to precautions, both as to dress and dwellings, which effectually guard the inhabitants against its injurious influence; while the variable temperature of the latter, causing the clothing which may be no more than comfortable one day, to be oppressively hot the next, induces a disposition to submit to some inconvenience from the cold rather than to have the trouble of constant changes. The dryness, too, of the air in the north, and its consequent feeble power of conducting heat, has much influ- ence in obviating injurious effects.* It is a great mistake to attempt to harden the body against the inclemencies of the weather in winter by light clothing in the day, and insufficient covering at night. Many may succeed, but many also will perish in the process. This fact has been strongly ex- emplified within my own observation. Negroes, from their greater suscepti- bility to cold than the whites, are much more subject to phthisis in cold or temperate climates. Whatever has a tendency to produce permanent or long-continued debility will generate, in some individuals, the consumptive diathesis. Hence, we may * From observations made during a visit, in the summer season, to England I was strongly impressed witli the conviction, that the great prevalence of phthisis in that country is owing, in part, to the coolness of the summer, which is often so great as to be uncomfortable, but is not sufficiently guarded against, from the inconvenience of frequently making fires, and changing clothing. The robust resist the sedative influ- ence, and from the reaction of their systems are apparently invigorated • but the feeble and those predisposed to phthisis, sink into that state of general depression which is most favourable to the deposition of tubercle. (Note to second edition.) CLASS III.] PHTHISIS. 89 enumerate among the predisposing causes, besides that just mentioned, an insufficient diet whether as to quantity or nutritive properties, living in an unwholesome air, sedentary habits, exhausting indulgences, grief, anxiety, dis- appointment whether of the affections or in business and all other depressing emotions, long watchings, copious evacuations both spontaneous and artificial, the abuse of mercury, and the influence of various debilitating diseases. The history of phthisis affords numerous instances in which the above causes, singly or combined, have induced the disease ; for, when the diathesis is suffi- ciently strong, no exciting cause is required to aid those which are here, not perhaps with strict propriety, denominated predisposing. 2. Exciting Causes.—Anything which is capable of irritating or inflaming the lungs, of producing in them an unusual influx of blood, or an unusual secretory effort, may act as an exciting cause of the deposition of tubercles, in persons predisposed to them. What would, in other persons under such circumstances, be organizable fibrin, or a product amenable to the vital pro- cess of absorption, becomes in these, in part at least, the matter of tubercles. Thus cold, which by its continued action is a powerful cause of the diathe- sis, is, by its intermittent action, a no less powerful exciting cause of the local affection. It operates chiefly by producing catarrh, though pneumonia and pleurisy, which are equally the result of it, appear sometimes to be the immediate predecessors of the tuberculous deposition. Other causes, capable of producing bronchitis or pneumonia, may through these give rise to the development of phthisis. Such are the inhalation of acrid gases or vapours, or irritating powders, any habitual and excessive exertion of the lungs, and external violence. The febrile movement appears to be an efficient exciting cause; as are also the suppression of long-continued morbid evacuations, the too hasty resolution of external scrofulous tumours, the healing of old ulcers, especially fistula in ano, and the cessation of the menses and of child-bearing. Tight lacing has been accused of frequently inducing consumption; and it is highly probable that, by interfering with the functions of the lungs, it may favour the formation of tubercles in those predisposed to them. There are certain influences, which, though referrible to one or both of the above heads, require a separate notice. Age is not without influence in the production of phthisis. The time of life at which there is the greatest proneness to the disease appears to be for some years after the cessation of growth. The force of nutrition, or that by which the aliment prepared by the processes of digestion and sanguification is ap- propriated to the growth or repair of the organs, is now much diminished, and probably in a greater degree than that of the two functions intended to supply it with material. This material, therefore, being in excess, is thrown out in a less elaborate condition, and, in those of a consumptive constitution, takes the form of tubercle. In this view of it, age may be considered as an exciting cause of the disease. Perhaps the ten years in which the greatest number of cases of phthisis originate are from seventeen to twenty-seven. It will be observed that this is somewhat different from the age at which the greatest number of deaths occur. This, according to Sir James Clarke, is from twenty to thirty. Louis places it between twenty and forty. The pe- riod of life in the next degree prolific in phthisis is infancy. Sex.—The disease is much more common in women than in men, occurs in them at an earlier age, and is generally more rapid in its progress. There are various causes for this difference. In the first place, the original organi- zation of the female is more delicate, and exposes her consequently more to diseases of relaxation and debility. In the next place, the sedentary habits of women, as well as their greater sensibility and probably greater exposure to the various depressing emotions, and their frequent and anxious watchings VOL. II. 7 90 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. in the confined and impure air of the sick chamber, have no little influence in producing the consumptive diathesis. Though less frequently exposed than men to the exciting causes, they are, from their previous habits of life and modes of dress, much more readily affected by them. Of 123 hospital cases noticed by Louis, 70 were in women. It is probable that the propor- tion of females is even larger than this in the higher walks of life. The earlier age at which woman attains her full growth, accounts for the earlier occurrence of the disease, as a general rule, in her case. Occupations.—The sedentary occupations are much more favourable to the occurrence of consumption than those which require vigorous exercise, especially in the open air. Hence weavers, tailors, milliners, sempstresses, teachers, students, and the inmates of convents and penitentiaries, are thought to be peculiarly liable to it. Occupations which expose the individual to the inhalation of acrid or irritating particles of matter, such as stone-cutting, dry- grinding, feather-dressing, and brush-making, are accused of a tendency to develope the disease. Residence.—The influence of a cold climate has been already noticed. It is thought that a damp and variable climate is more injurious than one which is steadily cold and dry. Even within the same country, consumption is found to prevail more in low and damp situations, than in those which are elevated and dry. The sea-coast is peculiarly liable to it, partly, in conse- quence of its exposure to the dampness of the ocean, but probably still more from the saline particles which are driven up into the air during storms and by the breakers, and serve to irritate the lungs when inhaled. On this account it is, probably, more than from difference of latitude, that Philadelphia is less exposed to phthisis than New York or Boston; for there is little differ- ence between these two latter cities. The climate in the north-western por- tions of our country, in the vicinity, for example, of Lake Superior, is said to be highly favourable to consumptive patients, in consequence of its uni- formity and dryness in winter.* Other Diseases.—These act in producing phthisis, partly by the relaxed and debilitated state in which they are apt to leave the system, and partly by a direct irritant influence upon the lungs, favouring the development of tubercles. It is, however, denied by some, and by Louis among the number, that the inflammatory pulmonary affections have been proved to exercise more influence in inducing phthisis than other diseases of a febrile character. But" the general experience and opinion of the profession are in opposition to this view. Some go so far as to maintain that tubercles always originate from inflammation, acting on a peculiar diathesis. But this dogma has certainly never been proved. Tubercles have frequently been observed, without the least evidence of inflammation, other than that which is afforded by their own existence; and to assert this as a proof is to beg the question. The truth probably lies between these extreme opinions. There can be little doubt that tubercles are often deposited from the mere intensity of the dia- thesis, without the slightest inflammatory excitement of the part • and this I am disposed to think is most frequently the case; but there is' I think as little doubt, that active congestion or inflammation often causes an earlier * This is confirmed by the reports of the officers of the TJ. S. army stationed in those regions; and, in a communication made by Dr. S. Kneeland to the Boston Medical and Surgical Journal, for Jan. 7,1858, it is stated that the writer, who passed nearlv a vear in the vicinity of Lake Superior in 1856-7, never met with a case of phthisis'durine the period of his residence there. A similar statement is made by Dr Haves one of the officers who attended the late Dr Kane's exploratory voyage into the Arctic regions in relation to the absence of tuberculous disease among the Esquimaux f% r„. • wj ' j Surg. Journ., Nov. 1857, p. blS.)-Note to the fifth edition. qUlmaUX- 0S<- Lo™ M^. and CLASS III.] PHTHISIS. 91 development than would otherwise take place, and sometimes perhaps gives rise to them, when, without its occurrence, the patient might escape alto- gether. The diseases which are peculiarly prone to be followed by phthisis are measles, smallpox, scarlatina, hooping-cough, typhoid fever, and the pul- monary inflammations, bronchitis, pleurisy, and pneumonia. Diagnosis. It is in general only in the first stage that there is much difficulty in recog- nizing phthisis. When a short cough, either quite dry or attended only with a slight mucous expectoration, continues for weeks or months, with more or less general emaciation, which cannot be explained by a loss of appetite or any apparent failure of digestion, there is reason to suspect the existence of tubercles. If to these symptoms are superadded irregular pains between the shoulders or about the breast, frequency of pulse, and shortness of breath upon exertion, the suspicion becomes very strong. An attack of haemoptysis would now complete the proof. In the absence of this, or in connection with it, the occurrence of dulness upon percussion in the subclavicular region, and any considerable deviation from their healthy character in the respiratory sounds, or vocal resonance, in the same part, would, in addition to the symp- toms above mentioned, render the existence of phthisis quite certain. But, in numerous instances, the characteristic symptoms and physical signs are much less distinct; and in all doubtful cases it is best, before giving a decided opinion, to wait for the development of further evidence. This is afforded by the appearance of the peculiar expectoration already described, the occur- rence of hectic fever, and the physical signs indicating a cavity near the sum- mit of the lungs. There is, however, one condition of the disease in which the physical signs often quite fail in establishing the diagnosis, and it is necessary to depend upon the somewhat equivocal evidence of the general symptoms. Allusion is here had to the form of acute phthisis characterized by the diffusion of miliary tubercles. A pr.etty good guess may be made, in instances of this kind, from the character and course of the symptoms; but the only absolute proof is that afforded by dissection.* Bronchitis is the complaint to which phthisis bears the closest resemblance in its general symptoms, and with which it is most liable to be confounded. But in the early stage, this affection, if sufficiently severe to impair the general health, is accompanied with more fever than phthisis, and, if mild, does not then present the emaciation, nor, in general, the frequent pulse of the latter affection. It is, moreover, unattended with haemoptysis; the ex- pectoration is usually much more copious than in the tuberculous affection; and the disease, instead of remaining long stationary or advancing slowly, is marked by successive and comparatively rapid stages of progress and decline. Those auscultatory signs which are common to the two affections are in bron- chitis spread more or less over the lungs, while, in phthisis, they are confined to the upper portion; and the dulness on percussion beneath the clavicle, as well as the sinking of the chest at the same spot, so characteristic of the latter, are wanting in the former. The greatest difficulty is in discriminating between bronchitis, and those cases of acute phthisis in which miliary tuber- cles are disseminated equably through the lungs. As before stated, the phy- sical signs may here fail entirely; but there is a difference in the physiognomy of the two diseases by which they can be distinguished with much probability, * M. Beau believes that he has discovered an almost invariable symptom in phthisis, which may be useful in the diagnosis of doubtful cases. This is tenderness on pressure with the finger in the anterior intercostal spaces, near their sternal extremity. In the early stages, this is confined to the upper spaces, being greatest in the first. (See Ed. Month. Retrosp. of Med. Sci , A. D. 1849, p. 200.) 92 LOCAL DISEASES.---RESPIRATORY SYSTEM. [PART II. if not an approach to certainty. The points of this difference have been already referred to. (See page 85.) The persistence for a long time of a mucous or submucous rale throughout one or both lungs, unchanged by all the treatment which usually proves effectual in chronic bronchitis, and attended with emaciation, frequent pulse, night-sweats, and other general symptoms of phthisis, would indicate with some degree of certainty the existenceof the miliary form of that complaint. In the advanced stages of the two diseases, there is in general little difficulty in the diagnosis. The absence of the pecu- liar sputa of phthisis (see page 77), the inferior degree of emaciation, the total want of dulness on percussion and of the ordinary signs of a cavity, together with the previous course of the complaint, and its exemption from attacks of haemoptysis, are sufficient to distinguish the bronchial from the tuberculous disease. It is only when dilatation of the tubes coincides with bronchitis, that material embarrassment occurs. In such cases, signs of a cavity exist; but this cavity is not often at the summit of the lungs, the resonance on per- cussion is not so much diminished as in phthisis, and the character of the signs is more unchangeable; and these circumstances, taken in connection with the absence, or much less degree, of some of the characteristic general symp- toms of tubercles, such as pains in the chest, emaciation, tuberculous expecto- ration, and occasional haemoptysis, enable the practitioner, for the most part, to arrive at a just conclusion. Pneumonia in its chronic form, which might present some analogy with phthisis, is a very rare disease, and still more rarely occupies the upper part of the lung. The previous course of the symptoms would also serve to dis- tinguish the affection. If attended with an abscess, it might be discriminated with greater difficulty; but the situation of the abscess in the lower lobe, and the previous signs of pneumonia, such as the crepitant rale followed by bron- chial respiration, and the rusty and viscid sputa, would be sufficiently diag- nostic. Gangrenous abscess may likewise be distinguished by its lower posi- tion, as well as by the intense fetor of the expectoration, and the want of the characteristic tuberculous sputa. Cirrhosis of the lung might readily be confounded with phthisis; but the diagnosis will be given when the former affection is considered. Pulmonary emphysema occurring near the summit of one lung only, and attended with catarrh, might lead to the suspicion, in consequence of the greater sonorousness on percussion of the side affected, that the sound side" might be the seat of tubercles ; but the affection may be distinguished by the greater feebleness of respiration on the more sonorous side, and by the swell- ing or bulging of the chest often attendant on emphysema. Pneumothorax, which might possibly be mistaken for a large tuberculous cavity, is distinguishable by its loud tympanitic resonance on percussion, by the want of any depression of the chest in the part, by the frequently movable character of the sounds, and by the coexistence of liquid effusion. Not unfrequently the diseases above mentioned are mingled with phthisis, and serve to mask it, so that it may not for some time even be suspected ; but a careful examination will generally enable the physician to detect its peculiar signs, and the more readily, as these are almost always to be found in the upper part of the chest, while those which characterize the other affections are generally connected with the lower part. Prognosis. In the very great majority of cases, this is certainly unfavourable • but I am not one of those who believe that phthisis is in all cases necessaril'y fatal On the contrary, I believe that, in one stage or another, it is occasionally cured, or at least ends in perfect recovery. It is no very unfrequent event CLASS III.] PHTHISIS. 93 to see threatening symptoms of phthisis give way under suitable treatment. It cannot be proved, with absolute certainty, that these symptoms were tuber- culous ; because the evidence of dissection is wanting, and the physical signs are not sufficiently positive, in mild cases of early phthisis, to authorize a certain conclusion. But they are undistinguishable from symptoms, which, in other cases, are the forerunners of confirmed phthisis ; and we have abun- dant evidence from dissection, that tubercles are capable of undergoing favourable modifications. The probability is, that the tuberculous matter is absorbed, and sometimes, as shown by dissection, replaced by calcareous matter; and, if the diathesis be so far subdued as to prevent the deposition of other tubercles, before these have completely run their course, the disease may be said to be cured. The circumstance that such remains of tubercles are not unfrequently found in the lungs of old persons, who have died of other diseases, would seem to show that these cures are sometimes permanent. But this is not all. It occasionally happens that consumptive symptoms disappear entirely, even in the second stage of the disease, after the forma- tion of a cavity. This event, it is true, is comparatively rare; but some such cases have probably fallen within the notice of almost every practitioner of extensive experience. Even should the disease ultimately return, still, the case may be said to have been cured ; as the occurrence of a second attack of pneumonia is certainly no proof that the first was not cured. But there have been cases in which no return of the symptoms has taken place during the residue of life, even though considerably protracted. Two instances of this kind have occurred in medical men of this city. One of the patients was affected, when a young man, with all the symptoms of phthisis, including fre- quent attacks of haemoptysis, severe cough, hectic fever, &c, from which he completely recovered, and continued exempt up to the time of his death, which occurred many years afterwards of typhoid fever. (See N. Am. Med. and Surg. Journ., viii. 277.) The other was my preceptor and friend, the late Dr. Joseph Parrish, who in early life laboured for a time under the symp- toms of phthisis, and, after his death, at an advanced age, was found to have several cicatrices in the upper part of one lung, which were obviously the remains of tuberculous cavities. (See Am. Journ. of Med. Sci., xxvi. 256.) The probabilities upon the whole are, that each tubercle has a tendency towards health, and, if alone, would in time end in perfect recovery; so that the great fatality in phthisis consists in the continued predisposition which causes the constant or frequently repeated deposition of other tubercles, be- fore those first deposited have had time to run a favourable course. We may, therefore, always entertain some hope, if applied to in the early stage, in cases of no great severity, of seeing a cure effected; and, even in the second stage, when the diathesis is not very strong, or the local disease extensive, there is no reason for absolute despair. Since the introduction of cod-liver oil into use, I have seen several cases of apparent phthisis in the early stage arrested; at least one case in the advanced stage, with a cavity, and general symptoms of the most threatening character, quite cured; and many cases in various degrees amended, of which I have been unable to trace the ultimate result. The post-mortem observations of Professor Bennett of Edinburgh, made in vast numbers in the Hospital of that city, have shown that from one-third to one-fourth of all who die after the age of forty, exhibit cretaceous masses, puckerings, or other evidences of previous tubercles in the lungs, which have undergone spontaneous cure; and similar examinations made by MM. Rogce and Uoudet, in the Hospitals of Paris, give analogous results. In his work on Pulmonary Tuberculosis, Professor Bennett gives in detail several con- sumptive cases, seen by him during life, which upon death subsequently from other diseases, have shown undoubted evidence in the lungs of pre-existing 94 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. tuberculous deposit. There can, therefore, scarcely be a doubt of the occa- sional cure of phthisis. Even in cases which appear to offer no chance of ultimate recovery, we may hope to be able very much to prolong the duration of the complaint, and sometimes even to add years to a valuable life. \\ hen the second stage is clearly established, with severe constitutional symptoms, and the physical signs of extensive disease in the lungs, there is little ground for hope. If to the ordinary symptoms, in such instances, are superadded continued vomiting and diarrhoea, the case may be considered as quite des- perate ; and speedy death may be expected. Treatment. As tubercles, when once formed, almost always run their course, notwith- standing all the remedies that can be employed, the prominent indications in the treatment of phthisis appear to be,'first, to prevent their further deposi- tion, and secondly, to guard the lungs and the system at large^ against their injurious influence during their progress. The first of these indications is all-important, and should claim the especial attention of the practitioner. 1. To prevent the further Deposition of Tubercles or Tuberculous Matter.—In fulfilling this indication, there are two objects to be aimed at; first, to correct the predisposition, and, secondly, to obviate the influence of the causes which excite the predisposition into action. So far as we understand the tuberculous diathesis, it consists in a depre- ciation of the general tone and vigour of the system, and of the character of the blood. Our object must, therefore, be to restore due vigour to the solids, and a healthy state to the circulating fluid. The remedy best adapted to these ends is exercise in the open air. To be effective, this must be vigorous and long-continued. It is not sufficient to take a short walk now and then when the weather is pleasant. Such exercise is altogether inadequate to the end in view, of changing the constitution of the patient. It must be sus- tained daily, and as far as possible unremittingly, for months and even for years. There is no necessity for carrying it to the point of great fatigue. It should at first be moderate, not longer continued nor severer than the patient can well bear, and gradually and perseveringly increased, as the increasing strength may permit. Cold weather should not be considered as any obstacle. By clothing himself warmly, and carefully protecting himself from the wet, the patient may, in the early stages of the disease, and frequently also in its second stage, venture out at all seasons and in almost any weather. Certainly it is better to encounter freely all the rigors of winter weather, properly guarded, than to shut one's self up for a whole season in a warm room of regu- lated temperature, as recommended by some. Nevertheless, the patient may be influenced, in this respect, in some degree by his own experience. If he find that exposure in bad weather occasions frequent attacks of catarrh, it may be best to avoid it. The contrary, however, will generally be found to be the case, with the precautions before mentioned ; and the liability to ca- tarrh will be found to diminish with the amount of exposure. Cold dry wea- ther may almost always be encountered with impunity. Of course, during the existence of any considerable hemorrhage from the lungs, or of intercur- rent attacks of pleurisy, pneumonia, or bronchitis, especially when attended with fever, it will be proper to intermit the exercise until they shall have been removed r after which it should be resumed as before. The remarks of the late Dr. Joseph Parrish upon this subject are highly valuable. That excellent physician, having early in his practice observed the futility of the modes of treating phthisis then in vogue, and indeed their frequently marked effect in hastening the march of the disease, was induced to throw them all aside and return to the practice recommended by Sydenham. The following remarks CLASS III.] PHTHISIS. 95 are extracted from a paper of his, published in the North American Medical and Surgical Journal (viii. 279). "Vigorous exercise, and free exposure to the air, are by far the most efficient remedies in pulmonary consumption. It is not, however, that kind of exercise usually prescribed for invalids—an occasional walk or ride in pleasant weather, and strict confinement in the intervals—from which much good is to be expected. Daily and long-con- tinued riding on horseback, or in carriages over rough roads, is, perhaps, the best mode of exercise; but, where this cannot be commanded, unremitting exertion of almost any kind in the open air, amounting even to labour, will be found highly beneficial. Nor should the weather be scrupulously studied. Though I would not advise a consumptive patient to expose himself reck- lessly to the severest inclemencies of the weather, I would nevertheless warn him against allowing the dread of taking cold to confine him on every occa- sion when the temperature may be low or the skies overcast. I may be told that the patient is often too feeble to bear the exertion ; but, except in the last stage, when every remedy must prove unavailing, I believe there are few who cannot use exercise without doors; and it sometimes happens that they who are exceedingly debilitated find, upon making the trial, that their strength is increased by the effort, and that the more they exert themselves the better able they are to support the exertion." Experience, from the time of Sydenham, has shown that the best mode of taking exercise, upon the whole, for consumptive patients, is on horseback. In his own case, Dr. Parrish resorted to the plan of driving over the rough pavements of the city, in a vehicle without springs, in his ordinary professional rounds; and to this cause, probably, as much as to any other, owed the for- tunate result. The great difficulty, in relation to exercise, is in inducing the patient to submit perseveringly to the necessary hardships. Hence, they are most fortunate who are so situated as to be compelled to exert themselves. It has often been observed that consumptive patients entering into military ser- vice have entirely surmounted the disease ; and it will be found, in civil life, that they who are under the necessity of exerting themselves to the utmost to gain bread are apt in the end to fare the best. The life of a country physi- cian who visits his patients on horseback is, probably, as conducive as any other to a favourable result in phthisis. The best substitute for this compul- sory exercise is a long journey on horseback, or in a somewhat rough vehicle; and, if some object of business or pleasure without reference to health, can be connected with the journey, it will be so much the better.* Another important measure is a proper regulation of the temperature of the body. The patient should sedulously guard against the general de- pressing influence of cold. This he is not to do by shutting himself up in a heated apartment during winter. He would thus lose the advantages of exercise and pure air, which are of greater importance than the uniformity of temperature. The best plan is to guard himself against the cold by flan- nel next the skin, and sufficient exterior covering to render him perfectly comfortable; care being taken, at the same time, to protect the lungs, if the temperature be very low, or the bronchia peculiarly sensitive, by means of * In a paper by Dr. P>. II. Washington, of Missouri, it is maintained that tuberculous deposition is owing to imperfect assimilation of the materials of the blood, that this may result in part from imperfect respiration, and that the reason why tubercles are prefer- ably deposited in the upper part of the lungs is that here respiration is most imperfectly performed, and the blood therefore least perfectly assimilated. As a method of cure, founded on this basis, he recommends, along with the other hygienic methods, the com- plete expansion of the chest in respiration. This must be done by frequently repeated voluntary efforts, which, however, should be suspended when they begin to produce vertigo. (Washington on Assimilation, Consumption and Scrofula, Louisville, 185G.) 96 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. two or three thicknesses of gauze worn over the face as a veil. Advantage will often accrue, with the present style of dress, from covering the breast by a dressed rabbit skin, or by cotton wadding quilted between pieces of silk, worn under the shirt. While in the house, the patient should take care never to allow himself to feel cold, and especially should cover himself warmly in bed. While thus avoiding the general sedative influence of cold, he should equally avoid that partial application of it, and that sudden alternation with warmth, which are so apt to occasion bronchial or other inflammation. He should, therefore, keep his feet and his hands dry and warm, should take care never to expose himself to cold when perspiring, and should avoid partial currents of air as much as possible, consistently with the more important object already mentioned. To insure the advantages of warmth, it may be advisable that, if residing in a cold region, he should remove during winter to one which is warmer. Another benefit resulting from such a removal is the opportunity which it affords for constant exercise out of doors, without the danger of taking cold. In choosing a place of residence, preference should be given to those situations which are at the same time dry and of a uniform temperature. For Americans, there is probably no better residence than the interior of Georgia, Alabama, and Florida. The immense pine forests of these regions may add the advantages of their exhalations to those afforded by the comparative dryness and warmth of the climate. Some of the West India Islands may also be selected; and preference is generally given to Santa Cruz or Cuba. In Europe, no situation is probably liable to so little objection as the South-eastern parts of Spain. Almost always, how- ever, a situation should be selected at some distance from the sea-shore. In- dependently of the dampness of the air, there is another great disadvantage, resulting from the salt driven up into the atmosphere with the spray, and carried for some distance inland. Experience has shown that this is often very irritating to delicate lungs. When it is impossible for the patient to remove to a distant region, he should endeavour to select the driest spot within his reach near home. But, while thus careful to guard against cold, the patient should exercise some caution also in relation to excessive heat. The,warmest portions of our summers are almost as injurious to consumptive patients, especially in the advanced stages, as the cold of winter. " From my own observations," says Dr. Chapman, " I am pretty well persuaded that, in this city (Philadelphia), the greatest degree of mortality is in the early part of the spring, and the close of summer; the effects of intense heat being more baneful than those of severe cold, and quite equal to the influence of the fluctuations in our vernal weather." (Led. on Thoracic and Abdom. Dis., p. 45.) If, therefore, the patient is to seek a warm climate in winter, he will find advantage, during the heats of summer, in a resort to some elevated mountainous district, not so high as to be involved in frequent fogs, and affording good opportunities for horseback exercise. The author has found no situation superior, in these respects, to Schooley's Mountain in New Jersey. It is a question, which experience must determine, whether the extremely cold, uniform, and dry air of our high northern latitudes may not operate more beneficially on the health of persons consumptively disposed, than'the more relaxing climate of the south; care being taken by sufficient warm clothing to prevent the depressing influence of a long-continued and constant coldness of the body, which has already been said to be probably one of the strongest predisposing causes of the disease. Some consideration is always necessary in sending a patient abroad in this disease. In severe cases, in the advanced stage, when there can be no hope of ultimate good, it would be cruel to separate him from the comforts and CLASS III.] PHTHISIS. 97 consolations of his own home, to suffer, and perhaps die, among strangers. Nor should he, as a general rule, be sent away while labouring under any active inflammation, which might be aggravated by the necessary exposures and disturbances of the removal. The regulation of the diet constitutes also an important part in the treat- ment of phthisis, under the first indication. As the objects are to sustain a vigorous tone of system, and at the same time to avoid the exciting influence of pulmonary inflammation and fever, the general rule is to recommend a generous diet, but with such restrictions as shall guard against the produc- tion of an inflammatory or febrile condition. While the most nutritious articles of food may be allowed, those should be preferred which are least stimulating. Thus, farinaceous substances, milk, fish, oysters, eggs, and the lighter meats, are preferable to the stronger meats which contain some stimu- lant principle independently of their mere nutriment; and, when the latter are employed, they should in general be boiled. Fruits and the digestible vegetables are very suitable. But, when there is fever, local inflammation, or hemorrhage, in the early stages, animal food should be suspended, and the patient confined exclusively to fruits, vegetables, and farinaceous substances. In doubtful cases, milk and the farinacea are excellent intermediate articles of diet. Stimulant drinks should not be allowed to persons previously unac- customed to them, in the first stage, unless indicated by debility; at least all excess in their use should be scrupulously avoided. It is proper, also, to proportion the diet in some degree to the amount of exercise, more "nutritious substances being allowed, and in greater quantity when the patient undergoes continued bodily fatigue, than under other circumstances. In the second stage, after suppuration has fairly set in, moderately stimulant drinks, such as porter and ale, are often useful. Mental influences are frequently important therapeutical agents in this disease. When there is reason to believe that the patient is sinking under some disappointment of the affections, or other grief or anxiety, concealed or open, every effort should be made to discover and remove the source of mis- chief. Intense application to study, or any sedentary business must be avoided. The hopes of the patient should be encouraged, and his tendency to cheerful- ness cherished, so far as may be deemed compatible with higher interests. It is probably in part to the agreeable distraction of the mind, and the stim- ulating influence of a succession of pleasing or interesting novelties, that travelling owes a portion of its success as a remedial measure. Short sea voyages, in interesting regions, may be useful in the same way. Medicines are generally of less avail in this disease than the hygienic mea- sures already recommended. Nevertheless they are sometimes highly useful. When the system readily responds to exercise, and the other means enume- rated, when the appetite and digestion remain unimpaired, and the nutrition improves, and when there is no derangement of function requiring interfer- ence, it will be best, upon the whole, to avoid energetic medicines altogether, with a single exception to be adverted to directly. But, should the case be otherwise; should the patient remain feeble and anemic, and the vital pro- cesses alluded to be inadequately performed, benefit will often accrue from the use of mild tonics. Of these, the one most applicable to the circumstances of phthisis is perhaps wild-cherry bark, the prunus virginiana of the U. S. Pharmacopoeia. This has the great advantage of uniting a tonic influence over the digestive and nutritive functions, with a sedative action upon the nervous system and the general circulation. The latter effect is strongly indicated by the great irritation of pulse, and general excitability of system, which attend and characterize this disease, often even in its earliest stage. The best plan of administering the remedy is in the form of the officinal in- 98 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. fusion, which may be given in the dose of a large wineglassful two, three, or four times a dav, and continued for months or even years, with occasional intermissions. With the exception before referred to, there is no other medi- cine which has seemed to me so efficacious. It was a favourite remedy with the late Dr. Parrish, and has come into extensive use. Should this become offensive to the patient, recourse may be had to pipsissewa, or one of the simple bitters, as columbo, gentian, quassia, or American centaury, to which either hydrocyanic acid or tincture of digitalis may be added, when the pulse is very frequent, and the system irritable. Occasionally, much good may be done by the use of the ckalybeat.es, which are especially indicated in anemic cases, and in females with amenorrhoea. The preferable preparations of iron are pill of carbonate of iron (U. S. Ph.), tartrate of iron and potassa, tinc- ture of chloride of iron, and solution of iodide of iron; but any other prepa- ration of the metal may be selected, which may happen to agree better with the stomach, taste, or prejudices of the patient. It is probably chiefly as a tonic, that iodine sometimes proves serviceable in the first stage of phthisis. When chalybeates are indicated, this may perhaps be given best in the form of iodide of iron ; otherwise the compound solution of iodine, or iodide of potassium, should be preferred. I have no faith in the influence of this medi- cine in promoting absorption of the tuberculous matter. The preparations of iodine should be immediately abandoned, if found to impair the digestive pro- cess, to excite bronchial irritation, or in any other way to disturb the func- tions. A general corroborant impression may be made on the system by frictions, applied to the whole surface of the body. But of the medicines used in phthisis no one, nor any combination of them, has hitherto proved so efficient as cod-liver oil. When the second edition of this work was published, the experience of the author had not been favourable to that remedy; but this was simply because he had not persevered with it a sufficient length of time, in the cases in which it was employed. The oil sel- dom produces any very observable effect under a period of from three to six weeks; and, despairing of any good result, he had in every instance omitted it too soon. Subsequent experience has convinced him of its inestimable value. For the last eight or nine years, he has used it in nearly every case of phthisis which has come under his notice either in private or hospital practice, and almost always, when it could be retained on the stomach, with either temporary or lasting benefit. His experience coincides generally with that of the writers who have testified favourably of its effects. In the worst cases, and most advanced stages, it usually improves the condition of the pa- tient, renders him more comfortable, and postpones the fatal issue. Under less desperate circumstances, it often arrests for a time the march of the dis- ease, giving hopes even of ultimate recovery; and, in some few instances, these hopes are justified by the result, so far as time has hitherto enabled us to judge. Given at the first appearance of the symptoms, I have frequently found it to set them aside altogether, and believe that, with the aid of other suitable remedies, it is capable of effecting permanent cures in many instances. Its observable effects are usually to improve the digestion, to render the pa- tient fatter and stronger, to diminish the frequency of the pulse and check the sweats at night, to relieve the cough, and, in fine, greatly to ameliorate all the general symptoms. The patient often becomes fleshy, exchanges his paleness for a ruddy or healthy colour, and feels himself nearly if not quite well. Unhappily, the physical signs do not generally undergo the same rapid improvement. If there was evidence of considerable solid deposition, this goes on to softening and the formation of a cavity ; if Jhere was a cavity at the commencement of the treatment, this not unfrequently enlarges while others form; and, after a period of very flattering amendment, perhaps for CLASS ni.] PHTHISIS. 90 months, perhaps for a year or more, the symptoms return, and the patient too often sinks at last. Yet it is not always so. Sometimes suspicious phy- sical signs in the early stage entirely disappear, and cavities either remain stationary or heal. The following, so far as I am capable of judging from my own observation, and the recorded experience of others, appears to be the real value of the remedy. It does not act as a specific, and is wholly in- capable of producing, by any direct influence of its own, the removal of the deposited tuberculous matter. But it invigorates digestion, improves the character of the blood, and by a peculiar power modifies the nutritive pro- cess, so as to obviate, in a greater or less degree, the tendency to the deposi- tion of tuberculous matter. When this tendency is not very strong, and other suitable measures are made to co-operate with the oil, it appears capable of arresting the further formation of tubercles altogether. But the matter de- posited must pass through its own destined changes. If small in quantity, as in the earliest stage of the disease, it may undergo the calcareous metamor- phosis, and thus cease to do harm. If larger, it must soften, and be discharged, leaving a cavity, which may ultimately heal if not increased by further acces- sions of tubercle. If abundant, it must undergo the same change, and then must necessarily prove fatal, should so much of the lung be destroyed in the process as to render the remainder insufficient to fulfil the purposes of respi- ration, or should the strength be inadequate to support the exhausting effects of the necessary irritation and suppuration. It is seen, therefore, that cod- liver oil, though a very valuable agent, perhaps the most valuable, should be looked on only as one of the means of confirming the general health, and thus affording the best possible protection against the further progress of the malady, and enabling the system to withstand the depressing and exhausting influences necessarily exerted upon it in the elimination of the tuberculous matter. These views are certainly encouraging ; and they would seem to be supported by the fact of the considerable diminution of the general mortality from phthisis, as evinced by the statistical reports, in the city of Philadelphia after the introduction of cod-liver oil into use.* But great care must be taken to guard against the error of relying on this alone, to the neglect of exer- cise, exposure to pure air, and the various other methods of invigorating the system, already referred to. A tablespoonful of the oil should be given three times a day, and the remedy persevered in for many months, nay, interrupt- edly, even for years, should it continue to agree with the patient, and the disease not appear to be sooner eradicated. As the diathesis is often con- stitutional and inherited, it will be necessary to be always on the watch, even after the disappearance of the symptoms, in order to meet them promptly should they return. As the oil favours the production of a rich blood, it is obvious that, upon the occurrence of haemoptysis or acute inflammation, it should be suspended until these have been subdued, and then resumed. For * From a report made by Dr. Jewell to the College of Physicians of Philadelphia, in August, 1857, it appears that the proportion of deaths from consumption, in the period from 184G to 1851 inclusive, was 1 to 8-03 of the whole mortality from disease; in the six years from 1852 to 1857 inclusive, 1 to 6-67; so that, though in the former period there had been a considerable falling off in the number of deaths from the disease ante- rior to 1846, yet during the latter it has risen to about the old standard. This may be explained on the principle, that the effect of postponement of death, under the influence of the oil, has been to throw more than its due proportion into the later years; so that the returns afford no grounds for relinquishing our confidence in the remedy. On the contrary, another fact stated in the report may be considered as favourable to its effi- ciency. According to Dr. Jewell, the proportion of deaths from consumption to the population in 1852 was 1 to 337-56, whereas in 1857 it was only 1 to 372-40, showing a considerable decrease; so that the returns would seem to show a greater general health- fulness, not a positive increase of mortality from phthisis. (See Am. Journ. of Med. Sci., April, 1858, p. 405.) 100 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. the best modes of administering it, and various other points in relation to it, of interest to the physician, the reader is referred to the last edition ot the U. S. Dispensatory.* . Among the measures requisite for the fulfilment of the first indication is attention to the various functions, which must be maintained in as healthy a condition as possible. It would be altogether superfluous to point out here the means that may become necessary for this purpose. They are mentioned elsewhere, under the heads of the several diseases consisting in derangement of these functions. It will be sufficient to call attention to such of the func- tions as most frequently require medical interference. The digestive organs should be especially attended to; dyspepsia, constipation, and diarrhoea should be corrected by means the least calculated to diminish the strength of the patient; the hepatic function should be sedulously guarded against derange- ment ; and the menses, if suppressed, should be restored as speedily as possible. The measures above recommended are calculated to correct the tuberculous diathesis. It comes next in order to notice those by which the influence of the exciting causes may be obviated. As the chief exciting causes are such as occasion irritation or inflammation of some portion of the lungs or their investment, attention should be directed to prevent these effects, and to cor- rect them when they take place. For this purpose, the patient should clothe himself warmly, should avoid unnecessary exposure to vicissitudes of tempera- ture, and especially to cold when perspiring with heat, should guard himself against the inhalation of noxious vapours or irritating powders, and, in pur- suing the various measures recommended for the general health, should always endeavour to restrain them within the point of producing inflammatory or febrile action. Should inflammation occur, it ought to be treated by measures least calculated to exhaust still further the failing powers of the system. Blood should be taken less freely than in the same affection under other circumstances; and local bleeding and blistering should be preferred to venesection, where there is a good probability that they will answer the purpose. As the arrest- ing of habitual discharges, and the removal of long-established external dis- eases, sometimes prove exciting causes of phthisis, it is proper, in this place, to put the practitioner upon his guard against a too hasty attempt to cure such affections. Thus, it is better, as a general rule, that old ulcers on the legs, fistula in ano, hemorrhoids, and external scrofulous tumours, should be en- couraged as safe outlets of the morbid tendencies, than that any effort should be made to get rid of them. In arranging his remedial plans, the physician should bear in mind the effects of pregnancy and lactation in checking the progress of phthisis, if not sometimes in arresting it altogether. The foregoing remarks are applicable to all stages of phthisis; for in all stages the only hope of cure is to prevent the further deposition of tubercles. Yet, when the amount of pectoral disease, as ascertained by the physical signs, is so great, and the strength of the patient, as evinced by the general symp- toms, so much exhausted, that the disease must necessarily prove fatal in a short time, it would be proper to urge the remedial measures suggested only so far as may be quite compatible with the comfort of the patient, which, under such circumstances, becomes the chief object of attention. * Other fixed oils, both animal and vegetable, have been employed as substitutes for the cod liver oil, but none, so far as I can gather from a general comparison of sentiment are altogether equal in their effects. Dr. Th. Thompson has found good effects from sperm oil, neat's-foot oil, and cocoa-nut oil, the last of which he thinks possesses similar properties to those of cod-liver oil. (Clin. Led. on Put. Consump., Am. ed. pp l<>0 122 and 128.) Under the impression that the oil owed its virtues to iodine, an attempt has been made to substitute for it other fixed oils impregnated with that medicine • but ex- perience has determined unfavourably as to the efficacy of the measure. (Arch Gen. \e ser., xxvii. 354.)—Note to the fourth edition. ' * CLASS III.] PHTHISIS. 101 2. To obviate the Effects of Tubercles.—As it is through these effects that all the sufferings of the patient arise, and that death comes at last, it is highly important to correct them as far as possible; and, though our powrers in this respect are limited, we are yet able to do much towards promoting comfort, prolonging life, and sometimes towards effecting a cure. Cough.—This, when troublesome or violent, must be alleviated, as, by agi- tating the lungs and disturbing sleep, it proves positively injurious. Demul- cents may be first tried, either in the form of lozenges, to be held in the mouth and allowed slowly to dissolve, or in the liquid form, to be occasionally sip- ped. Should these fail, it will be necessary to conjoin narcotic remedies with them. When the cough is one of mere irritation, or when it is attended with pretty free expectoration, no remedy is so efficient as opium, in some one of its various forms of preparation. Of these, the one should be preferred, in favour of which experience may pronounce in each particular case. Upon the whole, I prefer one of the salts of morphia, as they have appeared to me less disposed than opium, or most of its other preparations, to produce con- stipation, or restrain the bronchial secretion. Small doses, not exceeding the fifth or sixth of a grain of opium, or its equivalent, repeated two, three, or four times a day, should be given at first; and the inevitable tendency to in- crease the dose should be restrained, as far as may be at all compatible with the comfort of the patient. This remark is applicable to the other narcotics also. When the cough depends upon bronchitis, and the indication to pro- mote expectoration is prominent, or when opium disagrees with the patient, as occasionally happens, hyoscyamus, lactucarium, conium, stramonium, bella- donna, or hydrocyanic acid, may be substituted. Aconite and chloroform, internally administered, may also be tried. The narcotic employed should be given with mucilage or syrup, or combined with other ingredients in expec- torant mixtures; and it may be associated with almost any of the medicines which may be used to meet the indications of the disease. Sometimes the cough is very much aggravated by the irritation of an elongated uvula, which, in such a case, if not sufficiently contracted by astringents, should be ampu- tated. Dyspnoea.—So far as this is dependent solely upon organic disease of the lungs, whether tuberculous or inflammatory, it will yield only to measures addressed to that condition ; but there is occasionally much dyspnoea, arising from nervous derangement, which may be advantageously treated by the ner- vous stimulants and narcotics, such as assafetida, compound spirit of ether, aromatic spirit of ammonia, tincture of lobelia, extract of stramonium, &c, separately, or variously combined, to suit the individual case. Occasionally, too, relief may be obtained from the inhalation of the vapours of ether, cam- phor, or tincture of conium, or of the smoke of stramonium or tobacco; though these means should be employed with caution. Haemoptysis.—The hemorrhage from the lungs frequently requires atten- tion. Sometimes it affords relief to the pulmonary symptoms, and, in this case, if moderate, may be allowed to continue until it shall subside sponta- neously, as will generally happen in the course of a few days. But, if con- siderable, or not disposed to cease, it becomes an object of treatment. The same measures are to be employed as recommended under haemoptysis; but it should always be borne in mind, that, in phthisis, the great object is to husband the strength of the system ; and blood-letting, therefore, though it may be necessary if there is much general excitement with a strong full pulse, should be more moderate than might be deemed proper in cases un- connected with tubercles. As a general rule, it will be better to lessen the pulmonary congestion by cups or leeches to the chest, and the subsequent application of a blister, if necessary; while the patient is kept at rest, upon a 102 LOCAL DISEASES.--RESPIRATORY SYSTEM. [PART II. low diet, and under the use of refrigerating or sedative medicines, such as the antimonials, citrate of potassa, nitre, or ipecacuanha, with cool drinks. A little common salt taken undissolved into the mouth, and swallowed in that state, will often at once check the hemorrhage. If unattended with much fever, or symptoms of local congestion, it may be treated with astringents, as acetate of lead, kino, rhatany, or tannic acid, which may often be usefully combined with opium and ipecacuanha in minute doses I have repeatedly found the hemorrhage to yield very happily to oil of turpentine, or to ergot, when the astringents have failed. Pectoral Pains.—In the early stages of the disease, as the pains are pro- bably connected frequently with inflammation of the pulmonary tissue or pleura, excited by the neighbourhood of the tubercles, it may be proper to treat them by the occasional application of a few cups or leeches, which may be followed or alternated with small blisters, allowed to heal and then reap- plied. When the pains are moderate, it will often be sufficient to employ friction, dry cups, or some rubefacient liniment, such as liniment of ammo- nia, oil of turpentine diluted or not with olive oil according to the suscepti- bility of the skin, tincture of capsicum, &c.; and a plaster of Burgundy pitch, or a warming plaster, will occasionally afford much relief, if worn steadily for a considerable time. Issues, setons, and pustulation with tartar emetic, though sometimes useful, produce, I think, as a general result, less good by revulsion than harm by irritation. Bronchial Inflammation.—This almost constant accompaniment of phthi- sis requires particular attention, in the treatment of the disease. Allusion is here had not to the attacks of bronchitis which occur incidentally in the progress of the complaint, and may be seated in any portion of the lungs, but to the affection as it takes place in those bronchia only, which are in direct connection with the tuberculated structure, and is produced by the ir- ritation of the tubercles, or by the matter discharged from them. This is a cause of much of the severe cough of consumption, and of much of that copious expectoration which is apt to attend the latter stages. It often no doubt tends to aggravate the febrile symptoms, and contributes materially towards exhausting the strength of the patient. In the early stages, it may be advantageously combated by small doses of tartar emetic, ipecacuanha, sanguinaria, or lobelia. It is probable that the alleviation which sometimes accrues, in the early period of phthisis, from the long-continued use of a very weak solution of tartar emetic in cold water as a common drink, depends chiefly upon its influence over the bronchial affection. For this purpose, it has been proposed to dissolve about one-sixth or one-eighth of a grain of the antimonial in at least a pint of water, which may be used at meals, or when- ever the patient is thirsty. In a somewhat more advanced stage, when the expectoration begins to be opaque or purulent, squill or seneka, or both, may be added to the medicines above mentioned, or substituted for them. A very good mixture consists of equal measures of syrup of squill and syrup of seneka, and half the quantity of antimonial or ipecacuanha wine, and of the solution of sulphate of morphia; of which one or two fluidrachms may be given two, three, or four times in twenty-four hours. In the last stage of the disease, when suppuration is fully established, there may be advantage sometimes in resorting to the still more stimulating expectorants, as the balsams, turpentines, copaiba, ammoniac, assafetida, and even carbonate of ammonia. Creasote, pyro-acetic spirit, tar-water, and petroleum, or Bar- badoes tar, have also been used, with more or less success, to control exces- sive expectoration. The last-mentioned remedy is especially recommended by Dr. Theophilus Thompson. (Braiihwaite's Retrospect, xxx. 45.) In the selection, reference must be had to other existing indications, such as CLASS III.] PHTHISIS. 103 that of nervous disorder calling for assafetida, and that of great general de- bility calling for the ammoniacal remedies. The expectorants may often also, with great propriety, be combined with any tonic which may be employed. Thus, the compound mixture of iron of the Pharmacopoeia, in which myrrh acts the part of the expectorant, is an excellent remedy in certain anemic cases with amenorrhcea, and without gastric inflammation. The narcotics which may be deemed advisable to counteract the cough, or allay nervous disorder, may also be given in connection with the expectorants. Much benefit may be obtained, in reference to the bronchial inflammation, from certain inhalations ; and it is probable that the greatly vaunted results of these remedies, in certain cases of phthisis, have been owing more to their influence on the diseased mucous membrane than on the tubercles them- selves, or their cavities. It is not impossible, however, that in cavities quite emptied of tuberculous matter, and not surrounded by tuberculous deposit, they may favour the healing process by a gently stimulant impression. They should be employed only in the second stage of the disease. As a general rule, the best mode of effecting inhalation is to impregnate with the volatile matter the air ordinarily breathed by the patient. When circumstances con- fine him to his chamber, he may thus be kept constantly under the remedial influence ; and, at any rate, it may be made to act upon him through the night. This steady impression is much more effectual than a more powerful one made at certain intervals, while it will be less apt to irritate the lungs. When this mode of inhalation is impossible or inexpedient, some one of the instruments denominated inhalers may be resorted to. The particular sub- stance which, within my observation, has appeared most effectual, applied in this way, is tar vapour. The air of a chamber may be conveniently impreg- nated with it by placing a little tar in a cup, which is to be immersed in water contained in another vessel, and heated by a spirit-lamp. The common nurse- lamp answers the purpose admirably well. The effects of a water-bath are thus obtained, and the igneous decomposition of the tar prevented. Neither with this, nor with any other vapour, should the air be so far loaded as to be- come at all oppressive when breathed. Other terebinthinate and balsamic vapours may be applied in the same way. Their use, to be effectual, must be persevered in for months, sometimes for years. It is probable that the ad- vantage, which experience has shown to be occasionally derived from a resi- dence in the midst of pine forests, is owing chiefly to the terebinthinate exhalation from the trees. The inhalation of chlorine, and of the vapour of iodine, has of late years been much praised. I have occasionally tried them both, but with little observable advantage. Nevertheless, others have found them useful, and I do not wish to discourage their employment. Great care is requisite to prevent them from irritating the lungs; and a mistake in this respect may lead to serious disadvantage. As respects chlorine, the best mode is to cause it to be gradually extricated into the atmosphere of the chamber from a vessel containing some chloride of lime, or one of the alkaline chlorides, into which some dilute acid may be made to fall drop by drop. Iodine should be applied by means of an inhaler. (See U. S. Dispensatory.) for the treatment of the laryngeal affection which so frequently attends phthisis, the reader is referred to chronic laryngitis. Frequent Pulse.—The excessive frequency of pulse which constitutes so marked a feature of the disease, cannot but react injuriously on the system, and even on the lungs themselves, and should, therefore, be*controlled if possible. Wild-cherry bark, already recommended for another purpose, often serves in some degree to fulfil this indication. In the absence of this medi- cine, hydrocyanic acid may be tried alone. But the most effectual remedy 104 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. for restraining the frequency of the pulse, when not dependent on inflamma- tion, is probably digitalis; and this is the chief advantage to be expected from that once highly praised narcotic. Sometimes it acts most happily and speedily; but not unfrequently it either fails, or, while it depresses the pulse, depresses also injuriously the general strength. Dr. Chapman makes the following statement in relation to this remedy. " As the result of no slender experience with digitalis, I am prepared to state, that the only case of phthisis in which it can be much relied on, is the incipient stage, usually attended with a slight haemoptoe, small, quick, irritated pulse, extreme mobility of system, short impeded respiration, and hard, dry, diminutive cough, where venesection and other evacuant means are precluded." (Led. on Dis. of Thorac. and Abdom. Viscera, p. 60.) It is probable that black snake-root or cimicifuga, which has been long popularly employed in consumption in this country, and has been highly recommended by Dr. F. J. Garden, of Vir- ginia (Am. Med. Record, Oct., 1823), and Dr. C. C. Hildreth, of Ohio (Am. Journ. of Med. Sci., N. S., iv. 281), owes its beneficial effects, in part at least, to its sedative influence over the circulation. Dr. Hildreth found it peculiarly advantageous in the early stages, in combination with iodine. Night-sweats and Hectic Fever.—A vast variety of means have been recom- mended for the relief of these affections, and all of them too frequently without any permanent advantage. For the colliquative sweats, which, in consequence of their exhausting as well as very disagreeable effects, it is highly desirable to be able to control, nothing is probably, on the whole, more useful than the mineral acids, and especially the sulphuric, which is usually employed in the form of elixir of vitriol, or the aromatic sulphuric acid of the Pharmacopoeia. From five to fifteen drops of this preparation may be administered, in a wine- glassful or more of cold water, or some bitter infusion, three or four times a day, or more frequently. Nitric or nitromuriatic acid may be substituted, if more acceptable to the palate or stomach. Yarious other internal remedies have been recommended. Among them are acetate of lead, alum, tincture of chloride of iron, prepared chalk or lime-water, and the vegetable astrin- gents, of which pure tannic acid is probably the most efficient. Gallic acid, however, has been very highly commended. Much has recently been said of the extraordinary efficacy of oxide of zinc in controlling the night-sweats of phthisis, given at bedtime in the dose of four grains or more, with a little extract of hyoscyamus. Dover's powder may sometimes prove useful, by substituting its own active, but less copious diaphoresis, for the passive one of the disease. The prominent indication would seem to be to stimulate the skin moderately but universally; and this indication is met by a hot bath, ren- dered more excitant by the addition of common salt, or a little mustard or Cayenne pepper. Friction to the surface with a solution of alum in hot brandy, in the proportion of two drachms to a pint, is highly recommended ; but the fact is, that the spirit is the chief agent, as little if any of the alum is dis- solved. The flesh-brush, or friction with coarse flannel, is also sometimes useful. The patient should always sleep in flannel, which should, however, be very light in summer. It is said that sponging the body, at bedtime, with warm water, or warm vinegar, sometimes proves serviceable. For the hectic paroxysms, no remedy is so effectual as sulphate of quinia, which, given to the extent of ten or twelve grains in the intervals, will often set aside the chills, though they are very apt to return. It is obvious that nothing can permanently arrest them while the cause remains; and it is not only futile, but injurious, by endangering the healthy state of the stomach to load this viscus with that great variety of drugs which have been recommended for this affection. One of the least injurious is vinegar, of which one or two teaspoonfuls may be given every hour or two, sufficiently diluted with water CLASS III.] PHTHISIS. 105 and sweetened. Griffith's antihedic myrrh mixture (Mist. Ferri Comp., U. S. Ph.) may be tried, when the stomach is not irritated or inflamed. When the chills occur regularly, and are very distressing, they may fre- quently be prevented by anticipating them with a full dose of opium. During the fever, the patient may often be much relieved by small doses of the neu- tral mixture, or effervescing draught, or citrate of ammonia, with or without a little spirit of nitric ether, and solution of sulphate of morphia. Sponging the surface with warm vinegar or spirit sometimes has a soothing effect. Vomiting and Diarrhoea.—When the nausea or vomiting is attended with tenderness at the pit of the stomach, indicating gastritis, a few leeches may be applied, followed by emollients and blisters. If there is considerable fever, the patient should be confined for a time to demulcent or farinaceous drinks. When the general and local excitement is less, advantage will sometimes accrue from an exclusive diet of lime-water and milk, with stale bread or crackers ; but it often happens that the debility is too great to admit of this exclusiveness, and it is necessary to allow something more nutritious. The ordinary remedies for vomiting may be tried, such as the effervescing draught, when there is fever, and carbonic acid water, creasote, &c, under other cir- cumstances. (See Vomiting, vol. i., page 593.) Nitrate of silver, with a little opium, is likely to prove the most efficacious remedy, when there is reason to believe that the mucous membrane is ulcerated. For the diarrhoea, opiates, chalk, the various astringents, and a milk diet, may be used as palliatives; but, when it is considered that the affection generally depends upon tubercles in the bowels, little permanent good will be expected from any remedy that can be employed. Dr. Theophilus Thompson, of London, recommends strongly subnitrate of bismuth, in the dose of five grains, three times a day. (Lond. Med. Gaz., July 14, 1848.) M. Monneret employs the same remedy, in a quantity varying from two to twenty drachms in the course of a day, and de- clares that he has never observed the slightest inconvenience from these large doses, even in children. (Am. Journ. of Med. Sci, N. S., xviii, 463.) A mix- ture consisting of ten grains of the subnitrate, and three minims of officinal hydrocyanic acid, made into a draught with mucilage and mint-water, taken thrice daily, has proved peculiarly efficacious. (Lond. Med. Times and Gaz., Dec, 1854, p. 614.) Charcoal is said to be sometimes useful, its operation being ascribed to the absorption of acrid matters in the bowels. Dr. Physick once told the author, that he had found nothing so efficacious in the diarrhoea of phthisis as a diet exclusively of milk. The great debility of the last stage requires attention. One of the main objects in the treatment of this condition, is to impart sufficient muscular power to the patient to enable him to expectorate the secretions, which often accumulate in the bronchia, and, if not discharged, must produce suffocation. Carbonate of ammonia, wine-whey, milk-punch, and egg with wine, may be used. Life may sometimes be considerably protracted by these means. Lastly, it is often necessary, in the final stage, to protect the prominent points of the body, especially the hips, sacrum, and shoulders, by means of spirituous lotions, the lead plaster, down pillows, and circular pillows with an opening in the centre, from the inflammation, sloughing, and ulceration which are so apt to ensue from friction and pressure, in cases of great emaciation, and long confinement to bed. Dr. Purefoy states, in the Dublin Medical Press, that he has effectually prevented these unpleasant results, by placing under- neath the parts liable to injury a beef's bladder, oiled and partially filled with air. (Journ. de Pharm. etde Chim., xiii. 121.) The plan of treatment, above detailed, is that which the author believes best adapted to the alleviation, and, when this is possible, to the cure of the VOL. II. 8 106 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. disease. But numerous plans and remedies, not here mentioned, have been proposed at different times, many of them with the claims of a specific, and all with the support of asserted cures. Each, when announced, has been re- ceived with more or less confidence by an eager public, to be in its turn aban- doned after a trial of longer or shorter duration; and every now and then one of them is revived to run again a brief career of experiment, failure, and ne- glect. To enumerate and discuss all these plans and remedies in this place, would be incompatible with the purposes of the work. It will be sufficient to notice some of the more prominent or more recent among them. The fre- quent use of emetics, in the early stages, has been very strongly recommended. They have been given daily, or every other day, and continued for months. Different articles of the class have been employed by different practitioners, some preferring tartar emetic, others ipecacuanha, sulphate of zinc, or sul- phate of copper. Residence in a miasmatic district has been proposed, upon the grounds that the disease is much less frequent in such districts than in others of the same temperature, and that the occurrence of miasmatic fever sometimes supersedes phthisis. But these are very doubtful points, and the remedy is too hazardous for trial without more certain proof of its efficiency. Tanners are said to be remarkably exempt from the disease; and, this exemption having been ascribed to the exhalations from the oak bark employed in their business, attempts have been made to derive therapeutical effects from similar exhalations, by placing the material affording them in the sleeping apartment of the patient. The extravagant practice has even had its advocates, of causing patients to breathe habitually the air of stables, in which cows are kept, because the breath of these animals has been supposed to exercise a favourable influence over the disease. Among the inhalations which have been employed, at various times, besides those already mentioned, are oxygen gas, carburetted hydrogen, carbonic acid from burning char- coal, the vapours from copaiba and storax, hydriodic ether or iodide of ethyl* and air loaded with certain powders, such as myrrh, for example. It has even been proposed by Dr. Green, of New York, to inject a strong solu- tion of nitrate of silver into the air-passages, by means of a tube passed through the larynx, with a view to change the character of the disease in the tuberculous cavities ; and the attempt has been made, in some instances, to carry this proposition into effect; but there is reason to believe that, at least in the greater number of these instances, the injection has fortunately passed into the alimentary canal instead of the lungs. (See N. York Med. Times, July, 1855, iv. 350.) Digitalis and hydrocyanic acid have fallen from the rank of specifics, which many were at first disposed to give them, into that of mere palliatives of some of the symptoms. Naphtha and common salt have been more recently recommended, but with even less success. Sulphur- ous baths, and the use of sulphurous waters internally, have been supposed to have a specific curative influence. Alcoholic lotions to the chest are said by Dr. Marshall Hall to be among the most efficacious means of checking the deposition and softening of tubercles. (See Am. Journ. of Med. Sci, N. S., viii. 218.) Phosphate of lime alone, or in combination with other phosphates, as those of soda, iron, &c, has been of late considerably used; but experience has not decided in its favour. In a paper recently read before the French Academy of Medicine, Dr. Churchill claims great efficiency, in the treatment of phthisis, for the hypophosphites of soda and lime, given in quantities varying from about eight to forty grains through the day, the me- dium quantity being fifteen grains daily, or five grains three times a day, for an adult. He supposes the remedy to act by supplying the deficiency of * For the method of using this preparation see the U. S. Dispensatory, 11th ed., p. CLASS III.] ORGANIC AFFECTIONS OF THE LUNGS. 107 phosphorus, which he conceives to be the chief cause of tuberculous disease. (Anh. Gen., Sept., 1857, p. 357.) Dr. R. P. Cotton, of the Brompton Hospital for Consumption, has given a fair trial to this assumed remedy, and found that out of twenty patients in whom it was used, there were only two in whom any real benefit was experienced. He considers it, on the whole, as useless in the disease. (Lond. Med. Times and Gaz., Feb , 1858, p. 163.) Dr. Simpson, of Edinburgh, has suggested the external use of oil, on the ground that persons engaged in wool factories, whose skins are always greasy with the oil employed, are remarkably exempt from phthisis. Compres- sion of the chest, and even the operation of paracentesis, in order to induce collapse of the diseased lung, have been proposed, but are not likely to be adopted. Glycerin has been proposed by Dr. Crawcour, of New Orleans, as a substitute for cod-liver oil; but, though some reports have been made in its favour, it does not appear to have gained the confidence of the profes- sion generally. It is given in doses varying from one to four fluidrachms three times a day. Dr. D. H. Storer, of Boston, has found advantage from the use of fusel oil, given in doses of four drops, increased to six, after each meal. (Va. Med. and Surg. Journ., iv. 414.) 3. Prophylactic Treatment.—It is of the utmost importance, in cases of a supposed tendency to consumption, to prevent the establishment of the dia- thesis. For this purpose, all those measures, already treated of as applicable to the prevention of tuberculous deposition, should be brought to bear upon the case. The great object should be to impart vigour of constitution. There is no greater mistake, though it is one often made by anxious parents, than to bring up a child with a consumptive tendency, in a peculiarly delicate manner, and to give him a trade or occupation which requires little exposure or bodily exertion. Exactly the opposite course should be pursued. The business of a farmer, carpenter, seaman, engineer, &c, is greatly preferable, for such a person, to one of the sedentary trades or professions. An infant should never be allowed to derive its nourishment from the breast of a con- sumptive or scrofulous nurse. The frequent use of the cold bath, and fric- tions to the surface, will often serve a useful purpose in giving strength; and the former is more applicable as a prophylactic than a remedy, because the system is more likely to react efficiently before than after the development of the consumptive diathesis. It should be remembered, in the use of the cold bath, that, unless followed by prompt reaction, it will be likely to do more harm than good. Above all things, in guarding against consumption, we should insist on the necessity of vigorous exercise in the open air. Article VIII. YARIOUS ORGANIC AFFECTIONS OF THE LUNGS. The lungs are liable to various organic affections, besides those already described. Their rarity, however, the obscurity of their diagnosis, and the total incfficacy of treatment, render a minute account of most of them unnecessary, in a treatise like the present. It is scarcely necessary to call attention to the occasional existence of tumours in the air-passages, which, if they ever occur in the interior of the lungs, can seldom be recognized with an approach to certainty during life. Aneurisms of the great vessels within the chest, though they often very much interfere with the function of respiration, be- long properly to diseases of the circulatory apparatus. (See Aneurisms.) 108 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. Foreign bodies, accidentally introduced through the larynx, sometimes lodge in the bronchia, and give rise to very serious symptoms, which, however, may all be referred to obstruction more or less complete of the air-passages, and to inflammation of these passages, or of the substance of the lungs. Death may result very speedily from obstruction, in the course of a few days from inflammation, or after months or years of suffering from cough, dyspnoea, pains in the chest, purulent expectoration, and hectic fever. Cases have occurred in which, after many years, the patient has coughed up the offend- ing substance, and been restored to health. In some instances, the body is movable, and rises occasionally into the trachea or larynx, producing violent paroxysms of cough and dyspnoea. In such cases, there may be good hope of affording relief by the operation of tracheotomy. Calcareous, cartilaginous, and bony tumours are sometimes found in the lungs after death, chiefly in old persons, and most frequently in the upper portion of the organ. They are usually small, and during life seldom occasion symptoms which give rise to the suspicion of their existence. Occasionally, they may excite a little inflammation of the neighbouring pulmonary tissue, and they have been known to cause a slight dyspnoea by pressure on the bronchia. There is reason to suppose that, in some instances at least, they are the remains of tubercles which have undergone absorption. Serous cysts and hydatids have been observed in some very rare instances. The latter have been known to attain great magnitude, and to interfere much with the functions of the lungs. I have in my possession an hydatid cyst of enormous size, which projected from the upper surface of the liver high into the lungs, and was mistaken during life for pleuritic effusion. Sometimes small cysts or fragments of cysts, supposed to be of hydatid origin, have been coughed up, thus revealing the existence of the affection; but in general it is extremely obscure, and is seldom observed before death. In some cases, however, when the tumour has attained a great magnitude, it may be diagnos- ticated with considerable certainty. Such a case came under the notice of Dr. Yigla, of Paris, who not only detected its nature, but succeeded in effect- ing a cure. M. Yigla gives the following diagnostic characters, which seem to distinguish the affection from pleurisy, with which it is most liable to be confounded:—constant pain in the part affected; dyspnoea steadily increasing, and ending finally in death from asphyxia, unless anticipated by a superven- ing disease; an unequal expansion of the chest, with a partial convexity quite different from what is seen in pleurisy; flatness on percussion, extending around some spot in the chest, not from below upwards, without regular level, and sometimes stretching over to a point in the opposite side ; a de- velopment independently of the law of gravitation ; the absence, as a general rule of all respiratory sounds, as well as of bronchophony and aegophony; the remarkable want of constitutional symptoms; and, finally, an origin so gradual as to escape notice, a chronic condition throughout, slow progress, and long duration. These characters would justify strong suspicions of a large hydatid, but are not absolutely diagnostic; as a solid tumour might offer the same phenomena. This point may be tested by the insertion of a grooved needle. If a liquid escape, colourless and transparent, without reaction on test paper, not becoming turbid with nitric acid or heat, and especially if with this liquid there should be pieces of delicate and transparent membrane, the proof of the hydatid nature of the affection would be complete. In such a case, M. Yigla, after evacuating the liquid, injected about eight fluidounces of a mix- ture containing 1 part of iodine, 1 of iodide of potassium, 10 parts of alcohol, and 30 of distilled water. In 37 days after the operation, the patient was discharged from the hospital, able to attend to his duties, and ultimately was quite restored to health. (Arch. Gen., Sept. and Nov., 1855, pp. 280 and 523 ) CLASS III.] CIRRHOSIS OF THE LUNGS. 109 Malignant tumours occur in the lungs as elsewhere. Genuine scirrhus is exceedingly rare ; but the medullary or encephaloid disease is not very un- common, and melanosis is now and then observed. Fibro-plastic disease has also been found. These affections exist either in the form of encysted or non-encysted tumours, or of infiltration into the pulmonary tissue. They appear sometimes to undergo the process of softening and partial discharge, thus giving rise to cavities of greater or less magnitude. But they are much less apt to run this particular course than tubercles. Being usually slow in their progress, they give rise at first to few prominent symptoms. A little cough and oppression in breathing are perhaps all that attract attention. These increase, and are after a time attended with pains more or less severe, and at length with constitutional symptoms, such as a frequent pulse, ema- ciation, the sallow complexion of cancerous disease, and dropsical effusion. There is, however, usually, less fever than in phthisis. Haemoptysis is not unfrequent. The breath in the advanced stage is often fetid ; and, in the cases in which softening occurs, the morbid matter is sometimes visible in the puruloid expectoration, which, in the medullary cancer, may be streaked with red and white, and in melanosis may be occasionally black. The signs afforded by percussion and auscultation are such as indicate consolidation of the lungs, and sometimes those of a cavity. The diagnosis between these affections and phthisis is often only probable. The constant flatness on per- cussion over the affected part, the total absence of the healthy respiratory murmur, and the tubal or tracheal respiration without rales, are mentioned by Yalleix among the diagnostic characters. The occurrence of external tumefaction and hardness of the areolar tissue on the chest, neck, or arm, connected with the above signs, would tend to confirm the diagnosis. It would indicate the probable coagulation of the blood in one or more of the great venous trunks, consequent upon the cancerous disease. A case of this kind occurred to me, in which the whole upper portion of the chest and the right arm were enormously swollen and hardened, presenting characters not unlike those of phlegmasia dolens. Sometimes the tumour presses on the blood-vessels, respiratory passages, or oesophagus, producing various de- rangements, such as are not occasioned by pulmonary tubercle. In cases of cancerous infiltration of the lung, this organ is usually contracted, and the side of the chest is flattened, with slight depression of the intercostal spaces. But the most certain evidence of the disease is afforded by the existence of a corresponding affection in other parts of the body. When pectoral symp- toms of a consumptive character supervene upon external cancer or melano- sis, there is reason to suspect that the same disease exists in the lungs; and the suspicion would be strengthened, should the breath be fetid, and the patient wear away with comparatively little fever. The treatment is purely palliative, and confined chiefly to the use of narcotics. Cirrhosis of the lungs is an affection which merits special notice. Origi- nally confounded with chronic inflammation of the organ, it was first recog- nized as a peculiar affection by Dr. Corrigan, of Dublin, who gave it the name at the head of this paragraph, from its resemblance to the disease known as cirrhosis of the liver. It consists, probably, in a fibroid degenera- tion of the cellular tissue of the lungs, which is replaced by a white, shining, hard tissue, having the property of strongly contracting after exudation and organization. It will be most convenient to give first the anatomical char- acters, and afterwards the symptomatology of the disease. The whole or a part only of the lung may be affected. The diseased lung is firm and greatly shrunk, and its place supplied by the presence of the opposite lung, the heart, and the abdominal viscera, which are pressed into the affected side of the chest, while the thoracic wall on the same side is also much de- 110 LOCAL DISEASES.—RESPIRATORY SYSTEM. [: pressed and flattened. When the diseased lung is divided, a white, tough, fibroid matter, creaking when cut, is seen infiltrated into the areolar tissue, and especially into the interlobular spaces ; the spongy structure of the lung has wholly disappeared; and cavities sometimes of considerable size are seen, which appear excavated out of the solid mass, but are in fact dilated bron- chial tubes, as appears from a close examination of their structure. ^ Besides the proper disease, there are usually also found pleuritic adhesions, and various evidences of congestion or inflammation of the sound lung. The symptoms are cough, expectoration more or less copious of a mucous or muco-purulent, and often fetid matter, occasional hemorrhage, frequent pulse, emaciation, and at length slight hectic symptoms ; though the constitutional disturbance is much less than might be expected from the local phenomena, and the march of the disease is very slow, sometimes lasting for several years. Indeed, the most prominent symptoms, and the ultimate fatal issue, are more due to disordered condition in the unaffected lung, either accidental, or in- duced by the excess of duty thrown upon it, than to the immediate disease. The physical signs are, on inspection, retracted chest, depression of the inter- costal spaces, and displacement of the heart towards the affected side; on percussion, flatness with wood-like resistance immediately over the affected part, not unfrequently a tubular sound, arising from the dilated bronchia, and sometimes the cracked-metal sound, with exaggerated resonance elsewhere; upon auscultation, absence of the respiratory murmur over the diseased lung, increased murmur over the sound one, bronchial, cavernous, or amphoric re- spiration, bronchophony and sometimes pectoriloquy; in short, all the char- acters of solidified lung with cavities. The affections with which this is most likely to be confounded are phthisis, and chronic pleurisy, after absorption of the liquid effusion. From the first it is distinguished by its comparatively slow progress, the relatively slight constitutional disturbance, the almost entire absence of hectic, the limitation of the disease to one lung, the predominance of the signs of solidification over those of softening, and the greater retraction of the chest, and displace- ment of the heart and abdominal viscera. Cirrhosis of the lung bears con- siderable resemblance to chronic pleurisy after absorption, in the retraction of the chest and the displacement of the heart and other organs; but differs in its greater amount of constitutional disturbance, the more decided evi- dences of pulmonary solidification and cavities, and the want of the outward tilting of the scapula, and of the twisting of the ribs inwards and downwards. (Walshe, Med. Times and Gaz., Feb., 1856, p. 158.) It also differs in the general course of the disease, which is quite unlike that of pleurisy. The cause of the obliteration of the air-cells is probably the pressure of the substance infiltrated into the cellular tissue around them; that of the dilata- tion of the bronchia, the contraction of that substance, and the general diminu- tion of the capacity of the lung, whereby the expanding power of inspiration is exerted mainly on these tubes. The march of the disease is inevitably to a fatal issue, although in general very slowly. As death takes place rather by congestion and inflammation of the parts of the lung not cirrhosed, or their consequences, than directly through the cirrhosis itself, it follows that our efforts should be mainly directed to the correction of these conditions, when they become obvious, and to obviating their exhausting effects in their ad- vanced stages by duly supporting the general strength. It is possible also that, by employing measures calculated to maintain a sound and healthy as- similation and nutrition, we may in some measure obviate the tendency to the fibroid degeneration. Spurious Melanosis is the name given to an affection, described by recent English writers, as occurring in persons long confined to a smoky atmosphere, CLASS III.] APNG3A, OR ASPHYXIA. Ill or to one loaded with coal dust. A black carbonaceous matter, wholly dis- tinct in nature from the black matter of true melanosis, is found dispersed through the substance of the lungs. The patients exhibit during life the ordinary symptoms of pulmonary disease, with the expectoration of a black matter, by which the affection is characterized. After death, the lungs are found to be variously disorganized, exhibiting in some parts black hepatiza- tion, in others cavities containing an inky black fluid, and in others again an edematous condition with a serous fluid, which is also black. Even the sound parts of the lungs may present the same black colour. There seems to be no doubt that this is owing to carbonaceous matter derived from without, which, finding an entrance into the substance of the lungs, resists absorption on account of its insolubility, and remains unless discharged by the disor- ganization of the pulmonary tissue. The question is, how the black matter makes its way into this tissue. The most probable explanation is, that it enters through lesions already existing, and that the disorganization is less the effect of the carbonaceous matter than of previous organic disease. It is possible that, once admitted, it may act as an irritant, and extend the inflam- matory and ulcerative processes. The matter is capable of penetrating the epithelial cells, for it has been observed between their walls and the con- tained nuclei, by examination under the microscope. (Ed. Month. Journ. of Med. Sci., Sept., 1851, p. 265.) The most important point in the treatment is to remove the patient into a better atmosphere. In a pure air, the symp- toms are ameliorated ; and, if not affected with an incurable organic lesion, independently of the foreign matter, the patient may possibly recover. The bronchial glands not unfrequently become diseased, being sometimes merely enlarged by chronic inflammation, sometimes loaded with tubercu- lous deposit, and sometimes again affected with medullary, melanotic, or other malignant degeneration. Of these conditions, the tuberculous, which is the most common, is elsewhere specially treated of. The symptoms pro- duced by the enlargement of these glands, are chiefly such as result from pressure on the bronchial tubes and great blood-vessels. Its existence may be suspected when, in connection with such symptoms, there is dulness on percussion at the top of the sternum, without the characteristic signs of aneu- rismal tumours, and especially when the cervical or axillary glands are swol- len. The nature of the affection must be inferred from the character of dis- ease existing elsewhere, and the state of the constitution. When the com- plaint is not tuberculous or malignant, good effects may be expected from local depletion, revulsion by blisters, &c, and the general and local use of iodine or mercury. SUBSECTION IV. FUNCTIONAL DISEASE OF THE PULMONARY TISSUE. Article I. LOSS OF BREATH, APN(EA, or ASPHYXIA. A suspension of the respiratory process is usually designated by the very inappropriate name of asphyxia, which literally signifies want of pulse. I prefer the term apncea, employed by Dr. Watson, as at least equally eupho- nious, and of an origin corresponding with its application. The real pathological condition, in this affection, is a retardation or stop- page of the circulation through the pulmonary capillaries. The blood, arrested in the lungs, ceases to reach the heart in quantities sufficient to support the 112 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. actions of that organ, and the phenomena of life are suspended. In order that the blood may pass from the pulmonary arteries into the pulmonary veins, it must change from venous to arterial. The capillaries will not convey black or unarterialized blood in quantities sufficient to maintain the contractions of the heart. Why this is so must be left to the physiologists to determine. The fact has been sufficiently established by the experiments of Drs. Williams and Ray. Any cause, therefore, which prevents the arterialization of the blood, wili arrest the pulmonary circulation, and give rise to the phenomena of apncea or asphyxia. It is not at all impossible, that there may also be a condition of the pulmonary capillaries themselves, altogether independent of this change of the blood, which may disable them from performing their functions duly. Such a condition is often observed in the external capillaries. When these approach to a loss of their vitality, or quite lose it, the blood flows through them more slowly, or ceases to flow altogether. The pulmonary capillaries may in like manner become as it were palsied, and no longer contribute their share towards the conveyance of the blood. But we are too little acquainted with the nature or causes of this possible disease of the pulmonary capil- laries to make it a subject of discussion. So far as the actions of these ves- sels can be positively traced, they cease to convey the blood because this is not duly changed. The consequences of this diminution or cessation of the circulation in the pulmonary capillaries are of two kinds. In the first place, the blood reaches the left cavities of the heart in gradually decreasing quantities, until it be- comes insufficient to stimulate them to contraction; and we have all the results of a failure of the general circulation. Secondly, as there is a necessary accu- mulation of blood behind the place of obstruction, congestion takes place in the pulmonary arteries, the right cavities of the heart, the great venous trunks, and the larger viscera, as the brain, liver, spleen, stomach, and intestines; and the phenomena of venous engorgement are everywhere exhibited. With these two sets of morbid effects, a third is often more or less mingled, arising not directly from the suspension of the pulmonary circulation, but from the un- changed or insufficiently changed venous blood, which finds its way, though in gradually diminishing quantities, into the heart, and thence into the arte- rial system generally. It is highly probable that the presence of this bad blood in the nutritive vessels of the heart itself may tend to impair its powers; and some of the cerebral phenomena may depend upon the same injurious influence in the vessels of the brain. In tracing the chain of morbid actions from the incipient link in the capil- lary vessels, we come next to the encephalon. The nervous centres suffer both from a deficient supply of arterial blood, consequent upon the dimin- ished action of the left ventricle, and from venous congestion. They become, therefore, incapable of performing their functions, whether in the reception of impressions, or the transmission of nervous influence. The sensation of breathlessness, at first painfully excited by the failure of the proper respira- tory function, ceases to be felt; and the muscles of respiration, at first often tumultuously agitated by the stimulus from the troubled brain, now become powerless from an utter want of that stimulus. The patient, therefore, ceases to make any respiratory effort; and the original failure in the capillary cir- culation of the lungs, if before only partial, now becomes complete. The heart no longer receives the partial supply of blood, which, for a time, sus- tained its decreasing actions, and ceases to beat altogether. It is probable that this loss of motion in the heart depends upon the want of blood in its own peculiar arteries, quite as much as upon the same deficiency in its left cavities; for both sides of the heart cease to act simultaneously, though the right cavities are filled with blood. It has been supposed that the distension CLASS III.] APN03A, OR ASPHYXIA. 113 of the right cavities might be the cause of their suspended motion, by para- lyzing the muscular fibres; but if this were the sole cause, the opposite sides of the heart would scarcely stop at the same moment. The influence under which the whole organ becomes quiescent at once, must affect the whole of it equally; and such an influence can be exerted, so far as the supply of blood is concerned, only through the coronary arteries. It appears, then, that the heart is the last organ to die, in true and uncomplicated apncea. Observa- tion has proved that this organ even retains its contractility for a considerable time after its motions have ceased, and will resume its actions if the necessary stimulus be afforded. But there are many cases of apncea in which the starting-point of the dis- ease is in the nervous centre of respiration, or in the conductors by which that centre communicates with the organs which it controls. The affection, in such cases, is obviously complicated. The precise mode in which cerebral disease, involving the medulla oblongata, which is the centre of respiration, gives rise to the phenomena of asphyxia, has not been absolutely determined in all in- stances. There can be no doubt that it often acts by paralyzing the muscles of respiration, so as to render the expansion of the chest, and consequently the entrance of fresh air into the lungs impossible; and some maintain that this is the only mode in which it can act. But we occasionally meet with cases, in which, though the muscular movements of respiration are fully per- formed, and air is admitted freely into the lungs, symptoms closely analogous to those of apncea are exhibited, apparently dependent on a want of nervous power. This condition of things is sometimes presented in pernicious fevers, and other diseases characterized by great nervous prostration. It is not at all improbable that, in such cases, the pulmonary capillaries cease to convey the blood in consequence of some modification of their nervous condition not well understood; and it is possible that a similar modification, with similar results, may sometimes arise from the causes which tend to weaken or paralyze the muscles; so that the two influences may be exerted conjointly, and with a greater effect than would flow from either alone. Symptoms.—These vary essentially according to the state of the nervous centre, or that of the nerves connecting it with the respiratory apparatus. When these are not primarily involved, the most prominent symptom is at first a distressing sense of the want of breath, consequent upon the presence of unchanged venous blood in the capillaries of the lungs, and probably also, in some degree, of an insufficient supply of blood to the capillaries of the system generally. This sensation, which is the provision of nature for calling from the nervous centres a supply of energy to the respiratory movements, adequate to the increased wants of the system, becomes in the present in- stance, the source of greatly increased efforts, both voluntary and involuntary, for the supply of air to the lungs. Along, therefore, with great anxiety of countenance, and an intense expression of distress, there is quick and violent movement of all the muscles of respiration capable of action. The chest heaves, the shoulders are elevated, the alae nasi are dilated, and the patient, panting or gasping for breath, throws himself about convulsively, or seizes with a spasmodic grasp upon objects in his neighbourhood. But, when the affection is severe and acute, these symptoms do not last long. The brain soon becomes involved, and a feeling of vertigo is speedily followed by stupor and insensibility, not unfrequently attended with convulsions. Respiration now ceases to be in any degree under the influence of the will, and the move- ments which continue are involuntary and irregular. At the same time, signs of venous accumulation are presented in the livid hue of the face, the dark- purple colour of the lips, the distended veins, and the prominent eyes. In- voluntary discharges take place from relaxation of the sphincters. The pulse 114 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. gradually becomes weaker, but is still distinct. The involuntary movements of respiration now cease, and the patient breathes no more. The whole sur- face of the bodv exhibits a somewhat livid paleness, the feet and hands are purple, and purple patches are often seen on various parts of the body- At last, the pulse ceases at the wrist, though the heart continues to beat feebly for a short time after all external signs of life have ceased. Nor, even when this ceases to pulsate, is death absolute. Vitality still lingers for an uncer- tain period, prepared to respond to efforts of resuscitation; and a restoration of the respiratory process by artificial means has often revived the patient, when not a vital movement in any portion of the body could be detected. The degree to which the pulmonary circulation is suspended has a great influence over the phenomena. If the suspension is complete, the struggle is very speedily over; and sometimes the impression upon the _ brain is so quickly produced, that the patient experiences scarcely any suffering. Respi- ration, under such circumstances, usually ceases in a period varying from somewhat less than two to five minutes, and the circulation in about ten minutes; but there is in this respect much difference in individuals, and habit has a great influence. Divers in the pearl fishery, for example, can do without air much longer than others not accustomed to remain under water. When the obstruction to the pulmonary circulation is only partial, the suffer- ing is more or less protracted; and the patient maybe tortured with ex- cessive dyspnoea for days or weeks, nay even for months, before sinking into complete apncea. This is, indeed, among the most painful symptoms of vari- ous diseases which impede the due aeration of the blood. The sensation of want of breath is, in such cases, not unfrequently referred to the praecordia, when the real cause exists at some very distant point. In these protracted cases, death often results as much from a gradual failure of all parts of the system, under a deficient supply of imperfectly arterialized blood, as from the direct influence of suspended respiration. When the cause of the pulmonary affection resides in the nervous centre, or in the nerves of respiration, the symptoms may be in some respects very different from those above enumerated. Insensibility of the medulla oblon- gata, or imperfection in the afferent nerves, prevents the perception of the want of respiration, which is the essential stimulus to this function; and the individual ceases to breathe, without previous suffering, and of course with- out those struggles for breath which usually precede death from apncea. Should the imperfection exist only in the afferent nerves, the brain and effer- ent nerves remaining sound, respiration might be supported for a time under the suggestion of the intellect, and by the effort of the will, but it would be immediately interrupted by sleep. Practically, however, we very seldom meet with such a case.* When the defect is in the efferent nerves, or in any portion of the conducting medium between the nervous centre and the organs of respiration, as in the spinal marrow above the origin of the phrenic nerve, the brain and medulla oblongata remaining sound, the patient will experience all the distress of a want of breath incident to ordinary apncea, but will be unable to exhibit it in muscular efforts, because the muscles them- selves are paralyzed. After recovery from apncea of any considerable duration, and in the pro- * My colleague, Prof. S. Jackson, of the University of Pennsylvania, informs me that he has met with cases of this kind, in persons of exhausted nervous force. The patient in going to sleep, ceases to breathe, until awakened by a sense of suffocation, and then breathes with great voluntary effort; and sleep has thus been rendered impossible for a considerable time. He has succeeded in relieving them by a tonic treatment, and inculcating the caution to husband their nervous power, and carefully avoid exhausting it by over-exertion. (Note to the fifth edition.) CLASS III.] APNOZA, OR ASPHYXIA. 115 gress of partial apncea, the patient is apt to suffer from inflammation of the lungs, resulting from the congestion of the pulmonary arteries and their ramifications. Similar affections may be experienced in the brain, liver, kidneys, and bowels, arising from the venous engorgement of these organs. The obstruction of the pulmonary circulation endangers also hypertrophy and dilatation of the right ventricle of the heart; and the same cause may give rise to dropsical effusion in all parts of the body. Apncea, therefore, when incomplete and long-continued, is anything but an uncomplicated disease. Appearances after Death.—The livid appearance of the skin, occurring before the extinction of life, continues in the dead body; and the purple spots are found to depend upon vascular congestion, sometimes connected with extravasation of blood. The right cavities of the heart are distended with black blood, as are also the pulmonary arteries, the great venous trunks, and the vessels of the larger viscera, as the brain, liver, spleen, and intestines. Indeed, the whole venous system is more or less congested. At the same time, the left cavities of the heart, the pulmonary veins, and the arteries generally are nearly or quite empty. When death has been sudden, the blood is generally either quite fluid, or but imperfectly coagulated. This tendency of the blood to remain fluid, in suspended animation from apncea, is highly important in a therapeutical point of view; as its coagulation would render all attempts to restore the vital actions fruitless. Causes.—The causes of apncea are very numerous. Independently of those which primarily operate upon the aeration and consequent movement of the blood, there is a great number of diseases, especially of the brain and respiratory organs, in which death is finally accomplished in the capillaries of the lungs, after a series of morbid actions elsewhere. All the well-known causes may be ranked under the heads of 1. those which primarily operate by suspending the movements of respiration; 2. those which prevent the access of air to the vesicles of the lungs, without directly affecting the respiratory muscles; and 3. those, through the agency of which, though air may reach the vesicles, it is admitted in such a state as to be unfit for the arterializa- tion of the blood. To these might be added a fourth set, those, namely, which render the capillaries incapable of performing their office in the transmission of blood, even though air of the proper kind may be freely admitted; but we know too little of these causes to render it worth while to discuss them. It will be perceived that, of the three sets above mentioned, all have the effect of preventing the requisite change in the blood. 1. Of the causes which suspend the respiratory movements, the most fre- quent is a paralytic condition of the muscles concerned. This may arise from congestion, effusion, inflammation, or disorganization in the brain, involving the medulla oblongata primarily or secondarily; from similar disease, or from mechanical injury of the spinal marrow above the origin of the phrenic nerve, as in dislocation of the neck, by hanging; from the same affections of the spine below the origin of the phrenic nerve, but above that of the intercostals, in which case, though respiration may continue for some time, it is effected imperfectly, and at length ceases; from division or disorganization, in various degrees, of the afferent nerves on both sides; and, finally, from the operation of extreme cold, and of numerous narcotic poisons, which render the nervous centres insensible to the impressions sent up to them from the lungs, and incapable of transmitting the necessary influence to the muscles, through the nerves of motion. Under this head must also be ranked a continued spasmodic constriction of the muscles of respiration, such as sometimes occurs in tetanus, and is thought also to result from nux vomica in poisonous doses. Mechanical compression may have the same effect, as when the body, with 116 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. the exception of the head, is buried by the falling of loose earth about it, or as in the case of the pugilist, recorded by Dr. Roget (Cyc. of Pract. Med,, art. Asphyxia), whose chest, in consequence of an attempt to take a plaster- cast of his body in one piece, was so much compressed by the setting of the plaster as completely to prevent the action of the muscles of respiration, and to occasion imminent danger of death, which was the greater as he w-as pre- vented from speaking, and could not give warning to those about him. His situation, however, was fortunately perceived in time to save his life, by break- ing the case which was forming around him. 2. The causes which act by directly preventing the access of air are very numerous. Under this head may be ranked smothering by the closure of the mouth and nostrils, as in the notorious process of burking, or in the accident of being buried in falling earth; submersion either of the whole body, as in drowning, or of the face alone, as sometimes happens to the in- fant at birth in the maternal discharges, and to drunkards in a puddle ; and strangulation, whether by means of a cord around the neck, as in hanging, the application of the bow-string, &c, or by solid bodies in the larynx, pharynx, or oesophagus, mechanically closing the air-passage, or producing the same effect by causing spasm of the glottis. Similar effects often result from disease. Thus, excrescences in the larynx, closure of the rima glottidis by inflammatory swelling or spasm, palsy of the dilating muscles of the glottis, and tumours pressing upon the air-passages from without, as bronchocele, aneurisms, &c, may all produce suffocation by excluding the air. Accumulations in the bronchial tubes, whether solid or liquid, such as the false membranes of inflammation, blood from haemoptysis or the bursting of aneurisms, and mucus or pus in chronic bronchitis, the last stages of phthisis, and other pectoral affections in which the- secretion exceeds the ability to discharge it, all act in the same way. The obstruction may also exist in the air-cells or extravesicular tissue, as in extensive inflam- matory hepatization, tuberculous deposit, apoplectic congestion of the lungs, or pulmonary oedema. Finally, air is equally excluded from the lungs by pressure on their exterior surface, as by serous, purulent, or aeriform collec- tions in the pleural cavities, by the ascent of the abdominal contents through a rupture in the diaphragm, by the free admission of air into the chest through large wounds in both sides, or even by enormous tympanitic disten- sion of the abdomen. 3. The third set of causes are those which affect the air respired. As oxygen is the agent essential to the arterialization of the blood, and as the escape of carbonic acid from that fluid is equally essential to the same result, it follows that whatever excludes oxygen, or causes the retention of carbonic acid, must produce apncea. The atmospheric air may be so much rarefied as to supply an insufficient quantity of oxygen; and it is possible that suffoca- tion in the vicinity of great fires may arise partly from this cause, in connec- tion with the inhalation of the results of combustion. At very great heights, the air is so rarefied as often very much to affect respiration ; but no eleva- tion has yet been attained, at which fatal apncea would result from this cause alone. Nitrogen and hydrogen gases appear to have no direct noxious pro- perties, and may be inhaled for a short time with impunity. They allow of the escape of carbonic acid from the blood, but, not containing oxygen, they are insufficient to support life, and an animal soon dies of pure apncea, which is confined in them. These gases are, however, almost never a real source of danger to life, because they are nowhere collected in large quantities in na- ture, and, when artificially produced, are so confined as scarcely to admit of being breathed injuriously unless on purpose. The inhalation of carbonic acid is a frequent cause of death from apncea. Difference of opinion has CLASS III.] APNCEA, OR ASPHYXIA. 117 existed as to the action of this gas, some considering it as operating bv the mere exclusion of atmospheric oxygen, others ascribing its results to a posi- tively poisonous influence. That the former opinion is not correct is proved by the fact, that air containing the usual proportion of oxygen, but in which the place of the nitrogen has been supplied by carbonic acid, cannot be breathed with impunity. The latter opinion would seem scarcely more ten- able, when we reflect that carbonic acid is constantly present as a natural result in the blood, and in the air of the lungs. The probability appears to be, that it acts by opposing an obstacle, according to a well-known physical law, to the escape of carbonic acid from the blood of the pulmonary arteries, and consequently to the absorption of oxygen. Thus the blood not only re- ceives no oxygen, but retains its carbonaceous principles, and consequently either ceases to pass through the capillaries, or goes loaded with these prin- ciples to the heart and to the brain. Hence, the effects of the inhalation of carbonic acid are more rapid than those of hydrogen or nitrogen, which, though they furnish no oxygen, do not oppose a physical obstacle to the escape of the carbonic acid of the blood, and allow of the absorption of the little oxygen that may have previously existed in the bronchial tubes. It would appear, therefore, that carbonic acid is not itself positively poisonous, like certain other gases, but merely affords by its presence a physical impedi- ment to the changes necessary for the support of respiration. But even the poisonous gases, such as carburetted hydrogen, carbonic oxide, and hydrosul- phuric acid, act partly, and, when breathed in a concentrated state, probably in chief, by producing apncea. The inhalation of chloroform has of late been a frequent source of fatal apnoea. It probably acts, in general, by directly depressing the nervous centre of respiration, and thus suspending the func- tion ; but there is reason to believe that it has sometimes proved fatal by the mere exclusion of the atmospheric air, to the consequences of which the patient is rendered insensible by its anaesthetic operation. The highly irri- tant or corrosive gases, such as chlorine, muriatic acid gas, &c, scarcely ever enter the lungs sufficiently to occasion this affection directly. Their fatal effects are owing to inflammation of the respiratory passages. Of the above causes, many are themselves diseases, and as such are suffi- ciently treated of elsewhere in this work. But there are a few which merit particular notice here, as prominent agents in the production of apncea, and interesting, in a medical point of view, chiefly on that account. Such are drowning, strangulation, and extreme cold. Drowning.—A person falling into the water usually sinks, chiefly in con- sequence of the impulse of the fall, but partly, also, perhaps, from an in- creased specific gravity, resulting from the collapse of fear, and the refrige- rating effect of the new medium. In a short time, he generally rises again to the surface, aided by his partly voluntary and partly convulsive movements; but, unless able to swim, he speedily sinks again; and this alternation of sinking and rising is, in some instances, repeated several times before the last struggle is over. As the specific gravity of the body is, in general, slightly above that of water, it usually remains after death beneath the surface, until rendered lighter by the gases generated by decomposition. During the efforts at inspiration, water sometimes enters the bronchial tubes; but the proba- bility is, that, while life continues, this cannot happen to any considerable extent, in consequence of the spasmodic closure of the rima glottidis upon the contact of the liquid. After death, it occasionally finds its way into the lungs in considerable quantities, so as to fill the bronchia to their ultimate ramifications. Water is also sometimes swallowed largely, probably during the convulsive but vain respiratory efforts. Death from submersion has been referred to apoplexy; but it is surely un- 118 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. philosophical to ascribe a result, so easily accounted for upon other principles, to a cause, which, occurring under different circumstances, is seldom immedi- ately fatal. That cerebral congestion should be observed after death, is what might be expected from our knowledge of the pathology of apncea; and, when hemorrhagic effusion has been discovered, it has probably been the result of previous apoplexy, which may have led to the accident, or of some violent injury of the head, antecedent to or consequent upon the fall. Another con- jecture has made death the result of water in the lungs ; but experiment has abundantly shown, that the amount of water which usually enters the bron- chial tubes of drowning persons is altogether insufficient to destroy life. It is quite unnecessary to search for any other cause of death, in ordinary cases, than the mere exclusion of atmospheric air. It has been plausibly supposed that, in some instances, syncope or fainting may take place, either from alarm, or the physical shock of the accident upon the nervous system; and attempts have been made, upon this principle, to account for certain peculiarities in the appearances after death, and in the results of treatment. There is often about the mouth and nostrils of the drowned more or less frothy mucus, which is sometimes stained with blood. The same appearances are observed, upon dissection, on the surface of the air-passages; and some water in a frothy state is not unfrequently found in the bronchia. In most instances, the right cavities of the heart, the large veins, and the great vis- cera, including the brain, are gorged with venous blood; while the left ven- tricle contains comparatively little. Sometimes, however, the brain and all parts of the body are found in a normal state, without any marks of con- gestion ; as if the cord of life had been suddenly snapped, before the healthy course of the blood had become perverted. These are the cases in which syncope is supposed to have occurred immediately before, or at the moment of submersion. It is an important question, how long the body may remain under water before life becomes wholly extinct, and resuscitation impossible. If recovered within five minutes, there is every reason to hope that, though external signs of life may have disappeared, the patient may be saved; and there is no reason to despair of a favourable issue, though ten, fifteen, or even twenty minutes may have elapsed from the time of submersion. Resuscitation very seldom takes place after half an hour. The longest period in the records of the Humane Society of London, is three-quarters of an hour; and, out of twenty-three cases of recovery reported by the similar establishment at Paris, the patient had in one been under water three-quarters of an hour, in four half an hour, and in three fifteen minutes. It is true that accounts are on record of recoveries after hours of submersion; but no one at present attaches any faith to them. In those well-authenticated cases of recovery in which the period of apparent death has been protracted much beyond the usual time, it has been supposed that the patient might have been affected with syncope at the moment of submersion; as, in this condition, the system does not require the support of the respiratory process, and the vital susceptibili- ties may linger for a longer time than when impaired by the noxious in- fluence of the misplaced venous blood. Strangulation.—Allusion is here had to strangulation by means of a cord about the neck. This may be effected either without suspension or with it and the results are somewhat modified accordingly. In both cases death generally depends upon the exclusion of air, consequent upon a closure of the trachea. It has been ascribed to apoplexy, produced by pressure upon the jugular veins, and the prevention of a return of the blood from the head. There is, no doubt, great congestion of the cerebral veins and sinuses and hi some instances, probably apoplectic effusion. But death from this cause is CLASS III.] APNCEA, OR ASPHYXIA. 119 much slower than is usually the case in strangulation ; and, if it ever happen, it must be in cases in which the entrance into the lungs is not entirely closed. This occasionally occurs in consequence of ossification of the larynx, or an inaccurate adjustment of the cord, and the fatal event may be in this way considerably protracted, if not averted altogether. An instance is on record in which a female, after hanging all night, was found still living in the morn- ing, owing to the ossification of the larynx; and another, in which a man, in whom the trachea had been opened, and a tube inserted previously to hang- ing, though he became insensible, was restored to a brief animation, after having been taken down from the gallows. The inference is, that though, when the closure of the air-passages is incomplete, death may result from apoplectic congestion or effusion; yet, in ordinary cases, it scarcely even con- tributes to the result. When strangulation is effected by hanging, in the or- dinary mode in which criminals are executed, the weight of the body in falling sometimes occasions dislocation of the vertebrae, and death may then ensue immediately from injury of the spinal marrow, above the origins of the phrenic nerve. This also happens in other forms of strangulation adopted as a mode of execution, in which a sudden twisting of the neck is effected along with the closure of the trachea. The time, therefore, which elapses before death in hanging varies according to circumstances; and the phenomena of course also vary. When the neck is broken, death is almost immediate, and probably without the least suf- fering. When the closure of the trachea is complete, without dislocation of the cervical vertebrae, there is a brief feeling of suffocation, and a struggle for breath; but very soon the brain becomes insensible to pain, and the con- vulsive movements which take place are involuntary, and wholly without con- sciousness. When the closure is incomplete, as when the cord passes above the larynx, and over the angles of the jaw, consciousness and suffering con- tinue for a shorter or longer period; but, even in this case, insensibility and death ultimately ensue, either from pressure upon the brain, from the imper- fect admission of air, or from the two causes conjoined. It is a singular fact, that, in cases of strangulation by suspension, there is very often a turgescence of the genital organs, with erection of the penis, and even seminal discharge. This has been variously explained, but not quite satisfactorily. Perhaps it may be connected with disturbance of the spinal cord. The face is swollen and livid, the eyes open and prominent, the conjunctiva injected, and the tongue often projected from the mouth, from which also a bloody mucus occa- sionally issues. For the appearances after death, the reader is referred to works on medical jurisprudence. It may be mentioned here, that a mark produced by the cord around the neck is always visible.* Extreme Cold.—The first effect of severe cold, applied generally to the body, is extremely painful, owing to the impression made upon the extremi- ties of the nerves. Should the cause, however continue to operate after the tendency in the system to react has been overcome, the patient becomes sen- sible of a benumbing effect, and gradually evinces in his feelings and move- ments the signs of cerebral depression. If walking, his steps become uncer- tain and tottering, his utterance indistinct, and a drowsiness which he is un- able to resist, steals upon him, and gradually increases into deep sleep and entire insensibility, from which it is impossible to arouse him. Death now speedily follows. Different views have been taken of the pathology of the case. The fatal result has been ascribed to paralysis of the respiratory mus- * A case is recorded in the Dublin Quarterly Journal of Medical Srience (Aug. 1854, p. 86), in which this mark was so slight that, unless sought for, it might readily have escaped notice; and no disturbance of the subcutaneous tissue could be discovered upon dissection of the part. (Note to the fourth edition.) 120 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. cles from the direct influence of cold; but this view does not account for the cerebral phenomena. Some have supposed that the heart first feels the fatal influence, and that the patient dies of syncope. But this does not correspond with the appearances after death, which are those usually found in apncea. The probability is, that the benumbing influence, which is first experienced in the extreme nerves, gradually extends to the nervous centres, which are thus incapacitated for the performance of their functions, and respiration con- sequently ceases. After death the right cavities of the heart, the large venous trunks, and the great viscera, including the brain, are gorged with black blood; but no apoplectic effusion is observed.* Resuscitation has been ef- fected in these cases after all the phenomena of life had ceased. Treatment.—The first object, in the treatment of apncea, is to remove the cause, and, if this be obscure, the most careful examination should be di- rected to its discovery. This rule is equally applicable, whether the cause be extraneous to the system, or consist in some diseased state of the respira- tory organs, or other part of the body. Life not unfrequently depends upon prompt obedience to this precept; and hence the importance of studying carefully all the possible causes of the affection, so as to be prepared for any emergency. When the appearances of life have not ceased, the removal of the cause will often be the only remedial measure required. In suspended animation, the following measures may be employed, as a general rule. The body should be stripped of clothing, wrapped in a warm blanket, and placed in bed in a welUaired apartment, with the head and shoulders some- what elevated. As the suspension of respiration is the important pathologi- cal condition, efforts should be immediately made to restore this function, and it is of the utmost consequence that no time should be lost. The object may sometimes be accomplished by throwing cold water upon the face, or dashing it upon the shoulders, in cases in which the temperature of the surface has' not already been reduced by the cause of the apncea, as in freezing or drown- ing. The sudden impression of cold upon the surface is a powerful stimulus to the respiratory process. Any one may become sensible of this, by observ- ing that the effect of cold water, sprinkled upon his own face, is to induce immediately an involuntary gasping inspiration. When the nervous centre yet retains susceptibility, this slight remedy is sometimes alone sufficient to rouse it into action, and to cause a transmission of the requisite motor influ- ence to the muscles of respiration. The remedy is especially applicable, when the insensibility has been produced by a sedative poison, such as hy- drocyanic acid, or one of the irrespirable gases, as carbonic acid gas, or the vapours of chloroform. For a similar purpose, powerful irritants may be ap- plied carefully to the nostrils. One of the most efficient of these is the solu- tion or spirit of ammonia, which may be held near the nostrils, or applied, properly diluted, by means of a feather or camel's-hair pencil, to the Schneide- rian membrane.f Caution, however, is necessary to avoid such a use of it as * Some observations recently made, in Scotland, on the bodies of persons who had perished from intense cold, have given results somewhat different from those previously admitted. Along with a general deficiency of blood in the peripheral portion of the circulation, there was congestion of the large vessels near the heart, and of the heart itself, on both sides of the circulation, the blood being generally more or lsss coagu- lated, and in some instances dark-red, but in others brighter than in health (Brit. and For. Med.-Chir. Rev., Oct, 1855, p. 375.) ■j- It has been suggested that ammonia, in cases of apncea, may act partly by neutral- izing the carbonic acid in the lungs, reaching the remote parts of the air-passages through the property of diffusion, possessed by all gases; and, when it is considered how rapidly even a small quantity eliminated at one point, will impregnate the air of a whole apartment, the idea does not appear improbable. (Note to the fifth edition.) CLASS III.] APNCEA, OR ASPHYXIA. 121 to provoke inflammation of the nasal or respiratory passages, upon the oc- currence of reaction. Serious consequences may readily ensue from impru- dence in this respect. Perhaps the burning of a sulphur-match under the nos- trils, which has also been recommended, may be somewhat preferable on this account; as sulphurous acid gas is less corrosive than ammonia. It has been proposed to rouse the respiratory organs into activity by operating on the sensibility of the glottis, and for this purpose to introduce one or more fingers deep into the throat, so as to come into contact with the top of the larynx. This was done with success by Dr. Escallier in two cases of apncea from chloroform. (VUnion Med., A. D. 1849, No. 143.) But the all-important measure is artificial respiration. In relation to this measure, I shall first present a view of the plans generally pursued or recom- mended, until recently, and afterwards call attention to the method proposed by the late Dr. Marshall Hall, which, from the accounts published in the Journals, appears to have been employed with extraordinary success. Arti- ficial respiration should be resorted to in all cases of complete apncea, and should never be delayed longer than may be necessary for the requisite pre- paration. The measures above mentioned may be employed in the interval. The most convenient instrument for the purpose is a pair of bellows. The nozzle may be inserted either directly into one nostril, or into the larger end of a smooth tube, the smaller end of which has been introduced into the nasal passage. A pair of bellows, furnished, like those of the Humane So- cieties, with a flexible tube and a smooth nose-piecet should be preferred if at hand. The instrument being properly adjusted, an assistant should care- fully close the unoccupied nostril and the mouth with one hand, while with the other he gently presses the pomum adami of the larynx backward so as to close the oesophagus. The operator is then to blow into the lungs at in- tervals, allowing free exit to the air, after each inflation, by removing pres- sure from the nose and mouth, and aiding the elasticity of the walls of the chest by moderate pressure with his extended hand upon the epigastrium. Natural breathing should be imitated as nearly as possible, both in relation to the quantity of air injected, and the frequency of the operation. At one time, it was thought best to expand the chest to its utmost dimensions, so as to cause the air to penetrate fully into the air-cells, and to displace the use- less or injurious gases that might be contained in the chest. But such a procedure is hazardous, by endangering the rupture of the air-cells, and thus irreparably injuring the delicate pulmonary texture. Only so much, there- fore, should be introduced as may cause a degree of dilatation of the chest as nearly as possible equal to that of healthy respiration; and the operation should be repeated about fifteen times a minute. The force employed should be as slight as is compatible with the end in view. Should no proper instrument be at hand, the operator should use his own lungs, applying his mouth to that of the patient, or, what is better, to one of the nostrils by means of a suitable pipe, taking great care not to injure the delicate mucous membrane by the hardness or roughness of the tube employed. Whatever avenue for the admission of air maybe selected, the others should be closed, and gentle pressure should be made on the larynx in the manner already described. An objection has been urged to this mode of artificial re- spiration, on the ground that the air proceeding from the lungs of a living person has become unfit for use; but experience has shown that it is still suffi- ciently oxygenized to reanimate suspended respiration; and, in fact, chemical analysis has proved that each portion of air expired has undergone but little change. To obviate the objection, however, as far as practicable, the operator may take a deep breath two or three times before commencing the process of VOL. II. 9 122 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. inflation, so as to have the air in the purest possible state. Advantages of the method are that the air introduced is of the proper temperature, and that there is less danger of injury to the lungs of the patient, as the operator's own powers of insufflation will afford the best measure of the capacity of re- sistance in the organs acted on. Another advantage is, that it can be applied immediately, as soon as the body is placed in a proper position, and the air- passages, when requisite, properly cleansed. It is peculiarly adapted to cases of infants, and has been employed, within the knowledge of the author, with the effect of restoring suspended life in a child, apparently dead from the effects of laudanum. In order to obviate the difficulty which is sometimes experienced of forcing the air beyond the glottis, it may be advisable to attempt the introduction of a catheter or other tube into the larynx, and through it to force air into the lungs by a pair of bellows or the mouth. Orfila recommends a tube eight or nine inches long, larger anteriorly than posteriorly, somewhat flattened to- wards its smaller end, so as to adapt it to the shape of the larynx, properly curved, and surrounded near the flexure with a piece of soft leather which may serve to close the upper opening of the glottis. Asa last resort, should other means fail of introducing air into the lungs, tracheotomy should be performed, and artificial respiration sustained through a tube introduced into the opening. This, however, can be very seldom necessary, unless in the case of some positive obstruction existing in the larynx. A plan of effecting, artificial respiration by galvanism was proposed by M. Leroy d'Etioles, which consisted in introducing a fine needle into each side between the eighth and ninth rib, a few lines deep, so as to touch the attach- ments of the diaphragm, and then connecting the needles with the opposite poles of a small galvanic battery. As soon as the diaphragm feels the influ- ence of the passing current, it contracts. The galvanic circuit is now to be interrupted so as to allow of relaxation ; and afterwards to be renewed and interrupted alternately, so as to keep up a succession of contractions and re- laxations as in healthy breathing. The author of this process found it suc- cessful in animals, apparently dead from submersion. The plan of Dr. Hall, above referred to, is to restore respiration by means of alternate contraction and expansion of the chest, effected by a combination of position with artificial pressure. It was long since recommended, when proper instruments for artificial respiration were not at hand, to imitate their effects by first making pressure around the thorax and upon the abdomen, so as to lessen the dimensions of the thoracic cavity and thus expel a portion of the air, and then allowing expansion to take place through the elasticity of the chest, by which a fresh portion of air might be introduced. But this plan was not found to be efficient. One of the difficulties in effecting artificial respiration has been, according to Dr. Hall, the supine position of the pa- tient, by which the tongue fell back upon the glottis, and closed it against the entrance of air. This difficulty his method obviates. The following are the rules which he laid down, and which are asserted to have been very suc- cessful in practice. No time should be lost in putting the plan into operation. Immediately after the ineffectual trial of the ordinary methods already detailed of exciting respiration, such as irritating the nostrils and fauces, dashing cold water, or, as Dr. Hall advised, cold and hot water alternately, on the face and shoul- ders, the patient should be placed in a prone position, or upon his face with his arms under his head. By this position the tongue falls forward and the glottis opens for the admission of air. By the weight of the body, moreover, pressure is made upon the chest and abdomen, so as to produce a contraction of the thoracic cavity, and consequently the expulsion of a portion of air from CLASS III.] APNCEA, OR ASPHYXIA. 123 the lungs. This effect of posture should be aided by making pressure with the hands along the back and sides of the thorax. The body is then to be gradually turned completely upon the side, " and a little more," so that the chest through its elasticity may expand again, and the fresh air be made to enter. One act of respiration is thus effected. The same measure should be quietly and deliberately repeated, once every four seconds, so as to imitate natural breathing, and should be perseveringly continued until successful, or clearly hopeless. By whatever plan artificial respiration is carried into effect, it should not be hastily abandoned if unsuccessful; though perseverence for six hours, as recommended by Dr. Curry, can scarcely ever be requisite. An important caution is not to leave the patient too soon after resuscitation This is especially necessary when the cause still continues to operate, as in insensi- bility from narcotic poisons. An instance is on record, in which, after appa- rent death from opium, and complete resuscitation by artificial respiration, the patient was nearly lost in consequence of being prematurely left. A re- lapse took place, from which, however, a reapplication of the same measure, and a perseverance in its use, fortunately rescued the patient. (Am. Journ. of Med. Sci., xx. 450.) In relation to the efficacy of artificial respiration, suc- cess may be expected from it, if the heart continue to contract in the least degree, though respiration and arterial pulsation may have ceased; nor is there reason to despair even when the heart no longer moves; for, as before stated, this organ often retains its contractility for a short time afterwards, and may respond to the stimulus of arterialized blood. In apncea from sedative poisons, as chloroform, for example, the introduc- tion of nitrous oxide or the exhilarating gas into the lungs might prove useful; and I would suggest to the surgeon who may deem it advisable to have recourse to the anaesthetic properties of chloroform in his operations, the propriety of being provided with a bagful of this gas, which might be forced into the lung, should respiration cease. But, while attempts are thus made to restore the action of the lungs, the nervous centres should be stimulated by impressions made upon the skin and other accessible parts. The surface should be kept duly warm, and for this purpose, when not inconsistent with the method of artificial respiration em- ployed, bottles or other vessels filled with warm water, heated bricks wrapped in flannel, or woollen cloth sufficiently heated, should be applied about the body ; but caution must be observed, that the substances employed be not so hot as to burn the skin ; and a good rule is not to permit their temperature to exceed 100° F. Gentle friction over the whole surface may also be used, either with the hand, a piece of flannel, or a soft brush ; but here again care is requisite not to injure the skin. Dr. Hall particularly recommended that the friction should be applied to the extremities, and directed upward, as this is the course of the returning blood. Should the least sign of sensibility be evinced, rubefacients may also be resorted to, such as oil of turpentine, Cay- enne pepper heated with brandy, and liniment of ammonia, with the same regard to the present want of susceptibility, and to future possible reaction, as in the case of the other remedies. Though the skin may not exhibit, du- ring the collapse, the least evidence of the action of heat, friction, and rube- facients, yet an impression is made by them, which, when sensibility and vital action are restored, may evince itself, if due caution be not observed, in vio- lent inflammation, ulceration, and even sloughing. As the lower bowels often retain a degree of impressibility until the very last, it will generally be advisable to employ stimulating enemata, among which oil of turpentine, carbonate of ammonia in solution, the ethereal pre- parations, and brandy, are perhaps the most suitable. They are especially 124 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. indicated when the cause of the affection is of a directly depressing nature, as in the case of certain narcotic poisons. It has even been proposed to in- troduce these stimulants into the stomach by means of a tube and syringe; and cases no doubt occur in which the measure might prove salutary. The powerful agency of electro-magnetism may also be resorted to. A current made to pass from the pit of the stomach to the back part of the head will sometimes rouse sensation, when life is almost extinct. It has been a practice with some to detract blood in cases of apncea. This measure can be proper only in those instances in which, from the peculiar nature of the cause, there is unusual congestion in the brain; and even in these should be employed with great caution. The blood should be taken preferably from the jugular vein ; as both the brain and the right side.of the heart, which is also usually overloaded, are thus directly relieved. It has been sufficiently proved by experiment that, though there are valves at the mouth of the external jugular, yet, when the vein is much distended, the resistance of these valves to the reflux of the blood is overcome, and the depletion may, therefore, be effected immediately from the descending cava and the heart. (See Ed. Med. Journ., Nov. 1856, p. 425.) The danger is by no means always passed, in apncea, when the vital actions have been restored. The brain not unfrequently evinces signs of disorder, arising from the previous congestion ; and imperfect inflammation, and various functional derangement in the thoracic and abdominal viscera, are not uncom- mon from the same cause. The errors too of an irregular general reaction, sometimes excessive, and sometimes deficient, require careful watching. But, in the treatment of these affections, the physician must be guided by his general knowledge of disease ; as the effects are too diversified and uncertain to admit of special therapeutic rules. The original cause has much influence in the production or modification of these secondary symptoms, and not un- frequently it continues to operate, in a greater or less degree, after the patient has been rescued from its more violent effects. A few remarks in relation to special measures, required in apncea from certain peculiar causes, will be necessary to complete a view of the treatment. Drowning.—It has been a popular practice to suspend the body by the feet, immediately after removal from the water, in order to allow the liquid which may have been swallowed to run out by the mouth. It is scarcely necessary to state that this is an irrational practice, and can be productive only of in- jury, as it adds the influence of gravitation to the causes which have already overloaded the veins and sinuses of the brain. The body should be immediately stripped of the wet clothing, then wiped perfectly dry, and wrapped in a blanket as already recommended. It is espe- cially important, in cases of drowning, to keep the surface duly warm; as much of the vital heat has been withdrawn from the body by the conducting power of the medium by which it has been surrounded. It is true, as stated by Dr. Hall, that the coldness of the water has had a tendency to retain the excitability longer than if the body had been immersed in hot water, and there- fore to render the chances of restoration greater; but this is no proof that, when restorative measures are used, all possible efforts should not be made to call this excitability into action. The warm bath would not be a suitable agent for this purpose, because the influence of warm water is sedative and would rather favour than obviate apncea. But a moderate degree of dry heat appears to me to be clearly indicated. Dr. Hall advises that, in these cases the body should be immediately turned upon the face, in order to let liquids run out of the mouth, which should also be carefully cleansed by means of the finger, or the feathered part of a quill. Recourse should then be had to arti- ficial respiration, and the other measures above indicated; and the efforts at CLASS III.] DISEASES OF THE HEART. 125 restoration should not be relaxed for several hours. A remedy, formerly much relied on in the treatment of the drowned, was the injection of tobacco smoke into the rectum. This would seem, with our present notions about the sedative action of tobacco, to be clearly contraindicated; and, accord- ingly, most recent authors discard it altogether. But it should be recollected that the empyreumatic products of tobacco do not operate precisely in the same manner as that narcotic itself; and it is affirmed by Fodere (Did. des Scienc. Med., Art. Noyes), that the proportion of the drowned who have been rescued since the abandonment of this measure has been considerably less than while it was in use. It has been already stated that considerable quantities of water sometimes penetrate into the bronchial tubes, even down to their remotest ramifications. Now it is obvious that, in such cases, the beneficial operation of artificial respiration must be much impeded, if not altogether prevented; and it is highly important to rid the lungs of their burden. This may be done in some degree by suction. When, therefore, the chest yields a dull sound upon per- cussion, and respiration does not appear to be satisfactorily performed, at- tempts may be made, by means of a catheter introduced into the larynx, and an air-tight syringe or the mouth applied to its outer extremity, to withdraw the liquid from the air-passages. It has even been proposed to effect the same object, by the same instruments, through an artificial opening in the trachea; and this might be justifiable as a last resort. Strangulation.—The only special measure requiring attention in this case is the abstraction of blood. In consequence of the severe cerebral congestion which results, in most instances, from the mode in which the cause acts, it is more necessary in these than in ordinary cases of apncea to unload the veins of the brain; and a moderate bleeding from the jugular would therefore ap- pear to be called for. Freezing.—Here the first object is to restore warmth, but yet to restore it very gradually. It has been found that, in cases of insensibility from cold, the sudden exposure of the body to an elevated temperature is certainly fatal. If reaction takes place, it is short and violent, and the patient soon dies, not unfrequently with delirium. In order to avoid this danger, the surface should be first rubbed with snow if at hand, which, though cold, is when near the melting point warmer than the frozen body; or the patient should be im- mersed in a bath of very cold water; and afterwards the applications made should be gradually less and less cold, until the temperature is at length raised to the natural standard. As soon as the muscles and other soft parts are suf- ficiently relaxed to admit of easy motion, artificial respiration, and the other means already enumerated as appropriate to apncea in general, should be tried. SECTION IV. DISEASES OF THE CIRCULATORY SYSTEM. SUBSECTION I. DISEASES OF THE HEART. Disease of the heart was imperfectly understood until within a compara- tively receut period. In its organic forms, it was thought to be very rare, and almost uniformly fatal. It was not generally recognized until in its ad- vanced stage, when beyond the reach of remedies; and often it escaped recog- nition altogether, being concealed by certain prominent morbid affections of 126 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. which it was the cause, such as pulmonary congestion and hemorrhage, apo- plexy, and different forms of dropsy. Cases formerly considered and treated as simple hydrothorax were very generally diseases of the heart, These affections are now known to be very frequent. They are supposed, taken in the aggregate, to be inferior only to phthisis in fatality. Though confined to no age, they are much more frequent late than early in life. They have been said to be in the old what pulmonary consumption is in the young. Out of more than five hundred dissections witnessed by Dr. Clendinning, about one-third presented signs of diseased heart; and the proportion of males was twice that of females. Though very dangerous, they are not so uniformly fatal as was at one time supposed. Treated in their early and forming stages, they are often effectu- ally cured ; and, what is no less important, they may, in numerous instances, be prevented by a judicious treatment of certain conditions of the system, which, if neglected, are very apt to induce them, but which are entirely under the control of remedies. For our improved knowledge of cardiac diseases, we are indebted mainly to Corvisart, Laennec, Louis, Collin, and Bouillaud in France; Hope, Williams, Latham, and Stokes in Great Britain; and Dr. Pennock in this country; though facts of importance have been contributed by many others. As preliminary to the consideration of the particular diseases, it will be of advantage to treat of the means of exploring them which modern investiga- tions have placed in our hands, and which render their diagnosis at present almost as easy, with proper study and practice, as it was formerly difficult and uncertain. I shall take it for granted that the reader has a general knowledge of the structure, position, and actions of the heart; but introduce a figure, with brief anatomical references, in order that the student, by con- sulting it in connection with the remarks which follow, may be able more clearly to understand them.* The signs of the heart's action and condition * The figure here introduced, with the following references, has been copied, by per- mission of the author, with some slight changes, from a communication made by Dr. C. W. Pennock to the Pathological Society of Philadelphia, and published in the Medi- cal Examiner for April, 1840 (vol. iii. p. 213). "The heart is represented with the pericardium removed, the lungs drawn back- wards by hooks, leaving its entire anterior surface exposed—the cartilages and ribs in front of it, indicated by dotted lines. S, Outline of the sternum. the plane of the thorax), passing into the C, Clavicle. valves of the pulmonary artery. 1, 2, 3, 4, 5, 6, &c. The ribs. h, Vena cava descendens. V, 1', 3', 4', 5', 6', &c. The cartilages i, Line of direction of the mitral valve. of the ribs. The dotted portion is that part of it poste- 4//, Right and left nipples. rior to the right ventricle. a, Right ventricle. V, Needle introduced perpendicular to b, Left ventricle. the plane of the thorax, three inches from c, Septum between the ventricles. the left margin of the sternum, at the lower d, Right auricle. edge of the third rib, and passing into the e, Left auricle. mitral valve at its extreme left. /. The aorta k, Line of the tricuspid valve. /, Needle introduced through the mid- m, n, Needles introduced perpendicular die of the sternum, perpendicular to its to the thorax, at points where the dulness plane, opposite the cartilages of the third of percussion of the heart ceases, and rib, passing into the aortic valves. which, being projected, pass to the borders a, The pulmonary artery. of that organ. g', Needle introduced between the se- o, Trachea. cond and third cartilages, half an inch to p, Apex of the heart. the left of the sternum (perpendicular to "Upon reference to the drawing, it will be seen that the valves of the aorta lie beneath the middle of the sternum, opposite the lower edge of the cartilages of the third ribs • that the valves of the pulmonary artery are more superficial, and are placed to the left' CLASS III.] DISEASES OF THE HEART. 127 will be considered under the several heads of 1. those recognized by the touch, 2. those obvious to vision, 3. those afforded by percussion, 4. those yielded by auscultation, and 5. general symptoms. It will be most convenient, under each of these heads, so far as appropriate, to treat first of the signs as they are presented in health, and afterwards of their modifications, and of the new signs exhibited in disease. 1. Signs by Touch.—Pulsation or Impulse. The beating of the heart may almost always be felt in health, in one posi- tion or another of the body, by placing the hand upon the chest, as nearly as may be opposite to the apex of the organ. The pulsation is owing to the striking of the small extremity of the heart against the ribs. It has gene- rally been thought to be synchronous with the contraction of the ventricles, and to result from that contraction. According to Hope, during the systole of the ventricles, the apex is drawn somewhat towards the base of the heart, and at the same time tilted upwards and forwards. Yarious explanations have been given of the mechanism of the movement, one of which refers it to the greater length of the anterior muscular fibres of the ventricles; another, and about half an inch above. The aorta, from its origin, curves upwards towards the right, extending between the cartilages of the second and third ribs slightly beyond the right margin of the sternum; at the lower margin of the second cartilage, the arch of the aorta commences and inclines to the left, crossing the pulmonary artery where it lies beneath the left second rib, and, ascending as high as the first rib, turns downwards. The pulmonary artery, from its origin in contact with the sternum, commences at its left margin, where it is joined by the cartilage of the third rib, bulges at the interspace be- tween the second and third cartilages close to the sternum, and dips beneath the aorta opposite the junction of the second cartilage and sternum. "The right divisions of the heart, being most superficial, form the greater part of the anterior surface; the right auricle reaches from the cartilage of the third rib, to that of the sixth, and between the third and fourth, where its breadth is the greatest, it extends laterally near one inch and one-third (when full of blood*) to the right of the sternum. About one-third of the right ventricle lies beneath the sternum, the remaining two-thirds being to the left of that bone; the septum between the ventricles coincides with the osseous extremities of the third, fourth, and fifth ribs, and, on the fourth rib, is midway between the left margin of the sternum and nipple. A small part, say one-fourth of the left ventricle presents anteriorly; and, when the lungs are separated, a portion of the left auricle is visible between the second and third left ribs, two inches from the left margin of the sternum. With the exception of these portions, the whole of the left ventricle and auricle lie posteriorly to the right ventricle; and the entire left divisions, with the exception of a small portion of the base connected with the semi-lunar valves of the aorta, lie on the left of the sternum. "The heart being movable, the tricuspid and mitral valves necessarily change their relative position to the parietes of the thorax, with every change of posture of the body. When examined in the dead body, the normal situation of these valves is as follows: the tricuspid valve extends obliquely downwards from a point in the middle of the ster- num, immediately below the third rib, to the right edge of the sternum, at the lower margin of the cartilage of the fifth rib; the mitral valve commences beneath the lower margin of the left third rib, near the junction of its cartilage with its osseous extremity, (two and a half to three inches to the left of the sternum), and runs slightly downwards, terminating opposite the left margin of the sternum, where it is joined by the cartilage of the fourth rib. " The apex of the heart, when an individual is standing erect, beats between the fifth and sixth left ribs, about two inches below the nipple, and one inch on its sternal side. But, as the heart is attached only at its base by the large blood-vessels, 'the body of that organ is not. fixed in relation to the walls of the chest, but hangs in a certain degree loose,' and liable to displacement by change of posture, and by the motions of the chest. Hence, the pulsations of the apex are felt at different points of the chest, and the im- pulse is affected by the stage of the respiratory act. During full inspiration, the impulse of a healthy heart is scarcely perceptible, but upon expiration, and especially if, at the same time, the body be bent forward, the cardiac pulsations become very forcible." * Au alteration in the text suggested by Dr. Pennock. 128 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. to the contraction of the spiral muscles, which, fixed as these muscles are in the tendinous rings about the base of the heart, must have the effect of rais- ing upwards the apex towards the walls of the chest. It has always seemed to me, admitting the impulse to be systolic, that it most probably arises from the reaction of the current of blood in the great vessels, as they proceed from the heart, which must have the effect of projecting that organ forward to a greater or less extent; while the rigidity it acquires in its state of con- traction, may give to its contact with the walls of the chest the character of a blow. Somewhat different is the explanation of Dr. Gutbrod, of Germany, previously put forth by Dr. Alderson, of England, that the forward move- ment is owing to the rebound of the heart, consequent upon the pressure of its own blood, when by the opening of the valves that pressure becomes un- equal, exactly on the principle of the rebound of the gun, or the motion of Segner's wheel, which, as a jet of water proceeds in one direction from its circumference, turns in the opposite direction. But the cases are not exactly analogous; for the opening of the heart is into another cavity, upon the walls of which the force is exerted so as still to maintain very nearly an equilibrium. According to either of these latter views, the apex of the heart should be moved somewhat downward as well as forward, which is in fact what the phe- nomena of the impulse require. But no explanation hitherto given, is, I think, quite satisfactory; and, indeed, the question has not yet been defini- tively decided, whether the impulse really occurs during the systole, or is owing to the expansion of the heart in the diastole.* * In his work on General Pathology, Dr. Alfred Stills', of Philadelphia, defends the opinion that the impulse of the heart is synchronous with and produced by the diastole of the ventricle, and not, as generally supposed, the systole. The following is a sum- mary of his arguments in support of that view. It is difficult to comprehend how a hollow muscle by contracting could give a blow to a body exterior to itself. When the heart of a frog, which is transparent, is examined, the projection of the apex is found to coincide with the diastole, and its retraction with the systole of the ventricle. In one or two cases in which the human heart has been distinctly seen in action, the ven- tricular systole was observed to be accompanied by a contraction of the heart in every diameter, and the diastole, which had the rapidity and energy of an active movement, to be attended with a decided projection of the heart downwards. From an analysis by Dr. Corrigan, of Dublin, of a number of cases of ventricular hypertrophy, it appears that in all of them the impulse of the heart was less than natural, and in some could not be felt, proving that the impulse must be owing to some other cause than the ven- tricular contraction. If cases of hypertrophy of the heart, with increased impulse, are compared with others in which the impulse is diminished, it is found that in the former there is auricular hypertrophy, and in the latter either exclusive ventricular hypertro- phy or thinning and dilatation of the auricle. The want of correspondence, in some instances, between the number of the heart's pulsations and those of the arteries, is best explained by the hypothesis of the diastolic origin of the impulse. This want 'of cor- respondence occurs chiefly when the heart is weak, or the mitral orifice contracted. It may be readily conceived, under these circumstances, that the auricle may throw a quan- tity of blood into the ventricle sufficient to produce the impulse, but insufficient to excite it to contraction, and that two or even three of these efforts may be made, before the sys- tolic movement which produces the arterial pulsation is effected. (Elem.'of Gen. Pathol. p. 319.)—Note to the second edition. These arguments of Dr. Stille" are not without much force; and are supported very strongly by the observations of Dr. Thos. Robinson, of Petersburg, Virginia, and of M. Beau, of France. These were made in the cases of new-born infants, in whom the breast-bone was wanting, and the heart was exposed to view uncovered by the peri- cardium. Dr. Robinson's case is recorded in the American Journal of Medical Sciences (vol. xi. p. 346, Feb. 1833); and a reference to two similar cases presented bv M Beau to the Academy of Medicine of Paris, will be found in the Archives Generates (April, 1851 4* ser xxv. 460). In the case of Dr. Robinson, the following was the succession of the heart s actions as obvious to the eye. Beginning from a state of rest, the heart suddenly and forcibly dilated in all directions, the dilatation commencing apparentlv with the auricles and proceeding with great rapidity to the ventricles The apex thus CLASS III.] DISEASES OF THE HEART. 129 The point at which the apex of the heart strikes, and where the impulse is most distinctly felt, in a state of medium expansion of the chest, and in the erect position, is between the fifth and sixth ribs, about an inch within and two inches below the nipple, and somewhat more than two inches to the left of the junction between the sternum and xiphoid cartilage, in an individual of ordinary size. But this point varies very considerably in health, according to the position of the body, and the stage of the respiratory act. The heart hangs to a certain extent loosely in the cavity of the chest, and therefore yields in some degree to the influence of gravitation. In the erect posture, the apex is about an inch lower than in the horizontal. When an individual lies upon the back, the heart recedes from the walls of the chest, so that the impulse often ceases to be perceptible ; when upon the face, the organ falls upon the ribs and makes its pulsation very obvious. The same happens in the position upon the left side, in which the pulsation is often felt to the left of the nipple. During inspiration, the ribs move at the same time forwards and upwards, so as to remove the walls of the chest from the heart, and to lower the position of that organ in relation to any particular rib; and the con- trary takes place during expiration. Hence, when the chest is fully expanded, elongated was projected forwards, and would of course, in the normal condition of the parts, have struck against the parietes of the chest and produced an impulse. Imme- diately after the completion of the diastole, and without the least observable interval, the heart contracted forcibly, and was now diminished in all its dimensions, with a re- ceding of the apex. The systole began also in the auricles and proceeded to the ven- tricles with great velocity. The whole of this complicated movement was made with such rapidity that it almost seemed like one act of the heart, the systole beginning in the auricles at the instant of the completion of the diastole in the ventricles, and alto- gether occupying less than half a second. A period of rest followed, which considerably exceeded the time occupied by the diastolic and systolic motions combined. In the cases presented to the Academy, the heart, starting from a state of repose, appeared suddenly to dilate in all the dimensions of the ventricle, with projection of the apex, and then immediately to contract without observable interval, the apex retreating; after which came the period of rest. At a meeting of the Medical Society of the Hospitals of Paris, M. Aran stated that he and M. Bernard had performed experiments upon frogs, and young animals at birth, which confirm M. Beau's opinions as to the successive actions of the heart; namely, that the auricle, having been passively dilated during the repose, suddenly contracts, thus throwing the blood into the ventricle, which consequently suddenly dilates, and subsequently contracts without any observable interval. Hence, of the two periods of the heart's action, the first is occupied by the contraction of the auricle, and the dilata- tion and contraction of the ventricle, successively; the second by the dilatation of the auricle. (Archives Gen., Avril, 1854, p. 500.) It seems to me, after the most careful examination of much conflicting statement in reference to the heart's actions, that the theory which most plausibly explains the ad- mitted facts is the following; though I by no means wish to be considered as holding it to be demonstrated. I had hoped for some positive conclusion from the various exam- inations which have been made in the case of Mr. Groux, whose congenital deficiency in the sternum has brought the actions of the right auricle within the scope of investiga- tion ; but the conflicting accounts have not tended to diminish the previous confusion. Let us commence with the heart in a state of repose. It is gradually filled, both auricles and ventricles by the blood received from the veins. This is the passive diastole. Though filled, the heart is not distended. From this state of repose it starts quickly into action. Simultaneously the auricles contract, and the ventricles are actively and energetically dilated. This is the active ventricular diastole. Instantaneously after its completion, without any interval of time, so that the two actions seem one, the ventricles con- tract, and send the blood over the body. Then both auricles and ventricles relax, and suffer the blood to enter them passively as before. At the moment of active dilatation the heart strikes against the walls of the chest, and immediately afterwards, synchro- nous with the systole of the ventricles, is the pulse in the carotids. But, though this view of the heart's actions seems to me most plausible, it has not been generally adopted; and I have thought it best to retain in the text the more gene- rally admitted explanations, until the question can be positively determined by multi- plied experiment and observation. (Note to the third, fourth, and fifth editions.) 130 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. the pulsation is lost or rendered less distinct, and the apex will strike, if at all in contact with the chest, below the sixth rib; while, in a forced expira- tion, the pulsation is strongest between the fourth and fifth ribs, and may be felt to a considerable extent over the chest, so high sometimes as the third rib. From all this it is obvious that, when the pulsation of the heart is very indistinct, the best means of rendering it perceptible is to cause the patient to lie upon his face or left side, or, if in the sitting posture, to bend forward and to the left, and to exhaust his lungs as far as possible of air. The force and extent of the impulse vary greatly, in health, with the vary- ing activity of the circulation, and the thickness of the walls of the chest. In some persons it can scarcely be felt, especially in very fat and phlegmatic in- dividuals ; in others again it is very powerful, and may be felt through a large space, as in those who are very thin and of a nervous temperament. In chil- dren it is usually more distinct than in adults. After great muscular exertion, it is sometimes violent, and perceptible almost throughout the chest. The frequency of the pulsations is also liable to great diversity within per- fectly normal limits. For the average number in a minute, the reader is referred to the article upon the pulse (see vol. i. p. 187-8); under which head are also detailed the causes that occasion diversities in the number without deviation from health, as sex, age, the sleeping and waking state, the time of day, posture, muscular exertion of all kinds, mental influences, and various accustomed stimuli. It is sufficient here to state that the cardiac pulsation, in perfect health, corresponds in frequency with the arterial, as both depend upon the same cause. In the larger arteries the pulse is said to be synchronous with the beating of the heart, in that at the wrist, follows it at a very minute, though still appreciable interval, equal perhaps to one-quarter of a second. There is also in health a fixed relation between the number of respirations and of pulsations, the latter being to the former, according to Dr. Hooker, very nearly as four and a half to one. (See note, vol. i. p. 185.) In perfect health, the pulsations occur usually at regular intervals, though not uniformly so. In old persons, it is not uncommon to meet with inter- missions in the heart's contractions, and some persons are subject to them from infancy, without, in either case, the suspicion of disease. It is a singular fact, often noticed, that in such cases the irregularity is apt to disappear during attacks of fever or other severe illness, and to return with the return of health. Intermissions, however, in the pulse at the wrist are not always a sign of the same state in that of the heart; for it occasionally happens that the ventricular contraction, though sensible near the heart, is too weak to transmit an impulse to the extreme vessels; and the systole may even be so feeble as to occasion a seeming intermission in the beating at the chest. There are, however, frequently true intermissions in the ventricular contrac- tions, without amounting to disease. The impulse is much and variously altered by disease. It may be morbidly increased or diminished in strength and extent; may be changed in its char- acter ; may become more or less frequent than in health; and may suffer irregularities of different kinds in the relation of the successive pulsations. Its strength has been generally thought to be augmented by hypertrophy or excessive development of the walls of the heart, and by whatever stimulates that organ to excessive action; and sometimes becomes so great as to give the impression almost of a hammer within the chest. It is diminished, on the contrary, by weakness of the heart, whether functional or from thinness or degeneration of its parietes, and by whatever tends to remove that organ from the ribs, as adhesions posteriorly, distension of the pericardium, or the for- mation of a pleural sac anteriorly. It not unfrequently, indeed, happens that the impulse is wholly lost in disease. The extent to which it may be felt is CLASS III.] DISEASES OF THE HEART. 131 increased by excessive action, hypertrophy, or dilatation of the heart; and the increase may be confined to a few inches around the apex, or may em- brace almost the whole chest. The heart may be so confined by adhesions, that the point of impulsion against the ribs shall vary less than it ought to do with the varying position of the patient; while, on the contrary, in a dis- tended state of the pericardium, its beating, if felt at all, will be apt to change place more readily than in health, because the organ is no longer restrained in its movements by the investing membrane. The character of the impulse is often much altered. Perhaps to this category belongs the short, sharp, quick stroke of irritation, which is wholly different from mere frequency of beat, the former referring to the individual pulsations, the latter to their suc- cession. Instead of resulting from the striking of the apex of the heart against the ribs, the impulse is sometimes produced by the whole organ rising up as it were under the hand, and giving rise to the sense of a slow heaving motion, rather than of a blow.* This happens in dilatation and hypertrophy. In relation to the repetition of the impulse, it may become so frequent that it cannot be counted, even exceeding 200 strokes in a minute, or may be re- duced even so low as 15 or 20 in the same length of time. The relation of the successive impulses to each other is liable to excessive irregularities. Sometimes a stroke is now and then omitted, either at certain intervals or quite irregularly. In such cases the pulsation is said to be intermittent. Oc- casionally it is as it were remittent; one or several strokes being more feeble than those which precede and follow. Not unfrequently the rapidity of suc- cession varies greatly; the pulsations being now very short and rapid, almost running into one another, then again prolonged, slow, and distinct; and all these diversities may be combined in the same case. The double or triple impulse, which is sometimes felt in quick succession, may be owing to as many partial contractions of the ventricle, before the full systole is accom- plished. Some have supposed that the diastole is concerned in these irregu- larities, as there is at that period a sudden and apparently active swelling out of the ventricle, which must make some impression on the parieties of the chest. It has been maintained that there is normally a double impulse of the heart, scarcely sensible in its ordinary state, but becoming obvious in excitement, the first impulse being dependent upon the systole, the second, much feebler, upon the diastole, and felt between the second and third ribs. (Bellingham and Sibson, Lond. Med. Gaz., March, 1850, p. 445.)f All these derangements of the heart's impulse may be purely functional; but, when they persist steadily for a long time, without any return to the regular condition, there is reason to suspect the existence of some organic disorder. It must always be remembered that certain modifications of disordered im- pulse may depend upon diseases of the lungs or other neighbouring parts, the heart being itself perfectly sound. Thus, effusion in the pleura, tumours of different kinds, and even the upward pressure of the contents of the abdo- men, may change the place in which the heart will be felt beating. Venous Pulse.—Connected closely with the subject of cardiac disease is the consideration of the pulsation occasionally felt in the large veins near the heart, especially the jugulars. This is abnormal, and usually indicates * It appears to me that this fact is somewhat in favour of the opinion which ascribes the impulse of the heart to the diastole. f This may be readily understood, if the view of the heart's action be admitted which ascribes the main impulse to the active diastole. The systole immediately following, by throwing the blood into the great vessels which are posterior to its own base, must have tho effect of tilting the heart somewhat forward, and of course against the chest, so as probably to produce a sensible impulse when examined under favourable circum- stances. (Note to the third edition.) 132 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. disease of the right side of the heart. When synchronous with the contrac- tion of the ventricles, as it ordinarily is, it indicates insufficiency of the tri- cuspid valves, which permits the regurgitation of blood with the systole of the right ventricle. It is not, however, always thus synchronous. In a case described by Dr. E. R. Townsend, in the Dublin Quarterly Journal (May, 1855, p. 469), it corresponded in no degree with the action of the ventricle, and was found, after death, to have been owing to the auricular systole; the right ventricle being so small and feeble that it could not receive and carry forward the whole of the blood, which was therefore sent back by the auricle. Purring Tremor.—Besides the stroke or pulsation above treated of, the hand placed over the heart becomes occasionally sensible of an entirely differ- ent impression; a sort of thrill or slight jarring movement, very similar to that produced by a purring cat, and hence called purring tremor, and by the French writers fremissement cataire. This is the result of a quick vibratory movement of the walls of the chest, propagated from the interior of the heart or blood-vessels, and from the surface of the organ, arid depends upon the same causes as the bellows murmur and the friction sounds hereafter to be noticed, with which it is often associated. A similar sensation is often im- parted to the fingers by the pulse at the wrist in diseases of the heart. 2. Signs by Inspection. Mere inspection is of very little use in the diagnosis of diseases of the heart. In health, all that the eye can discover, having any direct relation to that organ, is occasionally a slight movement near the sixth rib. In certain morbid states, this becomes very manifest, so much so as to be visible through the clothing, and at a considerable distance. Occasionally, the action may be seen to extend to the carotids and even to the jugulars, and, in some instances of severe cardiac disease, the whole body seems to be jarred by the violence of the palpitation. But no inference can be drawn from this sign alone, ex- cept that the heart is acting inordinately. It may be of use in connection with others of a more definite character. Sometimes the outline of the chest is visibly altered. A prominence over the cardiac region is a not unfrequent attendant upon copious pericardial effusion, and is of some value as a sign of that affection. The left nipple in such cases is observably more projecting than the right. It is said that a contraction or sinking at the epigastrium is sometimes observed, during the contraction of the ventricles. Such a depression may be supposed to result from firm adhesions of the pericardium to the heart, as well as to the parts around it, so that, when the ventricles contract, being fixed posteriorly, they must pull backward the movable anterior parts of the chest. 3. Signs by Percussion. In the ordinary state of the heart and lungs, there is an irregular roundish space, an inch and a half or two inches across, extending from the sternum about the fourth intercostal space towards the left nipple, but without reach- ing it, in which a portion of the surface of the heart, including nearly the whole antero-superior surface of the right ventricle, a small part of the right auricular appendix, and the outer edge and apex of the left ventricle, lies in contact with the wall of the chest. In this space, percussion is decidedly dull. The dulness, however, is not marked by a precise boundary line, but is gra- dually shaded off into a clearer sound, as the overlapping portions of the lung become thicker, until at length the pure pulmonary resonance only is heard. Even when common percussion yields a clear sound, the dulness of the most deeply covered portions of the heart may in some degree be brought forth by CLASS III.] DISEASES OF THE HEART. 133 a stronger blow; and, by a delicate ear and practised hand, the outline of the heart may thus be ascertained and chalked out with tolerable accuracy, extend- ing obliquely downward from the third left sterno-costal articulation to a part of the fifth intercostal space about two inches to the left of the sternum, and, in a horizontal line, from the vicinity of the nipple to a short distance beyond the sternum, and thus embracing almost all the lower half of this bone. The sound elicited varies according to the position of the body, and the degree of expansion of the chest in health, and is much affected by dif- ferent diseases of the lung, pleura, or neighbouring parts, wholly independ- ent of the heart, all of which, therefore, must be taken into account before any practical inference is deduced from the results of percussion. The dul- ness is greater in the erect position than in supination, and still greater when the body bends forward, or lies upon the face. It inclines also to the side of the body which is lowermost. The affections which interfere with the indi- cations of percussion in complaints of the heart are, on the one hand, those which occasion dulness, such as pleuritic effusion, hepatization of the lung, tumours of various kinds, enlargement of the left lobe of the liver, an over- loaded stomach, &c, and, on the other, those which tend to counteract the dulness, as emphysema of the lungs, pneumothorax, and great gastric flatu- lence. With due allowances for all these circumstances, percussion may afford very useful indications in cardiac disease, by proving the existence of enlargement of the heart, or effusion into the pericardium. 4. Signs by Auscultation. The action of the heart is attended with sounds, which, though not audi- ble under ordinary circumstances in health, become so by the mediate or im- mediate application of the ear to the chest, and sometimes may be distinctly heard at some distance from the body, not only in disease, but also in certain conditions of excitement, which can scarcely be regarded as morbid. Persons sometimes distinctly hear the sounds of their own heart, so much so, indeed, as to be greatly annoyed by them. In examining these sounds by ausculta- tion, it is best generally to employ the stethoscope, at least when any great nicety of discrimination is necessary; as they are often very limited in their origin, and can scarcely be referred accurately to their several sources, unless by the aid of an instrument by which small and isolated spots can be exam- ined. As slight morbid sounds may not be brought out unless with a more than ordinarily rapid movement of the blood, it may sometimes be desirable to increase this movement, and consequently to direct the patient to walk about, or otherwise exert himself, previously to the examination. There are two sounds with every pulsation of the heart, one immediately following the other, and afterwards a short interval of silence. The first sound is heard during the contraction or systole of the ventricles, and is syn- chronous with the beating of the heart, and with the pulsation in the large arteries, near the centre of circulation, but anticipates, by a very minute, but still appreciable interval, the pulse at the wrist. It is longer and duller than the second, and is heard most distinctly over that part of the chest which is in contact with the ventricles, and in which percussion is dull, a space, namely, of nearly two inches in diameter, on the left of the sternum, below the inser- tion of the fourth rib. The second sound occurs during the dilatation of the ventricles. It is quicker, shorter, and clearer than the first, and bears a close resemblance to that produced by lightly tapping with the soft extremity of the finger of one hand near the ear, the knuckle of a bent finger of the other hand. (Rope.) It is heard most distinctly over the semilunar valves; that is, "upon the sternum, opposite to the inferior margin of the third rib, and thence for about 134 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. two inches upwards, along the diverging courses of the aorta and pulmonary artery respectively, the sound high up the aorta proceeding mainly from the aortic valves, and that high up the pulmonary artery being mainly from the pulmonic."* The whole period which elapses from the commencement of the sounds in one pulsation to the same point in the next, is usually about a second, of which, according to Dr. Hope, one-half is occupied by the first sound, one- quarter by the second, and the remaining quarter by the interval of silence. At best, however, this division is only an approximation to the reality.f Opinions have differed greatly as to the cause of the two sounds. Those at first entertained, being chiefly conjectural, have not stood the test of ex- amination. Those at present most prevalent have been deduced from nume- rous experiments, made with great care, and are probably in the main true. For an account of some of the most conclusive of these experiments, the reader is referred to Pennock's edition of Hope's Treatise on Diseases of the Heart. Our limits permit only a statement of the results. The first or systolic sound, is now generally admitted to be complex, and to proceed from different sources. One of these sources is undoubtedly the contraction of the ventricles. It has been proved that the contraction of muscles is attended with a sound audible by means of the stethoscope. Those of the heart, acting so energetically as they do, could scarcely fail to manifest this effect; and, accordingly, they have been found to emit a faint sound, even after separation from the body, and when the ventricles contained no blood. But with the muscular sound are combined others, proceeding from the auriculo-ventricular valves as they close and become tense, the rushing of the blood from the ventricles into the aorta and pulmonary artery, and pro- bably sometimes the impulse of the heart against the walls of the chest. At any rate, it is rational to suppose that the contact of the apex with the pa- rietes of the chest, may serve to convey the sounds produced in the interior of the organ more clearly to the ear. In addition to the above sources of the first sound, the contraction of the auricles must also be taken into account. The emission of sound by the contracting auricles was denied by Dr. Hope, but it has been satisfactorily proved by the experiments of Drs. Pennock and Moore, as well as others subsequently performed in England. The following has been considered as the succession of the heart's actions. First the auri- cles contract feebly, and throw into the ventricles, now perfectly quiescent and full, a little additional blood, by which they are distended, and thus stimulated to action; and the resulting ventricular systole immediately fol- lows the auricular, without the least appreciable interval, so that one seems to run into the other. After contraction, the ventricles suddenly and forcibly dilate, as if by an inherent active expansive power, and thus draw in blood from the auricles, now perfectly quiescent, causing them observably to shrink. Then follows a period of complete ventricular repose or passiveness, during which the auricles become distended by the influx of blood from the pulmo- nary veins, which again stimulates them to contraction ; and thus the circle of actions begins again. Now, as no appreciable interval exists between the * This explanation must be modified if we admit the impulse to be diastolic. In that case, the first sound must occupy the whole period of active diastole and systole, and the second must occur immediately after the systole, when the heart returns to its state of rest, and the elastic force of the aorta and pulmonary artery causes a quick closure of the semilunar valves. (Note to the third edition.) f The time occupied by the sounds is differently stated by different observers. Per- haps a nearer approximation to the reality than the time mentioned in the text is two- fifths of the whole interval for the first sound, one-fifth, or a little more for the second, and two-fifths or somewhat less for the period of silence. (Markham, Dis of the Heart v. 150-1.)—Note to the fifth edition. J 'y CLASS III.] DISEASES OF THE HEART. 135 auricular and ventricular contractions, it follows that none can exist between the sounds; and, as these sounds are of the same nature, though the auricular is more feeble, they must strike the ear as continuous, and therefore not dis- tinguishable. It is true that observers have usually found the first sound to commence and end with the ventricular systole; but the comparatively very feeble auricular sound may have escaped attention, absorbed as it is in the much louder one of the ventricles. Dr. Williams, to whom much credit is due for the investigation of the muscular sound of the heart, and who considers the first sound to proceed directly from the contraction of the ven- tricles, asserts that a thin ventricle produces a louder and clearer sound than a thick one, because, in the latter, the fibres "muffle each other's vibrations." The fact is, that an expanded heart sounds more loudly than one affected with hypertrophy; and they who regard the muscle as the chief or exclusive source of the sound, must admit the explanation, though not very satisfactory, in order to escape the inference, that the muscular walls of the heart convey the sound from within, and of course do so with more loudness and clearness when distended and thin than when thickened. Dr. Leared, of Wexford, Ireland, maintains the opinion that the first sound is ascribable mainly to the concussion of the columns of blood sent forth by the contracting ventricles with the quiescent columns of the aorta and pulmonary artery; and, in sup- port of this opinion, adduces experiments which show that a similar sound is produced by the shock of similarly meeting columns of liquid out of the body. (Dublin Quart. Journ. of Med. Sci., xiii. 354.) The second sound is now almost universally ascribed to the closing of the semilunar valves, by the elastic contraction of the aorta and pulmonary artery, during the diastole of the ventricles. Hence its short, quick, flapping char- acter, and abrupt close. Some have conjectured that the active expansion of the ventricles in the diastole might produce sound; but this has not been proved.* * The causes of the sounds, in accordance with the views given in previous notes, would not materially differ from those presented in the text, though the succession of the actions differs so much. Thus, the first sound might be considered as a combination of those produced 1. by the blood rushing into the ventricles through the auriculo-ventricular orifices during the active diastole, 2. by the impulse, 3. by the muscular contraction of the auricles and ventricles, 4. by the closure of the mitral and tricuspid valves, and 5. by the rushing of the blood through the orifices of the aorta and pulmonary artery; commencing with the first and ending with the last of these movements; and its com- parative duration may thus be explained, occupying the period of the active diastole and systole, which, according to Dr. Robinson, is about one-third, or perhaps somewhat more, of the whole period from the beginning of one pulsation to that of another. The second sound, in either view, succeeds the systole, and is produced by the closure of the semilunar valves. (Note to the third edition.) An instrument has recently been invented, called the sphygmoscope or cardiascope, which is calculated to measure the extent of the impulse of the heart and arteries, and to determine the relation as to the time of occurrence between impulses, in separate and even distant positions, as, for example, between that of the heart and of the artery at the wrist. Some of the results obtained by this instrument are given in a paper, read by Dr. S. Scott Alison to the Western Medical and Surgical Society of London. Among the most interesting are the following. The impulse of the heart is indicated by the rise of the instrument, the diastole (passive) by the fall. The extent of the cardiac impulse is greatest in children, women, tall and thin men, the nervous and excitable, and those affected with hypertrophy or with this and dilata- tion of the heart, or in the advanced stage of phthisis. The instrument is scarcely in- fluenced in those who are very fat. There is usually no pause at the end of the systole, or at that of the (passive) diastole. The first sound of the heart is synchronous with the ascent of the instrument, the second with the first part of the fall. 136 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. As the two sides of the heart act precisely together, the sounds produced by them must be perfectly synchronous, and therefore constitute in fact.one sound. It is probable, however, that the sounds produced by the two ventri- cles are somewhat different; as experiment has shown that, when the muscu- lar walls of the heart are thin, they produce a clearer and louder sound than when thick; and Dr. Pennock states, as the result of his observations, that the sound of the right ventricle is of a clearer and more flapping character than that of the left. The sounds of the heart undergo considerable diversity, in a state of per- fect health, in their loudness, duration, extent, and relation to each other. They are louder in proportion to the quickness and energy of the ventricular contraction; and are influenced also in this respect by the thickness of the walls of the chest. In very fat persons, they are comparatively feeble and of limited extent; in the very thin and narrow-chested, they are louder and more diffused. The interval of silence is sometimes almost annihilated, when the heart is acting rapidly, under the influence of mental emotion or great bodily exertion. The sounds may also be greatly modified by disease within the thorax, though the heart itself may be perfectly healthy. The extent over which they may be heard is much increased by any cause which substi- tutes a solid mass, or a collection of liquid, for the cellular tissue of the lungs. They may thus be conveyed even to the most distant parts of the chest; and occasionally they are louder at a distance than near the heart, where a solid structure intervenes in one case, and the loose texture of the lung in the other. We now come to the consideration of the sounds as affected by disease of the heart. The influence of disease maybe shown either in the alteration of the healthy sounds, or in the production of new ones. The healthy sounds may suffer change in their intensity, pitch, duration, extent, relation to each other, and rhythm or regularity of succession. Sometimes one of the sounds is quite wanting, and this may happen in relation to either. Sometimes the first sound is greatly prolonged, or is doubled from a double contrac- tion of the ventricle, in either case interfering with the second. It is as- serted that the sounds are sometimes increased to three or four instead of two; and this may be readily conceived, if it be admitted, that the ventricles may not always act simultaneously. Of course, the regular recurrence of the double sound must be liable to all the interruptions which have before been The radial pulse, and the pulse in any part of the body, even the most distant, are synchronous with the second sound of the heart, and consequently with the commence- ment of the (passive) diastole, and the first part of the fall of the instrument over the heart. The inference from this is that the pulse is owing not directly to the systole of the heart, but to the elastic contraction of the aorta. An important fact is that the pulse beat is conveyed through four feet or more of elas- tic tube without any loss of time. This proves that an impulse felt anywhere in the body, is positively synchronous with the cause directly producing it, and may have an important bearing on the decision of the question as to the cause of the heart's impulse. The carotid pulse, as shown by the instrument, precedes that of the radial artery of the wrist. (Pavy, Med. Times and Gaz., Nov., 1857, p. 523.) It must be produced, there- fore, by an antecedent cause. This can only be the systole of the heart, sending the blood into the aorta, the wave of which reaches the carotid before it is lost. But the carotid pulse follows by a decidedly appreciable interval that of the heart. (Ibid.) It follows that the impulse of the heart precedes the systole, and must be ascribed to the active diastole, which, according to the views given in a preceding note is synchronous with the auricular contraction. The instrument is capable of measuring the extent of movement of the chest in in- spiration, and the accordance or non-accordance of these movements in different parts of the chest. For an account of it see the Med. Times and Gaz. for Dec, 1856 (p. 656), and for a figure, the same for Nov., 1857 (p. 523).— Note to the fifth edition. CLASS III.] DISEASES OF THE HEART. 137 noticed in relation to the pulsation. None of these deviations, however, from the healthy state necessarily imply organic disease of the heart; and, when considered alone, may be of no very great importance ; but, in connection with other morbid signs, they sometimes acquire great significance. New or abnormal sounds often occur, mingling with, following, or quite superseding the healthy. These are usually denominated murmurs, and, with one or two exceptions, may be considered as modifications of the bellows mur- mur, or bruit de soufflet of the French. This, in its purest form, is a smooth blowing sound, named from its resemblance to that made by a bellows. It may be single or double, soft or loud, of a low or a high key, short so as merely a little to prolong one of the natural sounds, or continuous, so as to fill up more or less completely the space between the impulses. Sometimes it wholly supersedes the healthy sounds, and nothing is heard but one continuous bel- lows murmur; but such cases are rare. It often becomes in various degrees rough or broken; and attempts have been made to designate the modifica- tions thus produced by the terms filing, rasping, sawing, &c. Dr. Pennock very properly suggests, that as sawing is a double motion, the name should be restricted to the double murmurs produced by the alternate motion of the heart. (Hope's Treatise, Am. ed., p. 110.) In some instances, the murmur is of a musical or whistling character, and has been compared to the chirping of young birds. In its pure form, the bellows murmur often exists without any organic disease of the heart, and may be produced artificially by alterations in the diameter of one of the larger arteries, even in health. The mere pressure of the stethoscope upon the artery will sometimes occasion it. The most frequent cause of the sound is probably an abrupt contraction at one of the orifices, or in one of the tubes through which the blood passes. It will be readily un- derstood that the fluid, as it emerges from the stricture, and spreads out to fill the larger space beyond it, breaks into currents, which set against the sides of the tube, and being thence reflected, and perhaps again reflected, occasion vibrations which result in sound. They who have observed the appearance of the stream of urine, as it issues from a strictured urethra, can easily com- prehend this explanation. An abrupt expansion in the passage will have the same effect upon the currents of the blood, and consequently in the produc- tion of the murmur. Thus, the sound may result from contraction of any of the orifices of the heart, or the expansion of one of the great arteries imme- diately beyond them, and, in the former case, may be produced either by or- ganic, or by functional disease, as spasmodic constriction. Any pressure upon the heart or great vessels from without, so as to diminish the cavity, whether from tumours, deformity of the spine, or force applied to the chest, and any partial obstruction by concretions within, as by coagula of blood or fibrin, may give rise to the same effect. Another frequent cause of the bellows murmur is a watery state of the blood, such as occurs in chlorosis or anaemia. The liquid is in this state more mov- able, the particles more easily glide over each other; and hence currents are more easily formed by whatever affects the regular movement of the blood. It is in such cases that the bellows murmur is most easily produced bythe pres- sure of the stethoscope upon the arteries; and there can be no doubt that the anemic state very much favours the action of other causes operating in the heart, Indeed, a very watery state of the blood is alone capable of producing the sound, without any change in the capacity of the orifices ; the ordinary movements being sufficient, in such a case, to form the requisite currents. In anemic individuals, the slightest increase in the circulation is sufficient to ge- nerate the murmur; and, as the anemic state is very apt to be attended with excessive action of the heart, it seldom exists to any considerable extent with- VOL. II. 10 138 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. out this accompaniment. The condition can at any time be induced by free and frequent bleeding. . ., The roughness implied by the terms filing, rasping, and sawing, is ascnb- able to inequalities in the surface over which the blood flows, especially in the orifices of the great vessels, produced by depositions of lymph, excres- cences of various kinds, osseous or cartilaginous productions &c. Ihese modifications of the bellows murmur are accordingly in general supposed to indicate organic disease in the valves, or the valvular openings. Another source of cardiac murmurs is frequently some defect of the valves, either loss of substance, irregular thickening, dilatation of the orifice, or some- thing else which prevents their accurate closure, and thus allows regurgita- tion of the blood. It may be supposed that, in these cases, the sound is ascrib- able not only to the irregularity given to its backward movement through the insufficient valve, but also in some measure to the conflict of the reverted with the regular current of blood; as, for example, when the blood of the contracting ventricle is sent through the insufficient auriculo-ventricular valve against the current entering the auricle. The degree of softness or loudness is influenced by the less or greater force of the moving cause ; and hence the systolic ventricular murmurs are louder than the diastolic; the former depending on the powerful contraction of the ventricles, the latter on the much feebler elastic pressure of the great arteries. The key or tone of the murmur, according to Hope, is higher or lower, ac- cording as the sound is generated at a less or greater depth, by a less or greater force, or in a less contracted or more contracted passage. Rough- ness of sound is proportionate to irregularity in the surface producing it. The musical tone appears to afford no particular indication. Hope found it most frequently as an attendant upon regurgitation. Any of these sounds may be changed by altering the force of the heart's action. Thus, when the cardiac affection is insufficient to generate a murmur in the ordinary state of the circulation, the sound may sometimes be developed by exciting the heart; and a murmur which, under ordinary circumstances, is smooth, may be rough- ened by increasing the rapidity of the current. The quantity of blood, ac- cording to Dr. Williams, modifies the murmurs, increasing and prolonging them when excessive, and rendering them loud and short when defective,, and attended with excited action of the heart. By a close examination, it can often be ascertained in which of the val- vular orifices the murmur originates, and whether it depends upon obstruc- tion, or upon deficiency of the valves and consequent regurgitation. In the first place, the seat of the murmur, as perceived by the stethoscope, will tend to fix its origin. When the sound is loudest on the sternum, im- mediately below the insertion of the third rib, and thence extends upward for about two inches along the course of the great vessels, it may be considered as having its source in the semilunar valves. If the sound be perceived most distinctly along the course of the ascending aorta upon the right, it is pro- bably seated in the aortic valves; if along the pulmonary artery on the left, it is in the pulmonic valves. When the murmur is most distinct over that part of the chest on which percussion is dull, that is, where the ventricles are in contact with the walls, it may be inferred that it is generated either in the mitral or tricuspid valve; in the former, when the point of greatest loudness is a little to the right of the left nipple and an inch or so below it, in the latter, when the analogous point is on or near the sternum in the same horizontal line. In the second place, the solution of the question, whether the sound de- pends upon contraction or any other obstruction of the valvular opening, or upon deficiency or insufficiency of the valves themselves, in other words, CLASS III.] DISEASES OF THE HEART. 139 whether it is generated in the regular onward course of the blood, or by re- gurgitation, is aided by observing the course of the sound, its relation as to the time of occurrence to the contraction or dilatation of the ventricles, and the character of the sound itself. The course of the sound will generally be in the direction of the current of blood from the originating point. In con- traction of the semilunar valves, and insufficiency of the auriculo-ventricular valves, the sound will be synchronous with the ventricular systole; in the opposite states of these valves respectively, with the diastole. The sounds produced during the systole of the ventricle are louder than those during the diastole. First, in relation to the aortic valve, if it be obstructed, the mur- mur will be heard during the systole, will be rather loud, resembling, accord- ing to Dr. Hope, the whispered letter r, and will follow the course of the aorta, sometimes even as high as the carotid, without being perceived, or but faintly so, over the ventricle. If the valve be insufficient, so as to oc- casion regurgitation from the aorta, the murmur will be heard during the diastole, will be of a lower key than the preceding, resembling, according to Dr. Hope, the word awe whispered in inspiration, and will be most distinct over the ventricle into which the regurgitating current from the aorta is directed, though it may also be heard for some distance up the aorta. These two murmurs, succeeding each other, may be considered as a sure sign of conjoined contraction, and insufficiency of the aortic orifice. Secondly, in relation to the mitral valve, obstruction is indicated by a diastolic murmur, heard over the left ventricle, very feeble and low-toned in consequence of the weakness of the auricular contraction and the depth of the valve, and com- pared by Hope to the word who, whispered feebly. Insufficiency, produc- ing regurgitation, is attended with a louder sound of the same character, is systolic, and may be heard near the apex of the heart, but does not, like the semilunar murmur, extend far up the aorta. Thirdly, the same rules apply to the murmurs of the right side of the heart, those namely of the pulmonary semilunar valve, and the tricuspid. They are usually higher toned than those of the left side, because nearer the surface. They will be sought for of course along the direction of the pulmonary artery, or over the right ven- tricle. They are comparatively very rare. The auriculo-ventricular sounds are sometimes wanting, even when there is considerable constriction of the orifices, in consequence of the feebleness of the auricular contraction. They may occur either immediately after the systole, along with the second sound, in which case they are produced probably, in chief, by the force given to the blood by the suction of the dilated ventricle, or immediately before the systole and after the period of repose, when the contraction of the auricle takes place.* It is often very important to be able to decide whether a cardiac affection * Some modification of these views as to the auriculo-ventricular murmurs becomes necessary; if we adopt the theory of the diastolic impulse. Thus, the murmur often heard near the apex of the heart, synchronous with the impulse, and occurring in the time of the first sound, instead of being regurgitant, and indicating mitral insufficiency, must, on the diastolic theory, be considered as a murmur of contraction, produced by the rush of blood through the narrowed auriculo-ventricular opening during the active diastole; and the remarks made in the text on the signs of constriction of the auriculo- ventricular openings must be looked on as inaccurate. More will be said on this point under the head of chronic disease of the valves. The author will at present merely observe that the views given in the text are mainly those of Dr. Hope, and were proba- bly originally adopted by that writer as much from their conformity with his opinions in relation to (lie heart's actions, as in accordance with actual observation. They are, however, allowed to stand; because, though their entire accuracy is doubted by the author, they have high authority in their favour, and those of a different bearing still want the support of further investigation, and the sanction of general opinion. (Note to the fourth edition.) 140 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. is organic or merely functional. An accurate appreciation of these morbid sounds is valuable on this account. The pure bellows murmur is an attendant on both forms of disease; but when rough, of the rasping or grating character, it indicates usually some organic derangement of the valves. If the morbid sound be traced to one of the valves, and be found constant there, it may be considered as an almost certain sign of structural change. The murmurs of regurgitation are probably in general of organic origin, though it is pos- sible, that regurgitation at the mitral valve may sometimes occur, from a slight irregularity in the contraction of the fleshy columns, consequent upon nervous disturbance; and the same result might readily flow from gouty or rheumatic irritation affecting these columns. The same may be true also of the aortic and pulmonary regurgitant murmurs, if, as maintained by some anatomists, there are muscular fibres in the semilunar valves, the irregular action of which may interfere with their accurate closure.* A sound similar to the bellows murmur is sometimes caused in the bron- chial tubes by the pressure of an enlarged heart. This is distinguishable from the proper cardiac murmur by the fact, that it may be suspended by holding the breath. It may serve sometimes as a sign of disease of the heart, but may proceed from so many other causes, that little reliance can be placed upon it. A friction or rubbing sound, analogous to that sometimes observed in pleurisy, is often heard in disease of the pericardium, and results from the moving upon each other of the opposite surfaces of that membrane, rendered rough by the exudation of coagulable lymph. It may be distinguished from the similar sound of pleurisy by the circumstance, that it is not affected by a suspension of the respiration. When the membrane is at the same time very stiff and rough, it gives rise to a modification of the friction sound, which has been called creaking-leather sound, from its resemblance to the noise made by new leather. Both of these sounds have an alternating character, de- pendent on the double motion of the heart. They are said to be strongest in the systole, and after expiration. The friction sound often closely resem- bles the endocardial murmurs; and it is sometimes difficult to distinguish between them. It is generally increased by pressure; but this fact cannot always be received as diagnostic; for, as stated by Dr. Wm. Jenner, even mo- derate pressure over the base of the heart in children, whose chests are flexi- ble, is capable of producing a murmur by diminishing the cavity of the pul- monary artery. Strong pressure may sometimes even diminish the friction sound, by lessening the movement between the pericardial surfaces. A churning or washing sound occasionally results from the presence of a certain amount of liquid in the pericardium. All these pericardial sounds are more superficial than those proper to the heart itself. A strong pulsation of the heart may develope the mucous and sibilant rales by a movement given to the air in inflamed bronchial tubes, and sometimes occasions the metallic tinkling in large tuberculous cavities. Sometimes along with the sounds of the heart, whether otherwise normal or abnormal, there is heard a peculiar musical or metallic tinkling, the origin of which is not well understood. A similar sound may be at any time produced by applying the palm of the hand to the ear, and gently striking the back of it with the finger. It is noticed under various circumstances, and differ- ent explanations have been given. M. Barth has observed it in connection with the existence of air in the cavity of the pleura, and the idea has been suggested that it might in some instances be connected with gaseous dis- * See an abstract of a paper by Dr. Monneret, presented to the French Academv of Sciences, Oct. 16, 1849, in the Lond. Med. Gaz., March, 1850, p. 408. CLASS III.] DISEASES OF THE HEART. 141 tension of the stomach. It is most probably produced by a quick impulse of the heart, producing vibration in a tense structure, as a similar sound is caused in large cavities with elastic walls containing air. The sound is pro- bably often generated, in various degrees, by a strong impulse of the heart against the walls of the chest. It is of no great importance in diagnosis. Vascular Sounds.—A slight sound is sometimes occasioned by the motion of the blood in the arteries, which is very much increased by whatever roughens the internal surface, or produces any sudden change in the capacity of the vessels, whether aneurisms, or the pressure of a tumour from without. A watery condition of the blood very much promotes it, so much so, that, in anemic individuals, it can be produced with great facility by merely press- ing the artery with the end of the finger, or the stethoscope. It is synchro- nous with the systole of the heart, and consequently takes place during the diastole of the arteries. Sometimes a double murmur is produced in the arch of the aorta, the first corresponding with the systole, the second with the dias- tole of the heart. The diastolic murmur is supposed to be produced by a regurgitant movement of the blood from the great arterial branches in conse- quence of want of due elasticity in the diseased and dilated aorta. (Belling- ham, Lond. Med. Gaz., Sept. 1850, p. 399.) At. Beau thinks he has proved that the arterial murmur, and especially that of the carotids, is produced whenever an increased wave of blood is thrown into the great vessels, in consequence of dilatation of the heart. (Archives Generates, ie ser, xiv. 133.) In large veins, too, a peculiar murmur has been noticed, especially in ane- mic individuals, which received from M. Bouillaud the designation of bruit de diable, from the name of the humming top, the noise of which it was sup- posed to resemble. It may properly be called the humming sound. It is observed especially in the internal jugular vein ; but occurs also in the ex- ternal jugular, in the vena innominata, and in the crural vein. (Arch. Gen., 4e ser., xxiii. 326.) It differs from the arterial bellows murmur by being continuous, though it is by no means uniform, having characteristic swells and remissions, which correspond with the diastole and systole of the arteries. Occasionally it has quite a musical tone. It probably depends upon altered capacity of the vessel at the moment of examination, as by the tension caused by turning the head on one side, and upon a deficient viscidity or abnormal mobility of the blood. Dr. Ogier Ward states that it may be heard in all children under the age of seven, and considers the watery condition of their blood a sufficient explanation. (Lond. Med. Gaz., May, 1851, p. 784.) 5. General Symptoms. These are either directly connected with the heart, or secondary. To the former section belongs the pulse, which, though dependent on the contraction of the left ventricle, is not, as felt at the wrist, exactly synchronous with the impulse of the heart, but follows it at a slight interval. Being liable to all the irregularities of the cardiac pulsations, whether as to force, duration, or the relation to each other of the successive beats, it is highly important in diagnosis, and often enables us immediately to detect derangement in the central organ of the circulation. It is almost always more or less deranged in diseases of the heart. Its indications, however, must not be received without allowance. Intermission in the pulse is not always a sign of inter- mission in the contractions of the heart. It not unfrequently happens that an occasional ventricular contraction is too feeble to transmit an impulse to the arteries in the extremities. The pulse may be very weak when the heart appcacs to act tumultuously, because, though the extent of the motion is considerable, the force of the contraction is not great; or it may be, that the 1-42 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. left ventricle may contract under certain circumstances less vigorously than the right; or, finally, there may be an insufficient quantity of blood in the left ventricle, consequent upon the retardation of the current in the pulmo- nary capillaries. Very frequently the heart continues to beat after all pul- sation at the wrist has ceased.* Other circumstances which influence the condition of the pulse, independently of the mere cardiac contractions, are the quantity of blood in the vessels, and the general tone of the system. These facts are sufficient to show that the pulse is not to be relied on im- plicitly, as an index of the state of the heart. Its relation to particular car- diac diseases will be treated of under those diseases respectively. Dyspnoea is among the most prominent and distressing symptoms of car- diac affection. It sometimes depends upon mere nervous disorder; but more frequently arises from direct interference with the functions of the lungs, either by pressure upon them, congestion, or effusion into the pulmonary tissue or the pleural cavities. Pain is little to be depended on as a sign of disease of the heart. The most violent and fatal affections are often attended with little positive pain, even pericarditis and endocarditis sometimes running their course without it. In other cases it is very acute; and not unfrequently the patient experiences great distress about the prascordia, of a vague and indescribable character, altogether different from ordinary pain. Though thus uncertain, the exist- ence of pain in the region of the heart should be regarded with suspicion, and lead to an accurate investigation of its cause. Palpitations, by which are meant pulsations of the heart disagreeably sen- sible to the patient, are a very frequent symptom. It does not necessarily follow, that there should be an increase of the impulse of the heart against the chest. The symptom is often connected with very slight disease, and be- comes alarming only when long continued, or associated with other signs of a serious import. Its existence, however, for any length of time, should al- ways lead to inquiry. Palpitations will be more particularly treated of among the inorganic affections of the heart. The secondary symptoms are very numerous. They are chiefly such as in- dicate morbid effects of irregularities in the circulation. Either the blood is driven with too great a force into certain organs, as into the brain in hyper- trophy of the left ventricle, and into the lungs in the same condition of the right ventricle ; or it becomes congested in various parts, from impediment to its passage through the heart, as in the general venous system of the body, including especially the viscera of the abdomen, when the impediment exists in the right side, or in the pulmonary vessels when in the left; or, finally, it is distributed with insufficient force, or in insufficient quantity, to the body at large, in consequence of debility or obstruction of the propelling organ. Hence the phenomena of active or passive congestion in the brain, the lungs, the liver, the kidneys, and the whole alimentary canal. Hence vertigo, tor- menting headaches, irritable temper, epistaxis, apoplexy, pulmonary hemor- rhage and inflammation, hepatic disease, haematemesis, various forms of dis- ordered stomach and bowels, and an anemic state of the blood. Hence, too, dropsical effusion, sometimes general, sometimes in the form of anasarca or hydrothorax. The enlarged thyroid gland and prominent eyes sometimes _ * These anomalies are perhaps more readily explained on the theory of diastolic impulse. A ventricular contraction strong enough to produce a perceptible impulse upon the walls of the chest, should cause a pulsation in the artery at the wrist- but we may easily conceive that there may be a diastolic impulse, while the systole is'very feeble and insufficient to produce a pulse. Again, the seemingly tumultuous beating of the heart when the pulse is feeble may be diastolic, while the systole may correspond in feebleness with the movement of the artery at the wrist. (Note to the fourth edition ) CLASS III.] PERICARDITIS. 143 connected with disease of the heart, may be similarly explained. It is not pretended that these phenomena occur in all cases of affection of the heart • but there is not one of them which does not occasionally present itself. These symptoms of course vary, according as the congestion is active or passive. Thus, in the former we have the flushed and swollen face, the prominent eye, and the general turgid state of system; in the latter, the pallid or livid com- plexion, the purple lips, the puffy eyelids, and the universal tendency to oedema. It has been observed, that the great viscera are apt to be hyper- trophied in consequence of the congestion to which they are incident, and that this effect is produced whether the congestion is active or passive. Be- sides the sources of secondary disorder above mentioned, there is another, consisting in the pressure of the enlarged organ or distended pericardium upon the neighbouring lungs, and the disturbance of the pulmonary functions from the mere mechanical effect of the heart's frequently excessive action. It very seldom happens that the whole heart is diseased at once ; and, when both sides are affected, one is so ordinarily in a greater degree than the other. In like manner, when the two cavities of the same side are diseased, they seldom suffer equally. Not unfrequently the disease is confined to a single valve, or a single cavity. Article I. INFLAMMATION OF THE PERICARDIUM, or PERICARDITIS. The heart includes three distinct tissues, which, though frequently inflamed conjointly, are nevertheless liable to be separately affected, and therefore re- quire separate consideration. The tissues alluded to are the pericardium or investing membrane, the endocardium or lining membrane, and the intervening or muscular structure. Inflammation occurring in these several parts is de- nominated respectively pericarditis, endocarditis, and carditis. These affec- tions were formerly confounded, as no means existed of discriminating accu- rately between them. Nay, the diagnostic symptoms of inflammation of either or all of these tissues were so uncertain, that the best informed physicians were often at a loss to determine, in particular cases, whether it existed or not. Even Laennec admitted the impossibility of forming a certain diag- nosis in pericarditis. To Louis belongs the credit of opening the way to a more accurate knowledge of this complaint, by the discovery of certain characteristic signs. Since his publication, a flood of light has been poured from various sources upon the subject; and we are now in possession of the means, not only of recognizing the existence of pericarditis, but of distin- guishing it with considerable certainty from endocarditis. The same, how- ever, cannot yet be said in relation to inflammation of the muscular tissue, or carditis, the symptomatology of which, as a distinct affection, is very ob- scure. The student, in perusing the following remarks, must not forget that, in many, perhaps in most cases of pericarditis, inflammation of the lining membrane exists at the same time, and mingles its characteristic signs with those of the former complaint. Pericarditis is not unfrequent. It has been inferred from a vast number of post-mortem examinations, made in the hospitals of Paris and elsewhere, that about one in twenty-three of all who die at an adult age, exhibit marks of recent or former attacks of this disease. The proportion is probably greater of persons who are affected with it at some period of their lives; for there is reason to believe that it often occurs, in a moderate degree, without leaving any permanent vestiges behind it. I have no doubt that many slight 144 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. cases of it are quite overlooked. My attention has frequently been called to attacks of disease, sufficient to unfit the patient for his ordinary pursuits, yet not severe enough to induce him to take to his bed, in which a careful exami- nation has revealed the existence of a greater or less degree of pericarditis. Anatomical Characters.—The first effect of inflammation of the pericar- dium is probably to produce congestion, and consequent swelling of the sub- serous cellular tissue, with diminution of secretion, and dryness of the serous surface. But the first appearance, obvious to anatomical examination, is red- ness, which may be in points, or in patches or streaks of various shape and size, and, even in the latter case, has a somewhat punctuated or mottled char- acter. Mere redness, however, unattended with effusion, cannot be consid- ered as certainly indicative of inflammation; for it may result from congestion alone, or may be cadaveric. Nor is it always observable in cases of undoubted inflammation, disappearing sometimes in instances of very early death, as erysipelatous redness is known to do upon the skin. Very soon after the commencement of the attack, there is an increased secretion from the internal surface of the membrane. The matter secreted is sometimes almost exclu- sively coagulable lymph, which concretes as soon as it exudes, sometimes almost exclusively serum, which remains liquid; but, in the great majority of cases, is a mixture of the two; the coagulable lymph or fibrinous matter ad- hering to the surface, and the serum accumulating in the pericardial sac, with flocculi or shreds of the concrete matter often floating in it. The quantity of the liquid varies greatly, amounting, in some instances, to little more than three or four fluidounces, in others to as many pints. Gene- rally it exceeds nine fluidounces. Frank mentions a case in which six pounds of liquid were found in the cavity. Occasionally it is limpid and nearly colour- less ; but more generally is yellowish or greenish-yellow, opalescent, of a whey-like appearance, or milky; and sometimes is of a red or sanguineous hue. In certain hemorrhagic states of the constitution, it is largely mixed with blood. In some cases, especially in the advanced stages or chronic form of the disease, it is sero-purulent; and rare instances occur, in which, from the peculiar condition of system, it is originally pus, either well formed and nearly pure, or in various degrees sanious and offensive. The fibrinous matter or lymph is at first generally in the form of a soft delicate film, spread over the surface of the membrane, from which it is easily separable; but occasionally it is deposited in distinct masses. With the pro- gress of the inflammation, it increases in quantity, and at the same time be- comes firmer and more adhesive. Its colour is usually yellowish-white, but sometimes pinkish or reddish-brown from the intermixture of blood. It is singularly arranged, not being uniformly spread over the surface, but very irregularly, presenting a reticulated or cellular appearance, which has been aptly compared to that produced by first bringing into contact and then sepa- rating two layers of soft butter, spread upon pieces of board or other solid body. The irregular surface of the pericardial exudation is owing to a simi- lar cause. It is, no doubt, produced by the alternate meeting and separating of the cardiac and free surfaces of the membrane, with the alternate dilatation and contraction of the heart. The little prominences and depressions thus formed are altogether irregular in their shape, size, and arrangement. Thus, the surface has been variously compared, in different conditions of the exuda- tion, to that of a piece of cut sponge, to honey-comb, to the interior of the stomach of a ruminating animal, as seen in tripe, and to a congeries of earth- worms. Sometimes the pericardium is studded over with soft roundish «ranu- lations, and sometimes exhibits innumerable slender papillary projections. The coating of coagulable lymph or false membrane is of various thick- ness, from less than a line to nearly or quite an inch; but in general it is be- CLASS III.] PERICARDITIS. 145 tween one and three lines. In some instances, it covers the whole serous surface of the sac, in others, is confined either to the cardiac or to the free surface exclusively, and in others again, is in separate patches very different in their extent. It is commonly thickest upon the heart. Beneath it, the serous membrane is usually reddened, but not always. Dr. Hope states that the pericardium is itself very rarely thickened, and that, when apparently so, it generally owes the effect to a layer of old adherent false membrane, opaque and of a bluish-white colour, the result of previous inflammation. Real thick- ening, when it occurs, is seated not in the proper serous tissue, but in the cel- lular or fibrous structure without it. In consequence of the softening of this subserous cellular structure, the true membrane may sometimes be peeled off from its natural attachment. The anatomical changes which take place in the course of the complaint are not always the same. There is reason to believe that the inflammation sometimes terminates before effusion has occurred, and that in other instances absorption of the effused matter, whether fibrinous or serous, ensues, and reso- lution is effected. But generally, when coagulable lymph has been exuded, at least in any considerable quantity, the course is different. When the exu- dation is chiefly concrete, the opposite surfaces, though they may at first sepa- rate to a certain extent with every contraction of the heart, gradually, as the lymph hardens and becomes more adhesive, cohere more and more firmly, until they at length remain permanently united. Incipient blood-vessels, in the shape of red points and variously branching lines, soon show themselves in the new deposit, which thus by degrees becomes organized, at first imper- fectly, but, through the agency of absorption and the consequent removal of superfluous matter, in the end completely, so as to be converted into cellular tissue scarcely if at all distinguishable from original structure. The peri- cardial cavity is thus permanently obliterated, and the membrane sometimes appears as though it had never been double. In those cases, constituting much the greater number, in which the serous effusion is so copious early in the disease as to keep the opposite surfaces separate, adhesion is of course prevented so long as the liquid continues un- absolved. But, as the inflammation abates, the process of absorption takes place, the amount of serum is gradually diminished, and successive portions of the surfaces, coming into contact, unite together, and go through the same changes precisely as those above described. Sometimes, though rarely, the coating of coagulable lymph becomes organized before the serum is absorbed; and then, after death from other causes, the surface of the heart is observed to be covered, in the whole or greater part of its extent, with false membrane, without any obliteration of the pericardial cavity. I have recently seen a case of this kind. It has been stated that the layers of coagulable lymph are sometimes par- tial. When two of these patches are opposite to each other, they coalesce, and sometimes unite firmly, so that the sac, instead of being wholly oblite- rated, is divided into sections which may or may not communicate. But, in other instances, the union is not firm enough to resist the separating action of the heart, and the plastic lymph is thus drawn out into bands or filaments, which, being converted by the organizing process into cellular tissue, continue permanent in the sac. Often, however, the patches are not opposite. In such instances, they are equally converted into false membrane, but now form only whitish opaque spots, which have been frequently noticed, in post-mortem ex- aminations, on the surface of the heart, and were at first mistaken for mere discolorations. Their nature, however, is rendered evident by dissection, by means of which a lamina of thin membrane may be separated, leaving the proper surface of the pericardium quite distinct. These white patches are of 146 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. the size of the nail or larger, and, being the remains of former inflammation, are among the proofs of the frequently curable nature of pericarditis. Sometimes the effused liquid is only partially absorbed, and adhesion, from this cause, but partially effected. This is especially the case when the liquid is purulent, and hence pus is sometimes found, in such cases, filling the in- tervals of the adhesions. Again, the sac may continue long or permanently distended, either from defective absorption, or from the continuance of ex- udation. In such instances, coagulable lymph continues to be deposited, so that the coating sometimes at length attains great thickness, exhibit- ing different layers, which have different degrees of consistence and firm- ness, the most superficial, as the most recent, being generally the softest. The first layer, becoming organized, serves as an exuding surface from which the next may proceed. Cases of this kind are apt to terminate fatally; but sometimes not until after a long time and various changes. The liquid is occasionally at length absorbed, and the opposite layers, thus brought to- gether, form a thick mass, too unwieldy to admit of a perfect organization. Hence, it is converted into fibrous, or fibro-cartilaginous, and sometimes even into bony matter, which firmly embraces the heart, cramps its movements, and, by offering a constant stimulus to its actions, may end in hypertrophy, or, by restraining them, in atrophy of the organ. In tuberculous constitu- tions, the false membrane sometimes becomes the seat of tubercles. It ap- pears also to be liable to inflammation, and has occasionally been found interspersed with purulent collections. The substance of the heart is often morbidly affected in fatal cases of pericarditis, being, in relation to colour, redder, browner, or paler than in health ; in relation to consistence, harder or softer; in relation to bulk, in- creased, as in hypertrophy with or without dilatation, or diminished, as in atrophy. When long surrounded by liquid, it experiences the sedative in- fluence of such exposure, and becomes soft, flabby, and pale, with a great diminution of its energy. Symptoms.—The general symptoms of pericarditis are exceedingly di- versified, being very different in different cases, and though, when occurring conjointly in considerable numbers, they may serve to indicate the disease with an approach to certainty, yet they are very seldom conclusive, and often altogether insufficient to serve as the basis of a correct diagnosis. The attack is usually ushered in with a chill, wdiich is sometimes repeated, and always followed by fever. It is said that occasionally the onset is marked by faintness or positive syncope rather than by chilliness. Among the symp- toms which attend the complaint, though by no means always in the same cases, and in some nearly or quite wanting, are pain, oppression, weight or other uneasiness in the region of the heart, palpitations, cough and hurried respiration, dyspnoea, a preference for certain positions, occasional vomiting and painful deglutition, headache and delirium, frequent and often irregular pulse, great debility, attacks of faintness approaching or amounting to syn- cope, restlessness, great anxiety of countenance, and oedema of the face and extremities. From this enumeration of symptoms no definite notion of the complaint can be drawn ; and it is necessary to dwell more in detail upon each of them individually. Fever is always present, unless in very mild cases, and is attended by the usual signs of this affection in the phlegmasia? generally, such as frequent pulse, hot skin, sometimes dry and sometimes perspiring, furred tongue, loss of appetite, scanty urine, &c. The pulse is an important symptom. Dr. Todd states that an intermit- tent pulse, occurring when there is reason to apprehend the supervention of cardiac inflammation, is a very suspicious symptom, indicating the probable CLASS III.] PERICARDITIS. 147 approach of either pericarditis or endocarditis. According to Dr. Williams, the pulse is sometimes slower than natural at the commencement; but, unless in the chill, such an event must be very rare. It is usually, after the fever has been airly established, much increased in frequency, beating often from 110 to 120 times in a minute, and regular. Early in the disease, it is gene- rally full and strong, with a sharp angry beat; but sometimes it is small and wiry. As the complaint advances, it very often becomes irregular, and occa- sionally very much so, beating rapidly for a few strokes and then slowly, with a sort of hobbling movement, and not unfrequently intermittent. The irregu- larity is sometimes temporarily developed by excitement of any kind, as by quick motions or mental disturbance. Towards the close, it is small and very feeble, sometimes scarcely to be felt; and this weakness of the pulse at the wrist may be observed occasionally when the heart is apparently tumultuous in its action. It is probable that the irregularity and intermission of the pulse are often owing rather to accompanying endocarditis or carditis, than to the proper inflammation of the pericardium. When it is exceedingly fre- quent and small, or peculiarly jerking, endocarditis may be strongly sus- pected. The different condition of the pulse at different stages of the disease may be considered as indicative of the condition of the cardiac muscles; wThich are at first irritated into excessive action, as shown by the strong, full, sharp pulse; subsequently weakened but still irritated, causing the frequent and irregular pulse ; and lastly, prostrated by their previous excitement, so that the pulse becomes more and more feeble till the close. This weakness of the pulse, towards the end, may also be referred in part to the cramping influence of the effusion, liquid or concrete, by which the heart is surrounded. Dr. Stokes has noticed in two cases increased action of the carotids. Pain is a very uncertain symptom. Sometimes it is exceedingly acute, shooting from the praecordia to the back between the shoulders, and extend- ing often to the left shoulder and down the left arm, sometimes as low as the elbow or even the wrist. It is often aggravated by a deep inspiration or coughing, by percussion, by pressure on the intercostal spaces and in the epigastrium, especially upwards beneath the ribs somewhat to the left of the middle line, by forcible stretching, and by lying on the left side. Fre- quently, however, sharp pain is wanting, and it has been supposed that it is never experienced, in its severest form, unless the pericarditis is accompanied with pleurisy. This, however, is a mistake ; as uncomplicated inflammation of the pericardium has been known to occasion the most excruciating pain. Instead of this sharp pain, the patient very often complains only of a slight, dull, aching, or intermittent pain, or of indefinite uneasiness about the left portion of the chest, variously described as a feeling of tightness or constric- tion, weight, burning, or oppression, and occasionally involving, to a certain degree, the left shoulder or arm. In some instances, the uneasiness is refer- red to the epigastrium; and cases occur in which no pain of any kind is experienced, nor any sensation calculated to direct attention to the heart as the seat of disease. The cardiac uneasiness is, moreover, sometimes masked by severer pain in other parts of the body, or escapes notice in consequence of the delirium of the patient. When acute pain is felt, it is generally in the earlier stages, and is diminished upon the occurrence of effusion. Dyspnoea occurs in most, though not in all cases, and is sometimes very distressing. It is probably in part a nervous phenomenon, connected with derangement of the par vagum ; but it arises also from the pain caused by movements of the chest, and from pressure made by the accumulated fluid of the pericardium upon the lungs. Occasionally, it is so severe that the chest visibly heaves in respiration ; speaking is difficult, and the patient is unable to rest in the horizontal position, preferring to sit with his body leaning for- 148 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. ward and towards the left side. The respiration is in general nearly thirty in a minute, and sometimes much more, especially in cases complicated with pleurisy or pneumonia. The irritation occasionally extends to the diaphragm, giving rise to hiccough, and, as it is said, to the sardonic laugh ; but these symptoms, as well as the vomiting, difficulty of deglutition, and derangement of voice which sometimes attend the disease, are with as much probability ascribable to the propagation of disordered impressions through nervous channels. Cough, though it may attend pure pericarditis, is not a prominent symptom unless in complicated cases. It is usually dry. The palpitations are often violent, occurring most commonly in paroxysms, which are apt to come on in the night, and often without apparent cause. Sometimes, however, they are induced by any muscular exertion, or strong mental emotion. Cerebral dis- order is notunfrequent, being exhibited in headache, disturbed sleep, fright- ful dreams, delirium, muscular twitchings, &c.; and these symptoms are so severe, with so little obvious cardiac disease, that they have sometimes been referred to inflammation of the brain, and the heart quite overlooked, though dissection has proved the former organ to be sound, and the latter only affected. A disposition to syncope has been supposed to be characteristic of pericar- ditis. It no doubt occasionally exists, and fainting is sometimes probably the immediate cause of death; but it is by no means a constant symptom. Great restlessness, jactitation, anxiety of countenance, and general prostra- tion are phenomena of bad cases, and especially mark the close of the disease. The peculiar anxious expression is sometimes observed, when there is no pain or other local uneasiness to account for it, and has been ascribed to a nervous influence, propagated through the pneumogastric nerve to the brain, and thence transmitted to the muscles of the face. (Edema, though more common in the chronic form of the disease, is some- times observed in the acute, affecting more especially the lower extremities, and owing, in all probability, to the ineffectual action of the heart in the ad- vanced stages, and the consequent venous congestion. The blood in pericarditis almost always presents, when drawn from the arm, the buffy coat and cupped surface of inflammation, in a high degree; and is not apt to lose this character even after copious depletion. Physical Signs.—These are such as depend either 1. on simple excitement of the heart, 2.' on accumulation of liquid in the pericardium, or 3. on the friction of the roughened surfaces of the membrane upon each other. 1. In consequence of irritation propagated to the muscular tissue from the inflamed membrane at the outset, the ventricles contract with increased energy; and, consequently, both the sounds of the heart are louder, and its impulse stronger than in health, and than they are subsequently in the dis- ease. The impulse, however, though regular in its recurrence at this period, is often unequal in the relative strength of the successive pulsations. 2. When the effusion is considerable, dulness on percussion is always ob- servable to a greater extent than in health; and, as the cause is very com- mon, the sign is highly characteristic. It is not usually perceived, at the commencement of the disease, nor until it has continued for two, three, or four days ; though, in some instances, a copious effusion is one of the first effects, and dulness consequently one of the earliest signs. In extreme cases, it may extend from the edge of the false ribs to within two or three inches of the clavicle, and occupy a space seven and a half inches in height and nine inches across at the base of the heart. (Louis.) Sometimes the diaphragm is depressed by the distended sac, and the stomach and liver displaced But such instances are extremely rare. When the effusion is moderate it is best class in.] PERICARDITIS. 149 discovered by placing the patient in a sitting posture; because, when upon his back, the fluid is separated by gravitation from the anterior wall of the chest. The dulness is distinguished from that of pleurisy by its position, and its definite outline, and sometimes from that of hypertrophy with dilatation by extending more in the vertical direction. Allowance must be made for turgescence of the heart, which, in the early stage, may occasion some in- crease of dulness. The percussion sound over the lungs is sometimes more resonant than in health, probably from expansion of the thoracic walls, espe- cially in the young. When the effusion is so great as to produce considera- ble compression of the lung, the percussion sound occasionally acquires a some- what tympanitic character as in pleurisy. (A. Hudson, Dub. Quart. Journ., Nov. 1856, p. 285.) Other signs dependent upon the same cause are the absence of the respi- ratory sounds over the region of the heart, where they are observed in health, and a diminution of the cardiac sounds, which are feeble and seemingly dis- tant, in consequence of the intervening liquid, and are sometimes scarcely perceptible. But the second sound may be heard with considerable distinct- ness over the upper part of the sternum, in the course of the pulmonary artery and aorta, because these parts are uncovered, and the sound is generated at the valves of these arteries. The impulse of the heart is also much diminished, and sometimes its pulsations cannot be felt at all. When strong enough to be perceptible, they may often be observed to change their position i;i conse- quence of the free movement of the heart in the fluid of the pericardium, and impart an undulatory sensation to the hand, occasioned by the wave of the fluid as it is displaced with every systole. Dr. Latham says that this undu- lating motion is often visible to the eye between the cartilages of the second and third, or of the third and fourth ribs, or both at the same time ; but he has never seen it in any other place. (Led. on Clin. Med., &c, i. 133.) A common effect of copious effusion into the pericardium is, by pressing the heart backward and upward, to raise the point of impulse, and move it some- what to the left, so that the stroke is felt behind or even to the left of the nipple, when the patient is on his back. (Walshe.) Still another sign depend- ent upon the effusion of liquid is a prominence of the chest at the praecordial region, observable by the eye. This occurs later than the dulness, as it re- quires a greater amount of fluid for its production. It is often absent; and is most apt to take place in the young, in consequence of the greater flexibility of their cartilages and ribs. Avenbrugger noticed a swelling at the epigas- trium as one of the symptoms of the disease ; but this is rare. Most of these signs were pointed out by Louis, who thus made a vast advance in the diag- nosis of pericarditis. But they will not always answer; for the condition upon which they depend, that namely of a certain amount of effusion, does not always exist. Another sign dependent upon the effusion is a sort of churning sound, which is occasionally produced in the liquid by the move- ments of the heart. 3. Happily, another set of signs is afforded by cases in which the preced- ing are not observable. They are the rubbing sounds, produced by the fric- tion of the inflamed surfaces against each other. Attention was first called to the existence of these sounds by M. Collin, but they have since been much more accurately and thoroughly investigated by Dr. Stokes and other ob- servers. They are supposed to depend upon the roughness of the opposed surfaces produced by the coagulable lymph, sometimes possibly upon their dryness in the commencement of the disease. They are almost always double, from the double motion of the heart; and may be triple or even quadruple, as the contractions of the auricles are capable also of producing them. (Pen- 150 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. nock.) They are generally more distinct with the first cardiac sound.* They vary considerably in character, according to the roughness of the membrane, and probably also its stiffness or consistence, as well as to the energy of the heart's contraction. The ordinary form is that denominated simply friction sound, which is very similar to the friction sound of pleurisy, and is some- times so soft as to resemble the bellows murmur. The harsher forms are designated sometimes by the epithets grating, rasping, &c. Occasionally the sound imitates the rustling of crumpled parchment. As the varying cir- cumstances which modify the sound may all exist in the same case, so may also the different varieties of the sound. As first observed by M. Collin, it had a creaking character like that made by new leather, and this form of it is hence called the creaking-leather sound. The friction sound is not heard at the very commencement of the inflam- mation, but usually becomes sensible early in the disease, when the pericar- dial surfaces are not yet separated by liquid effusion, and have not contracted adhesion. It is then owing either to the dryness of the membrane, or the thin coating of coagulable lymph, and generally in all probability to the latter. When the effusion is slight, the sound should be sought for about the base of the heart, near the centre of the sternum. Moderate pressure with the stethoscope will sometimes develope it, when not otherwise sensible. Adhesion of the pericardium, or separation of its surfaces by the liquid ef- fused, soon abolishes it more or less completely. Sometimes it may be made to return, after having ceased, by causing the patient to lean forward, and thus throw the fluid towards the apex. When lost in consequence of ad- hesion, Williams states that it is last heard below the left breast. The sound is occasionally audible only over particular portions of the pericardium, inde- pendently of adhesions or the presence of fluid. Hence it has been inferred that the membrane is liable to partial inflammation; and the same inference has been drawn from the white patches now and then observed upon the heart; but, though the fact may be true, it requires other proofs than those mentioned; as the whole membrane may be inflamed, and yet concrete exu- dation take place only in parts of it. The friction sound, lost in consequence of copious effusion, is again heard after the liquid has been so far absorbed as to permit the surfaces to come once more into contact. But here again its duration is brief; for the surfaces soon contract adhesions, and cease to move upon each other. It is, therefore, to be sought for in the earlier, and in the somewhat advanced stages of peri- carditis, and answers an admirable purpose as a supplement to the signs de- rived from effusion, being present more especially under the circumstances in which these are wanting. There is some risk, unless with due attention, of confounding the friction sounds with the valvular murmurs which indicate the existence of endocar- ditis. Skoda states that, according to his experience, there is no endocardial murmur, except the whistling, which may not be imitated by a friction sound; and he knows no distinctive sign except that the internal murmur corresponds with the rhythm and the natural sounds of the heart, while the external follow its movements. (Treat, on Auscult. and Percus., Lond. ed., p. 219.) But the friction sounds are more superficial than the endocardial, are rougher, especially when coincident with the second sound of the heart, are more apt to change their position, and are inaudible at the distance of two or more inches up the pulmonary artery or aorta, where the murmurs of the sigmoid * If the diastolic impulse be admitted, the first friction sound would occur during the active dilatation and the immediately succeeding systole, while the second would be confined to the period of slow passive dilatation from the vis a tergo. In this view the greater distinctness of the former can be readily understood. CLASS III.] PERICARDITIS. 151 valves are heard distinctly, and are not, like the murmurs of the auriculo- ventricular valves, uniformly loudest near the apex of the heart. (Graves, Hope. Stokes.) They do not, like the endocardial murmur, replace the normal heart sounds. Besides, along with the friction sound, there is often a vibra- tory tremor distinctly felt by the hand placed over the region of the heart; and this is said by Dr. Hope to be generally stronger than the analogous thrill, sometimes attendant, in a slight degree, upon the valvular murmurs. (Treat, on Dis. of the Heart, Am. ed., p. 182.) Dr. Stokes observed it in five out of six cases He considers, as an important diagnostic character between the friction sound and the valvular, the fact that the former is very rapidly modified and often removed by local treatment, as by leeching or cupping, which has comparatively little effect upon the latter. Another dis- tinction is that the friction sound is increased by pressure, which has in gene- ral little effect on the endocardial murmurs. (Sibson.) Dr. Latham declares that the friction sound is in general not altered nor abolished by the effusion of serum; and that it may often coexist with the dulness. and is sometimes even preceded by it. By change of the position of the patient, the cardiac surface may generally, however great the effusion, be brought at some point or another in contact with the free surface, and thus give rise to friction. He ascribes this remarkable difference of the relation of the friction sound to the dulness in pericarditis and pleurisy, to the firm- ness of the heart contrasted with the yieldingness of the lungs. (Lectures on Clin. Med., &c, i. 129.) There may be some danger of confounding the friction sound with the raucous rales of bronchitis in the parts of the lungs lying over the heart; but the latter cease when the breath is held, while the former continues unabated. When the friction is strong, it may absorb the natural sounds of the heart, and thus lead to the suspicion that these are wanting. But the latter may always be perceived, under such circumstances, by applying the instrument to the upper part of the sternum. The loudness and roughness of the friction sound must not be taken as a measure of the amount of plastic exudation; as. with a weak action of the muscles, there may be little of the sound though the exudation is copious. Dependent on the same cause as the friction sound are the parietal vibra- tions, which communicate a thrilling sensation to the hand applied to the chest over the region of the heart. It has before been stated that, in a very large proportion of cases, endo- carditis coexists with pericarditis. In these, of course, both the friction sounds and valvular murmurs will be produced, though the latter may often be masked by the former. In relation to the valvular murmurs as signs of inflammation of the endocardium, more will be said under that disease. One cause, proba- bly, of the frequent coincidence of these two affections is the thinness of cer- tain parts of the cardiac walls, as in portions of the right auricle, and around the orifices of the aortic and pulmonary valves, where the investing and lining membranes come very nearly in contact, so that inflammation may readily pass from one to the other. Air has, in some very rare instances, been fouLd to exist in the pericardial cavity, being either secreted, or introduced from the stomach or lungs by a fistulous opening. It produces crackling, coughing, and metallic sounds very different from those ordinarily noticed, and sometimes so loud that they can be heard at a great distance. (Stokes, Dis. of Heart and Aorta, p 37.) When adhesion of the pericardial surfaces has taken place, there are no signs by which it can always be certainly recognized. Dr. Hope considers a peculiar jogging motion of the heart as characteristic of it; but his views upon this point are not generally admitted. When there is. at the same time, 152 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. adhesion between the external surface of the pericardium and the pleura ante- riorly, the obscurity is not so great. The heart, as observed by Dr. AN llliams, is then tied to the chest, in contact with which it must remain, whatever may be the motions of the ribs. Its movements, therefore, may be seen, and its impulse felt more distinctly than under ordinary circumstances, the intercostal space being drawn in at each contraction; and the site and distinctness of the pulsation, and the dulness on percussion, do not vary with the position of the patient, nor with the respiratory movements. Dr. Sanders has observed, in cases of close adhesion, each contraction of the ventricle to be attended by a depression in the left portion of the epigastrium ; and such an event may be readily conceived to occur, if the pericardium shall have also contracted adhesions posteriorly. According to Skoda, this is not true of the epigas- trium, at least he has not seen it; but, when the lower half of the sternum is retracted during the systole, it is a certain sign of adhesion of the pericar- dium to the heart, and to the vertebral column also. Skoda states, as the result of his observation, that the apex of the heart, though it may seem to cause a shock during the diastole, gives no systolic beat in pericardial adhe- sion, being prevented from moving downward and to the left, and drawn on the contrary to the right and upwards.* When, along with this absence of the systolic beat, there is retraction of the left intercostal spaces over the apex or above it, the existence of adhesion is indicated. (Markham, on Diseases of the Heart, pp. 114-15.) The most characteristic sign is probably a con- tinuance of the limits of dulness on percussion over the heart, unchanged by changes in the position of the body. Course and Termination.—In some violent cases, the disease has been known to run its course in a very short time, and to terminate fatally in less than forty-eight or even thirty hours. But such instances are extremely rare. Sometimes it is of a moderate grade and protracted march, running on for several weeks, without, however, entirely losing its acute character. But, in ordinary cases which terminate favourably, the disease generally begins to yield in the course of a week or ten days, and sometimes much sooner under active treatment. The fluid now begins to be absorbed, as shown by the diminishing dulness, the increasing sounds of the heart and respiration, the returning friction sounds, &c.; adhesion soon follows; and the cure is com- pleted in less than three weeks. In slight cases, there is good reason to believe that the cure may take place still sooner, and without adhesions. If about to prove fatal, the complaint is marked with great general weakness, oppres- sion, and anxiety; the pulse is very frequent, small, feeble, irregular, and at length scarcely to be felt; the extremities are cold; the face is pale, wan, and haggard, with purple lips; delirium not unfrequently comes on; and life at last closes, sometimes in the midst of convulsions. Occasionally, death occurs suddenly, without any premonition, under circumstances in which there was no apparent danger of such an issue. It is probably always tbe result of a direct loss of power in the muscles of the heart. Symptoms of Chronic Pericarditis.—Under the name of chronic pericar- ditis are included long-protracted cases of the acute disease which have lost their original violence, and certain other cases of a slow progress, which have been of the same mild grade from the beginning. These are often attended with pain, either dull or sharp, in the vicinity of the heart, sometimes extend- ing to the left shoulder or arm; but the pain is in general only occasional, and seldom very severe. Not unfrequently, too, the patient is without pain, and complains only of oppression, stricture, or weight. There is usually more or * This retraction of the apex of the heart during the systole seems confirmatory of the diastolic theory of the impulse; especially when considered in connection with the apparent diastolic shock observed by Skoda under similar circumstances. CLASS III.] PERICARDITIS. 153 less shortness and quickness of breath, and disturbance of pulse, the latter being somewhat more frequent than in health, and often irregular, but almost always feeble and irritated, rather than strong and active. It is occasionally hectic. The breathing is sometimes so much oppressed that the patient lies down with difficulty. Prominence over the region of the heart, dulness on percussion, absence of the respiratory sounds, distance and feebleness of those of the heart, and deficiency of impulse, are even more constant symptoms than in the acute form. The friction sound may also be occasionally heard. The face is usually pale and puffy, and the lips purplish; and I have seen the whole surface of the same dark hue. An anasarcous condition of the ex- tremities is very common. The patient is not usually confined to his bed; and often continues for months, sometimes better and sometimes worse, until at length the disease takes a favourable turn, or carries him off. Death, when it occurs, is often sudden. The disease may terminate in three or four months, or may run on much longer. The only affections with which this is likely to be confounded are dilata- tion of the heart, and dropsy of the pericardium. The former is usually attended with an extended and peculiar impulse, and even increased loudness of the cardiac sounds, and never with the noise of friction. When the car- diac muscles, however, are very feeble, the contractions may scarcely be suffi- ciently strong to produce sound. In such cases, the very gradual origin and very slow progress of the disease, will be sufficiently diagnostic. Dropsy of the pericardium is without local pain or febrile action, and may usually be distinguished by the coexistence of a universal dropsical tendency. The anatomical peculiarities of chronic pericarditis have already been de- tailed. Its causes, so far as they can be distinguished from those of the acute form, are an impoverished or depraved condition of the blood, feebleness of the general powers of the system, and a scrofulous or tuberculous diathesis. Tubercles are occasionally found in the pericardial tissue. Causes of Pericarditis.—The ordinary causes of inflammation are capable of producing it in the pericardium. One of the most frequent direct exciting causes is exposure to cold, when the body is warm and perspiring. Direct mechanical violence, fatiguing muscular effort, strong mental excitement, the abuse of stimulating drinks, suppression of hemorrhages or other morbid discharges, the retrocession of erysipelas or other eruptive affection, may also produce the disease. I have seen it result apparently from the cure of psoriasis by local applications. It is an occasional attendant on the exanthe- matous fevers. But pericarditis occurs more frequently, beyond all compari- son, as an attendant upon acute rheumatism, than from any other cause, or, perhaps, all others united. It is asserted by some of the highest authorities, that at least one-half of the cases of acute rheumatism are accompanied with pericarditis, endocarditis, or the two conjointly. Of 136 cases of acute rheumatism observed by Dr. Latham, 18, or between a seventh and an eighth of the whole number, were affected with pericarditis, either alone or in con- nection with endocarditis. (Lect. on Clin. Med., i. 144.) It has been dis- puted whether the cardiac affection in these cases is the result of metastasis, or is simply a part of the rheumatic disease. This appears to me to be very much a dispute about words. In rheumatism, it is well known that different parts, whether internal or external, are often affected successively, the inflam- mation leaving one seat as it fixes itself in another. It is also well known that many parts are often affected simultaneously. So it is in the case before us. Sometimes the rheumatic inflammation, when it seizes the membranes of the heart, is relieved in the limbs; and, under these circumstances, is said to be the result of metastasis. Sometimes it exists conjointly with the ex- ternal affection, and occasionally may even precede it. Though the connection VOL. II. 11 154 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. between rheumatism and pericarditis has long been known in Great Britain and this country, yet the profession is undoubtedly indebted to Bouillaud, m a considerable degree, for our present much more precise knowledge of the subject. Formerly the disease was supposed to be only an occasional inci- dent in the course of rheumatism; now it is known to be a very common accompaniment. Pleurisy and pneumonia probably often give rise to peri- carditis by the direct propagation of inflammation from tissue to tissue. It is not unfrequently associated with Bright's disease of the kidneys, and has been ascribed to the ureous impregnation of the blood attendant on that affection. The disease appears also to have sometimes occurred epidemically in confined localities. Among the predisposing causes, age must certainly be counted. The dis- ease is much more prevalent in early than in advanced life. Persons between eight and thirty-five are thought to be peculiarly predisposed to it. Sex also has some influence. Men are more frequently affected than women. The dis- ease is more apt to attack persons of vigorous constitution than the feeble and delicate. The rheumatic and gouty diathesis, convalescence from exanthe- matous diseases, especially scarlatina and erysipelas, and the existence of hypertrophy and dilatation of the heart, are undoubtedly predisposing causes; and the same is asserted of pregnancy and the puerperal state. Diagnosis.—The diseases with which pericarditis may be most readily con- founded are endocarditis, pleurisy, pneumonia, and pleurodynia. From the first it may be distinguished by the dulness on percussion, the prominence of the chest, the absence of the respiratory sounds, and the faintness or distance of those of the heart, or, in case of the want of these signs, by the existence of the friction sounds and the purring tremor, and the absence of the valvu- lar murmurs. From pleurisy it is distinguished by the more precise outline and peculiar position of the dulness, and its not changing with the posture of the patient, by the situation of the friction sounds, which accompany the heart's actions and not the movements of respiration, and by the absence of aegophony. Pneumonia may occasion dulness on percussion in the same re- gion, but it is without the projection of the chest, the friction sound, and the altered cardiac sounds; while it presents symptoms of its own not found in pure pericarditis, such as the rusty and viscid sputum, the crepitant rale, and the bronchial resonance and respiration. Pleurodynia is without any of the physical signs mentioned as characteristic of pericarditis, and is also usually unattended by some of the most prominent of its general symptoms, such as chill and fever, anxiety of countenance, oppression, irregular pulse, faintness, &c. The only coincident symptoms are acute pain, tenderness on pressure between the ribs, and difficulty of respiration. It must be great carelessness which would confound the two affections. But some embarrassment might be experienced in distinguishing pericardi- tis, when associated, as it often is, with the febrile phlegmasiae above men- tioned, especially with pleurisy and pneumonia of the left side. In the case of complication with pleurisy, the existence of the pericardial inflammation would be indicated by the friction sound over the heart existing independently of respiration. If this should be wanting, the general symptoms would aid much in deciding the point. Thus, should pain be felt over the heart, dul- ness and prominence exist in that region, and the cardiac sounds be feeble and distant, though these signs might arise from pleurisy, yet, if the pulse were very frequent and irregular, the countenance very anxious, and a ten- dency to syncope, with palpitations and distressing dyspnoea observable, there would be every reason to suspect the existence of pericardial inflammation. In pneumonia, a coexisting pericarditis would be indicated by the friction sounds, prominence of the praecordia, a greater degree of flatness on percas- CLASS III.] PERICARDITIS. 155 sion here than elsewhere, and by faintness and remoteness of the cardiac sounds. The general symptoms would here also aid the diagnosis. Indeed, the supervention of increased fever, with an irregular pulse, oppression, dys- pnoea, palpitation, &c, in a case of pectoral inflammation, would afford strong ground for suspecting that pericarditis had set in, and should lead to a careful physical examination of the heart. In cases, too, of apparent cere- bral affection, and of general inflammatory rheumatism, the practitioner should always be on his guard, and direct his attention to the praecordial re- gion, upon the occurrence of the slightest suspicious symptom.* Prognosis.—This is generally favourable. The disease was formerly con- sidered very dangerous, because recognized only in its worst forms. In the great majority of cases, it is a mild affection, and often wholly escapes notice in cases of inflammatory rheumatism, getting well under the treatment ad- dressed to the disease in general. Not unfrequently, in all probability, it would subside spontaneously, like so many other inflammations, under a pro- per regimen, as relates to diet, rest, &c. Simple cases of pericarditis rarely prove fatal. It is when complicated with pleurisy and pneumonia, and when occurring as an attendant upon other diseases deeply involving the constitu- tion, as Bright's disease, that it becomes so dangerous as it has generally been supposed to be. There is no doubt, however, that, even in its simplest form, it is capable of destroying life, and, therefore, requires prompt and energetic treatment. It is most fatal when supervening upon organic affec- tions of the heart, and occurring in persons worn out by previous disease. It may always be considered very dangerous when attended with a very frequent, irregular pulse, great dyspnoea, large effusion in the pericardium, and the general signs of imperfectly circulated, and badly aerated blood. There are two modes of favourable termination, one and the most favoura- ble in resolution, the other in adhesion. Some authors, however, have main- tained that adhesion is only a temporary cure ; and that sooner or later it almost always, if not always, leads to dangerous and even fatal lesions of the heart. Dr. Hope strenuously advocated this view. He believed that, among other effects, in consequence of the constant struggle of the muscles of the heart under the constraint of the adhering membrane, hypertrophy and all its terrible results ensue. This may be true in relation to some of those cases in which the effusion of coagulable lymph has been very copious, and in which an imperfect organization has been effected into a stiff, fibrous, or fibro- cartilaginous envelope. But I am quite convinced that it is not true as a gen- eral rule; and the opinion is combated by the best French authorities. Louis and others have observed in their dissections numerous instances of old peri- cardial adhesions, in persons who have died of other complaints, and in whom there was no suspicion of cardiac disease during life; and at present the weight of authority, even in Great Britain, is in opposition to the views of Dr. Hope. Pericardial adhesion is probably scarcely less innocent in relation to the heart, than the pleuritic in relation to the lungs. Treatment.—Bleeding is undoubtedly the most important remedy in the earlier stages of acute pericarditis. Yet it is not to be employed indiscrimi- nately and unsparingly in all cases. Great loss of blood indirectly stimulates the heart. The blood is rendered so thin and watery that it is incapable, as * A case is recorded in the Dublin Quarterly Journal of Medical Science (viii. 241), in which a rough crackling friction sound, heard over the region of the heart, and accom- panying the motions of that organ, was supposed, in connection with other symptoms, to indicate the existence of pericarditis, but after death was found to depend on emphy- sema of the anterior mediastinum. The pericardium was perfectly free from inflam- mation. The sound was produced by the pressure of the dilating heart upon the emphysematous structure. (Note to the third edition.) 156 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. ordinarily distributed, of supplying the wants of the system ; and such are the sympathies of the heart, that a sense of this deficiency, transmitted everywhere from the periphery of the circulation to the nervous centre, ex- cites, on every occasion calling for an increased expenditure of blood, exces- sive action in that organ, in order, by a more rapid current, to compensate for the defective quality of the fluid. Hence, any existing tendency to hy- pertrophy or dilatation is greatly promoted; and one of the very objects aimed at, that, namely, of quieting the heart, defeated. It is certainly pos- sible to push the depletion beyond the point of reaction; but this would scarcely be safe, in reference to immediate results. Besides, when the peri- carditis depends on rheumatism, as it usually does, bleeding alone will not generally subdue the inflammation; and the heart is thus left to struggle with the irritation of the disease, and the indirect irritation of the remedy. There is, under such circumstances, should the patient survive, great danger of organic disease of the viscus. These are not arguments against blood- letting, but only against its abuse. The application of the remedy is to be guided exactly upon the same principles as in other cases of serious inflam- mation. The stimulating quality of the blood should be reduced by deple- tion, and the direct sedative effects of its loss upon the heart obtained, without pushing it to the point calculated to promote reaction. The theory which urges to any amount of risk, in order to avoid the terrors of adhesion, should not be allowed the least weight. From a robust individual of previously unimpaired health, and at or near the commencement of the attack, from twelve to twenty-four ounces of blood may be taken at first, and the operation repeated, once and again, during the three or four succeeding days, if justified by the strength of the pulse, and the unchecked progress of the disease. After the first bleeding, which ought to be carried so far as to produce a decided impression on the pulse, but without inducing syncope, it is usually advisable, upon the recur- rence of the excitement, to attempt its reduction by cups freely applied over the region of the heart, so as to abstract from eight to twelve ounces. The general bleeding can afterwards be repeated if this should not be found to answer. In persons debilitated by previous disease, or ordinarily of a deli- cate or anemic constitution, blood must be drawn more sparingly; and, in many cases of this kind, it is best to rely upon local depletion by means of cups or leeches. It is generally advisable, after cups or leeches, to cover the praecordia with an emollient poultice, care being taken to protect the moist- ened surface from exposure to cold air. At the commencement of the treatment, the bowels should be thoroughly evacuated by some active cathartic, as, for example, by three or four compound cathartic pills, or a dose of infusion of senna with sulphate of magnesia, or from ten to fifteen grains of calomel, followed in a few hours by castor oil or Epsom salt. Afterwards, throughout the complaint, it will be sufficient to keep them open once or twice daily by saline laxatives or enemata if necessary. After reducing sufficiently the excitement of the pulse by depletion, and thoroughly evacuating the bowels, we are next to have recourse to mercury with the view of affecting the system. This is inferior only to the lancet in importance, and, in certain cases in which the propriety of depletion may be doubtful, will bear off the palm even from that remedy. The union of opium with the mercurial is beneficial, not only by obviating any tendency which the remedy may have to run off by the bowels, but also by restraining the violence of the heart's action. In pericarditis, every contraction of the heart tends to aggravate the disease, by keeping the inflamed part in motion. Opium renders it in some measure insensible to the irritation from the in- flamed membrane, and consequently has a tendency to diminish the frequency CLASS III.] PERICARDITIS. 157 of its contractions. During the existence, however, of the fever, it is best to qualify its stimulant action by combining it with a nauseating diaphoretic. These various indications will be met by giving from two to four grains of calomel, or from eight to sixteen grains of mercurial pill, with half a grain or a grain of opium, and double the quantity of ipecacuanha, every four hours. Or, the mercurial may be given with the opium alone, and, instead of the ipecacuanha, small doses of tartar emetic, as the eighth or sixth of a grain, may be given every hour or two. Should the skin be hot and dry, a table- spoonful of the neutral mixture, or a dose of the effervescing draught, or from five to ten grains of nitre, maybe given with each dose of the antimonial, or without it if ipecacuanha should be preferred. In conjunction with these measures, hot pediluvia may be employed daily. So soon as the gums are affected, the quantity of the mercurial should be moderated; but the impres- sion should be sustained for ten days or two weeks, or until convalescence is established. Should difficulty be experienced in affecting the gums, the ex- ternal use of mercury may be conjoined with the internal; and, for this pur- pose, a drachm of the mercurial ointment may be rubbed on the insides of the extremities once or twice in the day, and any blistered surface that may exist may be dressed with it daily. The course here recommended is appli- cable to severe cases. Should the symptoms be mild, the mercurial should be employed more sparingly; and in slight cases it may be omitted. After three or four days, should effusion have taken place, a large blister should be applied over the praecordia, and repeated, after the surface heals, if the symptoms continue. It is often proper in this stage, when there may be some uncertainty as to the sufficiency of the reduction, to apply cups or leeches again; and this may be conveniently done between the shoulders, in order to avoid interfering with the blistered surface. At this period of the disease, also, colchicum will sometimes be found use- ful, when the complaint is of rheumatic origin. Should the pulse be very frequent, it may be proper to control it by means of digitalis. To meet the two indications, when coexistent, twenty or thirty drops of the wine of colchi- cum root, and ten or fifteen of the tincture of digitalis, may be given every four hours; and, in cases of much nervous irritation, the addition of one of the narcotic tinctures, as that of hyoscyamus or conium, in pretty full doses, may be beneficial. Aconite, camphor, and hydrocyanic acid have been re- commended, under similar circumstances; and American hellebore would probably also be very useful by reducing the pulse. Perfect rest of body and composure of mind, throughout the complaint, are of the utmost importance. The patient should be sedulously guarded from the influence of causes calculated to excite him in any way; and all unneces- sary persons, therefore, should be excluded from the apartment. The diet should in the early stage consist of mucilaginous or farinaceous liquids, and animal food should be avoided up to the period of convalescence. Cooling drinks should be given throughout the complaint. In the form of pericarditis attendant on chronic Bright's disease, or occur- ring in the advanced stages of other exhausting affections, it is very obvious that general bleeding and mercury are quite contraindicated. Tonic and stimulant measures are here often necessary to support the system; and re- peated blistering, preceded by cupping when the strength permits, is the chief measure to be relied on for the relief of the inflammation. Opiates may also be employed freely, when there is no special contraindication, as stupor, for ex- ample. As in all other inflammatory diseases, in the advanced stages, when the powers of the heart are failing, and death from prostration is imminent, it is necessary to support life by stimulants and nutritious food. 158 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. In chronic pericarditis, it is advisable to sustain a slight mercurial im- pression , to keep up a constant succession of blisters over the heart; to apply occasionally, in case of pain, a few cups or leeches between the shoulders; and, when the effusion is copious, to employ the diuretics, especially squill, digitalis, and bitartrate of potassa. Some have recommended, instead of blisters, pus- tulation by tartar emetic, or the employment of a seton or issue; but it is doubt- ful whether these are in any respect preferable to the former remedy. Bouil- laud applies ten grains of the powder of digitalis daily to the blistered surface, when the heart continues to act excessively; but the remedy requires very cautious watching, lest it produce too great depression. Dr. Joy proposes turpentine in quantities sufficient to induce irritation of the urinary passages, in order to promote the absorption of the effused coagulable lymph; and states that iodide of potassium has been used advantageously with the same view. The alkaline carbonates and bicarbonates are also occasionally em- ployed. Narcotics are often required, in connection with the other remedies, to control nervous irritation, relieve pain, and produce sleep. The diet must vary with the condition of the patient. When the system is debilitated and the blood impoverished, animal food should be permitted; and it may some- times be advisable to allow a cautions use of the fermented liquors. In cases originally of a chronic character, the same general plan of treat- ment maybe employed; but in these cases moderate venesection may be occa- sionally called for; care being always taken not to induce an anemic condition of the blood. The remedy, however, upon which our main reliance must be placed is mercury, judiciously but perseveringly employed. The mercurial pill is usually preferable to calomel under these circumstances, as less liable to disturb the stomach and bowels. Should there be a reasonable supposi- tion of the existence of tubercles in the pericardium, and symptoms of a somewhat hectic character presented, the mercurial should be superseded by cod-liver oil and iodide of potassium. Paracentesis has been employed in some desperate cases; and, though the patient generally died afterwards, there is no reason to suppose that death resulted from the operation. In some cases decided relief was afforded. In a case recorded by M. Trousseau, the effusion did not return for nearly two months during which it was under observation. (Arch. Gen., Nov. 1854, p. 531.) M. Aran has also reported a case, in which the operation was twice performed, and each time followed by injection of iodine, not only without injury, but with great relief to the patient; and, after the second injection, the fluid did not again accumulate to any considerable extent. It would certainly be justifiable to puncture the pericardium, in cases where the effusion is so abundant as to put life in imminent danger, and all other means of relief have been tried ineffectually. Article II. INFLAMMATION OF THE ENDOCARDIUM, or ENDOCARDITIS. Endocarditis is inflammation of the interior or lining membrane of the heart. For much of what is known of the disease, we are indebted to M. Bouillaud. Others were aware of the fact, that the inner surface of the heart is sometimes the seat of inflammation; but the frequency of the affection, its rheumatic origin in most cases, and its fatal influence in the development of organic changes in the heart, were first clearly ascertained by the author mentioned. CLASS III.] ENDOCARDITIS. 159 Anatomical Characters.—Inflammation leaves behind it, in the internal membrane of the heart, much less prominent characters than in the external. The reason of this is obvious. Exuded fibrin, serum, and pus, the ordinary results and evidences of inflammation, are in this affection generally carried away from the diseased surface, as fast as thrown out or generated, by the incessant current of the blood. Hence, perhaps, it was, that endocarditis so frequently escaped the notice of pathological anatomists. Redness was visible; but this, being frequently the result of cadaveric imbibition, or of the same process in the last stages of life, has now long been considered as in itself but a very equivocal proof of the existence of inflammation, and certain only when accompanied with other evidences. These, however, though not very obvious, have revealed themselves to the more careful search of recent observers; and the frequent existence of endocarditis is now universally admitted. Redness in points, arborescent ramifications, or patches gradually fading into the general hue of the membrane, maybe observed more especially about or upon the left valves, and not unfrequently extending into the aorta. The reddened membrane is often thickened, is sometimes also softened, and occasionally presents roughness, inequality, or a whitish opacity of the surface, consequent on the exudation of fibrin into its substance or beneath it. Concrete fibrinous matter, notwithstanding the current of the blood, may generally be found in small quantities, either adhering to the valves and the membrane in their neighbourhood, or entangled in the meshes of the columnae carneae. (Bouillaud.) Sometimes it exists in the form of a filmy layer, but more frequently in granulations, from the size of a small shot to that of a pea. These granulations are either of crude lymph, or in various stages of organization; and are supposed to be the origin of the fungous or warty excrescences, called vegetations, which have often been observed in the same position. Watson speaks of them as disposed generally upon the semi- lunar valves, in the shape of two crescentic rows, one on each side of the central corpus aurantii, and extending thence to the point of insertion of the valve. These curved lines correspond with the edge of the fibrous structure, which is inclosed within the fold of serous tissue constituting the valves, but does not reach to the full extent of the duplicature, and leaves, consequently, a small portion of the membrane thinner and translucent, like the section of a plano-convex lens, the two points of which terminate respectively at the central corpuscle, and the place at which the valve is inserted. The rubbing of these thin portions of membrane against each other, at every closure of the valve, appears to displace the lymph that may be effused upon their surface, and to cause it to accumulate, in the lines alluded to, like a festoon of minute beads. In the auriculo-ventricular valves, upon the same authority, the ex- udation is arranged either in the shape of serrations upon the free edge of the laminae, or in a continuous line near it. In more advanced cases, the laminae of the valves are sometimes seen adhering to the surface of the heart, some- times to one another by their edges; causing in the former instance imperfect closure, and in the latter more or less obstruction. Besides being deranged in the modes above described, the valves are liable to be puckered up, and in various degrees distorted, and their tendons to be contracted, so as to inter- fere with the free movement of the blood through them, or, from imperfect closure, to admit of its regurgitation Another source of embarrassment to the circulation in endocarditis is the formation of fibrinous coagula directly from the blood, which are supposed to contract adhesions to the lining membrane, at any accidentally rough or prominent point, and may be seen twisting about the fleshy columns, and valvular tendons. (Bouillaud.) These are of various magnitude, whitish, elastic, and adhesive, analogous to the buffy coat of inflammatory blood, and 160 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. apparently capable of an imperfect organization. Indeed, Laennec ascribed the origin of the warty vegetations, before mentioned, to these coagula. They are stated sometimes to inclose a nucleus of exuded fibrin. Dr. Gerhard con- siders them as more frequently the cause than the effect of endocarditis, and ascribes their origin to that highly fibrinous condition of the blood which characterizes inflammatory diseases generally. (Tweedie's Syst. of Pract. Med.i Am. ed.) Sometimes they are so attached as to be movable in the cavity, and may thus at one time interfere with the passage of the blood, and at another leave the valvular openings free. In this way we may account, in part, for the fact, that the sounds which indicate derangement of the valves are not always constant, even in cases of permanent organic disease; and that the most alarming symptoms of cardiac obstruction, in cases of heart disease, sometimes suddenly come on, or as suddenly disappear, without any discoverable cause. It is said that ulceration, and even gangrene, have been observed as the result of acute endocarditis. But the former is exceedingly rare, and the existence of the latter in any case doubted. In chronic disease of the heart, ulcers are now and then seen upon the inner surface, which have been sup- posed to have their origin in some accidental rent or abrasion of the mem- brane, as from the separation of calcareous incrustations. It is believed that the fibrinous subserous exudation, which takes place in acute inflammation of the endocardium, is sometimes converted, in protracted cases, into dense, fibrous, cartilaginous, or bony structure, and thus produces permanent disease of the valves. Sometimes patches of a similar exudation upon the surface of the membrane become organized, and occasion whitish- opaque spots similar to those before noticed as occurring upon the outer sur- face of the heart, and capable of being detached by dissection, without affect- ing the integrity of the membrane. General Symptoms.—These are very nearly the same as those enumerated under pericarditis, and, as in that affection, are insufficient for the positive diagnosis of the disease, though they may lead to the suspicion of its exist- ence, and thus induce an examination by the stethoscope. It will be neces- sary here to notice only those which are somewhat characteristic. At an early period, before the valves are much affected, there may be frank open fever, with a pulse strong, full, and excited, without being extraordinarily frequent. At no period is there severe pain, unless the affection is compli- cated with pericarditis or pleurisy; and, according to Bouillaud, pure eudo- carditis is in no degree painful. There is, however, almost always more or less uneasiness about the region of the heart, and a feeling of anxiety which is often expressed upon the countenance of the patient. When the valves have become so much thickened, or in other modes deranged, or coagula have formed so largely as to interfere with the proper movement of the blood, a new and alarming train of symptoms sets in. Stimulated not only by the inflamed membrane, but also by the impediments offered to the circulation, the heart contracts with excessive rapidity, so that the pulse not unfrequently amounts to 140, and occasionally reaches 150, or even 160 in a minute. At the same time, though the heart appears to act quite tumultously, the pulse is extremely small and feeble. It is often also unequal and irregular, with occasional intermissions, which, however, are not always dependent upon a correspondent intermission in the cardiac pulsations, but upon a deficiency in the quantity of blood expelled from the ventricle. Another condition of the pulse is sometimes observed, which is connected with the existence of regurgitation through the aortic valve. The impulse produced by the sys- tole of the ventricle is propagated to the artery at the wrist with unimpaired force; but this is not sustained as in health by the entire effect of the elastic CLASS III.] ENDOCARDITIS. 161 contraction of the aorta, which is now partly expended in a backward direc- tion. The blood, therefore, appears suddenly to glide away from beneath the fingers ; and the pulse has a peculiar quick, jerking feel, somewhat charac- teristic of this condition of the heart. When either the excessively frequent, or this peculiar jerking pulse, occurs in a case of pericarditis, it may be strongly suspected that the inner membrane is also inflamed. Various other symptoms result from the altered movement of the blood in the heart. They proceed from two distinct sources, namely, from a deficient supply of arterial blood to the system at large, and from a congestion of the venous blood. The contracted or otherwise obstructed orifices do not permit enough blood to pass them ; or, if the defect be an insufficient closure of the valves and consequent regurgitation, that which has passed them returns in part upon its course, and consequently is not distributed in ordinary propor- tion through the body. The same causes which impede the onward move- ment of the arterial blood, occasion an accumulation of the venous blood be- hind ; whence ensues congestion in the right cavities, in the lungs, in the great venous trunks, and in fact in all the great organs, and to a certain extent in the whole venous system. Hence, in the worst cases, great debility, faint- ness sometimes amounting to syncope, an almost cadaveric paleness or livid- ness of the surface, cold sweats, extreme anxiety, great restlessness and jac- titation, and a most distressing sense of impending suffocation. The venous blood in the brain sometimes occasions mental wandering, drowsiness or stu- por, and even convulsions ; the same cause in the portal circle gives rise to various evidences of gastric and hepatic derangement; and the universal venous congestion produces in the end a more or less general oedema. In some cases, however, it is asserted that most of these symptoms have occurred without any signs of mechanical impediment to the circulation, and merely in consequence of imperfect or deranged innervation. Physical Signs.—Early in the disease, the impulse of the heart is felt much more strongly, and to a greater extent over the chest, than in health; and this strong impulse often continues after the pulse has become small and weak. At length, however, the muscular power of the organ is exhausted, and the impulse becomes feeble. There is usually a greater extent of dulness on percussion than in health, sometimes, according to Bouillaud, over twice as great a space. This is pos- sibly owing in part to a turgescence of the walls of the heart, but probably much more to a distension of the cavities by the accumulated blood. The dulness in this case may be distinguished from that of pericardial effusion, by the sounds of the heart being louder and less distinct, and by the impulse be- ing more superficial, as well to the sight as the touch, synchronous with the first sound instead of fluctuating, and confined to one spot, instead of moving from point to point of the chest. Nor is there, in this case, complete absence of respiration in the region of the heart. But incomparably the most valuable physical sign is the bellows murmur. This is usually perceived in a prolongation of the first sound, and, when com- bined with symptoms of an acute febrile disease, uneasiness in the prsecordia, palpitation, and a frequent small pulse, all occurring in a person previously in good health, may be considered as quite characteristic of endocarditis. If rheumatism exist at the same time, there can scarcely be a doubt as to the nature of the complaint.* The murmur proceeds, in these cases from partial * The reader, however, must bear in mind the fact, that the bellows murmur is an almost constant attendant on ansemia, and, when this condition of the blood exists, can- not be admitted as a sure sign of endocarditis, unless attended with other symptoms indi- cative of that affection, such as those mentioned in the text. (Note to the second edition.) There is another possible source of endocardial murmur, which is worthy of consider- 162 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. obstruction or defective closure of the valvular orifices, or from both causes conjoined. There is reason to believe that a spasmodic contraction of the columme carneae, attached to the auriculo-ventricular valves, may sometimes contribute to the production of the sound, by preventing a closure of the orifices during the systole of the ventricles. But, with the symptoms above mentioned, such a contraction would itself be an evidence of inflammation of the lining membrane. The murmur is sometimes soft, sometimes in various degrees rough or harsh, and sometimes musical. It is occasionally so power- ful as entirely to mask the ordinary sounds. Both sounds of the heart may be attended with the murmur in the early stages ; but, when the cavities have become greatly congested, the second sound maybe nearly or quite lost, and regurgitation cannot take place in a sufficient degree to occasion a murmur. In the general remarks upon the morbid cardiac sounds, the reader will find some rules for ascertaining whether the murmur is from a contracted passage or from regurgitation, and in which of the valves it may be seated. But great skill in auscultation, and. an acute ear, are necessary for a correct deci- sion ; and after all, the points to be decided are of no great practical import- ance ; for they do not affect the treatment. In the great majority of cases, the murmurs have their origin in the left cavities of the heart, which may therefore be considered as the most frequent seat of endocarditis ; and it has been observed that, in relation to the different valves, the aortic and mitral are simultaneously affected in by far the greater number of cases, and, when they are separately affected, that the mitral is much more apt to suffer than the aortic. (Barclay, Medico-Chirurg. Trans., xxxv. 10.) It has been before stated that this affection is very often associated with pericarditis. Their coexistence may generally be inferred, if the valvular mur- murs are heard in connection with the signs peculiar to the latter disease. Causes.—These do not materially differ from the causes of pericarditis, to the account of which, therefore, the reader is referred. Occasionally endo- carditis occurs as an original affection ; but it is much oftener an accompani- ment or the result of other diseases. The complaint with which it is most frequently associated is, beyond all comparison, acute rheumatism. It is more common in this affection even than pericarditis, though the two are fre- quently connected. The cause of this association is probably, in part, the intervention only of a little fibrous matter in certain parts of the heart, espe- cially in the vicinity of the valves, between the external and internal mem- branes, thus allowing a ready communication of disease from one to the other; but it is probable also that both are often simultaneously attacked, in conse- quence of their equal susceptibility to rheumatic inflammation, just as two joints suffer at the same time. Of one hundred and thirty-six cases of acute rheumatism observed by Dr. Latham, seventy-four were affected with endo- carditis (Led. on Clin. Med., i. 144); but, as that author considers the bel- lows murmur, occurring in acute rheumatism, a sure sign of inflammation of the endocardium, his evidence as to the frequency of the affection may not be implicitly received by all; for the bellows murmur is an ordinary accompani- ment of a certain condition of the blood, which may sometimes attend rheu- matism ; and there is reason to believe that fibrin may be deposited on the ation, though not sufficiently established by positive proof to justify us in allowing it at present great practical weight. It is well known that the blood is very highly fibrinous in acute rheumatism, and is consequently disposed to deposit fibrin. Now it is not im- possible that, in many of the supposed cases of endocarditis, as indicated by the valvular murmurs, the phenomenon may be due simply to such a deposition of fibrin on the surface of the valves, without any inflammation whatever. See remarks on this subject by Mr. Simon, in the American Journal of Medical Sciences, N. S., xx. 477, extracted from the London Lancet. (Note to the third edition.) CLASS III.] ENDOCARDITIS. 163 valves without inflammation in certain highly fibrinous states of the blood ; so that the murmur alone, without other symptoms of endocardial affection, might be deemed an uncertain sign. Pleurisy and pneumonia are sometimes accompanied with endocarditis; and some of the very worst cases of the dis- ease occur as a consequence of phlebitis, the inflammation being propagated directly along the lining membrane of the veins to the heart. Mechanical violence is probably less apt to induce the interior than the exterior inflam- mation ; but cases of endocarditis are said to have arisen from paroxysms of excessive coughing, and from violent muscular efforts, producing a rupture of the valves. According to Dr. Copland, the disease is not rare in infancy, occurring either as a primary affection, or as a sequel to one of the exanthe- mata. Organic diseases of the heart predispose to it. The presence of urea in the blood is supposed to occasion the several cardiac inflammations, which are not unfrequent attendants on disease of the kidneys, interfering with the excretion of that principle from the circulation. Prognosis.—Endocarditis generally ends in recovery, if not complicated with pleurisy, pneumonia, &c. Under proper treatment in the early stages, it may usually be brought to a favourable issue in a week or less. The ces- sation of the valvular murmurs is important as an indication of perfect cure. Should these remain after the subsidence of the febrile symptoms, they must be regarded with solicitude, as indicative of continued derangement of the valves; unless, indeed, they may be accounted for by the existence of anaemia. Violent cases, especially those of a complicated character, sometimes end in death in the course of a few days. It is supposed that coagula may in such instances form in the cavities of the heart, and thus arrest the circula- tion. Cases, however, with very threatening symptoms, occasionally run on for weeks before reaching a fatal termination. Extreme frequency, smallness, feebleness, and irregularity of pulse, violent palpitations, distressing dyspnoea, and syncope or a frequent tendency to it, are unfavourable symptoms. Upon the whole, the worst result of endocarditis is chronic alteration of the valves. It does not follow, however, that cases in which the bellows murmur remains, after the disappearance of the acute symptoms, will neces- sarily be attended with permanent valvular disease. On the contrary, the exuded lymph is often gradually absorbed, or dissolved in the blood, and the disease ends in perfect recovery. But sometimes it is otherwise; and the permanent embarrassment of the circulation, consequent upon the valvu- lar derangement, leads ultimately to the most fatal lesions, such as hyper- trophy and dilatation, and all their terrible consequences. Neglected rheu- matism is apt to have this termination. From the observations of Dr. Kirkes, of London, there is reason to be- lieve that endocarditis occasionally acts in another and before scarcely suspected mode, in producing serious disease, especially of the brain. Por- tions of the fibrinous deposit or exudation, as the case may be, detaching themselves from the valves or surface of the heart, appear to be carried with the current of the blood, and are sometimes of sufficient size to block up arteries of considerable magnitude, and thus give rise, in the parts to which the obstructed vessel is distributed, to all the consequences of a defective supply of blood. Softening of the brain and hemiplegia have resulted from this cause. (Lond. Medico-Chirurg. Trans., xxxv. 281.) Treatment.—This is almost precisely the same as in pericarditis; though it is probably even more important than in that affection alone to have early recourse to the lancet and mercury. It is unnecessary to repeat the several remedies and their succession, which were recommended under the head of pericarditis, to which the reader is referred. An important point in the treatment of endocarditis is not to consider the 164 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. patient safe, so long as the bellows murmur continues; and hence the pro- priety of continued watchfulness in such cases. To produce absorption or solution of the effused lymph, and in the mean time to control the excessive action of the heart, are the prominent indications; and these are to be met by the persevering, but at the same time very cautious use of mercury or the alkalies, and digitalis. These may be continued for many months if requisite, with occasional intermissions, care being taken never to push the mercurial influence beyond the slightest observable effect upon the gums. The prepa- rations of iodine may also be employed with the same view. Rest, low diet, and mental quietude are important auxiliaries. But another caution, of very great moment, is that the practitioner should not mistake the bellows murmur of anremia for that of organic valvular disease; for in the former affection mercury would be injurious, and an invigorating instead of reducing regimen is necessary. It is also important that, in the treatment of real chronic endo- carditis, he should not carry depletion or abstinence to a point calculated to produce ansemia. Much judgment and prudence are often necessary to enable the practitioner to steer a correct course between these difficulties. Article III INFLAMMATION OF THE HEART, or CARDITIS. By the term carditis is now generally understood inflammation of the mus- cular and intermingled cellular tissue of the heart. That this affection occa- sionally takes place, dissection has abundantly proved. It is evinced by the softening of the muscular fibre, with a dark-red and livid or a pale-grayish or yellowish discoloration, and the presence of pus. It is, however, an exceed- ingly rare event, to find the whole heart thus affected. One case is recorded in the Medico- Chirurgical Transactions for 1816 by Mr. Stanley, in which the whole muscular tissue was of an intensely dark-red or almost black colour, much softened and easily separable, and the ventricular walls infiltrated with a bloody pus. There was, at the same time, exuded coagulable lymph on the surface of the pericardium. But cases of partial inflammation are not very uncommon. Numerous instances are on record of small abscesses in the sub- stance of the heart, of the size of a bean, hazel-nut, &c. It has been supposed by some that these abscesses are metastatic. Occasionally they may be so; but generally they are attended with unequivocal marks of local origin. Ulcers of greater or less depth have also frequently been observed. These may sometimes result from the opening of abscesses, but they much more frequently commence upon the surface, and almost always upon the internal surface. Instances have occurred, in which they have completely perforated the walls of the heart, so as to allow of the escape of the blood into the peri- cardial cavity. They have also sometimes perforated the septum, and have been supposed, under these circumstances, to occasion cyanosis, in consequence of the mixture of the black and red blood. But this is not a necessary con- sequence ; for, as the two sides act simultaneously, unless the opening be very large, the pressure upon the two columns of blood will force each forward in the channel open to it, with little or no admixture. Should there be any difference in the force of the pressure, it must certainly be in favour of the left ventricle, so that any change of the current would probably be from the left to the right side. The evidences of inflammation above mentioned are unequivocal. But not unfrequently portions of the heart exhibit increased redness or other discolor- CLASS III.] CARDITIS. 165 ation, with softening or induration of the muscular tissue, without purulent infiltration, abscess, or ulceration; and, as these characters have been observed as the result of inflammation in other muscles, they are probably so in this, though the conclusion has not been universally admitted. A fact, very strongly confirmatory of their inflammatory nature, is their occurrence in cases of peri- carditis and endocarditis, in the more superficial part of the muscle in contact with the inflamed membrane; while the interior of the muscular wall is sound. There are, however, instances of softening, which, as they exhibit no other sign of inflammation, and occur especially in feeble cachectic states of the system, are probably dependent upon diseased nutrition rather than upon in- flammatory action. Induration, supposed to be the consequence of chronic inflammation, has been repeatedly noticed ; and sometimes the muscular tissue has degenerated, possibly under the influence of the same process, into some- thing like cartilage or even bony matter. Wherever inflammation of the substance of the heart has been observed, it has, thus far, been almost always associated with the same condition either of the investing or the lining membrane, or of both together. Such an affec- tion as independent carditis, of any considerable extent, has not yet been proved to exist. The symptoms of carditis are, therefore, necessarily intermingled with those of pericarditis and endocarditis. Nor can they be discriminated. When signs of proper cardiac inflammation have been observed after death, there have generally been, during life, pain in the praecordia or epigastrium, a fre- quent, irregular, fluttering pulse, much dyspnoea, anxiety, faintness, and great prostration, with cold sweats, &c. Sometimes death has been very speedy, sometimes protracted. It is highly probable that the peculiarly irregular and feeble pulse so often an attendant upon pericarditis and endocarditis, occasion- ally depends on inflammation of the substance of the heart, which is thus necessarily much disturbed in its actions. It is not impossible that the sud- den death which sometimes occurs in these affections may be the result of an acute carditis; the muscles of the heart losing their power of contraction, just as those of the intestines, which are equally involuntary muscles, are known to do under similar circumstances. The physical signs are equally fallible with the general symptoms, in the diagnosis of proper carditis. All pathologists agree as to the impossibility of distinguishing it from the membranous inflammations. It may, however, be suspected to exist, when, along with other symptoms of cardiac affection, the pulse becomes very frequent, irregular, intermittent, and fluttering, with faint- ness, dyspnoea, anxiety, and prostration, without any bellows murmur indica- tive of endocarditis and consequent obstructions in the heart, and without the signs of considerable pericardial effusion. The causes of carditis are the same as those of pericardial and endocardial inflammation. Persons in whom the evidences of the affection have been discovered upon dissection have usually been the subjects of rheumatism. In relation to the treatment, there is absolutely nothing in which it differs from that of the two affections mentioned. Indeed, it would not be amiss, in a practical point of view, to treat of pericarditis, endocarditis, and carditis as the same disease, under the name of inflammation of the heart; but the nicety of modern pathology requires that discrimination should be made; and, if we cannot better cure the disease, we are likely at any rate to have more precise ideas as to its nature and effects; and ultimately, perhaps, even therapeutics may be benefited. 166 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. Article IV. CHRONIC VALVULAR DISEASE. Chronic disease of the valves of the heart is frequent, and of very serious import. Those of the left side are much oftener affected than the right. From an examination of four hundred cases of valvular disease, Dr. Hope inferred that the proportion of disease in the right valve was about one in twenty. Dr. Clendinning found it once in every sixteen cases, out of a hundred which came under his notice. The causes of this discrepancy are not very obscure. The greater power of the left ventricle must cause a greater strain upon the valves; and, in relation to the auriculo-ventricular valves; the mitral, being accurately closed, while the tricuspid is supposed to remain partially open during the systole, may feel the strain in a still greater degree.* It is known, too, that the left side of the heart is much more liable to endocarditis than the right, and this affection is a copious source of valvular derangement. Possibly the greater predisposition to inflammation may be owing, in part, to the more stimulating character of the blood of the left cavities. The fibrous tissue in all parts of the body is peculiarly susceptible to the kinds of degene- ration with which the valves of the heart are most commonly affected; and, as this tissue is more abundant about the left than the right valves, because required to support the greater muscular action, it follows that the former will be more subject to disease than the latter. Sometimes valvular derange- ment exists in both sides at the same time; in which case, it is almost always worst in the left. Of the several valves, the aortic have been said to be most frequently diseased, next the mitral, and after these the tricuspid; those of the pulmonary artery being very rarely affected. But, from a table prepared by Dr. E. L. Ormerod, it appears that, in 132 cases, the mitral valves were diseased in 104, the aortic in 85, the tricuspid in 14, and the pulmonary in 6. (Lond. Med. Gaz., March, 1851, p. 507.) Anatomical Characters.—The morbid changes in the valves or their ori- fices are numerous. They may be merely thickened without any other alter- ation of structure, and retaining the natural consistence. This is the least serious of their diseases, and, unless followed by other changes, is usually of no great importance. Their edges may unite together by adhesive inflam- mation, so as very much to narrow the aperture through which the blood passes. Their laminae may, from the same cause, contract adhesions with the neighbouring surface, and thus prevent the possibility of closure. The tendinous cords and fleshy columns with which the valves are connected. sometimes become shortened and thickened, and sometimes elongated; in the former case injuriously restraining their motion, in the latter permitting them to move too freely. In either case, the orifice is not accurately closed. But a much more frequent affection is a degeneration of the fibrous tissue, which enters into the structure of the valves, and forms a sort of ring about their openings, thus giving them strength, and affording a tendinous attach- ment for the muscles. This undergoes the same changes as are often ob- served in the same tissue in other parts of the body. It is first thickened and indurated, and afterwards converted successively into fibro-cartilage, proper cartilage, and something similar to bone. The orifices are thus dimin- * It is denied by Valentin that the tricuspid valve is thus imperfect in its action He declares, as the result of careful experiment, that its several lamina are exactly adapted to each other in the systole of the ventricle, so that frequently not a drop of blood escapes into the auricle. (Lehrbuch des Physiol, des Menschen, band, i. s. 425 ) CLASS III.] CHRONIC VALVULAR DISEASE. 167 ished in various degrees by cartilaginous or osseous rings, or by irre- gular masses projecting from their edges; and the laminae of the valves become stiffened, and not unfrequently very much distorted, so that they are no longer susceptible of accurate adaptation, and therefore cannot fully close. At first, the surface of the serous membrane external to these morbid struc- tures is quite smooth, and the membrane may even be separated from the cartilage unaltered. But the growth appears at length to become irregular. giving a rough, tuberculated, or variously corrugated outline to the new tis- sue, and causing prominences of a corresponding shape upon the serous surface. Instead of this conversion of tissue, there is not unfrequently a deposition underneath the serous membrane of new matter, generally of a calcareous character, either in the form of small plates, or of irregular gra- nules, which in some instances coalesce so as to form considerable masses. In consequence of the pressure of this foreign matter, the membrane occa- sionally inflames, and is ulcerated or absorbed, leaving the calcareous surface bare. Steatomatous matter is sometimes deposited instead of calcareous. producing ulceration, and sometimes considerable destruction of the valves. In some cases, these conversions of tissue and depositions are confined to the fibrous tissue about the orifice, in others to the valvular laminae; sometimes affecting exclusively the base of the valves or their free border, leaving the central portions sound, and sometimes the whole structure. The stiffness and brittleness of the altered tissues cause the valves occasionally to give way to the force of the blood, and thus fissures and ruptures are produced. Ulcers, too, arise from the inflammation excited by the prominent morbid masses, and cause openings through the valvular laminae, or even separate them partially from their connections, so as to cause them to hang loosely in the heart's cavity. Ivvcrescences, as remarked under endocarditis, frequently form upon the surface of the valves, or neighbouring parts, sometimes few and isolated, sometimes thickly studding the membrane, of all dimensions, from that of a minute granule to the size of a pea, or even a large bean, and occasionally clustering so as to form irregular cauliflower tumours. Some of these are soft and fleshy, others warty and almost cartilaginous. Their colour is whitish, or presents some tint of yellow, gray, or red. They are apt to arrange themselves preferably along the edges of the valves, or at their base. The surface of the membrane beneath them is often diseased; and their for- mation is probably owing either to exudation from this surface, or to the adhesion of fibrinous coagula formed directly from the blood. Another organic affection of the valves is atrophy or wasting of their tis- sue, which sometimes proceeds so far as to reduce them almost to a gauze- like texture, and occasions openings through them, by which the blood is permitted to pass, and regurgitation thus produced. When the heart is much dilated, the valvular openings are enlarged in the same proportion ; but it sometimes happens, from their morbid state or other cause, that the valves themselves retain their original dimensions, and are thus insufficient to effect complete closure of the orifices. Causes.—The causes of these valvular affections are different. The most common is undoubtedly inflammation, either acute or chronic, and generally of rheumatic origin, or connected with granular disease of the kidneys. From this cause probably arise hypertrophy and adhesions of the valves, the various conversions of the fibrous tissue, and most of the excrescences upon the surface. Sometimes, however, the cartilaginous and bony degenerations appear to be independent of inflammation, occurring under the same influ- ences as those which produce ossification of the arteries, especially in old people. It is probable that calcareous depositions have, occasionally at 168 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. least, the same origin as the chalk stones in the joints of persons long sub- ject to gouty affections. Atheromatous depositions or conversions probably proceed from the same failure of vital force which gives rise to fatty degene- ration elsewhere. Excessive and continued action of the heart, by straining the valves, has a tendency to produce hypertrophy and induration of their tissues, if not ultimately the cartilaginous and osseous conversions. Violent straining or other excessive muscular effort occasionally produces rupture of the valves or their tendons, and especially when the tissue has been pre- viously rendered brittle by disease. Finally, an impoverished condition of the blood, or other depravation of health, may give rise to atrophy of the valves ; though it is not impossible that this affection may also sometimes proceed indirectly from inflammation. Dr. Williams state's that he has ob- served it in the greatest degree upon the right side of the heart, in which in- flammation is least common. Effects.—A moderate degree of disease of the valves may exist without materially impairing their efficiency, and consequently without giving rise to any serious results. This may continue indefinitely with little or no change, or may increase more or less rapidly, and occasion at last the most distressing and fatal consequences. The office of the valves is to open before the current of the blood passing in the legitimate direction, and to close against its return. If unable to per- form this duty, it is clear that they must occasion serious disturbances in the circulation. In the first place, contraction of the orifice, or any morbid de- rangement or change in the structure of the valves which impedes the passage of the blood, must produce accumulation in the cavities and vessels behind the point of impediment, while the supply is morbidly deficient to all the parts in front of it. Thus, constriction of the mitral valve must occasion congestion of the left auricle, of the pulmonary veins, and, if considerable, even of the pulmonary arteries, the right cavities, and the whole venous sys- tem; while the left ventricle, receiving less of the blood than is essential to the due performance of its office, is deficiently stimulated, and consequently falters in its actions, and the whole arterial system suffers. So also constric- tion of the aortic orifice, or any impediment there, causes congestion of the left ventricle, and may occasion, when considerable, a somewhat deficient supply to the arteries generally; but the ventricle is stimulated to increased contraction by the presence of the unusual quantity of blood, and is thus enabled, when the constriction is moderate, to obviate the latter consequence in a great degree. Secondly, an imperfect closure of the valves, when it is their duty to close, must allow regurgitation of the blood, and thus, in a different manner, pro- duce the same results as constriction, namely, accumulation behind and defi- ciency in front. Besides, it brings forces to bear upon parts which they were not intended by nature to act upon, and necessitates new modifications of these parts, either as the direct result of the pressure, or in order to enable them to sustain it. Thus, insufficiency of the mitral valve must permit the force of the left ventricle to bear in some measure upon the walls of the left auricle, where, as well as in the lungs, the right cardiac cavities, and the veins gene- rally, there must be accumulation; and, just in proportion to the excess of blood in this direction, must be its deficiency in the arteries. A similar con- dition of the valves of the aorta occasions regurgitation from that artery into the left ventricle during its diastole, resulting both from the elastic contrac- tion of the aortic coats, and, as some suppose, the active expansion of the heart. The ventricle is thus congested, and peculiar effects are produced upon the arteries by the sudden collapse of the current after its first vigorous impulse. It is easy to conceive what must be the result of similar changes in the CLASS III.] CHRONIC VALVULAR DISEASE. 169 valves of the right side of the heart, and the complicated effects of coexisting derangements of the different valves, or dissimilar derangements of the same; for it is very possible, and, indeed, not unfrequently happens, that a contract- ed aperture and imperfect power of closure exist in the same structure. But the irregularities of the circulation thus produced are not the only, nor the worst effects of diseased valves. The increased stimulus applied to the muscles of the heart, and the increased pressure within its cavities, give rise to excessive growth of the one, and excessive distension of the other; in other words, to hypertrophy and dilatation. These are almost uniformly, sooner or later, the result of any considerable disease of the valves, and con- sequently very much complicate the morbid effects which flow directly from that cause. These affections and their modes of production will be considered in a subsequent article. A remarkable coincidence between valvular disease of the heart and the existence of cataract has been observed by Mr. T. F. Jordan, of Birmingham, who in about twenty cases of the latter affection, found clear evidence of the former, and out of three times the number in which the chest was examined, states that in no one "could a perfectly healthy condition of the heart be con- fidently affirmed to exist." (B. andF. Med.-Chir. Rev., Am. ed., April, 185?.) Mr. Jordan is disposed to consider the cataract as a result of the cardiac dis- ease. It appears to me that the two are more probably the coincident re- sults of a common cause, as, for example, rheumatism, and those conditions of the general health which favour the various degenerations of tissue. General Symptoms.—The general symptoms of diseased valves are so in- timately associated with those of hypertrophy and dilatation, that it is diffi- cult if not impossible, accurately to discriminate between them, or to decide, in all cases, how much is to be attributed to the one, and how much to the other cause. I shall, therefore, postpone a full account of the symptoms until we reach these latter diseases. There is no doubt, however, that dis- ease of the valves is capable, of itself, and before the production of hyper- trophy or dilatation, of giving rise to obvious morbid phenomena, among which are the results of sanguineous congestion on the one hand, and of a deficiency of blood on the other. Very often the patient complains of some pain or uneasiness about the region of the heart, extending, not unfrequently, to the left shoulder and arm, and occasionally even to the fingers. In some cases, this pain is lancinating and severe, occurring in paroxysms, similar to the attacks of angina pectoris; but this is probably owing less to disease of the valves than to coexisting neuralgia of the heart. Perhaps, most frequently, it is only a vague sense of oppression, which is converted into positive pain, with a feeling of weight or tightness at the sternum, upon any considerable excitement of the heart from muscular exertion or other cause. There is usually also more or less dyspnoea, and occasional palpitation, which are ren- dered more obvious, and sometimes distressing, by any considerable exercise, such as running, or ascending heights. The pulse is often much deranged; and this is among the first symptoms by which attention is called to the state of the heart. The character of the pulse, however, varies much with the valves affected. Upon this point, the remarks of Dr. Hope are valuable. According to that author, in disease of the mitral valves, whether it impedes the flow of blood by contraction, or allows of regurgitation from imperfection, the pulse is "in various degrees small, weak, irregular, intermittent, and un- equal." This, indeed, might be inferred to be the case, from the diminished supply of blood to the left ventricle in the one instance, and the retrogression of a portion of it in the other. In very great contraction of the aortic valves, the pulse is sometimes small, weak, and irregular; but in general it continues full, regular, and of due strength in this affection. Regurgitation at the VOL. n. 12 170 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. aortic valves is attended with a peculiar jerking pulse, the stroke being at first quick and strong, but rapidly receding as it were from the fingers, in consequence no doubt of the backward movement of the blood at the origin of the aorta. Sometimes the pulse not only has the jerking character just mentioned, but, as stated by Dr. Corrigan, may be seen beating in various parts of the body. Dr. Williams considers this phenomenon, in its highest degree, and especially when it is observable in all states of the circulation, as characteristic of aortic regurgitation. Disease of the right valves has no direct effect upon the pulse. Disease of the valves, when attended only with the symptoms above enu- merated, may be considered serious, chiefly from the probable#indication which it affords of approaching disease of the proper structure of the heart. In its advanced stages, if it advance at all, the symptoms become much more dis- tressing, and conditions of system are gradually developed which sooner or later terminate in death. But, before it assumes this alarming character, hypertrophy, or dilatation, or both, have supervened, and the affection now ceases to be exclusively valvular. Cough, distressing dyspnoea, orthopncea, haemoptysis, apoplexy of the lungs, pneumonia, pulmonary oedema, dropsy of the pleura and pericardium, a pallid or livid complexion, purple lips, puffiness of the face, general anaemia, oedema of the extremities, passive hemorrhage from the alimentary mucous membrane, sickness and vomiting, bilious de- rangements, drowsiness or stupor, apoplexy, &c, are only a portion of the symptoms, which, in greater or less number and degree, attend this compli- cated disease of the heart. Physical Signs.—These consist in the bellows murmur and its modifica- tions, and the purring tremor. For a particular account of these, the reader is referred to the introductory remarks upon diseases of the heart. By means of the valvular murmurs, it is possible for an experienced ausculter to decide, with tolerable accuracy, in which of the valves the disease exists, and to a certain extent what is the nature of the disease, whether, for example, it con- sists in a constriction or insufficiency of the valves, whether it offers a direct impediment to the circulation, or permits regurgitation of the blood. The following are the rules, chiefly from Dr. Hope, by attention to which, accord- ing to that very high authority, an almost certain diagnosis may be made. It is proper, however, to observe that the want of murmurs is not a proof of the absence of all valvular disease, any more than their existence is a positive proof of its presence. Sometimes, in the advance of destructive cardiac dis- ease, murmurs previously existing may cease. This has been observed espe- cially in connection with contraction of the orifices. (Stokes.) It may depend on great muscular weakness of the heart. 1. Aortic Valves.—The murmur of contraction is heard during the ven- tricular systole, over the site of the valves, upon the sternum opposite the lower margin of the third rib, and thence two inches or more upwards towards the right of the sternum, along the course of the aorta, where it is louder than at any point below its place of origin. It may even sometimes be heard along the course of the descending aorta behind. The sound strikes the ear as superficial, and resembles the whispered letter r. That it does not proceed from the pulmonary valves is proved by the fact, that it is not heard high up the pulmonary artery towards the left. It cannot be connected with the auriculo-ventricular valves, because the murmur of these, if heard at all in the situation referred to, will be very faint and remote, and in a lower key, like the whispered word who. ^ The aortic murmur of regurgitation accompanies the second sound, or the diastole of the heart, and is distinguished from the synchronous auriculo- ventricular murmurs by being louder over the aortic valves than near the apex CLASS III.] CHRONIC VALVULAR DISEASE. 171 of the heart, where the latter are heard most distinctly. It may be known not to be seated in the valves of the pulmonary artery by being heard more loudly up the course of the aorta, and down the left ventricle, than up the pulmonary artery and down the right ventricle. From the murmur of aortic contraction it is distinguished by occurring during the period of the second sound, by being more audible down the ventricle, by its occasional prolonga- tion through the period of repose, and even through an intermission of the ventricular contractions, and by its inferior loudness, greater softness, and lower key, resembling as it does the word awe, whispered in inspiration. The jerking character of the pulse of regurgitation must also be borne in mind ; as well a», in some instances, the visible throbbing of the arteries over the body. Sometimes the reflux of the blood stimulates the ventricle to a second contraction. (Williams.) Occasionally the aortic orifice is contracted, at the same time that the valves cannot accurately close; and the two sounds are both produced, the one being heard after the other, and giving rise to a proper sawing murmur. 2. Pulmonary Valves.—The sounds of the pulmonary valves are the same as those of the aortic ; but they are nearer the ear, and of a higher key, ap- proaching a whispered s. They are inaudible two inches up the aorta, but quite distinct the same distance up the pulmonary artery. The murmur of regurgitation is not attended with any peeuliar jerking of the pulse, or visible throbbing of the arteries. The systolic murmur cannot be confounded with the synchronous auriculo-ventricular sound, because the latter is never heard up the pulmonary artery, or but very feebly. These murmurs of the pulmonary valves are very rare. 3. Mitral Valves.—The murmur of regurgitation is supposed to be heard during the systole, is often rough, and of a low key, like the whispered word who, and is louder near the apex of the heart, somewhat to the right of the nipple, than over the cartilage of the fourth rib, near the sternum, beneath which it is seated, because, in the latter position, the intervening lung deadens the sound. Other reasons why this murmur is heard most distinctly near the apex of the heart, are, first, that the fleshy columns attached to the valves are inserted at this part, and thus serve as direct conductors of the sound, and, secondly, that the apex is in contact with the wall of the chest at the time that the murmur is formed. The regurgitant mitral murmur sometimes quite drowns the healthy first sound on the left side. Dr. Hope says that he has met with the purring tremor more frequently with this than with any other valvular lesion, especially when associated with a hypertrophied and dilated ventricle. According to the observations of Dr. Williams, a very large pro- portion of the cardiac murmurs, say five-sixths, in women and in the young below twenty, arise from mitral regurgitation; while in the older and in men, more depend upon disease of the aortic valves. The murmur from contraction at the mitral valves is heard in the same positions as that of mitral regurgitation ; but occurs during the diastole or second sound, and is comparatively very feeble and soft, in consequence of the slight force with which the blood enters the ventricle. The purring tremor never attends it.* * An entirely different view of these mitral sounds must be taken in accordance with the theory of diastolic impulse, and one, as it seems to me, more compatible with acknow- ledged facts. Thus, the murmur considered as systolic and regurgitant is heard most distinctly at the apex of the heart, which is contrary to the supposed direction of the blood; a fact, 1 think, very unsatisfactorily explained in the text It ought to be loudest over the seat of the auriculo-ventricular valves where it is produced, or over the auri- cles, into which the curreut of regurgitant vibrating blood is directed. According to the diastolic theory, it is heard in the active diastole along with the impulse, and, so far 172 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. A mitral murmur, heard with an iucrease of the second sound in the right ventricle, or along the pulmonary artery, may be considered a pretty certain sign of organic disease of the mitral valves; as the effect of this is to produce impediment to the progress of the blood from the right side of the heart, which stimulates the right ventricle to increased effort, and thus increases the pulmonary semilunar sound. Skoda thinks that, without this increased in- tensity in the sound of the pulmonary valves, the mitral murmur cannot be considered as indicating defect of the mitral valves, but only roughness of their surfaces. (Treat, on Ascult. and Percus., Lond. ed., 229 and 230.) The absence of the first sound, and of all murmurs in the place of it, may result from excess of the causes which tend to dull the sounds of the heart, and may not, therefore, indicate disease of the mitral valve; but, according to Skoda, if there be at the same time greater loudness of the sound of the pulmonary valves, or the second sound over the left ventricle be replaced by a murmur, there is reason to believe that the mitral valves are contracted, and probably also defective. (Ibid., p. 231.) 4. Tricuspid Valves.—The morbid sounds of these valves are heard, like those of the mitral, a little above the apex of the heart; but are loudest more to the right, near or over the sternum. The pulse is not irregular, or but slightly so; and Dr. Hope states that he has never known the purring tremor attend them. Distension of the jugular veins, or a visible pulsation in these vessels, synchronous with a murmur replacing the first sound in the right ventricle, is pretty certain evidence of deficiency of the tricuspid valves. Without the murmur referred to, the venous pulsation might result from contraction of the right auricle alone. (Skoda.) Sometimes the auriculo-ventricular, and the semilunar valves produce mur- murs at the same time. In such instances, the characteristics of each are found in the same case, and the diagnosis may be made out with due atten- tion and patience. It is proper to state tbat very experienced ausculters consider the mere key of the murmur, to which Dr. Hope attached some importance, as not reliable in diagnosis, varying as it does with the varying force of the movement, and perhaps other not appreciable causes. Diagnosis.—The most important diagnostic question for solution, in cases attended with the general symptoms and physical signs of valvular disease, is, whether they may not be the result of mere functional derangement. Most of the general symptoms may undoubtedly accompany anemic disease, without any lesion of the valves. We meet with them not unfrequently in dyspepsia. The bellows murmur is well known to be present in similar cases, and even the purring tremor is occasionally felt. It is important that, in such cases, from being a regurgitant murmur, is one of contraction. It ought to be heard, as it is, most distinctly near the apex, because this is the direction of the current of blood which produces it. Dr. H6rard, of Paris, in a dissertation on the signs of derangement of the mitral orifice, asserts, as the result of observation, that the murmurs heard with the impulse at the apex are owing to the contraction of that orifice, and that insuffi- ciency of the mitral valves, generally supposed to give rise to this murmur, is, in the vast majority of cases, incapable of determining the production of any murmur whatever. (Archives Gen., Fev. 1854, p. 193.) Dr. Murkham states that the first sound, so far as his observation goes, is invariably associated with or superseded by a murmur, when the constriction of the orifice is considerable; that it is loudest at the apex, and that at the same place a distinct vibratory thrill is felt by the hand when the heart acts strongly. (Dis. of the Heart, p. 208-9.) Now it seems obvious to me, that this fact corresponds much better with the idea that a strong current is setting from the auricle towards the apex, than with that which refers the sound to a current in the exactly opposite direc- tion. If any regurgitant mmmur is produced, it must, according to the diastolic theory, immediately follow the impulse, occur with the closing portion of the first normal sound, immediately precede the normal second sound, and accompany the semilunar murmur of contraction, if this murmur exist. (Note to the fourth and fifth editions.) CLASS III.] CHRONIC VALVULAR DISEASE. 17-3 the decision should be correct; as it must influence the treatment. It will probably be sufficient to attend carefully to the following considerations. When the murmurs depend on organic disease, they are more constant, being in many cases heard under all circumstances of the circulation, whether the patient has been at rest or under excitement; and, when this is not the case, showing a certain degree of constancy under apparently similar circumstances, which is usually wanting in those of a merely nervous or functional charaeter. The latter are often absent when the patient is at rest, and the heart calm, and, though they may be temporarily excited by the stimulus of muscular exertion, are in the end benefited by moderate exercise, and often yield entirely to a tonic course of treatment. In nervous and anemic affections, the bellows murmur is free from roughness or harshness; in the organic, it is often very rough, with various modifications, forming the grating, rasping, sawing mur- mur, kc. In the latter, the continuous venous murmur of the jugulars, so characteristic of anaemia, is wanting, unless this complaint be a complication of the valvular disease. Dyspepsia is often accompanied with deranged action of the heart; but it is also a frequent result of disease of that organ, as are also those hepatic and gastric derangements usually called bilious symptoms. The physician should, therefore, be on his guard against mistaking real cardiac disease for mere dys- pepsia, or disorder of the liver. Whenever, along with the latter affections, there is irregular action of the pulse, especially if the patient exhibit dyspnoea, or complain of pain or tightness in the prascordia, and of palpitation, though these are very frequently nothing but purely nervous symptoms, the heart should be carefully examined by the stethoscope, so that any organic disease, if existing, may be detected. Treatment.—It will be sufficient, in this place, to treat only of those thera- peutic measures which have an immediate reference to the valvular disease. The plans of treatment adapted to the complicated affections which have their origin in that disease, will be more conveniently considered under hypertrophy and dilatation, which are generally the immediate agents in their productiou. Valvular disease is not necessarily fatal. Patients affected with it, in a greater or less degree, often live for many years, sometimes to old age, even though it may have begun early in life. In some instances, it appears to have no decided tendency to produce other organic changes in the heart; and its ordinary proneness to end in hypertrophy and dilatation may often be con- siderably controlled by treatment. Dr. Williams thinks that, while the ordi- nary sounds and impulses of the heart remain unimpaired, whatever abnormal sounds may be heard, and however loud, there is little ground for present alarm. It is when the healthy sounds are displaced by the abnormal, that most is to be apprehended, as the proper working of the heart is thus shown to be interfered with. A little excrescence, for example, may exist in a val- vular opening, which may produce a murmur; but the regular action of the valve may not be impaired, the normal sound remains, though mixed with the abnormal, and no serious result ensues. The remedial measures are, first, such as are calculated to correct the dis- ease of the valves, and, secondly, such as may prevent its effects, so far as possible, by restraining the action of the heart. Unfortunately, our attempts to meet the first of these indications are often altogether vain. The disease has but too frequently advanced so far, before being recognized, as to be quite insusceptible even of amelioration by treatment; and it is sometimes, at the very commencement, of a nature which no remedies can control. Should it, however, have proceeded from inflammation, whether acute or chronic, there may be some hope of removing it, especially if attacked in its earlier stages. The means to be employed are such as will promote the absorption of the 174 LOCAL DISEASES.---CIRCULATORY SYSTEM. [PART II. coagulable lymph already exuded, and prevent its further deposition. Of these, the moderate and long-continued use of mercury is perhaps the most efficient. It should be pushed no further than to produce the slightest observa- ble effect upon the gums, and may even stop short of this; but should be per- severed in for months, if necessary, with occasional intermissions. Indeed, it may be proper, in some cases, to give it at intervals for years, where physical examination shows that it operates favourably, while at the same time there is a great tendency to a return of the symptoms. The mildest preparations should be preferred; and, upon the whole, the blue pill is probably the best. The preparations of iodine may also be employed, with the hope of advantage. Either the compound solution, or iodide of potassium may be used internally, and the ointment maybe applied over^the region of the heart. This remedy, also, to be effectual, must be long employed; and care must be taken that it do not disturb the stomach, or excite the circulation materially. As rheu- matic or gouty disease may favour the deposition, any signs of these affections in or about the heart should be met as they occur by appropriate remedies, especially the wine of colchicum, with magnesia and a saline cathartic when laxatives may seem to be called for. Occasional cupping or leeching in the precordial region, or between the shoulders, and repeated blistering or pus- tulation by tartar emetic over the heart, may prove useful under similar cir- cumstances, or whenever the disease is attended with pain or much uneasiness. In gouty cases, or whenever, from calculous deposition elsewhere, there may be any reason to apprehend similar deposition about the valves, the free use of bicarbonate of soda or bicarbonate of potassa is indicated. Half a drachm of it may be given with carbonic acid water twice or three times a day, and continued for a long time. As the greatest danger from diseased valves is the production of hypertro- phy or dilatation, attention should be especially directed to the prevention of these affections, or, if their prevention be impracticable, to the rendering of their progress as slow as possible. For this purpose, it is necessary to restrain the action of the heart, and, as far as may be, obviate congestion in its cavi- ties. The remedies to be used must vary with the state of the system. If the patient is plethoric, with a florid face and* a full strong pulse, blood may be taken occasionally from the arm, in moderate quantities; but the practitioner must be on his guard not to push this remedy to the point of producing anaemia, which is even a more powerful stimulant to the heart than plethora. An occasional dose of sulphate of magnesia will be an excellent adjuvant to the lancet, or a substitute for it when the plethora may hardly be sufficient to-justify its use. In cases already anemic, with paleness of face, lips, and tongue, even though the pulse may be frequent and voluminous, bleeding should be avoided; and it may even be advisable to employ chalybeates, and the milder vegetable bitters. In cases not of great debility, digitalis or hydro- cyanic acid may be used in order to lessen the frequency of the pulse when excited. Should the heart beat frequently in consequence of disorder of the nervous system, narcotics and nervous stimulants will sometimes be useful, reference being had, in the selection of the article, to the general strength. Thus, hyoscyamus and conium are preferable in sthenic cases, opiates, with camphor-water, Hoffmann's anodyne, aromatic spirit of ammonia, valerian, or assafetida, in debility. Wild-cherry bark is admirably adapted to cases of this kind, in which tonics may be indicated. I am much in the habit of using it in connection with the tincture of digitalis. The state of the stomach should be carefully attended to, as any disorder of this organ is very apt to excite the heart. Hence, antacids, laxatives, and all the remedies applicable to dys- pepsia, are sometimes called for. Attention to the diet is highly important. This must be regulated, of CLASS III.] HYPERTROPHY AND DILATATION. 175 course, by the state of the system. As a general rule, it should be such as sufficiently to support nutrition, without stimulating. When there is decided plethora with vascular excitement, it should consist of vegetable food exclu- sively ; in ordinary cases, with a tendency to plethora, milk may be added to the vegetables ; and, when there is no such tendency, the more nutritious kinds of animal food may be allowed; but, unless in positive debility or anaemia, meats should be sparingly used, and should generally be preferred boiled, because in this state they are less stimulating. If the patient find by trial that milk and the farinaceous substances, with vegetables and fruits, are sufficient for the support of his strength, it would generally be best that he should restrict himself to them exclusively. Exercise is important, in order to sustain a due condition of the digestive and nutritive functions, and prevent an irritable state of the nervous system. Absolute rest, though well adapted to acute cardiac diseases, becomes highly injurious in chronic cases, by impairing the general health, and increasing the excitability of the heart. Yet active exercise is even more injurious, by directly stimulating the circulation. Hence, the patient should never run, nor walk very rapidly, nor ascend heights, nor use violent muscular exertion of any kind. It is necessary that he should keep a constant watchfulness over his movements in these respects. One hasty ascent of an abrupt or considerable elevation may undo the effects of months of caution. Passive exercise, on horseback or in a carriage, is usually preferable to walking; and, in selecting the horse, one of easy gait, and which requires little muscular effort to control him, should be preferred. Tranquillity of mind is essential in these cases; and the vigilance of the patient is more especially requisite in its preservation, as disease of the heart is very apt to be attended with an irritable or excitable temper. There is no lesson which it is more important to inculcate upon an individual affected with valvular disease of this organ, than to school himself early into a control over his emotions, and, when this is unattainable, to avoid with the greatest care every occasion of disturbance to his equanimity. ' Article V. HYPERTROPHY and DILATATION. The dimensions of the heart may be increased either by augmentation. of its muscular tissue, or enlargement of its cavities. To the former of these changes, when the result of an overgrowth of the organ, without appreciable degeneration of its substance, the name of hypertrophy has been given; to the latter, that of dilatation. As they are most frequently associated together, often dependent on the same cause, and in many respects productive of the same symptoms, they will be most conveniently treated of under one general head; all that is common to them in their several distinct relations being first considered, and afterwards what is peculiar to each. They were at one time confounded under the common name of aneurism of the heart, applied to them by Baillou and Lancisi. Corvisart made a great advance by distin- guishing two forms of cardiac expansion, one with increased thickness, the other with attenuation of the muscular parietes. The former he called active, the latter passive aneurism. But it was not till the publication of the memoirs of M. Bertin, in 1811, that the subject was fully understood. It was he who first clearly pointed out the occasional distinct existence of hypertrophy and dilatation, and gave that precision to the knowledge of their 176 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. different forms and associations which is now possessed by the profession. The five following forms are at present recognized, viz.: 1. simple hypertro- phy, in which the walls of the heart are thickened, without any change in the size of its cavities; 2. hypertrophy with contraction, in which, along with increased thickness of the walls, there is a diminution of one or more of the cavities; 3. hypertrophy with dilatation, in which the walls are increased and the cavities enlarged ; 4. simple dilatation, in which there is increase of the bulk of the heart, with attenuation of its parietes; and 5. partial dilata- tion, or proper aneurism of the heart, in which a portion only of the walls of one of the cavities is expanded, forming an aneurismal sac upon the surface. In order to decide, in all cases, upon the existence of either hypertrophy or dilatation, it is necessary that we should be acquainted with the dimen- sions of the heart in health. Unfortunately, these cannot be determined with accuracy. The heart varies in size with the period of life, not only growing with the growth of the body, but, according to the best authorities, continuing to enlarge after maturity, even to old age, at least so far as re- gards the left ventricle. It is considerably larger in males than females, and differs, in the same sex, according to the size of the body, especially the breadth of the chest or shoulders, to the relative proportion of the sangui- ferous system, and, in some degree, to the more or less vigorous habits of the individual; and all within the limits of perfect health. These circumstances, therefore, must be taken into consideration in determining how far any sup- posed enlargement of the heart is morbid; and, even in the case of a con- siderable deviation from the average standard of health, we should hesitate to pronounce it the result of disease, if no morbid phenomena had been pre- sented during life. Laennec roughly estimates the size of the healthy heart to be about that of the fist of the individual. Elaborate measurements have been made by M. Bouillaud, Dr. Clendinning, and M. Bizot, for an account of which the reader is referred to Dr. Pennock's edition of Hope's work upon Diseases of the Heart. According to Dr. Clendinning, the average weight of the adult heart is in the male about 9 ounces, in the female 8 ounces, or somewhat more. M. Bouillaud makes the mean circumference at the base 8 or 9 inches; the transverse and longitudinal diameters about 3 5 inches, the former being generally somewhat greater; the antero-posterior diameter about 2 inches; the thickness of the left ventricle at the base from 6 to 1 lines; that of the right ventricle at the base 2-5 lines, of the left auricle 1-5 lines, and of the right auricle 1 line. The ventricular walls are thickest near the base, and gradually diminish towards the apex. The left is somewhat more than twice as thick in the adult as the right; but the disproportion is less in the foetus and young infant, and gradually increases during life. The left ventricle does not collapse when opened, the right collapses. The four cavi- ties are about equal, but, the walls of the auricles being much thinner, these seem to constitute together only about one-third of the heart, Bouillaud states that the ventricular cavities will, on an average, contain a hen's egg, though the right is somewhat larger. From the tables of M. Bizot, it may be inferred that the several measurements of the heart, as to length, breadth, and thickness of the walls, are in children from 1 to 4 years old, somewhere about one-half, from 5 to 9 about two-thirds, and from 10 to 15 about three- quarters those of the adult above 50.* * For an elaborate paper on the weight and dimensions of the heart in health and disease, by Dr. Thos. B. Peacock, in which results obtained by himself are compared with those of others, as Bouillaud, Bizot, Reid, Ranking, &c, see the Edinburgh Monthly Journal of Medical Science, for Sept., Oct., and Nov., 1854. CLASS III.] HYPERTROPHY AND DILATATION. 177 Anatomical Chai^aeters. The enlargement, whether of hypertrophy, dilatation, or the two combined, may affect the whole heart, or only one or more of its cavities, leaving the others sound ; and the latter event is much more common than the former. In some instances, one cavity is affected in one manner, and another in an- other ; and it not unfrequently happens that, when two or more are affected by the same disease, they are so in different degrees. Hypertrophy with or without Dilatation.—The ventricles are more fre- quently hypertrophied than the auricles, and the left ventricle and auricle more frequently than the right. The whole heart is rarely affected, but the two ventricles not unfrequently The auricles are seldom thickened inde- pendently of the ventricles; and, when they become so, it is the appendix that is chiefly affected. The fleshy columns, the partitions between the cavi- ties, and even the valves, may also be thickened, either independently, or in connection with the walls. The right cavity has been known to be nearly filled with the overgrown columnse carnea?. The hypertrophy may even be confined to a portion of one of the ventricular walls. According to Cruveilhier, hypertrophy cannot be said to exist unless the heart wreigh 10 or 12 ounces, and, in relation to the ventricles, unless the left have a thickness of 7 or 8 lines, and the right of 4 or 5. Reference is had to the adult male. But, according to Bizot, a thickness of 3 lines would in- dicate hypertrophy of the right ventricle, which, upon the same authority, is in health only 2 1 lines thick in its thickest part, in men between the fiftieth and seventy-ninth year, and l-25 lines at the same age in women. Though the thickness in the ventricles is usually greatest near the base, and gradually diminishes towards the apex, yet sometimes it is nearly equal throughout, sometimes greatest either in the middle or at the point. In the left ventricle, it is said to have reached 2 inches, though it does not often exceed 125 inches or 15 lines. The right ventricle is rarely more than 5 or 6 lines thick, but has been known to be as much as 15 or more. It does not collapse, when cut into, as in the healthy state. The substance of the muscle is often changed in consistence and colour, being usually firmer and redder than in health. It is not, however, always thus ; but, in cases of a cachectic, anemic, or otherwise debilitated condition of system, sometimes participates in the paleness and flabbiness that charac- terize the muscular tissue in general. In some instances, too, it is found, when examined by the microscope, to have undergone fatty degeneration. Com- plications of pericardial adhesion, and of various alterations of the valves and lining membrane of the cavities, evincing previous inflammation, are not un- frequently found upon dissection. Simple Hypertrophy.—This is not frequent, as the capacity of the cavities is generally altered in one way or the other. The affection is confined to the ventricles ; the auricles when hypertrophied, being almost invariably dilated also. The bulk of the heart is somewhat increased, but not very greatly so. Hypertrophy with Contraction.—Concentric Hypertrophy. (Bertin.)— In this variety, the heart is not necessarily augmented in bulk. The walls are sometimes very thick, aud the cavity exceedingly contracted, occasionally to the size of a pigeon's egg, or even the shell of an almond. Doubts, however, have been entertained as to the morbid character of this diminution of capa- city. Cruveilhier has suggested that it might be owing to vigorous contrac- tion at the time of death, or immediately afterwards. In support of this opinion, the facts are adduced, that a similar diminution has been observed in criminals after execution, and that the contracted cavity has been dilated by the finger. But, though the explanation may apply to some cases, it cannot 178 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. be considered as applicable to all; for the contraction has been often observed in cases of lingering death, and, even admitting that the cavity may be dilated by the finger in all instances, which has certainly not been proved, still this may be owing to a mechanical expansibility of the tissue, and not to the re- laxation of a muscular spasm. Hijpertrophy with Dilatation. — Active Aneurism of the Heart. (Cor- visart.)—Eccentric Hypertrophy. (Bertin.)—This is by far the most fre- quent variety of cardiac enlargement. It may exist in two forms, in one with, in the other without thickening of the walls. As the cavities are dis- tended, it is obvious that, in the latter as well as in the former case, there must be increase of the muscular tissue, and consequently hypertrophy, unless the parietes are absolutely attenuated. Indeed, some attenuation might ex- ist, and the quantity of muscle still be greater than in health. The degree of enlargement varies from the slightest excess above the mea- sure of health, to twice, thrice, or even four times the ordinary volume. A case is on record, in which the weight of the organ was 5 pounds, and an- other in which the length was more than 9 inches, and the circumference at the base 15 5 inches. (Did. de Med., viii. 287.) Dr. Clendinning found the average weight in eighty hypertrophied hearts which he examined, to be 15 ounces, not quite double that of the healthy heart. The greatest weight found by him was 40 ounces 8 drachms, corresponding exactly with that of the heaviest heart examined by Dr. Peacock, and by Dr. Hope. (Ed. Monthly Journ., Oct. and Nov., 1854, pp. 323 and 406.) The cavity is sometimes ex- panded sufficiently to hold a large orange, or the fist. When the whole heart is affected, it usually assumes a somewhat globular shape, the apex being nearly or quite obliterated. It also takes a transverse position in the chest, when considerably dilated, as the diaphragm does not allow it to descend. When one side is greatly enlarged, and the other sound, the latter appears like a mere appendage to the former, sometimes not extend- ing more than half its length. The fleshy columns are sometimes thickened, sometimes stretched out and attenuated. The valvular orifices expand with the cavities; and the valves themselves usually increase in magnitude, so as to close the orifice, and support the increased pressure ; but, in cases of great dilatation, this coaptation does not always take place, and the valves are some- times imperfect, so as to allow of regurgitation. Simple Dilatation. — Passive Aneurism. (Corvisart.)—In this affection, the walls of the heart are simply distended or stretched out, without any ad- dition of substance. They are, therefore, thinner than in health; and the degree of attenuation is proportionate to that of dilatation. It is very rarely indeed that the whole heart is thus affected. The right ventricle is said to be more frequently dilated than the left, but both together more frequently than either separately. The auricles, though they yield more easily to any dis- tending force, are less subject to the disease than the ventricles, in conse- quence of being less exposed to the causes. The left auricle is more apt to be affected than the right, because the mitral valve is more frequently de- ranged than the tricuspid, and the distending force of the left is greater than that of the right ventricle. The fleshy columns appear as if stretched; the interventricular septum is less attenuated than the walls; and the valvular orifices, even more frequently than in hypertrophy with dilatation, are en- larged in greater proportion than the valves themselves, so as to be imper- fectly closed, and thus permit regurgitation of the blood. The degree of dilatation is sometimes very considerable, but not equal to that which may occur in connection with hypertrophy. The heart has been known to attain three times its natural size. The walls are in some instances very thin. Those of the left ventricle have been reduced to a thickness of CLASS III.] HYPERTROPHY AND DILATATION. 179 two lines; and, in some places, especially at the apex, the muscular fibre has been occasionally quite wanting; the external and internal membranes being in contact, or only separated by a deposit apparently intended to give them additional strength. As in hypertrophy with dilatation, the heart is apt to assume a roundish form, and a transverse position in the thorax. The heart is sometimes found greatly distended with blood after death, without having suffered dilatation. The former condition may be distin- guished from the latter by the disposition evinced to return to the ordinary size when emptied, whereas the dilated walls do not contract under similar circumstances. Pure dilatation, unmixed with hypertrophy, is comparatively rare; but, for practical purposes, all those cases in which the peculiar phenomena of dilatation predominate may, with propriety, be ranked under this head. The muscular fibre in this affection is usually pale, softened, and flaccid, sometimes, however, purplish or violet, as if congested in common with most of the other great organs. It is sometimes affected with fatty degeneration. The heart collapses when empty. In some instances the distension has been so great as to produce a rupture of the walls, and effusion of blood into the pericardium. Partial Dilatation.—Aneurism of the Heart.—The term aneurism applied to ordinary enlargement of the heart is not correct, as there is no analogy between that affection, and the disease of the arteries to which the name properly belongs. Such an analogy, however, is strikingly exhibited by the partial dilatation now under consideration, which has, therefore, very pro- perly been named aneurism of the heart by recent writers. To Mr. Thurn- ham the profession is indebted for the precision which has been introduced into the pathology of this affection. It consists of a pouch, produced by the dilatation of a portion of the walls of one of the cavities, and usually forms a tumour on the surface of the heart, though sometimes scarcely projecting, being formed in the wall itself by the expansion of the inner membrane, and the absorption of the muscular tissue before it. Generally only one pouch exists, but instances have been recorded in which there were two or more. They vary greatly in size, from the smallest dimensions up to those of an orange, or of the heart itself. Sometimes all the constituents of the walls are distended, including the muscular tissue; sometimes this is wanting, and the sac consists of the outer and inner membranes ; and again, the endocar- dium is ruptured or ulcerated, and the parts exterior to it dilated. In some instances, adhesions have been formed with the loose portion of the pericar- dium; in others, the tumour has opened into the cavity formed by that membrane. The sac often contains laminated coagula of blood, especially when its mouth is narrow. The tissues of the heart are found variously de- generated ; either the endocardium, or muscular layer, or both, exhibiting organic changes. An instance in which a complete spontaneous cure of a proper aneurism of the heart appears to have taken place is recorded in the London Medical Times and Gazette, for Nov., 1856 (p. 479). Symptoms. It will best conduce to an accurate understanding of the subject, to detail first the general symptoms common to the affection above mentioned, and afterwards, so far as they can be distinguished, those peculiar to each. The disease usually makes its advances very slowly. In the beginning, the patient complains only of occasional palpitations, dyspneea, and perhaps slight praecordial pain, stricture, or other uneasiness, induced by some un- wonted muscular exertion, mental excitement, or excess in eating or drink- ing, and sometimes without any obvious cause, especially at night. He finds 180 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. himself unable to run, or mount hills, or ascend flights of stairs, with the same facility as before, and is more readily fatigued by ordinary exercise. These svmptoms, however, are at first seldom sufficient to excite alarm. It is a fact noticed by Dr. Hope, that, though at the commencement of active movement the patient may experience some of the inconveniences alluded to, he often loses them by a continuance of the exertion, in consequence proba- bly of the blood being more strongly diverted to the surface. The disease may remain long in this state, sometimes, indeed, to extreme old age, if great care is taken to regulate the habits of body and mind; but it often gradually increases; slighter causes induce the peculiar symptoms; and the palpita- tions and dyspneea at length become habitual, being either induced by the least excitement, or never entirely absent, though still liable to remissions and exacerbations. The throbbing of the heart is almost always sensible to the hand applied to the praecordia, and often visible to the eye; and occasion- ally it is so violent as obviously to agitate not only the chest but the whole frame. Acute pains, similar to those of angina pectoris, shoot in some in- stances through the chest, and into the left arm; and, when these are want- ing, the patient frequently complains of dull pain, oppression, tightness, weight, or other uneasiness about the praecordia or epigastrium. The pulse is very differently affected, being sometimes full and strong, sometimes soft, small, and feeble, generally regular and little increased in frequency in the early stages, except during paroxysms of palpitation, but at an advanced period often becoming intermittent and irregular, and always so in cases in which certain kinds of valvular disease are connected with that of the muscular tissue. Along with these symptoms, which proceed immediately from the heart, the patient experiences many others resulting from various secondary affec- tions. The head generally suffers more or less, either from excess or defi- ciency of arterial blood, or from venous congestion. Hence headache, vertigo, ringing in the ears, flushed or pallid face, swollen features, prominent and watery eyes, frequent attacks of epistaxis, and, in the advanced stages, not unfrequently faintness or partial syncope, mental hebetude, drowsiness, stu- por, coma, and finally apoplectic effusion. The lungs are almost always sooner or later involved. The blood is driven into them too forcibly, or, escaping with difficulty through the pulmonary veins, becomes congested in their vessels. The proper function of the lungs is thus impeded ; effusion of serum, or sero-mucous fluid, or of blood, takes place into the bronchia and air-cells; serous liquid is often poured out into the cellular tissue of the lungs or into the pleural cavities; and bronchitis, pneumonia, or pulmonary apoplexy, may be added to the already formidable list. Dyspneea, cough, expectoration more or less copious and difficult, haemoptysis active or .passive, disturbed sleep, sudden startings at night, horrible dreams, great uneasiness in the horizontal position, and occasionally complete orthopncea, are the consequent symptoms. Indeed, many cases, such as were formerly considered as asthma, are nothing more than chronic dyspneea, dependent on disease of the heart. It is not difficult to understand the source of this disorder of respiration. The augmented size of the heart, the sanguineous congestion of the lungs, the collection of fluid in the air-cells, bronchial tubes, and intervesicular tissue, the consolidation from pneumonia, and the pressure from pleuritic effusion, all may contribute their part, some in one case and some in another, in preventing the proper access of air to the blood ; while, from the mechanical obstacle opposed by the cardiac dis- ease, the blood itself is detained in the lungs, and often cannot pass on in due quantity to fulfil its office in all parts of the system. From the lungs, there- fore, from the heart itself, and from all parts of the body, goes up by the CLASS III.] HYPERTROPHY AND DILATATION. 181 afferent nerves an impression to the nervous centres, which excites in these the painful sense of want of breath, and leads to violent reflex actions in the respiratory organs, for the purpose of supplying the deficiency. These severe respiratory symptoms occur more or less paroxysmally, being brought on by accidental influences disturbing the cardiac functions, and not unfrequently without appreciable cause. But the organs mentioned are not the only ones affected. Congestion of the liver, stomach, bowels, and kidneys, either active or passive, but espe- cially the latter, gives rise to numerous symptoms indicative of derangement in these viscera. Hence dyspeptic sensations in the epigastrium, irregular appetite, nausea and vomiting, constipation or diarrhoea, obvious enlargement of the liver, jaundice, disordered alvine evacuations, melaena, albuminous urine, and hemorrhage, usually of the passive kind, from the stomach, bowels, and urinary passages. It is not pretended that all these phenomena are pre- sent in every case ; but every one of them, and many others of a similar origin, make their appearance occasionally in one or another case of heart disease. It has, indeed, been ascertained by Dr. Clendinning, as the result of dis- section, that hypertrophy of the viscera mentioned is very apt to ensue, in consequence of the sanguineous congestion to which they are exposed. At length a universal disposition to dropsical effusion is developed. The venous system everywhere loaded, or the arterial capillaries everywhere dis- tended, relieve themselves by the extravasation of the serous portion of the blood. Edematous swelling, first showing itself as a general rule in the feet, gradually extends upwards, until it involves at length the whole body, in- cluding not only the cellular tissue, but often the serous cavities also. The urine becomes scanty and high coloured, and the skin dry, as in dropsy from other causes. The distress from shortness of breath now becomes extreme; the paroxysms of cough and dyspneea increase in violence; the patient, unable to lie down in bed, often sits day and night, with his body bending forward, and his head supported, harassed by want of rest, and the dread of impending suffocation; the chest heaves with the forced inspirations, and the body shakes under the tremendous impulses of the heart. The appetite fails, the pulse sinks, the skin becomes cool, and the lips and extremities assume a purple or livid hue. Finally, one of the great vital organs, the brain, the lungs, or the heart, sinks under the overwhelming burden; and death, frequently preceded by stupor or delirium, closes the long series of suffering. Happily, it is not always that the patient is exposed to these protracted and most painful struggles. Death not unfrequently surprises him at a com- paratively early period, and before he has yet suffered greatly. Sudden death is, indeed, one of the characteristics of heart affections. The patient, perhaps wholly unconscious of the nature of his complaint, supposing himself to be affected with asthma, or chronic catarrh, or dropsy in the chest, or possibly only with weakness, is suddenly seized, while walking in the street, or resting in his chair, or in his bed at night, with a sense of faintness, which soon be- comes perfect insensibility, and life is often extinct before relief can be obtained. Such a result sometimes proceeds from a rupture of the heart; but more fre- quently it is only a prolonged intermission, if we may so express ourselves, of the heart's pulsation. It is a continued syncope. Apoplexy is another mode which nature has kindly provided for escape from protracted suffering. It frequently happens, moreover, that some intercurrent inflammatory disease, which might prove harmless if occurring in health, is rendered fatal by the cardiac complication. In the last stages of the dropsical affection, the distended skin of the lower extremities sometimes gives way, either by rupture, ulceration, or inflamma- tion followed by sloughing; and considerable relief is obtained from the more violent symptoms by the escape of serum through the openings. In such 182 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. instances, however, death almost always follows in a short time, though in a mitigated form, from the exhaustion of the discharge, and of tlm irritative fever. Sometimes gangrene of the lower extremities takes place, independ- ently of the mere effusion, being the direct result of the impeded circulation. In the more complicated cases above described, the muscular affection of the heart is very often associated with disease of the valves, and it is by the united influence of the two forms of derangement that the symptoms are pro- duced. It is, in fact, in this way, that organic valvular disease, when it is to end fatally, generally terminates. Special Symptoms of Hypertrophy.—So far as relates to treatment, it is sufficient to point out the symptoms, characteristic severally of hypertrophy and dilatation, without attempting a more minute diagnosis. But, as the two affections are often united in various degrees, it is not always possible to draw a precise line between them. We must, therefore, be content with referring to the head of hypertrophy those cases in which, though there may be great dilatation, the symptoms characteristic of an excess of the muscular tissue predominate ; and to that of dilatation those in which the characteristic phe- nomena of the latter affection prevail, though there may actually be some degree of hypertrophy present. It is of no consequence to know that, in a case of enlarged heart, the absolute quantity of muscular fibre is greater than in health, provided all the indications of treatment, deduced from the symp- toms, are the same as in pure dilatation. The effects of hypertrophy, when not complicated with valvular disease, or fatty degeneration, are those of excessive action of the heart. The additional muscular fibre gives additional energy to the heart's contractions, and con- sequently increased force to the current of blood. In hypertrophy of the left ventricle or of both, the pulse is full, hard, strong, and prolonged, suggesting in its highest grades the comparison of the stroke of a sledge-hammer, and so characteristic of its cause, that its existence should always lead to the sus- picion of cardiac disease. It is said, moreover, to be less changed than the healthy pulse by difference of posture, and sometimes not to be changed at all. In the earlier stages, the general health does not appear to be materially im- paired. On the contrary, there is often a show of increased vigour in all the functions, consequent upon the more rapid supply of blood to all parts of the body. Yet, besides the pulse alluded to, the patient shows signs of the dis- ease in the occurrence, now and then, of vertigo, headache, or other sensorial disturbance, especially when stooping, and in occasional bleeding from the nostrils. When the complaint is in full force, the cephalic symptoms are highly characteristic. They are such as result from active determination of blood to the head, and not from venous congestion. The face is flushed, and of a bright-red or purplish hue, though sometimes, when naturally very pale, it is but little coloured; the features are swollen; the eyes projecting and bril- liant, and occasionally inflamed; the carotids beat with great force; and the fulness and tension of the cerebral arteries are said occasionally to result in attacks of apoplexy. The lungs suffer less than the brain in hypertrophy of the left ventricle, because their main supply of blood is from another source; and the same maybe said of the liver; though both these organs suffer occa- sionally from venous congestion, consequent upon disease of the mitral valves, associated with hypertrophy. It may be stated, in general, that all the parts freely supplied with arterial blood are kept in a state of tension and excite- ment highly favourable to the occurrence of inflammation or hemorrhage. It is asserted that the kidneys are generally enlarged in hypertrophy of the heart, and often undergo the kind of degeneration designated as Bright's disease. Dropsical symptoms often also result from this affection, though at a more advanced period, and to a less extent than in dilatation. CLASS III.] HYPERTROPHY AND DILATATION. 183 Various circumstances modify the above symptoms. When the hypertrophy is attended with contraction of the cavity of the ventricle, the pulse, though tense, is necessarily small from the diminished amount of blood sent forth at each ventricular systole. Disease of the valves also has a powerfully modify- ing influence. In mitral regurgitation, the force of the ventricle is partly expended in a backward direction; and, while congestion of the lungs thus results through the left auricle and pulmonary veins, the symptoms indicative of powerful arterial action are less observable in the pulse, in the head, and indeed throughout the system. In stricture of the aortic orifice, the smallness of the opening counteracts, in some measure, the force of the ventricle, and the pulse, though firm, is not so full as in pure hypertrophy, and the brain suffers less. It is said that the hypertrophy of the ventricle maybe so exactly balanced by the contraction of the orifice, as completely to neutralize its peculiar influence, and little deviation from health will be observed in the system at large, excepting merely a preternatural hardness of the pulse. When there is insufficiency of the aortic valve, and consequent regurgitation, a por- tion of the force of the ventricle is by reflection expended on itself, and less blood passes onward. Hence, the pulse, though strong from the ventricular impulse, is less full and prolonged than in pure hypertrophy, and has a quick jerking character. The brain in this case also receives less blood, and con- sequently suffers less than when the valve of the aorta is unaffected. In these valvular affections, moreover, the pulse differs from the purely hypertrophic pulse in being frequently irregular and intermittent. Hypertrophy of the right ventricle exclusively has no direct effect upon the arterial circulation through the body, and consequently wants entirely the characteristic symptoms of the same disease in the left ventricle. It was inferred theoretically that it must occasion in the lungs effects similar to those produced in the brain by the latter affection, namely, active congestion, hemor- rhage, and a tendency to inflammation; but observation has not fully confirmed this opinion. The comparative absence of these results in the lungs has been ascribed to the incomplete closure of the tricuspid valve, admitting of regurgi- tation, and consequently of a division of the ventricular force. But by this reaction through the tricuspid valve, the impulse is directed towards the brain, which thus suffers from venous congestion, and pulsation is imparted to the jugular vein. Though the patient, therefore, may suffer with vertigo, head- ache, &c, yet the face iustead of being turgid with red blood, is pale or of a dusky hue, and the lips are purplish or livid. A double pulsation of the jugular vein, the first being weak and corresponding with the auricular sys- tole, the second stronger and synchronous with that of the ventricle, may be considered as one of the most characteristic signs of hypertrophy, or of this with dilatation, of the right side of the heart. The physical signs of hypertrophy differ with the degree in which the heart is enlarged. In simple hypertrophy, the impulse is usually much stronger than in health, and may be felt over a somewhat larger extent of the chest. In some cases, however, though strong under excitement, it is, under ordi- nary circumstances, calm, or scarcely perceptible. When the heart is con- tracted as well as hypertrophied, the impulse is usually feeble. There is little or no observable alteration of the healthy resonance under percussion. But the sounds are materially changed. In consequence of the thickness of the ventricular walls, the first sound is prolonged and very dull, occasionally in- deed almost wanting. The second sound is also more feeble, and the interval of silence is shorter. In hypertrophy with dilatation, the field of impulse is extended in proportion to the expansion of the heart. There is a sensation of slow, heaving, and forcible movement imparted to the hand, and, when the ear is applied to the chest, the head of the observer maybe seen distinctly to 184 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. rise with every systole of the heart. The surface of the chest is often visibly elevated and depressed; and the whole chest and even the whole frame of the patient are sometimes observably shaken. According to Skoda, in order that the chest may be heaved with sufficient force to raise the head of the ausculter, there must be hypertrophy and dilatation of both ventricles. Dr. Hope noticed a sort of sudden shock following the recession of the impulse, which he ascribed to the quick refilling of the ventricle during the diastole.* The impulse is diminished, in the advanced stages, in consequence of the supervention of debility of the heart; and is occasionally masked by emphysema of the lung, though the latter is a very rare event. Percussion is dull to a greater extent than in health, sometimes over a space three or four inches in diameter, and, in extreme cases, from the third to the seventh or eighth rib. The sounds of the heart are heard over a wider space than in the normal state of the organ. They are loud in proportion to the thinness of the walls; and, when the dila- tation is considerable, with no great increase of thickness, a greater loudness of the first sound is produced than results from any other derangement of the heart. Auscultation should be resorted to, in these cases, when the heart is most tranquil. When the organ is excited, the sounds are sometimes heard by the patient, and by others at some distance from him. In very bad cases, a prominence may often be noticed in the praecordial region. In such cases, according to Dr. Hope, there is often adhesion of the pericardium, which prevents the heart from falling, and thus causes its expansion to be directed against one point of the chest. A prominence from this cause may be dis- tinguished from that resulting from pericardial effusion, by the continuance of the respiratory murmur over the former, wdiile it is wanting over the latter; the lung overlapping the heart in one case, and being wholly displaced in the other. When the valves are diseased, their peculiar murmurs mingle with the hypertrophic sounds. It is not always easy to distinguish hypertrophy of the right from that of the left ventricle by the physical signs. But, when the impulse and dulness on percussion are increased exclusively to the right of the praecordial region, or behind the lower portion of the sternum, we may infer that it is the right ventricle that is principally affected; while a similar extension towards the left side will indicate the corresponding ventricle as the seat of the disease; and the diagnosis will be much aided by attention to the general symptoms already alluded to. It may sometimes be important to form a correct diag- nosis in relation to hypertrophy of the right ventricle when it exists alone; for, as the symptoms of excessive vascular action and arterial congestion of the brain and other organs, which guide to a proper practice in hypertrophy of the left cavities, are wanting in that of the right, and yet the real indica- tions of treatment may be the same, it is only by recognizing the existence of the latter condition of the heart, that we are likely to pursue the correct therapeutical course. Special Symptoms of Dilatation.—The peculiar characters of dilatation have their origin either in the feebleness of the heart's contractions, or in venous congestion. The attenuation of the muscular tissue, as well perhaps as the condition of the tissue which led to the attenuation, is calculated to diminish its power ; and the accumulation of blood in the cavities of the heart, consequent upon this very debility, has a tendency to check the onward current in the rear. When the left side is dilated, the arterial blood is distributed with insufficient force, and in insufficient quantity through the branches of the aorta, whence arise symptoms of a want of aerated blood in the brain, and * According to the theory of diastolic impulse, this secondary shock may be readily explained by referring it to the systole, forcing the blood into the great vessels, which reacting on the base of the heart move the whole organ forward. (Note to the third edition.) CLASS III.] HYPERTROPHY AND DILATATION. 185 in fact in all parts of the system; while, at the same time, the pulmonary veins become loaded, and congestion extends backward successively to the capillaries of the lungs, to the pulmonary arteries, to the right cavities of the heart, and thence to the veins of the whole body. Dilatation of the right side throws back the venous blood upon the brain, liver, kidneys, stomach and bowels, and the venous system at large; while the pulmonary circulation, and consequently the arterial side of the heart, and the arteries generally are badly supplied, and the blood itself becomes anemic, from enfeebled digestion and assimilation. Hence arise the soft, weak, and not unfrequently, especially in the advanced stages, small and irregular pulse; the feeble prolonged palpitations; the general feeling of debility, and tendency to faintness or syncope ; the pale- ness of surface and coolness of extremities; the pallid, dusky, or livid hue of the countenance ; the purple lips; the dyspneea and bronchorrhcea of pulmo- nary congestion ; the mental hebetude, dejection, drowsiness, &c, of a feeble or congested brain; the nausea, vomiting, and other dyspeptic symptoms arising from an oppressed stomach; the general tendency to passive hemor- rhage from the mucous membranes, whether of the air-passages, the alimen- tary canal, or the urinary organs; and, finally, the universal dropsical effu- sion, arising from the loaded veins and watery blood, and forming so promi- nent a feature in cardiac affections Dilatation of the right ventricle is very apt to be attended, either as cause or effect, with various disease of the lungs and liver; as chronic bronchitis, emphysema, dilated bronchia, congestion, in- flammation, hemorrhage, &c, of the former, and great enlargement with dis- ordered or defective secretion of the latter. The general symptoms enumerated are insufficient to enable us to discrimi- nate between dilatation of the left and of the right ventricle ; nor is such a discrimination a point of any great practical importance. Perhaps the most characteristic general sign of dilatation of the right ventricle is the constant tension of the external jugular, without pulsation, and not disappearing when pressure is made upon the vessel in its upper part. In moderate cases of dilatation, the patient often continues for a long time without other signs of disease than slight symptoms of asthma, occasional palpitations, a pale or sallow hue of the face, and a feeling of greater or less general debility. The reader must guard himself against the impression, that the characters above given as those of hypertrophy and of dilatation respectively, are to be commonly met with unmixed in nature. Though sometimes found isolated, they are much more frequently mingled in the same case, because both elements usually exist more or less together, either in the same cavity, or in different cavities of the heart; and, in forming his therapeutical conclusions, the practitioner must endeavour to ascertain which element preponderates, and act accordingly. The physical signs of dilatation, compared with those presented in health, are an impulse usually felt over a larger space, but soft, neither forcible nor heaving, and sometimes, in very feeble cases, quite wanting; more extensive dulness on percussion; and, when the thinning of the walls is not attended with greatly enfeebled action, louder and clearer sounds of the heart, which are also heard over a larger portion of the chest. In relation to percussion, care is necessary to avoid fallacy from consolidated or com- pressed, and from emphysematous lung, the former of which occasions dul- ness, the latter sometimes masks it when existing. To obviate these sources of error, the patient should be told to lean forward, and to make a full expi- ration, so as to withdraw the lung from before the heart, and bring this into contact with the walls of the chest. In regard to the sounds, it is the first or systolic sound which is chiefly affected. It is quicker and shorter than VOL. II. 13 186 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. in health, and bears a closer resemblance to the second sound, from which it is sometimes scarcely distinguishable except from its relation to the pulsation, or from its position; the first sound being most distinct a little above the apex of the heart, the second over the semilunar valves near the insertion of the third rib, and thence up the sternum. In judging of the loudness of the sound, it should also be remembered, that this quality is increased by the intervention of compressed or consolidated lung, which conveys sound better than the loose pulmonary tissue. In extreme thinness of the walls of the heart, the first sound, instead"of being loud, is sometimes very feeble, in con- sequence of the very feeble contraction. The bellows murmur is often heard in dilatation, partly in consequence of valvular disease, but sometimes also without any valvular disease whatever, when it may possibly depend on the anemic state of the blood, which is common in this affection. The different position of the dulness and sounds, may serve to distinguish dilatation of the right from that of the left ventricle, as well as the symptom already alluded to of turgescence of the external jugular. Dilatation of the auricles may be suspected, when there are signs of disease of the auriculo- ventricular valves, along with those of dilatation in general. Dr. Stokes relates a case, in which dilatation of the right auricle was attended with a distinct diastolic impulse between the second and fifth ribs on the right side.* It has been thought that the position of the impulse also indicated the side of the heart affected, when on the left side, proceeding from disease of the left ventricle, and when behind the sternum, from that of the right. But the fact appears to be that the point of impulse depends, not on the part of the heart dilated or hypertrophied, but on the general position of the whole organ, whether horizontal or vertical; being in the former case on the left side, and in the latter behind the sternum. Enlargement of the heart itself, when considerable, has a tendency to produce the horizontal position, and consequently an impulse on the left; but various other circumstances extra- neous to the organ control this tendency, such as pleuritic effusion, pneumo- thorax, and emphysema, which push it towards the side opposite to their own, and, when on the left side, render it vertical under the sternum, and abdominal distension from any cause, which pushes it upward, and renders it consequently more horizontal. (Skoda.) Partial dilatation or aneurism of the heart cannot be distinguished, with an approach to certainty, by any signs during life. It should be borne in mind, in forming a diagnosis in diseases of the heart, that the import of many of the signs is very much modified by various organic affections exterior to the heart. Thus, tumours aneurismal or otherwise, and partial pleuritic effusions behind the heart, may push it forward, so that a larger portion shall be in contact with the chest, and thus occasion increased impulse, and dulness over a greater extent than in health. By similar causes, the heart may be removed laterally in either direction from its normal posi- tion, or may be thrust upward or downward, so as to vary the point at which its impulse may be felt, and its sounds heard. The effects of pulmonary con- solidation or compression, emphysema of the lungs, and effusion into the pericardium, in obscuring the diagnosis, have been already noticed. In rela- * On the theory of the diastolic impulse of the ventricles, this is what might be ex- pected. The diastolic impulse above referred to occurs immediately after the ordinary impulse of the heart. If this is diastolic, of course the auricular impulse must have occurred during the immediately following systole of the ventricle, which produced it by sending a regurgitant current towards the auricle, or simply by abruptly closing the tricuspid valves. Such an impulse or shock of the auricle was observed in the case of Mr. Groux, in whom a defect in the sternum permitted an examination of the actions of the right auricle. (See Med. Times and Gaz., Nov. 1857. p. 522.)—Note to the fifth edition. CLASS III.] HYPERTROPHY AND DILATATION. 187 tion to the last-mentioned affection, it may not be amiss to repeat that, along with the dulness on percussion which it has in common with enlargement of the heart, there are the distinguishing symptoms of the comparative feebleness and distance of the sounds of the heart, and the entire absence of those of respiration. Finally, it is often extremely difficult to decide between organic and functional derangement of this organ; as, in nervous and anemic cases, and under strong excitement, the heart not unfrequently presents phenomena which closely correspond with those enumerated among the characters of its anatomical changes. This subject will be treated of more fully under func- tional diseases of the heart. Causes. The causes of hypertrophy and dilatation are often the same, though ope- rating upon different principles. Whatever stimulates the muscular action of the heart may produce the former affection, whatever has a tendency to dis- tend the walls may produce the latter. Now no stimulus, probably, is greater to the muscular fibres than the pressure of the blood within the cavity which they surround; and no cause tends more strongly than this to produce dis- tension. It is not surprising, therefore, that the two conditions of hypertro- phy and dilatation often coexist in the same portion of the heart's structure. Whether one or the other shall predominate, depends chiefly upon the degree of constitutional vigour, and of the consequent tonic cohesiveness of the car- diac tissue. When these are great, the tendency is to the increase of the muscle, when feeble, to its distension; and it may happen that the power of resistance on the part of the muscle shall be sufficient to prevent all dilata- tion, or so exceedingly feeble as to offer scarcely any impediment to the pro- cess ; so that we may have pure hypertrophy or pure dilatation. It is not unlikely that, in many cases of enlarged heart, where both the walls are thickened and the cavities increased, the result may be one of over-action alone; for the natural result of the growth of a circular fibre is to enlarge the circle within it, as its length is greater than its thickness, and the growth will probably be proportionably greater in the former than in the latter direc- tion. Besides, there may be many causes of stimulation to the muscular fibre which have little or no effect in distending the cavity; and it is therefore easy to account for the fact, that pure hypertrophy is not very unfrequent. Dis- tension of one of the cavities must always be a stimulus to the muscular walls; therefore pure dilatation is comparatively rare. Special Causes of Hypertrophy.—Among the causes which immediately stimulate the heart, and may therefore operate in producing hypertrophy, are excessive and continued muscular exertion of any kind, exciting passions, sensual indulgences, excess in the use of stimulating food and drink, and nervous disorder giving rise to obstinate palpitation. Inflammatory irritation may have the same effect. Hypertrophy of structure is one of the natural results of a certain degree of irritation. Rheumatism and gout, but especially the former, undoubtedly affect occasionally the muscular tissue of the heart, and give rise immediately to this result. The affection may be original in this organ, or may be translated to it from some external part. An exten- sion of irritation, whether rheumatic or not, from the inflamed pericardium or endocardium to the muscle, may also develope hypertrophy in the latter. It is not impossible that repelled eruptions may sometimes operate in this way. The frequent association of hypertrophy of the left ventricle with Bright's disease, without any disorder of the cardiac valves, would seem to imply some causative agency in the latter affection. It may be conceived that this exists in the irritating state of the blood from ureous impregnation, or in its frequently anemic state, which indirectly acts as a powerful stimulus to the 188 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. heart, or possibly in obstruction in the systemic capillaries, arising, as some suppose from the changed character of the blood, which interferes with its cir- culation through the extreme vessels. There are some causes which are to a certain extent mechanical. Anything which impedes the current of blood, and causes it to accumulate in one of the cavities of the heart, may, for reasons already mentioned, produce hyper- trophy. Anything which diverts the current of blood from its due course may have the same effect, by bringing into play the sympathies that connect the heart with the rest of the body, and are intended to secure a due supply of blood to all its parts. It is on these principles that structural derange- ment of the valves, and of the great blood-vessels near the heart gives rise to the disease in question. The valves either impede the passage of the blood by their constricted orifices, or admit of its regurgitation by their insufficiency. Stricture of the aortic valvular orifice, or of the aorta itself, by causing an accumulation of the blood in the left ventricle, is a fruitful source of hyper- trophy of that cavity. The effect is, in this particular instance, increased by the augmented quantity of blood that is driven into the substance of the heart through its coronary vessels, in consequence of the excitement of the ventricle. Imperfection of the aortic valves, so as to permit regurgitation, has the same result by throwing back upon the ventricle a portion of the blood, while the ventricle is stimulated to increased action by the wants of the system. Contraction at the mitral valves causes accumulation in the left auricle, which thus becomes hypertrophied and dilated; and the congestion, extending backward through the lungs to the right side of the heart, occa- sions congestion and hypertrophy of the right ventricle. Sometimes it hap- pens that, while the right ventricle is hypertrophied and dilated from this cause, the left becomes thickened and contracted. The cause of the con- traction is obviously the deficient supply of blood in consequence of the nar- rowing of the mitral orifice; that of the hypertrophy is not so clear. Per- haps it is the sympathy which binds all parts of the heart in harmonious action, and causes the left ventricle to share in the same irritation which is stimulating the right; perhaps it is the wants of the system, insufficiently supplied with blood, stimulating the ventricle through the nervous centres. Deficiency of the mitral valves, with regurgitation, leads to increased efforts on the part of the left ventricle, consequent on the partial diversion of the current from its legitimate course, and to augmented pressure upon the cor- responding auricle, which not only receives more than its due share of blood, but is subjected also in a degree to the ventricular force, to which it is alto- gether unaccustomed. Hence, both these cavities may become diseased, the ventricle being hypertrophied, and the auricle both hypertrophied and dilated. In the same manner, precisely, disease of the right valves may induce disease of the right cavities; but, as the former is much less common than upon the left side, so also is the latter. From the observations of Dr. Clendinning, however, it may be inferred that hypertrophy, though not unfrequently the result of valvular disease, proceeds in a much larger proportion of cases from other causes. Of about 140 cases of hypertrophy, only about 30 presented well marked disease of the valves. Obstruction of the lungs operates in producing hypertrophy on the same principles precisely as disease of Ihe valves; namely, by impeding the on- ward course of the blood, and thus producing congestion in the right cavities of the heart. Hence, chronic bronchitis, pulmonary emphysema, asthma, artificial pressure upon the chest, &c, rank among the causes of this disease. Any obstruction in the systemic capillaries must have a similar effect by stimulating the left ventricle through the nervous centres. Dr. Gairdner has suggested, as another cause for cardiac distension, the expanding force of CLASS III.] HYPERTROPHY AND DILATATION. 189 inspiration, when the lung is diminished in capacity, as in the partial collapse often attendant on bronchitis. (Brit, and For. Medico-Chirurg. Rev., April, 1853, Am. ed., p. 371.) It maybe considered singular that phthisis, by which so large a portion of the lungs is often destroyed, and so small a portion left capable of carrying on the circulation, does not tend to produce disease of the heart. The reason probably is, that the quantity of blood becomes in this complaint gradually accommodated to the capacity of the lungs, and congestion of the heart is thus avoided. Permanent dilatation of the right side of the heart sometimes occasions distension of the left, with its necessary results, by pressing on the aorta. A preternatural communication between the two sides of the heart is said to induce hypertrophy of the right ventricle. That it should do so may be readily understood; as the opening tends to equalize the duties of the two ventricles, and thus to equalize also their powers, and consequently their amount of muscular fibre. Anaemia is another cause of hypertrophy. It acts by the excess in the cardiac contractions which it induces. (See Ansemia.) The muscular struc- ture, however, being badly nourished, is apt to be pale and flabby; and thus the heart becomes liable to dilatation also. Predisposing causes to hypertropy are original predominance of the cir- culatory system, inherited tendencies, and advanced age. The disease occurs at all periods of life, but most frequently in the old. Special Causes of Dilatation.—All the causes just enumerated, which are capable of producing distension of the heart's cavities, may give rise to dila- tation of its walls, if these have been previously weakened, as happens in anaemia, scurvy, typhoid and typhus fevers, and other diseases of debility. It is probable that the softness sometimes induced by inflammation predisposes to the same result. This diminution of the tonic cohesion of the muscular fibre is often connected with fatty degeneration. It may be alone sufficient to give rise to dilatation, as it incapacitates the heart from resisting the ordi- nary pressure of the blood, and leads to an increase of this very pressure, by lessening the force with which the blood is carried forward, and thus causing its accumulation in the cavities of the heart; but the cases are very rare in which dilatation exists uncomplicated with obstruction, or impediment to the circulation from valvular disease or other cause. This predisposing flabbi- ness of the muscular tissue is sometimes original, sometimes the consequence of disease. It is more apt to occur in women than in men, and hence dilata- tion is most common in persons of the former sex. Contraction of the mitral opening, is very often the origin of dilatation of the right cavities. Prognosis. By proper treatment in their earlier stages, both hypertrophy and dilata- tion, if not complicated with incurable valvular disease of the heart, nor attended with organic derangement of the muscular tissue, may often be effectually cured, and, when not curable, may be much palliated, and greatly retarded in their progress. They yield much more, readily in the young than in the old; and, in the cases of children, the hope may always be indulged that the enlargement of the heart, if it has not proceeded too far, will be overtaken by the general growth of the body, and that this organ will after- wards advance at even pace with the rest of the system. This is nothing more than we constantly see in other parts of the body. A muscle, hyper- trophied from excessive use, resumes its original dimensions when allowed to rest; and the urinary bladder, enormously as it is sometimes dilated, con- tracts again upon the removal of the distending cause. The reason that diseases of the heart have been looked upon with so much dread is, that they * 190 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. have usually not been detected until so far advanced as to be beyond the reach of remedies. Hence the importance of those means of diagnosis by which changes of structure can be recognized while yet curable. The dif- ficulty in diseases of the heart is, that the causes are often beyond our reach. Hence it is that they are so fatal when connected with chronic valvular dis- ease. As a general rule, it may be stated that hypertrophy or dilatation, with considerable organic derangement of the valves, is incurable. The same is the case in their advanced stages, when the secondary symptoms are pro- minent; when, for example, dropsy has been developed, and the dyspneea, which is at first occasional, has become constant. In old age, moreover, even moderate degress of the two complaints are generally incurable. But, in all these cases, much may be done to protract life, and to render it more com- fortable. Hypertrophy and dilatation are generally very slow in their pro- gress, running on usually for years, sometimes for many years, before they reach their fatal termination ; and individuals not unfrequently live to old age, with the heart more or less affected by one or the other or both of these diseases. In some instances, however, their advance is rapid and fatal. They are often greatly aggravated by the supervention of febrile or acute inflam- matory diseases, and, under such circumstances, not unfrequently render fatal an attack which might otherwise terminate favourably. Treatment. In both forms of enlargement of the heart, the first and most important indication is to remove the cause of the disease, and, when it is not remova- ble, to diminish its influence as much as possible. If the business pursuits, pleasures, indulgences, or habits of life of the patient, tend in any respect to sustain the affection, it is imperiously necessary that they should be regulated so as to obviate their injurious effects, or altogether abandoned. Should the moral influences under which he may be placed be suspected of any causative agency, they should be watched with the greatest solicitude, and modified as far as possible. Rheumatism or gout, if existing, should be treated by suita- ble remedies. If valvular disease be detected, measures should be adopted for its relief, when any chance of success may be presented ; and beneficial effects may sometimes be hoped for from a moderate and long-continued course of mercury. (See Valvular Disease of the Heart.) Disease of the lungs must be corrected if possible. Attention should be paid to the state of the nervous system, and to the condition of the blood. These, when dis- ordered, often act very injuriously by sustaining palpitation. The blood may over-stimulate the heart either directly by its too great richness, or indirectly by its poverty. In the one case it must be reduced, in the other enriched, so. as to keep it at the point at which the heart will be most tranquil under its influence. (See Plethora and Anaemia.) Lastly, the stomach and bowels should be carefully regulated. It is especially important to obviate dys- pepsia, constipation, &c.; as their constant tendency is to derange the ner- vous system, and through this to disturb the heart. In relation to the direct treatment of the cardiac affection, it may be divided into 1. that which is suitable in cases of hypertrophy, or in which the symp- toms of hypertrophy predominate, and 2. that adapted to simple dilatation, or to cases in which, though some hypertrophy may exist, the peculiar phe- nomena of dilatation are most prominent. It is very important that this distinction should be borne in mind. In the great majority of cases, there is a mixture of the two affections; but the treatment must be directed especially towards that which exhibits itself most prominently in the symptoms. 1. Hypertrophy.—Large bleedings, perfect rest, and the lowest diet have CLASS III.] HYPERTROPHY AND DILATATION. 191 been recommended in this affection; in short, the treatment employed by Yalsava with so much asserted success in aneurism. But experience has not proved its efficacy; and it is opposed by sound pathological doctrine. Hyper- trophy of the heart is a chronic affection, and cannot be cured in a short time. The enlargement is the result of excessive growth, and not of inflam- matory congestion. It must be removed therefore by a slow vital process— the reverse of that which called it into existence. A long-continued excess of action in the heart produced it; a steady continuance of reduced action must be aimed at in the cure. Now copious and quickly repeated bleedings, without at once removing the disease, exhaust the strength, so that a perse- verance in the plan becomes almost impossible, and a failure in the treatment of course unavoidable. Besides, the blood is rendered watery, and, according to principles elsewhere fully developed, the heart is stimulated by slight causes into excessive action. It has already been stated, that the anemic condition favours the production of hypertrophy of the heart. But moderate bleeding is highly important. Six or eight ounces may be taken, according to the degree of plethora, once or twice a month, or less fre- quently. Should pain exist about the heart, it would be best to take this amount of blood by cups or leeches between the shoulders, or upon the breast; under other circumstances, it should be drawn from the arm. In the intervals between the bleedings, saline cathartics should be employed in moderate doses, once or twice a week, or oftener. They diminish the volume of the blood, without depriving it too much of its nutritive matter; and some- times afford great relief to the patient. Sulphate of magnesia or bitartrate of potassa may be used. The latter has the advantage of stimulating the kid- neys as well as of operating on the bowels, but is probably rather more dis- posed to derange digestion. A low diet is also highly important, indeed indispensable. It should, how- ever, be regulated according to the condition of the blood. When this is rich and in excess, it should consist exclusively of vegetable food; but, as one great object is to prevent the production of anaemia and nervous or dyspep- tic disorder, which have a tendency to agitate the heart, it becomes important not to carry restriction too far; and, should the strength begin to fail, and the face to assume a palid hue, milk should be allowed, with occasionally some fish, or perhaps a soft boiled egg. Small quantities of meats may be given in cases with more decided symptoms of depression; but in no case should the diet be stimulating. In all doubtful cases, the practitioner can- not go far astray by confining the patient to milk and the more digestible vegetable substances. All kinds of stimulating drinks, including tea and coffee, should be strictly forbidden ; and spices should be very sparingly em- ployed, if at all. Absolute rest is not desirable ; as it favours the generation of dyspeptic and nervous derangements; but it is highly important to abstain from all kinds of exertion which over-stimulate the heart. Running, ascending heights, the use of wind instruments, singing or loud speaking, and long-continued standing should be avoided. Moderate and slow walking may be permitted and even encouraged ; but passive exercise is decidedly preferable to active ; and the patient should ride frequently in a carriage, or upon a very easy and quiet horse. Should the latter mode of exercise, however, be found to excite the heart, it should be abandoned. Equanimity is highly necessary for the patient, who should, therefore, scru- pulously avoid every occasion of mental excitement, and should keep a careful watch and command over his feelings on all occasions. The plan of treatment above prescribed is adapted to the earlier stages, and to cases in which there are obvious hypertrophic symptoms, with some 192 LOCAL DISEASES.---CIRCULATORY SYSTEM. [PART II. excitement. It is not absolutely necessary that the pulse should be very full and strong; for, when the right ventricle is hypertrophied, the pulse is not especially affected. But the impulse of the heart should always be strong before the plan is adopted. In weighing the symptoms, should the balance incline somewhat towards dilatation, or waver between the two forms of disease, depletion must be used with more caution, if not omitted altogether. On the contrary, should the action of the heart be very excessive, and symptoms threat- ening inflammation or hemorrhage in the brain or lungs appear, it may be proper to meet the indication by one or two copious bleedings, and when it has been fulfilled, to resort again to the original plan. As auxiliary to the above measures, recourse may be had to medicines cal- culated to diminish the action of the heart. The most efficient of these is digitalis, which may be given in the dose of a grain of the powder, or ten drops of the tincture, twice a day, and very cautiously increased until it is ascertained what quantity is sufficient to affect the system. It should never be carried so far as to sicken the stomach, or produce prostration. Hydrocyanic acid has also been recommended; and I have found it very serviceable in some cases, as a substitute for digitalis. I have employed acetate of lead with a view to its sedative as well as astringent action, and have seen the heart apparently diminished in size under its influence; but, in order to do good, it must be continued long, being suspended when it produces any symptoms of gastric or intestinal disorder, and resumed when these have ceased. I have not seen it do permanent injury; but have always made it a point to watch its action closely. Its careless employment might easily lead to the production of the lead disease. Dr. Sylvester speaks highly of the Iberis amara, or candytuft, in hypertrophy of the heart. He gives the seeds, rubbed to powder with cream of tartar, in the dose of from one to three grains. The remedy was first brought into notice by the late Dr. Williams of St. Thomas's Hospital, Lon- don. (Prov. Med. and Surg. Journ., Aug. 25, 1841.) Some good maybe expected, when there is pain or much uneasiness about the heart, from permanent external irritation and discharge, maintained by frequently repeated or perpetual blisters, by pustulation with tartar emetic or croton oil, or by an issue or seton. I prefer repeated blistering. This counter- irritation is especially useful in cases of a rheumatic origin or character. Dilatation.—In this affection, the most prominent indication is to bring about and sustain a proper balance between the quantity of blood, and the power of the heart to circulate it. As the disease very generally depends, in part, at least, upon a want of tone in the muscular tissue of the heart, it is necessary to obviate this condition. The watery or anemic state of the blood, so common in the complaint, is frequently one of the causes of the want of tone alluded to. It also indirectly stimulates the heart to excessive effort, and thus still further tends to exhaust it. Moreover, by the bulk of watery liquid which it contains, it distends the cardiac cavities, and thus directly favours dilatation. Hence, it is of the greatest importance to correct this state of the blood. Our efforts should be directed towards rendering that liquid at once moderate in quantity, and of good quality as regards its nutritive ingredients. From what has been said, it is obvious that bleeding can very seldom be required. Generally, indeed, it would prove highly pernicious. It will not even diminish the bulk of the blood permanently; for, in the place of that taken, water will be absorbed, and the vessels will soon be filled again. Its real effect upon the blood is still further to impoverish it, and thus secondarily to irritate, while it directly debilitates the heart. The mild tonics and a nutritious diet are the most efficient means of meet- ing the indications mentioned. Of the tonics, the chalybeates are the best, They at once strengthen the heart, and improve the blood. They should be continued until the anemic condition, if it exist, shall be corrected. The CLASS III.] HYPERTROPHY AND DILATATION. 193 vegetable bitters may be given as auxiliaries, or as substitutes when the iron has answered the desired purpose. The mineral acids are often excellent ad- juvants to the bitters, especially when there is defect of appetite. Small doses of the saline cathartics will sometimes prove useful by diminishing the watery portion of the blood. Animal food should be employed, but with care to select the most digestible and least stimulating varieties. Little drink should be taken, as it tends to make the blood watery. Porter or ale, in moderate quantities, may be allowed when the patient is very feeble. Another important indication is to diminish the frequency of the heart's contractions when it is excited, and to obviate palpitation. This tends to exhaust the heart by over-exertion. The object is in great degree effected by the means calculated to restore the blood to its normal state. But, in addition, it may sometimes be proper to employ sedatives. Digitalis may be used, but with greater caution than in hypertrophy, as its depressing effects might readily be carried too far. Perhaps one of the best remedies to meet this indication is hydrocyanic acid, in the shape of wild-cherry bark tea. This may be given as freely as the stomach of the patient will conveniently bear. Nervous disorder, which is so apt to cause palpitations, should be corrected by the antispasmodics, as assafetida, valerian, camphor-water, Hoffmann's ano- dyne, aromatic spirit or solution of carbonate of ammonia, &c. Narcotics are also useful for the same purpose. Opiates are the most effectual, and of these the salts of morphia are perhaps on the whole to be preferred. A little camphorated tincture of opium is often very useful. As substitutes or adju- vants of opium, conium, hyoscyamus, and lactucarium may be given inter- nally, and the extract of stramonium or belladonna applied externally in the form of plaster. Opium should not be used, at least in large doses, when the lungs are loaded and the expectoration deficient. Dyspepsia should be guarded against, and corrected if present. Constipation should be obviated by rhu- barb and aloes, or other laxatives, when the saline cathartics maybe no longer indicated. The stomach should never be overloaded. Moderate exercise of the passive kind is not less indicated in this complaint than in hypertrophy; but the patient should guard against all sorts of exertion calculated to bring on palpitations. He should not less carefully guard against mental excitement. Flannel next the skin is necessary to obviate the effects of cold ; and frictions to the surface are useful by giving a centrifugal direction to the blood, and thus relieving the heart. Secondary Affections.—In relation to these, it is not necessary to go into detail. They are to be treated very much in the same manner as similar affec- tions from other causes. When there is great determination of blood to the head, it may become necessary, in addition to general bleeding, to apply cups or leeches to the temples or back of the neck, cold water to the head, and hot stimulating pediluvia to the feet. Pulmonary apoplexy must be encountered with free depletion, when the patient will bear it; and in congestions, inflam- mations, and hemorrhage of the lungs, the usual remedies must be employed, qualified, however, by the state of the system. In dilatation, the pulmonary affections must be treated much more cautiously by depletion than in hyper- trophy. The stimulant expectorants, as seneka, ammoniac, squill, assafetida, and the ethereal and ammoniacal preparations may be used when there is great debility, with oppressive bronchial secretion. In the paroxysms of dyspneea, the antispasmodics, narcotics, and stimulating expectorants may be conjoined; and the hot foot-bath, used for a long time, occasionally affords much relief. In vomiting, the aromatic spirit of ammonia is one of the best remedies; but other anti-emetics may be employed if necessary. (See Vomit- ing.) The state of the liver sometimes requires an alterative course of one of the mercurials, with purgatives to relieve congestion. Nitromuriatic acid may sometimes be substituted both internally, and by pediluvium. The treat- 194 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. ment of cardiac dropsy is elsewhere considered. It is to be encountered chiefly by diuretics and hydragogue cathartics, of which bitartrate of potassa is the best. When the limbs become enormously swollen, with great oppression in breathing, it is proper to make shallow punctures with a very sharp lancet in the legs. These often afford great relief by allowing the escape of serum; though they sometimes occasion inflammation, and give rise to a sort of gan- grenous erysipelas, which hastens the fatal issue. In the latter stages of both hypertrophy and dilatation, the efforts of the practitioner should be directed to palliation exclusively. All very active measures should be abandoned, as there is no longer any hope of cure, and the object is to render the patient as comfortable as possible. In the treatment for the cure, in the earlier stages, the means employed should be persevered in steadily for one, two, or three years. This length of time is usually required for a restoration of the heart to its normal dimensions. Dr. Hope states that the great majority, of recoveries, within his experience, take place between one and two years from the beginning of treatment. Even should the symptoms disappear earlier, the remedies should nevertheless be persevered in; nor, indeed, should the patient consider himself free from dan- ger of a return of the malady, nor from the necessity of great caution in the regulation of his habits in all respects, during, the remainder of his life. Article VI VARIOUS ORGANIC DISEASES OF THE HEART. Atrophy. The heart is sometimes of much less than its average dimensions in health. Thus, it has been found in the adult scarcely larger than that of an infant at birth. The walls are usually quite sound. In some instances, their thick- ness is not diminisned, and the only morbid condition is a reduction of size. Occasionally a wrinkled appearance is presented, as if the organ had shrunk more interiorly than upon the surface. In other instances, again, the walls are attenuated, and this condition is usually accompanied with dilatation. All cases of dilatation in which the mass of the heart is less than in health, may be considered also as cases of atrophy. There are no symptoms by which this affection can be certainly recognized during life. It may be suspected when the pulse is uniformly threadlike and weak, the impulse of the heart against the ribs scarcely discoverable or quite wanting, the usual dulness on percussion diminished, the sounds very feeble, and no sign observable of other organic affection. The relative smallness of the heart has been thought to be sometimes con- genital, sometimes the result of a sudden arrest of development. It has also been ascribed to continued pressure upon the organ by morbid productions in its neighbourhood, or disease of its pericardial investment. It is said to have resulted from firm adhesion of the opposite surfaces of the pericardium, in the young. But the most common causes are probably those which interfere with the general function of nutrition, and produce emaciation throughout the body; such as severe and long-continued abstinence, and the wasting influence of various chronic complaints. Atrophy of the heart has also been traced to obstruction or obliteration of the coronary arteries. No treatment addressed especially to the heart will be likely to do good. All that can be expected from remedial measures is the cure or alleviation of the condition of the system upon which the atrophy may depend. CLASS III.] SOFTENING OF THE HEART. 195 Softening. Softening of the heart is not uncommon. The form of it which depends on inflammation has already been treated of under carditis. At present our attention will be confined to the affection proceeding from other causes. It may be general or partial; that is, may occupy the whole organ, or may be limited to the walls of one of the cavities, or even to a small spot in the walls. When the heart generally is involved, it is flaccid or flabby, and, in extreme cases, collapses when emptied or cut into, like a wet bladder. In all cases, the cohesion is more or less diminished. The muscular tissue is easily torn, often admits the finger to be readily passed through it, and is sometimes re- ducible by pressure to the state of a pulp. Occasionally, as in old age, it is of an almost gelatinous consistence ; the fibres being soft, tremulous, and of a translucent appearance. The colour is various ; sometimes very pale, gray- ish, or whitish, in other instances yellowish and compared by Laennec to that of dead leaves, and in others again deep-red, livid, or violaceous. Softening is often associated with other morbid conditions of the heart, as with obesity, fatty degeneration, and dilatation. The last-mentioned affection is thought very often to result from it. Symptoms.—The pulse is usually small, feeble, and intermittent, or other- wise irregular. The impulse of the heart is feeble, as are also the sounds, especially the first, which is sometimes wanting. It is probably owing to the attendant softness, that, in great dilatation, the heart, instead of yielding the loud sound which ordinarily accompanies that affection, can in some instances scarcely be heard. A disposition to syncope, and all the other consequences of an insufficient supply of arterial blood, and of venous congestion in the lungs and elsewhere, which have been enumerated under the heading of hy- pertrophy and dilatation, are experienced in softness of the heart. They are owing to the feebleness of the cardiac contractions, which fail to send the blood forward sufficiently, and consequently permit its accumulation poste- riorly. When these symptoms are offered in any case, without valvular mur- murs, or dilatation, and without any reason for ascribing them to nervous disorder, they may be considered as indicative of softening of the heart. Causes.—Whenever, along with the softening, there is pus in the muscular tissue, or ulceration, or inflammation of the investing or lining membrane, it may be considered as of an inflammatory character; and the same is probably the case with most of the partial softenings. In other instances, the affection depends either on defective nutrition from poverty of the blood or general debility, as in anaemia, wasting chronic complaints, old age, and the prostra- tion which follows acute diseases ; upon a depraved condition of the blood, as in malignant fevers and scurvy ; or, finally, upon continued venous congestion of the substance of the heart, as in certain valvular diseases of that organ, and in dilatation. It may also depend upon obstruction, or other morbid condition of the coronary vessels. When caused by anemic conditions of the system, or mere chronic debility, the softening is usually pale or yellowish. As attendant upon typhous or scorbutic disorder, it is often dark-red or livid, and is occasionally accompanied with extravasation of dark blood, either upon the surface of the heart, or in disseminated spots through its muscular sub- stance. It is frequently associated with fatty degeneration. Dr. Wm. Pep- per, of Philadelphia, found softening of the heart to accompany that sudden prostration of system which follows excessive fatigue, with exposure to a hot sun, and which, under the name of sun-stroke, is sometimes confounded with active congestion of the brain. (Summary of the Trans, of Coll. of Phys. ofPhila., iii. 100.) Effects.—Softening may prove fatal by rupture, dilatation, or syncope con- sequent upon the direct loss by the heart of its power of contracting. It is 196 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. probably often remediable, though it adds greatly to the danger of the com- plaints with which it is associated, and is probably one of the direct causes of fatal prostration in malignant fevers. Treatment.—This must be addressed to the state of the system. In chronic and anemic affections, the chalybeates are most to be relied on, aided occa- sionally by the simple bitters or quinia. The mineral acids are also useful, but must be employed cautiously with the preparations of iron, because some- times chemically incompatible with them. They may often be advantage- ously associated with tincture of chloride of iron. When the debility is very great, it may be necessary to resort to the more powerful stimulants, as car- bonate of ammonia, oil of turpentine, wine, and even brandy. The diet should always be in the highest degree nutritious and digestible. Induration. The muscular tissue of the heart sometimes becomes simply hardened, without undergoing any other appreciable change. Corvisart described a case in which the organ gave, when struck, a sound similar to that of a dice box, and produced a crepitant sound when cut. Cases similar in relation to the sound were noticed by Laennec and Hope; and Broussais mentioned instances, within his own observation, in which the heart resembled a cocoa-nut in hard- ness. One would suppose that the power of* contraction must be lost under such circumstances ; but this does not appear to be the case. The affection is extremely rare. It is of unknown origin, though referred by some to in- flammation. Degeneration, and Abnormal Products. Under this head are included all the affections in which the tissues of the heart undergo changes so as to lose entirely their original character, or in which morbid products, whether the result of growth or mere deposition, encroach upon its substance. These are numerous, but all of them rare. 1. Fibrous, cartilaginous, and osseous degeneration have before been treated of as occurring in the lining or investing membrane, or in the cellu- lar tissue intervening between these and the muscular structure, or in the valves. (See Pericarditis, Endocarditis, and Valvular Disease.) The same degeneration has been observed, in some rare instances, in the muscular tissue. It is probable, however, that, in these cases, the fibre has rather undergone absorption in consequence of the pressure of the newly deposited matter, than been the subject of transformation. Sometimes isolated calculous masses have been found embedded in the thickness of the cardiac walls. Ossification of the coronary artery is not a very rare occurrence in persons advanced in life. It does not necessarily give rise to observable morbid effects ; though angina pectoris has been ascribed to it. 2. Fatty degeneration has been noticed by various pathologists, and has been ascertained to be a more common affection than was at first supposed. The muscle undergoes a partial change into fatty matter ; and oil globules may be seen, by the aid of the microscope, occupying the place of the proper muscular fibre, within its sarcolemma. The heart, or the portion of it affected, is pale, yellowish, or of a dirty pink colour; and this discoloration is often in patches, giving the organ a mottled appearance. Sometimes the altered colour is confined to one portion of the heart. Softening to a greater or less extent is always present, sometimes having the character of flabbi- ness, sometimes of friability. The natural fibrous appearance gives place to a uniform or granular aspect of the cut surface. In advanced cases the fat is so copious as to be obvious to the eye, and to give a greasy feeling to the texture. The chief seats of the degeneration are said to be the inner portion of the walls of the heart, and the fleshy columns. CLASS III.] FATTY DEGENERATION OF THE HEART. 197 This affection is dependent on diminished vital force in the heart, allowing chemical influences to supersede the proper nutritive function, and may be connected either with general debility, or with local impediment to the due nourishment of the organ, as from disease or obstruction of the coronary arte- ries. Among the sources of this obstruction in the coronary arteries, atten- tion has been called by Dr. Hodgkin to the contraction or closure of these vessels, at their origin, by the contraction of plastic deposit in their coats, resulting from endocardial inflammation. (Med. Times and Gaz., April and June, 1856.) It is most apt to occur in old age, and is favoured by in- action and intemperance. It is not unfrequently observed in hypertrophied hearts. The affections with which it is most frequently associated are phthisis, chronic gout, chronic disease of the liver and kidneys, atheromatous degene- ration of the aorta, and a general tendency to fatty degeneration. It may or may not be attended with disease of the valves of the heart. The effects of this disease are "Such as necessarily result from debility in the central organ of circulation. A feeble, slow, and irregular pulse, faintness, syncope, precordial uneasiness or oppression with a sense of sinking at the heart, neuralgic pains in the chest, dyspnoea, vertigo, dimness of vision, and coma, are among the symptoms, not all, however, appearing in the same case. Attacks re- sembling apoplexy, but not accompanied with palsy, are not uncommon. Rupture of the heart sometimes takes place. In the great majority of cases, the disease ends in sudden death. The arcus senilis, or white zone observed in the eyes of the old, and sometimes also of the young, and ascertained to be a fatty degeneration of the cornea, has been found by Mr. Canton to be generally attended with the same affection of the heart, and may therefore be looked on as a valuable diagnostic symptom. (Ranking^ Abstract, Am. ed., xiii. 207.)* It is, however, stated by Dr. E. B. Haskins, of Clarksville, Tennessee, as the result of his observation of twelve cases of the arcus senilis, that only two offered any symptoms of organic alteration of the heart. (Am. Journ. of Med. Sci, N. S., xxv. 107.) In the very old, this affection of the cornea may be considered as a normal change in the tissue, incident to declining life ; but, in the young and middle-aged, it must be taken as in- dicating a morbid state of system, such as probably also disposes to fatty degeneration elsewhere. The characteristic physical signs are feeble im- pulse, and a feeble first sound, which is sometimes scarcely audible. There is not unfrequently a murmur with the first sound from disease of the aortic valves, while the second sound is healthful. The affection is incurable. Patients may live long with it, but are apt to die suddenly upon the occurrence of other diseases, of surgical operations, or of any accident that may interfere with the heart's action. It- is in this affec- tion, too, that rupture of the heart is most apt to take place. Though it is impossible to restore the muscular fibre which has undergone the fatty de- generation to its normal state, yet it is probable that much may be done, by correcting the state of system, to retard if not check its progress. This must be effected by the usual methods, care being taken to avoid everything calcu- lated to overtask the heart, lest it may suddenly fail to perform its duty. For a full account of the disease, the reader is referred to a paper by Dr. Rich- ard Quain, in the London Medico-Chirurgical Transactions (xxxiii. 121). 3. Obesity of the heart is not very unfrequent. The fat is deposited between the pericardium and muscular substance, and sometimes penetrates * I have recently had an opportunity of confirming this coincidence of the two affec- tions. An old seaman, entering the Pennsylvania Hospital, was observed to have the arcus senilis. The impulse and sounds of his heart were very feeble. Fatty degene- ration of the heart was diagnosticated. He died suddenly, and the diagnosis was fully confirmed on post-mortem examination. (Note to the fourth edition.) 198 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. between the fibres of the latter. Occasionally it accumulates in enormous quantities, so as completely to conceal the muscular structure, and materially to interfere with the heart's motion ; and has been thought in some instances to have caused death. The muscular layers beneath it sometimes become softened and attenuated, probably from absorption produced by pressure. The affection is most frequent in very fat individuals, though it has some- times been noticed in connection with great general emaciation. The symptoms are not usually striking. Sometimes no morbid pheno- mena are observed, and the existence of cardiac derangement is first disco- vered after death. In other cases, the patient suffers with dyspneea, palpita- tion, and other ordinary signs of embarrassed action of the heart. In the cases in which the fibres undergo atrophy, there are weakness and- irregu- larity of pulse, with feeble impulse and diminished sound. When these symp- toms occur in very fat persons, with no other discoverable cardiac disease, they may be conjecturally referred to obesity. They have been observed to increase and diminish with an increase and diminution of the general fatness; and a case is mentioned by Chomel, in which violent symptoms of derange- ment of heart, occurring in an obese individual whose case presented the phenomena just alluded to, yielded to abstinence and depletion. The treatment in this affection must be directed to the fatness in general, and should consist chiefly of a spare diet without fats, such depletion as the system can well support, exercise of the passive character, and the use of the vegetable acids as freely as can be borne without impairing digestion. 4. Tubercles have been found in the heart, but are very rare. The same is the case with cancerous disease, whether in the form of scirrhus or medul- lary fungus. These affections scarcely ever seize upon the heart, unless previously existing in other parts of the system. It is said that scirrhus has sometimes occasioned acute lancinating pains ; and the cachectic sallowness usually characteristic of cancer may be supposed to attend it. A certain diagnosis, however, in these cases, is quite impossible. Cysts and hydatids have been discovered in the heart upon dissection; but there are no signs by which they could be recognized during life. Rupture of the Heart. Rupture of the heart, in a healthy state of the organ, may happen from mechanical violence, as a heavy blow, a crushing fall, or the pressure of some great weight, as of a wagon-wheel, upon the chest. It may also happen from disease. Fatty degeneration of the heart is probably the most frequent cause of rupture. Extreme dilatation may have the result; and this is one of the fatal terminations of partial dilatation, or proper aneurism of the heart. The accident is not relatively unfrequent in hypertrophy. In that affection, the parietes are very often unequally thickened ; and, as the ventricle contracts with much more than the usual force, it might be expected that the thinnest portion would give way. Now, as the ventricle is thinnest at the apex, it would seem to be a fair inference, that the rupture must take place more frequently at or near that point than any other. The fact is, that it does occasionally take place there ; but it is asserted that a more frequent seat of the accident is in the thickest part of the heart, towards the base of the ven- tricle. The only explanation of which this fact appears to be susceptible is, that, in hypertrophy of the muscular substance, the fibres lose their cohesive- ness in a greater degree than their force of contraction; and that a rupture takes place, as in the gastrocnemius, from a sudden and violent action of that muscle. Whether the heart has been hypertrophied or dilated, con- traction of some one of the orifices has been noticed in a large proportion of the cases of rupture. It is obvious that, in the different organic changes to CLASS III.] RUPTURE OF THE HEART. 199 which the walls of the heart are exposed, a degree of brittleness may some- times result, which may predispose to rupture under an excited action of the organ; and hypertrophy of the heart has been ascertained to be not unfre- quently associated with fatty degeneration. Ulceration and abscess of the heart have sometimes been the cause of the accident, by reducing the walls to a thinness, unequal to the necessary resistance against the pressure to which they are exposed. The effusion of blood into the substance of the heart is also ranked among the disposing causes. Whatever may be the morbid state of the heart disposing to the rupture, it is apt to be caused imme- diately by an unusual degree of action or distension in the organ, proceeding from unusual muscular exertion, paroxysms of anger, violent coughing or vomiting, or some other source of excitement. It is said to occur more fre- quently in men than in women, and in old persons than in the young. The rupture is sometimes large and completed at once, sometimes small at first, and gradually extended. Cases are on record in which two or more openings existed in the same heart. The rupture is occasionally partial, not entirely penetrating the walls. Sometimes only the fleshy columns or chordae tendineae are broken. The accident is much more frequent in the left than in the right ventricle, and more so in the right ventricle than in either of the auricles. In cases, however, of rupture from violence, the right cavities are most apt to be affected, because more exposed by situation, and less able to resist from their thinner walls. Some rare instances are on record in which the coronary artery has been ruptured, filling the pericardium with blood. (Archives Generates, 4e ser., xiv. 195.) The antecedent symptoms vary, of course, according to the cardiac affec- tion which gives rise to the rupture. Sometimes none are observed, unless perhaps slight dyspneea. Instances have occurred in which the rupture was preceded for a short time by excruciating pain, remittent or continuous, shoot- ing from the praecordia to the back, and into the left shoulder and arm. This pain has been ascribed to the gradual rending of the muscular fibres. In the great majority of cases, the consequence of rupture of the heart, and effusion of blood into the pericardium, is almost instant death. The patient suddenly becomes excessively pale, speedily loses consciousness, and dies of syncope. This, however, is not always the case. Instances occur in which life continues several hours, and even for a considerable period. When the opening is very small, death may be long protracted; and there is reason to suppose that a spontaneous cure is not impossible. A case is on record, in which, after death from rupture, the remains of a former rupture were ob- served, in which the vacuity was filled up with a fibrinous concretion adhering to the walls of the heart. There are no symptoms by which a partial rupture of the walls can be re- cognized. When the fleshy columns or tendinous cords are torn, the loose ends of the columns, or the liberated laminae of the valves, float into and out of the orifices with the current of blood, and occasion much embarrassment of the circulation, both from obstruction and insufficient closure of the valves. There is usually violent pain, with sudden and great oppression amounting almost to suffocation, and much disturbance in the actions of the heart. The most confused sounds are heard in the chest, and among them not unfre- quently the murmurs of constriction and regurgitation. A tremulous uncer- tain pulsation of the heart may be felt by the hand in the cardiac region. Should the patient survive long, hypertrophy or dilatation is likely to ensue. Little need be said in relation to the treatment of rupture of the heart. Usually death has taken place before the physician arrives. Should the case be somewhat protracted, the indications are to keep the patient perfectly at rest, and to quiet any irritation of system by anodynes. The great point to 200 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. be aimed at is, that the heart should act as little as possible compatible with the maintenance of life. Fibrinous Coagula.—Polypous Concretions. Two kinds of fibrinous concretion are found in the cavities of the heart; one formed either after death or at the moment of dissolution, the other some time before death. The former are wholly unorganized, and consist of coagulated fibrin, which has separated from the mass of blood, as the buffy coat separates in inflamma- tory blood removed from the body. They are whitish or yellowish-white, translucent, sometimes of a tremulous jelly-like consistence, sometimes firmer, occasionally with a darker nucleus in the centre, and but slightly adhering to the surface of the cavity, from which they can be readily separated without altering the structure of the endocardium. They are usually found in the right cavities, and probably result from an excess of fibrin, or a high degree of coagulability of that principle, which is brought into action by the stasis of blood. The second variety of concretions, which better deserve the name of poly- pous that has been applied to both, are real morbid products, and give rise during life to very serious symptoms. These are firmer than the preceding, more opaque, of a fibrous texture, and sometimes composed of successive layers. In size they are extremely diversified, in some instances being very minute, in others almost filling one or more of the cavities of the heart, and of all intervening dimensions. Their colour is usually white, but occasionally reddish from the presence of blood, which has been thought to be contained in rudimentary vessels that ramify in the mass, and constitute the commence- ment of an imperfect organization. They adhere firmly to the surface of the endocardium, so that, when separated, they leave an appearance as if torn off; and sometimes a vascular communication seems to exist between them and the substance of the heart. Different opinions have been entertained as to their mode of formation, some ascribing them to the coagulation of a portion of the blood, which afterwards contracts adhesion with the heart, others con- sidering them as the product of fibrinous exudation from the inner cardiac surface in a state of inflammation. They are probably produced sometimes in the one way,' and sometimes in the other. When the blood contains an excess of fibrin, and is from any cause delayed in the heart, it may readily be conceived capable of forming coagula, and especially when a small portion of concrete exuded fibrin is present to serve as a nucleus. In like manner, it is altogether probable that the inflamed endocardium, like other serous mem- branes, sometimes throws out coagulable lymph in sufficient quantity to form concrete masses of considerable magnitude. To the former origin may be re- ferred the globular vegetations of Laennec, which vary in size from the magni- tude of a pea to that of a pigeon's egg, sometimes adhere to the surface by a pedicle more recent than themselves, and contain within a central cavity a bloody or pus-like fluid. To the latter probably belong the warty vegetations, which have been before mentioned as occasionally forming upon the valves and in their neighbourhood. These concretions may always be distinguished from the unorganized variety, according to the observations of M. Friedault, by containing proper pseudo-membranous matter, in which primarily cells are observable by aid of the microscope, and afterwards fibres formed from them. (Arch. Gen., 4e ser., xiv. 63.) But, however formed, these concretions prove sources of great inconvenience, and often of danger. They diminish the cavity in which they are placed, and, by narrowing the orifices through which the blood passes, or preventing a proper coaptation of the valves, may produce all the effects of the most serious CLASS III.] CYANOSIS, OR BLUE DISEASE. 201 valvular disease. Their symptoms are uncertain. They may be suspected however, when the movements of the heart, previously regular, become sud- denly much embarrassed, with irregular and confused pulsations, great dvs- pncea, and the general signs of a diminished supply of arterial blood on the one hand, and of venous congestion on the other. Among the most frequent symp- toms are great prostration, a feeble irregular pulse, coldness of the surface, pale- ness of face, extreme anxiety, the utmost difficulty in respiration, with a sense of suffocation and inability to lie down in bed. Nausea and vomiting have been noticed as attendants on the affection. (Basking, Am. Journ. of Med. Sci., N. S., xx. 404.) The symptoms, in some instances, cease for a time, and again return, probably in consequence of the newly formed mass being at one time carried within reach of the valves so as to derange their functions, and then floating away for a time so as to leave them free. This may easily happen when they are attached by a pedicle which allows them free motion in the cavity. But the diagnosis is always uncertain. It has been recommended, in order to prevent the formation of these con- cretions, to bleed very freely in cases of endocardial inflammation, or others, in which a tendency to their production may be supposed to exist. But to push depletion, from fear of cardiac concretions, beyond the point required upon other grounds, would be to run the hazard of very serious evils, to avoid one which may be altogether imaginary They may, therefore, very properly be left out of view, unless as an additional inducement to the cure of all in- flammatory diseases by means adapted to the obvious circumstances of each case. When already formed, they are generally beyond the reach of remedies; though, in recent cases, it may not be amiss to employ alkaline medicines, in the hope that their solvent influence over fibrin may have some effect in pro- moting the solution of the exuded or concreted matter. Malformation of the Heart. A great variety of congenital malformations of the heart are recorded. Most of them, however, have little interest for the practitioner. I shall notice them here only in connection with a certain state of the circulation, which, being marked to common observation chiefly by the discoloration of skin that attends it, has from this cause received the name of the blue disease. Cyanosis.—Morbus Cseruleus.—Blue Disease.—The colour of the skin in this affection is bluish, purplish, or livid, but varies very much in degree in different cases, and even in the same case, being sometimes slightly livid, sometimes so dark as to approach to blackness. In very mild cases, it is perceived chiefly in the lips, mucous membrane of the mouth, ends of the fingers, &c, where the capillaries are most numerous, or nearest the surface. In some instances, it is almost or quite wanting at one time, and present in a high degree at another. The intensity of the colour is very generally increased by whatever increases the action of the heart. Along with the discoloration is usually an unnatural coolness of the surface ; and the patient is either ha- bitually subject to dyspneea and palpitation, oris frequently attacked by them. Other attendant symptoms are an irregular and intermittent pulse, occasional fainting, in some cases convulsions, and, if the complaint continue long, more or less dropsical effusion. The patients are generally subject to violent suffo- cative paroxysms, in which the palpitations and dyspneea are excessive, and the skin assumes its deepest hue. Such attacks are induced by unusual muscular effort, mental emotion, or whatever else unduly excites the heart. They are very apt to end in syncope; and it is generally in one of these paroxysms that the patient expires. Cyanosis is most frequently congenital. Of 71 cases collated by Dr. More- ton Stifle, it existed at birth in 40. (Am. Journ. of Med. Sci., N. S., viii. vol. II. 14 202 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. 42.) When not congenital, it usually makes its appearance first in early childhood, though sometimes in adult age. It is often quickly fatal, but may run on for many years, and sometimes from birth even to middle or advanced life. Of the 40 congenital cases above alluded to, 17 died within a year, 10 between one and ten years, 10 between ten and twenty years, and three only survived the last-mentioned period, of whom one attained the age of 57. The disease is rather more frequent in males than in females. Bluish or purplish discoloration of skin may arise from different causes. Stagnation of the blood in the capillaries from debility of these vessels, gene- ral venous congestion from obstruction in the heart, lungs, or pulmonary ves- sels, and deficient aeration of the blood from any cause which permits a continuance of the circulation, may produce it. But, in that intense degree, and with those associated symptoms, which are necessary to constitute a case of cyanosis, as generally recognized, the affection depends exclusively upon organic disease of the heart or large vessels; and in that light only it is viewed here. There is not, however, even in regard to the disease thus re- stricted, a coincidence of opinion among pathologists as to the precise cause of the discoloration. Two different views are entertained, one ascribing the colour to an inter- mixture of the venous and arterial blood, and the other to general venous congestion consequent upon obstruction at the heart. But neither of these seems to be quite satisfactory. The opinion, which ascribes the result exclusively to an intermixture of the two kinds of blood, supposes that nothing more is necessary to its pro- duction than such a direct communication between the two sides of the heart, or between the cardiac receptacle of venous blood and the arteries which sup- ply the system, as to render some mixture necessary. Now cases have been adduced in which such a communication has beyond all doubt existed, and the arterial and venous' blood have necessarily flowed together intimately united throughout the body, and yet no cyanosis has resulted. Nor does it seem that it ought to be an essential physiological consequence of such a mixture. The colour of the surface in health is not owing to arterial blood alone. The venous and arterial capillaries ramify everywhere together, and the colour no doubt depends upon both, and may be considered as intermediate between the two. The effect, therefore, is the same as though the two kinds of blood were flowing together through the same vessels, mingled in the same proportion. It follows that their mere intermixture, instead of producing cyanosis, may give rise to the ordinary healthy hue of the skin, provided the change in the capillaries be diminished in the proportion of the amount of venous blood added to the arterial; and this may be readily conceived to be possible. Against the second opinion also, though plausible, there seem to be strong objections. If a mere impediment to the circulation existing in the heart or its great vessels, even a very considerable impediment, were sufficient alone to produce cyanosis, we ought to have it as a very frequent disease; for such impediments in the heart are of constant occurrence, often in such a degree as to prove fatal. But cyanosis is very rare, and especially in old age, when such cardiac obstructions are most common. It is true that a certain amount of discoloration is produced by this cause, especially in the lips and extremi- ties ; but no one thinks of ranking the cases in which it occurs with cyanosis. Indeed, it is impossible that an amount of venous congestion throughout the system, capable of producing this change of colour, could remain long with- out calling into operation the obviating powers of the system. The excess is thrown off in the form of dropsical effusion, hemorrhage, &c, and the ine- quality is thus to a certain extent relieved. CLASS III.] CYANOSIS, OR BLUE DISEASE. 208 What then is the true explanation of the change of colour? To answer the question correctly, we must understand what is the character of the le- sions with which the disease is connected. These may be included under two heads; first, those which establish a direct communication between the venous and arterial circulation; secondly, those which obstruct the access of blood to the lungs, or, by producing congestion in that organ, interfere with the due aeration of the blood. Under the first head may be ranked a want of closure in the foramen ovale, a preternatural opening between the two ventricles, perviousness of the ductus arteriosus, the existence of but one ven- tricle, and a false position of the great vessels, as, for example, of the aorta arising from both ventricles or from the right exclusively, or forming a com- mon trunk with the pulmonary artery. Of these, the open or enlarged fora- men ovale is, according to Gintrac, the most common, being found in 33 out of 53 cases. Sometimes it is so much enlarged as to admit the thumb. It is obvious that, in consequence of any one of these lesions, the venous blood may find entrance into the aorta, and circulate along with the arterial blood. Of the second set of lesions alluded to, the most frequent and important is partial or complete obstruction, or obliteration of the pulmonary artery. Of the 53 cases collected by Gintrac, this artery was contracted or obliterated in 27 ; and it may have been so in others, in which its condition appears not to have been stated. According to Dr. Stille, in whose valuable paper, be- fore referred to, much statistical information is collected and collated, of 62 cases in which the state of the pulmonary artery was observed, it was either "contracted, obliterated, or impervious" in 53. This, then, maybe consid- ered as one of the most common lesions in cyanosis. Others having pre- cisely the same effect, namely, to impede the access of blood to the lungs, are a contracted state of the right ventricle, and diminution of the right auriculo- ventricular orifice. Others, again, which may act by producing congestion of the lungs, and diminishing the amount of aerated blood, are contraction of the left ventricle or of the aorta near its origin, and diminution of the left auriculo-ventricular opening.* It appears, therefore, that in almost all cases of cyanosis there is the coex- istence of a preternatural communication between the arterial and venous circulation, with impediment to the access of blood to the lungs, or imperfect aeration of that which reaches them. Among all the cases collated by Dr. Stille there are only 5 exceptions to the former branch of this statement, and in two of these the cyanosis was partial. To the latter branch of the statement there is scarcely a single well-authenticated exception. This may be considered as a virtual establishment of the rule; as the very small num- ber of exceptions may be readily referred to imperfect or mistaken observa- vation, or to a latitude in the application of the name of the disease; a cer- tain amount of blueness of the skin being occasionally found wholly uncon- nected with organic lesions of the heart. These data being admitted, it is not difficult to explain the occurrence of cyanosis. A mere communication between the two cavities, even allowing that a considerable mixture of the venous and arterial blood may occur, which does not by any means necessarily follow, is insufficient to account for the phenomenon; as such a mixture may not produce a different colour from the * An ingenious explanation has been given, by M. Ch. Bernard, of the comparative frequency of congenital lesions of the pulmonary artery and the right side of the heart. After birth, the main duty of the circulation falls upon the left side of the heart, and, as parts are liable to disease in proportion to their normal activity, this side is much more frequently affected with inflammation and other organic disorder, the right side being rarely the seat of primary lesions. In the foetus it is otherwise; the office of circu- lation being performed mainly by the right side, and especially by the pulmonary artery. which thus becomes specially liable to disease. (Arch. Gt~n., Aout, 1856, p. 161.) 204 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. natural, unless the quantity of venous blood be very large. Hence, in cases in which such a communication exists, with a free access of blood to the lungs, and a free aeration of it there, cyanosis is not produced. But let the entrance of the blood into the lungs be impeded, as in obstruction of the pulmonary artery, or let aeration take place imperfectly, as in pulmonary congestion from various organic cardiac lesions, then, the proportion of arterialized or aerated blood being lessened, if the two kinds are mingled together, the venous must predominate; and everywhere in the capillaries of the body will circulate a blood darker than the mean of the two kinds, which exist in the interlacing venous and arterial capillaries in health, and upon which the natural colour of the surface depends. Hence, the skin must be darkened; and the intensity of the discoloration must be inversely proportionate to the amount of venous blood arterialized in the lungs, and directly to the degree in which the blood from the venous side of the circulation is mingled with the arterial. Much importance has been attached to the patency of the foramen ovale, much more, indeed, than it deserves. While the actions of the heart are pro- perly balanced, this is of little consequence. The venous and arterial blood might mingle slightly; but not to any considerable extent. The two auricles being filled at the same moment, and contracting together, balance each other, and each sends the blood into its corresponding ventricle. Any inferiority of power on the part of one of the auricles would speedily be corrected by an increase of growth, resulting from the stimulus of the increased pressure. It is only when connected with other lesions that this becomes important. Con- traction of the pulmonary artery, by causing accumulation in the right ven- tricle and auricle, must send a current through the foramen into the left side of the heart. Thus, the same cause which prevents aeration of a portion of the blood by preventing its access to the lungs, occasions its mixture with the portion already aerated. The opening of the foramen is probably produced or maintained in general by the accumulation of blood, and consequent excess of pressure in the right auricle; and may be considered as a provision of na- ture for partially remedying a greater evil, and thus prolonging life. That discoloration of skin which occasionally takes place in new-born in- fants, and speedily yields to the ordinary influences, is probably owing in general to a yet imperfect permeability of the lungs, and the consequent cir- culation of a non-aerated blood ; the foramen ovale being still open. The treatment of cyanosis must be merely palliative. Life may be pro- longed, and the comfort of the patient promoted by a strict observance of those rules calculated to maintain the circulation in a moderate and equable condition. Tranquillity of the body and mind are of the highest importance; and scarcely less so, a proper regulation of the diet, which should be mode- rately nutritious, without being in the least stimulating. Animal food should be used sparingly. The digestion should be attended to, and nervous disorder quieted, if necessary, by the occasional use of narcotics and antispasmodics. Passive exercise is highly useful. It would be improper to omit here the notice of a remedial measure, in the blueness of new-born infants, which comes recommended by the great expe- rience of Dr. C. D. Meigs, Professor of Midwifery in the Jefferson College of Philadelphia. His plan is to lay the infant "on its right side, with its head and shoulders inclined upwards on pillows," and to keep it "for several hours in that position." Dr. Meigs has succeeded by this treatment "in rescuing from impending death upwards of twenty persons." (Proceedings of Amer. Phil. Soc, iii. 174-5.) Though we may not admit the theory, which attributes the success of this measure to the effect of gravitation in keeping the foramen ovale closed, we have no right on that account to reject it as a therapeutical measure, sanctioned by so high an authority. CLASS III.] FUNCTIONAL DISEASES OF THE HEART. 205 Article VII FUNCTIONAL or NERVOUS DISEASES OF THE HEART. These are, on several accounts, highly deserving of the notice of the physician. They are very frequent, are in themselves often the source of much inconvenience, distress, and even danger, and occasionally terminate, when of long duration, in fatal organic affections of the heart. Besides, imitating, as they often do very closely, these affections, they are apt to occasion much anxious apprehension on the part of the patient, lest he may be labouring under incurable disease. In order, therefore, to be able to give all proper consolatory assurances, and with the view also of obtaining just indications of treatment, which often differ greatly in the two orders of dis- ease, it is of great importance to form a correct diagnosis. This is not difficult in decided cases; but there are some in which a sure decision is almost impossible, and the greatest skill must be satisfied with probable con- jecture. When, for example, an organic affection is in that stage of ad- vancement in which it exhibits signs only during an excited state of the heart, and when these signs coincide exactly with those which are sometimes offered by mere functional disorder, we must be content with a very doubtful appeal to the existing or preliminary state of system, the probable causes, and other circumstances of an equally uncertain character. In those cases, moreover, in which the functional is just passing into the organic, it is not possible always to determine the boundary between them; and when, as oc- casionally happens, the two are combined in the same case, without any neces- sary mutual dependence, as when rheumatic or gouty neuralgia supervenes upon a structural lesion, an accurate discrimination is not always within our reach. The best plan of diagnosis is, probably, first, to determine what cir- cumstances are incompatible with the idea of mere functional disorder, and secondly, what are compatible only with that idea. We shall thus, at least, separate the certain from the doubtful; and it will be found, in practice, that only a comparatively small number of cases will be left undecided. 1. In nervous or purely functional diseases, the characteristic symptoms are scarcely ever, perhaps never, constant during a great length of time. In the organic, though there are some cases in which the signs are not always obvious, and many in which they are much more obvious at one time than another, yet in the great majority, as the lesion is invariably present, so also are its evidences, which may be discovered if carefully sought for. When, therefore, the signs of cardiac disorder are discoverable at all times, and under all circumstances, by night and by day, in sleeping and waking, during rest and exertion, not only for days, but for weeks, months, or years, the inference is unavoidable that they are something more than functional. In cases attended with continued or permanent secondary affections, result- ing from the strong sanguineous determination and venous congestion of cardiac disease, such as bloated features, purple lips, bleedings from the nose, apoplexy, pulmonary hemorrhage and oedema, general dropsy, &c, the pro- babilities are altogether in favour of the existence of organic derangement. Of course, this rule does not hold, when the affections alluded to are mere accompaniments of the cardiac disease and not effects of it. Again, the same conclusion is justifiable, when the existence of preterna- tural dulness on percussion in the precordial region, not traceable to disease of the neighbouring parts, indicates enlargement of the heart, or distention of the pericardium. So also, when a morbid state of the second sound of the 206 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. heart exists, evincing regurgitation through the semilunar valves, which can scarcely happen from mere disordered action in the organ.* The case, how- ever, is different in regard to the auriculo-ventricular valves, regurgitation through which has been observed without organic lesion, probably dependent on spasm of one or more of the fleshy columns, connected with the valves through the tendinous cords. A strong murmur, traceable far up the large vessels, may be considered as indicative of organic disease. 2. When the symptoms of cardiac disease are ameliorated by vigorous ex- ercise, as not unfrequently happens, we may be very certain that the com- plaint is not organic. It does not follow that every case of functional de- rangement is directly relieved by this means. On the contrary, when such derangement accompanies anaemia, it is often greatly aggravated by bodily motion. We only infer that it must be functional, whenever it is susceptible of permanent alleviation in this way. Moreover, when the cardiac symptoms can be traced to some particular cause, appearing when that is in action, and disappearing when it ceases to act; as, for example, when they accompany the abuse of narcotic or stimu- lating substances, and vanish when these are used no longer, they must be considered as strictly functional. Cases which do not fall into one of the above categories, must be judged of according to the weight of probabilities. The conditions which should incline the scale towards organic disease have been mentioned under the in- dividual complaints belonging to that division. Those of a contrary ten- dency will be alluded to under the following heads. Functional disease of the heart may evince itself by alteration either in the movements or the sensations of the organ, and in either case may have the character of irritation or of depression. Deranged movement may be included under the two divisions of palpitation in which the heart is under excitement or irritation, and syncope in which it acts feebly or ceases to act. Neuralgia of the heart, or angina pectoris, includes all the cases of mere functional affection of a painful character; and this may be associated with elevation or depression of the vital power of the organ. I. PALPITATION. This term is used to signify inordinate pulsations of the heart, sensible to the patient himself, or readily perceived by the observer. Such pulsations are often excited, in a perfectly healthy individual, by incidents and emotions which come within the limits of ordinary life. Under these circumstances, they can scarcely be considered as morbid. Palpitation is a disease only when so frequent, or so readily excited, as to become a source of inconvenience or apprehension. It must be recollected that, in this place, we are consider- ing it only as a functional 'disorder, and not in its connection with organic disease of the heart, of which it is one of the most common attendants. Symptoms.—Palpitation varies, in degree, from a scarcely perceptible movement to one so tumultuous and violent that it visibly agitates the * If it be true, as maintained by some, that muscular fibres exist in the semilunar valves, controlling their movements, then regurgitant aortic and pulmonary murmurs may possibly be merely functional, and their presence less positively indicative than has been supposed of the existence of organic disease of the heart. (See Lond. Med. Gaz., March, 1850, p. 408.) Skoda states that he has occasionally heard a double second sound without any organic disease of the heart or its valves. This may be explained upon the supposition of a want of perfect synchronism in the action of the ventricles, which may depend on nervous disorder. CLASS III."! PALPITATION. 207 whole chest, and occasions great distress. The pulsations may be increased in frequency, or in force, or both. They are sometimes regular, but more frequently irregular, intermittent, and fluttering ; and the pulse partakes of the same qualities. The latter is in some instances small and feeble, in others fuller and stronger; but generally it is characterized rather by a quick, jerk- ing, irritated motion than by strength. The impulse of the heart may be felt much more widely than in health, sometimes over a great portion of the left side of the chest, and even on the right side. The sounds too are much louder. Occasionally they are heard distinctly by the patient himself, espe- cially when lying on his left side, and even by a bystander at the distance of some feet. The patient is sensible of a whizzing, rushing noise, which seems to ascend up the neck ; and sometimes he hears both of the cardiac sounds. When the palpitations are violent, a metallic ringing sound is often heard in auscultation, which has been ascribed to the impulse of the heart against the chest, but has seemed to me to proceed from a deeper source. Not unfre- quently a bellows murmur attends the first sound ; but is confined to this, and is said by Dr. Hope to be limited to the aortic valves; but it has been observed by others over the mitral valves. Often also the murmur charac- teristic of anaemia is heard in the jugular veins, and slight bellows murmurs are emitted by the large arteries when compressed. The attack often comes on under some mental or physical excitement; but often also when the patient is at rest, and not unfrequently in the night, awakening him perhaps from his first sleep. When violent, it may occasion much distress. The heart feels as if bounding upward into the throat; a sense of anxiety or oppression is experienced in the precordial region, with hurried respiration or dyspnoea, so that the patient is frequently unable to lie down ; ringing in the ears, and vertiginous sensations often occur; and oc- casionally faintness and even syncope. The duration of a paroxysm is quite uncertain, sometimes not exceeding a few minutes, sometimes lasting for days without absolute intermission, though varying much in violence during that time. Most commonly it terminates within thirty minutes or an hour, recur- ring afterwards quite irregularly, sometimes daily or several times a day, and sometimes not until after a long interval. Causes.—Strictly speaking, palpitation is rather the result of disease than a disease itself; and the real morbid condition upon which it depends, leaving organic affections out of view, is either deranged innervation of the heart, or an unhealthy state of the blood, which may be too rich and abundant, con- stituting plethora, or too watery or otherwise depraved, as in anaemia, scurvy, (fee. The true causes therefore, are such as produce either of these conditions. 1. The causes of deranged innervation are almost innumerable. Among the most prominent is the abuse of tea, coffee, alcoholic drinks, and tobacco. These induce an irritable state of the nervous system, in which it is liable to disturbance from causes that ordinarily only sustain its healthy action. It may be objected to this statement, that strong tea is sometimes very efficient in the relief of palpitation. This is exactly what might be expected. The morbid condition is not the direct result of the stimulant, but that which fol- lows its long-continued use. The resulting disorder is relieved for the time by a fresh dose ; as the horrors which succeed a debauch are relieved by an additional draught of the poison. Similar in their influence are various other causes which habitually and unduly excite the nervous system, such as severe study, diversified mental excitement, and all sorts of sensual excess. The depressing emotions, sedentary habits, and loss of rest, have a similar effect directly. It has often been remarked that students just entering into man- hood, and especially medical students, are peculiarly liable to palpitation. This may be readily accounted for by referring to the above list of causes. 208 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. Numerous diseases have the occasional effect of inducing palpitation. It is frequently the result of a gouty or rheumatic irritation, affecting the heart through the nerves. Dyspepsia is a fruitful source of it, partly by a direct irritation imparted through the nervous centres, partly by that irritable state of the nervous system which it is so apt to induce. The same may be said of hepatic disease. Any irritation in the alimentary canal may be propagated to the heart, and occasion palpitation. Hence, it arises from flatulence, acid in the stomach and bowels, and intestinal worms, especially the tape-worm. It is a very frequent attendant upon hysteria; and many violent cases may be traced to tenderness in the spine. Pulmonary disease produces it either by a direct sympathy, or by modifying the influences which the heart receives from the blood. Everything that causes pressure upon the heart may also derange its actions. Tight lacing, ascites, tympanites, abdominal tumours, and the pregnant uterus may all have this effect. 2. The causes which act through the blood are such as induce plethora on the one hand, or an impoverished or depraved state of that fluid on the other. These are sufficiently treated of elsewhere. (See Plethora, Anaemia, Scurvy.) An excess of nutritive or stimulant matter in the blood operates by directly exciting the heart into excessive action; and the affection, when unattended with fever, hemorrhage, &c, is considered simply as palpitation. In this case, the pulsations may be strong and regular; differing very strikingly from those which mark the affection as arising from other causes. Anaemia is one of the most frequent causes of obstinate and excessive palpitation. Its mode of operation is easily understood. The actions of the heart in health are ex- actly proportionate to the wants of the system in relation to the supply of blood. Let these wants be increased, as by vigorous muscular exertion or cerebral excitement, and the heart responds by an increase in the force or fre- quency of its contractions; let them be diminished, as by rest, and the actions of the heart are diminished. These wants are made sensible by the nerves proceeding from all parts of the body to the nervous centres ; and thence is transmitted the influence which regulates the heart. Now, in anaemia, the blood, being deficient in its healthy qualities, does not adequately meet the requisitions of the nutritive and other functions, and more of it is demanded to produce the necessary effect. The wants of the system are therefore greater; the sense of them is transmitted to the nervous centres more strongly; and a corresponding increase in the stimulant influence sent to the heart is the consequence. This organ is, therefore, stimulated, and often powerfully so, by this state of the blood. Of course, the stimulation is felt most strongly when there is any additional duty to be performed by the blood ; and consequently the least exertion is sufficient to induce palpitation. In this form of the complaint, the pulsations, though frequent, are not usually strong, because the heart wants power. On the contrary, they are apt to be weak, intermittent, and irregular, with a pulse, which, though it may be voluminous, and sometimes short or sharp, is always easily compressible. In this form also it is, that the cardiac murmurs are so much like those of valvu- lar disease. Unlike mere nervous palpitation, this is aggravated by active exercise. The depraved state of the blood in scurvy and malignant diseases, may give rise to palpitation of the heart, upon the same principles as its diluted state in anaemia. The age at which palpitation is most frequent is that which intervenes between puberty and perfect maturity. Females are more apt to be affected with it than males. Paroxysms of palpitation, in one predisposed to it, maybe induced by any- thing of an exciting nature, whether intellectual, emotional, or purely physical. Diagnosis.—The most important point, in the diagnosis of palpitation, is CLASS III.] PALPITATION. 209 to decide whether, in any particular case, it is or is not connected with organic disease of the heart. Rules have already been given, under the general head of functional diseases of the heart, in relation to cases in which the signs may be considered as certain. In others, the decision must be made upon the ground of strong probability. When palpitation occurs paroxysmally, with perfect intermissions; when it is apparently traceable to some one of the causes of functional disturbance above enumerated; when it occurs in a young person, or in a nervous or hysterical subject, and increases and subsides with the rise and subsidence of other nervous symptoms; when it is relieved by exercise, or, if not so, shows an evident connection with anaemia; when its paroxysms come on during perfect rest; when it is unattended with valvular murmurs, or these, if present, are perceptible equally on both sides, and only with the first sound,'and little if at all in perfect calmness of the heart; and, finally, when venous and arterial murmurs coexist with the palpitation; when all or most of these circumstances exist, there can be little doubt that the affection is purely functional; and, in proportion to the number of them which are observable in any instance, and the degree to which they prevail, will be the probabilities in favour of this view of the subject. The pulse in palpita- tion, unattended with altered structure of the heart, however violent and tu- multuous the action may be, is destitute of the extraordinary hardness and strength which characterize the pulse of hypertrophy; nor is the sensation of heaving force so strongly felt, when the ear is applied to the chest. Another point of distinction, according to Dr. Joy, between the palpitation of func- tional and that of organic disorder, is the greater feeling of distress which usually attends the former. Effects.—It may be readily conceived that excessive palpitation, frequently repeated and long continued, may at length induce hypertrophy ; and what is at first merely nervous, may thus end in organic disease. Injurious results may also happen to other organs from the irregular supply of blood consequent on this affection. Dr. Stokes describes a condition, first noticed by Dr. Graves, in which permanent excitation of the heart, without any necessary connection with organic disease of the organ, is attended with turgescence of the thyroid gland, and enlargement of the eyeballs. The double sound and impulse are often, in these cases, developed in the carotids, the throbbing of which is visible to the observer, and painful to the patient. The enlargement of the thyroid is attended with a diastolic pulsation and purring thrill. The vision is not necessarily impaired. The affection is most frequent in women, and is apt to be associated with hysteria, neuralgia, or uterine disorder. (Dis. of Heart and Aorta, p. 296.) Dr. James Begbie reported several cases of this affection, so early as 1849, and has recently given another, occurring in a man, which terminated fatally, and in which the blood was found watery, the cavities of the heart and venous trunks dilated, but without valvular lesion, the spleen enlarged, and the liver diseased. There was also dropsical effu- sion. Similar results were obtained by Sir H. Marsh, of Dublin, and certain German pathologists. The disease appears to be essentially anemic; the cardiac enlargement, splenic and hepatic disease, and dropsy, being second- ary results of that condition. Treated in time, before the organic affections have taken place, the patient generally recovers. (Ed. Med. and Surg. Journ., April, 1855.) Treatment.—In the treatment of functional palpitation, the most important point is to remove the cause. The use of all nervous stimulants and narcotics, including tea, coffee, and tobacco, should be suspended or abandoned; injurious habits of indulgence should be overcome; the most watchful guard should be kept by the patient over his emotions, and while the mind is moderately occu- 210 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. pied, all over-exertion should be avoided ; a due amount of sleep and of bodily exercise should be obtained; and, whenever there may be reason to suspect the agency of some other disease, our efforts should be especially directed to- wards its removal. As the anxieties and fears of the patient tend strongly to aggravate and perpetuate the complaint, we should endeavour to cheer him by every assurance of a favourable termination which the circumstances of the case may justify. It would be out of place to detail the various modes of cure adapted to the several diseases, of which the palpitation may be a result, or by which it may be sustained. It will be sufficient to say that, if the patient is clearly plethoric, with a full strong pulse, he should lose blood, take saline cathartics, and live upon vegetable food or milk until this condition has been subdued; if anemic, he should, on the contrary, use chalybeates and a generous diet; if gouty or rheumatic, he should be treated with colchicum, antacids, laxatives, and stimu- lating pediluvia; if dyspeptic, he should pay especial attention to his diet, ex- ercise freely in the open air, and employ mild tonics and laxatives; in fine, whatever source of irritation to the heart can be discovered, whether existing in the lungs, the liver, the intestines, the uterus, or the spine, should receive a careful attention, and be removed if possible. In the cases of spinal ten- derness, recourse should be had to cups or leeches over the tender spot, fol- lowed by blistering or pustulation. Tight lacing, and all other artificial modes of cramping the movements of the heart, should be avoided. In the paroxysms, relief will often be afforded by the nervous stimulants, as assafetida, musk, valerian, the ammoniacal and ethereal preparations, cam- phor, strong tea, &c. Among the best of these are Hoffmann's anodyne, and the aromatic spirit of ammonia, which may be given separately or mixed. The preparations of opium or hyoscyamus, or one of the other narcotics, may sometimes be usefully conjoined with the antispasmodics. A fluidrachm of the camphorated tincture of opium will often afford relief. Aromatics, com- bined with antacids, are sometimes useful by expelling flatus and correcting acid. One or two fluidrachms of the compound spirit of lavender may be given with this view, in connection with aromatic spirit of ammonia. When an overloaded stomach is suspected as the exciting cause, an emetic dose of ipecacuanha may not be amiss. Should a gouty or rheumatic diathesis exist, and stimulants be indicated, a good preparation is the ammoniated tincture of guaiac. None of these remedies, however, should be employed when the palpitation is dependent upon plethora. To control the tendency to excessive action in the heart, digitalis may be cautiously administered, in cases not attended with great debility, and should be continued for a considerable time. Hydrocyanic acid has also been recom- mended. These remedies should be seconded by measures calculated to in- vigorate the system, such as exercise in the open air, which should be of the passive kind in anemic cases, the occasional or daily use of the shower-bath, frictions to the surface, and a diet of nutritious and easily digested food. II. SYNCOPE. Syncope is a diminution or temporary cessation of the action of the heart, with loss of consciousness, and a suspension more or less complete of respira- tion. It sometimes comes on suddenly; but is much more frequently preceded by premonitory signs, such as a feeling of nausea or of sinking in the epigas- trium, clouded or otherwise disordered vision, mental confusion, pallid and shrinking features, and a rapidly failing pulse. In general, the prelimi- nary sensations are disagreeable, sometimes exceedingly so ; but occasionally CLASS III.] SYNCOPE. 211 they are grateful to the patient. In complete syncope, the features are col- lapsed and of a ghastly paleness, the surface cool, the pulse quite absent at the wrist, respiration suspended, and consciousness entirely wanting. Some- times involuntary discharges take place from the bowels and bladder. The heart, however, seldom quite ceases to beat. The ear applied to the chest will generally detect the first sound, greatly weakened, but not the second. This is an important sign in diagnosis; as, when observed, it always gives hope of saving life. After a short time, the patient again draws his breath, colour gradually reappears in the lips and cheeks, the pulse may be felt at the wrist, consciousness returns, and very soon the recovery is complete. This is sometimes attended with feelings of much distress. It very frequently happens that the syncope is only partial; the prelimi- nary symptoms above mentioned being exhibited in a greater or less degree, but the patient never entirely losing his consciousness, nor entirely ceasing to breathe ; while the pulse, if not perceptible at the wrist, may be felt in the larger arteries. Such a state is frequently designated as faintness, especially in its lighter grades. The duration of syncope is variable, sometimes not more than an instant, usually some seconds or minutes, and, in certain rare instances, extending to hours or days. The cases of apparent death, in which it is believed that pre- mature interment sometimes takes place, are of this kind. Instances have occurred in which the pulse, respiration, and consciousness have been absent for several days, and yet the patient has ultimately recovered. The system is in a sort of hybernation, in which vitality remains, though the vital func- tions are suspended. It is probable that, in such cases, a very careful auscul- tation might detect a slight sound in the heart. Causes.—These are such as act either directly upon the heart, or indirectly through the nervous system. Of the first set of causes there are compara- tively few, if we except the organic diseases of the heart, which not unfre- quently produce syncope, and occasionally terminate in that way. Among the direct causes, however, may be ranked sudden attacks of neuralgia of the heart, translated rheumatism or gout, certain poisons which operate immedi- ately upon the circulation, especially the antimonials, and a state of depression following excessive excitement of the organ. To the same category may be referred the sedative influence of the warm bath, the presence of air in the circulation, and a stroke of lightning. Air, admitted into the large veins, in consequence of surgical operations, has, in numerous instances, produced fatal syncope. It probably acts by entering the cavities of the heart, and depriving the organ of the requisite stimulus. The idea has been suggested, that air is sometimes spontaneously developed within the blood-vessels during life; but no satisfactory proof of the occurrence has been advanced. The causes of syncope which act on the heart through the nervous system are very numerous. Whatever opinion we may entertain as to the inherent and independent irritability of the heart, this much is quite certain, that it is under the controlling influence of the nervous system, and often ceases to act when that influence is suspended or perverted. Violent shocks, which para- lyze the cerebral centres for an instant, are frequent causes of syncope. Hence the effects of sudden intelligence, whether exciting or depressing; of certain offensive or fearful sights, as a public execution, or a painful surgical operation; of sudden and excruciating pain, as sometimes in spasm of the stomach or bowels; and of violent injuries, whether from accident, or the knife of the surgeon.* Much milder impressions on the nervous system often * Connected with this suspension of the heart's action from shock upon the nervous centres, is the fact determined by experiment, that, if the par vagum be divided, and the end of the lower section be irritated, the heart ceases to act, though respiration con- tinues. (Archives Ginirales, Dec, 1854, p. 748.) 212 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. have the same effect upon the heart; such, for example, as result from certain rich and oppressive odours, the feeling of nausea connected with gas- tric disorder, the sensations excited in pregnancy by the movements of the foetus, and excessive hunger, or rather want of food. The presence of indi- gestible matters in the stomach sometimes has a powerful effect of this kind. A well-known case of protracted syncope, in which the subject, a gentleman of this city, narrowly escaped interment, but ultimately recovered, and lived many years, was believed to have resulted from the eating of fresh and badly baked bread. Cold water, drank when the body is very hot and perspiring, especially after exercise, is apt to induce syncope of an alarming and often fatal character. Under the head of causes acting through the nervous sys- tem, may also be placed certain powerful poisons, as digitalis, tobacco, and hydrocyanic acid. Deficiency or loss of blood is well known to be a frequent cause of syncope. How far this acts directly on the heart is not certain. There can be no doubt that this organ must feel any deficiency in its wonted stimulus; but there is nevertheless reason to believe that the cause acts more powerfully through the brain than immediately upon the heart. When the former organ is defectively supplied with blood, the latter appears to feel the con- sequences almost instantaneously. Hence, the loss of much less blood is required to produce fainting in the erect than in the horizontal position. Hence, too, it not unfrequently happens that a person, already weak from deficiency of blood, faints suddenly upon attempting to sit up in bed, or to rise and walk. Sudden death is occasionally produced in this way in diseases of debility. Excessive loss of blood, with consequent syncope, may occur from the operation of bleeding, from accidental wounds, and from sponta- neous hemorrhage. The quantity requisite for the effect differs greatly in different individuals, and in different states of system. The robust and plethoric will bear a much greater loss, as a general rule, than the feeble and anemic and the very fat; and inflammatory diseases much more than the typhous or scorbutic. But individuals also have idiosyncrasies, in this re- spect, which cannot be explained by any general rule ; one person, for in- stance, fainting^rom a small loss of blood, and another bearing an enormous loss without this result, though there may be in other respects no very ob- servable difference between the two. The rapidity with which the blood is withdrawn has much effect. Fainting is produced by a smaller loss when the bleeding orifice is large than when it is small. Profuse discharges from excessive secretion, as in cholera and diarrhoea, often produce syncope. The sudden removal of a long-continued pressure upon any portion of the body, has the same effect. Hence the fainting which sometimes follows delivery, and the operation of tapping, unless care is taken to supply the place of the lost pressure by that of a bandage. The effect, in these cases, may be ascribed in part to a loss of balance between the blood in the brain and in the newly liberated vessels, but much more to the effect upon the nervous centres of the feeling of vacuity, consequent on the removal of the pressure. ^ Diagnosis.—The only conditions from which syncope may not be readily distinguished are apncea and death. In the former, there is the same ab- sence of consciousness, respiration, and pulse at the wrist; but the aspect of the body is in general sufficiently diagnostic. ' In apncea there are signs of general venous congestion, such as purple lips, swollen features, and a dingy or livid hue of the surface; while in syncope the countenance is pallid and collapsed, and the skin apparently bloodless. The cause, if known, will also frequently serve to aid in the diagnosis. If it be such as acts primarily on the lungs it produces apncea, if upon the heart, syncope. There is a condition of insensibility of an hysterical character, in which CLASS III.] SYNCOPE. 213 the patient lies sometimes for days, without motion or consciousness, and in which the breathing is so gentle that, Avithout close examination, it may be supposed to be suspended. I have been sent for, in such a case, to decide whether death had hot taken place. The physician, however, has no diffi- culty in the diagnosis ; for, upon placing the fingers upon the wrist, he finds the pulse beating as in health. An accidental deviation of the radial artery from its ordinary course, an event not at all uncommon, might in such a case lead to a very false conclusion, if the physician should not be upon his guard, and examine the pulse elsewhere. The most embarrassing problem, in relation to the diagnosis of syncope, is to decide between cases of apparent and positive death. In prolonged syn- cope, we might expect something in the general aspect of the case different from the exterior cadaveric characters, though it would be difficult to say what. There is occasionally something life-like in the countenance and sur- face, which has led on the part of observers to persevering convictions of continuing life, which the event has justified. In such cases, the interior temperature should be observed, and, if higher in the fauces or rectum than upon the surface, it must be considered as a favourable indication. The probability is, that a careful auscultation of the heart might detect some faint remaining sound. There is an absence, moreover, of the cadaveric rigidity, which is probably the last vital act of the expiring tissues, occurring some time after the great functions of life have been suspended. In real death, there is a sinking of blood to the most dependent parts of the body, indicating a complete surrender of the vital powers to the ordinary physical laws. But, whenever there is any doubt, the body should not be buried until after the commencement of putrefaction, which is quite decisive. Happily, the warmth necessary to the restoration of the patient, if living, hastens the occurrence of this decisive test in death. Prognosis.—This is generally favourable, when the syncope is unconnected with organic disease. Sometimes, however, the affection is fatal when it proceeds from the loss of blood, even though the hemorrhage may have ceased, from severe shocks upon the nervous system, and from slight exertion in cases of great debility. There is reason to believe that death takes place occasionally from syncope, consequent upon some sudden affection of the heart, paralyzing its power of contraction; as the closest post-mortem exami- nation, in instances supposed to be of this kind, has failed to detect any lesion to which the result could be ascribed. Treatment.—The first thing to be done in syncope, threatened or existing, is always to place the patient in a horizontal position, with the head at least as low, if not lower than the rest of the body. By this simple measure, em- ployed when the premonitory symptoms are first felt, an attack may very fre- quently be averted; and it is also one of the most effectual means of restora- tion after the attack; sometimes, indeed, absolutely essential to recovery. Hence the importance of distinguishing such cases from those dependent upon congestion of the brain. An individual subject to syncope, should at once lie down when he feels an attack approaching. Sometimes, as in cases of excessive hemorrhage, it is necessary to maintain the horizontal position steadily for a considerable time; until, in fact, the blood-vessels are again supplied in the course of nutrition. At the same time that this measure is employed, all pressure from tight dresses, corsets, cravats, A:c, should be carefully removed from the chest, neck, and abdomen, and the patient should be surrounded with pure fresh air. Means should also be employed to rouse the nervous system. For this purpose spirit or solution of ammonia, strong acetic acid, or other very pun- gent volatile substance, may be so applied that the vapours may enter the 214 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. nostrils; but care must be taken not to carry the remedy too far, lest it pro- duce severe inflammation of the part. The smoke of burnt feathers has been employed for the same purpose. Sprinkling cold water upon the face is also useful by the shock which it produces on the nerves. Slapping the palms of the hands, and making a shrill sound in the ears of the patient, are vulgar remedies not without effect. Any good result which may have followed the application of the tourniquet to a limb, is to be ascribed to the influence of the measure rather upon the nervous system than the circulation. If the patient can swallow, he may take a draught of cold water, which seems to act upon the mucous surface in the same manner as on the skin, by exciting a sensation that leads to reaction. Diffusible stimulants should also be ad- ministered, especially the ethereal and ammoniacal preparations; and, as in palpitations, the most convenient forms are Hoffmann's anodyne, and aromatic spirit of ammonia. In cases of great debility, brandy may be used. Should the patient be unable to swallow, and the syncope not speedily yield to the measures above recommended, stimulants, such as oil of turpentine, brandy, and carbonate of ammonia, properly diluted, should be injected into the rectum. Remedies must also be applied to the surface. The body should be kept warm, but not overheated; friction should be made with a flesh-brush or coarse flannel; and rubefacients should be applied along the spine and to the extremities, care being taken not to permit them to remain so long, or to be used of such a strength, as to endanger much inflammation on the occurrence of reaction. A good mode of exciting the skin might be one suggested to the author by Dr. Cartwright, of Natchez, that, namely, of slapping the whole surface with a lady's slipper. It has been recommended to apply briefly to the epigastrium, or over the spine, a piece of heated metal, as the blade of a case knife, or the bowl of a spoon, in order to excite sensation; and a live coal from the fire has been efficiently employed for the same purpose. Elec- tricity may also be cautiously used; and recourse should be had to artificial respiration in cases which resist other measures, though the same good is not to be expected from this remedy as in asphyxia. When the syncope has proceeded from large draughts of cold water taken into the stomach in hot weather, the patient, if able to swallow, should take full doses of laudanum, with ether, solution of ammonia, hot brandy-toddy, or even water alone made as hot as it can well be borne; and, in cases of complete unconsciousness, these or similar remedies should be administered by means of the stomach-tube. The other remedies above mentioned may be used at the same time, and especially a sinapism over the epigastrium. When an overloaded stomach, or some acrid or indigestible matter in the stomach, is the cause of the affection, it is proper to administer an emetic of powdered mustard with warm water or warm chamomile tea, which may be aided if necessary by a little ipecacuanha. III. NEURALGIA OF THE HEART, or ANGINA PECTORIS. Neuralgia of the heart and angina pectoris are considered by some as dif- ferent diseases; but it is impossible to point out any important distinction between them. Though angina has frequently been found in connection with organic disease of the heart, yet frequently also no such affection has been detected upon examination after death; so that it must be considered as essen- tially nervous. Angina is, therefore, a painful nervous affection, and this is the very definition of neuralgia. If it be maintained that angina appears under a peculiar characteristic form, differing from other painful affections of the heart, it may be stated in reply that, though there may be striking dif- CLASS III.] ANOINA PECTORIS. 215 ferences between two extremes of any affection which admits of diversity, yet this is not a valid reason for constituting them into distinct diseases, espe- cially when, as is the case with the complaint in question, the extremes are connected by a chain of insensible gradations, so that they cannot be sepa- rated without doing violence to some link. The only admissible distinction between the terms appears to be, that, while neuralgia shall be considered as embracing all the purely nervous cardiac pains, angina pectoris shall be limited to the more violent and dangerous. Symptoms.—The disease is characterized by severe pain in the precordial region, occurring paroxysmally, with freedom from pain in the intervals. In the paroxysm, the pain generally shoots through the chest towards the back, and into the left shoulder, and not unfrequently extends down the arm, where it is attended with a feeling of numbness. This combined sensation is some- times felt as far as the fingers, proceeding downward from the elbow along the course of the ulnar nerve. Sometimes also the pain spreads to the ante- rior part of the chest, ascends up the left side of the neck, or descends to the left leg; and cases are mentioned in which it has even extended to the right side of the body. There is occasionally exquisite tenderness of the left mam- ma in the female, and pain upon pressure in different parts of the chest, both anteriorly and posteriorly, in both sexes. There is every grade of vio- lence in the sensation, from a dull aching numbness, up to the most acute and excruciating pain, for which the imagination of the sufferer has laboured in vain to find terms of comparison sufficiently expressive. Along with the pain, in bad cases, there is often a sense of tightness or oppression in the chest, with dyspnoea, inability to lie down, and sometimes violent palpita- tions ; and the patient not unfrequently has the feeling that he cannot live unless speedily relieved. Though the breathing is apparently much oppressed and difficult, yet the lungs can generally be fully expanded by a voluntary effort. The pulse is usually small, irregular, and feeble, but sometimes strong and voluminous. Occasionally, the paroxysm ends in convulsions or syncope. There is often much flatulence of stomach, and the urine during the paroxysm is pale and limpid. The paroxysm varies in length from a few minutes to half an hour, or an hour, and sometimes, though rarely, exceeds the last-mentioned period. The patient is sometimes free from pain, and in apparent health, during the in- tervals; but more frequently he suffers with occasional uneasiness in the prsecordia, and often exhibits signs of cardiac disease. The first attack, which is in most cases comparatively mild, is usually ex- perienced upon the occasion of some extraordinary exertion, such as ascend- ing a height, especially in the face of a cold wind. The patient is suddenly seized with pain, and immediately stops, feeling that it is impossible for him to advance, and as if he should die were he to make the effort. After a few minutes, however, the pain subsides, and he is enabled to proceed. The attack is afterwards repeated, but at a very uncertain interval, after one or more Aveeks, for example, or months, or a year; but the interval generally diminishes with the continuance of the complaint; so that at length the patient becomes liable to a paroxysm upon the slightest excitement, and even without any apparent exciting cause. In this condition, any movement of the body, or any mental emotion, however slight, may become the cause of pain; and the swallowing of food, the act of defecation, turning in bed, coughing, or other equally insignificant cause, is sufficient to induce a parox- ysm. The patient is not unfrequently attacked at night, especially, as it is said, after the first sleep. He is now scarcely ever free from suffering or the apprehension of it, and life not unfrequently becomes a burden, which he is glad to lay down.. Cases which have advanced thus far sometimes terminate 216 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. suddenly, in fatal syncope. The patient is also frequently carried off by some of the secondary affections incident to organic disease of the heart, in which simple neuralgia, if severe and long continued, is apt to terminate. But there are many cases much less severe than those above described. The pain may not be less acute; but it is not so extensive, recurs quite irre- gularly both as to degree and time, and may disappear for a very long period, or never return. There are, indeed, fugitive pains in the heart as in other organs, depending on various causes of nervous derangement, and quite trivial in their nature, which it is necessary, if they are classified at all, to place along with neuralgia. The same may be said of that sort of uneasy feeling about the heart, extending often to the shoulder and arm, which con- sists in a sense rather of stricture, Aveight, or aching numbness, than of posi- tive pain, and which is not uncommon in nervous and dyspeptic patients of a gouty or rheumatic constitution. Instances of cardiac neuralgia have been observed, in which the paroxysms returned at certain fixed periods, with perfect freedom from pain in the in- terval. Such cases are strictly analogous to the intermittent or periodical neuralgia, which frequently occurs in other parts of the body. It is asserted that angina pectoris has sometimes disappeared upon the breaking out of certain eruptions upon the skin. Dissection often reveals nothing to which the complaint could be ascribed; but often also organic disease has been observed, such as ossification of the coronary vessels, valves, or aorta; hypertrophy, dilatation, or softening of the heart; morbid obesity, and pericardia] effusion. It is impossible to deter- mine how far these diseases are mere accidental coincidences, and how far they stand towards the neuralgic affection in the relation of cause or effect. Causes.—These are often very obscure; and, as in other cases of ob- scurity, various opinions have been advanced by authors. Dr. Parry, whose attention was particularly called to ossification of the coronary arteries, as- cribed the disease to that lesion. By others it has been referred to general plethora, to gout, to affections of the pericardium, to spasm of the diaphragm, and to organic disease of the liver or other abdominal viscera. Dr. Hope was inclined to the belief, that, in its worst forms, it Avas owing to structural disease of the heart or great vessels, in which some portion of them were de- prived of their elasticity by osseous, cartilaginous, or steatomatous degenera- tion, and that the pain was owing to over-tension of the rigid portion. But these affections so often occur without any trace of angina, and angina has been so often observed without structural disease, that great doubt is neces- sarily thrown over the correctness of this opinion. I am disposed to believe that, where the two affections coexist, they are both the result of the same morbid cause, or that the organic is the consequence, as so often happens elsewhere, of the continued functional derangement. The opinion of Dr. Chapman that angina is a gouty affection is probably true, in at least a large number of cases ; and the tendency of gouty irritation to favour the deposit of calculous matter in the fibrous tissues is well known. Both the pain and the ossification may in such instances be nothing more than gouty pheno- mena. So far as my personal observation has gone, neuralgic affections of the heart have generally occurred in persons who have inherited a gouty or rheumatic diathesis, but whose habits of life, more abstemious than those of their forefathers, have prevented the ordinary inflammatory development of those diseases, and given them a disposition to assume a neuralgic form. Like neuralgia in other situations, that of the heart may be associated with and possibly in some measure dependent upon, general debility, nervous de- rangement of the system at large, and the chlorotic or anemic condition of the circulation. It is one of the forms in which hysteria shows itself, and is CLASS III.] ANGINA PECTORIS. 217 apparently, in some instances, connected with tenderness of the spine. It occasionally alternates with neuralgia elsewhere, especially in gouty or rheu- matic individuals. It has sometimes appeared to originate in continued and deep distress of mind. There is good reason to believe that it is sometimes a result of miasmatic influence. Occasionally it is associated with general plethora, which may possibly serve as the exciting cause. Dyspepsia and disease of the liver often occasion neuralgic sensations in the heart, proba- bly through the nervous centres which associate the seats of these affections. The complaint is apt to come on when the stomach is overloaded with food, distended with flatus, or irritated by acid or indigestible matters. The com- munication of the irritation is probably effected through the instrumentality of the pneumogastric nerve. It is not improbable that disease at the origin or in the course of this nerve may sometimes be the source of the affection. Males over fifty are most liable to the severest forms of this complaint; females less advanced in life to the milder. Prognosis.—When the disease is associated with structural alteration in the heart, the prognosis is very unfavourable, though the patient often lives Jong. Under other circumstances, the affection may very generally be alle- viated, and sometimes cured. When of a gouty character, though removed for a time, it is always liable to return, because the gouty diathesis can scarcely be eradicated. Treatment.—The remedial measures are first, those adapted to the parox- ysm, and secondly, those which are to be used in the interval. 1. During the paroxysm, the patient should be kept at rest. If the pulse should be strong, and the general habit plethoric, blood may be taken freely from the arm; but bleeding is not frequently required, and, when the dis- ease is associated with general debility, or the anemic condition, would be positively injurious. Whenever the patient is habitually pale, with a languid circulation, and in a generally feeble state of health, blood should be taken very cautiously, if at all, and by cups or leeches between the scapula?, rather than by the lancet. Local bleeding may also be used, as an adjuvant of vene- section, in cases to which that remedy is adapted. To relieve the pain, anodyne and antispasmodic medicines should be given freely; and none are so efficacious as the preparations of opium, such as lauda- num, the black drop, and the salts of morphia, of one of which a large dose should be given promptly, and repeated if the first should not prove success- ful. Inhalation of chloroform has been recommended for the same purpose. When there is a gouty or rheumatic tendency, the wine of colchicum root should be given pretty freely along with the anodyne. Should the pulse be feeble, the skin cool, and the action of the heart corresponding, the am- moniacal or ethereal preparations, musk, assafetida, or camphor, should be prescribed, separately or variously combined; and, in such cases, with a gouty or rheumatic taint, ammoniated tincture of guaiac may be substituted for the preparation of colchicum. Should evidences of acid or flatus in the stomach exist, carbonate of ammonia, or aromatic spirit of ammonia, is well calculated to meet the indications; or various mixtures of aromatics and antacids may be administered. When there is reason to suspect an overloaded stomach as the cause, vomiting should be produced by ipecacuanha, aided by warm water or infusion of chamomile. Hot pediluvia, rendered more stimulating by mustard, or Cayenne pepper, should be employed simultaneously with the internal remedies, especially in gouty cases. Speedy rubefaction over the region of the heart, by means of strong solution of ammonia or sinapisms, is sometimes desirable ; and similar applications to the spine may not be without advantage. Laennec recom- mends the application of two magnets on opposite portions of the chest; but vol. n. 15 218 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. all their effects are probably produced through the mind of the patient. Acupuncture is said to be sometimes useful. 2. In the interval, the exciting causes should be carefully avoided, and the patient should, therefore, sedulously cultivate calmness of mind and perfect equanimity, while he avoids all vigorous muscular effort. At the same time, the general health should be carefully attended to as the best safeguard against the attacks of the disease. Dyspepsia should be corrected with espe- cial care, along with its concomitants, acidity, flatulence, and constipation. (See Dyspepsia.) In employing exercise in reference to the state of the gene- ral health, the passive kinds, as on horseback, or in a carriage, should be de- cidedly preferred to the active. Any existing morbid tendency which may have predisposed to the disease, or excited it, should receive due attention. Hence, gout, rheumatism, anaemia, or hysteria, if present should be treated with appropriate remedies ; but, when either of the first two of these affections is seated in a safe and convenient spot, caution should be observed not to re- move it by repellent measures. Sometimes advantage will accrue from a strong impression upon the nervous system by means of the metallic tonics, associated with narcotics. Nitrate of silver, sub-carbonate of iron in half drachm or drachm doses, sub- nitrate of bismuth, the salts of copper, or those of zinc, may be given in con- nection with the extract of belladonna, of stramonium, or of hyoscyamus, or of the three combined. For the periodical cases, sulphate of quinia is the appropriate remedy. The paroxysms, when apt to occur at bedtime, may sometimes be effectively anticipated by a full dose of opium. Nor should local remedies be neglected in the intervals. Issues in the thighs have been highly recommended. Blistering, antimonial pustulation, setons, or issues may be employed on the back between the shoulders. Ad- vantage has also accrued from a belladonna plaster upon the breast, and from frictions with aconitia or veratria. Finally, in very obstinate cases, not attended with serious structural dis- ease of the heart, much good may be expected from the mental distraction, various enjoyments, and exciting novelties of foreign travel, which places the nervous system under wholly new influences, and often subverts those tena- cious morbid associations which sustain, if they do not originate neuralgia. SUBSECTION II. DISEASES OF THE ARTERIES. Article I INFLAMMATION OF THE ARTERIES, or ARTERITIS. The arteries are one of the components of our frame least liable to inflam- mation. It is not unusual to find arterial trunks wholly sound, though sur- rounded with inflamed and even suppurating structure. Hence it may be inferred that idiopathic arteritis is a rare disease. Some pathologists, how- ever, have adopted a contrary opinion, based upon the supposition that the redness, often observed after death upon the inner surface of the arteries, is of an inflammatory character. Among these was Dr. Frank, of Vienna, who regarded arteritis as the essential cause of a very peculiar and dangerous form of fever. But a closer scrutiny has determined that the redness is not a cer- tain evidence of inflammation, but is, on the contrary, in general, the result CLASS III.] ARTERITIS. 219 of imbibition of blood after death, or during the last agony. The observa- tions of Chaussier, Laennec, Berard, Andral, MM. Trousseau and Rigot, and Dr. Hope, all concur to this end. The inference, therefore, as to the frequency of arteritis, drawn from the phenomenon alluded to, is not sup- ported ; and all other considerations lead to the conclusion that it is a rare disease. The want of vascularity in the interior membrane of the arteries would appear to be the chief cause of their resistance to ordinary causes of inflam- mation. Trousseau and Rigot found that neither alcohol of the sp. gr. 0835, nor dilute nitrous acid, nor putrefying animal substances, occasioned inflam- matory action in the arterial lining membrane. (Hasse's Anat. Descrip. of Dis. of Circ. and Resp., London ed., p. 59.) Symptoms.—The symptoms of arteritis are very uncertain. When mode- rate and of small extent, as it ordinarily occurs, for example, after the tying of an artery, it scarcely gives rise to any obvious disturbance. In a higher degree, it is said to occasion heat and pain along the course of the inflamed vessel, tenderness upon pressure, increased pulsation or throbbing, and a rust- ling sound upon auscultation, which has been ascribed to roughness of the internal surface. When seated in the larger vessels, it generally produces a sympathetic irritation of the heart, and other symptoms of fever, sometimes attended with restlessness, great anxiety, and a feeling of faintness. In the thoracic aorta, it may also give rise to oppressed breathing. The same symp- toms, however, may result from so many other morbid conditions, especially in the thoracic and abdominal cavities, that a certain diagnosis is almost im- possible ; and the practitioner must be content, even in the best marked cases, Avith a high degree of probability. The absence of any other discoverable lesion or functional disorder, to which the symptoms can be ascribed, will afford good probable grounds for referring them to this cause. It very seldom happens that the aorta, or other large arteries of the trunk, are absolutely obstructed in consequence of inflammation; but this result is occasionally attendant upon the disease in the arteries of the extremities. In such cases, the vessel, though it may have at first pulsated with more than its usual force, either suddenly ceases to beat, or gradually beats more and more feebly, until pulsation can no longer be felt, either at the seat of the affection, or in the limb below it. The artery may now be felt like a tense cord running along the limb. The obstruction may be owing either to the exudation of fibrin into its cavity, the deposition of fibrin from the blood, or the coagulation of the blood itself; and sometimes to a mere thickening of the coats. Virchow denies that exudation of fibrin ever takes place from the lining membrane of the arteries; founding his opinion upon the want of blood-vessels in that tissue, and supporting it by experiments made upon dogs. He admits, however, that fibrin, exuded in consequence of inflamma- tion of the outer and middle coats, may find an entrance into the cavity of the vessel by rupture of the lining membrane. It is of little consequence, patho- logically, whether the fibrin enters the artery by rupture of the lining mem- brane, or exudation through it; but he has, I think, adduced nothing which proves that the latter condition may not occur in this, as in other cases of ex- udation upon the surface of non-vascular tissues. The blood appears to have a strong tendency to coagulate upon the inflamed surface of the vessel, and the clot sometimes extends for a great distance along its course, blocking it up completely. The limb sometimes becomes swollen and painful during the pro- gress of the disease ; but, when the obstruction has occurred, the phenomena resulting from a deficient supply of blood are exhibited in a degree propor- tionate to that of the obstruction. A feeble or absent circulation, diminished temperature, a sensation of numbness or even paralysis, and lastly mortifica- 220 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. tion, preceded by gangrenous phlyctaenoe, are among the results. It is highly probable that many of the cases of apparently spontaneous gangrene of the extremities have their origin in inflammation of the arteries. The blood in the vessels of a mortified part coagulates; but the coagulation does not ne- cessarily extend far beyond the seat of the affection. In these cases of sup- posed spontaneous gangrene, the main artery has been observed to be filled, far above the utmost limit of the mortification, with coagulated blood ad- herent to its inner coat, or separated from it by a layer of pus; showing that the original disease Avas probably in the vessel itself, and the gangrene, there- fore, a result and not a cause. It would, however, be going too far to assert that, in all instances, spontaneous gangrene arises from arteritis. It un- doubtedly originates from various other causes. The loss of the limb is not a necessary consequence. Blood may be supplied to it through anastomosing vessels, or others generated on the occasion. Should this supply be furnished sufficiently before the occurrence of absolute mortification, the limb may be restored, and, even after mortification, only a portion may slough, and the remainder be preserved. But, in cases of extensive coagulation, reaching far up the artery, death is the necessary result. When recovery takes place, the artery becomes obliterated by absorption. If not completely obstructed, however, it may remain pervious on the subsidence of the inflammation. Inflammation and obstruction of the pulmonary arteries are somewhat peculiar in their results. As these are not, exclusively at least, the nutri- ent arteries of the lungs, the obstruction is not necessarily followed by gangrene. There are no symptoms by which the affection can be diagnosti- cated with an approach to certainty during life; and, of the cases on record, most if not all have been first discovered upon dissection. Of course, com- plete obstruction must be followed by speedy death from suspended circula- tion. But this is rare, and when it occurs is probably not inflammatory. Partial obstruction may exist to a considerable extent, without necessarily destroying life, or even greatly disturbing respiration or other important functions. As explained by Mr. Paget, if the amount of obstruction is small, the defect is supplied by a greater energy of action in the right ventricle, increasing the rapidity of the current; if more considerable, the balance of circulation is maintained by the diminished action of the left ventricle, con- sequent on the diminished supply of blood from the lungs ; while the excess of blood accumulates in the veins. Life may be thus maintained for a con- siderable time, with symptoms, of course, of anaemia, venous congestion, and general debility. But the patient is always in danger, proportionate to the degree of obstruction; and death may take place, either gradually, by the slow increase of the coagulation, or more suddenly, by an accidental attack of some disease which the system, in its deranged state, may be unable to re- sist, or some unusual excitation or muscular exertion, by which the systemic arteries may be emptied more rapidly than they can be supplied. The im- mediate cause of death, is the want of due impression on the cerebral nervous centres, or deficiency of blood in the heart. The. blood which passes through the lungs is properly aerated, and the ordinary symptoms of apncea or as- phyxia are, therefore, not presented. It is clear that diminished nutrition in the various organs, short of gan- grene, may ensue from partial arterial obstruction. Thus, the heart and brain may undergo fatty degeneration from this condition in the arteries which supply them respectively with blood; and syncope or a tendency to it in the one case, and palsy or apoplexy in the other, may result. In the advanced stages of extensive arteritis, a new set of phenomena are sometimes presented, consequent upon the contamination of the blood with the pus, lymph, &c, which may be secreted by the inflamed interior mem- CLASS III.] ARTERITIS. 221 brane, and washed away by the current of the circulation. The fever now assumes a typhoid character, with a frequent, feeble, and irregular pulse, torpid capillary circulation, hurried breathing, subsultus tendinum, and low, muttering delirium. This condition of system attends, from the beginning, certain cases of arteritis, originating in local inflammation, abscesses, or unhealthy ulcers, which appear to impart their own depraved action to the inner coat of the arteries of the part affected, along which it is transmitted towards the heart. Guthrie, who has published an account of such cases, considers the inflammation as erysipelatous. The cases are rare; for the tendency in arteries, unlike that of the veins, is to propagate inflammation towards the circumference, instead of the centre of the circulation. From the evidence of dissection, it may be inferred that chronic inflam- mation of the arteries is not unfrequent; if, indeed, it be admitted that the various organic changes which have been noted, such as alterations of texture and thickness, and different kinds of morbid deposition, are really the result of the inflammatory process. But there are seldom symptoms sufficiently marked to characterize the affection, before the organic change has taken place; and this then becomes the prominent object of attention. (See the next article.) Anatomical Characters.—Redness of the internal coat has been before stated not to be admissible alone as an evidence of previous inflammation. Scarlet and brown or violet discolorations are frequently the result of mere imbibition of blood. Berard considers the proposition incontestible, that " the red bands and patches of the internal surface of the arteries, which are not attended with any other appreciable physical change in the coats of these vessels, are not of an inflammatory nature." (Did. de Med., iv. 100.) But, when the redness is accompanied with a roughness or loss of polish upon the interior surface ; injection of the vasa vasorum ; softness, friability, loss of elasticity, or thickening of the parietes; a facility of separation between the several coats; and the existence of crude coagulable lymph or of pus, there can be no doubt of the previous existence of arteritis. The lymph has been observed variously in flocculi, patches adhering to the interior surface, and masses to a greater or less extent filling and obstructing the channel of the vessel. Pus is formed upon the inner surface, underneath layers of coagu- lated blood or false membrane, and sometimes between the coats. But it is not a frequent product of arteritis, which is much more disposed to plastic exudation than the generation of pus. Coagulated blood is frequently observed lining the vessels, or occupying their cavities, sometimes for a great distance. The presence, however, of pus or lymph is probably less frequent than it would be, were not these substances often washed along with the blood as fast as produced. Ulceration is sometimes seen upon the inner surface of the vessel, though very rarely as the result of acute arteritis. All these signs of inflam- mation are seldom or never observed in one case; nor are they all of equal value. Laennec is disposed to believe that thickening of the coats, and un- usual apparent vascularity, "may exist in connection with redness, without necessarily implying inflammation, when the body is much infiltrated, and the tissues very moist; and Dr. Hope states that he met with a case present- ing these phenomena, which a brief examination proved not to be inflamma- tory. (Cyc. of Pract. Med., Art. Arteritis.) The most incontestible evidence of inflammation is that afforded by the existence of exuded fibrin or of pus. ' The marks left by chronic arteritis are a dirty redness, thickness, softness, or other organic alteration of the coats, ulceration; and various morbid de- posits. Attention has been called by Dr. Hodgkin to constriction and ob- literation of arteries at their mouths, consequent upon contraction of the fibrinous deposit produced by inflammation, and to various results of local 222 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. anaemia from this cause. (Med. Times and Gaz., April 1856, p. 410.) In relation, however, to the organic changes of arteries, it is by no means cer- tain that they are always the result of inflammation. Some of them, indeed, would appear, from a close scrutiny, to be Avholly independent of that process in their origin. But, either as cause or effect, they usually have more or less connection with it; and they may therefore be most conveniently treated of here, so far as they require notice in an elementary treatise, at least with the exception of ossification and aneurism, which will be considered under dis- tinct headings. Non-inflammatory organic alterations.—Arteries are sometimes found dilated, and sometimes contracted. Of their dilatation occasion will be taken to treat under aneurism. Their contraction is either mere stricture Avithout alteration of their coats, or, as more frequently happens, it is the result of a thickening of one or more of the coats, or a deposition of foreign matters in their substance. In the former case, it is very limited; in the latter, it sometimes affects a considerable extent of the vessel. The coats of the arteries are variously changed. Occasionally they lose their elasticity, at the same time becoming white, more opaque, and denser than in health, without other appreciable alteration. This condition is said to predispose to dilatation. In other instances they are thickened, as well as inelastic and fragile, especially the inner coat; whence arises a diminution of their caliber, and sometimes even complete obstruction. Sometimes they are much softened; and this also is particularly true of the inner coat. In this condition, the vessel is liable to an accident to which attention was first called by Dr. Turner, in the Transactions of the Medico-Chirurgical Society of Edinburgh. In consequence of some movement in which the artery is elongated, the inner membrane is ruptured, and a portion of it, being rolled backward, impedes the current of the blood, and induces coagulation to such a degree as quite to obstruct the vessel. A sudden stoppage of circulation is experienced in the limb below, with all the necessary consequences of the want of blood. Of the morbid deposits, one of the most frequent consists of cartilage-like patches on the inner surface of the artery. From the researches of Bizot, it would appear that these are the result of acute inflammation ; having been traced from their incipient stage of a viscid gelatinous exudation, of a pale rosy colour, through gradual changes, to the state in which they are ulti- mately found, of firm, white patches, of almost cartilaginous hardness, sup- planting the inner coat of the vessel, in the places where they are deposited. (System of Pract. Med., article Arteritis.) Hasse, however, regards them as deposits directly from the blood. (Hasse's Anat. Descriptions, &c, p. 75.) According to the same author, these patches never ossify, differing in that respect strikingly from the affection to be noticed in the following paragraph. Another kind of deposition is that which has been variously denominated atheromatous (pulpy), melicerous (of the consistence of honey), and steato- matous (of the consistence of suet), according to its degree of cohesion. It is usually deposited in the form of a yellowish, soft, friable, cheesy substance, either in the cellular tissue between the inner and middle coats, or, according to Berard, in the substance of the lining membrane itself, between its two laminae. (Did. de Med., iv. 132.) It first appears in numerous minute granules, which coalesce and form masses, sometimes of considerable size. These masses either become the matrix of a calcareous deposition ; or, being gradually softened, and converted into a pus-like matter, by a process analo- gous to the softening of tubercles, produce ulceration or absorption of the middle and inner coat (Hasse, 18), and thus escape into the current of the blood, leaving small ulcers behind them. Sometimes the two changes go on CLASS III.] ARTERITIS. 223 simultaneously in the same patch. This deposit is found most frequently in the aorta, especially near its arch, and in the great vessels which put out from that trunk, especially near their commencement. There seems to be no rea- son to suppose that it is the product of inflammation, as no marks of this condition necessarily attend its origin. By the aid of the microscope, it has been found to consist of oily or fatty matter, which is said to be deposited from the blood, and not to result from a change of the tissue itself, which, though broken up and disintegrated, has become so by the compression made upon it, and the interruption of its nutrition. (Hanfield Jones, Brit, and For. Medico-Chirurg. Rev., April, 1853, p. 264.) Its effect, in the small arteries, is sometimes to produce obstruction; in the larger, to weaken then: coats so that they yield to the force of the circulation, or to accidental vio- lence, thus giving rise to aneurism, or to rupture and hemorrhage. Tubercles, and small abscesses from ordinary inflammation, are said to exist occasionally between the coats of arteries, and to produce ulcers by opening into the cavity of the vessels. They are, however, very rare, and it may even be doubted, whether, in the cases observed, they were not identical with the atheromatous deposition in some of its stages. Ulceration.—This is frequently observed as a consequence of the above derangements. It is said to result most frequently from the detachment of the cartilaginous scales from the surface of the vessels, from openings made through the inner coat by the atheromatous matter, or from irritation and in- flammation produced by the calcareous deposits. The ulcers vary in size from that of a mustard-seed to that of a split pea, are sometimes superficial and sometimes deep, and occasionally perforate all the coats of the artery, giving rise to fatal hemorrhage. They are also occasionally the first stage in the formation of aneurisms. Hasse states (Descriptions, &c, p. 81) that the ulcers are confined almost exclusively to the abdominal aorta. Some- times the ulcers produced by the disappearance of the atheromatous matter heal, leaving scars. (Ibid., p. 79.) Ulceration is sometimes propagated to the arteries from disease in neighbouring parts, such as abscesses, wounds, and ulcerous affections, whether simple or malignant. The morbid conditions above enumerated are seldom found separate. Often several of them are united in the same vessel; and thickness, fragility, and ulceration of the coats, may be found in association with the cartilaginous scales, the atheromatous deposit, and osseous degeneration. Causes.—The causes are, in many instances, not less obscure than the symptoms. It is known that various kinds of violence, as wounds either acci- dental or surgical, the tying of arteries, and sudden and great elongation of the vessels, sometimes produce arteritis. That it may originate in the vessels of parts inflamed or suppurating, and thence be carried towards the heart, has been already stated. Cold probably sometimes causes it, and it is highly probable that it may result from acrid and poisonous substances, Avhich have found an entrance into the blood-vessels by absorption or otherwise. Perhaps the abuse of alcoholic liquors may operate in this way, as well as by sustain- ing an excessive action of the heart. The disease is thought also to have arisen from repelled eruptions, and the metastasis of gout and rheumatism. Anything which has a tendency to over-excite the circulation, and thus dis- tend the blood-vessels, or subject them to an extraordinary impulse, may be looked upon as giving a predisposition to it. Hypertrophy of the heart may act in this way. Gouty and rheumatic subjects are thought to be peculiarly liable to the disease. It is probable that an inflammatory constitution of the blood Avould act as an especial predisposition. Adults are more apt to be affected than children. Of chronic arteritis one of the most frequent causes is probably the pre- 224 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. sence of morbid deposits, as of tuberculous, steatoraatous, and calcareous mat- ter, which act as irritants to the parts around them. This would be equally true, whether these deposits be considered as themselves originating from inflammation, or as the result of some other morbid process. Treatment.—Whenever the existence of arteritis can be well made out, if attended with the ordinary symptoms of inflammatory excitement, it should be treated by general and local bleeding, carried as far as the strength will bear. Saline cathartics, with the antimonials and other refrigerants, maybe given internally; the patient should be kept at perfect rest in the horizontal position; all compression of the limb or part affected should be carefully guarded against; and the whole antiphlogistic regimen should be adopted. Local bleeding is best effected by leeching along the course of the inflamed vessel. This may be followed by fomentations or cataplasms, and, ultimately, by blisters or pustulating applications. Should the disease not yield to de- pletion, recourse should be had to the mercurial impression. Calomel may be employed for this purpose, combined with opium, hyoscyamus, or other anodyne, to relieve the pain and restlessness. After gangrene has occurred, it will be necessary to support the system, until the processes requisite for the repair of the mischief shall have been completed. Article II OSSIFICATION OF THE ARTERIES. This term has been applied to that condition of the arteries, in which, in consequence of the presence of earthy or calcareous matter, they possess a firmness aud hardness analogous to that of bones. It has been questioned whether the new structure is really an osseous growth, or merely the result of a deposition of earthy matter in the pre-existing tissues. In favour of the former opinion is the fact, that, when these concretions are macerated in dilute muriatic acid, a portion of animal matter is left, having the appearance of organized parenchyma. But this may be merely the tissue in which the earthy substance was deposited. Brande found the bony laminae to consist of 65 5 per cent, of phosphate of lime, and 34 5 of animal matter; and, ac- cording to Dr. Hope, the proportion of the latter constituent is, in some in- stances, considerably less. This is not exactly the constitution of bone. Be- sides, in the atheromatous formations spoken of in the last article (page 222), it has been shown that calcareous particles exhibit themselves at first in small numbers, and gradually increase until they supplant the original pultaceous deposit. The affection is readily recognized by the hardness and diminished com- pressibility of the vessels under the fingers.. In the earliest stage, the de- parture from the healthy state is slight, and the sense imparted to the touch by the artery is rather that of cartilage than of bone. The firmness, however, gradually increases, until at length not unfrequently pulsation can be felt no longer, and a bony cord seems to have taken the place of the elastic tube. All parts of the arterial system, carrying red blood, are liable to this degene- ration. It is exceedingly rare in vessels which convey venous blood, though calcareous deposits have been in some instances noticed in the pulmonary artery. Dr. Hope, however, states that, of a thousand cases in which he had examined this vessel, he had never met with such a deposit in a single one. The affection is most frequent in the aorta, and, after this, in its larger divi- sions. It is stated to be more frequently met with in the ascending portion CLASS III.] OSSIFICATION OF THE ARTERIES. 225 and arch of the aorta than in any other part of that vessel. It is more com- mon in the lower extremities than in the upper. The ossification is usually partial, occupying but a small proportion of the vessels of the body; but sometimes it is almost universal. A case is recorded by Dr. Adams, in the Dublin Hospital Reports, in which no pulsation could be felt in any part of the body, and even the heart offered no other sign of action than a slight undulating sound. Upon dissection, in this case, even the coronary arteries were observed to be ossified, and their cavity quite obliterated for some dis- tance near their origin. The old are much more liable to be affected than the young or middle-aged, and men than women. No age, however, is quite exempt, and the affection has been observed even in infancy. The deposition generally takes place between the middle and inner coats, though the earthy phosphate is asserted to have been observed in the substance of both of these coats, especially of the former. At first, it occurs here and there, and often at distant points, in small plates or scales, which increase in number, and at length coalesce, forming patches of considerable extent, and sometimes complete bony tubes. The plates are sometimes marked by the annular fibres of the middle coat, with which they are in contact. Causes.—Ossification of the arteries has been ascribed to chronic inflam- mation, but altogether without proof. If marks of inflammation have some- times been observed in the ossified vessel, they have more frequently been quite wanting, and, when present, have much more probably been the result than the cause of the change of structure. It is not impossible that inflam- mation may sometimes determine a deposition of calcareous matter; but it is not the ordinary or necessary cause. Dr. Hope thinks that over-distension of the arteries produces a condition favourable to this species of degeneration, and adduces the following among other reasons; that the affection is most common when the left ventricle of the heart is hypertrophied, that it is more frequent in men than in women, who are less exposed to severe muscular exertion, and that it is most apt to attack the vessels most liable to disten- sion, as the arch of the aorta, and the arteries of the brain. (Cyc. of Pract. 3fed., Art. Arteritis.) It is probable that gout and rheumatism may favour calcareous depositions in the arteries, as in other parts of the body. In this case, the result is to be ascribed rather to vitiation of the blood than to vas- cular irritation. Old age strongly predisposes to the affection. It is, indeed, so common in old persons, that total exemption is comparatively rare, and the inference might also be drawn, that it is one of the normal results of ad- vanced life. Mr. Crisp has seen elevated soft patches on the coats of the arteries, some of which were advancing to the cartilaginous state with a little ossific deposition, others were half ossified; and he believes that ossification is in general the mere termination of the atheromatous and cartilaginous le- sions. (Treat, on Struct., Dis., &c, of the Blood-vessels, p. 72.) Hasse, hoAvever, denies that the cartilaginous patches ossify. Effects.—Ossification produces inequalities in the inner surface of the artery, and thus exposes particular points to an increased impulse from the current of the blood. The lining membrane, previously weakened by inflam- mation, or thinned by absorption, is readily ruptured. The middle coat is at the same time attenuated and enfeebled, from the pressure of the increas- ing deposition, and in its turn also gives way. The foundation is thus laid for aneurism. Sometimes the whole of the coats are ruptured, and fatal hemorrhage ensues. This is especially apt to happen in the arteries of the brain, from their want of the cellular coat, and the yielding medium in which they are embedded. Inflammation and ulceration of the artery sometimes result from the presence of the foreign matter within its coats; and the con- sequent exudation of fibrin, or coagulation of the blood, produces a complete 226 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. obstruction of the vessel. Hence atrophy or mortification of the parts which depend on the vessel for their blood. Gangrene of the extremities in old people sometimes arises from this cause. The ossified arteries, moreover, can no longer perform their part in the circulation; and may thus possibly contribute to the failing nutrition, and general decay of old age. Atrophy and consequent feebleness of the brain and of the heart have sometimes ap- peared to result from ossification of their vessels. Another injurious effect is an increased risk from surgical operations and accidental violence. There is no known remedy for ossification of the arteries; and our efforts must be confined to measures calculated to obviate its causes, and, as far as possible, its injurious effects. To prevent undue excitement of the heart, and unnecessary stress upon the vessels, are the chief indications; to answer which, mental equanimity, abstinence from stimulants, and the avoidance of strong muscular exertion, are the means most worthy of reliance. Article III ANEURISM. By the term aneurism, as here employed, is meant a tumour containing blood, and formed by the expansion of one or more of the coats of an artery. Scarpa made a distinction between dilatation and aneurism, applying the former name to an expansion of the whole of the arterial coats for a limited extent, the latter, to an expansion of the exterior coat, occurring in conse- quence of a solution of continuity in the inner and middle. In relation to cases in which the entire circumference of the vessel is dilated, there is some ground for the distinction; as certain phenomena characteristic of ordinary aneurismal tumours are wanting in these. But, when the dilatation affects only a portion of the circumference, tumours are formed in no respect dis- tinguishable, during life, from other aneurisms. Besides, in the progress of dilatation, the inner and middle coats not unfrequently undergo a solution of continuity, so that an identity of character is given to the two affections. So close a connection, therefore, exists between dilatation and aneurism, that they may be properly considered under one head. The following remarks apply particularly to internal aneurisms, which, from their position, are be- yond the reach of surgical aid.* The varieties which have been recognized are 1. complete dilatation; % partial dilatation; 3. sacculated expansion of the outer coat with solution of continuity in the two inner; 4. dissecting aneurisms, in which the blood separates the coats ; and 5. hernial aneurism, in which the interior coat protrudes through an opening in the middle. 1. Complete Dilatation.—In this affection, the whole circumference of the artery is expanded equably, or nearly so, and occasionally for a considerable extent. Sometimes the expansion is greatest at a certain point of the vessel, and gradually diminishes in both directions, so as to form a spindle-shaped or ovoidal tumour; and a number of fresh tumours may occur successively along the same vessel. In other cases, the dilatation is equable in the longi- tudinal direction, and consequently has a cylindrical shape. Again, the artery may be lengthened, as well as expanded, thus becoming somewhat tortuous, like a varicose vein; and the term aneurismal varix has been ap- plied to this affection. In dilatation of the artery, the coats sometimes be- * The internal aneurisms bear a large proportion to the whole number. Of 551 cases compared by Mr. Crisp, 288 were of that character, not including those of the carotids and external iliacs. (Treat, on Struct., Dis., £c. of the Blood-vessels, p. 113.) CLASS III.] ANEURISM. 227 come thinner than in health; but, in most cases, they either retain their original or acquire an increased thickness. They are almost always changed in structure; becoming denser, more opaque, and less elastic, or exhibiting some of those morbid depositions noticed under Arteritis and Ossification, with a rough, fragile, or softened state of the lining membrane. Hasse states that, in every instance which has come under his notice, in- cluding as well partial as complete dilatation, the inner surface was covered with semi-cartilaginous patches and false membranes, rendered uneven, soft- ened, or partially exulcerated by atheromatous deposits, and extensively ossified. (Anatom. Descrip., &c, p. 85.) The internal and middle coats are sometimes completely or almost completely destroyed, and their place supplied by these morbid deposits, which, however, may present the appear- ance of the natural coats, of which the middle is represented by the ather- omatous matter, and the inner by the cartilaginous patches, and a delicate, smooth, semi-transparent, false membrane. (Ibid., p. 86.) The predisposing cause of dilatation is probably almost always this altered, inelastic condition of the coats, which disables them, when expanded under the heart's impulse, from returning to their former dimensions when the im- pulse ceases. Whatever tends to accelerate or give increased force to the movement of the blood may prove an exciting cause. Hypertrophy of the left ventricle favours the production of the disease. Vicinity to the heart must have the same effect, as the greatest force is there applied to the blood- vessels. Hence, dilatation is most frequent in the ascending portion and arch of the aorta. It is sometimes, however, found in the larger branches of this trunk, especially those which go off at right angles, and even in the smaller and more distant vessels. It has been met with, though rarely, in the pulmonary artery. The aorta is often dilated to twice its ordinary cali- ber, and occasionally much more. Very large dilatations sometimes present lesser bulgings upon their surface. One of the points in Avhich these dilatations most strikingly differ from the ordinary forms of aneurism, is the want of coagula. The surface is too uniform to impede the movement of the blood, and thus favour its concretion. In some instances, hoAvever, when the inner membrane happens to be ulcer- ated, rent, or otherwise irregular, the blood coagulates upon its surface, forming layers which more or less completely fill the cavity. While the dilatation is small, it produces no observable effect upon neigh- bouring organs; but, when much increased, it may give rise to phenomena of compression, such as result from other aneurismal tumours. Sometimes the two inner coats lose their continuity from fissure, ulceration, or other cause, and the dilatation is converted into a proper aneurism. When the dilatation is considerable, it has been thought to occasion enlargement of the heart, which complicates the phenomena, and increases the danger. 2. Partial Dilatation.—Sometimes that condition of the coats which causes an artery to yield to the force of the circulation is confined to a portion of its circumference, which is consequently the only part dilated. A tumour is thus formed upon the side of the vessel, with which it communicates by an abrupt orifice, usually narrower than the body of the pouch. Such tumours have been repeatedly observed with all the coats of the artery apparently entire; but there is reason to believe that a smooth, false membrane, often found lining the aneurismal sac, has been mistaken, sometimes at least, for the proper inner tunic. They are sometimes denominated true aneurisms, to distinguish them from the following variety, to which, however, as by far the most frequent, the name would seem more appropriately to belong. The blood finfls an easy entrance into and exit from these tumours, but, being somewhat impeded in its passage, is more apt to coagulate than in the pre- 228 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. ceding form of dilatation. The coagula, however, do not generally adhere to the whole interior surface, forming concentric layers, as in the next variety; but appear to be attached by a kind of peduncle to certain parts of the surface, which, from being ulcerated, fissured, or otherwise roughened, en- tangle portions of the blood as it passes over them, and favour its coagulation. These partial dilatations are most frequent in the ascending portion and arch of the aorta, though found in other parts of this trunk, and occasionally also in its branches. They arise usually from the anterior or lateral portion of the aorta, where the vessel is least supported. They are much less fre- quent than dilatations affecting the Avhole circumference. They sometimes attain a great magnitude; but, in this case, the inner and middle coats are generally ruptured, the expansive force is directed against the outer or cellu- lar coat, and an aneurism of the following variety is engrafted upon the original dilatation. The affection thus complicated is called by some a mixed aneurism. In positions where the exterior coat is wanting, the artery bursts without previously forming this kind of tumour. Such is the case with dilatation of the aorta occurring near its origin, where, instead of the usual exterior coat, the vessel is invested with the pericardium. This, being less extensible than the ordinary cellular coating, gives way before the ex- panding force, and the blood escapes into the pericardial cavity. 3. Aneurism from Rupture of the Inner and Middle Coats.—This is by far the most frequent form of aneurism, and the one considered by Scarpa as especially entitled to the name. By many writers it is called false aneu- rism, in contradistinction to tumours arising from partial dilatation, Avhich have been called true aneurisms. In this variety, the interior and middle coats, either from absorption, ulceration, or rupture, give way at some point; and the blood, passing through the opening, presses directly upon the cellu- lar or outer coat, which, being tougher and more expansible, yields to the pressure, and forms a pouch or sac on the side of the artery. The orifice is of various shape and dimensions, but its diameter is generally less than that of the sac. It is not always in the middle of the tumour. The caliber of the artery is almost always diminished below the orifice. The tumour gradu- ally increases with the continuance of the distending force. Its walls, in- stead of being rendered thinner by the distension, take on increased nutritive activity, and become thicker, denser, and more resistant, so as sometimes to be fibrous or even fibro-cartilaginous. The tissues pressed upon by the tu- mour are either absorbed, or stretched over its parietes, with which they are sometimes incorporated, giving them increased thickness and strength. No structure has been found permanently to resist its progress. Even bone gradually yields, being absorbed, or worn away by the attrition of the blood, which, in consequence of the absorption of the periosteum, and the adhesion of the sac to the circumference of the denuded portion of the bone, sometimes plays directly upon its surface. The periosteum is sometimes absorbed, sometimes incorporated with the walls of the sac. In the latter case, it is said to secrete earthy matter, which serves to increase the strength as Avell as the bulk of this morbid structure. The viscera of the chest and abdomen, as the heart, lungs, stomach, liver, &c, are frequently forced out of their place by the augmenting tumour, or undergo a partial absorption to make room for it. Cartilage opposes the greatest resistance, being little if at all af- fected ; and portions of this tissue occasionally remain, after the bones to which they were attached have disappeared. The tumour at length fre- quently approaches the surface, and becomes obvious to inspection. In the mean time, changes have been going forward in the interior of the sac. Al- most from its commencement, the blood in contact with its rough internal surface coagulates, and successive fibrinous layers are formed, which are dis- CLASS III.] ANEURISM. 229 posed concentrically, and often fill up a large portion of the cavity. It is probable that inflammation of the surface of the sac favours this tendency to fibrinous deposition. The layers have been found to be light-coloured, and dense in proportion to their vicinity to the wall of the tumour; those near- est it being whitish or yellowish and firm, while the coagula near the centre are soft and blackish-red. The thickness of these layers is commonly from half an inch to an inch and a half, but it has been known to be three and even five inches. Sometimes the coagula, instead of being firm, are remarka- bly soft and fragile, owing probably to the peculiar state of the blood. In the progress of the aneurism, some portion of its covering, in consequence of a greater pressure from within or without, or from some peculiarity in its structure, is absorbed ; and the tissue beyond it, previously condensed by ad- hesive inflammation, supplies its place for a time. This is in its turn absorbed, and thus the sac advances until it reaches the skin or the lining membrane of some cavity, when an opening is effected, and the blood escapes. This happens somewhat differently in the different tissues. When only the skin in- tervenes between the contents of the sac and the external air, the' most prom- inent part assumes a bluish or purplish colour, and at length sloughs. As soon as the dead portion begins to separate, an oozing of blood takes place; and a more complete separation is often followed by a tremendous gush, which nothing can control, and which sometimes produces death almost in- stantaneously. The first portions of blood discharged are accompanied with dark and broken coagula from the sac. The opening of the aneurism into the mucous cavities is effected in the same manner. But when it approaches one of the serous membranes, this is thought to be mechanically ruptured by the distending force, without previous mortification. Hasse, however, be- lieves that the opening is in this, as in the other cases, a vital process. Instead of pursuing the course mentioned, the blood is sometimes effused, through an opening in the sac, into the cellular tissue, not previously consol- idated by inflammation, and then spreads to a considerable distance through this tissue, forming a diffused tumour. Aneurisms of the descending aorta, and of the smaller arteries, are gene- rally of the kind above described. They are said sometimes to originate in a different mode from the one pointed out. Corvisart met Avith encysted tumours beneath the outer coat of the artery, attended with a destruction of the two inner coats. These he supposed might be converted into aneurisms by the softening and discharge of their contents, and the entrance of the blood into the empty cysts; and such cysts have been subsequently seen already opened, communicating with the aorta, by M. Berard. (Did. de Med., iii. 15.) Hodgson, however, maintains that these tumours were the remains of cured aneurisms, instead of the origin of new ones. 4. Dissecting Aneurisms.—This name was given byLjaennee to a form of aneurism, in Avhich the blood, having passed through an opening in the inte- rior and middle coats, afterwards, instead of forming a prominent tumour by the distension of the outer coat, diffuses itself between this and the middle, along the course of the artery. Sometimes the blood re-enters the vessel by another opening ; and the portion of artery, intervening between the points of exit and re-entrance, may become obliterated. Several cases of this kind of aneurism are recorded by Dr. Pennock, in his edition of Dr. Hope's Treatise on Diseases of the Heart (Am. ed., A. D. 1842, p. 402). In one of these, under the care of Drs. Pennock and Goddard, the dissection of the aorta by effused blood extended around nearly its whole circumference, and throughout its length, beginning near the semilunar valves, and terminating in a cul-de- sac at the bifurcation into the primitive iliacs; so that the aorta appeared like a double artery, one tube being inclosed within the other. From an ex- 230 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. amination of this and other pathological specimens, and from the fact, ascer- tained by experiment, that the middle coat of the aorta consists of layers less firmly connected together than the outer coat is with the surface of the middle, Dr. Pennock was led to the conclusion, that, in dissecting aneurisms of considerable extent, the blood will be found not between the middle and exterior coats, but between the laminae of the middle coat. This explains the otherwise not readily explicable phenomenon, that the outer coat, usually so readily extensible, resists in these cases the force of the circulation, and con- fines the blood to the course of the artery. It is aided by the greater firm- ness and elasticity of one of the laminae of the middle coat. 5. Some cases are on record of another variety of aneurism, in which the middle or fibrous coat is ruptured, while the inner one remains entire. The latter is forced by the blood through the opening in the former, and thus produces a sort of aneurismal hernia. Such cases are very rare ; nor can the tumour ever attain a great magnitude without rupturing the inner coat, and thus being converted into the common aneurism of the third variety. In- stances have occurred of another kind of aneurismal hernia, in which the cellular coat has given way, and the inner and middle coats project. Effects of Aneurisms.—From all the varieties of aneurismal tumours the most serious consequences usually result. By pressure on the neighbouring organs, they materially derange their functions, and not unfrequently occa- sion organic changes of a dangerous and often fatal character. Not only does the organ immediately compressed suffer, but also distant parts and functions, which depend for their due condition upon the healthy state of that organ. As examples of these effects may be adduced, pressure upon the air-passages, producing dyspneea; upon the oesophagus, dysphagia; upon the heart, dis- placement of that organ and great disorder in its actions; upon the lungs, congestion, inflammation, pulmonary hemorrhage, and oppressed breathing; upon the arteries, obliteration of their cavities and consequent atrophy or gangrene in the dependent parts ; upon the great venous trunks, venous con- gestion, oedema of the face and limbs, and, when the descending cava is com- pressed, congestion of the brain, and even apoplexy; upon the thoracic duct, general atrophy and oedema; and upon the nervous centres or the nerves themselves, the most excruciating pains, innumerable disorders of sensation, motion, and other functions, and sometimes paralysis. In the abdomen, the functions of the stomach, bowels, liver, and urinary apparatus, are in different cases very seriously interfered with. The bones affected are chiefly the ster- num, ribs, clavicle, vertebrae, and scapula. By absorption of the bony case of the spinal marrow, and consequent irritation of this nervous structure, the most intense disturbance has been created in various functions depending for their healthfulness upon its integrity. Patients are not unfrequently de- stroyed by complicated suffering, and various functional and organic derange- ment from these causes, before the tumour has opened. Another effect, which aggravates the symntoms greatly, is a hypertrophied state of the left ventricle of the heart, which is a frequent attendant upon internal aneurisms, especially those of the ascending aorta and arch, being induced probably by the incessant stimulus extended to that organ by the embarrassed condition of the circulation. When the patient escapes these dangers, he is exposed to the utmost hazard from the rupture of the sac into one of the internal cavities. This sometimes takes place at a comparatively early stage, before the aneurism has become so far developed as to call attention to its existence. The first intimation of the disease is occasionally that afforded by dissection. The sac may open into the trachea or bronchia, producing copious haemoptysis, or overwhelming the lungs; into the oesophagus, giving rise to haematemesis; into other arteries, CLASS III.] ANEURISM. 231 the veins, or even one of the cavities of the heart, causing great derangement of the circulation ;* into the posterior mediastinum, and the pleural or pericar- dial cavities, fatally oppressing respiration and the action of the heart. In the abdomen, it may open into the peritoneal cavity, the stomach, intestines, or bladder. In most of these cases there is a twofold danger, that of sus- pension of one of the vital functions from the pressure of the effused blood, and that of exhaustion from its loss. A singular mode of fatal termination of an aneurism of the aorta recently occurred to myself in a patient in the Pennsylvania Hospital. A large col- lection of pus had formed in the aneurismal sac, which was discharged into the trachea, suffocating the patient, without any hemorrhage, which was pre- vented by the adhesion to the walls of the sac of the coagulum by which it Avas filled, below the abscess. (See for a report of this case the Am. Med. and Surg. Journ. for July, 1858.) Finally, should death result in neither of these modes, the tumour ulti- mately reaches the surface, and terminates life by external hemorrhage. The bleeding, whether internal or external, after the opening of the sac, is not always so copious as might have been anticipated. Sometimes it is restrained by the smallness of the cavity into which the blood escapes, sometimes by the narrowness of the opening, and adhesions formed around it, and some- times by the fibrinous depositions and coagula contained in the sac itself. The duration of the disease is very various. It may last only a few weeks or months, or may continue many years; and not unfrequently patients die of other diseases during the progress of this. NotAvithstanding these numerous dangers from internal aneurism, it is not necessarily fatal. Cases of cure have been recorded ; and the affection some- times terminates favourably without aid. Spontaneous cures take place in various modes. Sometimes the sac is completely filled by the deposited fibrin and coagula, and, being no longer distended by the blood entering it, gradu- ally contracts, undergoes absorption, and terminates at length in a small fleshy tumour attached to the artery ; the caliber of the vessel being usually oblite- rated if small, but remaining pervious if large, especially in the aorta. It is said that, even in dilatation, layers of coagulated blood, concentrically ar- ranged, sometimes fill up the expansion, leaving a smooth canal in the middle, of the size of the arterial caliber. Another possible mode of termination, though in relation to internal aneurism, it must be very rare, is the oblitera- tion of the artery above the orifice of the sac, by the pressure of the tumour upon it. Finally, inflammation or gangrene may come on in the sac, attended with effusion of fibrin and coagulation of blood so as to obliterate the artery; and the patient may ultimately recover, provided the parts below the tumour can be sufficiently supplied with blood by the anastomosing vessels, and pro- vided also there be sufficient vigour of constitution to sustain the long and exhausting processes of inflammation, sloughing, suppuration, granulation, &c, through which the diseased parts must pass in their return to health. Causes.—A diseased condition of the arteries is probably essential to the production of aneurism. It is doubtful whether any amount of force which the heart is capable of exerting, or any degree of mechanical injury, could directly induce aneurism such as Ave have described it, in an artery previously in perfect health. The inner or middle coat, or both coats may be ruptured; but, if the vessel is quite sound, there is reason to believe that coagulable lymph will be thrown out, and the injury repaired. The true causes of aneurism, therefore, are such as induce a morbid state of the arteries ; whether * Cases are on record in which aneurisms have opened into the right ventricle and right auricle, and into the pulmonary artery. 232 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. this consists in an altered condition of their proper tissue, or the deposition of new substances upon or Avithin their coats, such as atheromatous, cartilagin- ous, calcareous, or tuberculous matter. These causes and their results have been already sufficiently considered under arteritis, and ossification of the arteries. Syphilis has been supposed to occasion a softness of the arteries, and ulceration of their inner coat, favourable to the production of aneurism. The same may probably be said, with even more truth, of habitual intemper- ance, at least so far as concerns its effect upon the cohesion of the vascular tissue. There appears to be some affinity between aneurism and cancer. The aneurismal diathesis is seldom overcome. When one tumour disappears, an- other is apt to form in the same or a distant artery. The aspect of the patient, moreover, is frequently analogous to that so commonly observed in cancerous disease. (Rokitansky, quoted by Hasse, Anat. Descript., p. 95.) When the arteries are thus diseased, even the ordinary force of the circula- tion may bring on aneurism ; but whatever increases this force, whether ha- bitual or accidental, will hasten the occurrence of the affection, and render its progress more rapid. Hence, hypertrophy of the heart, the use of stim- ulants, and all excessive excitement, whether mental or bodily, may rank among the exciting causes. Tight lacing may have the same effect by pro- ducing irregularity in the caliber of the vessels, and exposing certain parts to greater distension than others. External violence, and especially such as occasions a sudden elongation of the artery, would be apt to rupture the coats already diseased, and thus bring on an immediate attack. Some of these causes act doubly, both as predisposing and exciting. Thus, a constant over-distension of the vessels by excessive action of the heart, may induce, in the end, either through an exhaustion of their excitability, or the produc- tion of chronic arteritis, a state of their coats favourable to aneurism, while it may directly bring on the complaint after the predisposition has been estab- lished. This'view is confirmed by the statement of Dr. W. S. Kirkes, made after a comparison of very many cases of disordered heart and arteries, that hypertrophy of the left ventricle, without enlargement of the valves, is very generally attended with disease of the aorta. (Med. Times and Gaz., Aug. 1857, pp. 110 and 135.) The position of the artery is not without influence in relation to its liability to aneurism. Vessels near the heart, or most ex- posed from their shape to the force of the current of blood, or from their position to external violence, are most apt to be affected. Men are much more liable than women, because more exposed to violence, over-exertion, intemperance, and other causes. Mr. Crisp states that, upon a comparison of upwards of 500 cases, he found the proportion of females rather less than one-eighth. The disease is very rare in infancy. General Diagnosis.—When the disease has made its way externally, and appears in the form of a tumour upon the surface, it may generally be distin- guished without difficulty. The tumour is usually roundish, with a greater prominence at one point; is soft and compressible, returning to its original shape upon the removal of the pressure; and pulsates under the finger, and sometimes visibly to the eye. Pulsation, synchronous with the action of the heart, is the most characteristic symptom of aneurismal tumours. It is of a somewhat peculiar quality, slow, expansive, and heaving, as if the whole tumour was enlarging under the hand. It may, moreover, be felt in all parts of the swelling. If the artery be compressed above the tumour, its bulk diminishes and the pulsation ceases; if below, the force of the pulsation is increased. Sometimes, however, from thickness of the walls of the sac, or the great quantity of coagulated blood contained in it, there is little or no pulsation, and the tumour scarcely yields to pressure. The same is to a cer- tain extent the case when the blood has been effused into the cellular tissue. CLASS III.] ANEURISM. 233 But, even in these cases, a careful examination will almost always detect pul- sation in some part of the swelling, at one time if not at another; and, if the fingers fail, recourse may be had to the stethoscope, which will reveal the pulsation, and frequently also render sensible a rasping or bellows sound in the tumour. Swellings which are not aneurismal sometimes pulsate in con- sequence of being situated over an artery, or connected with it, so as to be influenced by its movements. But, if they are solid, there can be little diffi- culty in distinguishing them. The pulsation is elevating instead of being expansive, and ceases if the tumour be separated from the artery by raising it. Nor will the tumour undergo any change by pressure on the artery be- tween it and the heart. Collections of liquid diffused around an artery might occasion more difficulty in the discrimination. In such cases, a just inference may generally be drawn from the circumstances attending the origin and pro- gress of the tumour. In relation to the signs of aneurism, while still con- fined Avithin the great cavities, I shall treat under the head of aneurisms of these cavities respectively. It is sufficient here to say that none of the gene- ral symptoms are absolutely conclusive, unless the tumour can be felt; and certainty can be attained only through the medium of the physical signs afforded by auscultation and percussion. Internal aneurisms occupy either the cavity of the cranium, that of the thorax, or that of the abdomen.* In relation to the first, little can be known of them during life, except conjecturally; and even for conjecture there is scarcely any plausible ground; for all the symptoms which they produce much more frequently arise from other causes. Dissection has occasionally revealed aneurismal enlargements, or more strictly dilatations of the carotid, vertebral, and basilar arteries; and death, with apoplectic symptoms, has resulted from their rupture. Indeed, from the deficiency of the cellular coat, they are peculiarly liable to rupture when dilated. Headache, vertigo, and tinnitus aurium, are among the symptoms which precede the attack of apoplexy in which they terminate. Possibly, auscultation may yet succeed in penetrating these mysteries, and surgical aid may be brought to the rescue of the patient. Indeed a case has been recorded by Dr. Whitney, of Newton, Massachusetts, in Avhich a harsh bellows murmur was perceived by applying the ear to the cranium, and an aneurism of the basilar artery Avas found upon dissection after death. (Am. Journ. of Med. Sci., N. S., vi. 314.) Our attention here will be confined to the two other cavities. Thoracic Aneurisms. All the considerable arteries of the chest are liable to aneurismal disease in some one of its forms. So long as it is confined within the bony walls of the cavity, the diagnosis is often exceedingly obscure, and sometimes, with all the aid that modern skill can bring to the investigation, more or less uncer- tain. The general signs can scarcely ever be confidently relied on. They, nevertheless, assist materially towards the forming of a correct judgment, in connection with those afforded by physical exploration. When the aneurism is not so large as injuriously to compress the neigh- bouring organs, it often escapes notice entirely, and, as before stated, may go on to fatal rupture without being suspected. Occasional dyspneea, and vague feelings of pulsation or other irregular action in the chest, are insuffi- cient to excite alarm. As it increases, however, and even almost from the * As to the relative frequency of these aneurisms, Mr. Crisp states that, of 288 cases, 175 were of the thoracic aorta, 2 of the pulmonary artery, 20 of the innominata, 23 of the subclavian, 59 of the abdominal aorta and its branches, 2 of the common iliac, and 7 of the cerebral arteries. (Treat, on Struct., Dis., $c. of Blood-vessels, p. 113 ) VOL.11. 16 234 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. commencement, in certain cases, it gives rise to various disorders of function, which, though perhaps few and slight at first, augment in number and de- gree, till they sometimes acquire a fearful intensity. The symptoms about to be enumerated never all occur together in the same case. Some cases are attended with one set of them, others by another, according to the situation and size of the tumour. Among the most common is a feeling of tightness, fulness, or oppression of the chest, resulting from the presence of a new body within a space already filled. Respiration is sometimes attended with a harsh, wheezing, hissing, or stridulous sound, proceeding from the chest; while ♦ the voice is hoarse, croaking, or whispering, owing to pressure upon one or more of the larger bronchial tubes or the trachea, or to irritation or injury of the recurrent nerve.. The alteration of the voice is sometimes so striking, and the dyspneea so great, that practitioners have supposed the larynx to be diseased, and have even performed tracheotomy. The absence, however, of pain upon pressure in the larynx, of swelling in the vicinity, and of redness of the fauces, taken in connection with the mode of attack, and the simultaneous and antecedent pectoral symptoms, will enable a just conclusion to be formed on this point. The breathing is often hurried and laborious, and sometimes attended with paroxysms of dyspneea like those of spasmodic asthma. Cough in various degrees is very common, sometimes troublesome and even violent and convulsive, with haemoptysis, or bloody expectoration. In consequence of pressure upon the bronchia, there is occasionally feebleness of respiration in one lung; and this is considered by Dr. Stokes, when not explicable by the presence of a foreign body in the air-passages, or other discoverable pec- toral disease, as a sign of great importance. It may result from a small tumour insufficient to cause pulsation, dulness, or stridor in breathing. The above symptoms, with various others, as palpitations, disposition to syn- cope, pallid, livid, or purplish complexion, oedema of the face and limbs, swelling at the lower part of the neck, dropsy of the serous cavities, oppres- sion of the brain, a varicose or distended state of the external veins of the chest, &c, arise partly from pulmonary congestion or inflammation excited by the tumour, partly from its pressure upon the venous or lymphatic trunks, but still more from disease of the heart, so frequent an attendant upon aneu- rism, and often one of its consequences. Congestion of the liver and whole portal circle, and of the brain amounting even to apoplexy, has resulted from compression of the ascending and descending vena cava. Another occa- sional symptom is greater or less difficulty in swallowing, and in the eructa- tion of gases, resulting from compression of the oesophagus, which, without care, may lead to the notion of the existence of stricture in this tube, and the consequent use of the bougie or probang. I have had a case in which excessive dyspnoea was induced by every attempt to swallow food, owing, as was proved upon dissection, to an aneurismal tumour pressing immediately on the trachea in front of the oesophagus. Pain of various degrees and character is often felt in the chest, sometimes vague and dull, sometimes acute, lancinating, and exceedingly severe, shooting, in different directions, from the middle of the cavity or from the back towards the diaphragm, neck, shoulders, and arms, especially the left arm, which is not unfrequently affected with formication, and partial loss of sensation and motion. The pressure of the tumour upon the spinal column, and the brachial plexus, is sufficient to account for these symptoms. Deep-seated and excruciating pains, of a boring character, are said to attend the wearing action of aneu- risms upon the spine. The pulse is frequently much deranged. When the aneurism intervenes between the heart and the arteries of the arm, the vibratory motion received by the blood in its passage must be extended more or less to the artery at the CLASS III.] ANEURISM. 235 wrist. Hence the thrill so often observable in the pulse in aneurisms of the chest. The pulse at the wrist is often different on the different sides, and is sometimes quite wanting in one arm, in consequence of compression or ob- struction of the innominata or left subclavian. From a degree of the same cause, the pulsation at one wrist has been observed, in some cases, to be con- siderably later than that of the heart. Dr. Billing has indicated a resilience of the pulse, depending on that of the aneurismal tumour, after each beat of the heart, as a means of detecting aneurism in its early stages; and Dr. Joy has suggested that the simultaneous presence of this character in the pulse of the upper and lower extremities, or its presence in the latter and absence in the former, might be an index of the position of the affection, in the one instance, near the origin or at the arch of the aorta, and in the other, at some point in the vessel below the origin of the left subclavian. (Tweedie's Syst. of Pract. Med.) Numerous other irregularities of the pulse frequently ac- company aneurisms, but they depend more commonly on the coexisting dis- ease of the heart, than on the arterial affection. The attitude of the patient will assist in the diagnosis. In consequence of the necessity of alleviating by position, as much as possible, the pressure of the tumour upon the air-passages, he generally prefers some one posture, to which, though he may frequently change it from restlessness, he is always disposed to return. This is different in different cases. The most common attitude is that of sitting, with the head bent forward, or to one side. Some find greater ease on one side than the other, and some even incline the body backward. The necessity of giving free scope for expansion of the chest, in consequence of effusion or other source of embarrassment to the respiration, is probably even a more cogent reason for the erect position. Dulness on percussion over certain parts of the chest, especially the middle and upper, often exists in cases of thoracic aneurism, though, according to Dr. Hope, not unless the tumour is larger than an egg. Sometimes the out- line of the tumour may be pretty accurately defined in this way. If the hand be applied over the middle or upper part of the sternum, a vibratory thrill may sometimes be felt, similar to the motion of a purring cat; and the same sensation is produced above the clavicles. This purring tremor, as it is called, sometimes results from mucus in the bronchia; but, in this case, may be readily distinguished by ceasing when the patient holds his breath. It is more observable, according to Dr. Hope, in simple dilatation than in sacculated aneurism; and is ascribed by him to the asperities of the inner surface so common in the former affection. But none of the foregoing phenomena is so characteristic as pulsation, distinct from that of the heart, and felt beneath the ribs or sternum at the upper part of the chest, or above the sternum and clavicles In order that it may be sensible in the latter position, it may be necessary to press the fingers down as deeply as possible, with the head of the patient bent forward. By pressing with the palm of one hand anteriorly on the chest, and with that of the other posteriorly, and by making the examination at the end of a full expiration, the impulse may sometimes be felt, when it would otherwise es- cape notice. (Stokes.) In thoracic aneurisms the impulse is usually double, a fact which is, I think, best explained by Dr. R. D. Lyons, of Meath. That this result should take place, it is necessary, according to Dr. Lyons, that the aneurism should be sacculated. The wave of blood sent forth by the sys- tole of the heart produces the first pulsation; the elastic contraction of the aorta wich follows, and which is not participated in by the sac, produces the second. (Dublin Quarterly Journ. of Med. Sci, ix. 344.) A throbbing of the aorta from mere functional disturbance, as from the irritation of gout, 236 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. may be mistaken for a time for the aneurismal impulse; but its subsidence and ultimate disappearance under treatment would correct the error. Evidences of Auscultation.—The stethoscope renders the pulsation more sensible to the ear, and at the same time reveals a peculiar sound in the aneurismal tumour. This, as described by Dr. Hope, is a deep, hoarse, bel- lows murmur, more or less rasping or grating, of short duration, and with an abrupt commencement and termination ; but the fact is, that it varies greatly in different cases, being sometimes closely similar to the first sound of the heart, sometimes very feeble, and not unfrequently wanting. When this sound is perceived, at a distance from the heart, it affords presumptive evi- dence of the existence of an aneurism. But the diagnosis is still not without its difficulties. The sounds of a diseased heart, and, in some thoracic affec- tions, those of the healthy state, are often to be heard over a considerable ex- tent of the chest, and might be mistaken for the sounds of an aneurism. The difficulty is less when the aneurismal sound is single ; but not unfrequently, these tumours, especially the thoracic, imitate the heart by offering a double sound, which tends to confuse the diagnosis. Dr. Hope, however, has sug- gested considerations which diminish, if they do not remove the difficulty. The aneurismal murmur is generally different from the first normal sound of the heart with which it is synchronous, and even from the murmurs produced by valvular disease of that organ. These are usually not so loud as the aneurismal sound, are less hollow and more prolonged, and have a gradual rise and fall, instead of the abruptness of the latter. The depth and hollow- ness of the aneurismal murmur are usually greater above the clavicles than below. If the sound be traced in a direction from its origin towards the apex of the heart, it is found gradually to diminish, and, at the distance of an inch from the apex, either to have ceased entirely, or to be feeble and re- mote ; while the sound' of the heart is loudest at that point, and diminishes as you recede from it. This remark is true both of the healthy sound of the heart, and of the morbid sound or murmur proceeding from regurgitation through the auricular valves. In relation to the murmur arising from ob- struction at the semilunar valves, there is greater difficulty. This murmur is propagated two inches or more along the aorta or pulmonary artery, as the case may be ; but it has been shown that, if louder and on a higher key, at this distance from the origin of the vessel, than opposite to the semilunar valves, the sound is owing to dilatation, aneurism, or roughness in the inner surface of the vessel; and if, supposing a tumour to exist at the side of the sternum, the murmur should be loud and distinct on the outer or humeral side of the tumour, the inference is justifiable that it is aneurismal; for the semilunar murmur is very feeble or quite inaudible at so great a distance from the course of the artery. When the first sound of the aneurism can thus be distinguished from that of the heart, the absence or presence of the second is of little importance. The first aneurismal sound is ascribable to the friction of the blood, trans- mitted from the heart, against the orifice and sides of the sac. There has been considerable difference of opinion in relation to the cause of the second sound. Sometimes it has been thought to be a murmur from the semilunar valves propagated along the column of blood in the artery, in which case it could be traced back Avith a progressive increase of intensity to its origin. In other instances, it has been ascribed to a regurgitation of blood from the aneurismal tumour during the diastole of the ventricle. In this case, it would be distinguishable from the valvular murmur by its brevity, and by not being audible down the course of the ventricles; and would add to the evi- dence of the existence of an aneurism. Dr. Bellingham ascribes it to the regurgitation into the aneurism of the blood from the aorta and great vessels CLASS III.] ANEURISM. 237 putting off from it. There can be no doubt that it proceeds from the same movement which produces the second impulse; and, consequently, Dr. Ly- ons' explanation is that which seems to the author most satisfactory; name- ly, that the two sounds are owing, the first to the systole of the heart, the second to the contraction of the aorta following its expansion, each move- ment driving blood into the sac. The aneurismal sound, though when distinct it has generally somewhat of the character above assigned it, is sometimes softer and sometimes harsher, and varies also in its pitch. In old aneurisms, with thick walls, and filled with fibrinous deposit, the sound is remote and dull,* Both the aneurismal murmur and the purring tremor are said to be stronger, when the blood-vessels are imperfectly filled, or contain a watery blood, than when in their healthy state in these respects. Hence they should be more observable in aortic regurgitation and anaemia. Another auscultatory sign of aneurism is a bronchial sound in respiration, heard sometimes at a considerable distance from the course of the aorta, on both sides of the chest, arising from narrowing of the trachea by the pressure of the tumour; and to a similar cause may be ascribed a certain harsh sonorous inspiration heard in distant parts of the chest. When these phenomena are observed, and can be traced to no other cause, they may be very probably re- ferred to a tumour pressing upon the trachea. Whether it is aneurismal or not must be determined by other considerations. In a case which recently oc- curred to me, the bronchial sound referred to, and a slight dulness on per- cussion, were the only signs of an aneurism, proved to be such by examina- tion after death. In a considerable proportion of cases, the physical signs are quite wanting, and the physician is thrown upon the general symptoms for a doubtful diagnosis. Aneurisms of the Aorta.—The aorta is by far the most frequent seat of thoracic aneurism, and the part of this vessel oftenest affected is the arch, and the upper portion generally. Near the origin of the vessel, wrhere it is covered with the pericardium, the disease is very rare. The investing membrane is too firm to be distended under the pressure of the blood, and, if the two inner membranes are ruptured, instead of dilating, it usually bursts, and the blood is poured into the cavity of the pericardium. A very few cases of sacculated aneurisms have been observed in this part of the artery. They are said to have a tendency to expand towards the heart, and the sac has been observed, in some instances, to be actually imbedded in its parietes. When the disease occupies the ascending portion, or the arch, pulsation is felt above the sternal ends of the clavicle, on both sides simultaneously. If the ascending portion exclusively is affected, though felt on both sides, the pul- sation is stronger on the right. If the disease be a simple dilatation, affecting the whole circumference, the pulsation is not felt upon the sternum or ribs, un- * Some interesting observations have been made by Dr. Bellingham in relation to the sounds of aneurism of the arch of the aorta, for an abstract of which the reader is re- ferred to the Am. Jour, of Med. Sci., N. S., xvi. 442. The more important inferences of Dr. Bellingham are, that aneurisms of the arch of the aorta are characterized by a double sound, which closely resembles the double sound of the heart; that either of these sounds or both may be replaced by a murmur, which may be either blowing, sawing, or filing in character, according to the condition of the surface in contact with which the blood flows; and that the first sound is thus much more frequently super- seded than the second, because of the greater force with which the blood is transmitted. All the sounds arise from friction of the blood against the orifice or walls of the sac, and the murmurs differ from the proper aneurismal sounds only from the roughness of the surface increasing the friction. It certainly seems to have been shown that Dr. Hope attaches too much importance, so far as aneurisms of the arch of the aorta are concerned, to the peculiar character of the murmur. 238 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. less the distension be very great. The purring tremor is sensible above the clavicles and not beloAv. A hoarse aneurismal murmur synchronous with the pulse is also perceived above the clavicles. It is said to be louder than in sacculated aneurism. If the dilatation affects the ascending portion, the sound is louder above the right than the left clavicle, is perceptible along the course of the vessel up the sternum, is of a superficial and hissing or whizzing character, and is usually distinctly audible in the back. Dr. Pennock says that percussion yields a dull sound to a greater extent than in health, along the margin and over the upper third of the sternum, provided emphysema of the lungs does not exist in the vicinity. (Am. ed. of Hope on Dis. of the Heart, p. 426.) General dilatation is usually distinguishable, according to Dr. Lyons, from the sacculated forms of aneurism by the absence of the double murmur. Anaemia is sometimes attended with pulsation and a bellows murmur above the clavicle ; but the impulse is feebler, and the murmur much slighter than in dilatation, and the purring tremor is feeble or wanting. The absence of dulness on percussion in pure anasmia, and the existence of the venous musi- cal murmur would be further diagnostic signs. Aortic regurgitation, accord- ing to Dr. Hope, is often also attended with similar phenomena above the clavicles; but the impulse is more jerking, and the sound not so hoarse as in dilatation; and, besides, there are signs by which this derangement may be discovered if attention be directed to the heart. In sacculated aneurism of the upper portion of the aorta, pulsation is felt on both sides above the clavicle, and generally in a still greater degree below. If the disease is seated in the ascending portion, the pulsation is strongest on the right side ; if in the beginning or middle of the arch, it is strongest above &nd below the right clavicle and about the top of the sternum, with some tumefaction in the same neighbourhood; if at the commencement of the descent, both the pulsation and tumefaction are most observable upon the left, and sometimes extend even to the shoulder. In every case, the pulsa- tion will be found to be stronger over the aneurismal tumour than at a point between it and the heart. Sometimes it is so strong as to produce a percep- tible heaving of the walls of the chest. The sound upon auscultation is of the same general character as in dilatation, but usually weaker and less rasp- ing. In old aneurisms filled with coagula, the sound is dull and remote, and sometimes loudest on the side of the neck opposite to that on which the tumour is situated. The sound may also be heard in the back. The purring tremor above the clavicles is weaker than in dilatation, and in old aneurisms is often wanting. Deficiency in the respiratory murmur, and in resonance upon percussion, is present in proportion to the magnitude of the tumour. When the aneurism is seated in the descending portion of the aorta, the pul- sation is not felt in front, but along the spine, especially on the left side, where the aneurismal murmur is also to be heard, and more loudly than upon the anterior part of the chest. If a sound can be detected along the spine, more abrupt and rasping than that of the heart in front, it is almost a certain proof of the existence of an aneurism. Occasionally, however, both the pulsation and sound in the back are wanting; and the diagnosis becomes very difficult. In this case, if the tumour be seated behind the heart, it is said by Dr. Hope to occasion in that organ a double impulse corresponding with the diastole and the systole, and described as of a jogging character, which results from two other causes only, adhesion of the pericardium, and displacement of the heart to the front of the spine. It is only, however, the existence of a tumour that is thus indicated, and upon other grounds must be based the decision as to its aneurismal character. In relation to sacculated aneurisms of the aorta, it must be borne in mind that various tumours occasionally exist in the chest, CLASS III.] ANEURISM. 239 to which pulsation is imparted by the vicinity of the great vessels. But, in these cases, the aneurismal sound is not perceived, or only in a slight degree, and no pulsation or thrill is to be felt above the clavicle. When the heart is pressed out of its proper position by collections of pus or serum in the pleural cavities, the existence of pulsation in an unusual spot may lead to the suspicion of aneurism. But if, under these circumstances, the pulsation of the heart should be found wanting in the normal position, the difficulty is at once solved. Aneurisms of the innominata, subclavian, and root of the carotid, when very large, are sometimes scarcely to be distinguished from those of the aorta. In relation, however, to the two latter arteries, there is a ground of diagnosis in the fact, that the pulsation, aneurismal murmur, and tremor above the clavicle, are usually confined to the affected side, and are more superficial and distinct than in aneurisms of the arch of the aorta. Dr. Hope compares the murmur of a subclavian or carotid aneurism to the sound of a small hand- bellows, while that of an aneurism of the aorta bears a greater resemblance to the blast of a forge-bellows.* Dilatation of the pulmonary artery is characterized, according to Dr. Hope, by pulsation and tremor between the cartilages of the second and third ribs of the left side, perceptible in a decreasing degree downwards, but wholly Avanting above the clavicle ; by a slight prominence between these ribs ; and by a very loud, superficial, harsh, sawing sound above the clavicles, and over the whole precordial region, but loudest upon the prominence between the two ribs mentioned. When aneurisms make their way out of the thoracic cavity so as to form tumours upon the surface of the body, they appear in positions correspond- ing in some measure with the portion of the artery from which they proceed. Those of the ascending portion and bend of the aorta, appear usually upon the right side of the chest and in front; those of the descending portion, upon the left side and behind. When the tumour appears on the right, at the level of the fifth and sixth ribs, it may be assumed to spring from near the origin of the aorta; when at the level of the third and fourth ribs, from the anterior part of the arch ; when at the root of the neck behind the sternum, from the uppermost part of the arch. (Chomel et Dalmas, Did. de Med.) Abdominal Aneurisms. Not only the aorta, but all the other considerable arteries of the abdomen are liable to aneurism. These tumours have been found, for example, in the cceliac, hepatic, splenic, superior mesenteric, spermatic, and iliac arteries. The general signs of abdominal aneurism, like those of the chest, are such as * Dr. T. S. Holland, of Cork, Ireland, gives the following as the diagnostic signs of aneurism of the innominata, compared with aneurism of the transverse part of the arch of the aorta, with which it may most easily be confounded. They were derived from an analysis of twenty-four cases of the former affection. In aneurism of the innomi- nata, external tumour is more frequent, earlier, and situated above the inner third of the right clavicle, while in that of the transverse arch it is to the left of the sternum or behind it. In the former, the arteries of the right arm and right side of the neck pul- sate more feebly than those of the left; in the latter, the case is reversed. The various affections of the voice, breathing, cough, and deglutition, so common in the aortic aneu- rism, are comparatively rare in that of the innominata. In the latter, pain, oedema, and venous enlargement begin on the right side of the arm and head: in the former, on the left. Partial paralysis of the right arm, and dislocation of the clavicle, trachea, or larynx, are frequent in the innominatal, and rare in the aortic affection. Alteration in the intensity of the respiratory murmur, so common in the latter, is rare in the for- mer. Murmurs in the right carotid and subclavian attend on the aneurism of the inno- minata, the pulsations of which are checked by pressure on those arteries; neither of which facts is true of that of the transverse arch. (Dub. Quart. Journ. of Med. Sci., xiii. 121)6.) ' 240 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. arise from the disturbance of function and organization in the parts pressed upon by the tumour. But, as the parietes of the abdomen are more disten- sible than those of the thorax, the organs have a greater opportunity of re- tiring before the pressure, and therefore suffer less, or at least suffer longer without fatal results. Abdominal aneurisms produce disorder of the stomach and bowels, in the form of dyspepsia, vomiting, colic, constipation, flatulence, &c.; of the liver, in that of jaundice, and hepatitis ; of the kidneys and blad- der, in that of nephritic irritation and inflammation. By pressure upon the nerves which so abundantly surround them, and on the spine in which they occasion caries or absorption, they sometimes give rise to a great diversity of deranged sensation and perverted function, and to the most acute abdomi- nal and lumbar pains, Avhich occasionally shoot doAvnward into the testicle and lower extremities. These also sometimes suffer from spasm, and, with the bladder, are in various degrees paralyzed, in consequence of injury to the spinal marrow. The abdominal derangements from aneurisms are generally attended with less disturbance of circulation, less defect of appetite and nutri- tion, and less general loss of health, than would be expected from an equal amount of suffering and disordered function, proceeding from original disease of the viscera. But none of these can be considered as characteristic symp- toms of aneurism. The latter must be looked for in the physical signs. Perhaps the most distinctive sign of abdominal aortic aneurism is a strong expansive pulsation, much stronger under the stethoscope than the hand, felt over the surface of a fixed and compressible tumour, the outline of which may be traced, by means of the instrument pressed down upon it, ex- tending beyond the line of the aorta. The pulsation is almost always single, though instances have been observed in which it was double. It is constant, and is felt as strongly laterally, or nearly so, as in the forward direction. If the tumour is very large, dulness on percussion will be obvious; and a brief, abrupt bellows sound, less loud and hoarse than that of thoracic aneurism, may often be heard over the course of the artery, in the front of the abdomen, and sometimes in the back. It is more perceptible below than above the tumour, because propagated dowmvard by the course of the blood. It is sometimes wanting. To render it perceptible, when not so under ordi- nary circumstances, it has been recommended to examine the patient in the recumbent posture, with the abdomen elevated above the chest, so as to diminish the pressure of the blood in the abdominal vessels, and thus favour its entrance into and exit from the sac. Sometimes a small artery runs over the sac, and, if pressed on by the stethoscope, yields a murmur which might be mistaken for the aneurismal. It may, however, be easily distinguished by being more superficial, more hissing, confined to one spot, and entirely removable by pressing with the instrument so as to close the artery. Besides the above signs, another is afforded in the vibratory thrill which may some- times be felt by pressing the hand firmly down over the surface of the tumour, and upon the vessel below. In some instances, the tumour is restrained by the crura of the diaphragm, or by viscera beneath which it may lie, and which may have contracted ad- hesions so as to render them immovable. In such cases, it cannot be felt by the hand, and might yield no impulse. But, should general signs lead to the suspicion of its existence, it is possible that this evidence might be con- firmed by the stethoscope applied along the spine. In cases of uncertainty in relation to the existence of a tumour, it has been suggested that, by placing one hand in front of the abdomen and the other on the back, and making pretty firm pressure, a tolerably correct inference might be draAvn from the apparent thickness of the intervening space. Tumours of various kinds existing in the abdomen, and receiving an im- CLASS III.] ANEURISM. 241 pulse from some neighbouring artery, might sometimes without care be mis- taken for aneurism. But the impulse is more feeble and less expansive, and is sometimes scarcely perceptible when the stethoscope is applied laterally, as may be done most conveniently by placing the patient on his side. If the tumour is displaced either laterally or anteriorly, the impulse will cease. The anterior displacement may be aided by causing the patient to support himself on his knees and elbows. Should the tumour, when removed from its position, still pulsate, the inference would be that it was an aneurism of one of the smaller arteries. The absence of aneurismal character might be inferred, if it were hard and quite incompressible. Such tumours by pressure upon an artery may occasion a bellows murmur; but it is much less percepti- ble than in aneurisms, and, if the tumour is displaced, or if the stethoscope is applied laterally, ceases with the impulse. Anemic pulsations of the aorta, as they are attended with the murmur, and are frequently associated writh compressible tumours arising from air confined in some portion of the bowels, may occasion embarrassment in the diagnosis; and, should solid tumours co- exist, they would receive a more than ordinary impulse from this cause. But attention to the condition of the system, and the existence of the anemic murmur elsewhere, would, independently of the different character of the sound, generally lead to a correct conclusion. The occasional removal and recurrence of the tumour if dependent on flatulence, would satisfactorily dis- prove its aneurismal character. If the stethoscope be pressed, along the course of the artery, firmly upon the vessel, it will indicate an equable diameter in different parts of it, showing that no part was expanded. The pulsation in- stead of being gradual, expansive, or heaving, as in aneurism, is quick and jerking though sufficiently vigorous. In cases of abdominal tumours gene- rally, the administration of brisk purgatives will sometimes settle the ques- tion by removing the source of difficulty, as in cases of impacted feces, con- cretions, flatulent collections, and masses of worms. Sometimes the aneurism opens into the cellular tissue without the perito- neum, and pulsating tumours form in various positions, which may continue for a considerable time before the fatal termination. Such tumours appear in the iliac, hypochondriac, and lumbar regions. In other instances, the aneurism gradually makes its way in the ordinary manner to the surface, re- moving everything that opposes it, and, when presenting posteriorly, causing a partial destruction of the ribs and vertebrae. It sometimes attains an enormous size before bursting. An aneurismal sac has been known to origi- nate near the upper boundary of the abdomen, and, after filling almost the whole cavity, to show itself beneath Poupart's ligament in the groin. Aneurisms of the smaller abdominal arteries cannot ahvays be accurately distinguished from those of the aorta. Inferences must be drawn from their position. When the tumour is readily movable, it may without hesitation be referred to one of the smaller vessels. Aneurisms of the primitive iliacs, in their early progress, must be judged of by the same rules which guide the practitioner in forming his opinion of those of the great arterial trunk. They often in the end make their appearance externally in the iliac fossa or the groin, and it is not always easy to distinguish them from those of the exter- nal iliacs. This, however, is a problem for the surgeon. > Treatment. Though internal aneurisms are in the end generally fatal, yet much may be done to palliate their harassing symptoms, and to prolong life ; and, when the tumour is of that kind in which coagula form, hopes may even be in- dulged of effecting cures. It is very certain that spontaneous cures have taken place ; and there is reason to believe, from the reports of practitioners, 242 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. that the efforts of nature have in some instances been materially aided by the resources of art. It must be always borne in mind by the physician, that the method of cure employed by nature is generally to fill the sac with fibrinous deposits or coagula of blood, and his efforts should be directed to assist in this process. Two indications are obvious—one to lessen the distending force, and the other to sustain or increase the coagulability of the blood. A third may be added; that, namely, of producing contraction in the parietes of the sac. These should be constantly borne in mind in the treatment. To meet the first indication, those measures at once suggest themselves which are calculated to reduce the heart's action, and lessen the volume of the blood; and of these venesection would seem to be the most efficient. Hence, this remedy long enjoyed great reputation in the treatment of aneurism, especially in connection with a very low diet and perfect rest. This was the method of cure employed by Valsalva and Albertini, which has given celebrity to their names. By copious and repeated bleeding, and a rigid system of abstinence and of rest, these physicians and their followers kept their patients, for months, at the lowest point of reduction compatible with life; and are said to have had considerable success. But subsequent experience has not confirmed the first favourable reports as to the efficacy of this plan; and the probability is, that, from the uncertain means of diagnosis at that time employed, cases were occasionally mistaken for aneurism which were of a different nature. Nor would the views at present prevalent, rela- tive to the influence of venesection upon the blood, lead us to expect any- thing else than failure from a plan of reduction so excessive. In the first place, inordinate depletion does not always produce a reduction of the heart's action. On the contrary, by inducing a state of anaemia, it frequently oc- casions an irritable condition of the circulation, in which the pulse becomes frequent and jerking, and the heart beats tumultuously; a condition anything but favourable to the cure of aneurisms. (See Anaemia.) In the second place, it impairs the coagulability of the blood, and thus deprives nature of the very instrument upon which she relies for the repair of the injury. Thirdly, it tends to increase that depressed condition of the vital forces, upon which the organic disease of the vessels, so often the first step in the formation of aneurism, probably, at least in some measure, depends. Be- sides, in a feeble constitution, especially when disease of the heart is associ- ated with the aneurism, it would favour the tendency to dropsical effusion, and would greatly increase the danger, already considerable, of fatal syncope. Nor will patients generally submit to so rigid a system of self-denial so long continued; and, if attempted, it can seldom be carried thoroughly into effect. The blood may be taken, and the strength thus reduced to the lowest stand- ard ; but who is to prevent some unusual and forbidden movement of the patient, which, in his state of exhaustion, might prove of serious injury, if not fatal, by calling the heart into a degree of action beyond its power ? But, notwithstanding these dangers of excessive depletion, the indication for a diminution of the quantity of the blood and the force of its motion still remains; and the question is how it may be best answered. The reply must depend on the condition of the system. If the patient is plethoric, with a strong, full pulse, and apparently rich blood, he should lose a sufficient quantity to reduce and keep down the excess. If the aneurism be compli- cated, as it not unfrequently is, with some thoracic or ventral inflammation, the indication for bleeding is strengthened. Perhaps it would be proper to keep the action of the heart a little below par. From twelve to twenty ounces may be taken at once, and afterwards a smaller quantity, say from six to eight ounces, at intervals of some weeks, or whenever the system may CLASS III.] . ANEURISM. 243 exhibit evidences of a return to the original excess. But if the paleness of lips, and irritable state of the circulation, characteristic of the anemic con- dition, should begin to make their appearance, the plan of depletion should be at once abandoned; and great caution should be exercised not to con- found this condition with one of real vital exaltation. Individuals show a marked constitutional difference in this respect, some being disposed to plethora and others to anaemia. This difference should be attended to, and allowed to influence the course of treatment. The lancet may with great propriety be aided by the use of purgative medicines; and these may be resorted to in cases in which that remedy might be improper. The saline cathartics are generally to be preferred; and jalap and cream of tartar form an excellent combination. The saline cathartics are peculiarly useful by diminishing the bulk of the circulating fluid, with- out depriving it in an equal degree of its coagulability, and, at the same time, by their tendency directly to diminish the action of the heart. Another advantage is the removal of the serous effusion, so frequently attendant upon the disease, and which, if in the chest, very greatly increases the distress of the patient. The cathartic may be repeated twice or three times a week, and even more frequently in some cases. A very good plan, when there are dropsical symptoms, is to give from half an ounce to two ounces of bitartrate of potassa, in divided doses, diffused in water, every day, and con- tinue the medicine until it shall produce dyspeptic symptoms, when it may be omitted, to be resumed after their disappearance. The diuretic action of this salt is of great advantage. In decidedly anemic cases, a wholly different plan of treatment must be adopted. In these, the excessive action of the heart is sustained by the im- poverished condition of the blood. To quiet the circulation it is necessary to enrich that fluid, and in doing so we meet also the second indication above referred to, that, namely, of rendering the blood more coagulable. Instead of the lancet and active purgation, we must now resort to mild tonics; and of those the preparations of iron are beyond all others applicable to the case. The pill of carbonate of iron, combined with a little rhubarb or aloes, if a laxative effect is required, and continued for a considerable time, will be found perhaps the most efficient remedy. The infusion of wild-cherry bark is also admirably calculated to meet the indication, by its tonic influence over the digestive function, and its sedative action on the heart. In either of the above cases, digitalis may be employed as an adjuvant. It should be given in moderate quantities, long continued, with occasional in- termissions, however, to prevent the effects of accumulation. It proves useful by repressing the action of the heart, without impairing the coagulability of the blood; and, by its diuretic action, lessens the quantity of watery fluid in the circulation, and promotes the absorption of any that may have been effused. Hydrocyanic acid may also be used in reference to its sedative in- fluence, but caution is required in its management. It is worthy of con- sideration whether ergot would not prove advantageous. Its application to this disease is suggested by its admitted power in restraining hemorrhage, and by its occasional extraordinarily sedative action upon the pulse. To do good it must be continued long. Danger might be apprehended from its known tendency, in large quantities, to occasion mortification of the ex- tremities. I have, however, never seen or heard of such a case, occurring in consequence of the employment of ergot in medicinal doses; and cannot but think that, with moderate caution in watching its effects, any danger of tke kind may be avoided. Acetate of lead has been considerably used as a remedy in aneurism, and very favourable accounts of its action have been published. I have employed 244 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. it with apparent benefit; but have never seen a complete recovery under its use. To be effectual it must be given so as to affect the system, and after- wards persevered in for a long time. In this case it is apt to produce colic, with nausea or vomiting, which proves so disagreeable to the patient, that he is sometimes with difficulty induced to resume the remedy after the sub- sidence of the symptoms. A grain may be given three or four times a day, and continued until it induces some disturbance of the primae A'iae, when it should be suspended for a time, and afterwards resumed. It is better cal- culated than any other internal remedy to meet the third indication in the treatment of aneurism, that of contracting the parietes of the sac. With the same view, alum has been employed in aortic aneurism. If thoracic or abdominal inflammation attend the aneurism, or if the sac itself is inflamed and painful, it may be proper to detract blood locally by cups or leeches, and afterwards to apply blisters or other revulsives. But if the tumour is near the surface, these remedies should not be applied immedi- ately over it, for fear of causing the skin to slough. Calomel and squill Avill sometimes prove useful, especially when there is effusion in the chest. It will often be necessary, in the course of the treatment, to employ nar- cotics or antispasmodics to relieve pain, and quiet nervous disturbance. Opium, hyoscyamus, camphor, assafetida, &c, may be resorted to. Local applications may be made over the tumour with the hope of aiding in its reduction. Cold water and ice have been recommended; but they can- not be long steadily persevered in. Perhaps some good might result from cold astringent poultices, made, for example, with decoction of oak bark or infusion of galls. Dr. Hope recommends a belladonna plaster, when the tumour is painful or requires support. The diet should conform to the circumstances of the case. It should always contain materials capable of furnishing fibrin to the blood. Bread, fruits, and vegetables, with milk, and a small quantity of boiled meat, would be applicable to ordinary cases. In those of an anemic character, meat may be more freely employed. Boiled are preferable to roasted meats, as less stimulating, while they contain an equal amount of fibrin. Broths are ob- jectionable, as they contain the most stimulating portions of meat, while they tend to increase the bulk of the blood. As little drink should be allowed as is compatible with the comfort of the patient. In relation to exercise, the patient should be kept for the most part at rest, and should most cautiously avoid all hasty movements, and all kinds of ex- ertion. Passive exercise in an easy carriage may prove useful by sustaining the digestion, and the general processes of secretion and nutrition, in a healthful state. The utmost care should be taken to preserve mental equa- nimity ; as few things have a more poAverful influence in calling the heart into undue and dangerous action than strong moral excitement. Article IV ARTERIAL PALPITATION. This name is given to an increased pulsation or throbbing in the arteries, which can be felt by the individual affected. It bears the same relation to the ordinary state of these vessels that palpitation of the heart does to the healthy action of that organ. It may occur in any of the larger arteries, but is most frequent in the aorta, especially in that portion of it which lies behind the epigastrium. It is only in the abdominal aorta that it has attracted par- CLASS III.] ARTERIAL PALPITATION. 245 ticular attention, or requires special notice here. From its frequent occur- rence at the pit of the stomach, it is sometimes designated by the name of epigastric pulsation. Symptoms.—TJpon the application of the hand to the epigastrium, the throbbing is distinctly felt; and so violent is it occasionally, that it may even become sensible to the eye. Though not usually attended with pain, it is often very annoying to the patient, and sometimes occasions harassing fears of aneurism, or other serious organic disease. It is in general intermittent in its character, occurring in paroxysms, which, however, are altogether irre- gular, both in their degree, and recurrence. In some instances, it remains pretty constant for a considerable length of time. A feeble bellows murmur has been observed generally to attend it, audible especially when the patient is in a horizontal position. It is not necessarily connected with over-action of the heart, though the two affections are not unfrequently coincident. Causes.—The causes are numerous. Whatever is capable of extending an irritation to the great sympathetic nerve, and especially to the solar plexus and its ganglia, seems to be capable of producing it. The persons in whom it is most apt to occur are those of a highly nervous temperament. Hypo- chondriacal, hysterical, and anemic individuals are peculiarly susceptible to it. Perhaps it is most frequent in anaemia, and especially in that form of it usually associated with uterine derangement, as in chlorotic and hysterical females. It has been observed to follow copious hemorrhage from the stomach, rectum, and uterus. Hepatic derangement, an irritated or dyspeptic state of stomach, disorder of the bowels, in short, congestion, irritation, or inflammation of the abdominal viscera generally, appear to be capable of exciting it. Tenderness in the epigastrium is a not unfrequent attendant. It has been observed in connection Avith tenderness of the spine. It sometimes appears to be one of the forms of nervous gout and rheumatism; as it has been known to cease suddenly upon the occurrence of gout in the extremities. There is reason to believe that it sometimes results from the excessive use of tobacco, coffee, and tea. Simple flatulence of the bowels will sometimes bring on a paroxysm in those predisposed to it. Dr. Stokes has found it to attend intestinal and peritoneal inflammation, as increased pulsation of the radial artery attends a Avhitlow. Indeed, he considers it a good sign of intestinal inflammation Avhen it exists along with fever, and the aortic pulsation is proportionably more ac- tive than that at the wrist. Notice has been especially attracted towards it as an accompaniment of pancreatitis, of which it has even been supposed to be a pathognomonic sign. It may arise from the pressure of tumours or enlarged viscera. It is not improbable that it sometimes results from an original irri- tation, active congestion, or inflammation of some portion of the solar plexus, Avhich supplies nerves to the artery. Diagnosis.—The affections for Avhich this pulsation is most apt to be mis- taken, are aneurism, and organic diseases of the heart. If no abdominal tumour exist, there will be little difficulty in distinguishing it from the former affection. Its irregular occurrence and frequent absence ; its occasional disap- pearance upon the removal of some temporary cause, such as flatulence; the state of system with which it#is frequently associated; and the character of the pulsation, which is quick and jerking, instead of being slow, expansive, and heaving, as in abdominal aneurisms, are generally sufficiently diagnostic. But positive certainty may be obtained Avith the stethoscope. By the aid of this instrument, the pulsation may be observed for a considerable distance along the aorta, instead of being confined to one spot, and in no part of the vessel extends laterally beyond its limits, as it does in aneurism. The double shock sometimes occurring in the latter affection is never perceived. The murmur, too, is very different from the aneurismal; and is often associated 246 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. with a similar murmur in the carotid and subclavian arteries, and a venous murmur in the jugulars'. When tumours exist in the abdomen, and receive an impulse from the throbbing artery, the diagnosis is more difficult, but may still in general be made out with sufficient distinctness. (See Aneurism, p. 240.) The absence of organic disease of the heart will be best proved by the want of its characteristic physical signs. Treatment.—From what has been said above, it will be inferred that no single plan of treatment is adapted to all cases of aortic palpitation, depend- ing as it does upon causes so numerous and different. The primary object must be to search out the derangement, functional or organic, in which it may have originated, and to apply remedies to this derangement. The condition of the liver, of the stomach, of the bowels, and of the abdominal contents generally should be carefully examined, and corrected by appropriate means if found deranged. Should evidences of inflammatory congestion or irritation exist in the spine, or should there appear good reason for suspecting its exist- ence in the solar plexus, cups or leeches applied to the back, followed by blisters or other revulsives, would be the proper remedies. It might even be advisable to take blood from the arm, should the pulse be strong and excited. Under the same circumstances, saline cathartics and a restricted diet will be useful. In anemic cases, an opposite plan must be adopted, consisting in the use of chalybeates and nutritious animal food. Care must be taken also to arrest all exhausting discharges. Sometimes narcotics and antispasmodics become necessary to allay nervous disorder. For this purpose, hyoscyamus, conium, lactucarium, camphor, valerian, assafetida, musk, compound spirit of ether, or opium, may be resorted to. The cold shower-bath will occa- sionally prove useful. If the patient is much troubled with flatulence, a fluidrachm of one of the aromatic tinctures, as the compound spirit of laven- der, or the compound tincture of cardamom, or a draught of strong infusion of ginger, will often dissipate the symptoms. In very obstinate cases, it may be advisable to resort to a gentle mercurial course, with the object of remov- ing any latent inflammation, in which the pulsation may originate. The use of tobacco, coffee, and strong tea should be abandoned, or at least suspended for a time, till it is ascertained whether they might have been the cause. Ex- ercise, fresh air, agreeable mental occupation, cheerfulness of spirit, and, as the most effectual method of combining these requisites, a journey to some watering-place, especially to one of the chalybeate and saline springs, will be among the most effectual remedies. SUBSECTION III. DISEASES OF THE VEINS. Article I. INFLAMMATION OF THE YELNS, or PHLEBITIS. Inflammation of the veins, though not often an original disease, is a fre- quent consequence of other affections, especially of wounds or other injuries, whether accidental or the result of operations, and is one of the greatest causes of solicitude to the surgeon and obstetrician. Symptoms, Course, &c.—The complaint is characterized by pain and great tenderness along the course of the affected vessel, which often feels like a hard cord, knotted at intervals, and rolling under the fingers. It is usually CLASS III.] PHLEBITIS. 247 attended with swelling of the parts adjacent, and of those through which the ramifications of the vessel are distributed. The limb below is often greatly distended, partly from the effusion of liquid consequent upon obstruction to the returning blood, and partly from the propagation of inflammation to the other tissues. This tumefaction sometimes obscures the hardness of the ves- sel itself, which therefore escapes notice unless upon careful examination. Fibrinous matter is thrown out by the coats of the inflamed vessel, and blood coagulates in layers upon its inner surface, so as at length completely to fill up its caliber, and thus to produce that obstruction to the circulation, and hardness of the vessel above alluded to. If the vessel affected is small, the consequences of the obstruction are not necessarily serious; but, if one of the larger trunks, especially those in the interior, is the seat of the inflamma- tion, they may be fatal, and are always dangerous. If the inflammation should now subside, it may happen, partly by the solution of the coagulum, and partly by the pressure from behind, that the blood may make its way again through the vessel, and the circulation be restored. But more frequently the obstruction continues, the blood finds a passage through other vessels which are enlarged for the purpose, and the inflamed vein, through a process of organization and absorption, is gradually reduced to the condition of a hard impervious cord, or ligamentous string. With the return of the circulation the swelling in the limb gradually subsides, and the patient ultimately recovers, though not always without some re- siduary hardness or tumefaction of the parts affected. But, if the disease advances, suppuration ensues; and the pus, which is sometimes largely produced, is either confined by the coagulated blood and effused lymph within certain portions of the vessel, thus constituting ab- scesses along the vein, or, if not thus restrained, is carried along with the current of blood, and contaminates the circulation. The former of these events is the more desirable; as the disease then remains local, and the question of recovery is resolved into the extent of the inflammation, and the patient's strength of constitution. If he have vigour enough to carry him through the processes requisite for the discharge of the pus, and the granu- lation of the abscesses formed, recovery will take place; and this may be confidently expected when only the smaller vessels are involved. But if the caliber of the vein remain pervious, and the pus mix with the mass of the blood, the consequences may be most serious. Even then, however, if the purulent admixture be very small, it is probable that no constitutional dis- turbance of any moment will ensue. If large, it often produces fatal disorder. In some cases, owing to peculiarity in the cause and consequent nature of the inflammation, or in the previous health or constitution of the patient, the formation of pus is not preceded or attended by adhesive inflammation and fibrinous exudation, and the blood in the vessel has no disposition to coagu- late. Pus is formed upon the inner surface of the vein, and is washed away by the current of the blood, which thus becomes contaminated. This condi- tion of venous inflammation is by far the most dangerous, giving rise to the most violent constitutional disturbance, and, if life is not thus immediately destroyed, to the production of abscesses or purulent depositions in various parts of the body, by which the system is at length exhausted.* The secondary effects of phlebitis are often of great importance. Inde- * Mr. Henry Lee, Surgeon of the Lock Hospital, London, infers from experiments performed by himself, that the coagulated fibrin, lining the inner surface of the veins, or more or less completely filling the cavity, in phlebitis, is not produced by exudation from the surface of the vein itself, but is deposited directly by the blood. In an expe- riment upon an ass, in which measures were taken to produce inflammation of the jugular vein, the blood being entirely excluded, the lining membrane was found per- 248 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. pendently of those to which attention will be called hereafter, as the milk-leg and metastatic abscess, inflammatory affections of important organs, more or less directly connected with the inflamed veins take place, Avhich add greatly to its dangers. Thus, caries of the bones of the ear sometimes becomes the starting-point of phlebitis, which in one direction penetrates the sinuses of the brain, and thence passes to its substance, and in another passes down the veins of the neck, and sets on foot inflammation of the lungs and pleura, generally of a low character, and sometimes ending in gangrene. (See Med. Times and Gaz., April, 1855, p. 351.) The constitutional symptoms of phlebitis vary with the stage of the inflam- mation and its character. In the ordinary adhesive variety, in its earlier stages, they are those of common symptomatic fever, commencing usually with more or less rigor, and differing only by greater frequency and less strength of pulse. The occurrence of suppuration is usually marked by re- peated chills, and a general relaxation of surface, attended frequently with profuse sAveats, especially during sleep. In those cases in which there is rea- son to believe that pus has somewhat largely entered the circulation, the fever is of a low and often typhoid character. The pulse is very frequent, small, and feeble; the respiration, hurried; the skin pale, and often salloAV or dusky; the extremities, cold; the countenance, anxious, sunken, and hag- gard ; the tongue, generally dry, and covered with sordes; the stomach, oc- casionally irritable; and the bowels, costive, or affected with diarrhoea. Ex- treme restlessness, muttering delirium, and other marks of nervous derange- ment are frequent attendants on the disease, which, under these circumstances, is generally fatal. It is not impossible that these symptoms may sometimes occur, independently of the generation of pus, from a propagation of inflam- mation extensively along the great venous trunks towards the heart, or from a general vitiation of the blood, and prostration of the nervous energy, in consequence of some other poisonous influence. When pus is produced in the larger veins, the danger is greater; for the chance is less that it will be confined by the obstruction of the vessel. The diagnosis of phlebitis in the extremities is usually not difficult; but obscurity often attends it when seated in the internal veins of the abdomen or thorax. In such cases, the occurrence of a hard edematous swelling, with more or less of a purplish aspect, in exterior parts, the veins of which carry blood into the interior trunk affected, may be regarded as a strong evidence of its existence. Thus, such a swelling in one of the lower extremities, occu- pying the whole limb, without any evidence of inflammation of the femoral vein, may be considered as diagnostic of phlebitis of the corresponding iliac vein, and, if in both limbs, of the same disease in the vena cava. I have had a case exactly of this kind, in which the diagnosis was confirmed by post- mortem examination. The original cause of the phlebitis, in such cases, is apt to be cancer of one or more of the viscera. Inflammation of the portal vein. Portal phlebitis.—Generally in rela- tion to the external veins, and not unfrequently in relation to the inferior fectly smooth and glossy, and there was no fibrinous exudation observable. (Medico- Chirurg. Trans., xxxv. 191.) It is probably true that the lining membrane of the veins, being like that of arteries without blood-vessels, is not capable of itself throwing out coagulable lymph, or any other product of inflammation; but as the other membranes of the veins are capable, when inflamed, of all the changes which other tissues undergo in a similar condition, it may be readily conceived that the liquor sanguinis exudes from them, passes through the inner membrane of the vein, exactly as through the proper serous tissue, which is equally exempt from vessels, and either coagulates on the inner surface, or is converted into pus, according to the state of the parts affected, and of the system. (Note to the fourth and fifth editions.) CLASS III.] PHLEBITIS. 249 venous trunks which convey the external blood to the heart, there are si«-ns by which inflammation may be recognized with considerable certainty. But it is different with the portal vein, which both begins and terminates within the abdomen. It is highly probable that inflammation of this vein and its ramifications occasionally takes place, and, ending favourably, escapes notice from the obscurity of its symptoms. It is only in the fatal cases, the nature of which is revealed by dissection, that it has been recognized with an ap- proach to certainty. A short account of the symptoms, in these cases, may prove useful by facilitating a diagnosis of the disease in its milder forms, or earlier stages, while yet amenable to remedies. The affection has been gene- rally overlooked by systematic writers. I am indebted for most of the fol- lowing facts to a paper of Dr. E. Leudet, of Paris, published in the Archives Generates for February, 1853 (page 145), which contains a detailed account of a case observed by himself, and a summary of facts deduced from an ex- amination of the cases heretofore placed on record. The affection makes its attack in general somewhat abruptly, but sometimes gradually. The first observable symptom is usually a dull pain in the epigastrium or hypogas- trium, increased by pressure, and, as the case advances, extending more or less over the abdomen, which becomes in some degree tympanitic. Occasion- ally the superficial veins are distended. Febrile symptoms set in, accompanied with a remarkable tendency to chills, which are among the most striking fea- tures of the complaint. These chills occur quite irregularly, in some instances several times in the same day, and are not generally followed by sweats, though these do sometimes take place. The liver is often enlarged, and the patient is more or less jaundiced; but neither of these conditions is universal. The spleen is also sometimes enlarged. Not unfrequently there is more or less nausea, vomiting, and diarrhoea. Typhoid symptoms make their ap- pearance before the close, with frequent pulse, delirium, coma, and great prostration. The duration of the complaint is from one to three weeks, or more. The cases have uniformly terminated fatally. The cause is for the most part unknown. In general the affection seems to have been idiopathic ; but, in a few instances, it has originated in a focus of inflammation or in local injury. In one case, the cause was a fish bone, which had passed through the coats of the stomach, and perforated the portal vein. In a case observed by M. Leudet, the starting-point seemed to be an injury inflicted on the rectum by the point of a syringe. A case is recorded in the New York Medical Times (ii. 162), which probably originated in inflammation of the bowel, con sequent on the partial strangulation of a fold of the intestine, passing through a rupture in the omentum. It is probable that some of the cases of multi- plied abscesses of the liver, accompanying tropical dysentery, are the result of portal phlebitis, having its origin in the ulcerative affection of the bowel. Anatomical Characters of Phlebitis.—The appearances after death are redness of the inflamed vessel; a thickened, contracted, softened, or indurated condition of its coats; coagulable lymph adhering to its inner surface, or loose within its cavity; coagula of blood often completely plugging up the vessel for a considerable extent; and generally more or less pus, sometimes confined by adhesions within small portions of the tube, sometimes completely sur- rounded by coagulated blood, and again lying loosely in the vessel. Occa- sionally, too, portions of the vein are quite obliterated, and reduced by ab- sorption to the form of an impervious cord. The parts about the vessel also exhibit signs of inflammation, having contracted adhesions from fibrinous exu- dation, or being more or less infiltrated with pus. Redness alone, without thickening, softening, ulceration, or either fibrinous exudation or the presence of pus, is not considered a sure sign of inflammation. In portal phlebitis, the coats of the veins have been found of a grayish VOL. II. 17 250 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. colour, and so much thickened that the vessels did not collapse. The inner coat was much thickened, coagulated fibrin adhered to the inner surface of the porta] A-ein, and occasionally the clots were so large as nearly to fill the vessel. There Avas usually abundance of pus, more or less mingled with blood, both in the trunk, and in its intestinal and hepatic ramifications, and sometimes in the splenic vein. Numerous abscesses existed in the liver, and between the folds of the mesentery; and the veins in their course were sometimes bathed in pus. In some instances, the peritoneum exhibited signs of inflammation. Causes.—Phlebitis almost always arises from local injury or inflammation, in which the veins of the part are involved, either directly, or by contiguous sympathy, or from the entrance of acrid or septic matters into their cavity. The inflammation once established, is readily propagated along their course; and the tendency of phlebitis appears to be, contrary to what has been ob- served of arteritis, to run from the smaller vessels to the larger with which they are continuous, thus following the course of the blood. Sometimes very slight injuries are sufficient to give rise to the disease, partly oAving to the state of the patient's constitution at the time, and partly to the peculiar cir- cumstances attending the injury. Thus, it may arise from a slight focus of inflammation, whether ulcerative or not, in one of the toes, and may thence run up the leg and thigh with serious consequences. Any wound of a vein, which from its nature or inaccurate closure, does not unite by adhesive in- flammation, is apt to generate phlebitis. Hence its occasional occurrence after venesection, especially when a dull lancet has been employed, or one soiled by contact with diseased matter. Hence too the frequency of the dis- ease after division of the saphena, or other operation for varicose veins of the leg. Perhaps the great liability to phlebitis, and the consequent danger in these cases, depend partly upon the previously morbid condition of the ves- sel. Amputations and operations on parts largely supplied with veins not unfrequently prove fatal, in consequence of venous inflammation proceeding from the cut surface. Puerperal women are peculiarly liable to this disease; the veins of the womb taking on inflammation after delivery, and propaga- ting it to the larger venous trunks with which they communicate. The veins proceeding from the part of the uterus at Avhich the placenta Avas attached are especially liable to be affected, and the spermatic vein upon one side is most frequently inflamed. The hypogastric veins are also apt to be attacked, and through them the inflammation sometimes reaches the iliac and femoral veins, and even extends into the vena cava. Some of the worst forms of puerperal fever probably owe their malignity to phlebitis originating in the womb ; and phlegmasia dolens may generally be traced to the same origin. Fractures of the skull are apt to occasion phlebitis. Contusions, abscesses, cancerous sores, caries, ulcerated surfaces, and any other form of suppurative inflammation, may become a focus whence the disease may spread, and carry the seeds of danger or death into the system. The veins running from such centres have often been observed to be filled with pus. It has been a ques- tion whether, in such cases, the pus is taken up by the veins, and merely conveyed by them into the circulation, or whether it is the result of an in- flammatory process in their own structure. Possibly both events may hap- pen; but, taking all the circumstances into consideration, it seems to me most probable that it is generated for the most part in the veins themselves; for, if it were taken up by them, Avhy should we not find the vessels simi- larly loaded in all cases of large purulent collections of similar character ? Of one of the results of this morbid process there will be occasion to treat directly. Phlebitis has sometimes, though very rarely, arisen from cold, like other inflammations ; and it is said to have resulted from the translation of rheumatic or gouty irritation. From the circumstance that it originates CLASS III.] PHLEGMASIA D0LENS. 251 generally in local injuries, it follows that the large interior venous trunks are seldom primarily affected. The existence of a predisposition seems to be, if not essential to the pro- duction of phlebitis, certainly very promotive of it; as precisely the same local condition, so far as can be discovered, which produces it in one case, will have no such consequence in many others. The character of the pre- disposition has great influence in determining whether the resulting inflam- mation is to be adhesive or suppurative. A feeble and depraved state of health is most favourable to the latter, and therefore greatly aggravates the danger of the disease. It is probable that some unknown distemperature of the atmosphere favours the origin of phlebitis, which appears occasionally to prevail almost epidemically, especially among puerperal women. There are two affections, usually considered of obscure origin, one of which has been recently traced, if not with certainty, yet with a considerable degree of probability, to phlebitis as its source, and the other is considered by many as having the same origin. These are phlegmasia dolens, and metastatic abscess. They can be considered nowhere more appropriately than in the present place. 1. Phlegmasia Dolens.-Phlegmasia Alba Dolens.-Crural Phlebitis.~Milk-leg.—This affection occurs generally in women after delivery, but sometimes also in the unmarried, and occasionally even in males. It usually commences about a week or two after delivery, though the interval may be much longer. In some instances, it is preceded by febrile symptoms, in others, is ushered in with a chill occurring simultaneously with the local affection, and in others again, and these are the most numerous, commences with pain. This is usually felt first in the loins or lower part of the abdo- men, whence it extends to the groin, and thence to the vulva, and down the thigh and leg. Sometimes, however, it shows itself first in the lower parts of the limb, as in the calf, travelling upwards, and in other cases in two distant points at the same time. At first it may be only an aching sensation with soreness, and a sense of weight or stiffness in the part; but it soon increases and becomes acute, severe, and sometimes even excruciating, being felt most along the course of the internal cutaneous and crural nerve in the thigh, and of the posterior tibial in the leg. The limb soon begins to swell, and, in the course of forty-eight hours, is sometimes of twice its usual dimensions. The labium pudendi is similarly affected. With the swelling, the acuteness of the pain generally abates in some measure, but the soreness continues, and is aggravated by every movement. The limb is in general slightly flexed, and quite motionless, as if paralyzed. The swelling, when at its height, is uniform over almost the whole limb, which is unnaturally white, shining, hot, and firm and elastic to the touch. It does not pit upon pressure, except some- times at the commencement, and at the decline of the swelling. When cut, it exudes only a small quantity of fluid. Sometimes red lines are observed in the course of the crural veins, and red patches here and there upon the limb; but the colour, as just stated, is usually white. The tenderness is greatest along the femoral vein, which may almost always be felt like a hard cord. Sometimes this hardness is confined to the groin, sometimes may be felt all the way down the thigh and leg, and in other instances occurs in distinct parts of the course of the vessel. The uuiformity of the cord is interrupted by occasional nodules, arising either from inflamed cellular tis- sue, or coagula in the cavity of the vessel. The lymphatic glands of the groin are usually hard and swollen. Both limbs are seldom attacked at ,the same time; but it sometimes happens that one becomes affected after the recovery of the other. The left is more frequently attacked than the right. 252 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. The disease is said sometimes to extend to the arm of the affected side. It is attended with a very frequent pulse and other febrile symptoms, often with nausea and vomiting, and sometimes with suppression of the lochia and the milk. Phlegmasia dolens generally terminates favourably, though constitutional symptoms occasionally make their appearance, such as have been ascribed above to the entrance of pus into the circulation, and the patient sinks. The acute symptoms are in most cases over in two weeks ; but the limb often con- tinues more or less swollen or hard, for a long period, sometimes even for life. In favourable cases, the symptoms gradually subside; the pain, hardness, and swelling abate ; and the blood, which can find no passage through the large internal veins of the limb, is returned by the superficial vessels, greatly en- larged for the purpose. Sometimes erysipelatous inflammation occurs in the limb, and abscesses form in different parts of it, as well as in different parts about the pelvis, greatly increasing the danger of the patient, and, in some instances, proving fatal. In all the fatal cases examined within a few years, marks of inflammation have been found in the femoral vein, frequently extending into the veins of the leg, and sometimes occupying almost all the venous ramifications of the limb. The caliber of these vessels has been filled by coagulated blood, effused fibrin, and pus; and coagula have also been observed in the external, inter- nal, and primitive iliac veins. In the external iliac the signs of inflamma- tion have been strongly marked, and were traced by Dr. Lee from these to the veins of the uterus. The other tissues of the limb have also been found inflamed, but apparently in a secondary manner. Very different opinions have been held as to the nature of phlegmasia dolens. At first considered as the result of a metastatic secretion of milk in the limb, it was afterwards with more appearance of reason ascribed to inflam- mation of the absorbents, and still later to general inflammation of the cellu- lar tissue, muscles, and inner surface of the skin. Various observers had de- tected evidences of phlebitis in the great veins of the thigh, among whom Dr. Davis, of England, and M. Bouillaud, of France, were the most conspicuous; and the opinion was advanced that the disease might consist essentially of this affection; but it was not until the inflammation was traced to the veins of the womb by Dr. Lee, and the point of origin thus clearly established, that this opinion acquired full confirmation. There scarcely appears room at pre- sent to doubt that, however other tissues may be subsequently involved in the disease, the structure primarily affected is the veins; and that, when the complaint is consequent upon delivery, inflammation of the uterine veins is its starting-point. But the comparative rarity of the disease, under circum- stances of delivery not essentially different, Avould seem to point to some other cause than injury of the uterine vessels ; and we must seek for this in pecu- liarity of constitution, or the peculiar state of system at the time. Affections in most respects identical with phlegmasia dolens have been ob- served in women after abortion, and in others affected with malignant ulcera- tion or other organic disease of the unimpregnated uterus, or in whom that organ had suffered violence, as from the application of a ligature for the re- moval of polypus. Men, too, have been similarly affected in consequence of organic disease in the pelvic viscera, or injury inflicted on these parts; and attention has been called by Drs. Tweedie, Graves, and Stokes, to the occa- sional occurrence of inflammation of the lower extremities, in all essential' points identical with that under consideration, following fevers. A case of the'tind occurred in a patient of my own, after recovery from an attack of peritonitis, which came on during convalescence from typhoid fever. The same thing has also been observed in dysentery; and, in one fatal case, in- CLASS III.] METASTATIC ABSCESS.—PURULENT INFECTION. 253 flammation and consequent obstruction of the common and external iliac and femoral veins were discovered upon dissection.* 2. Metastatic Abscess.—Purulent Infection.—Pyogenic Fever.—Abscesses, or collections of pus, occasionally form in various parts of the body, with little or no observable preceding inflammation in the part affected. Sometimes one of these collections springs suddenly into existence, and as suddenly disappears, to show itself in another situation. They have been observed especially in the parenchyma of the lungs and liver, where they are of various size, from the magnitude of a pea to that of a walnut; but they form also in other parts, and not unfrequently in the cellular tissue be- neath the skin, among the muscles, and even in and about the cavities of the joints. I have had a case in which a large deposit of pus was found in the hip-joint. The eye has been known to be broken down and destroyed by such an abscess. These purulent collections are usually surrounded by a greater or less amount of inflammation. In many instances, their formation lias been found to be coincident with the existence of some focus of ulcera- tion or suppurative inflammation, as in the stump of an amputated limb, can- cerous sores, caries of the bones, diseased uterus, ulcerated intestines, frac- tures of the skull, &c.; and the veins proceeding from such points have been observed loaded with pus. Different explanations have been given of these phenomena. One of the most obvious was that pus, absorbed from the focus of suppuration, and carried into the general circulation, is deposited at distant points, forming the abscesses in question. But to this view it was conclu- sively objected, that, in many instances, more pus exists in these metastatic * By experiments upon dogs, Dr. F. M. Mackenzie, of London has proved, 1. that inflammation artificially excited in the veins of these animals in health is confined to the vicinity operated on, and does not spread to the veins below, so as to produce phe- nomena analogous to those of phlegmasia dolens; 2. that irritation or inflammation of the internal surface of a vein causes the blood in contact with it to coagulate ; and 3. that, an irritant injected into the circulation, coming into contact with the internal sur- face of the veins generally, may produce extensive irritation and consequent coagulation of the blood. (Medico-Chirurg. Trans., xxxvi. 169.) Hence it was concluded by Dr. Mackenzie that phlegmasia dolens does not depend on the propagation of inflammation from the veins of the uterus to those of the lower extremity; but upon a diseased state of the blood, which, acting as an irritant to the inner surface of the veins of the limb, causes the coagulation of the blood within them, and thus gives rise to the phenomena of the disease. But it is not shown why the general condition of the blood should affect simply the veins of one extremity, in preference to those of other parts which are equally exposed to its irritant influence. It appears to the author that Dr. Mackenzie's experi- ments simply prove that, in health, a local phlebitis is not extensively propagated, and that in order to this result there must be some vice of constitution peculiarly predispos- ing to* it, which is exactly what has been stated in the text. Whether this vice exists in the solid tissues, or in the blood, has not been determined; but that it does not consist of an irritant in the circulating fluid, operating as the direct excitant agent, is, I think, shown by the almost uniform localization of the affection'in a particular part. It may readily be conceived that the predisposition consists in a peculiar irritability of the veins, the result possibly of a depraved nutrition, which determines that, a point of in- flammation being established, it shall rapidly spread through the tissue, just as, in the erysipelatous predisposition, inflammation in a single point of the skin will be rapidly propagated over an extensive surface. It seems, therefore, most probable that, in this disease, the focus of inflammation exists in the uterus, whence, in consequence of the predisposition referred to, there is a propagation of the affection through the coats of the veins, causing, wherever it attains a sufficient degree of intensity, coagula- tion of the blood in contact with the membrane; and this disposition to coagulation of the blood, under the circumstances mentioned, is the most interesting result of Dr. Mackenzie's experiments. Why the irritation should extend towards the origin of the veins, contrary to the direction of the blood, and contrary to what ordinarily hap- pens in phlebitis, is not obvious. Perhaps it may be that coagulation at any one point, producing obstruction there, and causing the blood to be delayed in the veins below, may be the determining agency. (Note to the fourth edition.) 254 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. collections than can possibly have been taken up from the supposed source, which is sometimes altogether trivial. But the difficulty was evaded by the supposition, that the corpuscles of pus, reaching capillaries too minute to admit of their entrance, are arrested in their progress, and excite inflamma- tion in the surrounding tissue, which, from the nature of the cause, speedily advances to a copious suppuration ; and this explanation was supported by the experiments of Cruveilhier, who found that metallic mercury, when intro- duced into the veins, was carried to the capillaries of the lungs, and there occasioned small abscesses, which, being opened, were found to contain a globule of the metal in their centre. But there was another difficulty in the way of this hypothesis. It often happens that large collections of pus disap- pear, probably by the process of absorption, without any of the evil conse- quences which are ascribed by the hypothesis to even small quantities enter- ing the veins. In reply it may be said that, when pus really enters the ves- sels by absorption, it must have been previously disintegrated and rendered liquid; as microscopic observation has shown, that no orifices exist in the walls of the vessels by Avhich the pus corpuscles can possibly gain admission. When thus prepared for absorption, it may be thought to have undergone changes which divest it of noxious properties. It may be only when ad- mitted into the circulation in the form of pus, that it produces the ill effects ascribed to it; and this happens not by absorption, but through openings in the veins, resulting either from ulceration or wounds. With the qualifica- tion here stated, it is certainly not impossible that the metastatic abscess should take place in the manner supposed. It is, hoAvever, I think more probable that the pus, found in the veins proceeding from suppurating parts, is not taken up by the vessels, but actu- ally formed in them, in consequence of inflammation of their tissue, pro- pagated from the original point of disease, and disposed to take on the suppurative character by the previous condition of the system. Phlebitis, according to this view, is the true source of metastatic abscess. That in- flammation of the veins has not always been detected, is no proof that it may not haAre existed; for, in a system of parts so extensive, an inflamed surface may easily have escaped observation, more especially as the indication af- forded by the presence of pus may be wanting, in consequence of this pro- duct being washed away by the blood as fast as formed. Another opinion, which on the whole appears to me to approach nearer the truth than either of the preceding, is that which looks upon the affec- tion as the result of purulent infection of the blood. By this expression is not meant a mere contamination of the blood by an admixture of pus, but a change effected in its essential constitution through a poisonous action of the cause, analogous to that produced in smallpox and typhus fever, by the ab- sorbed matter of contagion. The results, therefore, are not produced di- rectly by the pus, but by the morbid state of the blood which it may have induced by a sort of zymotic influence. Purulent deposits are not the only phenomenon to be noticed in these cases. There is a tendeucy also to a low erysipelatous inflammation in various parts of the surface, not unfrequently ending in subcutaneous suppuration, and sometimes in gangrenous abscesses. There is also a train of general symptoms of the typhoid character, such as a frequent feeble pulse, hurried respiration, a somewhat leaden or jaundiced hue of the skin, and, in bad cases, a dry tongue, sordes on the gums and teeth, stupor or low delirium, subsultus tendinum, sometimes diarrhoea, and great general prostration. The same state of system precisely may take place, quite independently of any known local inflammation as its origin. I have had under my care, in the Pennsylvania Hospital, a patient with all the symptoms characteristic of purulent infection, including abscesses in CLASS III.] CHRONIC PHLEBITIS. 255 various parts of the body, erysipelatous inflammation here and there upon the surface, and general typhoid symptoms, who was attacked in consequence of exposure to severe cold, great privations, and fatigue, with habits of in- temperate drinking, and without any discoverable original inflammation as the starting-point; and this is by no means the only case of the kind which has come under my observation. Here, as well as in the cases traceable to a local point of injury or inflammation, there is a diseased condition of the blood, and, so far as symptoms and results can be admitted as proof, this condition is the same in the two varieties of the affection. In the one case, it is produced apparently by altered pus, or other sanious product of inflam- mation, absorbed into the veins, and setting on foot a zymotic change in the blood, especially, it is probable, in the fibrin; in the other, by causes acting through the digestive organs and the nervous system. In both, the blood is degraded in character and at the same time irritant, so that it provokes a low inflammation, in which, instead of the plastic lymph, exuded in a vigor- ous state of that process, a matter is thrown out which is immediately con- verted into pus. It is not essential to the production of this affection, even when dependent on some focus of previous inflammation, that pus as such should have been absorbed. The probability is that it is rather a sanious product, resulting from decomposition of the pus, or thrown out by the dis- eased vessels in the inflamed part, which acts as a poison when absorbed into the circulation; for, as before stated, it can scarcely be allowed, in the present state of microscopic investigation, that unaltered pus can undergo absorption. In cases of true suppurative phlebitis, it is probable that the pus formed in the veins has the same effect on the blood. The name of pyogenic fever is given by Dr. Jenner, of London, to the affection here described. These cases of metastatic abscess or purulent infection are very apt to prove fatal; but they are by no means necessarily so; and in the milder forms often end in recovery. 3. Chronic Phlebitis.—Various organic changes have been observed in the veins after death, which may have originated in chronic inflammation. Thus, they have been found thickened so as considerably to diminish their caliber, ulcerated, perforated, and softened; and rupture has sometimes oc- curred, in consequence of an unusual stress upon their coats in this fragile state. They are not unfrequently thinned and distended; their valves are sometimes partially or wholly destroyed; and calcareous deposits are found, though very rarely, between their coats. The small, loose concretions, of the size of a pea, or less, called phlebolites, which are occasionally met with in the veins, may, as suggested by Andral, sometimes originate in their coats, and, projecting into the cavity with a slender attachment, may be separated by a slight force; but they are thought generally to form in the blood itself, probably at first as a coagulum of blood or lymph, in which calcareous matter may be subsequently deposited. The veins are liable also to other organic affections, as steatomatous tumours and hydatids, and participate in the various ordinary or malignant diseases of neighbouring tissues. The de- rangements alluded to, however, are more objects of curiosity than of prac- tical interest; for they generally offer during life no phenomena, which would lead either to an accurate diagnosis or a just treatment. Treatment.—The pulse in phlebitis is not usually strong enough to call for the lancet, though in some instances it may be resorted to with advan- tage, especially in the earlier stages. It should never be omitted when the symptoms are active, and the circulation tolerably vigorous. The very free use of leeches along the affected vein is of the greatest importance. They should not only be applied once, but should be repeated over and over again, if the symptoms of inflammation should persevere. In phlegmasia dolens, 256 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. they are in general most effectively applied in the groin and upper part of the thigh, over the femoral vein; but they should also follow the track of the tender and hardened vessel, wherever it can be traced. The leeches may be followed by cold saturnine lotions, or simply cold water, applied by means of linen cloths, or by warm fomentations and emollient cataplasms, according as one or the other of these measures is found most comfortable to the patient. The local vapour bath has sometimes proved salutary. To relieve the very severe pain, anodynes, such as the preparations of opium, hyoscyamus, bella- donna, conium, stramonium, or hops, may be incorporated with the refriger- ant or emollient applications. When the bowels are not already too much disturbed, as they are apt to be in bad cases of the disease, saline cathartics may be employed, alternated with diaphoretic doses of tartar emetic, the neutral mixture, and other internal refrigerant remedies. Should the disease not seem disposed to yield, mercury should be resorted to, and pushed to a moderate salivation. Calomel or the blue pill may be given, in combination with opium or hyoscyamus; and mercurial frictions may be employed to hasten the impression upon the system. Throughout the complaint, it is often necessary, or at least advisable to control the severe pain and relieve restlessness by anodynes, and especially opium, which may be combined with ipecacuanha or tartar emetic in the earlier stages. After the subsidence of the violent symptoms, if the swelling remain hard, and appear disposed to become indolent, blisters should be employed; and, when leeches cannot be procured, they may be resorted to at an earlier period. A low diet, and perfect rest of the limb affected in the horizontal position, are also essen- tial parts of the treatment. When great prostration comes on, whether from the absorption of pus, or the exhaustion of the suppurating process, it is necessary to support the system by stimulant remedies and a nutritious diet. Wine-whey, carbonate of ammonia, quinia or infusion of bark, opiates, and animal broths and jellies are now appropriate; and these general measures may be employed, even though it may appear proper to make efforts for the relief of the inflammation by local depletion. In cases of metastatic abscess or purulent infection, the indication is in like manner to support the strength. In addition to the means necessary for this purpose, I am in the habit of using nitromuriatic acid, with a view to its alterative influ- ence on the blood; and chlorate of potassa, chloride of lime or soda, or chlorine-water may be tried with the same object. During convalescence, care should be taken not to employ very energetic measures for hastening the reduction of the tumefaction. Time is required for the sufficient enlargement of the new veins, through which the blood must make its exit from the limbs. Premature irritation might endanger an in- creased inflammation. But, with this caution, ointments of iodine or mer- cury, or of both, may often be usefully applied with the view of promoting absorption ; and blisters may be resorted to with the same object. Should considerable oedema remain, it may generally be corrected by bandages/ and the use of diuretics, such as squill and bitartrate of potassa. Article II VARICOSE VEINS. This affection, which consists in a dilatation of the veins, belongs in gene- ral to the province of surgery, and a very few remarks will suffice in this place. The dilatation may be extensive and pretty uniform, or local, and as it were in pouches. The vein is also generally lengthened, causing that tor- CLASS III.] VARICOSE VEINS.—PLETHORA. 257 tuous appearance so common in the affection. In most instances, there are knots at intervals along its course. The coats of the vessels are sometimes thickened, sometimes attenuated. The affection may originate in relaxation of the veins, in consequence of which the ordinary pressure produces their expansion ; or in a long-continued and unusual degree of pressure from posi- tion, ligatures, &c, even though the vessel may have been previously healthy. Not unfrequently the two causes act conjointly. When the internal veins be- come obliterated or obstructed, those near the surface often enlarge very much, under the pressure of the increased amount of blood which seeks a passage through them. Varicose veins upon the surface of the chest and abdomen are among the signs of impediment to the passage of blood through the great trunks of the interior of these cavities. It is probable that they may also result from rapid growth, under the influence of the recuperative powers of the system. The affection has been ascribed to disease of the valves, which, ceasing to close the vessel, no longer support the column of blood, which therefore presses with undue force upon the coats below. This is probably true in some cases; but not to the extent at one time supposed. As the veins dilate, the valves become incapable of performing their duty, and the disease may advance more rapidly from this cause. In consequence of the pressure of the accumulated blood, its return from below is retarded, and hence arise tumefaction and occasional oedema of the limb, sometimes at- tended Avith much pain, inflammation, and obstinate ulceration. Spontaneous cures are sometimes effected by the occurrence of adhesive inflammation, giving rise to the exudation of coagulable lymph, obstruction of the vessel, and its ultimate obliteration through the process of absorption. Various attempts have been made to effect cures by surgical operations; but these have often proved fatal by inducing phlebitis, and are much less fre- quently resorted to than formerly. The safer measure of equable and firm pressure is preferred when it is applicable. This may be assisted by the fre- quent application of cold water over the enlarged vessels; and some advan- tage may be expected from astringent lotions and cataplasms, where circum- stances admit of their continued use. If inflammation should supervene, rest, a horizontal or elevated position, leeches, and lead-water, are the ap- propriate remedies. A stimulating diet and stimulating drinks should be avoided as conducive to plethora. The mechanical measures necessary to produce pressure, and give due support to the vessels, belong to the surgeon. SUBSECTION IV. DISEASES OF THE BLOOD. Article I PLETHORA. A morbid increase of the blood beyond the wants of the system is called plethora. It is not, however, a mere augmentation of volume in the circu- lating fluid that is entitled to that name. This may result from an excess of the Avatery ingredient, and is not incompatible with the state of anaemia, which is the opposite of that of plethora. There must be a morbid increase of those constituents of the blood upon which its nutritive and stimulant properties depend, and to which it owes its peculiar character, such as the red corpus- cles, fibrin, and albumen. There may or may not be an increase of bulk. 258 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. There is no precise proportion of the active principles of the blood, Avhich is alone compatible with health. Their quantity constantly varies Avith the varying sources of supply, and extent of consumption; and, Avithin certain limits, no inconvenience is experienced from this irregularity. Even Avhen derangement of function results from an excess of blood, if it be moderate, and speedily relieved, as very often happens, by an increased activity of se- cretion, or a diminished vigour of the process of sanguification, the excess scarcely deserves to be considered morbid. It is only when the derangement is threatening or very inconvenient, or continues long without relief, that the affection would come under the designation of plethora. It is not necessary that there should be an absolute increase of the blood, in order to the existence of the disease. The quantity may remain precisely the same, and yet, if the Avants of the system for the support of its various functions should diminish, the phenomena of plethora may result; for it is the loss of balance between the supply and consumption, the former being in excess, that constitutes the affection. Symptoms.—Florid cheeks, and redness of the lips, tongue, conjunctiva, and mucous surfaces generally wherever visible, are usually considered as evi- dences of plethora; and they frequently are so; but they are also occasion- ally wanting, when the capillaries are from any cause inactive, or the excess is not so much in the red corpuscles as in the other active constituents of the blood. The pulse is ordinarily full, strong, and somewhat accelerated. When the affection is moderate, there is a slight feeling of heaviness, mental and bodily hebetude, and disposition to sleep, which increases in severe cases, and is attended with a sense of fulness or tension in the head, vertigo, tinnitus aurium, or headache; and sometimes palpitations of the heart and oppressed breathing are added to, or replace the cephalic symptoms. Bleeding from the nose or rectum is not uncommon. Blood drawn from the arm is often more highly coloured than in health, and affords a larger coagulum, with compara- tively little serum. It seldom exhibits the buffy coat, unless the affection is complicated with inflammation. Plethora is said by Avriters to be frequently attended with obesity. This may occasionally be the case; but, though the habit is often full, I have not usually found plethoric patients fat, and not unfrequently they are quite thin; the very deficiency in the nutritive function being probably one of the causes of the excess of blood. The copious secre- tion of adipose matter has a tendency to keep down any plethoric accumula- tion to which the individual may be predisposed. Causes.—A loss of equilibrium between the supplying and expending pro- cesses is the immediate cause of plethora. Digestion and absorption are rela- tively more vigorous than nutrition and secretion. The former processes may be healthy, while the latter are defective; or the former may be in ex- cess while the latter are healthy; or both may be deranged in different direc- tions, and thus co-operate to the same result. Whatever occasions this loss of equilibrium, is a remote cause of the disease. Excessive eating, especially of animal food; stimulating condiments or drinks, which excite digestion into preternatural activity; and indolent or sedentary habits, which occasion a deficient expenditure of blood in the various vital processes, are, singly or conjointly, the most efficient agents in the production of plethora. It is especially apt to result, when long-continued active exercise is suddenly fol- lowed by sedentary life. The invigorated appetite and digestion produced by the former, continue for a while after its cessation, and throw copious supplies into the circulation; while the previous expenditure is cut short or diminished, in consequence of the want of bodily activity. Continued mode- rate warmth, especially following cold weather, sometimes gives a morbid vigour to the process of sanguification. Hence, the system is apt to become CLASS III.] PLETHORA. 259 plethoric in spring. Certain constitutional influences have the same effect; such, for example, as pregnancy, which is often attended with plethora. Some individuals have a peculiar tendency to the over-production of blood, and become plethoric without any assignable cause ; and these are of course most readily affected by ordinary causes. Whatever checks secretion may give rise to the complaint. Cold sometimes probably acts in this way. The sudden stoppage of an habitual discharge, to which the system has accommodated itself, is an occasional cause. Hence, in part, the accidents Avhich follow the drying up of long-continued issues, the healing of old ulcers, the cessation of habitual hemorrhage from the nostrils, rectum, or uterus, and the omission of venesection after its frequent employment at certain intervals. From what has been said, it might be inferred that plethora is more common in females than males; and such is asserted to be the fact. Children are thought to be less subject to it than adults, in consequence of the vigour of their nutritive function. Perhaps the period at which it is most apt to occur, is that of ap- proaching maturity, when the body ceases to expand, and the processes con- cerned in sanguification have not yet fully adapted themselves to the new condition of the system. Nature and Effects.—An excess of either of the active ingredients of the blood, without a diminution of the others, would strictly constitute plethora. The cases, however, which most frequently attract notice are those character- ized by a superabundance of the red corpuscles; because the affection is, in these, more obvious to a superficial examination, and the occurrence of hemor- rhages gives greater apparent occasion for solicitude. But there may be others not less important, in which the fibrin and albumen have become un- duly accumulated. The tendency, in the former cases, is to hemorrhages and febrile action, in the latter, probably, to inflammation. Both may give rise to congestions. Andral expresses the opinion, that plethoric patients are not more likely to contract inflammation than others; and the remark may be true if, with him, we restrict the application of the term plethora to cases of excess merely of the red corpuscles. My own observation would lead to a different conclusion in relation to the disease, as I understand and have defined it. Treatment.—In the treatment of plethora, reference must be had to its duration. If it be temporary, and not immoderate, it will be sufficient to restrict the diet to vegetable food exclusively, or to this along with milk, to administer refreshing and mucilaginous drinks, and to keep the bowels freely open by saline laxatives. Should the symptoms be in any degree alarming, threatening apoplexy, for example, or indicating dangerous pulmonary con- gestion, the lancet should be resorted to, and employed Avith a freedom cor- responding to the danger. There is some hazard, however, in a too frequent resort to venesection in this complaint. The system accommodates itself at length to the repeated losses by a proportionate increase in the activity of sanguification; and if, under these circumstances, the abstraction should be inadvertently omitted, serious hemorrhages or other lesions might ensue. In cases of a protracted character, where the tendency to plethora is such that an excess is generated almost as fast as relieved by depletion, the lancet is admissible only to obviate immediate danger. The cure is to be effected here by a careful removal of all the causes; by a regulation of the diet, the avoid- ance of stimulants and tonics, and by frequent bodily exercise, of a kind not calculated greatly to excite the heart. In relation to the food, the abstemi- ousness should be in proportion to the obstinacy of the case. The patient should not sleep too warmly, and mattresses are therefore preferable to feather beds. He should also avoid confinement in over-heated apartments. The secretions should be sustained. If the skin is dry and the capillaries inactive, advantage will accrue from the occasional use of the Avarm bath and moderate 260 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. friction to the surface. Scanty urine may be relieved by cold drinks, with the aid of saline diuretics, especially bitartrate of potassa. Constipation may be obviated by the refrigerant laxatives. But the most important remedies by far will be found in diet and exercise properly regulated. Article II ANJEMIA. By anaemia (from a, privative, and al/xa, blood,) is understood a morbid deficiency or poverty of the blood. It is not necessary that there should be a deficiency in the volume of the circulating fluid. On the contrary, this is often quite as great in the disease as in health, and perhaps sometimes even greater. But, in such cases, the nutritive constituents of the blood are in less than their regular proportion, while the watery part is in excess. Any condition of the blood would come under our notion of this disease, in Avhich, either from deficiency in its general amount, or want of due proportion in its nutritive and stimulant ingredients, the functions of the body should be de- ranged in a considerable degree, or for a considerable length of time. There are two forms of this disease, one suddenly, and the other gradually induced. The former may be called acute, the latter chronic anaemia. Under these names they are here considered. 1. Acute Anaemia. This consists in a sudden diminution of the mass of blood, produced by copious bleeding or profuse hemorrhage. The whole volume of the blood is lessened, while its ingredients bear to each other the ordinary relation. The morbid phenomena attending the affection depend on two causes, first, the sudden abstraction of the stimulus of pressure exerted upon all parts of the system Avhen the blood-vessels are full, and secondly, the diminution of the supporting and stimulant influence of the blood upon all the functions of life. It is marked by universal paleness and coolness of the surface, diminution in the force and volume of the pulse, giddiness, disordered or impaired vision, dilated pupil, nausea and vomiting, great muscular debility, faintness, cold sweats, and not unfrequently irregular muscular contraction, amounting even to convulsions. Sighing, gasping, restlessness, jactitation, and delirium, are also among the occasional symptoms. Not unfrequently complete syncope results. If, upon the occurrence of this phenomenon, the blood ceases to flow, recovery may generally be effected, though not always. If the loss continue unabated, it must terminate in death. It has its origin usually either in venesection, spontaneous hemorrhage, ruptured aneurisms, ulceration or sloughing of the larger vessels, bleeding from wounds, or flooding in childbirth. The treat- ment consists of means calculated to arouse the failing or suspended actions of life, and, when immediate danger is passed, of such as tend to supply the deficient blood. To answer the first purpose, the patient should be placed with his head low, cold water should be sprinkled on the face, and ammonia- cal liquids held near the nostrils. Should these fail, artificial respiration may be resorted to, or even the transfusion of blood from the veins of a healthy individual, in cases otherwise desperate. After animation has been restored, the patient should be kept at rest, in a recumbent position, for a time pro- portionate to the degree of debility; as injury might result from over-action of the heart consequent on fatiguing exertion under such circumstances. This measure is highly important. A man was once brought almost blood- less into the Pennsylvania Hospital, in consequence of profuse hemorrhage CLASS III.] ANiEMIA. 261 from the bowels. The hemorrhage had ceased, but he was in the last degree exhausted. Particular direction was given that he should on no account leave his bed; but in the night he arose to go to the water-closet, and fell dead on the floor. On examination no blood was found in the bowels, so that his death was not occasioned by a recurrence of the hemorrhage. It is scarcely necessary to state that the diet should consist of nutritious and easily digestible articles of food. 2. Chronic Anaemia.—Chlorosis. This is a frequent attendant upon other recognized diseases, which impair the processes of digestion and sanguification, or drain the system of its blood; but it also appears to have occasionally an independent existence, and often requires the chief attention of the practitioner. It, therefore, merits distinct consideration. One of its most ordinary forms is that usually designated by the name of chlorosis or green sickness. Some authors consider this as distinct from true anaemia; but even these place its characteristic feature in poverty of the blood ; and it would be difficult to point out a single essential phenome- non in the complaint, which may not be traced to that source. The circum- stance that it generally occurs in girls or young unmarried women, would only prove that there are circumstances in their situation, peculiarly operative in the production of the disease, and not that there is anything peculiar in the disease itself. Nor is chlorosis confined to girls, or even to the female sex. The authors who treat of it as a distinct affection, acknowledge that it is sometimes met with in married women, and in males of delicate constitu- tion, especially about the age of puberty. In these latter cases, there is scarcely a shadow of distinction between it and anaemia proceeding from causes which leave no doubt as to its nature. I shall, therefore, consider it under the present head. Symptoms.—When the complaint is fully formed, there is commonly uni- versal paleness of the skin; the lips, tongue, and mucous surfaces in general are also strikingly pale ; there is extreme whiteness of the conjunctiva; and the whole surface of the body appears bloodless. Sometimes the face is yel- lowish or sallow, and has a waxen aspect. With this change of colour there is often a puffiness of the face, especially of the eyelids; the skin seems translucent; and, when the fingers are held up, the light shines through their edges. The lower extremities are apt to be edematous. The patient is feeble, and cannot bear much exertion, to which also he is usually indisposed. The circulation is irregular, but almost always weak. The pulse is often full, fre- quent, and thrilling or vibrating as in aneurisms; but it is soft, and easily compressed, showing a want of energy in the heart's impulse. It is almost always greatly quickened by bodily exercise or mental emotion. When the patient is entirely quiet and in a recumbent posture, it is often small, rather slow, #nd feeble. Palpitation of the heart is a very common symptom. It is sometimes continuous, sometimes irregularly intermittent, and may be in- duced by the slightest causes mental or physical. Violent exertion often throAVS the heart into the most tumultuous action. Pulsation in the carotids is often obvious, and the stethoscope applied over these arteries or the sub- clavian, discovers almost always morbid sounds, such as the bellows murmur; while the large veins, as the jugulars, yield a humming sound. The respira- tion, though quiet when the patient is at rest, becomes hurried and even pain- fully agitated under exertion, as in running, ascending heights, &c. The nervous system is often much disordered. Vertigo, dizziness, tinnitus aurium, and faintness are very common ; and spasmodic movements of the muscles, sometimes amounting to convulsions, are not unfrequent, especially in females. Violent and obstinate neuralgic pains in the head, side, breast, or other part 202 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. of the body, are also frequent attendants upon the disease. Even delirium has been noticed. The secretions are sometimes diminished ; and associated with this condition are extraordinary dryness of the skin, brittleness of the nails, and harshness of the hair. In other cases, on the contrary, there are profuse and exhausting sweats. In females, the menses are almost ahvays either altogether wanting or greatly deficient, being scanty, and light-coloured or even serous. The bile is also frequently scanty; and costiveness, with un- healthy alvinc evacuations, and a dyspeptic state of stomach, are extremely common. The symptoms in young Avomen sometimes so closely resemble those of phthisis, that, unless the practitioner is on his guard, he may readily make an erroneous diagnosis. There are cough, palor, emaciation, frequent pulse, night-sweats, and irregularity of menstruation; but it need not be said that the characteristic signs of phthisis are wanting. Various organic affec- tions are often associated with anaemia, some of which act as causes of the affection, and others probably are effects. Among the latter, there is good reason to believe that hypertrophy and dilatation of the heart may be in- cluded. The excessive action of the heart so common in anaemia may lead to the former of these affections, and the feebleness of the parietes from defective nutrition, to the latter. Attention has within a few years been called to the conjoint existence of enlarged thyroid, and enlarged and projecting eyeballs, associated with aniemia, and excessive action of the heart. This affection has already been sufficiently noticed, under the head of palpitation, to which the reader is referred. (See page 209.) When blood is drawn, it is found to be much lighter-coloured than in health; sometimes, in extreme cases, appearing like reddish dish-Avater. Upon coagulation, it exhibits a great excess of serum; the clot being very small, of a light-reddish or rosy tinge, instead of the deep-redness of health, and floating in an abundance of nearly or quite colourless liquid. It is, how- ever, usually rather firm, and not unfrequently exhibits a buffy and even cupped surface. The proportion of red corpuscles is obviously much dimin- ished ; and the same is probably the case, to a certain extent, with the fibrin; for, though Andral states, as the result of his experiments, that the fibrin and the albumen are in the normal proportion in spontaneous anaemia, this remark is not applicable to cases which result from repeated hemorrhage, and even in the former case, considering the occasional exceeding diminu- tiveness of the coagulum, can hardly be received as of universal application, unless after a much more extended series of observations. It must be ad- mitted, however, that there is usually a great deficiency of red corpuscles, not only in relation to the watery portion of the blood, but also to its remain- ing solid constituents. Even in the anaemia from hemorrhage, this relative deficiency is observable; for, though all the constituents are lost in the same proportion, yet the organs concerned in the production of blood, find in the system much larger supplies of the albuminous and fibrinous principles, than of those which constitute the red corpuscles; and, besides, as these proba- bly are a higher result of vital organization, they must be the last to be gen- erated. The cause of the buffy coat of the clot in anaemia is the relative excess of the fibrin over the red corpuscles. It is altogether independent of inflammation. It has been stated that a bellows murmur is heard when the stethoscope is applied over the large arteries of the neck. The same sound is in a less degree heard in the heart. Andral asserts that it is never absent in true amemia, and that it is inseparably associated Avith a diminution in the due proportion of the red corpuscles. He never met with it in cases in Avhich the proportion of fibrin or of albumen alone was lessened. The degree and continuance of the sound bear some relation, though not a constant one, to CLASS III.] ANEMIA. 263 the diminution of the corpuscles. Supposing the mean proportion of the cor- puscles to be 125 in health, Andral found that the bellows sound exists con- stantly in the arteries when the proportion is reduced below 80, occasionally when it falls between this number and the physiological mean, and not at all when it exceeds the latter point. Some inference may thus be drawn as to the degree in which the blood is impoverished in anaemia. The commence- ment of the affection may thus also be detected, before it has begun to ex- hibit itself by its characteristic feature of paleness. Occasionally persons with a rather florid complexion exhibit many symptoms of anaemia, such as general debility, feebleness and excitability of the pulse, palpitation and hurried respiration during exertion, &c. In these it would be difficult to verify the existence of the affection unless by means of auscultation. In that form of anaemia commonly called chlorosis, the subjects are usually girls between the periods of puberty and maturity. The complaint is in most cases very gradual in its advance, and is often from the beginning at- tended Avith deranged digestion and costiveness. The appetite is irregular, sometimes defective, sometimes excessive, and occasionally morbid in its preference for particular substances. The breath is often offensive. List- lessness, indisposition to exertion, and an expression of sadness or dejection, are not unfrequent features of the disease in its earlier stage. The com- plexion gradually fades, until at length it becomes of a pale, sickly hue, with a yellowish or greenish tinge, which has given rise to the name of the complaint. The other symptoms already enumerated are slowly developed. The menses either do not make their appearance, or, if they have occurred, gradually undergo diminution in colour and amount, until they entirely cease. The nervous symptoms are peculiarly prominent, and the patient is not un- frequently afflicted with all the harassing train of hysterical disorders. In its early stage the disease is usually very manageable, and, Avhen there are no organic complications, and the patient can be Avithdrawn from the in- fluence of the causes, may in general be cured, or at-least placed in a* fair way of recovery, in a period of time varying from two to four Aveeks. Under opposite circumstances, and especially when improperly treated, it may ter- minate fatally. When long continued, it is apt to induce dropsy, and pro- bably also organic disease of the heart. The excessive action into which this organ is thrown by the call from the capillaries for a more rapid current of blood, to supply the deficiency of nutritive material, leads to an enlarge- ment ; while defective nutrition renders it soft and flabby. Upon dissection, the arteries and veins are found empty or scantily sup- plied with a serous fluid; the flesh is dry, and does not bleed Avhen cut; effu- sion of serum is observed in the pleura, pericardium, peritoneum, and cellu- lar tissue; the heart is pale, soft, flabby, and often dilated; and various organic affections are not unfrequently discovered, such as tubercles, carci- nomatous tumours, and enlargement or other disease of the liver, spleen, kidneys, or ovaries. When these latter affections are found, the probability is that they were the cause and not the effect of the morbid state of the blood. Causes.—The lymphatic temperament is believed to predispose to this complaint. The immediate causes are either such as directly detract from the amount of the blood, or such as diminish its production. Frequent bleedings repeated at short intervals, aud spontaneous hemorrhages con- stantly recurring, such as epistaxis, the hemorrhoidal flux, lneinatemesis, and menorrhagia, are among the first set of causes. In the same category may be placed extensive secretory discharges, especially from the bowels and uterus. To the second set of causes belong, in the first place, the Avant of due materials out of Avhich the blood may be elaborated, and, secondly, de- rangement of the processes of digestion and sanguification by which it is 264 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. produced. Food insufficiently nutritive, of difficult digestion, or otherwise unwholesome; the abuse of coffee and tobacco ; excessive drinking, even of water ; habitual exposure to cold and dampness; sedentary habits, or pro- longed over-exertion ; debilitating agencies in general; the depressing emo- tions, as grief, disappointment in love, ambition, or business, concealed and unanswered affections, and mental anxieties of all kinds, may be ranked among the causes of anaemia. The influence of the sexual apparatus may possibly in some unexplained mode interfere with sanguification, so far as to induce or favour the production of the disease. This is inferred merely from the circumstance that it is most apt to attack young women about the age of puberty. Amenorrhoea, which has been sometimes ranked among the causes of this disease, is more probably one of its effects, or at most a joint result of the same influence. Organic diseases of the stomach, bowels, liver, spleen, and heart, are frequent causes of anaemia, probably by interfering with the processes by which the blood is produced. Chronic debilitating dis- eases have the same effect, partly through a similar influence, and partly by exhausting the blood. Bright's disease of the kidneys, in its chronic form, is very generally attended with anaemia, resulting in part at least from the loss of albumen, and probably, as shown by Dr. J. T. Plummer, of the ex- tractives of the blood, with the urine. (See Am. J. of Med. Sci, N. S., xxvi. 389.) Among the most frequent causes of anasmia in this country are the miasmatic fevers, and the visceral disorder, whether splenic or hepa- tic, which they so frequently leave behind. Chronic disease of the spleen is an extremely frequent associate of the affection, and probably very often in the relation of its cause. Cases have occurred in which the disease has at- tacked at the same time numbers of persons employed in coal mines, and the result has been ascribed to the dampness and want of light and pure air; but such cases are uncommon, while the causes to Avhich they are ascribed are always in operation. In the particular cases recorded, the anaemia was preceded'by severe disease of the bowels, to which, probably, more than to the circumstance alluded to, the effect may be ascribed. (Did. de Med., xii. 581.) The constitutional action of the preparations of lead has sometimes been evinced in the production of anaemia. Treatment.—In the treatment of this disease it is of the utmost importance to remove the causes. While these continue to act, the use of remedies will be only of temporary benefit. Should the digestive system be in disorder, it must be corrected ; constipation must be obviated ; any hemorrhage or other drain which may exist must be arrested; the menses, if retained, suppressed, scanty, excessive, or otherwise irregular, must be restored to the healthy state; and, in general, any other existing disease which may impair the di- gestive and assimilative processes, or debilitate the system at large, must, as far as possible, be removed. The modes of treatment which may be neces- sary for these purposes are given under the heads of the affections respect- ively to be corrected, and need not be repeated here. Close attention must be paid to the peculiar circumstances of the patient; and, Avhenever any moral cause is discovered to which the complaint may in part or wholly be ascribed, efforts should be made to obviate its influence. In chronic cases, moderate exercise in the open air, and especially on horseback, should be encouraged; but in the acute, rest is necessary until the blood has been replenished. The patient should sleep in well ventilated apartments; and the ill effects of unequal temperature should be prevented by flannel next the skin. All these measures, by invigorating the general health, will have a tendency to pro- duce a more copious supply of well-conditioned blood. The same end will be promoted by a nutritious and digestible diet, as recommended in dyspepsia. The medicines best adapted to the disease are tonics, and especially the CLASS III.] ANAEMIA. 265 chalybeates, which, besides an invigorating influence over the process of digestion and the vital processes generally, have a peculiar power of increas- ing the richness and redness of the blood, by an operation not exactly under- stood. They produce, indeed, the very effect that is most wanted in this dis- ease, an augmentation, namely, of the proportion of red corpuscles.* Hence, the preparations of iron have been long considered almost as a sovereign re- medy in chlorosis. It matters little which of the preparations is employed, provided the iron finds access into the system. That one should be selected Avhich irritates the stomach least, and is most rapidly absorbed. Perhaps the best is the pill of carbonate of iron of the U. S. Pharmacopoeia, which may be given in the dose of from 5 to 20 grains three or four times a day. The black impalpable powder of iron, the subcarbonate, black oxide, tincture of the chloride, solution of the iodide, potassio-tartrate, citrate, lactate, or sul- phate, may also be used, at the discretion of the practitioner. Tannate of iron has been recommended as especially efficacious. When the case is one of pure anaemia, the chalybeates alone, united with a proper diet, will be sufficient for the cure. But, when the digestion is feeble, they may be advan- tageously combined with the simple bitters, such as the extract or infusion of gentian or quassia, and the powder or infusion of columbo ; and the com- bination will be rendered more acceptable to the stomach, by the conjunction of some aromatic, as ginger, or cinnamon. Mild laxatives may be added in cases of constipation, and of these, when uterine disorder is not involved, the best is rhubarb. But if amenorrhcea exist, aloes is the appropriate laxative, and should be given with each dose of the chalybeate in the quantity of one or two grains. The preparations of manganese have been recommended, and may be tried in cases which resist the chalybeates. The mineral acids are sometimes useful when the appetite is very languid, and, if the liver is func- tionally deranged, nitromuriatic acid should be preferred. But care should be taken that they do not prove injurious by a chemical incompatibility with the particular chalybeate employed. Nervous derangements may be com- bated by the occasional use of the antispasmodics, especially valerian and assafetida, and of the narcotic extracts, such as those of hyoscyamus and conium. The severe neuralgic pains which often attend the complaint may be relieved by blisters applied near the seat of the affection, and, if neces- sary, sprinkled Avith morphia after the removal of the cuticle. The daily use of the cold shower-bath, if followed duly by reaction, will often be found use- ful, and may be resorted to in obstinate cases; and dry frictions over the surface have been recommended. It is often advantageous, in order to hasten or confirm convalescence, or even as a remedy in obstinate cases, to send the patient upon excursions to chalybeate springs at a distance from home, so as to combine with the medi- cinal effects of the iron the happy influences of exercise, pure air, novelty of * The effect of iron upon the constitution of the blood is astonishing. The propor- tion of the solid constituents, and especially of the red corpuscles, is rapidly increased. The fibrin, however, appears to be somewhat diminished. The following results were obtained by Herberger, and correspond essentially with those of Andral and Gavarret, and of Simon. (See Simon's Chemistry, Syd. ed., i. 313.) The blood examined was that of a chlorotic female of 20 years. The first column contains the results before she had taken iron, the second, after a course of chalybeates, which continued eight weeks. Albumen Extractive matters and salts The diminution of fibrin is probably consequent upon its conversion into the sub- stance of the red corpuscles. VOL. II. 18 Water 1. 868-340 2. 807-080 Solid constituents Fibrin Fat 131-660 3-609 2-310 192-290 1-950 2-470 1. 2. 78-200 81-509 36-470 94-290 1-590 4-029 8-921 8-236 266 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. scene, and the enjoyments of society. Unless complicated with serious or- ganic lesions, the disease may generally be cured, or materially relieved, by the means above detailed, in a period varying from two to six Aveeks. Article III LEUCOCYTHyEMIA. Syn.—Leuchsemia. (Virchow.) The name leucocythaemia, signifying white-cell blood (huxoz, white, xuroc, cell, and al/ia, blood), was given by Prof. Bennett, of Edinburgh, to a peculiar form of anaemia, characterized by the presence in the blood of a great excess of the white or colourless corpuscles, readily distinguished from the blood-disks by their spherical shape, greater size, and granular aspect, and by the exhibition of nuclei when treated with acetic acid. Tavo cases of the disease were described in the Edinburgh Medical and Surgical Journal for October, 1845, one by Prof. Bennett, and the other by Dr. Craigie, in which, though the excess of white corpuscles was observed, they were con- sidered as pus corpuscles; and the affection was regarded by Prof. Bennett as suppuration of the blood. In the following month, Prof. Virchow, of Berlin, began a series of communications in a German journal, in Avhich he described several cases of the affection, and first put forth the opinion that the corpuscles referred to were really the white corpuscles of the blood. Considering the associated symptoms to characterize a peculiar disease, he gave to it the name of leuchaemia (from J.suxoq, white, and alp.u, blood). Subsequently Prof. Bennett published, in different numbers of the Edin- burgh Monthly Journal of Medical Sciences, for the years 1851 and 1852, and in a distinct Treatise, an elaborate account of the disease, illustrated by many cases; adopting Yirchow's views as to its nature, but substituting for the name proposed by him, the one given at the head of this article, as more accurately expressing the nature of the affection, which is not characterized by white blood, but by an excess of white cells in the blood. In this form of anaemia the surface is usually strikingly pale, and a dis- position to oedema exists. In all the cases hitherto observed, the affection has been associated with structural disease of one or more organs, upon which it probably depended; as, whenever an opportunity has been offered to make the requisite investigation, it has been found that the excess of white corpuscles did not begin to appear, until after the local lesion had been for some time in existence. Of these associated affections enlargement of the spleen is the most common, having, indeed, been noticed in almost all the cases. In many the liver also is enlarged, and not unfrequently the lym- phatic glands. I believe that no case has been observed, in which either the spleen or the lymphatic glands were not diseased; and the instances are very few in Avhich the latter were exclusively affected. Disease of the spleen, therefore, is the chief source of the affection of the blood. This organ is sometimes enormously enlarged. The complaint has usually a very sIoav march, lasting for years, and in some instances for many years, before the fatal termination. Beginning insidiously, it has often existed for a long time before attracting notice. With a gradually increasing anaemia, it is, in most instances, attended with disorders of the respiratory and digestive functions, as dyspnoea, diarrhoea alternating with constipation, vomiting, oedema of the extremities, ascites, CLASS III.] LEUCOCYTHJEMIA. 267 jaundice, &c.; some depending immediately on the splenic or hepatic dis- ease, others on the state of the blood. In the latter category is probably the dyspneea, which is often a prominent symptom. In some cases there is fever, with evening.exacerbations, and a tendency to assume the hectic char- acter. In others, hemorrhage, especially epistaxis, is a more prominent symptom, and is a source of great danger, exhausting the strength by its frequent recurrence, and sometimes causing immediate death by its abund- ance. Occasionally it occurs in the brain, and proves fatal, with apoplectic phenomena. Generally, however, death takes place, as the result of a slow and gradual failure of the vital powers, in an extreme state of marasmus. The disease is almost always sooner or later fatal, though not without periods of apparent amendment in its course. In those cases which have not ended in death, the result does not seem to have been positively de- termined in any instance. Yirchow states, in an article on the subject, published in 1856, that there had been no well authenticated instance of recovery. I have had three cases of the disease, one of which apparently recovered,* the second terminated fatally, and the third passed from under my care little altered. In all, the spleen was greatly enlarged. It is not improbable that the disease may exist to a considerable extent in the mias- matic districts of this country, Avhere disease of the spleen abounds; but I have ascertained, by observation, that it is not an ordinary complication of that form of amemia with enlarged spleen, which so frequently attends or follows miasmatic fevers. The blood during life has the ordinary red colour; but, when defibrinated and allowed to stand, it deposits first the red and afterwards the white cor- puscles, the latter of which form upon the surface of the former a yellowish- white layer, of the appearance of pus. After death, soft yellowish or greenish coagula are found in the right cavities of the heart, distinguishable from the fibrinous coagula of phlebitis by the absence of adhesions, and by being separable, by agitation with water, into the white globules which render the * This patient was a lad about seventeen years of age, who came to the hospital from sea, having been in the West Indies, and on the coast of North Carolina. We could not learn from him that he had been affected with intermittent or remittent fever. He was extremely anemic, with edematous limbs, and very feeble. The spleen was enormously enlarged, and the abdomen tumid. Dr. Addinell Hewson, one of the resident physicians of the hospital, examined the blood, and found it to abound in the white corpuscles. Not less than thirty were visible in a portion of diluted blood in the field of the micro- scope. The patient was put upon the use of sulphate of quinia, the pill of carbonate of iron, and rich animal food. His general health rapidly improved, the spleen grew less, the dropsical symptoms quite disappeared, and he became florid and full under the treatment. But the white corpuscles were little diminished; and it was soon noticed that, though the spleen had shrunk nearly to its normal size, the liver had become greatly enlarged, and was somewhat painful on pressure. Attributing the hepatic affection to excess of stimulation from the medicine and rich food, I directed the quinia and iron to be omitted, small doses of the blue mass to be administered, a blister to be applied over the liver, and the diet restricted to vegetable food. Under this plan the liver was soon much diminished, but the spleen again increased in size, and the anemic symptoms began to reappear with a somewhat mottled and purplish hue of the surface. As the gums were slightly affected by the blue pill, this was omitted, nitromuriatic acid was substituted, a blister applied over the spleen, and a milk diet directed. His health now rapidly improved, and the spleen and liver were both gradually reduced in size; but as he continued anemic, the acid was omitted, and the pills of carbonate of iron, with a full diet ordered. Under this treatment he continued steadily to amend, and at length was restored to perfect health, with a good colour, strong, fleshy, and free, so far as could be ascertained, from splenic or hepatic disease. The proportion, moreover, of the white corpuscles gradually diminished, and, when the blood was last examined, it exhibited only two or three in the field of the microscope, where thirty or more had been pre- viously seen. He was dismissed from the hospital, after having been under treatment 69 days. A particular account of the case has been published by Dr. Hewson, who made all the microscopic observations. (See Am. Journ. of Med. Set., N. S., xxiv. 365.) 268 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. liquid milky, and into a clot of fibrin. (Virchow.) The characteristic con- dition of the blood is a great diminution in the proportion of red corpuscles, and a very great increase in that of the white. Instead of one of the latter, to between 300 and 400 of the former, which is about the normal proportion, the blood in this affection contains, according to Dr. Pavy, one of the white to 21, 12, or IT of the red, and, in a case seen by Vogel, the proportion was increased to 1 to 2. (Arch. Gen., Fev. 1856, p. 130.) Virchow men- tions an instance in which two out of five of the corpuscles were white. The blood of leucocythaemia differs from that of simple anaemia by its great excess of white corpuscles; and from that of inflammation, in Avhich the proportion of these corpuscles is said to be increased, by its deficiency in red corpuscles, and its normal proportion of fibrin. Though ahvays associated with disease of the spleen or lymphatic glands, the change in the blood bears no special relation to the degree of the or- ganic lesions. Nevertheless, the prevalent opinion as to its cause is, that it depends upon an influence exerted on the blood by the diseased organs, which consume the red corpuscles as it passes through them, and supply their place by the production of an increased quantity of the white. In favour of this view is the fact, said to have been proved in relation to the healthy spleen, that the blood, upon leaving it, is poorer in the red and richer in the white corpuscles than when it entered; showing that its in- fluence in producing leucocythaemia is only an exaggeration of its healthful action. Still further confirmatory of the view is the statement of Virchow, that, in the cases connected with diseased lymphatic glands alone, he found the blood, instead of well-developed cells, conforming to those of the spleen, as in ordinary cases of the disease, to contain innumerable round granular nuclei, analogous to those found in the parenchyma of the lymphatic glands. (Arch. Gen., Fev. 1856, p. 132, from Gesammt. Abhandl. zurWissenschaft.3fedicin.) The idea is not without plausibility, that the disease is, as Prof. Bennett originally imagined, a kind of suppuration of the blood. In the first place, the general symptoms of the disease are of a character to render this highly probable; and secondly, according to M. De Chaumont, the corpuscles are affected in the same manner as pus corpuscles by chloroform, A\rhich clears them up and brings the nuclei into view, while it has no effect on the colourless corpuscles of the blood. (Ed. Month. Journ. of Med. Sci, May 1853, p. 4T0.) As to the treatment of leucocythaemia, little need be said. As nothing hitherto done can be asserted to have effected cures, the practitioner is thrown on his own resources, and must use the measures Avhich seem, in his best judgment, to be indicated by the appreciable morbid conditions. In a note upon the previous page will be found the measures employed by the author in a case which appeared to end favourably, but in which he has been unable to verify the persistence of the cure. Article IV SUPRA-RENAL CACHEXIA. Syn.—Addison's Disease.—Bronzed-skin Disease. The name at the head of this article is adopted provisionally, to be super- seded when a better can be found. It indicates two prominent characters of the disease; the cachectic state of the system, and the morbid condition of the supra-renal capsules. The name of Addison's disease was given to CLASS III.] SUPRA-RENAL CACHEXIA. 269 it in honour of the discoverer; that of bronzed-skin disease, as expressive of one of its most striking, though not positively essential phenomena. I place it among the blood diseases; because it is obvious that most of the symptoms, and probably the result, depend upon the state of that fluid. To Dr. Thos. Addison, of Guy's Hospital, London, belongs the undivided credit of having discovered this affection. Having noticed various instances of a peculiar discoloration of the skin, connected with an anemic or cachec- tic state of system, which sooner or later almost invariably ended in death; and having, on post-mortem examination, found, as a constant attendant on these phenomena, some organic lesion of the supra-renal capsules, often with- out any other discoverable lesion whatever, he felt himself justified in con- sidering these several morbid conditions as having an essential connection, and as constituting a distinct affection. His conclusion has, I believe, been universally received by the profession; and, whatever difference of opinion may exist as to the connection between the associated phenomena, no one refuses to admit the new claimant into the category of diseases. As defined by Addison, it is a peculiar form of anaemia, characterized by great general debility, feebleness of the pulse, and irritability of stomach, and associated with brown discoloration of the skin, and disease of the supra- renal capsules. Symptoms.—The complaint usually begins insensibly, and is very slow in its progress, often running on for months before it is recognized; but sometimes it is much more rapid, and ends fatally in a few weeks from its commencement. This difference is ascribed by Dr. Addison to the more or less rapid develop- ment of the supra-renal disease. The first observed symptoms, omitting for the present the consideration of the colour of the skin, is a remarkable degree of languor or weakness, with an indisposition to exertion, whether bodily or mental. The pulse is usually small, sometimes full, but always feeble; and, though it may be occasionally excited, is commonly normal in frequency. The appetite is diminished or lost; there is uneasiness or slight pain at the epigastrium; and nausea and vomiting are sometimes prominent symptoms. The bowels are usually inclined to costiveness; but are sometimes affected with diarrhoea. The patient loses flesh, but not in proportion to his increas- ing weakness ; and the emaciation is much less striking than in other wast- ing diseases, such as phthisis and carcinoma. It is rather a flabbiness or re- laxation of the tissues than a positive Avasting. Aching in the back and loins is complained of by many patients. There is sometimes more or less cerebral disorder, indicated by loss of memory, feelings of numbness, and even convul- sions ; but these symptoms are not general. In parts of the surface not dis- coloured, there is unhealthy paleness ; the tongue is pale; and the white of the eye is remarkably clear and pearly. The urine and biliary secretions are usually normal; and, in most cases, nothing is to be found in the state of the heart, liver, kidneys, lungs, or any other organ open to examination, which can explain the phenomena. "With these constitutional symptoms there is a remarkable discoloration of the skin ; at first of a dingy, sun-burnt hue, but darkening into some shade of "deep amber or chestnut-brown." (Addison.) Mr. Hutchinson describes it as bearing a close resemblance to the colour of a bronze statue, from which the gloss has been rubbed off; and the term bronzed is now generally applied to the discoloured skin in descriptions. When the colour is uniformly dif- fused, the patient, though white before, has very much the appearance of a mulatto. Sometimes it appears in ill-defined patches, with lighter coloured or even pale portions of skin between, giving to the surface a mottled aspect. In other instances, it is uniformly diffused over large portions of the surface. It is o-encrally most "strongly manifested on the face, neck,superior extremi- 270 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. ties, penis and scrotum, axilla, and around the navel." Black stains on the mucous lining of the lips are spoken of as constituting an important diagnos- tic character. The colour of the skin is not affected by pressure. The cir- cumstance that it is disposed to showitself especially where there is naturally a large proportion of pigment cells, as around the nipples, and does not ap- pear Avhere these are wanting, as in the palms of the hands and the matrices of the nails, would seem to prove, that it is OAving to the deposition in the skin of an excess of the normal pigment matter. (Hutchinson, Med. Times and Gaz., March, 1856, p. 281.) With the duration of the disease, the symptoms above enumerated undergo aggravation; the languor and Aveakness are extreme; the appetite is quite lost; the pulse becomes more and more feeble; till at length the vital actions gradually fail, and the patient dies. Sometimes typhoid symptoms precede death, and sometimes convulsions. Diagnosis.—The association and march of symptoms above described are unlike those of any other disease. Even without the discoloration of skin, the affection is sufficiently marked to be distinguished; and Dr. Addison mentions a case of the kind as having occurred at Guy's Hospital, and to have been proved to be such on examination after death. (Med. Times and Gaz., Feb., 1858, p. 203.) From almost all other cachectic affections, this is distinguished, independently of the colour, in the first place by the absence of any discoverable source of the phenomena, and secondly by the relatively moderate degree of emaciation, considered in connection with the other symp- toms, and with the inarch and termination of the disease. The colour, as it first appears, might be mistaken for that of a sunburnt skin; but it is seen also in parts covered by the clothing. The hue in Pityriasis versicolor bears considerable resemblance to it; but the patches of this affection are more defined ; it yields readily to remedies ; and the furfuraceous character of the surface, and the presence of a fungus visible under the microscope, leave no room for doubt. Finally, the colour in jaundice is sometimes not unlike that of the disease in question; but in the former the sclerotica always participates in the discoloration, in the latter is remarkably clear and pearly. Anatomical Characters.—In all the cases observed by Dr. Addison,* and in all which were subsequently collected from various sources and tabulated by Mr. Jonathan Hutchinson,y amounting to at least 2T, when- ever a post-mortem examination was made, the supra-renal capsules Avere found more or less diseased, and in not a few cases, were the only organs that were diseased. The affections of the capsules AA'ere various; in some instances simple inflammation and suppuration, in others atrophy with fibro- calcareous concretion, in a third set fibroid degeneration Avith induration and enlargement, in a fourth tubercle, and in a fifth carcinoma. Fatty degenera- tion, and cystoid disorganization have since been added to the list. In some instances the disease of the capsules Avas secondary, in others original and exclusive. These facts appeared sufficient to establish a fixed relation be- tween the disease of the capsules and the cutaneous discoloration; especially when supported by another important fact, that, out of 500 post-mortem ex- aminations, made in Guy's Hospital in the years 1854 and 1855, there was only one instance of disease of these capsules noticed in which there was no discoloration of the skin ; and, in that one, only a feAv malignant tumours grew from the surface of the organ. (B. and F. Medico-Chirurg. Rev., Oct., * On the Constitutional and Local Effects of Disease of the Supra-renal Capsules. London,1856. ■j- Medical Times and Gazette, March, 1855, p. 281. CLASS III.] SUPRA-RENAL CACHEXIA. 271 1856, p. 319.) Subsequent observation, however, has given somewhat dif- ferent results, which will be noticed directly. Nature.—Of the character of the connection between the discoloration of the skin and the capsular disease several views may be taken. 1. The con- nection may be simply accidental. This would seem most probable, had it occurred only in a small number of cases. But the coincidence, as above shown, has been very frequent, if not invariable. It is true that, since the publication of Mr. Hutchinson's paper, several instances of moderate dis- ease of the capsules, and one or two in which they have been wholly disor- ganized have occurred, without being attended with bronzing of the skin; but they have been very few, compared with those of a contrary character; and it seems to me impossible, in the face of these facts, to believe that the association of the two affections has been merely accidental. The exceptions referred to at most only prove that the connection is not absolutely necessary or essential. 2. It may be said that the disease of the capsules and the skin may depend on some common but hidden cause. This opinion, however, is quite untenable ; for the affections of the capsule have been so various that they could have proceeded from no one source. Inflammation, tubercle, car- cinoma, and fatty degeneration, which, besides other lesions have been found in the capsules, have very different causes, not one of which is known to pro- duce the cutaneous discoloration. 3. The relation between the two condi- tions may be that of cause and effect. But that the discoloration of the skin could not possibly have produced the supra-renal disorder, is sufficiently proved by the multiplicity of the latter, which cannot be conceived to have originated in one cause. It follows, therefore, that the disease of the supra- renal capsules must have directly or indirectly caused that of the skin. That we cannot understand hoAv the effect is produced is no argument against the fact. I cannot see how any other conclusion can be drawn from the foregoing facts and considerations than the one here arrived at. Against it, however, the cases have been adduced in which partial disease of the capsules existed without bronzing. The answer has been that the portion of the organs remaining unaffected might have been sufficient to perform the function. But very recently one or more instances have occurred, in which both capsules were completely disorganized, without the accompani- ment of the cutaneous symptom. The only rebutting arguments that appear available here are, first, that the office of the capsules may in some instances be transferred to or shared by some other organ or organs, and, secondly, that, as suggested by Mr. Hutchinson, the disorganization in the cases re- ferred to was so rapid, that time was not allowed for the change of colour, which is a very slow process. (Med. Times and Gaz., Feb., 1858, p. 203.) A feAv cases, moreover, have been published, in which, though the dis- coloration existed, the capsules after death were found perfectly free from disease. Most of them, however, have little weight; because it has been shown that, in one instance in Avhich the capsules appeared perfectly healthy to the eye, they had been found, on examination by the microscope, to be a mass of fatty degeneration; and consequently none assumed to be healthy from their appearance alone, could be admitted to be so unless after having been submitted to the microscope. But even allowing cases to have under- gone this test, they could not be received as evidence against the assumed de- pendence of the morbid colour on the supra-renal disease; for defective function in the capsules might lead to the same result as deranged structure ; as mere functional disorder of the liver is known often to be attended with suspension of the biliary secretion. Upon the whole, it appears to me that a positive relation of cause and effect has been made out to exist between the cutaneous and capsular 272 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. affections, and, that the latter is, at least in the great majority of cases, the cause of the former. But admitting this, it does not follow that other organs may not produce a similar effect. This has, indeed, been conjectured of the pituitary gland. Dr. Gull has found considerable analogy in struc- ture between this gland and the supra-renal capsule; and in a case of death with bronzed skin, in which there was no disease of the latter struc- ture, he found the pituitary gland considerably deranged. (Lancet, Am. ed., July, 185T, p. 61.) Theory of the Disease.—It is supposed that the supra-renal capsules, which have hitherto been overlooked physiologically, have some important function in the animal economy, upon a failure of which the digestive and as- similative processes suffer, imperfect blood is produced, the pigment matter is excessively deposited in the skin, and a general prostration is at length pro- duced incompatible with life. In what manner they exercise this influence, it is not pretended to decide. The conclusion is based exclusively on ob- servation. But a strong resemblance has been imagined between the struc- ture of the organs and the nervous centres ; and the idea has been advanced » that they might preside, in a similar manner, over the organic functions, pos- sibly in co-operation with the sympathetic system. To the opinion of their importance in the economy some strength was given by the experiments of M. Brown-Sequard, who found death to result within a few hours in the lower animals, when these bodies were extirpated. But the effect of these experiments has been weakened, if not nullified, by others more recently per- formed by Dr. George Harley, of London, who has removed the supra-renal capsules from cats and rats, in several instances, without serious consequences; and believes that the fatal results, in other instances, are to be ascribed mainly to injury of the solar plexus in the vicinity of this organ. Prognosis.—This is extremely unfavourable. No well-developed case has, I believe, been known to terminate in health. In one case, a "dirty-brown tinge" of the skin, which appeared suddenly, and disappeared after a month, can scarcely be considered as an exception to the general rule. But I can- not think that the affection is necessarily incurable, if recognized and treated in its earliest stage. In cases of malignant disease of the capsules there can be no hope ; nor, perhaps, in the advanced stages of the affection, when there may be reason to think that these structures are already disorganized. But, as the disease of the organs is sometimes inflammatory, and perhaps in other instances merely functional, or the result of impaired nutrition, surely we may hope, by the timely application of suitable remedies, to arrest and even cure it. Treatment.—The measures hitherto employed having proved fruitless, the practitioner is left to his best judgment in the application of remedies. Tonics, stimulants, and supporting measures have been tried, it seems, in vain. Upon them, therefore, reliance cannot be placed. It seems to me that re- medies should be addressed mainly to the supra-renal capsules. Watch for the first evidences of the disease in the comparatively light stain of the face or neck, and then, in the hope that the affection of the capsules may be inflam- matory, keep the patient at rest, restrict his diet, give saline cathartics if ad- missible, apply cups and blisters to the back over the seat of the capsules, and, if these fail, put the system under a moderate mercurial course. In the advanced stages, when the organ may have been destroyed by suppura- tion, this treatment would be of no use, and should not be adopted. It would be equally useless in cancerous cases, or those connected with malig- nant disease; but it would do little harm, as death must occur at all events. Nor would the antiphlogistic course be applicable to tuberculous cases, or to thqse of simple impaired nutrition or fatty degeneration. If there is good CLASS III.] COAGULA IN THE ELOOD. 273 reason to suspect either of these conditions, measures of a supporting char- acter would be indicated, such as chalybeates, the mineral acids, the prepa- rations of iodine, cod-liver oil, and a nutritious diet. Article V COAGULA IN THE BLOOD. Syn.—Thrombosis. (Virchow.) Most of the facts contained in this article are noticed, more or less fully, in different parts of the work, in connection with diseases to which they are specially related. But the subject has recently attracted so much attention, and is in itself so important, as to merit a separate consideration; though there is scarcely sufficient unity of morbid action in the several affections to be noticed, to entitle them to be considered as constituting strictly one spe- cial disease. Virchow thinks differently, and, adopting the name thrombus, from the Greek, for the clot or coagulum, dignifies the general condition of which it is one of the characters with the title of thrombosis. 1. Anatomical Characters.—Coagula may occur in the heart or the blood- vessels, and on either the arterial or venous side of the circulation ; in fact, wherever there is liquid blood out of which they may be formed. They are probably, however, most frequent in the heart, the valves of which, especially those of the left side, are their favourite seat. In form, they are extremely various, sometimes being a simple layer on the surface of the lining mem- brane, sometimes rising from it as roundish or irregular excrescences, and often in masses, either shapeless, or moulded by the cavity in which they lie, and to the walls of which they almost ahvays adhere. They are of all sizes, from that of a pin's head or less, to a magnitude nearly sufficient to fill one of the cavities of the heart, or large portions of one of the great arteries or veins. They vary in colour from the redness of the blood to Avhiteness, and in consistence from an almost diffluent softness, to a considerable degree of firmness and tenacity. They may contain all the ingredients of the ordi- nary clot of blood formed out of the body; but generally have less of the red corpuscles; and often consist exclusively of fibrin and the Avhite corpuscles. They usually have a somewhat laminated arrangement, as if formed by suc- cessive layers. In the vessels, they may line the inner surface more or less thickly, still allowing the blood to Aoav, or may fill up the caliber completely, so as to arrest the circulation. In the former case, they are apt to increase by new accretions in the direction from the heart, in the latter they advance in a similar manner towards the heart, until they reach the nearest bifurca- tion, when they terminate with a rounded extremity, which, in the veins, according to Virchow, projects somewhat into the main trunk, and floats loosely in the current of the blood. In most instances, they commence as a layer on the inner surface of the heart or vessel, whether by deposition of fibrin from the blood, or by exuda- tion from the vasa vasorum has not been determined; though probably some- times in one way, and sometimes in the other. Not unfrequently, also, they appear to be formed about a nucleus, which may itself be a portion of a fixed clot, broken off and carried to a new site. In either case, they in- crease by successive additions of coagulated blood or fibrin. After their formation, they undergo various changes, being sometimes organized, and ultimately converted into a kind of ligamentous tissue; in 274 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. other instances, becoming softer or harder, undergoing a fatty or calcareous conversion, or breaking up, especially when the blood is diseased, into a kind of puruloid matter. Not unfrequently, in all probability, they are dissolved in the blood, and washed away with it, leaving the vessel permeable. 2. Causes.—The condition which is thought to be most favourable to the formation of coagula is a stasis of the blood, either general or local; and, in proportion as the movement of the circulation is more or less com- pletely supended, is the greater or less tendency, other things being equal, to their generation. Hence the disposition to the production of the heart- clot in the last stage of life, or in extremely prostrate states of the system, when the blood almost stagnates in the ventricles. Whatever locally ar- rests the circulation favours the coagulation of the fibrin in the vessels. Suspended movement through the capillaries must have this effect on the blood in the vessels behind them. Inflammation; gangrene; the pressure of tumours; the induration or contraction of tissue; the enlargement of organs, whether normal, as in the gravid uterus, or abnormal, as in diseased liver and spleen, may all act in this way. The slow or arrested movement < of the blood in aneurismal cavities is probably the chief cause of the coagula by which they are almost always partially filled. The condition of the blood is another cause, which is sometimes alone sufficient to produce the effect; and very much favours the influence of the one just mentioned. A relative excess of fibrin in the blood, or excess of its contractility, as in acute rheumatism, some cases of anaemia, and the preg- nant and puerperal states, strongly conduces to the result. Mr. Paget has suggested the presence of urea in the blood as a cause ; and Dr. Lee and others consider that pus in the circulation may have the same effect; but both these opinions are doubtful. In Bright's disease, when urea accumulates in the blood, there is also frequently a cachectic condition, associated with defi- ciency of the red corpuscles and relative excess of fibrin, which probably disposes to coagulation. In relation to the effect of pus, it is true that Dr. Lee has produced coagulation of the blood by throwing this substance into the veins; but it is by no means certain that some slight concretions may not have entered with the pus, and have served as nuclei for coagula, or as direct causes by arresting the circulation in the capillaries, or producing foci of in- flammation. It is certain that pus has existed largely in the blood without having occasioned this effect. Fresh normal pus, strained before injection, is said not to produce it. (See B. and F. Med.-Chir. Rev., July, 1857, p. 21.) The condition of the inner surface of the heart or blood-vessels has much influence over the formation of coagula. Inequality from atheromatous, cartilaginous, or calcareous formations in the coats, ulceration or removal of the inner coat, and roughness from inflammation or other cause, favours the deposition of fibrin, in part from the slight impediment offered to the movement of the blood, but probably in chief from the affinity of the pro- jecting points for the fibrin. It has generally been thought that, in inflammation of the veins and arte- ries, fibrin is exuded from the inner surface, and induces coagulation of the blood so as to fill the vessel, and thus frequently suspend the circulation. Nor do I think that the experiments of Lee, Virchow, and others, have yet satisfactorily refuted this opinion. At all events, these very experiments have shown that fibrin is exuded, in the affection referred to, into the sub- stance of the coats, and finds its way not unfrequently into the caliber of the vessels by the rupture of the inner coat, if not by exudation through it. The inner coat, too, though without blood-vessels, is changed in its nature by inflammation, losing its smooth and shining character, and becoming more or less softened and brittle. CLASS III.] COAGULA IN THE BLOOD. 275 Carcinoma is a frequent cause of coagulation of the blood in the veins, either in consequence of the entrance of cancerous germs, or from ob- struction. 3. Effects.—In treating of this subject, I shall consider it in two points of view; first, in reference to the direct effects of coagula in general; and, secondly, in connection with the transportation of the coagula or portions of them to points distant from their place of origin, and the various resulting morbid conditions. (a) Direct Effects of Coagula.—With regard to the effects of coagula in the heart, in disturbing, and more or less restraining its movements, and sometimes causing sudden death by interrupting the general circulation, enough has perhaps been already said under the diseases of that organ. I would, however, call attention to opinions, strongly practical in their tenden- cies, put forth by our countryman, Dr. C. D. Meigs, in a paper published by him in the Medical Examiner for February, 1849 (page 141), and known to have been entertained by him before that time. According to Dr. Meigs, persons much reduced by hemorrhage, are particularly prone to the heart- clot, from the state of their blood. If from any cause, as by sitting up in bed, or any other mode of exertion, faintness or positive syncope is induced, the retarded movement of the blood favours the separation of the fibrin, and a coagulum is likely to be formed in the heart with fatal effect. He ascribes to this cause many of the instances of sudden death which occur in childbed. There is reason to think that coagula in the blood-vessels sometimes cause inflammation of the vascular coats, acting like foreign bodies upon them. This inflammation is generally not more than may be useful in producing the changes requisite for the organization, and ultimate conversion into ligamentous tissue of the clot itself, and is a natural process of cure. It is true that the blood-vessel is obliterated, but this in general is of little account; as the circulation is maintained by the enlargement of collateral branches. But it is possible that the inflammation may, in unfavourable states of the system, be in excess, or take on a depraved character, ending in suppuration and a further contamination of the blood. The effects of coagula in the arteries vary with the degree in which they produce impediment or obstruction to the circulation. When the ar- tery still remains permeable, they occasion, in greater or less degree, local anasmia in the parts supplied by the affected vessel, marked by paleness, coolness, shrinking of the tissue, and defective performance of function, If the impediment continue, nutrition is affected, atrophy of the part may occur, and ultimately fatty degeneration. If the organ is important, as the brain or heart, these results may be in the highest degree dangerous. But they are not necessarily fatal; for either the clot may be at length dissolved through a change in its own nature, or an altered condition of the blood, or collateral circulation may take place, and supply the deficiency. Nor is complete obstruction of an artery necessarily fatal to the parts supplied by it; for its office may be vicariously supplied by other vessels; but, when the co- agulation is extensive, not only affecting a main trunk, but spreading through its ramifications, mortification necessarily occurs from the want of blood, and life is generally, though not always lost; as the dead part may separate by sloughing, or may be removed, and the system survive the want of it. Another result of arterial coagula, is said to be the formation of cir- cumscribed fibrinous masses in the midst of an organ, the supply of which Avith blood is impeded, as in the lungs, spleen, and kidneys; and foci of ef- fused blood are said to be produced under similar circumstances. These occur- rences have not yet been satisfactorily explained, in connection with their supposed cause. 276 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. Finally, among the effects of impaired or obstructed supply of blood to one part or organ, the circulating fluid must be in excess elseAvhere; and congestion must take place at points more or less remote from the seat of the local anaemia or gangrene. Venous coagula have a somewhat different effect. The parts from which the blood is conveyed by the veins do not suffer from a want, but from an excess of blood. As in the case of the arterial clot, if the extent of the coagu- lum is small, no injury whatever results; as the blood is carried forward by anastomosing branches. If it be considerable, and especially in one of the great trunks, as the iliac veins, or the subclavian, there is swelling of the extremity drained by the vein, with a venous or purplish hue of the surface, and serous effusion, sometimes to a very considerable extent. Phlegmasia dolens and other similar affections are partially examples of the operation of this cause; but here phlebitis is conjoined with obstruction. In the con- gested state from venous obstruction, a sort of low inflammation is sometimes set up, with erysipelatous redness of the surface, and purulent infiltration and even gangrene of the tissues of the limb. The gangrene, however, is not original, but dependent on the preceding inflammation. (b) Transportation of Coagula.—Embolia. (Virchow.) To Virchow be- longs the credit, if not of having originated the conception of the transfer of coagula, or portions of them, from their original seat in the circulation to another and perhaps distant point, at least of having thoroughly investigated and systematized the subject, and given it the position it now holds in medi- cal science. So long since as 1846—7, he published his views on obstruction of the pulmonary artery from this cause, Avhich have been since much ex- tended, and noAv embrace the whole vascular system. In the Medico- Chi- rurgical Transactions for 1852 (page 281), is a paper by Dr. Wm. Sen- house Kirkes, detailing valuable observations, and putting forth interesting suggestions, upon the transfer of fragments of the excrescences upon the car- diac valves to the arteries of the brain and other organs, giving rise, by obstruction of the circulation, to serious diseases of those organs. Others have contributed valuable facts; and it is not impossible that the conception may have been independently formed by more than one ; but the chief merit, both in conception and execution, belongs undoubtedly to the distinguished pathologist first mentioned. It has been stated that clots may form in any part of the circulation. In whatever place they may be originally seated, unless in the minute arteries, fragments of them, or even a whole clot when small, may be conveyed along the course of the circulation, in the current of the blood, until they reach a vessel with a diameter too small to permit their further passage. Here they lodge, and, if not sufficiently large to fill the caliber of the vessel completely, generally increase by neAV additions until the obstruction becomes complete. The clots thus transported are called by Virchow emboli, the affection embo- lia; and the latter is distinguished into venous and arterial, according to the side of the circulation affected. If the clot be formed in one of the systemic veins, or in the right cavities of the heart, it will be carried ultimately into the pulmonary artery, in one of the branches of Avhich it will be arrested; so that the morbid results of venous emboli must be felt especially in the lungs. As fibrinous excres- cences are rarely formed upon the valves of the right side of the heart, the transported clots are produced generally in the veins. When a portion of blood in a vein coagulates so as to fill the caliber, it increases, as before stated, in the direction of the heart, until it reaches the next branch, beyond which its rounded end projects loosely into the main trunk, so as to be in the current of blood returning from the branch towards the heart. It is thus CLASS III.] COAGULA IX THE BLOOD. 277 kept in constant motion by the current, which, aided by the softening effect of the blood on the clot, separates a portion of the loose end of it, and car- ries it forward into the right auricle and ventricle, from which it is driven forcibly into the pulmonary artery, and wedged, as it were, into one of the subdivisions of that vessel. This explanation is given by Virchow, who has confirmed it by showing that the transported fragment has the same obvious and microscopic character as the original coagulum, and by its shape is calculated to fit precisely the irregularities which have been produced in the previously rounded end of the clot. The arterial emboli are derived from clots formed in the large arteries or the left side of the heart, and especially on the mitral and aortic valves, where they often have the appearance of globular, or irregular, warty excres- cences. Portions of these, separated by the incessant movement of the valves and of the blood, are driven onward with the current, and lodged at last at one of the more or less remote bifurcations, or at some sudden bend of a ves- sel, or Avhere the vessel enters a bony canal or passes through one of the aponeuroses, or, finally, at any point where the artery is too narrow to per- mit its further progress. Here it produces more or less complete obstruc- tion, with the effects before stated to arise from this cause. The arteries most frequently the seat of such obstruction are the middle artery of the brain, the internal and external carotids, the splenic, renal, and mesenteric, and those of the upper and lower extremities. In relation to the morbid effects of obstruction from these secondary clots, whether venous or arterial, it is necessary to consider the more important organs in which these effects have been more or less fully traced. In the lungs the effects of the transported venous clots are almost exclu- sively looked for; as it is in the ramifications of the pulmonary artery that they are necessarily arrested. It is remarkable how little often is the obvi- ous evil, even where the circulation is completely arrested in considerable portions of the artery. Gangrene never results, showing that the pulmo- nary is not the nutritive artery of the lungs, at least not the main one. There may be more or less dyspneea; and, when the clots are diseased, they may occasion foci of a suppurative inflammation. Congestion, too, must be produced in the portions of the lungs supplied by the permeable vessels, through Avhich the whole blood of the system must pass; but little is yet positively known on this interesting subject. When the arteries of the brain become the seat of the obstruction, por- tions of the cerebral structure pass into the condition of yellow softening, or fatty degeneration ; and vertigo, palsy, coma, and even apoplexy, in various degrees are the necessary result. Several of these cases have been described by Dr. Kirkes, in Avhich the disease of the brain was clearly traced to clots in the cerebral arteries, proceeding from fibrinous excrescences on the mitral or aortic valves. Should the coronary vessels of the heart become obstructed, it is presumed that, in complete obstruction, there would be paralysis of the organ and fatal syncope, and in the incomplete, more or less weakness of the circulation, fatty degeneration, and perhaps the symptoms of angina pectoris. In the parenchymatous organs, the prominent effects hitherto traced are the circumscribed fibrinous and sanguineous infarctions already referred to. The symptoms, short of gangrene, noticed in the extremities, have been shooting pains, sensations of pricking and numbness, and feeble or absent pulse. But, besides the local effects above enumerated, it is supposed that these coagula, scattered in numbers in one or more organs, and undergoing vari- ous degradation, may acquire the property of poisoning the whole blood, 278 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. and thus becoming the source of purulent infection, metastatic abscess, &c.; but much of this must, in the present state of our knowledge, be considered as simply possible, or at most probable, and not yet sufficiently established by observation to be admitted into the category of pathological truths. It is obvious that, should symptoms considered as characteristic of coagula in the vessels occur, more or less suddenly, an examination should be made of the heart. If murmurs be discovered, justifying the conclusion that there may be excrescences on the valves, or coagula in the cavities, the fact would be in a considerable degree confirmatory of the suspicion that the affection was of the embolic character. 4. Treatment.—Little can be done in the treatment of coagula, even Avhen ascertained or presumed to exist, except to palliate the symptoms. The cure, if to be effected at all, must be left mainly to nature. Nevertheless, as an excessively fibrinous state of the blood, positive or relative, is believed to favour the production of coagula, and as fibrin is dissolved in alkaline solu- tions, there would seem to be an indication to diminish the proportion of fibrin, and to increase the solvent power of the blood, by increasing its alka- linity. The carbonates or bicarbonates of the alkalies, the alkaline salts with vegetable acids, and iodide of potassium freely given, are calculated to meet these ends. Should the systemic actions be feeble, carbonate of ammonia might be used. In anemic cases, the proportionate excess of fibrin should be corrected by the use of chalybeates, which serve to increase the red cor- puscles, while the alkaline remedies may be given conjointly if deemed advis- able. There might be hope by these means of aiding in the solution of the existing coagula, and preventing the formation of others. Should inflammation of the veins or arteries be present, it must be coun- teracted by the measures enumerated under arteritis and phlebitis. Cachectic states of the system must be counteracted by remedies elsewhere recommended, as the mineral acids, quinia and other vegetable tonics, chlo- rate of potassa, opiates, nourishing food, and stimulants if necessary. Finally, care should be taken to favour the operations of nature by rest, position, and such local measures as the peculiar circumstances of each case may seem to require. Article VI SCURVY, or SCORBUTUS. Scurvy may be defined to be a disease in which the blood is depraved, and the system debilitated, with a tendency to hemorrhage and petechiae, and to local congestion or feeble and imperfect inflammation in various parts of the body, especially in the gums, and without any necessary febrile complication. There can scarcely be a doubt that its essential character is an altered state of the blood, and that all its phenomena flow directly or indirectly from that source. The complaint has probably existed from the earliest times; and obscure notices of it may be found in the writings of the ancients. The first distinct account of it is contained in the history of the Crusade of Louis IX., in the thirteenth century, against the Saracens of Egypt, during which the French army suffered greatly before Damietta, from this among other diseases. But it was little noticed by medical writers until the sixteenth century, when the revival of letters gave a new impulse to inquiry in every direction. At that time it prevailed endemically in various parts of Europe, especially in the CLASS III.] SCURVY. 279 north; and it continued to prevail, Avith little abatement, until towards the middle of the last century. Though found among the peaceable population of towns and villages, and especially among those engaged in other than agricultural pursuits, it Avas most destructive in armies and besieged cities, and in the seafaring classes; the hardships and privations incident to the life of the soldier and seaman being the most efficient causes of the disease. The accounts of its ravages given by historians and medical writers, during the period mentioned, are in the highest degree revolting. Many thousands were often cut off, within a few months, in single armies and garrisons; and it is probable that more seamen perished of scurvy alone than from all other causes combined, Avhether sickness, tempest, or battle. The narrative of almost every long voyage made in the sixteenth, seventeenth, and earlier part of the eighteenth centuries, is a record of its terrible fatality. Whole creAvs were prostrated, fleets crippled, and great expeditions frustrated by this single scourge. The memorable voyage of Lord Anson, in which more than eighty out of each hundred of the original crews perished of scurvy, is fami- liar to every reader. The extension and improvements of agriculture, the ameliorated condition of the lower classes, the altered modes of Avarfare, and a more generally diffused knowledge of the causes of the disease and the modes of preventing it, have gradually diminished its prevalence in Europe, where it is now comparatively rare; and, since the time of Captain Cook, who led the way in the adoption of effectual means of prevention at sea, it has ceased to be the terror of seamen, and occurs only where the requisite precautions have been carelessly neglected, or rendered nugatory by unavoid- able accident. In this country it is very little known, and there are many practitioners, even in our cities, who have never seen a decided case of it. But, as its prevalence depends on causes which may be brought into opera- tion at any time, and in any place, it becomes important that the profession should be thoroughly conversant with all that relates to it, so that it may be at once encountered when met with, and means of prevention suggested wherever they may seem to be required. This remark is especially applicable to the regulation of the diet in prisons, hospitals, asylums, garrisons, ships, by enlargement of the liver. The hem- orrhage is most apt to occur when hepatic obstruction originates suddenly. Disease of the spleen probably acts as a cause of stomachic hemorrhage in a somewhat different manner. There is reason to believe that one at least of the offices of this viscus is to serve as a diverticulum, or reservoir for the superfluous blood of the portal circulation, so as to prevent the injurious consequences which might otherwise much more frequently result from con- gestion in this system of veins. Now, when the spleen has become already congested, it is of course, in the same degree, Jess capable of serving as a diverticulum, and the consequences of the portal congestion, should it still continue, are more likely to be experienced in the stomach. Great enlarge- ment of the spleen may also act mechanically by impeding the circulation through the aorta, or through venous trunks Avhich return the blood from the viscera to the vena cava. In the former case, the stomach may suffer along with the other organs to which the excess of blood is sent that cannot find its way through the aorta; in the latter, by the direct interruption of its own returning blood. It has also been supposed that hemorrhage in the stomach may take place from ramifications of vessels communicating directly with the splenic vein, and thus be an immediate result of congestion of the spleen. Another mode in which disease of the spleen operates in producing hemorrhage, is by altering the condition of the blood. In many cases of haematemesis, of hepatic or splenic origin, the hemorrhage is probably useful, partly by directly relieving congestion of the stomach, and thus preventing more injurious results in that organ, partly by exhausting the sources of the disease in one or both of the viscera referred to. It is a recorded fact, that very large swellings of the spleen have been suddenly reduced by the occur- rence of hemorrhage from the stomach. 4. Other Organic Affections.—Solid tumours within the abdomen, whether scirrhous or not, large aneurisms, and even the pregnant uterus, may act as causes of haematemesis by pressure upon the veins which return the blood of the portal circle, or upon the great descending trunk of the aorta or the primitive iliacs. Organic diseases of the heart may have the same effect by impeding the return of the blood through the vena cava, and thus producing general venous congestion. Another origin of gastric hemorrhage may be the bursting of an aneurism into the stomach. A case is recorded by Dr. G. B. Hotchkin, of Media, Pa., in which repeated attacks of haematemesis, which ultimately proved fatal, proceeded from a tumour in the stomach, at the cardiac orifice, consisting of a congeries of varicose veins, which were all traced into the gastric vein, and which appeared to open by minute orifices into the stomach. (Am. Journ. of Med. Sci, Oct. 1856, p. 376.) Hamiatemesis is not a very uncommon affection in females, as the result of suppression of the menses ; and it is then, as before stated, apt to assume a periodical form. It is liable especially, to occur in nervous females; but perhaps this association is merely accidental; the nervous symptoms being a mere dependence of the uterine affection, without any direct relation to the hemorrhage from the stomach. It is, hoAvever, peculiarly apt to be excited in such patients by causes calculated to disturb their equanimity. This hemorrhage is also an occasional attendant upon malignant fevers, scurvy, purpura haemorrhagica, and other affections in which the blood has assumed the hemorrhagic character. In these cases, it is generally associated with hemorrhage from other sources, and is passive in its nature. 336 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. As in all the other hemorrhages, the blood in haematemesis may escape through a wound or rupture of the vessel, through an opening produced by ulceration or sphacelus, or through the coats without any discoverable solution of continuity; and, in the last-mentioned case, it may be active or passive, the result, namely, either of increased vascular action, or of a mere relaxa- tion of the walls, allowing the blood to pass without the usual resistance. How the blood maybe conceived to pass through the vascular coats, without a rupture, has been explained in the general observations on hemorrhage. Anatomical Characters.—If the hemorrhage has proceeded from a wound or rupture of a vessel, the orifice may generally be found upon close inspec- tion. A case is recorded in which it resulted from the bite of a leech swal- lowed with the water of a rivulet. (Did. de Med., xii. 330.) In many cases, the most careful examination of the surface of the stomach reveals no vascular solution of continuity; and the inference is almost irresistible that the hemor- rhage was a mere transudation. In these cases, the gastric mucous mem- brane is sometimes quite healthy both in consistence and colour; but, more frequently, it exhibits evidence of congestion or inflammation, in a greater or less degree of vascular redness, sanguineous effusion into the mucous or sub- mucous tissue, or of softening. In some instances, dark points appear thickly strewed over the mucons surface. Sometimes ulcers are discovered, with their surfaces covered over with thin coagula, or exhibiting specks here and there, at points from which the hemorrhage probably proceeded. Sometimes large vessels are found open by ulceration. Treatment.—The patient should be placed in bed, and kept perfectly quiet both in body and mind. He should take a little ice-water now and then, and may even swallow small pieces of ice if agreeable to him. At the same time, excitement should be directed towards the extremities by immersing the hands and feet in hot water. When the hemorrhage is very copious, it has been recommended to apply ice or cold water to the epigastrium. If there should be much nausea, retching, and ineffectual effort to vomit, with the discharge of a little coagulated blood, giving rise to the suspicion that much more blood might be remaining in the stomach, and serving as a source of irritation, it might be proper to effect its complete evacuation by a moderate dose of ipecacuanha. The action of the medicine would be less likely to provoke hemorrhage than the spontaneous movements alluded to, and after its operation the stomach would probably be left comparatively quiet. But, under ordinary circumstances, emetics are of doubtful propriety. Should the pulse be excited, and of sufficient strength, and especially if, at the same time, there should be symptoms of gastric inflammation or vas- cular irritation, blood should be taken from the arm, in quantities propor- tioned to the effects of the operation upon the pulse; and a continuance of the same circumstances would justify a repetition of the measure. Some- times, Avhen the patient is too feeble to admit of bleeding, and the local symptoms alluded to exist, leeches to the epigastrium may be substituted; and these will often be found useful auxiliaries to the lancet. The system, however, is often too much exhausted to admit of depletion in any shape. Sinapisms and blisters to the epigastrium may then be used. When the patient is very prostrate, with a pale and cold skin, and a feeble or absent pulse, much advantage may sometimes accrue from the hot bath, of the temperature of about 105°, by which the blood is drawn to the surface, and a safe stimulus applied to the system. The same remedy may also be used in less prostrate conditions, in the more advanced stages of the disease, when it is deemed highly advisable to give a centrifugal direction to the blood. Acetate of lead, in small and frequently repeated doses, combined with a little opium, is one of the most efficient internal remedies. If this should be CLASS III.] HAEMATEMESIS. 337 rejected, or should fail from other causes, recourse may be had to other astringents, such as alum, kino, catechu, krameria, aromatic sulphuric acid, and some of the liquid preparations of iron. But these are incompatible with much irritation, and with acute inflammation of the stomach. In the ad- vanced stages, and in cases of little or no local excitement at the commence- ment, oil of turpentine, or creasote, with, or without laudanum, may be given in small doses. The former is peculiarly adapted to the hemorrhage which sometimes occurs in the last stage of gastric inflammation. Ergot might be tried with some hope of advantage; but it occasionally nauseates, and the author has not employed it in this hemorrhage. Excessive irritability of the stomach should be allayed by lime-water and milk, if not incompatible with the case, by injections of laudanum, and by a sinapism or blister over the stomach. The bowels should be kept open, when the stomach is irritable, by enemata; when it is retentive, by mild cathartics, as the Seidlitz poAvders, magnesia, sulphate of magnesia, castor oil, &c. Some- times active purgation is indicated, especially in congestion of the portal circle, and then infusion of senna with Epsom salts may be used. When the liver is in fault, the hepatic secretion should be promoted by minute and frequently repeated doses of calomel or mercurial pill, alternated with mild cathartics; and this plan should be pursued until the stools exhibit yellow bile, or the gums of the patient are touched. In some cases, it is possible that a purgative dose of calomel would act more efficiently; but in general the alterative plan is preferable as the safer. Both in hepatic and splenic cases, remedies should be employed calculated to relieve the disease of these organs respectively. In splenic cases, advantage will often accrue from the combined use of iron, quinia, and purgation. When there is reason to suspect erosion of a blood-vessel, the general plan above indicated may be pursued ; care, however, being taken to avoid all sub- stances that might irritate the stomach. Perfect rest is the most important measure in these cases. Bleeding is seldom, if ever, admissible. In vicarious haematemesis, besides employing the means already mentioned, the practitioner should endeavour to produce a derivative effect towards the seat of the suppressed discharge by leeches, warm fomentations, and stimu- lating applications to the part. In cases of amenorrhoea, constitutional means should be employed for the restoration of the menses. In these cases, pur- gatives have been found highly beneficial. In passive haematemesis, the plan must be pursued which has already been pointed out, as applicable to the passive hemorrhages generally. (See page 310.) The chief remedies are the astringents, mineral acids, sulphate of quinia, the chalybeates, and oil of turpentine. Attention to the diet is important. In cases attended with local or general excitement, the patient should be confined to gum-water and farinaceous drinks. If debilitated, he may take rennet-Avhey, or diluted milk. Milk with lime-water sometimes answers an excellent purpose. In great debility, as when the -hemorrhage is passive, animal broths, jellies, egg beat with wine, and sometimes milk-punch may be employed. When the stomach rejects everything, the patient must be supported by nutritive enemata. In conva- lescence, only the lightest and most digestible animal food should be allowed. The prophylactic measures adapted to haematemesis are to be inferred from the remarks already made relative to the general preventive treatment of hemorrhage; and anything which may be peculiar to this particular form, will readily suggest itself to the reflecting practitioner. 338 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. Article VI HEMORRHAGE OF THE BOWELS, or MEL^ENA. Hemorrhage of the bowels, though not unfrequent as an incident of various organic affections, is somewhat rare as an original functional disease. In the latter case, it generally assumes the form of melsena; the blood having under- gone, after, or in the act of extravasation, such changes as to give the stools the black appearance characteristic of that affection. The name melaena has been rather loosely applied, and ought to be abandoned as designative of a disease. In its most extensive sense, it would include all black discharges from the bowels, whether of vitiated bile or altered blood. In this applica- tion of the term it is improper, as it combines two distinct affections under one designation. If confined to hemorrhage, it is inadequate ; for there are many instances of intestinal hemorrhage in which the discharges are not black; and there appears to be no good reason for making a mere difference in colour the basis of an arrangement into distinet varieties, especially as every diversity of shade is presented in different cases, from bright arterial redness of the stools to pitchy blackness. Discharges of dark and altered blood from the bowels are often a mere attendant upon haematemesis, and not necessarily connected with intestinal disease. A portion of the blood extravasated in the stomach passes the pylorus, and, being changed by admixture with the contents of the bowels, and their chemical reaction upon it, escapes in the form of black stools. Such a result may take place, even without vomiting; the whole of the effused blood passing downward. Again, the black evacuations may be derived di- rectly from the intestinal mucous membrane, though the patient may at the same time vomit blood ; and this is probably often the case; as the causes which produce haematemesis act, in many instances, with scarcely less energy upon the bowels than on the stomach. Still another case is that in which, though vomiting and purging of blood may exist, the seat of the hemorrhage is exclusively in the bowels ; the blood rising, as bile is often known to do, from the duodenum into the stomach. It is, therefore, by no means always easy to decide, in any particular case of bloody evacuations from the alimen- tary canal, whether or not intestinal hemorrhage, strictly so called, really exists. In forming a conclusion, we must be influenced by the character of the antecedent and attendant symptoms. According as these point more especially to the stomach or bowels, will be our inference as to the seat of the hemorrhage ; and, if they equally embrace both, we may fairly conclude that the hemorrhage also is from both sources. The quantity and colour of the blood discharged will have some influence on our judgment. When it passes by stool copiously, or without great alteration, it is, in all probability, of intestinal origin. In some cases, however, it is impossible to arrive at a certain conclusion. Happily, this is of the less importance ; as the causes and nature of the hemorrhage from the two sources are so analogous as to give a certain character of identity to the affection, in reference to treatment. Symptoms.—In most cases of intestinal hemorrhage, the discharge of blood is preceded by evidences of disease. Often, this disease is of a well known and marked character, as enteritis, dysentery, enteric fever, scurvy, purpura, &c, of all of which hemorrhage from the bowels is an occasional concomitant. But frequently also the preliminary symptoms are less definite. Feelings of oppression, weight, distension, or other uneasiness in the abdomen, pains in the hypochondriac regions, occasional tenderness upon pressure, a furred CLASS III.] INTESTINAL HEMORRHAGE.—MELAENA. 339 tongue, deficient or disordered appetite, constipation or diarrhoea, a pale, sallow, or dingy complexion, dejection of spirits, languor, weakness, and more or less disorder of the circulation, indicate a derangement of health of some duration, of which visceral disorder and impaired digestion are the most pro- minent ingredients. A patient in this condition is unexpectedly affected with griping pain, nausea, increased paleness, and more or less giddiness, faintness, depression of pulse, and coolness of the extremities, attended by a discharge from the bowels, which, on examination, proves to be blood of a black colour, very offensive, and otherwise altered in character. Occasionally a diarrhoea has existed for some days with more or less of the same symptoms, without, however, occasioning much uneasiness, until attention is accidentally called to the bloody nature of the stools. In some instances, again, the hemorrhage comes on without any premonitory symptoms; and the evacuation from the bowels, and its attendant depression, are the first obvious signs of disease. This depression is sometimes extreme, and the patient may even sink below the point of reaction. Sudden prostration and death have occurred without any evacuation, and the cause has remained concealed until dissection has revealed a vast collection of blood, fluid or coagulated, in the small intestines. In cases of sudden prostration, intestinal hemorrhage may be suspected, when the previous symptoms were those of portal congestion, or organic disease of the bowels, and when tumefaction of the abdomen with dulness on percus- sion, not before existing, is discovered upon investigation. But cases of so much violence, whether with or without discharge from the bowels, are com- paratively rare. Very generally the system rises out of the temporary de- pression, or the affection may even run its whole course without any serious evidences of prostration. Occasionally the bloody evacuations are attended and preceded by excruciating pain, which, however, is to be ascribed to some organic disease of the bowels. Quite as often there is little or no pain. The character of the blood discharged is very various. The quantity is sometimes scarcely more than sufficient to stain the fecal evacuations, while in other instances it may amount to pints or quarts. The colour may be bright-red; but is much oftener dark or almost black. The consistence of the blood may be fluid, or grumous from broken coagula, or thick, semi-liquid, and tar-like. It is sometimes mixed with the intestinal secretions, fecal mat- ter or bile, and sometimes as pure as if drawn from the arm. It is almost always very offensive. In certain cases, it is black, like soot or coffee-grounds, consisting of an insoluble dark matter floating in a colourless liquid; but, when of this condition, it can scarcely be called blood ; as it has probably undergone some change in its passage from the vessels. This kind of dis- charge is not necessarily offensive, and exhibits neither the red colour of blood nor the yellowness of bile, when viewed in thin layers. The black colour, so common in the different hemorrhagic discharges from the bowels, is not an indication that the blood comes from the veins; but is generally ascribed to the chemical influence of the intestinal fluids and gases. The nature of the evacuations may lead to plausible inferences as to the seat and character of the disease. If the blood is bright-red, it has probably come from the large intestines ; if dark-red, copious, and pure, from the small intestines, and from no very great extent of surface. If tarry or pitch-like, the inference is that it has proceeded from an ample surface, by a slow exu- dation, giving it an opportunity to be intimately mingled with the secretions. If of the appearance of coffee-grounds, it has probably issued from a mem- brane disorganized by inflammation or malignant ulceration, as in yellow fever and cancer of the bowels. A small discharge of bright blood, mingled with mucus, would imply that there was active inflammation, as in dysentery. If the blood is dark, and either imperfectly or not at all coagulable, it indi- 340 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. cates that it was depraved while still in the circulation, as in malignant fevers and purpura. If black, tarry, and exhibiting, in thin layers, both a red and bilious tinge, it may possibly, as maintained by Dr. Ayre to be generally the case in mekena, have proceeded from the liver. The course of the disease is altogether uncertain. The hemorrhage, as already stated, may prove immediately fatal; but this result is rare. Gene- rally, the bleeding is diminished or suspended for a time, to return again and again; and the disease may go on for weeks or months, Avith alternations of amendment and relapse, until at length it ceases, or wears out the patient. But, if not complicated with serious organic derangement of the bowels or other viscera, it will generally yield with sufficient facility to remedies; though, even after a cure, the predisposition is too apt to remain, and lead to a return. Something depends upon the age as to the result. In the old, the disease is much more apt to end fatally than in youth or middle life, perhaps because the result of a longer continuance of organic disorders, and a general break- ing up of health. When not complicated with such affections, or with deep depravity of the blood, it has usually, in the experience of the author, proved manageable, whether in the aged or the young. If considerable, it adds greatly to the dangers of diseases with which it may be associated. It need scarcely be stated that the general symptoms attending hemorrhage from the bowels are so exceedingly variable, from the variety of disease with which it is connected, that no one description will embrace them. Anatomical Characters.—Blood is always found in the bowels, of a char- acter bearing some analogy with that discharged. The mucous membrane is frequently stained by imbibition. Both it and the veins leading from it are often found congested ; but the congestion of the capillaries appears to have been sometimes relieved by the hemorrhage, and the membrane is unusu- ally pale. The orifices of the mucous follicles are occasionally seen distended with black coagulated blood, looking like sooty specks upon the surface. Dissection has in general afforded no ground for the notion that the blood proceeded from a ruptured or eroded vessel. The mucous membrane has been examined with the greatest care, without exhibiting any vascular solu- tion of continuity. This is not the place to detail the numerous morbid changes of structure, belonging to the diseases of which the hemorrhage is frequently but a symptom. Diagnosis.—On the occasional confusion of this hemorrhage with haemate- mesis enough has been already said. It may be distinguished from the black bilious discharges which are frequently met with as a form of diarrhoea, by viewing the two liquids in thin layers, or by diluting them. The blood, under this management, usually assumes its proper red, and the bile its yellow hue. Common salt, when added to dark blood is said to redden it, and does not produce the same effect with bile. The microscope may be resorted to in doubtful cases. Sometimes true melanotic matter is discharged from the bowels, and might be mistaken for hemorrhage. It probably proceeds from the breaking up of a melanotic tumour, and is very rare. It wants the red- ness of blood. (See Melanosis.) For the distinction between the hemorrhage under consideration, and that from the rectum or hemorrhoidal vessels, the reader is referred to the subsequent article. Causes.—These are so much the same as in haematemesis, that a particu- lar enumeration of them is unnecessary. Whatever is capable of producing irritation, congestion, inflammation, or ulceration of the intestinal mucous membrane, may occasion this form of hemorrhage. Among the direct irri- tants it will be sufficient to allude to drastic cathartics, which, in cases of pre- disposition to this disease, would be very apt to bring on an attack. The remarks made in relation to the various pathological conditions which lead CLASS III.] INTESTINAL HEMORRHAGE.—MELAENA. 341 to haematemesis are also applicable here. Inflammation and ulceration of the mucous coat, as in enteritis, dysentery, invagination, &c.; disease of the liver and spleen ; cancerous and other malignant ulcerative affections; solid tumours ; aneurisms; organic affections of the heart; suppression of the menses; malignant fevers, purpura, and scurvy; are all occasionally attended with hemorrhage from the bowels. The most common pathological condition in this, as in gastric hemorrhage, especially in the form of melaena, is pro- bably congestion of the portal system, dependent on torpor or organic dis- ease of the liver, or enlargement of the spleen. Hence its occasional occur- rence in protracted intermittents, and association with abdominal dropsy. Enteric fever, uniting occasionally the two conditions of a hemorrhagic state of the blood, and an inflamed and ulcerated state of the bowels, is liable to very serious and often fatal complication with intestinal hemorrhage. Treatment.—In the treatment of this hemorrhage, reference must always be had to the pathological state in which it originated, and which may sus- tain it. To this state the remedies are to be addressed. If the hemorrhage be not abundant, no other treatment will, in general, be required. Most commonly the liver or spleen, or both, are in fault, especially in melaena. If the hepatic affection is merely functional, an alterative course of mercury, as recommended by Dr. Ayre, will generally prove effectual. One-sixth of a grain of calomel, or from half a grain to a grain of the mercurial pill, may be given every hour or two, until from one to three grains of the former, or from three to nine of the latter, have been taken during the day. If the case is not urgent, the mercurial may be omitted on alternate days; if other- wise, it should be pushed steadily until the passages assume a healthy appearance, or the gums are touched. It may generally be very advantage- ously associated with opium and ipecacuanha in minute quantities, say one- twelfth or one-sixth of a grain of the former, and twice as much of the latter, with each dose of the mercurial. Advantage will often accrue from alter- nating the mercurial with a mild laxative, as rhubarb or magnesia. When mercury cannot be given, or has been given ineffectually, nitromuriatic acid may be substituted. Sometimes, however, the discharge is so profuse as necessarily to be the prominent object of attention. It must be arrested or diminished, to avoid the risk of fatal exhaustion, no matter what may be the disease with which it is associated. Under these circumstances, astringents should be combined with the other remedies. Acetate of lead has been much relied on; but the vegetable astringents, particularly kino and rhatany, may also be advanta- geously given. The latter are sometimes administered, in the form of pill, in connection with the acetate of lead; and, though this is decomposed, the resulting tannate of lead is probably not less useful. In cases of very pro- fuse hemorrhage, requiring a prompt and powerful astringent impression, I have great confidence in powdered kino, given very freely, without much refer- ence to precision of dose. Sulphuric acid, in the form of elixir of vitriol suf- ficiently diluted, or of compound infusion of roses, is sometimes advantageous, but should not be given simultaneously with the salt of lead. Much may be expected from ergot, with or without opium, in the arresting of the hemor- rhage. When the hemorrhage is of the passive character, oil of turpentine is perhaps the most effectual remedy. It may be given in the quantity of from live to twenty drops every hour or two, and may often be beneficially asso- ciated with a little laudanum. Dr. H. L. Byrd, of Savannah, Geo., obtained very speedy success in several cases of this hemorrhage, complicated with in- termittent fever, from the combined use of oil of turpentine and nitrate of silver. He gave about eight minims of the former every two hours, and one-half a grain of the latter every three hours, each combined with an opiate. (Charles- 342 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. ton Med, Journ. and Rev., vii. 164.) When the skin is cool, and the capil- laries of the surface generally inactive, the hot bath, or the Avarm salt-bath, repeated daily, will be highly serviceable. In the form of the disease associated with amenorrhoea, purging has been recommended, to be followed by remedies addressed especially to the men- strual disorder. I have never ventured upon active purging in this affection. Sometimes, perhaps, where the hepatic secretion is arrested, a purgative dose of calomel may be safe and advantageous; but generally, when the bowels are loaded with blood or feces, I prefer their evacuation by the mildest laxatives. There may be cases in which, from the activity and strength of the pulse, and the plethoric state of the circulation, bleeding may be called for; but this is seldom requisite in cases of intestinal hemorrhage, unless associated with inflammation. Cups or leeches and fomentations to the abdomen may be indicated in certain cases, and external derivatives are often useful. It is frequently necessary to support the strength by nutritious food, and sometimes by stimulants. This is especially the case in the hemorrhage attending low fevers. When there is nausea, milk mixed with lime-water will, on the whole, be the most suitable article of diet. The preparations of sago and tapioca, with nutmeg and a little wine, may also be given. Some- times it will be necessary to resort to animal broths and jellies. Should stimulation be advisable, it may be most safely effected by wine-whey. In cases attended with general excitement, the lightest and least stimulating kinds of food should be employed, such as are applicable to the active hemor- rhages generally. Care should be taken to allow no article of food which would be likely to pass undissolved through the stomach. Hence liquid aliment is generally preferable, and fresh vegetables of difficult digestion should be excluded. The patient should be kept at rest mentally as well as bodily, should breathe a cool fresh air, and should be allowed refreshing drinks, in small quantities at a time. After the hemorrhage has ceased, a strict attention should be paid to the general health, and such a course of remedial or hygienic treatment adopted as the case may seem to call for; one grand rule being always kept in view, to avoid everything likely to irritate the intestinal mucous membrane. Article VII HEMORRHAGE FROM THE RECTUM. Syn.—Hemorrhoidal Flux.—Hemorrhoids.—Bleeding Piles. Hemorrhage from the rectum, though most frequently connected with piles, is by no means necessarily so, but may proceed from the mucous mem- brane in a perfectly healthy state of the hemorrhoidal vessels, and may depend on the same pathological conditions as the other hemorrhages. Symptoms, Course, dec.—Before the appearance of blood, the patient frequently experiences a sensation of fulness, weight, aching, or other un- easiness in the region of the sacrum, with heat about the anus, indicating a congested state of the mucous membrane; but the hemorrhage may also take place without premonitory symptoms. The blood escapes by stool, sometimes without effort, sometimes with more or less straining, and is generally but not always attended with feculent discharges. Not unfre- quently the hemorrhage first appears after the expulsion of hardened feces. CLASS III.] HEMORRHAGE FROM THE RECTUM.—BLEEDING PILES. 343 In the great majority of cases, it is an accompaniment of hemorrhoidal tumours, either without the sphincter, or protruded at the time of stool. Occasionally it comes in a full stream, without any antecedent or attendant circumstances to explain the accident. The quantity of blood may be not more than sufficient to stain the feces or the linen after the discharge, or it may be very large, so as to produce great exhaustion. Its appearance is much diversified, being sometimes dark, when proceeding from a ruptured vein or venous cyst, or long retained in the rec- tum, and sometimes bright, when from a ruptured artery. It may be ob- served upon the surface of the feces, or mingled with them in streaks, or altogether unmixed. Sometimes, moreover, it is more or less coagulated, and is not unfrequently mixed with mucus, or Avith purulent or sanious liquids. The hemorrhage is, in general, quite irregular in its occurrence and dura- tion, owing to the various local causes which provoke it. But there are cases in which it seems disposed to return at certain intervals, and sometimes it is decidedly periodical. In females it occasionally comes on monthly, as a substitute for the menses, or along with them ; and even in men it has been observed to assume the same regularly periodical character. The bleeding may be inferred to depend upon piles, when tumours are ob- vious, or can be detected upon a close examination. It is not always possi- ble to determine whether it proceeds from the rectum, or a higher portion of the boAvels. But, when the blood is pure, or mixed only in distinct streaks with the feces, and when its discharge has been preceded, for some time, by uneasiness in the sacrum, without any sign of disorder of the upper bowels, the probability is that it is from the rectum. When intimately mingled with the ordinary contents of the bowels, and of a black tar-like aspect, it may be inferred to proceed from some higher position. Occasionally, upon close inspection, the point from which it issues, may be seen, upon a protrusion of the mucous membrane as in defecation. Hemorrhage from the rectum is seldom dangerous. In most cases, it is of little or no account, being merely an insignificant attendant on other af- fections. Sometimes it is beneficial by relieving general plethora, portal congestion, or determination of blood to other parts, especially to the head. It may even, by its long continuance, become essential to health, so that a sudden interruption of it may be dangerous. When copious and frequent, it may induce an alarming condition of anaemia; and cases of this kind, which are apt to be accompanied with great labour of the heart, have some- times been mistaken for plethora and general excitement, and very injuriously treated by depletion. In some rare instances, life is endangered immediately by the abundance of the hemorrhage. Causes.—The causes of hemorrhage, in general, are all capable of pro- ducing this particular form of it. Among .them may be ranked whatever occasions irritation, congestion, or inflammation of the mucous membrane of the rectum, and whatever is capable of wounding this tissue. Of this kind are falls upon the sacrum; hardened feces; straining at stool; drastic ca- thartics, or others having a peculiar affinity for the rectum, as aloes; medi- cines which have a tendency to the pelvic viscera generally, as cantharides and oil of turpentine; congestion of the portal circle from disease of the liver or spleen, or from other cause ; and suppression of the menses and other habitual discharges. Of all these, portal congestion is probably the most frequent. They are of course much aided by a hemorrhagic state of the circulation, whether consisting in plethora, or an altered constitution of the blood, or in both. Inflammation of the mucous membrane of the rectum is frequently attended with the discharge of blood, Avhich is, however, in this case, not often copious. But by far the most frequent source of this hemor- 344 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. rhage is in hemorrhoidal tumours. The blood may possibly, in some in- stances, proceed by exudation from the surface of the tumours; but much more frequently the hemorrhage results from a rupture of the dilated vein, or the hemorrhoidal cyst, from an abrasion or tearing of the investing mu- cous membrane, or from the division of a small vessel that may ramify in the membrane. In the last-mentioned case, the blood may sometimes be seen issuing from the point, of rupture. Relaxation of the mucous membrane, leading to prolapsus, may give occasion to the hemorrhage; as may also fissures or small wounds in the folds of the anus. Cancerous and other ul- cers of the rectum, are often attended with it, the former dangerously so. Like other hemorrhages, this may exist in the passive form, proceeding from vascular relaxation, and depraved blood, as in malignant diseases. Treatment.—When attendant upon hemorrhoidal tumours, this affection requires, in general, no other treatment than that which is extended to the main affection. (See Hemorrhoids, vol. i. page T01.) It may, however, be so copious as to demand especial attention, and then is to be treated as if it proceeded from other causes. Should plethora exist with general and local excitement, it may be proper to employ the lancet, with cups or leeches to the sacrum ; but these remedies are not often necessary. Rest, a cooling and laxative regimen, cold water or ice applied to the sacrum or fundament, or introduced into the rectum, and, if these should fail, the injection of a solu- tion of alum or acetate of lead, or of a vegetable' astringent infusion, will generally be found sufficient to arrest the hemorrhage. An enema consist- ing of three or four fluidounces of a solution of alum, made in the propor- tion of twenty grains to the fluidounce, and mixed with forty drops of lauda- num, repeated daily or twice a day, has almost always answered, in my experience. When the hemorrhage proceeds from a single point, pressure may be employed by means of a bougie, or a piece of prepared hogs' intes- tine, closed at one end, introduced into the rectum, then injected with cold water, and tied at the other end. The effects of constipation should, if necessary, be obviated by laxatives of the most unirritating character; and, if there be plethora or excitement, the saline cathartics, such as bitartrate of potassa, sulphate of magnesia, Seidlitz powders, &c, should be preferred. Congestion of the portal circle should be corrected by an alterative course of mercury alternated with laxatives, and by other means calculated to pro- mote hepatic secretion. Sometimes a full dose of calomel may be found useful. Relaxation of the mucous membrane of the rectum should be treated as directed under the head of prolapsus ani. When the affection is supple- mentary to the menses, efforts should be made to restore the uterine func- tion. If there be evidences of a determination of blood to the head, the hemorrhage should be checked with much caution; and, if measures for this end are employed, danger to the brain should be obviated by depletion, low diet, &c. The same caution should be observed in correcting a hemor- rhoidal flux which has become habitual and constitutional. It is a good rule, under these circumstances, to establish a revulsion towards some point of the surface by means of setons or issues, and at the same time, to prevent plethora by attention to the diet, occasional purgation with salts, and, if symptoms of a determination of blood to some vital organ be observed, by the use of the lancet. Passive hemorrhage must be treated by cold appli- cations, astringent injections, and the use of measures calculated to support the system and improve the blood. In such cases, some good might be ex- pected from oil of turpentine, copaiba, cubebs, etc., taken internally; and the same remedies may be found useful in chronic cases of hemorrhage, ori- ginally active, when all signs of general and local excitement have ceased. CLASS III.] HAEMATURIA, OR BLOODY URINE. 345 Article VIII HEMORRHAGE FROM THE URINARY ORGANS, or HEMATURIA. Syn.—Bloody Urine. The term haematuria is conveniently applied to the discharge of blood from the urinary passages, no matter from what portion of these passages the hemorrhage may proceed. Considered, however, in reference to its origin (ai/j.a, blood, and oupeca, I urinate), it would not embrace bleeding from the mucous coat of the urethra; for the blood from this source escapes without any effort of the patient similar to that of micturition. In this place, the term is employed in its most general acceptation. The complaint is by no means common, except as an attendant upon inflammation of some portion of the membrane lining the urinary passages, and, in this case, is seldom so considerable as to claim particular attention. Symptoms.—The discharge of blood is sometimes preceded by sensations indicating irritation or inflammation of the part affected, and sometimes takes place without preliminary symptoms. When it proceeds from any other part than the urethra, the blood is expelled by the contraction of the bladder, in the same manner as the urine. Occasionally the discharge is without uneasi- ness ; but, in other cases, there are symptoms similar to those of dysury; the patient having a disposition to micturate frequently, with bearing down sen- sations, ardor urinae, and pain, in a greater or less degree, at the neck of the bladder and along the urethra. In some instances, no blood escapes, in con- sequence of that which had been effused into the bladder having coagulated, and thus closed the entrance of the urethra. In such cases, there is a feeling of weight and painful distension above the pubes, and the other phenomena are presented which characterize the retention of urine. The quantity of the blood discharged is altogether indefinite, being often not more than sufficient to tinge the urine, and, in some rare cases, so con- siderable as to endanger life. Its appearance, moreover, is exceedingly di- versified. Sometimes it comes away of a bright-red colour, and nearly or quite pure, especially when the hemorrhage is copious; and afterwards co- agulates. It may also escape unmixed drop by drop, owing to the blood issuing from the urethra, or the bladder near its orifice. Most commonly it is more or less mixed with the urine, which is sometimes merely tinged by it of a red, brownish-red, or blackish colour, sometimes turbid from the partial coagulation of the blood, which floats at first in irregular flocculi through the liquid, but soon subsides in the form of a soft grumous mass. Occa- sionally small worm-like coagula are observed in the urine, more or less de- prived of their colouring matter. These are supposed to be formed in the ureters. When the blood coagulates in the bladder, its liquid portion first escapes with the urine tinged with the red corpuscles, and afterwards the coagulum broken up into a grumous mass. Thus the urine may continue to be bloody several days after the internal hemorrhage has ceased. Besides blood, various other matters of a mucous or purulent character, and occa- sionally fetid, are mixed with the urine in some cases of organic disease of the bladder or kidneys. The blood may proceed from the kidneys, ureters, bladder, or urethra; but it is not always possible to decide with certainty upon its precise source in particular cases. It may be supposed to come from the kidneys, when vol. ii. 23 346 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. the hemorrhage has been preceded by pain, heaviness, or other uneasiness in the loins, continued or not along the course of one or both ureters to the groin; when it has followed a blow or fall upon the back; Avhen it is an at- tendant upon obvious nephritis or other organic disease of the kidneys, or upon calculi in the pelvis of that organ; and, finally, when the blood is mixed intimately with the urine, or presents itself partly in the form of those cylin- drical coagula believed to be formed in the ureters. In relation to these coagula, if somewhat bleached, there can hardly be a doubt that they have come from one of the ureters; if soft and of a full-red colour, they may have been moulded in the urethra. The diagnosis of hemorrhage from the ureters is almost necessarily uncertain. It may be presumed to exist, when the escape of the blood has been preceded by the very painful passage of a cal- culus through one of these tubes. It is probably a very rare occurrence, un- less in this condition of things; and, even then, it is scarcely possible to be certain that the blood did not proceed from the kidney. The bladder is probably the seat of the hemorrhage, when, before or along with it, the pa- tient has experienced uneasiness over the pubes or in the perinaeum, or has received a blow or had a fall upon one of these parts; when he is known to have stone in the bladder; when the emission of the blood is attended with symptoms of dysury, and there is no reason to suppose the existence of a large coagulum in the bladder; when, in fine, the blood comes away unmixed or but little mixed with urine. In cases of malignant fungus at the neck of the bladder, when hemorrhage generally follows the introduction of a sound, the source of the blood may be confidently referred to that organ. When hemorrhage takes place from the urethra, it is generally known by the escape of the blood either drop by drop, or in a small stream, without any effort of the patient as in micturition, and without his ability to control the flow ex- cept by pressure upon the passage. The blood, too, is usually unmixed; and, when the patient micturates, the urine, though it may be slightly tinged at first, soon passes unchanged; the hemorrhage showing itself again after the cessation of the act. Injury to the urethra, or inflammation of that passage, would also lead to the inference that it might be the source of the blood. Occasionally, however, blood from the urethra, in consequence of a calculus, or of some other obstruction in the passage, flows back into the bladder, and thus tends to confuse the diagnosis. The course of this hemorrhage is altogether uncertain, depending on the various pathological conditions with which it is associated. Of itself, it is very seldom dangerous, though death has occurred from a profuse loss of blood from the urinary passages, without any discoverable organic lesion. It is not unfrequently serious as a sign of other affections; and is sometimes trouble- some and even hazardous by its consequences, as when it fills the bladder and ureters with coagulated blood, and thus obstructs the escape of the urine. The worst form of it is that which attends malignant diseases, and others characterized by a dark, feebly coagulable blood. Diagnosis.—In certain morbid states of the urinary organs, or of the sys- tem, the urine sometimes assumes so nearly the appearance of that mixed with blood, that some care is requisite to distinguish them. Thus, it may be deep-red, or reddish-brown, or blackish, may be turbid, and may deposit a dark sediment somewhat like that produced by blood. In gravel, it is some- times so concentrated, and so abundant in the reddish salts which mark the predominance of uric acid, that it might without difficulty be mistaken for hemorrhagic urine. It is also reddened by certain kinds of food, as the red beet, the prickly pear, &c, and the same effect is produced by madder. Bloody urine may usually be distinguished by the following properties. It is in general turbid when discharged, and afterwards becomes clear by subsidence j CLASS III.] HAEMATURIA, OR BLOODY URINE. 347 the matter deposited is not dissolved when the urine is heated; the clear portion, containing the serum of the effused blood, is, to a certain extent, coagulable by heat; linen dipped in it is stained of a red colour. On the contrary, the coloured urine, above alluded to, is often transparent when dis- charged, and becomes turbid upon standing; re-dissolves the deposit when heated; is not coagulable; and stains linen yellow, or orange, or brown, but seldom blood-red. The discovery of blood corpuscles by means of the micro- scope, and of albumen by the usual tests, would be decisive as to the nature of the fluid. The urine of females is sometimes tinged by the menstrual fluid, and by blood from the uterus or vagina; but there can be little difficulty in distinguishing this from the urine of haematuria, if the attention of the prac- titioner be directed to the circumstances of the case. Causes.—Blows or falls, violent horseback exercise, or the jolting of a rough carriage ; violence in severe or protracted labours ; venereal excesses; calculi in the pelvis of the kidney, ureters, bladder, or urethra; vascular or varicose tumours in the bladder; certain substances which irritate the uri- nary passages when taken internally, as cantharides and oil of turpentine ;* drastic cathartics which occasion much tenesmus; acrimony of the urine from great concentration, such as occurs in hot climates, where the liquid parts of the blood are carried off by perspiration; translation of gouty or rheumatic disease ; suppression of the menstrual, hemorrhoidal, or other habitual dis- charge ; all these, and whatever other causes are capable of inducing irrita- tion and congestion of the urinary organs, may give rise to haematuria, espe- cially when, from plethora or the constitution of the blood, there is a predis- position to hemorrhage. When there is a predisposition to this particular hemorrhage, from the state of the urinary organs, anything capable of stimu- lating the circulation, or giving the hemorrhagic character to the blood, may bring on an attack. Sex and age have some influence in forming such a pre- disposition ; at least it is more common in men than women, and in adults than young children; though the cause of this may be less a peculiar condi- tion of the constitution in the former, than a greater exposure of the parts affected to injurious influences. Pathological States.—Cases of haematuria no doubt occur, in which the affection depends merely upon an irritation or congestion of the bleeding sur- face, connected with a general hemorrhagic predisposition, and without the coexistence of other diseases. But such cases, even including among them those which are vicarious to the menses or hemorrhoidal flux, are very rare; and it is highly probable that a considerable proportion, supposed to be of this character, are actually dependent on some other concealed cause, per- haps a calculus which has escaped detection. The affection with which the hemorrhage is probably most frequently associated is inflammation, with or without ulceration of the mucous membrane. When merely inflammatory, it is seldom considerable; but when connected with ulceration, it may be copi- ous, though it is not easy nor always possible to discriminate between such cases during life. Bright's disease of the kidneys is often attended with bloody urine. Calculous disorder is a frequent source of this hemorrhage, sometimes by directly wounding the surface with which the concretion is in contact, sometimes by merely irritating or inflaming it. Carcinomatous disease of the parts concerned, generally, at some stage of its progress, gives rise to bloody urine. When the introduction of a catheter is always or generally * I have known bloody urine to result from inhalation of the vapours of oil of tur- pentine. The case was that of a patient in the Pennsylvania Hospital, who had been one of the crew of a vessel loaded with turpentine, among which he had worked and slept for several days. He informed me that two others of the crew were similarly af- fected. (Note to the second edition.) 348 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. followed by hemorrhage, this disease may be suspected in the neck of the bladder. Malignant fevers, as typhus, the plague, smallpox, measles, and scarlet fever, and other diseases characterized by a depraved condition of the blood, as scurvy and purpura hasmorrhagica, are sometimes attended with copious haematuria of the passive kind. Treatment.—When not involved in the treatment for associated affections, this should be conducted upon the principles applicable to hemorrhages in general. Rest, abstinence, cooling mucilaginous or other demulcent drinks, bleeding when required by the pulse, and leeches or cups to the loins, hypo- gastrium, or perinaeum, as auxiliary to the lancet or as a substitute for it, when there are signs of decided local irritation, are the remedies applicable to the early stage of active haematuria. When the hemorrhage is very copi- ous, ice or ice-water may be applied over the part from which the blood pro- ceeds ; when it is moderate, and attended with much irritation, warm fomen- tations or emollient cataplasms would be preferable. In the former case, cold water, in the latter laudanum, may be advantageously injected into the rectum. I have found great and almost immediate advantage from the ace- tate of lead, in small and often repeated doses. In the more advanced stages, other astringents, including uva ursi, may often be usefully employed ; and oil of turpentine is an excellent remedy in chronic and passive conditions of the disease. The bowels, if disposed to constipation, should be kept soluble by mild laxatives or enemata. It may sometimes be advisable to inject as- tringent solutions or infusions into the bladder; but this should always be done with caution. When coagulated blood in the bladder obstructs the discharge of urine, or resists the action of that liquid in breaking up and re- moving it, a sound should be carefully introduced so as to divide the coagu- lum, or warm liquids thrown up so as to aid in washing it out. In urethral hemorrhage, a bougie may be introduced, after cold, rest, astringents, &c, have failed. In passive luematuria, the general rules for the treatment of hemorrhage of this character are applicable ; and the same may be said of the prophylactic treatment. Article IX. HEMORRHAGE OF THE UTERUS. Syn.— Uterine Hemorrhage.—Menorrhagia. The term uterine hemorrhage embraces all bloody discharges from the uterus, whether dependent on functional or organic derangement, and whether occurring in the impregnated or unimpregnated state of the organ. In this place, however, those only will be considered which are unconnected with gestation; the others being more appropriately treated of in works upon midwifery. The term menorrhagia has a somewhat less extensive signification. Its origin (uijv, month, and ^yvu/u, I break), would confine it, in strictness, to an increased flow of the menses; but, as the menstrual discharge is now generally thought to be blood, and uterine hemorrhage, occurring in the un- impregnated state of the uterus, to be a mere increase of the menses, the term is extended so as to embrace that affection. They who consider the menses as a secretion, and not a hemorrhage, make the want of coagulability of the discharge its chief distinctive character. Though the menses usually appear every four weeks, continue for three or four days, and amount, on the average, to about five or six ounces, yet the interval may be much shorter, the continu- CLASS III.] UTERINE HEMORRHAGE.—MENORRHAGIA. 349 ance longer, and the quantity much greater, without being morbid, or requir- ing medical interference. No excess beyond the usual average, in any of these respects, would be entitled to the name of a disease, unless productive of injury to the health. Now an excess, to this degree, is very rare without being attended with unaltered and coagulable blood ; and Dr. Dewees states, in his work on the diseases of females, that he has known only one instance of the kind. It is, therefore, scarcely worth while to make a distinction be- tween morbidly superabundant menstruation and the hemorrhage which occurs at the same periods ; especially as the treatment of the two affections would be conducted upon the same principles. But hemorrhage connected with pregnancy, or dependent upon organie diseases of the uterus, could scarcely be included, with propriety, under the title of menorrhagia, having no rela- tion whatever to the menses. By the term, therefore, is here understood only that form of uterine hemorrhage which occurs simultaneously with the menses, or which, originating from mere functional derangement of the organ, may be considered as somewhat analogous to menstruation in its character. Menorrhagia has been divided into the active and passive. There is a real foundation for this division, though not recognized by all authors. The difference is simply this, that, in the former, the blood is extravasated in consequence of an irritation or increased action in the vessels themselves; in the latter flows through unresisting orifices merely upon the principle of gravitation, or under the impulse of the general circulating force. But it does not follow that all cases of hemorrhage attended with general debility are passive; and the probability is, that, in most of the instances in which menorrhagia is so considered, it is really active. Whenever the hemorrhage occurs at certain intervals answering to those of menstruation, and, even under apparently similar exciting causes, does not occur at other periods, it is probably active ; for it is only in consequence of a certain vital exaltation or irritation in the organ, that the current of blood is at these times espe- cially directed or invited to the uterus. The general forces which circulate the blood are quite passive in relation to its peculiar direction. Neverthe- less, it is important to attend to the strength of the patient; for cases ac- companied with debility, even though the uterine action may have the char- acter of irritation, require a very different treatment from those occurring in an opposite state of the system. True passive menorrhagia is that which, in a weakened state of the system and of the uterine vessels, may occur at any time under the influence of exciting causes. It may be the result either of an atonic, relaxed condition of the vascular walls, consequent or not upon previous excitement, or of a certain hemorrhagic condition of the blood, which disposes to a passive extravasation, such as takes place in malignant diseases. Symptoms.—Menorrhagia usually occurs at the regular periods of men- struation, or, if in the interval, at such stated times as to justify the conclu- sion, that it is in some degree under the influence of the causes which regulate the menstrual function. That this is the case may be inferred also from the fact, that the disease seldom occurs before puberty, or after the age at which the system has become quite accommodated to the abolition of this function. In most instances, various premonitory symptoms are observable, sometimes as much as two or three days before the appearance of the hemorrhage. Such are a feeling of weight, fulness, or heat in the region of the uterus, pains in the loins, bearing down sensations, slight swelling of the external parts of generation, tumefaction and uneasiness of the mammae, more or less derangement of digestion, heat of mouth, giddiness or headache, excitement of the pulse and mental depression. If the hemorrhage occurs at the regular monthly period, the first discharge, according to Dr. Dewees, generally has the characteristic properties of the menstrual fluid, but is soon followed by 350 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. blood, as shown by the clots or stringy coagula which attend it. The flow of blood frequently relieves the preceding symptoms of turgescence or excite- ment. After the first gush, it sometimes gradually subsides, and the patient experiences no further difficulty on the particular occasion ; but not unfre- quently, after partial subsidence, it returns again and again, and does not cease until it has considerably reduced the strength; leaving the patient pale, languid, and with a feeble pulse. Sometimes the hemorrhage is so profuse as to produce a condition of acute anaemia (see page 260), and even to involve life in apparent danger. Upon the cessation of the discharge, the patient gradually recovers her strength until the recurrence of the monthly period brings back the same routine of preliminary excitement, hemorrhage, and exhaustion. Occasionally the intervals are not longer than two or three weeks. The general health gradually gives way. The blood becomes deteriorated in quality; and the symptoms of chronic anaemia are at length established. The patient is extremely pale, and suffers much from palpitation, faintness, giddiness, tinnitus aurium, and violent neuralgic head- aches. The pulse is feeble, and is rendered very frequent by slight exertion. The returns of the hemorrhage become more irregular, and its duration longer. The discharge of blood is followed by that of coloured serum, and this not unfrequently by a profuse leucorrhcea. The slightest causes are sufficient to induce an attack. At length the patient is scarcely ever free from hemorrhage, which varies only from the extravasation of coagulable blood to that of a thin bloody serous liquid. The general symptoms are still further aggravated. Sallowness of complexion or excessive pallor, great emaciation, a very feeble and excitable pulse, a short and hurried res- piration, edematous extremities, and sometimes a general dropsical tendency, with derangement of the digestive and nervous functions, mark the extreme prostration of the system. Occasional profuse discharges, sometimes at- tended with syncope, aggravate the danger. If the patient is not relieved, she sinks under the exhaustion, or yields to some accidental disease which her system in ordinary health would have resisted. A fatal termination, however, is rare; as the disease is almost always within the reach of reme- dies, and the course above described is often cut short, at various points, either by the interposition of art, the cessation of the cause, or the resources of the system. In some instances, a condition of debility, similar to that produced by a long continuance of the hemorrhage, arises from other causes in a healthy condition of the menstrual function. The peculiar causes of menorrhagia, now occurring, superadd this affection. The attacks of hemorrhage, under these circumstances, are less apt to be heralded by premonitory symptoms, and are less regular in their recurrence than in a more vigorous state of sys- tem ; and the affection speedily assumes the character above described as belonging to the advanced stage. There are, moreover, between the two extremes of vigour and debility, all conceivable grades; so that it is not always easy to decide to which category any particular case may belong. Either in the induced, or in the original debilitated state of the general health, it is possible that the hemorrhage may assume the truly passive form; the vessels of the womb having lost, to a greater or less extent, their power of resisting the forces that tend to extravasate the blood. But true passive menorrhagia is probably more frequent as the result of a depraved character of the blood itself, in which it no longer retains the poAver of sup- porting the organic contractility of the tissues. In such cases, any cause that may direct the blood with more than usual force, or in more than usual quantity, to the uterus, will bring on a discharge; but the blood, instead of CLASS III.] UTERINE HEMORRHAGE.—MENORRHAGIA. 351 presenting its ordinary appearance, is apt to have a dark colour, and little tendency to coagulate. Women subject to menorrhagia are less apt to become pregnant, and, when they become so, are more liable to abortion than others not thus afflicted. Dr. Locockhas also "frequently remarked that those who have suffered much from menorrhagia, are peculiarly liable to uterine hemorrhage after abortion or parturition at the full time." (Cyc. of Pract. Med,, Article, Menorrha- gia.) Besides menorrhagia, women are subject to other forms of uterine hemorrhage. Inflammation of the womb is sometimes attended with a con- siderable flow of blood. The same thing occurs frequently from ulcers of the uterus, and from polypous tumours and other excrescences, which sustain a constant state of irritation and turgescence. Indeed, whenever frequent attacks of uterine hemorrhage occur, at altogether irregular intervals, even during the menstruating period of life, some organic derangement may be suspected, and an examination should be made. Carcinoma of the uterus is almost always productive of hemorrhage. About the period of life at which menstruation ceases, irregularities of this function are very common; and occasional excess of discharge, or even copious hemorrhage, may occur with- out serious disease of the organ. But, as cancer is apt to be developed about the same time, such hemorrhage is always a subject of suspicion. Should the hemorrhage come on after the menses have ceased entirely, and then occur irregularly, with lancinating pains in the region of the uterus, the grounds of suspicion are much stronger. In all such cases, an examina- tion per vaginam will determine the question. Causes.—The predisposing causes of this hemorrhage are such as affect the system at large, or operate especially upon the uterus. Among the first are all those calculated to induce a plethoric or otherwise hemorrhagic state of the blood. The causes most operative in the production of plethora in women, are, perhaps, sedentary habits, the free use of stimulating food and drink, confinement in hot rooms, and over indulgence in sleeping, especially in hot beds. A contrary set of causes, as scanty and unwholesome food, bad air, exposure to cold, privations of all kinds, and diseases which impair the digestive functions, sometimes predispose to passive menorrhagia by impover- ishing or depraving the blood. The time of life has also some influence. Women appear to be most subject to menorrhagia at the period when the menses, in the natural course of things, are about to cease. Of the causes which act locally, many are occasionally exciting as well as predisposing; in one instance, inducing a tendency to the hemorrhage, and in another, bring- ing an existing predisposition into action. Such are tight lacing, habitual constipation, congestion of the portal circulation from disease of the liver or spleen, long-continued leucorrhcea, and the frequent occurrence of abortion. Anything may act as an exciting cause which is capable of irritating the uterus, directly, or indirectly, or sending towards it a current of blood. Of this nature are the ordinary menstrual effort, great exertion, inordinate danc- ing, straining, blows or falls, mechanical violence of all kinds, medicines cal- culated to affect especially the pelvic viscera, as cantharides, oil of turpentine, savine, and aloes, drastic cathartics in general, hardened feces in the rectum, sexual indulgence, lascivious thoughts, exciting passions, piles, and irritating diseases of the bladder and urinary passages. Treatment.—In acute cases, the patient should be kept at rest in a hori- zontal position, upon a firm bed or mattress, and carefully guarded against causes of excitement, Avhether general or local. Everything having a ten- dency to invite the blood to the uterus, or to confine it there, should be re- moved. The dress, therefore, should be quite loose; constipation, if existing, should be obviated by laxative medicine or an enema; any irritation of the 352 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. urinary organs or rectum which may occasion dysury, tenesmus, or bearing down efforts, should be quieted by an opiate injection; and, if there be con- gestion of the portal circle, dependent on hepatic torpor or obstruction, it should be corrected by an alterative mercurial treatment. These are general directions, to be put in force in all cases presenting the requisite indications. But it is highly important, in conducting the treatment, to consider the state of system, in relation to the degree of elevation or depression. When the disease is recent, the circulation plethoric, the pulse full and strong, and the evidences of uterine excitement obvious, blood may be taken from the arm. After bleeding, and in cases which do not require the lancet, should symptoms of considerable local congestion of the uterus exist, much good may be derived from a few cups to the sacrum, or leeches over the pubes, to the vulva, or on the inner and upper parts of the thighs. Deple- tion, however, of this direct character, is comparatively seldom necessary. A saline cathartic to remove any existing constipation, the use of refrigerant or nauseating diaphoretics, rest, cool drinks, and a diet restricted to farinaceous liquids, will generally be sufficient to meet the constitutional indications in active cases. Small doses of tartar emetic or ipecacuanha, repeated so as to induce slight nausea, without vomiting, will often have a happy effect in relieving vascular excitement, and controlling the hemorrhage, while they do not exhaust the resources of the system. Emetics have been recommended; but, though good might result from the relaxation which precedes and follows their operation, there would be some risk of increased hemorrhage, from the straining and consequent compression of the pelvic viscera which attend the act of vomiting. They must, therefore, be looked upon as a doubtful remedy. Should there have been little or no vascular excitement originally, or should it have been subdued, great advantage may be expected from opium and ipecacuanha, given in the form of pill, or that of Dover's powder. Directing powerfully to the skin, this combination acts revulsively upon the uterus, while it quiets the various irritations, general or local, which often so strongly contribute to sustain the discharge. The patient may be kept constantly under its influence by a full dose every eight hours; or it may be adminis- tered at night, while other remedies are given through the day. When the stomach is very irritable, the remedy may be administered by the rectum, in twice or thrice the ordinary dose. Tincture of hemp has been found useful by Dr. Maguire, in this form of hemorrhage; and its efficacy is attested by Dr. Churchill, who gives it in the dose of five drops three times a day. (Braithwaite's Retrospect, xix. 329.) Dr. W. H. Dickerson, of London, has obtained extraordinary success in uterine hemorrhage, unconnected with or- ganic disease, from the use of infusion of digitalis. He believes it to act by producing contraction of the uterine fibres through the ganglia of the organ. (Lancet, Dec. 8, 1855.) Should the hemorrhage be considerable, efforts should be made to arrest it directly by producing contraction of the bleeding vessels. This indication is admirably fulfilled by acetate of lead, which may be given in doses of two or three grains every hour, two, or three hours, until the hemorrhage is checked, or until from thirty to forty grains have been taken. It may often be happily combined with the opium and ipecacuanha, and the different indi- cations thus simultaneously answered. If the salt of lead should fail, or be objectionable, recourse may be had to ergot, which is peculiarly adapted to hemorrhages of the uterus, and, in consequence of its sedative action upon the circulation, may be used in cases attended with some excitement. When the hemorrhage is alarmingly copious, it is necessary in addition to employ local measures. Of these, cold is one of the most efficient, and best adapted to this condition of the disease. Cloths wrung out of very cold water or CLASS III.] UTERINE HEMORRHAGE.—MENORRHAGIA. 353 spirit, or bladders containing ice, may be applied about the pelvis, over the pubes, or to the loins and back; the patient may be placed in a cold hip- bath ; cold water may be injected into the rectum; or ice introduced into the vagina. Care, however, must be taken that the vital actions, already, perhaps, depressed by the hemorrhage, be not reduced too low by the long continuance of the remedy. Should cold not prove effectual, the measure still remains of plugging the vagina, which, in the ordinary state of the uterus, can scarcely fail. The following observations upon this point are made by Dr. Locock. " A dossil of lint, or a fine cambric handkerchief may be gra- dually introduced into the vagina up to the os uteri, so as to fill the vagina firmly throughout its whole extent. Many prefer soaking the material pre- viously in some strong astringent liquid, and this is, perhaps, still more effi- cacious. If a plug produce pain, it must be withdrawn, and at all events it should not be allowed to remain more than twenty-four hours, because it is apt to become very offensive and irritating from the putrefaction of the dis- charge. On withdrawing it, unless it be done very gently and gradually, a fresh discharge of blood is apt to be occasioned; but it can easily be re- strained by another plug, or some of the other remedies." (Cyc. of Pract. Med., Article, Menorrhagia.) Dr. J. Henry Bennet, of London, in very ob- stinate cases, plugs the os uteri, instead of the vagina. Bringing the part into view by the speculum, he introduces two or three small pieces of cot- ton tied to a thread, wedges them firmly into the os uteri, and then covers the cervix with larger pieces before withdrawing the instrument. (Lond. Lancet, Feb. 1852.) When the case is originally attended with symptoms rather of general de- pression than elevation, or when it has become somewhat chronic, and as- sumed the condition usually considered as passive, other astringents besides acetate of lead may be employed with advantage. Among these, kino, catechu, rhatany, and pure tannic acid, from the vegetable kingdom; and alum, sul- phate of zinc, sulphate of iron, tincture of chloride of iron, and sulphuric acid from the mineral, are perhaps most esteemed. Gallic acid has been °f ^e strongly recommended; and Dr. T. H. Tanner, of London, has found tincture of cinnamon, in the dose of a drachm, every six hours, very efficacious. (See Med. Exam., N. S., ix. 781.) Others have met with success from the latter remedy, among whom is M. Gendrin. Capsicum has also been recom- mended, and probably acts in the same manner. The solution of arsenite of potassa is said to have proved useful. Oxide of silver, eulogized by Dr. Lane, has also been employed with great success by Dr. J. J. Thweatt, of Petersburg, Virginia. He gives it in doses varying from half a grain to two grains twice or three times a day, and always combines it with a little opium or morphia. (Am. Journ. of Med. Sci, N. S., xviii. p. TO.) Astrin- gent injections, consisting of alum dissolved in the infusion of kino or catechu, or of solution of acetate of lead, may be thrown into the vagina; and similar injections have even been introduced directly into the cavity of the uterus, by means of a male catheter passed through its orifice, though death is said to have resulted from the latter plan in more than one instance. M. Dupier- ris, of Havana, Cuba, has found a mixture, consisting of half a fluidounce of tincture of iodine and a fluidounce of water, injected into the cavity of the uterus, to arrest hemorrhage, without injury to the patient, in more than one hundred cases, with only a single failure. A speculum is employed to bring the os uteri into view, and the liquid is injected by means of a syringe, the end of which is introduced into the cavity of the uterus. The hemorrhage is usually diminished on the following day, and disappears on the third day. If not, the injection maybe repeated. (See N. Am. Medico-Chirurg. Rev., Jan., 1857, p. 95.) 354 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. In cases still feebler, where the system and the uterus are both relaxed, and the hemorrhage appears to be sustained by the relaxation, it becomes necessary, in addition to the measures above recommended for arresting the discharge, to employ others with the view of improving the character of the blood, and invigorating the general organic contractility. These measures are not to be confined to the periods of discharge, but continued also in the inter- val. The different bitters and chalybeates are now indicated. Sulphate of zinc, in the dose of two grains, and sulphate of copper, in that of one-quarter of a grain, repeated three or four times a day, are occasionally of advantage. The tonics may sometimes be beneficially associated with an aromatic tincture, as that of cinnamon, or of ginger. In old cases, where the uterus is very feeble and relaxed, remedies calculated to stimulate that organ directly have been recommended, such as a blister to the sacrum, aloetic preparations, and even savine and cantharides; but these must be employed with caution. Oil of turpentine has sometimes a very happy effect. If the bowels are cos- tive, they should be kept open by rhubarb with soap. The diet should consist of nutritious and easily digestible substances; and the malt liquors, or a little wine may be allowed for drink. A cold bath, or cold hip-bath, may be employed for a few minutes, night and morning, if, upon cautious trial, the system is found to react well under its use. Moderate exercise of a passive kind will sometimes be useful, by improving the general health ; but all jolting or jarring, and all active exertion should be carefully avoided. Among the most efficacious remedies is a journey to some of the chalybeate springs, and a free use of the waters. The occasions should be preferably seized for exercise, when the hemorrhage has been suspended. Much of the good effects of this remedy may be somewhat more safely ob- tained by means of friction with the flesh-brush. Much may be done, in the intervals of the hemorrhage, to ward off the attacks. The treatment adapted to the period of discharge, in the passive variety, is generally applicable also to that of suspension ; the line between these tvto conditions being frequently but indistinctly draAvn. This treatment has been already sufficiently detailed. In active cases, the accession of the hemorrhage may sometimes be usefully anticipated by a saline cathartic, and a reduction of the diet. At all times, in the interval, the diet should be moderate, and stimulant drinks avoided. Due activity should be imparted to the secretory and nutritive processes by means of exercise, so as to prevent an undue accumulation of blood in the circulation. All the functions should be maintained, as far as possible, in a healthy state ; and particular attention should be paid to the liver and bowels. In those cases in which the menses are postponed beyond the regular time, and are attended with hemorrhage, efforts should be made to bring them back to the proper period. For this purpose, a warm hip-bath, and copious draughts of warm herb teas may be resorted to about the regular menstrual period, preceded, if the pulse be full and strong, by the loss of a little blood. In all forms and circumstances of the affection, the causes should be care- fully studied, and, if possible, removed. Hepatic disorder, producing portal congestion, is said to favour it, and should be corrected if existing. An irri- table state of the nervous system, which is apt to attend the complaint, and may aggravate it, should be corrected by such narcotics and antispasmodics as may not be contraindicated by existing symptoms. Of these, opium or some one of its preparations is most effectual. Occasion may arise, also, for the use of hyoscyamus, camphor, assafetida, valerian, and compound spirit of ether. CLASS III.] HEMORRHAGE FROM THE SEROUS MEMBRANES. 355 Article X. HEMORRHAGE FROM THE SKIN. Hemorrhage from the skin in a sound state, with the cuticle entire, is exceedingly rare. Cases, however, have been observed. The blood is said to have escaped, in some instances, from the whole or large portions of the sur- face like sweat; but usually the hemorrhage is confined within a small space, as to the palms of the hands, soles of the feet, roots of the nails, nipple, navel, face, front of the chest, arm-pits, and groins. The blood oozes out like dew upon the surface, and, if wiped off, reappears in the same manner. The skin beneath is in some cases quite healthy in its aspect, in others is red, as if congested or inflamed. This form of hemorrhage is stated to have resulted sometimes from violent exertion or straining, and from strong mental emotions, especially of fear. But these causes could scarcely have induced it without a strong predisposi- tion, dependent probably upon the condition of the blood. It is occasionally vicarious to other discharges, healthy or morbid, and particularly to the menses. When from this cause, it has been observed to be periodical in some instances. Women are much more subject to it than men. But, though exudation of blood through the cuticle is rare, hemorrhage beneath the cuticle, and in a morbid state of the skin, is not uncommon. Bleeding from blistered or ulcerated surfaces, and from scratches, or other very slight injuries, often occurs in persons strongly predisposed to hemor- rhage ; and effusions in the cutis, in the form of petechiae, and beneath the cuticle, in the form of bloody blisters, are common attendants upon scurvy, and other diseases in which the blood is depraved. The consideration of hemorrhage from wounds belongs to the province of surgery. It may not, however, be amiss to mention here that the bleeding from leech-bites, espe- cially those of the European leech, is often profuse, and in children sometimes dangerous, particularly when there is a tendency to hemorrhage. The treatment in all these cases, so far as regards the cutaneous hemor- rhage, is very simple. In many instances, the affection is slight and disap- pears spontaneously, or subsides with the general disorder in which it had its origin. If so copious or protracted as to demand remedial measures, it may be treated with cold applications, astringent lotions, or compression. In the case of leech-bites, I have found a piece of cotton, wet with a satu- rated solution of alum in boiling-hot water, and then pressed upon the wound just before the salt begins to crystallize, a very effectual remedy. Another plan is to introduce the fine point of a piece of lunar caustic into the bite; and still another, to take a thin piece of caoutchouc, and, having heated it till it become soft and adhesive, to press it over the point of hemorrhage, and retain it there until it is firmly fixed. Article XI HEMORRHAGE FROM THE SEROUS MEMBRANES. This sometimes occurs, though very rarely, as a functional derangement, from causes similar to those which produce hemorrhage from the mucous tissue. It is more common as the result of inflammation. In very many cases of serous inflammation, more or less blood is effused with other liquids; 356 LOCAL DISEASES.—CIRCULATORY SYSTEM. [PART II. but this scarcely deserves to be considered as hemorrhage. To be entitled to this name, the blood should escape from the vessels in considerable quan- ties, and with little admixture. This sometimes happens in persons pre- disposed to hemorrhage; and is a not unfrequent attendant upon pleurisy, pericarditis, and peritonitis, occurring in scorbutic individuals. (See Scurvy.) Other sources of hemorrhage into the serous cavities are the bursting of aneurisms, the erosion of blood-vessels by ulceration, and their rupture in consequence of external violence. Though the effused blood is sometimes in quantity sufficient to produce fatal syncope, it is more commonly injurious by compressing the neighbour- ing vital organs, or by producing inflammation in the membrane. The diagnosis in these cases is often obscure; and not unfrequently the affection is first discovered after death. It may be suspected when, without sufficient pre-existing disease to explain the result satisfactorily in another manner, there suddenly occurs great prostration, with the symptoms of acute anaemia; and, at the same time, the functions of some one of the organs in- vested by a serous membrane, are deranged in a mode implying compres- sion. The diagnosis is aided by the fact that, very generally, when there is hemorrhage from a serous membrane, independent of organic disease, there is simultaneously hemorrhage from a neighbouring mucous membrane also; the causes which occasion the former being so general in their influence as almost necessarily to involve a tissue, so much disposed to this affection as the mucous. If, by the aid of percussion or auscultation, a fluid can be discovered in one of the serous cavities, the evidence is strengthened. These hemorrhages are not necessarily fatal. If the effused blood is not very copious, it coagulates, and, producing inflammation in the contiguous membrane, occasions the exudation of coagulable lymph, which may form an organized cyst around the mass, and ultimately remove it by absorption. Or the coagulum may itself become organized, and form a new structure not incompatible with the life of the patient. Art has little to do in such cases but to look on, and occasionally aid the efforts of nature by correcting de- rangements in the general health. Should the symptoms afford reason to think that the hemorrhage is still going on, and that it may be the result of an irritative transudation, it would be proper to endeavour to check it by bleeding, carried as far as the strength of the patient will admit; and if he be already reduced too far for this remedy, cold may be applied externally, as near the seat of the hemorrhage as possible. When the effusion is very abundant, nothing offers a chance of safety but the evacuation of the blood through an artificial opening; and the chance from this source is very slight. Hemorrhage of the pleura is one of the most frequent of-the serous hemor- rhages. It may be suspected when shortness of breath, great debility and faintness, and bloody expectoration, occur suddenly and simultaneously; while the chest affords, by percussion and auscultation, evidences of a liquid within the pleura, not previously existing there. It is generally fatal when considerable. Paracentesis has been performed in cases attended with large effusion, but not with very encouraging results. Dr. Karawagen, of Kron- stadt, performed the operation in four cases of hemorrhagic pleuritis, at- tendant on an epidemic scurvy which prevailed at that place in 1839, and in all with relief to the patients, though without ultimate success. Effusion of blood into the pericardium, when it occurs, is generally con- sequent on rupture of the heart or one of the large blood-vessels; but cases have been recorded in which it appeared to be the result of transudation; as no solution of continuity could be found upon the most careful examina- tion. Such cases have come under the notice of Baillie, Chomel, Carson, and Burrows. In ChomePs cases, the affection continued several days, and was CLASS III.] HEMORRHAGE OF THE CELLULAR TISSUES. 357 attended with orthopncea, an unequal and irregular pulse, the absence under the hand of any impulse of the heart, general oedema, and reddish expecto- ration. (Diet, de Med., xv. 173.) Dr. Karawagen performed the operation of paracentesis in two cases of hemorrhagic pericarditis, accompanying scurvy, in one with relief to the symptoms, in the other with complete success, the patient having ultimately recovered ; and this was the only case of recovery out of thirty affected with the disease. Three pints and a half of bloody liquid were extracted. (See Med. Examiner, iv. 525.) The same operation has been frequently performed by Dr. Kyber. In most cases, it merely served to protract life without preserving it; but, in four, a radical cure was ef- fected. (See Ranking's Abstract, vii. 64.) Hemorrhage of the peritoneum, independent of inflammation or organic disease, though rare, has been occasionally noticed. Sudden and very severe abdominal pains, nausea and vomiting, coldness of the surface, extreme feebleness of the pulse, a haggard countenance, and delirium, have been the prominent symptoms. The presence of blood in this cavity, whether from transudation or other cause, is probably less fatal than in the pleura; isola- tion, and ultimate absorption, organization, or elimination of the blood, being of occasional occurrence. The phenomena and effects of hemorrhage of the arachnoid will be de- tailed under diseases of the brain and spinal marrow. As to the tunica vaginalis testis and the synovial membranes, little need be said. Hemor- rhage in these membranes is almost always the result of violence, though it may sometimes occur from transudation in persons of a strong hemorrhagic diathesis. Blood has been found effused into the joints in scurvy. Article XII HEMORRHAGE OF THE CELLULAR AND PARENCHYMA- TOUS TISSUES. Extravasation of blood in the cellular tissue is a common result of a general predisposition to passive hemorrhage. In scurvy, purpura, and ma- lignant febrile affections, as well as in cases of constitutional predisposition to hemorrhage, it is among the most constant phenomena. The extravasa- tion takes place immediately under the skin, forming ecchymosis; beneath the mucous and serous membranes, producing elevated red patches in parts obvious to inspection; and among the muscles, giving rise to tumours, often of considerable size. In short, there is no portion of this tissue in which the effusion may not occur. The blood in these cases, if the patient survive the disease in which the hemorrhage originates, is either gradually absorbed, or becomes organized, and forms new structure, which ultimately disappears. The hemorrhage itself is seldom an object of treatment; the efforts of the practitioner being directed towards the general affection. Effusion of blood in the cellular tissue is a frequent result of external vio- lence, and, in persons with a constitutional tendency to hemorrhage, is pro- duced by the slightest causes. Large ecchymoses and bloody tumours are thus occasionally formed under the skin. They almost always, however, dis- appear gradually by absorption, if not tampered with. Evaporating lotions, as tincture of camphor, may sometimes hasten the process; and it is possible that gentle pressure may occasionally do good, though it must be used with caution. If attended with inflammation, they should be treated with cold water, or saturnine lotions. 358 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. Hemorrhage into the tissue of organs is of no unfrequent occurrence, though it probably results much oftener from an inflammatory or other organic lesion, or from external violence, than from mere transudation consequent upon irri- tation or congestion. It sometimes attends upon affections characterized by a hemorrhagic state of the blood. In most of the organs its existence can be known only after death. In the lungs and brain, however, it occasions characteristic phenomena which indicate it in many cases with sufficient clearness. It is almost never by the mere loss of blood that it does harm, but by interfering with the functions of the organ. In this way it is almost al- ways serious, and very often fatal. Apoplexy and palsy result from such effusions in the brain, and pulmonary apoplexy in the lungs. (See Apoplexy, and Hemorrhage of the Lungs). SECTION Y. DISEASES OP THE ORGANS OF SECRETION. This section might embrace all the diseases of all the secreting tissues, in- cluding the serous, cellular, and mucous membranes, the skin, and the con- glomerate glands ; but many of these are more conveniently considered under other functions, in the execution of which the tissues perform an essential part; as, for example, the complaints of the alimentary mucous membrane under digestion, and of the bronchial under respiration. I shall treat here only of the diseases of the serous and cellular tissues, the skin, the salivary glands, the liver, the spleen, the kidneys, and the appendages of these several organs. No arrangement of diseases can be so precise, that the different divisions will not occasionally trench upon one another. SUBSECTION I. DISEASES OF THE SEROUS AND CELLULAR TISSUES. In consequence of the connection of these tissues with other functions than the secretory, all of their diseases are considered elsewhere, except dropsy, which, being generally a disease of secretion, would appear to fall naturally into this division. Article I. DROPSY. Dropsy may be defined to be a morbid accumulation of watery or serous fluid in the cellular tissue or serous cavities. A certain portion of such fluid is essential to the healthy state of these parts. It is only when the wants of the tissues are exceeded, and an accumulation takes place productive of more or less inconvenience or injury, that it can be said to be morbid, and thus to constitute dropsy. Nor do I here include, under this term, the serous col- lections that sometimes take place in mucous cavities, in cysts or hydatids, or even in the bursas and synovial sacs. Though there is a certain analogy between these and dropsy, and though the name is not unfrequently applied to them, they differ in this respect, that they are generally quite local, and do not, like dropsy, depend upon causes which may produce a simultaneous ef- CLASS III.] DROPSY. 359 feet in all the ordinary seats of the affection. Thus, we may have serous effusion into the cellular tissue, the peritoneum, and the pleurae, at the same time, and from the same cause; but this does not extend into the mucous or encysted cavities, and seldom to the joints. The affections usually originate under different circumstances, obey different laws, and require different treat- ment. It is even most convenient to separate certain cases of effusion in se- rous cavities from the general category, and either to treat of them under the head of the organs which they severally affect, as when the discharge is a mere attendant upon inflammation, or to refer them to the surgeon, as in the case of hydrocele. The only localities of dropsy here considered are the cel- lular tissue, the arachnoid, the pleurae, the pericardium, and the peritoneum. When the effusion takes place in the cellular structure, it is denominated, if extensive, anasarca, if limited to one part, oedema; Avhen it affects the arachnoid, it is called hydrocephalus, or dropsy of the brain; when the pleurae, hydrothorax, or dropsy of the chest; when the pericardium, hydro- pericardium, or dropsy of the heart; when the peritoneum, ascites, or ab- dominal dropsy. The name of general dropsy is given to the affection when it occupies all or most of these positions, to a greater or less extent, at the same time. The complaint will be first treated of in its general relations, and afterwards in the several localities alluded to. Dropsy is rather a symptom or result of morbid action than itself a dis- ease. Nevertheless, it usually holds this rank in practical treatises, and, from its own striking characters, and the frequent obscurity of the true pathologi- cal condition in which it originates, will probably always continue to do so. The danger in which it frequently involves life, and the consequent necessity of employing measures for its removal, without reference to its source, are other considerations which entitle it to a place in the catalogue of distinct diseases. Pathological Condition. The first inquiry in relation to dropsy should be directed towards the pa- thological condition upon which the liquid accumulation depends, and which constitutes the true disease. This is not the same in all cases. Very differ- ent, and, indeed, opposite derangements of function or structure are the sources of dropsy. They may all be included under the following heads. 1. Irritation, Active Congestion, or Inflammation.—The serous and cel- lular tissues pour out an increased quantity of fluid when excited. The ex- citement may amount to inflammation. That dropsical effusion is sometimes associated with this condition of the membrane from which it proceeds, is evinced by the symptoms during life, and the results of examination after death. Pleuritic and abdominal pains with fever occasionally precede hy- drothorax and ascites; and, in some cases of anasarca, pressure upon the edematous part occasions considerable uneasiness. Indeed, inflammation of the serous tissues is generally attended with a fluid exudation, a portion of which has the serous character. When this is speedily absorbed, after the subsidence of the acute symptoms, it is not considered dropsical; but if it continues long, and especially if it increases and becomes complicated Avith external oedema, it is unhesitatingly admitted to that rank. Dissection after death, in such instances, often exhibits decisive evidence of pre-existent or persisting inflammation. In most cases, the inflammation is chronic ; and it is not unfrequently complicated with tubercles, which serve to sustain it. But, though inflammation sometimes lies at the foundation of dropsy, the disease is more frequently the result of mere irritation with vascular turges- cence. The very act of effusion relieves the vessels, and inflammation is prevented by the occurrence of dropsy. 360 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. 2. Debility or Relaxation.—An opposite condition of the tissues to that just mentioned may be productive of the same result, in relation to dropsical effusion. The vessels in debility sometimes become so relaxed, that the more liquid portions of the blood are allowed to pass through their walls, almost without resistance. We observe the same thing in the vessels of the skin, by which the watery part of the blood is often poured out abundantly in very feeble states of the system, in the form of colliquative sweats. The results of injection after death confirm this view of the pathological condition in cer- tain cases of dropsy. Dr. Horner, late Professor of Anatomy in the Univer- sity of Pennsylvania, stated that, in fine injections of whole dropsical subjects, scarcely any resistance is offered by the blood-vessels ; the injected fluid es- caping from them by their lateral porosities as fast as it can be thrown in. (Am. Journ. of Med. Sci, i. 265.) 3. Passive Congestion,—Distension of the blood-vessels, unattended with irritation, frequently results in serous effusion. If water be injected into the veins of an animal in considerable quantity, death takes place with symptoms of cerebral and pectoral oppression, and watery fluid is found, upon dissec- tion, in one or more of the serous cavities, and in the cellular tissue. If, previously to the injection, blood has been abstracted, and the quantity of water employed be merely sufficient to supply the loss, the same consequences do not follow. Distension, therefore, is the immediate cause of the effusion. Such distension frequently occurs, in various degrees, from a derangement of the proper balance between absorption and secretion, and from other causes. It is only when considerable, or from the nature of its cause, lasting, that dropsy is produced. It may be said that the distension produces irritation or increased action of the capillary vessels, and that the effusion is the result of an active process. This is no doubt often the case; but frequently also there is reason to believe that it is wholly or in great measure passive, as all evidences of excitement are wanting ; and the effusion is most apt to take place when the blood is watery, and the tissues relaxed. It is not improba- ble that many cases are of a mixed character; the extravasation being ascri- bable partly to irritation, partly to mere mechanical transudation. The preternatural fulness of the blood-vessels may be general, affecting the whole circulation, or it may be confined to the venous system, or to some portion of it, as to the portal circle, for example, or to a single limb. When partial, it is apt to be the result of some impediment to the return of the venous blood. The character of such impediments will engage our attention, under the causes of dropsy. The extent and position of the dropsy will of course be influenced by the locality of the congestion. 4. Altered Condition of the Blood.—There is little doubt that an altered composition of the blood is occasionally the true pathological condition in dropsy. What is the precise nature of the change has not been certainly determined. It is well known that anemic patients are occasionally attacked by dropsy; and it has been supposed that a watery-state of the blood favours the occurrence of the disease. In repeated instances, examination of anemic patients who have died of dropsy has detected no organic lesion whatever, to which the disease could be ascribed ; and a fair inference is that the blood was in fault. Two such cases are recorded by M. Castelnau in the Archives Generales, (4e ser., v. 141). According to Andral, the dropsical tendency is connected not with a deficiency of fibrin or red corpuscles, but of albumen in the blood. (Patholog. Haematology, Am. ed., 108, &c.) MM. Andral and Gavarrat always detected albumen in the urine, in dropsical cases in which they found a deficiency of that principle in the serum. (Arch. Gen., ie ser., v. 168.) This accounts for its deficiency in the blood, without the necessity of admitting that this deficiency was the cause of the dropsy. Dr. Rees, in CLASS III.] DROPSY. 361 many examinations of the blood of dropsical patients, never discovered a diminution in the proportion of albumen. (Ibid., 169.) In the two cases de- tailed by M. Castelnau, there was no albumen in the urine, and the inference is drawn by the author that it was not wanting in the blood, which was very watery and deficient in red corpuscles. Watery blood may, therefore, cause dropsy without any special deficiency of albumen; but there can be little doubt that such a deficiency really does contribute to the dropsical tendency. The fact is, that further experiments are required to decide what is the precise alteration in the blood which disposes to dropsy. In the present state of our knowledge, we can only say that it is in general apparently more watery than in health. How it is that this state of the blood induces effusion is equally uncertain. It may be that the greater tenuity of the liquid facilitates its escape through the pores of the capillaries; it may be that these pores them- selves become relaxed from the want of due stimulus from the blood; or, finally, both these causes may operate. It is highly probable, also, that ac- cumulation in the blood of urea and other unhealthy constituents, consequent upon diminished secretion of urine, may give rise to an irritant property in the circulating fluid, which, acting on the serous and areolar tissues, may oc- casion increased secretion, and thus cause dropsy. An affection, known in the East Indies by the name of beri-beri, ap- pears to be nothing more than dropsy connected with a depraved state of the blood, which, according to Dr. Morehead, is of a scorbutic character. The prominent symptoms are general weakness and indisposition to exer- tion, followed by pain, numbness, and stiffness of the limbs, anasarca, effu- sion into the serous cavities, epigastric uneasiness, and not unfrequently, in the advanced stages, vomiting, often repeated, and sometimes with dis- charges of blood. The disease runs its course in two or three weeks, or a shorter period, and often proves fatal. (Ranking^ Abstract, xxii., 42 ; from Trans, of Med. Soc. of Bombay, 1855.) • 5. Deficient Absorption.—In health there is a constant exhalation from the serous and cellular tissues, and an equally constant absorption of the effused fluid; and the two processes so far balance each other that no inju- rious accumulation takes place. It is obvious that dropsy may arise from an irregular condition of either or both of these functions; from an excess of exhalation while absorption remains unchanged, from a deficiency of ab- sorption, exhalation continuing as in health,'or from an increase of exhala- tion and diminution of absorption combined. No sufficient proof has been adduced that dropsy depends exclusively on deficient absorption. It has been inferred to do so from the fact, that obstruction of the absorbent ves- sels is sometimes followed by oedema of the limb below; but this is not a necessary consequence ; for even the thoracic duct has been found obstructed without giving rise to dropsy. Nor has it been shown that the action of the absorbents is at all diminished in most cases of the disease. On the contrary, rapid loss of flesh often attends the progress of dropsy; and the lymphatics running from dropsical parts have been sometimes observed to be greatly enlarged, as if they had been more than usually active. Besides, we have no proof that the fluid exhaled in dropsy is identical with that exhaled from the same tissues in health ; and the probabilities are that it is not so ; for albumen, which is found in dropsical fluid, is not usually a con- stituent of the normal secretions. But it is now generally believed that the veins are concerned in the process of absorption. Obstruction in these vessels, by producing congestion in the venous radicles below, must prevent the admission of fluid from without, and thus interfere with absorption, so far as the veins are concerned. The experiments of Magendie would appear to place this fact beyond doubt. They demonstrate that, when the venous vol. n. 24 362 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. system is artificially distended by the injection of water, absorption is impeded greatly, if not quite arrested. It is highly probable, therefore, that a defi- ciency of absorption in consequence of congestion of the veins is one of the pathological conditions upon which dropsical accumulations depend ; but it is equally probable that this is never the sole, nor even the original cause ; for, in all such cases, effusion is greatly increased in consequence of the dis- tended state of the vessels. The fact, before stated, of the enlargement of the lymphatics in such cases, goes to show that absorption is not diminished in the ratio of the increased effusion; a portion of the duty of the v.eins being performed by the absorbents, Avhich thus labour, though not in all instances effectually, to remedy the inconveniences arising from the venous congestion. The pathological conditions, above enumerated, are all that occur to me as being the immediate sources of dropsical accumulations. They constitute the true diseases of which the dropsy is a symptom. It is certain that vari- ous organic or functional derangements not yet mentioned are remotely the source of dropsy, but they all act by inducing one or more of these conditions, and will be more appropriately considered under the head of the causes of the disease. Two or more of the above conditions are often united. Thus, irritation may supervene upon a watery condition of the blood, and conges- tion of the vessels ; and it will be readily understood that, in such cases, the liability to the affection must be much greater than when either of the morbid states exists alone. We can thus explain why, in frequent instances, one of these states occurs without dropsy, while in other instances, being reinforced by one or both of the other conditions, it is-attended with the complaint. Symptoms, Course, Termination, &c. The symptoms which characterize dropsical effusion will be more conveni- ently detailed under the particular forms of dropsy. The affection sometimes comes on suddenly, with more or less febrile action, indicated by increased frequency and force of pulse, warmth of skin, furred tongue, &c. Sometimes it is gradual in its approach, advances slowly, and is associated with general debility, and depressed rather than excited vascular action. In the former case, it is sometimes called acute or febrile dropsy, in the latter chronic. But there is no definite line of demarcation between these varieties. Dropsy with feeble action sometimes makes its attack suddenly, and cases characterized by excitement may be slow in their progress ; while others beginning with febrile action may end in debility. It is important that the practitioner should be aware that the disease is attended with these different states of the system ; but little good can result from any attempt at classification on such a basis. Cases of excitement sometimes manifest obvious marks of inflam- mation, such as thoracic and abdominal pains in hydrothorax and ascites, and tenderness of the cellular membrane on pressure in anasarca. More generally, however, the local symptoms are those rather of irritation than of positive inflammation. In dropsy with debility, the skin is usually very pale, the pulse feeble, and the general condition of the patient not unfrequently anemic.^ In many instances, neither symptoms of excitement nor those of depression are very obvious. The urine is almost always scanty. In this, dropsies of whatever charac- ter, and from whatever cause, generally agree. It is not, hoAvever, always easy to determine exactly what constitutes scanty urine. The quantity of this secretion varies exceedingly in different persons, and in the same person under different circumstances, and within the limits of health. The average in twenty-four hours, in healthy individuals, may be stated at* two or three pints. In dropsy it is often not more than a pint in the same time, and some- CLASS III.] DROPSY. 363 times is much less. In some rare cases of the disease, the urine remains un- diminished, and is even increased, especially in the advanced stages. These are generally cases of debility, in which the serous portion of the blood finds a ready outlet through the relaxed vessels, whether of the kidneys, or the serous or cellular tissue. The character of the urine is variable. In different cases, it is deep-brown like beer, deep-red and lateritious, bloody, bilious, pale, light-yellow or red- dish, turbid, somewhat opalescent, limpid, and quite healthy in appearance. In febrile dropsy, it is generally dark-coloured and turbid, more or less albu- minous, and of a specific gravity less than in health. In cases dependent on disease of the liver, it is often very high-coloured and bilious, and is said to have the odour of honey. In renal cases, it is sometimes dark-brown or tinged with blood, generally more or less acrid and albuminous, and often abounds with epithelium thrown off by the tubuli uriniferi of the kidneys, and not unfrequently contains fibrinous casts of the tubes, discoverable by the microscope. Since the publication of Blackall's work on dropsy, considerable attention has been paid to albumen as a constituent of urine ; and the deter- mination of its presence or absence, and relative quantity, is considered im- portant as an aid to diagnosis. The subject has acquired additional import- ance from the researches of Dr. Bright and others. It will be treated of more extensively, when we come to the consideration of renal disease as a cause of dropsy. It will be sufficient here to point out the modes by which the presence of albumen may be detected. Tests of Albumen in the Urine.—One of the most convenient tests is heat. The urine, if turbid, should be first filtered, and, if alkaline to test paper, should be neutralized ; as alkalies counteract the coagulating property of heat, and, moreover, sometimes occasion a precipitation of the earthy phosphates in urine when heated, though it may contain no albumen. The urine should also always be examined before it has had time to undergo decomposition ; as the albumen may be changed along with the other principles, and thus no longer be sensible to the usual tests. When prepared for examination, the urine may be exposed in a glass tube, closed at one end, to the flame of a spirit-lamp, or simply heated in a silver spoon, or other convenient recipient, over the fire. According to the proportion of albumen present, will be the amount of insoluble matter produced. If it is very small, there will be a mere whitish cloudiness in the urine ; if larger, there will soon be a sensible precipitation of whitish, curdy flakes ; if very large, the whole mass of urine may gelatinize. The last result is rare. The proportion of the precipitate varies, from the smallest appreciable quantity, to a bulk which occupies nearly the whole of the fluid. Another test usually employed is nitric acid. This added to albuminous urine produces a flaky precipitate. But it cannot be relied upon alone, as it sometimes, in the absence of albumen, occasions a precipitation of uric acid, and sometimes of nitrate of urea, when this latter principle is in excess in the urine. Such precipitates, however, are redissolved upon the application of heat. It has before been stated that heat may cause a deposition of the earthy phosphates in alkaline urine. These are redissolved upon the addi- tion of nitric acid. Thus it appears that these two tests separately employed are liable to fallacies; but conjointly, their evidence may be considered cer- tain. They should both be tried in every case at all doubtful. According to Dr. II. Bence Jones, the presence of a little acid may prevent the coagu- lation of albumen by heat; as a compound of the acid and albumen, though insoluble in dilute acid, is soluble in a large proportion of pure water, hot or cold. He therefore advises that, before this test is tried, the tube should be av ashed thoroughly clean. (Lancet, March 16, 1850.) Additional proof 3G4 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. is afforded of the albuminous nature of the urine, if acetic acid should not precipitate the coagulum produced by heat and nitric acid, Avhen dissolved in solution of caustic potassa. It may be proper to observe that albumen, in very minute proportion, is capable, when coagulated, of rendering a clear liquid turbid, and that its bulk after precipitation is greatly disproportionate to its weight. Dr. Christison never found more than 27 parts in 1000 of urine, and states that, in the proportion of one part in 100, it gives to the urine almost the appearance of a thin pulp. When in considerable proportion, it coagulates at, 160°, but if much diluted requires the heat of boiling water. Perspiration is generally deficient in dropsy, The bowels are often cos- tive, and sometimes very insusceptible to purgative medicine, even of the most powerful kind. In some cases, however, the disease is complicated with chronic intestinal inflammation ; and then the patient is apt to be af- fected with diarrhoea. When this occurs without any amelioration of the dropsical symptoms, and especially in the advanced stages, or when dropsy supervenes during its prevalence, it is usually an unfavourable sign. Thirst is often a prominent symptom. It is not confined to the febrile form of the disease, but may attend the most feeble cases. The fluid effused in dropsy appears generally to consist of the serum of the blood, more or less altered. Though not absolutely identical under dif- ferent circumstances, it usually possesses closely analogous properties, being, for the most part, limpid, colourless, or slightly yellowish, and without smell. It is occasionally tinged with blood, especially when the dropsy is dependent on obstruction of the veins. In cases of inflammation, it is sometimes milky, and contains flakes of coagulated matter, and may also be mixed with pus. Its specific gravity is variable, but always exceeds that of water. It consists chiefly of water, but contains various principles existing in the blood. Albu- men is almost always present, but in very different quantities. In sixteen cases examined by Andral, he found proportions varying from four to forty- eight parts in 1000 of the fluid, and uniformly less than in the serum of the blood. The proportion was greatest in those cases in which the health ap- peared least impaired. (Pathol. Haematol., Am. ed., 115.) Besides albumen, Marcet found a peculiar animal principle which he named muco-extractive matter, and which was also in variable proportion. Urea was found in large proportion by Dr. Corrigan in the fluid of a case of ascites with symptoms of disease of the kidneys. (Dub. Journ. of Med. Sci, March, 1842.) M. Dela- harpe, of Lausanne, discovered fibrin, in several instances, in the fluid of abdominal dropsy, in such quantity that the liquid coagulated after being withdrawn. (Arch. Gen., Se ser., xiv. 174.) According to Marcet, the salts are in singularly uniform proportion, in whatever part the fluid is effused. They consist of chlorides of sodium and potassium, sulphate of potassa, soda either free or carbonated, and phosphates of lime, iron, and magnesia. The dropsical effusion may occupy any one of the serous cavities, or any portion of the cellular tissue, whether in the interior of the body, or beneath the skin. Gravitation, and consequently the position of the patient, have much effect in determining the position of the fluid, whether in the cavities, or the cellular tissue. In the latter, the communication between the cells allows it to traverse the body with little difficulty. Hence, the swelling in anasarca is usually first observed, and is greatest in the feet, ankles, and legs. Hence too, in the cellular tissue of the lungs, the effused fluid generally occu- pies the lower portion, in consequence of the erect position of the patient. The disease is confined to no time of life. It is not unfrequent in infancy, is frequent in old age, and occurs at all intervening periods. It is, hoAvever, most common towards the decline of life. It occasionally undergoes a spon- taneous cure. In such cases, the disappearance of the effusion is generally CLASS III.] DROPSY. 365 coincident Avith an increase of some one or more of the secretions; with the occurrence, for example, of a profuse diuresis, perspiration, or diarrhoea. Most of the disagreeable symptoms, in the progress of the complaint, arise from the deranged functions of the various organs, consequent upon the pressure of the effused fluid. Its greatest danger is from the same source. Thus, respiration and the action of the heart are embarrassed from the pres- sure of liquid in the thorax; and convulsions, coma, palsy, and apoplexy occur from a similar cause within the cranium. QMema of the glottis some- times occasions the most serious consequences. The pressure of the dis- tending fluid in the extremities not unfrequently occasions inflammation of the skin, terminating in gangrene, and ultimate exhaustion. More fre- quently, however, the fatal result in dropsy is owing to the organic diseases in which it originates, as those of the liver, kidneys, and heart. Inflamma- tions, such as pleurisy, bronchitis, and gastro-enteritis, not unfrequently occur in the advanced stages, and carry off the patient. In some instances, the effused fluid is entirely absorbed towards the close, and the patient dies exhausted, when the inexperienced practitioner might be indulging the hope of a favourable issue. Causes. I consider as causes of dropsy those which produce the several patho- logical conditions upon which the effusion depends. In the first place may be mentioned all those capable of inducing irritation or active congestion of the secreting tissue. Of these one of the most common is exposure to cold, especially in a state of profuse perspiration. If, in this condition, the kid- neys, from excess of excitement, or other cause, fail to perform the vicarious office that is thrown upon them, the irritation may be directed to the serous or cellular tissue, and dropsy result. In general, hoAvever, inflammation rather than dropsical irritation ensues; and, in order to the production of the latter, there must be a peculiar predisposition, consisting either in the state of the blood, or of the capillaries, or in some other and unknown con- dition. Somewhat similar in their effect to cold, are the retrocession of cutaneous eruptions, or of gouty and rheumatic irritations, and the suppres- sion of accustomed discharges, Avhether healthy or morbid, as of the urinary and menstrual secretions, hemorrhoidal flux, &c. The condition of system which follows delivery is said sometimes to favour the occurrence of dropsy, probably in consequence of a want of due accommodation of the general ex- citement, incident to the pregnant state, to the new order of things. Preg- nancy itself may sometimes produce dropsy, as an effect of its attendant vascular fulness and excitement, in cases where a predisposition to the dis- ease exists. Certain febrile diseases, especially the exanthemata, often leave behind them a tendency to that sort of irritation of tissue which occasions dropsy. The same is not unfrequently the case with protracted intermit- tent fever; though, in this instance, the pathological condition is probably rather an anemic state of the blood, or venous congestion from disease of the liver and spleen, than vascular irritation. The presence of tubercles in the tissues affected is another cause of dropsical irritation, and one of those least capable of being obviated. Secondly, in the catalogue of causes may be ranked those which operate by relaxing and debilitating the tissues, and impoverishing the blood. These are frequently coincident. Among them are insufficient or unwholesome food, insufficient clothing, habitual exposure to damp, cold, and impure air, impaired digestion, excessive secretion, great loss of blood, the intemperate use of alcoholic drinks, and long-continued and exhausting diseases, as irregular gout, scrofula, cancer, and scurvy. Dropsy is often the closing 366 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. scene of such affections, and its occurrence may generally be regarded as a sure evidence of the breaking up of the constitution. The abuse of mercury is said sometimes to havTe produced dropsy; but I have not witnessed this result. It has been already stated that protracted intermittents may rank in this class of causes. Chronic disease of the spleen is very frequently asso- ciated with the anemic state of the blood so favourable to dropsy, and very probably contributes to it. From what has been said before, it will be in- ferred that Avhatever favours the escape of albumen by the kidneys, and dimin- ishes that ingredient in the blood, may predispose to dropsy. Still another, and probably the most frequent set of causes, are those which obstruct, or in any way retard the return of the blood by the veins, and thus occasion venous congestion. These may act on portions of the venous sys- tem, or on the whole. Simple debility may, to a certain extent, operate in this way, by retarding the returning current of blood from depending parts. It will be apt to do so if aided by posture. Long standing sometimes in- duces dropsical effusion in the lower extremities of feeble individuals. Preg- nancy, uterine tumours, and enlarged ovaries, are thought to produce the same effect, by pressure on the veins. Anasarca occurring in the advanced stage of pregnancy is looked upon by some as indicating a disposition to puerperal convulsions. Inflammation and consequent obliteration of the veins themselves occasion serous effusion in the parts from which the blood is con- veyed by them ; and, when the great trunks are the seat of the affection, the dropsy may be very extensive. Organic diseases of the liver and spleen, and of the heart, act in a similar manner, and are among the most frequent causes of dropsy. The same result has been ascribed to obstruction in the lungs, impeding the flow of blood from the right to the left cavities of the heart. Some of the English writers consider dropsy as a not unfrequent result of pulmonary inflammation, whether of the bronchial membrane, or the paren- chyma ; and there can be no doubt that the affections are sometimes asso- ciated. It may be a question, however, Avhether they are not the mere effects of a common cause. One would suppose that dropsy must be a frequent result of those chronic pectoral affections, in which, either from a loss of substance or consolidation of tissue, free scope is not given for the passage of the blood of the pulmonary arteries. We should say a priori that the right side of the heart, and consequently the whole venous system must become congested, and dropsical effusion follow; but this result really happens much less fre- quently than might be imagined, probably because, in these chronic affec- tions, the mass of blood is diminished, so as to correspond to the diminished capacity of the lungs. Emphysema of the lungs is more frequently than other pulmonary affections followed by dropsy; because the general condi- tion of the system is comparatively little impaired, as much or nearly as much blood is required as in health, and, the lungs being unable to transmit the whole with due rapidity, a general venous plethora takes place. Compres- sion of the heart and of the great veins, by large dropsical collections in the serous cavities, is thought sometimes to induce anasarca by impeding the re- turn of blood from the various parts of the body. Besides the above causes, disease of the kidneys and of the lymphatics is yet to be mentioned. The first is among the most common, and has of late years attracted great attention. There will be occasion to recur to it directly. Of the latter, it is only necessary to say that dissection, in cases of dropsy, has sometimes shown the lymphatic glands, especially those about the great ves- sels, enlarged and indurated ; and that a diseased condition or extirpation of the glands in the groin or axilla has been followed by oedema of the corre- sponding extremities; facts which tend to show that obstruction in the absorb- CLASS III.] DROPSY. 367 ents may be the cause of dropsy; but much more frequently the glands are found diseased, or have undergone extirpation, without any such result. Before closing the subject of the causes of dropsy, it will be convenient to consider certain forms of the complaint in reference to the diseases in which they have their origin ; as the nature of the connection, in these cases, gives rise to pathological peculiarities of greater or less importance in a practical point of view. The forms alluded to are, dropsy following fever, and those dependent on intestinal, hepatic, cardiac, and renal disease. Scarlet Fever as a Cause of Dropsy.—The form of dropsy which follows scarlet fever does not seem in any degree connected with the grade of the previous disease. The mildest cases are probably as often succeeded by drop- sy as the most severe, and judging from my own observation more so. It would seem that the poison had not been completely eliminated in these mild cases, and remained to exert an irritant influence upon the serous and cellu- lar tissues, and on the kidneys, as before upon the skin. There is no regu- lar period at which the dropsical symptoms make their appearance. Some- times they occur almost immediately after the cessation of the fever, sometimes as late nearly as a month. Perhaps the most frequent period is from ten to twenty days after the occurrence of desquamation. It has been supposed that the dropsy is induced by the action of cold upon the delicate skin. This may be true to a certain extent, though my own observation would not have led me to this conclusion. The caution, however, is not amiss, to avoid ex- posing a patient, during or immediately after the process of desquamation, unnecessarily to the cold air. Anasarca is the most frequent form of the disease; but effusion not unfre- quently also takes place into the serous cavities. The complaint is usually inflammatory, with an accelerated pulse, furred tongue, diminished appetite, scanty urine, and constipation of the bowels. Occasionally it is attended vrith evidences of meningitis, or of thoracic inflammation. Headache, flushed face, dilated or contracted pupil, heaviness, stupor, convulsions, and palsy mark different stages of the first affection ; pain in the chest, cough, dyspneea, irre- gularity of pulse, and sometimes great oppression, indicate the second. Both are complicated with effusion before their close, and, if neglected in their early stages, are highly dangerous. Either the pleura, or the pericardium, or both may be affected. The peritoneal cavity is also frequently the seat of effusion. But the most constant pathological condition, and the one upon which the affection probably in chief depends, is active congestion or inflam- mation of the kidneys. Evidences of this are presented not only upon post- mortem examination, but also by the condition of the urine during life, which is scanty, highly albuminous, and often bloody, and, when inspected by the aid of the microscope, exhibits abundance of epithelial cells and cylindrical fibrinous casts of the uriniferous tubules. Indeed, in any case of convales- cence from scarlet fever, when the urine is albuminous and materially dimin- ished in quantity, dropsy may be apprehended. More will be said in a sub- sequent paragraph, and under the head of Bright's disease of the kidneys, of the influence of morbid states of this organ in producing dropsy. The anemic state in which the system is sometimes left after severe scarla- tina favours the occurrence of dropsy, and occasionally this cause co-operates with the renal affection in the production of the disease. The dropsy fol- lowing scarlatina, in the great majority of cases, yields readily to judicious treatment. Miasmatic Fever as a Cause of Dropsy.—One of the most common sources of dropsy, in this country, is the state of system following our ordinary inter- mittent and remittent fevers, and especially the former. These affections often leave the system extremely anemic, with a condition of the blood highly 368 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. favourable to serous transudation. The copious night-sweats which occur under these circumstances are familiar to every practitioner. I have often found the urine in the ensuing dropsies highly albuminous ; though it is by no means invariably so. The albumen thus drained out by the two emunc- tories, becomes deficient in the blood, and the condition most favourable to dropsical effusion takes place. Any cause which represses the action of the kidneys and skin, may now determine the production of the disease. The visceral disease consequent upon these fevers is probably another source of the dropsy. Enlargement of the spleen is a very frequent attendant, and seems to be in some way connected with the impoverished condition of the blood, not improbably, indeed, as one of its causes. Disease of the liver ope- rates in a manner explained further on. The dropsy following intermittents and remittents is most frequently anasarcous, though sometimes general, and, when the liver is especially involved, abdominal. It will almost always get well under judicious management. Dysentery as a Cause of Dropsy.—Chronic ulcerative affections of the bowels, whether coming under the denomination of diarrhoea or dysentery, but especially the latter, are frequently associated with dropsy in their ad- vanced stages. Not unfrequently bowel complaints come on in the course of renal dropsy, and are sometimes extremely obstinate, and tend much to em- barrass the treatment. But it is not to these that allusion is here made. There may be no special predisposition to dropsy, and no disease which is at all likely to end in it. In this condition of the system, an attack of dysen- tery may occur, which shall run on to a chronic form, and at last give rise to anasarca, with or without effusion into the peritoneum. The dropsy is the result of the dysentery, and of that alone. It is probably by inducing an impoverished or watery state of the blood, through its interference with the digestive process, that the latter disease acts in producing the former. If, under these circumstances, the bowel affection can be removed, the dropsy will either get well spontaneously, with the improvement of the blood, or will readily yield to remedies. Disease of the Liver as a Cause of Dropsy.—Disease of the liver may give rise to dropsy in two ways. The enlarged viscus may press upon the ascend- ing vena cava, and diminish its caliber so as to produce venous congestion in all its ramifications. In this case, we should probably have anasarca and ascites together. The same condition of the liver may lessen the caliber of the vena portarum and its branches; or changes in its interior structure, with- out enlargement, may interfere with the capillary circulation of the same set of vessels. In either of these events, there will be congestion of the whole venous system of the abdomen, and ascites may result. When obstinate abdominal dropsy exists, with yellowish conjunctiva, sallowness of the skin, and a jaundiced urine, without any sensible enlargement of the liver, there may be reason to apprehend scirrhus, cirrhosis, or extensive tuberculation of that organ. It is more frequently found enlarged in dropsical affections of hepatic origin than otherwise. This does not prove that the diseases which augment the volume of the liver more frequently occasion dropsy than those which derange its interior structure without enlarging it; but only that they are more common. Cases of the former kind are, in general, more easily curable; because the hepatic affection itself, being most frequently chronic inflammation, more readily yields to remedies. Dropsy does not generally occur as a consequence of hepatic disease, until the latter has been of long continuance. It is, therefore, very frequently attended with debility. The urine is scanty, high-coloured, and often bilious, but, unless when the hepatic disease is complicated with a morbid state of the kidneys, is not albuminous. Disease of the Heart as a Cause of Dropsy.—Organic disease of the heart, CLASS III.] DROPSY. 369 whether seated in the valves, or in the muscular tissue, very frequently re- sults in dropsy. The effusion is ascribed to congestion arising from irregu- larity in the circulation. Constriction at the valvular openings, by checking the current of blood, causes it to accumulate in the vessels behind; and inac- curate closure of the valves may cause the force of the heart's impulse to receive a direction contrary to nature, and thus similarly to retard the cur- rent. Let us take, for example, disease of the left auriculo-ventricular valve. If the orifice be narroAved, the onward flow of blood in the pulmonary veins is impeded; the resistance is propagated through the capillaries to the ramifi- cations of the pulmonary arteries, the right ventricle is thus overloaded and consequently enlarged, and the whole venous system becomes congested. If, on the contrary, the valve do not close accurately, the force of the ventricle is exerted on the pulmonary veins, and the same evil consequences are ex- tended through the capillaries to the pulmonary arteries, the right ventricle, and the veins of the body generally. An undue activity arising from hyper- trophy, or feebleness from dilatation, in one of the sides of the heart, must of course disturb the equable distribution of the blood, and congestion in one portion or another of the circulation must ensue. But this mechanical ex- planation of the agency of the heart in producing dropsy may be carried too far. Due weight should be given to the influence of a constantly excited cir- culation in developing irritation of the tissues. There can be little doubt that hypertrophy of the heart sometimes produces dropsy in this way. Be- sides, a watery condition of the blood is a very frequent accompaniment of dilatation and other organic derangements of the heart, whether as cause or effect; and very probably contributes largely to the production of dropsy in these cases. There is nothing in the character of the dropsy itself, which will serve as a means of diagnosis between this and other cases having a different origin. In every instance of dropsy not obviously traceable to a different source, the heart should be suspected, and its condition examined. If it should be found to have been long organically affected, the inference will be justifiable, that it has been mainly instrumental in the production of the disease; though it not unfrequently happens that other causes have co-operated, as hepatic or renal affections, or an anemic condition of the blood; and in some instances, probably, the heart is wholly innocent; for dropsy is by no means a constant or necessary consequence of its organic diseases. As might be concluded from the nature of its cause, dropsy of cardiac ori- gin is usually general. Commencing with anasarca, which for the most part shows itself first in the lower extremities, and gradually extends over the whole body, it invades also the serous cavities, and sometimes even the cellu- lar tissue of the lungs, giving rise to protracted and complicated suffering, from which, though the patient may be temporarily relieved by treatment, he is generally in the end rescued only by death. The disease is seldom attended with active inflammatory symptoms. The urine has been sometimes observed to be albuminous in cases which, after death, have exhibited no signs of renal disease; but in general it is not coagulable. Disease of the Kidneys as a Cause of Dropsy.—Whatever disables the kidneys from secreting a due amount of urine may occasion dropsy. Debility, irritation or congestion, inflammation, and disorganization of various char- acter, may have this effect. The excess of liquid in the blood-vessels, not escaping, as usual, by these organs, seeks another outlet, and, if the perspi- ratory function be now arrested by cold or other cause, it finds this outlet sometimes through the serous and cellular tissues. But diseases of the kid- neys of different kinds, even to the extent of complete disorganization, may, and frequently do exist, without giving rise to dropsy; and the particular 370 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. circumstances which occasion the complaint to be developed in one instance, while in others of a similar character, so far as the kidneys are concerned, no such result is experienced, have not been clearly ascertained. Some advance, howeA-er, has recently been made towards a solution of the difficulty. Under the name of Bright's disease, certain organic affections of the kid- neys have, Avithin a few years, attracted much attention, as being very fre- quently associated with, and probably the cause of dropsy. Of the nature of these affections, a particular account will be given hereafter. (See BrighVs Disease.) It will here be sufficient to say that recent investigations have determined at least two distinct renal derangements as having been con- founded under the title just mentioned; one a peculiar desquamative inflam- mation of the tubuli uriniferi of the kidneys, and the other a fatty degenera- tion of the same structure, both of which have the effect of interfering with the proper secretory function of the organ, and thus diminishing the quan- tity, as well as altering the quality of the urine. One of the most prominent of the changes in the urine is the abnormal presence of albumen. So charac- teristic has this symptom been supposed to be, that, when it has been observed in dropsy, some have been inclined to believe that it afforded sufficient evi- dence of a renal origin of that affection. Observation, however, has shown that albuminous urine is not invariably present in Bright's disease, that when it occurs, it is not invariably attended with dropsy, and that it is frequently met with in dropsy and other affections independently of any known disease of the kidneys. Indeed, cases are on record of death from dropsy with albu- minous urine, in which no disease of the kidneys could be detected by post- mortem examination. The action of mercury on the system is said to be sometimes attended with coagulable urine. I have repeatedly seen it in anasarca, consequent upon intermittent fever, in which there was no reason to suspect the kidneys. It is said sometimes to occur under the influence of blisters from cantharides. It will, of course be found whenever blood exists in the urine, whether derived from the kidneys, or any part of the urinary passages. It occasionally occurs in pregnancy; and, finally, it has been asserted that albuminous urine has been observed in health. The association, therefore, between Bright's disease of the kidneys, albuminous urine, and dropsy is not essential. Nevertheless, it is so frequent that there must be some bond of connection between them, some relationship of cause and effect, which it is desirable to be able to understand. It has been supposed that the dropsy might be the cause, and the renal derangement an effect. But this cannot well be ; as the latter often precedes for a considerable time the dropsical effusion. It has been said that the dropsy is consequent merely upon the diminished flow of the urine ; and this may have some effect in pro- ducing it; but it cannot be the sole cause; for, in the advanced stages of the kidney disease, the quantity of urine sometimes exceeds the healthy aver- age. The probability is that, in consequence of suspended function and ob- struction in the uriniferous tubules, produced in a manner which will be ex- plained under Bright's disease, the return of blood from the Malpighian bodies is impeded, congestion of these bodies is induced, and the serous por- tion of the blood escapes, if not the blood itself, in consequence of this con- gestion. Hence the albuminous and often bloody urine. The blood, being thus deprived of a considerable proportion of its albumen, becomes more watery and tenuous, and escapes more readily through the exhalant pores of the serous and cellular tissues. Another highly probable cause of the dropsy is the retention in the blood of the urea and other substances, which the kid- neys now cease to eliminate in due proportion, and which probably stimulate the secretory function of the different dropsical tissues. It is important to be able to form a correct diagnosis between dropsies CLASS III.] DROPSY. 371 depending on this affection of the kidneys, and those proceeding from other causes. This can generally be done by exercising an accurate scrutiny into all the circumstances of the case. The dropsy is almost always anasarcous in the beginning ; and, throughout, though one or more of the serous cavities may become involved, there is generally a predominance of the cellular effu- sion. The complaint is very seldom indeed confined exclusively to the chest or abdomen. The absence of any other known source of the disease would tend to fix suspicion upon the kidneys. If the heart, lungs, and liver were sound ; if intermittent or remittent fever had not immediately preceded the affection; if it had not occurred suddenly from exposure to cold, the checking of some wonted secretion, or the retrocession of a cutaneous eruption; if^ finally, it could not be traced directly to debilitating causes, such as the loss of blood, the scorbutic diathesis, or the long prevalence of exhausting dis- eases ; there might be strong reason for referring the origin of the complaint to the kidneys. This would be greatly strengthened by the previous occur- rence of accidents, which might be supposed to affect the kidneys, such as blows upon the back, or by the previous existence of symptoms, which might be immediately referred to these organs, as dull or acute pain in the lumbar region. If consequent on scarlet fever, the complaint may generally be re- ferred to the kidneys, as at least one of its sources. But the evidence afforded by the urine is most to be relied on. This is scanty in the beginning, and is always diminished when acute symptoms supervene upon those of the chronic form of the complaint. In the advanced stage, as before stated, it is sometimes natural in quantity or even in excess; and, if this condition of urine exist without the use of diuretics, and at the same time the dropsical symptoms increase or remain undiminished, the pre- sumption is strong, though by no means positive, that the kidneys are affected. The urine varies in relation to colour, the presence or absence of turbidness, the disposition to deposit a sediment or otherwise, as in other forms of dropsy; and sometimes it is not unhealthy, in either of these respects. One striking character, however, not so frequently observed in other cases, is the presence of blood, which sometimes merely tinges the urine, sometimes exhibits itself in the shape of a dark reddish-brown or blackish deposit. This bloody state of the urine is especially common in the earlier stages, and acute forms of the complaint. A disposition to froth readily, and the unusual permanence of the froth when produced, resulting from the presence of albumen, have also been observed. From what has been before said, it will be inferred that the mere fact of the coagulability of the urine by heat or nitric acid is not in itself sufficient proof of the renal origin of the dropsy. Taken in connection, however, with the foregoing circumstances, it would go far to establish the fact; and, if the albuminous impregnation persist for a long time, or show itself in large quantity, the evidence may be considered as almost conclusive. But the most decisive proof is that afforded by the microscope, which, by the detec- tion of epithelial cells of the uriniferous tubes and fibrinous casts of the same, gives indisputable evidence of desquamative inflammation of the kid- neys, or, by showing the existence of cells containing oil, indicates fatty de- generation of those bodies. Much importance has also been attached to the specific gravity of the urine as a diagnostic character. This is almost invariably diminished in Bright's disease. The sp. gr. of healthy urine, according to M. Solon, is from 1-020 to 1-024. In the complaint in question, it is gradually reduced as the dis- ease advances, being at first little different from health, and sinking, in the last stages, as low as D008, and sometimes even much lower. Solon, in one instance, observed it as low as 1*003, but states the mean at 1-013. But, in 372 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. drawing inferences from the specific gravity, reference must be had to the amount secreted; for the elimination of water by the kidneys may be increased without a corresponding increase of solid matter. The larger the quantity of the urine, the less will be its specific gravity. When, therefore, the quantity and specific gravity sink together, the evidence is strong of a morbid state of the kidneys. The reduction of the specific gravity has no direct relation to the presence of albumen. On the contrary, the albumen is in general most abundant early in the disease, diminishes with its progress, and is sometimes entirely and permanently Avanting before its close. It also not unfrequently disappears for a time, and fatal cases have occurred in which it has never been observed. In such instances, the specific gravity assists much in the diagnosis. If, for example, the urine in dropsy, contain no albumen, or but little, and have at the same time a low specific gravity, the presumption would be in favour of the existence of the kidney affection. If, having been coagulable, it should cease to be so, and, instead of reacquiring the healthy density, should remain light, or become lighter, the quantity not being in- creased, there would be evidence that the disease of the kidneys, so far from having yielded, was persisting and probably advancing. A necessary inference from the diminished specific gravity of the urine, even Avhen albumen is present, is that the other solid constituents are below the average in health. This has been ascertained by experiment to be actually the case. The quantity of urea and of saline matter, which constitute the chief solid constituents of healthy urine, has been found to be greatly re- duced ; according to Dr. Christison to one-fifth, and sometimes even as low as one-tAvelfth; the urea and saline matters being diminished in about the same proportion. The average quantity of urea in healthy urine is stated at three or four per cent., of saline matter at two or three per cent. It has been observed that, when the urea diminishes in the urine, it may sometimes be detected in the blood, where no trace of it can be found in health; so that the result is not owing to a conversion of this principle into albumen; but simply to the fact, that it is not separated by the kidneys from the circulating fluid, and is thus allowed to accumulate in the latter. Under the same cir- cumstances, it has been found in the dropsical fluid of the serous cavities. The blood, while it thus gains urea, loses a portion of its albumen and red corpuscles; and not unfrequently a strongly anemic condition is at length established. Hence, in part, a sallow or dingy paleness of complexion, which is often a striking feature of this variety of dropsy. There is nothing very peculiar in the character of the dropsical symptoms, or in their progress. When tke disease of the kidneys is acute, the anasarca usually appears at an early period; and, even in its more chronic forms, the commencement of the effusion, or its increase, is apt to be coincident with the supervention of inflammation or febrile excitement. This form of dropsy is peculiarly liable to be complicated with symptoms of cerebral derangement, such as headache, drowsiness, stupor, delirium, paralysis, apoplexy, and con- vulsions. They come on usually towards the close of the complaint, and are among the most frequent modes of its fatal issue. It has been observed that a marked diminution, or even total suspension of the secretion of urine, gene- rally precedes their appearance. They are sometimes probably owing to drop- sical effusion within the encephalon, as evinced by their occasional coincidence with the increase of the general dropsy, and by the discovery after death of serum in the ventricles, and in the tissue of the pia mater. But, in some in- stances, no such effusion is detected; and the cerebral affection must be ascribed to the altered state of the blood, consequent upon the diminished secretion of urine. Another frequent complication of renal dropsy is internal inflamma- tion, most commonly of the serous membranes, and especially of the pleura. CLASS III.] DROPSY. 373 This very much increases the danger of the complaint, and is probably often the immediate cause of death. Organic disease of the heart is also frequently associated with the affection of the kidneys; whether as cause or effect, or as the result of some common cause, has not been determined. The same is the case, though less frequently, with organic disease of the liver. Indeed, it is very rarely that the alteration of the kidneys is found, upon dissection, un- complicated Avith other morbid structural changes. For information upon various other points connected with this renal affec- tion, the reader is referred to the disease of the kidneys. I have aimed at considering it here only in its connection with dropsy. No age is exempt from this variety of drop'sy, though it is most common in adults. Men are more subject to it than women. In its early stages it is often curable; but it may always be regarded as a formidable disease; and, when the structural derangement of the kidneys has become considerable, though the dropsical symptoms may disappear, a restoration to health can scarcely be expected. Prognosis. Numerous cases are on record of the spontaneous cure of dropsy; and M. Mondii-re, as well from observation, as from the result of his researches into the medical annals, has come to the conclusion, that such a termination of the disease, is not very rare. (Arch. Gen., 3e ser., xiv. 461.) Sometimes the cure is very sudden, being effected in the course of a few days, and even a few hours. In general it appears to be the result of a great increase in one of the normal secretions; as, for example, of urine, of perspiration, or of the intestinal fluids. Instances are cited, in which profuse vomiting of serous fluid has speedily cured protracted cases; and the crisis by diarrhoea is not uncommon. M. Mondiere relates a number of cases in which the critical discharge was from sources which would be considered less probable; as from the salivary glands, the nasal or vaginal mucous membrane, and even from accidental secretory surfaces. Dr. Watson relates a case, in which hydrotho- rax Avas greatly relieved by the copious expectoration of a limpid fluid. The tendency to exhalation, instead of taking an external direction, is sometimes thrown upon another internal part, and a sort of metastasis of the dropsy takes place. Thus, the swelling may suddenly leave the extremities, and symptoms of compressed brain or lungs come on, in consequence of effusion into the ventricles or into the pleural cavities. In some instances, the dropsy has been known to disappear without any increased evacuation whatever. Dropsy very often also yields readily to remedies. Within my own expe- rience, it has very generally proved curable when not dependent on tubercu- lous inflammation of the tissues affected, or upon organic disease of the viscera, as the heart, liver, and kidneys. Even in these cases, the dropsical symptoms will often disappear under appropriate treatment, and, if, at the same time, the organic affection be cured, will not return. Thus, permanent cures are not unfrequently effected of ascites dependent on chronic inflam- mation and engorgement of the liver; and the same is true of renal dropsy, in the earlier stage of the affection of the kidneys. Occasionally, even Avhen the original disease remains, and marches steadily onwards toAvards a fatal issue, the dropsy, after having been removed by treatment, does not again make its appearance. But much more frequently, under such circumstances, it returns, and constitutes one of the greatest sources of distress to the pa- tient towards the close of his life. Sometimes it may be removed, and will return several times, before it finally gets the mastery; and, where the physi- cian cannot cure, he can often do very much to relieve. The great difficulty which he encounters is, that finally the strength of the patient gives way, and he is then precluded, even though he may call in the aid of supporting 374 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. treatment, from the use of those evacuating remedies upon which he has previously relied. Treatment. In a disease so various in its origin and character, no one plan of treat- ment will be generally applicable. The remedies must necessarily be adapted' to the particular circumstances of each case. Nevertheless, there are cer- tain indications which should always be kept in view. These are, 1. to cor- rect, as far as practicable, the particular pathological condition upon AA'hich the effusion may immediately depend ; 2. to remove by absorption, or other- wise, the effused fluid ; 3. to remedy any disease, AA-hether cardiac, hepatic, or renal, which may act as the remote cause of the dropsy; and 4. to sup- port the strength of the system, when this may be necessary, under the ex- hausting influence of the disease, or of the medicines employed. The same remedy will often answer more than one of these objects; and, where two or more remedies are required, they may very generally be given conjointly; so that, in detailing the treatment, the several indications cannot be exactly followed, without ceaseless repetition. They will, hoAvever, be borne in mind in the succeeding observations, as they always should be in practice. When there is reason to believe that the effusion is the result of an in- flammatory or highly irritated condition of the exhaling tissue, and the gen- eral symptoms are those of active febrile excitement, or, even in the absence of fever, should the pulse be full and strong, blood-letting may sometimes be employed with much benefit. It not only diminishes the secretory irri- tation, and thus checks the effusion, but disposes to the absorption of the effused fluid, according to the well-established principle, that the fulness of the blood-vessels and the activity of the absorption are in an inverse ratio to each other. The amount taken must be regulated entirely by the condi- tion of system. If the patient is vigorous, and the pulse full and tense, from twelve to eighteen ounces may be taken at first, and the operation re- peated once, or oftener, under similar circumstances. This remedy is some- times adequate alone to the cure of dropsy. But the cases are few which require or will support copious depletion, and much more frequently the remedy is not only not called for, but strongly contraindicated. The plan of promoting absorption, in all cases, Avhether in a vigorous or debilitated state of system, by the frequent repetition of small bleedings, while, in cases of debility, the general strength is supported by rich food and strong stimu- lants, is, I think, highly objectionable; for, though it may relieve the pa- tient for a time, it will be apt to leave him still more disposed to the disease than at first, Avith the additional disadvantage of a susceptibility more or less worn out by needless stimulation. It is well known that frequent losses of blood have been the cause of dropsy, by inducing anaemia. It is only, therefore, in cases presenting a decided elevation in the grade of general action, and an unimpaired state of the general forces, that bleeding is admis- sible. A buffy state of the blood, under these circumstances, will favour the repetition of the remedy, as marking the existence of inflammation. In cases of the same general character as those above alluded to, with little or no increased activity of the circulation, it would be safer," as a general rule, to trust to the refrigerant diuretics and hydragogue cathartics without bleeding; this being employed only when clearly indicated. When the dis- order of the serous tissue assumes the grade of inflammation, it will gene- rally be proper, in addition to the depletory measures mentioned, to apply cups or leeches to the vicinity of the affected part. Of these two remedies, cups are usually preferable as most effective. They may be applied to the chest or abdomen when these cavities are diseased ; and will sometimes be CLASS III.] DROPSY 375 found useful to the temples or back of the neck, when stupor or other evi- dence of determination to the brain is exhibited. Blisters are also useful under similar circumstances. Should the inflammatory action refuse to yield to these means, recourse may be had to calomel and opium, pushed to a moderate affection of the gums. When, instead of irritation of the secreting tissues, we have relaxation or debility, Avith an impoverished condition of the blood, perhaps a scarcely less frequent pathological condition than the former, a wholly different treatment is required. The indication now is to improve the condition of the blood, and give tone and increased contraction to the tissues. For this purpose, the preparations of iron, and those of Peruvian bark, are, upon the whole, the most efficient remedies. Five grains of the pill of carbonate of iron, of the U. S. Pharmacopoeia, conjoined with sulphate of quinia, may be given three or four times a day; and it will often be found convenient to unite in the same mass any diuretic or alterative medicines which the case may re- quire, such as squill, digitalis, calomel, or the mercurial pill. The prepara- tions of iron may be varied to meet the circumstances of the case. The tincture of chloride of iron, and the solution of the iodide would seem to be peculiarly appropriate ; as they add diuretic to their tonic and astringent properties. Nor need the practitioner confine himself to the tonics men- tioned. Almost any other of the class may be used, if any particular cir- cumstance in the case should seem to call for it. The pure bitters are much used. Among the remedies occasionally employed is the decoction of pip- sissewa, which is at the same time mildly tonic, astringent, and diuretic, and is admirably adapted to mild cases of this kind, requiring a gentle im- pression very long continued. Iceland moss has also been commended. To fulfil the same end of improving the condition of the blood, a diet of the most nutritious and digestible animal food, should be recommended, and porter or ale may be given for drink. The pathological condition which consists in passive venous congestion, may be complicated with one or the other of the above conditions, or may present no symptom of either, and, so far as the system is concerned, must be treated accordingly. When there is no evidence of excitement, and none of debility or anaemia, we may leave the general state of health out of the question, and address our remedies to the removal of the cause of conges- tion, and the promotion of absorption. In every case, we should endeavour to ascertain Avhether any obstruction to the circulation exists in any portion of the veins, and, if discovered, to remove it. Conjointly Avith attention to the general condition of the system, whereby we may check the disposition to excessive exhalation, we should endeavour to fulfil the second indication, that, namely, of removing the effused liquid. This is done most effectually by promoting the secretions. We thus diminish the amount of circulating fluid, and proportionably favour absorption. At the same time, the tendency to exhalation is incidentally diminished; and, if inflammatory excitement of the tissues exist, it is relieved by the depletion effected, and by a revulsive direction of excitement from the seat of disease to that of the stimulated function. Diuretics.__The symptoms strongly invite attention to the secretory func- tion of the kidneys, as the one which especially demands stimulation. The urine is almost always scanty; and the progress of the effusion not unfre- quently bears a close and direct relation to its diminution. To increase the action of the kidneys would, therefore, seem to afford a probable chance of relieving the disease; and experience has abundantly confirmed the deduc- tion. No remedies, upon the whole, prove more effective in the cure of dropsy than diuretics. When they can be brought to act freely, the disease 376 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. is almost always moderated, if not removed. Of the diuretics, I have, within my own experience, found bitartrate of potassa, or cream of tartar, most successful. When no organic visceral disease or tuberculous deposition has been at the root of the malady, and when the strength of the patient has been sufficient to hold out under the continued use of the remedy, I have generally been able to cure dropsy by this diuretic, with or without ad- juvants, according to the apparent requisitions of the case. But, in order to produce the greatest effect, it must be given properly, and in sufficient quantity. Attention is frequently not paid to the comparative insolubility of the cream of tartar, and the patient takes only the liquid which may have been directed as the vehicle, leaving most of the medicine at the bottom of the vessel. Many practitioners content themselves with directing half an ounce or an ounce to be taken at one dose, every day or every other day. The medicine thus given, acts as a purge, and, being removed from the bowels, is not absorbed, and consequently does not reach or affect the kid- neys. A better plan is to direct a certain quantity of the salt to be added to a pint of water or other vehicle in a bottle, and the whole to be taken, in wineglassful doses, at certain intervals, in the course of twenty-four hours; the caution being always strictly observed to shake the bottle thoroughly before pouring out the dose, and then to swallow this quickly before the salt has had time to subside. The quantity must vary with the case, and if, upon trial, that first employed should make no impression, it should be gradually increased until it operates actively upon the kidneys. Half an ounce in the course of the day will, in some rare instances, be sufficient; but much more frequently it will be necessary to increase to an ounce, an ounce and a half, or even two ounces, in the same period of time. If the patient should be much purged, it may be proper to administer a little laudanum occasionally, so as to check the alvine discharges, and give the remedy a direction to the kidneys. Should dyspeptic symptoms be induced, they may often be counteracted by employing as a vehicle for the salt, instead of water, an infusion of juniper berries, or wild-carrot seed, which are at once gently stimulant and diuretic; and some aromatic, as cardamom, fennel, or ginger, may be added if circumstances seem to require it. When, however, such additions are made, the infusion should be separately prepared and strained before being used as a vehicle; as, if the salt and its adjuvant be mingled together in infusion, the whole of the former cannot be taken with- out swallowing the solid residue of the latter, and it is, therefore, left in the vessel. Should the dyspeptic symptoms continue notwithstanding these means, the cream of tartar should be omitted for a time, and afterwards re- sumed if deemed advisable. I have given these somewhat minute directions from an experience of their usefulness, and the disadvantages which often accrue from their neglect. It has been stated above that, in all cases of dropsy not dependent on visceral disease or tubercles, nor complicated with too great debility, a cure might be hoped for from this remedy. I believe it to be peculiarly adapted to cases in which the pathological condition is inflammatory irritation of the exhaling tissue. But, even in the exceptional varieties of dropsy above mentioned, the cream of tartar, though it may not effect a permanent cure, will often produce great relief, and not unfrequently cause the complete disappearance, for a time, of the dropsical effusion. The only cases in which it is positively contraindicated are those of great de- bility. If the strength of the patient, no matter what may be the form of the disease, should be observed to give way under the continued use of the salt; and, if the additional employment of sulphate of quinia, with a nu- tritious diet and malt liquors, or a little wine, should fail to counteract its debilitating effects, it must be omitted altogether. CLASS III.] DROPSY. 377 Various other saline diuretics are employed with more or less success. Among them nitrate of potassa probably ranks next in efficacy to the bitart- rate. Like that salt, it is especially indicated in inflammatory or febrile dropsy; but, being even more sedative in its general influence, and more apt to induce gastric irritation, it is applicable to a less extensive range of cases, and should not be used when there are evidences of debility, or any suspicion of inflammation of the stomach. It is generally employed as an adjuvant to other more efficient remedies, though in some instances of itself sufficient to cure the disease. Little good, however, can be expected from it unless freely given. Until recently, fears have been entertained of its poisonous operation in large quantities. It has, however, been ascertained that, if sufficiently diluted with water, it may be administered safely in doses much beyond those formerly thought proper. As a remedy in dropsy, not less than two drachms should be given in twenty-four hours. This quantity should be dissolved in at least a pint of water, or of some mucilaginous or diuretic infusion, and given in doses of from ten to twenty grains at suitable intervals. Acetate of potassa was formerly thought so efficient in its action on the kidneys as to have received the name of sal diureticus, or diuretic salt. It is comparatively little used at present. The same may be said of soluble tartar and Rochelle salt, both of which have had some repute in the cure of dropsy. They are not without effect, but have given way to the more diu- retic salts above mentioned. Carbonate and bicarbonate of potassa are still occasionally used, and sometimes with benefit. They are peculiarly advan- tageous in cases attended with excess of acid in the primae viae, or in the urine; and will generally correct the lateritious sediment in that secretion, denoting the presence of urates. Though less effective as antacids than the corresponding salts -of soda, they are better adapted to dropsy by their greater diuretic power. They may be advantageously associated with bitter tonics, such as quassia or columbo, when these are indicated. Such com- binations have repeatedly proved adequate to the cure of dropsy. The bicarbonate is preferable to the carbonate in consequence of its milder taste. Squill is an active diuretic, much employed in this disease. It is in fact among the remedies in which the profession have the highest confidence. Being somewhat stimulating, it should not be given in febrile and inflamma- tory cases; and it usually fails, when the urine is strongly coagulable. It is moreover unsuited, in consequence of its nauseating and emetic properties, to cases of irritable or inflamed stomach. Under all other circumstances, it may be employed with the hope of benefit. It is considered by Blackall as peculiarly useful in dropsy of the chest, with scanty, high-coloured, and un- coagulable urine, which deposits a sediment on standing. In the dose of two grains, two or three times a day, in which it is commonly recommended, it will often entirely fail of effect. This may be a suitable dose to begin with, but it should be quickly increased, either in quantity or frequency of repeti- tion, until it produces decided nausea. As this effect is desirable merely as a test of the activity of the medicine, the dose should be somewhat reduced after it has been attained, and subsequently kept just within the nauseating point. I have often found it necessary to give two grains every two hours, before any decided effect could be obtained. If it purge, it should be combined with a little opium. Calomel is often most advantageously associated with squill, in cases which demand at once diuresis and the mercurial influence. Digitalis is another most valuable remedy in dropsy. Though it occa- sionally fails in materially increasing the flow of urine, yet in many cases it operates with great power, producing and sustaining a copious diuresis, and completely eradicating the complaint. A knowledge of the circumstances favourable to its action would be very desirable; and various attempts have vol. n. 25 378 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. been made to indicate the cases to which it is peculiarly adapted. Dr. With- ering, to whom the profession is mainly indebted for its introduction into regular practice, was of the opinion that it was better adapted to patients of feeble constitution, with a pale complexion, lax fibre, and edematous limbs pitting easily on pressure, than to the vigorous and florid, with a strong pulse and firmness of limb. It has also been stated to prove peculiarly effi- cacious in the dropsy of intemperate individuals. Dr. Blackall found it most successful in cases attended with coagulable urine, especially when the secretion was scanty, high-coloured, bloody, or disposed upon cooling to de- posit a branny or lateritious sediment. He considered it an almost certain remedy in the anasarca following scarlatina, when the urine is albuminous, and no fatal disorganization of parts exists. The same author thought cau- tion necessary in its use, in cases attended with pale and copious urine, even though coagulable. This condition of the urine indicates frequently an ad- vanced stage of organic disease of the kidneys, in Avhich few remedies can be of service, and the system, already greatly debilitated, might easily be pros- trated below the point of reaction. Dr. Blackall states that, Avhen it operates favourably, the urine becomes gradually less coagulable; and that, even when it removes the swelling, unless it occasions this change in the urine, it pro- duces no permanent good. My own experience has been to a considerable extent confirmatory of the observations of Dr. Blackall. I have met with much more success from the remedy in cases attended with albuminous urine than in others. Two instances of general dropsy of this kind are prominent in my recollection, in which, after a long continuance of the disease, and the fruitless employment of a great variety of means, complete success followed the use of digitalis. Its beneficial influence, however, is by no means confined to such cases. In dropsy depending on disease of the -heart, it often affords great relief; and it may be resorted to in any case in which the system is not too far worn out by organic disease, or the vital actions too feeble from other causes to resist so potent a sedative. Any tendency which digitalis may have to purge should be counteracted by opium, which is also a useful adjuvant, in some instances, by obviating the sedative effects of the remedy, without in- terfering with its diuretic action. The best mode of administering it is in substance or infusion. A tablespoonful of the officinal infusion, in which a drachm of the leaves is employed to nine fluidounces of menstruum, though it is the dose usually directed, much exceeds in amount a grain of the powder, which is the usual dose in the latter form. It would be best to begin with only one-half the quantity, repeated twice or thrice daily, and to increase it gradually until some symptoms of its action are observed. The dose may in this way be augmented to ten or fifteen grains, or its equivalent. In what- ever form or dose digitalis is employed, its effects should be closely watched, and the appearance of a decided impression of any kind should be the signal for a suspension of the remedy, or a diminution of the dose. Great increase of the urinary secretion, reduction in the frequency and force of the pulse or intermissions in its beat, nausea and vomiting, purging, faintness, giddiness, and a tensive pain of the head, sometimes over one eye, as noticed by Black- all, are among the signs of the action of the medicine which should not be overlooked. The tendency which digitalis has to accumulate, and, after hav- ing been given for some time Avithout apparent effect, to break forth suddenly from its quiescence into violent action, must also be borne in mind. The dropsical patient to whom this remedy is administered, should, as a general rule, be visited by his medical attendant every day. Powdered digitalis has also been employed externally. MM. Brera and Chrestien, of Montpellier, have succeeded, by friction with the powder upon various parts of the body, in bringing on copious and salutary diuresis. (Did. de Med., xvi. 34.) CLASS III.] DROPSY. 379 Tobacco has properties closely resembling those of digitalis, and like it oc- casionally proves powerfully diuretic. It was employed by Dr. Fowler with considerable success in dropsy; and Dr. Darwall speaks of it as "particu- larly useful in dropsy connected with enlargement of the liver and spleen, but little to be relied upon when the principal disease is situated in the chest." He also states "that he has never seen any evil effects resulting from its use." (Cyc. of Pract. Med., Article Dropsy.) It was given by Fowler in the form of an infusion, made by pouring a pint of boiling water on an ounce of the leaves, macerating for an hour, straining off fourteen ounces, and adding two ounces of alcohol. The dose was at first thirty drops three times a day, to be gradually increased until diuresis was produced, or the effects of the medi- cine upon the stomach or head were felt. Numerous other diuretics of greater or less power are occasionally em- ployed, either as remedies in chief or as adjuvants. The spirit of nitric ether may be usefully added to other remedies when there is not too great inflam- matory excitement, and especially when the disease is complicated with nerv- ous derangement. The infusion of juniper berries is much used as a vehicle and adjuvant, and will sometimes, unaided, remove moderate dropsical effu- sion ; such, for example, as is apt to come on towards the close of chronic pectoral affections. The compound spirit of juniper is a good addition to diuretic mixtures or drinks, in cases of debility. Infusion of buchu has been strongly recommended in connection with the alkaline bicarbonates. (Braith- waite's Retrospect, Am. ed., xvii. 33.) Infusion of wild-carrot, parsley-root, and the different species of erigeron or flea-bane, are occasionally adminis- tered with benefit, though never solely relied on. Dandelion in decoction or extract is peculiarly adapted to cases of dropsy, connected with chronic disease of the liver. Pipsissewa, in the same way, proves useful Avhere a gentle'tonic and astringent are indicated in conjunction with a diuretic. Va- rious liquid preparations of colchicum were formerly used, and, though nearly abandoned in dropsy, might prove serviceable in those instances, not very uncommon, in which the disease is associated with gout or rheumatism. Va- rious stimulating substances, with diuretic properties, may be employed in chronic cases, and others attended with great debility. Such are horserad- ish, mustard, onions, garlic, buchu, copaiba, oil of turpentine, and canthar- ides.* The two last-mentioned substances have been recommended in great insensibility or paralysis of the kidneys, with a more or less complete sup- pression of urine. Sulphate of copper was formerly employed in cases of debility; but is little used at present. Besides those mentioned, a long list of substances might be enumerated, which have enjoyed more or less credit as diuretics in dropsy ; but, having been mostly laid aside after experience of their inefficacy, they scarcely merit notice. It is, however, desirable to have at command, in a disease so frequently obstinate and protracted, numer- ous and diversified remedies, though of very unequal power. The caprices of the stomach, the prejudices and anxieties of the patient, and the frequent failure of even the most efficient remedies, render changes necessary; and, without a long catalogue, we should be compelled to stop for want of suffi- cient material. Besides, diuretics are notoriously uncertain, so that upon failure with one, it is necessary to resort to another; and not unfrequently a persevering trial of the means at command is at length repaid by success, when the physician has almost ceased to hope for it. Much may also be ef- * The following formula for a stimulating diuretic infusion was much employed by the late Dr. Parrish, and I have used it myself with advantage in long-standing dropsy with debility. Take of juniper berries, mustard seeds, ginger-root, each, bruised, gj ; horseradish, parsley-root, each, bruised, ^ij ; hard cider, Oiv. A wineglassful to be taken four times a day, and gradually increased. 380 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. fected by the combination of these remedies. Advantage has sometimes accrued from two or more diuretics mixed together, which had before sever- ally failed. Numerous formulae of this kind have been proposed by different authors, which it would be useless to repeat; as each practitioner acquainted with the list of remedies, and their several qualities, can just as efficiently arrange them for himself. The combination of diuretics with tonics is highly advantageous in cases of debility. Thus, squill and the saline diuretics may be given in connection with the infusion, tincture, or extract of the simple bitters, as gentian or quassia, with the preparations of cinchona, or with the salts of iron. Chalybeates are of great advantage in anemic cases, particu- larly those following miasmatic fevers; and sulphate of manganese is said to have proved effectual under similar circumstances. Nux vomica has also been recommended as an adjuvant to the diuretics in atonic dropsy. Cathartics.—Scarcely less efficient than diuretics are the medicines belong- ing to the class of cathartics. They operate upon the same principles, of pro- moting absorption by diminishing the amount of fluid in the blood-vessels, and of calling off irritation from the morbidly secreting surfaces to the seat of their own action. In the latter respect they are even more efficient than the diuretics. But they debilitate much more by an equal amount of depletion, and are, therefore, not so well adapted to cases of an asthenic character. There is very frequently, moreover, a degree of stomachic or intestinal irri- tation in dropsy, which renders their steady employment hazardous; and, in gouty cases, they might prove injurious by inviting the disease from some safe exterior position to the alimentary canal. With a due regard to these considerations they may be employed safely, and often with great effect. Dis- crimination is necessary in their selection. Those should obviously be pre- ferred which produce copious serous exhalation from the bowels, in other Avords, the hydragogue cathartics ; and even among these there is much room for choice. In febrile and inflammatory cases, the saline cathartics should be employed in consequence of their refrigerant properties. The best of these, for the purpose, are perhaps the bitartrate and tartrate of potassa, and the tartrate of potassa and soda. These should be given, not in small and re- peated doses, as when administered with a view to diuretic effect, but in large purgative doses, at distant intervals. When not of themselves sufficiently powerful, they should be combined with some one of the hydragogue vegeta- ble cathartics, such as senna, or jalap. A mixture of jalap and cream of tar- tar has long enjoyed high credit in the treatment of dropsy. In chronic cases, when the bowels are torpid, and the whole system exhibits rather a want of due susceptibility to impressions than actual debility or prostration, recourse may be had to the drastic hydragogues. Scammony, black helle- bore, buckthorn (rhamnus catharticus), gamboge, croton oil, and elaterium, are those which enjoy the highest reputation. Of these, gamboge and elate- rium are probably the most efficient. Dropsy not unfrequently yields to the judicious employment of these remedies alone. Gamboge, being apt to irri- tate the stomach, should generally be given in small doses, say from half a grain to two grains, repeated at intervals of one, two, or three hours, till it operates. Advantage will also accrue from combining each dose with a drachm or two of cream of tartar. The effects of elaterium are sometimes surpris- ingly prompt and powerful. I have known great distension of the abdomen to yield to two doses of this medicine. In consequence of its violence it must be administered with caution; and, if symptoms of gastro-intestinal inflam- mation should occur under its use, it should be at once suspended. Croton oil is strongly recommended by Dr. Geo. Fife, of Birmingham, England, in the dose of a drop daily. He considers it more efficacious even by its stimu- CLASS III.] DROPSY. 381 lating effect on the absorbents, than Jby its purgative operation. (Lancet, March 14, 1857, p. 20.) There is a set of emeto-cathartic medicines, possessing diuretic properties, which have been occasionally used in dropsy with good effect. Such are the broom (scoparius), hedge hyssop (gratiola officinalis), the inner bark of dif- ferent species of sambucus or elder, the juice of the root of black elder, cahinca, and the root of our indigenous apocynum cannabinum. In relation to the dose and proper mode of administration of these, and of the other medicines above named, the reader is referred to the Dispensatories. The frequency of repetition of the cathartic must be regulated by the strength and susceptibility of the patient. When the constitution is vigorous, and the bowels not peculiarly sensitive, it may be given every day. In feAv cases can much permanent good be expected from it, if repeated less fre- quently than twice or three times a week. The purgative, as in the case of the diuretic, may be combined with the bitter tonics or chalybeates, when these medicines are indicated; and, if the patient should be very feeble, ad- vantage might accrue from the use of the purgative tinctures, as those of senna, jalap, and black hellebore, in connection with other preparations. Diaphoretics.—In some instances, diuretics will not act, and purgatives are contraindicated, or have been tried without effect. Here diaphoretics may be resorted to, and will occasionally produce cures; though, upon the whole, they must be admitted to be much less efficient than medicines of the two preceding classes. The best diaphoretic in dropsy is probably the officinal powder of ipecacuanha and opium. It is asserted that dropsy has been cured by large doses of opium alone; but its efficacy is much increased in this com- bination. To do good, it must be used freely, and the patient kept for a con- siderable time under its influence, so as to sustain a copious and continued perspiration. In febrile cases, with a strong pulse, preference should be given to the antimonials and refrigerating diaphoretics, as citrate of potassa and acetate of ammonia, with which the spirit of nitric ether may sometimes be combined. During the course of the treatment, the patient should be kept in bed. The effect of the diaphoretic may be much increased by exter- nal means. When the skin is hot and the circulation active, the warm bath should be used. But in other instances, the vapour bath, or dry hot-air bath, might be found more effective. I have known one almost desperate case of general dropsy to yield to an energetic use of Dover's powder and the hot bath, after failure with diuretics. The excessive sweating induced by tempo- rary confinement in an apartment heated considerably above the temperature of the body, would probably prove highly serviceable in some cases of dropsy. Even friction to the surface is said to have effected cures. Emetics.—When the strength of the patient is sufficient to bear the ex- hausting effect of repeated emetics, it is probable that they might be advan- tageously used, as they are well known powerfully to promote absorption. The antimonial emetics were recommended by Sydenham in this disease. At present, however, neither these nor other medicines of the same class are much used in the treatment of dropsy. Mercury.—This is occasionally very efficient. Its power of increasing secretion and absorption would appear to render it applicable to dropsy in general; while its antiphlogistic action would render it especially useful in the advanced stages of those cases which have originated in inflammation, whether of the serous and cellular tissues, or of some important organ, as the liver or the heart. Hence, it is often most happily combined with other remedies, whether diuretic, diaphoretic, or purgative, increasing the powers of these remedies, at the same time that it exerts an independent influence of its own. The medicines with which it is most frequently associated in 382 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. dropsy are squill and digitalis. Calomel, the blue pill, or corrosive subli- mate may be employed according to the circumstances of the case. A com- bination of squill and calomel is considered as one of the most efficacious remedies in dropsy, especially when associated with chronic visceral inflam- mation. It has been customary to administer pills composed of two grains of squill and one of calomel three times a day. This quantity of squill, as the medicine is commonly found in our shops, is too small. The dose should be repeated every two or three hours unless it nauseate too much. That of the calomel is probably rather too large. Considering the excessive suscep- tibility of some dropsical cases to the influence of mercury, it would in gen- eral be better to commence with a smaller dose, and increase as the occasion may require. Perhaps the worst instance of salivation which I have per- sonally witnessed, and in which the patient barely escaped with life, arose from six grains of calomel given in doses of a grain each as above recom- mended, in a case of general dropsy. It is said that the system is peculiarly susceptible to this influence in the renal variety of dropsy, and mercury is consequently dreaded by some physicians in that affection. But cures of the dropsy sometimes follow these excesses of the remedy, Avhich would pro- bably, therefore, prove useful by a more moderate action ; and strict caution Avould sufficiently guard against inconvenient results. Mercury is decidedly contraindicated in cases of pure anaemia or great debility, and in those in which the dropsy depends upon some incurable organic affection, as scirrhus and tubercles of the liver, or a tuberculous condition of the dropsical tissue. Mechanical Means.—When the measures above detailed prove inadequate to the removal of the effused liquid, and the distension becomes painfully inconvenient, recourse may be had to mechanical means of relief, such as puncture with a sharp lancet, acupuncture, and tapping. Great relief is obtained by these means, and occasionally they seem to prepare the way for the efficient action of remedies which had failed before, probably by removing that compression which may have cramped absorption. It has occurred to me repeatedly to see the kidneys brought in this way into efficient action, and the health of the patient restored when almost despaired of. These measures, however, require to be used with caution. The particular circum- stances which justify or forbid their use will be most conveniently detailed under the different forms of dropsy considered in relation to their position. Remarks upon the subject of blisters, as depletory agents in dropsy, will be best postponed to the same occasion. It remains to treat of the measures of relief peculiarly adapted to those cases of dropsy which depend on certain organic affections. In the cardiac dropsies attention must be paid to the disease of the heart, Avhich, if incurable, must be palliated by appropriate remedies. It is espe- cially important, in all cases, that the patient should use no active exercise. When the dropsy is associated with chronic inflammation of the organ, great relief, if not a cure, may be hoped for from local depletion and blisters, and a moderate mercurial impression sustained for a considerable time, in con- nection with suitable remedies for the removal of the effusion. In the choice of these remedies, reference must be had, as in other cases of dropsy, to the state of the system ; and similar auxiliary means must be employed to reduce excessive, and support deficient action. It is indispensable that any anemic condition of the circulation should be corrected, as this has a powerful ef- fect in increasing the cardiac disease. Of the diuretics, digitalis is pecu- liarly applicable in consequence of its double action on the heart and the kidneys; and, combined with squill and calomel, or the blue mass, in cases calling for the mercurial influence, it is often productive of the best effects. The preparations of colchicum are also peculiarly adapted to cardiac drop- CLASS III.] DROPSY. 383 sies, from their control over the rheumatic or gouty irritation in which the affection of the heart has not unfrequently originated, and by the continu- ance or recurrence of which it is aggravated or sustained. Though effectual cures of dropsy originating in this cause can seldom be expected, much may be done for temporary effect; and, by a judicious employment of remedies, and regulation of the patient's habits, not only may his comfort be greatly promoted, but his life frequently much prolonged. Whatever is peculiar in the treatment of hepatic dropsy will be more con- veniently considered under ascites, which is the form of dropsy most fre- quently originating in disease of the liver. Renal dropsy, connected with active congestion or inflammation of the kidneys, sometimes requires, in its earlier stages, the application of cups to the small of the back, which may be repeated if the state of the circulation permit. In the variety following scarlet fever, it is sometimes advisable even to take blood from the arm, especially when there are threatening symptoms of meningitis, peritonitis, or other serous inflammation. Care, however, must be taken not to push depletion too far, in consequence of the strong disposition to anaemia which characterizes the affection in its more advanced periods. Some advantage may also be hoped from counter-irrita- tion to the loins by means of solution of ammonia, tartar emetic, or issues. Blisters, though recommended by some, are of doubtful propriety, from their tendency to produce strangury. Purgatives are peculiarly adapted to this variety of dropsy ; the indication being to divert excitement from the con- gested or inflamed kidneys. Upon the same principle diaphoretic measures promise favourably. Theory would certainly suggest these two means of evacuation, at least in the earlier stage of the disease, as preferable to diu- retics, the stimulant action of which is directed especially to the kidneys, and which might, therefore endanger an increase of the very affection supposed to lie at the root of the whole disorder. But our knowledge on this subject is yet too indefinite to justify the rejection, upon the ground of theoretical inference, of any measure that may have experience in its favour; and certainly there is strong testimony in support of the usefulness of at least two diuretics in this variety of dropsy; viz., cream of tartar and digi- talis. I have, indeed, found them the most effectual remedies as regards the dropsy, and productive of no observable injury to the kidneys, They may, therefore, be resorted to at any stage of the complaint, unless that of great- est debility. The same cannot be said of the more stimulating diuretics, which should be employed only under circumstances decidedly calling for their supporting influence. Perhaps, on the whole, the best plan would be first to try cathartics and diaphoretics, connected with direct depletion, in an obviously inflammatory condition of system, and, failing with these, to have recourse to the two diuretics alluded to, with others of a similar char- acter. Mercury must be looked upon as of doubtful propriety. It is as- serted of itself occasionally to give rise to coagulable urine, and is believed to have a direct influence in impoverishing the blood; effects which, as they are in some degree characteristic of renal dropsy, would seem to exclude their cause from the list of its remedies. Nevertheless, instances have oc- curred in which salivation was followed by permanent benefit; and, if the affection of the kidney be regarded as inflammatory in its character, the powerful antiphlogistic agency of this remedy would seem to be indicated. If employed, it should be so with much caution, in consequence of the pe- culiar susceptibility of patients in this disease to be violently affected by it; and its use should not be extended into the latter stages. It should never be used in the cases of renal dropsy dependent upon fatty degeneration of the kidneys. In these cases, along with the diuretics referred to, recourse 384 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. must be had to means calculated to improve the blood, and invigorate the system. (See BrighVs Disease.) Dr. Corrigan, of Dublin, has found iodide of potassium peculiarly efficacious in this form of dropsy. (Dub. Hosp. Gaz., Jan. 1856, p. 371.) Diet and Drink.—The free use of drinks was formerly denied to dropsical patients, under the impression that they served to supply additional stimulus to secretion, and at the same time additional material for the function. This theoretical ground of exclusion still continues, with the superadded reason, afforded by recent investigations, that fulness of the blood-vessels is the greatest impediment to absorption. Nevertheless, experience has decided against these hypothetical deductions; and nature, by the frequently urgent thirst which attends dropsy, and the extreme distress if it be denied gratifica- tion, throws the weight of her indications into the same scale. Practitioners now generally leave their patients to their own discretion in relation to the quantity of drink. A good rule is that the liquids should be taken cold, and in small quantities frequently repeated, rather than in large draughts at once. Thirst is thus effectually relieved, while the stomach and blood-vessels are not so much overloaded. The choice of the drink must depend upon circum- stances. Cold diuretic infusions sometimes satisfy the patient, and are better than cold water alone. In cases not inflammatory, old cider sometimes answers well; and, when spirituous liquors are indicated on account of pre- vious habits or debility, gin should be preferred. The infusion of horseradish, mustard, juniper, &c, in hard cider, as given in page 379, is sometimes useful. No general rule can be given in relation to diet. The practitioner will, in this respect, be guided by the particular circumstances of each case, enjoining an antiphlogistic regimen in inflammatory cases, nutritious food in the anemic and debilitated, an easily digestible diet in those complicated with enfeebled digestion, and in all avoiding unnecessary interference with the habits and preferences of the patient. Article II ANASARCA. This term, derived from the Greek (ava, through, and cap*, flesh), signifies dropsy of the exterior cellular or areolar tissue. It is not usually extended to effusions into the cellular tissue of the interior organs considered separately, as, for instance, into the parenchyma of the lungs, or the submucous struc- ture. Nor is it customary to apply it to dropsical effusions of the exterior cellular tissue when of very small extent and quite local; these being desig- nated by the term oedema. The first symptom of anasarca is usually a swelling of the feet and ankles, appearing towards evening, and diminishing, if not quite disappearing, before morning. It is distinguished from other swellings by pitting under pressure, that is, by retaining for a considerable time the indentations made by a com- pressing body. This tumefaction of the lower extremities does not imply that the effusion of fluid is confined to these parts. The cells of the areolar tissue communicate, so that fluid passes readily from one part of the body to another. In anasarca, the effusion generally takes place in various portions of the body, sometimes probably throughout the whole exterior structure. During the day the fluid gravitates into the feet, which are the lowest part, and at night is again diffused over the frame in consequence of its horizontal position. Sometimes, however, the effusion actually takes place first in the CLASS III.] ANASARCA. 385 feet and legs; as in cases of debility, in which the want of energy in the cir- culation allows the blood to accumulate in the veins of the extremities, and thus to induce a condition favourable to the transudation of serum. In some instances, the tumefaction is first observed in the face, particularly about the eyes. This is apt to happen in febrile dropsy, in which the liquid is more quickly effused, and does not appear to travel so rapidly, and in certain con- ditions of diseased heart, in which the greatest stress of the circulation is upon the upper part of the body. Another condition in which the effusion is likely to appear originally in the face, neck, or upper extremities, is that of obstruction in the veins which reconvey the blood from these parts, as in the descending vena cava. Cases of this kind have occurred, in which the dropsy was confined to one arm. In certain rare instances of extremely rapid effusion, the dropsical swelling has shown itself simultaneously over the whole body. The swelling of the feet and ankles, in most instances, gradually increases, extends up the legs and thighs, encroaches upon the abdominal and thoracic parietes, and at last reaches the head and upper extremities, so that the w7hole body becomes bloated, and sometimes to an enormous extent. The parts in which the cellular texture is loose suffer tumefaction in the greatest degree. Hence, the backs of the hands and tops of the feet, the eyelids and neigh- bouring parts, the scrotum and cellular tissue of the penis in males, and the labia pudendi in females, become greatly distended. The swelling of the privates is often so great as to occasion much inconvenience, and in the male even to interfere with micturition. The lower extremities are often enor- mously increased in bulk, and the skin stretched, tense, and shining. Some- times the cuticle rises in the form of blisters, or the skin itself gives way; an erysipelatous inflammation invades the integuments ; the cellular tissue sloughs; and sores are formed, which become the outlets of great quantities of serous fluid, and thus afford much relief to the patient. Instances have occurred, in which permanent cures have been effected in this way;' but more frequently, though the patient may obtain some ease from his oppression, the conjoined exhaustion and irritation are more than his enfeebled system can support, and the case terminates fatally. Most frequently the anasarca when extensive is attended with effusion into the serous cavities, which greatly increases the danger, and often proves the immediate cause of death. In some instances, however, the disease runs its course without such complication. Sometimes the anasarcous swelling sud- denly disappears, and, by a sort of metastasis, is succeeded by effusion into the ventricles of the brain, or into the thoracic or abdominal cavity. This form of dropsy is liable to all the diversities of character which have been described under the head of dropsy in general. It may be acute or chronic, sthenic or asthenic, febrile and inflammatory, or anemic. When it is of a febrile character, and dependent on irritation of the secreting tissue, the swelling is more firm and elastic, and the impressions made by the finger are sooner effaced than in other forms of the disease. In some instances, the excitement of the tissue amounts to inflammation, and disagreeable sen- sations are experienced in the affected part, with tenderness on pressure. The febrile forms of anasarca are occasionally, moreover, attended with inflamma- tion of some interior structure, especially of the serous membranes, and of the kidneys. In cases of the disease dependent on general debility or a watery state of the blood, or upon organic affections of the heart, the tumefaction is usually soft, and pits easily under the fingers Anasarca is usually attended with much loss of flesh, and, in those portions of the body not occupied by the effused fluid, the emaciation is sometimes extreme. This condition is very striking in old cases, in which a sudden ab- sorption of the dropsical fluid takes place. 386 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. The diagnosis of the affection is scarcely ever doubtful. Sometimes there may be difficulty for a time in deciding whether an edematous state of the feet and legs is merely local, and dependent on inflammation of the cellular tissue from gout, rheumatism, or other cause, or whether it is properly drop- sical. But, in the latter case, the progress of the disease will in general soon settle the question. General emphysema might possibly be confounded with dropsy; but the crackling under the fingers in the former affection will sufficiently distinguish it. After death from anasarca, the cellular tissue is found greatly distended. That beneath the skin is usually most so, but the effusion is observed also in the deeper structure, and even in the substance of the muscles and viscera, which are softened, pale, and disposed to speedy putrefaction. Sometimes the serum is observed to have accumulated in the tissue subjacent to the mu- cous membranes, which are elevated, and assume a somewhat jelly-like ap- pearance. Indeed, one of the causes of death in dropsy is the serous effusion beneath the mucous lining of the air-passages. In relation to the causes and general treatment, there is nothing so pecu- liar as to require particular notice. The reader is, therefore, referred to the subject of dropsy in general. A few observations, however, in relation to the local treatment of the disease will be in place here. Bandages to the limbs have been recommended. In most cases they can be of no service. But, when the affection is confined to the feet and legs, either originally, or towards the close of a more extensive affection, a well-regulated pressure may prove useful by promoting absorption. In some instances, too, of very great distension, it is possible that some good maybe effected by careful bandaging, in obviating inflammation, ulceration, and sloughing. Blisters to the extremities have sometimes been employed to promote the discharge of the effused serum, and they may undoubtedly afford relief in this way. But their advantages are far overbalanced by the danger of ob- stinate ulceration, erysipelatous inflammation, and gangrene from their use; and they have now been universally abandoned. I have seen one striking case, in which an enormous ulcer on each leg followed the application of blisters; and, though the dropsical symptoms entirely disappeared, the patient died under the combined irritation and exhaustion produced by them. Still less admissible are the actual cautery, and the seton, which are said to have been formerly recommended. Small punctures may often be made with advantage in cases of great dis- tension. The quantity of liquid which escapes even from a few of these minute wounds is sometimes astonishing, and the relief to the patient inde- scribable. But they are not without hazard. Even in robust patients they are often attended with more or less inflammation, and sometimes end in ob- stinate sores, though fatal effects very rarely ensue; but in the feeble, in whom the powers of life are already nearly exhausted, they not unfrequently seem to hasten the close. The inflammation extends rapidly over the limb, sinks into the cellular tissue, and occasionally gives rise to extensive gan- grene, preceded by severe pain. I have repeatedly known patients to die from the effects of these punctures, after having been greatly relieved for a time by the discharge of the effused fluid. They should, therefore, always be practised with caution, and never in the very feeble, unless the symptoms of oppression should be so excessive as to threaten immediate death. Under these circumstances, they may, perhaps, be considered as the less of two evils. In young or middle-aged patients, with considerable vigour of constitution, they may be resorted to whenever the distension becomes' very distressing, and has resisted the usual diuretic and purgative remedies. The punctures should be made with a very sharp lancet, and not deeper than merely through CLASS III.] HYDROCEPHALUS. 387 the skin. They should never be numerous, and frequently three or four in a limb will be sufficient at one time. They are most effectual for the discharge of the fluid when made on the top of the foot, or in the leg above the ankle; but are thought to be safest in the thighs. When the scrotum and penis, or labia pudendi, are very much swollen, they may often be punctured in the same way with much advantage. It is said that slight incisions, half an inch or an inch in length, merely through the cuticle, answer a good purpose, and are less liable to be followed by mischievous consequences. Acupuncture has been of late recommended as less hazardous than incision, though this also is not without its danger. The punctures should be made with a sharp, highly polished, and fine needle, should never be so deep as to penetrate a fascia, and should not be nearer to each other than an inch and a half or two inches. Incision would probably be preferable to puncture by very coarse or three- sided needles, which have been advised, as there would be less contusion, and probably less danger of inflammation. When the extremities become inflamed in dropsy, whether spontaneously or in consequence of wounds, the patient should lie in bed with the limb somewhat elevated; lead-water or flaxseed mucilage should be applied to the inflamed surface; or the parts should be enveloped in an emollient poultice, to which, in case of gangrene and sloughing, a solution of creasote may be added with advantage. Article III DROPSY OF THE BRAIN, or HYDROCEPHALUS. The term hydrocephalus is, in this work, considered as embracing only those cases of serous effusion within the cranium which are independent of inflammation. The affection usually denominated acute hydrocephalus is nothing more nor less than meningitis, either simple or tuberculous, and owes little or nothing of its symptoms or result to the effused liquid, which may or may not exist in any particular case. It has been questioned whether there is such an affection as proper acute hydrocephalus, in the sense in which the word is here used. The affection is undoubtedly rare; but there seems to be no rational ground for denying its existence; as cases have been reported in which death has occurred after a brief illness, with symptoms of cerebral dis- ease ; and serous fluid in abnormal quantity has been found within the cra- nium, without any other appreciable lesion. Yet there are no signs by which such an affection, occurring after a complete formation of the cranium, could be distinguished with certainty from apoplexy, or meningitis affecting the • base of the brain; and it is unnecessary, in a practical point of view, to give it a distinct consideration. The following observations, therefore, apply only to cases in which the disease is slowly developed. The effused liquid in hydrocephalus may occupy the ventricles, the cavity of the arachnoid, the tissue of the pia mater, or the substance of the brain, which is infiltrated with it. In the last tAvo situations, however, the quantity of the liquid is ahvays small; and its influence in producing the symptoms so doubtful that it may be left out of view. By some pathologists the situa- tion is indicated by the name ; the disease being denominated hydrocephalus interims when the effusion is seated in the ventricles, and hydrocephalus extern us when in the cavity of the arachnoid. The disease may be congenital or acquired. The congenital cases are almost always connected with organic defect in the encephalon, such as a par- 388 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. tial or entire want of brain; and, ending fatally either during labour, or within a short period after birth, scarcely merit the notice of the practitioner. It is only the acquired disease with which we are concerned. This occurs chiefly in the young, especially in infants before the closure of the fontanels ; but may happen at any period of life. Yet, in relation to cases in which the cranium is incapable of expansion, there must always be some doubt; as the only certain criterion of the presence of water is the increased size of the head. Various organic diseases of the brain, of a chronic charac- ter, are capable of producing symptoms closely analogous to those of hydro- cephalus ; and any diagnosis that may be formed in such cases must be more or less conjectural. All that can be said Avith propriety is, that, when a case exhibits the ordinary hydrocephalic signs, with the single exception of the expanded cranium, after the complete union of the bones of the head, there may very probably be dropsy of the brain. Symptoms, Course, &c.—The most obvious phenomenon in hydrocephalic patients is the enlarged, or gradually enlarging head. The expansion takes place usually in all parts of the bony case of the brain, except the base ; but it is generally most conspicuous in the frontal, parietal, and occipital regions; the top of the head being comparatively little affected. As the face is in general not larger than usual in health, the forehead and sides of the cranium are made to project very much, and give to the child a peculiar aspect. In some instances, it is said that the face undergoes a corresponding develop- ment, and the whole head appears gigantic. The enlargement is sometimes irregular, affecting especially the forehead, or the parietal region, and much greater on one side than the other, so as to occasion great deformity. The fontanels expand very much, the sutures not unfrequently open, and the bones of the cranium seem in some extreme cases to be almost floating upon a sur- face of liquid. Fluctuation can be perceived between them ; and the inter- osseous spaces are either at the level of the surface, or project somewhat above it. In some cases in which the collection of water is very great, the head appears somewhat translucent, if placed between the eye and the light. After a length of time, which is exceedingly variable, if the patient survive, the interosseous spaces are gradually converted into bone, and the cranium becomes entire ; but it is no uncommon event for the fontanels to remain open in hydrocephalic patients for many years. After the complete ossifica- tion of the cranium, the head ceases to expand; and, unless there should also be a cessation of the gradual increase of the effusion, severe symptoms soon make their appearance. While the bones yield readily to the accumulating liquid, and no great pressure is exerted upon the brain, it not unfrequently happens that the general symptoms are not striking. When the disease attacks children whose fontanels have closed, the expanding force is sometimes sufficient to reopen them, and this event has happened as late as the eighth or ninth year. The size which the cranium is capable of attaining in this complaint is enormous. Thus, the circumference of the head in a child two years old, under the notice of Willan, was twenty-nine inches; and in another of four- teen months, seen by Barthez and Rilliet, nearly twenty-three inches. In general, however, the size is much less, and it varies by every gradation from the least visible expansion to the largest dimensions mentioned. The first signs of the evil effects of the accumulated fluid are not easily de- fined. They consist usually in some deficiency or irregularity of nervous action. Certain symptoms are to be ascribed, in part at least, to the in- creased weight of the head. The child walks with a somewhat tottering or uncertain gait; and not unfrequently falls. He either holds his head stiffly and watchfully erect, so as to prevent its falling on either side, or supports CLASS III.] HYDROCEPHALUS. 389 it by his hand, or upon some object in his vicinity. In bed, he usually lies upon his back. The limbs are frequently affected with tremors. There is occasionally pain in the head or limbs, which appears to be paroxysmal, and, when most violent, causes the child to scream. The acuteness of the special Benses is diminished. Dimness of vision occurs, which in some instances in- creases to blindness, while in others the patient can see to the last. The skin becomes more or less insensible; and the smell and taste are sometimes af- fected. Hearing is usually the last of the special senses to fail. The intel- lect is seldom materially deranged in the earlier stages ; though the memory is obviously enfeebled, and not unfrequently a certain dulness or hebetude of mind is obvious. The digestive function often remains long unimpaired. In- deed, the appetite is sometimes keen, and, unless some other disease compli- cates the case, the patient may even increase in flesh. But more frequently he emaciates, notwithstanding that he may take more than the usual quantity of food. The bowels are costive throughout, and the urine scanty. A dis- position to copious secretion of tears and of saliva has been noticed. At length symptoms of more profound cerebral lesion appear; such as occasional vomiting, contraction of the flexors of the limbs, muscular rigidity, strabismus, grinding of the teeth, epileptic convulsions, partial palsy, and mental imbe- cility, with a disposition to drowsiness or stupor. These symptoms are soon followed by complete loss of consciousness, abolition of the senses, especially of vision, involuntary discharges from the bladder and bowels, a small, feeble, irregular, and frequent pulse, stertorous respiration, and death. The duration of the disease is uncertain. Most of those affected die in in- fancy. Some live on for many years, and now and then one to adult age, and, it is said, even to old age. Anatomical Characters.—The quantity of liquid found in the ventricles varies greatly. It may be only a few ounces, or it may be pounds. Dr. Bright has reported a case in which seven or eight pints were taken from the head of a man, who had been affected with the disease from infancy, and died when near thirty. The ventricles are often expanded into one great cavity. The consistence of the brain may be natural, though in some instances hard- ened, and in others softened to a greater or less depth from the surface of the ventricles. The brain is sometimes spread out, in the form of a layer, per- haps not more than half an inch or an inch in thickness, upon the inner sur- face of the cranium; the shape of the hemispheres being lost, and the convo- lutions obliterated. Instead of the ventricles, the arachnoid sometimes contains the liquid, in which case, instead of being unfolded into a sort of bag, the brain is appa- rently compressed into the bottom of the cranial cavity, with the liquid above it. In this case, the form of the brain is preserved, and the convolutions are not effaced. The head is thought not to be susceptible of so great an enlargement as when the effusion has taken place in the ventricles. In other instances, the cavity of the ventricles and that of the arachnoid are thrown into one by the opening of the commissures of the brain, of which the central portions now present upward, and the hemispheres appear as if folded back. It might be supposed that, compressed as the brain is by the liquid, it would be diminished in weight. But this does not seem to be the case in the varieties just described, at least not to any considerable extent. The liquid is usually perfectly colourless and limpid; but sometimes, espe- cially in the cavity of the arachnoid, it appears like a bloody serum, and is partially coagulable. It generally contains a minute proportion of albumen, sometimes a little ozmazome, and various saline substances, such as chloride of sodium, phosphate of soda, &c, also in very small proportion. 390 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. The bones of the cranium are sometimes as thin as paper, and very fragile, sometimes of a thickness not disproportionate to the size of the head, and in other instances much thickened, even to the extent of nine or ten lines. In the last case, they are usually spongy as in rachitis, and, when otherwise, owe their development, perhaps, to the deposition of bony matter upon the inner surface, to supply the deficiency resulting from the partial absorption of the effused liquid. Causes.—It is possible that the same condition of the blood and of the extreme vessels, which induces dropsy in the cellular tissue and the serous cavities, may operate in the brain so as to occasion hydrocephalus, especially when, from a want of union between the bones of the cranium, little resist- ance is offered to the accumulation. But, in the greater number of cases, the effusion appears to be OAving to tumours in the substance of the brain or cerebellum, and especially to tubercles, which press upon the veins, and thus induce effusion, exactly as tumours in the abdomen give rise to ascites. It is stated that tumours are not apt to produce this effect until they have at- tained considerable size, and they are more apt to produce it when seated in the cerebellum, or near the base of the brain, than elsewhere. Diagnosis.—There would seem to be little difficulty in distinguishing cases of hydrocephalus, when attended at once by enlargement of the head, and the general symptoms indicative of cerebral lesion. It is necessary, however, for the practitioner to be on his guard, not to mistake for this disease cases of naturally large heads, and those in which the cranium is thickened and spongy, as sometimes happens in rachitis. Hypertrophy of the brain, occur- ring at the same period of life, may be attended with increased dimensions of the cranium, and with signs of cerebral lesion; but, in this affection, there is perhaps less of evident cerebral disease in its progress, until the acuter symptoms come on which terminate fatally, and there is also less tendency to produce local derangements, as in a particular limb or muscle; but it must be confessed that the diagnosis is obscure. This affection, however, is comparatively very rare. Prognosis.—The prognosis is generally unfavourable. When dependent on mere functional derangement, this form of dropsy may end in recovery as well as any other form; but most frequently it is connected with irremova- ble causes, and necessarily ends in death. When consequent upon scarla- tina or other febrile disease, it may be considered as probably independent of organic lesion, and its cure may be hoped for. When associated with an obvious tuberculous diathesis, it may be considered as almost desperate. But, generally speaking, it is impossible to determine its precise origin; and a guarded prognosis should always be given. Treatment.—This consists essentially in the production of the mercurial impression, and the use of diuretics and cathartics. In addition, when the child is scrofulous or anemic, the chalybeates, preparations of iodine, decoc- tion of pipsissewa, and cod-liver oil may be used. Revulsion to the scalp by means of blisters, croton oil, oil of turpentine, or other irritant substances, has also been recommended. Care must be taken, in the use of the remedies, not to exhaust the strength of the patient. For producing the mercurial impression, small doses of calomel or the blue pill may be given internally; and mercurial ointment rubbed upon the inner surface of the limbs, and on the scalp. Of the diuretics, squill, spirit of nitric ether, bitartrate of potassa, and perhaps digitalis may be used, though the last always with caution. Cream of tartar, combined, when the patient is somewhat vigorous, with jalap, would be the best cathartic. Of the preparations of iodine, iodide of potassium is usually preferred. The following is the plan employed by Golis, for which he claims great CLASS III.] HYDROCEPHALUS. 391 success. The head is to be kept constantly covered with a woollen cap, and every night one or two scruples of mercurial ointment mixed with an oint- ment made from juniper berries, are to be rubbed upon the scalp. Calomel is to be given in doses of one-quarter or one-half of a grain, twice a day; care being taken that too much purging is not produced. For young in- fants, the best diet is the mother's milk, or that of a healthy nurse; for older children, meats, eggs, and coffee made from roasted acorns. Fat substances, and all alcoholic liquids are to be excluded. In pleasant weather, the child should be as much as possible in the open air. In winter, the temperature of the chamber should be about 68° or 70° F., and the child should lie on a mattress, and be carefully guarded against currents of air. Golis asserts that this plan, duly persevered in, has produced complete and lasting cures in many instances. Should no improvement be perceived at the end of two months, he advises the use of diuretics, such as acetate of potassa and squill, in connection with the former medicines, and the insertion of an issue in the neck or arm, which is to be kept discharging for several months. Should inflammatory symptoms supervene, the antiphlogistic treatment is to be employed. After the commencement of recovery, advantage some- times accrues from small doses of quinia. Dr. Watson relates the following mode of cure as having been effectual in two cases. It was employed at the suggestion of Dr. Gower, and succeeded after the blue pill, diuretics, purgatives, &c, had been used without effect. Ten grains of metallic mercury were rubbed with conserve of roses; five grains of fresh squill were added; and the whole made into pills with pow- dered liquorice-root. This quantity was taken three times a day, for nearly three weeks. It acted powerfully as a diuretic, Avithout salivation, but with great reduction of strength and flesh, and gradual relief to the symptoms. It was continued for two weeks longer, at first twice, and afterwards once daily; at the end of which time the cure Avas complete. The strength was restored by the use of iron, and the cure Avas permanent. Compression and tapping of the head have been frequently employed in cases of chronic hydrocephalus, and sometimes with asserted success. Mr. Barnard's method of compression, which has proved successful in several instances, is to apply strips of adhesive plaster, about three-quarters of an inch wide, completely round the head, from before backward; then to carry cross strips from one side of the head to the other over the crown, and lastly, one long strip from the root of the nose over the vertex to the nape of the neck. This plan is applicable only to cases in which the bones are loose, and the general powers feeble, as shown by paleness of the surface, flabbi- ness of the muscles, &c. (Watson's Lectures.) Should the symptoms be aggravated by the pressure, it should be relaxed or abandoned. Mr. Richard Phillips, employs, instead of strips of adhesive plaster, an elastic loop or fillet of strong caoutchouc webbing, two inches wide, with a circumference somewhat less than that of the head, which is consequently somewhat com- pressed when it is applied. As the bulk of the head lessens, it is necessary to lessen also the circumference of the fillet. The treatment should be con- tinued until the cranial bones are united. Mr. Phillips relates one case in which it was quite successful. (Lancet, Am. ed., Jan. 1858, p. 48.) The operation of tapping has been employed by many, and with variable success. In some instances, temporary relief has been obtained ; in others, the operation has appeared to aggravate the symptoms and hasten death; and in others again, though comparatively feAv, a complete cure has been effected. The operation should never be resorted to until all other measures have failed, and the case is considered desperate. The opening should be made by a small trochar, introduced perpendicularly, " at the edge of the ante- 392 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. rior fontanel, so as to be as much as possible out of the way of the longi- tudinal sinus, and the great veins emptying therein. The instant that the pulse becomes weak, or the dilated pupil contracts, or the expression of the child's countenance manifestly alters, the canula should be Avithdrawn, and the aperture in the skull closed. Gentle compression should be care- fully made to compensate, in some degree at least, the pressure that has been removed with the fluid." (Watson's Lectures.) Should inflammation follow, it must be treated by the usual antiphlogistic means. A case has been reported by Dr. J. M. Winn, in the London Lancet (Nov. 3, 1855, p. 408), in which, after tapping the head, and withdrawing seventy-two ounces of liquid, he injected two ounces of a solution of tincture of iodine, containing fourteen minims of the tincture, and then bandaged the head, with compression. It was a case of external hydrocephalus, in which the brain lay collapsed at the base of the cranium. Ten days after the operation the child died, but with little if any return of effusion. Article IV DROPSY OF THE CHEST, or HYDROTHORAX. Though generally applied at present exclusively to dropsical collections in the pleura, the term hydrothorax may, from its origin (uda>p, water, and dajpaZ, chest), be appropriately extended to any case of serous effusion, within the thoracic cavity; and in this enlarged acceptation I shall here em- ploy it. There are three positions which may be severally or jointly occu- pied by this affection ; the cavity of the pleura, that of the pericardium, and the pulmonary parenchyma. 1. Pleural Dropsy. More or less serous fluid is very often found in the pleural cavities after death, without having given rise, during life, to any disturbance of health. This may be the result of effusion occurring, like copious sweats, in the dying state, or may be purely cadaveric, or may have existed unnoticed during life. To constitute dropsy, the effusion must be so considerable as to derange in some degree the healthy functions. When it exists to this extent, it pro- duces more or less difficulty of breathing, which is increased by any bodily exertion, especially running, or ascending heights, and is greater in the horizontal than in the erect position. The dyspneea is slight at first, but increases as the disease advances, and often becomes excessive before its close, bearing a close relation to the amount of the effused liquid. The pa- tient lies preferably on the side most affected, generally with his head and shoulders elevated ; and, in the advanced stages is often unable to lie down at all, maintaining day and night the sitting posture. The pressure upon the lungs impedes the pulmonary circulation; and, as a consequence, the face has often a livid or purplish hue, and the lips are sometimes almost black in bad cases. This disease is often associated from the commencement with anasarca; and, when this is not the case, oedema of the face in the morning, and of the feet and ankles towards night, is very apt to make its appearance before the close. The chest is usually more prominent at the part where the liquid is col- lected. The projection is often obvious to the eye and may be demonstrated by measurement with a tape. When the effusion is very copious, the ribs CLASS III.] HYDROTHORAX. 393 are further separated than in health, and the intercostal spaces lose their ordinary depression, and sometimes even appear to bulge outward. The heart too is displaced, being pressed towards the opposite side. It is as- serted that, if the body be shaken, the agitation of the fluid may be heard; but this can happen only when there is also air in the cavity of the pleura. The vibration felt by the hand applied to the chest of an individual while speaking, is less sensible on the side affected with dropsy than on the other. Sometimes, when the effusion is very abundant, fluctuation can be perceived if one hand be laid upon the chest, and slight percussion be made by the other upon the intercostal spaces in the same vicinity. Bichat speaks of the increased dyspneea resulting from pressure upon the abdomen as a useful diagnostic symptom. This, however, is experienced in so many other affections of the chest as to be of little value. It may assist the diagnosis when one pleural cavity only is dropsical; as the pressure produces a much greater effect when applied on the sound, than on the diseased side. But the most certain evidences are those afforded by percussion and auscultation. There is always dulness on percussion, proportionate in a great degree to the amount of effusion. This dulness is usually first per- ceived in the lower part of the chest, and gradually mounts upward, with the increase of the effusion, until, in extreme cases it extends over the whole half of the thorax, except the portion corresponding with the root of the lungs. When the effusion is less extensive, the dulness changes its position with that of the patient, and thus shows clearly that it is owing to the pre- sence of a movable fluid in the pleura. If, for example, the instrument be applied upon the front of the chest, near the highest limit of the dulness, in the erect position, and the patient then be made to lie on his back, any decided difference between the sound emitted upon percussion, before and after the change of posture, will leave no doubt as to the existence of a liquid in the cavity. In the early periods of the disease, the peculiar resonance of the voice called aegophony, is sometimes perceived upon applying the ear over the seat of effusion ; but this disappears with the increase of the affection. The respiratory murmur is feeble at first, and at length ceases to be heard, in some bad cases over almost the whole chest. But, unless the collapse of the lung is complete, if the patient be placed upon his face, both aegophony and the respiratory murmur may be sensible in the posterior part of the chest, when they have ceased anteriorly. The only affections with which pleural dropsy is likely to be confounded are consolidation of the lung from pneumonia or other cause, and the pre- sence of pus or blood in the cavity. From the former, dropsy may be dis- tinguished, in moderate cases, by the changing position of the dulness and the auscultatory signs, with the change of posture by the patient; and, in severe cases in which the whole cavity is full, by the obvious expansion of the chest, the enlargement of the intercostal spaces, and the effacing of their regular depression. Besides, in pneumonia percussion is not usually so dull as in dropsy, the respiratory sounds are not so distant, the vibratory movement of the chest is increased instead of being diminished, and the condition of the sputum is quite characteristic. Empyema is distinguished with greater difficulty. The diagnostic signs of this affection are chiefly such as indicate the previous or coincident existence of inflammation; though it is not im- possible that, even with these, the liquid effused may be merely serum, and, therefore, if long continued, entitled to be considered as dropsical. Em- pyema is more apt than dropsy to be confined to one side, and is much less apt to be accompanied with oedema of the face and extremities. Should the signs exist of a communication between the cavity of the pleura and the vol. n. 26 394 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. lungs, the effusion may be looked on as certainly purulent. The existence of blood in the pleural cavity may be inferred, if the effusion has succeeded any violence, or has come on suddenly in cases of a hemorrhagic tendency, as in purpura and scurvy. Pleural dropsy is often only a portion of general dropsy, and is, in most instances, associated with more or less anasarca. Occasionally, however, it exists alone ; and this is especially the case when it arises from inflammation or active congestion of the pleura. Under the same circumstances, it is some- times confined to one side ; but more generally it exists in a greater or less degree in both cavities. In the latter case, however, it is very frequently in a greater degree upon one side than the other. When arising from disease of the lungs, it occurs most frequently on the affected side, and when from disease of the heart, according to Dr. Williams, upon the right side. Its course is very uncertain. Sometimes it comes on suddenly, and soon proves fatal; but much oftener it is chronic, lasting for a long time, sometimes bet- ter and sometimes worse, now yielding to treatment, and again returning, until at length the patient succumbs, either under the disease in which the dropsy originated, or from the effects of the dropsy itself. When originating from a general dropsical diathesis, or from a mere irritation of the pleura, it is often radically cured. Not unfrequently, however, it ends in death, be- cause dependent upon incurable affections. Upon examination after death, the lung is found more or less compressed, and forced inward and backward towards the mediastinum and spine. Occa- sionally old partial adhesions of the pleura are observed to restrain, in some measure, this change of position. In very bad cases, the bronchial tubes ap- pear almost entirely obliterated, and the lung had evidently quite ceased to admit air in respiration before death. But, even in such cases, it expands if air be blown into it through the trachea. The pleura is often quite free from disease, but sometimes exhibits traces of preceding inflammation. The liquid is sometimes limpid and colourless, but more frequently yellowish or brownish, or tinged with blood, and occasionally offers flakes of coagulated fibrin or albu- men, or is turbid from a similar impregnation. The quantity is exceedingly variable. It generally amounts to several pints, sometimes in bad cases to one or even two gallons, though the last-mentioned quantity is very rare. The causes of pleural dropsy do not differ from those of the general dis- ease. It originates most frequently in organic affections of the heart, the great blood-vessels, or the lungs, and is apt to be associated with tubercles in their earlier stages. As in all other forms of dropsy, the effusion may de- pend upon inflammation of the secreting membrane. Some authors consider the serous effusion arising from this cause as distinct from dropsy ; but fail to assign a good reason for the distinction. When the effusion is simply serous, it must be considered dropsical whatever may be its origin. The cases considered as idiopathic hydrothorax are probably, in most instances, the result of a high irritation of the membrane, which has not reached the point of inflammation simply because the blood-vessels have relieved them- selves by effusion. Sometimes the disease results from a sudden transfer of the morbid process, whatever it is, from the cellular tissue to the pleura; the anasarca disappearing as the hydrothorax occurs. In relation to the treatment, little need be added to what Avas said under general dropsy. When there is reason to believe that the effusion depends upon an inflammatory condition of the pleura, very great advantage may be expected from occasional cupping, and repeated and long-continued blister- ing. Of the internal remedies, perhaps most reliance is to be placed upon a combination of squill and calomel; the latter being carried to a slight ptyal- ism. Paracentesis may be resorted to with hope of benefit, when there is CLASS III.] HYDROTHORAX. 395 reason to believe that the disease has originated in inflammation or mere vascular irritation of the pleura. In other cases, it would be a desperate resort, at best calculated to afford but temporary relief at the hazard of pro- ducing fatal inflammation. Nevertheless, when the danger of death from suffocation is imminent, the practitioner would be justified in resorting to it as a temporary expedient. In no case should it be employed until other means have failed. 2. Pericardial Dropsy.—Hydropericardium.—Dropsy of the Heart. A certain quantity of serum in the pericardium does not appear to be in- compatible with health; at least, it is frequently found after death, without any previous symptoms that could have led to a suspicion of its existence. As in the pleura, the probability is, that the effusion is partly an attendant on the last agony, or merely cadaveric; but it can scarcely be doubted that, in many cases, it has existed during life. How much may be considered as constituting disease cannot be exactly determined; for the effects from the same quantity vary greatly with the rapidity of its accumulation. A small portion effused quickly will embarrass the heart more than a much larger quantity collected slowly, so as to allow that organ to be gradually accus- tomed to its presence. Corvisart considered six or seven ounces as on the average sufficient to indicate a morbid state; and it is probable that less will sometimes interfere with the circulation and respiration. As in pleural dropsy, there is much difficulty in distinguishing the symp- toms produced by the effusion from those of coexisting diseases, especially of the heart; and not unfrequently the same symptoms have their origin in both affections. Besides, hydropericardium is frequently associated with dropsy of other cavities, or with general dropsy, which very much complicates the phenomena. A small, feeble, irregular pulse, dyspneea, inability to retain the horizontal position, a livid or purplish hue of the face, deepest in the lips, and sometimes extending to the arms, are symptoms which result from dropsy of the pericardium; but they also frequently exist in diseases of the heart without this complication. Corvisart pointed out a characteristic symptom, observable in some rare cases of very copious effusion. In two instances of this kind, the heart could be felt beating at different spots at different times; the pericardium being so much distended as to allow that organ to float about in the liquid with which it was surrounded, in obedience to any impulse which it might receive. An elevation of the point at which the heart's pulsation is felt, and its removal further towards the left, are other occasional signs of pericardial effusion. A preternatural prominence of the thorax in the region of the heart, obvious to the eye, and oedema of the face and extremities, are still more important signs. But no certain evidence of the existence of the disease is offered except by percussion and auscultation. Dulness in a greater degree, and over a greater extent of the cardiac region than in health, is the result of considerable effusion into the pericardium. This same phenomenon is presented by dilatation of the heart; but it may be inferred to depend on effusion, if observed to vary in extent, either gradually increasing or gradu- ally diminishing within a moderate length of time. This alteration may be appreciated by marking the limits of the dulness at any given time, by means of" lunar caustic or other substance capable of imparting a durable stain to the cuticle, and comparing them with a similar outline at another time. The impulse imparted to the ear and to the hand in hydropericardium is some- what obscure, as if conveyed through a liquid, and not superficial as in dila- tation ; and the sounds of the heart seem more distant in the former than in the latter case. Besides, the respiratory murmur can be heard over the di- lated heart, in situations in which it would be inaudible in distension of the 396 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. pericardium. But these signs only indicate the existence of a liquid in the pericardial cavity. Whether it is dropsical or not must be inferred from at- tendant circumstances. If accompanied, or immediately preceded by the state of system, and the physical signs which indicate pericarditis, it may be considered as the sero-fibrinous or puruloid product of that affection; if occurring in a hemorrhagic state of system, it may consist of blood; in other cases it would probably be dropsy. This form of dropsy, when dependent on inflammatory irritation of the pericardium, or on a general dropsical diathesis, is susceptible of cure; but too frequently it is quite incurable, in consequence of the incurable nature of its cause ; and it is generally of this character when very abundant. The liquid is found on dissection very similar to that effused in pleural dropsy. The quantity is sometimes very considerable ; and a case is on record in which eight pounds were extracted. The pericardium sometimes exhibits signs of "former inflammation; but frequently it is entirely free from them; being paler than usual, and otherwise differing from the normal state only by an occasional greater thickness, consequent, as is not unfrequently the case with other hollow structures, upon the stimulus of distension. In relation to the causes of pericardial dropsy, it is scarcely necessary to add anything to what has been already stated. In its serious forms, it is most frequently the result of disease of the heart, great blood-vessels, of lungs. It has been traced also to a tuberculated condition of the pericar- dium. As the other kinds of dropsy, it may depend upon simple irritation of the membrane, or upon those conditions which give rise to general dropsy. Nor is there anything peculiar in the treatment. The therapeutical remarks on dropsy of the pleura are applicable to this affection. Paracentesis, how- ever must be resorted to with even greater reserve. Still, it would be justi- fiable, should life be in imminent danger, after all other measures had been tried ineffectually. No case, I believe, is on record of a favourable result of the operation in pericardial dropsy. 3. Pulmonary (Edema.—Dropsy of the Lungs. This name is applied to serous effusion in the parenchyma of the lungs. It may occupy the extra-vesicular cellular tissue, or the air-cells, or both. When considerable, it occasions great dyspneea, hurried breathing, and fre- quently cough, with the copious discharge of a thin, colourless, frothy liquid. There is more or less dulness upon percussion, which is most evident when the two lungs are unequally or one exclusively affected, the contrast between the two rendering the want of resonance in the dropsical lung more obvious. The respiratory murmur is diminished, but not altogether lost, unless in parts of the lungs in bad cases. Both the dulness on percussion, and the indistinct- ness of the respiration, are most decided in the lower and back portion of the chest. There is a subcrepitant rale during inspiration, resembling that of pneumonia, but not so fine, and attended with the mucous rale, indicative of liquid in the larger bronchia. The affection is very frequently accompanied by oedema of the face or extremities, and even general anasarca. From pleural dropsy it is distinguished by the absence of movement in the liquid, by the less decided dulness and loss of respiration, and by the inter- costal depressions not being effaced even when the chest is distended, as it sometimes appears to be in the lower part, by the great engorgement of the lungs. Another diagnostic sign is the increase of the costal vibration under the voice in pulmonary oedema, while it is diminished or quite lost in pleural effusion. Pneumonia, which it resembles in some of the earlier signs of that affection, differs by its febrile symptoms, the local pain which generally attends it, and its peculiar very viscid rusty or bloody sputum, strikingly different CLASS III.] ASCITES. 307 from that of oedema of the lungs. It has been stated that the crepitation is not so fine as in pneumonia, and more indicative of a thin tiquid in the bron- chial tubes. Congestion of the lungs presents phenomena not unlike those of oedema; but the expectoration is more viscid in the former, and apt to be tinged with blood; while the external dropsical symptoms which usually ac- company the latter will aid in the diagnosis. The affection is sometimes rapid, and terminates fatally in a few days -. but more frequently it is chronic, and runs a long and variable course, together with the diseases of which it is a part or an effect. It may frequently be cured when dependent on causes which are not themselves irremediable. After death, the lungs do not collapse upon the opening of the thorax, have a yellowish colour, pit on pressure, and are less crepitant and heavier than in health. When they are cut, serum Aoavs out, or may be pressed out. like water from a sponge. The causes of (.edema of the lungs are the same as those of dropsy in gene- ral, and need not be repeated here. It not unfrequently accompanies pleural dropsy; and is apt to be found in old cases of disease of the heart, with anemic symptoms. There is nothing special in the treatment. If curable, it will yield to the diuretics, purgatives. Sec, employed in general dropsy. Article V. ABDOMINAL DROFSY The term ascites is now confined to dropsy of the peritoneum. Serous cysts within the abdomen often produce great distension, and imitate ascites in some of its most prominent symptoms ; bat they constitute a different affec- tion, having a different origin, and requiring a different treatment They are usually designated as encysted dropsy, or, when connected with the ovaries, ovarian dropsy. Though not strictly belonging to the present category in a correct nosological arrangement, they will be most conveniently considered in this place, from their apparently close relation to ascites. 1. Ascites. This is a frequent form of dropsy ; but my own observation does not accord with that of the authors who make it the most frequent. It commences usually with an uneasy feeling of fulness in the abdomen, to which the atten- tion of the patient is first called by finding his clothes too tight. The dis- tension is first observable in the lower portion of the abdomen when the patient is in the erect position, and disappears when he lies down. But it gradually extends, and. when the complaint is at its height, the whole belly is uniformly, and often very greatly swollen. The character of the tumefaction is known by the wave-like impulse imparted to the hand placed in contact with the side of the abdomen, when slight percussion is made with the fingers of the other hand upon the opposite side. The sensation produced is quite distinctive, and can scarcely be mistaken. But, when the quantity of water is very small, the fluctuation cannot be made sensible in this way. In such a case, it is sometimes rendered evident, in the manner recommended by M. Tarral. by making slight percussiou a few inches only from a finger placed upon the abdomen, or by applying the thumb and middle finger of the same hand upon the surface, and percussing by the index finger between them. The sound, moreover, yielded by percussion aids the diagnosis. This is flat over the region where the liquid is collected; and the extent of the liquid 398 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. may sometimes be measured by the extent of the dulness ; as the portions of abdomen unoccupied by it are resonant in consequence of the presence of air in the intestines. When the effusion is slight, the liquid may sink wholly in the pelvis, in the erect position, so as to escape notice whether by the fluctuation or dulness on percussion. In such a case the patient should lie on his right side, with the pelvis somewhat elevated. The liquid is thus made to fall into the side, and substitutes flatness on percussion for the natural resonance of the colon. (Balard.) As, in consequence of the air which they contain, the bowels are specifically lighter than the liquid, those portions which are loose have a tendency to occupy the part of the abdomen which is uppermost. Consequently the resonance will be strongest over the upper part of the cavity in the erect position, and about the umbilicus when the patient is on his back. Exceptions to the latter statement will be found in the instances, noticed by Dr. Watson, in which the bowels are bound down to the back of the abdomen by adhesions, or in which the distension is so great that the attachments of the intestines are too short to allow them to reach the surface of the liquid. Another circumstance which indicates the nature of the complaint is the swelling or bulging out of the sides of the ab- domen, with depression of the anterior surface, in the supine position. Some- times anasarcous swelling of the walls of the abdomen is so great that it might readily, without caution, be mistaken for ascites, especially as it some- times causes a sense of obscure fluctuation when the blows are gentle. But attention to the possibility of such an error is sufficient to prevent it. Besides the characters enumerated, the disease is attended with various symptoms, either belonging to dropsy in general, or the result of the organic derangements in which it originates. Of the former, are frequently thirst, scanty urine, a dry skin, more or less edematous or anasarcous swelling, and, when this is absent, general and sometimes extreme emaciation. The latter vary, of course, with the organic affection, and do not require to be mentioned here. Yarious functional disturbances result from the great mass of the ef- fused fluid. Not to speak of the disagreeable feeling of distension and weight, and the inconvenience of movement, the patient often experiences great dyspneea from the upward pressure of the diaphragm; nausea, colicky pains, and flatulent disturbance from the compression of the stomach and bowels; and, in the advanced stages, anxiety, occasional disposition to faintness, and feeble irregular pulse, from interference with the action of the heart. The tumefaction of the abdomen often becomes enormous; and is sometimes ap- parently increased by an anasarcous condition of the parietes. The veins on the surface of the abdomen are much enlarged, in consequence of the com- pression of the venous trunks within. Occasionally, the skin at the umbilicus is stretched and everted so as to form a small projecting pouch. Instances have occurred, in which the skin of the pouch alluded to has ruptured, and the fluid been discharged externally. A communication has also been knoAAn to take place between the cavity of the abdomen and the bowels, so as to allow the escape of the liquid in this direction. In unfavourable cases, the debility becomes at length extreme, the action of the heart fails, drowsiness some- times occurs, and the patient dies from syncope, or with symptoms of op- pressed brain. Dissection often exhibits a bleached appearance of the abdominal contents, as if from maceration in the effused liquid. Evidences of former inflammation of the peritoneum are also often presented, in whitish opaque or thickened patches, a granulated surface, various abnormal growths upon the membrane, and adhesion and bands from organized fibrin. The liquid is of various character, transparent and colourless; turbid and either whitish, brown, or reddish, with albuminous flakes or purulent admixture; thin, or viscid like CLASS III.] ASCITES. 399 syrup, or almost gelatinous; and sometimes fetid. The quantity differs from a few pints to several gallons. The affections with Avhich ascites might possibly be confounded are preg- nancy, tympanites, an enormously distended bladder, and encysted dropsy. In ordinary cases of pregnancy there can be no difficulty. But when the uterus, as sometimes happens, is greatly distended with serous fluid, so as to impart a decided sense of fluctuation to the hand, or when pregnancy is complicated with ascites, the diagnosis is occasionally embarrassing. In pregnancy, however, the abdomen remains more prominent when the patient is on her back, and does not so much bulge out laterally; the uterus, rising up anterior to the intestines, renders percussion dull at the umbilicus in the same position; and, when ascites coexists, the fluctuation is more distinct in the upper portion of the cavity, at the hypochondria, for example, than in the lower portion which is occupied by the womb. Some aid may also be derived from the history of the case, and the presence or absence of the menses; though the frequent suppression of this discharge in dropsy may deprive the sign of its value. The detection, by means of the stethoscope, of the action of the foetal heart would be quite decisive. Should other methods fail, an examination per vaginam by an experienced accoucheur would settle the question. After all, however, it is not so much the difficulty of the dia- gnosis, as the liability to form a hasty decision, without particular examination, and from the mere statements of the patient, that requires notice. Ludicrous, if not serious mistakes, have sometimes resulted from a want of thought on the part of the practitioner. Nothing is easier than the diagnosis between dropsy and pure tympanites. The absence of fluctuation, and the universal resonance in the latter affection are sufficient distinctions. But the two affections are often complicated, and in such a manner as to render it somewhat difficult to decide how much of the distension is tympanitic, and how much dropsical. Dr. Chapman has known ascites so often preceded by tympanitic distension as to have suggested to him the idea, that an aeriform secretion is sometimes converted into a liquid. (Am. Journ. of Med. Sci,i. 161.) The relative degree of fluctuation, and of resonance on percussion, must decide the question as to the relative amount of liquid and air present. Fluctuation, and flatness on percussion must be sought for in the most depending parts of the abdomen. In relation to the distended bladder, it is only necessary that the young practitioner should be alive to the possibility that it may be mistaken for ascites, and to the fact that such a mistake has been made, in order to avoid it. The history of the affection, its attendant symptoms, the regular outline of the dulness in the lower part of the abdomen, and the pain on pressure, would sufficiently distinguish the distended bladder; and, if there should still be doubt, it Avould be at once removed by the introduction of the catheter. The diagnosis between ascites and encysted dropsy will be given, when the latter affection is considered. It is said that the dropsical effusion is some- times confined to the inner lamina? of the omentum, and that a large sac has been formed by the unfolding and dilatation of its cavity. But such cases are exceedingly rare; and could be recognized only after death. It is often important to decide, in cases of abdominal dropsy, whether it has arisen from organic derangement, and if so, what is the nature of that derangement. In forming his judgment, the practitioner will be guided by the symptoms, mingled with those peculiar to dropsy, which characterize the various affections that give origin to this disease. A careful examination of the abdomen will often throw light upon the subject. From abnormal hard- ness under the hand, circumscribed dulness on percussion, tenderness upon pressure, movements within the abdomen corresponding with changes in the 400 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. position of the body, even from irregularities in the outline of the abdomen, the practitioner will be enabled occasionally to draw important inferences as to the existence of an enlarged or indurated organ, or some morbid structure, concerned in the causation of the disease. Dr. Watson speaks of a sensation experienced when sudden pressure is made by the points of the fingers in a direction perpendicular to the surface, a sensation neither to be described nor mistaken, as of the displacement of a liquid, and the impinging of the fingers upon a solid substance. This is a valuable aid in the detection of enlarge- ment of the liver or spleen, ovarian tumours, and other morbid growths com- plicated with ascites. The same result may be obtained, in cases of movable tumours, by putting the patient into such a position that his abdomen shall be dependent, and pressing quickly upward with the ends of the conjoined fingers. The presence of a solid body within the cavity is rendered obvious by the sensation produced. Causes.—In relation both to the pathological condition and causes of ascites, there is little to be added to what has been said on general dropsy. When connected with pathological conditions of a general nature, or dependent on causes having a general action, such as debility, a morbid state of the blood, and organic affections of the heart and kidneys, it is most commonly asso- ciated with external oedema or anasarca. It is less frequently than anasarca of renal origin. When unaccompanied with dropsical effusion elsewhere, it depends, for the most part, either on a special irritation or inflammation of the peritoneum, or upon some impediment to the portal circulation, inducing venous congestion of all the abdominal viscera. The latter is the most fre- quent origin of exclusive ascites. That it occasionally arises from peritoneal inflammation is proved by the abdominal pain and tenderness, and the febrile symptoms, which have sometimes been observed to precede its appearance, and by the phenomena exhibited upon dissection. It is more frequently the result of chronic than of acute inflammation. It is probable that tubercles in the membrane itself, and various abdominal tumours sometimes occasion ascites by sustaining an irritation or inflammation of the peritoneum. The same causes may also act by impeding the flow of blood in the ramifications of the veins, and thus inducing congestion. Obstruction or remora of the portal circulation may arise from a stricture of the vena portarum, or a dimi- nution of its caliber in consequence of pressure from without it. This is most frequently met with in the liver, and hence hepatic disease is generally recognized as the most frequent cause of ascites. Enlargement of the liver from chronic inflammation or degeneration, cirrhosis, scirrhus, and tubercles, all produce it. Those conditions of the viscus are most effective, which per- vade its whole substance, and consequently everywhere compress the ramifi- cations of the portal veins. Hence, cirrhosis is one of its most frequent and fatal causes. The enlarged spleen and mesenteric glands, scirrhus of the pylorus, diseased pancreas, ond other tumours may possibly act in the same way, by diminishing the capacity of the portal vein or its tributaryjjranches; but, as before stated, they probably also act quite as much by sustaining irri- tation of the peritoneum. Prognosis.—Ascites, when dependent upon the same causes as external dropsy, and associated with it, is very often cured. When it exists exclu- sively, it is apt to be much more obstinate, because connected with affections of an intractable or incurable character. But even in this form, those writers go too far who affirm that it rarely gets well. It is true that, in very many cases, it is altogether unmanageable, and ends sooner or later in death. It is true also that, even in cases in which the fluid may be removed by general treatment, it often returns, because the root of the disorder has not been reached. But, nevertheless, instances of recovery are not uncommon. They CLASS III.] ASCITES. 401 have repeatedly occurred within my own observation. This result may be looked for with some confidence when the effusion depends upon simple peri- toneal irritation from checked perspiration, repelled eruptions, &c. ; and it not unfrequently happens in cases of tumefaction of the liver, from simple chronic inflammation. Occasionally a spontaneous cure takes place by the re-establishment of the urinary secretion, or the occurrence of copious dis- charges from the skin or bowels. A case is recorded in the London Lancet (March, 1842), in which a radical cure was effected by profuse sweating from the abdomen, which came on spontaneously. M. Dalmas witnessed the cure of ascites, in an infant, from the rupture of a pouch which had formed at the umbilicus. (Did. de Med., iv. 202.) Treatment.—This is to be conducted according to the plan detailed under general dropsy. Perhaps the most efficient remedies for the removal of the fluid are the hydragogue cathartics. Elaterium will sometimes act like a charm. But the debilitating effects of purgatives cannot ahvays be borne, and it is necessary to resort to the diuretics. Bitartrate of potassa often an- swers an admirable purpose. But, whatever remedy is employed for the evacuation of the serum, it is often essential to conjoin with it the use of mercury, especially when the disease originates in chronic inflammation of the liver. The mercurial should be cautiously employed, so as but slightly to affect the gums, and should be persevered in for a long time, occasionally for months. Some recommend, under similar circumstances, the use of iodide * of potassium; but this should never be relied on to the exclusion of mercury. Frictions with iodine ointment daily, or twice a day, over the region of the tumefied liver, may be employed. When the liver is affected with tubercles, cancer, or cirrhosis in its advanced stage, little good can be expected from these or any other remedies; but, in the uncertainty as to the precise con- dition of that viscus, it would be best to give the mercurial a fair trial, in the hope that the affection might be of a nature amenable to its influence. Dr. Christison and other practitioners of Edinburgh, imitating the practice of MM. Brera and Chrestien, of Montpellier, in France, have made use of digitalis externally with great benefit. A convenient mode of using it is to apply over the abdomen a cloth of spongy texture, soaked with an infusion of the leaves, made in the proportion of one ounce to twenty fluidounces of boiling water. The cloth should be worn steadily, and the evaporation of the liquid may be prevented by a covering of oiled silk. Its diuretic effect is usually produced in a few days. (Ed. Month. Journ. of Med, Sci, Oct. 1850, p. 312.) Should symptoms of inflammation exist, cups and blisters to the abdomen should be resorted to ; and a large blister will sometimes be found advan- tageous under other circumstances. Care, however, should be taken not to apply it in cases of great debility, or enormous anasarcous distension, for fear of gangrene. Well regulated compression of the abdomen by means of bandages has sometimes been of undoubted advantage. It is applicable to the earlier stages, before the distension has become so great as much to embarrass respi- ration. Dr. Gerhard has found this remedy, combined with the warm bath, very effectual. (Med. Exam., v. 209.) According to Dr. Dubini, in cases not encysted, and not attended with edematous extremities, it will, in the majority of instances, remove not only the effused liquid, but its cause ; and he has often succeeded admirably with its aid, in cases in which remedies had previously been ineffectual. (Braithwaite's Retrospect, Am. ed., xxi. 32.) Tapping has been much employed, and various opinions have been ex- pressed of its advantages. While some allow it only as a last resort, merely to obtain temporary relief when all ordinary means have failed, others have recommended it as a remedy, capable, in some instances, of effecting cures. 402 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. There can be no doubt that permanent cures have, in some rare cases, fol- lowed this operation; and the opinion held by some, that, by removing pres- sure from the kidneys, it favours the action of diuretics, is probably not entirely without foundation. Nevertheless, it very generally fails to do more than yield temporary relief; and the liquid accumulates again, often even more rapidly than before, so as to render a frequent resort to the operation necessary. The quantity of serum which has been drawn off, and the number of times that tapping has been repeated in some instances, are astonishing. In a case of Storck's, twelve and a half gallons were evacuated at one opera- tion : Dr. Beall, of Missouri, records a case, in which the operation was performed ninety-six times in the course of a few years, and the whole amount drawn off was two hundred and seventy-five gallons and a half; and a case was reported by M. Lecanu to the Paris Royal Academy of Medicine, in which a woman was tapped eight hundred and sixty-six times, and ultimately recovered under compression of the abdomen. (Dunglison's Notes to Cyc. of Pract. Med.) Nor is paracentesis without danger. Leaving out of the question the instances in which the intestines or uterus have been wounded, and an artery divided, there is occasional danger from inflammation of the peritoneum, and the operation has repeatedly been followed by fatal effects. It is probable, moreover, that, in most of those cases in which cures have fol- lowed it, the same result might have been obtained from other treatment. On the whole, it seems advisable to resort to paracentesis only when it be- comes necessary, from the failure of purgatives, diuretics, compression, &c, to afford the patient relief from great oppression, or to postpone for a period the fatal termination. In the performance of the operation, it is import- ant, as the fluid escapes, to make compression of the abdomen by means of a bandage, so as to supply artificially the pressure of the viscera to which the patient has been so long habituated, and the sudden withdrawing of which has repeatedly proved fatal when this precaution has been neglected. The evacuation of the fluid by means of acupuncture has been recom- mended, and is said to have been sometimes very successful. It is stated that the fluid escapes from the cavity of the peritoneum into the external cellular tissue, and is there absorbed. Dr. Pritchard employs a grooved needle, and has found it less painful than the ordinary trochar, and not less effectual. But for particulars as to the mode of performing the operation, the reader is referred to the works upon surgery. The plan of injecting stimulants into the cavity of the abdomen, as in the radical cure of hydrocele, has been recommended; but the hazard of fatal inflammation, in ordinary cases, greatly overbalances the prospect of benefit. A pupil of the author, however, Dr. John B. Sherrerd, formerly of Belvi- dere, New Jersey, recorded, in his inaugural essay (January, 1845), a case of apparently desperate abdominal dropsy in a female, in which Dr. Clark, of the same place, after tapping, injected a decoction of oak bark into the cavity of the abdomen, with the result of effecting a perfect cure. A case Ayas reported by M. Leriche, of Lyons, in which the injection of an ounce of tincture of iodine, and a drachm of iodide of potassium, with eight ounces of water, into the abdominal cavity, immediately after tapping, in a case of ascites, was followed by recovery (Med. Times, May 29, 1847); two other cases were afterwards treated successfully, in the same way, by the same practitioner (Arch. Gen., 4e ser., xxiii. 78); and the operation has since been repeatedly performed by different practitioners with variable re- sults. ^ Dr. E. P. Bennett, of Danbury, Conn., succeeded in curing a case, in which the abdomen was filled with a gelatinous matter, by making an in- cision three inches in length below the umbilicus, removing the matter, then washing out the cavity thoroughly with warm water, injecting four ounces of CLASS III.] ENCYSTED DROPSY. 403 tincture of iodine, and, after this had escaped, introducing a leaden tube so as to maintain a fistulous opening. (See Am. Journ. of Med. Sci., April, 1857, p. 556.) M. Tessier recommends that the cavity should not be emptied before the injection of the iodine, which is thus, by its diffusion through the liquid, prevented from acting too powerfully. If, however, the abdomen be very much distended, he performs a preliminary tapping, in order to diminish the extent of surface. He varies the strength of the in- jection according to the alkalinity and albuminosity of the liquid, throwing in from five drachms to an ounce of the tincture of iodine and half a drachm of iodide of potassium, when the liquid is clear and but slightly alkaline or albuminous, and twice the quantity when it is decidedly otherwise. (Gaz. Med. de Paris, Avril 22, 1854.) The operation should not be performed so long as there is any chance of relieving the patient by other methods, and is contraindicated whenever the abdominal dropsy depends on causes operating on the system at large, or through the heart, kidneys, or liver. 2. Encysted Dropsy.—Ovarian Dropsy. In this affection, the liquid, instead of occupying the cavity of the perito- neum, is contained in cysts morbidly developed within the abdomen, and gradually increasing in size until tumefaction becomes obvious to the eye, and fluctuation is discoverable upon examination in the usual manner by the hand. These cysts are produced either in the substance or upon the surface of the organs, and are supposed sometimes to originate as hydatids. Their most common attachment is to the ovary, or some of the uterine appendages, as, for example, to the broad ligaments; and, in such cases, the name of ova- rian dropsy is applied to the affection. The cysts which spring from the ovary are either the morbidly dilated Graafian vesicles, or new formations within the substance, or upon the surface of that organ. In some instances, it seems as if the whole ovary had under- gone this process of dilatation, and been converted into a sac with numerous cells. The cyst has sometimes only a single cavity, sometimes several, which may either communicate or be quite distinct; and occasionally it appears to consist of two or more distinct sacs which have coalesced. It may either be unconnected, except at the place of its origin, or may have formed adhesions with the contiguous structures. The cyst sometimes attains an enormous magnitude. Cases are on record in which the fluid contents are stated at from 100 to 120 pounds, and one in which the cyst is affirmed to have mea- sured six feet in circumference. The contents are exceedingly diversified in colour and consistence. They may be colourless, yellowish, brown, or milky; limpid like water, or turbid; thin and serous, or slimy, ropy, and gelatinous. They are described also as occasionally puruloid, bloody, oleaginous, even cretaceous or cheesy in consistence, and variously resembling the lees of wine, coffee-grounds, and molasses. It sometimes happens that the different cells of the same cyst have different contents. The affection is usually slow in its progress, and for a long time attended with little disturbance of the general health, though the menses are often irregular, and, when both ovaries are affected, are said to be almost invaria- bly suppressed. Sometimes it continues for thirty years or more before it terminates fatally, and persons affected with it not unfrequently attain a tolerably advanced age. But, in other instances, it is much more rapid in its progress, and destroys life in a few years. This is said to happen most fre- quently when it attacks the young and robust. The age at which it is most common is about that of the cessation of the menses. Married women are said to be more frequently attacked than the single; but this difference may be only apparent, and dependent on the much greater number of the former. 404 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. Dr. Magnus Huss, of Stockholm, has recorded a case in Avhich ovarian dropsy seemed tO be periodical, at first appearing in the interval of the menses, and disappearing at the time of the flow, and ultimately, though never entirely absent, yet increasing and diminishing under the same cir- cumstances. (Arch. Gen., Juillet, 1857, p. 1.) In its advanced stages it is apt to be attended Avith oedema of the extremi- ties, consequent on the interruption of the venous circulation by the bulk of the tumour. It may prove fatal by impeding respiration, by exciting perito- neal inflammation, or by an inflammatory action in the cyst itself, ending sometimes in suppuration, ulceration, and fistulous openings. Occasionally the cyst opens externally, occasionally into the cavity of the peritoneum; in either case generally terminating unfavourably, though spontaneous cures are said to have resulted in some rare instances of this kind. In one instance, the cyst was ruptured from external violence, and its contents poured into the peritoneal sac, where they were absorbed, and the patient recovered. In other cases of encysted dropsy, the cyst springs from the liver, spleen, or some other portion of the peritoneal surface. In this case, it often pro- bably originates in hydatids. I once witnessed the post-mortem examination of a case of this kind, in which the abdomen had become, in the course of many years, enormously distended, and, upon being opened, was found filled with numerous cells of various sizes, the walls of which were in every stage of development, from the state of delicate translucent membrane to that of a thick, rough, opaque, fleshy structure; and, in some of the cells, small trans- parent hydatids were found of various magnitude. Diagnosis.—The most important point for the practitioner, in relation to encysted dropsy, is to be able to form a correct diagnosis between it and proper ascites. This is not always easy when the former affection is in an advanced stage, and the cyst single, and distended so as to fill the abdominal cavity. But in general there is little difficulty. At an early period, the dis- tension, as well as the dulness on percussion, is confined to one portion of the abdomen; being observed, in ovarian dropsy, in the iliac fossa upon one side, and, when the cyst is of hepatic origin, in the upper part of the cavity. When the cyst is loose, it varies its position somewhat when the patient moves from side to side; but does not spread out uniformly, like free liquid, in obedience to the laws of gravitation. In ascites, the distension is first observed in the pubic region in the erect posture; but, in the recumbent, passes to the back portion and sides, which, when the effusion is considerable, swell outward, while the prominence of the abdomen is depressed. This lateral distension on both sides is not observed in encysted dropsy. In the advanced stage of the latter affection, the surface of the abdomen is generally uneven and some- what tuberculated, from the unequal development of the cells of the cyst. The fluctuation is usually much more obscure than in ascites. But percus- sion affords, perhaps, the best means of diagnosis. In encysted dropsy, par- ticularly the ovarian, the intestines are pushed to one side, or crowded into the back part of the abdomen; while, in ascites, they float on the top of the liquid. Hence, in the former, the percussion will be dull upon one side and in front of the abdomen, while it may be resonant on the other side, and will generally be so in the back of the abdomen. In the latter, the resonance should be in the upper part of the abdomen when the body is erect, upon the anterior surface about the umbilicus when it is horizontal. Exceptions to the latter fact are the instances before alluded to, in which the distension is so great that the intestines cannot reach the surface, or in which the bowels are bound to the back part of the abdomen by adhesions. Some value also belongs to the constitutional symptoms. In encysted cases there is, for a long time, little of that disturbance of the functions which CLASS III.] DISEASES OF THE SKIN. 405 usually attends dropsy. There is, for example, no peculiar thirst, dryness of the skin, or scantiness of urine. The patient retains a better appetite, and undergoes less emaciation than in ascites. The inconvenience arises chiefly if not exclusively from the mere distension. Treatment.—Little need be said upon this point. All the remedies found useful in dropsy, have been tried in this affection, and proved of little avail. The object of the practitioner should be to render the patient as comfortable as possible. Inflammation in the sac will be obviated by leeches, blisters, fomentations, emollient poultices, and cathartics, while the pain will be re- lieved by anodynes. Sometimes a gentle mercurial course may prove useful; and the preparations of iodine have been recommended. Frictions with iodine ointment over the tumour, steadily persevered in for a long time, may pos- sibly be productive of benefit. When the distension becomes very great, and exceedingly inconvenient if not dangerous, tapping may be resorted to. The operation must be performed in the centre of the most prominent portion of the abdomen, unless there may be reason to fear the division of an artery. This is necessary in consequence of the frequently cellular character of the cyst. But the operation is not without danger, and is never more than pal- liative, requiring in general to be frequently repeated, as the cavity rapidly fills up. The dangers are of effusion into the peritoneal cavity, of inflamma- tion of the cyst itself, of wounding some important organ, or of opening an artery. The operation should not, therefore, be inconsiderately resorted to. In some cases, cures take place in consequence either of the bursting of the cyst from violence, and the absorption of its contents, or of. inflammation of its inner surface, correcting the tendency to secretion, or giving rise to adhe- sion of its surfaces, and obliteration of the sac. Mr. Bainbridge, of Liverpool, effected a cure of this affection by making an incision into the cyst through the abdominal parietes, and keeping it open by means of a plug until sup- puration was established ; and he subsequently published the history of eigh- teen cases, which had been treated successfully by various practitioners upon the same principle. (See Am. Journ. of Med, Sci, N. S., xiv. 231.) In 1846, Dr. Allison, of Spencer, Indiana, cured a case of ovarian dropsy by injecting a solution of iodine into the sac. (Med. Examiner, N. S., iii. 459.) Dr. Simpson, of Edinburgh, has since repeatedly performed the operation, employing the undiluted tincture of iodine of the Edinburgh Pharmacopoeia, of which two or three ounces were usually thrown into the cyst. No serious constitutional symptoms followed, and in general little pain was suffered. In two or three cases the operation appears to have been successful; but it failed in a large proportion. (See Am, Journ. of Med. Sci, N. S., xxviii. 259.) In October, 1852, Dr. Boinet addressed a memoir on the subject to the French Academy of Medicine, in which he recommended the operation as always safe if properly performed, often successful in the cure of the affection, and, when this cannot be effected, always palliative. (Arch. Gen., ie ser., xxx. 483.) Two cases, however, have been reported in the London Medical Times and Gazette in which it proved fatal. (Feb. 1857, p. 138, and Nov. 1857, p. 508.) SUBSECTION II. DISEASES OF THE SKIN. The diseases of the skin described by medical writers are very numerous. Almost every diversity of morbid action in this tissue is obvious to examina- tion ; and various affections, which, judged of by their general effects alone, would appear identical, exhibit to the eye sufficient evidence of diversity to \ 406 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. authorize or require a distinct consideration. Were the diseases of the mucous membranes susceptible of the same close inspection, they might possibly be found equally numerous. Perhaps authors have carried their nicety of dis- crimination somewhat too far in relation to cutaneous affections; as the mul- tiplicity of names and distinctions tends to embarrass the learner, without always being of practical advantage. The treatment is governed not so much by trivial differences in the appearance of an eruption, as by the condition of the system, and intimate nature of the disease, which are not unfrequently the same, when the obvious phenomena differ. In the following remarks, therefore, I shall lay little stress upon many of the varieties which have been described, though, in accordance with general custom, I may deem it proper to notice them. But many of the cutaneous affections will be omitted in this place. Cer- tain functional derangements, such as excessive and deficient perspiration, and morbid heat and coldness of surface, occur almost always as symptoms of other diseases, to the history of which, therefore, an account of them properly belongs. Several highly important diseases of the skin are merely parts, though essential parts, of certain febrile movements; and, therefore, fall into the division of idiopathic fevers. Such are all the febrile exanthemata, as scarlatina, measles, smallpox, and not unfrequently erysipelas. Again, there are many skin disorders which are usually treated of in surgical works, the consideration of which in works on the practice of medicine would be useless repetition. Such are local erysipelas, furuncles, anthrax, cancer, and the dif- ferent external developments of syphilis. All these will be omitted. In the classification and nomenclature of complaints of the skin, I shall follow chiefly Willan and Bateman, though their arrangement is in some measure defective, as indeed every arrangement must be, until Ave become much better acquainted than we are with the nature and cause of these com- plaints. But no better system of classification has been proposed ; and, in regard to nomenclature, it is much better to retain the old, though not alto- gether acceptable, than to embarrass the learner by new names, which after all might not be deemed worthy of adoption. Modifications of their plan will be introduced, when rendered necessary by the progress of discovery since they wrote. The cutaneous diseases may be arranged in the classes of 1. rashes; 2. pimples ; 3. vesicles, including bullae ; 4. pustules ; 5. scales ; 6. tubercules; 7. discolorations; and 8. parasitic affections. To these, in order to include certain diseases which do not belong to either of the above categories, it is convenient to add a division of unclassifiable complaints. Rashes are characterized by a red, superficial efflorescence, diffused or in patches, disappearing under pressure, and commonly ending in desquamation. They are by some authors denominated exanthemata; but this term has also been applied to various other cutaneous eruptions, especially those attended with fever, and in the latter sense is employed in this work. Pimples (papulae) are small, somewhat conical elevations, pointed at the top, containing neither lymph nor pus, and ending usually in a scurf. Vesicles (vesiculse) are circumscribed elevations of the cuticle, containing lymph either limpid and colourless, or more or less opaque and whitish or pearl-coloured. When large, and consisting of a clear fluid separating the cuticle from the true skin, they are called bullae, blebs, or small blisters. Pustules (pustulae) are circumscribed elevations of the cuticle, containing pus. Willan and Bateman make four varieties ; viz. 1. phlyzacium, large, on a hard circular base of a vivid red colour, and followed by a thick, hard, dark scab; 2. psydracium, small, often irregularly circumscribed, but slightly elevated, terminating in a laminated scab, often clustering and confluent, and, CLASS III.] RASHES.—ERYTHEMA. 407 after the discharge of pus, pouring out a thin watery humour, which fre- quently forms an irregular incrustation ; 3. achor, small, pointed, containing a straw-coloured matter of the appearance and nearly the consistence of strained honey, and succeeded by a thin, brown or yellowish scab; and 4. favus, containing a more viscid matter than achor, with a frequently irregu- lar and slightly inflamed base, and ending in a yellow, semi-transparent, and sometimes cellular scab, like a honeycomb. But, in fact, the favus of Willan, as will be seen under the head of porrigo, is no pustule at all. Scales (squamae) are hard, thickened, whitish, opaque laminae of cuticle. Tubercules (tubercula) are small, hard, superficial, circumscribed, perma- nent tumours. They must not be confounded with the scrofulous or consump- tive tubercles.* Discolorations (maculae) are changes in the colour of the skin, produced by modifications of the colouring matter, independently of any other affection. Parasitic affections are those which depend essentially on the presence of microscopic animal or vegetable parasites. It is important that the learner should bear in mind, that the nosological divisions of cutaneous diseases are more or less abstractions. They will not by any means always be found in nature of the same precise and definite character as stated in the books. Certain striking cases may correspond sufficiently with the definitions; but, in numerous instances, they run into one another, so as to render discrimination difficult or impossible. Thus, the rashes are often mingled with papulous, vesicular, or pustular elevations; these latter are not unfrequently conjoined in the same case; and, in some diseases, the regular progress of the eruption is through the different states successively of pimple, vesicle, and pustule. Article I. RASHES. To this division belong, Rubeola, Scarlatina, Erysipelas, Erythema, Ro- seola, and Urticaria. By many writers, purpura is also included, but, for reasons before given, I consider that affection as belonging to diseases of the blood, and not to the cutaneous eruptions. Of the above-mentioned rashes, rubeola, scarlatina, and erysipelas belong to the idiopathic fevers. Only erythema, roseola, and urticaria are here considered. I. ERYTHEMA. This rash is characterized by superficial redness, generally in irregular patches of greater or less extent, sometimes nearly continuous, and not con- tagious. It may or may not be attended with constitutional disturbance. When strictly local, it arises from some direct source of irritation, as the contact of acrid secretions or excretions, continuity with inflamed mucous membrane, the friction of contiguous surfaces, continued pressure upon any portion of the body, and the application of rubefacient substances. In this form, it differs from local erysipelas mainly in its more superficial character, inferior intensity, and less disposition to spread. When produced by the * To distinguish these two kinds of bodies, which have nothing in common but their condition as small tumours, I have adopted the spelling of tubercule for the cutaneous affection, retaining the old name for the scrofulous tubercle; so that the reader may understand at once the meaning of the two terms respectively when he meets with them, without the necessity of being, on each occasion, specially guarded against mis- take. (Note to the fourth edition.) 408 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. friction of contiguous surfaces, it takes the name of intertrigo. This is apt to occur in the groin and axilla, in the cleft of the nates, beneath the mammae, and between the folds of the integuments in the neck and upper part of the thigh, in very obese adults after exercise, and in fat infants, especially when not frequently washed. The irritated parts often exude a thin viscid fluid, of a disagreeable smell, and, in the end, not unfrequently suffer excoriation, with much itching, heat, and other disagreeable sensations. Another kind of local erythema, is that which results from dropsical distension of the lower extremities. It is in smooth, shining, uniform patches, more or less conflu- ent, and is sometimes so considerable as to induce febrile action. In very feeble persons, it is apt to assume a purplish hue, and even to end in gan- grene. It is the erythema laeve of Willan. In the cases of erythema arising from constitutional causes, the affection generally occupies the face, limbs, or breast, but may occur in any other part, or even extend over nearly the whole body. It appears usually in irregularly circumscribed patches, sometimes quite distinct, but more frequently running more or less together, and occasionally quite continuous over an extensive surface. It is accompanied with a sense of heat, and sometimes with tingling; but seldom with burning or severe pain. There is usually little or no eleva- tion of skin; but the contrary is sometimes the case ; and, in one variety, the patches of redness rise into hard eminences of considerable size, which are not unfrequently tender and even painful. Sometimes there is considerable oedematous swelling of the neighbouring areolar tissue. The affection is often unattended with any obvious general disorder, though probably as often con- sequent upon some previously existing disease, and not unfrequently compli- cated Avith fever. In some instances, it is preceded or accompanied by depression of spirits, a feeling of debility, pains in the limbs, a frequent irri- tated pulse, and other evidences of nervous disturbance; and its sudden retrocession may give rise to various internal derangements. I have seen hemiplegia apparently result from this cause. It is irregular in its duration, sometimes lasting only two or three days, more commonly a week or two, but seldom becoming chronic. Occasionally it disappears and returns; and this may happen frequently, especially when it is connected with intermittent or remittent fever. It is sometimes distinctly intermittent, independently of any connection with a regular fever of that type. Upon retiring, it generally leaves more or less desquamation, and if it has occupied the scalp, the hair is apt to fall out. Willan and others make the following varieties; viz. 1. Erythema fugax, with irregular patches, appearing successively on the arms, neck, breast, and face, and disappearing in a short time; 2. E. laeve, above described as attend- ing dropsy of the lower extremities, though sometimes appearing in the limbs without oedema; 3. E. marginatum, in which the patches are bounded on one side by a hard, raised, tortuous, red border, sometimes obscurely papulous, without regular limits to the redness on the other side, uncertain in its dura- tion, and generally connected with some internal disorder; 4. E. circinatum, of a circular form, spreading at the circumference, and fading in the centre; 5. E. papulatum, consisting of small, definitely bounded and slightly promi- nent spots, somewhat papular in appearance, about as large as a small split pea, scattered upon the arms, neck, and breast, of a bright-red colour for the first few days, afterwards assuming a bluish hue, especially in the centre of the patches, and continuing for about two weeks; 6. E. tuberculatum, differing from the preceding mainly in the size of the patches, which are larger and more elevated, and subside in a week, leaving the redness, which becomes livid and disappears in another week, the affection being attended with fever, and much restlessness and irritability; and 7. E. nodosum, characterized by large, CLASS III.] RASHES.—ERYTHEMA. 409 oval, imperfectly defined patches upon the anterior parts of the legs, with their long diameter corresponding with the direction of the tibia, slowly rising into hard painful protuberances, afterwards softening, and subsiding in eight or ten days without suppuration, assuming a bluish colour as if bruised, and generally preceded or attended with febrile and nervous symptoms. Dr. Begbie considers this last form of erythema as closely analogous to rheuma- tism. (Ed. Month. Journ. of Med. Sci, May, 1850, p. 487.) It would require no great violence to reduce these varieties to three, E. fugax, E. papulatum, and E. nodosum; E. laeve being omitted as a mere local effect of distension of the skin.* Diagnosis.—The complaints with which erythema is most liable to be confounded are erysipelas and roseola. From the former it may be distin- guished by occurring more in patches, and being attended with less elevation or swelling of the skin, less burning and pain, and in general much less fever. It is also a much less serious affection. Roseola differs from it by its brighter rose-colour, the different arrangement of the eruption, which is often punctate, especially at the commencement, and not so much in continu- ous patches, and by the more frequent accompaniment of fever. Scarlet fever and measles have a somewhat similar eruption ; but erythema wants the pe- culiar course and accompaniments of these affections, and is not like them contagious. Its rash, moreover, is not crescentic or in splotches like the rube- olous, nor punctuated or widely and uniformly diffused as that of scarlet fever. * The E. tuberculatum of Willan appears to have been a mere attendant on a serious constitutional affection, which terminated fatally with hectic or hydrocephalic symp- toms, quite independently of the eruption. Dr. Elliotson, in his work on the " Prin- ciples and Practice of Medicine," speaks of one case which he had seen, in which the cutaneous affection disappeared, and was followed by paralysis and subsequently hec- tic, which proved fatal. The eruption was a trivial part of the disease. Under the name of " Erythema tuberculatum et osdematosum," Dr. Silas Durkee, of Boston, has described a curious chronic tuberculated affection of the lower extremities, beginning in small, hard, red elevations in the skin, gradually enlarging, and sometimes aggre- gating, so as to form masses of disease as large as the palm of the hand. The affection was attended with much edematous swelling. The tubercules were usually affected with vesication at the top, from which serous liquid continued to ooze for ten or fifteen days, after which the little tumours became flattened or depressed, in consequence of a destruction of the tissue beneath. The tubercules appeared to undergo a destructive disintegration, without suppuration; and, after a continuance of several months, during which portions of the subjacent tissue underwent a similar destruction, disappeared, leaving apeculiar " shrivelled or collapsed condition of the cuticle," marking the former site of the affection. The tubercules appeared in rapid succession until the whole leg and much of the thigh were covered with them. The patient ultimately died comatose. (Bost. Med. and Surg. Journ., April 17, 1856, p. 189.) The case above described is figured in the Va. Med, Journ. for September, 1856, p. 211. A somewhat analogous case is described in a subsequent number of the Boston Journal (April 17, p. 209), by Dr. H. G. Clark. It appears to me that the affection is entitled to be ranked rather with lupus than erythema; in consideration of its tuberculated character, chronic course, and tendency to the destruction of the part affected. M. Biett observed another variety, which he denominated E. centrifugum, and which is characterized by the mode of its extension, beginning by a point somewhere in the face, and gradually spreading in all directions, till it covers, perhaps, the whole cheek. In some instances, however, it occurs in distinct patches, more or less circumscribed, red, and prominent. It is without local sensation, unless when acute, and is then at- tended witli heat and pain. It is generally chronic, lasting, with various changes, some- times for years. On disappearing, it leaves a permanent cicatrix, or depression in the skin, but without preceding ulceration. It is a very rare disease, and has been trans- ferred bv Cazenave to Lupus, with which it much more closely corresponds in character than with Erythema. (See Lond. Med. Gaz., Nov. 1851, p. 858.) More recently it has been rendered probable by M. Chausit that the disease is really an atrophy of the seba- ceous follicles; and he proposes for it the name of atrophic acne, or Acne atrophica. (See note to Acne.)— Note to the fifth edition. vol. n. 27 410 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. When raised into wheals, erythema bears some resemblance to urticaria, from which, however, it is at once distinguished by the absence of the intense itching which characterizes the latter. The papulous form of it might be confounded with some varieties of lichen; but the smaller, rounder, firmer, and paler papula? of the latter, with the intense itching that often attends it, would sufficiently distinguish them. Care must be taken not to confound erythema with syphilitic eruptions. The greater duration of the latter, their coppery or grayish hue, and the general course of the disease of which they are a symptom, will serve as criteria. The causes of erythema are not ahvays evident. It is generally connected with a disordered state of system. It is apt to occur during dentition, and is occasionally produced by irritating substances in the stomach. Fevers and bowel complaints are occasionally attended with it during their course, or in the convalescence ; and it not unfrequently accompanies certain exanthema- tous fevers, such as smallpox, spreading over the skin in the intervals of the proper eruption. It is said also occasionally to have some connection with a deranged state of the menses. During the years 1828 and 1829, an epi- demic (acrodynia) prevailed at Paris, of which an erythematous eruption, with a thickening and desquamation of the cuticle, was one of the most pro- minent symptoms. I have seen a striking case of erythema in an individual affected with metastatic abscesses. The disease does not appear to be con- fined to any age, and occurs in both sexes. Treatment.—The treatment in local cases must be somewhat varied with the cause. If the erythema depend on acrid secretions, care must be taken to prevent as much as possible their contact with the skin, which should be protected by mild unctuous preparations, as the ointment of rose-water, sper- maceti ointment, &c. If the inflammation be considerable, lead-water may be applied. In cases of intertrigo, perfect cleanliness, frequent washing with cold water, separating the surfaces by a soft linen rag or otherwise, dusting the parts with some mild absorbent powder, as starch, tutty, calamine, or prepared chalk, the application of Goulard's cerate, or weak solutions of ace- tate or subacetate of lead, sulphate of zinc, or acetate of zinc, and, if the inflammation be considerable, mucilaginous or emollient applications, or what is, perhaps, the most effiacious, a strong solution of nitrate of silver, are the appropriate remedies. If the erythema proceed from pressure, this must be obviated by mechanical contrivances, and the skin protected by the common lead-plaster. Washing with spirit, or with a solution of alum in brandy, often modifies the condition of the skin so as to prevent this unplea- sant effect of pressure. In chronic cases, especially when there is excoriation, collodion may be usefully employed. It acts by excluding the air. When the local affection is connected with a morbid state of the system, or of the internal organs, little treatment is required, except what may be necessary to correct the disease in which it originates. The antiphlogistic regimen, antacid or saline laxatives, and, when there is fever, the refrigerant diaphoretics, as the antimonials and neutral mixture, are all that is required. Sometimes, when the pulse is very strong, it may be proper to take a little blood; but this is seldom requisite. Dr. Begbie has found quinia successful in E. nodosum. If the local affection be hot and painful, demulcent lotions, and the warm bath may be used. I have usually employed saturnine lotions in E. nodosum of the extremities. It is possible that leeches near the in- flamed part might be useful in obstinate cases. When the sudden retroces- sion of the eruption has occasioned unpleasant or alarming symptoms, a sinapism, blister, or other active external irritant should be applied to the portion of the surface which it had occupied. CLASS III.] RASHES.—ROSEOLA. 411 II. SCARLET RASH, or ROSEOLA. This is defined to be a rose-coloured efflorescence, variously figured, with- out Avheals or pimples, and not contagious. Roseola appears sometimes as a distinct exanthematous fever; sometimes as a mere symptomatic eruption. In the former case, it commences with slight febrile symptoms, which are attended with more or less gastric de- rangement, continue one, two, or three days before the appearance of the rash, and subside along with it. The eruption commences usually upon the face, neck, and breast, with specks or small patches, which sometimes remain distinct, but more frequently coalesce in a greater or less degree ; and oc- casionally the Avhole surface of the body, or large portions of it, are cov- ered with an almost uniform redness. The patient frequently complains of itching and tingling in the affected parts. The fauces are often red- dened, and the papillae of the tongue appear through a slight coating of fur. Sometimes there is a feeling of roughness and even soreness of throat. The eruption is generally of short continuance, sometimes lasting only a day or two, sometimes running on to the fourth or even fifth day, before it entirely disappears. It fades gradually, and is commonly followed with little or no desquamation. The efflorescence differs considerably in appearance. In some cases, it bears a close resemblance to that of scarlet fever in its punctuated character or general diffusion, and in its bright redness. In other cases, it is more like measles, with distinct, somewhat regular, slightly-elevated patches, of a darker hue. The patches vary in size from a mere speck to half an inch or even an inch in diameter. Occasionally they have the form of rings, with sound skin in the centre ; but this is comparatively rare. Sometimes the eruption disappears and returns, and, thus alternating, continues for a week or more before taking its final leave. When it recedes suddenly, symptoms of internal irritation occasionally appear, such as dis- ordered stomach, headache, giddiness, faintness, pains in the limbs, and de- jection of spirits, which are relieved by the recurrence of the rash. In some instances, these symptoms, and especially obstinate nausea and vomiting, precede for a time the appearance of the eruption, after which they subside immediately. The affection has been known to assume a chronic form ; the efflorescence coming and going at uncertain intervals, or fading in the morning to revive towards night; but such instances are rare. The itching and tingling which generally attend the eruption, are sometimes wanting. A roseolous efflorescence occasionally also occurs without fever. In no case is the affection contagious, and one attack does not secure against a second. Dr. Willan, with an unnecessary nicety, has made seven distinct varieties of roseola, founded either on the season at which the disease is most apt to occur (R. aestiva and .ft. autumnalis), on the form of the eruption (R. annu- lata), on the age of the patient (R. infantilis), or on the disease of which it is an attendant (R. variolosa, R. vaccini, and R. miliaris). The affection originates in a great diversity of causes. It often accompa- nies dentition. The vicissitudes of heat and cold in summer, the sudden checking of profuse sweat, the drinking of cold water during perspiration, are thought sometimes to cause it. It often results from gastric and intes- tinal irritation, and hence sometimes attends the bowel complaints of children, and dyspeptic affections in adults, and follows the introduction of irritating substances into the stomach. There is reason to think that it is occasion- ally provoked by gastric acidity. Copaiba sometimes produces a similar eruption, and I have seen it result apparently from the free use of dandelion. 412 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. It is not uncommon in smallpox whether natural or inoculated, and in vari- oloid, preceding the proper eruption in these complaints, sometimes cover- ing almost the whole surface, and disappearing in two or three days. In the varioloid, it is supposed to prognosticate a favourable character in the chief disease. I have seen it occur in that complaint very profusely, and be followed by only a single pustule ; and have reason to think that it has sometimes entirely replaced the original eruption. It has occasionally also been observed in the vaccine disease, appearing on the ninth or tenth day. Enteric or typhoid fever is sometimes attended Avith a roseolous ef- florescence, which, in such cases, is apt to be mingled Avith miliary vesicles. I have witnessed a case in which these two eruptions occupied jointly al- most the whole surface o'f the body; and both, in this case, came on after profuse sAveating. The patient recovered, though attacked with pleurisy upon the disappearance of the rash. Roseola sometimes attends rheuma- tism ami gout, and has been repeatedly observed in epidemic cholera, in the stage of reaction. It has been observed also in chronic pericarditis, but was probably an accidental complication. It sometimes occurs epidemically, and I have always noticed it most frequently during the prevalence of measles and scarlet fever. Diagnosis.—Roseola sometimes closely resembles erythema, and there is reason to believe that the tAvo affections often scarcely differ either as to their cause or nature. In decided cases, however, they may be readily distin- guished by the signs mentioned under erythema. It is more important to distinguish the complaint from scarlet fever and measles, with Avhich it is often confounded, and the more frequently from the circumstance that it is apt to prevail at the same time. It is probable that, in many of the cases in which scarlatina and rubeola are said to have occurred more than once in the same individual, roseola was mistaken for them. The tAvo former complaints are contagious, the latter is not. The precautions which are sometimes highly necessary in the one case, are superfluous in the other. Roseola is a comparatively trifling disease, and seldom need occasion anxiety; scarlatina is not without great apprehension of danger, either primarily or secondarily, even in its mild forms. In decided cases of the three complaints, there can be little difficulty in the diagnosis. Scarlet fever is attended Avith sore-throat, measles with catarrh, and roseola generally with neither. The fever and disturbance of system in the latter is much less, as a general rule, than in the former, especially scarlatina. The eruption of roseola is usually brighter, and the patches, while they are more regular than in scarlatina, are less so than in measles, and seldom have the crescentic character some- times observed in the last-mentioned complaint. Nevertheless, it is often impossible to discriminate between mild cases of scarlatina and roseola, es- pecially when the latter is accompanied with sore-throat; and, if it should be accidentally associated with catarrh, there might be the same impossibility to distinguish it from measles. It is only after the doubtful complaint is over, that a correct inference may be drawn from a general survey of its cause, course, and effects. Treatment.—This is very simple. The complaint will almost always ter- minate kindly without medical interference. In the severer cases, confine- ment to the house or chamber, a spare, cooling regimen, saline laxatives, magnesia if there is suspicion of acid in the stomach, antimonials or the neu- tral mixture if there is much fever, and the warm bath if the cutaneous irri- tation is considerable, are all that is requisite. Gentle friction with rye-meal may also be used to relieve the itching and tingling. Should the eruption recede, and unpleasant symptoms result, it should be recalled to the surface by external irritants, or the hot bath. At the commencement of the attack, CLASS III.] RASHES.—URTICARIA. 413 should the suspicion of scarlet fever be strong, an emetic of ipecacuanha may be given, and the bowels freely evacuated. At the worst, the treatment would be merely superfluous. In chronic cases, mineral acids and sea-bathing are said to have proved useful. III. NETTLE-RASH, or URTICARIA. This is a non-contagious affection, characterized by the cutaneous eleva- tions called wheals, which are usually surrounded by a diffused redness, and uniformly attended with itching, tingling, or other disagreeable sensation. Wheals are circumscribed swellings of the skin, of various shape and size, usually roundish or oblong, more or less hard, generally whiter, but sometimes redder than the healthy skin, containing no liquid, and having no tendency to suppuration. An example of them is offered in the small elevations which follow the application of nettles to the skin. Willan made six varieties of urticaria, of which three are recognized by Biett. There does not appear to be a necessity for any other division than into the acute and chronic. The acute form of the disease ( U. febrilis of Willan) generally commences with some fever, which precedes the eruption for two or three days, and is often complicated with signs of gastric and nervous disorder, such as head- ache, nausea and vomiting, pain in the epigastrium, anxiety, languor, faint- ness, and slight rigors. These symptoms commonly disappear upon the oc- currence of the rash, which presents itself usually in the form of erythematous patches of a vivid redness, with wheals rising irregularly in the midst of them. Being attended with excessive itching, it causes the patient to rub or scratch the skin, and thereby very much to increase the eruption, which will often, under this kind of irritation, break out upon apparently sound portions of the surface. It may attack any part of the body, but is generally most abundant upon the inside of the forearm, and about the shoulders, loins, and thighs. It often also attacks the face, and is said sometimes to appear on the inside of the mouth. The eruption comes and goes irregularly, often declining in the day, and returning in the evening, with slight febrile exacerbation, and coming on with peculiar violence when the patient undresses, and gets into bed. It has been said that the affection of the skin is aggravated by cold, and alleviated by warmth. The reaction produced in the surface after being cooled, no doubt often provokes the eruption; but I do not think that heat has any favourable influence upon it. The wheals last sometimes only a few minutes, at other times for several hours; and, on disappearing in one place, often return in another. In some instances they coalesce, giving rise to great tumefaction, tension and irregular hardness of the skin, and almost universal redness ( U. conferta of Willan). The attack generally lasts a week or ten days, with frequent remissions and exacerbations of the cutaneous affection, and the occasional occurrence, during its course, of various^ disturbances of system, such as have been mentioned as preceding the eruption. These are sometimes distressing, and even alarming upon a complete retrocession of the rash, and disappear upon its return. At the close of the attack, a slight desquamation of the cuticle usually takes place. In many instances, the eruption makes its appearance without previous fever. This happens especially when the disease proceeds from something taken into the stomach. In such cases, about an hour or two after the sub- stance has been swallowed, epigastric pain or uneasiness, nausea, ver- tigo, anxiety, &c, come on, and are soon folloAved by the eruption, which is occasionally very violent. The face, neck, and chest, sometimes even the whole surface of the body, are much swollen, with an almost universal ery- 414 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. thematous redness, interrupted here and there by single or clustered wheals; and the patient, along with an intolerable heat, itching, and tingling of the skin, suffers occasionally from oppressed breathing, which almost threatens suffocation. This violence continues only for a few hours, after which the complaint gradually subsides, and terminates usually in one or two days. In some cases, there is only redness of the skin, without the wheals. In the course of the affection, the patient often experiences severe pain in the stom- ach, nausea, anxiety, general distress, faintness, &c, alternating with or at- tending the eruption. The symptoms usually vanish very speedily after the stomach has been completely evacuated by means of an emetic or otherwise. Occasionally acute urticaria assumes a decidedly intermittent character, occurring in regular paroxysms every day, or every other day, either as an attendant on intermittent fever, or as an original affection. In the chronic form, there is no fever, and the eruption is not persistent, but appears and disappears irregularly ( U. evanida of Willan); being some- times absent for a considerable interval, and recurring from slight causes, as after violent exercise, or indulgence in the pleasures of the table. The wheals are usually whitish, and less apt than in the acute form to be surrounded by a red efflorescence, though attended with the tingling, itching, and stinging sensations characteristic of the disease. The patient often suffers more or less with the gastric and nervous symptoms before described. The duration of the complaint is very variable and uncertain, sometimes not exceeding a few days, and sometimes extending to months or years. Occasionally the wheals increase rapidly, and attain a considerable magni- tude, forming tumours in the loins, limbs, &c, sometimes as broad as the hand, and interfering with movement. These tumours are sometimes hot, tender, and painful, occur usually at night, and subside after continuing for a few hours, leaving behind them sensations as if the patient had been bruised or fatigued. This form of urticaria is the U. tuberosa. In other cases, the wheals, instead of lasting only a few hours or a day, persist for two or three weeks after the redness has disappeared, retaining more or less of their characteristic sensation, and at length gradually subside. They constitute Willan's U. perstans. It sometimes happens that the sensations bear no just relation to the amount of eruption; and Willan noticed a variety, which he called U. sub- cutanea, in which the patient suffers much from severe stinging pains as if needles were run into the skin, without any visible affection whatever, except an occasional eruption of wheals, which continue for tAvo or three days, and then disappear Avithout any relief to the morbid sensations. Diagnosis.—Urticaria is often mingled with other eruptive affections, such as erythema, roseola, lichen, and impetigo ; and it is not always easy to de- termine which is the prominent disease. But, when distinct, there is little difficulty in its diagnosis. The peculiar sensations which attend it, and the appearance of the wheals are, in general, sufficiently characteristic. Lichen urticatus, however, might without care be confounded with it, having both wheals, and the itching and tingling of nettle-rash. But the tumours in that complaint are smaller, less prominent, of a deeper colour, firmer, and much more persistent; and are always attended with true papulae, which cannot well be mistaken. (Cazenave and Schedel.) The tumours of erythema nodo- sum, though somewhat similar to the large wheals sometimes seen in urti- caria, are more durable, and without their disagreeable itching. The nettle-rash, though a very disagreeable and often troublesome com- plaint, is scarcely ever dangerous. Cases of death have been recorded, when the disease has arisen from substances taken into the stomach ; but it Avould be difficult to determine how far the result depended on the urticaria alone, CLASS III.] RASHES.—URTICARIA. 415 and how far on gastric inflammation or other internal disorder produced by the same cause. Causes.'—The most frequent causes of urticaria are internal irritations, especially of the stomach and bowels. It often attends dentition, and the bowel complaints of children. Acid and other irritant matters in the stom- ach frequently occasion it. Certain kinds of food have been long notorious as the occasional cause of nettle-rash. Of these, shell-fish, as lobsters, crabs, shrimps, and especially muscles of different kinds, are most apt to produce it. Salt and smoked fish have been accused by some writers; and it has been supposed that some fish are more poisonous at certain seasons than at others, as, for example, at the time of spawning. Particular parts of fish have also been supposed to be more noxious than others ; and Autenrieth concluded, from his researches, that the irritant principle exists in connection with the fatty matter. Other kinds of food, which have been enumerated as occasion- ally producing urticaria, are pork, mushrooms, honey, oatmeal, bitter and sweet almonds, raspberries, strawberries, and green cucumbers. The worst case of the disease which I have seen occurred in a woman from eating rasp- berries. She had been twice before attacked in the same manner from the same cause. The face, neck, and extremities were greatly swollen, and the respiration in the highest degree embarrassed ; but immediate relief was ob- tained by an emetic of ipecacuanha. Certain medicines also occasionally produce it, among which are mentioned valerian, copaiba, and the turpen- tines. I have seen it result also from pipsissewa (chimaphila umbellata). This susceptibility to urticaria from particular kinds of food or medicine is not general, but an idiosyncrasy of individuals ; and the food which will pro- duce it in one person will often not produce it in another, each person being liable to be affected by some particular substance. Over-exercise, strong mental excitement, indulgence in eating rich and high-seasoned food, and the intemperate use of stimulating drinks, sometimes produce attacks of urticaria. It is said to be most prevalent in the spring and summer ; yet some authors consider exposure to cold as a more frequent cause of it than heat. This can be readily understood, when it is recollected how much the face and hands of some persons swell and tingle during the reaction which follows exposure to cold. Peculiar delicacy of skin predisposes to the disease ; and some persons who have this character of surface are affected with it from the slightest causes. It is a not unfrequent attendant upon other diseases, especially fevers and febrile complaints ; and I believe that it is one of the forms in which those protean diseases, gout and rheumatism, occasionally show themselves. It is said sometimes to have prevailed epidemically. The disease occurs in all ages, from infancy upwards; but it is most com- mon in infants, and in young persons of the sanguine temperament, and at- tacks women more frequently than men, probably because their skin is more delicate, and Jess hardened by exposure. Treatment.—Little medical treatment is required in most instances. The avoidance of stimulating and indigestible food and drinks, and of everything especially which may be known to have disagreed with the patient, conjoined with rest and mild aperients, will, in general, be quite sufficient. As excess of acid in the stomach is often the source of the complaint, or at least serves to aggravate it, magnesia may be very properly employed as the laxative, either alone, or combined with one of the saline cathartics. Cool drinks should be given ; but lemonade, as recommended by some writers, is of doubt- ful propriety. When the fever is considerable, the neutral mixture, or small doses of tartar emetic may be used ; and it is possible that the lancet may sometimes be requisite. In gouty or rheumatic individuals, wine of colchi- 416 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. cum, in moderate doses, might be added to the other remedies. Should retrocession take place, with severe or alarming irritation, the disease should be invited again to the skin by stimulant applications and the hot-bath. In cases of great nervous disturbance, advantage may accrue from camphor- water, Hoffmann's anodyne, or other nervous stimulant. When the disease proceeds from any article of food, the stomach should be immediately evacuated by ipecacuanha, and the bowels aftenvards by a dose of sulphate of magnesia or castor oil; and, in severe cases of uncertain origin, it would be proper to employ the same treatment, as the offending cause would very probably be found in the stomach, and the emetic Avould at any rate have the probable effect of moderating the cutaneous affection. In chronic cases, which are sometimes very obstinate, Willan advises that the patient should abstain successively from the different kinds of food and drink which he had been in the habit of using, in the hope that the offending cause might thus be found and removed. In this way he frequently suc- ceeded in tracing the disease to its source, Avhich, in some, was malt liquors, in others spirit, in others wine, in others, again, vinegar, or fruit, or sugar, or fish, or raw vegetables. (Bateman's Synopsis.) Dr. Geo. Budd speaks highly of the efficacy of rhubarb, given in the dose of three or four grains, immediately before dinner or before breakfast and dinner, in cases disposed to recur frequently, in consequence of the influence of several articles of food conjointly. The addition of from half a grain to a grain and a half of ipecacuanha to the rhubarb, increases its efficacy. (Dis- eases of the Stomach, Am. ed., p. 216.) When the disease is very obstinate, and the habit of the patient plethoric, great advantage may be expected from the occasional loss of blood, and a rigid diet of bread and milk, so as to change the character of the circulating fluid. This treatment however should not be hastily adopted. In intermittent cases, sulphate of quinia will quickly effect a cure.' Full doses of the same medicine, continued for two or three days, are said to have proved promptly effectual in some of the worst forms of the disease, even when not periodical. Attention should, in chronic cases, always be paid to the general state of health. If the digestion is feeble, and the system debilitated, the simple bit- ters or sulphate of quinia may be used, associated, if there be acidity of stomach, with one of the alkaline carbonates. In other cases, the mineral acids have been found useful. Where other means fail, good may be hoped for from the arsenical solution. A most obstinate case of Urticaria tuberosa, which, for four years, had resisted various treatment, yielded, in the Hospital Saint-Louis, under M. Biett, to this remedy (Gazenave and Schedel.) A gentle course of mercury might also be rationally employed in cases of unusual obstinacy and continuance. It might be the means of removing some lurking internal inflammation, or of altering the character of the blood, and thereby removing the cause of the disease. The local treatment should be very simple in acute cases. Rubbing the skin gently with rye-meal sometimes affords partial relief. Cold lotions, as of spirit and water, vinegar, lemon-juice, and lead-water, should be very cau- tiously used, for fear of sudden retrocession. A case is related by Frank, in which fatal metastasis to the brain took place, in consequence of cold applied to the surface. The warm-bath, however, is safe, and may sometimes be ad- vantageously employed. Repeated daily in chronic cases, it is considered one of the most effective remedies. Alkaline baths, however, prepared with carbonate of potassa or soda, are said to be still more useful; and vapour baths, or the vapour douche, have been highly recommended. CLASS III.] PIMPLES.—STROPHULUS. 417 Article II PAPULOUS DISEASES. Syn.—Pimples, or Papulse. These have been generally considered as papillae, enlarged and somewhat indurated by inflammation. Erasmus Wilson believes them to consist in inflammation of the secretory orifices, whether sudoriferous or sebiferous. Plumbe thinks that they are the result of an effusion of coagulable lymph beneath the cuticle. Simon found them, under the microscope, to consist of slight elevations of the cutis, with the blood-vessels engorged with red cor- puscles, and the tissue infiltrated with a colourless fluid, more consistent than serum. In other words, they are the result of inflammation of minute isolated portions of the cutis. Willan and most writers after him, describe three papu- lous diseases: viz., strophulus, lichen, and prurigo. Some unite strophulus and lichen, considering the former as a mere variety of the latter. There is, indeed, no great difference between them; but, as strophulus belongs exclu- sively to infancy, there is a convenience in treating of them distinctly. None of the papulous affections are contagious. I. STROPHULUS. This is commonly called red gum when the eruption is florid, white gum when it is pale or whitish. It occurs usually in infants before or during the first dentition. The eruption is seated most frequently in the parts of the surface most exposed, as on the face, neck, arms, and hands; but it also fre- quently occupies other parts, and sometimes extends over the whole body. In its most common and simple form, it appears in minute florid pimples irregularly dispersed, with occasional specks or patches of redness without elevation, and sometimes a few small vesicles, especially on the extremities, which usually dry up without breaking. This is the S. intertinctus of Willan, and is observed most commonly in infants under two months. Sometimes, along with these red papulae, are mingled others of a whitish colour; and, when the irritation is slight, or the skin less than ordinarily vascular, the whole of the papulae have this appearance. Willan distinguishes two varie- ties of them, one which he calls S. albidus, characterized by minute, hard, slightly elevated whitish specks, with a little redness at the base, the other, S. candidus, having larger pimples, Avith a white shining surface, and no red- ness. In worse cases of the complaint (S. confertus of Willan), the eruption is more abundant, forming large, irregular patches, and sometimes rendering the whole surface occupied by it of a uniform redness. Occasionally there are, in these cases, much itching and pain, with more or less excoriation, especially when the eruption is seated in the thighs or lower part of the body, so that the affection resembles intertrigo. In another variety (S. volaticus of Willan), the eruption appears in small, circular, bright-red patches or clusters, which appear and disappear successively on different parts of the body, each patch turning brown, and beginning to exfoliate in about four days, and the whole continuing for three or four weeks. Strophulus is, with few exceptions, an acute disease, generally beginning to exfoliate and disappear in one or two weeks, and seldom continuing longer than a month. It is rarely attended with fever, and often occurs without any 418 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. observable disturbance of health. When febrile symptoms do occur, it is not always certain whether they are essentially associated Avith the eruption, or proceed from some other cause. Sometimes the papulae, when numerous, appear to occasion much distress to the child by their heat and itching, and these sensations arc increased when the surface is kept Avarm. The affection probably often depends upon causes acting directly upon the very irritable and vascular skin of the infant. Too great exposure to heat, rough flannel next the skin, the accumulation of filth upon the surface, whether from Avithout or from the infant's OAvn secretions, are causes of this kind. It is sometimes associated Avith disorder of the stomach and bowels, and often occurs as one of the results of dentition. But, in many instances, it is not possible to trace the affection to any known cause. Strophulus is almost always an innocent complaint. Its retrocession is thought sometimes to have been followed by serious internal irritations; but it is very difficult always to determine, in such cases, whether the disappear- ance of the eruption is cause or effect. Treatment,—Yery few remedies are required, and, unless the child appear to suffer, or the health to be otherwise disturbed, it would be better to do nothing, except to remove any obvious cause of the affection. The surface should be kept clean by frequent wrarm ablutions, the clothing should be of an unirritating character, and the infant should not be overheated. The diet also should be attended to; and, if the case is obstinate, it may be proper to change the nurse. When there seem to be much heat and itching of skin, relief may be given by the application of tepid milk and Avater, or mucila- ginous liquids, and the occasional use of the warm bath. The stomach and bowels should be attended to, and acidity, if existing, corrected by magnesia, the alkaline carbonates, or prepared chalk; one or the other of these remedies being employed according to the state of the bowels. Attention should also be paid to the condition of the gums. Cold applications to the surface should be avoided, lest they might occasion a sudden disappearance of the cutaneous irritation, and its translation to some interior organ. In the event of such translation, the warm bath, rubefacient lotions, and a few drops of aromatic spirit of ammonia internally, may be resorted to. In severe cases of stro- phulus, advantage is said to have accrued from an emetic. II. LICHEK Willan defines this to be "an extensive eruption of papulae, affecting adults, connected with internal disorder, usually terminating in scurf, recur- rent, not contagious." But this definition is defective; for the complaint frequently affects children beyond the age of infancy, and is by no means invariably connected with internal disorder. Willan enumerates seven varie- ties; and this number might be doubled, if every diversity of form Avere a sufficient ground for a nosological distinction; but for all purposes of prac- tical advantage, they may be included under the three following. 1. Lichen simplex.—This consists of small red pimples, about as large as the head of a pin, appearing usually on the hand, forearm, neck, face, and breast, but not unfrequently also elsewhere, and sometimes over almost the whole surface of the body. They are attended with heat, tingling, and itching in various degrees. Upon the face, they are often larger than else- where, and on the extremities are sometimes obscurely vesicular. Having continued stationary for several days, they begin to decline, and terminate usually with a slight scurf in one or two weeks. Sometimes, however, the attack is of much shorter duration; and sometimes, by the occurrence of CLASS III.] PIMPLES.—LICHEN. 419 successive crops of eruption, is prolonged for several weeks and even for months. In their course, the papulae frequently exhibit small bloody scabs upon their surface, arising from its abrasion by scratching In the more chronic forms of the complaint, they often scarcely differ from the skin in colour, but are always readily discovered by passing the fingers over the part affected. In these chronic cases, there is frequently much more desquamation, with some thickening of the skin; and the disease sometimes very much re- sembles psoriasis. When produced by the high temperature of summer, the complaint is com- monly called prickly heat, the L. tropicus of nosologists, which, however, is identical with the variety above described. It occurs in this country very frequently among boys, affecting especially their arms, neck, and breast. In tropical latitudes it is much more severe, most frequently attacking strangers from temperate climates, but by no means sparing the natives. The sensa- tions of tingling, itching, stinging, &c. which attend it, are described as scarcely supportable, giving rise to an almost irresistible propensity to scratching and locomotion, which only aggravate the irritation; and the best means of counteracting it are patience, quietness, and keeping cool, both physically and mentally. Sometimes the papulae occur chiefly or exclusively at the roots of the hairs, constituting the L. pilaris of Willan. In persons of scorbutic habit, or hemorrhagic constitution, they are apt to have a purplish or livid hue, which has given rise to the designation of L. lividus by the same author. Occasionally the papulae haAe a disposition to assume a circular arrange- ment, forming patches which are called ring-worms in the language of the common people, and L. circumscriptus in that of the learned These patches, at first small, gradually increase by the eruption of new pimples at the cir- cumference, whilst those in the centre fade and exfoliate. In some cases, they disappear spontaneously in a week or two; in others, continue for several weeks, slowly enlarging, and often running together. Willan states that this form of lichen is sometimes produced in adults by vaccination. Biett has described another form, which he names L. gyratus, in which the papulae are arranged in the shape of a somewhat tortuous band of consider- able length. In a case of this kind, alluded to by Cazenave and Schedel, the pimples, arranged in small groups, formed a kind of riband, which, setting out from the anterior surface of the chest, gained the inner part of the arm, and descended to the extremity of the little finger, following exactly the course of the cubital nerve. Lichen simplex is sometimes preceded for a short time by febrile symp- toms, which disappear when the eruption breaks out. Pains in the head or stomach, and other symptoms of internal disorder, also sometimes vanish under the same circumstances. But, in numerous instances, there is no con- stitutional disturbance whatever. 2. Lichen agrius.—This variety commences with fever, which subsides upon the occurrence of the eruption, though it does not always wholly dis- appear. The papulae are small, very numerous, red and inflamed, and clus- tered in large patches, which are surrounded, often to a considerable extent, by an erythematous redness of the skin. Occasionally small vesicles are in- termingled with the pimples; but they soon disappear. The eruption is usually more limited than in the milder forms of the disease, and is very seldom general. It occupies preferably the outer surface of the limbs, differ- ing in this respect from eczema, to which, in the advanced stage, it some- times bears a close resemblance. It sometimes also occurs in the cheek. The sensation of itching and tingling, general in lichen, is in this variety combined with burning and smarting pain, which is aggravated by the heat 420 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. of the bed, and by everything which has a tendency to excite or irritate the surface. The affection commonly remits in the morning, and undergoes ex- acerbation towards evening. After a few days, the tops of the pimples be- come slightly excoriated or ulcerated, and pour out a sero-purulent fluid, which concretes into small scabs. These are succeeded by minute scales, of a furfuraceous character, upon the separation of which the complaint may terminate, having run a course of two weeks or somewhat less. But often the surface remains more or less moist, or the scales fall and are replaced by others, or the eruptive affection vanishes for a time to return again; and thus successively for a period of several weeks, until at length the complaint exhausts itself, the sero-purulent discharge gradually diminishes, a dry furfuraceous surface succeeds, and the skin returns to a healthy state. In the moist state alluded to, the eruption resembles eczema or impetigo; and it is supposed by Willan, after repeated attacks, to terminate occasion- ally in the latter affection, though this is denied by others. During the pro- gress of the complaint, the skin is often thickened, chapped or fissured, and very painful upon being rubbed or otherwise disturbed. L. agrius some- times occurs originally in this form, and is sometimes a mere aggravation of the milder affection. 3. Lichen urticatus.—This variety is distinguished by the occurrence of small tumefactions, which are rather inflamed wheals than pimples, and resemble those produced by the bites of poisonous insects, or the sting of the nettle. These, however, subside in a day or two, and are followed by true papulae; while other wheals appear, to be in their turn succeeded by papulae ; so that at length the whole surface may become covered with the pimples, which are more or less confluent. Both the wheals and papulae are accompanied with extreme itching. The affection is usually obstinate. Bateman says that it is peculiar to children, occurring sometimes soon after birth, and continuing many months. Others have observed it in adults. It occasionally follows vaccination, and is ascribed by parents to that opera- tion ; but the association is probably quite accidental. It sometimes disap- pears and again returns, and ultimately terminates in desquamation. Causes.—One of the most frequent causes of lichen is heat. Hence, it commonly occurs in the warm seasons and in hot climates. Some persons are liable to a return of it every summer. It is brought on by exposure to the sun, by severe exercise, and by the use of stimulating drinks and condi- ments. The contact of certain stimulating powders with the skin may also induce it. Causes which disturb the general health, such as long watching, bad diet, and the abuse of alcoholic liquors, are thought sometimes to pre- dispose to it; but it probably more frequently occurs in persons in robust health. Like many other cutaneous affections, it is occasionally associated with irritations of the alimentary canal, evinced by disordered digestion, nausea or vomiting, and diarrhoea. It is sometimes a sequela of acute fevers. It affects persons of all ages, and of both sexes, but is most fre- quent in adults. In its milder forms, it would receive in suckling infants the name of strophulus. The diagnosis of lichen is often very difficult; as there are numerous cuta- neous affections to which, in some one of its forms or stages, it bears a more or less close resemblance. It has been mistaken for measles and scarlatina; but a moderate attention to the well-known characteristics of these several affections would leave no room for doubt. Sometimes it appears to be min- gled with these exanthemata. Enough has already been said of its relation to strophulus. The distinctive characters of prurigo, to which it bears a close analogy, will be mentioned under that head. L. urticatus might be confounded by careless observers with papulous erythema and urticaria, the CLASS III.] PIMPLES.—LICHEN. 421 diagnosis of which has been given under the heads of these complaints re- spectively. The occasional resemblance of lichen to eczema, impetigo, and psoriasis has already been pointed out. From the intense itching which attends it, and the frequent appearance of little bloody scabs upon the tops of the papulae in L. simplex, produced by scratching, it might be mistaken for the itch. In its ring-worm form, it might without care be confounded with herpes circinatus. For the diagnosis between lichen and these seve- ral complaints, the reader is referred to their respective titles in this work. Finally, this complaint, in the form of L. urticatus, bears some resemblance to certain syphilitic eruptions. The latter are distinguished by their copper colour, the absence of inflammation, their much less degree of itching, their greater permanence, and the circumstance that they are very frequently ac- companied, or were preceded by other characteristic symptoms of syphilis. Treatment.—Little general treatment is required in the ordinary acute forms of the disease. It is chiefly important to avoid the causes. The pa- tient should remain as much at rest as possible, avoid exposure to the sun, dress rather lightly in hot weather, and live moderately as regards food and drink, shunning rich meats, stimulating condiments, and all kinds of alcoholic liquid. All substances which may have directly irritated the skin, should be guarded against. If febrile symptoms attend the complaint, saline laxatives and refrigerant medicines may be given, though profuse diaphoresis is con- traindicated. In all cases, the bowels should be kept regularly open. In Lichen agrius, it may sometimes be advisable to take blood once or twice from the arm, and to apply leeches in the vicinity of the inflamed part. A strict antiphlogistic diet should be enjoined in the early stages of this variety. In the advanced stages of lichen, when the complaint has become chronic, and even at the commencement, if the system is feeble, as in L. lividus, it may be proper to give tonic medicines, as the mineral acids, sulphate of quinia or infusion of Peruvian bark, and the chalybeates; and the diet should now be nutritious. In very obstinate cases of long duration, some one of the arsenical preparations may be resorted to ; and Fowler's solution, Pearsou's solution, and the Asiatic pills have all been recommended. Devergie strongly recommends the tincture of cantharides, and has employed the alkaline reme- dies, both internally and externally, with much success. The local treatment is quite as important as the general. In the early stages irritant applications should be avoided; nor should cold be too freely employed, from the fear of retrocession, and the production of internal dis- order. Plumbe has observed an acute disease with great heat and thirst, frequent pulse, vomiting, pain in the bowels, headache, and delirium, follow imprudent exposure to cold in this complaint. The best local applications are demulcent washes, such as infusion of flaxseed, slippery elm, or sassafras pith, and emulsion of bitter almonds. The last-mentioned preparation is thought to be more effective in consequence of its hydrocyanic acid; and this acid itself, much diluted, has been recommended as a lotion. Lime-water, and solution of acetate of ammonia have also been found useful; and lotions of diluted vinegar sometimes yield relief. In the severer forms, the blandest oleaginous substances should be used, such as the ointment of rose-water, or pure and perfectly sweet almond oil. Glycerin is also a good application. Powdered starch may be employed. Wilson has derived benefit, in Lichen agrius, from the application of collodion; and still better, as it contracts less in drying, is a solution of gutta-percha or caoutchouc in chloroform. The Avarm bath is very useful; but care must be taken that it is not so hot as to be in any degree stimulating. M. Chausit strongly recommends a solution of aloes in glycerin, applied daily by means of a pencil. He has found it peculiarly useful in the excoriations and fissures of the skin frequently attend- 422 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. ant on lichen agrius. He prepares it by evaporating from four to eight parts of tincture of aloes till the alcohol is all driven off, and then adding gradu- ally thirty parts of glycerin. The first effect is usully a smarting sensation, which soon passes off. Five or six applications at most are sufficient to cause obstinate fissures to heal. (Gaz. des Hop., 1857, Nos. 50, 62.) When the disease has become chronic, sulphurous or alkaline baths may be substituted with advantage for the simple warm bath. For the prepara- tion of the alkaline bath, carbonate of potassa or carbonate of soda may be dissolved in water, in the proportion of an ounce to the gallon. These salts may also be used in the form of lotion or of ointment; two or three drachms to the pint of water being employed in the former shape, and from ten to fif- teen grains to the ounce of lard in the latter. The sulphur vapour-bath has been recommended by Plumbe. When the eruption has reached the furfura- ceous state, and continues obstinate like psoriasis, stimulating applications may be employed, as ointments of calomel or protiodide of mercury, of corro- sive sublimate in the proportion of fifteen or twenty grains to an ounce of lard, citrine ointment, and especially tar ointment. Erasmus Wilson has found greatest benefit from a tincture of the seeds of Croton Tiglium, made in the proportion of an ounce of the seeds to four fluidounces of alcohol. A papular eruption, attended with intolerable itching, and often inter- mingled with vesicles and pustules, and sometimes with erythematous patches or ulcerations, has been observed in Germany, as occurring in persons who pick gooseberries when ripe, or are exposed to the bushes. Jahn has found that this affection is owing to the attacks of minute insects of the genus Lep- tus. It is readily cured by washing the affected part with soap and Avater, or a solution of hepar sulphuris. (See Am. Journ. of Med. Sci., N. S., xx. 191.) III. PRURIGO. This is an eruption of papulae, having nearly the same colour as the healthy skin, and attended with excessive itching. It is closely analogous to lichen, and might, perhaps, without violence, be considered a modification of that disease. From the ordinary forms, however, of lichen it differs in the absence of redness, in the generally someAvhat larger and less pointed pimples, though these are not unfrequently very small, and in the greater intensity of the itching. Lichen is, moreover, most commonly acute, and often attended with fever; prurigo, on the contrary, chronic and without fever. Neither of the complaints is contagious. Willan makes three varieties of prurigo ; namely, P. mitis. P. formicans, and P. senilis. The first two differ only in degree; the last has some peculiarities which entitle it to distinct notice. The eruption in prurigo is sometimes confined to one spot, sometimes at- tacks several distinct parts at the same time, and occasionally, though very seldom, affects the whole surface. Its favourite seats are the neck, shoulders, back, and outer surface of the limbs. It is rare in the face, unless in severe chronic cases, and almost always spares the feet and palms of the hands. From their want of colour, the pimples are often not observed; the atten- tion being chiefly directed to the small black scabs scattered here and there over the affected parts. These are produced by the concretion of the bloody exudation from the tops of the papulae, abraded by the violent rubbing, or scratching, to which the patient is irresistibly impelled. But the papula? are readily distinguished by running the fingers over the surface. They are occasionally mingled with temporary wheals, and small inflamed pustules, produced by friction. In severe cases, along with the itching is a sense of formication and painful pricking, as if insects were crawling over the surface and stinging it, or as if the skin were pierced with hot needles. These sensa- CLASS III.] PIMPLES.—PRURIGO. 423 tions are almost incessant, but are aggravated by heat, and by sudden expo- sure to cold, as in undressing. They are often so distressing after the patient has become warm in bed, as to prevent sleep for several hours. Under proper treatment, the disorder sometimes disappears in two or three weeks, usually with a slight desquamation; but it is very apt to be- come chronic, persisting for months, and sometimes, Avith occasional remis- sions or suspensions, even for years. Dr. Willan says that, in its milder form, it is sometimes ultimately converted into contagious scabies; and, in its severer form, ends occasionally in impetigo. Some cases are recorded by Dr. Wm. W. Green, in the Boston Medical and Surgical Journal for Oct. 18, 1855 (page 239), which seem to show that there is a form of prurigo, which is itself contagious. This apparent contagiousness of prurigo, and its apparent conversion into scabies, are readily explicable, when it is understood that the irritation, caused by the itch-insect, sometimes shows itself in the form of pimples, instead of vesicles or pustules. The affection in these cases may have been really the itch from the commencement. In very old cases, of years' duration, the papulae become much enlarged, hardened, and sometimes confluent; the skin is thickened and often inflamed; the characteristic eruption is mingled with vesicles, pustules, and even boils; febrile symptoms and various internal disorder complicate the complaint; and the patient is reduced to a condition of indescribable wretchedness, too often beyond the reach of remedies. The want of sleep, arising from the inces- sant itching of the skin, must have a tendency to impair the general health. Plumbe ascribes the obstinacy of these cases to an organization of the en- larged papulae, consequent upon the long-continued inflammation. In the Prurigo senilis of Willan, the eruption is of the same kind as iu the ordinary forms, though perhaps rather flatter, and somewhat less abund- ant; but the variety is chiefly characterized by its occurrence almost exclu- sively in the old, by the extreme severity and permanence of the itching, and by the obstinacy of the complaint, which often resists every variety of treat- ment. Another distinguishing feature is its tendency to generate pediculi, which are sometimes very numerous and troublesome. It occurs most fre- quently in the feeble, and those exposed to the privations of extreme poverty. Causes.—Prurigo occurs at all periods of life, and in both sexes; but is most common in youth and old age. It is apt to make its attacks in the spring and beginning of summer, though not confined to any season. Some- times it appears to be connected with gastric or intestinal disorder. It has been ascribed to rich and stimulating food, to intemperate drinking, to the use of various irritating or indigestible articles of diet, as salt meats, certain kinds of fish, pickles and vinegar, and finally to the various circumstances of poverty which tend to deteriorate the health, among which may be mentioned, confined air, unwholesome food, and mental depression. Want of personal cleanliness, and of the proper change of clothing, is probably one of its most frequent causes. Its source, however, is not unfrequently altogether unknown. In relation to the diagnosis, nothing is necessary in addition to what has been said under lichen. Treatment.—Internal remedies have little direct efficacy in this complaint. The first object should be to correct any existing disorder, whether of a par- ticular organ or of the system. Hence, the state of the stomach, of the bowels, and of the liver should receive attention, and the menstrual condition should not be overlooked. If the patient is debilitated, he should be in- vigorated by tonics and nutritious food. The diet should be regulated. Indigestible, irritating, and highly stimulating substances should be avoided. Bread and milk would be very suitable, as a substitute for meats, in plethoric individuals. The medicines most highly recommended are sulphur and the alkaline carbonates, separate or combined. The compound decoction of 424 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. sarsaparilla is also thought to have been useful. In cases of debility, the vegetable and mineral tonics sometimes prove serviceable. Bateman states that he has seen considerable benefit from solution of chlorine; and nitro- muriatic acid might be advantageous. In a complaint so obstinate, all the ordinary alteratives have of course undergone a trial; but little can be said in their favour. " Strong purgatives, or a course of purgation, appear to be injurious; antimonials and mercurials are useless; and active sudorifics aggravate the complaint." (Bateman's Synopsis.) In obstinate cases, re- course may be had to iodine, arsenic, or the compound solution of these two with mercury, known as Donovan's solution. Anodynes are often necessary to allay the sufferings of the patient, and to procure sleep. Dr. Burgess re- commends, as peculiarly efficacious, the internal use of strychnia, and of phosphorus dissolved in ether. (Ranking^ Abstract, Am. ed., ix. 83.) The external treatment is more important than the internal. In mild cases, cures may generally be effected by frequent ablutions with warm water, or the persevering use of the warm-bath, though this is said at first some- what to aggravate the eruption. Cleanliness of person, and a frequent change of the clothing are essential. Sulphurous baths are still more ef- fectual than the simple warm bath; and, in the advanced stages, advantage is said to accrue from the external employment in this way of the alkaline carbonates. (See page 422.) Sea-bathing has also been recommended. Lotions of glycerin, spirit, diluted vinegar, solution of acetate of ammonia, liquid or unctuous preparations of aconite, weak hydrocyanic acid, and the liquid preparations of opium sometimes afford considerable alleviation. In the more obstinate and chronic cases, as in P. senilis, the applications may be more stimulating. A solution of corrosive sublimate or nitrate of silver in the proportion of two or three grains to a fluidounce of water, and the oil of turpentine diluted with olive oil, have been recommended as useful, not only for the relief of the eruption, but also for the destruction of the pediculi by which the skin is infested. Fumigation with cinnabar is employed for the same purpose. Mercurial ointment, and the ointment of nitrate of mercury may be used; but with care not to salivate. The ointments of sulphur, iodine, iodide of sulphur, tar, creasote, and oxide of zinc, have been employed with various success. Erasmus Wilson excites a new action by the tincture of croton seeds (see page 422), or the tincture of iodine. In cases so obsti- nate and long continued as those of P. senilis, abundant opportunity is of- fered for a great variety of remedies. Dr. Bellingham has found creasote more frequently useful than any other local remedy. He uses it in the form of lotion or of ointment, but prefers the latter. The ointment is made in the proportion of ten or twenty drops to the ounce of lard, the lotion in that of twenty or thirty drops to eight fluidounces of water, a little alcohol or acetic acid being added to render it more soluble. The application should be made every night at bedtime. (Dublin Med. Press, Sept. 8, 1847.) When oint- ments are used, care should be taken not to allow the skin to become un- cleanly. Plumbe recommends that, when the papulae have become enlarged and organized, they should be destroyed by the application of caustic to each one separately. Dr. Tournie has found the most successful application, in cases of pruritus of the genital, anal, and axillary regions, whether de- pendent on this or other forms of eruption, or even without apparent erup- tion, to be an ointment made of one part of calomel and six of lard, to be followed by a powder consisting of one part of camphor and four of starch, Avhich is to be sprinkled on the part. (See Am. Journ. of Med. Sci, N. S., xxii. 226.) Strong testimony has recently been given as to the efficiency of cod-liver oil, used externally, in obstinate cases of prurigo. Prof. Malm- sten, of Berlin, has obtained extraordinary success with the remedy, by CLASS III.] PIMPLES.—PRURIGO.—PRURITUS. 425 keeping the parts affected constantly in contact with the oil, the dressings being saturated with it. Where the surface generally is affected, the patient is made to lie in bed, Avith the bed-linen in the like manner saturated, and to continue thus till a cure is effected, which is usually accomplished in about two weeks. The only interruption to the treatment is that the patient is allowed an alkaline bath once a week. (Med. Times and Gaz., July, 1855, p. 8.) Sympathetic Pruritus.—Under the head of prurigo are usually considered certain affections characterized by severe itching of the skin, with very little or no papulous eruption. The itching, in many of these cases, is merely sympathetic of internal irritations, especially when seated near the termina- tions of the mucous passages. Thus, itching about the nostrils is often de- pendent upon worms, or some other irritating matter in the stomach or bowels; about the anus, upon ascarides in the rectum; about the end of the urethra, upon irritation of the bladder or its neck; about the labia pudendi, upon disorder of the uterus or vagina. Occasionally, a general pruritus, or one affecting different parts of the surface at different times, occurs without eruption, depending entirely upon some internal derangement of function. Such cases are sometimes mistaken for prurigo or psora, in consequence of the small bloody scabs which attend them, and which, though the mere con- sequence of slight excoriations by the nails, are apt to be looked upon as marks of abraded pimples or vesicles. It is highly important to form a true diagnosis; for the attention will then be directed to the real source of the evil, and those measures adopted by which alone relief can be obtained. Of course, the remedies must be adapted to the peculiar condition of system, or the special derangement of function which may be found in any particular case, and must, therefore, be left to the discretion of the practitioner. Sometimes local pruritus is produced by disordered secretion of the part affected, or its immediate neighbourhood. Such is the case occasionally with itching of the prepuce, which depends on derangement of the sebaceous secre- tion around the corona glandis. Not unfrequently also it proceeds from in- sects, especially when it affects the parts about the genitals. In the former case, it will be cured by occasional lotions of the salts of zinc or lead; in the latter, by shaving the parts, and keeping them perfectly clean, or by the use of mercurial ointment, or a weak solution of corrosive sublimate. In other instances, the itching cannot be accounted for; no disordered secretion, no eruption, and no disease of neighbouring internal organs being discoverable. The affection is purely nervous, and analogous to neuralgia. It may sometimes possibly be one of the forms in which a gouty or rheu- matic diathesis displays itself. Affections of this kind, attacking the anus and external genitals, both in males and females, are in some instances ex- ceedingly distressing, depriving the patient of sleep, impairing his health, and almost excluding him from society, by the impossibility of abstaining from rubbing or scratching the part affected. One of the evil consequences is occasionally the production of a habit of masturbation, and a consequent deterioration of the moral sense. Few affections are more distressing than some of the cases of this kind recorded by Avriters. In attempting to relieve them, remedies should be addressed to the general system, calculated to alter the character of the nervous actions; such as narcotics, the chalybeates in large doses, sulphate of quinia, and in short, all those means which are con- sidered useful in neuralgia. Various local measures have also been recom- mended. The applications before mentioned as employed in protracted cases of Prurigo senilis may also be used here. It is unnecessary to repeat them. Leeches, emollient poultices, demulcents, and narcotic lotions, ointments, or vol. n. 28 426 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. cataplasms, will sometimes afford relief. Scrupulous attention should be paid to cleanliness. I have not deemed it necessary to describe the pruriginous affections under the distinct local names which writers have attached to them; such as Pru- rigo pudicis, P. pudendi muliebris, P. pubis, P. prasputii, &c. It is suf- ficient to have given the general etiology and principles of treatment, which may readily be applied to any particular case. Article III VESICULAR DISEASES. I. HERPES. Before the reform introduced by Willan into the nomenclature of cuta- neous diseases, this term was applied vaguely to various very different affec- tions. At present, writers in general follow that dermatologist in restricting it to a vesicular eruption, occurring in circumscribed patches, upon an in- flamed base, which extends somewhat beyond their margin, leaving portions of sound skin between them. It may or may not be associated with consti- tutional disturbance. In the severer cases, the eruption is generally preceded or attended by more or less fever, but not so in those of a milder grade. There is almost always a greater or less degree of burning pain, itching, and tingling; and sometimes the local suffering is very considerable. The com- plaint usually runs its course in a period varying from one to three weeks, and is very rarely chronic. The lymph in the vesicles, at first perfectly limpid, gradually becomes milky and opaque, and at length concretes into scabs, which fall off, leaving a temporary redness of the skin. In some cases, a co- pious serous exudation takes place, the patches become superficially ulcerated, and even gangrene may ensue. But such cases are comparatively rare. In all its forms the disease is essentially mild, and never terminates unfavourably, unless accompanied with some vice of constitution, which would impart ma- lignancy to the gentlest affection. In its severer forms, herpes bears some resemblance to erysipelas, which is in like manner often attended with a copious vesicular eruption upon an in- flamed surface ; but the former disease may be readily diagnosticated by its distinct clusters, with skin of the natural colour intervening. The causes of herpes are very obscure. Sudden exposure to cold in a state of perspiration from heat or over-exertion, the direct action of irritants, and strong mental emotion, have been enumerated among its occasional causes; but they probably operate only by calling a pre-existing disposition into ac- tion. It is said to have sometimes occurred epidemically. It is most fre- quent in the young, and in persons with a delicate skin. The following are the varieties generally recognized. They differ chiefly in the mere position or form of the vesicular patches. 1. Herpes zoster.—Zona. — Shingles. — In this variety, the clusters are situated upon one side of the trunk, and are arranged in succession, so as to form an irregular band, with one extremity directed towards the spine, the other towards the sternum or linea alba. This band often extends one-half round the body, sometimes in a direct course, sometimes obliquely, and, in the latter case, though beginning on the trunk, it occasionally terminates either upon the thigh, or the arm. In some instances, the clusters com- mence in the middle of this line, and extend at each extremity; sometimes CLASS III.] VESICLES.—HERPES. 427 they occur first at opposite points of the trunk, and approach each other in ■the middle. It is a singular fact, that in the great majority of cases they occupy the right side, and that they very rarely pass the median line of the body. It is, indeed, asserted by some Avriters that the eruption never tran- scends these limits; and that, when it has appeared to do so, it was Herpes phlyctaenodes and not the shingles. But this is making the phenomena of a disease bend to a definition. There can be no doubt that the shingles some- times extend more than half round the body, and cases have been observed in which they have extended quite round it. The popular notion that such cases are necessarily fatal, is without the least foundation. Sometimes the row of clusters occupies the neck, or the side of the head, instead of the trunk; but in this case, also, it observes the general law of stopping at the middle line. Each cluster consists of numerous roundish vesicles, which are very minute at first, but when mature are generally of the size of pearls, and sometimes as large as a split pea or larger. They are often confluent, sometimes over a considerable surface. The red margin extends but a short distance beyond the vesicles. The clusters are irregular in shape and size, generally some- what longer in the direction around the body, and varying from one to three inches in diameter. They do not in general all occur at once, but succeed each other, and one has sometimes begun to fade before another is completely formed. The limpid fluid of the vesicles becomes opaque in three or four days, when they gradually decline, and the scabs usually fall off about the twelfth or fourteenth day; but as the clusters appear suc- cessively in point of time, and each runs its own course, the whole duration may extend to three weeks or more. Sometimes, from the friction of the clothes, or other causes, the patches ulcerate and tedious sores result. The eruption is usually preceded for two or three days by febrile symp- toms, with anorexia, general uneasiness, lassitude, &c, which are sometimes relieved when the clusters appear, sometimes continue in a greater or less degree in consequence of the irritation of the local affection. The patient often suffers considerably from the burning and smarting pain of the erup- tion; and not unfrequently experiences severe shooting pains more deeply seated in the trunk. In relation to the causes of shingles nothing need be added to what has been said of those of herpes in general. Its diagnosis is never difficult. 2. Herpes phlyctaenodes.—The clusters of this variety of herpes are ir- regular, and have no fixed position. They occur most frequently on the cheek, neck, arms, or breast, more rarely on the lower extremities. Some- times commencing on the breast, they spread successively over the whole trunk. When the eruption is. thus extensive, the vesicles are usually very small. When larger, as in shingles at maturity, the clusters are very few, not often exceeding two or three in number; and sometimes there is only one. The affection runs a rather shorter course than shingles. Each cluster usually completes its series of changes in a week or ten days; and the whole duration of the attack seldom exceeds two weeks. In some very rare cases, the affection assumes a chronic character, and it has been known to run on for months. In such instances, the clusters are very few or quite solitary. The general symptoms, and local sensations, do not ma- terially differ from those of 'Herpes zoster, though on the whole somewhat more moderate. 3. Herpes circinatus.—Ring-worm.—The distinguishing character of this variety of herpes is the occurrence of the vesicles in circular patches. In the common form of it, the vesicles appear at the circumference, forming a ring with a portion of skin in the centre free from eruption. Hence the 428 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. popular name of ring-worm, which it shares with other eruptive affections having a similar shape. The seat of it is usually in the upper portions of the body, as the face, neck, arms, and shoulders, and more rarely on the lower extremities. The vesicles are usually very small, sometimes so as to require a close examination, in order to be detected. They rise upon an erythematous ground, though the surface is perhaps less vividly red than in the other varieties mentioned. The vesicles usually break in three or four days, forming minute scabs or scales, which give the ring a furfuraceous ap- pearance. These fall off in about a week. But, as the clusters appear successively, the complaint often has a course of two or three Aveeks. It is seldom attended with fever or other constitutional disorder; and the local sensations, amounting generally only to a moderate tingling and itching, are less severe than in H. zoster and H. phlyctaenodes. This variety of ring- worm occurs most frequently in children ; and sometimes under circumstances which have encouraged the notion of its contagious nature, several members of the same family being affected at the same time. But this is owing not to contagion, but to similarity of exposure. Care is sometimes required to distinguish this affection from Trichosis furfuracea (Porrigo scutulata of Willan), and Lichen circumscripta, which have a similar form, and are also called ring-worm in popular language. Trichosis furfuracea is a cryptogamous affection, and will be more parti- cularly described hereafter. Lichen circumscripta is papulous, and has no vesicles. In the herpetic ring-worm, though the vesicles are often very mi- nute, either they or their remnants may be detected upon close examination. Besides, the borders are more inflamed than in lichen, and the central por- tion, which in the latter is usually filled with pimples in the earlier stages, exhibits in the former either a sound state of the skin, or a slight redness, and only becomes somewhat furfuraceous when the affection is declining. Occasionally this variety of herpes takes on a much more aggravated char- acter. The patch, instead of disappearing as the first ring of vesicles de- clines, is enlarged by a new crop at the circumference, and this, in its turn, is followed by another, and thus the circle goes on widening, until it em- braces a large extent of surface. In some cases, the vesiculated surface ulcerates, even to a considerable depth, and the complaint exhibits a suc- cession of belts in this state, an outer one forming as fast as the inner heals. This would fall under the title of Herpes exedens, which has been given to the affection when it assumes an ulcerative character, with a disposition to advance. It is sometimes very obstinate. The cases described by Bateman under this head, as consisting of circles filled with crowded vesicles, surrounded by an inflamed border, occurring successively upon various portions of the body, and attended with much burning pain, and more or less fever, would seem to belong properly to H. phlyctaenodes, from which they differ merely in the regularity of the circum- ference of the patches. Another form of herpes, first noticed by Bateman, and denominated by him Herpes Iris, exhibits circular patches, consisting of concentric rings of different shades of colour ; an arrangement from which it derived its name. It occurs usually upon the hands or arms, and sometimes on the instep. The eruption first appears as an efflorescence, which soon becomes distinctly vesicular, the central vesicle being yellowish-white, the ring immediately around it brownish-red, the second ring nearly of the same colour as the centre, the third narrower and dark-red, and the fourth of a light-red hue, forming a kind of areola, which gradually fades into the colour of the skin. The patches are small at first, and increase till they are three- quarters of an inch or more in diameter. They arrive at their height in a CLASS III.] VESICLES.—HERPES. 429 Aveek or nine days, are stationary for about two days, and occupy a week or more in their decline. They are attended with no constitutional disorder. The affection is slight, and very rare. It may, without violence, be placed with H. circinatus. 4. Herpes labialis.—This is distinguished merely by its locality, occurring, as its name implies, about the lips, of which it occupies a greater or less por- tion, being sometimes confined to a part of one lip, or to an angle of the mouth, sometimes extending from one angle to the other along the upper or loAver lip, and sometimes surrounding the whole mouth, by a succession of clustered vesicles. There is first a burning sensation, with redness, which is soon folloAved by vesicles; and the lip becomes hard, swollen, and often very painful. The lymph of the vesicles gradually becomes opaque, and sometimes purulent scabs begin to form in three or four days, and the disorder disap- pears entirely in ten or twelve days, or a shorter time. Sometimes the erup- tion occurs as an original affection with febrile symptoms, and occasionally soreness in the fauces, Avhich, upon examination, exhibit vesicles similar to those upon the lips. More frequently, however, it is an attendant upon other complaints, such as catarrhal, intermittent, remittent, and typhoid fevers, and the different phlegmasiae, in which its occurrence may be considered as a favourable sign, as it generally marks the commencement of convalescence. 5. Herpes prseputialis.—The peculiarity of this, like the last-mentioned variety, consists merely in its position, which is upon the prepuce, either upon its outer or inner surface. The clusters are very small, consisting each of five or six minute vesicles, which, if undisturbed, run the ordinary course, and get well in ten or tAvelve days. When on the inner surface, from the delicacy of the epithelium, they are apt to break, and end in superficial ulcers, which, from the irritation of the secretions of the part, the motions of the prepuce, or improper applications made under the impression of their syphilitic origin, become sometimes obstinate sores. This affection is distinguishable from syphilis by its vesicular origin, its occurrence in clusters, and, after ulceration, the superficial character of the ulcer, and the absence of those abrupt and hard edges, and that adhesive yellowish-white exudation on the surface, which characterize chancre. Treatment.—As herpes almost uniformly runs a favourable course, unless interrupted by disturbing causes, all that is, in general, requisite in the treat- ment is to guard against the operation of such causes, and to relieve the symp- toms when severe and painful. In reference to the first indication, stimulating food and drink should be avoided; the patient should remain at rest when the eruption is considerable, and especially when attended with constitu- tional symptoms; and care should be taken to prevent irritation of the in- flamed surface by the friction of the clothes, or by stimulating applications. When the eruption is seated in the face, the patient should avoid exposure of the part to the sun, or to a hot fire. If the complaint should be attended with febrile symptoms, cooling acidu- lous drinks, a strictly antiphlogistic diet, saline laxatives, and refrigerant dia- phoretics, may be directed. When the pain is severe, opiates may be added; and the best preparation is probably Dover's powder. Should the local affec- tion shoAv a tendency to gangrene, from a scorbutic state of system, or general debility, as sometimes happens in old people, the strength must be supported by tonics, moderately stimulating drinks, and nutritious food. The local treatment is, in general, not less simple. When the inflammation is considerable, and the sensations of the part distressing, recourse may be had to cooling or demulcent lotions, as flaxseed tea, infusion of slippery elm, and weak solution of acetate or subacetate of lead; and, if the eruption is extensive, relief will be obtained by the occasional use of the warm-bath. It 430 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. has been proposed to destroy the vesicles by nitrate of silver; but this is unnecessary in a complaint so favourably disposed, and of so short a duration. In mild cases, it will be sufficient merely to protect the affected surface, Avhen upon the trunk or extremities, by soft and fine linen. Should the surface be moist or ulcerated, it should be dressed with simple cerate, or spermaceti cerate, to prevent the adhesion of the clothes. When the ulcer appears, in- disposed to heal, Goulard's cerate may be applied, at first somewhat diluted with simple ointment, and afterwards, if necessary, undiluted. Collodion, and solutions of gutta-percha or caoutchouc in chloroform, have also been usefully employed, with the view of protecting the surface from the air. Cazenave recommends the application of a powder composed of one part of oxide of zinc and fifteen of starch. Should the case become chronic, and especially if the ulceration seem disposed to advance, it may be necessary to make use of mild caustic remedies, such as nitrate of silver or sulphate of copper. In H circinatus, no internal remedies are, as a general rule, required. The tingling and itching may be relieved by very weak solutions of sulphate of zinc, sulphate of iron, sulphate of copper, alum, or elixir of vitriol; and these applications appear to shorten the duration of the complaint. Ink is often popularly employed for the same purpose, and the frequent application of saliva is recommended by some writers. Alkaline lotions are also recom- mended. In the ulcerative and spreading variety, the caustic treatment above advised may be cautiously tried, and especially the use of nitrate of silver. H. labialis requires only the cooling or slightly astringent lotions above mentioned. Relief may here often be obtained by anointing the lips fre- quently with fresh cream cooled by ice, or with glycerin. H praeputialis may be treated by the same astringent lotions, care being taken that they are not made too strong; but generally it will be sufficient to guard the part against irritation from the clothing, or the frequent motion of the prepuce. When the eruption is seated on the inner surface, it will be proper to introduce some dry lint to prevent the contact of the opposite sur- faces, and to absorb irritant secretions. Should the irritation be considerable, it may be proper to inject demulcent liquids carefully beneath the prepuce, and to employ emollient applications without. The various irritant substances recommended by different authors in her- petic eruptions have reference to other and more obstinate affections, which were formerly confounded under the title of herpes. II. ECZEMA. This name was given by Willan to a non-contagious eruption, consisting of minute vesicles crowded together in irregular patches, with or without surrounding redness. It may be most conveniently considered under the two conditions of acute and chronic eczema. Acute Eczema.—In its mildest form (Eczema simplex), this appears in patches of very minute, closely crowded vesicles, glistening and transparent, with little or no intervening redness, without fever, and with no other local sensations than a disagreeable itching and tingling. In a short time, the serum in the vesicles becomes turbid or lactescent, and is either absorbed, or exudes and forms a minute scale, which soon separates, leaving the skin per- fectly sound. The whole course of the eruption occupies from one to three weeks; but, as the crop of vesicles is sometimes renewed, the affection may continue much longer. In a severer form (Eczema rubrum), the eruption is generally preceded and always accompanied by inflammation and redness of the skin. The CLASS III.] VESICLES.—ECZEMA. 431 vesicles show themselves at first like glistening points, which can scarcely be seen to contain a liquid, unless by the aid of the microscope. These enlarge, and when fully developed have about the size of a pin's head. In the mildest cases, the vesicles dry up in about a week, and are succeeded by desquama- tion, after which the surface remains of a reddish colour for a few days, and then resumes its healthy appearance. In the severer cases, the preceding and attendant inflammation is of a higher grade, with much heat, some swelling, and a vivid redness. Instead of drying up, many of the vesicles break, and a serous fluid exudes, often very copiously, which irritates and excoriates the skin, and thus increases the exuding surface. After a time, the secretion diminishes, and the extravasated liquid concretes into thin soft scales, which, upon separating, are followed by others several times successively; the sur- face of the skin after each separation being still red and inflamed. If a favourable termination is to take place, the exudation gradually ceases, the scales become firmer and more adherent, and upon separating leave the skin less inflamed; and, at the expiration of two or three weeks, the diseased surface resumes its healthy appearance. But frequently new crops of vesicles show themselves, either upon the part previously affected, or upon the sur- rounding healthy skin, so as to extend, in some instances very greatly, the limits of the disease. When, by the successive eruption of new vesicles, the affection is kept up for two or three months, it may be considered as having assumed the chronic form. In other cases (Eczema impetiginoides), the eruption, though at first vesi- cular, assumes afterwards a pustular form, similar to that of impetigo. The liquid in the vesicles becomes opaque, yellowish, and apparently puriform; and, upon concreting, gives rise to soft yellowish scabs. These soon sepa- rate, leaving inflamed surfaces, that exude a reddish liquid, and again cover themselves with scabs or scales, to go through the same process as those Avhich preceded them. Gradually, however, the surface becomes less inflamed, the scales thinner and dryer, and the skin returns to its healthy state in the course of two or three weeks, unless the disease degenerate into the chronic form. It is worthy of note that, in E. impetiginoides, though most of the eruption may have this apparently pustular form, yet very frequently some of the proper eczematous vesicles may be seen either upon the margin of the patches, or within them. In either of the above varieties, the affection may be confined to a single surface of variable extent, or may spread, in successive patches, more or less extensively over the body. Sometimes it happens that, when the affection becomes general, some of the patches maybe renewing and" extending them- selves by successive crops of vesicles, while others are healing. When the disease is extensive, it is very apt to give rise to fever. In all its forms, it is attended with disagreeable sensations, such as itching, tingling, burning, when the liver is greatly enlarged, it may occasion uneasiness by pressure upon the stomach. But this symptom is by no means constant; and sometimes the patient prefers lying upon the left side. In acute cases, the sitting posture, with the body bent forward, is occasionally found to be the least painful. Increase of the bulk of the liver is another frequent though not uniform attendant upon hepatitis. In the healthy state it seldom extends beyond the sixth rib upwards, or the loAver edge of the false ribs downward, and is scarcely to be detected in the left hypochondrium. Beyond these dimensions, it may generally be considered morbid. In some instances, especially in chronic disease of the organ, it becomes enormously enlarged; and cases have occurred in which it has reached as high as the third rib, has descended into the iliac fossa, and occupied almost the whole left hypochondrium. But, in estimating this diagnostic symptom, we must bear in mind that the liver is liable to be displaced, and that it may be observed in wholly abnor- mal positions without any enlargement. Thus, it may be pressed upwards in the chest by abdominal tumours and dropsy, and may fall much below the ribs in consequence of relaxation or stretching of the suspensory ligaments. Four cases have come within my OAvn observation, in which the liver, though itself in all respects- healthy, could be distinctly felt occupying the lumbar region, and could even be taken between the thumb arfd fingers of the exam- iner. In one, the descent could be traced to a very large scrotal hernia, which had existed in early life, in another it was probably owing to adhesion formed between the lower surface of the liver and the uterus from an injury, and consequent peritoneal inflammation, during pregnancy. In both, the symptom, connected as it was with occasional uneasiness in the side and epi- gastrium, occasioned much solicitude, Avhich was relieved Avhen the nature of the affection was understood. In the third case, the result was ascribable to a fall, which had probably ruptured the suspensory ligament. In this in- stance, the liver, in its false position, was mistaken for an abdominal tumour, and caused great mental uneasiness to the patient, until informed of the na- ture of the affection. The same solicitude existed in the fourth case, which, however, though clearly of like character with the others, I could not trace to any special cause. Such displacements may be detected by placing the patienton the back, when the liver either retires, or may be readily pushed within its proper limits. Percussion, moreover, by marking its outlines both above and beloAv, will demonstrate that the phenomena are ascribable not to its enlargement, but to its abnormal position. Increased bulk of the liver may often be rendered obvious to the eye by CLASS III.] HEPATITIS. 509 stripping the patient, and comparing the two sides. The lower ribs on the right side will be observed to bulge outward and forward considerably be- yond their proper outline. Any inequality of the sides will be most easily discovered by standing at the foot of the patient, and running the eye up- ward along the body, as suggested by Mr. Twining. When below the ribs, or the due boundary in the epigastrium, the outline of the liver may be usu- ally felt by the fingers, especially Avhen the patient is thin, and the abdominal muscles not very rigid. To facilitate the examination, the lower limbs should be drawn up, and the shoulders elevated, so as to relax the abdomen; or the patient may sit up with his body bent forward, or he may be placed upon his elbows and knees, so as to throw the liver forward. But various circum- stances often interfere to obscure the diagnosis, such as fat, tumours in the abdomen, ascites, &c.; and the aid of percussion may in such cases be advan- tageously resorted to. The sound yielded by the liver differs greatly from that of the ordinary contents of the abdomen below, and the lungs above. The extent of the liver is usually commensurate with that of the continuous flatness from the middle of the hypochondrium in all directions. Below is the clearer sound of the intestines and the stomach, above and at the left extremity, that of the lungs. It should be recollected, however, that a por- tion of the lung intervenes between the liver and the ribs, gradually increas- ing in thickness upAvard, so that the hepatic sound is somewhat modified, and in a gradually increased degree, by the pulmonic, as far as the sixth or seventh rib, Avhen the latter should be exclusively heard. If the dulness extend below the edge of the false ribs posterior to the angle, or considerably below it anterior to the angle, or more than an inch or two beyond the mesial line toAvards the left side, or above the sixth rib, the liver, unless displacement should be obvious, may be considered as enlarged. Tumours in the abdomen, pleuritic effusion in the right side, and consolidation of the lung from pneu- monia, might interfere with the diagnosis. But. in the first case, there would generally be observed a clearer sound between the liver and the tumour, which, moreover, might often be detected by being movable; in the case of pleurisy, the outline of the dulness changes with the position of the patient; and, in pneumonia, the sound is scarcely so dull as that of the enlarged liver, and at all events there are other signs, both physical and rational, which sufficiently mark the distinction, and which are indicated under inflammation of the lungs. Sometimes a thin edge of the liver extends below the ribs, over the intestines and the stomach; in which case the flat hepatic sound is modified by the hollow organ beneath; but in this case there is still some dulness, the lower limits of which will mark the extent of the liver. A com- parison between the extent of the hepatic sound downward and upward will show whether the liver is enlarged or merely displaced. In Avomen who dress tightly, the liver is pushed further toAvards the left than in the normal state. According to Dr. Malcolmson, auscultation affords a sign indicative of hepatic encroachment upon the lungs ; a loud sound, namely, between a cre- pitant rale and a bleating, owing, as he supposes, to the thin edge of the lung being compressed by the enlarged liver against the pleura. This sound is audible to the patient and even the bystander, and attended by a vibration of the thoracic parietes sensible to the hand. (Thompson on Dis. of Bil. Organs.) Dr. Walshe states that the sound occurs only in inspiration, near the end of the act, and requires a forced expansion of the chest for its de- velopment. (See Am. Journ. of Med. Sci., N. S., xx. 484.) The consistence of the liver is frequently altered. In the healthy state, though much firmer than the intestine, it has a certain degree of yielding- ness and elasticity, which may give place, especially in chronic inflamma- tion, to a greater or less degree of induration, readily detected by examination 510 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. with the hand. But neither enlargement nor induration can be considered as necessarily indicative of inflammation, unless attended with other symptoms, as they may result from organic changes of a different character. Cough is a frequent symptom, generally short and dry, but sometimes at- tended with expectoration. It may arise from pressure upon the lung, from the sympathetic propagation of irritation, or from the pulling down of the diaphragm by the Aveight of the liver. In acute cases, it comes on generally within a day or two from the commencement. Occasionally it appears to de- pend upon bronchial inflammation occurring simultaneously with the hepa- titis, and probably from the same cause. Dyspneea and palpitation sometimes result from the encroachment of the liver upon the lungs and pericardium. The stomach is very apt to be disordered; and gastric distress, nausea, and vomiting sometimes of bilious matter, and sometimes of mucus or the ordinary contents of the stomach, are not uncommon. The bowels are in some cases constipated, in others affected with looseness; and the stools are generally unhealthy, evincing, by an excess or deficiency or perverted state of the bile, a derangement of the secretory function of the liver. Now and then also dysenteric symptoms appear, with mucous or bloody stools. Hiccough is an occasional symptom. The eyes, and the skin upon the upper part of the body, are often yellow- ish, the urine is also deep-yellow or orange-coloured, the fur on the tongue is yellowish, with a bitterish taste in the mouth, and sometimes the patient is completely jaundiced. But these symptoms are often wanting, and pro- bably occur only when the parenchyma of the liver, or the biliary ducts are the seat of disease. Depression of spirits, a gloom sometimes amounting to insanity, headache, delirium, and coma occasionally evince the sympathy of the brain. These symptoms may also be ascribed to a morbid state of the blood, arising from defective hepatic secretion. Whatever may be the cause, hepatitis both acute and chronic is frequently attended with a melancholy, morose, or hypo- chondriacal state of the mind. There is generally more or less fever, and almost always in the acute form. It is usually ushered in with rigors, and does not differ from that which re- sults from inflammation of other important organs. (See Fever.) It is of every grade, from a mild febricula, showing itself in a moderately accelerated pulse Avith heat of skin, occurring towards evening, and subsiding in the night, up to a continued and tumultuous vascular disturbance, with all the other phenomena which characterize this form of disease. In most instances, the febrile action is sthenic; but sometimes it assumes the typhoid character, especially in the advanced stages. It is not, however, an essential accompa- niment ; for hepatitis has been known to run its whole course to the forma- tion of an abscess, Avithout the least sign of febrile disturbance. The course of the disease and its duration are exceedingly various. It may last only a few days, or continue for Aveeks, months, or years ; and may ter- minate in resolution, or run on to suppuration, induration, or gangrene, though there is reason to believe that the last termination is very rare. Under proper treatment, resolution may be generally effected. The febrile action subsides, the pain and tenderness gradually diminish, the tumefaction disappears, and the patient is restored to health. But, if due measures be not employed, and especially if the original cause continue to operate, sup- puration is very apt to ensue, either quickly or after a shorter or longer de- lay, according to the degree in which the case is acute or chronic. Not unfrequently, under similar circumstances, the acute subsides into the chronic form, which may ultimately yield to proper remedies, or, after numerous alternations, may at last end in abscess, or other organic change of a not CLASS III.] HEPATITIS. 511 less serious character. This is especially liable to happen in hot climates, where the original cause operates unceasingly, and the patient is in constant danger of a new accession of disease, before the original attack has been completely subdued. In the variety of hepatitis which attends dysentery, and which is apt to occur, in certain states of the system, whenever there is a suppurative focus in any part of the body, the tendency to suppuration is very strong; so that this may ensue in the course of two or three days from the first appearance of disordered hepatic symptoms, and sometimes even without any previous symptoms whatever that have called attention to the liver. The occurrence of suppuration is often marked by general rigors or chil- liness ; increased frequency of pulse, which is usually, according to Twining, above 105, though softer and weaker than before; relaxation of the surface with a tendency to perspiration; and a feeling of weight or throbbing in the side, with a diminution of pain, if this was previously acute. After the pro- cess has been fairly established, copious sweats are apt to occur during sleep, and sometimes complete hectic fever sets in, with great debility and exhaus- tion. Upon examining the side, it will sometimes be observed that, in place of the general intumescence, there is a more or less circumscribed swelling, which has at first a soft pasty feeling, and at length yields obvious signs of fluctuation, indicative of the presence of pus. This gradually advances to- wards the surface, and, if adhesion take place between the hepatic and parietal peritoneum, may ultimately be discharged by the spontaneous or artificial opening of the abscess. The opening may take place at any point in the vicinity of the liver, Avhether below or between the ribs, anteriorly or poste- riorly, or in the epigastrium. When between the ribs, the abscess is marked by a bulging of the intercostal spaces, which, in connection with the fluctua- tion of the tumour, and its circumscribed character, is one of the most certain diagnostic symptoms. The pus, in abscess of the liver, most frequently takes the external direction; and, as the right lobe is most frequently the seat of inflammation, and its convex surface presents externally, the liquid will gene- rally, unless in cases of great enlargement, seek an outlet between the ribs. Death from the combined exhaustion and irritation frequently occurs before the abscess opens, and the same causes may lead to a fatal issue after this event; but the patient is almost always relieved by the discharge, and is often restored to health. One great source of danger is the breaking of the abscess into the cavity of the peritoneum, in consequence of the Avant of ad- hesive inflammation between the opposite surfaces of that membrane, or the insufficiency of the adhesion that may have taken place. The patient is, under these circumstances, generally carried off speedily by peritoneal inflam- mation ; though this event does not necessarily follow; as the pus, if small in quantity, may remain circumscribed, and, becoming ultimately confined, in the form of an abscess, by the inflammation excited by its own presence, may seek its way externally, either through the intestines or the surface of the body. But the external direction, though the most frequent, is not the only one taken by hepatic abscesses. When the abscess is at the convex surface of the liver, the diaphragm becomes necessarily involved in the adhesive inflam- mation that precedes the progress of the pus, which, making its way through that muscle, may be discharged into the cavity of the pleura, if the opposite surfaces of this membrane should not have been united, thus constituting empyema. But much more frequently this union takes place, and tfie pus is either discharged externally between the ribs, as already noticed, or makes its way into the substance of the lungs. Even in this case, it may still reach the surface by the consolidation of the lung, the adhesion of the pulmonary 512 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. to the parietal pleura, and the gradual march of absorption towards the skin. But, instead of taking this direction, it is sometimes discharged into the bronchial tubes or pulmonary tissue, Avhere it may either produce suffocation by overwhelming the lung, or excite fatal inflammation of that organ, or ultimately escape by expectoration. In the latter case, the purulent matter coughed up is often tinged with bile ; and even pure bile is said to have been sometimes expectorated. The affection has been named hepatic phthisis, and, though always dangerous, is by no means necessarily fatal; as many instances of recovery are on record. When the abscess is seated near or upon the lower surface of the liver, it sometimes finds a safe outlet through the stomach and intestines, the perito- neal investment of which becomes agglutinated to the hepatic. When the pus enters the stomach it is usually discharged by vomiting, Avhen the colon, by stool, when the duodenum, by one or the other mode. It is therefore highly desirable, when hepatic abscess is suspected, that the matter dis- charged by vomiting or purging should be inspected. If at any time a copious discharge of pus should suddenly occur, there will be reason to sup- pose that the abscess has opened, and to hope for a favourable issue. It is thought that the pus sometimes penetrates the biliary ducts, and thus finds a passage into the duodenum, without disturbing the integrity of the hepatic or intestinal investments. In some very rare instances, it has escaped from the liver by other routes, as into the pericardium, vena cava, and pelvis of the kidney. There is reason to believe that it is sometimes absorbed, the abscess being gradually filled up by granulations, and leaving only a cicatrix. Some have supposed that the pus which has been occasionally discharged by urine, and from the bowels, in cases of hepatic disease which haA'e after- wards recovered, has been absorbed from the abscess of the liver, and been thrown off again by these emunctories after having entered the circulation. But this hypothesis is inadequately supported by facts. It is important to distinguish between abscesses and other morbid collec- tions of fluid, such as serous cysts, hydatids, and especially distended gall- bladder. For the diagnostic characters of these affections, the reader is referred to the heads of non-inflammatory organic diseases of the liver, and of diseases of the biliary passages. Hepatitis is a fruitful source of other morbid affections. Of these one of the most serious is dropsy, and especially ascites. It is said that the affec- tion of the liver which leads most frequently to this result is the organic de- generation denominated cirrhosis; but I have so often seen dropsy of the abdomen, connected with disease of the liver, yield to appropriate treatment directed to that organ, that I cannot doubt of its occasional origin in ordi- nary hepatitis. Various diseases of the alimentary canal have occasionally the same origin, as dyspepsia, bilious colic, diarrhoea, and dysentery; and, when it is considered how close is the sympathetic relation betAveen the liver and that canal, and how intimately the two structures are connected in their circulation, it would seem scarcely possible that one should be extensively diseased, without interfering in some degree Avith the functions of the other, if not with its organization. Disease of the spleen is also frequently de- pendent on that of the liver; and jaundice is so common a result, as to be ranked among the symptoms of hepatitis. It is not improbable that other organic affections of the liver itself may occasionally either directly result from inflammation of the viscus, or be called into action by its influence upon an existing predisposition." Reference has already been made to different forms of hepatitis. The fol- lowing deserve attention; and it must be understood that, in their descrip- tion, only those modifications of the phenomena already enumerated.are no- CLASS III.] HEPATITIS. 513 ticed, which are somewhat peculiar to the several varieties, and essential in their diagnosis. Acute Hepatitis.—This, though a very frequent disease within the tropics, is comparatively rare in cold and temperate latitudes. It is also a much more violent and fatal disease in the former than in the latter situation. In severe cases, it is usually ushered in Avith great pain, tension, or feelings of oppression in the region of the liver, sometimes attended with difficult re- spiration. Simultaneously, or somewhat subsequently, the patient is affected with chills, followed by the symptoms of severe pyrexia, among which nausea and vomiting or other gastric disorder are usually prominent. In some in- stances, the febrile symptoms precede any striking local evidences of the dis- ease. The pain is sometimes sharp and almost lancinating, at others obtuse, heavy, and aching. In milder cases, the onset of the disease is less sudden, the pains less severe, and the fever more moderate ; and sometimes only a degree of hypochondriac or epigastric uneasiness is felt, preceding, for a time, and afterwards accompanying the phenomena which mark the sympathy of the system at large, and especially of the stomach, with the hepatic disorder. The bowels are usually constipated, though sometimes relaxed, and the urine is scanty, high-coloured, and often bilious. The disease runs a brief course; and a week rarely elapses before a tendency to resolution or suppuration be- comes evident. Not unfrequently the severe symptoms yield very quickly to active treatment; but the inflammation remains unsubdued, and, if remedial measures should be suspended, or too soon relaxed, will be apt to advance to suppuration, or at best to assume the chronic form. The symptoms of acute hepatitis vary Avith the part of the liver affected. When the peritoneal coat is inflamed, the pain is sharp, and usually much more severe than when the disease is seated in the substance of the organ. The pain upon inspiration, and the consequent difficulty of breathing, are also much greater; and neighbouring organs are more apt to suffer sympatheti- cally. The locality of the inflammation may often be conjectured from the effect upon contiguous parts. Thus, when the convex surface is inflamed, the irritation extends more readily to the diaphragm and pulmonary organs; and the cough is consequently more troublesome, Avhile inspiration is more pain- ful than under other circumstances. On the other hand, inflammation of the lower surface affects especially the stomach and bowels; the gastric symptoms being most prominent when it is seated in the left lobe, and the intestinal when in the right. It rarely happens, hoAvever, that the peritoneal coat is much inflamed, Avithout involving also the substance of the liver to a greater or less depth. Hence, the symptoms characteristic of the inflamed parenchyma are apt to be mingled with those of the membranous affection. The substance of the liver is known to be inflamed Avhen the pain is obtuse and aching, the size of the organ considerably augmented, the conjunctiva and skin considerably jaundiced, and the urine loaded with bile. The yel- lowness of the skin, being ascribable to a deposition of colouring matter from the overloaded blood, must result from some cause which interferes with the secretion or excretion of the bile, especially the former; and this consequence is much more likely to ensue from disease of the secreting parenchyma than of the investing membrane. The locality of the parenchymatous inflammation may be inferred from the position and limited extent of the pain and tenderness, and from the peculiar sympathetic phenomena evolved. Thus, inflammation of the right lobe occa- sions pain and tenderness in the right side, and pain in the right shoulder; of the left lobe, pain and tenderness in the epigastrium, and pain in the left shoulder. The pulmonary symptoms may be expected to predominate when the inflammation is limited to the upper portion of the right lobe; the intes- 514 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. final, when to the lower portion of the same lobe; and the gastric, Avhen to the left lobe. According to Twining, a greater tension of the right rectus muscle than of the left, or of other parts of the abdominal parietes, indicates a tendency to inflammation and abscess in the substance of the right lobe; and the same author has observed a similar condition of the left rectus in patients who have afterwards died of abscess of the left lobe. (Diseases of the Liver and Spleen, by Wm. Twining.) Chronic Hepatitis.—Chronic inflammation very generally affects the substance of the liver. It is not unfrequently a sequela of acute hepatitis, but is, perhaps, still more frequently an original affection. It often comes on very insidiously, and may, indeed, run its whole course to suppuration or a cure, without any symptoms which would strongly call attention to the seat of the real disease. When, therefore, the slightest cause of suspicion exists, a careful examination should be made of the condition of the liver, which, if inflamed, will evince the fact by some degree of tenderness upon pressure, or some increase of its bulk. The phenomena in these masked cases are often almost precisely those of dyspepsia, attended, as that complaint frequently is, by derangement of the hepatic secretory function. In most instances of the disease, however, the obvious symptoms are more characteristic. These it is unnecessary to repeat in much detail, being the same as those already men- tioned as belonging to hepatitis in general, only moderate in degree. The pain is seldom acute or very severe, unless when the disease is complicated with neuralgia or cancer. Occasionally, instead of positive pain, there is only a vague uneasiness, or sense of Aveight or distension, and sometimes not even these. There is, however, almost always tenderness upon strong pressure, especially if directed upwards under the ribs. Enlargement and some degree of induration are not uncommon. Sometimes the liver is contracted. Dis- ordered stomach, occasional vomiting, irregular bowels, unhealthy alvine evacuations, a bitter or otherwise disagreeable taste, a tongue somewhat furred, a turbid or jaundiced hue of the eyes and skin, a harsh, dry surface, high-coloured, bilious, and acrid urine, which often irritates the urethra as it passes, a short, dry cough, depression of spirits, slight febrile excitement towards night, and general emaciation, constitute an epitome of symptoms, which, variously grouped, and in different degrees, not one of them being uniformly present, are, in connection with those above mentioned, sufficiently characteristic of the affection. Chronic hepatitis, like the acute, not unfre- quently ends in suppuration; but it may prove fatal by interfering with the various vital functions, and gradually wearing out the strength, without reaching that process. When not complicated with peculiar organic disease, or sustained by the continuance of its cause, it will generally yield to suitable treatment. Anatomical Characters. As hepatitis is rarely fatal in its first stage, the physician seldom has an opportunity of examining its earlier anatomical characters. It is only in cases of death from some other disease, in the course of AArhich the patient has been attacked with inflammation of the liver, that this opportunity is presented. When the investing coat is inflamed, it is redder and more vas- cular than usual, somewhat thickened, and often covered with an exudation of coagulable lymph, either semi-fluid, or so consistent as to glue together the contiguous surfaces. This exudation in time becomes vascular, and the foundation is thus laid for those permanent adhesions which are occasionally observed between the liver and neighbouring organs. When the parenchyma also is inflamed, the viscus is found partially or wholly congested with blood, more or less enlarged, generally softer and more friable than in health, pre- CLASS III.] HEPATITIS. 515 senting, when torn, a granular aspect, a brighter and deeper colour than natural, and a considerable oozing of blood. "Upon making a section of the viscus with a very sharp scalpel, and wiping with a sponge the cut sur- faces, these present a lighter-coloured reticulum or mesh, studded with red or brick-red granulae, and the divided ends of blood-vessels and biliary ducts." (Annesley.) Sometimes effusion of blood is observed, either diffused through the parenchyma, or filling distinct cavities, which it appears to have hollowed out in the substance of the organ. The outer surface is, in some instances, variously shaded Avith "red, brown, brick-coloured, greenish-brown, and even with almost black spots and streaks." (Annesley.) In the advanced stages, especially in the chronic form of the disease, the liver is sometimes indurated and enlarged from the coagulable lymph exuded into its tissue, and this in- duration may occupy either a part or the whole of the organ. Sometimes, along with the induration, there is diminution of bulk instead of enlarge- ment. This may be explained by the contraction of the fibrin which had been exuded around the vessels, and the consequent diminution or obliteration of their caliber, giving rise to atrophy from want of blood. But more fre- quently, instead of induration, we find softening, either partial or general; and this is sometimes very great, so that the texture of the organ is com- pletely broken up, and the parenchyma reduced almost to a pulpy mass. In the chronic indurations, the colour, instead of being darker or redder than in health, as is usually the case in the inflammatory softening, is apt to be light, and even yellowish-white. But among the most frequent appearances presented by the liver, in ad- vanced and fatal cases of hepatitis, are abscesses occupying either the sub- stance or surface of the organ. When situated in the parenchyma, they appear to have been formed by a softening of the part affected, the subse- quent infiltration of a sero-purulent fluid, and the gradual solution or absorp- tion of the softened tissue, Avhile the production of pus increases. The parts about the forming abscess are more vascular than natural. Sometimes there is only one abscess, sometimes two or more, and occasionally they are very numerous. They are of all sizes, from that of a filbert or less, up to that of one of the lobes, or even of the Avhole organ. Cases are on record in which the liver appears to have been converted into a purulent mass, en- closed in the investing membrane. The pus of one of these abscesses has been known to weigh eleven or tAvelve pounds. They are more apt to occupy the right than the left lobe. Sometimes they are encysted, that is, sur- rounded by a smooth membranous sac, resulting from the exudation of coagu- lable lymph; sometimes the pus is contained in a cavity which appears merely"to have been holloAved out of the substance of the liver, the paren- chyma of which forms its walls. The pus is either genuine, as in ordinary abscesses of the cellular tissue, or is variously altered, being sometimes con- taminated with bile, or the remains of the disorganized substance of the liver, and presenting very different qualities of colour and consistence. Thus, it may be reddish, greenish, or blackish, and either as thin almost as water, semi-liquid, or nearly concrete. Abscesses have also been observed upon the surface of the liver, produced either by the deposition of pus beneath the peritoneal coat, or in cavities formed by adhesions between that coat and contiguous surfaces. Cicatrices of abscesses occasionally exist upon the surface and in the in- terior of the liver, at least, portions of fibrous or cartilaginous matter have been noticed, Avith radii extending to a greater or less distance from the central point, which have been taken for cicatrices, and with the greater probability, as they have been found in persons \vho had been suspected, 516 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. during life, of having been affected with hepatic abscess. (Thompson on Diseases of the Liver and Biliary Passages.) Instances of undoubted gangrene of the liver, following inflammation, have been recorded ; but they are very rare ; and most of the cases which have been considered as gangrene, Avere probably mere softening, as the fetid odour was wanting. Causes. The most frequent cause of hepatitis is long-continued exposure to heat. Hence, the disease is much more common Avithin the tropics than in cold or temperate latitudes, and is generally prevalent in proportion to the degree and continuance of the heat, though this is not uniformly the case. An ele- vated temperature probably operates as a direct stimulus to the liver, and either excites it into inflammation, or sustains it in a state of excessive action, which strongly predisposes it to take on that condition, when exposed to the influence of any other cause. It is probable, also, that the liver is kept, in hot climates, in a constant state of exaltation by the duty of dis- charging from the system the excess of carbon, thrown upon it in conse- quence of an insufficient elimination of that substance through the lungs. Among the agencies which co-operate with heat, one of the strongest is probably that exercised by vicissitudes of temperature ; by changes, for ex- ample, from hot and dry to cold and damp weather, or by exposure to cold in any mode when heated and perspiring from over-exertion. Miasmatic influence is also probably among the frequent causes of hepa- titis. That it is capable of producing this effect indirectly, through the agency of the morbid processes which it sets up in the system, admits of no doubt; for inflammation of the liver is one of the recognized accompani- ments and results of bilious remittent and intermittent fevers. But there is also strong reason to believe that it is capable of immediately deranging the hepatic actions, and, under favouring circumstances, of producing hepatic inflammation. How otherwise can we explain the greater prevalence of all ordinary morbid affections, having their origin in the liver, in hot miasmatic regions than in those-which are at the same time hot and dry ? Hepatitis is said to have been sometimes epidemic ; but it is highly pro- bable that, where this has been thought to be the case, a closer examination would have discovered some local cause sufficient to account for the result, as, for example, miasmatic exhalation. Many other causes of this affection have been enumerated ; as direct in- jury to the liver by falls, blows, &c, or by the presence of gall-stones; violent and fatiguing bodily exertion ; excess in the use of rich animal food ; intem- perate drinking ; the abuse of mercury ; the translation of gout or rheuma- tism ; the suppression of accustomed discharges, especially from the hemor- rhoidal vessels ; paroxysms of violent emotion, as of anger, terror, &c.; and continued mental depression from grief, disappointment, or anxiety. Perhaps the most fruitful of these is habitual intemperance, which, in a vast number of instances, even in temperate latitudes, lays the foundation of chronic disease of the liver. That alcohol taken into the stomach should act with special energy upon the liver will be readily understood, if the prevalent opinion be admitted, that it enters the circulation by the route of the portal veins, and must, therefore, be distributed through the liver before it can reach the system generally. Much stress too has been laid, by some writers, upon the abuse of mercury, especially of calomel, given in such unstinted measure as it often has been in the treatment of bilious fevers, and other diseases incident to hot seasons and climates. The late Dr. CLASS III.] HEPATITIS. 517 Chapman, of the University of Pennsylvania, expressed, in decided terms, his opinion to this effect, and his experience entitles that opinion to great weight. The Avell-knoAvn excitant influence of mercury upon the hepatic functions, would of itself render the production of inflammation from a great excess of its action a highly probable result. I cannot, however, say, though much in the habit of using mercury as a remedy, that I have myself witnessed such an effect; but the reason may be that I have generally been very careful to use it moderately. The liver is undoubtedly often inflamed through the agency of morbid con- ditions of other parts of the system. Diseases of the heart which impede the flow of blood into its right cavities, and diseases of the lungs which produce indirectly the same result, frequently disturb the hepatic functions, and favour the production of chronic inflammation, by occasioning congestion of the ascending cava, and consequently of the liver. Tumours pressing upon the vena cava may have the same effect. Disorders of the stomach and intestines notoriously affect the liver. Between these Structures so close a sympathy exists, that some derangement of the one might be expected as an almost necessary result of serious disease in the other. It is supposed that irritation or inflammation of the orifice of the ductus communis choledochus may travel to the liver, and thus excite hepatitis. But the chief source of disorder of the liver, consequent upon diseases of the alimentary canal, is probably the change in the quantity and character of the blood sent into the former organ through the portal vessels. How frequently must hepatic congestion result from an over-active circulation in the stomach and bowels ! Besides, the noxious contents of the alimentary canal, whether introduced from without, or resulting from morbid secretion or chemical changes in the canal itself, are frequently absorbed into the portal vessels, and carried by its ramifications through every part of the liver before they can enter the system. Upon this organ, therefore, their injurious influence must be first exerted. Hence, dys- pepsia, chronic gastritis and enteritis, dysentery, colic, &c, are not unfre- quently associated with hepatitis, especially in its chronic forms, either as cause or effect. Probably sedentary habits favour the production of chronic hepatitis chiefly by their primary influence on the alimentary canal. Diseases of the brain have also frequently been observed in connection with hepatic inflammation, but whether in the direct relation of cause and effect has not perhaps been so clearly demonstrated. Abscesses in the liver, as the result of fatal injuries of the brain, have often attracted the notice of pathologists ; and many have ascribed them to a direct sympathy between these organs. But similar abscesses have been observed after surgical injuries elsewhere, such as amputation of a limb ; and it is well known that the liver is pecu- liarly apt to feel the influence of those diseases in which the blood may be supposed to suffer under peculiar contamination, such as cancer and fungus haematodes. It is now, therefore, supposed that hepatic abscesses, following extensive injuries, are the result rather of phlebitis and the consequent intro- duction of pus into the circulation, or of a purulent infection of the blood from some other cause, than of mere sympathy. A similar origin is ascribed by Dr. George Budd to the abscesses of the liver, so frequently found con- nected with ulcerations of the stomach and bowels, particularly of the large intestines in dysentery. The ulcer is the source of some acrid product, which, admitted into the blood-vessels, induces that condition of the blood which tends' to the formation of metastatic abscess. (See Metastatic Abscess or Purulent Infection.) Dr.'Budd thinks also that hepatic abscesses sometimes originate, on similar principles, from ulcers of the gall-bladder. (Diseases of the Liver, 2d ed., p. 84.) Finally, age and sex are supposed to have some influence in the causation 518 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. of hepatitis ; and it has been said that children and females are less liable to the disease than adults and males: but, if this difference really exist, it is probably much more owing to difference in exposure to the causes, than to any peculiar susceptibility of constitution. Treatment. In acute hepatitis, when the pulse is strong, and the constitution unim- paired, blood should be taken from the arm in quantities proportionate to the severity of the disease. Bleeding is especially demanded when there is reason to believe that the peritoneal surface is affected; but it is highly important also in the exclusively parenchymatous inflammation. The amount taken should be limited only by the effect upon the symptoms and the circulation. It is so altogether uncertain that no definite rule can be given. In urgent cases the bleeding should be copious, and may be repeated once and again if apparently called for. Even in cases less strikingly developed, it may still be important to resort to this Yemedy ; but always with reference to the pre- vious habits of the patient, and the general condition of his system. It is said not to be borne so well in hot as in temperate climates. Local bleeding is an excellent auxiliary to the lancet, or substitute for it when forbidden. It is very rarely indeed that, in acute hepatitis, blood cannot be taken with propriety from the vicinity of the disease. Some recommend preferably bleeding from the hemorrhoidal vessels ; but I believejthat, in in- flammation of an interior organ, no position is upon the whole so favourable for local depletion as the surface of the body immediately over the part affected. Theory may indicate another point as having a closer vascular connection with the inflamed organ; and it may be difficult to account, in the present state of our knowledge, for the extraordinary influence of the loss of blood from the surface : but speculation should yield to an experience almost universal, and which appears to me to hold as well in this as in other instances. Cups or leeches may be employed. The latter are preferable Avhen there is great tenderness upon pressure, and should of course be used when blood is to be taken from the anus. But, other circumstances being equal, cups are preferable to the side, and especially over the ribs, in consequence of the con- siderable revulsion they produce in addition to their depletory effect. Purgatives are useful, in acute hepatitis, both by their revulsive action, and by the depletion they indirectly produce from the portal veins. Mercurials are especially indicated, in consequence of their property of increasing the hepatic secretion, and thereby directly unloading the congested vessels of the liver. From five to fifteen grains of calomel should be given at the commence- ment of the treatment, and folloAved in a short time by one of the saline ca- thartics, or by the infusion of senna with salts. In the cases of individuals liable to suffer great irritation of stomach and bowels from calomel, an equi- valent quantity of the mercurial pill may be substituted. Sometimes it may be proper to administer the mercurial in connection with a quicker cathartic, as jalap, scammony, &c. ; but this plan is often forbidden by irritability of the stomach. Calomel in smaller doses, from one to three grains, for example, may afterwards be given at bedtime, and followed in the morning by a saline aperient, so as to have the bowels well opened every day. The saline cathar- tics should be largely diluted with water, so as to render them as little irri- tant as possible. It will often be found advantageous, AA'hen the first violence of the inflammatory excitement has been subdued #by depletion, or earlier in cases not requiring depletion, to combine with the calomel at night a grain of opium, and, if there is no irritability of stomach, an equal or double quan- tity of ipecacuanha. By this plan pain and irritation are allayed, the patient rests at night, and the secretory function of the liver is sustained; while, at CLASS III.] HEPATITIS. 519 the same time, the foundation is laid for a full mercurial course, should the disease not appear disposed to yield without it. Should the skin be hot and dry, and the stomach not irritable, tartar emetic in solution may be given in small doses, at short intervals, alone, Or combined with nitre or the neutral mixture. If the patient is affected Avith nausea or vomiting, the effervescing draught would be preferable as a refrigerant dia- phoretic. Under the same circumstances, the Seidlitz powder will be found useful as an aperient; and, should no indication exist either for diaphoresis or purging, the sickness of stomach may be controlled by small draughts of carbonic acid water, and external fomentations or revulsives. When.depletion, along Avith the measures proposed, fails to subdue the in- flammation, the mercurial impression should be unhesitatingly resorted to. In ordinary cases, it is unnecessary to do more than to produce a very slight effect upon the gums. For this purpose, the calomel before given only at night, may be repeated in smaller doses, say from half a grain to a grain, every two, three, or four hours, until it begins to produce some obvious effect upon the mouth; or the mercurial pill may be substituted in double or triple the dose. When the mouth is affected, the remedy should be omitted for a time, and resumed when found necessary to sustain the impression, which should be continued until all signs of the inflammation are subdued, or until it shall be found that mercury is inadequate to this effect. When the stom- ach and bowels do not bear the mercurial well, or the system resists its in- fluence, recourse may be had to the external use of mercurial ointment. In severe and rapid cases of the disease, such as are apt to occur in tropi- cal countries, the remedial means must be proportionably more energetic. In these calomel may be given more freely as a cathartic, and afterwards pushed more speedily in reference to its general effects upon the system; while its operation is aided by mercurial frictions or dressings. In common hepatitis of an acute or subacute character, two or three days or more may be given to the depletory method, before attempting to establish the general influence of mercury; in the more alarming cases, the two plans should be carried into effect simultaneously. While the measures already mentioned are in operation, they should be assisted, in the early stages, by fomentations or poultices to the side, and, after the violence of the inflammatory excitement has subsided under the lancet and pnrgation, by large blisters. These, in connection with mercury, often serve to complete the cure, and prevent the degeneration of the disease into the chronic state. Advantage Avill often accrue from a more or less fre- quent repetition of the blister, one being allowed to heal before another is produced. In some cases, it may be advisable to dress the blistered surface with mercurial ointment. Should evidence of suppuration be presented, both the depletory and mer- curial plans should be omitted, or at least very much relaxed. The indica- tions now are to hasten the suppurating process, to favour its tendency to the surface, and to support the general strength. If any advantageous specific influence over the liver can be substituted for the mercurial, Avhich would now be too exhausting, it should also be resorted to. These indications are best met by the nitromuriatic acid, which operates both as a tonic, and an hepatic alterative, and by emollient cataplasms to the side; Avhile irritation is calmed by opiates, or other narcotics, as hyoscyamus and conium. In many cases, it will be advisable to superadd the use of quinia and the fermented liquors. Recourse may also be had to other mineral acids, as the nitric, sulphuric, and muriatic, in order to vary the tonic impression. In the early stages, the patient should be alloAved cooling drinks, and con- 520 LOCAL DISEASES.—SECRETORY SYSTEM. [PART II. fined to a very low diet, consisting chiefly of farinaceous and mucilaginous liquids. As convalescence advances, the diet may be gradually improved as in other inflammatory affections. During suppuration, also, it is often neces- sary to allow the patient nutritious food, such as preparations of milk, broths, soft boiled eggs, oysters, preceded for a variable length of time, sometimes for many months, by symptoms indicative of deranged health; and these symptoms are often such as depend upon the existence of tubercles in other parts of the body. The child is affected with a dry cough, occasional fever, emaciation, paleness, listlessness, and want of spirits, and various signs of disorder in the digestive organs, such as irregular appetite, diarrhoea or constipation, and unhealthy discharges. Along with these there are also, in many cases, symptoms which belong to the affection of the brain. Occasional attacks of headache, with or without vomiting, are experienced, or the child exhibits other evidences of cerebral congestion. These spells occur usually at irregular intervals; but sometimes they come on at a certain time every day or every other day, with apparently good health between them, so as very much to resemble paroxysms of intermittent fever, for which they have occa- sionally been mistaken. These head affections may gradually deepen into the acuter form of the disease, so that it shall be impossible to decide when the latter precisely commences ; but more frequently the inflammatory symp- toms show themselves abruptly, and the transition from the comparatively latent state to that of excitement is obvious. Not unfrequently, moreover, the acute attack comes on in the midst of ap- parently perfect health, without any warning whatever from preliminary dis- order. In either case, it is marked with more or less of the following pheno- mena. There is in general a disposition in the disease to a certain succes- sion of symptoms, which may be arranged into three successive stages, accord- ing to the example set by that close observer, Dr. Robert Whytt, who pub- lished in 1768, the first very accurate description of the complaint. But it must be acknowledged that the distinction between these stages is not al- ways well observed, and that they are frequently a good deal confused to- gether. The prominent symptoms of the first stage are headache, vomiting, and constipation, with more or less febrile excitement. Not unfrequently the child is seized with a paroxysm of vomiting and pain in the head, without apparent cause, which disappears and returns daily, or two or three times a day, for two, three, or four days successively, before he is taken off of his feet. In other instances, the acute attack begins with chilliness or rigors, followed by fever, together with the local symptoms mentioned. After the disease is completely formed, the pain of the head is almost constant, in some degree, and seldom leaves the patient so long as sensibility remains. It is, however, much more severe at certain times than others ; and every now and then sudden and vio- lent lancinating attacks of it seem to occur, extorting sharp, quick cries or screams from the patient, which are among the characteristic features of the disease. The seat of the pain is most frequently in the anterior part of the head, though it is sometimes referred to the temples or occiput. In very young children, it is exhibited, independently of their cries, by the frequent application of their hands to the head, or by pressing it against the breast of the mother. The vomiting is apt to occur simultaneously with the pains, or soon after them. Sometimes food only is discharged, but more frequently bile. This is always a suspicious symptom in children, when occurring re- peatedly without apparent cause. It does not usually continue longer than four or five days, and sometimes ceases after the second or third. Occasion- CLASS III.] TUBERCULOUS MENINGITIS. 677 ally, however, it lasts much longer, especially when the disease commences with isolated paroxysms of headache and vomiting. Constipation is very common in the early stage, and sometimes yields with great difficulty even to active medicines. The stools, when obtained, are usually green or dark-coloured, and sometimes black. They are seldom quite healthy. Occasionally the patient experiences abdominal pains. The pulse is usually more or less excited, sometimes considerably so; and there is generally some febrile heat. The face, usually rather pale, exhibits at times remarkable flushes of redness, which quickly disappear, and often coincide in their occurrence with the paroxysms of severe pain and vomiting. The tongue is moderately furred and quite moist. There is little or no thirst; and occasionally the patient exhibits even aversion for drinks. The eyes are painfully sensitive to light, so that they are usually kept forcibly closed, and the patient cries if attempts are made to open them. The pupils are in some instances contracted, in others dilated; and these conditions sometimes quickly alternate. The child often has a characteristic frown upon his brow, and an expression of pain, or vacancy, or as if he were stunned, upon his countenance. The character appears to have undergone a change, and the playful temper of childhood is replaced by peevishness, fretfulness, or irasci- bility, without obvious cause. He is seldom, however, delirious at this period, but, if old enough, sometimes shows sagacity by his answers. Not unfrequently several days thus elapse, before he is quite confined to the bed. The second stage is characterized by the supervention of more decided nervous symptoms, and of diminished frequency with irregularity of the pulse. The period at which the change takes place is altogether uncertain. It may come on in a day or two, or be postponed for a week. The symptoms not unfrequently also mingle with those of the first stage, so that no distinction of stages can be made. The pulse gradually diminishes to 80, 70, or 60 in a minute; and Guersent states that he has known it to descend even to 48. At the same time it is rather full, and more or less irregular, being faster at one time than another, now large and then small, and almost always inter- mittent, either at fixed or uncertain intervals. The respiration also becomes irregular both as to the succession and length of inspirations, is occasionally broken by deep sighs or yawnings, and is in some instances so long inter- rupted as to suggest the fear that it may not return. It is slower than in the first stage. The heat of the skin diminishes, and the patient is often affected with partial or general sweats. The paroxysmal flushes of the face continue. A disposition to drowsiness or stupor comes on, during which the patient grinds his teeth, and if roused, has a look of idiocy or intoxication, answers with difficulty questions that may be asked, and immediately relapses into sleep. In this state he often moans, and occasionally sends forth sharp cries, probably marking attacks of pain. Instead of stupor, he is sometimes affected with delirium, which in a few instances is wild and restless, but is generally calm, and attended with low mutterings. This seldom continues more than two or three days, and then gives way to coma. The eyes are closed or par- tially open, and the patient seems unable to command the movements of the lids, which only partially obey the will when he wishes to raise them. The pupils are usually dilated, in some instances equally, in others unequally, and are little sensible to light; vision is impaired or disordered ; and strabismus often takes place, sometimes in a converging, and sometimes a diverging direction. The hearing is less affected than the sight. The tongue remains moist, the vomiting ceases, the constipation is less obstinate and yields to purgatives, and the abdomen is singularly retracted. There seems to be no disgust for food, and the patient swallows what is given him. This period often continues a week or ten days. In the course of it, a remarkable remis- 678 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. sion of almost all the symptoms occasionally takes place, giving to the inex- perienced strong hopes of convalescence. There is sometimes, under these circumstances, no other sign of the disease remaining than irregularity of the pulse, and an unnatural expression of countenance. But the amelioration soon disappears, and the symptoms return with others still worse. In the third stage, signs of a more profound cerebral lesion are presented. A disposition to tonic spasms is evinced in some part of the body. The flexors of one of the extremities, especially of the arm, contract somewhat rigidly, and attempts to straighten the limb are resisted, and appear to pro- duce pain. The jaws are sometimes stiffly closed, the muscles of the back become rigid, and the head is occasionally drawn backward. Painful contrac- tion of the cervical muscles is a very frequent symptom, aud may often be noticed before the supervention of the last stage. The rigidity is in cer- tain rare cases so extensive that the body seems as stiff as a board, and can be raised by the head and feet without bending. Along with these spastic contractions, there are occasional convulsive movements, more or less exten- sive. The patient is affected with subsultus, carphologia, and sometimes with a cataleptic state of the limbs. Partial palsy at length takes place in one or more of the extremities; the surface becomes insensible to the touch, and the eyes to light; hearing gives only vague evidences that it still exists; the patient sinks into profound coma; the pulse becomes regular, and more and more frequent, rising sometimes to 120, 140, or 160, in a minute, or even still higher, being at the same time very feeble; the face often assumes a violaceous hue, and is utterly expressionless ; the eye is quite dim and as if covered by an opaque film ; the surface becomes cold ; involuntary evacua- tions take place ; and the patient dies, often in convulsions. But this is not the uniform course of the disease ; and the symptoms enu- merated occur sometimes with great irregularity. Thus, in some instances, the attack begins with delirium. In others, convulsions take place at an early period; but, according to Barthez and Rilliet, only in cases in which there are tubercles in the substance of the brain. Cases have occurred in which there was a total want of drowsiness until near the close. Others have exhibited coma at the commencement, and throughout the course of the dis- ease. Instead of constipation at the beginning, there is sometimes diarrhoea, in consequence of complication with enteric inflammation. Occasionally the attack is made insidiously. The patient has some of the preliminary symp- toms enumerated, but not such as to rouse the attention of his attendants to the danger, when all at once the acute symptoms come on with great violence. The approach of the disease is, in other instances, concealed by scarlatina, smallpox, or other febrile affection; and it is not suspected until it comes forth under full sail from the mist which had enveloped it. The duration of the attack, counting from the first appearance of the vomiting and headache, is usually from one to three weeks ; though death may take place in a shorter time, even so early as the third or fourth day, and may be postponed for six weeks or two months. The greatest number of patients probably die in the course of the third week. Anatomical Characters.—The chief characteristic anatomical peculiarity of this disease is the existence of minute bodies, round or somewhat flattened, translucent or opaque, gray or whitish or yellow, from the size of a grain of sand to that of a pin's head, dispersed here and there over the surface of the brain and cerebellum, and situated beneath the arachnoid, in the substance of the pia mater. They are found upon all parts of the surface, the convex and lateral portions, as well as the base, in the anfractuosities of the convo- lutions, and in the fissures. They may be on both sides of the brain, or only upon one side ; and may be confined to a single spot, or may exist in several; CLASS III.] TUBERCULOUS MENINGITIS. 679 and all this without any appreciable bearing upon the symptoms of the case. From a table of cases given by Barthez and Rilliet, it would appear that, contrary to what had been previously supposed, they are more frequent upon the convex surface of the brain than at the base. They are much more abundant upon the brain than the cerebellum. They are often isolated, but sometimes grouped in patches, and are apt to be arranged along the veins of the pia mater. In number they vary exceedingly. Sometimes not more than four or five of them can be detected, sometimes they are scattered in count- less numbers through the pia mater. When the brain is exposed by the re- moval of the dura mater, they may be seen like yellowish specks through the transparent arachnoid, scarcely rising above the general surface. Sometimes, in order to see them distinctly, it is necessary to separate the membrane, and hold it up to the light. These bodies are altogether identical with the granulations found in other parts of the body, in tuberculous cases. In some instances, larger tubercles are found, from the size of a millet-seed to that of a filbert, and occasionally several miliary tubercles aggregated together, with portions of the pia mater included in their substance. In such cases, the number of the separate tubercles is always small. The free surface of the arachnoid exhibits few signs of inflammation. The membrane has now and then an opalescent appearance in particular situations, and not unfrequently is somewhat viscid upon the surface. More rarely, it is in places thicker and firmer than in health, and capable of being removed along with the pia mater without tearing. Occasionally there is a little serum in its cavity, but very seldom either coagulable lymph or pus. The pia mater almost always exhibits marks of inflammation, being in- jected, thickened, and infiltrated with a serous, gelatinous, or turbid liquid, but very rarely with fluid pus. But very often a concrete yellowish matter is seen deposited in its tissue, sometimes soft and inelastic, sometimes firmer, elastic, and somewhat shining, and supposed to consist of concrete pus, or coagulable lymph. This yellowish matter is either in patches, or deposited in lines bordering the blood-vessels; and is much more commonly seen at the base of the brain than upon its summit; as is the case also with the other signs of inflammation in the membrane. Miliary tubercles are often interspersed in the midst of the gelatinous and yellowish deposit. The latter sometimes covers almost the whole base of the brain in a continuous layer. But there is no precise relation between the numbers of granula- tions, and this product of inflammation ; nor do they necessarily occupy the same portions of the surface. Sometimes the tubercles are seen with only a slight redness or infiltration around them, scarcely amounting to in- flammation. The brain itself exhibits morbid appearances. The convolutions are much flattened, and sometimes quite effaced, either by the cerebral tur- gescence, or the amount of fluid in the ventricles. The cortical portion is reddened, and sometimes softened in the vicinity of the inflamed patches. The medullary portion, when cut, appears often as if sanded over with red specks. The ventricles usually contain an abnormal quantity of serum, either perfectly colourless and limpid, or somewhat turbid, probably from the pro- ducts of inflammation in the ventricular walls, as supposed by Abercrombie, or from the softened tissue of the brain itself, as suggested by Barthez and Rilliet. The amount of fluid varies from a few drachms to four, six, or eight ounces, and sometimes even exceeds the last-mentioned quantity. Oc- casionally however, there is no increase whatever beyond the healthy amount of serosity * and yet the symptoms during life are not materially different, 680 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. showing that the effusion is not an essential feature in the disease, which has, therefore, no claim to a place among the dropsies. The medullary substance which bounds the ventricles is much softened, sometimes to the consistence of cream. This change is especially observable in the septum lucidum, and the fornix. It may be of moderate extent, or may involve the whole of the walls of the ventricles ; and the amount of it bears no fixed relation to the quantity of fluid. Some writers, with Dr. Abercrombie, ascribe this softening to inflammation; others, taking into consideration the absence of all the other marks of this kind of affection, consider it as resulting from the infiltration of the medullary substance by the effused serum, in which it undergoes a kind of solution. Abercrombie gives cases in which the same softening was observed without any effusion. In almost all cases of tuberculous meningitis which have been examined, tubercles have been found in other parts of the body, as in the substance of the lungs, the bronchial glands, &c, showing that the cerebral disease is the result of a general tuberculous diathesis. The mucous coat of the stomach is frequently in a softened state. Causes.—This disease is often hereditary in the same sense as other tuber- culous diseases ; that is, the general diathesis or predisposition is derived from the parent, and circumstances afterwards give it one or another direction. The meningitis can scarcely be said to be itself hereditary ; as persons af- fected with it very seldom live to be parents. Nevertheless, children are certainly born not only with a general tuberculous diathesis, but also with a particular tendency to this disease; as proved by the fact, that in some families almost all the children die with it, one after the other, without any appreciable external cause, and solely in consequence of some peculiarity in their organization. It is possible that the diathesis may be created, after birth, by the opera- tion of those various causes which have been detailed under the head of tuberculosis, external scrofula, and phthisis, and which it is unnecessary to repeat here. But the probability is, that the predisposition is much less fre- quently created than in the case of consumptive patients, because the early age at which this form of meningitis comes on frequently precludes, to a very great extent, if not entirely, the operation of the predisposing causes. Among the influences which give a special tendency of the tuberculous predisposition to display itself in the brain, the most powerful is that of age. What it is in early life that leads to this result is not so certain. Some have ascribed great influence to the process of dentition; but it appears from recent researches that, though the disease is frequent during the period of the second dentition, it is rare during the first, which is so much more frequently the source of other diseases. Some other agency must, therefore, be sought for, and none appears to be so probable as the greater activity of the brain at this period of life, when not only more ideas are received than at any other period, but the necessities of a very rapid physical development require and sustain a constant excitement of the nervous centres. The time of life in which the disease is most frequent, is said to be between the fifth and tenth year. It is not uncommon from the second to the fifth year. Before the second, and after the fifteenth year, it is comparatively rare. Neither sex nor season appears to have any peculiar influence over the disease. Numerous causes have been accused of exciting the disease, or calling the diathesis into action. It is probable that whatever irritates the brain may tend to this result. When the tuberculous predisposition exists, what- ever over-excites the vessels of a part, and disposes to exudation, must endanger the elimination of tuberculous matter in that part. It is not sur- CLASS III.] TUBERCULOUS MENINGITIS. 681 prising, therefore, that falls upon the head, or other local injury should have the effect of producing attacks of tuberculous meningitis. Perhaps too much stress may have been laid upon this cause, but I do not think its oc- casional efficiency can be denied. Other exciting causes are direct exposure to the sun's rays, violent emotions as of anger or fright, a premature or too powerful exercise of the brain in the processes of education, the disappear- ance of cutaneous eruptions, worms and other causes of irritation in thte alimentary canal, various febrile diseases, and probably sometimes dentition, which, though it may not be sufficient to cause the disease before the pre- disposition to it is formed, is no doubt capable, in some instances, of acting as an exciting cause. Nature.—Some doubt has been entertained whether the tubercles, in these cases, are the cause, or the result of the inflammation. When the consist- ence of some of these small bodies, which are hard and resistant to pressure, is considered, it seems improbable that they should have been very rapidly produced; and, as they have been found without any attendant inflammation, or any signs of its previous existence, it is clear that this process is not essen- tial to their formation. The inference is not unfair, that they are sometimes at least the result of a slow, and probably uninflammatory deposition, and that, after attaining a certain degree of development, they may either directly excite meningitis, or may keep the membranes in a state of irrita- tion, which may be excited into inflammation, by slight accidental causes. But, at the same time, it is in the highest degree probable that an irritation or inflammation in the brain of a child, predisposed to this disease, may occa- sion the deposition of tuberculous matter; and that thus a scrofulous predis- position, without the present existence of tubercles in the meninges, may give a fatal character to accidental inflammation. It appears that, in many cases, there is a peculiar yellowish deposition, like concrete pus, within the meshes of the pia mater, which differs from the results of ordinary inflammation, observed in cases in which there are no tubercles in other parts of the body, and consequently no proofs of a scrofu- lous diathesis. The differences between this deposition and that which at- tends inflammation in persons without tuberculous tendency, as pointed out by Barthez and Rilliet, are, that the former is almost always solid, the latter almost always liquid; the former occurs more especially at the base of the brain, the latter upon the convex surface; the former is of limited extent, the latter may spread over the greater portion of the surface of the brain; and, finally, the former attacks almost exclusively the pia mater, while the latter occurs habitually in the great cavity of the arachnoid. ( Trait, des Malad. des Enfants, iii. 487.) This matter may be associated with tubercles in the pia mater, or may be wholly independent of them. When tubercles exist in this membrane, the deposition may occupy the same parts as the tubercles, or may be found in others. It is not, therefore, necessarily the direct result of the irritation of the tubercles; and must be ascribed to a peculiar influence exerted upon the nature and results of the inflammation by the scrofulous or tuberculous diathesis. It may possibly be the product of such an acute action of the vessels as, if chronic, might produce proper tuberculous matter. It appears, then, that, though tubercles in the meninges are commonly present in tuberculous meningitis, and serve as the exciting cause of the in- flammation, yet the scrofulous diathesis, as evinced by tuberculous deposi- tion in other parts of the system, is capable of producing the same kind of inflammation of the membranes of the brain, without the existence of granu- lations, or other form of tubercle within the cranium. Diagnosis.__The disease from which it is most difficult to distinguish the VOL. II. "" 682 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. one under consideration is simple meningitis ; and there can be little doubt that the two affections, as they occur in children, are very often confounded. Among the most certain criteria is the existence or non-existence of signs of scrofulous or tuberculous disease elsewhere. If the child has an obstinate cough, tumid abdomen and diarrhoea, or the marks of external scrofula, there is every reason to fear that the meningitis is tuberculous. In the absence of all such signs, the hope may be indulged that it will turn out to be simple. There are, however, points in which the two affections generally differ; though there may be individual cases which cannot be distinguished. In simple meningitis, the febrile excitement in the early stage is higher, with more heat and thirst, more delirium, and greater acuteness in all the symptoms. The vomiting is more frequent, the headache more continuous and less parox- ysmal, and the patient is sooner compelled to take to his bed. The march of the disease is more rapid, the agitation and wildness in the course of it are more striking, and comatose symptoms .appear more quickly. Simple me- ningitis often terminates in less than a week; the tuberculous generally con- tinues till the close of the second, or some time in the third week. The time of life should also be taken into account. Tuberculous meningitis seldom occurs before the end of the second year ; the simple inflammation often. The various febrile diseases may for a time, in certain stages, be mis- taken for tuberculous meningitis, especially enteric or typhoid fever; but the mistake cannot be of long duration. A careful study of the characteristic symptoms of each disease will guard against a continuance of the error. The violent and paroxysmal pains in the head; the vomiting without obvious cause; the sudden sharp screams; the pulse at first somewhat excited and afterwards slow, intermittent, and irregular; the irregular respiration, with deep sighs and yawns; the constipation, dark-green or black discharges, and retracted abdomen ; the dilated, contracted, or oscillating pupil; the strabismus; the tonic and clonic spasms; and the final partial palsy, will, in general, be suffi- cient to distinguish the meningeal affection. Occasionally almost all the peculiar symptoms of the disease are imitated by mere functional derange- ment, sympathetic with disease in the alimentary canal or elsewhere; and, in cases of this kind, dissection after death has revealed, to all appearance, a perfectly sound state of the encephalon. In such cases, however, there is generally some one characteristic wanting, either in the symptoms or the course of the disease, upon which a probable diagnosis may be founded. Thus, the patient may be affected with most of the prominent symptoms of tuberculous meningitis, but may want the characteristic condition of the pulse, somewhat excited at first and regular, then slow and intermittent, and finally rapid and again regular. Prognosis.—This is almost always unfavourable. It is scarcely possible that recovery should take place with the pia mater loaded with irremovable tubercles. Dr. Whytt states that he never cured one of his patients. MM. Barthez and Rilliet never saw a case recover. M. Guersent, who witnessed a great multitude of cases, considers the disease as scarcely curable in any instance in the second stage, and quite incurable in the third. He is dis- posed to think that he has been successful with some cases in the first stage, but admits that the precise character of these is always doubtful. Very dif- ferent accounts, however, are given by other practitioners of their success. Dr. Golis, of Vienna, who had charge of an institution for children in that city, states that he has witnessed 41 recoveries. According to Dr. Odier, of Geneva, one-third of the cases of acute hydrocephalus in that city get well. Formey cured nearly all wrhdm he had the opportunity to treat in the early stage. It is quite obvious that these statements have reference to different dis- eases. Many of the cases cured were undoubtedly either simple meningitis, CLASS III.] TUBERCULOUS MENINGITIS. 683 or mere imitative functional derangements of the brain. It is impossible otherwise to account for the different success of skilful practitioners, with plans of treatment not essentially different. / I have occasionally seen cases of cerebral disease recover, which appeared to me to present the characters of acute hydrocephalus, as this complaint was formerly defined; but I have never seen a well marked case of tuberculous meningitis end favourably. Still, the practitioner should not be discouraged, and should never intermit his efforts. There is always the hope, in the early stage, when the patient is not obviously tuberculous, that the disease may be simple meningitis, and consequently curable. There is the hope, too, that, even though the subject may be scrofulous, the tuberculous matter may not have been absolutely deposited in the brain, and the timely application of remedies may prevent the deposition. Even in the second or third stage, there is still the fact, that patients presenting the same symptoms have recovered; and the inference may be drawn, that possibly the diagnosis in the case under treatment may not be correct, and that the event may be equally fortunate. Treatment.—It has been recommended by some writers to be sparing in the use of depletory remedies in tuberculous meningitis; as it is well under- stood that whatever lowers the grade of vital power, and deteriorates the blood, favours the deposition of tubercle. This is undoubtedly true as a general fact; but the inference is not, I think, just, in relation to this par- ticular disease. It is admitted that, if tubercles are already formed in the membranes of the brain, sufficient to induce the symptoms of acute menin- gitis, there is scarcely any ground for hope. The disease, it is thought, must almost inevitably prove fatal. The most that can be expected is to protract life a short time, and with it the sufferings of the patient. Now this is scarcely desirable; and even this little will fail to be gained in the vast majority of cases. Abstinence from active measures has, therefore, little to recommend it. But, if the practitioner should have made a wrong diagnosis, or if the case should be one of those in which tubercles are not yet formed, but only in danger of being formed should the inflammation continue, it is obvious that the expectant plan surrenders a case as hopeless, in which great good may possibly accrue from energetic measures. The inference from this is, that active treatment can do little or no harm, even if unsuccessful, while it may possibly be the means of rescuing the patient. It appears, then, to be the duty of the physician to treat such cases with all the energy which the strength of the system will permit. Whatever danger there may be arises, in nearly all instances, immediately from the inflammation; for even where tubercles are present, it is through this process that they almost always work out their fatal results; and, where they are not yet formed, it is this which most strongly disposes to their depo- sition. It is inflammation, therefore, that is to be combated. The treatment recommended for simple meningitis is exactly that required, upon the princi- ples above stated, for the tuberculous variety. It is even more important in the latter, that the remedial measures should be early applied; for it is in the first stage especially that there may be some reason to hope that the tuber- culous deposition may be prevented. To give the treatment in detail in this place would be mere repetition. The reader is, therefore, referred to the article upon simple meningitis. General and local bleeding, active purgation with calomel and suitable adjuvants, cold to the head, revulsion by means of blisters over the scalp, and the introduction of mercury into the system both internally and through inunction, so as to produce its constitutional impres- sion, are the remedies to be employed. Depletion should be pushed to what- ever extent the strength of the patient will permit. No precise directions 684 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. can be given adapted to each case. As a general rule, this variety of menin- gitis does not bear bleeding so well as the simple; and, therefore, less blood must be taken. Calomel, however, as a purge, may be employed, in the cases of children, almost indefinitely. Enormous quantities have sometimes been given with impunity, and even with asserted benefit. But all that can be effected by these quantities can be gained from more moderate doses; as a great proportion of what is given lies inert in the bowels. From four to ten grains may be given at first to a child of two years or upwards, and, if it do not operate too actively, may be followed by the same quantity daily until the period for depletion is passed. After this time, it may be continued in smaller doses, frequently repeated, from one-quarter of a grain to a grain, for example, every hour, with a view to affect the system; while mercurial oint- ment is rubbed upon the insides of the limbs, and applied to a blistered sur- face over the scalp. When an impression is made upon the mouth, the mer- curial should be suspended. Instead of blisters to the scalp, and at the same period of the disease, pustulation by tartar emetic has been strongly recom- mended ; and Dr. Hahn, of Aix-la-Chapelle, records several cases in which the remedy has proved effectual, though it sometimes induces disagreeable ulceration and even sloughing in the infantile scalp, which may last long, and leave indelible traces behind them. He recommends to pustulate a sur- face of five or six inches in diameter, avoiding with great care the fontanels. The tartar emetic ointment is to be rubbed for about ten minutes on the scalp, previously shaved; and the application is to be repeated every two hours, until the surface becomes decidedly affected. (Archives Gen., ieser., xx. 411, and xxi. 58.) One additional remedy should be employed in this form of meningitis, from its supposed influence over the scrofulous habit of body, and in the hope that, if it do not promote the absorption of the tuberculous matter, it may possibly prevent its deposition. I allude to iodine. I would commence with it in such doses as the stomach of the child could bear, and continue it through- out the treatment. Iodide of potassium, or the compound solution of iodine (U. S. Ph.) should be employed. Iodide of mercury might, with great pro- priety, be substituted for the calomel at the stage at which it is desirable to aim at the mercurial impression; and, in this case, the other preparations of iodine should be abandoned. In the last stage, when the strength of the patient declines, it should be supported by mild stimulating measures and nutritious food, upon the ground that, should the disease be of a less serious character than it seems, life might not be lost from sheer prostration. Instances have occurred of recovery under apparently quite desperate circumstances. There can be little doubt that, in these cases, the nature of the disease was mistaken; but the most skilful are liable to similar errors, and the patient should not be allowed to lose the benefit of this chance. Besides the remedies mentioned, many others have been employed, most of which, however, so far as regards any impression on the disease, are useless or worse than useless; and to repeat them would be unnecessarily to embar- rass the student. A few merit, perhaps, a brief notice. Digitalis has been employed, in the early stage, in order to reduce excitement. I believe that it is useless for this purpose; but, combined with calomel or iodide of mer- cury, it may be given in the second stage, to promote the absorption of the effused fluid. Other diuretics have also been proposed, as squill, colchicum, spirit of nitric ether, and oil of turpentine; but they are of little use. In the progress of the complaint, indications are often presented for the ano- dyne and composing influence of opium, or other narcotics. All these are obviously contraindicated, in the early stages, by the excitement existing in the brain. In the advanced periods, they may be used more safely, but CLASS III.] TUBERCULOUS MENINGITIS. 685 always require caution. In cases which assume a somewhat chronic march, and especially when, with suspicious but not certainly characterized cerebral symptoms, there are evidences of a scrofulous state of system, cod-liver oil should be employed. I have seen the most threatening symptoms disappear under the use of that remedy. The functional or organic disorders, frequently occurring in the course of the disease, are to be combated by means which the general knowledge of the practitioner must suggest; reference being always had to the influence of such incidental measures upon the brain. Thus, vomiting is to be treated by small doses of effervescing draught, carbonic acid water, or lime-water and milk, internally, and by sinapisms, aromatic cataplasms, or other rubefacient applications, to the epigastrium; obstinate constipation, should it resist pur- gatives, by enemata of various kinds; diarrhoea, occurring in the advanced stages, or as a complication, by the cretaceous preparations, vegetable astrin- gents, and acetate of lead, &c.; abdominal pains with tenderness on pressure, by leeches, emollient poultices, and blisters ; and convulsions, independently of the remedies addressed directly to the disease, by the warm bath, garlic poultices to the feet, and frictions with garlic and brandy, oil of amber, oil of turpentine, &c, along the spine. But prevention is of more importance in this affection than remedial treat- ment. When, from the previous death of one or more children in a family, there may be reason to apprehend that others may be predisposed to the disease, a plan of preventive treatment should be commenced at birth, and perseveringly maintained till the period of danger is passed. This plan must be directed to the counteraction of the tuberculous diathesis. The basis of it must be to maintain the general health in a vigorous state, but without ex- citement. Care should be especially directed to the formation of healthy blood. The child should receive its nourishment from a perfectly healthy nurse, in whom there can be no reason to suspect any scrofulous tendency. If the mother have not these requisites, she should surrender this part of her charge to another. After weaning, the child should be fed on a nutritious and easily digestible, but not a stimulating diet. Milk, farinaceous products, the more digestible fruits and vegetables, and meats in moderation may be used. Tea and coffee should be entirely forbidden. The child should not be shut up in close rooms, but exposed to the air, and encouraged to exercise himself out of doors, as soon as his age will permit; the precaution being , always taken to keep him warmly clad, and to prevent the depressing effect of continued cold. The brain should never be overtasked; and mental edu- cation, though not entirely neglected, should be postponed to the physical. Long sitting in close school rooms would be highly injurious. Care should be taken to obviate the ill effects of dentition. If eruptive affections appear about the ears, too much solicitude should not be evinced for their removal; and, if any suspicion exist of a disposition to internal scrofulous affections, attempts should be made by blisters behind the ears, or upon the arm, by pustulation with croton oil in convenient situations, by a seton in the back of the neck, or some similar measure, to give the disease an external direction. These measures may be aided by the moderate internal use of cod-liver oil and the preparations of iodine. Children with such predispositions are apt to be injudiciously indulged, and every caprice attended to by the fond and fearful parent, lest injury might result from the irritation produced by de- nial. No plan of treatment could possibly be worse. An excitable state of the brain is thus fostered and sustained, and the child, besides, made liable to constant injury from the violence of temper occasioned by accidental dis- appointment. The contrary course should be adopted. The child should be taught to control his temper, to be moderate in his desires, and to meet disappointments with equanimity. 686 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. Article II ORGANIC DISEASES OF THE BRAIN. For the sake of brevity, this designation is here employed to express or- ganic affections of the brain not dependent upon inflammation, effusion, or rupture of the vessels. Strictly speaking, inflammation and hemorrhage, and the results of an abnormal collection of fluid within the cranium, are organic affections; but they are considered under other heads. This preliminary ex- planation is made in order to prevent misapprehension. 1. Non-inflammatory Softening of the Brain.—This is a not uncommon affection. It has already been referred to, in connection with inflammatory softening, under cerebritis; but its importance entitles it to a distinct consideration. Sometimes the whole brain is softened, as in cases of malignant febrile diseases, in which the blood is greatly depraved. I have seen the whole brain almost diffluent in a case of malignant scarlatina in an adult. But most frequently the affection is limited; and it is only in the latter condition that it is here to be considered. It may be seated in the brain or cerebellum, and in the gray or white matter. In the medullary por- tion it is of a white colour; and hence has been named white softening, to distinguish it from the softening of inflammation, which is either red from the presence of blood, or in various degrees yellow from pus. Its consistence varies from nearly that of healthy brain, to the diffluence of cream, so that it may be washed away by a stream of water, or float off into the liquid which may abnormally collect in the ventricles. Under the microscope, it may ex- hibit signs of fatty degeneration of the blood-vessels; but none of the pro- ducts of inflammation are discoverable, neither exudation or compound gran- ular corpuscles, nor those of pus. The symptoms are those of a failure of the cerebral functions, without any signs of excitement. General weakness, giddiness, uncertainty of gait in walking, and more or less intellectual feebleness, especially as regards the memory, are not unfrequent symptoms in the earlier stages. Tremulousness on attempt at motion, sometimes confined to a single limb, or greater in one limb than the others, is also not unfrequently observable. When these phe- nomena exist, with a pale face and feeble unexcited pulse, cerebral softening may be suspected. More decided symptoms, however, are sensations of numbness in some part of the body, and a gradual failure in the power of motion, which may be confined to one limb, one feature, or a single muscle, or may extend more or less to one-half of the body. This condition at length deepens into complete paralysis; and not unfrequently apoplexy takes place in consequence of the rupture of the enfeebled vessels, and the escape of blood into the substance of the brain. Palsy from this cause differs from that produced by cerebritis in the absence of those rigid contractions of the muscles so characteristic of inflammatory softening. A loss of sexual pro- pensity, and an incapability of associating movement, might lead to the sus- picion of softening of the cerebellum. The causes of the softening may be general or local. An impaired con- dition of the blood is the main condition through which the former causes operate. I have known an extremely anemic individual to be attacked with hemiplegia, which yielded to a tonic treatment, and which I believed to be dependent on softening of the brain. Intemperance probably acts partly in this way, and partly by over-excitation of the brain, followed by depression. CLASS III.] HYPERTROPHY OF THE BRAIN. 687 The local causes are such as impede the access of blood to the parts of the brain affected, so that their nutrition cannot be duly supported. Of this kind are diseased conditions of the arteries at the base of the brain, and in gene- ral those which supply that organ with blood, especially the carotids. Or- ganic affections of the coats inducing coagulation; arteritis producing the same effect, and sometimes causing obliteration of the vessel; fragments of fibrinous coagula transferred from the heart, or from an aneurismal tumour, to the cerebral vessels; the narrowing of these vessels by the pressure of tumours, and the tying of the carotid, are causes of the kind referred to. Another cause of softening is supposed to be infiltration of the cerebral sub- stance by serous liquid in the ventricles or the arachnoid cavity.* The treatment must consist of measures directed to the sources of the affection. In cases of general debility with impoverished blood, the obvious remedies are tonics, a nutritious diet, and the preservation of the various functions as nearly as possible in the normal state; and, among the tonics, the chalybeates are probably the most valuable. For the removal of the local causes, so far as they can be reached, the appropriate measures have already been mentioned under arteritis, coagula in the blood, &c. By a timely re- cognition of the disease, and the use of suitable means of cure, I have no doubt that many cases of cerebral softening may be arrested, and, where they cannot be cured, as too often happens from the irremediable nature of the cause, life may often be considerably protracted. 2. Hypertrophy Of the Brain.—This is an increase in the bulk of the brain from excessive nutrition, in other words an over-growth of the organ. Not unfrequently, upon opening the cranium and dura mater, in post-mortem examinations of patients who have died of cerebral disease, the brain bulges out more or less through the opening, in consequence of a real or apparent increase of dimensions from congestion, inflammation, hemor- rhage, or effusion into the ventricles. But this is not the affection alluded to in the present paragraph. In proper hypertrophy, the dimensions of the brain are not increased by the afflux of blood, or the formation of cavities within it containing liquid, but by an excessive production of the cerebral matter. When it occurs before the closure of the fontanels, so that the cranium may expand to correspond with the dimensions of the brain; or when the cranium is developed proportionably with the brain itself, the head may be so large as to occasion some inconvenience by its weight; but the affection can scarcely be considered as morbid. The case is much otherwise, when, as generally happens, the skull refuses to yield, and the brain is con- sequently compressed within dimensions which are too narrow for it. Under these circumstances, it constitutes a serious, though happily a very rare mopo QA When the dura mater is divided, the cerebral mass projects through it, as * Dr Duparcque of France, records cases of softening occurring in the brain in children, which, upon the closest examination, exhibited no appearance of inflamma- tion after death, and the symptoms of which differed from those of any recognized variety of cerebral inflammation. The attacks occurred in children of precocious or highly cultivated intelligence, whose minds had been fatigued by intellectual labour, or subjected to profound or vivid emotions. The prominent symptoms were headache vomiting, slight somnolency, trembling, integrity of the intellectual functions, and exaltation of special sensibility, without fever increased frequency of pulse convul- sions, rigidity of the muscles, or paralysis. Death occurred rather suddenly, with general prostration, and slight convulsive movements. (Arch. Gen ie ser., xxvm. 163. In the non-inflammatory softening produced by obstruced vessels, the most prommen symptom is ordinarily paralysis, with more or less headache and vertigo, and without the muscular rigidity which characterizes the lesion when dependent on inflammation. 688 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. if too large for its unyielding envelope. The convolutions appear flattened, and as it were "heaped upon one another;" the ventricles are obliterated; no serum is discoverable in any part of the cranial cavity; the membranes are remarkably dry; the blood-vessels are empty; the cortical portion appears blanched nearly to the paleness of the medullary; no red points are seen when the brain is divided ; the cerebral substance is firmer than in health; and the whole brain considerably heavier. It is obvious that fluids have been in great measure excluded by the accumulation of the cerebral matter. The cerebellum is in general not involved in the disease. Symptoms.—The affection may exist long with little observable derange- ment of health. Among the first symptoms is usually headache, which oc- curs generally in paroxysms, and is often exceedingly violent. In some in- stances, these paroxysms are attended with vomiting. After a longer or shorter time, other symptoms appear, of which the most prominent are con- vulsions. These are sometimes of an epileptic character, sometimes partial, affecting one or more limbs, the face, or one-half of the body. At length, the senses become affected; dimness of vision or temporary blindness occurs, especially during the paroxysms of headache and vomiting; hearing and the sense of touch are impaired; and, though palsy may not take place, there is uncertainty in the movements of the patient, who obviously has not complete control over the muscles. The mind, at first little disordered, and sometimes correct to the last, generally fails more or less as the disease advances; and depression of spirits, indifference, loss of memory, and intellectual hebetude come on, ending in permanent delirium or imbecility. The organic functions suffer little in the progress of the complaint. With the exception of occa- sional vomiting during the paroxysms, the digestive organs are scarcely de- ranged ; the skin remains cool; and the pulse, if in any respect altered, is somewhat slower than in health. At last, however, the convulsions become almost incessant; the bodily powers give way, and the patient, if not carried off by some incidental disease, dies with coma, convulsions, or syncope. The disease is often several years in running its course; during which, though there may be occasional remissions and partial amendment, the symptoms on the whole gradually become graver to the end. The chronic character of the affection distinguishes it from acute menin- gitis ; and the want of local rigidity and paralysis, from cerebritis. This last character may also serve to distinguish it from tumours in the brain. With chronic meningitis, and chronic effusion into the ventricles, it might easily be confounded, especially with the latter, when unattended with en- largement of the cranium. Dr. West gives the following diagnosis between hydrocephalus and hypertrophy in children. The cerebral disturbance is much more marked in the former. In both the head is enlarged, and ossifi- cation of the skull is tardy, but the enlargement is less in hypertrophy, and the fontanels and sutures not so widely open. Nor is there tension or prominence of the anterior fontanel as in hydrocephalus, but on the con- trary an actual depression in this position. The shape of the head is less rounded; the occiput being the first part enlarged in hypertrophy, and often continuing throughout to keep this predominance. When the forehead pro- jects, the eyes remain deep in their sockets, and want the prominence and downward direction given to them by the pressure of the fluid in hydroce- phalus upon the orbitar plates. The causes of hypertrophy of the brain are quite unknown. The affection is too rare, and comes under the notice of the physician at too late a period, to enable any very accurate investigations to be made. 3. Atrophy Of the Brain.—This term may be made, for the sake of convenience, to include cases both of diminution of the cerebral substance CLASS III.] TUMOURS IN THE BRAIN. 689 occurring after birth, and of congenital deficiency of the organ, though the latter affection is technically denominated cerebral agenesis. The deficiency may occur on one side or on both; but the former event is most common. The brain retains its natural consistence. The vacuity is usually filled up with watery fluid. Sometimes the cranium is depressed over the seat of the atrophy, giving a deformed appearance to the head. The affection may continue long without interfering materially with the organic functions; but it is generally attended with palsy of one or more limbs, or of one-half of the body, upon the opposite side to that in which the atrophy exists. In some instances, rigid contractions complicate the paralysis. Epileptic convulsions are frequent accompaniments. The senses are sometimes affected, but rarely to any great extent. The mind almost always suffers more or less. The memory is apt to be defective, the rational powers feeble, the passions irregular, and sometimes strong; and not unfre- quently the patient is nearly or quite idiotic. The causes are little known. The congenital affection has been ascribed to accidents to the mother during pregnancy, but always with some uncer- tainty. The acquired variety is sometimes traced to convulsions occurring in infancy, or to injuries of the head received at the same period of life. The patient often lives many years ; sometimes to old age; and death almost always accrues from some disease not immediately connected with the cerebral affection. 4. Tumours in the Brain.—Most of the varieties of tumour which are found in other parts of the body, are occasionally also met with in the substance of the brain. Cysts, non-malignant tumours, the different forms of carcinoma or cancer, tubercles, and hydatids, are sometimes generated in the midst of the medullary or cineritious structure, and produce the most deadly effects. After attaining a certain degree of development, it is of little consequence what the nature of the tumour may be. The effects are alike malignant. The progress of the symptoms may be more or less rapid; but there is a strong resemblance in their character; and their tendency is constantly towards death. While the tumour is yet small, it often happens that no inconvenience is experienced; and, in consequence of its frequently very gradual growth, the brain so far accommodates itself to the encroach- ment, that considerable magnitude has been sometimes attained without serious results. Thus, dissection after death from diseases in no way con- nected with the brain, now and then reveals cerebral tumours, the existence of which had never been suspected. But, when a certain magnitude has been attained, which is different in different cases, the circumstance that the brain occupies a cavity which cannot be enlarged, and cannot be much en- croached on with impunity, gives to productions, elsewhere innocent, an influ- ence scarcely less noxious than that of the most malignant. The ill-effects of these tumours are such as arise from direct compression of the cerebral substance, from irritation of the brain generally, from inflammation with softening, suppuration, &c, of the structure in their vicinity, and from com- pression of the veins, producing effusion in the ventricles, or chronic hydro- cephalus. The symptoms, therefore, must be the same as those which characterize the several affections mentioned. It is not the tumour which yields the signs directly, but the brain upon which it acts. Tubercles are the most frequent and most interesting of these products. As existing in the meninges they have been already noticed. (See Tuber- culous Meningitis.) Reference is here had only to those embedded in the cerebral substance. Their shape is usually spherical, and they are found of all sizes, from that of a millet-seed to that of a hen's egg;, or larger. Their numbers vary from one to twenty or more; but they are much less 690 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. numerous than usually in the membranes. Their consistence is that of the crude yellow tubercle. Sometimes masses of the translucent gray matter are found, with portions of the yellow within them. The larger are some- times formed by the aggregation of smaller tubercles. They occur most frequently in the hemispheres, and are more common in the cerebrum than the cerebellum. The brain around them is often injected, softened, or sup- purating. Symptoms.—Headache is very generally the first symptom observed. It is usually paroxysmal, and sometimes intensely violent. It may be general, or confined to a particular part of the head, though nothing can be inferred from its position, with an approach to certainty, in relation to the exact site of the tumour, unless, perhaps, we may consider its fixed location at the nape of the neck, as indicative of disease in the cerebellum. The pain often continues for a long time without any other prominent symptom, besides the vomiting which frequently attends it. Epileptic convulsions very often ensue, and continue subsequently throughout the complaint. Sometimes the spasmodic movements are confined to a particular part or parts of the body. More or less coma not unfrequently follows the convulsive paroxysms. Vision is apt to become deranged or impaired; and temporary blindness sometimes coincides with the cephalalgic and epileptic attacks. The local palsy, contraction of the flexors, and muscular rigidity, which characterize cerebritis, are often experienced as the disease advances; and they have almost invariably proved to be upon the side opposite to that occupied by the tumour. The mental faculties are usually at first little disturbed; but memory begins to fail after a time, sensation and perception are blunted, the rational powers are enfeebled, and a state approaching dementia not unfre- quently ensues, before the close of the complaint. Such affections are sel- dom fatal under a year, and they sometimes continue many years. All the general symptoms of chronic hydrocephalus sometimes precede death, which usually occurs in the midst of coma or convulsions. The above symptoms are not all present in every case. Sometimes one, sometimes another is more prominent; and not unfrequently a few are asso- ciated to the exclusion of the remainder. Attempts have been made to establish a diagnosis not only between tumours and other diseases, but between the different kinds of tumour. But it is sel- dom more than conjectural; except when the cerebral symptoms may happen to coincide with some affection in other parts of the body, which may serve as a clue to that of the brain. Thus, any form of cancerous disease, within the reach of observation, would point to cancer as the probable cause of the cerebral phenomena; and the existence of tubercles in the brain might be inferred, with an approach to certainty, if the symptoms above enumerated should coexist with those of external scrofula, phthisis, or tuberculated mesen- teric glands. In relation to the tumours generally, the most diagnostic signs are the very gradual approach and advance of the symptoms, with the occur- rence of local rigidity and paralysis. As to the part of the brain occupied, all is uncertainty. Should the pain be confined to the back of the head, and the patient exhibit a peculiarly staggering gait, or the want especially of the power of properly associating his movements, there might be some grounds for suspecting the cerebellum as the seat of the disease. Treatment.—Unfortunately this can be of little avail. There is, however, one rule applicable to all these cases of organic cerebral disease. In most of them, there is so much uncertainty in the diagnosis, that we may be justified in ascribing the symptoms to chronic inflammation of the brain, and treating them accordingly. Should existing debility, therefore, not forbid, the measures recommended in cerebritis may be carried into effect; the caution being always CLASS III.] APOPLEXY. 691 observed not to use depleting remedies rashly, nor to prostrate the system irrecoverably. As a general summary of the treatment, may be mentioned, occasional leeching or cupping to the temples, or back of the neck; frequent moderate purging; revulsion by means of perpetual blisters, setons, issues, or pustulating applications behind the ears, at the back of the neck, or between the shoulders ; a diet chiefly of vegetable food and milk, with the lighter kinds of flesh, when the strength appears to fail; and, finally, a moderate and sus- tained impression from mercury. These measures should be persevered in for months, and, if found productive of benefit, for years ; with occasional in- terruptions, as circumstances may seem to require, especially in relation to the mercurial treatment. In conjunction with them, the utmost care should be observed to guard the patient against causes likely to aggravate the dis- ease, such as excessive mental or bodily exertion, emotional excitement, sud- den vicissitudes of temperature, &c. In tuberculous cases, the antiphlogistic treatment must be used with more caution, and the mercurial omitted altogether. The constitutional remedies adapted to scrofula should be used, such as the preparations of iodine, the chalybeates, the mild vegetable tonics, moderate exercise, &c. In cases which are clearly cancerous, the measures should be palliative ; and the same may be said of all the other cases, when the perseverance or aggravation of the symptoms, notwithstanding all the means employed, suf- ficiently proves the incurable nature of the malady. Article III APOPLEXY. Apoplexy (ar:oTz).r^ia, from a-a and rJ.-qo-aa), I strike) is a disease char- acterized by the sudden loss, more or less complete, of sensation, voluntary motion, and consciousness, without a suspension of respiration and circulation, and depending on pressure upon the brain, originating within the cranium. It is necessary to include the immediate cause of the symptoms in the defini- tion ; as otherwise there are many affections, which, being attended with the phenomena above mentioned, would necessarily rank with apoplexy, without having any strict pathological relation to it. Such, for example, is the coma which sometimes marks the onset of certain malignant fevers, that resulting from various narcotic poisons, and that which occasionally accompanies ence- phalic inflammation, hysteria, and gastric irritation. Between these affections and true apoplexy, the real difference in character is so great, that they could not with any propriety be ranked in the same category. Pressure upon the brain enters essentially into the definition; and the pressure, moreover, must be somewhat sudden, and not the result of a slow organic growth, or very gradual liquid accumulation. Besides, it must originate within the cranium, as otherwise we should be compelled to rank compression of the brain, from fracture and depression of the bone, with apoplexy. By some writers the attempt has been made to identify the term apoplexy with cerebral hemorrhage. But in the present state of our knowledge, it is quite impossible to determine, in very many instances, whether hemorrhage exists or not; and, if this definition of apoplexy were admitted, it would be necessary to include in the same category the most overwhelming stroke of the disease as ordinarily defined, and the slightest local paralysis which might proceed from a little hemorrhage about some nervous centre. In all cases of true apoplexy, the symptoms are produced either by simple 692 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. congestion of the brain, hemorrhage within the cranium, or sudden serous effusion ; and the disease has been distinguished by some writers, according as it is attended by one or the other of these pathological conditions, into the simple or nervous, the sanguineous, and the serous. But such a division is useless for practical purposes; for we are in possession of no means of diagnosis which can be certainly relied on; and the treatment is determined not so much by our views of the exact pathological condition of the brain, as by certain exterior symptoms which may equally belong to the three varieties, and are liable to the same diversity in all of them. Symptoms, Course, &c.—In many instances, the attack of apoplexy is pre- ceded by certain symptoms which prove that the brain is unsound. Among these are a feeling of weight or fulness in the head, vertigo, headache and vomiting, drowsiness, dim or perverted vision, noises in the ears or temporary deafness, defect of memory, confusion of thought, apprehensions of impending evil, flushings of the face, epistaxis, numbness or formication in some portion of the body, unsteadiness of gait, faltering speech, and other evidences of slight partial palsy. Many other symptoms are enumerated by authors, but most of them have only an accidental relation to apoplexy, and need not, therefore, be repeated. Of those above mentioned, there may be only one present in a particular case, or there may be several; and they may precede the attack, in greater or less degree and more or less continuously for months, or only for a few hours or even minutes. Great difference exists between authors, as to the proportion of cases in which the premonitory symptoms are observed. Rochoux declares that of 69 cases of which he has collected the history, 11 only presented precursory symptoms. (Diet, de Med., iii. 470.) But my own observation conforms much more nearly with the statement of Dr. Bennet, that apoplexy rarely occurs without premonitory symptoms, though they may occasionally be so slight as to escape notice. (Tweedieh Syst. of Pract. Med.) It is certain, however, that the stroke does sometimes approach without warning, and in the midst of apparently sound health. When attacked, the patient, if standing or sitting, usually falls, deprived of consciousness, and more or less completely of sensation and the power of motion. If a limb be raised and let go, it falls as if destitute of life. Pinching the skin seems to occasion no uneasiness. Sight and hearing are suspended, and the patient is not roused by shaking, or by calling loudly in his ear. The countenance is marked with total absence of expression, and is often turgid with blood. Throbbing of the carotids is not uncommon. The pulse is full, slow, strong, and sometimes intermittent. This condition of the circulation, though not universal, is yet so frequent that, when a similar pulse is met with in other affections, it is often said to be apoplectic. The respiration too is slow, and frequently stertorous. The pupil is in some instances dilated, in others contracted, but generally immovable, and insensible to light. The power of deglutition is usually much impaired, and sometimes lost. The bowels are generally constipated ; and the urine is either passed involuntarily, or accumulates so as to distend the bladder, and then dribbles away under mere gravitation or pressure. Though the limbs are usually motionless, there is sometimes spasmodic contraction or rigidity of the muscles, which is generally confined to one side, while the other is quite relaxed. This condition of stupor continues variously from a few minutes to several days, sometimes even to the sixth or seventh day, when, if a fatal result does not take place, it slowly gives way, either spontaneously, or to the remedies employed. The patient, upon beginning to recover his conscious- ness, often has a peculiar expression of countenance, as if astonished. The symptoms may now all gradually decline, and health return without any re- CLASS III.] APOPLEXY. 693 mains of the disease. But this result is comparatively rare. Much more frequently it is observed, when the patient begins to exercise a little power over the muscles, that some part of the body, and generally one-half of it in the longitudinal direction, is more or less completely paralyzed. Indeed, this condition of hemiplegia may often be seen at the commencement of the attack; one side of the body retaining a certain degree of contractility and sensation, while the other appears quite insensible and powerless. Some- times, however, the palsy is less extensive, affecting only a single limb, one side of the face, the tongue, &c. Generally both sensation and the power of motion are lost, but sometimes only one. The side affected is apt to be opposite to the one convulsed; though in some instances, the muscles which refuse to obey the will contract spasmodically. The paralytic condition of the face is rendered obvious by the fallen and relaxed state of the features on the affected side; while there is a certain degree of contraction in the muscles of the other side, towards which the angle of the mouth is drawn. When the tongue is protruded, the point turns towards the paralytic side, because the muscles which draw it forward act only upon the other half of the organ. In consequence of this palsy of the tongue, the patient on re- covering consciousness is often unable to speak, or articulates imperfectly. These paralytic symptoms may disappear in a few hours or a few days, or may continue for months, or years, or to a greater or less extent during life. Upon the return of consciousness, the patient sometimes complains of head- ache, and symptoms of delirium not unfrequently appear. If these should be considerable or lasting, with wakefulness, an accelerated pulse, and some heat of skin, there would be reason to suspect the occurrence of inflamma- tion. After convalescence from the apoplectic symptoms, the palsy often remains for a long time ; the mind appears not unfrequently weakened ; the patient is apt to shed tears upon slight occasions, or without any oc- casion ; the memory is often defective, and words are miscalled, or one substituted for another of a wholly different meaning; and, in some in- stances, it is long before the patient recovers the power of speech after having lost it. After a time, however, which varies in different cases from a few months to several years, the apparently wrecked system is often gradually repaired by its own inherent powers; and the patient, though seldom as vigorous in mind or body as before the attack, regains a tolerable share of health, and is able to enter again into the routine of active duties. When the apoplectic attack is to end fatally, it seldom terminates before the lapse of three or four hours, and much more frequently not till the third or fourth day. Immediate death is very rare ; and the patient seldom sur- vives the eighth day. Before death, the coma, if at first imperfect, becomes profound; the sphincters frequently give way; the pulse sinks in force and volume, and increases in frequency; the extremities become cold; the sur- face often covers itself with a cold sweat; and the respiration is performed at gradually lengthening intervals till it ceases. The above is a general sketch of the disease as it most frequently ap- pears. But it is liable to numerous diversities. In some instances, instead of striking the patient down suddenly, it comes on by degrees, with a drow- siness increasing into stupor, and either ending in profound coma, or going off without a perfect loss of consciousness at any time. Even in the sudden attacks there is not always an utter loss of sensation or consciousness; the patient sometimes showing imperfect signs of intelligence when spoken to loudly Occasionally hemiplegia, or palsy of some one part of the body, precedes the apoplectic symptoms; and the patient, before losing his con- sciousness finds himself unable to speak, or to open and close one of his eyes or to move the arm or the leg upon one side, or finally to move any 694 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. portion of that side. Every now and then we meet with instances in which these paralytic symptoms occur without a loss of consciousness at any time. In one winter no less than four or five hemiplegic cases were brought into the Pennsylvania Hospital, in which the patients had never lost their con- sciousness for a minute. These, however, are not cases of apoplexy ; and the affection will hereafter be treated of under palsy. Instead of the flushed face, and the strong full pulse which ordinarily characterize apoplexy, there may be paleness of the countenance, and a small feeble pulse ; and in these respects there is every possible grade be- tween the two extremes. Sometimes we meet with instances in which the force of the blow seems to be at once overwhelming. The vital powers yield immediately, and the pallid features, cold skin, and scarcely perceptible pulse, indicate a condition of system closely resembling syncope. Dr. Abercrombie describes a form of apoplexy, commencing with sudden pain in the head, attended with paleness of face, faintness, nausea, and gene- rally vomiting. The skin is bloodless ; the pulse is feeble, and frequent, or irregular; and the patient either falls, in a state approaching to syncope, with occasionally some degree of convulsion, or simply experiences slight and transient confusion of mind. In either case, the symptoms pass off, with the exception of the headache. After a variable interval, which may not exceed a few minutes or hours, or may extend to several days, comatose symptoms gradually come ,on, with or without paralysis, and death ensues. In these cases, according to Dr. Abercrombie, there is always copious extra- vasation of blood; and the symptoms are of the worst possible augury. Before leaving the symptomatology of apoplexy, it will tend to render the subject clearer, if we consider successively the several phenomena which are most characteristic of the disease. The pulse, though commonly full, slow, and strong, and not unfrequently irregular or intermittent, is in some instances scarcely different from that of health, and in others small, feeble, and more or less frequent. There are two phenomena in the respiration which are worthy of notice, a stertorous or snoring sound in inspiration, and a peculiar noisy puffing out of the cheeks in expiration; the former probably arising from the torpid state of the velum pendulum, the latter from an equally torpid state of the bucci- nators, and other muscles of the face. Neither of them is present in every case. They usually indicate deep stupor, and the flapping of the cheeks is the worst sign of the two. The breathing is generally slower than in health, but is often irregular, and sometimes sighing or yawning. The face' is most frequently flushed, more or less turgid, and of a red, pur-. plish, or livid hue; but it is sometimes also pale, or of a yellowish or greenish tint; so that the colour is by no means to be relied on as a diagnostic symp- tom. There is always, however, a characteristic want of expression in the countenance, a deep soporose aspect, which serves to distinguish the affec- tion, in many instances, from other forms of coma. The pupil is in bad cases quite immovable, being either contracted or dilated, or one pupil being in one state, while the other is in the other. When the apoplexy is not profound, it is often sensitive to light. It has been already stated that convulsive movements, when they occur, are generally upon the opposite side to the one paralysed, though sometimes they occupy the same side, and are occasionally general. In some instances, tonic spasms and muscular rigidity are observed. These involuntary con- tractions may precede, accompany, or follow the apoplectic attack. Paralysis is present in the greater number of cases, and is thought to be very seldom wanting when there is hemorrhage. In some violent cases, all the limbs are paralysed ; but generally the affection is confined to one-half CLASS III.] APOPLEXY. 695 of the body, having the form of hemiplegia. Sometimes only a single limb is affected ; and, in this case, the arm is much more frequently paralysed than the leg. It is a singular fact, moreover, that, in recovery from hemiplegia, the leg almost always regains its powers and sensibility much before the arm; and it not unfrequently happens that the patient can walk, while the arm still hangs, like a dead weight, by the body. The paralysis may also be confined to the face, the tongue, the eyes or their lids, the oesophagus, or the larynx. In the face it produces, as already observed, inequality of the two sides; in the tongue, difficulty of articulation or inability to articulate at all, while the organ, when protruded, is apt to point towards the paralysed side; in the eye, want of vision, and often dropping of the eyelid, or its imperfect closure; in the oesophagus, inability to swallow, with symptoms of suffocation when the attempt is made ; in the larynx, loss of voice. But the disease is very rare in the last two positions. In general the palsy affects both sensation and motion ; but sometimes it is confined to one of these properties. Consciousness is affected in various degrees. As a result of pressure of the brain, there is every grade of stupefaction, from a slight confusion or vertigo, to profound coma. The case, however, scarcely meets the definition of apoplexy, unless consciousness is suspended, at least for an instant. It is said that, at the moment of attack, the patient sometimes has a feeling as if something were suddenly torn or rent in the interior of the head. After recovering in some degree from the proper apoplectic symptoms, the patient is liable to be attacked with those of cerebritis, consequent upon in- flammation excited in the cerebral substance by the presence of effused blood. Though the patient not unfrequently recovers entirely from one attack of apoplexy, and even from all its apparent consequences, he is yet very liable to returns of the disease, which in general, sooner or later, prove fatal. A third attack of the severer form of apoplexy is seldom survived. Of that milder kind, however, which depends on mere cerebral congestion, without effusion, the result is much less fatal; and it sometimes happens that a pa- tient has numerous attacks, which reduce him at length to a state of mental imbecility little short of idiocy. Anatomical Characters.—It is now generally admitted that death may occur with all the phenomena of apoplexy, without leaving any observable lesion in the brain. Such cases are denominated by some nervous apoplexy. They are very rare. The probability appears to me to be, either that some Blight phenomena of congestion have been overlooked, or that the blood- vessels, violently distended within a moderate space, sufficient to paralyse the action of one of the nervous centres essential to life, have become emptied of blood before death, after the mischief had been produced. In other cases, nothing which could account for the symptoms is discovered but a highly congested state of the cerebral vessels, such, for example, as is sometimes produced by exposure of the head to the direct rays of a very hot sun, constituting a variety of the affection, called by the French coup de soleil. It has been long known that patients sometimes die of apoplexy produced by the sudden effusion of serum into the ventricles, or the cavity of the arach- noid. The serum is sometimes limpid and colourless, sometimes turbid and reddish or yellowish. It may be wholly unattended with signs of inflam- mation or congestion, and apparently the result of a sudden extravasation of watery fluid, such as is occasionally observed in dropsy of the serous cavities. Such a case is related by Andral, in which a large quantity of perfectly trans- parent and limpid fluid was found in a cavity produced by the union of the two lateral ventricles with the third; the septum lucidum and fornix having been reduced into small fragments of white pulp, floating in the serosity. (Clin Med. v. 95.) Sometimes the effusion is attended with distension of the veins and sinuses of the brain, or with general congestion of the organ. 696 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. But hemorrhage within the cranium is the most frequent lesion. The blood may be effused between or upon the membranes, in the ventricles, or in the substance of the brain. A case is recorded by Dr. John Watts (Med. and Surg. Register of the New York Hosp., A. D. 1818, p. 145), in which blood was effused between the dura mater and the cranium, in consequence of caries of the inner table, of about the size of a sixpence, producing the rupture or erosion of a blood-vessel. It is more frequently found in the cavity of the arachnoid, diffused over the surface of the whole brain, or one of the hemispheres. Sometimes it occupies cysts made by laminae of false mem- brane upon the free surface of the arachnoid. (See Arch. Gen., 4e ser., xxii. 87.) It may occupy the lateral, the third, and the fourth ventricles, having sometimes been found in one or more of these cavities, and sometimes in all. In some instances, it has been found in the ventricles and the arachnoid cavity, communicating with a collection of blood in the cerebral substance. In such cases, it is supposed that the fluid has broken a passage from its source in the brain, through the substance of the organ, into the cavities. Beyond all comparison, the most frequent form of hemorrhage is that which occurs in the tissue of the brain. When this is met with after sudden death, it is usually accompanied with evidences of general congestion within the cranium ; the sinuses of the dura mater being full, the pia mater infil- trated with blood, and the cut surface of the brain exhibiting numerous little drops of blood. The extravasated blood is sometimes apparently infiltra- ted into the cerebral substance;' but much more frequently is collected in a cavity, which it has hollowed out for itself. The quantity found in such cavities varies from a few drops to six ounces or more. The situation of the cavity may be in any part of the brain or cerebellum, though, according to Rochoux, it is very seldom in the white substance. It is almost uniformly upon the side of the brain opposite to the paralyzed side of the body. Nevertheless, cases have been recorded, in which the effusion has been on the same side as the palsy. When the hemorrhage occurs on both sides of the brain, the palsy is apt to be on the side opposite to the larger cavity. There is a singular tendency to hemorrhage in the substance or vicinity of the corpora striata, and optic thalami. Of 386 cases of cerebral and spinal hemorrhage compared by Andral, 202 showed extravasation in the hemispheres on a level with these bodies, and at the same time in them; 61 in the corpora striata, and 35 in the optic thalami. Of the remainder, 22 were in the cerebellum, 8 in the spinal marrow, and 58 in other parts of the brain. The greater disposition to hemorrhage in the corpora striata, optic thalami, and their neighbourhood, is ascribed to the greater vascularity of that part of the encephalon. The walls of the hemorrhagic cavity are for a depth of one or two lines deep red, very soft, and of an irregular surface. Beyond this layer is usually another, from one to three lines thick, which is also soft, almost as much so as cream, but is of a light-yellow colour, and blends at its outer circumfer- ence with the healthy substance of the brain, so that no accurate line of sepa- ration can be drawn. (Rochoux.) It is asserted that the cerebral substance is sometimes also found perfectly healthy, immediately around the blood. The effects of time upon the effused blood have been examined with much care. A few days after the effusion, it is in the form of a blackish, soft coag- ulum. This gradually loses its colour, and acquires increased firmness, be- coming pale-reddish, or yellowish, and is at last wholly absorbed, leaving a cavity with smooth sides, which, if the cavity is small, are in contact without adhering, but, if large, are connected by transverse and interlacing filaments, forming a sort of areolar tissue, the cells of which are filled with a yellowish or reddish liquid of various consistence. If the hemorrhage was on the sur- CLASS III.] APOPLEXY. 697 face of the brain, a depression is left of larger or smaller dimensions. The coagulum may entirely disappear in four or five months, or may continue a year or two before being absorbed. Effusions of serum are sometimes found in old cases of apoplexy, as are also circumscribed softenings; and it is pro- bable that these conditions contribute sometimes to the fatal result. It is thought by Rochoux that the effused blood always leaves a visible alteration of the cerebral tissue behind it; and that thus the number of attacks, which an individual may have experienced of proper sanguineous apoplexy, may be ascertained after death. It is not uncommon to find two or three of these cicatrices, and M. Moulin and Dr. Abercrombie have each seen four in the same individual. M. Cruveilhier has seen fifteen. (Rochoux, Diet, de Med., iii. 485.) The cavities, however, filled by a yellowish coloured serum, which Rochoux considers the remains of apoplectic effusion, are, according to M. Durand-Fardel and others, the result merely of cerebral softening. The blood effused into the natural cavities is much less readily absorbed than that which has formed a cavity for itself in the substance of the brain. In some instances, it coagulates, then gradually loses its redness, and appears ultimately to undergo organization, and to be converted into a kind of false membrane. In other instances, it becomes encysted, and is enclosed in a sac which has the appearance of a newly formed serous tissue. Causes.—That there is a condition of the system, or of the brain, consti- tuting a predisposition to apoplexy, cannot be doubted. Among the causes which give rise to this condition, and which are, therefore, predisposing causes of the disease, inheritance is one of the most prominent. The complaint is much more likely, .as a general rule, to attack individuals descended from apoplectic parents than others. Old age is another predisposing cause, and probably the most powerful. Apoplexy may occur at any age; but it is vastly more frequent in the old than the young. Indeed, the disease is very rare under twenty. It is true that hemorrhage into the arachnoid is not very nncommon in infants. But it is in general not marked by the usual apoplectic phenomena, and ranks, by the symptoms, rather with meningitis than with the disease at present under consideration. The age at which the predispo- sition is strongest is above fifty. Of sixty-nine cases collected by Rochoux, two were between 20 and 30, ten between 30 and 40, seven between 40 and 50, thirteen between 50 and 60, twenty-four between 60 and 70, twelve be- tween 70 and 80, and one between 80 and 90. Thus, it appears that there were fifty cases beyond the fiftieth year, to nineteen short of it. When it is considered how much fewer are the numbers of persons living above fifty than below it, the disproportion, great as it is, will appear to be much increased. It was formerly supposed that a certain physical conformation predisposed to apoplexy. Persons with large heads, short necks, red and turgid faces, full habit of body, and generally of a sanguineous temperament, were looked upon as doomed victims of this disease. It is true that some individuals thus constituted suffer with apoplectic attacks ; but the vast majority escape ; and the number of patients who want these characteristics is probably much greater than those who possess them. It is no uncommon event for tall and thin persons, with pale faces and small heads, to die of apoplexy. Sedentary habits with high living have also been supposed to produce a predisposition to the disease by generating plethora. They undoubtedly fa- vour its development, when the predisposition already exists ; but in persons without any tendency to the complaint, it is very doubtful whether they would occasion it. , - , , It is probable that certain organic diseases of the heart and of the lungs, by producing and keeping up for a long time congestion, either active or VOL. II. ^ 698 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. passive, of the vessels of the brain, may so derange their organization as to dispose them to rupture, and may thus act as predisposing causes of apoplexy. They are, probably, however, more frequently merely exciting causes. The cardiac affection for which most influence of this kind is claimed is hypertro- phy of the left ventricle. It appears, at first sight, reasonable to suppose that the vastly increased force, sometiraes given to the current of blood by this condition of the ventricle, must be exerted with peculiar effect upon the vessels of the brain; and there can be no doubt that, when these vessels are already weakened, they will sometimes yield to the increased impulse, and rupture sooner than they otherwise would have done. Hence, cases have been repeatedly noticed, in which apoplexy and hypertrophy of the left ven- tricle were associated. But I believe that much more than the due import- ance has been attached by some writers to this cause. So far as my own observation has gone, comparatively few cases of disease of the heart ter- minate in apoplexy. Cardiac affections are very common in the Pennsyl- vania Hospital; and patients frequently die of their consequences; but, dur- ing the period of my attendance upon that institution, I cannot recall a case in which apoplexy resulted. M. Rochoux states that, of forty-two apoplec- tic patients whose bodies he examined, three only presented aneurism of the heart. (Diet, de Med. iii. 503.) Even in those instances in which the two affections have been found associated, it appears to me highly probable, as suggested by Dr. Watson, that they may have been quite as often merely coincident, as bearing to each other the relation of cause and effect. The same constitutional tendencies which occasion disease in the valves and parietes of the heart, would be likely to affect also the blood-vessels of the brain, and predispose them to rupture. It has been ascertained, moreover, that organic disease of the kidneys is a very frequent antecedent to apoplectic attacks; and it is highly probable that the poisoned state of the blood, resulting from the renal affection, may con- tribute to the disease of the cerebral tissue, which so often precedes the hem- orrhage. Out of 22 fatal cases of hemorrhagic apoplexy, Dr. W. S. Kirkes found the kidneys decidedly diseased in 14; and in 12 of these there was coincident disease also of the heart and cerebral vessels. (Med. Times and Gaz., Nov. 1855, p. 515.) These cases certainly prove a close relation be- tween the several morbid conditions referred to, either as the results of one common cause, or as exercising a causative agency among themselves. The probability is that all three conditions often result from a general morbid state of the system not well understood; but it is also highly probable, as before stated, that the disease of the kidneys acts injuriously both on the brain and heart by rendering the blood impure, and that the heart when dis- eased co-operates with the kidneys in increasing the cerebral affection. It is a highly interesting question, what is the state of the brain which gives it a tendency to apoplectic effusion. There can be little doubt that organic changes in the coats of the blood-vessels, such, for example, as ossi- fication, and atheromatous deposits or fatty degeneration, may so far lessen their power of resistance as to lead to rupture upon the application of any unusual force. Hence, perhaps, in part, the peculiar liability of old people to the disease. An aneurismal state of the cerebral vessels has been occa- sionally observed, and it is possible that this may sometimes be the cause of rupture, even when it escapes observation. The opinion appears to me very plausible, which ascribes the occurrence of apoplexy, in the greater number of cases, to a previous disease of the cerebral substance, predisposing it to hemorrhage. This opinion is ably supported by Rochoux, who considers hemorrhagic apoplexy, with effusion into the substance of the brain, as de- pendent in almost all cases upon a peculiar previous softening of the cerebral CLASS III.] APOPLEXY. 699 substance. Such a softening is almost always observed around the collection of blood; according to Rochoux in ninety-nine out of one hundred cases. (Banking's Half-yearly Abstract, i. 204.) This softening he believes to be peculiar, and not dependent upon inflammation. It is true that other ob- servers, as Cruveilhier, Carswell, and Durand-Fardel, consider the softening as consequent upon the hemorrhage, and not antecedent to it. It is asked, why the attack of apoplexy is so seldom preceded by signs of cerebral dis- ease, if so serious an organic change has been going on in the substance of the brain ? But this objection is met by the fact, that such changes have frequently existed in organs without any obvious signs during life, and have been first revealed by dissection. Besides, there often are preliminary symp- toms of a marked character; and it appears to me that the theory of M. Rochoux affords the best explanation of their occurrence. Admitting the previous existence, in many instances, of this hemorrhagic softening, we have been, until of late, completely in the dark as to its nature and immediate cause. But some observations of Mr. Paget, communicated to the London Medical Gazette in February, 1850 (page 229), render it in the highest degree pro- bable that, in many cases of apoplexy with cerebral softening, the previous condition of the brain is connected with, if it be not dependent on a fatty degeneration of the minute cerebral vessels. In such cases, even in the appa- rently healthy parts, minute particles of oil may be detected by the aid of the microscope, scattered in the substance of the vascular coats; while, in the diseased part, the vessels are so beset with them that the healthy structure becomes wasted, and at length completely lost, so that the vessel ruptures with great facility, and of course permits hemorrhagic effusion. Sex appears to have some influence in the production of the apoplectic predisposition; at least men are more subject to the disease than women. Thus, of 2297 cases compared by M. Falret, 1670 were in men, and only 627 in women. (Archives Generates, torn, ii.) The immediate or exciting causes of the apoplectic seizure are very nume- rous. It must be admitted that the attack not unfrequently occurs as the result of previous disease of the brain or its vessels, without any obvious excit- ing cause. Thus, it often happens that the patient is attacked while sitting, standing, or quietly walking, without the least unusual physical effort, and without any mental excitement or disturbance. Indeed, instances are not uncommon in which the seizure takes place during sleep. But in other in- stances, and those very numerous, the result can be clearly traced to some direct cause. Whatever is capable of increasing the force of the circulation, and especially of giving it a peculiar direction to the brain, and whatever impedes the return of blood from that organ, and thus produces congestion of its veins and sinuses, may act as the immediate cause of apoplexy. It is probable that such causes alone, without any peculiar predisposition, may produce the simple congestive form of the disease. It is even possible that they may occasion hemorrhage by transudation into the cavity of the arach- noid and ventricles, in a previously sound state of the brain. It is by no means certain that they may not also occasion rupture of healthy cerebral vessels, in the substance of the brain, when operating with peculiar violence. But the circumstance that apoplexy so seldom occurs in the young, who are even more exposed than the aged to these exciting causes, proves conclu- sively that without aid from other influences, they are seldom alone ade- quate to the production of the disease. Among the causes alluded to may be enumerated, 1. strong muscular effort, as lifting heavy burdens, violent coughing or sneezing, straining at stool, the act of vomiting, playing upon wind instruments, excessive exertion of the voice, and the act of coition; 2. any position favouring the accumulation of blood in the brain, as stooping, sus- 700 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. pension by the feet, and turning the head strongly in a direction differing from that of the body, so as to compress the jugulars; 3. compression of the neck by tight cravats or other ligatures, and general compression of the trunk; 4. external stimulation immediately to the head, as by the direct rays of a hot sun, and the heat of an intense fire; 5. internal stimulation directed especially to the brain, as by violent emotion, and the use of alcohol or other cerebral stimulant; 6. increased force of the general circulation, from hyper- trophy of the left ventricle, indulgences of the table, the hot bath, &e. ; 7. transfer of morbid action, from repelled eruptions, retrocedent gout or rheu- matism, the healing of old ulcers, the suppression of accustomed discharges; and 8. organic or other affections impeding the return of blood from the head, including tumours pressing on the jugular veins, diseases of the heart, congestion of the lungs, &c. Excessive cold is said also to produce apoplexy, probably by concentrating the blood in the interior organs. Nature.—The definition of apoplexy given in this work implies that the essence of the disease is a sudden pressure upon the brain. The pressure is produced by an active or passive congestion of the cerebral vessels, by effusion of serum, or by hemorrhage. Active congestion may be the result of an irri- tation in the brain, inviting, or of an exterior force, compelling, an undue quantity of blood into the organ. Passive congestion is produced by whatever prevents the return of blood from the head. In the former, it is the arteries which are loaded ; in the latter, the veins and sinuses. The effusion of serum may be the consequence of obstruction of the veins by tumours, &c, of a general dropsical disposition in which the cerebral membranes may partici- pate, or of a vascular irritation or inflammation of the arachnoid. Hemor- rhage may be the result either of transudation, or of rupture of the ves- sels. The former may perhaps be the case, in general, when the blood flows primarily into- the cavities, the latter wrhen it collects within the sub- stance of the brain. It has been questioned whether the brain is capable of being compressed. Observation has decided the question in the affirmative. In cerebral hyper- trophy, the organ after death expands considerably upon the opening of the cranium and dura mater, proving that it was previously in a state of com- pression. But, even allowing the essential incompressibility of the cerebral substance, there is little difficulty in explaining, to a certain extent, the effects of pressure in producing the symptoms of apoplexy. Every action of the brain, or any portion of it, requires a certain amount of arterial blood, either as a stimulus, or as furnishing materials essential to the action. If the sup- ply of fresh blood be unduly diminished, the actions also languish or cease. The brain can no longer perform its duty of receiving impressions, transmit- ting motive power, or generating thought. Palsy of sensation and voluntary motion, and the loss of consciousness are necessary results ; and these are the symptoms of apoplexy. But in what manner is the supply of blood to the acting cerebral substance diminished in this disease ? In the first place, in active congestion, as more blood is invited or forced into the arteries than legitimately belongs to them, the increased space thus occupied must be gained at the expense of all compressible spaces ; and the veins must therefore receive less, and consequently convey back the blood more slowly than in health. A stagnation in the capillaries is a necessary consequence, and the blood in them, soon becoming changed, can no longer afford the essential stimulus or mate- rial. In passive congestion, on the contrary, the gain by the veins must be supplied at the expense of the arteries, which are compressed, and less blood enters the capillaries than is essential to the due support of the cerebral func- tions. In serous and sanguineous effusion, it is obvious that the space occu- pied by the liquid is abstracted from that of the veins and arteries conjointly, CLASS III.] APOPLEXY. 701 and there is a consequent deficiency of the pabulum essential to action in the nervous centres. The above course of reasoning explains the phenomena so far as the cen- tres are concerned. It is probable also that the apoplectic symptoms may arise, in part, from an interruption of the communication between the nervous centres and the external parts under their control. The connecting cords may be so compressed that influence is but imperfectly conveyed along them in either direction, or they may be ruptured, as in effusion of blood into the cerebral substance, and their function cease altogether. In the former case, there may be imperfect sensation and imperfect motion ; in the latter, there must be a total want of both, so far as regards the particular part to which the communicating fibrils that have been ruptured run. Nor is it difficult to account, in the same way, for the absence of sensation alone in some cases, and of motion in others. All that is necessary to be supposed is, that the nervous cord which conveys impressions to the nervous centre is ruptured or compressed in the former cases, and that which carries the motor impulse in the latter. That respiration continues, during the deficiency of the other functions, must arise from the fact, that the centre which governs that func- tion is less liable than the sensorial centres to the effects of the compression within the cranium. Lying near the great outlet of the cavity, it probably participates partly in the security of the nervous structure without the en- closure. Should the medulla oblongata be the immediate seat of the com- pression, life may cease immediately from the cessation of breathing; and this is probably the case, in some instances of sudden death, and in some of those in which great prostration is experienced at the commencement, with coldness of the surface, feebleness of pulse, and a failing respiration. Diagnosis.—Is it possible to distinguish the varieties of apoplexy, depend- ent upon difference in the compressing cause; or to determine the portion of the brain occupied by the effused blood, when that is the source of the pheno- mena? I believe not with any certainty or precision. Occasionally, how- ever, we may reach very probable conclusions. When the attack speedily subsides, without producing palsy, or at least without leaving any paralytic phenomena behind it, and without any of those mental deficiencies which in- dicate a structural lesion of the brain, we may infer that it was congestive; and, whether active or passive, might be determined in some instances by the nature of the cause, and in most, with some degree of probability, by the symptoms which ordinarily distinguish the two conditions elsewhere ; as a full strong pulse with a red flushing of the face, in the active, and a comparatively weak or natural pulse, and a livid hue of the countenance, in the passive. But it would be going too far, to say that no case could be one of mere congestion in which a paralytic effect remained, or that the affection must be necessarily congestive when unaccompanied with palsy. It is well known that congestion alone may produce palsy; and it is possible that the paralytic effect may con- tinue for some time after the cause of it has ceased; just as the palsy of an arm produced by pressure upon the nerve, often outlasts considerably the compressing cause. It is, moreover, not at all impossible that hemorrhage may exist without producing observable paralysis It was formerly supposed that the existence of serous apoplexy was indi- cated by paleness of the face and feebleness of the pulse. Experience, how- ever, has proved this notion to have been a fallacy. It is, indeed, impossi- ble to diagnosticate these cases with an approach to certainty. When the attack supervenes upon chronic disease of the brain, or accompanies an ob- vious dropsical diathesis, or is marked by the occurrence of general instead of local or partial palsy, it may be suspected to be of this nature. Hemorrhagic apoplexy may be diagnosticated when hemiplegia precedes 702 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. the seizure, and generally, when this or any other form of palsy is left behind, after the apoplectic symptoms have disappeared. Should palsy of all the limbs result, the inference would be that the effusion of blood had been great. When, after a partial or complete loss of consciousness, the patient recovers, and soon afterwards becomes comatose with the ordinary symptoms of apo- plexy, the case may be almost always regarded as hemorrhagic. In relation to the seat of the effusion, inferrible from the symptoms, all that can be said with an approach to certainty is, that hemiplegia or partial palsy upon one side of the body indicates the existence of hemorrhage upon the opposite side of the brain ; and this is true, also, as a general rule, when the cerebellum is the seat of the hemorrhage, although the fibres of that structure do not, like those of the cerebrum, decussate before passing out of the cranium. More will be said upon this point under the head of palsy. A connection has also been observed between apoplexy of the cerebellum and disorder in the sexual appetite ; so that any unusual exaltation of this pro- pensity, or striking loss of it, immediately before the apoplectic seizure, might lead to the suspicion that the cerebellum was the seat of the disease.* The diagnosis between apoplexy and coma occurring from other causes is not always easy. When the insensibility has occurred suddenly, and is at- tended with a flushed and turgid face, a full, strong and slow pulse, and a slow, stertorous breathing, the probabilities are strongly in favour of apo- plexy ; and the probability is converted into certainty by the simultaneous occurrence of hemiplegia, or palsy of any one portion of the body. But cases of apoplexy are not always marked by these symptoms. Sometimes stertor is absent, the face is pale, and the pulse feeble and perhaps frequent. Even in such a case, the existence of palsy would go far to decide the question. But even this diagnostic character may be wanting ; or the palsy may have pre-existed. Under such circumstances, the decision must be based upon the history of the case, and upon the absence of characters indicating the exist- ence of other kinds of coma. For the diagnostic characters of these affec- tions, the reader is referred to Functional Disease of the Brain, Epilepsy, Hysteria, Meningitis, and Cerebritis. There are, however, two or three conditions, which may with propriety be particularly noticed in this place. The coma produced by narcotic poisons, particularly such of them as may be denominated cerebral stimulants, sometimes closely resembles apo- plexy. Profound intoxication from alcohol, and still more, perhaps, the * Hemorrhage in the cerebellum is attended with many of the ordinary phenomena of apoplexy; but, according to M. Coquerel, it presents certain diagnostic characters, by which it may be distinguished, with considerable certainty, from cerebral apoplexy. From a careful examination and comparison of many cases, he has drawn the following conclusions. The attack may be gradual or sudden. In the former case consciousness is not lost; in the latter, though in very rare instances lost for a short time, it generally returns. In the most violent cases, death is sometimes instantaneous, which is not the case in the cerebral disease. Another distinguishing character is vomiting, which is frequent and scarcely restrainable, while in ordinary apoplexy it is rare. In some cases of hemorrhage in the cerebellum, there is profound coma before death ; but, on the occur- rence of the attack, the patient evinces by cries and movement that he is sensible. There is usually inability to stand; but the patient has some power over his limbs, which he can raise from the bed, and hold for a time in that position. Hemiplegia occurs only in about one-third of the cases. The paralysis is always on the opposite side to the effusion. A tendency to a recoiling or rotatory motion was observed only in one case. Paralysis of the face and tongue, so common jn cerebral apoplexy, is very rare in this; yet there is a peculiar expression, as it were of astonishment, with fixedness of the eyes; which, however, does not continue long. General and special sensibility usually re- main unaffected. There are no convulsions, unless other portions of the nervous system are involved. The mean duration of the affection, omitting the cases of sudden death, is a day and a half. The termination is generally in death, though the disease is not insusceptible of cure. (Arch. Gen., Mai, 1858, p. 565.)—Note to the fifth edition. CLASS III.] APOPLEXY. 703 stupor from opium, strongly simulate that disease. To distinguish them, the circumstances under which they occurred should be ascertained, if pos- sible ; whether, for example, the patient had been drinking spirituous' liquors, or had been in a situation in which he might be supposed to have been drinking; whether an empty laudanum bottle was to be found upon his per- son, or in his vicinity ; whether any cause for the commission of suicide ex- isted, &c. &c. The smell of the breath will often serve as a diagnostic character. The absence of palsy in any one portion of the body ; the5 gene- ral capability of being somewhat roused in the earlier stages of narcotic poisoning; the extreme dilatation of the pupil from certain narcotics, as stramonium and belladonna ; the gradual progress of the symptoms, from a state of more or less excitement, to drowsiness, stupor, and ultimately coma; these circumstances, when existing, should have their weight in influencing the decision. When apoplexy may have been induced by alcoholic drinks', the case becomes more complicated, and, at a certain point in the affection, it might be impossible, in the absence of palsy, to decide the question. In the last stage of narcotic poisoning, when the coma is profound, the pulse has given way, and the general relaxation of the muscles is complete, the diagnosis must be based exclusively on pre-existing and attendant circum- stances ; and here the age of the patient would be of much assistance. In a young person, the presumption would be in favour of some other affection than apoplexy. The poisoning from irrespirable gas or vapours is generally known from the circumstances of its occurrence. In these cases, the pulse is apt to be weak, the surface cool, and the face, though it may be coloured, is rather livid than reddened. The effects produced upon the brain by an accumulation of urea and of bilious matter in the blood, sometimes bear a close resemblance to apoplexy; and, indeed, the suggestion has been advanced, that most of the cases of nervous apoplexy, as they have been called, might be referred to the exist- ence of Bright's disease of the kidneys. Two cases of this kind are re- corded by Dr. J. A. Wilson. (See Diet, de Med., iii. 458.) The gradual progress of the symptoms, the general absence of palsy, the suppression or great diminution of the renal secretion, with the presence of albumen in the urine, the existence of jaundice or of white or clay-coloured stools, would be sufficiently diagnostic. It is quite evident that the disease differs wholly from apoplexy as here defined. The one depends upon a poison accumu- lated in the blood, the other upon pressure on the brain. Perhaps the affection most difficult to be distinguished from apoplexy is the coma of chronic cerebritis, or of cerebral softening whether inflammatory or not. The difficulty of decision, in these cases, arises chiefly from the association of partial palsy with both affections. But the preliminary symptoms in cerebritis, especially the paroxysmal headache with vomiting, and the complication of the paralysis with rigid contraction of the flexor muscles of the extremities, will generally serve to distinguish it. In acute cases, the diagnosis is more difficult, and must rest chiefly on the greater tendency to muscular rigidity in the cerebral inflammation. Not unfrequently, the two affections are associated; apoplexy either supervening upon soften- ing, or giving rise to it after the effusion of blood has taken place. Prognosis.__Apoplexy is a very serious disease.^ though very often not immediately fatal. The cases consisting of congestion solely almost always recover under proper treatment. The patient may, indeed, survive numer- ous attacks of this form of apoplexy ; but there is always danger that a congestive stroke may be followed by one of a hemorrhagic character; and when this danger is escaped, the disease, as already stated, is apt to leave traces behind it in an enfeebled condition of the memory and intellect. 704 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. The hemorrhagic and serous forms of apoplexy are much more fatal. Rochoux thinks that less than one-third of the number attacked perish from the immediate effects of the blow. Among the signs which threaten an unfavourable issue, are convulsions, general paralysis, deep coma lasting two or three days, a gradual onset of the disease ending in profound coma and paralysis, complete immobility of the pupil, inability to swallow, flapping of the cheeks in respiration, foaming at the mouth, frequent yawning or sighing, repeated vomiting, involuntary evacuations, a frequent and irregular pulse, cold extremities, cold and clammy sweats, and a failure of the cir- culation succeeding great strength of pulsation, without any amendment in the other symptoms. The patient may survive the occurrence of any one of these phenomena ; but they must always be regarded as dangerous signs; and, when several of them are presented in the same case, the hope of a cure is feeble. In judging of the probable result, reference must be had to the number of previous attacks, and to the age of the patient. The prog- nosis is more unfavourable in the old than in the young, and, upon the whole, in proportion to the age. A second attack is more apt to be fatal than the first; and a third than the second. Favourable signs are the ab- sence of those above mentioned, and a general subsidence of the symptoms. In relation to the ultimate result, the prognosis is, on the whole, unfavoura- ble. The individual once attacked with hemorrhagic apoplexy, if he escape for the time, is very apt to die in the end, either of a subsequent attack, or of a general failure of the vital functions, consequent upon the mischief done to the brain. Treatment.—The indications of treatment are to check the hemorrhage, or reduce the congestion, to prevent a renewal of either affection, to obviate inflammation, and to promote the absorption of blood or serum that may have been effused. The same measures are calculated to meet most of these indications. The patient should be placed in a recumbent position, with his head and shoulders somewhat elevated by pillows; everything which acts as a ligature, should be removed from the neck and chest; and the air of the chamber should be rather cool, and frequently renewed. Persons not concerned in the treatment should be removed from the apartment. If the strength of the pulse admit, blood should be drawn immediately from the arm, through a large orifice, and to an extent proportionate to the vigour of the patient, and the force of the circulation. But bleeding is not to be indiscriminately resorted to, or pushed to an unlimited extent. Much injury has probably been done in this disease by excessive bleeding. It is not, in the first place, inflammation that is to be subdued, but merely hem- orrhage or congestion. The object of bleeding is not now so much to alter the character of the blood, as to check the current of it towards the head. If nature has already accomplished this purpose by a great reduction of the heart's impulse ; if the pulse at the wrist, instead of being full and strong, as it generally is, should be small and feeble, there is no advantage to be derived from the further loss of blood at the commencement of the treat- ment. It should be remembered that, in the hemorrhagic and serous cases, the disease is not over when the effusion is suppressed. The brain has sustained a great shock, and a long series of actions in the organ will be necessary to repair the mischief done. It is bad practice to destroy the resources of the system, which may be necessary to sustain this course of action, by an inconsiderate and exclusive obedience to the first indication; that, namely, of arresting effusion or correcting congestion. I would repeat, that the practitioner should be guided by the strength of the pulse whether he shall bleed or not; and by this, in connection with the general strength of the constitution, to what extent he shall bleed. From fifteen to thirty CLASS III.] APOPLEXY. 705 ounces may be taken from a robust patient at the first bleeding, should the pulse bear the loss well. But the operation should be checked as soon as the circulation shows evident signs of having slackened in force. The bleeding may sometimes be performed a second, third, or even fourth time, should the vigour of the pulse continue ; the quantity taken being dimin- ished each time. Allowance must be made for the pulse of hypertrophy of the left ventricle, which is sometimes full and strong almost to the last moment of existence. Very often a single bleeding will be found amply sufficient. After the circulation has been sufficiently reduced by general bleeding, and without that remedy should the pulse be feeble at the commencement, blood may be taken locally, by cups or leeches, from the temples or the back of the neck. From the great relief sometimes afforded to cerebral congestion by a moderate epistaxis, there would seem to be a propriety in applying some leeches to the interior of the nostrils. This situation for local depletion would be especially indicated, if the attack should have succeeded a sup- pressed epistaxis. When the apoplectic attack has followed the suppression of hemorrhage from the rectum or uterus, or of the menses, leeches should be applied to the anus or vulva. As the later bleedings are generally at- tended with the appearance of the buffy coat, signifying the existence of some inflammation in the brain, probably induced by the presence of the clot of blood, the local bleeding is especially indicated at this stage of the disease. Some authors have recommended emetics in apoplexy, and most continue to recommend them in cases which may have followed a full meal. I think that, in genuine hemorrhagic apoplexy, they can never be otherwise than injurious. If any one who may have vomited severely, will call to mind the feeling of intense distension in the temples, and general cerebral fulness, of which he has been sensible during the act, he would dread the thought of putting the vessels of the brain upon such a stretch, when already pouring out blood, or but just recovered from the hemorrhagic act. It seems to me that it could scarcely otherwise happen than that injury should result. If the stomach has been filled, it will gradually empty itself, even though the contents may be alcoholic; and, in the mean time, we have it in our power by means of the lancet, rest, position, &c, to control the force of the excited circulation. In those cases of coma from sympathetic irritation, which some- times follow the use of indigestible food, and which are anything but apo- plectic, an emetic is often of great service ; but never probably in true apo- plexy ; at least never with sufficient certainty to justify the hazard. Should the patient spontaneously vomit, or be affected with retching, it may be proper to facilitate the process, and calm the stomach by free dilution with mild liquids ; but this very seldom happens in genuine cerebral apoplexy. The late Dr. Jos. Parrish used to mention to his pupils the case of a young man who died of apoplexy, induced by the action of an emetic; and Andral relates a case, in which vomiting was obviously followed by a renewed attack, in a patient already apoplectic. (Clin. Med., v. 102.) Purging is very useful in apoplexy. It acts not only by depleting, but also by a powerful revulsion from the head, along the whole track of the aliment- ary canal. Active purgatives should be used at first. If the patient is able to swallow without much difficulty, the infusion of senna with sulphate of magnesia is probably the best cathartic that can be given. When there is reason to think that portal congestion or torpidity of the liver is associated with the attack, a full purgative dose of calomel should be administered, and followed by castor oil or Epsom salt. If there is difficulty of deglutition, croton oil may be administered in the dose of a drop every hour or two till it operates. Sometimes it will be found the best plan to put a drop of this 706 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. medicine upon the back part of the tongue, and allow it to remain until it excites the movement of deglutition. Should the throat be so far paralysed that the patient cannot swallow, strong infusion of senna, or some other active cathartic should be given by enema. In ordinary cases, cold should be applied to the head by means of cloths wet with iced water, or of bladders or water-proof bags filled with small pieces of ice. (See Meningitis, pp. 662-3.) But if the surface is cool, the face pale, and the pulse feeble, this remedy is contraindicated. Under these latter circumstances, some recommend warm emollient applications. Revulsion to the extremities should be kept up by the occasional use of hot stimulating pediluvia, sinapisms, &c. When the force of the circulation has been sufficiently reduced by the above measures, and the comatose symptoms continue at the end of three or four days, the head should be shaved, and the whole scalp covered with a blister. A powerful exterior revulsion is thus effected, and any tendency to inflam- mation of the meninges strongly counteracted. Lastly, should the disease not yield to these measures, the effect of a mer- curial impression should be tried. If unsuccessful, it can do no harm; if suc- cessfully brought about, it may prove useful in counteracting inflammation, and promoting the absorption of the effused blood, two of the indications above referred to. A very sore mouth, or profuse salivation should not be aimed at. A mercurial pill, or a grain of calomel may be given every two or three hours, and the operation assisted by gentle mercurial friction upon the inside of the thighs and arms. In the cases with depressed circulation, pale and cold surface, and collapsed rather than turgid countenance, should the debility not be in itself alarming, it may be proper to take some blood locally by cups or leeches from the tem- ples or back of the neck, or to make a small tentative bleeding from the arm. If, by the loss of a little blood, the pulse should acquire increased fulness and strength, it would be proper to proceed further; if, on the contrary, it should become somewhat more depressed, all thought of direct depletion should be abandoned, and the treatment should be confined to moderate pur- gation, revulsion towards the extremities, and to the surface of the scalp, and a gentle mercurial impression. Sometimes the debility approaches to syn- cope, and imperiously demands the employment of supporting measures. In such cases, an injection of oil of turpentine may be thrown into the rectum, blisters and rubefacients applied to the skin, and, if these should not suffi- ciently excite the circulation, carbonate of ammonia, arnica, capsicum, oil of turpentine, &c, may be given by the mouth; care being taken to avoid stimulants disposed to act immediately upon the brain, such as the fermented or distilled liquors, unless under circumstances of the strongest urgency. During the treatment, attention should be paid to the bladder, and the urine drawn off regularly if requisite by the catheter. Upon the restoration of consciousness, the greatest care should be taken to avoid all disturbances whether moral or physical. The diet should be of the lowest kind in the early stages, consisting of farinaceous or demulcent drinks, when the patient can swallow. As the case advances, it should be improved, and, in conva- lescence, the milder forms of animal food may be allowed in great modera- tion, such as milk, a soft boiled egg daily, boiled fowl or mutton, Sec, in con- nection with vegetable substances All premature efforts on the part of the patient should be sedulously guarded against. In the prostrate cases, it may be necessary to give animal broths even at an early period. Should paralytic symptoms succeed those of apoplexy, the treatment must be conducted upon the plan recommended under the head of palsy. Prophylactic Treatment.—This is of great importance in apoplexy. After CLASS III.] APOPLEXY. 707 one attack, the patient should be considered as peculiarly prone to the dis- ease, and put upon his guard at all points. His bowels should be kept regu- larly open once a day; and, if any tendency to constipation exist, he should take occasionally a small dose of sulphate of magnesia, or some other saline cathartic. Should vertigo or headache, with a flushed face, and a strong full pulse, come on at any time, no hesitation should exist in employing the lan- cet, or in taking blood locally from the head, or in the use of an active purge, according to the urgency of the symptoms. Care, however, should be taken not to confound merely nervous sensations from disordered diges- tion, hysterical tendencies, or other cause, with those resulting from sangui- neous congestion. All the causes of the disease should be most carefully avoided. The diet of the patient should consist chiefly of vegetable food and milk, with the lighter meats, especially boiled meats, in moderation. Stimulating drinks and condiments should be wholly proscribed. Even tea and coffee, if used at all, should be taken weak and in small quantities; and black tea should be preferred. The object should be to avoid plethora on the one hand, and anaemia, which provokes excessive action of the heart and disposes to cerebral softening, on the other. The patient should take moderate exercise, particu- larly of the passive kind; but should avoid all active muscular exertion, should never strain under any circumstances, even at stool, should never walk fast, or run, or mount a flight of stairs hastily. He should always sleep with the head elevated, and, though taking care to keep sufficiently warm at night, should avoid the other extreme of excessive heat. In warm weather, a mattrass should be preferred to a feather bed. In the use of the bath, care should be taken that it be not heated above 98°. The hot bath produces often almost as powerful an impression on the brain as wine. The cold bath should also be used with caution. Though the patient might often employ it with impunity and even advantage to his general health, yet there is always the risk that the blood may be too suddenly concentrated in the brain. Nor is less caution necessary in watching over his mental condition. It should be the care of the patient's life to maintain an equable frame of mind, and never to allow himself to be ex- cited into passion or strong emotion by any of the varying interests, or con- flicts, or vexations of this world. Severe intellectual occupation, also, if previously the habit of the patient, should be abandoned for the remainder of life. In short, it should be his aim, and that of his medical adviser, to maintain in all things, in eating, drinking, exercise, employment, pleasure, and pursuits of every kind, as well as in the state of the bodily functions, a wholesome moderation. Article IV. FUNCTIONAL DISEASES OF THE BRAIN. There are two points of view from which functional disease of the brain may be regarded ; first, in relation to the pathological state of the organ; secondly, in relation to certain symptoms or groups of symptoms, which, though in some instances they have the rank of diseases, are in fact only the effects of the true disease, and the signs by which it is made known. It will contribute to a clearer understanding of the subject, to consider it in both these lights. .,«... ., ,. . Before entering upon the special affections, there is one preliminary con- sideration which it is necessary to present to the student. A remarkable fact familiar to all pathologists, is, that similar phenomena very often pro- 708 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. ceed from precisely opposite conditions of the brain; so that it is occasion- ally very difficult to decide, from the symptoms alone, what is its real patho- logical state. To some pathologists this fact seems so difficult to be reconciled to a sound philosophy, that they have endeavoured, in the seemingly oppo- site states of the part, to discover some one action or influence of an identi- cal character, to which the effects may be ascribed. Such an influence is supposed to have been found in pressure on the brain, which is said to be produced when the condition of the cerebral circulation is in any way dis- turbed. Thus, if too much blood is sent into the arteries, pressure upon the cerebral substance in their vicinity is the necessary result. If too little is sent, then, as the cranium is a plenum, always kept full by the pressure of the atmosphere, there must be a corresponding excess in the veins, so that pres- sure is exerted in their neighbourhood. But this explanation is unsatisfac- tory. In the first place, it does not meet those cases in which the blood is altered in quality only, nor those in which the morbid phenomena are purely nervous without any vascular change ; and, in the second place, assumes, as . the result of pressure, symptoms which are very different from such as are known to proceed from that cause. Thus, stupor is well known to be pro- duced by pressure ; but I am not aware that morbid vigilance has ever been shown to be among its effects. But this peculiarity of cerebral disorder is really not so anomalous as at first sight it may seem to be. The phenomena of electricity, analogous, in various respects, to those of nervous action, are not less so in the present case. We obtain effects, to ordinary observation precisely the same, from positive and negative electricity. Both produce attraction and repulsion, the electric spark, the shock, and chemical decomposition. It is not sur- prising, therefore, that the brain, which is the great nervous battery, should exhibit similar effects from precisely opposite conditions. It is true that science can detect a difference between the effects of positive and negative electricity. It is highly probable that a similar difference will some time be detected also in the seemingly identical results of opposite cerebral disturb- ance. As it is, we can often, by a close observation, discover peculiarities which enable us to determine, with sufficient certainty, the particular patho- logical condition in which the phenomena, in any special case, may have ori- ginated. I do not wish it to be inferred that I believe the brain to act in the same manner as a galvanic battery. My object is simply to show that, in the apparent contradiction, there is in fact nothing opposed to the course of nature in other departments, and consequently nothing impossible, or really contradictory. I.' PATHOLOGICAL CONDITIONS. These may be included under the divisions of 1. pure nervous irritation, without any necessary participation of the blood-vessels; 2. vascular irrita- tion, or active congestion; 3. depression, whether nervous or vascular; and 4. mechanical or passive congestion. _ 1. Nervous Irritation.—The brain is peculiarly susceptible to irrita- tion of an essentially nervous character; that is, without necessary partici- pation of the blood-vessels. Too exclusive an importance has, I think, been attached to the state of the circulation in this organ. All the morbid pheno- mena have been ascribed by some pathologists to too much or too little blood, or to its unequal quality or distribution. These are undoubtedly frequent sources of cerebral disorder; but the brain is also frequently excited into dis- ease without them. The nervous system has a mode of action of its own, in which, though blood may be necessary as an instrument, it is not the main CLASS III.] NERVOUS IRRITATION OF THE BRAIN. 709 operating principle. This action is susceptible of exaltation, depression, or depravation in itself, and from the influence of its own peculiar agents. The fact here stated is not of merely speculative interest. It is in the highest degree practically important; and a vast deal of mischief has been done by looking to the blood-vessels exclusively as the seat or source of cerebral dis- order. But, in thus asserting for the nervous functions a capacity of exclu- sive and independent disease, we must not forget that their irritation fre- quently, in the end, involves the blood-vessels ; and that the affection, if not relieved, may terminate in active congestion or inflammation. Symptoms.—As the offices of the brain are numerous, so also must be the signs of its excessive excitation. To enumerate all these in the present place would be quite out of the question. Irritation in the brain obeys the general laws of that morbid affection. If moderate, it exalts the healthy functions without otherwise altering them ; if stronger, it more or less deranges the functions; in great excess, it entirely changes or abolishes them. Thus, sen- sation and perception may be simply rendered more acute; or they may be deranged, producing vertigo, pain, and every variety of disorder in vision, hearing, touch, &c, from buzzing in the ears, unnatural colouring of objects, a sense of tingling, formication, &c, to complete hallucination. The intel- lectual faculties and the emotions may be excited into increased vigour, or may be completely perverted, as in delirium and insanity. The general over- seeing faculty of the brain may be simply stimulated to increased vigilance, to a more ready and rapid response to all the intimations of its dependent func- tions ; or it may be thrown into excessive disorder, evinced by restlessness, jactitation, obstinate sleeplessness, &c. The motor faculty may merely im- part increased activity and energy to the muscles under the influence of the will; or it may throw off more or less completely subordination to that prin- ciple, and give rise to every variety of spasm and convulsion. Finally, all the functions above referred to may be overwhelmed by an excess of the irri- tation, and more or less completely lost in stupor and coma. Not only the proper cerebral functions become deranged in this species of irritation, but to a certain extent, also, many, I might perhaps say, all those of organic life. Connected with the digestive function we often have nausea and vomiting; with the secretory, disorder of the liver and kidneys; with the respiratory, hurried and otherwise irregular breathing; with the circu- latory, a frequent and agitated, though seldom full or energetic pulse. Various special diseases either consist exclusively in some modification of cerebral nervous irritation, or frequently partake of that affection. Such, among others, are insanity, epilepsy, chorea, neuralgia, and hysteria. Fre- quently also, it is met with at the threshold of other diseases, in which the morbid action consists mainly in vascular irritation or inflammation. It ex- ists, moreover, very often in its milder grades, without receiving any other name than the vague one of nervous disorder. Causes.__The nervous temperament, great mobility of the nervous system, as in children and females, and debility or poverty of the blood predispose to this form of disease. Causes which, in a vigorous frame, might induce vas- cular irritation, are apt in debility to excite only the nervous. Anaemia operates especially as a predisposing cause. When the blood is not rich enough to supply the wants of the system, the cerebral centres receive inti- mation of the deficiency from every function, in order that the due influence may be transmitted to tho heart, and are kept in a constant state of excite- ment which itself often amounts to irritation, or readily becomes so by the addition of any new stimulus. _ The exciting causes are excessive intellectual action, violent emotion, strong Impressions from without upon the senses, and almost every variety of local 710 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. irritation elsewhere, especially in the gums, the stomach, the bowels, and the uterus. The headache accruing from acid in the stomach, the delirium some- times excited by excessive pain, the insanity from hepatic disease, the coma of uterine affections, and the convulsions from intestinal spasm in infants, are often examples of this kind. It is important, in reference to treatment, to make a correct diagnosis be- tween purely nervous and vascular irritation of the brain; but the distinguish- ing characters will be most conveniently given under the following head. Treatment.—It is only the general principles of treatment that can be given in this place. The indications are, 1. to remove the cause of irritation, whether predisposing or exciting; 2. to diminish the susceptibility, or directly to repress the excitement of the cerebral centres ; and 3. to equalize the nervous action, either by medicines calculated to stimulate the whole nervous system, or by revulsive impressions upon other parts of the body. To meet the first indication, the patient must be protected as far as pos- sible from exterior sources of irritation ; and a close scrutiny into the state of all the organs must be instituted, in order that any existing disease in any portion of the system may be corrected. As a debilitated and anemic con- dition of system predisposes to the complaint, such a condition, if present, should be removed by the chalybeates and other tonics, exercise, pure air, and a nourishing diet. The second indication is to be fulfilled by opium and other narcotics, as extract of hemp, hyoscyamus, belladonna, stramonium, conium, aconite, chlo- roform, tobacco, digitalis, and hydrocyanic acid; the most efficient, beyond all comparison, being opium in some one or other of its various forms of prepara- tion. When the cause is temporary, this narcotic will often at once most hap- pily control the disease. Thus, I have seen the most violent delirium, de- pending upon temporary excitement, yield immediately to a full dose of opium. But, in the use of these medicines, especially of such of them as possess stimulating properties, and the power of producing congestion of the brain, great care must be exercised not to mistake vascular irritation for the nervous. In relation to those which rather diminish than excite vascu- lar fulness in the brain, including chloroform exhibited by the stomach, aco- nite, tobacco, digitalis, and hydrocyanic acid, the caution is not equally necessary; though these are in general much less efficient for the end in view, and are liable to the danger of producing too great prostration. Under this indication may come also the use of the warm bath. The third indication is met by the nervous stimulants or antispasmodics, such as musk, assafetida, camphor, the ethereal preparations, valerian, and garlic, internally or externally used; by the tonics which operate with pe- culiar energy on the nervous system, as quinia, and the metallic tonics generally; and by revulsives to the surface, including hot pediluvia, rube- facients, blisters, setons, issues, &c. Blisters often have a most happy ef- fect. It is not unusual for patients, restless, agitated, and wakeful, to be completely calmed, and to fall into a peaceful sleep under the operation of that remedy. Mental influences often operate like a charm in calming this variety of cerebral irritation, probably in chief by a kind of revulsive action within the brain; one function in excess being reduced by calling another into opera- tion. The principles of faith, hope, fear, the love of the marvellous, and the various affections, may be occasionally brought into play with great ef- fect ; and a strong or steady occupation of the imagination and reasoning faculties has occasionally a wonderful influence. Bleeding is seldom useful, and often injurious, by increasing debility or giving rise to anaemia j nevertheless, it may sometimes be called for by CLASS III.] VASCULAR IRRITATION, OR ACTIVE CONGESTION. ' 711 coexisting diseases; and cases not unfrequently occur in which vascular con- gestion is mingled with, or supervenes upon the nervous, in such a degree as to require the lancet. More or less congestion is a frequent consequence of an irritation originally exclusively nervous ; and, in such cases, even though there may be general debility, the local abstraction of blood often affords much relief; but the remedy should be resorted to with caution, especially in cases of long duration, lest its frequent repetition should do more harm by aggravating the disordered condition of system, than good by relieving the cerebral affection. 2. Vascular Irritation, or Active Congestion.—It is sup- posed by some that, as the brain is incompressible, and the cranial cavity a plenum, the quantity of blood in the organ is the same under all circum- stances. But it is not certain that the cerebral substance may not be some- what compressed, even by the force which the heart is capable of exerting, and consequently that an additional quantity of blood may not be admitted. Besides, under an increased pressure from without, or an increased attractive force from within, it is very possible that portions of the cerebral substance, or of the serous liquid impregnating its tissue, and contained in its cavi- ties, may be so far absorbed as to create space for the entrance of more blood. The arteries, moreover, may be distended, while the veins and sinuses are diminished in capacity; the compression of the latter being compensated by a more brisk current through them. At all events, there may be an increased rapidity of the cerebral circulation in general; so that a more than ordinary amount of influence may bear, within a given time, upon the susceptibilities of the organ. Vascular irritation, therefore, has full scope for its display in the brain ; and is, in fact, one of the most fre- quent modes of derangement. Symptoms.—The derangements of sensorial, mental, and motor function in the brain, already detailed as the effects of nervous irritation, may equally result from the vascular. Among the most common are a sense of fulness, weight, or distension in the head ; giddiness ; headache of every grade and variety; increased sensitiveness to sound, with buzzing, roaring, and other perversions of hearing; double, partial, luminous, painful, dim, or other- wise disordered vision, with muscae volitantes, scintillations, &c. ; tingling, formication, neuralgic pains, numbness, and partial or complete loss of sen- sation in various parts of the body ; nausea and vomiting ; morbid vigilance, or perhaps more frequently oppression, heaviness, drowsiness, and stupor in various degrees; mental confusion, loss of memory, and delirium ; and finally subsultus, spasm, convulsions, or the opposite condition, indicated by muscular weakness, tremors, and temporary paralysis of motion. It is, of course, understood that all these symptoms are not present in any one case. They are, indeed, often contradictory, and could not exist together. There may be one only, or a few, or many variously grouped. Active congestion of the brain is sometimes of itself serious, and may prove fatal; but its greatest danger is as the precursor of inflammation of the brain or its membranes, or of apoplectic effusion. Another injurious result, common to this and the preceding variety of cerebral disorder, is the establishment in the brain, under frequently renewed irritations, of a habit which may lead to the recurrence of the phenomena from slight causes, and even, in some instances, without any apparent exciting causes, as in epilepsy, some forms of hysteria, chronic headache, &c. It is a condition which requires attention; and by the proper management of which, at an early period, much subsequent suffering and danger may be prevented. Causes.__All the causes enumerated under the last head may produce vascular irritation, when the system is predisposed to it; and, as before 712 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. stated, it is very apt to be the result of the continuance of an irritation primarily purely nervous. But there are certain causes more especially operative, such as direct injury to the head by falls, blows, &c, exposure of the head to intense solar or artificial heat, external cold, alcoholic stimu- lants, the exciting passions, febrile diseases, translated gouty or rheumatic irritations, suppressed discharges, teething in children, hypertrophy of the left ventricle, and various intestinal and stomachic disorders. The san- guineous temperament, a plethoric state of the circulation, and an over- richness of the blood, may be considered as constituting predispositions to it. Men are probably more subject to it than women. It is common in in- fancy, at the age of puberty and from that up to maturity, and again in advanced life. Diagnosis.—It is sometimes highly important to distinguish active con- gestion of the brain from passive congestion, depression, or mere nervous irritation. In relation to the two former of these affections, the reader is referred to the subsequent part of this article. From nervous irritation it is to be distinguished chiefly by the state of the circulation. In active con- gestion, the face is usually flushed, the eyes suffused, and the whole counte- nance often turgid. If the patient is sensible, he is apt to complain of ful- ness, distension, or heaviness of the head; and any vertigo or headache which he may have is much increased by stooping, with the head downward. The temporal and carotid arteries sometimes may be seen to throb. These symptoms are often wanting in purely nervous irritation. The state of the pulse, too, is different. In the former condition it may be small or large, accelerated, or slow, but it is almost always in a greater or less degree tense, hard, and strong. In the latter, it may be natural as to frequency, or very much excited, but is generally rather feeble, or at least destitute of tension. In nervous irritation there is often an aspect of a lighter, more fugitive affection, sinking less deeply into the sources of life, which an experienced eye can readily detect. In congestion, when considerable, there is more tendency to drowsiness or stupor; the expression of countenance is duller, or more changed; and the case appears to approach nearer to the character of inflammation or cerebral hemorrhage. Treatment.—The treatment in this affection, independently of the measures necessary for the removal of the cause, which should never be neglected, is chiefly depletory, sedative to the circulation, and revulsive. Bleeding, gene- ral and local, purging, the warm bath, the antimonials when the stomach is not irritable, other saline refrigerants, cold to the head and hot pediluvia, mustard, blisters, &c, to the extremities, with low diet, rest, and an elevated position of the head are the principal remedies. Very often, in mild cases, the symptoms may be removed by a saline cathartic and attention to the diet. When serious, however, recourse should be had to the lancet. The internal use of aconite has been highly recommended; and American helle- bore would prove still more effective. It must be remembered that, though the warm bath may be useful, the hot bath might prove injurious by over- stimulation. But no permanent benefit can be expected while the offending cause remains. This, therefore, should be diligently sought for, and removed or corrected if possible. 3. Depression.—In this condition the activity of the brain is dimin- ished either by a directly depressing influence, or the withdrawing of an ac- customed stimulus. The symptoms, so far as regards the disorder of sensation, consciousness, mental action, and motive power, are the same as those already mentioned as resulting from irritation of the brain. We have the same headache, vertigo, disordered vision and hearing, wakefulness, delirium, convulsions, and coma. CLASS III.] DEPRESSION OP THE BRAIN. 713 There is not, as from the moderate influence of the other affection, increased cerebral energy; as indicated by greater acuteness of sensation, more bril- liancy of imagination, a more rapid flow of just thought and expression. These can only result from a positive excitement of the brain; but all the other derangements alluded to may be experienced. It may seem strange that obstinate wakefulness and violent convulsion should be among the effects of cerebral depression ; yet few facts in medicine appear to me to be better established. Thus, take away from the brain a stimulus to which it has been long accustomed, and one of the first results is morbid vigilance; and this condition is a not unfrequent attendant on the debility which succeeds ex- hausting acute diseases. The last vital act of the system, expiring under the loss of blood, is sometimes convulsions. It is well known that all the phenomena of advanced meningeal inflammation, or acute hydrocephalus, are sometimes imitated in children in the lowest stages of exhaustion from bowel affections; and the brain is found apparently healthy after death. The insanity which attends starvation might be adduced as another illustration of the resemblance between the phenomena of an excited and depressed brain; but it is probable that, in this case, there is a real and powerful irritation of the cerebral centres, proceeding from the impressions sent up to them so urgently from all parts of the suffering system. After death from cerebral depression, especially in cases of chronic debility, serous effusion has sometimes been observed in the cavities of the brain, and has been misinterpreted into an evidence of inflammation; especially as softening of the cerebral substance has been at the same time observed, re- sulting from the imbibition of the serum and a sort of maceration, or pos- sibly from some directly depressing influence. The presence of the effused fluid is nothing more than what might reasonably have been anticipated from the pre-existing condition. The brain is not sufficiently nourished, or not sufficiently supplied with blood, and, as the cranium does not admit of a vacuum, the loss of bulk is supplied by effusion of watery fluid from the blood-vessels. The causes of cerebral depression are long-continued or excessive cold; the depressing passions, such as fear and grief; various sedative poisons, as tobacco, digitalis, hydrocyanic acid, and chloroform; the irrespirable gases, as hydrosulphuric acid, carbonic acid, carburetted hydrogen, &c.; deficiency in the general amount of blood, or in its supply to the brain; an impover- ished state of the blood; an excess of carbonaceous matter, and the presence of urea and bilious matter in the blood ; the withdrawing of an accustomed stimulus; and, secondarily, any excessive excitement when it ceases. Of course, all the modes of living, the kinds of exposure, the accidents, the dis- eases which produce any of the above conditions, may act as remote causes of cerebral depression. To enumerate them here would be only to occupy space with what is already familiar to the reader. An important point is to discriminate between depression and vascular irritation of the brain. The greatest practical evils have resulted from error upon this point. Bleeding has often been resorted to in diseases of pure de- bility, because convulsions, or delirium, or insanity, or morbid vigilance, or some other symptom occurring in cerebral exaltation, has been misinterpreted into a necessary sio-n of that condition of the brain. The diagnosis is not always easy. But°we can generally reach a tolerably just conclusion, by taking into consideration the cause of the affection, and the signs exhibited by the organic functions. When, for example, the effect can be clearly traced to a directly sedative agent, or to the withdrawal of a direct stimulus, or to an obviously debilitated condition of the system ; when, at the same time, the pulse, though perhaps frequent, is less firm and strong than in health, the VOL. n. 46 714 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. face pale, livid, or purplish, the capillary circulation slow, and the patient disposed to faintness upon exertion, there can scarcely be a doub.t upon the subject. The aggravation of the symptoms upon rising from a stooping to an erect position is another valuable diagnostic sign. The difficulty is that, in cases of debility, an active congestion of the brain is sometimes induced by an irritant cause, and exhibits itself by cerebral symptoms similar to those of depression. But the nature of the cause will often enable us to decide justly; and a permanent flushing of the face, or other signs indicative of a steady determination of blood to the head, would very much aid the diagnosis. Another difficulty is sometimes presented by cases, in which a sudden and powerful irritant influence has overwhelmed the brain, and so far cramped its energies as to have induced a prostrate condition of the organic functions. A blow upon the head, an astounding piece of intelligence, the shock of a severe accident or surgical operation, or excessive pain in some structure, especially rich in sympathies, as in the stomach, bowels, kidneys, &c, occasionally pro- duces such a result. Here too we are aided by a knowledge of the nature of the cause; and, whenever there is good reason to suspect the existence of the condition of things alluded to, we should act cautiously in the application of stimulant measures, from the fear of subsequent reaction. Inflammation of the brain itself, or apoplectic congestion or effusion, by interfering with the ordinary influences of the organ, sometimes induces the same apparent signs of debility; but the previous symptoms and attendant circumstances will generally sufficiently evince the nature of the case. Treatment.—Tonics, stimulants, external irritants, and a nutritious diet, with the means necessary to remove the causes of the affection, are indicated in this condition of the brain. In cases at all doubtful, those stimulants should be preferred which have the least permanent impression upon the brain, such as carbonate of ammonia, oil of turpentine, capsicum, musk, and assafetida; while external stimulation by means of rubefacients, blisters, the hot bath, &c, and the powerful influence of electro-magnetism, should be mainly relied on, when deemed sufficient to meet the exigencies of the case. Should the respiration have been suspended, it should be restored artificially. This is especially important in the cases of poisoning from irrespirable gases. The shock of colc\ water suddenly dashed upon the surface is sometimes very effective, by rousing the suspended sensibilities of the brain. 4. Mechanical or Passive Congestion.—This results from causes interfering with the return of blood from the cerebral vessels. The blood accumulates in the veins and sinuses ; the capacity of the arteries is of course diminished; less arterial blood is admitted than is necessary for the support of the functions; and we have the double result of compression and depres- sion of the brain. The characteristic symptoms of this condition are a feeling of fulness, weight, and sometimes coldness in the head, an actual diminution of temper- ature in this part, a strong tendency to drowsiness or stupor, vertigo, faint- ness, impaired vision with inuscae volitantes, forgetfulness of things or words, dulness of countenance, a livid or purplish hue of the lips and different parts of the face, with paleness, occasionally nausea, and depression in the functions of circulation and respiration. The causes are ligatures around the neck, tumours pressing upon the ve- nous trunks, gravitation, and such an organic or functional derangement of the heart and lungs, as to impede the passage of the blood either into the right side of the heart, or from the right to the left side through the lungs, and consequently to produce accumulation in the descending cava. The treatment consists exclusively in the removal of the cause, and, when this is impossible, in the adoption of measures calculated to proportion, as CLASS III.] HEADACHE. 715 nearly as may be, the calls of the system upon the cerebral centres to their diminished capacity. The avoidance of all kinds of excess, mental or phy- sical, is especially requisite. II. MORBID PHENOMENA. I do not propose to treat, in this place, of all the phenomena of functional disease of the brain. Most of them have been already, or will be hereafter fully considered, in connection with special diseases, either consisting essen- tially of this kind of derangement, or associated with it. But there are cer- tain phenomena, which, though noticed elsewhere, and perhaps in various places, yet have not been presented so fully or so connectedly to the reader as their importance would seem to require ; and others which, not essentially connected with any other special complaint, and scarcely meriting the rank of distinct diseases themselves, yet demand some attention, and may be most conveniently noticed under this heading. The phenomena, or affections alluded to, may be included in the divisions of 1. sensorial disorder; 2. men- tal disorder; and 3. disorder in the motor power. 1. Sensorial Disorder. This may embrace all the cerebral derangements having reference to sen- sation and consciousness; and the morbid conditions which claim attention in this place may be arranged under the sub-heads of headache, stupor, and wakefulness. 1. Headache, or Cephalalgia.—In the widest acceptation, this may be considered as embracing all kinds of uneasy sensation in the head. Very often it is wholly independent of the brain, being seated in the scalp or cran- ium. Such is the case with many instances of gouty and rheumatic head- ache, neuralgia, various inflammatory affections of the exterior coverings of the cranium or of its sinuses, and syphilitic affections of the periosteum or bony case itself. These do not belong to the complaint as here considered, which is exclusively cerebral. Headache is of every degree, and of every conceivable diversity of char- acter. It may be confined to one small spot, in which case it is sometimes called clavus, as if it might proceed from a nail driven into the head; it may occupy a particular region of the cranium, as the frontal immediately over one or both eyes, the temporal, the parietal, or the occipital; it may embrace one side of the head as in hemicrania; or it may be diffused, and of indefi- nite extent. Sometimes it is fixed, sometimes changeable in its position. It may be apparently superficial, or felt in the depths of the brain. It is not less various in duration than in the other respects mentioned. It may con- tinue but for an instant, or may last for hours, days, or weeks. Indeed, in- stances have occurred in which it has never been absent, during consciousness, for months or years. Much more frequently, however, when so durable, it occurs in paroxysms with intervals of comparative or entire ease, the exacer- bations being quite irregular in their recurrence. Not unfrequently, how- ever, headache is regularly periodical, being either remittent or intermittent, and generally of the quotidian or tertian type, though the interval is some- times longer, and I have known it to occur regularly once in two weeks, with- out association with any natural periodical functiom 1 he pain may be sim- ple or mav be mingled with various other perverted sensations, such as gid- diness, fulness or distension, weight or lightness, emptiness, heat or coldness, hissing, buzzing, ringing or roaring in the ears, the sight of dark or lumi- nous spots, scintillations, double vision, half-vision, dimness of vision, and temporary blindness. 716 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. Headache may be the result of any one of the pathological conditions de- scribed in the beginning of this article, and is one of the most common of their effects. It appears to be the favourite sign by which nature makes known any deviation whatever from the normal state of the brain. Viewed in this light, it may be looked on as a safeguard, intended to give notice of disease which might otherwise escape attention, till too late to be remedied; and its indications should never be neglected. The physician, consulted for this affection, should not be content till he has traced it to its source, how- ever hidden ; for it is not the pain only that he is called on to relieve, but often the more serious affection of which it is a mere symptom. For the sake of convenience, we may consider headache as symptomatic when the result of some known disease, and idiopathic when the pathological state on which it may depend cannot be ascertained, or is not recognized among special diseases. It is obviously nothing more, strictly speaking, than a symptom in either case. Symptomatic headache is exceedingly common, and associated with a great number of diseases. It is an almost uniform attendant on the different forms of meningeal and cerebral inflammation; and is usually the first sign by which other organic affections of the brain, such as tumours, hydatids, and morbid growths or formations of all kinds, declare themselves. As the direct result of vascular irritation of the brain, it is one of the most common symptoms of all febrile diseases, whether idiopathic or symptomatic, and is a not unfre- quent precursor of apoplexy and epileptic convulsions. Gout and rheuma- tism often show themselves in this guise. In the nervous form, it is very often sympathetic of disease of the stomach constituting sick headache, of hepatic disease constituting bilious headache, of worms, constipation, and other disorders of the bowels, of renal and uterine affections, and of spinal irritation. It is sometimes dependent on decayed teeth, even when these do not ache. In every obstinate case of cephalalgia, of uncertain origin, particular examination should be made into the condition of the teeth, and, if any one of these is found decayed and tender on pressure, it should be ex- tracted. I once had a case of headache, which had continued for two or three months, with varying degrees of violence, and had resisted numerous remedies, which yielded immediately upon the extraction of some decayed teeth. Dis- eases of the heart are very frequently, and those of the lungs somewhat less frequently, attended with headache, dependent either on the greater impulse with which the blood is sent into the brain, as in hypertrophy of the left ven- tricle, upon the insufficient supply of blood, as in pure dilatation and soften- ing of the heart, mitral regurgitation, &c, or upon venous congestion conse- quent on impediment, either pulmonary or cardiac, to the passage of the blood from the venous to the arterial system. Anaemia and plethora are also affections which frequently occasion headache, though from opposite causes. Idiopathic headache is also not uncommon. It is usually distinguished by the name of nervous headache. It is exceedingly irregular in its modes of attack, duration, and recurrence, as well as in the character of the pain. Sometimes coming on suddenly in a state of apparently sound health, it prostrates at once the mental as well as physical energies of the patient, and, after a longer or shorter period, leaves him as abruptly as it approached, and with all his powers restored. In other instances, it comes on slowly, heralded perhaps by unaccountable depression of spirits, or acerbity of temper, and gradually increases for hours, perhaps for days, before it attains its acme and declines. In one patient, an attack is experienced at long intervals; in another, the pain returns frequently and quite irregularly; in a third, it is scarcely ever absent entirely for long periods of time; at least the individual never feels himself secure against it for a moment. Sometimes it interrupts CLASS III.] HEADACHE. 717 and prevents sleep; but more frequently the patient, though tormented dur- ing the day, will go to sleep at the usual hour, and upon awaking find that the pain has left him for a time. More frequently than any other variety of headache, this assumes the regular periodical form. In most instances, pro- bably, the pain is in the front of the head, over one or both eyes; but it is occasionally felt in the occiput, and is often diffused without a definite seat. Not unfrequently it occurs in the form of hemicrania. It may be dull and grumbling, or heavy and throbbing, or sharp and lancinating like neuralgia. After continuing a certain length of time, it not unfrequently provokes vomit- ing; but differs from sick headache in the circumstance, that the matter dis- charged from the stomach may be quite destitute of acid, bile, or any acrid property. Its duration is entirely uncertain. One attack seldom continues long; but the patient is liable to frequent returns of it, in many instances, for months or years, and in some even for life. It is purely functional, and leaves no traces in the brain after death. The headache itself never proves fatal; but it may, in the end, so far wear out the strength as to render the system less able to support the assaults of other diseases, and may thus con- tribute to shorten life. The causes of it are often obscure. One of the most common is, I be- lieve, the use of coffee, tobacco, and strong tea. Sedentary habits, combined with much mental exertion, and loss of sleep, sometimes give rise to it, inde- pendently of any primary disease of stomach. It may now and then be traced to a disordered state of the blood, consequent upon defective renal, hepatic, or cutaneous secretion, upon the absorption of unwholesome matters from the alimentary canal, or upon some concealed vice in the processes of assimi- lation. Occasionally I have observed the breath to smell offensively. It has appeared to me that, in many instances, this variety of headache is nothing more than a form of nervous gout and rheumatism. Treatment.—For the treatment of symptomatic headache, the reader is referred to the various diseases of which it is an accompaniment. Under the heads of nervous gout, sick headache, and neuralgia, he will find remedies for varieties of the disease in its nervous form. The treatment adapted especially to hemicrania is detailed under the last named affection. It is only for the disease in its idiopathic form that the mode of treatment is here given. The first and most important point is to discover and remove the cause. In the first place, if the patient is in the habit of using either strong tea, cof- fee, or tobacco habitually, he should be advised to try the effect of abandon- ing it for three or four weeks, by way of experiment. Very often he will find the headache relieved by this simple measure, and then will be sensible of the propriety of abstaining from the poison altogether. Should this mea- sure fail, it will be necessary to seek for some other cause, and if there is any one suspicious article of diet, the same course should be pursued with that as with the substances mentioned. The patient should also sleep sufficiently and regularly, should not overtask his mind or allow himself to be worried and perplexed by business or other cause, and should exercise freely in a pure air. If a citizen, he should be advised to take a journey into the coun- try. A long voyage is occasionally very useful. Sometimes a complete change of life, the substitution, for example, of the business of farming for that of a merchant or professional man in cities, has a most salutary effect. It need scarcely be added that the bowels should be kept regular, and the func- tions of the stomach, liver, kidneys, skin, and uterus, in a healthy state. The pain may almost always be temporarily relieved by opiates or other narcotics * and sometiraes, when it is very severe, it becomes advisable to have recourse to these remedies ; though their habitual use should be most 718 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. sedulously guarded against. The nervous stimulants or antispasmodies also frequently afford relief. One of the best of these is Hoffmann's anodyne, of which a fluidrachm may be given; but, on the whole, I have found nothing more effectual than two or three cups of strong tea or coffee. When the disease depends upon the use of tea or coffee, this remedy acts simply like ardent spirit in relieving the horrors of intemperance. It should, under these circumstances, not be employed, as it aggravates the evil in the end. But in other cases it will be found a valuable resource. Ether applied in the hollow of the hand to the forehead, chloroform rubbed upon the scalp and then confined by a piece of oiled silk, lotions with spirit of lavender, Cologne water, or bay-rum, the application of a mustard plaster to the back of the neck or the temples, or blisters behind the ears, and the external use of tincture of aconite, are sometimes advantageous. The taking of several deep inspirations in quick succession is said occasionally to afford relief. It was suggested by M. Tavignot, under the impression that the affection might in some instances be connected with a stasis of blood in the cerebral sinuses, or insufficient change in the lungs. (See Am. Journ. of Med. Sci., N. S., xxi. 201.) In relation to the permanent cure, sulphate of quinia should always be employed in intermittent cases, and may be tried with the hope of good in others. When there is any suspicion of gout or rheumatism, recourse should be had to occasional purgative doses of sulphate of magnesia and wine of colchicum, to which a full dose of sulphate of morphia may sometimes be added. The chalybeates should be used in anemic cases. In certain ex- tremely obstinate cases, especially if paroxysmal, arsenic proves wonderfully efficacious. A patient of mine, who had been for many months a martyr to the disease, in whom quinia, iodine, mercury pushed to salivation, and other powerful remedies, including depletion, had been employed in vain, began to improve immediately under the use of Fowler's solution, and was effectu- ally cured in two or three weeks. If the disease prove obstinate, the whole round of remedies recommended in neuralgia is at the command of the physician. _ 2. Stupor and Wakefulness.—These opposite conditions are men- tioned here, not with a view to minute description, but chiefly in order to call attention particularly to the fact, that they may each of them be the result of a depression or elevation of the cerebral actions. By stupor is meant that condition of the brain which consists in a suspen- sion more or less complete of the animal functions, while those of the organic life continue, and which bears a close resemblance to sleep, except in the cir- cumstances that it is much less under the control of the will, and depends upon some morbific cause. Under the name may be included various grades of the affection, from heaviness or slight drowsiness to absolute coma, in which all consciousness is lost, and from which the patient cannot be roused. It may be produced at any time by pressure upon the brain, whether proceed- ing from vital causes congesting the cerebral vessels, or giving rise to effu- sion within the cranium; or from mechanical causes, as"depression of the bone, or impediment to a return of the blood from the head. Some appear to consider it as dependent upon pressure alone. But, as this cause operates merely by suspending certain functions, there is no reason why stupor, in its different grades, should not arise from other causes capable of interrupting the same functions, whether by an excess of excitement or a direct sedative impression. I have no doubt whatever, that it often results from both these causes, altogether independently of pressure. Thus, I have seen coma conse- quent upon a sympathetic irritation extended to the brain from the stomach loaded with indigestible matter, when the face was quite pale, the pulse was CLASS III.] STUPOR AND WAKEFULNESS.—SUN-STROKE. 719 wholly undisturbed, and there was no reason whatever to suspect congestion within the cranium. I have seen it, moreover, result apparently from the loss of blood, and consequent simple depression of the cerebral functions. A boy fell upon his head from a great height, and was affected immediately with symptoms of concussion, for which he was at the moment improperly bled. His system, however, reacted, and along with the reaction the coma with which he was originally affected began to give way. The excitement was thought to exceed the just limits, and leeches were applied to the tem- ples. Immediately afterwards the coma increased; and it now became a question, whether this could be owing to an increased excitement of the ves- sels augmenting the pressure, or might be the result of an insufficient supply of blood to the brain. The weakened pulse, the paleness of face, and the diminished heat, induced his attendants to ascribe it to the latter cause. They administered stimulants and nutriment, and from the moment this plan was commenced, the child began to recover. He would probably have per- ished under other circumstances, and almost certainly had the bleeding been repeated. The practitioner, therefore, must be upon his guard in cases of coma, and prepared to treat it upon the principle either of morbid pressure, of simple excess of irritation, or of depression. As the result of the last mentioned cause, it frequently follows the influence of sedative narcotic poi- sons, such as tobacco, digitalis, or hydrocyanic acid, or the admission of ve- nous or carbonized blood into the arteries of the brain. Coma in children, with largely dilated pupils, and not ascribable to any obvious cause, may be conjecturally referred to narcotic poison, and, under circumstances favouring that supposition, may be treated with a gentle emetic. The late Dr. Dorsey was called to a child in this state, and saved his life by giving an emetic, which brought away a large quantity of stramonium seeds. Stroke of the Sun.—The coma which sometimes attacks individuals ex- posed to fatigue, in hot weather, and under a hot sun, and which is com- monly designated as coup de soleil, or stroke of the sun, though sometimes dependent on active congestion or apoplectic effusion within the cranium, is much more frequently the result of exhausting influences, acting probably in general on a previously enfeebled constitution. The persons affected are usually those who have been exposed jointly to fatigue and the direct rays of the sun; but cases sometimes occur from heat and exhausting labour, with- out direct solar influence. Bleeding, which is the most efficient remedy in active cerebral congestion, is in these cases very hazardous, and, there is rea- son to believe, has not unfrequently hastened if not caused the fatal issue. Post-mortem examination has revealed a total absence of congestion of the brain; and the symptoms during life, the pale and cool surface, and the feeble pulse, are indications of both general and cerebral prostration. The coma is often associated with convulsions, in the intervals of which muscular tremors not unfrequently occur, as in the delirium of drunkards. It often happens that, before collapse, the surface is very hot and the circulation much excited; but these are probably the mere results of irritation in a weakened system, and tend to a speedy exhaustion. Instead of being slow, full, and strong, as in apoplectic cases, the pulse is, in this affection, frequent and weak, varying, according to Dr H. S. Swift, of New York, who witnessed sixty cases, from 100 to 160 in the minute. (N. Y Journ. of Med., N. S., xiii. 51.) The breathing is often irregular and laborious, and sometimes noisy, though not stertorous; being attended with mucous ra es, which can be heard at some distance from the patient. (Dr. Bennet Dowler xV O.Med, and Surg. Journ., Jan 1856 p 479) IQ general the power of deglutition is wanting. A large proportion of the cases proves fatal. Death may take place in a few minutes or may be postponed for days. It not unfrequently occurs 720 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. from half an hour to two or three hours after seizure. In four cases, examined after death by Dr. Wm. Pepper in the Pennsylvania Hospital, the heart was found pallid, flaccid, and softened; while the other muscles were florid and firm. ( Transact, of the Col. of Phys. of Philad., iii. p. 100.) M ay not these have been cases of fatty degeneration of the heart, which suddenly suc- cumbed under fatigue and exhaustion, after a long previous existence of the affection? In other cases, the heart has appeared quite healthy. Dr. Bennet Dowler has found extensive pulmonary congestion in several cases, and believes that death is caused by asphyxia. He has known the heart to beat feebly after respiration had ceased. It is of the utmost importance to distinguish these cases from those of apoplectic congestion or effusion. The remedies required are the ammoniacal and alcoholic stimulants, which should be administered by injection when the patient cannot swallow. Oil of tur- pentine may also be given by injection; and active rubefacients should be employed externally. Cold water or ice should be applied to the head when heated. Dr. Swift states that convalescence is usually speedy, after the se- verity of the attack is passed ; but, in the affection as seen by Dr. Pepper, it was apt to be slow, and was sometimes attended with mental aberration. The mortality of the reported cases has been about one-half; and it is stated that most who are bled die. Wakefulness or morbid vigilance certainly proceeds, in many instances, from an over-excitement of the brain, whether merely nervous, or vascular. Thus, it is a frequent incident in the early stages of meningeal inflammation and insanity. It is well known, also, to be produced in many persons by coffee and tea, which powerfully stimulate the nervous system, with little effect upon the vascular; and is a common attendant upon the excitement of joy, hope, or anticipation. It appears to be a lower grade of that vascular excitement, which, carried further, ends in stupor. Very commonly a depression of the vascular actions of the brain, or a purely nervous depression, produces some grade of stupor ; but occasionally it may also give rise to morbid vigilance ; and this I consider an important practical fact. We see it, as already observed, and as will hereafter be fully shown, proceeding from the suspension of the use of powerful stimulants (see Delirium Tremens); and it is a frequent result of great general debility, without being at all traceable to any irritant cause. What are the peculiar circumstances which determine these opposite effects, as the consequences of apparently the same pathological condition, has not been determined. That the seeming anomaly is not without analogies in nature, has been already Bhown. (See pp. 107-8.) The student should be prepared to refer the symp- tom, when he may encounter it, to the true cause, whether of irritation or depression. His view upon the point will determine his practice. The remedies, whether for stupor or wakefulness, are to be addressed to the pathological condition, whatever that may be, and will be found detailed elsewhere. It may be stated here, that coffee and tea may often be advan- tageously used as powerful antihypnotics. 2. Mental Disorder. To this head belong delirium, insanity, and certain less usual forms of de- rangement, of which those especially deserving of notice appear to be ecstacy and somnambulism. Delirium in its different forms and relations has been, or will be sufficiently treated of elsewhere. Being always a symptom, it has been considered, in its general relations, under the head of Symptomatology (vol. i. page 196), and specially, in connection with the diseases which it attends, such as the different forms of fever, and of cerebral inflammation. One affection in which it constitutes a prominent character, namely, delirium CLASS III.] ECSTACY.—SOMNAMBULISM. 721 tremens, will be treated of distinctly; and there will be occasion to refer to it also in connection with other nervous affections which are yet to be con- sidered. Insanity forms the subject of a distinct article. It remains, then, in this place, only to notice the two disorders above alluded to under the names of ecstacy and somnambulism. These are curious mixtures of sen- sorial and intellectual disturbance, which approach more nearly to delirium or insanity than to any other form of cerebral disease. 1. Ecstasy,—This is an affection in which, with a loss of consciousness of existing circumstances, and insensibility to impressions from without, there is an apparent exaltation of the intellectual or emotional functions, as if the individual were raised into a different nature, or different sphere of existence. The patient appears wrapped up in some engrossing thought or feeling, with an expression upon his countenance as of lofty contempla- tion, or ineffable delight. Voluntary motion is usually suspended; and the patient either lies insensible to external influences, or, as in catalepsy, main- tains the position in which he may have been attacked. Sometimes, how- ever, the muscles obey the will, and the patient speaks or acts in accordance with his existing impulses. In these cases, the disease borders closely on somnambulism. The pulse and respiration may be natural, or more or less depressed ; the face is usually pale ; and the surface of the body cool. If the pulse is increased in frequency, it is usually more feeble also. The dura- tion of the attack is very uncertain ; in some instances not exceeding a few minutes, in others extending to hours or days. Upon recovering from the spell, the patient generally remembers his thoughts and feelings more or less accurately, and sometimes tells of won- derful visions that he has seen, of visits to the regions of the blessed, of ravishing harmony and splendour, of inexpressible enjoyment of the senses or affections. After the attack is over, he may return entirely to his ordi- nary health, and ordinary pursuits, or he may exhibit some permanent change of character, as the result either of the disease, or of the causes which produced it. The disease is usually brought on by causes which occasion a strain upon the mental functions; a profound exercise of thought, for example, or an overwhelming excitement of the emotions or affections. It is most frequent in persons of a nervous temperament, and women are peculiarly subject to it. The treatment is simple. During the continuance of the spell, little more is required than to take care that the patient is supplied with nour- ishment. Should the symptoms of prostration appear, they should be coun- teracted by external and internal stimulation. Should vascular irritation, on the contrary, threaten injury to the brain, it might become necessary to resort to the measures already recommended for that condition. In obsti- nate cases, the most effectual remedy would probably be to shave and blister the head. ' After the attack, attention should be paid to the functions ; and especial care should be taken to avoid all causes of excitement. 2 Somnambulism.—This is a state of the system in which, with an apparently rational concatenation of thought, and the power of con- sistent action, the patient has completely lost the consciousness of his actual condition, and, in a greater or less degree, the susceptibility to ordinary exterior influences. As it occurs most frequently at night, during sleep, and the patient is apt to rise from his bed, and walk about the house, or abroad, persons affected with it are commonly called sleep-walkers. Symptoms.__The most striking phenomenon in the affection is the ob- vious unconsciousness of the patient of his real position. Like a dreamer, he fancies himself under circumstances which do not really exist, but, unlike 722 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. the mere dreamer, he has the power of acting in accordance with those cir- cumstances. He rises from his bed, in pursuance of some course of action in which he supposes himself engaged, or to accomplish some purpose which his fancy has suggested, and all his movements are well concerted to those ends. He appears to be utterly insensible to danger, and frequently puts himself in situations, as upon the roofs of houses, or on the brink of pre- cipitous heights, in which, if awake, he would incur great hazard from the loss of all self-command. It is said that somnambulists, suddenly awakened in such situations, have fallen and perished. There appears to be a somewhat different condition of the senses in different cases. The eyes are in some instances closed, in others widely open. If, in the latter case, a bright light be held before them, it occasionally happens that no impression seems to be made; and other persons in the immediate vicinity are not apparently recognized. Sudden and loud noises may be made near the ear without being heard, or at least noticed. In some cases, one kind of food has been substituted for another, without any apparent perception of the differ- ence ; and snuff has been replaced by saw-dust without a discovery of the imposition. Yet the somnambulist will perform offices which require the greatest delicacy of vision; will frequently answer questions that may be put to him; and often proves himself possessed of an acute sense of touch. It is obvious, therefore, that it is not the senses, but the perceptive faculty that is defective. The patient seems to be able to appreciate impressions only from sources which have some relation to the object of his pursuit at the time; or at least which fall in with the existing current of his thoughts and feeling. In reference to such points his senses are often more acute than in health. Thus, a somnambulist will perform acts re- quiring the use of sight, in the midst of a darkness in which he becomes entirely lost if awakened. Occasionally the affection is associated with catalepsy. When aroused, the patient generally forgets the subject of his recent thoughts or actions; though he sometimes remembers them obscurely like a dream. It is asserted that, in some instances, the train of thought which had occupied the period of somnambulism, and which had been interrupted during the waking state, has returned upon the return of the paroxysm, and that this has happened in several successive alternations of the dreaming and waking state ; memory being active in each condition in relation to its own incidents, while those of the other state are forgotten. If left to himself, the sleep-walker gene- rally returns to his bed, sleeps naturally, and awakens at the usual time, quite unconscious of the incidents that have taken place, though sometimes fatigued by his exertions. He can often be awakened by disturbing him considerably in any manner; but among the most effectual methods is to throw cold water upon the surface. Causes.—The causes of somnambulism are not always obvious. Some- times it appears to be connected with derangement of the alimentary canal, or of the uterus. Intemperance is said to have occasioned it. In very mild forms, it is not uncommon in children, but generally ceases before adult age. The severer forms of it are said to occur most frequently in men under the middle age. The affection is asserted to be hereditary. Artificial Somnambulism.—Animal Magnetism.—Mesmerism.—This af- fection bears a close analogy to the preceding, and, though it has been ob- served in a much greater variety of phases, is probably identical with it. The methods usually employed to bring individuals into this state are too well known to require description. I believe that it is of very little conse- quence what manipulations are used, provided the mind of the patient be impressed in that peculiar manner which appears requisite to the production CLASS III.] ARTIFICIAL SOMNAMBULISM. 723 of the results. A steady look of the operator, with an expression of earnest conviction upon his face, as if he had that full power over the nervous sys- tem of the one acted on which he claims to have, will very often be suffi- cient. The subject of the operation soon begins to be sensible of a not un- pleasant heaviness ; the eyelids usually close ; and, and in a period of time varying from less than a minute to twenty minutes or more, a state of ap- parent sleep results. But examination shows that the condition is very dif- ferent from that of ordinary sleep. Thus, a cataleptic state of one or more of the limbs will sometimes be discovered on attempting to move them; and curious phenomena in relation to the power of muscular motion, or the loss of it, may be observed. Sensation is strangely modified. The patient is often quite insensible to painful impressions ; so that a tooth may be ex- tracted, or surgical operation performed without perceptible uneasiness. This has been too frequently tested to admit of reasonable doubt. But, while general sensibility is thus blunted, the special senses are often more acute than in health. The slightest sound, such as generally escapes notice altogether, is heard ; touch is occasionally exquisitely sensitive; and there is reason to believe that vision is also remarkably acute. As in spon- taneous somnambulism, it appears that all objects do not make an equally strong impression; but it is impossible to determine what principle it is that regulates this diversity of the sensorial function. The patient loses all con- sciousness of his real situation; but evinces in various ways considerable, and sometimes extraordinary mental activity. Present events apparently excite trains of thought which have no relation to the actual condition of the patient, but seem to be merely successive actions of the cerebral machinery, mental vibrations as it were, necessarily following the impressions from with- out. Thus, an individual acquainted with craniology, upon feeling the touch of a finger upon the part of the cranium corresponding with one of the supposed organs, will often set off into a most ludicrous series of actions illustrative of the operations of that organ. A slight sound, which no one else notices, suggests a course of thought in accordance with the cause of that sound, which strikes spectators sometimes as little short of miraculous. This property of somnambulism, connected with a wonderful sharpening of the memory, so that things long forgotten, and even circumstances that at the time of their occurrence seemed to make no impression, are recalled vividly, accounts satisfactorily for those phenomena, which, superficially viewed, have led to the most extravagant notions as to the mysterious pow- ers imparted by this strange condition of the nervous system. The patient may often be induced to rise and walk about the apartment, and sometimes does so spontaneously, in order to act out the course of thought with which the mind may be occupied. The actions, corporeal and mental, appear to be under the guidance of principles entirely differing from those which characterize the individual in health; as if another spirit, with different views and feelings, had taken up a temporary residence in the body. Thus, I have seen a little girl, on all occasions diffident and even bashful in health, become in this morbid'state pert and forward, joking with her elders and superiors as if quite on a footing with them ; and this change of character uniformly took place whenever the affection was produced. Along with the nervous phenomena above mentioned, there is a change in some of the or- ganic functions which if there were any doubt upon the reality of the state, would of itself be sufficient evidence. The pulse is accelerated, and there is an increased production of moisture, which is especially observable in the Very different opinions exist as to the nature and causes of this affection. Many suppose it to be a peculiar condition of the nervous system, produced 724: LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. by the influence of another nervous system, in a manner analogous to the electrical changes which take place, when an excited electric is placed in the near vicinity of other bodies. Now this is not altogether impossible. But I hold it to be unphilosophical to adduce a new principle in the explanation of phenomena, which admit of explanation upon principles already estab- lished. I see nothing mysterious in this magnetic or mesmeric state, as it has been called; at least nothing more so than in hysteria, catalepsy, epi- lepsy, &c, in all of which there is much that we cannot understand. It is merely one of the different phases of nervous disease, and is induced by the mental condition of the individual affected; as an attack of hysteria is often induced by a fit of vexation. The subjects of the disease are usually persons of nervous temperament, and generally in a position of inferiority, either physically, mentally, or by position to the operator; who, therefore, has a greater influence over their imaginations. The mysterious manipulations, the peculiarity of the occa- sion, the steadfast gaze of the operator, appearing as if he had no doubt of his own powers, excite in the susceptible mind of the subject a feeling of the strange, the mysterious, perhaps even of the awful, which appears to unhinge some connection in the brain necessary to keep the nervous machinery in its due order, and cause it to work for a while in a wholly new direction. Young women and children are most easily affected; and at each successive trial the effect is, in general, more readily produced ; so that at last, in certain very susceptible individuals, a look is sufficient to throw them into the mesmeric state ; and, indeed, the patient may fall into the state voluntarily, or spon- taneously without any exercise of will. I have met with one instance in which a boy, who had been frequently acted on, was attacked with an affec- tion in all essential respects similar, without apparent cause, and did not re- cover until, after two or three days of fruitless attempts by other means, a blister was at length applied over the whole scalp. Artificial somnambulism may sometimes be usefully employed as a remedial agent. Nervous headaches, neuralgic pains, morbid vigilance, great restless- ness, and various hysterical disorder may sometimes be removed, at least for a time, by bringing about this condition of system. The surgeon and dentist may also sometimes avail themselves of the insensibility to pain which it occasions, to perform their operations with less suffering to the patient. But, when it is understood that the person acted on is thrown into a condition, in which, while passions may be developed, control over the conduct, and the influence of habitual principle cease, the practice must strike the reflecting mind as extremely hazardous, and fraught with the possibility of so much unmitigated evil, that it can scarcely be justified as a remedy, and is alto- gether unjustifiable on any other score. Besides, the nervous system is ren- dered morbidly susceptible, and a tendency to diseases of this system conse- quently fostered, by the frequent repetition of the process. The morbid state, if left to itself, gradually subsides; but the restoration of the patient may be effected more speedily by artificial means. Among the most efficient apparently is a rapid motion of the hand near the patient, so as to bring a current of cool air in contact with the face. Probably a cup of cold water thrown upon the face would have a similar effect. In obstinate cases, it might be advisable to induce sound sleep by means of an opiate. This would imitate natural somnambulism, in which the individual, upon re- turning to his bed, falls asleep again, and awakes as usual in the morning. I have already mentioned one case in which a blister to the head appeared to me to be requisite. In relation to the cure of natural somnambulism, some- thing may probably be done by attending to the general health, correcting any deranged function, especially of the digestive organs, or the uterus, ob- CLASS III.] CONVULSIONS. 725 viating plethora if it exist, and giving an equable action to the nervous sys- tem by the metallic tonics, as the preparations of copper, zinc, or iron. The nervous stimulants, or antispasmodics, may sometimes be used advantage- ously. A combination of mugwort (Artemisia vulgaris) and assafetida, has been recommended as especially efficacious. (Ed. Month. Journ. of Med. Sci., Nov., 1851, p. 480.) Should the affection return nightly, and no sign of congestion of the brain exist, opium in full doses, or some other narcotic of similar powers, might be tried, in the hope of breaking the morbid habit. It is recommended to avoid suppers, and not to sleep upon the back. 3. Motor Disorder. The motor faculty may be deranged in two modes, independently of a morbid increase under the influence of the will, in which case it is the latter faculty that is affected, and the patient may be considered as insane. The two modes of derangement alluded to are involuntary contraction or spasm, and loss of the power of motion or palsy. To the latter subject a special article will be devoted. Of spasm, there are several varieties. One distinction is into clonic and tonic spasm, the former consisting in rapidly alternating contraction and relaxation, as in subsultus tendinum and convulsions, the latter of contractions having a certain duration, and attended with rigidity or hardness of the muscle, as in common cramps, and in tetanus. The latter is usually painful, the former either not painful or but slightly so. The tonic spasm is some- times also entitled spastic contraction. Another distinction is into, first, those contractions which bear no resemblance to ordinary voluntary mo- tion, and would appear to be wholly independent of the cerebral machinery by which the will acts, as when irritation, for example, is excited in the course of the motor cords or filaments, and, secondly, those in which the will seems to have been replaced by a new and morbid influence, acting through the same channels, or by the same instrumentality precisely, as hap- pens in the movements of chorea and catalepsy. Of several special diseases in which these different kinds of spasm are exhibited, I have had occasion to treat already, or shall treat hereafter under separate heads. Those only which require notice here are non-epileptic convulsions and catalepsy. 1. Convulsions.—Eclampsia.—These are clonic spasms of the muscles, producing visible motions of the limbs or other parts of the body, and gene- rally attended with unconsciousness. When the contraction is slight, feeble, and brief, so as to occasion a mere catching of the tendons, with very little observable movement of the parts into which the tendons are inserted, the affection is denominated subsultus tendinum. It may or may not be accom- panied with unconsciousness. It is an inferior degree of the same condition that exists in convulsions, often takes place under the same circumstances, and from the same causes, and is not unfrequently a precursor of them. It is exceedingly common in diseases of debility; and, except as an attendant on other complaints, scarcely requires notice. It is not, therefore, treated of here as a distinct affection. Should it become, in any case, the prominent object of attention, it must be treated upon the general principles laid down for the mangement of functional cerebral disease. It is not of convulsions, in all their relations, that I propose to treat in this place As a symptom of cerebral inflammation, and febrile diseases of all kinds they have been sufficiently considered already. As occurring in epilepsy 'and hysteria, they will be the subject of consideration in separate articles Puerperal convulsions belong especially to the department of ob- stetrical medicine But isolated attacks of convulsions are frequently met with which do not constitute an essential part of any other recognized dis- ease'and which though they may in some instances arise from sources of 720 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. irritation existing in various parts of the body, are yet the prominent object of attention, and that which especially demands practical interference. It is to these that the following remarks apply. Though occurring at all ages, they are incomparably more frequent in children before the conclusion of the second dentition than at any subsequent age, and are most frequent in infancy. Hence they are often considered separately, as belonging especially to this period of life, under the title of infantile convulsions. But there is nothing absolutely peculiar in the con- vulsions of infants; and the following remarks upon their pathology and treatment, except when necessarily exclusive from reference to the peculiar circumstances of infancy, may be considered as of general application. Symptoms, Results, &c.—The attack of convulsions may either be preceded by other signs of nervous disorder, or may come on abruptly, without warn- ing. The voluntary muscles of all parts of the body may be affected, or the spasms may be confined to one-half of the body, to a single limb, or to the features. There may be only a single attack, or several in more or less rapid succession. During the paroxysm, the face is sometimes pale, sometimes purplish or livid, the lips are bluish, the features often apparently swollen, the jugulars distended, the general surface more or less heated, and the pulse very frequent and often irregular. The abdomen is frequently swollen and tympanitic. Involuntary evacuations now and then take place. The dura- tion of the convulsions is exceedingly variable. It may be only a few mo- ments, or it may extend to hours or days ; but, in the latter case, there is always some remission or intermission of the convulsive movements; though the comatose symptoms continue. Perhaps the average duration of each paroxysm may be stated at from five to fifteen or twenty minutes. In the prolonged cases there is apt to be more or less rigidity or tonic spasm of the muscles. Upon the subsidence of the paroxysm, the patient is generally dis- posed to sleep, and not unfrequently remains somewhat comatose for a longer or shorter period. In some infantile cases, however, the child is bright and lively immediately after the cessation of the spasms; in others, the convul- sions go off with vomiting. Occasionally, when the paroxysm is over, it is found that some serious cerebral or spinal lesion has taken place, as indicated by partial paralysis, strabismus, and various mental disorder ; and sometimes the paroxysm is only the commencement of a series of subsequent attacks, occurring at irregular intervals, and constituting epilepsy. In these cases, the disease passes out of the category at present under consideration. Convulsions sometimes end fatally, though not often unless connected with other disease. Simple uncomplicated functional convulsions are seldom very dangerous. In fact, the affection is itself probably in many instances a safe- guard, by directing irritation from the nervous centres to the circumference. Nevertheless, convulsions may prove immediately the cause of death, by in- terrupting the due innervation of the lungs or heart; and they always de- mand a vigilant attention, as the possible evidence of very serious disease. After death from pure convulsions, there may be nothing discovered in the brain to account for the result. But, in the great majority of fatal cases, congestion, effusion, softening, tumours, or other signs of inflammation or organic affection of the brain or spinal marrow, prove that the convulsion was, in these cases, merely a symptom of some pre-existing or coincident lesion; and very generally, evidences of the existence of such lesion are presented during life, quite independently of the convulsive movements. Causes.—The peculiar state of the nervous system in infancy and early childhood may be considered as a predisposing cause. Very impressible from the necessities of the organization at this age, it must of course feel more sensibly than at other periods of life the influences of disturbing causes. But CLASS III.] CONVULSIONS. 727 there is also a great difference in children in this respect. In some the nerv- ous system is peculiarly liable to this mode of derangement, either from in- heritance, from powerful impressions, as some suppose, upon the nervous system of the mother during pregnancy, or from some inappreciable cause, which often determines, in all the children of certain parents, a predisposi- tion of this kind. Nothing is more common than to see all or most of the children of one family peculiarly subject to convulsions, though the parents may have exhibited no such tendency in their own persons. Children thus predisposed show themselves more impressible than others by ordinary causes, start frequently, are unusually excitable, if not properly controlled are apt to be fretful or irascible, and occasionally exhibit great precocity. Among adults, females are, for the same reasons, more subject to convulsions than males. The predisposition to the disease may also be induced by impure air, un- wholsome diet, and whatever has a tendency to lower the general standard of health. For reasons explained elsewhere, the anemic condition strongly pre- disposes to convulsions. The exciting or immediate causes are very numerous. Strong and sud- den emotion, as fear, anger, surprise, &c, is a frequent cause. Insolation, excessive artificial heat, exposure to cold, over-exertion, and falls or other accidents, may induce convulsions. But they are much oftener the result of an irritation transmitted to the brain from some other part of the body. One of their most frequent sources is the irritation of teething. Perhaps even more so is that proceeding from indigestible or acrid substances in the ali- mentary canal. Articles of food not readily dissolved by the infantile stom- ach are often the cause of convulsions. So also are acid in the stomach and bowels, intestinal worms, and the acrid secretions consequent upon disordered hepatic function. Whatever occasions spasms in the intestines may induce convulsions ; for there is nothing which more powerfully discomposes the in- fantile nervous system than violent pain. A cause, perhaps not sufficiently appreciated, is the milk of the mother or nurse. This occasionally produces the effect even when the nurse is apparently healthy. It is said that agitat- ing or exciting emotions will sometimes so affect the milk as to induce con- vulsions in the suckling. The use of certain articles of food or of medicine may have the same effect. I have known convulsions in the infant to be the apparent result of antimonial medicines taken by the mother. Irritating purgatives or other medicines have sometimes the same effect directly on the child. The practitioner cannot be too strongly impressed with the import- ance of looking to the gums, and to the alimentary canal of children, as the seat of the cause of convulsions. The retreat of an habitual irritation from the surface of the body is another occasional cause. Hence, convulsions sometimes follow the disappearance of a cutaneous eruption. The irritation of hooping-cough sometimes provokes them. Too great vascular fulness or excitement may induce the disease in those predisposed to it; and if, at the same time, there should exist peculiar nerv- ous disturbance, convulsions will be very apt to result. Hence their great frequency in febrile diseases. Some children never have an attack of fever without convulsions. They are peculiarly frequent in the exanthemata. Diagnosis.__The most interesting point in the diagnosis of convulsions is to determine whether they proceed from vascular irritation of the brain, or whether from mere nervous irritation, or depression. In the former case, depleting remedies are important, in the latter, anodynes and nervous stimu- lants * and what may prove very useful in the one, may be very injurious in the other. There are many in which the two conditions are mingled; and in whicli it is not possible to determine what share each of them may have in producing the sympto'ms. But this does not diminish the import- 728 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. ance of making a correct diagnosis when it is possible. It is by the symp- toms connected with the organic functions, and by a consideration of the cause in any particular case, rather than by the purely nervous phenomena, that the judgment is to be decided. In the cases of vascular irritation or congestion, the face is usually flushed, the pulse strong and tense, the surface warmer than in health, and the tongue often somewhat furred. The attack is frequently preceded by febrile symptoms ; and, upon the subsidence of the convulsion, the elevation of pulse, heat of skin, and tendency to coma which remain, evince the existence of an active focus of excitement in the brain. In the purely nervous cases, without vascular irritation, the face is generally pale, or, if coloured, is so in consequence not of any active determination to the head, but of the interference of the convulsions with respiration, and is rather of a livid hue than red. The pulse may be very frequent, but it is not stronger, and is generally feebler than in health, and subsides upon the sub- sidence of the paroxysms. Upon the cessation of the convulsions, the child, instead of being comatose, is at most simply disposed to sleep, and not un- frequently appears as though nothing had happened, resuming his infantile occupation or amusements. Attention was strongly called to this fact, as affording an important diagnostic sign, by the late Dr. Joseph Parrish, who published an excellent paper en infantile convulsions from intestinal spasm in the N American Medical and Surgical Journal, for January, 1827. The cause of the convulsion, and its frequent occurrence without preliminary cerebral disturbance, afford other valuable signs. Thus, when the source of the attack is some non-inflammatory irritation, as spasm in the stomach or bowels, for example, it would be inferred that the cerebral disease was pro- bably also merely nervous, especially if unattended with the ordinary marks of active congestion of the brain. I have repeatedly seen children in a state of apparently good health, except, perhaps, that some evidence of colicky disease had been presented, suddenly scream, throw themselves back with stiffened abdomen as if from severe pain in the bowels, and go off into a con- vulsive paroxysm ; and, upon coming out of such paroxysms, I have seen them look smilingly about, and begin to play as if nothing had happened. In such cases, there can be no doubt that the cerebral affection is purely nervous. An anemic condition of system would afford another indication, though not to be certainly relied on. Convulsions, arising from a positively depressing influence, are generally recognizable by their causes. When they follow the excessive loss of blood, or the operation of a directly sedative poison, as digitalis, tobacco, hydrocyanic acid, or sulphuretted hydrogen, they may be confidently referred to a depressed state of the cerebral func- tions. When dependent upon passive congestion, they may be known by their origin in morbid states of respiration, or in some other cause impeding the return of blood from the head. Treatment.—This divides itself into such as may be proper in the convul- sion, and such as may be required after it has subsided. During the parox- ysm, whatever may be the precise pathological condition of the brain, the patient should be placed where he may breathe a fresh and pure air, of a moderate temperature, and especially not too much heated ; and every part of the dress which may act as a ligature, should be loosened. Hot water may be immediately directed for the feet, sinapisms may be got ready for the extremities, and, if the head is at all heated or flushed, cold water may be applied in the manner before repeatedly directed to the scalp. In the mean time, investigation may be made into the cause and precise nature of the af- fection. Should the pulse be full and strong, the face turgid with red blood, and the previous symptoms such as point to the existence of active conges- tion, blood may be taken from the arm ; and", should the same symptoms in CLASS III.] CONVULSIONS. 729 some degree persist, leeches may be applied to the temples; but in the great majority of cases, there is no immediate urgency for these measures, and they may in general be omitted, or at least postponed until other means have failed. Hot pediluvia, sinapisms to the legs, arms, and over the epigastrium, care being taken not to allow them to be too strong with mustard, nor to remain too long in contact with the skin ; cold water to the head; and a purgative enema; are usually sufficient in moderate cases of vascular irritation. Should the convulsion not yield to these measures, the patient may be placed in a warm bath, while cool applications are made to the head; and, if this should fail, and blood either not have been taken, or not sufficiently, the patient may be bled, or leeched, or both, as circumstances may seem to indicate. After failure with all these measures, a gentle emetic of ipecacuanha, if the patient can swallow, will sometimes put an immediate end to the paroxysm; and, in cases of much cerebral fulness, this remedy always comes in better after de- pletion than at the commencement. Should the evidences of cerebral congestion not be decided, or the case appear to be one of mere nervous irritation, the use of antispasmodics, in connection with the other remedies mentioned, will be found advantageous. The feet may be enveloped in poultices of bread and milk or flaxseed meal, mixed with well-bruised garlic or onions; brandy heated with garlic, or a mixture of oil of amber, olive oil, brandy, and laudanum may be applied warm along the spine, and over the abdomen; and assafetida, musk, oil of turpentine, or oil of amber, may be injected into the rectum. In these cases the inhalation of ether may be tried, and will probably often produce relief. Sometimes it will be proper to attempt the removal of the cause, even during the existence of the convulsions, though in general this is best effected in the intervals. Thus, if there is reason to believe that indigestible food or other irritating matter may exist in the stomach, it should be evacuated by means of ipecacuanha, if the patient can swallow it, aided, if necessary, by a feather introduced into the fauces. The happiest effects occasionally result from this expedient in some obstinate cases. When convulsions can be traced to intestinal irritation, some of the measures to be pointed out directly may be employed with great benefit even in the paroxysm. If the gums are swollen and apparently painful, they should be freely lanced. But it very frequently happens that the physician does not see the patient till the convulsion is passed; and, when he arrives in time, he generally finds the simplest measures sufficient for its removal. It is in the intervals, for the most part, that he is called on to act, and can act most efficiently. Here again the question as to the state of the brain comes up for decision. If vascular irritation exists, it is of great moment that it should be overcome; as an attack of meningitis, or an amount of cerebral lesion which might otherwise end in permanent epilepsy, may thus be prevented. If, therefore, there are fulness and strength of pulse, with stupor or headache, blood should be taken generally, or locally, or both ; and, in infantile cases, a full cathartic dose of calomel should be administered, to be followed in due time, if it do not operate thoroughly, by a dose of castor oil. In doubtful cases, the prac- titioner may be content with the cathartic, which should seldom be omitted. The head should be kept cool, any existing febrile excitement met by means of the antimonials or neutral mixture, and nervous disturbance controlled by gentle antispasmodics, such as sweet spirit of nitre, Hoffmann's anodyne, or camphor water. At the same time, gentle revulsion should be maintained towards the extremities; the bowels should be kept in a soluble state by saline laxatives and the diet should be restricted to farinaceous substances, or in infants, to these with the milk of the nurse in moderation. Should there be a disposition to the return of the convulsions, more decided revul- vol. n. 4' 730 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. sion should be effected by means of blisters between the shoulders or to the extremities; and, in obstinate cases, after sufficient depletion, it may be pro- per to blister the whole scalp. In cases of pure irritation, besides removing the cause, it is proper to di- minish the nervous susceptibility, and to control the cerebral irritation by diffusing the excitement over the whole nervous system. To meet the first indication, narcotics may often be employed ; and none is more efficacious than opium, which, to lessen its stimulant influence, may be combined in some instances with ipecacuanha. Hyoscyamus, lactucarium, or conium may be substituted, if on any account thought preferable. But, before resorting to these remedies, the practitioner must be very sure of his grounds. He must be quite convinced that it is nervous irritation, and not active conges- tion of the brain that he has to encounter. The second indication above alluded to is to be fulfilled by antispasmodics, administered by the mouth, the rectum, or the skin, and by the use of tonics, of which the metallic are deemed most efficient. Of these the oxide of zinc has perhaps enjoyed most reputa- tion, though the chalybeates should be preferred in anemic cases. Should the digestion be impaired, and the system at large feeble, the simple bitters or quinia might be preferable to the metallic tonics. These remedies may often be combined in the same prescription. Thus, opium or hyoscyamus, assafetida, and either oxide of zinc, carbonate of iron, sulphate of quinia, or extract of gentian or quassia, may very properly go together. The cold or shower bath, cautiously used, may also serve to strengthen the nervous system. Fresh air and a nutritious diet of easy digestion are important. In frequently recurring convulsions, resisting other measures, and threat- ening life, the practitioner would be justifiable in resorting to the inhalation of chloroform, which will often quickly quiet the spasms, and, if reapplied with each return, may obviate danger until the tendency is past. It has the advantage, moreover, over other narcotics, of not congesting the cerebral centres, though the danger of fatal prostration from its use must not be forgotten. Even when asphyxia or apparent death may have resulted from the con- vulsions, hope should not be abandoned; but efforts should be made, by artificial respiration, to restore the function of the lungs, and consequently that of the heart. A case of recovery in an infant, by means of this measure, is recorded by Dr. A. W. Ely, in the New Orleans Medical and Surgical Journal (ix. 209). But an account of the treatment would be imperfect, without a more par- ticular reference to the mode of removing some of the more prominent causes. When the gums are in fault, they should be freely lanced; and, if the tendency to convulsions continue, a pair of blisters should be applied behind the ears. If the affection is connected with acid in the stomach and bowels, recourse should be had to the antacids, of which magnesia may be used when a laxative effect is desired; carbonate of lime, if diarrhoea exists; aromatic spirit of ammonia, when a stimulant effect is indicated; and one of the alka- line carbonates or bicarbonates, when there is no special indication, and the extrication of carbonic acid in the bowels is not feared. The existence of worms would lead to the employment of calomel as a purge, and of oil of wormseed, or oil of turpentine as an anthelmintic. Any derangement in the hepatic secretion should be carefully observed, and treated with minute doses of calomel, blue pill, or mercury with chalk. When the disease depends on intestinal spasm, great advantage will often accrue from the use of laudanum with assafetida or spirit of ammonia by the mouth, the injection of musk into the rectum, the application of a mustard cataplasm, or blister over the abdomen, and if, as often happens, the bowels CLASS III.] CATALEPSY. 731 arc distended with flatus, from the introduction of a catheter into the colon and drawing off the air by means of a syringe. This last measure is some- times of great importance. It was recommended by Dr. Parrish in the paper referred to, and I saw it employed with the happiest effects more than thirty years since. Should the disappearance of a cutaneous eruption have pre- ceded the convulsion, effort should be made to restore it by friction with cro- ton oil, or other active irritant. In urgent cases, a blister might be pro- duced by means of the strong solution of ammonia on the surface previously affected. Finally, great attention must be paid to the diet of the patient, in order that nothing irritating may enter the stomach; and when there is any reason to suspect the milk of the mother or nurse, it should be changed for that of another and perfectly healthy woman. 2. Catalepsy.—This term, derived from the Greek xardlr^nq, a seizure, is used to designate an affection, characterized by a loss more or less complete of consciousness, with a peculiar rigidity of the muscles, causing the body, and each portion of it to retain the position in which it may have existed at the moment of attack, or in which it may afterwards be placed. The disease is seldom idiopathic or solitary; but is generally combined with some other affection, especially hysteria, somnambulism, or insanity. It may attack both sides of the body, one side only, or a single limb. Sometimes the at- tack is preceded by signs of nervous disorder, sometimes comes on without premonition. In a case described by Dr. Puel, the disease came on peri- odically ; each paroxysm being preceded by severe pain and great tenderness in the epigastrium. (Arch. Gen., Aout, 1857, p. 208.) When the whole body is attacked, the patient becomes stiff like a statue, and remains standing, sitting, or lying, according to the posture at the time of seizure. Upon any attempt to move the limbs by another, though there is some degree of stiffness, they generally yield to the impulse, and after- wards retain the position in which they may be placed, however ludicrous or seemingly painful. The features are usually composed; though it is said that the muscles of the face obey the general law, and that the same expres- sion of countenance is retained as may have been exhibited at the moment of attack. The pulse is variously affected, being in some instances healthy, in others accelerated, and in others again diminished both in frequency and force. During the continuance of the attack, the evacuations are either sup- pressed or involuntary. The duration is quite uncertain. It may be only a few minutes, or it may extend to hours and days. In some cases, the attacks are repeated with greater or less frequency, and in this way the complaint may continue for months or years. Upon the solution of the paroxysm, the patient often com- plains of headache, and a feeling of muscular soreness or fatigue ; but is in general wholly unconscious of what has passed, and sometimes, it is said, re- sumes a conversation or action, in which he may have been engaged when attacked, at the point at which it was interrupted. There is usually in the intervals some evidence of nervous disorder, very often connected with derangement of the alimentary canal, or, in the female, of the uterus. The disease exhibits considerable diversity of symptoms. The rigidity varies, being occasionally so great as to resist strong efforts to overcome it, and in other cases so slight that the limb will not retain a new position, but falls slowly if elevated. Sometimes a degree of consciousness remains; and certain muscles may be moved under the influence of the will, while others are cataleptic. Cases, too, have occurred, in which the patients upon reco- very have declared that they were perfectly aware of their condition, and of all that was going on around them, but utterly unable to speak, or to move 732 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. the voluntary muscles, even those of the eye. In some very rare instances, circulation and respiration have been so far reduced, as to be scarcely if at all observable ; and the individuals have been supposed to be dead. But the expression of the face, the retention by the limbs of any new position in which they may be put, or an inflexibility greater than that of death, and the pre- servation of a certain degree of animal temperature, will generally serve to distinguish these cases if closely observed. It is probable also that some action of the heart would be discoverable by the stethoscope. A piece of cold clear glass held before the lips would detect any remains of respiration by the condensation of moisture. In itself the affection is generally innocent; but it is apt to be associated with cerebral disease, which may end in cere- britis, apoplexy, or insanity, and with serious organic disease of the viscera. Causes.—An excitable condition of the nervous system, analogous to that which exists in hysteria, constitutes a predisposition to this affection. Women and children are peculiarly liable to it. Any strong emotion, or unusual or protracted intellectual exertion, may serve as an exciting cause. Strong sexual desires, or excessive indulgence, are said to have brought on attacks. Paroxysms of the disease* have also been ascribed to worms, to the retroces- sion of cutaneous eruptions, to menorrhagia, and to the cessation of habitual discharges. Probably the most frequent exciting causes are stomachic, intes- tinal, and uterine irritations. Treatment.—If the pulse appear to call for it, blood may be taken from the arm, and by leeches or cups, once or oftener, from the temples or back of the neck. Purging is also indicated, especially in cases of amenorrhoea, in which aloes should be employed in full doses. Cold should be applied to the head, if it be in any degree heated. The warm bath may be tried, though its utility is not universally admitted. All the organic functions should be maintained as nearly as possible in the healthy state. Any spinal irritation that may exist must be corrected in the usual manner. Should the paroxysms be periodical in their recurrence, quinia might be expected to prevent them. Anemic cases would require the chalybeates. Nitrate of silver has been em- ployed successfully by Dr. Wm. R. King, of N. Carolina. (Am. Journ. of Med. Sci., Jan. 1858, p. 144.) Debility must be counteracted by tonics, the shower bath, or sea-bathing, exercise in the intervals of attack, and a nutri- tious easily digested diet. Advantage may sometimes accrue from the ner- vous stimulants; and oil of turpentine with aromatic spirit of ammonia, given several times a day, in connection with the warm bath, was used suc- cessfully by Dr. Radcliffe in the case of a child who was very severely affected. (Arch. Gen., 5e ser., i. 329, from the Lancet for 1852.) Should respira- tion be suspended, it should be restored artificially. Advantage has accrued from gentle friction along the cataleptic limb, especially from above down- ward, along the course of the affected muscle. (Puel, Arch. Gen., Aout, 1857, p. 210.) Article V. INSANITY. Syn.—Madness.—Mental Derangement.—Lunacy. Insanity is a general term, including all derangements of the intellectual and moral functions, not forming a part of some other recognized disease, nor an ordinary physiological result of the time of life. The delirium of fe- ver, the hallucinations of hysteria, the temporary cerebral irregularities from CLASS III.] • INSANITY. 733 excessive pain or functional disturbance in various parts of the body, the irra- tional confidence and hopes of phthisis, the equally irrational depression of dyspepsia, the stupor of apoplexy, and the imbecility of old age, can scarcely be considered as falling within the meaning of the term. Yet it must be ac- knowledged that the definition is imperfect, and perhaps necessarily so ; as our ideas of insanity are somewhat indefinite, and, when precision is wanting in our conceptions, it cannot be given by words. The disease is seated essentially in the brain. It is through that organ exclusively that we think, and experience emotion; and derangements in these two modes of mental exhibition, whatever may be their remote cause, are necessarily cerebral disorders. But insanity is by no means a simple mental condition. The brain, if not a complex organ, certainly has complex functions; and it may be deranged in the whole of these functions, or in one only, or in any number of them, and there is scarcely an end to the diversity of mental disorder which may thus arise. Some arrangement, however, is necessary for the purpose of description; and I know of none better than that which divides the disease, primarily, into general and partial insanity, and, subordinately, into mania and dementia, belonging to the first division, and moral insanity, monomania, and insane impulse, belonging to the second. By general insanity is meant a derangement, in a greater or less degree, of all the cerebral functions connected essentially with mind; by partial in- sanity, a derangement of one or a portion only of these functions. Mania is that form of general insanity in which there is an exaltation of the cere- bral actions; dementia, that in which the brain is enfeebled, and the mental operations all participate in its weakness. Partial insanity takes the name of moral insanity, when it affects only the emotional functions, as contra- distinguished from the intellectual; of monomania, when, with a general soundness of thought, there is delusion upon some one point, or in some one direction; and of insane impulse, when, without reflection, and without any known perversion of the feelings or passions, the patient is irresistibly impelled to some insane act. Each of these modes of insanity requires a distinct description. It is necessary to guard against the mistake of supposing that all cases of insanity can be referred clearly to one or the other of these varieties. Each one of them is occasionally well characterized; but cases are constantly oc- curring, either intermediate in their nature, or combining the peculiarities of two or more of the varieties, so that it would be impossible to refer them to anyone division; and the same case occasionally exhibits, in its different stages, all the different phases of the disease. As to the relative frequency of the several forms of insanity above referred to, it may be stated, in general terms, that the cases of general insanity, so far as can be inferred from the returns of hospitals, are more than one-half of the whole number. In relation to the subordinate varieties, mania and mono- mania are probably nearly equal. Esquirol, however, considers monomania as more frequent than mania; and the probability is, that of the insane who are not treated in the public institutions, much the larger proportion belong to the former class The cases of mania greatly exceed in numbers those of dementia; and of monomania those of pure moral insanity, and of insane impulse.* * Of 2010 insane patients admitted into the Pennsylvania Hospital, since the separate existence of the insane department, 981 are classed under mania 486 under melan- cholia, 285 under monomania, 247 under dementia, and 11 under delirium. As mono- mania is defined in this work, it includes the cases of melancholia, so that the whole number is 771, or about one-fifth less than those of mama. (Report of the Penn. Hosp. for the Insane, A. D. 1851, p. 13.) 734 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. Symptoms, Course, &c. 1. Mania.__This sometimes makes its attack suddenly, with little or no premonition; but much more frequently its approaches are very gradual, and often for a long time unperceived. After the nature of the case has become quite evident, the friends of the patient frequently call to mind traits of char- acter and conduct, which had, perhaps, somewhat surprised them, which they had ascribed to eccentricity or whim, or which had given them uneasiness as evincing a failure of principle or customary prudence, but which they had not thought of referring to its true source, in commencing insanity. ^ In this early stage, the patient sometimes evinces disorder only by a certain exag- geration in his feelings, views, expressions, and actions. He is apparently eager and enthusiastic, but generally unstable; flies from^ one object to another; and is found, perhaps, at last, to have been busied with trifles. He speaks much but vaguely, of his engagements, projects, and expecta- tions ; all of which come to nothing when examined. Not unfrequently he imagines evil of certain individuals; attributes to them impertinent interfer- ence in his own concerns, or some departure from general rectitude; and sometimes gains a partial belief from the unwary of his insane fictions in re- lation to their character and actions. His most intimate friends and rela- tives are often the subjects of these suspicions and charges. His feelings are morbidly excitable. He is irritated by slight causes ; often speaks in a quick and elevated tone ; is restless and anxious; loses much sleep; and not un- frequently rises from his bed at night, and walks about the chamber. At length, upon the occurrence of some unusual excitement, some opposition to his views or wishes, perhaps even of some unguarded and scarcely in- tended charge of insanity extorted by his singularities, he breaks out into violent and wholly irrational expressions; and his friends, convinced of the nature of the case, only wonder that it had not long before occurred to them. Not unfrequently, however, the increasing development of the dis- ease forces itself upon the attention, without any special and temporary occasion of excitement. Instead of this preliminary excitation, a wholly different character of feel- ing and deportment is sometimes exhibited. The patient is calm, but, if left to himself, is constantly imagining false facts, and forming false judgments of things and persons. The state of his mind is not at first obvious to others, because, when roused to exert himself, he can think correctly, and pursues his usual avocations, if with less, energy, yet without any very visible want of judgment. In time, however, the affection increases, and his insanity be- comes quite evident. Sometimes a period of great mental dejection or anxiety, perhaps consequent upon external circumstances, perhaps without obvious cause, precedes the period of false excitement or illusion. Between the two extremes of mental condition above alluded to, as char- acterizing the forming period of insanity, there is every possible gradation; and the modes in which the intellectual and moral aberration shows itself are diversified beyond all power of description. One prominent phenomenon, exhibited probably in the great majority of cases, before the occurrence of open and acknowledged insanity, is want of sleep. This is important, in a therapeutical point of view; as it cannot but exert an unfavourable in- fluence over the progress of the disease, and affords an indication of treat- ment which, if attended to, may sometimes lead to effectual preventive mea- sures. In women the preliminary symptoms are sometimes of an hysterical character. After an unusually violent paroxysm of crying, sobbing, laugh- ing, and perhaps of temporary unconsciousness, the patient is found, upon the subsidence of the nervous phenomena, to have quite lost her reason. CLASS III.] INSANITY. 735 The initial or incubative stage of insanity varies greatly in duration. It may not exceed a few days, or it may extend to months and years. It has been stated that the disease sometimes comes on suddenly. In such cases it is apt to have an acute form, and exhibits, in a greater or less de- gree, the phenomena of ordinary meningeal inflammation. Before the attack, the patient may complain of headache, vertigo, tinnitus aurium, &c, which disappear upon the occurrence of delirium. The pulse is increased in fre- quency and force; the face is flushed, the eyes are wild; the tongue is coated with a white fur; there are thirst, anorexia, constipation, scanty urine; the patient is restless, agitated, sleepless, often violent; he talks incessantly, raves, screams, laughs, flies from one thought to another, and is kept in bed only by force. The fever, however, is not usually so high as in common acute meningitis; there is less tendency to stupor; and the progress of the case is not so rapid. After a variable period of from one to three or four weeks, or longer, either the symptoms assume the character of cerebral oppression, and death ensues preceded by coma; or, what is much more common, a gradual amendment takes place, the febrile symptoms subside, the tongue cleans, the appetite returns, and the patient becomes convalescent, so far as the general health is concerned. It often happens that the delirium disappears with the other symptoms, and perfect recovery takes place. But often also the mind remains disordered, and a state of chronic insanity results. The degree of this febrile and inflammatory disturbance is very different in different cases. It is almost always greatest in the abrupt attacks. In those which have approached gradually there is often little of it observable. There may be a slight increase of the circulation and of the general temperature, some fur upon the tongue, an offensive breath, and more or less loss of appe- tite ; there may be some gastric or intestinal uneasiness; the skin may be dry; the menstrual flux in women, and any accidental discharge in men, may cease; some emaciation may take place; but the patient is not ill enough to be con- fined to bed, and not unfrequently continues upon his feet as if in health. In the great majority of cases, there is a tendency to constipation; and obstinate wakefulness is very frequent, continuing for many days, and, as some have asserted, occasionally for weeks and months. One of the peculiarities of the insane is an ability to support loss of sleep, with less injury than would be sustained from the same cause in ordinary states of health. Whatever may be the amount of derangement in the organic functions in the early stage, it generally subsides after a variable duration, and leaves the patient with little other observable disorder than the mental. Sometimes, indeed, it is scarcely sufficient to attract notice, even at the commencement; and, in certain cases, the patient appears rather debilitated than physically excited; the pulse being slower and less vigorous than in health. One of the ordinary characters of mania is the tendency to paroxysms of violence, with intervals of comparative quietness and composure. These par- oxysms are so common a feature of this variety of insanity, as to have acquired for it the name of raving madness. They are of variable duration, lasting sometimes only a few hours, sometimes for days, or weeks. During their continuance, the physical signs of disease are often increased as in the early stage; the pulse being accelerated, the tongue often furred, the appetite impaired, &c. • but it is not always easy to determine whether these are the effects of the excitement, or direct results of the same cause. They are pro- bably in some cases the one, and in others the other. Thus, the paroxysm sometimes comes on spontaneously, without any discoverable cause of irri- tation, and probably depends upon increased vascular action in the brain, which'is sufficient also to induce a certain degree of fever. In other instances, it is caused by some real or imaginary source of provocation; as opposition, 736 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. denial, compulsory restraint, &c.; and, in such cases, the physical disturbance may be the direct result of the violence. Instead of merely remitting, mania is sometimes quite intermittent; the symptoms of insanity occurring at somewhat regular periods, daily, every other day, weekly, monthly, semi-annually, once a year, or even at still longer intervals; and leaving the patient perfectly sane upon their subsidence. Sometiraes they recur "without apparent cause, sometiraes are excited by an accidental cause, such as exposure to the sun, over-exertion, excitement of the passions, or the use of alcoholic drinks. Some individuals are aware of the approach of the paroxysms, and voluntarily submit themselves to the necessary restraint. Cases of periodical mania occur, in which a state of mental depression takes the place of the intermission. An attempt to describe the various phases of mental disorder which mania- cal patients exhibit, would be quite out of place in a general treatise like the present. The reader is referred to the works upon insanity, among which those of Prichard and Esquirol merit especial notice. I shall only aim at a brief analysis of the phenomena. All the cerebral functions which express the state of the mind, whether active or passive, are deranged. There are undoubtedly various degrees of this derangement; but there is no one point, in relation either to the intel- lect, the feelings, the conscience, or the will, in which (the patient can be said to be perfectly sound. In some instances, the character of the insanity, both in its intellectual and moral bearings, receives an impress from the natural peculiarities of the indi- vidual. Ambition leads armies, sits upon thrones, or usurps even the place of Deity; vanity decks herself in gewgaws and tinsel; love lavishes upon in- animate objects the kiudly affections once perhaps rejected by the living. But frequently also, the character is wholly changed. Suspicion takes the place of confidence, affection is turned into hate, and the modesty which forms one of the chief charms of woman, gives way to utter wantonness of manner, and the grossest obscenity of language. Sometimes, along with the wreck of the intellect, there is some one promi- nent passion or illusion in which the thoughts appear to centre. Such cases are a link connecting mania with monomania. The ordinary deportment of the patient, except when under excitement, may not vary greatly from that of health; but often it is much otherwise. Sometimes he is abstracted, as if absorbed in his own thoughts, stands or sits long in the same position, talks to himself, or is obstinately silent. Some- times, on the contrary, he walks about incessantly, speaks to every one who will listen to him, holds conversations with imaginary persons, occupies him- self about imaginary concerns, engages in some mechanical pursuit when the means are afforded him, paints, writes letters, makes speeches, flies from one subject to another, seldom completing a train of reflection, and seldom ad- hering long to any one course of action. In some maniacs, the feelings have a cheerful character; the imaginations are all agreeable, and calculated to flatter the natural ruling propensity, as they are probably the result of it. They are contented, cheerful, even happy in their illusions. But with the greater number it is very different. They are disturbed, sad, gloomy, discontented, or morose; usually have some fan- cied cause of complaint; apprehend some danger; suspect individuals, com- munities, mankind in general, whom they consider as conspiring against them. But, in this species of insanity, when not of the character before al- luded to as having some analogy with monomania, there is only a general tendency to elevation or depression, without any steady direction*of the feel- ings towards a particular object; and, in many instances, the feelings vacil- CLASS III.] INSANITY. 737 late between the two conditions; the patient being at one time cheerful, at another time dull, now trustful and then again suspicious, the sport alike of every caprice of passion, and every vagary of the imagination. A striking peculiarity of mania, when fully formed, is the entire uncon- sciousness of the patient of his real condition. He has full faith, usually, in the correctness of his own judgments, and the reasonableness of his con- duct ; and, however much apparently the mere creature of impulse, is gene- rally not without a motive in his acts, which he can sometimes explain after convalescence, though it is often obscure, shadowy, or absurd. He is even aware not unfrequently that others think him insane, and will sometimes control his own acts and expressions, and conceal his convictions, from the consciousness that they will tend to confirm an unfavourable opinion of his sanity. Occasionally, from the opposition between his own standard of sanity and that of the world around him, he fancies that other people are mad, and sometimes exhibits considerable ingenuity in proving it; like the insane editors of a journal in one of the asylums, who, having collected from the newspapers numerous instances of violence, lawlessness, and crimi- nality, ended with the exclamation, " and this is the world that considers itself sane 1" A natural consequence of his belief in regard to the state of his own mind is, that he expects to be treated like one possessed of his rea- son, and is often very sensitive to any want of due consideration. The above remarks have reference to the general tenor of the patient's deportment and mental habit. In the paroxysms already referred to, as occurring frequently and irregularly in the course of the complaint, the phenomena are peculiar. The brain is now obviously labouring under great excitement. The face is often flushed, the eyes are wild and fiery, and the temples throb with the increased current of blood. The patient talks loudly, rapidly, incoherently; flies from one topic to another, and finishes none ; vociferates, screams, implores, threatens, curses; now shrieks as with the anguish of despair, and then breaks out into savage laughter ; gesticulates violently, breaks everything fragile about him, strikes, throws, tears his clothes, rends in pieces the covering of his bed, strips himself naked, even bites his own flesh in his insane fury. Broken thoughts chase one another with fierce haste through his brain; every wild and evil passion, malice, fury, hatred, revenge, despair, struggle as if for mastery in his agitated features ; his hair stands on end; every trait of his meagre countenance is distorted; even his intimate friends would scarcely recognize an acquaint- ance in the demoniac before them. It is not to be understood that every case of mania offers paroxysms so violent as this, nor that all the particular features are united in every violent case. In some instances, the paroxysms are very feeble, consisting in nothing more than occasional aggravation of the ordinary symptoms under exciting influences. Nor is it to be understood that even the greatest violence is always so incoherent in its mode of ex- pression. Occasionally, even maniacal patients confine themselves to one strain of feeling or thought. I have known a patient to rave, scream, and implore for an hour continuously, under the impression that he was sur- rounded by robbers who aimed at his life. After the subsidence of the paroxysms, the patient is weak, exhausted, pale, frequently gloomy and silent, or talks to himself, and apparently broods over his troubles. A short reference to the state of the individual psychological functions will close this description. Sensation is not in general materially deranged. Sight and hearing are sometimes more acute or sensitive in the early stages than in health* patients are occasionally extraordinarily insusceptible to extreme cold, and to painful impressions, or at least unmindful of them; and in the advanced stages there is often some decay of the senses, espe- 738 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. cially of hearing. But, until the affection lapses into dementia, morbid sensation is not a striking phenomenon. The perceptive faculty, more- over, is for the most part not very prominently affected. The patient usually recognizes persons and objects, appreciates sounds, and receives tolerably correct impressions through the senses of smell and taste. But this is not always the case. The perceptions are sometimes quite illusory. Imaginary sights are seen, imaginary sounds are heard, the patient con- verses aloud with imaginary persons, and there is reason to believe that his perceptions of odour and taste are different from those of health. One kind of misapprehension is not uncommon. The patient, struck with some real or fancied resemblance between a stranger and one of his friends or relatives, a wife, a husband, a child, for example, mistakes the former for the latter, and lavishes upon the new personage the attentions which the reality of the supposed relation would suggest. Even brute animals, or things without life, may become the objects of such attentions. Thus a bird, or a cat, may be gifted with the attributes of humanity ; a pillow, or a stick of wood may be fondled as a child; and we may sometimes see a patient holding up a bed, or lifting up a flower-pot, to save the bedstead or the flower-stand from fatigue. But it is probable that mistakes like these arise more from a per- verted mental action subsequent to perception, than from disorder of the perception itself. The reasoning faculty is always deranged. But it is not abolished. The patient can often follow out trains of ratiocination with considerable correctness, and sometimes even with much ingenuity. But he is apt to change abruptly from one course of thought to another before the first is completed; each idea that presents itself, however irrelative, becomes the starting point of a new succession, which is, in its turn, soon interrupted; and his intellectual action is thus broken up into disjointed fragments, fitted to no useful purpose. Again, the maniac may argue for a time with a show of reason; but he is apt to base his logic upon some ludicrously absurd assumption, of which he cannot perceive the folly, and therefore reaches equally absurd conclusions. He often, besides, mistakes some slight semblance, some mere shadow of association, a similarity of sound in a word, for example, for a legitimate link in a chain of reasoning, and thus, even when starting from correct premises, is led into the most egregious errors. The judgment is, perhaps, more perverted than any other faculty. It is the quality of mind which is most rarely perfect in health, and which might, therefore, be expected to be most defective in mental un- soundness. The maniac cannot duly appreciate his relation to the world around him, cannot shape his course in accordance with the various inter- ests, opinions, and feelings of others, and is, therefore, constantly encounter- ing difficulties and vexations, which aggravate his disease, and generally render confinement essential. The imagination in mania is often greatly excited, fruitful in its suggestions, not unfrequently brilliant in its illusive picturing; but always deranged. The pictures which it forms, like the workings of the insane reason, are without due connection or relation of parts, mere jumbled assemblages of the grotesque, the ludicrous, the wild, the fearful; shifting, too, like dreamy phantasms, to which it is probable that they bear no slight resemblance. Memory is one of the faculties that suffers least in this variety of insanity. Maniacs can often vividly recall past events, whether relating to themselves or others ; and they sometimes take a malicious pleasure in suggesting disagreeable recollections. Even incidents which attend their illness they frequently remember with greater or less accuracy, and often, after recovery, have a vivid recollection of the kindness or harshness with which they have been treated, and feelings such as these recollections are calculated to excite. The imitative quality is also CLASS III.] INSANITY. 739 retained by them in a considerable degree; and, like children, or some of the lower animals, they may often be induced, by the example of others around them, to regulate their deportment, and restrain their insane pro- pensities. We may often most usefully avail ourselves of this property of the maniacal character in our course of treatment. It is a fact of some in- terest, that, in the cerebral excitement of mania, faculties which before lay dormant, have been sometimes called into existence, as, for example, those of music and painting; and a certain degree of wit or humour is not un- common, either retained amid the ruin of nobler powers, or generated by the new stimulus to the brain. The emotional functions are not less disordered than the intellectual. In some cases, there is a morbid exaggeration of the natural qualities; in others, a complete change. In general, the maniac is more irascible than in health, surrenders himself more readily to every impulse, is often suspicious, revenge- ful, malicious ; and the countenance is sometimes fearfully expressive of his uncontrolled passions. Among the most common results of the disease is an alteration of the natural affections. Connubial, parental, and filial love are not unfrequently exchanged for indifference, forgetfulness, even suspicion and hatred. The dislike of the insane for their former nearest and most intimate friends is almost proverbial; and the exhibition of such a dislike is sometimes among the first observable symptoms of the disease. Excesses of pride, am- bition, and vanity are frequently witnessed. But the kindlier emotions are occasionally also morbidly developed or directed. The insane not unfre- quently form irrational or whimsical attachments. Love, in its purest form, is sometimes exhibited, especially by women, who betray their insanity by openly lavishing marks of tenderness, which in the'ir sane state they would have been most solicitious to conceal. Delicacy and the sense of shame appear often to be quite abolished. There is not unfrequently a strange propensity to go naked. Lascivious desires are expressed openly by language and ges- tures. Personal cleanliness is disgustingly neglected. Patients sometimes smear themselves with their own excrement. Notwithstanding the violence of maniacs, they are usually wanting in steady courage. It has been often observed that, if regarded fixedly and firmly by a sane individual, especially one having official power over them, they will drop their eye, and yield for a time, though the "moment before fierce and threatening. But this is not uni- versally true ; and some caution is advisable not to trust too much to their presumed submissiveness. As with the thoughts in mania, so is it generally also with the feelings. They are exceedingly unstable. The patient passes rapidly from one state to its opposite. The mental cords vibrate in quick succession with the"whole gamut of the passions. The exaltation otf^e cerebral actions is exhibited strongly in the increased muscular power. In their paroxysms, the insane sometimes evince almost incredible strength and activity, and an amount of endurance altogether be- yond their capacity in health. ,.,-,. -, .* , After the subsidence of the first symptoms of physical disorder, if such symptoms existed, the general health does not usually appear to be much impaired. The patient is liable to occasional attacks of the ordinary dis- eases * he is perhaps, for the most part, somewhat emaciated and of a squalid appearance * his stomach, bowels, and liver may be variously disordered; he may even suffer with accessions of acute cerebral symptoms; but in general there is little prominent derangement. The disease if it continue, may now pursue one of two courses. Either it may pa CLASS III.] DELIRIUM TREMENS. 779 in quantities sufficient to control the tendency, and to be gradually diminished or omitted as the occasion for its use lessens or ceases. Should the pulse be feeble, and the skin cool, the patient may be allowed from one to two bottles of ale or porter, or an equivalent quantity of wine, in twenty-four hours; and, should the debility be alarming, recourse may be had to brandy, or other form of ardent spirit. But it must be remembered that the alcoholic stimulus is employed simply to support a due degree of strength, and to obviate the danger of fatal prostration. Tincture of hops or of lupulin, in the dose of half a fluidounce every three or four hours, sometimes answers a very good purpose; affording the requisite support to the system, while it co-operates with the opium in producing sleep. To obviate the tremors when excessive, and in cases which exhibit a tend- ency to convulsions, the nervous stimulants should be added to the other re- medies. Assafetida, and compound spirit of sulphuric ether, are those upon which I place most reliance. In slight cases, infusion or oil of valerian may be employed. In cases of violent excitement, advantage may be expected from the inter- nal use of chloroform, which may be given in the dose of from forty to sixty drops, repeated at intervals of an hour or two, until its quieting or depress- ing effects are experienced. The most convenient mode of exhibition is that of emulsion with a little camphor, the yolk of an egg, and water. Care must be taken not to. carry the remedy so far as to produce prostration. Should the patient, as sometimes happens, be seized with sudden and alarming prostration, sulphuric ether should be given in the dose of from two to four fluidrachms, repeated at short intervals, in connection with powerful alcoholic stimulants. The condition of the organic functions should be attended to. If the bow- els are constipated, cathartics should be administered, adapted to the circum- stances of the case; calomel or mercurial pill being added to the other medi- cines, when the hepatic secretion is deficient. Magnesia, castor oil, rhubarb, and aloes are generally preferable to the more active depletory purgatives. Senna may be employed when something more energetic is requisite. Irri- tability of the stomach, if it exist, may be quieted by lime-water and milk, the effervescing draught, small draughts of carbonic acid water, aromatic spirit of ammonia, and a sinapism or blister to the epigastrium; and, should opiates be rejected from the stomach, they may be administered in twice the quantity by the rectum. Should the patient fall into the typhous condition, which very rarely hap- pens in the uncomplicated cases, his strength must be supported by carbonate of ammonia, brandy toddy, milk punch, egg beat up with brandy, essence of beef, &c, as in proper typhus fever. In very obstinate cases of sleeplessness, which resist the usual measures, and persist for a week or more, a blister over the whole scalp sometimes has a most happy effect. The same remedy should be resorted to when convul- sions occur or a tendency to coma supervenes. Wheu the disease has long resisted opium sleep has repeatedly been induced by ethereal inhalation; and chloroform has been employed for the same purpose, but requires much cau- tion for fear that its depressing influence may prove dangerous in the de- bilitated state of the patient. Dr. W. R. Richardson, assistant physician in the hospital at Black well Island, N. Y., states that, in two cases under his notice it had produced fatal effects almost immediately, and, in many instances, a similar result had been prevented only by assiduous care (Am. Journ. of Med Sci Oct 1856, p. 368.) Perhaps by combining ether and chloro- form, as practised by Dr. Joseph Parrish, of Burlington New Jersey, in a case recorded in the New Jersey Medical Reporter (1. 301), the great energy 780 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. of the latter may be obtained, while its prostrating effects may be counter- acted by the stimulant agency of the ether. Dr. James Grieve, of Dumfries, Scotland, has employed with advantage the extract of belladonna, as a local application, when the pupil was con- tracted, in order to expand it, and thus obviate the spectral illusions, which probably tend in some measure to prevent sleep. (Ed. Month. Journ. of Med. Sci., Nov. 1853, p. 430.) Great caution should be observed not to interrupt the sleep of the patient, unless it should appear to assume the form of coma; or the occurrence of a cold clammy skin, with sinking of the pulse, should indicate the necessity for stimulant and nutritive substances. Upon awaking, the patient should be furnished with some gently stimulating and nutritious substance, to obviate exhaustion; and perhaps nothing is better for the purpose than the yolk of egg beat up with ginger and hot water, to which a little wine or brandy may be added if deemed requisite. Some modification of the above treatment is necessary in those cases of protracted debauch, in which symptoms of active congestion or inflammation of the brain, the direct result of the excessive stimulation, are mingled with the peculiar symptoms of commencing delirium tremens. Here it sometimes becomes necessary, in order to prevent disorganization of the brain, to take blood either generally or locally or both, to make cold applications to the head, and to administer an active purge. Should the symptoms of conges- tion disappear, and a pure case of the ordinary delirium be developed, the plan already detailed should then be carried into effect. But, if stupor or convulsions continue, the whole scalp should be blistered with little delay; and the accruing debility counteracted by just as much stimulation as may be necessary to prevent the patient from sinking; the arterial and nervous stimulants, as carbonate of ammonia, capsicum, musk, assafetida, &c, being preferred to the alcoholic, until found to be insufficient to fulfil the indication. Oil of turpentine or assafetida may also be given by enema. In the complicated cases, the treatment must be modified according to the character of the complication. Should it be a surgical accident, the plan recommended for the simple cases should be carried out, and opium may be even more freely employed, unless the head be the part affected, and menin- geal and cerebral inflammation be apprehended. If the associated disease be one of debility, the necessity for alcoholic stimulants will be greater than under ordinary circumstances; and quinia will sometimes be found a most valuable auxiliary. But, beyond all comparison, the most frequent compli- cations are the phlegmasiae; and these offer to the physician one of his most perplexing therapeutical problems. The principles of treatment, however, appear to me to be pretty well determined. To prevent disorganization, the quality of the blood must be altered, and this can be effected in no way so satisfactorily as by bleeding. But the patient, already debilitated by his habits, will sink under this treatment, if his ordinary artificial support be withdrawn. It is, therefore, necessary to administer alcoholic drinks in such amount as maybe requisite to sustain the functions, and control the delirium. When the relief of the inflammation can be accomplished by leeching or cup- ping^ these should be preferred to the lancet; but there should be no hesita- tion in resorting to the latter, when the symptoms are very threatening, and the pulse tolerably strong. Blisters, too, should be freely employed in these cases. One of the most frequent of these local affections is gastritis; and leeches to the epigastrium may often be usefully applied, even when it is necessary to administer stimulants internally. Inflammation of the brain offers the most difficult question; as the force of the necessary stimulus bears in this instance especially upon the over-excited organ. The rule of treat- CLASS III.] DELIRIUM TREMENS. 781 ment, however, has been already stated ; namely, to deplete as far as the strength will permit, to blister, and to use only that amount of stimulus ab- solutely necessary to support life, preferring such substances as have least tendency to operate especially on the brain. It not unfrequently happens that the delirium of drunkards conceals some serious local inflammation, which may be sapping the foundations of life, while the physician is direct- ing his measures only against the obvious symptoms. In every case, there- fore, of delirium tremens, it is highly important that the several organs should be thoroughly investigated, to ascertain whether there may not be some phlegmasial complication. Should febrile symptoms attend the com- plaint, the presumption will be altogether in favour of the existence of such an affection. The question will early present itself, what course is to be pursued in rela- tion to the confinement of the patient. Is he to be forcibly kept in his bed ? to be shut up, as some have recommended, in a dark cell ? or to have a cer- tain amount of liberty of movement ? I prefer the last-mentioned course. Forcible confinement often leads to excessive and exhausting struggles; while solitude and darkness exaggerate the terrors of the patient, and fix his hallucinations more firmly. The proper plan, I think, is to allow as much liberty of movement as may be compatible with the safety of the pa- tient, and the convenience of his attendants, the most careful watch being kept over his actions, and all tendency to violence soothed or restrained. But when very weak he should be confined to his bed ; as fatal syncope may result from a continuance in the erect position, especially if muscular ex- ertion be used at the same time. In this prostrate condition, he should never be left without constant oversight. I have known death to result from a patient rising from his bed at night, during the absence of his at- tendants. The diet should be adapted to the circumstances of the case. In the earlier stages, when there is any local inflammation, it may be sufficient to give farinaceous substances; but ordinarily the patient may use milk and the lighter kinds of animal food; and great debility must be counteracted by broths, animal essences, egg and wine, milk-punch, &c. The above is the course of treatment which coincides best with my own judgment and experience in this complaint; and it probably accords more or less closely with the views of the majority of practitioners. Other plans, however, have been proposed. Of these the most successful, so far as regards immediate results, is pro- bably the purely stimulant plan as advocated by Dr. Gerhard. Under this plan, the proportion of deaths from delirium tremens in the Philadelphia Hospital (Blockley), was reduced from one in eight, which it had been ori- ginally, to one in about thirty-three. Dr. Gerhard gives from one to two fluidounces of brandy every two, three, or four hours, according to the pre- vious habits and the degree of debility, always employing the least quantity that will tranquilize the patient, and gradually diminishing as the occasion for the stimulus ceases. The largest quantity necessary at first, in each case, is seldom required longer than twenty-four hours. (Tweedie's Syst. of Pract. Med Am ed Article Delirium Tremens.) I have already given my reasons for not thinking this plan generally the most expedient. Another mode of treatment is the emetic plan, originally proposed by the late Dr Joseph Klapp, of Philadelphia, He was induced to adopt this treatment from observing that the disease was apt to occur upon the cessa- tion of an attack of vomiting in the intemperate, and that the spontaneous supervention of vomiting, during the disease, relieved the delirium. The fact that an attack of cholera morbus in an intemperate person, if arrested, 782 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. is apt to be followed by delirium tremens, I can verify by repeated observa- tion. The state of nausea appears to be, in some measure, incompatible with the cerebral condition peculiar to this disease. Dr. Klapp gave two grains of tartar emetic every fifteen minutes till it operated, and found it necessary to give from eight to sixteen grains before the effect was obtained. Much more than the largest quantity mentioned was sometimes necessary ; as the stomach or rather brain is remarkably insusceptible of the emetic impression. The symptoms were immediately ameliorated after vom- iting, and the patient rapidly recovered. (Eclectic Repertory, vii. 251, A. D. 1817.) This plan has also proved successful in other hands; but it has sometimes failed, and sometimes been attended with fatal results. Indeed, when it is considered that, in simple delirium tremens, debility is almost the only danger, it seems to be a necessary inference, that a remedy which must add to the debility, however quickly effectual in many cases, cannot but prove injurious in others, if indiscriminately employed. Besides, the stomach is often inflamed in drunkards, and it would seem that the large amounts of tartar emetic sometimes necessary, cannot but seriously aggravate the gas- tric disease. The practice has not been generally adopted ; but cases some- times occur, in which it might be preferable to the opiate plan, when the debility is not great, and the stomach in no degree inflamed. Dr. Alexander Peddie, of Edinburgh, has treated upwards of eighty cases with uniform success, chiefly by means of tartarized antimony, given, not as an emetic, but in moderate doses as a sedative. He gives from one-quarter to one-half a grain, every two hours, and conjoins with the antimonial pre- paration purgatives when necessary, freedom of bodily movement, nourish- ing food, and abundance of light. (Ed. Month. Journ. of Med. Sci., June, 1854, p. 506.) Mr. Paget has, in the more sthenic cases, advantageously combined antimony with opiates, in imitation of a similar practice of Dr. Graves, of Dublin, in the cerebral affections of typhus fever. (Med. Times and Gaz., Jan. 1858, p. 63.) Still another mode of treatment is that mentioned by Dr. Chapman as having been the practice of Dr. Kuhn, formerly one of the most respectable physicians of Philadelphia. It consisted simply in " confining the patient in a dark cell, and leaving the disease spontaneously to work itself off." Dr. Kuhn was known to declare that, after an extensive trial in the Penn- sylvania Hospital, he had found no measure to answer as well as this. (Phil. Journ. of Med. and Phys. Sci., iii. 242.) This plan has been followed by other practitioners, and something very similar to it is recommended by M. Calmeil, who does not, however, insist on darkness. There can be no doubt that great numbers will recover under this plan ; and it is certainly better than the depletory; yet it will not prevent death from prostration, which is the greatest danger of the simple cases. In the paper of Dr. Coates before referred to, Dr. Kuhn is stated, on the authority of Dr. Currie, to have employed the opiate practice so early as the year 1183. (North Am. Med. and Surg. Journ., iv. 235.) Perhaps the most dangerous method of treatment is that of bleeding, with other modes of depletion, founded on the notion of the inflammatory nature of the complaint. Though these remedies may be necessary in cer- tain complicated cases, they are, I think, altogether contraindicated in the unmixed disease; and the experience of the profession is certainly not op- posed to what seems to be the clear deduction of common sense. Prophylactic Treatment.—This should consist in a gradual abandonment of the habit of drinking alcoholic liquors. Individuals who are unable by their own unaided will to break this habit, often voluntarily place themselves in public institutions, in order to supply their deficiency of resolution by a CLASS III.] EPILEPSY. 783 species of exterior compulsion. I have frequently treated such cases in the Pennsylvania Hospital, and have never found any difficulty in safely with- drawing the accustomed stimulus, and dismissing the individual released, at least for a time, from his disgraceful thraldom. The plan is simply to give daily the least quantity of alcoholic liquor, generally ale or porter, that is necessary to ward off an attack of delirium tremens. This quantity dimin- ishes each succeeding day, and, in a period varying from one to three or four weeks, the stimulus can be altogether dispensed with. Advantage will sometimes accrue from counteracting nervous symptoms by opium. But the patient should not be dismissed until he has been entirely without both of these stimulants for a week or more. Article VII EPILEPSY. Syn.—Falling sickness. Epilepsy (from li:dr)d>ia, attack or seizure) is characterized by paroxysmal attacks of convulsions, with loss of sensibility and consciousness, without fever, and followed usually by coma. This definition is probably as correct as can be given, though not quite satisfactory, as it may include cases not strictly epileptic, certain hysterical convulsions, for example, and excludes others usually attached to epilepsy, and having the same essential nature, such as the vertiginous paroxysms to which attention will be called directly. But entire precision in a definition, which is founded on symptoms alone, can scarcely be expected; for it almost always happens, especially in ner- vous affections, that phenomena apparently similar may result from very dif- ferent pathological conditions. Symptoms, Course, &c.—I shall consider first, the paroxysms; then, their relations towards each other, with the condition of the system in the interval; and lastly, the general course and termination of the disease. 1. There are often premonitory symptoms, sufficient to warn the patient of the approach of the paroxysm. Yery different statements are made by authors as to the relative frequency of their occurrence. The result of the statistical researches of M. Beau (Archives Generates, torn, ii.) is, that the paroxysms are preceded by symptoms of this kind in about one-half of the cases; and this is probably near the truth. The precursory phenomena differ greatly in duration and character. They may continue but for an instant, may last several minutes, or may extend to hours or days. They are gene- rally brief, not longer than may afford opportunity to the patient to seek a favourable position, and often not long enough for that purpose. The follow- ing are among the symptoms alluded to ; though it must be recollected that often not more than one or two of them are manifested in the same case. Sometimes the premonition consists only in a general alteration of the state of feeling * the patient being either, on the one hand, unusually depressed, gloomy, morose, or irritable, or, on the other, unusually elevated and cheer- ful. There may be a failure of memory, or confusion of thought, or a state of apparent revery, in which the look is fixed and vacant. Headache, drow- siness vertigo, flushing or paleness of the face, and a feeling of fulness or emptiness of the head, are not unfrequently experienced. Among the most common symptoms are disordered sensations or perceptions, such as dimness of sight or temporary blindness; double, partial, or luminous vision; optical 9 784 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. illusions ; noise in the ears ; the perception of unreal odours and flavours; general uneasiness; and feelings of pain, tingling, or formication in the limbs, and other parts of the body. Strabismus, an altered state of the pupil, oscil- latory movements of the iris, sneezing, sighing, hiccough, and various singu- lar movements, as running, leaping, dancing, whirling round, &c, are also mentioned among the preliminaries. Sometimes the premonition consists in a deficiency or excess of appetite, or the coming on of nausea and vomiting. All writers on epilepsy treat of a singular and characteristic phenomenon, called aura epileptica, which consists in certain strange sensations, as of a stream of cold water or of cold air, or feelings of heat, pain, itching, or tingling, commencing at some point of the body distant from the brain, in a finger or toe for example, or in the leg, arm, uterus, testicle, top of the head, lips, breast, &c, and proceeding towards the brain. When the sensation reaches the head, or the epigastrium, if this lie in its route, there is an im- mediate loss of consciousness, and the patient remembers no more. This phenomenon, however, is comparatively rare. In the great majority of cases, nothing occurs to which the name of aura epileptica can be attached. Either after a longer or shorter duration of one or more of the above mentioned symptoms, or suddenly, without any premonition whatever, the patient falls as if struck down by a blow, frequently uttering a shrill pecu- liar cry, which is sometimes startling, and almost fearful. At the moment of falling, he is seized with general convulsions, which are often so power- ful as to require the strength of several persons to restrain them. The spasms usually alternate rapidly with relaxation; but some of the muscles, especially those of the trunk, are apt to be affected with rigid or tonic con- tractions ; and, though the limbs are thrown about with great violence, the body does not in general move far from the spot in which it fell. One side is frequently more affected than the other. The head is twisted round; the features are drawn to one side as by jerks, and frightfully distorted; the eyes are turned up so as to show only the whites, or roll from one side to the other, or are fixed with a rigid stare; the eyelids are closed or half-open, or widely and spasmodically distended : the jaws often grind together by an oblique motion, and the tongue which is thrust out of the mouth is sometimes badly wounded; the arms and legs are thrown about with violence, striking against neighbouring objects, and not unfrequently both receiving and inflicting in- jury ; and, while the muscles of the arm generally suffer alternate contraction and relaxation, the thumb is often rigidly flexed ; and the same is said to be sometimes the case with the toes. The pupil may be either contracted, or dilated, or neither; but is usually insensible to light and immovable. All the senses are for the moment paralysed. Impressions which in health are most powerful, the brightest light, the loudest sounds, the most pungent odours, the severest wounds, are quite unfelt. The face is usually swollen, flushed, and of a purplish or livid hue; and the veins of the neck also are swollen; though, in some instances, the opposite condition of shrunk and pallid features is observable. Respiration appears to be difficult and imper- fect. The rigidity or irregular contraction of the muscles prevents the due expansion of the chest; the air does not fully enter the lungs, and seems to be stopped in some measure at the glottis, which is probably sometimes spas- modically constricted; and hence in part the dark suffusion of the counte- nance. The struggle in the throat causes the air to be intimately mixed with the mucus, which appears in the shape of foam at the mouth. The pulse is generally small, frequent, and irregular; while the heart palpitates rapidly and often tumultuously. In some instances, involuntary evacuations from the rectum and bladder, and priapism with seminal emissions take place. After an uncertain but generally brief duration, the convulsive move- CLASS III.] EPILEPSY. 785 ments subside, the rigid spasm relaxes, the face becomes pallid and shrunken, a profuse perspiration often breaks out, and, though the insensibility still continues, the body is quiet, and nothing remains of the previous disturbance except perhaps some noise in respiration. At length consciousness gradually returns, though at first accompanied with some confusion of thought; and the patient, sitting up or rising upon his feet, looks about him with a stunned, astonished, vacant, or stupefied air, highly characteristic of the affection.' This may soon pass off, and the patient return to his ordinary state; but very frequently the fit is followed by various unpleasant symptoms, which will be detailed immediately. The duration of the paroxysm varies from a few moments to many hours. The average is probably somewhere between five and twenty minutes. When it continues several hours, or, as sometimes happens, for a day or more, there is scarcely ever a steady perseverance of the convulsions; but these alternate with periods of quiet coma; as if the whole consisted of distinct paroxysms, succeeding each other so rapidly that the second stage of one has not fully ended, before the first stage of the following one begins. More than fifty paroxysms may thus occur, in the course of one or two days. The symptoms which immediately follow the paroxysm are various. Some- times, as before stated, after a short period of mental confusion, the patient returns to his ordinary condition. Yery frequently he falls asleep, and after a time awakes in the possession of his faculties, and feeling well, except that he often has a sense of fatigue or exhaustion, and is sometimes bruised or wounded in consequence of his fall, or of the violent movements of the par- oxysm. In other instances, he is affected with headache, vertigo, mental confusion, and occasionally with nausea and vomiting. Sometimes he vomits blood, and passes black and altered blood by stool, probably in consequence of the congestion arising from the partially suspended respiration. Instead of mere drowsiness, from which the patient can be roused, there is sometimes stupor or coma, lasting for hours or days. Temporary insanity, in some cases, follows the paroxysm, varying, in different instances, from the slightest mental alienation to the most violent mania. In this latter form, the affec- tion is sometimes designated as the epileptic fury. These symptoms gene- rally subside in the course of two or three days. It may be mentioned here that, instead of following the convulsions, the mental affection occasionally precedes them; and instances have been noted in which the disease began with an attack of maniacal delirium. Sometimes, upon emerging from the paroxysm, the patient is found to be slightly paralytic; and instances of chorea have occurred under the same circumstances. There is an utter un- consciousness of all that passes during the paroxysm. The interval between the first shock of the disease and the period of awaking is a complete blank; and the patient only knows that he has had a fit by his soiled clothes, his bruises, his feelings of fatigue, or other derangements of which frequent ex- perience has taught him the significance. Death sometimes takes place in the paroxysm, in consequence either of apoplectic congestion or effusion, or of apncea resulting from suspended re- spiration. But this event is rare. The affection, as above described, is epilepsy in its full development. Not unfrequently the paroxysms are much milder; and instances every now and then occur in which, instead of convulsions and coma, the attack is merely vertiginous being attended with giddiness, mental confusion, and inability to stand but without a complete loss of consciousness. I have known the fit to consist of this condition, attended with something like paralytic sensa- tions and loss of power of particular limbs. In cases somewhat more severe, the patient becomes suddenly unconscious, has a fixed, open, meaningless eye, 786 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. and slight, partial convulsions as of a hand, an arm, one of the muscles of the face, &c. If standing at the time of attack, he may fall; but if sitting or lying, the condition may pass over almost without notice; and the patient himself, upon recovering, sometimes resumes his discourse where he had left off, as if nothing whatever had happened. These spells are usually very brief, sometimes lasting less than a minute. They are known to be epileptic, because it is not unfrequently in this way that the disease commences, be- cause these slighter paroxysms occasionally alternate with the severe in the same case, and because, in different cases, there is every grade between the mildest and the most violent. It is no uncommon event for these vertiginous spells to continue for several years, gradually increasing in intensity, and at length ending in the fully-formed convulsive and comatose paroxysms. Epileptic attacks may occur at any period of the twenty-four hours. Not unfrequently they take place at night, during sleep, and in some persons only at night. It is said that they are sometimes confined to this period at the commencement of the disease, and again near its close, when it is about to terminate favourably. This would seem to indicate that there is something promotive of epileptic convulsions in the condition of being in bed at night. Is it in the position, which favours the afflux of blood to the brain ? This is not probable ; for it is not till after sleep has begun that the effect is ex- perienced. The cause is probably connected with the sleeping state, which certainly has a tendency to favour spasmodic muscular movements. Every one is familiar with the sudden start which is so apt to arouse us from the first sleep. In febrile diseases, too, and in complaints of debility, attended with nervous disorder, the muscular twitchings and subsultus are much more marked in the sleeping than the waking state. The most plausible explana- tion appears to me to be, that, in the repose of the functions of animal life, the organic nervous centres acquire increased excitability, and are thrown into irregular and violent action by a degree of irritant influence, which they do not feel when the animal functions are in full exercise. 2. The interval between the paroxysms is not less variable than their degree of intensity. Sometimes, after the first attack, another does not fol- low for months or years, even for several years. In such cases, the succeed- ing paroxysms are apt to occur at gradually diminishing intervals. In other instances, the paroxysms are very frequent and numerous in the beginning, and afterwards become less so, settling down at last into a more or less regu- lar recurrence at longer or shorter intervals. The period of recurrence may be a year, six months, three months, a month, a week, a day. Several par- oxysms may take place upon one day, or within two or more succeeding days; and afterwards they may not recur for weeks or months. Some patients have one fit upon each recurrence; others have two or more. In general, though there may be a tendency to a particular interval, yet the recurrence of the fit is liable to great uncertainty. Often there is a total want of regu- larity, and not the least calculation can be made as to the period of attack. In some few instances, a regular periodicity is observed. This is most apt to occur in females, and has some connection with their menstrual function. Occasionally it appears to be connected with the causes of intermittent fever, in which case the disease has been regarded as a concealed intermittent. But I have no doubt that regular periodical attacks of epileptic convulsions occur, without any such obvious cause, in the same way precisely as we have inter- mittent headache, and intermittent neuralgia. Though epileptic patients may have excellent health in the intervals of their attacks, and their organic functions may go on with apparently perfect order, yet there is usually something in them different from the condition of other persons, some peculiarity which evinces that the cerebral functions are CLASS III.] EPILEPSY. 787 more or less deranged. They are often, for example, headstrong, obstinate, capricious; determined for the time being in what they will, but changing their will continually; with memories frequently feeble or defective, and an inability to fix the mind continuously upon any course of laborious thought or investigation. Perhaps this character is in part ascribable to the inju- dicious indulgence with which such patients are apt to be treated from their youth up. 3. The course of epilepsy is generally one of deterioration. The par- oxysms are apt to return with greater frequency, and to assume a higher grade of intensity, if originally very mild. But this is not all. The brain appears to be gradually more and more deranged in its functions, in the in- tervals of attack. The memory and intellectual powers in general become enfeebled. Sometimes positive mania ensues, ending at last in dementia. Sometimes the mental disorder has the character of debility from the com- mencement of the process of deterioration. In rare instances, an increased intellectual impairment may be seen after each paroxysm; much more fre- quently it is very gradual, and the effect is rendered striking only by com- paring distant points of time. The altered cerebral condition exhibits itself also in various effects upon the exterior. There is a striking change in the features. They become enlarged, coarse, less intellectual, and more sensual, not to say brutish in character. Beauty suffers greatly, in relation both to form and expression. The gait is slouching, often somewhat one-sided, partly perhaps from deficient power in some of the limbs, but quite as much from the loss of that consciousness of inherent strength and dignity, which tends to give erectness to the person, and firmness and precision to the move- ments. At last the patient sinks into complete imbecility. Not unfre- quently he is very troublesome from the unequal deterioration of his intel- lect and animal propensities ; the latter being often violent, because no longer restrained by the former. Along with the progress of imbecility, disorder in the motor functions becomes evident, in strabismus, rigid contraction of certain muscles, distortion of the features, a one-sided position of the head, &c. With these changes, the organic functions often continue little if at all impaired. Digestion and nutrition are vigorous, the generative faculty remains, and the female menstruates regularly, and may become pregnant. This course may be accomplished in a few months or years ; but much more frequently occupies a great number of years; and epileptic patients may grow up from infancy to middle age, and even to a somewhat advanced age. The progress towards imbecility is said to be more rapid in cases commencing be- fore than after puberty. Its rapidity also bears some proportion to the fre- quency of the paroxysms. It is probably increased by habits of life and other causes which lower the general tone of the system, such as masturbation, ex- cessive venery, and the abuse of alcohol and opium. Though the general course of epilepsy is thus towards imbecility, it is not always so ; and individuals occasionally reach a good old age without any material impairment of their mental faculties. Anatomical Characters.—Anatomy has revealed nothing that can throw light upon the pathology of epilepsy, except to show that it is not connected essentially with any peculiar organic derangement of the brain. This organ has often been found to all appearance healthy, in epileptic persons who have died of other diseases. It has also been found affected with every possible variety of lesion, which has in some instances probably stood in the relation of cause, sometimes of effect to the epileptic paroxysms, and has sometimes had no other than an accidental connection with them. Lesions have been detected also in other vital organs, especially the lungs, heart, and alimentary canal This is only what might have been anticipated. Epileptic patients 788 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. are liable to the same diseases as other individuals, and generally die of some other affection than that under which they have been long labouring. Of course, the traces of these diseases are discovered after death; but they afford no clue to the origin or nature of the convulsive affection. When death has resulted from a recent paroxysm, the brain and its me- ninges appear greatly congested; the white substance being of a reddish colour, and the cineritious substance deep-red, purple, or violaceous. But no lesion is exhibited, implying the existence of disease anterior to the conges- tive movement, which is probably simultaneous with the paroxysm. In old cases, in which death has been preceded by dementia, and perhaps something like paralytic symptoms, the marks of chronic inflammation have been observed ; as partial induration or softening of the gray and white sub- stance of the brain, and of the cerebellum, general injection and dilatation of the vessels, a dull white appearance of the medullary substance, and a mar- bled or rose colour of the cortical, disease of the pineal and pituitary glands, adhesions of the membranes to the surface of the brain, thickening of the mem- branes, and various effusion into the arachnoid cavity, or into the ventricles. These are probably rather results than causes of the epileptic disease. Other lesions, however, have been occasionally noticed, to which the epi- lepsy might be referred, as thickening of the cranium, projections of its inter- nal table consequent upon external violence, caries of the inner table, exos- toses pressing on the brain, thickening of the membranes, abscesses, hemor- rhages, and different kinds of tumours, especially carcinoma and tubercles. Causes.—The causes which predispose to epilepsy are not well understood; though, that a predisposition to it exists in many of those attacked, is quite obvious. Inheritance is usually considered among these causes ; and there is probably some truth in the general opinion. The time of life has certainly some influence over the tendency to the disease. It is more common in early than in advanced life. It very seldom originates in old age. More indivi- duals are attacked before the period of puberty than after it. The nervous system is naturally very excitable in infancy, and easily thrown into disorder by disturbing causes. Many cases occur about the age of puberty ; and the changes which the system undergoes at that period are thought by some to predispose to the disease. Whether sex has any influence in forming a pre- disposition to epilepsy is uncertain. From the statistics which have been given to the world, it might be inferred that females are somewhat more fre- quently affected with epilepsy than males. I am quite certain that, within my own circle of observation, there have been more male patients than female. Celibacy has by some been supposed to predispose to epilepsy, because a very large proportion of those affected with it are unmarried. But this is more reasonably ascribable to the fact, that the occurrence of epilepsy very often serves as a bar against marriage; and thus patients are unmarried because they are epileptic, not epileptic because unmarried. The exciting causes are very numerous. Judging from my own observa- tion, I should say that a considerable proportion of the cases occurring in early life have their origin in an attack of cerebro-meningitis. Injury of the brain from external violence not unfrequently induces the disease. This cause sometimes apparently operates by a direct lesion of the brain or the conse- quent inflammation, sometimes by the depression of a portion of the skull or of its inner table. Other tangible causes of the disease are congenital mal- formation of the head, and various organic affections of the cranium or ence- phalon, such as were mentioned among the anatomical characters. Whatever strongly disturbs the cerebral functions may prove an exciting cause of epilepsy; and some of these causes appear by their continued ope- ration to create a predisposition, which either an excess of the same cause, or CLASS III.] EPILEPSY. 789 some other one of a disturbing character may bring into action. Exposure to the direct heat of the sun, and excitation from violent bodily exertion have sometimes brought on an attack. Among the most fruitful sources of the disease is undoubtedly excess of the stronger passions. Terror is thought by some to have induced it more frequently than any other cause. The origin of the disease can often be traced directly to fright; and the same cause often induces paroxysms in individuals subject to the complaint. It has been ob- served that congenital cases are apt to have been preceded by some occasion of great terror to the mother during pregnancy. The forcing of early intel- lectual culture is probably a not unfrequent cause of the disease in delicate children. It is said that a strong excitement of the imitative principle has sometimes resulted in epilepsy; children, and especially girls, having, in many instances, been attacked by the complaint from merely witnessing the con- vulsive paroxysms in others. Some have even supposed that persons who have often feigned to have epipletic fits, have sometimes ended by becoming really subject to them. Masturbation and excessive venery are accused of very often inducing epilepsy. The abuse of alcoholic drinks and of opium is another fruitful exciting cause. The sexual functions appear to have some influence; at least the disease, as already stated, is apt to appear at the age of puberty, and in women has been observed to occur frequently during the menstrual period. There has been reason also occasionally to ascribe it to the irritation of pregnancy. Other diseases are frequent causes of this. Attacks of it sometimes follow the retrocession of gout and rheumatism, the disappearance of a cutaneous eruption, the healing of old ulcers, and the suppression of some habitual discharge, whether morbid or physiological. It is sometimes as- sociated with, and probably dependent upon disease of the kidneys. Ya- rious febrile diseases, especially smallpox, give origin to convulsive attacks which take on the form of epilepsy; and, as before stated, the regular periodical form of the disease has by some been considered as a masked intermittent fever. The complaint is said to have been sometimes induced by syphilis: Irritation from disease situated in various parts of the body, is among the most frequent provocatives of epilepsy. How could it be otherwise, when every part of the body has a centre of communication in the brain, to which it imparts all impressions made upon itself, and which must, there- fore, participate in all its disturbances ? Irritation of the stomach is a notorious exciting cause of epilepsy. Hence it is, probably, that corrosive poisons, such as arsenic, have occasionally induced the disease. Numerous instances have been recorded in which it was supposed to originate from worms in the bowels. Yarious functional and organic diseases of the heart, lungs liver, and urinary organs have been accused as causes of epilepsy. The same is the case with the uterus, and amenorrhcea is supposed to be a fruitful source of it. The occurrence of pregnancy is said to suspend, if not to remove this variety of the disease. Tumours along the course of nerves or hard bodies, as spicula of bone, wounding them, are said to have occasioned epilepsy. There is every reason to think that spinal irritation may sometimes excite it. The affection has received special names from its supposed origin in these extra-cerebral affections; as epilepsia gastrica, enterica, verminosa, hepatica, hysterica, &c.; but this is a useless compli- cation of nomenclature. . Nature —The disease probably consists in a morbid excitability of the brain and each paroxysm in a morbid excitement or irritation. A promi- nent effect of irritation, when beyond a certain point, is first to derange, and if still further increased, to abolish function. This law is applicable as 790 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. well to the brain as to other organs. The irritation which occasions the paroxysms is sufficient to suspend all the cerebral functions connected with the mind; sensation, perception, consciousness, intellectual action, emotion, volition ; but, in relation to the motor function, is sufficient only to derange, not to abolish it. In this respect epilepsy differs from apoplexy. In the latter affection, not only are all the mental functions suspended, but to a great extent, that of motion also. The difference may be owing to a less degree of the irritant or disturbing force in epilepsy, or to its more especial direction to the cortical substance, whereby the mental functions, which are probably connected with the latter, may suffer most, while the motor func- tion, connected essentially with the medullary substance, being as it were in the outskirts of the irritant influence, feels only enough of it to be excited into a morbid increase of action, and not enough to be overwhelmed en- tirely. It has been supposed that the involuntary muscular movements of the epileptic paroxysm must depend on irritation in the spinal centres, while the mental phenomena have their origin in the brain. But there does not appear to me to be any ground for this belief. It is true that the spinal centres are capable of producing involuntary muscular contractions; but they are not exclusively so. Every voluntary muscle has a centre in the brain, and nervous cords of connection, through which the will operates upon it. It is easy to conceive that the influence of the will may be suspended by a morbid or irritant action, which shall equally have the power of sending down motor influence from the brain; and this is, I think, undoubtedly the case in epilepsy. All the symptoms point to the brain as essentially the seat of the disease; and, when the originating point of irritation is in the spinal marrow, it is only like any other external source of irritation, as in the stomach, bowels, or uterus; it produces its effects secondarily through cerebral intervention. Now it is clear, if the above views are correct, that organic derangement of the brain is not essential to epilepsy. The cerebral anatomy may be per- fectly healthy; and yet the functions greatly deranged through irritation alone. But organic disease in the brain would be apt to excite the affec- tion, if not carried so far as to destroy function altogether. Epilepsy may, therefore, originate in and be sustained by inflammation of the brain, or by any other organic alteration, as tumours, osseous spicula or exostosis, de- pressed bone, thickened membranes, effusion, &c, which shall produce a certain amount of irritation in the cortical substance, sufficient to suspend function, and a somewhat less amount in the white substance, sufficient only to excite and derange function. If the cause operated on the former sub- stance alone, we should have coma or delirium; if on the latter alone, we should have spasm or paralysis, as in cerebritis. It is clear, too, that an irritation sent to the brain from any point of the body whatever, which shall be equally forcible as that originating in the brain, and have the same special directions, will produce the same effect. The epilepsy, strictly speak- ing, is the same in both cases. It is only the cause of it which differs. The true pathological condition is only a morbid excitability of the brain, which enables ordinary causes to produce the proper epileptic derangement of its functions, or a morbid excitement from some powerful cause capable of producing the derangement without predisposition. There does not, therefore, appear to be any strict basis for the division of epilepsy into idiopathic and symptomatic, or, according to the nomencla- ture of Dr. Hall, into centric and eccentric. It is the same affection, whether dependent upon a tumour within the encephalon, worms in the bowels, or a mere morbid excitability of the brain, through which it is thrown into derangement from ordinary causes. Nor is there sufficient CLASS III.] EPILEPSY. 791 ground for this distinction in relation to prognosis or therapeutics. It is true that the prognosis is more favourable, when the disease can be shown to have its origin in an external source; and it is also true that, in such a case, we know where to direct our remedies. But the fact is, that we can seldom be certain, perhaps never, that the disease does depend upon an ex- ternal cause, until it ceases upon the removal of that cause ; and it is always a good rule of treatment to remove any external possible source of the disease that may exist, whether the real cause be internal or external; so that nothing is gained practically by a mere conjectural reference of the disease to one or the other source. This view of the nature of epilepsy enables us, in some measure, to ac- count for its paroxysmal character. The morbid excitability is not equal. It is liable to all the fluctuations of the healthy excitability. Excessive excitement diminishes or exhausts it for a time; the parts subsequently become insensible to ordinary causes of disturbances ; and the actions remain healthy. Such an exhaustion is produced by the epileptic paroxysm, which, therefore leaves the brain in its ordinary state until the excitability shall again accumulate. A strong cause of irritation may produce a paroxysm at any time, provided its strength be more than proportionate to the dimi- nution of excitability. As the excitability accumulates, less and less of the cause is required to produce the paroxysm, and when it becomes again greatly in excess, the paroxysm will occur under the operation of ordinary healthy influences. The tumours, the spicula of bone, the thickened membrane, and all the other organic alterations within the brain operate in the same way. They act upon the portion of brain not organically affected as external sources of irritation. By their irritating influence they throw the brain into epileptic functional disorder. This diminishes or exhausts the excitability, so that the sound parts of the brain cease for a time to be sensible to the morbid in- fluence. When the excitability is recovered, the organic cause is again felt, and again we have a paroxysm, and so on indefinitely. It is thus seen that, though the source of irritation may be always in existence, it does not follow that it should sustain a constant paroxysmal condition. Indeed, the organ could not long support such an excess of irritation. It has been supposed that, in cases attended with the epileptic aura, the source of irritation probably exists in the point from which the sensation proceeds. This may be the case in some instances; but experience has shown that it is not generally so; nor is the supposition at all necessary; for, though the sensorial centre may be the part really deranged, it very often refers the sensation to some point in the exterior with which it communicates. This is constantly the case in health. It is the brain which feels the pain of a wound, but it refers the sensation to the wounded part. Habit has undoubtedly great influence in sustaining epilepsy. When the brain has once acted in an unusual manner, it much more readily acts in the same manner a second time, and at length falls into the new mode of action perhaps under ordinary influences, without the aid of the original cause. In- dividuals who are with the greatest difficulty put into the mesmeric state, I have known at length to be able to throw themselves into that morbid state at will So it is also, in some measure, with epilepsy. The brain acquires a certain habit of acting, which may remain after the original cause has ceased It can be easily conceived how an epileptic patient should gradually fall into a state of dementia and paralysis. The brain, frequently stimulated to excess in the paroxysms, and engorged with blood, gradually takes on a slow inflammation which in the end results in organic change. It is only another 792 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. illustration of the general rule, that repeated irritation tends ultimately to inflammation. The healthy excitability of the organ is also impaired by the excess of irritation, and a state of debility ensues, because the brain ceases to feel duly the ordinary mental influences essential to just thought and proper feeling. Hence a gradual approach to imbecility, even independent of in- flammation, and organic change. It is probable that the organic alterations found in old epileptic patients, indicative of chronic inflammation, have generally resulted in the manner above explained from the epilepsy itself. But sometimes they are the con- sequence of a continuance of an organic disease of the brain, in which the epilepsy may have originated. Diagnosis.—The only affections with which epilepsy can be confounded are apoplexy, certain forms of hysteria, and convulsions arising from some temporary cause, as meningitis, fever, the puerperal state, dentition, and intes- tinal irritation in children. There can be no difficulty in distinguishing an ordinary epileptic fit, in its early stage, from apoplexy. The violent convulsions of the former, and the comparatively motionless state of the latter are sufficiently diagnostic. But, when the epileptic paroxysm has subsided into quiet coma, there may be more difficulty. The paleness of the face, however, in this stage, the comparative feebleness of the pulse, the foam at the mouth, the general absence of snoring, and the want of paralytic symptoms, though not absolutely certain criteria, are generally sufficient to enable the physician to draw a just conclusion. The comparatively brief duration of the epileptic paroxysm, and the previous history of the case, will also enter into the means of judgment. Sometimes the two affections appear to be associated; the patient having attacks closely resembling apoplexy, intervening between those properly epileptic. The diagnosis between epilepsy and hysteria will be given under the head of the latter complaint. Occasional convulsions cannot be distinguished with any certainty from the epileptic, except by the circumstances which attend them. Thus, if the fit occur during the course of a febrile disease in children, from the irritation of swollen and painful gums, from obvious intestinal irritation, from acute meningitis, or from the disturbance of system attending the puerperal state, immediately anterior or subsequent to delivery, there may be good reason to hope that the tendency to convulsions may pass away with the temporary cause; in which case, the affection would hardly be looked upon as epileptic though it might be difficult to decide in what respect the convulsions differed in the two cases. In these occasional convulsions, there is very often a more sudden recovery of mental activity after the cessation of the convulsive move- ments, especially when the exciting cause is without the cranium. There is too, perhaps, as a general rule, less foaming at the mouth, and less embar- rassment of respiration. Should these convulsive fits be repeatedly experi- enced, at somewhat distant intervals, with a return to health in the mean time, there would be good reason to regard them as truly epileptic. Epilepsy is for various reasons not unfrequently feigned; and it sometimes becomes necessary for the physician to decide whether the case is real or a counterfeit. If the individual be seen during the paroxysms, there can be little difficulty. In real epilepsy there is profound insensibility. In the supposititious, the sensibility remains, and may be acted on. Thus, the indi- vidual will sneeze if snuff be blown up his nostrils; will shed tears or make a motion of avoidance, if strong solution of ammonia or a burning match be held near the nose ; will often start upon the occurrence of sudden loud sounds near his ear; or will show some sign of consciousness of what is said in his hearing, if ingeniously calculated to affect him strongly. Painful impressions class in.] EPILEPSY. 793 made upon the surface, or threats of such impressions sometimes exceed his fortitude; but the former of these measures should in general be avoided in consequence of the subsequent effects on real sufferers. The froth at the lips is said to be sometimes imitated by means of soap in the mouth, but I should suppose that the imitation would be clumsy. The immobility of the pupil on exposure to light, the dark-red or livid turgescence of the face, the irregu- larity of the pulse, and the peculiar vacant or astonished look of the patient on recovery, are signs which cannot easily be counterfeited. In the absence of the paroxysms, the counterfeiter wants the peculiar fea- tures of the habitual epileptic ; does not usually display the marks of injury on his person from bruises, wounding of the tongue, &c.; and, upon inquiry, will generally be found to have selected his place for falling, and never to have had a fit unless when he supposed himself in the sight of others. Prognosis.—When not dependent on any permanent organic disease, epi- lepsy may often be cured, if taken at the outset; and there is reason to be- lieve that the germ of many an epileptic case is destroyed by the proper treatment of the occasional convulsions, which so frequently come under the notice of the physician. Cures sometimes also take place in cases of con- siderable duration; and there is no reason to despair in any case, unless ob- viously connected with incurable organic disease, or evidences of deteriorated brain. The longer, however, the disease continues, the less, as a general rule, is the probability of a favourable issue. After six months the chances are much diminished ; and cases of a year's duration are often intractable, especially if, during that time, they have resisted judicious measures. When the disease appears before puberty, some hope may be indulged of a favour- able change at that period. The cases dependent on some source of irritation exterior to the encephalon are more easily cured, as a general rule, than those in which the brain is exclusively affected; but there is always difficulty in ascertaining the fact of such dependence. Congenital cases, or those beginning in early infancy, are generally unfa- vourable. So also are those which have supervened upon an attack of hy- drocephalus. Inheritance usually gives obstinacy to the disease. The prog- nosis is always unfavourable, when, from long-continued and deep-seated pain in the head, or from evidences of a scrofulous or cancerous constitution, there is reason to apprehend the existence of tuberculous, carcinomatous, or other organic disease within the cranium. Epileptic patients scarcely ever recover, in whom a gradual deterioration of the mind, and the occurrence of paralytic symptoms, or rigid contractions of the muscles are observable. Dr. James Jackson, of Boston, has seen no patient recover, in whom the disease was attended with those very slight attacks, already noticed under the name of vertiginous spells. (Letters to a Young Physician, p. 63.) The disease often undergoes amendment without obvious cause, and the patient escapes his paroxysms so long that he begins to hope they may never return; but the favourable promise is very generally illusory. Many reputed cases of cure are probably of this kind. According to Herpin, permanent spontaneous cures take place in about four per cent, of the cases. (See Brit, and For. Medico-Chir. Rev., April, 1853.) It is a fact often noticed, that a patient is apt to improve under any new medicine or plan of treatment, no matter what it may be. This is an evidence of the influence of the mind over the disease, and of how much a cheerful, hopeful and confident temper may do towards ameliorating the condition of the patient In judging of the effects of their remedies, practitioners should bear this fact in mind, and guard themselves against a too hasty conclusion in favour of certain remedies which they may have prescribed. Treatment.__There is no one exclusive course of treatment applicable to VOL. II. 51 794 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. epilepsy. It is necessary to consult the state of the system, to ascertain every irregularity of function or organization which can have any bearing on the disease, and to apply our remedies accordingly. The treatment di- vides itself into that which is adapted to the paroxysm, and that required in the interval. 1. In the paroxysm, little treatment is demanded. The patient should be placed upon a bed, with his head somewhat elevated; all tight parts of the dress should be loosened, especially about the neck and trunk ; the air of the chamber should be fresh and pure; a piece of soft wood should be placed between the teeth to prevent injury to the tongue; and the convulsive move- ments should be restrained so far as may be necessary to guard the patient from injury. In general, the fit will spontaneously subside in a few minutes. Depletion or strong impressions of any kind are unnecessary; and the former may be injurious, if often repeated, by deteriorating the general health. But, should the congestion of brain be so great as to threaten apoplexy, it would be proper to take blood from the arm, to make cold applications to the head, and produce revulsion towards the extremities by rubefacients, or by hot water if the movements of the patient will admit of its application. Should the paroxysm continue much longer than usual, or protracted coma follow, it will also be proper to bleed if the pulse be sufficiently strong; and cups or leeches to the temples and back of the neck may be used as adjuvants to the lancet, or as substitutes for it in doubtful cases. When the pulse is rather feeble than strong, and the convulsions persist, enemata of assafetida or oil of turpentine may be administered. In the pro- tracted paroxysm, after depletion, or when it is not required, the happiest effects sometimes proceed from ipecacuanha given as an emetic. The exter- nal application of certain nervous stimulants is also useful in some of these cases, especially in children. Garlic and brandy, or oil of amber mixed with olive oil, may be applied occasionally along the spine. The warm bath is beneficial in infantile cases. Should danger from apncea be apparent, ammoniacal liquids should be placed near the nostrils, sinapisms or hot water should be applied to the ex- tremities, and, in cases of suspended breathing, the electro-magnetic current may be directed through the diaphragm, and recourse may be had to arti- ficial respiration. Even Dr. Marshall Hall's proposed measure of tracheo- tomy might be employed, should the danger appear imminent; but it can be very rarely necessary. After the paroxysm has subsided, the patient should be kept quiet; and, if comatose symptoms continue, threatening serious mischief to the brain from persistent congestion, blood should be abstracted, generally or locally, according to the violence of the symptoms and the strength of the patient. Saline cathartics, and the warm bath may also be useful in guarding against subsequent mischief. It is necessary, throughout the paroxysm and its sequelae, to guard the patient from injuring himself or others. Sometimes, when maniacal violence is exhibited, it may be necessary to resort for a time to the strait-jacket. In- dividuals subject to epilepsy should not walk alone in the vicinity of water, even though shallow; for instances of death sometimes occur from falling with the face under water, even in a small puddle. Neither should they ride on horseback, or in an open carriage from which they may possibly fall, nor should they frequent precipitous places. It is recommended that epileptic patients, who are apt to be attacked during their sleep, should lodge in beds with a ledge around them, so as to prevent their falling out. But a better plan is to sleep on beds so low, that falling out would do them no injury. 2. In the treatment of the interval, there are two prominent indications, CLASS III.] EPILEPSY. 795 namely, first, to remove all appreciable or possible sources of irritation to the brain, and secondly, to render that organ less sensitive to morbid im- pressions, or better able to resist them. To meet the first indication, it is necessary to study well the state of the system, and, whenever any deviation from the healthy condition can be found, to remedy it if possible. If the blood-vessels are too full, and the blood too rich, it will be proper to administer occasional doses of the saline cathartics, to confine the patient to a diet exclusively vegetable, or of vegetables and milk, and to recommend moderate exercise so as to cause the blood to be duly expended by the various functions. This treatment may be confined to periods of temporary excitement, or may be continued for a long time when the tendency is strong and constant In instances of inordinate excitement, it may be proper to take blood. Should the patient, on the contrary, be anemic, the indication is scarcely less strong to correct this abnormal condition of the blood. When this fluid is deficient in nutritious qualities, all parts of the body suffer; and from all parts there go up to the brain intimations of this suffering, in order that, through the processes of circulation, respiration, digestion, &c, the deficiency may be supplied. The brain is the centre of communication between the suffering tissues and the organs, by the agency of which the suffering is to be relieved. The brain is, therefore, excited powerfully, and a state of great irritation is produced, which, though it may not exhibit itself in inflammation, is capable of inducing functional disorders, and among the rest convulsions. Anaemia, therefore, attending epilepsy, should be corrected; and excessive bleeding, even in plethoric cases, should be avoided for fear of inducing this condition. The chalybeates, simple bitters, sulphate of quinia, a nutritious diet, the cold bath if followed by reaction, sea-bathing, and passive exercise, are the remedies here indicated. Besides the general state of health, particular sources of irritation should be attended to. In infants, the gums should be lanced, if swollen and painful, and other measures adopted to relieve the local inflammation. (See Morbid Dentition, i. 538.) Acidity of stomach, and other sources of gastric irrita- tion should be corrected, and enfeebled digestion treated as directed for dys- pepsia. (See Irritation of Stomach, i. 581.) Yerminose affections should be met with the ordinary anthelmintics. Cases of epilepsy, dependent on tape-worm in the bowels, have been permanently cured by large doses of oil of turpentine. Constipation, deficient or deranged hepatic action, and any existing nephritic disorder, should be corrected by appropriate remedies. A cure of epilepsy connected with splenitis has been effected by the continued use of aloetic purges. When epilepsy is associated with organic diseases of the heart, little good can be expected from medicines; yet some relief may be obtained by pursuing the course recommended in these affections. Any existing disease of the kidneys should be corrected. Amenorrhcea should receive especial attention, as also should other uterine disorders; but this is not the place to detail the necessary remedies. Dr. Pritchard placed great reliance upon oil of turpentine in cases connected with uterine derangement; attention bein°* paid of course to the general state of the system. Spinal disease must be treated by local depletion and counter-irritation Should a tumour exist in the course of a nerve, or a spiculum of bone serve as a point of nervous irritation, the offending cause should be removed, if possible by a surgical operation. Cures are recorded, which have been ef- fected in this way. When the epileptic aura exists, it may be well to make pressure upon the limb, above the point at which the peculiar sensation commences by means of a ligature or tourniquet. It is said that the par- oxysm may' often be suspended by such a proceeding. Amputation has even 796 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. been resorted to; and a cure of epilepsy is said to have been effected by Tissot, by cutting off the great toe in which the sensation of the aura com- menced. In a case reported by Frank, in which the aura began in the tes- ticle, a permanent cure is asserted to have followed castration. _ A division of the radial nerves is stated by Portal to have effected a cure, in a case in which the paroxysm began with violent pain in the index finger. But suc- cess, in cases of this kind, has scarcely been sufficient to justify a resort to such extreme measures as amputation or castration under ordinary circum- stances. Many cures are reported as having been effected by the operation of trephining, whereby depressed or diseased portions of the skull have been elevated, or spicula of bone penetrating the brain have been removed. In- stances of this kind have occurred in our own country, to Dr. Dudley, of Lexington, Dr. Rogers, of New York, and Dr. Guild, of Alabama. (See Am. Journ. of Med. Sci., ii. 489, and iv. 97.) Such an operation might be justifiable in severe cases of the disease, in which a fixed pain in one part of the skull, with tumefaction, might indicate disease of the bone, or in cases following a blow or fall upon the head, and probably dependent on depressed bone. But that it should be resorted to, in ordinary cases of epilepsy, upon the principle of relieving the brain from pressure, or with the vague hope of discovering and removing the offending cause, is hardly consistent with sound therapeutical principles. Should the disease be associated with syphilitic affection of the skull or pericranium, a course of mercury or of iodide of potassium should be resorted to. Cures of epilepsy have sometimes followed a cure of syphilis by means of mercury. Dr. Fuller has used biniodide of mercury with advantage, in some cases in which he supposed thickening of the dura matter, or a deposit between it and the bone to exist. (Med. Times and Gaz., Feb. 1857, p. 167.) In order completely to fulfil the first indication, it is necessary to correct those habits, or counteract those exterior influences, which may have caused, or may sustain the disease. All sensual excesses, including the habit of masturbation, must be abandoned; and to aid the patient in overcoming his vicious propensities, dulcamara or other reputed antaphrodisiae medicine may be employed. Regular and moderate occupation, not calculated to overtask the mental or bodily powers, is among the most efficient measures for accomplishing this purpose. Excessive and premature mental exertion is highly injurious. All excess of the passions, of whatever kind, should be avoided. It need scarcely be said that abandonment of intemperate drink- ing is absolutely essential. In those cases in which the paroxysm is apt to occur in the night, the patient should avoid suppers, and should lie with his head elevated. Under this head may also be ranked the use of revulsive measures, calcu- lated to call off irritation from the brain, and to fix it in some safe external position. When the disease has followed the cure of a cutaneous eruption or an old ulcer, or the retrocession of a gouty or rheumatic disease, the measures alluded to are especially important; and, under these circumstances, they should be applied to the original seat of the affection. In other cases, they may be applied to the nape of the neck, behind the ears, or between the shoulders. Repeated blistering, pustulation by tartar emetic or croton oil, issues, setons, and cauterization by moxa, are the means referred to. Several cases have been related of the efficacy of tartar emetic ointment, rubbed upon the scalp so as to induce free suppuration. (See Ranking^ Abstract, vii. 174.) In cases attended with evidences of chronic inflammation of the brain and its membranes, it may not be amiss to make an incision, as has been re- commended, on the top of the scalp, along the sagittal suture, and keep it open by means of issue peas. A remedy, however, so harsh and disagreea- CLASS III.] EPILEPSY. 797 ble should not be thoughtlessly resorted to. It may be proper, also, in some comatose cases, to blister the whole scalp, once or oftener. The second indication of treatment, during the interval, is to diminish the excitability of the brain, so as to render it less sensible to irritant impres- sions, or better able to resist them. The remedies calculated to meet this indication are the narcotics, which diminish the sensibility of the brain; and the tonics and nervous stimulants which strengthen the nervous system, and tend to equalize its excitements. These remedies may often be advantage- ously conjoined. Of course, before they are resorted to, the system should, in compliance with the first indication, be freed as far as possible from any incompatible state of disease that may exist. Of the tonics, those derived from the mineral kingdom are usually pre- ferred. Nitrate of silver holds, perhaps, the highest rank among them. Many cures by that medicine have been reported, and its occasional efficiency in purely functional cases of the disease can scarcely be doubted. It should be given at first in doses of one-quarter or one-third of a grain, three times a day, to be gradually increased to one or two grains. The dose has some- times been enormously increased, and even a scruple has been given daily. But this is an abuse of the remedy, and may lead to serious evil. The mu- cous membrane of the stomach may be corroded, and a permanent dark stain fixed upon the skin. Esquirol mentions the case of a woman who had taken the nitrate for eighteen months, and whose stomach, upon her death at the ex- piration of that period, was found destitute of the mucous membrane over one- half of its inner surface, and in several points corroded to the peritoneal coat. Of the discoloration numerous instances are on record. I have not seen these effects in my own practice, though much in the habit of employing the salt; but I never exceed the quantity of a grain three or four times a day, and never continue the remedy longer than two or three months, without an intermission of as many weeks. The chloride, iodide, or oxide of silver might be substituted for the nitrate, and probably with equal effect, while there would be less danger of irritating the stomach. I should expect from them, however, the same effect upon the skin, if used very largely. For the dose of these medicines, the reader is referred to the dispensatories. Next, probably, in efficacy to the nitrate of silver, are the salts of copper. Either the sulphate of copper or ammoniated copper may be used. I have seen apparent benefit in epilepsy from a mixture of the latter of these pre- parations with assafetida. They should be employed in doses insufficient to irritate the stomach, and continued steadily for months. Both with these preparations and with nitrate of silver, a little opium may in general be use- fully associated. The preparations of zinc have also been used with asserted benefit. The sulphate and oxide are those usually employed. The oxide to be efficient must be given in large doses. From five grains at first, the dose may be increased to ten or fifteen grains three times a day, if found not to offend the stomach. Yalerianate of zinc has recently come into notice, and is said to have been used advantageously in the dose of a grain or two several times a day, increased as the stomach will bear it. Lactate and phosphate of zinc have also been recommended. The preparations of iron may be employed with the same view. Acetate of lead is said to have effected permanent cures in some cases; and its influ- encein directly depressing nervous action, when freely taken, would render this result probable ; but it should be used with caution. Of the vegetable tonics, a large number have been employed, but none probably with much other effect than to improve the digestion, except Peru- vian bark or sulphate of quinia, which might be expected to produce favour- 798 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. able effects in functional epilepsy, from its influence upon the brain. It ia especially adapted to cases which assume a regular periodical form. Of the antispasmodics, or nervous stimulants, valerian has probably en- joyed most credit. Assafetida, musk, and camphor, have been much used; and formerly some reliance was placed on Dippel's animal oil, which, how- ever, has gone out of use. I have seen a monthly recurring case, in a young female, yield apparently to cimicifuga or black snakeroot. Among the narcotics, stramonium and belladonna are probably the most efficacious. When the system is free from plethora, opium might sometimes prove useful; but it must be employed with caution. In the condition of great cerebral irritation, approaching or amounting to insanity, which sometimes follows an epileptic paroxysm, and may even occur without any immediately preceding convulsive attack, I have obtained the happiest effects from a mixture of chloroform and camphor, made into an emulsion with water by means of the yolk of an egg. From forty to sixty drops of the chloroform and five grains of the camphor, in a tablespoonful of the mixture, may be given every hour or two till relief is obtained, or it shall be found inapplicable to the particular case. I have seen it produce perfect calmness almost instantaneously. A great number of remedies have been given empirically in epilepsy, and acquired a temporary reputation, to be lost, revived, and lost again, in the fluctuation of medical experience. There can be no doubt that many wholly inert substances have attained some credit, partly from having been given on one of those occasions when the disease was about to undergo spontaneously a temporary amelioration, and still more, it is probable, from the influence of novelty, hope, &c, on the mind of the patient, and through this on the condition of his brain. Among the remedies recently introduced, indigo has attracted consider- able attention. It is asserted to have been effectual in many cases. A scru- ple may be given at first, and gradually increased to one or even two drachms, three times a day; and the medicine must be continued for two or three months. It is usually associated with some aromatic powder, and if it purge should be combined with a little Dover's powder. Artemisia vulgaris or mugwort, an old remedy in this complaint, has within a few years been re- vived in Germany. A species of Scutellaria, given freely in the form of decoction, has been successfully used by Dr. R. W. Evans, of West Canada. (See Am. Journ. of Med. Sci., N. S.,xvii. 495.) Dr. Thos. Salter, of Poole, and Dr. Joseph Buller, of Southampton, England, claim extraordinary powers for the inspissated juice of the cotyledon umbilicus (Ibid., xviii. 214) ; and the late Dr. Graves, of Dublin, related several cases in which it appeared to effect cures, or to afford relief. (Dub. Quart. Journ. of Med. Sci., xiv 257.) M. Michea found valerianate of atropia successful in six cases of the recent disease, originating in moral causes. (Va. Med. and S. Journ., ii. 285, from Gaz. Med. de Paris.) Cures are said to have been effected by the selinum palustre of Europe (Herpin), and the same is asserted of the bark of the black elder (Sambucus nigra), given in the form of infusion in anticipation of the paroxysm, and repeated every week. The oils of turpentine and cajeput, have been recommended. The mistletoe, peony rooty and orange leaves, are old remedies. Yarious aromatic, stimulant, and antispasmodic mixtures have met with partial and temporary success. Of this nature is the mixture of equal parts of powdered sage, ginger, and mustard, of which a teaspoon- ful given three times a day is said to have effected some cures. Cantharides, phosphorus, and galvanism or electricity, have had their advocates. Dr. Jonathan Osborne, of Dublin, has met with extraordinary success from the joint use of digitalis and tincture of cantharides, given so as to produce their CLASS III.] CHOREA. 799 characteristic effects ; care having been previously taken to remove any ob- vious source of cerebral irritation; and the cold douche being in most in- stances applied to the occiput morning and evening during the treatment. (Dublin Quart. Journ. of Med. Sci, Nov., 1856, p. 349.) Strychnia may be employed with some hope of advantage in paralytic cases. Emetics, re- peated every three or four days, have had the effect of postponing the paroxysms, and are reputed to have cured the disease in some instances. Mercury will no doubt occasionally prove serviceable, by correcting some of the organic affections without or within the cranium, which may have pro- duced, or may aggravate the disease. Sir Charles Locock has found bro- mide of potassium, in doses Of from five to ten grains, remarkably successful in hysterical cases. (Med. Times and Gaz., May, 1857, p. 491.) Dr. Marshall Hall has proposed the operation of tracheotomy, on the ground that spasmodic closure of the glottis in epilepsy is a necessary ele- ment in the convulsion; but the operation has not been attended with such success as to justify its employment, unless in extraordinary cases, in order to prevent asphyxia. Another surgical measure which has been proposed, and occasionally tried, is to tie one or both of the carotids; and still another, to secure the arteries which supply the soft parts without the cranium, the temporal for example, with the view of diminishing intra-cranial congestion by cutting off the supply of blood through the bone. But neither operation has been followed by very satisfactory results. The patient may sometimes succeed in keeping off a paroxysm when he has warning of its approach, by smelling ammoniacal substances, or one of the nervous stimulants, as musk or assafetida. Dr. Eberle knew an epileptic in- dividual, who used to produce this effect by drinking freely of cold water in anticipation of the fit. Anything that will make a strong impression on the nervous system, whether directly, or through the mind, will often have the same effect. Allusion has already been made to the plan of arresting the paroxysm, in cases attended with the epileptic aura, by a ligature or tourni- quet round the limb. Dr. James Jackson, of Boston, has found no remedial measure so effectual as a diet almost exclusively of vegetable food, with occasionally, when the health is at the best, milk, butter, or eggs, which, however, must be used cau- tiously, and mixed with farinaceous substances, as in puddings. Under this diet he has seen many recoveries; though it has often failed. He has never known a case to end favourably, after an unsuccessful trial of this diet, and has little confidence in medicines. (Letters, &c, p. 67.) Article VIII CHOREA. Syn.— St. Vitus's Dance.—Chorea Sancti Viti.—Danse de Saint Guy.—(French.) Chorea (from x°Peia> a dance) is characterized by involuntary muscular contractions, without loss of consciousness, and without entire loss of the power of the will. The contractions are somewhat peculiar, being neither rigid and persistent like those of tetanus, nor so quick and jerking as those of ordinary convulsions, but rather resembling the voluntary movements, for which they may be easily mistaken. The name St, Yitus's dance is said to have arisen from the custom, formerly prevalent, for those affected with the disease to make a pilgrimage to the shrine of St Yitus, called by the French St Guy near Ulm, where they were miraculously healed. 800 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. Symptoms, Course, &c—Chorea in general comes on gradually, and is often preceded by symptoms of gastro-enteric derangement, such as irregu- lar appetite, constipation, swollen abdomen, &c, which are sometimes also accompanied with depression of spirits, or other signs of nervous disorder. The first unusual movements are often noticed more especially in some one part of the body, as the face, the shoulders, or the hands ; the patient making ludicrous grimaces, or shrugging the shoulders, or incessantly working with the fingers, and perhaps incurring blame for behaving rudely, or acting absurdly, as if the motions were voluntary. But they are soon found to be beyond the control of the will. The irregular muscular action increases, and at length the whole body becomes more or less involved. Head, trunk, and extremi- ties are in almost constant movement. The features undergo various whim- sical distortions, as if the patient were making faces for the amusement of the spectators. The head is moved grotesquely upon the neck; the limbs exe- cute diversified, meaningless little gesticulations ; and the muscles of the trunk pull it now one way and now another, making the patient appear exceedingly fidgety, without greatly altering his position. If any voluntary motion is attempted, there is a curious and often ludicrous mixture of the regular and irregular actions of the muscles, which seem to be influenced by two opposite forces; but, unless the disease be very violent, or the object aimed at require some nicety or steadiness of movement, the will is generally in the end suc- cessful. Thus, patients cannot use the hand in writing, sewing, &c, but they can ordinarily convey objects to their mouth, or move from one place to another, though, in accomplishing the former object, the arm is jerked about in various opposite directions, before it reaches the point aimed at, and, in attempting the latter, the body often goes through numerous zig-zag ope- rations, advances with a sort of hitching gait and as if one foot were dragged after the other, and not unfrequently falls. The interior muscles of the mouth and of the fauces may participate in the morbid action; the tongue is rolled out occasionally between the lips; the patient stammers or hesitates in speaking; and even deglutition is sometimes performed with difficulty. In very bad cases, the patient loses the power of maintaining a standing or even sitting posture, and is compelled to lie in bed. One side is sometimes observed to be much more affected than the other. It seldom happens that the muscles are entirely quiescent, except during sleep, when the motions usu- ally cease entirely, or are very much diminished. In some instances, how- ever, they are so incessant as to interfere with sleeping. The disease is sub- ject to exacerbations and remissions ; and sometimes assumes a paroxysmal, and even an irregularly periodical or intermittent character. Indeed, cases have been noticed in which there was considerable regularity in the return of the paroxysms, with entire exemption in the interval. The irregular motions are often greatly increased by any emotion ; and it has been noticed that the patient is generally worse when conscious that others are observing him. It appears that, if the will cannot accurately regu- late the movements of the muscles, it has the power of calling them into ab- normal action; for the spasmodic contractions are much more frequent when the patient endeavours to execute any movement with peculiar precision, than when the will is quiescent. By the exertion of a strong determination, the patient can also often control the muscles in some degree, so as to keep them quiet for a time, though, if he allows or encourages them to move, it is im- possible to prevent them from moving in their own way. Chorea is sometimes attended with headache. The bowels are generally constipated, and the discharges often unhealthy. The appetite is in some instances natural, in others morbidly craving, deficient, or capricious. There CLASS III.] CHOREA. 801 is no fever. It is a singular fact, noticed by writers, that there is much less sense of fatigue in consequence of the incessant muscular action, than would result from an equal amount of it under the direction of the will. The tem- per is not unfrequently affected. It is more capricious, excitable, or appre- hensive than in health. The patient often weeps without apparent cause, or is gloomy, or apathetic, in short, evinces various nervous disorder not unlike that attendant upon hysteria, which is, indeed, not unfrequently associated with this disease, when it attacks females about or beyond the age of puberty. The mental disturbance sometimes amounts to delirium. Neuralgic affections, moreover, are not uncommon in patients who have been labouring under cho- rea ; and some authors have noticed a connection between the latter complaint and rheumatism of the muscles, pericardium, and spine. The course of chorea is not uniform. Under proper treatment, it may continue only a few days, or it may run on for months or years. There is reason to believe that it will generally, sooner or later, cease spontaneously. When long continued, it is thought to weaken the mental powers; and it is accused of inducing imbecility, epilepsy, paralysis, &c. The probability is, that these affections, when they occur, are merely effects of a common cause with chorea, and not the results of that disease. A partial palsy of the limbs sometimes follows a convulsive paroxysm. Instead of affecting the whole body, chorea is sometimes confined to a sin- gle part, as to the face, a leg, or an arm ; and the patient, though well in all other respects, is unable to prevent himself from making the most uncouth, whimsical, or ludicrous movements of this part, which subject him occasion- ally to inconvenience and mortification. I know an instance of this kind, in which a gentleman gives now and then offence to strangers by making faces, as if mocking or laughing at them, when in fact perfectly serious and well-disposed. This partial chorea is more difficult of cure than the general, and not unfrequently continues during life. It is probably, in many instances, rather the result of early habit confirmed by time, than a real disease. Dr. Addison has called the attention of the profession to the frequent ex- istence of a bellows murmur of the heart in chorea. It accompanies the first sound, and though sometimes aortic is more frequently mitral. It is proba- bly dependent in general upon anaemia, which, if the views of the heart's actions given at page 128 of this volume are correct, may readily produce the mitral as well as the aortic murmur with the first sound. Dr. H. Bence Jones has found the urine deficient in the phosphates, but with great excess of the sulphates and urea, ascribable to the excessive muscular action. (Lond. Med. Gaz., July, 1851, p. 81.) Another morbid state is frequently ranked with chorea, though, as ap- pears to me, improperly. The affection alluded to consists in an irresistible propensity to make and repeat incessantly, and without reason, certain strange motions, such as dancing in a whimsical manner at the sound of a musical instrument, jumping, whirling the body rapidly round upon the heel as a pivot, rotating the head backward and forward, beating the hand incessantly upon the knee, and a thousand other extravagances, such only as a diseased imagination could suggest. In these cases, the movements are voluntary and therefore quite different from those of chorea. They are the result'of a species of insanity, controlling the will, or possibly some- times a mere derangement of the will, without involving the general emo- tional or intellectual functions, a kind of monomania of the motor faculty of the brain.* * Vn affection has recently been described, with the designation of electrical chorea, by an Italian physician named Dubini, which, however, appears to me to have a closer 802 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. Anatomical Characters.—The evidences which anatomy affords of the nature of chorea are entirely negative. In uncomplicated cases, in which death has occurred either from the disease, or from some accidental cause, the brain and spinal marrow have, in many instances, after a most careful scrutiny by the most skilful pathological anatomists, been pronounced quite healthy. It is true that others have observed various lesions, such as serous effusions into the meningeal cavity of the spinal marrow, injection of the spinal marrow itself, injection, softening, &c, of the brain and its membranes, serum in the ventricles, and tumours and calculous concretions in the enceph- alon. But these were obvious complications, the results of diseases alto- gether independent of the chorea in their origin. Causes.—An unsteady, excitable state of the nervous system constitutes a predisposition to chorea. Such a state is apt to attend a feeble condition of the general health; and hence the disease has been frequently observed in individuals with disordered digestion, and defective nutrition; but this is by no means universally the case, and, in many instances, it has come on in persons previously healthy and robust. A predisposition to chorea is said to be often inherited. Age has great influence over the occurrence of the disease. It very seldom attacks either young infants or old persons, and is beyond all com- parison most frequent between the ages of six or seven and fifteen, that is between the second dentition and the period of puberty. Since my con- nection with the Pennsylvania Hospital, I recollect only three instances in which the disease has existed in adults. Two of these were females between twenty and thirty years old, in whom the complaint was complicated with hysterical or epileptic convulsions, and the other a man of about forty-five or fifty, in whom it had long existed. Nevertheless, no time of life is abso- lutely exempt; and cases now and then occur both in infancy and old age. A case is on record in which the patient was eighty-three. It would appear that the modifications produced in the nervous system by the irritation of the second dentition, and the changes connected with the development of the sexual functions, are favourable to the attacks of chorea. relation to epilepsy than to the disease under consideration. It consists in rapid and almost constant movements of certain muscles, resembling those produced by electri- cal shocks, with violent convulsive paroxysms in the same muscles, recurring twice or oftener in the day, attended by a rapid pulse, and followed by profuse sweating, and a more or less complete temporary paralysis of the part affected. At first the disease is confined to a limited space, as to a finger, an extremity, or one side of the face ; but gradually it extends to the whole of one side of the body. The same iden- tical muscles are always the seat of the convulsive movements, which are generally also limited to one side of the body, and that the right side. As the disease advances, the convulsions become more incessant, and sometimes invade the other half of the body. The least touch will occasionally bring on the most violent clonic spasms of the whole of the side affected. Articulation is difficult during the paroxysms. Towards the close of the disease, the convulsions give way to coma, and the patient at length dies with apoplectic symptoms. Sometimes pain in the head or spine precedes the at- tack. The intellect does not appear to be disordered until the supervention of the comatose phenomena. The appetite is at first good, but ultimately fails. Most of the patients void worms. The duration of the complaint is from one to five months or more. It is almost always fatal. Dissection has failed to reveal its nature. Venous congestion of the cerebral and spinal meninges is the only uniform abnormal condition observed. The persons attacked are usually between the ages of seven and twenty-one. In the ma- jority of cases the disease could be traced to fright, but in some no cause could be discovered. Various treatment has been tried, but none for which decided efficiency could be claimed. The best palliative appeared to be extract of hyoscyamus. (Med. Chirurg. Rev., October, 1846 ; from Annal. Universal, vol. 117.)—Note to the second edition. CLASS III.] CHOREA. 803 Sex also has a powerful influence. Females are much more liable to the disease than males. From a comparison of numerous statistical reports on this point, it results that the proportion of females is between two-thirds and three-quarters of the whole number. M. Rufz has inferred from his inquiries that the disease is little known in hot climates, and consequently that the rigorous or changeable weather of northern latitudes predisposes to it; yet it is said to occur more frequently in the hot than the cold seasons of the year. Whatever tends to debilitate the system generally, and to impoverish the blood, may be considered, in connection with age and sex, as predisposing to chorea, through the frequent disturbance which such a state of system occasions in the nervous centres. The exciting causes are strong and disturbing emotions, especially ter- ror ; excessive excitement of all kinds, whether mental or bodily, and the consequent over-exertion of the faculties; various extra cranial irritations, as those of dentition, decayed teeth, disordered stomach and bowels, hepatic derangement, worms, uterine disease, spinal tenderness, &c. ; suppression of the menses, repelled cutaneous eruptions, and translated rheumatism; depraved habits of life, and especially masturbation ; and finally, various organic affections of the brain and spinal marrow, which sometimes com- bine the symptoms of chorea with others more characteristic, as epilepsy, fatuity, and paralysis. It is said that females, affected with chorea at the approach of puberty, are almost always relieved of it upon the establishment of the menstrual function, proving the great influence which disorders of that function may exercise in the production of the disease. Nature.—Of the nature of chorea we know little or nothing more than that it is a functional disease of the brain. That it is not organic is proved by the absence of the ordinary symptoms of such disease, and by the evi- dence of dissection. Some believe that it is essentially an affection of the spinal marrow ; and that the involuntary movements are owing to the reflex action of the nervous centres in that structure. But the following consider- ations are opposed to this view. The motions are unlike those believed to proceed directly from spinal irritation, as the spasms of tetanus, and those induced by nux vomica, and much more closely resemble the voluntary mo- tions, which are all of cerebral origin. The irregular movements of chorea can in some measure be restrained by the will, which would hardly be the case were they spinal. They cease generally during sleep, in this respect differing from the movements springing directly from the spinal marrow, which does not sleep. The headache which not unfrequently accompanies the complaint is further evidence of its cerebral locality. It is probably a perversion of that function of the brain through which the will acts ; render- ing it partially subservient to other powers than the legitimate one. An in- timate association between chorea and pericarditis or endocarditis has been noticed by some writers; and the complaint has been ascribed, by Dr. Begbie and others, to a rheumatic constitution of the blood. It is very possible that rheumatic irritation affecting the cerebral centres may occasionally be an ex- citing cause ; and acute rheumatism has undoubtedly been sometimes asso- ciated with chorea. The frequent existence, moreover, of cardiac murmurs has tended to give plausibility to the theory. But, though chorea frequently comes under my notice in hospital practice, I have never happened to meet with it connected with rheumatism, or with positive evidence of cardiac inflamma- tion The murmurs I believe to be generally dependent either on the ane- mic state of the blood, which is a frequent attendant, or on irregular con- traction of the columnar earner under disordered nervous influence. Diagnosis__This is seldom difficult. The absence of fever, coma, delirium, 804 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. and rigid spasm, together with the whimsical and often ludicrous character of the movements, and the partial control of the will are sufficient to distinguish chorea from all other diseases of the brain or spinal marrow. There are, however, cases in which this disease is in various degrees complicated with epilepsy, hysteria, and palsy; and it is not always easy to determine how much belongs to the one affection, and how much to the other. Prognosis.—Pure chorea is very rarely fatal. Nevertheless, instances have occurred in which the system has been worn out by its violent and incessant agitations, or in which some vital function has been interrupted sufficiently long to occasion death. In complicated cases, it is not the chorea, but the accompanying affection that is dangerous. The probability is, that the dis- ease would, in most instances, sooner or later end favourably without the in- terference of medicine. By proper treatment, timely employed, its course is undoubtedly much shortened, its inconveniences greatly diminished, and what little danger may belong to it generally obviated. Its duration, under treat- ment, varies from a few days to several months ; but on the average may be stated at from two to six weeks. A few cases will not yield to remedies, and run on for years, or indefinitely ; and this is more especially apt to happen with those in which the long continuance of the disease has added the force of habit to the other causes. In the course of my practice I have met with only one instance of pure chorea which resisted treatment. This was the case already alluded to, of a man of middle age who entered the Pennsylva- nia Hospital with the disease already inveterate, and who left the institution, after a residence of several months, uncured. What a longer continuance of treatment might have effected cannot be determined. It is said that the local affections, before described as being usually classed with chorea, are much more obstinate than the general, and are often quite incurable. Re- lapses in this disease are not uncommon. Treatment.—The indications are first, to remove all obvious disease which may exist independently of the involuntary movements, and secondly, to give vigour to the nervous system, and equalize its actions. 1. Constipation should be promptly corrected by cathartics. It is highly probable that purgation is useful, not only by removing a source of irritation from the bowels, but also by acting revulsively from the brain, and by deple- tion in plethoric cases. Repeated daily, or every second or third day, as the strength will permit, cathartics will often of themselves cure the complaint in the course of a few weeks. Some discrimination should be exercised in the choice of the medicine. Should the system be plethoric, sulphate of mag- nesia, or one of the saline cathartics, senna and salts, or jalap and bitartrate of potassa, would best answer the purpose. Acid in the stomach would in- dicate magnesia ; debility of digestion with dyspeptic symptoms, rhubarb; amenorrhoea, aloes or black hellebore ; deficient or disordered hepatic action, calomel or the blue mass. The coexistence of several indications 'should lead to accordant medicinal combinations. Care should always be taken not materially to debilitate the patient, or irritate the stomach. In cases attended with headache, advantage will often accrue from local bleeding, which would be especially called for by the existence of a flushed face, and a full strong pulse, indicating active congestion of the brain. There may even be instances in which it would be proper and requisite to take blood from the arm. But these are rare. I have never seen a case of un- complicated chorea in which it appeared to me that general bleeding was indicated. If abused, it may do harm by inducing anaemia, which, as before explained, would probably aggravate the cerebral symptoms. Spinal tenderness would require cups or leeches to the tender spot, fol- lowed by repeated blisters, or antimonial pustulation. Amenorrhoea, if ex- CLASS III.] CHOREA. 805 isting, should be treated by appropriate measures. (See Amenorrhoea.) Chlorosis or anaemia would demand the chalybeates. For worms in the bowels, anthelmintics should be added to the cathartic medicine; and oil of turpentine, or oil of chenopodium would be especially applicable. 2. Measures for fulfilling the second indication should in general be em- ployed conjointly with those which may be deemed necessary, in accordance with the first. The only exception to this rule, are those rare cases in which there may be plethora and cerebral congestion. _ In these it is proper to postpone the measures referred to, until by purging, leeching, low diet, &c, the excitement shall have been sufficiently subdued. To give strength and equability to the nervous actions, tonics and anti- spasmodics or nervous stimulants are required. Of the former class, though sulphate of quinia is sometimes very efficient, the mineral tonics are gene- rally preferred. The preparations of iron and of zinc are, on the whole, the best and safest. Of the former, subcarbonate of iron may be given in the dose of a scruple or half a drachm twice or three times daily, with a little ginger to qualify its effects on the stomach; but any one of the officinal pre- parations may be selected; and ferrocyanuret of iron, or Prussian blue, has been specially recommended. Of the preparations of zinc, the sulphate has probably been most used, and is often very efficient. It is the tonic which I most frequently employ in chorea. It should be given in quantities as large as can be borne without irritating the stomach. Two grains, given at first three times a day, may be gradually increased to six or eight grains. The oxide and valerianate of zinc have also been used; but they have no decided advantage over the sulphate, and the oxide is less certain. Besides the me- tallic tonics mentioned, sulphate of copper, ammoniated copper, nitrate, oxide, chloride, and iodide of silver, and subnitrate of bismuth have been used; but they have no superiority over those first mentioned, while most of them are liable to act more harshly upon the stomach. Iodide of zinc is preferably employed by Dr. Barlow, of London, in cases complicated with struma. (Lond. Med. Times and Gaz., Aug. 1857, p. 195.) With the tonic which may be selected, it will be proper to combine the use of one of the nervous stimulants. Yalerian has enjoyed much reputation in chorea, and will often act advantageously. Assafetida is highly beneficial in many instances, especially when the disease is associated with hysteria. ^ Cam- phor and musk have also been recommended. But the remedy of this class which I prefer in chorea, is our indigenous cimicifuga or black snakeroot. This was introduced into use by Dr. Jesse Young, and is much employed. I have, in repeated instances, found it of itself adequate to the cure of the dis- ease.' From half a drachm to a drachm of the powder, from one to two fluidounces of the officinal decoction, or one or two fluidrachms of a saturated tincture should be given three or four times a day, and continued for several weeks • the dose being gradually increased until it produces some sensible effect as nausea, headache, vertigo, or disordered vision. It is important that 'the root should be of good quality, which is to be judged of by its properties of smell and taste. The fresher it can be obtained the better. In addition to these measures, the cold or shower bath will sometimes pro- duce the happiest effects ; and sea bathing is a highly valuable remedy. The cold bath should be employed only when followed by reaction. In Russia, the practice has been adopted of first placing the patient for half an hour in a bath as hot as he can bear it, and then, after he has been thrown into pro- fuse perspiration, of plunging him suddenly into cold water. The sulphur bath has been used with great asserted advantage in France. In obstinate cases it should be tried. Fresh pure air, and moderate exercise are very useful especially towards completing a cure. All these advantages, as well 806 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. as that of pleasing occupation of the attention, may be gained by a visit during summer to the sea shore, or some one of the sulphur springs; and this measure should be resorted to after others have failed, or to confirm con- valescence in those whose general health may be delicate, and constitutional tendency to the disease strong. To maintain the mind in a cheerful state, and the temper free from excitement, are points of some importance in the treatment of chorea. In relation to the diet, the only general rule is that it should be accommodated to the state of the system. If this be full and ex- cited, a vegetable or milk diet would be advisable; but in general the pa- tient may be permitted to use ordinary food, taking care to avoid indigestible and acescent substances. The habitual use of tea and coffee should be abandoned ; and temperance in all things observed. Besides the above remedies, many others have been employed in chorea, and most of them with more or less apparent benefit. The narcotics have been recommended; and belladonna, stramonium, hyoscyamus, and hydrocyanic acid have been chiefly employed. Friction with chloroform has been resorted to ; and, in some very severe cases, relief has been afforded by the same remedy inhaled. Opium also has had its ad- vocates. These medicines may be occasionally added with advantage to those above mentioned, when particularly called for by neuralgic pains or wakefulness. Opium is frequently useful in counteracting the effect of the irritant metallic tonics upon the stomach and bowels. Dr. Storer, of Boston, employed tincture of hemp (cannabis Indica) successfully, after failing with .carbonate of iron. (Boston Med. and S. Journ., liii. 209.) Emetics occasionally repeated, tartar emetic in large doses upon the contra- stimulant plan, Fowler's solution or other preparation of arsenic, the prepa- rations of iodine, oil of turpentine, chenopodium ambrosioides, cardamine pratensis, artemisia vulgaris, orange leaves, strychnia, gymnastic exercises in connection with the sulphur bath, electricity or galvanism, and antimonial pustulation over the shaved scalp, are remedies in favour of which respecta- ble authority might be cited. They may be tried when other methods have proved abortive. Dr. Jackson, of Boston, considers oil of turpentine as the most effectual remedy. Mr. Monahan, of Dublin, has cured a case by the application of splints. (Dub. Hosp. Gaz., Feb. 15, 1857, p. 55.) Dr. Bardsley, of Manchester, England, tried a great number of distinct remedies, and different plans, in the treatment of chorea, and earhe at last to the conclusion, that purgatives followed by antispasmodics were the most effectual. He gave purgatives until the discharges became healthy, and then administered musk and camphor, in the dose of four grains of each every four or five hours, with an enema of assafetida or a little laudanum at bedtime. SUBSECTION II. DISEASES OF THE SPINAL MARROW. A strong analogy exists between the spinal marrow and the brain, in their pathological relations. There is in both the same liability to inflam- mation of the membranes and the nervous matter, to derangement from non- inflammatory organic affections including hemorrhagic and serous effusion, and to various functional disorder; and these different affections in the one are not unfrequently merely extensions of the same affections in the other. Like the brain, too, the spinal marrow contains at once nervous centres and conducting filaments, and may suffer disease in these constituents separately or conjointly. CLASS III.] INFLAMMATION OF THE SPINAL MARROW. 807 It is a fact which must always be borne in mind, in estimating the diseases of the cord, that it has a double office; first, that of receiving impressions from other parts of the body and of transmitting influence to those parts, which it may do independently of the brain; and secondly, that of convey- ing influence to and from the brain. By the former office it regulates, con- jointly with the ganglia, most of the organic functions so far as nervous in- fluence is concerned; by the latter, it is necessary to sensation and voluntary motion over the greater portion of the body. Two sets of phenomena, there- fore, are consequent upon disease of the cord. In the first place, we have as the result of a perversion of its direct original action, symptoms of dis- order in the digestive, respiratory, circulatory, nutritive, secretory, and re- productive functions, all of which are more or less under the control of the spinal centres; and, in the second place, those indicative of interrupted or deranged cerebral influence, such as perverted, deficient, or abolished sensa- tion, and in various degrees the loss of the power of voluntary motion. In- voluntary or spasmodic muscular contractions may arise either from disorder of the reflex spinal function seated in the centres, or from disease of the conducting filaments. As different parts of the spinal marrow preside over different functions, and the nerves which convey influence to and from the brain leave the cord in different parts of its course, it follows that the morbid phenomena must vary with the portion of the cord affected. So far as the several spinal cen- tres are concerned, the expression of their disease will be confined chiefly to the organ or function over which they preside; but it is obvious that, in re- lation to cerebral influence, if interrupted by disease of the conducting por- tion of the spinal marrow, it must be so for all parts supplied with nerves below the seat of disease, while those above may be unaffected. Thus, disease of the cervical portion of the cord will affect speech, deglutition, respiration, and all the organic functions in the neck and upper extremities; while sen- sation and voluntary motion may be deranged in all parts of the body sup- plied with spinal nerves. Disease in the upper dorsal portion affects espe- cially the digestive function, more or less also respiration and circulation; while paralytic symptoms are confined to the trunk and lower extremities. The lower dorsal .and lumbar portion may involve in their disorder the bowels, and the urinary and genital apparatus, and produce palsy in the lower extremities, without affecting the chest and arms. In the following articles, the diseases of the spinal marrow are treated of under the several heads of 1. inflammation, 2. organic affections not neces- sarily inflammatory, and 3. functional disorder. Article I. INFLAMMATION OF THE SPINAL MARROW AND ITS MEMBRANES. There is in the spinal marrow the same difficulty as in the brain in dis- tinguishing between inflammation of the membranes and that of the nervous matter The fact is, that they are generally in a greater or less degree asso- ciated * and probably almost always so, when they occupy any considerable portion of the cord. Nevertheless, they appear sometimes to be distinct; and even when connected, often exhibit phenomena which indicate that one of these structures is more prominently affected than the other. It is not im- proper therefore, to treat of them distinctly; and I shall do so, under the 808 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. names of spinal meningitis and myelitis; though it is important that the reader should be aware that, in neither case, is the name exclusive; the former terra admitting the idea of attendant inflammation of the nervous matter, and the latter, that of the meninges. 1. Spinal Meningitis.—This is inflammation of the membranes of the spinal marrow, with or without inflammation of the medullary substance. The membranes are primarily and chiefly affected; and it is probable that the grade of action in the medullary matter often scarcely exceeds the point of high vascular irritation ; at least not to any considerable depth. The student will recollect that the membranes of the spinal cord are the same as those of the brain, with which they are continuous ; the pia mater immediately enveloping the proper cord, the dura mater lining the bony canal, and the arachnoid lying between them, and giving a coating to both. The arachnoid cavity of the spine is continuous with that of the brain. Of the membranes, the dura mater is sometimes chiefly affected, but very seldom exclusively. The arachnoid, from its want of vascularity, scarcely appears to suffer. The pia mater is almost always the prominent seat of the inflammation. It is chiefly through irritation of the nervous matter, either of the cord, or of the nerves passing out from it, that the disease makes itself known; almost all its peculiar symptoms being such as result from disturbance of the spinal functions. Spinal meningitis may be acute or chronic, and may exist separately, or in connection with cerebral meningitis. In its highly acute forms it is very often thus complicated. It will be most conveniently considered, in relation to the symptoms, in the three divisions of the acute, cerebro-spinal, and chronic. Acute Spinal Meningitis.—This is sometimes preceded by soreness or dull pains in the back, and feelings of heaviness or other uneasiness in the ex- tremities ; but not unfrequently it begins abruptly with severe pain in the spine, either confined to one part of the column, or beginning in one part, and extending through a greater or less portion of its length. The cervical portion is said to be attacked more frequently than the dorsal or lumbar. The pain is much increased by motion; and is very often attended with a feeling of constriction around the body, either in the chest or abdomen, ac- cording to the precise seat of the inflammation. This, indeed, is one of the most striking characteristics of spinal inflammation of whatever kind. Nor is the pain confined to the seat of the disease, or its immediate vicinity. In all parts of the body supplied with nerves from the affected part of the spine, there are uneasy sensations of various kinds, sometimes acute neuralgic pains, but more frequently tingling, formication, or numbness, especially in the extremities. Another very frequent and characteristic phenomenon is spasmodic rigidity of the muscles, more particularly of those lying along the spine. The head is drawn firmly backward, and long kept in that position; and sometimes the whole trunk is stiffly bent in the same direction, constituting complete opis- thotonos. Spasmodic closure of the jaws, and cramps of the extremities are not uncommon. Clonic spasms are also experienced amounting in some cases almost to convulsions, in others, only to twitching of the tendons. General convulsions are rare unless the brain is involved. The limbs are enfeebled; but the power of voluntary motion is seldom entirely lost, at least in the earlier stages. The attack is accompanied with febrile symptoms. The pulse is hard and frequent, though sometimes small; the impulse of the heart is strong; the skin is hot and often perspiring, sometimes profusely so; the respiration is laborious, hurried or slow, and almost always restricted; anorexia and con- CLASS III.] SPINAL MENINGITIS.—CEREBRO-SPINAL MENINGITIS. 809 stipation are ordinary symptoms; and retention of urine is very apt to occur requiring the use of the catheter. The symptoms occasionally remit considerably, as in cerebral meningitis, and are said even to intermit, but afterwards to return with increased vio- lence. At length, if relief is not obtained, the pulse becomes irregular, small, and feeble; symptoms of drowsiness, perhaps of delirium, occur, ending finally in coma; sometimes paralysis of the extremities may be observed ; in- voluntary evacuations take place from the rectum and bladder; and the patient dies, at a period varying from four or five days to two weeks from the commencement of the attack. When the spinal canal is opened after death, the cord usually appears swollen; but this is owing to thickening or effusion in the membranes; and not to increased bulk of the medulla itself, which may even be compressed. The dura mater is deeper coloured than usual in health; the arachnoid ex- hibits little change, unless that it may be more or less opaque ; the pia mater is reddened, injected, and swollen ; and these phenomena are observed more especially on the posterior face of the cord. A turbid serum is often seen, especially in the lower part of the spinal canal, where it is carried by gravi- tation. Coagulable lymph and pus are found between the arachnoid and pia mater, spread over the surface of the membranes. The medullary sub- stance may be somewhat injected, but is rarely softened, unless in the cases attended with paralysis. Cerebro-spinal Meningitis.—This form of the disease most commonly oc- curs epidemically, and has been observed, under such circumstances, to attack more especially young persons and males. Thus, in France it has prevailed among the young recruits, and in Ireland has been described as occurring almost exclusively in boys under twelve years of age. Commencing in 1837 in the south of France, it gradually extended over most of that country, at- tacking preferably the garrisoned towns. An epidemic of it in Ireland was described by Drs. Darby and Mayne, in the Dublin Journal.* A similar epidemic has prevailed of late years in limited districts in our South-western, and in the New England States, f In the severest cases, the attack is ushered in with a chill, during which the patient complains of acute abdominal pains, is not unfrequently affected with vomiting and purging, and sometimes sinks into a state resembling the collapse of cholera. After a time reaction takes place, and the characteristic phenomena of the disease are developed. In milder cases, the earlier symp- toms are general uneasiness, a feeling of fatigue, headache, pain in the neck, back, or along the whole length of the spine, a feeling of prickling and pain in the limbs, stiffness of the jaws, some difficulty in swallowing, perhaps also difficult micturition, and constipation. When the disease is completely formed, there are violent headache, increased sensitiveness to light and sound, delirium, convulsions; and, along with these cerebral symptoms, others indicating the spinal disease, such as already described under simple spinal meningitis, among the most striking of which are the rigid spasms or cramps, drawing the head stiffly backward, and sometimes rendering the whole body almost as rigid as a board. The countenance is said in some cases to assume the peculiar tetanic expression. High febrile excitement occurs, with a hot skin, very frequent pulse, insatiable thirst, vomiting, and epigastric tender- ness! Not unfrequently typhoid phenomena manifest themselves, as a dry * See Ranking'* Abstract, vol. ii. No. 1, p. 151, and No. 2 p. 191. t See papers by Dr. Hicks, of Vicksburg, Mississippi, and Dr. Taylor, of Whiteville, Tennessee in the N. 0. Med. and Surg. Journ., iv. -49; an elaborate paper by Dr. Ames, of Montgomery, Alabama, Ibid., v. 2U5; and a paper by Dr. A. Stone, in the Boston Med. and Surg. Journ., xl. 201. VOL. II. 0J 810 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. tongue with sordes, feeble pulse, prostration of strength, petechia?, &c. Should a favourable change not take place, comatose and paralytic symptoms make their appearance; and death soon follows, The disease sometimes completes its course in less than forty-eight hours ; but more frequently ter- minates about the fifth day; and sometimes runs on for two or three weeks. The mean duration of fatal cases is stated at about ten days. The appearances after death are those already detailed under cerebral and spinal meningitis. There is said, in some cases, to be an extraordi- nary absence of cerebral lesion; no induration, softening, or unusual vas- cularity being observed ; and instances occur in which both the brain and spinal cord are free from signs of inflammation. (Arch. Gen., Ae ser., xix. 391.) In general, the most striking appearance is that of an effusion of yellowish or greenish lymph between the arachnoid and pia mater, rather scanty on the hemispheres, more abundant at the base of the brain, and, in the spinal column, investing the cord completely, sometimes extending to the extremity of the caudex equina, and giving a coat to each of the spinal nerves. None of this secretion is ordinarily found in the cavity of the arachnoid, whether cranial or spinal. Sometimes the serous mem- branes generally, including also the synovial, show purulent manifestations. M. Boudin has identified this disease, as it has appeared in France, with typhus fever, from the more ordinary forms of which it differs simply in the seat of the local lesion. He believes it to be contagious, and thus accounts for its tendency to attack crowded populations, as military depots and gar- risons. Another strong argument in favor of this view of its nature is the powerlessness of purely antiphlogistic measures in its cure, while it yields not unfrequently to an opposite treatment. (Arch. Gen., ie ser., xix. 392.) Large doses of opium have proved very useful. The disease, as it has oc- curred epidemically in the United States, is probably of the same character. This is a point of great importance in relation to the treatment. If pure cerebro-spinal meningitis, it must be encountered by the energetic employ- ment of antiphlogistic measures; if a malignant febrile disease, simply at- tended with the cerebro-spinal inflammation, it is to be treated on other principles altogether. I have little doubt that, wherever it occurs as an epidemic, presenting the grave characters above described, it is in fact a form of malignant fever, belonging to the group of typhous diseases, and bearing a close analogy in general character to the typhous epidemic which prevailed in the United States in 1812 and for several years afterward, and to the malignant affection which has of late visited isolated tracts of our country, under the name of black tongue or malignant erysipelas.* Chronic Spinal Meningitis.—This is much less frequent than the acute, unless as a consequence of organic disease of the cord, or the vertebrae. It comes on with dull pains in some portion of the spinal column, with de- ranged sensations in the extremities, such as formication, tingling, &c, and disorder in the functions of the thoracic, abdominal, or pelvic viscera. The characteristic rigid or tonic spasms take place after a time ; the limbs become contracted, the head is sometimes drawn to one side, or perma- nently backward, and even the trunk distorted. The patient often suffers much from acute pains in the limbs, abdomen, &c. An acute attack some- times supervenes, and proves speedily fatal; or death takes place from the * In a communication to the N. Orleans dfedical and Surgical Journal (ix. 184), Dr. R. F. Taylor states that he has found the ordinary antiphlogistic remedies almost use- less, but has obtained great advantage from a combination of sulphate of quinia and opium, given freely until they produced a decided impression on the system, and then followed by twenty grains of calomel, combined with compound extract of colocynth, so as to produce full and free purgation. (Note to the fourth edition.) CLASS III.] MYELITIS. 811 consequences of paralysis, exhaustion, or a gradual failure of the vital func- tions, after many months or years of suffering. There is reason, however, to believe, that recovery often takes place under judicious treatment. 2. Myelitis (from ixueXoq, marrow) is here employed to signify inflam- mation of the substance of the cord. Like spinal meningitis, it may be acute or chronic. In very acute cases, there is much spinal pain, which is greatly increased by motion and pressure, and convulsions sometimes attend the early stage. Pains too are experienced in various parts of the body, supplied with nerves from the affected portion of the cord. Formication' tingling, numbness, and a feeling of coldness in the limbs are ordinary sensations. These may occur in a single limb, in both of the lower ex- tremities, or in one-half of the body. Along with deranged sensation there is also diminished power of the muscles, which is at first indicated by un- certainty of movement, and ends, if the case advance, in complete paralysis. Upon the occurrence of this affection, the pains generally cease. Some- times the paralysis begins at the remotest part of the extremities, and gradually ascends, until it involves the vital organs. Not unfrequently in- voluntary contractions of the muscles, either rigid or clonic, accompany this loss of voluntary motion. Sensation may continue, or be abolished. The continuance of sensation, when motion is lost, is explained by the dif- ferent origin of the nerves .of these functions. When there is paralysis of motion alone, the anterior nerves only are affected; when both functions are paralyzed, the disease has seized upon both sets of nerves. It was supposed that disease of the anterior and posterior spinal columns might have differences of effect, corresponding with the nerves proceeding respectively from them ; and a case of paralysis, as detailed from Abercrom- bie, in which the sensibility of the limbs continued unimpaired, and after death the anterior fasciculi of the dorsal portion of the cord were found diffluent, while the posterior retained their consistence, gave some counte- nance to the supposition. But another case has been recorded by Mr. Stan- ley, in which a precisely similar condition of the limbs, during life, was found, after death, to be accompanied with softening of the posterior column exclusively. (Watson's Lectures, 2d Am. ed., p. 296.) This apparent anomaly may be explained, upon the supposition that the conducting fibres cross each other before leaving the spinal column. The paralysis extends to the bowels,.producing obstinate constipation, and to the bladder, causing retention of urine ; but ultimately, the sphinc- ters becoming involved, these conditions are followed by incontinence. At the same time that the muscles thus lose their power, the organic func- tions are deranged. The stomach, the liver, the kidneys, the genital organs, are liable to various disorder. Palpitations, dyspneea, and hiccough are not unfrequent attendants on the disease. Febrile symptoms are not usually developed in any considerable degree. The pulse is seldom much accelerated, and is often slower than in health. The respiration is also slow and confined. Death sometimes takes place very speedily, even during the first or second day. The cause may be readily understood, when the affection occupies the cord above the point at which the respiratory nerves pass off. Respiration must cease if the spinal marrow above this point become incapable of con- veying influence from the respiratory centre. In the lower part of the spine, an equal amount of disease would be longer in producing death, because the functions immediately essential to life are not interrupted AVhen the case is at all protracted, eschars are apt to form upon the back and hips in consequence of pressure ; and the fatal issue is hastened by the exhausting discharges which take place. There is no fixed period for the 812 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. fatal termination of the disease. Though, as already stated, it may, in the acute form, end in less than forty-eight hours; yet, much more frequently, it runs on for a week or ten days, or longer; and its term may vary, according to its degree of acuteness or chronicity, from the period mentioned, to weeks months, or years. The chronic form of the disease, which is more frequent than the acute, commences almost insensibly, with a little uneasiness in the spine, slightly disordered sensations in the extremities, and unusual fatigue after exertion; but little apprehension is felt, until, at length, paralytic symptoms begin to be experienced. These slowly increase. The patient may be affected with tremors, which are sometimes almost constant. The gait becomes uncertain, vacillating, tottering. The limbs no longer support the body. The paralysis encroaches upon the trunk, affects the urinary organs, and ascends at last to the chest. Involuntary startings of the muscles, and sometimes rigid con- tractions mingle with the advancing paralysis. Sloughs and ulcers, with exhausting discharges, form upon the sacrum, hips, &c, and the patient loses all power over his evacuations. The pulse is usually slow and feeble, the surface pale, and the limbs frequently edematous. Death takes place as the result of exhaustion, and sometimes of asphyxia, the paralysis rising gradu- ally, until it involves the chest. The chief anatomical character of myelitis is softening of the medulla. This exists in various degrees, from a slight diminution of consistence to complete diffluence. Sometimes the colour of the softened part has some shade of red, but more frequently it is yellowish, or of the natural whiteness. The softness may occupy a portion only of the diameter of the cord, passing upward and downward in the direction of the column, or may involve its whole thickness. Doubts have been entertained whether the yellow and white softenings are really the result of inflammation. They are attended with the same symptoms during life. Signs of meningitis are often observed in con- nection with the myelitis, but not always. Diagnosis.—It has been suggested that meningeal inflammation might be recognized by the existence of tonic spasms or rigidity; but these happen also in pure myelitis, though less frequent or striking. Paralysis may gene- rally be considered as an evidence of the latter complaint, when attended with other marks of inflammation in the spinal column. It is, however, of little consequence to distinguish the two. affections, as their treatment is essentially the same. It is more important not to mistake spinal inflammation, whether meningeal or medullary, for rheumatism of the spinal ligaments, or of the neighbouring muscles. Cases of the former diseases have often been fatally neglected, under the impression that they belonged to the latter. It is only in the early stages that there can be any danger of such a mistake. The oc- currence of tonic spasms, or of paralytic symptoms, would sufficiently distin- guish the spinal inflammation. When these are absent, a just inference can sometimes be drawn from pressure, which, in spinal inflammation, will occa- sion most uneasiness when made upon the spinous processes, in muscular rheumatism, when made alongside of the spine. In this variety of rheumatism, moreover, the pain on motion is generally very obviously dependent on the contraction of the muscles. In cases of rheumatism affecting the ligamen- tous_ structure, these latter symptoms could not be depended on as diag- nostic. In such cases, however, the constitutional symptoms would be less severe than in inflammation of the cord, the pain would be less, except on movement, and the previous or contemporaneous existence of rheumatism elsewhere^ would be almost decisive. There may be some danger of con- founding inflammation of the spinal marrow, or its membranes, with spinal irritation; but the reader is referred to the latter affection for the diagnostic symptoms. class m.] MYELITIS. 813 Causes.—Among the most common causes of spinal inflammation are falls, blows, great and frequent straining, and fatiguing muscular exertion of all kinds. Abuse of the venereal propensity is also said to produce it, especially that form of it attended with softening. Vicissitudes of weather, alcoholic drinks, and other ordinary sources of inflammation occasionally act as causes. It is probable that rheumatism, in its inflammatory form, some- times seizes on the cord, and especially on the membranes. Occasionally the disease appears to result from epidemic influence. Other diseases of the spine occasion it, such as caries, tubercles, &c. It is very apt to be propa- gated from inflammation of the corresponding tissue in the brain. Spinal softening has often been observed in the epileptic and insane. Prognosis.—The severe forms of spinal and cerebro-spinal inflammation are very dangerous, though not so necessarily fatal as some writers appear to believe. Cures of this, as of cerebral meningitis, may be effected in many cases by prompt and energetic treatment. In some instances, it is true, es- pecially in the epidemic form, the death-blow seems to be given at the very commencement. Very discouraging opinions are also given of the prognosis in myelitis. After it has advanced to confirmed paralysis, there may not be much to hope for; but I am convinced that, in its early stages, it is often set aside by judicious remedies. In no case should the practitioner despair, unless when the powers of life are obviously giving way, when the patient loses com- mand of the sphincters, and a tendency to sloughing is evinced. Treatment.—The treatment of spinal inflammation is to be conducted upon the same plan as that of inflammation elsewhere. In the acute affec- tion, bleeding as freely and as frequently as the pulse and general strength will permit; copious and repeated local depletion by cups and leeches along the spine, with emollient lukewarm cataplasms in the intervals; purging with calomel in the beginning, and subsequently with the saline cathartics, but never violently; and, lastly, should the disease not yield to depletion, blisters over the whole length of the inflamed portion, with the use of mer- cury in reference to its constitutional impression, constitute the sum of the treatment. Some recommend cold to the spine, as to the head in cerebral inflammation; but I should apprehend the production of other internal dis- eases from this remedy, applied to the naked surface of the body with such steadiness as to be at all efficient. Refrigerant diaphoretics and cooling drinks may be given during the existence of febrile symptoms. Perfect rest should be enjoined; and the patient should never be permitted to rise even for the purposes of a stool. The diet, of course, must be rigidly antiphlo- gistic. Care should be taken to prevent undue accumulation of urine, and for this purpose recourse should be had, if necessary, to the catheter. The chronic affection is to be treated upon the same principles precisely, but less energetically. Repeated leeching and cupping will here be prefer- able to general bleeding. A constant succession of blisters must be main- tained ; or their place supplied by issues, setons, copious antimonial pustula- tion, or moxa. Some writers strongly recommend the actual cautery. Much may be expected from a moderate and long-sustained mercurial impression; but it will be important so to manage the remedy as scarcely to produce any effect upon the mouth. One of the most important measures is absolute rest in bed For the treatment of any paralytic affection, which may remain after the subsidence of the inflammation, the reader is referred to paralysis. The disposition to slough should be guarded against, as far as possible, by means of alcoholic lotions, the lead plaster, hollow cushions, down pillows, and oc- casional change of position; and, when ulcers have formed, they should be dressed frequently and carefully, so as to preserve cleanliness; and fetor should be corrected by creasotic or chlorine washes. 814 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. In epidemic cerebro-spinal meningitis, reference must be had to the state of the system, which often requires tonic and stimulant measures, such as are adapted to typhus fever, while the inflammation is to be encountered by leeches or cups, followed by blisters to the back of the neck and along the spine. Copious depletion is out of the question in the malignant cases. Article II ORGANIC DISEASES OF THE SPINAL MARROW. Allusion is here had to affections not essentially inflammatory in their character. As they all produce certain common effects, they may be most conveniently considered under one head. These effects, so far as the symp- toms are concerned, resolve themselves into those of pressure upon the cord, and of irritation, inflammation, or disorganization of its substance. Symptoms.—Pain of various degree and character is felt in the spine ; moderate or severe, dull or acute, burning, gnawing, lancinating, heavy, pul- sative, &c. There are also morbid sensations of different kinds in those portions of the body supplied with nervous influence from the part affected. Feelings of tingling, pricking, or formication, of numbness and coldness, and frequently of acute pain, sometimes stationary, sometimes shooting along the course of the nerves, are experienced in the limbs and different parts of the trunk and neck. Uneasy sensations of almost infinite diversity are felt in the chest, abdomen, or pelvis, according to the situation of the spinal affection ; and among these sensations sharp or neuralgic pains are not unfrequent. A sense of stricture, as of a band about the body, is very common. Superadded to deranged sensation, there is a gradually increasing weak- ness of the muscles, which at length ends in palsy, sometimes both of sense and motion, sometimes of the latter exclusively; and the paralytic affection may be confined to one limb or on one side, may extend to several limbs, or may embrace almost the whole body. Paraplegia is among the most com- mon results. Constipation and retention of urine, or the contrary condition of incontinence, are apt to occur, consequent on paralysis of the rectum and bladder in the former case, and of the sphincters in the latter. The palsied limbs undergo atrophy, and often become the seat of serous effusion. Involuntary muscular contractions very often accompany the loss of vol- untary power, and either tetanic rigidity, or clonic spasms, are experienced in different parts of the body. The digestion, respiration, and circulation undergo various disorder. Vomiting, dyspneea, and palpitation are not un- frequent. When the disease is near the foramen magnum, deglutition is difficult, and respiration especially disturbed. The brain sometimes becomes involved directly or sympathetically; and headache, delirium, convulsions, strabismus, stupor, coma, &c, are added to the other symptoms. Finally, sloughs upon the surface result from pressure, and are followed by exhaust- ing ulcers. Death takes place either from pure exhaustion, or from inter- ruption of one of the vital functions. The disease may be a few months, or many years, in completing its course. Of the affections alluded to, most are inevitably fatal. But I rank under the same head, effusion into the spinal canal, when sufficient to give rise to the above phenomena, or most of them ; and this may end favourably. The following is a brief enumeration of the several affections. Hemorrhage.—Blood may be effused without the dura mater, in the cavity of the arachnoid, between that and the pia mater, or in the substance of the marrow. It is very generally consequent upon active congestion, and there- CLASS III.] ORGANIC DISEASE OF THE SPINAL MARROW. 815 fore often associated with signs of inflammation; nor are we in possession of any means of forming an accurate diagnosis. But, when the symptoms of compression of the spinal marrow come on suddenly, we may suspect the existence of hemorrhage. The first symptoms of spinal hemorrhage are said to be general chilliness, and pain along the spine at the seat of the effusion, increased by pressure on the spinous processes. These are soon followed by paralysis, affecting either one or both sides of the body, or especially the side corresponding with the hemorrhage. As the blood sometimes travels from one part to another, the symptoms may be expected to change their seat. When effused around the cord, it may produce only a moderate degree of numbness or muscular weakness; when into its substance, it generally gives rise to com- plete paralysis. Either death may ensue, or the blood may become encysted and absorbed, as in the brain. When there is reason to suspect the exist- ence of hemorrhage, the remedies indicated are perfect rest, cold applications to the spine when the symptoms are threatening, depletion as far as the state of the system may warrant, and, finally, should signs of inflammation pre- sent themselves, the various measures applicable to that affection. Serous Effusion.—Hydrorachis.—As the spinal arachnoid cavity, and the space, if we may call it such, between the pia mater and arachnoid, are continuous with those of the brain, liquid effused within the cranium often finds its way into the spinal canal, and produces the symptoms resulting from pressure upon the cord. This not unfrequently takes place in hydrocephalic patients; and when, as occasionally happens, there is imperfection in the bony parietes of the canal, as in spina bifida, a tumour, disappearing or diminishing upon pressure, is apt to show itself upon the spine. Serous effusion may also originate within the spinal cavity, either occupying the spaces before alluded to, infiltrating the substance of the marrow, hollowing out for itself cavities in that substance, or confined to the space without the dura mater. In the last case it is necessarily spinal in its origin, as the dura mater adheres to the bone at the foramen magnum, in such a manner as to cut off any communication with the cranium. But, except in the instance of spina bifida above mentioned, we have no means of deciding upon the nature of these cases. At best we can only conjecture that there is serous effusion in the spinal canal, when the symptoms of compression of the spinal marrow, palsy, namely, of sense and motion, in various degrees, accompany evidences of cerebral effusion. When the fluid travels readily, it is rational to suppose that the erect position, through the influence of gravitation, may cause it to accumulate in the lower part of the spinal column, and thus produce the symptoms more especially of compression of this part. When, therefore, we find numbness and debility of the lower extremities increased by the erect posture, we may infer that there is probably serum in the canal. For the treatment of spina bifida the reader is referred to works on surgery. In other cases of supposed serous effusion, the remedies must be addressed to the pathological condition in which it may be thought to originate. Hypertrophy and Atrophy.—These affections have been occasionally noticed upon dissection, without being traceable to any other pathological state. They are, however, merely matters of anatomical curiosity; for they cannot be known during life. .,,,,„ Non-inflammatory softening of the spinal cord undoubtedly occasionally exists arising from similar causes with the same affection of the brain, and like it attended with fatty degeneration. It may be suspected whenever fee- bleness and palsy, more or less extensive, of the extremities takes place, traceable pretty clearly to the spinal column, and not preceded or accompa- nied with other signs of inflammation, or with other organic affections. It must be treated by rest and supporting measures. 816 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. Aneurisms, Hydatids, Tubercles, and Carcinomatous Tumours occa- sionally form within the spinal canal, and give rise to the phenomena already detailed. Aneurisms and carcinoma sometimes also press on the spine from without, and, producing absorption of the bony matter, come into an irritat- ing or destructive contact with the cord, and occasion the most harassing symptoms. The diagnosis in all these cases is very uncertain, and especially so when the disease is within the spinal canal. Sometimes a probable con- clusion may be formed from the nature of some existing disease elsewhere. Thus, when the symptoms enumerated occur in an individual who presents obvious signs of tuberculous or cancerous affection, they may without any great violence be referred to the same origin. The prognosis is almost al- ways unfavourable. The treatment is wholly palliative. To enjoin rest, to adapt the diet to the state of the system and of the digestive organs, to keep the bowels regular, to draw off the urine when requisite, to guard as much as possible against eschars, and to relieve pain by the internal and local use of anodynes, is all that is left for the physician in most of these cases. Happily they are rare. Article III FUNCTIONAL DISEASE OF THE SPINAL MARROW. When it is considered that from the spinal centres probably flows an in- fluence, which is requisite to sustain the various organic functions in their healthy condition, it can be readily understood that a great diversity of de- rangement in these functions may result from deficient, excessive, or per- verted action in the centres, without the necessary existence of any organic disease. It is, indeed, highly probable that many disorders of the digestive, respiratory, and circulatory organs, many derangements of the secretory and nutritive processes, of which the causes are obscure, might be traced to the spinal marrow as their source, had we the means of investigating accurately the functional disorders of that structure. But, with our present knowledge, such a reference must be conjectural, except in those cases in which some direct evidence exists of spinal disturbance. Still, even a conjectural refer- ence may lead to useful results; and remedies may often be advantageously addressed to the spine, when no other proof of disorder in the cord is offered than morbid phenomena of the organs over which it presides. It is, indeed, a good practical rule, in all these cases of functional disease in any part of the body supplied with spinal nerves, of which the cause is obscure, to bear in mind their possible origin in the medulla spinalis, and to be prepared, should other measures fail, to have recourse to such as may be calculated to influence that portion of the system. But, while it is probable that much disorder may depend on the spinal marrow, which cannot be clearly traced to it, there are numerous instances in which that structure affords direct evidence of a diseased condition, and thus enables us to refer various morbid phenomena existing elsewhere, with great confidence, to their true origin. A vast addition to our means of suc- cessfully combating disease has been made by the comparatively recent opening of this new field in therapeutics. The evidence of functional spinal disorder above alluded to is that offered by tenderness upon pressure on the spinous processes, when there is no reason to suspect the existence of spinal menin- gitis or myelitis. This symptom has been so frequently found associated with various disorders in different parts of the system, which have yielded to remedies addressed to the seat of it, that it has come to be regarded as the GLASS III.] SPINAL IRRITATION. 817 characteristic sign of a peculiar affection, which for want of a better name is generally denominated spinal irritation. The remainder of this article will be devoted especially to the consideration of that affection. Spinal Irritation.—It will be understood that, in this particular ap- plication of it, the term spinal irritation is not intended to embrace every example of morbidly increased excitement of the medulla spinalis, or a part of it, but only those cases in which the particular phenomenon above alluded to is offered; that, namely, of tenderness upon pressure on one or more of the spinous processes of the vertebrae. Symptoms.—These are immensely diversified. They are, indeed, almost as numerous as the possible derangements of function in all parts of the body, supplied with nerves from the spinal marrow. The only symptom common to all the cases is the pathognomonic one above referred to. Upon making pressure on the spinous processes, beginning at the neck and pro- ceeding downward, we may find either a general tenderness along the whole or the greater portion of the column, or, what is much more common, the tenderness may be confined to one or a very few of the vertebras; and, not unfrequently, one is more acutely sensitive, while above and below it the tenderness gradually diminishes until it ceases to be evident. The dorsal vertebras are most frequently affected. There is not less difference in the degree of tenderness, than in its precise seat. In some instances it is slight, requiring rather heavy pressure to develope it; in others it is exquisitely keen, so that a touch produces uneasiness, and the slightest pressure occa- sions intolerable pain. I have repeatedly known patients to start as if struck with a pistol ball, or pierced with a knife, upon gentle pressure being made with the finger on one of the spinous processes; and, even in a state of ap- parent coma, with all other parts of the body insensible to painful impres- sions, the most marked evidence of suffering will be presented by the face of the patient, and the movements of the body, when the tender vertebra is touched. The pain is often described as shooting through the body ante- riorly, and is not unfrequently attended with sensations of nausea, or sicken- ing faintness. A remarkable circumstance is, that, in the greater number of cases, there is little or no pain in the affected portion of the spine except when pressure is made, so that the real seat of disease might escape notice, were not the attention of the physician directed towards it by symptoms existing elsewhere. I shall not pretend to enumerate all these symptoms; but shall content myself with calling attention to some of the more prominent. They vary with the portion of the spine affected; those parts especially showing signs of disorder, which receive nerves directly or indirectly from the vicinity of the tender vertebras. But it will be more convenient to consider them in re- lation to the functions than the particular structures. Beginning with the digestive function, we have difficult deglutition, stricture of the oesophagus, gastrodynia, spasm of the stomach, excessive thirst, morbid appetite or ano- rexia, nausea and vomiting, and various most distressing and indescribable sensations in the epigastrium, such as attend the worst cases of dyspepsia. Some of the most obstinate instances of vomiting that I have witnessed ap- peared to be dependent on this cause. In the bowels there are neuralgic and colicky pains, flatulence, and the most diversified uneasiness. The respiratory organs are also liable to be attacked. The voice is some- times altered • violent cough from laryngeal irritation is not uncommon, and alarming spasm of the glottis occasionally has a similar origin. The dys- pnoea which attends the disease is sometimes very distressing, scarcely falling short of a violent paroxysm of asthma. Dr. S. C. Thornton, of Moorestown, N J has described a curious case of spasmodic contractions of the diaphragm 818 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. from this cause, coming on paroxysmally every six or eight months, and con- tinuing for two or three weeks. The spasms occur at regular intervals of about ten seconds, and persist for the whole period mentioned, producing great jarring, soreness, and distress, and preventing sleep. (Med. and Surg. Reporter, xi. 98.^ Palpitations of the heart are very frequent, and other signs of functional cardiac disorder are occasionally offered, such as faintness or syncope, and pains resembling those of angina pectoris. Deranged hepatic secretion, uneasy sensations in the liver, various urinary disorder, tenesmus, and derangements of the sexual functions, especially amenorrhoea, are not uncommon. Neuralgic pains are experienced in the muscles of the chest, extremities, shoulders, neck, and occiput. Pains, too, resembling those of rheumatism, are felt in various parts of the body. Other kinds of uneasiness, such as ting- ling, formication, pricking, intense itching, burning, numbness, coldness, and diversified anomalous sensations, occur in the limbs and trunk. Cramps, con- vulsive movements, and paralytic symptoms in various parts of the body may be added to the list. I have repeatedly witnessed comatose symptoms appa- rently dependent on the same cause ; the irritation being in such cases pro- bably sympathetically conveyed to the brain. In short, there is scarcely a morbid sensation or perversion of function, occurring in any part of the body beneath the head, which may not originate in spinal irritation; and, whenever the cause of any existing disorder of this kind is obscure, it should be sought for in the spine. The affection often attends other diseases. It is very common in hysteria, so much so as to be almost characteristic of that complaint. It is also occa- sionally observed in chorea and epilepsy. There is reason to believe that cases resembling tetanus and hydrophobia, and which have been mistaken for these complaints, have depended upon this kind of spinal irritation. Causes.—These are not well understood. The disease occurs most fre- quently in women, and especially during the menstruating period, or between the ages of fourteen and forty-five. It would seem, therefore, to have some connection with the uterus ; but such a connection is certainly not essential, for the disease often occurs in children, and sometimes in men. Spinal dis- tortion seems also to constitute a predisposition. Of the exciting causes, the changes in the weather are probably among the most frequent. Mental disturbance appears to be capable of inducing it, and perhaps any other cause calculated strongly to impress the nervous system. Nature.—Some difference of opinion has existed on this point. While the affection is generally considered as residing in the spinal cord, some have been unable to conceive that the extreme tenderness evinced in many cases could depend upon the cord itself, enclosed as it is within a firm bony case, and not even in close contact with that. The most rational view of the affec- tion appears to be, that it is seated essentially in the ligaments of the ver- tabrse, and is generally of a rheumatic or gouty character. It is readily con- ceivable that irritation may be propagated from this structure to the nervous tissue of the cord, or at least to the nerves which proceed from the cord, and receive as they pass an envelope probably of the diseased tissue. The char- acter of the affection in the ligaments may be inferred to be that of subacute rheumatic inflammation, and not merely neuralgic, from the circumstance that it yields often with so much facility to local depletion. Diagnosis.—The affection which this most resembles is inflammation of the spinal cord. It is distinguished by the absence of fever, the greater ten- derness upon slight pressure, with the comparative want of pain under other circumstances, the ability to move with little or no uneasiness, and the more CLASS III.] TETANUS. 819 shifting character of the complaint. The facility with which it is generally relieved is another diagnostic sign. Prognosis.—This is almost always favourable, at least in relation to any one attack. But there is in some a strong tendency towards it, so that, though relieved for a time, it often recurs ; and this tendency may persist for many years. It disappears, however usually in advanced life. The disposition to frequent return is another point of resemblance with rheumatism. When the affection is neglected, it may, probably, sometimes occasion serious organic disease in the parts at first only functionally disturbed. Treatment.—This must be directed chiefly to the spinal affection. A few cups or leeches applied to the tender spot, or its immediate vicinity, will often afford complete relief. Should one application of the remedy not answer, it may be repeated again, and again. After sufficient depletion in this way, a blister may be created immediately over the tender vertebras, and renewed as it heals. Should the disease be obstinate, pustulation with croton oil or tar- tar emetic, may be resorted to. The latter is the most effectual. Advan- tage will sometimes accrue from morphia sprinkled upon the blistered sur- face. Sometimes the rubefacients will answer instead of blistering or pus- tulation. Mustard, or solution of ammonia, more or less diluted, should be preferred. Sometimes, when the tendency to the affection is strong, it is necessary to sustain the antimonial pustulation for several months before it can be eradi- cated. Issues may be preferred in some of these cases. The constitutional treatment must be accommodated to the circumstances of the case. The bowels should be kept regular, hepatic or urinary disorder should be corrected, the menses, if retained or suppressed, should be restored, and anasmia treated in the usual manner. The neuralgic pains occurring in different parts of the body sometimes require attention; and any existing rheumatic or gouty tendency should be obviated. To treat of the means requisite for these various ends would be merely to repeat what has been detailed elsewhere. It not unfrequently happens that spinal tenderness, in women, is associated with retroversion or other abnormal position of the uterus, and yields to measures calculated to obviate this condition of things. Article IV. TETANUS. Syn.—Locked Jaw. Tetanus (from rsiva), I stretch) is a disease in which the muscles are in a state of rigid lasting contraction, with paroxysms of brief and painful spasm, alternating with irregular intervals of more or less complete relaxation, with- out coma or any essential disturbance of the mental faculties. Different names have been conferred upon the tetanic condition, according to the obvious effects of the spasm. Thus, when it produces a closure of the jaws the affection has been denominated trismus; when a curvature of the body backward opisthotonos; when forward, emprosthotonos; when to one side, pleurosthotonos. These conditions are now treated as mere symptom- atic'diversities of the same disease ,.*!., Tetanus has been divided into the idiopathic and symptomatic; the for- mer independent of any other known pathological condition; the latter, produced by some other distinct affection existing within or without the spine. The symptomatic variety, when originating in wounds or other external in- 820 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. jury, is called traumatic tetanus. This latter name, as embracing cases of very frequent occurrence, of a certain identity of origin, and peculiar violence of character, is very convenient, and almost universally employed. As, in relation to the disease from other sources, there is always much uncertainty; some ascribing it to one pathological condition, others to another, and all acknowledging its obscurity; there is a propriety in adopting some desig- nation, which, whether in itself correct or incorrect, may be generally re- ceived and understood. Most writers include under the title of idiopathic tetanus all cases not traumatic, whether strictly independent, or symptomatic of some other affection; and their example is followed in this work. Still another distinction of tetanus is into the acute and chronic; but, though cases of the disease do differ greatly in their degree and duration, there is no such peculiarity of character attached to their diversity of grade and persistence, as to require a separate grouping; and the terms, if em- ployed at all, should be considered as mere epithets expressive of certain differences of quality in one common affection. Symptoms, Course, &c.—Various symptoms are enumerated by authors as occasionally preceding an attack of traumatic tetanus; such as depression of spirits, an unaccountable feeling of terror, general uneasiness or lassitude, twitching in the wounded limb, deep pains in the affected part sometimes extending towards the spine, a sense of chilliness, &c. ; but these symptoms are very uncertain, and cannot be relied on. The first signs of a commencing attack, are commonly feelings of uneasiness and stiffness in the back of the neck; an unusual rigidity about the jaws, with some pain in attempting to open the mouth widely; and occasionally a disagreeable sensation in the throat, and slight embarrassment in swallowing. There is also frequently uneasiness in the epigastrium, which soon amounts to acute pain, shooting from the pit of the stomach towards the spine, and attended with a sensation of stricture or dragging, dependent, no doubt, upon spasm of the diaphragm. Other muscles become quickly involved, especially those of the face and trunk; the disease then extends to the limbs; and ultimately almost all the voluntary muscles of the body are more or less affected. There is a permanent rigidity or tonic spasm of the muscles, which exists in various degrees throughout the complaint, seldom undergoing complete relaxation. Slight at the commencement, it increases with the advance of the disease, and, when this is fully formed, imparts a degree of hardness to the muscles, almost like that of a board. But, besides this state of permanent rigidity, there are paroxysms of spasm, approaching to the clonic character, which are much shorter, but proportionally more violent, and alternate with periods of comparative relaxation. These paroxysms are at first slight, and at somewhat distant intervals; but gradually increase in frequency and vio- lence, until at length they occur every ten or fifteen minutes, or even more frequently, so that the patient is scarcely out of one before he falls into another ; and their force is such that they sometimes throw the whole body about in different directions, and endanger injury from this cause. These spasms produce extreme pain, of which some idea may be formed, when it is considered that the same feeling that attends ordinary cramps in the extremities is, in these cases, experienced in many muscles at once. The rigidity or permanent contraction is less painful, and is sometimes productive of no other sensation than a disagreeable stiffness. It is asserted, on high authority, that even the spasmodic paroxysms are not always painful; and one instance is related in which the sensation was said to be rather pleasura- ble than otherwise. The violence of the spasm is occasionally such as to produce a rupture of some of the muscular fibres or of the whole muscle, to fracture the bones, and to dislocate the joints. But these effects are com- paratively rare. CLASS III.] TETANUS. 821 The slightest causes are often sufficient to induce a paroxysm, such as an attempt to speak, or to swallow, any sudden noise, a draught of cold air, &c. The effects of tetanus on particular parts and functions require notice. One of the most striking of these effects is the firm closure of the jaws, which has given rise to the name of locked jaw by which the disease is often designated. In some instances, this takes place suddenly, as if by a snap; but generally it is effected slowly; the first feeling being that of stiffness, which increases until the patient becomes wholly unable to open the mouth; and the violence of the contraction is said sometimes to be so great as even to break the teeth. The other muscles of the face are also affected. The angles of the mouth are drawn upward and outward, the alas of the nose are elevated and expanded, the brows are contracted, the forehead wrinkled, the orbicularis muscle of the eyelids rigid, the eyes themselves sometimes fixed and staring; and the wrhole face is much distorted, sometimes having an ex- pression of anxiety and distress, sometimes exhibiting that fearful mockery of a smile, denominated the risus sardonicus, and generally presenting an aspect which the experienced eye at once recognizes as tetanic. The effect of the distortion is said occasionally to give an appearance of great age to the features even of the young. The pupil is in some instances contracted, in others dilated, and in others again unchanged. The tongue is liable to be thrust between the teeth while the jaws are somewhat relaxed, and then to be fearfully wounded by their sudden closure. Hence bloody froth or saliva sometimes issues from the mouth. The trunk is often erect and rigid, as hard and firm almost as a wooden statue, in consequence of the equal contraction of the muscles. But occa- sionally the body is distorted by their partial action; those of one part contracting while the opposing muscles are relaxed, or act less forcibly. One of the most common distortions is that of opisthotonos, in which the whole body is bent backward into the form of an arch, so that only the occiput and the heels touch the bed. In this case the abdominal muscles are also in general rigid, but their strength is insufficient to counteract that of the more powerful muscles placed along the spine. The forward curvature, or emprosthotonos, in which the shoulders are drawn towards the hips ante- riorly, and the thighs flexed upon the pelvis, is comparatively very rare; and the lateral curvature is still more so; for, though it is no uncommon event for the muscles of one side to contract much more powerfully than those of the other; yet they very seldom act in such a manner as to bend the body laterally.' The muscles of the extremities, as a general rule, are later and less affected than those of the trunk; though it is said that, in some instances of traumatic tetanus, the spasms commence in the wounded limb, and are severer there than elsewhere. It is a singular fact, that the muscles which move the wrists and hands are generally under the control of the will, though the trunk and arms may be rigid with spasm. The muscles of the fauces, and those of the larynx, participate in some degree in the general tendency, giving rise to difficulty of deglutition, and occasionally to suffocative paroxysms, which are extremely distressing and dangerous It is undoubtedly to spasm of the diaphragm that the violent and dragging pains at the scrobiculus cordis, extending through to the back, are to be ascribed. These pains are among the most characteristic symptoms of tetanus being rarely quite wanting throughout the whole course of the disease They generally begin and increase with it; but sometimes do not come on till in the advanced stage, or near the close. When very severe, they are apt to be attended with some degree of opisthotonos. The sphincters of the anus and bladder are sometimes rigidly contracted, favouring constipation in the one case, and retention of urine in the other; 822 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. and it has been observed, under these circumstances, that there is sometimes considerable difficulty in introducing the injection pipe and the catheter. All the muscles, hitherto spoken of as liable to spasm, are in health either wholly or partially under the control of the will. Indeed, it is thought by some that the disease is confined to the voluntary muscles. They are cer- tainly first and most violently affected. Life could be sustained but for a short time, if the involuntary muscles were equally liable to the disease. But there is no proof that they do not sometimes in the end participate; and it is not improbable that sudden death in tetanus may occasionally be owing to the disease seizing upon the heart. An account of the state of the several functions will close this enumera- tion of the symptoms. Deglutition, as before observed, is often difficult. When the attempt is made, in this case, to swallow liquids, they are apt to be thrown back through the mouth and nostrils; or, by entering the glottis, give rise to the most distressing paroxysms of dyspnoea, threatening suffocation. Hence, tetanic patients have in some cases a dread of liquids which is almost hydro- phobic. Notwithstanding this difficulty of swrallowing, the patient gene- rally retains his appetite. The tongue is at first, in complicated cases, moist and natural; but is liable in the end to become dry or clammy, proba- bly in part owing to the deficiency of liquid in the blood-vessels. Constipa- tion of the bowels is an almost constant attendant on the disease. This has been ascribed to a spasmodic constriction of the intestinal muscles, to constriction of the sphincter ani, and to the deficiency of secretion into the alimentary canal consequent on excessive secretion from the skin. But the chief cause is probably the diversion of the nervous influence requisite to the due sensibility of the bowels, and its powerful concentration upon the volun- tary muscles. The discharges are often unhealthy. Respiration suffers greatly. The breathing is often short, hurried, and anxious; and, in consequence of the rigidity of the diaphragm and other respiratory muscles, the chest is so imperfectly expanded, that a feeling of the most painful dyspnoea is sometimes experienced. In its highest grade, this amounts to absolute suffocation; the air in the lungs is unchanged; the face becomes livid; and death takes place from apncea. Another source of distress and danger is spasm of the glottis, an accession of which, is probably sometimes the cause of those sudden deaths which occur in the midst of a spasmodic paroxysm. The patient, under these circumstances, evinces signs of intense agitation and suffering, and by clutching at his throat seems to show that the difficulty exists in the larynx. The disagreeable harshness of voice, occasionally observed in tetanus, probably has its source in constriction of the muscles of the glottis. The circulation in pure cases of tetanus, when not excited by the action of the muscles, is often nearly or quite natural. But, as muscular contrac- tion always calls for an expenditure of blood, the heart is stimulated to a more frequent action during the spasmodic paroxysms; while the intense nervous disturbance gives irregularity and inefficiency to its efforts. Hence, under these circumstances, the pulse is apt to be frequent, small, irregular, and feeble, especially towards the close of the disease, when the heart is exhausted by the combined influence of intense irritation, and defective nu- trition. During the most violent paroxysms, the frequency is occasionally very great; and Mr. Curling mentions a case in which it amounted to 180 in a minute. There is no fever, strictly speaking, in tetanus unassociated with inflammation; and blood drawn from the body does not, exhibit the buffy coat. The temperature of the surface, however, is often above the natural standard, and sometimes very greatly so. In the case of a boy CLASS III.] TETANUS. 823 twelve years old, under the care of M. Prevost, of Geneva, a thermometer with the bulb in the axilla stood between 110° and 111° F.; and Dr. Bright describes a case in which the temperature in the axilla was 105°. The patient often perspires profusely, probably in consequence of the violent muscular action and great suffering. A miliary eruption sometimes attends the profuse sweats. The other secretions are ordinarily diminished. The bile flows less freely, exhalation from the mucous membranes is some- what checked, and the urine is generally scanty and high-coloured. The mind is in general remarkably clear throughout the complaint. There is no stupor, no delirium, and little other cephalic affection, until near the close of the case, when the intellect sometimes wanders. The patient is apt to be sleepless from excess of pain, or, if he falls asleep during the lull of the paroxysms, is soon awakened by their recurrence. It said that the spasm is relaxed during sleep. This is true of the paroxysmal spasm, but not generally of the tonic rigidity. The fact probably is, not that sleep suspends the paroxysm, but that it takes place in consequence of the suspen- sion. Mr. Mayo relates the case of a boy, in whom the muscles were com- pletely relaxed during sleep, and the spasmodic rigidity returned when he was awakened. Other similar cases have been observed. But it is well known that, in some instances of the disease, there is complete suspension of the muscular contraction, either spontaneously or under the effect of reme- dies. It could scarcely be otherwise in such cases, than that the interval should be occupied by sleep. The spasm returns when the patient is awak- ened, because the slightest agitation often brings about this result. It is a singular fact, that, though the violent spasms exhaust the excita- bility of the heart, they are not attended with the sense of fatigue that fol- lows great muscular exertion under the influence of the will. It should be borne in mind that all cases of tetanus do not present the whole series of phenomena above detailed. This disease has every possible grade, from a moderate stiffness of the muscles of the neck, of the jaws, of the back, perhaps of a single limb, up to those terrible cases in which al- most every voluntary muscle assumes in its turn a board-like rigidity, alter- nating occasionally with the most fearfully painful spasm. The course of the disease, moreover, differs in different cases. In some quite continuous, and advancing with an uninterrupted progress to a fatal result, it is in others remittent, and in others again intermittent; and this tendency to relaxation in the symptoms may be regarded as a favourable sign. In regard to its duration, it may terminate fatally in less than a day, or may continue for a week or more. Some doubtful cases are related, in which death has taken place almost immediately after the reception of the injury, or the commencement of the symptoms, and others, less suspicious, in which it has been postponed for two, three, or four weeks. But most frequently it occurs between the end of the first and beginning of the fifth day, and few survive the eighth day, who do not ultimately recover. Death occurs either from apncea, consequent on spasm of the glottis or immobility of the respiratory muscles, or from pure exhaustion of the vital powers through excessive nervous excitement and want of nutrition, or pos- sibly, sometimes, from a spasmodic seizure of the heart. Recovery is usually slow and gradual. The spasms diminish in violence and frequency, the rigidity relaxes, and not unfrequently the patient expe- riences a sense of formication in the limbs, as the muscles again come under the control of the will. Some cures take place in less than a week; but not unfrequently the disease runs on for several weeks, and sometimes two or even three months elapse before complete recovery. A certain de- gree of stiffness often remains long after the patient is deemed well. It is more especially the idiopathic variety that assumes the protracted form. 824 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. The disease is occasionally complicated with other affections. Sometimes epilepsy assumes something of the tetanic character; and we have, along with the coma and convulsions of that disease, a more or less extensive tonic rigidity of the muscles. Hysteria too is now and then associated with te- tanic symptoms. Inflammation of the spinal marrow and brain, or of their meninges, is a more common accompaniment. In such cases, with the spasms of tetanus, we have pain along the spine or in the head, fever, loss of appetite, a furred tongue, a frequent pulse, perhaps delirium, paralysis, and ultimately coma before death. There is an exceedingly fatal variety of tetanus which merits a distinct no- tice ; that, namely, which occurs in infants soon after birth, and has received the name of trismus nascentium. It is much more common in hot than in temperate latitudes ; and is very destructive among certain classes of the population in the West Indies, and portions of our Southern States. It is said to affect especially the children of the blacks, and in some situations, while more than one-half of the coloured infants who are born die of the dis- ease, scarcely a white child is attacked. The seizure takes place usually within the first week from birth, and has scarcely ever been noticed after the end of the second week. It is especially apt to be attended with spasmodic closure of the jaws, whence its name of trismus nascentium, though other muscles also are affected. It is usually ascribed to irritation arising from the cutting of the cord, and dissection has generally revealed ulceration at the umbilicus, with more or less inflammation of the investments of the um- bilical vessels, and of the peritoneal membrane. Much influence has been ascribed to improper or careless dressing of the umbilicus, so common with the class of people among whom this affection is generally found.* A bad state of the infant's constitution, arising from the hot and foul air in which it has been born, and by which it has been influenced while in the fetal state, through the system of the mother, probably constitutes an essential predis- position. The disease is very seldom cured. Many extensive practitioners, who have seen a great deal of it, have never known an instance of recovery. Prophylactic measures are, therefore, all important; and experience has proved that attention to ventilation, cleanliness, and the proper management of the infant, has vastly diminished the prevalence of the disease, f * This cause of trismus nascentium is much insisted on by Dr. John M. Watson, Pro- fessor of Obstetrics, &c, in the Nashville University, in a pamphlet upon this disease, published at Nashville, in 1851. Among the careless negro population of the South, where the disease most prevails, there is often extreme neglect of proper dressings to the umbilicus, which is not unfrequently found irritated by the urine and fecal matter with which the dressings are soaked, and offensive from the putrefaction of the cord. After extensive inquiries, Dr. Watson has found that the disease rarely, if ever, occurs when due attention is paid by an intelligent person to the dressing of the cord. This he believes to be one of the most effective prophylactic measures. Peculiar attention should be paid to the keeping of the part dry, and free from all sources of irritation, and especially from that of the urine or feces. After the separation of the funis, should there be the least appearance of irritation or inflammation, an emollient poultice should be applied. Besides this prophylactic measure, it is also important to provide for the general health, by attention to the usual hygienic influences, such as cleanliness, pure and fresh air, and wholesome diet, both in reference to mother and child, before and after delivery. (Note to the third edition.) f In communications by Dr. J. Marion Sims, of Montgomery, Alabama, to the Ame- rican Journal of the Medical Sciences (April, 1846, and July and October, 1848), new views have been advanced in relation to the cause of trismus nascentium, and very en- couraging statements made in relation to its curability. According to Dr. Sims, the proper pathological condition is undue pressure upon the medulla oblongata and the nerves originating from it, produced by some displacement of the cranial bones, and especially of the occipital. In the far greater number of cases, the occiput is displaced inwardly, with its edges overlapped by those of the parietal bones. This the author considers as an ordinary physiological result of the parturient state, and as becoming a CLASS III.] TETANUS. 825 Anatomical Characters.—It often happens that no material traces of dis- ease can be discovered either in the brain or spinal marrow. Dr. Gerhard de- clares that he has examined these parts with great care in ten or twelve sub- jects, and could detect no lesion which seemed to have the least influence in the production of the symptoms. (Tweedie's Syst. of Pract. Med., Am. ed., Article Tetanus.) Dr. Todd has repeatedly examined, by means of the mi- croscope, the spinal cords of animals killed by strychnia, without ever having been able to detect the slightest morbid change ; and it is well known that the effects of this poison are closely analogous with the symptoms of tetanus. (Lond. Med. Gaz., Sept. 1850, p. 915.) In many instances, however, san- guineous injection of the cerebral and spinal meninges, and of the roots of the spinal nerves, serous effusion into the cavities, and increased vascularity of the brain and spinal marrow, have been observed. Blood has been noticed within the spinal sheath. In a few cases, evidences of inflammation have been offered in thickening of the meninges, softening of the medulla or brain, and cerebral abscess; and tubercles and other concretions have been found within the cranium. Small bony or cartilaginous plates have been repeatedly seen beneath the spinal arachnoid; and these have been supposed to have some agency in the production of the disease; but they are often wanting. Mr. Curling, though he has examined the spine with care in a dozen instances, has never met with them. (Treat, on Tetan., Am. ed., p. 38.) The nerves involved in the wound, and proceeding from it towards the spine, have been found lacerated, reddened, thickened, softened, and other- wise variously altered; but the same phenomena have been observed in wounds not attended with tetanus. The ganglia, especially the cervical and semilunar, have also been found injected. Other occasional phenomena, no- ticed after death, have been rupture of the muscles, particularly of the rectus abdominis; an unusual rigidity of the muscles; worms in the alimentary canal; and signs of inflammation in the stomach, bowels, and peritoneum. The larger papillas at the base of the tongue have been seen swollen, and the larynx injected, and lined by a frothy mucus. A greatly diminished bulk of the heart, with extraordinary firmness of its parietes, has been observed in one case; but this is a rare phenomenon. pathological condition only by persistence for some time after birth. Pressure made on the occiput by the position of the infant on its back is a cause of this persistence. The remedy is to restore the bone to its proper position, which may be done generally by placing the infant upon its side. In some instances, it may be necessary to resort to a Burgical operation. (See the account of such an operation by Dr. Harrison, in the Am. Journ. of Med. Sci., N. S., xvi. 75.) In twelve cases, the disease was cured by simply rectifying the position of the occiput. (Note to the second edition.) Since the publication of Dr. Sims' paper, a case of trismoid disease has been success- fully treated by Dr. Ostrander, of Brownsville, Missouri, upon his principles; but it is proper to state that real trismus had not been fully developed. (St. Louis Med. and Surg. Journ. vi. 315.) Dr. John M. Watson, however, in the treatise above referred to, de- nies altogether the origin of trismus nascentium in displacement of the cranial bones; and Dr A G Mabry, in a paper on the diseases of Selma, Alabama, published in the New Orleans Med and Surg. Journ. (vi. 620), states that he has never been able to dis- cover any displacement of the bones of the cranium or vertebral column in this affection. (Note to the third edition.) . Twn ™«ps of trismus nascentium have been treated successfully with cannabis indica (InTan heZp) in Charleston, S. C, one by Dr. P. C Gaillard, the other by D, H. W De Saussure The quantity given varied from about 6 to 15 minims of the tincture, at intervals of from half an hour to two hours. (Charleston Med. Journ. and Rev., viii. 808.) Dr N Ransom of Salem, Tenn., has recorded two cases of cure, which he ascribes tr, thV internal 'use of chloroform; two or three drops being administered, in emulsion, Ifter each paroxysm. {South. Journ. of Med. and Phys. Sci., iu. 21.) Dr. H. L. Byrd auer earn pt» j \ f more than thlrty cases seen b h aU had prove(i of Savannah Geo. states t d under the internal ' f u f r ^ntine. mL^mTj^X 1857, P- 475.)-^e to the fourth and fifth editions. VOL. II. 53 826 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. Causes.—A peculiar predisposition is probably requisite to the produc- tion of tetanus ; as comparatively few are attacked of those exposed to the exciting causes, though these may be to all appearance similar. In what this predisposition consists is unknown. That a long continued prevalence of heat favours its production is highly probable ; for the disease is incom- parably more frequent between the tropics than in cold or temperate lati- tudes, and, in varying climates, is more apt to occur in the hot than the cold seasons. This at least has been generally admitted to be the case; but, from the account by Dr. Laurie of the cases treated in the Glasgow Hospital, and from the reported deaths from the disease in London for the ten years ending in 1851, it appears that, in Great Britain, the number of cases in the winter months is quite equal to that of the summer months, if not greater. (Lond. Med. Times and Gaz., June, 1854, p. 620.) The disease appears sometimes to occur under epidemic influence, espe- cially in the idiopathic form. Dr. J. E. Thompson, of Missouri, in a commu- nication published in the Boston Medical and Surgical Journal, (L. 314), states that, in the months of March, April, May, and June, 1853, he had at- tended no less than forty cases, of which two only were traumatic. It has been supposed that a depraved state of health, resulting from bad diet, vitiated air, and a residence in low, damp situations, sometimes consti- tutes a predisposition; and yet the traumatic form of the disease often occurs in the young, robust, and vigorous. Males are much more frequently and severely affected than females. This, no doubt, arises in part from the much greater exposure of the former to wounds, and other exciting causes; yet there is probably a constitutional difference in the two sexes in relation to nervous disease, corresponding in some measure with their respective physical energies; women being more liable to the mild affections of hysteria and chorea, while men suffer more from apoplexy and tetanus. Persons are most subject to the disease from ten to fifty ; but no age is ex- empt. It is rare in advanced life. As already stated, infants soon after birth are exceedingly apt to suffer from it, in certain regions within the tropics. It appears to be a wrell ascertained fact, that the negro is more disposed to tetanus than the white. Some have ascribed the difference to the greater exposure and worse living of the former; but, under apparently the same circumstances, negroes have appeared to suffer most. Of the exciting causes incomparably the most frequent, in cold and tem- perate countries, are wounds or other kinds of external violence. Much stress has been laid by different writers upon the condition and character of the wound. Dr. Rush observed that it was destitute of inflammation; and other writers have noticed an unhealthy appearance, such as a pale or livid colour, an ichorous secretion, dryness, &c. But the general impression, at present is, that tetanus is equally liable to occur in all conditions of the wound, whether healthy or unhealthy, before or after suppuration, in the process of healing, or after the healing has been completed; and the circum- stance of the occasional vicious state of the wound is rather ascribed to the same constitutional tendencies which lead to tetanus, than considered as a cause of it. Whether the wound is trifling or severe seems to be of little consequence. The slightest scratch will sometimes cause the disease, the most severe injury often fails to do so. As examples of the kinds of wounds which have given rise to tetanus, may be mentioned those produced by needles in the fingers, a splinter under the nail, the extraction of a tooth, a fishbone in the fauces, the insertion of artificial teeth, the cutting of corns, running nails in the feet, the insertion of a seton, cupping, fractures and dislocations, contusing and lacerating bodies, and all kinds of surgical operations. It is CLASS III.] TETANUS. 827 believed that lacerated and punctured wounds are worse in this respect than smooth cuts, and injuries of the fingers, soles of the feet, and joints, than wounds elsewhere. It is highly probable that, when the disease has been ascribed to slight injuries, perhaps already healed, it has sometimes originated from other causes. The interval between the reception of the wound and the occurrence of tetanus is very uncertain. According to the statement of authors, it may be a few minutes, a few hours, several days, or even weeks. Most commonly the attack comes on between the fourth and fourteenth day after the injury. If it should not supervene before the end of three weeks, the patient may be considered safe. The longer the interval, the milder generally is the attack said to be, and the more likely to end in recovery. The disease is thought to occur less frequently than formerly, in consequence of the greater care extended to the wounded, and the greater skill exhibited in their treatment. Soldiers wounded in battle are said to be more apt to suffer than those wounded in civil life, because so often exposed to cold, wet, and privations after their injuries, and often so badly cared for from the want of suitable surgical assistance. Other local irritation besides that of wounds may occasion the disease. Thus, it is thought to have arisen from swollen gums, ulcers, intestinal worms, calculi in the bladder, and a dead foetus in the womb; and has been ascribed to inflammation of the stomach and bowels. Inflammation of the spinal meninges is probably an occasional cause of it. Violent mental emotion, especially terror, has been accused of producing tetanus; and Dr. Rush re- lates a case in which it was ascribed to harsh grating sounds. Nux vomica and its kindred substances, in poisonous quantities, produce effects which cannot be distinguished from tetanus. I think it highly probable that rheu- matism or gout may sometimes seize upon the medulla spinalis, and produce the phenomena of this disease. But infinitely the most common cause of that variety of tetanus which is independent of wounds, and is here denomi- nated idiopathic, is exposure to cold, when the body has been hot and per- spiring. Sleeping out upon the damp ground is a frequent cause; and the use of a cold bath when perspiring, and of very cold water as a drink under similar circumstances, is said to have produced it. Such exposure is the most frequent cause of the disease in tropical countries. It is apt to come on within a few hours after the exposure. When arising from this cause, it is more apt to be chronic and curable than when from wounds. The oc- currence of traumatic tetanus is favoured by the co-operation of cold and other causes of irritation; and it is probable that the two causes together may give rise to it, when neither separately would have been sufficient. Nature.__There is little doubt that the proper seat of tetanus is in the spinal marrow, including the medulla oblongata. The morbid action may extend also to the white matter of the brain. The absence of coma and de- lirium would indicate the want of participation of the cortical^ substance. That the disease does not reside in the muscles is proved by the instant ces- sation of the spasm, in any particular muscle, when the nerve by which it communicates with the spine is divided. By some authors the disease is looked upon as simply a form of spinal meningitis or myelitis. But inflammation of an organ seldom leads to such an excess of function. On the contrary, it generally diminishes or abolishes function Hence one of the most common results of inflammation within the spine is paralysis. It is true that inflammation of one part may extend an irritant action to another and sound part; and hence we do really have tetanic spasms sometimes mingled with the other symptoms of myelitis. Hence tetanus does occasionally originate in inflammation within the spinal column But the inflammation does not constitute the disease. It is only 828 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. a cause of it; and in such cases there are symptoms of the myelitis or spinal meningitis, as pain and tenderness on pressure, fever, furred tongue, loss of appetite, and paralysis, mingled with the tetanic symptoms. Dissection often exhibits an injected state of the spinal and cerebral me- ninges, and, to a certain extent, of the nervous substance ; but this is only congestion, not inflammation. It is in all probability the result, and not the cause of the disease. Besides, even this indication of an excess of vascular action is sometimes wanting. The phenomena, as well during life as after death, are best explained upon the supposition, that the disease is a mere irritation of the spinal marrow, including the medulla oblongata, and possibly, to a certain extent, the white cerebral fibres. This irritation may be propagated from the injured ex- tremities of the nerves, as in wounds; or from other sources of excessive excitement, as the intestinal mucous membrane in verminose affections; or it may originate in the spinal marrow itself through causes acting on that structure, such as cold, or rheumatic influence. The irritation, thus excited in the medullary columns, is extended to the muscles, and produces tetanic spasm, exactly as the same effect is caused by irritating the spine directly by running an iron wire into it, or by mechanical injury of one of the motor nerves proceeding from it. As before suggested, spinal meningitis may sometimes produce tetanus by extending an irritation to the nervous matter; and even myelitis, in one part, may give rise to a mingling of tetanic spasms with paralysis, by propagating irritation to a neighbouring sound part. The vascular injection, without other marks of inflammation within the spinal canal, is the result of the irritation, just as redness of the conjunctiva is produced by neuralgia of the eye. How it should happen that the nerves of the wounded part should remain apparently quiescent for some time, oc- casionally even till the wound has healed, is one of the mysteries of which so many remain unsolved in relation to nervous action. We may conjecturally say that, at one period of the wound, the requisite irritability of the spinal marrow which constitutes the predisposition is not yet in existence, and is to become developed by the circumstances under which the patient may be placed. But, if this were true, it would only remove the difficulty a single step. It has been well ascertained that, though the spinal irritation may be set on foot by the local cause, it is afterwards capable of sustaining itself, and may continue even though the cause has quite ceased to operate. We may infer that the upper portion of the column is first and most se- verely irritated, as it is in the parts of the body supplied with nerves from that region that the spasms are first produced, and are most violent, as in the face, back of the neck, and muscles of the chest. The mode in which death is produced has been already explained ; and it will have been observed that it is not inflammatory disorganization of the spinal marrow which causes the result, but an interference of the exterior effects of the irritation with the vital processes. Diagnosis.—Tetanus is so striking in its characteristics that it can scarcely be confounded with any other disease. Hydrophobia resembles it in some points, but is very different in others. (See Hydrophobia) Hysteria some- times imitates it, as it imitates most other nervous diseases; but there are peculiarities which almost always render diagnosis easy. (See Hysteria.) The rigid, permanent muscular contraction of tetanus, with the paroxysms of acutely painful and more fugitive spasm; the peculiar pain at the scro- biculus cordis; the trismus, difficult deglutition, and embarrassed respira- tion ; the peculiar expression of countenance; and the absence of coma and delirium, except a little of the latter in the very last stage, are sufficiently characteristic. There may be occasionally some embarrassment in deciding, CLASS III.] TETANUS. 829 how far certain cases which appear to be a mixture of tetanus with other diseases,^ as with spinal meningitis, epilepsy, and perhaps we might add rheumatism and gout, should be considered as belonging to the one or the other complaint. The poisonous effects of nux vomica may be looked on as a variety of tetanus. They can be distinguished only by a careful view of the circumstances which attended the origin of the affection. Prognosis.—Traumatic tetanus is exceedingly fatal. Some who have seen much of the disease assert that they have scarcely known a case of recovery. The most successful report but a small proportion of cures. The journals, however, teem with cases which have ended favourably under one or another kind of treatment; and, though some allowance must be made for the pro- bable idiopathic character of some of the cases considered as traumatic, yet there can be little doubt of the accuracy of the statements in the greater number; and sufficient encouragement is offered to the practitioner to per- severe in an energetic use of measures which he may consider as indicated. The means of determining the general ratio of cures are altogether wanting; for it is not the custom to report unsuccessful cases. Out of forty-six trau- matic cases, mentioned in Curling's Treatise as having occurred to several surgeons in tropical climates, ten, or rather more than one in five recovered; and, as the disease is more severe in hot than cold climates, the average of recoveries may be considered as greater than that stated. The idiopathic form of the disease is much less fatal; and, as it occurs in temperate latitudes, is generally curable. It is highly probable that the milder cases of tetanus, whether traumatic or idiopathic, would sometimes end spontaneously in health ; so that caution is always necessary, in judging of the effects of remedies, not to confound them with the workings of nature. Favourable circumstances are original mildness of the symptoms, complete relaxation between the spasmodic paroxysms, the absence of any great em- barrassment of the respiration, a natural state of the circulation, the occur- rence of sleep under the influence of remedies, and the protraction of the case beyond the seventh day. Extreme severity of the paroxysms, uninterrupted rigidity of many of the muscles, great difficulty of deglutition and respira- tion, an apparent tendency to spasm of the glottis, insusceptibility to the action of powerful remedies, and a very feeble, frequent, and irregular pulse, are symptoms of very bad augury.* Treatment.__One who depends upon authority alone would find extreme difficulty in coming to any satisfactory conclusion as to the treatment of this disease; for occasional, and perhaps equal success, is claimed for the most opposite plans of management; and numerous remedies have been employed, each one of which is reported to have produced signal cures. But the fact appears to be, that the disease occasionally gets well of itself, and the credit * Mr. Colles believes that there are two distinct spasmodic affections resulting from wounds, which have hitherto been confounded under the name of tetanus. Confining the name of tetanus to the one which presents the ordinary phenomena of that disease, as described by authors, he draws the distinction between the two affections in the following manner. Tetanus seldom appears before the second or third week; begins •with stiffness in the throat; presents a constant rigidity of the muscles, rendering de- glutition very difficult, and giving a peculiar aspect to the features; is attended with pain not in the wound but at the scrobiculus cordis; may continue for three or four weeks- is in no degree benefited by amputation; and is in some measure a constitu- tional affection The other form of spasm comes on in three or four days ; commences in the wounded limb ; has intervals of relaxation in which the patient can swallow; is attended with pain in the limb, which is excruciating during the spasm ; runs its course in three or four days* is relieved by no other means than amputation, which affords some chance of cure; and seems to have more of a local character than the other. (Dub. Quart. Journ. of Med. Sci., xiii. 39.) 830 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. is given to the medicine or medicines which may have been used, though possibly without the least influence over the result. Another difficulty in coming to a conclusion arises from the complexity in the means employed, so that it is impossible to determine how much of the resulting good is due to one, how much to another, or how much to their combination. In this un- certainty, the physician is thrown upon his principles ; and will be justified in employing such measures as, according to his best judgment, may be indi- cated by the circumstances of the case, or may flow from his views of its pathology. The reader will bear in mind the views taken in the preceding pages of the nature of the disease ; to wit, that it consists essentially in irri- tation of the spinal axis, giving a vast increase to the motor influence of that structure; and that, though it may occasionally be associated with inflamma- tion, it is in no degree essentially connected with that condition. The following indications appear to* be offered under this view of the dis- ease ; 1. to remove any existing source of irritation ; 2. to lessen the suscep- tibility of the nervous centres to any irritating influence which may exist; 3. to diminish the irritation by means calculated to depress nervous excitement; and 4. to support the strength of the system, and especially of the heart, under the exhausting influence of the enormous muscular action. 1. To remove any source of irritation.—Attention should be directed to the state of the wound. It was at one time the custom to recommend the application of irritant and caustic substances, with the view of bringing about inflammation and suppuration. But satisfactory evidence is wanting that these measures have ever been beneficial; and it appears to me more ac- cordant with a rational view of the pathology of the disease, to endeavour to diminish irritation in the wound, by emollient and anodyne applications. Poultices, having solution of sulphate of morphia, chloroform, or some nar- cotic extract incorporated with them, would seem to be indicated. Early in the disease, if there is reason to believe that a nerve has been par- tially divided, contused, or lacerated, an incision may be made above the wound, so as to cut off its communication with the spine, provided the ope- ration can be performed without considerable inconvenience. Several cases are on record in which such a measure apparently proved effectual. Upon the same principle, amputation of the limb above the wound has been proposed; and the operation has been frequently performed in cases of trau- matic tetanus, in which the wound was of such a nature as to require it, inde- pendently of the nervous affection. In a few instances, it appears to have arrested the disease when early performed; but it has failed in the great majority, and cannot, therefore, be with propriety employed merely for the tetanus. Indeed, this disease has frequently supervened upon amputation. The most that can be said in its favour is that, when the practitioner, in a case of severe injury, may be balancing between the propriety of amputation, and an endeavour to save the limb, the occurrence of commencing tetanic symptoms might be allowed to determine him in favour of the operation. The division of the main nervous trunk, at a convenient point above the wound, has been practiced in more than one instance with success. Decided symptoms of commencing tetanus, consequent upon a wound in the foot by a rusty nail, immediately gave way when the posterior tibial nerve was divided. (Curling, Am. ed., p. 71.) It is only, however, in the early stages that such operations can be performed with much hope of benefit. It is obvious that they can be at best but partially effectual, when the irritation has be- come established in the spinal marrow.* * Several successful cases of this kind are reported by Dr. Moses Sweat, of North Parsonfield, Maine, in the New York Journ. of Med., N. S., vi. 194. CLASS III.] TETANUS. 831 The cauterization of the wound by iron heated to redness, or even white- ness, was recommended by Larrey, and has been since employed with sup- posed advantage. (See Am. Journ. of Med. Sci., N. S., xix. 217.) When there is any reason to suppose that the disease depends upon a de- cayed tooth, or upon one artificially inserted, it should be removed. Feculent accumulation, as a source of great irritation to the nervous centres, should be removed at the beginning of the treatment. Practitioners are almost universally agreed upon the propriety of purging. Some brisk cathartic should be given, which will operate without materially irritating the mucous membrane. Senna and sulphate of magnesia ; calomel combined with jalap or the compound extract of colocynth ; calomel and castor oil; the compound cathartic pill of the TJ. S. Pharmacopoeia ; or, in case of any existing difficulty of deglutition, croton oil might be selected. The bowels should be thoroughly cleansed at first, and afterwards kept open by mild cathartics, or enemata, as the case may require. Should worms exist at the same time, and especially the tape-worm, the best remedy would be a dose of oil of turpentine with castor oil, in the proportion of half a fluidounce or a fluidounce of the former to a fluidounce of the latter. Cases of the disease have given way after the expulsion of the tape-worm by this remedy. To meet the same indication, bleeding should be employed when the pulse is tense and voluminous, and suspicion of spinal inflammation exists; as, for example, when tetanus has followed an injury directly to the spine, or when the tetanic symptoms are associated with pain and tenderness of the spine on pressure, formication or numbness of the lower extremities, and fever. Here the bleeding is intended to cure the inflammation, which may aggravate, if it does not cause the tetanic symptoms. Blood should be taken freely from the arm, and by cups from the spine. But bleeding in simple tetanus, with- out symptoms of spinal or cerebral inflammation, and especially when the pulse is not strong, appears to me not only uncalled for, but, in view of the great tendency to prostration in the advanced stage, highly hazardous. In similar cases, mercury may be employed as an adjuvant to the lancet for the cure of the spinal inflammation ; and it should be pushed energeti- cally to the point of salivation. For this purpose calomel may be given very freely by the mouth, and mercurial frictions employed externally. To be useful, the impression must be promptly made. Mercury has often been used in ordinary cases of tetanus, and has been highly recommended by some practitioners. But, though many successful cases are on record, yet it is impossible in most of them to determine whether the result was ascribable to the mercury or the other means employed ; and ample evidence might be adduced to prove, not only that it has very often failed, but that patients have in numerous instances been attacked by tetanus while under the mer- curial influence. It possesses, therefore, no specific curative powers; and as, on the occurrence of ptyalism, the presence of saliva in the mouth may prove a source of excessive distress to the patient, from his dread of swal- lowing it, and yet inability to discharge it conveniently through his closed teeth, the medicine should be used only when the indication for its powerful antiphlogistic influence is called for. 2. To diminish the susceptibility of the nervous centres.—The remedies calculated to meet this indication are chiefly the narcotics or cerebral stimu- lants One of the most effectual of these, and the one which has been most employed is opium. Much difference of opinion has existed in relation to the propriety of using it. Notwithstanding the contrary judgment of some distinguished authors, I cannot but think that the weight of testimony is jrreatly in its favour. It has probably been employed as one of the remedies in the great majority of cures. It is true that it has often failed. But in 832 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. many cases all remedies fail. It is true, moreover, that it has been vastly abused, and that it has been murderously administered in some cases. What can be thought, for example, of a practitioner, who in the course of ten days should prescribe half a gallon of laudanum, and half a pound of opium ? And yet this is said to have been done in tetanus. Should the violent nervous symptoms yield in such cases, what could be expected but death from the opium remaining in the stomach ? There is in tetanus an extraordinary in- susceptibility to the action of opium ; and the most enormous doses have been without apparent narcotic effect. In such cases, it is probable that the greater portion remains unabsorbed and inert in the stomach ; but it is there, prepared to act, when the insusceptibility, or the obstacle to absorption shall cease. If good do not accrue from opium in less than poisonous doses, it is useless to persevere. The liquid forms should always be preferred to the solid, as more readily absorbed. From half a fluidrachm to a fluidrachm of laudanum, from thirty to sixty drops of the vinegar of opium, or from half a grain to a grain of one of the salts of morphia in solution, may be given every two hours until some narcotic effect is experienced, or the patient relieved; and, if no effect is produced in due time, the dose may be somewhat aug- mented ; but I should prefer applying the medicine additionally to other sur- faces, without increasing the quantity by the stomach. Thus, a grain or two of the sulphate of morphia may be injected into the rectum; or twice the quantity sprinkled upon a denuded surface in the epigastrium, obtained either by means of a fly blister, or more speedily by the application of the strongest solution of ammonia. In idiopathic cases, or when there is much strength of pulse, the opiate may be associated with ipecacuanha or tartar emetic. When a narcotic effect can be obtained by the opium, relief is generally experienced, and the symptoms ameliorated. Should opium fail, recourse can be had to extract of hemp, which has been highly recommended, and is thought to have effected cures in several cases. The great disadvantage of this remedy is the uncertainty of its strength; and the dose of any particular parcel must be ascertained by its effects. Two or three grains of the extract may be given at first, and repeated every half hour until its narcotic effect is experi- enced. In three or four hours, should it produce no effect, the quantity may be increased gradually till the dose amounts to ten grains; but the interval should now be lengthened to two or three hours. Alcohol is another remedy by which the same indication may sometimes be fulfilled. The object in the use of this medicine is to bring about its cerebral influence; in other words to intoxicate the patient, so that his brain and spinal marrow may be blunted to all impressions. Cures have repeatedly followed this plan of treatment. The nervous system has the same insuscep- tibility to the influence of this cerebral stimulant as to that of opium, and it is necessary to employ large quantities. The use of wine was strongly re- commended by Dr. Rush, and has had many advocates. Brandy would be more effectual; and alcohol has been recently employed. The quantity to be used is almost indefinite. Quarts and even gallons of wine have been used daily for many days together. As soon as symptoms of stupefaction appear, the stimulant should be suspended, and resumed when they cease, should the tetanus not have yielded. I confess that I prefer the opiate plan, and would resort to the alcoholic only in case of obvious weakness of the circulation, or as an adjuvant of the opium. It should, of course, never be used where there are symptoms of spinal inflammation. Stramonium and belladonna have also been administered ; but when opium and hemp fail, little good can be expected from these narcotics. Frictions over the whole body with a strong tincture made by rubbing up five parts of the extract of belladonna, and eleven of alcohol, are said to have proved effectual in one case. (See Lond. Med. Gaz., Aug. 1850.,. p. 263.) Immer- CLASS III.] TETANUS. 833 sion in a bath, made by infusing hops in boiling water, afforded great relief in a case recorded by Dr. J. M. Minor, and was believed by him to be the main instrument of the cure. (N. Y. Med. Times, iv. 38.) Numerous cases have been recorded in which recovery from tetanus fol- lowed the inhalation of ether or chloroform, and others in which these reme- dies afforded great relief, without preventing a fatal issue. Chloroform, however, must be used in this manner with great caution; as it is power- fully and sometimes fatally sedative; while one of the great dangers of the disease is from exhaustion. The same remedy is said to have been used suc- cessfully, applied by means of friction over the whole surface of the body. 3. To diminish directly the nervous irritation.—This indication may be met by two sets of measures; first, those which are sedative to the nervous ■system ; and secondly, those which act revulsively. Of the former the most efficient is tobacco. Many cures, said to have been effected by this powerful sedative, are on record ; and it is probably among the most efficacious reme- dies in tetanus. It is singular that, while the nervous system is so insuscep- tible to the influence of opium and the other cerebral stimulants, it should be easily impressed by tobacco and the nervous sedatives generally. But this remedy must be used with caution. The system may be easily prostrated be- low the point of reaction. The best form of administration is by enema. Half a drachm may be infused in half a pint of boiling water, and the whole administered by injection. In an hour, if no effect is experienced, the dose may be repeated ; and afterwards at intervals of two or three hours till its relaxing effects are obtained. The tobacco bath has also been used; but, while immersed in this, the patient should be closely watched, and removed immediately upon the occurrence of signs of prostration. The same sedative may be applied in the form of a cataplasm along the spine. Should prostra- tion ensue, it must be counteracted by carbonate of ammonia, brandy, or ether; and tobacco has been successfully employed conjointly with stimulants. Digitalis and hydrocyanic acid have been employed for the same purpose as tobacco; but they are less efficient and not so manageable. Another remedy, indicated from its powerful sedative properties, is aconite. A case has been recorded in which it proved successful, in doses of four drops of the saturated tincture of the root, repeated until symptoms of its peculiar poison- ous action were induced. (Banking's Abstract, vol. ii. part 1, p. 155.) Tinc- ture of lobelia has been used, with supposed advantage, by Dr. J. McF. Gaston, of Gaston, S. C. (Charles. Med. Journ., xi. 58.) Dr. Poitevin, of Mobile, succeeded in one case of the disease with tartar emetic and laudanum, given so as to sustain a profuse and constant perspiration ; but Dr. Dowler, of New Orleans, found the remedy to fail in a case in which he subsequently tried it. (N. O.Med, and Surg. Journ., x. 7 69.) The external application of cold water is another sedative measure which has often proved effectual. It is necessary that the water should be little above the freezing point, say 40° F., or between that and 50°. It may be poured from a considerable height by pailfuls on the naked patient, or may be used as a bath. Great reduction of the vital actions is induced, with relaxation of the spasms; and the remedy must be reapplied at proper in- tervals on their return. After its use the patient should be put into bed, wiped dry and stimulated by carbonate of ammonia, and hot spirit if requi- site But the plan is hazardous, and death from syncope has resulted in at least one instance. Ice to the spine has been successfully used.* *Dr B D Carpenter, of Cutchogue, Suffolk Co., Long Island, reports two cases of * ' mli;„ ♦ifnnns which recovered under the use of ice applied to the head, and severe traumatic tetanus, »»""-" *■- . * * . ' aW the whole length of the spine. The application was repeated at intervals vary- ing from two to eight hours, and continued from ten to thirty minutes each time. (New York Med. Times;, ii. 46.;) 834 LOCAL DISEASES.—NERVOUS SYSTEM. [PART II. The warm bath is another sedative which has sometimes been employed, though scarcely energetic enough to produce much effect in the more violent cases. It is recommended in the muscular rigidity which is apt to remain during convalescence. Cures by the vapour bath have been reported. The second mode of meeting the indication is by revulsives. A blister along the whole length of the spine has been employed. But the most ef- fectual plan is that put into practice by the late Dr. Jos. Hartshorne of this city. It consists in applying along the spine, from the occiput to the sacrum, a solution of caustic potassa, containing two or three drachms of the alkali in four fluidounces of water. This is rubbed upon the skin by means of a sponge, until the surface is much reddened, and signs of a caustic action are displayed, in some one point, by the discoloration of the skin. The remedy may be repeated when the inflammation disappears. It has been used with success in a number of cases. Dr. Hartshorne relied chiefly upon it, with opium moderately employed, and purging. He informed me that he had effected cures in six or seven instances. 4. To support the strength of the system.—This becomes all-important in the advanced stages, when the heart begins to give way. Whenever the pulse is feeble, no matter what may be the stage of the disease, cordial medicines and nutritious food should be employed. Wine and ardent spirit, milk, animal broths, the yolk of egg, &c, should be freely used. Sulphate of quinia may be administered with the same view. Besides the remedies above enumerated, many others have enjoyed more or less credit. One which promises fairly, and which experience has shown to be apparently efficacious, is sulphate of quinia, used not merely as a tonic, but with a view to its peculiar influence on the system in heroic doses. A drachm of it may be given in twenty-four hours, unless found to produce its characteristic effects on the brain in smaller doses. Subcarbonate of iron is another tonic which has been employed with as- serted success. It has been used in enormous quantities, in one instance to the extent of half an ounce every two or three hours, and even of a pound daily. These enormous doses are probably quite unnecessary; for of the quantity taken, a very large proportion must remain inert in the bowels. Oil of turpentine has had no little reputation in the treatment of tetanus. Cures effected by it have been reported. It may be given in the dose of a fluidrachm repeated every two hours, until it evinces some disagreeable effect, or the patient recovers. Acetate of lead in large doses, musk, carbonate of potassa, colchicum, strychnia, electricity or galvanism, and extract of stramonium or other nar- cotic injected into the veins, are remedies, which, alone, or conjointly with some of the measures above enumerated, are said to have effected cures. A patient of Cruveilhier recovered by sustaining, through voluntary effort, a constant regular respiration, in measured time, the inspirations being as deep as possible. This was kept up for four hours, when the patient fell into a profound sleep. It was renewed again when he awoke, and continued until he again fell asleep. After this the paroxysms were milder, and he gradually recovered. (Braithwaite's Retrospect, xxi. 96.) The following is a brief summary of the remedies which seem to be in- dicated, viz., the removal or correction of obvious sources of irritation ; active purgation; bleeding when the pulse is strong, and symptoms of spinal or cerebral inflammation exist; the use of opiates, hemp, tobacco, or aconite, and the inhalation of ether or chloroform ; the cautious use of the cold bath; the application of a solution of caustic potassa or a blister along the spine, or of ice to the same part; and the free employment of alcoholic stimulants, and nutritious food, when debility appears. CLASS III.] HYDROPHOBIA. 835 ^ In consequence of the closure of the jaws, there is occasionally some difficulty in introducing food ; but a vacancy can generally be found either from the loss of a tooth, or behind the last teeth, large enough for the admission of liquids. A greater difficulty is that often attendant upon deglutition. To obviate this it may be necessary to inject the food into the stomach through a tube ; or to attempt to supply the place of food by nutritious enemata. Article V. HYDROPHOBIA. Syn.—Rabies.—Rabies Canina. Hydrophobia (from odcop, water, and